Tactical Combat Casualty Care

 The Tactical Combat Casualty Care is a skills

needed for the operational element which
engaged in the firefight against the enemy.
 Students will demonstrate proficiency in
defined Tactical Combat Casualty Skills
through hands on skill by stations and
simulated task on tactical environments.
 
OBJECTIVES:
 Prevent additional casualties
 Treat the casualty
 Complete the mission
TC3 PLAN:
 The TCCC plan described is a generic sequence
of steps that will require modification in some way
for most casualty scenarios encountered during
missions.
 FACT “90% of combat deaths occur on the
battlefield before the casualty ever reaches a
medical treatment facility.”
THREE Phases of TCCC:
I. Care under Fire
II. Tactical Field Care
III. Casualty Evacuation
(CASEVAC/MEDEVAC)
I. CARE UNDER FIRE
 The care rendered at the scene of the
injury, while the team and the casualty are
still under effective hostile fire.
 Available medical equipment is limited to
that carried by the assaulter or medic in
his gear.
Critical Med Tasks:
Return fire
Cover during recovering the victim
Cover on safe area/call on TCP
Apply a Tourniquet
Agenda:
Task: To understand the first phase of TCCC, the Care
Under Fire phase.
Condition: Given this block of instruction, tourniquet
materials, and practical exercises with scenario based
training.
Standard: To identify and act appropriately during the
Care Under Fire scenario, properly apply a tourniquet,
and to move a casualty without causing further harm.
CARE UNDER FIRE
 
A. SCENE ASSESSMENT
Return fire as directed or required
Casualty should return fire if able
Prevent additional wounds to casualty
Maintain situational awareness!
B. QUICKLY IDENTIFY AND CONTROL
SEVERE BLEEDING
Tourniquet
Direct pressure is hard to maintain during casualty
transport under fire.
Tourniquets:
Tissue damage to the limb is rare if the tourniquet
is left in place less than an hour.
 Tourniquets are often left in place for several
hours during surgical procedures.
In the face of massive extremity hemorrhage, in
any event, it is better to accept the small risk of
tissue damage to the limb than to lose a casualty
to bleeding to death.
Take 10 mins. Break!
A Survivable Wound, Did not have an effective
tourniquet applied - bled to death from a leg
wound
C. MOVE THE CASUALTY TO COVER
If a casualty is able to move to cover, he
should do so to avoid exposing others to
enemy fire.
If casualty is unable to move and
unresponsive, the casualty is likely beyond
help and moving him while under fire may not
be worth the risk.
If a casualty is responsive but can’t move, a rescue
plan should be devised if tactically feasible.
Unit members should be TRAINED to move
themselves to point of first cover if able.
Don’t put two people at risk if avoidable.
DON’T FORGET COVERING FIRE!
If possible, let the casualty know what you plan.
Casualty Movement Rescue Plan
If you must move a casualty under fire, consider the
following:
Location of nearest cover
How best to move him to the cover
The risk to the rescuers
Weight of casualty and rescuer
Distance to be covered
Use suppression fire and smoke to best advantage!
Stop life-threatening external
hemorrhage if tactically feasible:
Direct casualty to control hemorrhage by self-
aid if able.
Use a tourniquet for any significant hemorrhage
Apply the tourniquet proximal to the bleeding
site, over the uniform, tighten, and move the
casualty to cover.
Special Considerations
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.
 Airway management is generally best deferred
until the Tactical Field Care phase
One-Person Drag
 Fireman’s Carry

Fireman’s Carry
Two-Person Drag
Two Man Belt Carry
Neck Drag Carry
How not to do it!
CARE UNDER FIRE Conclusion
Prosecuting the mission and caring for the
casualties may be in direct conflict.
What’s best for the casualty may NOT be what’s
best for the mission.
When there is conflict – which takes precedence?
Scenario dependent
If the firefight is ongoing - don’t try to treat your
casualty in the Kill Zone!
Take 10 mins. Break!
Suppression of enemy fire and moving casualties
to cover are the major concerns.
“Not every casualty scenario is a hostage rescue,
but these basic principles apply.
Imperative to get your casualty “Off the X” and
behind cover”
 Suppression of hostile fire will minimize the risk of both
new casualties and additional injuries to the existing
casualties.
 The firepower contributed by medical personnel and the
casualties themselves may be essential to tactical fire
superiority.
The best medicine on the battlefield is
Fire Superiority!
II. TACTICAL FIELD CARE
Rendered once the casualty is no longer under
hostile fire. Medical equipment is still limited to
that carried into the field by mission personnel.
Time frame prior to evacuation may range from a
few minutes to many hours. 
 Tactical considerations
 More time to render care and a reduced
level of hazard from hostile fire
 CPR?
 Non-Traumatic complications
 (hypothermia, near drowning,
electrocution)
Critical Med Task:
 Evaluate a Casualty
 Open and Maintain an Airway/ Assess “C A B”
 Seal an Open Chest Wound
 Needle decompression on a tension
Pneumothorax
 Initiate IV and begin fluid resusitation
Agenda
Task: Given a casualty who and scenario where it is tactically
feasible; perform the sequence of the Tactical Field Care.

