CASE CONFERENCE
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LAW ENFORCEMENT-APPLIED TOURNIQUETS: A CASE SERIES OF LIFE-SAVING INTERVENTIONS David W. Callaway, MD, FACEP, FAAEM, Joshua Robertson, MD, Matthew D. Sztajnkrycer, MD, PhD, FACEP
INTRODUCTION
ABSTRACT Although the epidemiology of civilian trauma is distinct from that encountered in combat, in both settings, extremity hemorrhage remains a major preventable cause of potential mortality. The current paper describes the largest case series in the literature in which police officers arriving prior to emergency medical services applied commercially available field tourniquets to civilian victims of violent trauma. Although all 3 patients with vascular injury arrived at the receiving emergency department in extremis, they were successfully resuscitated and survived to discharge without major morbidity. While this outcome is likely multifactorial and highlights the exceptional care delivered by the modern trauma system, tourniquet application appears to have kept critically injured patients alive long enough to reach definitive trauma care. No patient had a tourniquet-related complication. This case series suggests that law enforcement officers can effectively identify indications for tourniquets and rapidly apply such life-saving interventions. Key words: hemorrhage control; law enforcement; prehospital; tactical emergency casualty care; tourniquet
Isolated extremity hemorrhage remains the leading cause of potentially preventable death in combat. Hemorrhage is the second leading cause of death in civilian trauma behind head injury.1,2 Although the epidemiology of civilian trauma is distinct from that encountered in combat, in both settings, extremity hemorrhage remains a major preventable cause of potential mortality. Once a vilified technique, current data demonstrate that prehospital commercial tourniquet (TQ) application saves lives.3,4 Through aggressive Tactical Combat Casualty Care (TCCC) training and TQ fielding, mortality rates from isolated extremity hemorrhage have declined from approximately 9% in Vietnam to approximately 2% in Operations Iraqi and Enduring Freedom.5,6 Combat data indicate that successful mortality reduction requires a comprehensive trauma management system, with nonmedical personnel playing a critical role in initiating hemorrhage control – in essence, the first link in the “Trauma Chain of Survival.”7 Additionally, survival benefits are greatest when tourniquets are applied prior to development of shock.8 In the civilian setting, Tactical Emergency Casualty Care (TECC) guidelines outline a framework for trauma first response during high-threat incidents.9 Analogous to soldiers in combat, law enforcement officers (LEO) are frequently first on scene and fulfill a critical early link in the TECC Chain of Survival.10–12 Recent high-profile events, including the mass shooting in Tucson, Arizona and the Boston Marathon bombing, highlight the critical importance of training LEOs in robust hemorrhage control strategies, including tourniquets.13 This paper describes the nature and outcomes of a case series in which patrol officers arriving on scene prior to emergency medical services (EMS) applied commercially available field tourniquets to civilian victims of violent trauma.
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Received June 27, 2014 from the Division of Operational and Disaster Medicine, Department of Emergency Medicine, Carolinas Medical Center – Main, Charlotte, North Carolina (DWC, JR), and Division of Prehospital Care, Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota (MDS). Revision received August 9, 2014; accepted for publication September 2, 2014. The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper. Address correspondence to David W. Callaway, Director, Operational and Disaster Medicine, Department of Emergency Medicine, Carolinas Medical Center – Main, Charlotte, NC 28203, USA. E-mail: [email protected] doi: 10.3109/10903127.2014.964893
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CASE SERIES During a 12-month period between January 1, 2013 and December 31, 2013 in the Charlotte–Mecklenburg County area, 4 cases of LEO application of commercial tourniquets were observed (Combat Application Tourniquet – CAT, Composite Resources, Rock Hill, SC). Incident details were extracted from official police reports, EMS run sheets, the hospital electronic medical record, and personal interviews with providers. In Charlotte–Mecklenburg County, Charlotte Fire Department (basic life support) and MEDIC EMS (advanced life support) provide prehospital care. Prehosp Emerg Care Downloaded from informahealthcare.com by Nyu Medical Center on 06/15/15 For personal use only.
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Patient 1 A law enforcement officer was dispatched at 0001 hours to an assault with a deadly weapon and associated injury. The LEO arrived on scene approximately 2 minutes later and observed an elderly male lying on the floor “moaning incoherently.” Per the LEO report, “I could see that his lower body was covered in blood, his pants were soaked with it and the floor under his body had pooling blood.” The first officer began an initial assessment while a second officer secured the scene. The officer stated that “I saw that the victim had what appeared to be a gunshot wound to his right leg. . . an entry wound to the outside of his right leg next to his knee, an exit wound on the inside of his right leg just above his knee, an entry wound to the inside of his left leg in the middle of the thigh, and it appeared that the projectile had lodged itself in his left leg. I could clearly see a large lump in his left thigh. The amount of blood, the rate of blood loss, and the area of the wound indicated to me that the bleeding needed to be stopped immediately, so I instructed one of the firemen and another LEO to lift his leg as I applied a CAT tourniquet at 0008 hours to his right leg. I applied the CAT as high as it could go on his leg above the wound.” The officers then applied a pressure dressing over the wound itself and completed a primary assessment. EMS arrived at 0010 hours, noted adequate hemorrhage control and transported the patient to definitive care. Prehospital vital signs included highest heart rate of 120 beats per minute, lowest blood pressure was not recorded, and best Glasgow Coma Scale GCS 15. EMS was unable to obtain IV access prior to emergency department (ED) arrival. Upon arrival to the emergency department, the patient quickly decompensated with witnessed loss of pulse. Chest compressions were begun, a definitive endotracheal airway was established, and a left femoral 8 French cordis venous catheter was placed. Institutional massive transfusion protocol was initiated; the
patient received a total of 8 units packed red blood cells, 6 units fresh frozen plasma, and 1 unit of platelets in the ED. After several cycles of cardiopulmonary resuscitation (CPR), return of spontaneous circulation was achieved. The tourniquet (TQ) was noted to be in place and no active hemorrhage was observed from the wound site. Initial ED labs included hemoglobin of 13.6 g/dL and lactate of 16 mmol/L. The patient was taken emergently to the operating room where an end-to-end repair of a transected right popliteal artery, ligation of traumatic transection of right popliteal vein, and a prophylactic fourcompartment fasciotomy were performed. A pneumatic TQ was applied in the operating room with field TQ taken down immediately prior to pneumatic TQ application. Total prehospital and ED TQ time was approximately 78 minutes and pneumatic TQ time was approximately 160 minutes (total TQ time 238 minutes). At the 4-week follow-up, the patient had no evidence of lower extremity claudication, and postoperative right lower extremity edema was significantly improved.
