Prehospital tourniquets in civilian settings significantly decreased mortality

BALTIMORE – Prehospital tourniquet use on injured civilians in trauma situations was associated with a nearly sixfold decrease in mortality, according to a study presented at the annual meeting of the American Association for Surgery of Trauma.

While tourniquets have been an effective tool in military settings, data on successful applications in civilian settings have been scarce.

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Dr. Teixeira and his coinvestigators conducted a multicenter, retrospective study of 1,026 peripheral–vascular injury patients admitted to level I trauma centers between January 2011 and December 2016. Among the patients studied, 181 (17.6%) received a tourniquet prior to hospital admission.

A majority of tourniquets were applied to the limbs, with the most common application sites on the arm (49%) and the thigh (29%).Tourniquets were held in place for an average 77 minutes.

Of the patients in the study, 98 (9.6%) underwent an amputation; 35 of these patients had received a tourniquet.

After adjusting for confounding factors, such as age and mechanism of injury, investigators found patients who received tourniquets were nearly six times more likely to survive than were their nontourniquet counterparts (odds ratio, 5.86; 95% confidence interval, 1.41-24.47; P = .015).

While the overall mortality rate among those with a tourniquet – compared with those without a tourniquet – was significantly lower, the comparative mortality rate among amputee patients was not significant, which investigators hypothesized could be because of the smaller number of patients in this subgroup.

Additionally, patients who did not receive a tourniquet had lower injury severity scores, had better vital signs, and needed less blood, according to investigators.

The findings of this study mirror what many military medical professionals have historically, and adamantly, supported, according to discussant Jay J. Doucet, MD, FACS, medical director for the surgical intensive care unit at the University of California San Diego Medical Center and a former combat surgeon.

“The medical lessons on our battlefields that hold such great promise have to be carefully relearned, brought home, and fearlessly applied here,” said Dr. Doucet. “I have yet to meet an employed military surgeon who does not believe the tourniquet is an indispensable tool.” While Dr. Doucet did acknowledge the benefit of tourniquets outside military use and addressed the need for increased implementation among civilian hospitals, he did pose a query about the mortality rate that investigators had found.

“The no-tourniquet group has an adjusted odds of death at a rate that is 5.86 times higher, yet they had better vitals, needed less blood, had lower [injury severity scores], had less head injury, fewer traumatic amputations, and fewer complications,” said Dr. Doucet. “So why do they die?”

Investigators were not able to pinpoint the cause of death among patients because of the limitations of their study; however, Dr. Teixeira and his colleagues were able to determine the presence of cardiac complications, pulmonary complications, and acute kidney injury, none of which had a significantly different presence between the two study groups.

The data gathered from this study are strong enough to support the use of tourniquets in civilian situations, asserted Dr. Teixeira, which means the next hurdle is to integrate it into the health system.

“What’s important from our perspective as leaders of this issue is what we are doing to increase the rate [of tourniquet use],” said Dr. Teixeira. “I think one of the important things is the Stop the Bleed program, [in which] we are actually teaching the Austin police department, and we are trying to increase the use of the tourniquet and demonstrate its importance.”

Investigators reported no relevant financial disclosures.

ezimmerman@frontlinemedcom.com

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