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Recommended nonpneumatic limb tourniquets: acquisitions should be based on the best evidence currently
available.
Combat Application Tourniquet, Generation 6 (CAT-6)
Combat Application Tourniquet, Generation 7 (CAT-7) Therefore, it is incumbent that the CoTCCC:
SOF Tactical Tourniquet – Wide, Generation 3 (SOFTT-W)
Tactical Mechanical Tourniquet (TMT) • Ensure that we are providing the best-recommended
Ratcheting Medical Tourniquet-Tactical (RMT-T) / tools to fulfill our guidelines for tactical combat casu-
TX2 / TX3 Tourniquets alty care.
SAM Extremity Tourniquet (SAM-XT)
• Perform comprehensive reviews of all tourniquet litera-
Recommended pneumatic limb tourniquets: ture, data, studies, case reports, and product data.
Emergency and Military Tourniquet (EMT) • Assess and evaluate currently recommended commercial
Tactical Pneumatic Tourniquet, 2 inch (TMT2) tourniquets.
• Assess and evaluate NEW tourniquets for consideration
as CoTCCC recommended devices.
Proximate Cause for This Proposed Change
• Publish a clear statement as to why other tourniquets
The first two tourniquets recommended for use on the battle- were either not recommended or considered.
field at the point of injury (POI) were the Combat Application • Publish a CoTCCC Preferred Features statement for
Tourniquet (CAT) and the SOF Tactical-Tourniquet. These future tourniquet studies, development, and RDT&E
two tourniquets have performed well in combat casualty care, requirements.
but there have been no updated TCCC tourniquet recommen- • Assess and evaluate tourniquet-training methodologies
dations since 2005. for efficacies on performance on bleeding control.
• Codify CoTCCC protocol for reviewing previously rec-
In the past, the CoTCCC recommended that periodic, compre- ommended devices.
hensive, and standardized testing of the commercially avail- • Review methodology of “naming” specific commercial
able tourniquets be conducted by the Department of Defense products in the TCCC Guidelines.
(DoD). This would be helpful both to study new tourniquets
and to evaluate the impact of changes that have been made This review will NOT discuss the importance of limb tourni-
to previously recommended tourniquets. Both the CAT and quets for hemorrhage control in TCCC or any other setting. The
the SOFT-T have been significantly modified from the version CoTCCC position and guidelines are not changed or effected
tested by Dr Walters in 2004. 1 as pertaining to the currently recommended TCCC Guidelines
(01 AUG 2019). The critical need of tourniquets on the bat-
More recent tourniquet testing has been completed and pub- tlefield is well established and is not questioned. Reviews of
lished, but it has not been comprehensive or standardized, medical literature have documented the unquestioned success
making comparative quality assessments of the available tour- of properly applied tourniquet in saving lives and decreasing
niquet options more difficult. Nonetheless, several factors the incidence of prehospital death from limb hemorrhage.
make it important to review TCCC tourniquet recommenda-
tions at the present time despite the lack of comprehensive, Background
standardized testing:
The early and aggressive application of limb tourniquets has
1. Although the CAT and the SOFT-T have performed well been the key pillar of TCCC since its inception. In the early
in combat, there may be newer tourniquet technology that years of TCCC implementation there were limited prefabri-
offer advantages in cost, speed of application, ease of ap- cated limb tourniquet options available for units or the services
plication, durability, ease of training, or other aspects of to issue to troops. The device fielded by the DoD medical lo-
tourniquet performance over the two tourniquets currently gistics system since the 1960s was the simple strap-and-buckle
recommended by TCCC. Tourniquet, Nonpneumatic (former NSN: 6515-00-383-0565
2. Some commercially available tourniquets performed Non-pneumatic tourniquet) depicted in Figure 1. This device
poorly – either in laboratory testing or in casualty care. was completely inadequate as a true limb tourniquet. The
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These tourniquets need to be identified so that agencies are alternative was the classic stick-and-rag improvised windlass
aware of these issues when making tourniquet purchasing limb tourniquets. While the stick and rag improvised windlass
decisions. limb tourniquet can be as effective as commercially available
3. Some commercially available tourniquets lack substantial tourniquet, it has up to a 32% failure rate using the optimal
and objective evaluation. While these tourniquets may materials in a lab setting. Using this type of tourniquet may
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work well, without supporting data, they should not be not be practical due to the necessity for the required materials,
recommended and identified. the low arterial occlusion rate, and the prolonged time neces-
4. The newer versions of the CAT and the SOFT-T need to be sary to properly apply it.
evaluated in comparison to other tourniquets to study the
effect of post-2004 design changes on their performance. Through the efforts of innovative medics and physicians in the
5. Tourniquet use is increasing in the US civilian sector as a late 1990’s and early 2000s, new concepts for prefabricated
result of the Department of Homeland Security’s “Stop the limb tourniquets began to emerge. While many quickly fell by
Bleed” campaign that seeks to translate the survival bene- the wayside, the CAT and SOFT-T have endured to this day.
fit seen in US combat casualties after the TCCC-led intro- The tourniquet innovation did not slow down as several man-
duction of modern tourniquets. Many civilian agencies are ufacturers continued to develop, produce and sell tourniquet
requesting guidance from TCCC about which tourniquets devices to the point that there are several dozen options avail-
to acquire for their agencies. These large-scale tourniquet able today. However, the efficacy of many of these tourniquet
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28 | JSOM Volume 19, Edition 4 / Winter 2019