Tactical Combat Casualty Care

1. Tactical Combat Casualty Care 29 JUN 05 Tactical Combat Casualty Care Dan S. Mosely, MD MAJ, USA, MC, FS General Goals: � This presentation takes 100 minutes to present, if delivered all at once. If it is divided, it should be split just before the �CASEVAC Care� section. The first part takes 60 minutes to deliver. The second part takes 40 to deliver.General Goals: � This presentation takes 100 minutes to present, if delivered all at once. If it is divided, it should be split just before the �CASEVAC Care� section. The first part takes 60 minutes to deliver. The second part takes 40 to deliver.

2. Tactical Combat Casualty Care 29 JUN 05 Agenda Objectives Mortality in Combat Preventable mortality Care under fire Tactical Casualty care Evacuation Military vs. Civilian tactical care

3. Tactical Combat Casualty Care 29 JUN 05 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

4. Tactical Combat Casualty Care 29 JUN 05 Caveats When Applying Civilian Literature Different weapons Less pre-existing dehydration Pre-hospital time Surgical intervention Resource Monitoring Threat

5. Tactical Combat Casualty Care 29 JUN 05 Combat Mortality

6. Tactical Combat Casualty Care 29 JUN 05 Combat Mortality Killed in Action(86% KIA) versus Died of Wounds(12% DOW) This picture shows the effects of even a small rocket-propelled grenade (RPG) on the human body. [Figure 1-41 from the Textbook of Military Medicine, Pt I, Vol 5, p 30]This picture shows the effects of even a small rocket-propelled grenade (RPG) on the human body. [Figure 1-41 from the Textbook of Military Medicine, Pt I, Vol 5, p 30]

7. Tactical Combat Casualty Care 29 JUN 05 Combat Mortality KIA 31% are due to penetrating head trauma This picture demonstrates that the stress waves created by a high-velocity round can cause a hydraulic burst effect on the closed cranium. The explosion of the skull occurs at its weakest points, not necessarily at the point of bullet exit. [Figure 4-34 from the Textbook of Military Medicine, Pt I, Vol 5, p 145]This picture demonstrates that the stress waves created by a high-velocity round can cause a hydraulic burst effect on the closed cranium. The explosion of the skull occurs at its weakest points, not necessarily at the point of bullet exit. [Figure 4-34 from the Textbook of Military Medicine, Pt I, Vol 5, p 145]

8. Tactical Combat Casualty Care 29 JUN 05 Combat Mortality KIA 25% are due to surgically uncorrectable penetrating torso trauma This picture shows multiple exit wounds caused by several 7.62-mm bullets to the back. Note that one is in the region of the heart. [Figure 1-12 from the Textbook of Military Medicine, Pt I, Vol 5, p 11]This picture shows multiple exit wounds caused by several 7.62-mm bullets to the back. Note that one is in the region of the heart. [Figure 1-12 from the Textbook of Military Medicine, Pt I, Vol 5, p 11]

9. Tactical Combat Casualty Care 29 JUN 05 Combat Mortality KIA 10% are due to potentially correctable penetrating torso trauma The large entrance wound in this picture is most likely due to the 5.56-mm bullet striking the casualty�s web gear causing yaw or fragmentation before entering the skin. [Figure 4-20 from the Textbook of Military Medicine, Pt I, Vol 5, p 128]The large entrance wound in this picture is most likely due to the 5.56-mm bullet striking the casualty�s web gear causing yaw or fragmentation before entering the skin. [Figure 4-20 from the Textbook of Military Medicine, Pt I, Vol 5, p 128]

10. Tactical Combat Casualty Care 29 JUN 05 Combat Mortality KIA 9% are due to potentially correctable extremity trauma This picture shows a large exit wound in the distal medial thigh due to fragmentation of the 5.56-mm bullet after striking the femur. For orientation, the casualty�s scrotum can be seen on the right side and his left knee at the bottom. [Figure 4-44 from the Textbook of Military Medicine, Pt I, Vol 5, p 152]This picture shows a large exit wound in the distal medial thigh due to fragmentation of the 5.56-mm bullet after striking the femur. For orientation, the casualty�s scrotum can be seen on the right side and his left knee at the bottom. [Figure 4-44 from the Textbook of Military Medicine, Pt I, Vol 5, p 152]

