Is there a role for tourniquets or amputation to mitigate the risk of crush syndrome in patients with crush injury?
Date First Published:
July 17, 2026
Last Updated:
July 17, 2026
Report by:
Samuel Wilkins, Paramedic Clinical Team Mentor (West Midland Ambulance Service)
Search checked by:
Leo Wood, Emergency Medicine Trainee
Three-Part Question:
In adults with suspected crush injury does the use of tourniquets or amputation improve morbidity or mortality?
Clinical Scenario:
You are working overnight as a registrar in a Major Trauma Centre. A patient is builder is brought in with a significant crush injuries to his legs after being run over by a digger. Due to environmental challenges he remained trapped beneath the digger for a prolonged period whilst the Emergency Services freed him. Following hand over, the critical care paramedic advises that the team had had a discussion at the scene as to whether to apply a tourniquet or not and she asks if you know of any evidence for or against its use in the management of patients with crush injuries to the limbs.
Search Strategy:
For full search strategy please see:
http://tiny.cc/CrushBestBETsLitSearch
http://tiny.cc/CrushBestBETsLitSearch
Search Details:
A search was conducted on 2nd and 6th of December 2022 and repeated 19th November 2024 to include any articles published in the intervening period. Databases searched:
Medline on EBSCO platform
CINAHL on EBSCO platform
EMBASE on Ovid platform
Medline on EBSCO platform
CINAHL on EBSCO platform
EMBASE on Ovid platform
Outcome:
33 articles identified for review
No studies identified comparing treatments
3 case reports summarised below
No studies identified comparing treatments
3 case reports summarised below
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Management of Severe Crush Injuries in Austere Environments: A Special Operations Perspective Anderson JL, Cole M, Pannell D 31 May 2022 USA | Single case study of Special Operations Force Sniper who sustained crush injury. | Retrospective case review and proposed assessment and management | No specific outcome mentioned however guidelines discussed are to improve casualty survival to and beyond definitive care. | A single case study of a special forces sniper who sustained a crush injury. | Single case study of 1 person, in an extreme environment. Limited generalisability to civilian population. Did not follow case through, only proposed management options. |
| A general discussion of management strategies proposed use of arterial tourniquets for pinned limbs prior to extrication to prevent reperfusion and systemic insult due to hyperkalaemia and release of myoglobin. The authors propose these secondary effects would be better managed in a hospital setting. | |||||
| Bathroom Entrapment Leading to Cardiac Arrest From Crush Syndrome Whiffin et al. January-February 2019 USA | Single case study of a 76yr old woman who sustained a crush injury following a fall. | Retrospective case review and proposed management strategies. | Patient died in hospital on day of admission. | A single case study of a patient who developed crush syndrome from a trapped upper limb following a fall and trapping her arm in a hand rail. Upon release by EMS, she suffered a hyperkalaemic cardiac arrest. No tourniquet was used. | Single case study No tourniquet actually used, authors just speculating retrospectively as to possible management options. |
| The article hypothesised as to the value of tourniquet prior to release of the mechanism in containment of toxins, until the patient reaches definitive care where these secondary effects may be managed. This raised the question as to whether a tourniquet could have prevented this patient’s cardiac arrest in the pre-hospital setting. | |||||
| Immediate Lower Extremity Tourniquet Application to Delay Onset of Reperfusion Injury after Prolonged Crush Injury. Schwartz DS, Weisner Z, Badar J May 2015 USA | Single case study of a 30yr old male crushed by heavy machinery. | Retrospective case review and review of literature. | Patient made full recovery following discharge. No specific outcome measures discussed. | Case study of a patient crushed by heavy machinery. Bilateral tourniquets applied to legs to prevent reperfusion, which authors hypothesis facilitated safe extrication to hospital. Upon release of tourniquets in hospital patient experienced sudden cardiac dysrhythmia, which was successfully treated in the higher care centre. Patient made a full recovery, with full function of both lower limbs. The authors propose the ensuing dysrhythmia would have been less well managed in the pre-hospital setting. | Single case study Difficult to assess degree of injury, given patient made full recovery |
| Article proposes that, due to limited resources in the pre-hospital setting, the containment of toxins in ischaemic limbs improves haemodynamic and cardiac membrane stability until definitive care. Any risks associated with tourniquet application such as necrosis and nerve palsies are unfounded and outweighed by benefits. |
Author Commentary:
Research into the use of arterial tourniquets for the management of crush syndrome is limited to just a handful of individual case studies as discussed above. Despite evidence being predominantly anecdotal, it would seem from these limited cases that patients have the potential to rapidly deteriorate upon release due to hyperkalaemia associated with toxic reperfusion. Therefore, it would make hypothetical sense to contain said toxins within the crushed limb, until the secondary effects of the release of these toxins into the systemic circulation can be better managed in a hospital setting. There is some additional supporting evidence from Popov and Yakirevich, (2018) who conducted a retrospective case series on 38 casualties who suffered crush syndrome through large earthquakes. All 38 casualties had the same preventive treatment including tourniquet application prior to release to maintain stable haemodynamics. All patients survived with good outcomes; however, the study was not directly looking at tourniquets but a whole package of interventions, so it is impossible to establish cause and effect of multiple variables. Nevertheless, tourniquets are being used in this manner with minimal deleterious effects.
