Tactical Combat Casualty Care (TCCC) Guidelines

Caring for the warriors: How medics contribute to mission accomplishment.
Post Reply
RngrDoc75
Ranger
Posts: 61
Joined: November 14th, 2008, 6:57 am

Tactical Combat Casualty Care (TCCC) Guidelines

Post by RngrDoc75 »

For those interested, here are the current guidelines for Tactical Combat Casualty Care (TCCC). These guidelines were published by the Comittee on TCCC (CoTCCC), a subordinate committee to the Defense Health Board. Ranger medical personnel have been involved with TCCC since its beginning in 1996. Since the formation of the CoTCCC, Rangers have maintained voting membership on the committee. Currently, we have 2 of the 36 votes on the committee that decides tactical medical recommendations for the armed forces. Many civilian law enforcement and tactical EMS support units also use TCCC as their guidelines.

For those who are familiar with history of TCCC, these guidelines have been updated every couple of years since the original article was published in 1996.

The Ranger Regiment uses TCCC as the baseline for all medical training within the Regiment to include training for Ranger Medics, Squad EMTs, and Ranger First Responders (Ranger version of Combat Lifesaver).



Tactical Combat Casualty Care Guidelines
July 2008



Basic Management Plan for Care Under Fire
1. Return fire and take cover.
2. Direct or expect casualty to remain engaged as a combatant if
appropriate.
3. Direct casualty to move to cover and apply self-aid if able.
4. Try to keep the casualty from sustaining additional wounds.
5. Airway management is generally best deferred until the Tactical Field
Care phase.
6. Stop life-threatening external hemorrhage if tactically feasible:
- Direct casualty to control hemorrhage by self-aid if able.
- Use a CoTCCC-recommended tourniquet for hemorrhage that is
anatomically amenable to tourniquet application.
- Apply the tourniquet proximal to the bleeding site, over the uniform,
tighten, and move the casualty to cover.
Basic Management Plan for Tactical Field Care
1. Casualties with an altered mental status should be disarmed
immediately.
2. Airway Management
a. Unconscious casualty without airway obstruction:
- Chin lift or jaw thrust maneuver
- Nasopharyngeal airway
- Place casualty in recovery position
b. Casualty with airway obstruction or impending airway obstruction:
- Chin lift or jaw thrust maneuver
- Nasopharyngeal airway
- Allow casualty to assume any position that best protects the
airway, to include sitting up.
- Place unconscious casualty in recovery position.
- If previous measures unsuccessful:
- Surgical cricothyroidotomy (with lidocaine if conscious)

3. Breathing
a. In a casualty with progressive respiratory distress and
known or suspected torso trauma, consider a tension
pneumothorax and decompress the chest on the side of the injury
with a 14-gauge, 3.25 inch needle/catheter unit inserted in the
second intercostal space at the midclavicular line. Ensure that the
needle entry into the chest is not medial to the nipple line and is
not directed towards the heart.
b. All open and/or sucking chest wounds should be treated by
immediately applying an occlusive material to cover the defect
and securing it in place. Monitor the casualty for the potential
development of a subsequent tension pneumothorax.

4. Bleeding
a. Assess for unrecognized hemorrhage and control all sources of
bleeding. If not already done, use a CoTCCC-recommended tourniquet to control life-threatening external hemorrhage that is anatomically amenable to tourniquet application or for any traumatic amputation. Apply directly to the skin 2-3 inches above wound.
b. For compressible hemorrhage not amenable to tourniquet use or
as an adjunct to tourniquet removal (if evacuation time is
anticipated to be longer than two hours), use Combat Gauze as
the hemostatic agent of choice with WoundStat as the backup (if
the primary agent is not successful at controlling the hemorrhage
or if the wound characteristics call for a granular agent.) Both agents should be applied with at least 3 minutes of direct pressure. Before releasing any tourniquet on a casualty who has been resuscitated for hemorrhagic shock, ensure a positive
response to resuscitation efforts (i.e., a peripheral pulse normal in
character and normal mentation if there is no traumatic brain injury (TBI).
c. Reassess prior tourniquet application. Expose wound and determine if tourniquet is needed. If so, move tourniquet from over uniform and apply directly to skin 2-3 inches above wound. If tourniquet is not needed, use other techniques to control bleeding.
d. When time and the tactical situation permit, a distal pulse check
should be accomplished. If a distal pulse is still present, consider
additional tightening of the tourniquet or the use of a second
tourniquet, side by side and proximal to the first, to eliminate the distal pulse.
e. Expose and clearly mark all tourniquet sites with the time of
tourniquet application. Use an indelible marker.

