Page 116 - JSOM Spring 2025

used by the United States, British, French, and Dutch Mili- Who Needs a Tourniquet? And Who Does Not?
taries. Most of the studies focused on transfusion ratios, the Lessons Learned From a Review of Tourniquet Use in
movement of blood transfusions to more forward locations, the Russo-Ukrainian War
implementation of massive transfusions with different fibrin- J Trauma Acute Care Surg. 2024;97(2S Suppl 1):S45–S54.
ogen-to-red blood cell ratios, the addition of recombinant doi:10.1097/TA.0000000000004395
factor VII, and the use of predictive models for transfusion. Frank Butler, John B Holcomb, Warren Dorlac,
Lastly, we identified reports of improved survival for casu- Jennifer Gurney, Kenji Inaba, Lenworth Jacobs,
alties with the rapid implementation of various blood prod- Bob Mabry, Mike Meoli, Harold Montgomery, Mel Otten,
ucts (warm fresh whole blood, cold-stored low titer group Stacy Shackelford, Matthew D Tadlock, Justin Wilson,
O blood, freeze-dried plasma, and component therapy) and Kostiantyn Humeniuk, Oleksandr Linchevskyy,
literature relating to pediatric casualties and submassive trans- Oleksandr Danyliuk
fusions. Notable findings include the establishment of hemo- Background: Extremity tourniquets have proven to be lifesav-
dynamic and cell blood count parameters as predictors of ing in both civilian and military settings and should continue
the requirement for massive transfusions and the association to be used by first responders for trauma patients with life-
of higher fibrinogen-to-red blood cell ratios with decreased threatening extremity bleeding. This is especially true in com-
mortality.
bat scenarios in which both the casualty and the first responder
Conclusions: We identified 53 studies focused on blood trans- may be confronted by the imminent threat of death from hos-
fusions from the Global War on Terrorism conflicts. The ma- tile fire as the extremity hemorrhage is being treated. Not ev-
jority were related to transfusion ratios and the movement of ery extremity wound, however, needs a tourniquet. One of the
blood transfusions to more forward locations. We highlight most important aspects of controlling life-threatening extrem-
key lessons learned on the battlefield that have been translated ity bleeding with tourniquets is to recognize what magnitude
into scientific developments and changes in civilian trauma of bleeding requires this intervention and what magnitude of
methods. bleeding does not. Multiple studies, both military and civilian,
have shown that tourniquets are often applied when they are
Injury Trends Aboard US Navy Vessels: A 50-year Analysis not medically indicated. Overuse of extremity tourniquets has
of Mishaps at Sea not caused excess morbidity in either the recent conflicts in Iraq
J Trauma Acute Care Surg. 2023;95(2S Suppl 1):S41–S49. and Afghanistan or in the US urban civilian setting. In the pres-
doi:10.1097/TA.0000000000004047 ence of prolonged evacuation, however, applying a tourniquet
Derek A Benham, Matthew C. Vasquez, Jakob Kerns, when it is not medically indicated changes tourniquet applica-
Kyle D. Checchi, Ross Mullinax, Theodore D. Edson, tion from being a lifesaving intervention to one that may cause
Matthew D. Tadlock an avoidable amputation and the development of an array of
metabolic derangements and acute kidney injury collectively
Background: Maritime activities have been associated with called prolonged tourniquet application syndrome.
unique dangers to civilian and military sailors. We performed
a retrospective cohort study analyzing injury mechanisms and Methods: The recent literature was reviewed for papers that
clinical outcomes of casualties onboard US naval ships to de- documented the complications of tourniquet use resulting
termine common injury mechanisms, trends, and outcomes. from the prolonged casualty evacuation times being seen in the
We hypothesized there would be a downward trend of injuries current Russo-Ukrainian war. The literature was also reviewed
and fatalities on US naval ships during the study period. for the incidence of tourniquet application that was found to
not be medically indicated, in both the US civilian setting and
Methods: All mishaps recorded by the Naval Safety Command
aboard active service US naval ships from 1970 through 2020 from Ukraine. Finally, an in-person meeting of the US/Ukraine
were reviewed. Only mishaps resulting in injury or fatality Tourniquet Working Group was held in Warsaw, Poland, in
were included. Over time, injury mechanisms and casualty in- December of 2023.
cidence rates were trended and compared based on medical Results: Unnecessary loss of extremities and life-threatening
capabilities. Ships without surgical capabilities were catego- episodes of prolonged tourniquet application syndrome are
rized as Role 1, and those with surgical capabilities as Role 2. currently occurring in Ukrainian combat forces because of non-
indicated tourniquet use combined with the prolonged evacua-
Results: There were a total of 3,127 casualties identified and tion time seen in the Russo-Ukrainian war. Specific numbers of
analyzed, with 1,048 fatalities and 2,079 injuries. The injury the complications experienced as a result of tourniquet use by
mechanisms associated with the highest mortality included Ukrainian forces in the current conflict are treated as classified
electrocution, blunt head trauma, fall from height, man over- information and are not available, but multiple sources from
board, and explosion. There was a decrease in the trend of the Ukrainian military medical personnel and from the US ad-
mishaps resulting in casualties, fatalities, and injuries over visors providing medical assistance to Ukraine have all agreed
the 50-year study period. The mortality rate for select severe that the problem is substantial.
injury mechanisms was higher on Role 1 capable platforms,
compared with Role 2 (0.334 vs. 0.250, p < 0.05). Conclusion: Unnecessary tourniquet morbidity might also oc-
cur in US forces in a variety of potential future combat scenar-
Conclusion: Casualty incidences decreased over 50 years.
However, mortality still remains high for certain mechanisms ios in which evacuation to surgical care is delayed. Prehospital
no matter the operational platform. Furthermore, Role 1 ca- trauma training programs, including but not limited to tacti-
pable vessels have a higher overall mortality rate for severe cal combat casualty care, place insufficient emphasis on the
injuries compared with Role 2. The authors propose training, need to avoid leaving tourniquets in place when they are not
process improvement, and technology-related solutions to im- medically indicated. This aspect of training should receive em-
prove outcomes on Role 1 capable naval vessels. phasis in future Tactical Combat Casualty Care (TCCC) and
civilian first responder curriculum development. An interim ad

114 | JSOM Volume 25, Edition 1 / Spring 2025