Advanced Resuscitative Care in Tactical Combat Casualty Care: TCCC Guidelines Change 18-01:14 October 2018.

TCCC has previously recommended interventions that can effectively prevent 4 of the top 5 causes of prehospital preventable death in combat casualties-extremity hemorrhage, junctional hemorrhage, airway obstruction, and tension pneumothorax- and deaths from these causes have been markedly reduced in US combat casualties. Noncompressible torso hemorrhage (NCTH) is the last remaining major cause of preventable death on the battlefield and often causes death within 30 minutes of wounding. Increased use of whole blood, including the capability for massive transfusion, if indicated, has the potential to increase survival in casualties with either thoracic and/or abdominopelvic hemorrhage. Additionally, Zone 1 Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) can provide temporary control of bleeding in the abdomen and pelvis and improve hemodynamics in casualties who may be approaching traumatic cardiac arrest as a result of hemorrhagic shock. Together, these two interventions are designated Advanced Resuscitative Care (ARC) and may enable casualties with severe NCTH to survive long enough to reach the care of a surgeon. Although Special Operations units are now using whole blood far-forward, this capability is not routinely present in other US combat units at this point in time. REBOA is not envisioned as care that could be accomplished by a unit medic working out of his or her aid bag. This intervention should be undertaken only by designated teams of advanced combat medical personnel with special training and equipment.

Measuring US Army medical evacuation: Metrics for performance improvement.

BACKGROUND: The US Army medical evacuation (MEDEVAC) community has maintained a reputation for high levels of success in transporting casualties from the point of injury to definitive care. This work served as a demonstration project to advance a model of quality assurance surveillance and medical direction for prehospital MEDEVAC providers within the Joint Trauma System. METHODS: A retrospective interrupted time series analysis using prospectively collected data was performed as a process improvement project. Records were reviewed during two distinct periods: 2009 and 2014 to 2015. MEDEVAC records were matched to outcomes data available in the Department of Defense Trauma Registry. Abstracted deidentified data were reviewed for specific outcomes, procedures, and processes of care. Descriptive statistics were applied as appropriate. RESULTS: A total of 1,008 patients were included in this study. Nine quality assurance metrics were assessed. These metrics were: airway management, management of hypoxemia, compliance with a blood transfusion protocol, interventions for hypotensive patients, quality of battlefield analgesia, temperature measurement and interventions, proportion of traumatic brain injury (TBI) patients with hypoxemia and/or hypotension, proportion of traumatic brain injury patients with an appropriate assessment, and proportion of missing data. Overall survival in the subset of patients with outcomes data available in the Department of Defense Trauma Registry was 97.5%. CONCLUSION: The data analyzed for this study suggest overall high compliance with established tactical combat casualty care guidelines. In the present study, nearly 7% of patients had at least one documented oxygen saturation of less than 90%, and 13% of these patients had no documentation of any intervention for hypoxemia, indicating a need for training focus on airway management for hypoxemia. Advances in battlefield analgesia continued to evolve over the period when data for this study was collected. Given the inherent high-risk, high-acuity nature of prehospital advanced life support and emphasis on the use of nonphysician practitioners in an out-of-hospital setting, the need for ongoing medical oversight and quality improvement assessment is crucial. LEVEL OF EVIDENCE: Care management, level IV.

Awake Cricothyrotomy: A Novel Approach to the Surgical Airway in the Tactical Setting.

Airway obstruction on the battlefield is most often due to maxillofacial trauma, which may include bleeding and disrupted airway anatomy. In many of these cases, surgical cricothyrotomy (SC) is the preferred airway management procedure. SC is an emergency airway procedure performed when attempts to open an airway using nasal devices, oral devices, or tracheal intubation have failed, or when the risks from intubation are unacceptably high. The aim of this overview is to describe a novel approach to the inevitably surgical airway in which SC is the first and best procedure to manage the difficult or failed airway. The awake SC technique and supporting algorithm are presented along with the limitations and future directions. Awake SC, using local anesthetic with or without ketamine, will allow the knowledgeable provider to manage patients with a compromised airway across the continuum of emergency care ranging from remote/en route care, austere settings, and prehospital to the emergency department.

Tactical Study of Care Originating in the Prehospital Environment (Tacscope): Acute Traumatic Coagulopathy on the Contemporary Battlefield.

