DMI Combat Trauma Manual

Combat Trauma Medicine
(CTM)

Student Reference Manual

Deployment Medicine International
2

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COURSE INTENT
Combat Trauma Medicine (CTM)

1. We are medical trainers; we do not establish policy or protocol. We
contribute to these processes through our individual and collective
experience on the field of battle. We are educators and trainers devoted to
the transformation of warriors into warrior healers; the ultimate Warfighter
trained to save lives as well as take them.

2. This course of instruction is designed to address the medical theory and
science behind the special needs of providers in a theatre of war. Our goal
is to augment the skills already given you through your service schools and
other trainingto present you with innovative lessons learned from the
battlefieldto give you additional confidence and knowledge. Our mission
it to train you to be your best when youre best is needed in combat. Our
mission is to train you to save the life of the operator sitting next to you.

3. The DMI CTM (with Live Tissue Training) course addresses the mission of
the operational emergency medical care, remote medical care, prolonged
transport times, unique military wounding and the pre-hospital
environment. In this course we stress both the How and Why of every
combat trauma medical task.

4. We provide a course based on current science and actual experience
specific to the unique environments and resources of operational units to
build on previous non-medical training to specify and train to the treatment
options available to you, the Warfighter, in the combat environment
based on the best academic medical consensus (as a minimum, Tactical
Combat Casualty Care; Basic and Advanced Pre-hospital Trauma Life
SupportCurrent Version), real casualty data, and actual combat
experience to include (as a minimum):
Managing Blood Loss
Airway Management (Non Surgical)
Respiratory Injury Management
Circulation Shock Management
Head Injury and Hypothermia
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Casualty Assessment
Medical Ramifications of Blast Injury
Operational Burn Injury Management
Prolonged Care
Advanced Wound Care Management
Pain Management
Maximizing Operational Performance
Field Exercises and Tactically Relevant Scenarios

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5. Training for todays warrior healer (Warfighter) has changed tremendously
in the past decade. Lessons learned in previous conflicts and
requirements for military transformation have been incorporated into this
training. The warrior healer of today is the most technically advanced,
highest trained, and best equipped ever produced by the United States
Militaryour mission is to take your training to the next level.

6. We account for every minute of your training time to maximize your training
experience.

7. Your missions ask questions, contribute, and remain present and
focused. Everything you learn over the next several days will save your
life, or the lives of your comrades should you have to apply what is taught
in this course pay attention.

8. We believe that proper, detailed, and current medical science taught in the
classroom, and reinforced in the Live Tissue Training will bring together
the students performance, knowledge and skills. Therefore, we stress
critical points of operational medicine and lessons learned through case
studies and experience in austere operational environments. We are
dedicated to giving our students the time, training, and experience
necessary for them to remain this Nations vanguard.

9. Classroom didactic lecture, simulator training, and practical exercise (mini
labs) will incorporate the following (as a minimum) course criteria DMI
will add to this the curriculum and include a much broader spectrum to
training for the non-medical operator or combat lifesaver.

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COURSE METHOD

The Hybrid Training Model

1. Although not new to the military training regime, performance oriented
training (Task, Condition & Standard) developed in the 1970s and 1980s
was adopted years ago as the teaching mechanism of choice by
Deployment Medicine International (DMI). DMI accepts performance-
oriented training as the baseline standard for all of its training programs.
However, training has evolved in the decades following the inception of
service wide performance oriented training programsespecially in the
field of operational medicine. Therefore, DMI has adopted a four-phased
hybrid-training model, which expands the students learning experience in
two functional areas (performance and retention). We do this to ensure a
definitive result where it is needed mostin battle.

2. The four-phases of the hybrid-training model are:

a. The Classroom Didactic. This will be the lecture portion of your
class, each day, wherein the theory, science, and case studies of
each learning objective are discussed.

b. Practical Exercise, Lab and Simulator training (mannequin,
FAST-1, others). This portion of the training model involves the (in
class) use of simulators, practical demonstrations, videos, hands on
applications and practice using mannequins and other simulators, as
well as the experience of performing (permitted) medical procedures
on each other and on harvested animal tissues (swine tracheas and
ears).

c. Live Tissue Procedures (a half day of medical procedures on
anesthetized animals). The field training exercise training is divided
into two-phases (procedures and scenarios). Phase 1 of the live
tissue portion of your training involves the intensive focus of
performing life-saving battlefield trauma procedures on fully
anesthetized animals. DMI instructors monitor and train you
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walking you through each procedure, demonstrating, and then
allowing you and your team to perform the procedure under their
tutelage. DMIs veterinary staff and instructors constantly monitor
your patients (anesthetized swine). Students will assist in this
attention.

d. Live Tissue Scenarios (a half day of hyper-realistic, tactically
relevant scenario based training using anesthetized animals). The
term tactically relevant in Phase II of live tissue training is critical.
You are expected to respond to scenarios that template OIF/OEF
battlefield conditions, and you will be likely to provide care to the
wounded in all three phases of Tactical Combat Casualty Care, (1)
Care Under Fire, (2) Tactical Field Care, and (3) Prolonged Field
Care conditions.

3. Why do we employ the hybrid-training model; why not just teach medicine?
This is a very good question; however, the training mission of DMI is not
only to teach medicine, it is to teach medicine employed in high-threat
environments. This is medicine to save life while all around you; the
enemy will be trying to take your life. To function in this environment
requires the convergence of two elements of the human performance
model: the performance curve, and the retention curve.

4. The performance curve defines your ability to do just that, perform, to see
the patient, access the patient, decide the optimum course of action to
treat the patient and then treatsave life. Many of your
colleagues/operators have adopted the adage, Minutes equal blood, and
blood equals life. The performance curve must peak at the point of
wounding, often under fire (care under fire) or facing imminent danger as
you treat (tactical field care), or during prolonged field care. History
demonstrates that performance curves are high in low stress environments
and markedly low in high stress environments. Therefore, how do you
ensure that your performance curve peaks at the point of wounding? In
addition, what other mechanisms drive this peak performance?
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5. The other element of measurement in training is the retention curvethe
ability to recall all of the decision variables related to a life saving task at
the speed of thought, during the worst of circumstancesat the point of
wounding. The classroom didactic, the practical labs and Phase I of the
live tissue training are all designed to build muscle memory, to reinforce
analysis, decision, and right action. Through decades of educational
science, it has been determined that the retention curve is affected
differently than the performance curve in high stress learning
environments. In this instance, the stressors of the classroom environment
build and embed neural patterns affecting muscle memory. These
patterns are called upon in battle; what you know must coalesce at
precisely the right moment as action (performance) if you are to be
effective in battle.
10

The illustration above (first figure) shows the retention curve and
performance curve coming together past the point of woundingthis
equates to lives lost. The illustration below (second figure) demonstrates
the desired outcome of the emergence of the performance and retention
curves at the point of woundinga condition of training via the hybrid
model.

6. To summarize, in education and training we are dealing with two curves:
performance and retention. In high stress learning environments, the
performance curve decreases; you do not perform at your highest state
when learning complex tasks under high stress conditions. Conversely,
when learning complex tasks under low stress conditions, you perform at a
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higher level; however, you retain less. This is the educators dilemma,
especially when training Warfighters to be their best when their best is
needed.

7. The objective is to bring both the retention curve and the performance
curve together, at their peak state, and most critically at the point of
wounding. To do so, requires a hybrid-training model. This is why, we do
not simply teach medicine from a classroom didactic perspective, nor do
we limit your experience to practical exercise, labs and simulatorsto do
so would not provide the level of stress necessary to influence both
learning curves optimally. To achieve the necessary impact, we involve
live tissue in two phases; gradually increasing the environmental training
stressors to a level that increases retention, and to a degree decreases
performance (in the moment). Instructors focus on reinforcing
performance, and retrain where required in the high stress environment
here is where optimal learning occurs.

8. The objective and evidence of this hybrid-training model is increased
performance and situational awareness through rapid recall of all the steps
necessary to perform any given medical task, no matter the complexity.
The hybrid-training model trains our medical personnel at all levels to spin
the decision cycle faster. Medical personnel are trained to see, access,
decide and react under even the most incomprehensible battlefield
environments. Remember, Minutes equal blood, and blood equals life. If
the sights, sounds, tastes, smells and textures of the battlefield are not
unfamiliar to you; if you have to a degree experienced these factorsyou
will perform at a higher ratethis is the objective of this course of study
and practical exercise.

9. DMI employs educational scientists who continually review the manner in
which we present information to our studentsensuring we explore
mechanisms involved in the development of battlefield injury, review
human and animal studies, and conduct constant research on and off the
battlefield. We commit to being hyper-vigilant; collecting and teaching
current information as it pertains to the development of injury and
treatment on the battlefield. While teaching the science and mechanism of
battlefield trauma now, we also pledge our continued focus to the future of
battlefield medicine.

10. This Student Manual is designed to serve you in several ways: a
guide for your classroom didactic portion (lecture), a guide for your
practical exercises in class using simulators and during practical labs. This
manual is not meant to be an exhaustive review, or finite reference; rather
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it is an introduction to key principals of the field of combat trauma
medicine. It is meant to be a concise manual for those of you preparing to
enter the global war on terror as medical providers across the spectrum,
from physician to corpsman. The aim of this course is to inspire you with
the theory, the science, and the practical What do I do now? level of
information. You will be inundated with a great deal of information; this
reference manual will serve as a historical source document for your use,
to reflect back on this experience; to use as an azimuth check during your
experience in operational medicine.

11. Do not hesitate to ask the faculty for clarification on any training
objective, or to ask for further reference if it is not contained in the master
reference list provided.

12. As the field of operational medicine progresses, so shall this
reference manual. We attempt to update as necessary.
13
WHY THIS COURSE?

Dep|oyment Med|c|ne Internat|ona| M|ss|on Statement: - A team of
profess|ona|s comm|tted to prov|d|ng unsurpassed operat|ona| med|ca| tra|n|ng
comp|emented by unmatched d|rect dep|oyed med|ca| support and m|ss|on
or|ented research.

We (DMI) believe that proper, detailed, and current medical science taught
in the classroom, and reinforced in the field exercises will bring together the
students performance and retention curves at the point of wounding.
Therefore, we stress critical points of operational medicine and lessons
learned through case studies and experience in austere environments.

DMI has been training physicians, combat medics, Special Forces soldiers,
conventional war-fighters, and personal protection details including White
House, and law enforcement in operational medicine for over 15 years.
DMI is unique because it is focused on operational medicine.

There is no greater reward for our instructors than to know they made a
difference through the passing of knowledge and thereby saved a life.

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COURSE PREREQUISITES

1. Originally, the intended audience for the various DMI training courses was
the Special Operations Forces (SOF) medic, (US Army 18D, US Air Force
Para Rescue, US Air Force Special Operations Medics, US Marine Corps
RECON Corpsmanor equivalent) and key personnel (Physicians,
Physician Assistants, Registered Nurses and Emergency Medical
TechnicianParamedics, Intermediate and Basic, Independent Duty
Corpsman) associated with suchor equivalent.

2. These mission requirements to support the national forces operational
tempo have shifted the prerequisite skill levels necessary to attend CTM to
include basic graduates of the Field Medical Training Battalion corpsman
training (and equivalent), as well as, members of the Local, State and
Federal Law Enforcement Agencies, as well as other Federal Agencies.

3. Essentially, if you have any medical training at all, you will benefit from the
training offered in this course. Even individuals without medical training
have attended this course (non-military) and have expressed a relative
degree of comfort with the material (due primarily to the manner and
mechanism of instruction) and have stated and demonstrated increased
confidence and competence in providing medical aid in emergency trauma
situations.

4. It is entirely the decision of the operational commander to challenge the
student to meet or exceed the commanders training expectations. DMI
will meet the expectations of any operational commander to train their
troops, to augment their skills, improve their confidence and competence
to sustain life at the point of wounding on the battlefield.

5. DMI conducts all training in accordance with the applicable guidelines
established by the Committee on Tactical Combat Casualty Care
(CoTCCC), and Pre-Hospital Trauma Life Support PHTLS (Current
Version) and other policy guidance for Combat Trauma Training (CTT) that
includes Live Tissue Training (LTT). This includes ATTP 4-02, OCT 2011,
table 2-2, page 2-3 or other appropriate and current US Army Doctrine.

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COURSE COMPLIANCE

Information concerning this training is considered to be of a
sensitive nature. Therefore, the release of any information
pertaining to this course is prohibited without the express written
consent of the Medical Director for Deployment Medicine
International (DMI).

TACTICAL COMBAT CASUALTY CARE (TCCC)
SKILL SETS

Course content is based on skill level.

Course material in this manual is limited to skill sets for deploying
combatants as listed in the tables below.

Supplements to this manual are provided for combat lifesaver,
corpsmen, medics and PJs.

PHTLS FIGURE 24-1 PHTLS 7
TH
EDITION, PAGE 595

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FIGURE 24-1 TACTICAL COMBAT
CASUALTY CARE (TCCC) SKILL SETS
ALL DEPLOYING COMBATANTS
SKILL
HEMOSTASIS
APPLY TOURNIQUET
APPLY DIRECT PRESSURE
APPLY BANDAGE
APPLY COMBAT GAUZE
APPLY PRESSURE DRESSING
CASUALTY MOVEMENT TECHNIQUES
AIRWAY
CHIN LIFT/JAW THRUST MANEUVER
NASOPHARYNGEAL AIRWAY
RESCUE BREATHING PATTERN
SIT UP/LEAN FORWARD AIRWAY POSITION
BREATHING
TREAT SUCKING CHEST WOUND
INTRAVENEOUS ACCESS AND IV THERAPY
ASSESS FOR SHOCK
PREVENT HYPOTHERMIA
ORAL AND INTRAMUSCULAR THERAPY
ORAL ANTIBIOTIC
ORAL ANALGESIA
FRACTURE MANAGEMENT
SPLINTING

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COMBAT LIFESAVER
SKILL
HEMOSTASIS
APPLY TOURNIQUET
APPLY BANDAGE
APPLY COMBAT GAUZE
AIRWAY
BREATHING
NEEDLE THORACOSTOMY
ASSESS FOR SHOCK
PREVENT HYPOTHERMIA
ORAL ANTIBIOTIC
ORAL ANALGESIA
IM MORPHINE
FRACTURE MANAGEMENT
SPLINTING
TRACTION SPLINTING

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CORPSMAN/MEDIC/PJ
SKILL
HEMOSTASIS
APPLY TOURNIQUET
APPLY BANDAGE
APPLY COMBAT GAUZE
AIRWAY
LARYNGEAL MASK AIRWAY (LMA)
SURGICAL AIRWAY
ENDOTRACHEAL INTUBATION
COMBITUBE
BREATHING
NEEDLE THORACOSTOMY
CHEST TUBE
ADMINISTER OXYGEN
ASSESS FOR SHOCK
START IV LINE/SALINE LOCK
OBTAIN INTRAOSSEOUS ACCESS
IV FLUID RESUSCITATION
IV ANALGESIA
IV ANTIBIOTICS
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ADMINISTER PACKED RED BLOOD CELLS
PREVENT HYPOTHERMIA
ORAL ANTIBIOTIC
ORAL ANALGESIA
IM MORPHINE
FRACTURE MANAGEMENT
SPLINTING
TRACTION SPLINTING
ELECTRONIC MONITORING

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INTRODUCTION TO OPERATIONAL MEDICINE

A combination of battlefield tactics and immediate casualty care are
essential to mission success and Warfighter survival. This type of
combat casualty care is defined as Operational Medicine.

TRAINING OBJECTIVES:

1. Explain the role of the non-medical Warfighter in combat casualty care.

2. Explain the combat casualty mortality curve.

3. Identify the Warfighters role in participating in a 3-phase approach to tactical
trauma care.

a. Care Under Fire
b. Tactical Field Care
c. Tactical Evacuation Care
d. ADVANCED: Prolonged Field Care

4. Explain the difference between civilian and combat medicine.

5. Explain the M. A. R. C. H. algorithm approach to combat casualty care:

1. Massive Bleeding
2. Airway
3. Respiration
4. Circulation
5. Head injury & Hypothermia

6. Answer all remaining questions regarding the science of combat casualty care.

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The focus of this course is on casualty care and how the non-medical
Warfighter must participate in an active role to ensure tactical and
medical objectives are achieved.

Mission success is no longer defined as just achieving the mission
objective but now requires team survival with minimal casualties.

Operational Medicine-Combat Casualty Care

1. Emergency medical care provided in austere and/or remote locations.

2. Casualty care is often secondary to completing the mission.

3. Injuries are primarily penetrating trauma from either fragmentation or gunshot
wounds (GSW).

4. Injuries often occur in a resource-limited environment, where medical supplies
are limited to a Warfighters individual medical kit or a medical providers
rucksack.

