Page 110 - JSOM Spring 2026

While the 2-hour reassessment window is supported by avail- must be able to recognize life-threatening physiologic deteri-
able evidence and longstanding TCCC guidance, these time oration and act decisively to preserve life until advanced care
thresholds should be understood as risk management bound- is available.
aries rather than absolute physiologic limits. Individual toler-
ance to ischemia and reperfusion injury varies based on injury How would this change affect training delivery
severity, patient factors, and operational conditions and re- and implementation?
mains incompletely defined in prolonged care environments. Integrating reassessment and conversion capabilities into ASM
Accordingly, the recommended time cutoffs are intended to training can be accomplished through a focused, supplemen-
support consistent decision-making under battlefield con- tal training module rather than a multi-tiered review, revision,
straints while preserving clinical judgment and tier-specific and redesign of the TCCC standardized curricula. Because
authority. ASMs are already taught the fundamental signs of shock and
bleeding control, these updates primarily reinforce existing
How does a failed conversion attempt affect competencies while providing a structured decision-making
time thresholds? framework.
A frequently raised operational question concerns whether a
failed conversion attempt—or briefly loosening a tourniquet The Fiscal Year 2017 National Defense Authorization Act
to check for bleeding—should “reset” ischemic time or extend (NDAA 2017) mandated standardized combat casualty care
the safe conversion window. Available evidence and histori- instruction for all servicemembers, presenting an opportunity
cal doctrine strongly advise against this practice. Early guid- to modernize how lifesaving skills are taught and sustained.
ance from Walters and Mabry emphasized that a tourniquet In response, the Joint Trauma System (JTS) and its partners
should never be intermittently loosened and retightened and developed next-generation learning science and training tech-
that failed conversion attempts should not delay evacuation or nologies (LSTTs) to deliver TCCC curricula in alignment with
11
alter time documentation. Subsequent literature supports a Department of Defense Instruction (DODI) 1322.24. 19–21
continuous-time model in which ischemic injury risk increases These strategies, distributed through the Deployed Medicine
with duration regardless of transient reperfusion. 10,13,16–18 Ef- website and mobile application, now provide tiered instruc-
forts to create “reperfusion intervals” or alternating tourni- tion adaptable to institutional, organizational, and self-devel-
quet cycles have proven impractical and potentially hazardous opment domains of learning, using no-, low-, and high-fidelity
in prehospital settings. simulation options.

Therefore, ischemic time must be measured continuously from Building upon this framework, the Working Group recom-
initial application until final removal. A failed conversion (de- mends incorporating a concise 2–3-hour supplemental module
fined as an unsuccessful transition from tourniquet to another into the ASM curricula that integrates shock recognition, ca-
method of hemorrhage control that requires re- tightening) sualty monitoring, and hands-on practice in tourniquet reas-
does not restart the 2-hour reassessment or the 2–6-hour sessment, repositioning, and conversion. This training can be
maximum thresholds. If conversion fails near the upper lim- delivered within the existing TCCC curricula’s structure and
its, the tourniquet should remain in place, and removal should supported by the established learning platforms to promote
be deferred until definitive monitored care is available. All standardization and scalability across the Department.
reassessment attempts should be clearly documented on the
TCCC Casualty Card, including times of conversion attempts, Because these updates expand capability to nonmedical re-
re-tightening, and clinical observations. sponders, they may necessitate revisions to TCCC trainer
qualification requirements and Service-level policies to ensure
Should ASMs be taught to recognize shock consistent oversight and safety during implementation. Insti-
if it is a contraindication to conversion? tutionalizing these updates through the JTS education archi-
Shock recognition is already an established component of cur- tecture will allow the Department of War to leverage modern
rent Tier 1 ASM and Tier 2 CLS curricula. ASMs are taught learning science and ensure all servicemembers are trained,
to recognize basic signs of shock (such as rapid breathing, equipped, and credentialed to reassess, reposition, or convert
loss of focus or difficulty engaging, and cool, clammy, pale, or tourniquets when indicated, regardless of tier or operational
gray skin). Combat LifeSavers receive additional instruction setting.
in assessing perfusion through pulse quality, mental status,
and skin findings. Because these skills are already embedded How was the tourniquet reassessment algorithm
in TCCC training, extending shock recognition to guide tour- developed and adapted for TCCC implementation?
niquet reassessment and conversion requires minimal modifi- The Working Group developed a standardized tourniquet re-
cation. The Working Group supports maintaining shock as a assessment algorithm to guide nonmedical personnel in safe,
contraindication for tourniquet conversion while emphasizing structured decision-making. This new algorithm was adapted
simple, observation-based recognition appropriate for non- from the NATO STO HFM Specialist Team model and tai-
medical responders. lored for TCCC implementation to align with U.S. Military
training tiers and doctrine. 9
A clearer, more deliberate approach to teaching shock recog-
nition will also improve ASM performance in other key areas To inform its design, the group conducted a focused review
of Tactical Field Care. The same visual and behavioral cues of published literature, military protocols, and prior tourni-
that inform safe tourniquet reassessment directly support quet conversion algorithms. Military sources, including previ-
better triage decisions and help identify casualties requiring ously published algorithms from the 75th Ranger Regiment,
higher evacuation priority. This reinforces the broader TCCC formed the structural foundation for the TCCC algorithm, de-
goal that all servicemembers, medical and nonmedical alike, fining time-based reassessment thresholds, and tiered decision

108 | JSOM Volume 26, Edition 1 / Spring 2026