Page 30 - Journal of Special Operations Medicine - Spring 2015

www.tacmedsolutions.com/), and the Emergency & The Israeli Defense Force experience was reported in a
Military Tourniquet (Delfi Medical Innovations Inc.; retrospective study of 550 casualties, 91 of whom re­
http://www.delfimedical.com/) were all effective at stop­ ceived a tourniquet. They reported no deaths from un­
14
ping distal blood flow in human volunteers. The C­A­T controlled limb hemorrhage and a 47% incidence of
has since become the most widely fielded tourniquet in nonindicated tourniquet placement, based on both tacti­
28
the US military, initially by USSOCOM and later by cal and anatomic indications taught in training; 78% of
the rest of the US military. By 2006, after a decade of tourniquets were effective (completely stopped bleeding)
commitment by key advocates to design, test, train, and neurologic complications occurred in 6.4% of limbs
and field battlefield tourniquets, tourniquet use on the with tourniquet times of 109 to 187 minutes. 31
battlefield had become ubiquitous. 7,17 In 2009, Kragh et
al. demonstrated clearly that for casualties with uncon­ A retrospective review of all 165 patients arriving at
trolled limb hemorrhage, survival with tourniquet use Baghdad’s 31st Combat Support Hospital (CSH) in
was higher than without, particularly if a tourniquet 2004 with major traumatic amputation, extremity vas­
was applied before onset of shock, emphasizing that, cular injury, or prehospital tourniquet compared casu­
within the comprehensive military trauma system, with alties with tourniquets applied prehospital and in the
effective devices, along with training and fielding to all emergency department (40% of casualties) to those
forces, mortality was improved while morbidity was without tourniquet use (60%). Tourniquet use was
minimized. 9 associated with improved hemorrhage control in this
study. Of note, 18% of tourniquets were nonindicated,
Preventable Deaths 15% were ineffective, and rebleeding occurred in an­
Analysis of combat mortality data during the Iraq and other 15% after resuscitation. No tourniquet­related
Afghanistan wars led to an improved understanding of complications were reported. This study, conducted at
the potentially preventable causes of combat death and a time before widespread tourniquet training and dis­
spurred new strategies for medical treatment, training, tribution to US forces, demonstrated that four of seven
and equipment. A focus on limb hemorrhage, in par­ deaths might have been prevented with earlier tourni­
ticular, provided the data to support widespread imple­ quet use. 32
mentation of tourniquet use by US forces. An analysis
of 82 fatalities in US SOF from 2001 to 2004 showed In 2006–2007, a prospective observational survey (in
12 deaths (15%) resulted from potentially survivable three time periods) was conducted at a single CSH in
wounds, including three of 12 (25%) with “tourniqu­ Iraq. These reports demonstrated 90% mortality for ca­
15
etable” hemorrhage. A larger study published in 2008 sualties with tourniquets placed after the onset of shock
of 982 US military fatalities showed similar results, with and 10% mortality for those with tourniquets placed
24% of deaths designated potentially survivable and before shock onset, providing strong support for early
33% of the potentially preventable deaths attributed to tourniquet use. Ineffective tourniquet placement (per­
limb hemorrhage. 29 sistent bleeding or persistent distal pulses) occurred in
28% of patients. Morbidity in this series was low, with
In 2012, Eastridge et al. published an analysis of 4,596 a 1.7% incidence of transient nerve palsy and no ampu­
30
battlefield deaths occurring from 2001 to 2011. This tation directly attributable to tourniquet use alone, al­
largest study reinforced the findings of prior studies, with though an increase in both amputation and fasciotomy
24% of prehospital combat deaths designated as poten­ rates was associated with tourniquet use longer than
tially survivable. Of the potentially survivable deaths, 2 hours. Morbidity assessment was challenging with
91% resulted from hemorrhage, with 12% attributed many associated injuries, and long­term follow­up was
specifically to limb hemorrhage. This study also focused absent in these reports. However, the lifesaving benefit
renewed attention on prehospital interventions, since of early tourniquet use was clearly demonstrated. 1,9,10,33
87% of combat deaths occurred before arrival at a medi­
cal treatment facility. A clear decrease in deaths from The 75th Ranger Regiment experience was reported
limb hemorrhage over the course of the war was dem­ in a retrospective study of 419 casualties; a total of 89
onstrated, with a 6.7­fold decrease in limb­hemorrhage limb tourniquets were applied to 66 casualties with no
deaths occurring after full implementation of training resultant complications. Of these casualties with tourni­
and dissemination of tourniquets among US forces. quets, 95% reached the next level of care alive and 94%
ultimately survived. Sixteen percent of these survivors
Published Series on Tourniquet Use had underlying injuries that resulted in limb amputa­
Battlefield tourniquet use in the modern era has demon­ tions; however, no amputation was attributed directly
strated a positive risk­to­benefit ratio, saving lives with to tourniquet use. Additionally, this study noted that
low incidence of morbidity. Several series of combat use nonmedical personnel performed 42% of tourniquet
have been reported. applications. 34

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