This page contains the quarterly TacMed, TCCC, and CoTCCC Updates that are published in the Journal of Special Operations Medicine.
Remley MA, Riesberg JC, Drew B, Deaton TG, Montgomery HR, Jensen S, Gurney J. Ahead of Print. (Classical Conference)
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Anonymous A. 22(4). 132 - 135. (Classical Conference)
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Anonymous A. 22(3). 109 - 117. (Classical Conference)
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Fisher AD, DesRosiers TT, Papalski W, Remley MA, Schauer SG, April MD, Blackman V, Brown J, Butler FK, Cunningham CW, Gurney J, Holcomb JB, Montgomery HR, Morgan MM, Motov SM, Shackelford SA, Springer T, Drew B. 22(2). 154 - 165. (Classical Conference)
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Analgesia in the military prehospital setting is one of the most essential elements of caring for casualties wounded in combat. The goals of casualty care is to expedite the delivery of life-saving interventions, preserve tactical conditions, and prevent morbidity and mortality. The Tactical Combat Casualty Care (TCCC) Triple Option Analgesia guideline provided a simplified approach to analgesia in the prehospital combat setting using the options of combat medication pack, oral transmucosal fentanyl, or ketamine. This review will address the following issues related to analgesia on the battlefield: 1. The development of additional pain management strategies. 2. Recommended changes to dosing strategies of medications such as ketamine. 3. Recognition of the tiers within TCCC and guidelines for higher-level providers to use a wider range of analgesia and sedation techniques. 4. An option for sedation in casualties that require procedures. This review also acknowledges the next step of care: Prolonged Casualty Care (PCC). Specific questions addressed in this update include: 1) What additional analgesic options are appropriate for combat casualties? 2) What is the optimal dose of ketamine? 3) What sedation regimen is appropriate for combat casualties?
Keywords: analgesia; prehospital; casualties; Tactical Combat Casualty Care (TCCC) Triple Option Analgesia guideline; fentanyl; ketamine
Anonymous A. 22(1). 11 - 17. (Classical Conference)
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Remley MA, Loos PE, Riesberg JC. 22(1). 18 - 47. (Classical Conference)
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Anonymous A, Anonymous A. 22(1). 144 - 145. (Classical Conference)
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Weber S, Josse F. 21(4). 83 - 84. (Classical Conference)
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Anonymous A. 21(4). 85 - 89. (Classical Conference)
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Keywords: mental health; military psychology; military personnel; emergency responders; stigma; partners; health services accessibility
Deaton TG, Auten JD, Betzold R, Butler FK, Byrne T, Cap AP, Donham B, DuBose JJ, Fisher AD, Hancock J, Jourdain V, Knight RM, Littlejohn LF, Martin MJ, Toland K, Drew B. 21(4). 126 - 137. (Classical Conference)
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Hemorrhagic shock in combat trauma remains the greatest life threat to casualties with potentially survivable injuries. Advances in external hemorrhage control and the increasing use of damage control resuscitation have demonstrated significant success in decreasing mortality in combat casualties. Presently, an expanding body of literature suggests that fluid resuscitation strategies for casualties in hemorrhagic shock that include the prehospital use of cold-stored or fresh whole blood when available, or blood components when whole blood is not available, are superior to crystalloid and colloid fluids. On the basis of this recent evidence, the Committee on Tactical Combat Casualty Care (TCCC) has conducted a review of fluid resuscitation for the combat casualty who is in hemorrhagic shock and made the following new recommendations: (1) cold stored low-titer group O whole blood (CS-LTOWB) has been designated as the preferred resuscitation fluid, with fresh LTOWB identified as the first alternate if CS-LTOWB is not available; (2) crystalloids and Hextend are no longer recommended as fluid resuscitation options in hemorrhagic shock; (3) target systolic blood pressure (SBP) resuscitation goals have been redefined for casualties with and without traumatic brain injury (TBI) coexisting with their hemorrhagic shock; and (4) empiric prehospital calcium administration is now recommended whenever blood product resuscitation is required.
