Care Under Fire / Threat

Basic Management Plan for Care Under Fire / Threat

1. Return fire and take cover.

2. Direct or expect casualty to remain engaged as a combatant if appropriate.

3. Direct casualty to move to cover and apply self-aid if able or when tactically feasible, move or drag casualty to cover.

4. Try to keep the casualty from sustaining additional wounds.

5. Casualties should be extracted from burning vehicles or buildings and moved to places of relative safety. Do what is necessary to stop the burning process.

6. Stop life-threatening external hemorrhage if tactically feasible:

  • Direct casualty to control hemorrhage by self-aid if able.
  • Use a CoTCCC-recommended limb tourniquet for hemorrhage that is anatomically amenable to tourniquet use.
  • Apply the limb tourniquet over the uniform clearly proximal to the bleeding site(s). If the site of the life-threatening bleeding is not readily apparent, place the tourniquet “high and tight” (as proximal as possible) on the injured limb and move the casualty to cover.

7. Airway management is generally best deferred until the Tactical Field Care phase.

Tactical Field Care

Basic Management Plan for Tactical Field Care

Establish a security perimeter in accordance with unit tactical standard operating procedures and/or battle drills. Maintain tactical situational awareness.

Triage casualties as required. Casualties with an altered mental status should have weapons and communications equipment taken away immediately.

a. Assess for unrecognized hemorrhage and control all sources of bleeding. If not already done, use a CoTCCC-recommended limb tourniquet to control life- threatening external hemorrhage that is anatomically amenable to tourniquet use or for any traumatic amputation. Apply directly to the skin 2-3 inches above the bleeding site. If bleeding is not controlled with the first tourniquet, apply a second tourniquet side-by-side with the first.

b. For compressible (external) 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)
    • iTClamp (may be used alone or in conjunction with hemostatic dressing or XStat.
  • 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. (Note: XStat is not to be removed in the field, but additional XStat, other hemostatic adjuncts, or trauma dressings may be applied over it.)
  • If the bleeding site is amenable to 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.

c. For external hemorrhage of the head and neck where the wound edges can be easily re-approximated, the iTClamp may be used as a primary option for hemorrhage control. Wounds should be packed with a hemostatic dressing or XStat, if appropriate, prior to iTClamp application.

  • The iTClamp does not require additional direct pressure, either when used alone or in combination with other hemostatic adjuncts.
  • If the iTClamp is applied to the neck, perform frequent airway monitoring and evaluate for an expanding hematoma that may compromise the airway. Consider placing a definitive airway if there is evidence of an expanding hematoma.
  • DO NOT APPLY on or near the eye or eyelid (within 1cm of the orbit).

d. Perform initial assessment for hemorrhagic shock (altered mental status in the absence of brain injury and/or weak or absent radial pulse) and consider immediate initiation of shock resuscitation efforts.

a. Conscious casualty with no airway problem identified:

  • No airway intervention required

b. Unconscious casualty without airway obstruction:

  • Place casualty in the recoveray position
  • Chin lift or jaw thrust maneuver OR
  • Nasopharyngeal airway OR
  • Extraglottic airway

c. Casualty with airway obstruction or impending airway obstruction:

  • Allow a conscious casualty to assume any position that best protects the airway, to include sitting up and/or leaning forward.
  • Use a chin lift or jaw thrust maneuver
  • Use suction if available and appropriate
  • Nasopharyngeal airway OR
  • Extraglottic airway (if the casualty is unconscious)
  • Place an unconscious casualty in the recovery position.

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

  • Cric-Key technique (preferred option)
  • Bougie-aided open surgical technique using a flanged and cuffed airway cannula of less than 10 mm outer diameter, 6-7 mm internal diameter, and 5- 8 cm of intratracheal length
  • Standard open surgical technique using a flanged and cuffed airway
  • cannula of less than 10mm outer diameter, 6-7 mm internal diameter, and 5-8 cm of intra-tracheal length (least desirable option)
  • Use lidocaine if the casualty is conscious.

e. Cervical spine stabilization is not necessary for casualties who have sustained only penetrating trauma.

f.  Monitor the hemoglobin oxygen saturation in casualties may change over time and requries frequent reassessment.

g. Always remember that the casualty’s airway status may change over time and requires frequent reassessment.

