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Limb Amputation/Mangled/Major Hemorrhage

Date Last Search Run: Jan 14, 2025
Table last updated: Nov 26, 2024
Data last added: Nov 21, 2024

Recommendation RECOMMENDATION FOR INTERVENTION
STRENGTH OF EVIDENCE FOR INTERVENTION   SUPPORTIVE (Green) NEUTRAL (Yellow) AGAINST (Red) NOT YET GRADED (White)
1 (strong evidence exists)  
2 (fair evidence exists)    
3 (weak evidence exists)  


Interventions

Direct Pressure
Level Direction Primary Outcome Patient/Process Setting Reference
II Supportive (Green) Hemorrhage Control Patient Other Charlton NP, Swain JM, Brozek JL, Ludwikowska M, Singletary E, Zideman D, et al. Control of Severe, Life-Threatening External Bleeding in the Out-of-Hospital Setting: A Systematic Review. Prehosp Emerg Care 2021; 25(2):235-67. Medline
III Neutral (Yellow) correct performance of intervention Patient PH-Paramedic Lairet JR., Bebarta VS., Burns CJ., Lairet KF., Rasmussen TE., Renz EM., et al. Prehospital interventions performed in a combat zone: a prospective multicenter study of 1,003 combat wounded. J Trauma Acute Care Surg 2012; 73(2S1):S38-42. Medline

Elevate extremity
Level Direction Primary Outcome Patient/Process Setting Reference

Hemostatic dressing
Level Direction Primary Outcome Patient/Process Setting Reference
II Supportive (Green) Effectiveness Patient PH-Paramedic Boulton AJ., Lewis CT., Naumann DN., Midwinter MJ. Prehospital haemostatic dressings for trauma a systematic review. EMJ 2018; 35(7) 449-57. Medline
II Supportive (Green) Cessation of bleeding Patient Other Charlton NP, Swain JM, Brozek JL, Ludwikowska M, Singletary E, Zideman D, et al. Control of Severe, Life-Threatening External Bleeding in the Out-of-Hospital Setting: A Systematic Review. Prehosp Emerg Care 2021; 25(2):235-67. Medline
II Supportive (Green) Efficacy Patient Leonard J., Zietlow J., Morris D., et al. A multi-institutional study of hemostatic gauze and tourniquets in rural civilian trauma. The journal of Trauma and Acute Care Surgery 2016; 81(3):441-4. Medline
III Supportive (Green) Cessation of bleeding Patient PH-Paramedic Brown M., Daya M., Worley J. Experience with chitosan dressings in a civilian EMS system. J Emerg Med 2009; 37(1):1-7. Medline
III Supportive (Green) Cessation of bleeding Process ED-MD Cox E., Schreiber M., McManus J., Wade C., Holcomb J. New hemostatic agents in the combat setting. Transfusion 2009; 49 (S5):248S-55S. Medline
III Supportive (Green) Blood loss Patient Kheirabadi BS., Edens JW., Terrazas IB., Estep JS., Klemcke HG., Dubick MA., Holcomb JB. Comparison of new hemostatic granules/powders with currently deployed hemostatic products in a lethal model of extremity arterial hemorrhage in swine. J Trauma 2009; 66(2):316-28. Medline
III Supportive (Green) Hemorrhage Control Patient PH-Paramedic Ran Y., Hadad E., Daher S., Ganor O., Kohn J., Yegorov Y., Bartal C., Ash N., Hirschhorn G. QuikClot Combat Gauze Use for Hemorrhage Control in Military Trauma: January 2009 Israel Defense Force Experience in the Gaza Strip—A Preliminary Report of 14 Cases. Prehosp and Dis Med 2010; 25(6):584-8. Medline
III Supportive (Green) Hemorrhage Control Patient PH-Paramedic Wedmore I., McManus J., Pusateri A., Holcomb J. A Special Report on the Chitosan-based Hemostatic Dressing: Experience in Current Combat Operations. J Trauma 2006; 60(3):655-8. Medline
III Supportive (Green) Survival Patient Other Welch M., Barratt J., Peters A., Wright C. Systematic review of prehospital haemostatic dressings. J R Army Med Corps 2019. Medline
III Neutral (Yellow) Mortality Patient ED-MD Granville-Chapman J., Jacobs N., Midwinter MJ. Pre-hospital haemostatic dressings: A systematic review. Injury 2011; 2(5):447-59. Medline
III Neutral (Yellow) correct performance of intervention Patient PH-Paramedic Lairet JR., Bebarta VS., Burns CJ., Lairet KF., Rasmussen TE., Renz EM., et al. Prehospital interventions performed in a combat zone: a prospective multicenter study of 1,003 combat wounded. J Trauma Acute Care Surg 2012; 73(2S1):S38-42. Medline
