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Combat Casualty Care

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Title: Combat Casualty Care


1
TACTICAL COMBAT CASULATY CARE
2
  • Tactical Combat Casualty Care in Special
    Operations
  • CAPT Butler/LTC Hagmann
  • Military Medicine Supplement
  • August 96

3
  • 90 of combat deaths occur on the battlefield
    before the casualty ever reaches a medical
    treatment facility.
  • COL Ron Bellamy

4
Tactical Context
  • Incoming fire
  • Darkness
  • Environmental factors
  • Casualty transportation problems
  • Delays to definitive care
  • Command decisions

5
  • Two of the obvious differences (in combat
    casualty care) are the adverse conditions of war
    and the fact that under certain tactical
    conditions, the care of the patient is secondary
    to the mission at hand.
  • CAPT Byron Holley

6
Cocaine Lab Raid
  • 32 man Ranger team
  • Planned raid on a cocaine lab in dense jungle
  • Estimated hostile strength is 8 men with
    automatic weapons
  • Insertion from HELO
  • 8 Kilometer movement to target

7
Cocaine Lab Raid
  • As patrol reaches the objective area, a booby
    trap is tripped resulting in a point man without
    pulse or respirations and a squad leader with
    massive trauma to the leg and femoral bleeding
  • Heavy incoming fire as hostiles respond
  • Planned extraction by boat at point on river 1/2
    mile from target

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10
Tactical Combat Casualty Care
  • Good medicine
  • can sometimes be bad tactics!

11
Tactical Combat Casualty Care
  • Bad tactics can get everyone killed and/or cause
    the mission to fail!

12
Tactical Combat Casualty Care
  • Casualty scenarios in Ranger operations usually
    entail both a medical problem and a tactical
    problem.
  • We want the best possible outcome for both the
    man and the mission.

13
Combat Casualty Care Objectives
  • Treat the casualty
  • Prevent additional casualties
  • Complete the mission

14
Editorial
  • The most important aspect of caring for trauma
    victims on the battlefield is well thought out
    planning for that environment and appropriate
    training of Ranger First Responders and Combat
    Medical Personnel.

15
Phases of Care
  • Care under Fire
  • Tactical Field Care
  • Casualty Evacuation (CASEVAC)

16
"Care under Fire"
  • The care rendered by the RFR/NREMT-B/ Ranger
    Medic at the scene of the injury, while he and
    the casualty are still under effective hostile
    fire.
  • Available medical equipment is limited to that
    carried by the individual Ranger or medic in his
    gear.

17
"Tactical Field Care"
  • Care rendered by the RFR/NREMT-B/ Ranger Medic
    when no longer under effective hostile fire.
  • Applies to situations in which an injury has
    occurred on a mission, but there has been no
    hostile fire.
  • Available medical equipment limited to that
    carried into the field by mission personnel.

18
CASEVAC"
  • Care rendered once the casualty (and usually the
    rest of the mission personnel) have been
    extracted by aircraft, vehicle, or boat.
  • Personnel and medical equipment previously staged
    in these assets are now available.
  • Use "CASEVAC" to describe this phase vs the
    commonly used term "MEDEVAC".

19
Basic Tactical Combat Casualty Care Plan
Key Point
  • The plan described is presented as a generic
    sequence of steps that will probably require
    modification in some way for almost any casualty
    scenario encountered in Ranger Operations.

20
Care under Fire
  • Return fire as directed or required
  • Try to keep yourself from getting shot
  • Try to keep the casualty from sustaining
    additional wounds
  • Stop any life-threatening external hemorrhage
    with an Emergency Trauma Dressing and/or
    tourniquet

21
Care under Fire
  • What does returning fire have to do with medical
    care?

22
Care under Fire
  • The best medicine on the battlefield is
  • Fire Superiority!
  • Fire superiority and control of the tactical
    situation is a must. The Tactical Commander (TM
    LDR, SQD LDR, PLT SGT) must have control of the
    situation to effectively manage casualties.

23
Care under Fire
  • No immediate management of the airway should
    be anticipated at this point because of the need
    to move the casualty to cover as quickly as
    possible.

24
Care under Fire
  • Exsanguination from extremity wounds is the 1
    cause of preventable death on the battlefield.
  • Control of hemorrhage is the top priority!
  • Hemorrhage from extremity wounds was the cause of
    death in more than 2500 casualties in Vietnam who
    had no other injuries.

