The formal publication of these changes will in an upcoming edition of the Journal of Special Operations Medicine (JSOM).

Analgesia in the military prehospital setting is one of the most essential elements of caring for casualties wounded in combat. The goals of casualty care is to expedite the delivery of life-saving interventions, preserve tactical conditions, and prevent morbidity and mortality. The Tactical Combat Casualty Care (TCCC) Triple Option Analgesia guideline provided a simplified approach to analgesia in the prehospital combat setting using the options of combat medication pack, oral transmucosal fentanyl, or ketamine. This review will address the following issues related to analgesia on the battlefield:

1. The development of additional pain management strategies.

2. Recommended changes to dosing strategies of medications such as ketamine.

3. Recognition of the tiers within TCCC and guidelines for higher-level providers to use a wider range of analgesia and sedation techniques.

4. An option for sedation in casualties that require procedures.

This review also acknowledges the next step of care: Prolonged Casualty Care (PCC). Specific questions addressed in this update include:

1) What additional analgesic options are appropriate for combat casualties?

2) What is the optimal dose of ketamine?

3) What sedation regimen is appropriate for combat casualties?

Hemorrhagic shock in combat trauma remains the greatest life threat to casualties with potentially survivable injuries. Advances in external hemorrhage control and the increasing use of damage control resuscitation have demonstrated significant success in decreasing mortality in combat casualties. Presently, an expanding body of literature suggests that fluid resuscitation strategies for casualties in hemorrhagic shock that include the prehospital use of cold-stored or fresh whole blood when available, or blood components when whole blood is not available, are superior to crystalloid and colloid fluids.

On the basis of this recent evidence, the Committee on Tactical Combat Casualty Care (TCCC) has conducted a review of fluid resuscitation for the combat casualty who is in hemorrhagic shock and made the following new recommendations:

(1) cold stored low-titer group O whole blood (CS-LTOWB)has been designated as the preferred resuscitation fluid, with fresh LTOWB identified as the first alternate if CS-LTOWB is not available;

(2) crystalloids and Hextend are no longer recommended as fluid resuscitation options in hemorrhagic shock;

(3) target systolic blood pressure (SBP) resuscitation goals have been redefined for casualties with and without traumatic brain injury (TBI) coexisting with their hemorrhagic shock; and

(4)empiric prehospital calcium administration is now recommended whenever blood product resuscitation is required.

Based on careful review of the Tactical Combat Casualty Care(TCCC) Guidelines, the authors developed a list of proposed changes and edits 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, operational, or educational rather than clinical in nature.

2. The change was a minor modification to the language of an existing TCCC Guideline.

3. The change, though clinical, was straightforward and noncontentious. The authors initially presented their list to the TCCC Collaboration Group for review at the 11 August 2020 online virtual meeting of the Committee on Tactical Combat Casualty Care(CoTCCC). Based on discussions during the virtual meeting and following revisions, a second presentation of guideline modifications was presented during the CoTCCC session of the online virtual Defense Committee on Trauma meeting on02 September 2020. The CoTCCC conducted voting on the guideline changes in early October 2020 with subsequent inclusion in the updated TCCC Guidelines published on 01 November2020.

1. Change “Care Under Fire” phase to “Care Under Fire/Threat.”

2. Add text to Care Under Fire/Threat line 3 to include dragging and/or carrying a casualty to cover when tactically feasible.

3. Change text in Care Under Fire/Threat line 5 from extricated to extracted.

4. Add text to Tactical Field Care Airway Management, Paragraph4-c, bullet 1.

5. Shift assessment of hemorrhagic shock to an earlier text and reference point in the guidelines.

6. Add a new first line to 14. Burns paragraph.

7. Add a new bullet text to 14-d under burn fluid resuscitation paragraph.

8. Swap paragraph 16. Communication and paragraph 17.Cardiopulmonary resuscitation in sequence.

9. Separate the TACEVAC guidelines from the TCCC Guidelines to become a stand-alone document and the baseline guidelines managed by the Committee on En Route Combat Casualty Care (CoERCCC).

10. TCCC medication indicated for intraosseous (IO) infusion

Historically, about 20% of hospitalized combat injured patients have an abdominal injury. Abdominal evisceration maybe expected to complicate as many as one-third of battle-related abdominal wounds. The outcomes for casualties with eviscerating injuries may be significantly improved with appropriate prehospital management. While not as extensively studied as other forms of combat injury, abdominal evisceration management recommendations extend back to at least World War I, when it was recognized as a significant cause of morbidity and was especially associated with bayonet injury.

More recently, abdominal evisceration has been noted as a frequent result of penetrating, ballistic trauma. Initial management of abdominal evisceration for prehospital providers consists of assessing for and controlling associated hemorrhage, assessing for bowel content leakage, covering the eviscerated abdominal contents with a moist, sterile barrier, and carefully reassessing the patient. Mortality in abdominal evisceration is more likely to be secondary to associated injuries than to the evisceration itself.

Attempting to establish education, training, and a standard of care for nonmedical and medical first responders and to leverage current wound management technologies, the Committee on Tactical Combat Casualty Care (CoTCCC)conducted a systematic review of historical Service guidelines and recent medical studies that include abdominal evisceration.

For abdominal evisceration injuries, the following principles of management apply:

• Control any associated bleeding visible in the wound.
• If there is no evidence of spinal cord injury, allow the patient to take the position of most comfort.
• Rinse the eviscerated bowel with clean fluid to reduce gross contamination.
• Cover exposed bowel with a moist, sterile dressing or a sterile water-impermeable covering. It is important to keep the wound moist; irrigate the dressing with warm water if available.
• For reduction in wounds that do not have a substantial loss of abdominal wall, a brief attempt may be made to replace/reduce the eviscerated abdominal contents. If the external contents do not easily go back into the abdominal cavity, do not force or spend more than 60 seconds attempting to reduce contents. If reduction of eviscerated contents is successful, reapproximate the skin using available material, preferably an adhesive dressing like a chest seal (other examples include safety pins, suture, staples, wound closure devices, etc.). Do not attempt to reduce bowel that is actively bleeding or leaking enteric contents.
• If unable to reduce, cover the eviscerated organs with water-impermeable, nonadhesive material (transparent preferred to allow ability to reassess for ongoing bleeding; examples include a bowel bag, IV bag, clear food wrap, etc.), and then secure the impermeable dressing to the patient using an adhesive dressing (e.g., Ioban, chest seal).
• Do NOT FORCE contents back into abdomen or actively bleeding viscera.
• Death in the abdominally eviscerated patient is typically from associated injuries, such as concomitant solid organ or vascular injury, rather than from the evisceration itself.
• Antibiotics should be administered for any open wounds, including abdominal eviscerating injuries. Parenteral ertapenem is the preferred antibiotic for these injuries.

The literature continues to provide strong support for the early use of tranexamic acid (TXA) in severely injured trauma patients. (1) Questions persist, however, regarding the optimal medical and tactical/logistical use, timing, and dose of this medication, both from the published TXA literature and from the TCCC user community. The use of TXA has been explored outside of trauma, new dosing strategies have been pursued, and expansion of retrospective use data has grown as well. These questions emphasize the need for a reexamination of TXA by the CoTCCC. The most significant updates to the TCCC Guidelines are (i) including significant traumatic brain injury (TBI) as an indication for TXA, (ii) changing the dosing protocol to a single 2g IV/IO administration, and (iii) providing for administration via IV/IO push.

NEW Wording to TCCC Guidelines:

Tactical Field Care & TACEVAC Care

c. Tranexamic Acid (TXA)

•If a casualty will likely need a blood transfusion (for example: presents with hemorrhagic shock, elevated lactate, one or more major amputations, penetrating torso trauma, or evidence of severe bleeding)

OR

•If the casualty has signs or symptoms of significant TBI or has altered metal status associated with blast injury or blunt trauma:

–Administer 2g of tranexamic acid via slow IV or IO push as soon as possible but NOT later than 3 hours after injury.

As an outcome of combat injury and hemorrhagic shock, trauma-induced hypothermia (TIH) and the associated coagulopathy and acidosis result in significantly increased risk for death. In an effort to manage TIH, the Hypothermia Prevention and Management Kit™ (HPMK) was implemented in 2006 for battlefield casualties. Recent feedback from operational forces indicates that limitations exist in the HPMK to maintain thermal balance in cold environments, due to the lack of insulation. Consequently, based on lessons learned, some US Special Operations Forces are now upgrading the HPMK after short-term use (60 minutes) by adding insulation around the casualty during training in cold environments. Furthermore, new research indicates that the current HPMK, although better than no hypothermia protection, was ranked last in objective and subjective measures in volunteers when compared with commercial and user-assembled external warming enclosure systems. On the basis of these observations and research findings, the Committee on Tactical Combat Casualty Care decided to review the hypothermia prevention and management guidelines in 2018 and to update them on the basis of these facts and that no update has occurred in 14 years. Recommendations are made for minimal costs, low cube and weight solutions to create an insulated HPMK, or when the HPMK is not readily available, to create an improvised hypothermia (insulated) enclosure system.

NEW Wording to TCCC Guidelines:

Tactical Field Care & Tactical Evacuation Care

7. Hypothermia Prevention

a. Take early and aggressive steps to prevent additional body heat loss and add external heat when possible for trauma and severely burned casualties.

b. Minimize casualty’s exposure to cold ground, wind, and air temperatures. Place insulation material between the casualty and any cold surface as soon as possible. Keep protective gear on or with the casualty if feasible.

c. Replace wet clothing with dry clothing, if possible, and protect from additional heat loss.

d. Place an active heating blanket on the casualty’s anterior torso and under the arms in the axillae (to prevent burns, do not place any active heating source directly on the skin or wrap around the torso).

e. Enclose the casualty in the exterior impermeable enclosure bag.

f. As soon as possible, upgrade a hypothermia enclosure system to a well-insulated enclosure system using a hooded sleeping bag or other readily available insulation inside the enclosure bag/external vapor-barrier shell.

g. Pre-stage an insulated hypothermia enclosure system with external active heating for transition from the noninsulated hypothermia enclosure systems; seek to improve on existing enclosure system when possible.

h. Use a battery-powered warming device to deliver IV resuscitation fluids, in accordance with current CoTCCC guidelines, at flow rate up to 150mL/min with a 38°C (100°F) output temperature.

i. Protect the casualty from exposure to wind and precipitation on any evacuation platform.

