Written by: Greg Ellifritz
With the growing number of commercially made tourniquets, an increase in availability of medical courses focusing on gunshot wounds, a greater chance of getting caught up in an active killer event, and the classes like Stop the Bleed being offered everywhere, the issue of tourniquets is on many of my readers’ minds.
There is a massive amount of poor information on this topic available in old medical books and in new YouTube videos. How do you know which tourniquet is the best? With organized propaganda and misinformation campaigns from tourniquet manufacturers combining with ignorant commentary on the internet, it can be a confusing choice. My goal with this article is to provide a centralized location for the curation of all the best recommendations and scientific studies about tourniquet use.
Let’s talk a little bit about tourniquets…
Tourniquets are designed to stop serious arterial bleeding from an arm or a leg. Most of the commercially available tourniquets will do that, at least some times under some conditions. The problem is that there are a lot of tourniquets on the market that don’t work in some of the conditions you may experience. For general tourniquet use guidelines read:
Tourniquets and Hemorrhagic Control on the Battlefield
Tourniquet use in the civilian prehospital setting
Bleeding Control With Limb Tourniquet Use in the Wilderness Setting: Review of Science
Safety and Appropriateness of Tourniquets in 105 Civilian
Impact of time and distance on outcomes following tourniquet use in civilian and military settings
You can go on YouTube and find video evidence that whatever tourniquet you research will stop bleeding. That’s awesome, but it’s not good enough.
Tourniquets must occlude distal blood flow to be effective. That’s the bare minimum performance standard. Almost all of the commercially available tourniquets will stop bleeding on some people some of the time. That’s not the tourniquet’s sole performance objective.
I could probably put any commercially manufactured tourniquet on someone in a classroom setting and pull it tight enough to shut down distal blood flow, even when measured by doppler ultrasound. Quite simply, that’s what a tourniquet is designed to do.
After we establish that it is generally able to stop extremity blood flow, then we start asking the more difficult questions:
– Will it stop all blood flow on all sizes of limbs? Will it work on big thighs? Statistically any limb larger than 25″ in circumference will require more than one tourniquet. Is this one better or worse than others in terms of stopping blood flow on muscular or obese patients?
-How quickly can it be put on?
– Will it work when I try to apply it to myself with slippery, blood-covered hands while I go into hypovolemic shock?
– Will it stay tight during the rough handling of a patient evacuation?
-Will it stay on during aggressive movement in a fight?
-Will it rigorously resist environmental conditions such as rain, snow, ice, and mud?
-How much pain does it create for the patient when applied? A narrow tourniquet band usually causes more pain than the wider versions.
– Will it resist bright sun light and heat (which regularly degrade plastic)?
– Will a long duration application cause any nerve or tissue damage?
– If the tourniquet is applied incorrectly due to stress or poor training, will it cause the patient further harm?
–Will it work while wearing full kit gear, in low light and no light?
-Can it be used with flight gloves, MOPP gloves, shooting gloves, and cold weather gloves without affecting performance?
No one knows the answers to these questions with regards to a lot of the latest and greatest tourniquets. They’re new. Those tests haven’t been conducted.
As I stated, almost all the tourniquets on the market will occlude blood flow in ideal conditions. A lot of them fail in regards to the issues I raised above. Just because you can get a tourniquet to work in a single application during a stress-free classroom training session doesn’t mean it’s a good tourniquet.
If you need a tourniquet, you are in danger of bleeding to death. When death is the consequence of a poor product performance, I tend to buy the best gear possible. Why take a chance on something new when there are already products that have a proven track record in combat available for less than $30 each?
“Cheap and easy” is not the criteria I’m looking for when purchasing life saving gear.
So what tourniquets have passed the kind of tests I wrote about above?
The Committee on Tactical Combat Casualty Care does the most authoritative testing on tourniquets and medical gear for all branches of the US military. That group contains all the true rock stars of emergency trauma medicine. They are a really smart group of doctors, surgeons, medics, and PAs who have access to the best information on the planet. That group analyzes all the studies and puts out the best recommendations and practice guidelines for tourniquet use.
As of December 15, 2021 the CoTCCC has issued new recommendations, including several tourniquets that were not previously recommended. Click on “view book” at the link to see all the new recommendations. The 2019 version of these guidelines recommended several newer tourniquets that for the first time since 2004.
You can find a quick video review of all the approved tourniquets at the SkinnyMedic YouTube Channel.
