Use of tourniquets and their effects on limb function in the modern combat environment

The history of tourniquet use in limb surgery

PURPOSE

As tourniquets have been present in medicine since almost its conception, understanding and following their development through time is not only an exercise in history but also an insight into the evolution of medical devices over more than two millennia. From simple leather bands wrapped around patients' limbs to the modernised digital devices used widely in surgical theatres globally, tourniquets have undergone tectonic change both in their design and application, moving from battlefields to hospitals. Hence, the aim of this article is to outline the historical development of these devices alongside their present and modern use.

METHODS

The historical development of emergency and surgical tourniquets is chronologically outlined, with particular emphasis on the impact of warfare on their widespread adoption in trauma and emergency medicine and elective surgery. Novel surgical trends and their impact on the future of tourniquet use are evaluated.

RESULTS

The development of tourniquets across two millennia has closely reflected both the scientific understanding of human physiology and anatomy as well as technological discoveries and advancements that have reshaped their design and application. Prominent figures in the field of surgery, such as Sushruta, Fabricius Hildanus, John Louis Petit, Joseph Lister, Harvey Cushing and James McEwen, all fundamentally influenced their evolution and helped popularise and modernise them. The views on their use have been controversial and drastically changed across different eras, with data collected from modern warfare serving to embed their use in clinical practice.

CONCLUSION

The historical development of tourniquets since pre-historic times represents an excellent outline of the adaptive nature of medicine, led, firstly, by scientific rigour and discipline and, secondly, by pioneers who serve as catalysts for change and improvement. The modern inflatable cuff tourniquets that are omnipresent in theatres globally will undoubtedly remain the standard of care for the foreseeable future. Tourniquets that can dynamically monitor blood pressure and consequently adjust inflation pressures, as well as ones with inbuilt axonal excitability monitoring, will further improve their safety profile, reduce associated complication rates and represent the next step in the evolution of these devices. Notably, there might be a shift away from tourniquet use altogether, reflected by the wide use of the wide-awake local anaesthesia no-tourniquet technique that has become the new norm in hand surgery.

Prehospital Tourniquet Usage and Diabetes Mellitus Associated with Increased Incidence, Odds, and Risk of Acute Kidney Injury: A Pilot Study

INTRODUCTION

Tourniquets are the standard of care for civilian and military prehospital treatment of massive extremity hemorrhages. Over the past 17 years, multiple military studies have demonstrated rare complications related to tourniquet usage. These studies may not translate well to civilian populations due to differences in baseline health. Experimental studies have demonstrated increased rates of post-traumatic acute kidney injuries (AKIs) in rats with obesity and increased oxidative stress, suggesting that comorbidities may affect AKI incidence with tourniquet usage. Two recently published retrospective studies, focused on the safety of tourniquets deployed within civilian sectors, documented increased incidence of AKI in patients with a prehospital tourniquet as compared to previously published military results. This study aimed to provide descriptive data concerning the association between the use of prehospital tourniquets and AKIs amongst civilian patient populations as AKIs increase mortality in hospitalized patients.

METHODS

This was a single-center, observational, cross-sectional, pilot study involving chart review of participants presenting to a tertiary Level 1 trauma center. Patient data were extracted from prehospital and hospital electronic medical records. For this study, AKI was defined using the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines.

RESULTS

A total of 255 participants were included. Participants with a history of diabetes mellitus had a significantly higher incidence of AKI as compared to those without. Analysis revealed an increased odds of AKI with diabetes in association to the use of a prehospital tourniquet. Participants with diabetes had an increased relative risk of AKI in association to the use of a prehospital tourniquet. The incidence of AKI was statistically higher than what was previous reported in the military population in association with the use of a prehospital tourniquet.

CONCLUSION

The incidence of AKIs was higher than previously reported. Patients with diabetes had an associated higher risk and incidence of sustaining an AKI after the use of a prehospital tourniquet in association with the use of a prehospital tourniquet. This may be due to the known deleterious effects of diabetes mellitus on renal function. This study provides clinically relevant data that warrant further multi-site investigations to further investigate this study's associated findings and potential causation. It also stresses the need to assess whether renally-impacting environmental and nutritional stressors affect AKI rates amongst military personnel and others in which prehospital tourniquets are used.

