Prehospital tourniquet use and associated outcomes in a low-resource conflict setting: prospective observational casualty data and tourniquet classification system from the Sahel

Introduction Tourniquet (TQ) application is a key component of extremity haemorrhage control in high-resource military and civilian trauma systems. In settings with prolonged evacuation times, TQs can cause complications including limb loss, rhabdomyolysis, or death, yet limited data exist on the scope and impact of this problem. Methods We conducted a single-centre prospective observational analysis at the largest military hospital in Burkina Faso to describe injury epidemiology, TQ application practices and early outcomes among casualties with conflict-related injuries who underwent prehospital TQ application from January to July 2025. Results 100 casualties (N) were included in the analysis. Mean prehospital time was 11.9 hours. The most common mechanism of injury was gunshot wound (64.0%, n=64) followed by explosion (36.0%, n=36). 114 TQs were placed. 5.3% (n=6) of TQs were both medically necessary and appropriately placed. Of 24 amputations, 54.2% (n=13) were performed at an anatomical level more proximal than otherwise indicated due to TQ application and 50.0% (n=12) were associated with TQs that were not medically necessary. Mortality was 5.0% (n=5), three of which were attributable to TQ-associated complications (eg, rhabdomyolysis, cardiac arrest). Conclusions TQs can reduce preventable death from extremity haemorrhage but can also have harmful consequences in settings with prolonged evacuation times. In our sample from the Sahel, a low proportion of prehospital TQs were medically necessary and appropriately placed, with substantial TQ-associated morbidity and mortality. Context-appropriate clinical algorithms and training programmes are needed to reduce these complications while upholding the role of appropriate TQ use for haemorrhage control in conflict.