Emergencias 2019;31:47-54

REVIEW ARTICLE Tourniquet use in out-of-hospital emergency care: a systematic review

Mara Alonso-Algarabel 1, Xavier Esteban-Sebastià 2, Azucena Santillán-García 3, Rafael Vila-Candel 4,5

Objective. Uncontrolled bleeding from serious injuries continues to be one of the main causes of preventable deaths Author affiliation: 1Surgery Unit and Outpatient, outside hospitals. Tourniquets could be useful for quickly stemming blood flow and prevent exsanguination, although Hospital Universitario Miguel evidence supporting their use and effectiveness in civilian accidents is limited. To analyze the effectiveness of tourni - Servet, Zaragoza, Spain. quets for stopping bleeding in out-of-hospital emergencies and to explore factors associated with effectiveness. 2Emergency Department, Hospital Comarcal Vinarós, Castellón, Methods. We undertook a systematic review of the literature in Spanish and English. Search protocols to identify Spain 3 studies that evaluated the use of various devices and their effectiveness in stemming arterial blood flow. We included Cardiology Department, Hospital Universitario de Burgos, Burgos, studies published between 2011 and 2016 in which tourniquets were used to prevent massive blood loss. Spain 4Department of Obstetrics and Results. We included 17 articles. Tourniquets were effective in stopping massive bleeding in all studies. Pain, the most Gynecology, Hospital Universitario frequently described adverse effect, was observed in 420 patients (35.7%). Delayed application of a tourniquet was de la Ribera, Alzira, Valencia, associated with more negative outcomes. Spain. 5Nursing Department, Conclusions. Tourniquets are effective for stopping massive blood loss. There are few complications, most of which are Universidad Católica de Valencia attributable to the critical state of patients rather than to application of the tourniquet. A tourniquet should be applied San Vicente Mártir, Valencia, Spain. in major trauma cases in civilian settings if massive, life-threatening bleeding cannot be stopped with direct pressure. Keywords: Tourniquets. Hemorrhage. Exsanguination. Emergency medical services. Corresponding author: Rafael Vila Candel Department of Obstetrics and Gynecology Hospital Universitario de la Ribera Utilización del torniquete en la asistencia extrahospitalaria: revisión Crtra. Corbera, km. 1 sistemática 46600 Alzira, Valencia, Spain E-mail: Objetivo. La hemorragia no controlada producida por un traumatismo grave sigue siendo una de las principales cau - [email protected] sas de muerte evitable en el entorno extrahospitalario. En estas situaciones, los torniquetes podrían ser una herra - Article information: mienta rápida y útil para detener el sangrado exanguinante, aunque existe evidencia limitada en cuanto a su utiliza - Received: 17-1-2018 ción y efectividad en el entorno civil. Analizar la efectividad del torniquete para detener las hemorragias en Accepted: 18-3-2018 Online: 13-6-2018 situaciones de urgencia extrahospitalaria y los factores relacionados. Método. Revisión sistemática de la bibliografía en español e inglés. Se elaboraron protocolos de búsqueda para locali - Editor in charge: Juan González del Castillo zar estudios que valoraran la utilización de los distintos dispositivos y la efectividad en la detención del flujo arterial. Se incluyeron estudios publicados entre 2011 y 2016, con utilización del torniquete en hemorragias exanguinantes. Resultados. Se analizaron 17 artículos. En todos los estudios se observó que el torniquete fue efectivo en la detención de la hemorragia, siendo el dolor el efecto adverso más frecuentemente descrito (35,7% de los casos). El retraso en su aplicación es un factor determinante que afecta negativamente a la efectividad. Conclusiones. Los torniquetes son efectivos deteniendo la hemorragia exanguinante. Sus complicaciones son escasas y la mayoría son atribuibles al estado crítico de los pacientes y no a su colocación. A nivel extrahospitalario, el torni - quete debería utilizarse en pacientes con traumatismo mayor si la presión directa no es suficiente para controlar una hemorragia exanguinante que amenace la vida. Palabras clave: Torniquetes. Hemorragia. Exanguinación. Servicios médicos de emergencia.

