Page 61 - JSOM Winter 2025

Tourniquet Management Beyond the Golden Hour

A Call for Doctrinal Change in TCCC

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Max Beerbaum, MS *; James White, MS, NRP, FP-C, CCP-C, TP-C, WP-C ;
Jonathan Henderson, MD 3

ABSTRACT
Tourniquets have proven lifesaving in modern combat, partic- during the later years (2008–2017). Due to multidomain supe-
ularly during the Global War on Terror, where rapid evacua- riority, transport within the “Golden Hour” became a reality
tion often mitigated the risks of prolonged and non-medically for 75% of casualties. These two aspects of American combat
indicated application. However, in future large scale combat medicine are estimated to have saved nearly 750 Soldiers’ lives
operations (LSCOs), prolonged field care and delayed evacua- between 2001 and 2017. However, when surgical interven-
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tion will be common. Without timely reassessment, medically tion is not readily available to provide definitive treatment to
unnecessary or ineffective tourniquets may lead to avoidable extremity injuries, there is increased morbidity and mortality
morbidity, including limb loss, rhabdomyolysis, and compart- from both medically indicated tourniquets and tourniquets not
ment syndrome. Data from U.S. and Ukrainian surgical teams optimized or converted early upon reassessment during the
reveal tourniquet reassessment, conversion, and optimization Tactical Field Care (TFC) phase of TCCC. Tourniquet opti-
are not being practiced in the field to effectively control hem- mization (TO) describes both reassessment of the initial inter-
orrhage. Despite this, current TCCC doctrine lacks sufficient vention and improved secondary tourniquet placement from
emphasis on tourniquet reassessment, conversion (TC), and “high and tight” to 2–3 inches proximal of the injury. Tourni-
optimization (TO)—especially among non-medical personnel. quet conversion (TC) describes the skill of using a hemostatic
This paper calls for doctrinal change to classify tourniquet re- or pressure dressing to control bleeding, allowing for removal
assessment, TC, and TO as Tier 1 (All Service Member) skills. or loosening of the initial tourniquet. Reassessment, TC, and
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We recommend updating TCCC training, emphasizing reas- TO are critical skills needed on the modern battlefield to re-
sessment within 2 hours of application, incorporating TC/TO duce morbidity and mortality in large scale combat operations
into training lanes, and revising the DD1380 TCCC card to (LSCOs) where transport times exceed the Golden Hour.
document these interventions. Preparing for LSCOs requires
shifting from the “fire-and-forget” mindset. Equipping all Rapid transport times in Iraq and Afghanistan have created
service members with the skills to reassess and manage tour- a troublesome mindset in Soldiers that tourniquets are a “fire
niquets appropriately can reduce preventable morbidity and and forget” intervention with a minimal need for reassess-
preserve lives in prolonged care environments without com- ment. A 2011 review by a U.S. forward surgical team (FST) of
promising the proven benefits of rapid hemorrhage control. 79 tourniquet applications found only 14 arterial injuries with
five effective arterial tourniquets; 83% of tourniquets had pal-
Keywords: military medicine; medicine; trauma; tourniquets; pable distal pulses, and 82% were not medically indicated.
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TCCC; LSCO The 2011 TCCC guidelines for circulation during TFC in-
structs to “reassess prior tourniquet application.” These tour-
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niquets were all placed by Special Operations combat medics,
flight medics, combat medics, and general surgeons, suggesting
Military Tourniquet Use in 21st Century
a lack of emphasis on tourniquet reassessment after initial ap-
Between 2001 and 2011 peripheral-extremity hemorrhage ac- plication, even by highly trained medical personnel. In 2016,
counted for 12.2% of potentially preventable combat deaths, Dr. Yatsun, a Ukrainian vascular FST surgeon, observed that
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prompting the Joint Trauma System (JTS) to emphasize tour- 75% of 102 tourniquets assessed were not medically indicated,
niquet application as a lifesaving intervention. As a result, mirroring the 2011 U.S. FST data. 6
tourniquet application increased over time in both Afghanistan
and Iraq. In Afghanistan, tourniquet usage rose from 13.8% Regardless of medical necessity, tourniquets left in place for
of all patients during the early years of the war (2001–2006) over 3 hours increase the chance of tourniquet-related mor-
to 34.1% in the later period (2009–2017). In Iraq, tourniquet bidity. Muscles ischemic for 1–3 hours can be re-perfused, but
use increased from 2.3% in the early period (2003) to 18.5% 40%–50% of limbs cannot be after 5 hours. Acid-base balance

*Correspondence to maxbeerbaum@gmail.com
1 2nd Lt Max Beerbaum is affiliated with the School of Medicine, Uniformed Services University of the Health Sciences (USUHS), Bethesda, MD.
2 MAJ James White is affiliated with the School of Medicine, Duke University, Durham, NC. Lt Col Jonathan Henderson is affiliated with the
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Department of Military & Emergency Medicine, USUHS. Bethesda, MD.
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