Tactical combat casualty care

TCCC logo.

Tactical Combat Casualty Care (TCCC or TC3) is — the standard of care in Prehospital Battlefield Medicine. The TCCC Guidelines are routinely updated and published by the Committee on Tactical Combat Casualty Care (CoTCCC). TCCC was designed in the mid-'90s for the Special Operations medical community. Originally a Naval Special Warfare and USSOCOM Medical Research & Development initiative, TCCC developed battlefield appropriate and evidence-based casualty care based on injury patterns of previous conflicts. The original TCCC concept and guidelines were published in a Military Medicine Supplement in 1996.^[1] The primary intent of TCCC is to reduce preventable combat death through a means that allows a unit to complete its mission while providing the best possible care for casualties. Now it is a DOD course, conducted by NAEMT.^[2] TCCC or similar standards are used by most allied countries.^[3]

The Committee on Tactical Combat Casualty Care (CoTCCC) was originally established by the US Special Operations Command in 2002 before shifting to the Naval Medical Education & Training Command in 2004. The CoTCCC was shifted again in 2007 as a standing subcommittee of the Defense Health Board (DHB). In 2012, the CoTCCC was moved to the DoD Joint Trauma System (JTS) where it currently resides. The CoTCCC has 42 voting members, who are specialized physicians, providers, and enlisted medical specialties from the Army, Navy, USAF, USMC, and USCG. The TCCC Working Group is larger group operating in conjunction with the CoTCCC consisting of non-voting members from throughout the DoD, US government agencies, civilian medical professionals, and partner nations.

Tactical combat casualty care training at Camp Buehring, Kuwait, Feb. 23, 2016.

TCCC Guidelines

The TCCC Guidelines are a set evidence-based and best practice guidelines for battlefield trauma care have been developed over more than 14 years of war and are embodied in the Joint Trauma System (JTS) TCCC guidelines. Oversight of the TCCC guidelines is provided by the Committee on TCCC (CoTCCC).

• The current TCCC Guidelines are posted at http://cotccc.com/
• The guidelines are also routinely available at:
  • National Association of Emergency Medical Technicians: http://www.naemt.org/education/TCCC/guidelines_curriculum
  • Journal of Special Operations Medicine: https://www.jsomonline.org/TCCC.html
  • Joint Trauma System: http://www.usaisr.amedd.army.mil/10_jts.html
  • Special Operations Medical Association: http://www.specialoperationsmedicine.org/Pages/tccc.aspx

Phases of Care

In TCCC prehospital battlefield care is divided into 3 phases:

• Care Under Fire (CUF) - CUF is characterized as the care rendered to a casualty while still under effective fire. In this case, the first action is to return fire and take cover as fire superiority over the enemy is the best medicine to include the casualty remaining engaged if able. As an enemy is suppressed, casualties can move or be move to more secure positions. The only medical treatment rendered in CUF if stop life-threatening hemorrhage (bleeding). TCCC actively endorses and recommends the early and immediate use of tourniquets to control massive external hemorrhage of limbs. All other treatment should be delayed until the casualty can be moved to a more secure and covered position and transitioned to tactical field care.
• Tactical Field Care (TFC) - TFC is care rendered by first responders or prehospital medical personnel (primarily medics, corpsman, and pararescuemen) while still in the tactical environment. TFC is focused on assessment and management using the MARCH acronym. Massive hemorrhage is managed through the use of tourniquets, hemostatic dressings, junctional devices, and pressure dressings. The airway is managed by rapid and aggressive opening of the airway to include cricothyroidotomy for difficult airways. Respirations and breathing is managed by the assessment for tension pneumothorax and aggressive use of needle decompression devices to relieve tension and improve breathing. Circulation impairment is assessed and managed through the initiation of intravenous access followed up by administration of tranexamic acid (TXA) if indicated, and a fluid resuscitation challenge using the principles of hypotensive resuscitation. TCCC promotes the early and far forward use of blood and blood products if available over the use colloids and discourages the administration of crystalloids such as normal saline (sodium chloride). Hypothermia prevention is an early and critical intervention to keep a traumatized casualty warm regardless of the operational environment. Continued assessment and management in TFC includes treating penetrating eye trauma, assessing for traumatic brain injury or head injuries, treating burns, spling fractures, and dressing non-life-threatening wounds. TCCC promotes the early and aggressive use of analgesia (pain management) on the battlefield through the administration of Ketamine and/or Oral Tranmuccossal Fentanyl for casualties with moderate to severe pain. TCCC also promotes the early administration oral and intravenous or intramuscular antibiotics. The remainder of TFC care is dedicated is reassessment of injuries and interventions, documentation of care, communicating with tactical leadership and evacuation assets. TFC culminates with packaging a casualty for evacuation and then evacuating by available air, ground, or maritime assets.
• Tactical Evacuation Care (TACEVAC) - TACEVAC care encompasses the same assessment and management included in TFC with additional focus on advanced procedures that can be initiated when en route to a medical treatment facility. The caveat of TACEVAC is the evacuation means and care may or may not be dedicated medical platforms such as a MEDEVAC helicopter. TACEVAC can also include the evacuation of casualties on available non-medical assets and the provision of care in such circumstances.