Patient 2 An off-duty LEO responded to a call at 0242 hours that subjects were fighting within his vicinity. Upon arrival, the officer heard gunfire and witnessed a vehicle fleeing the scene. No other obvious threats were identified at the scene. A young male was discovered with a single gunshot wound to the left arm with “a great deal of blood on the ground next to the vehicle the victim was in and a great deal of blood on the interior of the vehicle.” The victim was holding his left arm close to his body and stated he had been shot in the arm. Upon straightening the victim’s arm, “blood began to squirt out of the wound site, indicating an arterial bleed.” A second LEO arrived and applied direct pressure to the wound while the first officer applied a CAT tourniquet. The TQ was “placed high into the victim’s arm pit (0245 hours) and tightened until the bleeding stopped. I then checked for a distal pulse and could not find one, which indicated to me that the tourniquet was doing the job.” EMS arrived on scene soon thereafter and transported the patient to definitive care. Highest prehospital heart rate was 130 beats per minute (bpm), lowest blood pressure was 84/50 mmHg, and best GCS was 15. EMS established two large-bore IVs prior to ED arrival. Upon arrival to the ED, providers noted a 0.5-cm wound to the medial aspect of the patient’s left arm proximal to the antecubital fossa. There was no active hemorrhage. Pulses were 2+ in the bilateral carotid, femoral arteries, and right radial artery; no pulse was noted in the left radial artery. Initial ED vitals signs included a heart rate 130 bpm, blood pressure 188/102
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322 mmHg, and GCS 15. The patient was combative. During a brief TQ takedown, the team noted pulsatile hemorrhage from the LUE and “tight” forearm compartments. Initial ED labs were notable for hemoglobin 13.6 g/dL and lactate 9.63 mmol/L. The patient received 2 units packed red blood cells (PRBC) in the ED. The patient was emergently taken to the operating room and underwent repair of left brachial artery transection with reversed greater saphenous vein interposition graft, and prophylactic left forearm volar fasciotomy. The field TQ (CAT) was taken down with placement of pneumatic TQ in the operating room (OR) and isolation with vascular clamping of the brachial artery. Total prehospital and ED TQ time was approximately 67 minutes and pneumatic TQ time was 22 minutes (total TQ time 89 minutes). At 1-week post discharge patient was noted to have minimal swelling in his upper extremity, “excellent wound healing and granulation tissue.” The patient noted some minor limitations in elbow extension secondary to early wound healing.
Patient 3 An LEO responded to a call for an assault with deadly weapon at 2138 hours. Upon arrival, an injured victim was identified and LEO and CFD evaluated the patient concurrently. Examination revealed a GSW in the anterior and posterior left upper thigh. CFD placed a field tourniquet at 2140 hours. Successful arterial occlusion was not appreciated by LEO/FD on scene per the EMS report. As a consequence, the field TQ was taken down at 2141 and reapplied by LEO with adequate control of bleeding at 2143 hours. EMS arrived on scene at 2144. EMS documented an estimated blood loss on scene of 500 cc. Upon transfer to the stretcher, the patient was noted to be lethargic with no palpable radial or brachial pulses. Prehospital vital signs included highest heart rate 170 bpm, lowest blood pressure 70/30 mmHg, and best GCS 15. EMS was unable to obtain IV access prior to ED arrival. Upon arrival to the ED, the patient’s initial vital signs included heart rate of 170 bpm, blood pressure of 100/70 mmHg, and GCS 15. Two large-bore IVs were established and a right 8 French femoral cordis venous catheter was placed. Initial ED labs were notable for hemoglobin 9.5 g/dL and lactate 6.78 mmol/L. ED resuscitation included 2000 cc of IV crystalloid and 4 units of PRBC, with improvement of heart rate from 170 to 100 bpm. The patient was taken to the operating room and underwent repair of left superficial femoral and proximal popliteal artery laceration by reverse greater saphenous vein interposition graft, femoral vein ligation, and four-compartment fasciotomy. The field TQ was taken down with placement of pneumatic TQ in
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the OR with vascular clamping of superficial femoral artery. Total prehospital and ED TQ time was 77 minutes and total pneumatic TQ time was 14 minutes (total TQ time of 91 minutes). At two and a half weeks post-discharge the patient reported no significant pain in left lower extremity and was ambulating without difficulty.
Patient 4 An LEO responded to a call of an assault with deadly weapon at 2254 hours. A second patrol car stated they had intercepted a vehicle attempting to travel to the hospital with a victim in it. Three passengers were removed from the vehicle and questioned by LEO. A revolver was found with 5 spent casings. LEO rendered safe the revolver and secured the scene. LEO identified the patient and found a GSW to the left inner thigh and “immediately put gloves on and applied direct pressure to the wound. Officers noted there was “a good amount of blood in the passenger area and the victim kept saying he felt like he was going to faint.” An LEO on scene applied a CAT TQ to the wounded leg at 2257 hours. EMS arrived on scene soon thereafter and transported the patient to the hospital to definitive care. Prehospital vital signs included highest heart rate 68 bpm, lowest blood pressure 110/70 mmHg, and best GCS 15. EMS gained IV access prior to ED arrival. Upon arrival to the ED, the patient was noted to have a gunshot wound to the left thigh. Physical exam revealed a normal neurovascular exam in the bilateral lower extremities. After initial assessment, the TQ was taken down and the physician noted no active bleeding from the left lower extremity. Total TQ time was approximately 60 minutes. Plain films confirmed a bullet fragment in the left inner thigh with no bony injury or dislocation. The patient was able to ambulate, noted pain only with weight bearing, and denied any numbness or tingling. The patient was discharged in stable condition with pain medication. Although subsequently lost to follow-up, review of the electronic medical record demonstrates no further visits to the major health-care systems in the region (accounting for 100% of emergency departments, >90% of urgent care facilities and a majority of primary care groups). In addition, the Mecklenburg County coroner has no reports of death related to this patient.
DISCUSSION Tourniquets have a contentious history. The Greeks and Romans were the first to document the concept of circumferential constriction of extremities to control hemorrhage.14–16 In the modern era, concerns about limb loss and permanent neurovascular injury resulted
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in removal of tourniquets from civilian and military trauma care. Following the Battle of Mogadishu, Somalia, October 3–4, 1993, After Action Reports (AAR) from Special Operations medics highlighted differences between traditional civilian prehospital trauma care and the care required in dynamic combat zones. In particular, the AAR emphasized the need for prioritizing extremity hemorrhage control and noted the utility of tourniquets.17 Attitudes toward tourniquets are changing. Modern combat data clearly demonstrate that early tourniquet application reduces mortality.9,18 Extensive military and now expanding civilian data demonstrate that early application of commercial tourniquets is the essential first step in effective damage control resuscitation strategies.19–22 In the civilian arena, the Committee for Tactical Emergency Casualty Care (C-TECC), best practice development group for prehospital care in high-threat environments, also supports expanded commercial tourniquet use.9 The C-TECC strongly endorses LEO- based TQ programs as a critical component of the trauma “Chain of Survival” in active violent incidents (e.g., active shooters) and mass casualty incidents (MCI). The American College of Surgeons also recently released evidence-based guidelines for hemorrhage control in the prehospital setting that call for early TQ use and seem to support LEO-based tourniquet programs.23 Finally, the 2013 Hartford Consensus statement supports the position that medical training for external hemorrhage control techniques is essential for all law enforcement officers.24 These position statements were initially drafted to address “dynamic” or ongoing violent events where ongoing threat may limit traditional prehospital medical provider access to casualties, thus leaving LEO as the only potential providers. While LEO-TQ programs are clearly applicable in high-threat MCI events, this case series is the first to suggest a survival benefit of LEO tourniquet application in nondynamic environments (e.g., no active threat to first responders). The current case series demonstrates the life-saving potential of commercial tourniquets in the management of penetrating extremity trauma, even when applied by nonmedical first responders in the civilian setting (Table 1). Three of the 4 patients in the case se-
