Security

Establish a security perimeter in accordance with unit tactical standard operating procedures and battle drills. Maintain tactical situational awareness.

Triage

Triage casualties as required. Casualties with an altered mental status should have weapons and communications equipment taken away immediately.

Tourniquet Reassessment and Application

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 anatomically amenable to tourniquet use or for any traumatic amputation.

• Apply the tourniquet 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.

Hemostatic Dressings (CoTCCC Recommended)

For compressible external hemorrhage not amenable to limb tourniquet use, or as an adjunct to tourniquet removal:

Dressing	Use / Role
Combat Gauze	CoTCCC hemostatic dressing of choice.
Celox Gauze	Alternative hemostatic adjunct.
ChitoGauze	Alternative hemostatic adjunct.
XStat	Best for deep, narrow-tract junctional wounds. NOT to be removed in the field.
iTClamp	May be used alone or in conjunction with a hemostatic dressing or XStat.

Application Rules

• Apply hemostatic dressings with at least 3 minutes of direct pressure (optional for XStat).
• If one dressing fails, it may be removed and a fresh dressing of the same or different type applied.
• XStat is not removed in the field, but additional XStat, hemostatic adjuncts, or trauma dressings may be applied over it.
• If the site is amenable to a junctional tourniquet, immediately apply one. Do not delay. Apply hemostatic dressings with direct pressure while the junctional tourniquet is being readied.

iTClamp — Head and Neck

For external hemorrhage of the head and neck where wound edges can be re-approximated, the iTClamp may be used as a primary hemorrhage control option. Pack wounds with hemostatic dressing or XStat, if appropriate, before iTClamp application.

• The iTClamp does not require additional direct pressure, alone or with other adjuncts.
• If applied to the neck, perform frequent airway monitoring and evaluate for an expanding hematoma that may compromise the airway. Consider a definitive airway if an expanding hematoma develops.
• Do NOT apply on or near the eye or eyelid — within 1 cm of the orbit.

Initial Assessment for Hemorrhagic Shock

Initial Airway Steps

1. Assess for an unobstructed airway.
2. If there is traumatic airway obstruction or impending obstruction, prepare for direct airway intervention.
3. Allow a conscious casualty to assume any position that best protects the airway, including sitting up or leaning forward.
4. Place an unconscious casualty in the recovery position, head tilted back, chin away from chest.
5. Use suction if available and appropriate.

Surgical Cricothyroidotomy

If the previous measures are unsuccessful and the casualty's airway obstruction is unmanageable (examples: facial fractures, direct airway injury, blood, deformation, or burns), perform a surgical cricothyroidotomy using one of the following:

Ongoing Airway Management

• Frequently reassess SpO2 (blood oxygen saturation via pulse oximetry), EtCO2, and airway patency — airway status may change over time.
• Cervical spine stabilization is NOT necessary for casualties who have sustained only penetrating trauma.

Suspect Tension Pneumothorax 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 (rapid breathing)
• Absent or markedly decreased breath sounds on one side of the chest
• Hemoglobin oxygen saturation less than 90 percent on pulse oximetry
• Shock
• Traumatic cardiac arrest without obviously fatal wounds

Initial Treatment Steps

Needle Decompression (NDC) Sites

Technique

• Insert the needle/catheter unit at an angle perpendicular to the chest wall and just over the top of the lower rib at the insertion site.
• Insert all the way to the hub. Hold in place 5-10 seconds to allow decompression.
• After decompression, remove the needle and leave the catheter in place.
• If the 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.

NDC Considered Successful When

• Respiratory distress improves, OR
• There is an obvious hissing sound as air escapes from the chest (may be difficult to hear in high-noise environments), OR
• Hemoglobin oxygen saturation increases to 90 percent or greater (may take several minutes; may not happen at altitude), OR
• A casualty with no vital signs has return of consciousness or a radial pulse.

If Initial NDC Fails

• 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.
• Consider, based on mechanism of injury and physical findings, whether decompression of the opposite side of the chest may be needed.
• Continue to reassess.