Introduction from a joint of the torso to the extremities, specifically, the base of the neck, shoulder, armpit, perineum, but - Traumatic aetiology is the sixth leading cause of de - tocks, buttock area, and groin. For this type of blee - ath and the fifth leading cause of moderate and severe ding, limb tourniquets cannot be applied as they can - disability globally, as well as the leading cause of death not control the bleeding. For this reason, junctional and disability in people under 35 years of age 1,2 . tourniquets have been developed, which have proven Tourniquets can first be defined as strips of cloth to be effective in controlling bleeding in the joint area 5. tied tightly around the limbs to stop bleeding by com - In the military context, the current indication for pressing the arteries that supply the area of injury 3. the use of the emergency tourniquet is its application Tourniquets work properly when compression of limb in a limb wound to which pressure can be applied and tissues stops arterial blood flow and the distal pulse is where the personnel who place it value it as a life-thre - not present 4. Union hemorrhage is defined as bleeding atening hemorrhage 6. In this scenario, the application

47 Alonso-Algarabel M, et al. Emergencias 2019;31:47-54

of the tourniquet is the initial and primary method for ces 6,13 . There are no published data on the prevalence the control of severe bleeding. In contrast, the use of of tourniquet use applicable to our environment 14 , al - tourniquets by civil emergency medical services (EMS) though the main commercial tourniquets currently in is not widespread 6. In different countries, civilian EMS use have been identified (Table 1) 4,5,15 . use direct pressure, compressive bandages, bandages, Its use in the military environment has extensive ex - and limb elevation to treat extreme bleeding, using perience, together with the use of haemostatic tourniquets as a last resort 7,8 . This practice is supported agents 8,16,17 . Although the designs and application proto - by different clinical practice guidelines, which recom - cols for tourniquets have been progressively improved, mend its use when all the classic methods of halting there is controversy in the civil pre-hospital setting re - bleeding have failed, due to the limited evidence of its garding their application. Risks due to inappropriate use in the civilian population 9,10 . Different reasons have use, lack of training of professionals or maintenance of been described, such as the variability in its use betwe - prolonged tourniquet times could have led to negative en different international EMS or that its overuse, in results that favoured their lack of use 18 . substitution of the basic bleeding control methods, Therefore, the objective of this systematic review is could cause greater morbidity and mortality 11 . to analyze the effectiveness of a tourniquet in stopping The use of tourniquets has been associated with a bleeding in out-of-hospital emergency situations, as number of muscular, cardiac and neurovascular compli - well as to identify associated factors that favour or dimi - cations 8,12 that could have life-threatening consequen - nish this effectiveness.

Table 1. Types of tourniquets marketed Type of tourniquet Description Image and additional information CAT (Combat Application Tourniquet) It has a strap that must be securely fastened to the end before attaching the Limb tourniquet plastic reel. The strap is secured on itself with velcro, and there is a locking point for the reel. The strap should go through the buckle differently if used for the 4 upper or lower extremity . www.EMSWorld.com MET (Emergency & Military Tourniquet) It is an open loop system composed of a strong belt and aluminum reel. It has Limb tourniquet two fixing points to lock the reel, one that is adjustable and another with velcro 4.

www.savelives.com EMT (Emergency Medical Tourniquet) It is a pneumatic tourniquet similar to a pressure cuff that is easily applied and, Limb tourniquet unlike a blood pressure cuff, the pneumatic bladder in EMT is reinforced to prevent air loss when inflated, allowing the pressure in the limb to be maintained 4 once it is blocked . www.delfimedical.com SWAT-T (Stretch Wrap and Tuck Tourniquet) Elastic band that is applied by wrapping the device around the extremity and Limb tourniquet pressing through the total stretch of the band 4.

www.EMSWorld.com SOFTT (Special Operations Forces Tactical It's an open loop system with a metal reel. It has a narrow strap and a metal Tourniquet) Limb tourniquet "crocodile" clip to secure the strap. Once the reel is applied there are two plastic fixing points 4. www.tacmedsolutions.com SOFTT-W (Special Operations Forces Tactical It has a wider strap than the SOFTT and the clip and locking system were Tourniquet-Wide) replaced by a detachable buckle 4. Limb tourniquet www.EMSWorld.com CRoC (Combat Ready Clamp) It is a small bucket with an aluminium structure to exert mechanical pressure Junctional tourniquet directly on the wound or indirectly on the groin area to stop bleeding 15 .

www.EMSWorld.com JETT (Junctional Emergency Treatment Tool) It consists of a belt system, with two trapezoidal pressure pads and threaded Junctional tourniquet pullers in a T shape 15 .

www.EMSWorld.com SJT (SAM Junctional tourniquet) It is composed of a belt and two pneumatically inflatable bags. It serves to Junctional tourniquet stabilize pelvic fractures and to control joint bleeding in the axillary and inguinal area 15 . www.EMSWorld.com AAT (Abdominal Aortic Tourniquet) o AAJT It is a pneumatic belt that is placed around the abdomen with the inflated part (Abdominal Aortic and Junctional Tourniquet) over the navel, the buckle is manually closed down and tightened with the reel Junctional tourniquet iTClamp Hemorrhage located in the front of the device 15 . Control System Junctional hemorrhage www.EMSWorld.com iTClamp Hemorrhage Control System A mechanical clamp with several small needles that seals a wound by firmly Junctional hemorrhage approaching the edges of the wound 6.

