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TITLE
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Tou nique s as a haemo hage-con ol measu e in mili a y and ci ilian ca e se ings: an
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in eg a i e e iew
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ABSTRACT
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Aims and objec i es: The aim o e iew was o desc ibe and syn hesise he e idence on
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he use o ou nique s o con ol haemo hages, summa ising bo h ci ilian and mili a y
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use.
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Backg ound: T auma- ela ed haemo hage cons i u e one o he mos p e en able dea hs
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among inju ed pa ien s, pa icula ly in mul i-casual y inciden s and disas e s. In his
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con ex , sa e ins umen s such as ou nique s a e essen ial o help heal hca e p o essionals
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o minimise loss o li e and maximise pa ien eco e y.
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Design and Me hods: An in eg a i e e iew was conduc ed in Medline, Nu sing & Allied
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Heal h P emium, and Heal h & Medical Collec ion, using published da a un il Ma ch
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2021 and ollowing he PRISMA guidelines.
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Resul s: A o al o 25 a icles we e included. E idence has been syn hesised o unde s and
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he use o di e en ypes o ou nique s, en i onmen o applica ion, indica ion o hei
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placemen and po en ial complica ions associa ed wi h ou nique placemen .
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Conclusions: Comme cial ou nique s such as Comba Applica ion Tou nique o
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Eme gency Tou nique models a e a aluable and sa e ins umen o haemo hage
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con ol in bo h mili a y and ci ilian ou -o -hospi al ca e se ings. Nu ses, as pa o
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eme gency eams, and o he p o essionals should be awa e ha he e is a possibili y o
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ad e se complica ions, bu hey a e di ec ly p opo ional o he ime o ou nique
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placemen and gene ally empo a y. In addi ion, na ional and in e na ional guidelines
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ensu e he need o all ci ilian eme gency se ices o be equipped wi h hese de ices, as
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well as o he aining o heal hca e p o essionals and i s esponde s in hei use.
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Rele ance o clinical p ac ice: Despi e he lack o complica ions in he use o ou nique s
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in hese cases, hei use has been a ma e o deba e o decades. In his sense, his e iew
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yields up- o-da e guidelines in he use o ou nique s, hei ecommenda ions and hei
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signi icance among p o essionals o manage complica ed si ua ions.
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KEYWORDS
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Ex emi y auma; Fi s aid; Hemo hage con ol; Inju ies; Re iew Li e a u e as Topic;
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Tou nique s
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IMPACT STATEMENT
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Wha does his pape con ibu e o he wide global clinical communi y?
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• The indings o his in eg a i e e iew shed some ligh on he con o e sial use o
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ou nique s in bo h ci ilian and mili a y se ings. Lack o aining in hese
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ins umen s appea s as one o he majo conce ns among ci ilian p o essionals
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pa icula ly in p ehospi al se ings and ollowing mass-casual y inciden s o
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disas e s.
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• Comme cial ou nique s cons i u e a sa e and aluable ins umen o heal hca e
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p o essionals and i s esponde s, including nu ses, in p ehospi al, ou -o -hospi al
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and hospi al ca e. Howe e , u he esea ch is needed o unde s and he speci ic
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needs and di icul ies o hese p o essionals in his ma e .
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In oduc ion
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T auma- ela ed inju ies a e one o he leading causes o mo ali y and disabili y,
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accoun ing o 29.6% o dea hs wo ldwide as pe he la es da a om he Wo ld Heal h
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O ganiza ion (WHO, 2018). Al hough many o hese inju ies a e unin en ional, iolen
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auma con ibu es signi ican ly o he mo ali y o mass-casual y inciden s (MCIs) o
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disas e s, which ha e become mo e equen in ecen decades (Ahmad, 2018; Haide e
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al., 2014). As a esul o hese inju ies, pos - auma ic bleeding ep esen s he majo cause
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o po en ially p e en able dea h among inju ed pa ien s, bu which may quickly lead o
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hypo olemic shock and be a al i no apidly con olled (Day, 2016; Rossain e al.,
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2016).
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Haemo hage is a medical eme gency and is de ined as an acu e blood loss o
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in a ascula olume ha could lead o hemodynamic ins abili y (Tin inalli e al., 2020).
