Here on ITS Tactical, we follow the TCCC (Tactical Combat Casualty Care) Guidelines very closely and have designed our ETA Kit around them.

Tactical Combat Casualty Care (Pronounced “T-Triple C”) is a set of guidelines developed by USSOCOM (United States Special Operations Command) to properly train non-medics to deal with the preventable causes of death in the field.

The latest updates for 2011 are out and we wanted to share them with you; The changes since the August 2010 updates are the usage of the CRoC (Combat Ready Clamp), information on TXA (Tranexamic Acid),  bilateral needle decompression to casualties in order ensure no tension pneumothorax exists and guidelines on CRP in TACEVAC Care.

We’ve posted the updated 2011 guidelines in their entirety here, but also have them available in .pdf format to download.

Tactical Combat Casualty Care Guidelines – 8 August 2011

* All changes to the guidelines made since those published in the 2010 Seventh Edition of the PHTLS Manual are shown in bold text. The most recent changes are shown in red text.

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). If a lower extremity wound is not amenable to tourniquet application and cannot be controlled by hemostatics/dressings, consider immediate application of mechanical direct pressure including CoTCCC recommended devices such as the Combat Ready Clamp (CRoC.)
   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. Tranexamic Acid (TXA)
   If a casualty is anticipated to need significant blood transfusion (for example: presents with hemorrhagic shock, one or more major amputations, penetrating torso trauma, or evidence of severe bleeding)
   – Administer 1 gram of tranexamic acid in 100 cc Normal Saline or Lactated Ringers as soon as possible but NOT later than 3 hours after injury.
   - Begin second infusion of 1 gm TXA after Hextend or other fluid treatment.
7. 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.
8. 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 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 mentioned gear is not available, use dry blankets, poncho liners, sleeping bags, or anything that will retain heat and keep the casualty dry.
   f. Warm fluids are preferred if IV fluids are required.
9. 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.
10. Monitoring
    Pulse oximetry should be available as an adjunct to clinical monitoring.
    Readings may be misleading in the settings of shock or marked hypothermia.
11. Inspect and dress known wounds.
12. Check for additional wounds.
13. 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
14. Splint fractures and recheck pulse.
15. 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
16. 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.
17. Communicate with the casualty if possible.
    - Encourage; reassure
    - Explain care
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.
19. 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.) If a lower extremity wound is not amenable to tourniquet application and cannot be controlled by hemostatics/dressings, consider immediate application of mechanical direct pressure including CoTCCC recommended devices such as the Combat Ready Clamp (CRoC.)
   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. Tranexamic Acid (TXA)
   If a casualty is anticipated to need significant blood transfusion (for example: presents with hemorrhagic shock, one or more major amputations, penetrating torso trauma, or evidence of severe bleeding)
   – Administer 1 gram of tranexamic acid in 100 cc Normal Saline or Lactated Ringers as soon as possible but NOT later than 3 hours after injury.
   - Begin second infusion of 1 gm TXA after Hextend or other fluid treatment.
6. Fluid resuscitation
   Reassess for hemorrhagic shock (altered mental status in the absence of brain injury and/or change in pulse character.) If BP monitoring is available, maintain target systolic BP 80-90 mmHg.
   a. If not in shock:
   - No IV fluids necessary.
   - PO fluids permissible if conscious and can swallow.
   b. If in shock and blood products ARE NOT available:
   - Hextend 500-mL IV bolus.
   - Repeat once after 30 minutes if still in shock.
   - 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:Continue resuscitation with packed red blood cells (PRBCs), Hextend, or Lactated Ringer’s solution (LR) as indicated.
   – Resuscitate with 2 units of plasma followed by packed red blood cells (PRBCs) in a 1:1 ratio. If blood component therapy is not available, transfuse 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 TBI 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.
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 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 mentioned gear is not available, use dry blankets, 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 open.
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
   Institute pulse oximetry and other electronic monitoring of vital signs, if indicated.
10. Inspect and dress known wounds if not already done.
11. Check for additional wounds.
12. 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.
13. Reassess fractures and recheck pulses.
14. 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
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 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.
16. 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.
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.
18. 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 2011 TCCC Guidelines in .pdf format to download

After returning from my overseas tour, I was given an assignment within the training unit at my agency. It didn’t take long before I realized that there were some shortfalls to the First Aid and Self First Aid program we were offering.