Tourniquet Application for Bleeding Control in a Rural Trauma System: Outcomes and Implications for Prehospital Providers

Introduction: Uncontrolled bleeding is a preventable cause of death in rural trauma. Herein, we examined the appropriateness, effectiveness, and safety of tourniquet application for bleeding control in a rural trauma system.Methods: Medical records of adult patients admitted to our academic Level I trauma center between July 2015 and December 2018 were retrospectively reviewed. Demographics (age, gender), injury (Injury severity score, Glascow Coma scale, mechanism of injury), tourniquet (type, tourniquet application site, tourniquet duration, place of application and removal, indication), and outcome data (complications such as amputation, acute kidney injury, rhabdomyolysis, or nerve palsy and mortality) were collected. Tourniquet indications, effectiveness, and complications were evaluated. Data were compared to those in urban settings.Results: Ninety-two patients (94 tourniquets) were identified, of which 58.7% incurred penetrating injuries. Eighty-seven tourniquets (92.5%) were applied in the prehospital setting. Twenty tourniquets (21.3%) were applied to patients without an appropriate indication. Two of these tourniquets were applied in a hospital setting, while 18 occurred in the prehospital setting (p = 0.638). Patients with a non-indicated tourniquet presented with a higher hemoglobin level on admission, received less packed red blood cell units within the first 24 hours of hospitalization, and were less likely to require surgery for hemostasis. None of the non-indicated tourniquets led to a complication. Indicated tourniquets were deemed ineffective in seven cases (9.5%); they were all applied in the prehospital setting. The average tourniquet time was 123 min in rural vs. 48 min in urban settings, p < 0.001. There was no significant difference in mortality, amputation rates and incidence of nerve palsy between the rural and urban settings.Conclusion: Even with long transport times, early tourniquet application for hemorrhage control in rural settings is safe with no significant attributable morbidity and mortality compared to published studies on urban civilian tourniquet use. The observed rates of non-indicated and ineffective tourniquets indicate suboptimal tourniquet usage and application. Opportunity exists for standardized hemorrhage control training on the use of direct pressure and pressure dressings, indications for tourniquet use, and effective tourniquet application.

Design and Development of a Hemorrhagic Trauma Simulator for Lower Limbs: A Pilot Study

One of the main preventable leading causes of death after a trauma injury is the hemorrhagic shock. Therefore, it is extremely important to learn how to control hemorrhages. In this paper, a hemorrhagic trauma simulator for lower limb has been developed and a pilot study has been accomplished to trail the simulator. Four different bleeding scenarios have been tested per participant, gathering information about the manual pressure exerted to control the bleeding. Data, altogether, from 54 hemorrhagic scenarios managed by final year medical students and doctors were gathered. Additionally, a post-simulation questionnaire, related to the usability of the simulator, was completed. All the participants managed to control the simulated bleeding scenarios, but the pressure exerted to control the four different scenarios is different depending if the trainee is a student or a doctor, especially in deep venous hemorrhages. This research has highlighted the different approach to bleeding control treatment between medical students and doctors. Moreover, this pilot study demonstrated the need to deliver a more effective trauma treatment teaching for hemorrhagic lesions and that hemorrhagic trauma simulators can be used to train and evaluate different scenarios.

Prehospital Tourniquets in Civilians: A Systematic Review

OBJECTIVES

Terrorist attacks and civilian mass-casualty events are frequent, and some countries have implemented tourniquet use for uncontrollable extremity bleeding in civilian settings. The aim of this study was to summarize current knowledge on the use of prehospital tourniquets to assess whether their use increases the survival rate in civilian patients with life-threatening hemorrhages from the extremities.

DESIGN

Systematic literature review in Medline (Ovid), Embase (Ovid), Cochrane Library, and Epistemonikos was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Guidelines. The search was performed in January 2019.

SETTING

All types of studies that examined use of tourniquets in a prehospital setting published after January 1, 2000 were included.

