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.