5. Evacuation of casualties is often measured in hours requiring strategic planning
of evacuation assets.

6. Casualty care is usually initiated by non-medic Warfighters and continued by
medical providers.

7. Resources and personnel are often overwhelmed with multiple casualties and
limited number of medically trained personnel.

Changing tactics is not a consideration in operational medical care!

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THE COMBAT MORTALITY CURVE

1. Following trauma, the chances of a casualty surviving are dependent upon
numerous variables, including the speed at which appropriate medical treatment
is administered. During this session, we will look at the factors that can affect the
chances of a casualty surviving as injuries develop from initial trauma, through
hemorrhage and/or respiration compromise, as well as shock and infection.

2. The Combat Mortality Curve is based on battlefield penetrating trauma (gunshot
wounds, fragmentation). It was derived from research the lethality of weapons
during the Vietnam conflict. This research provides an understanding of the
survivability of combat casualties over an extended timeline of 72 hours. The
Combat Casualty Mortality Curve also provides a comparison between the
survivability of casualties that receive no medical care and those that do.

%
TIME
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COMBAT MORTALITY CURVE DATA

Combat Mortality Curve
100%
90%
70%
60%
50%
80%
6 min 1 hr 6 hr 24 hr 72 hr
-Massive Bleeding
-Respiratory
-Head Injury
-Hypothermia
-Wounds
(Infection)
-Self Aid &
Buddy Aid
-Advanced Life
Support (Medic)
-Surgery &
Antibiotics
-Airway
-Circulation
(Shock)
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Time Line
1. 0-6 Minutes:
a. Historically 20% of injuries produce an Inevitable Death Rate (IDR)
no matter what medical care they receive. These would include
casualties with major system trauma (heart, brain or spinal). The
IDR has changed very little during the last 200 years. The use of
modern Personal Protective Equipment (PPE) has reduced the rate
from 25% to 20%. There are documented cases of casualties with
non-survivable injuries surviving for up to six minutes. Therefore,
after six minutes, about 80% of the casualties will be alive. Currently
reports show an 18% instantaneous death rate.

2. 6 Minutes-1 Hour
a. By the end of the first hour, another 10% will die from
exsanguinating hemorrhage (large vessels of the extremities and
neck) or from obstruction of the airway (choking) displaced facial
tissue and/or swelling occluding the airway. If a casualty can survive
the first hour, it is highly probable they will make it to the third hour.
Therefore, after 60 minutes, about 70% will survive.

3. 1 Hour-6 Hours
a. By six hours, another 10% will succumb to breathing complications.
Some casualties will show the first signs of shock caused by the
body running on less blood than normal. Although at this stage, they
are unlikely to die from shock alone. After six hours, about 60% will
survive.

4. 6 Hours-24 Hours
a. Between six and 24 hours, deaths occur from shock early on, but
after this condition, they remain relatively stable although dirty
wounds will continue to become more and more infected. After six
25
hours, the curve is relatively unchanged, about 60% will be alive.

5. 24 Hours-72 Hours
a. Between 24 and 72 hours around 10% of the remaining casualties
are lost due to infection or the lack of surgical intervention.

6. 72 Hours
a. By 72 hours, deaths occur mostly from wound infections. At 72
hours approximately 50% will survive.

Combat Mortality Curve Timeline

Mitigating Factors:

1. Zero to six minutesPrevent injuries. Personal Protective Equipment (PPE)
and good tactics.

2. Six to sixty minutesSelf Aid & Buddy Aid. Stop the bleeding and open the
airway.

3. One to six hoursSkilled Warfighter and Advanced Life Saving (ALS) level
skills to include decompression of tension pneumothorax, chest tubes, oxygen
therapy, IV access / fluid resuscitation, antibiotics and advanced airway
management.

4. Six hours or moresurgical intervention and additional infection control are
required to show any marked improvements in survival rates beyond the 6-hour
mark.

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NOTES:
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WAR CASUALTY STATISTICS

In World War II, 30 percent of the Americans injured in combat died.
In Vietnam, 24 percent of Americans injured in combat died.
In the war in Iraq and Afghanistan, about 10 percent of those injured
have died.
Half of battlefield deaths occur within 30 minutes of wounding, largely
on account of blood loss.
US forces in OIF/OEF are primarily engaged in counterinsurgency
operations within irregular war, in which enemy tactics are primarily
based on terrorism, insurgency and guerilla warfare.
There is no uniformed enemy, no defined front lines or order of battle,
and allegiances can be fluid. As a result, most combat casualties
occur due to ambush or increasingly from the use of improvised
explosive devices (IEDs). IEDs are destructive devices constructed
from homemade, commercial, or military explosive material that are
deployed in ways other than conventional military means. IEDs are
designed to destroy, disfigure, or otherwise interdict military assets in
the field and include buried artillery rounds, antipersonnel mines and
car bombs.
The number of casualties due to explosives has increased relative to
those caused by gunshot.
An analysis of the epidemiology of injuries in OIF/OEF documented
that 81% of all injuries were due to explosions.

(Reference: LTC Philip et al. Epidemiology of Combat Wounds in Operation Iraqi
Freedom and Operation Enduring Freedom: Orthopedic Burden of Disease.
Journal of Surgical Orthopedic Advances. 2010 Vol 19:1 pg. 2-7)

The use of body armor by US soldiers provides increased protection
to the thorax and to a lesser extent the abdomen and pelvis, and its
effects were first observed in Operation Desert Storm, which saw a
decline in thoracic injuries to 5% compared to 13% seen in Vietnam.

(Reference: Belmont, P.J et al. Incidence and Epidemiology of Combat Injuries
Sustained During The Surge Portion of Operation Iraqi Freedom by a U.S.Army
Brigade Combat Team. J. Trauma. 2010; 68 p.204-210)

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WAR CASUALTY STATISTICS

Current Literature: A study from 2011 looking at 2001-2009 combat
statistics shows that
48.6% of mortality secondary to combat wounds was considered
non-survivable.
51.4% of mortality secondary to combat wounds is considered
survivable.
80% of the potentially survivable combat mortalities were
secondary to hemorrhage.
Of the hemorrhage related mortalities the major regions affected
were:
Torso 48%
Extremity 31%
Junctional region; neck, armpit and groin. 21%

Total 100%
Non Survivable cases:
TBI, 83%
Hemorrhage 16%
Other causes 1%

Total 100%

(Reference: Eastridge B.J. et al. Died of wounds on the battlefield: causation and
implications for improving combat casualty care. J. Trauma 2011;71:S4-S8) See
Table 4 and 5 below.

29
US Military Casualties

Data taken from: Defense Casualty Analysis System
Website: www.dmdc.osd.mil; access date: 8/1/12

30

31

32

33

Time Line: Operation Iraqi Freedom, Operation New Dawn and
Operation Enduring Freedom

34

What we have seen is the [Interceptor] Body Armor; particularly
what are called the SAPI plates (small arms protective inserts), the
ceramic material plates that go inside the flack (Kevlar) vest that Marines
wear in the field. It's the standard body armor that is now distributed to
everybody; that plus the Kevlar helmets that everyone wears. The result
has been that there has been a decrease in the number of Marines
wounded in the thorax, in the chest and the abdomen-fewer trunk wounds
because of the protective effects of that body armor. And therefore what
wounds that might previously have penetrated the chest or abdomen and
caused fatal or serious injury is not occurring. And that's led to a shift in
the proportion of casualties that we're seeing with extremity injuries and
with head and face and neck injuries.

Capt. Gerard Cox, MC, USN, Director of Medical Programs

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35
INTRODUCTION TO COMBAT CASUALTY CARE

These medical concepts are specific to battlefield casualty care:

1. Not civilian (EMS) ambulance or hospital care.

2. Involves a combat situation with the possibility of limited available medical
resources or lengthy evacuation times.

3. Concepts in this environment need to remain simple and oriented toward good
tactics.

4. Process begins with the involvement of the Warfighter.

5. If the process doesnt begin or is delayed, more casualties will die.

The Phases of Combat Casualty Care:

1. Consider the management of casualties that occur during combat missions as
being divided into three distinct phases:

2. This approach recognizes a particularly important principle: Perform the
correct intervention at the correct point on the timeline of care.

3. A medically correct intervention at the wrong time in combat may lead to further
casualties, which may be going against good tactics. Remember, the
tactical situation always take precedence over the medical situation.

%'()
*+,)( -.()
/'01.0'2
-.)2, %'()
/'01.0'2
34'05'1.6+
36
CARE UNDER FIRE PHASE

1. Care Under Fire is the care rendered by the first responder at the scene of the
injury while he and the casualty are still under effective hostile fire. Available
medical equipment is limited to that carried by the Warfighter. Typically,
equipment is made available in personal cargo pouches or provided to
individuals in personal first aid kits.

2. The risk of injury to other personnel and additional injury to the wounded will be
reduced if immediate attention is directed to the suppression of hostile fire.

3. As soon as the Warfighter is able to, keeping the casualty from sustaining
additional injuries is the first major medical objective.

4. Wounded Warfighters who are unable to participate further in the engagement
should lie flat and still if no ground cover is available, or move as quickly as
possible if nearby cover is available. If there is no cover and the casualty is
unable to move himself to find cover, he should remain motionless on the ground
so as not to draw additional fire. A tourniquet that can be applied by the casualty
himself is the most reasonable initial choice to stop major bleeding.

37

Basic Management Plan for Care Under Fire
1. Return fire and take cover.
2. Direct or expect casualty to remain engaged as a
combatant if appropriate.
3. Direct casualty to move to cover and start self-aid if
able.
4. Try to keep the casualty from sustaining additional
wounds.
5. Casualties should be extricated from burning
vehicles or buildings and moved to places of
relative safety. Do what is necessary to stop the
burning process.
6. Airway management is generally best deferred until the
Tactical Field Care phase.
7. Stop life-threatening external hemorrhage if tactically
feasible:
Direct casualty to control hemorrhage by self-aid
if able.
Use of 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.
PHTLS Military Manual Version Seven, Figure 25-1, Page 600

38

CASUALTY MOBILITY
Casualty mobility is of the utmost importance in the Care Under Fire phase of care.

Casualty drag maneuvers, hasty litters, and drag straps should be used, when needed
to rapidly and safely move a casualty to cover and concealment.

It is imperative that deploying units integrate casualty mobility exercises into their pre-
deployment training.

Consider the benefits and limitations of rigid litters during this phase of casualty care.

Casualty Movement Methods

1. Immobilize casualty
a. Default Drag: Grab any available equipment point
b. Wheelbarrow Drag: Grab both feet facing away from casualty
c. Two Person Drag: Each individual grabs a shoulder strap
d. Drag Strap: Attach a tubular nylon strap to the casualty with a D-ring
e. Multiple Rescuer Carry: Requires minimum of three persons to pick up
casualty at waist

2. Semi-Mobile Casualty
a. Assisted walk: Place the casualty over shoulder and bear the weight of
the injured casualty while moving
b. Firemans Carry: Pick up casualty and carry over shoulder (REQUIRES
CASUALTY TO ASSIST)

39

CONSIDERATIONS:

1. Understand that various situations will call for different movement techniques.
2. Casualty condition, terrain, available equipment and combat situation will all
play a part in which casualty movement method is used
3. Train on all movement techniques prior to deployment
4. Casualty movement SOPs should focus on simple and reproducible methods
that requires a minimal amount of specialty equipment.

NOTES:

40

CASUALTY MOBILITY DEVICES:

TALON II LITTER

FOXTROT LITTER

41

TACTICAL FIELD CARE PHASE

1. Tactical Field Care is the care rendered by the first responder or medic once he
and the casualty are no longer under effective hostile fire. It also applies to
situations in which an injury has occurred, but there has been no hostility.
Available medical equipment is limited to that carried into the field by the team.
Timeline during this phase may vary from a few moments to many hours.

2. This period may consist of only a short opportunity to assess and treat life-
threatening problems due to the need to re-engage threat or it may allow for long
period of casualty management.

3. Tactics, situation and evacuation time will determine the available timeframe.

42
a. With casualty behind cover/concealment perform an examination of the
casualty and determine the severity of the injuries (See Casualty
Assessment M.A.R.C.H.)
b. Apply the interventions you have been taught and do so knowing that
your situation can quickly change back to Care Under Fire.
c. Be prepared to move and continually communicate with your team.
d. Be aware of your tactical situation.
e. Use your skill and know your time limitations.
f. Get some help!
g. Initiate a TACEVAC request as soon as possible.

4. Take care to reassess earlier interventions:

a. After major movements
b. After re-engaging a threat
c. As soon and as often as the situation allows
d. Go back and look at the interventions you performed while you were under
fire. These actions were performed quickly and may not have been
effective or will not remain effective.

5. Assess the casualty in M.A.R.C.H. order:

43
a. It is essential to maintain strict adherence to the M.A.R.C.H. algorithm in
this phase of care.
b. As listed above, this phase of care may be short or long in duration. If
wounds are treated out of sequence, life-threatening wounds may remain
untreated prior to TACEVAC.

6. Packaging the casualty for movement or evacuation:

a. The casualty will need to be packaged for protection and evacuation.
Special care will be required when dealing with casualties that are no
longer awake or might lose consciousness during transport or evacuation.
b. Dust and debris during helicopter transport is expected.
c. Casualties that have lost a lot of blood are at risk for hypothermia.
d. Ensure they are covered and kept war.
e. If you are wearing ear protection then you should provide it for your
casualty.
f. Secure arms and legs as necessary-they tend to fall off stretchers during
movement and get banged up during loading casualties on helicopters
and in vehicles.
g. Do not cause further injury!

44
7. Document the casualtys condition and treatments: Fill out the TCCC
(recommended) Casualty Card (DA Form 7656), or assign a person to do
it for you.

8. PHTLS 7
th
edition Figure 26-17 pg 633

45

9. Prepare for casualty turnover.

a. Complete an A.T.M.I.S.T. report
i. The A.T.M.I.S.T report is an organized method of turning over
essential casualty information to receiving TACEVAC personnel
and receiving treatment facility.
b. The goal of the A.T.M.I.S.T report is to be organized and concise. This is
essential when turning over casualties to TACEVAC personnel in the
noisy environment of a Landing Zone.
c. Many units also use the A.T.M.I.S.T approach when passing casualty
information over the radio.

