The ACEP Clinical Policies Committee regularly reviews guidelines published by other organizations and professional societies. Periodically, new guidelines are identified on topics with particular relevance to the clinical practice of emergency medicine. This article highlights recommendations for external hemorrhage control published by the American College of Surgeons (ACS) Committee on Trauma in 2014.¹

So your prehospital guys want to use tourniquets. This seems to be a pretty frequent situation nowadays. Everyone has heard about the success of tourniquets in the battlefield; why not use them in civilian care? After all, isolated extremity trauma carries a significant risk of morbidity and mortality. Kauvar et al published a study focusing on the rate of death and amputation among a cohort of patients with isolated lower-extremity trauma as recorded in the National Trauma Data Bank. They found that the mortality rate is 2.8 percent and the major amputation rate is more than double that at 6.5 percent.² Moreover, a committee that included representatives from ACEP and the National Association of Emergency Medical Services Physicians recommended that all basic and advanced life support ambulances carry commercially available arterial tourniquets.³ With all this in mind, the ACS Committee on Trauma also reviewed this topic and published new evidence-based guidelines in 2014 on appropriate use of tourniquets.¹ The project looked at extremity and junctional (ie, in the groin proximal to the inguinal ligament, the buttocks, the gluteal and pelvic areas, the perineum, the axilla and shoulder girdle, and the base of the neck) hemorrhage.

The ACS Committee on Trauma members included experts from both the United States and Canada representing a variety of practitioners. Among them were experts in prehospital trauma care from the military’s Committee on Tactical Combat Casualty Care, PreHospital Trauma Life Support, civilian state emergency medical services (EMS) directors, trauma surgeons, emergency physicians, a pediatric surgeon, an EMS researcher, a paramedic, as well as a Grading of Recommendations Assessment, Development, and Evaluation methodologist. This group searched 13 databases for articles printed in English and reporting on prehospital care of traumatic hemorrhage with tourniquets or hemostatic dressing kits currently available in the United States. After exclusions and reviews, 16 clinically relevant studies on tourniquet use and seven on hemostatic agents were included in the evidentiary table.

Recommendations

The clinical questions focused on tourniquet use and efficiency. The first and most important question addressed the tourniquet’s effect on limb salvage, morbidity, and mortality. The committee then made the following strong recommendation with a moderate level of evidence: