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Tactical Combat Casualty Care

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Title: Tactical Combat Casualty Care


1
Tactical Combat Casualty Care
  • Dan S. Mosely, MD
  • MAJ, USA, MC, FS

2
Agenda
  • Objectives
  • Mortality in Combat
  • Preventable mortality
  • Care under fire
  • Tactical Casualty care
  • Evacuation
  • Military vs. Civilian tactical care

3
Discussion Objectives
  • Identify the top two causes of preventable combat
    mortality
  • List three methods of controlling hemorrhage in
    the field
  • Write both two-condition criteria for diagnosis
    of tension pneumothorax
  • Outline additional equipment and skills available
    with evacuation assets
  • Compare and contrast civilian and military
    tactical medical care

4
Caveats When Applying Civilian Literature
  • Different weapons
  • Less pre-existing dehydration
  • Pre-hospital time
  • Surgical intervention
  • Resource
  • Monitoring
  • Threat

5
Combat Mortality
6
Combat Mortality
  • Killed in Action(86 KIA)
  • versus
  • Died of Wounds(12 DOW)

7
Combat Mortality
  • KIA
  • 31 are due to penetrating head trauma

8
Combat Mortality
  • KIA
  • 25 are due to surgically uncorrectable
    penetrating torso trauma

9
Combat Mortality
  • KIA
  • 10 are due to potentially correctable
    penetrating torso trauma

10
Combat Mortality
  • KIA
  • 9 are due to potentially correctable extremity
    trauma

11
Combat Mortality
  • KIA
  • 7 are due to mutilating blast injuries

12
Combat Mortality
  • KIA
  • 5 are due to tension pneumothorax

13
Combat Mortality
  • KIA
  • 1 are due to airway obstruction
  • (1/2 actual airway)
  • (1/2 decreased LOC)

14
Combat Mortality
  • DOW
  • 12 are mostly due to complicationsof shock
    orlate infection

15
Serious Wounds in Vietnam Surviving to Facility
Face Eyes 5
Head 4
Neck Cervical Spine 1
Thorax Thoracic Spine
5
Abdomen Lumbar Spine Pelvis 8
Soft Tissues 44
Multiple sites with major injuries
5
Extremities bony neural 28
16
PREVENTABLE Mortality Vietnam
  • Airway obstruction (6)
  • Tension pneumothorax (33)
  • Hemorrhage from extremity wounds (60)

17
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18
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19
Serious Wounds in OEF/OIF
Face Eyes 10
Head 11
Neck Cervical Spine 6
Thorax Thoracic Spine
4
Abdomen Lumbar Spine Pelvis 6
Soft Tissue/Other 6
Multiple sites with major injuries
lt1
Extremities bony neural 58
20
PREVENTABLE MortalityOEF/OIF
  • Airway obstruction (??)
  • Tension pneumothorax (??)
  • Hemorrhage from extremity wounds (??)

21
Tactical Combat Casualty Care
  • Care Under Fire
  • Tactical Field Care
  • Evacuation Care

22
Care Under Fire
  • Care rendered while subjected to effective
    hostile fire
  • Initial wounds
  • Additional wounds
  • Medical equipment limited
  • Carried by casualty or medical personnel
  • Difficult to use equipment in situation

23
Tactical Field Care
  • Care rendered when not subjected to effective
    hostile fire
  • Warm zone
  • Available medical equipment limited
  • Individuals
  • Team or unit
  • Time prior to evacuation is highly variable

24
Evacuation Care
  • Care rendered during transportation out of
    tactical environment
  • Aircraft
  • Ground vehicle
  • Watercraft
  • Pre-staged personnel and medical equipment
    available on platform
  • Evacuation terminology
  • MEDEVAC
  • CASEVAC

25
  • Care Under Fire

26
Care Under Fire
  • Return fire
  • Return fire
  • Return fire

27
Care Under Fire
  • Return fire
  • What does returning fire have to do with
    medical care?

28
Care Under Fire
  • Return fire
  • What does returning fire have to do with
    medical care?
  • Victory is the best medicine !!

