Tactical Emergency Casualty Care Research Articles

Audit and Inventory of Federal Law Enforcement Agency Tactical Medic Bags.

Separate evidence-based, best practice guidelines and recommendations exist for the prehospital management of traumatic injuries sustained in combat settings and those encountered during high-threat civilian operational incidents. The Bureau of Alcohol, Tobacco, Firearms and Explosives (ATF) Tactical Medic Program is a mature operational medicine asset supporting high-threat federal law enforcement operations. The ATF conducted an audit of its agency-issued tactical medic bags with regards to completeness, as defined by authorized medical protocols, which are aligned with current Tactical Combat Casualty Care and Tactical Emergency Casualty Care guidelines.

IBERO Protocol: A Multi-agency Coordination Framework for the Tactical Emergency Casualty Care Spanish System

Introduction:Despite Spanish experience in counterterrorism, jihadism means new modus operandi, based on active mass casualty incidents, involving new injury patterns as mass bleeding ones. Therefore, the environment is completely different to first responders' structure. This change forced the revision of the tactical response model, led by the Spanish Association for Emergency Medicine's Tactical Care Secretary, who provides a discussion forum to its members, reaching a joint framework document, IBERO, adapted to Spanish tactical emergency capabilities.Method:Methodology was based on three parameters: 1)Literature revision, selecting three sources: Books and academic papers, TCCC and TECC guidelines, and Hartford Consensus, and AARs from the main active incidents with similarities to jihadist ones.2)Formation of discussion groups: Threat definition, tactile response, and prehospital care, triage and evacuation systems.3)A final group formed by representatives of each discussion group wrote the final document.Results:The protocol defines a staged plan of action, adapted to Spanish legislation and institutions, following the acronym IBERO: 1)Information: threat intelligence and information transmitted to responders from the incident location and dispatchers.2)Block the threat by perimeter, zonification and suppression of the threat.3)Escalation of resources. Definition of areas of action according to direct threat, indirect threat and safe areas of action.4)Response and Rescue. Extrication to safe areas, including different stages of triage and protection against secondary attacks.5)Order and evacuation. Access to other emergency services, and psychological first aid.Conclusion:The document proves the need for a coordinating framework of the Spanish emergency system to be fully adapted to these new threats. The discussion groups have identified the need for regular training on threat identification, zonification setting, mass bleeding control, extrication, and evacuation techniques during hostile situations. To achieve this goal, realistic training is mandatory.

Proceedings of the 2023 Spring/Summer Meeting of the Committee for Tactical Emergency Casualty Care (C-TECC) and Committee Updates.

Proceedings of the 2023 Spring/Summer Meeting of the Committee for Tactical Emergency Casualty Care (C-TECC) and Committee Updates.

Police prehospital trauma care and hemorrhage control training as an indicator for elevated performance: A systematic review of literature

The global escalation of terrorist and felonious assaults in the civilian environment along with the Emergency Medical Services lack of training in tactical emergency casualty care lead the police forces to look for new training strategies regarding penetrating trauma management from Law Enforcement Personnel. USA police agencies approached the military committee for guidelines due to similarities presented between civilian incidents and warfare. Therefore, modified Tactical Emergency Casualty Care programs were developed. These programs were also adapted by the Hellenic Police Force, along with German, Italian, French and British Police. The aim was to elevate Law Enforcement Officers medical knowledge and practical skills in bleeding control, tension pneumothorax and airway management using hemostatic dressings, tourniquets, decompression needles and nasopharyngeal tubes respectively, in an ongoing situation. It is evident that LEOs training nowadays is more demanding as far as it concerns severe and life-threatening injury management, resulting to increased self-confidence and medical skill development. On the other hand, such training should be accessible and cost-efficient to the majority of field-operating personnel.

Tactical Emergency Casualty Care and the Art of Practicing Nonmaleficence in Harm's Way.

This exploration of the author's training and experience as a tactical physician underscores the benefits of physicians' work with law enforcement personnel in field-based operations that are ethically complex. The article points in particular to physicians' roles in assessing potential risks and benefits-especially of use of force-to promote community safety.

Immediate Paramedic Tactical Response Unit in a Civilian Emergency Medical Service: The First Year Experience.

