Advertisement

Field tourniquets in an austere military environment: A prospective case series

  • D.C. Covey
    Correspondence
    Corresponding author at: Department of Orthopaedic Surgery, University of California, 200 West Arbor Drive, San Diego, CA 92103.
    Affiliations
    Department of Orthopaedic Surgery, University of California, San Diego, 200 West Arbor Drive, San Diego, CA 92103, USA

    Level 2 United States Marine Corps Surgical Company, Al Anbar Province, Iraq
    Search for articles by this author
  • Christopher E. Gentchos
    Affiliations
    Concord Orthopaedics PA, 264 Pleasant Street, Concord, NH 03301, USA

    Level 2 United States Marine Corps Surgical Company, Al Anbar Province, Iraq
    Search for articles by this author
Open AccessPublished:July 27, 2022DOI:https://doi.org/10.1016/j.injury.2022.07.044

      Highlights

      • Field tourniquets applied for severe bleeding can significantly reduce transfusion requirements and help maintain adequate blood pressure.
      • Proper use of field tourniquets has few complications.
      • Field tourniquets have an important role in battlefield casualty care and in civilian prehospital care of extremity vascular injuries.

      Abstract

      Objective

      Field tourniquets are often used for battlefield extremity injuries. Their effectiveness has been documented by a large combat theater trauma center. However, their use and effectiveness by an austere forward surgical team has not been reported. Aims of this study were to determine: Whether field tourniquets: (1) Were placed for appropriate indications; (2) significantly reduced hemorrhage as measured by transfusion requirements; (3) influenced vital signs and injury severity scores; and (4) did they cause limb amputation, changed amputation level, or other complications.

      Methods

      Twenty-five patients with 30 involved extremities presenting to a forward surgical team in Iraq met the inclusion criteria. We prospectively collected data regarding the presence, indications for, and effectiveness of field tourniquets based on the need for blood transfusion. We recorded any complications associated with their use.

      Results

      Tourniquets significantly reduced hemorrhage from penetrating injuries as measured by transfusion requirements. Those having major vascular injuries with effective tourniquets, a total of 12 units of blood were transfused (1.7 units/vascular injury; 2 units/patient). However, 19 units were transfused in patients (3.3 units/vascular injury; 3.8 units/patient) who had an ineffective or no tourniquet (p = 0.0006). Transfusion requirements were related the presence of an effective tourniquet regardless of concomitant injuries. The group with effective tourniquets and compressed hemorrhage presented with higher mean systolic (p = 0.003) and diastolic (p = 0.023) blood pressures than the group with no tourniquets or ineffective ones. Complications included one peroneal nerve palsy and no amputations resulted from tourniquet application.

      Conclusion

      Field tourniquets applied for penetrating injuries with severe bleeding can significantly reduce transfusion requirements and help maintain adequate blood pressure. Tourniquets were not the proximate cause of amputation and did not determine the choice of immediate amputation level.

      Keywords

      Introduction

      Uncontrolled extremity hemorrhage is a major cause of potentially preventable death in combat casualties [
      • Bellamy R.F.
      The causes of death in conventional land warfare: implications for combat casualty care research.
      ], and field tourniquets are frequently used in the initial treatment of patients with life-threatening musculoskeletal injuries. They were used in the Iraq War and are used in combat operations in Afghanistan [
      • Kragh J.F.
      • Baer D.G.
      • Walters T.J.
      Extended (16-Hour) Tourniquet application after combat wounds: a case report and review of the current literature.
      ,
      • Walters T.J.
      • Mabry R.L.
      Issues related to the use of tourniquets on the battlefield.
      ,
      • Dunn J.C.
      • Kusnezov N.
      • Schoenfeld A.J.
      • Orr J.D.
      • Cook P.J.
      • Belmont P.J.
      Vascular injuries in combat-specific soldiers during operation Iraqi freedom and operation enduring freedom.
      ,
      • Dunn J.C.
      • Fares A.
      • Kusnezov N.
      • Chandler P.
      • Cordova C.
      • Orr J.
      • Belmont P.
      • Pallis M.
      US service member tourniquet use on the battlefield: Iraq and Afghanistan 2003-2011.
      ]. Most orthopedic surgeons are familiar with tourniquet use for surgery in civilian operating rooms [
      • Bruner J.M.
      Safety factors in the use of the pneumatic tourniquet for hemostasis in surgery of the hand.
      ,
      • Flatt A.E.
      Tourniquet time in hand surgery.
      ,
      • Graham B.
      • Breault M.J.
      • McEwen J.A.
      • et al.
      Occlusion of arterial flow in the extremities at subsystolic pressures through the use of wide tourniquet cuffs.
      ,
      • Moore M.R.
      • Garfin S.R.
      • Hargens A.R.
      Wide tourniquets eliminate blood flow at low Inflation pressures.
      ,
      • Odinsson A.
      • Finsen V.
      The position of the tourniquet on the upper limb.
      ,
      • Shaw J.A.
      • Murray D.G.
      The relationship between tourniquet pressure and underlying soft-tissue pressure in the thigh.
      ,
      • Swanson A.B.
      • Livengood L.C.
      • Sattel A.B.
      Local hypothermia to prolong safe tourniquet time.
      ,
      • Wakai A.
      • Winter D.C.
      • Street J.T.
      • Redmond P.H.
      Pneumatic tourniquets in extremity surgery.
      ]. In this controlled setting, tourniquet times ranging from one to three hours can usually be safely tolerated [
      • Klenerman L.
      Tourniquet time-how long?.
      ,
      • Kam P.C.
      • Kavanagh R.
      • Yoong F.F.
      • et al.
      The arterial tourniquet: pathophysiological consequences and anaesthetic implications.
      ]. Even though operating room tourniquets are wide, well-padded, carefully positioned and have controlled pressures [
      • Crenshaw A.G.
      • Hargens A.R.
      • Gershuni D.H.
      • Rydevik B.
      Wide tourniquet cuffs more effective at lower Inflation pressures.
      ], complications such as nerve palsy [
      • Odinsson A.
      • Finsen V.
      The position of the tourniquet on the upper limb.
      ] or muscle necrosis [
      • Williams J.E.
      • Tucker D.B.
      • Read J.M.
      Rhabdomyolysis-myoglobinuria: consequences of prolonged tourniquet.
      ] may still occur.
      Field tourniquet use for hemorrhage control in civilian extremity trauma has been questioned by some authors [
      • Husum H.
      • Gilbert M.
      • Wisborg T.
      • Pillgram-Larsen J.
      Prehospital tourniquets: there should be no controversy.
      ,
      • Lee C.
      • Porter K.M.
      • Hodgetts T.J.
      Tourniquet use in the civilian prehospital setting.
      ]. Potential concerns included severe ischemia with reperfusion injury, limb loss, and causing a more proximal amputation level than might otherwise be needed. These concerns also extended to tourniquet use on the battlefield. Conversely, a study by Lackstein et al. [
      • Lakstein D.
      • Blumfenfeld A.
      • Sokolov T.
      • Lin 6.
      • Bssorai R.
      • Lynn M.
      • Ben-Abraham R
      Tourniquets for hemorrhage control on the battlefield: a 4-year accumulated experience.
      ] on the tourniquet experience of the Israeli Defense Force in treating combat casualties found that 78% of 110 of tourniquets were effective and acute complications occurred in only 5 of 91 patients. Nevertheless, questions persisted regarding proper indications, application, timing, and complications of tourniquet use for combat casualty care [
      • Walters T.J.
      • Mabry R.L.
      Issues related to the use of tourniquets on the battlefield.
      ].
      In a comprehensive review of battlefield-related injuries, Owens et al. [
      • Owens B.D.
      • Kragh J.F.
      • Macaitis J.
      • Svoboda S.J.
      • Wenke J.C.
      Characterization of extremity wounds in operation Iraqi freedom and operation enduring freedom.
      ] reported that of 82% of 1566 military personnel who sustained combat injuries had extremity trauma. In a study of vascular injuries, Fox et al. [
      • Fox C.J.
      • Gillespie D.L.
      • 0′Donne 11 S.D.
      • Rasmussen T.E.
      • Goff J.M.
      • Johnson C.A.
      • Gaglon R.E.
      • Sarac T.P.
      • Rich N.M.
      Contemporary management of wartime vascular trauma.
      ] reported known or suspected vascular injuries in 7% of 1524 combat casualties of which 88% involved the extremities. In the initial care of today's combat casualties, tourniquets are often applied on the battlefield for extremity trauma with presumptive vascular injury. Military first responders (corpsmen and medics) are taught that tourniquets can be lifesaving [
      • Kragh J.F.
      • Baer D.G.
      • Walters T.J.
      Extended (16-Hour) Tourniquet application after combat wounds: a case report and review of the current literature.
      ], and they usually decide on its use at the point of injury.
      Aims of this study were to determine: Whether field tourniquet placement (1) was made for appropriate indications, (2) significantly reduced hemorrhage from penetrating injuries as measured by transfusion requirements, (3) if vital signs and injury severity scores were influenced by an effective tourniquet; and (4) did a tourniquet result in limb amputation, affect the immediate amputation level, or cause other complications.

