DTIC ADA513463: Battle Casualty Survival with Emergency Tourniquet Use to Stop Limb Bleeding

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ARTICLE IN PRESS
TheJournalofEmergencyMedicine,Vol.xx,No.x,pp.xxx,2009
PublishedbyElsevierInc.
PrintedintheUSA
0736-4679/09$–seefrontmatter
doi:10.1016/j.jemermed.2009.07.022
Original
Contributions
BATTLE CASUALTY SURVIVAL WITH EMERGENCY TOURNIQUET USE TO
STOP LIMB BLEEDING
John F. Kragh, Jr, COL, MC, USA,* Michelle L. Littrel, CPT, AN, USA,† John A. Jones,*
Thomas J. Walters, PHD,* David G. Baer, PHD,* Charles E. Wade, PHD,* and John B. Holcomb, MD*†
*US Army Institute of Surgical Research (USAISR), Fort Sam Houston, Texas and †Department of Nursing, Brooke Army Medical
Center, Fort Sam Houston, Texas
Reprint Address: John F. Kragh, Jr, COL, MC, USA, Bone and Soft Tissue Trauma Research Program, US Army Institute of Surgical
Research, 3400 Rawley E. Chambers Ave., Bldg. 3611, Room L82-16, Fort Sam Houston, TX 78234-6315
e Abstract—Background: In a previous study conducted study 1 and 1.5% for study 2; major limb shortening was
atacombatsupporthospitalinIraq,wereportedthemajor 0.4% for both. Survival was associated with prehospital
lifesaving benefits of emergency tourniquets to stop bleed- application(89%vs.78%hospital,p<0.01)andapplica-
inginmajorlimbtrauma.Morbidityassociatedwithtour- tionbeforetheonsetofshock(96%vs.4%after).Conclu-
niquet use was minor. Study Objectives: The objective of sions: This study shows consistent lifesaving benefits and
this study is to further analyze emergency tourniquet use lowriskofemergencytourniquetstostopbleedinginmajor
in combat casualty care. Design and Setting: This report limbtrauma. PublishedbyElsevierInc.
is a continuation of our previous study of tourniquet
use in casualties admitted to a combat support hospital e Keywords—tourniquet; trauma; major; military; limb
(NCT00517166atwww.ClinicalTrials.gov).Methods:After injury;hemorrhagecontrol
verifyingcomparablemethodologiesforthefirststudyand
the current study, we compared patient results for these
twotimeperiodsandthenpooleddatatoanalyzeoutcomes
INTRODUCTION
withalargersamplesize.Results:Thetotalstudypopula-
tion was 499 (232 in the previous study and 267 in the
currentstudy).Inall,862tourniquetswereappliedon651 Despite recent positive reports of the use of emergency
limbs.Survivalwas87%forbothstudyperiods.Morbidity tourniquetsfromstudiesconductedatUnitedStates(US)
ratesforpalsiesatthelevelofthetourniquetwere1.7%for combat support hospitals in Iraq, these devices are still
considered controversial by some providers (1,2). We
recently reported major lifesaving benefits and minor
Thisstudywasperformedatthe10th&28thCombatSupport morbidity risks with emergency tourniquet use to stop
Hospitals, US Army, (Ibn Sina Hospital, International Zone,
bleedinginmajorlimbtrauma(3,4).Ourgoalwastosee
Baghdad, Iraq). The trial number is NCT00517166 at www.
if our preliminary findings would hold true as the war
ClinicalTrials.gov.
