Abstract
Hintergrund
Gemäß der Handlungsempfehlung „Tourniquet“ der Deutschen Gesellschaft für Anästhesiologie und Intensivmedizin (DGAI) erfolgt die Anlage eines Tourniquets bei lebensbedrohlichen Extremitätenblutungen, wenn die Kompression der Wunde nicht ausreicht oder in der gegebenen Situation nicht durchführbar ist. Hierdurch wird ein fortdauernder, unkontrollierbarer Blutverlust vermieden.
Material und Methode
Anhand der Ergebnisse einer systematischen Literaturrecherche (Januar 2015 bis Januar 2018) wird die publizierte Handlungsempfehlung Tourniquet der DGAI kritisch reevaluiert. Hierfür sind 17 Fragen zu 6 Themen im Vorfeld formuliert. Die PRISMA-Empfehlungen werden eingehalten, und die Studie ist im International Prospective Register of Systematic Reviews (PROSPERO; ID CRD42018091528) registriert.
Ergebnisse
Von 284 Treffern zur Stichwortsuche „Tourniquet“ und „Trauma“ im Suchzeitraum von Januar 2015 bis Januar 2018 bei PubMed werden 50 Originalarbeiten zur prähospitalen Anwendung von Tourniquets bei lebensbedrohlichen Extremitätenblutungen in die Auswertung inkludiert. Zu keiner vorformulierten Frage kann eine prospektive randomisierte Interventionsstudie gefunden werden. Nur indirekt, meist als deskriptive Beschreibung, lassen sich wissenschaftliche Rückschlüsse ziehen.
Schlussfolgerung
Bei insgesamt sehr inhomogener Studienlage werden die bestehenden Aussagen der 2016 publizierten Handlungsempfehlung zur prähospitalen Anwendung von Tourniquets der DGAI bestätigt. Eine Abweichung ergibt sich zur „Konversion des Tourniquets“. Diese wird im zivilen Rettungsdienst bei den geringen Transportzeiten kaum nötig sein. Zukünftig könnte in dieser Frage jedoch strikt unterschieden werden, zwischen Tourniquets, die aus taktischer, und solchen, die aus medizinischer Notwendigkeit angelegt wurden.
Abstract
Introduction
The effectiveness of a tourniquet in the case of life-threatening hemorrhages of the extremities is well recognized and led to the recommendations on “Tourniquet” of the German Society of Anaesthesiology and Intensive Care (DGAI) in 2016. The aim of this systematic review was to re-evaluate the current medical literature in relation to the published DGAI recommendations.
Material and methods
Based on the analysis of all studies published from January 2015 until January 2018 in the PubMed databases, the publicized recommendations for action on “Tourniquet” of the DGAI were critically re-evaluated. For this purpose, 17 questions on 6 subjects were formulated in advance. The systematic review followed the PRISMA recommendations and is registered in PROSPERO (International prospective register of systematic reviews, Reg.-ID: CRD42018091528).
Results
Of the 284 studies identified with the keywords tourniquet and trauma in the period from January 2015 to January 2018 in PubMed, 50 original papers discussing the prehospital application of tourniquet for life-threatening hemorrhage of the extremities were included. The overall level of evidence is low. No article addressed any of the formulated questions with a prospective randomized interventional study. Scientific deductions could be found only in an indirect way in a descriptive manner.
Conclusion
The 50 original articles included in this qualitative, systematic review revealed that the recommendations “Tourniquet” of the DGAI published in 2016 are mostly still up to date despite an inhomogeneous study situation. A deviation occurred in the conversion of a tourniquet but due to the short prehospital treatment time in the civilian setting this is of little importance; however, in the future a strict distinction should be made between tourniquets which were placed for tactical reasons and those placed as a medical necessity.
