TCCC Guidelines 2019 (Review)

In this segment, I’m going to do a step-by-step review of the new 2019 TCCC Guidelines using the “MARCHE-PAWSB” pneumonic.  My goal is to hopefully promote a deeper understanding of the guidelines that’ll lead to smooth application of tactical medicine on the battlefield.  Gotta pump those TCCC compliance numbers up.

This is the 2019 TCCC Guidelines in it’s entirety is shown here:

TCCC Guidelines 2019

For a quick overview, this study guide breaks it down into 2 pages:

The “MARCHE-PAWSB“ pneumonic stands for:

Massive Hemorrhage

Airway

Respirations

Circulation

Hypothermia

Eye injuries

Pain

Antibiotics

Wounds

Splinting

Burns

Okay!  Now that housekeeping is done, let’s get right to it with an introduction to TCCC:

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Nothing crazy to add here, just want to emphasize some key points:

  • TCCC is for the TACTICAL environment 🔫
    • Following this approach in a garrison environment or a non-tactical environment would be inappropriate.
  • Initial care will almost always be provided by fellow combatants 👨‍👦‍👦..NOT YOU!
    • We have the highest casualty survival rate in history and it’s because we understand now that training non-medical service members in TCCC is just as, if not more, important than training ourselves.
  • Hemorrhage is still the #1 cause of death 🥇
    • With airway obstruction and tension pneumothorax as icing on the killer cake.  Not all deaths are preventable, but we know 15%-28% of them are.  TCCC is all about that 15%-28%!
  • Doing the right thing 👍 at the WRONG time 🕗 can kill you.  Good medicine can be bad tactics:
    • Care Under Fire: Very limited care that can be provided while casualty and provider are under effective enemy fire (Basically just the “M” in MARCHE-PAWSB)
    • Tactical Field Care: Performed on the battlefield, but not under effective enemy fire.  (Full MARCHE-PAWSB care provided)
    • Tactical Evacuation Care: Care is rendered during transport off battlefield on the way to more definitive (Full MARCHE-PAWSB, but with some subtle differences due to more advanced equipment on hand)

Solid intro.  Now we’re going to jump right into Care Under Fire.  You’ll notice that there’s only one video for Care Under Fire….that’s because we’re not doing much 🤷‍♂️

CARE UNDER FIRE (“M” in MARCHE-PAWSB)

For Care Under Fire, TCCC guidelines state:

Basic Management Plan for Care Under Fire

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.

4. Try to keep the casualty from sustaining additional wounds.

5. Casualties should be extricated 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:

  • Direct casualty to control hemorrhage by self-aid if able.
  • Use a CoTCCC-recommended limb tourniquet for hemorrhage that is anatomically amenable to tourniquet use.
  • Apply the limb tourniquet over the uniform clearly proximal to the bleeding site(s). If the site of the life-threatening bleeding 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.

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This is probably one of the most important videos, so try to engrain some of these pearls in your head 🧠:

  • Tourniquets ONLY! ☝️
    • Tourniquets are the ONLY thing you should be using in Care Under Fire.  While taking effective fire, we do not have the time or luxury to apply pressure dressings, set up junctional devices, or pack wounds with hemostatic agents and hold it for 3 minutes
  • Improvised Tourniquets SUCK! 🤮
    • Instead of teaching soldiers how to make improvised tourniquets, we should be aggressively ensuring that every soldier has CoTCCC-recommended tourniquets available and knows how to use them!
  • When in doubt, go HIGH AND TIGHT! ⬆️
    • They make a point in the video that you shouldn’t put tourniquets on for life-threatening bleeding or put them on too proximally when the bleeding is clearly distal, but unless you have casualty’s pants cut off and you can clearly identify the bleeding status of both the entry and the exit wounds (which will be impossible during CUF), you’re not going to know this.  Therefore, you should wouldn’t be wrong if you put a high and tight tourniquet above ANY bleeding you find on the extremities during the CUF phase.  When you get to Tactical Field Care, you can reevaluate the need for the tourniquet and make adjustments as needed.  No harm done!

The next several videos are incredibly boring and monotonous 🙄, but we have to know them nonetheless.  They go over the various techniques for applying different types of tourniquets (the CAT tourniquet and the SOFT tourniquet) in a loop vs self-routed way, on both yourself and your buddy.  Watch all of these videos real quick and then we’ll discuss a few points.  But remember, these videos are useless unless you go out and physically practice what they’re telling you to do! ☝️

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  • Remember, if the tourniquet you plan on using on yourself isn’t already self-looped, you’re going to make things a lot harder on yourself.

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  • Some people may have been taught using the older generation tourniquets, which allowed you to feed the velcro through the friction adapter twice.  If you have these tourniquets, and you have the time and the means, it’s not a terrible idea to feed through it twice instead of once to ensure it doesn’t come undone.  However, it does take longer and more errors have been reported using this method, particularly when the velcro adheres to itself as you’re going through the second slit.  When teaching other non-medical soldiers, I find it best to just keep things simple with feeding the velcro through one slit

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  • Nothing changes from last video.  Just add a buddy! 👬

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  • If you’re using the tourniquet from your buddy’s IFAK (as you’re supposed to), it’s more than likely going to already be looped unless you’ve instructed your guys to do otherwise.

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  • You can tell it’s a little harder to tighten down with the SOFT-T than it is with the CAT because he had to use his chin to hold it still.  Keep that in mind when choosing which tourniquets to pack 🤔

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  • No changes, just add a buddy! 👬

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  • Little easier to clip the SOFT-T than it is to route a CAT through the small slit.

Monotonous right?  Here are a few questions you might be asking:

  • Why CAT vs SOFT-T?
    • I mean, it’s not really a competition…both of them are very effective when applied correctly, but the SOFT-T has few solid advantages over the CAT.  For starters, the windlass is made out of metal instead of plastic so you don’t need to worry about turning it so hard that it breaks.  Second, when applied self-routed, it doesn’t take quite as much fine motor movement with your fingers to get it around the extremity.  For the CAT, you have to guide the strap through a buckle.  For the SOFT-T, you only have to reach around and clip it.  However, whatever you train best with will be the tourniquet for you 🤓
  • Looped vs Routed?
    • Which way should we be doing it?  You really need to know both and have tourniquets set up to do both if needed.  The looped tourniquet is going to be the only real way to self-apply a tourniquet to your arm so there’s the benefit in that.  However, the routed method is the gold standard if we’re trying to minimize the amount of movement for the limb.  Both of them have their pros and cons.  Practice them both ✌️

This marks the end of everything you need to know about Care Under Fire, which is not much.  However, this is what’s probably going to save the MOST preventable losses.  Now we’re going to get into the meat of the bones: Tactical Field Care.  THIS is where the MARCHE-PAWSB algorithm really begins!