PRIMARY/SECONDARY OUTCOMES

The primary outcome was mortality with and without tourniquet, while adverse effects of tourniquet use were secondary outcomes.

RESULTS

Among 3,460 screened records, 55 studies were identified as relevant. The studies were highly heterogeneous with low quality of evidence. Most studies reported increased survival in the tourniquet group, but few had relevant comparators, and the survival benefit was difficult to estimate. Most studies reported a reduced need for blood transfusion, with few and mainly transient adverse effects from tourniquet use.

CONCLUSION

Despite relatively low evidence, the studies consistently suggested that the use of commercial tourniquets in a civilian setting to control life-threatening extremity hemorrhage seemed to be associated with improved survival, reduced need for blood transfusion, and few and transient adverse effects.

External Soft-Tissue Hemostatic Clamp Compared to a Compression Tourniquet as Primary Hemorrhage Control Device in Pilot Flow Model Study

INTRODUCTION

Acute blood loss represents a leading cause of death in both civilian and battlefield trauma, despite the prioritization of massive hemorrhage control by well-adopted trauma guidelines. Current Tactical Combat Casualty Care (TCCC) and Tactical Emergency Casualty Care (TECC) guidelines recommend the application of a tourniquet to treat life-threatening extremity hemorrhages. While extremely effective at controlling blood loss, the proper application of a tourniquet is associated with severe pain and could lead to transient loss of limb function impeding the ability to self-extricate or effectively employ weapons systems. As a potential alternative, Innovative Trauma Care (San Antonio, Texas USA) has developed an external soft-tissue hemostatic clamp that could potentially provide effective hemorrhage control without the aforementioned complications and loss of limb function. Thus, this study sought to investigate the effectiveness of blood loss control by an external soft-tissue hemostatic clamp versus a compression tourniquet.

HYPOTHESIS

The external soft-tissue hemostatic clamp would be non-inferior at controlling intravascular fluid loss after damage to the femoral and popliteal arteries in a normotensive, coagulopathic, cadaveric lower-extremity flow model using an inert blood analogue, as compared to a compression tourniquet.

METHODS

Using a fresh cadaveric model with simulated vascular flow, this study sought to compare the effectiveness of the external soft-tissue hemostatic clamp versus the compression tourniquet to control fluid loss in simulated trauma resulting in femoral and posterior tibial artery lacerations using a coagulopathic, normotensive, cadaveric-extremity flow model. A sample of 16 fresh, un-embalmed, human cadaver lower extremities was used in this randomized, balanced two-treatment, two-period, two-sequence, crossover design. Statistical significance of the treatment comparisons was assessed with paired t-tests. Results were expressed as the mean and standard deviation (SD).

RESULTS

Mean intravascular fluid loss was increased from simulated arterial wounds with the external soft-tissue hemostatic clamp as compared to the compression tourniquet at the lower leg (119.8mL versus 15.9mL; P <.001) and in the thigh (103.1mL versus 5.2mL; P <.001).

CONCLUSION

In this hemorrhagic, coagulopathic, cadaveric-extremity experimental flow model, the use of the external soft-tissue hemostatic clamp as a hasty hemostatic adjunct was associated with statistically significant greater fluid loss than with the use of the compression tourniquet.Paquette R, Bierle R, Wampler D, Allen P, Cooley C, Ramos R, Michalek J, Gerhardt RT. External soft-tissue hemostatic clamp compared to a compression tourniquet as primary hemorrhage control device in pilot flow model study. Prehosp Disaster Med. 2019;34(2):175-181.

Prehospital Assessment of Trauma

The organization of prehospital care for trauma patients began in the military arena. At the urging of multiple stakeholders and providers, these lessons were applied to the civilian setting and emergency medical services were created across the nation. Advances have taken place in the triage, transport, and management of severely injured patients. Many issues remain in the care of trauma patients in the prehospital environment. Collaboration between stakeholders and providers, regionalization of trauma care, and protocol-driven care may be solutions to some of these issues. Further research is necessary to dictate standard of care in this early phase after injury.

