The US military maintains and publishes emergency medical protocols for service members to follow during combat missions called Tactical Combat Casualty Care or TCCC.

It focuses on care in the field, meaning outside of a hospital, and deals with a large variety of treatments for trauma.

Not all of the treatments TCCC uses are available to non-military folks, but a great number of them are, which makes knowledge of TCCC protocols useful even for regular folk. 

TCCC is relevant to civilian use and adaptation in a number of ways:

• It's a stripped down assessment protocol, which makes quickly identifying and treating traumatic injuries a simple as possible.
• Many of the injuries covered by the TCCC can happen in day to day life, and are not only battlefield problems.
• For those who want to study field medicine, but don't have the time or inclination to become an EMT or Paramedic, this is a great intermediate way to get trained.
• The IFAK (Individual First Aid Kit) used in TCCC is compact yet extremely powerful and allows those with knowledge to handle severe life threatening injuries quickly. 

What TCCC training does NOT do: 

• Inform you on how to identify and treat medical issues like: diabetes, heart attack, severe allergic reactions, etc.
• Some of the treatments in TCCC likely go beyond Good Samaritan laws, you might get in trouble for doing something to someone you aren't certified to do by an accredited agency.
• Give you a solid foundation of CPR, which is critical for civilian first responders to have.

What I'm going to try to accomplish with this blog post is to give you a brief overview of what TCCC does, how you can learn more, and how you can apply it to civilian treatment protocols.

This is not meant to be an exhaustive training, nor is this guide appropriate for active duty military - since I will not spend much time on treatments which cannot be used outside of the civilian purview. 

BTW in the civilian world it's called TECC, or Tactical Emergency Casualty Care, since combat typically isn't a thing outside of the militaries purview - but active shooter scenarios do occur in civilian environments so the fundamentals still apply

Warning: some of the material included below or in some of the videos linked will be graphic in nature in order to illustrate the situations being discussed, which includes bleeding, wounds, and amputations. 

Here is the intro to TCCC video from DeployedMedicine.com (more on them in a minute)

(YouTube has it behind an age filter due to graphic content)

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Recommended Reading

The NAEMT publishes a TECC guide which is geared towards first responder and civilian use. It is an excellent resource, and if you are at all serious about the subject, it what I would recommend picking up: 

TECC: Tactical Emergency Casualty Care

Typical Price: $27

Formed in 1975 and more than 32,000 members strong, the National Association of Emergency Medical Technicians (NAEMT) is the nation’s only organization solely dedicated to representing the professional interests of all EMS practitioners, including paramedics, emergency medical technicians, emergency medical responders and other professionals working in prehospital emergency medicine. NAEMT members work in all sectors of EMS, including government service agencies, fire departments, hospital-based ambulance services, private companies, industrial and special operations settings, and in the military.

$27Amazon $27eBay

There are a few other decent TCCC books out there, another one that I like and recommend is Tactical Combat Casualty Care Handbook, Version 5. It's a little dated on some fronts, but it's got most of the info you'd be interested in. 

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One other important resource: Deployed Medicine

Deployed Medicine is a platform used by the Defense Health Agency to trial new innovative learning models aimed at improving readiness and performance of deployed military medical personnel.

You can download a huge amount of information and training for free from this site, and it has the most up to date info being used in the field. 

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Fundamentals of TCCC

In the TCCC protocols there are three phases of tactical care: 

• Direct care provided in the Hot zone - while under attack or in dangerous conditions.
• Indirect care in the Warm zone - threats remain but are not imminent, so care providers can apply the MARCH algorithm to patients. 
• Evacuation care in the Cold zone - where and how to evacuate and continue to provide care

In each phase different interventions are appropriate.

Direct Threat Care / Hot Zone

This zone represents the greatest danger to both the caregiver and the patient. Further injury is highly possible. The scene is dynamic and unpredictable. 

In this zone your main consideration is to remove the patient and the caregiver to a safer area so that lifesaving treatment can be provided. This means dragging, carrying, lifting or by whatever means available, moving the patient away from danger. 

In this area there are only two interventions a caregiver may provide:

1. place the patient in the recovery position, and
2. control massive hemorrhage via tourniquet application. 

See our list of the best tourniquets. 