      Patients and methods

      This study was approved by the Institutional Review Board of Naval Medical Center, San Diego. Tourniquet data was prospectively collected by a U.S. Marine Corps far forward surgical team in Al Anbar Province, Iraq, that received casualties from the point of injury. This surgical team was part of a Level 2 treatment facility within a 5-level echelon system where a higher number denotes increased sophistication of patient care [
      • Bagg M.R.
      • Covey D.C.
      • Powell E.T.
      Levels of medical care in the global war on terrorism.
      ].
      This case series included 25 consecutive patients (30 involved extremities) who sustained extremity trauma during a defined four-month period. There were 24 males and one female, and the mean age was 29 years (range, 6 to 66 years). The decision to use a field tourniquet (Combat Application Tourniquet; CAT Resources, Rock Hill, SC) was made by a corpsman or medic in the field at the time of injury using the following guidelines: (1) If under fire, tourniquets should be placed proximal to the site of hemorrhage, over the casualty's uniform, and tightened as necessary to stop the bleeding; (2) once the patient is not under fire, the wound should be reevaluated, the tourniquet applied directly to the skin 2 to 3 inches above the bleeding site, and tightened sufficiently to stop the distal pulse; (3) tourniquets should be rechecked frequently to ensure that the hemorrhage is still controlled; (4) tourniquets should be left in place without attempts to transition to other methods of hemorrhage control if evacuation is expected to take 2 h or less; (5) tourniquets should be used for all traumatic amputations; and (6) application time should always be documented [
      • Butler F.K.
      Tactical combat casualty care: update 2009.
      ].
      Each consecutive casualty who presented with a tourniquet in place composed Group 1, and those with presumptive extremity vascular injury based on clinical signs without a tourniquet composed Group 2 (Fig. 1). Patients were further classified as those who presented with an effective tourniquet (resulting in compressed hemorrhage), and those who presented either with an ineffective tourniquet or had major arterial hemorrhage without a tourniquet (uncompressed hemorrhage).
      Patients having any arterial or major venous injury were considered to have a vascular injury. However, a major vascular injury was defined in this study as a proximal venous injury, a large arterial injury requiring repair or ligation (such as in cases traumatic amputations of mangled extremities) above the knee or elbow [
      • Fox C.J.
      • Gillespie D.L.
      • 0′Donne 11 S.D.
      • Rasmussen T.E.
      • Goff J.M.
      • Johnson C.A.
      • Gaglon R.E.
      • Sarac T.P.
      • Rich N.M.
      Contemporary management of wartime vascular trauma.
      ]. Casualties with major vascular injuries were further divided into subgroups: those having a major vascular injury with an effective tourniquet (compressed major vascular injuries); and those with a major vascular injury without a tourniquet or an ineffective one (uncompressed major vascular injuries).

