Tactical Combat Casualty Care


Mihail Păduraru




REASON & MOTIVATION
Why should you care?

TCCC is about treating the most immediate lifethreatening injuries first.
It is designed for a opeator to save their own life and treat their own injuries
And if you can save your own life, you can save someone else’s

But the Medic will save me, so why should I care about medicine?
Moroccan Officer

If you are in a gunfight, and your rifle stops working, do you shout for an armorer or weaponsmith?


The three goals of Tactical
Combat Casualty Care (TCCC)
are:

–1. Save preventable deaths

–2. Prevent additional casualties

–3. Complete the mission


• This approach recognizes a particularly important principle:

– To perform the correct intervention at the correct time in the continuum of Tactical Care

– A medically correct intervention performed at the wrong time in combat may lead to further casualties

COMBAT DEATHS

 KIA: 31% PENETRATING HEAD TRAUMA

 KIA: 25% SURGICALLY UNCORRECTABLE TORSO TRAUMA

 KIA: 7% MUTILATING BLAST TRAUMA

 KIA: 10% POTENTIALLY SURGICALLY
CORRECTABLE TRAUMA

 KIA: 9% HEMORRHAGE FROM EXTREMITY
WOUNDS

 KIA: 5% TENSION PNEUMOTHORAX

 KIA: 1% AIRWAY PROBLEMS

 DOW: 12% MOSTLY FROM INFECTIONS AND COMPLICATIONS OF SHOCK


PREVENTABLE CAUSES OF
COMBAT DEATH

• 60% Hemorrhage from extremity wounds

• 33% Tension pneumothorax

• 6% Airway obstruction e.g., maxillofacial trauma

• * Data is extrapolated from Vietnam to present day Iraq and Afghanistan


Factors influencing combat casualty care
• Enemy Fire

• Medical Equipment Limitations

• Widely Variable Evacuation Time

“Soldiers that died…
…that shouldn’t have.”

UP TO 90% OF ALL COMBAT DEATHS OCCUR
BEFORE A CASUALTY REACHES A MEDICAL
TREATMENT FACILITY

• What does this mean?
– It means that YOU and your skills (Medic or Nonmedic) may be the only medical treatment a casualty receives immediately after injury.


3 PHASES OF CARE IN TCCC


#1 Care Under Fire

Care Under Fire

• “Care under fire” is the care rendered by the Tactical Medic or Tactical Operator at the scene of the injury while still under effective hostile fire

• Available medical equipment is limited to that carried by the medic or first responder in his/her aid bag

• “The best medicine on any battlefield is fire superiority”

• Medical personnel’s firepower may be essential in obtaining tactical fire superiority

• Attention to suppression of hostile fire will minimize the risk of additional injuries or casualties

• Medical personnel may need to assist in returning fire instead of stopping to care for casualties

• Wounded operators who are unable to fight should lay flat and motionless if no cover is available or move as quickly as possible to any nearby cover. Self Aide should be rendered.

• No attention to airway at this point because of need to move casualty to cover quickly

• Control of hemorrhage is essential since injury to a major vessel can result in hypovolemic shock in a short time frame

• Remember the “Average” person can exsaguinate in 3-5 minutes with a major vessel injury i.e. Femoral Artery Disruption



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




• All personnel engaged in High Threat missions should have a
suitable tourniquet readily available at a standard location on
their gear and be trained in its use

• The tourniquet should be placed as high up on the extremity as possible, ignoring the clothing


• Conventional litters may not be available for movement of casualties
• Consider alternate methods to move casualties such as a SKEDD/Drags

• Smoke, shields and vehicles may act as screens to assist in casualty movement

• Armored Vehicles may also be employed as a means of egress

KEY POINTS

• Return fire as directed or required

• If able, the casualty(s) should also return fire

• Try to keep from being shot

• Try to keep the casualty from sustaining additional wounds

• Airway management is best deferred until the Tactical Field Care phase

• Stop any life threatening hemorrhage with a commercially available tourniquet (CAT)

• Reassure the casualty

#2 Tactical Field Care

Tactical Field Care

• “Tactical Field Care” is the care rendered by the medic once no longer under effective hostile fire

• Also 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 may vary considerably

• Reduced level of hazard from hostile fire or enemy action

• Increased time to provide care

• Available time to render care may vary considerably

• In some cases, tactical field care may consist of rapid treatment of wounds with the expectation of a reengagement
of hostile fire at any moment

• In some circumstances there may be ample time to render whatever care is available in the field

• The time to evacuation may be quite variable from minutes to hours

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 their weapon.

