T A C T I C A L C O M B A T C A S U A LT Y C A R E · 2 0 2 6 G U I D E L I N E S

TCCC Concept Study Guide

Made simple, pointwise & memory-friendly

Prepared for UNITAR Training

The One Big Idea

TCCC = Tactical Combat Casualty Care — how to save a wounded person on a battlefield without
becoming a casualty yourself and without losing the fight.
It is not normal hospital first aid. It always balances two things at once:

Good Medicine + Good Tactics

The system rests on one truth — on the battlefield, people mostly die from 3 preventable things:
1. Bleeding out (haemorrhage)
2. Blocked airway
3. Collapsed lung (tension pneumothorax)
Everything you learn is about fixing these fast, in the right order.

Structure — The 3 Phases

Think of it as a story that moves the casualty from danger → safety → hospital.

Phase Where Safety What you can do

1. Care Under Fire (CUF) Still being shot at Very dangerous Almost nothing — only stop major
bleeding

2. Tactical Field Care Behind cover, threat Safer Full assessment & treatment
(TFC) reduced (MARCH)

3. Tactical Evacuation On vehicle / helicopter Moving to Same as TFC + oxygen +

(TACEVAC) hospital advanced airway

Memory hook: Fight → Field → Flight

The Master Mnemonic: MARCH

The single most important thing to memorise. In every phase you treat in this exact order — because
it follows what kills fastest.

Letter Meaning Why it's in this order

M Massive haemorrhage Bleeding kills in minutes — fix first

Airway No open airway = no oxygen in

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 A

R Respiration (breathing) Find & treat collapsed lung

C Circulation Blood, fluids, shock control

H Hypothermia / Head Cold kills a bleeding patient; protect the brain

After MARCH comes the "second wave": Pain → Antibiotics → Wounds → Splints → Burns → Comms →
Documentation.

PHASE 1

Care Under Fire (CUF)

"Win the firefight first"

CORE RULE
The best medicine here is superior firepower. A dead medic saves no one.

1. Return fire and take cover.

2. Keep the casualty in the fight if they still can.
3. Tell them to move to cover and self-aid (or drag them to cover).
4. Stop them getting more wounds.
5. Get casualties out of burning vehicles/buildings.
6. Massive bleeding = the ONLY medical treatment here:
◦ Use a CoTCCC-recommended limb tourniquet.
◦ Apply over the uniform, high and tight if the exact site isn't obvious.
7. Airway is DEFERRED to the next phase — no time under fire.

Memory hook (CUF): Shoot, Move, Tourniquet. Nothing fancy.

PHASE 2

Tactical Field Care (TFC)

The main phase — this is where MARCH lives

First: set up security, keep situational awareness, and triage if multiple casualties. Then work through
MARCH.

M Massive Haemorrhage
• Find and stop all bleeding.
• Tourniquet: apply directly to skin, 2–3 inches (5–7 cm) ABOVE the wound.
• Not stopping? → Second tourniquet side-by-side, just above the first.
• Junctional wounds (neck, groin, armpit): pack with Combat Gauze (first choice). Alternatives: Celox,
ChitoGauze, XStat, iTClamp.
• Hold direct pressure ≥ 3 minutes (except XStat).
• iTClamp closes head/neck wounds — but never within 1 cm of the eye.

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 WARNING
XStat is NOT removed in the field.

LOCK THIS IN
Tourniquet = 2–3 inches above wound, on skin.

A Airway (updated in 2026)

Simplest first:
1. Conscious → let them sit up / lean forward.
2. Unconscious → recovery position, head tilted back, chin off chest.
3. Use suction if available.
4. Airway blocked & unfixable (facial fracture, burns, blood) → surgical cricothyroidotomy. Confirm with
EtCO2; use lidocaine if awake.

5. Penetrating trauma alone → no cervical collar needed.

Memory hook: Position → Suction → Surgical airway (last resort).

R Respiration / Breathing
The star here = Tension Pneumothorax (trapped air crushing the lung & heart) — the #2 killer.
Suspect it when torso/blast injury PLUS any of: severe/worsening breathing difficulty, very fast breathing,
no breath sounds one side, SpO2 < 90%, shock, or cardiac arrest without fatal wounds.

TREATMENT — NEEDLE DECOMPRESSION (NDC)

Needle 14g or 10g, 3.25 inch · Site: 5th ICS anterior axillary line OR 2nd ICS mid-clavicular
line (don't go medial to nipple) · Insert over top of the lower rib, to the hub, hold 5–10 sec, remove
needle, leave the catheter.

• Open ("sucking") chest wound → vented chest seal (non-vented if none).

• Keep SpO2 ≥ 92% for moderate/severe head injury.

LOCK THIS IN
14g/10g, 3.25 inch · 5th ICS AAL or 2nd ICS MCL.

C Circulation
Three parts: Bleeding review → Access → Fluids.
1. Bleeding & tourniquet management
• Pelvic binder for suspected pelvic fracture (blunt/blast + pelvic pain, amputation, shock,
unconsciousness).
• Re-check earlier tourniquets — move over-uniform ones to skin, 2–3 inches above wound.
• Convert tourniquet → dressing if all 3 true: not in shock + can watch wound + not an amputation.
Try within 2 hours. Do NOT remove if > 6 hours (unless monitoring + lab).
• Mark the TIME with permanent marker + on the TCCC Card (DD 1380).
2. IV / IO Access — 18-gauge IV preferred; can't get a vein fast → IO (into bone).
3. TXA (Tranexamic Acid) — the anti-bleeding drug: 2 g slow IV/IO push if likely to need blood OR signs
of TBI.

