M. Scerbo1, E. Taub1, J. P. Mumm1, K. S. Gates1, J. B. Holcomb1, B. A. Cotton1 1University Of Texas Health Science Center At Houston,Acute Care Surgery/Surgery,Houston, TX, USA
Introduction: Field us of tourniquets (TQ) in military medicine is regarded as an effective adjunct for preventing hemorrhage-related deaths from extremity trauma. Their use in the civilian setting, however, has not been widely adopted. The most recent publication of Guidelines for Field Triage of Injured Patients (2011), gives no recommendation for pre-hospital TQ use, stating there is limited evidence to support their use and potential for increased injury. The purpose of this study was to assess whether pre-hospital TQ in the civilian setting can be (1) effective in hemorrhage control and (2) safely applied.
Methods: Following IRB approval, patients arriving to a level-1 trauma center between 01/2009 and 05/2013 were reviewed. All patients with prehospital TQ application were included in the analysis. Cases were adjudicated and assigned the following designations: absolute indication (underwent operation within 2 hours for extremity injury, arterial or venous injury requiring repair/ligation, or traumatic amputation), relative indication (major musculoskeletal or soft-tissue injury requiring operation >2 hours after arrival, documented large blood loss at scene), non-indicated. Patients with absolute or relative indications were placed into the INDICATED group; others were placed into non-INDICATED cohort. An orthopedic, trauma or hand surgeon then adjudicated iatrogenic injuries resulting from TQ application. Univariate analysis was performed to compare groups. Logistic regression was then conducted to assess independent predictors of requiring additional or replacement of pre-hospital TQ to control hemorrhage.
Results: 110 patients had pre-hospital TQ placement. 94 patients (85%) were in the INDICATED group and 16 (15%) in the non-INDICATED. With the exception of higher blunt mechanism (70 vs. 43%; p=0.048), there were no differences in demographics, transport, or scene vitals between groups. INDICATED patients were more likely to have lower extremity TQ (46 vs. 6%; p=0.007) but were less likely to pre-hospital bleeding controlled (71 vs. 100%; p=0.012). 28% of INDICATED patients had their TQ removed in the ED (vs. 100%; p<0.001). Only 16% of INDICATED patients had an additional or new TQ applied in the ED (vs. 7%; p=0.420). Venous thromboembolic events (4.3 vs. 0.0%; p=0.401) and peripheral nerve injuries (5.3 vs. 0.0%; p=0.345) were similar. The amputation rate was 31% for INDICATED patients (vs. 0%; p=0.009). There were no nerve palsies or tissue/muscle injuries leading to amputation/debridement attributable to TQ use in either group. After controlling for scene vital signs and mechanism of injury, the likelihood of requiring an additional or new TQ after arrival to the ED was independently associated with ground transport (odds ratio 6.3, 95% C.I. 1.47-29.08; p=0.014).
Conclusion: Our study suggests that pre-hospital personnel can safely and effectively use TQ in patients with severe extremity injuries.