TACTICAL FIELD CARE (MARCHE-PAWSB)

MASSIVE HEMORRHAGE 

For Massive Hemorrhage, the TCCC guidelines state:

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.

  • 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)
    • 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 different 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 CoTCCC-recommended 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.

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Don’t get me wrong, I love the video.  However, they do leap frog a little bit in the algorithm so let me just clear some things up 🧐:

  • For Massive Hemorrhage, you will simply control ALL massive bleeding using the following:
    • Tourniquets (For limbs) ……if not already done in CUF!
    • Junctional Tourniquets (For junctional regions: neck, groin, axilla)
    • Hemostatic Gauze (For limbs and junctional regions)
  • Later, in Circulation, you will do tourniquet conversions, pelvic binding, etc.  These things are important, but they’re not worth skipping Airway and Respirations.  Just wanted to clear that up!

Now for the fun part 😬.  Here are the videos for the skills we haven’t covered thus far:

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  • Pro-Tip: Not all wounds are going to be that large!  For the tiny ones that are hard to get your fingers into, using hemostats to pack the wound is a good idea.

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  • Keep in mind that the guidelines specifically state that this is “best suited for deep, narrow tract junctional wounds”.  It’s a cool adjunct, but know when to use it.

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  • Not sure why they don’t want to mention this, but taping it up afterwards with 3-inch tape is critical for making sure those plastic teeth don’t come undone.

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  • Definitely a lot of fine motor skills required to operate it.  Practice is key! 🔑

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You’ll need to control massive hemorrhage quick because the next part of the algorithm that’s almost just as time sensitive is…..

AIRWAY

For Airway, the TCCC guidelines state:

4. Airway Management

a. Conscious casualty with no airway problem identified:

  • No airway intervention required

b. Unconscious casualty without airway obstruction:

  • Place casualty in the recovery position
  • Chin lift or jaw thrust maneuver or
  • Nasopharyngeal airway or 
  • Extraglottic airway

c. Casualty with airway obstruction or impending airway obstruction:

  • Allow a conscious casualty to assume any position that best protects the airway, to include sitting up
  • Use a chin lift or jaw thrust maneuver
  • Use suction if available and appropriate
  • Nasopharyngeal airway or
  • Extraglottic airway (if the casualty is unconscious)
  • Place an unconscious casualty in the recovery position.

d. If the previous measures are unsuccessful, perform a surgical cricothyroidotomy using one of the following:

  • Cric-Key technique (preferred option)
  • Bougie-aided open surgical technique using a flanged and cuffed airway cannula of less than 10 mm outer diameter, 6-7 mm internal diameter, and 5-8 cm of intratracheal length
  • Standard open surgical technique using a flanged and cuffed airway cannula of less than 10mm outer diameter, 6-7 mm internal diameter, and 5-8 cm of intratracheal length (least desirable option)
  • Use lidocaine if the casualty is conscious.

e. Cervical spine stabilization is not necessary for casualties who have sustained only penetrating trauma. f. Monitor the hemoglobin oxygen saturation in casualties to help assess airway patency.

g. Always remember that the casualty’s airway status may change over time and requires frequent reassessment.

Notes:

* The i-gel is the preferred extraglottic airway because its gel-filled cuff makes it simpler to use and avoids the need for cuff inflation and monitoring. If an extraglottic airway with an air-filled cuff is used, the cuff pressure must be monitored to avoid overpressurization, especially during TACEVAC on an aircraft with the accompanying pressure changes.

* Extraglottic airways will not be tolerated by a casualty who is not deeply unconscious. If an unconscious casualty without direct airway trauma needs an airway intervention, but does not tolerate an extraglottic airway, consider the use of a nasopharyngeal airway.

* For casualties with trauma to the face and mouth, or facial burns with suspected inhalation injury, nasopharyngeal airways and extraglottic airways may not suffice and a surgical cricothyroidotomy may be required.

* Surgical cricothyroidotomies should not be performed on unconscious casualties who have no direct airway trauma unless use of a nasopharyngeal airway and/or an extraglottic airway have been unsuccessful in opening the airway.

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Let’s see if I can summarize this:

  • If conscious and no airway problem:
    • Do nothing!
  • If unresponsive, but no immediate problem:
    • Place in the recovery position
    • Use chin lift, jaw thrust
    • Use NPA
  • If there is an airway obstruction, or impending airway obstruction (regardless of responsiveness)
    • Cric Key, Bougie-Aided, or Standard Surgical Cric

*There is one more trick that’s been placed in the 2018 guidelines, but not yet updated in the video.  It’s the use of extraglottic airways such as the I-gel for deeply unconscious patients.  There is a video below to show more.

*In addition, there is also endotracheal intubation, however this is only for medical personnel with advanced training and right now it’s only recommended in the tactical evacuation care phase in the guidelines for those trained on it.  For fun, I included that video as well.

Enjoy the videos! 🙃

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  • They don’t really mention this, but the Jaw Thrust is only really necessary when you suspect a C-Spine injury and you’re trying to avoid moving C-spine unnecessarily.  If you’re keeping the casualty supine for whatever reason, you may need to repeat these maneuvers.  However, the recovery position itself is pretty good at maintaining a patent airway 👍

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  • In case you’re wondering WHY it works, it’s not because the hollow tube is super patent.  More often than not, you’re going to get garbage like blood and mucous stuck in it ☹️.  Plus, the tube itself occludes about 30% of your nostril.  So what good is it?  It’s because the distal end of it rests behind the tongue, preventing the tongue from relaxing and blocking the airway.

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  • They don’t specifically mention it, but the reason why it won’t work unless they’re deeply unconscious is because they may still be maintaining a gag reflex if they’re not.  Some providers out there will suggest that if you brush the eyelashes, you can tell whether or not someone is maintaining a gag reflex by whether or not their eyes twitch.  However, this is not proven to be quite as accurate as we thought 😕. Unfortunately, the only real way to test it is to just cautiously try to use the device and see if they gag or not.
  • Keep in mind that if they are unresponsive, but you think that you’ll be able to fix their unresponsiveness with fluid resuscitation later, then you may want to hold off on applying one of these things so that they don’t wake up with a massive device in their throat 😳

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  • Can’t go wrong using a bougie!  You might consider the use of a bougie a redundant additional step 🙄, but it’s going to help improve your success rate.  It’s already improved first-time success rates with endotracheal intubations on the civilian side.