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No wi hs anding se e al compensa o y mechanisms a e ac i a ed a he onse o auma-
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ela ed haemo hage, his sympa he ic esponse may ail i he ci cula o y olume
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becomes oo low. I so, shock ollows as a esul o an accumula ion o oxygen deb , as
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well as p og essi e cellula and o gan dys unc ion (Con e ino e al., 2016; Schille e
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al., 2017). In his scena io, es ima ing blood loss can be complica ed by a numbe o
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ac o s, including oedemas o u ina y loses, al hough he es ima ed adul blood olume is
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7% o body weigh and 8-9% o child en. Likewise, he e is a classi ica ion o ou
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classes o haemo hage in o de o help guide olume eplacemen . This classi ica ion
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sys em is b oken down om Class I, whe e he e is a non-shock s a e as a dona ion o one
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blood uni , o Class IV, which is conside ed a p e e minal e en and agg essi e measu es
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a e equi ed. Blood loss in Class I is up o 750 ml wi h no mal blood p essu e and no mal
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o inc eased pulse p essu e, whe eas he blood loss in Class IV is g ea e han 2000 ml
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wi h dec eased blood p essu e and pulse p essu e (Caldwell e al., 2020; Cannon, 2018;
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Tin inalli e al., 2020).
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In his manne , ea ly ecogni ion and p omp ac ion o s op bleeding a e li esa ing,
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especially in p ehospi al and ou -o -hospi al ca e. Haemo hage managemen s a egies
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include handling isible haemo hage, ensu ing adequa e in a enous access and
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e alua ing issue pe usion (Klein e al., 2020; Peng, 2020; T an e al., 2019). Ex e nal
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wound bleeding can usually be con olled by di ec p essu e, al hough a ou nique migh
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be equi ed o massi e blood loss. Tou nique s ha e been used o decades as a quick
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and e ec i e aid o con ol majo bleeding, and include some widely-used comme cial
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ypes such as Comba Applica ion Tou nique (CAT), Eme gency Tou nique (EMT),
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SOF-Tac ical Tou nique -Wide (SOFTT-W) o S e ch-W ap-And-Tuck Tou nique
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(SWATT) (D ew e al., 2014; Ross e al., 2018). Tou nique use and haemo hage-con ol
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aining ha e shown a educ ion in mo ali y om app oxima ely 10 o 16% in he
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ba le ield, which can be mi o ed in inju ed ic ims in ci ilian con ex s, whe e he
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li e a u e is mo e limi ed (Goolsby e al., 2019; Ko wal e al., 2011). Whe eas i is ue
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ha adequa e knowledge and aining o nu ses and medical s a has shown o be
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e ec i e o sa e use o ou nique (Jensen e al., 2019), u he unde s anding o hei use
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in o he scena ios, such as MCIs o disas e s whe e eme gency eams need o ake quick
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and e icien decisions, is s ill needed (Moo e, 2017; Peppe e al., 2019).
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Ha ing said ha , he e is s ill a con o e sy o e he use o ou nique s due o hei
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po en ial isks caused by inapp op ia e usage, lack o aining o p olonged use (Jensen e
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al., 2019; McCa y e al., 2019). These may lead o some o ad e se e ec s, which en ail
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pe manen ne e and muscle inju y, ischemia, ascula inju y o skin nec osis (Ahn e al.,
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2019; Sp uce, 2017). Fo hese easons, some s udies ha e discou aged hei use
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pa icula ly in non-mili a y p ehospi al ca e se ings, highligh ing he need o be e
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aining, mo e consis en p o ocols and adequa e numbe o heal hca e i s esponde s o
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sa ely ea pa ien s (Duignan e al., 2018; Lee e al., 2007; Wall e al., 2014), al hough
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ecen li e a u e shows hei e icacy and sa e y in bo h ci ilian p ehospi al ca e
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(Cunningham e al., 2018; A. A. Smi h e al., 2019; Teixei a e al., 2018) and hospi al
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ca e (Mas i e al., 2020; P æs egaa d e al., 2019). Howe e , li le has been w i en abou
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he g ade o e idence o hei use, agglu ina ing bo h ci ilian and mili a y use o
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ou nique s when used in ou -o -hospi al o p ehospi al ca e. In iew o he incidence o
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auma- ela ed inju ies and he impo ance o con olling hei bleeding, o ganiza ions
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and p o essionals mus he e o e ensu e ha up- o-da e e idence-based p ac ices a e used
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in o de o minimise any po en ial isks, pa icula ly in he e en o MCIs o disas e s
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(Sanak e al., 2018; Wall e al., 2014).
