Tactical Combat Casualty Care

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Tactical Combat Casualty Care
Charles W. Beadling, MD, FAAFP, IDHA, DMCC Center
for Disaster and Humanitarian Assistance
Medicine Department of Military and Emergency
Medicine Uniformed Services University PART II
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Tactical Field Care
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Tactical Field Care

• Care rendered by the Medic once he and the
  casualty are no longer under effective hostile
  fire.
• Applies to situations in which an injury has
  occurred, but there has been no hostile fire.
• Available medical equipment still limited to
  that carried into the field by medical personnel.
  Time to evacuation to a MTF may vary considerably.

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Tactical Field Care

• Casualty Assessment
• Airway
• Adjuncts
• Definitive Control
• Chest Wounds
• Continued Hemorrhage Control
• Hemostatic Agents, Pressure Dressings
• Fluid resuscitation
• Hypothermia, Infection

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Tactical Field Care

• If a victim of a blast or penetrating injury is
  found without a pulse, respirations, or other
  signs of life, DO NOT attempt CPR
• Casualties with confused mental status should be
  disarmed immediately of both weapons and grenades

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Tactical Field Care

• Initiate Shock Prevention Protocols
• Pain Control
• Antibiotics
• Splint Fractures
• Prevent Hypothermia
• Prepare Casualty for Evacuation
• Documentation

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Airway Adjuncts and Control

• Recovery Position
• NPA
• Cric

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Nasopharyngeal Airway
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Why No Endotracheal Intubation

• DEBATABLE
• No studies on well trained medics
• Most medics have never used live tissue
• Standard ETT uses white light
• Extremely difficult with bloody maxillo-facial
  wounds
• Esophogeal intubations much less identifiable in
  the field

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Tension Pneumothorax
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Breathing

• Tension Pneumothorax
• Respiratory distress
• Decreased breath sounds
• Hyperresonance
• Tracheal deviation
• JVD

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Needle Thorocostomy

• 1996 Presumptive Dx and Tx
• Unilateral penetrating chest trauma progressive
  respiratory distress
• 2003 2006 modified slightly
• Now includes blunt torso trauma respiratory
  distress even if it is not progressive

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Needle Thoracentesis

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

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SubCommitee on Hemostatic Agents (CoTCCC Feb,
09)

• By 26/1 vote WountStat is no longer recommended
  in TCCC guidelines

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Combat Gauze
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Emergency Bandage(Israeli Pressure Dressing)
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Emergency Bandage
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Fluid Resuscitation Protocol
Hemorrhage Controlled

• No Radial Pulse or Poor Mentation
• Gain Access (saline lock) - 18Ga
• Intraosseos

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What Fluid?

• Bolus 500cc Hextend
• Re-assess after 30 min
• 500cc Hextend Bolus
• No more than 1L Hextend
• Crystalloid
• Normal Saline, Ringers Lactate
• Blood
• PO Fluids?

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Blood Products

• PRBC on CASEVAC (if feasible)
• 11 FFP

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Reasons NOT to start an IV

• Takes time
• Potential waste of fluids

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Combat Pill Pack

• Tylenol 650mg x 2
• Mobic (meloxicam) 15mg
• Moxifloxacin 400mg

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Provider Adjuncts

• Fentanyl (Oral Transmucosal Fentanyl Citrate)
  800 mg taped to finger
• Morphine 10 mg IV/IM
• Promethazine 25mg IV/IM
• Cefotetan 2gm IV/IM or
• Ertapenem 1gm IV/IM

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Improved First Aid Kit

• Tourniquet
• Nasopharyngeal Airway
• Gloves
• Israeli Battle Dressing
• Gauze
• Tape
• 14ga Angiocath

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IFAK
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Combat Casualty Evacuation Care
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Combat Casualty Evacuation Care

• Care rendered during transport to higher level
  care.
• First opportunity for additional medical
  resources (if pre-staged and available during
  this phase of operation).

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Evacuation Terminology
CASEVAC MEDEVAC
Both types of evacuation are included in the new
term Tactical Evacuation
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Combat Casualty Evacuation Care

• MEDEVAC transporting casualties via vehicles
  SPECIFICALLY CONFIGURED, EQUIPPED, AND STAFFED to
  provide medical care
• CASEVAC moving casualties via NON-MEDICAL assets

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Hypothermia Prevention

• Lethal Triad
• Hypothermia
• Acidosis
• Coagulopathy
• Hypothermia Prevention Kit
• Blizzard Wrap
• Readi-Heat Blanket
• Thermo-lite

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Stokes, SKED, Talon II Litters
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Future Issues

• Recombinant factor VIIa
• Fresh Frozen Plasma
• Fresh whole blood
• Ketamine

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Summary

• Addressing Leading Causes of Preventable Deaths
  may Reduce KIA rate by 15
• 1 Extremity Hemorrhage
• 2 Tension Pneumothorax
• 3 Airway Occlusion
• Cannot Rely on Traditional Measures to Assess
  Casualty Status
• Monitors/BP cuff/stethoscope
• Tools

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Summary

• Hemorrhage Control Techniques
• Tourniquet
• Pressure Dressing
• Combat Gauze
• Recognize Tension Pneumothorax in Tactical
  Environment
• Penetrating/blunt Chest Wound
• Respiratory Distress

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Summary

• CASEVAC First Opportunity for Additional Assets
• Oxygen
• Blood
• Special Equipment
• Monitors
• Additional Providers

Only available if you were in on the Planning
and fought for the space
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Summary

• Tactical Casualty Care Requires Aggressive,
  Full-Contact Measures
• MUST Know Equipment Capabilities and Limitations
• Adapt to Environment AND situation

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Conclusion

• If during the next war you could do only two
  things, 1) place a tourniquet and 2) treat a
  tension pneumothorax, then you can probably save
  between 70 and 90 percent of all the preventable
  deaths on the battlefield. -COL Ron
  Bellamy

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Questions?