      Data collection

      Patient demographics, injury mechanism, and clinical and surgical data were recorded for each patient (Table 1). Reports of obvious arterial bleeding, massive bleeding, or uncontrolled bleeding were frequently recounted by the corpsman or patient at the time the field tourniquet was applied.
      Table 1Patient characteristics, injury, tourniquet and treatment data.
      PatientAgeTourniquet Time (min)Tourniquet EffectiveVital SignsExamMechanismSurgical FindingsVascular InjuryAssociated InjuriesProcedure(s)TransfusionNISS
      12560YesBP 129/60 HR 84 GCS 15 RR 16No R. DP or PT a. pulses until tourniquet releaseDismounted IED3B R. tib/fib fxs, no vascular injury (AIS = 3)NoneBlast bil. LEs (AIS = 2); face; arms (AIS = 2); jaw fx (AIS = 1); 3A L. ulna fx (AIS = 2)I&D, ex-fix R. tib/fib, I&D, splint L ulna fx, I&D soft tissue woundsNone13
      22270YesBP 92/50 HR 121 GCS 15 RR 30No R. radial or ulnar a. pulses, global paresthesiasGSWR. medial arm wound, laceration brachial a. (AIS = 3)Brachial a.GSW L RF (AIS = 1)Brachial a. shunt; SVG & fasciotomy (storm precluded medevac)1 U O+10
      329150YesBP 132/73 HR 94 GCS 15 RR 24No R. radial, ulnar a. pulses; hand cold, pale7-ton truck MVCR. near AEA, lacerated brachial a. (AIS = 3)Brachial a.Closed R. femur fx (AIS = 3); lig. injury L. knee (AIS = 2)AEA completion, ex-fix R. femurNone18
      41885YesBP 127/60 HR 76 GCS 15 RR 20No L. DP & PT a. pulses until tourniquet releaseDismounted IEDModerate size L thigh wounds w/o fx (AIS = 2)NoneNoneI&D woundsNone4
      52860YesBP 137/76 HR 113 GCS 15 RR 18No DP, PT a. pulses until tourniquet release; nerve deficit resolvedDismounted IEDR. leg soft tissue wounds (AIS = 2)NoneNoneI&D wounds, delayed partial closureNone4
      63658NoBP 114/73 HR 102 GCS 15 RR 16R. DP & PT a. pulses on arrivalDismounted IEDSoft tissue wound thigh, (AIS = 2)NoneNoneI&D wounds,None4
      72770YesBP 130/70 HR 91 GCS 15 RR 20R. leg pale, cool; no pulses, R. arm cool, no pulsesDismounted IEDMangled R. leg, 3 arteries transected, 3C tib/fib fxs (AIS = 3)Subclavian a., ant. tibial, post. tibial a; peroneal a.Shoulder girdle fxs (AIS = 3); colon injury (AIS = 4) hemothorax (AIS = 3)R. BKA; R. shoulder disarticulation3U O+; 2U Whole Blood25
      82470Yes, bothB/P 150/97 HR 85 GCS 15 RR 16R. foot traumatic amputation, no arterial bleeding; R. hand burns, no pulses, coolDismounted IEDMangled R. leg, 3 arteries transected (AIS =  3) Return of hand pulses, bone loss MC 3–5, soft tissue injury (AIS = 3)R. leg ant., post. tib. a, peroneal a; R. UE tourniquet w/o vascular injuryFacial laceration, hip laceration (AIS = 1)Guillotine R BKA, debride hand woundsNone18
      9*20154Yes, allBP 54/45 HR 129 GCS 11 (eyes = 1, motor = 5) RR 20L. arm cool & pale w/o pulses, open humerus fx; L. knee traumatic amputation; mangled R. legDismounted IEDTourniquet in place & no arterial bleeding during resuscitation from L. arm (AIS = 3) or bil. legs AIS = 3,4)L. brachial artery; R SFA; mangled RLE with vascular injuriesOpen head traumaPresenting temp 31° C, intra-thoracic active rewarming followed by open cardiac massagenone24
      1023125YesBP 95/43 HR 120 GCS 14 (Verbal = 4) RR 20Absent pulses; R. foot cool, paleGSWR. 3C tib/fib, peroneal a. lac.; tense compartments, pulses present with tourniquet release AIS = 3)Peroneal a.GSW abd & liver lac. (AIS =  3) GSW hemothorax (AIS = 3); GSWs gluteal region & R. thigh (AIS = 2)Ex-lap; L. chest tube; I&D; ex-fix & fasciotomy w/ ligation of peroneal a.5U O+, 4U Whole Blood18
      112470YesBP 73/56 HR 104 GCS 15 RR 24L foot absent pulses, cool, paleGSW & RPG blastNo fx; soft tissue wounds thigh (AIS = 2)None1) Bil. hemo-pneumothorax (AIS = 4) 2) small bowel perforation (AIS = 4)Bilateral chest tubes; ex-lap & small bowel resection; I&D soft tissue wounds3U autotransfusion32
      122486YesBP 132/68 HR 68 GCS 15 RR 21Traumatic amputation R. hand at mid carpusGrenade (picked up and threw to save others)Traumatic amputation of R. mid carpus (AIS = 3)Radial, ulnar a.Small frag wounds bil. thighs (AIS = 1) and chin (AIS = 1)I&D open amputation, ligation of radial, ulnar a.None10
      135679YesBP 130/80 HR 61 GCS 15 RR 24R. hand cool; pulses presentGSWRadius fx, lg. soft tissue defect, intact radial, ulnar a; tense forearm swelling (AIS = 3)NoneGSW chest/hemothorax (AIS = 3)R. chest tube I&D/fasciotomy R. forearm GSWNone18
      1450118YesBP 129/83 HR 92 GCS 15 RR 22L. arm cool, pale, absent distal pulsesGSWBBFA fx, radial a. segmental loss, intact, dominant ulnar a. (AIS = 3)Radial a.GSW L. thigh (No fx, ABI  = 1.1) (AIS = 2)I&D forearm w/ ex-fix, ligation radial a.None13
      1566170YesBP 150/65 HR 83 GCS 15 RR 24Absent pulses, DP, PT and Popliteal, R. foot coolGSWProximal saphenous v. lac, fxs superior & inferior pubic rami (AIS = 3)Saphenous v.GSW L. shoulder, no fracture, intact pulses (AIS = 2)I&D wounds, ligation saphenous v.None13
      16*3675No (both)BP 55/palp HR 134 GCS 8 RR 30Traumatic bilateral AKAsMounted IED blunt/blastTourniquets loose, no blood flow bil. SFA during resuscitation (AIS = 4 R., 4 L.)R. SFA; L. SFAPossible blast injury to lungs & heartB/L SFA ligation during resuscitation effort7U O+32
      173445NoBP 139/88 HR 115 GCS 15 RR 16Pressure dressing L. arm, palp rad pulse, hand pink/warmGlass laceration during room clearanceLacs. dorsal branch ulnar a., dorsal sensory branch ulnar n., FDS/FDP SF, MF; FCU (AIS = 2)L. ulnar a. (branch)noneI&D; nerve repair; artery ligated; flexor tendon repairsNone4