* The i-gel is the preferred extraglottic airway because its gel-filled cuff makes it simpler to use and avoids the need for cuff inflation and monitoring. If an extraglottic airway with an air-filled cuff is used, the cuff pressure must be monitored to avoid overpressurization, especially during TACEVAC on an aircraft with the accompanying pressure changes.

* Extraglottic airways will not be tolerated by a casualty who is not deeply unconscious. If an unconscious casualty without direct airway trauma needs an airway intervention, but does not tolerate an extraglottic airway, consider the use of a nasopharyngeal airway.

* For casualties with trauma to the face and mouth, or facial burns with suspected inhalation injury, nasopharyngeal airways and extraglottic airways may not suffice and a surgical cricothyroidotomy may be required.

* Surgical cricothyroidotomies should not be performed on unconscious casualties who have no direct airway trauma unless use of a nasopharyngeal airway and/or an extraglottic airway have been unsuccessful in opening the airway. 

 

a. Assess for tension pneumothorax and treat as necessary.

  • Suspect a tension pneumothorax and treat when a casualty has significant torso trauma or primary blast injury and one or more of the following:
    • Severe or progressive respiratory distress
    • Severe or progressive tachypnea
    • Absent or markedly decreased breath sounds on one side of the chest
    • Hemoglobin oxygen saturation < 90% on pulse oximetry
    • Shock
    • Traumatic cardiac arrest without obviously fatal wounds

NOTE:  If not treated promptly, tension pneumothorax may progress from respiratory distress to shock and traumatic cardiac arrest.

  • Initial treatment of suspected tension pneumothorax:
    • If the casualty has a chest seal in place, burp or remove the chest seal.
    • Establish pulse oximetry monitoring.
    • Place the casualty in the supine or recovery position unless he or she is conscious and needs to sit up to help keep the airway clear as a result of maxillofacial trauma.
    • Decompress the chest on the side of the injury with a 14-gauge or a 10-gauge, 3.25-inch needle/catheter unit.
    • If a casualty has significant torso trauma or primary blast injury and is in traumatic cardiac arrest (no pulse, no respirations, no response to painful stimuli, no other signs of life), decompress both sides of the chest before discontinuing treatment.

NOTE:  Either the 5th intercostal space (ICS) in the anterior axillary line (AAL) or the 2nd ICS in the mid-clavicular line (MCL) may be used for needle decompression (NDC.)  If the anterior (MCL) site is used, do not insert the needle medial to the nipple line.

The needle/catheter unit should be inserted at an angle perpendicular to the chest wall and just over the top of the lower rib at the insertion site. Insert the needle/catheter unit all the way to the hub and hold it in place for 5-10 seconds to allow decompression to occur.

After the NDC has been performed, remove the needle and leave the catheter in place.

  • The NDC should be considered successful if:
    • Respiratory distress improves, OR
    • There is an obvious hissing sound as air escapes from the chest when NDC is performed (this may be difficult to appreciate in high-noise environments), OR
    • Hemoglobin oxygen saturation increases to 90% or greater (note that this may take several minutes and may not happen at altitude), OR
    • A casualty with no vital signs has return of consciousness and/or ` radial pulse.
  • If the initial NDC fails to improve the casualty’s signs/symptoms from the suspected tension pneumothorax:
    • Perform a second NDC on the same side of the chest at whichever of the two recommended sites was not previously used. Use a new needle/catheter unit for the second attempt.
    • Consider, based on the mechanism of injury and physical findings, whether decompression of the opposite side of the chest may be needed.
    • Continue to re-assess!
  • If the initial NDC was successful, but symptoms later recur:
    • Perform another NDC at the same site that was used previously. Use a new needle/catheter unit for the repeat NDC.
    • Continue to re-assess!
  • If the second NDC is also not successful:
    • Continue on to the Circulation section of the TCCC Guidelines.