Clinical features of 27 shark attack cases on La Réunion Island

BACKGROUND

Between January 2000 and September 2016, there have been 27 documented shark attacks on La Réunion Island. The insular nature of La Réunion has allowed us to perform an extensive survey of these attacks. The objective was to describe the clinical features of these shark attacks, as only case reports have been published up to now.

METHODS

This was a retrospective observational study of the 27 cases of nonprovoked shark attacks that have occurred between January 2000 and September 2016. Post-humate predation, provoked attacks, and isolated attack on devices were excluded. All bone and vascular injuries were documented in the 21 remaining cases. Prehospital tourniquet use was specifically recorded.

RESULTS

Among the 21 victims, eight died (38%) despite rapid use of resuscitation techniques in five cases when it was feasible; these techniques were not needed in the survivors. Thirteen patients were immediately treated in the operating room. Amputation or disarticulation occurred 13 times in 10 victims, five of whom died. Twelve injuries to major vascular structures were found in 11 victims, six of which died. A prehospital tourniquet was applied in four of the five surviving victims who had injuries to major vascular structures (including one victim with major humeral and femoral artery damage) and in one victim who died (the very proximal wound was not controlled).

CONCLUSION

Our study found that quickly applying a tourniquet to the injured limb(s) contributes to the victim's survival. Disarticulation is a particular feature of shark attacks. The number and severity of shark attacks at La Réunion Island are worse than in the rest of the world.

LEVEL OF EVIDENCE

Epidemiological, level V.

Belts Evaluated as Limb Tourniquets: BELT Study Comparing Trouser Supporters Used as Medical Devices in a Manikin Model of Wound Bleeding

OBJECTIVE

The purpose of the present study is to compare several models of commercially designed belts as used as a tourniquet.

METHODS

In the Belts Evaluated as Limb Tourniquets (BELT) study, an experiment was designed to test the effectiveness of pants belts as nonimprovised medical devices to control hemorrhage in a manikin. Models of belts included Tourni-belt, Tourniquet Belt, ParaBelt, and Battle Buddy. Data collected included effectiveness, time to stop bleeding, total time of application, pressure, blood loss, and composite results (score count of good results; composite outcome good if every component was good).

RESULTS

Differences in effectiveness percentages among models were not statistically significant. The difference in mean between users was statistically significant for stop time, total time, pressure, blood loss, composite score, and composite outcome. Mean time to stop bleeding differed for only 1 pair of models after the Tukey-Kramer adjustment; ParaBelt was faster than Tourniquet Belt. Mean total time of application differed between ParaBelt-Tourniquet Belt and Tourni-belt-Tourniquet Belt; the former model in both pairs was faster. No significant difference in mean blood loss measured by model was found. For composite outcome score, no pairwise difference between models was significant. For composite outcome (good-bad), ParaBelt had good results in 75% of tests; the other 3 models had significantly worse results.

CONCLUSIONS

In a preliminary laboratory analysis of belt tourniquet models using a manikin, performance differed by model. ParaBelt performed better than other models for the composite outcome.

Prehospital control of life-threatening truncal and junctional haemorrhage is the ultimate challenge in optimizing trauma care; a review of treatment options and their applicability in the civilian trauma setting

Introduction

Exsanguination following trauma is potentially preventable. Extremity tourniquets have been successfully implemented in military and civilian prehospital care. Prehospital control of bleeding from the torso and junctional area’s remains challenging but offers a great potential to improve survival rates. This review aims to provide an overview of potential treatment options in both clinical as preclinical state of research on truncal and junctional bleeding. Since many options have been developed for application in the military primarily, translation to the civilian situation is discussed.

Methods

Medline (via Pubmed) and Embase were searched to identify known and potential prehospital treatment options. Search terms were|: haemorrhage/hemorrhage, exsanguination, junctional, truncal, intra-abdominal, intrathoracic, intervention, haemostasis/hemostasis, prehospital, en route, junctional tourniquet, REBOA, resuscitative thoracotomy, emergency thoracotomy, pelvic binder, pelvic sheet, circumferential. Treatment options were listed per anatomical site: axilla, groin, thorax, abdomen and pelvis Also, the available evidence was graded in (pre) clinical stadia of research.