III Neutral (Yellow) Hemorrhage control Process Other Schauer SG., April MD., Naylor JF., Fisher AD., Cunningham CW., Ryan KL., et al. QuikClot® Combat Gauze® Use by Ground Forces in Afghanistan The Prehospital Trauma Registry Experience. Journal of special operations medicine; 17(2) 101-6. Medline

Pre-alert (massive transfusion protocol)
Level Direction Primary Outcome Patient/Process Setting Reference
II Supportive (Green) The area under the receiver operator characteristic curve Process PH-Paramedic Chow JH, Richards JE, Galvagno SM, Coleman PJ, Lankford AS, Hendrix C, et al. The Algorithm Examining the Risk of Massive Transfusion (ALERT) Score Accurately Predicts Massive Transfusion at the Scene of Injury and on Arrival to the Trauma Bay: A Retrospective Analysis. Shock 2021; 56(4):529–36. Medline
II Supportive (Green) Need for immediate hemostatic intervention Patient PH-Paramedic & MD Hamada SR, Rosa A, Gauss T, Desclefs JP, Raux M, Harrois A, et al. Development and validation of a pre-hospital "Red Flag" alert for activation of intra-hospital haemorrhage control response in blunt trauma. Crit Care 2018; 22(1):113. Medline
II Neutral (Yellow) Derivation of transfusion risk score Process ED-MD Avital G, Gelikas S, Radomislensky I, Tsur AM, Sorkin A, Shinar E, et al. A prehospital scoring system for predicting the need for emergent blood product transfusion. Transfusion 2021; 61 (Suppl 1):S195–205. Medline
II Neutral (Yellow) Hemorrhage control Patient PH-Paramedic & MD Partyka C, Miller M, Johnson T, Burns B, Fogg T, Sarrami P, Singh H, Dee K, Dinh M. Prehospital activation of a coordinated multidisciplinary hospital response in preparation for patients with severe hemorrhage: A statewide data linkage study of the New South Wales “Code Crimson” pathway. J Trauma Acute Care Surg 2022; 93(4):521–9. Medline
III Supportive (Green) Time to transfusion Process PH-Paramedic Bassett AK., Auten JD., Zieber TJ., Lunceford NL. Early, prehospital activation of the walking blood bank based on mechanism of injury improves time to fresh whole blood transfusion. Journal of special operations medicine : a peer reviewed journal for SOF medical professionals. 2016;16(2):5-8. Medline
III Supportive (Green) Mortality Patient ED-Paramedic & MD Heelan GA, Peltz ED, McIntyre RC, Vega S, Krell R, Velopulos C, et al. Effect of Pre-Hospital Use of the Assessment of Blood Consumption Score and Pre-Thawed Fresh Frozen Plasma on Resuscitation and Trauma Mortality. J Am Coll Surg 2018. Medline
III Supportive (Green) 24 hour and 30 day mortality. Process OR Meyer DE., Vincent LE., Fox EE., Okeeffe T., Inaba K., Bulger E., et al. Every minute counts Time to delivery of initial massive transfusion cooler and its impact on mortality. The journal of trauma and acute care surgery 2017; 83(1) 19-24. Medline

Tourniquet (junctional)
Level Direction Primary Outcome Patient/Process Setting Reference
III Supportive (Green) Complete interruption of popliteal arterial flow Patient Meusnier JG., Dewar C., Mavrovi E., Caremil F., Wey PF., Martinez JY. Evaluation of two junctional tourniquets used on the battlefield: Combat ready clamp® versus SAM® junctional tourniquet. Journal of Special Operations Medicine : a peer reviewed journal for SOF medical professionals 2016; 16(3):41-46. Medline
III Supportive (Green) Occlusion of blood flow Patient Other Webster S, Ritson JE, Barnard EBG. Abdominal aortic junctional tourniquet (AAJT-S): a systematic review of utility in military practice. BMJ Mil Heal July 2023. Medline
III Neutral (Yellow) survival Process Other Bonanno AM., Hoops HE., Graham T., Davis BL., McCully BH., Wilson LN., et al. Efficacy of the Abdominal Aortic Junctional Tourniquet-Torso Plate in a Lethal Model of Noncompressible Torso Hemorrhage. Journal of special operations medicine 2018; 18(4) 106-10. Medline
III Neutral (Yellow) Time to successful application Process Other Flecha I., Naylor JF., Schauer SG., Curtis RA., Cunningham CW. Combat lifesaver-trained, first-responder application of junctional tourniquets a prospective, randomized, crossover trial. Military Medical Research 2018; 5(1) 31. Medline
