PERFORMING TACTICAL COMBAT CASUALTY CARE

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PERFORMING TACTICAL COMBAT CASUALTY CARE
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Tactical Combat Casualty Care

• 1. BAD TACTICS CAN GET EVERYONE KILLED.
• 2. BAD TACTICS CAN CAUSE THE MISSION TO FAIL.

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Timing is Everything

• The Right Things To Do
• AND
• The Right Time to Do Them

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Introduction About 90 percent of combat deaths
occur on the battlefield before the casualties
reach a medical treatment facility (MTF). Most
of these deaths cannot be prevented by you or the
medic. Examples Massive head injury, massive
trauma to the body.
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• About 15 percent of the casualties that
  die before reaching a medical treatment facility
  can be saved if proper measures are taken.
• Stop severe bleeding (hemorrhaging)
• Relieve tension pneumothorax
• Restore the airway

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In the Vietnam conflict, over 2500 soldiers died
due to hemorrhage from wounds to the arms and
legs even though the soldiers had no other
serious injuries. These soldiers could have
been saved by applying pressure dressings and
tourniquets to stop the bleeding.
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Combat Lifesaver

• Functioning as a Combat Lifesaver is your
  secondary mission.
• Your primary mission is still your combat duties.
• You should render care only when such care does
  not endanger your primary mission.

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Tactical Context

• Incoming fire
• Darkness
• Environmental factors
• Casualty transport problems
• Delays to definitive care
• Command decisions

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Tactical Combat Casualty Care

• 3 Distinct Phases
• Care Under Fire
• Tactical Field Care
• Combat Casualty Evacuation Care

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• The three goals of Tactical Combat Casualty
  Care (TCCC) are
• 1. Save preventable deaths
• 2. Prevent additional casualties
• 3. Complete the mission

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• This approach recognizes a particularly
  important principle
• To perform the correct intervention at the
  correct time in the continuum of combat care
• A medically correct intervention performed at
  the wrong time in combat may lead to further
  casualties

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Care Under Fire

• Care rendered by the medic or first responder at
  the scene of the injury while still under
  effective hostile fire
• Very limited as to the care you can provide

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Tactical Field Care

• Care rendered once you are no longer under
  effective hostile fire
• You and the casualty are safe and you are free to
  provide casualty care (primary mission is
  complete)

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Combat Casualty Evacuation Care

• Care rendered during casualty evacuation
• Additional medical personnel and equipment may
  have been pre-staged and available at this stage
  of casualty management

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Care Under Fire
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The Toohey Amendment

• I also expect the casualties to continue to
  return fire as long as they are able to do so.
• CDR Pat
  Toohey
• 
  Commanding Officer
• SEAL
  Team Four

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Care Under Fire

• The best medicine on any battlefield is fire
  superiority
• Medical personnels firepower may be essential in
  obtaining tactical fire superiority
• Attention to suppression of hostile fire will
  minimize the risk of additional injuries or
  casualties

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Care Under Fire

• If the casualty can function, direct him to
  return fire, move to cover, and administer
  self-aid
• If unable to return fire or move to safety and
  you cannot assist, tell the casualty to play
  dead
• Communicate the medical situation to the team
  leader
• Use cover/concealment such as smoke

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Care Under Fire
Improved First Aid Kit

• No attention to the airway at this point because
  of the need to move casualty to cover quickly
• If the casualty has severe bleeding from a limb
  or has an amputation, apply a tourniquet

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Care Under Fire

• Hemorrhage from extremities is the 1st leading
  cause of preventable combat deaths
• Prompt use of tourniquets to stop the bleeding
  may be life-saving in this phase

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OIF Fatality

• Marine shot in leg in Iraq
• Pulsatile femoral artery bleeding
• Corpsman arrived 10 minutes later
• Attempted to use hemostatic material - failed
• IV attempted - failed
• Tourniquet finally applied
• Casualty died

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Combat Application Tourniquet (CAT)
WINDLASS
OMNI TAPE BAND
WINDLASS STRAP
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Tourniquets
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Care Under Fire

• Reassure the casualty
• If unresponsive, move the casualty and his
  mission-essential equipment to cover as the
  tactical situation permits

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Tactical Field Care
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Tactical Field Care

• Perform tactical field care when you and the
  casualty are not under direct enemy fire.
• Recheck bleeding control measures if they were
  applied while under fire.

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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
• CPR performers may get killed
• Mission gets delayed
• Casualty stays dead

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Tactical Field Care

• Casualties with confused mental status should be
  disarmed immediately of both weapons and
  grenades.

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Determine Level of Consciousness

• AVPU system
• A The casualty is alert, knows who he is, the
  date, where he is, and so forth.
• V The casualty is not alert, but does respond to
  verbal commands.
• P The casualty responds to pain, but not verbal
  commands.
• U The casualty is unresponsive (unconscious).
• Recheck every 15 minutes

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Tactical Field Care

• Initial assessment is the ABCs
• Airway
• Breathing
• Circulation

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Tactical Field Care Airway

• Open the airway with a chin-lift or jaw-thrust
  maneuver
• If unconscious and spontaneously breathing,
  insert a nasopharyngeal airway
• Place the casualty in the recovery position

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Nasopharyngeal Airway
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A survivable airway problem
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Tactical Field Care Breathing

• Traumatic chest wall defects should be closed
  quickly with an occlusive dressing without regard
  to venting one side of the dressing
• Also may use an Asherman Chest Seal
• Place the casualty in the sitting position if
  possible.

