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Tourniquet use at the Boston Marathon bombing: Lost in translation

King, David Richard MD; Larentzakis, Andreas MD; Ramly, Elie P. MDThe Boston Trauma Collaborative

Journal of Trauma and Acute Care Surgery: March 2015 - Volume 78 - Issue 3 - p 594–599
doi: 10.1097/TA.0000000000000561
Original Articles

BACKGROUND The Boston Marathon bombing was the first major, modern US terrorist event with multiple, severe lower extremity injuries. First responders, including trained professionals and civilian bystanders, rushed to aid the injured. The purpose of this review was to determine how severely bleeding extremity injuries were treated in the prehospital setting in the aftermath of the Boston Marathon bombing.

METHODS A database was created and populated by all the Boston Level I trauma centers following the Boston Marathon bombing. Data regarding specific injuries, extremities affected, demographics, prehospital interventions (including tourniquet types), and outcomes were extracted.

RESULTS Of 243 injured, 152 patients presented to the emergency department within 24 hours. Of these 152 patients, there were 66 (63.6% female) experiencing at least one extremity injury, with age ranging from younger than 15 years to 71 years, and with a median Injury Severity Score (ISS) of 10 (range, 1–38). Of the 66 injured patients, 4 had upper limbs affected, 56 had injuries on the lower limbs only, and 6 had combined upper and lower limbs affected. The extremity Abbreviated Injury Scale (AIS) scores had a median of 3 (range, 1–4). There were 17 lower extremity traumatic amputations in 15 patients. In addition, there were 10 patients with 12 lower extremities experiencing major vascular injuries. Of 66 injured patients, 29 patients had recognized extremity exsanguination at the scene. In total, 27 tourniquets were applied: 16 of 17 traumatic amputations, 5 of 12 lower extremities with major vascular injuries, and 6 additional limbs with major soft tissue injury. All tourniquets were improvised, and no commercial, purpose-designed tourniquets were identified. Among all 243 patients, mortality was 0%.

CONCLUSION After the Boston Marathon bombings, extremity exsanguination at the point of injury was either left untreated or treated with an improvised tourniquet in the prehospital environment. An effective, prehospital extremity hemorrhage control posture should be translated to all civilian first responders in the United States and should mirror the military’s posture toward extremity bleeding control. The prehospital response to extremity exsanguination after the Boston Marathon bombing demonstrates that our current practice is an approach, lost in translation, from the battlefield to the homeland.

LEVEL OF EVIDENCE Epidemiologic study, level V.

From the Division of Trauma, Emergency Surgery, Surgical Critical Care, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.

Submitted: September 5, 2014, Revised: November 22, 2014, Accepted: December 5, 2014.

The Boston Trauma Collaborative includes the following institutions: Beth Israel Deaconess Medical Center, Boston Medical Center, Brigham and Women’s Hospital, Massachusetts General Hospital, and Tufts Medical Center, Boston.

Address for reprints: LTC David R. King, MD, US Army Joint Special Operations Command, Harvard Medical School, Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital and Harvard Medical School, 165 Cambridge St, Suite 810, Boston, MA 02141; email:

© 2015 Lippincott Williams & Wilkins, Inc.