If Initial NDC Succeeded but Symptoms Recur

• Perform another NDC at the same site that was used previously. Use a new needle/catheter unit.
• Continue to reassess.

If the second NDC is also unsuccessful, continue to the Circulation section.

Open / Sucking Chest Wounds

Immediately apply 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 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.

Pulse Oximetry and Oxygen

• Initiate pulse oximetry. All individuals with moderate to severe TBI (traumatic brain injury) should be monitored with pulse oximetry. Readings may be misleading in shock or marked hypothermia.
• Casualties with moderate or severe TBI should be given supplemental oxygen when available to maintain oxygen saturation greater than 90 percent.
• If the casualty has impaired ventilation and uncorrectable hypoxia with decreasing oxygen saturation below 90 percent, consider insertion of a properly sized Nasopharyngeal Airway and ventilate using a 1000 mL resuscitator Bag-Valve-Mask.
• Use continuous EtCO2 and SpO2 monitoring to help assess airway patency.

Pelvic Binder

A pelvic binder should be applied for suspected pelvic fracture. Indications: severe blunt force or blast injury with one or more of the following:

• Pelvic pain
• Any major lower limb amputation or near amputation
• Physical exam findings suggestive of pelvic fracture
• Unconsciousness
• Shock

Tourniquet Reassessment (TFC)

Tourniquet Conversion Criteria

Limb and junctional tourniquets should be converted to hemostatic or pressure dressings as soon as possible if ALL three criteria are met:

1. The casualty is not in shock.
2. It is possible to monitor the wound closely for bleeding.
3. The tourniquet is not being used to control bleeding from an amputated extremity.

Tourniquet Documentation

Expose and clearly mark all tourniquets with the time of application. On the TCCC Casualty Card, document: tourniquets applied and time of application, time of re-application, time of conversion, and time of removal. Use a permanent marker to mark on the tourniquet and casualty card.

IV / IO 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
• 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 IV, use the IO route.

Tranexamic Acid (TXA)

Administer 2 grams of TXA via slow IV or IO push as soon as possible but NOT later than 3 hours after injury, if the casualty meets either criterion:

1. Will likely need a blood transfusion (examples: hemorrhagic shock, one or more major amputations, penetrating torso trauma, evidence of severe bleeding), OR
2. Has signs or symptoms of significant TBI or altered mental status associated with blast injury or blunt trauma.

Fluid Resuscitation — Fluids of Choice

Resuscitation fluids for casualties in hemorrhagic shock, listed from most to least preferred:

Priority	Fluid
1	Cold stored low titer O whole blood
2	Pre-screened low titer O fresh whole blood
3	Plasma, red blood cells (RBCs), and platelets in a 1:1:1 ratio
4	Plasma and RBCs in a 1:1 ratio
5	Plasma or RBCs alone

Resuscitation Management

• 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 protocol: resuscitate in the order listed above.
• Reassess after each unit. Continue resuscitation until a palpable radial pulse, improved mental status, or systolic blood pressure of 100 mmHg is present.
• Discontinue fluid administration when one or more of these end points is achieved.
• If blood products are transfused, administer 1 gram of calcium (30 mL of 10 percent calcium gluconate OR 10 mL of 10 percent calcium chloride) IV or IO after the first transfused product.

Unscreened Blood and Rh Considerations

• Transfusion of unscreened group O fresh whole blood or type-specific fresh whole blood should only be performed under appropriate medical direction by trained personnel, given the increased risk of a potentially lethal hemolytic reaction.
• Transfusion should occur as soon as possible after life-threatening hemorrhage to keep the casualty alive. If Rh-negative blood products are not immediately available, Rh-positive blood products should be used in hemorrhagic shock.

TBI with Weak or Absent Radial Pulse

If a casualty with 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 blood pressure monitoring is available, maintain a target systolic BP between 100-110 mmHg.

Recurrent Shock

Reassess frequently. If shock recurs, re-check all external hemorrhage control measures to ensure they are still effective, and repeat fluid resuscitation as above.