ries arrived at the receiving ED in extremis (Table 2), yet were successfully resuscitated and survived to discharge without major morbidity (Table 3). While this outcome is likely multifactorial and highlights the exceptional care delivered by the modern trauma system, tourniquet application appears to have kept critically injured patients alive long enough to reach definitive trauma care. The fourth case was always hemodynamically stable, but appears to have suffered no adverse effects from the commercial tourniquet application. There is little debate about the efficacy of properly applied, CoTCCC-approved commercial tourniquets to interrupt distal blood flow in extremities. Walters et al. showed 100% effectiveness of distal arterial occlusion with human volunteers who self-applied TQs, and research from recent combat theaters has shown an effectiveness of 79% in emergency use.25 If arterial occlusion is not achieved with a single TQ, a second device can be deployed to create a wider area of compression, dramatically improving the success rate and further reducing the occlusion pressure required.4,9 In this case series, a single TQ applied proximal to the entry wound effectively controlled extremity hemorrhage in all cases. Three of 4 patients in this case series had isolated life-threatening extremity hemorrhage. Based on the nature of the injury and presenting vital signs, expeditious TQ application appeared to be the critical initial life saving intervention in all 3 cases. Kragh et al. demonstrated that TQ application prior to onset of shock is critical. In a study of pooled data from two different time intervals from the Global War on Terrorism, researchers compared placement of tourniquets before or after the onset of shock, measured by weak radial pulse or altered mental status. Tourniquet application prior to the onset of clinical shock reduced mortality from 96 to 4%.4 Data from the first data set suggests a greater than twofold reduction in mortality if the tourniquet is applied in the prehospital arena versus first application in the emergency department.9 Current military data likewise suggest that earlier hemorrhage control greatly reduces the transfusion requirement during resuscitation and operative intervention.26 There is little reason to suspect that, as in combat, early hemorrhage control in the
TABLE 1. Prehospital course Patient
Dispatch
LEO arrival
TQ secured
EMS arrival (scene/patient)
TQ secured prior to EMS arrival (seconds)
1 (FM)
LEO: 0001 EMS: 0001
0003
0008
0009/0010:07
126
2 (TL)
LEO: 0242 EMS: 0244
0243
0245
0246:26/ (N/A)
≥86
3 (TS)
LEO: 2138 EMS: 2138
2138
2143
2144:00/2145:02
122
4 (DS)
LEO: 2254 EMS: 2255
2255
2257
2257:26/ (N/A)
≥26
Medical observation
Confused, pooling blood, rapid rate of blood loss, 4 GSW on LE Pooling blood, 1 GSW to proximal LUE, pulsatile blood loss LEO: No documentation EMS: ∼500 cc blood loss Pooling blood, 2 GSW to proximal LLE
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TABLE 2. EMS and emergency department course Patient
EMS arrival to ED
1 (FM)
0030
2 (TL)
0258
3 (TS)
4 (DS)
EMS vitals
ED vitals
ED evaluation
Resuscitation
Fluids, blood products
HHR: 120 LBP: No palpable pulse GCS: 3 HHR: 130 LBP: 84/50 GCS:15
HHR: 150 LBP: no palpable pulse GCS: 4
GSW to right lower extremity (RLE), TQ in place proximal RLE
ACLS, L Fem cordis placed, patient intubated
IVF: Unknown PRBC: 8 FFP: 6 PLT: 1
HHR: 130 LBP: 188/102 GCS: 15
2 large-bore IVs established by EMS
IVF: Unknown PRBC: 2 units FFP: 0
2158
HHR: 170 LBP: 70/30 GCS: 15
HHR: 170 LBP: 100/70 GCS: 15
2 large-bore IVs + R cordis
IVF: 2 L PRBC: 4 units FFP: 0
2344
HHR: 68 LBP: 110/70 GCS: 15
HHR: 64 LBP: 147/74 GCS: 15
GSW to medial LUE, combative, with TQ takedown pulsatile hemorrhage, tight arm compartments GSW to LLE, hypotensive, tachycardic, TQ applied, sig hemorrhage with TQ takedown NOI GSW proximal LLE, pain with weight bearing. No hemorrhage. Neurovascular intact. No bony injury/dislocation
1 large-bore IV established by EMS. Bullet fragment removed (at skin edge). Ancef 1G given.
IVF: 0 PRBC: 0 FFP: 0
civilian sector would not reduce mortality. Interestingly, in this case series, all 3 patients with vascular injury were in class 3 hemorrhagic shock on initial EMS evaluation. On ED presentation, all 3 demonstrated further clinical or laboratory signs of hemorrhagic shock requiring aggressive resuscitation with blood products. Their survival was directly linked to early TQ application as part of a robust damage control resuscitation (DCR) process that included aggres-
sive use of blood products, hypothermia prevention, tranexamic acid, and early operative repair. Though this process is similar to the resuscitation protocols seen in the military, the very rapid transport time may account for the significantly improved mortality compared to Kragh’s combat data. The MEDIC EMS providers utilize radio communication to document arrival at scene and at patient. Times for this series were taken from official MEDIC
TABLE 3. Hospital course Patient
Time to OR
TQ Time
OR Findings
1 (FM)
0114
FTQ: 0008–0126 (78 min) PNM TQ: 0126–0406 (160 min)
Transected R pop A&V
2 (TL)
0325
FTQ: 0245–0352 (67 min) PNM TQ: 0352–0411, 0417–0420 (22 min)
Transected left Brachial artery
3 (TS)
2230
FTQ: 2143–2300 (77 min) PNM TQ: 2300–2314 (14 min)
4 (DS)
NA
FTQ: 2257–ED assessment (60 min)
Laceration Superficial femoral artery and popliteal artery transection. NA
OR Intervention
Complications
Follow-up
End-to-end anastamosis of right popliteal artery, Ligation of right popliteal vein, 4-compartment fasciotomy of Right calf Repair of left brachial artery with reverse saphenous vein interposition graft, prophylactic forearm volar fasciotomy Reverse saphenous vein interposition graft, femoral vein ligation, prophylactic 4-compartment fasciotomy NA
Split thickness skin graft 2/2 inability to close fasciotomy
105 days post-op: healing well, ambulating unassisted, back to baseline
None
24 days post-op: wound healing well, healthy granulation tissue, limited extension from scar tissue. 26 days post-op: ambulating, minimal pain. No additional follow-up information. Patient ambulatory without assistance on discharge. No further ED/urgent care visits.
None
NA
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and LEO reports. Given the small sample size, statistical analysis is of limited value. However, of particular note, in this case series all TQs were applied by law enforcement and secured with hemorrhage control an average of 43 ± 20 seconds prior to EMS arrival on scene. In the 2 cases where EMS arrival time at patient side was documented, the LEO TQ was secured 67 and 122 seconds prior to EMS initial evaluation. Review of daily trauma response times in our system shows an average time from scene arrival to patient arrival of 60 seconds, supported by the observations in this case series. This supports the observation that these LEO-applied tourniquets prevented 1–2 minutes of additional hemorrhage in patients already suffering class 3 hemorrhagic shock. Previous studies have noted that LEOs arrive on scene prior to definitive EMS assets in 60–80% of 91-1 calls.11–13 Given the severity of hemorrhage in our patients, it is reasonable to surmise that further delay in TQ application while awaiting EMS arrival might have increased both morbidity and mortality. As demonstrated by this case series, LEO can be trained to identify and mitigate a defined set of potential life threats, such as extremity exsanguination (Table 1). Legitimate concerns exist regarding the morbidity associated with prolonged and improper tourniquet use. The major safety concerns include tourniquetrelated amputations, fasciotomies, or permanent neurovascular compromise. It is important to note that initial data on safe TQ duration was derived from the operating theater where pneumatic tourniquets were used generally on bloodless limbs. Though little grade 1 evidence exists, traditional safe duration for tourniquet application is considered 2 hours.27–31 A survey of Norwegian orthopedic surgeons supports the 2-hour window, reporting a single complication in 2,442 surgeries that “might have been related to tourniquets” when total TQ time was less than 120 minutes.32 In addition, multiple recent studies from the prehospital military environment support the 2-hour application time as a conservative and safe duration for tourniquet application. In this case series, total TQ application time ranged from 60 to 238 minutes. All four TQ times were less than 120 minutes from application to definitive care. For patients 1, 2, and 3, definitive care was provided in the operating theater. Total tourniquet times were 238, 89, and 91 minutes, respectively. Of note, patient 1, who experienced nearly 4 hours of combined tourniquet time, has returned to baseline function at 105 days postoperative intervention. Patient 4 had a total TQ time of 60 minutes (all field TQ) and no significant vascular injury. In the ED, no significant neurologic deficit or local tissue damage was noted and the patient was discharged. From a safety and liability standpoint, Patient 4 represents the most commonly cited concern
with LEO TQ programs: the application of a TQ to an extremity that ultimately has no significant vascular injury. In this case, no adverse consequences were noted. For patients with more severe extremity injuries, there are additional potential adverse effects of tourniquets. Regarding specific TQ complications, amputation is the most dramatic potential morbidity associated with improper TQ utilization. In the largest prehospital cohort studies to date, Kragh et al. demonstrated a 0% rate of tourniquet-related amputations.9 For casualties with amputations, reported reasons for the procedure included massive limb injury from trauma, failed vascular salvage, or better fitting prosthetic. A separate study conducted by Beekley et al. evaluated 165 patients with isolated extremity hemorrhage: 67 with prehospital tourniquets and 98 who did not received prehospital tourniquets. Similar to the Kragh study, they did not observe a single amputation secondary to injury sustained from tourniquet use.5 In our case series, no patient had a tourniquet-related amputation. Fasciotomies are considered another potential complications of TQ use and may be a marker for adverse outcomes or inappropriate use. In this case series, all 3 patients who underwent operative repair received fasciotomies. In all 3 cases, the procedure was done prophylactically based on clinical experience that dual vessel injuries ultimately require fasciotomies as opposed to specific concern for TQ-related injuries. In all cases, the patients lived and had return of normal function in the affected limb. Existing data suggest that 2 hours is a safe and reasonable time frame for tourniquet application to removal for evaluation at definitive care. In our case series, all patients had time from TQ application to definitive care of less than 2 hours. However, in systems with potentially prolonged transports, protocols can be developed for EMS/ED conversion of tourniquets after hemorrhage control in order to further mitigate safety concerns from LEO TQ use.
