Page 102 - JSOM Spring 2024

Tactical Combat Casualty Care (TCCC) Guidelines

25 January 2024

Travis Deaton, MD; Brendon Drew, DO; Harold Montgomery, ATP; Frank Butler, MD

RED text indicates new text in this year’s update to the TCCC Guidelines; BLUE text indicates text that did not change but was
relocated within the guidelines.

Recent changes include airway management and traumatic brain injury management in tactical field care.

Basic Management Plan for Care Under Fire/Threat

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 or when tactically feasible, move or drag casualty to cover.
4. Try to keep the casualty from sustaining additional wounds.
5. Casualties should be extracted from burning vehicles or buildings and moved to places of relative safety. Do what is necessary
to stop the burning process.
6. Stop life-threatening external hemorrhage if tactically feasible:
a. Direct casualty to control hemorrhage by self-aid if able.
b. Use a CoTCCC-recommended limb tourniquet for hemorrhage that is anatomically amenable to tourniquet use.
c. Apply the limb tourniquet over the uniform clearly proximal to the bleeding site(s). If the site of the life-threatening bleed-
ing is not readily apparent, place the tourniquet “high and tight” (as proximal as possible) on the injured limb and move
the casualty to cover.
7. Airway management is generally best deferred until the Tactical Field Care phase.

Basic Management Plan for Tactical Field Care

1. Establish a security perimeter in accordance with unit tactical standard operating procedures and/or battle drills. Maintain
tactical situational awareness.
2. Triage casualties as required. Casualties with an altered mental status should have weapons and communications equipment
taken away immediately.
3. Massive Hemorrhage
a. Assess for unrecognized hemorrhage and control all sources of bleeding. If not already done, use a CoTCCC- recommended
limb tourniquet to control life-threatening external hemorrhage that is anatomically amenable to tourniquet use or for any
traumatic amputation. Apply directly to the skin 2–3 inches above the bleeding site. If bleeding is not controlled with the
first tourniquet, apply a second tourniquet side-by-side with the first.
b. For compressible (external) hemorrhage not amenable to limb tourniquet use or as an adjunct to tourniquet removal, use
Combat Gauze as the CoTCCC hemostatic dressing of choice.
• Alternative hemostatic adjuncts:
– Celox Gauze or
– ChitoGauze or
– XStat (best for deep, narrow-tract junctional wounds)
– iTClamp (may be used alone or in conjunction with hemostatic dressing or XStat)
• Hemostatic dressings should be applied with at least 3 minutes of direct pressure (optional for XStat). Each dressing
works differently, so if one fails to control bleeding, it may be removed and a fresh dressing of the same type or a dif-
ferent type applied. (Note: XStat is not to be removed in the field, but additional XStat, other hemostatic adjuncts, or
trauma dressings may be applied over it.)
• If the bleeding site is amenable to use of a junctional tourniquet, immediately apply a junctional tourniquet. Do not
delay in the application of the junctional tourniquet once it is ready for use. Apply hemostatic dressings with direct
pressure if a junctional tourniquet is not available or while the junctional tourniquet is being readied for use.
c. For external hemorrhage of the head and neck where the wound edges can be easily re-approximated, the iTClamp may be
used as a primary option for hemorrhage control. Wounds should be packed with a hemostatic dressing or XStat, if appro-
priate, prior to iTClamp application.

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