1
|
Salchner H, Isser M, Banyai L, Schachner T, Wiedermann FJ, Lederer W. Arterial Occlusion Effectiveness of Space Blanket‒Improvised Tourniquets for the Remote Setting. Wilderness Environ Med 2023; 34:269-276. [PMID: 37100664 DOI: 10.1016/j.wem.2023.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 01/09/2023] [Accepted: 02/08/2023] [Indexed: 04/28/2023]
Abstract
INTRODUCTION Control of severe extremity hemorrhage by tourniquet can save lives. In remote areas or in mass casualty incidents with multiple severely bleeding victims, lack of conventional tourniquets may make it necessary to improvise tourniquets. METHODS Occlusion of the radial artery and delayed onset of capillary refill time resulting from windlass-type tourniquets were experimentally investigated by comparing a commercial tourniquet and a space blanket‒improvised tourniquet with a carabiner as a rod. This observational study was conducted on healthy volunteers in optimal application circumstances. RESULTS Operator-applied Combat Application Tourniquets were deployed more swiftly (27 s, 95% CI: 25.7-30.2 vs 94 s, 95% CI: 81.7-114.4) and achieved 100% complete radial occlusion compared with improvised tourniquets, as assessed by Doppler sonography (P<0.001). When space blanket‒improvised tourniquets were used, traces of radial perfusion persisted in 48% of the applications. In Combat Application Tourniquets, capillary refill times were significantly delayed (7 s, 95% CI: 6.0-8.2 vs 5 s, 95% CI: 3.9-6.3) compared with those when using improvised tourniquets (P=0.013). CONCLUSIONS Improvised tourniquets should be considered only in dire circumstances with uncontrolled extremity hemorrhage and when no commercial tourniquets are available. Complete arterial occlusion was achieved in only half of the applications using a space blanket‒improvised tourniquet when a carabiner was used as a windlass rod. The speed of application was inferior to that for Combat Application Tourniquets. Similar to Combat Action Tourniquets, the correct assembly and application of space blanket‒improvised tourniquets on upper and lower extremities have to be trained. TRIAL REGISTRATION ClinicalTrials.gov identifier: BASG No.: 13370800/15451670.
Collapse
Affiliation(s)
- Hannah Salchner
- Department of Anesthesiology and Critical Care Medicine, Medical University of Innsbruck, Innsbruck, Austria; Medical Division, Austrian Mountain Rescue Service-Tyrol, Telfs, Austria
| | - Markus Isser
- Medical Division, Austrian Mountain Rescue Service-Tyrol, Telfs, Austria
| | - Lukas Banyai
- Department of Anesthesiology and Critical Care Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Thomas Schachner
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Franz J Wiedermann
- Department of Anesthesiology and Critical Care Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Wolfgang Lederer
- Department of Anesthesiology and Critical Care Medicine, Medical University of Innsbruck, Innsbruck, Austria.
| |
Collapse
|
2
|
Yánez Benítez C, Lorente-Aznar T, Labaka I, Ribeiro MAF, Viteri Y, Morishita K, Baselga M, Güemes A. Tourniquet self-application assessment in cold weather conditions. BMC Emerg Med 2023; 23:101. [PMID: 37653492 PMCID: PMC10472695 DOI: 10.1186/s12873-023-00871-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 08/17/2023] [Indexed: 09/02/2023] Open
Abstract
BACKGROUND Our study aimed to assess the ability of nonmedical civilians to self-apply extremity tourniquets in cold weather conditions while wearing insulating technical clothing after receiving basic training. METHODS A field study was conducted among 37 voluntary participants of an expedition party to the Spanish Antarctic base. The researchers assessed the participant's ability to self-apply five commercial extremity tourniquets (CAT, OMNA, RMT, SWAT-T, and RATS) over cold-weather clothing and their achieved effectiveness for vascular occlusion. Upper extremity self-application was performed with a single-handed technique (OHT), and lower extremity applying a two-handed technique (THT). Perceptions of self-application ease mean values ± standard deviation (SD) were compared by applying a 5% statistical significance threshold. Frequency count determined tourniquet preference. RESULTS All the tested ETs, except the SWAT-T, were properly self-applied with an OHT, resulting in effective vascular occlusion in the upper extremity. The five devices tested were self-applied correctly in the lower extremities using THT. The ratcheting marine-designed OMNA ranked the highest for application easiness on both the upper and lower extremities, and the windlass CAT model was the preferred device by most participants. CONCLUSIONS Civilian extremity tourniquet self-application on both upper and lower extremities can be accomplished in cold weather conditions despite using cold-weather gloves and technical clothing after receiving brief training. The ratcheting marine-designed OMNA ranked the highest for application ease, and the windlass CAT model was the preferred device.
Collapse
Affiliation(s)
- Carlos Yánez Benítez
- General and GI Surgery Department, San Jorge University Hospital, SALUD, Avenida Martínez de Velasco, 36, Huesca, 22004, Spain.
| | | | - Idurre Labaka
- Emergency Medicine, Donostia University Hospital, C/ Begiristain Doktorea Pasealekua, Donostia, Spain
| | - Marcelo A F Ribeiro
- Division of Trauma, Critical Care, and Acute Care Surgery, Sheikh Shakhbout Medical City, Khalifa University, Abu Dhabi, United Arab Emirates
| | - Yosu Viteri
- Emergency Department, Torrelodones University Hospital, Avenida Castillo Olivares, s/n, Madrid, 28250, Spain
| | - Koji Morishita
- Department of Acute Critical Care and Disaster Medicine, Tokyo Medical and Dental University Hospital of Medicine, Tokyo, Japan
| | - Marta Baselga
- Clinical and Experimental Research Group, Institute for Health Research of Aragón, C/ de San Juan Bosco, 13, Zaragoza, 50009, Spain
| | - Antonio Güemes
- Department of General Surgery, Lozano Blesa University Hospital, Avenida San Juan Bosco, 15, Zaragoza, 50009, Spain
| |
Collapse
|
3
|
The Untrained Public's Ability to Apply the Layperson Audiovisual Assist Tourniquet vs a Combat Application Tourniquet: A Randomized Controlled Trial. J Am Coll Surg 2023; 236:178-186. [PMID: 36165504 DOI: 10.1097/xcs.0000000000000432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND Although the Stop the Bleed campaign's impact is encouraging, gaps remain. These gaps include rapid skill decay, a lack of easy-to-use tourniquets for the untrained public, and training barriers that prevent scalability. A team of academic and industry partners developed the Layperson Audiovisual Assist Tourniquet (LAVA TQ)-the first audiovisual-enabled tourniquet for public use. LAVA TQ addresses known tourniquet application challenges and is novel in its design and technology. STUDY DESIGN This study is a prospective, randomized, superiority trial comparing the ability of the untrained public to apply LAVA TQ to a simulated leg vs their ability to apply a Combat Application Tourniquet (CAT). The study team enrolled participants in Boston, MA; Frederick, MD; and Linköping, Sweden in 2022. The primary outcome was the proportion of successful applications of each tourniquet. Secondary outcomes included: mean time to application, placement position, reasons for failed application, and comfort with the devices. RESULTS Participants applied the novel LAVA TQ successfully 93% (n = 66 of 71) of the time compared with 22% (n = 16 of 73) success applying CAT (relative risk 4.24 [95% CI 2.74 to 6.57]; p < 0.001). Participants applied LAVA TQ faster (74.1 seconds) than CAT (126 seconds ; p < 0.001) and experienced a greater gain in comfort using LAVA TQ than CAT. CONCLUSIONS The untrained public is 4 times more likely to apply LAVA TQ correctly than CAT. The public also applies LAVA TQ faster than CAT and has more favorable opinions about its usability. LAVA TQ's highly intuitive design and built-in audiovisual guidance solve known problems of layperson education and skill retention and could improve public bleeding control.
