Assessing Evidence Bias for Prehospital Tourniquet Use: A Scoping Review

The available evidence for the prehospital use of tourniquets is largely based on the military experience of high-resource countries over the last 30 years. Though the lifesaving benefits of an appropriately applied tourniquet to stop catastrophic bleeding are undeniable, the potential consequences of tourniquet application differ greatly within different environments. In many low resource settings, both the time until initial treatment and the evacuation time to a qualified medical care can range from hours to days. The global burden of trauma disproportionally affects low- and middle-income countries, however the guidelines and training regimes surrounding tourniquet use are based upon data collected from high resource settings may not be directly transferable to these settings.

A scoping review was employed to assess the geographical and socioeconomic distribution of the currently available reports with clinical outcomes regarding prehospital tourniquet use. Multiple factors were analyzed including socioeconomic, civilian/military, and geographic variables. Following PRISMA-ScR guidelines, the search strategy was outlined, and a title/abstract screening followed by a full text screening was performed separately by two qualified physicians. Reports not presenting outcome measures were excluded.

A total of 52 reports involving 27,429 patients were included in this scoping review. Most reports were conducted in the USA (48%) or Iraq/Afghanistan (31%), with all primary authors affiliated with high-income countries, such as the USA, Israel, and the UK. No reports meeting the inclusion criteria had primary authors based in low-income countries. The study population was predominantly young (mean age 31 years) and male (89%). Penetrating trauma from ballistic injuries and blasts were the most common mechanisms of injury. The average pre-hospital tourniquet application time was 146 min (median: 72 min). Mortality was the most frequently reported outcome (85%), followed by limb salvage (63%) and neurological impairment (48%).

This review highlights the limited data on pre-hospital tourniquet use in resource-limited settings, creating a gap that risks misinformed interventions in these contexts. The absence of research originating from authors in the low-income settings being studied is notable. Addressing this disparity is crucial to developing safe and effective guidelines applicable across diverse global healthcare environments.