EMS FOCUS Webinar Recap: Tourniquets and Hemostatic Dressings -
The New Evidence-Based Guideline


EMS Focus Webinar

Drew Dawson, Director of NHTSA'S Office of Emergency Medical Services, opened the webinar that included informative discussions about the importance of evidence-based guidelines (EBGs) for prehospital care, the U.S. military's experience with tourniquets and hemostatic dressings and the recently-published evidence-based guideline on external hemorrhage control, developed in partnership with the American College of Surgeons.


Dawson then introduced several physician experts who explained the purpose and implementation of the evidence-based guideline.


Why Does EMS Need Evidence-Based Guidelines for Prehospital Care?

Peter Taillac, MD, FACEP, and the State of Utah EMS medical director, explained the purpose of EBGs for prehospital care and why EMS needs them. He defined EBGs as systematically developed statements designed to assist EMS systems, medical directors and field personnel make decisions about appropriate health care for patients in specific clinical situations.


The "evidence-based" language implies that the recommendations were created not only using the best scientific evidence available, but also that the process used to develop the EBGs was transparent, unbiased, and systematic. The EBGs are recommendations - not rules - supported by the best available evidence in scientific literature.


According to Taillac, EBGs are important because they provide EMS systems with a tool to help improve patient care. For field providers, this means they can be confident that the care they provide their patients is based on the best available medical evidence; EMS system adoption of EBGs means every patient receives the same high standard of care.


Why does EMS need prehospital EBGs?

• To improve patient outcomes
• To provide the best possible patient care based on the available medical evidence
• To minimize variability in patient care
• To increase patient safety
• To decrease liability
• To improve prehospital research
• Enhance performance improvement


Dr. Taillac posed questions to the audience regarding the current state of EMS protocols in their systems. These questions included, who creates the prehospital protocols in your system? Are your protocols up-to-date? Do they reflect the current best evidence or are they based on old protocols, training, habits or preferences?


Taillac noted that EBGs could be challenging to implement due to state or regional limitations, financial constraints and skepticism. He emphasized that the world of prehospital research is a new and growing field and that EBGs should be developed and implemented now and updated regularly to stay current and optimize benefits to the patient and provider.


History of the Bleeding Control Evidence-Based Guideline


Richard Hunt, MD, FACEP, Director for Medical Preparedness Policy with the National Security Council Staff explained the history of the bleeding control evidence-based guideline. In February 2013, leading national trauma experts met with Federal agency and White House staffs to provide input on the gaps in the U.S. trauma system and to identify opportunities for system improvement. During that discussion, particular emphasis was placed on implementing the lessons learned by the Department of Defense to critical issues facing civilian trauma care in the United States.


There was far-reaching discussion about opportunities to improve the trauma system, but the final recommendation was that one simple step could significantly improve the care of civilians: Build on the lessons learned from the military to promote the use of tourniquets and hemostatic dressings to control bleeding for injured civilians. And, how timely this advice was - the Boston Marathon bombing and other tragic events that followed demonstrated the critical importance of bleeding control.


Dr. Hunt explained that prompt and proper bleeding control is not just a matter of good emergency medical services; it is also a matter of national security and national resilience.


Hunt praised the American College of Surgeons' Committee on Trauma in coordination with NHTSA and EMS for Children for the collaborative development of the Evidence-Based Practice Guidelines for External Hemorrhage Control in a remarkably short time period.


Military Experience & Evidence


Colonel Todd Rassmussen, MD, FACS, provided insight into the military's experience with bleeding control guidelines. Of the variety of statistics he shared, most notable was from a study of preventable deaths on the battlefield - that is deaths in which there were no mortal head or cardiac wounds or complex body disruption. Ninety percent of preventable deaths were due to hemorrhage.


Upon further investigation of that 90 percent, half of those deaths were a direct result of bleeding from the torso, making non-compressible torso hemorrhage the leading cause of preventable death in U.S. service personnel in the wars in Iraq and Afghanistan.


He went on to discuss the importance of mitigating these preventable deaths, and talked about how the lessons learned on the battlefield have translated to use by EMS professionals. Rassmussen also cited several media stories and medical journal articles highlighting the argument that lessons learned in combat abroad should be used to address civilian trauma issues.


Col. Rassmussen also said that the Department of Defense Trauma Registry is the largest repository of injury and injury management information in history - and that researchers in EMS should be looking at it more closely


External Hemorrhage Control in the Prehospital Setting - The Evidence-Based Guideline


Dr. Eileen Bulger, MD, FACS, who was instrumental in the development of this EBG and who chairs the America College of Surgeons Committee on Trauma, discussed the process used to develop a guideline for civilian prehospital management of external hemorrhage using a systematic literature review and the GRADE methodology.


The development of EBGs using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology includes a priori development of key clinical questions, a systematic literature review, evaluation of the quality and applicability of the evidence and grading the strength of recommendations, balancing factors such risk, benefit, patient preference and cost.


Dr. Bulger shared a summary of the recommendation:
The use of tourniquets in the prehospital setting is recommended for the control of significant extremity hemorrhage if direct pressure is ineffective or impractical.


The review committee suggested the following:

• Use commercially produced windlass, pneumatic, or ratcheting devices that have been demonstrated to occlude arterial flow
• Do not use narrow, elastic, or bungee-type devices
• Use Improvised tourniquets only if commercial tourniquets are not available
• Do not release a tourniquet that has been properly applied in the prehospital setting until the patient has reached definitive care, except as advised by online medical direction


Additionally, the committee made recommendations regarding the use of topical hemostatic dressings, including:

• Use topical hemostatic agents in combination with direct pressure
• Deliver the hemostatic agents in a gauze format that supports wound packing
• Only use products determined effective and safe in a standardized laboratory


Dr. Bulger noted that the EBG advised that:

• Tourniquets and topical hemostatic agents be used under clinical practice guidelines and following product specific training;
• Prehospital personnel receive training to use hemostatic agents including proper wound packing and pressure application techniques; and that
• The use of tourniquets and topical hemostatic agents use be expanded to include all prehospital personnel, including emergency medical responders in law enforcement and fire services.


The final portion of the webinar provided an update from Scott Youngquist, MD, medical director of the Salt Lake City Fire Department, about the implementation of tourniquets in his agency.


Additional information about the evidence-based guideline and supporting materials from the webinar, including the presentation slide deck can be found at EMS.gov. Questions regarding the tourniquet and hemostatic dressing guideline and the webinar can be directed to nhtsa.ems@dot.gov.


The next installment of the EMS FOCUS webinar series will take place in the fall. Check ems.gov for details soon.


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