Collapse
|
4
|
Precise Limb Tourniquet Arterial Occlusion Pressure Determination using Real-Time Ultrasonography and a Capacitive-Based Force Sensor. Prehosp Disaster Med 2022; 37:772-777. [PMID: 36254701 DOI: 10.1017/s1049023x2200142x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Hemorrhage control prior to shock onset is increasingly recognized as a time-critical intervention. Although tourniquets (TQs) have been demonstrated to save lives, less is known about the physiologic parameters underlying successful TQ application beyond palpation of distal pulses. The current study directly visualized distal arterial occlusion via ultrasonography and measured associated pressure and contact force. METHODS Fifteen tactical officers participated as live models for the study. Arterial occlusion was performed using a standard adult blood pressure (BP) cuff and a Combat Application Tourniquet Generation 7 (CAT7) TQ, applied sequentially to the left mid-bicep. Arterial flow cessation was determined by radial artery palpation and brachial artery pulsed wave doppler ultrasound (US) evaluation. Steady state maximal generated force was measured using a thin-film force sensor. RESULTS The mean (95% CI) systolic blood pressure (SBP) required to occlude palpable distal pulse was 112.9mmHg (109-117); contact force was 23.8N [Newton] (22.0-25.6). Arterial flow was visible via US in 100% of subjects despite lack of palpable pulse. The mean (95% CI) SBP and contact force to eliminate US flow were 132mmHg (127-137) and 27.7N (25.1-30.3). The mean (95% CI) number of windlass turns to eliminate a palpable pulse was 1.3 (1.0-1.6) while 1.6 (1.2-1.9) turns were required to eliminate US flow. CONCLUSIONS Loss of distal radial pulse does not indicate lack of arterial flow distal to upper extremity TQ. On average, an additional one-quarter windlass turn was required to eliminate distal flow. Blood pressure and force measurements derived in this study may provide data to guide future TQ designs and inexpensive, physiologically accurate TQ training models.
Collapse
|
5
|
Stop the Bleed®. Curr Probl Surg 2022; 59:101193. [DOI: 10.1016/j.cpsurg.2022.101193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
6
|
Nichols R, Horstman J. Recommendations for Improving Stop the Bleed: A Systematic Review. Mil Med 2022; 187:e1338-e1345. [PMID: 35084491 DOI: 10.1093/milmed/usac019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 12/28/2021] [Accepted: 01/24/2022] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION In response to mass casualty events, The Hartford Consensus brought together subject matter experts across multiple disciplines in health care and public safety to create guidelines and publications intended to improve survivability in active shooter events. Among the recommendations was the earlier recognition and treatment application of life-threatening hemorrhage control. These recommendations culminated in efforts to create the Stop the Bleed Campaign, which aims to empower the layperson to render aid in a life-threatening bleeding emergency. As of February 2020, the program has held over 86,000 courses, trained over 1.4 million attendees, and over 77,000 instructors since its inception. In addition to spreading within the United States, American College of Surgeons (ACS) Stop the Bleed (StB) classes have been held in 118 different countries. This systematic narrative review aims to answer the following research question: What does the ACS StB Initiative do well, and where can it improve? MATERIALS AND METHODS The following search terms were utilized: "Stop the Bleed," "American College of Surgeons," "bleeding control," "first-aid," tourniquet, "wound pack," "direct pressure" hemorrhage, and bystander. The inclusion criteria were that the article needed to speak to the program or some aspect of bystander first aid, the article needed to be in a civilian setting, the article needed to be more than a case study or overview, and the first aid tools needed to be in the StB curriculum. 4 databases were searched, which produced 138 articles for screening. One hundred four full-text articles were able to be retrieved, and 56 articles were determined to meet the inclusion criteria once the full text was reviewed. RESULTS Fifty-six articles were included in the final review and were placed into the following categories: Needs Within the Community, Confidence and Knowledge, Training Modalities, Barriers and Gaps in Training, Instructor Selection, Skill Retention, and Patient Outcomes. The articles were then organized into each outcome for synthesis and reporting of the results. The program overwhelmingly improves short-term confidence, but gaps in skill retention, data collection on patient outcomes, and settings that would benefit were identified. CONCLUSION StB is an effective tool in building confidence in laypersons, which is its biggest strength. A review of the literature shows several areas where the curriculum and materials could be better developed. Research can also be further refined to better quantify the program's impact.
Collapse
Affiliation(s)
- Ryoma Nichols
- Elson S. Floyd College of Medicine, Washington State University, Spokane, WA 99202-2131, USA
| | - Jordan Horstman
- Kansas City University School of Osteopathic Medicine, Kansas City University, Kansas City, MO 64106, USA
| |
Collapse
|
7
|
Sidwell RA, Spilman SK, Feist B, Fuchsen EA, Taber PS, Pelaez CA. Hemorrhage Control Training: Preparing Adolescents to Act at Home, at School, or in Public. Pediatr Emerg Care 2022; 38:4-8. [PMID: 32530841 DOI: 10.1097/pec.0000000000002164] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Uncontrolled bleeding is the leading cause of preventable death after a traumatic event, and early intervention to control bleeding improves opportunities for survival. It is imperative to prepare for local and national disasters by increasing public knowledge on how to control bleeding, and this preparation should extend to both adults and children. The purpose of this study is to describe a training effort to teach basic hemorrhage control techniques to early adolescent children. METHODS The trauma and emergency departments at a combined level I adult and level II pediatric trauma center piloted a training initiative with early adolescents (grades 6-8) focused on 2 skills: packing a wound and holding direct pressure, and applying a Combat Application Tourniquet. Students were evaluated on each skill and completed presurveys and postsurveys indicating their likelihood to use the skills. RESULTS Of the 194 adolescents who participated in the trainings, 97% of the students could successfully pack a wound and hold pressure, and 97% of the students could apply a tourniquet. Before the training, 71% of the adolescents indicated that they would take action to assist a bleeding victim; this increased to 96% after the training. CONCLUSIONS Results demonstrate that basic hemorrhage control skills can be effectively taught to adolescents as young as 6th grade (ages 11-12 years) in a small setting with age-appropriate content and hands-on opportunities to practice the skills and such training increases students' perceived willingness to take action to assist a bleeding victim.
Collapse
|
8
|
Schlanser VL, Tatebe LC, Karalius VP, Liesen E, Pekarek S, Impens A, Ivkovic K, Bajani F, Khalifa A, Dennis AJ. The Windlass Tourniquet: Is It Taking the Wind Out of the "Stop the Bleed" Sails? J Surg Res 2021; 271:91-97. [PMID: 34856457 DOI: 10.1016/j.jss.2021.09.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 09/07/2021] [Accepted: 09/22/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Civilians are often first-line responders in hemorrhage control; however, windlass tourniquets are not intuitive. Untrained users reading enclosed instructions failed in 38.2% of tourniquet applications. This prospective follow-up study replicated testing following Stop the Bleed (STB) training. MATERIALS AND METHODS One and six months following STB, first-year medical students were randomly assigned a windlass tourniquet with enclosed instructions. Each was given one minute to read instructions and two minutes to apply the windlass tourniquet on the TraumaFX HEMO trainer. Demographics, time to read instructions and stop bleeding, blood loss, and simulation success were analyzed. RESULTS 100 students received STB training. 31 and 34 students completed tourniquet testing at one month and six months, respectively. At both intervals, 38% of students were unable to control hemorrhage (P = 0.97). When compared to the pilot study without STB training (median 48 sec, IQR 33-60 sec), the time taken to read the instructions was shorter one month following STB (P <0.001), but there was no difference at 6 months (P = 0.1). Incorrect placement was noted for 19.4% and 23.5% of attempts at 1 and 6 months. Male participants were more successful in effective placement at one month (93.3% versus 31.3%, P = 0.004) and at six months (77.8% versus 43.8%, p = 0.04). CONCLUSIONS Skills decay for tourniquet application was observed between 1 and 6 months following STB. Instruction review and STB produced the same hemorrhage control rates as reading enclosed instructions without prior training. Training efforts must continue; but an intuitive tourniquet relying less on mechanical advantage is needed.
