Prehospital tourniquet use: An evaluation of community application and outcome

Abstract

BACKGROUND:There is substantial investment in layperson and first responder training involving tourniquet use for hemorrhage control. Little is known however about prehospital tourniquet application, field conversion, or outcomes in the civilian setting. We describe the experience of a metropolitan region with prehospital tourniquet application. METHODS:We conducted a retrospective cohort study characterizing prehospital tourniquet use treated by emergency medical services (EMS) in King County, Washington, from January 2018 to June 2019. Emergency medical services and hospital records were abstracted for demographics, injury mechanism, tourniquet details, clinical care, and outcomes. We evaluated the incidence of tourniquet application, who applied the device (EMS, law enforcement, or layperson), and subsequent course. RESULTS:A total of 168 patients received tourniquet application, an incidence of 5.1 per 100,000 person-years and 3.48 per 1,000 EMS responses for trauma. Tourniquets were applied for penetrating trauma (64%), blunt trauma (30%), and bleeding ateriovenous fistulas (7%). A subset was critically ill: 13% had systolic blood pressures of <90 mm Hg, 8% had Glasgow Coma Scale score of <13, and 3% had cardiac arrest. Among initial applications, 48% were placed by law enforcement, 33% by laypersons, and 18% by EMS. Among tourniquets applied by layperson or law enforcement (n = 137), EMS relied solely on the original tourniquet in 45% (n = 61), placed a second tourniquet in 20% (n = 28), and removed the tourniquet without replacement in 35% (n = 48). Overall, 24% required massive transfusion, 59% underwent urgent surgery, and 21% required vascular surgery. Mortality was 3% (n = 4). At hospital discharge, the tourniquet limb was fully functional in 81%, partially functional in 10%, and nonfunctional in 9%; decreased function was not attributed to tourniquet application. CONCLUSION:The high rate of application, need for urgent hospital intervention in a subset, and low incidence of apparent complication suggest that efforts to increase access and early tourniquet use can provide public health benefit.

Prehospital hemorrhage management in low‐ and middle‐income countries: A scoping review

“…Studies have shown that tourniquet usage in rural settings can be beneficial. Tourniquets have equalized rural morbidity and mortality compared to urban settings, 38 though its utility does depend on hospital transfer times not being increased 39 . Most significantly, prior literature has documented significant reductions in civilian mortality (1% and 9%) due to prehospital tourniquet use, 37,40 along with a reductions in limb amputations (8%) and fasciotomies (19%) in an 8‐year retrospective study 41 …”

A framework for the design and implementation of Stop the Bleed and public access trauma equipment programs

“…22,23 A growing body of literature has shown the safety and impact of prehospital tourniquets. 24,25 Smith et al found that prehospital tourniquets were safely used to control bleeding in major extremity penetrating trauma without increased risk of major complications and were also associated with increased systolic blood pressure on arrival to the emergency department, decreased blood product use, and decreased incidence of limb-related complications. 26 Bonk et al reviewed autopsy records and estimated 235 isolated extremity injury-related deaths could be prevented and an additional estimated 4354 concurrent extremity and central injury-related deaths could potentially receive enhanced care with early tourniquet placement.…”

“…A growing body of literature has shown the safety and impact of prehospital tourniquets 24,25 . Smith et al found that prehospital tourniquets were safely used to control bleeding in major extremity penetrating trauma without increased risk of major complications and were also associated with increased systolic blood pressure on arrival to the emergency department, decreased blood product use, and decreased incidence of limb‐related complications 26 .…”