Impact of Time and Distance on Outcomes Following Tourniquet Use in Civilian and Military Settings: a Scoping Review

Joarder M et Al. https://doi.org/10.1016/j.injury.2023.01.031

Background: The last two decades have seen the reintroduction of tourniquets into guidelines for the management of acute limb trauma requiring haemorrhage control. Evidence supporting tourniquet application has demonstrated low complication rates in modern military settings involving rapid evacuation timeframes. It is unclear how these findings translate to patients who have prolonged transport times from injury in rural settings. This scoping review investigates the relationship between time and distance on metabolic complications, limb salvage and mortality following tourniquet use in civilian and military settings.

Methods: A systematic search strategy was conducted using PubMed, Embase, and SafetyLit databases. Study characteristics, setting, mechanism of injury, prehospital time, tourniquet time, distance, limb salvage, metabolic response, mortality, and tourniquet removal details were extracted from eligible studies. Descriptive statistics were recorded, and studies were grouped by ischemia time (< 2 hours, 2-4 hours, or > 4 hours).

Results: The search identified 3103 studies, from which 86 of studies were included in this scoping review. Of 86 studies, 55 studies were primarily civilian environments and 32 were based in military settings. One study included both settings. Blast injury was the most common mechanism of injury sustained by patients in military settings (72.8% [5968/8200]) followed by penetrating injury (23.5% [1926/8200]). In contrast, in civilian settings penetrating injury was the most common mechanism (47.7% [1633/3426]) followed by blunt injury (36.4% [1246/3426]).

Tourniquet time was reported in 66/86 studies. Tourniquet time over four hours was associated with reduced limb salvage rates (57.1%) and higher mortality rates (7.1%) compared with a tourniquet time of less than two hours. The overall limb salvage and mortality rates were 69.6% and 6.7% respectively. Metabolic outcomes were reported in 28/86 studies with smaller sample sizes and inconsistencies in which parameters were reported.

Conclusion: This scoping review presents literature describing comparatively safe tourniquet application when used for less than two hours duration. However, there is limited research describing prolonged tourniquet application or when used for protracted distances, such that the impact of tourniquet release time on metabolic outcomes and complications remains unclear. Prospective studies utilising the development of an international database to provide this dataset is required.

Tourniquet Conversion. A Recommended Approach in the Prolonged Field Care Setting

Brendon D. et Al. J Spec Oper Med . Fall 2015;15(3):81-5.

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Les auteurs de ce document proposent le concept du tourniquet +1 lors de la réévaluation d'un garrot posé en contexte tactique. Ceja consiste à oser un second garrot au dessous du premier avant de desserrer le premier garrot. Ils s'appuie sur la fréquence d'après eux de rupture de garrot lors de cette manoeuvre. Cette manoeuvre est à proscrire si le garrot est en place depuis plus de 6 heures. Elle est systématique si ce dernier est en place depuis moins de 2 heures. Entre les deux elle peut être réalisée. Leurs recommandations ne sont pas très claires.

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Life-saving interventions take precedence over diagnostic maneuvers in the Care Under Fire stage of Tactical Combat Casualty Care. The immediate threat to life with an actively hemorrhaging extremity injury is addressed with the liberal and proper use of tourniquets. The emphasis on hemorrhage control has and will continue to result in the application of tourniquets that may not be needed past the Care Under Fire stage. As soon as tactically allowable, all tourniquets must be reassessed for conversion. Reassessment of all tourniquets should occur as soon as the tactical situation permits, but no more than 2 hours after initial placement. This article describes a procedure for qualified and trained medical personnel to safely convert extremity tourniquets to local wound dressings, using a systematic process in the field setting.

Tournquet choice.jpg

Source: CoTCCC_Meeting_Minutes_2019_02.pdf

High Tourniquet Failure Rates Among Non-Medical Personnel Do Not Improve with Tourniquet Training, Including Combat Stress Inoculation: A Randomized Controlled Trial.

Tsur AM, et Al 2019 Jun;34(3):282-287.

BACKGROUND:

The rate of failing to apply a tourniquet remains high.

