20 TECC-Summer-Fall 11-2_TCCC 9/5/11 6:40 PM Page 104

TacTical EmErgEncy casualTy carE (TEcc):

guidElinEs for ThE Provision of PrEhosPiTal
Trauma carE in high ThrEaT EnvironmEnTs
Callaway DW; Smith ER; Cain J; Shapiro G; Burnett WT; McKay SD; and
Mabry R
Corresponding Author:

David W. Callaway, MD
Director, The Operational Medicine Institute (OMI)
Assistant Professor of Emergency Medicine
Carolinas Medical Center
1000 Blythe Blvd
Charlotte, NC 28203

Authors

E. Reed Smith, MD W Thomas Burnett, MD, FACEP

Operational Medical Director Operational Medicine Director
Arlington County Fire Department Department of Emergency Medicine
Assistant Professor of Emergency Medicine Virginia Tech Carilion School of Medicine
The George Washington University
Address is 1020 North Hudson Street, 3rd Floor Sean D. McKay, EMT-P
Arlington, VA 22201 Associate, Asymmetric Combat Institute (ACI)
115-136 Wade Hampton Blvd.
Jeffery S. Cain, MD Taylors, SC 29687
Medical Director, McKinney SWAT
2804 Atwood Drive Robert L. Mabry, MD
McKinney, TX 75070 United States Army
Institute of Surgical Research
Geoff Shapiro, EMT-P 3400 Rawley E, Chambers Ave
Coordinator, Operational Medicine Programs Fort Sam Houston, TX 78234
The George Washington University
2131 K Street, NW Suite 510
Washington, DC 20037

104 Journal of Special Operations Medicine Volume 11, Edition 3 / Summer/Fall 11

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inTroducTion
Civilian Tactical Emergency Medical Support (TEMS) has a long history in the United States. Enormous
progress has been made during the past ten years in developing professional and operational standards within the field.
However, to date, there still exists no standard of care within TEMS specifically, and more broadly for high threat pre-
hospital trauma care. Current civilian first responder practices and principles do not adequately address the need for
point of wounding care in atypical, high threat emergency response. The enclosed Tactical Emergency Casualty Care
(TECC) guidelines are based upon the principles of Tactical Combat Casualty Care and specifically designed to address
this operational gap.1
The “holy grail” of trauma care outcomes remains eliminating preventable deaths. In 1996, Butler and Hag-
mann’s seminal paper on modern battlefield prehospital care examined the manner in which people die in combat, dis-
cussed the limitations of Advanced Trauma Life Support (ATLS) for combat medics and proposed a new set of principles
for high threat trauma care: Tactical Combat Casualty Care (TCCC).2 The initial TCCC guidelines focused on the three
major preventable causes of death on the modern battlefield: isolated extremity hemorrhage, tension pneumothoraces
and airway obstruction. Perhaps more importantly, TCCC initiated a paradigm shift in prehospital trauma care, empha-
sizing tactical constraints (e.g., incoming fire, light/noise discipline, and mission success) as a major determinant of
trauma intervention.
During the past decade, the implementation of Tactical Combat Casualty Care (TCCC) has been one of the major
factors in reducing preventable death on the modern battlefield. 3 TCCC guidelines are credited with reducing the case fa-
tality rate (CFR) in current combat operations from approximately 14% in Vietnam to 7.4-9.4% during Operation Iraqi
Freedom (OIF) and Operation Enduring Freedom (OEF).4,5 In a memorandum dated 6 August 2009, the Defense Health
Board (DHB) noted that in several Special Operations units in which all members were trained in TCCC, no reported in-
cidents of preventable battlefield fatalities occurred during the entirety of their combat deployments. Given this high rate
of efficacy, the DHB now recommends TCCC training for all deploying combatants and medical department personnel.
The proven success of TCCC on the battlefield, led the civilian medical community, both tactical and conven-
tional, to examine closely the tenants of the TCCC doctrine and integrate portions into civilian trauma care. Many agen-
cies have simply implemented TCCC as their standard of care. Others have resisted, citing semantic concerns about
“military language” and operational concerns regarding difference in target populations, resource limitations, and legal
constraints.
As a result, civilian tactical and emergency medical elements stand at the same crossroads where the Special Op-
erations medical community stood in the 1990s. Rigid, en bloc application of TCCC guidelines in civilian protocols is
as fundamentally flawed as utilizing civilian ATLS principles for battlefield trauma management. TCCC is written for
the combat medic operating in a combat theater, not for the civilian tactical medic operating in a single-dwelling, small-
scale urban tactical environment. Undoubtedly, weapons and wounds are similar between the two settings and federal and
civilian tactical teams are indeed “in combat”. Despite these similarities, just as ATLS did not address many of the unique
factors specific to the military combat environment, TCCC does not address the differences between military and civil-
ian environments (Figure 1).

figure 1: characteristics that distinguish civilian from military high threat prehospital environments.
• Scope of practice and liability: Federal and civilian medical responders must practice under State and local scope
of practice and protocols, and are subject to both negligence and liability that the military provider is often not.
• Patient population to include geriatrics and pediatrics: TCCC data and research was heavily based off of an 18-30
year old population, not all age groups as represented in civilian operations. TCCC was written primary to address
the wounded combatant and does not address high threat care for innocent non-combatants. Generally shorter
distances and greater resources available for evacuation to definitive care.
• Differences in barriers to evacuation and care: Despite the threat of dynamic terrorist attacks, secondary attacks and
armed resistance to evacuation is far less common in the civilian setting.
• Baseline health of the population: The TCCC combatant population is relatively healthy and physically fit without
the high incidence of chronic medical illness that exists in the civilian population.
• Wounding patterns: Although the weapons are similar between military and civilian scenarios, the wounding pat-
terns differ given the prevalence of and differences in protective ballistic gear, as well as the use of and strength of
improvised explosive devices in the military setting.
• Chronic medication use in the injured: TCCC does not account for or address the effects of chronic medication use,
such as beta- blockers and anti-coagulants.
• Special populations: Special populations (e.g. pregnant or physically disabled) are prevalent in the civilian setting
and the required differences in their care are relevant in domestic counter- terrorism and anti- terrorism response.

Tactical Emergency Casualty Care (TECC):

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The TECC guidelines are a set of best-practice recommendations for casualty management during high- threat
civilian tactical and rescue operations.6 The guidelines are based on the principles of Tactical Combat Casualty Care
(TCCC), but account for differences in the civilian environment such as allocation and availability of resources, variances
in patient populations, and scopes of practice. The goals of Tactical Emergency Casualty Care are to:
• Balance the threat, civilian scope of practice, differences in civilian populations, medical equipment limits, and
variable resources for responses to atypical emergencies.
• Establish frameworks that balance risk - benefit ratios for all civilian operational medical response elements.
• Provide guidance on medical management of preventable deaths at or near the point of wounding.
• Minimize providers’ risks while maximizing patients’ benefits.

TacTical EmErgEncy casualTy carE (TEcc)

In conventional emergency medical services (EMS protocols, scene safety is the first priority. However, this al-
gorithmic tenet does not account for unsecure scenes. Civilian first responders are increasingly required to operate in high-
threat environments. Traditional care guidelines are inherently limited in that they are solely patient- focused, without
acknowledgement of the surrounding operational or tactical constraints. The TECC principles are a sound compilation of
trauma guidelines, integrating operational and medical requirements into a consolidated set of best practices specific to high-
threat prehospital care. As with the battle-tested concepts of Tactical Combat Casualty Care (TCCC), the TECC principles
are just that: principles, not inflexible or rigid protocols.
In Tactical Emergency Casualty Care, operational scenarios and relative threat levels drive clinical interventions. The
three phases of TECC are modeled on TCCC, and represent translated “lessons learned” from combat and their applica-
tion to high-threat, civilian pre- hospital care. The phases are dynamic, occasionally overlapping, and rarely linear. It is
of utmost importance to recognize that the threat zones are situational, not geographic. This concept is a critical compo-
nent of the application of TECC in real world settings. The three phases of TECC are:

• Direct Threat Care/Care Under Fire (DT/CUF)

