TCCC 2009 Guidelines

You will notice WoundStat has been removed as the secondary hemostatic.

TCCC 2009 Guidelines

Surgical Airway/Cricothyroidotomy: How to

This video is a supplement to training and is neither comprehensive nor a replacement for proper instruction.

A surgical airway/cricothyroidotomy is the advanced airway of choice in combat, due to the types of injuries encountered. Severe maxofacial trauma secondary to blasts are common and may require more invasive treatment when neither the recovery position nor NPA nor King Oropharyngeal Airway (King-LTD) will suffice. It is important to note that only airway management is generally best left to the Tactical Field Care (TFC) phase of treatment. Furthermore, less than 1% of trauma casualties require an airway, so prudence is required when deciding to intervene. The indications and contraindication are as follows:


–Airway obstruction due to maxillofacial trauma that cannot be corrected by positioning or a nasopharyngeal airway
–Anaphylaxis that is or is about to compromise the airway
–Inhalation burns injury
–Where other means to secure the airway have failed


–Airway can be maintained by other means

Please note that we illustrate a vertical incision instead of the traditional horizontal, because we feel it is the preferred method in the tactical environment. First, a vertical incision minimizes the risk of involving (e.g., cutting) the vascular structure of the neck. Second, it creates a larger “window,” thereby simplifying landmark identification. Finally, a vertical incision allows one to select a different location above or below the initial site, if one should misplace the initial cut, due to lack of familiarity with the procedure.

Three-Step Cric?

Below you will find an article published in Military Medicine. It argues that traditional ways of providing a surgical airway in a tactical environment are flawed. Therefore, the authors continue, a new approach is needed. Three-step Cric

Objective: Surgical cricothyroidotomy is the airway of choice in combat. It is too dangerous for combat medics to perform orotracheal intubation, because of the time needed to complete the procedure and the light signature from the intubation equipment, which provides an easy target for the enemy. The purpose of this article was to provide a modified approach for obtaining a surgical airway in complete darkness, with night-vision goggles. Methods: At our desert surgical skills training location at Nellis Air Force Base (Las Vegas, Nevada), Air Force para-rescue personnel received training in this technique using human cadavers. This training was provided during the fall and winter months of 2003-2006. Results: Through trial and error, we developed a “quick and easy” method of obtaining a surgical airway in complete darkness, using three steps. The steps involve the traditional skin and cricothyroid membrane incisions but add the use of an elastic bougie as a guide for endotracheal tube placement. We have discovered that the bougie not only provides an excellent guide for tube placement but also eliminates the use of additional equipment, such as tracheal hooks or dilators. Furthermore, the bevel of the endotracheal tube displaces the cricothyroid membrane laterally, which allows placement of larger tubes and yields a better tracheal seal. Conclusion: Combat medics can perform the three-step surgical cricothyroidotomy quickly and efficiently in complete darkness. An elastic bougie is required to place a larger endotracheal tube. No additional surgical equipment is needed.

Equipment Considerations: Level 1

When planning for a mission, a medic must pack relevant equipment that reflects the highest percentages of injuries he could face (e.g, splinting material for air ops) . More important, medics must pack in accordance with the priority of treatment. That is to say, medics ought to pack their gear in three levels.

Level 1:
Level 1 equipment is needed for life threatening injuries. It ought to be carried on your person. For example, tourniquets, bandages, NPAs, etc, are needed to prevent death from the high-percentage killers. These items ought to be carried in IFAKs (your personal as well as your operators’), in leg-rigs, or on your vest. Accessibility is key, especially if you are going to use the equipment in the CUF phase. Also, medics must train to use the casualty’s equipment first, so he does not exhaust his equipment too rapidly. This requires operators to carry their own gear, not rely on the medic to carry it for them. Finally, do not use your personal first-aid kit unless absolutely necessary.

What do you carry in your Level 1 Gear?

Levels 2 and 3 will be covered in future posts.

Holiday Absence

We apologize for the time elapsed between posts. Now that the holidays have past, we shall post every two weeks.


The Importance of the Basics for LEOs

Saving lives is not the sole domain of Paramedics or Tactical Medics. Preparing Law Enforcement Officers (LEOs) to perform basic live-saving procedures in the field can pay huge dividends if faced the challenge of saving a life–theirs or a citizen’s.

Had the Gainesville Police and Alachua County Sheriff’s Departments in Florida assumed the position that “Medics do Medicine” by not implementing this program, this story would have ended differently.


How long Is Your Needle?

Chest Wall Thickness in Military Personnel: Implications for Needle Thoracentesis in Tension Pneumothorax

HARCKE H. Theodore ; PEARSE Lisa A. ; LEVY Angela D. ; GETZ John M. ; ROBINSON Stephen R. ;

Journal Title
Military Medicine ISSN 0026-4075


Needle thoracentesis is an emergency procedure to relieve tension pneumothorax. Published recommendations suggest use of angiocatheters or needles in the 5-cm range for emergency treatment. Multidetector computed tomography scans from 100 virtual autopsy cases were used to determine chest wall thickness in deployed male military personnel. Measurement was made in the second right intercostal space at the midclavicular line. The mean horizontal thickness was 5.36 cm (SD = 1.19 cm) with angled (perpendicular) thickness slightly less with a mean of 4.86 cm (SD 1.10 cm). Thickness was generally greater than previously reported. An 8-cm angiocatheter would have reached the pleural space in 99% of subjects in this series. Recommended procedures for needle thoracentesis to relieve tension pneumothorax should be adapted to reflect use of an angiocatheter or needle of sufficient length.

