Tourniquet: Bien en contexte civil AUSSI

The trauma center is too late: Major limb trauma without a pre-hospital tourniquet has increased death from hemorrhagic shock

Scerbo MH et Al. Journal of Trauma and Acute Care Surgery,10.1097/TA.0000000000001666

 

Background: To date, no civilian studies have demonstrated that pre-hospital (PH) tourniquets improve survival. We hypothesized that late, trauma center (TC) tourniquet use would increase death from hemorrhagic shock compared to early (PH) placement.

Methods: All patients arriving to a Level-1, urban TC between 10/2008 and 01/2016 with a tourniquet placed prior to (T-PH) or after arrival to the TC (T-TC) were evaluated. Cases were assigned the following designations: indicated [absolute indication (vascular injury requiring repair/ligation, operation within 2 hours for extremity injury, or traumatic amputation), or relative indication (major musculoskeletal/soft-tissue injury requiring operation 2-8 hours after arrival, documented large blood loss)], or non-indicated. Outcomes were death from hemorrhagic shock, physiology upon arrival to the TC and massive transfusion requirements. Following univariate analysis, logistic regression was carried out to assess independent predictors of death from hemorrhagic shock.

Results: 306 patients received 326 tourniquets for injuries to 157 upper and 147 lower extremities. 281 (92%) had an indication for placement. 70% of patients had a blunt mechanism of injury. T-TC patients arrived with a lower systolic blood pressure [101 (86, 123) versus 125 (100, 145)mmHg, p<0.001], received more transfusions in the first hour of arrival (55% versus 34%, p=0.02) and had a greater mortality from hemorrhagic shock (14% vs. 3.0%, p=0.01). When controlling for year of admission, mechanism of injury and shock upon arrival (SBP  ≤90mmHg or HR ≥120 bpm or base deficit ≤ 4), indicated T-TC had a 4.5-fold increased odds of death compared to T-PH [OR 4.5, 95% CI 1.23-16.4, p=0.02)].

Conclusions: Waiting until TC arrival to control hemorrhage with a tourniquet was associated with worsened blood pressure and increased transfusion within the first hour of arrival. In routine civilian trauma patients, delaying to T-TC was associated with 4.5-fold increased odds of mortality from hemorrhagic shock