actep2014: hot zone
DESCRIPTION
Hot zone care: How to keep everybody safe - พ.ท.สุธี อินทรชาติ, พ.ต.ธนานันต์ อิศรางกูร ณ อยุธยาTRANSCRIPT
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Care in HOT ZONE
Major Thananan Isarangul Na Ayudhya Emergency Physician,
ANANDAMAHIDOL Hospital
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Scenario
• Your unit is in a 5-vehicle convoy moving through a small Iraqi village when an IED explodes under the 2nd vehicle
• Moderate sniper fire follows and the rest of the convoy is busily engaged in suppressing it
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Scenario
• You are a medic in the disabled vehicle which is not on fire and Rt side up
• You are not injured and able to assist
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Scenario
• The person next to you has bilateral mid-thigh traumatic amputations
– Heavy arterial bleeding Lt stump
– Mild oozing from Rt stump
– Conscious and in moderate pain
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What phase of care are you in?
• What is you immediate concern?
• Should you treat the casualty or return fire?
• Why?
• What is your next action?
• Should you put a tourniquet on the second stump?
• Why?
• What are your next actions?
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Objectives
• DESCRIBE the role of firepower supremacy in the prevention of combat trauma
• DEMONSTRATE techniques that can be used to quickly move casualties to cover while the unit is engaged in a firefight
• EXPLAIN the rationale for early use of a tourniquet to control life-threatening extremity bleeding during Care Under Fire
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Phases of Care in TCCC
• Care Under Fire
• Tactical Field Care
• Tactical
Evacuation Care
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Care Under Fire
• Care rendered by the first responder or combatant at the scene of the injury
• Still under effective hostile fire
• Available medical equipment is limited
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Care Under Fire Guidelines
1. Return fire and take cover
2. Direct or expect casualty to remain engaged as a combatant if appropriate
If the firefight is ongoing - don’t try to treat your casualty in the Kill Zone!
The best medicine on the battlefield is Fire Superiority
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Care Under Fire Guidelines
3. Direct casualty to move to cover and apply self-aid if able
4. Try to keep the
casualty from
sustaining additional
wounds
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Casualty Movement Rescue Plan
If you must move a casualty under fire, consider the following:
– Location of nearest cover
– How best to move to the cover
– The risk to the rescuers
– Weight of casualty and rescuer
– Distance to be covered
– Use suppression fire and smoke to best advantage!
– Recover casualty’s weapons if possible
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1) While under fire and without a weapon,
Gunnery Sgt. Ryan P. Shane runs to Sgt. Lonnie
Wells, to pull him to safety during USMC combat
operations in Fallujah
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2) Gunnery Sgt Shane attempts to pull a fatally
wounded Sgt Wells to cover
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3) Another Marine comes to help
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4) Gunnery Sgt. Shane (left) is hit by enemy fire
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5) Gunnery Sgt Shane, on ground at left, was hit by
insurgent sniper fire
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Types of Carries for Care Under Fire
• One-person drag with/without line
• Two-person drag with/without line
• SEAL Team Three Carry
• Hawes Carry
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One-Person Drag
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Two-Person Drag
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Two-Person Drag Using Lines
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SEAL Team Three Carry (1)
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SEAL Team Three Carry (2)
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Hawes Carry
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Care Under Fire Guidelines
5. Casualties should be extricated from burning vehicles or buildings and moved to relative safety – Do what is necessary to stop the burning process
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Care Under Fire Guidelines
6. Airway management is generally best deferred until the Tactical Field Care phase
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Care Under Fire Guidelines
7. Stop life-threatening external hemorrhage if tactically feasible: – Direct casualty to control hemorrhage by self-aid if
able
– Use a CoTCCC-recommended tourniquet for hemorrhage that is anatomically amenable to tourniquet application
– Apply the tourniquet proximal to the bleeding site, over the uniform, tighten, and move the casualty to cover
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Care Under Fire Guidelines Direct casualty to control hemorrhage by self-aid if able
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Care Under Fire Guidelines • Use a CoTCCC-recommended tourniquet for
hemorrhage that is anatomically amenable to tourniquet application
1. Combat Application Tourniquet™ (C-A-TTM)
2. SOF® Tactical Tourniquet (SOF®TT)
3. Emergency and Military Tourniquet (EMT™)
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Combat Application Tourniquet™ (C-A-TTM)
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SOF® Tactical Tourniquet (SOF®TT)
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Emergency and Military Tourniquet
(EMT™)