MEDEVAC at Tactical combat casualty care training, Camp Buehring, Kuwait, Feb. 23, 2016.

MARCH

TCCC uses MARCH acronym to assess a casualty and to prioritize treatment. Different from the traditional ABC approach (Airway, Breathing, Circulation), TCCC and MARCH prioritizes Massive Hemorrhage/Bleeding ahead of other treatments as hemorrhage is the number one preventable death on the battlefield.

• M - Massive Bleeding
• A - Airway
• R - Respirations
• C - Circulation
• H - Hypothermia/Head^[3]

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TCCC Guidelines

The TCCC Guidelines are updated annually or as significant changes are needed based on evidence, best practices, or new equipment. Below is an abbreviated version of the January 2017 TCCC Guidelines

Basic Management Plan for Care Under Fire

• Return Fire and take cover.
• Direct or expect casualty to remain engaged as a combatant if appropriate.
• Direct casualty to move to cover and apply self-aid if able.
• Try to keep the casualty from sustaining additional wounds.
• Stop life-threatening external hemorrhage if tactically feasible:
  • Direct casualty to control hemorrhage by self-aid if able.
  • Use a CoTCCC-recommended limb tourniquet for extremity hemorrhage.
  • Move the casualty to cover

• Airway management is generally best deferred until the Tactical Field Care phase.