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Aims
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Thus, he aim o e iew was o desc ibe and syn hesise he g ade o e idence on he use
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o ou nique s o con ol haemo hages, summa ising bo h ci ilian and mili a y use.
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Based on limi ed e idence o he use o ou nique s in ci ilian con ex s, which some imes
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mi o ed hose seen in he mili a y con ex , bo h se ings we e chosen o p o ide b oade
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e idence o ou nique managemen .
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Me hods
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Design
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An in eg a i e e iew design was used o concep ualise and p o ide new unde s anding
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abou he opic, ollowing he P e e ed Repo ing I ems o Sys ema ic Re iews and
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Me a-Analyses (PRISMA) guidelines (Supplemen a y File 1). The p ocess included a
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de ini ion o he sea ch s a egy, assessmen o me hodological quali y in selec ed a icles,
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analysis and in e p e a ion o he da a, and syn hesis o he indings (Whi emo e & Kna l,
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2005). In his manne , he ollowing esea ch ques ion based on PIO (Pa ien -
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In e en ion-Ou come) amewo k (S one, 2002) was aised o his pu pose: “Is he
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ou nique (I) ecommended (O) o bleeding con ol in ou -o -hospi al o p ehospi al ca e
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(P)?”.
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Sea ch s a egy
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Th ee elec onic da abases, Medline, Nu sing & Allied Heal h P emium, and Heal h &
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Medical Collec ion, we e consul ed ia P oQues un il Ma ch 2021, using na u al and
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s uc u ed language based in he ollowing sea ch s a egy, alida ed by a lib a ian:
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((((Tou nique [Ti le/Abs ac ]) OR Tou nique s [MeSH Te ms])) AND (((Bleeding
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[Ti le/Abs ac ]) OR Hemo hage [Ti le/Abs ac ]) AND Hemo hage [Mesh Te ms]))
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(Supplemen a y File 2). Snowball s a egy and g ey li e a u e we e no included in his
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in eg a i e e iew.
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Inclusion and exclusion c i e ia
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The inclusion c i e ia we e as ollows: (i) a icles published in English o Spanish, (ii)
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and pape s ocused on he use o ou nique s o con ol haemo hages, (iii) p emised on
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MCIs o disas e s. Simila ly, (i) pape s based on paedia ic popula ion, (ii) hose
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in es iga ing he use o ou nique s in su ge ies o bleeding con ol, and (iii) p eclinical
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s udies.
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Da a sc eening
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Ini ially, wo au ho s (AR, PR) independen ly pe o med a i s sc eening o i les and
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abs ac s and a ull- ex eading. In case o disc epancy, a hi d au ho (MR) was consul ed
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o each a consensus based on he aim o he s udy and esea ch ques ion.
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Quali y app aisal
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App op ia e c i e ia we e used o each s udy, depending on he esea ch design used in
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each one o hem, acco ding o C i ical App aisal Skills P og amme ools (CASP, 2019).
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The G ading o Recommenda ions Assessmen , De elopmen and E alua ion (GRADE)
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anking sys em was used o e alua e he quali y o e idence o s udy ou comes, a ed
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om A (high) o D ( e y low). The GRADE app oach e alua es i e domains: isk o
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bias, inconsis ency/indi ec ness, inadequa e p ecision, and publica ion bias, classi ies he
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bodies o andomized con olled ials as ini ially s a ing wi h high ce ain y and he
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bodies o obse a ional s udies as ini ially s a ing wi h low ce ain y (Schünemann e al.,
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2013).
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Da a abs ac ion and syn hesis
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Consecu i ely, he da a om he included s udies was ex ac ed by wo au ho s
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independen ly (AR, PR) and, i necessa y, a hi d au ho (MR) was consul ed o each a
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consensus based on he aim and esea ch ques ion. Da a we e abula ed in an Excel shee
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acco ding o (i) au ho (s), (ii) me hods, (iii) ype o ou nique , (iii) ana omic loca ion,
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(i ) en i onmen o use (mili a y o ci ilian), ( ) pa icipan s numbe s and ( i) main
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indings (Table 1). Finally, desc ip i e and na a i e analyses we e used o syn hesise he
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ex ac ed da a, acco ding o he esea ch ques ions and collabo a i ely analysed by all
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au ho s.