Collapse
Affiliation(s)
- Victoria L Schlanser
- Department of Trauma and Burn Surgery, Cook County Health, Chicago, Illinois; Department of Surgery, Midwestern University, Downers Grove, Illinois; Department of Surgery, Rush University, Chicago, Illinois.
| | - Leah C Tatebe
- Department of Trauma and Burn Surgery, Cook County Health, Chicago, Illinois; Department of Surgery, Midwestern University, Downers Grove, Illinois; Department of Surgery, Rush University, Chicago, Illinois
| | - Vytas P Karalius
- Department of Trauma and Burn Surgery, Cook County Health, Chicago, Illinois; Department of Emergency Medicine, Northwestern University, Chicago, Illinois
| | - Erik Liesen
- Department of Trauma and Burn Surgery, Cook County Health, Chicago, Illinois; Department of Surgery, Midwestern University, Downers Grove, Illinois
| | - Sydney Pekarek
- Department of Trauma and Burn Surgery, Cook County Health, Chicago, Illinois; Department of Surgery, Midwestern University, Downers Grove, Illinois
| | - Ann Impens
- Institute for Healthcare Innovation, Midwestern University, Downers Grove, Illinois
| | - Katarina Ivkovic
- Institute for Healthcare Innovation, Midwestern University, Downers Grove, Illinois
| | - Francesco Bajani
- Department of Trauma and Burn Surgery, Cook County Health, Chicago, Illinois
| | - Andrew Khalifa
- Department of Trauma and Burn Surgery, Cook County Health, Chicago, Illinois
| | - Andrew J Dennis
- Department of Trauma and Burn Surgery, Cook County Health, Chicago, Illinois; Department of Surgery, Midwestern University, Downers Grove, Illinois; Department of Surgery, Rush University, Chicago, Illinois
| |
Collapse
|
9
|
Matinrad N, Reuter-Oppermann M. A review on initiatives for the management of daily medical emergencies prior to the arrival of emergency medical services. CENTRAL EUROPEAN JOURNAL OF OPERATIONS RESEARCH 2021; 30:251-302. [PMID: 34566490 PMCID: PMC8449697 DOI: 10.1007/s10100-021-00769-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/28/2021] [Indexed: 05/31/2023]
Abstract
Emergency services worldwide face increasing cost pressure that potentially limits their existing resources. In many countries, emergency services also face the issues of staff shortage-creating extra challenges and constraints, especially during crisis times such as the COVID-19 pandemic-as well as long distances to sparsely populated areas resulting in longer response times. To overcome these issues and potentially reduce consequences of daily (medical) emergencies, several countries, such as Sweden, Germany, and the Netherlands, have started initiatives using new types of human resources as well as equipment, which have not been part of the existing emergency systems before. These resources are employed in response to medical emergency cases if they can arrive earlier than emergency medical services (EMS). A good number of studies have investigated the use of these new types of resources in EMS systems, from medical, technical, and logistical perspectives as their study domains. Several review papers in the literature exist that focus on one or several of these new types of resources. However, to the best of our knowledge, no review paper that comprehensively considers all new types of resources in emergency medical response systems exists. We try to fill this gap by presenting a broad literature review of the studies focused on the different new types of resources, which are used prior to the arrival of EMS. Our objective is to present an application-based and methodological overview of these papers, to provide insights to this important field and to bring it to the attention of researchers as well as emergency managers and administrators.
Collapse
Affiliation(s)
- Niki Matinrad
- Department of Science and Technology, Linköping University, Norrköping, 60174 Sweden
| | - Melanie Reuter-Oppermann
- Information Systems - Software and Digital Business Group, Technical University of Darmstadt, 64289 Darmstadt, Germany
| |
Collapse
|
10
|
Mikdad S, Mokhtari AK, Luckhurst CM, Breen KA, Liu B, Kaafarani HMA, Velmahos G, Mendoza AE, Bloemers FW, Saillant N. Implications of the national Stop the Bleed campaign: The swinging pendulum of prehospital tourniquet application in civilian limb trauma. J Trauma Acute Care Surg 2021; 91:352-360. [PMID: 33901049 DOI: 10.1097/ta.0000000000003247] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Prehospital tourniquet (PHT) utilization has increased in response to mass casualty events. We aimed to describe the incidence, therapeutic effectiveness, and morbidity associated with tourniquet placement in all patients treated with PHT application. METHODS A retrospective observational cohort study was performed to evaluate all adults with a PHT who presented at two Level I trauma centers between January 2015 and December 2019. Medically trained abstractors determined if the PHT was clinically indicated (placed for limb amputation, vascular hard signs, injury requiring hemostasis procedure, or significant documented blood loss). Prehospital tourniquets were further designated as appropriately or inappropriately applied (based on PHT anatomic placement location, occurrence of a venous tourniquet, or ischemic time defined as >2 hours). Statistical analyses were performed to generate primary and secondary results. RESULTS A total of 147 patients met study inclusion criteria, of which 70% met the criteria for trauma registry inclusion. Total incidence of PHT utilization increased from 2015 to 2019, with increasing proportions of PHTs placed by nonemergency medical service personnel. Improvised PHTs were frequently used. Prehospital tourniquets were clinically indicated in 51% of patients. Overall, 39 (27%) patients had a PHT that was inappropriately placed, five of which resulted in significant morbidity. CONCLUSION In summary, prehospital tourniquet application has become widely adopted in the civilian setting, frequently performed by civilian and nonemergency medical service personnel. Of PHTs placed, nearly half had no clear indication for placement and over a quarter of PHTs were misapplied with notable associated morbidity. Results suggest that the topics of clinical indication and appropriate application of tourniquets may be important areas for continued focus in future tourniquet educational programs, as well as future quality assessment efforts. LEVEL OF EVIDENCE Epidemiological, level III; Therapeutic, level IV.
Collapse
Affiliation(s)
- Sarah Mikdad
- From the Division of Trauma, Emergency Surgery and Surgical Critical Care (S.M., A.K.M., C.M.L., K.A.B., B.L., H.M.A.K., G.V., A.E.M., N.S.), Massachusetts General Hospital, Boston, Harvard Medical School, Boston, Massachusetts; and Department of Trauma Surgery (S.M., F.W.B.), Amsterdam UMC, Amsterdam, the Netherlands
| | | | | | | | | | | | | | | | | | | |
Collapse
|
11
|
Roman P, Rodriguez-Alvarez A, Bertini-Perez D, Ropero-Padilla C, Martin-Ibañez L, Rodriguez-Arrastia M. Tourniquets as a haemorrhage control measure in military and civilian care settings: An integrative review. J Clin Nurs 2021. [PMID: 33969561 DOI: 10.1111/jocn.15834] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 04/14/2021] [Accepted: 04/19/2021] [Indexed: 11/30/2022]
Abstract
AIMS AND OBJECTIVES The aim of review was to describe and synthesise the evidence on the use of tourniquets to control haemorrhages, summarising both civilian and military use. BACKGROUND Trauma-related haemorrhage constitutes one of the most preventable deaths among injured patients, particularly in multi-casualty incidents and disasters. In this context, safe instruments such as tourniquets are essential to help healthcare professionals to minimise loss of life and maximise patient recovery. DESIGN AND METHODS An integrative review was conducted in Medline, Nursing & Allied Health Premium, and Health & Medical Collection, using published data until March 2021 and following the PRISMA guidelines. RESULTS A total of 25 articles were included. Evidence has been synthesised to understand the use of different types of tourniquets, environment of application, indication for their placement and potential complications associated with tourniquet placement. CONCLUSIONS Commercial tourniquets such as Combat Application Tourniquet or Emergency Tourniquet models are a valuable and safe instrument for haemorrhage control in both military and civilian out-of-hospital care settings. Nurses, as part of emergency teams, and other professionals should be aware that there is a possibility of adverse complications, but they are directly proportional to the time of tourniquet placement and generally temporary. In addition, national and international guidelines ensure the need for all civilian emergency services to be equipped with these devices, as well as for the training of healthcare professionals and first responders in their use. RELEVANCE TO CLINICAL PRACTICE Despite the lack of complications in the use of tourniquets in these cases, their use has been a matter of debate for decades. In this sense, this review yields up-to-date guidelines in the use of tourniquets, their recommendations and their significance among professionals to manage complicated situations.
