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

1 TITLE 1 Tourniquets as a haemorrhage-control measure in military and civilian care settings: an 2 integrative review 3 ABSTRACT 4 Aims and objectives: The aim of review was to describe and synthesise the evidence on 5 the use of tourniquets to control haemorrhages, summarising both civilian and military 6 use. 7 Background: Trauma-related haemorrhage constitute one of the most preventable deaths 8 among injured patients, particularly in multi-casualty incidents and disasters. In this 9 context, safe instruments such as tourniquets are essential to help healthcare professionals 10 to minimise loss of life and maximise patient recovery. 11 Design and Methods: An integrative review was conducted in Medline, Nursing & Allied 12 Health Premium, and Health & Medical Collection, using published data until March 13 2021 and following the PRISMA guidelines. 14 Results: A total of 25 articles were included. Evidence has been synthesised to understand 15 the use of different types of tourniquets, environment of application, indication for their 16 placement and potential complications associated with tourniquet placement. 17 Conclusions: Commercial tourniquets such as Combat Application Tourniquet or 18 Emergency Tourniquet models are a valuable and safe instrument for haemorrhage 19 control in both military and civilian out-of-hospital care settings. Nurses, as part of 20 emergency teams, and other professionals should be aware that there is a possibility of 21 adverse complications, but they are directly proportional to the time of tourniquet 22 placement and generally temporary. In addition, national and international guidelines 23 ensure the need for all civilian emergency services to be equipped with these devices, as 24 well as for the training of healthcare professionals and first responders in their use. 25 Relevance to clinical practice: Despite the lack of complications in the use of tourniquets 26 in these cases, their use has been a matter of debate for decades. In this sense, this review 27 2 yields up-to-date guidelines in the use of tourniquets, their recommendations and their 28 significance among professionals to manage complicated situations. 29 KEYWORDS 30 Extremity trauma; First aid; Hemorrhage control; Injuries; Review Literature as Topic; 31 Tourniquets 32 IMPACT STATEMENT 33 What does this paper contribute to the wider global clinical community? 34 • The findings of this integrative review shed some light on the controversial use of 35 tourniquets in both civilian and military settings. Lack of training in these 36 instruments appears as one of the major concerns among civilian professionals 37 particularly in prehospital settings and following mass-casualty incidents or 38 disasters. 39 • Commercial tourniquets constitute a safe and valuable instrument for healthcare 40 professionals and first responders, including nurses, in prehospital, out-of-hospital 41 and hospital care. However, further research is needed to understand the specific 42 needs and difficulties of these professionals in this matter. 43 Introduction 44 Trauma-related injuries are one of the leading causes of mortality and disability, 45 accounting for 29.6% of deaths worldwide as per the latest data from the World Health 46 Organization (WHO, 2018). Although many of these injuries are unintentional, violent 47 trauma contributes significantly to the mortality of mass-casualty incidents (MCIs) or 48 disasters, which have become more frequent in recent decades (Ahmad, 2018; Haider et 49 al., 2014). As a result of these injuries, post-traumatic bleeding represents the major cause 50 of potentially preventable death among injured patients, but which may quickly lead to 51 hypovolemic shock and be fatal if not rapidly controlled (Day, 2016; Rossaint et al., 52 2016). 53 3 Haemorrhage is a medical emergency and is defined as an acute blood loss of 54 intravascular volume that could lead to hemodynamic instability (Tintinalli et al., 2020). 