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  • The Cric key has the advantages of the bougie, but without having to put together two separate pieces of equipment.  This is likely why it’s the most preferred 🤔

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  • Always good to know that this is still an option in the absence of a cric key or bougie 👌

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  • Endotracheal intubation is a complex skill that requires a lot of training, but you won’t need to worry about it unless you’re an advanced level provider or you’re providing care in the Tactical Evacuation Care phase (more equipment and provider support available).  The video does a decent job explaining the procedure, but just know that unless they are deeply unconscious from their injuries, intubated patients will need continued sedation and analgesic support 🧐

Once the airway has been managed, we have to shift our focus into the next step of TFC…..

RESPIRATIONS 

For Respirations, the TCCC guidelines state:

5. Respiration/Breathing

a. Assess for tension pneumothorax and treat as necessary.

  • Suspect a tension pneumothorax and treat when a casualty has significant torso trauma or primary blast injury and one or more of the following:
    • Severe or progressive respiratory distress
    • Severe or progressive tachypnea
    • Absent or markedly decreased breath sounds on one side of the chest
    • Hemoglobin oxygen saturation < 90% on pulse oximetry
    • Shock
    • Traumatic cardiac arrest without obviously fatal wounds

Note:

* If not treated promptly, tension pneumothorax may progress from respiratory distress to shock and traumatic cardiac arrest.

  • Initial treatment of suspected tension pneumothorax:
    • If the casualty has a chest seal in place, burp or remove the chest seal.
    • Establish pulse oximetry monitoring.
    • Place the casualty in the supine or recovery position unless he or she is conscious and needs to sit up to help keep the airway clear as a result of maxillofacial trauma.
    • Decompress the chest on the side of the injury with a 14-gauge or a 10- gauge, 3.25-inch needle/catheter unit.
    • If a casualty has significant torso trauma or primary blast injury and is in traumatic cardiac arrest (no pulse, no respirations, no response to painful stimuli, no other signs of life), decompress both sides of the chest before discontinuing treatment.

Notes:

* Either the 5th intercostal space (ICS) in the anterior axillary line (AAL) or the 2nd ICS in the mid-clavicular line (MCL) may be used for needle decompression (NDC.) If the anterior (MCL) site is used, do not insert the needle medial to the nipple line.

* The needle/catheter unit should be inserted at an angle perpendicular to the chest wall and just over the top of the lower rib at the insertion site. Insert the needle/catheter unit all the way to the hub and hold it in place for 5-10 seconds to allow decompression to occur.

* After the NDC has been performed, remove the needle and leave the catheter in place.

  • The NDC should be considered successful if:
    • Respiratory distress improves, or
    • There is an obvious hissing sound as air escapes from the chest when NDC is performed (this may be difficult to appreciate in high-noise environments), or
    • Hemoglobin oxygen saturation increases to 90% or greater (note that this may take several minutes and may not happen at altitude), or
    • A casualty with no vital signs has return of consciousness and/or radial pulse.
  • If the initial NDC fails to improve the casualty’s signs/symptoms from the suspected tension pneumothorax:
    • Perform a second NDC on the same side of the chest at whichever of the two recommended sites was not previously used. Use a new needle/catheter unit for the second attempt.
    • Consider, based on the mechanism of injury and physical findings, whether decompression of the opposite side of the chest may be needed.
  • If the initial NDC was successful, but symptoms later recur:
    • Perform another NDC at the same site that was used previously. Use a new needle/catheter unit for the repeat NDC.
    • Continue to re-assess!
  • If the second NDC is also not successful:
    • Continue on to the Circulation section of the TCCC Guidelines.

b. All open and/or sucking chest wounds should be treated by immediately applying a vented chest seal to cover the defect. If a vented chest seal is not available, use a non-vented chest seal. Monitor the casualty for the potential development of a subsequent tension pneumothorax. If the casualty develops increasing hypoxia, respiratory distress, or hypotension and a tension pneumothorax is suspected, treat by burping or removing the dressing or by needle decompression.

c. Initiate pulse oximetry. All individuals with moderate/severe TBI should be monitored with pulse oximetry. Readings may be misleading in the settings of shock or marked hypothermia.

d. Casualties with moderate/severe TBI should be given supplemental oxygen when available to maintain an oxygen saturation > 90%.

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A lot of really great points in here!  Let me just emphasize a few more….. 😬

How do we diagnose a tension pneumothorax?  All the casualty needs is…

    • Mechanism of torso trauma (From GSW, motor vehicle accident, blast, etc.)
      • AND
    • One or more of the following:
      • Severe or progressive respiratory distress
      • Severe or progressive tachypnea
      • Absent or markedly decreased breath sounds on one side of the chest
      • Hemoglobin oxygen saturation < 90% on pulse oximetry
      • Shock
      • Traumatic cardiac arrest without obviously fatal wounds
  • It doesn’t take much to diagnose!  The threshold for performing needle decompressions used to be higher (shock was mandatory).  But now the military is seeing that the potential benefits of a needle decompression far outweigh the risks of one being performed and not needed!
  • Are Occlusive Dressings a good thing? 🤨
    • They’re a GREAT thing! But keep in mind, an occlusive dressing may exacerbate a tension pneumothorax by not allowing any air to escape.  You’ll need to be ready to burp and perform needle decompressions!

These are the videos for the skills we need to know:

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  • Nice pearl about wiping the clot away.  I wouldn’t have even thought about that! 🤔

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Great video, although I did want to clarify one thing real quick…..

  • They state that the 2 signs for a needle chest decompression are mechanism of injury (MOI) and progressive respiratory distress.  This is not quite right….
    • The indication for a needle chest decompression is signs/symptoms of a tension pneumothorax, which is everything you saw above ^^ (MOI + shock/absent breath sounds/Sp02 < 90%/ traumatic arrest/etc.).  Not just progressive respiratory distress.  This is according to the 2018 TCCC guidelines.  They may have just been trying to simplify it for everybody, but I don’t want someone with a mechanism for a tension pneumothorax and an Sp02 of 78% to not get a needle decompression just because his breathing doesn’t appear to be “progressively” getting worse 😳

Here comes the fun part!  The part of the algorithm that keeps blood going round and round is……..

