Developing Protocols for Tactical EMS Care

Protocols must include considerations for providing advanced care under threatening conditions–or conditions that somehow limit response.

This is a preview of a feature article on developing tactical EMS protocols that appears in the February issue of EMS World Magazine. Click here to read the full article.

Tactical EMS protocols should be written to fit somewhere between combat medicine protocols and the typical prehospital protocols followed by today’s paramedics. Since tactical medics may find themselves in a position that does not allow patient evacuation, protocols must include considerations for providing advanced care under threatening conditions–or conditions that somehow limit response. Different EMS systems have different resources and transport times, so medical directors must determine which protocol topics are appropriate for their tactical medics. Here's a quick review of important protocol considerations:

Tactical Supportive Care: This protocol should address topics such as resuscitation decision-making, remote assessment, the challenges of triage and the dangers of introducing oxygen into the tactical environment. It is also important to address the impracticality of spinal motion restriction (SMR) during most phases of TCCC.

Cardiopulmonary Resuscitation: CPR in tactical environments often isn’t practical. CPR should be evaluated considering the available resources and access to definitive care. 

Remote Assessment: If there’s a direct threat, tactical medics may need to assess a potential patient and determine the patient’s viability from a distance. This remote assessment usually requires using binoculars, night-vision goggles or similar optics. 

Triage: In tactical settings, triage might be complicated by the need to extract patients from unsafe areas.  Protocols are likely to vary due to available resources. 

Oxygen: Keep oxygen cylinders in the cold (safe) zone. They present an explosive hazard in the presence of projectiles.

Spinal Motion Restriction: SMR requires bulky equipment and multiple providers and is typically not practical in a tactical environment.

Hemorrhage control: The most common cause of preventable battlefield death is from wounds where hemorrhage might have been controlled using a tourniquet. Develop protocols supporting the use of tourniquets earlier than you would in a conventional EMS setting. The temporary use of tourniquets in the tactical environment frees the rescuer’s hands for other tasks.

Hemostatic Agents: Consider protocols for using hemostatic agents to treat wounds on the axilla, groin, torso, neck, face and scalp -- areas where tourniquets cannot be used.

Shock Management: Shock management, following hemorrhage control, is paramount. Administer fluids when indicated, recognizing that in the tactical environment this takes a “hypotensive resuscitation” approach. 

Airway Management: Protocols should recognize that airway dysfunction occurs less often in tactical settings than in conventional EMS. Typically, very few patients in this setting experience a primary life-threatening airway or breathing problem.

Pneumothorax: Tension pneumothorax is the second-leading cause of preventable combat death. Tactical medics must be prepared to seal any open chest wound. When managing penetrating trauma to the chest, tactical medics should diagnose pneumothorax in any case involving progressive respiratory distress. Conduct needle decompression in the presence of torso trauma with respiratory distress, regardless of progression. This differs from many civilian pre-hospital protocols.

Advanced Airway Options: Consider endotracheal intubation only when a patient is experiencing respiratory compromise directly associated with trauma-induced airway obstruction.  Blind insertion airway devices are another option.

Elliot D. Carhart, MHS, RRT, EMT-P, EMT-T, is an assistant professor of emergency services at Jefferson College of Health Sciences in Roanoke, VA. He is currently an EdD candidate at Nova Southeastern University, where his studies have focused on healthcare education. He is a former firefighter/paramedic, registered respiratory therapist, and has experience in tactical EMS and technical rescue. Contact him at

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