11. Tactical Combat Casualty Care 29 JUN 05 Combat Mortality KIA 7% are due to mutilating blast injuries This picture shows the effects of larger pieces of shrapnel from high-explosive artillery or mortar random-fragment munitions. [Figure 1-23 from the Textbook of Military Medicine, Pt I, Vol 5, p 18]This picture shows the effects of larger pieces of shrapnel from high-explosive artillery or mortar random-fragment munitions. [Figure 1-23 from the Textbook of Military Medicine, Pt I, Vol 5, p 18]

12. Tactical Combat Casualty Care 29 JUN 05 Combat Mortality KIA 5% are due to tension pneumothorax This picture shows eight 7.62-mm bullet holes in the left posterolateral thoraco-abdominal area. For orientation, the casualty�s axilla can be seen in the left lower corner. [Figure 1-12 from the Textbook of Military Medicine, Pt I, Vol 5, p 11]This picture shows eight 7.62-mm bullet holes in the left posterolateral thoraco-abdominal area. For orientation, the casualty�s axilla can be seen in the left lower corner. [Figure 1-12 from the Textbook of Military Medicine, Pt I, Vol 5, p 11]

13. Tactical Combat Casualty Care 29 JUN 05 Combat Mortality KIA 1% are due to airway obstruction (1/2 actual airway) (1/2 decreased LOC)

14. Tactical Combat Casualty Care 29 JUN 05 Combat Mortality DOW 12% are mostly due to complicationsof shock orlate infection The top picture shows a casualty hit by a piece of shrapnel from a 105-mm shell that injured his T2 vertebra, left lung, left subclavian artery, and likely gave him a pneumothorax and massive hemothorax. He died within 3 hours of wounding. [Figure 4-15 from the Textbook of Military Medicine, Pt I, Vol 5, p 125] The bottom picture shows a casualty who made it to surgery for a repair of his Axillary artery after a GSW to the left shoulder. However, gas gangrene set in within 8 hours of wounding. A forequarter amputation was performed, but the casualty died 22 hours after this second surgery. Note the edema and bronze discoloration of the skin over the areas of the clostridial myonecrosis. [Figure 5-33 from the Textbook of Military Medicine, Pt I, Vol 5, p 212]The top picture shows a casualty hit by a piece of shrapnel from a 105-mm shell that injured his T2 vertebra, left lung, left subclavian artery, and likely gave him a pneumothorax and massive hemothorax. He died within 3 hours of wounding. [Figure 4-15 from the Textbook of Military Medicine, Pt I, Vol 5, p 125] The bottom picture shows a casualty who made it to surgery for a repair of his Axillary artery after a GSW to the left shoulder. However, gas gangrene set in within 8 hours of wounding. A forequarter amputation was performed, but the casualty died 22 hours after this second surgery. Note the edema and bronze discoloration of the skin over the areas of the clostridial myonecrosis. [Figure 5-33 from the Textbook of Military Medicine, Pt I, Vol 5, p 212]

15. Tactical Combat Casualty Care 29 JUN 05 Serious Wounds in Vietnam Surviving to Facility

16. Tactical Combat Casualty Care 29 JUN 05 PREVENTABLE Mortality Vietnam Airway obstruction (6%) Tension pneumothorax (33%) Hemorrhage from extremity wounds (60%)

17. Tactical Combat Casualty Care 29 JUN 05

18. Tactical Combat Casualty Care 29 JUN 05

19. Tactical Combat Casualty Care 29 JUN 05

20. Tactical Combat Casualty Care 29 JUN 05

21. Tactical Combat Casualty Care 29 JUN 05 Tactical Combat Casualty Care Care Under Fire Tactical Field Care Evacuation Care This is a list of different situations. I don�t like to call them phases, because that implies a time-order or sequence to me. What are the characteristics that define each of these situations?This is a list of different situations. I don�t like to call them phases, because that implies a time-order or sequence to me. What are the characteristics that define each of these situations?

