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Prehospital Tourniquet Use in Operation Iraqi Freedom: Effect on Hemorrhage Control and Outcomes

Beekley, Alec C. MD, FACS; Sebesta, James A. MD; Blackbourne, Lorne H. MD; Herbert, Garth S. MD; Kauvar, David S. MD; Baer, David G. PhD; Walters, Thomas J. PhD; Mullenix, Philip S. MD; Holcomb, John B. MCMembers of the 31st Combat Support Hospital Research Group

The Journal of Trauma: Injury, Infection, and Critical Care: February 2008 - Volume 64 - Issue 2 - p S28-S37
doi: 10.1097/TA.0b013e318160937e
Presented Papers

Background: Up to 9% of casualties killed in action during the Vietnam War died from exsanguination from extremity injuries. Retrospective reviews of prehospital tourniquet use in World War II and by the Israeli Defense Forces revealed improvements in extremity hemorrhage control and very few adverse limb outcomes when tourniquet times are less than 6 hours.

Hypothesis: We hypothesized that prehospital tourniquet use decreased hemorrhage from extremity injuries and saved lives, and was not associated with a substantial increase in adverse limb outcomes.

Methods: This was an institutional review board-approved, retrospective review of the 31st combat support hospital for 1 year during Operation Iraqi Freedom. Inclusion criteria were any patient with a traumatic amputation, major extremity vascular injury, or documented prehospital tourniquet.

Results: Among 3,444 total admissions, 165 patients met inclusion criteria. Sixty-seven patients had prehospital tourniquets (TK); 98 patients had severe extremity injuries but no prehospital tourniquet (No TK). Extremity Acute Injury Scores were the same (3.5 TK vs. 3.4 No TK) in both groups. Differences (p < 0.05) were noted in the numbers of patients with arm injuries (16.2% TK vs. 30.6% No TK), injuries requiring vascular reconstruction (29.9% TK vs. 52.5% No TK), traumatic amputations (41.8% TK vs. 26.3% No TK), and in those patients with adequate bleeding control on arrival (83% TK vs. 60% No TK). Secondary amputation rates (4 (6.0%) TK vs. 9 (9.1%) No TK); and mortality (3 (4.4%) TK vs. 4 (4.1%) No TK) did not differ. Tourniquet use was not deemed responsible for subsequent amputation in severely mangled extremities. Analysis revealed that four of seven deaths were potentially preventable with functional prehospital tourniquet placement.

Conclusions: Prehospital tourniquet use was associated with improved hemorrhage control, particularly in the worse injured (Injury Severity Score >15) subset of patients. Fifty-seven percent of the deaths might have been prevented by earlier tourniquet use. There were no early adverse outcomes related to tourniquet use.

From the Department of General Surgery, Madigan Army Medical Center (A.C.B., J.A.S., G.S.H.), Fort Lewis, Washington; the Trauma/Critical Care/Burn Service (L.H.B.), the Institute of Surgical Research (L.H.B., D.G.B., T.J.W., J.B.H.), and the Department of General Surgery (D.S.K.), Brooke Army Medical Center, Fort Sam Houston, Texas; and the Walter Reed Army Medical Center (P.S.M.), Washington, D.C.

Submitted for publication October 30, 2007.

Accepted for publication October 30, 2007.

The opinions and assertions contained in this article are solely the authors’ private ones and are not to be construed as official or reflecting the views of the United States Army or the Department of Defense. This article was prepared by United States Government employees and therefore cannot be copyrighted and may be copied without restriction.

Presented at the Western Trauma Association Meeting, Big Sky, Montana, March 2006.

Address for reprints: Alec C. Beekley, MD, FACS, Department of General Surgery, Madigan Army Medical Center, 9040-A Fitzsimmons Road, Ft. Lewis, WA 98431-1100; email:

© 2008 Lippincott Williams & Wilkins, Inc.