III Neutral (Yellow) Hemorrhage control at junctional sites. Patient PH-Paramedic Schauer SG., April MD., Fisher AD., Cunningham CW., Gurney J. Junctional Tourniquet Use During Combat Operations in Afghanistan The Prehospital Trauma Registry Experience. Journal of special operations medicine; 18(2) 71-4. Medline
X Not Yet Graded (White) - Patient Kragh JF., Lunati MP., Kharod CU., et al. Assessment of groin application of junctional tourniquets in a manikin model. Prehosp Disaster Med. 2016;31(4):358-63. Medline

Tourniquet (limb)
Level Direction Primary Outcome Patient/Process Setting Reference
I Neutral (Yellow) Mortality Patient PH-Paramedic Latina R, Iacorossi L, Fauci AJ, Biffi A, Castellini G, Coclite D, et al. Effectiveness of Pre-Hospital Tourniquet in Emergency Patients with Major Trauma and Uncontrolled Haemorrhage: A Systematic Review and Meta-Analysis. Int J Env Res Public Heal 2021; 18(23). Medline
II Supportive (Green) Effectiveness and complication rate. Patient PH-Bystander Beaucreux C., Vivien B., Miles E., Ausset S., Pasquier P. Application of tourniquet in civilian trauma Systematic review of the literature. Anaesthesia, critical care & pain medicine 2018; 37(6) 597-606. Medline
II Supportive (Green) Indicated tourniquet use Patient Other Bedri H, Ayoub H, Engelbart JM, Lilienthal M, Galet C, Skeete DA. Tourniquet Application for Bleeding Control in a Rural Trauma System: Outcomes and Implications for Prehospital Providers. Prehosp Emerg Care 2021:1-9. Medline
II Supportive (Green) Efficacy Patient PH-Paramedic Bedri H, Ayoub H, Engelbart JM, Lilienthal M, Galet C, Skeete DA. Tourniquet Application for Bleeding Control in a Rural Trauma System: Outcomes and Implications for Prehospital Providers. Prehosp Emerg Care 2021:1-9. Medline
II Supportive (Green) Hemorrhage control Patient Other Charlton NP, Swain JM, Brozek JL, Ludwikowska M, Singletary E, Zideman D, et al. Control of Severe, Life-Threatening External Bleeding in the Out-of-Hospital Setting: A Systematic Review. Prehosp Emerg Care 2021; 25(2):235-67. Medline
II Supportive (Green) Survivability Patient PH-Paramedic & CCT Hashmi ZG, Hu PJ, Jansen JO, Butler FK, Kerby JD, Holcomb JB. Characteristics and Outcomes of Prehospital Tourniquet Use for Trauma in the United States. Prehosp Emerg Care 2023; 27(1):31-7. Medline
II Supportive (Green) In hospital mortality Patient PH-Paramedic Henry R, Matsushima K, Ghafil C, Henry RN, Theeuwen H, Golden AC, et al. Increased Use of Prehospital Tourniquet and Patient Survival: Los Angeles Countywide Study. J Am Coll Surg 2021. Medline
II Supportive (Green) Mortality Process PH-Paramedic Ko YC, Tsai TY, Wu CK, et al. Effectiveness and safety of tourniquet utilization for civilian vascular extremity trauma in the pre-hospital settings: a systematic review and meta-analysis. World J Emerg Surg. March 2024; 19(1):10. Medline
II Supportive (Green) Morbidity Patient PH-Paramedic Kragh JF, Jr. Practical Use Emerg Tourniquets. Journal of Trauma 2008; 64(2):S38-50. Medline
II Supportive (Green) - Patient Kragh JF, Jr. Survival With Emergency Tourniquet Use to Stop Bleeding in Major Limb Trauma. Ann Surgery 2009; 249(1):1-7. Medline
II Supportive (Green) Efficacy Patient Leonard J., Zietlow J., Morris D., et al. A multi-institutional study of hemostatic gauze and tourniquets in rural civilian trauma. The journal of Trauma and Acute Care Surgery 2016; 81(3):441-4. Medline
II Supportive (Green) Feasibility Process PH-Paramedic & CCT Passos E., Dingley B., Smith A., Engels PT., Ball CG., Faidi S., Nathens A., Tien H. Tourniquet use for peripheral vascular injuries in the civilian setting. Injury 2014; 45(3):573-7. Medline
II Supportive (Green) Death from hemorrhage Patient ED-Paramedic & CCP Scerbo MH, Holcomb JB, Taub E, Gates K, Love JD, Wade CE, et al. The trauma center is too late: Major limb trauma without a pre-hospital tourniquet has increased death from hemorrhagic shock. The journal of trauma and acute care surgery 2017; 83(6):1165-72. Medline
