Title: Tactical Combat Casualty Care
1Tactical Combat Casualty Care
- Dan S. Mosely, MD
- MAJ, USA, MC, FS
2Agenda
- Objectives
- Mortality in Combat
- Preventable mortality
- Care under fire
- Tactical Casualty care
- Evacuation
- Military vs. Civilian tactical care
3Discussion 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
4Caveats When Applying Civilian Literature
- Different weapons
- Less pre-existing dehydration
- Pre-hospital time
- Surgical intervention
- Resource
- Monitoring
- Threat
5Combat Mortality
6Combat Mortality
- Killed in Action(86 KIA)
- versus
- Died of Wounds(12 DOW)
7Combat Mortality
- KIA
- 31 are due to penetrating head trauma
8Combat Mortality
- KIA
- 25 are due to surgically uncorrectable
penetrating torso trauma
9Combat Mortality
- KIA
- 10 are due to potentially correctable
penetrating torso trauma
10Combat Mortality
- KIA
- 9 are due to potentially correctable extremity
trauma
11Combat Mortality
- KIA
- 7 are due to mutilating blast injuries
12Combat Mortality
- KIA
- 5 are due to tension pneumothorax
13Combat Mortality
- KIA
- 1 are due to airway obstruction
- (1/2 actual airway)
- (1/2 decreased LOC)
14Combat Mortality
- DOW
- 12 are mostly due to complicationsof shock
orlate infection
15Serious 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
16PREVENTABLE Mortality Vietnam
- Airway obstruction (6)
- Tension pneumothorax (33)
- Hemorrhage from extremity wounds (60)
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19Serious 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
20PREVENTABLE MortalityOEF/OIF
- Airway obstruction (??)
- Tension pneumothorax (??)
- Hemorrhage from extremity wounds (??)
21Tactical Combat Casualty Care
- Care Under Fire
- Tactical Field Care
- Evacuation Care
22Care 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
23Tactical 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
24Evacuation 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 26Care Under Fire
- Return fire
- Return fire
- Return fire
-
27Care Under Fire
- Return fire
- What does returning fire have to do with
medical care? -
28Care Under Fire
- Return fire
- What does returning fire have to do with
medical care? - Victory is the best medicine !!
29Care Under Fire
- Move the casualty to cover
- Dont get shot while trying to do 1
30Care 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
31Care 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?
32Hemorrhage Control
- Dressing
- Pressure dressing
- Tourniquet
33Tourniquets
- 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
34Tourniquets
- 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
35Care Under Fire
- Return fire
- Dont be a hero
- Find cover for yourself and your casualty
- Stop any life-threatening external hemorrhage
36Questions?
37 38Tactical 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
39External 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
40Airway ManagementConscious Casualty
- No attempt at airway intervention if the
casualty is conscious and breathing well on his
or her own
41Airway 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
42Airway ManagementObstruction
- Liquid removal options
- Gravity
- Suction
- Definitive airway options
- Endotracheal intubation
- Cricothyroidostomy
43Breathing
- Tension Pneumothorax
- Decreased breath sounds
- Tracheal deviation
- Percussion
- JVD
44Auscultation
- 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
45Auscultation
- 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
46Auscultation
47Auscultation with Stab Wounds
48Auscultation with GSW Wounds
49Tension Pneumothorax
- Deceased preload
- Increased afterload
- Mechanical pressure on heart
- Decreased Alveolar surface
- Pleural space agitation
50Needle 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
51Needle Thoracentesis
- Emergently decompress affected hemithorax with
14-gauge needle inserted over 3rd rib in 2nd
inter-costal space at mid-clavicular line
52Tube Thoracostomy
- Contraindicated for life-threatening tension
pneumothorax - Difficult to perform
- Infection risk higher when inserting tube in
non-sterile conditions - Prior to Evacuation?
53Open 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
54Supplemental Oxygen
- Controversial the tactical environment
- Cylinders of compressed gas heavy and risky for
tactical operations - Transportation of casualty difficult without
vehicle
55Shock Management
- Shock is a state of inadequate organ perfusion
- Diagnosed by noting end-organ dysfunction
- Altered mental status
- Poor peripheral perfusion
- Anxiety
56Shock Management
- Therapeutic goals
- Increase oxygenation of blood
- Increased trans-alveolar oxygen
- Increased hemoglobin concentration
- Increase cardiac output
- Increased preload
- Increased stroke volume
57Intravenous 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
58Controlled 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
59Controlled 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
60Uncontrolled Hemorrhage With or Without Shock
- NO immediate fluid resuscitation
- Spend time controlling exsanguination
- External
- Internal
- Save IV fluids
- Permissive hypotension
61Cardiopulmonary Resuscitation
- Only in cases of nontraumatic cardiac arrest
should CPR be considered prior to Evacuation - Electrocution
- Hypothermia
- Near-drowning
62Additional 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
63Questions?
64Evacuation
65CASEVAC versus MEDEVAC
- CASEVAC
- Casualty evacuation from the battlefield
- MEDEVAC
- Medical evacuation of casualties
66CASEVAC 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
67CASEVAC Care
- Primary focus is clearing casualties off the
battlefield and not medical care enroute - Adaptability is key
- Maximize your mission within the CASEVAC mission
68CASEVAC Care
- Tactical aircraft/vehicles have restrictions
against white light - Laryngoscopes
- Blood identification
- Wound identification
- Black out sheets
69MEDEVAC Care
- Medical personnel part of asset
- Medical personnel operating vehicle designed for
them - Additional medical equipment available on
evacuation platform - Oxygen
- Suction
- Monitoring
- Positioning
70MEDEVAC Care
- Difficult to get far-forward
- No part of assault planning
- Communications
71MEDEVAC Care
- FLA
- UH-60Q
- Combat medic
- Augmentation
- CCATT
- Strategic MEDEVAC
72Questions?