Page 132 - Journal of Special Operations Medicine - Fall 2014

Tactical Combat Casualty Care Guidelines
2 June 2014

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. An acceptable alternate site is the 4th or 5th intercostal space at the anterior axillary line
(AAL).
b. All open and/or sucking chest wounds should be treated by immediately applying a vented chest seal to cover the defect.
If a vented chest seal is not available, use a non-vented chest seal. Monitor the casualty for the potential development of a
subsequent tension pneumothorax. If the casualty develops increasing hypoxia, respiratory distress, or hypotension and a
tension pneumothorax is suspected, treat by burping or removing the dressing or by needle decompression.
c. Casualties with moderate/severe TBI should be given supplemental oxygen when available to maintain an oxygen satura-
tion >90%.
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.

Notes: *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.
*These recommendations are intended to be guidelines only and are not a substitute for clinical judgment.

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