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Semi-Automatic Tourniquet : SIAM-III
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Care Under Fire Guidelines
• Apply the tourniquet proximal to the bleeding site, over the uniform, tighten, and move the casualty to cover
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Tourniquet Application
• Non-life-threatening bleeding should be ignored until the Tactical Field Care phase
• Apply the tourniquet without removing the uniform – make sure it is clearly proximal to the bleeding site
• Tighten until bleeding is controlled
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Tourniquet Application
• May need a second tourniquet applied just above the first to control bleeding
• Don’t put a tourniquet directly over the knee or elbow
• Don’t put a tourniquet directly over a holster or a cargo pocket that contains bulky items
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(Data based on the Wound Data Munitions Effectiveness Team (WDMET) during the Vietnam War between 1967 and 1969)
NEXT
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Safety of Tourniquet Use Kragh - Journal of Trauma 2008
• Combat Support Hospital in Baghdad
• 232 patients with tourniquets on 309 limbs
• CAT was best field tourniquet
• No amputations caused by tourniquet use
• Approximately 3% transient nerve palsies
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Impact of Tourniquet Use Kragh - Annals of Surgery 2009
• Ibn Sina Hospital, Baghdad, 2006
• Tourniquets are saving lives on the battlefield
• Better survival when tourniquets were applied
BEFORE casualties went into shock
• 31 lives saved in this study by applying
tourniquets prehospital rather than in the ED
• Estimated 1000-2000 lives saved in war to date by
tourniquets (data provided to Army Surgeon General)
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Preventable Death on the
Battlefield: OEF and OIF
Eastridge 2012 Study:
• 4,596 U.S. deaths
• 87% pre-hospital deaths
• 24% of pre-hospital deaths were potentially survivable
Holcomb, et al, 2005 – US SOF Preventable Deaths = 15% Kelly, et al, 2008 – US Military Preventable Deaths = 24%
Eastridge, et al, 2011, 2012 – US Military Preventable Deaths = 27.6% 4 Unclassified
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Hot zone TCCC PHTLS
Scene Care under fire Return fire and take cover Fire superiority
Scene size up Universal precaution
Goal Mission >> Casualty Save patient
Harm Continue Controlled (mostly)
Resource Limit Level of EMS
Personnel Self aid Buddy aid Combat life saver
EMS team
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Hot zone TCCC PHTLS
Sequence of care C – A – B A – B – C
Airway & C-spine Deferred Significant
Breathing & Ventilation
Deferred Significant
Circulation Significant Also significant
Control of bleeding Tourniquet Ignored
Pressure dressing Tourniquet (lessly)
Cardiac Arrest No CPR Perform CPR
Moving Drag or carry Immobilized as need
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Tactical Field Care
• Safe situation in battlefield,
not under the enemy fire
• Recheck bleeding control measure
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Priority is A-B-C
No attempt to CPR
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Life Threatening condition in Tactical Field Care
• Airway Obstruction: tongue, saliva, blood
• Breathing: tension pneumothorax
• Circulation: exsanguinate and shock
• C-spine ?
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CASEVAC Combat Casualty Evacuation Care
• Care En Route
• Keep warm
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Convoy IED Scenario
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Convoy IED Scenario
First decision:
• Return fire or treat casualty?
– Treat immediate threat to life
– Why?
• Rest of convoy providing suppressive fire
• Treatment is effective and QUICK
• First action?
– Tourniquet on stump with arterial bleed
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Convoy IED Scenario
Next action?
• Tourniquet on second stump?
– Not until Tactical Field Care Phase
– Not bleeding right now
Next actions?
• Drag casualty out of vehicle and move to best cover
• Return fire if needed
• Communicate info to team leader
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Summary of Key Points
• Return fire and take cover!
• Direct or expect casualty to remain engaged
• Direct casualty to move to cover
• Keep the casualty from additional wounds
• Get casualties out of burning vehicles or buildings
• Airway management : deferred
• Stop life-threatening external hemorrhage
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Questions?
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Airway – Will Cover in Tactical Field Care
No immediate management of the airway is anticipated while in the Care Under Fire phase
– Don’t take time to establish an airway while under fire
– Defer airway management until you have moved casualty to cover
– Combat deaths from compromised airways are relatively infrequent
– If casualty has no airway in the Care Under Fire phase, chances for survival are minimal
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C-Spine Stabilization
Penetrating head and neck injuries do not require C-spine stabilization
–Gunshot wounds (GSW), shrapnel
– In penetrating trauma, the spinal cord is either already compromised or is in relatively less danger than would be the case with blunt trauma
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C-Spine Stabilization
Blunt trauma is different!
– Neck or spine injuries due to falls, fast-roping injuries, or motor vehicle accidents may require C-spine stabilization
– Apply only if the danger of hostile fire does not constitute a greater threat
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