Page 161 - Journal of Special Operations Medicine - Winter 2015

Military History of Increasing Survival

The U.S. Military Experience with Tourniquets and
Hemostatic Dressings in the Afghanistan and Iraq Conflicts

Frank K. Butler, MD, FAAO, FUHM,
Chairman, Committee on Tactical Combat Casualty Care,
Department of Defense, Joint Trauma Systems

Tourniquets Tourniquet use was a central focus of the TCCC paper.
ourniquets are at least half a millennium old, and After recognizing the disconnect between the very sig-
yet they were not routinely fielded and used by the nificant incidence of preventable deaths from extremity
TU.S. military at the onset of the conflict in Afghani- hemorrhage in Vietnam and the ongoing failure of the
stan in 2001. By 2014, however, an article in the Journal U.S. military in the mid-1990s to field modern tourni-
of Trauma discussing tourniquets stated, “Tourniquets quets and to train combat medical personnel in their
have been the signature success in battlefield trauma use, the authors of the TCCC paper noted the following:
care in Afghanistan and Iraq. Based on the work of U.S.
Army Colonel John Kragh and colleagues, the number It is very important, however, to stop major bleeding
of lives saved from this intervention has been estimated as quickly as possible, since injury to a major vessel
to be between 1,000 and 2,000.” How did the U.S. mil- may result in the very rapid onset of hypovolemic
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shock. . . . Although ATLS [Advanced Trauma Life
itary come to make this remarkable journey? Support] discourages the use of tourniquets, they are
appropriate in this instance because direct pressure
The conventional wisdom in 2001 in civilian and most is hard to maintain during casualty transport under
military trauma courses was that the use of a tourniquet fire. Ischemic damage to the limb is rare if the tour-
for hemorrhage control would likely result in ampu- niquet is left in place less than an hour and tourni-
quets are often left in place for several hours during
tation of the injured limb and that the harmful effects surgical procedures. In the face of massive extremity
of tourniquets far outweighed the benefits. The results hemorrhage, in any event, it is better to accept the
of this mind-set were predictable. The review by Kelly small risk of ischemic damage to the limb than to
et al. of combat fatalities from the early years of the lose a casualty to exsanguination . . . the need for
conflicts in Southwest Asia found that 77 U.S. service- immediate access to a tourniquet in such situations
makes it clear that all SOF [special operations forces]
men and servicewomen had bled to death from extrem- operators on combat missions should have a suitable
ity wounds. These deaths made up 7.8 percent of all tourniquet readily available at a standard location on
2
combat fatalities reviewed. This incidence of death from their battle gear and be trained in its use. 4
extremity hemorrhage was essentially unchanged from
the 7.4 percent noted in Vietnam, a quarter of a century Despite the publication of the TCCC paper, however,
earlier. and a series of briefings to military medical audiences
3
and senior military medical leaders, the principles of
The resurgence of tourniquet use in the U.S. military care outlined in the TCCC program gained little traction
originated with the Tactical Combat Casualty Care in the U.S. military before the events of September 11,
(TCCC) program. The TCCC was the result of a mil- 2001. The only units that adopted the TCCC prior to
itary medical research effort conducted jointly by the 2001 were the U.S. Navy SEALs, the 75th Ranger Regi-
U.S. Special Operations Command (USSOCOM) and ment, the U.S. Army Special Missions Unit, the U.S. Air
the Uniformed Services University of the Health Sci- Force Special Operations community, and a small num-
ences. This project was undertaken in 1993 to review ber of other special operations and conventional units.
the principles of battlefield trauma care employed by the
U.S. military at the time and to see if these principles The value of extremity tourniquets was also taught at
were supported by the available evidence. The product the Joint Trauma Training Center in Houston from
of this research effort was a paper titled “Tactical Com- 1999 to 2001, but the recommendation for expanded
bat Casualty Care in Special Operations,” published in tourniquet use languished. Even the units that had em-
Military Medicine in 1996. 4 braced tourniquet use at the start of the recent war in

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