LIMITATIONS The primary limitation of this study is that it is a retrospective case series involving a small number of patients. While the results suggest mortality benefit from the prehospital use of commercial TQs by law enforcement personnel, further study is needed, especially in terms of surveillance for adverse outcomes. In this series, the total tourniquet time is not precise. Police records document TQ application in the context of other concurrent tasks, making definitive application times difficult, though felt accurate to within 2 minutes when examined in the context of EMS and fire department run sheets. Additionally, surgical records do not always indicate field TQ removal, though
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they do denote pneumatic TQ (PTQ) application and total PTQ time. Despite these realities, after discussions with officers on scene and physicians involved, as well as further discussion and operational experience within our health-care system, we do know that continuous application times were less than 2 hours in all cases. Finally, there is no national standard for law enforcement TQ training. The CMPD officers in question have gone through routine TECC and TQ education, including scenario-based training and live fire exercises. It is possible therefore, that these cases do not represent the true “average patrol officer.” Having trained thousands of law enforcement personnel, the authors strongly feel that TQ training can be done in a rapid, cost-effective, and life-saving manner for all first responders.
CONCLUSIONS This is the largest case series of law enforcementapplied tourniquets reported to date. The observations suggest that law enforcement officers can effectively identify indications for tourniquets and rapidly apply life-saving interventions. This case series has important public policy and medical response implications. Though attitudes are changing, tourniquets remain a point of controversy in some areas of the United States. The existing scientific and operational data demonstrate a clear mortality advantage to early TQ application, that LEOs are first on scene in a majority of traumatic events, and that LEOs can learn the indications for and proper application of tourniquets. Further study is needed to evaluate both the efficacy and safety of LEO-TQ application. However, this case series demonstrates the potential for life-saving outcomes of TQ application by first responding law enforcement personnel.
References 1. Sauaia A, Moore FA, Moore EE, Moser KS, Brennan R, Read RA, Pons PT. Epidemiology of trauma deaths: a reassessment. J Trauma. 1995 Feb;38(2):185–93. 2. Evans JA, van Wessem KJ, McDougall D, Lee KA, Lyons T, Balogh ZJ. Epidemiology of traumatic deaths: comprehensive population-based assessment. World J Surg. 2010 Jan;34(1):158–63. 3. Kragh JF Jr, Littrel ML, Jones JA, Walters TJ, Baer DG, Wade CE, Holcomb JB. Battle casualty survival with emergency tourniquet use to stop limb bleeding. J Emerg Med. 2011. 4. Beekley AC, Sebesta JA, Blackbourne LH, Herbert GS, Kauvar DS, Baer DG, Walters TJ, Mullenix PS, Holcomb JB; 31st Combat Support Hospital Research Group. Prehospital tourniquet use in Operation Iraqi Freedom: effect on hemorrhage control and outcomes. J Trauma. 2008 Feb;64(2 Suppl):S28–S37; discussion S37. 5. Kragh JF. Use of tourniquets and their effects on limb function in the modern combat environment. Foot Ankle Clin N Am. 2010;15:23–40.
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Bellamy RF. The causes of death in conventional land warfare: implications for combat casualty care research. Mil Med. 1984;149:55–62. Kotwal RS, Montgomery HR, Kotwal BM, Champion HR, Butler FK Jr, Mabry RL, Cain JS, Blackbourne LH, Mechler KK, Holcomb JB. Eliminating preventable death on the battlefield. Arch Surg. 2011 Dec;146(12):1350–8. Kragh JF Jr, Walters TJ, Baer DG, Fox CJ, Wade CE, Salinas J, Holcomb JB. Survival with emergency tourniquet use to stop bleeding in major limb trauma. Ann Surg. 2009 Jan;249(1):1–7. Callaway DW, Smith ER, Cain J, Shapiro G, Burnett WT, McKay SD, Mabry R. Tactical Emergency Casualty Care (TECC): Guidelines for the provision of prehospital trauma care in high threat environments. J Spec Oper Med. 2011 Summer;11(3):104–22. Myerburg RJ, Fenster J, Velez M, Rosenberg D, Lai S, Kurlansky P, Newton S, Knox M, Castellanos A. Impact of communitywide police car deployment of automated external defibrillators on survival from out-of-hospital cardiac arrest. Circulation. 2002;106:1058–64. Husain S, Eisenberg M. Police AED programs: a systematic review and meta-analysis. Resuscitation. 2013;84:1184–91. Alonso-Serra HM, Delbridge TR, Auble TE, et al. Law enforcement agencies and out-of-hospital emergency care. Ann Emerg Med. 1997 Apr;29(4):497–503. Caterson EJ, Carty MJ, Weaver MJ, Holt EF. Boston bombings: a surgical view of lessons learned from combat casualty care and the applicability to Boston’s terrorist attack. J Craniofac Surg. 2013 Jul;24(4):1061–7. Majno G. The Healing Hand: Man and Wound in the Ancient World. Cambridge, MA: Harvard University Press; 1975:278–9, 403–5. 15. Salazar CF, ed. The Treatment of War Wounds in GraecoRoman Antiquity: Studies in Ancient Medicine. Boston: Brill; 2000. Kragh JF, Swan KG, Smith DC, Mabry RL, Blackbourne LH. Historical review of emergency tourniquet use to stop bleeding. Am J Surg. 2012;203:242–52. Mabry, RL, Holcomb JB, Baker AM, Cloonan CC, Uhorchak JM, Perkins DE, Canfield AJ, Hagmann JH. United States Army Rangers in Somalia: an analysis of combat casualties on an urban battlefield. J Trauma. 2000 Sep;49(3):515–29. Kragh JF Jr, O’Neill ML, Walters TJ, Jones JA, Baer DG, Gershman LK, Wade CE, Holcomb JB. Minor morbidity with emergency tourniquet use to stop bleeding in severe limb trauma: research, history, and reconciling advocates and abolitionists. Mil Med. 2011 Jul;176(7):817–23. Niven DJ, Stelfox HT, Ball CG, Kirkpatrick AW. Prehospital intravenous fluid administration is associated with higher mortality in trauma patients: a National Trauma Data Bank analysis. Ann Surg. 2014 Feb;259(2):e16. Cohen MJ, Kutcher M, Redick B, Nelson M, Call M, Knudson MM, Schreiber MA, Bulger EM, Muskat P, Alarcon LH, Myers JG, Rahbar MH, Brasel KJ, Phelan HA, del Junco DJ, Fox EE, Wade CE, Holcomb JB, Cotton BA, Matijevic N; PROMMTT Study Group. Clinical and mechanistic drivers of acute traumatic coagulopathy. J Trauma Acute Care Surg. 2013 Jul;75(1 Suppl 1):S40–S47. del Junco DJ, Holcomb JB, Fox EE, Brasel KJ, Phelan HA, Bulger EM, Schreiber MA, Muskat P, Alarcon LH, Cohen MJ, Cotton BA, Wade CE, Myers JG, Rahbar MH; PROMMTT Study Group. Resuscitate early with plasma and platelets or balance blood products gradually: findings from the PROMMTT study. J Trauma Acute Care Surg. 2013 Jul;75(1 Suppl 1):S24–S30. Kutcher ME, Kornblith LZ, Narayan R, Curd V, Daley AT, Redick BJ, Nelson MF, Fiebig EW, Cohen MJ. A paradigm shift in trauma resuscitation: evaluation of evolving massive transfusion practices. JAMA Surg. 2013 Sep;148(9):834–40.