HYPOTHESIS:

The study objective was to examine whether early advanced training under conditions that approximate combat conditions and provide stress inoculation improve competency, compared to the current educational program of non-medical personnel.

METHODS:

This was a randomized controlled trial. Male recruits of the armored corps were included in the study. During Combat Lifesaver training, recruits apply The Tourniquet 12 times. This educational program was used as the control group. The combat stress inoculation (CSI) group also included 12 tourniquet applications, albeit some of them in combat conditions such as low light and physical exertion. Three parameters defined success, and these parameters were measured by The Simulator: (1) applied pressure ≥ 200mmHg; (2) time to stop bleeding ≤ 60 seconds; and (3) placement up to 7.5cm above the amputation.

RESULTS:

Out of the participants, 138 were assigned to the control group and 167 were assigned to the CSI group. The overall failure rate was 80.33% (81.90% in the control group versus 79.00% in the CSI group; P value = .565; 95% confidence interval, 0.677 to 2.122). Differences in pressure, time to stop bleeding, or placement were not significant (95% confidence intervals, -17.283 to 23.404, -1.792 to 6.105, and 0.932 to 2.387, respectively).

Tourniquet failure.jpeg

Tourniquet placement was incorrect in most of the applications (62.30%).

CONCLUSIONS:

This study found high rates of failure in tourniquet application immediately after successful completion of tourniquet training. These rates did not improve with tourniquet training, including CSI. The results may indicate that better tourniquet training methods should be pursued.

Tactical tourniquet: Surgical management must be within 3 hours.

Caubère A et Al. 2019 Jul 3;22:100217. doi: 10.1016/j.tcr.2019.100217. eCollection 2019 Aug.

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L'usage précoce et libéral des garrot a prouvé son bien fondé. Encore faut il que ce que l'on appelle le garrot tactique soit bien on, mis en oeuvre. En effet ce garrot sauve la vie au prix de certaines complications dès lors que sa durée dépasse 02h00 (1). Cette stratégie libérale repose sur quelques éléments fondamentaux (une pose bien indiquée et réalisée interrompant le flux artériel ET une réévaluation précoce systématique visant à établir le besoin et la mise en oeuvre éventuelle d'alternatives. Ceci n'est pas toujours parfaitement fait. C'est ce que montre cette publication qui rappelle quelques fondamentaux. Curieusement certaines leçons du passé ont été oubliées notamment celles qui portent sur les alternatives au garrot quand les durées d'évacuations sont longues (2)

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Despite longstanding controversy, tourniquets are widely used in tactical combat casualty care, with undisputed benefits for recent conflicts in Iraq and Afghanistan. Increased time delays are a particular issue in large areas, such as the Sahel-Saharan band. Complications associated with tourniquet use are predominantly related to acute ischemia with risk of amputation and ischaemia-reperfusion injury, as shown in the first clinical case. Often stated but poorly described, misuse of tourniquet and subsequent failure to interrupt arterial blood flow is also a clinical scenario that should be recognized. In the case of misuse of the tourniquet, more significant blood loss may be expected because of venous compression (« venous tourniquet », second clinical case). Early medical re-evaluation of the tourniquet is an essential component in prolonged field care. This includes reassessment of the tourniquet's ability to achieve hemostasis, abolish the downstream pulse and the relevance of the tourniquet altogether. This combat tool requires training to be successful and complications are time dependent. Tourniquet use requires appropriate application, re-evaluation and triage of wounded personnel within 3 h towards more structured surgical management.

Bleeding control in combat fields with extreme transfer time

Ratnayake AS et Al 2019 Feb 6. pii: jramc-2018-001120. doi: 10.1136/jramc-2018-001120.

Cette lettre à l'éditeur émane d'une équipe srilankaise qui a l'expertise de prise en charge de plaies vasculaires avec des délais de prise en charge de près de 04heures (1) Ceci se rapproche des conditions dans lesquelles opèrent nos équipes. Les auteurs y rappellent tout l'intérêt lors de la révision du bien fondé de la pose d'un garrot du packing de plaies ET des compressions sélectives par des pansements adaptés dont un exemple est proposé ici.

