Tactical Combat Casualty Care Update

Tactical Combat Casualty
Care Update - 2017
Special Operations Medical

Association Scientific Assembly
25 May 2017
Dr. Frank Butler
Disclaimers
“The opinions or assertions contained herein

are the private views of the author and are not
to be construed as official or as reflecting the
views of the Departments of the Army, Air
Force, Navy or the Department of Defense.”
- No financial interests in items discussed
- Off label uses: TXA, OTFC, Ketamine
Thanks!
Overview
• Brief History of TCCC

• Recent Advances
• TCCC Policy
• TCCC Red/Green Chart
• TCCC Training
• Non-Compressible Hemorrhage in TCCC 4
5
Battlefield Trauma Care:
Vietnam
“All seem uncertain regarding the best
method to implement factual knowledge
to the man most in need, the front line
trooper….citing our ineptness in the field
of self-help and first aid …..”little if any
improvement has been made in this
phase of treatment of combat wounds in
the past 100 years.”
CAPT J.S. Maughon

Mil Med 1970 6
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 arrival. In fact there were
193 deaths due to wounds of the upper and
lower extremities, …… of the 2600.”
CAPT J.S. Maughon
Mil Med 1970
* Extremity hemorrhage math in Vietnam:
193 of 2600 = 7.4% x 46,233 fatalities = 3,421
7
preventable US deaths from extremity hemorrhage
1992
• 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 shock
• Civil War-vintage technology for battlefield analgesia IM
morphine)
• SOF medics – IV cutdowns for difficult venous access
• No tactical context for 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 8
Butler, Smith Carmona
J Trauma 2015
“The US Military had not effectively sustained many of the lessons learned from past
conflicts and went to war in Afghanistan without wide availability of tourniquets,
without modern battlefield analgesics, without prehospital plasma, and without
trauma care guidelines designed specifically for use on the battlefield. Hemostatic
dressings had not yet been developed and fielded. There was no military deployed
trauma system, no Department of Defense trauma registry (DoDTR), no weekly
worldwide trauma teleconferences to review treatments and outcomes for all
casualties occurring in the preceding week, and no Committee on Tactical Combat
Casualty Care (CoTCCC).”
Evaluating Evidence and
Changing Cultures
“It seems unthinkable. Special operators, America’s best

warriors, getting shot in the arm or the leg and bleeding to
death. But it was happening over and over.“
Chancellor William McRaven – May 2017 10

Evaluating Evidence and
Changing Cultures
USS Arizona
“As far as sinking a ship with a bomb is concerned –

you just can't do it.“
11
Rear Admiral Clark Woodward, 1939
Tactical Combat Casualty Care
The Prehospital Arm of the Joint Trauma System
• Medics, Corpsmen, PJs

TCCC • Combat Lifesavers
• All Combatant Self/Buddy Care
• Includes Tactical Evacuation Care
12
Photo – MSG (R) Harold Montgomery
Now
• 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
• Resuscitation with blood products
• 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
13
• Junctional Tourniquets/XStat/Pelvic binders
TCCC: How Do We Know
That It’s Working?
• Near universal DoD acceptance after 14 years of war
• 67% reduction in deaths from extremity hemorrhage
• Tarpey 2005: “Overwhelming Success” in 3rd ID
• Kragh: Estimated over 1000 lives saved with
tourniquet use – in 2008
• Kotwal: Lowest incidence of preventable deaths
ever documented by a combat unit
• Savage: Highest casualty survival rate in Canadian
Military’s history
• Acceptance by NAEMT/American College of
Surgeons /Hartford Consensus/WH Stop the Bleed14
Overview

• Recent Advances
• TCCC Policy
• TCCC Training
• Non-Compressible Hemorrhage in TCCC15
Recent Advances in TCCC 16
“Three Things I Would
Change in TCCC” Talks
• Surg CAPT Steve Bree – February 2016

• Top recommendation – add pelvic binders
• TCCC Working Group agreed
• Proposed change on pelvic binders pending
– Col Stacy Shackelford
Pelvic Binders in TCCC:
APPROVED
Col Stacy Shackelford

