Tactical Combat Casualty Care (TCCC) is a set of evidence-based medical guidelines designed for managing trauma and life-threatening injuries in high-threat, hostile environments. Developed initially by the U.S. military, TCCC adapts life-saving medical interventions to the unique constraints of the battlefield or similar tactical situations. The framework ensures that both medical care for the injured and the operational safety of the team are considered simultaneously. TCCC has since been adopted by law enforcement, rescue, and security organizations operating where the risk of hostile action or severe logistical challenges exist.
The Guiding Principles of TCCC
The foundational philosophy of TCCC centers on reducing preventable combat death (PCD), requiring a departure from traditional civilian trauma protocols. Analysis of combat fatalities revealed that most deaths occurred before reaching a medical facility, with massive hemorrhage being the most frequent cause. This necessitated a system focused on rapid control of major bleeding and early treatment of other common causes of death, such as tension pneumothorax and airway obstruction.
The core principle is the integration of good medicine with sound small-unit tactics, acknowledging that the patient’s well-being is only one part of the mission. Unlike civilian emergency medical services, TCCC prioritizes the mission and the prevention of further casualties before comprehensive medical care is rendered. A medically correct intervention may be a bad tactical decision if it endangers the rescuer or compromises the unit’s ability to fight.
The guidelines are continuously reviewed and updated by the Committee on TCCC (CoTCCC), a joint-service group of physicians, providers, and medical technicians. This committee ensures the TCCC protocols reflect the latest evidence and lessons learned from the field, maintaining relevance as the accepted prehospital standard of care in combat environments. This approach has been credited with significantly improving survival rates for injured service members.
The Three Distinct Phases of Care
TCCC is structured around three distinct, sequential phases that dictate the appropriate level of medical intervention based on the tactical situation. This phased approach recognizes that the environment and immediate threat level determine what care is safe and feasible. The transition between phases is guided by tactical safety rather than purely medical needs.
Care Under Fire (CUF)
The first phase, Care Under Fire, occurs while the casualty and the care provider are still under effective hostile fire. The overriding priority is achieving fire superiority and moving the casualty to a position of relative safety or cover. Medical intervention is extremely limited because the risk of the rescuer becoming a casualty is too high.
The only medical action recommended in this phase is to control life-threatening external hemorrhage from an extremity with a CoTCCC-approved tourniquet, if tactically feasible. All other injuries, including airway problems, are ignored until the tactical threat is suppressed. The casualty is encouraged to apply self-aid if possible, focusing solely on preventing massive blood loss.
Tactical Field Care (TFC)
Tactical Field Care begins once the casualty and the provider are no longer under effective hostile fire and have reached a position of relative safety. This phase allows for a more systematic and thorough assessment, as the immediate threat has been minimized. Medical equipment is limited to what the personnel carried into the field.
The assessment and treatment follow the M.A.R.C.H. algorithm, which prioritizes interventions based on the most common causes of preventable death. M stands for Massive Hemorrhage control, followed by Airway management, Respirations (treating pneumothorax or chest injuries), Circulation (addressing shock and internal bleeding), and Head injury and Hypothermia prevention. Comprehensive treatments, such as applying chest seals, establishing intravenous or intraosseous access, and administering pain medication or antibiotics, are performed during this phase.
Tactical Evacuation Care (TEC)
The final phase is Tactical Evacuation Care, covering the period during transport to a higher level of medical care. This care continues the interventions initiated during Tactical Field Care, but additional resources and specialized medical personnel may become available. This phase includes continuous monitoring of the casualty’s condition and documentation of injuries and treatments rendered.
TEC involves reassessing all injuries and interventions to ensure stability during movement, which may be prolonged depending on the operational environment. The focus shifts to sustaining the patient until they can be handed off to a definitive care facility, often involving more advanced monitoring equipment and potentially blood products.
How TCCC Differs from Standard Civilian First Aid
TCCC fundamentally differs from standard civilian prehospital care due to the unique operating constraints of the tactical environment. Civilian protocols, like Advanced Trauma Life Support (ATLS), assume a safe scene and rapid transport to a hospital. In contrast, TCCC must contend with the persistent threat of hostile action, necessitating the strict tactical prioritization of “mission first.”
A major difference is the expectation of prolonged time until definitive care, known as evacuation delay. Civilian emergency services expect transport time measured in minutes, whereas tactical environments can involve hours or even days, requiring the TCCC provider to perform more advanced and sustaining care with limited resources. Equipment is restricted to what personnel can carry, making compact, effective hemorrhage control tools like tourniquets and hemostatic gauze paramount.
TCCC addresses the specific pattern of injuries seen in combat, such as penetrating trauma from gunshots and blast injuries, which are less common in civilian trauma. This focus leads to the adoption of the M.A.R.C.H. sequence, placing massive hemorrhage control before airway management—a reversal of the traditional civilian “Airway, Breathing, Circulation” (ABC) approach. TCCC guidelines incorporate field-specific interventions, such as the early administration of battlefield antibiotics and aggressive hypothermia management, which are not standard for civilian first responders.