55 Notwithstanding several compensatory mechanisms are activated at the onset of trauma56 related haemorrhage, this sympathetic response may fail if the circulatory volume 57 becomes too low. If so, shock follows as a result of an accumulation of oxygen debt, as 58 well as progressive cellular and organ dysfunction (Convertino et al., 2016; Schiller et 59 al., 2017). In this scenario, estimating blood loss can be complicated by a number of 60 factors, including oedemas or urinary loses, although the estimated adult blood volume is 61 7% of body weight and 8-9% for children. Likewise, there is a classification of four 62 classes of haemorrhage in order to help guide volume replacement. This classification 63 system is broken down from Class I, where there is a non-shock state as a donation of one 64 blood unit, to Class IV, which is considered a preterminal event and aggressive measures 65 are required. Blood loss in Class I is up to 750 ml with normal blood pressure and normal 66 or increased pulse pressure, whereas the blood loss in Class IV is greater than 2000 ml 67 with decreased blood pressure and pulse pressure (Caldwell et al., 2020; Cannon, 2018; 68 Tintinalli et al., 2020). 69 In this manner, early recognition and prompt action to stop bleeding are lifesaving, 70 especially in prehospital and out-of-hospital care. Haemorrhage management strategies 71 include handling visible haemorrhage, ensuring adequate intravenous access and 72 evaluating tissue perfusion (Klein et al., 2020; Peng, 2020; Tran et al., 2019). External 73 wound bleeding can usually be controlled by direct pressure, although a tourniquet might 74 be required for massive blood loss. Tourniquets have been used for decades as a quick 75 and effective aid to control major bleeding, and include some widely-used commercial 76 types such as Combat Application Tourniquet (CAT), Emergency Tourniquet (EMT), 77 SOF-Tactical Tourniquet-Wide (SOFTT-W) or Stretch-Wrap-And-Tuck Tourniquet 78 (SWATT) (Drew et al., 2014; Ross et al., 2018). Tourniquet use and haemorrhage-control 79 training have shown a reduction in mortality from approximately 10 to 16% in the 80 battlefield, which can be mirrored in injured victims in civilian contexts, where the 81 literature is more limited (Goolsby et al., 2019; Kotwal et al., 2011). Whereas it is true 82 that adequate knowledge and training of nurses and medical staff has shown to be 83 effective for safe use of tourniquet (Jensen et al., 2019), further understanding of their use 84 4 in other scenarios, such as MCIs or disasters where emergency teams need to take quick 85 and efficient decisions, is still needed (Moore, 2017; Pepper et al., 2019). 86 Having said that, there is still a controversy over the use of tourniquets due to their 87 potential risks caused by inappropriate usage, lack of training or prolonged use (Jensen et 88 al., 2019; McCarty et al., 2019). These may lead to some of adverse effects, which entail 89 permanent nerve and muscle injury, ischemia, vascular injury or skin necrosis (Ahn et al., 90 2019; Spruce, 2017). For these reasons, some studies have discouraged their use 91 particularly in non-military prehospital care settings, highlighting the need for better 92 training, more consistent protocols and adequate number of healthcare first responders to 93 safely treat patients (Duignan et al., 2018; Lee et al., 2007; Wall et al., 2014), although 94 recent literature shows their efficacy and safety in both civilian prehospital care 95 (Cunningham et al., 2018; A. A. Smith et al., 2019; Teixeira et al., 2018) and hospital 96 care (Masri et al., 2020; Præstegaard et al., 2019). However, little has been written about 97 the grade of evidence of their use, agglutinating both civilian and military use of 98 tourniquets when used in out-of-hospital or prehospital care. In view of the incidence of 99 trauma-related injuries and the importance of controlling their bleeding, organizations 100 and professionals must therefore ensure that up-to-date evidence-based practices are used 101 in order to minimise any potential risks, particularly in the event of MCIs or disasters 102 (Sanak et al., 2018; Wall et al., 2014). 103 Aims 104 Thus, the aim of review was to describe and synthesise the grade of evidence on the use 105 of tourniquets to control haemorrhages, summarising both civilian and military use. 106 Based on limited evidence of the use of tourniquets in civilian contexts, which sometimes 107 mirrored those seen in the military context, both settings were chosen to provide broader 108 evidence of tourniquet management. 