I will discuss each of the group’s recommendations and the science behind those recommendations below. The tourniquets and links to research are organized by tourniquet type.
Traditional Windlass Tourniquets
As I mentioned above, the list of recommended tourniquets has been very small since it came out in 2004. From 2004 until 2019, the CAT and the SOFT-T Wide were the only non-pneumatic tourniquets recommended by the Committee on Tactical Combat Casualty Care (CoTCCC).
The CAT and the SOFT-T Wide remain on the recommended list. Here are the instructions for applying the CAT.
I like using the SOFT-T W for application on another person, but really prefer the CAT for self-application. I find the CAT is easier to self-apply and it is a bit lighter in weight. Either of these tourniquets will serve your needs nicely.
Please be careful where you source your tourniquets, especially with the CAT. There are a lot of counterfeit CAT tourniquets being sold on the internet. If your vendor isn’t a licensed distributor for North American Rescue, your tourniquets are likely to be counterfeit and may fail in an emergency. CAT tourniquets cost around $30. If you are buying them for $12.99, you are getting a fake. Read Detecting Counterfeit CAT Tourniquets to learn to tell the difference between the two.
Here is some of the relevant research regarding the CAT and SOFT-T.
The new SAM SXT tourniquet is not superior to the CAT.
TMT Tourniquet not Superior to CAT
RATS and TMT tourniquets Inferior to CAT
CAT Performs Better than improvised tourniquets
National EMT Association Guidelines Recommend Only CAT and SOFT-T
The Combat Application Tourniquet Versus the Tactical Mechanical Tourniquet.
Preliminary Comparison of New and Established Tactical Tourniquets in a Manikin Hemorrhage Model.
Practical use of emergency tourniquets to stop bleeding in major limb trauma
Effectiveness of self-applied tourniquets in human volunteers.
CAT and SOFTT were found to be superior to the IRT
The Military Emergency Tourniquet Program’s Lessons Learned With Devices and Designs
Different Width and Tightening System Emergency Tourniquets on Distal Limb Segments
From Pull to Pressure: Effects of Tourniquet Buckles and Straps
The Tourniquet Gap: A Pilot Study of the Intuitive Placement of Three Tourniquet Types by Laypersons
How do Tactical Tourniquets Compare?
Tourniquets and Occlusion: The Pressure of Design
Efficacy of Tourniquets Exposed to the Afghanistan Combat Environment
Re-Evaluating the Field Tourniquet for the Canadian Forces
The Combat Application Tourniquet Versus the Tactical Mechanical Tourniquet
CAT Gen 7 is better than CAT Gen 6
CAT tourniquet is 79% effective
RMT tourniquet worked better than CAT or SWAT -T
Commercial CAT performed better than either improvised tourniquet.
C-A-Ts mechanically fit the simulated limbs of infants aged 3-5 months
Effectiveness rates of TQ (mostly CATs) varied between 78% and 100%
The C-A-T and SOFTT-W were quickest to occlude and secure
On a simulator test, the CAT led to a slightly better survival rate than the SAM-XT or SOFT-T Wide
The CAT is as effective as the TMT and significantly more effective than the SOFTT-W.
CAT 79% effective in 7 months of battlefiend injuries in Iraq war
Layperson responders more successfully apply CAT than STAT tourniquets
SAM Extremity Tourniquet (SAM-XT)
The SAM tourniquet is similar in design to the CAT and SOFT-T. One big difference is that users will hear and feel an audible click when the tourniquet is placed tightly enough. Loose initial placement regularly causes tourniquet failures. The clicking feature is designed to prevent that.
There hasn’t been as much published research on the SAM tourniquet.
The new SAM SXT tourniquet is not superior to the CAT.
From Pull to Pressure: Effects of Tourniquet Buckles and Straps
Urgent Medical Device Recall: Sam XT Extremity Tourniquet
On a simulator test, the CAT led to a slightly better survival rate than the SAM-XT or SOFT-T Wide
Tactical Mechanical Tourniquet (TMT)
The primary advantage of this newer tourniquet is its width. It’s a full two inches wide. That’s wider than a lot of other tourniquets that are one inch or 1.5 inches wide. A wider tourniquet may reduce the need for a secondary tourniquet application if the first one fails to stop the bleeding.
The TMT tourniquet can be unbuckled (if you can’t slide the loop around the extremity) much easier than either the CAT or the SOFT-T. The windlass catch is a little harder to use, but looks like it will hold the windlass in place better than the CAT. I did not find this tourniquet quite as easy to self-apply as a CAT, but very fast to place on someone else. An additional advantage is that it is less sensitive to UV light than the CAT tourniquet.
