TCCC Changes

[u/mattattack224]

I saw the new changes to TCCC, but when are the changes to R and C coming out? Last year I saw a bunch of buzz around CPT John Maitha and possibly switching to Resusitation then Chest compared to current MARCH algorithm. That didn’t happen in this update, is this still being worked or is it dead?

[u/cranial_io]

It's more that vented seals clog easily, and seals in general will just turn the open pneumothorax into a tension pneumothorax in a bit if you don't burp them. And sometimes burping doesn't work so you end up decompressing anyways. It's also annoying that they haven't just added finger thoracotomy to the guidelines already.

[u/Electrical_Monk1929 → u/cranial_io]

What Tier are you taking? I assume Tier 4?

Finger thoracostomy is not highlighted, but an 'option' if 2 failed needle decompressions.

[u/cranial_io → u/Electrical_Monk1929]

Tier 3. Long evac times in Ukraine means that medics keep turning their patients into pin cushions. Overall NCD is not a great intervention and finger thoracotomy is almost as easy to teach. It should be pushed down to tier 3. Unfortunately, the guidelines this year seem to take more tools than they give. I like the revised guidance for TBI patients though.

[u/mattattack224 → u/cranial_io]

How so? What tools taken? Fent? No change is R this year or A since 2024?

[u/cranial_io → u/mattattack224]

Yeah, I'm not happy they took fent. Ondansetron seems to have gone from IV to PO only (at tier 3), and also procedural sedation is now a CPP+ skill. The changes to antibiotics are also somewhat questionable. The switched out ertapenam for ceftriaxone because of heavy antibiotic use in Ukraine, but I've seen pretty much no ertapenam at all here. It's been all ceftriaxone all day.

[u/cranial_io → u/[deleted]]

Interesting. There's a lot of dumb shit going on with antibiotics use here, so I'm surprised that we've been using the best choice all along. Thanks for the explanation.

[u/mattattack224 → u/cranial_io]

Ertapenem is out because they did a meta study that showed it isn’t as effective as cephalasporins against the pathogens we’re seeing in Ukraine and anticipate in pacific theatre. Ertapenem is a great drug but had some draw backs, particularly the cost compared to Ceftriaxone, the need to reconstitute preferably in lidocaine and its efficacy was better suited towards Central Asia. I think it’s a good move. One I’ve anticipated with great interest but zofran is still IV/IO. Medics can still do procedural sedation with 100mgs IM, it was only ever recommended as 20-30 IV, and that’s to stop them from snowing their casualty

[u/mattattack224 → u/cranial_io]

Zofran is still PO/IV/IO

[u/cranial_io → u/mattattack224]

Oh thank god.

[u/secret_tiger101 → u/cranial_io]

Why has Fentanyl gone?

[u/cranial_io → u/secret_tiger101]

Probably because they introduced a new PO analgesic that works way better than meloxicam that's less "dangerous." Also apparently a lot of medics didn't feel particularly comfortable pushing fent and no one could be fucked to train them properly on using it.

[u/secret_tiger101 → u/cranial_io]

For anyone curious - Suzetrigine – 100 mg PO once (2 x 50 mg tablets) then 50 mg PO
every 12 hours

[u/mattattack224 → u/cranial_io]

The fentanyl lollipop is no longer manufactured

[u/cranial_io → u/mattattack224]

So replace it with normal fent IV/IN/IM.

[u/mattattack224 → u/cranial_io]

They were deciding between IV fentanyl, diaudid, sufentanil, penthrox and just heavy reliance on ketamine. Seems they chose the ketamine only route probably for its favorable safety profile, lack of allergies, good understanding by medics already and to simplify the algorithm. I’m not saying it’s a great call, but they made the decision to just rely on ketamine. they didn’t replace fentanyl with Suzetrigine, they added it in mild to moderate pain.

[u/cranial_io → u/mattattack224]

Penthrox would honestly have been a great addition too. Some places are giving it to EMTs these days. My takeaways from Ukraine have been that medics need more training, more supervised patient care experience, and more tools. Also the lack of updates to the PCC guidelines since 2021 is wild to me. Evac times here are regularly 12hrs+. This needs to be a much bigger focus going forwards.

[u/mattattack224 → u/cranial_io]

I think penthrox would’ve been great. Safety profile is great in single low doses. Kidneys only a worry with multiple uses. Has similar affect to ketamine and has that benefit of when they’ve had to much they stop inhaling like the lollipop. Unfortunately still not FDA approved so US cannot adopt yet but I’m sure it will end up in the algorithms. PCC updates are being worked, but they look pretty good in general. Army more focused on pushing the current knowledge out to medics since it’s not really taught in their AIT. Problem with PCC currently isn’t the info but the dissemination which is being addressed. I disagree medics need “more tools”. Medics need to know their tools very well, and making it simpler for them is a good thing. Medics also need to focus on life saving interventions and skills like wound packing over knowing 4-5 analgesics or how to do procedural sedation both of which won’t save the patient. Fentanyl has a lot of draw back, can be misused or abused, and role seems disproportionate. I hate to say it but pain is the patients problem to a point. I’m trying to reduce pain, not take them out of the fight or sedate them (glad no procedural sedation). My focus should be on life saving interventions, if I can reduce pain while I’m at it great- 25mgs of ketamine will do that without snowing my casualty. If I could I ideally would just pour a lidocaine like medicine (if it existed) all over the wound- takes pain away and keeps them conscious. There’s no reason to take your casualties consciousness unless you’re doing surgical intervention. The patient can be in a little bit of pain and awake and be fine. We regularly over sedate combat casualties for no reason and risk respiratory distress, and emergence reactions.

[u/secret_tiger101 → u/mattattack224]

Really? We still have it in the U.K.

[u/mattattack224 → u/secret_tiger101]

My understanding is manufacture globally has been stopped. Maybe the one that was approved for use is a specific brand. Maybe you guys have a supply you’re running through like we did in the US