Published evidence and battlefield experience accumulated over the 25 years since the original TCCC paper was published have resulted in all services in the U.S. Military and many allied nations using TCCC concepts to care for their combat wounded. All U.S. combat medics, corpsmen, and pararescuemen are now taught battlefield trauma care techniques based on the TCCC Guidelines. Military units that have trained all their members, including both medical and non-medical personnel, in TCCC have documented the lowest incidence of preventable deaths among their casualties in the history of modern warfare. TCCC-based prehospital trauma training is now widespread in the US civilian sector as well.

TCCC guidelines are reviewed on an ongoing basis and updated as needed by the CoTCCC. Proposed changes to the Guidelines must be approved by a 75% majority of the CoTCCC to be accepted. Changes recommended by the CoTCCC are then forwarded to the Director of the Joint Trauma System for final approval. Once approved, updated versions of the TCCC Guidelines are posted on the Joint Trauma System website as well as the websites of the Defense Health Agency (“Deployed Medicine”), the National Association of Emergency Medical Technicians (NAEMT), the Journal of Special Operations Medicine, and the Special Operations Medical Association. TCCC-based training now provided to all U.S. combat medical personnel includes:

- Phased care in the tactical environment to ensure that good medicine is combined with good small-unit tactics. The three defined phases of care are:
  - Care Under Fire
  - Tactical Field Care
  - Tactical Evacuation (TACEVAC) Care
- Casualty and medic actions during the Care Under Fire phase that focus on gaining and maintaining the tactical advantage, with application of limb tourniquets, when needed, the only medical care recommended for this phase of care.
- The most thorough guidelines available to optimize the use of limb tourniquets, including the use of a second tourniquet when needed to control bleeding; elimination of the distal pulse as a secondary goal for tourniquet application; and the recommendation to attempt conversion from a tourniquet to other methods of bleeding control if the casualty has not yet arrived at a definitive care facility after two hours of tourniquet time.
- The use of hemostatic dressings to control life-threatening hemorrhage from external bleeding at sites that are not amenable to tourniquet use.
- The use of tranexamic acid to help prevent death from non-compressible and junctional hemorrhage as well as moderate/severe traumatic brain injury (TBI).
- The use of junctional tourniquets to help prevent death from junctional hemorrhage.
- The hemostatic adjunct XStat as another option for controlling junctional hemorrhage from wounds with narrow wound tracts.
- Use of the ITClamp to help gain control of external bleeding, especially in casualties with severe bleeding from head and neck trauma.
- Circumferential pelvic binding devices to help reduce the life-threatening internal bleeding that may accompany pelvic fractures.
- The use of nasopharyngeal airways to maintain a patent airway when there is no airway obstruction from direct maxillofacial or neck trauma.
- Initial management of the airway in maxillofacial trauma by having the casualty sit up and lean forward, if possible, thus allowing blood to simply drain out of the oropharynx, clearing the airway.
- Surgical airways for maxillofacial or neck trauma when airway compromise is present, and the sit-up-and-lean-forward position is not feasible or not successful.
- Aggressive needle thoracostomy with a 10 or a 14-gauge, 3.25-inch needle for suspected tension pneumothorax.
- A different approach to spinal precautions – they are not emphasized for casualties with penetrating trauma only, but are still recommended, if tactically feasible, when blunt trauma is present.
- Intravenous (IV) or intraosseous (IO) access only when required for medications or fluid resuscitation.
- The preferential use of a saline lock for IV access as opposed to an IV catheter running fluids at a maintenance (“keep the vein open” or KVO) rate.
- The use of intraosseous devices when vascular access is needed but difficult to obtain.
- Resuscitation of casualties in shock with whole blood or balanced blood components as soon as this becomes logistically feasible in the continuum of care.
- More aggressive fluid resuscitation and supplemental oxygen as needed to avoid hypotension and hypoxia in casualties with traumatic brain injury (TBI).
- The TCCC “Triple-Option Analgesia” plan to provide titrated, faster, safer, and more efficacious battlefield analgesia, using oral analgesics when feasible and ketamine instead of opioids when the casualty is in or at risk of hemorrhagic shock or respiratory distress.
- Ondansetron to control the nausea and vomiting that may be associated with either pain from battlefield trauma or the analgesic medications used to treat it.
- Prevention of hypothermia and secondary coagulopathy through the use of the best available methods to prevent heat loss while in the prehospital phase of care.
- The use of fluoroquinolones and ertapenem on the battlefield to reduce preventable deaths and morbidity from wound infections.
- Combat scenario-based trauma training, emphasizing that trauma care on the battlefield must be consistent with good small-unit tactics.
- Identification of casualties likely to derive the most benefit from supplemental oxygen during TACEVAC.
- Strategies for management of wounded hostile combatants.
- Combat evacuation “Rules of Thumb” and the use of specific injury patterns to help determine casualty evacuation priorities.