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Riesberg JC, Gurney JM, Morgan M, Northern DM, Onifer DJ, Gephart WJ, Remley MA, Eickhoff E, Miller C, Eastridge BJ, Montgomery HR, Butler FK, Drew B. 21(4). 138 - 142. (Classical Conference)
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Historically, about 20% of hospitalized combat injured patients have an abdominal injury. Abdominal evisceration may be expected to complicate as many as one-third of battle-related abdominal wounds. The outcomes for casualties with eviscerating injuries may be significantly improved with appropriate prehospital management. While not as extensively studied as other forms of combat injury, abdominal evisceration management recommendations extend back to at least World War I, when it was recognized as a significant cause of morbidity and was especially associated with bayonet injury. More recently, abdominal evisceration has been noted as a frequent result of penetrating, ballistic trauma. Initial management of abdominal evisceration for prehospital providers consists of assessing for and controlling associated hemorrhage, assessing for bowel content leakage, covering the eviscerated abdominal contents with a moist, sterile barrier, and carefully reassessing the patient. Mortality in abdominal evisceration is more likely to be secondary to associated injuries than to the evisceration itself. Attempting to establish education, training, and a standard of care for nonmedical and medical first responders and to leverage current wound management technologies, the Committee on Tactical Combat Casualty Care (CoTCCC) conducted a systematic review of historical Service guidelines and recent medical studies that include abdominal evisceration. For abdominal evisceration injuries, the following principles of management apply: (1) Control any associated bleeding visible in the wound. (2) If there is no evidence of spinal cord injury, allow the patient to take the position of most comfort. (3) Rinse the eviscerated bowel with clean fluid to reduce gross contamination. (4) Cover exposed bowel with a moist, sterile dressing or a sterile water-impermeable covering. It is important to keep the wound moist; irrigate the dressing with warm water if available. (4) For reduction in wounds that do not have a substantial loss of abdominal wall, a brief attempt may be made to replace/reduce the eviscerated abdominal contents. If the external contents do not easily go back into the abdominal cavity, do not force or spend more than 60 seconds attempting to reduce contents. If reduction of eviscerated contents is successful, reapproximate the skin using available material, preferably an adhesive dressing like a chest seal (other examples include safety pins, suture, staples, wound closure devices, etc.). Do not attempt to reduce bowel that is actively bleeding or leaking enteric contents. (6) If unable to reduce, cover the eviscerated organs with water-impermeable, nonadhesive material (transparent preferred to allow ability to reassess for ongoing bleeding; examples include a bowel bag, IV bag, clear food wrap, etc.), and then secure the impermeable dressing to the patient using an adhesive dressing (e.g., Ioban, chest seal). (7) Do NOT FORCE contents back into abdomen or actively bleeding viscera. (8) Death in the abdominally eviscerated patient is typically from associated injuries, such as concomitant solid organ or vascular injury, rather than from the evisceration itself. (9) Antibiotics should be administered for any open wounds, including abdominal eviscerating injuries. Parenteral ertapenem is the preferred antibiotic for these injuries.
Keywords: abdominal injury; abdominal evisceration; battle-related abdominal wounds; prehospital management
Anonymous A. 21(3). 100 - 106. (Classical Conference)
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Montgomery HR, Drew B, Butler FK. 21(2). 120 - 121. (Classical Conference)
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Montgomery HR, Drew B, Torrisi J, Adams MG, Remley MA, Rich TA, Greydanus DJ, Shaw TA. 21(2). 122 - 127. (Classical Conference)
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Based on careful review of the Tactical Combat Casualty Care (TCCC) Guidelines, the authors developed a list of proposed changes and edits for inclusion in a comprehensive change proposal. To be included in the proposal, individual changes had to meet at least one of three criteria: 1. The change was primarily tactical, operational, or educational rather than clinical in nature. 2. The change was a minor modification to the language of an existing TCCC Guideline. 3. The change, though clinical, was straightforward and noncontentious. The authors initially presented their list to the TCCC Collaboration Group for review at the 11 August 2020 online virtual meeting of the Committee on Tactical Combat Casualty Care (CoTCCC). Based on discussions during the virtual meeting and following revisions, a second presentation of guideline modifications was presented during the CoTCCC session of the online virtual Defense Committee on Trauma meeting on 02 September 2020. The CoTCCC conducted voting on the guideline changes in early October 2020 with subsequent inclusion in the updated TCCC Guidelines published on 01 November 2020.1
Keywords: Tactical Combat Casualty Care; TCCC; guidelines; change proposal
Butler FK. 21(1). 127 - 133. (Classical Conference)
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The Tactical Combat Casualty Care (TCCC) project initiated by Naval Special Warfare and continued by the US Special Operations Command has developed a new set of combat trauma care guidelines that seek to combine good medical care with good small-unit tactics. The principles of care recommended in TCCC have gained increasing acceptance throughout the Department of Defense in the four years since their publication and increasing numbers of combat medical personnel and military physicians have been trained in this concept. Since casualty scenarios in small-unit operations typically present tactical as well as medical problems, however, it has become apparent that a customized version of this course suitable for small-unit mission commanders is a necessary addition to the program. This paper describes the development of a course in Tactical Medicine for SEAL Mission Commanders and its transition into use in the Naval Special Warfare community.