www.EMSWorld.com

48 Alonso-Algarabel M, et al. Emergencias 2019;31:47-54

Method Table 3. Search strategies applied Database Search Strategy Once the area of uncertainty concerning the use of Medline ((("Tourniquets"[Mesh]) AND "Hemorrhage"[Mesh]) tourniquets in out-of-hospital areas was detected, a se - OR "Exsanguination"[Mesh]) NOT "Arthroplasty, arch and review protocol was drawn up in September Replacement, Knee"[Mesh] 2016. In order to carry out this protocol, a team of re - (“Tourniquets” [Mesh]) AND “Emergency Medical Services” [Mesh] viewers was created following the recommendations of ("Tourniquets/utilization"[Mesh]) AND "Emergency 19 both the Cochrane Collaboration and the Joanna Medical Services"[Mesh] Briggs Institute 20 . “from 2011 to 2016” AND “humans” AND Once the review team was established, all partici - “languages: Spanish and English” pants approved the protocol in October 2016. Follo - Science Direct ("Tourniquets" AND "Hemorrhage") OR ("tourniquets" AND "Emergency Medical Service") wing the protocol, a search of the available literature in ("Tourniquets" AND "Utilization") English and Spanish was conducted through the Medli - “from 2011 to 2016” AND “Nursing and Health ne, Scopus and Science Direct databases. The search Professions” AND “Journal” started from a clinically answerable question in PICO Scopus (“Tourniquets” AND “Exsanguination”) OR 3 (“Tourniquets” AND “Emergency Medical Services”) format (Table 2) and from this, search strategies were ("Tourniquets” AND “Emergency Medical Services” designed, as shown in Table 3. AND “Utilization") Inclusion criteria were: scientific literature published (“Tourniquets” AND “Utilization") between 2011 and 2016; research designs for clinical “from 2011 to 2016” AND “languages: Spanish and trials, systematic reviews or analytical observational stu - English” AND “Article and Review” dies (cohorts and case-control); sample of studies com - posed of adults and use of tourniquet in emergency or exsanguinating situations. On the other hand, studies RedETS (Red de Agencias de Evaluación de la Tecnolo - using surgical tourniquets were excluded. gía Sanitaria de España) and contemplate the evalua - The choice of articles, variables and methodological tion of the biases of the different methodological de - 23 quality was made by two reviewers, with the rest of the signs . In addition, they facilitate homogeneity in the researchers intervening in the disagreements. Finally, an evaluation among reviewers. The critical reading was inverse search was performed, reviewing tertiary sour - carried out in pairs, with a third reviewer intervening in ces (Cochrane Library, clinical practice guidelines) and case of discrepancy. grey literature manually (Tactical Combat Casualty Care Guide) to verify if there were other papers that had not been found in the initial search. Results After selecting the studies, a previously designed ex - traction template was used to obtain the following da - The initial search resulted in 751 articles from Medli - ta: author, country and date, type of study, methodolo - ne, Science Direct and Scopus. After eliminating dupli - gical quality, type of scenario, sample size, tourniquet cates (356 articles), and after reading titles and abs - model, effectiveness, survival, adverse effects and mean tracts, 372 were excluded because they were not duration of tourniquet application. Effectiveness was de - related to the emergency tourniquet (Figure 1). fined as the ability to stop the blood flow in the limb in Twenty-three full-text articles were analyzed. Finally, 17 which the device was applied 21,22 . Survival was defined articles were considered valid, as 6 articles were discar - as no death during hospital admission 11 . ded after a more detailed critical reading and were de - The selection of articles, variables and methodologi - termined to be descriptive studies. Table 4 summarizes cal quality was done by two reviewers, with the rest of the main characteristics of the 17 studies analyzed (Ta - researchers intervening in the disagreements. ble 4) 5,11,21,22,24-36 . The majority were from the United Sta - To evaluate the methodological quality of the arti - tes (10), and the rest from the United Kingdom (3), Ca - cles we used the Critical Reading Cards (FLC 2.0) deve - nada (2), Turkey (1) and Holland (1). Studies ranged loped by Osteba, Servicio de Evaluación de Tecnologías from 10 to 4,297 patients (5,654 in total), and were Sanitarias. The FLC 2.0 contemplates the evaluation cri - published between 2011 and 2016. With regard to the teria of the main recognized tools according to the re - type of design, the same number of publications with search design that evaluates each card (Cochrane, PRIS - experimental design as observational (7) were found, MA, and AGREE among the most important). In this with a clearly higher number than the systematic re - regard, the review team also observed the risk of bias, views (3). in addition to the methodological quality of the studies. In all publications the efficiency of the tourniquet These files are validated by the eight agencies of the could be appreciated, although only in 7 of them it was evaluated quantitatively 21,25-27,30,32,34 . We observe that Table 2. Structure of the PICO question limb tourniquets were effective between 69- 26,27,30,32,34 P (patient) Adult patient with exanguinant hemorrhage. 97% . The Emergency Medical Tourniquet (EMT) I (intervention) Use of the tourniquet to stop the bleeding. model showed greater effectiveness over the Combat C (comparison) Does not exist. Application Tourniquet (CAT), since EMT was able to O (results) Containment of bleeding, reduction of side effects. stop arterial flow in patients with a body mass index