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 pneumothorax is suspected, treat by burping or removing the dressing or by needle decompression.

c. Initiate pulse oximetry. All individuals with moderate/severe TBI should be monitored with pulse oximetry. Readings may be misleading in the settings of shock or marked hypothermia.

d. Casualties with moderate/severe TBI should be given supplemental oxygen when available to maintain an oxygen saturation > 90%.

a. Bleeding

  • 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
  • Reassess prior tourniquet application. Expose the wound and determine if a tourniquet is needed. If it is needed, replace any limb tourniquet placed over the uniform with one applied directly to the skin 2-3 inches above the bleeding site. Ensure that bleeding is stopped. If there is no traumatic amputation, a distal pulse should be checked. If bleeding persists or a distal pulse is still present, consider additional tightening of the tourniquet or the use of a second tourniquet side-by-side with the first to eliminate both bleeding and the distal pulse. If the reassessment determines that the prior tourniquet was not needed, then remove the tourniquet and note time of removal on the TCCC Casualty Card.
  • Limb tourniquets and junctional tourniquets should be converted to hemostatic or pressure dressings as soon as possible if three criteria are met: the casualty is not in shock; it is possible to monitor the wound closely for bleeding; and the tourniquet is not being used to control bleeding from an amputated extremity. Every effort should be made to convert tourniquets in less than 2 hours if bleeding can be controlled with other means. Do not remove a tourniquet that has been in place more than 6 hours unless close monitoring and lab capability are available.
  • Expose and clearly mark all tourniquets with the time of tourniquet application. Note tourniquets applied and time of application; time of re- application; time of conversion; and time of removal on the TCCC Casualty Card. Use a permanent marker to mark on the tourniquet and the casualty card.

b. Assess for hemorrhagic shock (altered mental status in the absence of brain injury and/or weak or absent radial pulse).

c. IV/IO Access

  • Intravenous (IV) or intraosseous (IO) access is indicated if the casualty is in hemorrhagic shock or at significant risk of shock (and may therefore need fluid resuscitation), or if the casualty needs medications, but cannot take them by mouth.
    • An 18-gauge IV or saline lock is preferred.
    • If vascular access is needed but not quickly obtainable via the IV route, use the IO route.

d. Tranexamic Acid (TXA)

  • If a casualty will likely need a blood transfusion (for example: presents with hemorrhagic shock, 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 2 gm of tranexamic acid via slow IV or IO push as soon as possible but NOT later than 3 hours after injury.

e. Fluid resuscitation

  • Assess for hemorrhagic shock (altered mental status in the absence of brain injury and/or weak or absent radial pulse).
  • The resuscitation fluids of choice for casualties in hemorrhagic shock, listed from most to least preferred, are:

1. Cold stored low titer O whole blood

2. Pre-screened low titer O fresh whole blood

3. Plasma, red blood cells (RBCs) and platelets in a 1:1:1 ratio

4. Plasma and RBCs in a 1:1 ratio

5. Plasma or RBCs alone

NOTE: Hypothermia prevention measures [Section 7] should be initiated while fluid resuscitation is being accomplished.

If not in shock:

  • No IV fluids are immediately necessary.
  • Fluids by mouth are permissible if the casualty is conscious and can swallow.

If in shock and blood products are available under an approved command or theater blood product administration protocol:

  • Resuscitate with cold stored low titer O whole blood, or, if not available
  • Pre-screened low titer O fresh whole blood, or, if not available
  • Plasma, RBCs, and platelets in a 1:1:1 ratio, or, if not available
  • Plasma and RBCs in a 1:1 ratio, or, if not available
  • Reconstituted dried plasma, liquid plasma or thawed plasma alone or RBCs alone
  • Reassess the casualty after each unit. Continue resuscitation until a palpable radial pulse, improved mental status or systolic BP of 100 mmHg is present.
  • Discontinue fluid administration when one or more of the above end points has been achieved.
  • If blood products are transfused, administer one gram of calcium (30 ml of 10% calcium gluconate or 10 ml of 10% calcium chloride) IV/IO after the first transfused product.

Given increased risk for a potentially lethal hemolytic reaction, transfusion of unscreened group O fresh whole blood or type specific fresh whole blood should only be performed under appropriate medical direction by trained personnel.

Transfusion should occur as soon as possible after life-threatening hemorrhage in order to keep the patient alive.  If Rh negative blood products are not immediately available, Rh positive blood products should be used in hemorrhagic shock.

If a casualty with an altered mental status due to suspected TBI has a weak or absent radial pulse, resuscitate as necessary to restore and maintain a normal radial pulse. If BP monitoring is available, maintain a target systolic BP between 100-110 mmHg.