5. Intravenous (IV) access
- Start an 18-gauge IV or saline lock if indicated.
- If resuscitation is required and IV access is not obtainable, use the
intraosseous (IO) route.

6. Fluid resuscitation
Assess for hemorrhagic shock; altered mental status (in the absence
of head injury) and weak or absent peripheral pulses are the best field
indicators of shock.
a. If not in shock:
- No IV fluids necessary
- PO fluids permissible if conscious and can swallow
b. If in shock:
- Hextend, 500-mL IV bolus
- Repeat once after 30 minutes if still in shock.
- No more than 1000 mL of Hextend
c. Continued efforts to resuscitate must be weighed against
logistical and tactical considerations and the risk of incurring
further casualties.
d. If a casualty with TBI is unconscious and has no peripheral pulse,
resuscitate to restore the radial pulse.

7. Prevention of hypothermia
a. Minimize casualty’s exposure to the elements. Keep protective
gear on or with the casualty if feasible.
b. Replace wet clothing with dry if possible.
c. Apply Ready-Heat Blanket to torso.
d. Wrap in Blizzard Rescue Blanket.
e. Put Thermo-Lite Hypothermia Prevention System Cap on the
casualty’s head, under the helmet.
f. Apply additional interventions as needed and available.
g. If mentioned gear is not available, use dry blankets, poncho liners,
sleeping bags, body bags, or anything that will retain heat and
keep the casualty dry.

8. Penetrating Eye Trauma

If a penetrating eye injury is noted or suspected:
a) Perform a rapid field test of visual acuity.
b) Cover the eye with a rigid eye shield (NOT a pressure patch.)
c) Ensure that the 400 mg moxifloxacin tablet in the combat pill pack
is taken if possible and that IV/IM antibiotics are given as outlined
below if oral moxifloxacin cannot be taken.

9. Monitoring
Pulse oximetry should be available as an adjunct to clinical
monitoring. Readings may be misleading in the settings of shock or
marked hypothermia.

10. Inspect and dress known wounds.

11. Check for additional wounds.

12. Provide analgesia as necessary.

a. Able to fight:
These medications should be carried by the combatant and self-
administered as soon as possible after the wound is sustained.
- Mobic, 15 mg PO once a day
- Tylenol, 650-mg bilayer caplet, 2 PO every 8 hours

b. Unable to fight:
Note: Have naloxone readily available whenever administering
opiates.
- Does not otherwise require IV/IO access
- Oral transmucosal fentanyl citrate (OTFC), 800 ug
transbuccally
- Recommend taping lozenge-on-a-stick to
casualty’s finger as an added safety measure
- Reassess in 15 minutes
- Add second lozenge, in other cheek, as
necessary to control severe pain.
- Monitor for respiratory depression.
- IV or IO access obtained:
- Morphine sulfate, 5 mg IV/IO
- Reassess in 10 minutes.
- Repeat dose every 10 minutes as necessary to control severe pain.
- Monitor for respiratory depression
- Promethazine, 25 mg IV/IM/IO every 6 hours as needed for
nausea or for synergistic analgesic effect

13. Splint fractures and recheck pulse.

14. Antibiotics: recommended for all open combat wounds

a. If able to take PO:
- Moxifloxacin, 400 mg PO one a day

b. If unable to take PO (shock, unconsciousness):
- Cefotetan, 2 g IV (slow push over 3-5 minutes) or IM every 12 hours
or
- Ertapenem, 1 g IV/IM once a day

15. Communicate with the casualty if possible.
- Encourage; reassure
- Explain care

16. Cardiopulmonary resuscitation (CPR)
Resuscitation on the battlefield for victims of blast or penetrating
trauma who have no pulse, no ventilations, and no other signs of life
will not be successful and should not be attempted.

17. Documentation of Care
Document clinical assessments, treatments rendered, and changes
in the casualty’s status on a TCCC Casualty Card. Forward this
information with the casualty to the next level of care.

