Extended (16-Hour) Tourniquet Application After Combat Wounds: A Case Report and Review of the Current Literature

Abstract

We present a case of emergency tourniquet use of unusually long duration. The patient was wounded during combat operations, and the subsequent battle and evacuation caused a significant delay in surgical treatment of his wounds. Emergency tourniquets can be lifesaving, but are not benign interventions. In general, the extent of tourniquet injury increases with increasing time of application. Despite having a tourniquet in place for 16 hours, the limb was salvaged and significant functional recovery was accomplished. We conducted a search of the published literature including the Medline database, and present a review of the relevant articles concerning emergency tourniquet use, tourniquet injury, and mitigating treatments. Given the widespread use of tourniquets in ongoing military operations, it seems likely that tourniquets will transition to civilian use. Thus it is important for physicians to understand tourniquet injury and appreciate that even extended tourniquet application times does not necessarily doom the affected limb.

Practical Use of Emergency Tourniquets to Stop Bleeding in Major Limb Trauma

“…3 Historically, there are many anecdotes of devastating complications associated with emergency tourniquet use such as clots, palsies, and blisters. 4,10,13,26,27 Tourniquetrelated complications are well documented in animal studies.…”

“…12 We have previously reported a case from Afghanistan that had more than 16 hours of tourniquet use and kept his upper extremity and returned to piloting helicopters. 3 Tourniquets that are overtightened have been associated with palsies by damaging the peripheral nerves by compression, and these all occurred with prehospital use. The too loose tourniquets preponderantly occurred in the prehospital group.…”

“…3 In response to the US Army design, testing, training, and fielding of battlefield tourniquets, 4,5 all military personnel in theater carry tourniquets, and they are now common on the battlefields of Iraq and Afghanistan, both in the hands of medical and nonmedical personnel.…”

Prolonged prehospital tourniquet placement associated with severe complications: a case report

“…14,15 In the military context, tourniquet times longer than 4, or sometimes even 8, hours has not necessarily resulted in amputation. [16][17][18][19] Although no guidelines exist regarding the safe duration of tourniquet application, we recommend that tourniquets be removed as soon as possible.…”

A Preliminary Comparison of Three Tourniquet Instructions for Just-in-Time Guidance of a Simulated Tourniquet Application

“…Department of Homeland Security, 2015). Military experience demonstrates that tourniquet use saves lives; even after many hours of tourniquet use, tissues that were deprived of blood can still heal without the need for amputation (Beekley et al, 2008;Kragh Jr, Baer, & Walters, 2007;Kragh Jr et al, 2009;Lakstein et al, 2003). Although the civilian literature is sparse, similar results have been noted (Scerbo et al, 2016;Stiles, Cook, & Sztajnkrycer, 2017).…”