Purpose: Tourniquets are life-saving in severe extremity haemorrhage, but prolonged application raises concerns regarding limb ischaemia. Western Australia’s vast geography and single Level 1 trauma centre may result in extended prehospital tourniquet times. The purpose of this study was to examine patterns of prehospital tourniquet use, duration, and outcomes in major trauma patients. Methodology: A retrospective registry and chart review was performed of major trauma patients (ISS >12) with prehospital tourniquet application admitted to Royal Perth Hospital between 2013 and 2022. Demographics, injury characteristics, tourniquet duration (where documented), interventions, amputation, and mortality were analysed, including comparison between metropolitan and rural presentations. Results: Seventy-two patients (79 limbs) were included (85% male; mean age 37.4 years; mean ISS 25.8). Injuries occurred in metropolitan areas in 71% and rural areas in 29%; 35% were transported by air. Blunt trauma predominated (78%). Tourniquet duration was documented in 40 limbs, with a mean time of 3 h 25 min. Rural patients had significantly longer tourniquet times than metropolitan patients (4 h 28 min vs 2 h 40 min; p=0.044). Open fractures occurred in 77% of limbs. Amputation occurred in 43%, likely reflecting injury severity. Overall mortality was 20.8%, with haemorrhage contributing to over half of deaths. Conclusion: In this civilian cohort, prehospital tourniquet durations, particularly in rural Western Australia, were substantially longer than reported elsewhere. Despite prolonged application and high injury severity, outcomes are comparable with international experience, supporting tourniquet use in geographically dispersed trauma systems.