BACKGROUND: Uncontrolled major hemorrhage and delayed evacuation remain substantial contributors to potentially survivable combat death, along with mission, environment, terrain, logistics, and hostile action. Life-saving interventions and the onset of acute traumatic coagulopathy (ATC) may also contribute. OBJECTIVE: Analyze US casualty records from the DoD Trauma Registry, using International Normalized Ratio (INR) of 1.5 for onset of ATC. METHODS: Retrospective cohort study from September 2007 to June 2011, inclusive. Independent variable was INR. Primary dependent variables were transfusion volume, massive transfusion (MT) defined as >10 units RBC/fresh whole blood in first 24 h, and 30-day survival. We used T test and chi-square analysis. Our IRB reviewed and exempted this study. RESULTS: In total, 8,913 cases were available. Fifty one percent had complete data with INR. Of excluded cases, 98.9% survived, average injury severity scales (ISS) was 7 (IQR 1-8), and less than 1% received MT. Among included cases, 98.5% survived, average ISS was 10 (IQR 2-14), average INR was 1.16 (CI95 1.14-1.17), and 2.7% received MT. There were 383 cases with ATC (8.4%). After stratification, we found that ATC cases were more likely to die (odds ratio (OR) 28, CI 16-48), receive MT (OR 9.6, CI 6.4-14.4), and were acidotic (pH 7.27 (7.24-7.31) vs. 7.38 (7.38-7.39)). Other significant differences included Injury Severity Score, Revised Trauma Score, blast mechanism, and penetrating injury. CONCLUSION: ATC is substantially associated with greater injury severity, MT, and mortality. Prehospital identification of MT casualties may expedite triage and evacuation, and enable remote damage control resuscitation to delay ATC onset and improve outcomes.

Analysis of Prehospital Documentation of Injury-Related Pain Assessment and Analgesic Administration on the Contemporary Battlefield.

In addition to life-saving interventions, the assessment of pain and subsequent administration of analgesia are primary benchmarks for quality emergency medical services care which should be documented and analyzed. Analyze US combat casualty data from the Department of Defense Trauma Registry (DoDTR) with a primary focus on prehospital pain assessment, analgesic administration and documentation. Retrospective cohort study of battlefield prehospital and hospital casualty data were abstracted by DoDTR from available records from 1 September 2007 through 30 June 2011. Data included demographics; injury mechanism; prehospital and initial combat hospital pain assessment documented by standard 0-to-10 numeric rating scale; analgesics administered; and survival outcome. Records were available for 8,913 casualties (median ISS of 5 [IQR 2 to 10]; 98.7% survived). Prehospital analgesic administration was documented for 1,313 cases (15%). Prehospital pain assessment was recorded for 581 cases (7%; median pain score 6 [IQR 3 to 8]), hospital pain assessment was recorded for 5,007 cases (56%; median pain score5 [CI95% 3 to 8]), and 409 cases (5%) had both prehospital and hospital pain assessments that could be paired. In this paired group, 49.1% (201/409) had alleviation of pain evidenced by a decrease in pain score (median 4,, IQR 2 to 5); 23.5% (96/409) had worsening of pain evidenced by an increase in pain score (median 3, CI95 2.8 to 3.7, IQR 1 to 5); 27.4% (112/409) had no change; and the overall difference was an average decrease in pain score of 1.1 (median 0, IQR 0 to 3, p < 0.01). Time-series analysis showed modest increases in prehospital and hospital pain assessment documentation and prehospital analgesic documentation. Our study demonstrates that prehospital pain assessment, management, and documentation remain primary targets for performance improvement on the battlefield. Results of paired prehospital to hospital pain scores and time-series analysis demonstrate both feasibility and benefit of prehospital analgesics. Future efforts must also include an expansion of the prehospital battlefield analgesic formulary.

Learning Curves of Emergency Tourniquet Use Exploring for Utility in Training.

