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

1. Clarification of tourniquet conversion guidelines. Since its inception, Tactical Combat Casualty Care (TCCC) has emphasized early and liberal use of tour­ niquets to control life­threatening hemorrhage in the care­under­fire (CUF) phase. Because evacuation times in Iraq and Afghanistan have been relatively short, the recommendation in the TCCC guidelines to re­evaluate the need for a tourniquet in the tac­ tical­field­care phase of care and use other means of hemorrhage control has been de­emphasized in practice. There is often no attempt to convert tourni­ quets to hemostatic or pressure dressings because of the short evacuation times in Afghanistan at present. Increasingly, worldwide casualty care scenarios are anticipated to include long­range evacuation; recent real­world events in theaters other than the Middle East have demonstrated that reinforcement of tour­ niquet conversion guidelines is needed. 2. Clarification of effective tourniquet placement. Inef­ fective venous tourniquets have been shown to be a relatively common occurrence that increases blood loss and complications.1–3 Optimal use of limb tour­ niquets must stop both bleeding and the distal pulses in the extremity. 3. Clarification of the location of tourniquet placement during CUF. During a prehospital trauma care as­ sessment in Afghanistan in 2012, inconsistencies re­ lating to tourniquet placement were noted between the TCCC guidelines and actual training in some TCCC courses. In particular, “high­and­tight” tour­ niquet placement (also termed “hasty” tourniquet placement) is not specified in the TCCC guidelines, which call for tourniquet placement proximal to the bleeding site in the CUF phase. This update supports placement of the tourniquet high and tight (as proxi­ mal as possible) on the injured limb during CUF. 4. Review recommendation for Combat Application Tourniquet® (C-A-T) routing of the band through the buckle. Armed Forces Medical Examiner Feed­ back to the Field #11, February 2012, reported a survey of tourniquets recovered from deceased Ser­ vice members. It was found that the standard­ issue C­A­T commonly was placed with the friction band routed once through the buckle (“single­slit rout­ ing”) in 35% of lower extremity placements and 53% of upper extremity placements.4 Previous train­ ing and manufacturer’s instructions supported single­ slit routing only for the upper extremity during self­ application.5 However, accumulated experience and recent evidence6 indicate that single­slit routing of the C­A­T is effective, faster, and reduces blood loss compared to double­slit routing.