49 Alonso-Algarabel M, et al. Emergencias 2019;31:47-54

(22.7%) from the only study that assessed it. Infection Num ber of records identified by database secondary to tourniquet application was found in 17 search (n=751) patients (8.6%) from a single study 24 , a similar figure to venous thromboembolism, with 9 (8.6%), also identi - fied in a single publication 31 . The incidence of compart - ment syndrome was 19 cases (6.3%), described in two Num ber of duplicate records removed publications 31,34 . Other adverse effects observed, al - (n = 356) though less frequently, were: 7 cases (3.6%) of ische - mic injury in one study 34 , 21 (3.2%) of clot formation in 24 Number of records one study , 26 (2.7%) of nerve paralysis in three stu - Num ber of records excluded by title dies 31,34,36 , 10 (1.3%) of renal failure in two studies 31,24 , reviewed t hrough and abstract 24 tit le and abstract 13 (1.9%) of paradoxical bleeding in one study , 10 (n = 395) (not related to the topic) 24 (n = 372) (1.5%) of myonecrosis in one study and 1 (0.2%) of rigidity in one study 24 . Finally, respiratory distress, nau - sea and dizziness were also described, although no data 25 Num ber of full-text Number of full-text on incidence were provided . art icles evaluated arti cles excluded as Regarding the relationship of these adverse effects for eligibility desc riptive studies (n = 23) (n = 6) with the tourniquet application time, one of the publi - cations analyzed 34 found that the group of patients with ischemia or compartment syndrome had the tourniquet applied for less time than those who did not suffer the - Num ber of studies includ ed in the se complications, and therefore may not have been due systematic review to the application of the tourniquet. On the other (n = 17) hand, different studies 24,36 do not show a relationship between the prolonged time of application of the tour - Figure 1. Flowchart for study selection. niquet and cases of nervous paralysis, pain, renal failu - re, formation of clots or myonecrosis. and a higher mean arterial pressure compared to the Lastly, in 9 studies (52.9%) 11,24,26-28,31,34-36 researchers CAT device 29 . Regarding the union models, Combat Re - considered the relationship between tourniquet use and ady Clamp (CRoC) and SAM Junctional tourniquet (SJT) survival. Some of them 24,26 determined a survival increa - were the best rated and their effectiveness ranged from se in the cases in which the tourniquet was applied be - 77-87% 21,25 . fore the appearance of shock signs (pre-shock: 90-96% Different factors associated with the effectiveness of and postshock: 4-18%) 24,26 . Other authors 11 related sur - the tourniquet have been described, such as the seve - vival to the severity of the injury, determining that me - rity and location of the lesion27, its correct and rapid an survival in subjects with lesions in the extremities application30,32 and the time between the lesion and when applying the tourniquet was 96% [578/603], and the application of the tourniquet 26,31,34,36 . decreases as the severity of the injury increases (severe In 11 studies (64.7%) 21,22,24,25,30-36 adverse effects rela - = 98% [550/563], very severe = 76% [28/37], and criti - ted to the application of the tourniquet were described, cal = 0% [0/3]). Other studies 27,31,34 affirm the existence although they were not permanent, except in cases in of an improvement in patient survival through the use which the use of the tourniquet was not performed co - of the tourniquet, although they do not provide speci - rrectly. The most frequently reported adverse effect was fic data. pain, as it was identified in 420 patients (35.7%) and Thanks to the analysis of the methodological qua - evaluated in 7 studies (41.2%) 21,22,24,25,30,32,33 . Differences lity, two publications with a low level of evidence we - were observed between different models of tourniquets re identified, so the information they provide was not in terms of the pain perceived by the volunteers to considered relevant in comparison with the studies whom they were applied. Different studies determined that obtained high (9 studies) and medium (6 studies) that the CAT model produced more pain than the evidence. other models evalu ated, the Special Operations Forces Tactical Tourniquet (SOFTT), Special Operations Forces Tactical Tournique- Wide (SOFTT-W) and Stretch Wrap Discussion and Tuck Tourniquet (SWAT-T) 22,30 . Regarding the junc - tional tourniquets, the application of the Abdominal The results of this review indicate that tourniquet is Aortic and Junctional Tourniquet (AAJT) model was effective in stopping exsanguinating bleeding (high evi - found to produce more pain than the application of dence), with the CAT, EMT and SWAT-T tourniquet mo - the Combat Ready Clamp (CRoC), Junctional Emer - dels showing the greatest effectiveness 22,29 . As for the gency Treatment Tool (JETT) and SAM Junctional tour - possible complications derived from the use of the tour - niquet (SJT) 25 models. niquet, no permanent or serious adverse effects have The second most frequent adverse effect was the been identified that can be directly related to its regula - need for fasciotomy, as it was identified in 148 patients ted application. The most frequently described are pain