10. The A.T.M.I.S.T. report:

46

!
Age
#
Time of Injury
$
Mechanism of Injury
Examples: Gunshot wound, Blast, Motor Vehicle acciden, blunt
trauma, fall
%
Injuries Sustained
&
Signs and Symptoms
Respiratory rate, pulse rate, casualty feedback
#
Treatments
Describe what you have done and what time the procedure was
done
Organize to M.A.R.C.H or head to toe
47
Basic Management Plan for Tactical Field Care

1. Casualties with an altered mental status should be
disarmed immediately.
2. 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 obstruction:
Chin lift or jaw thrust maneuver
Nasopharyngeal airway
Allow casualty to assume any position that
best protects the airway, to include sitting
up.
Place unconscious casualty in the recovery
position.
If previous measures unsuccessful:
! Surgical Cricothyroidotomy (with
lidocaine if conscious)
3. Breathing
a. In a casualty with progressive respiratory
distress and known or suspected torso trauma,
consider a tension pneumothorax and
decompress the chest on the side of the injury
with a 14-gauge, 3.25 inch needle/catheter unit
inserted in the second intercostal space at the
midclavicular line. Ensure that the needle entry
into the chest is not medial to the nipple line and
is not directed towards the heart.
b. All open and/or sucking chest wounds should
be treated by immediately applying an occlusive
material to cover the defect and securing it in
place. Monitor the casualty for the potential
development of a subsequent tension
pneumothorax.
4. Bleeding
a. Assess for unrecognized hemorrhage and
control all sources of bleeding. If not already
done, use a CoTCCC-recommended tourniquet
application or for any traumatic amputation.
Apply directly to the skin 2-3 inches above
wound.
b. For compressible hemorrhage not amenable to
tourniquet use or as an adjunct to tourniquet
removal (if evacuation time is anticipated to be
longer than 2 hours), use Combat Gauze as the
hemostatic agent of choice. Combat Gauze
should be applied with at least 3 minutes of
direct pressure. Before releasing any tourniquet
on a casualty who has been resuscitated for
hemorrhagic shock, ensure a positive response
to resuscitation efforts (i.e., a peripheral pulse
normal in character and normal mentation of
there is no traumatic brain injury (TBI).

c. Reassess prior tourniquet application. Expose
wound and determine if tourniquet is needed. If
so, move tourniquet from over uniform and
apply directly to skin 2-3 inches above wound. If
tourniquet is not needed, use other techniques
to control bleeding.
d. When time and the tactical situation permit, a
distal pulse check should be accomplished. If a
distal pulse is still present, consider additional
tightening of the tourniquet or the use of a
second tourniquet, side-by-side and proximal to
the first, to eliminate the distal pulse.
e. Expose and clearly mark all tourniquet sites with
the time of tourniquet application. Use an
indelible marker.
5. Intravenous (IV) access
Start an 18-gauge IV or saline lock if
indicated.
If resuscitation is required and IV access is
not obtainable, use the Intraosseous (IO)
route.
6. Fluid resuscitation
Assess for hemorrhagic shock. Altered mental status
(in the absence of head injury) and weak or absent
peripheral pulses are the best field indicators of
shock.
a. If not in shock:
NO IV fluids necessary
PO fluids permissible if casualty is
conscious and can swallow
b. If in shock:
Hextend, 500-ml IV bolus
Repeat once after 30 minutes if still in
shock.
No more than 1000 ml of Hextend
c. Continued efforts to resuscitate must be
weighed against logistical and tactical
considerations and the risk of incurring further
casualties.
d. If a casualty with TBI is unconscious and has no
peripheral pulse, resuscitate to restore the
radial pulse.
7. Prevention of hypothermia
a. Minimize casualtys exposure to the elements.
Keep protective gear on or with the casualty if
feasible.
b. Replace wet clothing with dry if possible.
c. Apply Ready-Heat blanket to torso.
d. Wrap in Blizzard survival blanket.
e. Put Thermo-Lite Hypothermia Prevention
System cap on the casualtys head, under the
helmet.
f. Apply additional interventions as needed and
available.
g. If mentioned gear is not available, use dry
blankets, poncho liners, sleeping bags, body
bags, or anything that will retain heat and keep
the casualty dry.
48
Basic Management Plan for Tactical Field Care (Cont)

8. Penetrating Eye Trauma
If a penetrating eye injury is noted or suspected:
a. Perform a rapid field test of visual acuity.
b. Cover the eye with a rigid eye shield (NOT a
pressure patch).
c. Ensure that the 400 mg moxifloxacin tablet in
the combat pill pack is taken, if possible, or that
IV/IM antibiotics are given as outlined below if
oral moxifloxacin cannot be taken.
9. Monitoring
Pulse oximetry should be available as an adjunct to
clinical monitoring. Note: Readings may be
misleading in the settings of shock or marked
hypothermia.
10. Inspect and dress known wounds.
11. Check for additional wounds.
12. Provide analgesia as necessary.
a. Able to fight:
Note: These medications should be carried by
the combatant and self-administered as soon as
possible after the wound is sustained.
Mobic, 15 mg PO once a day
Tylenol, 650-mg bilayer caplet, 2 PO every
8 hours
b. Unable to fight:
Note: Have naloxone readily available
whenever administering opiates.
Does not otherwise require IV/IO access:
! Oral transmucosal fentanyl citrate
(OTFC), 800 mcg transbuccally
(a) Recommend taping lozenge-on-a-
stick to casualtys finger as an
added safety measure
(b) Reassess in 15 minutes
(c) Add second lozenge, in other
cheek, as necessary to control
sever pain.
(d) Monitor for respiratory depression.
IV or IO access obtained:
! Morphine sulfate, 5 mg IV/IO
! Reassess in 10 minutes.
! Repeat dose every 10 minutes as
necessary to control severe pain.
! Monitor for respiratory depression
! Promethazine, 25 mg IV/IM/IO every 6
hours as needed for nausea or for
synergistic analgesic effect
13. Splint fractures and recheck pulses.
14. Antibiotics (recommended for all open combat
wounds):
a. If able to take PO:
Moxifloxacin, 400 mg PO once a day
b. If unable to take PO (shock, unconsciousness):
Cefotetan, 2 g IV (slow push over 3-5
minutes) or IM every 12 hours, or
Ertapenem, 1 g IV/IM once a day

15. Burns*
a. Facial burns, especially those that occur in
closed spaces, may be associated with
inhalation injury. Aggressively monitor airway
status and oxygen saturation is such patients
and consider early surgical airway for
respiratory distress or oxygen desaturation.
b. Estimate total body surface area (TBSA) burned
to the nearest 10% using the Rule of Nines.
c. Cover the burn area with dry, sterile dressings.
For extensive burns (>20%), consider placing
the casualty in the Blizzard survival blanket in
the hypothermia prevention kit in order to both
cover the burned areas and prevent
hypothermia.
d. Fluid resuscitation (USAISR Rule of Ten):
If burns are greater than 20% of Total body
Surface Area, fluid resuscitation should be
initiated as soon as IV/IO access is
established. Resuscitation should be
initiated with Lactated Ringers, normal
saline, or Hextend. If Hextend is used, no
more than 1000 ml should be given,
followed by Lactated Ringers or normal
saline as needed.
Initial IV/IO fluid rate is calculated as
%TBSA x 10 ml/hour for adults weighing
40-80 kg, increase initial rate by 100
ml/hour.
If hemorrhagic shock is also present,
resuscitation for hemorrhagic shock takes
precedence over resuscitation for burn
shock. Administer IV/IO fluids per the
TCCC Guidelines in Section 6.
e. Analgesia is accordance with TCCC Guidelines
in Section 12 may be administered to treat burn
pain.
f. Pre-hospital antibiotic therapy is not indicated
solely for burns, but antibiotics should be given
per TCCC guidelines in Section 14 if indicated
to prevent infection in penetrating wounds.
g. All TCCC interventions can be performed on or
through burned skin in a burn casualty.
16. Communicate with the casualty if possible.
Encourage: reassure
Explain care
17. Cardiopulmonary resuscitation (CPR)
Resuscitation on the battlefield for victims of blast or
penetrating trauma who have no pulse, no
ventilations, and no other signs of life will be
successful and should not be attempted.
18. Documentation of Care
Document clinical assessments, treatments
rendered, and changes in the casualtys status on a
TCCC Casualty Card. Forward this information with
the casualty to the next level of care.

PHTLS Military Manual Version Seven, Figure 26-1, Page 613-614
49

TACTICAL FIELD CARE

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50

TACTICAL EVACUATION CARE

TRAINING OBJECTIVE:

1. Define the Warfighters role in the casualty evacuation phase of combat casualty
care.
2. Explain the importance of initiating a 9-Line.
3. Explain the importance of communication in combat casualty care.
4. Define what information is essential to CASEVAC/MEDEVAC initiation.
5. Explain the principles of managing a casualty collection point.
6. Define triage in modern combat casualty care.
7. Explain considerations unique to CASEVAC/MEDEVAC.
8. Explain proper casualty movement procedures.
9. Explain the considerations associated with the various platforms used in casualty
evacuation.
10. Answer all remaining questions regarding casualty evacuation in combat casualty
care

51

TACTICAL EVACUATION CARE

1. Combat Tactical Evacuation Care is the care rendered once an aircraft, vehicle
or boat has picked up the casualty.

2. Additional medical personnel and equipment may be available at this stage of
care, which may allow more advanced medical procedures to be performed.

3. Initiate TACEVAC early and with good information.

4. You are responsible for your casualty until you are not.

5. It is also always a good idea to preposition medical supplies if possible. You can
store them in vehicles or other strategic places in case you need them later. This
52
will allow you to have a cache of medical supplies that are too bulky or heavy for
individuals to be carrying, but are nearby if and when you need them.

CONSIDERATIONS:

1. Standard litters for patient evacuation may not be available for movement of
casualties in the care under fire phase. Consider alternate methods of patient
movement (e.g. dragging the casualty by the web gear or using ponchos, etc.).

2. Keep in mind that if you and the receiving aircraft or vehicle doesnt have the
necessary litters for all of your patients, you can floor load the patients and
secure them with cargo straps. Always defer to the direction of the flight crews
who will guide you in all patients loading and unloading.

3. Consider the use of obscurants (such as smoke) to assist in casualty movement.

4. Vehicles can also be used as shields during evacuation attempts.

5. Once the patient has been transported to the site where evacuation is
anticipated, consider loosening or removing tourniquets and using direct
pressure or direct pressure with hemostatic agents to control bleeding if the
tactical situation allows.

6. Vehicles (ground and air) present unique difficulties with ongoing patient
assessment. In the back of a noisy, dark, turbulent, and windy helicopter, it can
be impossible to perform a basic assessment (e.g. you can only feel for
respirations with a hand on the chest.

7. A patient with a wound that is not properly controlled can bleed in the back of a
53
dark vehicle without the medical providers knowledge. It is imperative that all
bleeding is absolutely controlled prior to transport.

8. Another consideration of vehicle transport is the threat of hypothermia. In rotary
winged assets you must deal with colder temperatures and high winds
associated with these assets. You must take great care to ensure your patients
are packaged warmly and appropriately.

9. Lastly, remember that more than likely there will be a limited number of medical
providers in any one particular vehicle or asset. You should ensure that as much
medical gear as possible has been given prior to transport. For instance, if there
is one medical provider in the back of a helicopter and he must provide
ventilations for one of the patients, it will be impossible for him to care for and
assess the other patients that are on board. The non-medic may need to
accompany the patient(s) so the medical provider can care for all of the patients.

10. The final phase of casualty care can be the most problematic. Casualties require
a lot of effort to prepare for transport. Insurgent attacks on advanced medical
providers and the vehicles that are utilized are common. If your casualties
require transport by helicopter you must consider the likelihood of an attack
during evacuation. Prior to evacuating your patients, secure a safe landing zone
or extraction point. Establish good communications with the incoming unit(s) and
update them if and when the situation changes.

54
INITIATING CASUALTY EVACUATION:
.
1. Initiate early. Per the usual operational SOP, only the first three lines of the 9-line
are required to initiate TACEVAC/CASEVAC. Ensure that this information is
available as early as possible.
2. Update the evacuation asset and Command & Control (C2) as the injuries and
situation are better understood or change.
3. Carry a 9-Line request card on your person.
4. Relay: Who, What, When, Where, Why and How many

ACTIONS REQUIRED PRIOR TO CASUALTY EVACUATION:

1. Control bleeding (Have a plan to do so throughout transport).

2. Airway Management (Have a plan for managing the casualtys airway throughout
transport).

3. Ensure respiration assessment is conducted for presence of tension
pneumothorax (See Respiration section).

4. Reassess M.A.R.C.H.

5. Prepare A.T.M.I.S.T. report for each casualty
Age
Time of injury
Mechanism of Injury
Injuries
Signs & Symptoms
Treatments
55

6. Reassess earlier interventions

7. Casualty eye/ear protection

8. Cross-load mission essential gear

9. Treat for hypothermia

10. Provide pain management as necessary (see page 111 for TCCC update)

ADDITIONAL CONSIDERATIONS:

1. Store bulky or heavy equipment and supplies in vehicles and evacuation assets.
These items may include:
Oxygen
Mass casualty kits
High angle rescue equipment
Vehicle extrication equipment
M.A.S.T. pants
Femur traction splint
Ice packs
Cervical collars
Hypothermia Prevention and Burn blankets

56
EVACUATION PLATFORM CONSIDERATIONS:

1. Ground or Air

2. Number of casualties/condition asset that evacuation assets/s can be taken.

3. Know the medical plan for turning casualties over.

4. Space Available.

5. Different platforms have different passenger ingress routes.

6. Always follow crew chief or flight medics instructions for loading the aircraft.

7. Situational awareness, i.e. landing zone selection, safety, etc.

ENROUTE TREATMENT CONSIDERATIONS:

1. Consider the use of NVG (Night Vision Goggle) compatible lights.

2. Senses may be impaired (wind, turbulent, darkness, etc.) Learn to use feel
instead of listen techniques

3. Not all platforms have a dedicated TACEVAC/CASEVAC medic; you may
become the TACEVAC/CASEVAC medical provider needed to assist.

4. Have all the kit you will need for the flight (plan ahead in case of flight delays).
57
COMBAT CASUALTY TRIAGE

1. The following is one of many triage systems.

2. Your medical control and casualty evacuation system must support this
system prior to using it.

TRIAGE PRINCIPLES:

1. Do the greatest good for the greatest number of casualties.

2. Employ the available resources in the most efficient way.

3. Triage does not stop, it only repeats.

1. 4. Current triage concepts focus on establishing casualty treatment and
evacuation priority.

4. Focus on updating the Command & Control (C2) element in real time.

5. Plan, prepare and train for triage situations.

TRIAGE CONSIDERATIONS:

1. 1.Triage should:
a. Be used when the number of casualties overwhelms the
medical treatment capabilities, not when medical treatment
providers are not comfortable with the number of casualties.
b. Casualties may be neglected in mass casualty situations.

2. All the casualties will be treated. Triage is focused on the order and priority of
treatment, not which casualties will receive treatment. The exception is casualties
with wounds incompatible with life and those showing no signs of life.

3. Utilize ALL available personnel not currently involved in security operations or
Command & control (C2) efforts.
58

4. Take into account resupply assets when making decisions regarding how many
medical supplies to use.

TRIAGE CATEGORIES:

1. Immediate: Casualties with high chances of survival who require life-saving
surgical procedures or medical care.

2. Delayed: Casualties who require surgery or medical care, but whose general
condition permits a delay in treatment without unduly endangering the
casualty.

3. Minimal: Casualties who have relatively minor injuries or illnesses and can
effectively care for themselves or be helped by non-medical personnel.

4. Expectant: Casualties with wounds so extensive that even with the benefit of
optimal medical resource application, their survival is unlikely.

CASUALTY COLLECTION POINT OPERATIONS

1. Ensure area is secure.

2. Place all casualties in a manageable configuration. See the Tactical Field Care
section for diagram.

3. Consolidate medical supplies.

4. Triage; Number, Severity, Supplies

5. Ensure Command and control (C2) group is given current reports of casualty
conditions and triage status.

6. Your entire team must understand the principles of CCP operations and the
correct configuration of casualties and resources.
59

NOTES:

60
CASUALTY COLLECTION POINT CONFIGURATIONS:

1. TRIANGLE CONFIGURATION
a. Beneficial to distribution of medical supplies and information.
b. Arguable more tactically sound than other methods
c. Casualties should be placed with their heads pointed to the center of the
triangle for easy assessment of their airways.

61
2. LINEAR CONFIGURATION
a. Easy to organize
b. Allows for easiest priority of movement to TACEVAC/CASEVAC

62

HEMORRHAGE CONTROL


1. Explain the importance of hemorrhage control in combat casualty care.

2. Define the Warfighters role in hemorrhage control.

3. Describe hemorrhage control concepts.

4. Describe and demonstrate proper direct pressure application.

5. Explain current tourniquet application concepts.

6. Demonstrate the application of tourniquets in DOD circulation.

7. Perform tourniquet practical application lab.

8. Explain correct application of gauze in combat wounds.

9. Demonstrate the application of pressure dressings in DOD circulation.
63

10. Perform pressure dressing practical application lab.

11. Define hemostatic agent application criteria.

12. Explain the process of applying hemostatic agents.

13. Define hemostatic agent re-application criteria.

14. Explain post application management of wounds treated with hemostatic
agents.

15. Answer all remaining questions regarding hemorrhage control in combat
casualty care.

64
HEMORRHAGE CONTROL METHODS

PRIMARY METHODS:

1. Direct Pressure
2. Tourniquets
3. Wound Packing
4. Hemostatic Agent
5. Pressure Dressing

ADJUNCT METHODS:
(Not definitive, makes your primary interventions more effective).

1. Indirect pressure
a. Leg pressure points.
b. Arm pressure points.
2. Elevation
3. Anatomical/Rigid Splinting
NOTES:

65

DIRECT PRESSURE

THE GOAL OF DIRECT PRESSURE TO COMPRESS THE BLEEDING VESSEL
AGAINST THE BONE

CONSIDERATIONS FOR DIRECT PRESSURE:

1. Direct pressure is the usual initial control measure for hemorrhage. Your first
response in most settings is direct pressure. While the tourniquet is being
retrieved from its storage location-apply direct pressure to the wound to control
the bleeding. Use gauze, a blouse or anything that will assist you in applying
direct pressure. If the wound requires the application of a hemostatic agent,
apply direct pressure while you locate the agent and prepare to apply it. Time is
critical and the tactical situation always takes precedence over the medical
situation. Apply direct pressure while assessing the situation and decide the
correct course of action.