Tactical Field Care and
TACEVAC Care
4. Bleeding
c. 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
What Exam Findings Are
Suggestive of a Pelvic Fracture?
Exam Findings:
– Pelvic pain
– Laceration or bruising at bony
prominences of the pelvic ring
– Deformed or unstable pelvis
– Unequal leg length
– Scrotal, perineal, or perianal bruising
– Blood at the urethral meatus
– Massive hematuria
– Blood in the rectum or vagina
– Neurologic deficits in lower extremities
Monty’s Megachange –
APPROVED
• Approved 31 Jan 2017

• 23 Separate items
21
Monty’s Megachange
Inclusion Criteria
1) Tactical rather than medical issue

- Establish a security perimeter at start of TFC
2) Clarification of wording
- Timing of TXA administration
3) Non-contentious
- “Control Massive Hemorrhage” as the first
medical action in TFC
* Unanimous approval by CoTCCC 22

TCCC Literature Review
"First get your facts; then you can distort

them at your leisure."
Mark Twain
Wilderness Medical Society
TCCC Preconference 2016
June 2017
Dedicated TCCC issue of “Wilderness
and Environmental Medicine”
• July 2016
• Dr. Brad Bennett and COL Ian Wedmore
• 22 TCCC presenters
24
TCCC Journal Watch
TCCC Article Abstracts:

Monthly focused PUBMED search
of prehospital trauma literature
TCCC Distro List

• TCCC Change Notices
• TCCC Article Abstracts
• TCCC Info Items
* To be added to the list:

danielle.m.davis.civ@mail.mil
TCCC in Social Media
Thanks, Monty!
26
27
TCCC Quick Reference
Guide - Monty
• PDF
• Will be given to ALL TCCC students
• v1 contents:
- TCCC Clinical Algorithms
- Abbreviated TCCC Guidelines
- TCCC Equipment list
- DD 1380 and TCCC AAR
- TCCC Evacuation Priority Recommendations
- TCCC casualty planning chapter
(Kotwal and Montgomery)
- TCCC Medication Reference Sheet
28
- 9-line format
TCCC Clinical Algorithms
Monty/Butler/Giebner
29
Overview

• Recent Advances
• TCCC Policy
• TCCC Training
Secretary of Defense
James Mattis
• General Mattis letter to Service Chiefs

• Written during his time as CENTOM Commander
• Highlights Ranger success with TCCC
• Stresses importance of TCCC training 31
Secretary of Defense
James Mattis
32
33
34
*Thanks to Mr. Ed Whitt and Mr. Kevin Kelley
Overview

• Recent Advances
• TCCC Policy
• TCCC Training
Old 75th Ranger
Regiment Saying
10. Lessons Learned aren’t

really lessons learned -
unless you actually learn
them.
COL Russ Kotwal

MSG “Monty” Montgomery
TCCC Red/Green Chart:
Opportunities to Improve
Yes No
Evidence-Based
Continually
Updated
Strategic
Messaging
Medical Rapid
Fielding Plan
TCCC Training
Standardized
and Mandated
Physician TCCC
Training
DoD-FDA Panel
TCCC 37
Documentation
Overview

• Recent Advances
• TCCC Policy
• TCCC Training
Non-Standard TCCC
Courses
• Many “TCCC” courses (unit-based, service-
based, and vendor-based) – aren’t!
• Incorrect messaging
– Instructor drift
– “Never take off a tourniquet in the field”
– “Let the tourniquet down every 15 minutes”
• Incorrect messaging has been DIRECTLY
associated with adverse outcomes
• Inappropriate training
39
RECENT Preventable
Adverse Outcomes
• One Special Operations member suffered a leg
amputation from prolonged tourniquet use – only
amputation from tourniquet use in US forces. Unit
members had been told never to take off a tourniquet in
the field at their “TCCC” course. Tourniquet was left on
for over 8 hours.
• Casualty Suffered pulmonary edema at a foreign
medical facility from getting 9 liters of NS during
resuscitation from hemorrhagic shock
• Deaths from unrecognized tension pneumothorax
• Respiratory arrest from using midazolam after fentanyl
lozenges
Do You Really Know What
Your Medics Are Learning?
• Course widely used in DoD

• Banned by USSOCOM in 2005
• Continued to be used by other DoD
organizations
• Until Medical Director lost his license
• How does this happen?

