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.
"Nearly 90 percent of combat fatalities occur before a casualty reaches a medical treatment facility. Therefore, the pre-hospital phase of care is needed to focus on reducing the number of combat deaths"
"The pre-hospital phase of care is needed to focus on reducing the number of combat deaths"
"When you have casualties on the battlefield, you must determine the sequence in which the casualties are to be treated and how to treat their injuries"
Most common types of injuries on the battlefield:
• Injury to extremities including amputations
• Hemorrhage
• Chest/abdominal/head wounds
• Burns
• Controlling shock/pain
History & Background
Tactical Combat Casualty Care was originally developed for Special Operations Forces in 1996 by U.S. Navy Capt (Ret.) Frank Butler and Lt. Col. (Ret.) John Hagmann. A review and analysis of the literature and historical medical data from the Vietnam War, the Korean War and World War II revealed that potentially preventable causes of death remained constant: about 9% of casualties died from extremity wounds, 5% from tension pneumothorax and 1% from airway obstruction. Consequently, recommended treatments were tourniquet application for bleeding extremity wounds, needle decompression for tension pnemothoraces, nasopharyngeal airway placement for airway obstruction secondary to decreased level of consciousness and surgical cricothyrotomy for airway obstruction secondary to maxillofacial trauma. Butler and colleagues also recognized the unique challenges faced by combat medical personnel and the requirement to combine good medicine with good tactics. Although TCCC principles aim to treat potentially preventable causes of death on the battlefield, they also acknowledge that application of these treatments may place the provider and even the mission in jeopardy if performed at the wrong time.
Therefore, TCCC classifies the tactical situation with respect to health care provision into 3 phases (care under fire, tactical field care and tactical evacuation) and only permits certain interventions to be performed in specific phases based on the danger to the provider and casualty. In addition, combat lifesavers were being called on to practice their trade in the face of many other adverse conditions, including austere environment, low light, limited medical equipment, prolonged evacuation times and the need to triage and treat multiple casualties with minimal backup. It rapidly became clear that the prehospital trauma courses being taught to troops did not address these challenges and that significant change was needed.
Phases of TCCC
3 phases of care:
Care Under Fire(CUF) "Care under fire is the care rendered by the medic at the scene of the injury while he and the casualty are still under effective hostile fire. Available medical equipment is limited to that carried by the individual or the medic in his medical aid bag"
Tactical Field Care (TFC) "Tactical field care is the care rendered by the medic once he and the casualty are no longer under effective hostile fire. It also applies to situations in which an injury has occurred, but there is no hostile fire. Available medical equipment is still limited to that being carried into the field by medical personnel. The time needed to evacuate the casualty to a medical treatment facility (MTF) may vary considerably"
Tactical Evacuation Care (TEC) "Combat casualty evacuation (CASEVAC) care is the care rendered once the casualty has been picked up by an aircraft, vehicle, or boat. Additional medical personnel and equipment may have been pre-staged and are available at this stage of casualty management"
Objectives of TCCC
• Treat injured combatants
• Limit the risk of further casualties
• Achieve mission success
Types of TCCC
• TCCC-Medical Provider (TCCC-MP) is training for medical personnel
• TCCC-All Combatants (TCCC-AC) is training for first responders and non-medical personnel
Tactical Considerations
Sometimes the mission will take precedence over medical care (mission continuity before first aid).
Aid should not be rendered until tactical/local fire superiority has been achieved.
First aid may need to be periodically stopped in order to maintain tactical advantage.
If possible, wounded service members should return fire, seek cover and perform self aid.
First aid supplies from the injured service member should be used, not your own supply.
Hemorrhage is theleading cause of preventable battlefield death.
Tourniquets are the best way to control severe bleeding on the battlefield.
