Tourniquets as a haemorrhage control measure in military and civilian care settings: An integrative review

1 TITLE 1 Tou nique s as a haemo hage-con ol measu e in mili a y and ci ilian ca e se ings: an 2 in eg a i e e iew 3 ABSTRACT 4 Aims and objec i es: The aim o e iew was o desc ibe and syn hesise he e idence on 5 he use o ou nique s o con ol haemo hages, summa ising bo h ci ilian and mili a y 6 use. 7 Backg ound: T auma- ela ed haemo hage cons i u e one o he mos p e en able dea hs 8 among inju ed pa ien s, pa icula ly in mul i-casual y inciden s and disas e s. In his 9 con ex , sa e ins umen s such as ou nique s a e essen ial o help heal hca e p o essionals 10 o minimise loss o li e and maximise pa ien eco e y. 11 Design and Me hods: An in eg a i e e iew was conduc ed in Medline, Nu sing & Allied 12 Heal h P emium, and Heal h & Medical Collec ion, using published da a un il Ma ch 13 2021 and ollowing he PRISMA guidelines. 14 Resul s: A o al o 25 a icles we e included. E idence has been syn hesised o unde s and 15 he use o di e en ypes o ou nique s, en i onmen o applica ion, indica ion o hei 16 placemen and po en ial complica ions associa ed wi h ou nique placemen . 17 Conclusions: Comme cial ou nique s such as Comba Applica ion Tou nique o 18 Eme gency Tou nique models a e a aluable and sa e ins umen o haemo hage 19 con ol in bo h mili a y and ci ilian ou -o -hospi al ca e se ings. Nu ses, as pa o 20 eme gency eams, and o he p o essionals should be awa e ha he e is a possibili y o 21 ad e se complica ions, bu hey a e di ec ly p opo ional o he ime o ou nique 22 placemen and gene ally empo a y. In addi ion, na ional and in e na ional guidelines 23 ensu e he need o all ci ilian eme gency se ices o be equipped wi h hese de ices, as 24 well as o he aining o heal hca e p o essionals and i s esponde s in hei use. 25 Rele ance o clinical p ac ice: Despi e he lack o complica ions in he use o ou nique s 26 in hese cases, hei use has been a ma e o deba e o decades. In his sense, his e iew 27 2 yields up- o-da e guidelines in he use o ou nique s, hei ecommenda ions and hei 28 signi icance among p o essionals o manage complica ed si ua ions. 29 KEYWORDS 30 Ex emi y auma; Fi s aid; Hemo hage con ol; Inju ies; Re iew Li e a u e as Topic; 31 Tou nique s 32 IMPACT STATEMENT 33 Wha does his pape con ibu e o he wide global clinical communi y? 34 • The indings o his in eg a i e e iew shed some ligh on he con o e sial use o 35 ou nique s in bo h ci ilian and mili a y se ings. Lack o aining in hese 36 ins umen s appea s as one o he majo conce ns among ci ilian p o essionals 37 pa icula ly in p ehospi al se ings and ollowing mass-casual y inciden s o 38 disas e s. 39 • Comme cial ou nique s cons i u e a sa e and aluable ins umen o heal hca e 40 p o essionals and i s esponde s, including nu ses, in p ehospi al, ou -o -hospi al 41 and hospi al ca e. Howe e , u he esea ch is needed o unde s and he speci ic 42 needs and di icul ies o hese p o essionals in his ma e . 43 In oduc ion 44 T auma- ela ed inju ies a e one o he leading causes o mo ali y and disabili y, 45 accoun ing o 29.6% o dea hs wo ldwide as pe he la es da a om he Wo ld Heal h 46 O ganiza ion (WHO, 2018). Al hough many o hese inju ies a e unin en ional, iolen 47 auma con ibu es signi ican ly o he mo ali y o mass-casual y inciden s (MCIs) o 48 disas e s, which ha e become mo e equen in ecen decades (Ahmad, 2018; Haide e 49 al., 2014). As a esul o hese inju ies, pos - auma ic bleeding ep esen s he majo cause 50 o po en ially p e en able dea h among inju ed pa ien s, bu which may quickly lead o 51 hypo olemic shock and be a al i no apidly con olled (Day, 2016; Rossain e al., 52 2016). 53 3 Haemo hage is a medical eme gency and is de ined as an acu e blood loss o 54 in a ascula olume ha could lead o hemodynamic ins abili y (Tin inalli e al., 2020). 