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Bulger EM, Snyder D, Schoelles K, Gotschall C, et al. An evidence-based prehospital guideline for external hemorrhage control: America College of Surgeons Committee on Trauma. Prehosp Emerg Care. 2014 Apr;18(2):168–73. 24. Jacobs LM, Wade DS, McSwain NE, Butler FK, Fabbri WP, Eastman AL, Rotondo M, Sinclair J, Burns KJ. The Hartford Consensus: THREAT, a medical disaster preparedness concept. J Am Coll Surg. 2014 Mar;218(3):467–75. 25. Walters TJ, Wenke JC, Kauvar DS, McManus, JG, Holcomb JB, Baer DG. Effectiveness of self-applied tourniquets in human volunteers. Prehosp Emerg Care. 2005 Oct/Dec;9(4):416–22. 26. Kragh JF, O’Neill ML, Beebe DF, Fox CJ, Beekley AC, Cain JS, Parsons DL, Mabry RL, Blackbourne LH. Survey of the indications for use of emergency tourniquets. J Spec Op Med. 2011 Winter;11(1):30–8.
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327 27. Fitzgibbons PG, DiGiovanni C, Hares S, Akelman, E. Safe tourniquet use: a review of the evidence. J Am Acad Orthop Surg. 2012 May;20(5):310–9. 28. Wilgis EFS. Observations on the effects of tourniquet ischemia. J Bone Joint Surg Am. 1971;53:1343–6. 29. Solonen KA, Hjelt L. Morphological changes in striated muscle during ischaemia. Acta Orthop Scandinav. 1968;39:13–9. 30. Klenerman L. The Tourniquet Manual. London: Spring; 2003. Wheeless CR. Wheeless’ Textbook of Orthopaedics. Extremity Tourniquets. Available online: www.wheelessonline.com/ ortho/extremity tourniquets (Accessed September 1, 2014) 31. Klenerman L. Tourniquet time–how long? Hand. 1980 Oct;12(3):231–4. 32. Odinsson A, Finsen V. Tourniquet use and its complications in Norway. J Bone Joint Surg Br. 2006 Aug;88(8):1090–2.
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LAW ENFORCEMENT-APPLIED TOURNIQUETS: A CASE SERIES OF LIFE-SAVING INTERVENTIONS David W. Callaway, MD, FACEP, FAAEM, Joshua Robertson, MD, Matthew D. Sztajnkrycer, MD, PhD, FACEP
INTRODUCTION
ABSTRACT Although the epidemiology of civilian trauma is distinct from that encountered in combat, in both settings, extremity hemorrhage remains a major preventable cause of potential mortality. The current paper describes the largest case series in the literature in which police officers arriving prior to emergency medical services applied commercially available field tourniquets to civilian victims of violent trauma. Although all 3 patients with vascular injury arrived at the receiving emergency department in extremis, they were successfully resuscitated and survived to discharge without major morbidity. While this outcome is likely multifactorial and highlights the exceptional care delivered by the modern trauma system, tourniquet application appears to have kept critically injured patients alive long enough to reach definitive trauma care. No patient had a tourniquet-related complication. This case series suggests that law enforcement officers can effectively identify indications for tourniquets and rapidly apply such life-saving interventions. Key words: hemorrhage control; law enforcement; prehospital; tactical emergency casualty care; tourniquet
Isolated extremity hemorrhage remains the leading cause of potentially preventable death in combat. Hemorrhage is the second leading cause of death in civilian trauma behind head injury.1,2 Although the epidemiology of civilian trauma is distinct from that encountered in combat, in both settings, extremity hemorrhage remains a major preventable cause of potential mortality. Once a vilified technique, current data demonstrate that prehospital commercial tourniquet (TQ) application saves lives.3,4 Through aggressive Tactical Combat Casualty Care (TCCC) training and TQ fielding, mortality rates from isolated extremity hemorrhage have declined from approximately 9% in Vietnam to approximately 2% in Operations Iraqi and Enduring Freedom.5,6 Combat data indicate that successful mortality reduction requires a comprehensive trauma management system, with nonmedical personnel playing a critical role in initiating hemorrhage control – in essence, the first link in the “Trauma Chain of Survival.”7 Additionally, survival benefits are greatest when tourniquets are applied prior to development of shock.8 In the civilian setting, Tactical Emergency Casualty Care (TECC) guidelines outline a framework for trauma first response during high-threat incidents.9 Analogous to soldiers in combat, law enforcement officers (LEO) are frequently first on scene and fulfill a critical early link in the TECC Chain of Survival.10–12 Recent high-profile events, including the mass shooting in Tucson, Arizona and the Boston Marathon bombing, highlight the critical importance of training LEOs in robust hemorrhage control strategies, including tourniquets.13 This paper describes the nature and outcomes of a case series in which patrol officers arriving on scene prior to emergency medical services (EMS) applied commercially available field tourniquets to civilian victims of violent trauma.
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Received June 27, 2014 from the Division of Operational and Disaster Medicine, Department of Emergency Medicine, Carolinas Medical Center – Main, Charlotte, North Carolina (DWC, JR), and Division of Prehospital Care, Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota (MDS). Revision received August 9, 2014; accepted for publication September 2, 2014. The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper. Address correspondence to David W. Callaway, Director, Operational and Disaster Medicine, Department of Emergency Medicine, Carolinas Medical Center – Main, Charlotte, NC 28203, USA. E-mail: [email protected] doi: 10.3109/10903127.2014.964893
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CASE SERIES During a 12-month period between January 1, 2013 and December 31, 2013 in the Charlotte–Mecklenburg County area, 4 cases of LEO application of commercial tourniquets were observed (Combat Application Tourniquet – CAT, Composite Resources, Rock Hill, SC). Incident details were extracted from official police reports, EMS run sheets, the hospital electronic medical record, and personal interviews with providers. In Charlotte–Mecklenburg County, Charlotte Fire Department (basic life support) and MEDIC EMS (advanced life support) provide prehospital care. Prehosp Emerg Care Downloaded from informahealthcare.com by Nyu Medical Center on 06/15/15 For personal use only.
