Page 27 - Journal of Special Operations Medicine - Spring 2015

Optimizing the Use of Limb Tourniquets

in Tactical Combat Casualty Care:
TCCC Guidelines Change 14-02

Stacy A. Shackelford, MD; Frank K. Butler Jr, MD; John F. Kragh Jr, MD; Rom A. Stevens, MD;
Jason M. Seery, MD; Donald L. Parsons, PA-C; Harold R. Montgomery, NREMT/ATP;
Russ S. Kotwal, MD; Robert L. Mabry, MD; Jeffrey A. Bailey, MD

Proximate Cause for the Proposed Change

The early use of limb tourniquets has been documented placement of the tourniquet high and tight (as proxi­
to save lives on the battlefield but has the potential for mal as possible) on the injured limb during CUF.
significant morbidity. This change has four goals: 4. Review recommendation for Combat Application
Tourniquet (C-A-T) routing of the band through
®
1. Clarification of tourniquet conversion guidelines. the buckle. Armed Forces Medical Examiner Feed­
Since its inception, Tactical Combat Casualty Care back to the Field #11, February 2012, reported a
(TCCC) has emphasized early and liberal use of tour­ survey of tourniquets recovered from deceased Ser­
niquets to control life­threatening hemorrhage in the vice members. It was found that the standard­ issue
care­under­fire (CUF) phase. Because evacuation C­A­T commonly was placed with the friction band
times in Iraq and Afghanistan have been relatively routed once through the buckle (“single­slit rout­
short, the recommendation in the TCCC guidelines ing”) in 35% of lower extremity placements and
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to re­evaluate the need for a tourniquet in the tac­ 53% of upper extremity placements. Previous train­
tical­field­care phase of care and use other means ing and manufacturer’s instructions supported single­
of hemorrhage control has been de­emphasized in slit routing only for the upper extremity during self­
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practice. There is often no attempt to convert tourni­ application. However, accumulated experience and
quets to hemostatic or pressure dressings because of recent evidence indicate that single­slit routing of
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the short evacuation times in Afghanistan at present. the C­A­T is effective, faster, and reduces blood loss
Increasingly, worldwide casualty care scenarios are compared to double­slit routing.
anticipated to include long­range evacuation; recent
real­world events in theaters other than the Middle The TCCC guidelines address junctional tourniquets
East have demonstrated that reinforcement of tour­ and limb tourniquets. Junctional tourniquets are identi­
niquet conversion guidelines is needed. fied as such in the text. Otherwise, “tourniquet” refers
2. Clarification of effective tourniquet placement. Inef­ to limb tourniquets.
fective venous tourniquets have been shown to be a
relatively common occurrence that increases blood Background
loss and complications. Optimal use of limb tour­
1–3
niquets must stop both bleeding and the distal pulses The use of a tourniquet as a first aid tool on the battle­
in the extremity. field is the foremost advance in prehospital care dur­
3. Clarification of the location of tourniquet placement ing the wars in Iraq and Afghanistan, with an estimated
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during CUF. During a prehospital trauma care as­ 1,000–2,000 lives saved by tourniquet application. In
sessment in Afghanistan in 2012, inconsistencies re­ prior conflicts, prolonged tourniquet use led to limb
lating to tourniquet placement were noted between loss from ischemia; morbidity observed from tourniquet
the TCCC guidelines and actual training in some use led to controversy regarding battlefield tourniquet
TCCC courses. In particular, “high­and­tight” tour­ use. Recent military experience, however, has clearly
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niquet placement (also termed “hasty” tourniquet
placement) is not specified in the TCCC guidelines, Keywords: tourniquet, Tactical Combat Casualty Care guide-
which call for tourniquet placement proximal to the lines, external hemorrhage control, shock, resuscitation,
bleeding site in the CUF phase. This update supports emergency medical services

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