Literatur
Alpert EA, Lipsky AM, Elie ND et al (2015) The contribution of on-call, volunteer first responders to mass-casualty terrorist attacks in Israel. Am J Disaster Med 10:35–39
Balakrishnan V, Wilson J, Taggart B et al (2016) Impact of phlebotomy tourniquet use on blood lactate levels in acutely ill patients. CJEM 18:358–362
Ballas R, Saetta G, Peuchot C et al (2017) Clinical features of 27 shark attack cases on La Reunion Island. J Trauma Acute Care Surg 82:952–955
Barron MR, Kuckelman JP, McClellan JM et al (2017) Smartphone-based mobile thermal imaging technology to assess limb perfusion and tourniquet effectiveness under normal and blackout conditions. J Trauma Acute Care Surg 83:1129–1135
Bayerisches Staatsministerium des Inneren (2016) Handlungsempfehlungen für Rettungsdiensteinsätze bei besonderen Einsatzlagen/ Terrorlagen (REBEL)
Beaucreux C, Vivien B, Miles E et al (2018) Application of tourniquet in civilian trauma: Systematic review of the literature. Anaesth Crit Care Pain Med. https://doi.org/10.1016/j.accpm.2017.11.017
Butler FK Jr., Hagmann J, Butler EG (1996) Tactical combat casualty care in special operations. Mil Med 161:3–16
Cousins GR, Gill SL, Tinning CG et al (2015) Arm versus forearm tourniquet for carpal tunnel decompression – Which is better? A randomized controlled trial. J Hand Surg Eur Vol 40:961–965
Van Dillen CM, Tice MR, Patel AD et al (2016) Trauma simulation training increases confidence levels in Prehospital personnel performing life-saving interventions in trauma patients. Emerg Med Int 2016:5437490
Dowling ST, Lin BW (2017) Outcomes in patients treated with a novel, simple method for Hemostasis of dermal Avulsion injuries. Adv Ski Wound Care 30:460–463
Dreier M, Borutta B, Stahmeyer J et al (2010) Vergleich von Bewertungsinstrumenten für die Studienqualität von Primär- und Sekundärstudien zur Verwendung für HTA-Berichte im deutschsprachigen Raum. Schriftenreihe Health Technology Assessment, Bd. 102. Deutsches Institut für Medizinische Dokumentation und Information (DIMDI), Köln
DuBose JJ, Savage SA, Fabian TC et al (2015) The American association for the surgery of trauma PROspective observational vascular injury treatment (PROOVIT) registry: multicenter data on modern vascular injury diagnosis, management, and outcomes. J Trauma Acute Care Surg 78:215–222 (discussion 222–213)
Dunn JC, Kusnezov N, Schoenfeld AJ et al (2016) Vascular injuries in combat-specific soldiers during operation Iraqi freedom and operation enduring freedom. Ann Vasc Surg 35:30–37
Eastridge BJ, Costanzo G, Jenkins D et al (2009) Impact of joint theater trauma system initiatives on battlefield injury outcomes. Am J Surg 198:852–857
Fischer C, Josse F, Lampl L et al (2010) Stop the bleeding! New aspects of hemostasis from civil and military aspects. Notfall Rettungsmed 13:384–392
Flohé S, Matthes G, Paffrath T et al (2018) Schwerverletztenversorgung – Diagnostik und Therapie der ersten 24 Stunden. Thieme, Stuttgart
Fortuna G, DuBose JJ, Mendelsberg R et al (2016) Contemporary outcomes of lower extremity vascular repairs extending below the knee: A multicenter retrospective study. J Trauma Acute Care Surg 81:63–70
Frank B, Maher Z, Hazelton JP et al (2017) Venous thromboembolism after major venous injuries: Competing priorities. J Trauma Acute Care Surg 83:1095–1101
Godfrey BW, Martin A, Chestovich PJ et al (2017) Patients with multiple traumatic amputations: An analysis of operation enduring freedom joint theatre trauma registry data. Injury 48:75–79
Goolsby C, Chen E, Branting A et al (2016) Analysis of Layperson tourniquet application using a novel color-coded device. Disaster Med Public Health Prep 10:274–280
Gursul C, Ekinci Akdemir FN, Akkoyun T et al (2016) Protective effect of Naringin on experimental hindlimb ischemia/reperfusion injury in rats. J Enzyme Inhib Med Chem 31:56–61
Haider AH, Piper LC, Zogg CK et al (2015) Military-to-civilian translation of battlefield innovations in operative trauma care. Surgery 158:1686–1695