Refractory Shock

If a casualty in shock is not responding to fluid resuscitation, consider untreated tension pneumothorax as a possible cause. Thoracic trauma, persistent respiratory distress, absent breath sounds, and hemoglobin oxygen saturation less than 90 percent support this diagnosis.

Treat 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. Finger thoracostomy may not remain patent; finger decompression through the incision may have to be repeated. Consider decompressing the opposite side of the chest if indicated.

Nine Hypothermia Prevention Actions

Prevent Hypoxemia — Goal SpO2 Greater Than 90-95 Percent

• If basic airway maneuvers fail to maintain SpO2 greater than 90 percent, or are not tactically feasible, ensure low oxygen saturations are not due to tension pneumothorax or hemorrhage.
• Consider definitive airway if unable to maintain SpO2 greater than 90 percent.

Prevent Hypotension — Maintain Systolic BP 100-110 mmHg

• Transfuse whole blood or plasma preferentially if the casualty is in hemorrhagic shock.
• Otherwise, use 1-2 liter bolus of crystalloid if there is no evidence of hemorrhage or hemorrhagic shock.

Identify and Treat Herniation

Signs of impending herniation: declining neurologic status with asymmetric or fixed/dilated pupil(s), or posturing.

Herniation Treatment Protocol

• Administer 250 mL of 3% or 5% hypertonic saline OR 30 mL of 23.4% hypertonic saline via slow IV or IO push over 10 minutes, followed by a saline flush.
• Repeat in 20 minutes if no response — maximum 2 doses.
• Monitor IV or IO site and discontinue if signs of extravasation (fluid leaking into surrounding tissue).
• Elevate head 30 degrees if the casualty is not in shock and it is tactically feasible.
• Loosen cervical collar if present and keep head facing forward.
• Hyperventilate using continuous capnography — goal EtCO2 32-38 mmHg.

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, IO, or IM antibiotics are given per the antibiotics section if oral moxifloxacin cannot be taken.

Initiate advanced electronic monitoring if indicated and if monitoring equipment is available.

Non-Medical First Responders

For mild to moderate pain, when the casualty is still able to fight:

• TCCC Combat Wound Medication Pack (CWMP): Acetaminophen 500 mg, 2 tablets by mouth every 8 hours. Meloxicam 15 mg by mouth once a day.

Medical Personnel — Four Options

Option 1 — Mild to Moderate Pain, Still Able to Fight

TCCC CWMP: Acetaminophen 500 mg, 2 tablets by mouth every 8 hours. Meloxicam 15 mg by mouth once a day.

Option 2 — Mild to Moderate Pain, NOT in Shock or Respiratory Distress

Casualty is also NOT at significant risk of developing either condition.

• Oral Transmucosal Fentanyl Citrate (OTFC) 800 micrograms. May repeat once more after 15 minutes if pain is uncontrolled.
• TCCC Combat Paramedics or Providers: Fentanyl 50 micrograms IV or IO (0.5-1 microgram per kilogram). May repeat every 30 minutes.
• Fentanyl 100 micrograms intranasal. May repeat every 30 minutes.

Option 3 — Moderate to Severe Pain WITH Shock, Respiratory Distress, or Risk

• Ketamine 20-30 mg (or 0.2-0.3 mg/kg) slow IV or IO push. Repeat doses every 20 minutes as needed. End points: control of pain or development of nystagmus (rhythmic back-and-forth movement of the eyes).
• Ketamine 50-100 mg (or 0.5-1 mg/kg) IM or intranasal. Repeat doses every 20-30 minutes as needed.

Option 4 — Sedation (Paramedics or Providers)

Sedation is required for significant severe injuries requiring dissociation for casualty safety or mission success, or when a casualty requires an invasive procedure. Must be prepared to secure the airway.

• Ketamine 1-2 mg/kg slow IV or IO push initial dose. Endpoints: procedural (dissociative) anesthesia.
• Ketamine 300 mg IM (or 2-3 mg/kg IM) initial dose. Endpoints: procedural (dissociative) anesthesia.
• If an emergence phenomenon occurs, consider 0.5-2 mg IV or IO midazolam.
• If continued dissociation is required, move to the Prolonged Casualty Care (PCC) analgesia and sedation guidelines.