II Supportive (Green) Death by hemorrhagic shock Patient ED-Paramedic & MD Scerbo MH, Holcomb JB, Taub E, Gates K, Love JD, Wade CE, et al. The trauma center is too late: Major limb trauma without a pre-hospital tourniquet has increased death from hemorrhagic shock. The journal of trauma and acute care surgery 2017; 83(6):1165-72. Medline
II Supportive (Green) Incidence of shock on arrival to the trauma centre Patient PH-Paramedic Schroll R, Smith A, Alabaster K, Schroeppel TJ, Stillman ZE, et al. AAST multicenter prospective analysis of prehospital tourniquet use for extremity trauma. J Trauma Acute Care Surg 2022; 92(6):997–1004. Medline
II Supportive (Green) Safety Patient PH-Paramedic Schroll R., Smith A., McSwain NE., Jr, et al. A multi-institutional analysis of prehospital tourniquet use. J Trauma Acute Care Surg 2015; 79(1):10-4; discussion 14. Medline
II Supportive (Green) blood product utilization Patient PH-Paramedic Smith AA., Ochoa JE., Wong S., Beatty S., Elder J., Guidry C., et al. Prehospital tourniquet use in penetrating extremity trauma Decreased blood transfusions and limb complications. The journal of trauma and acute care surgery 2019; 86(1) 43-51. Medline
II Supportive (Green) In hospital mortality. Patient PH-Paramedic Teixeira PGR., Brown CVR., Emigh B., Long M., Foreman M., Eastridge B., et al. Civilian Prehospital Tourniquet Use Is Associated with Improved Survival in Patients with Peripheral Vascular Injury. J Am Coll Surg 2018; 226(5) 769-76. Medline
II Neutral (Yellow) Time to artery occlusion Patient PH-Paramedic King RB., Filips D., Blitz S., Logsetty S. Evaluation of possible tourniquet systems for use in the Canadian Forces. J Trauma 2006; 60:1061-71. Medline
II Neutral (Yellow) Mortality Patient Kragh J., Nam J., Berry K., Mase V., Aden J., Walters T., Dubick M., Baer D., Wade N., Blackbourne L. Transfusion for Shock in US Military War Casualties With and Without Tourniquet Use. Ann Emerg Med 2015; 65(3):290-6 Medline
II Neutral (Yellow) Nerve palsy/Compartment syndrome Patient PH-Paramedic Legare T, Schroll R, Hunt JP, Duchesne J, Marr A, Schoen J, et al. Prehospital Tourniquets Placed on Limbs Without Major Vascular Injuries, has the Pendulum Swung Too far? Am Surg 2022:31348221088968. Medline
II Neutral (Yellow) Appropriate use Patient ED-MD Mikdad S, Mokhtari AK, Luckhurst CM, Breen KA, Liu B, Kaafarani HM, et al. Implications of the national Stop the Bleed campaign: The swinging pendulum of prehospital tourniquet application in civilian limb trauma. J Trauma Acute Care Surg 2021; 91(2):352–60. Medline
II Neutral (Yellow) In-hospital mortality Patient Passos E., Dingley B., Smith A., Engels P., Ball C., Faidi S., Nathens A., Tien H. Canadian Trauma Trials Collaborative Tourniquet use for peripheral vascular injuries in the civilian setting. Injury 2014; 45(3):573-7. Medline
II Opposes (Red) Deep Infection Patient PH-Paramedic Beekley A., Sebesta J., Blackbourne L., Herbert G., Kauvar D., Baer D., Walters T., Mullenix P., Holcomb J., Members of the 31st Combat Support Hospital Research Group. Prehospital Tourniquet Use in Operation Iraqi Freedom: Effect on Hemorrhage Control and Outcomes. Jtrauma 2008; 64(2 Suppl):S28-37. Medline
II Opposes (Red) Appropriate use Process PH-Paramedic Duignan KM., Lamb LC., DiFiori MM., Quinlavin J., Feeney JM. Tourniquet use in the prehospital setting Are they being used appropriately? American journal of disaster medicine 2018; 13(1) 37-43. Medline
II Opposes (Red) Risk of AKI Patient PH-Paramedic Paquette R, Wampler D, Schaefer R, Blume A, Casillas H, Echols B, et al. Prehospital Tourniquet Usage and Diabetes Mellitus Associated with Increased Incidence, Odds, and Risk of Acute Kidney Injury: A Pilot Study. Prehosp Disaster Med 2022; 37(3):360–4. Medline
