Prehospital tourniquet use in penetrating extremity trauma: Decreased blood transfusions and limb complications

Abstract

BACKGROUND Despite increasing popularity of prehospital tourniquet use in civilians, few studies have evaluated the efficacy and safety of tourniquet use. Furthermore, previous studies in civilian populations have focused on blunt trauma patients. The objective of this study was to determine if prehospital tourniquet use in patients with major penetrating trauma is associated with differences in outcomes compared to a matched control group. METHODS An 8-year retrospective analysis of adult patients with penetrating major extremity trauma amenable to tourniquet use (major vascular trauma, traumatic amputation and near-amputation) was performed at a Level I trauma center. Patients with prehospital tourniquet placement (TQ) were identified and compared to a matched group of patients without tourniquets (N-TQ). Univariate analysis was used to compare outcomes in the groups. RESULTS A total of 204 patients were matched with 127 (62.3%) in the prehospital TQ group. No differences in patient demographics or injury severity existed between the two groups. Average time from tourniquet application to arrival in the emergency department (ED) was 22.5 ± 1.3 minutes. Patients in the TQ group had higher average systolic blood pressure on arrival in the ED (120 ± 2 vs. 112 ± 2, p = 0.003). The TQ group required less total PRBCs (2.0 ± 0.1 vs. 9.3 ± 0.6, p < 0.001) and FFP (1.4 ± 0.08 vs. 6.2 ± 0.4, p < 0.001). Tourniquets were not associated with nerve palsy (p = 0.330) or secondary infection (p = 0.43). Fasciotomy was significantly higher in the N-TQ group (12.6% vs. 31.4%, p < 0.0001) as was limb amputation (0.8% vs. 9.1%, p = 0.005). CONCLUSION This study demonstrated that prehospital tourniquets could be safely used to control bleeding in major extremity penetrating trauma with no increased risk of major complications. Prehospital tourniquet use was also associated with increased systolic blood pressure on arrival to the ED, decreased blood product utilization and decreased incidence of limb related complications, which may lead to improved long-term outcomes and increased survival in trauma patients. LEVEL OF EVIDENCE Therapeutic, level IV.

2020 International Consensus on First Aid Science With Treatment Recommendations

“…For the important outcome of complications/adverse effects (including compartment syndrome nerve palsy, fasciotomy, thromboembolic episodes), we identified very low-certainty evidence (downgraded for serious risk of bias and imprecision) from 3 prehospital civilian cohort studies 148,151,152 of 1420 participants. Study heterogeneity prevented combining results for meta-analysis.…”

“…We identified very low-certainty evidence (downgraded for serious risk of bias) from 5 prehospital civilian cohort studies 145,148,151,152,157 of 1686 participants reporting the complication of amputation. Study heterogeneity prevented combining the results for meta-analysis, and all reported similar amputation rates with the use of tourniquets compared with the use of direct manual pressure alone.…”

The European Perspective on the Management of Acute Major Hemorrhage and Coagulopathy after Trauma: Summary of the 2019 Updated European Guideline

“…The tourniquet is to be torn and fixed until the bleeding stops and the time point of application is documented. In a retrospective study, tourniquet use was associated with improved cardiocirculatory stability at hospital admission (BPsyst 120 ± 2 vs. 112 ± 2 mm Hg, p = 0.003) and reduced transfusion requirement (packed red blood cells [pRBC]: 2.0 ± 0.1 vs. 9.3 ± 0.6, p < 0.001; fresh frozen plasma concentrates [FFP]: 1.4 ± 0.08 vs. 6.2 ± 0.4, p < 0.001) along with a non-increased risk for complications, e.g., nerve injuries and infections [20]. With increasing magnitude of injury, the occurrence of displaced pelvic injuries with active bleeding mostly from the venous peritoneal plexus increases; of note, only 10-15% of all pelvic bleedings are arterial [21,22].…”

The influence of ischemia limb reperfusion on mineralization condition under connected abdomino-skeletal injury and massive treatment

“…Âèêîðèñòàííÿ êðîâîñïèííèõ äaeãóò³â ç ìåòîþ çóïèíêè êðîâîòå÷³, çà äàíèìè äîñë³äaeåíü [14], º áåçïå÷íèì òà ïîêðàùóº ðåçóëüòàòè ë³êóâàííÿ. Ðàçîì ç òèì ó òàêèõ ïîñòðàaeäàëèõ ìîaeëèâèé ðîçâèòîê ðàáäîì³îë³çó òà ñèñòåìíèõ çì³í [15].…”