Military and civilian trauma can be distinctly different but the leading cause of preventable trauma deaths in the prehospital environment, extremity hemorrhage, does not discriminate. The current paper is the most comprehensive review of limb tourniquets employable in the tactical combat casualty care environment and provides the first update to the CoTCCC-recommended limb tourniquets since 2005. This review also highlights the lack of unbiased data, official reporting mechanisms, and official studies with established criteria for evaluating tourniquets. Upon review of the data, the CoTCCC voted to update the recommendations in April 2019.

Goals: The primary goal of this comprehensive tourniquet review was to (1) review the previously recommended tourniquets, (2) determine if additional commercial tourniquets warrant CoTCCC recommendation, and (3) identify commercial tourniquets that require further review or do not currently warrant recommendation. A deep-dive analysis of medical literature on limb tourniquets primarily published since 2012 was used to extrapolate data to be scored against criteria established the CoTCCC tourniquet working group in 2018.

Scoring: For the purposes of this review, each component of tourniquet criteria was scored on a weighted scale of 0 to 10 or 0 to 5. As such, the maximum score a tourniquet could receive was 50 with a score of 40 being considered the cut-off for a nonpneumatic limb tourniquet to be recommended.

Scoring Criteria:

• Arterial occlusion was the most critical score as a limb tourniquet must adequately demonstrate that it can effectively occlude arterial blood flow of an extremity.
• Speed of application to achieve initial occlusion <60 seconds.
• The simplicity of application was determined as a combination of how easily the device can be applied, how many steps are required for application and/or the number of twists, turns, clicks or pumps necessary to achieve occlusion.
• Within optimal occlusion pressure range of 180 and 500mmHg.
• Specifications of ≥1.5 inches wide, ≥37.50 inches in length, a locking mechanism, time recording area, and weight <8 ounces.
• Known reported or published complications, failures, or safety issues of devices.
• Combat usage reports, civilian usage reports and user preferences in published literature; and logistics data.

Recommended nonpneumatic limb tourniquets:

• Combat Application Tourniquet, Generation 6 (CAT-6)
• Combat Application Tourniquet, Generation 7 (CAT-7)
• SOF Tactical Tourniquet – Wide, Generation 3 (SOFTT-W)
• Tactical Mechanical Tourniquet (TMT)
• Ratcheting Medical Tourniquet-Tactical (RMT-T)
• TX2 / TX3 Ratcheting Tourniquets
• SAM Extremity Tourniquet (SAM-XT)

Recommended pneumatic limb tourniquets:

• Emergency and Military Tourniquet (EMT)
• Tactical Pneumatic Tourniquet, 2 inch (TMT2)

The 2012 study Death on the battlefield (2001–2011) by Eastridge et al. demonstrated that 7.5% of the prehospital deaths caused by potentially survivable injuries were due to external hemorrhage from the cervical region. The increasing use of Tactical Combat-Casualty Care (TCCC) and other medical interventions have dramatically reduced the overall rate of combat-related mortality in US forces; however, uncontrolled hemorrhage remains the number one cause of potentially survivable combat trauma. Additionally, the use of personal protective equipment and adaptations in the weapons used against US forces has caused changes in the wound distribution patterns seen in combat trauma. There has been a significant proportional increase in head and neck wounds, which may result in difficult to control hemorrhage. More than 50% of combat wounded personnel will receive a head or neck wound. The iTClamp (Innovative Trauma Care Inc., Edmonton, Alberta, Canada) is the first and only hemorrhage control device that uses the hydrostatic pressure of a hematoma to tamponade bleeding from an injured vessel within a wound. The iTClamp is US Food and Drug Administration (FDA) approved for use on multiple sites and works in all compressible areas, including on large and irregular lacerations. The iTClamp’s unique design makes it ideal for controlling external hemorrhage in the head and neck region. The iTClamp has been demonstrated effective in over 245 field applications. The device is small and lightweight, easy to apply, can be used by any level of first responder with minimal training, and facilitates excellent skills retention. The iTClamp reapproximates wound edges with four pairs of opposing needles. This mechanism of action has demonstrated safe application for both the patient and the provider, causes minimal pain, and does not result in tissue necrosis, even if the device is left in place for extended periods. The Committee on TCCC recommends the use of the iTClamp as a primary treatment modality, along with a CoTCCC-recommended hemostatic dressing and direct manual pressure (DMP), for hemorrhage control in craniomaxillofacial injuries and penetrating neck injuries with external hemorrhage.

TCCC has previously recommended interventions that can effectively prevent 4 of the top 5 causes of prehospital preventable death in combat casualties-extremity hemorrhage, junctional hemorrhage, airway obstruction, and tension pneumothorax- and deaths from these causes have been markedly reduced in US combat casualties. Noncompressible torso hemorrhage (NCTH) is the last remaining major cause of preventable death on the battlefield and often causes death within 30 minutes of wounding. Increased use of whole blood, including the capability for massive transfusion, if indicated, has the potential to increase survival in casualties with either thoracic and/or abdominopelvic hemorrhage. Additionally, Zone 1 Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) can provide temporary control of bleeding in the abdomen and pelvis and improve hemodynamics in casualties who may be approaching traumatic cardiac arrest as a result of hemorrhagic shock. Together, these two interventions are designated Advanced Resuscitative Care (ARC) and may enable casualties with severe NCTH to survive long enough to reach the care of a surgeon. Although Special Operations units are now using whole blood far-forward, this capability is not routinely present in other US combat units at this point in time. REBOA is not envisioned as care that could be accomplished by a unit medic working out of his or her aid bag. This intervention should be undertaken only by designated teams of advanced combat medical personnel with special training and equipment.

This change to the Tactical Combat Casualty Care (TCCC) Guidelines that updates the recommendations for management of suspected tension pneumothorax for combat casualties in the prehospital setting does the following things:

1. Continues the aggressive approach to suspecting and treating tension pneumothorax based on mechanism of injury and respiratory distress that TCCC has advocated for in the past, as opposed to waiting until shock develops as a result of the tension pneumothorax before treating. The new wording does, however, emphasize that shock and cardiac arrest may ensue if the tension pneumothorax is not treated promptly.

2. Adds additional emphasis to the importance of the current TCCC recommendation to perform needle decompression (NDC) on both sides of the chest on a combat casualty with torso trauma who suffers a traumatic cardiac arrest before reaching a medical treatment facility.

3. Adds a 10 gauge, 3.25 inch needle/catheter unit as an alternative to the previously recommended 14 gauge, 3.25 inch needle/catheter unit as recommended devices for needle decompression.

4. Designates the location at which NDC should be performed as either the lateral site (5th intercostal space {ICS} at the anterior axillary line {AAL}) or the anterior site (2nd ICS at the midclavicular line {MCL}). For the reasons enumerated in the body of the change paper, participants on the 14 December 2017 TCCC Working Group teleconference favored including both potential sites for NDC without specifying a preferred site.

5. Adds two key elements to the description of the NDC procedure: insert the needle/catheter unit at a perpendicular angle to the chest wall all the way to the hub, then hold the needle/catheter unit in place for 5-10 seconds before removing the needle in order to allow for full decompression of the pleural space to occur.

6. Defines what constitutes a successful NDC, using specific metrics such as: an observed hiss of air escaping from the chest during the NDC procedure; a decrease in respiratory distress; an increase in hemoglobin oxygen saturation; and/or an improvement in signs of shock that may be present.

7. Recommends that only two needle decompressions be attempted before continuing on to the “Circulation” portion of the TCCC Guidelines. After two NDCs have been performed, the combat medical provider should proceed to the fourth element in the “MARCH” algorithm and evaluate/treat the casualty for shock as outlined in the Circulation section of the TCCC Guidelines. Eastridge’s landmark 2012 paper documented that noncompressible hemorrhage caused many more combat fatalities than tension pneumothorax. 

Since the manifestations of hemorrhagic shock and shock from tension pneumothorax may be similar, the TCCC Guidelines now recommend proceeding to treatment for hemorrhagic shock (when present) after two NDCs have been performed.

8. Adds a paragraph to the end of the Circulation section of the TCCC Guidelines that calls for consideration of untreated tension pneumothorax as a potential cause for shock that has not responded to fluid resuscitation. This is an important aspect of treating shock in combat casualties that was not presently addressed in the TCCC Guidelines.

9. Adds finger thoracostomy (simple thoracostomy) and chest tubes as additional treatment options to treat suspected tension pneumothorax when further treatment is deemed necessary after two unsuccessful NDC attempts – if the combat medical provider has the skills, experience, and authorizations to perform these advanced interventions and the casualty is in shock. These two more invasive procedures are recommended only when the casualty is in refractory shock, not as the initial treatment.

Extraglottic airway (EGA) devices have been used by both physicians and prehospital providers for several decades. The original TCCC Guidelines published in 1996 included a recommendation to use the laryngeal mask airway (LMA) as an option to assist in securing the airway in Tactical Evacuation (TACEVAC) phase of care.

A variety of EGAs have been used in combat casualty care over the past 20 years. In 2012, the Committee on TCCC (CoTCCC) and the Defense Health Board (DHB) reaffirmed support for the use of supraglottic airway (SGA) devices in the TACEVAC phase of TCCC, but did not recommend a specific SGA based on the evidence available at that point in time. This paper will use the more inclusive term “extraglottic airway” instead of the term “supragottic airway” used in the DHB memo.

Current evidence suggests that the i-gel EGA performs as well or better than the other EGAs available and has other advantages in ease of training, size and weight, cost, safety, and simplicity of use. The gel-filled cuff in the i-gel both eliminates the need for cuff pressure monitoring during flight and reduces the risk of pressure-induced neuropraxia to cranial nerves in the oropharynx as a complication of EGA use. The i-gel thus makes the medic’s tasks simpler and frees him or her from the requirement to carry a cuff manometer as part of the medical kit.

