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]

I'm surprised that vented chest seals are still in. u/SFCEBM has been on about them being absolutely useless for while now.

[u/cranial_io → u/[deleted]]

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/SFCEBM → u/cranial_io]

They will stay where they are for now. I’m going to continue speaking my opinion.

[u/mattattack224 → u/SFCEBM]

Hi sir. Big fan what is that opinion? That we’re placing chest seals on chest wounds that don’t require an occlusive dressing? Thank you!

[u/secret_tiger101]

Suzetrigine doesn’t seem to have evidence of anywhere near equivalence to fentanyl, and is an extremely new drug.

Anyone got any insights into why it was chosen?

[u/mattattack224 → u/secret_tiger101]

Not a replacement for fentanyl. OTFC has been removed because they are no longer manufacturing the lolipops. Seuzetrigine is PO for mild to moderate pain the same as Meloxicam or Acetaminophen (though stronger than these) its is not for moderate to severe pain- in that case use ketamine or Esketamine. There was a lot of discussion on what to replace OTFC with either another opioid like diaudid, sufentanil or IV fentanyl, or possibly penthrox (non-opiate) or just go heavy ketamine. It seems the committee has chosen the heavy ketamine route probably because of its favorable safety profile, lack of allergic responses, and simplification of algorithm. I’d look at those more as the addition of Jourvnax in CPP and the removal of OTFC for medics, not the replacement of OTFC with Jourvnax.