2. Palm pressure as opposed to Finger Tip pressure:

a. Diffuse pressure is key, no artery hunting with fingertips.

b. More effective due to the surface area covered.

c. Allows for greater pressure to be applied.

d. Can be maintained for long periods.

e. Fingertip pressure does not provide full contact with wound.

3. Body position is important

a. Arms are straight to reduce fatigue.

b. Shoulders are directly over the wound.

66
c. Full body weight is required to compress an arterial injury.

4. Packing material is packed into the wound to assist direct pressure.

a. Packing material means gauze, other bandage material or clothing in a
resource limited environment.

b. Packing material allows for more pressure into the wound.

c. Packing material must be in full contact with the wound site to be effective.

5. Hemostatic agents increase the effectiveness of direct pressure, but direct
pressure is critical for the success of hemostatic agents.

6. Direct pressure requires the ground or another hard surface under the casualty
for counter pressure

7. Direct pressure must be dedicated.

a. Do not remove direct pressure to assess the wound. This will invite re-
bleeding. Re-bleeding can be fatal.

b. When transitioning to a pressure bandage, do not release pressure from
the wound.

8. Kneeling on wound site in extreme situations.
a. A knee may be effective if gauze allows transmission of pressure to
wound.

67

NOTES:

68
TOURNIQUETS

Extremity Bleeding

1. One of the first considerations for bleeding control

a. The amount of blood loss is an important factor in patients survival, in the
absence of unlimited medical resources (blood, I.V. Fluids, etc.) and the
length of time before the patient will receive definitive treatment

b. The first choice during CARE UNDER FIRE PHASE

c. A bleeding wound requires pressure enough to block the arteries.

d. Tactical situation requires immediate management of blood loss to ensure
the best outcome for the casualty.

2. Lessons from OEF/OIF indicate the use of tourniquets provides better outcome
for casualties.

a. Quickest and easiest way to control extremity hemorrhage

b. Should be used on bleeding extremities initially

NOTES:

69

Figure 26-4 PHTLS Manual 7
th
Edition pg. 619

FIGURE 26-4 Tourniquet Tips
POINTS TO REMEMBER
Damage to the arm or leg is rare if the tourniquet is left on
less than 2 hours
Tourniquets are often left in place for several hours during
surgical procedures
In the face of massive extremity hemorrhage, it is better to
accept the small risk of damage to the limb than to allow a
casualty to bleed to death.
SIX MAJOR TOURNIQUET MISTAKES
1. Not using the tourniquet when it should be used
2. Using a tourniquet when it should not be used
3. Putting the tourniquet on too proximally
4. Not tightening the tourniquet well enough
5. Not taking the tourniquet off when possible
6. Periodically loosening the tourniquet to allow intermittent
blood flow
DEATH FROM EXANGUINATION
How long does it take to bleed to death from a complete femoral
artery and vein disruption?
Casualties with such an injury are likely to die in about 10
minutes, but some will bleed to death in as little as 3 minutes.
TOURNIQUET APPLICATION
1. Apply without delay for life-threatening bleeding in the Care
under Fire phase
Both the casualty and the corpsmen/medic are in serious
danger while a tourniquet is being applied in this phase
The decision regarding the relative risk of further injury versus
that of bleeding to death must be made by the person
rendering care
NOTE: The life-saving benefit of a tourniquet is far more
pronounced when the tourniquet is applied BEFORE the casualty
70
has gone into shock from his wound.
2. Non-life-threatening bleeding should be ignored until the
Tactical Field Care phase
3. Apply proximal to the site of hemorrhage over the uniform
during Care Under Fire
4. Tighten the tourniquet until bleeding stops
5. During Tactical Field Care, expose the wound and reapply the
tourniquet directly to the skin 2-3 inches above the bleeding
site
6. Check for distal pulse
7. Tighten the tourniquet or apply a second tourniquet side-by-
side and just proximal to the first as needed to eliminate the
distal pulse
8. Note the time of tourniquet application
REMOVING THE TOURNIQUET
Remove as soon as direct pressure or hemostatic dressings
become feasible and effective, unless the casualty is in shock
or the tourniquet has been on for more than 6 hours
Only a combat medic, or physicians assistant, or a physician
should remove the tourniquets
Do not remove tourniquet if the distal extremity is gone
Do not attempt to remove the tourniquet if the casualty will
arrive at a hospital in 2 hours or less after application
TECHNIQUE FOR REMOVAL
1. Apply Combat Gauze as per instructions
2. Loosen the tourniquet
3. Apply direct pressure for 3 minutes
4. Check for bleeding
5. If no bleeding, apply pressure dressing over the Combat
Gauze
6. Leave tourniquet in place but loose
7. Monitor for bleeding from underneath the pressure dressings
8. If bleeding does not remain controlled, retighten tourniquet,
remove dressings, and expedite evacuation

71

TOURNIQUET APPLICATION:

1. Ensure tourniquet is as tight as possible prior to engaging the windlass or other
mechanical system.
2. The common problem with tourniquet application is OIF/OEF is that they are not
tight enough.
3. Ensure the tourniquet is secured after it is tightened.
4. The tourniquet should ideally be applied directly to the skin. Remove the uniform
if possible.
5. Use two if necessary:
a. The second tourniquet should ideally be applied above the first if possible.
6. Mark the tourniquet (Time of placement)
NOTES:

72
STATISTICS ON TOURNIQUET USE

Kragh 2009

91% of tourniquet use in Baghdad was 2 hours or less with low risk of
complications.

Kragh 2008 Baghdad Combat Support hospital)
85% of battle casualties with (one or more) tourniquets had the device applied
before arrival to a facility (prehospital tourniquet)
15% had their first tourniquet applied in the hospital.

Kragh 2009
232 patients; 428 tourniquets were used on 300 limbs
31 of these died due to primary injury; secondary was hemorrhage with no
deaths attributed to tourniquet use
10 patients had tourniquet use AFTER shock and 9 died
222 patients had tourniquets used BEFORE shock and 22 died
No amputations were solely due to tourniquet use
40% of Tourniquets placed pre-hospital are NOT MARKED

Kragh 2011
The pressure in or under the tourniquet is not the key to optimal use.
The key to effectiveness is the occluding the artery,
Users often assume that optimal use requires more force, but optimal use is not
synonymous with effective use; optimal use must include safe use.
More force was associated with misuse.

73
IDEAL EMERGENCY TOURNIQUET TRAITS

TRAIT IDEAL
Effective Stops distal pulse
Use width Wide compression
Length Fits casualty
Use ease Simple to apply
Weight Low carry weight
Tactical use Care under fire
Cost Inexpensive
Torque control User can limit force
Size small volume
Application speed don quickly
Self-application casualty dons on and off
Open-ended design can route proximal
Don single handedly single-handed
Toughness wears little in use
Doff emergently rapid removal
Stable stays effective
Mechanics internal capacity
Power twist or pump
Placement stays put
Multisetting field to hospital
Replacement can don again
Repair ease few repairs needed
Cleaning ease washes quickly
Storage cube stores densely
Storage life shelf life>10 years
Safety safe use limit
Safe pressure manometer
Monitors pressure, timer
Conformity kept maintains shape
Rugged materials field ready
User expectations preconceptions met

Abridged from Kragh JF. The military emergency tourniquet program's lessons
learned with devices and designs. Mil Med 176:1144 (2011) Table III. Ideal Emergency
Tourniquet Traits

74

TOURNIQUET REASSESSMENT:

1. Tourniquets applied in the combat environment may become ineffective after the
initial success due to:
a. Casualty movement
b. Shifting of the tourniquet due to placement over uniform
c. Anatomical changes in the shape of the extremity due to movement
d. Physiological changes in the casualty as a result of I.V. fluid treatments
e. Removal or loosening of the tourniquet by the casualty due to pain

2. Reassess the wound for re-bleeding:
a. After making movement
b. After rolling the casualty
c. After engaging an enemy threat
d. After augmenting the casualtys circulatory volume
e. As often as possible

75
PAIN CONSIDERATIONS:

1. Tourniquets are painful when applied

a. When properly applied, a tourniquet can cause more pain than the wound.

b. Casualties with tourniquets applied may beg for the tourniquet to be
removed or attempt to remove it themselves.

c. Tourniquets become more painful over time (ischemia sets in
approximately 20 minutes after application). Pain management
considerations should take into account this anticipated tourniquet pain.

d. Reassurance and pain management is important.

NOTES:

76
TOURNIQUET REMOVAL

The decision to remove a tourniquet should be made by a medical provider

PICKING THE RIGHT TOURNIQUET:

1. Types of Tourniquets:
a. Mechanical
b. Windlass
c. Pneumatic
d. Other
2. Combat Effective Tourniquet Criteria:
a. Must STOP arterial blood flow in the lower extremities.
b. You must be able to self-apply the tourniquet.
c. Incremental (ratcheting) adjustment to increase pressure or decrease
pressure.
3. Should be tested and approved by medical control.

NOTES:

77

TOURNIQUETS

CoTCCC Approved

1. Combat Application Tourniquet (C-A-T): wide strap with Velcro and stick for windlass

C-A-T Generation 6

Emergency Tourniquet Program
example, the inner strap folds went clockwise or counterclock-
wise depending on the direction of hand twisting of the wind-
lass (plastic rod of glass-reinforced nylon with a chamfered
slot passing the inner strap). More importantly, when the CAT
was applied loosely (not enough slack was taken out) before
windlass twisting began, too many twists of the windlass were
needed (>540, one twist was 180) to take in the slack before
compressing the limb. Such loosely applied devices had to be
overtwisted since hemorrhage was not controlled with fewer
twists and the device rolled in the direction of twisting (Fig, 2),
As roll progressed, the windlass and its slot became perpen-
dicular to the pull of the inner strap instead of being parallel as
it was before twisting. Roll then put the windlass at a structural
and mechanical disadvantage as less than half of the windlass
diameter resisted torque instead of the whole. This phenom-
enon was observed in care, and direct feedback for complying
with the instructions to remove slack before twisting the wind-
lass minimized roll and improved results. Noncompliance led
to device deformation, breakage, and ineffectiveness. Most
(63%, 61/97) CAT windlass rods had a craze, a fine crack,
at the chamfered slot; and this undisplaced crack occurred
only at one spot, <2.5 mm from the apex (Fig. 3), The crazes
were seen as a fine, white-gray line originating at the slot apex
and going outward; they originated adjacent to the site of the
maximal inner strap deformation. Furthermore, in rare occa-
sions, the inner strap tore before the windlass broke; and in
these cases, there was no craze. Therefore, the windlass was
the weakest component more often than the inner strap. In
laboratory testing, a craze was caused to form with forceful
torque and even to break the windlass. Several CATs that were
similarly damaged during training, familiarization, and infor-
mal assessments were also gathered. Breaks originated only
at the craze. Discussions with the manufacturer indicated that
the device engineers knew that the mechanical and structural
properties are well beyond the clinical need of effective force
and that the overtwisting in misuse might lead to breakage,
which was a way to keep users from harming casualties inad-
vertently. These facts converge on the idea that overtwisted
windlasses can be broken. This occurred rarely in clinical use
but commonly in the laboratory when the slack was not taken
out before twisting and overtwisting rolled the windlass slot
perpendicular to the intended use.
EMT, the Most Common Hospitai Device
The EMT (Fig. 4), designed and distributed by Delfi Medical
Innovations (Vancouver, BC, Canada), was invented by a
team led by James A. McEwen and made by a company with
extensive organizational expertise in designing tourniquets for
elective use in the operating room. The company is led by a
clinical engineer, and the EMT is manufactured in a surgical
tourniquet manufacturing facility with extensive quality con-
trol measures.
The EMT device is a pneumatic tourniquet that has a blad-
der that goes around the limb, a clamp that limits the inflated
portion while holding the bladder close to the limb, and an
inflator bulb with connector tube and twist cap. The bladder,
88 mm wide, has midpoint spot welds so that the cuff lies
flat and wide on the skin and does not become torus shaped
and roll down the limb. These features make it similar to a
FIGURE 2, CATs before and after twisting.
Photograph of the CATs in a laboratory demonstration without (left) and with
rod twisting (right). The left CAT band is perpendicular to the long axis of the
limb, and all the slack was pulled out; the right CAT was perpendicular, but
some slack remained before twisting. The twisting made the right CAT band
yaw right (the top portion turned right) with right-handed twisting (applier's
wrist supination). The right CAT has begun to roll (right) and pitch forward
slightly in this process, and continued to do so when overtwisted in clinical
use. As the inner strap twisted about the rod aperture, the outer, self-adhering
band became redundant and bunched up as the limb was compressed so the
strap folds became proininent.
FIGURE 3. CAT alter use and windlass pieces after breakage.
Photograph of a portion of a CAT below in the USAISR laboratory demon-
strating the craze on the right side of the windlass aperture as a fine white line
(with cross-striations along the materials microfibers). The craze is transverse
to the rod and is underlaid by the edge of the inner strap. The CAT windlasses
above are shown in pieces after a laboratory test demonstrating that the break-
age began at the craze.
1148
MILITARY MEDICINE, Vol. 176, October 2011
78
C-A-T before (LEFT) and after (RIGHT) twisting

C-A-T after use and windless pieces after breakage

2. SOF-T Tourniquet: No Velcro, Strap with screw to prevent release and aluminum bar
for windlass.

Emergency Tourniquet Program
example, the inner strap folds went clockwise or counterclock-
wise depending on the direction of hand twisting of the wind-
lass (plastic rod of glass-reinforced nylon with a chamfered
slot passing the inner strap). More importantly, when the CAT
was applied loosely (not enough slack was taken out) before
windlass twisting began, too many twists of the windlass were
needed (>540, one twist was 180) to take in the slack before
compressing the limb. Such loosely applied devices had to be
overtwisted since hemorrhage was not controlled with fewer
twists and the device rolled in the direction of twisting (Fig, 2),
As roll progressed, the windlass and its slot became perpen-
dicular to the pull of the inner strap instead of being parallel as
it was before twisting. Roll then put the windlass at a structural
and mechanical disadvantage as less than half of the windlass
diameter resisted torque instead of the whole. This phenom-
enon was observed in care, and direct feedback for complying
with the instructions to remove slack before twisting the wind-
lass minimized roll and improved results. Noncompliance led
to device deformation, breakage, and ineffectiveness. Most
(63%, 61/97) CAT windlass rods had a craze, a fine crack,
at the chamfered slot; and this undisplaced crack occurred
only at one spot, <2.5 mm from the apex (Fig. 3), The crazes
were seen as a fine, white-gray line originating at the slot apex
and going outward; they originated adjacent to the site of the
maximal inner strap deformation. Furthermore, in rare occa-
sions, the inner strap tore before the windlass broke; and in
these cases, there was no craze. Therefore, the windlass was
the weakest component more often than the inner strap. In
laboratory testing, a craze was caused to form with forceful
torque and even to break the windlass. Several CATs that were
similarly damaged during training, familiarization, and infor-
mal assessments were also gathered. Breaks originated only
at the craze. Discussions with the manufacturer indicated that
the device engineers knew that the mechanical and structural
properties are well beyond the clinical need of effective force
and that the overtwisting in misuse might lead to breakage,
which was a way to keep users from harming casualties inad-
vertently. These facts converge on the idea that overtwisted
windlasses can be broken. This occurred rarely in clinical use
but commonly in the laboratory when the slack was not taken
out before twisting and overtwisting rolled the windlass slot
perpendicular to the intended use.
EMT, the Most Common Hospitai Device
The EMT (Fig. 4), designed and distributed by Delfi Medical
Innovations (Vancouver, BC, Canada), was invented by a
team led by James A. McEwen and made by a company with
extensive organizational expertise in designing tourniquets for
elective use in the operating room. The company is led by a
clinical engineer, and the EMT is manufactured in a surgical
tourniquet manufacturing facility with extensive quality con-
trol measures.
The EMT device is a pneumatic tourniquet that has a blad-
der that goes around the limb, a clamp that limits the inflated
portion while holding the bladder close to the limb, and an
inflator bulb with connector tube and twist cap. The bladder,
88 mm wide, has midpoint spot welds so that the cuff lies
flat and wide on the skin and does not become torus shaped
and roll down the limb. These features make it similar to a
FIGURE 2, CATs before and after twisting.
Photograph of the CATs in a laboratory demonstration without (left) and with
rod twisting (right). The left CAT band is perpendicular to the long axis of the
limb, and all the slack was pulled out; the right CAT was perpendicular, but
some slack remained before twisting. The twisting made the right CAT band
yaw right (the top portion turned right) with right-handed twisting (applier's
wrist supination). The right CAT has begun to roll (right) and pitch forward
slightly in this process, and continued to do so when overtwisted in clinical
use. As the inner strap twisted about the rod aperture, the outer, self-adhering
band became redundant and bunched up as the limb was compressed so the
strap folds became proininent.
FIGURE 3. CAT alter use and windlass pieces after breakage.
Photograph of a portion of a CAT below in the USAISR laboratory demon-
strating the craze on the right side of the windlass aperture as a fine white line
(with cross-striations along the materials microfibers). The craze is transverse
to the rod and is underlaid by the edge of the inner strap. The CAT windlasses
above are shown in pieces after a laboratory test demonstrating that the break-
age began at the craze.
1148
MILITARY MEDICINE, Vol. 176, October 2011
79

TOURNIQUETS SUMMARY:

1. In Care Under Fire apply tourniquet on extremity as close to torso as possible

2. Apply it tight

3. Reassess often

4. Ensure that any tourniquet that you or your team carries is approved by your
medical control.

5. Learn how it is used-train frequently.

a. Train your team: Ensure everyone you deploy with or work with knows
how to use your type of tourniquet and you know how to use his or hers.

b. Practice using it
1. -One hand application
2. -Two hand application
3. -Upper extremity
4. -Lower extremity
5. -Under light conditions
6. -Under no-light conditions.

ii. Know how to use it----absolutely.

