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Standifird CH, Kaisler S, Triplett H, Lauria MJ, Fisher AD, Harrell AJ, White CC. Implementing Tourniquet Conversion Guidelines for Civilian EMS and Prehospital Organizations : A Case Report and Review. Wilderness Environ Med 2024; 35:223-233. [PMID: 38509815 DOI: 10.1177/10806032241234667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/22/2024]
Abstract
Since the first documented use of a tourniquet in 1674, the popularity of tourniquets has waxed and waned. During recent wars and more recently in Emergency Medical Services systems, the tourniquet has been proven to be a valuable tool in the treatment of life-threatening hemorrhage. However, tourniquet use is not without risk, and several studies have demonstrated adverse events and morbidity associated with tourniquet use in the prehospital setting, particularly when left in place for more than 2 h. Consequently, the US military's Committee on Tactical Combat Casualty Care has recommended guidelines for prehospital tourniquet conversion to reduce the risk of adverse events associated with tourniquets once the initial hemorrhage has been controlled. Emergency Medical Services systems that operate in rural, frontier, and austere environments, especially those with transport times to definitive care that routinely exceed 2 h, may consider implementing similar tourniquet conversion guidelines.
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Affiliation(s)
| | - Sean Kaisler
- University of New Mexico School of Medicine, Albuquerque, NM, USA
| | - Hunter Triplett
- Kirk Kerkorian School of Medicine, University of Nevada, Las Vegas, NV
| | - Michael J Lauria
- Department of Emergency Medicine, University of New Mexico School of Medicine, Albuquerque, NM, USA
- Lifeguard Air Emergency Services, Albuquerque, NM, USA
| | - Andrew D Fisher
- Department of Surgery, University of New Mexico School of Medicine, Albuquerque, NM, USA
| | - Andrew J Harrell
- Division of Prehospital, Austere, and Disaster Medicine, Department of Emergency Medicine, University of New Mexico School of Medicine, Albuquerque, NM, USA
- Dr George Kennedy Center for Law Enforcement Operational Medicine, Albuquerque, NM, USA
- Grand Canyon National Park, Arizona, and New Mexico State Police and State Search and Rescue, Sante Fe, NM, USA
| | - Chelsea C White
- Division of Prehospital, Austere, and Disaster Medicine, University of New Mexico School of Medicine, Albuquerque, NM, USA
- UNM Center for Rural and Tribal Medicine, Department of Emergency Medicine, University of New Mexico School of Medicine, Albuquerque, NM, USA
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Wend CM, Fransman RB, Haut ER. Prehospital Trauma Care. Surg Clin North Am 2024; 104:267-277. [PMID: 38453301 DOI: 10.1016/j.suc.2023.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Abstract
Prehospital trauma evaluation begins with the primary assessment of airway, breathing, circulation, disability, and exposure. This is closely followed by vital signs and a secondary assessment. Key prehospital interventions include management and resuscitation according to the aforementioned principles with a focus on major hemorrhage control, airway compromise, and invasive management of tension pneumothorax. Determining the appropriate time and method for transportation (eg, ground ambulance, helicopter, police, private vehicle) to the hospital or when to terminate resuscitation are also important decisions to be made by emergency medical services clinicians.
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Affiliation(s)
- Christopher M Wend
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, 1830 East Monument Street Suite 6-100, Baltimore, MD 21287, USA
| | - Ryan B Fransman
- Department of Trauma, Acute Care Surgery, and Surgical Critical Care, Emory University School of Medicine, Grady Memorial Hospital, 80 Jesse Hill Jr. Drive, SE, Atlanta, GA 30303, USA
| | - Elliott R Haut
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, 1830 East Monument Street Suite 6-100, Baltimore, MD 21287, USA; Department of Surgery, Division of Acute Care Surgery, Johns Hopkins University School of Medicine, Sheikh Zayed 6107C, 1800 Orleans Street, Baltimore, MD 21287, USA; Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Health Policy and Management, The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
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Parvin-Nejad FP, Vegunta G, Mele G, Sifri ZC. Stop the Bleed in the Era of Virtual Learning: A Novel Strategy for Remote Teaching and Evaluation. J Surg Res 2024; 296:759-765. [PMID: 38377702 DOI: 10.1016/j.jss.2024.01.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Revised: 11/16/2023] [Accepted: 01/06/2024] [Indexed: 02/22/2024]
Abstract
INTRODUCTION Traumatic hemorrhage is a leading cause of preventable mortality worldwide. The Stop the Bleed (STB) course was developed to equip layperson bystanders with basic bleeding control knowledge and skills. However, large in-person courses have been disrupted due to COVID-19. The aim of this study was to determine the feasibility of teaching and evaluating STB skills through remote video-based instruction. METHODS After undergoing COVID-19 screening, groups of up to eight STB-naive adults were seated in a socially distanced manner and given individual practice kits. A remote STB-certified instructor provided the standard STB lecture and led a 10-min skills practice session via videoconferencing. Participants' skills were evaluated on a 10-point rubric by one in-person evaluator and three remote evaluators. Participants completed a postcourse survey assessing their perceptions of the course. RESULTS Thirty-five participants completed the course, all scoring ≥8/10 after examination by the in-person evaluator. Remote instructors' average scores (9.8 ± 0.45) did not significantly differ from scores of the in-person evaluator (9.9 ± 0.37) (P = 0.252). Thirty-three participants (94%) completed the postcourse survey. All respondents reported being willing and prepared to intervene in scenarios of life-threatening hemorrhage, and 97% reported confidence in using all STB skills. CONCLUSIONS STB skills can be effectively taught and evaluated through a live video-based course. All participants scored highly when evaluated both in-person and remotely, and nearly all reported confidence in skills and knowledge following the course. Remote instruction is a valuable strategy to disseminate STB training to students without access to in-person courses, especially during pandemic restrictions.
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Affiliation(s)
| | | | - Giovanna Mele
- Rutgers New Jersey Medical School, Newark, New Jersey
| | - Ziad C Sifri
- Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
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Ko YC, Tsai TY, Wu CK, Lin KW, Hsieh MJ, Lu TP, Matsuyama T, Chiang WC, Ma MHM. Effectiveness and safety of tourniquet utilization for civilian vascular extremity trauma in the pre-hospital settings: a systematic review and meta-analysis. World J Emerg Surg 2024; 19:10. [PMID: 38504263 PMCID: PMC10949629 DOI: 10.1186/s13017-024-00536-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Accepted: 02/26/2024] [Indexed: 03/21/2024] Open
Abstract
BACKGROUND Tourniquets (TQ) have been increasingly adopted in pre-hospital settings recently. This study examined the effectiveness and safety of applying TQ in the pre-hospital settings for civilian patients with traumatic vascular injuries to the extremities. MATERIALS AND METHODS We systematically searched the Ovid Embase, PubMed, and Cochrane Central Register of Controlled Trials databases from their inception to June 2023. We compared pre-hospital TQ (PH-TQ) use to no PH-TQ, defined as a TQ applied after hospital arrival or no TQ use at all, for civilian vascular extremity trauma patients. The primary outcome was overall mortality rate, and the secondary outcomes were blood product use and hospital stay. We analyzed TQ-related complications as safety outcomes. We tried to include randomized controlled trials (RCTs) and non-randomized studies (including non-RCTs, interrupted time series, controlled before-and-after studies, cohort studies, and case-control studies), if available. Pooled odds ratios (ORs) were calculated and the certainty of evidence was assessed using Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. RESULTS Seven studies involving 4,095 patients were included. In the primary outcome, pre-hospital TQ (PH-TQ) use significantly decrease mortality rate in patients with extremity trauma (odds ratio [OR], 0.48, 95% confidence interval [CI] 0.27-0.86, I2 = 47%). Moreover, the use of PH-TQ showed the decreasing trend of utilization of blood products, such as packed red blood cells (mean difference [MD]: -2.1 [unit], 95% CI: -5.0 to 0.8, I2 = 99%) or fresh frozen plasma (MD: -1.0 [unit], 95% CI: -4.0 to 2.0, I2 = 98%); however, both are not statistically significant. No significant differences were observed in the lengths of hospital and intensive care unit stays. For the safety outcomes, PH-TQ use did not significantly increase risk of amputation (OR: 0.85, 95% CI: 0.43 to 1.68, I2 = 60%) or compartment syndrome (OR: 0.94, 95% CI: 0.37 to 2.35, I2 = 0%). The certainty of the evidence was very low across all outcomes. CONCLUSION The current data suggest that, in the pre-hospital settings, PH-TQ use for civilian patients with vascular traumatic injury of the extremities decreased mortality and tended to decrease blood transfusions. This did not increase the risk of amputation or compartment syndrome significantly.
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Affiliation(s)
- Ying-Chih Ko
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
- Section of Emergency Medicine, Department of Medicine, National Taiwan University Cancer Center, Taipei, Taiwan
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Tou-Yuan Tsai
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
- Emergency Department, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan
- School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Chien-Kai Wu
- Section of Emergency Medicine, Department of Medicine, National Taiwan University Cancer Center, Taipei, Taiwan
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Kai-Wei Lin
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Ming-Ju Hsieh
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan.
| | - Tzu-Pin Lu
- Institute of Health Data Analytics and Statistics, College of Public Health, National Taiwan University, Taipei, Taiwan.
| | - Tasuku Matsuyama
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kamigyo-ku, Kyoto, Japan
| | - Wen-Chu Chiang
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Department of Emergency Medicine, National Taiwan University Hospital Yun-Lin Branch, Yunlin, Taiwan
| | - Matthew Huei-Ming Ma
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Department of Emergency Medicine, National Taiwan University Hospital Yun-Lin Branch, Yunlin, Taiwan
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Kulkarni AJ, Batra A, Eisner ZJ, Delaney PG, Pine H, Klapow MC, Raghavendran K. Prehospital hemorrhage management in low- and middle-income countries: A scoping review. World J Surg 2024; 48:547-559. [PMID: 38265259 DOI: 10.1002/wjs.12054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 11/14/2023] [Indexed: 01/25/2024]
Abstract
INTRODUCTION Low- and middle-income countries (LMICs) account for 90% of deaths due to injury, largely due to hemorrhage. The increased hemorrhage mortality burden in LMICs is exacerbated by absent or ineffective prehospital care. Hemorrhage management (HM) is an essential component of prehospital care in LMICs, yet current practices for prehospital HM and outcomes from first responder HM training have yet to be summarized. METHODS This review describes the current literature on prehospital HM and the impact of first responder HM training in LMICs. Articles published between January 2000 and January 2023 were identified using PMC, MEDLINE, and Scopus databases following PRISMA-ScR guidelines. Inclusion criteria spanned first responder training programs delivering prehospital care for HM. Relevant articles were assessed for quality using the Newcastle-Ottawa scale. RESULTS Of the initial 994 articles, 20 met inclusion criteria representing 16 countries. Studies included randomized control trials, cohort studies, case control studies, reviews, and epidemiological studies. Basic HM curricula were found in 15 studies and advanced HM curricula were found in six studies. Traumatic hemorrhage was indicated in 17 studies while obstetric hemorrhage was indicated in three studies. First responders indicated HM use in 55%-76% of encounters, the most frequent skill they reported using. Mean improvements in HM knowledge acquisition post-course ranged from 23 to 58 percentage points following training for pressure and elevation, gauze application, and tourniquet application. CONCLUSIONS Our study summarizes the current literature on prehospital HM in LMICs pertaining to epidemiology, interventions, and outcomes. HM resources should be a priority for further development.
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Affiliation(s)
- Ashwin J Kulkarni
- University of Michigan Medical School, Ann Arbor, Michigan, USA
- LFR International, Los Angeles, California, USA
- Michigan Center for Global Surgery, Ann Arbor, Michigan, USA
| | - Amber Batra
- LFR International, Los Angeles, California, USA
- Washington University in St. Louis, St. Louis, Missouri, USA
| | - Zachary J Eisner
- University of Michigan Medical School, Ann Arbor, Michigan, USA
- LFR International, Los Angeles, California, USA
- Michigan Center for Global Surgery, Ann Arbor, Michigan, USA
| | - Peter G Delaney
- LFR International, Los Angeles, California, USA
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Haleigh Pine
- LFR International, Los Angeles, California, USA
- Washington University in St. Louis, St. Louis, Missouri, USA
| | - Maxwell C Klapow
- LFR International, Los Angeles, California, USA
- Department of Social Policy and Intervention, University of Oxford, Oxford, UK
| | - Krishnan Raghavendran
- LFR International, Los Angeles, California, USA
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
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Pratt GA, Kishman AJ, Glaser JJ, Castro C, Lorenzen AL, Cardin S, Tiller MM, McNeal ND, Neidert LE, Morgan CG. Evaluation of hemostatic devices in a randomized porcine model of junctional hemorrhage and 72-hour prolonged field care. J Trauma Acute Care Surg 2024; 96:256-264. [PMID: 37858305 DOI: 10.1097/ta.0000000000004164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2023]
Abstract
BACKGROUND Hemorrhage control in prolonged field care (PFC) presents unique challenges that drive the need for enhanced point of injury treatment capabilities to maintain patient stability beyond the Golden Hour. To address this, two hemostatic agents, Combat Gauze (CG) and XSTAT, were evaluated in a porcine model of uncontrolled junctional hemorrhage for speed of deployment and hemostatic efficacy over 72 hours. METHODS The left subclavian artery and subscapular vein were isolated in anesthetized male Yorkshire swine (70-85 kg) and injured via 50% transection, followed by 30 seconds of hemorrhage. Combat Gauze (n = 6) or XSTAT (n = 6) was administered until bleeding stopped and remained within subjects for observation over 72 hours. Physiologic monitoring, hemostatic efficacy, and hematological parameters were measured throughout the protocol. Gross necropsy and histology were performed following humane euthanasia. RESULTS Both CG and XSTAT maintained hemostasis throughout the full duration of the protocol. There were no significant differences between groups in hemorrhage volume (CG: 1021.0 ± 183.7 mL vs. XSTAT: 968.2 ± 243.3 mL), total blood loss (CG: 20.8 ± 2.7% vs. XSTAT: 20.1 ± 5.1%), or devices used (CG: 3.8 ± 1.2 vs. XSTAT: 5.3 ± 1.4). XSTAT absorbed significantly more blood than CG (CG: 199.5 ± 50.3 mL vs. XSTAT: 327.6 ± 71.4 mL) and was significantly faster to administer (CG: 3.4 ± 1.6 minutes vs. XSTAT: 1.4 ± 0.5 minutes). There were no significant changes in activated clot time, prothrombin time, or international normalized ratio between groups or compared with baseline throughout the 72-hour protocol. Histopathology revealed no evidence of microthromboemboli or disseminated coagulopathies across evaluated tissues in either group. CONCLUSION Combat Gauze and XSTAT demonstrated equivalent hemostatic ability through 72 hours, with no overt evidence of coagulopathies from prolonged indwelling. In addition, XSTAT offered significantly faster administration and the ability to absorb more blood. Taken together, XSTAT offers logistical and efficiency advantages over CG for immediate control of junctional noncompressible hemorrhage, particularly in a tactical environment. In addition, extension of indicated timelines to 72 hours allows translation to PFC.
