TACTICAL COMBAT TACTICAL COMBAT CASUALTY CASUALTY

CARECARE

RIFLES LIFESAVERSRIFLES LIFESAVERS

IntroductionIntroduction

The three goals of Tactical Combat The three goals of Tactical Combat Casualty Care (TCCC) are:Casualty Care (TCCC) are:

–1. Save 1. Save preventable deathspreventable deaths

–2. Prevent additional casualties2. Prevent additional casualties

–3. Complete the mission3. Complete the mission

IntroductionIntroduction

This approach recognizes a particularly This approach recognizes a particularly important principle:important principle:– To perform the To perform the correct interventioncorrect intervention at the at the

correct timecorrect time in the continuum of combat care in the continuum of combat care– A medically correct intervention performed at A medically correct intervention performed at

the the wrong timewrong time in combat may lead to in combat may lead to further further casualtiescasualties

Combat DeathsCombat Deaths

KIA: 31% Penetrating head traumaKIA: 25% Surgically uncorrectable torso traumaKIA: 10% Potentially surgically correctable traumaKIA: 9% Hemorrhage from extremity woundsKIA: 7% Mutilating blast traumaKIA: 5% Tension pneumothoraxKIA: 1% Airway problemsDOW: 12% Mostly from infections and complications of shock

PREVENTABLEPREVENTABLE CAUSES OF CAUSES OF COMBAT DEATHCOMBAT DEATH

60% Hemorrhage from extremity wounds

33% Tension pneumothorax

6% Airway obstruction, e.g., maxillofacial trauma

Factors influencing combat Factors influencing combat casualty care casualty care

Enemy FireEnemy Fire

Medical Equipment LimitationsMedical Equipment Limitations

Widely Variable Evacuation TimeWidely Variable Evacuation Time

STAGES OF CARE:STAGES OF CARE:3 Distinct Phases3 Distinct Phases

Care Under FireCare Under Fire

Tactical Field CareTactical Field Care

Combat Casualty Evacuation Combat Casualty Evacuation CareCare

Care Under FireCare Under Fire

““Care under fire” is the care rendered Care under fire” is the care rendered by the medic or first responder at the by the medic or first responder at the scene of the injury while still under scene of the injury while still under effective hostile fireeffective hostile fire

Available medical equipment is Available medical equipment is limited to that carried by the medic or limited to that carried by the medic or first responder in his aid bagfirst responder in his aid bag

Tactical Field CareTactical Field Care

““Tactical Field Care” is the care rendered by Tactical Field Care” is the care rendered by the medic once no longer under effective the medic once no longer under effective hostile firehostile fireAlso applies to situations in which an injury Also applies to situations in which an injury has occurred, but there has been no hostile has occurred, but there has been no hostile firefireAvailable medical equipment still limited to Available medical equipment still limited to that carried into the field by medical that carried into the field by medical personnelpersonnelTime to evacuation may vary considerablyTime to evacuation may vary considerably

Combat Casualty Evacuation Combat Casualty Evacuation CareCare

““Combat Casualty Evacuation Care” Combat Casualty Evacuation Care” is the care rendered once the is the care rendered once the casualty has been picked up by casualty has been picked up by evacuation vehiclesevacuation vehiclesAdditional medical personnel and Additional medical personnel and equipment may have been pre-staged equipment may have been pre-staged and available at this stage of casualty and available at this stage of casualty managementmanagement

Care Under FireCare Under Fire

Care Under FireCare Under Fire

““The best medicine on any battlefield The best medicine on any battlefield is fire superiority”is fire superiority”Medical personnel’s firepower may be Medical personnel’s firepower may be essential in obtaining tactical fire essential in obtaining tactical fire superioritysuperiorityAttention to suppression of hostile fire Attention to suppression of hostile fire will minimize the risk of additional will minimize the risk of additional injuries or casualtiesinjuries or casualties

Care Under FireCare Under Fire

Personnel may need to assist in Personnel may need to assist in returning fire instead of stopping to returning fire instead of stopping to care for casualtiescare for casualtiesWounded soldiers who are unable to Wounded soldiers who are unable to fight should lay flat and motionless if fight should lay flat and motionless if no cover is available or move as no cover is available or move as quickly as possible to any nearby quickly as possible to any nearby covercover

Care Under FireCare Under Fire

No attention to airway at this point No attention to airway at this point because of need to move casualty to because of need to move casualty to cover quicklycover quicklyControl of Control of hemorrhagehemorrhage is essential since is essential since injury to a major vessel can result in injury to a major vessel can result in hypovolemic shock in a short time framehypovolemic shock in a short time frameOver 2500 deaths occurred in Viet Nam Over 2500 deaths occurred in Viet Nam secondary to hemorrhage from extremity secondary to hemorrhage from extremity wounds onlywounds only

