TCCC is the standard of pre-hospital battlefield trauma care developed by the US SOCOM/USAISR. It is now adopted across GCC military medical services.
Phase 1 Care Under Fire
Return fire, take cover
Stop life-threatening haemorrhage with tourniquet only
Move casualty to cover
No detailed assessment — too dangerous
Phase 2 Tactical Field Care
Threat reduced — perform MARCH assessment
Wound packing, airway management, IV access
Reassess tourniquets, manage shock
Hypothermia prevention
Phase 3 Tactical Evacuation Care (TACEVAC)
CASEVAC (non-dedicated) or MEDEVAC (dedicated)
Monitoring, advanced airway, IV fluids
Prepare for handover to Role 2/3 facility
Documentation: DD Form 1380 (TCCC card)
MARCH Algorithm — Priorities of Care
M — Massive HaemorrhageTourniquet / wound packing / junctional
A — AirwayHead tilt, NPA, surgical airway if needed
R — RespirationChest seal, needle decompression, O2
C — CirculationIV/IO access, fluids, blood products
H — Hypothermia & Head InjuryWrap, GCS, pupils, glucose
Key Principle: Haemorrhage kills faster than any other cause of preventable battlefield death. The MARCH sequence differs from ABCDE — it deliberately prioritises bleeding control over airway in the tactical environment.
ChitoGauze (chitosan) — alternative, no shellfish contraindication in trauma
Pack wound tightly, apply 3 min direct pressure
Do not remove packing — secure with pressure dressing
CASEVAC vs MEDEVAC
Feature
CASEVAC
MEDEVAC
Definition
Casualty evacuation — any platform
Medical evacuation — dedicated medical platform
Red Cross Marking
No
Yes — protected under Geneva Convention
Medical Personnel
Not required
Required (medic/nurse/physician on board)
Examples
Pickup truck, combat vehicle
UH-60 Black Hawk (MEDEVAC config), fixed-wing)
GCC Context
Used in austere/hot LZ situations
Standard for stable/critical patients
CAT Tourniquet — Step-by-Step Application Guide▶
Self-application (one-handed): Thread limb through loop, position 2–3 inches above wound
Pull free end of strap as tight as possible — secure with hook-and-loop
Twist windlass clockwise until bleeding stops (expect patient to report pain — this is expected)
Lock windlass into the windlass clip/retention strap
Secure windlass retention strap around limb
Write time on white label with permanent marker
Report application time to receiving medic/nurse
Reassess in 2 min — if bleeding persists, apply second TQ proximal to first
Do NOT pad under TQ — this reduces effectiveness
Do NOT cover TQ — it must remain visible at all times
Never remove a tourniquet in the field — conversion should only occur at Role 2 or higher with surgical backup available. Sudden removal can cause fatal rebound haemorrhage and hyperkalaemia.
Trauma & Damage Control
Damage Control Resuscitation (DCR)
DCR is the overall strategy pairing damage control surgery with haemostatic resuscitation to prevent the "lethal triad".
Lethal Triad of Trauma Death: Hypothermia (<35°C) + Acidosis (pH <7.2) + Coagulopathy (INR >1.5) — each component worsens the others in a fatal spiral.
