INTRODUCTION:

Trauma is a very serious injury to a person's body that creates unpleasant experience. Traumatic injury is the leading cause of death worldwide among persons between 5 and 44 years of age and accounts for 10% of all deaths. It is the fifth leading cause of death in the India, with uncontrolled bleeding it leads to potentially preventable death. (Lewis, 2004)

United Nations Organization, (2009), in its Global Status Report on Road Safety, estimated that over 90% of the world’s fatalities on the roads occur due to uncontrolled hemorrhage. Predicts that road traffic injuries will rise to become the fifth leading cause of death by 2030. At the same time, injuries are considered one of the most avoidable health problems. Bleeding is the loss of blood from circulatory system. Improving our ability to control bleeding may represent the next major hurdle in reducing trauma mortality. Uncontrolled or severe bleeding can contribute to shock, circulatory disruption, or more serious health consequences such as damage to tissues and major organs, which can lead to death, (Hilbert P, 2012).

According to Indian express (2008), The number of road accident deaths per lakh of population which is 10.5 in India. As many as 51% of all deaths in the first 48 hours of hospitalization are related to lack of homeostasis in the early period which is a golden hour. World Health Statistics During the year 2010, there were around 5 lakh road accidents, which resulted in deaths of 134, 513 people and injured more than 5 lakh persons in India. These numbers translate into 1 road accident every minute and 1 road accident death every four minutes. The loss to the Indian economy due to fatalities and accident injuries estimated at 3% of GDP in 2000-2010 is particularly due to severe bleeding of 53.1% of road accident victims and were in the age group of 25 to 65 years in 2010, (WHO, 2010).

Severe bleeding accounts for about one third of in-hospital deaths due to trauma. It is an important contributory factor for other causes of death. The cause of external hemorrhage can be varied depending on the setting in which the injury has taken place. Some of these causes include, but are not limited to, gunshots, stabbings, shrapnel, vehicle accidents and blasts. Failure to start appropriate early management in bleeding trauma patients is a leading cause of preventable death from trauma, (David Prieto-Merino, 2011).

Failures to stop bleeding within the first 24 hours are almost uniformly fatal. You must also recognize the type of bleeding, apply the appropriate hemorrhage control techniques, understand the varying degrees of risk associated with types of hemorrhage, and how to estimate blood loss, (Thomas J, 2011). External bleeding can result in severe of blood loss with resultant shock and subsequent death. Injury can cause damage to vital organs, painful, swelling, weakness, faintness, increased thirst, dropping of blood pressure, dilated pupils, nausea and vomiting. Mainly noticed signs are Massive blood loss and obvious signs and symptoms of shock, (Joyce M black, 2006). In 2008, 800000 injury related deaths in Europe accounted for 8.3% of total deaths (WHO, 2006). Gujarat it stands in fourth place per road injuries causing death. Gujarat leads in India and as fast growing cities more accidents and among surat is leading city with trauma and road traffic accidents. Applying appropriate haemorrhage control techniques are of much help to reduce the mortality rates due to massive bleeding. Techniques such as apply fingertip pressure directly on the point of bleeding, elevation of bleeding extremity, packing the wound with sterile dressing, direct hand pressure, pressure points, splints, pressure splints, and tourniquet application, (Moore FA, 2010)

A tourniquet acts as a constricting or compressing device used to control venous and arterial circulation to an extremity for a period of time. A tourniquet represents a simple and efficient method for acute external hemorrhage control. Tourniquet should be left in place until surgical control of bleeding is achieved, (Holcomb, 2008).