Once you have stopped the bleeding, get the patient out of there and into the: 

Indirect Threat Care / Warm Zone

The warm zone assumes an area of relative safety - the threat may be nearby but is not imminent. It can become a Hot zone again, but is not at the moment. 

As a civilian caregiver, you will not likely be in a Warm zone scenario, unless you are dealing with an active shooter or terrorist type of event. That said the first rule of emergency provider is Scene Safety, always make sure you are not walking into danger and become a casualty yourself. 

Being in a Warm zone allows caregivers to provide more comprehensive care than just massive bleeding since risks to themselves and their patients have been mitigated enough to do allow it. 

This is where the MARCH assessment and treatment protocol comes into play. MARCH stands for: 

• Massive Hemorrhage
• Airway
• Respiratory
• Circulation
• Head/Hypothermia

These are listed in order of priority. You start with Massive Hemorrhage and work your way through to Head/Hypothermia. 

We will dive into MARCH later. 

Evacuation Care / Cold Zone

The Cold zone is an area of relative security. This is the state most civilian emergencies would reside in.

You will still apply the MARCH protocol here if not already done, and if completed, you will be reassessing all medical interventions routinely, every 5-10 minutes typically. 

In the Cold zone, oxygen therapy, spinal motion restrictions, IV or IO lines, endotracheal intubations and more can be introduced. Don't worry if you don't know what all that means yet.

This is where CPR can be performed, as well as more comprehensive treatments for shock and hypothermia. 

Your first step here is to always activate the Emergency Medical System by calling 911. Any treatments you perform are only giving the patient more time to get to the hospital, but get to the hospital they must for more comprehensive treatments. 

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MARCH Assessment

MARCH is a tool to help you remember what to look for, what to address first, and how and when to treat life threatening injuries. 

Memorize it! 

• Massive Hemorrhage
• Airway
• Respiratory
• Circulation
• Head/Hypothermia

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Massive Hemorrhage

Large bleeds need to be identified as quickly as possible - seconds count - which is why its first on the list. 

Make sure you are wearing gloves since you are dealing with bleeding, and you won't want to contract any blood borne pathogens your patient may have. 

Direct Pressure

When you are first assessing a patient for massive hemorrhage, look for any obvious arterial bleeding or amputation as you approach your patient and get pressure on those wounds asap with your hands. 

If you need your hands for other interventions, use elbows or knees. If your patient can respond, have them apply pressure as well. 

Get the pressure as directly onto the wound as possible. Hold for at least 3 minutes to see if the pressure is having an impact but do not release the pressure until you have an alternative treatment available. 

Extremity Tourniquets

Apply a tourniquet to those heavy arterial bleeds that you find in the arms or legs.

High and tight is the preferred method, in the crotch or armpit. At a minimum place the tourniquet 3 inches above the wound. Never place them directly on a knee or elbow. 

If speed is required, place the tourniquet over clothing, but it is preferred to remove clothing first and place the tourniquet directly on the skin. 

If one tourniquet doesn't work, apply another just above or below the original. 

Tourniquets are safe to use and have on for several hours and will NOT lead to limb amputation. Those are dangerous and old ideas which have somehow persisted to this day. 

Tourniquets do hurt when properly applied. They are quite painful, but that pain is better than death from bleeding out. 

Junctional Hemorrhage

Major vascular injuries are possible in the neck, axilla and groin areas of course, but they cannot easily be treated with a traditional tourniquet or pressure bandage. 

There are tools which are available for these types of wounds, such as the CRoC, JETT, and SAM Junctional tourniquets, or you can attach 2 CAT tourniquets together and use something like a water bottle on the underside to apply pressure to the desired location. 

Hemostatic Dressings 

One of my favorite medical interventions, one which I have had to use personally on several occasions, is hemostatic gauze. 

Hemostatic gauze uses one of two methods of action: it either speeds up the bloods own natural coagulation (Quick Clot / Combat Gauze), or congeals any liquid which it comes into contact with (CELOX.)

Quick Clot is the least expensive of the available options, but it doesn't work on heparinated ("thinned" blood) so if that's something you might have to contend with, you'll want CELOX instead. 