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Patient 1 A law enforcement officer was dispatched at 0001 hours to an assault with a deadly weapon and associated injury. The LEO arrived on scene approximately 2 minutes later and observed an elderly male lying on the floor “moaning incoherently.” Per the LEO report, “I could see that his lower body was covered in blood, his pants were soaked with it and the floor under his body had pooling blood.” The first officer began an initial assessment while a second officer secured the scene. The officer stated that “I saw that the victim had what appeared to be a gunshot wound to his right leg. . . an entry wound to the outside of his right leg next to his knee, an exit wound on the inside of his right leg just above his knee, an entry wound to the inside of his left leg in the middle of the thigh, and it appeared that the projectile had lodged itself in his left leg. I could clearly see a large lump in his left thigh. The amount of blood, the rate of blood loss, and the area of the wound indicated to me that the bleeding needed to be stopped immediately, so I instructed one of the firemen and another LEO to lift his leg as I applied a CAT tourniquet at 0008 hours to his right leg. I applied the CAT as high as it could go on his leg above the wound.” The officers then applied a pressure dressing over the wound itself and completed a primary assessment. EMS arrived at 0010 hours, noted adequate hemorrhage control and transported the patient to definitive care. Prehospital vital signs included highest heart rate of 120 beats per minute, lowest blood pressure was not recorded, and best Glasgow Coma Scale GCS 15. EMS was unable to obtain IV access prior to emergency department (ED) arrival. Upon arrival to the emergency department, the patient quickly decompensated with witnessed loss of pulse. Chest compressions were begun, a definitive endotracheal airway was established, and a left femoral 8 French cordis venous catheter was placed. Institutional massive transfusion protocol was initiated; the
patient received a total of 8 units packed red blood cells, 6 units fresh frozen plasma, and 1 unit of platelets in the ED. After several cycles of cardiopulmonary resuscitation (CPR), return of spontaneous circulation was achieved. The tourniquet (TQ) was noted to be in place and no active hemorrhage was observed from the wound site. Initial ED labs included hemoglobin of 13.6 g/dL and lactate of 16 mmol/L. The patient was taken emergently to the operating room where an end-to-end repair of a transected right popliteal artery, ligation of traumatic transection of right popliteal vein, and a prophylactic fourcompartment fasciotomy were performed. A pneumatic TQ was applied in the operating room with field TQ taken down immediately prior to pneumatic TQ application. Total prehospital and ED TQ time was approximately 78 minutes and pneumatic TQ time was approximately 160 minutes (total TQ time 238 minutes). At the 4-week follow-up, the patient had no evidence of lower extremity claudication, and postoperative right lower extremity edema was significantly improved.
Patient 2 An off-duty LEO responded to a call at 0242 hours that subjects were fighting within his vicinity. Upon arrival, the officer heard gunfire and witnessed a vehicle fleeing the scene. No other obvious threats were identified at the scene. A young male was discovered with a single gunshot wound to the left arm with “a great deal of blood on the ground next to the vehicle the victim was in and a great deal of blood on the interior of the vehicle.” The victim was holding his left arm close to his body and stated he had been shot in the arm. Upon straightening the victim’s arm, “blood began to squirt out of the wound site, indicating an arterial bleed.” A second LEO arrived and applied direct pressure to the wound while the first officer applied a CAT tourniquet. The TQ was “placed high into the victim’s arm pit (0245 hours) and tightened until the bleeding stopped. I then checked for a distal pulse and could not find one, which indicated to me that the tourniquet was doing the job.” EMS arrived on scene soon thereafter and transported the patient to definitive care. Highest prehospital heart rate was 130 beats per minute (bpm), lowest blood pressure was 84/50 mmHg, and best GCS was 15. EMS established two large-bore IVs prior to ED arrival. Upon arrival to the ED, providers noted a 0.5-cm wound to the medial aspect of the patient’s left arm proximal to the antecubital fossa. There was no active hemorrhage. Pulses were 2+ in the bilateral carotid, femoral arteries, and right radial artery; no pulse was noted in the left radial artery. Initial ED vitals signs included a heart rate 130 bpm, blood pressure 188/102
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322 mmHg, and GCS 15. The patient was combative. During a brief TQ takedown, the team noted pulsatile hemorrhage from the LUE and “tight” forearm compartments. Initial ED labs were notable for hemoglobin 13.6 g/dL and lactate 9.63 mmol/L. The patient received 2 units packed red blood cells (PRBC) in the ED. The patient was emergently taken to the operating room and underwent repair of left brachial artery transection with reversed greater saphenous vein interposition graft, and prophylactic left forearm volar fasciotomy. The field TQ (CAT) was taken down with placement of pneumatic TQ in the operating room (OR) and isolation with vascular clamping of the brachial artery. Total prehospital and ED TQ time was approximately 67 minutes and pneumatic TQ time was 22 minutes (total TQ time 89 minutes). At 1-week post discharge patient was noted to have minimal swelling in his upper extremity, “excellent wound healing and granulation tissue.” The patient noted some minor limitations in elbow extension secondary to early wound healing.
Patient 3 An LEO responded to a call for an assault with deadly weapon at 2138 hours. Upon arrival, an injured victim was identified and LEO and CFD evaluated the patient concurrently. Examination revealed a GSW in the anterior and posterior left upper thigh. CFD placed a field tourniquet at 2140 hours. Successful arterial occlusion was not appreciated by LEO/FD on scene per the EMS report. As a consequence, the field TQ was taken down at 2141 and reapplied by LEO with adequate control of bleeding at 2143 hours. EMS arrived on scene at 2144. EMS documented an estimated blood loss on scene of 500 cc. Upon transfer to the stretcher, the patient was noted to be lethargic with no palpable radial or brachial pulses. Prehospital vital signs included highest heart rate 170 bpm, lowest blood pressure 70/30 mmHg, and best GCS 15. EMS was unable to obtain IV access prior to ED arrival. Upon arrival to the ED, the patient’s initial vital signs included heart rate of 170 bpm, blood pressure of 100/70 mmHg, and GCS 15. Two large-bore IVs were established and a right 8 French femoral cordis venous catheter was placed. Initial ED labs were notable for hemoglobin 9.5 g/dL and lactate 6.78 mmol/L. ED resuscitation included 2000 cc of IV crystalloid and 4 units of PRBC, with improvement of heart rate from 170 to 100 bpm. The patient was taken to the operating room and underwent repair of left superficial femoral and proximal popliteal artery laceration by reverse greater saphenous vein interposition graft, femoral vein ligation, and four-compartment fasciotomy. The field TQ was taken down with placement of pneumatic TQ in
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the OR with vascular clamping of superficial femoral artery. Total prehospital and ED TQ time was 77 minutes and total pneumatic TQ time was 14 minutes (total TQ time of 91 minutes). At two and a half weeks post-discharge the patient reported no significant pain in left lower extremity and was ambulating without difficulty.