      182460NoBP 112/54 HR 63 GCS 15 RR 16R. foot pink and warm, palpable pulsesDismounted GSWR. thigh ant. 2 × 2 cm wound, 7 × 3 cm post. wound, no fx (AIS = 2)NoneGSW R. forearm with distal radius fracture (AIS=3)I&D forearm, splint; I&D thigh woundsNone13
      194090NoBP 120/80 GCS 15 RR 16Foot pink and warm, palpable DP pulseGSW escalation of forceSFA 6 cm intimal injury just proximal to Hunter's canal; no fractures (AIS = 3)L. SFANone1° repair SFA2U O+9
      20*20N/AN/ABP 80/40 HR 160 GCS 11 (3 = eye 4 = Verbal 4 = motor) RR 30Palpable pulses bil. legs, open fracturesIED blast & vehicle rollover (blunt/blast)Comminuted bil. open tib/fib fxs (AIS = 3 R & 3 L), tense swelling; L. peroneal a. lacL peroneal a.Pelvis fracture (AIS = 4); L. hip dislocation (AIS = 3); bil calc. fxs (AIS = 2); L knee lig. injury (AIS = 2)Spanning ex-fix of bil. legs & fasciotomies7U O+ 1U whole blood25
      2123N/AN/ABP 111/66 HR 83 GCS 15 RR 18Absent L. DP, PT, popliteal a. pulsesGSWIntimal flap tear SFA; lac. saphenous v. (AIS = 3)SFA, saphenous v.NoneI&D wounds, ligation saphenous v.; SFA bypass with reverse SVG2U O+9
      22*21190YesBP 100/28 HR 131 GCS 8 RR 10Absent L. foot pulses; pale, coolIED & MVC (Blunt/Blast)3C L. tib/fib fxs with ant tibial a. injury (AIS = 3)Anterior tibial a.Splenic rupture (AIS = 4); bil. globe injury) (AIS = 3); 3A femur fx (AIS = 3)Ex-lap with splenectomy; L knee-spanning ex fix; I&D wound6U O+25
      236N/AN/ABP 99/37 HR 131 GCS 13 (4 = verbal 5 = pain) RR 10Absent radial/ulnar a. pulsesMortar attackProximal R brachial artery (AIS = 3)Brachial a.Small bowel wounds (AIS = 4), 3A L tibia, open L knee (ASI = 3), multiple soft tissue wounds R thigh/leg (AIS = 2)Small bowel resection; shunt to R brachial a.; I&D splint R leg 4) I&D, L knee joint3U O+25
      2428125YesBP 145/91 GCS 15 RR = 20No DP, PT a. pulses, R. leg cool and blueDismounted IEDSFA lacerations (no fracture) (AIS = 3)SFA & ant. tibial a.Colon & small bowel injuries (AIS = 4); soft tissue wounds R arm (AIS =  2) & R leg (AIS = 2)R hemi-colectomy, small bowel resection, R SFA shunt, R leg fasciotomy4U O+ PRBC 4U whole blood25
      252962YesBP 147/81 HR 86 GCS 15 RR 18Absent L. PT & DP a. pulsesGSWPopliteal a. & v. transection; lateral tibial plateau fx (AIS = 3)Popliteal a. & v.NoneShunt SFA to popliteal a.; ligation popliteal v., L leg fasciotomy3U O+9
      Abbreviations: AEA – Above elbow amputation; AIS – Abbreviated Injury Score; BBFA – Both-bone forearm; BKA – Below knee amputation; Calc – calcaneus; DP – Dorsalis pedis; Ex-fix – External fixation; Ex-lap – Exploratory laparotomy; FCU – Flexor carpi ulnaris; FDP Flexor digitorum profundus, FDS – Flexor digitorum superficialis; Fx – fracture; GCS – Glascow Coma Scale; GSW – Gunshot wound; 3C – Gustillo grade 3C open fracture; I&D – Irrigation and debridement; IED – Improvised explosive device; MF – Middle finger; MVC – Motor vehicle collision; PT – Posterior tibial; RPG – Rocket propelled grenade; RF – Ring finger; SF – Small finger, SFA – Superficial femoral artery; SVG – Saphenous vein graft; Tib/fib – Tibia and fibula; N/A – Presentation without tourniquet.
      Physical examination in the casualty receiving area determined the effectiveness of a tourniquet. It was considered effective if there was absence of palpable pulses or lack of active bleeding from a mangled or traumatically amputated limb [
      • Lee C.
      • Porter K.M.
      • Hodgetts T.J.
      Tourniquet use in the civilian prehospital setting.
      ]. Secondary indicators of included a relatively cooler limb and decreased capillary refill. Tourniquet application time was typically well documented, but in several instances was estimated based on time of injury. Field tourniquets were typically removed in the operating room before wound exploration to better control any profuse hemorrhage that may occur. Surgical findings, operative procedures, transfusion requirements and whether a tourniquet influenced the surgical amputation level were recorded. Specifically, the relationship between an in situ tourniquet and the decision to amputate a mangled extremity or revise an existing traumatic amputation to a level proximal to the tourniquet was made by clinical assessment of limb viability.
      The Abbreviated Injury Scale (AIS) [
      • Greenspan L.
      • McLellan B.
      • Greig H.
      Abbreviated injury scale and injury severity score: a scoring chart.
      ] was assigned to all injuries. New Injury Severity Scores (NISS) [
      • Osier T.
      • Baker S.
      • Long W.
      A modification of the injury severity score that both improves accuracy and simplifies scoring.
      ] and Revised Trauma Scores (RTS) [
      • Champion H.
      • Sacco W.
      • Copes W.
      • Gann D.
      • Gennarelli T.
      • Flanagan M.
      A revision of the trauma score.
      ] were calculated for all patients. These scoring systems were based on the modifications to the AIS in the case of the NISS; and on the patient's Glasgow Coma Scale, systolic blood pressure and respiratory rate for the RTS. Surgical interventions, a complete list of injuries, as well as follow up data were obtained via the Joint Theater Trauma Registry (JTTR), a prospective database that captures information on patients treated in combat theater U.S. Military treatment facilities. Non-U.S. service members were tracked until discharged to an Iraqi civilian hospital or other facility.

