Tactical Combat Casualty Care (TCCC) – Core Concepts

Trauma Care Settings

• Civilian trauma centers
  • Well-lighted, climate-controlled, secure, technology-rich environments
  • Staffed by multidisciplinary teams with rapid access to blood products, imaging, and surgical suites
• Tactical combat settings
  • Example: shrapnel wound to the hip at 10{,}000\;\text{ft} in the Hindu Kush Mountains, Afghanistan
  • Characteristics: hostile fire, altitude, weather extremes, limited equipment, evacuation delays
  • Care delivered primarily by combat medics/corpsmen/PJs under fire, often at night, with minimal resources
• Implication: management plans, priorities, and acceptable risk differ markedly; TCCC provides the doctrinal framework that defines those differences

Historical Battlefield Trauma Care (Pre-9/11)

• Training modeled on civilian standards
  • Emergency Medical Technician (EMT) courses
  • Advanced Trauma Life Support (ATLS)
• Tactical factors rarely addressed; assumption that civilian best practice = battlefield best practice

Battlefield Trauma Care in 2001 (Immediately Pre-TCCC)

• "Legacy" doctrine features
  • Medics taught not to use tourniquets
  • No hemostatic dressings or junctional tourniquets
  • Large-volume crystalloid resuscitation
  • Intramuscular morphine (Civil War–era analgesia)
  • IV cut-downs for difficult access
  • Automatic placement of two large-bore IVs
  • Heavy emphasis on endotracheal intubation
  • No focus on trauma-induced coagulopathy
  • Little or no tactical context integrated into protocols

Why Different Strategies Are Required

• Combat ≠ Civilian
  • Hostile fire, darkness, extremes of heat/cold, dust, altitude
  • Different wounding patterns (blast, fragmentation, high-velocity GSWs)
  • Limited gear and personnel, prolonged evacuation timelines
  • Need to continue the fight and protect the team
• Expertise gap
  • Trauma surgeons understand physiology, damage-control surgery
  • Combat medics understand tactics, small-unit operations
  • TCCC melds both to optimize prehospital battlefield care
• Tourniquets: classic example of battlefield innovation that lagged because civilian dogma discouraged their use

Preventable Causes of Death on the Battlefield

1. Extremity hemorrhage – #1 cause
   • Rapid exsanguination if uncontrolled
2. Junctional hemorrhage (groin, axilla, neck) – common after IEDs
3. Tension pneumothorax – #2 preventable killer
   • Pathophysiology: injured lung leaks air ➔ rising intrathoracic pressure ➔ lung collapse ➔ mediastinal shift ➔ decreased venous return ➔ obstructive shock
4. Airway trauma – smaller percentage but many are preventable with timely airway control

Three Objectives of Tactical Combat Casualty Care (TCCC)

• Treat the casualty
• Prevent additional casualties
• Complete the mission

Governance: Committee on TCCC (CoTCCC)

• Prehospital arm of the Joint Trauma System
  • 42 members (DoD + civilian)
  • Includes trauma surgeons, EM/critical care physicians, operational unit doctors, medical educators, medics/corpsmen/PJs
  • 100\% have deployment experience (as of 2018)
• Meets periodically; updates guidelines based on evidence & battlefield feedback

Contemporary Battlefield Trauma Care (TCCC Today)

• Phased approach: Care Under Fire (CUF) ➔ Tactical Field Care (TFC) ➔ Tactical Evacuation (TACEVAC)
• Key interventions
  • Early aggressive limb tourniquets in CUF
  • Combat Gauze (kaolin impregnated) + pressure for compressible bleeding
  • Needle thoracostomy for suspected tension PTX
  • Airway: sit-up, lean-forward positioning; surgical cricothyrotomy for maxillofacial trauma
  • Hypotensive (permissive) resuscitation; avoid large crystalloids
  • IV only when needed; intraosseous (IO) if vascular access difficult
  • "Triple-Option" battlefield analgesia: PO meds, oral transmucosal fentanyl citrate (OTFC), or ketamine
  • Hypothermia prevention (Hypothermia ≠ cold weather only)
  • Early antibiotics (e.g., moxifloxacin)
  • Tranexamic acid (TXA) within 3 h of wounding
  • Junctional tourniquets, XStat, pelvic binders for non-compressible junctional/pelvic bleeding

Evidence That TCCC Works

• Early OEF/OIF (2001-2004): limited adoption
  • Preventable deaths from uncontrolled extremity hemorrhage ≈ 7.4\%-7.8\% (similar to Vietnam data)
• Tourniquet adoption surged 2005{-}2006
  • Study (J Trauma 2012): 2.6\% preventable deaths ➔ 67\% reduction versus earlier wars
  • TCCC Transition Initiative (2005-2006): 67 tourniquet applications, zero avoidable limb losses
• Conclusion: Proper tourniquet use = major survival benefit

