Abstract
Background
Tourniquets are crucial for controlling life-threatening hemorrhage and, therefore, in preventing avoidable deaths in both military and civilian settings. Its increased use since the launch of the Stop the Bleed campaign, however, has raised concerns regarding possible complications associated with its application, including limb ischemia and amputation. The objective of this study was to synthesize the existing evidence regarding complications associated with the use of tourniquets for extremity injuries and identify gaps in knowledge to guide future research on this topic.
Methods
A review of the literature between 2016 and 2024 was performed including open access retrospective studies, case series, clinical cases, and systematic reviews that addressed tourniquet use in a civilian or military setting in patients with extremity injuries, following the PRISMA-ScR 2018 checklist. PubMed, ScienceDirect, and Cochrane databases were queried, identifying 1,398 articles on the use of extremity tourniquets in military and civilian contexts, focusing on complications. Of these, 1,343 articles were excluded due to duplication or irrelevance based on the title. From the 55 remaining, 37 were excluded after abstract review for not meeting inclusion criteria. Of the 18 full-text articles reviewed, 10 were excluded due to insufficient data, leaving 8 studies for detailed analysis.
Results
Prolonged application in emergency situations may lead to severe complications, such as nerve injuries, post-tourniquet syndrome and thromboembolic event risks. Nerve palsy has been identified as the most prevalent complication associated with prolonged tourniquet use.
Conclusion
Improved training is essential to help providers accurately assess bleeding severity and apply appropriate interventions, reducing complications and enhancing outcomes. Future research opportunities should consider: (1) prospective interventional randomized controlled studies aiming to compare the use of tourniquets to different methods of hemorrhage control; (2) development and validation of easy-to-use scores predicting complications and the need of amputation in both civilian and military settings including upper and lower extremities, to better guide clinical decisions and future guidelines; (3) development of better ways to teach lay providers to recognize life threatening bleeding; and (4) development of guidelines for timing of tourniquet loosening, removal or conversion.
Keywords: Extremity tourniquet, Tourniquet, Complications, Trauma, Military and civilian setting, Stop the bleed campaign.
Background
Tourniquet use has been critical in preventing avoidable deaths in both military and civilian settings, with its origins tracing back to ancient civilizations. Evidence shows its utilization in Egyptian civilization around 1500 BC [1]. Modern tourniquet application began during the Napoleonic Wars (1803–1815), when French surgeon Jean-Louis Petit employed tourniquets to control battlefield hemorrhages (Fig. 1) [2].
Fig. 1.
The Petit screw tourniquet (personal author, MAFRJ file)
During the American Civil War (1861–1865), tourniquets became essential for wound management [3]. In World War I (1914–1918), advanced tourniquets like the Esmarch type were developed [4]. By World War II (1939–1945), tourniquet use became common, with established protocols for battlefield application [5]. The 1993 Battle of Mogadishu marked a turning point in tourniquet use history, prompting revisions to combat wound treatment protocols and training methods. Currently, the complications resulting from excessive use of tourniquets in the Russo-Ukrainian conflict continue being studied [6]. Considering the increased number of tourniquet applications in the world the idea of building this scoping review of open access studies was born.
Tourniquets rely on the principle of vascular flow occlusion, which means that its correct application will produce limb ischemia distally. When arterial inflow and venous outflow are reestablished reperfusion injury may occur. Increased tourniquet use raises concerns about the risk of complications, including amputation, vascular and nerve injuries, soft tissue damage, and systemic repercussions such as reperfusion injury, post-tourniquet syndrome [7–9] and thromboembolic events [10].
Despite their potential to produce complications, tourniquets have been proven to reduce mortality and minimize complications in military and civilian settings. However, care is required to avoid ischemic injuries and other risks [11]. Evidence suggests complications increase with tighter application over longer time periods [12].
Studies have demonstrated the effectiveness of tourniquets in reducing shock upon arrival at trauma centers, with high rates of successful bleeding control. Amputation rates appear to correlate with the severity of the injury rather than the tourniquet itself, suggesting that injury complexity plays a significant role [13].
In 2013, the American College of Surgeons (ACS) Trauma Committee identified the need to improve hemorrhagic emergency response. The US government launched the “Stop the Bleed” campaign in 2015, promoting immediate intervention in hemorrhagic emergencies. Concerns regarding the proper application of tourniquets in civilian trauma and the potential complications will be discussed in this article [14].
This scoping review aims to identify and synthesize current evidence regarding complications associated with tourniquet application for extremity injuries in both civilian and military populations and to provide guidance regarding knowledge gaps that should be addressed in future research.