An immediate paramedic tactical response unit was implemented into a civilian emergency medical services (EMS) system. This was compared with the preexisting traditional tactical EMS support (TEMS). The primary aim of the study was to evaluate the effect on tasking frequencies. The secondary aims of the study were to assess mission timings and the effect on patient encounters. Paramedics with tactical emergency medical training provided immediate response on a 24/7 basis. They responded to support police in high-risk TEMS scenarios and incidents in a Tactical Emergency Casualty Care (TECC) role. Tasking frequencies, timings, and clinical input were compared between the first year of immediate response and 3 preceding years of TEMS. The number of TEMS dispatches increased from an average of 5 to 54 annually. The median time from dispatch to scene arrival decreased from a median of 54 minutes (interquartile range [IQR] 39-65) to 17 minutes (IQR 11-26) (p < .0001). The overall mission duration decreased from a median of 3 hr 13 min (IQR 2 h 29 min to 4 h 40 min) to 1 h 12 min (IQR 34 min-1 h 18 min) (p < .0001). The number of treated patients increased from one minor injury annually to 13 severe and six minor injuries annually. Implementing immediate tactical paramedic response significantly decreases response time and mission duration and increases the number of activations and resultant number of treated patients.

How to Stop the Bleed: First Care Provider Model for Developing Public Trauma Response Beyond Basic Hemorrhage Control.

IntroductionSince 2013, the First Care Provider (FCP) model has successfully educated the non-medical population on how to recognize life-threatening injuries and perform interventions recommended by the Committee for Tactical Emergency Casualty Care (C-TECC) and the Hartford Consensus in the disaster setting. Recent programs, such as the federal “Stop The Bleed” campaign, have placed the emphasis of public training on hemorrhage control. However, recent attacks demonstrate that access to wounded, recognition of injury, and rapid evacuation are equally as important as hemorrhage control in minimizing mortality. To date, no training programs have produced a validated study with regard to training a community population in these necessary principles of disaster response.MethodsIn our study, we created a reproducible community training model for implementation into prehospital systems. Two matched demographic groups were chosen and divided into “trained” and “untrained” groups. The trained group was taught the FCP curriculum, which the Department of Homeland Security recognizes as a Stop the Bleed program, while the untrained group received no instruction. Both groups then participated in a simulated mass casualty event, which required evaluation of multiple victims with varying degree of injury, particularly a patient with an arterial bleed and a patient with an airway obstruction.ResultsThe objective measures in comparing the two groups were the time elapse until their first action was taken (T1A) and time to their solution of the simulation (TtS). We compared their times using one-sided t-test to demonstrate their responses were not due to chance alone. At the arterial bleed simulation, the T1A for the trained and untrained groups, respectively, were 34.75 seconds and 111 seconds (p-value = .1064), while the TtS were 3 minutes and 33 seconds in the trained group and eight minutes in the untrained groups (physiologic cutoff) (p-value = .0014). At the airway obstruction simulation, the T1A for the trained and untrained groups, respectively, were 20.5 seconds and 43 seconds (p-value = .1064), while the TtS were 32.6 seconds in the trained group and 7 minutes and 3 seconds in the untrained group (p-value = .0087). Simulation values for recently graduated nursing students and a local fire department engine company (emergency medical services [EMS]) were also given for reference. The trained group’s results mirrored times of EMS.ConclusionThis study demonstrates an effective training model to civilian trauma response, while adhering to established recommendations. We offer our model as a potential solution for accomplishing the Stop The Bleed mission while advancing the potential of public disaster response.

Characteristics of Prehospital Response to Terrorism: A systematic literature review

Background: Terrorism is increasingly the aetiology of mass casualty incidents. Improved prehospital response capability targeted to the unique characteristics of high threat incidents is an area of urgent focus. Gaps in current knowledge coupled with inconsistent reporting and difficulties in accessing data create difficult conditions for capability enhancement.&#x0D; Methods: A systematic literature review was conducted to describe the characteristics of prehospital response to terrorism from 2011 -2017. Papers were included if they described a prehospital response to a terrorist incident, were in English or translatable to English and full text was available.&#x0D; Results: 6115 records were located in the initial search of grey and published literature, with 71 retrieved for full text after screening of title and abstract. 23 papers were included in the final analysis, describing 6 separate terrorist attacks. The majority of literature was published by physicians, all were from Western countries with advanced Emergency Medical Services(EMS) and a standard reporting template was not identified. The level of evidence was low to very low. Themes of tactical triage, coordinated activation and response, use of damage control resuscitation and tactical casualty care were common throughout the papers.&#x0D; Conclusions: The paucity of high level evidence and systematic reporting of lessons learned in the prehospital terrorism response field requires a renewed push for access to data and the establishment of reporting systems that are inclusive of all responders.&#x0D; Keywords: Terrorism, Pre-hospital, Response, Tactical Emergency Casualty Care, Tactical Combat Casualty Care

Tactical Emergency Casualty Care (TECC) and the Pediatric Population

Purpose of review With the increased number of mass shootings in recent years, this paper seeks to review recent literature on the management of active shooter settings and the care for pediatric victims.

