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A bullet severs the popliteal artery in anarea between the tibia and fibula that’sdifficult to compress with external pres-sure. This is the type of wound and uncontrollable hemorrhage that could be easily managed through tourniquetapplication.

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Uncontrolled hemorrhagefrom isolated penetratingextremity wounds can result

in 100% mortality, but significant con-troversy still surrounds tourniquet usein civilian prehospital care. It’s beenproposed that 10% of combat deaths inthe Vietnam War resulted from uncon-trolled hemorrhage from extremitywounds; many of the deaths were duesolely to ineffective field hemorrhagecontrol methods.1 Multiple U.S. and for-eign military reports confirm theimportance of tourniquets in control-ling exsanguination on the battlefield.2,3

As a result, the use of tourniquets is nowactively promoted in the U.S. military,with all service personnel carrying atourniquet with their gear.2

In the civilian trauma setting, thedebate continues. In fact, numerousprehospital system medical personnelare specifically discouraged from utiliz-ing tourniquets, and many ambulancesdon’t even carry them. Some of the rea-sons tourniquets haven’t been deployedin the prehospital setting include thenotions that: 1) Manual pressure shouldsuffice to control hemorrhage; 2) Theproximity of urban trauma centers tothe scene of an injury should precludeexsanguination before the patientreaches definitive care; and 3)

Tourniquets lead to increased rates ofamputation, ischemic complication andneurologic dysfunction.

A 2005 study identified 14 civilianpatients who died from isolated pene-trating extremity injuries despitereaching the hospital and havinginjuries that are usually survived intothe operating room (OR) for definitivecare.4 None of these patients had atourniquet applied in the prehospitalsetting, and the authors report thateight out of the 14 had an injury loca-tion amenable to tourniquet use.4

Further, although an increasingnumber of reports have recentlyemerged on the historical use oftourniquets and their theoreticaladvantages and disadvantages, nostudies have attempted to criticallyexamine the role of tourniquets in thecivilian trauma setting.2,5

In response to fatalities that wereconsidered possibly preventable fromisolated extremity vascular injuries,Boston Medical Center (a Level 1 trauma center) and Boston EMS, in themid-90s, developed unofficial guide-lines for the prehospital application ofextremity tourniquets. These includedpenetrating extremity wounds, sys-tolic blood pressure (SBP) < 80 andsevere blood loss at the scene—as esti-

mated by the paramedics. We hypothesized that prehospital

tourniquets could safely and effectivelycontrol life-threatening extremity vas-cular injuries, and that highly trainedprehospital providers could appropri-ately apply tourniquets by followingthe guidelines. We then studied compli-ance with these guidelines and the out-come of patients who had prehospitaltourniquets applied in the field.

This article describes the patientswho had the prehospital tourniquetsapplied, examines the appropriate-ness of tourniquet application andreports on the effectiveness of pre-hospital tourniquets on multiplepatient outcomes.

BACKGROUND & METHODSBetween January 1999 and April 2006,patients with penetrating extremitywounds who were brought to the BMCEmergency Department (ED) after theapplication of a prehospital tourniquetwere identified from a retrospectivereview of the trauma database and med-ical records. Once these patients wereidentified, their charts were reviewed,including the prehospital patient carereport (PCR), the ED trauma record, andall trauma service notes. Collected datafor each patient included the following:

ORIGINAL RESEARCH EVALUATES THE EFFECTIVENESS OF PREHOSPITAL TOURNIQUETS FOR CIVILIAN

PENETRATING EXTREMITY INJURIES>> BY JEFFREY KALISH, MD; PETER BURKE, MD; JIM FELDMAN, MD; SURESH AGARWAL, MD;

ANDREW GLANTZ, MD; PETER MOYER, MD; RICHARD SERINO, NREMT-P; & ERWIN HIRSCH, MD

46 JEMS AUGUST 2008

patient demographics, mecha-nism and location of injury, pre-hospital vital signs and scene/transport times, ED vital signsand treatment times, tourniquetapplication times and durations,operative findings, and clinicaland extremity outcomes. TheBMC Institutional Review Boardapproved this retrospective study.

RESULTSEleven patients were identified ashaving prehospital tourniquetsapplied for their penetratingextremity wounds. The mean ageof the patients was 27 years, andall were male.

Gunshot wounds (GSWs)accounted for six (55%) of theinjuries, stab wounds (SWs) for three (27%),and lacerations (LACs) for two (18%). Thelower extremity was the site of injury for allGSWs and SWs, and the upper extremity wasthe site of injury for both LACs.