CIRCULATION

For Circulation, the TCCC guidelines state:

6. Circulation

a. Bleeding

  • A pelvic binder should be applied for cases of suspected pelvic fracture:
    • Severe blunt force or blast injury with one or more of the following indications:
      • Pelvic pain
      • Any major lower limb amputation or near amputation
      • Physical exam findings suggestive of a pelvic fracture
      • Unconsciousness
      • Shock
  • Reassess prior tourniquet application. Expose the wound and determine if a tourniquet is needed. If it is needed, replace any limb tourniquet placed over the uniform with one applied directly to the skin 2-3 inches above the bleeding site. Ensure that bleeding is stopped. If there is no traumatic amputation, a distal pulse should be checked. If bleeding persists or a distal pulse is still present, consider additional tightening of the tourniquet or the use of a second tourniquet side-by-side with the first to eliminate both bleeding and the distal pulse. If the reassessment determines that the prior tourniquet was not needed, then remove the tourniquet and note time of removal on the TCCC Casualty Card.
  • Limb tourniquets and junctional tourniquets should be converted to hemostatic or pressure dressings as soon as possible if three criteria are met: the casualty is not in shock; it is possible to monitor the wound closely for bleeding; and the tourniquet is not being used to control bleeding from an amputated extremity. Every effort should be made to convert tourniquets in less than 2 hours if bleeding can be controlled with other means. Do not remove a tourniquet that 6 has been in place more than 6 hours unless close monitoring and lab capability are available.
  • Expose and clearly mark all tourniquets with the time of tourniquet application. Note tourniquets applied and time of application; time of re-application; time of conversion; and time of removal on the TCCC Casualty Card. Use a permanent marker to mark on the tourniquet and the casualty card.

b. IV Access

  • Intravenous (IV) or intraosseous (IO) access is indicated if the casualty is in hemorrhagic shock or at significant risk of shock (and may therefore need fluid resuscitation), or if the casualty needs medications, but cannot take them by mouth.
    • An 18-gauge IV or saline lock is preferred.
    • If vascular access is needed but not quickly obtainable via the IV route, use the IO route.

c. Tranexamic Acid (TXA)

  • If a casualty is anticipated to need significant blood transfusion (for example: presents with hemorrhagic shock, one or more major amputations, penetrating torso trauma, or evidence of severe bleeding):
    • Administer 1 gm of tranexamic acid in 100 ml Normal Saline or Lactated Ringer’s as soon as possible but NOT later than 3 hours after injury. When given, TXA should be administered over 10 minutes by IV infusion.
    • Begin the second infusion of 1 gm TXA after initial fluid resuscitation has been completed.

d. Fluid resuscitation

  • Assess for hemorrhagic shock (altered mental status in the absence of brain injury and/or weak or absent radial pulse).
  • The resuscitation fluids of choice for casualties in hemorrhagic shock, listed from most to least preferred, are: whole blood*; plasma, red blood cells (RBCs) and platelets in a 1:1:1 ratio*; plasma and RBCs in a 1:1 ratio; plasma or RBCs alone; Hextend; and crystalloid (Lactated Ringer’s or Plasma-Lyte A). (NOTE: Hypothermia prevention measures [Section 7] should be initiated while fluid resuscitation is being accomplished.)
    • If not in shock:
      • No IV fluids are immediately necessary.
      • Fluids by mouth are permissible if the casualty is conscious and can swallow.
    • If in shock and blood products are available under an approved command or theater blood product administration protocol:
      • Resuscitate with whole blood*, or, if not available
      • Plasma, RBCs and platelets in a 1:1:1 ratio*, or, if not available
      • Plasma and RBCs in a 1:1 ratio, or, if not available
      • Reconstituted dried plasma, liquid plasma or thawed plasma alone or RBCs alone
      • Reassess the casualty after each unit. Continue resuscitation until a palpable radial pulse, improved mental status or systolic BP of 80-90 is present.
    • If in shock and blood products are not available under an approved command or theater blood product administration protocol due to tactical or logistical constraints:
      • Resuscitate with Hextend, or if not available
      • Lactated Ringer’s or Plasma-Lyte A
      • Reassess the casualty after each 500 ml IV bolus.
      • Continue resuscitation until a palpable radial pulse, improved mental status, or systolic BP of 80-90 mmHg is present.
      • Discontinue fluid administration when one or more of the above end points has been achieved.
  • If a casualty with an altered mental status due to suspected TBI has a weak or absent radial pulse, resuscitate as necessary to restore and maintain a normal radial pulse. If BP monitoring is available, maintain a target systolic BP of at least 90 mmHg.
  • Reassess the casualty frequently to check for recurrence of shock. If shock recurs, re-check all external hemorrhage control measures to ensure that they are still effective and repeat the fluid resuscitation as outlined above.

Note:

* Currently, neither whole blood nor apheresis platelets collected in theater are FDA-compliant because of the way they are collected. Consequently, whole blood and 1:1:1 resuscitation using apheresis platelets should be used only if all of the FDAcompliant blood products needed to support 1:1:1 resuscitation are not available, or if 1:1:1 resuscitation is not producing the desired clinical effect.

e. Refractory Shock

  • If a casualty in shock is not responding to fluid resuscitation, consider untreated tension pneumothorax as a possible cause of refractory shock. Thoracic trauma, persistent respiratory distress, absent breath sounds, and hemoglobin oxygen saturation < 90% support this diagnosis. Treat as indicated with repeated NDC or finger thoracostomy/chest tube insertion at the 5th ICS in the AAL, according to the skills, experience, and authorizations of the treating medical provider. Note that if finger thoracostomy is used, it may not remain patent and finger decompression through the incision may have to be repeated. Consider decompressing the opposite side of the chest if indicated based on the mechanism of injury and physical findings.

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Whoa, that was a lot of good stuff.  Before we tease apart some of those things, let me give you a summary of what the guidelines say that you should be doing during the Circulation portion, in order:

  • Step 1: Apply Pelvic Binder, Reassess Tourniquets, Convert to pressure dressings as needed (Remember from earlier?) 🤔
    • Replace hasty (high and tight) tourniquets over the uniform with deliberate tourniquets 2-3 inches above the wound
    • Apply Pelvic Binder for suspected pelvic fractures to control bleeding
  • Step 2: Establish IV/IO access (ONLY if meds or fluids will be needed) 💉
    • Single 18 Gauge IV/Saline lock or FAST1/EZ IO.
  • Step 3: TXA (If you think a blood transfusion will be needed)
    • 1 gram in 100ml of Normal Saline/Lactated Ringers over 10 minutes
    • Second infusion (same dose) can be given after the 1st dose.
  • Step 4: Fluid Resuscitation (Only if altered w/o presence of brain injury and/or weak/absent radial pulse)
    • DO NOT OVER-RESUSCITATE (stop as soon as radial pulse is achieved, patient becomes less altered, or systolic BP of 80-90 mmhg is present).
    • Use one of the following:
      • Whole Blood << Most Preferred
      • Plasma, RBC’s, and Platelets in 1:1:1 Ratio
      • Plasma and RBC’s in 1:1 Ratio
      • Plasma or RBC’s alone
      • Hextend
      • Crystalloid (Normal Saline/Lactated Ringers)  << Least Preferred

Whole Blood deserves a very special mention.  The military is in the midst of trying to get rid of ALL clear fluids in TCCC and using only blood products, particularly fresh whole blood.  This is a VERY good change.  However, if you’re unit or medical section isn’t ready to transition over to this protocol, you need to start making things happen.  Push for both training and equipment that support this endeavor.  