• Indirect Threat Care/Tactical Field Care (ITC/TFC)
• Evacuation/Tactical Evacuation (EVAC/TACEVAC)

dirEcT ThrEaT carE/ carE undEr firE

Direct Threat/Care Under Fire (DT/CUF) describes actions taken in response to a casualty where the external, on-
going threat to life is as dangerous, or more dangerous, than the injury sustained. Very minimal “medical” intervention is
generally warranted. The risk of further injuries to the casualty and the rescuer is extremely high while under direct hos-
tile threat in high-risk environments. Examples of DT/CUF include a law enforcement officer shot in the doorway of an
apartment during a high-risk warrant search or a fire fighter rapid intervention team (RIT) member encountering an injured
team mate during imminent structural compromise. Available medical equipment is often limited and the tactical scenario
dictates medical interventions.
The military adage that “the best medicine on the battlefield is fire superiority” has caused significant concern in
the application of TCCC to civilian high- threat environments. First, law enforcement personnel must deploy a broader spec-
trum of options to subdue threats than the military. For example, they are rarely able to conduct “recon by fire,” are lim-
ited in the application of “suppressive fire,” and even under direct threat, have wider responsibilities beyond their own
protection and that of their team, including the protection of victims and preservation of the community. Second, TECC
applies beyond Special Operations law enforcement; it is applicable to all high-risk prehospital providers. The concepts
of TECC are salient to EMS personnel responding to an underground subway blast, a firefighter rapid intervention team
(RIT) member in a structural collapse, or a medic responding to a dynamic school shooting. However, the concept of bal-
ancing the benefit of immediate trauma intervention with the threat posed by an ongoing direct threat applies across all of
these disciplines.
While under direct threat, TECC priorities are to prevent the casualty and responder from sustaining additional in-
juries, keep the response team engaged in neutralizing the threat, minimize public harm, and control life- threatening ex-
tremity hemorrhage. If injured while under direct threat, casualties should attempt to remain in the fight, take cover, provide
their own initial care, and control severe hemorrhage. They should then re-engage and assist their unit with neutralizing
continued active threats. Team members and medics in this phase can assist casualties in seeking cover, and may render
self-aid or buddy-aid to control severe hemorrhage while utilizing tactics that minimize the chance that other members of
the team will sustain additional casualties.

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Casualty extraction
Casualty extraction is a critical principle in TECC guidelines, from the point of wounding throughout various phases
of care. When examining the evidence based treatment modalities, it is crucial to remember these should not be performed
until the casualty and rescuer are behind cover. The adage “we don’t treat in the street” is sometimes lost in the chaos of the
moment; failure to adhere to this warning exposes casualties and rescuers to further harm. Effective point-of-wounding ex-
traction techniques are critical links in the chain of survival for casualties injured in high-threat environments. In real world
events, the need for unconventional extraction continues throughout all phases of care, to eventual casualty hand-off to higher
echelons of care. This could include the capability of breaching into lockdown situations for casualty collection points (CCP)
acquisition, breaching for casualty egress through restricted area (padlock systems, drywall, concrete block walls, etc), hasty
mechanical advantage or lowering systems for casualty removal from multi-story structures, expedient confined space /
structural collapse response, and rescue tactics, techniques, and procedures (TTPs) for chemical, biological, radiological, nu-
clear, and explosive (BRNE) events when operations dictate self-contained breathing apparatuses (SCBA) utilization. When
creating these rescue guidelines, it is important to fully understand the relevance and shortcomings of civilian-based rescue
capabilities, and if these elements are able to dynamically adapt to environmental variables with only organic assets.

Hemorrhage control
Early hemorrhage control is critical in operational medicine and trauma management. In the high-threat environ-
ment, this medical fact must be balanced with operational risk assessments. Accordingly, TECC recommends rapidly con-
trolling potentially life-threatening extremity hemorrhage. Tourniquets are the most effective, rapid intervention available.
Hemostatic dressings require 3-5 minutes of continuous pressure and should be deferred until the Indirect Threat Care/ Tac-
tical Field Care phase.
Uncontrolled extremity hemorrhage was the leading cause of preventable death in Vietnam (9% of total casualties)
and remains so in the current conflicts in Iraq and Afghanistan (2-3% of total casualties).7-9 Extremity trauma and exsan-
guination is also a major cause of preventable death in civilian trauma.10,11 Increasingly, civilian EMS and high-risk med-
ical teams are deploying tourniquets for routine utilization in daily operations. There is strong evidence supporting the
efficacy of tourniquets in controlling life-threatening hemorrhage,12,13 the importance of tourniquet placement prior to pro-
gression to states of shock, and the safety of tourniquet use for periods less than 2-4 hours.14
The U.S. Army Institute of Surgical Research (USAISR) conducted an extensive series of laboratory and field
tourniquet studies to identify the ideal characteristics for a field tourniquet as well as determine the most effective existing
commercial options. The criteria for the tourniquets are described in Table 1.15 Currently, the Combat Application Tourni-
quet (CAT) and the Special Operations Tactical Tourniquet (SOFT-T Wide) are the two most commonly utilized and demon-
strably effective options for high-risk prehospital environments. Both can be applied with one or two hands and have shown
100% efficacy in abolishing radial and femoral pulses.16 Other commercial tourniquets are available, but should be utilized
with caution and after thorough investigation.
During the DT/CUF phase of CTECC, the Table 1: characteristics of tourniquets utilized in tactical
tourniquet should be applied as proximal as possible on and high-threat environments (adapted from the u.s.
the limb to facilitate speed and efficacy. It may be placed army institute of surgical research)
over the uniform, but caution should be exercised to in-
sure no objects obstruct the compression band (e.g., 1. Complete occlusion of arterial blood flow in thigh
knives in pockets or drop holster). The time of tourniquet 2. Capable of easy release and re-application
application should be clearly marked on the casualty and 3. Application time = 60 seconds
communicated to accepting providers during transfer. 4. Cost: < $20-30
5. Weight: <8oz (250g)
Airway management 6. Simplicity of application
In TCCC, airway management is deferred until 7. Easy application in the tactical environment (dark, cold,
Tactical Field Care. However, several Operators and hot, wet, sand, mud, or ice)
medics felt that placing the casualty in the recovery po- 8. Minimal familiarization
sition (i.e., on right or left side) to reduce likelihood of 9. No assembly; No batteries
airway obstruction was a rapid intervention that should 10. Width: >1.5 – 2.0”
be considered if judged necessary and if tactically feasi- 11. Shelf life of 10yr
ble. An illustrative example would be a combined shoot-
ing and blast incident with ongoing active shooter response. Victims may be suffering from facial trauma and airway
obstruction or be unconscious from blast injury. As the contact team moves toward the target, rapidly placing the casualties
in the recovery position may be a worthwhile intervention that quickly saves lives by preventing airway obstruction.

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Spinal Immobilization
In isolated penetrating injuries of the neck, spinal immobilization is rarely useful.17 However, the rescuer should
be cognizant of cervical spine protection during extraction if there is a significant blunt mechanism injury such as blast,
fall, or structural collapse. The tactical situation should dictate rescuer actions, and the risk of immediate death to the
rescuer should be weighed against the risk of further spinal cord injury from non- stabilized extraction of casualties.

indirEcT ThrEaT carE/ TacTical fiEld carE (iTc/Tfc)

The ITC/TFC articulates a set of trauma care priorities relevant during high-risk operations during periods when
the casualty and the provider are in an area of higher security, such as a casualty collection point (CCP) with cover and/or
concealment. Assessment and treatment priorities are similar to those under TCCC TFC: Major Hemorrhage control, Air-
way, Breathing/Respirations, Circulation, Head & Hypothermia, and Everything Else (MARCHE). Although the higher
degree of security for the casualty and the responder generally allow for a more deliberate approach to providing casu-
alty care, the first responder must remain cognizant that a tactical operation represents a dynamic process and scene se-
curity can change instantly. First responders must weigh the potential benefits of providing medical care against the
risks of the ongoing tactical operation and/or delaying opportunity to evacuate the casualty from the scene.

Disarm the Casualty

An important aspect of conducting a casualty assessment is ensuring that the casualty does not pose a threat to
himself or the rescuer. If the casualty has any degree of altered mental status, ensure casualty and rescuer safety by clear-
ing their weapons in an approved method, or removing their weapon from their person entirely. Responders should main-
tain high vigilance for safety when distraction devices or other explosive devices are present on the casualty’s kit.

