Use of Tourniquets and Their Effects on Limb Function in the Modern Combat Environment

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The importance of new emergency tourniquet use

Orthopedic surgeons are the main care providers receiving casualties with emergency tourniquets recently applied. Many have extensive predeployment experience with tourniquets used for elective surgeries. As such, they are the subject matter experts on tourniquets, and receive the most questions on their use and misuse. Severe limb injuries can be lethal; tourniquet use can be lifesaving if used properly, or morbid if used improperly.3

Epidemiology: incidence of tourniquet use

A recent study of the emergency room of the combat support hospital in Baghdad's International Zone demonstrated that 18% of trauma admissions had emergency tourniquets applied.2 That Baghdad case accrual rate was 29 times faster than any prior report.2, 6 Another recent military study from the United Kingdom reported 5% of battle casualties had tourniquet use.7 These data are rare; many trauma systems do not track tourniquet use or death rate from limb exsanguinations.8, 9

At Brooke Army

Hemorrhage and mortality

Before widespread, proper tourniquet use uncontrolled hemorrhage through a wounded extremity was the most common cause of preventable death on the battlefield.21 It is the second leading cause of death in civilian trauma after head injury.22, 23, 24 Exsanguination from a limb wound constituted about 9% of United States combat deaths in the Vietnam War.21 With more frequent tourniquet use in the wars after Vietnam, the rate of limb exsanguination death decreased such that the rate currently is

Survival rates and hemorrhage control

Hemorrhage control in casualties is associated with less blood loss, less need for transfusion, and improved survival.37 Lack of hemorrhage control is associated with death.37 The easiest way to gain control of substantial limb bleeding in battle casualties is by tourniquet use as long as the bleeding is compressible.37 A study conducted during Operation Iraqi Freedom showed that tourniquets effectively control hemorrhage,1 and another showed that they improve survival.3

Animal data indicate

Prehospital care

In a recent study within the Baghdad Combat Support Hospital about 85% of battle casualties with (one or more) tourniquets had the device applied before arrival to a facility (prehospital tourniquet), and the remaining 15% had their first tourniquet applied in the hospital (hospital tourniquet). Lay persons, soldiers, soldier-medics, civilian contractors, policemen, nurses, physician assistants, physicians, and surgeons applied the devices, but most seemed to be applied by soldiers and medics.2

Emergency department care

According to the military hospital providers in Baghdad in a recent study, all of the 15% of casualties with their first tourniquet applied in the hospital should have had application prehospital.1, 2 Additionally, there was a 5% unindicted (12 of 232) use rate but a 2% miss rate (5 of 232). The miss rate was the casualty death rate for those indicated for tourniquet where a tourniquet was inaccessible or unavailable.2 The previously mentioned Israeli study had a 47% unindicated use rate.6

Operating room and intensive care

In civilian settings, surgery is frequently the main cause of blood loss, but on the battlefield it is penetrating trauma.21, 42 Together, losses from trauma and surgery may require more tourniquet use in the operating room. Although use of tourniquets in elective surgery is common, surgeon knowledge of tourniquet science is limited.43, 44 The resuscitative context of emergency tourniquet use differs from elective use in that the preinjury medical history or peripheral vascular status of the

Indications for emergency tourniquet use

The current indication for emergency tourniquet use is any compressible limb wound that the applier assesses as having potentially lethal hemorrhage. In this environment tourniquet use may be the initial and primary method to control severe hemorrhage. This is in contrast to a historical stepwise approach that used application of direct pressure and pressure points to control hemorrhage before tourniquet application.

