Tactical Combat Casualty Care
Guideline Change 14-02: Optimizing
Tourniquet Use in TCCC
Interim Change Slides
28 October 2014
Care Under Fire
Care Under Fire
Guidelines
7. Stop life-threatening external hemorrhage
if tactically feasible:
• Direct casualty to control hemorrhage by self-aid if able.
• Use a CoTCCC-recommended limb tourniquet for hemorrhage
that is anatomically amenable to tourniquet use.
• Apply the limb tourniquet over the uniform clearly proximal
to the bleeding site(s). If the site of the life-threatening
bleeding is not readily apparent, place the tourniquet “high
and tight” (as proximal as possible) on the injured limb and
move the casualty to cover.
The Number One
Medical Priority in CUF
Early control of severe hemorrhage is
critical.
– Extremity hemorrhage in the past was the
most frequent cause of preventable battlefield
deaths.
– Over 2500 deaths occurred in Vietnam
secondary to hemorrhage from extremity
wounds.
– Injury to a major vessel can quickly lead to
shock and death.
– Only life-threatening bleeding warrants
intervention during Care Under Fire.
Question
• How long does it take to bleed to death from a
complete femoral artery and vein disruption?
• Answer:
– Casualties with such an injury can bleed to death
in as little as 3 minutes
Video:
Femoral Artery Bleeding
Care Under Fire
The need for immediate access to a
tourniquet in such situations makes it clear
that all personnel on combat missions
should have a CoTCCC-recommended
tourniquet readily available at a standard
location on their battle gear and be trained
in its use.
- Casualties should be able to easily and
quickly reach their own tourniquet.
Care Under Fire
Where a tourniquet can be applied, it is the first
choice for control of life-threatening
hemorrhage in Care Under Fire.
A Preventable Death
Did not have an effective tourniquet applied bled to death from a leg wound
Tourniquet Application
• Apply without delay if indicated.
• Both the casualty and the medic are in grave
danger while a tourniquet is being applied in this
phase – don’t use tourniquets for wounds with
only minor bleeding.
• The decision regarding the relative risk of further
injury versus that of bleeding to death must be
made by the person rendering care.
Tourniquet Application
• Non-life-threatening bleeding should be ignored until the
Tactical Field Care phase.
• Apply the tourniquet without removing the uniform –
make sure it is clearly proximal to the bleeding site.
• If you are uncertain about exactly where the major
bleeding site is on the extremity (night operations,
multiple wounds), apply the tourniquet “high and
tight” (as proximal as possible) on the arm or leg.
Tourniquet Application
• Tighten the tourniquet until bleeding is controlled.
• If the first tourniquet fails to control the bleeding,
apply a a second tourniquet just above (proximal to)
the first.
• Don’t put a tourniquet directly over the knee or elbow.
• Don’t put a tourniquet directly over a holster or a
cargo pocket that contains bulky items.
Anatomy of a C-A-T
The Combat Application Tourniquet (C-A-T) is a small
and lightweight one-handed tourniquet that can
completely occlude arterial blood flow in an extremity.
Combat Application
Tourniquet
The C-A-T is Delivered in Its One-Handed
Configuration
C-A-T One-Handed
Application
to an Arm
Step 1: Insert the wounded extremity through
the C-A-T
C-A-T One-Handed
Application to an Arm
Step 2: Pull the Self-Adhering Band tight
and securely fasten it back on itself.
C-A-T One-Handed
Application to an Arm
Step 3: Adhere the band around the arm. Do
not adhere the band past the clip.
C-A-T One-Handed
Application to an Arm
Step 4: Twist the rod until the bleeding has
stopped.
C-A-T One-Handed
Application to an Arm
Step 5: Lock the rod in place in the Windlass
Clip.
C-A-T One-Handed
Application to an Arm
Hemorrhage is now controlled.
C-A-T One-Handed
Application to an Arm
For added security, and always before moving
a patient, proceed to secure the Windlass Rod
with the Windlass Strap as follows.