Collapse
Affiliation(s)
- Pablo Roman
- Faculty of Health Sciences, Department of Nursing Science, Physiotherapy and Medicine, University of Almeria, Almeria, Spain
- Research Group CTS-451 Health Sciences, University of Almeria, Almeria, Spain
- Health Research Centre, University of Almeria, Almeria, Spain
| | | | | | - Carmen Ropero-Padilla
- Faculty of Health Sciences, Pre-Department of Nursing, Jaume I University, Castellon de la Plana, Spain
- Research Group CYS, Faculty of Health Sciences, Jaume I University, Castello de la Plana, Spain
| | - Luis Martin-Ibañez
- Field Artillery Group, Light Infantry Brigade "King Alfonso XIII" II of the Legion, Almeria, Spain
| | - Miguel Rodriguez-Arrastia
- Faculty of Health Sciences, Pre-Department of Nursing, Jaume I University, Castellon de la Plana, Spain
- Research Group CYS, Faculty of Health Sciences, Jaume I University, Castello de la Plana, Spain
| |
Collapse
|
12
|
El Bashtaly A, Khalil E, Méthot F, Ledoux-Hutchinson L, Franc JM, Homier V. Tourniquet application by schoolchildren-a randomized crossover study of three commercially available models. J Trauma Acute Care Surg 2021; 90:666-672. [PMID: 33405474 DOI: 10.1097/ta.0000000000003055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Life-threatening hemorrhage is a major cause of preventable mortality in trauma. Studies have demonstrated the effectiveness and safety of commercial tourniquets when used by adult civilians. However, there are no data about tourniquet application by children.This study's goal is to determine which of three commercially available tourniquets is most effective when used by children. METHODS A randomized crossover study was conducted in four elementary schools in Montreal to compare three commercially available tourniquets. The study population is primary school children aged 10 to 12 years (5th-6th grade). A total of 181 students were invited to participate; 96 obtained parental approval and were recruited. Participants underwent a short 7-minute video training on the use of three commercial tourniquets and were subsequently given a 2-minute practice period. Students were evaluated on their ability to successfully apply the tourniquet and the time to complete application. After applying all three tourniquets, the students selected their favorite model. The primary outcome is the proportion of successful applications per tourniquet model. Secondary outcomes include time to successful application for each tourniquet model and tourniquet model preference. RESULTS The mechanical advantage tourniquet (MAT) outperformed the combat application tourniquet (CAT) and the stretch wrap and tuck tourniquet (SWATT) in terms of success rate (MAT, 67%; CAT, 44%; SWATT, 24%; p < 0.0001), time to application (MAT, 57 seconds; CAT, 80 seconds; SWATT, 90 seconds; p < 0.0001), and preference (MAT, 64%; CAT, 30%; SWATT, 6%; p < 0.0001). CONCLUSION In this study, the MAT performs better in terms of success rate, time to application, and preference when used by school-aged children. This study can be helpful when facilities are purchasing tourniquets for use by students.
Collapse
Affiliation(s)
- Alaa El Bashtaly
- From the Faculty of Medicine (A.E.B., F.M., L.L.-H.), Université de Montreal; Pediatric Emergency Medicine (E.K.), Montreal Children's Hospital, Montreal, Quebec; Faculty of Medicine (J.M.F.), University of Alberta, Edmonton, Alberta; and Adult Emergency Medicine (V.H.), McGill University Health Centre, Montreal, Quebec, Canada
| | | | | | | | | | | |
Collapse
|
13
|
Goolsby C, Rojas LE, Rodzik RH, Gausche-Hill M, Neal MD, Levy MJ. High-School Students Can Stop the Bleed: A Randomized, Controlled Educational Trial. Acad Pediatr 2021; 21:321-328. [PMID: 32473216 DOI: 10.1016/j.acap.2020.05.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 05/15/2020] [Accepted: 05/19/2020] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To determine high-school students' ability to learn hemorrhage control skills and knowledge via 3 educational modalities. BACKGROUND Trauma is the leading cause of death for young Americans, and there are calls to teach children about hemorrhage control. However, little is known about adolescents' ability to perform hemorrhage control, and the ideal way(s) to teach them. METHODS This randomized controlled trial enrolled high-school students from 39 states at a 2019 national conference. After answering questions about their willingness to use tourniquets, participants received hemorrhage control education in 1 of 3 formats: instructor-led, web-only, or blended (combining web and instructor-led). Participants were then assessed on their ability to apply a tourniquet and to identify wounds that require a tourniquet. Finally, they completed an attitude questionnaire. RESULTS Two hundred and four (82%) of 248 participants applied a tourniquet correctly: 72 (88%) instructor-led, 50 (61%) web-only, and 79 (94%) blended. The instructor-led and blended arms were superior to the web-only arm (P < .001). Nearly all participants passed an assessment requiring them to identify wounds warranting a tourniquet (99% instructor-led and blended, and 98% web-only). All modalities improved participants' self-reported willingness and comfort in using tourniquets (P < .001). CONCLUSIONS This is the first study to demonstrate that high-school students can learn hemorrhage control via multiple methods. Blended and instructor-led education led to highly successful skill performance. Students learned to identify wounds requiring tourniquets and showed an improved willingness to aid from all modalities. These findings should encourage educators to offer multiple educational modalities.
Collapse
Affiliation(s)
- Craig Goolsby
- Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences (C Goolsby), Bethesda, Md; National Center for Disaster Medicine and Public Health (C Goolsby, LE Rojas, and RH Rodzik), Rockville, Md.
| | - Luis E Rojas
- National Center for Disaster Medicine and Public Health (C Goolsby, LE Rojas, and RH Rodzik), Rockville, Md; The Henry M. Jackson Foundation for the Advancement of Military Medicine (LE Rojas and RH Rodzik), Bethesda, Md
| | - Raphaelle H Rodzik
- National Center for Disaster Medicine and Public Health (C Goolsby, LE Rojas, and RH Rodzik), Rockville, Md; The Henry M. Jackson Foundation for the Advancement of Military Medicine (LE Rojas and RH Rodzik), Bethesda, Md
| | - Marianne Gausche-Hill
- Los Angeles County Emergency Medical Services Agency (M Gausche-Hill), Los Angeles, Calif; Departments of Emergency Medicine and Pediatrics, David Geffen School of Medicine at the University of California (M Gausche-Hill), Los Angeles, Calif; Departments of Emergency Medicine and Pediatrics, Harbor-UCLA Medical Center (M Gausche-Hill), Torrance, Calif
| | - Matthew D Neal
- Departments of Surgery, Critical Care Medicine, and the Clinical and Translational Science Institute (CTSI), University of Pittsburgh (MD Neal), Pittsburgh, Pa; University of Pittsburgh Medical Center (MD Neal), Pittsburgh, Pa
| | - Matthew J Levy
- Department of Emergency Medicine, Johns Hopkins University School of Medicine (MJ Levy), Baltimore, Md; Howard County Department of Fire and Rescue Services (MJ Levy), Columbia, Md
| |
Collapse
|
14
|
Villegas CV, Gupta A, Liu S, Curren J, Rosenberg J, Barie PS, Winchell RJ, Narayan M. Stop the Bleed: Effective Training in Need of Improvement. J Surg Res 2020; 255:627-631. [PMID: 32659538 DOI: 10.1016/j.jss.2020.02.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 01/22/2020] [Accepted: 02/02/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND The "Stop the Bleed" (StB) campaign aims to educate laypersons on performing bleeding control techniques in any setting that requires hemorrhage control, such as motor vehicle crashes or mass casualty incidents. Participants undergo a didactic and practical session, the latter incorporating a mannequin. We hypothesized that participants would increase content knowledge after StB participation and that the training could be improved by a more life-like bleeding modification of the mannequin. MATERIALS AND METHODS From July 2017 to January 2018, hospital and community members from a major metropolitan area participated in StB training. Participants provided demographic data regarding prior emergency training and were asked pre- and post-test questions (five-point Likert scale) regarding their response to hemorrhage. Individuals also evaluated the mannequin on bleeding simulation. Scores were reported as means with standard deviation or medians with interquartile ranges (IQRs) with subset analysis stratified by experience. RESULTS Of 402 participants, 310 provided complete data. On the composite, pre-test self-assessment, participants had a median score of 24 of 30 points (IQR 16-30). Post-testing demonstrated a statistically significant increase with a median score of 29 (IQR 25-30, P < 0.05). Subset analysis by prior emergency training (n = 102) demonstrated that both those with prior emergency training and those with no prior emergency training had significant improvement. On evaluation of the mannequin, participants reported that a more realistic model would increase their confidence in technique. Both subgroups reported that training would be enhanced if the mannequins were more realistic. CONCLUSIONS StB is an effective education program. Those without prior experience or training in hemorrhage cessation demonstrated the most improvement. Regardless of background, participants reported overwhelmingly that the training would be more effective if it were more realistic. Future work to design and develop cost-effective mannequins demonstrating pulsatile blood flow and cessation of hemorrhage could enable learners to actually "Stop the Bleed".