Major Hemorrhage Control

Massive hemorrhage is the primary threat to life in most trauma patients, and gaining rapid hemorrhage control
is the first priority. Aggressively apply firm direct pressure to a wound site while the injury is exposed, as direct pres-
sure is the most effective method for controlling bleeding. If the rescuer cannot hold direct pressure for an extended pe-
riod of time, other measures of hemorrhage control should be applied. As discussed under the DT/CUF section,
appropriate tourniquet devices represent the most rapid and effective option for controlling extremity hemorrhage. If a
tourniquet was applied during the DT/CUF phase, it should be re-assessed during the ITC/TFC phase for effectiveness
or necessity. Tourniquets applied hastily over uniform clothing may not achieve adequate pressure to occlude arterial
blood flow. A hastily conducted aggressive casualty movement from the point of injury to a more secure location may
dislodge an otherwise adequate tourniquet. Additionally, as tourniquets are applied more liberally in tactical situations
for wounds with apparent significant hemorrhage, some will be applied to wounds that do not actually require tourniquets
for definitive hemorrhage control. If the trained medic examines the wound under more secure conditions and determines
a tourniquet is not required, he or she should apply an appropriate pressure dressing and release the tourniquet slowly,
and carefully assess the extremity for appropriate reperfusion and/or signs of compartment syndrome or vascular com-
promise.
For ongoing extremity hemorrhage not addressed during the DT/CUF phase that is amenable to tourniquet ap-
plication, apply the tourniquet directly over the skin proximal to the injury and tighten until a distal pulse is no longer
palpable. Eliminating as much distal blood flow as possible is important to prevent (or at least minimize potential for)
development of compartment syndrome.18-20
Soft tissue injuries can appear more severe, but are rarely life-threatening if expeditiously treated. Without
major vascular disruption, many bleeding soft tissue injuries can be adequately managed through applying appropriate
pressure dressings. Medical directors should strongly consider incorporating wound packing into these protocols, as
packing with sterile gauze in addition to compressive bandages provides more significant hemorrhage- control capabil-
ities than topically applied dressings alone.
Major vascular injuries within the neck, axilla, and groin (i.e., junctional zones) are not amenable to tourniquet
application and effective pressure dressings are often extremely difficult to apply. Hemostatic dressings used by mili-
tary forces demonstrate successful bleeding control in these types of injuries. Combat Gauze®, a kaolin-impregnated
gauze packing agent, is the primary hemostatic agent recommended by the Committee on Tactical Combat Casualty Care.
Many units are utilizing one of two chitosan-based gauze products (Chitogauze® and Celox Gauze®) with equally suc-
cessful results. Medical directors must ensure that appropriate tactical protocols incorporating wound packing are in
place when considering the addition of these hemostatic agents, as they are not intended for simple topical applications.
Some vascular injuries within these junctional zones cannot be controlled with tourniquets, pressure dressings,
or hemostatic agents. When tactical situations preclude rescuers from maintaining prolonged direct manual pressure, con-

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sider using mechanical devices to achieve prolonged direct pressure. When considering adding these mechanical devices
to existing protocols, we recommend selecting devices that have been clinically evaluated and received Food and Drug
Administration (FDA) approval.

Breathing
Combat data, as well as civilian police data, indicates that tension pneumothorax, although relatively simple to treat,
remains a significant cause of preventable death.21 As part of the initial assessment in ITC/TFC, the chest should be ex-
posed and examined thoroughly for any open chest wound not previously addressed. In ITC/TFC, operational limitations
often make it difficult to properly monitor for developing tension pneumothorax using the traditional physical signs of hy-
poxia, narrowing pulse pressure, tachycardia, and tracheal deviation. Instead, in ITC/TFC and other high-risk prehospital
settings, any patient with penetrating chest trauma that has progressive respiratory distress should be assumed to have a de-
veloping tension pneumothorax and should be treated with needle decompression. Leaving the catheter in place versus re-
moving it after 1-2 minutes is a matter of local protocol and preference. In most cases the catheter will clot off in a few
minutes making it no longer effective in evacuating air. The argument for removing the needle is to prevent providers from
assuming that a tension pneumothorax cannot develop because the catheter is continuously venting the space. The argu-
ment against removing the catheter is that it is a quick visual landmark to allow for subsequent needle decompressions.
There is no need to place a flutter valve on the catheter if left in place, as it will not create an open pneumothorax. The re-
sistance created by the small internal diameter of the 14-gauge catheter is such that air will move in and out of the larger
diameter mouth and trachea instead of the 14-gauge catheter. The patient with a penetrating chest wound needs to be closely
monitored for development of tension pneumothorax, especially if he/she required needle decompression. The TECC
guideline appendix describes two different techniques for needle decompression.

Circulation/ Resuscitation
Intravenous fluid resuscitation remains controversial, despite growing evidence that using non-blood products as
primary resuscitation fluids for hemorrhagic hypovolemia contributes to increased morbidity and mortality.22-25 The deci-
sion to initiate IV resuscitation should be based upon the casualty’s degree of blood loss and shock, as well as other factors
such as evacuation time to a definitive care facility. In general, young, healthy adult trauma patients with a palpable radial
pulse and normal mentation after hemorrhage control do not require emergent IV fluid therapy. Permissive hypovolemic
IV fluid resuscitation protocols have been used with great success by several military forces throughout ongoing multiple
global conflicts. A risk- versus- benefit analysis prior to administering IV fluids should be conducted for any trauma ca-
sualty. The current CoTCCC guidelines are included as an example of a hypovolemic protocol only. The U.S. military rec-
ommends Hextend as their IV fluid of choice as primarily for logistical advantages. For military forces lacking immediate
resupply capability who may experience delays in casualty evacuation ranging from multiples of hours to days, the bene-
fit of the duration of the intravascular volume expansion seen with that hetastarch-based fluid enables their personnel to op-
timize carried medical supplies 26-28 In the civilian setting, the significantly higher cost of colloid solutions must be balanced
against the limited medical benefits.

Hypothermia prevention and casualty packaging

Hypothermia in trauma patients results in dysfunctional clotting cascades, acidosis and subsequent increased mor-
tality. Hypothermia prevention begins during ITC/TFC. Casualties should be moved to a warmed location if possible. If
possible, the casualty should be packaged utilizing a heat retention system at minimum. In cold environments, the use of
active external rewarming may be beneficial. There are several commercial heat-producing hypothermia kits available and
in use currently by the military that can be considered. If unavailable, anything that will retain heat (e.g., dry blankets, body
bags, spare gortex jacket, etc.) should be applied.
In mass casualty scenarios, once the patient has been moved to an area where there is no direct or indirect exter-
nal life threat, primary triage can occur to identify critical patients and sort patients into groups according to their need for
immediate resources. This may occur during the ITC/TFC or during early stages of the EVAC/TACEVAC depending upon
the tactical scenario.

EvacuaTion carE / TacTical EvacuaTion carE (Evac/TacEvac)

Evacuation Care/Tactical Evacuation Care (EVAC/TACEVAC) describes actions taken to continue providing ap-
propriate trauma care during transport to definitive medical care when there is generally reduced threat to the patient and
medical provider. An example of EVAC/TACEVAC Care would be the care provided in the Triage/Treatment area or a se-
cure CCP during a mass casualty event while the patients are waiting for transport to a higher level of care.
In many civilian scenarios, this phase of care may be limited in the prehospital setting. A large percentage of civil-
ian high-risk scenarios will have resources and circumstances that allow for the patient to be rapidly transferred without

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scene delay directly to a high level fixed medical center. In these cases, the patient essentially moves from ITC/TFC di-
rectly into the trauma bay. However, if there is any delay in transfer due to the tactical scenario, logistics, or sheer vol-
ume of patients (e.g., mass-casualty incidents (MCI) or if the actual transfer requires a long transit time, then the
application of the guidelines of EVAC/TACEVAC become even more important
Providers in emergency departments and trauma centers should be familiar with the EVAC/TACEVAC guide-
lines. There are anecdotal published case reports of pre-hospital providers using appropriate equipment and interventions,
such as a commercial tourniquet, that are met with disbelief and confusion on the part of the civilian clinical staff in the
trauma bay. These providers must have baseline familiarity with the guidelines and procedures occurring outside of their
facility, and must have an understanding of how to assess and utilize prehospital interventions.
In the civilian setting, evacuation is generally via ground or helicopter- based EMS/ critical care platforms. De-
spite the usual methods, EVAC/TACEVAC must account for hasty evacuation with vehicles of opportunity (e.g., police
car, sport utility vehicle (SUV), armored vehicle, etc.). This section primarily discusses options for care on platforms with
either secure space or additional capabilities. Individual units should evaluate their evacuation assets and customize their
TTPs to account for mission- specific limitations.