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"Asherman Chest Seal"
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Tactical Field Care Breathing

• Progressive respiratory distress in the presence
  of unilateral penetrating chest trauma should be
  considered tension pneumothorax
• Tension pneumothorax is the 2nd leading cause of
  preventable death on the battlefield
• Cannot rely on typical signs such as shifting
  trachea, etc.
• Needle chest decompression is life-saving

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Needle Chest Decompression
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Tactical Field Care Circulation

• Any bleeding site not previously controlled
  should now be addressed
• Only the absolute minimum of clothing should be
  removed, although a thorough search for
  additional injuries must be performed

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Tactical Field Care Circulation

• Apply a tourniquet to a major amputation of the
  extremity
• Apply an emergency trauma bandage and direct
  pressure to a severely bleeding wound
• If a tourniquet was previously applied, consider
  changing to a pressure dressing and/or using
  hemostatic dressings (HemCon) or hemostatic
  powder (QuikClot) to control any additional
  hemorrhage

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Chitosan Hemostatic Dressing

• Apply directly to bleeding site and hold in place
  2 minutes
• If dressing is not effective in stopping bleeding
  after 4 minutes, remove original and apply a new
  dressing

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Chitosan Hemostatic Dressing

• Additional dressings cannot be applied over
  ineffective dressing
• Apply a battle dressing/bandage to secure
  hemostatic dressing in place
• Hemostatic dressings should only be removed by
  responsible persons after evacuation to the next
  level of care

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Tactical Field Care Shock

• Hypovolemic shock results
  
  when there is a sudden
  decrease in the amount of fluid in the casualtys
  circulatory system.
• Heat stroke, diarrhea, and dysentery can also
  cause hypovolemic shock.
• The casualty may also have internal bleeding,
  such as bleeding into the abdominal or chest
  cavities.

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Tactical Field Care IV fluids

• FIRST, STOP THE BLEEDING!
• IV access should be obtained using a single
  18-gauge catheter because of the ease of starting
• A saline lock may be used to control IV access in
  absence of IV fluids
• Ensure IV is not started distal to a significant
  wound

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Reasons NOT to Start IVs on All Combat Casualties

• Minimize interference with combatants who can
  continue to participate in the engagement
• Conserve limited IV fluid supplies
• Attend to casualties with more severe wounds
• Avoid delaying tactical movement - waiting 5
  minutes to start an IV may get 5 members of your
  team killed

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Saline Lock
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Tactical Field Care Additional injuries

• Splint fractures as circumstances allow while
  verifying pulse and prepare for evacuation

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Warning!

• Do not take aspirin, ibuprofen (Motrin) or
  related medications while in theater
• Interfere with blood clotting
• Increase risk of fatal hemorrhage if wounded

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Tactical Field Care

• Communicate Let your unit leader know the
  casualtys condition Will casualty return to
  duty? Does the casualty require medical evac to
  save life or limb? Non-medical evac?
• Initiate a Field Medical Card (DD Form 1380)
• Monitor the casualty Airway, breathing,
  bleeding, and IV infusion

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Combat Casualty Evacuation Care
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Casevac Care

• If the casualty requires evacuation, prepare the
  casualty
• Use a blanket to keep the casualty warm
• If the casualty is to be evacuated by medical
  transport, you may need to prepare and transmit a
  MEDEVAC request

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Preservation of Amputation Parts

• Rinse amputated part free of debris
• Wrap loosely in saline-moistened sterile gauze
• Seal amputated part in a plastic bag or cravat
• Place in a cool container, do not freeze
  
• Never place amputated part in water
• Never place amputated part directly on ice
• Never use dry ice to cool an amputated part

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Casevac Care

• Use a SKED litter or improvised litter if the
  casualty must be moved to a casualty collection
  point
• If transported by a non-medical vehicle
  (CASEVAC), you may need to arrange the vehicle to
  accommodate the casualty
• If an unconscious casualty is transported on a
  non-medical vehicle, you may need to accompany
  the casualty and render additional care as needed
• Restock your aid bag when possible

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Summary

• There are three categories of casualties on the
  battlefield
• 1. Soldiers who will live regardless
• 2. Soldiers who will die regardless
• 3. Soldiers who will die from preventable deaths
  unless proper life-saving steps are taken
  immediately (7-15)

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• What Happened
• This individual was wounded by an IED
  (improvised explosive device). He sustained a
  penetrating shrapnel injury to the neck with
  laceration of his right common carotid artery
  from which he bled to death.
• What Might Have Saved Him
• Sustained direct pressure
• over the bleeding site
• HemCon dressing
• Faster evacuation

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• What Happened
• This individual sustained a GSW after a
  helicopter crash. He was wounded in the abdomen
  below his body armor. He was reported to have
  lived for almost five hours after wounding,
  indicating a relatively slow rate of bleeding.
  The injury was determined to have been readily
  amenable to surgical repair.
• What Might Have Saved Him
• Faster evacuation
• Packed Red Blood Cells on
• the helicopter (as recommended
• by TCCC guidelines)

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• What Happened
• This casualty was wounded by an RPG explosion
  and sustained a traumatic amputation of the right
  forearm at the mid-forearm level and a right
  thigh wound with femoral bleeding. He bled to
  death from the thigh wound despite the placement
  of three field-expedient tourniquets. The
  treating first responder clearly had the right
  idea, but lacked an adequate tourniquet and was
  unable to improvise an effective one in time.

What Could Have saved Him C.A.T. Tourniquet
Better training for all unit members (Medic
killed at onset of action)
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What Happened This casualty sustained a gunshot
wound to his upper thigh at an anatomic location
too high for effective use of a tourniquet.
What Could Have Saved Him Sustained direct
pressure on the wound or Pressure on the femoral
artery at the pressure point or HemCon dressing
and Faster evacuation
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Summary

• 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