Tactical Combat Casualty Care - acep.org · •RPG • Team Leader ... • 2 day education course...
Transcript of Tactical Combat Casualty Care - acep.org · •RPG • Team Leader ... • 2 day education course...
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CAPT Peter Rhee, MC, USNMD, MPH, DMCC, FACS, FCCMProfessor of Surgery /Molecular Cellular Biology
Tactical Combat Casualty Care
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Good medicine in bad places
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Tactical Care• 24 man team – raid• Building in urban
environment• RPG• Team Leader
– massive trauma to leg– femoral arterial bleeding
• Two with minor fragmentation injuries
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Civilian vs Military
• Patient number• Location security• Supplies and advice• Environment• Prehospital phase• Clothing• Communication• Transport – time /
capability
• Mass casualties -triage• Tactical considerations• Limited• Heat/cold/rain/light• Extended• Gear• Not always available• Evacuation is delayed
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• Emergency Medical Technicians • Basic Trauma Life Support (BTLS)• Prehospital Trauma Life Support
(PHTLS)• Advanced Trauma Life Support
(ATLS)
Civilian Trauma
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Casualty Care
• Mission has higher priority• Often conflicts with standard of care
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TCCC• Tactical Combat Casualty Care• Committee on TCCC – COTCCC• Naval Special Warfare Command – 2002• Approved by BUMED
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Who / What is the TCCC?
• Standing Tactical Medicine Committee• Tri-Service• Sponsored by USSOCOM and BUMED• Naval Operational Medicine Institute• Military physicians of various specialties• Civilian trauma surgeons• Military medical enlisted
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Review - strategies -managing combat trauma in the tactical Special Operations environment and make recommendations for changes as appropriate.
Tactical Combat Casualty Carein Special Operations
Military MedicineSupplementAugust 1996
SEAL Biomedical R+DTask Statement 3-93
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•Published in Revised 5th Edition•American College of Surgeons•National Association EMTs
TCCC Revision 2003
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PHTLS Textbook• Civilian educational care
material• Military chapter
– Uniqueness of the combat environment
– Special requirements for medical care in combat
– Special treatment algorithms
• Airway• Shock• Hemorrhage control
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PHTLS & Military Relationship• 3rd edition discussions re military education
(VADM Michael Cowan)• 4th edition
– Military chapter written• 5th edition
– TCCC• 5th edition military version
– Release 1 September 2004– Minor changes
• 6th edition– Civilian version
• 2 day education course– Military version
• 2 sections = 2 jobs• 6 chapters• 1-2 day education course
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Educational Program
Civilian• 2 days• Lecture• Labs• Skills• Testing
Combat• 1-2 days• Lecture• Labs• Skills• Testing
Total 3-4 days
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PHTLS 6eMilitary Chapters
• Unique needs of the Combat Medic • Bomb/blast injury• First responder burn care• Urban warfare• Stratevac/Medevac• Ethics• Battlefield triage
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TCCC Transition
TCCC - Who’s Using it Now?
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TCCC Transition
• Naval Special Warfare–BUMED UMO Course 1996–NSW Standard of Care 1997–Corpsman TCCC Course 1997–SEAL Junior Officer Course 1998–All BUD/S Graduates 2000
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TCCC Transition
• U.S. Army (Rangers, SF, 91W)• USAF - AFSOC PJ Manual• C4 Course (DMRTI)• Marine Divisions• NTTC
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TCCC Transition
Allied Nations• Israeli Defense Force• British SAS• Canadian Counterterrorist Unit• Belgium• Sweden
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TCCC Transition
Allied Nations• Israeli Defense Force• British SAS• Canadian Counterterrorist Unit• Belgium• Sweden
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Goals of TCCC
1) Treat the casualty2) Prevent additional casualties3) Complete the mission
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Important Differences
1. Tactical 2. Resources3. Evacuation
= Bad tactics
1. More wounded or killed2. Mission failure
Good medicine
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Stages of Care in TCCC
• Care Under Fire• Tactical Field Care• Combat Casualty Evacuation Care
(CASEVAC)– MEDEVAC – non-combat medical transport
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ATLS - Primary Survey
• A - Airway with cervical spine protection
• B - Breathing• C – Circulation
– control external bleeding
• D – Disability– Neurologic status
• E - Exposure and Environment
• A – get your ASS down• B – get your BUTT out of
the line of fire• C – Circulation
– control bleeding
• D – disability,– assess only
• E – expose what is necessary
Trauma Center Field
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Care Under Fire
1) Casualty to stay engaged as combatant if appropriate
2) Return fire as directed or required3) Keep yourself from being shot4) Try to keep the casualty from sustaining
additional injuries5) Airway management is best deferred until
the Tactical Field Care Phase
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Care Under Fire
6) Stop life threatening external hemorrhage:- Use a tourniquet for extremity hemorrhage- For non extremity wounds, apply pressure
and / or a Hem Con Dressing / or QuikClot
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Example of a Wound That DOES NOT Need a Tourniquet
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U.S. ArmyOne-HandedTourniquet
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Ranger RatchetTourniquet
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RPG wound of left hip
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HemCon (chitosan) Dressing
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Care Under Fire
6) Stop life threatening external hemorrhage:- Use a tourniquet for extremity hemorrhage- For non extremity wounds, apply pressure
and / or a Hem Con Dressing / or QuikClot7) Communicate with the patient if possible
- Offer reassurance and encouragement- Explain first aid actions
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Semiprone recovery position
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““This audience has gotten completely out of hand.”
