Tourniquets That Actually Work
Objective: Put a tourniquet on so arterial bleeding actually stops — deliberate placement on skin 2–3 inches above the wound, not a loose “venous only” band.
Why This Is Hard
A tourniquet that looks applied and still spurts is a venous tourniquet — it can make bleeding worse. TCCC/TECC teaching is mechanical and boring: tight enough that the distal pulse and the bleed both stop. CoTCCC: in tactical field care, place a recommended limb tourniquet directly on the skin 2–3 inches above the bleeding site. Not over the elbow or knee. If the first one fails, a second goes side-by-side, proximal.
- Write the time on the TQ or the forehead. The receiving trauma team will ask.
- Do not loosen it on the ramp “to see if they still need it.” Convert only if trained, the new TQ holds, and protocol allows.
- Junctional bleeds and the groin are not limb-TQ problems — that is packing. This lesson is extremities.
- Arterial extremity bleed — TQ now, not after a perfect exam
- On skin, 2–3 inches above, not on a joint
- Windlass until bleeding and distal pulse stop; lock it; note the time
- Still spurting → second TQ proximal / side-by-side — do not loosen to peek
Hasty vs Deliberate (Education)
- Chaos / care-under-fire analog: high and tight, over clothing if you must, as proximal as needed to stop the dying. Civilian translation: active shooter, dark ditch, you cannot see the hole yet.
- Then convert to deliberate: expose, place a TQ on skin 2–3 inches above the wound, tighten, then slowly release the hasty one if the new one holds. Do not convert if you are minutes from the trauma bay and it is working, or if conversion would restart a bleed you cannot control.
Street Rules
- Commercial windlass devices you train with beat improvised belts — but a working improvised TQ is better than a polite pressure dressing on a stump.
- Wide straps. Narrow cords cut tissue and fail.
- Write the time on the TQ and the PCR. Tell the receiving team.
- Reassess after every move. Packaging loosens windlasses.
- Junctional bleeds (groin, axilla, neck) are not limb-TQ problems — see wound packing.
Field Pitfalls
- TQ over the knee “because that’s where the strap landed.”
- Loosening every two minutes to “see if they still need it.”
- One click of the windlass and a still-spurting femoral.
Practice
60-second drill
On a training limb, clock a CAT-style TQ until a simulated pulse is gone. Call the time. Partner tries to slide two fingers under — if they can, it is not done.
Related: Massive Hemorrhage First, Wound Packing.
Sources & Further Study
Named guidelines for further study. They are not clinical orders and do not replace your protocol or medical direction.
- NASEMSO National Model EMS Clinical Guidelines (2022) — U.S. EMS model language; protocol still wins
- Committee on Tactical Combat Casualty Care (TCCC) — on-skin, 2–3 inches above, second TQ if needed
- Tactical Emergency Casualty Care (TECC)
- Stop arterial flow. Note the time. Protocol owns conversion and when to leave it on.
Education only. Apply learning within your protocols and medical direction. This is not clinical care guidance.
Check Your Understanding
Street decisions from this lesson only. After you check, the key is highlighted. Education practice — not a certification exam.