Page 26 - 2020 JSOM Winter

Operations Command had the highest rate of overall adher- 2020;20(1):101–111
ence, but rates were still low (68.5%). Medical officers had Canine Tactical Combat Casualty Care (K9TCCC) Guidelines
the highest rates of overall administration. The low rates of Edwards TH, Palmer LE, Baxter RL, Sager TC, Coisman JG,
administration and adherence persisted across all subgroups. Brown JC, George C, McGraw AC
Conclusion: Rates of analgesia administration remained low
overall and in subgroup analyses. Medical officers appeared ABSTRACT: First introduced in 1996, Tactical Combat Casu-
to have higher rates of compliance with TCCC guidelines alty Care (TCCC) redefined prehospital, point-of-injury (POI),
for analgesia administration, but overall adherence to TCCC battlefield trauma care for the human combat casualty. Today,
guidelines was low. Future research will be aimed at finding many consider TCCC as one of the most influential inter-
methods to improve administration and adherence rates. ventions for reducing combat-related case fatality rates from
preventable deaths in human combat casualties. Throughout
Keywords: analgesia; combat; compliance; military; pain; history, Military Working Dogs (MWDs) have proved and
prehospital; Tactical Combat Casualty Care continue to prove themselves as force multipliers in the suc-
cess of many military operations. Since the start of the Global
2019;19(3):31–44 War on Terror in 2001, these elite canine operators have ex-
Management of Hemorrhage From Craniomaxillofacial Inju- perienced an upsurge in combat-related deployments, placing
ries and Penetrating Neck Injury in Tactical Combat Casualty them at a higher risk for combat-related injuries. Until recently,
Care: iTClamp Mechanical Wound Closure Device TCCC consensus- based Canine-TCCC (K9TCCC) guidelines for POI
Guidelines Proposed Change 19-04 06 June 2019 Onifer DJ, battlefield trauma care did not exist for the MWD, leaving a
McKee JL, Faudree LK, Bennett BL, Miles EA, Jacobsen T, critical knowledge gap significantly jeopardizing MWD sur-
Morey JK, Butler FK vival. In 2019, the Canine Combat Casualty Care Commit-
tee was formed as an affiliate of the Committee on Tactical
ABSTRACT: The 2012 study Death on the battlefield (2001-
2011) by Eastridge et al.1 demonstrated that 7.5% of the pre- Combat Casualty Care with the intent of developing evi-
hospital deaths caused by potentially survivable injuries were dence-based, best practice K9TCCC guidelines. Modeled after
due to external hemorrhage from the cervical region. The in- the same principles of the human TCCC, K9TCCC focuses on
creasing use of Tactical Combat-Casualty Care (TCCC) and simple, evidence-based, field-proven medical interventions to
other medical interventions have dramatically reduced the eliminate preventable deaths and to improve MWD survival.
overall rate of combat-related mortality in US forces; how- Customized for the battlefield, K9TCCC uniquely adapts the
ever, uncontrolled hemorrhage remains the number one cause techniques of TCCC to compensate for canine-specific ana-
of potentially survivable combat trauma. Additionally, the tomic and physiological differences.
use of personal protective equipment and adaptations in the Keywords: canine; military working dog; Tactical Combat
weapons used against US forces has caused changes in the Casualty Care; prehospital care; trauma
wound distribution patterns seen in combat trauma. There
has been a significant proportional increase in head and neck 2020;20(2):95–103
wounds, which may result in difficult to control hemorrhage. Quality Assurance in Tactical Combat Casualty Care for Med-
More than 50% of combat wounded personnel will receive a ical Personnel Training 16 April 2020 Greydanus DJ, Hass-
head or neck wound. The iTClamp (Innovative Trauma Care mann LL, Butler FK
Inc., Edmonton, Alberta, Canada) is the first and only hem-
orrhage control device that uses the hydrostatic pressure of ABSTRACT: At present, however, there is no systematic,
a hematoma to tamponade bleeding from an injured vessel comprehensive quality assurance program for TCCC training
within a wound. The iTClamp is US Food and Drug Admin- throughout the DoD. Individual courses and instructors may
istration (FDA) approved for use on multiple sites and works or may not use all of the materials in the JTS-approved cur-
in all compressible areas, including on large and irregular riculum; they may or may not add content that is not part of
lacerations. The iTClamp’s unique design makes it ideal for the JTS curriculum; and they may or may not add additional
controlling external hemorrhage in the head and neck region. training in the form of advanced simulation, hands-on training
The iTClamp has been demonstrated effective in over 245 field with moulaged casualties, graded trauma lanes, or live- tissue
applications. The device is small and lightweight, easy to ap- training. A recent pilot appraisal of four Tactical Combat
ply, can be used by any level of first responder with minimal Casualty Care for Medical Personnel (TCCC-MP) training
training, and facilitates excellent skills retention. The iTClamp courses found that TCCC-MP courses are not presenting all
reapproximates wound edges with four pairs of opposing nee- of the course material recommended by the Joint Trauma
dles. This mechanism of action has demonstrated safe appli- System (JTS), despite TCCC training having been mandated
cation for both the patient and the provider, causes minimal by the Department of Defense (DoD) for all US military per-
pain, and does not result in tissue necrosis, even if the device sonnel. Some of the omitted material is essential to ensuring
is left in place for extended periods. The Committee on TCCC that students are fully prepared to perform TCCC on the bat-
recommends the use of the iTClamp as a primary treatment tlefield. Further, there was incorrect messaging presented in
modality, along with a CoTCCC-recommended hemostatic the TCCC-MP courses that were appraised, some of which, if
dressing and direct manual pressure (DMP), for hemorrhage actually reflected in the care provided on the battlefield, would
control in craniomaxillofacial injuries and penetrating neck likely result in adverse casualty outcomes. Other aspects of
injuries with external hemorrhage. the TCCC messaging presented in the appraised courses that
is not at present part of the JTS-approved curriculum might,
Keywords: craniomaxillofacial injury; penetrating neck injury; however, be appropriate for inclusion into the TCCC Guide-
junctional hemorrhage; compressible hemorrhage; hemor- lines and the course curriculum. Examples of material that
rhage control; iTClamp; TCCC; Tactical Combat Casualty should be considered for incorporation into the TCCC curric-
Care ulum include modifying the method of tranexamic acid (TXA)

24 | JSOM Volume 20, Edition 4 / Winter 2020