The Relevance of Tactical Combat Casualty Care (TCCC)
Guidelines to Civilian Law Enforcement Operations

By Kevin B. Gerold, DO, JD; Capt. Mark Gibbons, EMT-P; and Sean McKay, EMT-P

The National Tactical Officers Association (NTOA) endorses and supports the
incorporation of a well-trained and equipped Tactical Emergency Medical Support
(TEMS) element into all tactical teams.  TEMS is the provision of preventative, urgent
and emergent medical care during high-risk, extended duration and mission-driven law
enforcement special operations. Just as law enforcement special operations teams have
responded to changing patterns of violence and criminal activity by adopting militarystyle
weapons and tactics, TEMS providers are turning to military-style medical practices
when conventional EMS practices fail to address the needs of these unconventional law
enforcement missions.

States such as Maryland and major cities such as Dallas are responding to the
needs of the law enforcement special operations community by adopting expanded
practices to their EMS practice guidelines to accommodate the unique needs of
emergency medical providers supporting law enforcement operations special operations.
Tactical Combat Casualty Care (TCCC) guidelines currently form the basis for
combat trauma training within the Special Operations Command. First implemented more
than 10 years ago and recently updated, these guidelines were developed when it became
apparent that civilian pre-hospital medical care models, including Advanced Trauma Life
Support (ATLS), Basic Trauma Life Support (BTLS) and Advanced Cardiac Life
Support (ACLS) were unsatisfactory models for providing care during combat missions.
In 1993, the Naval Special Warfare Command began researching combat
associated deaths due to penetrating trauma. This study was later assumed by the United
States Special Operations Command (USSOCOM) and their results were published in a
supplement to Military Medicine in 1996 (Butler, F.K. Jr., 1996). The findings from this
study became the foundation for a combat trauma curriculum intended to combine good
medical care with good small unit tactics. The premier course was first taught by the
Navy Bureau of Medicine and Surgery in 1996 during the Undersea Medical Officer’s
Course and was later adopted by the Navy SEALs. This course has been tested during
combat operations, updated periodically, and now represents the best practices for
providing care during combat missions. This course is now taught to soldiers throughout
the Department of Defense.

During conventional ground combat operations, most deaths (85%) result from
catastrophic wounds. Regrettably, no amount of modern medical care can save these
soldiers. TCCC directs medical resources to caring for the remaining 15% of injured
soldiers, who, when treated aggressively, will survive their wounds. Most of these (60%
of preventable or 9% of all ground combat deaths) result from exsanguinating extremity
hemorrhage amenable to a tourniquet or direct pressure. Other causes of preventable
injuries include tension pneumothorax (33% of preventable or 5% of all deaths) from
penetrating chest trauma, and from maxillofacial trauma causing airway obstruction (6%
of preventable or 1% of all deaths). Advances in medical care, personal and vehicular
armor, changing tactics, and the widespread use of improvised explosive devices by
opposition forces in Iraq and Afghanistan are changing these numbers slightly.
Despite the evolving characteristics of warfare, the vast majority of potentially
survivable deaths due to injuries sustained in combat remain extremity and compressible
hemorrhage, readily controllable with tourniquets, direct pressure and hemostatic agents.
The lessons outlined in TCCC remain valid; the success of medical care provided during
active combat operations must incorporate good small unit tactics to minimize the risk of
incurring additional casualties, and initial lifesaving care requires a small number of
simple interventions and requires minimal equipment.
As law enforcement programs incorporate TEMS into their special operations
missions, EMS medical directors are increasingly asked by law enforcement commanders
to expand or modify existing pre-hospital care guidelines so that EMS providers can
support law enforcement missions. While we recognize that civilian law enforcement
operations differ significantly from active combat operations, we believe that TCCC
should serve as a foundation for TEMS protocols, practices and training. Medical
directors should incorporate relevant aspects of the TCCC guidelines into their TEMS
program. To assist medical directors with developing TEMS protocols, we are publishing
the recently updated version of the TCCC guidelines with minimal editorial comment.
TCCC divides the care rendered during active combat operations into three
phases:
Care Under Fire: The initial medical care provided to a casualty when operators
remain under effective fire by a hostile opposition force.
Tactical Field Care: The initial care provided by medical providers after effective
hostile fire has ended, often in austere conditions.
Tactical Evacuation Care: The care provided during transport to a trauma
hospital and which most closely resembles conventional civilian EMS operations.