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Resul s
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Cha ac e is ics o selec ed pape s
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In a i s s age, 877 a icles we e e ie ed om Medline (n=461), Nu sing & Allied
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Heal h Da abase (n=172), and Heal h & Medical Collec ion da abases (n=244). A e i le,
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abs ac and ull- ex sc eening, a o al o 568 a icles we e excluded on he basis o he
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selec ion c i e ia. Ul ima ely, 25 s udies we e included in his e iew (Figu e 1).
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[INSERT FIGURE 1 ABOUT HERE]
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All included a icles a e displayed in Table 1. Ten (40%) o hese a icles we e p ima y
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esea ch s udies, among which 3 we e andomized con olled ials, 2 used a coho
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design, 1 wi h a quasi-expe imen al design, 3 we e case epo s, and 1 was a clinical s udy.
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Based on hese p ima y s udies, he sample size in each s udy anged om 1 o 562
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pa icipan s. Fi een (60%) o he emaining a icles we e li e a u e e iews. O e all, 3
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(12%) pape s aimed hei s udies a bo h ci ilian and mili a y se ings o use ou nique s,
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while 15 (60%) we e ocused only a ci ilian con ex s and 7 (28%) a mili a y scena ios.
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[INSERT TABLE 1 ABOUT HERE]
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The da a syn hesis e ealed ou ca ego ies ela ed o he cu en e idence on he use o
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ou nique s o con ol haemo hages. In his manne , his e idence would be associa ed
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wi h he use o di e en ypes o ou nique s, en i onmen o applica ion, indica ion o
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hei placemen and po en ial complica ions associa ed wi h ou nique placemen . These
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ca ego ies a e desc ibed below.
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Using di e en ypes o ou nique s
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The imp o ised ou nique is a ype o ou nique used by he mili a y and medical
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se ices, pa icula ly in e en o disas e s o MCIs (D. R. King e al., 2015). In o de o
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be e ec i e, hese ou nique s mus mee he ollowing c i e ia: (i) be wide enough so ha
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hey do no p oduce nec osis in he applied a ea, and (ii) ha e enough p essu e o occlude
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a e ies o which an elemen ac ing as a windlass is equi ed. In his sense, he indings
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show he e ec i eness o comme cial ou nique s as opposed o imp o ised ones.
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Comme cial ou nique s usually ha e a wide band wi h di e ences be ween models and
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di e en de ices o achie e adequa e p essu e, such a windlass o a pinwheel, among
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o he s (Chaudha y e al., 2019; R. B. King e al., 2006; Kue e al., 2015).
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Amongs he wide ange o comme cial ou nique s a ailable, mos o he selec ed a icles
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deal wi h CAT o EMT sys ems (Callaway e al., 2015; R. B. King e al., 2006; Kue e
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al., 2015; Sce bo e al., 2017; Sco e al., 2020). The CAT model appea s o be he
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ou nique o choice in he a my due o i s ease o anspo , i s high du abili y o e ime
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and i s abili y o sel -apply, which enables soldie s o apply he ou nique wi h minimal
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and necessa y aining (Bea en e al., 2017).
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Acco ding o Bea en and collabo a o s (2017) as well as Ellis and collabo a o s (2020),
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he CAT model is ine ec i e in he con ol o bleeding in mid- high inju ies, one o he
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mos common ana omical bleeding loca ions, and he e o e he use o EMT model is
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ecommended due o i s e icacy in his si ua ion. No wi hs anding he po en ial o he
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EMT sys em o s op he haemo hage mo e quickly and less pain ully as i dis ibu es
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p essu es mo e e enly (K agh e al., 2012), i s g ea es limi a ion is he g ea e amoun o
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exposed issue and he e o needed o achie e he necessa y ension (Lewis, 2014).
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Likewise, he CAT model is associa ed wi h a highe a e o pain among all ypes o
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ou nique s a ailable. This is due o he wid h o i s cu being 30mm, a smalle han
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ha o he EMT model (being 110mm), which would pinch he skin and cause mo e pain
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by dis ibu ing he p essu e less e enly (D ew, Bi d, e al., 2015; Lewis, 2014; Mullins &
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Ha ahill, 2009). The ecommenda ion o eme gency and mili a y se ices is he e o e
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o ha e and use bo h ypes o EMT and CAT sys ems on he basis o hese easons
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(Bea en e al., 2017; Goodwin e al., 2019).