Balloon tamponnade.jpeg

Can they stop the bleed? Evaluation of tourniquet application by individuals with varying levels of prior self-reported training.

McCarty et Al. Injury. 2019 Jan;50(1):10-15. doi: 10.1016/j.injury.2018.09.041.

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1 garrot sur 3 posé correctement malgré une formation ad-hoc.

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BACKGROUND:

Application of extremity tourniquets is a central tenet of multiple national initiatives to empower laypersons to provide hemorrhage control (HC). However, the efficacy of the general population who self-report prior first-aid (FA) or HC training on individual's ability to control bleeding with a tourniquet remains unknown. Therefore, the objective of this study was to assess the effectiveness of laypeople with self-reported prior FA or HC training to control bleeding with a tourniquet.

STUDY DESIGN:

Employees of a stadium were assessed via simulation in their ability to apply a Combat Application Tourniquet. As a subgroup analysis of a larger study, participants who self-reported: 1) No prior training, 2) FA training only or 2) FA + HC training were compared. Logistic regression adjusting for age, gender, education, willingness-to-assist, and comfort level in HC was performed.

RESULTS:

317 participants were included. Compared to participants with no prior training (14.4%,n = 16/111), those with FA training only (25.2%,n = 35/139) had a 2.12-higher odds (95%CI:1.07-4.18) of correct tourniquet application while those with FA + HC (35.8%,n = 24/67) had a 3.50-higher odds (95%CI:1.59-7.72) of correct application. Participants with prior FA + HC were more willing-to-assist and comfortable performing HC than those without prior training (p < 0.05).

However, reporting being very willing-to-assist [OR0.83,95%CI:0.43-1.60] or very comfortable [OR1.11,95%CI:0.55-2.25] was not associated with correct tourniquet application.

CONCLUSION:

Self-reported prior FA + HC training, while associated with increased likelihood to correctly apply a tourniquet, results in only 1/3 of individuals correctly performing the skill. As work continues in empowering and training laypeople to act as immediate responders, these findings highlight the importance of effective layperson education techniques.

Comparison of Two Tourniquets on a Mid-Thigh Model: The Israeli Silicone Stretch and Wrap Tourniquet vs. The Combat Application Tourniquet.

Glick CPTY et Al. 2018 Mar 1;183(suppl_1):157-161. doi: 10.1093/milmed/usx169.

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Le succès des garrots artériels tels que le SOFT-T et le CAT ne doit pas occulter l'intérêt des bandes de compression élastiques (Bande d'Esmach, SWAT-Tourniquet, IDF Silicone Tourniquet) préconisées en médecine rurale lors d'explosion de mines antipersonnelles (1). Ce travail met en avant leur efficacité.

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Introduction:

Experience from recent conflicts underlines the dramatic impact of effective tourniquet use on combat casualty mortality. Although the Combat Application Tourniquet (CAT) is replacing the silicone band tourniquets (IST; "Israeli Silicone Tourniquet") in the Israeli Defense Forces, no direct comparison was made between them. The purpose of this study is to compare the performance of the two tourniquets on a mid-thigh model.

Methods:

Participants were Israeli military recruits who previously had the military first aid course. Each participant applied both the CAT and the IST. Applications were assessed by the HapMed Leg Tourniquet Trainer, which measured the applied pressure and the time required to reach it.

Results:

IST application resulted in higher rates of effective occlusion pressure compared with the CAT (91% vs. 73.1%, p < 0.01), and a higher mean occlusion pressure (41 mmHg, p < 0.01) was recorded using the IST. Among effective attempts, application time did not differ significantly between the tourniquets.

Effect of Elapsed Time Since First Aid Course on Success Rate

	Experience More Than 1 mo (n = 15)	Experience Equal to or Less Than 1 mo (n = 63)	p-Value
Succeeded with CAT, n (%)	7 (46.7)	50 (79.4)	0.01
Succeeded with IST, n (%)	14 (93.3)	57 (90.5)	0.5

Conclusion:

The IST was superior to the CAT in producing effective occlusion pressure while not prolonging application time. These results may indicate that the IST remains a valid option for controlling mid-thigh bleeding.