Such situations as care under gunfire are routine in combat where the

Contraindications

Currently, there are no data that clearly show contraindications to emergency tourniquet application. Without any situational indication, however, bleeding lesions controlled by simpler, safer means are theoretically a contraindication to tourniquet use. Such means may include direct wound pressure, a pressure dressing, limb elevation, pressure point compression, or hemostatic dressings. The effectiveness of such methods, however, is lacking or unconvincing.45 Swan and colleagues47 reported

Goals of care

Care goals of emergency tourniquet use can be seen as hemorrhage control, shock prevention, improved survival rates, lengthening survival times, elimination of distal pulses, and limb salvage rates. The immediate aim of the applicant is to stop bleeding, thereby making the other goals attainable; however, hemorrhage control may be temporary if the distal pulse persists. When a distal pulse is present in a limb with a tourniquet, it is a venous, not arterial, tourniquet, and problems soon arise.2

Design

Tourniquet design affects ease of use, durability and mechanical effectiveness (stopping bleeding and ridding the distal pulse). Weight, cost, durability, simplicity, packaging volume, and user expectations are other design considerations. Improvised and poorly designed tourniquets are suboptimal, and the best tourniquets require consideration of tourniquet science and human factors.2 One of the most important design features concerning effectiveness is tourniquet width.44 Those without

Tourniquet use, tissue ischemia, and limb function

Skin, bone, tendon, fat, fascia, joints, and vessels tolerate ischemia and reperfusion better than muscle tissue. Myocytes are much more susceptible to the ischemia and reperfusion effects associated with prolonged tourniquet use. Ischemia-reperfusion myopathy is inadequately studied especially in recovery, but animal data indicate that the muscle necrosis incurred recovers incompletely over several days.58 Having followed hundreds of casualties whose treatment involved tourniquet use (some for

Reconciliation of historically bad experiences with current supportive evidence

Historical experience with tourniquets has been so bad that they were often banned.44, 51, 60, 61 The United States military's recent tourniquet experience may seem like a quixotic triumph of hope over experience. It is actually the result of a comprehensive multifaceted program, however, aimed to solve preventable deaths on the battlefield (Fig. 5). Good judgment comes from bad experience, and the key to reconciling the disparate experiences was in the question asked. Whether one should use a

Use duration, doctrine, and training

Tourniquet use is simply a component of damage control orthopedics.62 For a casualty, temporary tourniquets control hemorrhage, prevent shock, and save lives allowing resuscitation to be effective.3 Tourniquet on and off times should be recorded so that the duration of tourniquet use can be calculated. Using an indelible marker to mark the time of application on the casualty's forehead permits the surgeon to know how long the tourniquet has been on. Subtracting the off time (observed directly

Effects on tissues under tourniquets

The tissue most susceptible to the pressure tourniquet impart is peripheral nerve. The location at which nerves are most affected are at the edges of the device; this coincides with the point of maximal tissue pressure gradient. Nerve tissue under the proximal edge of the tourniquet is more susceptible than that at the distal edge. This steep pressure gradient is spatially associated with a specific nerve deformation morphologically similar to that seen with intestinal intussusceptions. The

Stewardship tasks of the emergency tourniquet program

Lessons learned in the Baghdad Combat Support Hospital can contribute to disaster planning. The goals of its emergency tourniquet program focused on achieving best care for casualties with tourniquets. In 2006 that program was moribund but was soon reorganized. Tasks included finding used tourniquets about the hospital; cleaning, testing, maintaining, repairing, and drying them; storing them for future use; reordering to maintain adequate supplies; recording use for performance improvement;

Lessons learned on tourniquet use from the global war on terror

Tourniquets are powerful lifesaving devices and given scientific design, widespread training, modern doctrine, and thorough fielding to an integrated trauma system with rapid evacuation, have shown minor morbidity, but systems with inadequate devices, poor training, no doctrine, or slow evacuation have shown severe morbidity and mortality.50, 51, 60, 61, 71 Tourniquets may save lives if the right device is used in the right way at the right time for the right patient.

Summary

Tourniquets are lifesaving in emergency care of bleeding casualties by controlling hemorrhage and preventing shock. Modern tourniquets used in combat after widespread fielding and universal training have been consistently associated with improved survival with minor morbidity.

Acknowledgments

I acknowledge Amy Newland and Otilia Sanchez in assistance of manuscript preparation.

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    The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or reflecting the views of the Department of Defense or United States Government. The authors are employees of the United States government. This work was prepared as part of their official duties and, as such, there is no copyright to be transferred.

    This work has not yet been presented. There are no grants or other financial support beside the normal government salaries of the workers. There is no compensation for consulting.

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