5 IntroductionAbout 90 percent of combat deaths occur on the battlefield before the casualties reach a medical treatment facility (MTF). Most of these deaths cannot be prevented by you or the medic. Examples: Massive head injury, massive trauma to the body.
8 Stop severe bleeding (hemorrhaging) Relieve tension pneumothorax About 15 percent of the casualties that die before reaching a medical treatment facility can be saved if proper measures are taken.Stop severe bleeding (hemorrhaging)Relieve tension pneumothoraxRestore the airway
9 In the Vietnam conflict, over 2500 soldiers died due to hemorrhage from wounds to the arms and legs even though the soldiers had no other serious injuries. These soldiers could have been saved by applying pressure dressings and tourniquets to stop the bleeding.
10 Combat LifesaverFunctioning as a Combat Lifesaver is your secondary mission.Your primary mission is still your combat duties.You should render care only when such care does not endanger your primary mission.
11 Tactical Context Incoming fire Darkness Environmental factors Casualty transport problemsDelays to definitive careCommand decisions
12 Tactical Combat Casualty Care 3 Distinct PhasesCare Under FireTactical Field CareCombat Casualty Evacuation Care
13 The three goals of Tactical Combat Casualty Care (TCCC) are: 1. Save preventable deaths2. Prevent additional casualties3. Complete the mission
14 This approach recognizes a particularly important principle: To perform the correct intervention at the correct time in the continuum of combat careA medically correct intervention performed at the wrong time in combat may lead to further casualties
15 Care Under FireCare rendered by the medic or first responder at the scene of the injury while still under effective hostile fireVery limited as to the care you can provide
16 Tactical Field CareCare rendered once you are no longer under effective hostile fireYou and the casualty are safe and you are free to provide casualty care (primary mission is complete)
17 Combat Casualty Evacuation Care Care rendered during casualty evacuationAdditional medical personnel and equipment may have been pre-staged and available at this stage of casualty management
19 The Toohey Amendment“I also expect the casualties to continue to return fire as long as they are able to do so.”CDR Pat TooheyCommanding OfficerSEAL Team Four
20 Care Under Fire“The best medicine on any battlefield is fire superiority”Medical personnel’s firepower may be essential in obtaining tactical fire superiorityAttention to suppression of hostile fire will minimize the risk of additional injuries or casualties
21 Care Under FireIf the casualty can function, direct him to return fire, move to cover, and administer self-aidIf unable to return fire or move to safety and you cannot assist, tell the casualty to “play dead”Communicate the medical situation to the team leaderUse cover/concealment such as smoke
22 Care Under FireImproved First Aid KitNo attention to the airway at this point because of the need to move casualty to cover quicklyIf the casualty has severe bleeding from a limb or has an amputation, apply a tourniquet
23 Care Under FireHemorrhage from extremities is the 1st leading cause of preventable combat deathsPrompt use of tourniquets to stop the bleeding may be life-saving in this phase
24 OIF Fatality Marine shot in leg in Iraq Pulsatile femoral artery bleedingCorpsman arrived 10 minutes laterAttempted to use hemostatic material - failedIV attempted - failedTourniquet finally appliedCasualty died
29 Tactical Field CarePerform tactical field care when you and the casualty are not under direct enemy fire.Recheck bleeding control measures if they were applied while under fire.
30 Tactical Field CareIf a victim of a blast or penetrating injury is found without a pulse, respirations, or other signs of life, DO NOT attempt CPRCPR performers may get killedMission gets delayedCasualty stays dead…
31 Tactical Field CareCasualties with confused mental status should be disarmed immediately of both weapons and grenades.
32 Determine Level of Consciousness AVPU systemA The casualty is alert, knows who he is, the date, where he is, and so forth.V The casualty is not alert, but does respond to verbal commands.P The casualty responds to pain, but not verbal commands.U The casualty is unresponsive (unconscious).Recheck every 15 minutes
33 Tactical Field Care Initial assessment is the ABCs Airway Breathing Circulation
34 Tactical Field Care: Airway Open the airway with a chin-lift or jaw-thrust maneuverIf unconscious and spontaneously breathing, insert a nasopharyngeal airwayPlace the casualty in the recovery position
37 Tactical Field Care: Breathing Traumatic chest wall defects should be closed quickly with an occlusive dressing without regard to venting one side of the dressingAlso may use an “Asherman Chest Seal”Place the casualty in the sitting position if possible.