109 Methods 110 Design 111 An integrative review design was used to conceptualise and provide new understanding 112 about the topic, following the Preferred Reporting Items for Systematic Reviews and 113 5 Meta-Analyses (PRISMA) guidelines (Supplementary File 1). The process included a 114 definition of the search strategy, assessment of methodological quality in selected articles, 115 analysis and interpretation of the data, and synthesis of the findings (Whittemore & Knafl, 116 2005). In this manner, the following research question based on PIO (Patient117 Intervention-Outcome) framework (Stone, 2002) was raised to this purpose: “Is the 118 tourniquet (I) recommended (O) for bleeding control in out-of-hospital or prehospital care 119 (P)?”. 120 Search strategy 121 Three electronic databases, Medline, Nursing & Allied Health Premium, and Health & 122 Medical Collection, were consulted via ProQuest until March 2021, using natural and 123 structured language based in the following search strategy, validated by a librarian: 124 ((((Tourniquet [Title/Abstract]) OR Tourniquets [MeSH Terms])) AND (((Bleeding 125 [Title/Abstract]) OR Hemorrhage [Title/Abstract]) AND Hemorrhage [Mesh Terms])) 126 (Supplementary File 2). Snowball strategy and grey literature were not included in this 127 integrative review. 128 Inclusion and exclusion criteria 129 The inclusion criteria were as follows: (i) articles published in English or Spanish, (ii) 130 and papers focused on the use of tourniquets to control haemorrhages, (iii) premised on 131 MCIs or disasters. Similarly, (i) papers based on paediatric population, (ii) those 132 investigating the use of tourniquets in surgeries for bleeding control, and (iii) preclinical 133 studies. 134 Data screening 135 Initially, two authors (AR, PR) independently performed a first screening of titles and 136 abstracts and a full-text reading. In case of discrepancy, a third author (MR) was consulted 137 to reach a consensus based on the aim of the study and research question. 138 6 Quality appraisal 139 Appropriate criteria were used for each study, depending on the research design used in 140 each one of them, according to Critical Appraisal Skills Programme tools (CASP, 2019). 141 The Grading of Recommendations Assessment, Development and Evaluation (GRADE) 142 ranking system was used to evaluate the quality of evidence for study outcomes, rated 143 from A (high) to D (very low). The GRADE approach evaluates five domains: risk of 144 bias, inconsistency/indirectness, inadequate precision, and publication bias, classifies the 145 bodies of randomized controlled trials as initially starting with high certainty and the 146 bodies of observational studies as initially starting with low certainty (Schünemann et al., 147 2013). 148 Data abstraction and synthesis 149 Consecutively, the data from the included studies was extracted by two authors 150 independently (AR, PR) and, if necessary, a third author (MR) was consulted to reach a 151 consensus based on the aim and research question. Data were tabulated in an Excel sheet 152 according to (i) author(s), (ii) methods, (iii) type of tourniquet, (iii) anatomic location, 153 (iv) environment of use (military or civilian), (v) participants numbers and (vi) main 154 findings (Table 1). Finally, descriptive and narrative analyses were used to synthesise the 155 extracted data, according to the research questions and collaboratively analysed by all 156 authors. 157 Results 158 Characteristics of selected papers 159 In a first stage, 877 articles were retrieved from Medline (n=461), Nursing & Allied 160 Health Database (n=172), and Health & Medical Collection databases (n=244). After title, 161 abstract and full-text screening, a total of 568 articles were excluded on the basis of the 162 selection criteria. Ultimately, 25 studies were included in this review (Figure 1). 163 [INSERT FIGURE 1 ABOUT HERE] 164 7 All included articles are displayed in Table 1. Ten (40%) of these articles were primary 165 research studies, among which 3 were randomized controlled trials, 2 used a cohort 166 design, 1 with a quasi-experimental design, 3 were case reports, and 1 was a clinical study. 167 Based on these primary studies, the sample size in each study ranged from 1 to 562 168 participants. Fifteen (60%) of the remaining articles were literature reviews. Overall, 3 169 (12%) papers aimed their studies at both civilian and military settings to use tourniquets, 170 while 15 (60%) were focused only at civilian contexts and 7 (28%) at military scenarios. 