Basic Management Plan for Tactical Field Care

• Establish Security Perimeter IAW Tactical SOPs.  Maintain situational awareness.
• Triage Casualties as required. Altered mental status is criteria to have weapons cleared/secured, communications gear secured and sensitive items redistributed.
• Massive Hemorrhage                                                            
  • Assess for unrecognized hemorrhage and control all life-threatening bleeding.
  • Use one or more CoTCCC-recommended limb tourniquets if necessary.
  • Use a CoTCCC approved hemostatic dressing for compressible hemorrhage not amenable to limb tourniquet use.
  • Immediately apply a CoTCCC-recommended junctional tourniquet if the bleeding site is amenable to use of a junctional tourniquet.
• Airway Management    
  • Unconscious casualty without airway obstruction:
    • Chin lift or jaw thrust maneuver
    • Nasopharyngeal airway
    • Place the casualty in the recovery position
  • Casualty with airway obstruction or impending airway obstruction:
    • Allow a conscious casualty to assume any position that best protects the airway, to include sitting up
    • Chin lift or jaw thrust maneuver
    • Nasopharyngeal airway
    • Place an unconscious casualty in the recovery position
  • If the previous measures are unsuccessful perform a surgical cricothyroidotomy using one of the following:
    • CricKey technique
    • Bougie-aided open surgical technique
    • Standard open surgical technique
    • Use lidocaine if the casualty is conscious
•  Respiration/Breathing
  • In a casualty with progressive respiratory distress and known or suspected torso trauma, consider a tension pneumothorax:
    • Decompress the chest on the side of the injury at the primary or alternate site.
  • All open and/or sucking chest wounds should be treated by:
    • Applying a vented chest seal (preferred)
    • Applying a non-vented chest seal
    • Burp the wound if indicated for breathing difficulty
  • Initiate pulsoximetry monitoring.
  • Monitor for tension pneumothorax.
  • Casualties with moderate/severe TBI should be given supplemental oxygen when available to maintain an oxygen saturation > 90%.
• Circulation - Bleeding
  • Apply a pelvic binder for suspected pelvic fracture and/or severe blunt force or blast injury. 
  • Reassess prior tourniquet application:
    • Expose the wound and determine if a tourniquet is needed; if bleeding is not controlled then tighten tourniquet if possible.
    • If the first tourniquet does not control bleeding after tightening, then add a second tourniquet side-by-side with the first.
  • Convert Limb tourniquets and junctional tourniquets if the following three criteria are met:
    • The casualty is not in shock.
    • It is possible to monitor the wound closely for bleeding.
    • The tourniquet is not being used to control bleeding from an amputation.
  • Convert tourniquets in less than 2 hours if bleeding can be controlled with other means.
  • Expose and use an indelible marker to clearly mark all tourniquet sites with the time of tourniquet application, reapplication, conversion, or removal.
• Circulation - IV/IO Access
  • Start an 18-gauge IV or Saline Lock if indicated.
  • If IV access is not obtainable, use an intraosseous (IO) needle.
• Circulation - TXA
  • If a casualty is anticipated to need a blood transfusion, then administer 1 gram of tranexamic acid (TXA) in 100ml of NS or LR over 10min ASAP but NOT beyond 3 hours post injury.
• Circulation - Fluid Resuscitation
  • Assess for hemorrhagic shock:
    • If not in shock PO fluids are permissible if casualty is conscious and can swallow.
    • If in shock resuscitate with:
      • Whole blood (preferred) or
      • Plasma, RBCs and platelets (1:1:1) or
      • Plasma and RBCs (1:1) or
      • Plasma or if blood products not available,
      • Hextend or Lactated Ringers or Plasma-Lyte-A
  • Resuscitate with above fluids until a palpable radial pulse, improved mental status or systolic BP of 80-90 mmHg is present. Discontinue fluids when one or more end points are achieved.
  • Reassess casualty frequently to check for recurrence of shock.  If shock recurs, verify all hemorrhage is under control and repeat fluid resuscitation as above.
• Hypothermia Prevention
  • Minimize casualty environmental exposure and promote heat retention.
  • Keep personal protective gear on if feasible.  Replace wet clothing if possible. Get casualty onto insulated surface ASAP.
  • Use a hypothermia prevention kit with active rewarming.
  • If none above is available, then use dry blankets, poncho liners, or sleeping bags and keep the casualty warm and dry.
  • Warm IV fluids are preferred.
•  Penetrating Eye Trauma - If penetrating eye injury is noted or suspected:
  • Perform a rapid field test of visual acuity and document findings.
  • Cover eye with a rigid eye shield (not a pressure patch).
  • Administer Combat Wound Medication Pack if possible and/or administer IV/IM antibiotics per below.
• Monitoring – Initiate advanced electronic monitoring of vital signs if available.
•  Analgesia/Pain Management
  • Analgesia on the battlefield should generally be achieved by one of three options:
  • Mild to Moderate Pain and/or Casualty can swallow and is still able to fight:
    • Administer TCCC Combat Wound Medication Pack (CWMP)
  • Moderate to Severe Pain and casualty IS NOT in Shock
    • Oral Transmucosal Fentanyl Citrate (OTFC) 800mcg
  • Moderate to Severe Pain and casualty is in hemorrhagic shock or respiratory distress
    • Administer Ketamine 50mg IM or IN repeating q30min prn
    • OR
    • Administer Ketamine 20mg Slow IV or IO repeating q20min prn
      • *Endpoint control of pain or development of nystagmus.
    • *Consider Ondansetron 4mg ODT/IV/IO/IM q8hours prn for nausea and vomiting.
• Antibiotics
  • If able to take PO, then administer Moxifloxacin 400mg PO qDaily from CWPP.
  • If unable to take PO, administer Ertapenem 1 gram IV/IM qDaily.
•  Wounds
  • Inspect and dress known wounds.
  • Check for Additional Wounds.
• Burns
  • Facial burns should be aggressively monitored for airway status and potential inhalation injury.
  • Estimate total body surface area (TBSA) burned to nearest 10%.
  • Cover burned areas with dry, sterile dressings.  For burns >20% TBSA, consider placing casualty immediately in HPMK or other hypothermia prevention means.
  • Fluid Resuscitation (USAISR Rule of Ten):
    • If burns >20% TBSA, initiate IV/IO fluids ASAP with Lactated Ringers, NS, or Hextend. If Hextend, then no more than 1000ml followed by LR or NS as needed.
    • Initial IV/IO fluid rate = %TBSA X 10ml/per hour for adults 40-80 kg (+100ml/hr for every 10kg above 80kg).
    • If hemorrhagic shock is present then resuscitate IAW fluid resuscitation in Circulation section.
  •  All TCCC interventions may be performed on or through burned skin.
• Splinting - Splint Fractures and Recheck Pulses.
•  Communication
  • Communicate with the casualty if possible. Encourage, reassure, and explain care.
  • Communicate with tactical leadership ASAP and throughout treatment.  Provide casualty status and evac requirements.
  • Communicate with the evacuation system to arrange TACEVAC.
  • Communicate with medical personnel on evacuation assets and relay mechanism of injury, injuries sustained, signs/symptoms and treatments rendered.
• Documentation
  • Document clinical assessments, treatments rendered, and changes in the casualty's status on a TCCC Casualty Card (DD Form 1380) and forward this information with the casualty to the next level of care.
• Cardiopulmonary resuscitation (CPR)
  • Battlefield blast or penetrating trauma casualties with no pulse, no ventilations, and no other signs of life should not be resuscitated.
  • Casualties with torso trauma or polytrauma with no pulse or respirations should have bilateral needle decompression performed to confirm/deny tension pneumothorax prior to discontinuing care.
• Prepare for Evacuation
  • Complete and secure TCCC casualty Card (DD1380) to casualty.
  • Secure all loose ends of bandages and wraps.
  • Secure hypothermia prevention wraps/blankets/straps.
  • Secure litter straps and consider additional padding for long evacuations.
  • Provide instructions to ambulatory patients as needed.
  • Stage Casualties for evacuation.
  • Maintain security at evacuation site.

