2009 TCCC Guidelines

by July 10, 2009 07/10/09

800px-flag_of_the_red_crossA few days ago we mentioned the TCCC (Tactical Combat Casualty Care) Guidelines and wanted to share the latest February 2009 updates.

The only change in these updated TCCC guidelines from the July 2008 version is that WoundStat has been removed as a secondary hemostatic agent, which leaves QuikClot Combat Gauze and the primary and only hemostatic agent.

We’ve posted the updated guidelines in their entirety here, but also have them available in .pdf format. (File updated to reflect Nov. 2009 changes)

Tactical Combat Casualty Care Guidelines –  February 2009

* The only change in these updated TCCC guidelines from the July 2008 version is that WoundStat has been removed as a recommended hemostatic agent. All changes to the guidelines made since those published in the 2006 Sixth Edition of the PHTLS Manual are shown in bold text.

Update: November 2009 updates are shown in red/bold text below to include combat burn management.

Basic Management Plan for Care Under Fire

  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.
  4. Try to keep the casualty from sustaining additional wounds.
  5. Casualties should be extricated from burning vehicles or buildings and moved to places of relative safety. Do what is necessary to stop the burning process.
  6. Airway management is generally best deferred until the Tactical Field  Care phase.
  7. Stop life-threatening external hemorrhage if tactically feasible:
    - Direct casualty to control hemorrhage by self-aid if able.
    - Use a CoTCCC-recommended tourniquet for hemorrhage that is  anatomically amenable to tourniquet application.
    - Apply the tourniquet proximal to the bleeding site, over the uniform,  tighten, and move the casualty to cover.