29
Care Under Fire
  • Move the casualty to cover
  • Dont get shot while trying to do 1

30
Care Under Fire
  • Top priority is early control of life-threatening
    external hemorrhage!
  • Exsanguination from extremity wounds is the
    number one cause of preventable death on the
    battlefield
  • Hemorrhage from extremity wounds was the cause of
    death in more than 2500 casualties in Vietnam who
    had no other injuries

31
Care Under Fire
  • Top priority is early control of life-threatening
    external hemorrhage!
  • Exsanguination from extremity wounds is the
    number one cause of preventable death on the
    battlefield
  • Hemorrhage from extremity wounds was the cause of
    death in more than 2500 casualties in Vietnam who
    had no other injuries
  • What are the options for control in this setting?

32
Hemorrhage Control
  • Dressing
  • Pressure dressing
  • Tourniquet

33
Tourniquets
  • Discouraged in the civilian setting
  • Most reasonable initial choice to stop
    life-threatening bleeding
  • Direct pressure is hard to maintain during
    casualty movement
  • The risk-benefit ratio

34
Tourniquets
  • Ischemic damage to an extremity is rare if the
    tourniquet is left in place less than 60-90 min
  • Surgical/anesthesia literature states 5 min off
    every 30 mins after tourniquet has been on for
    120 min
  • Risk/Benefit ratio

35
Care Under Fire
  • Return fire
  • Dont be a hero
  • Find cover for yourself and your casualty
  • Stop any life-threatening external hemorrhage

36
Questions?
37
  • Tactical Field Care

38
Tactical Field Care
  • Reduced risk/warm zone
  • Cover/Concealment
  • Variable amount of time available
  • Mission
  • Casualty evacuation
  • Field conditions
  • Temperature and weather
  • Darkness
  • Non-sterile environment

39
External Hemorrhage
  • Stop bleeding
  • Transport casualty to extraction site
  • If tourniquet used earlier
  • Consider loosening then reassessing
  • Try direct pressure to control bleeding
  • May be able to remove tourniquet
  • Expose/Environment

40
Airway ManagementConscious Casualty
  • No attempt at airway intervention if the
    casualty is conscious and breathing well on his
    or her own

41
Airway ManagementAltered Mental Status
  • Usual cause is hemorrhagic shock or penetrating
    head trauma
  • Manual correction options
  • Chin lift/jaw thrust maneuver
  • Nasopharyngeal airway
  • Gravity positioning
  • Low-yield for immobilization of cervical spine

42
Airway ManagementObstruction
  • Liquid removal options
  • Gravity
  • Suction
  • Definitive airway options
  • Endotracheal intubation
  • Cricothyroidostomy

43
Breathing
  • Tension Pneumothorax
  • Decreased breath sounds
  • Tracheal deviation
  • Percussion
  • JVD

44
Auscultation
  • Seventy-one patients (60) had a hemothorax,
    pneumothorax, or hemopneumothorax. Auscultation
    to detect hemothorax, pneumothorax, or
    hemopneumothorax had a sensitivity of 58, a
    specificity of 98, and a positive predictive
    value of 98.
  • Chen SC. Markmann JF. Kauder DR. Schwab CW.
    Hemopneumothorax missed by auscultation in
    penetrating chest injury. Journal of
    Trauma-Injury Infection Critical Care.
    42(1)86-9, 1997 Jan

45
Auscultation
  • Thirty of 71 patients (42) were found to have
    pleural space blood or air missed by
    auscultation. Auscultation missed hemothorax up
    to 600 mL, pneumothorax up to 28, and
    hemopneumothorax up to 800 mL and 28.
  • Chen SC. Markmann JF. Kauder DR. Schwab CW.
    Hemopneumothorax missed by auscultation in
    penetrating chest injury. Journal of
    Trauma-Injury Infection Critical Care.
    42(1)86-9, 1997 Jan

46
Auscultation
47
Auscultation with Stab Wounds
48
Auscultation with GSW Wounds
49
Tension Pneumothorax
  • Deceased preload
  • Increased afterload
  • Mechanical pressure on heart
  • Decreased Alveolar surface
  • Pleural space agitation

50
Needle Thoracentesis
  • Casualties with penetrating chest trauma will
    generally have some degree of hemopneumothorax
  • Additional trauma from needle thoracentesis will
    not significantly worsen casualties conditions
    if no pneumothorax present

51
Needle Thoracentesis
  • Emergently decompress affected hemithorax with
    14-gauge needle inserted over 3rd rib in 2nd
    inter-costal space at mid-clavicular line

52
Tube Thoracostomy
  • Contraindicated for life-threatening tension
    pneumothorax
  • Difficult to perform
  • Infection risk higher when inserting tube in
    non-sterile conditions
  • Prior to Evacuation?

