INSTRUCTOR GUIDE FOR INTRODUCTION TO TCCC-MP 180801 1

Tactical Combat Casualty Care is the standard of care in

Tactical Combat Casualty Care for Medical
battlefield prehospital medicine. If you have not been
Personnel
trained in TCCC, then your previous medical training
August 2018
1. may not have contained the material presented in the
following lessons. Medical care in combat is
(Based on TCCC-MP Guidelines 180801)
significantly different than that provided on the streets of
Anywhere, USA.
Introduction to TCCC

Disclaimer

“The opinions or assertions contained herein

are the private views of the authors and are not
to be construed as official or as reflecting the
2. views of the Departments of the Army, Air Read the disclaimer.
Force, Navy or the Department of Defense.”

There are no conflict of interest disclosures.

Learning Objectives

• IDENTIFY the three objectives of TCCC.

• DESCRIBE the key factors influencing
combat casualty care.
3. Read the text.
• IDENTIFY the evidence that documents the
lifesaving impact of TCCC use.
• DESCRIBE the three phases of care in TCCC.
• IDENTIFY the most common causes of
preventable death among combat casualties.
 INSTRUCTOR GUIDE FOR INTRODUCTION TO TCCC-MP 180801 2

4. TCCC Click on the photo to play the video.

What is TCCC and Why Do I Need to Learn

about it??

Military units that have trained all of their

members in TCCC have documented the lowest
TCCC has been remarkably successful at keeping our
incidence of preventable deaths among their
5. wounded warriors alive.
casualties in the history of modern warfare.
Today we are going to teach you how to do it.
TCCC is now used by all services in the U.S.
Military and many allied nations as well to care
for their combat wounded. TCCC-based
prehospital trauma training is now becoming
widespread in the US civilian sector as well.
Trauma Care: Military vs Civilian

• Prehospital trauma care is very different in the

military vs the civilian settings.
• TCCC was developed to address these
differences.
6. • Military units that have trained all unit Read the text.
members in TCCC have achieved the lowest
incidence of preventable combat deaths in
history.
• TCCC has now been made the standard for the
US military and TCCC training is required for
everyone in the Department of Defense.
 INSTRUCTOR GUIDE FOR INTRODUCTION TO TCCC-MP 180801 3

If you are injured and taken to a civilian trauma center,

you will be treated by a skilled team of medical
professionals using the latest technology and working in
7. Trauma Care Setting
a well-lighted, climate-controlled, secure area.
What about trauma that occurs in a tactical combat
setting?

This is a good example of where the combat corpsmen

and medics live and practice.
This picture was taken at about 10,000 feet altitude in
the Hindu Kush mountains in Afghanistan.
Tactical Trauma Care Setting –
8. The wound is a shrapnel wound of the hip.
Shrapnel Wound in the Hindu Kush
In this setting, care is much more difficult.
Common sense tells you that the management plan will
need to be different here.
TCCC helps to define how it’s different.

Battlefield Trauma Care Prior to 9/11 These are the training programs that are used to teach
trauma care in the civilian community.
• Combat medical training historically was They are all EXCELLENT training programs.
modeled on civilian courses. However, they are designed for the civilian trauma
9. – Emergency Medical Technician setting - the principles they reflect often need to be
– Advanced Trauma Life Support modified for the tactical setting.
• We trained to the standard of care in non- Emerging civilian guidelines/programs are only recently
tactical (civilian) settings. beginning to address providing care in conjunction with
• Tactical factors were not considered. an ongoing threat.
 INSTRUCTOR GUIDE FOR INTRODUCTION TO TCCC-MP 180801 4

Battlefield Trauma Care: 2001

• Based on trauma courses NOT developed for

combat
• Medics taught NOT to use tourniquets
• No hemostatic agents
• No junctional tourniquets
• Large volume crystalloid fluid resuscitation for
Read the text.
shock
10. • Civil War-vintage technology for battlefield
Show of hands – how many people in the audience were
analgesia (IM morphine)
trained on these concepts of care?
• SOF medics – IV cutdowns for difficult venous
access
• No tactical context for the care rendered
• 2 large bore IVs on all casualties with
significant trauma
• No focus on prevention of trauma-related
coagulopathy
• Heavy emphasis on endotracheal intubation
Tourniquets: The Primary Driver for TCCC

