Introduction to Tactical Combat Casualty Care (TCCC)
Tactical Combat Casualty Care (TCCC or TC3) are the United States military guidelines for trauma life support in prehospital combat medicine, designed to reduce preventable deaths while maintaining operation success. The TCCC guidelines are routinely updated and published by the Committee on Tactical Combat Casualty Care (CoTCCC), which is part of the Defense Committees on Trauma (DCoT) division of the Defense Health Agency (DHA).
TCCC was designed in the 1990s for the Special Operations Command medical community. Originally a joint Naval Special Warfare Command and Special Operations Medical Research & Development initiative, CoTCCC developed combat-appropriate and evidence-based trauma care based on injury patterns of previous conflicts. The original TCCC corpus was published in a Military Medicine supplement in 1996. TCCC has since become a Department of Defense (DoD) course, conducted by National Association of Emergency Medical Technicians.
TCCC (Tactical combat casualty care) outlines the priorities of care for casualties in combat applications:
Nearly 90% of combat fatalities occur before reaching a medical treatment facility
Prehospital phase is the focus of efforts to reduce deaths in combat
TCCC Working Group includes trauma surgeons, EM physicians, internists, family physicians, physician assistants, combat medical educators, trauma researchers, pathologists, combat medical doctrine developers, medical equipment specialists, combat medics, corpsmen, and PJs
This group has taken the TCCC guidelines as they existed in 2001 and continually updated them throughout 15 years of war based on developments in both civilian and military theatres
TCCC offers guidelines for a range of combat personnel – from recommendations for all combatants to combat paramedics and SOF medics
TCCC is divided into 3 phases
Care under fire
Tactical field care
Tactical evacuation care
Care under fire
This initial stage is unique to military and law enforcement applications compared to civilian pre-hospital scenarios. The focus here remains on gaining fire superiority and minimizing further injury to the casualty and other team members. As the opposing force is suppressed, casualties can be moved to safer locations. The only medical intervention attempted during this phase is early application of tourniquets to halt life-threatening hemorrhage, and only if tactically feasible.
Return fire and take cover
Prevent further injuries to casualty – direct the casualty to:
Remain engaged as combatant, or
Move to cover / apply self-aid
If tactically feasible:
Stop life-threatening external hemorrhage (or direct self-aid)
i.e. apply limb tourniquet “high and tight” for extremity hemorrhage
Life-threatening bleeding:
Spurting / flowing blood
Blood rapidly soaking uniform or pooling on ground
Complete amputation
Move the casualty to cover
Fastest method is dragging along long axis of patient’s body by two rescuers
Spinal precautions only considered after removed from threat
Tactical Field Care
Establish security perimeter, maintain situational awareness
Triage casualties
If altered mental status – clear/secure weapons, communications equipment, and sensitive items
MARCH algorithm
M – Massive Hemorrhage
Assess for unrecognized hemorrhage
Control life-threatening bleeding
Depending on the site of bleeding, immediately apply limb tourniquet, hemostatic dressing, or junctional tourniquet
A – Airway Management
Unconscious, no Airway (A/W) obstruction
Chin lift or jaw thrust, NPA, recovery position
A/W obstruction or impending obstruction
Allow conscious casualty to assume ANY position that best protects A/W
Chin lift or jaw thrust, NPA
If unconscious: recovery position
If previous measures unsuccessful:
Surgical cricothyroidotomy
R – Respiration / Breathing
Tension Pneumothorax
Consider TPTX if:
Progressive respiratory distress or hypoxia
Known / suspected torso trauma
Hypotension
Treatment: needle decompression
Open / Sucking chest wound
Apply vented chest seal
Burp the wound, if indicated, for breathing difficulty
Initiate pulse oximetry monitoring
If mod./severe TBI – apply supplemental O2 to maintain SpO2 >90% SpO2
C – Circulation
Bleeding
Apply pelvic binder if:
Suspected pelvic fracture
Severe blunt force or blast injury
Reassess tourniquet application
If bleeding not controlled: tighten tourniquet, re-assess, then add 2nd tourniquet side-by-side with 1st
Convert tourniquets in < 2h if bleeding can be controlled by other means
Use indelible marker to clearly mark time of application, re-application, conversion, removal
Convert tourniquets if (3) criteria are met
(1) Casualty is not in shock
(2) Can monitor wound closely for bleeding
(3) Tourniquet is not being used to control bleeding from an amputation
IV/IO Access
Start 18g IV or SL; if IV not attainable, use IO
Tranexamic Acid
If anticipated to need blood transfusion, give 1g IV TXA (NOT beyond 3h post injury)
