Page 139 - JSOM Fall 2018

TCCC Guidelines for Medical Personnel

1 August 2018

RED text indicates new text in this year’s update to the TCCC Guidelines, which includes the recent changes on extraglottic
airways and management of suspected tension pneumothorax.

Basic Management Plan for Care Under Fire • Hemostatic dressings should be applied with at least
1. Return fire and take cover. 3 minutes of direct pressure (optional for XStat).
2. Direct or expect casualty to remain engaged as a combatant Each dressing works differently, so if one fails to con­
if appropriate. trol bleeding, it may be removed and a fresh dressing
3. Direct casualty to move to cover and apply self­aid if able. of the same type or a different type applied. (Note:
4. Try to keep the casualty from sustaining additional wounds. XStat is not to be removed in the field, but additional
5. Casualties should be extricated from burning vehicles or XStat, other hemostatic adjuncts, or trauma dress­
buildings and moved to places of relative safety. Do what is ings may be applied over it.)
necessary to stop the burning process. • If the bleeding site is amenable to use of a junctional
6. Stop life­threatening external hemorrhage if tactically tourniquet, immediately apply a CoTCCC­recom­
feasible: mended junctional tourniquet. Do not delay in the
a. Direct casualty to control hemorrhage by self­aid if able. application of the junctional tourniquet once it is
b. Use a CoTCCC­recommended limb tourniquet for hem­ ready for use. Apply hemostatic dressings with direct
orrhage that is anatomically amenable to tourniquet pressure if a junctional tourniquet is not available or
use. while the junctional tourniquet is being readied for
c. Apply the limb tourniquet over the uniform clearly prox­ use.
imal to the bleeding site(s). If the site of the life­threaten­ 4. Airway Management
ing bleeding is not readily apparent, place the tourniquet a. Conscious casualty with no airway problem identified:
“high and tight” (as proximal as possible) on the injured • No airway intervention required
limb and move the casualty to cover. b. Unconscious casualty without airway obstruction:
7. Airway management is generally best deferred until the • Place casualty in the recovery position
Tactical Field Care phase. • Chin lift or jaw thrust maneuver or
• Nasopharyngeal airway or
• Extraglottic airway
Basic Management Plan for Tactical Field Care c. Casualty with airway obstruction or impending airway
1. Establish a security perimeter in accordance with unit tac­ obstruction:
tical standard operating procedures and/or battle drills. • Allow a conscious casualty to assume any position
Maintain tactical situational awareness. that best protects the airway, to include sitting up
2. Triage casualties as required. Casualties with an altered • Use a chin lift or jaw thrust maneuver
mental status should have weapons and communications • Use suction if available and appropriate
equipment taken away immediately. • Nasopharyngeal airway or
3. Massive Hemorrhage • Extraglottic airway (if the casualty is unconscious)
a. Assess for unrecognized hemorrhage and control • Place an unconscious casualty in the recovery
all sources of bleeding. If not already done, use a position.
CoTCCC­recommended limb tourniquet to control d. If the previous measures are unsuccessful, perform a sur­
life­threatening external hemorrhage that is anatomi­ gical cricothyroidotomy using one of the following:
cally amenable to tourniquet use or for any traumatic • Cric­Key technique (preferred option)
amputation. Apply directly to the skin 2–3 inches above • Bougie­aided open surgical technique using a flanged
the bleeding site. If bleeding is not controlled with the and cuffed airway cannula of less than 10mm outer
first tourniquet, apply a second tourniquet side­by­side diameter, 6–7mm internal diameter, and 5­8cm of in­
with the first. tratracheal length
b. For compressible (external) hemorrhage not amenable • Standard open surgical technique using a flanged
to limb tourniquet use or as an adjunct to tourniquet and cuffed airway cannula of less than 10mm outer
removal, use Combat Gauze as the CoTCCC hemostatic diameter, 6­7mm internal diameter, and 5­8cm of in­
dressing of choice. tratracheal length (least desirable option)
• Alternative hemostatic adjuncts: • Use lidocaine if the casualty is conscious.
– Celox Gauze or e. Cervical spine stabilization is not necessary for casual­
– ChitoGauze or ties who have sustained only penetrating trauma.
– XStat (Best for deep, narrow­tract junctional f. Monitor the hemoglobin oxygen saturation in casualties
wounds) to help assess airway patency.

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