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Affiliation(s)
- Gilbert A Pratt
- From the Naval Medical Research Unit San Antonio (G.A.P., A.J.K., J.J.G., C.C., A.L.L., S.C., M.M.T., N.D.M.N., L.E.N., C.G.M.), JBSA-Fort Sam Houston, TX; Naval Medical Research Command (M.M.T.), Silver Spring, MD; and Naval Submarine Medical Research Laboratory (N.D.M.N.), Groton, CT
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Brown JB, Schreiber M, Moore EE, Jenkins DH, Bank EA, Gurney JM. Commentary on gaps in prehospital trauma care: education and bioengineering innovations to improve outcomes in hemorrhage and traumatic brain injury. Trauma Surg Acute Care Open 2024; 9:e001122. [PMID: 38196935 PMCID: PMC10773423 DOI: 10.1136/tsaco-2023-001122] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 08/23/2023] [Indexed: 01/11/2024] Open
Abstract
Hemorrhage remains the leading cause of preventable death on the battlefield and the civilian arena. Many of these deaths occur in the prehospital setting. Traumatic brain injury also represents a major source of early mortality and morbidity in military and civilian settings. The inaugural HERETIC (HEmostatic REsuscitation and Trauma Induced Coagulopathy) Symposium convened a multidisciplinary panel of experts in prehospital trauma care to discuss what education and bioengineering advancements in the prehospital space are necessary to improve outcomes in hemorrhagic shock and traumatic brain injury. The panel identified several promising technological breakthroughs, including field point-of-care diagnostics for hemorrhage and brain injury and unique hemorrhage control options for non-compressible torso hemorrhage. Many of these technologies exist but require further advancement to be feasibly and reliably deployed in a prehospital or combat environment. The panel discussed shifting educational and training paradigms to clinical immersion experiences, particularly for prehospital clinicians. The panel discussed an important balance between pushing traditionally hospital-based interventions into the field and developing novel intervention options specifically for the prehospital environment. Advancing prehospital diagnostics may be important not only to allow more targeted applications of therapeutic options, but also to identify patients with less urgent injuries that may not need more advanced diagnostics, interventions, or transfer to a higher level of care in resource-constrained environments. Academia and industry should partner and prioritize some of the promising advances identified with a goal to prepare them for clinical field deployment to optimize the care of patients near the point of injury.
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Affiliation(s)
- Joshua B Brown
- Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Martin Schreiber
- Surgery, Oregon Health and Science University, Portland, Oregon, USA
| | - Ernest E Moore
- Surgery, Ernest E Moore Shock Trauma Center at Denver Health, University of Colorado Denver, Denver, Colorado, USA
| | - Donald H Jenkins
- Surgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Eric A Bank
- Harris County Emergency Services District No 48, Katy, Texas, USA
| | - Jennifer M Gurney
- Defense Committees on Trauma, Joint Trauma System, JBSA Fort Sam Houston, San Antonio, Texas, USA
- Department of Surgery, San Antonio Military Health System, San Antonio, Texas, USA
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Silver DS, Sperry JL, Beiriger J, Lu L, Guyette FX, Wisniewski S, Moore EE, Schreiber M, Joseph B, Wilson CT, Cotton B, Ostermayer D, Fox EE, Harbrecht BG, Patel M, Brown JB. Association Between Emergency Medical Service Agency Volume and Mortality in Trauma Patients. Ann Surg 2024; 279:160-166. [PMID: 37638408 PMCID: PMC10840871 DOI: 10.1097/sla.0000000000006087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/29/2023]
Abstract
OBJECTIVE The aim of this study was to evaluate the association of annual trauma patient volume on outcomes for emergency medical services (EMS) agencies. BACKGROUND Regionalization of trauma care saves lives. The underlying concept driving this is a volume-outcome relationship. EMS are the entry point to the trauma system, yet it is unknown if a volume-outcome relationship exists for EMS. METHODS A retrospective analysis of prospective cohort including 8 trauma centers and 20 EMS air medical and metropolitan ground transport agencies. Patients 18 to 90 years old with injury severity scores ≥9 transported from the scene were included. Patient and agency-level risk-adjusted regression determined the association between EMS agency trauma patient volume and early mortality. RESULTS A total of 33,511 were included with a median EMS agency volume of 374 patients annually (interquartile range: 90-580). Each 50-patient increase in EMS agency volume was associated with 5% decreased odds of 6-hour mortality (adjusted odds ratio=0.95; 95% CI: 0.92-0.99, P =0.03) and 3% decreased odds of 24-hour mortality (adjusted odds ratio=0.97; 95% CI: 0.95-0.99, P =0.04). Prespecified subgroup analysis showed EMS agency volume was associated with reduced odds of mortality for patients with prehospital shock, requiring prehospital airway placement, undergoing air medical transport, and those with traumatic brain injury. Agency-level analysis demonstrated that high-volume (>374 patients/year) EMS agencies had a significantly lower risk-standardized 6-hour mortality rate than low-volume (<374 patients/year) EMS agencies (1.9% vs 4.8%, P <0.01). CONCLUSIONS A higher volume of trauma patients transported at the EMS agency level is associated with improved early mortality. Further investigation of this volume-outcome relationship is necessary to leverage quality improvement, benchmarking, and educational initiatives.
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Affiliation(s)
- David S Silver
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Jason L Sperry
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Jamison Beiriger
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Liling Lu
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Francis X Guyette
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Stephen Wisniewski
- Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - Ernest E Moore
- Department of Surgery, Ernest E. Moore Shock Trauma Center at Denver Health, Denver, CO
| | - Martin Schreiber
- Division of Trauma, Critical Care, & Acute Care Surgery, Oregon Health & Science University, Portland, OR
| | - Bellal Joseph
- Department of Surgery, Division of Trauma, Surgical Critical Care, Burns, and Acute Care Surgery, University of Arizona, Tucson, AZ
| | - Chad T Wilson
- Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Bryan Cotton
- Department of Surgery, Division of Acute Care Surgery and Center for Translational Injury Research, McGovern Medical School at the University of Texas Health Science Center, Houston, TX
| | - Daniel Ostermayer
- Department of Emergency Medicine, University of Texas Health Science Center, McGovern Medical School, Houston, TX
| | - Erin E Fox
- Department of Surgery, Division of Acute Care Surgery and Center for Translational Injury Research, McGovern Medical School at the University of Texas Health Science Center, Houston, TX
| | | | - Mayur Patel
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Joshua B Brown
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
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Mace EH, Maiga AW, Beyene RT, Smith MC, Streams JR, Peetz AB, Dennis BM, Guillamondegui OD, Gondek SP. Vascular imaging immediately after tourniquet removal does not increase vasospasm risk. Injury 2024; 55:110974. [PMID: 37563047 DOI: 10.1016/j.injury.2023.110974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 07/22/2023] [Accepted: 08/01/2023] [Indexed: 08/12/2023]
Abstract
BACKGROUND Prehospital tourniquet use is now standard in trauma patients with diagnosed or suspected extremity vascular injuries. Tourniquet-related vasospasm is an understudied phenomenon that may confound management by causing erroneous arterial pressure indices (APIs) and abnormalities on computed tomography angiography (CTA) that do not reflect true arterial injuries. We hypothesized that shorter intervals between tourniquet removal and CTA imaging and longer total tourniquet times would be correlated with a higher likelihood of false positive CTA. MATERIALS AND METHODS We performed a single-institution retrospective cohort study of patients presenting to a busy, urban Level 1 Trauma Center with prehospital tourniquets from 2019 to 2021. Patients who presented with a tourniquet disengaged upon arrival or who died prior to admission to the Trauma Unit were excluded. Tourniquet duration, time between tourniquet removal and CTA imaging (CTA interval), CTA findings, and management of extremity arterial injuries were extracted. The proportion of false positive injuries on CTA was assessed for correlation with increasing time interval from tourniquet removal to CTA imaging and correlation with increasing total tourniquet time using multivariable logistic regression. RESULTS 251 patients were identified with prehospital tourniquets. 127 underwent CTA of the affected extremity, 96 patients had an abnormal CTA finding, and 57 (45% of total CTA patients) had false positive arterial injuries on imaging. Using multivariable logistic regression, neither the CTA interval nor the tourniquet duration was associated with false positive CTA injuries. Female sex was associated with false positive injuries on CTA (OR 2.91, 95% CI: 1.01 - 8.39). Vasospasm was cited as a possible explanation by radiologists in 40% of false positive CTA reports. CONCLUSIONS Arterial vasospasm is a frequent finding on CTA after tourniquet use for extremity trauma, but concerns regarding tourniquet-related vasospasm should not alter trauma patient management. Neither the duration of tourniquet application nor the time interval since removal is associated with decreased CTA accuracy, and any delay in imaging does not appear to reduce the likelihood of vasospasm. These findings are important for supporting expedited care of trauma patients with severe extremity injuries.
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Affiliation(s)
- Eric H Mace
- Vanderbilt University Medical Center, Department of General Surgery, Nashville, Tennessee, Medical Center North, D-5203, Suite CCC-4312, 1161 21st Avenue South, Nashville, TN 37232-2730, USA
| | - Amelia W Maiga
- Vanderbilt University Medical Center, Division of Acute Care Surgery, Nashville, Tennessee, Medical Arts Building, Suite 404, 1211 21st Avenue South, Nashville Tennessee 37212-1750, USA.
| | - Robel T Beyene
- Vanderbilt University Medical Center, Division of Acute Care Surgery, Nashville, Tennessee, Medical Arts Building, Suite 404, 1211 21st Avenue South, Nashville Tennessee 37212-1750, USA
| | - Michael C Smith
- Vanderbilt University Medical Center, Division of Acute Care Surgery, Nashville, Tennessee, Medical Arts Building, Suite 404, 1211 21st Avenue South, Nashville Tennessee 37212-1750, USA
| | - Jill R Streams
- Vanderbilt University Medical Center, Division of Acute Care Surgery, Nashville, Tennessee, Medical Arts Building, Suite 404, 1211 21st Avenue South, Nashville Tennessee 37212-1750, USA
| | - Allan B Peetz
- Vanderbilt University Medical Center, Division of Acute Care Surgery, Nashville, Tennessee, Medical Arts Building, Suite 404, 1211 21st Avenue South, Nashville Tennessee 37212-1750, USA
| | - Bradley M Dennis
- Vanderbilt University Medical Center, Division of Acute Care Surgery, Nashville, Tennessee, Medical Arts Building, Suite 404, 1211 21st Avenue South, Nashville Tennessee 37212-1750, USA
| | - Oscar D Guillamondegui
- Vanderbilt University Medical Center, Division of Acute Care Surgery, Nashville, Tennessee, Medical Arts Building, Suite 404, 1211 21st Avenue South, Nashville Tennessee 37212-1750, USA
| | - Stephen P Gondek
- Vanderbilt University Medical Center, Division of Acute Care Surgery, Nashville, Tennessee, Medical Arts Building, Suite 404, 1211 21st Avenue South, Nashville Tennessee 37212-1750, USA
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Thai AP, Tseng ES, Kishawi SK, Robenstine JC, Ho VP. Prehospital tourniquet application in extremity vascular trauma: Improved functional outcomes. Surgery 2023; 174:1471-1475. [PMID: 37735036 DOI: 10.1016/j.surg.2023.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 07/21/2023] [Accepted: 08/08/2023] [Indexed: 09/23/2023]
Abstract
BACKGROUND Support for prehospital tourniquet use has increased, with recent data suggesting that tourniquet usage decreases shock without increasing limb complications. We hypothesized that prehospital tourniquet application in extremity vascular trauma, compared with no prehospital tourniquet application, is associated with lower rates of delayed amputation and better functional mobility. METHODS We retrospectively studied adult patients with extremity vascular trauma at an urban civilian Level 1 trauma center (June 2016-May 2021). Outcomes of interest included delayed amputation and mobility at hospital discharge, measured by the Activity Measure for Post-Acute Care "6 Clicks" Basic Mobility Score. The "6 Clicks" Basic Mobility Score was documented by physical therapy; higher scores indicate more independent mobility. Injury mechanism, initial lactate, 24-hour transfusions, mortality, and acute kidney injury were also collected. Comparisons were performed using χ2 analysis and Fisher Exact and Wilcoxon rank-sum tests. RESULTS Of 232 patients, prehospital tourniquet application was not associated with mortality or lactate level (both P > .05). The prehospital tourniquet application group had more transfusions, lower rates of acute kidney injury, and fewer delayed amputations (all P < .05). Ninety-one patients (45 prehospital tourniquet application and 46 without prehospital tourniquet application) were evaluated for "Moving between Bed and Chair" in the "6 Clicks" Basic Mobility Score, with patients in the prehospital tourniquet application group demonstrating higher levels of independence (P = .034). CONCLUSION Prehospital tourniquet application was associated with favorable outcomes, including higher functional mobility and decreased delayed amputation. This suggests that tourniquet use should be encouraged in the civilian setting to improve outcomes and reduce the risk of limb loss.
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Affiliation(s)
- Anthony P Thai
- Case Western Reserve University, School of Medicine, Cleveland, OH
| | - Esther S Tseng
- Case Western Reserve University, School of Medicine, Cleveland, OH; Division of Trauma Surgery, Acute Care Surgery, Critical Care, and Burns, Department of Surgery, MetroHealth Medical Center, Cleveland, OH
| | - Sami K Kishawi
- Case Western Reserve University, School of Medicine, Cleveland, OH; Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Jacinta C Robenstine
- Case Western Reserve University, School of Medicine, Cleveland, OH; Division of Trauma Surgery, Acute Care Surgery, Critical Care, and Burns, Department of Surgery, MetroHealth Medical Center, Cleveland, OH
| | - Vanessa P Ho
- Case Western Reserve University, School of Medicine, Cleveland, OH; Division of Trauma Surgery, Acute Care Surgery, Critical Care, and Burns, Department of Surgery, MetroHealth Medical Center, Cleveland, OH; Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, OH.
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11
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Holcomb JB, Dorlac WC, Drew BG, Butler FK, Gurney JM, Montgomery HR, Shackelford SA, Bank EA, Kerby JD, Kragh JF, Person MA, Patterson JL, Levchuk O, Andriievskyi M, Bitiukov G, Danyljuk O, Linchevskyy O. Rethinking limb tourniquet conversion in the prehospital environment. J Trauma Acute Care Surg 2023; 95:e54-e60. [PMID: 37678162 PMCID: PMC10662576 DOI: 10.1097/ta.0000000000004134] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 08/20/2023] [Accepted: 08/23/2023] [Indexed: 09/09/2023]
Abstract
We have highlighted the issue of overuse of tourniquets and described why tourniquet conversion and replacement should be taught and done in the prehospital setting.