1) Adds extraglottic airways (EGAs) as an option for airway management in Tactical Field Care; 

2) Recommends the i-gel as the preferred EGA in TCCC because its gel-filled cuff makes it simpler to use than EGAs with air-filled cuffs and also eliminates the need for monitoring of cuff pressure; 

3) Notes that should an EGA with an air-filled cuff be used, the pressure in the cuff must be monitored, especially during and after changes in altitude during casualty transport; 

4) Emphasizes COL Bob Mabry’s often-made point that extraglottic airways will not be tolerated by a casualty unless he or she is deeply unconscious and notes that an NPA is a better option if there is doubt about whether or not the casualty will tolerate an EGA; 

5) Adds the use of suction as an adjunct to airway management when available and appropriate (i.e., when needed to remove blood and vomitus); 

6) Clarifies the wording regarding cervical spine stabilization to emphasize that it is not needed for casualties who have sustained only penetrating trauma (without blunt force trauma); 

7) Reinforces that surgical cricothyroidotomies should not be performed simply because a casualty is unconscious; 

8) Provides a reminder that, for casualties with facial trauma or facial burns with suspected inhalation injury, neither NPAs nor EGAs may be adequate for airway management, and a surgical cricothyroidotomy may be required; 

9) Adds that pulse oximetry monitoring is a useful adjunct to assess airway patency and that capnography should also be used in the TACEVAC phase of care; 

10) Reinforces that a casualty’s airway status may change over time and that he or she should be frequently re-assessed.

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.

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.

Blast injuries resulting from improvised explosive device(IED) attacks have been a major cause of combat injury in the Afghanistan conflict. Dismounted IED attacks are frequently associated with pelvic fractures, which in turn may result in massive hemorrhage and death. Pelvic fracture is also frequently caused by penetrating trauma and high-energy blunt trauma such as motor vehicle crash.

The Committee on Tactical Combat Casualty Care (CoTCCC) reviewed the use of pelvic binders in 2008 and decided at the time that there was insufficient evidence of benefit to warrant their addition to the TCCC Guidelines. At the February 2016 meeting of the CoTCCC, CAPT Stephen Bree, the UK Liaison Officer to the US military and an experienced combat medical provider, was asked to present the top three items that he thought needed to be changed about TCCC. One of those three items was to add the use of pelvic binders to the TCCC Guidelines. Col Stacy Shackelford presented a review of this topic for the committee. An extensive review of the literature and consideration by the CoTCCC led the committee to recommend that pelvic binders be reconsidered for addition to the TCCC Guidelines.

1. Add a new initial paragraph to Tactical Field Care paragraph 4. Bleeding, c and to TACEVAC Care paragraph 3. Bleeding, c.

c. A pelvic binder should be applied for cases of suspected pelvic fracture:

– Severe blunt force or blast injury with one or more of the following indications:

• Pelvic pain

• Any major lower limb amputation or near amputation

• Physical exam findings suggestive of a pelvic fracture

• Unconsciousness

• Shock

Exsanguination from wounds in the so-called junctionalregions of the body (i.e., the neck, the axilla, and thegroin) was responsible for 19% of the combat fatalitieswho died from potentially survivable wounds sustainedin Afghanistan or Iraq during 2001 to 2011. The developmentof improved techniques and technology tomanage junctional hemorrhage has been identified inthe past as a high-priority item by the Committee onTactical Combat Casualty Care (CoTCCC) and theArmy Surgeon General’s Dismounted Complex BlastInjury (DCBI) Task Force. Additionally, prehospitalcare providers have had limited options with which tomanage hemorrhage resulting from deep, narrow-track,penetrating trauma. XStat™ is a new product recentlyapproved by the US Food and Drug Administration as ahemostatic adjunct to aid in the control of bleeding fromjunctional wounds in the groin or axilla. XStat has nowbeen recommended by the CoTCCC as another tool forthe combat medical provider to use in the managementof junctional hemorrhage. The evidence that supportsadding XStat to the TCCC Guidelines for the treatmentof external hemorrhage is summarized in this paper.

1. Revision to Tactical Field Care paragraph 4. Bleeding, b and to TACEVAC Care paragraph 3. Bleeding, b.

b. For compressible hemorrhage not amenable to limb tourniquet use or as an adjunct to tourniquet removal,use Combat Gauze™ as the CoTCCC hemostatic dressing of choice.

Alternative hemostatic adjuncts:

– Celox Gauze or

– ChitoGauze or

– XStat (best for deep, narrow-tract junctional wounds)

Hemostatic dressings should be applied with at least 3 minutes of direct pressure (optional for XStat). Each dressing works differently, so if one fails to control bleeding, it may be removed and a fresh dressing of the same type or a different type applied.

The performance of a surgical airway is an infrequently performed, but occasionally lifesaving, procedure on the battlefield. Since a combatant who sustains a wound that damages the upper airway structures is often in extremis shortly after the wound is sustained, this is a procedure that must be performed by the individual who is caring for the casualty at the point of injury: the combat medic.There are a variety of techniques and equipment available to perform this technique. In the past, the Committee on Tactical Combat Casualty Care (CoTCCC) has not recommended a specific equipment item for the performance of surgical airways. A recent study with Army 68-Whiskey medics trained to the Emergency Medical Technician–Basic (EMT-B) level found that the use of a new equipment item, the CricKey, resulted in surgical airways being performed on fresh human cadavers by medics faster than with the standard open surgical technique, and with a 100% first-pass success rate compared with a 70% first-pass success rate using the standard technique. At this time, the CricKey has the best supporting evidence for enabling successful performance of surgical airways by combat medical personnel and is proposed as the device of choice for TCCC.

1.  Of the techniques and cannula types reviewed in this report, we recommend an open technique via a vertical,midline incision. This approach will maximize anatomic exposure, minimize bleeding, and allow for extension of the incision at either end if the initial incision is not optimally placed.

2. Revision of the Airway Management paragraph in Tactical Field Care:

c. If the previous measures are unsuccessful, perform a surgical cricothyroidotomy using one of the following:

• CricKey technique (preferred option)

• Bougie-aided open surgical technique using aflanged and cuffed airway cannula of less than10mm outer diameter, 6mm to 7mm internal diameter,and 5cm to 8cm of intratracheal length

• Standard open surgical technique using a flangedand cuffed airway cannula of less than 10mmouter diameter, 6mm to 7mm internal diameter,and 5cm to 8cm of intratracheal length (least desirableoption)

Use lidocaine if the casualty is conscious.

3. Revision of the Airway Management paragraph in TACEVAC Care:

b. Casualty with airway obstruction or impending airway obstruction:

– Chin lift or jaw thrust maneuver

– Nasopharyngeal airway

– Allow casualty to assume any position that bestprotects the airway, to include sitting up.

– Place unconscious casualty in the recoveryposition.– If the previous measures are unsuccessful, assess the tactical and clinical situations, the equipment at hand, and the skills and experience of the person providing care, and then select one of the following airway interventions:

– Supraglottic airway, or

– Endotracheal intubation or

– Perform a surgical cricothyroidotomy using one of the following:

• CricKey technique (preferred option)

• Bougie-aided open surgical technique using a flanged and cuffed airway cannula of less than 10mm outer diameter, 6mm to 7mm internal diameter, and 5cm to 8cm of intratracheal length

• Standard open surgical technique using a flanged and cuffed airway cannula of less than 10mm outer diameter, 6mm to 7mm internal diameter, and 5cm to 8cm of intratracheal length (least desirable option)

Use lidocaine if the casualty is conscious.

c. Spinal immobilization is not necessary for casualties with penetrating trauma.

The current Tactical Combat Casualty Care (TCCC)Guidelines recommend parenteral promethazine as the single agent for the treatment of opioid-induced nausea and/or vomiting and give a secondary indication of“synergistic analgesic effect.” Promethazine, however,has a well-documented history of undesired side effects relating to impairment and dysregulation of the central and autonomic nervous systems, such as sedation, extra pyramidal symptoms, dystonia, impairment of psychomotor function, neuroleptic malignant syndrome,and hypotension. These may be particularly worrisome in the combat casualty. Additionally, since 16 September 2009, there has been a US Food and Drug Administration(FDA) black box warning for the injectable form of promethazine, due to “the risk of serious tissue injury when this drug is administered incorrectly.”Conversely, ondansetron, which is now available in generic form, has a well-established favorable safety profile and demonstrated efficacy in undifferentiated nausea and vomiting in the emergency department and prehospital settings. It has none of the central and autonomic nervous system side effects noted with promethazine and carries no FDA black box warning. Ondansetron is available in parenteral form and an orally disintegrating tablet, providing multiple safe and effective routes of administration. Despite the fact that it is an off-label use, ondansetron is being increasingly given for acute, undifferentiated nausea and vomiting and is presently being used in the field on combat casualties by some US and Allied Forces. Considering the risks involved with promethazine use, and the efficacy and safety of ondansetron and ondansetron’s availability in a generic form, we recommend removing promethazine from the TCCC Guidelines and replacing it with ondansetron.

Revision to paragraph 13k in both Tactical Field Care and TACEVAC Care. 

– Ondansetron, 4mg ODT/IV/IO/IM, every 8 hours as needed for nausea or vomiting. Each 8 hour dose can be repeated once at 15 minutes if nausea and vomiting are not improved. Do not give more than 8mg in any 8 hour interval. Oral ondansetron is NOT an acceptable alternative to the ODT formulation.

The early use of limb tourniquets has been documented to save lives on the battlefield but has the potential for significant morbidity.  Since its inception, Tactical Combat Casualty Care (TCCC) has emphasized early and liberal use of tourniquets to control life-threatening hemorrhage in the care-under-fire (CUF) phase.

A decrease in the frequency of preventable deaths has been achieved though widespread training, and dissemination and use of tourniquets. The likelihood of tourniquet morbidity had been reduced through selection of better devices, more training of potential users, and more rapid evacuation. To minimize complications, it is important that training emphasize early conversion of tourniquets that are no longer needed; tourniquets must be frequently reassessed to ensure that hemorrhage is stopped and venous tourniquets avoided, particularly when evacuation time is long.

Tourniquets that are no longer needed should be converted to hemostatic or pressure dressings as soon as possible if the criteria for safe removal are met to reduce tourniquet pain and minimize the risks of complications. If the tourniquet is still on the extremity 2 hours after placement, a mandatory reassessment of the continued need for the tourniquet should occur.

The goals of tourniquet placement are to stop both bleeding and the distal pulse. Tactical and clinical situations dictate which goal(s) can be monitored; however, the likelihood of maximum benefit and minimum risk occurs only when both goals are attained.

Tourniquets placed during CUF should be positioned clearly proximal to the bleeding site(s). If the site of life-threatening bleeding is not readily apparent, the tourniquet should be placed high and tight (as proximal as possible) on the injured extremity as soon as possible.