Basic Plan for Care Under Fire
1. Return fire and take cover.
2. Direct or expect casualty to remain engaged as a combatant, if appropriate.
3. Direct casualty to move to cover and apply self-aid, if able.
4. Try to keep the casualty from sustaining additional wounds.
5. Airway management is generally best deferred until the Tactical Field Care phase.
6. Stop life-threatening external hemorrhage if tactically feasible:
a. Direct casualty to control hemorrhage by self-aid, if able.
b. Use a CoTCCC-recommended tourniquet for hemorrhage that is
anatomically amenable to tourniquet application.
c. Apply the tourniquet above the wound high on the extremity, over the
uniform and tighten to stop arterial bleeding or until distal pulse is lost.
Move the casualty to cover.

Note: Contrary to the many stereotypes surrounding penetrating wounds, most
non-lethal injuries sustained during active operations do not incapacitate the operator or
prevent him from remaining in the operation. If injured while under fire, casualties
should attempt to remain in the fight, take cover, provide their own initial care and
control severe hemorrhage, then re-engage and assist their unit with neutralizing
continued active threats. Team members and medics in this phase can assist casualties
with seeking cover and may render self-aid or buddy-aid to control severe hemorrhage
using tactics that minimize the chance that other members of the team will sustain
additional casualties.

During training, instructors should avoid creating training scars by running
operators through scenarios during which they incur incapacitating injuries. Effective
training should reinforce that operators can quickly render care self-care or assist their
teammates and continue in the mission. Consider using non-operator role players as
casualties when scenarios include injuries that would make continuing in an active
operation impossible.

The physical and mental stress associated with active operations is known to
impair decision-making and will degrade fine and complex motor skills, thus impairing
the ability to perform medical procedures.5 TEMS providers should prepare for these
effects by participating in reality-based training that limits the number of decisions for
providing care, simplifies the types of interventions and incorporates atypical scenarios.

Basic Plan for Tactical Field Care
1. Casualties with an altered mental status should be disarmed immediately.
2. Airway management
a. Unconscious casualty without airway obstruction:
-Chin lift or jaw thrust maneuver
-Nasopharyngeal airway
-Place casualty in recovery position
b. Casualty with airway obstruction or impending airway obstruction:
-Chin lift or jaw thrust maneuver
-Nasopharyngeal airway
-Allow casualty to assume any position that best protects the airway,
to include sitting up.
-Place unconscious casualty in recovery position
If previous measures unsuccessful:
-Surgical cricothyroidostomy (with lidocaine if conscious)

Note: Armed law enforcement operators who become injured and exhibit changes
in their mental status due to shock, traumatic brain injury or hypoxemia lose their ability
to interpret events around them and become incapable of making the proper judgments
about threats and the use of their weapons. For this reason, disarming cognitively
impaired casualties should occur promptly and the weapons rendered safe.
When compared to conventional EMS operations, unstable injuries to the cervical
spine are uncommon in penetrating injury and assume a lower priority than caring for
exsanguinating hemorrhage or airway obstruction. Cervical spine injury remains a
significant priority in casualties sustaining blast injuries or blunt force mechanisms such
as falls or motor vehicle crashes.

Endotracheal intubation is a procedure generally deferred until the Tactical
Evacuation phase of care or when hand-off to EMS occurs. In a six-year study of 1480
patients intubated in an urban trauma system, 486 were intubated without drugs. Of
these, only one (0.2%) survived. The authors concluded that the easy passage of a
tracheal tube without sedation or paralysis required a patient to be profoundly
unconscious and this condition predicted a poor outcome and suggests a limited use for
this procedure in austere conditions.6 During civilian operations, less invasive
alternatives to cricothyroidostomy or endotracheal intubation include the King Airway,
the Combi-Tube Airway and the Laryngeal Mask Airway (LMA).

3. Breathing
a. In a casualty with progressive respiratory distress and known or suspected
torso trauma, consider a tension pneumothorax and decompress the chest
on the side of the injury with a 14-gauge, 3.25 inch needle/catheter unit
inserted in the second intercostal space at the midclavicular line. Ensure
that the needle entry into the chest is not medial to the nipple line and is not
directed towards the heart.
b. Treat all open and/or sucking chest wounds 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.

