The tight rope act: A multicenter regional experience of tourniquets in acute trauma resuscitation
Tatebe LC, Schlanser V, Hampton D, et al. The Tight Rope Act: A Multicenter Regional Experience Of Tourniquets In Acute Trauma Resuscitation [published online ahead of print, 2021 Dec 6]. J Trauma Acute Care Surg. 2021;10.1097/TA.0000000000003491. doi:10.1097/TA.0000000000003491
Background: As tourniquets have become more prevalent, device use has been questioned. This study sought to characterize the incidence, indication, and efficacy of tourniquet placement in acute trauma resuscitation.
Methods: Nine regional Level 1 Trauma Centers prospectively enrolled for 12 months adult patients (≥18 yrs) who had a tourniquet placed. Age, gender, mechanism, tourniquet type, indication, applying personnel, location placed, level of occlusion, and degree of hemostasis were collected. Major vascular injury, imaging and operations performed, and outcomes were assessed. Analyses were performed with significance at p < 0.05.
Results: 216 tourniquet applications were reported on 209 patients. There were significantly more male patients (183, 88%) and penetrating injuries (186, 89%) with gunshots being most common (127, 61%). Commercial tourniquets were most often used (205, 95%). 92% were placed in the prehospital setting (by fire/paramedics 56%, police 33%, bystanders 2%). The most common indications were pooling (47%) and pulsatile (32%) hemorrhage. Only 2% were for amputation. The most frequent location was high proximal extremity (70%). 4% were placed over the wound and 0.5% were distal to the wound. Only 61% of applications were arterial occlusive. Median application time was 30 min (IQR 20-40 min). Imaging was performed in 54% of patients. Overall, 36% had a named arterial injury. Tourniquet application failed to achieve hemostasis in 22% of patients with a named vascular injury. There was no difference in hemostasis between those with and without vascular injury (p = 0.12) or between who placed the tourniquet (p = 0.07). 70 patients (34%) required vascular operations. 34% of patients were discharged home without admission.
Conclusion: Discerning which injuries require tourniquets over pressure dressings remains elusive. Trained responders had high rates of superfluous and inadequate deployments. As tourniquets continue to be disseminated, emphasis should be placed on improving education, device development, and quality control.