References

Bennett BL, Giesbrect G, Zafren K, et al: Management of Hypothermia in Tactical Combat Casualty Care: TCCC Guideline Proposed Change 20-01 (June 2020. J Spec Oper Med 2020;20:21-35

Butler FK Jr, Holcomb JB, Shackelford S, et al: Management of Suspected Tension Pneumothorax in Tactical Combat Casualty Care: TCCC Guidelines Change 17-02. J Spec Oper Med 2018;18:19-35.

Butler FK: Introduction to TCCC Changes Summary 6 May 2021. J Spec Oper Med 2021;21:107

Butler FK. Two decades of saving lives on the battlefield: Tactical Combat Casualty Care turns 20. Mil Med. 2017;182(3):e1563-e1568.

Butler FK, Blackbourne LH, Gross KR. The Combat Medic Aid Bag: 2025.

CoTCCC top ten recommended battlefield trauma care research, development, and evaluation priorities for 2015; J Spec Oper Med. 2015;15(4):7-19.

Butler FK. Tactical combat casualty care: update 2009. J Trauma. 2010;69(suppl):S10–S13.

Deaton T, Auten J, Betzhold R, et al: Fluid Resuscitation in Tactical Combat Casualty Care: TCCC Guidelines Change 21-01. J Spec Oper Med 2021;21: 126-137

Drew B, Auten JD, Cap AP, et al: The Use of Tranexamic Acid in Tactical Combat Casualty Care: TCCC Guidelines Change 20-02. J Spec Oper Med 2020;20:36-43

Drew B, Montgomery HR, Butler FK: Tactical Combat Casualty Care (TCCC) Guidelines for Medical Personnel: 05 November 2020. J Spec Oper Med 2020;20:144-151

Grissom CK, Weaver LK, Clemmer TP, Morris AH. Theoretical advantage of oxygen treatment for combat casualties during medical evacuation at high altitude. J Trauma 2006;61:461–467.

Montgomery HR, Drew BG, Butler FK: Summary of Recent Changes to the TCCC Guidelines: 14 April 2021. J Spec Oper Med 2021;21:107-108

Montgomery HR, Drew BG: Tactical Combat Casualty Care (TCCC) Update. J Spec Oper Med 2020;20:152-153

Onifer D, McKee J, Faudree L, et al: Management of hemorrhage form craniomaxillofacial injuries and penetrating neck injury in Tactical Combat Casualty Care: iTClamp mechanical wound closure device TCCC Guidelines proposed change 19-04 06 June 2019. J Spec Oper Med 2019;19:31-44

Onifer D, Butler F, Gross K, et al: Replacement of promethazine with ondansetron for treatment of opioid and trauma-related nausea and vomiting in tactical combat casualty care. J Spec Oper Med 2015;15:17-24

Riesberg J, Gurney J, Moore M: The Management of Abdominal Evisceration in Tactical Combat Casualty Care. TCCC Guideline Change 21-02. J Spec Oper Med – In Press

Sims K, Montgomery H, Dituro P, et al: Management of external hemorrhage in Tactical Combat Casualty Care: the adjunctive use of XStat™ compressed hemostatic sponges: TCCC Guidelines change 15-03. J Spec Oper Med 2016;16:19-28