Note: Tension pneumothorax from penetrating wounds to the chest is believed to
cause about one-third of preventable combat associated deaths. In patients sustaining a
penetrating chest wound who then go on to show signs of progressive respiratory
distress, performing needle decompression poses little danger of causing further injury
and can be lifesaving. In its later stages, tension pneumothorax looks clinically similar to
hypovolemic shock. Needle decompression of the chest is a skill that can be taught to first
responders. Recent studies measuring chest wall thickness have shown that the catheter
used to decompress a chest should be at least 3.25 inches (8 cm). In a study of 110
patients admitted to a Level 1 trauma center, computerized tomography (CT) scanning
measured the chest wall thickness of the second intercostal space in the mid-clavicular
line to be 4.5 cm (+/- 1.5 cm) on the right, and 4.1 cm (+/- 1.4 cm) on the left. 50% of
patients in this study had a chest wall thickness measuring over 4.4 cm (1.75 in). These
authors concluded that among a general civilian population, a standard 5 cm (2-inch)
angiocatheter would likely be unsuccessful at reaching the pleural space in 50% of
patients.7 In a similar study of patients who may better represent the law enforcement
special operations community, CT scanning was used in 100 male military personnel to
measure the chest wall thickness at the second intercostal space in the midclavicular line.
The mean perpendicular thickness was 4.86 cm (SD 1.10 cm). As expected, the chest wall
thickness of these men was greater than the general civilian population. These authors
concluded that an 8 cm angiocatheter would have reached the pleural space in 99% of
subjects.

4. Bleeding
a. Assess for unrecognized hemorrhage and control all sources of bleeding. If
not already done, use a CoTCCC-recommended tourniquet to control life
threatening external hemorrhage that is anatomically amenable to
tourniquet application or for any traumatic amputation. Apply the
tourniquet above the wound high on the extremity, over the uniform and
tighten to stop arterial bleeding or until distal pulse is lost.
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), use Combat Gauze as the hemostatic agent of choice.
Combat Gauze should be applied with at least three minutes of direct
pressure.
c. Before releasing any tourniquet on a casualty who has been resuscitated for
hemorrhagic shock, ensure a positive response to resuscitation efforts [i.e.,
a peripheral pulse normal in character and normal mentation if there is no
traumatic brain injury (TBI)].
d. Reassess prior tourniquet application. Expose wound and determine if
tourniquet is needed. If so, move tourniquet from over uniform and apply
directly to skin 2-3 inches above wound. If tourniquet is not needed, use
other techniques to control bleeding.
e. When time and the tactical situation permit, a distal pulse check should be
accomplished. 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.
f. Expose and clearly mark all tourniquet sites with the time of tourniquet
application. Use an indelible marker.

Note: While EMS medical directors express concern about the appropriate use
and safety of tourniquets, their ability to increase survival in casualties sustaining
combat associated major limb trauma is well established and concerns that their
widespread use may cause additional injury and increase limb morbidity is
unsubstantiated.

The updated TCCC guidelines include two new hemostatic agents, Combat Gauze
and WoundStat. These agents were proven superior to the previously recommended
hemostatic agents HemCon and QuikClot for controlling severe hemorrhage in animal
models. In December 2008, Dr. Bijan Kheirabadi at USAISR presented his additional
research on the safety aspects of WoundStat and Combat Gauze at the Special
Operations Medical Association meeting in Tampa, Fla. His research concluded that
“WoundStat treatment of the injured vessels resulted in development of occlusive thrombi
in carotid arteries (7 of 8) and jugular veins (6 of 8) two hours after surgical repair and
blood reflow. There was evidence of WoundStat residues and emboli in the lungs of two
animals as well.” As a result of these findings, a review of the safety aspects of
WoundStat was conducted at a meeting of the Committee on Tactical Combat Casualty
Care held on February 3, 2009. Dr. Kheirabadi again presented his new research
findings and noted that the histology from the WoundStat-treated vessels in his recent
study demonstrated evidence of endothelial toxicity. Following the review, the Committee
removed WoundStat from the TCCC Guidelines, leaving Combat Gauze as the hemostatic
agent of choice.
5. Intravenous (IV) access
a. Start an 18-gauge IV or saline lock if indicated.
b. If resuscitation is required and IV access is not obtainable, use the
intraosseous (IO) route.
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:
-No IV fluids necessary
-PO fluids permissible if conscious and can swallow
b. If in shock:
-Hextend, 500-mL IV bolus
-Repeat once after 30 minutes if still in shock
-No more than 1000 mL of Hextend
c. Continued efforts to resuscitate must be weighed against logistical and
tactical considerations and the risk of incurring further casualties.
d. If a casualty with traumatic brain injury (TBI) is unconscious and has no
peripheral pulse, resuscitate to restore the 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.
c. Apply Ready-Heat Blanket to torso.
d. Wrap in Blizzard Rescue Blanket.
e. Put Thermo-Lite Hypothermia Prevention System Cap on the casualty’s
head, under the helmet.
f. Apply additional interventions as needed and available.
g. If mentioned gear is not available, use dry blankets, poncho liners, sleeping
bags, body bags or anything that will retain heat and keep the casualty dry.
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).
c. Ensure that the 400mg moxifloxacin tablet in the combat pill pack is taken
if possible and that IV/IM antibiotics are given as outlined below if oral
moxifloxacin cannot be taken.
9. Monitoring
Pulse oximetry should be available as an adjunct to clinical monitoring. Readings
may be misleading in the settings of shock or marked hypothermia.
10. Inspect and dress known wounds.
11. Check for additional wounds.
12. Provide analgesia as necessary.
a. Able to fight:
-Meloxicam (Mobic), 15mg PO once a day. Meloxicam is an NSAID
-Acetaminophen (Tylenol), 650mg bi-layer caplet, 2 PO every 8
hours