Care Under FireCare Under Fire

HemorrhageHemorrhage from extremities is the from extremities is the 11stst leading cause of preventable leading cause of preventable combat deathscombat deaths

Prompt use of tourniquets to Prompt use of tourniquets to stop stop the bleedingthe bleeding may be life-saving in may be life-saving in this phasethis phase

TourniquetsTourniquets

Care Under FireCare Under Fire

All soldiers engaged in combat All soldiers engaged in combat missions should have a suitable missions should have a suitable tourniquet readily available at a tourniquet readily available at a standard location on their battle gear standard location on their battle gear and be trained in its useand be trained in its use

Various types of tourniquets existVarious types of tourniquets exist

Combat Application Tourniquet Combat Application Tourniquet (CAT)(CAT)

WINDLASS

OMNI TAPE BANDWINDLASS STRAP

Care Under Fire Care Under Fire

Conventional litters may not be available Conventional litters may not be available for movement of casualtiesfor movement of casualties

Consider alternate methods to move Consider alternate methods to move casualties such as a Talon II littercasualties such as a Talon II litter

Smoke, CS, and vehicles may act as Smoke, CS, and vehicles may act as screens to assist in casualty movementscreens to assist in casualty movement

Tanks have been used successfully as Tanks have been used successfully as screens in OIFscreens in OIF

KEY POINTSKEY POINTS

Return fire as directed or requiredReturn fire as directed or requiredIf able, the casualty(s) should also return fireIf able, the casualty(s) should also return fireTry to keep from being shotTry to keep from being shotTry to keep the casualty from sustaining Try to keep the casualty from sustaining additional woundsadditional woundsAirway management is best deferred until the Airway management is best deferred until the Tactical Field Care phaseTactical Field Care phaseStop any life threatening hemorrhage with a Stop any life threatening hemorrhage with a tourniquettourniquetReassure the casualtyReassure the casualty

Tactical Field CareTactical Field Care

Tactical Field CareTactical Field Care

Reduced level of hazard from hostile Reduced level of hazard from hostile fire or enemy actionfire or enemy action

Increased time to provide careIncreased time to provide care

Available time to render care may Available time to render care may vary considerablyvary considerably

Tactical Field CareTactical Field Care

In some cases, tactical field care may In some cases, tactical field care may consist of rapid treatment of wounds with consist of rapid treatment of wounds with the expectation of a re-engagement of the expectation of a re-engagement of hostile fire at any momenthostile fire at any momentIn some circumstances there may be In some circumstances there may be ample time to render whatever care is ample time to render whatever care is available in the fieldavailable in the fieldThe time to evacuation may be quite The time to evacuation may be quite variable from 30 minutes to several hoursvariable from 30 minutes to several hours

Tactical Field CareTactical Field Care

If a victim of a blast or penetrating injury is If a victim of a blast or penetrating injury is found without a pulse, respirations, or found without a pulse, respirations, or other signs of life, other signs of life, DO NOTDO NOT attempt CPR attempt CPR Casualties with confused mental status Casualties with confused mental status should be disarmed immediately of both should be disarmed immediately of both weapons and grenadesweapons and grenades

Tactical Field CareTactical Field Care

Initial assessment is the ABCsInitial assessment is the ABCs– Airway Airway – BreathingBreathing– CirculationCirculation

Tactical Field Care: AirwayTactical Field Care: Airway

Open the Open the airwayairway with a chin-lift or jaw-thrust with a chin-lift or jaw-thrust maneuvermaneuver

If unconscious and spontaneously breathing, If unconscious and spontaneously breathing, insert a nasopharyngeal airwayinsert a nasopharyngeal airway

Place the casualty in the recovery positionPlace the casualty in the recovery position

Nasopharyngeal AirwayNasopharyngeal Airway

A survivable A survivable airwayairway problem problem

Tactical Field Care: BreathingTactical Field Care: Breathing

Traumatic chest wall defects should Traumatic chest wall defects should be closed quickly with an occlusive be closed quickly with an occlusive dressing without regard to venting dressing without regard to venting one side of the dressingone side of the dressingAlso may use an “Asherman Chest Also may use an “Asherman Chest Seal”Seal”Place the casualty in the sitting Place the casualty in the sitting position if possible.position if possible.