Results

Identified treatment options were wound clamps, injectable haemostatic sponges, pelvic circumferential stabilizers, resuscitative thoracotomy, resuscitative endovascular balloon occlusion of the aorta (REBOA), intra-abdominal gas insufflation, intra-abdominal self-expanding foam, junctional and truncal tourniquets. A total of 70 papers on these aforementioned options was retrieved. No clinical reports on injectable haemostatic sponges, intra-abdominal insufflation or self-expanding foam injections and one type of junctional tourniquets were available.

Conclusion

Options to stop truncal and junctional traumatic haemorrhage in the prehospital arena are evolving and may offer a potentially great survival advantage. Because of differences in injury pattern, time to definitive care, different prehospital scenario’s and level of proficiency of care providers; successful translation of various military applications to the civilian situation has to be awaited. Overall, the level of evidence on the retrieved adjuncts is extremely low.

Control of Traumatic Extremity Hemorrhage

Although most extremity hemorrhage from trauma can be controlled with direct pressure and/or pressure dressings, the occasional uncontrolled hemorrhage can be life threatening. Tools that may be able to control such life-threatening extremity hemorrhage include hemostatic dressings, tourniquets, and several new devices that have recently become available. Hemostatic dressings, a relatively new concept, incorporate materials that increase coagulation into a dressing that is applied directly to the wound. Although the use of tourniquets has a long history, recent military conflicts have provided numerous studies that supported and refined their use. The novel extremity hemorrhage control devices effectively control bleeding in one of several ways: direct compression, arterial compression above the level of injury, and sealing the wounds’ edges, creating a hematoma.

Emergency tourniquets for civilians: Can military lessons in extremity hemorrhage be translated?

BACKGROUND

Among civilians, emergency tourniquet (TKT) use is infrequent because of concern for TKT-related complications. In large part because of positive reports from the military on emergency TKT use, all ambulances serving Mecklenburg County, which includes the city of Charlotte, North Carolina, were equipped with commercial TKTs in September 2012. This study compares the outcomes of emergency TKT use with conservative hemorrhage control in an urban civilian setting and evaluates outcomes related to appropriate TKT placement.

METHODS

Emergency medical service and hospital records from September 2012 to November 2013 were reviewed. Injury characteristics, clinical interventions, outcomes, and TKT-related complications were reported, and appropriateness of TKT use was assessed. Primary analysis compared all TKT patients with non-TKT patients who received other hemorrhage control measures. Secondary analysis compared all appropriate TKT patients with those who had delayed/missed TKTs.

RESULTS

Fifty-six patients met inclusion criteria (24 TKT, 32 non-TKT). Four patients died (three TKT, one non-TKT) (7.1%). There were no reported TKT-related complications. Of all the patients, 46.4% (16 of 56) demonstrated signs of shock in the prehospital or emergency department setting. Seventy-five percent (12 of 16) of the patients in shock had a vascular injury (p = 0.023). Of the non-TKT patients, 9.4% (3 of 32) should have received a TKT and were classified as "missed." One "missed" patient died in the emergency department. Among TKT patients, 62.5% (15 of 24) of TKTs were appropriate, 20.8% (5 of 24) were inappropriate, and 16.7% (4 of 24) were "delayed." Overall, there was a delayed/missed TKT rate of 12.5% (7 of 56). Patients with delayed/missed TKTs had higher incidences of shock (85.7% vs. 60%), inpatient admission (100% vs. 76.9%), and blood transfusions (71.4% vs. 40%).

CONCLUSION

The majority of TKTs were appropriately applied to civilians who had vascular injuries or required operative intervention for hemorrhage control. With appropriate indications, an emergency TKT is a valuable instrument for hemorrhage control in the civilian prehospital setting and has a low rate of associated complications.

LEVEL OF EVIDENCE

Therapeutic study, level IV.

