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Kotwal RS, Montgomery HR, Kotwal BM, et al. Eliminating prevent- o Care Under Fire/Threat
able death on the battlefield. Arch Surg. 2011;146(12):1350–1358. o Tactical Field Care
doi:10.1001/archsurg.2011.213 o Tactical Evacuation (TACEVAC) Care
Kragh JF Jr, Walters TJ, Westmoreland T, et al. Tragedy into drama: an
American history of tourniquet use in the current war. J Spec Oper • Casualty and medic actions during the Care Under Fire phase
Med. 2013;13(3):5–25. doi:10.55460/QN66-A9MG that focus on gaining and maintaining the tactical advantage,
Kragh JF Jr, Walters TJ, Baer DG, et al. Survival with emergency with application of limb tourniquets, when needed, the only
tourniquet use to stop bleeding in major limb trauma. Ann Surg. medical care recommended for this phase of care.
2009;249(1):1–7. • The most thorough guidelines available to optimize the use
Kragh JF Jr, Walters TJ, Baer DG, et al. Practical use of emergency of limb tourniquets, including the use of a second tourniquet
tourniquets to stop bleeding in major limb trauma. J Trauma. 2008; when needed to control bleeding; elimination of the distal
64(2 Suppl):S38-S50. doi:10.1097/TA.0b013e31816086b1 pulse as a secondary goal for tourniquet application; and the
Mabry R, McManus JG. Prehospital advances in the management recommendation to attempt conversion from a tourniquet to
of severe penetrating trauma. Crit Care Med. 2008;36(7 Suppl): other methods of bleeding control if the casualty has not yet
S258–S266. doi:10.1097/CCM.0b013e31817da674 arrived at a definitive care facility after 2 hours of tourniquet
Malish RG. The medical preparation of a special forces company for time.
pilot recovery. Mil Med. 1999;164(12):881–884. • The use of hemostatic dressings to control life-threatening
Maughon JS. An inquiry into the nature of wounds resulting in killed hemorrhage from external bleeding at sites that are not amena-
in action in Vietnam. Mil Med. 1970;135(1):8–13. ble to tourniquet use.
Pappas CG. The ranger medic. Mil Med. 2001;166(5):394–400. • The use of tranexamic acid, administered as soon as possible
Pennardt A. TCCC in One Special Operations unit. Presentation at for casualties in or at risk for hemorrhagic shock, to help pre-
CoTCCC Meeting; 3 February 2009.
Salomone JP. Letter to Assistant Secretary of Defense for Health Af- vent death from non-compressible and junctional hemorrhage
fairs, 10 June 2008. as well as moderate/severe traumatic brain injury (TBI).
Savage E, Forestier C, Withers N, Tien H, Pannell D. Tactical com- • The use of junctional tourniquets to help prevent death from
bat casualty care in the Canadian Forces: lessons learned from junctional hemorrhage.
the Afghan war. Can J Surg. 2011;54(6):S118–S123. doi:10.1503/ • The hemostatic adjunct XStat as another option for con-
cjs.025011 trolling junctional hemorrhage from wounds with narrow
Sohn VY, Miller JP, Koeller CA, et al. From the combat medic to the wound tracts.
forward surgical team: the Madigan model for improving trauma • Use of the ITClamp to help gain control of external bleeding,
readiness of brigade combat teams fighting the Global War on Ter- especially in casualties with severe bleeding from head and
ror. J Surg Res. 2007;138(1):25–31. doi:10.1016/j.jss.2006.09.006 neck trauma.
Tarpey M. Tactical combat casualty care in Operation Iraqi Freedom. • Circumferential pelvic compression devices to help reduce the
U.S. Army Medical Department Journal. 2005;April–June:38–41. life-threatening internal bleeding that may accompany pelvic
Tien HC, Jung V, Rizoli SB, Acharya SV, MacDonald JC. An evalua- fractures.
tion of tactical combat casualty care interventions in a combat en- • The use of nasopharyngeal airways to maintain a patent air-
vironment. J Am Coll Surg. 2008;207(2):174–178. doi:10.1016/j. way when there is no airway obstruction from direct maxillo-
jamcollsurg.2008.01.065 facial or neck trauma.
Westmoreland T. Presentation at the Special Operations Medical As- • Initial management of the airway in maxillofacial trauma by
sociation. December 2005.
having the casualty sit up and lean forward, if possible, thus
allowing blood to simply drain out of the oropharynx, clearing
Battlefield Trauma Care in 2022 the airway.
Published evidence and battlefield experience accumulated over • Surgical airways for maxillofacial or neck trauma when airway
the 25 years since the original TCCC paper was published have compromise is present, and the sit-up-and-lean-forward posi-
resulted in all services in the U.S. Military and many allied nations tion is not feasible or not successful.
using TCCC concepts to care for their combat wounded. All U.S. • Aggressive needle thoracostomy with a 10 or a 14-gauge, 3.25-
combat medics, corpsmen, and pararescuemen are now taught inch needle for suspected tension pneumothorax.
battlefield trauma care techniques based on the TCCC Guidelines. • A different approach to spinal precautions – they are not em-
Military units that have trained all their members, including both phasized for casualties with penetrating trauma only, but are
medical and non-medical personnel, in TCCC have documented still recommended, if tactically feasible, when blunt trauma is
the lowest incidence of preventable deaths among their casualties present.
in the history of modern warfare (Butler 2017 – TCCC Turns 20). • Intravenous (IV) or intraosseous (IO) access only when re-
TCCC-based prehospital trauma training is now widespread in quired for medications or fluid resuscitation.
the U.S. civilian sector as well.
• The preferential use of a saline lock for IV access as opposed to
TCCC guidelines are reviewed on an ongoing basis and updated an IV catheter running fluids at a maintenance (“keep the vein
as needed by the CoTCCC (Butler 2015 – Combat Medic Aid open” or KVO) rate.
Bag, Butler 2009). Proposed changes to the Guidelines must be • The use of intraosseous devices when vascular access is needed
approved by a 75% majority of the CoTCCC to be accepted. but difficult to obtain.
(Deaton 2021, Montgomery 2020). Changes recommended by the • Resuscitation of casualties in shock with whole blood as soon
CoTCCC are then forwarded to the Chief of the Joint Trauma as this becomes logistically feasible in the continuum of care.
System for final approval (Butler 2015 – Combat Medic Aid Bag). • More aggressive fluid resuscitation and supplemental oxygen
Once approved, updated versions of the TCCC Guidelines are as needed to avoid hypotension and hypoxia in casualties with
posted on the Joint Trauma System website as well as the websites traumatic brain injury (TBI).
of the Defense Health Agency (“Deployed Medicine”), the Na- • The TCCC “Triple-Option Analgesia” plan to provide titrated,
tional Association of Emergency Medical Technicians (NAEMT), faster, safer, and more efficacious battlefield analgesia, using
the Journal of Special Operations Medicine, and the Special Op- oral analgesics when feasible and ketamine instead of opioids
erations Medical Association. TCCC-based training now provided when the casualty is in or at risk of hemorrhagic shock or re-
to all U.S. combat medical personnel includes: spiratory distress.
• Ondansetron to control the nausea and vomiting that may be
Phased care in the tactical environment to ensure that good med- associated with either pain from battlefield trauma or the anal-
icine is combined with good small-unit tactics. The three defined gesic medications used to treat it.
phases of care are:

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