Single-slit routing of the C-A-T band through the buckle is effective and may reduce blood loss and time for application; this method is recommended during the CUF phase.

1. Clarification of tourniquet conversion guidelines.

2. Clarification of effective tourniquet placement.

3. Clarification of the location of tourniquet placement during CUF.

4. Review recommendation for Combat Application Tourniquet® (C-A-T) routing of the band through the buckle.

This report reviews the recent literature on fluid resuscitation from hemorrhagic shock and considers the applicability of this evidence for use in resuscitation of combat casualties in the prehospital Tactical Combat Casualty Care (TCCC) environment. A number of changes to the TCCC Guidelines are incorporated: (1) dried plasma(DP) is added as an option when other blood components or whole blood are not available; (2) the wording is clarified to emphasize that Hextend is a less desirable option than whole blood, blood components, or DP and should be used only when these preferred options are not available; (3) the use of blood products in certain Tactical Field Care (TFC) settings where this option might be feasible (ships, mounted patrols) is discussed;(4) 1:1:1 damage control resuscitation (DCR)is preferred to 1:1 DCR when platelets are available as well as plasma and red cells; and (5) the 30-minute wait between increments of resuscitation fluid administered to achieve clinical improvement or target blood pressure(BP) has been eliminated. Also included is an order of precedence for resuscitation fluid options. Maintained as recommendations are an emphasis on hypotensive resuscitation in order to minimize (1) interference with the body’s hemostatic response and (2) the risk of complications of over resuscitation. Hextend is retained as the preferred option over crystalloids when blood products are not available because of its smaller volume and the potential for long evacuations in the military setting.

1. The preferred fluids for resuscitation of casualties in hemorrhagic shock, in descending order of preference,are:

– Whole blood

– 1:1:1 plasma, RBCs, and platelets

– 1:1 plasma and RBCs

– Reconstituted DP, liquid plasma, or thawed plasma alone or RBCs alone

– Hextend

– LR or Plasma-Lyte A

2. Blood products are becoming increasingly available in the prehospital setting and are the resuscitation fluids of choice when feasible.

3. Both fresh whole blood and apheresis platelets, as currently collected and screened in deployed medical treatment facilities, are not FDA compliant. Non–FDA-compliant platelets should be used only when FDA-compliant platelets are not available (as is currently the case in deployed MTFs). Non–FDA compliant whole blood should be used only when treatment with FDA-compliant blood components is not producing the desired clinical effect and FDA compliant whole blood is not available.

4. In order to administer blood components safely in the prehospital combat setting and to optimize the benefit obtained from their use, a command or theater-approved protocol that has been coordinated with the appropriate clinical and blood and banking facilities should be in place. All medical personnel who will be responsible for administering blood products in the prehospital combat setting should be trained in the approved protocol.

5. Hextend is less desirable than blood components for fluid resuscitation. When available for point-of-injury care, liquid (never-frozen) or thawed plasma,or reconstituted DP is preferred over both crystalloids and colloids. The French DP product is currently being used by selected Special Operations units under a treatment protocol. The DoD should continue its aggressive efforts to obtain an FDA-approved DP product so that the use of DP can expanded to all military medical personnel who may care for combat casualties at or near the point of injury.

6. The DoD and the FDA should move to establish a Military Use Panel with a charter to grant military specific approval where appropriate for medications not labeled for trauma or other products not yet FDA approved, but which are documented to be safe and effective and are of special interest to the military for use in battlefield trauma care.

7. The volume of fluid used in the resuscitation of casualties in hemorrhagic shock is an important factor in determining outcomes and the optimal volume may vary based on the type of injuries present.

8. Large-volume crystalloid fluid resuscitation for patients in shock caused by penetrating torso trauma has been shown to decrease patient survival compared with resuscitation with restricted volumes of crystalloid.

9. Larger volumes of infused crystalloids have also been associated with increased mortality in trauma patients in studies where the authors did not categorize patients by controlled versus uncontrolled hemorrhage.

10. The smaller required volume and sustained intravascular presence of Hextend as recommended by TCCC is important to combat medical personnel who treat casualties in austere environments where evacuation times may be prolonged. Hextend may also decrease complications of crystalloid resuscitation such as ARDS and ACS, but does not decrease the dilutional coagulopathy caused by crystalloid resuscitation.

11. When tactical and logistical constraints prevent the use of the recommended blood products, hypotensive resuscitation with Hextend as outlined in the current TCCC guidelines should continue to be used for the resuscitation of casualties in hemorrhagic shock.

12. The emerging evidence on hetastarch use and acute kidney injury has not documented a problem with Hextend use for the indication (hemorrhagic shock)and in the volumes recommended by TCCC.

Hemorrhage remains the leading cause of combat death and a major cause of death from potentially survivable injuries. Great strides have been made in controlling extremity hemorrhage with tourniquets, but not all injuries are amenable to tourniquet application. Topical hemostatic agents and dressings have also contributed to success in controlling extremity and compressible junctional hemorrhage, and their efficacy continues to increase as enhanced products are developed. Since the addition of Combat Gauze™ (Z-Medica Corporation, Wallingford, CT, USA; http://www.z-medica.com/)in April 2008 to the Tactical Combat Casualty Care(TCCC) Guidelines, there are consistent data from animal studies of severe hemorrhage that chitosan-based hemostatic gauze dressings developed for battlefield application are, at least, equally efficacious as Combat Gauze. Successful outcomes are also reported using newer chitosan-based dressings in civilian hospital based surgical case reports and prehospital (battlefield)case reports and series. Additionally, there have been no noted complications or safety concerns in these cases or across many years of chitosan-based hemostatic dressing use in both the military and civilian prehospital sectors.Consequently, after a decade of clinical use, there is added benefit and a good safety record for using chitosan-based gauze dressings. For these reasons, many specific US military Special Operations Forces, NATO militaries, and emergency medical services (EMS) and law enforcement agencies have already implemented the widespread use of these new recommended chitosan based hemostatic dressings. Based on the past battlefield success, this report proposes to keep Combat Gauze as the hemostatic dressing of choice along with the new addition of Celox™ Gauze (Medtrade Products Ltd.,Crewe, UK; http://www.celoxmedical.com/usa/products/celox-gauze/) and ChitoGauze® (HemCon Medical Technologies,Portland, OR, USA; http://www.hemcon.com/)to the TCCC Guidelines.

No current hemostatic agent or dressing has proven to be ideal for all trauma scenarios in normal and coagulopathic casualties. However, this review of animal studies and clinical case reports found that Celox Gauze and ChitoGauze are as efficacious as Combat Gauze. These chitosan-based dressings were not statistically different than Combat Gauze for most outcome measures.

Based on the larger experience of the US Military with Combat Gauze, this dressing should remain in the guidelines as the hemostatic dressing of choice but with the knowledge that both Celox Gauze and ChitoGauze show similar efficacy and are viable alternatives. Therefore, the TCCC Guidelines should continue to include Combat Gauze, with the addition of Celox Gauze and ChitoGauze dressings.

Tactical Field Care and TACEVAC, Para 3-b Revised:

b. For compressible hemorrhage not amenable to tourniquet use or as an adjunct to tourniquet removal (if evacuation time is anticipated to be longer than 2 hours), use Combat Gauze as the CoTCCC hemostatic dressing of choice. CeloxGauze and ChitoGauze may also be used if Combat Gauze is not available. Hemostatic dressings should be applied with at least 3 minutes of direct pressure. Before releasing any tourniquet on a casualty who has been resuscitated for hemorrhagic shock, ensure a positive response to resuscitation efforts (i.e., a peripheral pulse normal in character and normal mentation if there is no traumatic brain injury [TBI]). If the bleeding site is appropriate for use of a junctional tourniquet, immediately apply a CoTCCC-recommended junctional tourniquet. Do not delay in the application of the junctional tourniquet once it is ready for use. Apply hemostatic dressings with direct pressure if a junctional tourniquet is not available or while the junctional tourniquet is being readied for use.

Although the majority of potentially preventable fatalities among U.S. combat forces serving in Afghanistan and Iraq have died from hemorrhagic shock, themajority of U.S. medics carry morphine auto-injectors for prehospital battlefield analgesia. Morphine given intramuscularly has a delayed onset of action and,like all opioids, may worsen hemorrhagic shock. Additionally,on a recent assessment of prehospital care in Afghanistan, combat medical personnel noted that Tactical Combat Casualty Care (TCCC) battlefield analgesia recommendations need to be simplified—there are too many options and not enough clear guidance on which medication to use in specific situations. They also reported that ketamine is presently being used as a battlefield analgesic by some medics in theater with good results. This report proposes that battlefield analgesia be achieved using one or more of three options:(1) the meloxicam and Tylenol in the TCCC Combat Pill Pack for casualties with relatively minor pain who are still able to function as effective combatants; (2)oral transmucosal fentanyl citrate (OTFC) for casualties who have moderate to severe pain, but who are not in hemorrhagic shock or respiratory distress and are not at significant risk for developing either condition; or (3) ketamine for casualties who have moderate to severe pain but who are in hemorrhagic shock or respiratory distress or are at significant risk for developing either condition. Ketamine may also be used to increase analgesic effect for casualties who have previously been given opioids (morphine or fentanyl.)

1. The current TCCC Guidelines for battlefield analgesia need to be simplified.

2. There are better choices for battlefield analgesia than IM morphine available in 2013.

3. The optimal analgesic option will vary with the nature of the casualty’s injuries, his or her physiologic condition, and the tactical circumstances present in the casualty scenario.

4. The meloxicam and acetaminophen contained in the CoTCCC-recommended Combat Pill Pack provide limited analgesia but avoid unwanted adverse effects. They should be used for casualties whose pain is relatively less severe and who are still able to be effective combatants.

5. If opioids are required and safe to use for a particular casualty, OTFC provides rapid and effective analgesia, equivalent to that obtained with IV morphine. OTFC is also easier and faster to administer than IV morphine or ketamine.

6. Therefore, for casualties with more severe pain in whom relief of pain takes precedence over preserving combat effectiveness, OTFC is the analgesic of choice if the casualty is not in hemorrhagic shock or respiratory distress and is judged to be at low risk for the subsequent development of either condition.

7. Opioid analgesia should be avoided in casualties in shock, in respiratory distress, or at significant risk for developing either condition.