Condition: Given this instruction, materials for chest seals and

dressings, and practical exercises with scenario based training.
Standards: Understand the appropriate environment for the
Tactical Field Care, perform the MARCH sequence correctly.
Perform Airway management, treat open chest wounds, and
address any circulation issues while preventing shock.
 
Objectives
STATE the common causes of altered states of
consciousness on the battlefield and why the
casualty should be disarmed.
DESCRIBE airway control techniques and devices
appropriate to the Tactical Field Care phase.
DESCRIBE the diagnosis and initial treatment of
tension pneumothorax on the battlefield.
LIST the criteria for the diagnosis of tension
pneumothorax on the battlefield
STATE the tactically relevant indicators of shock in
combat settings.
 DESCRIBE the management of penetrating eye
injuries in TCCC.
DESCRIBE how to prevent blood clotting problems
from hypothermia.
Disarm Individuals with Altered Mental Status
Armed combatants with an altered mental status
may use their weapons inappropriately.
Secure long gun, pistols, knives, grenades,
explosives.
Possible causes of altered mental status are
Traumatic Brain Injury (TBI), shock, hypoxia, and
pain medications.
Explain to casualty: “Let me hold your weapon for
you while the doc checks you out”
TACTICAL FIELD CARE
Initial Assessment
Talk to the casualty
Alert: Patient can talk and respond to questions (if patient
can talk, Airway is patent)
Verbal: Patient can respond to your voice
Pain: Patient responds to pain
Unresponsive: Patient does not respond to any stimulus
Continue to talk to the casualty throughout and reassess
Mental Status
TREATMENT PRIORITIES
Primary Survey - Stop any life-threatening
external hemorrhage with a tourniquet
M - Massive Bleeding
A - Airway
R - Respiration (Breathing)
C - Circulation
H - Head to Toe (Expose/ Environment)
M - MASSIVE BLEEDING
Tourniquet should have been in place after the Care
Under Fire Phase
Reassess tourniquet and ensure that it is still working
Any significant bleeding missed, use a tourniquet now
A - AIRWAY
Check for patent airway
Open with manual methods as needed
Insert simple airway adjunct if needed
- Assess for Airway Obstruction!
- Difficulty breathing
- Patient conduct (anxious, combative)
- Abnormal sounds
- Improve/Establish Airway Through Maneuvers
- Chin lift
- Jaw thrust
- Remove Debris
- Airway Adjuncts: Nasal airway (Primary)
Take 10 mins. Break!
Airway Obstruction
The most common obstruction is from a
prolapsed tongue! Blood Clots, Teeth
Soft Tissue & Bones
Swelling
Position of Head
Rescue breathing sequence: ASSESS
AIRWAY
Head Injury
Inspect the oral cavity for potential
obstructions
Clear with suction, finger sweep, or turn the
casualty as a whole to one side.
INSERT APPROPRIATE AIRWAY ADJUNCT
R - RESPIRATIONS
Inspect/palpate entire thorax and seal open
chest wound (Asherman Chest Seal/4 sided
occlusive) if needed
Check for breathing, respiratory rate/depth
Hint: 1q2=30, 1q3=20, 1q4=15, 1q5=12
Check for tension pneumothorax and
perform needle decompression if needed
ASSESS BREATHING
LOOK - “I see bilateral rise and fall of the chest.”
LISTEN - “I hear deep and normal respiratory effort.”
FEEL - “I feel exhalation on my ear. I have a strong
regular carotid pulse.”
RATE: Too Fast vs. Too Slow.
Greater than 30 less than 10?
RHYTHM: Regular vs. Irregular.
QUALITY: Shallow vs. Deep.
Respiration
Inspect the Thoracic area (chest and back)
Look for any open wounds
Any wounds from navel to chin; use an
occlusive dressing
Palpate and feel for blood or crepitus in the
ribs
Listen for sucking chest wound
OPEN PNEUMOTHORAX
Develops when penetration injury to the chest allows the pleural space
to be exposed to atmospheric pressure - “Sucking Chest Wound”
Q- WHAT MAY CAUSE A SCW?

