Implications Of The National Stop The Bleed Campaign: The Swinging Pendulum Of Prehospital Tourniquet Application In Civilian Limb Trauma

BACKGROUND Prehospital tourniquet (PHT) utilization has increased in response to mass casualty events. We aimed to describe the incidence, therapeutic effectiveness, and morbidity associated with tourniquet placement in all patients treated with PHT application. METHODS A retrospective observational cohort study was performed to evaluate all adults with a PHT who presented at two Level I trauma centers between January 2015 and December 2019. Medically trained abstractors determined if the PHT was clinically indicated (placed for limb amputation, vascular hard signs, injury requiring hemostasis procedure, or significant documented blood loss). Prehospital tourniquets were further designated as appropriately or inappropriately applied (based on PHT anatomic placement location, occurrence of a venous tourniquet, or ischemic time defined as >2 hours). Statistical analyses were performed to generate primary and secondary results. RESULTS A total of 147 patients met study inclusion criteria, of which 70% met the criteria for trauma registry inclusion. Total incidence of PHT utilization increased from 2015 to 2019, with increasing proportions of PHTs placed by nonemergency medical service personnel. Improvised PHTs were frequently used. Prehospital tourniquets were clinically indicated in 51% of patients. Overall, 39 (27%) patients had a PHT that was inappropriately placed, five of which resulted in significant morbidity. CONCLUSION In summary, prehospital tourniquet application has become widely adopted in the civilian setting, frequently performed by civilian and nonemergency medical service personnel. Of PHTs placed, nearly half had no clear indication for placement and over a quarter of PHTs were misapplied with notable associated morbidity. Results suggest that the topics of clinical indication and appropriate application of tourniquets may be important areas for continued focus in future tourniquet educational programs, as well as future quality assessment efforts.