Injury 51 (2020) 1210–1215 Contents lists available at ScienceDirect Injury journal homepage: www.elsevier.com/locate/injury The effects of military-wide introduction of advanced tourniquets in the Israel Defense Forces Avishai M. Tsur a,1,∗ , Roy Nadler a,b,1 , Avi Benov a,c , Elon Glassberg a,c,d , Maya Siman-Tov e , Irina Radomislensky e , Moran Bodas e , Kobi Peleg e , Patrick Thompson f , Noam Fink a , Jacob Chen a a Israel Defense Forces, Medical Corps, Tel Hashomer, Ramat Gan, Israel b Department of General Surgery and Transplantation-Surgery B, Chaim Sheba Medical Center, Tel Hashomer, Affiliated to Sackler School of Medicine, Tel Aviv, Israel c The Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel d The Uniformed Services University of the Health Sciences, Bethesda, MD, United States e Israel National Center for Trauma and Emergency Medicine Research, Sheba Medical Center, Gertner Institute for Epidemiology and Public Health Policy Research, Tel-Hashomer, 52621, Ramat Gan, Israel f Combat casualty care trainer a r t i c l e i n f o Article history: Accepted 23 January 2020 Keywords: Tourniquets Haemorrhage Shock Haemorrhagic Extremities Wounds and injuries a b s t r a c t Background: Early application of tourniquets has reduced injury death rates. At the end of 2013, the Israel Defense Forces Medical Corps completed a military-wide introduction of the Combat Application Tourni- quet as the standard-issued tourniquet. The accompanying clinical practice guideline encouraged combat soldiers and medical teams towards a liberal use of tourniquets for extremity injuries, even when in doubt. Objectives: This study aimed to assess the effects of the wide introduction of advanced tourniquets on the rate of tourniquet applications, the type of tourniquet applied, and the differences in hospitalisation outcomes following the introduction. Methods: The study population was composed of hospitalised military casualties with an extremity in- jury treated by military medical teams between 2006 and 2015. Prehospital data were extracted from the Israel Defense Forces Trauma Registry and matched to corresponding hospital data from the Israeli National Trauma Registry. Two periods were compared: 2006–2013 "pre-intervention period" and 2014– 2015 "post-intervention period". Results: A total of 1,578 casualties were recorded during the study period. Of these, 320 (20.3%) occurred between 2014–2015. Characteristics of casualties in the post-intervention period were similar to those in the pre-intervention period including the rate of traumatic amputations (2.5% vs 2.2%, p = 0.93) and Injury Severity Score of 16 or above (12.8% vs 14.9%, p = 0.40). The rate of tourniquet application was more than four-fold in the post-intervention period compared to the pre-intervention period (22.8% vs 5.5%, p < 0.001). Nevertheless, rates of in-hospital amputations (1.6% vs 1.6%, p = 1.00) and death (0.9% vs 1.3%, p = 0.53) were similar in the two periods. Conclusion: Following the IDF military-wide introduction of advanced tourniquets, the tourniquet appli- cation rate rose sharply, the use of old tourniquets ceased over time, and in-hospital amputation rate did not increase. These findings suggest that the awareness for haemorrhage control using advanced tourni- quets rose. © 2020 Elsevier Ltd. All rights reserved. ∗ Corresponding author at: Keren Hayesod 9/25 Givat Shmuel Israel. E-mail addresses: avishaitsur@gmail.com (A.M. Tsur), irinar@gertner.health.gov.il (I. Radomislensky), pat@atem.org.uk (P. Thompson), noamfink@bezeqint.net (N. Fink). 1 AMT and RN contributed equally. Background Early application of tourniquets has reduced death rates [1]. Therefore, medical organisations advise that both medical and non- medical personnel be competent in tourniquet use [2]. https://doi.org/10.1016/j.injury.2020.01.033 0020-1383/© 2020 Elsevier Ltd. All rights reserved.