Efficacy of publicly accessible tourniquets: a systematic review of layperson performance utilizing simulation models

A large portion of preventable deaths is a result of uncontrolled bleeding due to a delay in medical intervention. While publicly accessible tourniquets raise the concern of incorrect application by laypeople, tourniquets have proven efficacy and can be effectively applied by bystanders. This systematic review aims to identify if tourniquets applied by laypeople using a basic manikin or tourniquet trainer extremity with little to no training can effectively control bleeding.

The authors used EBSCOHost to simultaneously search the following databases: Cumulated Index in Nursing and Allied Health Literature (CINAHL) Ultimate, Academic Search Premier, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Medical Literature Analysis and Retrieval System Online (MEDLINE) with Full Text. Boolean search strategy included tourniquet AND (layperson OR laypeople) AND ((bleeding AND control) OR (hemorrhage AND control) OR "stop the bleed") NOT surgery. The search was limited to January 1, 2013, to August 31, 2023. Inclusion criteria were layperson participants in peer-reviewed randomized controlled or clinical trials, available in English, that assessed at least one outcome measure related to the efficacy of tourniquet application in a simulated context. Articles including duplicate data and those regarding tourniquet use/efficacy in settings other than prehospital care or bleeding control were excluded. Two independent reviewers selected studies according to prespecified inclusion and exclusion criteria. Risk of bias was assessed using the Cochrane RoB 2 tool.

The initial search identified 83 studies, with 10 retained for inclusion in this review. Two different windlass rod tourniquets and one ratcheting strap tourniquet performed the best in terms of successful application by laypeople. Completing formal bleeding control training increased the average application success rate compared to no prior training. The Layperson Audiovisual Assist Tourniquet was the only audiovisual point-of-care aid that significantly increased the rate of successful applications. Just-in-Time visual cards also increased success rates significantly, showing comparable benefits to manufacturer instructions.

Although some laypeople can successfully place tourniquets without prior training, successful placement rates can be improved with point-of-care aids and formal bleeding control training using a basic manikin or tourniquet trainer extremity.