Hart D, Rush R, Rule G et al (2017) Training and assessing critical airway, breathing, and hemorrhage control procedures for trauma care: live tissue versus synthetic models. Acad Emerg Med 25(2):148–167
Hartford Consensuns Collaboration of the American College of Surgeons (2015) Hartford Consensus Compendium. ACS Bulletin Supplement, S 1–88
Hauschild SW, Nöldge-Schomburg G, Hoitz J (2013) Hemostasis with a tourniquet in preclinical emergency medicine. Notfall Rettungsmed 16:291–304
Heldenberg E, Aharony S, Wolf T et al (2015) Evaluating new types of tourniquets by the Israeli Naval special warfare unit. Disaster Mil Med 1:1
Hodgetts T, Mahoney P, Russell MQ et al (2006) ABC to ,C.ABC: redefining the military trauma paradigm. Emerg Med J 23:745–746
Horlocker TT, Hebl JR, Gali B et al (2006) Anesthetic, patient, and surgical risk factors for neurologic complications after prolonged total tourniquet time during total knee arthroplasty. Anesth Analg 102:950–955
Hossfeld B, Holsträter S, Bernhard M et al (2015) Prähospitale Analgesie beim Erwachsenen. Notfallmed Up2date 10:269–284
Hossfeld B, Josse F, Kulla M et al (2016) Handlungsempfehlung prähospitalen Anwendung von Tourniquets. Anästh Intensivmed 57:698–704
Hossfeld B, Adams HA, Bohnen R et al (2017) Zusammenarbeit von Rettungskräften und Sicherheitsbehörden bei bedrohlichen Lagen. Anästh Intensivmed 58:573–583
Hossfeld B, Wurmb T, Josse F et al (2017) Mass casualty incident – special features of “threatening situations”. Anasthesiol Intensivmed Notfallmed Schmerzther 52:618–629
Inaba K, Siboni S, Resnick S et al (2015) Tourniquet use for civilian extremity trauma. J Trauma Acute Care Surg 79:232–237 (quiz 332–233)
Jacobs LM, Burns KJ (2015) Tourniquet application training for individuals with and without a medical background in a hospital setting. J Trauma Acute Care Surg 78:442–445
Jawhar A, Hermanns S, Ponelies N et al (2016) Tourniquet-induced ischaemia during total knee arthroplasty results in higher proteolytic activities within vastus medialis cells: a randomized clinical trial. Knee Surg Sports Traumatol Arthrosc 24:3313–3321
Jawhar A, Ponelies N, Schild L (2016) Effect of limited ischemia time on the amount and function of mitochondria within human skeletal muscle cells. Eur J Trauma Emerg Surg 42:767–773
Josse F, Hossfeld B, Lampl L et al (2014) Anwendung von Tourniquets zum Stoppen kritischer Extremitätenblutungen. Notfallmed Up2date 9:7–13
Josse F, Helm M, Kulla M et al (2015) Stopp the bleeding in the prehospital setting: Hemostyptic dressings. Notarzt 31:153–157
Josse F, Helm M, Kulla M et al (2015) Prehospital Measures to Stop Bleeding: The Tourniquet. Notarzt 31:103–107
Kauvar DS, Dubick MA, Walters TJ et al (2018) Systematic Review of Prehospital Tourniquet Use in Civilian Limb Trauma. J Trauma Acute Care Surg. https://doi.org/10.1097/ta.0000000000001826
King DR, Larentzakis A, Ramly EP et al (2015) Tourniquet use at the Boston Marathon bombing: Lost in translation. J Trauma Acute Care Surg 78:594–599
Koehler SM, Fields A, Noori N et al (2015) Safety of tourniquet use in total knee arthroplasty in patients with radiographic evidence of vascular calcifications. Am J Orthop 44:E308–E316
Kovar F, Jauregui JJ, Specht SC et al (2016) Upper extremity nerve function and pain in human volunteers with narrow versus wide tourniquets. J Long Term Eff Med Implants 26:173–181
Kovar FM, Jaindl M, Oberleitner G et al (2015) Nerve compression and pain in human volunteers with narrow vs wide tourniquets. World J Orthop 6:394–399
Kragh JF Jr., O’Neill ML, Walters TJ et al (2011) The military emergency tourniquet program’s lessons learned with devices and designs. Mil Med 176:1144–1152
Kragh JF Jr., Dubick MA, Aden JK et al (2015) U.S. Military use of tourniquets from 2001 to 2010. Prehosp Emerg Care 19:184–190
Kragh JF Jr., Nam JJ, Berry KA et al (2015) Transfusion for shock in US military war casualties with and without tourniquet use. Ann Emerg Med 65:290–296