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 TIME-CRITICAL
TXA must be given within 3 hours of injury (later = harmful).

4. Fluid Resuscitation — the "blood ladder" (best → worst):

1. Cold-stored low-titer O whole blood
2. Fresh low-titer O whole blood
3. Plasma : RBC : Platelets = 1:1:1
4. Plasma : RBC = 1:1
5. Plasma or RBC alone
• Not in shock? → no IV fluids; can drink if conscious.
• Endpoint: stop at palpable radial pulse, better mental status, or SBP ≈ 100 mmHg.
• After blood → give 1 g calcium (30 ml 10% gluconate OR 10 ml 10% chloride).
• Refractory shock (not responding)? → think untreated tension pneumothorax.

LOCK THIS IN
TXA 2 g < 3 hrs · SBP target ≈ 100 · Radial pulse = your goal.

H Hypothermia (and Head injury)

Hypothermia prevention — a cold patient can't clot (deadly triad: cold + acid + bleeding).
• Off cold ground, remove wet clothes, wrap in heating blanket + impermeable enclosure.
• Warm IV fluids: up to 150 ml/min at 38°C.
Traumatic Brain Injury (TBI) (updated in 2026):
• Moderate/Severe TBI = can't follow simple commands (thumbs up / two fingers / blink) beyond 10
min after injury.
• Get to neurosurgery within 5 hours.
• Protect-the-brain bundle: Oxygen ≥ 92% · SBP > 100 (treat bleeding first if both) · EtCO2 35–45
(no monitor → 10 breaths/min = 1 every 6 sec) · elevate head > 30° if not in shock.
• Herniation signs (blown/unequal pupil, posturing) → hypertonic saline: 250 ml of 3%/5% OR 30 ml of
23.4%, IV/IO over ≥ 10 min; repeat once after 20 min (max 2 doses).

WARNING
Hypertonic saline is NOT a resuscitation fluid — never use it "just in case."

LOCK THIS IN
Neurosurgery in 5 hours · Follow commands after 10 min = OK.

After MARCH — The Second Wave

Area Key points

Penetrating Eye Rigid eye shield (NEVER a pressure patch) · Ceftriaxone 2 g IV/IM or cefadroxil 1 g PO.

Analgesia Can fight: CWMP — Acetaminophen 1000–1300 mg q8h, Meloxicam 15 mg daily,

Suzetrigine 100 mg then 50 mg q12h. Can't fight: Ketamine (100 mg IM / 50 mg IN / 25
mg IV-IO) or Esketamine 14–28 mg IN. Endpoint = pain reduced OR nystagmus. Never
mix benzodiazepines with ketamine/opioids.

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 Antibiotics All open wounds. Can swallow → Cefadroxil 1 g PO daily (or Cephalexin 500 mg q6h).
Can't → Ceftriaxone 2 g IV/IO/IM daily.

Wounds Inspect & dress. Abdominal evisceration → moist/impermeable cover, keep NPO.

Burns Rule of Nines (nearest 10%). Fluids if > 20% TBSA — Rule of Ten: %TBSA × 10 ml/hr
(40–80 kg); +100 ml/hr per 10 kg over 80 kg. Treat as a trauma casualty with burns,
not a burn casualty. Extra hypothermia care.

Splint Splint fractures, re-check pulses.

CPR Do NOT do CPR for blast/penetrating trauma with no signs of life. BUT torso/polytrauma
with no pulse → bilateral needle decompression first before stopping.

Comms & Docs Reassure casualty; update leadership & evacuation cell. Record all on TCCC Card (DD
1380) — it travels with the casualty.

PHASE 3

Tactical Evacuation (TACEVAC)

"Same as TFC, plus more resources"

Almost everything is identical to Tactical Field Care. The key additions:

1. Transition of care: hand over cleanly — say stable/unstable, injuries, treatments given.
2. Airway: endotracheal intubation now allowed (if trained) instead of surgical airway.
3. Oxygen: give for low SpO2, unconsciousness, TBI (≥ 92%), shock, altitude, smoke inhalation.

4. CPR: may now be attempted if no fatal wounds and a surgical hospital is close.

Memory hook: TACEVAC = TFC with a helicopter, oxygen, and a real airway tube.

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One-Page Memory Sheet

THE FRAMEWORK
Phases: Fight → Field → Flight | Priority always: M – A – R – C – H | 3 killers: Bleeding · Airway ·
Tension pneumothorax

Item Number to remember

Tourniquet placement 2–3 inches above wound, on skin

Hemostatic pressure ≥ 3 minutes

Needle decompression 14g/10g, 3.25 in; 5th ICS AAL or 2nd ICS MCL

TXA 2 g, within 3 hours

SBP target (shock / TBI) ≈ 100 mmHg / > 100 for TBI

SpO2 target (TBI) ≥ 92%

Calcium after blood 1g

Convert tourniquet try < 2 hrs; don't remove if > 6 hrs

TBI = moderate/severe can't obey commands > 10 min

Neurosurgery window within 5 hours

Ventilation (TBI) 10 breaths/min (every 6 sec), EtCO2 35–45

Burns fluid (Rule of Ten) %TBSA × 10 ml/hr (40–80 kg)

GOLDEN PRINCIPLE
Good medicine can be bad tactics. Always fix the fight, then fix the wound — and bleeding always
outranks everything.

WHAT'S NEW IN 2026

Mainly Airway management and Traumatic Brain Injury management in the Tactical Field Care
phase — give these two sections extra attention.

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