55 No wi hs anding se e al compensa o y mechanisms a e ac i a ed a he onse o auma- 56 ela ed haemo hage, his sympa he ic esponse may ail i he ci cula o y olume 57 becomes oo low. I so, shock ollows as a esul o an accumula ion o oxygen deb , as 58 well as p og essi e cellula and o gan dys unc ion (Con e ino e al., 2016; Schille e 59 al., 2017). In his scena io, es ima ing blood loss can be complica ed by a numbe o 60 ac o s, including oedemas o u ina y loses, al hough he es ima ed adul blood olume is 61 7% o body weigh and 8-9% o child en. Likewise, he e is a classi ica ion o ou 62 classes o haemo hage in o de o help guide olume eplacemen . This classi ica ion 63 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 64 blood uni , o Class IV, which is conside ed a p e e minal e en and agg essi e measu es 65 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 66 o inc eased pulse p essu e, whe eas he blood loss in Class IV is g ea e han 2000 ml 67 wi h dec eased blood p essu e and pulse p essu e (Caldwell e al., 2020; Cannon, 2018; 68 Tin inalli e al., 2020). 69 In his manne , ea ly ecogni ion and p omp ac ion o s op bleeding a e li esa ing, 70 especially in p ehospi al and ou -o -hospi al ca e. Haemo hage managemen s a egies 71 include handling isible haemo hage, ensu ing adequa e in a enous access and 72 e alua ing issue pe usion (Klein e al., 2020; Peng, 2020; T an e al., 2019). Ex e nal 73 wound bleeding can usually be con olled by di ec p essu e, al hough a ou nique migh 74 be equi ed o massi e blood loss. Tou nique s ha e been used o decades as a quick 75 and e ec i e aid o con ol majo bleeding, and include some widely-used comme cial 76 ypes such as Comba Applica ion Tou nique (CAT), Eme gency Tou nique (EMT), 77 SOF-Tac ical Tou nique -Wide (SOFTT-W) o S e ch-W ap-And-Tuck Tou nique 78 (SWATT) (D ew e al., 2014; Ross e al., 2018). Tou nique use and haemo hage-con ol 79 aining ha e shown a educ ion in mo ali y om app oxima ely 10 o 16% in he 80 ba le ield, which can be mi o ed in inju ed ic ims in ci ilian con ex s, whe e he 81 li e a u e is mo e limi ed (Goolsby e al., 2019; Ko wal e al., 2011). Whe eas i is ue 82 ha adequa e knowledge and aining o nu ses and medical s a has shown o be 83 e ec i e o sa e use o ou nique (Jensen e al., 2019), u he unde s anding o hei use 84 4 in o he scena ios, such as MCIs o disas e s whe e eme gency eams need o ake quick 85 and e icien decisions, is s ill needed (Moo e, 2017; Peppe e al., 2019). 86 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 87 po en ial isks caused by inapp op ia e usage, lack o aining o p olonged use (Jensen e 88 al., 2019; McCa y e al., 2019). These may lead o some o ad e se e ec s, which en ail 89 pe manen ne e and muscle inju y, ischemia, ascula inju y o skin nec osis (Ahn e al., 90 2019; Sp uce, 2017). Fo hese easons, some s udies ha e discou aged hei use 91 pa icula ly in non-mili a y p ehospi al ca e se ings, highligh ing he need o be e 92 aining, mo e consis en p o ocols and adequa e numbe o heal hca e i s esponde s o 93 sa ely ea pa ien s (Duignan e al., 2018; Lee e al., 2007; Wall e al., 2014), al hough 94 ecen li e a u e shows hei e icacy and sa e y in bo h ci ilian p ehospi al ca e 95 (Cunningham e al., 2018; A. A. Smi h e al., 2019; Teixei a e al., 2018) and hospi al 96 ca e (Mas i e al., 2020; P æs egaa d e al., 2019). Howe e , li le has been w i en abou 97 he g ade o e idence o hei use, agglu ina ing bo h ci ilian and mili a y use o 98 ou nique s when used in ou -o -hospi al o p ehospi al ca e. In iew o he incidence o 99 auma- ela ed inju ies and he impo ance o con olling hei bleeding, o ganiza ions 100 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 101 in o de o minimise any po en ial isks, pa icula ly in he e en o MCIs o disas e s 102 (Sanak e al., 2018; Wall e al., 2014). 103 Aims 104 Thus, he aim o e iew was o desc ibe and syn hesise he g ade o e idence on he use 105 o ou nique s o con ol haemo hages, summa ising bo h ci ilian and mili a y use. 106 Based on limi ed e idence o he use o ou nique s in ci ilian con ex s, which some imes 107 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 108 e idence o ou nique managemen . 