title: Tourniquet use at the Boston Marathon bombing: Lost in translation.
abstract: 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%.
  
  
  CONCLUSIONS
  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.
  
  
  METHODS
  Epidemiologic study, level V.
authors.affiliation: From the Division of Trauma, Emergency Surgery, Surgical Critical Care, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
authors.forename: David Richard
authors.initials: DR
authors.lastname: King
authors.forename: Andreas
authors.initials: A
authors.lastname: Larentzakis
authors.forename: Elie P
authors.initials: EP
authors.lastname: Ramly
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D001134:Arm Injuries / Q000628:therapy*; D001753:Blast Injuries / Q000628:therapy*; D001900:Boston; D005260:Female; D006470:Hemorrhage / Q000628:therapy*; D006801:Humans; D015601:Injury Severity Score; D007869:Leg Injuries / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D023481:Terrorism; D014111:Tourniquets / Q000706:statistics & numerical data*; D014193:Trauma Centers; D016896:Treatment Outcome