Page 113 - JSOM Spring 2026

Levels of Evidence for the Recommendations 3. Training optimization – Evaluate learning outcomes when
the algorithm is integrated into ASM and CLS courses, fo-
The Committee on Tactical Combat Casualty Care (CoTCCC) cusing on skill retention, decision accuracy, task execution
employs a structured, evidence-based process to develop and times, and instructor qualification standards.
update the TCCC guidelines, integrating the best available sci- 4. Telemedicine integration – Develop and test telemedical
entific data with battlefield performance improvement findings consultation protocols and digital decision aids to guide
and expert consensus. To support consistent and transparent reassessment and conversion in prolonged casualty care
grading of recommendations, the CoTCCC uses the Ameri- environments.
can College of Cardiology/American Heart Association (ACC/ 5. Data collection and feedback – Leverage JTS performance
AHA) evidence classification system, adapted to the unique improvement databases and combat casualty registries to
operational, ethical, and logistical constraints of combat and monitor outcomes, track adherence to reassessment time-
prehospital battlefield environments. lines, and inform ongoing guideline refinement.

Evidence considered by the CoTCCC includes peer-reviewed
military and civilian medical literature, observational and Author Contributions
performance improvement data from operational settings, EJK conceived and wrote the initial draft of this manuscript.
laboratory and preclinical studies when applicable, and ex- All authors contributed to the development of all drafts. Final
pert opinion when higher-level evidence is unavailable or im- submission was jointly agreed among all authors.
practical to obtain. In recognition of the inherent challenges
of conducting randomized controlled trials in combat, recom- Disclaimer
mendations may rely on nonrandomized data or expert con- The opinions or assertions contained herein are the private
sensus while remaining subject to ongoing review. views of the authors and are not to be construed as official or
as reflecting the views of the Department of War. The recom-
Each recommendation is assigned a Level of Evidence (LOE) mendations contained in this paper are intended to be guide-
reflecting the quality, consistency, and applicability of the sup- lines only and are not a substitute for clinical judgment.
porting data. Recommendations supported by lower levels of
evidence are re-evaluated as additional operational experience, Release
performance improvement data, and research findings be- This document was reviewed by the Chief of the Joint Trauma
come available, ensuring continuous refinement of the TCCC System and by the Public Affairs Office and the Operational
guidelines. 26 Security Office at the Defense Health Agency. It is approved
for unlimited public release.
The overall LOE for this change proposal ranges from B-NR
to C-EO (Table 1), depending on the specific change. Class of This article contains contributions prepared by U.S. Govern-
Recommendation ranges from I to IIa. ment employees as part of their official duties, which are in the
public domain under 17 U.S.C. § 105. Copyright is claimed
TABLE 1 Level of Evidence for Recommendations only in the non-U.S. Government portions of the work by the
respective authors or publisher. This article reflects work con-
Level of Class of ducted under the auspices of the Committee on Tactical Com-
Recommended change evidence recommendation bat Casualty Care, Defense Committee on Trauma.
ASM/CLS reassess tourniquet <2h B-NR I
ASM/CLS may convert tourniquet C-LD IIa Disclosures
<2h The authors have indicated they have no financial relation-
ASM/CLS to require medical
oversight to convert tourniquet C-LD IIa ships relevant to this article to disclose.
2–6h
ASM shock assessment C-EO IIa Artificial Intelligence Declaration
Language simplification C-EO IIa No generative AI programs were used in the preparation of
ASM = All Service Member; CLS = Combat LifeSavers. this manuscript.

References
Recommendations for 1. Butler FK Jr. Military History of Increasing Survival: The U.S. mil-
Further Research and Development itary experience with tourniquets and hemostatic dressings in the
Afghanistan and Iraq conflicts. J Spec Oper Med. 2015;15(4):149–
Further study is needed to optimize both physiologic and ed- 152. doi:10.55460/dxbq-yhd0
ucational aspects of tourniquet reassessment across all TCCC 2. Medby C, Ricks J, Ingram B, et al. Removal of tourniquets: the next
tiers. The Working Group recommends: step in saving lives and limbs. BMJ Mil Health. 2025;171(4):288–
289. doi:10.1136/military-2024-002785
3. Yatsun V. Application of hemostatic tourniquet on wounded ex-
1. Physiologic research – Conduct controlled studies and pro- tremities in modern “trench” warfare: the view of a vascular sur-
longed casualty care simulations to better define thresholds geon. Mil Med. 2024;189(1-2):332–336. doi:10.1093/milmed/
of safe conversion beyond 2 hours and to characterize sys- usac208
temic effects of reperfusion injury between 2 and 6 hours. 4. Patterson JL, Bryan RT, Turconi M, et al. Life over limb: Why not
2. Algorithm validation – Perform iterative TCCC responder both? Revisiting tourniquet practices based on lessons learned
testing of the TCCC tourniquet reassessment algorithm from the war in Ukraine. J Spec Oper Med. 2024;24(1):18–25.
doi:10.55460/V057-2PCH
through simulation, training exercises, and operational de- 5. Lukiianchuk V, Linchevskyy O, Dorlac WC, et al. Morbidity and
ployment to confirm usability, comprehension, and safety mortality associated with ischemia-reperfusion injury after pro-
among nonmedical personnel. longed tourniquet use: A wartime single-center treatment algorithm.

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