Tactical Combat Casualty Care (TCCC) is the military version of Prehospital Trauma Life Support and was developed in the mid-90s by the Naval Special Warfare Command. The lessons taught have been saving lives on the battlefield and in many civilian tactical situations. Many of the principles utilized by TCCC have a direct application in the wilderness setting.

One of the most effective principles in TCCC is tourniquet application. Tourniquet usage is the first-line treatment for life-threatening extremity hemorrhage on the battlefield. While tourniquets have been shunned in the civilian setting, the military has shown that they are effective with minimal complications. There have been no reported amputations arising from military tourniquet application, but a small number of transient nerve palsies were noted. As extremity hemorrhage is one of the most preventable causes of death. The prompt application of a tourniquet has saved approximately 1,000 – 2,000 military personnel since the advent of TCCC.

Definitive surgical care is delayed in a firefight, and the same holds true for many wilderness expeditions. While the mechanism of injury is often different than the typical military casualty, the prompt application of a suitable tourniquet could save lives in the backcountry. There are guidelines for tourniquet usage and not all tourniquets are created equal. The old cravat and stick routine has gone the way of a Tyrannosaurus rex. There are TCCC recommended tourniquets that have undergone extensive testing under harsh environments. The Combat Application Tourniquet (CAT) and the SOF-Tactical Tourniquet are, perhaps, the most commonly used, and can be purchased by non-military through a reputable online company. These tourniquets are designed for single-hand self-application and can be applied in seconds should you not have a buddy around. Commonly utilized practice tests are to be done blindfolded, then effectively apply the tourniquet in less than 2 minutes. These commercial tourniquets are small and lightweight. They utilize a self-adhering band with hook and loop closures. A windlass system is incorporated for single-hand use and ensures a tight fit.

Whichever tourniquet is chosen, one must be adept at its use and familiar with the indications for application. The indication for usage is life-threatening extremity hemorrhage. In other words, it should not be applied for wounds where simple direct pressure can easily stop a bleed. There is no need to immediately remove clothing as a tourniquet is designed to apply over these items and you save precious time in stopping the bleed. Excess clothing can be removed at a later time during your secondary survey and the tourniquet repositioned, on the skin surface, 2-3 inches proximal to the wound. Do not apply over cargo pockets or other areas containing bulky items as this will limit the effectiveness of the tourniquet. Tourniquets should be left in place no longer than 2 hours before attempting to reassess hemorrhage although, when used in a surgical environment, tourniquets have been left in place up to 6 hours with no untoward effects.

A common mistake is waiting to apply the tourniquet in the setting of a life-threatening hemorrhage. Upon recognizing this situation, a tourniquet should be applied promptly. Another mistake is applying the tourniquet too loosely. A properly applied tourniquet should abolish the distal pulse on the involved extremity resulting in tamponade of blood flow. It is not uncommon, in the setting of profuse hemorrhage, to apply two tourniquets in order to achieve this goal. The tourniquet should never be applied over a joint surface, as this will prevent proper vessel compression against the bone and result in the tourniquet loosening when the joint is moved.

An important caveat to remember is that a properly applied tourniquet will hurt! If you are equipped to do so, pain management will likely be needed. If the tourniquet is applied to a lower extremity, prolonged ambulation will be next to impossible. This is the time when those improvised litter skills come in handy! The addition of a TCCC commercial tourniquet to your rucksack is an invaluable investment. While tourniquets are simple to use, learn proper instruction in the application of these devices.

Recommended Reading:

PHTLS: Prehospital Trauma Life Support, Military Edition, 7th edition. Kragh Jr, JF, Walters TJ, Baer, DG, et al. Practical use of emergency tourniquets to stop bleeding in major limb trauma. J Trauma. 2008; 64(2 Suppl): S38–S50.