Methods
A literature search was performed on PubMed, ScienceDirect and Cochrane databases, using the following algorithm: ((extremity tourniquet) AND (complications) AND (trauma)). Filters were applied to include papers published between the years 2016 and 2024, after The Stop the Bleed awareness campaign was launched in October 2015, incorporating open access review articles, case reports, case series, and original research articles in English.
Following the PRISMA-ScR 2018 guidelines (Fig. 2), the preliminary search included a total of 1,398 articles [15]. Out of these, 1,343 were excluded due to either duplication or title analysis, after which 37 articles were removed after abstract assessment. Studies involving tourniquet application in the operating room or for non-traumatic wound management were excluded. Furthermore, after the full text reading, 10 articles were discarded due to lack of relevant information for our study, pertaining to complications. This process resulted in the selection of 8 articles for inclusion review and data retrieval [15].
Fig. 2.
Prisma-ScR flow diagram displaying the article selection process
Extracted data included: age, gender, mechanism of injury (MVC, GSW, stab wound, fall, other), injury severity scores, transfers, indication for tourniquet use, tourniquet location, type of tourniquet (improvised or commercial), total tourniquet time (in minutes), number of tourniquets placed, person responsible for the tourniquet (EMS, non-EMS or unknown), and complications (Table 1).
Table 1.
Extracted data compilation. TQ - tourniquet; EMS - Emergency medical system; non-EMS - Non emergency medical system; EMT - Emergency medical technician; ISS - Injury Severity Score; NISS - New Injury Severity Score; MESS - Mangled Extremity Severity Score; DVT - Deep venous thrombosis; AKI - Acute kidney injury; NA - not available; NCS - not clearly specified
Results
The selected articles included four retrospective observational cohort studies [14, 16–18]one retrospective observational case series [19]one prospective observational case series [20]one prospective multicenter observational cohort study [13]and one systematic review of 14 retrospective studies [10]. Four reports were from the United States [13, 14, 18, 20]two reports from Europe [17, 19] (Sweden and France), one report from Brazil [10]and one from Australia [16]. These manuscripts were published between 2020 and 2024, covering the period between 2010 and 2022 [10, 13, 14, 16–20].
All cases regarding civilian and military tourniquet applications in extremities were retrieved, encompassing an entire sum of 5,016 patients, ranging from 29 to 57 years-old, mostly of male gender (Fig. 3). Regarding the injury mechanism (Fig. 4), penetrating trauma was the most common, with 2,247 cases, followed by blunt with 1,468 cases, blast with 45 cases, other non-traumatic or non-specific mechanisms were categorized as “other” (bleeding from arterio-venous hemodialysis fistulas, varicose veins, and abscesses) [10, 13, 14, 16–20].
Fig. 3.
Reported gender distribution
Fig. 4.
Mechanism of trauma distribution
Two studies did not utilize any standardized tools for injury evaluation [10, 14]. The most common used scores were the Injury Severity Score (ISS), the New Injury Severity Score (NISS), and the Mangled Extremity Severity Score (MESS) [13, 16–20]. Two of the articles that used ISS reported injury severities between 9 and 17 (moderate and severe injury). The third article that used ISS classified blunt and penetrating trauma separately, with, respectively, a median ISS of 13 (moderate) and of 4 (minor) [16–18]. One study used MESS, reporting for the majority of cases a score over 7, which is predictive of extremity amputation [19]. One paper used NISS, reporting scores between 4 and 32, which translate into minor to very severe injuries. One review used both ISS and MESS to assess injury severity reporting a mean ISS of 10 points (moderate) and a mean MESS of 4.4 (with no prediction of amputation) [13].
Regarding tourniquet placement, the vast majority were applied in the prehospital setting, one paper did not specify the location of placement, and most of the patients required a tourniquet according to their injuries [10]. Most of the tourniquets were applied to the lower extremities, although two studies did not specify the affected extremity [14, 20].
In most studies, commercial tourniquets were predominant over improvised ones and were mainly placed by an emergency medical technician or paramedic. Additionally, in most cases, improvised tourniquets were removed or replaced once the patient had been admitted to the hospital. The total tourniquet time ranged between 40 and 153 min (Fig. 5), with a reportedly higher incidence of complications with prolonged tourniquet use. One hundred and fifty-one patients required more than one tourniquet [10, 13, 14, 16–20].
Fig. 5.