Basic Management Plan for Tactical Field Care

  1. Casualties with an altered mental status should be disarmed  immediately.
  2. Airway Management
    a. Unconscious casualty without airway obstruction:
    - Chin lift or jaw thrust maneuver
    - Nasopharyngeal airway
    - Place casualty in the recovery position
    b. Casualty with airway obstruction or impending airway obstruction:
    - Chin lift or jaw thrust maneuver
    - Nasopharyngeal airway
    - Allow casualty to assume any position that best protects the  airway, to include sitting up.
    - Place unconscious casualty in the recovery position.
    - If previous measures unsuccessful:
    - Surgical cricothyroidotomy (with lidocaine if  conscious)
  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 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.
    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.
  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).
    c. Reassess prior tourniquet application. Expose wound and determine if tourniquet is needed. If so, move tourniquet from over uniform and apply directly to skin 2-3 inches above wound. If a tourniquet is not needed, use other techniques to control bleeding.
    d. When time and the tactical situation permit, a distal pulse check  should be accomplished. If a distal pulse is still present, consider  additional tightening of the tourniquet or the use of a second  tourniquet, side by side and proximal to the first, to eliminate the distal pulse.
    e. Expose and clearly mark all tourniquet sites with the time of  tourniquet application. Use an indelible marker.
  5. Intravenous (IV) access
    - Start an 18-gauge IV or saline lock if indicated.
    - If resuscitation is required and IV access is not obtainable, use the  intraosseous (IO) route.
  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:
    - No IV fluids necessary
    - PO fluids permissible if conscious and can swallow
    b. If in shock:
    - Hextend, 500-mL IV bolus
    - Repeat once after 30 minutes if still in shock.
    - 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 TBI is unconscious and has no peripheral pulse,  resuscitate to restore the radial pulse.
  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.
    c. Apply Ready-Heat Blanket to torso.
    d. Wrap in Blizzard Rescue Blanket.
    e. Put Thermo-Lite Hypothermia Prevention System Cap on the  casualty’s head, under the helmet.
    f. Apply additional interventions as needed and available.
    g. If mentioned gear is not available, use dry blankets, poncho liners,  sleeping bags, body bags, or anything that will retain heat and  keep the casualty dry.
  8. Penetrating Eye Trauma
    If a penetrating eye injury is noted or suspected:
    a) Perform a rapid field test of visual acuity.
    b) Cover the eye with a rigid eye shield (NOT a pressure patch.)
    c) Ensure that the 400 mg moxifloxacin tablet in the combat pill pack  is taken if possible and that IV/IM antibiotics are given as outlined  below if oral moxifloxacin cannot be taken.
  9. Monitoring
    Pulse oximetry should be available as an adjunct to clinical monitoring.
    Readings may be misleading in the settings of shock or marked hypothermia.
  10. Inspect and dress known wounds.
  11. Check for additional wounds.
  12. Provide analgesia as necessary.
    a. Able to fight:  These medications should be carried by the combatant and self-  administered as soon as possible after the wound is sustained.
    - Mobic, 15 mg PO once a day
    - Tylenol, 650-mg bilayer caplet, 2 PO every 8 hours
    b. Unable to fight:  Note: Have naloxone readily available whenever administering  opiates.
    - Does not otherwise require IV/IO access
    - Oral transmucosal fentanyl citrate (OTFC), 800 ug  transbuccally
    - 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.
    - 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
    - Promethazine, 25 mg IV/IM/IO every 6 hours as needed for  nausea or for synergistic analgesic effect
  13. Splint fractures and recheck pulse.
  14. Antibiotics: recommended for all open combat wounds
    a. If able to take PO:
    - Moxifloxacin, 400 mg PO one a day
    b. If unable to take PO (shock, unconsciousness):
    - Cefotetan, 2 g IV (slow push over 3-5 minutes) or IM every  12 hours  or
    - Ertapenem, 1 g IV/IM once a day
  15. Burns
    a. 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.
    b. Estimate total body surface area (TBSA) burned to the nearest 10% using the Rule of Nines.
    c. Cover the burn area with dry, sterile dressings. For extensive burns (>20%), consider placing the casualty in the Blizzard Survival Blanket in the Hypothermia Prevention Kit in order to both cover the burned areas and prevent hypothermia.
    d. Fluid resuscitation (USAISR Rule of Ten)
    — If burns are greater than 20% of Total Body Surface Area, 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 10cc/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.
    e. Analgesia in accordance with the TCCC Guidelines in Section 12 may be administered to treat burn pain.
    f. Prehospital antibiotic therapy is not indicated solely for burns, but antibiotics should be given per the TCCC guidelines in Section 14 if indicated to prevent infection in penetrating wounds.
    g. All TCCC interventions can be performed on or through burned skin in a burn casualty.
  16. Communicate with the casualty if possible.
    - Encourage; reassure
    - Explain 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.
  18. Documentation of Care
    Document clinical assessments, treatments rendered, and changes  in the casualty’s status on a TCCC Casualty Card. Forward this  information with the casualty to the next level of care.