Reported a systematic review and Meta-analysis published randomized controlled trials evaluating the efficacy of tourniquet in reducing blood loss and transfusion in limb injury patients. The data were evaluated using the generic evaluation tool designed by the Cochrane Bone, Joint and Muscle Trauma Group. We identified 11 clinical trials which were suitable for detailed extraction of data. A total of seven studies (comprising 350 patients) were eligible for the blood loss outcome data. The use of tourniquet reduced intra-operative blood loss by a mean of 104 ml (95% confidence interval (CI) −164 to −44, p = 0.0006, heterogeneity ( 0%), postoperative blood loss by a mean of 172 ml (95% CI −263 to −81, p = 0.0002, heterogeneity ( 63%) and total blood loss by a mean of 289 ml (95% CI −440 to −138, p < 0.0002, heterogeneity (54%). tourniquet led to a significant reduction in the proportion of patients requiring allogeneic blood transfusion (risk difference −0.20, 95% CI −0.29 to −0.11, p < 0.00001, I² 15%). There were no significant complications among the study groups, (M. Sukeik, 2010).

Smith (2009), conducted a random-effects meta-analysis study in Norfolk & Norwich University Hospital, United Kingdom. This study compares the intra- and post-operative outcomes of upper limb orthopaedic surgical procedures performed with and without tourniquet assistance. A systematic review was undertaken assessing the electronic databases Medline, CINAHL, AMED and EMBASE. The evidence-base was critically appraised using the Cochrane Bone, Joint and Muscle Trauma Group quality assessment tool. Study heterogeneity was statistically tested using chi- square statistics. Where appropriate random-effects meta-analysis was undertaken to pool results of primary studies assessing mean difference of each outcome. Two studies investigating 55 patients undergoing upper limb surgery were identified. The limited findings suggest that the use of tourniquets will reduce 76% (i.e CI = 3.1, MD= 0.1) (P= <0.001). Therefore the researcher is interested in application of tourniquet to control external bleeding as it is a preventable by taking proper measures in right time which is so called “GOLDEN HOUR”

STATEMENT OF PROBLEM:

Effectiveness of tourniquet application on external bleeding among trauma patients at METAS Adventist Hospital, Surat, Gujarat.

OBJECTIVES:

1. To assess the level of external bleeding among trauma patients in experimental and control group after tourniquet application.

2. To determine the effectiveness of tourniquet application on external bleeding among trauma patients in control group and experimental group.

3. To find out the association between the post test scores of tourniquet application on external bleeding among trauma patients with their demographic variables in experimental and control group.

HYPOTHESES:

H1: There is significant reduction of external bleeding among trauma patients in control group and experimental group after tourniquet application.

H2:There is significant effectiveness of tourniquet application on external bleeding among trauma patients in experimental group than control group.

H3: There is significant association between the post test scores of tourniquet application on external bleeding among trauma patients in control group and experimental group with their demographic variables.

DELIMITATIONS:

This study was delimited to

· Assess the effectiveness of tourniquet application.

· Identify the external bleeding at 10 min interval in group I, 15 min interval and 20 min interval.

· Trauma patients

· METAS Adventist Hospital, Surat, Gujarat.

MATERIALS AND METHODS:

Research Approach:

A quantitative research approach was selected to collect the data from the trauma patients to evaluate the external bleeding.

Research Design:

True experimental, Posttest with control group design was selected to evaluate the effectiveness of tourniquet application on external bleeding among trauma patients.

Randomly selected trauma patients.	Intervention	Post Test
	X1	O1
Experimental group	X2	O2
	X3	O3
Control Group	-	O4

Setting of the study:

The study was conducted in METAS Adventist Hospital at Surat, Gujarat.

Population:

The population for the present study was the trauma patients.

Sample:

The sample consists of 40 trauma patients.

Sampling Technique:

All the trauma patients admitted in emergency department during the period of data collection was selected as samples.

Exclusion Criteria:

Trauma patients with, Shock, Severe head injury, Brain death, No bleeding, Petechial bleeding, mild bleeding and debilitating bleeding according to WHO grading scale.

Development of the tool:

A baseline Proforma and Revised trauma scale on external bleeding on trauma patients was prepared with the help of review of literature, clinical experience and discussion with experts.