“The striking feature was to see healthy young

Americans with a single injury of the distal
extremity arrive at the magnificently equipped
field hospital, usually within hours, but dead on 3,421 is a staggering number when all these deaths were
arrival. In fact, there were 193 deaths due to potentially preventable.
wounds of the upper and lower extremities, …… How would a Medical Center react if you had a
11.
of the 2600.” meningitis or a pyelonephritis patient come in and you
CAPT J.S. Maughon didn’t get around to starting antibiotics and the patient
Mil Med 1970 died?

* Extremity hemorrhage math in Vietnam: 193

of 2600 = 7.4% x 46,233 fatalities = 3,421
preventable US deaths from extremity
hemorrhage
 INSTRUCTOR GUIDE FOR INTRODUCTION TO TCCC-MP 180801 5

Different Trauma Requires Different Care

Strategies

• It is intuitive that combat and civilian trauma

are different, BUT…
TCCC principles are now determined by physicians and
• It is difficult to devise and implement needed
combat medical personnel working as a team.
changes.
In the past, the failure of these two groups to
12. • No one group of medical professionals has all
communicate well slowed the implementation of critical
the necessary skills and experience.
trauma care measures.
• Trauma docs and combat medical personnel
We will look at a dramatic example of this.
have different skill sets. Both are needed to
optimize battlefield trauma care strategies.
• Tourniquets are one striking example of how
battlefield trauma care has sometimes been
slow to change.
Prehospital Trauma Care:
Military vs. Civilian

•Hostile fire
•Darkness
What factors must we think about when defining combat
13. •Environmental extremes
trauma care?
•Different wounding epidemiology
•Limited equipment
•Need for tactical maneuver
•Long delays to hospital care
•Different medic training and experience

Tactical Combat Casualty Care in Special

Operations In the mid-90s, the Special Operations medical
community began looking for some better answers for
combat trauma and Tactical Combat Casualty Care was
14. Military Medicine Supplement born. TCCC has always focused on the most common
August 1996 causes of preventable death on the battlefield. The
common causes of preventable death from combat
Trauma care guidelines trauma are shown in the following slides.
customized for the battlefield
 INSTRUCTOR GUIDE FOR INTRODUCTION TO TCCC-MP 180801 6

Here is a classic example of a preventable cause of death

- arterial hemorrhage from a leg wound, in this case, a
pig.
Forget about the “Golden Hour” – bleeding like this
15. Extremity Hemorrhage will kill you in a few minutes.
If no one controls this type of bleeding in a casualty, that
casualty is going to die very quickly.

Click on the photo to play the video.

Junctional Hemorrhage
Junctional hemorrhage (bleeding from wounds where the
16. limbs or neck join the trunk) is another common cause of
These types of wounds are often caused by IEDs
preventable death on the battlefield.
and may result in junctional hemorrhage.

This X-ray shows a tension pneumothorax, which, in

combat, is usually secondary to a penetrating injury to
the chest.
This condition may be quickly fatal if not identified and
17. Tension Pneumothorax
treated.
Tension pneumothorax is the SECOND LEADING
cause of preventable death on the battlefield after
hemorrhage.
 INSTRUCTOR GUIDE FOR INTRODUCTION TO TCCC-MP 180801 7

Deaths from airway trauma are a small percentage of

combat fatalities, but many of these deaths are
preventable.
If the casualty is conscious, he will instinctively protect
his own airway.
While this patient has a significant injury to his
airway, he is able to breathe on his own reasonably
18. Airway Trauma
well if he is sitting up and leaning forward.
This casualty survived and did well after
reconstructive surgery.
Could you lay this casualty down on a litter on his back
to transport him?
Probably a bad idea - all that blood and mucus would
funnel right into his airway.

The ongoing mission does not stop just because there is

Three Objectives of TCCC
a casualty.
The 3 objectives of TCCC are to provide lifesaving care
19. • Treat the casualty
to the injured combatant, to limit the risk of taking
• Prevent additional casualties
further casualties, and to enable the unit to achieve
• Complete the mission
mission success.

Changes in TCCC: How Are They Made?