171 [INSERT TABLE 1 ABOUT HERE] 172 The data synthesis revealed four categories related to the current evidence on the use of 173 tourniquets to control haemorrhages. In this manner, this evidence would be associated 174 with the use of different types of tourniquets, environment of application, indication for 175 their placement and potential complications associated with tourniquet placement. These 176 categories are described below. 177 Using different types of tourniquets 178 The improvised tourniquet is a type of tourniquet used by the military and medical 179 services, particularly in event of disasters or MCIs (D. R. King et al., 2015). In order to 180 be effective, these tourniquets must meet the following criteria: (i) be wide enough so that 181 they do not produce necrosis in the applied area, and (ii) have enough pressure to occlude 182 arteries for which an element acting as a windlass is required. In this sense, the findings 183 show the effectiveness of commercial tourniquets as opposed to improvised ones. 184 Commercial tourniquets usually have a wide band with differences between models and 185 different devices to achieve adequate pressure, such a windlass or a pinwheel, among 186 others (Chaudhary et al., 2019; R. B. King et al., 2006; Kue et al., 2015). 187 Amongst the wide range of commercial tourniquets available, most of the selected articles 188 dealt with CAT or EMT systems (Callaway et al., 2015; R. B. King et al., 2006; Kue et 189 al., 2015; Scerbo et al., 2017; Scott et al., 2020). The CAT model appears to be the 190 tourniquet of choice in the army due to its ease of transport, its high durability over time 191 and its ability to self-apply, which enables soldiers to apply the tourniquet with minimal 192 and necessary training (Beaven et al., 2017). 193 8 According to Beaven and collaborators (2017) as well as Ellis and collaborators (2020), 194 the CAT model is ineffective in the control of bleeding in mid-thigh injuries, one of the 195 most common anatomical bleeding locations, and therefore the use of EMT model is 196 recommended due to its efficacy in this situation. Notwithstanding the potential of the 197 EMT system to stop the haemorrhage more quickly and less painfully as it distributes 198 pressures more evenly (Kragh et al., 2012), its greatest limitation is the greater amount of 199 exposed tissue and the effort needed to achieve the necessary tension (Lewis, 2014). 200 Likewise, the CAT model is associated with a higher rate of pain among all types of 201 tourniquets available. This is due to the width of its cuff being 30mm, far smaller than 202 that of the EMT model (being 110mm), which would pinch the skin and cause more pain 203 by distributing the pressure less evenly (Drew, Bird, et al., 2015; Lewis, 2014; Mullins & 204 Harrahill, 2009). The recommendation for emergency and military services is therefore 205 to have and use both types of EMT and CAT systems on the basis of these reasons 206 (Beaven et al., 2017; Goodwin et al., 2019). 207 Environment of application 208 In some cases, the results can be extrapolated despite the variability of the tourniquet 209 application scenarios (Callaway et al., 2015; Drew, Bennett, et al., 2015; D. R. King et 210 al., 2015; Kragh et al., 2012; Lewis, 2014; Scerbo et al., 2017). However, in scenarios 211 other than MCIs or disasters, the mechanisms of injury in both military and civilian 212 scenarios are rather different. Bullet and blast injuries are more unusual in civilian out213 of-hospital contexts, where unintended injuries are mainly related to road accidents, falls, 214 machine crushing, or other trauma-related injuries. Moreover, differences between 215 populations should be also taken into account, since soldiers are usually young without 216 pathologies, whereas civilians include all age ranges and may or may not have associated 217 pathologies (Beekley et al., 2008; Goodwin et al., 2019). 218 Nevertheless, the results in both areas coincide with the safety and suitability of the use 219 of tourniquets in prehospital, out-of-hospital and hospital care, as well as the need to 220 prepare nurses and other emergency professionals (military and civilian) for use in 221 emergency situations as they play a key role identifying the risk factors for complications 222 and planning their use (Brodie et al., 2007; Kauvar et al., 2018; D. R. King et al., 2015; 223 Scerbo et al., 2016). 