Page 146 - 2020 JSOM Winter

Tactical Combat Casualty Care (TCCC) Guidelines
for Medical Personnel

05 November 2020

Brendon Drew, DO; Harold Montgomery, ATP; Frank Butler Jr, MD

RED text indicates new text in this year’s update to the TCCC the bleeding site. If bleeding is not controlled with the
Guidelines; BLUE text indicates text that did not change but first tourniquet, apply a second tourniquet side-by-side
was relocated within the guidelines. Recent changes include with the first.
tranexamic acid administration, prevention of trauma induced b. For compressible (external) hemorrhage not amenable
hypothermia, fluid resuscitation, analgesia, abdominal evis- to limb tourniquet use or as an adjunct to tourniquet
ceration, and separation of the TACEVAC guidelines. removal, use Combat Gauze as the CoTCCC hemostatic
dressing of choice.
• Alternative hemostatic adjuncts:
Basic Management Plan for Care Under Fire/Threat
■ Celox Gauze or
1. Return fire and take cover. ■ ChitoGauze or
2. Direct or expect casualty to remain engaged as a combatant ■ XStat (best for deep, narrow-tract junctional
if appropriate. wounds)
3. Direct casualty to move to cover and apply self-aid if able ■ iTClamp (may be used alone or in conjunction
or when tactically feasible, move or drag casualty to cover. with hemostatic dressing or XStat)
4. Try to keep the casualty from sustaining additional wounds. • Hemostatic dressings should be applied with at least
5. Casualties should be extracted from burning vehicles or 3 minutes of direct pressure (optional for XStat).
buildings and moved to places of relative safety. Do what is Each dressing works differently, so if one fails to con-
necessary to stop the burning process. trol bleeding, it may be removed and a fresh dressing
6. Stop life-threatening external hemorrhage if tactically of the same type or a different type applied. (Note:
feasible: XStat is not to be removed in the field, but additional
a. Direct casualty to control hemorrhage by self-aid if able. XStat, other hemostatic adjuncts, or trauma dress-
b. Use a CoTCCC-recommended limb tourniquet for hem- ings may be applied over it.)
orrhage that is anatomically amenable to tourniquet use. • If the bleeding site is amenable to use of a junctional
c. Apply the limb tourniquet over the uniform clearly tourniquet, immediately apply a CoTCCC-recom-
proximal to the bleeding site(s). If the site of the life- mended junctional tourniquet. Do not delay in the
threatening bleeding is not readily apparent, place the application of the junctional tourniquet once it is
tourniquet “high and tight” (as proximal as possible) on ready for use. Apply hemostatic dressings with direct
the injured limb and move the casualty to cover. pressure if a junctional tourniquet is not available or
7. Airway management is generally best deferred until the while the junctional tourniquet is being readied for
Tactical Field Care phase. use.
c. For external hemorrhage of the head and neck where
the wound edges can be easily re-approximated, the
Basic Management Plan for Tactical Field Care
iTClamp may be used as a primary option for hemor-
1. Establish a security perimeter in accordance with unit tac- rhage control. Wounds should be packed with a hemo-
tical standard operating procedures and/or battle drills. static dressing or XStat, if appropriate, prior to iTClamp
Maintain tactical situational awareness. application.
2. Triage casualties as required. Casualties with an altered • The iTClamp does not require additional direct pres-
mental status should have weapons and communications sure, either when used alone or in combination with
equipment taken away immediately. other hemostatic adjuncts.
3. Massive hemorrhage • If the iTClamp is applied to the neck, perform
a. Assess for unrecognized hemorrhage and control frequent airway monitoring and evaluate for an
all sources of bleeding. If not already done, use a expanding hematoma that may compromise the air-
CoTCCC-recommended limb tourniquet to control way. Consider placing a definitive airway if there is
life-threatening external hemorrhage that is anatomi- evidence of an expanding hematoma
cally amenable to tourniquet use or for any traumatic • DO NOT APPLY on or near the eye or eyelid (within
amputation. Apply directly to the skin 2–3 inches above 1cm of the orbit).

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