Fire superiority can be achieved by:
• Small arms/crew served weapons
• Indirect fire/CAS
• Use of smoke as concealment
"How to" Videos
Care Under Fire
React to Contact
Seek Cover/Buddy Carries
Hemorrhage Control
Burn Management
Tactical Field Care
Wound Packing
Pressure Dressing
XStat Application
Airway Management
Surgical Cricothyroidotomy
Chest Trauma
Chest Seal
Needle Decompression
IV Fluid Administration
Rigid Eye Shield
Pelvic Binder
Hypothermia Mitigation
'Combat Pill Pack'
Care Under Fire
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.
1)Fire superiority is paramount
Nothing can proceed unless the tactical advantage is returned to the unit in contact, even if temporarily and/or only in certain parts of the battlefield.
Injured troops should return fire and seek cover. Once they reach cover they should perform self aid with their own medical supplies, if possible. If they can't move and/or are injured, they should 'play dead'.
Incapacitated troops should only be moved once fire superiority/concealment has been reached.
2)Hemorrhage control is key to survivability Failure to stop major bleeding can quickly result in hypovolemic shock and subsequent death.
The use of temporary tourniquets is the #1 action that can save a life on the battlefield.
3) Airway Management
Airway management is NOT performed at this phase due the limited time available:
• To achieve fire superiority
• Low percentage of airway obstructions (<1% cases)
• Need to move to cover/concealment
4) C-spine Immobilization
In the CUF phase, cervical immobilization is:
• Not performed for penetrating injuries (<2% needed)
• Other cervical related injuries may require a rigid collar (from a Medic's Aid Bag)
• The danger to life must be more imminent than hostile fire
• A 'splint' may be used to replace a rigid collar
5) Litters
Since litters may not be available in this phase consider:
• 'Poleless' litters
• Ponchos
• SKEDCO/Talon litters
• Battlefield debris such as tables/doors
• Manual carry (dragging/one-man/buddy carries)
6) Injured Equipment
Do NOT salvage equipment that is not mission essential (rucksacks etc.)
DO retain (and possibly redistribute) an injured's:
• Weapon system
• Ammunition
• Sensitive items (NVGs/GPS/thermal/radio/maps/code words etc.)
Actions to be taken in CUF phase:
1. Non-injured personnel should return fire
2. Injured personnel should also return fire (if possible)
3. Verbally direct the casualty to cover and apply self-aid (if possible)
4. Try best to keep the casualty from receiving any additional wounds.
5. Stop any life-threatening hemorrhage with a tourniquet and/or hemostatic dressing
6. Airway management is generally best deferred until the Tactical Field Care phase
Tactical Field Care
TFC is care rendered by first responders or prehospital medical personnel (primarily medics, corpsman, and pararescuemen) while still in the tactical environment.
Tactical field care is a phase in which:
• More care can be given
• Less danger from hostile fire
• Time allowed to treat injuries is often fluid from minutes to hours
Considerations
Blast/burn/penetrating victims with no pulse/respiration...
Even in peacetime settings, these types of injuries are overwhelmingly fatal
Do NOT perform CPR on injuries involving:
• Blast
• Burns
• Penetrating injuries
DO perform CPR for non-traumatic conditions: • Hypothermia
• Near drowning
• Electrocution
Injured troopers with signs of altered mental status should:
• Be disarmed of all weapons (long rifle/pistol/grenades/knives etc.) • Have their communications taken away (so as not impede mission critical communications)
Treatment
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.
• 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.
Initial assessment consists of bleeding, airway, breathing and circulation
1) Bleeding Use of tourniquets and hemostatic dressings to stop any and all major bleeding
Check injured person for entrance/exit wounds
If not covered in the CUF phase, it must be covered here.
2) Airway
Make sure the injured person has a patent airway (not obstructed).
Use of a ACCUVAC device & nasopharyngeal airway device typically helps to clear obstructed airways.
3) Breathing
Traumatic chest wall injuries should be:
• Sealed on all '4 sides' (especially if a needle decompression is available).