Here is the research on this model:
RATS and TMT tourniquets Inferior to CAT
Tactical Mechanical Tourniquet not Better than CAT
Research Summary on TMT tourniquet.
The Combat Application Tourniquet Versus the Tactical Mechanical Tourniquet.
Preliminary Comparison of New and Established Tactical Tourniquets in a Manikin Hemorrhage Model.
Evaluation of Extremity Tourniquets
From Pull to Pressure: Effects of Tourniquet Buckles and Straps
The Combat Application Tourniquet Versus the Tactical Mechanical Tourniquet
The C-A-T and TMT had comparable responses for most measures
The CAT is as effective as the TMT and significantly more effective than the SOFTT-W.
Ratcheting Tourniquets
Three ratcheting strap tourniquets were recently approved. Early in the TCCC days, there was an additional ratchet tourniquet that was in regular military use for a short time. Branches of the military stopped issuing this older model ratcheting tourniquet after some failures in the field. Many knowledgeable folks have questioned the efficacy of ratcheting tourniquets ever since.
The major advantage of the ratcheting tourniquet is in size and simplicity. Tourniquets without a windlass pack down to a much smaller size and are easier to carry.
RevMed TX-2 and TX-3 Tourniquets
HERE is a list of instructions for RevMed use. The wider TX-2 and TX-3 may cause less pain than other recommended tourniquets. They are also safe to use for practice (unlike the windless tourniquets). Find more details on these tourniquets at this video from the Skinny Medic.
Ratcheting Medical Tourniquet -Tactical (RMT-T) (not the civilian version)
Read the instructions for the RMT HERE.
Similar to the SAM tourniquet, there isn’t much available public research on these designs. The links below are what I was able to dig up.
Different Width and Tightening System Emergency Tourniquets on Distal Limb Segments
Evaluation of possible battlefield tourniquet systems for the far-forward setting.
Tourniquet pressures: strap width and tensioning system widths.
From Pull to Pressure: Effects of Tourniquet Buckles and Straps
The Tourniquet Gap: A Pilot Study of the Intuitive Placement of Three Tourniquet Types by Laypersons
RMT tourniquet worked better than CAT of SWAT -T
The tourniquets I’ve profiled above are the only ones I would use. Full stop. I personally wouldn’t carry an unproven tourniquet design when better options are readily available.
There are, however, a lot of tourniquets on the market that did not get recommended by the CoTCCC. Many of you are likely carrying one of those unapproved tourniquets right now. Let’s take a look at the research covering the tourniquets that weren’t recommended.
Teaching tourniquet application in a medical class.
Elastic Tourniquets Without a Windlass
Elastic tourniquets like the RATS, SWAT-T, STAT, and TK-4 are extremely popular among cops and aware citizens. They are inexpensive and generally pack down to a smaller size than the windless or ratcheting tourniquets.
None of the elastic tourniquets on the market got the CoTCCC recommendation. That should be worrisome for those of you who are relying on these sub-par tourniquets to save your own life or that of a loved one.
Insert random internet meme here.
Commonly cited problems with elastic tourniquet use center around their taking a longer time to apply, the rubber breaking, potential limb damage caused by very narrow applications, and the difficulty involved in keeping the tourniquet tight during evacuation. I personally don’t recommend any elastic tourniquet. They are poor choices. Here is the research to prove it:
STAT Tourniquet: 21 of 24 applications FAIL
RATS and TMT tourniquets Inferior to CAT
Is the R.A.T.S. Tourniquet Misleading Consumers with TCCC Approval?
SWAT-T Takes Approximately Twice as Long to Apply as Compared to CAT
Preliminary Comparison of New and Established Tactical Tourniquets in a Manikin Hemorrhage Model.
Does Pain Have a Role When It Comes to Tourniquet Training?
Tourniquet pressures: strap width and tensioning system widths.
The Tourniquet Gap: A Pilot Study of the Intuitive Placement of Three Tourniquet Types by Laypersons
How do Tactical Tourniquets Compare?
Tourniquets and Occlusion: The Pressure of Design
Lighting did not affect self-application of a stretch and wrap style tourniquet.
RMT tourniquet worked better than CAT of SWAT -T
Stretch and Wrap Style Tourniquet Effectiveness With Minimal Training (opens to PDF)
All novel TQ systems were non-inferior to the military-approved CAT7.