      Statistical analysis

      Descriptive statistics were used for demographic data. Power calculations showed that a minimum of 18 patients would be needed to differentiate mean systolic and diastolic blood pressure differences of 20 mm Hg with a power of 0.80 and a significance level of 0.05. Other data was analyzed using rank-sum, chi squared, and Fisher's Exact tests with STAT/SAS software (SAS Institute Inc., Cary, NC). Statistical significance for these calculations was set at p < 0.05.

      Results

      Injury mechanisms

      Penetrating trauma was the cause of injury in most cases (Table 2). The majority of penetrating trauma was caused by explosive ordnance (56%), followed by gunshot wounds (36%). Vascular injuries were most seen followed by open fractures (Table 3). Two patients had traumatic amputations at presentation.
      Table 2Mechanisms of injury resulting in tourniquet use.
      MechanismNo. of Patients (%)
      Improvised explosive device11 (44)
      Gunshot wound9 (36)
      Gunshot wound + rocket propelled grenade1 (4)
      Grenade1 (4)
      Mortar1 (4)
      Broken glass1 (4)
      Motor vehicle crash1 (4)
      Table 3Type and number of injuries.
      InjuryNo.
      Vascular13
      Open fracture10
      Soft tissue6
      Traumatic amputations

      Above knee (2)

      Below knee (2)

      Above elbow (1)