6. Carry it with you-all the time-and carry more than one.

2. 7. C-A-T shown to be the safest and most effective tourniquet and requires
30% less pressure to achieve successful occlusion of the blood flow, which
means that the C-A-T is not only more effective, but also less likely to cause
permanent nerve damage, faciotomies, an amputation or blood clots. (Kragh
JF. The military emergency tourniquet program's lessons learned with devices
and designs. Mil Med 176:1144 (2011). C-A-T has been recommended as the
80
primary battlefield tourniquet by US Army Institute of Surgical Research
(USAISR) and TCCC Committee

NOTES:

81
WOUND PACKING

THE GOAL OF WOUND PACKING:

1. Wound packing transmits pressure to the source of the bleeding.
2. Maintain the pressure that wound packing provides.
a. Maintaining pressure on the source of bleeding while packing the wound is
of critical importance.
b. This is accomplished by performing a one for one placement of pressure
while packing. This means that prior to removing pressure from one hand,
there must be pressure in place from the opposite hand
3. Pack out the entire wound.
a. Emphasis should be placed on directing pressure to the source of
bleeding and then to the sides of the wound.
4. Pack to the bone:
a. In many cases, it is very difficult to find the source of the bleeding.
b. Default to packing to the bone.
c. Large arteries lay close to large bone structures.

82

FEMORAL INJURY

83
WOUND PACKING MATERIAL:

1. Gauze:
a. Gauze is used as the primary packing material because of its surface area
and ability to conform to wound created by high velocity weapons.

b. By filling and conforming to the wound, gauze allows for better application
of pressure to the source of bleeding.

c. Applying gauze to a wound without a source of pressure is nothing more
than wound decoration and will not result in hemorrhage control.

2. Tampons:
a. A tampon will not conform to the inner surface of a ballistic wound.

3. Miscellaneous Material:
a. If no gauze is available, other material may be used to include uniforms
and elastic bandaging material.

84

PRESSURE DRESSINGS

1. Definition of Dressings

a. Gauze with a means to hold itself in place.
b. Dressings are more absorbent and provide better protection to wounds
than just gauze.
c. Reasonable answer as the only intervention for minor wounds left over
after addressing massive bleeding.

2. Definition of Pressure Dressings:

a. Includes elastic material, which allows the dressing to hold a pressure
load.
b. Allows for application of increased pressure to the wound site.
c. Maintains long-term direct pressure at the wound site in absence of palm
pressure.
d. Allows for responder to move on to next wound.
e. The effective use of elastic wrap and gauze together has spawned new
dressings.

Notes:

85
PRESSURE DRESSING APPLICATION:

1. Long-term combination of pressure and gauze.

2. Allows for application of increased pressure to the wound site providing better
management of blood loss.

3. Pressure at wound site must be greater than or equal to pressure of blood exiting
wound.

4. Application Principles:

a. Keep dressing flat
b. Anchor dressing/ make sure it will not shift
c. Multiple wraps are what increase pressure/effectiveness.
d. Wrap above and below the wound to account for wound tracks
Notes:

86
TYPES OF PRESSURE DRESSINGS:

1. Israeli (Emergency Bandage) Dressing

2. Cinch Tight Dressing

3. Elastic Bandage

87

HEMOSTATIC AGENTS

Training Objectives:

1. Provide an answer to injuries that are not manageable through other techniques
due to their severity and location on the body.

2. Application Locations:

a. Axilla (Shoulder)

b. Inguinal Crease (Groin)

3. Application Criteria:

a. Arterial Bleeding
b. High Pressure
c. High volume
d. Non-compressible
e. Not able to be controlled with a tourniquet.

4. Hemostatic agents come at a cost:

a. Complexity of application
b. Time required to apply.
c. Requires special packaging and handling of casualty.
d. High potential of re-bleeding.

5. Not currently designed to deal with:
88

a. Abdominal injury (belly wounds).

b. Intra-thoracic injury (chest wounds).

6. Hemostatic agents are used where other less costly techniques are not
successful or applicable.

7. The use of a hemostatic agent is aimed at solving one problemthe occlusion or
partial reduction of an arterial insult that is unable to be controlled by lesser
methods.

8. Hemostatic agent application is a complex process that requires a systematic
approach to ensure application success on the battlefield.

89

HEMOSTATIC AGENTS

PURPOSE:

1. Provide an answer to injuries that are not manageable through other
techniques due to their severity and location on the body.

2. Facilitate clot formation on high limb (torso-extremity junction) arterial I
njury.

3. The use of a hemostatic agent is aimed at solving one problem-the
occlusion or partial reduction of an arterial insult that is unable to be
controlled by lesser methods.

4. Currently designed for a free-flowing bleeding wound accessible from the
surface.

90
APPLICATION:

1. Application Locations (Edge of Armor Injuries):
a. Axilla (Shoulder)
b. Inguinal Crease (Groin)
c. Neck

2. Primary Application Criteria:
a. Arterial Bleeding
b. High Pressure
c. High Volume
d. Not able to be controlled with a tourniquet
e. Not able to be controlled with a pressure dressing

3. Secondary Application Criteria (Gauze based agents): Extremity wound in
conjunction to pressure dressing to reduce tourniquet.

4. Not currently designed to deal with:
a. Abdominal injury (belly wounds).
b. Intra-thoracic injury (chest wound).
c. NEVER place inside a body cavity (chest, abdomen, skull or pelvis).
91
PRIMARY HEMOSTATIC AGENT APPLICATION LOCATIONS:
(CIRCLE AREAS)

92
CONSIDERATIONS:

1. Hemostatic agents are not magic:
a. A hemostatic agent is an augmentation to pressure, not a replacement
for pressure

2. Hemostatic agent management:

a. Cover agent with gauze and a firm pressure dressing after successful
application to maintain control of bleeding
b. Re-examine wound for signs of additional blood loss or clot breakage.
c. If clot breaks apply direct pressure and reapply with more hemostatic
agent or gauze
d. Apply anatomical and rigid splinting techniques to avoid excessive
movement of injured area

3. Hemostatic agent applications require gauze
reinforcement and a pressure dressing

4. Problems with use of hemostatic agents:

a. Reliance on hemostatic agents as the only method of controlling
junctional bleeding
b. Not applying the agent to the source(s) of the bleeding
c. Allowing the agent to shift away from the source of the bleeding
d. Removing pressure from the wound
e. Not reinforcing the agent with a firm pressure dressing
f. Improper training
93

5. Proper Training:
a. All hemostatic agents must be used correctly to achieve any benefit
b. Hands-on-training is essential and intensive LTT experience is best
c. Proficiency in the use of standard gauze in wound packing is essential
to hemostatic agent application

COMBAT GAUZE:

94

1. Combat Gauze is made from cotton material that has been
impregneated with a clotting agent. This agent does not produce
heat and can be applied to any actively bleeding wound.

2. Combat Gauze is applied just as you would apply regular gauze.
The product MUST touch the point of bleeding directly with constant
direct pressure. Dedicated direct pressure must be applied and
maintained on the wound to control bleeding.

3. TCCC guidelines recomends Combat Gauze as the first line of
treatment for life threatening hemorrhage that is not amenable to
tourniquet placement.

TCCC guideline update 8 August 2011/ 7 Sept 2012. Tactical Field Care, section
4. Bleeding, item b.

2

Basic Management Plan for Tactical Field Care

1. Casualties with an altered mental status should be disarmed
immediately.

2. Airway Management
a. Unconscious casualty without airway obstruction:
- Chin lift or jaw thrust maneuver
- Nasopharyngeal airway
- Place casualty in the recovery position
b. Casualty with airway obstruction or impending airway obstruction:
- Chin lift or jaw thrust maneuver
- Nasopharyngeal airway
- Allow casualty to assume any position that best protects the
airway, to include sitting up.
- Place unconscious casualty in the recovery position.
- If previous measures unsuccessful:
- Surgical cricothyroidotomy (with lidocaine if
conscious)

3. Breathing
a. In a casualty with progressive respiratory distress and
known or suspected torso trauma, consider a tension
pneumothorax and decompress the chest on the side of the injury
with a 14-gauge, 3.25 inch needle/catheter unit inserted in the
second intercostal space at the midclavicular line. Ensure that the
needle entry into the chest is not medial to the nipple line and is
not directed towards the heart.
b. All open and/or sucking chest wounds should be treated by
immediately applying an occlusive material to cover the defect
and securing it in place. Monitor the casualty for the potential
development of a subsequent tension pneumothorax.

4. Bleeding
a. Assess for unrecognized hemorrhage and control all sources of
bleeding. If not already done, use a CoTCCC-recommended tourniquet
to control life-threatening external hemorrhage that is anatomically
amenable to tourniquet application or for any traumatic amputation.
Apply directly to the skin 2-3 inches above wound.
b. For compressible hemorrhage not amenable to tourniquet use or
as an adjunct to tourniquet removal (if evacuation time is
anticipated to be longer than two hours), use Combat Gauze as
the hemostatic agent of choice. Combat Gauze should be applied
with at least 3 minutes of direct pressure. Before releasing any
tourniquet on a casualty who has been resuscitated for
95

NOTES:

8
development of a subsequent tension pneumothorax.

3. Bleeding
a. Assess for unrecognized hemorrhage and control all sources of
bleeding. If not already done, use a CoTCCC-recommended tourniquet
to control life-threatening external hemorrhage that is anatomically
amenable to tourniquet application or for any traumatic amputation.
Apply directly to the skin 2-3 inches above wound.
b. For compressible hemorrhage not amenable to tourniquet use or
as an adjunct to tourniquet removal (if evacuation time is
anticipated to be longer than two hours), use Combat Gauze as
the hemostatic agent of choice. Combat Gauze should be applied
with at least 3 minutes of direct pressure. Before releasing any
tourniquet on a casualty who has been resuscitated for
hemorrhagic shock, ensure a positive response to resuscitation
efforts (i.e., a peripheral pulse normal in character and normal
mentation if there is no TBI.) If a lower extremity wound is not
amenable to tourniquet application and cannot be controlled by
hemostatics/dressings, consider immediate application of
mechanical direct pressure including CoTCCC recommended
devices such as the Combat Ready Clamp (CRoC).
c. Reassess prior tourniquet application. Expose wound and determine if
tourniquet is needed. If so, move tourniquet from over uniform and apply
directly to skin 2-3 inches above wound. If a tourniquet is not needed,
use other techniques to control bleeding.
d. When time and the tactical situation permit, a distal pulse check
should be accomplished. If a distal pulse is still present, consider
additional tightening of the tourniquet or the use of a second
tourniquet, side by side and proximal to the first, to eliminate the
distal pulse.
e. Expose and clearly mark all tourniquet sites with the time of
tourniquet application. Use an indelible marker.

4. Intravenous (IV) access
a. Reassess need for IV access.
- If indicated, start an 18-gauge IV or saline lock
- If resuscitation is required and IV access is not obtainable,
use intraosseous (IO) route.

5. Tranexamic Acid (TXA)
If a casualty is anticipated to need significant blood transfusion (for
example: presents with hemorrhagic shock, one or more major
amputations, penetrating torso trauma, or evidence of severe bleeding)
96
Other Hemostatic AgentsTHESE ARE NOT CoTCCC
recommended; only Combat Gauze is.
1. HemCon

2. Quick Clot ACS
QC ACS QC ACS+

97

3. Celox

98

HEMORRHAGE CONTROL SUMMARY

1. Focus is needed to understand how to deal with massive hemorrhage management.

2. Achieve control of situation through:
a. No hesitation
b. Standardized approach to management
c. Positive control of the wound site
d. Communication
e. Team work

3. Success is based on maintaining pressure sufficient to occlude or partially occlude
artery (i.e. sufficient direct pressure).

4. Principles of Arterial Wound Management:
a. Achieve complete or partial hemorrhage control with pressure and gauze.
b. Early application of a tourniquet if possible.
c. The addition of a hemostatic agent as an adjunct to pressure and gauze if
bleeding is still uncontrolled.
d. Furthering management of wound with pressure dressing and splinting.

NOTES:

99
AIRWAY MANAGEMENT


1. Explain the relevance of airway management in combat casualty care.
2. Define the goal of airway management.
3. Explain the Warfighters role in airway management.
4. Explain mechanisms that cause airway obstruction in combat casualty care.
5. Explain airway obstruction signs and symptoms.
6. Explain and demonstrate airway assessment.
7. Explain the difference between an adequate and an inadequate airway and how to
recognize the difference in the field.
8. Explain the management of conscious patients with airway obstruction.
9. Explain and demonstrate airway management techniques for casualties with altered
mental status.
10. Explain and demonstrate manual airway techniques.
11. Perform manual airway procedure practical application lab.
12. Explain the role of nasopharyngeal airway adjuncts in combat casualty care.
13. Perform nasopharyngeal airway practical application lab.
14. Explain the importance of recognizing an airway obstruction that requires medically
trained personnel to manage.
15. Answer all remaining questions regarding airway management in combat casualty
care.
100
AIRWAY MANAGEMENT

CLEAR & SECURE AIRWAY + VENTILATION (AS NEEDED)
=
LIVE CASUALTY

AIRWAY MANAGEMENT GOAL: The aim is to achieve an open and secure airway
that will enable ventilation to be maintained.

1. The quickest way of evaluating the airway is to ask the casualty Are you alright?

2. If he can answer you:

a. He/she is, at least temporarily controlling his/her own airway.
b. The casualty is not struggling too much to breath.
c. Cerebral perfusion is sufficient to maintain consciousness and mental
function.
d. Need to consider the mechanism of injury, will the airway become obstructed
later?
e. What happens if the casualty vomits?

AIRWAY OBSTRUCTIONS:

1. Consider the airway as a simple tube or cylinder. There are essentially three ways
in which the internal diameter can be reduced or compromised. These are:
a. Obstruction in the airway tube or opening
b. Something in the wall of the tube protruding into the inside
c. Something pressing on the outside of the tube

2. Mechanism of Injury:
a. Altered mental status
b. Penetrating trauma
c. Burns
d. Blast (unconsciousness)
e. Blunt trauma
101

3. Airway obstruction may be partial or complete and may have a rapid or delayed
onset

4. Types of Obstructions:
a. Tongue (MOST COMMON CAUSE)
b. Distorted anatomy
c. Vomit or mucus
d. Foreign bodies
e. Blood from trauma
f. Swelling from burns
g. Swelling from trauma
h. Air trapped under skin/ Blood trapped under skin (Hematoma)
i. Posture of neck
j. Anaphylaxis from an allergic reaction

NOTES:

102
TYPES OF AIRWAY OBSTRUCTION:

TONGUE OBSTRUCTION:

FOREIGN BODY OBSTRUCTION:

103
GOAL OF AIRWAY ASSESSMENT: The goal of an airway assessment is to
rapidly determine if the casualty has any of the following:

1. Open airway

2. Active breathing

3. Airway obstruction (complete or partial)
a. Complete obstruction
b. Partial obstruction

4. Injuries that may lead to an airway obstruction
a. Trauma
b. Burns

Demonstration:

1. Place your face/ear over the mouth of your partner and get him to inhale deeply.

2. Look for signs of effort during obstructed inhalation.

3. Observe the sternal notch and the trachea pulled back.

4. Observe the more prominent sternocleidomastoid muscles (Neck Muscles).

5. Note the intercostal (Rib Space) recession with drawing in and softening of the
intercostal spaces.

104

TALK, LOOK, LISTEN & FEEL ASSESSMENT:

TALK TO YOUR CASULTY

1. ARE YOU ALRIGHT?

2. COUNT FROM 1 TO 10 IN ONE BREATH, DO IT NOW!
a. If the casualty can count to ten in one breath, their airway is intact and
they are able to breathe without difficulty.
b. If they cannot count to ten in one breath, you will need to investigate
further to fine the cause, it may just be they are out of breath due to
exertion or he may have an airway obstruction.