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51 Alonso-Algarabel M, et al. Emergencias 2019;31:47-54

and fasciotomy 11,21,22,30-34,37 , although different au - others, given its easy application and degree of effective - thors 28,31,34 determined that the complications were not ness 22,32 . Therefore, if direct pressure is ineffective in con - attributable to the use of the tourniquet, but rather to trolling hemorrhages in the extremities, the use of com - the severity of the lesions. mercial tourniquets such as SWAT-T is recommended. Historically, the use of tourniquets in emergency The four tourniquets approved by the Food & Drug medical care has always been linked to military con - Administration (CRoC, AAJT, JETT, SJT) 38 have been flicts 21 . In recent years, there have been changes in mili - shown to be effective in occlusion of bleeding, with tary practice motivated by recent conflicts in Afghanis - varying degrees of manipulation by users 32 . CRoC and tan, Syria and Iraq. There has been an increase in the SJT models are the most effective and safe, as no se - use of tourniquets and topical haemostatic agents with rious adverse effects have been described 25 . The AAJT good results in the management of trauma on the bat - model is also effective in eliminating axillary and femo - tlefield 34 , although it is not clear if the results in the mi - ral blood flow, although several studies 21,25,33 reported litary field can be extrapolated in a beneficial way to moderate to severe application discomfort that resolved the civilian environment 27,34,36 . immediately after removal of the device. A systematic Today we face an increase in traumatic events of review 5 analysing the different treatment options for the every kind: stabbing and firearms, explosions or other control of junctional and trunk haemorrhage in the pre - terrorist attacks 5,27 . After the attack during the Boston hospital or experimental setting concluded that the le - Marathon in 2013, there were many amputations of lo - vel of evidence from the included studies was low and wer limbs because the devices detonated were strategi - therefore the information it provided was of little use cally placed close to the ground for further damage. on the use of junctional tourniquets. Several of the in - Different health authorities raised the need to imple - terventions discussed require a high level of ability on ment the use of the emergency tourniquet to stop ble - the part of healthcare personnel to control non-com - eding after severe limb trauma 11,27 . In today's military pressible bleeding. We must bear in mind that there is conflicts, there has also been a change in injury pat - a wide variety of devices designed for union bleeding terns because the explosive devices used produce pelvic and that many of them are new to the market, so there fractures, traumatic lower limb amputations and torso are still few studies evaluating them. For the time injuries that require control of union hemorrhages 4. being, controlling bleeding in the junctional and non- Recently, the declaration of the IV Hartford Consen - compressible trunk areas remains a challenge, so we sus 5,35 promotes the application of tourniquets and the cannot make a recommendation on their use due to use of topical hemostatic dressings by all prehospital the small number of quality studies evaluating them. staff, including emergency medical services, and first There is an association between the correct applica - responders to stop bleeding early. TCCC (Tactical Com - tion of the tourniquet, the effectiveness and the survival bat Casualty Care) 37 was first to recommend the use of of the patient 11 . Of all the factors related to effective - tourniquet to control bleeding from limb trauma. Its ness, the correct application stands out, avoiding ve - guidelines also promote the use of tourniquets by te - nous tourniquets (venous stasis without arterial com - ams that provide the first assistance response, health pression, which leads to inflammation of the limb), personnel or passers-by who may be closer to the vic - which can cause a compartment syndrome 36 . Therefore, tim, especially in the case of hostile incidents 31 . adequate training ensures correct and rapid application As far as the effectiveness of the use of the tourni - of the device, reducing exposure time and improving quet in the extremities it is necessary to consider the the survival of the injured 26,31,36 . Different studies have great variety of commercial devices available. The stu - shown that patients without a tourniquet needed more dies analyzed show that the CAT and EMT models are blood transfusions compared to those with a tourniquet the tourniquets that seem to have the best designs 29 . applied early, finding that such application increases CAT is a fast applying device that occludes distal blood survival 11,26,36 . However, a study of 190 patients from flow better than SOFTT and SOFTT-W 27,30 models. On two large trauma centers found no statistically signifi - the other hand, Taylor et al. in 2011 (high methodolo - cant differences in the mortality rate between patients gical quality) conclude that CAT is not effective in stop - who received a pre-hospital tourniquet and those who ping bleeding if applied at mid-thigh level compared to did not. It should be noted that this study was limited EMT pneumatic tourniquet 29 . However, despite the ad - by the small number of patients who received pre-hos - vantage of EMT over CAT, in the military setting the pital tourniquets 28 . use of EMT is not recommended because it is not de - In the civilian population, in which pre-hospital signed for self-application 29 . On the other hand, Wall et tourniquets were used, most of the cases were applied al. in 2013 (medium methodological quality) compared safely and effectively 26,34 . Patients who lose the pre-hos - the CAT system with the SWAT-T model, observing that pital tourniquet or it is applied late have a higher inci - the effectiveness of SWAT-T is identical and also has the dence of shock (85.7% vs 60%) and blood transfusions advantage of requiring less pressure to achieve occlu - (71.4% vs 40%) 26 . However, in the study by Schroll et sion compared to the first 22 . al. (high methodological quality) 34 no significant diffe - In view of the results, we could say that the SWAT-T rences were observed between the mortality of patients model is designed to be used in tactical or first aid sce - who were in a state of shock and those who were not narios by soldiers, military doctors or the police, among at the time of applying the tourniquet (2.7% vs 1.5%;