Note: These medications should be carried by the combatant and selfadministered
as soon as possible after the wound is sustained.
b. Unable to fight:
-Does not otherwise require IV/IO access
-Oral transmucosal fentanyl citrate (Actiq), 800 mcg transbucally
-Recommend taping lozenge-on-a-stick to casualty’s finger as an
added safety measure.
-Reassess in 15 minutes
-Add second lozenge, in other cheek, as necessary to control severe
pain.
-Monitor for respiratory depression.
-IV or IO access obtained:
-Morphine sulfate, 5mg IV/IO
-Reassess in 10 minutes
-Repeat dose every 10 minutes as necessary to control
severe pain
-Monitor for respiratory depression
-Promethazine (phenergan), 25mg IV/IM/IO every 6 hours as needed
for nausea or for synergistic analgesic effect

Have naloxone (Narcan) readily available whenever administering opiates.

Note: May substitute ondansetron (Zofran) for promethazine. The dose of
ondansetron is 4 mg IV/IM/PO repeated every four hours, as needed.
13. Splint fractures and recheck pulse.
14. Antibiotics are recommended for all open combat wounds.
a. If able to take PO:
-Moxifloxacin (Avelox), 400mg PO every 24 hours
b. If unable to take PO (shock, unconsciousness):
-Cefotetan, 2g IV (slow push over 3-5 minutes) or IM every 12 hours
or
-Ertapenem (Invanz), 1g IV/IM once a day
15. Communicate with the casualty if possible.
a. Encourage; reassure
b. Explain care
16. Cardiopulmonary resuscitation (CPR)
Resuscitation on the battlefield 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.
17. Documentation
Document clinical assessments, treatments rendered and changes in the
casualty’s status on a TCCC Casualty Card.

