Advanced Trauma Life Support ATLS Student Course Manual 2018

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APPENDIX C n Trauma Care in Mass-Casualty, Austere, and Operational Environments
Care (TCCC). Initially developed as a curriculum for
U.S. Special Operations Command, TCCC has now been
implemented across the battlefield and is the standard
for combat prehospital care. A military edition of the
Prehospital Trauma Life Support textbook was developed
to support this curriculum.
The widespread implementation and training of all
combat personnel as competent initial responders has
resulted in demonstrable reductions in preventable
death on the battlefield. Today, the TCCC and PHTLS
curricula represent a highly successful collaborative
effort between the U.S. Department of Defense
Committee on Tactical Combat Casualty Care,
the American College of Surgeons Committee on
Trauma, and the National Association of Emergency
Medical Technicians.
TCCC divides point-of-injury care into three distinct
phases: (1) Care Under Fire, (2) Tactical Field Care, and
(3) Tactical Evacuation.
Care Under Fire
The Care Under Fire phase involves the care rendered
by fellow soldiers (“buddy aid”) or the unit medic or
corpsman at the scene of the injury while the immediate
responder and the casualty are still under effective
direct or indirect hostile fire. The primary focus for
this phase of field medical care is fire superiority and
suppression of the source of ongoing attacks. The
only medical intervention conducted in this phase
is rapid control of ongoing hemorrhage, typically by
applying a tourniquet and/or hemostatic dressing.
These supplies can be self-administered or applied by
a fellow combatant or a combat medic.
Tactical Field Care
In the second phase, care is provided by the medic or
corpsman once no longer under effective hostile fire.
Tactical Field Care can be highly variable depending
on the setting, but all efforts should be expended to
minimize the time from injury to arrival at a forward
medical treatment facility (MTF) with surgical
capabilities. In addition, reengagement with the enemy
remains a possibility and must always be anticipated.
In this phase of care, the standard critical prehospital
trauma assessments and interventions are conducted.
In contrast to the ordered ABCDE approach emphasized
in standard ATLS teachings, TCCC emphasizes
hemorrhage control (or “C”) first, followed by airway
and breathing. This approach is based on consistent
findings that the most common cause of potentially
preventable deaths on the modern battlefield (up
to 90%) is due to uncontrolled hemorrhage. Other
interventions emphasized in this phase include
establishing a secure airway if needed, decompression
of tension pneumothorax, judicious resuscitation
using permissive hypotension, pain control, antibiotic
administration if indicated, and preparation for
transport to the next phase of care.
Tactical Evacuation Care
Tactical Evacuation care is rendered once the
casualty has been placed in the medical evacuation
(MEDEVAC) platform. It includes care provided
from the point of injury and during transport to the
most appropriate higher-level medical facility. Care
during this phase focuses on continuing the initial
interventions performed in the Tactical Field Care
phase, assessment and intervention for any additional
life- or limb-threatening injuries, and initiating fluid
resuscitation, pain control, and antibiotic therapy if not
already begun. More detailed evaluation and greater
options for intervention are indicated in this phase of
care. The primary philosophy involves minimizing
unnecessary or nonurgent interventions and focusing
on rapid transportation to a higher level of care.
ATLS in the Operational Environment
(ATLS-OE)
Just as TCCC is to PHTLS, ATLS in the Operational
Environment (ATLS-OE) is a course of instruction that
emphasizes the importance of maintaining situational
awareness while providing care in a potentially
hostile, resource-constrained, and manpowerlimited
environment. The unique situational and
environmental factors in the operational setting
often include severely constrained resources or
supply chains, variable communication capabilities,
limited evacuation and transport options, extremes
of weather, and a dynamically changing security or
tactical environment. In addition, the numbers of
casualties, severity and types of injuries, and wounding
mechanisms seen with modern combat or even largescale
disasters may be considerably different when
compared with standard civilian trauma patterns.
The operational or combat environment involves
various unique challenges that require providers to
be ever cognizant. These challenges rarely present
an issue in the stable civilian environment, although
some of these same concepts are also applicable to
the rural environment. Providers who render trauma
care in an austere environment will be required not
only to deliver high-quality modern trauma care, but
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