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Tourniquet Use in Out-Of-Hospital Emergency Care: a Systematic Review

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Tourniquet Use in Out-Of-Hospital Emergency Care: a Systematic Review 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
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