Tourniquets and Vascular Shunting

Educational Objectives

The goal of this program is to improve utilization of tourniquets and vascular shunting. After hearing and assimilating this program, the clinician will be better able to:

1. Consider the evidence supporting use of tourniquets and vascular shunting for the management of trauma.

Summary

Impacts on lives in combat: Beeckley et al (2008) show that 57% of deaths in the pre-tourniquet era would have been prevented with tourniquet application; Howard et al (2019) showed that tourniquets, blood transfusion, and prehospital transportation helped save a significant amount of lives among patients and war fighters with an injury severity score >25

Evidence: Teixeira et al (2018) demonstrated a 6-fold reduction in mortality for patients with peripheral vascular injury who were brought to the emergency department (ED) following civilian prehospital tourniquet placement; King et al (2015) noted that 27 of 152 patients from the Boston Marathon bombing already had improvised or commercial tourniquets upon arrival to the ED

Intravascular shunting: previously considered a temporary measure during damage control resuscitation to increase collateral circulation and save a limb; the use of shunting in the military has increased limb salvage and can improve patient pedal acceleration time classification from level 2 to level 1

Bullets: cause cavitary injury through creation of a change in pressure and rapid expansion of gases that are usually dissolved in the blood; the cavitary wave can be ≤25 times the diameter of the bullet; patient may experience loss of distal pulses; angiography may reveal a distinct cutoff; an intramural hematoma can form within an intact vessel; a thrombus may develop secondary to the cavitary wave; newer-style military-grade bullets cause intimal disruption

Readings

Howard JT, Kotwal RS, Stern CA, et al. Use of combat casualty care data to assess the US Military Trauma System during the Afghanistan and Iraq conflicts, 2001-2017 [published correction appears in JAMA Surg. 2019 May 1;:]. JAMA Surg. 2019;154(7):600-608. doi:10.1001/jamasurg.2019.0151; Tatebe LC, Schlanser V, Hampton D, et al. The tight rope act: a multicenter regional experience of tourniquets in acute trauma resuscitation. J Trauma Acute Care Surg. 2022;92(5):890-896. doi:10.1097/TA.0000000000003491; Teixeira PGR, Brown CVR, Emigh 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):769-776.e1. doi:10.1016/j.jamcollsurg.2018.01.047.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Hampton was recorded at 3rd Annual How to Save a Life: IR and Surgical Management of the Trauma Patient Conference, held November 6-8, 2023, in Lake Buena Vista, FL, and presented by the University of Chicago Pritzker School of Medicine. For information about upcoming CME activities from this presenter, please visit https://cme.uchicago.edu/SaveALife2023#group-tabs-node-course-default4. Audio Digest thanks the speakers and presenters for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0.50 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0.50 CE contact hours.

Lecture ID:

GS710402

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.

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