8. Ketamine also provides excellent analgesia. This agent requires slightly more time and expertise to administer than OTFC, but avoids the risk of cardiorespiratory depression. Ketamine may be use IV, IM, or IN.

9. For casualties with more severe pain in whom relief of pain takes precedence over preserving combat effectiveness, ketamine is therefore the analgesic of choice if the casualty is in hemorrhagic shock or respiratory distress or is judged to be at significant risk for the subsequent development of either condition.

Revised Guidelines:

Tactical Field Care Analgesia on the battlefield should generally be achieved using one of three options:

1. Mild to Moderate Pain 

Casualty is still able to fight TCCC Combat Pill Pack:

Tylenol – 650mg bilayer caplet, 2 PO every 8 hours Meloxicam – 15mg PO once a day

2. Moderate to Severe Pain 

Casualty IS NOT in shock or respiratory distress AND Casualty IS NOT at significant risk of developing either condition

– Oral transmucosal fentanyl citrate (OTFC) 800μg

– Place lozenge between the cheek and the gum

– Do not chew the lozenge

3. Moderate to Severe Pain

Casualty IS in hemorrhagic shock or respiratory distress OR Casualty IS at significant risk of developing either condition

– Ketamine 50mg IM or IN OR– Ketamine 20mg slow IV or IO*Repeat doses q30min prn for IM or IN*Repeat doses q20min prn for IV or IO*End points: Controlof pain or development of nystagmus (rhythmic back-and-forth movement of the eyes)

*Analgesia notes

1. Casualties may need to be disarmed after being given OTFC or ketamine.

2. Document a mental status exam using the AVPU method prior to administering opioids or ketamine.

3. For all casualties given opiods or ketamine – monitor airway, breathing, and circulation closely

4. Directions for administering OTFC:– Recommend taping lozenge-on-a-stick to casualty’s finger as an added safety measure OR utilizing a safety pin and rubber band to attach the lozenge (under tension) to the casualty’s uniform or plate carrier.– Reassess in 15 minutes– Add second lozenge, in other cheek, as necessary to control severe pain– Monitor for respiratory depression

5. IV Morphine is an alternative to OTFC if IV access has been obtained– 5mg IV/IO– Reassess in 10 minutes.– Repeat dose every 10 minutes as necessary to control severe pain.– Monitor for respiratory depression

6. Naloxone (0.4mg IV/IN/IM) should be available when using opioid analgesics.

7. Both ketamine and OTFC have the potential to worsen severe TBI. The combat medic, corpsman, or PJ must consider this fact in his or her analgesic decision, but if the casualty is able to complain of pain, then the TBI is likely not severe enough to preclude the use of ketamine or OTFC.

8. Eye injury does not preclude the use of ketamine. The risk of additional damage to the eye from using ketamine is low and maximizing the casualty’s chance for survival takes precedence if the casualty is in shock or respiratory distress or at significant risk for either.

9. Ketamine may be a useful adjunct to reduce the amount of opioids required to provide effective pain relief. It is safe to give ketamine to a casualty who has previously received morphine or OTFC. IV Ketamine should be given over 1 minute.

10. If respirations are noted to be reduced after using opioids or ketamine, provide ventilatory support with a bag-valve-mask or mouth-to-mask ventilations.

11. Promethazine, 25mg IV/IM/IO every 6 hours may be given as needed for nausea or vomiting.

12. Reassess – reassess – reassess!

The vast majority of combat casualties who die from their injuries do so prior to reaching a medical treatment facility. Although most of these deaths result from nonsurvivable injuries, efforts to mitigate combat deaths can still be directed toward primary prevention through modification of techniques, tactics, and procedures and secondary prevention through improvement and use ofpersonal protective equipment. For deaths that result from potentially survivable injuries, mitigation efforts should be directed toward primary and secondary preventionas well as tertiary prevention through medical care with an emphasis toward prehospital care as dictated by the fact that the preponderance of casualties die in the prehospital environment. Since the majority of casualties with potentially survivable injuries died from hemorrhage, priority must be placed on interventions,procedures, and training that mitigate death from truncal, junctional, and extremity exsanguination. In response to this need, multiple novel and effective junctional tourniquets have recently been developed.

There are now three junctional tourniquets and one truncal tourniquet (the AAT) cleared by the FDA for control of junctional hemorrhage. The junctional tourniquets are important new tools for combat medical personnel to have available for use to control hemorrhage from junctional areas.

There is presently insufficient evidence to make a recommendation for which of the four currently cleared devices is the optimal choice for junctional hemorrhage control.

Because of the relatively short maximum duration of application (one hour) recommended for the AAT and the relative contraindication to using this device in penetrating abdominal trauma (which is often present in conjunction with junctional hemorrhage), the AAT has significant limitations that make it the device of last resort among the four devices being considered for junctional hemorrhage control. The AAT is a truncal rather than a junctional tourniquet.

The three CoTCCC-recommended junctional tourniquetsare:

1. The Combat Ready Clamp

2. The Junctional Emergency Treatment Tool

3. The SAM Junctional Tourniquet

The JETT and the SAM may also play an important role in stabilizing pelvic fractures, which are often seen in association with proximal lower extremity amputations and junctional hemorrhage. 

Junctional hemorrhage control should be started with Combat Gauze and direct pressure while the junctional tourniquet is being prepared and applied. Note that if junctional bleeding is controlled with Combat Gauze and direct pressure alone, there may not be an immediate need for the junctional tourniquet.

Guidelines Revisions:

Tactical Field Care

4b. Bleeding: If the bleeding site is appropriate for use of a junctional tourniquet, immediately apply a CoTCCC recommended junctional tourniquet. Do not delay in the application of the junctional tourniquet once it is ready for use. Combat Gauze applied with direct pressure should be used if a junctional tourniquet is not available or while the junctional tourniquet is being readied for use.

Tactical Evacuation Care

3b. Bleeding: If the bleeding site is appropriate for use of a junctional tourniquet, immediately apply a CoTCCC recommended junctional tourniquet . Do not delay in the application of the junctional tourniquet once it is ready for use. Combat Gauze applied with direct pressure should be used if a junctional tourniquet is not available or while the junctional tourniquet is being readied for use.

During the recent United States Central Command (USCENTCOM)and Joint Trauma System (JTS) assessment of prehospital trauma care in Afghanistan, the deployed director of the Joint Theater Trauma System (JTTS),CAPT Donald R. Bennett, questioned why TCCC recommends treating a nonlethal injury (open pneumothorax)with an intervention (a nonvented chest seal) that could produce a lethal condition (tension pneumothorax).New research from the U.S. Army Institute of Surgical Research (USAISR) has found that, in a model of open pneumothorax treated with a chest seal in which increments of air were added to the pleural space to simulate an air leak from an injured lung, use of a vented chest seal prevented the subsequent development of a tension pneumothorax, whereas use of a nonvented chest seal did not. The updated TCCC Guideline for the battlefield management of open pneumothorax is: “All open and/or sucking chest wounds should be treated by immediately applying a vented chest seal to cover the defect. If a vented chest seal is not available, use a non-vented chest seal. Monitor the casualty for the potential development of a subsequent tension pneumothorax. If the casualty develops increasing hypoxia, respiratory distress, or hypotension and a tension pneumothorax is suspected,treat by burping or removing the dressing or by needle decompression.” This recommendation was approved by the required two-thirds majority of the Committeeon TCCC in June 2013.

There are now data from an animal model of open pneumothorax and ongoing intrathoracic air leak treated with both vented and nonvented chest seals that document that a vented chest seal prevents the subsequent development of a tension pneumothorax and that a nonvented chest seal does not.2 In observance of primum non nocere (first, do no harm), it is best to err on the side of safety in treating open pneumothorax, and the animal data noted here suggest that vented chest seals may confer a safety advantage over unvented chest seals in treating open pneumothorax in the presence of an on going air leak from an injured lung.

This statement is especially true on the battlefield, where a single multitasked medic in a mass casualty situation may be distracted by other casualties and fail to notice a developing tension pneumothorax in a casualty who has had his or her open pneumothorax treated with an unvented occlusive dressing.

Guideline Revisions:

Tactical Field Care 

3. Breathing

b. All open and/or sucking chest wounds should be treated by immediately applying a vented chest seal to cover the defect. If a vented chest seal is not available,use a non-vented chest seal. Monitor the casualty for the potential development of a subsequent tension pneumothorax. If the casualty develops increasing hypoxia,respiratory distress, or hypotension and a tension pneumothoraxis suspected, treat by burping or removing the dressing or by needle decompression.

Tactical Evacuation Care

2. Breathing

d. All open and/or sucking chest wounds should be treated by immediately applying a vented chest seal to cover the defect. If a vented chest seal is not available,use a non-vented chest seal. Monitor the casualty for the potential development of a subsequent tension pneumothorax.If the casualty develops increasing hypoxia,respiratory distress, or hypotension and a tension pneumothoraxis suspected, treat by burping or removing the dressing or by needle decompression.

Optimizing trauma care delivery is paramount to saving lives on the battlefield. During the past decade of conflict,trauma care performance improvement at combat support hospitals and forward surgical teams in Afghanistan and Iraq has increased through Joint Trauma System and DoD Trauma Registry data collection, analysis,and rapid evidence-based adjustments to clinical practice guidelines. Although casualties have benefitted greatly from a trauma system and registry that improves hospital care, still lacking is a comprehensive and integrated system for data collection and analysis to improve performance at the prehospital level of care. Tactical Combat Casualty Care (TCCC) based casualty cards, TCCC after action reports, and unit-based prehospital trauma registries need to be implemented globally and linked to the DoD Trauma Registry in a seamless manner that will optimize prehospital trauma care delivery.

The lack of adequate documentation of prehospital care rendered to U.S. casualties is a clear obstacle to ongoing TCCC and JTS efforts to improve that care. “You can’t improve what you can’t measure, and you can’t measure without data.” (Eastridge 2011) Since 87% of combat fatalities occur in the prehospital phase in the continuum of care, (Eastridge 2012) documenting and analyzing what occurs in this phase of care is crucial.

The lack of adequate documentation of prehospital care rendered to U.S. casualties is a clear obstacle to ongoing TCCC and JTS efforts to improve that care. “You can’t improve what you can’t measure, and you can’t measurewithout data.” (Eastridge 2011) Since 87% of combat fatalities occur in the prehospital phase in the continuum of care, (Eastridge 2012) documenting and analyzing what occurs in this phase of care is crucial.

