Reducing harm associated with prehospital tourniquet application in resource‐limited settings

Over the course of the United States (US)-led wars in Iraq and Afghanistan, a series of trauma care advances were implemented to address preventable death among combat casualties, leading to what ultimately became the mature Joint Trauma System.1 Reviews of casualty data from the Department of Defense Trauma Registry identified extremity hemorrhage as one of the leading causes of preventable death on the battlefield. In response, rapid tourniquet application to address catastrophic extremity hemorrhage became a core tenet of military medical training programs such as tactical combat casualty care (TCCC).2, 3 Subsequent studies demonstrated significant survival advantage resulting from prehospital tourniquet application in a well-resourced military setting among US and other Coalition (During the wars in Iraq and Afghanistan, Coalition forces were comprised of both NATO and non-NATO militaries as well as host nation security forces fighting alongside the US Military.) Personnel.4-6 As with many trauma care advances catalyzed by wartime experience, emphasis on prehospital tourniquet application has been widely adopted into high-resource civilian environments.7 A shift from the algorithm of ABCDE (Airway, breathing, circulation, disability, and exposure.) to versions of C-ABCDE, where C stands for “catastrophic hemorrhage,” includes the prioritization of liberal prehospital tourniquet application. Emphasis on rapid hemorrhage control via prehospital tourniquet application has led to a proliferation of training programs for prehospital personnel as well as laypersons such as the American College of Surgeons Committee on Trauma Stop the Bleed program.7-10 These concepts have been exported to other countries and settings, most recently with many Ukrainian health care personnel trained according to TCCC guidelines. The focus on early recognition and treatment of catastrophic bleeding with effective tourniquet application is not controversial when (a) tourniquet application occurs rapidly following extremity trauma with exsanguination; (b) the tourniquet used meets Committee on TCCC standards and successfully stops arterial blood flow; (c) the indication for the tourniquet can be revisited within 2 h by a qualified care provider to evaluate for tourniquet conversion (TC); or (d) rapid evacuation to damage control or definitive care is anticipated to occur within this window. However, the application of hemorrhage control guidelines derived in high-income settings with inadequate adaptation has adverse consequences. Such consequences have recently been described in a series of reports from Ukraine, where significant morbidity has resulted from prehospital tourniquet application with prolonged evacuation times.11-15 The adverse ramifications of prehospital tourniquet application in low-resource settings (LRS) and other austere environments with prolonged prehospital times extend far beyond than the war in Ukraine. For example, the authors have repeatedly observed adverse consequences associated with prolonged tourniquet application among casualties in the current conflict in Burkina Faso, frequently for injuries that in retrospect did not warrant an initial application (Figure 1). The global burden of trauma disproportionately affects LRS.16 The majority of trauma patients are neither service members in the armed forces nor civilians in urban centers of high-income countries with well-resourced care close to the point of injury and intact evacuation chains including aeromedical capabilities.17 Yet, the evidence base for tourniquet use is derived almost exclusively from high-resource, predominantly military, settings. For example, all but one included study in a systematic review of prehospital tourniquet use in civilian settings was from high-income countries.18 Consequences of tourniquet misapplication in low-resource conflict settings. (A) Tourniquet application when not indicated. (B) Tourniquet application more proximal than indicated. (C) Consequences of tourniquet misapplication. Credit: Dr. Zakaria Zeba and Dr. Yves Nacanabo, Burkina Faso Armed Forces. Even in high-resource civilian settings, issues are encountered with tourniquet application by laypersons and prehospital personnel. While positive outcomes have been reported, other studies have found that 50% of tourniquets applied in a civilian trauma setting were not indicated, with an additional 25% found to be misapplied leading to complications including compartment syndrome requiring fasciotomy and permanent nerve palsy.13, 19, 20 In a cohort from Ukraine, only 25% of tourniquets applied were found to be indicated or appropriate.21 Improvized tourniquets, particularly when applied by nonmedical personnel, have an unreliable effect.22-25 Yet in