      Shoulder disarticulation (1)
      6
      Neurologic1

      Patients and tourniquets

      Twenty-two patients presented with tourniquets on 26 extremities. Eleven of these patients (13 extremities) had major vascular injuries, and 8 patients had non-major vascular injuries. Eight of 11 patients with major vascular injuries presented with an effective tourniquet, and the other 3 presented without a tourniquet or an ineffective one (Table 4). Five of the above 26 extremities (19%) had tourniquets that were ineffective because palpable pulses were present distal to the tourniquet; but they did not have uncontrolled hemorrhage. There were no identifiable vascular injuries in 8 limbs where tourniquets were utilized. In those patients who presented without a tourniquet (Group 2), 3 patients (4 extremities) had vascular injuries. All patients who presented with traumatic amputations or mangled extremities had a tourniquet upon arrival (Fig. 2).
      Table 4Tourniquet use in patients with successful vs. unsuccessful compression of hemorrhage.
      Patients with Compressed HemorrhagePatients with Uncompressed HemorrhageTotalP (FET)
      VariableCategoryNo.%No.%#
      Tourniquet UsedYes1169%531%160.058
      No00%3100%3
      Vascular InjuryYes873%327%110.516
      No360%240%5
      Tourniquet EffectiveYes1192%18%120.003*
      No00%4100%4
      *Significant at P < 0.05; FET: Fisher's Exact Test.
      Fig. 2
      Fig. 222-year-old Marine with bilateral tourniquets in place for severe lower extremity trauma due to detonation of an improvised explosive device.

      Blood products

      Thirty-one packed or whole blood units were transfused in 11 patients with major vascular injuries of the extremities. Immediate transfusion requirements for initial resuscitation were different (p = 0.0006) depending upon the presence and effectiveness of a field tourniquet, regardless of concomitant injuries. Twelve units were transfused in 6 patients (1.7 units/vascular injury or 2 units/patient) whose tourniquets were effective. Nineteen units were transfused into 5 patients with six major vascular injuries (3.3 units/vascular injury 3.8 units/patient) who had no tourniquet or an ineffective one.

      Vital signs

      The group with effective tourniquets presented with significantly higher mean systolic (p = 0.003) and diastolic (p = 0.023) blood pressures than the group with no tourniquets or ineffective ones (Table 5). Furthermore, the group with effective tourniquets had a significantly greater mean score on the Glasgow Coma Scale (Table 5). There were no significant differences in heart rate, respiratory rate, AIS and NISS between groups.
      Table 5Major vascular injury patients with successful vs. unsuccessful compression of hemorrhage.
      VariableSuccessful (C) or Unsuccessful (U) Bleeding CompressionNo. of PatientsMean ± SDP 1
      Tourniquet Time (minutes)C1188.6 ± 35.50.363
      U570.6 ± 12.7
      SBP mm HgC11131.5 ± 15.00.003*
      U8102.6 ± 24.3
      DBP mm HgC1175.4 ± 13.00.023*
      U853.7 ± 23.5
      HRC1191.4 ± 19.20.297
      U7109.1 ± 33.8
      RRC1121.2 ± 4.20.295
      U819.5 ± 7.1
      GCSC1115.0 ± 00.032*
      U813.4 ± 2.6
      AISC112.7 ± 0.50.075
      U83.2 + 0.7
      NISSC1111.5 ± 5.90.209
      U817.8 ± 10.2
      1From rank-sum test. *Significant at 0.05 level. SBP: Systolic Blood Pressure. DBP: Diastolic Blood Pressure. HR: Heart Rate. RR: Respiratory Rate. GCS: Glasgow Coma Scale. AIS: Abbreviated Injury Scores. NISS: New Injury Severity Scores.

      Tourniquet complications

      The use of a tourniquet did not affect choice of immediate amputation level for those presenting with a mangled or traumatically amputated extremity based upon clinical criteria. Signs of limb viability were assessed in the operating room and included tissue color and consistency, bleeding ability and muscle contractility. There was one case (patient 5) of motor and sensory common peroneal nerve palsy after having had a thigh tourniquet applied for a proximal leg wound without a vascular injury that resolved after tourniquet release.

      Mortality

      Of the 4 patients (9, 16, 20, 22) who died of wounds (DOW), 4 effective tourniquets were placed for two major vascular injuries, while 2 ineffective tourniquets were placed for 2 other major vascular injuries. Patient 20 had no tourniquets in place when he presented with a pelvic fracture, which was immediately addressed [
      • Meccariello L.
      • Razzano C.
      • De Dominicis C.
      • Herrera-Molpeceres J.A.
      • Liuzza F.
      • Erasmo R.
      • Rocca G.
      • Bisaccia M.
      • Pagliarulo E.
      • Cirfeda P.
      • Gómez Garrido D.
      • Rollo G
      A new prognostic pelvic injury outcome score.
      ] as well as other severe injuries resulting from an IED blast and vehicle rollover. He was treated with damage control resuscitation and external fixation but died of his wounds soon thereafter. The number of DOW patients was small, and thus no correlation was found between presence and effectiveness of a tourniquet and survivability in these patients. Mean Glasgow Coma Scale at presentation for patients who died of wounds was 9.5 compared to 14.9 for survivors.

