Tactical Combat Casualty Care (TCCC) is the evidence-based protocol developed by the U.S. military for treating life-threatening injuries without immediate hospital access. Its three core interventions — tourniquet for extremity hemorrhage, wound packing for non-extremity hemorrhage, and airway management — address the preventable causes of trauma death: uncontrolled bleeding (31% of trauma deaths), airway obstruction, and tension pneumothorax. This guide covers the civilian-applicable elements of TCCC for wilderness and grid-down medical emergencies. More detail on specific field injury scenarios is in field wound care and infection prevention.
The MARCH Protocol
TCCC uses the MARCH assessment sequence to prioritize interventions by preventable lethality:
- M — Massive hemorrhage: Stop life-threatening bleeding first. A person can lose all survivable blood volume in 3–5 minutes from a major extremity wound. This takes priority over airway.
- A — Airway: Open and maintain the airway. Unconscious patients with airway obstruction die in 4–6 minutes.
- R — Respiration: Assess breathing for tension pneumothorax (collapsed lung) and open chest wounds.
- C — Circulation: Treat shock, maintain fluid volume (oral hydration if conscious and no abdominal injury).
- H — Hypothermia/Hyperthermia: Prevent heat or cold loss. Trauma victims lose thermoregulation rapidly — hypothermia worsens coagulopathy (blood’s ability to clot).
Tourniquet Application: CAT and SOFTT-W
A tourniquet stops extremity hemorrhage in 30–60 seconds. Two tourniquet designs are used in TCCC:
- Combat Application Tourniquet (CAT) Gen 7 (~$30): One-handed application; self-applied to an arm in under 25 seconds with training. The windlass (twisting rod) tightens the band until bleeding stops; a safety clip locks the windlass in place.
- SOFTT-Wide (~$30): Wider band (1.5 inches vs 1 inch for CAT) distributes pressure over more tissue — preferred for thigh application. Somewhat more complex to apply one-handed.
Application procedure (CAT, for arm):
- Apply 2–3 inches above the wound (not over a joint — do not place over elbow or knee). Pull the band through the buckle and tighten until snug.
- Twist the windlass clockwise until bleeding stops. This requires substantial tightening — a tourniquet that is not painful is probably not tight enough to stop arterial flow. The distal pulse (pulse below the tourniquet) should disappear when correctly tightened.
- Lock the windlass in the safety clip. Write the time of application on the tourniquet band with a marker (or on the patient’s forehead) — time on tourniquet matters for tissue preservation decisions during extended care.
- Do not remove a correctly applied tourniquet in the field — removal without surgical support risks fatal hemorrhage from re-opening.
Safe tourniquet time: Current TCCC guidance supports tourniquet times up to 2 hours without significant risk of permanent limb damage. Longer application times increase ischemic injury but are preferable to exsanguination. Tourniquets have been left on for 6+ hours in combat with limb salvage outcomes — prior teaching about tourniquet danger was overstated.
Wound Packing with Hemostatic Gauze
For wounds where a tourniquet cannot be applied (groin, armpit, neck, shoulder junction) or for deep wounds, wound packing with direct manual pressure is the intervention. Hemostatic gauze (QuikClot Combat Gauze, Celox Gauze, HemCon) accelerates clot formation to stop hemorrhage from these otherwise-lethal locations.
Wound packing procedure:
- Locate the bleeding source by inserting a gloved finger into the wound to find the deepest point of hemorrhage.
- Pack the hemostatic gauze as deep into the wound as possible — the gauze must contact the bleeding vessel to be effective. Do not leave air space at the bottom of the wound.
- Continue packing gauze on top of the first until the wound is full.
- Apply firm, direct manual pressure on the wound for 3 minutes minimum (5 minutes for QuikClot-type). Do not lift and re-check — this disrupts clot formation.
- Apply a pressure bandage (Israeli dressing) over the packed wound to maintain pressure after manual pressure is released.
Airway Management
An unconscious patient’s airway obstructs due to tongue and soft tissue collapse. Two simple interventions:
- Recovery position: Roll the patient onto their side. Gravity pulls the tongue forward and prevents aspiration if they vomit. This is the preferred airway management for an unconscious but breathing patient without suspected spinal injury.
- Nasopharyngeal airway (NPA): A flexible rubber tube (~$5) inserted through one nostril into the back of the throat, bypassing tongue obstruction. NPA can be used in semi-conscious patients who would gag on an oral airway. Lubricate with gel or petroleum jelly. Insert bevel toward the nasal septum. Tolerated in patients who are breathing but poorly responsive.
Fracture Stabilization
A fracture must be stabilized before evacuation to prevent further injury from movement. The SAM splint (thin aluminum core with foam padding) forms to any limb shape and provides rigid stabilization.
- Arm/wrist fracture: Apply SAM splint along the arm’s dorsal surface from palm to mid-forearm. Wrap with elastic bandage. Support in a sling fashioned from a shirt or triangular bandage.
- Lower leg fracture: Two SAM splints applied medial and lateral, padded with clothing. Wrap with elastic bandage or strips of fabric. Splint must extend one joint above and one joint below the fracture.
- Improvised splint (no SAM available): Any rigid material (trekking poles, cut branches, sleeping pad) padded and secured with clothing strips performs the same function.
Hypothermia in Trauma
Trauma victims lose body heat rapidly due to blood loss, immobility, and loss of thermoregulatory capacity. Hypothermia in a trauma patient causes coagulopathy (impaired blood clotting), creating a deadly cycle: trauma causes hypothermia, hypothermia worsens bleeding, more blood loss causes deeper hypothermia.
Prevention: Insulate the patient from the ground immediately (ground conduction is faster than air convection). Wrap in a survival blanket or sleeping bag. Remove wet clothing if a dry replacement is available. Do not overlook hypothermia while managing other injuries — it is a treatable killer that gets worse without active intervention.
Evacuation Decision Points
In grid-down or wilderness conditions, you must decide when a patient can be monitored in place versus when immediate evacuation is necessary regardless of difficulty. Evacuate immediately for:
- Uncontrolled bleeding not stopped by tourniquet or wound packing
- Altered mental status (confusion, unresponsiveness) — suggests traumatic brain injury or severe shock
- Difficulty breathing — suspected tension pneumothorax or hemothorax
- Suspected spinal injury with neurological symptoms (numbness, paralysis)
- Open fractures (bone exposed through skin) — infection risk escalates rapidly without surgical intervention
Where to Go Next
Specific wound care for infections, improvised splints for fractures, and field treatment for hypothermia, hyperthermia, and shock are in field wound care and infection prevention, improvised splints for fractures and dislocations, and hypothermia, hyperthermia, and shock: field recognition and treatment.