progressed and tourniquets continued to be used. The
The opinions or assertions contained herein are the private
fielding of tourniquets during the current war and the
viewsoftheauthorsandarenottobeconstruedasofficialor
number of casualties permitted us to study and continue
reflecting the views of the Department of Defense or United
States Government. The authors are employees of the US to evaluate performance (5,6). Improving prehospital
government. This work was prepared as part of their official hemorrhage control is vital to military and civilian
dutiesand,assuch,thereisnocopyrighttobetransferred. trauma care, and we continue our efforts to fill knowl-
RECEIVED: 28 October 2008; FINAL SUBMISSION RECEIVED: 11 May 2009;
ACCEPTED: 10 July 2009
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1. REPORT DATE 3. DATES COVERED
11 MAY 2009 2. REPORT TYPE 00-00-2009 to 00-00-2009
4. TITLE AND SUBTITLE 5a. CONTRACT NUMBER
Battle Casualty Survival with Emergency Tourniquet Use to Stop Limb
5b. GRANT NUMBER
Bleeding
5c. PROGRAM ELEMENT NUMBER
6. AUTHOR(S) 5d. PROJECT NUMBER
5e. TASK NUMBER
5f. WORK UNIT NUMBER
7. PERFORMING ORGANIZATION NAME(S) AND ADDRESS(ES) 8. PERFORMING ORGANIZATION
United States Army Institute of Surgical Research ,3400 Rawley E. REPORT NUMBER
Chambers Avenue ,Fort Sam Houston,TX,78234-6315
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ARTICLE IN PRESS
2 J.F.Kraghetal.
edge gaps regarding first aid of limb-injured patients room,wereexcluded.Detaineesandprisonersofwarare
(7–13).Thereisnoconsensusontourniquetuseincivil- restricted from research by military policies and were
ian trauma, but an adequate collection of military data also excluded.
may help to change this. In our continued study of The study period was 1 year, divided into two con-
patientswhohadtourniquetsappliedinthefieldorinthe secutive6-monthtimeperiods.Theprimaryinvestigator
emergency department (ED), our objective was to ana- (first author), an orthopedic surgeon with extensive ex-
lyze use and possibly refine our understanding of when perience with emergency tourniquet use, was the site
and if tourniquets should be used as first aid, to refine investigator for the first time period; the second author, a
doctrine and training if indicated. Specifically, our ob- registerednursenewtotourniquets,wasthesiteinvestigator
jective was to assess morbidity and mortality associated for the second time period. The nurse was a founding
with tourniquet use. member of a deployed research team. Hospital providers
werereplacedatthesametimeastheinvestigators.
MATERIALS AND METHODS
Methods of Measurement
Study Design, Setting, and Participant Selection
We evaluated tourniquet use in two ways. We catego-
Thecurrentreportwasdesignedtotesttheconsistencyof rized patients by whether their tourniquets were applied
the findings of our previous reports on emergency tour- prehospitalorintheED,andalsowhentheywereplaced
niquet use (3,4). The design was an observational study physiologically in relation to shock. ED tourniquet pa-
ofpatientcare;therewasnoexperimentorintervention. tients were those patients who had a tourniquet first
Before the study began we predetermined the data of placed on a limb in the ED; the other patients had a
interest, that is, possible morbidity as well as the mor- tourniquet placed on a limb in the prehospital setting.
tality rates with the use of tourniquets. The study was Shock was defined by medics or hospital providers
approved by our institutional review board as part of an as a weak or absent radial pulse in an uninjured limb
ongoing prospective performance improvement project without a tourniquet. Patients with tourniquets first
ontourniquetuse(NCT00517166atwww.ClinicalTrials. placed after the onset of shock were analyzed as “shock
gov). The informed consent waiver was approved. Pro- present,” and all other patients were “shock absent”
cedures followed were in accord with the Helsinki Dec- before application of first tourniquet. This validated ap-
laration of 1975. proach is consistent with the clinical definitions used by
The setting was a military hospital in support of the Tactical Combat Casualty Care course, taught to all
combat and related security work in Iraq, where casual- militarymedics,andcorrelatedwithsystolicbloodpres-
ties, including civilians, were admitted directly or trans- sures as described by McManus et al. (14,15).