Kragh JF Jr., Wallum TE, Aden JK 3rd et al (2015) Which improvised tourniquet windlasses work well and which ones won’t? Wilderness Environ Med 26:401–405
Kragh JF Jr., Dubick MA, Aden JK 3rd et al (2016) U.S. Military experience from 2001 to 2010 with extremity fasciotomy in war surgery. Mil Med 181:463–468
Kragh JF Jr., Moore VK 3rd, Aden JK 3rd et al (2016) Short report comparing generation 6 versus prototype generation 7 combat application tourniquet(R) in a manikin hemorrhage model. J Special Oper Med 16:14–17
Kruse H, Christensen KP, Moller AM et al (2015) Tourniquet use during ankle surgery leads to increased postoperative opioid use. J Clin Anesth 27:380–384
Kue RC, Temin ES, Weiner SG et al (2015) Tourniquet use in a civilian emergency medical services setting: a descriptive analysis of the boston EMS experience. Prehosp Emerg Care 19:399–404
Kulla M, Bernhard M, Hinck D et al (2015) Treatment options for the critical bleeding in the out of hospital setting. Notarzt 31:47–53
Kulla M, Josse F, Helm M et al (2015) Prähospitale Traumaversorgung – Versorgung kritischer Blutungen. In: Kluge S, Markewitz A, Jorch G, Putensen C, Quintel M, Sybrecht GW (Hrsg) DIVI Jahrbuch 2015/2016. MWV – Medizinisch Wissenaschaftliche Verlagsgesellschaft, Berlin, S 351–359
Kumar N, Yadav C, Singh S et al (2015) Evaluation of pain in bilateral total knee replacement with and without tourniquet; a prospective randomized control trial. J Clin Orthop Trauma 6:85–88
Lakstein D, Blumenfeld A, Sokolov T et al (2003) Tourniquets for hemorrhage control on the battlefield: a 4-year accumulated experience. J Trauma 54:S221–225
LaPorta A, Kirkpatrick AW, McKee JL et al (2017) Randomised controlled trial comparing marksmanship following application of a tourniquet or haemostatic clamp in healthy volunteers. J R Army Med Corps 163:177–183
Leonard J, Zietlow J, Morris D et al (2016) A multi-institutional study of hemostatic gauze and tourniquets in rural civilian trauma. J Trauma Acute Care Surg 81:441–444
Lott C, Araujo R, Cassar MR et al (2009) The European Trauma Course (ETC) and the team approach: past, present and future. Resuscitation 80:1192–1196
Maeda H, Iwase H, Kanda A et al (2017) A study of the blood flow restriction pressure of a tourniquet system to facilitate development of a system that can prevent musculoskeletal complications. Am J Disaster Med 12:139–145
Mase VJ Jr., Roe JL, Christy RJ et al (2016) Postischemic conditioning does not reduce muscle injury after tourniquet-induced ischemia-reperfusion injury in rats. Am J Emerg Med 34:2065–2069
McEwen JA, Kelly DL, Jardanowski T et al (2002) Tourniquet safety in lower leg applications. Orthop Nurs 21:55–62
Meizoso JP, Valle EJ, Allen CJ et al (2015) Decreased mortality after prehospital interventions in severely injured trauma patients. J Trauma Acute Care Surg 79:227–231
Moher D, Liberati A, Tetzlaff J et al (2009) Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Plos Med 6(7):e1000097
Moritz M, Pfeifer S, Balmayor ER et al (2017) VEGF released from a fibrin biomatrix increases VEGFR-2 expression and improves early outcome after ischaemia-reperfusion injury. J Tissue Eng Regen Med 11:2153–2163
Ode G, Studnek J, Seymour R et al (2015) Emergency tourniquets for civilians: Can military lessons in extremity hemorrhage be translated? J Trauma Acute Care Surg 79:586–591
Ondruschka B, Baier C, Dressler J et al (2017) Additional emergency medical measures in trauma-associated cardiac arrest. Anaesthesist 66:924–935
Ramly E, Runyan G, King DR (2016) The state of the union: Nationwide absence of uniform guidelines for the prehospital use of tourniquets to control extremity exsanguination. J Trauma Acute Care Surg 80:787–791
Reihsen TE, Alberti L, Speich J et al (2016) Feasibility of a perfused and ventilated cadaveric model for assessment of lifesaving traumatic hemorrhage and airway management skills. J Trauma Acute Care Surg 80:799–804
Roth KE, Mandryka B, Maier GS et al (2015) In-vivo analysis of epicutaneous pressure distribution beneath a femoral tourniquet – an observational study. Bmc Musculoskelet Disord 16:1
