Abstract / Summary
Background: Extremity tourniquets are established lifesaving interventions for severe traumatic hemorrhage, but much of the supporting evidence comes from systems in which evacuation and surgical care occur rapidly. Wilderness, rural, disaster, and contemporary battlefield environments may expose patients to substantially longer tourniquet times. This review examined duration-related outcomes of prolonged emergency tourniquet use and the implications for delayed evacuation.
Methods: A rapid review was performed using PubMed/MEDLINE, Google Scholar, backward citation searching, and relevant wilderness and military guidance through Aug 6, 2026. Human trauma studies reporting tourniquet duration and clinical outcomes were eligible. Primary prolonged-use cohorts were included in an exploratory random-effects meta-analysis of amputation proportion. Prolonged use was defined as more than 120 minutes for the primary synthesis; a sensitivity analysis was restricted to cohorts with tourniquet duration greater than 4 hours.
Results: Three primary prolonged-use cohorts provided extractable patient-level amputation data (105 patients). The pooled amputation proportion was 35.3% (95% CI, 26.8%-44.9%; I2=0%). Restriction to the two cohorts with tourniquet duration greater than 4 hours produced a similar estimate of 34.9% (95% CI, 25.8%-45.2%). Prolonged cohorts also reported substantial rates of nerve injury, infection, acute kidney injury, rhabdomyolysis, dialysis, and compartment syndrome. In contrast, military and civilian studies dominated by shorter application times reported low tourniquet-attributable morbidity and substantial hemorrhage-control benefit.
Conclusions: Emergency tourniquets remain appropriate for life-threatening extremity hemorrhage, but the risk profile changes as evacuation time lengthens. The available evidence supports aggressive reassessment and, when trained personnel and appropriate conditions are present, timely conversion to another effective hemorrhage-control method before ischemic exposure becomes prolonged. Beyond approximately 6 hours, reperfusion and release become higher-risk decisions that should occur with advanced monitoring and resuscitative capability whenever possible. The certainty of evidence is low because prolonged-use studies are small, retrospective, and strongly confounded by injury severity.