• It could be avoided by a
training standard. 41
TCCC Training – The
Need for a Standard
• In the absence of a standard TCCC

course with a professionally developed
curriculum, "TCCC Training" in the DoD
can wind up being an hour of
Powerpoint slides or 11 days of
inappropriate training - or anything in
between.
42
The Military Training Network:
No Prehospital Trauma Courses
• Advanced Cardiac Life Support

• Advanced Trauma Life Support
• Basic Life Support
• Pediatric Life Support
• NO TCCC
* BUT – USUHS is now

Working on this!
43
Joint Trauma System
White Paper to Service SGs
• Outlined the problem

• Documented the bad outcomes from non-standardized
TCCC training
• Recommended that we use the JTS-developed TCCC
44
curriculum as taught through NAEMT
Right Training Standard
NAEMT
ACLS/BLS – American Heart Assn

ATLS – ACS Committee on Trauma
TCCC – JTS and CoTCCC
ACS COT and NAEMT
* Key point: NAEMT training sites can be established

at military bases anywhere in the world or with
commercial TCCC training vendors
46
TCCC Critical Decision
Videos
47
The Biggest Challenge
• WHEN to intervene
• COL Bob Mabry’s airway video
• Especially with surgical airways and NDC

– Can cause harm as well as help
• “When To” TCCC Decision Videos pending

at present as a new CoTCCC knowledge
product 48
TCCC Critical Decision
Videos - The Setting
• Small unit on foot patrol

• Incoming fire from two hostiles
• Hostile threat eliminated

• One of your unit members has a gunshot
wound to the lower face
• There is no further effective incoming fire
49
TCCC Critical Decision Videos
- The Casualty
• Casualty awake
• Facial wounds to lower jaw and teeth
• Blood in the mouth
• Casualty noted to have noisy, rapid breathing while in
supine position
• Struggling to breathe
• Dashboard (Inset on the video)

AVPU Awake
Airway Facial injuries
Breathing RR 22 - Noisy and rapid
Radial Pulse Strong
O2 Saturation 75% 50
Videos Coming Soon:

Thanks USAISR!
COL Elizabeth Mann-Salinas
Ms. Tricia Garcia 51
Question
What is the next action you should take?
1) Cricothyroidotomy
2) Nasopharyngeal airway
3) Endotracheal intubation
4) Allow a conscious casualty to assume any position that
best protects the airway, to include sitting up.
52
Correct Answer and Feedback
The correct answer is (4). The diagnosis is potential
airway obstruction due to maxillofacial injuries. The
principle is to open the airway. Since the casualty is
conscious, Allow the conscious casualty to assume
any position that best protects the airway, to include
sitting up and leaning forward.
53
Overview

• Recent Advances
• TCCC Policy
• TCCC Training
Noncompressible hemorrhage
is the NUMBER ONE cause
of preventable death
in US combat fatalities.
Question
What is the NUMBER ONE

Thing That a Combat Trauma Surgeon
Needs To Be Successful?
Answer
A LIVE CASUALTY to operate on!

TCCC and Hemorrhage
May 2017
Compressible Non-Compressible
Tourniquets Pelvic Binders
Hemostatic Dressings
Junctional Tourniquets
XStat
Both
Minimize Evacuation Time to Surgical Capability
Optimize TXA Use
Prehospital Damage Control Resuscitation
Avoidance of Platelet-impairing NSAIDs
TCCC Triple-Option Analgesia Plan
58
Hypothermia Prevention
Noncompressible Hemorrhage
in TCCC
Can Be Done Now

Minimize evacuation time to surgical capability
Pelvic Binders
Far-Forward Whole Blood
Optimize TXA use; administer it immediately
when indicated
Avoidance of platelet-impairing NSAIDs
Triple-Option Analgesia
59
COL (Ret) Russ Kotwal
TIME IS IMPORTANT!
Kotwal et al – JAMA Surg 2015

For NCH, Sooner Is Better.
Period.
“In this analysis, we noted a precipitous incremental rise

in patient mortality in patients with high-grade injuries at
prehospital times 0-15 and 16-30 min, irrespective of
mechanism.” 62
For NCH, Sooner Is Better.
Period.
P85 – R. Adams Cowley
Baltimore Shock Trauma
1969
The University Hospital at this point
in time had refused to staff the new
ORs in Shock Trauma, requiring
trauma patients to be moved to
main hospital’s ORs.
“In one eight-month period I lost