Point of injury tourniquet application during Operation Protective Edge-What do we learn?

Shlaifer A et Al J Trauma Acute Care Surg. 2017 Aug;83(2):278-283

BACKGROUND:

Hemorrhage is a leading cause of preventable death on the battlefield. Timely tourniquet application to massively bleeding extremity wounds is critical for casualty survival albeit with reported adverse effects to extremity integrity. The aim of this study was to describe the immediate- and short-term outcomes of point of injury (POI) tourniquet applications during "Operation Protective Edge" (OPE).

METHODS:

A case series study regarding tourniquet application at the POI during OPE was collected. The data gathered included reports by medical providers at the POI, aerial and land evacuation vehicles, and receiving hospitals. Variables collected included, the number of tourniquet applications, caregiver level, tourniquet type, limb characters, tourniquet effectiveness, in-hospital procedures, complications, and short-term limb outcome.

RESULTS:

During OPE, the Israeli Defense Forces Medical Corps treated 704 casualties. Of these, 90 casualties were treated with 119 tourniquets of which 79 survived. Penetrating trauma was the mechanism of injury in 97.8% (88 of 90) of the casualties. Injuries sustained from improvised explosive devices and shrapnel were related to the use of more than one tourniquet per casualty and per limb (p = 0.034). The success rate of the first tourniquet was reported to be 70% (84 of 119), regardless of caregiver level (p = 0.56), tourniquet type (p = 0.16), or limb characters (p = 0.48). Twenty-seven (25.7%) of 105 of the tourniquets were converted to direct pressure dressings enroute to receiving hospitals two of the conversions failed and thus a new tourniquet was applied. Fasciotomy was performed on eight casualties (a single limb in each). Vascular injury was presumed to be the indication for fasciotomy in three of these cases, in the other five limbs (6%, 5 of 85), no vascular involvement was discovered during surgery, and the fasciotomy is suspected as tourniquet related. 7%) 6 of 85) suffered from neurological sequela that could not be explained by their primary injury. Total complication rate was 11.7% (10 of 85) (one patient had both fasciotomy and neural complication without vascular injury).

CONCLUSION:

Tourniquet use on the battlefield is a simple method of eliminating preventable death, we believe that clinical practice guidelines should promote liberal use of tourniquets by trained combatants and medical personnel with abilities to convert to direct pressure hemorrhage control when possible since an unjustified tourniquet application risks low rates minor morbidity, whereas a justifiable tourniquet not applied may be lethal.

A brief history of the tourniquet

Welling DR et Al. Vasc Surg 2012;55:286-90

Matas Cmpressor.jpg

Le compresseur de Matas

Clic ici pour accéder à l'article

The Tourniquet Gap: A Pilot Study of the Intuitive Placement of Three Tourniquet Types by Laypersons

Ross EM et Al. http://dx.doi.org/10.1016/j.jemermed.2017.09.011

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La pose de garrot par l'intervenant le plus proche d'une victime blessé semble être une évidence. Pourtant ce travail met en évidence un taux relativement important d'échec. Ceci milite pour la conduite de campagne de formation avant toute mise à disposition de garrot industriel

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Background

The “Stop the Bleed” campaign in the United States advocates for nonmedical personnel to be trained in basic hemorrhage control and that “bleeding control kits” be available in high-risk areas. However, it is not clear which tourniquets are most effective in the hands of laypersons.

Objectives

The objective of this pilot study was to determine which tourniquet type was the most intuitive for a layperson to apply correctly.

Methods

This project is a randomized study derived from a “Stop the Bleed” education initiative conducted between September 2016 and March 2017. Novice tourniquet users were randomized to apply one of three commercially available tourniquets (Combat Action Tourniquet [CAT; North American Rescue, LLC, Greer, SC], Ratcheting Medical Tourniquet [RMT; m2 Inc., Winooski, VT], or Stretch Wrap and Tuck Tourniquet [SWAT-T; TEMS Solutions, LLC, Salida, CO]) in a controlled setting. Individuals with formal medical certification, prior military service, or prior training with tourniquets were excluded. The primary outcome of this study was successful tourniquet placement.