Blood Product Ratio (1:1:1)
1 unit PRBC : 1 unit FFP : 1 unit Platelets
Mimics whole blood transfusion
Reduces dilutional coagulopathy vs crystalloid resuscitation
Tranexamic Acid (TXA) 1g IV within 3 hours of injury — reduces mortality (CRASH-2 trial)
Permissive Hypotension
Target MAP 50–60 mmHg for penetrating trauma (uncontrolled haemorrhage)
Systolic BP ~80–90 mmHg acceptable until surgical haemostasis
Atropine 2–4mg IV/IM — repeat every 5–10 min until secretions dry (not heart rate target)
Pralidoxime (2-PAM) 1–2g IV — reactivates AChE if given early (before "ageing")
MARK I Autoinjector: Atropine 2mg + 2-PAM 600mg — self/buddy aid
Diazepam 10mg IV/IM for seizures
Decontaminate before treating
Cyanide Poisoning
Signs
Rapid loss of consciousness
Seizures, lactic acidosis (high anion gap)
Bright red venous blood (O₂ not extracted)
Bitter almond smell (unreliable — genetic anosmia in 40%)
Treatment
Hydroxocobalamin (Cyanokit) 5g IV — preferred, no methaemoglobinaemia risk
Amyl nitrite (inhaled) — bridge while IV access obtained
Sodium nitrite 300mg IV + Sodium thiosulphate 12.5g IV
High-flow O₂ — increases cyanide detoxification
Blister Agents (Vesicants)
Agents: Mustard Gas (HD), Lewisite (L), Phosgene Oxime
Mustard: delayed onset 2–24h, alkylates DNA, no antidote
Lewisite: immediate pain, arsenic compound — BAL (dimercaprol) antidote
Eyes, skin, respiratory tract affected
Decontamination Priority
Immediate decon within 1–2 min for Lewisite (delayed decon for mustard less effective)
Flush skin/eyes with copious water (15+ min)
Remove clothing (removes 80% contamination)
M291 Skin Decontamination Kit (RSDL)
Radiation Injury — Acute Radiation Syndrome (ARS)
Syndrome
Dose (Gy)
Onset
Hallmark
Bone Marrow (Haematopoietic)
1–6 Gy
Days–weeks
Pancytopenia, infections, bleeding
Gastrointestinal
6–10 Gy
Days
Bloody diarrhoea, mucosal sloughing
Cerebrovascular (CNS)
>10 Gy
Minutes–hours
Ataxia, seizures, death in days
Management: G-CSF (Neupogen) for bone marrow; KI (potassium iodide) for thyroid protection after radioiodine exposure; DTPA for transuranics; supportive care.
CBRN Decontamination Priority Algorithm▶
Stop exposure — move casualty upwind/upstream from hazard
Remove clothing and equipment — removes ~80% contamination
Gross decontamination: Copious water flush (avoid scrubbing — increases absorption)
Technical decontamination: RSDL/M291 kit for skin; eye irrigation with saline
Medical decontamination: Specific antidotes as per agent
Secondary survey in Cold Zone with full PPE (down to Level C after decon)
Monitoring: Radiation — use dosimeter; Chemical — M8A1 alarm, M256 kit
Priority order in contaminated casualties: (1) Ambulatory walk-through decon → (2) Non-ambulatory (litter) decon → (3) Immediate life threats only in Warm Zone → (4) Full care in Cold Zone post-decon.
Biological Agents — Post-Exposure Management
Anthrax (Bacillus anthracis)
Inhalational — most lethal, mediastinal widening on CXR
Ciprofloxacin 500mg BD or Doxycycline 100mg BD × 60 days post-exposure
Anthrax vaccine (AVA) — pre-exposure prophylaxis for GCC military personnel
Smallpox (Variola)
Synchronous deep vesicular rash (cf. chickenpox — different stages)
Vaccinia vaccine (Dryvax/ACAM2000) within 4 days of exposure
Tecovirimat (TPOXX) — antiviral for smallpox and mpox
Strict respiratory and contact isolation
Aeromedical Evacuation
Flight Physiology — Key Concepts
Hypoxia at Altitude
Cabin altitude in military aircraft: 6,000–8,000 ft
PaO₂ falls as altitude increases (partial pressure of O₂ decreases)
SpO₂ can drop to 90–93% in healthy — critical in trauma patients
Supplement O₂ for SpO₂ <92% or any respiratory compromise
Types of hypoxia: Hypoxic, Anaemic, Stagnant, Histotoxic
Gas Expansion — Boyle's Law
P₁V₁ = P₂V₂ — as altitude increases, pressure falls and trapped gas expands.
Pneumothorax: expands — must drain before flight
Pneumocephalus: contraindication to flight
Air splints: must be monitored/deflated
ETT cuff: fill with saline (not air) — avoids over-inflation
Exertional heat stroke target: Cool first, transport second. Target core temp <38.9°C within 30 min. Cold water immersion (CWI) is most effective — 15-20°C water, full body immersion.
