Tactical Field Care Tactical Combat Casualty Care 02 June 2014.
Tactical Combat Casualty Care 7 December 2012
-
Upload
ethan-ballard -
Category
Documents
-
view
30 -
download
1
description
Transcript of Tactical Combat Casualty Care 7 December 2012
![Page 1: Tactical Combat Casualty Care 7 December 2012](https://reader035.fdocuments.us/reader035/viewer/2022062422/56813751550346895d9ee518/html5/thumbnails/1.jpg)
Current Performance Improvement Issues
Tactical Combat Casualty Care7 December 2012
![Page 2: Tactical Combat Casualty Care 7 December 2012](https://reader035.fdocuments.us/reader035/viewer/2022062422/56813751550346895d9ee518/html5/thumbnails/2.jpg)
TCCC Lessons Learned in Iraq and Afghanistan
• Reports from Joint Trauma System (JTS) weekly Trauma Telecons – every Thursday morning–Worldwide telecon to discuss every serious casualty
admitted to a Level III hospital from that week• Published medical reports• Armed Forces Medical Examiner’s Office reports• Feedback from doctors, corpsmen, medics, and PJs
![Page 3: Tactical Combat Casualty Care 7 December 2012](https://reader035.fdocuments.us/reader035/viewer/2022062422/56813751550346895d9ee518/html5/thumbnails/3.jpg)
Overcalling CAT A Evacuations
![Page 4: Tactical Combat Casualty Care 7 December 2012](https://reader035.fdocuments.us/reader035/viewer/2022062422/56813751550346895d9ee518/html5/thumbnails/4.jpg)
NATO/ISAF Standard Evacuation Categories
International Security Assistance Force
SOP #312:• Governs operations in Afghanistan • Follows NATO doctrine • Specifies three categories for casualty
evacuation:• A - Urgent• B - Priority• C - Routine
![Page 5: Tactical Combat Casualty Care 7 December 2012](https://reader035.fdocuments.us/reader035/viewer/2022062422/56813751550346895d9ee518/html5/thumbnails/5.jpg)
• CAT A – Urgent (denotes a critical, life-threatening injury)
– Significant injuries from a dismounted IED attack– Gunshot wound or penetrating shrapnel to chest,
abdomen or pelvis– Any casualty with ongoing airway difficulty– Any casualty with ongoing respiratory difficulty– Unconscious casualty
NATO/ISAF Standard Evacuation Categories
![Page 6: Tactical Combat Casualty Care 7 December 2012](https://reader035.fdocuments.us/reader035/viewer/2022062422/56813751550346895d9ee518/html5/thumbnails/6.jpg)
• CAT A – Urgent (continued)
– Casualty with known or suspected spinal injury– Casualty in shock – Casualty with bleeding that is difficult to control–Moderate/Severe TBI– Burns greater than 20% Total Body Surface Area
NATO/ISAF Standard Evacuation Categories
![Page 7: Tactical Combat Casualty Care 7 December 2012](https://reader035.fdocuments.us/reader035/viewer/2022062422/56813751550346895d9ee518/html5/thumbnails/7.jpg)
• CAT B – Priority (serious injury)– Isolated, open extremity fracture with bleeding
controlled– Any casualty with a tourniquet in place– Penetrating or other serious eye injury– Significant soft tissue injury without major
bleeding– Extremity injury with absent distal pulses – Burns 10-20% Total Body Surface Area
NATO/ISAF Standard Evacuation Categories
![Page 8: Tactical Combat Casualty Care 7 December 2012](https://reader035.fdocuments.us/reader035/viewer/2022062422/56813751550346895d9ee518/html5/thumbnails/8.jpg)
• CAT C – Routine (mild to moderate injury)
– Concussion (mild TBI)
– Gunshot wound to extremity - bleeding controlled without tourniquet
–Minor soft tissue shrapnel injury
– Closed fracture with intact distal pulses
– Burns < 10% Total Body Surface Area
NATO/ISAF Standard Evacuation Categories
![Page 9: Tactical Combat Casualty Care 7 December 2012](https://reader035.fdocuments.us/reader035/viewer/2022062422/56813751550346895d9ee518/html5/thumbnails/9.jpg)
Training
![Page 10: Tactical Combat Casualty Care 7 December 2012](https://reader035.fdocuments.us/reader035/viewer/2022062422/56813751550346895d9ee518/html5/thumbnails/10.jpg)
Train ALL Combatants and all Operational Medical
Providers in TCCC• Line commanders must take the lead to have an
effective TCCC training program for all combatants• Docs, nurses, PAs must know what their combat
medical personnel know about TCCC
![Page 11: Tactical Combat Casualty Care 7 December 2012](https://reader035.fdocuments.us/reader035/viewer/2022062422/56813751550346895d9ee518/html5/thumbnails/11.jpg)
Tourniquets Being Placed Too Proximal and
Not Adjusted during TFC
![Page 12: Tactical Combat Casualty Care 7 December 2012](https://reader035.fdocuments.us/reader035/viewer/2022062422/56813751550346895d9ee518/html5/thumbnails/12.jpg)
E-mail from an orthopedic surgeon: “…. tourniquet was applied on the proximal biceps for a middle finger amputation.”