For the best information on blood transfusions, visit:

In addition, these two videos will show the procedure of confirming blood type and an example of the procedure for actual Fresh Whole Blood Transfusion:

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Ok, now that we’ve got that straightened out, I just want to mention a little something about TXA because it’s fairly new…..

  • How does it work?
    • To put simply, your body has a process called fibrinolysis that is constantly running to break down clots in the body that might harm us in the form of heart attacks, strokes, etc.
    • The problem is, fibrinolysis is harmful to us when we’re experiencing severe bleeding.  In some cases, fibrinolysis kicks into a sort of “overdrive” (hyperfibrinolysis) because it senses that our body is in trouble and it wants to “help”.  But this keeps us from being able to maintain clots and control internal bleeding.  So it’s bad! 😳
    • TXA works by essentially keeping fibrinolysis in check and protecting the clots from being dissolved by our own body’s mechanisms.  This is incredibly important because these clots are our only shot at being able to save soldiers who are suffering from bleeding that can’t be controlled on our own terms.  There’s much more to the physiology behind it, but I won’t bore you.
  • What’s the deal with this 3 hour thing? 🤨
    • Nobody really knows why it happens, but it’s pretty clear that mortality increases if you give it 3 hours after the injury.  If you want to know more, look up the “CRASH-2” Trial where they studied it.

Ok, I’m done writing for this video….I promise!  Below are the videos for the basic skills we need to know to complete this step in the algorithm:

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  • Be sure to check the exposed area very thoroughly!  Also, there’s no video for it, but you can also convert that hasty tourniquet into a pressure dressing if you do not feel a tourniquet was necessary for the wound in the first place 👌

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  • The Fast1 is really nice because it utilizes the sternum, which is tough and centralized on the body.  That means that it’ll be resilient to most battlefield injuries and readily available for IO use 👍

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  • On the civilian side, this comes in the form of a battery-powered drill.   Having a manual form though is very handy.  The other site that can be used is the proximal tibia, but it doesn’t look like that’s been endorsed just yet.

That marks the end of the hard stuff!  Should be smooth sailing from here ⛵️.  The next one is pretty straightforward….

HYPOTHERMIA ☃️

For Hypothermia, the guidelines state:

7. Hypothermia Prevention

a. Minimize casualty’s exposure to the elements. Keep protective gear on or with the casualty if feasible.

b. Replace wet clothing with dry if possible. Get the casualty onto an insulated surface as soon as possible.

c. Apply the Ready-Heat Blanket from the Hypothermia Prevention and Management Kit (HPMK) to the casualty’s torso (not directly on the skin) and cover the casualty with the Heat-Reflective Shell (HRS).

d. If an HRS is not available, the previously recommended combination of the Blizzard Survival Blanket and the Ready Heat blanket may also be used.

e. If the items mentioned above are not available, use dry blankets, poncho liners, sleeping bags, or anything that will retain heat and keep the casualty dry.

f. Warm fluids are preferred if IV fluids are required.

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They do a good job covering all the bases with Hypothermia.  Here’s just a little bit more additional info:

  • How do I warm my IV fluids? 🔥
    • Commercial products are the way to go on this one, if you’re able to fit one in your bag.  The QuinFlow device has received a great review on it in the latest Advanced Resuscitative Care Guidelines.  There have been a few studies that showed MRE heat packs as an acceptable way to warm IV fluids.  However, if it’s not monitored closely, you run the risk of overheating the fluids.  Some soldiers have advocated the use of placing the bag of fluid underneath the clothing of another soldier, although I don’t believe the effectiveness of this has been studied yet.

That was short and sweet.  The next easy peasy one is….

EYE INJURIES 👁

For Eye injuries, the TCCC guidelines state:

8. Penetrating Eye Trauma

a. If a penetrating eye injury is noted or suspected:

  • Perform a rapid field test of visual acuity and document findings.
  • Cover the eye with a rigid eye shield (NOT a pressure patch.)
  • Ensure that the 400 mg moxifloxacin tablet in the Combat Wound Medication Pack (CWMP) is taken if possible and that IV/IM antibiotics are given as outlined below if oral moxifloxacin cannot be taken.

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The video says it all.  Just for the sake of emphasis, these are the key steps to remember:

  • Step 1: Perform rapid field test of visual acuity 👀
    • Read print, count fingers, hand motion, light perception.  NO CHARTS!
  • Step 2: Cover with Rigid Eye Shield
    • MUST BE STURDY!  NO PRESSURE PATCH!
  • Step 3: Take Moxifloxacin (400mg PO) 💊
    • If they can’t do PO, give Ertapenem (1 gram IV/IM)

If you want to refresh yourself on how to apply the rigid eye shield, here’s a quick little video:

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This next topic is a BIG one.  We’re now at the point where we can start managing our patient’s…..

PAIN 😫

For Pain Management, the TCCC guidelines state:

10. Analgesia

a. Analgesia on the battlefield should generally be achieved using one of three options:

  • Option 1
    • Mild to Moderate Pain
    • Casualty is still able to fight
      • TCCC Combat Wound Medication Pack (CWMP)
        • Tylenol – 650 mg bilayer caplet, 2 PO every 8 hours
        • Meloxicam – 15 mg PO once a day
  • Option 2
    • Moderate to Severe Pain
    • Casualty IS NOT in shock or respiratory distress AND
    • Casualty IS NOT at significant risk of developing either condition
      • Oral transmucosal fentanyl citrate (OTFC) 800 µg
        • Place lozenge between the cheek and the gum
        • Do not chew the lozenge
  • Option 3
    • Moderate to Severe Pain
    • Casualty IS in hemorrhagic shock or respiratory distress OR
    • Casualty IS at significant risk of developing either condition
      • Ketamine 50 mg IM or IN Or
      • Ketamine 20 mg slow IV or IO
        • Repeat doses q30min prn for IM or IN
        • Repeat doses q20min prn for IV or IO
        • End points: Control of pain or development of nystagmus (rhythmic back-and-forth movement of the eyes)