Description of the tool:

Section-A:

Demographic variables of trauma patients.

Section-B:

Revised trauma scale to assess severity of bleeding by world trauma organization.

Scoring Procedure of external bleeding for trauma patients:

Based on the percentage of scores the level of selected vital parameters was graded into four Grades i.e. categories i.e, “No bleeding”, “Petechial bleeding”,” Mild bleeding”, and “Gross bleeding”.

LEVEL OF BLEEDING	ACTUAL SCORE	PERCENTAGE
Gross blood loss	1-3	25%
Mild blood loss	4-6	50%
Petechial bleeding	7-9	75%
No bleeding	10-12	100%

PLAN FOR DATA ANALYSIS:

· Assess the level of external bleeding among control and experimental group of trauma patients after tourniquet application was analyzed by using frequency and percentage.

· Assess the effectiveness of tourniquet on external bleeding among trauma patients in experimental and control group was analyzed by using mean, standard deviation, mean percentage, paired ‘t’ test and unpaired ‘t’ test.

· Association between post test scores of tourniquet application among control and experimental group of external bleeding with their demographic variables was analyzed by using Chi-square test.

RESULTS:

Section A: Frequency and percentage distribution of control and experimental groups post test scores of external bleeding among trauma patients (N1=10) (N₂=10) (N3=10) (N4=10).

Level of external bleeding	POST TEST SCORES
	Experimental group I		Experimental group II
	Frequency N₁	%	Frequency N₂	%
Gross blood loss	-	-	-	-
Mild blood loss	-	-	-	-
Petechial bleeding	6	60	1	10
No bleeding	4	40	9	90

Level of external bleeding	POST TEST SCORES
	Experimental group III		Control group
	Frequency N₃	%	Frequency N₄	%
Gross blood loss	-	-	-	-
Mild blood loss	-	-	-	-
Petechial bleeding	1	10	6	60
No bleeding	9	90	4	40

80

Section B:

Unpaired’ test value of post test scores of External bleeding in control group and experimental groups.

Level of external bleeding	Unpaired ‘t’ test		Level of Significant
Level of external bleeding	Calculated value	Table value	Level of Significant
Control group and experimental group-I posttest	0.8	2.021	P>0.05 Not Significant
Control group and experimental group-II posttest	2.62	2.021	P<0.05 Significant
Control group and experimental group-III posttest	3.896	2.021	P<0.05 Significant

DF =38 Table value=2.021 P<0.05 significant

Section C:

Comparison of mean, standard deviation, and mean percentage of level of external bleeding among control and experimental group-I, II and III post test.

Trauma patients	Max scores	Post test scores			Difference from control group mean %
Trauma patients	Max scores	Mean	SD	Mean %	Difference from control group mean %
Control Group	12	9.4	1.05	78.3	-
Experimental Group-I	12	9	1.24	75	3.3
Experimental Group-II	12	10.7	1.20	89.1	0.8
Experimental Group-III	12	11.2	1.05	93.3	15

Comparison of mean, SD, and mean percentage of control and experimental group-I post test scores reveals that, in control group post test the mean score was (9.4 ± 1.05), which is 78.3%, in experimental group-I post test the mean score was (9 ± 0.24), which is 75%, showing a difference of 3.3 on reduction of external bleeding. experimental group-II, post test the mean score was (10.7 ± 1.20), which is 89.1%, showing a difference of 10.8 on reduction of external bleeding, where as in experimental group-III, post test the mean score was (11.2 ± 1.05), which is 93.3%, showing a difference of 15% on reduction of external bleeding. It seems that tourniquet was effective on external bleeding among trauma patients.

CONCLUSION:

· In experimental group I most of the trauma patients with external bleeding were males, in the age group 18-27 years and 28-36 years, and lower limb injury.

· In experimental group II most of the trauma patients with external bleeding were males, in the age group 37-45 years, and lower limb injury.