The most outstanding concern was the lack of training concerning the use and deployment of a tourniquet. After taking a good look at our program, I proposed a lesson plan, which included the purpose and use of the tourniquet. It was approved after a short review and the trend began. Slowly, I was able to affect the entire agency, by exposing them to tourniquet training.

This is when I realized the enormous communication gap between our Military and Law Enforcement agencies. I began a personal campaign to bring attention to the fact that our soldiers (young as they may be) are considered trainable in combat life saving skills by our government and most of the Law Enforcement agencies in our country consider this type of training,”out of the realm or scope” and perhaps too difficult.

The Need For Training

That fact of the matter is that the skills needed to become proficient in combat life saving skills can be taught to police officers in the same manner it’s taught to soldiers. It’s common knowledge that special units have this type of training, but what about the patrol officer?

I often make this statement when I’m asked to sum up my reasons or inspirations for writing my book, A Police Officer’s Guide and Handbook to Tactical Casualty Care (Under Fire). When a Deputy or Police Officer approaches the next door of the next house on the next call and they get shot through the front door, for the next several minutes they may be fighting for their lives. During those few moments, he or she is in “COMBAT.” So then, why do we fail to prepare them for this increasingly common event?

For the most part, the response is just silence. I strongly believe that there is no reason our patrol officers should be at a disadvantage.

The Book

The target audience of my book is Law Enforcement. Whether on patrol, the court room or in a correctional facility, the concepts and skills organized in this book apply to everyone.

It’s designed to supplement the First Aid and Self First Aid courses mandated by Police Academies and presented in most agencies. It focuses on immediate hemorrhage control and explains the mindset required to survive such a traumatic event.

Here’s a look inside the book and what you’ll find within the chapters. I’ve included a few relevant quotes from each chapter too.

• Chapter One – Concepts, Goals and Relevance of Tactical Casualty Care to The Law Enforcement Community. “Several well written books have covered this subject very thoroughly but I have yet to find one that covers the subject of care under fire dedicated for the officer on patrol or who is not part of a specialized team.”

• Chapter Two – Three Stages of Care During a Critical Incident and Factors that Influence This Care. “Many agencies require medical transport to be summoned to your location to transport an injured person. Some agencies don’t address the issue at all. Think about this for a moment; would a violation of your agency’s policy be justified to save the life of a fellow officer?”

• Chapter Three – How to distinguish the Difference Between Life Threatening and Non-Life Threatening Injuries. “Keep in mind, the officer’s status is just one factor in your hasty rescue plan. Do not allow yourself to become emotionally involved and get drawn into becoming another victim. If this occurs, you won’t be able to perform the rescue, and now a second rescue (for you) will be required. Think scene safety!”

• Chapter Four – Understanding When and Where to Treat Life Threatening and Non-Life Threatening Injuries. “If the officer is awake and able to move, order the officer to initiate self-aid as appropriate, while awaiting rescue. Unfortunately, many people equate being shot with being helpless or dead, something frequently reinforced in training. Nothing could be further from the truth.”

• Chapter Five – The Application and Use of Field Dressings, Pressure Dressings, and Tourniquets. “The tourniquet has always been a subject of controversy. As a matter fact, some agencies may not even allow the subject to be used or even trained. Until about three years ago, my agency experienced the same issue. When the concerns were identified to our staff, examples and supporting documentation was provided showing in our case specifically, the training and use of the tourniquet would be beneficial, the training and use was approved.” 

• Chapter Six – Recommendations for Assembling a “Gunshot Kit.” “*TUCSON – Some of the first deputies to arrive at the scene of the Jan. 8 shooting rampage here described a scene of “silent chaos” on Friday, and they added that the carnage probably would have been much worse without the help of a $99 first-aid kit that recently became standard-issue.” 

