1. PERFORMING TACTICAL COMBAT CASUALTY CARE

2. Tactical Combat Casualty Care
1. BAD TACTICS CAN GET EVERYONE KILLED.
2. BAD TACTICS CAN CAUSE THE MISSION TO FAIL.

3. Timing is Everything The Right Things To Do AND
The Right Time to Do Them

5. Introduction
About 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 pneumothorax
Restore 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 Lifesaver
Functioning 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 problems
Delays to definitive care
Command decisions

12. Tactical Combat Casualty Care
3 Distinct Phases
Care Under Fire
Tactical Field Care
Combat Casualty Evacuation Care

13. The three goals of Tactical Combat Casualty Care (TCCC) are:
1. Save preventable deaths
2. Prevent additional casualties
3. 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 care
A medically correct intervention performed at the wrong time in combat may lead to further casualties

15. Care Under Fire
Care rendered by the medic or first responder at the scene of the injury while still under effective hostile fire
Very limited as to the care you can provide

16. Tactical Field Care
Care rendered once you are no longer under effective hostile fire
You 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 evacuation
Additional medical personnel and equipment may have been pre-staged and available at this stage of casualty management

18. Care Under Fire

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 Toohey
Commanding Officer
SEAL 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 superiority
Attention to suppression of hostile fire will minimize the risk of additional injuries or casualties

21. Care Under Fire
If the casualty can function, direct him to return fire, move to cover, and administer self-aid
If 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 leader
Use cover/concealment such as smoke

22. Care Under Fire
Improved First Aid Kit
No attention to the airway at this point because of the need to move casualty to cover quickly
If the casualty has severe bleeding from a limb or has an amputation, apply a tourniquet

23. Care Under Fire
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

24. OIF Fatality Marine shot in leg in Iraq
Pulsatile femoral artery bleeding
Corpsman arrived 10 minutes later
Attempted to use hemostatic material - failed
IV attempted - failed
Tourniquet finally applied
Casualty died

25. Combat Application Tourniquet (CAT)
WINDLASS
OMNI TAPE BAND
WINDLASS STRAP

26. Tourniquets

27. Care Under Fire Reassure the casualty
If unresponsive, move the casualty and his mission-essential equipment to cover as the tactical situation permits

28. Tactical Field Care

29. Tactical Field Care
Perform 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 Care
If a victim of a blast or penetrating injury is found without a pulse, respirations, or other signs of life, DO NOT attempt CPR
CPR performers may get killed
Mission gets delayed
Casualty stays dead…

31. Tactical Field Care
Casualties with confused mental status should be disarmed immediately of both weapons and grenades.

32. Determine Level of Consciousness
AVPU system
A 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 maneuver
If unconscious and spontaneously breathing, insert a nasopharyngeal airway
Place the casualty in the recovery position

35. Nasopharyngeal Airway

36. A survivable airway problem

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 dressing
Also may use an “Asherman Chest Seal”
Place the casualty in the sitting position if possible.

38. "Asherman Chest Seal"

40. Tactical Field Care: Breathing
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, etc.
Needle chest decompression is life-saving

41. Needle Chest Decompression

42. Tactical Field Care: Circulation
Any bleeding site not previously controlled should now be addressed
Only 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 extremity
Apply an emergency trauma bandage and direct pressure to a severely bleeding wound
If 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 minutes
If 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 dressing
Apply a battle dressing/bandage to secure hemostatic dressing in place
Hemostatic 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 starting
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

48. Reasons NOT to Start IVs on All Combat Casualties
Minimize interference with combatants who can continue to participate in the engagement
Conserve limited IV fluid supplies
Attend to casualties with more severe wounds
Avoid delaying tactical movement - waiting 5 minutes to start an IV may get 5 members of your team killed

49. Saline Lock

50. Tactical Field Care: Additional injuries
Splint fractures as circumstances allow while verifying pulse and prepare for evacuation

51. Warning!
Do not take aspirin, ibuprofen (Motrin) or related medications while in theater
Interfere with blood clotting
Increase risk of fatal hemorrhage if wounded

52. 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

53. Combat Casualty Evacuation Care

54. Casevac Care If the casualty requires evacuation, prepare the casualty
Use a blanket to keep the casualty warm
If the casualty is to be evacuated by medical transport, you may need to prepare and transmit a MEDEVAC request

55. Preservation of Amputation Parts
Rinse amputated part free of debris
Wrap loosely in saline-moistened sterile gauze
Seal amputated part in a plastic bag or cravat
Place in a cool container, do not freeze
Never place amputated part in water
Never place amputated part directly on ice
Never use dry ice to cool an amputated part

56. Casevac Care
Use a SKED litter or improvised litter if the casualty must be moved to a casualty collection point
If transported by a non-medical vehicle (CASEVAC), you may need to arrange the vehicle to accommodate the casualty
If an unconscious casualty is transported on a non-medical vehicle, you may need to accompany the casualty and render additional care as needed
Restock your aid bag when possible

58. Summary There are three categories of casualties on the battlefield:
1. Soldiers who will live regardless
2. Soldiers who will die regardless
3. Soldiers who will die from preventable deaths unless proper life-saving steps are taken immediately (7-15%)

59. What Happened
This 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 Him
Sustained direct pressure
over the bleeding site
HemCon dressing
Faster evacuation

60. What Happened
This 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 Him
Faster evacuation
Packed Red Blood Cells on
the helicopter (as recommended
by TCCC guidelines)

61. What Happened
This 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 Him
C.A.T. Tourniquet
Better training for all unit members
(Medic killed at onset of action)

62. What Happened
This 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 Him
Sustained direct pressure on the wound or
Pressure on the femoral artery at the pressure point or
HemCon dressing and
Faster evacuation

63. 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