Re-assess the casualty

Immediately assess the patient and re-assess all interventions that were applied in previous phases of care. The
interventions were likely applied in a hasty fashion, may have loosened during movement of the patient, and may no longer
be effective. The provider in EVAC/TACEVAC should take the time to look at all interventions and immediately address
any that appear to be ineffective and creating a life-threatening situation, or a situation that can lead to re-injury or den-
igration in clinical condition.

Airway
In EVAC/TACEVAC, if all major life threatening hemorrhage has been controlled in ITC/TFC, the provider
should move directly to controlling and maintaining the airway. With decreased external risk to the provider and patient,
this phase of care can be approached in a more traditional sense of Airway-Breathing-Circulation. The basic airway in-
terventions remain the same here as in previous phases, with the additional consideration for rapid sequence intubation
(RSI). The use of RSI and endotracheal intubation are time and resource intensive. The process requires that the provider
concentrates on the procedure and airway, sacrificing situational awareness. Thus, it is only introduced as a treatment
consideration in this phase when the external threat risk is mitigated. This intervention is most likely to only be avail-
able if the casualty is transported on a platform staffed with advanced providers (i.e., physicians, critical care nurse, or
paramedics).
Spinal immobilization may have a more important role in EVAC/TACEVAC. In EVAC/TACEVAC, the risk-
benefit ratio for spinal immobilization leans toward benefit; thus, if available immobilization should be implemented for
any patient with hard physical signs of neurologic injury and for any patient with a high-risk mechanism. In this phase,
consideration should be given to clearing the c-spine clinically using either the NEXUS or Canadian c-spine criteria.
This easily applied criterion has become standard of care in emergency departments and can identify patients that do not
need immobilization with almost 100% sensitivity. Caution should be used when applying the criteria to patients over
the age of 65 years, as there is a higher risk of occult injury in this age group. While treatment will be guided by local
protocols, delaying evacuation for patients in extremis with penetrating neck injures while performing meticulous spinal
immobilization must be balanced against getting the patient to definitive care.

Breathing
The interventions from ITC/TFC are continued into EVAC/TACEVAC. During evacuation, additional moni-
toring such as pulse oximetry are more routinely available. These adjuncts should be used to provide additional infor-
mation on the respiratory status of the casualty. Note that oxygen desaturation is a relatively late sign of respiratory
compromise, and newer techniques such as nasal end tidal CO2 may provide more timely information.
Although many trauma patients, such as those with isolated musculoskeletal injury, do not require supplemen-
tal oxygen, in this phase oxygen should be readily available in almost all civilian operational settings and should be lib-
erally applied. In mass casualty settings where resources are scarce, supplemental oxygen can be reserved for patients
with injuries to the respiratory system causing impaired oxygenation, casualties in shock, casualties with head injury, un-
conscious casualties, and any casualty with low oxygen saturation by pulse oximetry.
Chest tube placement should be considered on any patient who requires repeated needle decompressions, is
being air evacuated, or if there is a long delay in transport to definitive care. This is an advanced surgical procedure that
requires proper training, medical oversight and appropriate local protocols. Chest tubes always require a one-way valve.

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Bleeding
In EVAC/TACEVAC phase, all wounds should be fully exposed and evaluated to assess for efficacy of interven-
tions applied in prior phases of care. The patient should be exposed, including removal of protective gear if present, to allow
thorough evaluation for missed wounds. The gear should be examined for signs of damage and kept with the patient. At-
tention must be paid to prevent hypothermia. Any untreated major extremity wound or any extremity wound with bleed-
ing uncontrolled by prior interventions should be treated using a tourniquet applied 2-3 inches above the wound or by using
an appropriate pressure dressing with deep wound packing.
All tourniquets should be re-evaluated both for efficacy and for necessity. The complications of tourniquets are
all directly related to length of time in place; thus, the sooner they can be removed, the lower the complication rates. Sev-
eral studies show no complications in tourniquets left in place up to 120 minutes.29 Although there are certainly mass ca-
sualty and austere scenarios in which there may be a delay to definitive care of greater than 120 minutes, in high risk
scenarios with a limited number of casualties, the patient should be in definitive care at a fixed facility well within the two
hour window. The decision in this phase thus becomes whether to attempt to downgrade/remove the tourniquet or to leave
well enough alone until definitive care. If the tourniquet is necessary and effective, and the casualty will be quickly evac-
uated to a definitive care facility, it should remain in place. However, if there is an anticipated significant delay in trans-
fer to definitive care, consider transitioning the tourniquet to a pressure dressing.
Before any effective tourniquet is removed on a patient who has received IV fluid for shock, the patient must be
assessed clinically for positive responses to interventions. To move a tourniquet distally to a site 2-3 inches above the
wound, a new tourniquet should be placed in the new location. Once properly applied, the prior tourniquet can be loos-
ened. To downgrade a tourniquet to a pressure dressing, an appropriate pressure dressing with hemostatic or non-hemo-
static deep wound pack should be applied to the wound. Once applied, the tourniquet should be loosened and the wound
should be examined for signs of bleeding. If bleeding, the tourniquet is re-tightened and the pressure dressing is rein-
forced. If bleeding occurs when the tourniquet is loosened after reinforcement, the tourniquet is reapplied and left in place.
If there is no bleeding once the tourniquet is loosened, it is left in place.
Any distal pulse noted in a limb with a needed tourniquet in place should be addressed by additional tightening
or by application of a second tourniquet side-by-side (ideally proximal to the first tourniquet) to the first in order to apply
a wider base of pressure to the supplying vasculature. All tourniquets need to be clearly marked with indelible marker show-
ing the time of application.
Hemostatic agents should be utilized as in prior phases for any significant bleeding in wounds located in anatomic
areas not amenable to tourniquet placement, or for downgrading of tourniquets. The current, recommended fourth-gener-
ation hemostatic agents are primarily in the form of impregnated gauze.

Intravenous access and resuscitation

All patients with truncal injury, shock or signs of impending shock should have an 18-gauge IV saline lock placed.
The flow rates through an 18-gauge are not significantly lower than the 16- or 14-gauge IV needles and are easier to place
in the hypotensive casualty in the uncontrolled field setting. The casualty should be assessed for hemorrhagic shock, ei-
ther with blood pressure monitoring or, if unavailable, with assessment of mental status and peripheral pulses. Mental sta-
tus, in the absence of traumatic head injury, is the most effective marker of perfusion and shock; this, along with the presence
and character of peripheral pulses provides the caregiver with an excellent method to monitor for hemorrhagic shock.
If the patient is not in shock, no IV fluids are immediately necessary. Oral fluids may be considered in casualties
who are conscious, can swallow, and has no injury that would require emergent surgery. Oral fluids should also be con-
sidered if there is a significant delay in evacuation to care, as they will help comfort the patient.
For casualties exhibiting signs of hemorrhagic shock, blood products should be considered if readily available with
an appropriate provider and approved medical protocol. Several studies on combat wounded have shown the superior ef-
fect of resuscitation with blood products in a 1:1 ratio of plasma to packed red blood cells and/or whole blood when com-
pared to traditional resuscitation with intravenous fluids.30,31 Plasma rapidly addresses the coagulopathy of trauma,
essentially addressing one arm of the lethal triad of hypothermia-coagulopathy-acidosis. Although more studies are needed
in the civilian pre-hospital setting, the military data is strong enough to endorse this recommendation.32,33 If blood prod-
ucts are not available or not approved under local protocols, use of Hextend colloid or appropriate crystalloid in 500cc bo-
luses every 30 minutes to maintain hypotensive resuscitation is recommended. The goal systolic is 80-90mmHg and
improvement and mental status. Hextend should be limited to 1000cc total. Hypotensive resuscitation should be avoided
in casualties with concomitant head injury. In TBI, resuscitative fluid blouses should be administered to maintain the goal
systolic blood pressure of at least 90mmHg or palpable radial pulse. Any patient with a suspected traumatic brain injury
who is not in shock should be positioned with the head elevated to 30 degrees.

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Prevention of hypothermia
All efforts should be made in EVAC/TACEVAC phase to prevent the development of hypothermia while pack-
aging casualties and during transport to definitive care. Wet clothing should be removed and replaced with dry clothing
(if available), and the patient should be placed on a vapor barrier to prevent conductive heat loss to the ground or other
surfaces. Warmed IV fluids are preferred for resuscitation. It is important for providers to maintain this vigilance against
hypothermia while en route to definitive care, especially during air transport where cabin temperatures are often lower
than the temperature at the point of casualty collection.

