title: Forward assessment of 79 prehospital battlefield tourniquets used in the current war.
abstract: BACKGROUND
  Battlefield tourniquet use can be lifesaving, but most reports are from hospitals with knowledge gaps remaining at the forward surgical team (FST). The quality of tourniquet applications in forward settings remain unknown. The purpose of this case series is to describe observations of tourniquet use at an FST in order to improve clinical performance.
  
  
  METHODS
  War casualties with tourniquet use presenting to an FST in Afghanistan in 2011 were observed. We identified appliers by training, device effectiveness, injury pattern, and clinical opportunities for improvement. Feedback was given to treating medics.
  
  
  RESULTS
  Tourniquet applications (79) were performed by special operations combat medics (47, 59%), flight medics (17, 22%), combat medics (12, 15%), and general surgeons (3, 4%). Most tourniquets were Combat Application Tourniquets (71/79, 90%). With tourniquets in place upon arrival at the FST, most limbs (83%, 54/65) had palpable distal pulses present; 17% were pulseless (11/65). Of all tourniquets, the use was venous in 83% and arterial in 17%. In total, there were 14 arterial injuries, but only 5 had effective arterial tourniquets applied.
  
  
  CONCLUSIONS
  Tourniquets are liberally applied to extremity injuries on the battlefield. 17% were arterial and 83% were venous tourniquets. When ongoing bleeding or distal pulses were appreciated, medics tightened tourniquets under surgeon supervision until distal pulses stopped. Medics were generally surprised at how tight a tourniquet must be to stop arterial flow ? convert a venous tourniquet into an arterial tourniquet. Implications for sustainment training should be considered with regard to this life-saving skill.
authors.forename: David R
authors.initials: DR
authors.lastname: King
authors.forename: Gwendolyn M
authors.initials: GM
authors.lastname: van der Wilden
authors.forename: John F
authors.initials: JF
authors.lastname: Kragh
authors.forename: Lorne H
authors.initials: LH
authors.lastname: Blackbourne
mesh_terms: D000346:Afghanistan; D005121:Extremities; D006470:Hemorrhage / Q000628:therapy; D006801:Humans; D014111:Tourniquets; D014857:Warfare; D014947:Wounds and Injuries