Page 28 - Journal of Special Operations Medicine - Spring 2015

illustrated that tourniquets can prevent death from limb tourniquet use. Also, maturation of the Joint Theater
hemorrhage. 9,10 Such lifesaving tourniquet use has been Trauma System and dispersion of medical assets in the­
realized through careful attention to process improve­ ater allowed for an average transport time of less than
ments aimed at maximizing the benefit while minimiz­ 1 hour from point of injury to a surgical facility.
ing the morbidity.
Tourniquet­related morbidity has been assessed using
The first edition of the Tactical Combat Casualty Care available data; however, knowledge gaps still remain.
(TCCC) guidelines supported early use of tourniquets Fasciotomy rates increased after implementation of
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to control life­threatening hemorrhage from extremity tourniquets, likely due to increased numbers of lives
wounds; such support contradicted longstanding doc­ saved and limbs salvaged. However, the relation of fas­
trine in which the tourniquet was an intervention of last ciotomy to tourniquet use has not been clearly defined
resort. 12,13 A decade of concerted effort ensued, with the and potential for otherwise unnecessary fasciotomy
US Special Operations Command (USSOCOM), US Cen­ exists, particularly in cases of a “venous tourniquet,”
tral Command, US Army Institute of Surgical Research which occludes venous outflow while failing to occlude
(USAISR), and the Committee on TCCC (CoTCCC) arterial inflow. 1,18,19 Although studies to date show no
combining efforts to develop the evidence base, doctrine, increased limb dysfunction or late amputations as a
training, policy, and implementation that ultimately re­ function of prehospital tourniquet use, detailed long­
sulted in the issuing of tourniquets to every deploying term follow­up studies have not been done.
Service member with training to support immediate
application for life­threatening limb hemorrhage. The Due to commonly short evacuation times in Afghanistan
turning point in tourniquet use occurred in 2005 as the after the Secretary of Defense directive for such in 2009,
result of three highly publicized articles: (1) a laboratory tourniquets routinely have been left in place until the
evaluation of battlefield tourniquets by the USAISR, patient is under the care of a surgeon. When evacuation
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(2) an internal report later published as an analysis of time is long, which is common in immature theaters of
the causes of death in special operations forces, and (3) conflict and on Special Operations missions, failure to
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a Baltimore Sun front­page newspaper article detailing re­evaluate and convert tourniquets that are no longer
combat deaths from wounded extremities and the mili­ needed to hemostatic or pressure dressings may lead to
tary’s bureaucratic inertia in fielding much­needed tour­ prolonged ischemia and avoidable loss of the extremity.
niquets to its troops, culminating in a strong expression Recently, a casualty suffered a surgical amputation of
of senatorial concern to the Secretary of Defense. the lower limb due to a tourniquet left in place during
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a long evacuation to a local national hospital, with a
Successful use of tourniquets on the modern battlefield total tourniquet time of 8 hours; upon surgical explo­
resulted from a combination of factors: new and im­ ration of the leg, no major vascular injury was found.
proved manufactured tourniquet designs, laboratory If the tourniquet had been converted to a hemostatic
testing of tourniquet effectiveness, and documentation or pressure dressing during tactical field care (TFC) or
of preventable deaths from extremity hemorrhage early tactical evacuation (TACEVAC) care, it would be rea­
in the conflicts in Iraq and Afghanistan, when tourni­ sonable to expect that the amputation could have been
quets were not routinely issued and improvised tour­ prevented. This case illustrates the point that the need
niquets were not effective. At the onset of hostilities in for a tourniquet must be re­assessed during both TFC
Af ghanistan, only a few selected Special Operations and TACEVAC phases of TCCC—at most, 2 hours after
units (Navy SEALs, the Army Special Mission Unit, the initial tourniquet placement—and serves as a reminder
75th Ranger Regiment, and Air Force Special Opera­ that vigilance is required to prevent or minimize tour­
tions Forces [SOF]) mandated training and fielding of niquet­related morbidity, particularly when evacuation
tourniquets to all of their personnel. Beginning in is long or delayed. There have been no known cases of
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2005, standardized tourniquet training became manda­ limbs lost to tourniquet ischemia in US casualties of the
tory throughout the US military, along with fielding of Iraq or Afghanistan wars, although there were at least
lightweight, easily carried, effective tourniquets to both two unpublished cases in Afghanistan of limb loss from
medical and nonmedical personnel. Dedicated data col­ tourniquets inadvertently left in place for extended pe­
lection through approved research protocols and through riods in Afghan casualties under Coalition care. These
the Department of Defense Trauma Registry allowed events reinforce the need for awareness that, even in
detailed analysis of preventable deaths and certain limb­ well­established combat trauma systems, communica­
related outcomes. Such data spurred ongoing process im­ tion errors and handoff errors can occur, leading to fail­
provements that included five refinements in the design ure to remove a tourniquet and resulting in avoidable
of the Combat Application Tourniquet (C­A­T ; Com­ harm. Altogether, the tourniquet evidence in the current
®
®
posite Resources Inc.; http://combattourniquet.com/) de­ war indicates that compliance with the TCCC guide­
sign and four updates to the TCCC guidelines relating to lines by the tourniquet user has been associated with

18 Journal of Special Operations Medicine Volume 15, Edition 1/Spring 2015