Collapse
Affiliation(s)
- Cassandra V Villegas
- Division of Trauma, Department of Surgery, Burns, Acute and Critical Care, Weill Cornell Medicine, New York, New York
| | - Aakanksha Gupta
- Division of Trauma, Department of Surgery, Burns, Acute and Critical Care, Weill Cornell Medicine, New York, New York
| | - Susan Liu
- Department of Nursing, New York-Presbyterian Hospital / Weill Cornell Medical Center, New York, New York
| | - Jeffrey Curren
- Department of Nursing, New York-Presbyterian Hospital / Weill Cornell Medical Center, New York, New York
| | - Jay Rosenberg
- Division of Trauma, Department of Surgery, Burns, Acute and Critical Care, Weill Cornell Medicine, New York, New York
| | - Philip S Barie
- Division of Trauma, Department of Surgery, Burns, Acute and Critical Care, Weill Cornell Medicine, New York, New York; Division of Medical Ethics, Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Robert J Winchell
- Division of Trauma, Department of Surgery, Burns, Acute and Critical Care, Weill Cornell Medicine, New York, New York
| | - Mayur Narayan
- Division of Trauma, Department of Surgery, Burns, Acute and Critical Care, Weill Cornell Medicine, New York, New York.
| |
Collapse
|
15
|
McCarty JC, Hashmi ZG, Herrera-Escobar JP, de Jager E, Chaudhary MA, Lipsitz SR, Jarman M, Caterson EJ, Goralnick E. Effectiveness of the American College of Surgeons Bleeding Control Basic Training Among Laypeople Applying Different Tourniquet Types: A Randomized Clinical Trial. JAMA Surg 2020; 154:923-929. [PMID: 31339533 DOI: 10.1001/jamasurg.2019.2275] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Importance More than 500 000 laypeople in the United States have been trained in hemorrhage control, including tourniquet application, under the Stop the Bleed campaign. However, it is unclear whether after hemorrhage control training participants become proficient in a specific type of tourniquet or can also use other tourniquets effectively. Objective To assess whether participants completing the American College of Surgeons Bleeding Control Basic (B-Con) training with Combat Application Tourniquets (CATs) can effectively apply bleeding control principles using other tourniquet types (commercial and improvised). Design, Setting, and Participants This nonblinded, crossover, sequential randomized clinical trial with internal control assessed a volunteer sample of laypeople who attended a B-Con course at Gillette Stadium and the Longwood Medical Area in Boston, Massachusetts, for correct application of each of 5 different tourniquet types immediately after B-Con training from April 4, 2018, to October 9, 2018. The order of application varied for each participant using randomly generated permutated blocks. Interventions Full B-Con course, including cognitive and skill sessions, that taught bleeding care, wound pressure and packing, and CAT application. Main Outcomes and Measures Correct tourniquet application (applied pressure of ≥250 mm Hg with a 2-minute time cap) in a simulated scenario for 3 commercial tourniquets (Special Operation Forces Tactical Tourniquet, Stretch-Wrap-and-Tuck Tourniquet, and Rapid Application Tourniquet System) and improvised tourniquet compared with correct CAT application as an internal control using 4 pairwise Bonferroni-corrected comparisons with the McNemar test. Results A total of 102 participants (50 [49.0%] male; median [interquartile range] age, 37.5 [27.0-53.0] years) were included in the study. Participants correctly applied the CAT at a significantly higher rate (92.2%) than all other commercial tourniquet types (Special Operation Forces Tactical Tourniquet, 68.6%; Stretch-Wrap-and-Tuck Tourniquet, 11.8%; Rapid Application Tourniquet System, 11.8%) and the improvised tourniquet (32.4%) (P < .001 for each pairwise comparison). When comparing tourniquets applied correctly, all tourniquet types had higher estimated blood loss, had longer application time, and applied less pressure than the CAT. Conclusions and Relevance The B-Con principles for correct CAT application are not fully translatable to other commercial or improvised tourniquet types. This study demonstrates a disconnect between the B-Con course and tourniquet designs available for bystander first aid, potentially stemming from the lack of consensus guidelines. These results suggest that current B-Con trainees may not be prepared to care for bleeding patients as tourniquet design evolves. Trial Registration ClinicalTrials.gov identifier: NCT03538379.
Collapse
Affiliation(s)
- Justin C McCarty
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Zain G Hashmi
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Juan P Herrera-Escobar
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Elzerie de Jager
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Muhammad Ali Chaudhary
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Stuart R Lipsitz
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Molly Jarman
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Edward J Caterson
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Eric Goralnick
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
16
|
Goralnick E, Ezeibe C, Chaudhary MA, McCarty J, Herrera-Escobar JP, Andriotti T, de Jager E, Ospina-Delgado D, Goolsby C, Hunt R, Weissman JS, Haider A, Jacobs L, Andrade E, Brown J, Bulger EM, Butler FK, Callaway D, Caterson EJ, Choudhry NK, Davis MR, Eastman A, Eastridge BJ, Epstein JL, Evans CL, Gausche-Hill M, Gestring ML, Goldberg SA, Hanfling D, Holcomb JB, Jonson CO, King DR, Kivlehan S, Kotwal RS, Krohmer JR, Levy-Carrick N, Levy M, Meléndez Lugo JJ, Mooney DP, Neal MD, Niskanen R, O'Neill P, Park H, Pons PT, Prytz E, Rasmussen TE, Remley MA, Riviello R, Salim A, Shackelfold S, Smith ER, Stewart RM, Swaroop M, Ward K, Uribe-Leitz T, Jarman MP, Ortega G. Defining a Research Agenda for Layperson Prehospital Hemorrhage Control: A Consensus Statement. JAMA Netw Open 2020; 3:e209393. [PMID: 32663307 DOI: 10.1001/jamanetworkopen.2020.9393] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
IMPORTANCE Trauma is the leading cause of death for US individuals younger than 45 years, and uncontrolled hemorrhage is a major cause of trauma mortality. The US military's medical advancements in the field of prehospital hemorrhage control have reduced battlefield mortality by 44%. However, despite support from many national health care organizations, no integrated approach to research has been made regarding implementation, epidemiology, education, and logistics of prehospital hemorrhage control by layperson immediate responders in the civilian sector. OBJECTIVE To create a national research agenda to help guide future work for prehospital hemorrhage control by laypersons. EVIDENCE REVIEW The 2-day, in-person, National Stop the Bleed (STB) Research Consensus Conference was conducted on February 27 to 28, 2019, to identify and achieve consensus on research gaps. Participants included (1) subject matter experts, (2) professional society-designated leaders, (3) representatives from the federal government, and (4) representatives from private foundations. Before the conference, participants were provided a scoping review on layperson prehospital hemorrhage control. A 3-round modified Delphi consensus process was conducted to determine high-priority research questions. The top items, with median rating of 8 or more on a Likert scale of 1 to 9 points, were identified and became part of the national STB research agenda. FINDINGS Forty-five participants attended the conference. In round 1, participants submitted 487 research questions. After deduplication and sorting, 162 questions remained across 5 a priori-defined themes. Two subsequent rounds of rating generated consensus on 113 high-priority, 27 uncertain-priority, and 22 low-priority questions. The final prioritized research agenda included the top 24 questions, including 8 for epidemiology and effectiveness, 4 for materials, 9 for education, 2 for global health, and 1 for health policy. CONCLUSIONS AND RELEVANCE The National STB Research Consensus Conference identified and prioritized a national research agenda to support laypersons in reducing preventable deaths due to life-threatening hemorrhage. Investigators and funding agencies can use this agenda to guide their future work and funding priorities.
