Emergency tourniquets for civilians: Can military lessons in extremity hemorrhage be translated?

BACKGROUND Among civilians, emergency tourniquet (TKT) use is infrequent because of concern for TKT-related complications. In large part because of positive reports from the military on emergency TKT use, all ambulances serving Mecklenburg County, which includes the city of Charlotte, North Carolina, were equipped with commercial TKTs in September 2012. This study compares the outcomes of emergency TKT use with conservative hemorrhage control in an urban civilian setting and evaluates outcomes related to appropriate TKT placement. METHODS Emergency medical service and hospital records from September 2012 to November 2013 were reviewed. Injury characteristics, clinical interventions, outcomes, and TKT-related complications were reported, and appropriateness of TKT use was assessed. Primary analysis compared all TKT patients with non-TKT patients who received other hemorrhage control measures. Secondary analysis compared all appropriate TKT patients with those who had delayed/missed TKTs. RESULTS Fifty-six patients met inclusion criteria (24 TKT, 32 non-TKT). Four patients died (three TKT, one non-TKT) (7.1%). There were no reported TKT-related complications. Of all the patients, 46.4% (16 of 56) demonstrated signs of shock in the prehospital or emergency department setting. Seventy-five percent (12 of 16) of the patients in shock had a vascular injury (p = 0.023). Of the non-TKT patients, 9.4% (3 of 32) should have received a TKT and were classified as missed. One missed patient died in the emergency department. Among TKT patients, 62.5% (15 of 24) of TKTs were appropriate, 20.8% (5 of 24) were inappropriate, and 16.7% (4 of 24) were delayed. Overall, there was a delayed/missed TKT rate of 12.5% (7 of 56). Patients with delayed/missed TKTs had higher incidences of shock (85.7% vs. 60%), inpatient admission (100% vs. 76.9%), and blood transfusions (71.4% vs. 40%). CONCLUSION The majority of TKTs were appropriately applied to civilians who had vascular injuries or required operative intervention for hemorrhage control. With appropriate indications, an emergency TKT is a valuable instrument for hemorrhage control in the civilian prehospital setting and has a low rate of associated complications. LEVEL OF EVIDENCE Therapeutic study, level IV.