Introduction

Tactical combat casualty care (TCCC or TC3) is the accepted battlefield prehospital standard of care. TCCC was reviewed and approved by the Committee on Tactical Combat Casualty Care (CoTCCC) which was established by the US Special Operations Command in 2002. Now, the CoTCCC operates under the Department of Defense (DoD) Joint Trauma System (JTS). The committee is formed by physicians, providers, and medical technicians across branches of the United States Army, Navy, Air Force, Marines, and Coast Guard and has 42 voting members.

TCCC originated as a Naval Special Warfare biomedical research project in the early 1990s and was first published as a Military Medicine supplement in 1996. This research was stimulated by evidence showing that tactical medicine environment and care differed substantially from typical prehospital medicine, that 90% of all combat deaths occur prior to reaching a treatment facility, and that extremity hemorrhage was a major cause of combat death. This places the wounded combatant, unit medic, or fellow soldier in the primary role of life-sustaining care. Early and effective use of the tourniquet substantially improved outcomes through evaluation from 1993 to 1996; because of this, TCCC was formed and implemented, initially in small unit group tactics and eventually becoming the basis for trauma care in the battlefield setting. Currently, TCC is a DoD course that is offered by National Association of Emergency Medical Technicians (NAEMT) in either a 2-day course for medical personnel or a 1-day course for all combatants. NAEMT also offers Tactical Emergency Casualty Care (TECC) for civilian emergency medical services (EMS).[1]

Issues of Concern

Holcomb et al. showed that the adoption of TCCC across the United States military services substantially improved soldier fatality rates in 2006. A study of fatality rates spanning from 1941 to 2005 showed improved from 19.1% during World War II, 15.8% during the Vietnam War, down to an all-time low of 9.4% during Operation Iraqi Freedom and Operation Enduring Freedom.[2]

In 2012, Eastridge et al. established the primary causes of death on the battlefield as hemorrhage, 91%; airway obstruction, 7.9%; and tension pneumothorax, 1.1%. Massive hemorrhage was found to include extremity wounds, 13.5%; junctional wounds, 19.2%; and truncal wounds, 67.3%. Because of this, the typical trauma primary survey has been rearranged from airway, breathing, circulation, and disability to follow the MARCH mnemonic of massive hemorrhage, airway, respiration, circulation, and hypothermia. [3]

Clinical Significance

The primary objectives of TCCC are to provide early, life-sustaining medical care to the casualty, limit further casualties, and achieve mission success. TCCC is divided into three phases of care: Care Under Fire (CUF), Tactical Field Care (TFC), and Tactical Evacuation Care (TACEVAC).[4]

1. Care Under Fire (CUF) is the first objective of TCCC and begins once a casualty is established. The primary goal is fire superiority and movement of the casualty to cover. Cover is defined as concealment (something that visibly hides the combatant) that will stop bullets, ballistics, and bombs (explosives). Fire superiority in order to suppress hostile forces limits additional casualties and allows the injured militant to either move themselves to cover and begin self-aid or for additional forces to intervene as appropriate. To achieve fire superiority the medical personnel and casualty firepower, if capable, are essential for success. At this point, an unresponsive victim is assumed to be beyond capabilities of care and rescue plans are evaluated on a risk basis. The only initial medical intervention during CUF is the early application of tourniquets for major hemorrhage control. All other interventions are delayed until a secure location is obtained and tactical field care is begun.  Tourniquet placement is “high and tight” meaning rapidly placed over the uniform, proximal to the wound, and tightened until bleeding is stopped. If the first tourniquet fails, place the second tourniquet more proximal, leaving the first in place. Multiple tourniquets should be easily accessible by either upper extremity for self-aid.[5]
2. Tactical Field Care is the basis of EMS/medic or prehospital tactical care which is rendered once the appropriate cover has been achieved while still within the battlefield environment. Generally, medical care provided through gear carried by the medical personnel. Care during TFC follows the MARCH algorithm. Ideally, massive hemorrhage has been controlled during CUF; if not, tourniquet placement is the first priority.[5] Airway management focuses on maintaining a patent airway through head tilt-chin lift maneuver, nasopharyngeal airway, or oropharyngeal airway. If unsuccessful, the next airway maneuver is surgical airway via cricothyroidotomy, though this has had poor success rates in the field for severe airway injuries.[6] Evaluation of respirations is focused on assessing and treating tension pneumothorax, sucking chest wounds, and supporting ventilation as applicable. In the event of torso trauma and respiratory distress, medical personnel perform needle decompression. Sucking chest wounds are treated with application of vented chest seals.[7][8] Evaluation of the circulation is to detect any ongoing bleeding, establish intravenous (IV) or intraosseous (IO) access and administer fluids to prevent shock. The casualty is assessed for any ongoing bleeding, exposure of wounds, and placement of a tourniquet if needed. During this phase of care, tourniquets should be placed directly on the skin and any previously placed tourniquets should be evaluated and converted to direct placement on the skin.[9] Combat gauze or hemostatic dressings should be packed into and wrapped over wounds. Bleeding at junctional sites i.e., groin, axilla, or neck hemorrhage is treated with either junctional tourniquets, packed with hemostatic dressings, or using a rapid hemostasis system that injects into the wound.[10] Once IV or IO access is established (if needed) tranexamic acid (TXA) and fluids should be initiated. TXA is indicated in massive hemorrhage, hemorrhagic shock, or suspected intrathoracic or intraabdominal hemorrhage. Early use of blood products is highly promoted within TCCC and ideal when available.[11] Hypothermia protocols prevent the casualty from further deterioration of the condition through ongoing exposure to the elements by wrapping the patient with insulated surfaces.[12] Additional aspects of TFC include administration of analgesia and antibiotics as well as treating or dressing non-life-threatening wounds.
3. Tactical Evacuation Care continues with ongoing monitoring and intervention encompassed through TFC during transport out of the tactical environment to the hospital facility. During this phase of care, more invasive maneuvers such as supraglottic or endotracheal airway interventions can be performed along with ongoing evaluation and monitoring following the MARCH algorithm.[13]