背景:止血带(TQ)最近在院前设置中越来越多地被采用。这项研究检查了在院前环境中对四肢创伤性血管损伤的平民患者应用TQ的有效性和安全性。
方法:我们系统地搜索了OvidEmbase,PubMed,和Cochrane中央对照试验注册数据库从成立到2023年6月。我们比较了院前TQ(PH-TQ)使用与没有PH-TQ,定义为到达医院后应用的TQ或根本不使用TQ,用于民用血管四肢创伤患者。主要结果是总死亡率,次要结局是血液制品的使用和住院时间.我们分析了TQ相关并发症作为安全性结果。我们试图纳入随机对照试验(RCTs)和非随机研究(包括非RCTs,中断的时间序列,控制前后研究,队列研究,和病例对照研究),如果有的话。计算汇总赔率比(OR),并使用建议评估分级评估评估证据的确定性,发展,和评估(等级)方法。
结果:纳入7项研究,涉及4,095名患者。在主要结果中,院前TQ(PH-TQ)使用显着降低四肢创伤患者的死亡率(比值比[OR],0.48,95%置信区间[CI]0.27-0.86,I2=47%)。此外,PH-TQ的使用呈现出血液制品利用率下降的趋势,如浓缩红细胞(平均差[MD]:-2.1[单位],95%CI:-5.0至0.8,I2=99%)或新鲜冷冻血浆(MD:-1.0[单位],95%CI:-4.0至2.0,I2=98%);然而,两者都没有统计学意义。在住院和重症监护病房的住院时间上没有观察到显着差异。对于安全结果,使用PH-TQ并没有显著增加截肢(OR:0.85,95%CI:0.43至1.68,I2=60%)或室综合征(OR:0.94,95%CI:0.37至2.35,I2=0%)的风险。在所有结果中,证据的确定性非常低。
结论:当前数据表明,在院前环境中,PH-TQ用于四肢血管创伤性损伤的平民患者可降低死亡率,并倾向于减少输血。这并没有显着增加截肢或骨筋膜室综合征的风险。
Tourniquets (TQ) have been increasingly adopted in pre-hospital settings recently. This study examined the effectiveness and safety of applying TQ in the pre-hospital settings for civilian patients with traumatic vascular injuries to the
extremities.
We systematically searched the Ovid Embase, PubMed, and Cochrane Central Register of Controlled Trials databases from their inception to June 2023. We compared pre-hospital TQ (PH-TQ) use to no PH-TQ, defined as a TQ applied after hospital arrival or no TQ use at all, for civilian vascular extremity trauma patients. The primary outcome was overall mortality rate, and the secondary outcomes were blood product use and hospital stay. We analyzed TQ-related complications as safety outcomes. We tried to include randomized controlled trials (RCTs) and non-randomized studies (including non-RCTs, interrupted time series, controlled before-and-after studies, cohort studies, and case-control studies), if available. Pooled odds ratios (ORs) were calculated and the certainty of evidence was assessed using Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology.
Seven studies involving 4,095 patients were included. In the primary outcome, pre-hospital TQ (PH-TQ) use significantly decrease mortality rate in patients with extremity trauma (odds ratio [OR], 0.48, 95% confidence interval [CI] 0.27-0.86, I2 = 47%). Moreover, the use of PH-TQ showed the decreasing trend of utilization of blood products, such as packed red blood cells (mean difference [MD]: -2.1 [unit], 95% CI: -5.0 to 0.8, I2 = 99%) or fresh frozen plasma (MD: -1.0 [unit], 95% CI: -4.0 to 2.0, I2 = 98%); however, both are not statistically significant. No significant differences were observed in the lengths of hospital and intensive care unit stays. For the safety outcomes, PH-TQ use did not significantly increase risk of amputation (OR: 0.85, 95% CI: 0.43 to 1.68, I2 = 60%) or compartment syndrome (OR: 0.94, 95% CI: 0.37 to 2.35, I2 = 0%). The certainty of the evidence was very low across all outcomes.
The current data suggest that, in the pre-hospital settings, PH-TQ use for civilian patients with vascular traumatic injury of the
extremities decreased mortality and tended to decrease blood transfusions. This did not increase the risk of amputation or compartment syndrome significantly.