External Soft-Tissue Hemostatic Clamp Compared to a Compression Tourniquet as Primary Hemorrhage Control Device in Pilot Flow Model Study.

Acute blood loss represents a leading cause of death in both civilian and battlefield trauma, despite the prioritization of massive hemorrhage control by well-adopted trauma guidelines. Current Tactical Combat Casualty Care (TCCC) and Tactical Emergency Casualty Care (TECC) guidelines recommend the application of a tourniquet to treat life-threatening extremity hemorrhages. While extremely effective at controlling blood loss, the proper application of a tourniquet is associated with severe pain and could lead to transient loss of limb function impeding the ability to self-extricate or effectively employ weapons systems. As a potential alternative, Innovative Trauma Care (San Antonio, Texas USA) has developed an external soft-tissue hemostatic clamp that could potentially provide effective hemorrhage control without the aforementioned complications and loss of limb function. Thus, this study sought to investigate the effectiveness of blood loss control by an external soft-tissue hemostatic clamp versus a compression tourniquet. The external soft-tissue hemostatic clamp would be non-inferior at controlling intravascular fluid loss after damage to the femoral and popliteal arteries in a normotensive, coagulopathic, cadaveric lower-extremity flow model using an inert blood analogue, as compared to a compression tourniquet. Using a fresh cadaveric model with simulated vascular flow, this study sought to compare the effectiveness of the external soft-tissue hemostatic clamp versus the compression tourniquet to control fluid loss in simulated trauma resulting in femoral and posterior tibial artery lacerations using a coagulopathic, normotensive, cadaveric-extremity flow model. A sample of 16 fresh, un-embalmed, human cadaver lower extremities was used in this randomized, balanced two-treatment, two-period, two-sequence, crossover design. Statistical significance of the treatment comparisons was assessed with paired t-tests. Results were expressed as the mean and standard deviation (SD). Mean intravascular fluid loss was increased from simulated arterial wounds with the external soft-tissue hemostatic clamp as compared to the compression tourniquet at the lower leg (119.8mL versus 15.9mL; P &lt;.001) and in the thigh (103.1mL versus 5.2mL; P &lt;.001). In this hemorrhagic, coagulopathic, cadaveric-extremity experimental flow model, the use of the external soft-tissue hemostatic clamp as a hasty hemostatic adjunct was associated with statistically significant greater fluid loss than with the use of the compression tourniquet.Paquette R, Bierle R, Wampler D, Allen P, Cooley C, Ramos R, Michalek J, Gerhardt RT. External soft-tissue hemostatic clamp compared to a compression tourniquet as primary hemorrhage control device in pilot flow model study. Prehosp Disaster Med. 2019;34(2):175-181.

Effects of Tactical Emergency Casualty Care Training for Law Enforcement Officers.

This study evaluated how Tactical Emergency Casualty Care (TECC) training prepared law enforcement officers (LEOs) with the tools necessary to provide immediate, on-scene medical care to successfully stabilize victims of trauma. This was a retrospective, de-identified study using a seven-item Fairfax County (Virginia USA) TECC After-Action Questionnaire and Arlington County (Virginia USA) police reports. Forty-six encounters were collected from 2015 through 2016. Eighty-four percent (n=39) of the encounters were from TECC After-Action Questionnaires and 15% (n=7) were from police reports. The main injuries included 13% (n=6) arterial bleeds, 46% (n=21) mild/moderate bleeds, 37% (n=17) large wounds, 20% (n=9) penetrating chest wounds, and 13% (n=6) open abdominal wounds. One-hundred percent of officers reported success in stabilizing victim injuries. Seventy-four percent of officers (n=26) did not encounter problems caring for a patient while 26% (n=9) encountered a problem. Ninety-seven percent (n=37/38) answered Yes, the training was sufficient, and three percent (n=1) indicated it was OK. This is the most comprehensive study of TECC use among LEOs to date that supports the importance of TECC training for all LEOs in prehospital trauma care. Results of this study showed TECC training prepared LEOs with the operational tools necessary to provide immediate, on-scene medical care to successfully stabilize victims of trauma. Continuing to train increasing numbers of LEOs in TECC is key to saving the lives of victims of trauma in the future. RothschildHR, MathiesonK. Effects of Tactical Emergency Casualty Care training for law enforcement officers. Prehosp Disaster Med. 2018;33(5):495-500.

Intramuscular Tranexamic Acid in Tactical and Combat Settings.