Reassess the casualty frequently to check for recurrence of shock. If shock recurs, re-check all external hemorrhage control measures to ensure that they are still effective and repeat the fluid resuscitation as outlined above.

f. Refractory Shock

  • If a casualty in shock is not responding to fluid resuscitation, consider untreated tension pneumothorax as a possible cause of refractory shock. Thoracic trauma, persistent respiratory distress, absent breath sounds, and hemoglobin oxygen saturation < 90% support this diagnosis. Treat as indicated with repeated NDC or finger thoracostomy/chest tube insertion at the 5th ICS in the AAL, according to the skills, experience, and authorizations of the treating medical provider. Note that if finger thoracostomy is used, it may not remain patent and finger decompression through the incision may have to be repeated. Consider decompressing the opposite side of the chest if indicated based on the mechanism of injury and physical findings

a. Take early and aggressive steps to prevent further body heat loss and add external heat when possible for both 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 further 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 with the exterior impermeable enclosure bag.

f. As soon as possible, upgrade 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 non-insulated hypothermia enclosure systems; seek to improve upon existing enclosure system when possible.

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

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

a. If a penetrating eye injury is noted or suspected:

  • Perform a rapid field test of visual acuity and document findings.
  • Cover the eye with a rigid eye shield (NOT a pressure patch.)
  • Ensure that the 400 mg moxifloxacin tablet in the Combat Wound Medication Pack (CWMP) is taken if possible and that IV/IO/IM antibiotics are given as outlined below if oral moxifloxacin cannot be taken.

a. Initiate advanced electronic monitoring if indicated and if monitoring equipment is available.

TCCC non-medical first responders should provide analgesia on the battlefield achieved by using:

    • Mild to Moderate Pain
    • Casualty is still able to fight
      • TCCC Combat Wound Medication Pack (CWMP)
        • Acetaminophen – 500 mg tablet, 2 PO every 8 hours
        • Meloxicam – 15 mg PO once a day

 TCCC Medical Personnel:

Option 1

  • Mild to Moderate Pain
  • Casualty is still able to fight
    • TCCC Combat Wound Medication Pack (CWMP)
      • Acetaminophen – 500 mg tablet, 2 PO every 8 hours
      • Meloxicam – 15 mg PO once a day

 Option 2

  • Mild to Moderate 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) 800 μg
      • May repeat once more after 15 minutes if pain uncontrolled by first

 TCCC Combat Paramedics or Providers:

    • Fentanyl 50 mcg IV/IO (0.5-1 mcg/kg
      • May repeat q 30 min
    • Fentanyl 100 mcg IN
      • May repeat q 30 min

 Option 3

  • Moderate to Severe Pain
  • Casualty IS in hemorrhagic shock or respiratory distress OR
  • Casualty IS at significant risk of developing either condition:
    • Ketamine 30 mg (or 0.3 mg/kg) slow IV or IO push
      • Repeat doses q 20min prn for IV or IO
      • End points: Control of pain or development of nystagmus (rhythmic back-and-forth movement of the eyes).
    • Ketamine 50-100 mg (or 0.5-1 mg/kg) IM or IN
      • Repeat doses q20-30 min prn for IM or IN

Option 4

TCCC Combat Paramedics or Providers:

  • Sedation required: significant severe injuries requiring dissociation for patient safety or mission success or when a casualty requires an invasive procedure; must be prepared to secure the airway:
    • Ketamine 1-2 mg/kg slow IV/IO push initial dose
      • Endpoints: procedural (dissociative) anesthesia
    • Ketamine 300 mg IM (or 2-3 mg/kg IM) initial dose
      • Endpoints: procedural (dissociative) anesthesia

If an emergence phenomenon occurs, consider giving 0.5-2 mg IV/IO midazolam.

If continued dissociation is required, move to the Prolonged Casualty Care (PCC) analgesia and sedation guidelines.

  •  If longer duration analgesia is required:
    •  Ketamine slow IV/IO infusion 0.3 mg/kg in 100 ml 0.9% sodium chloride over 5-15 minutes.
      • Repeat doses q45min prn for IV or IO
      • End points: Control of pain or development of nystagmus (rhythmic back-and-forth movement of the eyes).

