“High and tight to pack and press”: Prioritization of tourniquet conversion in unconventional warfare improves outcomes

BACKGROUND: In military conflicts beyond the global war on terror, combatants often lack air superiority, rapid evacuation to surgical care, and sufficient medical resources. Consequently, obtaining definitive care becomes a significant challenge, leading to complications associated with tourniquet (TQ) use in many active combat zones. METHODS: Data were retrospectively analyzed from a mobile surgical team operating in an unconventional warfare environment. Descriptive statistics summarized demographics, injury mechanisms, interventions, and outcomes, with categorical variables reported as frequencies and percentages. RESULTS: Results from a mobile surgical team supporting a MASCAL in unconventional warfare were analyzed. A total of 46 casualties were evaluated and treated. There were 14 TQs utilized on 12 patients. All 14 TQs were evaluated, and 93% (13) of these TQs were converted. Thirty-one percent (4) of the converted TQs required surgical intervention for hemostasis before packing and pressure. One (7%) TQ was transitioned lower on the extremity closer to the point of wounding. There were no deaths from extremity hemorrhage and no complications reported related to TQ use. CONCLUSIONS: Prioritization of TQ conversion in an unconventional warfare environment with prolonged evacuation times can save lives and limbs. ( J Trauma Acute Care Surg . 2026;101: 291-296. Copyright © 2026 Wolters Kluwer Health, Inc. All rights reserved.). LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.