• Chapter Seven – Techniques for Moving Casualties. “The primary purpose of all rescue work is to get injured people out of danger and to medical help as quickly as possible. If you have never attempted to physically move another person, you will be surprised to learn that it is not always as easy as it looks.”

• Chapter Eight - Scenario Based, Realistic and Dynamic Training. “No matter how you look at it, tactical casualty care under fire, addresses a moment in time which requires your immediate reaction and responses to a deadly attack. To assume that being exposed to a four-hour block of instruction in a classroom setting is enough, would be a huge misunderstanding of how your mind and body reacts to these types of emergencies.”

• Chapter Nine – Sample Lesson Plan. “Students will have an understanding of what “Tactical Casualty Care (Under Fire)” is and how the “Warrior mindset” plays an important role.”

• Chapter Ten – Sample Scenario Script with Timeline. “1st two hours, classroom with concepts and practical exercises. 2nd two hours, step by step application and scenarios.”

It is my intent to present this material to as many Law Enforcement personnel as possible, with the hopes to provide the basic knowledge and skills needed for survival. It would be a great add-on to the basic First Aid courses provided in most Law Enforcement Academies.

Editor’s note: Please join us in welcoming Rafael Navarro as a contributor on ITS Tactical. He’s currently serving in the Law Enforcement Training Division of the Pinellas County Sheriff’s Office, Florida. Rafael’s been in Law Enforcement since 2000; serving 4 years with the SWAT team, retiring as a SFC/E-7 after 21 Years of military service with the United States Army, Military Police Corps. and 24 months in Afghanistan in support of combat operations during Operation Enduring Freedom.

*By Sandhya Somashekhar and Sari Horwitz, Washington Post Staff Writers, Friday, January 21, 2011

We just received an email this morning about our ETA Trauma Kits being used out in the field to save a life. Here’s the account of the incident from the first responder. As he states, certain details have been left off, including his name and location.

I’d like to apologize first for the lack of proper medical terminology as I’m only trained minimally and anything beyond that is self taught. Due to OPSEC I have to be brief on my story, sorry.

None the less, we were under fire, seconds felt like minutes and minutes felt like hours. Making use of rubble as cover during a rain of fire, I noticed my buddy next to me hit the ground, getting hit with what looked like two ricochet rounds. Making sure all the targets were neutralized and covered, I then rushed to my buddy to assess his injuries.

He was bleeding from two areas, the first area was where he was holding his left side of his abdominal, which was a quarter sized hole about three inches above his pelvis. His second wound was to his left leg. Falling back on my training, I was taught that 90% of leg wounds need of a Tourniquet. At that point I made the decision to address his leg wound first, as it was bleeding a lot faster than his abdominal wound. Due to the location on his leg where he was hit, I was worried it might have been a major artery.

I grabbed my “blow out bag” which had one of your ETA Trauma Kits in it, as well as a SOF Tactical Tourniquet. I quickly put on the tourniquet to help stop the bleeding as much as possible. I then cut open his BDU’s and the blood came rushing out, in my mind I was saying “OH F**K” but the words that came out my mouth to my buddy were “Piece of cake buddy… your gonna be ok… stay with me.”

I ripped open the ETA Trauma Kit, grabbed the QuikClot Combat Gauze and packed it into his wound. Once I was done with that, I grabbed the Z-Pak Dressing and placed it on the top to make a seal; ensuring the QuikClot stayed in the wound. I then wrapped his leg with the Israeli Bandage to finish treating it, before moving on to his second wound.

As I was treating his leg, I was telling him to keep pressure on his other wound to his abdominal area. Maybe I should of put some gauze on it, but at the time I was worried about his leg and had to make a quick decision; I couldn’t waste time.

His abominable wound was a clean through shot and by the time I started to treat it the bleeding had pretty much stopped. I grabbed another ETA Trauma Kit out of my buddy’s backpack, placed some gauze on the exit wound and a HALO Seal over it. I then put some gauze and the other HALO over the entry wound. He was stable enough for our 75 mile ride to the nearest medical facility in our given area.