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12
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Yánez Benñitez C, Lorente-Aznar T, Labaka I, Soteras I, Baselga M, Morishita K, Ribeiro M, Güemes A. Extremity Tourniquet Self-Application by Antarctica Zodiac Crew Members. Disaster Med Public Health Prep 2023; 17:e561. [PMID: 37937358 DOI: 10.1017/dmp.2023.179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2023]
Abstract
Search and rescue teams and Antarctic research groups use protective cold-water anti-exposure suits (AES) when cruising on Zodiacs. Extremity tourniquet (ET) self-application (SA) donned with AESs has not been previously studied. Our study therefore assessed the SA of 5 commercial ETs (CAT, OMNA, RATS, RMT, and SWAT-T) among 15 volunteers who donned these suits. Tourniquet's SA ability, ease of SA, tolerance, and tourniquet preference were measured. All ETs tested were self-applied to the upper extremity except for the SWAT, which was self-applied with the rest to the lower extremity. Ease- of- SA mean values were compared using the Friedman and Durbin-Conover post hoc tests (P < 0.001). Regarding the upper extremity, OMNA achieved the highest score of 8.5 out of 10, while RMT, and SWAT received lower scores than other options (P < 0.001). For lower extremities, SWAT was found to be inferior to other options (P < 0.01). Overall, OMNA was the best performer. The RATS showed significantly lower tolerance than the other groups in repeated- measures ANOVA with a Tukey post hoc test (P < 0.01). Additionally, out of the 5 ETs tested, 60% of subjects preferred OMNA. The study concluded that SA commercial ETs are feasible over cold-water anti-exposure suits in the Antarctic climate.
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Affiliation(s)
- Carlos Yánez Benñitez
- Department of General, GI, and Acute Care Surgery, San Jorge University Hospital, Huesca, Spain
| | - Teófilo Lorente-Aznar
- Department of Primary Care Medicine, Antarctic Expedition, Jaca Health Center, Paseo de la Constitución, Huesca, Spain
| | - Idurre Labaka
- Emergency Medicine, Donostia University Hospital, Donostia, Spain
| | - Iñigo Soteras
- Emergency Medical System (SEM), Department of Medical Science, University of Girona, Girona, Spain
| | - Marta Baselga
- Surgical, Clinical and Experimental Research Group, Institute for Health Research Aragón, University of Zaragoza, San Juan Bosco, Zaragoza, Spain
| | - Koji Morishita
- Department of Acute Critical Care and Disaster Medicine, Tokyo Medical and Dental University Hospital of Medicine, Tokyo, Japan
| | - Marcelo Ribeiro
- Department of Trauma, Burns, Critical Care and Acute Care Surgery, Sheikh Shakhbout Medical City, Abu Dhabi, U.A.E
| | - Antonio Güemes
- Department of General Surgery, Lozano Blesa University Hospital, Zaragoza, Spain
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13
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Salchner H, Isser M, Banyai L, Schachner T, Wiedermann FJ, Lederer W. Arterial Occlusion Effectiveness of Space Blanket‒Improvised Tourniquets for the Remote Setting. Wilderness Environ Med 2023; 34:269-276. [PMID: 37100664 DOI: 10.1016/j.wem.2023.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 01/09/2023] [Accepted: 02/08/2023] [Indexed: 04/28/2023]
Abstract
INTRODUCTION Control of severe extremity hemorrhage by tourniquet can save lives. In remote areas or in mass casualty incidents with multiple severely bleeding victims, lack of conventional tourniquets may make it necessary to improvise tourniquets. METHODS Occlusion of the radial artery and delayed onset of capillary refill time resulting from windlass-type tourniquets were experimentally investigated by comparing a commercial tourniquet and a space blanket‒improvised tourniquet with a carabiner as a rod. This observational study was conducted on healthy volunteers in optimal application circumstances. RESULTS Operator-applied Combat Application Tourniquets were deployed more swiftly (27 s, 95% CI: 25.7-30.2 vs 94 s, 95% CI: 81.7-114.4) and achieved 100% complete radial occlusion compared with improvised tourniquets, as assessed by Doppler sonography (P<0.001). When space blanket‒improvised tourniquets were used, traces of radial perfusion persisted in 48% of the applications. In Combat Application Tourniquets, capillary refill times were significantly delayed (7 s, 95% CI: 6.0-8.2 vs 5 s, 95% CI: 3.9-6.3) compared with those when using improvised tourniquets (P=0.013). CONCLUSIONS Improvised tourniquets should be considered only in dire circumstances with uncontrolled extremity hemorrhage and when no commercial tourniquets are available. Complete arterial occlusion was achieved in only half of the applications using a space blanket‒improvised tourniquet when a carabiner was used as a windlass rod. The speed of application was inferior to that for Combat Application Tourniquets. Similar to Combat Action Tourniquets, the correct assembly and application of space blanket‒improvised tourniquets on upper and lower extremities have to be trained. TRIAL REGISTRATION ClinicalTrials.gov identifier: BASG No.: 13370800/15451670.
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Affiliation(s)
- Hannah Salchner
- Department of Anesthesiology and Critical Care Medicine, Medical University of Innsbruck, Innsbruck, Austria; Medical Division, Austrian Mountain Rescue Service-Tyrol, Telfs, Austria
| | - Markus Isser
- Medical Division, Austrian Mountain Rescue Service-Tyrol, Telfs, Austria
| | - Lukas Banyai
- Department of Anesthesiology and Critical Care Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Thomas Schachner
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Franz J Wiedermann
- Department of Anesthesiology and Critical Care Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Wolfgang Lederer
- Department of Anesthesiology and Critical Care Medicine, Medical University of Innsbruck, Innsbruck, Austria.
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14
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Yánez Benítez C, Lorente-Aznar T, Labaka I, Ribeiro MAF, Viteri Y, Morishita K, Baselga M, Güemes A. Tourniquet self-application assessment in cold weather conditions. BMC Emerg Med 2023; 23:101. [PMID: 37653492 PMCID: PMC10472695 DOI: 10.1186/s12873-023-00871-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 08/17/2023] [Indexed: 09/02/2023] Open
Abstract
BACKGROUND Our study aimed to assess the ability of nonmedical civilians to self-apply extremity tourniquets in cold weather conditions while wearing insulating technical clothing after receiving basic training. METHODS A field study was conducted among 37 voluntary participants of an expedition party to the Spanish Antarctic base. The researchers assessed the participant's ability to self-apply five commercial extremity tourniquets (CAT, OMNA, RMT, SWAT-T, and RATS) over cold-weather clothing and their achieved effectiveness for vascular occlusion. Upper extremity self-application was performed with a single-handed technique (OHT), and lower extremity applying a two-handed technique (THT). Perceptions of self-application ease mean values ± standard deviation (SD) were compared by applying a 5% statistical significance threshold. Frequency count determined tourniquet preference. RESULTS All the tested ETs, except the SWAT-T, were properly self-applied with an OHT, resulting in effective vascular occlusion in the upper extremity. The five devices tested were self-applied correctly in the lower extremities using THT. The ratcheting marine-designed OMNA ranked the highest for application easiness on both the upper and lower extremities, and the windlass CAT model was the preferred device by most participants. CONCLUSIONS Civilian extremity tourniquet self-application on both upper and lower extremities can be accomplished in cold weather conditions despite using cold-weather gloves and technical clothing after receiving brief training. The ratcheting marine-designed OMNA ranked the highest for application ease, and the windlass CAT model was the preferred device.
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Affiliation(s)
- Carlos Yánez Benítez
- General and GI Surgery Department, San Jorge University Hospital, SALUD, Avenida Martínez de Velasco, 36, Huesca, 22004, Spain.
| | | | - Idurre Labaka
- Emergency Medicine, Donostia University Hospital, C/ Begiristain Doktorea Pasealekua, Donostia, Spain
| | - Marcelo A F Ribeiro
- Division of Trauma, Critical Care, and Acute Care Surgery, Sheikh Shakhbout Medical City, Khalifa University, Abu Dhabi, United Arab Emirates
| | - Yosu Viteri
- Emergency Department, Torrelodones University Hospital, Avenida Castillo Olivares, s/n, Madrid, 28250, Spain
| | - Koji Morishita
- Department of Acute Critical Care and Disaster Medicine, Tokyo Medical and Dental University Hospital of Medicine, Tokyo, Japan
| | - Marta Baselga
- Clinical and Experimental Research Group, Institute for Health Research of Aragón, C/ de San Juan Bosco, 13, Zaragoza, 50009, Spain
| | - Antonio Güemes
- Department of General Surgery, Lozano Blesa University Hospital, Avenida San Juan Bosco, 15, Zaragoza, 50009, Spain
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15
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Read DJ, Wong J, Liu R, Gumm K, Anderson D. Prehospital tourniquet use in civilian extremity trauma: an Australian observational study. ANZ J Surg 2023; 93:1896-1900. [PMID: 37150975 DOI: 10.1111/ans.18492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 03/21/2023] [Accepted: 04/17/2023] [Indexed: 05/09/2023]
Abstract
BACKGROUND Prehospital tourniquets (PHTQ) for trauma have been shown to be safe and effective in the military environment and in some civilian settings. However, the supporting civilian data are mostly from North America with a differing case mix and trauma system and may not be applicable to the Australian environment. The aim of this study is to describe our initial experience with PHTQ from safety and efficacy viewpoints. METHOD Retrospective review of all patients with PHTQ from 1 August 2016 to 31 December 2019 was conducted. Data were matched from the RMH Trauma Registry and Ambulance Victoria Registry. Clinical presentation including prehospital observations, PHTQ times, limb outcomes and complications are described. RESULTS Thirty-one cases met inclusion criteria, for whom median age was 37 (IQR: 23.9-66.3), median ISS 17 (13-34) and 80.6% were male. The majority (n = 19, 61.3%) were as a result of road traffic crash, and six (19.4%) from penetrating mechanisms, usually glass. Over a quarter (29.0%) suffered a traumatic amputation. The median prehospital SBP was 100 (IQR: 80-110), the median prehospital HR was 101 (IQR: 77.0-122.3) and was the median PHTQ time was 124 min (IQR: 47-243). Complications attributable to the tourniquet were seen in 4/30 cases (13.3%). CONCLUSION This Australian series differs from North American civilian PHTQ series with a lower penetrating trauma rate and longer PHTQ times. Despite this, complication rates are within the published literature's range. Concerns regarding limited transferability of overseas studies to the Australian context suggests that ongoing audit is required.
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Affiliation(s)
- David J Read
- The Trauma Service, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Department of Surgery, University of Melbourne, Melbourne, Victoria, Australia
| | - Jessica Wong
- The Trauma Service, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Raine Liu
- The Trauma Service, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Kellie Gumm
- The Trauma Service, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - David Anderson
- Ambulance Victoria, Melbourne, Victoria, Australia
- Department of Paramedicine, Monash University, Melbourne, Victoria, Australia
- Department of Intensive Care & Hyberbaric Medicine, The Alfred Hospital, Melbourne, Victoria, Australia
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16
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Dragset E, Blix S, Melau J, Wilson T, Lund-Kordahl I. Assessing Firefighters' Tourniquet Skill Attainment and Retention: A Controlled Simulation-Based Experiment. Disaster Med Public Health Prep 2023; 17:e409. [PMID: 37317556 DOI: 10.1017/dmp.2023.68] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
BACKGROUND The aim of this study was to train and assess firefighters' skill attainment in the use of tourniquets, and to assess their skill retention after 3 mo. The purpose is to show if firefighters can successfully apply a tourniquet after a short course based on the Norwegian national recommendation for civil prehospital tourniquet use. METHODS This is a prospective experimental study. The study population were firefighters, and the inclusion criterion was any on-duty firefighter. The first phase consisted of baseline precourse testing (T1), a 45-min course, followed by immediate retesting (T2). The second phase consisted of retesting of skill retention after 3 mo (T3). RESULTS A total of 109 participants at T1, 105 at T2, and 62 participants at T3. The firefighters achieved a higher proportion of successful tourniquet applications at T2 (91.4%; 96 of 105) as well as T3 (87.1%; 54 of 62) compared with 50.5% at T1 (55 of 109) (P = 0.009). Mean application time was 59.6 s (55.1-64.2) in T1, 34.9 s (33.3-36.6) in T2 and 37.7 s (33.9-41.4) in T3. CONCLUSION A sample of firefighters can successfully apply a tourniquet after a 45-min course based on the 2019 Norwegian recommendation for civil prehospital tourniquet use. Skill retention after 3 mo was satisfactory for both successful application and application time.
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Affiliation(s)
- Erik Dragset
- UiT - The Arctic University of Norway, Tromsø, Troms, Norway
- Vestfold Hospital Trust, Tønsberg, Vestfold, Norway
| | - Sigurd Blix
- UiT - The Arctic University of Norway, Tromsø, Troms, Norway
- Finnmark Hospital Trust, Kirkenes, Finnmark, Norway
- Norwegian Home Guard, Rapid Task Force Ida&Lyra, Lillehammer, Norway
| | - Jørgen Melau
- Joint Medical Services, Norwegian Armed Forces, Ullensaker, Akershus, Norway
| | - Thomas Wilson
- University Hospital of North Norway, Tromsø, Troms, Norway
| | - Inger Lund-Kordahl
- National Advisory Unit on Trauma, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
- Haukeland University Hospital, Bergen, Norway
- Inland University of Applied Sciences, Norway
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17
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Coleman K, Grabo D, Wilson A, Bardes J. Prehospital Tourniquet Use Should be a Trauma Team Activation Criterion. Am Surg 2023; 89:1561-1565. [PMID: 34974713 PMCID: PMC9511206 DOI: 10.1177/00031348211060422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE Prehospital tourniquet application is not a standard trauma team activation (TTA) criterion recommended by the ACS COT. Tourniquet use has seen a resurgence recently with associated risks and benefits of more liberal usage. Our institution added tourniquet application as TTA criterion in January 2019. This study aimed to evaluate the effect this would have on patient care and overtriage. METHODS A prospective analysis was conducted for all TTA associated with tourniquets placed during 2019. An overtriage analysis was conducted utilizing a modified Cribari method as described in Resources for the Optimal Care of the Injured Patient, comparing patients that met standard TTA criteria (TTA-S), to those who met criteria due to tourniquet placement (TTA-T). RESULTS During the study, there were 46 TTA with tourniquets. Mean prehospital tourniquet time was 80 minutes. Median ISS was 10, 8 (17%) had an ISS >15. Urgent operative intervention was needed in 74%, with 23% and 21% requiring orthopedic and vascular procedures, respectively. Tourniquets were correctly placed in 80% and clinically appropriate in 57%. Of these subjects, 25 (54%) were TTA-S and 21 TTA-T. Overtriage analysis was performed. Overtriage for TTA-T was 33.3%. Overtriage among TTA-S was 4%. CONCLUSION Patients with prehospital tourniquets are frequently severely injured. The immediate presence of a trauma surgeon can have significant impacts in these cases. This is particularly important in a rural environment with long tourniquet times. Prehospital tourniquet application as a TTA criteria does not result in excessive overtriage.