ferred from forward surgical teams. Prehospital tourni- Survivalratewastheprimaryoutcomeandmorbidity
quets were applied by people with a wide range of rate was the secondary outcome. We defined indicated
medical skills and included casualties themselves, lay and appropriate use by the following criteria: indicated
bystanders, soldiers, medics, nurses, and doctors. Tour- usewasmedical(vessellesionhemorrhageunresponsive
niquets are part of standard prehospital care to stop to a pressure dressing) or tactical for care under fire;
bleeding in combat and are often used before pressure appropriate use entailed no misplacement (e.g., wrong
dressings during care under fire. All deployed US servi- limbordistaltoawound),purposefulvenoustourniquet,
cepersons get tourniquet training with instructions to or misuse (e.g., upside down).
apply them as soon as possible to stop potentially lethal Data were collected prospectively by the two on-site
external limb bleeding; the soldiers were taught how to investigators.Datawerecollectedfromthepatients,their
use the tourniquets using a simplified form of Tactical providersorattendants,records,ormedicalreportssuch
Combat Casualty Care in Prehospital Trauma Life Sup- asthemorbidityandmortalityreports.Wehadaccessto
port (14). The aim of tourniquet use is to prevent hem- electronic records of casualties. Data collected included
orrhagicshockandsaveliveswhileminimizingmorbid- patient age, gender, application time (time between in-
ity. Casualties were eventually transferred to other juryanduse)inminutes,settingoftourniquetapplication
hospitals for definitive care. (prehospitalorED),mechanismofinjury,treatment(in-
Allpatientsatthecombatsupporthospitalwhohada cludingoperativeprocedures,numberoftransfusedunits
tourniquetofanytypeusedintheiremergenthealthcare [all blood products were summed]), injury severity
were included in the study. Patients with tourniquets scores, abbreviated injury score (AIS), base deficit, sys-
ready at the bedside, purposefully left loose, or whose tolic blood pressure, international normalized ratio, ini-
first applied tourniquet was in the hospital operating tial heart rate, injury description (e.g., traumatic ampu-
ARTICLE IN PRESS
SurvivalwithTourniquetUse 3
Table1. ComparisonofKeyVariablesoftheTwoTimePeriods
Study
Unit% Previous Current
StudyPopulationVariable n(cid:1)499 n(cid:1)232 n(cid:1)267 pValue
Mechanismofinjury:explosion %ofMechanisms 69 75 0.14
Usesite
Prehospital %ofPatients 84 86 0.51
Emergencydepartment %ofPatients 16 14 0.51
Survivalrate %ofPatients 87 87 0.95
Morbidityrate
Palsy %ofPatients 1.7 1.5 0.84
Majorlimbshortening %ofPatients 0.4 0.4 0.92
tation, open fracture, artery lesion), outcome (e.g., limb patients. The average age was 29 years. Follow-up av-
salvage, death), complications (e.g., necrotic muscle, eraged 36 days.
compartment syndrome, nerve palsy), and duration of Therewere862tourniquetsappliedto651limbs(328
follow-up. leftand323right;176upperlimbsand475lowerlimbs).
For the 862 tourniquets with known number per limb,
one tourniquet was used in 445 limbs, two tourniquets
Statistical Analysis wereusedin166limbs,threetourniquetswereusedin24
limbs,fourtourniquetswereusedintwolimbs,andfive
For comparison of time periods 1 and 2, we compared tourniquets were used in one limb. For 875 tourniquets,
proportions of key variables such as survival rates. We the study averaged 1.4 patients and 2.4 tourniquets per
used descriptive statistics and Fisher’s exact test for day, with 1.3 tourniquets per limb. The body regions
contingency testing. Software included Excel (version (forearm,arm,leg,andthigh)wherethetourniquetswere
97, Microsoft Corporation, Redmond, WA), and SAS/ appliedincluded13forearms,162arms,46legs,and436
STAT (version 9.1, SAS Institute, Cary, NC). thighs. Eight limbs had tourniquets applied above and
below the major joints (knee or elbow). For two limbs,
data on which body region had the tourniquet were
RESULTS missing.
