In massive hemorrhage you learned that tourniquets should be applied more deliberately in the TFC setting, to maximize effectiveness and minimize the amount of healthy tissue that might be impacted by a tourniquet placed too high on the limb. So, if a tourniquet is, in fact, necessary, replace high and tight (hasty) tourniquets or tourniquets applied over the clothing with more deliberate (directly on the skin) tourniquets. Tourniquets applied over clothing are not as effective as tourniquets applied directly to the skin.

This is done by placing a replacement tourniquet directly on the skin, 2-3 inches above the wound and tightening it. Then, slowly release the original tourniquet over one minute, while monitoring the casualty for signs of recurrent bleeding or resumption of a distal pulse. Slide originally placed tourniquet(s) down, but leave in place proximal to the newly placed tourniquet. In cases of recurrent bleeding or pulses, the original tourniquet can be retightened and the replacement tourniquet can be tightened further, or repositioned and tightened further.

Afterwards, the original tourniquet is slowly released again to confirm bleeding control. It may require a second tourniquet be placed side-by-side with the replacement tourniquet, as well. Occasionally an attempt to replace a tourniquet will not be successful, and reverting back to the prior tourniquet location may be needed.

If the initial tourniquet remains tightened in its original position, there is a risk of a compartment syndrome developing between the two tourniquets. But rather than removing the original tourniquet completely, it can be slid down the extremity and positioned just proximal to the replacement tourniquet, but only partially tightened by having the slack of the tourniquet removed and the strap secured to prevent it from catching or being in the way during casualty assessments or movements.

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