The mean scene time was 8.5 ± 4.6 min-utes (range 3–17 minutes), and the meantransport time was 6.3 ± 1.8 minutes (range4–10 minutes). The mean tourniquet applica-tion time was 75 ± 38 minutes (range 37–167minutes) (see Table 1).

All patients were taken to the OR forexploration, and the prehospital tourni-quets were removed as directed by the oper-ating surgeon. The estimated blood loss(EBL) on scene, as well as the scene bloodpressure (BP) and operative findings andfunctional outcomes for each patient, areshown in Table 2, p. 50.

All six patients with GSW (100%) had aninjury to a major artery, and three of thosesix (50%) had a concomitant injury to amajor vein. Only one of the SW patients(33%) had a major arterial injury, and thispatient also had a concomitant majorvenous injury. The other two SW patients(67%) had muscular bleeding only. The twoLAC patients (100%) had major arterialinjuries in their upper extremities.

Of all the patients, there was one death;this patient was pulseless at the scene andonly regained vital signs after CPR. Theremainder of the patients survived and weredischarged from the hospital.

All patients with injuries to the lowerextremities (GSW and SW) retained com-

plete neurologic function post-operatively.All of the vascular repairs were patent in theimmediate post-operative period and subse-quent early outpatient visits, but long-termfollow-up was not possible. Two of the GSWpatients (33%) had fasciotomies at the timeof operation, and both fasciotomies wereclosed prior to discharge from the hospital.The two LAC patients had motor and sensorylosses, but these deficits resulted directlyfrom primary injuries.

DISCUSSIONExtremity injuries are common on the mili-tary battlefield, and tourniquets have beenused with increasing frequency and great suc-cess in Iraq and Afghanistan to preventexsanguination and unnecessary mortality.Numerous military reports have confirmedthe effectiveness of tourniquets, as well as

their safety and low incidence ofadverse events.3,6,7 Nevertheless,controversy persists in civiliansettings and within the civiliantrauma literature regardingtheir safety and effectiveness.

As military struggles havere-emerged as a focus in con-temporary society, the issuessurrounding tourniquet usagehave similarly re-emerged foranother round of debate.Evidence for this growing inter-est is the increasing number ofhistorical reports regardingtourniquets that have surfacedin the literature over the pasttwo years.

Two recently published, com-prehensive historical reviews

delve into the evolution of military tourni-quet use and the changing attitudes duringdifferent time periods and wars.2,5 Mostrecently, the 2004 revision of Emergency WarSurgery issued by the U.S. government againurged the early application of tourniquets toarrest blood loss.8

Further, the U.S. military has kept thependulum swinging in favor of tourniquetuse because of its recent mandate to issue aCombat Application Tourniquet (C.A.T.) toall field troops in Afghanistan and Iraq.Although no data has been published,anecdotal reports indicate these self-applied tourniquets are beneficial forextremity injuries.2

A retrospective review of tourniquet useby the Israeli Defense Force (IDF) found thatapplication of an elastic/silicone band waseffective in arresting hemorrhage in 71% of

A distal thigh tourniquet, like the rubber tubing & surgical clamp shown here,is typically required for popliteal and more distal injuries.

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Patient Mechanism Extremity Scene Time Transport Time Tourniquet(min) (min) (min)

1 GSW Lt thigh 10 10 1672 GSW Rt thigh 5 5 473 GSW Lt thigh 12 7 704 GSW Rt knee 3 5 815 GSW Lt knee 11 5 536 GSW Rt thigh 8 7 777 Stab Rt thigh 10 10 438 Stab Rt thigh 7 7 379 Stabs B/L thighs 17 4 7210 Laceration Rt forearm 5 10 5711 Laceration Rt forearm 10 7 120

Mean + Standard Deviation 8.5 + 4.6 min 6.3 + 1.8 min 75 + 38 min

Table 1: Prehospital & Tourniquet Times in Patients with Penetrating Extremity Injuries

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lower extremity wounds and 94% of upperextremity wounds.3 Only 53% of the tourni-quet applications were indicated based onguidelines created by the IDF. Those authorsconceded that inappropriate use was attribut-able to stressful situations coupled with theinsufficient experience of most of the medicalcare providers.

Despite the overuse of tourniquets in thisstudy, neurologic complications occurred inonly 5.5% of the patients.3 This low complica-tion rate was a direct result of rapid evacua-tion and early in-hospital definitive surgicalcare, resulting in short ischemic times of twoto three hours.