Care Under Fire (CUF)

• Simultaneously fight and provide life-saving aid
  • Return fire & take cover first; suppress enemy to achieve fire superiority ("best medicine on the battlefield")
• Immediate actions
  • Direct casualty to stay engaged if able
  • Instruct casualty to self-aid / move to cover
  • Extract from burning vehicles/structures, extinguish flames by any means
  • Prevent additional wounds
• Mission vs casualty care dilemma
  • Example success: Raid on Entebbe, 27 Jun 1976 – unit finished assault before treating wounded commander LTC Yoni Netanyahu (survived)
  • Example tragedy: Ma'alot school siege, 15 May 1974 – delay led to 22 children killed

Moving Casualties in CUF

• If responsive & mobile ➔ self-move to cover
• Unresponsive & immobile ➔ often non-salvageable; rescue may be too risky
• Responsive but immobile ➔ devise rescue plan
  • Consider cover distance, weight, suppression fire, smoke, casualty’s weapons
• Carries/drags
  • One-person or two-person drag (with/without line)
  • SEAL Team Three (Shoulder-belt) carry
  • Hawes / Pack-strap carry

Cervical Spine (C-Spine) in CUF

• Penetrating head/neck wounds (GSW, shrapnel) ➔ no C-spine stabilization needed
• Blunt trauma (falls, MVAs, fast-rope injuries) ➔ consider stabilization only if tactical situation permits

Burn Prevention in CUF

• Remove from burning platforms ASAP
• Extinguish flames with non-flammable fluids, smothering, or rolling

Hemorrhage Control Priority

• #1 medical task in CUF: stop life-threatening bleeding
• Extremity bleeding statistics
  • >2{,}500 extremity-hemorrhage deaths in Vietnam
• Life-threatening bleeding indicators
  • Pulsatile/steady spurting
  • Rapidly forming ground pool
  • Clothing/bandages saturated
  • Traumatic amputation
  • Casualty now in shock after earlier bleeding (pale, confused, unconscious)

Tourniquet Principles

• Every combatant carries a CoTCCC-recommended limb tourniquet in a standard, accessible location
• First-line intervention for severe extremity hemorrhage during CUF – skip direct pressure/pressure dressings at this stage
• Application guidelines
  • Apply immediately when indicated
  • Do not remove clothing; place tourniquet proximal to wound; if site uncertain ➔ "high & tight"
  • Tighten until bleeding and distal pulse stop
  • Second tourniquet proximal to first if bleeding continues
  • Avoid joints (knee/elbow) and bulky gear pockets
  • Continuously reassess to ensure bleeding control
• Pain
  • Effective tourniquets hurt; pain ≠ misapplication; manage per TCCC analgesia
• Recommended devices
  • Combat Application Tourniquet (C.A.T.)
  • SOF Tactical Tourniquet (SOFT-T)
  • Emergency & Military Tourniquet (EMT)
• Common mistakes
  1. Delay or failure to apply when needed
  2. Not pulling slack before tightening
  3. Using for minimal bleeding
  4. Insufficient tightness (bleeding/pulse persists)
  5. Failing to apply second tourniquet if required
  6. Periodically loosening to "let blood flow" (contraindicated)
  7. Placing unnecessarily far proximal when wound clearly visible
  8. Neglecting to remove/convert during Tactical Field Care (when appropriate)
• Real-world lesson: U.S. soldier bled to death from knee wound after improvised tourniquets failed (unit medic KIA). Proper tourniquet = preventable death.

Ethical, Philosophical & Practical Implications

• Balance between mission accomplishment and casualty care highlights ethical tension unique to combat medicine
• TCCC embodies utilitarian principle: greatest good for greatest number (fire superiority first ➔ fewer casualties overall)
• Data-driven updates via CoTCCC demonstrate continuous quality improvement ethos; contrasts with previous static doctrine
• Successful integration of surgeon-level knowledge and medic-level reality shows value of interdisciplinary collaboration

Key Takeaways for Exam Preparation

• Memorize the three objectives of TCCC and the three phases of care
• Know the top four preventable causes of death and interventions that address them (tourniquet, junctional devices, needle thoracostomy, airway maneuvers)
• Be able to discuss why combat trauma differs from civilian trauma (tactical factors, evacuation delay, wounding patterns)
• Understand tourniquet indications, application steps, and common errors
• Recall landmark data demonstrating 67\% reduction in preventable deaths after TCCC implementation
• Recognize ethical case studies (Entebbe vs. Ma'alot) illustrating mission–medicine trade-offs