Basic Management Plan for Tactical Evacuation Care

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

  1. Airway Management
    a. Unconscious casualty without airway obstruction:
    - Chin lift or jaw thrust maneuver
    - Nasopharyngeal airway
    - Place casualty in the recovery position
    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 recovery position.
    - If above measures unsuccessful:
    - Laryngeal Mask Airway (LMA)/intubating LMA or
    - Combitube or
    - Endotracheal intubation or
    - Surgical cricothyroidotomy (with lidocaine if  conscious).
    c. Spinal immobilization is not necessary for casualties withpenetrating trauma.
  2. Breathing
    a. In a casualty with progressive respiratory distress andknown 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 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.
    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.
  3. 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 TBI.)
    c. Reassess prior tourniquet application. Expose wound and determine if tourniquet is needed. If so, move tourniquet from over uniform and apply directly to skin 2-3 inches above wound. If a tourniquet is not needed, use other techniques to control bleeding.
    d. When time and the tactical situation permit, a distal pulse check  should be accomplished. If a distal pulse is still present, consider  additional tightening of the tourniquet or the use of a second  tourniquet, side by side and proximal to the first, to eliminate the distal pulse.
    e. Expose and clearly mark all tourniquet sites with the time of  tourniquet application. Use an indelible marker.
  4. Intravenous (IV) access
    a. Reassess need for IV access.
    - If indicated, start an 18-gauge IV or saline lock
    - If resuscitation is required and IV access is not obtainable,  use intraosseous (IO) route.
  5. Fluid resuscitation
    Reassess for hemorrhagic shock (altered mental status in the  absence of brain injury and/or change in pulse character.)
    a. If not in shock:
    - No IV fluids necessary.
    - PO fluids permissible if conscious and can swallow.
    b. If in shock:
    - Hextend 500-mL IV bolus.
    - Repeat once after 30 minutes if still in shock.
    - No more than 1000 mL of Hextend.
    c. Continue resuscitation with packed red blood cells (PRBCs),  Hextend, or Lactated Ringer’s solution (LR) as indicated.
    d. If a casualty with TBI is unconscious and has a weak or absent  peripheral pulse, resuscitate as necessary to maintain a systolic  blood pressure of 90 mmHg or above.
  6. Prevention of hypothermia
    a. Minimize casualty’s exposure to the elements. Keep protective  gear on or with the casualty if feasible.
    b. Continue Ready-Heat Blanket, Blizzard Rescue Wrap, and Thermo-Lite Cap.
    c. Apply additional interventions as needed.
    d. Use the Thermal Angel or other portable fluid warmer on all IV  sites, if possible.
    e. Protect the casualty from wind if doors must be kept open.
  7. Penetrating Eye Trauma
    If a penetrating eye injury is noted or suspected:
    a) Perform a rapid field test of visual acuity.
    b) Cover the eye with a rigid eye shield (NOT a pressure patch).
    c) Ensure that the 400 mg moxifloxacin tablet in the combat pill pack  is taken if possible and that IV/IM antibiotics are given as outlined  below if oral moxifloxacin cannot be taken.
  8. Monitoring
    Institute pulse oximetry and other electronic monitoring of vital signs, if  indicated.
  9. Inspect and dress known wounds if not already done.
  10. Check for additional wounds.
  11. Provide analgesia as necessary.
    a. Able to fight:
    - Mobic, 15 mg PO once a day
    - Tylenol, 650-mg bilayered caplet, 2 PO every 8 hours
    b. Unable to fight:  Note: Have naloxone readily available whenever  administering opiates.
    - Does not otherwise require IV/IO access:
    - Oral transmucosal fentanyl citrate (OTFC) 800 ug  transbuccally
    - 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.
    - 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.
    - Promethazine, 25 mg IV/IM/IO every 6 hours as needed for  nausea or for synergistic analgesic effect.
  12. Reassess fractures and recheck pulses.
  13. Antibiotics: recommended for all open combat wounds
    a. If able to take PO:
    - Moxifloxacin, 400 mg PO once a day
    b. If unable to take PO (shock, unconsciousness):
    - Cefotetan, 2 g IV (slow push over 3-5 minutes) or IM every 12  hours,  or
    - Ertapenem, 1 g IV/IM once a day
  14. Burns
    a. 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.
    b. Estimate total body surface area (TBSA) burned to the nearest 10% using the Rule of Nines.
    c. Cover the burn area with dry, sterile dressings. For extensive burns (>20%), consider placing the casualty in the Blizzard Survival Blanket in the Hypothermia Prevention Kit in order to both cover the burned areas and prevent hypothermia.
    d. Fluid resuscitation (USAISR Rule of Ten)
    — If burns are greater than 20% of Total Body Surface Area, 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 10cc/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 5.
    e. Analgesia in accordance with TCCC Guidelines in Section 11 may be administered to treat burn pain.
    f. Prehospital antibiotic therapy is not indicated solely for burns, but antibiotics should be given per TCCC guidelines in Section 13 if indicated to prevent infection in penetrating wounds.
    g. All TCCC interventions can be performed on or through burned skin in a burn casualty.
    h. Burn patients are particularly susceptible to hypothermia. Extra emphasis should be placed on barrier heat loss prevention methods and IV fluid warming in this phase.
  15. The Pneumatic Antishock Garment (PASG) may be useful for stabilizing  pelvic fractures and controlling pelvic and abdominal bleeding.  Application and extended use must be carefully monitored. The PASG  is contraindicated for casualties with thoracic or brain injuries.
  16. Documentation of Care  Document clinical assessments, treatments rendered, and changes in  casualty’s status on a TCCC Casualty Card. Forward this information  with the casualty to the next level of care.