Longer-Duration Analgesia

Ketamine slow IV or IO infusion 0.3 mg/kg in 100 mL of 0.9 percent sodium chloride over 5-15 minutes. Repeat doses every 45 minutes as needed. End points: control of pain or development of nystagmus.

Analgesia and Sedation Notes

Rule	Detail
Disarm the casualty	After being given OTFC, IV/IO fentanyl, ketamine, or midazolam.
Goals	Analgesia — reduce pain to a tolerable level while still protecting airway and mentation. Sedation — stop awareness of painful procedures.
Mental status exam	Document using the AVPU method (Alert, Verbal, Pain, Unresponsive) before administering opioids or ketamine.
Monitoring	For all casualties given opioids, ketamine, or benzodiazepines — monitor airway, breathing, and circulation closely.
OTFC directions	Place lozenge between cheek and gum. Do not chew. Tape lozenge-on-a-stick to the casualty's finger, or use a safety pin and rubber band to attach the lozenge (under tension) to uniform or plate carrier. Reassess in 15 minutes. Add a second lozenge in the other cheek as needed. Monitor for respiratory depression.
Ketamine concentrations	Higher concentration (100 mg/mL) is recommended for intranasal dosing to minimize volume.
Naloxone	0.4 mg IV/IO/IM/IN should be available when using opioid analgesics.
TBI and eye injury	Do NOT preclude the use of ketamine. Use caution with OTFC, IV/IO fentanyl, ketamine, or midazolam in TBI casualties — may make it difficult to perform a neurologic exam or determine decompensation.
Ketamine as opioid adjunct	May reduce the amount of opioids required. Safe to give to a casualty who has previously received a narcotic. IV ketamine should be given over 1 minute.
Reduced respirations	After opioids or ketamine: reposition into a "sniffing position". If that fails, provide ventilatory support with BVM or mouth-to-mask.
Ondansetron	4 mg Orally Dissolving Tablet (ODT) / IV / IO / IM every 8 hours as needed for nausea or vomiting. Each dose can be repeated once after 15 minutes if not improved. Maximum 8 mg per 8-hour interval. Oral ondansetron is NOT acceptable — use the ODT formulation.
Benzodiazepines	Routine use is NOT recommended for analgesia. May be considered for behavioral disturbances or unpleasant (emergence) reactions during procedural sedation. Should not be used prophylactically.
Polypharmacy	Not recommended. Benzodiazepines should NOT be used in conjunction with opioid analgesia.
Partial dissociation	If a casualty appears partially dissociated, it is safer to administer more ketamine than to use a benzodiazepine.

Antibiotics are recommended for all open combat wounds.

Route	Drug / Dose
Able to take by mouth	Moxifloxacin (from the CWMP) 400 mg by mouth once a day.
Unable to take by mouth (shock, unconsciousness)	Ertapenem 1 gram IV / IO / IM once a day.

Inspect and Dress Known Wounds

Inspect and dress all known wounds.

Abdominal Evisceration

• Control bleeding. Rinse with clean (and warm if possible) fluid to reduce gross contamination.
• Hemorrhage control: Apply Combat Gauze or a CoTCCC-recommended hemostatic dressing to uncontrolled bleeding.
• Cover exposed bowel with a moist, sterile dressing or sterile water-impermeable covering.

Reduction Protocol

• If no evidence of bowel leakage and hemorrhage is visibly controlled, a single brief attempt (less than 60 seconds) may be made to replace or reduce the eviscerated abdominal contents.
• If unable to reduce: cover the eviscerated organs with water-impermeable non-adhesive material (transparent preferred to allow ability to re-assess for ongoing bleeding). Examples: bowel bag, IV bag, clear food wrap. Secure the impermeable dressing to the casualty using adhesive dressing (examples: Ioban, chest seal).
• Do NOT force contents back into the abdomen or actively bleeding viscera.
• The casualty should remain NPO (nothing by mouth).

