Key Points

Establish a security perimeter in accordance with unit tactical standard operating procedures and/or battle drills. Maintain tactical situational awareness.

Triage casualties as required. Casualties with an altered mental status should immediately have weapons cleared and secured, communications secured, and sensitive mission items redistributed.

During the Tactical Field Care of TCCC, further efforts can be made to achieve hemorrhage control.

  • Assess for unrecognized hemorrhage and control all sources of bleeding. If not already done, use a CoTCCC-recommended limb tourniquet to control life-threatening external hemorrhage that is anatomically amenable to tourniquet use or for any traumatic amputation. Apply directly to the skin 2-3 inches above the bleeding site. If bleeding is not controlled with the first tourniquet, apply a second tourniquet side-by-side with the first. 
  • For compressible hemorrhage not amenable to limb tourniquet use or as an adjunct to tourniquet removal, use one of the CoTCCC-recommended hemostatic dressings.

Hemostatic dressings should be applied with at least 3 minutes of direct pressure. Each dressing works differently, so if one fails to control bleeding, it may be removed and a fresh dressing of the same type or a different type applied.

If the bleeding site is amenable to use of a junctional tourniquet, immediately apply a CoTCCC-recommended junctional tourniquet. Do not delay in the application of the junctional tourniquet once it is ready for use. Apply hemostatic dressings with direct pressure if a junctional tourniquet is not available or while the junctional tourniquet is being readied for use. 

Junctional Areas include the groin, buttocks, perineum, axilla, base of the neck, and extremities at sites too proximal for a limb tourniquet.

A pelvic binder should be applied for cases of suspected pelvic fracture:

  • Severe blunt force or blast injury with one or more of the following indications:
    • Pelvic pain
    • Any major lower limb amputation or near amputation
    • Physical exam findings suggestive of a pelvic fracture
    • Unconsciousness
    • Shock

Reassess prior tourniquet application. Expose the wound and determine if a tourniquet is needed. If it is needed, replace any limb tourniquet placed over the uniform with one applied directly to the skin 2-3 inches above bleeding site. Ensure that bleeding is stopped. If there is no traumatic amputation, a distal pulse should be checked. If bleeding persists or a distal pulse is still present, consider additional tightening of the tourniquet or the use of a second tourniquet side-by-side with the first to eliminate both bleeding and the distal pulse. If the reassessment determines that the prior tourniquet was not needed, then remove the tourniquet and note time of removal on the TCCC Casualty Card.

Although a tourniquet may stop the active bleeding, it also prevents venous blood from returning to the heart. If arterial blood continues to flow past the tourniquet, pressure can build up distally in the limb and create a compartment syndrome. This is why the tourniquet should be tightened until there is no longer a distal pulse – to minimize the chance of harm from a developing compartment syndrome.

Limb tourniquets and junctional tourniquets should be converted to hemostatic or pressure dressings as soon as possible if three criteria are met: the casualty is not in shock, it is possible to monitor the wound closely for bleeding, and the tourniquet is not controlling bleeding from an amputated extremity. Every effort should be made to convert tourniquets in less than 2 hours if bleeding can be controlled with other means. Do not remove a tourniquet that has been in place more than 6 hours unless close monitoring and lab capability are available. 

Do not convert the tourniquet if:
  • The casualty is in shock.
  • You cannot closely monitor the wound for re-bleeding.
  • The extremity distal to the tourniquet has been traumatically amputated.​
  • The tourniquet has been on for more than 6 hours.
  • The casualty will arrive at a medical treatment facility within 2 hours after time of application….or
  • Tactical or medical considerations make transition to other hemorrhage control methods inadvisable.

Expose and clearly mark all tourniquets with the time of tourniquet application. Note tourniquets applied and time of application; time of reapplication; time of conversions; and time of removal on the TCCC Casualty Card. Use a permanent marker to mark on the tourniquet and the casualty card.