22. Tactical Combat Casualty Care 29 JUN 05 Care Under Fire Care rendered while subjected to effective hostile fire Initial wounds Additional wounds Medical equipment limited Carried by casualty or medical personnel Difficult to use equipment in situation

23. Tactical Combat Casualty Care 29 JUN 05 Tactical Field Care Care rendered when not subjected to effective hostile fire Warm zone Available medical equipment limited Individuals Team or unit Time prior to evacuation is highly variable

24. Tactical Combat Casualty Care 29 JUN 05 Evacuation Care Care rendered during transportation out of tactical environment Aircraft Ground vehicle Watercraft Pre-staged personnel and medical equipment available on platform Evacuation terminology MEDEVAC CASEVAC

25. Tactical Combat Casualty Care 29 JUN 05 Care Under Fire

26. Tactical Combat Casualty Care 29 JUN 05 Return fire Return fire Return fire Care Under Fire

27. Tactical Combat Casualty Care 29 JUN 05 Return fire What does returning fire have to do with medical care? Care Under Fire

28. Tactical Combat Casualty Care 29 JUN 05 Return fire What does returning fire have to do with medical care? Victory is the best medicine !! Care Under Fire

29. Tactical Combat Casualty Care 29 JUN 05 Move the casualty to cover Don�t get shot while trying to do #1 Care Under Fire

30. Tactical Combat Casualty Care 29 JUN 05 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 Care Under Fire

31. Tactical Combat Casualty Care 29 JUN 05 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? Care Under Fire

32. Tactical Combat Casualty Care 29 JUN 05 Hemorrhage Control Dressing Pressure dressing Tourniquet

33. Tactical Combat Casualty Care 29 JUN 05 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 Tourniquets

34. Tactical Combat Casualty Care 29 JUN 05 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 Tourniquets

35. Tactical Combat Casualty Care 29 JUN 05 Return fire Don�t be a hero Find cover for yourself and your casualty Stop any life-threatening external hemorrhage Care Under Fire

37. Tactical Combat Casualty Care 29 JUN 05 Tactical Field Care

38. Tactical Combat Casualty Care 29 JUN 05 Reduced risk/warm zone Cover/Concealment Variable amount of time available Mission Casualty evacuation Field conditions Temperature and weather Darkness Non-sterile environment Tactical Field Care

39. Tactical Combat Casualty Care 29 JUN 05 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 External Hemorrhage

40. Tactical Combat Casualty Care 29 JUN 05 No attempt at airway intervention if the casualty is conscious and breathing well on his or her own Airway Management:Conscious Casualty

41. Tactical Combat Casualty Care 29 JUN 05 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 Airway Management:Altered Mental Status

42. Tactical Combat Casualty Care 29 JUN 05 Liquid removal options Gravity Suction Definitive airway options Endotracheal intubation Cricothyroidostomy Airway Management:Obstruction

43. Tactical Combat Casualty Care 29 JUN 05 Breathing Tension Pneumothorax Decreased breath sounds Tracheal deviation Percussion JVD

44. Tactical Combat Casualty Care 29 JUN 05 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. Hemopneumothorax missed by auscultation in penetrating chest injury. Journal of Trauma-Injury Infection & Critical Care. 42(1):86-9, 1997 Jan

45. Tactical Combat Casualty Care 29 JUN 05 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. Hemopneumothorax missed by auscultation in penetrating chest injury. Journal of Trauma-Injury Infection & Critical Care. 42(1):86-9, 1997 Jan

46. Tactical Combat Casualty Care 29 JUN 05 Auscultation

47. Tactical Combat Casualty Care 29 JUN 05 Auscultation with Stab Wounds

48. Tactical Combat Casualty Care 29 JUN 05 Auscultation with GSW Wounds

49. Tactical Combat Casualty Care 29 JUN 05 Tension Pneumothorax Deceased preload Increased afterload Mechanical pressure on heart Decreased Alveolar surface Pleural space agitation

50. Tactical Combat Casualty Care 29 JUN 05 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 Needle Thoracentesis

51. Tactical Combat Casualty Care 29 JUN 05 Emergently decompress affected hemithorax with 14-gauge needle inserted over 3rd rib in 2nd inter-costal space at mid-clavicular line Needle Thoracentesis

52. Tactical Combat Casualty Care 29 JUN 05 Contraindicated for life-threatening tension pneumothorax Difficult to perform Infection risk higher when inserting tube in non-sterile conditions Prior to Evacuation? Tube Thoracostomy

