title: Prehospital tourniquet use in Operation Iraqi Freedom: effect on hemorrhage control and outcomes.
abstract: 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.
  
  
  OBJECTIVE
  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.
authors: Department of General Surgery, Madigan Army Medical Center, Fort Lewis, WA 98431-1100, USA. alec.beekley@us.army.mil
authors: Alec C
authors: AC
authors: Beekley
authors: James A
authors: JA
authors: Sebesta
authors: Lorne H
authors: LH
authors: Blackbourne
authors: Garth S
authors: GS
authors: Herbert
authors: David S
authors: DS
authors: Kauvar
authors: David G
authors: DG
authors: Baer
authors: Thomas J
authors: TJ
authors: Walters
authors: Philip S
authors: PS
authors: Mullenix
authors: John B
authors: JB
authors: Holcomb
mesh_terms: D000328:Adult; D001134:Arm Injuries / Q000150:complications / Q000628:therapy*; D004632:Emergency Medical Services; D005260:Female; D006470:Hemorrhage / Q000209:etiology / Q000517:prevention & control*; D006801:Humans; D054542:Iraq War, 2003-2011; D007869:Leg Injuries / Q000150:complications / Q000628:therapy*; D008297:Male; D012189:Retrospective Studies; D014111:Tourniquets; D016896:Treatment Outcome; D014481:United States