CIVILIAN USEAlthough tourniquet usereceives tremendous atten-tion in military arenas, todate no other attempts havebeen made to examinetourniquet use in the civil-ian setting. The most appli-cable study in the civiliantrauma literature was a ret-rospective study of 14patients who died from iso-lated penetrating extremityinjuries despite reaching thehospital.4

Twelve of the 14 patients (86%) showedsigns of life in the field and underwent CPR enroute to the hospital. Nine patients (63%)underwent immediate ED thoracotomy(ECT) and one patient (7%) had CPR only,while four patients (28%) were declared deadon arrival.

Nine patients (63%) were resuscitatedand taken to the OR. Unfortunately, all ofthe patients died, with 93% succumbing totheir isolated injury within 12 hours.Prehospital hemorrhage control was prima-rily performed by gauze dressings, and theauthors report that eight out of the 14patients had an injury location amenable toa tourniquet.4

As a result of the shortage of informationon civilian tourniquet use, the small retro-spective analysis by BMC/BEMS representsthe first attempt to examine the role of pre-hospital tourniquets in a critical fashion.

TOURNIQUET TIPSFor many years BMC trauma surgeonshave employed tourniquets under certain

circumstances and developed specific cri-teria for their use. Like many of the tourni-quets employed in World War II and theVietnam War, this tourniquet consists sim-ply of 1/2" circular rubber tubing and asurgical clamp (preferably a Kelly clamp).The tubing is stretched and wrapped oncearound the most distal part of the extremi-ty to control the hemorrhage, and the tub-ing is then secured with the clamp. In theproximal thigh, a double wrap of the tub-ing is usually necessary.

In a recent study from the Canadian mili-tary, this same rubber-tubing tourniquet waspraised for its effectiveness, ease of use, low

cost and lightweight/durable nature.7

Other tourniquets, such as the C.A.T., offera wide band that can be applied and securedwith one hand, and a large, pre-attached wind-less that’s rotated three times for hemorrhagecontrol, secured in a “U”-shaped holder andlocked safely in place by a Velcro® tab.

The most critical point in the applicationof any tourniquet is that it be tightened withenough pressure to impede both arterialinflow and venous outflow. The lower legusually doesn’t provide a good location fortourniquet application because the tibia andfibula preclude adequate arterial compres-sion; therefore, a distal thigh tourniquet istypically required for popliteal and more dis-tal injuries.

The 11 patients identified in this study hadtourniquets applied in the prehospital settingby BEMS EMTs and paramedics. Although noofficial tourniquet guidelines had been sanc-tioned for EMTs or paramedics in Boston oranywhere else in the country, BMC traumasurgeons and BEMS cooperated in develop-ing proposed guidelines for tourniquet use.

Each application of a tourniquet was

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>> Mean age of the patients was 27 years. All weremale.

>> Gunshot wounds (GSWs) accounted for six (55%)of the injuries, stab wounds (SWs) for three(27%), and lacerations (LACs) for two (18%).

>> The lower extremity was the site of injury for all GSWs and SWs, and the upper extremity was site of injury for both LACs.

>> Mean EMS scene time was 8.5 + 4.6 minutes (range 3–17 minutes).

FAST FACTS

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subjected to a case-specific follow-up discus-sion regarding the indications for andtechnique of tourniquet application.Based on the arterial injuries encounteredin nine of the 11 patients, our study con-firmed the appropriateness of these inclu-sion criteria for determining the need for aprehospital tourniquet and for limiting thenumber of false positive applications.

More specifically, all six GSW patients(100%) met the inclusion criteria and also hadan injury to a major artery requiring repair.There was only one death. This patient wassimilar to the patients described in Dorlac’sseries, in which all died even if they survivedthrough the operative period.4

One of the Boston SW patients (33%) metinclusion criteria and had a major arterialinjury requiring repair. One SW patient(33%) had a blood pressure of 126 (thus notmeeting criteria), and didn’t have a majorarterial injury. (Note: This patient wasflagged as a violation of the tourniquetprotocol having not warranted atourniquet.)

The third SW patient was a para-plegic with multiple concomitant stabwounds who was discovered in achaotic scene involving a suicideattempt, thus precluding a reliableassessment of the need for a tourni-quet by the paramedics.

One of the two LAC patients (50%)met the tourniquet criteria, and both hadmajor upper extremity arterial injuries.However, it’s possible that these patientscould’ve had their hemorrhages controlledwith other methods, such as direct pressure.