Analgesia notes:

a. Casualties may need to be disarmed after being given OTFC or ketamine.

b. Document a mental status exam using the AVPU method prior to administering opioids or ketamine.

c. For all casualties given opioids or ketamine – monitor airway, breathing, and circulation closely

d. Directions for administering OTFC:

  • Recommend taping lozenge-on-a-stick to casualty’s finger as an added safety measure OR utilizing a safety pin and rubber band to attach the lozenge (under tension) to the patient’s uniform or plate carrier.
  • Reassess in 15 minutes
  • Add second lozenge, in other cheek, as necessary to control severe pain
  • Monitor for respiratory depression

e. IV Morphine is an alternative to OTFC if IV access has been obtained

  • 5 mg IV/IO
  • Reassess in 10 minutes.
  • Repeat dose every 10 minutes as necessary to control severe pain.
  • Monitor for respiratory depression.

f. Naloxone (0.4 mg IV or IM) should be available when using opioid analgesics.

g. Both ketamine and OTFC have the potential to worsen severe TBI. The combat medic, corpsman, or PJ must consider this fact in his or her analgesic decision, but if the casualty is able to complain of pain, then the TBI is likely not severe enough to preclude the use of ketamine or OTFC.

h. Eye injury does not preclude the use of ketamine. The risk of additional damage to the eye from using ketamine is low and maximizing the casualty’s chance for survival takes precedence if the casualty is in shock or respiratory distress or at significant risk for either.

i. Ketamine may be a useful adjunct to reduce the amount of opioids required to provide effective pain relief. It is safe to give ketamine to a casualty who has previously received morphine or OTFC. IV Ketamine should be given over 1 minute.

j. If respirations are noted to be reduced after using opioids or ketamine, provide ventilatory support with a bag-valve-mask or mouth-to-mask ventilations.

k. Ondansetron, 4 mg Orally Dissolving Tablet (ODT)/IV/IO/IM, every 8 hours as needed for nausea or vomiting. Each 8-hour dose can be repeated once at 15 minutes if nausea and vomiting are not improved. Do not give more than 8 mg in any 8-hour interval. Oral ondansetron is NOT an acceptable alternative to the ODT formulation.

l. Reassess – reassess – reassess!

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Dope.  This is probably the coolest part of TCCC, but it’s also one of the most dangerous 😳.  Let’s take a moment and briefly discuss a few things about each of the TCCC drugs:

  • Morphine
    • Works by binding to opiate receptors in the brain, spinal cord, etc. and blocking pain signals from reaching the brain.  Been used effectively for years, but it’s no longer the most preferred option.  It’s a strong opiate, but it comes with some nasty side effects like respiratory depression and even some hypotension.  Studies have been pretty clear: Although morphine is a splendid drug, using it for severely injured patients will increase their mortality.  Beware!
  • Fentanyl
    • It’s an opiate just like morphine, but about 100X more potent.  Of course, it’s dosed in micrograms, so it’s balanced out.  On the civilian side, it can also be given IV/IO/IM like morphine, but the transmucosal route makes it a little more friendly.  It can still cause respiratory depression, but it doesn’t cause a histamine release, so you don’t need to worry about fentanyl dropping someones blood pressure too much.
  • Naloxone
    • It’s an opiate antagonist, which means that it essentially “boots out” opiates from their receptor sites.  This causes an almost complete reversal of the effects of opiates like morphine, fentanyl, etc.  You’re going to be using this when you feel like the opiates you gave may be causing harm to the patient.  This drug works very fast, so be ready when they wake up!
  • Ketamine
    • It’s a PCP-derivative that acts as a dissociative anesthetic.  It’s rated as both an analgesic and a sedative, which makes it particularly versatile.  It has a really good safety profile because it’s particularly hard to overdose somebody on it.  Plus, instead of dropping blood pressure and causing respiratory depression, it actually increases blood pressure a little bit and dilates the bronchioles.   It’s pretty awesome.
  • Ondansetron
    • It’s an antiemetic drug that works by blocking serotonin sites in the central nervous system and GI Tract, which are responsible for the feeling of nausea.  Pretty safe drug with few side effects, but it typically works better before the vomiting actually begins.  Keep this handy, especially if you give any opiate drugs like morphine or fentanyl.  You have opiate receptors in your gut as well, which is why those drugs can make you nauseous and why ondansetron is a must have in your aid bag.
  • Promethazine
    • This is also an antiemetic drug, but it works differently.  It blocks Histamine 1 receptors (making it an antihistamine), which helps with nausea/vomiting.  It works very well, especially in soldiers with active vomiting.  However, it has sedative properties that make it less than ideal for soldiers in the tactical environment.  This is why promethazine is no longer recommended in TCCC.
  • Acetaminophen (Tylenol)
    • Pain is largely transmitted through chemical messengers called prostaglandins.  Acetaminophen works by inhibiting these chemical messengers, thus reducing pain.  Tylenol is often overlooked, but recent studies have showed that when 1 gram of acetaminophen is paired with 400mg of Ibuprofen, it provides approximately the same pain relief as 2mg of Morphine IV.  In TCCC, we’re giving a little bit more than a gram of tylenol and replacing ibuprofen with Mobic, which works a little better.  Moral of the story, this combo works pretty well.
  • Meloxicam (Mobic)
    • This also works on inhibiting the prostaglandins to reduce pain, but it’s an NSAID like ibuprofen, so it has anti-inflammatory properties.  The perks of Mobic over ibruprofen though is the fact that instead of constantly administering ibuprofen 4-6 times a day, you can achieve the same analgesic effect with one daily 15mg dose of Mobic.  And of course, as the video states, it doesn’t affect the clotting mechanisms of the body which is very ideal.

Next up on our algorithm is…..