Law enforcement-applied tourniquets: a case series of life-saving interventions

Although the epidemiology of civilian trauma is distinct from that encountered in combat, in both settings, extremity hemorrhage remains a major preventable cause of potential mortality. The current paper describes the largest case series in the literature in which police officers arriving prior to emergency medical services applied commercially available field tourniquets to civilian victims of violent trauma. Although all 3 patients with vascular injury arrived at the receiving emergency department in extremis, they were successfully resuscitated and survived to discharge without major morbidity. While this outcome is likely multifactorial and highlights the exceptional care delivered by the modern trauma system, tourniquet application appears to have kept critically injured patients alive long enough to reach definitive trauma care. No patient had a tourniquet-related complication. This case series suggests that law enforcement officers can effectively identify indications for tourniquets and rapidly apply such life-saving interventions.

3 Echo: Concept of Operations for Early Care and Evacuation of Victims of Mass Violence

This report describes the successful use of a simple 3-phase approach that guides the initial 30 minutes of a response to blast and active shooter events with casualties: Enter, Evaluate, and Evacuate (3 Echo) in a mass-shooting event occurring in Minneapolis, Minnesota USA, on September 27, 2012. Early coordination between law enforcement (LE) and rescue was emphasized, including establishment of unified command, a common operating picture, determination of evacuation corridors, swift victim evaluation, basic treatment, and rapid evacuation utilizing an approach developed collaboratively over the four years prior to the event. Field implementation of 3 Echo requires multi-disciplinary (Emergency Medical Services (EMS), fire and LE) training to optimize performance. This report details the mass-shooting event, the framework created to support the response, and also describes important aspects of the concepts of operation and curriculum evolved through years of collaboration between multiple disciplines to arrive at unprecedented EMS transport times in response to the event.

AutreyAW, HickJL, BramerK, BerndtJ, BundtJ. 3 Echo: concept of operations for early care and evacuation of victims of mass violence. Prehosp Disaster Med. 2014;29(4):1-8.

[Tourniquet use in civil and military medicines]

OBJECTIVES

The purpose of this literature review is, after a history and a point about current situation, to present the military use and precautions of use of tourniquet for civil and military medicine.

DATA SOURCES

A review of the Anglo-Saxon and French literature was performed in PUBMED database, from 1962 to 2012. The research was conducted using the following keywords: "tourniquet", "complications", "haemorrhage", "emergency", "military medicine", used alone or in combination.

DATA EXTRACTION

The extracted data concerned the history, the epidemiology, the interest of tourniquet during peacetime and wartime, adverse effects and the ratio benefit/risk.

DATA SYNTHESIS

The tourniquet is "a device which is tightened, in case of haemorrhage, around a limb in order to slow or stop the venous or arterial circulation before surgery…". This item is thus used in surgery to reduce intraoperative bleeding and in emergency medicine as a rescue technique for bleeding places non accessible to compression or to other technical hemostasis. It is also used for treating bleeding of mass casualties. However, its use is too poorly managed by health professionals and it remains risky. Recent armed conflicts have yet revived its day use.

CONCLUSION

The tourniquet has utility in times of war and in peacetime. In each case, indications and complications must be known.

Life, limb or off-label recombinant VIIa use in the setting of limited blood assets: a case study

Due to the lack of adequate controlled trials, the off-label use of recombinant factor VIIa (rFVIIa) to control hemorrhage in trauma patients remains controversial. The decision regarding when to initiate rFVIIa therapy is particularly problematic. Whereas most reports and trials have delayed use until significant bleeding has occurred, there is some evidence that coagulopathy develops early in some trauma patients, raising the possibility that early rFVIIa use may be more clinically efficacious. Herein, we report the case of a hemodynamically unstable patient with massive blood loss from multiple gunshot wounds and who had a potentially salvageable upper extremity. Rapid hemorrhage despite efforts to surgically control the bleeding resulted in virtual exhaustion of the facilities' limited blood component supply. Hemorrhage was controlled when rFVIIa was added to hypotensive resuscitation allowing salvage of the arm and significant conservation of blood products. This case raises the question as to whether earlier off-label use of this agent should be considered when amputation for hemorrhage control is being considered and/or conservation of limited blood assets is needed.

Development of adaptive pneumatic tourniquet systems based on minimal inflation pressure for upper limb surgeries

Background

Pneumatic tourniquets are medical devices that occlude blood flow to distal part of extremities and are commonly used in upper limb surgeries to provide a dry, clean and bloodless field. To decrease pressure-related injuries and potential risk of complications subjected to the high inflation pressure of pneumatic tourniquet, minimal inflation pressures are recommended.