high-resource settings, consequences associated with tourniquet misapplication are unlikely to be grave as median tourniquet time is rarely >2 h.8 In contrast, there is no “golden hour in trauma” among civilians or local combatants injured in LRS.26 Only 5.8% of individuals in a cohort of war-injured civilians in Kabul, Afghanistan reached a health facility within the first hour after injury compared with 75.2% of US military service members.3, 27 Placement of non-indicated tourniquets in LRS can have devastating complications due to prolonged prehospital times with irreversible limb ischemia. Tourniquet time >4 h is associated with >50 percent reduced limb salvage, increased mortality, and complications including compartment syndrome, renal failure, and unnecessarily proximal amputation.28, 29 The impact and potential harms of prolonged prehospital tourniquet application in LRS are not yet quantified. Two main types of error leading to preventable harm from tourniquet application in LRS are (a) tourniquet placement when not indicated (i.e., in the setting of nonlife-threatening hemorrhage/soft tissue wounds without underlying vascular injury that could be controlled by other means) and (b) tourniquet placement higher than is warranted based on the level of injury, leading to tissue ischemia that necessitates more proximal levels of amputation. “High and tight,” the axiom regarding tactical tourniquet application, is specific to care rendered under hostile conditions in combat environments where time cannot be taken to precisely identify the location of bleeding as both casualty and care provider may be under active fire. In this scenario, rapid placement of a tourniquet as proximally as possible on the affected extremity facilitates effective hemorrhage control and rapid evacuation. The safety of this approach assumes organized prehospital transport to facilitate patient movement to damage control surgical care in a timeframe close to the golden hour. Although not taught in civilian Stop the Bleed programs, this guidance designed for dramatically different circumstances nonetheless often filters into practice in other environments including LRS leading to permanent disability in the absence of appropriate TC. The consequences for livelihoods are profound given the severe limitations encountered in accessing high-quality prosthetics in LRS. Research: Observational prospective studies should be conducted in LRS with adequate representation from trauma care providers in affected settings to empirically evaluate the outcomes of patients undergoing prehospital tourniquet application in this environment, including modality of tourniquet applied, tourniquet time, rates of limb salvage, level of injury, level of amputation, metabolic complications, acute renal failure, mortality, and functional outcomes. A range of settings should be examined as LRS and other austere environments differ widely with respect to human and material resource constraints and security dynamics in the setting of active conflict. Training: Hemorrhage control trainings in conflict-affected LRS should be developed in partnership with trauma care providers working in these settings. In the 1990s, a locally led prehospital trauma training in landmine-contaminated areas of Iraq and Cambodia reported a decrease in trauma-related mortality from 40% to 15% over a 5-year study period.30 Their approach to hemorrhage control prioritized meticulous wound packing by first responders with limited use of tourniquets.31 Hemorrhage control trainings delivered in LRS should place equal emphasis on alternative modalities of hemorrhage control, harms associated with prolonged tourniquet application, as well as extensive content on appropriate TC. Timely, coordinated action to address gaps in training and context-appropriate hemorrhage control algorithms is required to prevent the survival advantage of appropriate tourniquet application from reaching those in resource-constrained conflict and post-conflict settings. Hannah Wild: Conceptualization; investigation; methodology; supervision; visualization; writing—original draft; writing—review & editing. Zakaria A. A. Zeba: Conceptualization; investigation; resources; writing—review & editing. Yves Aziz Nacanabo: Conceptualization; investigation; resources; writing—review & editing. Serhii V. Tertyshnyi: Conceptualization; writing—review & editing. Moumini Niaone: Writing—review & editing. Eileen Bulger: Supervision; writing—review & editing. Charles Mock: Conceptualization; methodology; supervision; writing—review & editing. Henrik Hedelin: Conceptualization; investigation; methodology; supervision; writing—original draft; writing—review & editing. HW is supported by the Global Health Equity Scholars Program NIH FIC and NIH OBSSR (Award no. D43TW010540). The authors have no conflicts of interest to declare.