Tactical combat casualty care

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), a component of the Joint Trauma System (JTS) division of the Defense Health Agency[1]. 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.[2] 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.[3] TCCC or similar standards are used by most allied countries.[4]

TCCC logo.

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). In August 2018, the JTS along with CoTCCC were realigned as a directorate of the Defense Health Agency (DHA). The CoTCCC now operates as a component of the Defense Committees on Trauma (DCoT). The CoTCCC has 42 voting members, who are specialized physicians, providers, and enlisted medical specialties from the U.S Army, U.S. Navy, U.S. Air Force, U.S. Marine Corps, and U.S. Coast Guard.[5] 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.[6]

TCCC Guidelines

The TCCC Guidelines are a set evidence-based best practice guidelines for battlefield trauma care have been developed over more than 18 years of war. Oversight of the TCCC guidelines is provided by the Committee on TCCC (CoTCCC). The guidelines are continually updated.

Objectives of TCCC

The three objectives of TCCC are to provide lifesaving care to the injured combatant, to limit the risk of further casualties, and to help the unit achieve mission success.

  • Treat injured combatants
  • Limit the risk of further casualties
  • Achieve mission success

Phases of Care
Care Under Fire training at Moody AFB, GA Feb 14 2018
Tactical combat casualty care training at Camp Buehring, Kuwait, Feb. 23, 2016.
MEDEVAC at Tactical combat casualty care training, Camp Buehring, Kuwait, Feb. 23, 2016.

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 moved to more secure positions. The only medical treatment rendered in CUF is stopping 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.[2]

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.[2] TFC is focused on assessment and management using the MARCH acronym.[7]

  • 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, splinting 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 of 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.[7]

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.[2]

TCCC Works on the Battlefield

A significant amount of medical literature attests that TCCC is the most viable and reliable methodology to prepare for and manage casualties on the modern battlefield. Most battlefield casualties died of their injuries before ever reaching a surgeon. As most pre-medical treatment facility (pre-MTF) deaths are nonsurvivable, mitigation strategies to impact outcomes in this population need to be directed toward injury prevention. To significantly impact the outcome of combat casualties with potentially survivable (PS) injury, strategies must be developed to mitigate hemorrhage and optimize airway management or reduce the time interval between the battlefield point of injury and surgical intervention.[8] A command-directed casualty response system that trains ALL personnel in Tactical Combat Casualty Care resulted in unprecedented reduction of killed-in-action deaths, casualties who died of wounds, and preventable combat death.[9] There are key components of a prehospital casualty response system, emphasize the importance of leadership, underscore the synergy achieved through collaboration between medical and nonmedical leaders, and provide an example to other organizations and communities striving to achieve success in trauma as measured through improved casualty survival.[10] The success of the medical improvements during the wars in Iraq and Afghanistan have served to maintain the lowest case fatality rate on record.[11]


Historical Revisions of the TCCC Guidelines

Revisions to the TCCC Guidelines are produced by the CoTCCC and published in medical journal literature.

Change 19-04 - Management of Hemorrhage From Craniomaxillofacial Injuries and Penetrating Neck Injury in TCCC using iTClamp[12]

Change 18-01 - Advanced Resuscitative Care in TCCC[13]

Change 17-02 - Management of Suspected Tension Pneumothorax in Tactical Combat Casualty Care[14]

Change 17-01 - Extraglottic Airways in Tactical Combat Casualty Care[15]

Change 16-03 - TCCC Guidelines Comprehensive Review and Update[16]

Change 16-02 - The Use of Pelvic Binders in Tactical Combat Casualty Care[17]

Change 15-03 - Management of External Hemorrhage in Tactical Combat Casualty Care: The Adjunctive Use of XStat Compressed Hemostatic Sponges. [18]

Change 15-01 - Emergency Cricothyroidotomy in Tactical Combat Casualty Care[19]

Change 14-03 - Replacement of Promethazine with Ondansetron for Treatment of Opioid- and Trauma-Related Nausea and Vomiting[20]