• On going assessment in this phase is:

A.B.C
– Airway
– Breathing
– Circulation

Airway

• Open the airway with a chin-lift

• If unconscious and spontaneously breathing, insert a nasopharyngeal airway

• Place the casualty in the recovery

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” or HyFin TM (North American Rescue Products)

• Place the casualty in the sitting position or on effected side.





• 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 (late sign and very difficult to appreciate)

• Needle chest decompression is life-saving ( 14 gauge 3.25 inch catheter)







Circulation

• Any bleeding site not previously controlled should now be
aggressively addressed.

• Only the absolute minimum of clothing should be removed,
although a thorough search for additional injuries must be performed

• Once the tactical situation permits, a new tourniquet can be applied 2-3 inches above wound on bare skin.

Distal pulse should be checked, If present, tighten tourniquet until distal pulse is absent

• Initiate IV access

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

• Additional dressings cannot be applied over ineffective dressing

• Pack wound with gauze (enough to fill cavity)

• Apply a battle dressing/bandage to secure hemostatic dressing in place

• If bleeding controlled, do not remove dressing




IV fluids

• FIRST, STOP THE BLEEDING!

• IV access should be obtained using a single 18-gauge catheter because of the ease of starting. Rapidly consider I/O access

• IV fluids be administered in amounts enough to maintain systolic B/P between 70-80 mmHg with 0.9 NS (Hextend?)

• 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

Additional injuries

• Splint fractures as circumstances allow while verifying pulse and prepare for evacuation (SAM SPLINT)

• Continually reevaluate casualties for changes in condition while maintaining situational awareness

• Consider Emergency Airway

#3 Casualty Evacuation
(CASEVAC)

TACTICAL EVAC

• “Tactical Evacuation” is the care rendered once the casualty has been picked up by evacuation vehicles

• Additional medical personnel and equipment may have been prestaged and available at this stage of casualty management


• At some point in the operation the casualty will be evacuated

• Time to evacuation may be quite variable from minutes to hours

• The tactical medic may be among the casualties or otherwise debilitated

• A MASS CALSULTY EVENT may exceed the capabilities of the
medic

• Higher level medical personnel MAY accompany the TAC EVAC vehicle

• Additional medical equipment MAY be brought in with the TAC EVAC asset, which may include

– Electronic equipment for monitoring of the patient’s blood pressure, pulse, and pulse oximetry

– Oxygen is usually available during this phase


• There are three categories of casualties on the battlefield:

1. Operators who will live regardless

2. Operators who will die regardless

3. Operators who will die from preventable deaths unless proper life-saving steps are taken immediately (60% Hemorrhage, 33% Tension Pneumo and 6% Airway Obstruction

• This is the group MEDICS can help the most.




Summary


THE MARCH-ON ALGORITHM


                 Massive Bleeding
Airway
       Respiration
      Circulation
         Hypothermia
                    Head Wounds
             Handling
          Open Wounds
No Pain

You are concerned with SECURITY

1.Return Fire

2.Stop Life threatening Bleeding

3. Take Cover


Tactical Field Care

Massive Bleeding

TREAT ANY SERIOUS BLEEDING

TOOLS:
-TOURNIQUETS
- SOF-T / CAT (BANNED BY USASOC) / NATO

HEMOSTATIC AGENTS, GAUZE & WOUND PACKING

CONDUCT BLOOD SWEEPS AND QUICKLY INSPECT FROM HEAD TO TOE, FRONT AND BACK TO RULE OR TREAT ANY MASSIVE BLEEDING

CHECK RESPONSIVENESS WHILE TREATING
MASSIVE BLEEDING, USE “A-V-P-U” TO ESTIMATE

ALERT – casualty is alert and responding coherently
VERBAL – casualty responds but is incoherent
PAIN – casualty responds only to painful stimulation
UNRESPONSIVE – patient does not respond

