Civilian use of tourniquets has significantly increased in recent years because of the successful military implementation of tourniquets in Iraq and Afghanistan, as well as the 2014 Hartford Consensus and lay person programs such as the Stop the Bleed .¹ Civilian mass-casualty events have seen growing use of tourniquets, and prehospital tourniquet application is becoming more common.¹ Recent research has shown children as young as 8 can effectively learn tourniquet application.²

When applied properly, tourniquets are extremely effective. They are strongly associated with survival in combat and may provide up to a sixfold survival benefit in prehospital civilian populations.^1,3 However, as prehospital tourniquets become more ubiquitous, emergency physicians should be aware of the potential for associated complications.

Potential Complications

The U.S. military campaigns in Iraq and Afghanistan featured some of the most efficient medical evacuation (medevac) systems in the history of warfare. Evacuated soldiers with penetrating injury had a median tourniquet application duration of only 60 minutes.⁴ In other theaters, such as the Sahelian strip in Africa, which featured antiterrorism operations across five countries and five million square kilometers, medevac systems were far more strained, and tourniquet duration for injured soldiers frequently exceeded two hours, resulting in significant complications.⁴ The Russo-Ukrainian War is an even more extreme example, with a mean medevac time of as long as 21 hours.⁵ These conflicts have shown the dangers of Prolonged Tourniquet Application Syndrome (PTAS).

PTAS is also likely to become more common in the civilian setting. Although medically indicated tourniquets are lifesaving, civilian settings have an incidence of not medically indicated tourniquets that ranges from 10.5 percent to 100 percent in various case studies.⁵

Tourniquets that have been in place for longer than two hours carry significant risks, including local and systemic reperfusion effects when removed, compartment syndrome, and rhabdomyolysis.³ Tourniquet use also induces a hypercoagulable state and increases the risk for thromboembolism.⁶ The release of antioxidants from reperfusion may have a wide range of cascading effects, with potential for hepatic, renal, and pulmonary dysfunction after tourniquet removal.⁶ Given this, the two-hour mark should be considered critical for emergency physicians.³

Tourniquets in the ED

FIGURE 1: ED management of prehospital tourniquet.³ Click to enlarge. (Reprinted from The Journal of Emergency Medicine, 60:1, Levy MJ et al., “Removal of the Prehospital Tourniquet in the Emergency Department, Copyright 2021, with permission from Elsevier.)

Upon arrival to the emergency department (ED), any patient with a prehospital tourniquet should have the time of their tourniquet application determined. If a specific time is not known, it should be assumed to be at the same time that EMS arrived at the scene of the accident.³ It should also be determined if the tourniquet is medically necessary—not medically indicated tourniquets are often applied in the prehospital setting.⁵