The TCCC casualty card (DA Form 7656) needs to be updated and designated as a Department of Defense document. The CoTCCC endorses the use of the newly developed proposed DD Form for this purpose. [NOTE: DD Form 1380 was subsequently approved in 2014 as the TCCC Casualty Card]

Guideline Revisions: 

Tactical Field Care

19. Documentation of Care Document clinical assessments, treatments rendered,and changes in the casualty’s status on a TCCC Casualty Card (DD Form XXXX). Forward this information with the casualty to the next level of care.

Tactical Evacuation Care

19. Documentation of Care Document clinical assessments, treatments rendered,and changes in casualty’s status on a TCCC Casualty Card (DD Form XXXX). Forward this information with the casualty to the next level of care.

Of 355,425 diagnoses of traumatic brain injury (TBI) between 2000 and 2011, 45,131 were moderate, severe or penetrating. 1 The Department of Defense (DoD) has made significant advancements in expanding guidance regarding the treatment of Service members with mild TBI (mTBI), but limited guidance exists for the treatment of casualties with severe TBI, especially on the battlefield. The Tactical Combat Casualty Care (TCCC) Guidelines are currently the standard used for training medics and many other deploying medical providers. As such, the Defense Health Board (DHB) recommends amending the TCCC Guidelines to include guidance for the treatment of casualties with suspected moderate/severe TBI, simply defined as penetrating brain injury or head injury with altered level of consciousness. This report provides an overview of the issue and the recommended additions to the TCCC Guidelines, as provided by the Committee on Tactical Combat Casualty Care (CoTCCC), and subsequently approved by the Trauma and Injury Subcommittee and DHB.

The DHB concludes that the changes to the TCCC Guidelines proposed by the CoTCCC and approved by the Trauma and Injury Subcommittee reflect the best available evidence and most important aspects of prehospital care for casualties with moderate/severe TBI based on the consensus-derived opinion of CoTCCC and Trauma and Injury Subcommittee members. Because the DHB notes a paucity of robust evidence-based research regarding prehospital ( and battlefield) treatment of suspected severe TBI, the Board further recommends that the DoD make priorities prehospital data collection and additional research regarding prehospital management of moderate/severe TBI. 

RECOMMENDATIONS 

The Board recommends that DoD incorporate the following changes regarding the management of moderate/severe TBI to the TCCC Guidelines (additions are underlined below). These additions will help combat medics, corpsmen, and Pararescuemen recognize and treat impending cerebral herniation in TBI casualties on the battlefield and during evacuation.

The Tactical Combat Casualty Care (TCCC) Guidelines for Tactical Evacuation (TACEVAC) Care outline stepped airway management interventions for a casualty with airway obstruction or impending airway obstruction. These include the chin lift/jaw thrust maneuver, nasopharyngeal airway and recovery position as first-line interventions. Should these prove unsuccessful, the Guidelines recommend the laryngeal mask airway (LMA) or Combitube (Combitube) device for supraglottic airway (SGA) interventions, endotracheal intubation or surgical cricothyroidotomy. Many new SGA devices have emerged since the development of the TCCC Guidelines. Evidence is inconclusive as to whether any one device is superior over another. Patient safety and provider competency literature suggests that provider experience may be a better indicator of safety and efficacy than individual device capabilities. Therefore, the Defense Health Board (DHB) recommends that the specific devices referenced in the TCCC Guidelines for SGA interventions during TACEVAC Care be removed.

1.    The specific devices referenced in the TCCC Guidelines for SGA interventions during TACEVAC Care be removed.

2.    Recommendations advocating a specific SGA device be based on the best available evidence demonstrating its superiority. Should such a device emerge, the military Services should ensure providers are trained on its use and are equipped to field it in theater.

3.    Absent evidence indicating one device is superior over another, the military Services should enhance the safety of Service members by selecting a limited number of devices and ensuring that the inventory, training and equipping practices are aligned and consistent with the devices selected. Provider training should be appropriate and realistic, and should ensure the sustainment of acquired skills and proficiencies.

4.    SGA devices be evaluated on an ongoing basis as new data emerge and recently developed devices are further tested.

5.    Continued research and adequate prehospital data collection be ensured as they are vital for identifying best practices.

6.    Equipment inventories, as well as provider training and equipping, eventually be standardized across the military Services. Current initiatives to standardize training, such as the Tri-­Service training provided for enlisted medical personnel at the Medical Education and Training Campus at Fort Sam Houston, Texas, may also serve as an impetus for the military Services to adopt a common equipment inventory and fielding practice in theater.

7.    Inventory practices should account for the rapid, continuous evolution of medical best practices, where feasible. This would facilitate a timely adoption and fielding of optimal devices based on the best available scientific evidence. Emerging patient safety data indicate that the issue of ensuring consistency regarding SGA device use across inventory, training and equipping practices may also be pertinent to other equipment fielded in theater.

The Defense Health Board (DHB) submitted a report to the Assistant Secretary of Defense (Health Affairs) (ASD(HA)) on October 11, 2011 recommending changes to the TCCC Guidelines pertaining to tension pneumothorax (TP). The Board recommended that the Department of Defense (DoD) amend the TCCC Guidelines to include performing bilateral needle decompression (ND) at the second intercostal space (ICS) along the midclavicular line (MCL) for any casualty in cardiorespiratory arrest with known or suspected torso trauma.

Case report findings and feedback from the field highlight a lack of consensus surrounding ND techniques, including reported failure rates for ND. Inadequate needle length, improper technique, and muscle mass of casualties may be contributing to high ND failure rates, emphasizing the need to consider alternative ND techniques. As such, the Board is issuing this updated report, which includes utilizing the fourth or fifth ICS along the anterior axillary line (AAL) as an additional site for ND.

The Board recommends DoD incorporate the following text allowing the fourth or fifth ICS at the AAL as alternative sites for needle decompression, into the TCCC Tactical Field Care and TACEVAC Guidelines (proposed additions are underlined):

Tactical Field Care:

3.    Breathing

a.    In a casualty with progressive respiratory distress and known or suspected torso trauma, consider a tension pneumothorax and decompress the chest on the side of the injury with a 14-gauge, 3.25 inch (8cm) needle/catheter unit inserted in the second intercostal space at the midclavicular line. Ensure that the needle entry into the chest is not medial to the nipple line and is not directed towards the heart. An acceptable alternate site is the 4th or 5th intercostal space at the anterior axillary line (AAL). 

b. All open and/or sucking chest wounds should be treated by immediately applying an occlusive material to cover the defect and securing it in place. Monitor the casualty for the potential development of a subsequent tension pneumothorax.

18. Cardiopulmonary resuscitation (CPR)

Resuscitation on the battlefield for victims of blast or penetrating trauma who have no pulse, no ventilations, and no other signs of life will not be successful and should not be attempted. However, casualties with torso trauma or polytrauma who have no pulse or respirations during TFC should have bilateral needle decompression performed to ensure they do not have a tension pneumothorax prior to discontinuation of care. The procedure is the same as described in section 3 above.

Tactical Evacuation Care:

2.    Breathing

a.    In a casualty with progressive respiratory distress and known or suspected torso trauma, consider a tension pneumothorax and decompress the chest on the side of the injury with a 14-gauge, 3.25 inch (8cm) needle/catheter unit inserted in the second intercostal space at the midclavicular line. Ensure that the needle entry into the chest is not medial to the nipple line and is not directed towards the heart. An acceptable alternate site is the 4th or 5th intercostal space at the anterior axillary line (AAL).

b.    Consider chest tube insertion if no improvement and/or long transport is anticipated.

c.    Most combat casualties do not require supplemental oxygen, but administration of oxygen may be of benefit for the following types of casualties:

-    Low oxygen saturation by pulse oximetry

-     Injuries associated with impaired oxygenation

-     Unconscious casualty

-    Casualty with TBI (maintain oxygen saturation > 90%)

-    Casualty in shock

-    Casualty at altitude

d. All open and/or sucking chest wounds should be treated by immediately applying an occlusive material to cover the defect and securing it in place. Monitor the casualty for the potential development of a subsequent tension pneumothorax.

17.    CPR in TACEVAC Care

a.    Casualties with torso trauma or polytrauma who have no pulse or respirations during TACEVAC should have bilateral needle decompression performed to ensure they do not have a tension pneumothorax. The procedure is the same as described in section 2 above. 

 b. CPR may be attempted during this phase of care if the casualty does not have obviously fatal wounds and will be arriving at a facility with a surgical capability within a short period of time. CPR should not be done at the expense of compromising the mission or denying lifesaving care to other casualties. 

 Because definitive evidence does not exist regarding the superiority of either the second ICS at the MCL or the fourth or fifth ICS at the AAL, every effort should be made to collect evidence regarding comparative effectiveness of the two sites in order for inform future guidelines.

The Tactical Combat Casualty Care (TCCC) Guidelines are a set of trauma care guidelines customized for use in the pre-hospital combat setting. The Guidelines identify three stages of care: (1) care under fire; (2) tactical field care; and (3) tactical evacuation care (TACEY AC). TCCC is currently used in training for medics by all Services in the Department of Defense (DoD) and by many U.S. coalition partners. The Committee on Tactical Combat CasualtyCare (CoTCCC), a work group of the Defense Health Board (DHB) Trauma and Injury Subcommittee, performs a quarterly review of current evidence demonstrating the successes and shortcomings of the TCCC Guidelines, and considers proposed updates and revisions. 

Ketamine offers a useful addition to the combat medic's options for battlefield pain management. Adding ketamine to the TCCC Guidelines would enhance the combat medic's ability to adequately control pain in tactical settings without the risk of opioid-induced hypotension and respiratory depression. Should these recommendations be included in the TCCC Guidelines, those responsible for developing and maintaining the TCCC curriculum should include additional information regarding the common side effects and contraindications to using ketamine.

The Board recommends DoD incorporate the following text, allowing ketamine to be used for analgesia, into the TCCC Tactical Field Care and Tactical Evacuation Care Guidelines (addition is represented below by underlining): 

12. Provide analgesia as necessary.NOTE: Ketamine must not be used if the casualty has suspected penetrating eye injury or significant TBI (evidenced by penetrating brain injury or head injury with altered level of consciousness).

a.    Able to fight:These medications should be carried by the combatant and self-administeredas soon as possible after the wound is sustained.

