Key Takeaways
What Prompted This Change?
- Lessons learned from the Russo-Ukrainian War identified frequent tourniquet use in situations where tourniquets were not medically indicated.
- Prolonged evacuation timelines resulted in extended tourniquet application times and increased concern for ischemic complications.
- These operational challenges highlighted the need for a simpler, standardized approach to tourniquet reassessment and conversion.
What Does Proposed Change 25-2 Do?
- Standardizes tourniquet reassessment, repositioning, and conversion practices across all TCCC tiers.
- Replaces the term replacement with repositioning to improve clarity and consistency.
- Introduces a simplified, time-based algorithm written in plain language.
- Establishes a reassessment window within the first 2 hours after tourniquet application.
- Reserves tourniquet conversion beyond 2 hours for qualified medical personnel.
Why Is This Important?
- Effective hemorrhage control remains the priority in preventing preventable combat deaths.
- Unnecessary or prolonged tourniquet use may increase the risk of ischemic injury and other complications.
- Standardized reassessment can help balance lifesaving hemorrhage control with preservation of limb function and overall patient outcomes.
What Does This Mean for Non-Medical Responders?
- Tourniquet management does not end once the bleeding is controlled.
- Trained non-medical personnel play a critical role in documenting application times, monitoring casualties, and conducting reassessments within the first two hours when tactically feasible.
- The proposed guidance provides a practical framework that supports safe decision-making while remaining within established training and scope-of-practice limitations.
Operational Bottom Line
- Apply tourniquets rapidly for life-threatening extremity hemorrhage.
- Document the time of application.
- Reassess tourniquets within the first two hours when conditions permit.
- Maintain effective hemorrhage control throughout casualty care.
- Communicate tourniquet status, application time, and reassessment findings during every casualty handoff.
Introduction
Tourniquets remain among the most effective lifesaving interventions in modern combat casualty care. Their widespread adoption during operations in Iraq and Afghanistan contributed significantly to reductions in preventable deaths from extremity hemorrhage (Butler et al., 1996). However, recent conflicts have highlighted new challenges related to tourniquet management in environments characterized by delayed evacuation and prolonged field care.
Lessons learned from the Russo-Ukrainian War revealed that tourniquets were frequently applied in situations where they were not medically indicated and often remained in place for extended periods because of prolonged evacuation times (Koch et al., 2026). In response, the Committee on Tactical Combat Casualty Care (CoTCCC) convened a multidisciplinary working group to evaluate tourniquet reassessment and conversion practices across all levels of Tactical Combat Casualty Care (TCCC),These observations prompted the development of TCCC Proposed Change 25-2, which seeks to standardize tourniquet reassessment and conversion practices across all TCCC tiers.
Operational Background
The operational environment that informed Proposed Change 25-2 differs substantially from previous conflicts characterized by rapid evacuation to higher levels of care. In Ukraine, delayed casualty evacuation has resulted in prolonged tourniquet application times and associated complications (Koch et al., 2026).
The working group identified increased concern regarding Prolonged Tourniquet Application Syndrome (PTAS), which may include:
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Limb ischemia
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Compartment syndrome
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Amputation
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Metabolic acidosis
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Hyperkalemia
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Acute kidney injury
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Death in severe cases
These operational findings emphasized the need for a structured approach to ongoing tourniquet management rather than viewing tourniquet application as a single intervention (Koch et al., 2026).
Rationale for Standardization
The CoTCCC Working Group reviewed existing practices and identified inconsistencies in terminology, training, and decision-making across TCCC levels. These discrepancies created confusion, particularly among nonmedical personnel responsible for initial hemorrhage control (Koch et al., 2026).
Working in collaboration with NATO allies and partner nations, the group developed a simplified, time-based algorithm designed to:
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Improve recognition of unnecessary tourniquet use.
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Standardize reassessment procedures.
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Reduce ischemic complications.
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Improve coalition interoperability.
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Simplify education and operational implementation.
The overarching objective is to balance the lifesaving benefits of tourniquet use with the risks associated with prolonged ischemia (Koch et al., 2026).
Key Components of Proposed Change 25-2
1.Terminology Change: Replacement to Repositioning
One of the most significant updates is the replacement of the term replacement with repositioning. According to the Working Group, inconsistent interpretation of the term replacement led to confusion during training and operational execution. The term repositioning more accurately describes moving a tourniquet to a more anatomically appropriate location while maintaining effective hemorrhage control (Koch et al., 2026).
Standardized terminology is intended to improve consistency across training programs, operational communication, and clinical documentation.
2. Establishment of a Two-Hour Reassessment Window
The proposed change formally establishes a reassessment window within two hours of tourniquet application. During this period, appropriately trained nonmedical personnel, including All Service Members (ASM), may reassess a tourniquet and determine whether repositioning or conversion is appropriate according to established criteria (Koch et al., 2026). This modification acknowledges the reality that the first responder caring for a casualty is often not a medic and that timely reassessment may reduce complications associated with unnecessary prolonged tourniquet use.
3.Restriction of Conversion Beyond Two Hours
While reassessment authority is expanded, tourniquet conversion after two hours remains restricted to medical personnel. The Working Group concluded that conversion decisions become increasingly complex as ischemic time lengthens, requiring advanced clinical judgment and risk assessment (Koch et al., 2026). Consequently, nonmedical personnel may continue to monitor and reassess the casualty but should not perform tourniquet conversion beyond the two-hour threshold.