53
Open Pneumothorax
  • Seal defect through which air moving and cover
    with dressing
  • Allow for pressure release
  • Difficult to do reliably in tactical setting
  • Observe closely for development of tension
    pneumothorax
  • Asherman valve may be option

54
Supplemental Oxygen
  • Controversial the tactical environment
  • Cylinders of compressed gas heavy and risky for
    tactical operations
  • Transportation of casualty difficult without
    vehicle

55
Shock Management
  • Shock is a state of inadequate organ perfusion
  • Diagnosed by noting end-organ dysfunction
  • Altered mental status
  • Poor peripheral perfusion
  • Anxiety

56
Shock Management
  • Therapeutic goals
  • Increase oxygenation of blood
  • Increased trans-alveolar oxygen
  • Increased hemoglobin concentration
  • Increase cardiac output
  • Increased preload
  • Increased stroke volume

57
Intravenous Access
  • IV access
  • Cleaning the skin before venipuncture
  • Saline lock should be used unless casualty
    requires immediate fluid resuscitation
  • Flushing the lock with 5 mL of normal saline
    every 2 hours will usually keep it open

58
Controlled Hemorrhage Without Shock
  • NO immediate fluid resuscitation
  • Save IV fluids for those who really need them
  • No unnecessary tactical delays do not wait 5
    minutes to start an IV in this patient

59
Controlled Hemorrhage With Shock
  • Administer IV fluids in boluses to correct
    end-organ dysfunction
  • 0.9 (normal) or 3 saline solutions
  • Lactated Ringers solution
  • 6 hetastarch Hespan
  • DO NOT use normal vital signs as endpoints for
    fluid resuscitation
  • Increased blood pressure
  • Hemoglobin, platelets, and clotting factors

60
Uncontrolled Hemorrhage With or Without Shock
  • NO immediate fluid resuscitation
  • Spend time controlling exsanguination
  • External
  • Internal
  • Save IV fluids
  • Permissive hypotension

61
Cardiopulmonary Resuscitation
  • Only in cases of nontraumatic cardiac arrest
    should CPR be considered prior to Evacuation
  • Electrocution
  • Hypothermia
  • Near-drowning

62
Additional Considerations
  • Minimize further contamination
  • Promote hemostasis
  • Check for additional wounds
  • Exit sites may be remote from entry
  • Some sites are easily overlooked
  • Splint fractures and recheck distal pulses
  • Analgesic medications
  • Antibiotic medications

63
Questions?
64
Evacuation
65
CASEVAC versus MEDEVAC
  • CASEVAC
  • Casualty evacuation from the battlefield
  • MEDEVAC
  • Medical evacuation of casualties

66
CASEVAC Care
  • Medical personnel may accompany evacuating asset
  • No reliance on field personnel providing care
  • Medical personnel operating in tactical vehicle
  • Additional medical equipment may be available on
    evacuation platform
  • Variable

67
CASEVAC Care
  • Primary focus is clearing casualties off the
    battlefield and not medical care enroute
  • Adaptability is key
  • Maximize your mission within the CASEVAC mission

68
CASEVAC Care
  • Tactical aircraft/vehicles have restrictions
    against white light
  • Laryngoscopes
  • Blood identification
  • Wound identification
  • Black out sheets

69
MEDEVAC Care
  • Medical personnel part of asset
  • Medical personnel operating vehicle designed for
    them
  • Additional medical equipment available on
    evacuation platform
  • Oxygen
  • Suction
  • Monitoring
  • Positioning

70
MEDEVAC Care
  • Difficult to get far-forward
  • No part of assault planning
  • Communications

71
MEDEVAC Care
  • FLA
  • UH-60Q
  • Combat medic
  • Augmentation
  • CCATT
  • Strategic MEDEVAC

72
Questions?
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