C-A-T One-Handed
Application to an Arm
Step 6: Adhere the Self-Adhering Band over
the Windlass Rod and continue around the
extremity as far as it will go.
C-A-T One-Handed
Application to an Arm
Step 7: Secure the Rod and the Band with the
Windlass Strap. Grasp the strap, pull it tight,
and adhere it to the opposite hook on the
Windlass Clip.
C-A-T One-Handed
Application to an Arm
The casualty is now ready for transport.
Video: C-A-T One-Handed
Application to an Arm
Video courtesy North American Rescue
C-A-T Two-Handed
Application to a Leg
Step 1: Route the Self-Adhering Band around the
leg. Pass the free-running end of the Band through
the inside slit of the friction adaptor buckle.
C-A-T Two-Handed
Application to a Leg
Step 2: Pass the Band through the outside slit
of the buckle.
C-A-T Two-Handed
Application to a Leg
Step 3: Pull the Self-Adhering Band tight and
securely fasten it back on itself.
C-A-T Two-Handed
Application to a Leg
Step 4: Twist the Rod until bright red bleeding
has stopped.
C-A-T Two-Handed
Application to a Leg
Step 5: Lock the Rod in place in the Windlass
Clip.
C-A-T Two-Handed
Application to a Leg
Hemorrhage is now controlled.
C-A-T Two-Handed
Application to a Leg
Step 6: Secure the Rod with the Windlass Strap.
Grasp the Windlass Strap, pull it tight, and adhere
it to the opposite hook on the Windlass Clip.
C-A-T Two-Handed
Application to a Leg
The casualty is now ready for transport
Video: C-A-T Two-Handed
Application to a Leg
Video courtesy North American Rescue
CAT Tourniquet
Application
• Although the manufacturer recommends passing the
Self-Adhering Band through both slits in the buckle,
experience and research have shown that routing it
through only one of the slits is also effective and allows
the tourniquet to be applied a little more quickly.
• If the CAT is applied in this manner, monitor the
casualty closely to ensure that the tourniquet remains
tight and that bleeding remains controlled.
SOFT-T Tourniquet
• The SOF Tactical Tourniquet (SOFTT) by
Tactical Medical Solutions, Inc is shown above
• Equally recommended with the C.A.T. for
carriage by Combat Medics on the battlefield.
Photo courtesy TMS, Inc.
The EMT Tourniquet
• The Emergency and Military Tourniquet (EMT) by Delfi
Medical Innovations, Inc. is shown above
• The EMT is an excellent tourniquet and is recommended for
use in evacuation platforms and medical treatment facilities,
but not for carriage by medics on the battlefield at this point.
Photo courtesy Wafflephile/Wikipedia
Tourniquet Use and Survival
Kragh - Annals of Surgery 2009
• Ibn Sina Hospital, Baghdad, 2006
• Tourniquets are saving lives on the battlefield
• Better survival when tourniquets were applied
BEFORE casualties went into shock than after
• 31 lives were saved in this study by applying
tourniquets prehospital rather than in the ED
• Estimated 1000-2000 lives saved in war to date by
tourniquets (data provided to Army Surgeon General)
Tourniquet Use and Safety
Kragh - J Trauma 2008
• Combat Support Hospital in Baghdad
• 232 patients with tourniquets on 309 limbs
• CAT was the best field tourniquet
• No limb amputations caused by tourniquet use
• Approximately 3% transient nerve palsies
Examples of Extremity Wounds That
Do NOT Need a Tourniquet
Use a tourniquet ONLY
for severe bleeding!
Tourniquet Mistakes
to Avoid!
•
•
•
•
•
•
•
•
•
*
Not using a tourniquet when you should
Using a tourniquet for minimal bleeding
Putting it on too proximally
Not taking it off when indicated during TFC
Taking it off when the casualty is in shock or has
only a short transport time to the hospital
Not making it tight enough – the tourniquet
should eliminate the distal pulse
Not using a second tourniquet if needed
Waiting too long to put the tourniquet on
Periodically loosening the tourniquet to allow
blood flow to the injured extremity
These lessons learned have been written in blood. *
Tourniquet Pain
• Tourniquets HURT when applied effectively
• This pain does not necessarily indicate a
mistake in application
• Does not mean you should take it off!
