Effect of prehospital tourniquets on resuscitation in extremity arterial trauma

Abstract

BackgroundTimely tourniquet placement may limit ongoing hemorrhage and reduce the need for blood products. This study evaluates if prehospital tourniquet application altered the initial transfusion needs in arterial injuries when compared with a non-tourniquet control group.MethodsExtremity arterial injuries were queried from our level I trauma center registry from 2013 to 2017. The characteristics of the cohort with prehospital tourniquet placement (TQ+) were described in terms of tourniquet use, duration, and frequency over time. These cases were matched 1:1 by the artery injured, demographics, Injury Severity Score, and mechanism of injury to patients arriving without a tourniquet (TQ−). The primary outcome was transfusion within the first 24 hours, with secondary outcomes of morbidity (rhabdomyolysis, renal failure, compartment syndrome), amputation (initial vs. delayed), and length of stay. Statistical tests included t-test and χ2 for continuous and categorical variables, respectively, with p<0.05 considered as significant.ResultsExtremity arterial injuries occurred in 192 patients, with 69 (36%) having prehospital tourniquet placement for an average of 78 minutes. Tourniquet use increased over time from 9% (2013) to 62% (2017). TQ+ patients were predominantly male (81%), with a mean age of 35.0 years. Forty-six (67%) received blood transfusion within the first 24 hours. In the matched comparison (n=69 pairs), TQ+ patients had higher initial heart rate (110 vs. 100, p=0.02), frequency of transfusion (67% vs. 48%, p<0.01), and initial amputations (23% vs. 6%, p<0.01). TQ+ patients had increased frequency of initial amputation regardless of upper (n=43 pairs) versus lower (n=26 pairs) extremity involvement; however, only upper extremity TQ+ patients had increased transfusion frequency and volume. No difference was observed in morbidity, length of stay, and mortality with tourniquet use.DiscussionTourniquet use has increased over time in patients with extremity arterial injuries. Patients having prehospital tourniquets required a higher frequency of transfusion and initial amputation, without an increase in complications.Level of evidenceTherapeutic study, level IV.

Tourniquet use for civilian extremity hemorrhage: systematic review of the literature

“…All the selected studies were retrospective, eleven extracted data from hospital records, one from the National Emergency Medical Systems (NEMSIS) 11 , and one from records of the Los Angeles Fire Department (LAFD) 12 . Most of the studies collected data over five years [13][14][15][16][17][18][19][20][21] , thirteen reports were from the United States and one from Canada 15 . Six studies where multiinstitutional [14][15][16]18,[22][23] , five single-center 13,17,[19][20]24 and two were database registries 11-12 . All the cases of civilian TQ applications for extremity hemorrhage were extracted.…”

“…Age was reported in twelve publications with a mean of 38 years [11][12][13][14][15][16][17][18][19][20][21]23 , gender accounted in eight 11,[13][14][15][16][19][20]22 , 2434 (79%) males, and 656 (21%) females. The mechanism of injury was described in all the publications [11][12][13][14][15][16][17][18][19][20][21][22][23] but with a heterogeneity of categories. Schroll et al published cases of penetrating trauma exclusively 22 , five studies included solely trauma cases, and nine distinguished extremity hemorrhage due to traumatic and non-traumatic conditions.…”

“…Schroll et al published cases of penetrating trauma exclusively 22 , five studies included solely trauma cases, and nine distinguished extremity hemorrhage due to traumatic and non-traumatic conditions. Among [11][12][13][14][15][16][17][18][19][20][21][22]24 . Less frequent trauma mechanisms accounted for were blast injuries (explosive [13][14][15][16][17]19,[21][22][23][24] .…”

“…The improvised devices were frequently blood pressure cuffs, rubber tubing, and home-made devices not specified. The vast majority of the improvised TQs were replaced by commercial windlass TQs by a physician at arrival to the ED, and the duration of TQ use was reported in all but one publication with a mean time of 49 minutes 11,[13][14][15][16][17][18][19][20][21][22][23] .…”

“…Complications associated with TQ use were described in eight publications [13][14][15][17][18][19][20]22 , and reported with different classifications between the studies (Table 2) Our review reveals that the most common cause of hemorrhage requiring TQ application is trauma. Of the studies analyzed, six focused on trauma related TQ use [16][17][18][19][20]23 , one solely described penetrating trauma 17 , and eight considered both trauma and nontrauma related extremity TQ use, the second referred to as non-traumatic or medical. These less frequent causes of TQ application included hemodialysis arteriovenous shunt bleeding, chronic wounds and varicose vein ruptures [11][12][13][14][15]21,23,24 .…”