BACKGROUND: Recent trends in prehospital tourniquet use remain underreported. In addition, the impact of prehospital tourniquet use on patient survival has not been evaluated in a population-level study. We hypothesized that prehospital tourniquets were used more frequently in Los Angeles County and their use was associated with improved patient survival. STUDY DESIGN: This is a retrospective cohort study using a database maintained by the Los Angeles County Emergency Medical Services Agency. We included patients who sustained extremity vascular injuries between October 2015 and July 2019. Patients were divided into the following study groups: prehospital tourniquet and no-tourniquet group. Our primary end point was in-hospital mortality. The secondary outcomes included 4- and 24-hour transfusion requirements and delayed amputation. RESULTS: A total of 944 patients met our inclusion criteria. Of those, 97 patients (10.3%) had prehospital tourniquets placed. The rate of tourniquet use increased linearly throughout our study period (goodness of fit, p = 0.014). In multivariable analysis, prehospital tourniquet use was significantly associated with improved mortality (adjusted odds ratio 0.32; 95% CI, 0.16 to 0.85; p = 0.032). Similarly, transfusion requirements were significantly lower within 4 hours (regression coefficient –547.76; 95% CI, –762.73 to –283.49; p < 0.001) and 24 hours (regression coefficient –1,389.82; 95% CI, –1,824.88 to –920.97; p < 0.001). There was no significant difference in delayed amputation rates (adjusted odds ratio 1.07; 95% CI, 0.21 to 10.88; p < 0.097). CONCLUSIONS: Prehospital tourniquet use has been on the rise in Los Angeles County. Our results suggest that the use of prehospital tourniquets for extremity vascular injuries is associated with improved patient survival and decreased blood transfusion requirements, without an increase in delayed amputations.
BACKGROUND: Resuscitative endovascular balloon occlusion of the aorta (REBOA) has been increasingly used as part of damage control resuscitation for patients with non-compressible truncal hemorrhage. We hypothesized that there might be a select group of patients that could have benefited from prehospital placement of the REBOA. STUDY DESIGN: This was a retrospective cohort study including patients who presented to a Level I trauma center with cardiac arrest between January 2014 and March 2018. The findings of a full autopsy were reviewed for the details of internal injuries. A patient was determined to be a REBOA candidate if the patient sustained abdominal organ injuries or pelvic fractures and no associated severe head injuries. The candidate group was compared with the non-candidate group based on prehospital vital signs and other patient characteristics. A multiple logistic regression analysis was performed to identify certain prehospital factors associated with candidacy for prehospital REBOA. RESULTS:A total of 198 patients met our inclusion criteria. Of those, 27 (13.6%) patients were deemed REBOA candidates. Median Injury Severity Score was 22 (interquartile range 17 to 29). Patients in the candidate group were more likely to have a Glasgow Coma Scale score 9 (48% vs 15%; p ¼ 0.012), oxygen saturation >90% (56% vs 35%; p ¼ 0.03), and systolic blood pressure <90 mmHg (48% vs 26%; p ¼ 0.04) in the field. Logistic regression showed that these 3 clinical parameters of prehospital vital signs were significantly associated with REBOA candidacy. CONCLUSIONS: Our data suggest that >10% of trauma patients who presented with cardiac arrest could have benefited from prehospital REBOA. Additional prospective studies are warranted to validate the use of field vital signs in selecting candidates. (J Am Coll Surg 2019;229:383e388.
For trauma patients with noncompressible truncal hemorrhage (NCTH), aortic occlusion (AO) is attempted with either resuscitative thoracotomy (RT) or the resuscitative endovascular balloon occlusion of the aorta (REBOA). However, it is often challenging to identify the group of patients who would benefit from AO procedures. We hypothesized that patients who met simple clinical criteria would have better outcomes following AO procedures. This is a retrospective cohort study using the Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery database (November 2013-August 2019) which included patients who arrived with signs of life and underwent AO procedures (RT or zone 1 REBOA). Outcomes were compared between patients who met the criteria (admission vital signs: Glasgow Coma Scale (GCS) ≥9 and systolic blood pressure <90 mm Hg) and those who did not. Subgroup analyses were then conducted on patients who had a REBOA placed and those who underwent RT. A total of 998 patients met our inclusion criteria. Of those, a REBOA was placed in 364 patients (37%), while 634 (64%) underwent RT. The overall mortality rate in the criteria (+) group was significantly lower than that in the criteria (−) group (62 vs. 79%, P < .001). In patients who survived beyond the emergency department following AO procedures, those who met the criteria underwent hemorrhage control procedures more frequently (83% vs. 57%, P < .001). Our data suggest that simple clinical criteria could guide the provider for proceeding with AO in patients with suspected NCTH.
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