Page 29 - JSOM Winter 2019

2019 Recommended Limb Tourniquets in
Tactical Combat Casualty Care

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Harold R. Montgomery, SO-ATP *; Rick Hammesfahr, MD ; Andrew D. Fisher, MPAS, PA-C, LP ;
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Jeffrey Cain, MD ; Dominique J. Greydanus, 18D (Ret) ; Frank K. Butler Jr, MD ;
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Craig Goolsby, MD, MEd, FACEP ; Alexander L. Eastman, MD, MPH, FACS, FAEMS 8
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ABSTRACT
Military and civilian trauma can be distinctly different but or 0 to 5. As such, the maximum score a tourniquet could
the leading cause of preventable trauma deaths in the prehos- receive was 50 with a score of 40 being considered the cut-off
pital environment, extremity hemorrhage, does not discrim- for a nonpneumatic limb tourniquet to be recommended.
inate. The current paper is the most comprehensive review
of limb tourniquets employable in the tactical combat casu- Scoring Criteria:
alty care environment and provides the first update to the
CoTCCC-recommended limb tourniquets since 2005. This • Arterial occlusion was the most critical score as a limb
review also highlights the lack of unbiased data, official re- tourniquet must adequately demonstrate that it can ef-
porting mechanisms, and official studies with established cri- fectively occlude arterial blood flow of an extremity.
teria for evaluating tourniquets. Upon review of the data, the • Speed of application to achieve initial occlusion <60
CoTCCC voted to update the recommendations in April 2019. seconds.
• The simplicity of application was determined as a com-
Goals: The primary goal of this comprehensive tourniquet bination of how easily the device can be applied, how
review was to (1) review the previously recommended tour- many steps are required for application and/or the num-
niquets, (2) determine if additional commercial tourniquets ber of twists, turns, clicks or pumps necessary to achieve
warrant CoTCCC recommendation, and (3) identify com- occlusion.
mercial tourniquets that require further review or do not • Within optimal occlusion pressure range of 180 and
currently warrant recommendation. A deep-dive analysis of 500mmHg.
medical literature on limb tourniquets primarily published • Specifications of ≥1.5 inches wide, ≥37.50 inches in
since 2012 was used to extrapolate data to be scored against length, a locking mechanism, time recording area, and
criteria established the CoTCCC tourniquet working group weight <8 ounces.
in 2018. • Known reported or published complications, failures, or
safety issues of devices.
Scoring: For the purposes of this review, each component of • Combat usage reports, civilian usage reports and user
tourniquet criteria was scored on a weighted scale of 0 to 10 preferences in published literature; and logistics data.
*Correspondence to hrmontgomery75@gmail.com
1 Mr Montgomery is a retired Special Operations medic whose assignments were the senior enlisted medical advisor of USSOCOM and the senior
medic for the 75th Ranger Regiment with multiple combat deployments. He is program coordinator for the Committee on Tactical Combat
Casualty Care of the Joint Trauma System division of the Defense Health Agency. Dr Hammesfahr is an orthopedic surgeon and formerly the
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chairman of the Curriculum and Examination Board for US Special Operations Command; he has been extensively involved in developing med-
ical protocols and interoperability training for USSOCOM. He is actively involved in teaching TCCC and Tactical Emergency Casualty Care
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to civilian special operations teams and serves as the medical director for tactical emergency medical service teams in Georgia. MAJ Fisher is a
physician assistant in the Texas Army National Guard and fourth-year medical student at Texas A&M College of Medicine. He previously served
on active duty as a battalion and regimental physician assistant for the 75th Ranger Regiment and with Medical Command, Texas Army National
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Guard, Austin. Dr Cain previously served as an infantry officer and later battalion surgeon in the 75th Ranger Regiment with multiple combat
deployments and was the director of combat medic training of the AMEDDC&S. He is medical director for ALERRT and the THR Emergency
Center in McKinney, TX. Mr Greydanus is a retired Special Forces Medical Sergeant (18D) and one of the original instructors for the TCCC
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transition training initiative sponsored by USSOCOM and the USAISR. He is TCCC performance improvement coordinator for the Joint Trauma
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System. Dr Butler was a Navy SEAL platoon commander before becoming a physician. He is an ophthalmologist and a Navy undersea medical
officer with more than 20 years of experience providing medical support to Special Operations Forces. He has served as the command surgeon for
the U.S. Special Operations Command and was chairman of the Department of Defense’s Committee on TCCC. Dr Goolsby is a former USAF
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emergency medicine physician with multiple combat deployments and has recently been a leader in the military-to-civilian knowledge transfer
efforts, particularly for the Stop the Bleed education program. He is an Associate Professor and Vice Chair with the Department of Military
and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, and Science Director at the National Center for
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Disaster Medicine and Public Health, Rockville, MD. Dr Eastman is a trauma surgeon and police officer with the Dallas Police Department with
extensive SWAT experience including on-site tactical support including the 2016 Dallas police shooting incident. He is senior medical officer with
the US Department of Homeland Security and associate professor of surgery, Uniformed Services University of the Health Sciences, Dallas, Texas.
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