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Affiliation(s)
- Kennith Coleman
- Department of Surgery, West Virginia University, Morgantown, WV, USA
| | - Daniel Grabo
- West Virginia University Health Sciences Center, Morgantown, WV, USA
| | - Alison Wilson
- West Virginia University Health Sciences Center, Morgantown, WV, USA
| | - James Bardes
- West Virginia University Health Sciences Center, Morgantown, WV, USA
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18
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Joarder M, Noureddine El Moussaoui H, Das A, Williamson F, Wullschleger M. Impact of time and distance on outcomes following tourniquet use in civilian and military settings: A scoping review. Injury 2023; 54:1236-1245. [PMID: 36697284 DOI: 10.1016/j.injury.2023.01.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Revised: 12/01/2022] [Accepted: 01/16/2023] [Indexed: 01/19/2023]
Abstract
BACKGROUND The last two decades have seen the reintroduction of tourniquets into guidelines for the management of acute limb trauma requiring hemorrhage control. Evidence supporting tourniquet application has demonstrated low complication rates in modern military settings involving rapid evacuation timeframes. It is unclear how these findings translate to patients who have prolonged transport times from injury in rural settings. This scoping review investigates the relationship between time and distance on metabolic complications, limb salvage and mortality following tourniquet use in civilian and military settings. METHODS A systematic search strategy was conducted using PubMed, Embase, and SafetyLit databases. Study characteristics, setting, mechanism of injury, prehospital time, tourniquet time, distance, limb salvage, metabolic response, mortality, and tourniquet removal details were extracted from eligible studies. Descriptive statistics were recorded, and studies were grouped by ischemia time (< 2 h, 2-4 h, or > 4 h). RESULTS The search identified 3103 studies, from which 86 studies were included in this scoping review. Of the 86 studies, 55 studies were primarily in civilian environments and 32 were based in military settings. One study included both settings. Blast injury was the most common mechanism of injury sustained by patients in military settings (72.8% [5968/8200]) followed by penetrating injury (23.5% [1926/8200]). In contrast, in civilian settings penetrating injury was the most common mechanism (47.7% [1633/3426]) followed by blunt injury (36.4% [1246/3426]). Tourniquet time was reported in 66/86 studies. Tourniquet time over four hours was associated with reduced limb salvage rates (57.1%) and higher mortality rates (7.1%) compared with a tourniquet time of less than two hours. The overall limb salvage and mortality rates were 69.6% and 6.7% respectively. Metabolic outcomes were reported in 28/86 studies with smaller sample sizes and inconsistencies in which parameters were reported. CONCLUSION This scoping review presents literature describing comparatively safe tourniquet application when used for less than two hours duration. However, there is limited research describing prolonged tourniquet application or when used for protracted distances, such that the impact of tourniquet release time on metabolic outcomes and complications remains unclear. Prospective studies utilizing the development of an international database to provide this dataset is required.
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Affiliation(s)
- Maisah Joarder
- Faculty of Medicine, University of Queensland, Herston, QLD, Australia; Jamieson Trauma Institute, Royal Brisbane and Women's Hospital, Herston, QLD, Australia.
| | - Hussein Noureddine El Moussaoui
- Faculty of Medicine, University of Queensland, Herston, QLD, Australia; Jamieson Trauma Institute, Royal Brisbane and Women's Hospital, Herston, QLD, Australia
| | - Arpita Das
- Jamieson Trauma Institute, Royal Brisbane and Women's Hospital, Herston, QLD, Australia
| | - Frances Williamson
- Faculty of Medicine, University of Queensland, Herston, QLD, Australia; Jamieson Trauma Institute, Royal Brisbane and Women's Hospital, Herston, QLD, Australia; Trauma Service, Royal Brisbane and Women's Hospital, Herston, QLD, Australia
| | - Martin Wullschleger
- Faculty of Medicine, University of Queensland, Herston, QLD, Australia; Jamieson Trauma Institute, Royal Brisbane and Women's Hospital, Herston, QLD, Australia; Trauma Service, Royal Brisbane and Women's Hospital, Herston, QLD, Australia
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19
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Hashmi ZG, Hu PJ, Jansen JO, Butler FK, Kerby JD, Holcomb JB. Characteristics and Outcomes of Prehospital Tourniquet Use for Trauma in the United States. PREHOSP EMERG CARE 2023; 27:31-37. [PMID: 34990299 DOI: 10.1080/10903127.2021.2025283] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
INTRODUCTION The use of the extremity tourniquet in military environments has reduced preventable deaths due to exsanguinating hemorrhage, leading to increased use in civilian settings. However, the outcomes of contemporary prehospital tourniquet use in civilian settings are not well-described nationally. The objective of this study was to describe the characteristics and outcomes following prehospital tourniquet use by emergency medical services (EMS) in the United States. METHODS All trauma activations reported to the National EMS Information System 2019 (NEMSIS) were included. Patients who had ≥1 tourniquet applied were identified. Descriptive analyses were used to compare characteristics between tourniquet and no-tourniquet cohorts. Coarsened exact matching was performed to generate a k2k match (on age, sex, lowest-systolic blood pressure, initial patient acuity, provider's initial impression, injury mechanism, and presence of upper/lower extremity injuries) and used to compare outcomes. Trauma patients who may have potentially benefited from tourniquet application (extremity injury, shock index ≥1 and no documented tourniquet application) were identified. RESULTS A total of 7,161 tourniquets were applied among 4,571,379 trauma activations (1.6/1000 activations). Patients in the tourniquet cohort were younger (40 ± 18 vs 52 ± 26 mean ± SD years), more hypotensive (16.1% vs. 2.5%) and had higher initial acuity (65.0% critical/emergent vs. 20.6%) [p < 0.01 for all]. A total of 7,074 patients in the tourniquet cohort were matched with 7,074 patients in the non-tourniquet cohort. Post-match analysis revealed that the patients in tourniquet cohort had a higher final acuity (80.8% vs. 75.0%, p < 0.01), lower scene-time (15.4 ± 13.6 vs. 17.0 ± 14.2 mean ± SD minutes, p < 0.01), and higher survival-to-hospital (83.6% vs. 75.1%, p < 0.01). A total of 141,471 trauma patients who may have potentially benefited from tourniquet application were identified. CONCLUSION Prehospital tourniquet use by EMS in the United States is associated with lower scene-time and improved survivability to hospital. Results indicate that patients might benefit from wider tourniquet use in the civilian prehospital setting.
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Affiliation(s)
- Zain G Hashmi
- Center for Injury Science, University of Alabama at Birmingham, Birmingham, Alabama.,Division of Trauma and Acute Care Surgery, Department of Surgery, University of Alabama at Birmingham, Alabama
| | - Parker J Hu
- Center for Injury Science, University of Alabama at Birmingham, Birmingham, Alabama.,Division of Trauma and Acute Care Surgery, Department of Surgery, University of Alabama at Birmingham, Alabama
| | - Jan O Jansen
- Center for Injury Science, University of Alabama at Birmingham, Birmingham, Alabama.,Division of Trauma and Acute Care Surgery, Department of Surgery, University of Alabama at Birmingham, Alabama
| | - Frank K Butler
- Department of Military & Emergency Medicine, Uniformed Services University, Bethesda, Maryland
| | - Jeffrey D Kerby
- Center for Injury Science, University of Alabama at Birmingham, Birmingham, Alabama.,Division of Trauma and Acute Care Surgery, Department of Surgery, University of Alabama at Birmingham, Alabama
| | - John B Holcomb
- Center for Injury Science, University of Alabama at Birmingham, Birmingham, Alabama.,Division of Trauma and Acute Care Surgery, Department of Surgery, University of Alabama at Birmingham, Alabama
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20
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Muacevic A, Adler JR, Hoxhaj M, Light MB, Dadario NB, Cook B, Cataldo MJ, Jafri FN. The Impact of the Addition of a Virtual Reality Trainer on Skill Retention of Tourniquet Application for Hemorrhage Control Among Emergency Medical Technician Students: A Pilot Study. Cureus 2023; 15:e34320. [PMID: 36865981 PMCID: PMC9971574 DOI: 10.7759/cureus.34320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/28/2023] [Indexed: 01/30/2023] Open
Abstract
INTRODUCTION Trauma is a leading cause of preventable death in the United States. Emergency Medical Technicians (EMTs) often arrive first at the scene of traumatic injuries to perform life-saving skills such as tourniquet placement. While current EMT courses teach and test tourniquet application, studies have shown efficacy and retention of EMT skills such as tourniquet placement decay over time, with educational interventions needed to improve retention of skills. METHODS A prospective randomized pilot study was conducted to determine differences in retention of tourniquet placement among 40 EMT students after initial training. Participants were randomly assigned to either a virtual reality (VR) intervention or a control group. The VR group received instruction from a refresher VR program 35 days after initial training as a supplement to their EMT course. Both the VR and control participants' tourniquet skills were assessed 70 days after initial training by blinded instructors. Results: There was no significant difference in correct tourniquet placement between both groups (Control, 63% vs Intervention, 57%, p = 0.57). It was found that 9/21 participants (43%) in the VR intervention group failed to correctly apply the tourniquet while 7/19 of the control participants (37%) failed in tourniquet application. Additionally, the VR group was more likely to fail the tourniquet application due to improper tightening than the control group during the final assessment (p = 0.04). Conclusion: In this pilot study, using a VR headset in conjunction with in-person training did not improve the efficacy and retention of tourniquet placement skills. Participants who received the VR intervention were more likely to have errors relating to haptics, rather than procedure-related errors.
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Ronconi RWF, Moreira LH, de Lima CJ, Neto OP, Osorio RAL. Tourniquets, types and techniques in emergency prehospital care: A narrative review. Med Eng Phys 2023; 111:103923. [PMID: 36792231 DOI: 10.1016/j.medengphy.2022.103923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 10/19/2022] [Accepted: 11/15/2022] [Indexed: 11/18/2022]
Abstract
Massive uncontrolled hemorrhage is an important cause of preventable death in trauma. Therefore, applying an arterial tourniquet (TQ) is recommended as a pre-hospital measure to control bleeding after severe traumatic bleeding. Limb TQ applies circumferential compression proximally to the injury site to compress the arteries, resulting in blood flow and consequently hemorrhage interruption. The use of commercial tourniquets (C-TQ), which are designed, tested, and registered to control hemorrhages in pre-hospital care, is a consensus. However, they are still uncommon in many prehospital emergency services and the overall level of evidence in most studies is low. This narrative review aimed to characterize the importance of tourniquets use in prehospital emergency care and its application techniques. Furthermore, it proposes to stimulate the development of new devices, more accessible and easier to use, to suggest new directions of studies and medical education demands, with manikin and simulation development.
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Affiliation(s)
- Roger William Freire Ronconi
- Biomedical Engineering Institute, Universidade Anhembi Morumbi UAM, São José dos Campos, São Paulo, Brazil; Biomedical Engineering Department, Center for Innovation, Technology and Education CITE, São José dos Campos, São Paulo, Brazil; Tacmed Brasil, Taubaté, São Paulo, Brazil.
| | - Livia Helena Moreira
- Biomedical Engineering Institute, Universidade Anhembi Morumbi UAM, São José dos Campos, São Paulo, Brazil; Biomedical Engineering Department, Center for Innovation, Technology and Education CITE, São José dos Campos, São Paulo, Brazil
| | - Carlos José de Lima
- Biomedical Engineering Institute, Universidade Anhembi Morumbi UAM, São José dos Campos, São Paulo, Brazil; Biomedical Engineering Department, Center for Innovation, Technology and Education CITE, São José dos Campos, São Paulo, Brazil
| | - Osmar Pinto Neto
- Biomedical Engineering Institute, Universidade Anhembi Morumbi UAM, São José dos Campos, São Paulo, Brazil; Biomedical Engineering Department, Center for Innovation, Technology and Education CITE, São José dos Campos, São Paulo, Brazil; Arena235 Research Lab, São José dos Campos, São Paulo, Brazil
| | - Rodrigo Alexis Lazo Osorio
- Biomedical Engineering Institute, Universidade Anhembi Morumbi UAM, São José dos Campos, São Paulo, Brazil; Biomedical Engineering Department, Center for Innovation, Technology and Education CITE, São José dos Campos, São Paulo, Brazil
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22
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Mokhtari AK, Mikdad S, Luckhurst C, Hwabejire J, Fawley J, Parks JJ, Mendoza AE, Kaafarani HMA, Velmahos GC, Bloemers FW, Saillant NN. Prehospital extremity tourniquet placements-performance evaluation of non-EMS placement of a lifesaving device. Eur J Trauma Emerg Surg 2022; 48:4255-4265. [PMID: 35538361 DOI: 10.1007/s00068-022-01973-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 03/26/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND The education of civilians and first responders in prehospital tourniquet (PT) utilization has spread rapidly. We aimed to describe trends in emergency medical services (EMS) and non-EMS PT utilization, and their ability to identify proper clinical indications and to appropriately apply tourniquets in the field. METHODS A retrospective cohort study was conducted to evaluate all adult patients with PTs who presented at two Level I trauma centers between January 2015 and December 2019. Data were collected via an electronic patient query tool and cross-referenced with institutional Trauma Registries. Medically trained abstractors determined if PTs were clinically indicated (limb amputation, vascular hard signs, injury requiring hemostasis procedure, or significant documented blood loss). PTs were further designated as appropriately or inappropriately applied (based on tourniquet location, venous tourniquet, greater than 2-h ischemic time). Descriptive statistics and univariate analyses were performed. RESULTS 146 patients met inclusion criteria. The incidence of yearly PT placements increased between 2015 and 2019, with an increase in placement by non-EMS personnel (police, firefighter, bystander, and patient). Improvised PTs were frequently utilized by bystanders and patients, whereas first responders had high rates of commercial tourniquet use. A high proportion of tourniquets were placed without indication (72/146, 49%); however, the proportion of PTs placed without a proper indication across applier groups was not statistically different (p = 0.99). Rates of inappropriately applied PTs ranged from 21 to 46% across all groups applying PTs. CONCLUSIONS PT placement was increasingly performed by non-EMS personnel. Present data indicate that non-EMS persons applied PTs at a similar performance level of those applied by EMS. Study LevelLevel III.
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Affiliation(s)
- Ava K Mokhtari
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Harvard Medical School, 165 Cambridge Street, Suite 810, Boston, MA, 02114, USA.
| | - Sarah Mikdad
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Harvard Medical School, 165 Cambridge Street, Suite 810, Boston, MA, 02114, USA
- Department of Trauma Surgery, VU Medical Center, Amsterdam UMC, Amsterdam, The Netherlands
| | - Casey Luckhurst
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Harvard Medical School, 165 Cambridge Street, Suite 810, Boston, MA, 02114, USA
| | - John Hwabejire
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Harvard Medical School, 165 Cambridge Street, Suite 810, Boston, MA, 02114, USA
| | - Jason Fawley
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Harvard Medical School, 165 Cambridge Street, Suite 810, Boston, MA, 02114, USA
| | - Jonathan J Parks
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Harvard Medical School, 165 Cambridge Street, Suite 810, Boston, MA, 02114, USA
| | - April E Mendoza
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Harvard Medical School, 165 Cambridge Street, Suite 810, Boston, MA, 02114, USA
| | - Haytham M A Kaafarani
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Harvard Medical School, 165 Cambridge Street, Suite 810, Boston, MA, 02114, USA
| | - George C Velmahos
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Harvard Medical School, 165 Cambridge Street, Suite 810, Boston, MA, 02114, USA
| | - Frank W Bloemers
- Department of Trauma Surgery, VU Medical Center, Amsterdam UMC, Amsterdam, The Netherlands
| | - Noelle N Saillant
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Harvard Medical School, 165 Cambridge Street, Suite 810, Boston, MA, 02114, USA
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23
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AAST multicenter prospective analysis of prehospital tourniquet use for extremity trauma. J Trauma Acute Care Surg 2022; 92:997-1004. [PMID: 35609289 DOI: 10.1097/ta.0000000000003555] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Tourniquet use for extremity hemorrhage control has seen a recent increase in civilian usage. Previous retrospective studies demonstrated that tourniquets improve outcomes for major extremity trauma (MET). No prospective study has been conducted to date. The objective of this study was to evaluate outcomes in MET patients with prehospital tourniquet use. We hypothesized that prehospital tourniquet use in MET decreases the incidence of patients arriving to the trauma center in shock. METHODS Data were collected prospectively for adult patients with MET at 26 Level I and 3 Level II trauma centers from 2015 to 2020. Limbs with tourniquets applied in the prehospital setting were included in the tourniquet group and limbs without prehospital tourniquets were enrolled in the control group. RESULTS A total of 1,392 injured limbs were enrolled with 1,130 tourniquets, including 962 prehospital tourniquets. The control group consisted of 262 limbs without prehospital tourniquets and 88 with tourniquets placed upon hospital arrival. Prehospital improvised tourniquets were placed in 42 patients. Tourniquets effectively controlled bleeding in 87.7% of limbs. Tourniquet and control groups were similarly matched for demographics, Injury Severity Score, and prehospital vital signs (p > 0.05). Despite higher limb injury severity, patients in the tourniquet group were less likely to arrive in shock compared with the control group (13.0% vs. 17.4%, p = 0.04). The incidence of limb complications was not significantly higher in the tourniquet group (p > 0.05). CONCLUSION This study is the first prospective analysis of prehospital tourniquet use for civilian extremity trauma. Prehospital tourniquet application was associated with decreased incidence of arrival in shock without increasing limb complications. We found widespread tourniquet use, high effectiveness, and a low number of improvised tourniquets. This study provides further evidence that tourniquets are being widely and safely adopted to improve outcomes in civilians with MET. LEVEL OF EVIDENCE Therapeutic/Care Management; Level IV.
