Page 23 - JSOM Spring 2024

It is clear that there are many systemic differences at play in the
war in Ukraine compared with the GWOT, both in the tactical
environment as well as the model of training and protocoliza-
tion. It is not known whether there were medical indications
in these cases. However, we can hypothetically apply GWOT,
Israeli, and other data, and extrapolate from these reports that
rates of prolonged application are high. 32,33 It would seem very
FIGURE 1 probable that the number-needed-to-treat per tourniquet ap-
A resuscitation area plication for mortality benefit in the war in Ukraine war is less
in Ukraine, where favorable than that of the GWOT.
tourniquets are
routinely washed and
re-used for multiple More data are necessary to understand the impact of the
patients. heavily condensed training, based on TCCC/TECC concepts,
deployed in rapid fashion to Ukrainian Servicemembers and
medical personnel. However, we have identified three major
factors impacting tourniquet practices: prolonged evacuation
times, rigid protocolization of concepts, and systemic differ-
ences in the definition, training, and availability of field med-
ics. Understanding how these factors interact with existing
TCCC/TECC paradigms is crucial to guide interventions.

Tourniquet indications can be tactical or medical; tactical Evacuation Times
indications are notoriously difficult to analyze in retrospect. In the war in Ukraine, evacuation time is likely the most signifi-
Lessons learned from the U.S. SOF community emphasize that cant factor impacting tourniquet complications. In the absence
promoting other means to control hemorrhage while under of air superiority or mobile aid stations, evacuation times are
immediate danger places both the casualty and responder at reported to be significantly longer than those in the GWOT,
26
increased risk. Although TCCC guidelines contemplate tour- when there was reliance on chains of evacuation composed
niquet application under fire as an appropriate stopgap to of multiple echelons of care and air transport, which typically
manage “life-threatening hemorrhage,” this condition can be delivered patients to definitive care within 1 hour. 2,14,30,31,34 In
difficult to diagnose under duress of immediate threat. Studies near-peer conflicts, evacuation resources are likely to be lim-
have found that the majority of tourniquets placed at or near ited by contested airspace, resulting in more prolonged, com-
the POI are not medically indicated. 27,28 plex, high-risk ground evacuation platforms. Unpublished
reports and sources on the ground report that current casualty
A four-year review by Israeli Defense Forces (IDF), also a pro- evacuation times to the first facility in Ukraine often exceed
ponent of liberal tourniquet practices, concluded that 54% of the 4-hour mark and frequently go beyond 12 hours.
tourniquets had “situational and non-medical” indications.
27
In a U.S. study of GWOT casualties, 74% of limbs with The body of evidence documenting the safety of tourniquets
tourniquets applied in the field did not have a major vascu- reports exceedingly low rates of usage over 150 minutes, and
lar injury, and 83% of tourniquets were venous, meaning the cases that exceed this duration are outliers with high rates
placement was tight enough to occlude venous but not arterial of morbidity. 7,8,10,14,27,31 The mean time of tourniquet dura-
flow. While these tourniquets may have initially been ap- tion in the IDF study was 78 minutes, and all but one of the
28
plied correctly, tourniquets will loosen over time due to mus- small number of complications observed were in cases with
27
cle relaxation, fluid shift, and blood loss. Without proper times over 150 minutes. Since 2001, there has been only one
29
re-evaluation and tightening, tourniquets can become venous, known case of inappropriate limb loss by a U.S. Servicemem-
which increases the risk of ongoing arterial bleeding. Mis- ber due to prolonged tourniquet use. During a 2014 combat
uses such as these are common, even when applied by highly mission in Africa, a tourniquet placed high and tight on a limb
trained operators. 7,14,26,27 was not found by medical personnel until 8 hours after ap-
plication. There was ultimately no vascular injury, and med-
By the end of the GWOT, the tourniquet pendulum had ical personnel believed that the amputation would have been
swung to the point where they were routinely applied to mi- avoided with earlier tourniquet conversion. 14
nor wounds during Care Under Fire (CUF), usually “high and
tight.” 14,30 This trend has continued in the war in Ukraine, with Shackelford et al. anticipated the issue of prolonged evacua-
tourniquets being liberally applied at the POI for any signs of tion impacting TCCC paradigms in future conflicts in their
14
limb trauma. They are then often left on without clear reas- 2014 proposal of guideline changes. A need for clarification
sessment until arrival at the first receiving facility. The NGO and increased training on tourniquet conversion was empha-
medic from Case 2 observed that in 18 months working in sized, noting that as a result of the short evacuation times in
CCP settings, including personal assessments of approximately GWOT, attempts to convert tourniquet to hemostatic dress-
25 casualties, they did not see any cases in which conversion ings had been “de-emphasized in practice by users,” despite
had been attempted during prolonged evacuation wait times. the recommendation in guidelines that tourniquets placed in
Multiple other sources in similar positions reported the same CUF should be re-evaluated in the Tactical Field Care (TFC)
14
observation—conversion is often first attempted at the receiv- phase of care. This trend in GWOT is understandable given
ing surgical facility. The lack of tourniquet conversion occur- that casualties arrived in a facility within minutes, and the
ring in the field is complicated and multifactorial and will be data analysis by the JTR revealed no complications from this
addressed further in the discussion. practice.

Tourniquet Practices: Lessons from the War in Ukraine | 21