Uncontrolled hemorrhage remains a leading cause of preventable death in tactical and combat settings. Alternate routes of delivery of tranexamic acid (TXA), an adjunct in the management of hemorrhagic shock, are being studied. A working group for the Committee for Tactical Emergency Casualty Care reviewed the available evidence on the potential role for intramuscular (IM) administration of TXA in nonhospital settings as soon as possible from the point of injury. EMBASE and MEDLINE/PubMed databases were sequentially searched by medical librarians for evidence of TXA use in the following contexts and/or using the following keywords: prehospital, trauma, hemorrhagic shock, optimal timing, optimal dose, safe volume, incidence of venous thromboembolism (VTE), IM bioavailability. A total of 183 studies were reviewed. The strength of the available data was variable, generally weak in quality, and included laboratory research, case reports, retrospective observational reviews, and few prospective studies. Current volume and concentrations of available formulations of TXA make it, in theory, amenable to IM injection. Current bestpractice guidelines for large-volume injection (i.e., 5mL) support IM administration in four locations in the adult human body. One case series suggests complete bioavailability of IM TXA in healthy patients. Data are lacking on the efficacy and safety of IM TXA in hemorrhagic shock. There is currently insufficient evidence to support a strong recommendation for or against IM administration of TXA in the combat setting; however, there is an abundance of literature demonstrating efficacy and safety of TXA use in a broad range of patient populations. Balancing the available data and risk- benefit ratio, IM TXA should be considered a viable treatment option for tactical and combat applications. Additional studies should focus on the optimal dose and bioavailability of IM dosing of patients in hemorrhagic shock, with assessment of potential downstream sequelae.

A Descriptive Analysis of Tactical Casualty Care Interventions Performed by Law Enforcement Personnel in the State of Wisconsin, 2010-2015.

This was a descriptive analysis of a convenience sample of cases submitted to the Wisconsin Tactical Medicine Initiative (Wisconsin USA), after the provision of successful patient care, between January 2010 and December 2015. The study was reviewed by the Mayo Foundation Institutional Review Board (Rochester, Minnesota USA) and deemed exempt. Nineteen agencies submitted information during the study period. Of the 56 episodes of care reported, four (7.1%) cases involved care provided to injured officers while 52 (92.9%) involved care to injured civilians, including suspects. In at least two cases, on-going threats existed during the provision of medical care to an injured civilian. Law enforcement rendered care prior to Emergency Medical Services (EMS) arrival in all but two cases. The current case series demonstrates the life-saving potential for law enforcement personnel trained and equipped under current Tactical Combat Casualty Care (TCCC)/ Committee on Tactical Emergency Casualty Care (C-TECC) tactical casualty care guidelines. Although originally developed to save the lives of wounded combat personnel, in the civilian sector, the training appears more likely to save victims rather than law enforcement personnel. Stiles CM , Cook C , Sztajnkrycer MD . A descriptive analysis of tactical casualty care interventions performed by law enforcement personnel in the State of Wisconsin, 2010-2015. Prehosp Disaster Med. 2017;32(3):284-288.

Proceedings From the 2016 Mid-Year Meeting of the Committee for Tactical Emergency Casualty Care (C-TECC) and Committee Updates.

Proceedings From the 2016 Mid-Year Meeting of the Committee for Tactical Emergency Casualty Care (C-TECC) and Committee Updates.

Clinical care in the warm zone: a responder's perspective upon clinical practice in support of UK tactical medical operations

Active shooter incidents both nationally and internationally have embedded significant cultural reforms within emergency medical services response frameworks. The deployment of specialist responders within specific pre-identified areas or ‘zones’ of an active shooter incident is unprecedented, and reflects the level of public expectation now required of the ambulance service. As seen within the recent 2015 Paris attacks, the delivery of effective clinical practice in tactical medical operations (TMO) facilitates a range of unique challenges for clinical responders. Conflicting priorities between operational tactics and clinical priorities, especially within multiagency working, has historically led to ‘Good medicine becoming bad tactics, and bad tactics leading to further casualties' ( Butler, 2001: 625 ). Although situational dynamics may make it impossible to ever achieve an absolute equilibrium of safety and tactical efficiency within this sphere of practice, this article intends to contribute toward achieving this ideal by reviewing the Tactical Emergency Casualty Care (TECC) guidelines to establish if this framework would be compatible for use within the UK's TMO response framework.

Field intubation in civilian patients with hemorrhagic shock is associated with higher mortality.