Thepatientsshowedpathophysiologyassociatedwith
The two study periods were similar for the number of hemorrhage and coagulopathy (Table 2).
patients,deaths,palsiesatthelevelofthetourniquet,and
limbs with major shortening, so these data were consis-
tent (Table 1), and therefore we pooled data for further Indicated and Unindicated Emergency Tourniquet Use
analysis.
Of all 651 limbs (499 patients), 635 (483 patients) had
indicated tourniquet use. There were 16 limbs (15 pa-
Study Group Demographics tients) that had tourniquets applied but did not have a
medical or tactical indication. Of the 15 patients, one
The study group consisted of 499 patients from 13 na- Iraqihadarightbicepsbrachiisofttissueinjury,buthad
tions,andincluded257Iraqisand226Americans.There atourniquetappliedprehospitaltotheleftupperextrem-
were479malesand20females,16childrenand5elderly ity. The tourniquet was removed in the ED; it had been
Table2. PathophysiologicDataSummaryoftheStudyGroup
n Average(cid:2)SD Median Minimum Maximum
Initialbasedeficit 424 (cid:3)6(cid:2)6.5 (cid:3)4 (cid:3)27 3
Initialheartrate 464 105(cid:2)32.5 107 0 208
INR(internationalnormalizedratio) 414 1.6(cid:2)3.8 1.2 0.6 74
Transfusionunits 472 16(cid:2)25.6 6 0 194
SD(cid:1)standarddeviation;n(cid:1)numberofpatientswithdata.
ARTICLE IN PRESS
4 J.F.Kraghetal.
used for 25 min. The patient had no morbidity from the Table4. ResultsComparingSurvivalofPatientswith
TourniquetsUsedvs.NotUsed
tourniquet, and this use was unindicated medically (a
pressure dressing sufficed) and misplaced (wrong limb). PatientswithTourniquet PatientswithTourniquet
Forthisonepatient,thetourniquetwasindicatedforcare Time UsewithShockAbsent UsewithShockPresent
Period (nSurvivors/nTotal,%) (nSurvivors/nTotal,%)
under fire. Fourteen patients had 15 tourniquets for 15
softtissueinjuriesthatwereconvertedtopressuredress- 1 222/232,96% 10/232,4%
ings in the ED, and no tactical indication was present 2 255/267,96% 12/267,4%
Pooled 477/499,96% 22/499,4%
prehospital for these 14 patients. A prehospital pressure
dressing would have sufficed for the 15 wounds. Of the
16unindicatedtourniquets,themaximumtourniquetdu-
ration was 2 h, and none of the 16 limbs had morbidity. available(noneatscene),inaccessible(packedawayand
found after the patient died), or not placed in time after
extrication from vehicles or after transport before the
Appropriateness, Inappropriateness, and Misuse of patient died. Cause of death in all 10 patients was ex-
Emergency Tourniquet Use sanguination from limb injuries. In contrast to the 10
casualtieswithouttourniquets,inthe499casualtieswith
All patients except one had emergency tourniquet use tourniquets,16ofthe65deathswerefromisolatedlimb
thatwasappropriate.Allwereaimedatbeinganarterial exsanguination,oftenwithtourniquetsplacedaftershock
tourniquet except for one patient who had a purposeful onset (19 had severe [AIS 3 to 6] head wounds, 15 had
venous tourniquet. This one patient, with open type 3B severeabdominalwounds,7hadseverechestwounds,4
tibiaandfibulashaftfractures,hadamedicallyindicated had severe burns, and 2 had two or more equally severe
tourniquetusedinappropriatelyasavenoustourniquetin body regions injured). From the 10 patients without
the ED. The patient also had 40% body surface area tourniquets (0% survival) and the 499 with tourniquets
burns. No complications other than blood loss were (87% survival), we measured the mortality rate of pa-
attributable to inappropriate tourniquet use, and tour- tients who exsanguinated from isolated limb injuries at
niquet replacements or corrections were made on the 2% (10/519).
spot (3).