25
Tourniquets
  • Most reasonable initial choice to stop major
    bleeding in the Care Under Fire Phase
  • Direct pressure is hard to maintain during
    casualty transport under fire

26
Tourniquets
  • Tissue damage to the limb is rare if the
    tourniquet is left in place less than an hour.
  • Tourniquets often left in place for several
    hours during surgical procedures.
  • In the face of massive extremity hemorrhage, in
    any event, it is better to accept the small risk
    of tissue damage to the limb than to lose a
    casualty to bleeding to death.

27
Tourniquets
  • The need for immediate access to a tourniquet
    in such situations makes it clear that all
    Rangers on combat missions should have a suitable
    tourniquet readily available at a standard
    location on their battle gear and be trained in
    its use.

28

Questions?
29
Tactical Field Care
  • Reduced level of hazard from hostile fire
  • Amount of time available extremely variable
  • Time prior to extraction may range from less than
    a half hour to many hours.
  • Limited visibility
  • Nonsterile field conditions

30
Airway Management Conscious Patient
  • No attempt at airway intervention is required
    if the patient is conscious and breathing without
    difficulty on his own.

31
Airway Management Unconscious Patient
  • Without airway obstruction
  • Usual cause is hemorrhagic shock or penetrating
    head trauma
  • Chin lift or jaw thrust maneuver
  • No need for cervical spine immobilization
  • Nasopharyngeal airway if no obstruction

32
Nasopharyngeal Airway
  • Better tolerated than an oropharyngeal airway
    should the patient subsequently regain
    consciousness
  • Less likely to be dislodged during patient
    transport.

33
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4
37
Suction
  • If blood or other obstructions are present in
    the mouth, they should be removed by hand.

38
Breathing
  • Tension pneumothorax is the second leading cause
    of preventable death on the battlefield.
  • Consider progressive, severe respiratory distress
    resulting from unilateral chest trauma to
    represent a tension pneumothorax and decompress.

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40
Tension pneumothorax
  • Signs/Symptoms
  • Decreased breath sounds
  • Tracheal shift
  • Hyperresonance to percussion
  • Difficult to appreciate on the battlefield!

41
Needle Thoracostomy
  • Decompress affected side with a 14 gauge needle
    inserted at 2nd ICS at MCL.
  • A patient with penetrating chest trauma will
    generally have some degree of hemothorax or
    pneumothorax as a result of the primary wound.
  • Additional trauma from needle thoracostomy will
    not significantly worsen patients condition if
    no tension pneumo.

42
Needle Thoracostomy
  • RFRs, Squad EMTs, and Medics are trained in
    this technique
  • Technically easy to perform
  • May be lifesaving if the patient does in fact
    have a tension pneumothorax.

43
Open Pneumothorax
  • Occlusive dressing
  • Not necessary to vent one side of the wound
    dressing difficult to do reliably in a combat
    setting
  • Watch for development of a tension pneumothorax
  • Asherman Chest Seal is the standard

44

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46
Bleeding
  • Ranger survivability on the battlefield is
    measured by immediate control of hemorrhage.
  • When tactically feasible consider standard
    bleeding control procedures.
  • Dont hesitate to use a tourniquet under more
    severe battlefield conditions (Care Under Fire).
  • Application of a tourniquet is only acceptable
    under extreme circumstances.

47
Bleeding
  • Tourniquets are only used to control serious
    extremity bleeding by RFRs under real world
    combat conditions.

48
Bleeding
  • Remove minimum clothing required to expose and
    treat injuries
  • Emergency Trauma Dressing
  • Ranger Rescue Wrap
  • Need to protect the patient against the
    environment

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51
Ranger Rescue Wrap
52
IV Therapy
  • Large IV catheters are needed to administer large
    volumes of blood products rapidly
  • Not a factor in the tactical setting since blood
    products will not be available
  • 18 gauge catheter preferred in the field setting
    because of increased success rate

53
IV Therapy
  • Larger gauge IVs may have to be started at MTF
  • Common practice to discontinue prehospital IVs
    upon arrival at MTF because of concern about
    contamination of the IV site

54
IV Therapy
  • Don't start on an extremity distal to a
    significant wound
  • Saline locks are used (Eliminates the logistical
    difficulties of managing the IV bag during
    transport)

55
IV Therapy
  • Extremity (Upper gt Lower) vein first choice
  • External jugular vein next option
  • Sternal Intraosseous is last option

56
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58
Fluid Resuscitation
  • 1. Controlled bleeding/ no shock
  • Saline lock, NO IV fluids required
  • 2. Controlled bleeding/shock
  • Saline lock, IV Hespan 500 - 1000cc
  • 3. Uncontrolled bleeding
  • Saline lock, NO IV fluids

59
Fluid Resuscitation
  • Despite its widespread use, the benefit of
    prehospital fluid resuscitation in trauma
    patients has not been established.