40 Tactical Field Care: Breathing Progressive respiratory distress in the presence of unilateral penetrating chest trauma should be considered tension pneumothoraxTension pneumothorax is the 2nd leading cause of preventable death on the battlefieldCannot rely on typical signs such as shifting trachea, etc.Needle chest decompression is life-saving
42 Tactical Field Care: Circulation Any bleeding site not previously controlled should now be addressedOnly the absolute minimum of clothing should be removed, although a thorough search for additional injuries must be performed
43 Tactical Field Care: Circulation Apply a tourniquet to a major amputation of the extremityApply an emergency trauma bandage and direct pressure to a severely bleeding woundIf a tourniquet was previously applied, consider changing to a pressure dressing and/or using hemostatic dressings (HemCon) or hemostatic powder (QuikClot) to control any additional hemorrhage
44 Chitosan Hemostatic Dressing Apply directly to bleeding site and hold in place 2 minutesIf dressing is not effective in stopping bleeding after 4 minutes, remove original and apply a new dressing
45 Chitosan Hemostatic Dressing Additional dressings cannot be applied over ineffective dressingApply a battle dressing/bandage to secure hemostatic dressing in placeHemostatic dressings should only be removed by responsible persons after evacuation to the next level of care
46 Tactical Field Care: Shock Hypovolemic shock results when there is a sudden decrease in the amount of fluid in the casualty’s circulatory system.Heat stroke, diarrhea, and dysentery can also cause hypovolemic shock.The casualty may also have internal bleeding, such as bleeding into the abdominal or chest cavities.
47 Tactical Field Care: IV fluids FIRST, STOP THE BLEEDING!IV access should be obtained using a single 18-gauge catheter because of the ease of startingA saline lock may be used to control IV access in absence of IV fluidsEnsure IV is not started distal to a significant wound
48 Reasons NOT to Start IVs on All Combat Casualties Minimize interference with combatants who can continue to participate in the engagementConserve limited IV fluid suppliesAttend to casualties with more severe woundsAvoid delaying tactical movement - waiting 5 minutes to start an IV may get 5 members of your team killed
52 Warning!Do not take aspirin, ibuprofen (Motrin) or related medications while in theaterInterfere with blood clottingIncrease risk of fatal hemorrhage if wounded
53 Tactical Field Care:Communicate: Let your unit leader know the casualty’s condition: Will casualty return to duty? Does the casualty require medical evac to save life or limb? Non-medical evac?Initiate a Field Medical Card (DD Form 1380)Monitor the casualty: Airway, breathing, bleeding, and IV infusion
55 Casevac Care If the casualty requires evacuation, prepare the casualty Use a blanket to keep the casualty warmIf the casualty is to be evacuated by medical transport, you may need to prepare and transmit a MEDEVAC request
56 Preservation of Amputation Parts Rinse amputated part free of debrisWrap loosely in saline-moistened sterile gauzeSeal amputated part in a plastic bag or cravatPlace in a cool container, do not freezeNever place amputated part in waterNever place amputated part directly on iceNever use dry ice to cool an amputated part
57 Casevac CareUse a SKED litter or improvised litter if the casualty must be moved to a casualty collection pointIf transported by a non-medical vehicle (CASEVAC), you may need to arrange the vehicle to accommodate the casualtyIf an unconscious casualty is transported on a non-medical vehicle, you may need to accompany the casualty and render additional care as neededRestock your aid bag when possible
59 Summary There are three categories of casualties on the battlefield: 1. Soldiers who will live regardless2. Soldiers who will die regardless3. Soldiers who will die from preventable deaths unless proper life-saving steps are taken immediately (7-15%)
60 What HappenedThis individual was wounded by an IED (improvised explosive device). He sustained a penetrating shrapnel injury to the neck with laceration of his right common carotid artery from which he bled to death.What Might Have Saved HimSustained direct pressureover the bleeding siteHemCon dressingFaster evacuation
61 What HappenedThis individual sustained a GSW after a helicopter crash. He was wounded in the abdomen below his body armor. He was reported to have lived for almost five hours after wounding, indicating a relatively slow rate of bleeding. The injury was determined to have been readily amenable to surgical repair.What Might Have Saved HimFaster evacuationPacked Red Blood Cells onthe helicopter (as recommendedby TCCC guidelines)
62 What HappenedThis casualty was wounded by an RPG explosion and sustained a traumatic amputation of the right forearm at the mid-forearm level and a right thigh wound with femoral bleeding. He bled to death from the thigh wound despite the placement of three field-expedient tourniquets. The treating first responder clearly had the right idea, but lacked an adequate tourniquet and was unable to improvise an effective one in time.What Could Have saved HimC.A.T. TourniquetBetter training for all unit members(Medic killed at onset of action)
63 What HappenedThis casualty sustained a gunshot wound to his upper thigh at an anatomic location too high for effective use of a tourniquet.What Could Have Saved HimSustained direct pressure on the wound orPressure on the femoral artery at the pressure point orHemCon dressing andFaster evacuation
64 TCCC in IRAQThe adoption and implementation of the principles of TCCC by the medical platoon of TF 1-15 IN in OIF 1 resulted in overwhelming success. Over 25 days of continuous combat with 32 friendly casualties, many of them serious, we had 0 KIAs and 0 Died From Wounds, while simultaneously caring for a significant number of Iraqi civilian and military casualties.
65 TCCC in IRAQ (cont)This success should serve as a model for other conventional combat units throughout the army involved in Level 1 treatment.The principles of TCCC are well-researched and proven effective and should be the foundation of the treatment of battlefield casualties.CPT Michael TarpeyBattalion Surgeon 1-15 IN20 January 2005
66 Summary“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