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AN EVIDENCE-BASED PREHOSPITAL GUIDELINE for EXTERNAL HEMORRHAGE CONTROL:AMERICAN COLLEGE of SURGEONS COMMITTEE on TRAUMA Eileen M

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AN EVIDENCE-BASED PREHOSPITAL GUIDELINE for EXTERNAL HEMORRHAGE CONTROL:AMERICAN COLLEGE of SURGEONS COMMITTEE on TRAUMA Eileen M SPECIAL CONTRIBUTION AN EVIDENCE-BASED PREHOSPITAL GUIDELINE FOR EXTERNAL HEMORRHAGE CONTROL:AMERICAN COLLEGE OF SURGEONS COMMITTEE ON TRAUMA Eileen M. Bulger, MD, FACS, David Snyder, PhD, Karen Schoelles, MD, FACP, Cathy Gotschall, ScD, Drew Dawson, BA, Eddy Lang, MD, CM CCFP (EM) CSPQ, Nels D. Sanddal, PhD, NREMT, Frank K. Butler, MD, FAAO, FUHM, Mary Fallat, MD, FACS, Peter Taillac, MD, Lynn White, MS, CCRP, Jeffrey P. Salomone, MD, FACS, NREMT-P, William Seifarth, MS, NREMT-P, Michael J. Betzner, MD, FRCPC, Jay Johannigman, MD, FACS,NormanMcSwain,Jr.,MD,FACS,NREMT-P ABSTRACT This report describes the development of an evidence-based Received January 21, 2014 from the University of Washington, guideline for external hemorrhage control in the prehospital Seattle, Washington (EB), ECRI Institute of Health Technology setting. This project included a systematic review of the liter- Assessment, Washington DC (DS, KS), Office of Emergency Medical ature regarding the use of tourniquets and hemostatic agents Services National Highway Traffic Safety Administration, Wash- for management of life-threatening extremity and junctional ington DC (CG, DD), University of Calgary, Alberta, Canada (EL, MJB), American College of Surgeons, Chicago, IL (NDS), Committee hemorrhage. Using the GRADE methodology to define the on Tactical Combat Casualty Care, Joint Trauma System (FKB), key clinical questions, an expert panel then reviewed the re- University of Louisville, Louisville, Kentucky (MF), University of sults of the literature review, established the quality of the For personal use only. Utah,SaltLakeCity,Utah(PT),AmericanMedicalResponse,Inc. evidence and made recommendations for EMS care. A clini- (LW), Maricopa Medical Center, Phoenix, Arizona (JPS), Department cal care guideline is proposed for adoption by EMS systems. of Homeland Security, Office of Health Affairs (WS), University of Key words: tourniquet; hemostatic agents; external hemor- Cincinnati, Cincinnati, Ohio (JJ), and Tulane School of Medicine, rhage New Orleans, Louisiana (NM). Revision received February 12, 2014; accepted for publication February 13, 2014. PREHOSPITAL EMERGENCY CARE 2014;18:163–173 The systematic review of the evidence used for the development of these guidelines was conducted by ECRI Institute with funding INTRODUCTION provided by the National Highway Traffic Safety Administration, DTNH22-11-C-00223. External hemorrhage has been increasingly recognized This publication was developed in part with funding from the Na- as a major cause of potentially preventable death tional Highway Traffic Safety Administration (NHTSA) of the U.S. following severe injury. This issue has been thor- Department of Transportation (DOT). The opinions, findings and oughly addressed by the U.S. military Tactical Com- Prehosp Emerg Care Downloaded from informahealthcare.com by University of Washington on 03/18/14 conclusions expressed in this publication are those of the authors bat Casualty Care Committee (TCCC) in response to and not necessarily those of NHTSA or DOT. The United States Gov- the increase in life-threatening external hemorrhage ernment assumes no liability for its content or use thereof. If trade or manufacturer’s names or products are mentioned, it is because they seen in the conflicts in Iraq and Afghanistan (www. are considered essential to the object of the publication and should health.mil/Education And Training/TCCC.aspx). Im- not be construed as an endorsement. The United States Government plementation of the TCCC guidelines for tourniquet does not endorse products or manufacturers. use has been associated with a significant reduction The opinions or assertions contained herein are the private views of in the number of combat deaths attributed to ex- the authors and are not to be construed as official or as reflecting the tremity hemorrhage.1 Lessons learned from the mil- views of the Department of the Army or the Department of Defense. itary management of these injuries are beginning to The authors report no conflicts of interest. The authors alone are re- be adopted in the civilian community and the re- sponsible for the content and writing of the paper. cent Boston marathon bombing event highlighted this 2 Address correspondence to Eileen M. Bulger, MD, Professor of issue. A report from the National Trauma databank Surgery, Chief of Trauma, Box 359796, Harborview Medical Center, suggests that mortality for patients with isolated lower 325 9th Avenue, Seattle, WA 98104, USA. E-mail: [email protected] extremity trauma with an arterial injury is 2.8%, with a doi: 10.3109/10903127.2014.896962 6.5% amputation