Combat Stress & PTSD
Combat Stress Reaction (CSR) vs PTSD
CSR: Acute, during/immediately after combat — reversible with PIE (Proximity, Immediacy, Expectancy)
Qatar: Financial support + medical NGO partnerships
Participation in ICRC-linked medical missions in Yemen conflict
GCC Exam Preparation — MCQs
DHA / MOH / SCFHS / QCHP style questions. Click "Show Answer" to reveal the correct response with explanation.
1. A soldier has a tourniquet applied to the left thigh for a blast injury. The tourniquet time is 3 hours 45 minutes. On arrival at Role 2, you note the limb is cold and mottled distal to the tourniquet. What is the MOST appropriate next action?
A. Remove the tourniquet immediately and reassess circulation
B. Document the time and notify the surgeon for early surgical assessment
C. Apply a second tourniquet distal to the first
D. Loosen the tourniquet gradually over 10 minutes
Answer: B — Tourniquet conversion must only occur in a surgical environment with haemorrhage control capability. Cold/mottled limb at 3h45min is expected; the surgeon must assess risk of limb vs life. Never remove or loosen a TQ in the field or without surgical backup — fatal rebound haemorrhage can occur.
2. A CBRN casualty presents with miosis, excessive salivation, bronchospasm, and seizures following exposure to an unknown chemical. Which drug should be administered FIRST?
A. Sodium thiosulphate 12.5g IV
B. Atropine 2–4mg IM, repeated until secretions dry
C. Hydroxocobalamin 5g IV
D. Diazepam 10mg IV
Answer: B — The clinical picture is classic nerve agent (organophosphate) poisoning: SLUDGE + bronchospasm + seizures. Atropine is the first-line antidote targeting muscarinic receptors. Pralidoxime (2-PAM) follows to reactivate AChE. Diazepam addresses seizures but is not first-line. Hydroxocobalamin is for cyanide; sodium thiosulphate is also for cyanide.
3. During aeromedical evacuation, a patient with a previously sealed open chest wound begins to deteriorate with decreasing SpO2, tracheal deviation, and absent left breath sounds as the aircraft ascends. What is the MOST likely cause?
A. Pulmonary oedema from fluid overload
B. Tension pneumothorax due to gas expansion at altitude (Boyle's Law)
C. Hypoxia from altitude — increase supplemental O2
D. Chest seal displacement — reapply and monitor
Answer: B — Boyle's Law: as cabin altitude increases, pressure decreases and trapped gas expands. A non-vented chest seal (or a vented seal that has failed) can allow air to accumulate and expand, causing tension pneumothorax. Clinical signs confirm this. Treatment: needle decompression at 4th/5th ICS AAL. This is why vented chest seals and pre-flight chest drain assessment are mandatory.
4. A Saudi military nurse with 4 years of SANGHA ICU experience wishes to apply for a DHA (Dubai) nursing licence. Which of the following is the CORRECT pathway?
A. Apply directly through MOH Saudi Arabia — DHA accepts SCFHS registration automatically
B. Submit QCHP application as DHA and QCHP are interchangeable within GCC
C. Complete Dataflow credential verification, submit DHA application, pass Prometric DHA nursing exam
D. Military experience is not recognised — must complete a civilian nursing programme first
Answer: C — DHA requires: (1) Dataflow primary source verification of qualifications, (2) DHA online application with supporting documents including military service letter from SANGHA/MOD, (3) Prometric DHA nursing licensing exam. SCFHS registration does not automatically confer DHA licensure — they are separate authorities. QCHP is Qatar's authority and is not interchangeable with DHA.
5. Using the MARCH algorithm, during Tactical Field Care you assess a casualty and find: tourniquet in place and effective, airway patent, bilateral breath sounds present, and chest seal in situ. You now assess circulation. Which finding would prompt IMMEDIATE activation of the Massive Transfusion Protocol (MTP)?
A. Heart rate 98, BP 100/70, GCS 15, warm peripheries
B. Heart rate 124, SBP 82, positive FAST exam, mechanism: penetrating abdominal injury
Answer: B — ABC Score ≥2 activates MTP. This patient scores: HR >120 (+1), SBP <90 (+1), penetrating mechanism (+1), positive FAST (+1) = 4/4. MTP should be activated immediately — do not wait for lab results. In the military context, 1:1:1 blood product ratio and TXA administration should commence as soon as possible.