109 Me hods 110 Design 111 An in eg a i e e iew design was used o concep ualise and p o ide new unde s anding 112 abou he opic, ollowing he P e e ed Repo ing I ems o Sys ema ic Re iews and 113 5 Me a-Analyses (PRISMA) guidelines (Supplemen a y File 1). The p ocess included a 114 de ini ion o he sea ch s a egy, assessmen o me hodological quali y in selec ed a icles, 115 analysis and in e p e a ion o he da a, and syn hesis o he indings (Whi emo e & Kna l, 116 2005). In his manne , he ollowing esea ch ques ion based on PIO (Pa ien - 117 In e en ion-Ou come) amewo k (S one, 2002) was aised o his pu pose: “Is he 118 ou nique (I) ecommended (O) o bleeding con ol in ou -o -hospi al o p ehospi al ca e 119 (P)?”. 120 Sea ch s a egy 121 Th ee elec onic da abases, Medline, Nu sing & Allied Heal h P emium, and Heal h & 122 Medical Collec ion, we e consul ed ia P oQues un il Ma ch 2021, using na u al and 123 s uc u ed language based in he ollowing sea ch s a egy, alida ed by a lib a ian: 124 ((((Tou nique [Ti le/Abs ac ]) OR Tou nique s [MeSH Te ms])) AND (((Bleeding 125 [Ti le/Abs ac ]) OR Hemo hage [Ti le/Abs ac ]) AND Hemo hage [Mesh Te ms])) 126 (Supplemen a y File 2). Snowball s a egy and g ey li e a u e we e no included in his 127 in eg a i e e iew. 128 Inclusion and exclusion c i e ia 129 The inclusion c i e ia we e as ollows: (i) a icles published in English o Spanish, (ii) 130 and pape s ocused on he use o ou nique s o con ol haemo hages, (iii) p emised on 131 MCIs o disas e s. Simila ly, (i) pape s based on paedia ic popula ion, (ii) hose 132 in es iga ing he use o ou nique s in su ge ies o bleeding con ol, and (iii) p eclinical 133 s udies. 134 Da a sc eening 135 Ini ially, wo au ho s (AR, PR) independen ly pe o med a i s sc eening o i les and 136 abs ac s and a ull- ex eading. In case o disc epancy, a hi d au ho (MR) was consul ed 137 o each a consensus based on he aim o he s udy and esea ch ques ion. 138 6 Quali y app aisal 139 App op ia e c i e ia we e used o each s udy, depending on he esea ch design used in 140 each one o hem, acco ding o C i ical App aisal Skills P og amme ools (CASP, 2019). 141 The G ading o Recommenda ions Assessmen , De elopmen and E alua ion (GRADE) 142 anking sys em was used o e alua e he quali y o e idence o s udy ou comes, a ed 143 om A (high) o D ( e y low). The GRADE app oach e alua es i e domains: isk o 144 bias, inconsis ency/indi ec ness, inadequa e p ecision, and publica ion bias, classi ies he 145 bodies o andomized con olled ials as ini ially s a ing wi h high ce ain y and he 146 bodies o obse a ional s udies as ini ially s a ing wi h low ce ain y (Schünemann e al., 147 2013). 148 Da a abs ac ion and syn hesis 149 Consecu i ely, he da a om he included s udies was ex ac ed by wo au ho s 150 independen ly (AR, PR) and, i necessa y, a hi d au ho (MR) was consul ed o each a 151 consensus based on he aim and esea ch ques ion. Da a we e abula ed in an Excel shee 152 acco ding o (i) au ho (s), (ii) me hods, (iii) ype o ou nique , (iii) ana omic loca ion, 153 (i ) en i onmen o use (mili a y o ci ilian), ( ) pa icipan s numbe s and ( i) main 154 indings (Table 1). Finally, desc ip i e and na a i e analyses we e used o syn hesise he 155 ex ac ed da a, acco ding o he esea ch ques ions and collabo a i ely analysed by all 156 au ho s. 157 Resul s 158 Cha ac e is ics o selec ed pape s 159 In a i s s age, 877 a icles we e e ie ed om Medline (n=461), Nu sing & Allied 160 Heal h Da abase (n=172), and Heal h & Medical Collec ion da abases (n=244). A e i le, 161 abs ac and ull- ex sc eening, a o al o 568 a icles we e excluded on he basis o he 162 selec ion c i e ia. Ul ima ely, 25 s udies we e included in his e iew (Figu e 1). 