Page 29 - Journal of Special Operations Medicine - Spring 2015

a reduction of morbidity and mortality compared with effective. The authors strongly advocated for early and
noncompliance. 1,19,20 effective tourniquets.
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With the drawdown of combat operations in Afghani­ The Korean and Vietnam wars saw the development of
stan, we find ourselves at a transition point in combat helicopter evacuation from the battlefield, reducing the
casualty care that leads us to develop preparations for time to reach surgical treatment. The World War II era
future worldwide conflicts. For casualties in future con­ tourniquet continued to be used despite ineffectiveness,
flicts, we aim not only to maximize survival but also to and many tourniquets were improvised.
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optimize function. Better documentation and analysis of
prehospital care along with improved long­term follow­ The 1975 revision of Emergency War Surgery stated, “As
up will allow more detailed assessment of late complica­ an emergency measure, until more effective measures can
tions and limb­related functional outcomes in relation be instituted, external hemorrhage can often be checked
to prehospital tourniquet use. by direct pressure. . . . Tourniquets are rarely needed for
the control of hemorrhage and should be used only when
all other methods fail. A tourniquet properly applied can
Discussion save life but endanger limb.” This recommendation was
12
repeated in the 1988 revision of the text. 13
Historic Perspective on Tourniquet Use
Tourniquet use was a controversial topic in first aid for Bellamy’s analysis of Vietnam combat deaths recorded
nearly two millennia. 8,21 The earliest use of tourniquets that 9% of those killed in action exsanguinated from
to control blood loss was for surgical amputations, al­ extremity wounds and 88% of deaths occurred prehos­
lowing surgeons to perform the procedure with mini­ pital. He noted that “a substantial number of these
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mum blood loss. During the American Civil War in casualties exsanguinated from arterial wounds at sites
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1862, Samuel Gross of the Union Army recommended where simple first aid measures (direct pressure, pressure
issuing a tourniquet­like device to every combat Soldier on the cognate artery, or application of a tourniquet)
along with appropriate training. However, criticisms might have been expected to control hemorrhage.” He
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of tourniquet use also occurred during this conflict, of­ also stated, “First and foremost, there is a need to im­
ten associated with poor outcomes as a result of limited prove the field management of hemorrhage.” 26
training or prolonged transport time (many hours or
even days) to surgical hospitals. The modern era of tourniquet use in the US military re­
quired a doctrinal change from tourniquet use as a means
World War I brought the introduction of the battle­ of last resort to a means of first aid. Experience gained in
field medic, while transport to field hospitals was of­ Special Operations translated into a formal assessment of
ten delayed. Surgeons often saw the negative effects of needs during TCCC and the publication of guidelines in
tourniquets, and the prevailing viewpoint was that the 1996, for the first time formally describing the circum­
tourniquet should be used only after attempting eleva­ stances of medical care under fire (CUF) and presenting
tion and compression of pressure points, and, as stated appropriate guidelines for three phases of prehospital
in the official British manual of 1918, that “the system­ care. The tourniquet was the only medical interven­
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atic use of the elastic tourniquet cannot be too severely tion recommended under fire, followed by consideration
condemned.” 23 of tourniquet removal and conversion to hemostatic or
pressure dressing to control bleeding under more con­
The controversy between the potential lifesaving ben­ trolled circumstances during TFC and TACEVAC Care.
efit of the tourniquet and the potential harm persisted TCCC, including aggressive use of tourniquets to control
through the remainder of the 20th century. Most pub­ life­threatening limb hemorrhage, was incorporated in
lished opinions, however, were written by surgeons casualty response programs in the Naval Special Warfare
and ignored the fact that casualties who exsanguinated Command in 1997, followed quickly by the Army Special
from limb hemorrhage never reached the hospital, while Mission Unit, the 75th Ranger Regiment, and Air Force
those who did survive to reach the hospital experienced Special Operations Forces.
complications.
A formal evaluation of various tourniquets was first
In World War II, Wolff and Adkins reported their ob­ published in 2000, demonstrating a new commit­
27
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servations of tourniquets applied prehospital and of­ ment to optimizing device performance. In 2003, tour­
fered lessons learned from a year in combat in the Italian niquet devices were further evaluated for use in Iraq
theater. They noted that the standard­issue tourniquet and Afghanistan. Testing at the USAISR found that the
of the time, a simple canvas strap with spring­tension C­A­T, the Special Operations Forces Tourniquet­
buckle, lost tension during placement and was often not Tactical (SOFTT; Tactical Medical Solutions Inc, https://

TCCC Limb Tourniquet Guidelines Change 14-02 19