![Page 13: Tactical Combat Casualty Care 7 December 2012](https://reader035.fdocuments.us/reader035/viewer/2022062422/56813751550346895d9ee518/html5/thumbnails/13.jpg)
Care Under Fire Guidelines
7. Stop life-threatening external hemorrhage if tactically feasible:– Direct casualty to control hemorrhage by self-aid
if able. – Use a CoTCCC-recommended tourniquet for
hemorrhage that is anatomically amenable to tourniquet application.
– Apply the tourniquet proximal to the bleeding site, over the uniform, tighten, and move the casualty to cover.
![Page 14: Tactical Combat Casualty Care 7 December 2012](https://reader035.fdocuments.us/reader035/viewer/2022062422/56813751550346895d9ee518/html5/thumbnails/14.jpg)
Three Key Points
• “Proximal to the bleeding site” does not necessarily mean at the upper biceps for a hand injury or at the upper thigh for a foot injury
• The tourniquet should be moved to a skin location 2-3 inches above the bleeding site during Tactical Field Care.
• Reassess the bleeding site frequently to ensure that tourniquet is still effective.
![Page 15: Tactical Combat Casualty Care 7 December 2012](https://reader035.fdocuments.us/reader035/viewer/2022062422/56813751550346895d9ee518/html5/thumbnails/15.jpg)
Tourniquet Mistakesto Avoid!
• Not using one when you should• Using a tourniquet for minimal bleeding• Putting it on too proximally• Not taking it off when indicated during TFC• Taking it off when the casualty is in shock or has
only a short transport time to the hospital• Not making it tight enough – the tourniquet
should eliminate the distal pulse• Not using a second tourniquet if needed• Waiting too long to put the tourniquet on• Periodically loosening the tourniquet to allow
blood flow to the injured extremity* These lessons learned have been written in blood. *
![Page 16: Tactical Combat Casualty Care 7 December 2012](https://reader035.fdocuments.us/reader035/viewer/2022062422/56813751550346895d9ee518/html5/thumbnails/16.jpg)
Eye Injuries: Recent Increase in Eye Injuries from Not Wearing Eye
Protection
![Page 17: Tactical Combat Casualty Care 7 December 2012](https://reader035.fdocuments.us/reader035/viewer/2022062422/56813751550346895d9ee518/html5/thumbnails/17.jpg)
Wear Your Eye Protection!
• Jan 2010• 22 y/o near IED without eye protection• Now blind in both eyes• Don’t let this happen to you – see slides below
With eye pro – eyes OK! Without eye pro – both eyes lost
![Page 18: Tactical Combat Casualty Care 7 December 2012](https://reader035.fdocuments.us/reader035/viewer/2022062422/56813751550346895d9ee518/html5/thumbnails/18.jpg)
Eye Armor – It Works!
![Page 19: Tactical Combat Casualty Care 7 December 2012](https://reader035.fdocuments.us/reader035/viewer/2022062422/56813751550346895d9ee518/html5/thumbnails/19.jpg)
Penetrating Eye Trauma
• Rigid eye shield for obvious or suspected eye wounds - often not being done – SHIELD AND SHIP!
• Not doing this may cause permanent loss of vision – use a shield for any injury in or around the eye
• Eye shields not always in IFAKs• IED + no eye pro + facial wounds = Suspected Eye Injury!
Shield after injury No shield after injury
![Page 20: Tactical Combat Casualty Care 7 December 2012](https://reader035.fdocuments.us/reader035/viewer/2022062422/56813751550346895d9ee518/html5/thumbnails/20.jpg)
• Use your tactical eyewear to cover the injured eye if you don’t have a shield.• Using tactical eyewear in the field will generally prevent the eye injury from happening in the first place!
Eye Protection
![Page 21: Tactical Combat Casualty Care 7 December 2012](https://reader035.fdocuments.us/reader035/viewer/2022062422/56813751550346895d9ee518/html5/thumbnails/21.jpg)
JTTS Trauma Telecon9 Sept 2010
• Recent case of endophthalmitis (blinding infection inside the eye)• Reminder – shield and moxifloxacin in the field for penetrating eye injuries – combat pill pack!• Also – need to continue moxi both topically and systemically in the MTFs• Many antibiotics do not penetrate well into the eye
![Page 22: Tactical Combat Casualty Care 7 December 2012](https://reader035.fdocuments.us/reader035/viewer/2022062422/56813751550346895d9ee518/html5/thumbnails/22.jpg)
Patched Open Globe 22 July 2010
• Shrapnel in right eye from IED• Had rigid eye shield placed• Reported as both pressure patched and as having a
gauze pad placed under the eye shield without pressure – NO pressure patches on eye injuries
• Extruded uveal tissue (intraocular contents) noted at time of operative repair of globe
• Do not place gauze on injured eyes! COL Robb Mazzoli: Gauze can adhere to iris tissue and cause further extrusion when removed even if no pressure is applied to eye.