rate.3 163 164 PREHOSPITAL EMERGENCY CARE APRIL/JUNE 2014 VOLUME 18 / NUMBER 2 The use of tourniquets and hemostatic agents in the Representatives were from both the United States and civilian EMS community is not widespread.4,5 While Canada. Panelists provided input to the formulations there is increasing interest in the use of these agents of the PICOTS (populations, interventions, compara- by civilian EMS agencies, the differences between the tors, outcomes, timing, and settings) questions prior to civilian and military populations may be important. the initiation of the literature review. For the PICOTS These considerations, not well addressed in the pub- questions, the population of interest was defined lished military experience, include the use of these to be individuals with extremity hemorrhages; the modalities in elderly and pediatric patients and the interventions were commercially available tourniquets impact of medical comorbidities on outcome. Even as and hemostatic dressings; comparators were external recently as 2011, the Guidelines for Field Triage of In- wound pressure and nontourniquet or nonhemostatic jured Patients does not include a recommendation for interventions; outcomes of interest were limb salvage, tourniquet use as a trauma triage criteria because “ev- hypovolemic shock, survival, and adverse effects. idence is limited regarding the use of tourniquets in Because timing and setting were considered to be civilian populations; use of tourniquets among EMS key aspects of the investigation the PICO format was systems varies; inclusion of tourniquet use as a cri- expanded to include both immediate and long-term terion could lead to overuse of tourniquets instead outcomes and the setting for the intervention was of basic hemorrhage control methods, and thus defined as the prehospital environment, before any potentially result in overtriage.”6 However, the Na- procedures are performed in the hospital emergency tional EMS Scope of Practice Model published in 2007 department or operating theater. Following the com- lists tourniquet use as part of the minimum psy- pletion of the systematic literature review, the panel chomotor skill set for emergency trauma care for emer- met to review the literature in a full day meeting gency medical technicians. In addition, tourniquets in Washington DC, October 2013. An expert in the have been included as required basic life support (BLS) application of the GRADE methodology facilitated the equipment in the Joint Policy Statement: Equipment meeting and the panel used this approach to develop for Ambulances.7 Topical hemostatic agents are listed recommendations for each PICOTS question. as optional basic equipment. The recent Hartford con- sensus conference also encourages wider civilian use Evidence Review of tourniquets for management of hemorrhage in ac- tive shooter events.8 A systematic review of the literature was conducted The purpose of this project was to develop evidence- by the ECRI Institute, one of the eleven Evidenced- For personal use only. based guidelines for the use of tourniquets and Based Practice Centers designated by the U.S. Agency hemostatic dressings in the U.S. civilian prehospi- for Healthcare Research and Quality. Their system- tal setting. The recommendations were based on a atic literature review and evidence tables were used systematic review of the current literature and were by the expert panel to develop these recommenda- developed using the GRADE methodology.9 External tions. A summary of the findings is included in this hemorrhage is defined as blood loss originating from manuscript; the full ECRI report will be simulta- a ruptured blood vessel and appearing on the body neously published by the National Highway Traffic surface. For the purposes of our review, this includes Safety Administration (NHTSA) and will be available extremity hemorrhage and junctional hemorrhage. at www.ems.gov. The PICOTS questions used to guide Junctional hemorrhage includes the groin proximal the literature review were developed with input from to the inguinal ligament, the buttocks, the gluteal and the multidisciplinary expert panel. pelvic areas, the perineum, the axilla and shoulder Literature search included 13 external and inter- Prehosp Emerg Care Downloaded from informahealthcare.com by University of Washington on 03/18/14 girdle, and the base of the neck.10 nal electronic databases, including CINAHL, EM- BASE, and Medline, from 2001 to the present for fully published, primary, clinical studies. The APPROACH Cochrane Database of Systematic Reviews (Cochrane Expert Panel Reviews), Database of Abstracts of Reviews of Ef- fects (DARE), and Health Technology Assessment and An expert panel was convened by the American Database (HTA) were also searched for secondary College of Surgeons Committee on Trauma EMS reviews. Additional search steps included manual Committee to include nationally recognized
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