Tactical Combat Casualty Care Guidelines 28 October 2013 * All changes to the guidelines made since those published in the 2010 Seventh Edition of the PHTLS Manual are shown in bold text. The most recent changes are shown in red text. * These recommendations are intended to be guidelines only and are not a substitute for clinical judgment. 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. Casualties should be extricated from burning vehicles or buildings and moved to places of relative safety. Do what is necessary to stop the burning process. 6. Airway management is generally best deferred until the Tactical Field Care phase. 7. 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.

BACKGROUND IN 1996, THE NAVAL SPECIAL WARFARE COMMAND DEVELOPED A NEW SET OF TACTICALLY APPROPRIATE BATTLEFIELD TRAUMA CARE GUIDELINES NAMED TCCC. THE TCCC GUIDELINES WERE ADOPTED BY THE U.S. SPECIAL OPERATIONS COMMAND (USSOCOM) AND APPROVED BY THE AMERICAN COLLEGE OF SURGEONS (ACS) AND THE NATIONAL ASSOCIATION OF EMERGENCY MEDICAL TECHNICIANS. THE COMMITTEE ON TCCC WAS ESTABLISHED IN 2001 AND WAS DIRECTED TO FURTHER DEVELOP THE TCCC STANDARDS AND GUIDELINES. THE COMMITTEE ON TCCC FUNCTIONS AS A WORKING GROUP OF THE TRAUMA AND INJURY SUBCOMMITTEE OF THE DEFENSE HEALTH BOARD (DHB), WHICH HAS A CHARTER TO PROVIDE MEDICAL RECOMMENDATIONS TO ASD (HA) AND THE SERVICE SURGEONS GENERAL. TCCC CONCEPTS WERE INCORPORATED INTO THE 8404 CORPSMAN TRAINING CURRICULUM IN 2005. THE TCCC/CLS TRAINER COURSE WAS DEVELOPED IN 2006 TO PROVIDE CORPSMEN AS TRAINERS TO TEACH AND SUSTAIN TCCC STANDARDS TO CORPSMEN AND CLS SKILLS TO SELECTED MARINES WITHIN THE OPERATING FORCES. THE IMPLEMENTATION OF TCCC ACROSS ALL SERVICES HAS BEEN IDENTIFIED AS ONE OF THE CONTRIBUTING FACTORS TO THE HIGHEST COMBAT CASUALTY SURVIVAL RATES IN HISTORY AND IS RECOMMENDED BY ASD (HA) FOR USE WHEN TRAINING COMBAT MEDICAL PERSONNEL, REF B. TCCC INFORMATION IS PUBLISHED IN THE PREHOSPITAL TRAUMA LIFE SUPPORT MANUAL (PHTLS), MILITARY EDITION, WHICH IS UPDATED EVERY FOUR YEARS. DEPARTMENT OF DEFENSE (DOD) APPROVED TCCC TRAINING CURRICULA ARE UPDATED ON THE DOD WEBSITE MHS.OSD.MIL/EDUCATION AND TRAINING/TCCC.ASPX AS THE TCCC GUIDELINES CHANGE. GOAL. ELIMINATE PREVENTABLE LOSS OF LIFE ON THE BATTLEFIELD. IN ACCOMPLISHING THIS GOAL, THE MOST RECENT TCCC GUIDELINES APPROVED BY DOD ARE TO BE UTILIZED AS A MEANS OF PROVIDING STANDARDIZED TRAINING TO THE MARINE CORPS AND IMPROVING FIRST RESPONDER CARE AT THE POINT OF INJURY. HISTORY OF TCCC: a. It is important to realize that civilian trauma care in a non-tactical setting is dissimilar to trauma care in a combat environment. TCCC and CLS are an attempt to better prepare medical and non-medical personnel for the unique factors associated with combat trauma casualties. b. Historical data shows that 90% of combat wound fatalities die on the battlefield before reaching a military treatment facility. This fact illustrates the importance of first responder care at the point of injury. c. TCCC was originally a US Special Operations research project which was composed of trauma management guidelines focusing on casualty care at the point of injury. d. TCCC guidelines are currently used throughout the US Military and various allied countries. e. TCCC guidelines were first introduced in 1996 for use by Special Operations corpsmen, medics, and pararescue (PJs). f. The TCCC guidelines are currently endorsed by the American College of Surgeons, Committee on Trauma and the National Association of Emergency Medical Technicians. The guidelines have been incorporated into the Prehospital Trauma Life Support (PHTLS) text since the 4th edition. STUDENT CURRICULUM: Tactical Combat Casualty Care/CLS Overview Identify Medical Fundamentals Manage Hemorrhage Maintain Casualty Airway Manage Penetrating Chest Injuries Manage Hemorrhagic Shock Manage Burn Casualties Perform Splinting Techniques Administer Battlefield Medications Perform Casualty Movement Perform Combat Lifesaver Triage Perform Combat Lifesaver Care