Monitoring
Available monitoring including end-tidal CO2 for intubated patients should be instituted while waiting and dur-
ing transport to definitive care. All vital signs should be recorded for trending and continuity of care. With multiple ca-
sualties or noisy environments, pulse oximetry can be a useful adjunct to give a continuous visual reporting of pulse (as
well as oxygen saturation). Providers should ensure that pulse oximetry is measured on unaffected or uninjured limbs to
gain accurate readings.

Re-assess and re-triage

As time permits, a proper head-to-toe, front-to-back secondary survey should be performed. Any significant in-
juries not previously addressed should be treated including splinting of long bone or joint injuries and application of
pelvic binding techniques. A secondary triage of the patient should be preformed to determine mode and destination for
evacuation to definitive care.

Analgesia and antibiotics

In EVAC/TACEVAC, considerations for the casualty to continue the mission are less significant. However, in
certain scenarios, it may be necessary for the casualty to maintain mental faculties and remain operationally active. In
these scenarios and in cases where the casualty is experiencing only mild to moderate pain, oral or IV non-narcotic med-
ications are appropriate.
In cases of moderate to severe pain, in addition to oral and IV non-narcotic analgesics, narcotics are appropri-
ate and should be administered in any form and then titrated to effect. It is important to note that the onset of action for
intramuscular (IM) injection of narcotics can be up to 45-60 minutes so the medic should exercise caution and avoid
stacking. If utilizing narcotics, the provider must monitor closely for adverse effects and should have naloxone available.
Additionally, consideration should be given to having anti-emetics available when using narcotics for pain control. Dur-
ing evacuation, it is prudent utilize available electronic non-invasive monitoring if delivering narcotic analgesia.
The administration of antibiotics is not a traditional pre-hospital intervention. However, in high-risk opera-
tional settings such as wilderness rescue or austere scenarios where there may be a very significant delay in evacuation
to care, early administration of antibiotics for penetrating wounds and eye injuries may be beneficial to outcomes. In these
specific cases, the potential need should be anticipated and appropriate medical oversight should be involved.

Burns
Burn care in EVAC/TACEVAC phase is a continuation of care initiated in ITC/TFC phase. Early aggressive air-
way control and/or RSI should be initiated for any casualty with signs of inhalational injury. Total Body Surface Area
(TBSA) should be calculated and the patient should be covered with dry, sterile dressings. If possible, dressings and con-
certed efforts to prevent hypothermia should be initiated. In mass casualty situations where delay to evacuation may be
significant, consideration may be given to utilizing commercial burn dressings for pain control in casualties with burns
less than 20% TBSA. The risk of induced hypothermia from commercial burn dressings increases with larger burns and
thus should be avoided. Burn resuscitation should be initiated according to local protocol. Although burn patients will
eventually require significant amounts of fluids, the calculated requirements are for the first 8 and 24 hours and can be
easily made up using high volume infusers once the patient has reached definitive care; thus, excessive fluids do not
need to be immediately initiated in the EVAC/TACEVAC phase. Prevention of hypothermia and hypotensive resuscita-
tion for hemorrhagic shock takes clear precedence over burn fluid resuscitation in the field. Aggressive analgesic use for
burn casualties is appropriate.

Additional priorities
The rescuer must prepare casualties for movement with considerations given to environmental factors and other
evacuation procedures such as vertical lifts. At all points throughout the care of the patient in the EVAC/TACEVAC
phase, the casualty should be encouraged and reassured, even if they are unconscious. All information and procedures
should be explained in real time, and emphasis should be placed on keeping the casualty fully informed.

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Documentation of care needs to be completed in accordance to local protocols, ideally in the form of an approved
standardized local casualty care card for consistency. All assessments, treatments and medications rendered, trends and
changes in patient status need to be accurately documented and passed to the definitive care facility to provide effective con-
tinuity of care.
Cardiopulmonary resuscitation (CPR) may have a larger role during the evacuation phase especially for patients
with electrocution, hypothermia, non- traumatic arrest or near drowning. If resources are available and transit time is short,
CPR may be appropriate in the above settings.

conclusion
The Tactical Emergency Casualty Care (TECC) guidelines offer a set of principles for trauma management in
high-threat prehospital environments based upon the hard lessons learned from a decade of war. TECC defines what should
be done and when it should be done to stabilize the casualty in the civilian arena until the risk can be eliminated and the
casualty can be treated at a definitive care facility. The TECC guidelines represent a treatment framework that accepts mit-
igated risk while providing a significant life saving benefit.
Based upon the hard work of the Committee for TCCC and the sacrifices of American war fighters, the indications
and applications for TECC extend well beyond tactical law enforcement. ‘Tactical’ should not imply that the guidelines
are only for Law Enforcement operations. Tactical in this sense means operational, as tactics are performed on the fire
ground and in other operational settings every day. The Law Enforcement (LE) and special weapons and tactics (SWAT)
operations are a critical area for implementation. But, they are not the only end-users. TECC should be utilized in any high
risk and/or austere operational setting where the risk-benefit ratio to providers and patients drives decision- making, in-
cluding, but not limited to: active shooter response, improvised explosive device (IED) and blast response, CBRNE and ter-
rorism-related events, any mass casualty, wilderness and austere settings and rescue, and even in traditional trauma response.
The initial TECC guidelines are based upon anecdotal experience from warriors, best-practice recommendations
from combat medics, input from physicians, discussions with domestic first responders and scientific evaluation from our
academic institutions. As with TCCC, the TECC guidelines will evolve. The Committee for Tactical Emergency Casualty
Care will continue to update the guidelines through Journal of Special Operations Medicine, the C-TECC website and in
collaboration with the Special Operations Medical Association (SOMA).

Special Thanks to CAPT Frank Butler for his guidance, the CoTCCC for their continued dedication to the warfighter, and
to the men and women in harm’s way; on the battlefield and in our streets.

rEfErEncEs
1. Callaway DW, Smith ER, Cain J, McKay SD, Shapiro G, Mabry RL. The Committee for Tactical Emergency Casualty Care (C-
TECC): Evolution and application of TCCC Guidelines to civilian high threat medicine. J Special Operations Medicine 2011;
11(2): 84-89.
2. Butler FK, Hagmann J, and Butler GE. Tactical Combat Casualty Care in Special Operations. Mil Med 1996; 161( Suppl 3): 1-16.
3. Beekley AC, Starnes BW, Sebesta JA. Lessons learned from modern military surgery. Surg Clin N Am. 2007;87:157–184.
4. Holcomb JB, Stansbury LG, Champion HR, et al. Understanding combat casualty care statistics. J Trauma. 2006;60:397-401.
5. Gerhardt RT, DeLorenzo RA, Oliver J et al. Out-of-Hospital Combat Casualty Care in the Current War in Iraq. Ann Emerg Med
2009; 53(2): 169-174.
6. Callaway DW, Smith ER, Cain J, McKay SD, Shapiro G, Mabry RL. The Committee for Tactical Emergency Casualty Care (C-
TECC): Evolution and application of TCCC Guidelines to civilian high threat medicine. J Special Operations Medicine 2011;
11(2): 84-89.
7. Bellamy RF. The causes of death in conventional land warfare: implications for combat casualty care research. Mil Med
1984;149(2):55–62.
8. Champion HR, Bellamy RF, Roberts CP, et al. A profile of combat injury. J Trauma 2003;54(Suppl 5):S13–9.
9. Kragh JF, Littrel ML, Jones JA et al. Battle Casualty Survival With Emergency Tourniquet Use to Stop Bleeding. J Emerg Med
2009; Aug 28.
10. Acosta JA, Yang JC, Winchell RJ, et al. Lethal injuries and time to death in a level I trauma center. J Am Coll Surg
1998;186(5):528–33.
11. Dorlac WC, DeBakey ME, Holcomb JB, et al. Mortality from isolated civilian penetrating extremity injury. J Trauma
2005;59(1):217–22.
12. Beekley AC, Sebesta JA, Blackbourne LH, et al. Prehospital tourniquet use in Operation Iraqi Freedom: effect on hemorrhage
control. J Trauma 2008;64(2): S28–37.
13. Kragh JF Jr, Walters TJ, Baer DG, et al. Practical use of emergency tourniquets to stop bleeding in major limb trauma. J
Trauma 2008;64:S38–50.

