Page 109 - JSOM Spring 2026

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derangements related to reperfusion injury. As a result of con- The term replacement should be eliminated from the TCCC
strained casualty movement on Ukrainian battlefields, many lexicon. These simplified definitions reduce confusion during
casualties are managed primarily by nonmedical responders instruction and enhance cross-tier communication. Adopting
during point of injury care, underscoring the need to expand this standardized terminology is a foundational step toward
reassessment capabilities to the ASM level. improving comprehension and consistent application across
TCCC provider tiers.
Simultaneously, attacks on healthcare infrastructure have
shifted greater responsibility for casualty management to first Should tourniquet reassessment and conversion extend
6,7
responders with limited medical training. Early in the con- to the All Service Member (ASM) level?
flict, Ukrainian military medical authorities recognized wide- The Working Group determined that tourniquet reassessment
spread overuse of tourniquets and the absence of standardized and conversion should extend to the ASM level within clearly
reassessment practices. Ukrainian national leaders issued guid- defined boundaries. This determination was based on the op-
ance promoting simplified, time-based tourniquet reassess- erational reality that ASMs are increasingly responsible for
8
ment and conversion procedures for nonmedical personnel. casualty care in environments characterized by delayed evacu-
These efforts demonstrated that structured, straightforward ation and limited access to medical personnel, rather than on
decision tools could be safely applied outside of medical chan- an assumption of medical equivalence with trained providers.
nels to reduce potentially preventable complications. While both repositioning and conversion carry inherent risk,
the potential benefits of timely reassessment (reducing prevent-
Building upon these field observations, a NATO Science and able complications, restoring perfusion when appropriate, and
Technology Organization (STO) Human Factors and Medicine preserving limb viability) outweigh those risks when guided by
(HFM) Specialist Team on Reducing Tourniquet Complications a structured, time-based algorithm.
developed and validated a standardized, evidence-informed al-
gorithm to formalize these principles across NATO and part- Empowering ASMs to reassess their own or another casual-
ner nations. Within the U.S. Military, tourniquet reassessment ty’s tourniquet is essential for current and future operational
9
and conversion training under TCCC were initially reserved environments characterized by delayed evacuation, denied air
for medical personnel (Tiers 3 and 4). However, based on early superiority, and limited access to medical personnel. If an in-
operational insights from Ukraine, this training was expanded dividual has the capability to apply a tourniquet, they should
in 2023 to include CLS (Tier 2) personnel, reflecting growing also have the competence and capacity to reassess that inter-
recognition that early reassessment by trained nonmedical re- vention as soon as it is tactically feasible.
sponders can mitigate preventable complications when medi-
cal evacuation is delayed. 10 Expanding reassessment authority to the ASM level there-
fore enhances casualty survivability, promotes responder au-
The TCCC Tourniquet Reassessment Working Group was tonomy, and aligns with the broader TCCC principle that all
subsequently established to evaluate how these principles servicemembers are responsible for sustaining life until high-
could be operationalized at the ASM level within the existing er-level care is available.
TCCC framework. Deliberations focused on adapting medi-
cal procedures for nonmedical users, clarifying terminology, What are the appropriate time cutoffs for conversion
determining time thresholds and contraindications for each across TCCC tiers?
tier, and aligning recommendations with NATO guidance and The duration of tourniquet application remains the principal
available field data. The Working Group’s objective was to determinant of ischemic and reperfusion complications. A con-
determine how to operationalize tourniquet reassessment and sistent body of evidence from both military and civilian stud-
conversion for nonmedical users within existing TCCC prin- ies supports a strict reassessment window within the first 2
ciples while maintaining simplicity, safety, and interoperabil- hours of application. 10–14 Weinrauch’s Tourniquet Traffic Light
ity across tiers. model further reinforces this time-dependent risk, categorizing
less than 2 hours as “safe,” 2–6 hours as “cautionary,” and
beyond 6 hours as “critical.” 15
Discussion
Language Simplification Accordingly, the Working Group recommends:
The Working Group identified that complex or inconsistent
terminology surrounding tourniquet reassessment has cre- • All tiers of TCCC responders on the battlefield should per-
ated barriers for nonmedical personnel learning and applying form a reassessment of applied tourniquets as soon as tac-
TCCC skills. To eliminate unnecessary medical jargon and im- tically feasible, but not later than 2 hours after application:
prove clarity, the group recommended standardizing terminol- • ASM (Tier 1) and CLS (Tier 2) should perform reassessment,
ogy across all TCCC tiers. repositioning, or conversion within 2 hours of application,
as soon as tactically feasible and in the absence of contrain-
The following definitions were proposed for all future TCCC dications, such as shock (pursuant to the indicators taught
educational and doctrinal materials: in the TCCC curricula) or inability to monitor the wound.
• CMC and CPP (Tiers 3–4) may attempt conversion be-
• Removal – Taking the tourniquet off the injured extremity tween 2–6 hours with continuous monitoring, resuscitative
• Conversion – Removing the tourniquet and replacing it capability, and, when available, laboratory support to man-
with an alternative method for control of bleeding (e.g., age reperfusion injury.
hemostatic or pressure dressing) • Beyond 6 hours prehospital conversion is not advised; tour-
• Repositioning – Moving the tourniquet to a location closer niquet removal should occur only in an environment with
to the wound on the injured extremity advanced monitoring and treatment capabilities.

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