• Sealed on '3 sides' to allow the cavity to remain properly pressurized.
Applying a '3 sided' chest seal under tactical conditions is NOT easy.
It is easier to apply a '4 sided' seal and perform a needle decompression soon after.
Tension pneumothorax is the second leading cause of preventable battlefield death.
4) Circulation
Check tourniquets/bandages for continued bleeding
Check the injured for other bleeds not previously noted
Consider loosening or removing a tourniquet if the bleeding is controlled/has stopped
If bleeding continues, tighten the 'T' and leave in place
Apply direct pressure/elevate limb for at least 3 minutes to control bleeding.
Utilize a hemostatic dressing
'Pack' wound utilizing:
• 'Clock' method • Cardinal method (N/S/E/W)
5) Intravenous access
Gain IV use by way of a single 18-gauge catheter
The IV site should be proximal to the injury (not distal)
If no IV site can be achieved:
• Consider creating a sternal intraosseous (IO) line
• Utilize a 'First Access for Shock and Trauma' (F.A.S.T.1) device
Fluid of choice is: Hextend (colloid over solution crystalloid)
Significant traumatic injuries often require IV/IO access.
Even without significant trauma you should create an IV/IO port,
No casualty should receive more than 1,000 ml of Hextend.
500ml of Hextend is equivalent to 3,000ml of lactated Ringer's lactate
Uncontrolled hemorrhage must be controlled BEFORE adding fluids.
6) Head, Hypothermia & Other Injuries
• Identify any head or eye injuries (should be done in the bleeding phase)
• Protect injured from hypothermia (thermal blanket, warm and dry location, etc)
7) Pain Management
If the injured CAN fight, administer: • Anti-inflammatory drug (NSAID) to reduce swelling/inflammation such as Meloxicam (15 mg)
• An analgesic drug such as 1,000 mg acetominophen to reduce pain
• An antibiotic such as Gatifloxacin (400 mg) to reduce the risk of infection Use of OTP (On The Person) antibiotics
During Operation Gothic Serpent, ALL traumatic open wounds of Rangers became infected Battlefield ingestion of the injured's Combat Pill Pack significantly reduces the chance of such infections.
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.
Tactical Evacuation Care
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.
Considerations
• Monitoring of patient
• Head to toe final assessment of patient
• Address any and all final wounds
• Additional antibiotics & pain management
• Tactical evacuation preparation (TC3 card)
• Documentation of care
• MEDEVAC/CASEVAC
IFAK Comparison
Real Life Lessons Learned
One of the strengths of TCCC within our organization is the constant drive for adaptation. Feedback and lessons learned have been sought out, collected and implemented in an unprecedented, timely fashion. This has included provider feedback from the battlefield and data from clinical research. The following are some of the more important and perhaps contentious key lessons learned from real life statistical data.
Tourniquet use, the principle intervention during CUF, was potentially the most important lesson learned from this conflict. Despite the fact that the leading cause of potentially preventable deaths on the battlefield in Vietnam was exsanguination from compressible extremity injuries, 2 tourniquets were not recommended by civilian trauma experts. As a result, they fell out of military favor, were to be considered only as a last resort and were even deemed to be “an instrument of the devil that sometimes saves a life.” The arguments made by TCCC challenged this thinking, and tourniquets have become commonplace in modern combat medicine. Furthermore, there is now hard evidence from operations in Iraq and Afghanistan to demonstrate that tourniquets save lives, especially when applied before the onset of shock, and that their benefits far outweigh their risks in the military environment. The strong belief, later reinforced by data, of the military community that tourniquets save lives on the battlefield was the impetus for evolution in their design. The initial tourniquet was improvised from surgical tubing and progressed to field-durable, user-friendly, light windlass tourniquets that have proven themselves highly effective in the laboratory and on the battlefield. Currently every deployed trooper is trained to use and carries at least 1 commercially available windlass tourniquet, such as a Combat Application Tourniquet (CAT; Composite Resources). Medical technicians also carry other types of tourniquets to give them more options for different situations.
