AAST multicenter prospective analysis of prehospital tourniquet use for extremity trauma

Abstract

BACKGROUND:Tourniquet use for extremity hemorrhage control has seen a recent increase in civilian usage. Previous retrospective studies demonstrated that tourniquets improve outcomes for major extremity trauma (MET). No prospective study has been conducted to date. The objective of this study was to evaluate outcomes in MET patients with prehospital tourniquet use. We hypothesized that prehospital tourniquet use in MET decreases the incidence of patients arriving to the trauma center in shock. METHODS:Data were collected prospectively for adult patients with MET at 26 Level I and 3 Level II trauma centers from 2015 to 2020. Limbs with tourniquets applied in the prehospital setting were included in the tourniquet group and limbs without prehospital tourniquets were enrolled in the control group. RESULTS:A total of 1,392 injured limbs were enrolled with 1,130 tourniquets, including 962 prehospital tourniquets. The control group consisted of 262 limbs without prehospital tourniquets and 88 with tourniquets placed upon hospital arrival. Prehospital improvised tourniquets were placed in 42 patients. Tourniquets effectively controlled bleeding in 87.7% of limbs. Tourniquet and control groups were similarly matched for demographics, Injury Severity Score, and prehospital vital signs ( p > 0.05). Despite higher limb injury severity, patients in the tourniquet group were less likely to arrive in shock compared with the control group (13.0% vs. 17.4%, p = 0.04). The incidence of limb complications was not significantly higher in the tourniquet group ( p > 0.05). CONCLUSION:This study is the first prospective analysis of prehospital tourniquet use for civilian extremity trauma. Prehospital tourniquet application was associated with decreased incidence of arrival in shock without increasing limb complications. We found widespread tourniquet use, high effectiveness, and a low number of improvised tourniquets. This study provides further evidence that tourniquets are being widely and safely adopted to improve outcomes in civilians with MET.

Prehospital tourniquet use in civilian extremity trauma: an Australian observational study

“…The major finding of this study is that the mechanism of injury substantially differs compared to civilian series from the USA, with only 19.4% of this series injured by penetrating mechanism, less than the 42.7–77% reported in published series (Table 4.) Furthermore, in the current series, there were no gunshot wounds, compared with 33% in the largest multicentre study from the USA 11 . It is noted that eight of 31 (25.8%) subsequently required a major vascular arterial procedure, and another nine (29.0%) had a traumatic amputation, suggesting the majority had a likely robust indication for PHTQ application.…”

“…Furthermore, in the current series, there were no gunshot wounds, compared with 33% in the largest multicentre study from the USA. 11 It is noted that eight of 31 (25.8%) subsequently required a major vascular arterial procedure, and another nine (29.0%) had a traumatic amputation, suggesting the majority had a likely robust indication for PHTQ application. However, it was not possible to accurately assess the effectiveness of PHTQ application from the RMH database nor the electronic medical record, as there was limited documentation regarding the presence or absence of a distal pulse.…”

Rethinking limb tourniquet conversion in the prehospital environment

“…[22][23][24][25] With the endorsement of multiple civilian professional organizations, TQ use spread into the nonmedical, law enforcement community and then lay responder and now includes placement next to automatic external defibrillators in public gathering places. [26][27][28][29][30][31][32] However, much like in the US military, most of the reported civilian use of TQs has been in areas with rapid urban transport, mitigating the risk of prolonged TQ times. In more austere rural and wilderness settings, the issue of prolonged TQ time remains as transportation to definitive care frequently exceeds 2 hours.…”

“…Limited adoption by hospitals and emergency medical services (EMS) began in 2008 and this subsequently increased to wider use 22–25 . With the endorsement of multiple civilian professional organizations, TQ use spread into the nonmedical, law enforcement community and then lay responder and now includes placement next to automatic external defibrillators in public gathering places 26–32 . However, much like in the US military, most of the reported civilian use of TQs has been in areas with rapid urban transport, mitigating the risk of prolonged TQ times.…”

Advances in the Management of Coagulopathy in Trauma: The Role of Viscoelastic Hemostatic Assays across All Phases of Trauma Care

“…However, bleeding can be controlled temporarily in the field with direct pressure, packing, and placement of pelvic binders and tourniquets, as well as in the ED with other advanced maneuvers, including resuscitative endovascular balloon occlusion of the aorta. [33][34][35][36][37] The goal is to transfer the patient to the OR, interventional suite, or hybrid OR for definitive hemorrhage control. [38][39][40][41] Resuscitation strategies for bleeding patients have changed dramatically over the last several decades with an emphasis on early transfusion of balanced ratios of packed red blood cells, plasma, and platelets, or whole blood (where available), and avoidance of crystalloids.…”