Change 14-02 - Optimizing the Use of Limb Tourniquets in TCCC

Optimizing the Use of Limb Tourniquets Tactical Combat Casualty Care: TCCC Guidelines Change 14-02

Stacy Shackelford, MD; Frank K. Butler, 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.

Journal of Special Operations Medicine

J Spec Oper Med. 2015;Spring, 15(1):17-31.

Abstract

The early use of limb tourniquets has been documented to save lives on the battlefield but has the potential for significant morbidity.  Since its inception, Tactical Combat Casualty Care (TCCC) has emphasized early and liberal use of tourniquets to control life-threatening hemorrhage in the care-under-fire (CUF) phase.

A decrease in the frequency of preventable deaths has been achieved though widespread training, and dissemination and use of tourniquets. The likelihood of tourniquet morbidity had been reduced through selection of better devices, more training of potential users, and more rapid evacuation. To minimize complications, it is important that training emphasize early conversion of tourniquets that are no longer needed; tourniquets must be frequently reassessed to ensure that hemorrhage is stopped and venous tourniquets avoided, particularly when evacuation time is long.

Tourniquets that are no longer needed should be converted to hemostatic or pressure dressings as soon as possible if the criteria for safe removal are met to reduce tourniquet pain and minimize the risks of complications. If the tourniquet is still on the extremity 2 hours after placement, a mandatory reassessment of the continued need for the tourniquet should occur.

The goals of tourniquet placement are to stop both bleeding and the distal pulse. Tactical and clinical situations dictate which goal(s) can be monitored; however, the likelihood of maximum benefit and minimum risk occurs only when both goals are attained.

Tourniquets placed during CUF should be positioned clearly proximal to the bleeding site(s). If the site of life-threatening bleeding is not readily apparent, the tourniquet should be placed high and tight (as proximal as possible) on the injured extremity as soon as possible.

Single-slit routing of the C-A-T band through the buckle is effective and may reduce blood loss and time for application; this method is recommended during the CUF phase.

Summary of Changes

1. Clarification of tourniquet conversion guidelines.

2. Clarification of effective tourniquet placement.

3. Clarification of the location of tourniquet placement during CUF.

4. Review recommendation for Combat Application Tourniquet® (C-A-T) routing of the band through the buckle.