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24
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Petrone P, Baltazar G, Jacquez RA, Akerman M, Brathwaite CEM, Joseph DK. Stop the Bleed: A Prospective Evaluation and Comparison of Tourniquet Application in Security Personnel Versus Civilian Population. Am Surg 2022:31348221101489. [PMID: 35567282 DOI: 10.1177/00031348221101489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Stop the Bleed (STB) is a national training program aiming to decrease the mortality associated with life-threatening bleeding due to injury. The purpose of this study was to evaluate the efficacy and confidence level of security personnel placing a tourniquet (TQ) compared to civilians. METHODS Pre and post questionnaires were shared with security personnel (Group 1) and civilians (Group 2). Both groups were assessed to determine comfort level with TQ placement. Time and success rate for placement was recorded pre- and post-STB training. A generalized linear mixed model or generalized estimating equations was used to compare pre and post measurements. RESULTS There were 234 subjects enrolled. There was a statistically significant improvement between the pre- and post-training responses in both groups with respect to comfort level in placing a TQ. Participants also demonstrated increased familiarity with the anatomy and bleeding control after STB training. A higher successful TQ placement was obtained in both groups after STB training (Pre-training: Group 1 [17.4%], Group 2 [12.8%]; Post-training: Group 1 [94.8%], Group 2 [92.3%]). Both groups demonstrated improved time to TA placement with a longer mean time improvement achieved in Group 1. Although the time to TQ placement pre-and post-training was statistically significant, we found that the post-training times between Groups 1 and 2 were similar (P = .983). CONCLUSIONS Participants improved their confidence level with the use of hemorrhage control techniques and dramatically increased the rate and time to successful placement of a TQ. While civilians had the greatest increase in comfort level, the security personnel group saw the most significant reduction in the time to successful TQ placement. These findings highlight the critical role of STB in educating and empowering both civilians and security personnel in bleeding control techniques.
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Affiliation(s)
- Patrizio Petrone
- Departments of Surgery, NYU Long Island School of Medicine, NYU Langone Hospital-Long Island, Mineola, NY, USA
| | - Gerard Baltazar
- Departments of Surgery, NYU Long Island School of Medicine, NYU Langone Hospital-Long Island, Mineola, NY, USA
| | - Ricardo A Jacquez
- Departments of Surgery, NYU Long Island School of Medicine, NYU Langone Hospital-Long Island, Mineola, NY, USA
| | - Meredith Akerman
- Departments of Biostatistics, NYU Long Island School of Medicine, NYU Langone Hospital-Long Island, Mineola, NY, USA
| | - Collin E M Brathwaite
- Departments of Surgery, NYU Long Island School of Medicine, NYU Langone Hospital-Long Island, Mineola, NY, USA
| | - D'Andrea K Joseph
- Departments of Surgery, NYU Long Island School of Medicine, NYU Langone Hospital-Long Island, Mineola, NY, USA
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Dayal S, Portela R, Taylor S, Byquist BR, Piner A, Adams J, March J. Measuring the Effect of Audio Instructions on the Time and Effectiveness of Tourniquet Application by Laypeople. PREHOSP EMERG CARE 2022:1-5. [PMID: 35500205 DOI: 10.1080/10903127.2022.2072551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Objective: The "Stop the Bleed" campaign was created to educate laypeople about bleeding control and make bleeding control kits available in public locations. Unfortunately, previous research has indicated that up to half of all laypeople cannot effectively apply a tourniquet. The purpose of this study was to determine if laypeople could apply tourniquets more effectively with just-in-time training using combined audio-written instructions versus written-only instructions.Methods: We conducted a prospective randomized study comparing the application of a tourniquet using a simulated bleeding arm. Participants were laypeople 18 years and older and excluded those with any previous tourniquet experience or training. Participants were randomized to just-in-time training using either audio-written or written-only instructions. Time in seconds to tourniquet application and the effectiveness of the tourniquet application was recorded. Effective application was defined as stopping the flow or significantly slowing the flow to a slow drip. Ineffective tourniquet placement was defined as not significantly changing the flow. Statistical analysis was performed using Fisher's exact, t-test, and linear regression.Results: Eighty-two participants were included; 40 were in the audio-written instructions group, and 58.5% were male. The audio-written group's effective application rate was 92.5% and that of the written-only group was 76.2%. A significantly higher rate of ineffective tourniquet application was noted for the written-only group, (23.8%), versus the audio-written group (7.5%), p=.04. Regardless of the type of instructions used, time to effective application of the tourniquet decreased as participant age increased (p = 0.02, 95%CI (-1.24, -0.13). There was no relationship between age and effective tourniquet application (p = 0.06). Time for tourniquet placement was not different between the audio-written (mean 100.4 seconds) and written-only (mean 106.1 seconds) groups (p = 0.58).Conclusion: This study suggests that combined audio-written instructions decrease the rate of ineffective tourniquet application by laypeople compared with written-only instructions. Further studies are needed to assess if audio instructions and just-in-time training can further maximize effective tourniquet application.
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Tatebe LC, Schlanser V, Hampton D, Chang G, Hanson I, Doherty J, Issa N, Ghandour H, Kingsley S, Stewart A, Anstadt M, Dennis A. The tight rope act: A multicenter regional experience of tourniquets in acute trauma resuscitation. J Trauma Acute Care Surg 2022; 92:890-896. [PMID: 34882594 DOI: 10.1097/ta.0000000000003491] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND As tourniquets have become more prevalent, device use has been questioned. This study sought to characterize the incidence, indication, and efficacy of tourniquet placement in acute trauma resuscitation. METHODS Nine regional level 1 trauma centers prospectively enrolled for 12 months adult patients (18 years or older) who had a tourniquet placed. Age, sex, mechanism, tourniquet type, indication, applying personnel, location placed, level of occlusion, and degree of hemostasis were collected. Major vascular injury, imaging and operations performed, and outcomes were assessed. Analyses were performed with significance at p < 0.05. RESULTS A total of 216 tourniquet applications were reported on 209 patients. There were significantly more male patients (183 [88%]) and penetrating injuries (186 [89%]) with gunshots being most common (127 [61%]). Commercial tourniquets were most often used (205 [95%]). Ninety-two percent were placed in the prehospital setting (by fire/paramedics, 56%; police, 33%; bystanders, 2%). The most common indications were pooling (47%) and pulsatile (32%) hemorrhage. Only 2% were for amputation. The most frequent location was high proximal extremity (70%). Four percent were placed over the wound, and 0.5% were distal to the wound. Only 61% of applications were arterial occlusive. Median application time was 30 minutes (interquartile range, 20-40 minutes). Imaging was performed in 54% of patients. Overall, 36% had a named arterial injury. Tourniquet application failed to achieve hemostasis in 22% of patients with a named vascular injury. There was no difference in hemostasis between those with and without vascular injury (p = 0.12) or between who placed the tourniquet (p = 0.07). Seventy patients (34%) required vascular operations. Thirty-four percent of patients were discharged home without admission. CONCLUSION Discerning which injuries require tourniquets over pressure dressings remains elusive. Trained responders had high rates of superfluous and inadequate deployments. As tourniquets continue to be disseminated, emphasis should be placed on improving education, device development, and quality control. LEVEL OF EVIDENCE Prognostic/Epidemiologic, Level III.
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Affiliation(s)
- Leah Carey Tatebe
- From the Department of Trauma and Burn Surgery (L.C.T., V.S., A.D.), Cook County Health, Rush University, Midwestern University, Chicago, Illinois; Department of Surgery (D.H.), University of Chicago, Chicago, Illinois; Department of Surgery (G.C., I.H.), Mount Sinai Hospital, Chicago, Illinois; Department of Surgery (J.D.), Advocate Christ Medical Center, Oak Lawn, Illinois; Department of Surgery (N.I.), Northwestern University, Chicago, Illinois; Department of Surgery (H.G., S.K.), Advocate Illinois Masonic Medical Center, Chicago, Illinois; Department of Surgery (A.S.), Advocate Lutheran General Hospital, Park Ridge, Illinois; and Department of Surgery (M.A.), Loyola University, Maywood, Illinois
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27
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Legare T, Schroll R, Hunt JP, Duchesne J, Marr A, Schoen J, Greiffenstein P, Stuke L, Smith A. Prehospital Tourniquets Placed on Limbs Without Major Vascular Injuries, has the Pendulum Swung Too far? Am Surg 2022; 88:2103-2107. [PMID: 35435022 DOI: 10.1177/00031348221088968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Combat applications of tourniquets for extremity trauma have led to increased civilian prehospital tourniquet use. Studies have demonstrated that appropriate prehospital tourniquet application can decrease the incidence of arrival in shock without increasing limb complications. The aim of this study was to examine outcomes of prehospital tourniquet placement without definitive vascular injury. METHODS Retrospective review was performed of a prospectively maintained database by the American Association for the Surgery of Trauma from 29 trauma centers. Patients in this subset analysis did not have a significant vascular injury as determined by imaging or intra-operatively. Patients who received prehospital tourniquets (PHTQ) were compared to patients without prehospital tourniquets (No-PHTQ). Outcomes were amputation rates, nerve palsy, compartment syndrome, and in-hospital mortality. RESULTS A total of 622 patients had no major vascular injury. The incidence of patients without major vascular injury was higher in the PHTQ group (n = 585/962, 60.8 vs n = 37/88, 42.0%, P < .001). Cohorts were similar in age, gender, penetrating mechanism, injury severity scores (ISS), abbreviated injury score (AIS), and mortality (P > .05). Amputation rates were 8.3% (n = 49/585) in the PHTQ group compared to 0% (n = 0/37) in the No-PHTQ group. Amputation rates were higher in PHTQ than No-PHTQ with similar ISS and AIS (P = .96, P = .59). The incidence of nerve palsy and compartment syndrome was not different (P > .05). CONCLUSIONS This study showed a significant amount of prehospital tourniquets are being placed on patients without vascular injuries. Further studies are needed to elucidate the appropriateness of prehospital tourniquets, including targeted education of tourniquet placement.
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Affiliation(s)
- Timothy Legare
- Department of Surgery, 12258Louisiana State University Health Science Center, New Orleans, LA, USA
| | - Rebecca Schroll
- Department of Surgery, 12255Tulane University School of Medicine, New Orleans, LA, USA
| | - John P Hunt
- Department of Surgery, 12258Louisiana State University Health Science Center, New Orleans, LA, USA.,University Medical Center, New Orleans, LA, USA
| | - Juan Duchesne
- Department of Surgery, 12255Tulane University School of Medicine, New Orleans, LA, USA.,University Medical Center, New Orleans, LA, USA
| | - Alan Marr
- Department of Surgery, 12258Louisiana State University Health Science Center, New Orleans, LA, USA.,University Medical Center, New Orleans, LA, USA
| | - Jonathan Schoen
- Department of Surgery, 12258Louisiana State University Health Science Center, New Orleans, LA, USA.,University Medical Center, New Orleans, LA, USA
| | - Patrick Greiffenstein
- Department of Surgery, 12258Louisiana State University Health Science Center, New Orleans, LA, USA.,University Medical Center, New Orleans, LA, USA
| | - Lance Stuke
- Department of Surgery, 12258Louisiana State University Health Science Center, New Orleans, LA, USA.,University Medical Center, New Orleans, LA, USA
| | - Alison Smith
- Department of Surgery, 12258Louisiana State University Health Science Center, New Orleans, LA, USA.,University Medical Center, New Orleans, LA, USA
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Schwartz DS, Thompson J, Locrotondo T, Heggers S. Initial acuity of firearm injuries in the United States: are civilian injuries similar to combat casualty statistics. Intern Emerg Med 2022; 17:857-863. [PMID: 34378085 DOI: 10.1007/s11739-021-02821-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 07/29/2021] [Indexed: 11/26/2022]
Abstract
Military studies have identified significant trends in combat related preventable death, particularly with respect to limb hemorrhage. Little is known, however regarding preventable death due to firearms in the civilian patient population, or the anatomic distribution of these injuries. An understanding of this information and the applicability of military studies to the civilian patient population is critical to developing strategies for treating these injuries. A retrospective database review of The National Emergency Medical Services Information Systems (NEMESIS) national database based on ICD 10 codes for firearm injuries logged in 2019 in the pre-hospital environment. Twenty three thousand three hundred and thirty-three firearm injuries were logged in NEMESIS in 2019, of which 15,148 were ultimately included as the other cases had incomplete information. Of these injuries there were 1438 (9.49%) to the chest, 913 (6.03%) to the abdomen, 221 (1.46%) to the neck, 468 (3.09%) to the back. These four anatomic locations were the most likely to be classified as Critical-Red by prehospital providers: 62.66% of chest injuries, 54.22% of abdomen injuries, 48.42% of neck injuries, and 42.31% of back injuries. The NEMESIS data on patient acuity indicates that the number of firearm related preventable deaths due to torso injury may be significantly greater than those due to limb exsanguination. In addition to the focus on tourniquet use, research focused on improved prehospital care of firearm injuries to the torso may provide additional strategies for reducing preventable death.
