Outcomes of Prolonged Tourniquet Application on the Battlefield: Is a Liberal Application Policy Always Justifiable?

Objectives: To provide insight into the implications of prolonged tourniquet use on the battlefield, ultimately contributing to the optimization of clinical practices in military and civilian healthcare settings.

Methods: Design: Retrospective observational study.

Setting: Two academic Level I Trauma Centers.

Patient selection criteria: Adults who suffered high-energy battlefield injuries to the limbs on October 7th, 2023, with prolonged battlefield tourniquet application (>4h). Patients who underwent immediate limb amputation upon arrival at the hospital were excluded.

Outcome measures and comparisons: Clinical outcomes including hemodynamic status, vascular repairs, rhabdomyolysis, renal injury, infection, nerve injury, amputation, and functional outcomes were reviewed.

Results: Eighteen patients (mean age 24 years; range 19-50 years) with 21 high-energy limb injuries and>4h tourniquet application were included (100% male); 9 (42.9%) upper limb injuries, and 12 (57.1%) lower limb injuries. The mean age of the cohort was 24 (SD 8.9, range 19-50). The mean tourniquet time was 5.8h (SD 1.2, range 4-9h). All of the patients (100%) underwent urgent fasciotomies upon arrival. Five patients (27.8%) required vascular repair. Seven patients (38.9%) developed temporary acute kidney injury (AKI), 2 patients (11.1%) required hemodialysis. Eight patients (44.4%) developed bacterial infections and required additional surgical interventions. Of these eight, limb salvage occurred in 6 (33.3%) and the remaining 2 (11.1%) underwent limb amputation. A total of 5 patients (27.8%) ultimately underwent amputation, all of which were lower limb amputations. Sixteen patients (88.9%) sustained lingering nerve injuries. The average Upper Extremity Functional Index (UEFI) score was 40.6 (SD 14.9 range 30-57) and the average Lower Extremity Functional Index (LEFI) was 42.3 (SD 20.1, range 14-68), indicating moderate functional limitation1,2. Longer tourniquet time was associated with a higher complication rate. CPK levels increased with each additional hour, and 100% of the patients requiring hemodialysis had tourniquet time exceeding 6 h. Additionally, 80% of amputation and 75% of infections occurred when tourniquet time exceeded 6 h.

Conclusions: In a cohort of 18 patients with 21 high-energy limb injuries, a tourniquet time >4h did not preclude limb salvage, with an overall amputation rate of 23.8%. Tourniquet times exceeding 6 hours were associated with higher rates of complications.

Level of evidence: A level IV retrospective study.