International perspective of tourniquet use in extremity vascular trauma: a commentary from the Sri Lankan civil war exp
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LETTER TO THE EDITOR
International perspective of tourniquet use in extremity vascular trauma: a commentary from the Sri Lankan civil war experience Amila Ratnayake1 · Miklosh Bala2 · Tamara Jean Worlton3 Received: 1 August 2019 / Accepted: 15 August 2019 © Springer-Verlag GmbH Germany, part of Springer Nature 2019
Civilian trauma care has always been influenced by lessons learned in war trauma. Currently this transfer of knowledge has been exemplified by The Hartford Consensus III: Implementation of Bleeding Control which examines and advocates for tourniquet use in civilian settings [1]. The authors seek to share their unique experience with combat extremity vascular trauma for a global perspective on use of tourniquets in unconventional warfare. A recent single-institution retrospective analysis by Smith et al. of pre hospital tourniquet application matched with a comparable group without tourniquets in a civilian level 1 trauma center concluded that tourniquet application was favorably associated with less shock at presentation to emergency department, decreased blood product utilization and decreased limb related complications. In this study, the average time from tourniquet placement to arrival in the Emergency Department was 23.9 min and the majority were placed by trained medical professionals (68.5%). Overall, the use of tourniquets increased over the 8 years that were retrospectively analyzed [2]. The data from this study corresponds well with the US experience from Operation Iraqi Freedom and Operation Enduring Freedom. In these well-developed combat theaters, the application of tourniquets is coupled with rapid aeromedical evacuation to definitive limb revascularization [3]. Multiple studies also show that the injury patterns from improvised explosive devices (IED) in Afghanistan in particular resulted in exsanguinating hemorrhage that would * Tamara Jean Worlton [email protected] 1
Military Hospital Narahenpita, 08 Elvitigala Mawatha, Colombo 00800, Sri Lanka
2
Hadassah Medical Center, Kiryat Hadassah, POB 12000, 91120 Jerusalem, Israel
3
Department of General Surgery, Walter Reed National Military Medical Center, 8901 Wisconsin Ave, Bethesda, MD 20889, USA
be amenable to tourniquet application and potentially twothirds of fatalities could have been prevented with correct and immediate application of tourniquets [4, 5]. However, when looking at longer evacuation times, there are recognized complications from prolonged use of tourniquets. In the 2014 update to the Tactical Combat Casualty Care (TCCC) guidelines the authors cited a patient with an avoidable amputation secondary to tourniquet application for 8 h which on eventual exploration showed no major vascular injury. They used this opportunity to address alternative means of hemorrhage control and reemphasize early tourniquet conversion to pressure or hemostatic dressing in the absence of shock, capable of close monitoring for re-bleed and not being applied for amputation [3]. This oft-overlooked update in TCCC was more app
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