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14. Lakstein D, Blumenfeld A, Sokolov T, et al. Tourniquets for hemorrhage control on the battlefield: A 4-year accumulated expe-
rience. J Trauma 2003;54(Suppl 5): S221–5.
15. Walters TJ, Wenke JC, Kauvar DS, McManus JG, Holcomb JB, Baer DG. Effectiveness of self-applied tourniquets in human
volunteers. Prehosp Emerg Care 2005 Oct-Dec;9(4):416-22.
16. Walters TJ, Wenke JC, Kauvar DS, McManus JG, Holcomb JB, Baer DG. Effectiveness of self-applied tourniquets in human
volunteers. Prehosp Emerg Care 2005 Oct-Dec;9(4):416-22.
17. Arishita GI, Vayer JS, Bellamy RF. Cervical spine immobilization of penetrating neck wounds in a hostile environment. J
Trauma 1989; 29: 332.
18. Tien, et al. Tactical Combat Casualty Care interventions. J Am Coll Surg 2008: 207(2): 174-178.
19. Kragh,JF et al. Survey for the indications for use of emergency tourniquets. J Special Operations Medicine 2011; 11: 30-38.
20. Kheirabadi BS, Scherer MR, Estep JS, Dubick MA, Holcomb JB. Determination of efficacy of new hemostatic dressings in a
model of extremity arterial hemorrhage in swine. J Trauma. 2009;67:450–459; discussion 459–460.
21. Sztajnkrycer MD. Tactical medical skill requirements for law enforcement officers: A 10-year analysis of line-of-duty deaths.
Prehosp Disaster Med 2010 Jul-Aug; 25(4):346-52.
22. Butler F. Fluid resuscitation in tactical combat casualty care: Brief history and current status. J Trauma 2011; 70(5): S11-12.
23. Haut ER, Kalish BT, Cotton BA et al. Prehospital intravenous fluid administration is associated with higher mortality in
trauma patients: A National Trauma Data Bank Analysis. Ann Surg 2011;253(2):371-377.
24. Dretzke J, Sandercock J, Bayliss S, et al. Clinical effectiveness and costeffectivenessof prehospital intravenous fluids in trauma
patients. Health Technol Assess 2004;8(23):iii,1–103.
25. Ley EJ, Clond MA, Srour MK, et al. Emergency department crystalloid resuscitation of 1.5L or more is associated with in-
creased mortality in elderly and non-eldely trauma patients. J Trauma 2011; 70 (2): 398-400.
26. McSwain NE, et al. State of the art fluid resuscitation 2010: prehospital and immediate transition to hospital. J Trauma 2011;
70(5): S2-10.
27. Schreiber MA. The use of normal saline for resuscitation in trauma. J Trauma 2011; 70(5): S13-14.
28. Lissauer ME et al. Association of 6% hetastarch resuscitation with adverse outcomes in critically ill trauma patients. Am J Surg
2011; 202(1): 53-58.
29. Lakstein D, Blumenfeld A, Sokolov T, et al. Tourniquets for hemorrhage control on the battlefield: A 4-year accumulated expe-
rience. J Trauma 2003;54(Suppl 5): S221–5.
30. Wafaisade A, Maegele M, Lefering R, et al. High plasma to red blood cell ratios are associated with lower mortality rates
in patients receiving multiple transfusions. J Trauma 2011; 70: 81-89.
31. Holcomb JB. Optimal use of blood products in severely injured trauma patients. Hematology 2010; 465-469.
32. Niles SE, McLaughlin DF, Perkins JG, et al. Increased mortality associated with the early coagulopathy of trauma in combat
casualties. J Trauma 2008;64:1459 –1465.
33. Holcomb JB, Wade CE, Michalek JE, et al. Increased plasma and platelet to red blood cell ratios improves outcome in 466
massively transfused civilian trauma patients. Ann Surg 2008; 248:447-458.

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TacTical EmErgEncy casualTy carE (TEcc) guidElinEs

dirEcT ThrEaT carE/ carE undEr firE (dT/cuf)

goals:
1. Accomplish the mission with minimal casualties
2. Prevent the casualty from sustaining additional injuries
3. Keep response team maximally engaged in neutralizing the existing threat (e.g. active shooter, unstable building,
confined space HAZMAT, etc.)
4. Minimize public harm

Principles:
1. Establish tactical supremacy and defer in depth medical interventions if engaged in ongoing direct threat (e.g., active
fire fight, unstable building collapse, dynamic explosive scenario, etc.).
2. Threat mitigation techniques will minimize risk to casualty and to provider.
3. Minimal trauma interventions are warranted.
4. Consider hemorrhage control
a. TQ application is the primary “medical” intervention to be considered in CUF/ Direct Threat.
b. Consider instructing casualty to apply direct pressure to the wound if no tourniquet available or
application is not tactically feasible.
5. Consider quickly placing or directing casualty to be placed in position to protect airway.

guidelines:
1. Mitigate the threat and take cover (e.g. Return fire, utilize less lethal technology, assume an overwhelming force pos-
ture, extraction from immediate structural collapse, etc.).
2. Direct the casualty to stay engaged in operation if appropriate.
3. Direct the casualty to move to cover and apply self aid if able.
4. Casualty Extraction
a. If a casualty can move to safety, they should be instructed to do so.
b. If a casualty is unresponsive, the scene commander or team leader should weigh the risks and benefits
of a rescue attempt in terms of manpower and likelihood of success. Remote medical assessment tech-
niques should be considered.
c. If the casualty is responsive but cannot move, a tactically feasible rescue plan should be devised.
d. Recognize that threats are dynamic and may be ongoing, requiring continuous threat assessments.
5. Stop life threatening external hemorrhage if tactically feasible:
a. Direct casualty to apply effective tourniquet if able
b. Apply the tourniquet over the clothing as proximal—high on the limb—as possible.
c. Tighten until cessation of bleeding and move to safety. Consider moving to safety prior to application
of the TQ if the situation warrants.
d. Tourniquet should be readily available and accessible with either hand
e. Consider instructing casualty to apply direct pressure to the wound if no tourniquet available or applica
tion is not tactically feasible
f. Consider quickly placing casualty, or directing the casualty to be placed, in position to protect airway if
tactically feasible

skill sets:
1. Tourniquet application
a. Consider PACE Methodology- Primary, Alternative, Contingency, Emergency
b. Commercially available tourniquets
c. Field expedient tourniquets
2. Tactical casualty extraction
3. Rapid placement in recover position

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indirEcT ThrEaT carE/TacTical fiEld carE (iTc/Tfc)

goals:
1. Goals 1-4 as with DT/CUF care
2. Stabilize the casualty as required to permit safe extraction to dedicated treatment sector or medical evacuation assets.

Principles:
1. Maintain tactical supremacy and complete the overall mission.
2. As applicable, ensure safety of both first responders and casualties by rendering weapons safe and/or rendering any ad-
junct tactical gear safe for handling (flash bangs, gas canisters, etc).
3. Conduct dedicated patient assessment and initiate appropriate life-saving interventions as outlined in the ITC/TFC
guidelines. DO NOT DELAY casualty extraction/evacuation for non-lifesaving interventions.
4. Consider establishing a casualty collection point if multiple casualties are encountered.
5. Establish communication with the tactical and/or command element and request or verify initiation of casualty extrac-
tion/evacuation.
6. Prepare casualties for extraction and document care rendered for continuity of care purposes.

guidelines:
1. Law Enforcement Casualties should have weapons made safe once the threat is neutralized or if mental status is altered.
2. Bleeding:
a. Assess for unrecognized hemorrhage and control all sources of major bleeding:
i. If not already done, use a tourniquet or an appropriate pressure dressing with deep wound packing
to control life-threatening external hemorrhage that is anatomically amenable to such treatment.
- Apply the tourniquet over the clothing as proximal— high on the limb— as possible, or if
able to fully expose and evaluate the wound, apply directly to the skin 2-3 inches above
wound.
- For any traumatic total or partial amputation, a tourniquet should be applied regardless of
bleeding.
b. For compressible hemorrhage not amenable to tourniquet use, or as an adjunct to tourniquet removal (if
evacuation time is anticipated to be longer than two hours), apply a hemostatic agent in accordance with
the directions for its use and an appropriate pressure bandage. Before releasing any tourniquet on a casu-
alty who has received IV fluid resuscitation for hemorrhagic shock, ensure a positive response to resusci-
tation efforts (i.e., a peripheral pulse normal in character and normal mentation).
c. Reassess all tourniquets that were applied during previous phases of care. Consider exposing the injury
and determining if a tourniquet is needed. Tourniquets applied hastily during DT/CUF phase that are de-
termined to be both necessary and effective in controlling hemorrhage should remain in place if the casu-
alty can be rapidly evacuated to definitive medical care. If ineffective in controlling hemorrhage or if
there is any potential delay in evacuation to care, expose the wound fully, identify an appropriate location
2-3 inches above the injury, and apply a new tourniquet directly to the skin. Once properly applied, the
prior tourniquet can be loosened. If a tourniquet is not needed, use other techniques to control bleeding
and remove the tourniquet.
d. When time and the tactical situation permit, a distal pulse check should be accomplished on any limb
where a tourniquet is applied. If a distal pulse is still present, consider additional tightening of the tourni-
quet or the use of a second tourniquet, side by side and proximal to the first, to eliminate the distal pulse.
e. Expose and clearly mark all tourniquet sites with the time of tourniquet application.
3. Airway Management:
a. Unconscious casualty without airway obstruction:
i. Chin lift or jaw thrust maneuver
ii. Nasopharyngeal airway
iii. Place casualty in the recovery position
b. Casualty with airway obstruction or impending airway obstruction:
i. Chin lift or jaw thrust maneuver
ii. Nasopharyngeal airway
iii. Allow casualty to assume position that best protects the airway- including sitting up
iv. Place unconscious casualty in the recovery position