Junctional (i.e., axillary and inguinal) hemorrhage are areas not amenable to tourniquet use and continue to be significant causes of potentially preventable death among troops. The need for a management plan for these injuries in the military environment was another important lesson of the conflict in Afghanistan. As a result, hemostatic agents have been developed with different modes of action and in different forms. Hemostatic agents can be found in granular format or issued as impregnated gauze. Granular agents can be poured into junctional wounds, or impregnated gauze can be used to pack these wounds to control hemorrhage. The mechanisms of action of these hemostatic agents typically focus on the liquid evapourative properties of zeolite and smectite, or the tissue sealant characteristics of chitosan. Currently, the granular agent WoundStat (TraumaCure Inc.) and Combat Gauze (Z-Medica Corp.) are thought to be the most effective topical agents available for junctional hemorrhage control in noncoagulopathic patients.
Many issues regarding the ideal hemostatic dressing remain unresolved. Current hemostatic dressings are effective in noncoagulopathic patients, but a better understanding of how they perform in coagulopathic patients is needed. Also, a recent paper has questioned the safety of granular hemostatic agents owing to their ability to cause intravascular clotting and embolism. Furthermore, treating brisk bleeding from puncture wounds by pouring in an agent in powder form without concurrently packing and compressing the wound may render the treatment noneffective in the field. Finally, feedback from the medics and TCCC providers on the battlefield suggested that, although effective, granular agents, such as the zeolite Quik Clot (Z-Medica Corp.), were difficult to handle in high-wind situations caused by, for example, helicopter rotor-wash. This, combined with the highly exothermic nature of the reaction, has led various militaires to abandon their initial use of granular agents and choose impregnated gauze as the preferred hemostatic agent.
Tension pneumothorax is traditionally considered to be 1 of the 3 potentially preventable causes of death on the battlefield. As such, needle decompression was initially included in the armamentarium of TCCC providers, who are non-medical personnel with enhanced medical training. As the war progressed, the length of the needle used for decompression was increased as we learned that the chest wall thickness of military members was enough to make standard needle decompression ineffective up to 75% of the time. However, as blast injuries became more commonplace, technicians began to rethink the use of needle decompression on the battlefield. The crux of the argument centered on 2 issues: first, that tension pneumothoraces were less frequently noted in casualties, likely because of the advanced personal protective equipment that service members were wearing and, second, that providers continued to landmark incorrectly when performing needle decompression, risking injury to the heart and great vessels. One proposed solution to mitigate this risk has been performing needle decompression laterally in the anterior axillary line. However, preliminary research conducted suggests that needle decompression performed laterally is also likely to be ineffective because of kinking of the catheter by the patients’ adducted arms. As the need for needle decompression continues to be debated, various SOPs have limited nonmedical providers to perform needle decompression only under the direction and supervision of a medic.
In the civilian prehospital environment, spinal immobilization is an integral part of trauma management and casualty transport. However, there are significant obstacles to spinal immobilization on the battlefield. It takes 2 prehospital care providers an average of 5 minutes to immobilize a casualty, requiring a significant equipment load that simply cannot be carried easily into combat. Reviewed data from the Vietnam War discovered that 10% of casualties occurred during the treatment of other casualties and that only 1.4% of penetrating neck injuries may have benefited from spinal immobilization. Similar findings have been reported in studies of penetrating neck injuries in civilians and casualties in Afghanistan. When all of this was taken into consideration, the very real risk of creating more casualties combined with a logistically difficult skill set that might benefit only a small group led initial TCCC guidelines to deemphasize spinal immobilization. However, the pattern of injury seen in the war in Afghanistan has changed; blast has now become the predominant mechanism of injury. The magnitude of these explosions is increasing, and casualties are sustaining spinal injuries consistent with blunt trauma. The question of how to balance the need for spinal immobilization with the imperatives of tactical field care remains. In the interim, TCCC guidelines have been amended to re-emphasize spinal precautions, especially when transporting casualties with blunt or blast trauma.
