Page 22 - JSOM Spring 2024

a tourniquet. Dressings were applied to all six limbs and the and tight on both limbs. He remained at the site of the blast
tourniquets were converted with effective hemostasis. The sev- for 3 hours before evacuation, and his tourniquets were on for
enth casualty was pale and unresponsive. A tourniquet had 16 hours total. Per the available records that were transferred
been placed on his left lower extremity high and tight, with with the patient, no vascular injuries were found to either
blood pooling on the pants and gurney. On exposure, no ex- limb, but he had rhabdomyolysis and compartment syndrome
tremity wound was found but penetrating trauma to the lower requiring amputation of both limbs.
thorax was revealed. The casualty was pronounced dead at the
CCP. No reassessment of initial care rendered at the POI was Case 7 (report from combat medic): An adult male arrived at
reported to have occurred during the prolonged period from a TSP within an hour of injury with a fragmentation injury to
injury to evacuation; the first assessment of tourniquet place- his left upper arm. A tourniquet had been applied in the field
ments occurred at the CCP. high and tight on the limb, and, on reassessment by a com-
bat medic at the TSP, ongoing bleeding from a grapefruit-sized
Case 3 (report from transferring team and follow-up from sur- wound was noted. The medic tightened the tourniquet wind-
gical team): An adult male presented to a TSP with several inju- lass one turn with cessation of bleeding. The casualty was then
ries including fragmentation wounds of the face, right arm, and transferred immediately to the next echelon of care for surgical
left thigh. At or near the POI, a tourniquet was placed above management. The total time from tourniquet placement to sur-
the wound on the left lower extremity and remained in place gical evaluation was less than 2 hours.
for more than 10 hours until evacuation. He was treated and
transferred to a higher level of care in a nearby major city. At Discussion
the time of transfer, he was intubated and placed on a venti-
lator. On arrival at the surgical hospital, he underwent a de- The network of NGOs, partner nations, and Ukrainian stake-
compression fasciotomy of the left thigh and lower leg. It is holders involved in the delivery of prehospital medicine and
unclear if a vascular injury was present. The following day, he training are currently engaged in multidirectional conversa-
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underwent an amputation of the left lower extremity at the tions on how to refine best practices. We aim to contribute
level of the thigh. He had an acute kidney injury that required to this effort through observations of tourniquet practices and
hemodialysis. The available medical record documentation did identification of priorities for action. Although biased toward
not include who placed the tourniquet, if conversion was at- representation of morbidity, these cases demonstrate an obser-
tempted, or a timeline of following interventions/patient status. vational pattern from multiple parties.

Case 4 (direct patient encounter): An adult male with no known In addition to the lives saved from vascular injury to limbs,
medical history arrived at the first hospital in the evacuation medical personnel across Ukraine report high rates of condi-
chain with a fragmentation injury to the left leg. The casualty tions associated with tourniquet complications in casualties
arrived on a litter at the same time as several other casualties suffering limb trauma throughout the casualty care chain.
and was placed in a waiting area. On first assessment, a tour- Such complications include renal failure, hemodialysis, com-
niquet was noted to have been applied over clothing to the partment syndrome, fasciotomies, amputations, and limb sal-
left leg and blood was persistently pooling under the wound. vage complications such as osteomyelitis. Sequelae from these
Medical personnel at the hospital first tightened the tourni- complications greatly impact the recovery courses of surviving
quet without resolution of the bleeding. The extremity was casualties. Additionally, the long-term burden on the health-
then exposed by a volunteer NGO medic who noted persistent care system of not only Ukraine but of supporting European
hemorrhage, suggesting an ineffective venous tourniquet. Di- allies may be significant.
rect pressure was applied to the wound and the tourniquet
was loosened, with effective hemostasis noted with pressure Although these patterns of suboptimal tourniquet use are
dressing alone. Tourniquet placement time was unknown. largely due to specific ground truths, potentially confound-
ing variables should be acknowledged. These patterns may be
Case 5 (direct patient encounter): An adult male with multi- (and likely are, in part) due also to the complexity of injuries,
ple injuries following indirect fire was brought to a forward armaments, targeting patterns, and volume of polytrauma. It
surgical team via combat medics. Prior to arrival, the patient is difficult to extrapolate from limited data what morbidity
had tourniquets applied to both lower extremities, vented chest is due to injury versus tourniquet, a complex task even in a
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seals applied to fragmentation wounds of the chest, and pres- mature system that gathers meticulous data. Patients with
sure dressings on other wounds. After resuscitation, the patient significant limb trauma are more likely to have tourniquets
underwent damage control surgery to address the limb injuries. placed, so the presence of both injury and tourniquet can con-
In the operating room, a tourniquet was loosened to help iden- found outcomes. 13,17 During the GWOT, an increased rate of
tify a vascular injury. A wound distal to that tourniquet began fasciotomies after implementation of tourniquet practices was
to hemorrhage, and the surgeon attempted to re-apply the tour- noted; it is unclear if this was related to the increased num-
niquet, which broke, resulting in significant blood loss until a ber of lives and limbs saved, increased awareness and training,
new tourniquet was procured. The patient became hypotensive or tourniquet complications. Variations in medical manage-
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and, while waiting on blood products, died. ment and protocols downstream in the casualty care chain in
the hours and weeks after injury may also affect outcomes.
Case 6 (direct patient encounter, review of available records): An additional confounding issue may be the already widely
An adult male arrived at a major surgical hospital after under- reported use of non-recommended, fraudulent, or fake tour-
going a high right arm and high left leg amputation as damage niquets (Figure 1). 21,22 TCCC guidelines depend upon the use
control surgery. Per the records and the patient, he sustained of recommended tourniquets. Cheap counterfeit tourniquets,
injuries to his right arm and left leg from a missile strike. At which are readily available on the internet, may contribute to
the POI, another soldier helped him apply tourniquets high current morbidity and mortality. 23–25

20 | JSOM Volume 23, Edition 1 / Spring 2024