Collapse
Affiliation(s)
- Eric Goralnick
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Chibuike Ezeibe
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Muhammad Ali Chaudhary
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Justin McCarty
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Juan P Herrera-Escobar
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Tomas Andriotti
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Elzerie de Jager
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | | | - Craig Goolsby
- Department of Military and Emergency Medicine, Uniformed Services University, Bethesda, Maryland
- National Center for Disaster Medicine and Public Health, Rockville, Maryland
| | - Richard Hunt
- National Health Care Preparedness Program, Department of Health and Human Services, Washington, DC
| | - Joel S Weissman
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Adil Haider
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
- Office of the Dean, Medical School, Aga Khan University, Karachi, Pakistan
| | - Lenworth Jacobs
- Department of Surgery, Hartford Hospital, Hartford, Connecticut
| | | | - Erin Andrade
- Department of Surgery, Washington University in St Louis, Missouri
| | - Jeremy Brown
- Department of Emergency Medicine, George Washington University School of Medicine, Washington, DC
| | | | - Frank K Butler
- Defense Health Agency, Joint Trauma System, Joint Base San Antonio-Fort Sam Houston, Texas
| | - David Callaway
- Department of Emergency Medicine, Carolinas Medical Center, Atrium Health, Charlotte, North Carolina
| | - Edward J Caterson
- Division of Plastic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Niteesh K Choudhry
- Center for Healthcare Delivery Sciences, Harvard Medical School, Boston, Massachusetts
| | - Michael R Davis
- Combat Casualty Care Research Program Army Medical Research and Materiel Command, Fort Detrick, Maryland
| | - Alex Eastman
- Countering Weapons of Mass Destruction Office Department of Homeland Security, Washington, DC
| | - Brian J Eastridge
- Department of Surgery, The University of Texas Health Science Center at San Antonio
| | - Jonathan L Epstein
- Training Services Division, American Red Cross, American Red Cross, Washington, DC
| | - Conor L Evans
- Wellman Center for Photomedicine, Massachusetts General Hospital, Boston
| | - Marianne Gausche-Hill
- Department of Emergency Medicine, Harbor-University of California, Los Angeles Medical Center, Torrance
| | - Mark L Gestring
- Department of Surgery, Rochester Medical Center, Rochester, New York
| | - Scott A Goldberg
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Dan Hanfling
- Forum on Medical and Public Health Preparedness for Catastrophic Events, National Academies of Science, Washington, DC
| | | | - Carl-Oscar Jonson
- Center for Disaster Medicine and Traumatology, Linköping University, Linköping, Sweden
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - David R King
- Department of Surgery, Massachusetts General Hospital, Boston
| | - Sean Kivlehan
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Russ S Kotwal
- Joint Trauma System, Defense Health Agency Combat Support, San Antonio, Texas
| | - Jon R Krohmer
- Office of Emergency Medical Services, National Highway Traffic Safety Administration, Washington, DC
| | - Nomi Levy-Carrick
- Department of Psychiatry, Brigham and Women's Hospital, Boston, Massachusetts
| | - Matthew Levy
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - David P Mooney
- Department of Surgery, Boston Children's Hospital, Boston, Massachusetts
| | - Matthew D Neal
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | | | - Habeeba Park
- Department of Surgery, University of Maryland Shock Trauma Center, Baltimore
| | - Peter T Pons
- Department of Emergency Medicine, University of Colorado School of Medicine, Denver
| | - Erik Prytz
- Department of Computer and Information Science, Linköping University, Linköping, Sweden
| | - Todd E Rasmussen
- Department of Surgery, F. Edward Hébert School of Medicine Uniformed Services University, Bethesda, Maryland
| | - Michael A Remley
- Joint Trauma System, Defense Health Agency Combat Support, San Antonio, Texas
| | - Robert Riviello
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Ali Salim
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Stacy Shackelfold
- Joint Trauma System, Defense Health Agency Combat Support, San Antonio, Texas
| | - E Reed Smith
- Department of Emergency Medicine, George Washington University School of Medicine, Washington, DC
| | - Ronald M Stewart
- Department of Surgery, The University of Texas Health Science Center at San Antonio
| | - Mamta Swaroop
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Kevin Ward
- Department of Emergency Medicine, University of Michigan, Ann Arbor
- Department of Biomedical Engineering, University of Michigan, Ann Arbor
| | | | - Molly P Jarman
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Gezzer Ortega
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| |
Collapse
|
17
|
The Efficacy of Novel Commercial Tourniquet Designs for Extremity Hemorrhage Control: Implications for Spontaneous Responder Every Day Carry. Prehosp Disaster Med 2020; 35:276-280. [DOI: 10.1017/s1049023x2000045x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractIntroduction:Tourniquets (TQs) save lives. Although military-approved TQs appear more effective than improvised TQs in controlling exsanguinating extremity hemorrhage, their bulk may preclude every day carry (EDC) by civilian lay-providers, limiting availability during emergencies.Study Objective:The purpose of the current study was to compare the efficacy of three novel commercial TQ designs to a military-approved TQ.Methods:Nine Emergency Medicine residents evaluated four different TQ designs: Gen 7 Combat Application Tourniquet (CAT7; control), Stretch Wrap and Tuck Tourniquet (SWAT-T), Gen 2 Rapid Application Tourniquet System (RATS), and Tourni-Key (TK). Popliteal artery flow cessation was determined using a ZONARE ZS3 ultrasound. Steady state maximal generated force was measured for 30 seconds with a thin-film force sensor.Results:Success rates for distal arterial flow cessation were 89% CAT7; 67% SWAT-T; 89% RATS; and 78% TK (H 0.89; P = .83). Mean (SD) application times were 10.4 (SD = 1.7) seconds CAT7; 23.1 (SD = 9.0) seconds SWAT-T; 11.1 (SD = 3.8) seconds RATS; and 20.0 (SD = 7.1) seconds TK (F 9.71; P <.001). Steady state maximal forces were 29.9 (SD = 1.2) N CAT7; 23.4 (SD = 0.8) N SWAT-T; 33.0 (SD = 1.3) N RATS; and 41.9 (SD = 1.3) N TK.Conclusion:All novel TQ systems were non-inferior to the military-approved CAT7. Mean application times were less than 30 seconds for all four designs. The size of these novel TQs may make them more conducive to lay-provider EDC, thereby increasing community resiliency and improving the response to high-threat events.