Basic Management Plan for Tactical Evacuation Care (TACEVAC)

In addition to the principles of Tactical Field Care consider the following for Tactical Evacuation Care:

• Transition of Care
  • Tactical force should establish evacuation point security and stage casualties for evacuation.
  • Tactical force personnel/medic should communicate patient status to TACEVAC personnel to include stable/unstable, injuries identified, and treatments rendered.
  • TACEVAC personnel stage casualties on evac platform as required.
  • Secure casualties on evac platform IAW unit policies, platform configurations, and safety requirements.
  • TACEVAC medical personnel reassess casualties and re-evaluate all injuries and interventions.
•  Airway Management- Consider the following for casualty with airway obstruction or impending airway obstruction:
  • Supraglottic airway, or
  • Endotracheal intubation
• Breathing
  • Consider chest tube insertion if no improvement and/or long transport is anticipated.
  •  Administer oxygen when possible for the following types of casualties:
    • Low oxygen saturation by pulse oximetry
    • Injuries associated with impaired oxygenation
    • Unconscious casualty
    • Casualty with TBI (maintain oxygen saturation > 90%)
    • Casualty in shock
    • Casualty at altitude
• Traumatic Brain Injury-Casualties with moderate/severe TBI should be monitored for:
  • Decreases in level of consciousness
  • Pupillary dilation
  • SBP should be >90 mmHg
  • O2 sat > 90
  • Hypothermia
  • PCO2 (If capnography is available, maintain between 35-40 mmHg)
  • Penetrating head trauma (if present, administer antibiotics)
  • Assume a spinal (neck) injury until cleared
  •  If impending herniation is suspected take the following actions:
    • Administer 250 cc of 3 or 5% hypertonic saline bolus
    • Elevate the casualty’s head 30 degrees
    • Hyperventilate the casualty
• Communication
  • Communicate with the casualty if possible. Encourage, reassure, and explain care
  • Communicate with next level of care and relay mechanism of injury, injuries sustained, signs/symptoms, and treatments rendered.

References