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Drew B, Montgomery HR, Butler FK. 20(4). 144 - 151. (Classical Conference)
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Montgomery HR, Drew B. 20(2). 152 - 153. (Classical Conference)
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Butler FK, Greydanus DJ. 20(1). 148 - 161. (Classical Conference)
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Anonymous A. 19(4). 22 - 24. (Classical Conference)
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Keywords: case reports; bleeding; TCCC
Anonymous A. 19(4). 130 - 131. (Classical Conference)
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Anonymous A. 19(3). 18 - 21. (Classical Conference)
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Keywords: case reports; airway; TCCC
Anonymous A. 19(3). 94 - 99. (Classical Conference)
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Butler FK, Giebner S. 19(3). 134 - 146. (Classical Conference)
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Butler FK, Giebner S. 19(2). 143 - 145. (Classical Conference)
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Butler FK, Giebner S. 19(1). 136 - 145. (Classical Conference)
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Josse F. 18(4). 111 - 112. (Classical Conference)
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Luhrs J. 18(4). 113 - 114. (Classical Conference)
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Anonymous A. 18(4). 115 - 122. (Classical Conference)
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Anonymous A. 18(4). 159 - 161. (Classical Conference)
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Anonymous A. 18(3). 79 - 85. (Classical Conference)
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Anonymous A. 18(3). 136 - 146. (Classical Conference)
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Butler FK. 18(2). 153 - 153. (Classical Conference)
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Hartford B, Shapiro G, Marino MJ, Smith R, Tang N. 18(1). 160 - 161. (Classical Conference)
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Butler FK, Giebner S. 18(1). 164 - 171. (Classical Conference)
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Butler FK. 17(4). 142 - 147. (Classical Conference)
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Montgomery HR, Butler FK. 17(3). 154 - 154. (Classical Conference)
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Montgomery HR, Butler FK, Kerr W, Conklin CC, Morissette DM, Remley MA, Shaw TA, Rich TA. 17(2). 21 - 38. (Classical Conference)
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Based on careful review of the Tactical Combat Casualty Care (TCCC) Guidelines, the authors developed a list of proposed changes for inclusion in a comprehensive change proposal. To be included in the proposal, individual changes had to meet at least one of three criteria: (1) The change was primarily tactical rather than clinical; (2) the change was a minor modification to the language of an existing TCCC Guideline; and (3) the change, though clinical, was straightforward and noncontentious. The authors presented their list to the TCCC Working Group for review and approval at the 7 September 2016 meeting of the Committee on Tactical Combat Casualty Care (CoTCCC). Twenty-three items met with general agreement and were retained in this change proposal.
Keywords: Tactical Combat Casualty Care; TCCC; T3; Tactical Combat Casualty Care guidelines; TCCC Guidelines Comprehensive Review and Update; battlefield trauma care; Role 1 Care
Butler FK. 17(2). 166 - 172. (Classical Conference)
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Background: Twenty years ago, the original Tactical Combat Casualty Care (TCCC) article was published in this journal. Since TCCC is essentially a set of bestpractice prehospital trauma care guidelines customized for use on the battlefield, the presence of a journal with a specific focus on military medicine was a profound benefit to the initial presentation of TCCC to the US Military. Methods: In the two ensuing decades, which included the longest continuous period of armed conflict in our nation's history, TCCC steadily evolved as the prehospital trauma care evidence base was augmented and as feedback from user medics, corpsmen, and pararescuemen was obtained. Findings: TCCC has taken a leadership role in advocating for battlefield trauma care advances such as the aggressive use of tourniquets and hemostatic dressings to control lifethreatening external hemorrhage; improved fluid resuscitation techniques for casualties in hemorrhagic shock; increased emphasis on airway positioning and surgical airways to manage the traumatized airway; faster, safer, and more effective battlefield analgesia; the increased use of intraosseous vascular access when needed; battlefield antibiotics; and combining good medicine with good small-unit tactics. With the continuing assistance of Military Medicine, these advances and the evidence base that supports them have been presented to TCCC stakeholders. Discussion/Impact: Now-20 years later-TCCC has been documented to produce unprecedented decreases in preventable combat death in military units that have trained all of their members in TCCC. As a result of this proven success, TCCC has become the standard for battlefield trauma care in the US military and for the militaries of many of our allied nations. Committee on TCCC members and the Joint Trauma System also work closely with civilian trauma colleagues through initiatives such as the Hartford Consensus, the White House Stop the Bleed campaign, and the development of National Association of Emergency Medical Technicians TCCC-based courses to ensure that advances in prehospital trauma care pioneered by the military on the battlefield are translated into civilian practice on the streets of America. Active shooter incidents, terrorist bombings, and the day-today trauma that results from motor vehicle accidents and criminal violence create the potential for many additional lives to be saved in the civilian sector. Along with the other components of the Department of Defense's Joint Trauma System, the Committee on TCCC, and the TCCC Working Group have been recognized as a national resource and will continue to advocate for advances in best-practice battlefield trauma care as opportunities to improve are identified.
