Association between prehospital tourniquet application and post-traumatic stress disorder in military personnel: A retrospective cohort study.

BACKGROUND

Post-traumatic stress disorder (PTSD) is a well-documented consequence of combat-related trauma. While tourniquet application is a cornerstone of hemorrhage control in military settings, its mental health consequences have not been explored. We aimed to assess the association between prehospital tourniquet application and subsequent PTSD among military personnel with extremity injuries.

METHODS

In this retrospective cohort study, we utilized linked military and national trauma registries to identify military personnel with extremity injuries and Injury Severity Score (ISS) ≤8 between 2006 and 2021. Participants were grouped based on documented prehospital use of tourniquets. Service-connected PTSD diagnoses were retrieved from the Ministry of Defense Rehabilitation Department disability claim records and validated by the PTSD Checklist for DSM-5 (PCL-5). Logistic regression models were used to assess associations between tourniquet use and PTSD, adjusting for confounders including injury mechanism, event type, head injury, number of injured persons, and hospitalization status.

RESULTS

During 31,690 person-years of follow-up, a total of 2,876 military personnel met the inclusion criteria, of whom 123 (4.3%) received a tourniquet. PTSD was diagnosed in 244 (8.5%) of all casualties, with a prevalence of 30.9% (n=38) among those who received a tourniquet, compared with 7.5% (n=206) among those who did not ( p <0.0001). In unadjusted analyses, tourniquet use was strongly associated with increased odds of PTSD (odds ratio, 5.53; 95% confidence interval, 3.64-8.26). After adjusting for confounders, tourniquet use remained significantly associated with PTSD (odds ratio, 1.70; 95% confidence interval, 1.07-2.66).

CONCLUSIONS

Tourniquet use was associated with increased odds of PTSD, even after accounting for key confounders. While essential for hemorrhage control, this association should be interpreted with caution, as it may reflect underlying injury context, operational intensity, or other unmeasured confounders rather than a direct causal effect. Tourniquet use was associated with increased odds of PTSD; however, this association should not be interpreted as causal and does not support changes to current point-of-injury tourniquet guidelines. Rather, it may reflect underlying injury context, operational intensity, or other unmeasured confounders. ( J Trauma Acute Care Surg . 2026;101: S106-S113. Copyright © 2026 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Association for the Surgery of Trauma.).

LEVEL OF EVIDENCE: Prognostic/epidemiological, Level III.