III Supportive (Green) Tourniquet application Patient PH-Bystander Barnard LM, Guan S, Zarmer L, Mills B, Blackwood J, Bulger E, et al. Prehospital tourniquet use: An evaluation of community application and outcome. J Trauma Acute Care Surg 2021; 90(6):1040–7. Medline
III Supportive (Green) Mortality Patient PH-Paramedic Brodie S., Hodgetts T., Ollerton J., McLeod J., Lambert P., Mahoney J. Tourniquet Use in Combat Trauma: UK Military Experience. J Spec Oper Med 2007; 9(1):74-7. Medline
III Supportive (Green) Controlling hemorrhage Patient Gibson R., Aden JK., Dubick MA., Kragh JF. Preliminary comparison of pneumatic models of tourniquet for prehospital control of limb bleeding in a manikin model. J Spoec Ops Med 2016;16(2):21-7. Medline
III Supportive (Green) Hemostasis Process SIM Guo J., Liu Y., Ma Y., Pi H., Wang J. Evaluation of emergency tourniquets for prehospital use in China. Chi J Trauma 2011; 14(3):151-5. Medline
III Supportive (Green) Bleeding control Patient PH-Paramedic Jacobs LM., Burns KJ., Priest HS., Muskett W. Use of a tourniquet by LIFE STAR air medical crew: A case report. Conn Med 2015; 79(9):537-41. Medline
III Supportive (Green) Effectiveness, Mortality, complications Patient Kauvar DS., Dubick MA., Walters TJ., Kragh JF. Systematic review of prehospital tourniquet use in civilian limb trauma. The journal of trauma and acute care surgery 2018; 84(5) 819-25. Medline
III Supportive (Green) Mortality Patient PH-Paramedic Kragh J., Cooper A., Aden J., Dubick M., Baer D., Wade C., Blackbourne L. Survey of Trauma Registry Data on Tourniquet Use in Pediatric War Casualties. Ped Emerg Care 2012; 28(12):1362-5. Medline
III Supportive (Green) Efficacy and Pulse cessation Patient Kragh JF., Aden JK., Dubick MA. Evaluation of models of pneumatic tourniquet in simulated out-of-hospital use. Journal of special operations medicine : a peer reviewed journal for SOF medical professionals. 2016;16(3):21-29. Medline
III Supportive (Green) Mortality Patient PH-Paramedic Kue R., Temin E., Weiner S., Gates J., Coleman M., Fisher J., Dyer S. Tourniquet Use in a Civilian Emergency Medical Services Setting. A Descriptive Analysis of the Boston EMS Experience. Prehosp Emerg Care 2015; 19(3):399-404 Medline
III Supportive (Green) Time to application Process PH-Paramedic Lakstein D., Blumenfeld A., Sokolov T., Lin G., Bssorai R., Lynn M., Ben-Abraham R. Tourniquets for Hemorrhage Control on the Battlefield: A 4-Year Accumulated Experience. J Trauma 2003; 54(5S):S221. Medline
III Neutral (Yellow) Perfusion of extremity Patient PH-Paramedic Gushing J, Blair SG, Albrecht RM, Sawar Z, Stewart K, Knoles C, Little C, Quang CY. Prehospital tourniquet placement in extremity trauma. Am J Surg August 2023. Medline
III Neutral (Yellow) Time to artery occlusion Patient PH-Paramedic King D., van der Wilden G., Kragh J., Blackbourne L. Forward Assessment of 79 Prehospital Battlefield Tourniquets Used in the Current War. J of Spec Oper Med 2012; 12(4):33-9. Medline
III Neutral (Yellow) Mortality Patient Kragh J., Littrel M., Jones .J, Walters T., Baer D., Wade C., Holcomb J. Battle Casulty Survival with Emergency Tourniquet Use to Stop Limb Bleeding. J Emerg Med 2011; 41(6):590-7. Medline
III Neutral (Yellow) correct performance of intervention Patient PH-Paramedic Lairet JR., Bebarta VS., Burns CJ., Lairet KF., Rasmussen TE., Renz EM., et al. Prehospital interventions performed in a combat zone: a prospective multicenter study of 1,003 combat wounded. J Trauma Acute Care Surg 2012; 73(2S1):S38-42. Medline
III Neutral (Yellow) Ease of use Process SIM Lairet JR., Bebarta VS., Burns CJ., Lairet KF., Rasmussen TE., Renz EM., et al. Prehospital interventions performed in a combat zone: a prospective multicenter study of 1,003 combat wounded. J Trauma Acute Care Surg 2012; 73(2S1):S38-42. Medline
III Neutral (Yellow) Complication rate Patient PH-Paramedic Read DJ, Wong J, Liu R, Gumm K, Anderson D. Prehospital tourniquet use in civilian extremity trauma: an Australian observational study. ANZ J Surg 2023. Medline