Basic Management Plan for Tactical Evacuation Care
* The new term “Tactical Evacuation” includes both Casualty Evacuation (CASEVAC) and Medical Evacuation (MEDEVAC) as defined in Joint Publication 4-02.

1. Airway Management
a. Unconscious casualty without airway obstruction:
- Chin lift or jaw thrust maneuver
- Nasopharyngeal airway
- Place casualty in recovery position

b. Casualty with airway obstruction or impending airway obstruction:
- Chin lift or jaw thrust maneuver
- Nasopharyngeal airway
- Allow casualty to assume any position that best
protects the airway, to include sitting up.
- Place unconscious casualty in recovery position.
- If above measures unsuccessful:
- Laryngeal Mask Airway (LMA)/intubating LMA or
- Combitube or
- Endotracheal intubation or
- Surgical cricothyroidotomy (with lidocaine if
conscious).
c. Spinal immobilization is not necessary for casualties with
penetrating trauma.

2. Breathing

a. In a casualty with progressive respiratory distress and
known or suspected torso trauma, consider a tension
pneumothorax and decompress the chest on the side of the injury
with a 14-gauge, 3.25 inch needle/catheter unit inserted in the
second intercostal space at the midclavicular line. Ensure that the
needle entry into the chest is not medial to the nipple line and is
not directed towards the heart.
b. Consider chest tube insertion if no improvement and/or long
transport is anticipated.
c. Most combat casualties do not require supplemental oxygen, but
administration of oxygen may be of benefit 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
d. All open and/or sucking chest wounds should be treated by
immediately applying an occlusive material to cover the defect and securing it in place. Monitor the casualty for the potential development of a subsequent tension pneumothorax.

3. Bleeding
a. Assess for unrecognized hemorrhage and control all sources of
bleeding. If not already done, use a CoTCCC-recommended tourniquet to control life-threatening external hemorrhage that is anatomically amenable to tourniquet application or for any traumatic amputation. Apply directly to the skin 2-3 inches above wound.
b. For compressible hemorrhage not amenable to tourniquet use or
as an adjunct to tourniquet removal (if evacuation time is
anticipated to be longer than two hours), use Combat Gauze as
the hemostatic agent of choice with WoundStat as the backup (if
the primary agent is not successful at controlling the hemorrhage
or if the wound characteristics call for a granular agent.) Both
agents should be applied with at least 3 minutes of direct
pressure. Before releasing any tourniquet on a casualty who has
been resuscitated for hemorrhagic shock, ensure a positive
response to resuscitation efforts (i.e., a peripheral pulse normal in
character and normal mentation if there is no TBI.)
c. Reassess prior tourniquet application. Expose wound and determine if tourniquet is needed. If so, move tourniquet from over uniform and apply directly to skin 2-3 inches above wound. If tourniquet is not needed, use other techniques to control bleeding.
d. When time and the tactical situation permit, a distal pulse check
should be accomplished. If a distal pulse is still present, consider
additional tightening of the tourniquet or the use of a second
tourniquet, side by side and proximal to the first, to eliminate the distal pulse.
e. Expose and clearly mark all tourniquet sites with the time of
tourniquet application. Use an indelible marker.

4. Intravenous (IV) access
a. Reassess need for IV access.
- If indicated, start an 18-gauge IV or saline lock
- If resuscitation is required and IV access is not obtainable,
use intraosseous (IO) route.

5. Fluid resuscitation
Reassess for hemorrhagic shock (altered mental status in the
absence of brain injury and/or change in pulse character.)
a. If not in shock:
- No IV fluids necessary.
- PO fluids permissible if conscious and can swallow.
b. If in shock:
- Hextend 500-mL IV bolus.
- Repeat once after 30 minutes if still in shock.
- No more than 1000 mL of Hextend.
c. Continue resuscitation with packed red blood cells (PRBCs), Hextend, or Lactated Ringer’s solution (LR) as indicated.
d. If a casualty with TBI is unconscious and has a weak or absent peripheral pulse, resuscitate as necessary to maintain a systolic
blood pressure of 90 mmHg or above.

6. Prevention of hypothermia
a. Minimize casualty’s exposure to the elements. Keep protective
gear on or with the casualty if feasible.
b. Continue Ready-Heat Blanket, Blizzard Rescue Wrap, and Thermo-
Lite Cap.
c. Apply additional interventions as needed.
d. Use the Thermal Angel or other portable fluid warmer on all IV
sites, if possible.
e. Protect the casualty from wind if doors must be kept open.