ANTIBIOTICS 💊

For Antibiotics, the TCCC guidelines state:

11. Antibiotics: recommended for all open combat wounds

a. If able to take PO meds:

  • Moxifloxacin (from the CWMP), 400 mg PO once a day

b. If unable to take PO meds (shock, unconsciousness):

  • Ertapenem, 1 gm IV/IM once a day

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This video is fine, just understand that even though they talk about Tylenol and Mobic in the antibiotic video, they are NOT antibiotics.  The antibiotics in the video are Moxifloxacin and Ertapenem, and here are some things you should know about them:

  • Moxifloxacin 💊
    • It’s a broad spectrum antibiotic (specifically a fluoroquinolone) that works on both gram-positive and gram-negative bacteria by inhibiting their DNA replication.  It’s great for battlefield wounds and it’s much easier to administer than Ertapenem.  Another added bonus is that it works well with ocular injuries, as we saw earlier in the eye injuries video.
  • Ertapenem (Invanz) 💉
    • Also a broad spectrum antibiotic, but it’s a carbapenem so it works by interfering with the bacterial cell wall integrity and synthesis.  It comes in a powder, so it has to be reconstituted with saline/lidocaine before it’s drawn back up and administered IV/IM.  This takes time though, so if you can administer the moxifloxacin PO, then that’s the preferred antibiotic.

Remember: ANTIBIOTICS ARE RECOMMENDED FOR ALL OPEN COMBAT WOUNDS!  Don’t blow it off for the next echelon of care to give antibiotics.

The next one is easy….

WOUNDS 

There’s no video for this one because there’s really not a whole lot to say about it 🤷‍♂️. The reason why this section is part of the algorithm is because of two simple instructions in the TCCC guidelines that come precisely after antibiotic administration…..

12. Inspect and dress known wounds.

13. Check for additional wounds

It’s so easy, a caveman could do it.  But the reason why they have to specifically emphasize this one more time, despite you having more than likely done a full body exam between Massive Hemorrhage and Circulation, is because WOUNDS STILL GET MISSED!  And I’m not just talking about abrasions and minor lacerations, I’m talking about deadly GSW’s and shrapnel that are small enough to evade your eyes.  A missed injury like that is good way to get your soldier killed, so this is your opportunity to double check yourself and do another thorough assessment to look for both the big stuff and the small stuff.

Next one is even EASIER!

SPLINTING

Again, no video for this one either because there’s not much to say!  Verbatim, this is what the TCCC guidelines have to say about splinting:

15. Splint fractures and re-check pulses

However, I’m going to say a little bit more about splinting…… 🧐

  • Why bother splinting?
    • In the Circulation section, we splinted the pelvis because it can bleed a ton and we wanted to control the bleeding a little bit by immobilizing it.  But the pelvis isn’t the only bone thing that can bleed.   Here’s the amount of blood you can lose from other bone fractures, according to PHTLS guidelines:
      • Rib: 125mL
      • Radius or Ulna: 250-500mL
      • Humerus: 500-750mL
      • Tibia or Fibula: 500-1000mL
      • Femur: 1000-2000mL
      • Pelvis: 1000-massive 😮
    • If you’re thinking “Holy crap, that’s a lot of blood”.  You’d be correct.  Keep in mind that it only takes roughly 2000mL of blood loss to die from hypovolemic shock.  That could just be from one bad femur fracture.
  • How are we going to splint these fractures? 
    • Rib fractures can be stabilized using a bulky dressing, which will definitely be necessary if the soldier has a flail segment
    • Radius/Ulna/Tibia/Fibula fractures can all be splinted with board splints or SAM splints.  Keep in mind though that if it’s an open fracture, we’re going to cover the exposed bone ends with moist dressings.
    • Femur fractures are the tough ones.  In a perfect world, we’d treat them with traction splints if it was a closed fracture and only fractured at one sight.  However, we don’t always carry those big traction splints with us.  Thus, you may have to consider using tourniquets on these soldiers if you suspect that internal bleeding hasn’t been controlled.  However, I haven’t found any particularly good guidance for these situations
    • Pelvic fractures require a pelvic binder!

Last, but certainly not least……

BURNS 🔥

For Burns, the TCCC guidelines state:

14. Burns

a. Facial burns, especially those that occur in closed spaces, may be associated with inhalation injury. Aggressively monitor airway status and oxygen saturation in such patients and consider early surgical airway for respiratory distress or oxygen desaturation.

b. Estimate total body surface area (TBSA) burned to the nearest 10% using the Rule of Nines.

c. Cover the burn area with dry, sterile dressings. For extensive burns (>20%), consider placing the casualty in the Heat-Reflective Shell or Blizzard Survival Blanket from the Hypothermia Prevention Kit in order to both cover the burned areas and prevent hypothermia.

d. Fluid resuscitation (USAISR Rule of Ten)

  • If burns are greater than 20% of TBSA, fluid resuscitation should be initiated as soon as IV/IO access is established. Resuscitation should be initiated with Lactated Ringer’s, normal saline, or Hextend. If Hextend is used, no more than 1000 ml should be given, followed by Lactated Ringer’s or normal saline as needed.
  • Initial IV/IO fluid rate is calculated as %TBSA x 10 ml/hr for adults weighing 40- 80 kg.
  • For every 10 kg ABOVE 80 kg, increase initial rate by 100 ml/hr.
  • If hemorrhagic shock is also present, resuscitation for hemorrhagic shock takes precedence over resuscitation for burn shock. Administer IV/IO fluids per the TCCC Guidelines in Section (6).

e. Analgesia in accordance with the TCCC Guidelines in Section (10) may be administered to treat burn pain.

f. Prehospital antibiotic therapy is not indicated solely for burns, but antibiotics should be given per the TCCC guidelines in Section (11) if indicated to prevent infection in penetrating wounds.

g. All TCCC interventions can be performed on or through burned skin in a burn casualty.

h. Burn patients are particularly susceptible to hypothermia. Extra emphasis should be placed on barrier heat loss prevention methods.

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Here are the answers to some of the burning questions you might have…. 😬

  • Why are Burn injuries the last part of TCCC?
    • Technically speaking, it’s not.  It’s second last (Splinting is supposed to be last, but having splinting at the end of the pneumonic just doesn’t have the same ring to it).  But anyways, it’s still one of the last things because everything terrible about burns has pretty much been handled at this point throughout the MARCHE-PAWSB algorithm: The closing airway, the hypothermia, the pain, the infection, the dressing of the wounds, etc.  The only thing that needs to be accounted for is the hypovolemia from burn shock, but if they are hypovolemic from hemorrhagic shock, then treatment for that takes precedence.
  • Why Rule of Ten for fluid resuscitation?  Why not just give lots of fluids?
    • Because when casualties suffer from burn injuries, they lose fluid at a particular rate…not all at once ☝️.  It’s a slow process, but it’s constant over the course of several hours.  The rate by which they lose fluid is based on the size of the burn and the size of the person, which is where the formula comes from.  If you give too much fluid or you give it too quickly, then they will become fluid overloaded and they may suffer from things like pulmonary edema, etc.

Holy cow, did we just finish the algorithm?????????????