Median tourniquet time (in minutes)
The studies selected for the literature review have documented a wide range of complications, (Fig. 6). Yañez et al. reported that 10.7% of patients (57/533) experienced nerve palsy, with other complications including rhabdomyolysis in 10.6% (17/164), fasciotomy in 9.8% (6/61), pulmonary complications in 7% (13/181), thromboembolic events in 5% (21/419), acute renal failure in 4% (18/455), compartment syndrome in 3.9% (36/917), and cardiac complications in 2.8% (5/181). Bleeding (1.1%) and shock (1%) were noted in a few cases, while one case of tourniquet-related amputation was described because of prolonged tourniquet time [10]. Mikdad et al. divided indicated and non-indicated tourniquet use, with significant variability in complications. Among the identified group with indicated tourniquet application, deep vein thrombosis (DVT) occurred in 40% (2/5), acute kidney injury (AKI) in 20% (1/5), nerve palsy in 20% (1/5), and compartment syndrome in 20% (1/5). Nevertheless, in the non-indicated tourniquet group, nerve palsy was more prevalent, affecting 50% (2/4) of patients, DVT, AKI, and compartment syndrome occurred with less frequency [14]. In Read et al.‘s study, complications included amputation in nine cases, compartment syndrome in one case, limb ischemia with or without reperfusion injury in two cases, and neurological impairment in two cases, one sensory only, and one motor and sensory [16]. Wellme et al. observed total complications in 17 patients (30.1%), including amputations following hospital admission (2), fasciotomies (4), acute kidney injury (1), and nerve damage in 13 cases. Of the 13 patients with nerve damage, 10 had loss of motor function, 11 had loss of sensory function, and 8 had both. Twelve patients recovered nerve function 2 weeks after the initial trauma, and one required 8 months to reach full recovery [17]. Schroll et al. documented initial complications, including 10.7% amputation (103/962), and 1.6% nerve palsy (14/962). In their subgroup analysis, nerve palsy increased to 19.6% (75/383), with other complications such as secondary infections (7.1%), compartment syndrome (6.3%), and ischemia-reperfusion injury (6.3%).13 Bedri et al. revealed amputation in 19.1% (18/94), rhabdomyolysis in 2.2% (2/94), acute kidney injury in 3.3% (3/94), and nerve palsy in 2.2% (2/94).18 Covey et al. found motor and sensory nerve palsy of the common peroneal nerve in one patient with a non-indicated tourniquet [20]. Jazottes et al. reported one patient that was affected by a combination of compartment syndrome, rhabdomyolysis, ischemia-reperfusion syndrome, and acute renal failure. Another experienced musculocutaneous nerve palsy, which was deemed to be caused by direct nerve compression. Additionally, one patient presented with rhabdomyolysis [19].
Fig. 6.
Distribution of reported complications
Discussion
In combat environments, tourniquets have been pivotal in saving lives by quickly stopping arterial bleeding, allowing victims to survive long enough to reach surgical care. Civilian studies have similarly demonstrated their effectiveness in preventing mortality, especially in mass casualty events or traumatic injuries caused by accidents. Advances in tourniquet technology, such as the Combat Application Tourniquet (CAT), have improved ease of use and reliability, even for lay responders. When applied correctly and promptly, tourniquets can can prevent exsanguination, reduce the need for extensive blood transfusions, and improve overall patient outcomes, making them indispensable in trauma care [6]. It remains difficult to attribute complications to the primary injury itself or to secondary injuries potentially caused by tourniquet use.
Evidence suggests that nearly half of tourniquet placements lack appropriate clinical justification, with approximately 27% being misapplied, which may lead to complications such as venous occlusion, compartment syndrome, nerve palsy, and even exacerbated hemorrhage. Additionally, studies report prolonged tourniquet times and improper positioning as potential contributors to these adverse outcomes. While tourniquets are undeniably effective when applied correctly, there might be variability in training and inconsistent adherence to guidelines, underlining the need for standardized education and quality monitoring [14].
Overall, the most used severity score was ISS (Injury Severity Score), which is not applied prospectively, since it requires AIS (Abbreviated Injury Scale) knowledge and training. Although it is indispensable when comparing groups of patients for their injury severity, it is not useful in clinical settings to guide decision making. The next most utilized score was the Mangled Extremity Scoring System (MESS). The MESS score was originally published in 1990 and was formulated to predict limb salvage in lower extremity trauma. It was not developed or validated for the upper extremity, in which it does not perform very well, especially when isolated vascular injury is present. It is also not very accurate for military trauma, in which firearms and explosive injuries are prevalent. Its liberal use might be explained due to its relative simplicity and the inclusion of objective criteria. The development and validation of similar easy-to-use scoring systems that can be applied in routine clinical settings to guide decision making is, therefore, an important topic for future research [21–24].