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c. If previous measures unsuccessful:

i. Surgical cricothyroidotomy (with lidocaine if conscious)
ii. Oro/nasotracheal intubation
iii. Consider Supraglottic Devices (e.g. King LT, CombiTube, or LMA) per protocol.
d. Consider applying oxygen if available
4. Breathing:
a. All open and/or sucking chest wounds should be treated by immediately applying an occlusive material
to cover the defect and securing it in place. Monitor the casualty for the potential development of a
subsequent tension pneumothorax.
b. In a casualty with progressive respiratory distress and known or suspected torso trauma, consider a ten-
sion pneumothorax and decompress the chest on the side of the injury with a 14-gauge, 3.25 inch nee-
dle/catheter unit inserted:
i. In the second intercostal space at the midclavicular line. Ensure that the needle entry into the
chest is lateral to the nipple line and is not directed towards the heart.
ii. If properly trained, consider a lateral decompression, inserting the needle in the 2-4th inter
costals space, anterior to the mid- axillary line on the injured side.
5. Intravenous (IV) access:
a. Start an 18-gauge IV saline lock if indicated
b. If resuscitation is required and IV access is not obtainable, use the intraosseous (IO) route (per agency
protocol).
6. Fluid resuscitation: Assess for hemorrhagic shock; altered mental status (in the absence of head injury) and weak or
absent peripheral pulses are the best field indicators of shock.
a. If not in shock:
i. No IV fluids necessary
ii. PO fluids permissible if:
a. Conscious, can swallow, and has no injury requiring potential surgical intervention
b. If confirmed long delay in evacuation to care
b. If in shock:
i. Administer appropriate IV fluid bolus (500cc NS/LR/Hextend) and re-assess casualty. Repeat
bolus once after 30 minutes if still in shock.
ii. If a casualty with an altered mental status due to suspected TBI has a weak or absent peripheral
pulse, resuscitate as necessary to maintain a desired systolic blood pressure of 90mmHg or a
palpable radial pulse.
7. Prevention of hypothermia:
a. Minimize casualty’s exposure to the elements. Keep protective gear on or with the casualty if feasible.
b. Replace wet clothing with dry if possible. Place the casualty onto an insulated surface as soon as possi-
ble.
c. Cover the casualty with commercial warming device, dry blankets, poncho liners, sleeping bags, or
anything that will retain heat and keep the casualty dry.
d. Warm fluids are preferred if IV fluids are required.
8. Penetrating Eye Trauma: If a penetrating eye injury is noted or suspected:
a. Perform a rapid field test of visual acuity.
b. Cover the eye with a rigid eye shield (NOT a pressure patch). If a commercial eye shield is not avail-
able, use casualty’s eye protection device or anything that will prevent external pressure from being ap-
plied to the injured eye.
9. Reassess casualty:
a. Complete secondary survey checking for additional injuries. Inspect and dress known wounds that were
previously deferred.
b. Consider splinting known/suspected fracture to include applying pelvic binding techniques for sus-
pected pelvic fractures.
10. Provide analgesia as necessary.
a. Able to continue mission:
i. Consider oral non-narcotic medications such as Tylenol
b. Unable to continue mission:
i. Consider oral non-narcotic medications for mild to moderate pain

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ii. Consider use of oral/intra-nasal/IV/IO narcotic medications (hydrocodone, oxycodone, trans

mucosal fentanyl citrate, etc.) for moderate to severe pain
iii. Consider adjunct administration of anti-emetic medicines
Note: Have naloxone readily available whenever administering opiates
iv. Monitor for adverse effects such as respiratory depression or hypotentension.

11. Antibiotics: Consider initiating antibiotic administration for casualties with open wounds and penetrating eye injury
when evacuation to definitive care is significantly delayed or infeasible. This is generally determined in the mis
sion planning phase and requires medical oversight.
12. Burns:
a. Facial burns, especially those that occur in closed spaces, may be associated with inhalation injury. Ag-
gressively monitor airway status and oxygen saturation in such patients and consider early definitive air-
way management for respiratory distress or oxygen desaturation.
b. Estimate total body surface area (TBSA) burned to the nearest 10% using the appropriate locally ap-
proved burn calculation formula.
c. Cover the burn area with dry, sterile dressings and initiate measures to prevent heat loss and hypother-
mia.
d. If burns are greater than 20% of Total Body Surface Area, fluid resuscitation should be initiated under
medical control as soon as IV/IO access is established. If hemorrhagic shock is also present, resuscita-
tion for hemorrhagic shock takes precedence over resuscitation for burn shock as per the guidelines.
e. All previously described casualty care interventions can be performed on or through burned skin in a
burn casualty.
f. Analgesia in accordance with TECC guidelines may be administered.
g. Aggressively act to prevent hypothermia for burns greater than 20% TBSA.
13. Monitoring: Apply appropriate monitoring devices and/or diagnostic equipment if available. Obtain and record
vital signs.
14. Prepare casualty for movement: Consider environmental factors for safe and expeditious evacuation. Secure casu-
alty to a movement assist device when available. If vertical extraction required, ensure casualty secured within ap-
propriate harness, equipment assembled, and anchor points identified.
15. Communicate with the casualty if possible. Encourage, reassure and explain care.
16. Cardiopulmonary resuscitation (CPR) within a tactical environment for victims of blast or penetrating trauma who
have no pulse, no ventilations, and no other signs of life will not be successful and should not be attempted. In cer-
tain circumstance, such as electrocution, drowning, atraumatic arrest, or hypothermia, performing CPR may be of
benefit and should be considered in the context of the tactical situation.
17. Documentation of Care: Document clinical assessments, treatments rendered, and changes in the casualty’s status
in accordance with local protocol. Consider implementing a casualty care card that can be quickly and easily com
pleted by non-medical first responders. Forward this information with the casualty to the next level of care.

skill set:

1. hemorrhage control:
a. Apply Tourniquet
b.Apply Direct Pressure
c. Apply Pressure Dressing
d. Apply Wound Packing
e. Apply Hemostatic Agent
2. airway:
a. Apply Manual Maneuvers (chin lift, jaw thrust, recovery position)
b. Insert Nasal pharyngeal airway
c. Insert Supraglottic Device (LMA, King-LT, Combitube, etc)
d. Perform Tracheal Intubation
e. Perform Surgical Cricothyrotomy
3. Breathing:
a. Application of effective occlusive chest seal
b. Assist Ventilations with Bag Valve Mask
c. Apply Oxygen

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d. Apply Occlusive Dressing

e. Perform Needle Chest Decompression
4. circulation:
a. Gain Intravascular Access
b. Gain Intraosseous Access
c. Apply saline lock
d. Administer IV/IO medications and IV/IO fluids
e. Administer blood products
5. Wound management:
a. Apply Eye Shield
b. Apply Dressing for evisceration
c. Apply Extremity Splint
d. Apply Pelvic Binder
e. Initiate Basic Burn Treatment
f. Initiate Treatment for Traumatic Brain Injury
6. Prepare casualty for Evacuation:
a. Move Casualty (drags, carries, lifts)
b. Apply Spinal Immobilization Devices
c. Secure casualty to litter
d. Initiate Hypothermia Prevention
7. other skills:
a. Perform Hasty Decontamination
b. Initiate Casualty Monitoring
c. Establish Casualty Collection Point
d. Perform Triage

Note: The recommended skill sets are based upon 10 years of ongoing combat. Care provided within the ITC/TFC
guidelines is based upon individual first responder training, available equipment, local medical protocols, and med-
ical director approval.

