Is Your Hemorrhage Control Training Current? What the 2026 TCCC Guidelines Require

Once casualty care begins, control of life-threatening external hemorrhage remains the first medical priority. The current guidance underneath that principle is more specific than many personnel remember, particularly around tourniquet reassessment, conversion criteria, wound-packing adjuncts, junctional bleeding, and resuscitation.

The May 2026 TCCC Guidelines incorporated changes driven in part by operational experience from the Russo-Ukrainian War, which revealed both over-application of tourniquets and an increase in ischemic complications from prolonged application during extended evacuations. The rationale was published as TCCC Proposed Change 25-2 by Koch et al. in the Journal of Special Operations Medicine and was incorporated into the May 2026 guideline language.

A Tourniquet Is Not Done Once It Is Applied

The Care Under Fire phase retains the established approach: apply a limb tourniquet over the uniform, clearly proximal to the bleeding site. When the site is not immediately apparent, the tourniquet goes high and tight, as proximal as possible on the injured limb.

In Tactical Field Care, every applied tourniquet must be reassessed. Providers expose the wound and determine whether the tourniquet is actually needed. If a tourniquet was placed over the uniform, or was positioned high and tight before the wound could be exposed, reassessment may require moving effective control to a tourniquet placed directly on the skin, 2 to 3 inches above the bleeding site. The original tourniquet is then loosened, and the provider confirms that bleeding remains controlled. If there is no traumatic amputation, a distal pulse is checked. If bleeding persists or a distal pulse remains, the tourniquet is tightened further or a second tourniquet is applied side-by-side to eliminate both bleeding and the distal pulse.

Reassessment also covers necessity. If it determines the tourniquet was not needed, it is removed and the time of removal is documented on the TCCC Casualty Card.

Conversion Has a Time Window and a Scope Limit

Converting a tourniquet to hemostatic or pressure dressings requires all three criteria to be met: the casualty is not in shock, the wound can be closely monitored for bleeding, and the tourniquet is not controlling hemorrhage from a traumatic amputation. When all three criteria are met, every effort should be made to convert within 2 hours.

The guidelines establish a clear scope limit on who makes that call. All Service Member and Combat Lifesaver trained personnel should not attempt tourniquet conversion beyond 2 hours post-application unless directed by TCCC Combat Medic/Corpsman or Paramedic/Provider level personnel, or other advanced medical personnel. Beyond two hours, ASM- and CLS-trained personnel leave the tourniquet in place, continue monitoring it, and correct any loss of hemorrhage control while awaiting higher-level care. A tourniquet in place more than 6 hours is not removed in the field unless close monitoring and lab capability are available.

Each tourniquet is marked with its application time. Application, reapplication, conversion, and removal times are also recorded on the TCCC Casualty Card.

Wound Packing Depends on the Adjunct

Combat Gauze remains the CoTCCC hemostatic dressing of choice for compressible hemorrhage not amenable to tourniquet use. Alternative hemostatic adjuncts include Celox Gauze, ChitoGauze, and XStat, with XStat best suited to deep narrow-tract junctional wounds. The guideline also includes the iTClamp as a separate mechanical wound-closure adjunct, not a hemostatic dressing.

Hemostatic dressings should be applied with at least 3 minutes of direct pressure. The guideline makes direct pressure optional for XStat. If a hemostatic dressing fails to control bleeding, it may be removed and replaced with a fresh dressing of the same type or a different type. XStat is not removed in the field. Additional XStat, other hemostatic adjuncts, or trauma dressings may be applied over it.

For head and neck hemorrhage where wound edges can be re-approximated, the iTClamp may be used as a primary option, alone or in conjunction with hemostatic dressings or XStat. Wounds should be packed with a hemostatic dressing or XStat, if appropriate, before iTClamp application. The iTClamp does not require additional direct pressure in either configuration. If applied to the neck, frequent airway monitoring is required and any expanding hematoma that may compromise the airway must be evaluated. The iTClamp must not be applied on or near the eye or eyelid, within 1 centimeter of the orbit.

Junctional Bleeding Requires the Right Device for the Anatomy

For anatomically amenable junctional hemorrhage, particularly in the groin or axilla, the guideline calls for immediate application of a junctional tourniquet. Hemostatic dressings with direct pressure are applied when a junctional tourniquet is not available or while it is being readied. Once ready, its application is not delayed. Head and neck hemorrhage is addressed separately: wound packing and, when wound edges can be re-approximated, possible iTClamp use.

A pelvic binder addresses a different problem. It is applied for suspected pelvic fracture when severe blunt force or blast injury is combined with any of the following: pelvic pain, any major lower limb amputation or near-amputation, physical exam findings suggestive of pelvic fracture, unconsciousness, or shock.

Eastridge et al., analyzing U.S. combat fatalities from 2001 to 2011, found that hemorrhage accounted for 90.9 percent of potentially survivable deaths occurring before arrival at a medical treatment facility. The Hartford Consensus drew on that finding to shape a civilian active-shooter response model, placing hemorrhage control second only to threat suppression in its THREAT framework and identifying external hemorrhage control as a core law-enforcement skill.

Resuscitation Guidance Applies at the Appropriate Medical Level

The following section applies to personnel operating at an appropriate medical scope and under an approved blood-product protocol.

Field indicators of hemorrhagic shock include altered mental status in the absence of brain injury and/or a weak or absent radial pulse. When shock is identified and blood products are available, the preferred hierarchy is cold-stored low-titer group O whole blood; pre-screened low-titer group O fresh whole blood; plasma, RBCs, and platelets in a 1:1:1 ratio; plasma and RBCs in a 1:1 ratio; and, when those are unavailable, plasma or RBCs alone. The guideline further identifies reconstituted dried plasma, liquid plasma, or thawed plasma as plasma-only options in the operational resuscitation sequence.

Tranexamic acid is indicated when a casualty will likely need a blood transfusion, or presents with hemorrhagic shock, one or more major amputations, penetrating torso trauma, or evidence of severe bleeding. It is also indicated when there are signs or symptoms of significant TBI or altered mental status from blast or blunt trauma. The dose is 2 grams via slow IV or IO push, as soon as possible and no later than 3 hours after injury.

The current guideline calls for 1 gram of calcium after the first transfused blood product: 30 milliliters of 10 percent calcium gluconate or 10 milliliters of 10 percent calcium chloride, administered IV or IO.

Training Should Match Current Language, Not the Date on the Certificate

Any curriculum developed before the May 2026 guidelines should be checked against the current language, particularly the standardized tourniquet reassessment and conversion instructions. Publication date alone does not establish curriculum accuracy in either direction.

The Hartford Consensus identified external hemorrhage control as a core law-enforcement skill and called for police departments to train and equip officers to use tourniquets and hemostatic dressings. The doctrine those officers are trained to is now more specific about what happens after the tourniquet goes on. That specificity is where the gap between current guidelines and what personnel were last taught tends to be widest.