many dogmas relating to tourniquet use persist, tourniquets have reemerged in
Tactical Emergency Medical Support (TEMS) as the standard of care in the
tactical environment due to their ease of use, rapid application, and complete
stoppage of blood loss.
of viewing the use of the tourniquet as last resort, as has been the case in
the past with civilian Emergency Medical Services (EMS) and emergency room
physicians, the new Tactical Combat Casualty Care (TCCC) protocol considers the
military tourniquet as an initial lifesaving intervention to control massive
hemorrhage from an extremity.
guidelines differ from the Advanced Trauma Life Support (ATLS) guidelines on
which civilian trauma care has been based in most countries in the ATLS model;
injuries are diagnosed and treated in accordance with the ABCDE sequence:
Airway, Breathing, Circulation, Disability, Environment and exposure. In the
TCCC model, injuries are diagnosed and treated in accordance with the MARCH
sequence: Massive hemorrhage, Airway, Respirations, Circulation, Head injury.
recognizing that civilian law enforcement operations differ from military
combat operations, the National Tactical Officers Association (NTOA) believes
that “TCCC should serve as a foundation for TEMS protocols, practices and
has three goals: 1) treat the casualty; 2) prevent additional casualties; and
3) complete the mission. There are three phases to combat casualty care: 1)
Care Under Fire; 2) Tactical Field Care; and 3) Combat Casualty Evacuation
TCCC Basic Plan for Care Under Fire is: 1) return fire and take cover, 2) direct
or expect the wounded to remain engaged as a combatant, 3) direct the wounded to
move to cover and apply self-aid, 4) try to keep the wounded from sustaining
additional wounds, and 5) airway management should be delayed until the
Tactical Field Care phase.
6) stop life-threatening external hemorrhage if tactically feasible by
directing the wounded to control hemorrhage by self-aid, use a tourniquet for
hemorrhage that is anatomically amenable to tourniquet application, and apply
the tourniquet above the wound high on the extremity, over the uniform, and tighten
to stop arterial bleeding or until pulse is lost. Move the wounded to cover.
Guidelines for Bleeding Control
Committee on Tactical Combat Casualty Care (CoTCCC) Tactical Combat Casualty
Care Guidelines has guidelines for bleeding. Assess for unrecognized hemorrhage
and control all sources of bleeding. If not already done, use a
CoTCCC-recommended tourniquet to control life-threatening external hemorrhage
that is anatomically amenable to tourniquet application or for any traumatic
amputation. Apply directly to the skin 2-3 inches above wound.
compressible hemorrhage not amenable to tourniquet use or as an adjunct to
tourniquet removal (if evacuation time is anticipated to be longer than two
hours), use combat gauze as the hemostatic agent of choice. Combat gauze should
be applied with at least three minutes of direct pressure. Reassess prior
tourniquet application. Expose wound and determine if tourniquet is needed. If
so, move tourniquet from over uniform and apply directly to skin 2–3 inches above
wound. If a tourniquet is not needed, use other techniques to control bleeding.
time and the tactical situation permit, a pulse check should be accomplished.
If a pulse is still present, consider additional tightening of the tourniquet
or the use of a second tourniquet, side by side and proximal to the first, to
eliminate the pulse. Expose and clearly mark all tourniquet sites with the time
of tourniquet application. Use an indelible marker.
Composite Resources Combat Application Tourniquet® (C-A-T) and Tactical MedicalSolutions SOF Tactical Tourniquet® (SOF-TT) are the only two CoTCCC recommended
tactical tourniquets. The COTCC based its recommendation on a 2004 study of
nine battlefield tourniquets conducted by the U.S. Army Institute of Surgical
Research. Seven of these were commercially available and two were prototype
tourniquets were identified that were 100 percent effective in stopping
arterial blood flow. These were the
C-A-T, the SOF-TT, and the Emergency and Military Tourniquet (EMT). The EMT is
an inflatable pneumatic device that is best suited for aid stations and
hospitals. The C-A-T and SOF-TT are both windlass-type devices. The C-A-T and
SOF-TT are lightweight and reasonably inexpensive. Due to its lighter weight
and it being slightly easier to use, the C-A-T was selected as the primary
tourniquet, followed by the SOF-TT.
have been a number of recent enhancements to the C-A-T. The C-A-T tourniquet
strap now features a red elliptical tip to aid users in threading it. It has a
polymer windlass and reinforced windlass clip that is secured with Velcro®. The
windlass rod is twice as strong. The windlass clip has a highly visible
security tab and includes a writable area to record time of application. NorthAmerican Rescue is the sole distributor for the C-A-T in the U.S.
