P113: A systematic review and meta-analysis of tourniquet devices for speed of application, successful hemostasis and patient tolerance

Abstract

Introduction: Tourniquets are a mainstay of hemorrhage management. However, there is insufficient evidence to guide device sselection. This review analyses the literature on tourniquets, for the following outcomes: lower-extremity arterial hemostasis, application speed, and pain. Methods: Studies were limited to English. Non-human studies, case series, and intra-operative applications were excluded. A systematic review of MEDLINE, PubMed, Google Scholar, and the Cochrane Database from 1992 to Dec 2017 was performed. Article citations were also assessed. Results: Twenty-one studies met criteria, testing 28 tourniquet devices. The most popular devices for arterial hemostasis were the Combat Application Tourniquet (C-A-T) (662 applications), Special Operations Forces Tactical Tourniquet (SOFTT) (307 applications), blood pressure cuff (80 applications), rubber tubing (58 applications) and the Emergency Medical Tourniquet (EMT) (52 applications). The blood pressure cuff achieved the highest (weighted averages) rate of 99% (95% CI 93 to 100) based on four studies of 80 applications. Followed by the EMT which achieved 83% (95% CI 72 to 93), based on three studies of 52 applications (p<0.01). The fastest device to apply, taking 17 seconds (95% CI 11 to 23), was surgical tubing, based on two studies totalling 30 applications. The next fastest was the blood pressure cuff, requiring 20 seconds (95% CI 18 to 22), based on two studies totaling 58 applications (though there was no statistical difference in application time, p=0.08). Tolerance could not be analyzed, due to heterogeneity of outcome measures. Conclusion: This is the first meta-analysis of tourniquet outcomes. The literature lacks a standard approach to device application. The quality of evidence is of very low due to the small sample sizes, lack of blinding, selective outcome reporting and result inconsistency. Common medical equipment appear to outperform commercial tourniquets for arterial hemostasis and speed of application; however, they are some of the least studied devices.