Page 24 - JSOM Summer 2020

Tourniquest

Piper Wall, DVM, PhD *; Charisse Buising, PhD 2
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mergency-use limb tourniquets are now widely consid- recommendation of the C-A-T for all Soldiers and U.S. mili-
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ered appropriate first aid equipment for point of injury tary fielding of 277,409 C-A-Ts by July 2005. With predom-
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Euse in both military and civilian settings. This state of inantly commercial emergency-use limb tourniquets (mostly
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affairs was far from inevitable. Consensus that keeping blood C-A-Ts), the Kragh et al. report provided effectiveness, mor-
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within the central circulation is a good idea has existed for bidity, and mortality data that made not supporting the early
quite some time, but consensus that limb tourniquets are use of effective emergency-use limb tourniquets embarrassing.
an appropriate tool for accomplishing that task is relatively The follow-on publications by Kragh et al. in 2009 12–14 pro-
recent. vided another look and a doubling down on data. 13,14 The
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answers were plain: using tourniquets to stop limb bleeding as
Limb tourniquet use is far from a new first aid concept, and early as possible is life-saving 12,13 with little tourniquet-related
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today’s Tactical Combat Casualty Care guidelines regarding morbidity risk, 13,14 but the tourniquets need to stop the arterial
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tourniquets line up nicely with the 1945 recommendations of flow into the limb. 10,14 Additional military use data confirmed
Wolff and Adkins. So how did strong disagreement become that patients with limb tourniquets need to have tourniquet
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the current “pro limb tourniquets” consensus? Relentless data conversion or definitive care within a limited time frame 15,16
collection, analysis, and publications regarding military causes that is impacted by limb temperature. 17
of death and data-driven pursuit of the elimination of prevent-
able deaths from combat. Based on cause of death data, the Getting the majority of the players involved in US civilian pre-
1996 TCCC guidelines included tourniquet use during Care hospital trauma patient care to see the emergency-use limb
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Under Fire and Tactical Field Care, and research regarding tourniquet light took some additional time and publications
emergency-use limb tourniquet designs was supported and containing civilian trauma patient data with tourniquet use.
started being published. In 2003, the Lakstein et al. report
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regarding Israeli military tourniquet experience from 1997 to The critical pieces for optimizing survival while minimizing
2001 was published; it included hard numbers for total tour- morbidity are to reach and maintain arterial occlusion proxi-
niquets (110 tourniquets on 91 of 550 casualties), tourniquet mal to the injury as soon as possible with tourniquet designs
types, tourniquet locations, and tourniquet effectiveness. In and application techniques that are effective, rapid, and min-
2007, the Brodie et al. report regarding UK military tourni- imally injurious to underlying tissue. To optimize tourniquet
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quet experience from 2003 to 2007 was published; it included designs and application techniques, the current emergency-use
hard numbers for total tourniquets (107 tourniquets on 70 of limb tourniquet questions are not some version of “Should we
1375 casualties, only 6 of those casualties before April 2006, use them?” and “What are the risks?” but are instead things
which was when Combat Application Tourniquets (C-A-Ts) such as: “Is that design effective and in what circumstances?
were introduced as an individual first aid item), injury mech- What are the pros and cons of different designs (elastic/non-
anisms and types, prehospital versus emergency department elastic, securing systems, redirect buckle designs, tightening
(106 versus 1), and direct complications (3). In 2008, the systems, etc.)? What can we use for effectiveness monitoring?
Beekley et al. and Kragh et al. reports regarding U.S. mili- What application techniques are optimal?” and “How can we
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tary tourniquet experience during 2004 and 2006, respectively, maximize the chances that an applier will use optimal applica-
were published. The hard numbers in the Beekley et al. report tion techniques?” Research, “the systematic investigation into
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were 165 of 3,444 casualties had traumatic limb amputation, and study of material and sources in order to establish facts
major limb vascular injury, or a prehospital tourniquet and did and reach new conclusions,” is the key to answering these
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not have a lethal trunk or head injury. Among those 165 ca- questions. Only by asking and answering questions can we ex-
sualties, 67 received 80 tourniquets. Tourniquet effectiveness pect to be able to intentionally and intelligently improve limb
data were available for 42 casualties with 52 tourniquets: 8 tourniquet designs and use.
tourniquets weren’t controlling hemorrhage on arrival and 11
tourniquets that were controlling hemorrhage on arrival failed Disclosures
to maintain hemorrhage control once active resuscitation be- The authors have no financial relationships relevant to this
gan. The physiologic data (blood pressure, heart rate, base article to disclose.
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deficit, etc.), the mortality rate, and the rate of secondary am-
putations were not significantly different for the 67 casualties References
with tourniquets versus the 98 without tourniquets. The hard 1. Committee on Tactical Combat Casualty Care. TCCC Guide-
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lines for Medical Personnel 1 August 2019. https://www.naemt
numbers in the Kragh et al. report were 232 of 1,462 casu- .org/docs/default-source/education-documents/tccc/tccc-mp
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alties with 428 tourniquets on 309 limbs. The data collection -updates-190801/tccc-guidelines-for-medical-personnel-190801
period of the Kragh et al. report was after the 2004 CoTCCC .pdf?sfvrsn=cc99d692_2. Accessed 10 April 2020.
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*Correspondence to piperwall@q.com
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1 Dr Wall is a researcher in the Surgery Education Department, UnityPoint Health Iowa Methodist Medical Center, Des Moines, Iowa. Dr Buising
is a professor of biology and the director of the Biochemistry, Cell and Molecular Biology Program, Drake University, Des Moines, Iowa.
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