Increased Use of Prehospital Tourniquet and Patient Survival: Los Angeles Countywide Study

Abstract

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.

The tight rope act: A multicenter regional experience of tourniquets in acute trauma resuscitation

“…6 Our 24-hour cutoff for data collection to allow for full deidentification precluded us from evaluating for the need for delayed amputation reported in other studies. 7 We were also not able to reliably report whether the cause of death was related to extremity hemorrhage or other traumatic injuries such as traumatic brain injury or noncompressible torso hemorrhage. Finally, we did not collect the use of ankle-brachial index as a diagnostic tool for arterial injury.…”

“…Following the national trend of increased prehospital tourniquet application, 7 our urban trauma centers experienced an analogous increase, and the question was raised regarding appropriate and effective usage. We hypothesized the following: (1) indications for tourniquet placement would be heterogeneous, (2) tourniquet placement would not correlate with named vascular injury, and (3) there would be a significant number of nonarterial occlusive tourniquets.…”

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…”

“…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.…”

Prehospital Tourniquets Placed on Limbs Without Major Vascular Injuries, Has the Pendulum Swung Too Far?

“…7 Retrospective investigations of the civilian population have demonstrated that using a tourniquet applied prehospital vs at the trauma center decreased patient mortality, transfusion requirements, and decreased shock on arrival as indicated by a higher systolic blood pressure. [8][9][10] These studies, in conjunction with the "Stop the Bleed" campaign, resulted in more widespread usage of prehospital tourniquets for traumatic limb injuries.…”