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Palmer LE, Yee A. 17(2). 174 - 187. (Classical Conference)
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Keywords: canines; K9s; Operational K9s; Tactical Emergency Casualty Care
Shackelford S, Hammesfahr R, Morissette DM, Montgomery HR, Kerr W, Broussard M, Bennett BL, Dorlac WC, Bree S, Butler FK. 17(1). 135 - 147. (Classical Conference)
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Keywords: pelvic binder; prehospital guidelines; TCCC Guideline
Shapiro G, Tang N, Kamin R, Smith R. 17(1). 149 - 151. (Classical Conference)
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Keenan S. 16(4). 86 - 86. (Classical Conference)
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Cancio LC, Powell D, Adams B, Bull K, Keller A, Gurney J, Pamplin JC, Shackelford S, Keenan S. 16(4). 87 - 98. (Classical Conference)
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Butler FK, Giebner S. 16(4). 130 - 131. (Classical Conference)
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Pennardt A. 16(4). 132 - 132. (Classical Conference)
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Anonymous A. 16(3). 99 - 119. (Classical Conference)
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Callaway DW. 16(3). 120 - 122. (Classical Conference)
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Butler FK. 16(2). 120 - 137. (Classical Conference)
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Anonymous A. 16(2). 138 - 147. (Classical Conference)
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Tang N, Shapiro G, Smith ER, Kamin R, Callaway DW. 16(2). 148 - 150. (Classical Conference)
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Butler FK. 16(1). 132 - 135. (Classical Conference)
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Shapiro G, Smith R, Callaway DW. 16(1). 137 - 139. (Classical Conference)
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Butler FK. 15(4). 164 - 174. (Classical Conference)
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Anonymous A. 15(4). 175 - 177. (Classical Conference)
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Anonymous A. 15(3). 129 - 147. (Classical Conference)
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Callaway DW, Smith R, Shapiro G, McKay SD, Kamin R. 15(3). 148 - 152. (Classical Conference)
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Anonymous A. 15(2). 154 - 167. (Classical Conference)
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Callaway DW, Smith R, Shapiro G, Hartford B, McKay SD, Kamin R. 15(2). 168 - 170. (Classical Conference)
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Butler FK, Cordoni L. 15(1). 136 - 141. (Classical Conference)
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Selected Meeting Highlights
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Smith R, Bobko JP, Shapiro G, Hartford B, Callaway DW. 15(1). 143 - 145. (Classical Conference)
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Giebner S. 14(4). 144 - 145. (Classical Conference)
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Callaway DW, Smith R, Shapiro G. 14(4). 146 - 147. (Classical Conference)
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Anonymous A. 14(3). 124 - 132. (Classical Conference)
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Callaway DW, Smith R, Shapiro G, McKay SD. 14(3). 134 - 134. (Classical Conference)
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Callaway DW, Smith R, Shapiro G, Bobko JP, McKay SD. 14(3). 135 - 139. (Classical Conference)
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The Johns Hopkins Center for Law Enforcement Medicine and Division of Special Operations in Baltimore generously hosted the June 2014 Committee for Tactical Emergency Casualty Care meeting (C-TECC). The C-TECC meeting focused on several critical issues including guideline updates, review of C-TECC member involvement in recent federal efforts regarding active violent incidents, examination of national best practices, and new partnership agreements.
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Anonymous A. 14(2). 113 - 120. (Classical Conference)
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Schwartz RB, Lerner B, Llewellyn C, Pennardt A, Wedmore I, Callaway DW, Wightman JM, Casillas R, Eastman AL, Gerold KB, Giebner S, Davidson R, Kamin R, Piazza G, Bollard GA, Carmona PA, Sonstrom B, Seifarth W, Nicely B, Croushorn J, Carmona PA. 14(2). 122 - 138. (Classical Conference)
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Callaway DW, Smith R, Shapiro G, McKay SD. 14(2). 139 - 139. (Classical Conference)
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Anonymous A. 14(1). 113 - 115. (Classical Conference)
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Carmona PA. 14(1). 116 - 117. (Classical Conference)
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Smith R. 14(1). 118 - 120. (Classical Conference)
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