LAUSR

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 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 applicable for the civil war in Sri Lanka. This conflict spanned from 1983 to 2009 and during this time liberal application of tourniquets was not common. In the author’s experience, documented transfer time of casualties was an average of 335 min. In this unique setting, 80% (103/129) of documented extremity arterial injuries had preservation of the injured limb [6]. Within this cohort, the authors noted two subsets of extremity ballistic wound profiles. The first presented with catastrophic hemorrhage and the second with less severe bleeding and evidence of distal ischemia. The first population should be managed with the expedient application of tourniquets to prevent exsanguination. The second, in contrast, should be managed with hemostatic gauze packing or pressure dressing to preserve collateral distal circulation to allow vascular reconstruction and limb preservation at the definitive medical treatment facility as outlined in Table 1 [6]. A major shortcoming of our research is that killed in action (KIA) data in the Sri Lanka civil war is incomplete and there are no established rates of KIA due to extremity exsanguination. Despite this gap in knowledge, it is established from the Russian data from the Soviet War in * Tamara Jean Worlton [email protected]