224 9 Indication for tourniquet placement 225 One of the main controversies about using the tourniquet is about when a tourniquet 226 should be placed. In this regard, some authors identified a number of indications for the 227 use of tourniquets, including: not controlling bleeding with direct pressure or direct 228 pressure bandages, amputation, haemorrhaging in multiple locations, protrusion of a 229 foreign body, the need to control airways, situations such as fires or total darkness, and 230 events involving multiple victims (Beekley et al., 2008; R. B. King et al., 2006; Schauer 231 et al., 2017). 232 Conversely, Beekley and collaborators (2008) suggested the use of tourniquet as a first233 line treatment when exsanguinating haemorrhage occurs, as it achieves almost total 234 haemorrhage control in a short time compared to other traditional methods, increasing 235 survival with few associated complications. In this sense, Drew, Bennett and 236 collaborators (2015) compared the results between traditional methods, including direct 237 pressure, pressure points, elevations of limbs, compression bandage and improvised 238 tourniquets as a last resort, and current methods of haemorrhage control. As suggested by 239 these authors, limb elevation and pressure points show efficacy only initially, as 240 coagulation is resumed within 60 seconds in the upper limb and 30 seconds in the lower 241 limb. Therefore, these two measures may be useful for a short period of time while placing 242 a commercial tourniquet, compressive bandage or haemostatic agent, which are currently 243 considered to be recommended haemorrhage control measures (Eilertsen et al., 2021; R. 244 B. King et al., 2006; Schauer et al., 2017; E. R. Smith et al., 2016). 245 At the same level of results, the most common mistakes made by participants without 246 prior training when placing the tourniquets were excessive belt slack and few turns of the 247 windlass. In order to avoid them, the literature suggests that it is necessary to tighten the 248 belt strongly before starting to turn the windlass and to make as many turns of the 249 windlass as necessary to stop the bleeding or to achieve the absence of a pulse (Beaven 250 et al., 2017; Cornelissen et al., 2020; Kragh et al., 2012). In particular, a pressure of 200 251 mmHg or more is necessary in order to achieve total bleeding control, for which between 252 630-1170 degrees of windlass rotation must be carried out, coinciding between 2 and 4 253 turns, or more when applied at the mid-thigh level (D. R. King et al., 2015; R. B. King et 254 al., 2006; Lewis, 2014). 255 16 https://doi.org/10.1080/17474086.2018.1548929 425 Caubère, A., de Landevoisin, E. S., Schlienger, G., Demoures, T., & Romanat, P. (2019). 426 Tactical tourniquet: Surgical management must be within 3 hours. Trauma Case 427 Reports, 22, 100217. https://doi.org/10.1016/j.tcr.2019.100217 428 Chaudhary, M.A., McCarty, J., Shah, S., Hashmi, Z., Caterson, E., Goldberg, S., Goolsby, 429 C., Haider, A., & Goralnick, E. (2019). Building community resilience: A scalable 430 model for hemorrhage-control training at a mass gathering site, using the RE-AIM 431 framework. Surgery, 165(4), 795–801. https://doi.org/10.1016/j.surg.2018.10.001 432 Convertino, V.A., Wirt, M.D., Glenn, J.F., & Lein, B.C. (2016). The compensatory 433 reserve for early and accurate prediction of hemodynamic compromise: A review 434 of the underlying physiology. Shock, 45(6), 580–590. 435 https://doi.org/10.1097/SHK.0000000000000559 436 Cornelissen, M.P., Brandwijk, A., Schoonmade Linda, Giannakopoulos Georgios, van 437 Oostendorp Stefan, & Leo, G. (2020). The safety and efficacy of improvised 438 tourniquets in life-threatening hemorrhage: A systematic review. European 439 Journal of Trauma and Emergency Surgery, 46(3), 531–538. 440 https://doi.org/10.1007/s00068-019-01202-5 441 Cunningham, A., Auerbach, M., Cicero, M., & Jafri, M. (2018). Tourniquet usage in 442 prehospital care and resuscitation of pediatric trauma patients-Pediatric Trauma 443 Society position statement. The Journal of Trauma and Acute Care Surgery, 444 85(4), 665–667. https://doi.org/10.1097/TA.0000000000001839 445 Day, M.W. (2016). Control of Traumatic Extremity Hemorrhage. Critical Care Nurse, 446 36(1), 40–51. https://doi.org/10.4037/ccn2016871 447 17 Drew, B., Bennett, B.L., & Littlejohn, L. (2014). Application of Current Hemorrhage 448 Control Techniques for backcountry Care: Part One, Tourniquets and 449 Hemorrhae Control Adjuncts. 