Methods

A new occlusion pressure mathematical model for the upper limb was established based on the correlation analysis between several possible influencing parameters and the minimal pneumatic tourniquet pressure at which the peripheral pulse disappeared was recorded using a digital plethysmograph. A prototype of an adaptive pneumatic tourniquet which automatically varies the pressure in the tourniquet cuff according to the above prediction model was developed for the upper limb which used the lowest possible inflation pressure to achieve occlusion. The prototype comprises a blood pressure monitoring module, an inflatable tourniquet cuff, and a pressure relief mechanism to maintain an optimal cuff inflation pressure. Simulation experiments were conducted to verify the function and stability of the designed adaptive pneumatic tourniquet and clinical experiments using volunteers were undertaken to evaluate the performance of the prototype design in achieving adequate haemostasis in the upper limb.

Results

Results demonstrated that the mean arterial occlusion pressure was 152.3 ± 16.7 mmHg, obviously below the 250 to 300 mmHg previously recommended (J Bone Joint Surg Br 68:625-628, 1986 and Arthroscopy 11:307–311, 1995).

Conclusions

In conclusion, this adaptive method and apparatus which can provide minimal inflation pressure may be a clinically practical alternative for upper limb surgery performed with pneumatic tourniquets.

Injury severity score underpredicts injury severity and resource utilization in combat-related amputations

OBJECTIVE

Assess effectiveness of Injury Severity Score (ISS) in predicting injury severity in combat-related amputations.

DESIGN

Retrospective evaluation of prospectively collected data.

SETTING

Military medical center.

PATIENTS

One hundred and nine patients with major extremity amputations sustained in overseas combat.

INTERVENTION

Standard combat casualty care.

MAIN OUTCOME MEASUREMENTS

Difference in injury severity as measured by ISS, numbers of extremity(s) amputated, number of associated injuries, blood products used, intensive care unit length of stay, hospital length of stay in those with an upper extremity amputation (UEA) compared with those with an isolated lower extremity amputation.

RESULTS

Thirteen patients (11.9%) sustained at least one UEA. Patients with an UEA had a greater number of amputations per casualty compared with patients with a lower extremity alone (2.5 vs. 1.5; P < 0.001). The mean hospital length of stay (P = 0.02) and intensive care unit length of stay (P = 0.02) were significantly greater in those with an UEA. Mean blood product utilization was also significantly greater in those with an upper extremity amputation (P < 0.05). There was no difference in ISS between the two groups (P > 0.05).

CONCLUSIONS

The presence of an UEA is associated with increased injury severity as evident by increased intensive care unit requirements, blood product utilization, and hospital length of stay. ISS underestimates the severity of injury and therefore resource utilization in patients with multiple combat-related amputations. Recognition of this limitation in addition to the development of a military-specific ISS is required for more effective resource utilization to continue to improve combat casualty care.

LEVEL OF EVIDENCE

Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Remote damage control resuscitation and the Solstrand Conference: defining the need, the language, and a way forward

Damage control resuscitation (DCR) is emerging as a standard practice in civilian and military trauma care. Primary objectives include resolution of immediate life threats followed by optimization of physiological status in the perioperative period. To accomplish this, DCR employs a unique hypotensive-hemostatic resuscitation strategy that avoids traditional crystalloid intravenous fluids in favor of early blood component use in ratios mimicking whole blood. The presence of uncontrolled major hemorrhage (UMH) coupled with a delay in access to hemostatic surgical intervention remains a primary contributor to preventable death in both combat and in many domestic settings, including rural areas and disaster sites. As a result, civilian and military emergency care leaders throughout the world have sought a means to project DCR principles forward of the traditional trauma resuscitation bay, into such remote environments as disaster scenes, rural health facilities, and the contemporary battlefield. After reflecting on experiences from past conflicts, defining current capability gaps, and examining available and potential solutions, a strategy for "remote damage control resuscitation" (RDCR) has been proposed. In order for RDCR to progress from concept to clinical strategy, it will be necessary to define existing gaps in knowledge and clinical capability; develop a lexicon so that investigators and operators may understand each other; establish coherent research and development agendas; and execute comprehensive investigations designed to predict, diagnose, and mitigate the consequences of hemorrhagic shock and acute traumatic coagulopathy before they become irreversible. This article seeks to introduce the concept of RDCR; to reinforce the importance of identifying and optimally managing UMH and the resulting shock state as part of a comprehensive approach to out-of-hospital stabilization and en route care; and to propose investigational strategies to enable the development and broad implementation of RDCR principles.