Change 14-02 - Optimizing the Use of Limb Tourniquets Tactical Combat Casualty Care[21]

Change 14-01 - Fluid Resuscitation for Hemorrhagic Shock in Tactical Combat Casualty Care[22]

Change 13-05 - Management of External Hemorrhage in Tactical Combat Casualty Care: Chitosan-Based Hemostatic Gauze Dressings[23]

Change 13-04 - A Triple-Option Analgesia Plan for Tactical Combat Casualty Care[24]

Change 13-03 - Management of Junctional Hemorrhage in Tactical Combat Casualty Care.[25]  

Change 13-02 - [SUPERSEDED by change 17-02] Management of Open Pneumothorax in Tactical Combat Casualty Care[26]

Change 13-01 - The Tactical Combat Casualty Care Casualty Card[27]

References
  1. "Committee on Tactical Combat Casualty Care, Joint Trauma System".
  2. Butler, F. K.; Hagmann, J.; Butler, E. G. (1996-08-01). "Tactical combat casualty care in special operations". Military Medicine. 161 Suppl: 3–16. doi:10.1007/978-3-319-56780-8_1. ISSN 0026-4075. PMID 8772308.
  3. NAEMT cite
  4. Savage, E; Forestier, C; Withers, N; Tien, H; Pannell, D (2011). "Tactical combat casualty care in the Canadian Forces: lessons learned from the Afghan war". Can J Surg. 54 (6): S118–23. doi:10.1503/cjs.025011. PMC 3322653. PMID 22099324.
  5. "Committee on Tactical Combat Casualty Care (CoTCCC)". Joint Trauma System.
  6. "Joint Trauma System". Military Health System.
  8. Eastridge, Brian J.; Mabry, Robert L.; Seguin, Peter; Cantrell, Joyce; Tops, Terrill; Uribe, Paul; Mallett, Olga; Zubko, Tamara; Oetjen-Gerdes, Lynne; Rasmussen, Todd E.; Butler, Frank K. (December 2012). "Death on the battlefield (2001-2011): implications for the future of combat casualty care". The Journal of Trauma and Acute Care Surgery. 73 (6 Suppl 5): S431–437. doi:10.1097/TA.0b013e3182755dcc. ISSN 2163-0763. PMID 23192066.
  9. Kotwal, Russ S.; Montgomery, Harold R.; Kotwal, Bari M.; Champion, Howard R.; Butler, Frank K.; Mabry, Robert L.; Cain, Jeffrey S.; Blackbourne, Lorne H.; Mechler, Kathy K.; Holcomb, John B. (December 2011). "Eliminating preventable death on the battlefield". Archives of Surgery. 146 (12): 1350–1358. doi:10.1001/archsurg.2011.213. ISSN 1538-3644. PMID 21844425.
  10. Kotwal, Russ S.; Montgomery, Harold R.; Miles, Ethan A.; Conklin, Curtis C.; Hall, Michael T.; McChrystal, Stanley A. (June 2017). "Leadership and a casualty response system for eliminating preventable death". The Journal of Trauma and Acute Care Surgery. 82 (6S Suppl 1): S9–S15. doi:10.1097/TA.0000000000001428. ISSN 2163-0763. PMID 28333833.
  11. Kelly, Joseph F.; Ritenour, Amber E.; McLaughlin, Daniel F.; Bagg, Karen A.; Apodaca, Amy N.; Mallak, Craig T.; Pearse, Lisa; Lawnick, Mary M.; Champion, Howard R.; Wade, Charles E.; Holcomb, John B. (February 2008). "Injury severity and causes of death from Operation Iraqi Freedom and Operation Enduring Freedom: 2003-2004 versus 2006". The Journal of Trauma. 64 (2 Suppl): S21–26, discussion S26–27. doi:10.1097/TA.0b013e318160b9fb. ISSN 1529-8809. PMID 18376168.