Clinical Significance
Tourniquets achieve hemorrhage control through complete arterial occlusion distal to the device. While effective for preventing exsanguination, prolonged interruption of blood flow can contribute to progressive tissue injury.
Potential consequences of prolonged ischemia include:
Prompt reassessment helps determine whether a tourniquet remains necessary and whether alternative hemorrhage control measures, such as wound packing and pressure dressings, may safely maintain hemostasis while reducing ischemic exposure (Koch et al., 2026).
The proposed algorithm therefore balances two competing priorities: maintaining definitive hemorrhage control and minimizing preventable tourniquet-related morbidity.
Relevance to Non-Medical Responders
A notable strength of Proposed Change 25-2 is its recognition of the critical role non-medical personnel play in modern combat casualty care. In contemporary operational environments, the first individual to provide hemorrhage control is frequently not a medic but an All Service Member, Combat Lifesaver, law enforcement officer, or other trained first responder.
The proposed guidance acknowledges this reality by providing a simplified, time-based algorithm written in plain language that can be applied across TCCC tiers. By authorizing trained non-medical personnel to reassess tourniquets within the first two hours after application, the guideline expands the ability to identify unnecessary tourniquet use, recognize opportunities for repositioning or conversion when appropriate, and communicate findings to subsequent levels of care (Koch et al., 2026).
Importantly, the proposed change does not expand non-medical practice beyond established training limits. Rather, it provides clearly defined decision points intended to support safe reassessment while preserving higher-risk conversion decisions for medical personnel after the two-hour threshold. This approach balances operational necessity with patient safety and reflects the realities of prolonged casualty care in austere environments.
For commanders, instructors, and unit leaders, the proposal reinforces that effective hemorrhage control extends beyond initial tourniquet application. Successful casualty care requires accurate documentation of application time, ongoing reassessment, effective communication during casualty handoff, and recognition that tourniquet management is a continuous process rather than a one-time intervention.
Implications for TCCC Education and Training
Proposed Change 25-2 has important implications for future TCCC training programs. Emphasis should be placed on:
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Accurate documentation of tourniquet application time.
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Routine reassessment of all applied tourniquets.
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Education regarding repositioning and conversion criteria.
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Standardized terminology across TCCC curricula.
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Preparation for prolonged casualty care environments.
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Enhanced competency among non-medical responders responsible for battlefield hemorrhage control.
The revision reinforces that tourniquet management is a dynamic clinical process requiring continued reassessment throughout the continuum of care (Koch et al., 2026).
Operational Impact
The proposed guidance reflects the evolving realities of large-scale combat operations, where prolonged evacuation timelines and contested logistics may delay access to definitive medical care. By empowering non-medical personnel to perform structured reassessments while reserving higher-risk conversion decisions for medical providers, Proposed Change 25-2 expands battlefield capability without compromising patient safety.
If adopted broadly, the guidance may reduce preventable tourniquet-related complications, enhance coalition interoperability, and strengthen casualty management across all operational environments.
Conclusion
TCCC Proposed Change 25-2 represents an evidence-informed evolution in combat casualty care derived from lessons learned during contemporary large-scale combat operations. By standardizing terminology, establishing a two-hour reassessment window for non-medical personnel, and restricting conversion beyond two hours to trained medical providers, the proposed guidance seeks to reduce preventable morbidity while preserving the lifesaving benefits of tourniquet use (Koch et al., 2026).
Equally important, the guideline recognizes the increasingly central role of trained non-medical responders in battlefield medicine and provides them with a standardized framework for safe tourniquet reassessment during the critical early phase after injury.
As military operations increasingly involve prolonged evacuation timelines and extended field care environments, standardized reassessment and conversion practices may improve casualty outcomes, enhance interoperability, and ensure TCCC principles remain aligned with modern battlefield realities.
Clinical Disclaimer
Clinical Disclaimer: This article is intended solely for educational and informational purposes and summarizes published and proposed Tactical Combat Casualty Care (TCCC) guidance. It does not replace formal TCCC instruction, medical education, clinical judgment, organizational protocols, or operational directives. Tourniquet reassessment, repositioning, and conversion should be performed only by personnel appropriately trained and authorized under current TCCC guidelines and applicable policies. Clinical decisions must be individualized based on patient condition, available resources, and the tactical environment.
References
Butler, F. K., Hagmann, J., & Butler, E. G. (1996). Tactical Combat Casualty Care in special operations. Military Medicine, 161(Suppl.), 3-16.
Joint Trauma System. (n.d.). Committee on Tactical Combat Casualty Care (CoTCCC). Defense Health Agency. https://jts.health.mil/index.cfm/committees/cotccc
Joint Trauma System. (n.d.). Tactical Combat Casualty Care (TCCC) guidelines. Deployed Medicine. https://deployedmedicine.com
Koch, E. J., Andersen, M., Barbee, G. A., Boyd, A., Clayton, C., Hewitt, C. W., Maitha, J. C., Remley, M. A., Nguyen, A., Kaleiohi, J., Montgomery, H. R., Deaton, T. G., Butler, F. K., & Gurney, J. M. (2026). Standardizing tourniquet reassessment and conversion across TCCC tiers: TCCC Guidelines Proposed Change 25-2. Journal of Special Operations Medicine, 26(1), 105-106. https://doi.org/10.55460/J.Spec.Oper.Med.2026.M4V1-O3Y7