Basic Management Plan for Tactical Evacuation Care
Note: The new term “Tactical Evacuation” includes both Casualty Evacuation
(CASEVAC) and Medical Evacuation (MEDEVAC) as defined in Joint Publication 4-02.
1. Airway Management
a. Unconscious casualty without airway obstruction:
-Chin lift or jaw thrust maneuver
-Nasopharyngeal airway
-Place casualty in recovery position
b. Casualty with airway obstruction or impending airway obstruction:
-Chin lift or jaw thrust maneuver
-Nasopharyngeal airway
-Allow casualty to assume any position that best protects the airway,
to include sitting up.
-Place unconscious casualty in recovery position.
-If above measures unsuccessful:
-Laryngeal Mask Airway (LMA)/intubating LMA or
-Combitube or
-Endotracheal intubation or
-Surgical cricothyroidotomy (with lidocaine if conscious).
Note: The King Airway has widely replaced use of the LMA or Combitube
airway.
c. Spinal immobilization is not necessary for casualties with penetrating
trauma.
2. Breathing
a. In a casualty with progressive respiratory distress and known or suspected
torso trauma, consider a tension pneumothorax and decompress the chest on the
side of the injury with a 14-gauge, 3.25 inch needle/catheter unit inserted in the
second intercostal space at the midclavicular line. Ensure that the needle entry into
the chest is not medial to the nipple line and is not directed towards the heart.
b. Consider chest tube insertion if no improvement and/or long transport is
anticipated.
c. Most combat casualties do not require supplemental oxygen, but
administration of oxygen may be of benefit for the following 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
d. 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.
3. Bleeding
a. Assess for unrecognized hemorrhage and control all sources of bleeding. If
not already done, use a CoTCCC-recommended tourniquet to control lifethreatening
external hemorrhage that is anatomically amenable to tourniquet
application or for any traumatic amputation. Apply the tourniquet above the
wound high on the extremity, over the uniform and tighten to stop arterial bleeding
or until distal pulse is lost.
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), use Combat Gauze as the hemostatic agent of choice. This should be
applied with at least 3 minutes of direct pressure. Before releasing any tourniquet
on a casualty who has been resuscitated for hemorrhagic shock, ensure a positive
response to resuscitation efforts (i.e., a peripheral pulse normal in character and
normal mentation if there is no traumatic brain injury (TBI).
c. Reassess prior tourniquet application. Expose wound and determine if
tourniquet is needed. If so, move tourniquet from over uniform and apply directly
to skin 2-3 inches above wound. If tourniquet is not needed, use other techniques
to control bleeding.
d. When time and the tactical situation permit, a distal pulse check should be
accomplished. 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.
4. Intravenous (IV) access
a. Reassess need for IV access.
-If indicated, start an 18-gauge IV or saline lock
-If resuscitation is required and IV access is not obtainable, use
intraosseous (IO) route.
5. Fluid resuscitation
Reassess for hemorrhagic shock (altered mental status in the absence of brain
injury) and/or change in pulse character.
a. If not in shock:
-No IV fluids necessary.
-PO fluids permissible if conscious and can swallow.
b. If in shock:
-Hextend 500ml IV bolus.
-Repeat once after 30 minutes if still in shock.
-No more than 1000ml of Hextend.
c. Continue resuscitation with packed red blood cells (PRBCs), Hextend, or
Lactated Ringer’s solution (LR) as indicated.
d. If a casualty with TBI is unconscious and has a weak or absent peripheral
pulse, resuscitate as necessary to maintain a systolic blood pressure of 90mmHg or
above.
6. Prevention of hypothermia
a. Minimize casualty’s exposure to the elements. Keep protective gear on or
with the casualty if feasible.
b. Continue Ready-Heat Blanket, Blizzard Rescue Wrap, and Thermo-Lite
Cap.
c. Apply additional interventions as needed.
d. Use the Thermal Angel or other portable fluid warmer on all IV sites, if
possible.
e. Protect the casualty from wind if doors must be kept open.
7. 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).
c. Ensure that the 400mg moxifloxacin tablet in the combat pill pack is taken
if possible and that IV/IM antibiotics are given as outlined below if oral
moxifloxacin cannot be taken.
8. Monitoring
Institute pulse oximetry and other electronic monitoring of vital signs, if indicated.
9. Inspect and dress known wounds if not already done.
10. Check for additional wounds.
11. Provide analgesia as necessary.
a. Able to fight:
-Mobic, 15mg PO once a day
-Tylenol, 650mg bilayered caplet, 2 PO every 8 hours
b. Unable to fight:
Note: Have naloxone readily available whenever administering opiates.
-Does not otherwise require IV/IO access:
-Oral transmucosal fentanyl citrate (OTFC) 800ug transbucally
-Recommend taping lozenge-on-a-stick to casualty’s finger as an
added safety measure.
-Re-assess in 15 minutes.
-Add second lozenge, in other cheek, as necessary to control severe
pain.
-Monitor for respiratory depression.
-IV or IO access obtained:
-Morphine sulfate, 5mg IV/IO
-Reassess in 10 minutes
-Repeat dose every 10 minutes as necessary to control severe pain.
-Promethazine, 25mg IV/IM/IO every 6 hours as needed for nausea
or for synergistic analgesic effect.
12. Reassess fractures and recheck pulses.
13. Antibiotics: recommended for all open combat wounds.
a. If able to take PO:
-Moxifloxacin, 400mg PO once a day
b. If unable to take PO (shock, unconsciousness):
-Cefotetan, 2g IV (slow push over 3-5 minutes) or IM every 12 hours,
or
-Ertapenem, 1g IV/IM once a day
14. Pneumatic Antishock Garment (PASG) may be useful for stabilizing pelvic
fractures and controlling pelvic and abdominal bleeding. Application and extended use
must be carefully monitored. The PASG is contraindicated for casualties with thoracic or
brain injuries.
15. Document clinical assessments, treatments rendered, and changes in casualty’s
status on a TCCC Casualty Card. Forward this information with the casualty to the next
level of care.

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