LAUSR

To the Editor: We read with interest the study by Heldenberg et al. presenting the impact of vascular trauma (VT) and nonvascular trauma on the prognosis of civilian casualties of improvised explosive devices explosions. In this 5-year retrospective analysis of the Israeli Trauma Registry, 1,261 patients were injured by terrorist explosions, with VT diagnosed among 109 (8.6%) of the patients. Lower-extremity VT was the most prevalent (36.7%, 40/109) injury, whereas upperextremity VT concerned 20 (18.35%) of the 109 VT patients. Finally, the mortality rate was significantly higher among VT compared with patients with nonvascular trauma (22.9% vs 4.9%, respectively, p G 0.0001), also demonstrated bymultivariate regression analysis, after adjusting for age, sex, and facility (odds ratio, 2.9 [95.5% confidence interval, 1.51Y5.72]). In their article, the authors discussed the differences observed in VT between the unprotected civilians and the armed troops during Operation Iraqi Freedom and Operation Enduring Freedom, advocating that ‘‘the different primary settingVwell-protected soldiers as compared with nonprotected civiliansVrenders the civilians much more vulnerable to terror attacks.’’ Wewould like to go further into the discussion because the prehospital use of tactical tourniquet (TK) for management of limb injuries could be another major prognostic difference between these two populations. Indeed, bleeding prevention and control by tourniquet use by out-ofhospital caregivers are a major breakthrough in military medicine of current wars. Tourniquet use reliably stops bleeding from limb wounds and prevents mortality in prehospital settings; moreover, brief tourniquet use appears to be safe. These two lessons have become so evident that civilian emergency medical systems have begun using them, albeit unevenly. A recent systematic nationwide assessment of emergency medical services prehospital extremity exsanguination control protocols hypothesized that most states within the United States lack a detailed uniform extremity exsanguination protocol that includes tourniquet use. It has revealed considerable discrepancy and frequent deficiencies in extremity bleeding control recommendations. Only 13 statewide protocols (31%) referred to ‘‘commercial’’ or ‘‘approved’’ tourniquets, and only three (7%) recommended a particular commercial device. However, in a retrospective review of emergency medical services and hospital records from a large metropolitan county (Mecklenburg County, North Carolina), the majority of TKs were appropriately applied to civilians who had vascular injuries or required operative intervention for hemorrhage control (15/22 tourniquet ‘‘eligible’’ patients). Regardless of the circumstances of tourniquet application, there were no adverse sequelae related to emergency tourniquet use among any patient who received a tourniquet in this study. The liberal use of TKs in the civilian setting posed a much lower risk for adverse sequelae than the risk of fatal exsanguination in the setting of uncontrolled extremity hemorrhage. Actually, in another retrospective review (2007Y2014) of 87 adult patients admitted to the Los Angeles County + University of Southern California Hospital with an extremity injury requiring tourniquet application, a total of 15 amputations were performed. Fourteen amputations (93.3%) occurred at the scene or were directly attributed to the extent of tissue damage. In the remaining patient, the tourniquet was lifesaving but likely contributed to limb loss. Seven patients sustained 13 other complications; however, none was directly attributed to tourniquet use. Tourniquet use was associated with a low complication rate and high potential for benefit, supporting the aggressive use of this potentially lifesaving intervention. To conclude, we believe that tourniquet use could be of interest in management of VT civilian casualties of terror-related explosions. Moreover, we would like to know if Heldenberg et al. could provide further details regarding its use in their study of 109 VT victims of 1,261 explosion civilian casualties and the development of dedicated prehospital protocols for the management of VT in their institution, including or not the use of tourniquet.