The SWAT-T was successfully tightened over all sites of all CPR manikins except the infant.
The rapid application tourniquet system had a 4% failure rate.
SWAT-T had the highest ineffective application rate (55.5%) than any other tourniquet type
Tourniquets on Kids
A lot of folks justify their elastic tourniquet choices by stating that the CoTCCC-approved tourniquets don’t tighten small enough to reliably occlude the blood vessels of very small children and/or pets. That simply isn’t true. It’s marketing disinformation from the elastic tourniquet companies purposely designed to prey on the fears of parents and pet owners.
First of all, tourniquets are acceptable to apply to children. For reference, “The PTS (Pediatric Trauma Society) supports the usage of tourniquets in the prehospital setting and during the resuscitation of children suffering from exsanguinating hemorrhage from severe extremity trauma.”
The CAT and the SOFT-T have recently been proven to work on children. Take a look at the studies referenced in Do commercially available tourniquets work on kids? From the article:
“Dr. John Kragh, an orthopedic surgeon and military researcher on tourniquet use, studied 88 children seen in US Military Hospitals in Iraq and Afghanistan on whom US DOD tourniquets were placed. Children ranged in age from 4 to 17 years old. 64% were injured by explosions and 30% gunshot wounds. 7 of the 88 died. They identified no pediatric-specific problems in applying the tourniquets on kids despite the tourniquets being designed for adult casualties. The tourniquets seemed to work on kids just fine.”
The article above also reports on a newly-released study showing that the CAT tourniquet was 100% effective on all of the kids’ arms. The CAT had a 93% effectiveness rate on the legs of children between six and 16 years old.
The complete study referenced above is the Survey of Trauma Registry Data on Tourniquet Use in Pediatric War Casualties.
An even more inclusive study Pediatric Extremity Hemorrhage and Tourniquet Use in the Journal of EMS reviewed of all the literature on the topic of pediatric tourniquet use as well as looked at average limb size in kids broken down by age group. The C-A-Ts mechanically fit the simulated limbs of infants aged 3-5 months.
The Pediatric Appendix of the Tactical Combat Casualty Care guidelines supports the use of the CAT and SOFT-T on children.
Another study showed that the CAT tourniquet was 100% successful at arterial occlusion on both arms and legs of real-life children aged two to seven years in a surgical setting.
The Pediatric Trauma Society position statement also supports the use of commercial tourniquets in pediatric patients. There is video evidence showing a police officer using a CAT Tourniquet to Save a Baby’s Life. It’s an N=1 study, but the CAT clearly worked.
It seems that despite marketing claims, the CAT and SOFT-T are the best choices for use on infants and children. With the exception of the CAT7 and the SOFTT-W at the mid-thigh, no windlass TQ was successfully tightened at any extremity location on the infant.
Supporting the study above a review of pediatric tourniquet placements demonstrated that windlass tourniquets were able to abolish distal pulses in children as young as two years of age. A similar study showed that C-A-Ts mechanically fit the simulated limbs of infants aged 3-5 months,
Even as the child ages, it appears that tourniquets work well with arterial occlusion on 100% of patients aged two to seven years in one study. Another study suggests that tourniquets designed for adults also fit children as well.
I did find one study, however, that showed The SWAT, TMK9 and RATS were successful stopping the flow of water on all sized manikins. This study was non-blinded and used manikin models. I’m not sure how well the research translates into real life performance.
SOFT-T being easily applied to a 45 pound three year old by my friend Morgan Atwood of No One Coming
Bottom line? The CAT and the SOFT-T work on both children and infants. Some others may not. The other CoTCC recommended tourniquets will likely work as well.
Tourniquets on Dogs
Correct tourniquet placement on a dog leg is very high on the hip/shoulder. CATs and SOFT-Ts will work at this location even on small dogs. I would expect the newer recently-recommended tourniquets to work just as well. Take a look at the photo below illustrating proper dog tourniquet placement.
Proper tourniquet placement sites for dog limbs
The problem with the use of any tourniquet on a dog’s leg is that the leg is funnel-shaped. Tourniquets placed high up on the limb tend to slip downward, causing reduced efficacy for bleeding control. There are no scientific studies showing that an elastic tourniquet will reduce such slipping any better than a CAT or SOFT-T. For more information on that subject, read Dr. Pugliese’s article on Controlling Life Threatening Bleeding in Dogs.
