Control of Severe, Life-Threatening External Bleeding in the Out-of-Hospital Setting: A Systematic Review

Objective Trauma, with resultant bleeding, is a significant cause of morbidity and mortality throughout the world; however, the best possible method of bleeding control by immediate responders is unknown. We performed a systematic review of the effectiveness of treatment modalities for severe, life-threatening external bleeding in the out-of-hospital first aid setting. Methods: We followed the Cochrane Handbook for Systematic Reviews of Interventions methodology and report results according to PRISMA guidelines. We included randomized controlled trials, non-randomized comparative studies and case series investigating adults and children with severe, life-threatening external bleeding who were treated with therapies potentially suitable for first aid providers. We assessed the certainty of the evidence and risk of bias. Outcomes were prioritized by first aid specialists based on importance for patients and decision-makers and included mortality due to bleeding, all-cause mortality, cessation of bleeding, time to cessation of bleeding, a decrease in bleeding, and complications/adverse effects. Results were reported in Evidence Profiles. Results: Of the 1,051 full-text articles screened, 107 were included for analysis including 22,798 patients. The primary methods of bleeding control were tourniquets (n = 49), hemostatic dressings (n = 34), hemostatic devices (n = 14), pressure dressings/bandages/devices (n = 8), pressure points (n = 4), including 2 studies that reported multiple hemorrhage control methods. Overall, certainty of evidence was very low and often relied on indirect evidence and poorly controlled studies. Tourniquets were associated with a decrease in mortality when compared with direct manual pressure. Hemostatic dressings resulted in a shorter time to hemostasis than direct manual pressure using standard dressings. Direct manual compression resulted in a shorter time to hemostasis than pressure dressings/devices. Conclusion: Overall, data regarding the control of life-threatening bleeding is of very low certainty, making it difficult to draw robust conclusions for treatment by immediate responders. While more robust data is needed on first aid treatments of life-threatening bleeding, this systematic review aggregates the most comprehensive to date to help guide recommendations. Key words: bleeding; hemorrhage; tourniquet; hemostatic dressing; direct pressure

创伤伴发出血是全球范围内导致发病与死亡的重要诱因之一，但现场急救人员目前尚无公认的最佳出血控制方案。本研究针对院外急救场景下危及生命的严重外出血治疗手段的有效性开展了系统综述。方法：本研究遵循《Cochrane干预性系统综述手册》（Cochrane Handbook for Systematic Reviews of Interventions）的方法学规范，并按照PRISMA指南报告研究结果。本研究纳入了针对成人与儿童严重危及生命的外出血、且采用适用于急救人员的治疗手段的随机对照试验、非随机对照比较研究以及病例系列研究。本研究对证据质量与偏倚风险进行了评估。急救专家基于对患者与决策者的重要性对结局指标进行了优先级排序，包括出血相关死亡率、全因死亡率、出血停止情况、出血停止时间、出血量减少情况以及并发症/不良反应。研究结果以证据概要表（Evidence Profiles）形式呈现。结果：本次检索共筛选出1051篇全文文献，最终纳入107篇进行分析，涉及22798名患者。纳入研究的主要出血控制手段包括止血带（n=49）、止血敷料（n=34）、止血装置（n=14）、加压敷料/绷带/加压装置（n=8）以及按压止血点（n=4），其中2项研究同时报道了多种出血控制手段。整体而言，本研究纳入的证据质量极低，且多依赖间接证据与方法学质量欠佳的研究。与徒手直接按压相比，使用止血带可降低患者死亡率。相较于使用标准敷料的徒手直接按压，止血敷料可缩短止血所需时间。徒手直接按压的止血时间短于加压敷料/加压装置。结论：整体而言，现有关于危及生命的外出血控制的数据证据质量极低，难以针对现场急救人员的临床救治得出可靠结论。尽管针对危及生命的外出血急救治疗的高质量数据仍有待补充，但本系统综述整合了目前为止最为全面的相关研究证据，可为临床推荐方案的制定提供参考。关键词：出血；大出血；止血带；止血敷料；直接按压