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En i onmen o applica ion
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In some cases, he esul s can be ex apola ed despi e he a iabili y o he ou nique
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applica ion scena ios (Callaway e al., 2015; D ew, Benne , e al., 2015; D. R. King e
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al., 2015; K agh e al., 2012; Lewis, 2014; Sce bo e al., 2017). Howe e , in scena ios
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o he han MCIs o disas e s, he mechanisms o inju y in bo h mili a y and ci ilian
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scena ios a e a he di e en . Bulle and blas inju ies a e mo e unusual in ci ilian ou -
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o -hospi al con ex s, whe e unin ended inju ies a e mainly ela ed o oad acciden s, alls,
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machine c ushing, o o he auma- ela ed inju ies. Mo eo e , di e ences be ween
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popula ions should be also aken in o accoun , since soldie s a e usually young wi hou
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pa hologies, whe eas ci ilians include all age anges and may o may no ha e associa ed
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pa hologies (Beekley e al., 2008; Goodwin e al., 2019).
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Ne e heless, he esul s in bo h a eas coincide wi h he sa e y and sui abili y o he use
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o ou nique s in p ehospi al, ou -o -hospi al and hospi al ca e, as well as he need o
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p epa e nu ses and o he eme gency p o essionals (mili a y and ci ilian) o use in
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eme gency si ua ions as hey play a key ole iden i ying he isk ac o s o complica ions
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and planning hei use (B odie e al., 2007; Kau a e al., 2018; D. R. King e al., 2015;
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Sce bo e al., 2016).
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Indica ion o ou nique placemen
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One o he main con o e sies abou using he ou nique is abou when a ou nique
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should be placed. In his ega d, some au ho s iden i ied a numbe o indica ions o he
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use o ou nique s, including: no con olling bleeding wi h di ec p essu e o di ec
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p essu e bandages, ampu a ion, haemo haging in mul iple loca ions, p o usion o a
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o eign body, he need o con ol ai ways, si ua ions such as i es o o al da kness, and
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e en s in ol ing mul iple ic ims (Beekley e al., 2008; R. B. King e al., 2006; Schaue
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e al., 2017).
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Con e sely, Beekley and collabo a o s (2008) sugges ed he use o ou nique as a i s -
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line ea men when exsanguina ing haemo hage occu s, as i achie es almos o al
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haemo hage con ol in a sho ime compa ed o o he adi ional me hods, inc easing
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su i al wi h ew associa ed complica ions. In his sense, D ew, Benne and
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collabo a o s (2015) compa ed he esul s be ween adi ional me hods, including di ec
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p essu e, p essu e poin s, ele a ions o limbs, comp ession bandage and imp o ised
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ou nique s as a las eso , and cu en me hods o haemo hage con ol. As sugges ed by
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hese au ho s, limb ele a ion and p essu e poin s show e icacy only ini ially, as
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coagula ion is esumed wi hin 60 seconds in he uppe limb and 30 seconds in he lowe
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limb. The e o e, hese wo measu es may be use ul o a sho pe iod o ime while placing
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a comme cial ou nique , comp essi e bandage o haemos a ic agen , which a e cu en ly
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conside ed o be ecommended haemo hage con ol measu es (Eile sen e al., 2021; R.
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B. King e al., 2006; Schaue e al., 2017; E. R. Smi h e al., 2016).
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A he same le el o esul s, he mos common mis akes made by pa icipan s wi hou
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p io aining when placing he ou nique s we e excessi e bel slack and ew u ns o he
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windlass. In o de o a oid hem, he li e a u e sugges s ha i is necessa y o igh en he
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bel s ongly be o e s a ing o u n he windlass and o make as many u ns o he
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windlass as necessa y o s op he bleeding o o achie e he absence o a pulse (Bea en
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e al., 2017; Co nelissen e al., 2020; K agh e al., 2012). In pa icula , a p essu e o 200
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mmHg o mo e is necessa y in o de o achie e o al bleeding con ol, o which be ween
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630-1170 deg ees o windlass o a ion mus be ca ied ou , coinciding be ween 2 and 4
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u ns, o mo e when applied a he mid- high le el (D. R. King e al., 2015; R. B. King e
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al., 2006; Lewis, 2014).
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