The DoD has a group with a charter to keep the TCCC
20.
The Committee on Tactical Combat Casualty Guidelines updated.
Care
 INSTRUCTOR GUIDE FOR INTRODUCTION TO TCCC-MP 180801 8

Committee on Tactical Combat Casualty Care

• The prehospital arm of the Joint Trauma

System
• 42 members from all services in the DoD and Read the text.
civilian sector
21.
• Trauma Surgeons, Emergency Medicine, and The CoTCCC continuously updates the TCCC
Critical Care physicians, combatant unit guidelines.
physicians; medical educators; combat medics,
corpsmen, and PJs
• 100% deployed experience as of 2018
• Meet periodically; update TCCC as needed
Battlefield Trauma Care Today

• Phased care in TCCC

• Aggressive use of tourniquets in CUF
• Combat Gauze as hemostatic agent
• Aggressive needle thoracostomy
• Sit up and lean forward airway positioning
• Surgical airways for maxillofacial trauma These are the advances made by the CoTCCC since it
22.
• Hypotensive resuscitation with blood products began updating the TCCC guidelines in 2001.
• IVs only when needed/IO access if required
• PO meds, OTFC, ketamine as “Triple Option”
for battlefield analgesia
• Hypothermia prevention; avoid NSAIDs
• Battlefield antibiotics
• Tranexamic acid
• Junctional Tourniquets/XStat/Pelvic binding

One way to assess the impact of TCCC is to examine the

23. TCCC: How Do We Know That It’s Working?
results attained when the guidelines are put into practice.
 INSTRUCTOR GUIDE FOR INTRODUCTION TO TCCC-MP 180801 9

TCCC Early in the Iraq and Afghanistan

Conflicts

• NOT widely used at the start of the wars

Even though recommended in the TCCC guidelines,
• Increased use by both Special Operations and
there were few tourniquets on the battlefield before
conventional units beginning in 2005
2005.
• The Drivers:
Some were homemade; some were commercially
• Early reports of success with TCCC,
manufactured.
24. especially TQs
The performance of these tourniquets was variable.
• Holcomb study: “Causes of SOF Deaths
Tourniquet implementation was not gradual from the
2001-2004”
start. It happened through a series of discrete events,
• USAISR tourniquet study by Walters et al
starting with an ISR study identifying the best
(2005)
tourniquets.
• USSOCOM TCCC message - March 2005
• USCENTCOM tourniquet and hemostatic
agents (HemCon) message - 2005

Preventable Combat Deaths from Not Using

Tourniquets

• Maughon – Mil Med 1970: Vietnam

– 193 of 2,600
– 7.4% of total combat fatalities Once limb tourniquets were broadly trained, distributed,
• Kelly – J Trauma 2008: OEF + OIF (2003/4 and used, their efficacy became apparent. Before limb
and 2006) tourniquets were widely used on the battlefield, more
– 77 of 982 (in both cohorts of fatalities) than 7% of combat fatalities were due to extremity
25.
– 7.8% of total fatalities – no better then hemorrhage that could have been controlled by a
Vietnam tourniquet. After tourniquets became widely used on the
• Tourniquets became widely used in 2005- battlefield, deaths due to extremity hemorrhage fell to
2006 2.6%.
• Eastridge – J Trauma 2012: OEF + OIF (to
Jun 2011)
– 119 of 4,596
– 2.6% of total fatalities – a 67% decrease
 INSTRUCTOR GUIDE FOR INTRODUCTION TO TCCC-MP 180801 10

Tourniquet Outcomes in TCCC Transition The USSOCOM TCCC Transition Initiative was a
Initiative Report program that provided just-in-time TCCC training and
equipage to Special Operations forces about to deploy. It
26. • Sixty-seven successful tourniquet applications included an after-action analysis of trauma care
identified in 2005 and 2006 delivered during the unit’s deployment. Early indications
• No avoidable loss of limbs due to tourniquet were that limb tourniquets were effective at controlling
use identified extremity hemorrhage, and were also safe.