A-Examples Include:
GSW, Stab Wounds, Impaled Objects, Etc...
S/sx of Open pneumothorax
Shortness of Breath (SOB), Pain
Sucking or gurgling sound as air moves in and out of the pleural space
through the wound
 Sucking Chest Wound

MANAGEMENT OF SCW
 Apply an Asherman Chest Seal or 4 sided Occlusive
dressing.
 Observe for development of a Tension
Pneumothorax
EARLY S/x OF TENSION PNEUMOTHORAX
 ANXIETY!, Increased respiratory distress, Unilateral
chest movement, Unilateral decreased or absent
breath sounds
MANAGEMENT OF TENSION PNEUMOTHORAX
Asherman Chest Seal or 4 sided Occlusive
Needle Decompression
Bag Valve Mask Assistance (be prepared to administer
an airway adjunct)
Chest Tube
C - CIRCULATION
Check for and control remaining external hemorrhage using
necessary means
1) Tourniquet
2) Bandages or dressings
Kerlex and ACE wrap
Emergency Dressing

Check for pulse presence, quality, rate, and rhythm & skin
capillary refill time, color, temperature, and moisture
Vital Sign
 Carotid pulse
- Patient generally has a blood
pressure of at Least 60
systolic
 Radial pulse

- PT Generally Radial pulse has

a systolic BP of at least 80
Pedal pulse
- Located on the top of the foot
- Pt generally has a BP with a systolic of 90

Posterior Tibial Artery Normal Pulse Rate: 60-100 Adult

DRESSINGS AND BANDAGES
Apply to venous bleeds or heavy capillary bleeds
If dressing/bandage does not stop bleed, apply a
pressure dressing or reapply a tourniquet

Open Wounds Closed wounds

 Open dressing
Do not touch white sterile side of dressing.
Place white side of dressing on wound.
Wrap tails of dressing to cover all white edges. This
will also help keep wound clean
Tuck any remaining tails inside to avoid catching
them
Tie knot on the side of wound.
You should be able to slip 1-2 fingers under knot.
Pressure Dressings
If a dressing is not enough, apply a pressure
dressing
Wad up a dressing (or piece of BDU) and
apply on top of dressing in place
Wrap with another bandage and tie not on
top for additional pressure
Take 10 mins. Break!
 Things Not to Do
Never apply direct pressure
to a neck wound because it
can interfere with breathing
Instead, carefully pinch the
wound closed
Never apply direct pressure
to the eye because
permanent damage may be
caused
IV Access
NOT ALL CASUALTIES NEED IVs!
IV fluids not required for minor wounds
IV fluids and supplies are limited – save them for the casualties who
really need them
IVs take time
Distract from other care required
May disrupt tactical flow – waiting 10 minutes to start an IV on a
casualty who doesn’t need it may endanger your unit unnecessarily
18 gauge catheter preferred in the field setting because of
increased success rate of a first time stick.
IV Therapy
Don't start on an extremity distal to a
significant wound
Extremity vein first choice
AC is preferred
External jugular vein
Sternal Intraosseous
 DO NOT start IVs on casualties who are
unlikely to need fluid resuscitation for
shock or IV medications. The alleged need
to start two large-bore IVs on every
casualty is a medical “urban myth.”That
concept is outdated on the modern
battlefield. Combat leaders need to know
this fact.
Agenda
Task: To identify the signs and symptoms of shock
and to initiate an IV.
Condition: Given this class and through practical
exercises and small group scenarios.
Standard: Properly identify the signs and
symptoms of shock and to properly initiate at least
one IV under supervision.
Objectives

DESCRIBE and identify the signs and symptoms of

shock. DESCRIBE the pre-hospital fluid resuscitation
strategy for hemorrhagic shock in combat casualties.
DEMONSTRATE the appropriate procedure for initiating
a rugged IV field setup.
Shock
 Note that regardless of the classification, the
underlying defect is always:
 Inadequate Organ Perfusion and Tissue Oxygenation !
Hemorrhagic Shock
Hemorrhage = acute loss of circulating blood
Most common cause of shock after injury
Virtually all patients with multiple injuries have an element of
hypovolemia
Compensated shock
The bodies ability to adapt to the loss of blood
and maintain perfusion to all the important and
vital organs. As it looses this to protect all of the
organs it transfers into- DECOMPENSATED SHOCK
ASSESSMENT:
Evaluation of the patient in shock must be
directed at assessing oxygenation and perfusion of
the various body organs. S/Sx:
Breathing: Increased respirations
Circulation: Increased pulse rate 60-110 normal
110 or above concerned Cool and clammy skin
Thirst Nausea
Disability: Agitation
Circulation:
Radial pulse = 80 mm Hg systolic
Femoral pulse = 70 mm Hg systolic
Carotid pulse = 60 mm Hg systolic
Shock Management
control bleeding + give fluids
monitor patient’s response
Goal = restoration of organ perfusion
H – HEAD TO TOE
Check patient from Head to Toe
 Expose patient fully to visualize body
 Treat any wounds as you go
 Use a systematic approach
 My Eyes look where my hands go