60
Fluid Resuscitation Uncontrolled Bleeding
  • Several studies noted that only after
    previously uncontrolled hemorrhage was stopped
    did fluid resuscitation prove to be of benefit.

61
Fluid Resuscitation Uncontrolled Bleeding(Human)
  • World War I combat trauma patients
  • Concluded that initiating IV fluid replacement
    without first obtaining surgical hemostasis
    promoted further hemorrhage.
  • Cannon

62
Fluid Resuscitation Uncontrolled Bleeding
  • Weight of evidence at this time favors
    withholding aggressive IV fluid resuscitation in
    patients with uncontrolled hemorrhage from
    penetrating thoracic or abdominal trauma until
    the time of surgical intervention.

63
Fluid Resuscitation Controlled Bleeding
  • Immediate fluid resuscitation is still
    recommended for casualties on the battlefield
    whose hypovolemic shock is the result of bleeding
    from an extremity wound which has been controlled.

64
  • Comments/Questions?

65
Inspect and Dress Wound
  • Minimize further contamination
  • Promote hemostasis

66
Check for Additional Wounds
  • A careful check for additional wounds should be
    made, since high velocity projectiles from
    assault rifles will tumble and take erratic
    courses when travelling through tissue.
  • Exit sites are often remote from the entry wound.

67
Splint Fractures and Recheck Pulse
  • Check distal pulses both before and after
    splinting
  • Remedy any decrease in the pulse caused by
    splinting by adjusting the position of the splint

68
Cardiopulmonary Resuscitation (CPR)
  • Battlefield CPR for victims of blast or
    penetrating trauma who have no pulse, no
    respirations, and no other signs of life, will
    not be successful and should not be attempted.
  • Attempts to resuscitate trauma patients in arrest
    have been futile even in the urban setting where
    the victim is in close proximity to a trauma
    center.

69
Cardiopulmonary Resuscitation
  • The battlefield cost of attempting to perform
    CPR on casualties with what are inevitably fatal
    injuries will be measured in additional lives
    lost as care is withheld from patients with less
    severe injuries and as Rangers are exposed to
    additional hazard from hostile fire because of
    their attempts.

70
CardiopulmonaryResuscitation
  • Only in the case of nontraumatic disorders
    such as hypothermia, near drowning, or
    electrocution should CPR be considered prior to
    the CASEVAC phase.

71
CASEVAC Care
  • Two significant differences will be present in
    progressing from the Tactical Field Care phase to
    the CASEVAC phase
  • Additional medical personnel may accompany the
    evacuating asset.
  • Additional medical equipment may be pre-staged
    on the evacuating asset.

72
CASEVAC Care Monitoring
  • Helicopter transport impairs or precludes the
    provider's ability to auscultate the lungs or
    even to palpate the carotid pulse
  • Electronic monitoring systems capable of
    providing blood pressure, heart rate, pulse
    oximetry, and capnography are commercially
    available and needed for air medical transport

73
Recommendations
  • 1. Base planning for Ranger combat casualties
    should be incorporated into specific mission
    scenarios to aid in identifying the unique
    medical and tactical requirements that will have
    to be addressed in that scenario.

74
Recommendations
  • 2. On combat missions, all Rangers should have a
    suitable tourniquet readily available at a
    standard location on their battle gear.
  • 3. All Rangers should be trained to use a
    tourniquet.

75
Recommendations
  • 4. Designate and train Combat Casualty Transport
    Teams.
  • 5. In the event of a conflict, assign these
    teams to the JSOTF commander.

76
Vision Statement
  • We must also have the intellectual agility to
    conceptualize creative, useful solutions to
    ambiguous problems.this means training and
    educating people on
  • how to think, not just what to think.
  • Gen Peter Schoomaker
  • Commander-in-Chief

77
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