ABSTRACT
Compared with advanced healthcare providers (HCP), organisational protocols for tourniquet de-escalation by non-medical (NM) defence personnel require greater emphasis on simplicity, procedural efficiency, minimised decision-making and redundancy. This article describes how the 2026 TCCC tourniquet de-escalation guidelines may be further developed to incorporate design features specific to the requirements of NM defence providers.
DISCUSSION
The current Russo–Ukrainian War has exposed limitations in Tactical Combat Casualty Care (TCCC) tourniquet application protocols when used without coordinated forward de-escalation measures.1-8 Traditional tourniquet-management protocols, while proven in counterinsurgency operations, are less suitable for combat environments dominated by extended-duration evaluation resulting from contested mobility or longer-distance transportation to advanced clinical care. To mitigate the risk of iatrogenic tourniquet ischaemia in current and emerging warfare environments, a North Atlantic Treaty Organisation (NATO) Specialist Working Group published guidelines in 2025 to extend tourniquet de-escalation to appropriately trained non-medical (NM) military personnel.9 Consistent with these recommendations, the recently revised Joint Trauma System TCCC Guidelines 2026 now include an expectation for All Service Member (ASM) proficiency in the conduct of tourniquet de-escalation procedures (Figure 1).10,11
Tourniquet de-escalation is a set of potentially high-risk clinical procedures, particularly when conducted by NM defence providers within resource-limited environments with limited or no supervision. Organisational protocols and educational products to enable safe NM defence provider tourniquet de-escalation therefore require design features specific to the requirements of a relatively inexperienced target group and awareness of their anticipated operational environment.
Compared with the training requirements of advanced health providers, protocols designed for tourniquet de-escalation by NM defence personnel require greater emphasis on simplicity, procedural efficiency, minimised decision-making and redundancy. This commentary describes how the TCCC Guidelines 2026 for NM provider tourniquet de-escalation may be optimised prior to implementation within the Australian Defence Force.
Simplification of decision nodes within the tourniquet de-escalation sequence
The TCCC Guidelines define two de-escalation procedures suitable for conduct by NM defence providers: 1) tourniquet conversion and 2) tourniquet repositioning. Arbitrarily, conversion and repositioning are described as independent procedures; however, from a clinical outcomes perspective, these interventions are better considered as two outputs on a graduated spectrum of ischaemic harm minimisation. How is this distinction useful?
When faced with a severely injured casualty with a tourniquet in situ, the NM defence provider needs first to decide their initial clinical response, namely: ‘Do I perform tourniquet repositioning or do I perform tourniquet conversion?’ (Figure 1). While advanced healthcare providers (HCP) are trained to make these judgements and can seamlessly flow between different clinical strategies based on pattern of wounding, adequacy of resuscitation and the tactical environment, this level of complexity may be less suitable for inexperienced NM defence providers performing their first live tourniquet de-escalation on a severely wounded casualty without supervision.
Protocolising a decision to conduct tourniquet repositioning in the initial instance based on provider assessment of wounding severity presents several potential risks. Within the 2026 TCCC framework, tourniquet repositioning is presented as an end point intervention. Once successfully completed, whether by initial selection or required due to unsuccessful tourniquet conversion, the de-escalation sequence under this protocol is complete (Figure 1).
However, during tourniquet repositioning, the protocol describes no attempt at local haemorrhage control by ‘pack, wrap & press’ (compression wound packing, pressure dressing application & local pressure). While for complete limb amputations, the initial decision to conduct tourniquet repositioning is intuitive, the perception of what constitutes a severely mangled extremity, in terms of vascular compromise and limb salvageability, relies on experience. The danger in relying on the lay provider for this assessment is illustrated by the high rates of medically non-indicated initial tourniquet application, both in civilian and military trauma. The point to emphasise is that in the hands of inexperienced NM defence providers, the currently proposed TCCC algorithm may result in salvageable limbs being denied a reasonable attempt at tourniquet conversion because it places insufficient emphasis on non-tourniquet-facilitated haemorrhage control.