TCCC: Success in Combat 3rd Infantry

Division

“The adoption and implementation of the

principles of TCCC by the medical platoon of TF
Read the text.
27. 1-15 IN in OIF 1 resulted in overwhelming
success. Over 25 days of continuous combat with
32 friendly casualties, many of them serious, we
had 0 KIAs and 0 Died From Wounds, while
simultaneously caring for a significant number of
Iraqi civilian and military casualties.”
Tourniquets – Kragh et al: Two Landmark COL Kragh and his colleagues examined battlefield limb
Papers tourniquet use, and compiled the two most important
tourniquet papers ever published. The most important
• Published in 2008/2009 lesson from these papers was that when a tourniquet is
• Tourniquets are saving lives on the battlefield needed, it should be applied AS SOON AS POSSIBLE
28.
• 31 lives saved in 6 months by tourniquets because survival is improved when hemorrhagic shock is
• Author estimated 2000 lives saved with prevented.
tourniquets in this conflict up to that date
(2009) NOBODY is arguing about whether tourniquets save
• No arms or legs lost because of tourniquet use lives any more.
 INSTRUCTOR GUIDE FOR INTRODUCTION TO TCCC-MP 180801 11

Eliminating Preventable Death on the

Battlefield The Army Rangers have achieved the lowest preventable
death rate ever reported in a major conflict. They did it
29. • TCCC in the 75th Ranger Regiment by training everyone in TCCC, not just their medics.
• All Rangers and docs trained in TCCC Their success in eliminating preventable combat deaths
• Ranger preventable death incidence: 3% is remarkable.
• Overall U.S. military preventable deaths: 24%

What Do the Soldiers Say?

Medics and doctors are not the only ones who appreciate
A recent U.S. Army Training and Doctrine the life-saving potential of TCCC practiced by every
Command survey of Soldiers in combat units member of the unit. Non-medical combatants trained in
30.
found that TCCC is the second most valued TCCC recognize the possibility that it may enable them
element of their training, exceeded only by to save their own lives or the lives of their wounded
training in the use of their individual weapons. teammates.

TCCC in Canadian Forces

Savage et al: Can J Surg 2011

Conclusion:
“For the first time in decades, the CF has been
involved in a war in which its members have
participated in sustained combat operations and Canadian Forces also train medics and non-medics in
have suffered increasingly severe injuries. TCCC. Savage and others reporting on the
31. Despite this, the CF experienced the highest implementation of TCCC in the Canadian Forces gave
casualty survival rate in history. Though this much of the credit for the highest casualty survival rate
success is multifactorial, the determination and in their history to TCCC training.
resolve of CF leadership to develop and deliver
comprehensive, multileveled TCCC packages to
soldiers and medics is a significant reason for
that and has unquestionably saved the lives of
Canadian, Coalition and Afghan Security
Forces…..”
 INSTRUCTOR GUIDE FOR INTRODUCTION TO TCCC-MP 180801 12

Limb Tourniquets in the U.S. Military

In 2001, almost nobody in the U.S. Military had a Because limb tourniquets have been so effective at
tourniquet. controlling extremity hemorrhage, and because they
32.
have proven safe when properly applied and monitored,
In 2018, thanks to TCCC, no American Soldier, they have become standard battlefield issue.
Sailor, Airman, or Marine goes onto the
battlefield without a tourniquet.

Hartford Consensus
2 April 2013

• Working group organized by American College

of Surgeons Board of Regents and FBI Read the text.
• In response to Sandy Hook shootings
33.
• Excerpt from findings: The life-saving lessons learned from TCCC are being
adopted into civilian trauma care.

In February 2014, the Assistant Secretary of Defense for

34. ASDHA TCCC Letter 14 February 2014 Health Affairs gave notice that uniform TCCC training
would be directed throughout the Department.
 INSTRUCTOR GUIDE FOR INTRODUCTION TO TCCC-MP 180801 13

Secretary of Defense James Mattis

• General Mattis letter to Service Chiefs When Secretary Mattis was CENTCOM Commander, be
35. • Written during his time as CENTOM recognized that TCCC as practiced by the Rangers saves
Commander lives….
• Highlights Ranger success with TCCC
• Stresses importance of TCCC training