EvacuaTion/TacTical EvacuaTion carE (Evac/TacEvac):

goals:
1. Maintain any life saving interventions conducted during DTC/CUF and ITC/TFC phases
2. Provide rapid and secure extraction to a appropriate level of care
3. Avoid additional preventable causes of death

Principles:
1. Reassess the casualty or casualties
2. Utilize additional resources to maximize advanced care
3. Avoid hypothermia
4. Communication is critical, especially between tactical and non tactical EMS teams.

guidelines:
1. Reassess all interventions applied in previous phases of care. If multiple wounded, perform primary triage.
2. Airway Management:
a. The principles of airway management in Evacuation Care are similar to that in ITC/TFC with the addi-
tion of increased utility of supraglottic devices and endotracheal intubation.
b. Unconscious casualty without airway obstruction: Same as ITC/TFC
c. Casualty with airway obstruction or impending airway obstruction:
i. Initially, same as ITC/TFC Naso/oropharyngeal airway
ii. If previous measures unsuccessful, it is prudent to consider supraglottic Devices (King LT,
CombiTube, LMA, etc), endotracheal intubation/Rapid Sequence Intubation or surgical
cricothyroidotomy (with lidocaine if conscious).

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d. If intubated and attached to a mechanical ventilator, consider lung protective strategies and reassess for
respiratory decline in patients with potential pneumothoraces.
e. Consider the mechanism of injury and the need for spinal immobilization. Spinal immobilization is not
necessary for casualties with penetrating trauma if the patient is neurologically intact. Maintain high
clinical suspicion for casualties over age of 65yo with blunt mechanism. Additionally, patients may be
clinically cleared from spinal immobilization under a locally approved protocol if they have none of
the following:
- Midline c-spine tenderness
- Neurologic impairment
- Altered mental status
- Distracting injury
- Intoxication
3. Breathing:
a. All open and/or sucking chest wounds should be treated by immediately applying an occlusive material
to cover the defect and securing it in place. Monitor the casualty for the potential development of a
subsequent tension pneumothorax. Tension pneumothoraces should be treated as described in
ITC/TFC.
b. Reassess casualties who have had chest seals applied or had needle decompression. If there are signs
of continued or progressive respiratory distress:
i. Consider repeating the needle decompression. If this results in improved clinical status, the de
compression can be repeated multiple times.
ii. If appropriate provider scope of practice and approved local protocol, consider placing a chest
tube if no improvement of respiratory distress after decompression if long duration or air trans-
port is anticipated.
c. Administration of oxygen may be of benefit for all traumatically injured patients, especially for the follow-
ing types of casualties:
- Low oxygen saturation by pulse oximetry
- Injuries associated with impaired oxygenation
- Unconscious casualty
- Casualty with TBI (maintain oxygen saturation > 90%)
- Casualty in shock
- Casualty at altitude
- Casualties with pneumothoraces
4. Bleeding:
a. Fully expose wounds to reassess for unrecognized hemorrhage and control all sources of major bleed-
ing.
b. If not already done, use a tourniquet or an appropriate pressure dressing with deep wound packing to
control life-threatening external hemorrhage that is anatomically amenable to such treatment.
i. Apply the tourniquet directly to the skin 2-3 inches above wound.
ii. For any traumatic total or partial amputation, a tourniquet should be applied regardless of bleed-
ing.
c. Reassess all tourniquets that were applied during previous phases of care. Expose the injury and deter-
mine if a tourniquet is needed.
i. Tourniquets applied in prior phases that are determined to be both necessary and effective in con-
trolling hemorrhage should remain in place if the casualty can be rapidly evacuated to definitive
medical care.
ii. If ineffective in controlling hemorrhage or if there is any potential delay in evacuation to care,
identify an appropriate location 2-3 inches above the injury, and apply a new tourniquet directly
to the skin. Once properly applied, the prior tourniquet can be loosened.
iii. If delay to definitive care longer than 2 hours is anticipated and wound for which tourniquet was
applied is anatomically amenable, attempt a tourniquet downgrade as described in ITC/TFC.
d. A distal pulse check should be performed on any limb where a tourniquet is applied. If a distal pulse is
still present, consider additional tightening of the tourniquet or the use of a second tourniquet, side-by-
side and proximal to the first, to eliminate the distal pulse.
e. Expose and clearly mark all tourniquet sites with the time of tourniquet application. Use an indelible
marker.

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5. Fluid resuscitation: Reassess for hemorrhagic shock (altered mental status in the absence of brain injury, weak or
absent peripheral pulses, and/or change in pulse character). If BP monitoring is available, maintain target systolic
BP 80-90mmHg.
a. Establish intravenous or intraosseous access if not performed in ITC/TFC phase
b. Management of resuscitation as in ITC/TFC with the following additions:
i. If in shock and blood products are not available or not approved under scope of practice/local
protocols resuscitate as in ITC/TFC.
ii. If in shock and blood products are available with an appropriate provider scope of practice
under an approved medical protocol:
- Resuscitate with 2 units of plasma (FFP) and 2 units of packed red blood cells (PRBCs) in
a 1:1 ratio.
- If blood component therapy is not available, and appropriate training, testing and proto-
cols are in place, consider transfusing fresh whole blood.
- Continue resuscitation as needed to maintain target BP or clinical improvement.
iii. If a casualty with an altered mental status due to suspected TBI has a weak or absent periph
eral pulse, resuscitate as necessary to maintain a desired systolic blood pressure of 90mmHg
or a palpable radial pulse.
iv. If suspected TBI and casualty not in shock, raise the casualty’s head to 30 degrees.
6. Prevention of hypothermia:
a. Minimize casualty’s exposure to the elements. Move into a medic unit, vehicle, or warmed structure if
possible. Keep protective gear on or with the casualty if feasible.
b. Replace wet clothing with dry if possible. Place the casualty onto an insulated surface as soon as possi-
ble.
c. Cover the casualty with commercial warming device, dry blankets, poncho liners, sleeping bags, or
anything that will retain heat and keep the casualty dry.
d. Warm fluids are preferred if IV fluids are required.
7. Monitoring:
a. Institute electronic monitoring if available, including pulse oximetry, cardiac monitoring, etCO2 (if in-
tubated), and blood pressure.
b. Obtain and record vital signs.
8. Reassess casualty:
a. Complete secondary survey checking for additional injuries. Inspect and dress known wounds that
were previously deferred.
b. Determine mode and destination for evacuation to definitive care.
c. Splint known/suspected fractures and recheck pulses.
d. Apply pelvic binding techniques for suspected pelvic fractures.
9. Provide analgesia as necessary:
a. Mild pain:
i. Consider oral non-narcotic medications
b. Moderate to severe pain:
i. Consider use of oral/intra-nasal/IV/IO narcotic medications (hydrocodone, oxycodone,
transmucosal fentanyl citrate, morphine, etc.)
ii. Consider adjunct administration of anti-emetic medicines
iii. Have naloxone readily available whenever administering opiates
iv. Monitor for adverse effects such as respiratory depression, hypotentension
10. Burns:
a. Burn care is consistent with the principles described in ITC/TFC.
b. Be cautious of off-gassing from patient in the evacuation vehicle if there is suspected chemical expo-
sure (e.g. cyanide) from the fire.
c. Consider early airway management if there is a prolonged evacuation period and the patient has signs
of significant airway thermal injury (e.g. singed facial hair, oral edema, carbonaceous material in the
posterior pharynx and respiratory difficulty.)
11. Prepare casualty for movement: Consider environmental factors for safe and expeditious evacuation. Secure casu-
alty to a movement assist device when available. If vertical extraction required, ensure casualty secured within ap-
propriate harness, equipment assembled, and anchor points identified.
12. Communicate with the casualty if possible and with the accepting facility. Encourage, reassure and explain care.

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13. Cardiopulmonary resuscitation (CPR) may have a larger role during the evacuation phase especially for patients
with electrocution, hypothermia, non traumatic arrest or near drowning.
14. Documentation of Care: Continue or initiate documentation of clinical assessments, treatments rendered, and
changes in the casualty’s status in accordance with local protocol. Forward this information with the casualty to
the next level of care.

skills:
1. Familiarization with advanced monitoring techniques
2. Familiarization with transfusion protocols
3. Ventilator and advanced airway management

122 Journal of Special Operations Medicine Volume 11, Edition 3 / Summer/Fall 11