Mortality in female war veterans of operations enduring freedom and Iraqi freedom

BACKGROUND

Combat-wounded service members are surviving battle injuries more than ever. Given different combat roles held by men and women, female service members should survive wounds at an unprecedented rate.

QUESTIONS/PURPOSES

We determined whether the casualty rates for females differ from their male counterparts and characterized wounds sustained by female casualties.

METHODS

We calculated the percentage of the 5141 deaths among the 40,531 casualties by gender for those serving in Operations Enduring Freedom (OEF) and Iraqi Freedom (OIF) from Defense Manpower Statistics between 2001 and 2009. We searched the Joint Theatre Trauma Registry for female casualties and described their injury characteristics. No matched cohort of male casualties was searched.

RESULTS

Female veterans comprised 1.9% of all casualties and 2.4% of all deaths. In OIF, the percent death for women was 14.5% (103 deaths) versus 12.0% (4226 deaths) for men. In OEF, the percent death for women was 35.9% (19 deaths) versus 17.0% (793 deaths) for men. Battle-injured females had a greater proportion of facial and external injuries and more severe extremity injuries compared with those nonbattle-injured.

CONCLUSIONS

The casualty death rate appears higher for women than men although the mechanisms of fatal injuries are not known and may not be comparable. Although facial, external, and extremity injuries were common among battle-injured females, no conclusion can be made as to whether male casualties sustain similar wounding patterns.

LEVEL OF EVIDENCE

Level II, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.

Advancing critical care: joint combat casualty research team and joint theater trauma system

Despite the severity and complexity of injuries, survival rates among combat casualties are equal to or better than those from civilian trauma. This article summarizes the evidence regarding innovations from the battlefield that contribute to these extraordinary survival rates, including preventing hemorrhage with the use of tourniquets and hemostatic dressings, damage control resuscitation, and the rapid evacuation of casualties via MEDEVAC and the US Air Force Critical Care Air Transport Teams. Care in the air for critically injured casualties with pulmonary injuries and traumatic brain injury is discussed to demonstrate the unique considerations required to ensure safe en route care. Innovations being studied to decrease sequelae associated with complex orthopedic and extremity trauma are also presented. The role and contributions of the Joint Combat Casualty Research Team and the Joint Theater Trauma System are also discussed.

The 2009 Sydney shark attacks: case series and literature review

BACKGROUND

There were 59 unprovoked shark attacks worldwide in 2008. Twelve of these occurred in Australia, ranking it as second only to the USA. In February 2009, two attacks occurred within 72 h in Sydney, Australia.

METHODS

The two patients involved survived severe limb trauma. Case 1 suffered bite trauma to the lower limb and hand and underwent staged debridement and early amputation. Case 2 presented with a hand severed at the level of the wrist that was initially replanted. However, it would succumb to progressive necrosis after 12 days. We discuss the aspects of these cases that contributed to the patients' survival and ultimately good functional outcomes.

DISCUSSION

New paradigms for the management of major trauma patients have emerged over the last decade. We consider recent advances in the understanding of pre-hospital tourniquet use, rapid transit to the operating suite and damage control surgery, and examine how they impacted on the management of our patients. Very little is known about the microbiology of shark bites. Organisms from sea water, the patient's skin and the shark's mouth must all be considered when selecting appropriate antimicrobial prophylaxis. The planning of definitive surgery in severe limb trauma is dependent on the interactions of a number of factors including physical, psychological and social issues. The decision to ultimately replant or amputate the effected limb is best made in union with the patient and their family.