The THIRD STEP in hemorrhage control if STEP 1 and STEP 2 are ineffective is to apply a tourniquet (Combat Application Tourniquet/CAT).
Give strong consideration to prophylactically applying a tourniquet to the affected limb without tightening in all but the most minor cases of hemorrhage. Situations can change rapidly and being prepared for the unexpected is the safest practice.
The application of a tourniquet to a massive bleed is time-sensitive! The tourniquet should be applied to stop bleeding within 1 minute and be fully secured within 3 minutes. A casualty with massive bleeding that is not controlled can die within 3 minutes!!!
Expose and clearly mark all tourniquets with the time of tourniquet application. Note the tourniquets applied and the time of application; time of re-application; time of conversion; and time of removal on the TCCC Casualty Card. Use a permanent marker to mark the tourniquet and the casualty card.
CUF: 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.
TFC: 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 the 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 the time of removal on the TCCC Casualty Card.
Safe Tourniquet Times
1-1.5 hours of hand
2 hours of leg
Winter Time - 1 hour
Improper or prolonged placement of a tourniquet because of poor medical training can lead to serious injuries, such as nerve damage and limb ischemia.
Never attempt to convert a tourniquet that has been in place for 6 or more hours without physician supervision and not unless close monitoring and lab capability are available.
The goal is to convert any applied tourniquet within the time frames referenced above to an alternative method of hemorrhage control.
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 being used to control bleeding from an amputated extremity.