53. Tactical Combat Casualty Care 29 JUN 05 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 Open Pneumothorax

54. Tactical Combat Casualty Care 29 JUN 05 Controversial the tactical environment Cylinders of compressed gas heavy and risky for tactical operations Transportation of casualty difficult without vehicle Supplemental Oxygen

55. Tactical Combat Casualty Care 29 JUN 05 Shock Management Shock is a state of inadequate organ perfusion Diagnosed by noting end-organ dysfunction Altered mental status Poor peripheral perfusion Anxiety

56. Tactical Combat Casualty Care 29 JUN 05 Shock Management Therapeutic goals Increase oxygenation of blood Increased trans-alveolar oxygen Increased hemoglobin concentration Increase cardiac output Increased preload Increased stroke volume What can be done in the field? Can only address oxygenation by: Preventing further decreases Airway problems Pneumothorax (open or tension) Cannot improve and can possible worsen hemoglobin concentration Can only address preload by: Preventing further decrease Tension pneumothorax Hemorrhage Increasing Fluids (IV or PO) Positioning? Should not directly augment rate or contractility with medicationsWhat can be done in the field? Can only address oxygenation by: Preventing further decreases Airway problems Pneumothorax (open or tension) Cannot improve and can possible worsen hemoglobin concentration Can only address preload by: Preventing further decrease Tension pneumothorax Hemorrhage Increasing Fluids (IV or PO) Positioning? Should not directly augment rate or contractility with medications

57. Tactical Combat Casualty Care 29 JUN 05 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 Intravenous Access

58. Tactical Combat Casualty Care 29 JUN 05 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

59. Tactical Combat Casualty Care 29 JUN 05 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 Don�t forget maintenance if NPO. LR 250 mL/hr has been recommended.Don�t forget maintenance if NPO. LR 250 mL/hr has been recommended.

60. Tactical Combat Casualty Care 29 JUN 05 Uncontrolled Hemorrhage: With or Without Shock NO immediate fluid resuscitation Spend time controlling exsanguination External Internal Save IV fluids Permissive hypotension

61. Tactical Combat Casualty Care 29 JUN 05 Only in cases of nontraumatic cardiac arrest should CPR be considered prior to Evacuation Electrocution Hypothermia Near-drowning Cardiopulmonary Resuscitation

62. Tactical Combat Casualty Care 29 JUN 05 Minimize further contamination Promote hemostasis Check for additional wounds Exit sites may be remote from entry Some sites are easily overlooked Splint fractures and recheck distal pulses Analgesic medications Antibiotic medications Additional Considerations

63. Are there questions about the concept of TCCC or the phases?Are there questions about the concept of TCCC or the phases?

64. Tactical Combat Casualty Care 29 JUN 05 Evacuation

65. Tactical Combat Casualty Care 29 JUN 05 CASEVAC Casualty evacuation from the battlefield MEDEVAC Medical evacuation of casualties CASEVAC versus MEDEVAC

66. Tactical Combat Casualty Care 29 JUN 05 Medical personnel may accompany evacuating asset No reliance on field personnel providing care Medical personnel operating in tactical vehicle Additional medical equipment may be available on evacuation platform Variable CASEVAC Care

67. Tactical Combat Casualty Care 29 JUN 05 CASEVAC Care Primary focus is clearing casualties off the battlefield and not medical care enroute Adaptability is key Maximize your mission within the CASEVAC mission

68. Tactical Combat Casualty Care 29 JUN 05 CASEVAC Care Tactical aircraft/vehicles have restrictions against white light Laryngoscopes Blood identification Wound identification Black out sheets

69. Tactical Combat Casualty Care 29 JUN 05 MEDEVAC Care Medical personnel part of asset Medical personnel operating vehicle designed for them Additional medical equipment available on evacuation platform Oxygen Suction Monitoring Positioning

70. Tactical Combat Casualty Care 29 JUN 05 MEDEVAC Care Difficult to get far-forward No part of assault planning Communications

71. Tactical Combat Casualty Care 29 JUN 05 MEDEVAC Care FLA UH-60Q Combat medic Augmentation CCATT Strategic MEDEVAC