III Neutral (Yellow) Complications Patient PH-Paramedic & MD Sabate-Ferris A, Pfister G, Boddaert G, Daban JL, de Rudnicki S, Caubere A, Demoures T, Travers S, Rongieras F, Mathieu L. Prolonged tactical tourniquet application for extremity combat injuries during war against terrorism in the Sahelian strip. Eur J Trauma Emerg Surg 2022; 48(5):3847–54. Medline
III Neutral (Yellow) Loss of popliteal pulse Patient SIM Taylor DM., Vater GM., Parker PJ. An evaluation of two tourniquet systems for the control of prehospital lower limb hemorrhage. J Trauma 2011; 71(3):591-595. Medline
III Neutral (Yellow) Prediction of 28-day mortality Process ED-MD Wall PL., Duevel DC., Hassan MB., Welander JD., Sahr SM., Buising CM. Tourniquets and occlusion: The pressure of design. Mil Med 2013; 178(5):578-587. Medline
X Not Yet Graded (White) - Patient Clasper JC., Brown KV., Hill P. Limb complications following pre-hosptial tourniquet use. J R Army Med Corps 2009; 155(3):200-2. Medline
X Not Yet Graded (White) - Eilertsen KA, Winberg M, Jeppesen E, Hval G, Wisborg T. Prehospital Tourniquets in Civilians: A Systematic Review. Prehosp Disaster Med 2021; 36(1):86-94. Medline

Tranexamic Acid
Level Direction Primary Outcome Patient/Process Setting Reference
I Supportive (Green) In-hospital mortality Process PH-Paramedic Broome JM, Nordham KD, Piehl M, et al. Faster refill in an urban emergency medical services system saves lives: A prospective preliminary evaluation of a prehospital advanced resuscitative care bundle. J Trauma Acute Care Surg May 2024; 96(5):702-7. Medline
I Supportive (Green) Adverse events Patient PH-Paramedic Deeb AP, Hoteit L, Li S, Guyette FX, Eastridge BJ, Nirula R, Vercruysse GA, O'Keeffe T, Joseph B, Neal MD, Sperry JL, Brown JB. Prehospital synergy: Tranexamic acid and blood transfusion in patients at risk for hemorrhage. J Trauma Acute Care Surg 2022. Medline
I Supportive (Green) Mortality Patient Other Fouche PF, Stein C, Nichols M, Meadley B, et al. Tranexamic Acid for Traumatic Injury in the Emergency Setting: A Systematic Review and Bias-Adjusted Meta-Analysis of Randomized Controlled Trials. Ann Emerg Med Nov 2023. Medline
I Supportive (Green) Mortality Patient PH-Paramedic Ker K. Antifibrinolytic drugs for acute traumatic injury. Cochrane Database of Systematic Reviews 2015:5. Medline
I Supportive (Green) Mortality/survival Patient PH-Paramedic Li SR, Guyette F, Brown J, Zenati M, Reitz KM, Eastridge B, et al. Early Prehospital Tranexamic Acid Following Injury is Associated with a 30-day Survival Benefit: A Secondary Analysis of a Randomized Clinical Trial. Ann Surg 2021. Medline
I Supportive (Green) Mortality Patient PH-Paramedic Mazzei M, Donohue JK, Schreiber M, et al. Prehospital tranexamic acid is associated with a survival benefit without an increase in complications: results of two harmonized randomized clinical trials. J Trauma Acute Care Surg. March 2024. Medline
I Supportive (Green) Need for blood transfusion Patient OR Montroy J, Hutton B, Moodley P, Fergusson NA, Cheng W, Tinmouth A, Lavallée LT, Fergusson DA, Breau RH.The efficacy and safety of topical tranexamic acid: A systematic review and meta-analysis. Transfus Med Rev. 2018 [Epub ahead of print] Medline
I Supportive (Green) Death Patient ED-MD Roberts I., Shakur H., Coats T., et al. The CRASH-2 trial: A randomised controlled trial and economic evaluation of the effects of tranexamic acid on death, vascular occlusive events and transfusion requirement in bleeding trauma patients. Health Technol Assess 2013; 17(10):1-79. Medline
I Neutral (Yellow) 30-day mortality from trauma Patient PH-Paramedic & CCT Guyette FX, Brown JB, Zenati MS, Early-Young B, Adams PW, Eastridge BJ, et al. Tranexamic Acid during Prehospital Transport in Patients at Risk for Hemorrhage after Injury: A Double-blind, Placebo-Controlled, Randomized Clinical Trial. JAMA Surgery 2020. Medline
II Supportive (Green) Mortality Patient PH-Paramedic & CCT Almuwallad A, Cole E, Ross J, Perkins Z, Davenport R. The Impact of Pre-Hospital TXA on Mortality among Bleeding Trauma Patients: A Systematic Review and Meta-Analysis. J Trauma Acute Care Surg 2021. Medline