As tourniquet opponents have argued formany decades, ischemic and neurological

complications can occur if a tourniquet isused improperly.9 However, in this study, noinjuries resulted in any neurologic compro-mise caused specifically by tourniquet use,with mean tourniquet application times asshort as 75 ± 38 minutes (range 37–167minutes). The two patients with upper

extremity injuries did suffer motor and sen-sory loss, but these deficits were the resultof the penetrating injuries themselves, notthe tourniquet application. Even patientswho required fasciotomies had thosewounds closed prior to discharge, with nolong-term sequelae from any ischemia due

to the tourniquet. Given short transit times and rapid

movement of patients into an OR for defin-itive vascular control, tourniquet times caneasily be limited to fewer than three hours.In such short periods of time, the ischemiaand reperfusion that occur shouldn’t lead toirreversible muscle cell damage or pro-longed systemic inflammatory responses.10

Further, trauma surgeons can heed the les-sons from successful tourniquet use in ORsacross the country for various orthopedicand vascular procedures.11-13

Before removing an appropriately placedand functioning tourniquet, it’s critical thatthe patient is in the proper arena with defini-tive surgical control achieved (i.e., the ORwith proximal arterial control). With a policyin place for prehospital tourniquet applica-tion and strict criteria established for tourni-quet use, surgeons should rely on the prehos-pital system to determine which patients

need definitive care in an OR. The importance of case-by-case eval-

uation and appropriate feedback can’tbe underestimated, because an effectiveprehospital tourniquet policy can besuccessful only when there’s continuedpost-operative communication betweenthe trauma surgeons caring for thepatients and the prehospital crews mak-ing the initial decisions in the field.

This study has numerous limitationsgiven the small sample size and lack of atrue control group. Additional concernsinclude selection bias and the difficultiesinherent to chart review. Last, the findingsmay not be applicable to EMS providersoutside of the urban trauma environmentor within systems that lack coordination

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The MAT (Mechanical Advantage Tourniquet) iseasy to apply and tighten with one hand.

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Patient Age/Sex Mechanism Extremity EBL (field) SBP (field) Injury (Artery/Vein) Outcome(mmHg)

1 44/M GSW Lt thigh Unknown <80 AK pop/SFV Fasciotomy closed2 16/M GSW Rt thigh Heavy 62 SFA/SFV Normal3 29/M GSW Lt thigh Heavy 0 (80 after CPR) SFA “Expired (PE, brain death)”4 22/M GSW Rt knee 2 Liters 60 Pop Normal5 30/M GSW Lt knee Heavy Not palp Pop/pop Fasciotomy closed6 32/M GSW Rt thigh Heavy 80 Profunda I+D’s Rt hip7 24/M Stab Rt thigh Heavy 80 Pop/pop Normal8 16/M Stab Rt thigh Heavy 126 Muscle Normal9 27/M Stabs B/l Thighs Bloody tub 78 None Already T4 paraplegic10 30/M Laceration Rt forearm Heavy 98 Brachial/brachial “Fasciotomy, preop motor+sensory loss”11 28/M Laceration Rt forearm Heavy Not palp Radial+ulnar Preop motor+sensory loss

Table 2: Demographics, Injuries & Outcomes in Patients with Penetrating Extremity Injuries

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With proper education and training,tourniquets can be adopted into theprehospital system without adverseeffects on limb salvage or functional outcome.

between prehospital providers and the hos-pital trauma services.

CONCLUSIONTourniquets have been incorporated intotrauma care for many centuries, and thedebate regarding their utility has continuedfor the same amount of time. Prospectivestudies are nonexistent; retrospective studies are sparse. This is especially evident in civilian trauma literature. Unfortunately,anecdotal reports thus comprise the founda-tion for physicians’ and paramedics’ opinionsof this uncomplicated medical procedure.

The BMC/BEMS cohort study indicates thatprehospital tourniquets can be appropriatelyapplied to control life-threatening hemor-rhage from an extremity injury, and that theiruse isn’t associated with neurovascular com-plications. In similar case series, some of thepatients we’ve described appear to have diedbecause of inadequate hemorrhage control.It’s thus quite unlikely that a well-controlledclinical trial could be conducted to truly deter-mine the safety and efficacy of this interven-

tion. Nevertheless, our findings emphasize theneed to re-evaluate the standard teaching thattourniquets are to be used only as a last resortbecause of safety concerns.

We believe properly applied tourniquetscan safely, rapidly and effectively control life-

threatening bleeding from a penetratingextremity injury. Further, we believe this inter-vention should be more routinely considered,especially in prehospital systems that haveappropriate quality control procedures. JEMS

Jeffrey Kalish, MD, is the vascular surgery fellow at

Beth Israel Deaconess Medical Center in Boston, Mass.