MASSIVE HEMORRHAGE FROM EXTREMITIES IS THE
1ST LEADING CAUSE OF PREVENTABLE DEATHS
ON THE BATTLEFIELD


Airway

 OPEN THE AIRWAY

-CHIN-LIFT OR JAW-THRUST MANEUVER

 SECURE THE AIRWAY

 TOOLS:
NASOPHARYNGEAL AIRWAY (NPA) - IF SEMICONSCIOUS
- KING LT - IF UNCONSCIOUS
- CRICOTHYROTOMY – SURGICAL AIRWAY IF AIRWAY IS OBSTRUCTED

* Airway obstruction is now the 2nd leading cause of preventable death on the battlefield (Eastridge Study)

 IF YOU MUST MOVE TO ANOTHER PATIENT PLACE THE CASUALTY IN THE RECOVERY POSITION





WHY RECOVERY POSITION ?

Moscow Theater, 2002, 850 Hostages, 50 Chechen Terrorists
Russian Spetznaz uses sleeping gas.
They evacuate all hostages, yet 129 Hostages die after the event?
Why?

They were left face up and aspirated on vomit or their airway was obstructed by their tongue.

Respiration

TREAT ALL CHEST WOUNDS WITH AN OCCLUSIVE DRESSING /CHEST SEAL

 TOOLS:
-CHEST SEALS: SAM® , HYFIN®, HALO®, BOLIN®, ASHERMAN®, IMPROVISED FOUR-SIDED OCCLUSIVE

 RECOGNIZE & TREAT TENSION PNEUMOTHORAX
- Progressive respiratory distress with penetrating chest
trauma should be considered tension pneumothorax
- Tension pneumothorax was the 2nd leading cause of preventable death on the battlefield, is now the 3rd…

 DO NOT rely on typical signs such as shifting trachea &
PMI or JVD, these are late signs.

 Needle chest decompression is life-saving

 TOOLS: 14ga catheter at 2nd ICS Mid-Clavicular Line or 5th ICS Mid Axillary Line





TREAT ALL WOUNDS!

 Check the back or “down side”

 Log Roll the casualty or just have him sit up on his own

Rule out neck, pelvic, or femur fractures before you roll
him…

 PLACE THE CASUALTY IN POSITION OF COMFORT

 If they want to sit upright, let them sit up




CALL FOR MEDEVAC AS SOON AS POSSIBLE

KNOW AND TREAT LIFE THREATENING INJURIES FIRST

KNOW THE SERIOUSNESS (EVAC PRIORITY) OF YOUR CASUALTY(S) DON’T OVERCALL

CALL IMMEDIATELY AFTER ASSESSING/ TREATING 
M-A-R AND RAPID REASSESSMENT

DO NOT DELAY THE EVACUATION OF THE CASUALTY
FOR MINOR TREATMENTS 

YOU CAN CONDUCT MINOR, NON-LIFE SAVING TREATMENTS DURING EVACUATION



Circulation

Gain IV access w/ 18ga+ catheter
 I.V. THERAPY – FLUIDS OR SALINE LOCK?
– DETERMINED BY RADIAL PULSE
• RADIAL PULSE =SALINE LOCK
• ABSENT RADIAL PULSE =FLUID RESUSCITATION + TXA

 DETERMINE NEED FOR TRANEXAMIC ACID (TXA) OR FLUID RESUSCITATION

 SEVERE BLEEDING AND ALERT =TXA
 SEVERE BLEEDING AND UNRESPONSIVE = TXA then 500 ml Colloids
BEST OPTION IS TO HAVE TWO IV LINES AND ADMINISTER BOTH TXA AND FLUIDS SIMULTANEOUSLY