Collapse
|
18
|
Portela RC, Taylor SE, Sherrill CS, Dowlen WS, March J, Kitch B, Brewer K. Application of Different Commercial Tourniquets by Laypersons: Would Public-access Tourniquets Work Without Training? Acad Emerg Med 2020; 27:276-282. [PMID: 32202366 DOI: 10.1111/acem.13857] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Revised: 08/20/2019] [Accepted: 09/09/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND The White House "Stop the Bleed" campaign has renewed interest in public-access bleeding kits and the use of tourniquets by the lay public. The objective of this study was to determine which type of tourniquet could be applied most effectively by the lay public using only manufacturer instructions included with each tourniquet. METHODS This prospective study randomized participants to one of four different tourniquets (SOFTT-W, CAT, RMT, SWAT-T). Participants were all over 18 years of age. Individuals with prior military, EMS, or patient-care medical experience were excluded. Using only the manufacturer's packaging instructions, participants were asked to apply a tourniquet on a simulated bleeding arm. A trained observer noted if tourniquet application by the participant was effective, partially effective, or ineffective based on reduction or cessation of simulated blood flow. Participant's application of the tourniquet was also timed (in seconds) by the observer. The primary outcome of our study was the effectiveness of application for each of the four tourniquets. Secondary outcome was time to effective application. RESULTS A total of 176 participants were enrolled. For untrained laypersons the RMT had the highest effective application rate of 64.4% and was also the most rapidly applied at 100.9 ± 8.8 seconds (95% confidence interval [CI] = 83.1 to 118.6). The SWAT-T had the highest ineffective application rate (55.5%) than any other tourniquet type (p = 0.002). There was no effect of age or education on time to application for any tourniquet type. Effective applications were performed significantly faster than partially effective or ineffective applications (93.4 ± 5.8 [95% CI = 81.7 to 104.9] vs. 136.7 ± 8.7 [95% CI = 118.8 to 154.7] vs. 151.9 ± 8.3 [95% CI = 135.2 to 168.6]; p ≤ 0.001). There was no difference in time between partial and ineffective applications (p = 0.261). CONCLUSIONS Our study suggests that laypersons could benefit from prior training to effectively apply tourniquets in emergency situations. Of the tourniquets studied, the RMT was the most effectively and most rapidly applied.
Collapse
Affiliation(s)
- Roberto C. Portela
- Department of Emergency Medicine Division of EMS East Carolina University, Brody School of Medicine Greenville NC
| | - Stephen E. Taylor
- Department of Emergency Medicine Division of EMS East Carolina University, Brody School of Medicine Greenville NC
| | - Cameron S. Sherrill
- Department of Emergency Medicine Division of EMS East Carolina University, Brody School of Medicine Greenville NC
| | - Whitman S. Dowlen
- Department of Emergency Medicine Division of EMS East Carolina University, Brody School of Medicine Greenville NC
| | - Juan March
- Department of Emergency Medicine Division of EMS East Carolina University, Brody School of Medicine Greenville NC
| | - Bryan Kitch
- Department of Emergency Medicine Division of EMS East Carolina University, Brody School of Medicine Greenville NC
| | - Kori Brewer
- Department of Emergency Medicine Division of EMS East Carolina University, Brody School of Medicine Greenville NC
| |
Collapse
|
19
|
Latuska KM, Graf RL, Zwislewski A, Meyer LK, Nanassy AD. Stop the Bleed Training Improves Knowledge, Skills, and Confidence Among School Nurses. J Contin Educ Nurs 2019; 50:501-507. [DOI: 10.3928/00220124-20191015-06] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Accepted: 06/24/2019] [Indexed: 11/20/2022]
|
20
|
Abstract
INTRODUCTION The aim of this study was to determine if school personnel can understand and apply the Sort, Assess, Life-saving interventions, Treat/Transport (SALT) triage methods after a brief training. The investigators predicted that subjects can learn to triage with accuracy similar to that of medically trained personnel, and that subjects can pass an objective-structured clinical exam (OSCE) evaluating hemorrhage control. METHODS School personnel were eligible to participate in this prospective observational study. Investigators recorded subject demographic information and prior medical experience. Participants received a 30-minute lecture on SALT triage and a brief lecture and demonstration of hemorrhage control and tourniquet application. A test with brief descriptions of mass-casualty victims was administered immediately after training. Participants independently categorized the victims as dead, expectant, immediate, delayed, or minimal. They also completed an OSCE to evaluate hemorrhage control and tourniquet application using a mannequin arm. RESULTS Subjects from two schools completed the study. Fifty-nine were from a private school that enrolls early childhood through grade eight, and 45 from a public school that enrolls grades seven and eight (n = 104). The average subject age was 45 years and 68% were female. Approximately 81% were teachers and 87% had prior cardiopulmonary resuscitation (CPR) training. Overall triage accuracy was 79.2% (SD = 10.7%). Ninety-six (92.3%) of the subjects passed the hemorrhage control OSCE. CONCLUSIONS After two brief lectures and a short demonstration, school personnel were able to triage descriptions of mass-casualty victims with an overall accuracy similar to medically trained personnel, and most were able to apply a tourniquet correctly. Opportunities for future study include integrating high-fidelity simulation and mock disasters, evaluating for knowledge retention, and exploring the study population's baseline knowledge of medical care, among others.
Collapse
|
21
|
Jones AR, Brown MR, Esslinger A, Strickland VS, Kerby JD. Evaluation of “Stop the Bleed” training among K‐12 faculty and staff in Alabama. Public Health Nurs 2019; 36:660-666. [DOI: 10.1111/phn.12638] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 06/16/2019] [Accepted: 06/21/2019] [Indexed: 11/27/2022]
Affiliation(s)
- Allison R. Jones
- Department of Acute, Chronic & Continuing Care, School of Nursing University of Alabama at Birmingham Birmingham Alabama
| | - Michelle R. Brown
- Department of Health Services Administration, School of Health Professions University of Alabama at Birmingham Birmingham Alabama
| | | | | | - Jeffrey D. Kerby
- Department of Surgery University of Alabama at Birmingham Birmingham Alabama
| |
Collapse
|
22
|
Fisher AD, Carius BM, Lacroix J, Dodge PM, Dodd J, Soderlund E, Thompson D, Loos P, Fannin J, Montgomery HR, Gestring ML. National Stop the Bleed Day: The impact of a social media campaign on the Stop the Bleed program. J Trauma Acute Care Surg 2019; 87:S40-S43. [PMID: 31246905 DOI: 10.1097/ta.0000000000002341] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND National Stop the Bleed Day (NSTBD) was created to increase public awareness of the official Stop-the-Bleed initiative and the Bleeding Control Basic course. The goal was to develop and employ an effective national social media strategy that would encourage and support efforts already in place to train the public in basic bleeding control techniques. METHODS March 31, 2018, was designated as NSTBD. Analysis focused on a 2-week window centered on NSTBD. The number of courses offered, number of instructors registered and total number of students trained overall during this period was derived from the American College of Surgeons (ACS) website bleedingcontrol.org. Courses not registered with the ACS were not included. Data on overall website activity were also included for analysis. RESULTS Forty-three states and 18 countries participated in NSTBD. During the study period, there were 1884 courses registered on bleedingcontrol.org. Comparatively, over a 4-month period from August to November 2017, the mean number of registered courses per month was 834. There were 34,699 students trained during the two-week study period as opposed to August to November 2017, the mean number of people trained per month was 9,626. In addition, 576 new B-Con instructors were certified during this time window. Additionally, the international coordinators reported 1500 students were trained during the study period. During this time, the ACS reported a significant increase in website activity. This included 10,530 new visitors, 12,772 visitors overall and 35,342 page views recorded during the study period. CONCLUSION The NSTBD effort was successful in generating widespread interest for the Stop-the-Bleed initiative. The use of a targeted social media campaign in this context was successful in driving people to available training opportunities while also increasing awareness of the overall effort. While only in its early stages, the NSTBD concept is a good one and should be developed further in coming years. LEVEL OF EVIDENCE Retrospective, Level V.