We made it to the medical facility where he was treated by higher echelon care and survived his wounds. Because of your ETA Trauma Kits I had what I needed to help my buddy survive. Even someone not as highly trained as myself was able to save a life! Your kits had everything and more that I needed for that particular scenario.

Thanks a lot guys, I didn’t personally buy your kits but I had the chance to use them in the field. I did just pick up your ETA Trauma Kit Pouch though, as we always need a good quickly accessible pouch.

I hope this info was helpful and I’ll be buying more from your company in the future!

Thanks,
***Name Withheld***

The VALOR Project truly surprised me with information that changed what I thought I knew about self- and buddy-care in combat for law enforcement officers. Law enforcement shares many similarities with the military, though the missions are very different. Due to the the similarities, law enforcement frequently adopts methods, tools and techniques pioneered in military service.

Tactical Combat Casualty Care (TCCC), developed by the US military in the wake of the Battle of Mogadishu, is one of those protocols that is finding widespread acceptance in law enforcement. What if TCCC doesn’t properly prepare law enforcement officers for the realities of civilian combat? Is it possible that police officers are not learning the things they need to stay alive if wounded in combat?

That’s where the VALOR Project comes in.

TCCC

Tactical Combat Casualty Care is a military protocol that integrates medical care for wounded servicemen into the tactical response to a combat situation. TCCC acknowledges that doing the “correct thing” for the medical treatment of the casualty may worsen the overall situation and survivability of the team. As Captain Frank K. Butler, Jr (USN) stated:

Good medicine can be bad tactics, and bad tactics can get everyone killed.

Therefore, civilian medical protocols for patient treatment are overridden by the realities of combat.

The US military determined that there are a certain number of casualties who are instantly killed or so massively wounded that no amount of medical care will allow the patient to survive. TCCC protocols were developed to address preventable combat deaths: deaths that could have been prevented with the proper intervention in the field.

Examining detailed casualty data, the US military determined that almost 2/3 (61%) of preventable deaths were due to hemorrhaging (bleeding) from isolated extremity trauma. From this fact, the rapid application of tourniquets to control life-threatening bleeding became a key component of TCCC.

The second most common form of preventable death in military combat was from tension pneumothorax (33%). Tension pneumothorax is a condition that frequently develops from penetrating wounds to the chest, which allows air from the lungs to fill the chest cavity, building a crushing pressure on the lungs and heart.

The third form of preventable death identified in the TCCC protocols is from airway compromise. This accounts for only about 6% of preventable combat deaths.

Based on the TCCC protocols, I presumed that preventable law enforcement deaths from felonious assaults should be in roughly the same proportion. Research conducted by Matthew D. Sztajnkrycer, MD, PhD, showed that my presumption was clearly suspect.

VALOR Project

The VALOR Project collects data from a wide variety of sources regarding assaults on law enforcement officers, and police deaths and injuries. From the data, the Project then attempts to distill the data into information that can be used to help officers improve their odds of survival in a life-threatening situation.

Sztajnkrycer published several papers on the subjects of downed officer rescue, medical intervention for wounded officers and the feasibility of training non-medical personnel in needle thoracostomy (releasing the pressure of tension pneumothorax using a needle inserted into the chest). Additionally, Sztajnkrycer is working on several new research projects that study chest trauma, the use of helicopter EMS response and a wounding study using dash-cam video.

Sztajnkrycer has also created the Law Enforcement Near-Miss Database (LENMDB). The LENMDB is a voluntary reporting database where law enforcement officers can anonymously submit “near-miss” incidents. The VALOR Project defines a near-miss as “any event which had the potential to result in officer death, including those that resulted in life-threatening injuries, as well as those that resulted in minor or no injuries. “

Officer Deaths

In Learning from tragedy: Preventing officer deaths with medical interventions, Sztajnkrycer examined the data on 341 law enforcement officers killed in the line of duty from 1998 to 2007. Sztajnkrycer’s research showed that only two officers appeared to have died from an isolated extremity hemorrhage. This worked out to be about 1.6% of the potentially preventable deaths. Compared to the 61% found in military studies of combat troops, 1.6% suggests a large difference between law enforcement and military trauma.