Research indicates that tourniquets may be of some utility in dogs, but the situations where tourniquets are effective are somewhat rare.
“Although tourniquet application is a life-saving intervention in humans experiencing extremity hemorrhage, it is not considered a necessary, immediate-action life-saving intervention for canines with extremity injuries.”
Clinical Update: Concepts of Prehospital Traumatic Hemorrhage Control in the Operational K9, Journal of Special Operations Medicine
Palmer LE. 18(4). 123 – 130. (Journal Article)
Improvised Tourniquets
I hear lots of folks tell me “I don’t need one of those fancy tourniquets. I can use my belt.” I hate to burst your bubble, but simply wrapping a belt around a limb, no matter how tightly it is buckled, will not likely occlude arterial bleeding. It may slow some capillary or venous bleeding, but due to the stiff nature of most belts, they can’t be tightened enough to compress the arteries (which lie deeper inside the extremity than the veins). The ultra-stiff belts designed for concealed carry (which many of you wear) make it even harder to twist tighten.
Want to see how well belts work as tourniquets? Watch this short video from Jeff Bloovman and Steve Fisher (opens to Facebook).
Ditch the idea of using your belt as a tourniquet. Improvised tourniquets using a windlass were 32% effective. The improvised tourniquets without a windlass showed a 99% failure rate. You definitely need a windlass to make an improvised tourniquet successful. How are you going to effectively twist a thick leather belt with a stick or a pen? Belts are not tourniquets.
The best makeshift tourniquets are between one and two inches wide and made of a pliable enough material that a windlass can be inserted to tighten the material until the bleeding stops. A simple triangular bandage, cravat, or even a neck tie would do a far better job than any belt.
The best makeshift tourniquet method I have ever seen was introduced to me by my late friend Paul Gomez. He uses a carabiner and a key ring in conjunction with a triangular bandage. The carabiner and ring make finding and securing the windlass very easy. If you don’t have these items, use another item for a windlass (stick, flashlight, pistol mag, pocket knife, etc.) and secure it by tying or taping the ends of the bandage. Watch Paul explain his method in the embedded video below:
While we are on the topic of makeshift tourniquets, DO NOT use shoe laces, paracord, or zip ties. These are too narrow to cause enough of the total tissue compression required to stop arterial bleeding. They and are also far more likely to cause tissue and nerve damage. A ripped up piece of a t-shirt is a better choice than shoe laces if you need to make a quick tourniquet.
While knowing how to improvise a tourniquet is a life-saving skill, please don’t depend on an improvised tourniquet if you have any other options. Their real-life success rate ranges between 1% and 50%. Most of the commercial tourniquets have success rates that are above 95%.
CAT Performs Better than improvised tourniquets
Improvised Tourniquets: Good to have an alternate plan
Which Improvised Tourniquet Windlasses Work Well and Which Ones Won’t
Improvised tourniquets: Obsolete or obligatory?
Improvised Tourniquet Success Rate Between 40% and 50%
Narrow improvised tourniquets only 25% effective
Which Improvised Tourniquet Windlasses Work Well and Which Ones Won’t?
We suggest that improvised tourniquets be applied only if no commercial device is available.
Without a windlass, improvised tourniquets failed to stop bleeding in 99% of tests
CAT had 100% effectiveness, but both improvised tourniquets had poor effectiveness (40% and 10%)
Use of a “space blanket” as an improvised tourniquet
Improvised tourniquets using a windlass were 32% effective.
Testing Tourniquet Use in a Manikin Model: Two Improvised Techniques
Proficiency in Improvised Tourniquets for Extremities: A Review
Arterial Occlusion Effectiveness of Space Blanket‒Improvised Tourniquets for the Remote Setting
Improvised Esmarch Tourniquet effective 61% of time in Russo-Ukrainian War
Improvised tourniquet 40-50% effective in Canadian military trial
For even more information about improvised tourniquets, check out the meta analysis experiment titled The safety and efficacy of improvised tourniquets in life-threatening hemorrhage: a systematic review. From the article:
“The cloth and wooden dowel design reached success percentages of 42–100% with multiple cases of success over prolonged periods. Other designs such as belts, wires and cloths with no dowel were either completely unsuccessful or reached up to 25% success rate.”
Improvised TQs reported in the retrieved studies seem unable to reliably achieve hemorrhage control as all studies comparing commercial devices to improvised designs showed the improvised design to be inferior regarding efficacy.
I hope you found this information useful. I will continually update the article whenever I see new research come out.
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