Field intubation (FI) by emergency medical service personnel on severely injured trauma patients remains a contentious practice. Clinical studies suggest an association between FI and adverse outcomes in patients with traumatic brain injury. Military tactical emergency casualty care recommends deferring intubation and providing supplemental oxygenation until reaching a more equipped destination. In addition, animal models with penetrating hemorrhagic shock demonstrate increased acidosis with intubation before resuscitation. The purpose of this study was to evaluate the impact of FI on outcomes in trauma patients with hemorrhagic shock requiring massive transfusion. The Los Angeles County Trauma System Database was retrospectively queried for all trauma patients 16 years or older with hemorrhagic shock requiring massive transfusion (≥6 U packed red blood cells in the first 24 hours) between January 1, 2012, and June 30, 2014. Demographics, clinical and transfusion data, and outcomes were compared between patients who received FI and those who did not (NO-FI). Multivariate regression analysis was used to adjust for confounders. Of 552 trauma patients meeting inclusion criteria, 63 (11%) received FI, and the remaining 489 (89%) were NO-FI. Age, sex, and incidence of blunt injury were similar between the FI and the NO-FI group. The FI cohort presented with a lower median Glasgow Coma Scale (GCS) score (3 vs. 14, p < 0.001), a lower median systolic blood pressure (86 mm Hg vs. 104 mm Hg, p < 0.001), and a higher median Injury Severity Score (ISS) (41 vs. 29, p < 0.001). Mortality was significantly higher in FI patients (83% vs. 43%, p < 0.001). Transfusion patterns and total field times were similar in both groups. After adjusting for confounders, FI patients had increased odds of mortality (adjusted odds ratio, 2.89; 95% confidence interval, 1.08-7.78; p = 0.035). In addition, FI was identified as an independent predictor of mortality (adjusted odds ratio, 3.41; 95% confidence interval, 1.35-8.59; p = 0.009). FI may be associated with higher mortality in trauma patients with hemorrhagic shock requiring massive transfusion. Less invasive airway interventions and rapid transport might improve outcomes for these patients. Therapeutic study, level IV; epidemiologic study, level III.

Integration of Tactical Emergency Casualty Care Into the National Tactical Emergency Medical Support Competency Domains

Tactical emergency medical support (TEMS) is a critical component of the out-of-hospital response to domestic high-threat incidents such as hostage scenarios, warrant service, active shooter or violent incidents, terrorist attacks, and other intentional mass casualty-producing acts. From its grass-roots inception in the form of medical support of select law enforcement special weapons and tactics (SWAT) units in the 1980s, the TEMS subspecialty of prehospital care has rapidly grown and evolved over the past 40 years. The National TEMS Initiative and Council (NTIC) competencies and training objectives are the only published recommendations of their kind and offer the opportunity for national standardization of TEMS training programs and a future accreditation process. Building on the previous work of the NTIC and the creation of acknowledged competency domains for TEMS and the acknowledged civilian translation of TCCC by the Committee for Tactical Emergency Casualty Care (C-TECC), the Joint Review Committee (JRC) has created an opportunity to bring forward the work in a form that could be operationally useful in an all-hazards and whole of community format.

TacMed Updates: Committee for Tactical Emergency Casualty Care Spring Update

TacMed Updates: Committee for Tactical Emergency Casualty Care Spring Update

Proceedings of the 2016 Spring/Summer Meeting of the Committee for Tactical Emergency Casualty Care

Proceedings of the 2016 Spring/Summer Meeting of the Committee for Tactical Emergency Casualty Care

The Hartford Consensus on Active Shooters: Implementing the Continuum of Prehospital Trauma Response

BackgroundActive shooter incidents have led to the recognition that the traditional response paradigm of sequential response and scene entry by law enforcement, first responders, and emergency medical service (EMS) personnel produced delays in care and suboptimal victim outcomes. The Hartford Consensus Group developed recommendations to improve the response to and outcomes from active shooter events and urged that a continuum of care be implemented that incorporates not only EMS response, but also the initiation of care by law enforcement officers and potentially by lay bystanders. ObjectiveTo develop and implement tiered educational programs designed to teach police officers and lay bystanders the principles of initial trauma care and bleeding control using as a foundation the U.S. military's Tactical Combat Casualty Care course and the guidelines of the Committee on Tactical Emergency Casualty Care. DiscussionThe Tactical Casualty Care for Law Enforcement and First Responders course is a 1-day program combining didactic lecture, hands-on skills stations, and clinical scenarios designed primarily for police officers. The Bleeding Control for the Injured is a 2- to 3-h program for the potential citizen responder in the skills of hemorrhage control. In addition, we document the application of these skills by law enforcement officers and first responders in several real-life incidents involving major hemorrhage. ConclusionsDeveloping and implementing tiered educational programs for hemorrhage control will improve response by police officers and the lay public. Educating law enforcement officers in these skills has been demonstrated to improve trauma victim survival.