 Analgesia and sedation notes:

  • Casualties need to be disarmed after being given OTFC, IV/IO fentanyl, ketamine, or midazolam.
  • The goal of analgesia is to reduce pain to a tolerable level while still protecting their airway and mentation.
  • The goal of sedation is to stop awareness of painful procedures.
  • Document a mental status exam using the AVPU method prior to administering opioids or ketamine.
  • For all casualties given opioids, ketamine or benzodiazepines – monitor airway, breathing, and circulation closely.
  • Directions for administering OTFC:
    • Place lozenge between the cheek and the
    • Do not chew the lozenge
    • 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 patient’s uniform or plate
    • Reassess in 15 minutes
    • Add second lozenge, in other cheek, as necessary to control severe
    • Monitor for respiratory
  • Ketamine comes in different concentrations; the higher concentration option (100 mg/ml) is recommended when using IN dosing route to minimize the volume administered intranasally.
  • Naloxone (0.4 mg IV/IO/IM/IN) should be available when using opioid analgesics.
  • TBI and/or eye injury does not preclude the use of ketamine. However, use caution with OTFC, IV/IO fentanyl, ketamine, or midazolam in TBI patients as this may make it difficult to perform a neurologic exam or determine if the casualty is decompensating.
  • 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 a narcotic. IV Ketamine should be given over 1 minute.
  • If respirations are reduced after using opioids or ketamine, reposition the casualty into a “sniffing position”. If that fails, provide ventilatory support with a bag-valve-mask or mouth-to-mask ventilations.
  • Ondansetron, 4 mg Orally Dissolving Tablet (ODT)/IV/IO/IM, every 8 hours as needed for nausea or vomiting. Each 8-hour dose can be repeated once after 15 minutes if nausea and vomiting are not improved. Do not give more than 8 mg in any 8-hour interval. Oral ondansetron is NOT an acceptable alternative to the ODT formulation.
  • The use routine of benzodiazepines such as midazolam is NOT recommended for analgesia. When performing procedural sedation, benzodiazepines may also be considered to treat behavioral disturbances or unpleasant (emergence) reactions. Benzodiazepines should not be used prophylactically and are not commonly needed when the correct pain or sedation dose of ketamine is used.
  • Polypharmacy is not recommended; benzodiazepines should NOT be used in conjunction with opioid analgesia.
  • If a casualty appears to be partially dissociated, it is safer to administer more ketamine than to use a benzodiazepine.

Antibiotics: recommended for all open combat wounds

a. If able to take PO meds:

  • Moxifloxacin (from the CWMP), 400 mg PO once a day

b. If unable to take PO meds (shock, unconsciousness):

  • Ertapenem, 1 gm IV/IO/IM once a day

  • Inspect and dress known wounds. 
  • Abdominal evisceration – [Control bleeding]; rinse with clean fluid to reduce gross contamination. Hemorrhage control – apply combat gauze or CoTCCC approved hemostatic dressing to uncontrolled bleeding. Cover exposed bowel with a moist, sterile dressing or sterile water-impermeable covering.
    • Reduction- a single brief attempt may be made to replace/reduce the eviscerated abdominal contents. If successful, re-approximate the skin using available material, preferably an adhesive dressing like a chest seal (other examples include suture, staples, wound closure devices).
    • If unable to reduce; cover the eviscerated organs with water impermeable non-adhesive material (transparent preferred to allow ability to re-assess for ongoing bleeding); examples include a bowel bag, IV bag, clear food wrap, etc. and secure the impermeable dressing to the patient using adhesive dressing (examples: ioban, chest seal).
    • Do NOT FORCE contents back into abdomen or actively bleeding viscera.
    • OK to administer combat pill pack.
    • Prolonged Care Considerations:
      • It is OK to attempt reduction if a patient presents late after injury.
      • Odds of a stable, successful reduction are low – make a single attempt to reduce and then dress in place.
      • Hypothermia – monitor closely as exposed abdominal contents will result in more rapid heat loss.
      • Re-evisceration – In the event of re-evisceration (hernia) remove the skin closure and cover the eviscerated organs as recommended in 12 b.
      • If no known endpoint exists for surgical care, consider NOT attempting reduction.

