Tactical Combat Casualty CareCharles W. Beadling, MD, FAAFP, IDHA, DMCC

Center for Disaster and Humanitarian Assistance MedicineDepartment of Military and Emergency Medicine

Uniformed Services UniversityPART II

Tactical FieldCare

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.

Tactical Field Care

• Casualty Assessment• Airway

– Adjuncts– Definitive Control

• Chest Wounds• Continued Hemorrhage Control

– Hemostatic Agents, Pressure Dressings– Fluid resuscitation

• Hypothermia, Infection

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

Tactical Field Care

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

Airway Adjuncts and Control

• Recovery Position

• NPA

• Cric

Nasopharyngeal Airway

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

Tension Pneumothorax

Breathing

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

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

Needle Thoracentesis

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

SubCommitee on Hemostatic Agents

(CoTCCC Feb, ’09)

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

Combat Gauze

Emergency Bandage(Israeli Pressure Dressing)

Emergency Bandage

Fluid Resuscitation Protocol

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

Hemorrhage Controlled

What Fluid?

• Bolus 500cc Hextend®

– Re-assess after 30 min– 500cc Hextend® Bolus– No more than 1L Hextend®

• Crystalloid– Normal Saline, Ringer’s Lactate

• Blood

PO Fluids?

Blood Products

PRBC on CASEVAC (if feasible)1:1 FFP

Reasons NOT to start an IV

• Takes time• Potential waste of fluids

Combat Pill Pack

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

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

Improved First Aid Kit

TourniquetNasopharyngeal AirwayGloves Israeli Battle DressingGauzeTape14ga Angiocath

IFAK

Combat Casualty Evacuation Care

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

Both types of evacuation are includedin the new term “Tactical Evacuation”

CASEVAC MEDEVAC

• MEDEVAC = transporting casualties via vehicles SPECIFICALLY CONFIGURED, EQUIPPED, AND STAFFED to provide medical care

• CASEVAC = moving casualties via NON-MEDICAL assets

Combat Casualty Evacuation Care

Hypothermia Prevention

• Lethal Triad:– Hypothermia– Acidosis– Coagulopathy

• Hypothermia Prevention Kit– Blizzard® Wrap– Readi-Heat® Blanket– Thermo-lite

Stokes, SKED, Talon II Litters

Future Issues

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

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

Summary

• Hemorrhage Control Techniques– Tourniquet– Pressure Dressing– Combat Gauze

• Recognize Tension Pneumothorax in Tactical Environment– Penetrating/blunt Chest Wound– Respiratory Distress

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

Summary

• Tactical Casualty Care Requires Aggressive, Full-Contact Measures

• MUST Know Equipment Capabilities and Limitations

• Adapt to Environment AND situation

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

Questions?