Currently, there are no published studies on tension pneumothorax and officers killed in the line of duty. However, Sztajnkrycer points out that about 38% of the officers he studied died of chest trauma, suggesting that tension pneumothorax may be a larger issue in law enforcement deaths than we have previously considered.

Law Enforcement and TCCC

Does Sztajnkrycer’s research indicate that TCCC is not appropriate for law enforcement? Not hardly. Whether or not extremity hemorrhage is a preventable cause of death at the same rate in law enforcement as it is in the military does not mean that the precepts of TCCC are invalid.

What medical interventions we use on a wounded officer may vary from the military TCCC system depending on what research shows. Mechanisms of injury are likely to be very different between military combat and police combat. For example, soldiers are more likely to encounter IEDs and explosives, while police officers are more likely to be stabbed or shot with a handgun at close range. These differences require that we adapt medical training to address the most likely form of injury.

Adapting the kinds of medical intervention that we provide should be easy to do in the TCCC framework. Remember that one of the most basic concepts in TCCC is that helping a wounded soldier (or officer in this discussion) is a tactical decision.

What medical care we provide to a wounded partner takes a backseat to being able to safely treat him or her while minimizing risk to the others on the team. It may be that the best treatment to an injured officer is to neutralize the threat. This TCCC principle is still very valid.

It is also possible that, due to the relative closeness of trauma centers and a professional emergency medical system, most of the officers killed on duty suffer wounds that are non-survivable. In other words, we’re already saving most of the wounded officers from death due to timely EMS intervention.

However, we’re not saving everyone. While only two officers died from isolated extremity hemorrhage in Sztajnkrycer’s study, both of the officers had been shot through the femoral artery and bled to death on the scene. Had these officers had fast medical intervention with a tourniquet, their odds of survival would have been vastly improved.

While the percentages of the causes of death may be off from the military experience, we in law enforcement can still improve how many officers we save. Hopefully, using Sztajnkrycer’s research at the VALOR Project, we can gain additional insight and train our people with the skills they need to prevail.

Richard is a Police Officer with a mid-sized department in the Tampa Bay area and also publishes the police training site, BlueSheepdog.com

As you’ve no doubt heard us reference on ITS Tactical, we follow the TCCC (Tactical Combat Casualty Care) Guidelines very closely and have designed our ETA Kit around them.

Tactical Combat Casualty Care (Pronounced “T-Triple C”) is a set of guidelines developed by USSOCOM (United States Special Operations Command) to properly train non-medics to deal with the preventable causes of death in the field.

The latest updates for 2010 are out and we wanted to share them with you; The only change since the November 2009 updates is new material on hypothermia prevention.

Prior to these updates, the 2009 TCCC stated that WoundStat had been removed as a secondary hemostatic agent, which left QuikClot Combat Gauze and the primary and only hemostatic agent recommended.

We’ve posted the updated 2011 guidelines in their entirety here, but also have them available in .pdf format for download.

Tactical Combat Casualty Care Guidelines – 18 August 2010

* All changes to the guidelines made since those published in the 2006 Sixth Edition of the PHTLS Manual are shown in bold text. The new material on hypothermia prevention is shown in red text.

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. Get the casualty onto an insulated surface as soon as possible.
   c. Apply 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 mentioned gear is not available, use dry blankets, poncho liners, sleeping bags, or anything that will retain heat and keep the casualty dry.
   f. Warm fluids are preferred if IV fluids are required.
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. Replace wet clothing with dry if possible. Get the casualty onto an insulated surface as soon as possible.
   c. Apply 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 mentioned gear is not available, use dry blankets, 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 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 2011 TCCC Guidelines in .pdf format to download

A 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