52 Alonso-Algarabel M, et al. Emergencias 2019;31:47-54

p > 0.05). This study was limited by the low overall Ethical Responsibilities: All authors have confirmed the maintenance of confidentiality and respect for patients' rights in the author's responsibi - mortality rate, in addition to having a small number of lities document, publication agreement, and assignment of rights to patients in a state of shock at the time of application. EMERGENCIAS. Thus, the evidence suggests that the use of a tourni - Article not commissioned by the Editorial Board and peer-reviewed quet before the onset of shock improves survival 11,26,31,36 . externall The use of tourniquets in military and civil prehospital settings is recommended for the control of significant References limb bleeding if direct pressure is ineffective 28,34,35 . No permanent or serious adverse effects have been 1 Alberdi F, García I, Atutxa L, Zabarte M. Grupo de Trabajo de Trau - identified with regard to the possible complications ari - ma y Neurointensivismo de SEMICYUC. Epidemiología del trauma grave. Med Intensiva. 2014;38:580-8. sing from the use of the tourniquet. Pain was identified 2 Organización Mundial de la Salud. Primeras 10 causas de muerte as the most common adverse effect. In the study by [Internet]. 2017. (Consultado 13 Febrero 2017). Disponible en: 24 http://www.who.int/gho/mortality_burden_disease/causes_death/top Kragh et al. (mean methodological quality) , the au - _10/en/ thors describe that along with pain there were 8 cases 3 Inaba K, Siboni S, Resnick S, Zhu J, Wong MD, Haltmeier T, et al. of nerve paralysis derived from its application that were Tourniquet use for civilian extremity trauma. J Trauma Acute Care Surg. 2015;79:232-7. remitting in a period of between 3 minutes and 3 days. 4 Reed Smith E, Shapiro G. The Facts & Details About Different Types Different authors 31,34 determined that the complications of Tourniquets. JEMS. 2013;38:48-52. observed were not attributable to the use of the tourni - 5 van Oostendorp SE, Tan ECTH, Geeraedts LMG, Jr. Prehospital con - trol of life-threatening truncal and junctional haemorrhage is the ul - quet, but rather to the severity of the injuries produced timate challenge in optimizing trauma care; a review of treatment by the trauma in patients. Passos et al. (high methodo - options and their applicability in the civilian trauma setting. Scand J 28 Trauma Resusc Emerg Med. 2016;24:110. logical quality) agree with this assertion, since they 6 Kragh JF Jr. Use of tourniquets and their effects on limb function in found that the use of a tourniquet did not cause a hig - the modern combat environment. Foot Ankle Clin. 2010;15:23-40. her percentage of compartment syndrome or limb am - 7 Doyle GS, Taillac PP. Tourniquets: a review of current use with proposals for expanded prehospital use. Prehosp Emerg Care. 2008;12:241-56. putations, but that these effects were related to the se - 8 Lee C, Porter KM, Hodgetts TJ. Tourniquet use in the civilian prehos - verity of the trauma. In addition, not applying the pital setting. Emerg Med J. 2007;24:584-7. tourniquet may increase the severity of the injury or 9 Singletary EM, Charlton NP, Epstein JL, Ferguson JD, Jensen JL, Mac - Pherson AI, et al. Part 15: First aid: 2015 American Heart Association compromise the patient's life. and American red cross guidelines update for first aid. Circulation. As limitations of the present study, we have obser - 2015;132:S574-89. 10 Monsieurs KG, Nolan JP, Bossaert LL, Greif R, Maconochie IK, Niko - ved the lack of existing bibliography on this subject laou NI, et al. Recomanacions per a la Ressuscitació 2015 del Consell that provides good methodological quality, in addition Europeu de Ressuscitació (ERC) Secció 1: Principals novetats. Resusci - to the existence of a wide variety of tourniquets that tation. 2015;95:1-8. 