Patient 4 An LEO responded to a call of an assault with deadly weapon at 2254 hours. A second patrol car stated they had intercepted a vehicle attempting to travel to the hospital with a victim in it. Three passengers were removed from the vehicle and questioned by LEO. A revolver was found with 5 spent casings. LEO rendered safe the revolver and secured the scene. LEO identified the patient and found a GSW to the left inner thigh and “immediately put gloves on and applied direct pressure to the wound. Officers noted there was “a good amount of blood in the passenger area and the victim kept saying he felt like he was going to faint.” An LEO on scene applied a CAT TQ to the wounded leg at 2257 hours. EMS arrived on scene soon thereafter and transported the patient to the hospital to definitive care. Prehospital vital signs included highest heart rate 68 bpm, lowest blood pressure 110/70 mmHg, and best GCS 15. EMS gained IV access prior to ED arrival. Upon arrival to the ED, the patient was noted to have a gunshot wound to the left thigh. Physical exam revealed a normal neurovascular exam in the bilateral lower extremities. After initial assessment, the TQ was taken down and the physician noted no active bleeding from the left lower extremity. Total TQ time was approximately 60 minutes. Plain films confirmed a bullet fragment in the left inner thigh with no bony injury or dislocation. The patient was able to ambulate, noted pain only with weight bearing, and denied any numbness or tingling. The patient was discharged in stable condition with pain medication. Although subsequently lost to follow-up, review of the electronic medical record demonstrates no further visits to the major health-care systems in the region (accounting for 100% of emergency departments, >90% of urgent care facilities and a majority of primary care groups). In addition, the Mecklenburg County coroner has no reports of death related to this patient.
DISCUSSION Tourniquets have a contentious history. The Greeks and Romans were the first to document the concept of circumferential constriction of extremities to control hemorrhage.14–16 In the modern era, concerns about limb loss and permanent neurovascular injury resulted
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in removal of tourniquets from civilian and military trauma care. Following the Battle of Mogadishu, Somalia, October 3–4, 1993, After Action Reports (AAR) from Special Operations medics highlighted differences between traditional civilian prehospital trauma care and the care required in dynamic combat zones. In particular, the AAR emphasized the need for prioritizing extremity hemorrhage control and noted the utility of tourniquets.17 Attitudes toward tourniquets are changing. Modern combat data clearly demonstrate that early tourniquet application reduces mortality.9,18 Extensive military and now expanding civilian data demonstrate that early application of commercial tourniquets is the essential first step in effective damage control resuscitation strategies.19–22 In the civilian arena, the Committee for Tactical Emergency Casualty Care (C-TECC), best practice development group for prehospital care in high-threat environments, also supports expanded commercial tourniquet use.9 The C-TECC strongly endorses LEO- based TQ programs as a critical component of the trauma “Chain of Survival” in active violent incidents (e.g., active shooters) and mass casualty incidents (MCI). The American College of Surgeons also recently released evidence-based guidelines for hemorrhage control in the prehospital setting that call for early TQ use and seem to support LEO-based tourniquet programs.23 Finally, the 2013 Hartford Consensus statement supports the position that medical training for external hemorrhage control techniques is essential for all law enforcement officers.24 These position statements were initially drafted to address “dynamic” or ongoing violent events where ongoing threat may limit traditional prehospital medical provider access to casualties, thus leaving LEO as the only potential providers. While LEO-TQ programs are clearly applicable in high-threat MCI events, this case series is the first to suggest a survival benefit of LEO tourniquet application in nondynamic environments (e.g., no active threat to first responders). The current case series demonstrates the life-saving potential of commercial tourniquets in the management of penetrating extremity trauma, even when applied by nonmedical first responders in the civilian setting (Table 1). Three of the 4 patients in the case se-
ries arrived at the receiving ED in extremis (Table 2), yet were successfully resuscitated and survived to discharge without major morbidity (Table 3). While this outcome is likely multifactorial and highlights the exceptional care delivered by the modern trauma system, tourniquet application appears to have kept critically injured patients alive long enough to reach definitive trauma care. The fourth case was always hemodynamically stable, but appears to have suffered no adverse effects from the commercial tourniquet application. There is little debate about the efficacy of properly applied, CoTCCC-approved commercial tourniquets to interrupt distal blood flow in extremities. Walters et al. showed 100% effectiveness of distal arterial occlusion with human volunteers who self-applied TQs, and research from recent combat theaters has shown an effectiveness of 79% in emergency use.25 If arterial occlusion is not achieved with a single TQ, a second device can be deployed to create a wider area of compression, dramatically improving the success rate and further reducing the occlusion pressure required.4,9 In this case series, a single TQ applied proximal to the entry wound effectively controlled extremity hemorrhage in all cases. Three of 4 patients in this case series had isolated life-threatening extremity hemorrhage. Based on the nature of the injury and presenting vital signs, expeditious TQ application appeared to be the critical initial life saving intervention in all 3 cases. Kragh et al. demonstrated that TQ application prior to onset of shock is critical. In a study of pooled data from two different time intervals from the Global War on Terrorism, researchers compared placement of tourniquets before or after the onset of shock, measured by weak radial pulse or altered mental status. Tourniquet application prior to the onset of clinical shock reduced mortality from 96 to 4%.4 Data from the first data set suggests a greater than twofold reduction in mortality if the tourniquet is applied in the prehospital arena versus first application in the emergency department.9 Current military data likewise suggest that earlier hemorrhage control greatly reduces the transfusion requirement during resuscitation and operative intervention.26 There is little reason to suspect that, as in combat, early hemorrhage control in the
TABLE 1. Prehospital course Patient
Dispatch
LEO arrival
TQ secured
EMS arrival (scene/patient)
TQ secured prior to EMS arrival (seconds)
1 (FM)
LEO: 0001 EMS: 0001
0003
0008
0009/0010:07
126
2 (TL)
LEO: 0242 EMS: 0244
0243
0245
0246:26/ (N/A)
≥86
3 (TS)
LEO: 2138 EMS: 2138
2138
2143
2144:00/2145:02
122
4 (DS)
LEO: 2254 EMS: 2255
2255
2257
2257:26/ (N/A)
≥26
Medical observation
Confused, pooling blood, rapid rate of blood loss, 4 GSW on LE Pooling blood, 1 GSW to proximal LUE, pulsatile blood loss LEO: No documentation EMS: ∼500 cc blood loss Pooling blood, 2 GSW to proximal LLE
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TABLE 2. EMS and emergency department course Patient
EMS arrival to ED
1 (FM)
0030
2 (TL)
0258
3 (TS)
4 (DS)
EMS vitals
ED vitals
ED evaluation
Resuscitation
Fluids, blood products
HHR: 120 LBP: No palpable pulse GCS: 3 HHR: 130 LBP: 84/50 GCS:15
HHR: 150 LBP: no palpable pulse GCS: 4
GSW to right lower extremity (RLE), TQ in place proximal RLE
ACLS, L Fem cordis placed, patient intubated
IVF: Unknown PRBC: 8 FFP: 6 PLT: 1
HHR: 130 LBP: 188/102 GCS: 15
2 large-bore IVs established by EMS
IVF: Unknown PRBC: 2 units FFP: 0
2158
HHR: 170 LBP: 70/30 GCS: 15
HHR: 170 LBP: 100/70 GCS: 15
2 large-bore IVs + R cordis
IVF: 2 L PRBC: 4 units FFP: 0
2344
HHR: 68 LBP: 110/70 GCS: 15
HHR: 64 LBP: 147/74 GCS: 15
GSW to medial LUE, combative, with TQ takedown pulsatile hemorrhage, tight arm compartments GSW to LLE, hypotensive, tachycardic, TQ applied, sig hemorrhage with TQ takedown NOI GSW proximal LLE, pain with weight bearing. No hemorrhage. Neurovascular intact. No bony injury/dislocation
1 large-bore IV established by EMS. Bullet fragment removed (at skin edge). Ancef 1G given.