Results

Of 236 possible participants, 198 met the eligibility criteria. Demographics were similar across groups. The rates of successful tourniquet application for the CAT, RMT, and SWAT-T were 16.9%, 23.4%, and 10.6%, respectively ( p = 0.149). The most common causes of application failure were: inadequate tightness (74.1%), improper placement technique (44.4%), and incorrect positioning (16.7%).

Conclusion

Our pilot study on the intuitive nature of applying commercially available tourniquets found unacceptably high rates of failure. Large-scale community education efforts and manufacturer improvements of tourniquet usability by the lay public must be made before the widespread dissemination of tourniquets will have a significant public health effect.

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

Tactical Médical Solutions qui est le fabricant du SOFT-Tourniquet, garrot en dotation dans l'armée française, propose une nouvelle version de son garrot Wide. Sa nouvelle boucle est d'emploi bien plus aisé que la précédente et positionne ce garrot parmi les tous meilleurs(CAT, SOFT-T, TK4,...)

productimage-picture-sof-tactical-tourniquet-wide-new-buckle-1502.png

Clic sur l'image pour accéder au site. Le distributeur en France.

Belts Evaluated as Limb Tourniquets: BELT Study Comparing Trouser Supporters Used as Medical Devices in a Manikin Model of Wound Bleeding.

Bequette BW et Al Wilderness Environ Med. 2017 Apr 19. pii: S1080-6032(17)30060-1.

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Une idée, qui n'est pas nouvelle de même que celui de pantalon intégrant un garrot (1), mais on devrait plutôt dire un tourniquet pour ceinture. Ce travail est par ailleurs intéressant car il aborde la problématique des garrots insuffisamment serrés.

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OBJECTIVE:

The purpose of the present study is to compare several models of commercially designed belts as used as a tourniquet.

METHODS:

In the Belts Evaluated as Limb Tourniquets (BELT) study, an experiment was designed to test the effectiveness of pants belts as non improvised medical devices to control hemorrhage in a manikin. Models of belts included Tourni-belt, Tourniquet Belt, ParaBelt, and Battle Buddy. Data collected included effectiveness, time to stop bleeding, total time of application, pressure, blood loss, and composite results (score count of good results; composite outcome good if every component was good).

RESULTS:

Differences in effectiveness percentages among models were not statistically significant. The difference in mean between users was statistically significant for stop time, total time, pressure, blood loss, composite score, and composite outcome. Mean time to stop bleeding differed for only 1 pair of models after the Tukey-Kramer adjustment; ParaBelt was faster than Tourniquet Belt. Mean total time of application differed between ParaBelt-Tourniquet Belt and Tourni-belt-Tourniquet Belt; the former model in both pairs was faster. No significant difference in mean blood loss measured by model was found. For composite outcome score, no pairwise difference between models was significant. For composite outcome (good-bad), ParaBelt had good results in 75% of tests; the other 3 models had significantly worse results.

CONCLUSIONS:

In a preliminary laboratory analysis of belt tourniquet models using a manikin, performance differed by model. ParaBelt performed better than other models for the composite outcome.our tourniquet ?

Point of injury tourniquet application during Operation Protective Edge - what do we learn?

Shlaifer A et Al. J Trauma Acute Care Surg. 2017 Feb 23.

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Un point récent sur l'emploi du garrot dans un contexte de combat mixte zone urbaine mais aussi hors de la ville. Disons immédiatement que ce travaille CONFIRME l'intérêt du garrot, qui doit pouvoir être rapidement converti. Le contexte de pose du garrot est avant tout tactique (exposition au feu, plusieurs blessés, nuit complète). L' efficacité du premier garrot est de 70%. Près d'1/4 nécessitent au moins 2 garrots et encore 1/4 sont convertis pendant la medevac. Sur 13% des blessés sont réalisés des gestes de sauvetage: décompression thoracique /Intubation ou Cricothyrotomie. Ce document exprime parfaitement l'importance de la maîtrise et partant de l'entraînement à la réalisation des gestes de la procédure du sauvetage au combat.

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