Expose/Environment
Expose only as needed for survey
Protect from the environment and prevent hypothermia
Secondary Survey TREAT WOUNDS AS YOU GO!
Head-to-toe evaluation Eye Care
“Where my hands go, my eyes Splinting
follow” Reassess ABC’s “Look, listen, Burn Care
and feel "See, don’t just look! Hear, Pain Control
don’t just listen! Feel, don’t just
touch!
A rigid shield will protect the eye from any
pressure.
Pressure could force the interior contents of the
eye to come out – this is a BAD THING!
Rigid shield should be in first aid kits and medical
sets.
Use your tactical eyewear to cover the injured eye
if you don’t have a shield.
 Using tactical eyewear in the field will generally
prevent the eye injury from happening in the first
place!
 Splint fractures and recheck pulse.
Open or Closed: Associated with an overlying skin
wound
Closed Fracture:
Trauma with significant pain AND Marked
swelling, Audible or perceived snap, Different
length or shape of limb, Loss of pulse or
sensation distal, Crepitus (“crunchy” sound)
no overlying skin.
Head to Toe Assessment
 Casualty movement in TFC may be better
accomplished using litters
Remember that we used carries and drags in Care
under Fire.
We did it that way to get the casualty to cover as
quickly as possible.
Now have time to use litters Often better for
moving casualty a long distance.

Prepare casualty for movement constantly reassess

 
Tactical Field Care recaps:
Use the MARCH method in this phase
M- Massive Bleeding
A- Airway
R- Respirations
C- Circulation
H- Head to Toe
III. CASEVA
 
Rendered while the casualty is evacuated to a higher echelon of care. Any
additional personnel and medical equipment pre-staged in these assets will be
available during this phase.
Two significant differences will be present in progressing from
the Tactical Field Care phase to the CASEVAC phase:
Additional medical personnel may accompany the evacuating
asset.
Additional medical equipment may be pre-staged on the
evacuating asset.
Combat re-supply can be requested
Package and prepare for casualty evacuation Non-
ambulatory via SKEDCO litter or field expedient
means. (Improvise Litter)
Aid and litter teams
Security teams
Aircraft Evacuation Planning
Flying rules are very different for different aircraft and
units
Consider: Distances and altitudes involved
Day versus night
Passenger capacity Hostile threat
Medical equipment Medical personnel
Ensure that your evacuation plan includes aircraft capable
to fly the missions you need
Primary, secondary, tertiary options
Always have a backup plan. Or to KNOW the flying rules
for all of your potential evacuation aircraft.
CCP/CASEVAC
Definitive sections need to be identified
CCP area and Triage site
Treatment area
Transportation Holding area
Expectant area
Begins with self-aid/ buddy aid
Third Phase of TCCC after Care Under Fire and Tactical
Field Care
Continues to a Casualty Collection Point (CCP)
Ends when the casualty is evacuated to a medical
treatment facility
Casualty Collection Point (CCP)
Triage patients
Organize CCP by triage precedence
Continue to assess and treat patientsQuick method to
assess multiple casualties
Prevents medics from spending valuable time and
resources unnecessarily on patients
Sets precedence for Casevac by setting categories:
Urgent (30min-2 hours)
Priority (2-6 hours)
Routine (6+ hours)
During the planning phase, the decision needs to
be made on how the casualty will be movedIf
Primary asset (Air, Ground Ambulance) is not
available, the casualty needs to be moved by any
means to the next level of care
Casualty needs to be constantly reassessed and the
secondary survey must be repeated
Recommendations:
Base planning for combat casualties should be
incorporated into specific mission scenarios to aid in
identifying the unique medical and tactical requirements
that will have to be addressed in the scenario.
On combat missions, all operatives should have a
suitable tourniquet readily available at a standard
location on their battle gear and trained to use a
tourniquet.
 
END OF SLIDE