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Affiliation(s)
- Daniel Stephen Schwartz
- Center of Operational Medicine, Medical College of Georgia, Augusta University, 1120 15th Street, AF-2054, Augusta, GA, 30909, USA.
| | | | - Tony Locrotondo
- Center of Operational Medicine, Medical College of Georgia, Augusta University, 1120 15th Street, AF-2054, Augusta, GA, 30909, USA
| | - Spencer Heggers
- Center of Operational Medicine, Medical College of Georgia, Augusta University, 1120 15th Street, AF-2054, Augusta, GA, 30909, USA
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Nichols R, Horstman J. Recommendations for Improving Stop the Bleed: A Systematic Review. Mil Med 2022; 187:e1338-e1345. [PMID: 35084491 DOI: 10.1093/milmed/usac019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 12/28/2021] [Accepted: 01/24/2022] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION In response to mass casualty events, The Hartford Consensus brought together subject matter experts across multiple disciplines in health care and public safety to create guidelines and publications intended to improve survivability in active shooter events. Among the recommendations was the earlier recognition and treatment application of life-threatening hemorrhage control. These recommendations culminated in efforts to create the Stop the Bleed Campaign, which aims to empower the layperson to render aid in a life-threatening bleeding emergency. As of February 2020, the program has held over 86,000 courses, trained over 1.4 million attendees, and over 77,000 instructors since its inception. In addition to spreading within the United States, American College of Surgeons (ACS) Stop the Bleed (StB) classes have been held in 118 different countries. This systematic narrative review aims to answer the following research question: What does the ACS StB Initiative do well, and where can it improve? MATERIALS AND METHODS The following search terms were utilized: "Stop the Bleed," "American College of Surgeons," "bleeding control," "first-aid," tourniquet, "wound pack," "direct pressure" hemorrhage, and bystander. The inclusion criteria were that the article needed to speak to the program or some aspect of bystander first aid, the article needed to be in a civilian setting, the article needed to be more than a case study or overview, and the first aid tools needed to be in the StB curriculum. 4 databases were searched, which produced 138 articles for screening. One hundred four full-text articles were able to be retrieved, and 56 articles were determined to meet the inclusion criteria once the full text was reviewed. RESULTS Fifty-six articles were included in the final review and were placed into the following categories: Needs Within the Community, Confidence and Knowledge, Training Modalities, Barriers and Gaps in Training, Instructor Selection, Skill Retention, and Patient Outcomes. The articles were then organized into each outcome for synthesis and reporting of the results. The program overwhelmingly improves short-term confidence, but gaps in skill retention, data collection on patient outcomes, and settings that would benefit were identified. CONCLUSION StB is an effective tool in building confidence in laypersons, which is its biggest strength. A review of the literature shows several areas where the curriculum and materials could be better developed. Research can also be further refined to better quantify the program's impact.
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Affiliation(s)
- Ryoma Nichols
- Elson S. Floyd College of Medicine, Washington State University, Spokane, WA 99202-2131, USA
| | - Jordan Horstman
- Kansas City University School of Osteopathic Medicine, Kansas City University, Kansas City, MO 64106, USA
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30
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Stopping extremity hemorrhage: More than just a tourniquet. Surg Open Sci 2022; 7:42-45. [PMID: 35028549 PMCID: PMC8741618 DOI: 10.1016/j.sopen.2021.11.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 11/11/2021] [Indexed: 11/21/2022] Open
Abstract
Major extremity hemorrhage is a surgical emergency, and the physical examination is essential to help dictate appropriate clinical decision making. Hard signs that require immediate surgical intervention include ongoing bleeding, expanding hematoma, ischemic limb, as well as partial/complete amputation. Packing, compression, balloon tamponade, and tourniquets are very helpful to temporize major hemorrhage. Mangled extremities are very challenging to manage and require a multidisciplinary approach. Temporary vascular shunts are excellent tools for vascular/orthopedic damage control and for temporary stabilization prior to transport for definitive care.
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Parvin-Nejad FP, Padmanaban V, Jalloh S, Barrie U, Sifri ZC. Stop the Bleed in Rural Sierra Leone: One Year of Interventions and Outcomes by Nursing Trainees. J Surg Res 2022; 273:79-84. [PMID: 35032824 DOI: 10.1016/j.jss.2021.12.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 09/13/2021] [Accepted: 12/15/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Low- and middle-income countries (LMICs) bear the bulk of the global burden of traumatic injury, yet many lack adequate prehospital trauma care systems. The Stop the Bleed (STB) course, designed to equip bystanders with bleeding control skills, is infrequently offered in LMICs, and its impact in these settings is unknown. To examine the frequency and effectiveness of STB interventions in LMICs, we quantified nursing student trainees' encounters with bleeding victims after STB training in rural Sierra Leone. METHODS Local providers and volunteers from a US-based surgical nongovernmental organization taught an STB course to nursing students in Kabala, Sierra Leone. One month and 1 year after the course, trainees completed follow-up surveys describing encounters with traumatic hemorrhage victims since the course. RESULTS Of 121 total STB trainees, 82 completed the 1-month follow-up survey, with 75% reporting at least one encounter with a bleeding victim. This increased to 98% at 12 months (100 responses, average 2 ± 2 encounters). Injuries were most commonly sustained on victims' legs (32%) and most often precipitated by motorcycle crashes (31%). Respondents intervened in 99% of encounters, and 97% of patients receiving intervention survived. Although only 20% of respondents used a tourniquet, this technique produced the highest survival rate (100%). CONCLUSIONS Nearly all respondents had encounters with victims of traumatic hemorrhage within 1 year of the STB course, and trainees effectively applied bleeding control techniques, leading to 97% survival among victims receiving intervention. These findings indicate the lifesaving impact of STB training in one rural LMIC setting.
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Affiliation(s)
| | - Vennila Padmanaban
- Rutgers New Jersey Medical School, Department of Surgery, Newark, New Jersey
| | - Samba Jalloh
- College of Medicine and Allied Health Sciences (COMAHS), University of Sierra Leone, Freetown, Sierra Leone
| | - Umaru Barrie
- Department of Family Medicine and Community Health, Duke University, Durham, North Carolina
| | - Ziad C Sifri
- Rutgers New Jersey Medical School, Department of Surgery, Newark, New Jersey
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Kleinsorge GHD, Teixeira PGR, Pfannes CCB, Lago RDVD, Abib SDCV. Prognostic factors in treatment of traumatic femoropopliteal arterial injuries at a Brazilian trauma center. J Vasc Bras 2022; 21:e20220020. [PMID: 36187215 PMCID: PMC9499723 DOI: 10.1590/1677-5449.202200202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 07/13/2022] [Indexed: 11/29/2022] Open
Abstract
Background Despite significant improvements in outcomes, traumatic arterial limb injuries remain a significant cause of limb loss and mortality. Objectives This study sought to identify predictors of mortality and major amputation in patients undergoing revascularization after femoropopliteal arterial trauma. Methods This was a retrospective review of a trauma registry from an urban trauma center in Brazil. All patients admitted to our hospital with a femoropopliteal arterial injury from November 2012 to December 2017 who underwent vascular reconstruction were included. Univariate analyses and logistic regression analyses were conducted to identify factors independently associated with the primary outcome of amputation and the secondary outcome of mortality. Results Ninety-six patients were included. Eleven patients (11.5%) had an amputation and 14 (14.6%) died. In the logistic regression model for amputation, patients with ischemia duration greater than 6 hours were approximately 10 times more likely to undergo an amputation compared to those with ischemia duration less than or equal to 6 hours (adjusted odds ratio (AOR) [95% confidence interval (CI)]: 9.6 [1.2-79.9]). The logistic regression model for mortality revealed that patients with ischemia duration greater than 6 hours were approximately 6 times more likely to die compared to those with ischemia duration less than or equal to 6 hours (AOR [95% CI]: 5.6 [1.3 to 24.7). Conclusions Ischemia duration remains the most important factor independently associated with limb loss and mortality for patients undergoing femoropopliteal arterial revascularization after traumatic injuries. Physiological status on admission and trauma scores are also important.
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Latina R, Iacorossi L, Fauci AJ, Biffi A, Castellini G, Coclite D, D’Angelo D, Gianola S, Mari V, Napoletano A, Porcu G, Ruggeri M, Iannone P, Chiara O. Effectiveness of Pre-Hospital Tourniquet in Emergency Patients with Major Trauma and Uncontrolled Haemorrhage: A Systematic Review and Meta-Analysis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:12861. [PMID: 34886586 PMCID: PMC8657739 DOI: 10.3390/ijerph182312861] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 11/25/2021] [Accepted: 11/26/2021] [Indexed: 11/26/2022]
Abstract
Trauma is one of the leading causes of uncontrolled haemorrhage, death, and disability. Use of a tourniquet can be considered an optimal anti-haemorrhagic resource, in pre-hospital and emergency settings, and its lifesaving effect is clinically contradictory. This review aims to assess the clinical efficacy of the tourniquet in the emergency pre-hospital care setting for the management of haemorrhage. We conducted the systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses, the PRISMA statement. We searched the following electronic databases: EMBASE, MEDLINE, and Cochrane-CENTRAL. All studies included were appraised for risk of bias. Prevalent primary outcomes were mortality and use of blood products. Secondary outcomes were related to adverse effects. The quality of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation approach (GRADE). Four studies were involved (1762 trauma patients). The adjusted odds ratio (aOR) of 0.47 (95% confidence Interval (CI) 0.19-1.16; three studies; 377 patients) for overall mortality estimates did not give a clear indication of the benefits of emergency pre-hospital tourniquets (PH-TQ) versus no pre-hospital tourniquet (NO PH-TQ) placement. The adjusted mean difference for blood product use was -3.28 (95% CI -11.22, 4.66) for packed red blood cells (pRBC) and -4.80 (95% CI -5.61, -3.99) for plasma, respectively. The certainty of evidence was downgraded to very low for all outcomes. Our results suggest an unclear effect of emergency pre-hospital tourniquet placement on overall mortality and blood product use. However, this systematic review highlights the availability of only observational studies and the absence of high quality RCTs assessing the efficacy of PH-TQs. Randomized controlled trials are needed.
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Affiliation(s)
- Roberto Latina
- National Centre for Clinical Excellence Healthcare Quality and Safety, Istituto Superiore di Sanità, Via Giano della Bella 34, 00162 Rome, Italy; (R.L.); (L.I.); (A.J.F.); (D.C.); (D.D.); (V.M.); (P.I.)
- Department of Health Promotion Science, Maternal and Infant Care, Internal Medicine and Medical Specialities, University of Palermo, Piazza delle Cliniche 2, 90127 Palermo, Italy
| | - Laura Iacorossi
- National Centre for Clinical Excellence Healthcare Quality and Safety, Istituto Superiore di Sanità, Via Giano della Bella 34, 00162 Rome, Italy; (R.L.); (L.I.); (A.J.F.); (D.C.); (D.D.); (V.M.); (P.I.)
- IRCCS Regina Elena National Cancer Institute, Via Elio Chianesi 53, 00144 Roma, Italy
| | - Alice Josephine Fauci
- National Centre for Clinical Excellence Healthcare Quality and Safety, Istituto Superiore di Sanità, Via Giano della Bella 34, 00162 Rome, Italy; (R.L.); (L.I.); (A.J.F.); (D.C.); (D.D.); (V.M.); (P.I.)
| | - Annalisa Biffi
- Laboratory of Healthcare Research and Pharmacoepidemiology, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Piazza dell’Ateneo Nuovo 1, 20126 Milan, Italy; (A.B.); (G.P.)
| | - Greta Castellini
- Unit of Clinical Epidemiology, IRCCS Istituto Ortopedico Galeazzi, Via Riccardo Galeazzi 4, 20161 Milan, Italy; (G.C.); (S.G.)
| | - Daniela Coclite
- National Centre for Clinical Excellence Healthcare Quality and Safety, Istituto Superiore di Sanità, Via Giano della Bella 34, 00162 Rome, Italy; (R.L.); (L.I.); (A.J.F.); (D.C.); (D.D.); (V.M.); (P.I.)
| | - Daniela D’Angelo
- National Centre for Clinical Excellence Healthcare Quality and Safety, Istituto Superiore di Sanità, Via Giano della Bella 34, 00162 Rome, Italy; (R.L.); (L.I.); (A.J.F.); (D.C.); (D.D.); (V.M.); (P.I.)
| | - Silvia Gianola
- Unit of Clinical Epidemiology, IRCCS Istituto Ortopedico Galeazzi, Via Riccardo Galeazzi 4, 20161 Milan, Italy; (G.C.); (S.G.)
| | - Veronica Mari
- National Centre for Clinical Excellence Healthcare Quality and Safety, Istituto Superiore di Sanità, Via Giano della Bella 34, 00162 Rome, Italy; (R.L.); (L.I.); (A.J.F.); (D.C.); (D.D.); (V.M.); (P.I.)
| | - Antonello Napoletano
- National Centre for Clinical Excellence Healthcare Quality and Safety, Istituto Superiore di Sanità, Via Giano della Bella 34, 00162 Rome, Italy; (R.L.); (L.I.); (A.J.F.); (D.C.); (D.D.); (V.M.); (P.I.)
| | - Gloria Porcu
- Laboratory of Healthcare Research and Pharmacoepidemiology, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Piazza dell’Ateneo Nuovo 1, 20126 Milan, Italy; (A.B.); (G.P.)
| | - Matteo Ruggeri
- National Centre for Health Technology Assessment, Istituto Superiore di Sanità, Via Giano della Bella 34, 00162 Rome, Italy;
| | - Primiano Iannone
- National Centre for Clinical Excellence Healthcare Quality and Safety, Istituto Superiore di Sanità, Via Giano della Bella 34, 00162 Rome, Italy; (R.L.); (L.I.); (A.J.F.); (D.C.); (D.D.); (V.M.); (P.I.)
| | - Osvaldo Chiara
- General Surgery and Trauma Team, ASST Grande Ospedale Metropolitano Niguarda, University of Milan, Piazza Ospedale Maggiore 3, 20162 Milan, Italy;
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Sharrock M. The mangled extremity: assessment, decision making and outcomes. Acta Orthop Belg 2021; 87:755-760. [PMID: 35172444 DOI: 10.52628/87.4.22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The management of the mangled extremity continues to pose a significant challenge for ortho- paedic trauma surgeons. This article provides a comprehensive, up-to-date literature review on the assessment of complex limb injuries, and the variables that affect decision-making and outcomes in both limb salvage and amputation. Initial assessment involves using a systematic approach, saving life before limb, with early involvement of the relevant surgical specialities and multidisciplinary team. The decision to attempt limb salvage or perform amputation can be extremely difficult. Scoring systems can be used as a guide but should not be wholly relied upon; instead more emphasis should be placed on the surgeon's experience, extent of soft tissue damage, and patient factors and wishes. Outcomes following amputation versus limb salvage are comparable, with some studies suggesting amputation may be favourable. It is important to advise patients and families on what treatment is in their best interest so they can make an informed decision, and this must utilise a multidisciplinary approach.
