Page 111 - JSOM Spring 2026

points. 13,18,22 Complementary civilian algorithms, provided ad- emphasizes simple, time-based reassessment, with clearly de-
ditional perspectives on conversion safety, ischemia tolerance, fined contraindications and preserves tier-specific roles and
and prehospital application. 16,23–25 Collectively, these resources medical oversight where appropriate.
ensured that the resulting algorithm integrated operational ex-
perience with established medical evidence. As with other elements of TCCC, these recommendations
should be applied using sound judgment and adapted as addi-
The algorithm was written in plain, action-oriented language tional operational experience and evidence become available.
and uses intuitive, color-coded flow paths modeled after the
15
Tourniquet Traffic Light concept. Distinct zones highlight Current Wording in the TCCC Guidelines
time-based risk categories (<2 hours, 2–6 hours, >6 hours) and
delineate tier-specific actions for reassessment, repositioning, Tactical Field Care (Circulation – Bleeding)
and conversion. Key decision points include triggers for tele- • Reassess prior tourniquet application. Expose the wound
medicine consultation and documentation of time and outcome. and determine if a tourniquet is needed. If it is needed, re-
place any limb tourniquet placed over the uniform with one
The resulting TCCC tourniquet reassessment algorithm (Fig- applied directly to the skin 2–3 inches above the bleeding
ure 1) illustrates the tiered, time-based decision framework site. Ensure that bleeding is stopped. If there is no traumatic
proposed by the Working Group and serves as a simple, amputation, a distal pulse should be checked. If bleeding
evidence-informed decision aid that empowers all servicemem- persists or a distal pulse is still present, consider additional
bers to reassess lifesaving interventions safely and consistently, tightening of the tourniquet or the use of a second tourniquet
bridging the gap between hemorrhage control and prolonged side-by-side with the first to eliminate both bleeding and the
casualty care. distal pulse. If the reassessment determines that the prior
tourniquet was not needed, then remove the tourniquet and
note the time of removal on the TCCC Casualty Card.
Summary
• Limb tourniquets and junctional tourniquets should be con-
The TCCC Tourniquet Reassessment Working Group con- verted to hemostatic or pressure dressings as soon as possi-
vened to determine whether tourniquet reassessment and ble if three criteria are met: the casualty is not in shock; it
conversion practices should extend to the All Service Member is possible to monitor the wound closely for bleeding; and
(ASM) level and to develop a standardized framework applica- the tourniquet is not being used to control bleeding from
ble across all TCCC tiers. Drawing on medical lessons learned an amputated extremity. Every effort should be made to
from recent conflicts, the group identified that both prolonged convert tourniquets in less than 2 hours if bleeding can be
and non-medically indicated tourniquet use contributed to po- controlled with other means. Do not remove a tourniquet
tentially preventable complications, particularly in operational that has been in place more than 6 hours unless close mon-
environments characterized by delayed evacuation, denied air itoring and lab capability are available.
superiority, and limited access to medical personnel. • Expose and clearly mark all tourniquets with the time of
tourniquet application. Note tourniquets applied and time
To close this operational gap, the Working Group developed of application; time of re-application; time of conversion;
a time-driven algorithm for TCCC implementation. The al- and time of removal on the TCCC Casualty Card. Use a
gorithm provides clear, plain language guidance for reassess- permanent marker to mark on the tourniquet and the ca-
ment, repositioning, and conversion, empowering nonmedical sualty card.
responders to act safely and decisively while preserving limb
viability and minimizing systemic risk.
Proposed Changes to the TCCC Guidelines
The proposed change standardizes terminology, eliminates Tactical Field Care (Circulation – Bleeding)
unnecessary medical jargon, and introduces repositioning in *Changes bolded and in italics
place of replacement. It also affirms the 2-hour reassessment • Reassess prior tourniquet application. Expose the wound
window for all personnel and the 6-hour upper limit for con- and determine if a tourniquet is needed. If it is needed, re-
version attempts under medical supervision. Together, these position any limb tourniquet placed over the uniform by
updates align with current operational realities, extend capa- applying a second one directly to the skin 2–3 inches above
bility to the ASM and CLS levels, and maintain the core TCCC the bleeding site, then loosening the first tourniquet. En-
principles of simplicity, safety, and scalability. sure that bleeding is stopped. If there is no traumatic ampu-
tation, a distal pulse should be checked. If bleeding persists
Limitations and Risk Acceptance or a distal pulse is still present, consider additional tighten-
The Working Group recognizes that the available evidence ing of the tourniquet or the use of a second tourniquet side-
informing tourniquet reassessment and conversion practices, by-side with the first to eliminate both bleeding and the
particularly in the prolonged casualty care environment, re- distal pulse. If the reassessment determines that the prior
mains limited and continues to evolve. While existing military tourniquet was not needed, then remove the tourniquet and
and civilian data support early reassessment within defined note the time of removal on the TCCC Casualty Card.
time windows, precise physiologic thresholds for ischemia tol- • Limb tourniquets and junctional tourniquets should be con-
erance and reperfusion risk are not fully characterized across verted to hemostatic or pressure dressings as soon as possi-
all operational contexts. ble if three criteria are met: the casualty is not in shock; it
is possible to monitor the wound closely for bleeding; and
Accordingly, the recommendations in this paper are intended the tourniquet is not being used to control bleeding from
to guide decision-making under operational constraints rather an amputated extremity. Every effort should be made to
than to establish absolute clinical rules. The proposed approach convert tourniquets in less than 2 hours, if bleeding can be

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