 NOTE: Sodium Chloride 9% (Normal Saline) can be poison to a
trauma patient – use it wisely

 Gain Intra-Osseous (IO) access if BP<90 and IV unsuccessful

 TOOLS: FAST-1, B.I.G., EZ-IO

To treat patients with severe bleeding with Tranexamic Acid (TXA)

 Give 1g TXA in 100mL NS or LR before 3 hours
post-wounding

 Avoid pushing IV fluids too aggressively in case of unstable hemorrhagic and closed Head Injury patients

 An early saline lock can secure IV access in case a casualty needs fluids or drugs later

 Gaining IV access may prove difficult later, if the casualty loses more blood or goes into shock

 Also consider Oral Fluids



Treat all wounds

– TOOLS:
• BANDAGES
• HEMOSTATIC AGENTS

– QUIKCLOT / HEMCON / CELOX / COMBAT GAUZE
• JUNCTIONAL OR AORTIC CLAMPS OR TOURNIQUETS
• SPLINTS

– SAM SPLINT / PELVIC SPLINT / TRACTION SPLINT
• SLING & SWATHE FOR ARMS

• Remove as little clothing as possible
– BUT DON’T MISS ANY WOUNDS
– DO A THOROUGH SEARCH
– SEE AND TOUCH EVERYTHING

• Reassess Tourniquets and downgrade if possible
– consider converting to a pressure dressing and/or using hemostatic dressings (Quick Clot Gauze)

• Treat additional injuries
– Consider a C-Collar if you suspect a cervical spine injury

• Not every patient needs one

• Treat Hypovolemic shock
– Caused by a sudden decrease in the amount of
fluid in the circulatory system.
– Rule out internal bleeding, such as bleeding into
the abdominal, chest, pelvic cavities.

• Splint fractures as circumstances allow while
verifying pulse, think
– Pulse
– Motor
– Sensory



Hypothermia / Handling / Head injuries

• Treat hypothermia as early as possible
– TOOLS:
• HYPOTHERMIA BLANKETS
• ACTIVE WARMING W/ HEAT PACKS OR BODY HEAT

THE PATIENT BEGINS LOSING BODY HEAT AND THE
ABILITY TO KEEP HIMSELF WARM THE INSTANT HE IS
INJURED

• Handle the patient carefully to avoid breaking blood clots

• Recognize if a patient has a potential head injury and treat accordingly

Open Wounds

• Administer antibiotics early to avoid possible life threatening infections
– Ertapenem (Invanz) 1g IV

• Difficult to get in Europe and expensive

• Alternative:
– Moxifloxacin 400mg IV or PO
– Cefotetan 1-2 grams SIVP

No Pain

• Administering pain meds to patients helps with long term prognosis and recovery

• Consider treating early if needed
– Morphine 5-10 mg SIVP
– Fentanyl 800 mcg PO
– S – Ketamine 0.25 – 1 mg/Kg/hr
                         • 20 mg SIVP


Combat Casualty Evacuation Care

* Prepare the casualty for transport
 Consider the type of Litter you need
 Consider Spinal Immobilization and its side effects
 Prevent Hypothermia
 How will the evacuation route/method affect the casualty?
 ALTITUDE ON LUNG INJURIES DURING AIR EVAC?
 ROUGH ROADS AND HEMORRHAGE CONTROL?
 ROUGH ROADS AND PAIN MANAGEMENT?

* Reassess the casualty until hand-over

* Give as thorough a hand-over as possible
 M-I-S-T-A-T

* Do not delay transport for minor treatments or procedures


PEARLS OF WISDOM

• Have a detailed PACE plan that makes sense and is
flexible, then TEST IT TO ENSURE IT WORKS!

• Use a SKED / FoxTrot litter or improvised litter to move the casualty to a casualty collection point (CCP)

• If transported by a non-medical vehicle (CASEVAC), arrange the vehicle to accommodate the casualty

• If an unconscious casualty is transported on a nonmedical vehicle, you may need to accompany the casualty and render additional care as needed

• Restock your aid bag when possible

“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


Stay Safe My Brothers !

SEMPER FI

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