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

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Presentation on theme: "Tactical Combat Casualty Care 09 SEP 02 Tactical Combat Casualty Care Troy R Johnson, MD MAJ, USA, MC, FS."— Presentation transcript:

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

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

3 Tactical Combat Casualty Care 09 SEP 02 Discussion Objectives 1.Identify the top two causes of preventable combat mortality 2.List three methods of controlling hemorrhage in the field 3.Write both two-condition criteria for diagnosis of tension pneumothorax 4.Outline additional equipment and skills available with evacuation assets 5.Compare and contrast civilian and military tactical medical care

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

5 Tactical Combat Casualty Care 09 SEP 02 Combat Mortality

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

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

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

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

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

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

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

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

14 Tactical Combat Casualty Care 09 SEP 02 Combat Mortality DOW 12% are mostly due to complications of shock or late infection

15 Tactical Combat Casualty Care 09 SEP 02 Serious Wounds in Vietnam Surviving to Facility Face Eyes 5% Neck Cervical Spine 1% Thorax Thoracic Spine 5% Abdomen Lumbar Spine Pelvis 8% Head 4% Extremities bony & neural 28% Soft Tissues 44% Multiple sites with major injuries 5%

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

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

18 Tactical Combat Casualty Care 09 SEP 02 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

19 Tactical Combat Casualty Care 09 SEP 02 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

20 Tactical Combat Casualty Care 09 SEP 02 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

21 Tactical Combat Casualty Care 09 SEP 02 Care Under Fire

22 Tactical Combat Casualty Care 09 SEP 02  Return fire Care Under Fire

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

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

25 Tactical Combat Casualty Care 09 SEP 02 1.Move the casualty to cover 2.Don’t get shot while trying to do #1 Care Under Fire

26 Tactical Combat Casualty Care 09 SEP 02  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

27 Tactical Combat Casualty Care 09 SEP 02  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

28 Tactical Combat Casualty Care 09 SEP 02 Hemorrhage Control  Dressing  Pressure dressing  Tourniquet

29 Tactical Combat Casualty Care 09 SEP 02  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

30 Tactical Combat Casualty Care 09 SEP 02  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

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

32 Questions?

33 Tactical Combat Casualty Care 09 SEP 02 Tactical Field Care

34 Tactical Combat Casualty Care 09 SEP 02  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

35 Tactical Combat Casualty Care 09 SEP 02  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

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

37 Tactical Combat Casualty Care 09 SEP 02  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

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

39 Tactical Combat Casualty Care 09 SEP 02 Breathing  Tension Pneumothorax  Auscultation  Tracheal deviation  Percussion  JVD

40 Tactical Combat Casualty Care 09 SEP 02 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

41 Tactical Combat Casualty Care 09 SEP 02 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

42 Tactical Combat Casualty Care 09 SEP 02 Auscultation

43 Tactical Combat Casualty Care 09 SEP 02 Auscultation with Stab Wounds

44 Tactical Combat Casualty Care 09 SEP 02 Auscultation with GSW Wounds

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

46 Tactical Combat Casualty Care 09 SEP 02  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

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

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

49 Tactical Combat Casualty Care 09 SEP 02  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

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

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

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

53 Tactical Combat Casualty Care 09 SEP 02  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

54 Tactical Combat Casualty Care 09 SEP 02 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

55 Tactical Combat Casualty Care 09 SEP 02 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

56 Tactical Combat Casualty Care 09 SEP 02 Uncontrolled Hemorrhage: With or Without Shock  NO immediate fluid resuscitation  Spend time controlling exsanguination  External  Internal  Save IV fluids  Permissive hypotension

57 Tactical Combat Casualty Care 09 SEP 02 Only in cases of nontraumatic cardiac arrest should CPR be considered prior to Evacuation  Electrocution  Hypothermia  Near-drowning Cardiopulmonary Resuscitation

58 Tactical Combat Casualty Care 09 SEP 02  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

59 Questions?

60 Tactical Combat Casualty Care 09 SEP 02 Evacuation

61 Tactical Combat Casualty Care 09 SEP 02  CASEVAC  Casualty evacuation from the battlefield  MEDEVAC  Medical evacuation of casualties CASEVAC versus MEDEVAC

62 Tactical Combat Casualty Care 09 SEP 02  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

63 Tactical Combat Casualty Care 09 SEP 02 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

64 Tactical Combat Casualty Care 09 SEP 02 CASEVAC Care  Tactical aircraft/vehicles have restrictions against white light  Laryngoscopes  Blood identification  Wound identification  Black out sheets

65 Tactical Combat Casualty Care 09 SEP 02 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

66 Tactical Combat Casualty Care 09 SEP 02 MEDEVAC Care  Difficult to get far-forward  No part of assault planning  Communications

67 Tactical Combat Casualty Care 09 SEP 02 MEDEVAC Care  FLA  UH-60Q  Combat medic  Augmentation  CCATT  Strategic MEDEVAC

68 Questions?

69 Tactical Combat Casualty Care 09 SEP 02 Military vs Civilian Tactical Medical Support

70 Tactical Combat Casualty Care 09 SEP 02 Military vs. Civilian Tactical Medical Support  Lines are purling  Proximity to Tertiary level of care  Additional resources  Acceptance of casualties  Philosophy  Offense vs. defense  Containment vs. destruction

71 Tactical Combat Casualty Care 09 SEP 02 Questions ?


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