Airway compromise from penetrating neck and maxillofacial injuries was historically the third leading cause of potentially preventable deaths on the battlefield. This mechanism of injury, along with the knowledge that combat lifesavers do not have the training or experience to be consistently successful in rapid-sequence intubation, posed a dilemma. Combat lifesavers are skilled in the use of various supraglottic airways; however, it is understood that not only are most airway casualties not obtunded enough to tolerate these airways, but also that they are not the airway of choice for treating patients with facial injuries. This led to recommended surgical cricothyrotomy as the definitive airway of choice. Standardized procedures, protocols and medical equipment have been scrutinized and amended to maximize the probability of successful cricothyroidotomy in the prehospital environment. The recognition of skill fade with this complex procedure is minimized with live tissue training that is delivered with combat simulation to replicate stresses during the course and then again just before deployment. One of the early lessons learned was the pitfall of using cut-down endo-tracheal tubes for cricothyroidotomies. There were at least 2 incidents noted in patients transported to Kandahar Airfield in Afghanistan where cricothyroidotomies using cut-down endo-tracheal tubes had migrated into the right mainstem bronchus resulting in hypoxia and misdiagnosis of left tension pneumothorax. Ever since, Surgical Airway Sets with a cuffed 6.0 tracheostomy tube were adopted to prevent these complications. Despite successes with this advanced skill, there are still airway-related deaths well as errors made in landmarking and placement of field cricothyroidotomies. As a result, the emphasis on education and training must continue to ensure that all casualties with airway compromise are treated consistently and correctly. This procedure likely will not be delegated to providers below the level of a combat lifesaver who has specifically demonstrated proficiency in this technique.
Conclusion
TCCC is a set of evidence-based best practice guidelines for battlefield trauma care that has been developed over more than 18 years of war. 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.
Before the development of TCCC, most battlefield casualties died of their injuries before ever reaching a surgeon.
To significantly impact the outcome of combat casualties with potentially survivable (PS) injury, strategies were developed to mitigate hemorrhage and optimize airway management or reduce the time interval between the battlefield point of injury and surgical intervention.
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.
The success of the medical improvements during the wars in Iraq and Afghanistan have served to maintain the lowest case fatality rate on record.
The 21st Century has seen various conflicts in which many have participated in sustained combat operations and have suffered increasingly severe injuries. Despite this, the most recent conflicts have experienced the highest casualty survival rate throughout years of war. Though this success is multifactorial, the determination and resolve of tactical leadership to develop and deliver comprehensive, multileveled TCCC packages to all troops is a significant reason for that and has unquestionably saved the lives of many coalition forces.
Furthermore, the level of TCCC has centered combat lifesavers in unique positions: their extensive responsibility of providing battlefield medicine in volatile areas of conflict while commanding and assisting allied forces in medical responsibilities presented continuous occasions to collect and reflect on lessons learned. This, combined with the cohesiveness and effects-oriented mindset of medical leadership, ensured that these lessons learned were implemented in a timely, efficient, effective and systematic manner resulting in world-class medical care.
Despite the many advances in battlefield medicine, the constant drive among allied forces for comprehensive feedback, research and improvement continues. Current efforts in TCCC are focused on methods to improve survival of casualties with truncal and junctional hemorrhage with improved hemostatic agents for junctional bleeding and lyophilized blood products, such as fresh frozen plasma, that can be used at the point of injury.
The introduction of TCCC has fundamentally changed the way medical care is provided on the battlefield. As our mission moves towards combat operations and education of allied personnel, it is imperative that momentum is not lost. Rather, we must continue to teach our warfighters principles that are flexible enough to be adapted to any future mission and continue to save lives.