23018. https://doi.org/10.1016/j.wem.2014.08.016 450 Drew, B., Bennett, B.L., & Littlejohn, L. (2015). Application of Current Hemorrhage 451 Control Techniques for Backcountry Care: Part One, Tourniquets and 452 Hemorrhage Control Adjuncts. Wilderness & Environmental Medicine, 26(2), 453 236–245. https://doi.org/10.1016/j.wem.2014.08.016 454 Drew, B., Bird, D., Matteucci, M., & Keenan, S. (2015). Tourniquet Conversion: A 455 Recommended Approach in the Prolonged Field Care Setting. Journal of Special 456 Operations Medicine, 15(3), 81–85. 457 Duignan, K.M., Lamb, L.C., DiFiori, M.M., Quinlavin, J., & Feeney, J.M. (2018). 458 Tourniquet use in the prehospital setting: Are they being used appropriately? 459 American Journal of Disaster Medicine, 13(1), 37–43. 460 https://doi.org/10.5055/ajdm.2018.0286 461 Eilertsen, K.A., Winberg, M., Jeppesen, E., Hval, G., & Wisborg, T. (2021). Prehospital 462 Tourniquets in Civilians: A Systematic Review. Prehospital and Disaster 463 Medicine, 36(1), 86–94. https://doi.org/10.1017/S1049023X20001284 464 Ellis, J., Morrow, M.M., Belau, A., Sztajnkrycer, L.S., Wood, J.N., Kummer, T., & 465 Sztajnkrycer, M.D. (2020). The Efficacy of Novel Commercial Tourniquet 466 Designs for Extremity Hemorrhage Control: Implications for Spontaneous 467 Responder Every Day Carry. Prehospital and Disaster Medicine, 35(3), 276–280. 468 https://doi.org/10.1017/S1049023X2000045X 469 Goodwin, T., Moore, K.N., Pasley, J.D., Troncoso, R., Levy, M.J., & Goolsby, C. (2019). 470 From the battlefield to main street: Tourniquet acceptance, use, and translation 471 18 from the military to civilian settings. Journal of Trauma and Acute Care Surgery, 472 87, S35–S39. https://doi.org/10.1097/TA.0000000000002198 473 Goolsby, C., Strauss-Riggs, K., Rozenfeld, M., Charlton, N., Goralnick, E., Peleg, K., 474 Levy, M.J., Davis, T., & Hurst, N. (2019). Equipping Public Spaces to Facilitate 475 Rapid Point-of-Injury Hemorrhage Control After Mass Casualty. American 476 Journal of Public Health, 109(2), 236–241. 477 https://doi.org/10.2105/AJPH.2018.304773 478 Haider, A.H., Young, J.H., Kisat, M., Villegas, C.V., Scott, V.K., Ladha, K.S., Haut, E.R., 479 Cornwell, E.E., MacKenzie, E.J., & Efron, D.T. (2014). Association Between 480 Intentional Injury and Long Term Survival After Trauma. Annals of Surgery, 481 259(5), 985–992. https://doi.org/10.1097/SLA.0000000000000486 482 Jensen, J., Hicks, R.W., & Labovitz, J. (2019). Understanding and Optimizing Tourniquet 483 Use During Extremity Surgery. AORN Journal, 109(2), 171–182. 484 https://doi.org/10.1002/aorn.12579 485 Kauvar, D.S., Dubick, M.A., Walters, T.J., & Kragh, J.F. (2018). Systematic review of 486 prehospital tourniquet use in civilian limb trauma. The Journal of Trauma and 487 Acute Care Surgery, 84(5), 819–825. 488 https://doi.org/10.1097/TA.0000000000001826 489 King, D.R., Larentzakis, A., Ramly, E.P., & Boston Trauma Collaborative (2015). 490 Tourniquet use at the Boston Marathon bombing: Lost in translation. The Journal 491 of Trauma and Acute Care Surgery, 78(3), 594–599. 492 https://doi.org/10.1097/TA.0000000000000561 493 King, R.B., Filips, D., Blitz, S., & Logsetty, S. (2006). Evaluation of Possible Tourniquet 494 Systems for Use in the Canadian Forces. Journal of Trauma and Acute Care 495 Surgery, 60(5), 1061–1071. https://doi.org/10.1097/01.ta.0000215429.94483.a7 496 19 Klein, M.K., Tsihlis, N.D., Pritts, T.A., & Kibbe, M.R. (2020). Emerging Therapies for 497 Prehospital Control of Hemorrhage. The Journal of Surgical Research, 248, 182– 498 190. https://doi.org/10.1016/j.jss.2019.09.070 499 Klenerman, L. (2005). The tourniquet manual principles and practice. Springer. 500 Knickerbocker, C., Gomez, M. F., Lozada, J., Zadeh, J., Costantini, E., & Puente, I. 501 (2019). Wound patterns in survivors of modern firearm related civilian Mass 502 Casualty Incidents. American Journal of Disaster Medicine, 14(3), 175–180. 503 https://doi.org/10.5055/ajdm.2019.0329 504 Kotwal, R.S., Montgomery, H.R., Kotwal, B.M., Champion, H.R., Butler, F.K., Mabry, 505 R.L., Cain, J.S., Blackbourne, L.H., Mechler, K.K., & Holcomb, J.B. (2011). 506 Eliminating preventable death on the battlefield. Archives of Surgery, 146(12), 507 1350–1358. https://doi.org/10.1001/archsurg.2011.213 508 Kragh, J.F., O Neill, M.L., Beebe, D.F., Fox, C.J., Beekley, A.C., Cain, J.S., Parsons, 509 D.L., Mabry, R.L., & Blackbourne, L. H. (2011). Survey of the indications for use 510 of emergency tourniquets. Journal of Special Operations Medicine, 11(1), 30–38. 