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Tactical Field Care1) Casualties with an altered mental status
should be disarmed immediately2) Airway management
a Unconscious casualty without airway obstruction• Chin lift or jaw-thrust maneuver• Nasopharyngeal airway• Place casualty in recovery position
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Tactical Field Care1) Casualties with an altered mental status should
be disarmed immediately2) Airway management
a Unconscious casualty without airway obstruction• Chin lift or jaw-thrust maneuver• Nasopharyngeal airway• Place casualty in recovery position
b Casualty with airway obstruction or impending airway loss• Chin lift or jaw-thrust maneuver• Nasopharyngeal airway• Place casualty in recovery position• Surgical cricothyroidotomy if above unsuccessful (lidocaine if
conscious)
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Tactical Field Care3) Breathing
- Consider tension pneumothorax- Needle thoracostomy- torso trauma / respiratory distress
- Sucking chest wound- Vaseline gauze – expiration- Cover with field dressing- Sitting position- Monitor for tension pneumothorax
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Tactical Field Care4) Bleeding
- Assess for unrecognized hemorrhage and control all sources of bleeding
- Assess for discontinuation of tourniquets- Pressure dressing- Hemostatic dressing (Hem Con)- Hemostatic dressing (QuikClot)
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Tactical Field Care5) IV
- Start an 18 gauge IV or saline lock, if indicated
- If IV not obtainable – intra-osseous
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Tactical Field Care5) Intra-osseous
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Tactical Field Care6) Fluid resuscitation
- Assess for hemorrhagic shock – mental status or absent peripheral pulses are best field indicator of shock (if no head injury)
a. If not in shock:- No IV fluids necessary- PO fluids permissible if conscious
b. If in shock:- Hextend 500 mL IV bolus- Repeat once after 30 minutes if still in shock- No more than 1L of Hextend
- Continued efforts – must be weighed against logistical and tactical considerations
- Risk of incurring further casualties- Unconscious casualty with TBI has no peripheral
pulse, resuscitate to restore radial pulse
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2000cc Blood Loss
3.0 Liters Blood Volume
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Tactical Field Care7) Inspect and dress known wounds8) Check for additional wounds9) Analgesia as necessary
a. Able to fight:- Rofecoxib 50 mg PO qd- Acetaminophen 1000 mg PO q6h
b. Unable to fight- Morphine 5 mg IV / IO- Reassess and repeat q 10 minutes- Monitor for respiratory depression- Promethazine 25 mg IV / IO / IM q4h
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Tactical Field Care10) Splint fractures and recheck pulse11) Antibiotics: for all combat wounds
- Gatifloxacin 400 mg PO qd- Unable to take PO cefotetan 2 g IV / IM
- Slow push 3-5 min q12h
12) Communicate with patient- Encourage, reassure- Explain care
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Tactical Field Care13) CPR for trauma
- Resuscitation on the battlefield:- Will not be successful- Should not be attempted
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Casevac
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CASEVAC care1) Airway management
a Unconscious casualty without airway obstruction• Chin lift or jaw-thrust maneuver• Nasopharyngeal airway• Place casualty in recovery position
b Casualty with airway obstruction or impending airway loss• Chin lift or jaw-thrust maneuver• Nasopharyngeal airway• Place casualty in recovery position or LMA or Combitube or• Surgical cricothyroidotomy if above unsuccessful (lidocaine
if conscious)c Spinal immobilization is not necessary for casualties
with penetrating trauma
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2) Breathing- Consider tension pneumothorax
- Needle thoracostomy- torso trauma / respiratory distress
- Consider chest tube if no improvement and/or long transport anticipated
- Most combat casualties do not require oxygen except- Low pulse oximeter- Unconscious- TBI
- Sucking chest wound- Vaseline gauze – expiration- Cover with field dressing- Sitting position- Monitor for tension pneumothorax
CASEVAC care
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CASEVAC Care
3) Bleeding-Assess for unrecognized hemorrhage and control
all sources of bleeding
- Assess for discontinuation of tourniquets
- Pressure Dressing
- Hemostatic dressing (Hem Con)
- Hemostatic dressing (QuikClot)
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4) IV- Reassess need for IV access- In indicated – 18 gauge IV or saline lock- If IV not obtainable – intra-osseous
CASEVAC Care
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5) Fluid resuscitation- Reassess for hemorrhagic shock – mental status or
abnormal vital signs (if no head injury)a. If not in shock:
- No IV fluids necessary- PO fluids permissible if conscious
b. If in shock:- Hextend 500 mL IV bolus- Repeat once after 30 minutes if still in shock- Continue with PRBC, Hextend or LR as indicated
- Unconscious casualty with TBI has no peripheral pulse, resuscitate to maintain SBP > 90 mmHg
CASEVAC Care
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7) Inspect and dress wound if not already done8) Check for additional wound9) Analgesia as necessary
a. Able to fight:- Rofecoxib 50 mg PO qd- Acetaminophen 1000 mg PO q6h
b. Unable to fight- Morphine 5 mg IV / IO- Reassess and repeat q 10 minutes- Monitor for respiratory depression- Promethazine 25 mg IV / IO / IM q4h
CASEVAC Care6) Monitoring
- Institute ECG, Pulse ox and vital signs if indicated
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10) Reassess fractures and recheck pulses11) Antibiotics: for all combat wounds
- Gatifloxacin 400 mg PO qd- Unable to take PO cefotetan 2 g IV / IM
- Slow push 3-5 min q12h
12) PASG maybe useful for pelvic fractures and abdominal bleeding.
- Extended use must be carefully monitored- Contraindicated for thoracic and brain injuries
CASEVAC Care
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(click to start)
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The End
• Questions?