Page 70 - JSOM Spring 2024

FIGURE 1 Use of tourniquets at the stages of tactic medical care. The long-term use of the tourniquet on the limbs usually hin-
dered the evacuation of the wounded owing to heavy enemy
fire, which ignored the norms of international humanitarian
laws. Evacuation of the wounded was also difficult during sig-
nificant separation of the assault groups from the main forces.
No cases of delayed care or treatment were recorded at the
military hospitals.

The casualties associated with limb tourniquets included 57
fatalities: 17 (0.7%) due to massive blood loss and 27 (1.1%)
associated with infectious-septic complications or the pres-
ence of a background comorbidity. An additional 13 patients
(0.5%) died from multiple-organ failure.

Limb amputations were performed in 92 (3.7%) of the 2,437
wounded who survived. In all cases, amputations were per-
formed to treat multi-fragment explosive injuries without
the possibility of reconstructive intervention. The duration of
During active hostilities, the medical units of the Southern Op- tourniquet use in these cases ranged from 210 to 380 minutes.
erational Command received 2,496 patients with limb injuries Seventy-eight amputations were performed in cases involving
that required the application of tourniquets. Injuries involving tourniquet use of more than 6 hours. Amputations of patients
lower extremities were most often observed, in 2,107 cases or having tourniquets in place for longer than 6 hours were at-
84.4% of all patients, while upper extremity lesions were seen tributed to extensive tissue necrosis distal to the tourniquet.
in 389 cases (15.6%). A single tourniquet was applied in 1,538
cases (61.6%), two tourniquets in 533 cases (21.4%), and Among limbs without amputations, 938 cases of neuropathy
three tourniquets in 425 cases (17.0%). From 2014 to 2021, were detected, 679 of which resolved within the 24-month
Esmarch’s tourniquet was most commonly used. However, in post-injury observation period. Primary limb injury was the
2022, it was mostly replaced by CAT and similar systems, such cause of unresolved neuropathy in147 cases.
as Sich and Dnipro. Various tourniquets were frequently ap-
plied to the limb segments of wounded combatants and civil- Limb amputations were performed in 92 cases (3.7%), usually
ians, as shown in Table 1. involving multi-fragment explosive injuries, when the possi-
bility of reconstructive intervention was excluded. Massive
The duration of the tourniquet on the limb ranged from 50 to blood loss was the primary cause of death in 68 (2.7%) of the
380 minutes (mean duration 205.9 [standard error; SE 8.1] wounded soldiers. Infectious-septic complications or comor-
min), resulting in prolonged tissue ischemia in a significant bid diseases resulted in the deaths of another 33 (1.3%).
number of cases (Figure 2).

FIGURE 2 Distribution of clinical cases treated with tourniquets for Discussion
limbs based on the duration of intervention.
Prolonged tourniquet use increases the risk of irreversible soft
tissue damage. In particular, skeletal muscles cannot tolerate
ischemia for longer than 6 hours without complete loss of vi-
ability. However, cases of functional preservation of limb have
been reported even when the tourniquet was applied for more
than 15 hours. In the literature, there are various approaches
10
to naming changes in the soft tissues of the extremities after
the prolonged use of a tourniquet. We propose the term tour-
niquet syndrome for compartment syndrome resulting from
prolonged tourniquet application. This will avoid confusion
when comparing different clinical cases.

We present our own clinical case of post-ischemic edema fol-
lowing tourniquet use for more than 6 hours. Following fasci-
otomy, severe muscle swelling was observed, and the wound

TABLE 1 Frequency of Tourniquet Application
Windlass rod
No. of applied tourniquets Esmarch’s tourniquet tightening systems Improvised systems
Location 1 2 3 2014–2021 2022 2014–2021 2022 2014–2021 2022
Upper arm 298 55 — 128 66 14 149 — —
Forearm 29 7 — 11 6 3 12 — —
Thigh 833 394 392 231 123 152 1468 23 12
Calf 395 86 7 51 28 56 59 3 1

68 | JSOM Volume 23, Edition 1 / Spring 2024