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Schlanser VL, Tatebe LC, Karalius VP, Liesen E, Pekarek S, Impens A, Ivkovic K, Bajani F, Khalifa A, Dennis AJ. The Windlass Tourniquet: Is It Taking the Wind Out of the "Stop the Bleed" Sails? J Surg Res 2021; 271:91-97. [PMID: 34856457 DOI: 10.1016/j.jss.2021.09.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 09/07/2021] [Accepted: 09/22/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Civilians are often first-line responders in hemorrhage control; however, windlass tourniquets are not intuitive. Untrained users reading enclosed instructions failed in 38.2% of tourniquet applications. This prospective follow-up study replicated testing following Stop the Bleed (STB) training. MATERIALS AND METHODS One and six months following STB, first-year medical students were randomly assigned a windlass tourniquet with enclosed instructions. Each was given one minute to read instructions and two minutes to apply the windlass tourniquet on the TraumaFX HEMO trainer. Demographics, time to read instructions and stop bleeding, blood loss, and simulation success were analyzed. RESULTS 100 students received STB training. 31 and 34 students completed tourniquet testing at one month and six months, respectively. At both intervals, 38% of students were unable to control hemorrhage (P = 0.97). When compared to the pilot study without STB training (median 48 sec, IQR 33-60 sec), the time taken to read the instructions was shorter one month following STB (P <0.001), but there was no difference at 6 months (P = 0.1). Incorrect placement was noted for 19.4% and 23.5% of attempts at 1 and 6 months. Male participants were more successful in effective placement at one month (93.3% versus 31.3%, P = 0.004) and at six months (77.8% versus 43.8%, p = 0.04). CONCLUSIONS Skills decay for tourniquet application was observed between 1 and 6 months following STB. Instruction review and STB produced the same hemorrhage control rates as reading enclosed instructions without prior training. Training efforts must continue; but an intuitive tourniquet relying less on mechanical advantage is needed.
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Affiliation(s)
- Victoria L Schlanser
- Department of Trauma and Burn Surgery, Cook County Health, Chicago, Illinois; Department of Surgery, Midwestern University, Downers Grove, Illinois; Department of Surgery, Rush University, Chicago, Illinois.
| | - Leah C Tatebe
- Department of Trauma and Burn Surgery, Cook County Health, Chicago, Illinois; Department of Surgery, Midwestern University, Downers Grove, Illinois; Department of Surgery, Rush University, Chicago, Illinois
| | - Vytas P Karalius
- Department of Trauma and Burn Surgery, Cook County Health, Chicago, Illinois; Department of Emergency Medicine, Northwestern University, Chicago, Illinois
| | - Erik Liesen
- Department of Trauma and Burn Surgery, Cook County Health, Chicago, Illinois; Department of Surgery, Midwestern University, Downers Grove, Illinois
| | - Sydney Pekarek
- Department of Trauma and Burn Surgery, Cook County Health, Chicago, Illinois; Department of Surgery, Midwestern University, Downers Grove, Illinois
| | - Ann Impens
- Institute for Healthcare Innovation, Midwestern University, Downers Grove, Illinois
| | - Katarina Ivkovic
- Institute for Healthcare Innovation, Midwestern University, Downers Grove, Illinois
| | - Francesco Bajani
- Department of Trauma and Burn Surgery, Cook County Health, Chicago, Illinois
| | - Andrew Khalifa
- Department of Trauma and Burn Surgery, Cook County Health, Chicago, Illinois
| | - Andrew J Dennis
- Department of Trauma and Burn Surgery, Cook County Health, Chicago, Illinois; Department of Surgery, Midwestern University, Downers Grove, Illinois; Department of Surgery, Rush University, Chicago, Illinois
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Agarwal D, Barker CF, Naji A, Schwab CW. Reciprocal Learning Between Military and Civilian Surgeons: Past and Future Paths for Medical Innovation. Ann Surg 2021; 274:e460-e464. [PMID: 31599807 PMCID: PMC8500370 DOI: 10.1097/sla.0000000000003635] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Numerous surgical advances have resulted from exchanges between military and civilian surgeons. As part of the U.S. National Library of Medicine Michael E. DeBakey Fellowship in the History of Medicine, we conducted archival research to shed light on the lessons that civilian surgery has learned from the military system and vice-versa. Several historical case studies highlight the need for immersive programs where surgeons from the military and civilian sectors can gain exposure to the techniques, expertise, and institutional knowledge the other domain provides. Our findings demonstrate the benefits and promise of structured programs to promote reciprocal learning between military and civilian surgery.
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Affiliation(s)
- Divyansh Agarwal
- Medical Scientist Training Program, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Clyde F Barker
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Ali Naji
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - C William Schwab
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Penn Presbyterian Medical Center, Philadelphia, PA
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Borgers F, Van Boxstael S, Sabbe M. Is tactical combat casualty care in terrorist attacks suitable for civilian first responders? J Trauma Acute Care Surg 2021; 91:e86-e92. [PMID: 34238863 DOI: 10.1097/ta.0000000000003337] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Prehospital management of intentional mass casualty incidents is a unique challenge to Emergency Medical Services. Tactical Combat Casualty Care (TCCC) and the use of tourniquets for extremity hemorrhage have already proven to reduce mortality on the battlefield. This literature review aims to determine the place of these military concepts in a civilian high-threat prehospital setting. METHODS The PubMed database was searched for articles published between January 1, 2000, and December 1, 2019, containing descriptions, discussions, or experiences of the application of tourniquets or other TCCC-based interventions in the civilian prehospital setting. Data extraction focused on identifying important common themes in the articles. RESULTS Of the 286 identified articles, 30 were selected for inclusion. According to the Oxford Centre for Evidence-based Medicine Levels of Evidence, overall level of evidence was low. Most articles were observational, retrospective cohort studies without a nontourniquet control group. Outcome measures and variables were variably reported. Two articles specifically analyzed tourniquet use during high-threat situations, and three described their application by law enforcement personnel. Overall, tourniquets were found to be effective in stopping major limb bleeding. Reported mortality was low and related complications appeared to be infrequent. Only four articles mentioned the application of other TCCC-based maneuvers, such as airway and respiratory management. CONCLUSION This literature review shows that tourniquets appear to be safe tools associated with few complications and might be effective in controlling major bleeding in civilian limb trauma. For example, during mass casualty incidents, their use could be justified. Training and equipping ambulance and police services to deal with massive bleeding could likewise improve interoperability and victim survival in a civilian high-threat prehospital setting. More qualitative research is needed to further evaluate the effects of hemorrhage control training for first responders on patient outcomes. Literature describing the application of other TCCC-based principles is limited, which makes it difficult to draw conclusions regarding their use in a civilian setting. LEVEL OF EVIDENCE Systematic review, level III.
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Affiliation(s)
- Felix Borgers
- From the Department of Anesthesiology (F.B.), University Hospitals Leuven, Leuven, Belgium; Emergency Department (V.B.), ZOL Hospital Genk, Genk, Belgium; and Emergency Department (M.S.), University Hospitals Leuven, Leuven, Belgium
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Mikdad S, Mokhtari AK, Luckhurst CM, Breen KA, Liu B, Kaafarani HMA, Velmahos G, Mendoza AE, Bloemers FW, Saillant N. Implications of the national Stop the Bleed campaign: The swinging pendulum of prehospital tourniquet application in civilian limb trauma. J Trauma Acute Care Surg 2021; 91:352-360. [PMID: 33901049 DOI: 10.1097/ta.0000000000003247] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Prehospital tourniquet (PHT) utilization has increased in response to mass casualty events. We aimed to describe the incidence, therapeutic effectiveness, and morbidity associated with tourniquet placement in all patients treated with PHT application. METHODS A retrospective observational cohort study was performed to evaluate all adults with a PHT who presented at two Level I trauma centers between January 2015 and December 2019. Medically trained abstractors determined if the PHT was clinically indicated (placed for limb amputation, vascular hard signs, injury requiring hemostasis procedure, or significant documented blood loss). Prehospital tourniquets were further designated as appropriately or inappropriately applied (based on PHT anatomic placement location, occurrence of a venous tourniquet, or ischemic time defined as >2 hours). Statistical analyses were performed to generate primary and secondary results. RESULTS A total of 147 patients met study inclusion criteria, of which 70% met the criteria for trauma registry inclusion. Total incidence of PHT utilization increased from 2015 to 2019, with increasing proportions of PHTs placed by nonemergency medical service personnel. Improvised PHTs were frequently used. Prehospital tourniquets were clinically indicated in 51% of patients. Overall, 39 (27%) patients had a PHT that was inappropriately placed, five of which resulted in significant morbidity. CONCLUSION In summary, prehospital tourniquet application has become widely adopted in the civilian setting, frequently performed by civilian and nonemergency medical service personnel. Of PHTs placed, nearly half had no clear indication for placement and over a quarter of PHTs were misapplied with notable associated morbidity. Results suggest that the topics of clinical indication and appropriate application of tourniquets may be important areas for continued focus in future tourniquet educational programs, as well as future quality assessment efforts. LEVEL OF EVIDENCE Epidemiological, level III; Therapeutic, level IV.
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Affiliation(s)
- Sarah Mikdad
- From the Division of Trauma, Emergency Surgery and Surgical Critical Care (S.M., A.K.M., C.M.L., K.A.B., B.L., H.M.A.K., G.V., A.E.M., N.S.), Massachusetts General Hospital, Boston, Harvard Medical School, Boston, Massachusetts; and Department of Trauma Surgery (S.M., F.W.B.), Amsterdam UMC, Amsterdam, the Netherlands
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Pottecher J, Lefort H, Adam P, Barbier O, Bouzat P, Charbit J, Galinski M, Garrigue D, Gauss T, Georg Y, Hamada S, Harrois A, Kedzierewicz R, Pasquier P, Prunet B, Roger C, Tazarourte K, Travers S, Velly L, Gil-Jardiné C, Quintard H. Guidelines for the acute care of severe limb trauma patients. Anaesth Crit Care Pain Med 2021; 40:100862. [PMID: 34059492 DOI: 10.1016/j.accpm.2021.100862] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
GOAL To provide healthcare professionals with comprehensive multidisciplinary expert recommendations for the acute care of severe limb trauma patients, both during the prehospital phase and after admission to a Trauma Centre. DESIGN A consensus committee of 21 experts was formed. A formal conflict-of-interest (COI) policy was developed at the onset of the process and enforced throughout. The entire guidelines process was conducted independently of any industrial funding (i.e., pharmaceutical, medical devices). The authors were advised to follow the rules of the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) system to guide assessment of the quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasised. Few recommendations remained non-graded. METHODS The committee addressed eleven questions relevant to the patient suffering severe limb trauma: 1) What are the key findings derived from medical history and clinical examination which lead to the patient's prompt referral to a Level 1 or Level 2 Trauma Centre? 2) What are the medical devices that must be implemented in the prehospital setting to reduce blood loss? 3) Which are the clinical findings prompting the performance of injected X-ray examinations? 4) What are the ideal timing and modalities for performing fracture fixation? 5) What are the clinical and operative findings which steer the surgical approach in case of vascular compromise and/or major musculoskeletal attrition? 6) How to best prevent infection? 7) How to best prevent thromboembolic complications? 8) What is the best strategy to precociously detect and treat limb compartment syndrome? 9) How to best and precociously detect post-traumatic rhabdomyolysis and prevent rhabdomyolysis-induced acute kidney injury? 10) What is the best strategy to reduce the incidence of fat emboli syndrome and post-traumatic systemic inflammatory response? 11) What is the best therapeutic strategy to treat acute trauma-induced pain? Every question was formulated in a PICO (Patient Intervention Comparison Outcome) format and the evidence profiles were produced. The literature review and recommendations were made according to the GRADE® methodology. RESULTS The experts' synthesis work and the application of the GRADE method resulted in 19 recommendations. Among the formalised recommendations, 4 had a high level of evidence (GRADE 1+/-) and 12 had a low level of evidence (GRADE 2+/-). For 3 recommendations, the GRADE method could not be applied, resulting in an expert advice. After two rounds of scoring and one amendment, strong agreement was reached on all the recommendations. CONCLUSIONS There was significant agreement among experts on strong recommendations to improve practices for severe limb trauma patients.
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Affiliation(s)
- Julien Pottecher
- Service d'Anesthésie-Réanimation & Médecine Péri-Opératoire, Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, 1 avenue Molière, 67098 Strasbourg Cedex, France; Université de Strasbourg, FMTS, France.
| | - Hugues Lefort
- Structure des urgences, Hôpital d'Instruction des Armées Legouest, BP 9000, 57077 Metz Cédex 03, France
| | - Philippe Adam
- Service de Chirurgie Orthopédique et de Traumatologie, Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, 1 Avenue Molière, 67098 Strasbourg Cedex, France
| | - Olivier Barbier
- Service de Chirurgie Orthopédique et Traumatologie, Hôpital d'Instruction des Armées Sainte Anne, 2 boulevard Sainte Anne, 83000 Toulon, France; Ecole du Val de Grace, 2 place Alphonse Laveran, 75005 Paris, France
| | - Pierre Bouzat
- Université Grenoble Alpes, Pôle Anesthésie-Réanimation, Centre Hospitalo-Universitaire Grenoble-Alpes, Grenoble, France
| | - Jonathan Charbit
- Soins critiques DAR Lapeyronie, CHU Montpellier, France; Réseau OcciTRAUMA, Réseau Régional Occitanie de prise en charge des traumatisés sévères, France
| | - Michel Galinski
- Pôle urgences adultes - SAMU 33, Hôpital Pellegrin, CHU de Bordeaux 3300 Bordeaux, France; INSERM U1219, ISPED, Bordeaux Population Health Research Center INSERM U1219-"Injury Epidemiology Transport Occupation" Team, F-33076 Bordeaux Cedex, France
| | - Delphine Garrigue
- Pôle d'Anesthésie Réanimation, Pôle de l'Urgence, CHU Lille, F-59000 Lille, France
| | - Tobias Gauss
- Service d'Anesthésie-Réanimation, Hôpital Beaujon, DMU PARABOL, AP-HP Nord, Clichy, France; Université de Paris, Paris, France
| | - Yannick Georg
- Service de Chirurgie Vasculaire et Transplantation Rénale, Hôpitaux Universitaire de Strasbourg, Strasbourg, France
| | - Sophie Hamada
- Département d'Anesthésie Réanimation, Hôpital Européen Georges Pompidou, APHP, Université de Paris, Paris, France
| | - Anatole Harrois
- Département d'anesthésie-réanimation, Assistance Publique-Hôpitaux de Paris (AP-HP), Université Paris Saclay, 78 rue du Général Leclerc, 94275 Le Kremlin Bicêtre, France
| | - Romain Kedzierewicz
- Ecole du Val de Grace, 2 place Alphonse Laveran, 75005 Paris, France; Bureau de Médecine d'Urgence, Division Santé, Brigade de Sapeurs-Pompiers de Paris, 1 place Jules Renard, 75017 Paris, France
| | - Pierre Pasquier
- Département anesthésie-réanimation, Hôpital d'instruction des armées Percy, Clamart, France; Brigade de Sapeurs-Pompiers de Paris, Paris, France
| | - Bertrand Prunet
- Ecole du Val de Grace, 2 place Alphonse Laveran, 75005 Paris, France; Brigade de Sapeurs-Pompiers de Paris, Paris, France
| | - Claire Roger
- Service de Réanimation Chirurgicale, Pôle Anesthésie Réanimation Douleur Urgence, CHU Carémeau, 30000 Nîmes, France
| | - Karim Tazarourte
- Service SAMU-Urgences, CHU Edouard Herriot, Hospices civils de Lyon, Lyon, France; Université Lyon 1 Hesper EA 7425, Lyon, France
| | - Stéphane Travers
- Ecole du Val de Grace, 2 place Alphonse Laveran, 75005 Paris, France; 1ère Chefferie du Service de Santé, Villacoublay, France
| | - Lionel Velly
- Service d'Anesthésie Réanimation, CHU Timone Adultes, 264 rue St Pierre 13005 Marseille, France; MeCA, Institut de Neurosciences de la Timone - UMR 7289, Aix Marseille Université, Marseille, France
| | - Cédric Gil-Jardiné
- Pôle Urgences adultes SAMU-SMUR, CHU Bordeaux, Bordeaux Population Health - INSERM U1219 Université de Bordeaux, Equipe IETO, Bordeaux, France
| | - Hervé Quintard
- Soins Intensifs, Hôpitaux Universitaires de Genève, Genève, Suisse
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Bulger EM. A Growing Body of Evidence Supports the American College of Surgeons Stop the Bleed Program. J Am Coll Surg 2021; 233:239-240. [PMID: 34304820 DOI: 10.1016/j.jamcollsurg.2021.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 04/05/2021] [Indexed: 11/26/2022]
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Barnard LM, Guan S, Zarmer L, Mills B, Blackwood J, Bulger E, Yang BY, Johnston P, Vavilala MS, Sayre MR, Rea TD, Murphy DL. Prehospital tourniquet use: An evaluation of community application and outcome. J Trauma Acute Care Surg 2021; 90:1040-1047. [PMID: 34016927 DOI: 10.1097/ta.0000000000003145] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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. LEVEL OF EVIDENCE Therapeutic, level IV.