11 Kragh JF, Dubick MA, Aden JK, McKeague AL, Rasmussen TE, Baer can be used for limb and joint hemorrhage. In relation DG, et al. U.S. Military Use of Tourniquets from 2001 to 2010. Pre - to the quality of the evidence generated and the possi - hosp Emerg Care. 2015;19:184-90. bility of risk of bias of the selected articles, the non-ran - 12 Kragh JF Jr, Walters TJ, Baer DG, Fox CJ, Wade CE, Salinas J, et al. Practical use of emergency tourniquets to stop bleeding in major domized designs stand out as follow-up studies, with limb trauma. J Trauma. 2008;64(2 Supl):S38-49. consecutive sampling systems in some occasions, but 13 Fitzgibbons PG, Digiovanni C, Hares S, Akelman E. Safe tourniquet use: a review of the evidence. J Am Acad Orthop Surg. 2012;20:310-9. indeterminate in others, and the absence, in some ca - 14 El Sayed MJ, Tamim H, Mailhac A, Mann NC. Trends and Predictors ses, of a masking system that prevents to interpret if of Limb Tourniquet Use by Civilian Emergency Medical Services in the application of the tourniquet is effective in compari - the United States. Prehosp Emerg Care. 2017;21:54-62. 15 Kotwal RS, Butler FK, Gross KR, Kheirabadi BS, Baer DG, Dubick MA, son to the classic techniques of compression. Following et al. Management of Junctional Hemorrhage in Tactical Combat Ca - the Cochrane recommendations 19 , articles with "high" sualty Care: TCCC Guidelines? Proposed Change 13-03. J Spec Oper and "unclear" risk of bias were first combined and then Med. 2013;13:85-93. 16 Richey SL. Tourniquets for the control of traumatic hemorrhage: a compared with those with "low" risk. review of the literature. World J Emerg Surg. 2007;10:1-10. We can conclude that in the pre-hospital environ - 17 Navarro Suay R, Pérez Ferrer A, Jiménez Vizuete JM. Control de la hemorragia en el ámbito militar. Rev Esp Anestesiol Reanim. ment, the use of the limb tourniquet is effective, with the 2012;59:562-72. SWAT-T model being the best rated. Complications from 18 Inaba K, Siboni S, Resnick S, Zhu J, Wong MD, Haltmeier T, et al. these devices are rare and most are attributable to the cri - Tourniquet use for civilian extremity trauma. J Trauma Acute Care Surg. 2015;79:232-3. tical state of the patients and not to their placement. De - 19 Centro Cochrane Iberoamericano, traductores. Manual Cochrane de Revisio - lay in their application is a determining factor that negati - nes Sistemáticas de Intervenciones, versión 5.1.0 [actualizada en marzo de vely affects their effectiveness. Therefore, at an 2011] [Internet]. Barcelona: Centro Cochrane Iberoamericano; 2012. (Consul - tado 27 Febrero 2017). Disponible http://www.cochrane.es/?q=es/node/269. out-of-hospital level the tourniquet should be used in pa - 20 Centro español para los cuidados de salud basados en la evidencia tients with major trauma if direct pressure is not sufficient (CECBE). Criterios para realizar revisiones sistemáticas a través del centro colaborador español del Instituto Joanna Briggs para los cuida - to control a life-threatening exanguinant hemorrhage. dos de salud basados en evidencias [Internet]. Madrid: Centro Cola - borador Español JBI; 2014. (Consultado 27 Febrero 2017). Disponible Conflicting interests: The authors declare no conflict of interests in re - en: http://www.evidenciaencuidados.es/evidenciaencuidados/pdf/Cri - lation to this article. terios_Revisiones_sistematicas_JBI.pdf Contribution of the authors: All authors have confirmed their authors - 21 Taylor DM, Vater GM, Parker PJ. An evaluation of two tourniquet hip in the author's responsibilities document, publication agreement systems for the control of prehospital lower limb hemorrhage. J and transfer of rights to EMERGENCIAS. Trauma. 2011;71:591-5. 22 Wall PL, Duevel DC, Hassan MB, Welander JD, Sahr SM, Buising CM. Financing: The authors declare the non-existence of external funding in Tourniquets and Occlusion: The Pressure of Design. Mil Med. relation to this article. 2013;178:578-87.