15 patients just trying to get them
from here over to the main
hospital…”
Dr. Catherine Musemeche 63

R. Adams Cowley
in TCCC
Can Be Done Now

Pelvic Binders
when indicated
64
in TCCC
Can Be Done Now

Pelvic Binders
when indicated
65
Fluid Resuscitation from
Hemorrhagic Shock
“The historic role of crystalloid and colloid
solutions in trauma resuscitation represents
the triumph of hope and wishful thinking over
physiology and experience.”
COL Andre Cap
J Trauma, 2015
There is an increasing awareness that fluid

resuscitation for casualties in hemorrhagic shock
is best accomplished with fluid that is identical to
that lost by the casualty - whole blood.
Advocates for:
• FWB as the optimal prehospital choice for hem. shock
• TXA as an adjunct to whole blood
• Balanced blood components if FWB not feasible
TCCC Fluid Resuscitation fm
Hemorrhagic Shock: 2014
Journal of Special Operations Medicine - 2014

TCCC Fluid Resuscitation fm
Hemorrhagic Shock: 2014
Updated Fluid Resuscitation Plan
Order of precedence for fluid resuscitation of
casualties in hemorrhagic shock
1. Whole blood
2. 1:1:1 plasma:RBCs:platelets
3. 1:1 plasma: RBCs
4. (tie) Plasma (liquid, thawed, dried) or RBCs
alone
8. Hextend
9. (tie) Lactated Ringers or Plasma-Lyte A
Butler et al – JSOM 2014
70
CDR Geir Strandenes - THOR 2016
Tactical DCR
Fisher et al 2015
• FWB is the best prehospital resuscitation fluid

• 75th Ranger Regiment program
• Type O – Low Titer Anti-A, Anti-B abs
• Donors pre-screened for type, titers,
and infectious diseases
• Use donor pool to transfuse casualties in shock
Type O Low Titer Whole Blood
with a Prolonged Shelf Life
• The “Holy Grail” of prehospital
fluid resuscitation options?
• Identify Type O Low donors
• Collect the blood CONUS or closer
to theater
• Screen for pathogens – FDA compliant
• New technology for cryopreservation to
enable prolonged storage without
loss of efficacy
• Move far-forward with electrically
powered blood coolers (Wild 2013)
ASBPO Letter
11 April 2016
73
in TCCC
Can Be Done Now

Pelvic Binders
when indicated
74
75
Huang – TXA Meta-Analysis
J Surg Res 2013
• Results: “A total of 46 randomized controlled trials

involving 2925 patients were included. The use of TXA
reduced total blood loss by a mean of 408.33 mL….”
TXA Take-Homes
• The best way to prevent death from hemorrhage

is to PREVENT blood loss.
• There is Level A evidence that TXA reduces
blood loss in elective surgery patients.
• There is Level A evidence that TXA does not
increase the risk of thromboembolic
complications in elective surgery patients.
• TXA is given BEFORE the bleeding starts in
elective surgery.
Harvey – TXA
Annals Emerg Med 2014
?
Question
• For a trauma patient with ongoing life-
threatening extremity hemorrhage – what
is the best time to apply a tourniquet?
• Within 1 hour?
Illustration:
• Within 3 hours? Dr. Lenworth Jacobs
• RIGHT NOW? Hartford Consensus
• So – for a patient with non-compressible torso

hemorrhage – give TXA immediately!
in TCCC
Can Be Done Now

Pelvic Binders
when indicated
80
Many Ibuprofen-Type Meds
Can Help You Bleed to Death!
• Aspirin, ibuprofen, ketorolac, and other
nonsteroidal anti-inflammatory medicines
(NSAIDS) other than meloxicam should be avoided
while in a combat zone because they interfere with
blood clotting.
• Aspirin, ibuprofen, and similar drugs may inhibit
platelet function for approximately 7-10 days after
the last dose.
• You definitely want to have your platelets working
normally if you get shot.
• Acetaminophen (Tylenol) and meloxicam (Mobic)
DO NOT interfere with platelet function – this is the
primary feature that makes them the non-narcotic
pain medications of choice.
Text from TCCC Curriculum
NSAID Use in Deployed
US Forces
• Forward Operating Base in Afghanistan

• Soldiers surveyed about over-the-counter or
prescription NSAID use 82
NSAID Use in Deployed
US Forces
• 175 soldiers surveyed - 75% reported using