-    Mobic, 15 mg PO once a day

-    Tylenol, 650-mg bilayer caplet, 2 PO every 8 hoursb.    

Unable to fight:Note: Have naloxone readily available whenever administering opiates.

-    Does not otherwise require IV/IO access

-    Oral transmucosal fentanyl citrate (OTFC), 800 µg transbucally

-    Recommend taping lozenge-on-a-stick to casualty’s finger as an added safety measure

-    Reassess in 15 minutes

-    Add second lozenge, in other cheek, as necessary to control severe pain

-    Monitor for respiratory depression

-Ketamine 50-100mg IM

-    Repeat dose every 30 minutes to 1 hour as necessary to control severe pain or until the casualty develops nystagmus (rhythmic eye movement back and forth)

OR

-    Ketamine 50 mg intranasal (using nasal atomizer device)

-    Repeat dose every 30 minutes to 1 hour as necessary to control severe pain or until the casualty develops nystagmus

-    IV or IO access obtained:

-    Morphine sulfate, 5 mg IV/IO

-    Reassess in 10 minutes.

-    Repeat dose every 10 minutes as necessary to control severe pain.

-    Monitor for respiratory depression

OR

-    Ketamine 20 mg slow IV/IO push over 1 minute

-    Reassess in 5-10 minutes.

-    Repeat dose every 5-10 minutes as necessary to control severe pain or until the casualty develops nystagmus

-    Continue to monitor for respiratory depression and agitation

- Promethazine, 25 mg IV/IM/IO every 6 hours as needed for nausea or for synergistic analgesic effect

The Committee on Tactical Combat Casualty Care (CoTCCC), a work group of the Defense Health Board (DHB) Trauma and Injury Subcommittee, reviewed recent evidence and feedback from theater regarding issues pertaining to tension pneumothorax. Needle decompression (ND) following traumatic cardiac arrest may be lifesaving if an unsuspected tension pneumothorax is present. Current TCCC Guidelines for Tactical Field Care indicate that battlefield cardiopulmonary resuscitation (CPR) will not be successful and should not be attempted for either blast or penetrating trauma casualties with no vital signs. 

The Board has issued recommendations to the Department amending current TCCC Tactical Field Care Guidelines to include performing bilateral ND for any casualty in cardiorespiratory arrest with known or suspected chest trauma. The Board also recommended the Department include these changes to tactical evacuation (TACEVAC) guidelines, as well. In light of current practice in theater, the DHB approved the recommendation that CPR be added to the TACEVAC guidelines as an optional intervention, if the casualty did not incur obviously fatal wounds and would be arriving within a short period of time at a medical treatment facility with surgical capability. However, CPR should not be performed at the expense of compromising the mission or denying lifesaving care to other casualties.

The Board recommends DoD incorporate the following additions to the TCCC Guidelines for Traumatic Cardiac Arrest and Needle Decompression (proposed additions are italicized within the excerpt below): 

Tactical Field Care:

17.Cardiopulmonary Resuscitation (CPR): Resuscitation on the battlefield for victims of blast or penetrating trauma who have no pulse, no ventilations, and no other signs of life will not be successful and should not be attempted. However, casualties with torso trauma or polytrauma who have no pulse or respirations during TFC should have bilateral needle decompression performed prior to discontinuation of care to ensure they do not have a tension pneumothorax. This procedure is the same as described in section 3 above.

Tactical Evacuation Care:

16.    Cardiac Arrest During TACEVAC

a.    Casualties with torso trauma or polytrauma who have no pulse or respirations during TACEVAC should have bilateral needle decompression performed to ensure they do not have a tension pneumothorax. The procedure is the same as described in section 2 above.

b.    CPR may be attempted during this phase of care if the casualty does not have obviously fatal wounds and will be arriving at a facility with a surgical capability within a short period of time. CPR should not be done at the expense of compromising the mission or denying lifesaving care to other casualties.

Traumatic hemorrhage is the leading cause of preventable death on the battlefield. A comprehensive review of the literature (as provided in this report) found that the antifibrinolytic tranexamic acid (TXA) has proven to decrease all cause mortality following major trauma. In trauma patients experiencing severe hemorrhage on the battlefield, tranexamic acid has the potential to reduce both-mortality and morbidity. In light of these findings, the Defense Health Board recently approved a recommendation for the addition of tranexamic acid to the Tactical Combat Casualty Care (TCCC) guidelines.

A cost benefit analysis of TXA use noted that 2,050 patients were entered into the Joint Theater Trauma Registry between October 2003 and June 2009 who received transfusions and met inclusion criteria for the CRASH-2 trial. The overall mortality rate for this cohort was 14.6 percent, which is similar to that reported by the CRASH-2 collaborators. Based on the application of the all-cause mortality RR reduction observed in CRASH-2 (9 percent), if these patients had been treated with TXA, a transfused combat casualty mortality reduction of 1.3 percent is expected. This would translate to 26 additional lives saved at a cost of about $6,300 per life (one regimen of TXA costs approximately $80 per patient). For perspective, the cost to the U.S. military of procuring one unit of packed red blood cells is approximately $100 (excluding the costs of blood storage and shipment to theater, disposables and nursing time associated with blood administration, or blood unit cross-matching). The costs of administering TXA are thus substantially lower than the costs of administering one unit of red blood cells. Further, a study using data from the CRASH-2 trial on the cost-effectiveness of TXA concluded that early administration of TXA to bleeding trauma patients would be cost­ effective worldwide.

The Board recommends DoD incorporate the following addition to the TCCC Tactical Field Care and Tactical Evacuation Guidelines (before Intravenous Fluids section) regarding bleeding: (proposed additions are italicized within the excerpt below): 

If a casualty is anticipated to need significant blood transfusion (for example: presents with hemorrhagic shock, one 01· more major amputatlons, penetrating torso trauma, or evidence of severe bleeding): 

Administer 1 gram of tranexamic acid (TXA) in 100 cc in Normal Saline or Lactated Ringer's as soon as possible but not later than 3 hours after injury.

Begin second infusion of 1 gm TX.A after Hextend or other fluid treatment. 

Additionally, the Board recommends DoD ensure that ongoing analysis of the use of TXA in theater be a critical element in Performance Improvement measures by the Services.

Junctional hemorrhage sustained in the course of combat operations is recognized as a leading cause of mortality in the current conflict in Afghanistan. Tourniquets may be difficult or impossible to apply at these sites and QuikClot Combat Gauze may not always be effective at controlling the hemorrhage. The Combat Ready Clamp™(CRoC™) (Combat Medical Systems, Fayetteville, NC) is a U.S. Food and Drug Administration (FDA)-approved medical device indicated for the control of hemorrhage in the inguinal area that is not amenable to the application of a toumiquet.

The CoTCCC began reviewing the data supporting the use of the CRoC™ in November 2010. On August 2, 2011, the CoTCCC approved the proposed addition of the CRoC™ for hemorrhage control to the TCCC Guidelines. This recommendation was approved by the DHB Trauma and Injury Subcommittee on August 3, 2011 and subsequently approved by unanimous vote of the DHB, on August 8, 2011.

The Board recommends DoD incorporate the following addition to the TCCC Tactical Field Care Guidelines regarding bleeding: (proposed additions are italicized within the excerpt below):

Tactical Field Care Guidelines

4.    Bleeding

a.    Assess for unrecognized hemorrhage and control all sources of bleeding. If not already done, use a CoTCCC-recommended tourniquet to control life-threatening external hemorrhage that is anatomically amenable to tourniquet application or for any traumatic amputation. Apply directly to the skin 2-3 inches above wound.

b. For compressible hemorrhage not amenable to tourniquet use or as an adjunct to tourniquet removal (if evacuation time is anticipated to be longer than two hours), use Combat Gauze as the hemostatic agent of choice. Combat Gauze should be applied with at least 3 minutes of direct pressure. Before releasing any tourniquet on a casualty who has been resuscitated for hemorrhagic shock, ensure a positive response to resuscitation efforts (i.e., a peripheral pulse normal in character and normal mentation if there is no traumatic brain injury (TBI). If a lower extremity wound is not amenable to tourniquet application am/ cannot be controlled by hemostatics,dressings, consider immediate application of mechanical direct pressure including CoTCCC-recommended devices such as the Combat Ready Clamp (CRoC).

On August 3, 2010, the CoTCCC recommended proposed revisions to the TCCC Guidelines on fluid resuscitation in Tactical Field Care and Tactical Evacuation Care. The proposed changes were presented to the Trauma and Injury Subcommittee and unanimously approved on August 4, 20 I 0. The recommendations were deliberated and unanimously approved in open session at the Defense Health Board (DHB) meeting on November 1, 2010.

Following a review of current best practices on fluid resuscitation in the tactical evacuation setting, the CoTCCC noted several perceived deficiencies in the previous TCCC Guidelines. Among those deficiencies were:

a.    Recommending the use of Hextend instead of blood products when both are available in Tactical Evacuation Care (TACEVAC);

b.    Not reflecting the current theater trauma practice of administering packed red blood cells (PBRCs) and thawed plasma in a 1: I ratio when blood products are available during TACEVAC;

c.    Not including a provision for the use of blood pressure measurements to guide fluid resuscitation during TACEVAC, at which point electronic measurement of blood pressure should be available;

d.   Need for modifying fluid resuscitation strategies to base decisions on fluid resuscitation in casualties with traumatic brain injury (TBI) on pulse character or measured blood pressure, not mental status.

Based on recent literature and expert opinion on fluid resuscitation in battlefield trauma care, the Board advises the Department that the changes to the TCCC Guidelines noted below should be incorporated into the TCCC Guidelines and forwarded to the Services for use in their battlefield trauma care training programs (proposed changes are bolded and italicized):

a.    Tactical Field Care

6.    Fluid Resuscitation: Assess for hemorrhagic shock􀀲 altered mental status (in the absence of head injury) and weak or absent peripheral pulses are the best field indicators of shock.

( a)    If not in shock:

(i)    No IV fluids necessary

(ii)    PO fluids permissible if conscious and can swallow

(b)    If in shock:

(i)    Hextend, 500 mL IV bolus

(ii)    Repeat once after 30 minutes if still in shock

(iii)    No more than 1000 mL of Hextend

(c)    Continued efforts to resuscitate must be weighed against logistical and tactical considerations and the risk of incurring further casualties.