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23 López de Argumedo M, Reviriego E, Andrío E, Rico R, Sobradillo N, al. Safety and Appropriateness of Tourniquets in 105 Civilians. Pre - Hurtado de Saracho I. Revisión externa y validación de instrumentos hosp Emerg Care. 2016;20:712-22. metodológicos para la Lectura Crítica y la síntesis de la evidencia cien - 32 Wall PL, Welander JD, Singh A, Sidwell RA, Buising CM. Stretch and tífica. Madrid: Plan Nacional para el SNS del MSC. Servicio de Evalua - wrap style tourniquet effectiveness with minimal training. Mil Med. ción de Tecnologías Sanitarias del País Vasco (Osteba); 2006. Informes 2012;177:1366-73. de Evaluación de Tecnologías Sanitarias: OSTEBA Nº 2006/02. 33 Lyon M, Shiver SA, Greenfield EM, Reynolds BZ, Lerner EB, Wedmo - 24 Kragh JF, O’Neill ML, Walters TJ, Jones JA, Baer DG, Gershman LK, et re IS, et al. Use of a novel abdominal aortic tourniquet to reduce or al. Minor morbidity with emergency tourniquet use to stop bleeding eliminate flow in the common femoral artery in human subjects. J in severe limb trauma: research, history, and reconciling advocates Trauma Acute Care Surg. 2012;73:S103-5. and abolitionists. Mil Med. 2011;176:817-23. 34 Schroll R, Smith A, Mcswain NE, Myers J, Rocchi K, Inaba K, et al. A 25 Kragh JF, Kotwal RS, Cap AP, Aden JK, Walters TJ, Kheirabadi BS, et multi-institutional analysis of prehospital tourniquet use. J Trauma al. Performance of Junctional Tourniquets in Normal Human Volunte - Acute Care Surg. 2015;79:10-4. ers. Prehosp Emerg Care. 2015;19:391-8. 35 Bulger EM, Snyder D, Schoelles K, Gotschall C, Dawson D, Lang E, 26 Ode G, Studnek J, Seymour R, Bosse MJ, Hsu JR. Emergency tourni - et al. An Evidence-based Prehospital Guideline for External Hemor - quets for civilians. J Trauma Acute Care Surg. 2015;79:586-91. rhage Control: American College of Surgeons Committee on Trau - 27 Unlu A, Kaya E, Guvenc I, Kaymak S, Cetinkaya RA, Lapsekili EO, et ma. Prehospital Emerg Care. 2014;18:163-73. al. An evaluation of combat application tourniquets on training mili - tary personnel: Changes in application times and success rates in 36 Mawhinney A, Kirk S. A systematic review of the use of tourniquets three successive phases. J R Army Med Corps. 2015;161:332-5. and topical haemostatic agents in conflicts in Afghanistan and Iraq. J 28 Passos E, Dingley B, Smith A, Engels PT, Ball CG, Faidi S, et al. Tour - R Nav Med Serv. 2015;101:147-54. niquet use for peripheral vascular injuries in the civilian setting. In - 37 Academia Politécnica Naval. Cartilla TCCC 2013 - Actualización jury. 2014;45:573-7. Guías de Manejo TCCC 11 de Noviembre 2015 [Internet]. Cruz Jara - 29 Taylor DM, Coleman M, Parker PJ. The evaluation of an abdominal millo M, editor. 2016. (Consultado 12 Marzo 2017). Disponible en: aortic tourniquet for the control of pelvic and lower limb hemorrha - http://www.apolinav.cl/wp-content/uploads/2016/06/cartilla-C4-ac - ge. Mil Med. 2013;178:1196-201. tualizacion-TCCC-28jun2016.pdf 30 Savage E, Pannell D, Payne E, O’Leary T, Tien H. Re-Evaluating the 38 U.S. Food & Drug Administration. Silver Spring (MD). Drug Safety Field Tourniquet for the Canadian Forces. Mil Med. 2013;178:669- and Availability [Internet]. Food & Drug Administration. 2017. (Con - 75. sultado 23 Marzo 2017). Disponible en: https://www.fda.gov/ 31 Scerbo MH, Mumm JP, Gates K, Love JD, Wade CE, Holcomb JB, et Drugs/DrugSafety/default.htm

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