NSAIDs more than twice a week
• TCCC: Use acetaminophen and meloxicam
83
for minor pain at your forward location!
in TCCC
Can Be Done Now

Pelvic Binders
when indicated
84
Warning: Morphine and
Fentanyl Contraindications
• Hypovolemic shock – opioids
may cause a further
decrease in blood pressure
• Respiratory distress
• Unconsciousness
• Severe head injury
• DO NOT give morphine or fentanyl to
casualties with these contraindications.
TCCC Curriculum
Option 3
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
in TCCC
Can Be Done Now

Pelvic Binders
when indicated
87
and Coagulation
• Even a small decrease in body
temperature can interfere with blood
clotting and increase the risk of bleeding
to death.
• Casualties in shock are unable to generate
body heat effectively.
• Wet clothes and helicopter evacuations
increase body heat loss.
• Remove wet clothes and cover casualty
with hypothermia prevention gear.
• Hypothermia is much easier to prevent
than to treat!
Text from TCCC Curriculum
NEW HPMK
89
Use the HPMK to prevent hypothermia in casualties
in TCCC
What is the impact of

these interventions?
90
Reducing Deaths from Bleeding:
Memorial Hermann 2017
TCCC bleeding interventions

as used in the civilian sector 91
“Concentrating on the first hour post injury, the

primary cause of death changed from hemorrhage
(60.3%) followed by head injury (37.5%) in
2005–2006 to mostly head injuries (52.7%)
followed by hemorrhage (38%) in 2012–2013.”
• 37% reduction in bleeding deaths in the first hour

92
• 11% absolute reduction in deaths from bleeding

93
On the Horizon
Options for the management of noncompressible

hemorrhage in TCCC currently being evaluated
94
Noncompressible Hemorrhage:
Future Treatment Options?
More Research and/or FDA Approval Needed

Dried Plasma - if no whole blood or 1:1
Compensatory Reserve Index Monitor
ResQFoam
REBOA
Re-Look at AAJT?
Pelvic Hemostatic belt
95
Questions?
Thank You!
96

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Tactical Combat Casualty

Care Update - 2017

Special Operations Medical

“The opinions or assertions contained herein

• Brief History of TCCC

CAPT J.S. Maughon

“It seems unthinkable. Special operators, America’s best

Chancellor William McRaven – May 2017 10

“As far as sinking a ship with a bomb is concerned –

The Prehospital Arm of the Joint Trauma System

• Medics, Corpsmen, PJs

• Brief History of TCCC

• Surg CAPT Steve Bree – February 2016

Col Stacy Shackelford

• Approved 31 Jan 2017

1) Tactical rather than medical issue

* Unanimous approval by CoTCCC 22

"First get your facts; then you can distort

TCCC Article Abstracts:

TCCC Distro List

* To be added to the list:

• Brief History of TCCC

• General Mattis letter to Service Chiefs

• Brief History of TCCC

10. Lessons Learned aren’t

COL Russ Kotwal

• Brief History of TCCC

• Course widely used in DoD

• How does this happen?

• In the absence of a standard TCCC

• Advanced Cardiac Life Support

* BUT – USUHS is now

• Outlined the problem

ACLS/BLS – American Heart Assn

* Key point: NAEMT training sites can be established

• COL Bob Mabry’s airway video

• Especially with surgical airways and NDC

• “When To” TCCC Decision Videos pending

• Small unit on foot patrol

• Hostile threat eliminated

• Dashboard (Inset on the video)

Videos Coming Soon:

• Brief History of TCCC

What is the NUMBER ONE

A LIVE CASUALTY to operate on!

Can Be Done Now

Kotwal et al – JAMA Surg 2015

“In this analysis, we noted a precipitous incremental rise

“In one eight-month period I lost

Dr. Catherine Musemeche 63

Can Be Done Now

Can Be Done Now

There is an increasing awareness that fluid

Journal of Special Operations Medicine - 2014

• FWB is the best prehospital resuscitation fluid

Can Be Done Now

• Results: “A total of 46 randomized controlled trials

• The best way to prevent death from hemorrhage

• So – for a patient with non-compressible torso

Can Be Done Now

• Forward Operating Base in Afghanistan

• 175 soldiers surveyed - 75% reported using