      Discussion

      In this investigation, we found that field tourniquets applied for penetrating injuries with severe bleeding can significantly reduce transfusion requirements and help maintain adequate blood pressure. The effective tourniquet group also had a significantly greater mean score on the Glasgow Coma Scale. Our observation that tourniquet use did not result in immediate limb amputation and did not affect the immediate amputation level was a clinical one made at our forward surgical team prior to onward medical evacuation of the patient. However, it is possible that tourniquet pressure may cause injury through local compression and temporary interruption of perfusion leading tissue damage that may not be appreciated during the immediate surgery. This might lead to soft tissue necrosis necessitating a different final amputation level.
      A study by Kragh et al. [
      • Kragh J.F.
      • Walters T.J.
      • Baer D.G.
      • Fox C.J.
      • Wade C.E.
      • Salinas J.
      • Holcomb J.B.
      Practical use of emergency tourniquets to stop bleeding in major limb trauma.
      ] of casualties with tourniquets treated at a Level 3 trauma center found no association between tourniquet time and morbidity, no amputations that resulted solely from tourniquet use, but 4 patients (2%) had transient nerve palsies at the tourniquet level. The most likely factor that ultimately contributed to limb viability was the mechanism and energy of the injury, and not the application of a field tourniquet. Dunn et al. [
      • Dunn J.C.
      • Fares A.
      • Kusnezov N.
      • Chandler P.
      • Cordova C.
      • Orr J.
      • Belmont P.
      • Pallis M.
      US service member tourniquet use on the battlefield: Iraq and Afghanistan 2003-2011.
      ] retrospectively studied tourniquet use in US Army cavalry scouts wounded-in-action over an eight-year period during the Iraq and Afghanistan Wars. In a cohort of 313 patients having adequate documentation, 23 of 24 service members survived who had tourniquets in place upon arrival at a forward surgical team. Most of these soldiers were injured by an explosive device.
      A field tourniquet is not appropriate for all extremity trauma [
      • Smith A.H.
      • Laird C.
      • Porter K.
      • Bloch M.
      Haemostatic dressings in prehospital care.
      ]. There are areas of the extremities that are readily accessible and lend themselves to techniques of rapid bandage application even under combat conditions [
      • Zietlow J.M.
      • Zietlow S.P.
      • Morris D.S.
      • Berns K.S.
      • Jenkins D.H.
      Prehospital use of hemostatic bandages and tourniquets: translation from military experience to implementation in civilian trauma care.
      ]. Another consideration is use of Combat Gauze [
      • Gegel B.T.
      • Austin P.N.
      • Johnson A.D.
      An evidence-based review of the use of a combat gauze (QuikClot) for hemorrhage control.
      ] which is composed of a kaolin-impregnated rayon and polyester hemostatic dressing that may preclude the need for tourniquet application. In cases of below elbow or below knee vascular injuries a tourniquet can be utilized if needed, but a pressure dressing for an isolated below knee or below elbow injury may provide adequate hemostasis as these anatomic regions have smaller diameter vessels with lower occlusion pressures than proximal limb vessels [
      • Covey D.C.
      Blast and fragment injuries of the musculoskeletal system.
      ].
      Another consideration to assist in hemostasis in battlefield trauma is use of tranexamic acid, an antifibrinolytic drug that has been safely used to decrease blood loss after major surgery. Schiavone et al. [
      • Schiavone A.
      • Bisaccia M.
      • Inkov I.
      • Rinonapoli G.
      • Manni M.
      • Rollo G.
      • Meccariello L.
      • Vicente C.I.
      • Ceccarini P.
      • Ruggiero C.
      • Caraffa A.
      Tranexamic acid in pertrochanteric femoral fracture: is it a safe drug or not?.
      ] found that tranexamic acid given at the time of surgical incision significantly reduced blood loss in nailing of pertrochanteric femur fractures. Similarly, Porter at al [
      • Porter S.B.
      • Spaulding A.C.
      • Duncan C.M.
      • Wilke B.K.
      • Pagnano M.W.
      • Abdel M.P.
      Tranexamic acid was not associated with increased complications in high-risk patients with hip fracture undergoing arthroplasty.
      ] found that use of tranexamic acid in high-risk patients undergoing arthroplasty for hip fractures was not associated with an increased risk of mortality, deep venous thrombosis, pulmonary embolism, myocardial infarction, or stroke. Although not available for use in our series, given its efficacy in safely reducing postoperative blood loss, it should be considered for use by surgical teams during future deployments. There are several limitations of our study. First, although our study was adequately powered for the parameters of systolic and diastolic blood pressure, but it did not have the large patient numbers required to further refine statistical analysis. Second, because the vascular injuries were diagnosed by direct inspection of wounds, minor vascular injuries may have been underestimated. When penetrating trauma was not near a major vascular structure, and palpable pulses were present, the assumption was made that there was likely no major arterial injury. In some instances, this could be an inaccurate assumption because vascular injuries can be occult and present with delayed clinical symptoms [
      • Fox C.J.
      • Gillespie D.L.
      • 0′Donne 11 S.D.
      • Rasmussen T.E.
      • Goff J.M.
      • Johnson C.A.
      • Gaglon R.E.
      • Sarac T.P.
      • Rich N.M.
      Contemporary management of wartime vascular trauma.
      ]. Third, tissue viability was determined by clinical assessment by the surgeon, which is to a degree subjective, and might lead to under diagnosis of potentially adverse tourniquet effects.
      The successful use of tourniquets in the Iraq and Afghanistan Wars has stimulated interest in using these devices in the management of civilian patients with severe extremity trauma [
      • Lee C.
      • Porter K.M.
      • Hodgetts T.J.
      Tourniquet use in the civilian prehospital setting.
      ]. Although most external bleeding can be controlled with direct pressure, there are cases where this is insufficient to stop arterial bleeding and may lead to exsanguination. Schroll et al. [
      • Schroll R.
      • Smith A.
      • McSwain N.E
      • Myers J.
      • Rocchi K.
      • Inaba K.
      • Siboni S.
      • Vercruysse G.A.
      • Ibrahim-Zada I.
      • Sperry J.L.
      • Martin-Gill C.
      • Cannon J.W.
      • Holland S.R.
      • Schreiber M.A.
      • Lape D.
      • Eastman A.L.
      • Stebbins C.S.
      • Ferrada P.
      • Han J.
      • Meade P.
      • Duchesne J
      A multi-institutional analysis of prehospital tourniquet use.
      ] performed a multi-center, retrospective study of 197 adult trauma patients admitted to Level I trauma centers with prehospital extremity tourniquets. They found that tourniquets were applied safely and effectively in their cohort, no limb loss was directly attributable their use, and that their results compared favorably to a similar military study [
      • Kragh J.F.
      • Walters T.J.
      • Baer D.G.
      • Fox C.J.
      • Wade C.E.
      • Salinas J.
      • Holcomb J.B.
      Survival with emergency tourniquet use to stop bleeding in major limb trauma.
      ]. Furthermore, in a retrospective study of 190 civilian patients who sustained extremity arterial injuries requiring amputation or revascularization, Passos et al. [
      • Passos E.
      • Dingley B.
      • Smith A.
      • Engels P.T.
      • Ball C.G.
      • Faidi S.
      • Nathens A.
      • Tien H.
      Canadian trauma trials collaborative
      Tourniquet use for peripheral vascular injuries in the civilian setting.
      ] showed that early tourniquet placement increased patient survival compared to no tourniquet. Our study lends support to these findings as tourniquets were placed in the field by junior personnel with training analogous to civilian first responders.
      The austere location of our study could be likened to some rural or remote civilian environments where sophisticated trauma care such as revascularization is not readily available [
      • Fludger S.
      • Bell A.
      Tourniquet application in a rural Queensland HEMS environment.
      ]. In such settings, tourniquet control of compressible extremity bleeding can be lifesaving. Although no large studies that address this issue, case reports have shown that use of tourniquets can lifesaving in cases of uncontrolled hemorrhage from a farm machinery injury in rural Queensland, Australia [
      • Fludger S.
      • Bell A.
      Tourniquet application in a rural Queensland HEMS environment.
      ], from a gunshot wound in a remote region of Quebec, Canada [
      • Malo C.
      • Bernardin B.
      • Nemeth J.
      • Khwaja K.
      Prolonged prehospital tourniquet placement associated with severe complications: a case report.
      ], or from a rollover motor vehicle crash in Pennsylvania, USA [
      • Sims C.
      • Polk T.
      Rollover car crash almost costs driver his life, limb.
      ]. The first two of these cases had prolonged evacuation times to reach surgical care.
      In practice, field tourniquets are appropriate in the prehospital setting for control of significant extremity hemorrhage if direct pressure is ineffective or impractical [
      • Bulger E.M.
      • Snyder D.
      • Schoelles K.
      • Gotschall C.
      • Dawson D.
      • Lang E.
      • et al.
      An evidence-based prehospital guideline for external hemorrhage control: American college of surgeons committee on trauma.
      ]. The field tourniquet may be applied over clothing and is then tightened until the bleeding has stopped. In most cases, it should be left on until care is assumed by the surgical team. In cases where the tourniquet is in place for a prolonged period, its use should be reassessed frequently. Malo et al. [
      • Malo C.
      • Bernardin B.
      • Nemeth J.
      • Khwaja K.
      Prolonged prehospital tourniquet placement associated with severe complications: a case report.
      ] recommended that unless the patient is hemodynamically unstable, the environment is unstable, or insufficient assistance is available, direct pressure or a pressure dressing can be applied to the hemorrhage site, and the tourniquet pressure released while leaving it in place. If significant bleeding recurs, the tourniquet can be retightened. Before removal, one should be cognizant of the possibility of sudden cardiovascular collapse due to reperfusion and release of toxic cytokines into the systemic circulation.

