During the study period, 662 patients with extremity trauma were admitted to the trauma unit. Out of these, 303 patients’ admission notes and ambulance reports were analysed. Fifty-six patients with a documented prehospital placement of TQ were identified and included in the study (50 males and 6 females) (Table 1). Paediatric patients, burn trauma and military trauma were excluded. Flowchart for patient identification described in Fig. 1. 12 patients needed intensive care with a mean length of stay in the intensive care unit (ICU) of 7.58 days. Out of the 36 patients arriving with ambulance, 31 patients had a Glasgow Coma Scale (GCS) between 14 and 15 prior arriving to hospital, indicating that the majority of the patients were awake with minor risk of brain damage. The most frequent mechanism of injury was penetrating trauma caused by knives or firearms (Fig. 2). Among blunt trauma, the majority of injuries were caused by traffic accidents (Table 2; Fig. 2).
Table 1 Demographic and clinical parameters of patients with a placement of tourniquets Table 2 Mechanism of injury indicating use of tourniquet The foremost indication (> 50%) for a placement of TQ was potentially life-threatening haemorrhage (Table 3). In several cases, a pulsating bleeding was present. Documented TQ time ranged from 15 to 100 min in 21 patients, in more than 50% of the cases data on TQ time was missing.
Table 3 The use of tourniquet Based on medical records from the ambulance and the admission note, 16 (28.6%) of the injuries were categorised as non-life threatening. In four of these cases, the TQ was removed completely upon arrival at the scene by ambulance personnel, in all cases because of an unindicated use with no active bleeding.
In all but one patient, the TQ was sufficient to stop the bleeding effectively without the addition of a pressure bandage, making the TQ effective in 98.2% of the cases. No patient received two TQs on the same limb. In patients with a potentially life-threating haemorrhage, the TQ was applied after an attempt to stop the bleeding with direct pressure in more than 40% of the cases.
Almost one third (32.1%) of the patients had injuries requiring blood transfusion (Table 4). Eight of these received blood according to a massive transfusion protocol. In this group, four patients had a fibrinogen equal to or lower than 1.7 g/l; however, no correlation was found between low fibrinogen and blood transfusion. In one case, a blood pressure cuff was used as TQ and in nine cases, an improvised TQ was placed; most frequently a belt but also bed sheets and in one case, a dog leash. In four of these cases, the improvised TQ was replaced by a commercial TQ upon arrival of prehospital personnel.
Table 4 Specification of blood products for patients (n = 18) who received blood transfusion Death occurred in two cases (30-day mortality 3.6%). Both patients arrived at the trauma unit with ongoing CPR. The first patient died in the ICU due to anoxic brain injury 2 days after admission following complications to massive haemorrhage from a stab wound in the femoral artery. The second patient was declared dead upon arrival to the trauma unit after multiple gunshot wounds to the chest and arms. The leading cause of death in both cases were exsanguination.
The total rate of complications was 30.1% (Table 5). There were seven amputations, five of which were traumatic due to the initial trauma. Two below knee amputations were necessary after admission to hospital, one due to post-operative infection and one following the initial trauma with development of necrotic ulcers. No amputations due to TQ use were seen in this study.
Table 5 Mortality and complications Four patients acquired a fasciotomy, of these three were made prophylactic. One case of compartment syndrome was identified. Three patients developed secondary acute kidney injury (AKI), one case due to fluid overload and pulmonary oedema, one due to septic shock and multi-organ failure, 7 days post-trauma and one due to hypoperfusion and rhabdomyolysis due to compartment syndrome. The latter two cases needed haemodialysis over a period.
Nerve damage was seen in 13 (23.2%) of the patients. In eight of these cases, the damage was clearly described to be caused by the initial trauma. In two cases, the nerve injury might have been caused by the application of TQ, according to the information provided in the medical records. In these cases, the nerve function recovered within 2 weeks. In three patients, it was not possible to verify the cause of the nerve damage; however, in these cases, the damage to the nerve was more distally than the site of the TQ. The nerve damage for 12 of the patients were transient within 2 weeks of the trauma. One patient with sensory nerve damage, due to the initial trauma, required 8 months until full recovery.
One patient developed a subcutaneous hematoma at the site of the TQ.
All patients were categorized into three groups depending on the final diagnosis after admission—vascular damage, deep tissue damage and superficial tissue damage (Table 6; Fig. 3). All 14 (25%) patients in the first category needed vascular surgery or intervention. Patients in the second category (n = 25, 44.6%) required orthopaedic surgery, and wound revision. The 17 (30.4%) patients with a superficial tissue damage needed skin sutures, wound dressing or no intervention at all. The majority of patients in this group had an injury categorized as non-life threatening.
Table 6 Patients categorized according to type of damage