Collapse
Affiliation(s)
- Andrew D Fisher
- From the Medical Command, Texas Army National Guard (A.D.F.), Austin; Texas A&M College of Medicine (A.D.F.), Temple, Texas; Prehospital Research in Military and Expeditionary (A.D.F.) Environments (PRIME2), San Antonio, Texas; San Antonio Military Medical Center (B.M.C.), Joint Trauma System (J.L., H.R.M), JBSA Fort Sam Houston, Houston, Texas; Aviation Regiment (P.M.D.), New Hampshire Army National Guard, Concord, New Hampshire; American College of Surgeons (J.D.), Chicago, Illinois; Pinellas County Sheriff's Office (E.S.), Largo, Florida; US Army EMS, AMEDD C&S (D.T.), JBSA Fort Sam Houston, Texas; Joint Special Operations Medical Training Center(P.L.), Fort Bragg, North Carolina; City of Troy (J.F.), Troy, Alabama; Department of Surgery, School of Medicine, University of Rochester (M.L.G.), Rochester, New York
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
23
|
Motameni A, Pike AI, Denzik KR, Arnold LF, Muradov JM, McKinley WI, Benns MV, Harbrecht BG. Stop the Bleed: Is Mass Education the Best Approach? Am Surg 2019. [DOI: 10.1177/000313481908500623] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The Stop the Bleed (STB) course teaches trainees prehospital hemorrhage control with a focus on mass education. Identifying populations most likely to benefit can help save on the significant cost and limited resources. In this study, we attempted to identify those populations and performed a cost analysis. Trainees underwent STB education and completed a survey on completion to assess demographics and prior experiences where STB skills could have been useful. Five hundred seventy-one trainees categorized as first responders (14%), students (56%), and the working public (30%) completed the survey. Most trainees found the lecture and simulation helpful, 96 per cent and 98 per cent, respectively. There were significant differences among groups who had previously been in situations where the STB course would have been helpful (88% first responders versus 40% students versus 43% public workers) ( P < 0.001). Teaching a class of 10 students costs approximately $455; the cost can be as high as $1246 for a class of 50 students. Most STB trainees found the course helpful. First responders are most likely to be exposed to situations where course information could be helpful. Focusing on specific high-yield groups rather than mass education might be a more efficient approach to STB education.
Collapse
Affiliation(s)
- Amirrezat Motameni
- Department of Surgery, University of Louisville, Louisville, Kentucky; and
| | - Annabelle I. Pike
- Department of Surgery, University of Louisville, Louisville, Kentucky; and
| | - Kim R. Denzik
- Department of Surgery, University of Louisville, Louisville, Kentucky; and
| | - Lindsay F. Arnold
- Department of Surgery, University of Louisville, Louisville, Kentucky; and
| | | | | | - Matthew V. Benns
- Department of Surgery, University of Louisville, Louisville, Kentucky; and
| | - Brian G. Harbrecht
- Department of Surgery, University of Louisville, Louisville, Kentucky; and
| |
Collapse
|
24
|
Tatebe L, Speedy S, Kang D, Barnum T, Cosey-Gay F, Regan S, Stone L, Swaroop M. Empowering Bystanders to Intervene: Trauma Responders Unify to Empower (TRUE) Communities. J Surg Res 2019; 238:255-264. [PMID: 30954087 DOI: 10.1016/j.jss.2019.02.029] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Revised: 01/10/2019] [Accepted: 02/14/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND Timely and effective bystander first aid can improve outcomes for trauma victims. Bystanders are present at most traumas and are more likely to assist with prior training. MATERIALS AND METHODS An evidence-based course was created for the general public in high-risk Chicago neighborhoods focused on basic traumatic first aid, including scene management, hemorrhage control, and mitigating the psychological impact of trauma to overcome the bystander effect. Prospectively, participants completed knowledge-based and self-efficacy assessments precourse, postcourse, and 6 mo follow-up. The change in self-efficacy and knowledge scores was analyzed. RESULTS Over 32 courses, 503 participants were taught; 474 and 460 participants completed precourse and postcourse surveys, respectively, whereas 60 of 327 who consented for follow-up completed the 6-mo survey. Postcourse, participants were more likely to assist trauma victims and felt more confident in the quality of care they could provide; the effect remained significant at 6 mo (all P < 0.001). All seven self-efficacy empowerment-based questions individually demonstrated improvement from precourse to postcourse (P < 0.001), with an overall mean (SD) increase of 2.8 (2.1, P < 0.001); six maintained significance at follow-up with an overall mean increase of 2.8 (1.9, P < 0.001). Knowledge scores improved from 6.2 of 10 to 7.2 postcourse and 7.7 at follow-up (P < 0.001). Most improved were the ability to render first aid and apply tourniquets. CONCLUSIONS The TFRC increased self-efficacy, successfully teaching initial trauma care, particularly hemorrhage control and scene safety, suggesting that a grassroots approach to trauma care may improve outcomes in communities that experience high violence rates.
Collapse
Affiliation(s)
- Leah Tatebe
- Department of Surgery, Northwestern University, Chicago, Illinois
| | - Sedona Speedy
- Department of Surgery, Northwestern University, Chicago, Illinois
| | - Danby Kang
- Department of Surgery, Rush University, Chicago, Illinois
| | - Trevor Barnum
- Department of Surgery, Northwestern University, Chicago, Illinois
| | - Franklin Cosey-Gay
- Chicago Center for Youth Violence Prevention, University of Chicago, Chicago, Illinois
| | - Sheila Regan
- Cure Violence, University of Illinois, Chicago, Chicago, Illinois
| | - LeVon Stone
- Cure Violence, University of Illinois, Chicago, Chicago, Illinois
| | - Mamta Swaroop
- Department of Surgery, Northwestern University, Chicago, Illinois.
| |
Collapse
|
25
|
Erdman MO, Chardavoyne P, Olympia RP. School Nurses on the Front Lines of Medicine: The Approach to a Student With Severe Traumatic Bleeding. NASN Sch Nurse 2019; 34:280-286. [PMID: 30920935 DOI: 10.1177/1942602x19837525] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
With the continued threat of mass casualty incidents in schools and surrounding communities, it is essential for school nurses to be knowledgeable regarding the recognition of hemorrhagic shock due to massive bleeding and the acute management of these victims. In the past decade, increased interest and research in acute bleeding control have led to published evidence-based guidelines to reduce morbidity and mortality for victims of violent acts. It is essential that healthcare providers, including nurses who are the first responders in schools, are aware of methods to assess and control massive bleeding. This article summarizes the most up-to-date recommendations for the management of children with traumatic bleeding.
Collapse
Affiliation(s)
| | | | - Robert P Olympia
- Professor, Departments of Emergency Medicine and Pediatrics, Penn State College of Medicine,Attending Pediatric Emergency Medicine Physician, Penn State Hershey Medical Center, Hershey, PA
| |
Collapse
|
26
|
Rega PP, Sexton M, Fink B, McKenzie N, Ochs N. The Tourniquet Gap Exists Even Among Health Care Students. J Emerg Med 2019; 56:342. [PMID: 30910063 DOI: 10.1016/j.jemermed.2018.06.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 06/24/2018] [Indexed: 06/09/2023]
Affiliation(s)
- Paul P Rega
- College of Medicine, University of Toledo, Toledo, Ohio
| | - Martha Sexton
- College of Nursing, University of Toledo, Toledo, Ohio
| | - Brian Fink
- College of Health and Human Services, University of Toledo, Toledo, Ohio
| | - Nicole McKenzie
- College of Health and Human Services, University of Toledo, Toledo, Ohio
| | - Nicole Ochs
- College of Health and Human Services, University of Toledo, Toledo, Ohio
| |
Collapse
|