Tactical Combat Casualty Care

1. Tactical Combat Casualty Care Troy R Johnson, MD MAJ, USA, MC, FS Tactical Combat Casualty Care 09 SEP 02

2. Agenda • Objectives • Mortality in Combat • Preventable mortality • Care under fire • Tactical Casualty care • Evacuation • Military vs. Civilian tactical care Tactical Combat Casualty Care 09 SEP 02

3. 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 Tactical Combat Casualty Care 09 SEP 02

4. Caveats When Applying Civilian Literature • Different weapons • Less pre-existing dehydration • Pre-hospital time • Surgical intervention • Resource • Monitoring • Threat Tactical Combat Casualty Care 09 SEP 02

5. Combat Mortality Tactical Combat Casualty Care 09 SEP 02

6. Combat Mortality Killed in Action(86% KIA) versus Died of Wounds(12% DOW) Tactical Combat Casualty Care 09 SEP 02

7. Combat Mortality KIA 31% are due to penetrating head trauma Tactical Combat Casualty Care 09 SEP 02

8. Combat Mortality KIA 25% are due to surgically uncorrectable penetrating torso trauma Tactical Combat Casualty Care 09 SEP 02

9. Combat Mortality KIA 10% are due to potentially correctable penetrating torso trauma Tactical Combat Casualty Care 09 SEP 02

10. Combat Mortality KIA 9% are due to potentially correctable extremity trauma Tactical Combat Casualty Care 09 SEP 02

11. Combat Mortality KIA 7% are due to mutilating blast injuries Tactical Combat Casualty Care 09 SEP 02

12. Combat Mortality KIA 5% are due to tension pneumothorax Tactical Combat Casualty Care 09 SEP 02

13. Combat Mortality KIA 1% are due to airway obstruction (1/2 actual airway) (1/2 decreased LOC) Tactical Combat Casualty Care 09 SEP 02

14. Combat Mortality DOW 12% are mostly due to complicationsof shock orlate infection Tactical Combat Casualty Care 09 SEP 02

15. 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% Tactical Combat Casualty Care 09 SEP 02

16. PREVENTABLE Mortality • Airway obstruction (6%) • Tension pneumothorax (33%) • Hemorrhage from extremity wounds (60%) Tactical Combat Casualty Care 09 SEP 02

17. Tactical Combat Casualty Care • Care Under Fire • Tactical Field Care • Evacuation Care Tactical Combat Casualty Care 09 SEP 02

18. Care Under Fire • Return fire • Return fire • Return fire Tactical Combat Casualty Care 09 SEP 02

19. Care Under Fire • Return fire What does returning fire have to do with medical care? Tactical Combat Casualty Care 09 SEP 02

20. Care Under Fire • Return fire What does returning fire have to do with medical care? Victory is the best medicine !! Tactical Combat Casualty Care 09 SEP 02

21. Care Under Fire • Move the casualty to cover • Don’t get shot while trying to do #1 Tactical Combat Casualty Care 09 SEP 02

22. 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 Tactical Combat Casualty Care 09 SEP 02

23. 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? Tactical Combat Casualty Care 09 SEP 02

24. Hemorrhage Control • Dressing • Pressure dressing • Tourniquet Tactical Combat Casualty Care 09 SEP 02

25. 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 Tactical Combat Casualty Care 09 SEP 02

26. 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 Tactical Combat Casualty Care 09 SEP 02

27. Care Under Fire • Return fire • Don’t be a hero • Find cover for yourself and your casualty • Stop any life-threatening external hemorrhage Tactical Combat Casualty Care 09 SEP 02

28. Questions?

29. 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 Tactical Combat Casualty Care 09 SEP 02

30. 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 Tactical Combat Casualty Care 09 SEP 02

31. Airway Management:Conscious Casualty No attempt at airway intervention if the casualty is conscious and breathing well on his or her own Tactical Combat Casualty Care 09 SEP 02

32. Airway Management:Altered 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 Tactical Combat Casualty Care 09 SEP 02

33. Airway Management:Obstruction • Liquid removal options • Gravity • Suction • Definitive airway options • Endotracheal intubation • Cricothyroidostomy Tactical Combat Casualty Care 09 SEP 02

34. Breathing • Tension Pneumothorax • Auscultation • Tracheal deviation • Percussion • JVD Tactical Combat Casualty Care 09 SEP 02

35. 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. Hemopneumothoraxmissed by auscultation in penetrating chest injury.Journal of Trauma-Injury Infection & Critical Care. 42(1):86-9, 1997 Jan Tactical Combat Casualty Care 09 SEP 02

36. 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. Hemopneumothoraxmissed by auscultation in penetrating chest injury. Journal of Trauma-Injury Infection & Critical Care. 42(1):86-9, 1997 Jan Tactical Combat Casualty Care 09 SEP 02

37. Auscultation Tactical Combat Casualty Care 09 SEP 02

38. Auscultation with Stab Wounds Tactical Combat Casualty Care 09 SEP 02

39. Auscultation with GSW Wounds Tactical Combat Casualty Care 09 SEP 02

40. Tension Pneumothorax • Deceased preload • Increased afterload • Mechanical pressure on heart • Decreased Alveolar surface • Pleural space agitation Tactical Combat Casualty Care 09 SEP 02

41. 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 Tactical Combat Casualty Care 09 SEP 02

42. Needle Thoracentesis • Emergently decompress affected hemithorax with 14-gauge needle inserted over 3rd rib in 2nd inter-costal space at mid-clavicular line Tactical Combat Casualty Care 09 SEP 02

43. Tube Thoracostomy • Contraindicated for life-threatening tension pneumothorax • Difficult to perform • Infection risk higher when inserting tube in non-sterile conditions • Prior to Evacuation? Tactical Combat Casualty Care 09 SEP 02

44. 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 Tactical Combat Casualty Care 09 SEP 02

45. Supplemental Oxygen • Controversial the tactical environment • Cylinders of compressed gas heavy and risky for tactical operations • Transportation of casualty difficult without vehicle Tactical Combat Casualty Care 09 SEP 02

46. Shock Management • Shock is a state of inadequate organ perfusion • Diagnosed by noting end-organ dysfunction • Altered mental status • Poor peripheral perfusion • Anxiety Tactical Combat Casualty Care 09 SEP 02

47. Shock Management • Therapeutic goals • Increase oxygenation of blood • Increased trans-alveolar oxygen • Increased hemoglobin concentration • Increase cardiac output • Increased preload • Increased stroke volume Tactical Combat Casualty Care 09 SEP 02

48. 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 Tactical Combat Casualty Care 09 SEP 02

49. 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 Tactical Combat Casualty Care 09 SEP 02

50. Controlled Hemorrhage: With Shock • Administer IV fluids in boluses to correct end-organ dysfunction • 0.9% (normal) or 3% saline solutions • Lactated Ringer’s solution • 6% hetastarch [Hespan®] • DO NOT use normal vital signs as endpoints for fluid resuscitation • Increased blood pressure • Hemoglobin, platelets, and clotting factors Tactical Combat Casualty Care 09 SEP 02