He previously served as administrative chief resident at

Boston Medical Center. He can be reached at

jkalish@bidmc.harvard.edu.

Peter Burke, MD, is chief of trauma surgery at

Boston Medical Center and professor of surgery at the

Boston University School of Medicine.

Jim Feldman, MD, MPH, is associate professor of

emergency medicine at the Boston Medical Center. He

also serves as president of the Massachusetts College of

Emergency Physicians.

Suresh Agarwal, MD, is a trauma surgeon at Boston

Medical Center and assistant professor of surgery at the

Boston University Medical School.

Andrew Glantz, MD, is a trauma surgeon at Boston

Medical Center and associate professor of surgery at

the Boston University Medical School.

Peter Moyer, MD, MPH, is medical director of

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The C.A.T. (Combat Application Tourniquet) is aone-hand tourniquet that features a pre-attached windless and “U”-shaped holder andVelcro® strip, which locks it securely in place.

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Boston Police, Fire Department and EMS, and professor

of emergency medicine at the Boston University

School of Medicine.

Richard Serino, NREMT-P, is assistant director of

Boston Public Health Commission, chief of Boston EMS

and a member of the National Faculty for the Domestic

Preparedness Program.

Erwin Hirsch, MD, (1936–2008) was chief of trauma

surgery at Boston Medical Center for more than 25 years.

He taught surgery and directed the Medical Education

and Inter-regional Harmonization Program for Nuclear

Accident Preparedness at the Boston University School

of Medicine. He created Boston MedFlight, a non-profit

that uses air and ground vehicles to transport patients,

and served on its board of directors.

This article is dedicated to the memory of ErwinHirsch, MD. Dr. Hirsch died unexpectedly in May.He was an icon who saved thousands of lives,modernized EMS by redefining the way trauma istreated and was among the first to welcomefemale surgeons in the operating room. He helpedmake Boston Medical Center one of the nation’spremiere trauma centers and was instrumental insecuring its Level 1 Trauma Center designation.

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land warfare: Implications for combat casualty careresearch.” Military Medicine. 149(2):55–62, 1984.

2. Welling DR, Burris DG, Hutton JE, et al: “A balancedapproach to tourniquet use: Lessons learned andrelearned.” Journal of the American College ofSurgeons. 203(1):106–115, 2006.

3. Lakstein D, Blumenfeld A, Sokolov T, et al:“Tourniquets for hemorrhage control on the battle-field: A 4-year accumulated experience.” Journal ofTrauma. 54(5 Suppl):S221–S225, 2003.

4. Dorlac WC, DeBakey ME, Holcomb JB, et al:“Mortality from isolated civilian penetrating extrem-ity injury.” Journal of Trauma. 59(1):217–222, 2005.

5. Mabry RL: “Tourniquet use on the battlefield.”Military Medicine. 171(5):352–356, 2006.

6. Calkins D, Snow C, Costello M, et al: “Evaluation ofpossible battlefield tourniquet systems for the far-for-ward setting.” Military Medicine. 165(5):379–384, 2000.

7. King RB, Filips D, Blitz S, et al: “Evaluation of possibletourniquet systems for use in the Canadian forces.”Journal of Trauma. 60(5):1061–1071, 2006.

8. Burris DG, FitzHarris JB, Holcomb JB, et al (eds):Emergency war surgery. Third U.S. revision. United

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9. Navein J, Coupland R, Dunn R: “The tourniquet contro-versy.” Journal of Trauma. 54(5 Suppl):S219–S220, 2003.

10. Blaisdell FW: “The pathophysiology of skeletal mus-cle ischemia and the reperfusion syndrome: Areview.” Cardiovascular Surgery. 10(6):620–630, 2002.

11. Kam PC, Kavanagh R, Yoong FF: “The arterial tourni-quet: Pathophysiological consequences and anaes-thetic implications.” Anaesthesia. 56(6):534–545, 2001.

12. Wakai A, Winter DC, Street JT, et al: “Pneumatictourniquets in extremity surgery.” Journal of theAmerican Academy of Orthopaedic Surgeons.9(5):345–351, 2001.

13. Choksy SA, Chong PL, Smith C, et al: “A randomizedcontrolled trial of the use of a tourniquet to reduceblood loss during transtibial amputation for periph-eral arterial disease.” European Journal of Vascularand Endovascular Surgery. 31(6):646–650, 2006.

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