· In experimental group III most of the trauma patients with external bleeding were males, in the age group 37-45 years, and had lower limb injury.

· In control group most of the trauma patients with external bleeding were males, in the age group 28-36 years, and had lower limb injury.

· There was no significant effectiveness of tourniquet on external bleeding among trauma patients in control group with routine procedures and experimental group-I with tourniquet after 10 minutes of time duration.

· There was a mild significant effectiveness of tourniquet on external bleeding among trauma patients in experimental group-II (15 minutes).

· There was a moderate significant effectiveness of tourniquet on external bleeding among trauma patients in experimental group-III (20 minutes).

· There was no significant association between post test scores on external bleeding among experimental group and control group with their selected demographic variables such as age in years, gender and site of bleeding.

IMPLICATIONS FOR NURSING:

Nursing Service

· Tourniquet can be used by the Nursing professionals for controlling external bleeding in trauma patients for 20 minutes of time duration.

· It is easy procedure, time saving, cost effectiveness reduces mortality.

· Nursing professionals can use tourniquet as an alternative procedure for controlling external bleeding which is effective and easily available.

· Tourniquet can be used in prehospital set up and remote areas as first aid treatment in controlling external bleeding.

Nursing Education:

· Nurse educator should educate the students regarding tourniquet application and its importance.

· Nurse educator should encourage the Nursing personnel to practice the tourniquet application in their clinical settings.

· Nurse educator should educate the Nursing personnel regarding the mode of application of tourniquet in order to use as an alternative procedure.

Nursing Administration:

· Nurse administrator can review the policies to include tourniquet application as a protocol for managing trauma patients with external bleeding in emergency and trauma department.

· Nurse administrator can encourage the researchers to conduct the research to identify the effectiveness of tourniquet on external bleeding.

Nursing Research:

· The study may be issued for further reference.

· Further large scale study can be done in different settings.

RECOMMENDATIONS:

· A study can be conducted with large samples to generalize the findings.

· A similar study can be conducted in prehospital setting for early controlling of external bleeding.

· A similar study can be conducted in the battle field to prevent deaths from uncontrolled external bleeding from upper and lower limbs.

· A similar study can be compared with alternative techniques like direct hand pressure, elevation of bleeding extremity, packing the wound with sterile dressing, use of splints and pressure splints,

· A comparative study can be conducted to assess the effectiveness of tourniquet among trauma patients with upper limbs Vs lower limbs.

REFERENCES:

1. Holcomb JB, et al. Mortality from isolated civilian penetrating extremity injury. Journal of Trauma. 2005;59: 217-222.

2. Sebesta JA, et al. Prehospital tourniquet use in Operation Iraqi Freedom: Effect on hemorrhage control and outcomes. Journal of Trauma. 2008; 64: S28-S37.

3. Kragh JF, et al. Practical use of emergency tourniquets to stop bleeding in major limb trauma. Journal of Trauma. 2008;64: S38-S50.

4. Jones JA, et al. Battle casualty survival with emergency tourniquet use to stop limb bleeding. Journal of Emergency Medicine. 2009. Article in press

5. Dorlac WC, et al. Impact of bleeding-related complications. Journal of trauma and accident.2007; volume-2:Pp46-54.

6. DeBakey ME et al. Survey of the indications for use of emergency tourniquets. Journal of Trauma.2011;2011;S42-S49

7. Black Bourne LH, et al. bleeding trauma patients. Journal of Emergency Medicine. 201264: S38-S47

8. Littrel ML, et al. Damage Control Resuscitation in trauma. Health Services Research 2011. S18-S25

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Received on 18.05.2015 Modified on 20.06.2015

Asian J. Nur. Edu. and Research 5(4): Oct.- Dec.2015; Page 526-530

DOI: 10.5958/2349-2996.2015.00108.1

*Corresponding Author Email: mose_kana2000@yahoo.com