(d)    If a casualty with an altered mental status due to suspected TBI has a weak or absent peripheral pulse, resuscitate as necessary to maintain a palpable radial pulse.

b.    Tactical Evacuation Care

5.  Fluid Resuscitation: Reassess for hemorrhagic shock (altered mental status in the absence of brain injury and/or change in pulse character). If blood pressure (BP) monitoring is available, maintain target systolic BP 80-90 mmHg.

(a)    If not in shock:

(i)    No IV fluids necessary

(ii)    PO fluids permissible if conscious and can swallow

(b)    If in shock and blood products are not available:

(i)    Hextend 500-mL IV bolus

(ii)    Repeat after 30 minutes if still in shock

(iii)    Continue resuscitation with Hextend or crystalloid solution as needed to maintain target BP or clinical improvement

(c)    If in shock and blood products are available under an approved command or theater protocol:

(i)    Resuscitate with two units of plasma followed by packed red blood cells(PRBCs) in a 1:1 ratio. If blood component therapy is not available,tranfuse fresh whole blood. Continue resuscitation as needed to maintain target BP or clinical improvement.

d.  If a casualty with an altered mental status due to suspected TB/ has a weak or absent peripheral pulse, resuscitate as necessary to maintain a palpable radial pulse. If BP monitoring is available, maintain target systolic BP of at least 90 mmHg.

The Defense Health Board (DHB) met in open session on August 18, 2010, during which the Board deliberated proposed recommendations regarding the revised Tactical Combat Casualty Care (TCCC) Guidelines on the Prevention of Hypothermia.

Following a brief on August 3, 2010, the CoTCCC recommended proposed revisions to the TCCC Guidelines regarding hypothermia prevention. These changes were presented to the DHB Trauma and Injury Subcommittee and unanimously approved on August 4, 2010. The recommendations were then presented on behalf of the Subcommittee at the DHB meeting on August 18, 2010, and subsequently deliberated and passed unanimously by the Board in open session on August 18, 2010.

The most frequent cause of preventable death on the battlefield is hemorrhage. Hypothermia-induced coagulopathy is well-described and results from decreases in platelet function, slowing of coagulation cascade enzyme activity, and alterations of the fibrinolytic system. Even a small decrease in body temperature can interfere with blood clotting and increase the risk of exsanguination. Additionally, combat casualties in shock are at an even greater risk of hypothermic coagulopathy. Hypovolemic shock results in a decreased ability to produce heat and to maintain normal body temperature. Shock victims are thus predisposed to hypothermia. Due to the physics of heat transfer, hypothermia is far easier to prevent than it is to treat, so prevention of heat loss should begin as soon after wounding as the tactical situation permits.

Based on recent literature and expert opinion on the prevention of hypothermia in Tactical Field Care and Tactical Evacuation Care, the Board advises the Department that the changes to the TCCC Guidelines noted below should be incorporated into Service battlefield trauma care training programs (proposed changes are italicized):

a.    Tactical Field Care

7.    Prevention of Hypothermia

(a)    Minimize casualty's exposure to the elements. Keep protective gear on or with the casualty if feasible.

(b)    Replace wet clothing with dry if possible. Get the casualty onto an insulated surface as soon as possible.

(c)    Apply the Read-Heat Blanket from the Hypothermia Prevention and Management Kit (HPMK) to the casualty's torso (not directly on the skin) and cover the casualty with the Heat-Reflective Shell (HRS).

(d)  If an HRS is not available, the previously recommended combination of the Blizzard Survival Blanket and the Ready-Heat Blanket may also be used.

(e)  If the items mentioned above are not available, use dry blankets, poncho liners, sleeping bags, or anything that will retain heat and keep that casualty dry.

(f)  Warm fluids are preferred if intravenous (IV) fluids are required.

b.    Tactical Evacuation Care

6.    Prevention of Hypothermia

(a)    Minimize casualty's exposure to the elements. Keep protective gear on or with the casualty if feasible.

(b)    Replace wet clothing with dry if possible. Get the casualty onto an insulated surf ace as soon as possible.

(c)    Apply the Ready-Heat Blanket from the Hypothermia Prevention and Management Kit (HPMK) to the casualty's torso (not directly on the skin) and cover the casualty with the Heat-Reflective Shell (HRS).

(d)    If an HRS is not available, the previously recommended combination of the Blizzard Survival Blanket and the Ready-Heat Blanket may also be used.

(e)    If the items mentioned above arc not available, use poncho liners, sleeping bags, or anything that will retain heat and keep the casualty dry.

(f)  Use a portable fluid warmer capable of warming all IV fluids including blood products.  

(g)  Protect the casualty from wind if doors must be kept open.

Tactical Combat Casualty Care (TCCC) comprises a set of trauma management guidelines customized for use on the battlefield. TCCC was first introduced in the Special Operations community, but the conflicts in Iraq and Afghanistan have seen TCCC become the standard in all services in the US Military.

TCCC Changes 2008–2009 The CoTCCC meets on a quarterly basis to consider additions or revisions to the TCCC guidelines. Prospective randomized controlled studies are the exception rather than the rule in the prehospital trauma literature as a result of informed consent issues and the nature of the events that lead to traumatic injuries— especially in battlefield trauma care.Therefore, the CoTCCC reviews the available published prehospital trauma literature, direct input from combat medical personnel with recent combat experience, new research performed at military medical research facilities, and material submitted to service medical lessons learned centers. The changes to the TCCC guidelines outlined below were approved during 2008 and 2009. A detailed rationale for the changes is contained in the upcoming seventh military edition of the Prehospital Trauma Life Support Manual.

1.  Removal of Hemostatic Agent Use From Care Under Fire.

2.  Tourniquet use clarifications.

3.  Combat Gauze as preferred hemostatic.

4.  Needle decompression with minimum 3.25" catheter.

5.  Recommend immediate sealing of open pneumothorax wounds

6.  Rigid eye shield for penetrating eye trauma.

7.  Documentation of Care in TCCC

8.  Terminology changing CASEVAC to TACEVAC.

The Tactical Combat Casualty Care (TCCC) project begun by the Naval Special Warfare Command and continued by the U.S.Special Operations Command developed a set of tactically appropriate battlefield trauma care guidelines that were initially published in 1996. Transition of these guidelines into use throughout the Department of Defense has been ongoing since that time. The need for updates to the TCCC guidelines was recognized early on and has been carried out by the Committee on Tactical Combat Casualty Care established and operated bythe Naval Operational Medicine Institute. The evolution of these guidelines from the 1996 recommendations to thepresent is described. Numerous reports in the medical literature and collected from combat first responders have documented that TCCC is saving lives on the battlefield and improving the tactical flow of missions on which casualties have occurred.Present challenges to the optimized implementation of TCCC in U.S. combat units include the need to expedite transition of new TCCC techniques and technologies to deploying units, to provide TCCC training for all U.S. combatants, and to ensure adequate funding for the Committee on TCCC.

1.  Tourniquet Use/Selection - The USAISR tourniquet study noted that an ideal tourniquet for battlefield use should be light, durable, easily applied under combat conditions, and capable of reliable occlusion of arterial blood flow. Cost is also a factor. This study examined seven tourniquets available from commercial sources at the time and found that three were successful in completely occluding blood flow in both upper and lower extremities: the Emergency Military Tourniquet (Delfi), the Combat Application Tourniquet (Phildurango LLC), and the Special Operations Force Tactical Tourniquet (Tactical Solutions LLC). The report from this study recommended that the Combat Application Tourniquet be carried by all combatants and that medics also carry the Emergency Medical Tourniquet.

2.  Hemostatics - Both the chitosan-based bandage HemCon (Hem-Con Medical Technologies, Portland, Oregon) and the zeolite powder QuikClot (Z-Medica, Wallingford, Connecticut) were judged to be effective based on study findings to date. Although the committee was not able to identify a clear winner based on efficacy, there were concerns about burns from the exothermic reaction produced by QuikClot and HemCon was selected as the initial TCCC hemostatic agent of choice

3.  Surgical Airways - The 1996 TCCC guidelines called for the aggressive use of surgical airways in the Tactical Field Care phase when maxillofacial trauma makes the use of a nasopharyngeal airway inadequate to open the airway. This recommendation has been carried forward into the 2003 and 2006 guidelines.

4.  Needle Decompression - The 2003 and 2006 guidelines modified the needle decompression indications to include blunt torso trauma and respiratory distress even if it not progressive as part of the indication for needle thoracostomy:“Consider tension pneumothorax and decompress with needle thoracostomy if a casualty has torso trauma and respiratory distress”.

5.  IV Access - TCCC recommends a more conservative approach to establishing prehospital intravenous (IV) access than civilian practice,recommending this intervention during the Care Under Fire and Tactical Field Care phases only when fluid resuscitation is indicated or if IV medications are required.

6.  Fluid Resuscitation - The 2006 guidelines included a caveat to the hypotensive resuscitation strategy highlighted in the original 1996 guidelines that calls for more aggressive fluid resuscitation in individuals with traumatic brain injury (TBI) and decreased radial pulse, reflecting the need to maintain cerebral perfusion in individuals who may have increased intracranial pressure.

7.  Antibiotics - Moxifloxacin was selected as a suitable broad-spectrum oral antibiotic to replace the previously recommended gatifloxacin.

8.  Analgesia - The 2006 guidelines  substituted meloxicam and added extended-release acetaminophen for oral analgesia for those individuals in a combat setting with relatively minor wounds who can continue to perform effectively in their unit as long as they are not given narcotics for analgesia. An addition to battlefield analgesia in the 2006 guidelines was oral transmucosal fentanyl citrate (OTFC).

9.  Oxygen on the Battlefield - TCCC guidelines are now more precise in this area and state that most casualties do not require oxygen during CASEVAC,but that supplemental oxygen should be administered for the following indications: low oxygen saturation by pulse oximetry; injuries associated with impaired oxygenation; unconscious casualties;TBI patients (maintain oxygen saturation >90); casualties in shock; and casualties at altitude.

10.  Blood Products on the Battlefield - The 2003 guidelines recommended that packed red blood cells be available on CASEVAC platforms when logistically feasible. This recommendation has been carried forward into the 2006 guidelines with more specific guidance on when to use type O PRBCs and how much to administer.

11. Hypothermia - A number of specific interventions have been recommended in the 2006 TCCC guidelines to prevent hypothermia in combat casualties.