      Conclusion

      Field tourniquets have a distinct role in combat casualty care [
      • Howard J.T.
      • Kotwal R.S.
      • Stern C.A.
      • Janak J.C.
      • Mazuchowski E.L.
      • Butler F.K.
      • et al.
      Use of combat casualty care data to assess the US military trauma system during the Afghanistan and Iraq conflicts, 2001–2017.
      ] and a role in civilian prehospital treatment as well [
      • Goodwin T.
      • Moore K.N.
      • Pasley J.D.
      • Troncoso R.
      • Levy M.J.
      • Goolsby C.
      From the battlefield to main street: tourniquet acceptance, use, and translation from the military to civilian settings.
      ]. When applied for upper or lower extremity penetrating injuries with severe bleeding, they can significantly reduce hemorrhage. The results of the current study show that immediate transfusion requirements for resuscitation were less if the patient had an effective a field tourniquet in place regardless of concomitant injuries. Also, those with effective tourniquets had higher mean systolic and diastolic blood pressures and higher GCS scores than those with no or ineffective tourniquets. Furthermore, this study found that field tourniquet use did not result in limb amputation or affect the immediate amputation level in otherwise mangled extremities.

      Declaration of Competing Interest

      None.

      References

        • Bellamy R.F.
        The causes of death in conventional land warfare: implications for combat casualty care research.
        Mil Med. 1984; 149: 55-62
        • Kragh J.F.
        • Baer D.G.
        • Walters T.J.
        Extended (16-Hour) Tourniquet application after combat wounds: a case report and review of the current literature.
        J Orthop Trauma. 2007; 21: 274-278
        • Walters T.J.
        • Mabry R.L.
        Issues related to the use of tourniquets on the battlefield.
        Mil Med. 2005; 170: 770-775
        • Dunn J.C.
        • Kusnezov N.
        • Schoenfeld A.J.
        • Orr J.D.
        • Cook P.J.
        • Belmont P.J.
        Vascular injuries in combat-specific soldiers during operation Iraqi freedom and operation enduring freedom.
        Ann Vasc Surg. 2016; 35: 30-37
        • Dunn J.C.
        • Fares A.
        • Kusnezov N.
        • Chandler P.
        • Cordova C.
        • Orr J.
        • Belmont P.
        • Pallis M.
        US service member tourniquet use on the battlefield: Iraq and Afghanistan 2003-2011.
        Trauma. 2016; 18: 216-220
        • Bruner J.M.
        Safety factors in the use of the pneumatic tourniquet for hemostasis in surgery of the hand.
        J Bone Joint Surg Am. 1951; 33: 221-224
        • Flatt A.E.
        Tourniquet time in hand surgery.
        Arch Surg. 1972; 104: 190-192
        • Graham B.
        • Breault M.J.
        • McEwen J.A.
        • et al.
        Occlusion of arterial flow in the extremities at subsystolic pressures through the use of wide tourniquet cuffs.
        Clin Orthop. 1993; 286: 257-261
        • Moore M.R.
        • Garfin S.R.
        • Hargens A.R.
        Wide tourniquets eliminate blood flow at low Inflation pressures.
        J Hand Surg Am. 1987; 12: 1006-1011
        • Odinsson A.
        • Finsen V.
        The position of the tourniquet on the upper limb.
        J Bone Joint Surg Br. 2002; 84: 202-204
        • Shaw J.A.
        • Murray D.G.
        The relationship between tourniquet pressure and underlying soft-tissue pressure in the thigh.
        J Bone Joint Surg Am. 1982; 64: 1148-1152
        • Swanson A.B.
        • Livengood L.C.
        • Sattel A.B.
        Local hypothermia to prolong safe tourniquet time.
        Clin Orthop. 1991; 264: 200-208
        • Wakai A.
        • Winter D.C.
        • Street J.T.
        • Redmond P.H.
        Pneumatic tourniquets in extremity surgery.
        J Am Acad Orthop Surg. 2001; 9: 345-351
        • Klenerman L.
        Tourniquet time-how long?.
        Hand. 1980; 12: 231-234
        • Kam P.C.
        • Kavanagh R.
        • Yoong F.F.
        • et al.
        The arterial tourniquet: pathophysiological consequences and anaesthetic implications.
        Anaesthesia. 2001; 56: 534-545
        • Crenshaw A.G.
        • Hargens A.R.
        • Gershuni D.H.
        • Rydevik B.
        Wide tourniquet cuffs more effective at lower Inflation pressures.
        Acta Orthop Scand. 1988; 59: 447-451
        • Williams J.E.
        • Tucker D.B.
        • Read J.M.
        Rhabdomyolysis-myoglobinuria: consequences of prolonged tourniquet.
        J Foot Surg. 1983; 22: 52-56
        • Husum H.
        • Gilbert M.
        • Wisborg T.
        • Pillgram-Larsen J.
        Prehospital tourniquets: there should be no controversy.
        J Trauma. 2004; 56: 214-215
        • Lee C.
        • Porter K.M.
        • Hodgetts T.J.
        Tourniquet use in the civilian prehospital setting.
        Emerg Med J. 2007; 24: 584-587
        • Lakstein D.
        • Blumfenfeld A.
        • Sokolov T.
        • Lin 6.
        • Bssorai R.
        • Lynn M.
        • Ben-Abraham R
        Tourniquets for hemorrhage control on the battlefield: a 4-year accumulated experience.
        J Trauma. 2003; 54: S221-S225
        • Owens B.D.
        • Kragh J.F.
        • Macaitis J.
        • Svoboda S.J.
        • Wenke J.C.
        Characterization of extremity wounds in operation Iraqi freedom and operation enduring freedom.
        J Orthop Trauma. 2007; 21: 254-257
        • Fox C.J.
        • Gillespie D.L.
        • 0′Donne 11 S.D.
        • Rasmussen T.E.
        • Goff J.M.
        • Johnson C.A.
        • Gaglon R.E.
        • Sarac T.P.
        • Rich N.M.
        Contemporary management of wartime vascular trauma.
        J Vasc Surg. 2005; 41: 638-644
        • Bagg M.R.
        • Covey D.C.
        • Powell E.T.
        Levels of medical care in the global war on terrorism.
        J Am Acad Orthop Surg. 2006; 14: S7-S9
        • Butler F.K.
        Tactical combat casualty care: update 2009.
        J Trauma. 2010; 69 (July): S10-S13
        • Greenspan L.
        • McLellan B.
        • Greig H.
        Abbreviated injury scale and injury severity score: a scoring chart.
        J Trauma. 1985; 25: 60-64
        • Osier T.
        • Baker S.
        • Long W.
        A modification of the injury severity score that both improves accuracy and simplifies scoring.
        J Trauma. 1997; 43: 922-926
        • Champion H.
        • Sacco W.
        • Copes W.
        • Gann D.
        • Gennarelli T.
        • Flanagan M.
        A revision of the trauma score.
        J Trauma. 1989; 29: 623-629
        • Meccariello L.
        • Razzano C.
        • De Dominicis C.
        • Herrera-Molpeceres J.A.
        • Liuzza F.
        • Erasmo R.
        • Rocca G.
        • Bisaccia M.
        • Pagliarulo E.
        • Cirfeda P.
        • Gómez Garrido D.
        • Rollo G
        A new prognostic pelvic injury outcome score.
        Med Glas. 2021; 18 (Zenica)Feb 1: 299-308
        • Kragh J.F.
        • Walters T.J.
        • Baer D.G.
        • Fox C.J.
        • Wade C.E.
        • Salinas J.
        • Holcomb J.B.
        Practical use of emergency tourniquets to stop bleeding in major limb trauma.
        J Trauma. 2008; 64 (S38 –50)
        • Smith A.H.
        • Laird C.
        • Porter K.
        • Bloch M.
        Haemostatic dressings in prehospital care.
        Emerg Med J. 2013; 30: 784-789
        • Zietlow J.M.
        • Zietlow S.P.
        • Morris D.S.
        • Berns K.S.
        • Jenkins D.H.
        Prehospital use of hemostatic bandages and tourniquets: translation from military experience to implementation in civilian trauma care.
        J Spec Oper Med. 2015; 15: 48-53
        • Gegel B.T.
        • Austin P.N.
        • Johnson A.D.
        An evidence-based review of the use of a combat gauze (QuikClot) for hemorrhage control.
        AANA J. 2013; 81 (Dec 1): 453-458
        • Covey D.C.
        Blast and fragment injuries of the musculoskeletal system.
        J Bone Joint Surg Am. 2002; 84: 1221-1234
        • Schiavone A.
        • Bisaccia M.
        • Inkov I.
        • Rinonapoli G.
        • Manni M.
        • Rollo G.
        • Meccariello L.
        • Vicente C.I.
        • Ceccarini P.
        • Ruggiero C.
        • Caraffa A.
        Tranexamic acid in pertrochanteric femoral fracture: is it a safe drug or not?.
        Folia Med. 2018; 60 (Plovdiv): 67-78
        • Porter S.B.
        • Spaulding A.C.
        • Duncan C.M.
        • Wilke B.K.
        • Pagnano M.W.
        • Abdel M.P.
        Tranexamic acid was not associated with increased complications in high-risk patients with hip fracture undergoing arthroplasty.
        J Bone Joint Surg Am. 2021; 103: 1880-1889
        • Schroll R.
        • Smith A.
        • McSwain N.E
        • Myers J.
        • Rocchi K.
        • Inaba K.
        • Siboni S.
        • Vercruysse G.A.
        • Ibrahim-Zada I.
        • Sperry J.L.
        • Martin-Gill C.
        • Cannon J.W.
        • Holland S.R.
        • Schreiber M.A.
        • Lape D.
        • Eastman A.L.
        • Stebbins C.S.
        • Ferrada P.
        • Han J.
        • Meade P.
        • Duchesne J
        A multi-institutional analysis of prehospital tourniquet use.
        J Trauma. 2015; 79: 10-14
        • Kragh J.F.
        • Walters T.J.
        • Baer D.G.
        • Fox C.J.
        • Wade C.E.
        • Salinas J.
        • Holcomb J.B.
        Survival with emergency tourniquet use to stop bleeding in major limb trauma.
        Ann Surg. 2009; 249: 1-7
        • Passos E.
        • Dingley B.
        • Smith A.
        • Engels P.T.
        • Ball C.G.
        • Faidi S.
        • Nathens A.
        • Tien H.
        • Canadian trauma trials collaborative
        Tourniquet use for peripheral vascular injuries in the civilian setting.
        Injury. 2014; 45: 573-577
        • Fludger S.
        • Bell A.
        Tourniquet application in a rural Queensland HEMS environment.
        Air Med J. 2009; 28: 291-293
        • Malo C.
        • Bernardin B.
        • Nemeth J.
        • Khwaja K.
        Prolonged prehospital tourniquet placement associated with severe complications: a case report.
        Can J Emerg Med. 2015; 17 (Jul): 443-446
        • Sims C.
        • Polk T.
        Rollover car crash almost costs driver his life, limb.
        J Emerg Med Serv. 2012; 37: 30-31
        • Bulger E.M.
        • Snyder D.
        • Schoelles K.
        • Gotschall C.
        • Dawson D.
        • Lang E.
        • et al.
        An evidence-based prehospital guideline for external hemorrhage control: American college of surgeons committee on trauma.
        Prehosp Emerg Care. 2014; 18 (Apr 3): 163-173
        • Howard J.T.
        • Kotwal R.S.
        • Stern C.A.
        • Janak J.C.
        • Mazuchowski E.L.
        • Butler F.K.
        • et al.
        Use of combat casualty care data to assess the US military trauma system during the Afghanistan and Iraq conflicts, 2001–2017.
        JAMA Surg. 2019; 154: 600-608
        • Goodwin T.
        • Moore K.N.
        • Pasley J.D.
        • Troncoso R.
        • Levy M.J.
        • Goolsby C.
        From the battlefield to main street: tourniquet acceptance, use, and translation from the military to civilian settings.
        J Trauma. 2019; 87: S35-S39