Again, here are the TCCC Guidelines in .pdf format to download


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Aaron Oosterhart
Aaron Oosterhart

Hey guys, in the updated "Burns" sections, in part "d." of both:

"– Initial IV/IO fluid rate is calculated as %TBSA x 10cc/hr for adults weighing 40-80 kg.

– For every 10 kg ABOVE 80 kg, increase initial rate by 100 ml/hr."

If 1cc = 1ml, which it does, it seems odd to me that for adults weighing 40-80 kg that infusion would start at 10cc/hr (10ml/hr) but for every 10kg above 80kg you would add an additional *100ml/hr (100cc/hr)*. why would you make an increase at the rate of an entire order of magnitude for an extra ten kilos? I've not checked it out yet, but there is either a zero missing from the "initial" dosing or a zero was added to the "supplemental" dosing recommendations... I'll look into this further when I have some time (winter term classes just started) unless someone else already knows or has an answer to this....

Aaron Oosterhart
Aaron Oosterhart

Hey guys, in the updated "Burns" sections, in part "d." of both: "– Initial IV/IO fluid rate is calculated as %TBSA x 10cc/hr for adults weighing 40-80 kg. – For every 10 kg ABOVE 80 kg, increase initial rate by 100 ml/hr." If 1cc = 1ml, which it does, it seems odd to me that for adults weighing 40-80 kg that infusion would start at 10cc/hr (10ml/hr) but for every 10kg above 80kg you would add an additional *100ml/hr (100cc/hr)*. why would you make an increase at the rate of an entire order of magnitude for an extra ten kilos? I've not checked it out yet, but there is either a zero missing from the "initial" dosing or a zero was added to the "supplemental" dosing recommendations... I'll look into this further when I have some time (winter term classes just started) unless someone else already knows or has an answer to this....

Dom
Dom

The burn formula that is above is the new Institute of Surgical Research rules of ten. It currently substitutes the parkland burn formula for military personnel. This is the golden standard according to the Committee of TCCC. What they have found with the parkland burn formula is that, patients are being flooded with fluids when not needed.

“– Initial IV/IO fluid rate is calculated as %TBSA x 10cc/hr for adults weighing 40-80 kg.

– For every 10 kg ABOVE 80 kg, increase initial rate by 100 ml/hr.”

Say for instance you have a patient who weights approximately 90kg with 30% body surface area (BSA) burned then, according to the ISR rules of ten, 30% x 10cc = 300, but since the patient weights 10kg more than the formula you add an additional 100cc, making it 400cc/hr. Your overall affect is to get 30-50 cc urine output. Once you have this achieved maintain urine output.

Dom
Dom

The burn formula that is above is the new Institute of Surgical Research rules of ten. It currently substitutes the parkland burn formula for military personnel. This is the golden standard according to the Committee of TCCC. What they have found with the parkland burn formula is that, patients are being flooded with fluids when not needed. “– Initial IV/IO fluid rate is calculated as %TBSA x 10cc/hr for adults weighing 40-80 kg. – For every 10 kg ABOVE 80 kg, increase initial rate by 100 ml/hr.” Say for instance you have a patient who weights approximately 90kg with 30% body surface area (BSA) burned then, according to the ISR rules of ten, 30% x 10cc = 300, but since the patient weights 10kg more than the formula you add an additional 100cc, making it 400cc/hr. Your overall affect is to get 30-50 cc urine output. Once you have this achieved maintain urine output.

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