  12. Onifer, Dana J.; McKee, Jessica Lynn; Faudree, Lindsey Kyle; Bennett, Brad L.; Miles, Ethan A.; Jacobsen, Toran; Morey, John Kip; Butler, Frank K. (2019). "Management of Hemorrhage From Craniomaxillofacial Injuries and Penetrating Neck Injury in Tactical Combat Casualty Care: iTClamp Mechanical Wound Closure Device TCCC Guidelines Proposed Change 19-04 06 June 2019". Journal of Special Operations Medicine. 19 (3): 31–44. ISSN 1553-9768. PMID 31539432.
  13. Butler, Frank K.; Holcomb, John B.; Shackelford, Stacy; Barbabella, Sean; Bailey, Jeffrey A.; Baker, Jay B.; Cap, Andrew P.; Conklin, Curtis C.; Cunningham, Cord W.; Davis, Michael; DeLellis, Stephen M. (Winter 2018). "Advanced Resuscitative Care in Tactical Combat Casualty Care: TCCC Guidelines Change 18-01:14 October 2018". Journal of Special Operations Medicine. 18 (4): 37–55. ISSN 1553-9768. PMID 30566723.
  14. Butler, Frank K.; Holcomb, John B.; Shackelford, Stacy; Montgomery, Harold R.; Anderson, Shawn; Cain, Jeffrey S.; Champion, Howard R.; Cunningham, Cord W.; Dorlac, Warren C.; Drew, Brendon; Edwards, Kurt (Summer 2018). "Management of Suspected Tension Pneumothorax in Tactical Combat Casualty Care: TCCC Guidelines Change 17-02". Journal of Special Operations Medicine. 18 (2): 19–35. ISSN 1553-9768. PMID 29889952.
  15. Otten, Edward J.; Montgomery, Harold R.; Butler, Frank K. (Winter 2017). "Extraglottic Airways in Tactical Combat Casualty Care: TCCC Guidelines Change 17-01 28 August 2017". Journal of Special Operations Medicine. 17 (4): 19–28. ISSN 1553-9768. PMID 29256190.
  16. Montgomery, Harold R.; Butler, Frank K.; Kerr, Win; Conklin, Curtis C.; Morissette, Daniel M.; Remley, Michael A.; Shaw, Travis A.; Rich, Thomas A. (2017). "TCCC Guidelines Comprehensive Review and Update: TCCC Guidelines Change 16-03". Journal of Special Operations Medicine. 17 (2): 21–38. ISSN 1553-9768. PMID 28599032.
  17. Shackelford, Stacy; Hammesfahr, Rick; Morissette, Daniel; Montgomery, Harold R.; Kerr, Win; Broussard, Michael; Bennett, Brad L.; Dorlac, Warren C.; Bree, Stephen; Butler, Frank K. (Spring 2017). "The Use of Pelvic Binders in Tactical Combat Casualty Care: TCCC Guidelines Change 1602 7 November 2016". Journal of Special Operations Medicine. 17 (1): 135–147. ISSN 1553-9768. PMID 28285493.
  18. Sims, Kyle; Montgomery, Harold R.; Dituro, Paul; Kheirabadi, Bijan S.; Butler, Frank K. (2016). "Management of External Hemorrhage in Tactical Combat Casualty Care: The Adjunctive Use of XStat™ Compressed Hemostatic Sponges: TCCC Guidelines Change 15-03". Journal of Special Operations Medicine. 16 (1): 19–28. ISSN 1553-9768. PMID 27045490.
  19. Mabry, Robert; Frankfurt, Alan; Kharod, Chetan; Butler, Frank (2015). "Emergency Cricothyroidotomy in Tactical Combat Casualty Care". Journal of Special Operations Medicine. 15 (3): 11–19. ISSN 1553-9768. PMID 26360349.
