A guideline to efficiently treating traumatic brachial artery injury

Impact of time and distance on outcomes following tourniquet use in civilian and military settings: A scoping review

BACKGROUND

The last two decades have seen the reintroduction of tourniquets into guidelines for the management of acute limb trauma requiring hemorrhage control. Evidence supporting tourniquet application has demonstrated low complication rates in modern military settings involving rapid evacuation timeframes. It is unclear how these findings translate to patients who have prolonged transport times from injury in rural settings. This scoping review investigates the relationship between time and distance on metabolic complications, limb salvage and mortality following tourniquet use in civilian and military settings.

METHODS

A systematic search strategy was conducted using PubMed, Embase, and SafetyLit databases. Study characteristics, setting, mechanism of injury, prehospital time, tourniquet time, distance, limb salvage, metabolic response, mortality, and tourniquet removal details were extracted from eligible studies. Descriptive statistics were recorded, and studies were grouped by ischemia time (< 2 h, 2-4 h, or > 4 h).

RESULTS

The search identified 3103 studies, from which 86 studies were included in this scoping review. Of the 86 studies, 55 studies were primarily in civilian environments and 32 were based in military settings. One study included both settings. Blast injury was the most common mechanism of injury sustained by patients in military settings (72.8% [5968/8200]) followed by penetrating injury (23.5% [1926/8200]). In contrast, in civilian settings penetrating injury was the most common mechanism (47.7% [1633/3426]) followed by blunt injury (36.4% [1246/3426]). Tourniquet time was reported in 66/86 studies. Tourniquet time over four hours was associated with reduced limb salvage rates (57.1%) and higher mortality rates (7.1%) compared with a tourniquet time of less than two hours. The overall limb salvage and mortality rates were 69.6% and 6.7% respectively. Metabolic outcomes were reported in 28/86 studies with smaller sample sizes and inconsistencies in which parameters were reported.

CONCLUSION

This scoping review presents literature describing comparatively safe tourniquet application when used for less than two hours duration. However, there is limited research describing prolonged tourniquet application or when used for protracted distances, such that the impact of tourniquet release time on metabolic outcomes and complications remains unclear. Prospective studies utilizing the development of an international database to provide this dataset is required.

<p>Upper Limb Salvage of a Mangled Limb with Reconstruction of Brachial, Ulnar and Radial Arteries Using an Extremely Long Reversed Bifurcated Great Saphenous Vein: A Case Report with Long-Term Follow-Up</p>

Acute elbow dislocation complicated by arterial injury of upper limb is rare but serious injury. We present the case about destructive injury of brachial, ulnar, and radial arteries with an open posterior dislocation of the right elbow, and a 25cm long reversed bifurcated great saphenous vein graft was applied for arterial reconstruction. The patient had obvious distal pulses after the operation. Ten years’ follow-up showed the good function of the right arm. Using an extremely long vein graft for the upper limb arterial reconstruction is challenging but feasible and provides good results.