Sort of……

There are few sections in the guidelines that aren’t specifically covered in MARCHE-PAWSB: Communication, CPR, Documentation, and Preparation for Evacuation.  These are critical, but I won’t be doing you any justice by trying to simplify it further.  So here is what the TCCC guidelines specifically say about them:

16. Communication

  • a. Communicate with the casualty if possible. Encourage, reassure and explain care.
  • b. Communicate with tactical leadership as soon as possible and throughout casualty treatment as needed. Provide leadership with casualty status and evacuation requirements to assist with coordination of evacuation assets.
  • c. Communicate with the evacuation system (the Patient Evacuation Coordination Cell) to arrange for TACEVAC. Communicate with medical providers on the evacuation asset if possible and relay mechanism of injury, injuries sustained, signs/symptoms, and treatments rendered. Provide additional information as appropriate

17. Cardiopulmonary resuscitation (CPR)

  • a. Resuscitation on the battlefield for victims of blast or penetrating trauma who have no pulse, no ventilations, and no other signs of life will not be successful and should not be attempted. However, casualties with torso trauma or polytrauma who have no pulse or respirations during TFC should have bilateral needle decompression performed to ensure they do not have a tension pneumothorax prior to discontinuation of care. The procedure is the same as described in section (5a) above.

18. Documentation of Care

  • a. Document clinical assessments, treatments rendered, and changes in the casualty’s status on a TCCC Card (DD Form 1380). Forward this information with the casualty to the next level of care.

Documentation deserves a special mention.  As it stands right now, our TCCC card rate with the casualty is only 3%.  This could be for any number of reasons, but documentation cannot be negotiable.  If the next echelon of care isn’t tracking injuries, interventions, analgesia, antibiotics, etc. , then we’re setting our patients up for failure.  We can’t rely on verbal reports alone.

19. Prepare for Evacuation.

  • a. Complete and secure the TCCC Card (DD 1380) to the casualty.
  • b. Secure all loose ends of bandages and wraps.
  • c. Secure hypothermia prevention wraps/blankets/straps.
  • d. Secure litter straps as required. Consider additional padding for long evacuations.
  • e. Provide instructions to ambulatory patients as needed.
  • f. Stage casualties for evacuation in accordance with unit standard operating procedures.
  • g. Maintain security at the evacuation point in accordance with unit standard operating procedures.

OK! NOW WE’RE DONE WITH TACTICAL FIELD CARE!

TACTICAL EVACUATION CARE

(MARCHE-PAWSB)…ish 😅

Good news 😃: There is almost NO difference between Tactical Field Care and Tactical Evacuation Care.

Bad news ☹️: There are still SOME subtle differences

To save you from having to fish out those differences in the guidelines, I went ahead and did it for you.  Here they are:

  • A “Transition of Care” section is added in Tactical Evacuation Care.  Here’s what it says 📖
    • a. Tactical force personnel should establish evacuation point security and stage casualties for evacuation.
    • b. Tactical force personnel or the medic should communicate patient information and status to TACEVAC personnel as clearly as possible. The minimum information communicated should include stable or unstable, injuries identified, and treatments rendered.
    • c. TACEVAC personnel should stage casualties on evacuation platforms as required.
    • d. Secure casualties in the evacuation platform in accordance with unit policies, platform configurations and safety requirements.
    • e. TACEVAC medical personnel should re-assess casualties and re-evaluate all injuries and previous interventions.
  • Endotracheal Intubation is added as an option for airway management under Tactical Evacuation Care.  Not specifically recommended in Tactical Field Care.
  • Guidelines for the pulse oximetry and administration of oxygen are provided for Tactical Evacuation Care.  Here is what it says:
    • b. Initiate pulse oximetry if not previously done. All individuals with moderate/severe TBI should be monitored with pulse oximetry. Readings may be misleading in the settings of shock or marked hypothermia.
    • c. Most combat casualties do not require supplemental oxygen, but administration of oxygen may be of benefit for the following types of casualties:
      • Low oxygen saturation by pulse oximetry
      • Injuries associated with impaired oxygenation
      • Unconscious casualty
      • Casualty with TBI (maintain oxygen saturation > 90%)
      • Casualty in shock
      • Casualty at altitude
      • Known or suspected smoke inhalation
  • Guidelines for TBI management are added to Tactical Evacuation Care, specifically after Circulation.  This is what they say (Brace yourself.  I’ll cover this in another crash course 😳):
    • 6. Traumatic Brain Injury
      • a. Casualties with moderate/severe TBI should be monitored for:
        • Decreases in level of consciousness
        • Pupillary dilation
        •  SBP should be >90 mmHg
        • O2 sat > 90
        • Hypothermia
        • End-tidal CO2 (If capnography is available, maintain between 35-40 mmHg)
        • Penetrating head trauma (if present, administer antibiotics)
        • Assume a spinal (neck) injury until cleared.
      • b. Unilateral pupillary dilation accompanied by a decreased level of consciousness may signify impending cerebral herniation; if these signs occur, take the following actions to decrease intracranial pressure:
        • Administer 250 ml of 3 or 5% hypertonic saline bolus.
        • Elevate the casualty’s head 30 degrees.
        • Hyperventilate the casualty.
          • Respiratory rate 20
          • Capnography should be used to maintain the end-tidal CO2 between 30-35 mmHg
          • The highest oxygen concentration (FIO2) possible should be used for hyperventilation.
        • *Note: Do not hyperventilate the casualty unless signs of impending herniation are present. Casualties may be hyperventilated with oxygen using the bag-valve-mask technique.
  • For Hypothermia ☃️, the guidelines for Tactical Evacuation Care mention the use of a portable fluid warmer.  In addition, they recommend keeping the doors closed during evacuation 🚁
  • In Tactical Evacuation Care, they mention initiating electronic monitoring of vitals after Eye Injuries 👀.  Technically, they mention doing so in Tactical Field care as well, but what are the odds that you’re carrying around any advanced electronic monitor on the battlefield?
  • Guidelines for CPR are slightly more flexible in Tactical Evacuation Care.  They state that if you have a casualty with no obviously fatal wounds and you will be arriving at a facility with surgical capability within a short period of time, you MAY perform CPR so long as it’s not done at the expense of providing lifesaving care to other casualties ☝️

Congratulations! 🎉 You’ve officially completed the TCCC crash course for medical providers.  Again, for a basic summary of what you just learned, check out this study guide:

If you like badge cards, feel free to print and laminate the TCCC review badge card:

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Till next time!

-Simpson

Brandon Simpson, PA-C
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