Over 2,300 total pages ... OVERVIEW Tactical Combat Casualty Care (TCCC) was developed to emphasize the need for continued improvement in combat pre-hospital care. The Committee on Tactical Combat Casualty Care (CoTCCC) was established in 2001 and is part of the Defense Health Board. CoTCCC is a standing multi-service committee charged with monitoring medical developments in regards to practice, technology, pharmacology and doctrine. New concepts in hemorrhage control, airway management, fluid resuscitation, analgesia, antibiotics and other lifesaving techniques are important steps in providing the best possible care for our Marines and Sailors in combat. The TCCC guidelines are published every 4 years in the Prehospital Trauma Life Support manual. It has been recognized that TCCC guidelines and curriculum will need to change more often than the 4-year cycle of the PHTLS textbook publication. The National Association of Emergency Medical Technicians (NAEMT) will include the updated TCCC guidelines and curriculum on its website as they are approved as a way to help get this new information out to the combat medical personnel in the military that need it. PRINCIPLES OF TACTICAL COMBAT CASUALTY CARE (TCCC) The principles of Tactical Combat Casualty Care are fundamentally different from those of traditional civilian trauma care, where most medical providers and medics train. These differences are based on both the unique patterns and types of wounds that are suffered in combat and the tactical conditions medical personnel face in combat. Unique combat wounds and tactical conditions make it difficult to determine which intervention to perform at what time. Besides addressing a casualty’s medical condition, responding medical personnel must also address the tactical problems faced while providing care in combat. A medically correct intervention at the wrong time may lead to further casualties. Put another way, “good medicine may be a bad tactical decision” which can get the rescuer and the casualty killed. To successfully navigate these issues, medical providers must have skills and training oriented to combat trauma care, as opposed to civilian trauma care. The specifics of casualty care in the tactical setting will depend on the tactical situation, the injuries sustained by the casualty, the knowledge and skills of the first responder, and the medical equipment at hand. In contrast to a hospital Emergency Department setting where the patient IS the mission, on the battlefield, care of casualties sustained is only PART of the mission. TCCC recognizes this fact and structures its guidelines to accomplish three primary goals: 1. Treat the casualty 2. Prevent additional casualties 3. Complete the mission In thinking about the management of combat casualties, it is helpful to divide care into three distinct phases, each with its own characteristics and limitations.

INTRODUCTION: What is TCCC and Why Do I Need to Learn about it?? 1. Coalition forces presently have the best casualty treatment and evacuation system in history. 2. TCCC is what will keep you alive long enough to benefit from it. 3. Originally a Special Operations research effort Trauma management plans that take into account the unique challenges faced by combat medical personnel Now used throughout U.S. military and by most allied countries TCCC has helped U.S. combat forces to achieve the highest casualty survival rate in history. TCCC Approach: 1. Identify the causes of preventable death on the battlefield 2. Address them aggressively 3. Combine good medicine with good tactics Phases of Care in TCCC: 1. Care Under Fire Care under fire is the care rendered by the first responder or combatant 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 by the medical provider in his or her aid bag. 2. Tactical Field Care Tactical Field Care is the care rendered by the first responder or combatant 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 has been no hostile fire. Available medical equipment is still limited to that carried into the field by unit personnel. Time to evacuation to a medical treatment facility may vary considerably. 3. 3. Tactical Evacuation Care Tactical Evacuation Care is the care rendered once the casualty has been picked up by an aircraft, vehicle or boat. Additional medical personnel and equipment that may have been pre-staged should be available in this phase of casualty management.

PHTLS: Prehospital Trauma Life Support, Military Edition consists of the PHTLS core content and features thirteen chapters written by military prehospital trauma care experts for practitioners in the military environment. PHTLS: Prehospital Trauma Life Support, Military Edition is created in partnership between the National Association of Emergency

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