The first phase of Tactical Combat Casualty Care (TCCC) is Care Under Fire (CUF). Care Under Fire is the care rendered by the first responder or combatant at the scene of the injury while he/she and the casualty are still under effective hostile fire. Available medical equipment is limited to that carried by the individual or by the medical provider in his or her aid bag.
Suppression of hostile fire will minimize the risk of both new casualties and additional injuries to the existing casualties. Casualty movement or extraction may be required to get them out of the kill zone before treatment should be initiated.
Massive bleeding or uncontrolled hemorrhage is the leading cause of preventable death on the battlefield, and as a result it is the number one medical priority in the CUF phase of TCCC. Early control of severe hemorrhage is critical to survival. Injury to a major vessel can quickly lead to shock and death. Due to the hostile environment encountered during CUF, only life-threatening bleeding warrants intervention.
In this module, you will learn to recognize life-threatening bleeding and the options available to control the bleeding while you are still under hostile fire. We will discuss strategies for proper tourniquet application when you have to work quickly, and identify common mistakes made during initial tourniquet applications.
Tighten the tourniquet until bleeding is controlled. If the first tourniquet fails to control the bleeding, apply a second tourniquet just above the first. Don’t put a tourniquet directly over the knee or elbow. Don’t put a tourniquet directly over a holster or a cargo pocket that contains bulky items.
COL John F. Kragh, Jr., MC, USA, Thomas J. Walters, PhD, David G. Baer, PhD, LTC Charles J. Fox, MC, USA, Charles E. Wade, PhD, Jose Salinas, PhD, and COL John B. Holcomb, MC, USA
Annals of Surgery
Volume 249, Number 1, January 2009
The purpose of this study at a combat support hospital in Baghdad was to determine if emergency tourniquet use saved lives.
Increase in survival rate by tourniquet use. By breaking down, the tourniquet use by whether the patient was prehospital or ED, whether there was shock present or absent at the time of application, and whether tourniquets were used or not, a comparison of raw differences in survival rates indicates that the survival benefit to tourniquet use is more strongly related to tourniquet use before the patient has progressed to shock than to prehospital use.
John F. Kragh, Jr., MD, Thomas J. Walters, PhD, David G. Baer, PhD, Charles J. Fox, MD, Charles E. Wade, PhD, Jose Salinas, PhD, and COL John B. Holcomb, MC
The Journal of TRAUMA, Injury, Infection, and Critical Care
J Trauma. 2008;64:S38 –S50
Few studies describe the actual morbidity associated with tourniquet use in combat casualties. The purpose of this study was to measure tourniquet use and subsequent complications. A prospective survey of casualties who required tourniquets was performed at a combat support hospital in Baghdad during 7 months in 2006. Patients were evaluated for tourniquet use, limb outcome, and morbidity.
Management of External Hemorrhage in Tactical Combat Casualty Care: The Adjunctive Use of XStat™ Compressed Hemostatic Sponges. TCCC Guidelines: Change 15-03.
Kyle Sims; F. Bowling, Harold Montgomery, Paul Dituro; Bijan S. Kheirabadi, PhD, Frank Butler, MD
Journal of Special Operations Medicine
J Spec Oper Med. 2016 Spring;16(1):19-28
Management of External Hemorrhage in Tactical Combat Casualty Care: Chitosan-Based Hemostatic Gauze Dressings. TCCC Guidelines – Change 13-05.
Brad L. Bennett, PhD, NREMT-P; Lanny F. Littlejohn, MD; Bijan S. Kheirabadi, PhD;
Frank K. Butler, MD; Russ S. Kotwal, MD; Michael A. Dubick, PhD; Jeffrey A. Bailey, MD
Journal of Special Operations Medicine
J Spec Oper Med. 2014 Fall;14(3):40-57
Comparison of novel hemostatic gauzes to QuikClot Combat Gauze in a standardized swine model of uncontrolled hemorrhage.
Jason M. Rall, PhD, Jennifer M. Cox, BS, Adam G. Songer, MD, Ramon F. Cestero, MD,
and James D. Ross, PhD
Journal of Trauma Acute Care Surgery
J Trauma Acute Care Surg. 2013; 75(2 Suppl 2):S150-6.
Hemostasis in a noncompressible hemorrhage model: An end-user evaluation of hemostatic agents in a proximal arterial injury.
Steven Satterly, MD, Daniel Nelson, DO, Nathan Zwintscher, MD, Morohunranti Oguntoye, MD, Wayne Causey, MD, Bryan Theis, BS, Raywin Huang, PhD, Mohamad Haque, MD,
Matthew Martin, MD, J Gerald Bickett EMT, and Robert M. Rush Jr, MD
Journal of Surgical Education
J Surg Educ. 2013;70(2):206-11.
Advanced hemostatic dressings are not superior to gauze for care under fire scenarios.
Jennifer M. Watters, MD, Philbert Y. Van, MD, Gregory J. Hamilton, BS, Chitra Sambasivan, MD, Jerome A. Differding, MPH, and Martin A. Schreiber, MD
Journal of TRAUMA Injury, Infection, and Critical Care
J Trauma 2011;70:1413-18.
Comparison of two packable hemostatic Gauze dressings in a porcine hemorrhage model.
Richard Bruce Schwartz MD, Bradford Zahner Reynolds MD, Stephen A. Shiver MD, E. Brooke Lerner PhD, Eric Mark Greenfield DO, Ricaurte A. Solis DO, Nicholas A. Kimpel DO, Phillip L. Coule MD & John G. McManus MD
Prehospital Emergency Care
Prehosp Emerg Care 2011;15:477-482
A synthesis of studies performed to evaluate the efficacy of the various hemostatic agents available at the point of injury show that they all perform equally.
Novel hemostatic devices (QuikClot Combat Gauze, QuikClot Combat Gauze XL, Celox Trauma Gauze, Celox Gauze, or HemCon ChitoGauze) perform at least as well as the current Committee on Tactical Combat Casualty Care standard for point-of-injury hemorrhage control. Despite their different compositions and sizes, the lack of clear superiority of any agent suggests that contemporary hemostatic dressing technology has potentially reached a plateau for efficacy.
There is no significant difference in hemostasis between hemostatic bandages for proximal arterial hemorrhage. Hemostasis significantly improves between 2 and 4 minutes using direct pressure and hemostatic agents. Prior medical training leads to 20% greater efficacy when using hemostatic dressings.
ChitoGauze and CombatGauze appear to be equally efficacious in their hemostatic properties, as demonstrated in a porcine hemorrhage model.
XStat (a non-absorbable, expandable, hemostatic sponge) is a new product recently approved by the FDA as a hemostatic adjunct to aid in the control of bleeding from junctional wounds in the groin or axilla. XStat is a new option for the control of external hemorrhage from junctional bleeding sites that are not adequately addressed by tourniquets, Combat gauze, Celox gauze, Chitogauze, Combat Ready Clamp, Junctional Emergency Treatment Tool, or the SAM Junctional Tourniquet.