Misuse occurred in 13 cases, including the patient
described above who had a tourniquet placed on the Survival Rate was Higher When Shock was Not
wrong limb (Table 3). These problems were addressed Present before Tourniquet Use Compared to When
with improved training, device design refinements, and Shock was Present
more device testing and maintenance procedures.
The results of tourniquet use with shock present vs.
absent were consistent in the two time periods, so we
pooledthedata(Tables4,5).Overall,patientshada90%
Survival Rate was Higher in Patients with Tourniquets
(429/476)survivalwhentourniquetswereappliedbefore
Used vs. Not Used
shock,comparedtoan18%(4/22)survivalwhenplaced
aftertheonsetof shock(Table 5).Tourniquetuseinthe
Ten patients who came to our hospital during the study
absence of shock was associated with survival (p (cid:4)
period had isolated limb exsanguination amenable to
0.001),andprehospitalusewasassociatedwithsurvival
tourniquet application, but tourniquets were either un-
(p (cid:1) 0.015; Table 6).
Prehospital use was associated with shock absence
and ED use was associated with shock presence (p (cid:4)
Table3. MisuseOccurrences
Onepatienthadatourniquetonawronglimb
Onepatienthadupside-downuseofapneumatictourniquet
Table5. SurvivalRatesbyPrehospitalvs.EDTourniquet
Userstwistedtheairreleasecapoffandthusbroketwo
UseandShockPresentvs.AbsentattheTimeof
pneumatictourniquets
Application
Onebarbrokeonawindlasstourniquet
Oneclampjammedonapneumaticdevice
ShockAbsent ShockPresent
Onepneumaticbladderfoldedoverandjammedintheclamp
Onepneumaticbulbpoppedoff
Hospital
Onetourniquetbarwithasmoothtexturewastoobloodyand
Prehospital 90% 20%
slipperytosecure
Emergencydepartment 93% 23%
Fourpneumaticbladdersleaked(scalpelorneedledroppedon
itduringcatheterization)
ED(cid:1)emergencydepartment.
ARTICLE IN PRESS
SurvivalwithTourniquetUse 5
Table6. Shock,Survival,andSettingResultsfrom2-by-2 (3,5,6,19–24).IntheVietnamWar,whentourniquetuse
ContingencyTesting
was uneven, about 9% of casualties died from isolated
Givenshockpresence,prehospitalvs.EDuse p(cid:1)1.0 limb exsanguination (7,25). In Somalia, tourniquet use
wasnotassociatedwithsurvival was more common than in Vietnam, and 7% of battle-
Givenshockabsence,prehospitalvs.EDuse p(cid:1)0.5
fieldcasualtiesdiedoflimbexsanguination(26).Earlyin
wasnotassociatedwithsurvival
Givensurvivors,prehospitalvs.EDusewas p(cid:4)0.001 thecurrentwar,2%ofcasualtiesdiedfromisolatedlimb
associatedwithshock(absentvs.present) exsanguination, and isolated limb exsanguination is no
Givennon-survivors,prehospitalvs.EDuse p(cid:4)0.001
longerconsideredtheleadingcauseofpreventabledeath
wasassociatedwithshock(absentvs.
present) onthebattlefieldinUScasualties(27,28).AmongIsraeli
Givenprehospitaluse,shock(absentvs. p(cid:4)0.001 soldiers, the most avid users of tourniquets, investiga-
present)wasassociatedwithsurvival
tors found that 0% patients died from isolated limb
GivenEDuse,shock(absentvs.present)was p(cid:4)0.001
associatedwithsurvival exsanguination (29).
