Tactical Combat Casualty Care

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Tactical Combat Casualty Care

• Dan S. Mosely, MD
• MAJ, USA, MC, FS

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Agenda

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

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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

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Caveats When Applying Civilian Literature

• Different weapons
• Less pre-existing dehydration
• Pre-hospital time
• Surgical intervention
• Resource
• Monitoring
• Threat

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Combat Mortality
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Combat Mortality

• Killed in Action(86 KIA)
• versus
• Died of Wounds(12 DOW)

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Combat Mortality

• KIA
• 31 are due to penetrating head trauma

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Combat Mortality

• KIA
• 25 are due to surgically uncorrectable
  penetrating torso trauma

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Combat Mortality

• KIA
• 10 are due to potentially correctable
  penetrating torso trauma

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Combat Mortality

• KIA
• 9 are due to potentially correctable extremity
  trauma

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Combat Mortality

• KIA
• 7 are due to mutilating blast injuries

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Combat Mortality

• KIA
• 5 are due to tension pneumothorax

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Combat Mortality

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

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Combat Mortality

• DOW
• 12 are mostly due to complicationsof shock
  orlate infection

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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
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PREVENTABLE Mortality Vietnam

• Airway obstruction (6)
• Tension pneumothorax (33)
• Hemorrhage from extremity wounds (60)

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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
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PREVENTABLE MortalityOEF/OIF

• Airway obstruction (??)
• Tension pneumothorax (??)
• Hemorrhage from extremity wounds (??)

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Tactical Combat Casualty Care

• Care Under Fire
• Tactical Field Care
• Evacuation Care

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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

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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

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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

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• Care Under Fire

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Care Under Fire

• Return fire
• Return fire
• Return fire

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Care Under Fire

• Return fire
• What does returning fire have to do with
  medical care?

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Care Under Fire

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

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Care Under Fire

• Move the casualty to cover
• Dont get shot while trying to do 1

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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

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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?

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Hemorrhage Control

• Dressing
• Pressure dressing
• Tourniquet

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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

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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

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Care Under Fire

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

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Questions?
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• Tactical Field Care

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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

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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

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Airway ManagementConscious Casualty

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

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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

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Airway ManagementObstruction

• Liquid removal options
• Gravity
• Suction
• Definitive airway options
• Endotracheal intubation
• Cricothyroidostomy

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Breathing

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

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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

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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

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Auscultation
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Auscultation with Stab Wounds
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Auscultation with GSW Wounds
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Tension Pneumothorax

• Deceased preload
• Increased afterload
• Mechanical pressure on heart
• Decreased Alveolar surface
• Pleural space agitation

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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

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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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Tube Thoracostomy

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

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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

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Supplemental Oxygen

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

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Shock Management

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

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Shock Management

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

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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

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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

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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

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Uncontrolled Hemorrhage With or Without Shock

• NO immediate fluid resuscitation
• Spend time controlling exsanguination
• External
• Internal
• Save IV fluids
• Permissive hypotension

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Cardiopulmonary Resuscitation

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

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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

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Questions?
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Evacuation
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CASEVAC versus MEDEVAC

• CASEVAC
• Casualty evacuation from the battlefield
• MEDEVAC
• Medical evacuation of casualties

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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

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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

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CASEVAC Care

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

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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

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MEDEVAC Care

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

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MEDEVAC Care

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

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Questions?