How to use Hemostatic Gauzes:

• Remove clothing around the wound if possible
• Clear out excessive pooled blood
• Locate the source of the most active bleeding
• Open the package and pack the gauze into the wound - really get it in there!
• Apply pressure for at least 3 minutes
• Combat Gauze may be repacked or a second gauze used over the initial application if would continues to bleed
• Wrap to secure the gauze with a compression bandage
• Reassess frequently 

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QuikClot Advanced Clotting Gauze - 3 x 24 in (2 Strips)

Typical Price: $20

Tested and proven through years of combat use by the U.S. Military, QuikClot can be depended on to save time when every second counts. The hemostatic gauze works on contact to stop bleeding by accelerating your body’s natural clotting process, clotting blood five times faster.

This pack contains two gauzes impregnated with kaolin, the same technology used by the US troops to stop even the worst bleeding wounds. Kaolin activates fibers in the blood plasma – makes them sticky, traps platelets and stops bleeding fast! Inorganic and inert, kaolin is non-allergenic, making it safe and effective to use.

QuikClot’s extremely absorbent gauze is flexible and pliable, easily contouring to wounds and allowing you to get them to the nearest medical center.

$20Amazon 

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Airway

The next part of MARCH is Airway. The airway consists of the mouth and nose, throat and lungs. 

If the airway is blocked, breathing can't occur normally, which can lead to death. 

Trauma Jaw Thrust and Chin Lift

THe first step to ensuring a patent (open) airway is to perform the Jaw Thrust and Chin Lift maneuver. 

This technique is designed to keep cervical spinal movement to a minimum, should there be damage along that area. 

It moves the tongue forward, away from the posterior airway, and opening the mouth. 

Nasopharyngeal Airway

You can also use an airway adjunct such as an NPA (nasopharyngeal airway) to keep the airway patent. 

An NPA is a soft tube which gets inserted into the nose, with the assistance of the application of a water based lubricant.

It needs to be measured and properly sized.  Measure from the earlobe to the tip of the nose. 

NPA's come standard in all TCCC IFAK kits. If you carry and IFAK for you, make sure the NPA in there is the right size for your nose. 

Recovery Position

Unconscious patients would benefit from being placed into a semi-prone recovery position. 

This can present fluids from building up in the airway, or being inhaled by using gravity to pull them out of the mouth and nose. 

Conscious patients who can hold themselves up should protect their own airway by sitting up and leaning forward, and allow the blood and fluids to drain on their own. 

Laying the patient down, or forcing them to lay down can complicate the airway and is not suggested. 

Complex Airways

These lie beyond the scope of our civilian practice, but if you want to know a little bit more about them, there are a few kinds of complex airways which fall within the TCCC protocols:

• Supraglottic Airways: king tubes, iGel, etc
• Orotracheal & Nasotracheal Intubation
• Surgical Cricothyroidotomy

There are videos out there about them all, worth looking into for educational purposes. Most of these are not difficult procedures to perform, but they do require the proper training to be done safely. 

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Breathing / Respiration

When it comes to Breathing, TCCC & TECC does not typically address assistive breathing measures, such as 0₂ application or positive pressure ventilation using a bag valve mask - however it would behoove you to know how to use a BVM or pocket mask, and to have both items in your first aid kit. 

We discuss them both in more detail here: Build an EMT & Paramedic First Aid Kit

In TCCC we are concerned with treating Open and Tension Pneumothorax injuries.

Open Pneumothorax

An open wound to the chest can cause lungs to collapse, by allowing air to escape into the plural space around the lungs. 

These are often dubbed "sucking" chest wounds due to the type of noise they make as air moves in and out of the injury. 

Wounds like these are often caused by penetrative trauma from a bullet or fragments of an explosive device. 

Your patient will be in obvious respiratory distress. 

You will need to seal the hole, with a glove, a plastic bag, aluminum foil, or an occlusive dressing like a HyFin Vent Chest Seal. 

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North American Rescue Hyfin Vent Chest Seal

Typical Price: $17

The HyFin Vent Chest Seal Twin Pack from North American Rescue sets the standard for the prevention, management and treatment of an open and/or tension pneumothorax potentially caused by a penetrating chest trauma.

Two seals, each individually packaged, are designed to allow the user to apply a seal to both an entry or an exit wound while also giving the option to only apply one and store the other until needed as the situation requires. This innovative design provides 3-vented channels designed to prevent airflow into the chest cavity during inhalation while allowing air to escape through the vent channels during exhalation.