BACKGROUND: Emergency tourniquet use to control hemorrhage from limb wounds is associated with improved survival and control of shock. In 2013, we introduced a way to measure learning curves of tourniquet users. With a dataset from an unrelated study, we had an opportunity to explore learning in detail. The study aim was to generate hypotheses about measurement methods in the learning of tourniquet users. METHODS: We gathered data from a previous experiment that yielded a convenient sample of repeated tourniquet applications used as a marker of learning. Data on consecutive applications on a manikin were used in the current report and were associated with two users, three models of tourniquet, and six metrics (i.e., effectiveness, pulse cessation, blood loss, time to effectiveness, windlass turn number, and pressure applied). There were 840 tests (140 tests per user, two users, three models). RESULTS: Unique characteristics of learning were associated with each user. Hypotheses generated included the following: trainee learning curves can vary in shape (e.g., flat, curved) by which metric of learning is chosen; some metrics may show much learning, whereas others show almost none; use of more than one metric may assess more comprehensively than using only one metric but may require more assessment time; number of uses required can vary by instructional goal (e.g., expertise, competence); awareness of the utility of specific metrics may vary by instructor; and some, but not all, increases in experience are associated with improved performance. CONCLUSIONS: This first-aid study generated hypotheses about caregiver learning for further study of tourniquet education and standards.

The Effect of a Golden Hour Policy on the Morbidity and Mortality of Combat Casualties.

IMPORTANCE: The term golden hour was coined to encourage urgency of trauma care. In 2009, Secretary of Defense Robert M. Gates mandated prehospital helicopter transport of critically injured combat casualties in 60 minutes or less. OBJECTIVES: To compare morbidity and mortality outcomes for casualties before vs after the mandate and for those who underwent prehospital helicopter transport in 60 minutes or less vs more than 60 minutes. DESIGN, SETTING, AND PARTICIPANTS: A retrospective descriptive analysis of battlefield data examined 21,089 US military casualties that occurred during the Afghanistan conflict from September 11, 2001, to March 31, 2014. Analysis was conducted from September 1, 2014, to January 21, 2015. MAIN OUTCOMES AND MEASURES: Data for all casualties were analyzed according to whether they occurred before or after the mandate. Detailed data for those who underwent prehospital helicopter transport were analyzed according to whether they occurred before or after the mandate and whether they occurred in 60 minutes or less vs more than 60 minutes. Casualties with minor wounds were excluded. Mortality and morbidity outcomes and treatment capability-related variables were compared. RESULTS: For the total casualty population, the percentage killed in action (16.0% [386 of 2411] vs 9.9% [964 of 9755]; P < .001) and the case fatality rate ([CFR] 13.7 [469 of 3429] vs 7.6 [1344 of 17,660]; P < .001) were higher before vs after the mandate, while the percentage died of wounds (4.1% [83 of 2025] vs 4.3% [380 of 8791]; P = .71) remained unchanged. Decline in CFR after the mandate was associated with an increasing percentage of casualties transported in 60 minutes or less (regression coefficient, -0.141; P < .001), with projected vs actual CFR equating to 359 lives saved. Among 4542 casualties (mean injury severity score, 17.3; mortality, 10.1% [457 of 4542]) with detailed data, there was a decrease in median transport time after the mandate (90 min vs 43 min; P < .001) and an increase in missions achieving prehospital helicopter transport in 60 minutes or less (24.8% [181 of 731] vs 75.2% [2867 of 3811]; P < .001). When adjusted for injury severity score and time period, the percentage killed in action was lower for those critically injured who received a blood transfusion (6.8% [40 of 589] vs 51.0% [249 of 488]; P < .001) and were transported in 60 minutes or less (25.7% [205 of 799] vs 30.2% [84 of 278]; P < .01), while the percentage died of wounds was lower among those critically injured initially treated by combat support hospitals (9.1% [48 of 530] vs 15.7% [86 of 547]; P < .01). Acute morbidity was higher among those critically injured who were transported in 60 minutes or less (36.9% [295 of 799] vs 27.3% [76 of 278]; P < .01), those severely and critically injured initially treated at combat support hospitals (severely injured, 51.1% [161 of 315] vs 33.1% [104 of 314]; P < .001; and critically injured, 39.8% [211 of 530] vs 29.3% [160 of 547]; P < .001), and casualties who received a blood transfusion (50.2% [618 of 1231] vs 3.7% [121 of 3311]; P < .001), emphasizing the need for timely advanced treatment. CONCLUSIONS AND RELEVANCE: A mandate made in 2009 by Secretary of Defense Gates reduced the time between combat injury and receiving definitive care. Prehospital transport time and treatment capability are important factors for casualty survival on the battlefield.