Savage EC, Tenn C, Vartanian O et al (2015) A comparison of live tissue training and high-fidelity patient simulator: A pilot study in battlefield trauma training. J Trauma Acute Care Surg 79:S157–163
El Sayed MJ, Tamim H, Mailhac A et al (2017) Trends and predictors of limb tourniquet use by civilian emergency medical services in the united states. Prehosp Emerg Care 21:54–62
Scerbo MH, Mumm JP, Gates K et al (2016) Safety and appropriateness of tourniquets in 105 civilians. Prehosp Emerg Care 20:712–722
Scerbo MH, Holcomb JB, Taub E et al (2017) The trauma center is too late: Major limb trauma without a pre-hospital tourniquet has increased death from hemorrhagic shock. J Trauma Acute Care Surg 83:1165–1172
Schauer SG, April MD, Naylor JF et al (2017) A descriptive analysis of data from the Department of Defense Joint Trauma System Prehospital Trauma Registry. US Army Med Dep J 3‑17:92–97
Schauer SG, April MD, Simon E et al (2017) Prehospital interventions during mass-casualty events in Afghanistan: a case analysis. Prehosp Disaster Med 32:465–468
Schroll R, Smith A, McSwain NE Jr. et al (2015) A multi-institutional analysis of prehospital tourniquet use. J Trauma Acute Care Surg 79:10–14 (discussion 14)
Shamseer L, Moher D, Clarke M et al (2015) Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015: elaboration and explanation. BMJ 350:g7647
Shaw JA, Murray DG (1982) The Relationship between Tourniquet Pressure and Underlying Soft-Tissue Pressure in the Thigh. J Bone Jt Surg 64:1148–1152
Shlaifer A, Yitzhak A, Baruch EN et al (2017) Point of injury tourniquet application during operation protective edge-what do we learn? J Trauma Acute Care Surg 83:278–283
Sidwell RA, Spilman SK, Huntsman RS et al (2017) Efficient hemorrhage control skills training for healthcare employees. J Am Coll Surg 226(2):160–164
Smith ER, Shapiro G, Sarani B (2016) The profile of wounding in civilian public mass shooting fatalities. J Trauma Acute Care Surg 81:86–92
Sokol KK, Black GE, Azarow KS et al (2015) Prehospital interventions in severely injured pediatric patients: Rethinking the ABCs. J Trauma Acute Care Surg 79:983–989
Su J, Cao X (2017) Risk factors of wound infection after open reduction and internal fixation of calcaneal fractures. Medicine (Baltimore) 96:e8411
Swan KG Jr., Wright DS, Barbagiovanni SS et al (2009) Tourniquets revisited. J Trauma 66:672–675
Tu H, Zhang D, Corrick RM et al (2017) Morphological regeneration and functional recovery of neuromuscular junctions after tourniquet-induced injuries in mouse Hindlimb. Front Physiol 8:207
Unlu A, Kaya E, Guvenc I et al (2015) An evaluation of combat application tourniquets on training military personnel: changes in application times and success rates in three successive phases. J R Army Med Corps 161:332–335
Unlu A, Petrone P, Guvenc I et al (2017) Combat application tourniquet (CAT) eradicates popliteal pulses effectively by correcting the windlass turn degrees: a trial on 145 participants. Eur J Trauma Emerg Surg 43:605–609
Zietlow JM, Zietlow SP, Morris DS et al (2015) Prehospital use of hemostatic bandages and tourniquets: translation from military experience to implementation in civilian trauma care. J Special Oper Med 15:48–53
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Dr. S. Holsträter gilt ein besonderer Dank für die redaktionelle Überarbeitung der Einzelbeiträge sowie der Abbildungen.
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B. Hossfeld, R. Lechner, F. Josse, M. Bernhard, F. Walcher, M. Helm und M. Kulla geben an, dass kein Interessenkonflikt besteht.
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Hossfeld, B., Lechner, R., Josse, F. et al. Prähospitale Anwendung von Tourniquets bei lebensbedrohlichen Extremitätenblutungen. Unfallchirurg 121, 516–529 (2018). https://doi.org/10.1007/s00113-018-0510-y
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DOI: https://doi.org/10.1007/s00113-018-0510-y