Page 141 - Journal of Special Operations Medicine - Fall 2015

Tactical Combat Casualty Care Guidelines for Medical Personnel:

3 June 2015

All changes to the guidelines made since the 140602 annual update are shown in bold text. These recommendations
are intended to be guidelines only and are not a substitute for clinical judgment.

Basic Management Plan for Care Under Fire

1. Return fire and take cover. – Standard open surgical technique using a flanged and
2. Direct or expect casualty to remain engaged as a combat- cuffed airway cannula of less than 10mm outer di-
ant if appropriate. ameter, 6mm to 7mm internal diameter, and 5cm to
3. Direct casualty to move to cover and apply self-aid if able. 8cm of intratracheal length (Least desirable option)
4. Try to keep the casualty from sustaining additional wounds. – Use lidocaine if the casualty is conscious.
5. Casualties should be extricated from burning vehicles or 3. Breathing
buildings and moved to places of relative safety. Do what is a. In a casualty with progressive respiratory distress and
necessary to stop the burning process. known or suspected torso trauma, consider a tension
6. Airway management is generally best deferred until the pneumothorax and decompress the chest on the side
Tactical Field Care phase. of the injury with a 14-gauge, 3.25-inch needle/cath-
7. Stop life-threatening external hemorrhage if tactically eter unit inserted in the second intercostal space at the
feasible: midclavicular line. Ensure that the needle entry into the
– Direct casualty to control hemorrhage by self-aid if able. chest is not medial to the nipple line and is not directed
– Use a Committee on Tactical Combat Casualty Care toward the heart. An acceptable alternate site is the
(CoTCCC)-recommended limb tourniquet for hemor- fourth or fifth intercostal space at the anterior axillary
rhage that is anatomically amenable to tourniquet use. line (AAL).
– Apply the limb tourniquet over the uniform clearly b. All open and/or sucking chest wounds should be treated
proximal to the bleeding site(s). If the site of the life- by immediately applying a vented chest seal to cover the
threatening bleeding is not readily apparent, place the defect. If a vented chest seal is not available, use a non-
tourniquet “high and tight” (as proximal as possible) vented chest seal. Monitor the casualty for the potential
on the injured limb and move the casualty to cover. development of a subsequent tension pneumothorax. If
the casualty develops increasing hypoxia, respiratory
distress, or hypotension and a tension pneumothorax is
Basic Management Plan for Tactical Field Care suspected, treat by burping or removing the dressing or
1. Casualties with an altered mental status should be dis- by needle decompression.
armed immediately. c. Casualties with moderate/severe traumatic brain injury
2. Airway management (TBI) should be given supplemental oxygen when avail-
a. Unconscious casualty without airway obstruction: able to maintain an oxygen saturation > 90%.
– Chin lift or jaw thrust maneuver 4. Bleeding
– Nasopharyngeal airway a. Assess for unrecognized hemorrhage and control all
– Place casualty in the recovery position sources of bleeding. If not already done, use a CoTCCC-
b. Casualty with airway obstruction or impending airway recommended limb tourniquet to control life-threaten-
obstruction: ing external hemorrhage that is anatomically amenable
– Chin lift or jaw thrust maneuver to tourniquet use or for any traumatic amputation. Ap-
– Nasopharyngeal airway ply directly to the skin 2 to 3 inches above the wound.
– Allow casualty to assume any position that best pro- If bleeding is not controlled with the first tourniquet,
tects the airway, to include sitting up. apply a second tourniquet side-by-side with the first.
– Place unconscious casualty in the recovery position. b. For compressible hemorrhage not amenable to limb
c. If the previous measures are unsuccessful, perform a tourniquet use or as an adjunct to tourniquet removal,
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surgical cricothyroidotomy using one of the following: use Combat Gauze as the CoTCCC hemostatic dress-
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– Cric-Key technique (Preferred option) ing of choice. Celox Gauze and ChitoGauze may also
– Bougie-aided open surgical technique using a flanged be used if Combat Gauze is not available. Hemostatic
and cuffed airway cannula of less than 10mm outer dressings should be applied with at least 3 minutes of
diameter, 6mm to 7mm internal diameter, and 5cm direct pressure. If the bleeding site is amenable to use of
to 8cm of intratracheal length a junctional tourniquet, immediately apply a CoTCCC-
recommended junctional tourniquet. Do not delay in

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