511 Kragh, J.F., Swan, K.G., Smith, D.C., Mabry, R.L., & Blackbourne, L.H. (2012). 512 Historical review of emergency tourniquet use to stop bleeding. American Journal 513 of Surgery, 203(2), 242–252. https://doi.org/10.1016/j.amjsurg.2011.01.028 514 Kue, R.C., Temin, E.S., Weiner, S.G., Gates, J., Coleman, M.H., Fisher, J., & Dyer, S. 515 (2015). Tourniquet Use in a Civilian Emergency Medical Services Setting: A 516 Descriptive Analysis of the Boston EMS Experience. Prehospital Emergency 517 Care, 19(3), 399–404. https://doi.org/10.3109/10903127.2014.995842 518 Lee, C., Porter, K.M., & Hodgetts, T.J. (2007). Tourniquet use in the civilian prehospital 519 setting. Emergency Medicine Journal: EMJ, 24(8), 584–587. 520 https://doi.org/10.1136/emj.2007.046359 521 20 Lewis, P.C. (2014). Chapter 9. Prehospital tourniquets: Review, recommendations, and 522 future research. Annual Review of Nursing Research, 32, 203–232. 523 https://doi.org/10.1891/0739-6686.32.203 524 Malo, C., Bernardin, B., Nemeth, J., & Khwaja, K. (2015). Prolonged prehospital 525 tourniquet placement associated with severe complications: A case report. 526 Canadian Journal of Emergency Medicine, 17(4), 443–446. 527 https://doi.org/10.1017/cem.2014.44 528 Martín-Ibáñez, L., Pérez-Martínez, J., Zamora-Mínguez, D., Alcón-Rubio, F., González529 Alonso, V., Aroca García-Rubio, S., Hernández-Hernández, J. M., Díaz, F., & 530 Román-López, P. (2019). A civilian tactical survival chain for incidents involving 531 multiple intentionalinjury victims: The Victory I Consensus Report. 532 Emergencias: Revista De La Sociedad Espanola De Medicina De Emergencias, 533 31(3), 195–201. 534 Masri, B.A., Eisen, A., Duncan, C.P., & McEwen, J.A. (2020). Tourniquet-induced nerve 535 compression injuries are caused by high pressure levels and gradients—A review 536 of the evidence to guide safe surgical, pre-hospital and blood flow restriction 537 usage. BMC Biomedical Engineering, 2, 7. https://doi.org/10.1186/s42490-020538 00041-5 539 McCarty, J.C., Hashmi, Z.G., Herrera-Escobar, J.P., de Jager, E., Chaudhary, M.A., 540 Lipsitz, S.R., Jarman, M., Caterson, E.J., & Goralnick, E. (2019). Effectiveness 541 of the American College of Surgeons Bleeding Control Basic Training Among 542 Laypeople Applying Different Tourniquet Types: A Randomized Clinical Trial. 543 JAMA Surgery, 154(10), 923–929. https://doi.org/10.1001/jamasurg.2019.2275 544 Moore, K. (2017). Stop the Bleeding: The Hartford Consensus. Journal of Emergency 545 Nursing, 43(5), 482–483. https://doi.org/10.1016/j.jen.2017.06.009 546 21 Mullins, J. & Harrahill, M. (2009). Use of a Tourniquet After a Gunshot Wound to the 547 Thigh. Journal of Emergency Nursing, 35(3), 285. Health & Medical Collection. 548 https://doi.org/10.1016/j.jen.2009.01.008 549 Peng, H.T. (2020). Hemostatic agents for prehospital hemorrhage control: A narrative 550 review. Military Medical Research, 7(1), 13. https://doi.org/10.1186/s40779-020551 00241-z 552 Pepper, M., Archer, F., & Moloney, J. (2019). Triage in Complex, Coordinated Terrorist 553 Attacks. Prehospital and Disaster Medicine, 34(4), 442–448. 554 https://doi.org/10.1017/S1049023X1900459X 555 Præstegaard, M., Beisvåg, E., Erichsen, J.L., Brix, M., & Viberg, B. (2019). Tourniquet 556 use in lower limb fracture surgery: A systematic review and meta-analysis. 557 European Journal of Orthopaedic Surgery & Traumatology: Orthopedie 558 Traumatologie, 29(1), 175–181. https://doi.org/10.1007/s00590-018-2282-z 559 Ross, E.M., Mapp, J.G., Redman, T.T., Brown, D.J., Kharod, C.U., & Wampler, D.A. 560 (2018). The tourniquet gap: A pilot study of the intuitive placement of three 561 tourniquet types by laypersons. The Journal of Emergency Medicine, 54(3), 307– 562 314. https://doi.org/10.1016/j.jemermed.2017.09.011 563 Rossaint, R., Bouillon, B., Cerny, V., Coats, T.J., Duranteau, J., Fernández-Mondéjar, E., 564 Filipescu, D., Hunt, B.J., Komadina, R., Nardi, G., Neugebauer, E.A.M., Ozier, 565 Y., Riddez, L., Schultz, A., Vincent, J.L., & Spahn, D.R. (2016). The European 566 guideline on management of major bleeding and coagulopathy following trauma: 567 Fourth edition. Critical Care, 20(1), 100. https://doi.org/10.1186/s13054-016568 1265-x 569 Sanak, T., Brzozowski, R., Dabrowski, M., Kozak, M., Dabrowska, A., Sip, M., Naylor, 570 K., & Torres, K. (2018). Evaluation of tourniquet application in a simulated 571 22 tactical environment. Turkish Journal of Trauma & Emergency Surgery, 24(1), 572 9–15. https://doi.org/10.5505/tjtes.2017.84899 573 Scerbo, M.H., Holcomb, J.B., Taub, E., Gates, K., Love, J.D., Wade, C.E., & Cotton, 574 B.A. (2017). The trauma center is too late: Major limb trauma without a pre575 hospital tourniquet has increased death from hemorrhagic shock. Journal of 576 Trauma and Acute Care Surgery, 83(6), 1165–1172. 