3. An impaired response may be due to acute/severe airway obstruction.

4. Their response will also give you an indication of their level of consciousness
(LOC)

105
LOOK AT THE CASUALTY & INTO THE AIRWAY

1. Casualty conduct: Do they look anxious?

2. Do you see indications of difficulty breathing?
a. Rise and fall of the chest
i. Respiratory rate (fast or slow)
ii. Accessory muscle use

3. Look into the airway for:
a.Trauma
b.Burns: Look for burns around the mouth and swelling of the vocal cords.
c. Foreign objects
d. Blood
e. Distorted anatomy
106
LISTEN:

1. If the casualty can speak, note the sound of their voice for:
a. Agitation due to cerebral hypoxia
b. Changes in voice (high pitch)

2. Note that a clear airway makes very little noise. If you hear sounds that dont sound
normal then the airway is not clear.

3. Inadequate airway sounds: Noisy breathing
a. Gurgling
b. Wheezing
c. Snoring
d. Inhalation noises (high pitched)
e. Hoarse voice

4. Location of obstruction:
a. Noise on inspiration (breathing in), which is an indicator of a upper airway
obstruction (above the vocal cords).
b. b. Noise on expiration (breathing out), which is an indicator of a lower
airway obstruction (below the vocal cords).

107
FEEL:

1. Breath coming out of the casualtys mouth on your cheek. This requires you to have
your face right next to the casualtys mouth. The goal is to measure the volume as it
corresponds to the rate and effort of breathing.

2. Rise and fall of the chest with your hand. Slide your hand under the casualtys chest
plate.

NOTES:

108
SIGNS OF AIRWAY OBSTRUCTION:

1. Effort of breathing:
a. 1-2 two words at a time (difficulty breathing).
b. Just because a casualty can speak doesnt mean that they have an
adequate airway. 1-2 word may indicate that the airway obstructions not
complete, but may get worse over time.

2. Accessory muscle use:
a. A casualty that is breathing normally will primarily use their diaphragm
(belly breathing).
b. A casualty that must increase the effort of his/her breathing against an
airway obstruction will use both chest and neck muscles.
3. Casualty conduct:
a. Conscious casualties with an airway obstruction will often position
themselves leaning forward or kneeling on all fours. (Tripoding Breathing)
b. Conscious casualties with an airway obstruction will become oxygen
starved resulting in panic.

NOTES:

109

MANAGEMENT OF AIRWAY OBSTRUCTION

1. Always start with basic, simple management techniques after the initial
approach and LOOK, LISTEN, and FEEL AFTER EACH INTERVENTION.

2. The tongue is the most common cause of airway obstruction. As a casualties
conscious level deteriorates, a loss in submandibular muscle tone allows the
tongue to slide back and occlude the oropharynx.

3. Other causes are unstable jaw fractures, hemorrhage in the mouth obstructing
the oropharynx and direct obstruction of the larynx.

4. In most cases, pulling the tongue forward can provide an airway. This is most
commonly achieved using the chin lift or jaw thrust technique.

5. In the case of facial injuries (providing other injuries permit) placing the casualty
semi-prone or the Recovery Position uses gravity to assist.

6. It is important that the effectiveness of these maneuvers is assessed using the
'look, listen and feel' method.

7. Naso-pharyngeal airway

8. Advanced procedures
a. airway adjuncts
b. surgical airway

110
RECOVERY POSITION

111
POSITIONING (GRAVITY):
1. The tongue is the most common cause of airway obstruction. As a casualtys level of
consciousness deteriorates, a loss jaw muscle tone allows the tongue to slide back
and block the back of the mouth.
2. Other causes are unstable jaw fractures, hemorrhage in the mouth or obstruction.
3. In the case of facial injuries (providing other injuries permit) placing the casualty
semi-prone or the Recovery Position uses gravity to assist.
4. The recovery position allows the first responder to quickly position the casualty so
his airway is held open by gravity and any fluids (vomit and blood) will drain out of
the mouth rather than down the airway.
5. This procedure may be all that is needed to maintain an unconscious casualtys
airway throughout the phases of care.
6. It is preferred to transport an unconscious patient in the recovery position to prevent
inhalation of vomit.
7. Always roll the casualty towards you to facilitate airway assessment.
8. Depending on the tactical situation, consider removal of the helmet to improve the
position of the casualtys head.

112
RECOVERY POSITION (SEMI-PRONE)

MANUAL MANEUVER (CHIN LIFT)

1. In most cases, pulling the tongue forward can provide an airway. This is most
commonly achieved using the chin lift technique.
2. The chin lift is best suited for combat casualty care because it is simple is
accomplished with one hand.
3. The chin lift allows for better viewing inside the mouth
4. In the case of cervical spine injury, defer to using the jaw thrust maneuver over the
chin lift.
5. Inserting the thumb behind the lower front teeth and using the index and middle
finger to pull the top of the jaw forward to perform the chin lift.
113

MANUAL MANEUVER (SNIFFING POSITION)

1. Placing the casualty into the sniffing position to straighten and open the airway.
2. The sniffing position should be considered as an improvement to the casualty
recovery position.
3. Casualtys with mild airway obstruction of the tongue (present with snoring sounds)
may benefit from the sniffing position.
4. Procedure:
a. Elevate the shoulders (the back plate of the casualtys body armor will
accomplish this)
b. Extend the head and flex the neck into the last drop of beer position.
114

NORMAL POSITION

SNIFFING POSITION

115

MANUAL MANEUVER (OBJECT REMOVAL):

1. If an object is noted inside the mouth it must be removed to either open the airway or
prevent the airway from being occluded later.

2. Objects that could be found in the mouth include:
a. Blood or blood clots
b. Loose pieces of tissue
c. Just about anything (chewing tobacco)
3. Removal of pieces of tissue should be done if the tissue is easily removed
4. When removing objects from the airway it is important to:
a. Place the casualty to the side (recovery position)
b. Visualize the obstructing object
c. Pinch the object with your fingers to prevent it falling back into the
airway, and remove if possible
5. Blood that has clotted near the back of the airway often requires suction to remove.
6. Do not cause the casualty to gag by reaching into the airway. (Gag reflex is on the
back 1/3 of the tongue).
116

117
Nasopharyngeal Airway Placement (NPA)

* If the casualty cannot protect their airway: introduce a
nasopharyngeal airway (NPA).

*Training Note: This procedure must be performed on a mannequin
only and not on a human being.

Insertion Procedure:

1. Preferred size of tube (26-28 fr) (French)

2. Use surgical lubricant or the casualties saliva to lubricate the tube

3. Insert the tube through the nose in a smooth movement and with a slight turning
action

4. If you feel resistance, stop and do not force it as this may cause hemorrhaging
and try the other nostril.

5. Secure with tape to prevent ejection.

6. Assess the effectiveness of the NPA by performing a LOOK, LISTEN, FEEL
assessment.
118
RESPIRATION


1. Explain the significance of respiratory injury management in combat casualty
care.

2. Explain the anatomy of the chest.

3. Explain the mechanism of breathing and injuries that disrupt the breathing
process.

4. Explain what respiratory distress is and how to recognize it.

5. Define a sucking chest wound, tension pneumothorax, and fail chest.

6. Explain the immediate and long term treatment of sucking chest wounds.

7. Explain the immediate and long-term treatment of tension pneumothorax.

8. Explain the immediate and long term treatment of flail chest.

9. Explain the process of relieving tension pneumothorax by performing a needle
decompression.

10. Perform occlusive dressing practical application lab.

11. Answer all remaining questions regarding respiratory injury management in
combat casualty care.

119
RESPIRATION
1. Process of Breathing
a. Breathing is divided into two parts: inspiration and expiration, at a 1 to 3
ratio.
b. For every 1 second it takes someone to inhale it should take 3 seconds to
exhale.
c. You can listen to a patient without even seeing them and tell which part is
inhalation and which is exhalation. When a person breathes at a normal
rate, there should be no apparent sound or effort.
d. However, if you can hear breath sounds from a patient without using a
stethoscope it indicates that there is something abnormal with their
respiratory function.
e. Any breathing sound that is heard on inspiration (short phase) indicates a
problem above the vocal cords.
f. Any breathing sound that is heard on expiration (long phase) indicates a
problem that is occurring below the vocal cords.

NOTES:

120

MECHANISM OF BREATHING

INHALATION

Chest cavity expands creating negative pressure
inside the chest

Negative Pressure = Inward Airflow

EXHALATION

Chest wall relaxes allowing air to leave

Positive Pressure = Outward Airflow

121
Signs of Respiratory Distress:

1. Increased respiratory
2. Increased respiratory effort
3. Accessory muscle use
4. Conscious patients will want to sit up
5. Entire body moves with respiration

Chest Injuries that Cause Respiratory Distress:

1. Sucking chest wound
2. Tension pneumothorax
3. Flail chest
MECHANISMS THAT CAUSE RESPIRATORY INJURY:

1. Penetrating trauma (gunshot wound, blast fragment)
2. Blunt trauma
3. Blast overpressure

INJURIES THAT CAUSE RESPIRATORY DISTRESS:

1. Flail chest
2. Sucking Chest Wound
3. Tension pneumothorax
4. Outer chest burns of the skin and muscle
5. Bruised or broken ribs
122

SIGNS OF RESPIRATORY DISTRESS:

1. Vital sign changes:
a. Increased respiratory rate and effort
2. Noisy respirations
3. Visual Signs
a. Accessory muscle use
b. Entire body moves with respiration
4. Casualty conduct:
a. Conscious patients will want to sit up
b. Conscious patients will complain, I cant breathe
c. Inability to count from 1 to 10 in one breath

123
FLAIL CHEST SEGMENT

1. A flail chest occurs when three or more ribs are broken in two more places.
2. As the casualty breathes in, the negative pressure sucks in the unstable segment.
This is usually not harmful until increased ventilatory pressures are required, as with
partial airway obstruction or underlying pulmonary contusion. As the casualtys
condition worsens, the paradoxical rib motion becomes more severe, making
respiration inefficient. The unconscious casualty, who does not use the chest wall
muscles to splint the injured area, will have a more pronounced flail effect.

FLAIL CHEST

Expiration Inspiration

124
Treatment of Flail Chest

1. Pain Control
2. If the flail segment is impairing air exchange, the flail segment should be supported
by a firm chest wrap or temporarily by laying the casualty with the flail segment down
against a solid surface. This prevents the flail segment from moving out in the
opposite direction the rest of the chest is moving during expiration.

SUCKING CHEST WOUND

An open wound allows air to be sucked into the chest with each inhalation. If large enough, it may
interfere with air motion in the lungs by decreasing the amount of negative pressure that can be
generated during inspiration. Small wounds can form one-way valves, leading to tension
pneumothorax.

125
Treatment of Sucking Chest Wounds

1. These wounds are a lesser priority to massive bleeding and airway issues.
2. The initial treatment of a sucking chest wound consists of placing a hand as a stop gap
method, over the wound. Then place an occlusive dressing over the wound to seal it.
3. Occlusive dressings need to be aggressively taped in place to avoid leaks.
4. Tape all four sides as opposed to only taping three. This is done to avoid failure of the
entire dressing.

OCCLUSIVE DRESSINGS

BOLIN CHEST SEAL PETROLATUM GAUZE

126

OCCLUSIVE DRESSINGS

HALO CHEST SEAL

HYDROGEL PLASTIC FILM

127
Notes:

128
CIRCULATION (SHOCK)


1. Explain the significance of circulation shock in combat casualty care.

2. Define shock.

3. Define the significance of hypovolemic shock in combat casualty care.

4. Define the signs and symptoms of shock.

5. Define the significance of pulse points in casualty assessment.

6. Explain the difference between compensated and uncompensated shock.

7. Explain the treatment of casualties in shock.

8. Explain the modern science of oral rehydration as it applies to combat casualty
care.

9. Explain the role of various oral rehydration fluids in operational medicine.

10. Answer all remaining questions regarding circulation shock in combat casualty
care.

129
Hypovolemic Shock:

1. There are different types of shock, but the one that is pertinent on the battlefield
is:

a. Hypovolemic Shock: shock due to bleeding and thus depletion of the
bodies supply of blood so that you cant deliver enough oxygen to the
cells of the body.

Shock follows a logical progression of symptoms:

1. Sweaty, but cool skin (clammy skin)

2. Paleness of skin

3. Restlessness, nervousness, combativeness

4. Thirst

5. Loss of blood (bleeding)

6. Confusion (or loss of awareness)

7. Faster-than-normal breathing rate

8. Blotchy or bluish skin (especially around the mouth and lips)

9. Nausea and or vomiting.

130
Vital sign changes:

1. Pulse gets faster

2. Breathing gets faster

3. Blood pressure drops

Compensated Shock:

1. Vessels clamp down

2. Blood from extremities is pulled into core

3. Heart speeds up to move the remaining blood

4. Breathing increases to oxygenate the blood faster

Uncompensated Shock:

1. Onset rapid (guy was doing fine then flops)

2. Vessels get tired and open up = BP drops

3. Lack of Oxygen causes permanent damage to organs

4. Heart doesnt have enough blood to pump

131
Resuscitation Protocol:

1. Check for a radial pulse

2. Get the hemorrhage under control prior to resuscitating

3. Do not resuscitate an uncontrolled hemorrhage

Oral Rehydration:

1. Water (Lacking essential electrolytes, Sodium and Potassium.

2. Sports Drinks i.e. Gatorade (Too much sugar, very light in Sodium and
Potassium):

3. WHO Oral Rehydration salts (Proven mixture of electrolytes)

4. Cera-lyte (Proven mixture of electrolytes)

Circulation supplement is available for advanced level providers

132

133
INTRAOSSEOUS ACCESS

1. Definition:

a. An Intraosseous (IO) device is a piece of equipment that place a needle into
the bone marrow of a bone, normally the sternum, tibia or infrequently the
humerus (the sternum is the most useful marrow cavity in adults for infusion
of fluids).

b. The IO device allows for I.V. fluid and drug access when traditional I.V.
access is unavailable. This is particularly useful in the battlefield environment
where obtaining I.V. access may be especially difficult due to both patient and
operating environment constraints.

Intraosseous Access supplemental material is available for Advanced Level Providers

134

CPR ON THE BATTLEFIELD

1. It is a widely accepted recommendation that no CPR in cardiac arrest due to the
battlefield trauma be performed in care under fire (CUF).

2. Reasons for not performing CPR in CUF:
a. CPR performers may get killed
b. Mission gets delayed
c. Casualty stays dead

CPR on the battlefield = mouth-to-mouth to restore ventilations only
(Rescue breaths)

Case Study (Airfield Seizure Operation in Grenada)

1. Ranger shot in head by sniper
2. No pulse or respirations
3. CPR attempted-unsuccessful
4. Operation delayed while CPR performed
5. Ranger PA finally intervened

135

TCCC Guidelines8 August 2011

Item #18 under Tactical Field Care (TFC).L cardiopulmonary resuscitation (CPR)
______________________________________________________________________

______________________________________________________________________

6
(>20%), consider placing the casualty in the Heat-Reflective Shell
or Blizzard Survival Blanket from the Hypothermia Prevention Kit in
order to both cover the burned areas and prevent hypothermia.
d. Fluid resuscitation (USAISR Rule of Ten)
If burns are greater than 20% of Total Body Surface Area, fluid
resuscitation should be initiated as soon as IV/IO access is
established. Resuscitation should be initiated with Lactated
Ringers, normal saline, or Hextend. If Hextend is used, no more
than 1000 ml should be given, followed by Lactated Ringers or
normal saline as needed.
Initial IV/IO fluid rate is calculated as %TBSA x 10cc/hr for adults
weighing 40- 80 kg.
For every 10 kg ABOVE 80 kg, increase initial rate by 100 ml/hr.
If hemorrhagic shock is also present, resuscitation for hemorrhagic
shock takes precedence over resuscitation for burn shock.
Administer IV/IO fluids per the TCCC Guidelines in Section 7.
e. Analgesia in accordance with the TCCC Guidelines in Section 13 may
be administered to treat burn pain.
f. Prehospital antibiotic therapy is not indicated solely for burns, but
antibiotics should be given per the TCCC guidelines in Section 15 if
indicated to prevent infection in penetrating wounds.
g. All TCCC interventions can be performed on or through burned skin in
a burn casualty.