Saving Lives on the Battlefield (Part II) ? One Year Later A Joint Theater Trauma System and Joint Trauma System Review of Prehospital Trauma Care in Combined Joint Operations Area?Afghanistan (CJOA-A) Final Report, 30 May 2014.

The United States has achieved unprecedented survival rates, as high as 98%, for casualties arriving alive at the combat hospital. Our military medical personnel are rightly proud of this achievement. Commanders and Servicemembers are confident that if wounded and moved to a Role II or III medical facility, their care will be the best in the world. Combat casualty care, however, begins at the point of injury and continues through evacuation to those facilities. With up to 25% of deaths on the battlefield being potentially preventable, the prehospital environment is the next frontier for making significant further improvements in battlefield trauma care. Strict adherence to the evidence-based Tactical Combat Casualty Care (TCCC) Guidelines has been proven to reduce morbidity and mortality on the battlefield. However, full implementation across the entire force and commitment from both line and medical leadership continue to face ongoing challenges. This report on prehospital trauma in the Combined Joint Operations Area?Afghanistan (CJOA-A) is a follow-on to the one previously conducted in November 2012 and published in January 2013. Both assessments were conducted by the US Central Command (USCENTCOM) Joint Theater Trauma System (JTTS). Observations for this report were collected from December 2013 to January 2014 and were obtained directly from deployed prehospital providers, medical leaders, and combatant leaders. Significant progress has been made between these two reports with the establishment of a Prehospital Care Division within the JTTS, development of a prehospital trauma registry and weekly prehospital trauma conferences, and CJOA-A theater guidance and enforcement of prehospital documentation. Specific prehospital trauma-care achievements include expansion of transfusion capabilities forward to the point of injury, junctional tourniquets, and universal approval of tranexamic acid.

Emergency Department Patients Support the Use of Combat Medics in Their Clinical Care.

BACKGROUND: As US military combat operations draw down in Afghanistan, the military health system will shift focus to garrison- and hospital-based care. Maintaining combat medical skills while performing routine healthcare in military hospitals and clinics is a critical challenge for Combat medics. Current regulations allow for a wide latitude of Combat medic functions. The Surgeon General considers combat casualty care a top priority. Combat medics are expected to provide sophisticated care under the extreme circumstances of a hostile battlefield. Yet, in the relatively safe and highly supervised setting of contiguous US-based military hospitals, medics are rarely allowed to perform the procedures or administer medications they are expected to use in combat. This study sought to determine patients? opinions on the use of combat medics in their healthcare. METHODS: Patients in hospital emergency department (EDs) were offered anonymous surveys. Examples of Combat medic skills were provided. Participants expressed agreement using the Likert scale (LS), with scores ranging from "strongly agree" (LS score, 1) to "strongly disagree" (LS score, 5). The study took place in the ED at Bayne-Jones Army Community Hospital, Fort Polk, Louisiana. Surveys were offered to adult patients when they checked into the ED or to adults with other patients. RESULTS: A total of 280 surveys were completed and available for analysis. Subjects agreed that Combat medic skills are important for deployment (LS score, 1.4). Subjects agreed that Combat medics should be allowed to perform procedures (LS score, 1.6) and administer medications (LS score, 1.6). Subjects would allow Combat medics to perform procedures (LS score, 1.7) and administer medications (LS score, 1.7) to them or their families. Subjects agreed that Combat medic activities should be a core mission for military treatment facilities (MTFs) (LS score, 1.6). CONCLUSION: Patients support the use of Combat medics during clinical care. Patients agree that Combat medic use should be a core mission for MTFs. Further research is needed to optimize Combat medic integration into patient healthcare.

Prehospital pain medication use by U.S. Forces in Afghanistan.

We report the results of a process improvement initiative to examine the current use and safety of prehospital pain medications by U.S. Forces in Afghanistan. Prehospital pain medication data were prospectively collected on 309 casualties evacuated from point of injury (POI) to surgical hospitals from October 2012 to March 2013. Vital signs obtained from POI and flight medics and on arrival to surgical hospitals were compared using one-way analysis of variance test. 119 casualties (39%) received pain medication during POI care and 283 (92%) received pain medication during tactical evacuation (TACEVAC). Morphine and oral transmucosal fentanyl citrate were the most commonly used pain medications during POI care, whereas ketamine and fentanyl predominated during TACEVAC. Ketamine was associated with increase in systolic blood pressure compared to morphine (+7 ± 17 versus -3 ± 14 mm Hg, p = 0.04). There was no difference in vital signs on arrival to the hospital between casualties who received no pain medication, morphine, fentanyl, or ketamine during TACEVAC. In this convenience sample, fentanyl and ketamine were as safe as morphine for prehospital use within the dose ranges administered. Future efforts to improve battlefield pain control should focus on improved delivery of pain control at POI and the role of combination therapies.