Chest Wall Thickness

Improvised Medicine Part 1

As mentioned in earlier entries, one of the keys to success in the tactical environment is flexibility. A Medic’s ability to improvise with his equipment or other items greatly increases their level of flexibility. Improvising can allow you to reduce in size and lighten your load, or to treat an injury you didn’t think you had the ability to treat.
While these solutions are generally not definitive treatments, they are often better than nothing at all. If you have the right gear, use it. The point is to be prepared for when you don’t.

In this first entry, we will cover some basic principles:

1. Think ahead- know the equipment you have and think of other ways to use it.

2. Don’t “pre-improvise”-Yes it can save time, but chances are if you modify a supply or component it is a permanent change that will either eliminate its ability to perform its original task or at least reduce that ability. This does not apply to everything so use your head and do what makes sense.

3. Don’t improvise with highly specialized items unless you have no other choice- It makes little sense to use a 14ga angiocath to improvise a trach-hook if I can do the same thing with a safety pin. There are few ways to improvise an angiocath, none of which I’d want to try or have tried on me. That’s an item that is specialized.

4. Don’t bury your head in your aid bag- The great thing about improvising is that you have the world at your disposal. Just because an item in not labeled “medical” does not mean you can’t use it.

Planned improvisation
An example of planned improvisation is the decision to not carry scalpel handles or full-sized disposable scalpels. I can carry 10 blades of differing design to one disposable scalpel that only offers me one blade choice. By using the blade wrapper to create a handle (see the video for a demo) I now have a functional instrument that I can use to perform just about any procedure that requires a scalpel. The control of the blade is not as fine, but it is more than acceptable (if practiced) for the majority of emergency procedures conducted in the field.

Developing a Tactical Emergency Medical Support Program

This post is geared toward TEMS Medics. We will be posting a video in two weeks detailing medical equipment improvisation techniques for the field. Dr. Schwartz recently published a book that examines TEMS programs in greater detail. There is a link to it in the right margin of the page, under the heading Recommended Readings.

By Joshua S. Vayer, BA; Richard B. Schwartz, MD, FACEP

The development of a tactical emergency support (TEMS) program is an involved process. Multiple TEMS models effectively function and there is no “best model” for every agency. This article summarizes common components that must be considered in the development of a TEMS program. Components discussed include: goals of TEMS program, structure of the TEMS element, training for TEMS providers, law enforcement status, TEMS provider skill level, arming of TEMS providers, operating location, liability issues, insurance issues, and equipment for TEMS units. The proper development of a TEMS program will meet the primary goal of enhancing the tactical unit’s mission accomplishment. Key words: CASEVAC, explosive ordinance disposal, hostage rescue team, special weapons and tactics, special response team, tactical combat casualty care, tactical emergency medical support, tactical medicine.


Post-engagement Hearing Loss and Factors Affecting the Use of Diagnostics

One of the challenges associated with tactical medicine is the lack of diagnostic equipment at the point of injury and throughout the evacuation process. The tactical situation can limit the ability to use exam lights (of any color) and post-engagement hearing loss or environmental noise can eliminate your ability to use a stethoscope or to hear at all.

It is important to practice different techniques for assessing your casualties’ status that do not require the use of diagnostic tools or one specific sense. Hearing is the most regularly affected sense in the combat environment and it is the sense medics rely on the most heavily. Large blasts or firing a weapon can cause a significant ringing or a muffle in your ears. Therefore, when listening for slight variations in breath sounds or a fading pulse, it can be next to impossible to hear. That is why you must learn alternate methods for assessing your casualties’ status.

One skill that is often affected is measuring blood pressure. If you don’t know how to take a palp. blood pressure or know how pulse presence roughly correlates to levels of BP, you need to learn and practice the techniques. They also come in handy when working in the back of a helicopter or loud vehicle such as a track-vehicle or Stryker that are on the move. Here are some examples of pulse pressures associated with the presence of a pulse in various locations.

Pulse Location/Correlating Pulse pressure

Dorsalis-pedis pulse/90
Tibialis-posterior pulse/90
Radial pulse/80
Femoral pulse/70
Carotid pulse/60

These are very rough estimates and should only be used when no other means of measuring pressure are available. Studies have shown that this method often causes medical personnel to overestimate their patients’ pressure. We suggest this method be used to note which pulses are palpable during the initial set of vitals. Mark the location of these pulses with a Sharpie® when they are found. If a pulse that was present becomes weaker or disappears as time elapses, your casualty may be deteriorating, and you need to do something to address the cause of that deterioration. As stated earlier, this method should not be used if an accurate pressure is required.

The inability to use the sense most suited for the evaluation of a casualty is not just limited to taking blood pressure. It affects your ability to assess a needle decompression in a helicopter, looking for unilateral rise and fall of the chest, feeling for injuries and many other portions of your assessment. Regular practice of alternate methods of assessment should be included in your training regimen, because it’s too late to practice after your ears are ringing from the IED blast.