- Encourage; reassure
- Explain care

Resuscitation on the battlefield for victims of blast or penetrating
trauma who have no pulse, no ventilations, and no other signs of life
will not be successful and should not be attempted. However, casualties
with torso trauma or polytrauma who have no pulse or respirations
during TFC should have bilateral needle decompression performed to
ensure they do not have a tension pneumothorax prior to
discontinuation of care. The procedure is the same as described in
section 3 above.

Document clinical assessments, treatments rendered, and changes
in the casualtys status on a TCCC Casualty Card. Forward this
information with the casualty to the next level of care.

136
HYPOTHERMIA
THE SILENT KILLER


1. Explain the relevance of hypothermia in combat casualty care.

2. Explain the morbidly factor hypothermia plays in traumatic injury.

3. Define factors that predispose casualties to hypothermia.

4. Define the signs of hypothermia.

5. Define the factors that lead to body heat loss.

6. Explain the need to prevent hypothermia in combat casualty care.

7. Explain the role of casualty packaging in hypothermia prevention.

8. Explain field expedient methods of preventing and treating hypothermia.

9. Answer all remaining questions regarding hypothermia in combat casualty
care.

137
WHY HYPOTHERMIA IS IMPORTANT:

1. Reduced blood-clotting mechanism therefore less bleeding control with direct
pressure or hemostatic clotting agents; contributes to limb loss due to
extended tourniquet times.

2. Increased infection rates due to compromised casualty immune system.

3. Heart rhythm issues due to hypothermia causing electrical conduction issues
in the heart.

4. Death-rates increase as temperature decreases from a normal 98.6 F
(37 F)

a. (93F/33.9 C) Body temperature resulted in 40% death rate.
b. (91.5F/33.0 C) body temperature 69% death rate.
c. (89.5F/32.0 C) body temperature 100% death-rate

5. Case study:
a. Measured hypothermic patients and their outcome.
b. All patients who reached hypothermia of 32 degrees Celsius
(89.5F) died.
c. Hypothermia makes everything else worse.

138
CONTRIBUTORS TO HYPOTHERMIA:

1. Casualties cant thermo-regulate due to decreased metabolism and muscle
activity.

2. Trauma impedes the bodys normal responses to heat loss.

3. In addition, you lose heat most rapidly when you are wet. Most casualties are
covered in blood and sweat.

4. The bottom line is that a casualty can become hypothermic in an environment where
you wouldnt think they would; and in a cold environment, they become hypothermic
very quickly.
5. Case Study:
a. Harborview Hospital, WA: over 20% of casualties were found to
be >2 degrees hypothermic by the time they reached the
hospital.
b. This study was repeated in San Diego with the same results.

Factors predisposing casualties to hypothermia:

1. Blood Loss and dehydration due to low amounts of nutrients because there is not
enough fluid volume in the blood for the muscles to properly metabolize nutrients
and dispose of wastes through the liver and kidneys.

2. Burns (large body surface area), due to the temperature regulation being
compromised and aggressive cooling caused by the medical provider.

3. Water immersion due to conduction of heat.

4. Long air evacuations due to low temperatures on thin-skinned aircraft.

139
Signs and Symptoms of Hypothermia:

1. Shivering

2. Cyanosis (blue, gray, or pale-colored skin)

3. Bizarre behavior

4. Lethargy

Types of heat loss encountered on the battlefield

1. Conduction surface against surface:

2. Convention is the loss of heat due to wind or rain added to the body.

3. Radiation is the loss of heat due to the environment being colder than the body.

4. Evaporation is the loss of heat due to sweating, talking, and breathing.
Notes:

140
141
TREATING HYPOTHERMIA

1. Prevention, prevention, prevention

2. It is very difficult to warm a casualty in the field.

3. Use all means i.e. blankets or drapes from local homes

4. Cover injured areas after assessing wounds, but monitor for changes/
degradation.

5. Package for transport

6. Buddy Warming (The Myth- we warm our buddy, the fact- we warm the boundary
layer so the casualty doesnt have to expend energy for it).

7. Use what your casualty is carryingWatch Cap (Quickest, easiest and most
effective intervention), Poncho w/Liner, Sleeping mat, Sleeping bag,
Survival Blanket.

8. Material around the battlefield (cardboard underneath, trash bag over the top,
enemy clothing to swaddle the head).

9. Layers of packaging:

a. Top: wind and rain-protective layer

b. Between top and casualty: insulation that provides a dead air space.

c. Directly below- a layer that provides a NON-Compressible layer or dead
air space.

d. A bottom layer to protect from moisture and possibly be the taco shell
for carrying the casualty.

KEY NOTE: All listed TCCC IV and Resuscitation below is to be provided by a
medical provider only. SEE SKILLS SET OUTLINE IN FIGURE 24-1 PHTLS 7
TH

EDITION, PAGE 595 or outline above

142

TCCC Guidelines- 8 August 2011. Item 8: Prevention of hypothermia. Pg.4

Preventable Causes of hypothermia:

1. Using cold I.V. fluids (medical provider level)

2. Excessive time in the field

3. Failure to insulate the casualty- no dead air space on the top, and thinner,
compressible material underneath.

4
b. If in shock:
- Hextend, 500-mL IV bolus
- Repeat once after 30 minutes if still in shock.
- No more than 1000 mL of Hextend
c. Continued efforts to resuscitate must be weighed against
logistical and tactical considerations and the risk of incurring
further casualties.
d. If a casualty with an altered mental status due to suspected TBI
has a weak or absent peripheral pulse, resuscitate as necessary to
maintain a palpable radial pulse.

8. Prevention of hypothermia
a. Minimize casualtys exposure to the elements. Keep protective
gear on or with the casualty if feasible.
b. Replace wet clothing with dry if possible. Get the casualty onto an
insulated surface as soon as possible.
c. Apply the Ready-Heat Blanket from the Hypothermia Prevention
and Management Kit (HPMK) to the casualtys torso (not directly
on the skin) and cover the casualty with the Heat-Reflective Shell
(HRS).
d. If an HRS is not available, the previously recommended
combination of the Blizzard Survival Blanket and the Ready Heat
blanket may also be used.
e. If the items mentioned above are not available, use dry blankets,
poncho liners, sleeping bags, or anything that will retain heat and keep
the casualty dry.
f. Warm fluids are preferred if IV fluids are required.

9. Penetrating Eye Trauma
If a penetrating eye injury is noted or suspected:
a) Perform a rapid field test of visual acuity.
b) Cover the eye with a rigid eye shield (NOT a pressure patch.)
c) Ensure that the 400 mg moxifloxacin tablet in the combat pill pack
is taken if possible and that IV/IM antibiotics are given as outlined
below if oral moxifloxacin cannot be taken.

10. Monitoring
Pulse oximetry should be available as an adjunct to clinical monitoring.
Readings may be misleading in the settings of shock or marked hypothermia.

11. Inspect and dress known wounds.


143

PHTLS 7
th
edition page 627
Figure 26-13 Hierarchical Equipment List for
Prevention of and Treatment of
Hypothermia
1. Blizzard Survival Blanket NSN 6532-01-524-6932
2. TechTrade Ready-Heat Blanket NSN 653201-525-4063
3. TechStyles Thermo-Lite Hypothermia Prevention System
Cap
4. Space Blanket (Heavy duty)
5. Wool Blanket (green)
6. Thermal Angel NSN 6515-01-500-3521
7. Belmont FMS 2000 NSN 6515-01-370-5019
8. Bair Hugger NSN 6530-01-463-6823

NOTES:

144
THE SCIENCE OF CASUALTY REWARMING:

1.MAIN PRINCIPLE:

a. Principle concept to remember: The human body generates
around 80 Kcal/hour of heat.

b. This is around the same as a100-watt light bulb.

c. We have been unable to find a more effective or efficient source of heat
when trying to re-warm a patient than using the patients own body
heat.

2. Techniques of Re-warming:

a. Lavage: at around 2 liters/hour with entry and drainage. 110 F (44.3C)
is the hottest you can make the fluid without burning the patient.

i. This technique can also cause you to inadvertently cool the
patient by wetting them from the drainage.

ii. Lavage is not practical in the field.

b. Warm I.V fluids : Max rate is two liters per hour. of IV fluids = +8
Kcal/Hr. of heat transfer. You can only use fluids up to 110 degrees
without burning the patient. The heart also beats slower in a hypothermic
patient so the pumping of this fluid is diminished.

c. Hot sugary drinks: The glucose helps, but the heat does very little to
warm the patient. You can only drink up to two liters per hour. so there is
not much benefit.

d. Hot Packs: Causes damage due to skin vasoconstriction and lack of
heat distribution.

e. Warm, humid oxygen: the equivalent of heating ! of trash can of water
with a hair dryer. The will produce + 0.5 Kcal/Hr. of heat.

f. Warm water immersion:

i. In theory it should work but we never do a good job of it because
we leave the head out of the water part so the patient can breathe.

ii. The head loses a large amount of heat, especially if it is wet.

145
iii. It is important to remember it is not the transfer of heat that re-
warms apatient. A human sized ice cube can take up to two days
to melt.

iv. Immersion is a slow method of heat transfer. What it does is
allow the body to retain its own heat

g. The Naked Ranger Buddy:

i. The concept is that a buddy gets naked and then gets inside the
same sleeping bag as the patient, spooning up next to the patient
and re-warming them.

ii. This works but not in the way you would think.

iii. The partner is not transferring heat to the patient. What he is
doing is serving as a patient advocate that can tell you when he is
cold, and what needs to be done to make it less cold. The partner
also acts as a heater for the sleeping bag.

iv. For example, he will tell you to put more insulation under them
because the ground is cold, or zip up the bottom of the sleeping
bag better because there is a draft down there, etc. This allows the
patient to retain his own heat better.

v. KEY: Allowing the patients to re-warm themselves by
retaining as much heat as possible is the answer to
hypothermia.

vi. In the operational environment, there is no better source of heat
than the human body.

3. Review of major sources of heat loss:

a. Contact with the ground.

b. Air flow (High velocity air flow is the fastest way to become cold).

c. Contact with fluid that is less than body temperature.

4. BOTTOM LINE: As you get hypothermic you generate less heat. A person who is
barely alive will generate 40 Kcal/Hr. of heat so it is still more effective than other re-
warming techniques.

IMPORTANT NOTE: The gold standard in medicine that a patient is not dead until
they are warm and dead
146

MEDICAL RAMIFICATIONS OF BLAST


1. Explain the relevance of blast injury in operational medicine.
2. Define blast dynamics
3. Explain blast injury vocabulary
4. Explain first degree blast injuries
5. Explain secondary degree blast injuries
6. Explain third degree blast injury
7. Explain fourth degree blast injury
8. Explain the medical aspects of current IEDs
9. Explain the role of PPE in blast injury mitigation
10. Explain the importance of the M.A.R.C.H. algorithm in blast injury treatment.
11. Review blast injury case studies and videos
12. Answer all remaining question regarding blast injury in combat casualty care.

147
MEDICAL RAMIFICATIONS OF BLAST

BLAST INJURY VOCABULARY:

1. Primary (1)

a. Blast wave injury of the lungs, GI tract, sinuses, middle ear and
eardrum.
b. Also, shell shock or Traumatic Brain Injury (TBI)

2. Secondary (2)
a. Fragmentation, penetrating shrapnel and debris.

3. Tertiary (3)

a. Blunt or penetrating trauma- blast wind throws the individual
against a solid object.

4. Quaternary (4)
a. Miscellaneous burns, fume poisoning, suffocation,
building collapse, crush injuries.

6. Quinary (5)

a. Long term injury caused by radiological, chemical and medical
complications.

7. Blast Injuries do not occur in isolation.

8. A casualty with blast lung (1) may also have:

a. Penetrating glass shards (2)
b. Traumatic amputation (3)
c. Burns, inhalation injury, deafness (4),

148

PRIMARY BLAST INJURY:

1. Due to absorbing a blast wave. The impact of overpressure (blast wave) on/in the
body.

2. Body parts affected are usually gas filled organs or the brain.

149
a. Lungs. The lung injury is not really from blast filling the lungs. The mechanism
of injury is the shear-force caused when the blast wave hits the chest wall and
travels through the body. The lateral shear of the blast wave changing speed as
it hits tissue of differing densities tears the lung tissue.
b. Abdomen
c. Ruptured ear.
d. Brain. Injured via a shearing effect similar to lung tissue

3. Types of injuries are:

a. Blast lung.

b. Ear drum rupture and middle ear injury.

c. Abdominal hemorrhage and perforation.

d. Closed head injury - concussion or traumatic brain injury (TBI).

SECONDAY BLAST INJURY:

1. Injury due to flying debris, bomb fragments, and other projectiles.

2. Any body part can be affected.

3. Types of injuries:

a. Penetrating ballistic injuries.

b. Blunt force trauma.

c. Ocular penetration.

150
TERTIARY BLAST INJURY:

1. Injury due to individuals being thrown by blast wave.

2. Any body part can be affected.

3. Types of injuries:

a. Fracture and traumatic amputation.

b. Closed and open brain injury.

5. Blunt trauma solid object strikes, or victim is thrown against solid object, includes
impalement.

6. These types of injuries are not always immediately obvious and take time to manifest.
Look for swelling and bruising.

QUARTERNARY BLAST INJURY:

1. Burns (flash, partial, and full thickness); crush injuries; closed and open brain injury;
asthma, chronic obstructive pulmonary disease, smoke inhalation, or respiratory
illnesses related to dust, fumes, toxic smoke.

2. Crush injuries.

3. Suffocation and fume poisoning.

4. Burns.

151
QUINARY BLAST INJURY:

1. Described as miscellaneous not fully understood.

2. The patients hyper inflammatory behavior, unrelated to their injury complexity and
severity of trauma, indicates a new injury pattern in explosions, termed the quinary
blast injury pattern. Reference: Kluger Y, Nimrod A et al. The quinary pattern of blast
injury. Am J Disaster Med. 2007 Jan-Feb; 2(1):21-5

3. Unconventional materials used in the manufacture of the explosive can partly explain
the observed early hyper inflammatory state.

4. Medical personnel caring for blast victims should be aware of this new type of blast
injury.

Notes:

152
CONFINED SPACE BLAST INJURY:

1. Confined space blasts or those blasts occurring in close proximity to a confined
space (e.g. roadside bomb adjacent to cover troop carrier, bomb outside cave entrance)
are controlled within this space increasing their exposure to the contents within.

2. Compared to troops in the open, injuries to those inside or around armored vehicles,
or within tunnels are characterized by:

a. Increased overall frequency of injuries.

b. Increased severity of injury and mortality (up to 50%).

c. Increased incidence of burns and traumatic amputations (confined force of
blast wind).

d. Blast effects are magnified in confined space.

e. Concentrated overpressures.

f. Concentrated and directed blast winds.

g. concentrated thermal exposure.

153

IED CONSIDERATIONS:

1. Combine penetrating, blunt trauma, and burn injuries. The shrapnel includes not only
nails, bolts, and the like, but also dirt, clothing, even bone from assailants.

2. Victims of IED attacks can exsanguinate from multiple seemingly small wounds.

3. Apply the same M.A.R.C.H. steps along the timeline of casualty care.

4. Care Under Fire consider possibility of secondary devices.

5. Tactical Field Care Primary blast wounds will develop over time.

6. Tactical Evacuation Care casualties may deteriorate quickly. Evacuate ASAP!

Notes:

154
Medical Aspects of Blast injury caused by IEDs:

1. Combine penetrating, blunt, and burn injuries. The shrapnel includes not only nails,
bolts, and the like, but also dirt, clothing, even bone from assailants.

2. Victims of IED attacks can exsanguinations from multiple seemingly small wounds,
even those in the back.

3. Surgeons also discovered a dismayingly high incidence of blinding injuries. Soldiers
had been directed to wear eye protection, but they evidently found the issued goggles
too ugly.