Battlefield Analgesia: TCCC Guidelines Are Not Being Followed.

BACKGROUND: Servicemembers injured in combat often experience moderate to severe acute pain. Early and effective pain control in the prehospital setting has been shown to reduce the sequelae of untreated pain. Current data suggest that lack of point-of-injury (POI) analgesia has significant, downstream effects on healthcare quality and associated costs. METHODS: This was a process improvement project to determine the current rate of adherence to existing prehospital pain management guidelines. The records of patients who had sustained a major injury and met current Tactical Combat Casualty Care (TCCC) criteria for POI analgesia from July 2013 through March 2014 were reviewed to determine if pain medication was given in accordance with existing guidelines, including medication administration and routes. On 31 October 2013, the new TCCC guidelines were released. The "before" period was from July 2013 through October 2013. The "after" period was from November 2013 through March 2014. RESULTS: During the project period, there were 185 records available for review, with 135 meeting TCCC criteria for POI analgesia (68 pre-, 66 postintervention). Prior to 31 October 2013, 17% of study patients received analgesia within guidelines at the POI compared with 35% in the after period. The most common medication administered pre-and post-release was oral transmucosal fentanyl citrate. Special Operations Forces had higher adherence rates to TCCC analgesia guidelines than conventional forces, but these still were low. CONCLUSION: Less than half of all eligible combat casualties receive any analgesia at the POI. Further research is needed to determine the etiology of such poor adherence to current TCCC guidelines.

A comparison of the incidence of cricothyrotomy in the deployed setting to the emergency department at a level 1 military trauma center: a descriptive analysis.

Airway management is a critical skill of emergency medicine physicians and prehospital providers. Airway compromise is the cause of 1.8% of battlefield deaths. Cricothyrotomy is a critical, lifesaving procedure. In this study, we conducted a retrospective descriptive analysis comparing the incidence of cricothyrotomies in the deployed setting versus the incidence in a military level 1 trauma center emergency department (ED) setting in San Antonio, Texas. The deployed/in-theater procedures were performed from September 2007 to July 2009. The ED procedures were performed from April 2010 to February 2012. Over these study periods, 28 cricothyrotomies were performed in the deployed setting against a backdrop of 11,492 trauma admissions compared to 4 cricothyrotomies performed during 2,741 trauma admissions in the ED setting. The per admission incidence of deployed cricothyrotomies was 0.24% versus an incidence of 0.15% in the ED (p=0.46). We conclude that this rare, lifesaving procedure is performed more often in the deployed setting than the ED, but this difference was not statistically significant.

Prehospital analgesia with ketamine for combat wounds: a case series.

BACKGROUND: No data have been published on the use of ketamine at the point of injury in combat. OBJECTIVE: To provide adequate pain management for severely injured Rangers, ketamine was chosen for its analgesic and dissociative properties. Ketamine was first used in the 75th Ranger Regiment in 2005 but fell out of favor because medical providers had limited experience with its use. In 2009, with new providers and change in medic training at the battalion level, the Regiment implemented a protocol using doses of ketamine that exceed the current Tactical Combat Casualty Care recommendations. METHODS: Medical after-action reports were reviewed for all Ranger casualties who received ketamine at the point of injury for combat wounds from January 2009 to October 2014. Patients and medics were also interviewed. RESULTS: Unit medical protocols authorize ketamine for tourniquet pain, amputations, long-bone fractures, and pain refractory to other agents. Nine of the 11 patients were US Forces; two were local nationals (one female, one male). The average initial dose given intramuscularly was 183 mg, about 2 to 3 mg/kg and intravenously 65 mg, about 1 mg/kg. The patients also received an opioid, a benzodiazepine, or both. There was one episode of apnea that was corrected quickly with stimulus. Eight of the 11 patients required the application of at least one tourniquet; four patients needed between two and four tourniquets to control hemorrhage. Pain was assessed with a subjective 1-10 scale. Before ketamine, the pain was rated as 9-10, with one patient claiming a pain level of 8. Of the US Forces, seven of the nine had no pain after receiving ketamine and two had a pain level of four. Two of the eight had posttraumatic stress disorder. CONCLUSIONS: In this small, retrospective sample of combat casualties, ketamine appeared to be a safe and effective battlefield analgesic.