  20. Onifer, Dana J.; Butler, Frank K.; Gross, Kirby R.; Otten, Edward J.; Patton, Robert; Russell, Robert J.; Stockinger, Zsolt; Burrell, Elizabeth (2015). "Replacement of Promethazine With Ondansetron for Treatment of Opioid- and Trauma-Related Nausea and Vomiting in Tactical Combat Casualty Care". Journal of Special Operations Medicine. 15 (2): 17–24. ISSN 1553-9768. PMID 26125161.
  21. Shackelford, Stacy A.; Butler, Frank K.; Kragh, John F.; Stevens, Rom A.; Seery, Jason M.; Parsons, Donald L.; Montgomery, Harold R.; Kotwal, Russ S.; Mabry, Robert L.; Bailey, Jeffrey A. (2015). "Optimizing the Use of Limb Tourniquets in Tactical Combat Casualty Care: TCCC Guidelines Change 14-02". Journal of Special Operations Medicine. 15 (1): 17–31. ISSN 1553-9768. PMID 25770795.
  22. Butler, Frank K.; Holcomb, John B.; Schreiber, Martin A.; Kotwal, Russ S.; Jenkins, Donald A.; Champion, Howard R.; Bowling, F.; Cap, Andrew P.; Dubose, Joseph J.; Dorlac, Warren C.; Dorlac, Gina R. (2014). "Fluid Resuscitation for Hemorrhagic Shock in Tactical Combat Casualty Care: TCCC Guidelines Change 14-01--2 June 2014". Journal of Special Operations Medicine. 14 (3): 13–38. ISSN 1553-9768. PMID 25344706.
  23. Bennett, Brad L.; Littlejohn, Lanny F.; Kheirabadi, Bijan S.; Butler, Frank K.; Kotwal, Russ S.; Dubick, Michael A.; Bailey, Jeffrey A. (2014). "Management of External Hemorrhage in Tactical Combat Casualty Care: Chitosan-Based Hemostatic Gauze Dressings--TCCC Guidelines-Change 13-05". Journal of Special Operations Medicine. 14 (3): 40–57. ISSN 1553-9768. PMID 25344707.
  24. Butler, Frank K.; Kotwal, Russ S.; Buckenmaier, Chester C.; Edgar, Erin P.; O'Connor, Kevin C.; Montgomery, Harold R.; Shackelford, Stacy A.; Gandy, John V.; Wedmore, Ian S.; Timby, Jeffrey W.; Gross, Kirby R. (2014). "A Triple-Option Analgesia Plan for Tactical Combat Casualty Care: TCCC Guidelines Change 13-04". Journal of Special Operations Medicine. 14 (1): 13–25. ISSN 1553-9768. PMID 24604434.
  25. Kotwal, Russ S.; Butler, Frank K.; Gross, Kirby R.; Kheirabadi, Bijan S.; Baer, David G.; Dubick, Michael A.; Rasmussen, Todd E.; Weber, Michael A.; Bailey, Jeffrey A. (2013). "Management of Junctional Hemorrhage in Tactical Combat Casualty Care: TCCC Guidelines?Proposed Change 13-03". Journal of Special Operations Medicine. 13 (4): 85–93. ISSN 1553-9768. PMID 24227566.
  26. Butler, Frank K.; Dubose, Joseph J.; Otten, Edward J.; Bennett, Donald R.; Gerhardt, Robert T.; Kheirabadi, Bijan S.; Gross, Kriby R.; Cap, Andrew P.; Littlejohn, Lanny F.; Edgar, Erin P.; Shackelford, Stacy A. (2013). "Management of Open Pneumothorax in Tactical Combat Casualty Care: TCCC Guidelines Change 13-02". Journal of Special Operations Medicine. 13 (3): 81–86. ISSN 1553-9768. PMID 24048995.
  27. Kotwal, Russ S.; Butler, Frank K.; Montgomery, Harold R.; Brunstetter, Tyson J.; Diaz, George Y.; Kirkpatrick, James W.; Summers, Nancy L.; Shackelford, Stacy A.; Holcomb, John B.; Bailey, Jeffrey A. (2013). "The Tactical Combat Casualty Care Casualty Card TCCC Guidelines ? Proposed Change 1301". Journal of Special Operations Medicine. 13 (2): 82–87. ISSN 1553-9768. PMID 23877773.
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