One of the most severe outcomes is ischemic damage to the limb, which can lead to tissue necrosis and necessitate amputation. Prolonged tourniquet application syndrome (PTAS) can occur and is characterized by metabolic derangements, acute kidney injury, and rhabdomyolysis, especially in scenarios where evacuation to surgical care is delayed. It remains unclear whether it is beneficial (and if so, at which time point) to loosen the tourniquet to permit any level of reperfusion until the patient is transferred to an appropriate medical facility to receive definitive care.
Nerve palsy was the most prevalent complication linked to the use of tourniquets and might be associated with its inappropriate placement. Compartment syndrome are additional complications observed in both military and civilian settings. In military conflicts, particularly during the Russo-Ukrainian war, prolonged evacuation times often exceeding 21 h, have exacerbated these risks, resulting in potentially avoidable amputations and acute kidney injuries due to PTAS [6].
Stevens et al. (2024) recently published a paper that acknowledges the complications arising from the misuse of tourniquets in the Ukraine war, emphasizing that the evacuation time can exceed 6 h because of the lack of control of the air by the Ukrainian forces, interfering with helicopter extraction. It is also alarmingly stated that the appropriate use of tourniquets was found in only 24.6% of cases, resulting in a significant morbidity increase, adding to the fact that many Ukrainian forces lack combat trained medics, resulting in the application of limb tourniquets by the wounded soldier or their comrades. This paper proposed that many of the cases of limb amputation were due to improper placement of tourniquets, unnecessarily proximal positioning, or to leaving the tourniquets on for too long. Some soldiers experienced “prolonged tourniquet syndrome,” which not only led to amputations but, in some cases, necessitated hemodialysis due to acute renal failure from rhabdomyolysis, pushing fatality rates above 30%. In this article it is also assessed the importance of improving training in tourniquet use and raising awareness of the risks of prolonged or improper tourniquet use [25].
The difficulty of distinguishing whether complications arise from the primary injury itself or from the torniquet use (appropriate or not) has been a significant challenge. The severity of the primary injury might be a confounding factor when analyzing outcomes, since more injured extremities are also more likely to require a tourniquet, adding an important bias to these studies. The observational and retrospective nature of most of them also configure biases that make it unlikely to differentiate between the two cases. This highlights the importance of further research into the prevention, diagnosis, evaluation, and management of tourniquet-related complications.
Nevertheless, even when considering the possibility of complications being caused directly by the tourniquet, resulting in either temporary or permanent damage, it is noteworthy that it should not be disregarded as a valuable method of hemorrhage control. When confronted with a threatening extremity injury, the possibility of complications should always be considered but never be the sole reason to discard this life-saving method of hemostasis.
Conclusion
Although tourniquets are effective in controlling extremity hemorrhage, their use is associated with significant complications, particularly when applied for prolonged periods of time or improperly. The most frequently reported complications were nerve palsy, compartment syndrome, rhabdomyolysis, acute kidney injury, and thromboembolic events. Strengthening the training of both healthcare providers and lay responders is essential to reduce complications and improve clinical decision-making.
Future research opportunities should consider: (1) prospective interventional randomized controlled studies aiming to compare the use of tourniquets to different methods of hemorrhage control (regarding both their effectiveness and association to complications); (2) development and validation of easy-to-use scores predicting complications and the need of amputation in both civilian and military settings including upper and lower extremities, to better guide clinical decisions and future guidelines; (3) development of better ways to teach lay providers to recognize life threatening bleeding; and (4) development of guidelines for timing of tourniquet loosening, removal or conversion.
Author contributions
M.A.F.R.J developed the concept and idea; A.X.T, G.C.F, V.R.V, M.M.R performed the search in the literature and paper selection; A.X.T, G.C.F, V.R.V, M.M.R, M.A.F.R.J wrote the paper; M.A.F.RJ, S.M.H, T.M.S reviewed the manuscript and made suggestions for improvement; All authors reviewed the final manuscript.
Funding
This Research did not receive any funding.
Data availability
No datasets were generated or analysed during the current study.
Declarations
Ethics approval and consent to participate
considering the nature of the study, ethics, Consent to Participate, and Consent to Publish declarations ARE not applicable.
Competing interests
None of the authors presented any competing interests related to this study.
Footnotes
Publisher’s note
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Associated Data
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Data Availability Statement
No datasets were generated or analysed during the current study.