• Manage pain per TCCC Guidelines
Questions?
Tourniquet Practical
Tactical Field Care
Tactical Field Care Guidelines
4. Bleeding
a. 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
wound. If bleeding is not controlled with the
first tourniquet, apply a second tourniquet
side-by-side with the first.
Tactical Field Care Guidelines
4. Bleeding
b. For compressible hemorrhage not amenable to limb
tourniquet use or as an adjunct to tourniquet removal, use
Combat Gauze as the CoTCCC hemostatic dressing of
choice. Celox Gauze and ChitoGauze may also be used if
Combat Gauze is not available. Hemostatic dressings should
be applied with at least 3 minutes of direct pressure. 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.
Tactical Field Care Guidelines
4. Bleeding
c. Reassess prior tourniquet application. Expose the
wound and determine if a tourniquet is needed. If it
is, replace any limb tourniquet placed over the
uniform with one applied directly to the skin 2-3
inches above wound. Ensure that bleeding is
stopped. When possible, 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 sideby-side with the first to eliminate both bleeding
and the distal pulse.
Tactical Field Care Guidelines
4. Bleeding
d. 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.
Tactical Field Care Guidelines
4. Bleeding
e. Expose and clearly mark all tourniquet
sites with the time of tourniquet
application. Use an indelible marker.
Tourniquets:
Points to Remember
• Damage to the arm or leg is rare if the
tourniquet is left on for less than two hours.
• Tourniquets are often left in place for several
hours during surgical procedures.
• In the face of massive extremity hemorrhage, it
is better to accept the small risk of damage to
the limb than to have a casualty bleed to death.
Tourniquets:
Points to Remember
• If the tourniquet is still in place 2 hours after it was
applied, apply Combat Gauze to the wound with
direct pressure, then slowly release the tension on
the tourniquet. If bleeding remains controlled with
Combat Gauze, leave the loosened tourniquet in
place. If the bleeding is not controlled with Combat
Gauze, re-tighten the tourniquet until bleeding
stops.
• Restoring blood flow to the limb by transitioning to
Combat Gauze at the 2-hour mark will minimize the
chance of ischemic damage due to the tourniquet.
Tourniquets:
Points to Remember
• If the transition to Combat Gauze at 2 hours failed,
try again at 6 hours using the steps outlined in the
previous slide.
• Do not release the tourniquet after 6 hours of
application unless close monitoring and lab support
are available to evaluate for metabolic
complications of prolonged tourniquet use.
Tourniquets:
Points to Remember
• All unit members should have a CoTCCCapproved tourniquet at a standard location on their
battle gear.
– Should be easily accessible if wounded – DO
NOT bury it at the bottom of your pack
• Tourniquets should be left in their protective
packaging until needed to treat casualties.
– Harsh environments may contribute to
tourniquet failure if not left in packaging
Tourniquets:
Points to Remember
• Training tourniquets should never
be used as mission tourniquets
• Repetitive applications of a
tourniquet may cause it to fail
Tourniquets:
Points to Remember
• When a tourniquet has been applied,
DO NOT loosen it intermittently to
allow circulation to return to the
limb.
– Causes unacceptable additional blood
loss
– This HAS been happening in the past,
and was responsible for at least one
near fatality.
Tourniquets:
Points to Remember
Tightening the tourniquet enough to eliminate
the distal pulse will help to ensure that all
bleeding is stopped, and that there will be no
damage to the extremity from blood entering
the extremity
but not being
able to get out.
Tourniquets:
Points to Remember
Do not remove the tourniquet if:
– The extremity distal to the tourniquet has been
traumatically amputated.
– The casualty is in shock.
– 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.
– Tactical or medical considerations make transition
to other hemorrhage control methods inadvisable.
Tourniquets:
Points to Remember
• Only medics, physician assistants, or
physicians should remove tourniquets.
Questions?