Medical Solutions has recently come out with a new version, the SOF Tactical
Tourniquet Wide (SOF-TT-W). The SOF-TT-W is the result of a two-year study that
compiled end user research and laboratory studies to develop a more effective
tourniquet for all environments. Tac Med Solutions was able to reduce the
weight of the tourniquet by 25 percent while enhancing performance. It’s faster
and easier to apply and stronger. The SOF-TT-W features a snap-lock buckle for
rapid, easy application and wider 1.5-inch strap for additional arterial
compression. Aluminum alloy components are utilized in all areas of critical
new tourniquet that is gaining interest in the tactical community is TEMS Solutions
unique SWAT-Tourniquet™. Of stretch-retention design, the SWAT-T (Stretch, Wrap
and Tuck) is exceptionally versatile. It may be employed as a tactical
tourniquet, pressure dressing, and elastic bandage. In testing conducted by
trauma surgeon Sydney Vail, MD, the SWAT-T has proven 100 percent effective in
stopping arterial blood flow. The SWAT-T is lightweight, easy to apply, and
reusable. It has been applied 5,000 times, used in the sub-zero temps of
Antarctica, and boiled in water with no strength degradation.
H& H Associates’ Tourni-Kwik™-4 (TK-4) and Tourni-Kwik-4L (TK-4L) are also
popular tactical tourniquets. The TK-4 was one of the top-performing
tourniquets in the Naval Experimental Diving Units (NEDU) evaluation of
self-applied tourniquets for combat applications. The TK4L improved upon the
TK-4 for use on lower extremities by adding a tensioner at one end to allow
more force to be applied. The TK-4 and TK-4L are stretch-retention tourniquets.
They are compact, lightweight, and are quick and easy to apply, as well as inexpensive.
agents are wise companions in your blow-out kit in addition to a tourniquet. A
hemostatic agent is the first line of treatment for a life-threatening
hemorrhage on external wounds that are not amendable to tourniquet placement.
Z-Medica QuikClot® Combat Gauze™ was chosen by the CoTCCC as the hemostatic
product to be carried by all branches of the U.S. military for the temporary
external control of life-threatening traumatic hemorrhage.
Combat Gauze combines surgical gauze with an inert mineral called kaolin. Kaolin
is a white aluminosilicate that initiates the clotting cascade upon contact
with blood by activating Factor XII, Factor XI and prekallikrein. Kaolin-based
QuikClot gauze is the most effective product among the dressings tested,
allowing the least amount of hemorrhage and resulted in the highest survival
rate. The hemostasis time for kaolin-based QuikClot gauze was typically five
previous QuikClot products, which were zeolite-based, kaolin-based QuikClot
products generate no heat. The new generation of QuikClot products also stops
arterial and venous bleeding more rapidly than the earlier Z-Medica products.
Gauze is a soft, white, sterile, non-woven 3-inch by 4 yards rolled gauze. It
also comes in a z-folded version called Combat Gauze LE. Z-Medica also makes QuikClot Sport™ and
QuikClot Sport Silver™ Advanced Clotting Sponges™. Like Combat Gauze, they come
in a foil pouch and employ kaolin. QuikClot Sport Silver has ionic silver to
prevent the growth of bacteria and fungi until more advanced medical care is
available. They all come in a vacuum-packed easy-tear-opening aluminum pouch.
carrying one tourniquet in your blow-out kit and one where you can quickly
access it. Keep one of the tourniquets
close to the centerline of the combat vest or chest rig. In this position, it
is easy to access the tourniquet with either hand. Another popular place to keep
a tourniquet is on the belt. Standardize on the position of the tourniquet, and
make certain that others with you know where it’s located.
smart solution is to carry your tourniquet in a pouch, one that fully protects
your tourniquet and also affords easy access, such as T3 Tourniquet Pouch, Gen
2 for the combat tourniquet, Blackhawk Pop Up Tourniquet Pouch, North American
Rescue C-A-T Holder, and Tac Med Solutions Tourniquet Case. All are MOLLE
compatible and available in several colors.
Med Solutions also makes a Stealth Tourniquet Holster (STH). It mounts on the
inside of a police duty belt, saving space on the outside. Although the STH is
designed for the SOF-T-W, it will accommodate other tourniquets as well. Tourniquet
pouches should be marked with a T, TK, TQ or a red cross to clearly identify
rules have changed on tourniquet use. Always carry a tourniquet, one that is
easily accessed and protected from the elements. Know how and when to use it.
Always carry a good hemostatic agent. The life you save may be your own.
provides investigative and tactical consulting services and is a former
officer. He may be reached at firstname.lastname@example.org.