Tactical Combat Casualty Care Charles W. Beadling, MD, FAAFP, IDHA, DMCC Center for Disaster and Humanitarian Assistance Medicine Department of Military and Emergency Medicine Uniformed Services University PART II

Tactical Field Care

Care rendered by the Medic once he and the casualty are no longer under effective hostile fire. Applies to situations in which an injury has occurred, but there has been no hostile fire. Available medical equipment still limited to that carried into the field by medical personnel. Time to evacuation to a MTF may vary considerably.

Tactical Field Care Casualty Assessment Airway – Adjuncts – Definitive Control Chest Wounds Continued Hemorrhage Control – Hemostatic Agents, Pressure Dressings – Fluid resuscitation Hypothermia, Infection

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 Casualties with confused mental status should be disarmed immediately of both weapons and grenades

Tactical Field Care Initiate Shock Prevention Protocols Pain Control Antibiotics Splint Fractures Prevent Hypothermia Prepare Casualty for Evacuation Documentation

Airway Adjuncts and Control Recovery Position NPA Cric

Nasopharyngeal Airway

Why No Endotracheal Intubation DEBATABLE No studies on well trained medics Most medics have never used live tissue Standard ETT uses white light Extremely difficult with bloody maxillo-facial wounds Esophogeal intubations much less identifiable in the field

Tension Pneumothorax

Breathing Tension Pneumothorax – Respiratory distress – Decreased breath sounds – Hyperresonance – Tracheal deviation – JVD

Needle Thorocostomy 1996 – Presumptive Dx and Tx – Unilateral penetrating chest trauma & progressive respiratory distress 2003 & 2006 – modified slightly – Now includes blunt torso trauma & respiratorydistress even if it is not progressive

Needle Thoracentesis Emergently decompress affected hemithorax with 14- gauge needle inserted over 3 rd rib in 2 nd inter-costal space at mid-clavicular line

SubCommitee on Hemostatic Agents (CoTCCC Feb, ’09) By 26/1 vote WountStat is no longer recommended in TCCC guidelines

Combat Gauze

Emergency Bandage (Israeli Pressure Dressing)

Emergency Bandage

Fluid Resuscitation Protocol No Radial Pulse or Poor Mentation Gain Access (saline lock) - 18Ga Intraosseos Hemorrhage Controlled

What Fluid? Bolus 500cc Hextend ® – Re-assess after 30 min – 500cc Hextend ® Bolus – No more than 1L Hextend ® Crystalloid – Normal Saline, Ringer’s Lactate Blood PO Fluids?

Blood Products PRBC on CASEVAC (if feasible) 1:1 FFP

Reasons NOT to start an IV Takes time Potential waste of fluids

Combat Pill Pack Tylenol 650mg x 2 Mobic (meloxicam) 15mg Moxifloxacin 400mg

Provider Adjuncts Fentanyl (Oral Transmucosal Fentanyl Citrate) 800 mg taped to finger Morphine 10 mg IV/IM Promethazine 25mg IV/IM Cefotetan 2gm IV/IM or Ertapenem 1gm IV/IM

Improved First Aid Kit Tourniquet Nasopharyngeal Airway Gloves Israeli Battle Dressing Gauze Tape 14ga Angiocath 14ga Angiocath

IFAK

Combat Casualty Evacuation Care

Care rendered during transport to higher level care. First opportunity for additional medical resources (if pre-staged and available during this phase of operation).

31 Evacuation Terminology Both types of evacuation are included in the new term “Tactical Evacuation” CASEVAC MEDEVAC

MEDEVAC = transporting casualties via vehicles SPECIFICALLY CONFIGURED, EQUIPPED, AND STAFFED to provide medical care CASEVAC = moving casualties via NON- MEDICAL assets Combat Casualty Evacuation Care

Hypothermia Prevention Lethal Triad: – Hypothermia – Acidosis – Coagulopathy Hypothermia Prevention Kit – Blizzard ® Wrap – Readi-Heat ® Blanket – Thermo-lite

Stokes, SKED, Talon II Litters

Future Issues Recombinant factor VIIa Fresh Frozen Plasma Fresh whole blood Ketamine

Summary Addressing Leading Causes of Preventable Deaths may Reduce KIA rate by 15% – #1: Extremity Hemorrhage – #2: Tension Pneumothorax – #3: Airway Occlusion Cannot Rely on Traditional Measures to Assess Casualty Status – Monitors/BP cuff/stethoscope – Tools

Summary Hemorrhage Control Techniques – Tourniquet – Pressure Dressing – Combat Gauze Recognize Tension Pneumothorax in Tactical Environment – Penetrating/blunt Chest Wound – Respiratory Distress

Summary CASEVAC First Opportunity for Additional Assets – Oxygen – Blood – Special Equipment – Monitors – Additional Providers Only available if you were in on the Planning and fought for the space

Summary Tactical Casualty Care Requires Aggressive, Full-Contact Measures MUST Know Equipment Capabilities and Limitations Adapt to Environment AND situation

Conclusion “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

Questions?