Page 108 - JSOM Spring 2026

Standardizing Tourniquet Reassessment

and Conversion Across TCCC Tiers

TCCC Guidelines Proposed Change 25-2

Eric J. Koch, DO *; Michael Andersen, MD ; George A. Barbee, DSc, EM PA-C ;
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Antonio Boyd, Submarine IDC ; Cyril Clayton, EMT-P ; Christopher W. Hewitt, DO ;
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John C. Maitha, MPAS, APA, PA-C ; Michael A. Remley, NRP, ATP ;
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Alexandre Nguyen, MD ; Joseph Kaleiohi, PA ; Harold Montgomery, ATP ;
Travis Deaton, MD ; Frank Butler, MD ; Jennifer Gurney, MD 14
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ABSTRACT
Operational experience from the Russo-Ukrainian War re- 1. Enable timely and structured tourniquet reassessment by
vealed frequent use of tourniquets that were not medically all servicemembers, ensuring consistency and safety in ca-
indicated and an increase in ischemic complications from pro- sualty care environments.
longed tourniquet application as a consequence of extended 2. Clarify and standardize terminology—introducing reposi-
evacuation times. In response to this, the Committee on Tac- tioning and removing replacement—to improve communi-
tical Combat Casualty Care (CoTCCC) convened a working cation, instruction, execution, and documentation across
group to evaluate whether tourniquet reassessment and con- all TCCC tier levels: Tier 1 – All Service Members (ASM),
version practices should extend to the All Service Member Tier 2 – Combat LifeSavers (CLSs), Tier 3 – Combat
(ASM) level. With input from NATO and partner nations, the Medic/Corpsman (CMC), and Tier 4 – Combat Paramedic/
Working Group developed a standardized, time-based algo- Provider (CPP).
rithm that provides plain language guidance for reassessment, 3. Align TCCC guidance with NATO and partner nation rec-
repositioning, and conversion. The proposed change replaces ommendations to enhance interoperability and ensure shared
the term replacement with repositioning, affirms a reassess- terminology and decision logic for nonmedical personnel.
ment window within 2 hours for nonmedical personnel, and 4. Support the Department of War’s broader effort to syn-
limits conversion beyond 2 hours to medical personnel. These chronize TCCC guidelines, curricula, and knowledge prod-
updates will expand lifesaving capability to nonmedical re- ucts through regular comprehensive review.
sponders, reduce preventable morbidity and mortality from
tourniquet use, and align TCCC principles with current oper- Background
ational realities.
Tourniquet use has long been a cornerstone of TCCC and was
Keywords: Tactical Combat Casualty Care; TCCC; Tourniquet instrumental in reducing preventable deaths from extremity
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Conversion; All Service Member; Tier 1; Prolonged hemorrhage during the conflicts in Iraq and Afghanistan.
Casualty Care The operational context within those theaters included rapid
evacuation that minimized complications from tourniquet use.
Additionally, widespread supporting policy, training and tour-
niquet fielding led to near elimination of deaths from extremity
Proximate Cause for This Proposed Change
bleeding. However, emerging operational variables and envi-
Incorporate operational lessons and best practices identified ronments have presented new challenges that necessitate recon-
from recent conflicts, including the Russo-Ukrainian War, where sideration of tourniquet reassessment and conversion practices.
prolonged tourniquet application times caused by lengthy de-
lays to evacuation, ranging from several hours to several days, Data from the Russo-Ukrainian War demonstrate a high in-
have caused excess morbidity and mortality among casualties. cidence of tourniquet use when not medically indicated.
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Lengthy tourniquet times have produced a large number of Additionally, delayed evacuation (driven by denied air supe-
casualties with prolonged tourniquet application syndrome riority, extended lines of communication, and limited medical
(PTAS), which includes both compartment syndrome and am- personnel at the point of injury) has led to prolonged tourni-
putations caused by tourniquet ischemia as well as metabolic quet application times. These factors have contributed to a
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complications, such as acidosis, hyperkalemia, acute kidney marked increase in ischemic complications, including poten-
injury, and death. tially preventable amputations, renal failure, and metabolic
*Correspondence to koch.eric.j@gmail.com
Author affiliations can be found on page 112.

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