The 3-vent channels are designed to allow blood to escape and also provide a backup fail-safe system, as even if two of the three channels become obstructed, the vent is designed to remain fully operational.

$17Amazon 

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Tension Pneumothorax

If air enters the pleural space but cannot escape, pressure can build up and create a tension pneumothorax. This not only leads to respiratory distress, but affects the hearts ability to pump as well. 

This can lead to profound shock and is incredibly dangerous. 

If an occlusive dressing has been applied, briefly lift it up to "burp" the wound and see if that improves the patients breathing. 

If not, a needle decompression might be indicated. This is beyond the scope of this article but there are numerous resources out there that can explain it more. 

(But as a hint, the latest guidance prefers placement in the fifth intercostal space, along the midaxillary line with a 10 gauge needle.)

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Circulation

The civilian caregiver has limited options in the circulation part of the MARCH assessment since they cannot get venous access, use tranexamic acid (TXA) or saline. 

So in this case we will look at the circulation category as a re-assessment. Check any bleeding interventions that you might have already applied. 

Make sure bandages and tourniquets are still doing their job, and are holding, especially if you've moved the patient. 

Shock Assessment

Shock describes the metabolic change from aerobic metabolism (normal) to anaerobic metabolism (inadequate long term.) What this means is not enough oxygen is getting into the cells, which will lead to death. 

It can take several hours for this to occur, but shock must be identified and treated early to help ensure patient survival. 

Shock is defined as: 

• Pulse rate hight than 140 bpm
• Inadequate tissue perfusion at the cellular level
• Diastolic blood pressure below 50 mmHg for more than 20 minutes
• Pulse oximeter Spo₂ reading of less that 84%. 

What you are really looking for is decreased level of consciousness, meaning they aren't acting quite right: confused, sleepy, unable to speak clearly or coherently. 

The will also likely have cold, clammy skin - and look pale. 

You also want to check the radial pulses, and if they are abnormal, assume shock. 

Shock Treatment

Lay the patient on their back, being mindful of possible spinal injuries. If the patient is having difficulty breathing this might not be possible. 

Elevate the legs above the head, as long as the patient does not have an un-splinted broken bone, an abdominal or head injury. 

You're trying to get more blood into the core of the body to help perfusion, but only do so if that doesn't exacerbate any other problems. 

You want to prevent chilling or overheating. This might mean putting a blanket on them, even in warm weather, especially if there has been significant blood loss. 

This is why having a space blanket in your IFAK is not a terrible idea. 

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Hypothermia & Head Injury

Hypothermia means "low body temperature." It is a leading cause of death for trauma patients. 

You have to keep your patient warm in order to increase their chances of survival by doing the following:

• Remove wet/bloody clothing
• Avoid cold surfaces
• Cover casualties
• Place blankets below patient

Head injury, shock, and spinal cord injury can increase hypothermia. 

As we mentioned above, using a space blanket or another blanket to warm your patient is critical. 

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TCCC IFAK

If you want to build an Individual First Aid Kit with treatments we discussed in this article, you'll need the following: 

If you are looking for a good pre-made first aid kit that you can make into a TCCC kit, grab a TFAK from MyMedic. 

Along the outside I've added a Condor EMT Glove Pouch to one side, and a CAT Gen 7 Tourniquet in a North American Rescue CAT Tourniquet Holder on the other.

You can add the ARS Needle, but you really do need to be trained on how to use it. 

MyMedic TFAK | First Aid Kit

Typical Price: $160

A micro trauma kit packed with essential life-saving supplies. Designed by medical and firearm professionals, a first aid kit perfect for hunting, the gun range, your car, and more.

• Contains over 35 quality supplies, including 15 trauma items, such as chest seals and a tourniquet
• Packable, all-in-one medical kit for the range
• HSA/FSA approved

$160MyMedic

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Conclusion

Medical training is not only essential, but it's interesting, and dare I say it, fun. 

If you have the time and inclination, become an EMT. It really isn't that difficult, and is a couple of nights a week for 5 months, plus 5-7 days of actual in the field work within a fire station or hospital. 

That experience will be life altering - you will know exactly what to do as first steps during nearly any traumatic or medical emergency. 

Giving your patient that extra time before EMS arrives, or noticing something is wrong quickly enough can mean the difference between losing a loved one or having a positive outcome. 

We prefer the latter.