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Affiliation(s)
- Leslie M Barnard
- From the Division of Emergency Medical Services Pubic Health Seattle & King County (L.M.B., S.G., J.B., T.D.R.), Seattle, Washington; Department of Neurobiology (L.Z.), University of California Los Angeles, Los Angeles, California; Harborview Injury Prevention and Research Center (B.M., M.S.V.), University of Washington, Seattle, Washington; Department of Epidemiology (B.M.), University of Washington, Seattle, Washington; Department of Surgery (E.B., P.J.), University of Washington, Seattle, Washington; Department of Emergency Medicine (B.Y.Y., M.R.S., D.L.M.), University of Washington, Seattle, Washington; Department of Anesthesiology and Pain Medicine (M.S.V.), University of Washington, Seattle, Washington; Seattle Fire Department (M.R.S.); and Department of Medicine (T.D.R.), University of Washington, Seattle, Washington
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Erste Hilfe. Notf Rett Med 2021. [DOI: 10.1007/s10049-021-00886-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Roman P, Rodriguez-Alvarez A, Bertini-Perez D, Ropero-Padilla C, Martin-Ibañez L, Rodriguez-Arrastia M. Tourniquets as a haemorrhage control measure in military and civilian care settings: An integrative review. J Clin Nurs 2021. [PMID: 33969561 DOI: 10.1111/jocn.15834] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 04/14/2021] [Accepted: 04/19/2021] [Indexed: 11/30/2022]
Abstract
AIMS AND OBJECTIVES The aim of review was to describe and synthesise the evidence on the use of tourniquets to control haemorrhages, summarising both civilian and military use. BACKGROUND Trauma-related haemorrhage constitutes one of the most preventable deaths among injured patients, particularly in multi-casualty incidents and disasters. In this context, safe instruments such as tourniquets are essential to help healthcare professionals to minimise loss of life and maximise patient recovery. DESIGN AND METHODS An integrative review was conducted in Medline, Nursing & Allied Health Premium, and Health & Medical Collection, using published data until March 2021 and following the PRISMA guidelines. RESULTS A total of 25 articles were included. Evidence has been synthesised to understand the use of different types of tourniquets, environment of application, indication for their placement and potential complications associated with tourniquet placement. CONCLUSIONS Commercial tourniquets such as Combat Application Tourniquet or Emergency Tourniquet models are a valuable and safe instrument for haemorrhage control in both military and civilian out-of-hospital care settings. Nurses, as part of emergency teams, and other professionals should be aware that there is a possibility of adverse complications, but they are directly proportional to the time of tourniquet placement and generally temporary. In addition, national and international guidelines ensure the need for all civilian emergency services to be equipped with these devices, as well as for the training of healthcare professionals and first responders in their use. RELEVANCE TO CLINICAL PRACTICE Despite the lack of complications in the use of tourniquets in these cases, their use has been a matter of debate for decades. In this sense, this review yields up-to-date guidelines in the use of tourniquets, their recommendations and their significance among professionals to manage complicated situations.
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Affiliation(s)
- Pablo Roman
- Faculty of Health Sciences, Department of Nursing Science, Physiotherapy and Medicine, University of Almeria, Almeria, Spain
- Research Group CTS-451 Health Sciences, University of Almeria, Almeria, Spain
- Health Research Centre, University of Almeria, Almeria, Spain
| | | | | | - Carmen Ropero-Padilla
- Faculty of Health Sciences, Pre-Department of Nursing, Jaume I University, Castellon de la Plana, Spain
- Research Group CYS, Faculty of Health Sciences, Jaume I University, Castello de la Plana, Spain
| | - Luis Martin-Ibañez
- Field Artillery Group, Light Infantry Brigade "King Alfonso XIII" II of the Legion, Almeria, Spain
| | - Miguel Rodriguez-Arrastia
- Faculty of Health Sciences, Pre-Department of Nursing, Jaume I University, Castellon de la Plana, Spain
- Research Group CYS, Faculty of Health Sciences, Jaume I University, Castello de la Plana, Spain
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TURA İ, ERDEN S. Evidence-Based Recommendations For Non-Cpr First Aid Applications. KAHRAMANMARAŞ SÜTÇÜ İMAM ÜNIVERSITESI TIP FAKÜLTESI DERGISI 2021. [DOI: 10.17517/ksutfd.907345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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Increased Use of Prehospital Tourniquet and Patient Survival: Los Angeles Countywide Study. J Am Coll Surg 2021; 233:233-239.e2. [PMID: 33895335 DOI: 10.1016/j.jamcollsurg.2021.03.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 03/08/2021] [Accepted: 03/22/2021] [Indexed: 10/21/2022]
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.
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A Survey of Hospitalized Trauma Patients in Hemorrhage Control Education: Are Trauma Victims Willing to Stop the Bleed? J Surg Res 2021; 264:469-473. [PMID: 33852987 DOI: 10.1016/j.jss.2021.03.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 03/02/2021] [Accepted: 03/10/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND The Stop the Bleed (STB) campaign was developed in part to educate the lay public about hemorrhage control techniques aimed at reducing preventable trauma deaths. Studies have shown this training increases bystanders' confidence and willingness to provide aid. One high-risk group might be better solicited to take the course: individuals who have been a victim of previous trauma, as high rates of recidivism after trauma are well-established. Given this group's risk for recurrent injury, we evaluated their attitudes toward STB concepts. METHODS We surveyed trauma patients admitted to 3 urban trauma centers in Baltimore from January 8, 2020 to March 14, 2020. The survey was terminated prematurely due to the COVID-19 pandemic. Trauma patients hospitalized on any inpatient unit were invited to complete the survey via an electronic tablet. The survey asked about demographics, prior exposure to life-threatening hemorrhage and first aid training, and willingness to help a person with major bleeding. The Johns Hopkins IRB approved waiver of consent for this study. RESULTS Fifty-six patients completed the survey. The majority of respondents had been hospitalized before (92.9%) and had witnessed severe bleeding (60.7%). The majority had never taken a first aid course (60.7%) nor heard of STB (83.9%). Most respondents would be willing to help someone with severe bleeding form a car crash (98.2%) or gunshot wound (94.6%). CONCLUSIONS Most patients admitted for trauma had not heard about Stop the Bleed, but stated willingness to respond to someone injured with major bleeding. Focusing STB education on individuals at high-risk for trauma recidivism may be particularly effective in spreading the message and skills of STB.
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El Bashtaly A, Khalil E, Méthot F, Ledoux-Hutchinson L, Franc JM, Homier V. Tourniquet application by schoolchildren-a randomized crossover study of three commercially available models. J Trauma Acute Care Surg 2021; 90:666-672. [PMID: 33405474 DOI: 10.1097/ta.0000000000003055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Life-threatening hemorrhage is a major cause of preventable mortality in trauma. Studies have demonstrated the effectiveness and safety of commercial tourniquets when used by adult civilians. However, there are no data about tourniquet application by children.This study's goal is to determine which of three commercially available tourniquets is most effective when used by children. METHODS A randomized crossover study was conducted in four elementary schools in Montreal to compare three commercially available tourniquets. The study population is primary school children aged 10 to 12 years (5th-6th grade). A total of 181 students were invited to participate; 96 obtained parental approval and were recruited. Participants underwent a short 7-minute video training on the use of three commercial tourniquets and were subsequently given a 2-minute practice period. Students were evaluated on their ability to successfully apply the tourniquet and the time to complete application. After applying all three tourniquets, the students selected their favorite model. The primary outcome is the proportion of successful applications per tourniquet model. Secondary outcomes include time to successful application for each tourniquet model and tourniquet model preference. RESULTS The mechanical advantage tourniquet (MAT) outperformed the combat application tourniquet (CAT) and the stretch wrap and tuck tourniquet (SWATT) in terms of success rate (MAT, 67%; CAT, 44%; SWATT, 24%; p < 0.0001), time to application (MAT, 57 seconds; CAT, 80 seconds; SWATT, 90 seconds; p < 0.0001), and preference (MAT, 64%; CAT, 30%; SWATT, 6%; p < 0.0001). CONCLUSION In this study, the MAT performs better in terms of success rate, time to application, and preference when used by school-aged children. This study can be helpful when facilities are purchasing tourniquets for use by students.
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Affiliation(s)
- Alaa El Bashtaly
- From the Faculty of Medicine (A.E.B., F.M., L.L.-H.), Université de Montreal; Pediatric Emergency Medicine (E.K.), Montreal Children's Hospital, Montreal, Quebec; Faculty of Medicine (J.M.F.), University of Alberta, Edmonton, Alberta; and Adult Emergency Medicine (V.H.), McGill University Health Centre, Montreal, Quebec, Canada
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Zideman DA, Singletary EM, Borra V, Cassan P, Cimpoesu CD, De Buck E, Djärv T, Handley AJ, Klaassen B, Meyran D, Oliver E, Poole K. European Resuscitation Council Guidelines 2021: First aid. Resuscitation 2021; 161:270-290. [PMID: 33773828 DOI: 10.1016/j.resuscitation.2021.02.013] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
The European Resuscitation Council has produced these first aid guidelines, which are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. The topics include the first aid management of emergency medicine and trauma. For medical emergencies the following content is covered: recovery position, optimal positioning for shock, bronchodilator administration for asthma, recognition of stroke, early aspirin for chest pain, second dose of adrenaline for anaphylaxis, management of hypoglycaemia, oral rehydration solutions for treating exertion-related dehydration, management of heat stroke by cooling, supplemental oxygen in acute stroke, and presyncope. For trauma related emergencies the following topics are covered: control of life-threatening bleeding, management of open chest wounds, cervical spine motion restriction and stabilisation, recognition of concussion, cooling of thermal burns, dental avulsion, compression wrap for closed extremity joint injuries, straightening an angulated fracture, and eye injury from chemical exposure.
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Affiliation(s)
| | | | - Vere Borra
- Centre for Evidence-based Practice, Belgian Red Cross, Mechelen, Belgium; Cochrane First Aid, Mechelen, Belgium
| | - Pascal Cassan
- International Federation of Red Cross and Red Crescent, France
| | - Carmen D Cimpoesu
- University of Medicine and Pharmacy "Grigore T. Popa", Iasi, Emergency Department and Prehospital EMS SMURD Iasi Emergency County Hospital "Sf. Spiridon" Iasi, Romania
| | - Emmy De Buck
- Centre for Evidence-based Practice, Belgian Red Cross, Mechelen, Belgium; Cochrane First Aid, Mechelen, Belgium; Department of Public Health and Primary Care, Faculty of Medicine, KU Leuven, Leuven, Belgium
| | - Therese Djärv
- Department of Medicine Solna, Karolinska Institute and Division of Acute and Reparative Medicine, Karolinska University Hospital, Sweden
| | | | - Barry Klaassen
- Emergency Medicine, Ninewells Hospital and Medical School Dundee, UK; British Red Cross, UK
| | - Daniel Meyran
- French Red Cross, Bataillon de Marins Pompiers de Marseille, France
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Gallagher JJ, Adamski J. Mass Casualties and Disaster Implications for the Critical Care Team. AACN Adv Crit Care 2021; 32:76-88. [PMID: 33725109 DOI: 10.4037/aacnacc2021235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Preparing for disasters both natural and anthropogenic requires assessment of risk through hazard vulnerability analysis and formulation of facility and critical care-specific disaster plans. Disaster surge conditions often require movement from conventional to contingency or crisis-level operations to meet the needs of the many under our care. Predisaster planning for modification of critical care space, staffing, and supplies is essential to successful execution of operations during a surge. Expansion of intensive care unit beds to nonconventional units such as perioperative areas, general care units, and even external temporary units may be necessary. Creative, tiered staffing models as well as just-in-time education of noncritical care clinicians and support staff are important to multiply capable personnel under surge conditions. Finally, anticipation of demand for key equipment and supplies is essential to maintain stockpiles, establish supply chains, and sustain operations under prolonged disaster scenarios.
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Affiliation(s)
- John J Gallagher
- John J. Gallagher is Professor, Department of Acute & Tertiary Care, School of Nursing, University of Pittsburgh, 3500 Victoria Street, Pittsburgh, PA 15213
| | - Jennifer Adamski
- Jennifer Adamski is Adult-Gerontology Acute Care Nurse Practitioner Program Director and Assistant Professor, Emory University, Atlanta, GA; and Critical Care Nurse Practitioner, Critical Care Flight Team, Cleveland Clinic, Cleveland, Ohio
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Real-time breath recognition by movies from a small drone landing on victim's bodies. Sci Rep 2021; 11:5042. [PMID: 33658612 PMCID: PMC7930045 DOI: 10.1038/s41598-021-84575-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 02/15/2021] [Indexed: 11/08/2022] Open
Abstract
In local and global disaster scenes, rapid recognition of victims' breathing is vital. It is unclear whether the footage transmitted from small drones can enable medical providers to detect breathing. This study investigated the ability of small drones to evaluate breathing correctly after landing on victims' bodies and hovering over them. We enrolled 46 medical workers in this prospective, randomized, crossover study. The participants were provided with envelopes, from which they were asked to pull four notes sequentially and follow the written instructions ("breathing" and "no breathing"). After they lied on the ground in the supine position, a drone was landed on their abdomen, subsequently hovering over them. Two evaluators were asked to determine whether the participant had followed the "breathing" or "no breathing" instruction based on the real-time footage transmitted from the drone camera. The same experiment was performed while the participant was in the prone position. If both evaluators were able to determine the participant's breathing status correctly, the results were tagged as "correct." All experiments were successfully performed. Breathing was correctly determined in all 46 participants (100%) when the drone was landed on the abdomen and in 19 participants when the drone hovered over them while they were in the supine position (p < 0.01). In the prone position, breathing was correctly determined in 44 participants when the drone was landed on the abdomen and in 10 participants when it was kept hovering over them (p < 0.01). Notably, breathing status was misinterpreted as "no breathing" in 8 out of 27 (29.6%) participants lying in the supine position and 13 out of 36 (36.1%) participants lying in the prone position when the drone was kept hovering over them. The landing points seemed wider laterally when the participants were in the supine position than when they were in the prone position. Breathing status was more reliably determined when a small drone was landed on an individual's body than when it hovered over them.
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