Extremity hemorrhage control in urban warfare: A retrospective analysis of the Swords of Iron War.
The journal of trauma and acute care surgery · 2026-03-20 · Registry study
Abstract
BACKGROUND: Tourniquets are a life-saving intervention for controlling life-threatening extremity hemorrhage. However, prolonged tourniquet application can lead to significant morbidity. This study aimed to assess tourniquet usage among military personnel in modern urban warfare and evaluate the proportion of cases potentially suitable for tourniquet conversion. METHODS: This was a retrospective cohort analysis of all Israeli military casualties hospitalized between October 27, 2023, and November 30, 2024, with war-related injuries during the Hamas-Israel War. Data were obtained from the prehospital trauma registry and the Israel National Trauma Registry. The study population comprised hospitalized soldiers who were treated with tourniquets during the prehospital phase. The primary outcome was "nonconvertible tourniquets," defined by the presence of vascular injury and/or the need for early limb amputation. A logistic regression was applied to identify injury-related factors independently associated with nonconvertible tourniquets. RESULTS: Of 2,127 hospitalized patients, 589 (27.7%) were treated with prehospital tourniquets. Vascular injuries were diagnosed in 106 patients (18.0%), and 54 patients (9.2%) required early limb amputation. In total, 144 of 589 casualties (24.4%) had injuries that prevented prehospital tourniquet conversion. Factors associated with nonconvertible tourniquets included the presence of hemorrhagic shock (adjusted odds ratio=3.79, 95% confidence interval=2.44-5.92, p <0.001) and tourniquet application by an Advanced Trauma Life Support (ATLS) provider (adjusted odds ratio=1.55, 95% confidence interval=1.03-2.32, p =0.035). CONCLUSIONS: Most tourniquets applied in tactical situations can potentially be converted to other hemorrhage control methods. However, particular caution is warranted in patients presenting with hemorrhagic shock or when tourniquets are applied by ATLS providers. Prehospital trauma training programs should emphasize not only the rapid application of tourniquets but also the effective identification and conversion of medically unnecessary tourniquets to minimize limb ischemia and associated complications. ( J Trauma Acute Care Surg . 2026;101: S36-S43. Copyright © 2026 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Association for the Surgery of Trauma.). LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.