The side effects associated with tourniquet use are likely a significant factor as to why this course of management is not routine in practice today. For example, Sever and Vanholder (2012) state that tourniquets should only be used for catastrophic haemorrhage control and not as an adjunct to crush syndrome due to risk of nerve palsies and necrosis. The above articles propose that these side effects are based on old evidence and that the side effect profile of tourniquet use may be overstated. A patient who has suffered a crush injury with prolonged extrication will already have some degree of ischaemia and the potential benefits of reducing adverse outcome risks, including cardiac arrest upon release are outweighed by any potential threat to limb. Authors of the above studies propose the use of tourniquets may be of value in the prehospital management of crush injuries to limbs as part of wider management strategy especially in areas with prolonged transfer and extrication times. Further research, ideally in the form of randomised control trials, is required to fully evaluate the risk-benefit of tourniquet use in this setting. However due to the small incidence of crush injuries and crush syndrome particularly in developed countries, the feasibility of such studies would be challenging.
No studies investigated amputation as a prophylactic measure to prevent reperfusion and subsequent systemic toxin release in the pre-hospital setting. Sever and Vanholder (2012) stated that that amputations should not be performed to prevent crush syndrome, only as a last resort if the limb is not salvageable or is required for a rapid extrication if the patient’s safety is at imminent risk. Nevertheless, they state that should amputation be indicated, it is best performed as soon as possible following injury. There is an array of literature discussing amputations in association with crush syndrome in the hospital phase, but this is usually secondary to infection or severe necrosis. While again there is a hypothetical benefit to removing the limb with toxins contained to prevent reperfusion, this effect could be similarly achieved with use of a tourniquet, and the limb remains salvageable, as demonstrated in the case above.
The side effects associated with tourniquet use are likely a significant factor as to why this course of management is not routine in practice today. For example, Sever and Vanholder (2012) state that tourniquets should only be used for catastrophic haemorrhage control and not as an adjunct to crush syndrome due to risk of nerve palsies and necrosis. The above articles propose that these side effects are based on old evidence and that the side effect profile of tourniquet use may be overstated. A patient who has suffered a crush injury with prolonged extrication will already have some degree of ischaemia and the potential benefits of reducing adverse outcome risks, including cardiac arrest upon release are outweighed by any potential threat to limb. Authors of the above studies propose the use of tourniquets may be of value in the prehospital management of crush injuries to limbs as part of wider management strategy especially in areas with prolonged transfer and extrication times. Further research, ideally in the form of randomised control trials, is required to fully evaluate the risk-benefit of tourniquet use in this setting. However due to the small incidence of crush injuries and crush syndrome particularly in developed countries, the feasibility of such studies would be challenging.
No studies investigated amputation as a prophylactic measure to prevent reperfusion and subsequent systemic toxin release in the pre-hospital setting. Sever and Vanholder (2012) stated that that amputations should not be performed to prevent crush syndrome, only as a last resort if the limb is not salvageable or is required for a rapid extrication if the patient’s safety is at imminent risk. Nevertheless, they state that should amputation be indicated, it is best performed as soon as possible following injury. There is an array of literature discussing amputations in association with crush syndrome in the hospital phase, but this is usually secondary to infection or severe necrosis. While again there is a hypothetical benefit to removing the limb with toxins contained to prevent reperfusion, this effect could be similarly achieved with use of a tourniquet, and the limb remains salvageable, as demonstrated in the case above.
Bottom Line:
The are no published articles collecting objective data to support or refute the use of tourniquets to delay reperfusion and the subsequent adverse effects of this. The only available data are individual case reports. As such, the use of tourniqets in the prehospital management of patients suffering a crush injury cannot be routinely recommended. The collection of objective data is required to facilitate further understanding of the risk-benefit of tourniquets in the crush injury patient and subsequently discussion of their potential use.
Level of Evidence:
Level 3: Small numbers of small studies or great heterogeneity or very different population
References:
- Anderson JL, Cole M, Pannell D. Management of Severe Crush Injuries in Austere Environments: A Special Operations Perspective
- Whiffin et al.. Bathroom Entrapment Leading to Cardiac Arrest From Crush Syndrome
- Schwartz DS, Weisner Z, Badar J. Immediate Lower Extremity Tourniquet Application to Delay Onset of Reperfusion Injury after Prolonged Crush Injury.