Page 98 - JSOM Winter 2025

Background 1994, Bellamy 1987, Baker 1994). Tactical Combat Casualty Care
is a set of evidence-based, best-practice prehospital trauma care
For those who are wounded on the battlefield, the most critical guidelines that was developed specifically for use on the battle-
phase of care is the period between the time they are injured and field. Following the publication of the original TCCC paper in
the time that they arrive at a medical treatment facility (MTF) 1996 (Butler 1996), prehospital trauma care in the U.S. military
capable of providing the surgical care they need. Almost 90% of has undergone an unprecedented transformation.
combatants who die from their wounds do so before they arrive at
an MTF. If a casualty survives long enough to reach the care of a References
combat surgeon, the likelihood is very high that he or she will sur- Baker MS. Advanced trauma life support: Is it acceptable stand-alone
vive. This fact highlights the importance of the battlefield trauma training for military medicine? Mil Med. 1994;159(9):581–590.
care provided by combat medics, corpsmen, and pararescuemen Bellamy RF. How shall we train for combat casualty care? Mil Med.
(PJs) as well as by non-medical unit members in improving the 1987;152(12):617–621.
survival of the casualties of war. Butler FK, Blackbourne LH. Battlefield trauma care then and now: a
Battlefield trauma care varies in many respects from prehospital decade of tactical combat casualty care. J Trauma Acute Care Surg.
2012;73(6 Suppl 5):S395–S402. doi:10.1097/TA.0b013e3182754850
trauma care in the civilian sector. The types and severity of the in- Butler FK Jr, Hagmann J, Butler EG. Tactical Combat Casualty Care in
juries are different from those encountered in civilian settings, and Special Operations. Mil Med. 1996;161 Suppl:3–16. doi:10.1007/
combat medical personnel face multiple additional challenges in 978-3-319-56780-8_1
caring for their wounded teammates in tactical settings. They may Heiskell LE, Carmona RH. Tactical emergency medical services: an
be required to provide care while under hostile fire, often working emerging subspecialty in emergency medicine. Ann Emerg Med.
in the dark, with multiple casualties and with limited equipment. 1994;23(4):778–785. doi:10.1016/s0196-0644(94)70314-0
They must also often contend with prolonged evacuation times as
well as the need for tactical manuever superimposed upon their Tourniquets Reconsidered and the Need for TCCC
efforts to render care. Treatment guidelines developed for the ci- TCCC began as the result of a Naval Special Warfare biomedical
vilian setting do not necessarily translate well to the battlefield. research effort that was undertaken after a striking paradox in
Preventable deaths and unnecessary additional casualties may re- battlefield trauma care was identified. Extremity hemorrhage had
sult if the tactical environment is not considered when developing been reported to be a leading cause of preventable death on the
battlefield trauma care strategies. battlefield during the Vietnam conflict (Bellamy 1987, Maughon
The above considerations notwithstanding, at the onset of the con- 1970). However, in 1992, U.S. military combat medics, corpsmen,
flict in Afghanistan in 2001 following the terrorist attacks of 9/11, and PJs were not being taught to use a readily available and highly
most U.S. combat medical personnel were being trained using the effective treatment for extremity bleeding—a tourniquet—despite
following civilian-based principles of trauma care (Butler 2012): the fact that tourniquets had long been routinely used by orthope-
• Care was to be rendered with no structured consideration of dic surgeons to perform extremity surgery (Butler 2017 – TCCC
the evolving tactical situation Beginnings , Butler 2017 – TCCC Turns 20, Butler 2015 – US Mil
• No use of tourniquets to control extremity hemorrhage Hx with TQs). The realization that such a major opportunity to
• External hemorrhage was managed with prolonged direct improve had not been acted upon prompted a systematic review of
pressure, precluding the medic from attending to the other in- all aspects of battlefield trauma care by the Naval Special Warfare
juries that the casualty may have sustained or from rendering Biomedical Research Program. The TCCC project was conducted
care to other casualties from 1993 to 1996 as a joint effort of Special Operations medical
• There was no use of hemostatic dressings personnel and the Uniformed Services University. This 4-year re-
• Two large-bore IVs were to be started on all patients with sig- search effort culminated with the publication of the original TCCC
nificant trauma paper in 1996 (Butler 2017 – TCCC Turns 20, Butler 2017 –
• Hypovolemic shock was treated in the prehospital phase of TCCC Beginnings, Butler 1996).
care with large-volume crystalloid fluid resuscitation The original TCCC guidelines provided combat medics and corps-
• There were no special considerations for traumatic brain in- men with trauma management strategies that combined good
jury (TBI) with respect to avoiding hypotension or hypoxia medicine with good small-unit tactics. TCCC recognizes that there
• Management of the airway in facial trauma or unconscious are three goals for trauma care in the tactical environment: (1)
casualties taught with an emphasis on endotracheal intubation treat the casualty; (2) prevent additional casualties; and (3) com-
• There were no specific techniques or equipment to prevent hy- plete the mission.
pothermia and secondary coagulopathy in combat casualties
• Management of pain in combat casualties was with intramus- After a 4-year research effort, the original TCCC paper proposed
cular (IM) morphine—a battlefield analgesic that dated back some (at the time) radical changes to battlefield trauma care,
to the Civil War including:
• There was little training or equipment on intraosseous access • A three-phase approach to tactical trauma care to ensure that
capability the care being rendered is tailored to the evolving tactical
• The was no use of prehospital electronic monitoring used by environment
ground force medics • The aggressive use of tourniquets to control life-threatening
• There was no use of effective non-parenteral analgesic extremity bleeding
medications • Tactically appropriate fluid resuscitation
• There were no prehospital antibiotics • Improved battlefield analgesia (IV vs. IM morphine)
• There was no delineation of which casualties might benefit • Battlefield antibiotics
most from supplemental oxygen during tactical evacuation • Nasopharyngeal airways as first-line airway devices for uncon-
• Spinal precautions were applied broadly to casualties with sig- scious casualties without airway obstruction
nificant trauma, without consideration of tactical concerns or • Surgical airways for maxillofacial trauma with airway
mechanism of injury obstruction
• There was no guidance on how to manage wounded hostile • Aggressive diagnosis and needle decompression of tension
force prisoners pneumothorax
• Combat medic input into the TCCC guidelines
Reconsideration of trauma care guidelines for tactical settings • Scenario-based TCCC training
had not been accomplished by the U.S. military as of 1992, even • A standing committee of experts in tactical medicine to monitor
though the need had long been recognized (Heiskell and Carmona the success and shortcomings of the original TCCC Guidelines;

96 | JSOM Volume 25, Edition 4 / Winter 2025