Tactical combat casualty care


Tactical Combat Casualty Care 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, a component of the Joint Trauma System division of the Defense Health Agency. 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. 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. TCCC or similar standards are used by most allied countries.
The Committee on Tactical Combat Casualty Care 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. In 2012, the CoTCCC was moved to the DoD Joint Trauma System. In August 2018, the JTS along with CoTCCC were realigned as a directorate of the Defense Health Agency. The CoTCCC now operates as a component of the Defense Committees on Trauma. 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. 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.

TCCC Guidelines

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 Committee on TCCC. The guidelines are continually updated.
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.
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. 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.

Tactical Field Care (TFC)

TFC is care rendered by first responders or prehospital medical personnel while still in the tactical environment. TFC is focused on assessment and management using the MARCH acronym.
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 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)

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.

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 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 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. 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. 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. The success of the medical improvements during the wars in Iraq and Afghanistan have served to maintain the lowest case fatality rate on record.

Historical Revisions of the TCCC Guidelines

Revisions to the TCCC Guidelines are produced by the CoTCCC and published in medical journal literature.
2019 Recommended Limb Tourniquets in Tactical Combat Casualty Care.
Change 19-04 - Management of Hemorrhage From Craniomaxillofacial Injuries and Penetrating Neck Injury in TCCC using iTClamp
Change 18-01 - Advanced Resuscitative Care in TCCC
Change 17-02 - Management of Suspected Tension Pneumothorax in Tactical Combat Casualty Care
Change 17-01 - Extraglottic Airways in Tactical Combat Casualty Care
Change 16-03 - TCCC Guidelines Comprehensive Review and Update
Change 16-02 - The Use of Pelvic Binders in Tactical Combat Casualty Care
Change 15-03 - Management of External Hemorrhage in Tactical Combat Casualty Care: The Adjunctive Use of XStat Compressed Hemostatic Sponges.
Change 15-01 - Emergency Cricothyroidotomy in Tactical Combat Casualty Care
Change 14-03 - Replacement of Promethazine with Ondansetron for Treatment of Opioid- and Trauma-Related Nausea and Vomiting
Change 14-02 - Optimizing the Use of Limb Tourniquets Tactical Combat Casualty Care
Change 14-01 - Fluid Resuscitation for Hemorrhagic Shock in Tactical Combat Casualty Care
Change 13-05 - Management of External Hemorrhage in Tactical Combat Casualty Care: Chitosan-Based Hemostatic Gauze Dressings
Change 13-04 - A Triple-Option Analgesia Plan for Tactical Combat Casualty Care
Change 13-03 - Management of Junctional Hemorrhage in Tactical Combat Casualty Care.  
Change 13-02 - Management of Open Pneumothorax in Tactical Combat Casualty Care
Change 13-01 - The Tactical Combat Casualty Care Casualty Card