Check for additional wounds

a. Assess and treat as a trauma casualty with burns and not burn casualty with injuries.

b. Facial burns, especially those that occur in closed spaces, may be associated with inhalation injury. Aggressively monitor airway status and oxygen saturation in such patients and consider early surgical airway for respiratory distress or oxygen desaturation.

c. Estimate total body surface area (TBSA) burned to the nearest 10% using the Rule of Nines.

d. Cover the burn area with dry, sterile dressings. For extensive burns (>20%), consider placing the casualty in the Heat-Reflective Shell or Blizzard Survival Blanket from the Hypothermia Prevention Kit in order to both cover the burned areas and prevent hypothermia.

e. Fluid resuscitation (USAISR Rule of Ten)

  • If burns are greater than 20% of TBSA, fluid resuscitation should be initiated as soon as IV/IO access is established. Resuscitation should be initiated with Lactated Ringer’s, normal saline, or Hextend. If Hextend is used, no more than 1000 ml should be given, followed by Lactated Ringer’s or normal saline as needed.
  • Initial IV/IO fluid rate is calculated as %TBSA x 10 ml/hr for adults weighing 40- 80 kg.
  • For every 10 kg ABOVE 80 kg, increase initial rate by 100 ml/hr.
  • If hemorrhagic shock is also present, resuscitation for hemorrhagic shock takes precedence over resuscitation for burn shock. Administer IV/IO fluids per the TCCC Guidelines in Section (6).
  • Consider oral fluids for burns up to 30% TBSA if casualty is conscious and able to swallow.

f. Analgesia in accordance with the TCCC Guidelines in Section (10) may be administered to treat burn pain.

g. Prehospital antibiotic therapy is not indicated solely for burns, but antibiotics should be given per the TCCC guidelines in Section (11) if indicated to prevent infection in penetrating wounds.

h. All TCCC interventions can be performed on or through burned skin in a burn casualty.

i. Burn patients are particularly susceptible to hypothermia. Extra emphasis should be placed on barrier heat loss prevention methods.

Splint fractures and re-check pulses.

a. 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 (5a) above.

a. Communicate with the casualty if possible. Encourage, reassure and explain care.

b. Communicate with tactical leadership as soon as possible and throughout casualty treatment as needed. Provide leadership with casualty status and evacuation requirements to assist with coordination of evacuation assets.

c. Communicate with the evacuation system (the Patient Evacuation Coordination Cell) to arrange for TACEVAC. Communicate with medical providers on the evacuation asset if possible and relay mechanism of injury, injuries sustained, signs/symptoms, and treatments rendered. Provide additional information as appropriate.

Document clinical assessments, treatments rendered, and changes in the casualty’s status on a TCCC Card (DD Form 1380). Forward this information with the casualty to the next level of care.

a. Complete and secure the TCCC Card (DD 1380) to the casualty.

b. Secure all loose ends of bandages and wraps.

c. Secure hypothermia prevention wraps/blankets/straps.

d. Secure litter straps as required. Consider additional padding for long evacuations.

e. Provide instructions to ambulatory patients as needed.

f. Stage casualties for evacuation in accordance with unit standard operating procedures.

g. Maintain security at the evacuation point in accordance with unit standard operating procedures.

Tactical Evacuation Care

Principles of Tactical Evacuation Care (TACEVAC)

The Tactical Evacuation Care Guidelines are now a separate document managed by the Committee on En Route Combat Casualty Care (CoERCCC).

TACEVAC Guidelines can be found in the En Route Care Collection on Deployed Medicine.

* The term “Tactical Evacuation” includes both Casualty Evacuation (CASEVAC) and Medical Evacuation (MEDEVAC) as defined in Joint Publication 4-02.

a. Tactical force personnel should establish evacuation point security and stage

casualties for evacuation.

b. Tactical force personnel or the medic should communicate patient information and status to TACEVAC personnel as clearly as possible. The minimum information communicated should include stable or unstable, injuries identified, and treatments rendered.

c. TACEVAC personnel should stage casualties on evacuation platforms as required.

d. Secure casualties in the evacuation platform in accordance with unit policies, platform configurations and safety requirements.

e. TACEVAC medical personnel should re-assess casualties and re-evaluate all injuries and previous interventions.

Endotracheal intubation may be considered in lieu of cricothyroidotomy if trained.

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
  • Known or suspected smoke inhalation

Casualties with moderate/severe TBI should be monitored for:

    • Decreases in level of consciousness
    • Pupillary dilation
    • SBP should be >90 mmHg
    • O2 sat > 90
    • Hypothermia
    • End-tidal CO2 (If capnography is available, maintain between 35-40 mmHg)
    • Penetrating head trauma (if present, administer antibiotics)
    • Assume a spinal (neck) injury until cleared.