7. Penetrating Eye Trauma
If a penetrating eye injury is noted or suspected:
a) Perform a rapid field test of visual acuity.
b) Cover the eye with a rigid eye shield (NOT a pressure patch).
c) Ensure that the 400 mg moxifloxacin tablet in the combat pill pack
is taken if possible and that IV/IM antibiotics are given as outlined
below if oral moxifloxacin cannot be taken.

8. Monitoring
Institute pulse oximetry and other electronic monitoring of vital signs, if
indicated.

9. Inspect and dress known wounds if not already done.

10. Check for additional wounds.

11. Provide analgesia as necessary.
a. Able to fight:
- Mobic, 15 mg PO once a day
- Tylenol, 650-mg bilayered caplet, 2 PO every 8 hours
b. Unable to fight:
Note: Have naloxone readily available whenever
administering opiates.
- Does not otherwise require IV/IO access:
- Oral transmucosal fentanyl citrate (OTFC) 800 ug
transbuccally
- Recommend taping lozenge-on-a-stick to casualty’s finger as an added safety measure.
- Reassess in 15 minutes.
- Add second lozenge, in other cheek, as necessary to control severe pain.
- Monitor for respiratory depression.
- IV or IO access obtained:
- Morphine sulfate, 5 mg IV/IO
- Reassess in 10 minutes
- Repeat dose every 10 minutes as necessary to control severe pain.
- Monitor for respiratory depression.
- Promethazine, 25 mg IV/IM/IO every 6 hours as needed for nausea or for synergistic analgesic effect.

12. Reassess fractures and recheck pulses.

13. Antibiotics: recommended for all open combat wounds
a. If able to take PO:
- Moxifloxacin, 400 mg PO once a day
b. If unable to take PO (shock, unconsciousness):
- Cefotetan, 2 g IV (slow push over 3-5 minutes) or IM every 12 hours,
or
- Ertapenem, 1 g IV/IM once a day

14. The Pneumatic Antishock Garment (PASG) may be useful for stabilizing
pelvic fractures and controlling pelvic and abdominal bleeding.
Application and extended use must be carefully monitored. The PASG
is contraindicated for casualties with thoracic or brain injuries.

15. Documentation of Care
Document clinical assessments, treatments rendered, and changes in
casualty’s status on a TCCC Casualty Card. Forward this information
with the casualty to the next level of care.
Last edited by RngrDoc75 on January 8th, 2009, 2:27 pm, edited 2 times in total.
RngrDoc75
Ranger Medic, 75th RGR Regt
1990-1995 at 1/75
1995 to 2012 at RHQ
2012 to 2015 at USSOCOM
2015 to Present CoTCCC/Joint Trauma System

if you can do the math and have been in the Regt medical team in those years, then you probably know who I am...

Dominatus Comminus Rememdium
"Mastery in Close Combat Medicine"
Ranger Bill
Ranger
Posts: 7009
Joined: December 12th, 2005, 3:48 pm

Re: Tactical Combat Casualty Care (TCCC) Guidelines

Post by Ranger Bill »

Help a FOG out... How do I access the attachment?
WE NEED MORE RANGERS!

http://www.75thrra.com" onclick="window.open(this.href);return false;

Mentor to Pellet2007, ChaoticGood & RFS1307

Ranger School Class 3-69

7th Special Forces Group
K Company (Ranger) 75th Infantry (Airborne)
4th Infantry Division
82d Airborne Division
12th Special Forces Group
RngrDoc75
Ranger
Posts: 61
Joined: November 14th, 2008, 6:57 am

Re: Tactical Combat Casualty Care (TCCC) Guidelines

Post by RngrDoc75 »

As soon as I figure out how to attach it, the I'll try to help you out.

The forum won't accept .pdf or .doc files.

Still trying...
RngrDoc75
Ranger Medic, 75th RGR Regt
1990-1995 at 1/75
1995 to 2012 at RHQ
2012 to 2015 at USSOCOM
2015 to Present CoTCCC/Joint Trauma System

if you can do the math and have been in the Regt medical team in those years, then you probably know who I am...

Dominatus Comminus Rememdium
"Mastery in Close Combat Medicine"
Post Reply

Return to “Medical Issues”