II Supportive (Green) Mortality Patient ED-MD Cole E., Davenport R., Willett K., Brohi K. Tranexamic acid use in severely injured civilian patients and the effects on outcomes: A prospective cohort study. Ann Surg 2015; 261(2):390-4. Medline
II Supportive (Green) Survival to 30 days Patient PH-Paramedic Donohue JK, Iyanna N, Lorence JM, et al. Missingness matters: a secondary analysis of thromboelastography measurements from a recent prehospital randomized tranexamic acid clinical trial. Trauma Surg Acute Care Open February 2024; 9(1):e001346. Medline
II Supportive (Green) Mortality Patient ED-MD Eckert MJ, Wertin TM, Tyner SD, Nelson DW, Izenberg S, Martin MJ. Tranexamic acid administration to pediatric trauma patients in a combat setting: the pediatric trauma and tranexamic acid study (PED-TRAX). J Trauma Acute Care Surg. 2014 Dec;77(6):852-8; discussion 858. doi: 10.1097/TA.0000000000000443. PMID: 25423534. Medline
II Supportive (Green) 24-hour mortality Patient PH-Paramedic El-Menyar A., Sathian B., Asim M., Latifi R., Al-Thani H. Efficacy of prehospital administration of tranexamic acid in trauma patients A meta-analysis of the randomized controlled trials. Am J Emerg Med 2018; 36(6) 1079-87. Medline
II Supportive (Green) Venous thromboembolism Patient ED-MD Knowlton LM, Arnow K, Trickey AW, Sauaia A, Knudson MM. Does tranexamic acid increase venous thromboembolism risk among trauma patients? A prospective multicenter analysis across 17 level I trauma centers. Injury Nov 2023; 54(11):111008. Medline
II Supportive (Green) In Hospital mortality at 24 and 48 hours Patient PH-Paramedic Morrison JJ., Dubose JJ., Rasmussen TE., Midwinter MJ.. Military application of tranexamic acid in trauma emergency resuscitation (MATTERs) study. Arch Surg 2012; 147(2):113-9. Medline
II Supportive (Green) In-hospital mortality Patient PH-Paramedic Morrison JJ., Ross JD., Dubose JJ., Jansen JO., Midwinter MJ., Rasmussen TE. Association of cryoprecipitate and tranexamic acid with improved survival following wartime injury: Findings from the MATTERs II study. JAMA Surg 2013; 148(3):218-25. Medline
II Supportive (Green) Mortality recorded at 24 hours Patient PH-Paramedic Neeki MM, Dong F, Toy J, Vaezazizi R, Powell J, Wong D, et al. Tranexamic Acid in Civilian Trauma Care in the California Prehospital Antifibrinolytic Therapy Study. The western journal of emergency medicine 2018; 19(6):977-86. Medline
II Supportive (Green) Blunting of measures of coagulopathy Patient PH-Paramedic & CCT Stein P., Studt JD., Albrecht R., Maller S., von Ow D, Fischer S., et al. The Impact of Prehospital Tranexamic Acid on Blood Coagulation in Trauma Patients. Anesth Analg 2018; 126(2) 522-9. Medline
II Neutral (Yellow) 30 day mortality Patient PH-MD & CCT Bossers SM, Loer SA, Bloemers FW, Den Hartog D, Van Lieshout EMM, Hoogerwerf N, et al. Association Between Prehospital Tranexamic Acid Administration and Outcomes of Severe Traumatic Brain Injury. JAMA Neurol 2021; 78(3):338-45. Medline
II Neutral (Yellow) In hospital mortality Patient ED-Paramedic & MD Boutonnet M., Abback P., Le Sachac F., Harrois A., Follin A., Imbert N., et al. Tranexamic acid in severe trauma patients managed in a mature trauma care system. The journal of trauma and acute care surgery 2018; 84(6) S54-62. Medline
II Neutral (Yellow) Hospital LOS Patient Other Cornelius BG., McCarty K., Hylan K., Cornelius A., Carter K., Smith KWG., et al. Tranexamic Acid Promise or Panacea The Impact of Air Medical Administration of Tranexamic Acid on Morbidity, Mortality, and Length of Stay. Advanced emergency nursing journal; 40(1) 27-35. Medline
II Neutral (Yellow) Appropriate use Process PH-Paramedic Kheirbek T, Jikaria N, Murray B, Martin TJ, Lueckel SN, Stephen AH, et al. Unjustified Administration in Liberal Use of Tranexamic Acid in Trauma Resuscitation. J Surg Res 2021; 258:125-31. Medline