Unilateral pupillary dilation accompanied by a decreased level of consciousness may signify impending cerebral herniation; if these signs occur, take the following actions to decrease intracranial pressure:

    • Administer 250 ml of 3 or 5% hypertonic saline IV/IObolus.
    • Elevate the casualty’s head 30 degrees.
    • Hyperventilate the casualty.
      • Respiratory rate 20
      • Capnography should be used to maintain the end-tidal CO2 between 30-35 mmHg.
      • The highest oxygen concentration (FIO2) possible should be used for hyperventilation.
      • Do not hyperventilate the casualty unless signs of impending herniation are present. Casualties may be hyperventilated with oxygen using the bag-valve-mask technique.

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 (4a) above.

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.

Communicate with the casualty if possible. Encourage, reassure and explain care.

Communicate with medical providers at the next level of care as feasible and relay mechanism of injury, injuries sustained, signs/symptoms, and treatments rendered. Provide additional information as appropriate

Download Guidelines

Download Current TCCC Guidelines

READ FULL PDF

Summary of 2020 Changes

The Use of Tranexamic Acid in Tactical Combat Casualty Care

Brendon Drew, DO; Jonathan Auten, DO; Benjamin Donham, MD; Andre Cap, MD, PhD;Travis Deaton, MD; Warren Dorlac, MD; Joseph DuBose, MD, FACS, FCCM;Andrew D. Fisher, MD, PA-C; Alan J. Ginn; James Hancock, MD; John B. Holcomb, MD;John Knight, MD; Ryan Knight, MD; Albert “Ken” Koerner, MD; Lanny Littlejohn, MD;Matthew J. Martin, MD; John Morey; Jonathan Morrison, MD; Martin Schreiber, MD;Philip C. Spinella, MD, FCCM; Ben Walrath, MPH, MD; Frank Butler, MD

Journal of Special Operations Medicine

J Spec Oper Med. Fall 2020, Volume 20, Edition 3.

Abstract & Summary

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.

Management of Hypothermia in Tactical Combat Casualty Care

B. L. Bennett, PhD; Gordon Giesbrecht, PhD; Ken Zafren, MD; Ryan Christensen; Lanny Littlejohn, MD; Brendon Drew, DO; Andrew Cap, MD, PhD; Ethan Miles, MD;Frank Butler, MD; John B. Holcomb, MD; Stacy Shackelford, MD

Journal of Special Operations Medicine

J Spec Oper Med. Fall 2020, Volume 20, Edition 3.

Abstract & Summary

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.

Analgesia and Sedation for Tactical Combat Casualty Care

Andrew D. Fisher, MD; Taylor T. DesRosiers, MD; Wayne Papalski; Michael A. Remley; Steven G. Schauer, DO; Virginia Blackman, PhD; Jacob Brown, 18D; Frank K. Butler, MD; Cord W. Cunningham, MD; Erin M. Eickhoff, DNP, RN; Jennifer M. Gurney, MD; John B. Holcomb, MD; Patricia N. Meza, PhD, RN; Harold R. Montgomery, ATP; Meg Moore, MD; Sergey M. Motov, MD; Tim Sprunger; Stacy A. Shackelford, MD; Brendon G. Drew, DO

Abstract & Summary PENDING

The Management of Abdominal Evisceration in Tactical Combat Casualty Care

Jamie Riesberg, MD; Brian Eastridge, MD; Meg Moore, MD; Marc Northern, MD; Dana Onifer, MD; William Gephardt, PA, RN; Erin Eickhoff; Michael Remley, NRP; Carl Miller

Abstract & Summary

Historically about 20% of combat wounds are abdominal injuries.  Abdominal evisceration (AE) may be expected to complicate as many as 1/3 of battle-related abdominal wounds.   Evisceration is an injury with potential for improved outcomes if managed appropriately in the pre-hospital phases.

While not as extensively studied as other forms of combat injury, abdominal evisceration management recommendations extend back to at least Word War I, when it was recognized as a significant cause of morbidity especially associated with bayonet injury. More recently, abdominal evisceration has been noted as a not infrequent result of penetrating ballistic trauma.  