Prehospitalvs.EDusewasassociatedwith p(cid:1)0.015 After studying 499 casualties, it is clear that patients
survivalwithoutconsideringshock
were eligible for tourniquet use in emergency settings if
Shock(absentvs.present)wasassociated p(cid:4)0.001
withprehospitalvs.EDusewithout they had a compressible limb area proximal to a wound
consideringsurvival that risks lethal exsanguination. The tourniquet was not
Shock(absentvs.present)wasassociated p(cid:4)0.001
designed to save patients with associated catastrophic
withsurvivalwithoutconsidering
prehospitalvs.EDuse head, chest, and abdominal injuries. One patient beyond
savinghadatraumatichemipelvectomy;nocompression
ED(cid:1)emergencydepartment. was effective about the hemipelvectomy wound. Very
proximal wounds in the groin and axilla have poor re-
sultsiflesionsarenon-compressible,lesionsofinterme-
0.001; Table 6). Survival was associated with use both diatecompressibilityhaveintermediateresults,andfully
beforeshockonset(96%beforevs.4%after,477/499vs. compressible lesions have good results (4). The present
22/499, respectively) and prehospital (89% prehospital findings help define which patients are the best candi-
vs. 78% hospital, 374/422 vs. 59/76, respectively, p (cid:1) dates for emergency tourniquet use.
0.015; Table 5). The data of the present study indicate that the ideal
time to use a tourniquet is before the onset of shock.
Shockpreventionseemstobeadeterminantofsurvival,
DISCUSSION and prehospital tourniquet use simply treats more pa-
tients before shock onset. The main lifesaving opportu-
The main finding of the present report is that the major nity on the battlefield is prehospital hemorrhage control
lifesaving benefits of emergency tourniquet use were ob- for limb-injured patients (7,25,30,31). The evidence in-
served again, and the consistent finding reinforces the dicatesthattourniquetspreventbutdonotreverseshock.
recommendation to consider tourniquets in similar care Usemaypreventshockfromworsening,andmaylessen
settings. Additionally, the minor morbidity risks were the risk of additional resuscitation and its sequelae.
also consistent with the prior reports (3,4). Despite dif- The wrong time is late, after shock onset, meaning
ferentproviders,patients,andsiteinvestigators,albeitat that,bythen,muchofthelifesavingbenefithasbeenlost.
the same site using the same methods, the consistent Casualtieswithtourniquetsappliedafterextricationfrom
findings increase the generalizability of the previous vehicles or when casualties exsanguinated before care
reports.Rarelyisevidenceavailabletoshowthatfirstaid was given have a high mortality. Hemorrhage can be
is lifesaving for limb-injured patients. The only analo- incremental during transportation, arrival at hospital,
gousdevicetothetourniquetistheThomassplint,which during resuscitation, and before, during, and after oper-
also controls hemorrhage in battlefield open femur frac- ation, thus, continuous monitoring for hemorrhage con-
tures(16,17).Mostfirstaiddevicesaresimilartopelvic trol is recommended (4,22,24,32,33). Even though pro-
binders,thatis,theyhavenosurvivalbenefitevidenced, viders such as ambulance and flight medics provide
and military anti-shock trousers are associated with in- prehospitalcare,tourniquetuseatsuchtimeprovedtobe
creasedmortalityforpatientswithsomediagnoses(18). too late after shock onset, and earlier use would prevent
A minor finding of the present report was that pre- shock. Battle casualties may exsanguinate rapidly from
hospital death rates from isolated limb exsanguination limb injury, perhaps lethally, in just a minute or 2
have dropped to 2%, compared to 9% in the Vietnam (19,26,30,34–37). Casualties sometimes died quickly
War. Tourniquets can control limb hemorrhage, a lead- from hemorrhage without tourniquets, whereas others
ingcauseofdeathonthebattlefield,withmorefrequent with tourniquets survived more often and for a longer
tourniquetuseattributedtofewerdeathsfromthiscause time,andlongersurvivalpermittedmoreeffectiveresus-
ARTICLE IN PRESS
6 J.F.Kraghetal.
citation (4). We were able to save several patients who Limitations
hadlostvitalsigns,andtourniquetswerealsoanadjunct
to other damage control resuscitation measures (38). Limitationsofthepresentreportarethatitdoesnotdetail
Tourniquet issue to individual soldiers is justified in morbidity and that it is a wartime study. Wartime con-
war,asearlyusewasassociatedstronglywithmorelives strainedustoapractical,prehospitaldefinitionofshock
saved.Tourniquetsshouldbeavailable(withtheindivid- withmanualvitalsigns,forexample,lossofradialpulse
ual soldiers), accessible (easily found in first aid kits), in an uninjured limb, which generally concords with
class 3 and 4 hemorrhagic shock. Such prehospital def-
and used before shock onset for lifesaving benefit.
