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Use of Tourniquet

Question Type:
Intervention
Full Question:
Among adults and children with severe external limb bleeding  (P), does the application of a tourniquet (I), compared with not applying a tourniquet  (C), change hemostasis, vital signs, blood loss, functional limb recovery, complications, incidence of cardiac arrest, overall mortality (O)?
Consensus on Science:
For the critical outcome of hemostasis, we identified low-quality evidence from 1 human study(Beekley 2008, S28) with a comparison group enrolling 70 patients showing benefit where 83% of those who had a tourniquet applied (35/42) achieved hemostasis compared with 61% of those who did not have a tourniquet applied (17/28) (RR, 10.54; 95% CI, 6.55–16.96), and very-low-quality evidence (downgraded for risk of bias and indirectness) from 6 human case series(Lakstein 2003, S221; Wall 2008, A49; Swan KG Jr 2009, 672; Guo 2011, 151; King 2012, 33; Kue 2015, 399) enrolling a total of 750 patients demonstrating that 74.7% of patients who had a tourniquet applied (560/750) achieved hemostasis (MD not estimable because control group was lacking). For the critical outcome of mortality, we identified low-quality evidence (downgraded for risk of bias) from 3 human studies(Beekley 2008, S28; Passos 2014, 573; Kragh JF Jr 2015, 290) with a comparison group enrolling 1768 patients showing no difference, where 12% of patients who had a tourniquet applied (91/791) died compared with 9% of patients who did not have a tourniquet applied (89/977) (RR, 1.08; 95% CI, 0.82–1.43) and 7 very-low-quality evidence (downgraded for risk of bias) human case series(Lakstein 2003, S221; Brodie 2007, 310; Tien 2008, 174; Kragh JF Jr 2011, 590; King 2012, 33; Kragh JF Jr 2012, 1361; Kue 2015, 399) enrolling 903 patients, where 10% of those patients who had a tourniquet applied (92/903) died. For the critical outcome of vital signs, we identified low-quality evidence (downgraded for risk of bias) from 3 human studies with a comparison group(Beekley 2008, S28; Passos 2014, 573; Kragh JF Jr 2015, 290) enrolling 1642 participants demonstrating no benefit, with an MD in HR of 3 BPM more (95% CI, 0.21–6.91) if a tourniquet was applied, and low-quality evidence (downgraded for to risk of bias and imprecision) from 2 human studies with a comparison group(Beekley 2008, S28; Passos 2014, 573) enrolling 284 participants demonstrating no benefit, with an MD in SBP of 9 mm Hg less (95% CI, −14.13 to −3.43) if a tourniquet was applied. For the critical outcome of complications, low-quality evidence (downgraded for risk of bias and imprecision) from 1 human study with a comparison group(Beekley 2008, S28) enrolling 165 patients showed benefit to tourniquet application, where 6% of patients who had a tourniquet applied (6/67) had complications compared with 9% who did not have a tourniquet applied (9/98) had complications (RR, 0.19; 95% CI, 0.06–0.55), and very-low-quality evidence (downgraded for risk of bias and imprecision) from 4 human case series studies(Lakstein 2003, S221; Brodie 2007, 310; Kragh JF Jr 2012, 1361; Kue 2015, 399) enrolling 846 patients documented that complications from tourniquets occurred in 4.3% of patients (36/846).
Treatment Recommendation:
We suggest first aid providers use a tourniquet when standard first aid hemorrhage control (including direct pressure with or without a dressing) cannot control severe external limb bleeding (weak recommendation, low-quality evidence). Values, Preferences, and Task Force Insights In making this recommendation, we place increased value on the benefits of hemostasis, which outweigh the risks (such as compartment syndrome, nerve palsy, or secondary amputation). The cost of the intervention is moderate. The tourniquets used in the studies evaluated included a mix of improvised and commercial devices. The maximum length of time for leaving a tourniquet in place was not reviewed. The literature search was rerun in January 2015, and 2 additional studies were added to the consensus on science and GRADE table, 1 from the military setting(Kragh JF Jr 2015, 290-296) and 1 from the civilian EMS setting,(Kue 2015, 399-404) both supporting our treatment recommendation. The task force believes that application of a tourniquet will be most effective and safe if the provider is trained with the type(s) of tourniquet to be used and if the tourniquet is applied properly and rapidly. Other situations when a tourniquet might be used instead of direct pressure were discussed. Such situations are thought to include mass casualty incidents, an unsafe scene, a complex or prolonged transfer, inability to access an injury, and caring for someone with multiple injuries requiring triage of injuries. A major finding in this review is that the rate of adverse events with tourniquet application is low, and the rate of successful hemostasis is high. However, we did not find a relationship between the application of tourniquet and improved survival.
CoSTR Attachments:
2015 02 15.1 CoSTR Tourniquet.docx    
2015 02 15.1 GRADE table Tourniquet - after re-run search - refs correct.docx    

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