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Limb Amputation/Mangled/Major Hemorrhage

Date Last Search Run: Feb 01, 2022
Table last updated: Apr 02, 2022
Data last added: Mar 27, 2022

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

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) 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
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
X Not Yet Graded (White) - 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
X Not Yet Graded (White) - 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

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 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
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) 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) 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) 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) 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) 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 Process 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 Patient 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
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) 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) 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
X Not Yet Graded (White) - 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

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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