As of 2021, many of the above TCCC recommendations are in various stages of transition to the civilian sector. Tourniquets have probably been the best example of a successful translation, largely because of the ease with which external hemorrhage can be identified as well as the ease with which tourniquets can be applied when needed, but also because of the pioneering efforts of Dr. Jacobs, the Hartford Consensus Group, and the American College of Surgeons discussed previously.

Prior to the onset of hostilities in Afghanistan in 2001, because of the widespread and erroneous belief that the risks of tourniquet use outweighed the benefits, civilian tourniquet use was almost non-existent. TCCC was virtually the only entity advocating for their prehospital use in trauma patients. By 2008, tourniquet use was ubiquitous in the U.S. military, but not in the civilian sector. In their 2019 paper, Goodwin and her co-authors examined the National Emergency Medical Services (NEMSIS) database from 2008 to 2016. The authors noted that in the years 2008 and 2009, in 8,940,451 EMS activations in the civilian sector, there were exactly 0 instances of tourniquet use. By 2016, there were 3995 instances of tourniquet use in 29,919,652 EMS activations. The authors attribute this dramatic change directly to the TCCC initiative, noting that:

“Over the past two decades, the early and judicious use of tourniquets for prompt control of life-threatening extremity hemorrhage has become the cornerstone of the US military's Tactical Combat Casualty Care (TCCC) program. It has substantially improved survival, particularly from compressible sites of hemorrhage and what were deemed “preventable deaths.”

It is not known how many potentially preventable deaths have occurred because of the lack of prehospital tourniquet use over the years, but there have been numerous papers that clearly document the lifesaving benefits of civilian tourniquet use in the recent past. Despite the well-documented success of tourniquets at saving lives in the civilian sector at this point in time, a December 2021 paper by Bulger noted that in the area surveyed in her study, “Although they observed an increase in the use of tourniquets over time, it is concerning that overall, only 10% of the cohort received a tourniquet, and in the last year of the study, 2019, only 18% received a tourniquet."

Another TCCC intervention that has translated well into the civilian EMS setting is hemostatic dressings. After having been a research priority for the U.S. military since the Battle of Mogadishu, hemostatic dressings were developed and tested at military medical research laboratories and widely used by combat troops after several year of conflict in Afghanistan and Iraq. Absent from civilian trauma systems prior to their being recommended by TCCC, hemostatic dressings are now widely reported to be used and of benefit in controlling external hemorrhage in the civilian sector.

Prehospital fluid resuscitation for trauma victims in hemorrhagic shock is a third example of military prehospital innovations translating well to the civilian sector. The prevailing wisdom regarding prehospital fluid resuscitation when the TCCC effort began in 1992 was the administration of large volumes of crystalloid (2 liters of normal saline or lactated Ringers.) The TCCC researchers found that this approach was not well-supported by the best evidence available at the time and recommended a different approach to prehospital fluid resuscitation, limiting the amount of crystalloid administered and using hetastarch solutions so that the fluid administered would remain intravascular for a much longer period of time than would be the case with crystalloid.

These initial recommendations continued to evolve throughout the course of the conflicts in Iraq and Afghanistan as evidence from those conflicts became available. The repositioning of the Committee on TCCC from the Defense Health Board to the Joint Trauma System in 2013 strengthened its tie with the military trauma surgery and critical care communities who were responsible for the in-hospital advances in trauma care, including a shift from predominantly red blood cell (RBC) resuscitation, to a balanced approach using a 1:1:1 volume ratio of plasma: RBCs:platelets and later to the preferential use of low-titer O whole blood (LTOWB.) The life-saving benefits of whole blood in the resuscitation of combat casualties in hemorrhagic shock has now been well-documented.

The recent conflicts have also provided evidence that whole blood and blood products improve survival when administered in the prehospital phase of care and should be administered as soon as possible when indicated. Shackelford et al reviewed the records of 502 casualties from Afghanistan and found that – quite literally – minutes matter. When casualties required a transfusion of either whole blood or blood components, the earlier they got them. the better their chances of surviving were, both at 24 hours and 30 days after wounding.

Later Gurney et al published several studies designed to determine the impact of fresh whole blood as compared to blood components in improving the survival of casualties who required transfusions. The researchers found that for severely injured casualties the risk of death was almost three times as great in those casualties who did not receive fresh whole blood.

The use of whole blood when feasible and RBCs or plasma when whole blood is not available may have a much larger impact on casualty survival in future conflicts that may see U.S. troops conducting combat operations in less mature theaters of conflict than Iraq and Afghanistan were in the later years of those wars. Military operations in the U.S. IndoPacific Command in particular may include shipboard casualties who may have prolonged evacuation times to a surgical capability.

On the civilian side, there is starting to be movement away from the old prehospital fluid resuscitation paradigm of large volume crystalloid. The recognition of LTOWB as a favorable option for the resuscitation by civilian organizations such as the American Association of Blood Banks has increased the visibility of this option in the civilian sector and a growing number of civilian EMS agencies have recognized that whole blood and other blood products offer a distinct survival benefit over large volume crystalloid solutions in the civilian sector.

In 2021, Guyette and colleagues conducted a comparison of resuscitation with electrolyte solution to resuscitation with blood products in severely injured patients who were transported by 27 helicopter emergency medical services, Prehospital administration of plasma and red blood cells was found to reduce mortality by 62% in comparison to electrolyte solutions. Hashmi et al reported that the proportion of American College of Surgeons-verified trauma centers transfusing whole blood for trauma patients was 16.7% (45/269) in 2015; that percentage had increased to 24.5% (123/502) by the first quarter of of 2020.