In an effort to manage abdominal eviscerations, the US Military Services have each published recommendations for the pre-hospital provider, medic and corpsman.   Initial management of abdominal evisceration consists of assessing for and controlling associated hemorrhage, covering the eviscerated abdominal contents with a moist, sterile barrier, and carefully reassessing the patient.  Attempting to establish a standard of care for non-medical and medical first responders and to leverage current wound packaging 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.   Recommendations are made for overall management and specific wound dressing considerations.

TCCC Guidelines Comprehensive Review and Edits 2020

Harold R. Montgomery, ATP; Brendon G. Drew, DO; Jeremy Torrisi, ATP; Matthew G. Adams, NREMT; Shawn Anderson, NRP; Michael A. Remley, NRP; Thomas A. Rich, NRP; Dominic Thompson, NRP; Dominique Greydanus, 18D; Travis Shaw, NRP; Tom Culpepper, NRP; Frank K. Butler, MD

Abstract & Summary
  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, Paragraph 4-c, bullet 1 to include: and/or leaning forward.
  5. Shift assessment of hemorrhagic shock to an earlier text and reference point in the guidelines.
  6. Add a new first line to paragraph 14. Burns to read: a. Assess and treat as a trauma casualty with burns and not burn casualty with injuries.
  7. Add a new last bullet to paragraph 14-d to read: Consider oral fluids for burns up to 30% TBSA if casualty is conscious and able to swallow.
  8. Swap paragraph 16. Communication and paragraph 17. Cardiopulmonary resuscitation in sequence.
  9. Separate TACEVAC portion of the TCCC guidelines to be managed and published by CoERCCC as the proponent.
  10. All medications in the TCCC guidelines indicated for IV administration will be edited to reflect to also include IO administration.

Summary of Aug 2019 Changes

Management of Hemorrhage From Craniomaxillofacial Injuries and Penetrating Neck Injury in Tactical Combat Casualty Care.  iTClamp Mechanical Wound Closure Device - TCCC Guidelines Proposed Change 19-04

Dana Onifer, MD; Jessica McKee, BA, MSc; Lindsey (Kyle) Faudree, PA-C; Brad Bennett, PhD; Ethan Miles, MD; Toran Jacobsen, SO-ATP; John “Kip” Morey, SO-ATP; Frank Butler, MD.

Journal of Special Operations Medicine

J Spec Oper Med. Fall 2019, Volume 19, Edition 3.

Abstract & Summary

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.

Summary of August 2018 Changes

Management of Suspected Tension Pneumothorax in Tactical Combat Casualty Care: TCCC Guidelines Change 17-02

Frank K. Butler, MD, John Holcomb, MD, Stacy Shackelford, MD, Harold R. Montgomery, ATP, Shawn Anderson, NREMT-P, Jeff Cain, MD, Howard Champion, MD, Cord Cunningham, MD, Warren Dorlac, Brendon Drew, MD, Kurt Edwards, MD, John Gandy, MD, Elon Glassberg, MD, Jennifer Gurney, MD, Theodore Harcke, MD, Don Jenkins, MD, Jay Johannigman, MD, Bijan Kheirabadi, MD, Russ Kotwal, MD, Lanny Littlejohn, MD, Matthew Martin, MD, Edward Mazuchowski, MD, Edward Otten, MD, Travis Polk, MD, Kyle Remick, MD, Peter Rhee, MD, Jason Seery, MD, Zsolt Stockinger, MD, Jeremy Torrisi, ATP, Avi Yitzak, MD, Ken Zafren, MD, Scott Zietlow, MD.

Journal of Special Operations Medicine

J Spec Oper Med. Summer 2018, Volume 18, Edition 2.

Abstract & Summary

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.

Summary of Aug 2017 Changes

Extraglottic Airways in Tactical Combat Casualty Care: TCCC Guidelines Change 17-01

Edward J. Otten, MD, Harold R. Montgomery, ATP, Frank K. Butler, MD.

Journal of Special Operations Medicine

J Spec Oper Med. Summer 2017, Volume 17, Edition 4

Abstract & Summary

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.

Summary of Changes

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.

Summary of Jan 2017 Changes

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

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

Journal of Special Operations Medicine

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

Abstract & Summary

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

Summary of Changes

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

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

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

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

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

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

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

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

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

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

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

12. Clarify tourniquet documentation requirements.

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

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

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

16. Eliminate cefotetan as a recommended antibiotic option.

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

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

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

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

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

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

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