From an organisational perspective, protocols and techniques developed for tourniquet de-escalation by NM defence providers thus need to minimise reliance on clinical experience-based decision-making. From a practical perspective, this involves balancing the risk of recurrent haemorrhage against the risk of failing to attempt tourniquet conversion appropriately. One way to reconcile this is to implement protocols biased towards local wound packing, pressure dressing application and an attempt at tourniquet conversion in all limb wounds that do not involve amputation. In this way, even if tourniquet conversion is unsuccessful, appropriate adjunctive local wound management techniques will still assist with achieving haemorrhage control during tourniquet repositioning.12,13
Preparing for failure: Building redundancy into tourniquet de-escalation sequences
In mitigating the risk of iatrogenic tourniquet ischaemia in modern warfare, what is the appropriate end state after unsuccessful tourniquet conversion? If prolonged tourniquet application times are anticipated, then tourniquet repositioning should be attempted in all cases of failed conversion as a routine part of a graduated harm minimisation strategy. Providers may recognise unsuccessful conversion either immediately or in a delayed manner, due to reduced vasospastic arterial occlusion or upon hypotension reversal. In either case, optimised protocols for tourniquet de-escalation by NM defence providers should have integrated redundancies to efficiently manage unsuccessful tourniquet conversion and minimise the risk of procedural haemorrhage. However, by describing conversion and repositioning as separate procedures, a therapeutic gap is potentially created between recognising unsuccessful conversion and transitioning to the application of a deliberate tourniquet.11,14 One technique to address this concern is to routinely pre-position a deliberate tourniquet (without tightening) prior to attempting tourniquet conversion.12,13 In the event of an unsuccessful tourniquet conversion, the pre-positioned deliberate tourniquet may be tightened to efficiently arrive at the next most appropriate de-escalation state (Figure 2). These techniques reflect current practice in several pre-hospital services within Australia, including the New South Wales Ambulance Special Operations Unit. Figure 3 presents the associate tourniquet-management and de-escalation protocol, optimised for NM defence providers.
While advanced HCP in a resource-limited environment may elect to perform tourniquet conversion without pre-positioning of a deliberate tourniquet, this method has less integrated redundancy and a less efficient transition to tourniquet repositioning. It is therefore arguably less suitable for NM defence providers.
Likewise, what is the outcome of successful tourniquet repositioning according to 2026 TCCC protocols? In this situation, the immediate action (initial) tourniquet remains loosely in place and is slid down the limb to a position adjacent to the deliberate tourniquet. If re-bleeding occurs, then a dual tourniquet strategy may be efficiently employed. While this approach minimises the risk of venous congestion and potential compartment syndrome, these benefits must be weighed against repositioning the immediate action tourniquet away from a location previously proven to provide adequate haemostasis. For military wounding with high-velocity projectiles and blast injury, where the level of vascular injury may potentially be proximal to the external wound or segmental due to projectile fragmentation, ballistic cavitation or vascular retraction, the original high location of the immediate action tourniquet provides a ‘no fail’ alternative for delayed haemorrhage after tourniquet conversion. Leaving the immediate action tourniquet loose in the original high position, rather than repositioning it to a more distal location, therefore, provides a greater level of safety for NM providers (Figure 2; Step 4).
CONCLUSION
The 2026 TCCC recommendations enabling NM defence providers to conduct forward tourniquet de-escalation represent an evidence-based logical response to the changing landscape of mobility contested warfare. Protocols and techniques for tourniquet de-escalation have traditionally been designed for use by dedicated HCP. Transitioning a potentially high-risk medical procedure into the hands of relatively inexperienced personnel in austere environments with minimal support requires provider-specific adaptation of our traditional protocols and techniques.
APPROVALS
The Australian Defence Force has approved publication of this manuscript.
DISCLAIMER
The views expressed within this manuscript are those of the authors and do not reflect current policy of the Australian Defence Force or New South Wales Ambulance Service.
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