"Asherman Chest Seal""Asherman Chest Seal"

Tactical Field Care: BreathingTactical Field Care: Breathing

Progressive respiratory distress in the presence Progressive respiratory distress in the presence of unilateral penetrating chest trauma should be of unilateral penetrating chest trauma should be considered considered tension pneumothoraxtension pneumothorax Tension pneumothoraxTension pneumothorax is the 2 is the 2ndnd leading cause leading cause of preventable death on the battlefieldof preventable death on the battlefieldCannot rely on typical signs such as shifting Cannot rely on typical signs such as shifting trachea, etc.trachea, etc.Needle chest decompression is life-savingNeedle chest decompression is life-saving

Needle Chest DecompressionNeedle Chest Decompression

Tactical Field Care: CirculationTactical Field Care: Circulation

Any bleeding site not previously Any bleeding site not previously controlled should now be addressedcontrolled should now be addressed

Only the absolute minimum of Only the absolute minimum of clothing should be removed, although clothing should be removed, although a thorough search for additional a thorough search for additional injuries must be performedinjuries must be performed

Tactical Field Care: CirculationTactical Field Care: Circulation

Significant bleeding should be controlled Significant bleeding should be controlled using a tourniquet as described previously using a tourniquet as described previously

Once the tactical situation permits, Once the tactical situation permits, consideration may be given to loosening consideration may be given to loosening the tourniquet and using direct pressure or the tourniquet and using direct pressure or hemostatic dressings (HemCon) or hemostatic dressings (HemCon) or hemostatic powder (QuikClot) to control hemostatic powder (QuikClot) to control any additional hemorrhageany additional hemorrhage

Chitosan Hemostatic DressingChitosan Hemostatic Dressing

Apply directly to bleeding site and hold in Apply directly to bleeding site and hold in place 2 minutesplace 2 minutesIf dressing is not effective in stopping If dressing is not effective in stopping bleeding after 4 minutes, remove original and bleeding after 4 minutes, remove original and apply a new dressingapply a new dressingAdditional dressings cannot be applied over Additional dressings cannot be applied over ineffective dressingineffective dressingApply a battle dressing/bandage to secure Apply a battle dressing/bandage to secure hemostatic dressing in placehemostatic dressing in placeHemostatic dressings should only be Hemostatic dressings should only be removed by responsible persons after removed by responsible persons after evacuation to the next level of careevacuation to the next level of care

Tactical Field Care: IV fluidsTactical Field Care: IV fluids

FIRST, STOP THE BLEEDING!FIRST, STOP THE BLEEDING!

IV access should be obtained using a single 18-IV access should be obtained using a single 18-gauge catheter because of the ease of startinggauge catheter because of the ease of starting

IV fluids should be started as soon as they are IV fluids should be started as soon as they are available in the OIF setting due to dehydrationavailable in the OIF setting due to dehydration

A saline lock may be used to control IV access A saline lock may be used to control IV access in absence of IV fluidsin absence of IV fluids

Ensure IV is not started distal to a significant Ensure IV is not started distal to a significant woundwound

Saline LockSaline Lock

Tactical Field Care: Additional Tactical Field Care: Additional injuriesinjuries

Splint fractures as circumstances Splint fractures as circumstances allow while verifying pulse and allow while verifying pulse and prepare for evacuationprepare for evacuation

Continually reevaluate casualties for Continually reevaluate casualties for changes in conditionchanges in condition

CASEVAC CareCASEVAC Care

Casevac CareCasevac Care

At some point in the operation the At some point in the operation the casualty will be evacuatedcasualty will be evacuatedTime to evacuation may be quite Time to evacuation may be quite variable from minutes to hoursvariable from minutes to hoursThe medic may be among the The medic may be among the casualties or otherwise debilitatedcasualties or otherwise debilitatedA MASCAL may exceed the A MASCAL may exceed the capabilities of the mediccapabilities of the medic

Casevac CareCasevac Care

Higher level medical personnel may Higher level medical personnel may accompany the CASEVAC vehicleaccompany the CASEVAC vehicle

Additional medical equipment may be Additional medical equipment may be brought in with the CASEVAC asset, brought in with the CASEVAC asset, which may includewhich may include– Electronic equipment for monitoring of the Electronic equipment for monitoring of the

patient’s blood pressure, pulse, and pulse patient’s blood pressure, pulse, and pulse oximetryoximetry

– Oxygen is usually available during this phaseOxygen is usually available during this phase

SummarySummary

There are three categories of casualties There are three categories of casualties on the battlefield:on the battlefield:1. Soldiers who will live regardless 1. Soldiers who will live regardless 2. Soldiers who will die regardless 2. Soldiers who will die regardless 3. Soldiers who will die from 3. Soldiers who will die from preventable deathspreventable deaths

unlessunless proper life-saving steps are taken proper life-saving steps are taken immediately (7-15%)immediately (7-15%)

This is the group of soldiers we can save with RLS This is the group of soldiers we can save with RLS (CLS enhanced) training(CLS enhanced) training

SummarySummary

““If during the next war you could do If during the next war you could do only two things, 1) place a tourniquet only two things, 1) place a tourniquet and 2) treat a tension pneumothorax, and 2) treat a tension pneumothorax, then you can probably save between then you can probably save between 70 and 90 percent of all the 70 and 90 percent of all the preventable deathspreventable deaths on the battlefield.” on the battlefield.” --COL Ron BellamyCOL Ron Bellamy

QUESTIONS?QUESTIONS?