initionsofshockarepracticalandvalidbuthavelimita-
Searchingthroughaseriesofotherpersons’packstofind
tions,includinglimitedstudyintheciviliancommunity.
enough tourniquets to treat casualties loses precious
The scientific merit of a randomized prospective trial
time. The accessibility of the individual first aid kit, a
would be great by limiting confounding variables, but it
standardissueitem,appliedonthefrontsideofthetorso
would be unethical. Dead casualties might have had
bodyarmor,wascommonandideal;buryingtourniquets
undetected lesions. Persons with limited training most
in the bottom of a rucksack or a vehicle bin was lethal.
frequently made the decision to use tourniquets; there
Misuse of tourniquets increases morbidity and mor-
werenocontrolsforinjuryseverityorotherconfounding
tality, whereas using them in the right way improves
variableslikeheadortorsoinjuries.Thecostsoffielding
survivalwithminormorbidity(3,4,32).Snugtourniquets
tourniquets (the standard Combat Application Tourni-
stay in place and reliably occlude the arteries (assuming
quet costs about $28) and training soldiers were not
the tourniquet is wide enough for the limb). Loose tour-
studied.
niquetsslidearoundandmaynotoccludethearteriesor
Further research should include detailed morbidity
veins. Looseness was associated with clothing, equip- analyses,cohortstudiescomparingusevs.non-usefrom
ment, or pocket cargo under the tourniquet, and move- databases like the military trauma registry, studies com-
ment of the patient or limb in evacuation or transfer. paring medical (anatomic lesions) vs. tactical indica-
Looseness was associated with rebleeding and death. tions, and study at sites other than Baghdad to assess
Looseness is an example of why monitoring and re- generalizabilityfurther.Inreal-worldshockstudies,con-
checkingpatientsisvital.Awarenessandvigilanceofthe founding exists because individual casualties have dif-
myriad ways that hemorrhage can occur, continue, or ferent propensities to develop shock, perhaps based on
recur in casualties, especially in the first 2 days after their initial blood volume or genetic make-up.
injury, are vital lessons relearned (24,33). Clothing was
associated with missed wounds proximal to the location
of the tourniquet, and such clothing and resultant distal CONCLUSIONS
tourniquet use was associated with death (3). In these
Battle casualty survival rates are consistently high with
499 patients, we noted occasional problems with tourni-
emergency tourniquet use to stop bleeding, and morbid-
quets that broke, bladders that were cut by dropped
ity rates remain low. Evidence indicates that when used
needles and knives, and a tourniquet used upside down.
attherighttimeintherightway,emergencytourniquets
Population risk assessment for major limb injury and
are lifesaving.
lethalexsanguinationseemsprudentwhendeterminingif
tourniquets are right for the population. Awareness of
how much limb casualties bleed is limited, even on the
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ARTICLE IN PRESS
8 J.F.Kraghetal.
ARTICLE SUMMARY
1. Why is this topic important?
Tourniquet use as first aid is lifesaving on the battle-
field but controversial in civilian trauma, and recent mil-
itary experiences are referents of lessons learned.
2. What does this study attempt to show?
Battle casualty survival rates remain high with emer-
gency tourniquet use to stop limb bleeding, whereas
morbidity rates remain low in comparison with prior
reports.
3. What are the key findings?
Evidence indicates that when used for the right patient
at the right time in the right way, emergency tourniquets
save lives. Placing a tourniquet before the onset of shock
improves the survival rate in exsanguinating limb injuries.
4. How is patient care impacted?
Tourniquet use for limb hemorrhage control on the
battlefieldincreasessurvivaltime,permittingmoreeffec-
tive resuscitation and yielding higher survival rates.