163 [INSERT FIGURE 1 ABOUT HERE] 164 7 All included a icles a e displayed in Table 1. Ten (40%) o hese a icles we e p ima y 165 esea ch s udies, among which 3 we e andomized con olled ials, 2 used a coho 166 design, 1 wi h a quasi-expe imen al design, 3 we e case epo s, and 1 was a clinical s udy. 167 Based on hese p ima y s udies, he sample size in each s udy anged om 1 o 562 168 pa icipan s. Fi een (60%) o he emaining a icles we e li e a u e e iews. O e all, 3 169 (12%) pape s aimed hei s udies a bo h ci ilian and mili a y se ings o use ou nique s, 170 while 15 (60%) we e ocused only a ci ilian con ex s and 7 (28%) a mili a y scena ios. 171 [INSERT TABLE 1 ABOUT HERE] 172 The da a syn hesis e ealed ou ca ego ies ela ed o he cu en e idence on he use o 173 ou nique s o con ol haemo hages. In his manne , his e idence would be associa ed 174 wi h he use o di e en ypes o ou nique s, en i onmen o applica ion, indica ion o 175 hei placemen and po en ial complica ions associa ed wi h ou nique placemen . These 176 ca ego ies a e desc ibed below. 177 Using di e en ypes o ou nique s 178 The imp o ised ou nique is a ype o ou nique used by he mili a y and medical 179 se ices, pa icula ly in e en o disas e s o MCIs (D. R. King e al., 2015). In o de o 180 be e ec i e, hese ou nique s mus mee he ollowing c i e ia: (i) be wide enough so ha 181 hey do no p oduce nec osis in he applied a ea, and (ii) ha e enough p essu e o occlude 182 a e ies o which an elemen ac ing as a windlass is equi ed. In his sense, he indings 183 show he e ec i eness o comme cial ou nique s as opposed o imp o ised ones. 184 Comme cial ou nique s usually ha e a wide band wi h di e ences be ween models and 185 di e en de ices o achie e adequa e p essu e, such a windlass o a pinwheel, among 186 o he s (Chaudha y e al., 2019; R. B. King e al., 2006; Kue e al., 2015). 187 Amongs he wide ange o comme cial ou nique s a ailable, mos o he selec ed a icles 188 deal wi h CAT o EMT sys ems (Callaway e al., 2015; R. B. King e al., 2006; Kue e 189 al., 2015; Sce bo e al., 2017; Sco e al., 2020). The CAT model appea s o be he 190 ou nique o choice in he a my due o i s ease o anspo , i s high du abili y o e ime 191 and i s abili y o sel -apply, which enables soldie s o apply he ou nique wi h minimal 192 and necessa y aining (Bea en e al., 2017). 193 8 Acco ding o Bea en and collabo a o s (2017) as well as Ellis and collabo a o s (2020), 194 he CAT model is ine ec i e in he con ol o bleeding in mid- high inju ies, one o he 195 mos common ana omical bleeding loca ions, and he e o e he use o EMT model is 196 ecommended due o i s e icacy in his si ua ion. No wi hs anding he po en ial o he 197 EMT sys em o s op he haemo hage mo e quickly and less pain ully as i dis ibu es 198 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 199 exposed issue and he e o needed o achie e he necessa y ension (Lewis, 2014). 200 Likewise, he CAT model is associa ed wi h a highe a e o pain among all ypes o 201 ou nique s a ailable. This is due o he wid h o i s cu being 30mm, a smalle han 202 ha o he EMT model (being 110mm), which would pinch he skin and cause mo e pain 203 by dis ibu ing he p essu e less e enly (D ew, Bi d, e al., 2015; Lewis, 2014; Mullins & 204 Ha ahill, 2009). The ecommenda ion o eme gency and mili a y se ices is he e o e 205 o ha e and use bo h ypes o EMT and CAT sys ems on he basis o hese easons 206 (Bea en e al., 2017; Goodwin e al., 2019). 207 En i onmen o applica ion 208 In some cases, he esul s can be ex apola ed despi e he a iabili y o he ou nique 209 applica ion scena ios (Callaway e al., 2015; D ew, Benne , e al., 2015; D. R. King e 210 al., 2015; K agh e al., 2012; Lewis, 2014; Sce bo e al., 2017). Howe e , in scena ios 211 o he han MCIs o disas e s, he mechanisms o inju y in bo h mili a y and ci ilian 212 scena ios a e a he di e en . Bulle and blas inju ies a e mo e unusual in ci ilian ou - 213 o -hospi al con ex s, whe e unin ended inju ies a e mainly ela ed o oad acciden s, alls, 214 machine c ushing, o o he auma- ela ed inju ies. Mo eo e , di e ences be ween 215 popula ions should be also aken in o accoun , since soldie s a e usually young wi hou 216 pa hologies, whe eas ci ilians include all age anges and may o may no ha e associa ed 217 pa hologies (Beekley e al., 2008; Goodwin e al., 2019). 