• At least two other recent occurrences of patching
![Page 23: Tactical Combat Casualty Care 7 December 2012](https://reader035.fdocuments.us/reader035/viewer/2022062422/56813751550346895d9ee518/html5/thumbnails/23.jpg)
Pressure Dressings on Eye Injuries
The wrong thing to do – makes a bad situation potentially much worse – SHIELD ONLY
![Page 24: Tactical Combat Casualty Care 7 December 2012](https://reader035.fdocuments.us/reader035/viewer/2022062422/56813751550346895d9ee518/html5/thumbnails/24.jpg)
Battlefield Analgesia
![Page 25: Tactical Combat Casualty Care 7 December 2012](https://reader035.fdocuments.us/reader035/viewer/2022062422/56813751550346895d9ee518/html5/thumbnails/25.jpg)
NO Narcotic Analgesia for Casualties in Shock
• Narcotics (morphine and fentanyl) are CONTRAINDICATED for casualties
who are in shock or who are likely to go into shock; these agents may worsen their shock and increase the risk of death• Four casualties in two successive weekly telecons
were noted to have gotten narcotics and were in shock during transport or on admission to the MTFs
• Use ketamine for casualties who are in shock or at risk of going into shock but are still having significant pain
![Page 26: Tactical Combat Casualty Care 7 December 2012](https://reader035.fdocuments.us/reader035/viewer/2022062422/56813751550346895d9ee518/html5/thumbnails/26.jpg)
Case ReportSeptember 2012
• Male casualty with GSW to thigh• Bleeding controlled by tourniquet• In shock – alert but hypotensive• Severe pain from tourniquet• Repeated pleas to PA to remove the tourniquet• PA did not want to use opioids because of the shock• Perfect candidate for ketamine analgesia• Not fielded at the time with this unit
![Page 27: Tactical Combat Casualty Care 7 December 2012](https://reader035.fdocuments.us/reader035/viewer/2022062422/56813751550346895d9ee518/html5/thumbnails/27.jpg)
Platelet-Inhibiting Drugs in the Battle Space
![Page 28: Tactical Combat Casualty Care 7 December 2012](https://reader035.fdocuments.us/reader035/viewer/2022062422/56813751550346895d9ee518/html5/thumbnails/28.jpg)
First – Do No HarmHarris et al – Mil Med 2012
• Platelets help to keep you from bleeding to death if you are wounded. Some drugs keep them from working.• Survey of 175 Soldiers at a FOB in SE Afghanistan• “Do you take over-the-counter or prescription NSAIDs?”• If so, how often?
![Page 29: Tactical Combat Casualty Care 7 December 2012](https://reader035.fdocuments.us/reader035/viewer/2022062422/56813751550346895d9ee518/html5/thumbnails/29.jpg)
First – Do No HarmHarris et al – Mil Med 2012
![Page 30: Tactical Combat Casualty Care 7 December 2012](https://reader035.fdocuments.us/reader035/viewer/2022062422/56813751550346895d9ee518/html5/thumbnails/30.jpg)
First – Do No HarmHarris et al – Mil Med 2012
Recommendations:• Earlier platelets in DCR• Consider restricting NSAIDs in theater• Other analgesic choices: acetaminophen, cox-2 selective NSAIDs, tramadol
![Page 31: Tactical Combat Casualty Care 7 December 2012](https://reader035.fdocuments.us/reader035/viewer/2022062422/56813751550346895d9ee518/html5/thumbnails/31.jpg)
Note that other drugs and some nutritional
supplements may inhibit platelets as well. Check with your doc on this!
![Page 32: Tactical Combat Casualty Care 7 December 2012](https://reader035.fdocuments.us/reader035/viewer/2022062422/56813751550346895d9ee518/html5/thumbnails/32.jpg)
Documentation of TCCC Care
![Page 33: Tactical Combat Casualty Care 7 December 2012](https://reader035.fdocuments.us/reader035/viewer/2022062422/56813751550346895d9ee518/html5/thumbnails/33.jpg)
![Page 34: Tactical Combat Casualty Care 7 December 2012](https://reader035.fdocuments.us/reader035/viewer/2022062422/56813751550346895d9ee518/html5/thumbnails/34.jpg)
TCCC Card –Fill It Out!
• You’re not done taking care of your casualty until this is done
• Mission Commanders – this is a leadership issue!
![Page 35: Tactical Combat Casualty Care 7 December 2012](https://reader035.fdocuments.us/reader035/viewer/2022062422/56813751550346895d9ee518/html5/thumbnails/35.jpg)
Questions?