36. Secretary of Defense James Mattis …. and supported its adoption.

DOD Instruction on Medical Readiness

Training
On 16 March 2018, DoD Instruction 1322.24 was
37.
officially published.
16 March 2018
 INSTRUCTOR GUIDE FOR INTRODUCTION TO TCCC-MP 180801 14

This instruction:
1) Makes TCCC the standard for battlefield
trauma care in the US military
DOD Instruction on Medical Readiness
38. 2) Mandates that everyone in the US military
Training
be trained in TCCC at his or her appropriate level
(All Service Member, Combatant,
Combat Lifesaver, Medical Personnel

Summary of Key Points

• Prehospital trauma care in tactical settings is

TCCC is different from civilian trauma care training
very different from civilian settings.
you may have received in the past.
• Tactical and environmental factors have a
This improvement in how we approach the combat
profound impact on trauma care rendered on the
39. casualty has resulted in significantly lower death rates in
battlefield.
combat.
• Good medicine can be bad tactics.
Good battlefield care is paramount in avoiding
• Up to 24% of combat deaths today are
preventable deaths.
potentially preventable.
• Good first responder care is critical.
• TCCC will give you the tools you need!

Care Under Fire is the very limited care that can be

Summary of Key Points
provided while the casualty and the provider are under
effective enemy fire.
• Three phases of care in TCCC
40. Tactical Field Care is performed on the battlefield, but
– Care Under Fire
not under effective enemy fire.
– Tactical Field Care
TACEVAC Care is rendered during transport off the
– TACEVAC Care
battlefield on the way to more definitive care.
 INSTRUCTOR GUIDE FOR INTRODUCTION TO TCCC-MP 180801 15

Summary of Key Points

TCCC is NOT necessarily the standard of care in
civilian prehospital settings.
• TCCC was designed for combat.
41. For those of you who practice in civilian EMS settings,
• BUT many of these concepts have excellent
you should follow the guidance established by your
applicability in civilian prehospital settings,
Emergency Medical Services Director.
too.

Deployed Medicine is the official website to get the

most up-to-date TCCC materials.
Deployed Medicine is a platform used by the Defense
Health Agency to trial new, innovative learning models
Official TCCC Education Sites
aimed at improving readiness and performance of
42.
deployed military medical personnel.
www.deployedmedicine.com
Even though it is a .com website, it is an official site
owned and managed by the Department of Defense.
You can view the updated guidelines, educational and
procedural videos and TCCC reference material.

The Deployed Medicine website is synchronized with a

mobile app you can download to smartphones or tablets.
The same material is available on both the website and
the app.
43. TCCC Mobile App “Deployed Medicine”
You can watch the TCCC How-To videos or listen to the
latest TCCC podcast. You will also be able to receive
notifications of significant TCCC updates or availability
of new training material.

TCCC is active in social media. All major TCCC

announcements, like guideline updates or a new video
release, are broadcast on our social media platforms.
Follow us on Facebook, Twitter, or Instagram. The
44. Follow TCCC on Social Media TCCC training videos are also available on the TCCC
YouTube channel and you can join TCCC discussions
on LinkedIn.
Beware of fake or alternative social sites. These are the
ONLY official TCCC social media sites.
 INSTRUCTOR GUIDE FOR INTRODUCTION TO TCCC-MP 180801 16

TCCC Quick Reference Guide

Download an authorized copy of the Tactical

Combat Casualty Care (TCCC) Quick Reference
Guide You can also download a copy of the TCCC Quick
Reference Guide. The QRG has various versions of the
• Current abbreviated guidelines TCCC guidelines including an abbreviated version and a
45. • TCCC algorithms TCCC algorithm for easy reference and learning of
• Pharmacology references appropriate TCCC-based decision making.
• Planning considerations. This item is copyrighted but you have permission to
download and print it or use it on a smartphone or tablet.
Download at:
https://www.deployedmedicine.com/market/11/c
ontent/87

TCCC Engagement

Provide TCCC feedback

You can engage with the TCCC staff and the Committee
Ask a TCCC question
on Tactical Combat Casualty Care (CoTCCC). Make a
46. Get on the TCCC Distribution List
suggestion, submit an idea, ask a question, or get on the
TCCC e-mail distribution list.
usarmy.jbsa.medcom-aisr.mbx.jts-
[email protected]

47. Questions?