577 https://doi.org/10.1097/TA.0000000000001666 578 Scerbo, M.H., Mumm, J.P., Gates, K., Love, J.D., Wade, C.E., Holcomb, J.B., & Cotton, 579 B.A. (2016). Safety and Appropriateness of Tourniquets in 105 Civilians. 580 Prehospital Emergency Care, 20(6), 712–722. 581 https://doi.org/10.1080/10903127.2016.1182606 582 Schauer, S.G., April, M.D., Simon, E., Maddry, J.K., Carter, R., & Delorenzo, R.A. 583 (2017). Prehospital Interventions During Mass-Casualty Events in Afghanistan: 584 A Case Analysis. Prehospital and Disaster Medicine, 32(4), 465–468. 585 https://doi.org/10.1017/S1049023X17006422 586 Schiller, A.M., Howard, J.T., & Convertino, V.A. (2017). The physiology of blood loss 587 and shock: New insights from a human laboratory model of hemorrhage. 588 Experimental Biology and Medicine, 242(8), 874–883. 589 https://doi.org/10.1177/1535370217694099 590 Schünemann, H., Brożek, J., Guyatt, G., & Oxman, A. (2013). GRADE handbook. 591 https://gdt.gradepro.org/app/handbook/handbook.html 592 Scott, G., Olola, C., Gardett, M.I., Ashwood, D., Broadbent, M., Sangaraju, S., Stiegler, 593 P., Fivaz, M.C., & Clawson, J.J. (2020). Ability of Layperson Callers to Apply a 594 Tourniquet Following Protocol-Based Instructions From an Emergency Medical 595 Dispatcher. Prehospital Emergency Care, 24(6), 831–838. 596 23 https://doi.org/10.1080/10903127.2020.1718259 597 Smith, A.A., Ochoa, J.E., Wong, S., Beatty, S., Elder, J., Guidry, C., McGrew, P., 598 McGinness, C., Duchesne, J., & Schroll, R. (2019). Prehospital tourniquet use in 599 penetrating extremity trauma: Decreased blood transfusions and limb 600 complications. The Journal of Trauma and Acute Care Surgery, 86(1), 43–51. 601 https://doi.org/10.1097/TA.0000000000002095 602 Smith, E.R., Shapiro, G., & Sarani, B. (2016). The profile of wounding in civilian public 603 mass shooting fatalities. Journal of Trauma and Acute Care Surgery, 81(1), 86– 604 92. https://doi.org/10.1097/TA.0000000000001031 605 Spruce, L. (2017). Back to basics: Pneumatic tourniquet use. AORN Journal, 106(3), 219– 606 226. https://doi.org/10.1016/j.aorn.2017.07.003 607 Stone, P.W. (2002). Popping the (PICO) question in research and evidence-based 608 practice. Applied Nursing Research: ANR, 15(3), 197–198. 609 https://doi.org/10.1053/apnr.2002.34181 610 Teixeira, P.G.R., Brown, C.V.R., Emigh, B., Long, M., Foreman, M., Eastridge, B., Gale, 611 S., Truitt, M.S., Dissanaike, S., Duane, T., Holcomb, J., Eastman, A., Regner, J., 612 & Texas Tourniquet Study Group (2018). Civilian prehospital tourniquet use is 613 associated with improved survival in patients with peripheral vascular injury. 614 Journal of the American College of Surgeons, 226(5), 769-776.e1. 615 https://doi.org/10.1016/j.jamcollsurg.2018.01.047 616 Tintinalli, J.E., Ma, O.J., Yealy, D.M., Meckler, G.D., Stapczynski, J.S., Cline, D., & 617 Thomas, S.H. (2020). Section 21. Trauma. In Tintinalli’s emergency medicine: A 618 comprehensive study guide (9th Ed., pp. 1661–1762). McGraw-Hill Education. 619 Tran, T., Lund, S.B., Nichols, M.D., & Kummer, T. (2019). Effect of two tourniquet 620 techniques on peripheral intravenous cannulation success: A randomized 621 24 controlled trial. The American Journal of Emergency Medicine, 37(12), 2209– 622 2214. https://doi.org/10.1016/j.ajem.2019.03.034 623 Wall, P.L., Welander, J.D., Smith, H.L., Buising, C.M., & Sahr, S.M. (2014). What do 624 the people who transport trauma patients know about tourniquets? The Journal of 625 Trauma and Acute Care Surgery, 77(5), 734–742. 626 https://doi.org/10.1097/TA.0000000000000433 627 Whittemore, R., & Knafl, K. (2005). The integrative review: Updated methodology. 628 Journal of Advanced Nursing, 52(5), 546–553. https://doi.org/10.1111/j.1365629 2648.2005.03621.x 630 WHO (2018). Global Health Estimates 2016: Estimated deaths by age, sex, and cause. 631 World Health Organization. 632 https://www.who.int/healthinfo/global_burden_disease/GHE2016_Deaths_Glob 633 al_2000_2016.xls 634 Funding 635 This research received no specific grant from any funding agency in the public, 636 commercial, or not-for-profit sectors. 637