DOD JTS Guidelines on Tourniquet Application Duration
According to the DOD Joint Trauma System guidelines, tourniquets should be left in place until surgical control of bleeding is achieved; however, this time span should be kept as short as possible, with some publications suggesting a maximum application time of two hours, though military reports document cases where tourniquets remained in place for up to six hours with survival of the extremity. 1
Recommended Duration and Considerations
- Tourniquets should be left in place until surgical control of bleeding is achieved 1
- The time to removal should be shortened as much as possible 1
- Some publications suggest a maximum application time of two hours 1, 2
- Military reports document cases where tourniquets remained in place for up to six hours with survival of the extremity 1
Potential Complications of Prolonged Tourniquet Use
- Improper or prolonged placement can lead to complications such as:
- However, these adverse effects are relatively rare 1
Special Considerations for Extended Transport Times
- For EMS systems operating in rural, frontier, or austere environments with transport times exceeding 2 hours, tourniquet conversion guidelines may be considered 3
- In cases requiring prolonged tourniquet use, some evidence suggests removing the tourniquet every 2 hours to assess bleeding; if bleeding has stopped, replace with a pressure bandage to minimize tissue damage 2
- When reconstruction of main arteries is needed after prolonged tourniquet use, a longer than usual anastomosis line is advised 4
Recent Evidence on Tourniquet Duration
- A recent study of civilian prehospital tourniquet use found a median application time of 43 minutes, with successful hemorrhage control in 98% of cases 5
- The serious complication rate in this study was 7.7%, with complications including temporary paresthesia, ecchymosis, need for fasciotomy, and compression nerve injury 5
- Despite concerns about prolonged application, case reports exist of successful limb salvage even after extended tourniquet times of up to 16 hours 6
Clinical Application
- Tourniquets should be properly applied to completely control hemorrhage 1
- Commercially available tourniquets (such as CAT, SOFTT, EMT) are superior to improvised ones 1
- In civilian settings with short transport times, the risk of complications from tourniquet use is generally low compared to the benefit of hemorrhage control 5
- For patients with significant blood loss, the duration of ischemia should be calculated from the time of injury rather than from the time the tourniquet was applied 4