Prehospital and en route cricothyrotomy performed in the combat setting: a prospective, multicenter, observational study.

INTRODUCTION: Airway compromise is the third most common cause of potentially preventable combat death. Surgical cricothyrotomy is an infrequently performed but lifesaving airway intervention. There are limited published data on prehospital cricothyrotomy in civilian or military settings. Our aim was to prospectively describe the survival rate and complications associated with cricothyrotomy performed in the military prehospital and en route setting. METHODS: The Life-Saving Intervention (LSI) study is a prospective, institutional review board-approved, multicenter trial examining LSIs performed in the prehospital combat setting. We prospectively recorded LSIs performed on patients in theater who were transported to six combat hospitals. Trained site investigators evaluated patients on arrival and recorded demographics, vital signs, and LSIs performed. LSIs were predefined and include cricothyrotomies, chest tubes, intubations, tourniquets, and other procedures. From the large dataset, we analyzed patients who had a cricothyrotomy performed. Hospital outcomes were cross-referenced from the Department of Defense Trauma Registry. Descriptive statistics or Wilcoxon test (nonparametric) were used for data comparisons; statistical significance was set at p<.05. The primary outcome was success of prehospital and en route cricothyrotomy. RESULTS: Of the 1,927 patients enrolled, 34 patients had a cricothyrotomy performed (1.8%). Median age was 24 years (interquartile range [IQR]: 22.5-25 years), 97% were men. Mechanisms of injury were blast (79%), penetrating (18%), and blunt force (3%), and 83% had major head, face, or neck injuries. Median Glasgow Coma Scale score (GCS) was 3 (IQR: 3-7.5) and four patients had GCS higher than 8. Cricothyrotomy was successful in 82% of cases. Reasons for failure included left main stem intubation (n=1), subcutaneous passage (n=1), and unsuccessful attempt (n=4). Five patients had a prehospital basic airway intervention. Unsuccessful endotracheal intubation preceded 15% of cricothyrotomies. Of the 24 patients who had the provider type recorded, six had a cricothyrotomy by a combat medic (pre-evacuation), and 18 by an evacuation helicopter medic. Combat-hospital outcome data were available for 26 patients, 13 (50%) of whom survived to discharge. The cricothyrotomy patients had more LSIs than noncricothyrotomy patients (four versus two LSIs per patient; p<.0011). CONCLUSION: In our prospective, multicenter study evaluating cricothyrotomy in combat, procedural success was higher than previously reported. In addition, the majority of cricothyrotomies were performed by the evacuation helicopter medic rather than the prehospital combat medic. Prehospital military medics should receive training in decision making and be provided with adjuncts to facilitate this lifesaving procedure.

An observational study assessing completion time and accuracy of completing the tactical combat casualty care card by combat medic trainees.

INTRODUCTION: Prehospital care documentation is crucial to improving battlefield care outcomes. Developed by United States Army Ranger Special Operations Combat Medics (SOCMs), the Tactical Combat Casualty Care (TCCC) is currently fielded to deployed units to record prehospital injury data. This study documents length of time and accuracy of U.S. Army Combat Medic trainees in completing the minimum preestablished required fields on the TCCC card, establishing a baseline for point-of-injury cards. DESIGN AND METHODS: This was a prospective observational study in which U.S. Army combat medic trainees were timed while recording data on the TCCC card in both the classroom and simulated combat environment. We hypothesized that trainees could complete the TCCC card in less than 1 minute with 90% or greater accuracy. RESULTS: We enrolled 728 U.S. Army Combat Medic trainees in the study during May?June 2011 at Fort Sam Houston, TX. We observed an average TCCC card completion time of less than 1 minute with greater than 90% accuracy in the unstressed classroom environment but an increase to nearly 2 minutes on average and a decrease to 85% accuracy in the simulated combat environment. CONCLUSION: RESULTS imply that the TCCC card is well designed to quickly and accurately record prehospital combat injury information. Further investigation and future studies may compare other prehospital data collection methods with the TCCC card in terms of timely and accurate data collection.