Prehospital Tourniquets in Civilians: A Systematic Review

Abstract

Objectives: Terrorist attacks and civilian mass-casualty events are frequent, and some countries have implemented tourniquet use for uncontrollable extremity bleeding in civilian settings. The aim of this study was to summarize current knowledge on the use of prehospital tourniquets to assess whether their use increases the survival rate in civilian patients with life-threatening hemorrhages from the extremities. Design: Systematic literature review in Medline (Ovid), Embase (Ovid), Cochrane Library, and Epistemonikos was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Guidelines. The search was performed in January 2019. Setting: All types of studies that examined use of tourniquets in a prehospital setting published after January 1, 2000 were included. Primary/Secondary Outcomes: The primary outcome was mortality with and without tourniquet, while adverse effects of tourniquet use were secondary outcomes. Results: Among 3,460 screened records, 55 studies were identified as relevant. The studies were highly heterogeneous with low quality of evidence. Most studies reported increased survival in the tourniquet group, but few had relevant comparators, and the survival benefit was difficult to estimate. Most studies reported a reduced need for blood transfusion, with few and mainly transient adverse effects from tourniquet use. Conclusion: Despite relatively low evidence, the studies consistently suggested that the use of commercial tourniquets in a civilian setting to control life-threatening extremity hemorrhage seemed to be associated with improved survival, reduced need for blood transfusion, and few and transient adverse effects.

The European guideline on management of major bleeding and coagulopathy following trauma: sixth edition

“…The use of tourniquets has become the standard of care for severe external haemorrhage in military medicine and several publications report the effectiveness of tourniquets in this specific context in adults [ 22 ] and children [ 23 ]. In the civilian setting, several small studies and systematic reviews suggest reduced mortality with the use of pre-hospital tourniquets and a low risk of complications, although there is a lack of high-quality randomised controlled trials (RCTs) to support this practice [ 24 , 25 ]. Tourniquets should be left in place until surgical control of bleeding is achieved; however, time to removal should be shortened as much as possible [ 20 ].…”

“…Tourniquets should be left in place until surgical control of bleeding is achieved; however, time to removal should be shortened as much as possible [ 20 ]. Improper or prolonged placement of a tourniquet can lead to complications such as nerve paralysis and limb ischaemia, but these effects are rare [ 25 – 27 ].…”

Singapore First Aid Guidelines 2021

“…While SRFAC will continue to teach improvised tourniquets as a foundational skill (in the event that a commercial one is unavailable or the first aider is unfamiliar), familiarity of use by the first aider is the most important point. (1,49) Direct pressure is a quick and effective method that can be easily performed by all first aiders, (50)(51)(52)(53) particularly if the bleeding site is not amenable to tourniquet use. Firm pressure maintained for a prolonged duration is necessary for successful control of bleeding.…”

A efetividade dos torniquetes no atendimento pré-hospitalar

“…O torniquete é um dispositivo de compressão usado para controlar o fluxo sanguíneo arterial e venoso de uma extremidade por um período de tempo, a fim de conter hemorragias graves nos membros inferiores e superiores (Eilertsen et al, 2020). O primeiro uso conhecido de um torniquete, realizado em ambiente militar, foi em 1674, por Ettiene J. Morel, sendo que, quase 200 anos depois, em 1864, Joseph Lister descreveu o uso civil do torniquete para obter campo cirúrgico adequado com menos sangramento (Benítez et al, 2021).…”