Every effort should be made to convert tourniquets in less than 2 hours if bleeding can be controlled by other means unless there has been an amputation, the casualty is in shock or you cannot closely monitor the wound for re-bleeding;28, 29 However, do not attempt tourniquet conversion if the tourniquet has been on for six or more hours.30 Also, consider leaving the tourniquet in place if the tactical or medical considerations make the transition to other hemorrhage control methods inadvisable, or if it is likely that the casualty will have access to surgery within 2 hours.31

While the original tourniquet is still in place controlling the bleeding, pack the wound with hemostatic gauze, if available, and hold pressure for three minutes. Then apply a pressure bandage over the dressing, maintaining pressure. Afterward, slowly release the tourniquet (over at least one minute) while closely observing for bleeding. If the wound packing and pressure bandage do not control the bleeding, retighten the tourniquet or follow the steps to replace the tourniquet if it is above the clothing, like a high and tight tourniquet.32,33 In cases where the conversion has failed, it is appropriate to try again within the next two hours, as long as it hasn’t been more than six hours since the original tourniquet was applied.34,35

If the conversion is successful, loosen the tourniquet and move it down to just above the pressure dressing, loose but with no slack in the strap, in case it is needed later, and annotate the time of tourniquet removal on the DD Form 1380, TCCC Casualty Card.36 Periodically reassess the wound for recurrent bleeding and reassess after any casualty movements.

The evidence to support the conversion of tourniquets, when amenable, relies largely on retrospective reviews and subject matter expert consensus. There are a handful of animal model prospective studies on hemostatic agents that tend to support its use, as well. In cases requiring the use of a tourniquet, the caregiver removes the tourniquet every 2 hours and assesses the bleeding; if the bleeding has stopped, then the tourniquet should be replaced with a pressure bandage to minimize tissue damage.

The level of evidence supporting the guidance for tourniquet conversion in the tactical environment is based on Clinical Consensus, Expert Opinion, and discussion.