IVF: 0 PRBC: 0 FFP: 0
civilian sector would not reduce mortality. Interestingly, in this case series, all 3 patients with vascular injury were in class 3 hemorrhagic shock on initial EMS evaluation. On ED presentation, all 3 demonstrated further clinical or laboratory signs of hemorrhagic shock requiring aggressive resuscitation with blood products. Their survival was directly linked to early TQ application as part of a robust damage control resuscitation (DCR) process that included aggres-
sive use of blood products, hypothermia prevention, tranexamic acid, and early operative repair. Though this process is similar to the resuscitation protocols seen in the military, the very rapid transport time may account for the significantly improved mortality compared to Kragh’s combat data. The MEDIC EMS providers utilize radio communication to document arrival at scene and at patient. Times for this series were taken from official MEDIC
TABLE 3. Hospital course Patient
Time to OR
TQ Time
OR Findings
1 (FM)
0114
FTQ: 0008–0126 (78 min) PNM TQ: 0126–0406 (160 min)
Transected R pop A&V
2 (TL)
0325
FTQ: 0245–0352 (67 min) PNM TQ: 0352–0411, 0417–0420 (22 min)
Transected left Brachial artery
3 (TS)
2230
FTQ: 2143–2300 (77 min) PNM TQ: 2300–2314 (14 min)
4 (DS)
NA
FTQ: 2257–ED assessment (60 min)
Laceration Superficial femoral artery and popliteal artery transection. NA
OR Intervention
Complications
Follow-up
End-to-end anastamosis of right popliteal artery, Ligation of right popliteal vein, 4-compartment fasciotomy of Right calf Repair of left brachial artery with reverse saphenous vein interposition graft, prophylactic forearm volar fasciotomy Reverse saphenous vein interposition graft, femoral vein ligation, prophylactic 4-compartment fasciotomy NA
Split thickness skin graft 2/2 inability to close fasciotomy
105 days post-op: healing well, ambulating unassisted, back to baseline
None
24 days post-op: wound healing well, healthy granulation tissue, limited extension from scar tissue. 26 days post-op: ambulating, minimal pain. No additional follow-up information. Patient ambulatory without assistance on discharge. No further ED/urgent care visits.
None
NA
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and LEO reports. Given the small sample size, statistical analysis is of limited value. However, of particular note, in this case series all TQs were applied by law enforcement and secured with hemorrhage control an average of 43 ± 20 seconds prior to EMS arrival on scene. In the 2 cases where EMS arrival time at patient side was documented, the LEO TQ was secured 67 and 122 seconds prior to EMS initial evaluation. Review of daily trauma response times in our system shows an average time from scene arrival to patient arrival of 60 seconds, supported by the observations in this case series. This supports the observation that these LEO-applied tourniquets prevented 1–2 minutes of additional hemorrhage in patients already suffering class 3 hemorrhagic shock. Previous studies have noted that LEOs arrive on scene prior to definitive EMS assets in 60–80% of 91-1 calls.11–13 Given the severity of hemorrhage in our patients, it is reasonable to surmise that further delay in TQ application while awaiting EMS arrival might have increased both morbidity and mortality. As demonstrated by this case series, LEO can be trained to identify and mitigate a defined set of potential life threats, such as extremity exsanguination (Table 1). Legitimate concerns exist regarding the morbidity associated with prolonged and improper tourniquet use. The major safety concerns include tourniquetrelated amputations, fasciotomies, or permanent neurovascular compromise. It is important to note that initial data on safe TQ duration was derived from the operating theater where pneumatic tourniquets were used generally on bloodless limbs. Though little grade 1 evidence exists, traditional safe duration for tourniquet application is considered 2 hours.27–31 A survey of Norwegian orthopedic surgeons supports the 2-hour window, reporting a single complication in 2,442 surgeries that “might have been related to tourniquets” when total TQ time was less than 120 minutes.32 In addition, multiple recent studies from the prehospital military environment support the 2-hour application time as a conservative and safe duration for tourniquet application. In this case series, total TQ application time ranged from 60 to 238 minutes. All four TQ times were less than 120 minutes from application to definitive care. For patients 1, 2, and 3, definitive care was provided in the operating theater. Total tourniquet times were 238, 89, and 91 minutes, respectively. Of note, patient 1, who experienced nearly 4 hours of combined tourniquet time, has returned to baseline function at 105 days postoperative intervention. Patient 4 had a total TQ time of 60 minutes (all field TQ) and no significant vascular injury. In the ED, no significant neurologic deficit or local tissue damage was noted and the patient was discharged. From a safety and liability standpoint, Patient 4 represents the most commonly cited concern
with LEO TQ programs: the application of a TQ to an extremity that ultimately has no significant vascular injury. In this case, no adverse consequences were noted. For patients with more severe extremity injuries, there are additional potential adverse effects of tourniquets. Regarding specific TQ complications, amputation is the most dramatic potential morbidity associated with improper TQ utilization. In the largest prehospital cohort studies to date, Kragh et al. demonstrated a 0% rate of tourniquet-related amputations.9 For casualties with amputations, reported reasons for the procedure included massive limb injury from trauma, failed vascular salvage, or better fitting prosthetic. A separate study conducted by Beekley et al. evaluated 165 patients with isolated extremity hemorrhage: 67 with prehospital tourniquets and 98 who did not received prehospital tourniquets. Similar to the Kragh study, they did not observe a single amputation secondary to injury sustained from tourniquet use.5 In our case series, no patient had a tourniquet-related amputation. Fasciotomies are considered another potential complications of TQ use and may be a marker for adverse outcomes or inappropriate use. In this case series, all 3 patients who underwent operative repair received fasciotomies. In all 3 cases, the procedure was done prophylactically based on clinical experience that dual vessel injuries ultimately require fasciotomies as opposed to specific concern for TQ-related injuries. In all cases, the patients lived and had return of normal function in the affected limb. Existing data suggest that 2 hours is a safe and reasonable time frame for tourniquet application to removal for evaluation at definitive care. In our case series, all patients had time from TQ application to definitive care of less than 2 hours. However, in systems with potentially prolonged transports, protocols can be developed for EMS/ED conversion of tourniquets after hemorrhage control in order to further mitigate safety concerns from LEO TQ use.
LIMITATIONS The primary limitation of this study is that it is a retrospective case series involving a small number of patients. While the results suggest mortality benefit from the prehospital use of commercial TQs by law enforcement personnel, further study is needed, especially in terms of surveillance for adverse outcomes. In this series, the total tourniquet time is not precise. Police records document TQ application in the context of other concurrent tasks, making definitive application times difficult, though felt accurate to within 2 minutes when examined in the context of EMS and fire department run sheets. Additionally, surgical records do not always indicate field TQ removal, though
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they do denote pneumatic TQ (PTQ) application and total PTQ time. Despite these realities, after discussions with officers on scene and physicians involved, as well as further discussion and operational experience within our health-care system, we do know that continuous application times were less than 2 hours in all cases. Finally, there is no national standard for law enforcement TQ training. The CMPD officers in question have gone through routine TECC and TQ education, including scenario-based training and live fire exercises. It is possible therefore, that these cases do not represent the true “average patrol officer.” Having trained thousands of law enforcement personnel, the authors strongly feel that TQ training can be done in a rapid, cost-effective, and life-saving manner for all first responders.
CONCLUSIONS This is the largest case series of law enforcementapplied tourniquets reported to date. The observations suggest that law enforcement officers can effectively identify indications for tourniquets and rapidly apply life-saving interventions. This case series has important public policy and medical response implications. Though attitudes are changing, tourniquets remain a point of controversy in some areas of the United States. The existing scientific and operational data demonstrate a clear mortality advantage to early TQ application, that LEOs are first on scene in a majority of traumatic events, and that LEOs can learn the indications for and proper application of tourniquets. Further study is needed to evaluate both the efficacy and safety of LEO-TQ application. However, this case series demonstrates the potential for life-saving outcomes of TQ application by first responding law enforcement personnel.
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