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Editorial
Removal of tourniquets: the next step in saving lives and limbs
  1. Christian Medby1,2,
  2. J Ricks3,
  3. B Ingram4,5,
  4. C Forestier6,
  5. D Parkhouse7,
  6. I Gurney7,
  7. C A Burnett8 and
  8. A Faas9
  1. 1Norwegian Armed Forces Joint Medical Services, Sessvollmoen, Norway
  2. 2Department of Trauma, St. Olav's University Hospital, Trondheim, Norway
  3. 3NATO Centre of Excellence for Military Medicine, Budapest, Hungary
  4. 4NATO Allied Special Operations Forces Command, Mons, Belgium
  5. 5Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
  6. 6Canadian Armed Forces Health Services Headquarters, Ottawa, Ontario, Canada
  7. 7Research and Clinical Innovation, Defence Medical Services, Birmingham, UK
  8. 8Landstuhl Regional Medical Center, Landstuhl, Germany
  9. 9Military Medical Center Frauenfeld, Frauenfeld, Switzerland
  1. Correspondence to Dr Christian Medby; cmedby{at}mil.no

https://doi.org/10.1136/military-2024-002785

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    The current use of tourniquets in Ukraine has caused an unacceptably high rate of complications, including rhabdomyolysis, compartment syndrome, thrombosis and myonecrosis, preventable amputations, renal failure and even death.1 There is no questioning that tourniquets have saved numerous lives on the battlefields since the introduction of Tactical Combat Casualty Care (TCCC).2 Indeed, in a mature operational environment with a military trauma system and short evacuation times, there appear to be few complications related to their use.3 On the other hand, complications due to the prolonged application of tourniquets are well known.4 These complications must be anticipated in situations involving delayed evacuation, such as near peer conflicts where air superiority is not guaranteed, and ground evacuation is contested. The severe complications of tourniquets are mainly related to ischaemia, due to obstruction of arterial blood flow, and are time dependent.5 Shorter ischaemia times will have few complications, but ischaemia lasting more than 6 hours will result in irreversible myonecrosis distal to the tourniquet. Exactly how long a tourniquet can safely be left in situ is controversial and likely depends on multiple factors such as the physiological status of the casualty. The tourniquet management recommendations in this article are based on experience from elective orthopaedic surgery, animal studies and from emergency use of tourniquets on the battlefields and in civilian practice (evidence level V).

    Data from the current conflict, provided to us by the Ukrainian Ministry of Defence, suggest that up to 60% of tourniquets were left in situ for more than 2 hours. 70–80% of tourniquets applied could have been converted to pressure …

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    Footnotes

    • Contributors JR presented the Ukraine data and led a discussion on tourniquet use at the Spring MHCWG Meeting. CM wrote the first draft of the manuscript and is the guarantor. All authors contributed to the discussion and development of the manuscript.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Disclaimer The views expressed are those of the authors and of the NATO Military Health Care Working Group. They may not reflect the official position of any affiliated organizations.

    • Competing interests None declared.

    • Provenance and peer review Not commissioned; internally peer reviewed.