218 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 219 o ou nique s in p ehospi al, ou -o -hospi al and hospi al ca e, as well as he need o 220 p epa e nu ses and o he eme gency p o essionals (mili a y and ci ilian) o use in 221 eme gency si ua ions as hey play a key ole iden i ying he isk ac o s o complica ions 222 and planning hei use (B odie e al., 2007; Kau a e al., 2018; D. R. King e al., 2015; 223 Sce bo e al., 2016). 224 9 Indica ion o ou nique placemen 225 One o he main con o e sies abou using he ou nique is abou when a ou nique 226 should be placed. In his ega d, some au ho s iden i ied a numbe o indica ions o he 227 use o ou nique s, including: no con olling bleeding wi h di ec p essu e o di ec 228 p essu e bandages, ampu a ion, haemo haging in mul iple loca ions, p o usion o a 229 o eign body, he need o con ol ai ways, si ua ions such as i es o o al da kness, and 230 e en s in ol ing mul iple ic ims (Beekley e al., 2008; R. B. King e al., 2006; Schaue 231 e al., 2017). 232 Con e sely, Beekley and collabo a o s (2008) sugges ed he use o ou nique as a i s - 233 line ea men when exsanguina ing haemo hage occu s, as i achie es almos o al 234 haemo hage con ol in a sho ime compa ed o o he adi ional me hods, inc easing 235 su i al wi h ew associa ed complica ions. In his sense, D ew, Benne and 236 collabo a o s (2015) compa ed he esul s be ween adi ional me hods, including di ec 237 p essu e, p essu e poin s, ele a ions o limbs, comp ession bandage and imp o ised 238 ou nique s as a las eso , and cu en me hods o haemo hage con ol. As sugges ed by 239 hese au ho s, limb ele a ion and p essu e poin s show e icacy only ini ially, as 240 coagula ion is esumed wi hin 60 seconds in he uppe limb and 30 seconds in he lowe 241 limb. The e o e, hese wo measu es may be use ul o a sho pe iod o ime while placing 242 a comme cial ou nique , comp essi e bandage o haemos a ic agen , which a e cu en ly 243 conside ed o be ecommended haemo hage con ol measu es (Eile sen e al., 2021; R. 244 B. King e al., 2006; Schaue e al., 2017; E. R. Smi h e al., 2016). 245 A he same le el o esul s, he mos common mis akes made by pa icipan s wi hou 246 p io aining when placing he ou nique s we e excessi e bel slack and ew u ns o he 247 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 248 bel s ongly be o e s a ing o u n he windlass and o make as many u ns o he 249 windlass as necessa y o s op he bleeding o o achie e he absence o a pulse (Bea en 250 e al., 2017; Co nelissen e al., 2020; K agh e al., 2012). In pa icula , a p essu e o 200 251 mmHg o mo e is necessa y in o de o achie e o al bleeding con ol, o which be ween 252 630-1170 deg ees o windlass o a ion mus be ca ied ou , coinciding be ween 2 and 4 253 u ns, o mo e when applied a he mid- high le el (D. R. King e al., 2015; R. B. King e 254 al., 2006; Lewis, 2014). 255 16 h ps://doi.o g/10.1080/17474086.2018.1548929 425 Caubè e, A., de Lande oisin, E. S., Schlienge , G., Demou es, T., & Romana , P. (2019). 426 Tac ical ou nique : Su gical managemen mus be wi hin 3 hou s. 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The Jou nal o 625 T auma and Acu e Ca e Su ge y, 77(5), 734–742. 626 h ps://doi.o g/10.1097/TA.0000000000000433 627 Whi emo e, R., & Kna l, K. (2005). The in eg a i e e iew: Upda ed me hodology. 628 Jou nal o Ad anced Nu sing, 52(5), 546–553. h ps://doi.o g/10.1111/j.1365- 629 2648.2005.03621.x 630 WHO (2018). Global Heal h Es ima es 2016: Es ima ed dea hs by age, sex, and cause. 631 Wo ld Heal h O ganiza ion. 632 h ps://www.who.in /heal hin o/global_bu den_disease/GHE2016_Dea hs_Glob 633 al_2000_2016.xls 634 Funding 635 This esea ch ecei ed no speci ic g an om any unding agency in he public, 636 comme cial, o no - o -p o i sec o s. 637