Check for Additional Wounds

Perform a secondary survey to identify any wounds not yet treated.

Core Principle

Assess and treat as a trauma casualty with burns, not a burn casualty with injuries.

Inhalation Injury

Facial burns, especially in closed spaces, may be associated with inhalation injury. Aggressively monitor airway status and oxygen saturation. Consider early surgical airway for respiratory distress or oxygen desaturation.

TBSA Estimation

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

Burn Dressings

Cover burn areas with dry, sterile dressings. For extensive burns greater than 20 percent TBSA, consider placing the casualty in the Heat-Reflective Shell or Blizzard Survival Blanket from the Hypothermia Prevention Kit to cover the burned areas and prevent hypothermia.

Fluid Resuscitation — USAISR Rule of Ten

• Burns greater than 20 percent of TBSA: initiate fluid resuscitation as soon as IV/IO access is established.
• Initiate 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.
• If hemorrhagic shock is also present, resuscitation for hemorrhagic shock takes precedence over burn shock resuscitation. Administer IV/IO fluids per Circulation (TFC 6).
• Consider oral fluids for burns up to 30 percent TBSA if the casualty is conscious and able to swallow.

Other Burn Considerations

• Analgesia per TFC 11 may be administered to treat burn pain.
• Prehospital antibiotic therapy is NOT indicated solely for burns, but antibiotics should be given per TFC 12 if indicated to prevent infection in penetrating wounds.
• All TCCC interventions can be performed on or through burned skin.
• Burn casualties are particularly susceptible to hypothermia. Extra emphasis on barrier heat loss prevention.

Splint Fractures

Splint fractures and re-check pulses after splinting.

CPR in Tactical Field Care

Exception: 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 before discontinuing care. Procedure is the same as Respiration/Breathing section.

Communication

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

Documentation of Care

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

Prepare for Evacuation

Transition of Care

• Tactical force personnel should establish evacuation point security and stage casualties for evacuation.
• Tactical force personnel or the medic should communicate casualty information and status to TACEVAC personnel as clearly as possible. Minimum information: stable or unstable, injuries identified, treatments rendered.
• TACEVAC personnel should stage casualties on evacuation platforms as required.
• Secure casualties in the evacuation platform in accordance with unit policies, platform configurations, and safety requirements.
• TACEVAC medical personnel should re-assess casualties and re-evaluate all injuries and previous interventions.

Airway Management Change in TACEVAC

Endotracheal intubation may be considered in lieu of cricothyroidotomy if trained. This is the key difference from TFC airway management.

Respiration / Breathing — Oxygen Indications

Most combat casualties do not require supplemental oxygen, but administration of oxygen may benefit:

• Low oxygen saturation by pulse oximetry
• Injuries associated with impaired oxygenation
• Unconscious casualty
• Casualty with TBI — maintain oxygen saturation greater than 90 percent
• Casualty in shock
• Casualty at altitude
• Known or suspected smoke inhalation

Sections Identical to Tactical Field Care

The following sections are the same as Tactical Field Care: Massive Hemorrhage, Circulation, Moderate/Severe TBI, Hypothermia Prevention, Penetrating Eye Trauma, Monitoring, Analgesia, Antibiotics, Inspect and Dress Wounds, Check for Additional Wounds, Burns, Splint Fractures, Documentation of Care.

CPR in TACEVAC

• Casualties with torso trauma or polytrauma who have no pulse or respirations during TACEVAC should have bilateral needle decompression performed to ensure they do not have a tension pneumothorax. Same procedure as Respiration/Breathing.
• CPR may be attempted during this phase of care if the casualty does not have obviously fatal wounds AND will be arriving at a facility with surgical capability within a short period of time.
• CPR should NOT be done at the expense of compromising the mission or denying lifesaving care to other casualties.

Communication

• Communicate with the casualty if possible. Encourage, reassure, and explain care.
• Communicate with medical providers at the next level of care as feasible. Relay mechanism of injury, injuries sustained, signs/symptoms, and treatments rendered.