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
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
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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
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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
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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 & respiratory
distress even if it is not progressive
Needle Thoracentesis
• Emergently decompress affected hemithorax with 14gauge needle inserted over 3rd rib in 2nd 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
Hemorrhage Controlled
• No Radial Pulse or Poor Mentation
• Gain Access (saline lock) - 18Ga
• Intraosseos
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
IFAK
Combat Casualty
Evacuation Care
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).
Evacuation Terminology
CASEVAC
MEDEVAC
Both types of evacuation are included
in the new term “Tactical Evacuation”
31
Combat Casualty Evacuation Care
• MEDEVAC = transporting casualties via
vehicles SPECIFICALLY CONFIGURED,
EQUIPPED, AND STAFFED to provide medical
care
• CASEVAC = moving casualties via NONMEDICAL assets
Hypothermia Prevention
• Lethal Triad:
– Hypothermia
– Acidosis
– Coagulopathy
• Hypothermia Prevention
Kit
– Blizzard® Wrap
– Readi-Heat® Blanket
– Thermo-lite
Stokes, SKED, Talon II Litters
Future Issues
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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?