1. Tactical Trauma Care Jeffery C. Metzger, M.D.
Tactical Physician, Dallas Police Department
Fellow, Government Emergency Medical Security Services
Assistant Professor, University of Texas, Southwestern Medical Center
Deputy Medical Director, Biotel Systems

2. Objectives Levels of tactical trauma care Zones of Care
Alternatives to “street medicine”

3. Mortality curve penetrating trauma
Instantaneous Death
100%
Breathing
complications
80%
70%
60%
50%
PPE and
good tactics
Shock
Hemorrhage
Airway obstruction
Infections
ALS level skills
Self aid
Buddy aid
EMT-B
Surgery interventions
And Antibiotics
6min hr hr hr hr

4. How People Die in Ground Combat
KIA 31% Penetrating Head Trauma
KIA 25% Surgically Uncorrectable Torso Trauma
KIA 10% Potentially Correctable Surgical Trauma
KIA 9% Exsanguination from Extremity Wounds
KIA 7% Mutilating Blast Trauma
KIA 5% Tension Pneumothorax
KIA 1% Airway Problems
DOW12% (Mostly infections and complications of shock)

5. Causes of Preventable Death
Hemorrhage from extremity wounds (60%)
Tension pneumothorax (33%)
Airway obstruction (6%)
NOTE: ALL of these will kill you long before reaching the hospital if not identified and addressed
Data from Vietnam

6. Serious Wounds in Vietnam Surviving to Facility
Face
Eyes 5%
Head 4%
Neck
Cervical Spine 1%
Thorax
Thoracic Spine 5%
Abdomen
Lumbar Spine
Pelvis 8%
Soft Tissues
44%
Multiple sites with
major injuries 5%
Extremities
bony & neural
28%

7. Tactical Combat Casualty Care
Three goals of TCCC
1. Treat the casualty
2. Prevent additional casualties
3. Complete the mission

8. “Phases” of Tactical Medical Care
Care Under Fire
Tactical Field Care
Evacuation Care
Implies sequential performance, when in fact they may or may not all happen and maybe not in sequence

9. Care Under Fire Step 1 – Don’t get shot Step 2 – Don’t get shot
Step 4 – Return fire (“Victory is the best medicine”

10. Care Under Fire Move casualty to cover (best if done by self) Self aid
Buddy aid
Medic aid

11. Care Under Fire
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

12. Care Under Fire Stop the red stuff from coming out Bandages
Tourniquets
Clotting agents

13. Care Under Fire Tourniquets 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

14. Care Under Fire Hemostatic Agents
Use in civilian tactical environments
Military applications

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

16. Tactical Field Care Airway management Conscious casualty
No attempt at airway intervention if the casualty is conscious and breathing well on his or her own

17. Tactical Field Care Airway Management
Altered Casualty
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

18. Tactical Field Care Liquid removal options Definitive airway options
Gravity
Suction
Definitive airway options
Endotracheal intubation
Cricothyroidotomy

19. Tactical Field Care Breathing Tension Pneumothorax
Decreased breath sounds
Tracheal deviation
Percussion
JVD

20. Tactical Field Care
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

21. Tactical Field Care Tension Pneumothorax Deceased preload
Increased afterload
Mechanical pressure on heart
Decreased Alveolar surface
Pleural space agitation

22. Tactical Field Care Needle Thoracentesis
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

23. Tactical Field Care
Emergently decompress affected hemithorax with 14-gauge needle inserted over 3rd rib in 2nd intercostal space at mid-clavicular line

24. Tactical Field Care Open Pneumothorax (Sucking Chest Wound
Less effective respirations
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

25. Tactical Field Care Supplemental Oxygen
Controversial the tactical environment
Cylinders of compressed gas heavy and risky for tactical operations
Transportation of casualty difficult without vehicle

26. Tactical Field Care 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

27. Tactical Field Care Controlled Hemorrhage without signs of 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

28. Tactical Field Care 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

29. Tactical Field Care Uncontrolled Hemorrhage with shock
NO immediate fluid resuscitation
Spend time controlling exsanguination
External
Internal
Save IV fluids
Permissive hypotension

30. Tactical Field Care CPR
Only in cases of nontraumatic cardiac arrest should CPR be considered prior to Evacuation
Electrocution
Hypothermia
Near-drowning

31. Tactical Field Care 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

32. Evacuation Depends on system you are working in
Generally civilian EMS or tactical medics (issues with tactical medics leaving scene prior to operation completion)

33. Case Review
Disclaimer: This incident is still under investigation and what is presented is my personal observations and understanding of the events as they transpired.

34. Case Review February 16th, 2006
Dallas Police SWAT team was asked by the DEA’s Dallas Division to execute a knock-and-announce search warrant on Alejandro Tamayo at 1228 Oak Park in Dallas

36. Case Review
During the search, law enforcement officers seized approximately $130,000 in U.S. currency, eight firearms and approximately two kilograms of cocaine.

37. Follow-up
A federal indictment released April 7th 2006 charges ringleader Alejandro Tamayo, age 44, with one count of conspiracy to distribute methamphetamine, one count of possession with intent to distribute cocaine, one count of possession of a firearm during and in relation to a drug trafficking crime, one count of possession of a firearm during and in relation to a crime of violence and two counts of assault on a federal officer. If convicted Tamayo faces a minimum of 10 years imprisonment and a maximum of life imprisonment without parole. Tamayo is presumed innocent until proven guilty.

38. Contact Information
Jeffery C. Metzger, M.D.
Mail Code 8890
5323 Harry Hines Blvd.
Dallas TX,
cell (972)