Fluid resuscitation
Assess for hemorrhagic shock (AMS or weak/absent radial pulse)
If no shock, conscious, able to swallow – PO fluids
If SHOCK, resuscitate with:
Whole blood (preferred) or
Plasma, RBCs, Platelets (1:1:1)
Plasma, RBCs (1:1)
If above not available: Hextend, or RL, or Plasma-Lyte-A
Reassess after each 500mL bolus
Resuscitate until:
Palpable radial pulse
Improved mental status
sBP 80-90 mmHg
Reassess frequently, if recurrence of shock, then verify all hemorrhage is under control and repeat resuscitation above
H – Hypothermia prevention
Minimize environmental exposure, promote heat retention
Keep protective gear on if feasible, replace wet clothing, place on insulated surface
Use hypothermia kit with active re-warming
If not available: dry blankets, poncho liners, sleeping bags
Warm IV fluids are preferred
Other interventions / treatments
Penetrating eye trauma – rapid test of visual acuity, cover with rigid eye shield
Monitoring – initiate advanced monitoring if available
Analgesia
Mild/Moderate pain – Combat wound medication pack
Tylenol, Meloxicam, Moxifloxacin
Moderate/Severe pain
No shock – transmucosal fentanyl
Hemorrhagic shock or respiratory distress – ketamine IN/IM/IV/IO
Antibiotics
PO – Moxifloxacin
IV/IM – Ertapenem
Wounds – inspect and dress, search for additional wounds
Burns
All TCCC interventions can be performed on/through burned skin
Facial burns – monitor for A/W status and inhalational injury
Estimate TBSA to nearest 10%
>20% – consider placing immediately in hypothermia management kit or other hypothermia prevention means
Otherwise, cover burned areas with dry/sterile dressings
If burns >20% TBSA
Initiate IV/IO fluids ASAP – RL, NS, or Hextend
Initial fluid rate = %TBSA x 10mL/h if 40-80kg (+100ml/h every 10kg above 80kg)
If hemorrhagic shock – resuscitate as above (Circulation)
Fractures – splint and recheck pulses
Communication
Encourage, reassure, explain care to casualty
Communicate with tactical leadership throughout treatment
Provide casualty status and evac requirements
Arrange TACEVAC
Communicate with medical personnel
SIT
Stable or unstable
Injuries – life threats, mechanism of injury
Treatments – drugs, interventions
Documentation
CPR
Blast or penetrating trauma with no pulse, no ventilations, no other signs of life should NOT be resuscitated
Torso trauma or polytrauma with no pulse or respirations should have bilateral needle decompression to confirm/treat TPTX prior to DC of care
Prepare for evacuation
Secure bandages, wraps, litter straps, additional padding
Provide instructions to ambulatory patients
Stage causalities for evacuation
Maintain security at evacuation site
Tactical Evacuation Care (TACEVAC)
TACEVAC includes the same assessment and management included in Tactical Field Care with additional focus on advanced procedures (as applicable) during transportation to higher level medical care facilities.
Transition of care
Tactical force should establish evacuation point security and stage casualties for evacuation
Communicate patient status to TACEVAC personnel – SIT
TACEVAC personnel to reassess casualties and re-evaluate injuries/interventions
Airway Management
Consider supraglottic airway or endotracheal intubation
Breathing
Consider chest tube insertion (if no improvement in respiratory distress or long transport time)
Administer supplemental O2
Low O2 sat
Injuries associated with impaired oxygenation
Unconscious
TBI (maintain >90% SpO2)
Shock
Casualty at altitude
Traumatic Brain Injury
If mod./severe TBI – monitor for:
Decreased LOC
Pupillary dilation
sBP <90 mmHg
O2 sat <90%
Hypothermia
pCO2 >35-40mmg
p\Penetrating injury – administer Abx
Assume C-spine injury until cleared
If impending herniation:
Administer 250cc 3-5% hypertonic saline bolus
Elevate head 30 degrees
Hyperventilate casualty
Communication
Encourage, reassure, explain care
Communicate with next level of care facility
The TCCC guidelines are a set of evidence-based best practice guidelines for battlefield trauma care that have been developed over more than 18 years of war. Oversight of the TCCC guidelines is provided by the CoTCCC, which continually update them. Current guidelines are available online through the Deployed Medicine site, or through the Joint Trauma System site. They are also reproduced by the National Association of Emergency Medical Technicians websites, the Journal of Special Operations Medicine, and the Special Operations Medical Association.
This online Tactical Combat Casualty Care (TCCC) course introduces evidence-based, life-saving techniques and strategies for providing the best trauma care in all hostile environments. Ideal for medical and non-medical personnel involved in any unit or team, whether it is military, law enforcement, anti-poaching units or civilian/private sectors. This course includes 20 practical video lessons and 28 Skill Cards to save on a mobile device, or print for a quick reference guide and TCCC certification upon completion.
