TCCC Guidelines Comprehensive Review and Update: TCCC Guidelines Change 16-03

Harold R. Montgomery, ATP, Frank K. Butler, MD, Win Kerr, ATP, Curtis C. Conklin, ATP,  Daniel Morissette, ATP, Michael A. Remley, ATP, Travis A. Shaw, NREMT-P and Thomas A. Rich, NREMT-P.

Journal of Special Operations Medicine

J Spec Oper Med. 2017;Summer, 17(2):21-38.

Abstract & Summary

Based on careful review of the Tactical Combat Casualty Care (TCCC) Guidelines, the authors developed a list of proposed changes for inclusion in a comprehensive change proposal. To be included in the proposal, individual changes had to meet at least one of three criteria: (1) The change was primarily tactical rather than clinical; (2) the change was a minor modification to the language of an existing TCCCGuideline; and (3) the change, though clinical, was straightforward and noncontentious. The authors presented their list to the TCCC Working Group for review and approval at the 7 September 2016 meeting of the Committee on Tactical Combat Casualty Care (CoTCCC). Twenty-three items met with general agreement and were retained in this change proposal.

Summary of Changes

1. Add establishing a security perimeter to the beginning of tactical field care (TFC).

2. Specify securing both weapons and communications equipment of casualties with altered mental status in TFC.

3. Add a “Massive Hemorrhage” paragraph as the first medical intervention in TFC and tactical evacuation(TACEVAC) care.

4. Change the Breathing section title to Respiration/Breathing.

5. Change the Bleeding section title to Circulation.Make the first subsection “Bleeding” and include in it pelvic binders, replacing or doubling limb tourniquets, converting tourniquets, and recording times of tourniquet events. Follow the Bleeding subsection with the subsections IV Access, TXA (tranexamic acid), and Fluid Resuscitation.

6. Shift the initiation of pulse oximetry to the Respiration/Breathing section.

7. Add known or suspected smoke inhalation as an indication for supplemental oxygen when available.

8. Replace the term wound site with bleeding site throughout the TCCC Guidelines when addressing hemorrhage control.

9. Add “Remove tourniquet if it was never actually needed to control bleeding” to the subsection Bleeding.

10. Modify “check a distal pulse if possible” to specify that the “if possible” caveat applies to a traumatic amputation.

11. Clarify that XSTAT®, unlike other hemostatic dressings,should not be removed by Combat medical personnel in the field after it has been applied, but more XSTAT may be added and/or a different hemostatic dressing applied over the XSTAT.

12. Clarify tourniquet documentation requirements.

13. Specify the indications for establishing intravenous(IV) or intraosseous (IO) access.

14. Clarify the wording regarding time urgency and the duration of infusion of TXA.

15. Specify that hypothermia prevention should generally be undertaken concurrently with fluid resuscitation when the latter is indicated.

16. Eliminate cefotetan as a recommended antibiotic option.

17. Add a requirement to document the results of the rapid field test of visual acuity in known or suspected eye injuries.

18. Recommend advanced electronic monitoring in TFC if and when the technology is available in this phase.

19. Change the name of the oral medication package from “Combat Pill Pack” to “Combat Wound Medication Pack.”

20. Expand the communication paragraph in TFC to include communicating with tactical leadership and the evacuation system, as well as with the casualty.Add a similar paragraph to TACEVAC.

21. Add a section on preparing the casualty for evacuation to the end of TFC.

22. Add a section on transition of care to the beginning of TACEVAC.

23. Rearrange the Guidelines as needed to reflect the actual priority of clinical interventions.