II Neutral (Yellow) Mortality Patient PH-Paramedic Neeki MM, Dong F, Toy J, Vaezazizi R, Powell J, Jabourian N, et al. Efficacy and Safety of Tranexamic Acid in Prehospital Traumatic Hemorrhagic Shock: Outcomes of the Cal-PAT Study. The western journal of emergency medicine 2017; 18(4):673-83. Medline
II Neutral (Yellow) survival with a favorable functional outcome at 6 months after injury Patient PH-Paramedic PATCH-Trauma Investigators and the ANZICS Clinical Trials Group; Gruen RL, Mitra B, Bernard SA, McArthur CJ, et al. Prehospital Tranexamic Acid for Severe Trauma. N Engl J Med 2023. Medline
II Neutral (Yellow) Incidence of Myocardial Injury Patient ED-Paramedic & MD Stroda A, Thelen S, M’Pembele R, et al. Possible effect of the early administration of tranexamic acid on myocardial injury in patients with severe trauma. J Thromb Thrombolysis February 2024; 57(2 PG-179-185):179-185. Medline
II Neutral (Yellow) In-hospital mortality Patient PH-Paramedic Van Wessem KJP, Jochems D, Leenen LPH. The effect of prehospital tranexamic acid on outcome in polytrauma patients with associated severe brain injury. Eur J Trauma Emerg Surg 2021; 1–11. Medline
II Neutral (Yellow) Neutral on TXA Administration Patient Other Van Wessem KJP, Leenan LPH. Does Liberal Prehospital and In-Hospital Tranexamic Acid Influence Outcome in Severely Injured Patients? A Prospective Cohort Study. World J Surg 2021; 45(8):2398–407. Medline
II Neutral (Yellow) Adverse outcomes Patient PH-Paramedic van Wessem KJP, Leenen LPH. Does Liberal Prehospital and In-Hospital Tranexamic Acid Influence Outcome in Severely Injured Patients? A Prospective Cohort Study. World J Surg 2021; 45(8):2398-407. Medline
II Opposes (Red) Reliability Process PH-Paramedic Valle EJ., Allen CJ., Van Haren RM., et al. Do all trauma patients benefit from tranexamic acid? J Trauma Acute Care Surg 2014; 76(6):1373-1378. Medline
III Supportive (Green) Management of hemorrhagic shick Patient PH-Paramedic Cathers AD, Forsythe J, Sippel N, Williamson C, Kohler JE, Brazelton TB, et al. Tranexamic Acid Use in Pediatric Hemorrhagic Shock From Farm-Related Trauma: A Case Report. Air Med J 2020; 39(5):414-6. Medline
III Supportive (Green) Managing hemorrhagic shock Patient PH-MD & CCT Lima LPST, Santos PRS, Martins HJ, Rodrigues DAS, Silva LM, Libardi MBO, et al. Use of Tranexamic Acid in Traumatic Resuscitation in a Prehospital Setting: A Case Report. Air Med J 2021; 40(5):359–62. Medline
III Supportive (Green) Efficacy Patient PH-Paramedic Vu EN, Wan WCY, Yeung TC, Callaway DW. Intramuscular Tranexamic Acid in Tactical and Combat Settings. Journal of special operations medicine: a peer reviewed journal for SOF medical professionals; 18(1):62-8. Medline
III Neutral (Yellow) Hyperfibrinolysis Patient PH-Paramedic Kunze-Szikszay N., Krack LA., Wildenauer P., et al. The pre-hospital administration of tranexamic acid to patients with multiple injuries and its effects on rotational thrombelastometry: A prospective observational study in pre-hospital emergency medicine. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2016; 24(1):122. Medline
III Opposes (Red) Adverse event Patient ED-MD Carroll ND., Restrepo CS., Eastridge BJ., Stasik CN. Left atrial thrombi following tranexamic acid in a bleeding trauma patient-A word of caution. J Card Surg 2018; 33(2) 83-5. Medline
X Not Yet Graded (White) - Patient Wafaisade A., Lefering R., Bouillon B., Bohmer AB., Gassler M., Ruppert M., et al. Prehospital administration of tranexamic acid in trauma patients. Crit Care 2016; 20(1):143-016-1322-5. Medline

Vascular Clamps
Level Direction Primary Outcome Patient/Process Setting Reference

Wound packing
Level Direction Primary Outcome Patient/Process Setting Reference
III Supportive (Green) Time on examination and intervention Process SIM Blix SW, Melau J, Lund-Kordahl I. Performance of Norwegian civilian EMTs and army medics in penetrating trauma: a controlled simulation-based assessment. Acta Anaesthesiol Scand 2017; 61(7):848-853. Medline

Wrap saline gauze-sterile bag-ice water
Level Direction Primary Outcome Patient/Process Setting Reference


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