Literature Review: Tourniquet Use
Kragh JF, Jr., Walters TJ, Baer DG, et al. Survival with emergency tourniquet use to stop bleeding in major limb trauma. Ann Surg 249(1):1–7, Jan 2009. Abstract
The purpose of this study was to determine if emergency tourniquet use saved lives. Tourniquets have been proposed as lifesaving devices in the current war and are now issued to all soldiers. Few studies, however, describe their actual use in combat casualties. Methods-A prospective survey of injured who required tourniquets was performed over seven months in 2006. Follow-up averaged 28 days. The study was at a combat support hospital in Baghdad. Among 2,838 injured and admitted civilian and military casualties with major limb trauma, 232 (8%) had 428 tourniquets applied on 309 injured limbs. [Authors] looked at emergency tourniquet use, and casualties were evaluated for shock (weak or absent radial pulse) and prehospital versus emergency department tourniquet use. [Authors] also looked at those casualties indicated for tourniquets who had none used. [They] assessed survival rates and limb outcomes.
Results-There were 31 deaths (13%). Tourniquet use when shock was absent was strongly associated with survival (90% vs. 10%; p < 0.001). Prehospital tourniquets were applied in 194 patients, of whom 22 died (11% mortality), and tourniquets were applied in the emergency department to 38 patients, of whom nine died (24% mortality; p = 0.05). The five casualties indicated for tourniquets who had none used had a survival rate of 0%, versus 87% for those casualties with tourniquets used (p < 0.001). Four patients (1.7%) sustained transient nerve palsy at the level of the tourniquet. No amputations resulted solely from tourniquet use. Conclusions-Tourniquet use when shock was absent was strongly associated with saved lives, and prehospital use was also strongly associated with lifesaving. No limbs were lost due to tourniquet use. Education and fielding of prehospital tourniquets in the military environment should continue. Comment
Tourniquets were once a commonly recommended first aid treatment. However, concerns about complications from lack of blood supply causing tissue damage, injury to nerves, and the possibility of actually increasing blood loss (by applying enough pressure to keep blood from returning through the veins but not enough to stop blood flow out through the arteries) have kept EMS systems from using them. Now the military conflicts in Afghanistan and Iraq have resulted in a large number of penetrating extremity wounds, and tourniquets have been used extensively.
This is one of several recent military reports that conclude patients are more likely to survive severe limb trauma with hemorrhage if a tourniquet is used, and that the complication rate is very low. Tourniquets appear to be an excellent treatment for these patients. As we gain more knowledge on the use of tourniquets, EMS systems should consider developing protocols that allow their use in patients with moderate to severe hemorrhage from limb wounds.
Angelo Salvucci, Jr., MD, FACEP, is an emergency physician and medical director for the Santa Barbara County and Ventura County (CA) EMS agencies.