4. Apply the same M.A.R.C.H. steps along the Timeline of Casualty Care

5. Care Under FireConsider possibility of secondary devices.

6. Tactical Field Care, Primary blast wounds will develop over time.

7. Casualty Evacuation Care, Casualties will deteriorate quickly. EVAC ASAP!

155
BURN INJURIES


1. Explain the relevance of burn injury in combat casualty care

2. Explain the different types of burn injury in operational medicine

3. Explain the three classifications of burns

4. Explain how to stop the burning process in the operational setting

5. Explain how to treat burn casualties with items in the IFAK (Water-Jel)

6. Explain the importance of recognizing high-risk burns

7. Explain the use of field expedient techniques in operational burn treatment

8. Explain the importance of hypothermia prevention in burn treatment

9. Explain the long-term care concepts of burn casualty care

10. Answer all remaining questions regarding burn injury in combat casualty care.

156
BURN INJURIES

OPERATIONAL BURN INJURY:

1. Approximately 8% of current operational casualties have a burn component to their
injuries.

2. Often associated with blast injury

3. Higher mortality : Combat burns have a higher mortality due to other associated
trauma.

FACTORS THAT MAKE UP BURN SEVERITY:

1. Source of burn

2. Depth of burn

3. Total body surface (TBSA) burned

4. Access to appropriate facilities

5. Delay in initiating treatment

6. Other injuries (multi trauma, dehydration, etc.)

157
OPERATIONAL BURN TYPES:

1. Thermal

2. Flash (secondary to explosion)

3. Flame

4. Contact

5. Scald

6. Chemical - Acid, alkali, hydrocarbons

7. Electrical

158

BURN INJURY CLASSIFICATION

Categorizing burns is geared towards burn center management (need for grafting, etc)
and burn can evolve (2
nd
going to 3
rd
). First responders and field medical practitioners
simply report approximate % TBSA burns (2
nd
and 3
rd
).

1. Superficial (1st degree)

2. Partial thickness (2nd degree)

3. Full thickness (3rd degree)

4. There is no need to further break down burn categories for the operational setting.

5. Many times burn depth is not apparent for days.

6. Total Body Surface Area (TBSA), when calculating severity of burns only includes 2
nd

and 3rd degree burns (partial/full thickness).

159
Superficial Burn (1
st
Degree)

1. A bad sunburn!

2. Pain and redness, without blisters, and not life-threatening

3. Not included in Total Body Surface Area count

Partial Thickness (2
nd
Degree)

1. Blisters, sloughing, weeping (wet) skin.

2. Very painful, hypersensitive.

3. Skin blanches with touch.

Full Thickness (3
rd
Degree)

1. Dark, leathery, may be waxy white, with no capillary refill and no pain. Generally dry.

2. Typically 2nd and 1st degree burns will lie at the margins of 3
rd
degree burns.

160
Total Body Surface Area

1. Calculated for all partial and full thickness (2nd and 3rd degree) burns.

2. Different for children

3. High risk areas automatically need burn center treatment.

4. TBSA is more important than burn depth.

Calculation Considerations

1. Palm = 1%

2. The rule of nines is the preferred method of calculating TBSA.

3. If youre unsure, estimate the TBSA to the best of your ability.

4. Try not to underestimate!
161

Estimating Burn Area

High Risk Burns:

1. Airway

2. Face

3. Hands

4. Genitalia

5. Burns over fractures

6. (5% TBSA 3rd degree burn)

7. (10% 2nd and 3rd TBSA if age <10, or >50)

8. (20% 2nd and 3rd TBSA any age
162

High Risk Burn Considerations

1. Need evacuation ASAP

2. Need burn center level care ASAP.

3. Higher morbidity/mortality if not treated properly.

4. Burns greater than 20% TBSA require circulatory volume support (fluids).

Airway Burn Indicators

1. Singed facial hairs

2. Soot in the mouth

3. Hoarseness

4. Difficulty breathing

5. Difficulty swallowing

6. Swollen lips = swollen vocal cords (Notify medical provider).

Notes:

163
Chemical Burns

1. Acid burns - Morbidity and mortality depends on %TBSA plus what type of acid
chemical (concentration).

2. Alkali burns - Produces deeper burn penetration into skin (often to bone), and has a
worse prognosis.

3. Treatment: Both acid and alkali burns should be copiously irrigated or submerged, if
wet; brush off the skin in the case of dry chemicals.

Electrical Burns

1. Produces deep burn under the surface of the skin (extent may not be apparent).
Fatal cardiac rhythms can come from electricity that crosses the chest.

Burn Management

1. Immediate: Stop the burning process and stop massive bleeding.

2. Minutes: Secure at-risk airways. Provide pain relief.

3. Hours: Fluid management, mitigate infection.

164
Burn Casualty Considerations

1.Saran Wrap (cling wrap, plastic wrap) -Saran Wrap provides a physical barrier that
reduces pain sensitivity and infection and helps to retain heat.

2.Hypothermia is common in burn casualties, which is due to:

a. Overly aggressive stopping the burning process.

b. Loss of skin surface area that regulates the bodys ability to retain heat.

c. Not protecting the casualty from the environment after initiating treatment.

3. Hypothermic casualties do poorly, especially those with associated hemorrhage.

4. Red urine = dead muscle/destroyed blood cells.

5. Ensure limbs are well perfused (consider escharotomy).

6. Increase urine output to 1-2cc/kg/hr. This is necessary to prevent renal failure.

7. Prevention of infection begins at the time of injury, although effects are not seen for
days.

165
8. Early prevention includes:

a. Clean early and often

b. Copious irrigation with clean vs. sterile water

c. Sterile coverings (Saran Wrap, sterile dressings)

9. With proper treatment, burns have a low incidence of serious bacterial infection.

10. Silvadene Cream or Acticote burn dressings are of limited value in the operational
setting (expensive, bulky, and primarily work against pseudomonas bacteria) this will be
used later.

11. No value of prophylaxis with antibiotics.

12. Inappropriate use of antibiotics causes multi drug resistant bacteria

13. Antibiotics may be used later, once the bacteria species is identified.

14. Burn injuries consume a lot of the bodys energy.

a. Casualties consume 4-5 times the normal amount of calories during the
166
early stages of healing from burns.

b. High calorie intake must be provided (up to 5,000 cal per day).

c. Burn fevers are common, and dont necessarily mean infection. Febrile
burn casualties may have common infections (urine, pneumonia, injuries,
etc.)

d. The body has difficulty with temperature regulation.

NOTES:

167
15. TCCC guidelines dated 11 August 2011; section on Burns (item #16, page 5

_____________________________________________________________________

5
a. Able to fight:
These medications should be carried by the combatant and self-
administered as soon as possible after the wound is sustained.
- Mobic, 15 mg PO once a day
- Tylenol, 650-mg bilayer caplet, 2 PO every 8 hours
b. Unable to fight:
Note: Have naloxone readily available whenever administering
opiates.
- Does not otherwise require IV/IO access
- Oral transmucosal fentanyl citrate (OTFC), 800 ug
transbuccally
- Recommend taping lozenge-on-a-stick to
casualtys finger as an added safety measure
- Reassess in 15 minutes
- Add second lozenge, in other cheek, as
- Monitor for respiratory depression.
- IV or IO access obtained:
- Morphine sulfate, 5 mg IV/IO
- Reassess in 10 minutes.
- Repeat dose every 10 minutes as necessary to
control severe pain.
- Monitor for respiratory depression
- Promethazine, 25 mg IV/IM/IO every 6 hours as needed for
nausea or for synergistic analgesic effect

14. Splint fractures and recheck pulse.

15. Antibiotics: recommended for all open combat wounds
- Moxifloxacin, 400 mg PO one a day
- Cefotetan, 2 g IV (slow push over 3-5 minutes) or IM every
12 hours
or
- Ertapenem, 1 g IV/IM once a day

16. Burns
a. Facial burns, especially those that occur in closed spaces, may be
associated with inhalation injury. Aggressively monitor airway status
and oxygen saturation in such patients and consider early surgical
airway for respiratory distress or oxygen desaturation.
b. Estimate total body surface area (TBSA) burned to the nearest 10%
using the Rule of Nines.
c. Cover the burn area with dry, sterile dressings. For extensive burns
6
(>20%), consider placing the casualty in the Heat-Reflective Shell
or Blizzard Survival Blanket from the Hypothermia Prevention Kit in
order to both cover the burned areas and prevent hypothermia.
resuscitation should be initiated as soon as IV/IO access is
established. Resuscitation should be initiated with Lactated
Ringers, normal saline, or Hextend. If Hextend is used, no more
than 1000 ml should be given, followed by Lactated Ringers or
normal saline as needed.
weighing 40- 80 kg.
If hemorrhagic shock is also present, resuscitation for hemorrhagic
shock takes precedence over resuscitation for burn shock.
Administer IV/IO fluids per the TCCC Guidelines in Section 7.
e. Analgesia in accordance with the TCCC Guidelines in Section 13 may
be administered to treat burn pain.
antibiotics should be given per the TCCC guidelines in Section 15 if
a burn casualty.

- Encourage; reassure
- Explain care

Resuscitation on the battlefield for victims of blast or penetrating
trauma who have no pulse, no ventilations, and no other signs of life
will not be successful and should not be attempted. However, casualties
with torso trauma or polytrauma who have no pulse or respirations
during TFC should have bilateral needle decompression performed to
ensure they do not have a tension pneumothorax prior to
discontinuation of care. The procedure is the same as described in
section 3 above.

Document clinical assessments, treatments rendered, and changes
in the casualtys status on a TCCC Casualty Card. Forward this
information with the casualty to the next level of care.

168
PROLONGED FIELD CARE


1. Explain the significance of the prolonged field care phase of combat casualty care

2. Define the Warfighters role in prolonged care

3. Define previous situations that have required prolonged field care

4. Define when to initiate prolonged field care

5. Explain the T.R.I.-A.E.I.O.U. algorithm approach to prolonged care

6. Answer all remaining questions regarding prolonged care in combat casualty care.

169
PROLONGED FIELD CARE

WHEN TO START PROLONGED FIELD CARE:

1. The term Prolonged Field Care (PFC) can be misleading. Initiating Prolonged Field
Care should not be delayed for several hours. It should be initialed as soon as practical,
within the first hour or two.

2. There are obviously numerous reasons why PFC can be delayed, but it is essential
for good outcome.

3. If transport delays are possible, additional PFC medical logistics are required as well
as additional pain control resources.

4.Bottom Line: Delayed evacuation to higher echelons of care is possible in ALL
theaters.

BE PREPARED TO CONDUCT PROLONGED FIELD CARE.

170
TRIAEIOU ALOGORITHM

#
Tubes
'
Record and Reassess
%
Infection
!
Analgesia
(
Environment
%
Intake
>
Output
?
Ulcers
171
TUBES:
1. Functioning
2. Clean
3. Secure

RECORD and REASSESS:
1. Flow sheet
2. Repeated vital signs
3. Record of each event/treatment
4. M.I.S.T. Report

INFECTION:
1. Antibiotics: Early as possible
2. Wound care: Initiate 1-6 hours post hemostasis

ANALGESIA:
1. Chemical pain control
2. Psychological techniques
3. Re-splint wounds
4. Adjust bandages
5. Release tourniquets when appropriate

ENVIRONMENT:
1. Always work to improve your casualtys environment
2. Think about: heat, cold, sun, insects etc.,

INTAKE:
1. Fluids
a. route (I.V. vs. Oral)
b. Amount
c. Type of fluids
d. Volume based on urine output
2. Electrolytes
3. Food and amount of calories consumed

OUTPUT:
1. Urine
a. Per hour (100 ml/Hr.)
2. Drainage technique (spontaneous, catheter, or suprapubic bladder tap)
3. Stool

ULCERS:
1. Pressure sores
2. Tubes
3. Eyes
4. Gastric
172
TRI-AEIOU
PROLONGED FIELD CARE ALOGORITHM
FILL IN

#
Tubes
'
Record and Reassess
%
Infection
!
Analgesia
(
Environment
%
Intake
>
Output
?
Ulcers
173
WOUND CARE

WHY IS WOUND CARE IMPORTANT: Operational wound care consists of the
aggressive initial and prolonged care of combat wounds to minimize wound infection
and increase casualty survivability.

WHAT CAUSES AN INFECTION?

1. Bacterial Food (Dead Tissue)

2. Bacterial Fortress (Debris)

a. Stone/Wood/Any foreign Body

b. Dirt

c. Bloody Gauze you packed into the wound.

3. Bacterial count (# of germs) (Bacterial introduced by wounding + Bacteria growth
after wounding = Bacteria count)

WOUND CARE TIMELINE:

1. Wounding time 0 to 1 hours

a. Infections Starts

b. Advanced medical care is available, cover wounds to protect from further
contamination and transport.

2. 1-6 hours

a. If medical care will be delayed, begin wound care at 1-6 hours and every 12
hours thereafter.

b. If transport to medical care is delayed you will need to clean the wound.

3. 6 plus hours

a. Surgery is essential to good outcome.

174

WOUND CARE TREATMENTS:

1. Protect wound from further contamination (apply a dressing).

2. Antibiotics as early as possible.

3. If casualty is able to swallow have them swallow the contents of a Combat Pill Pack.

4. Clean out the wound

5. Remove debris (bacteria fortress) i.e. dirt, clothing, anything foreign

6. Irrigation

a. Any water good enough to drink will work. 0.9% normal saline is best or salty,
clean water. (9 grams of salt per one liter of water)

b. Combine with mechanical and surgical debridement for best results.

7. Clean gauze dressings (not a pressure dressing)

SIGNS OF INFECTION:

1. These are not seen immediately after injury

a. Swelling

b. Warm

c. Painful

d. Draining pus (late sign)

e. Red streaking (late sign)

f. Bad smell (decaying death)

2. If the infection goes systemic the casualty may have:

a. Fevers/chills (late sign)

b. Feel generally ill (late sign)

175
c. Hypotension (shock) (late sign)

d. Altered mental status (sate sign)

3. TCCC guidelines dated 8 August 2011. Section 15, page 5 (Antibiotics)

______________________________________________________________________

______________________________________________________________________

BLAST INJURY WOUNDS

1. Large wound areas- lots of dead tissue.

2. Heavy contamination, large amount of foreign bodies and particularly soil are blasted
deep into wound.

3. Third world bacteria in soil bring nasty infections with it.

4. Aggressive wound care is essential to good casualty outcome.

WOUNDS ASSOCIATED WITH SEVERE INFECTIONS:

1. Abdominal Wounds

a. Bullet/Shrapnel tears bowel and spills bacteria-filled contents, into abdominal
cavity guaranteeing infection and death if untreated.

b. Surgical intervention within 6 hours required for best outcome.

2. Chest Wound

a. Projectile/blast introduces bacteria into chest cavity causing severe infection.

b. Surgical intervention within 6 hours required for best outcome.
5
a. Able to fight:
b. Unable to fight:
Note: Have naloxone readily available whenever administering
opiates.
- Oral transmucosal fentanyl citrate (OTFC), 800 ug
transbuccally
- Recommend taping lozenge-on-a-stick to
casualtys finger as an added safety measure
- Add second lozenge, in other cheek, as
- Monitor for respiratory depression.
- Repeat dose every 10 minutes as necessary to
control severe pain.
- Promethazine, 25 mg IV/IM/IO every 6 hours as needed for
nausea or for synergistic analgesic effect

14. Splint fractures and recheck pulse.

- Moxifloxacin, 400 mg PO one a day
- Cefotetan, 2 g IV (slow push over 3-5 minutes) or IM every
12 hours
or

16. Burns
176

OPERATIONAL PAIN MANAGEMENT

TRAINING OBJECTIVES

1. Explain the relevance of pain management in combat casualty care
2. Define pain
3. Define the different types of pain
4. Explain the impact pain has on combat casualties
5. Explain the bodys response to pain
6. Explain the physiological and psychological aspects of pain
7. Define the Warfighters role in pain management
8. Explain how proper bandaging and splinting impacts casualty pain levels
9. Explain the role of narcotics in combat casualty pain management
10. Explain the role and complications of common chronic pain medication in the
operational setting
11. Explain the treatment of chronic pain in the operational setting
12. Explain the treatment of acute pain in the operational setting
13. Answer all remaining questions regarding pain management in combat casualty
care
14. Pain management is an essential part of casualty care. Beyond the physical
discomfort, pain causes a profound physiological change in the body. Pain
impairs the bodies immune system and delays healing and leads to worse
patient outcome.

177

OPERATIONAL PAIN MANAGEMENT

WHY IS PAIN CONTROL IMPORTANT?

1. Its the right thing to do.

2. It makes procedures easier to do.

3. It makes your job easier (such as keeping a tourniquet in place)

4. Pain decreases a casualtys ability to fight infection

TCCC updates: 8 August 2011 and 7 Sept 2012
See below
178

12
11. Inspect and dress known wounds if not already done.


NOTE: Ketamine must not be used if the casualty has suspected penetrating eye
injury or significant TBI (evidenced by penetrating brain injury or head injury with
altered level of consciousness).
a. Able to fight:
b. Unable to fight:
Note: Have naloxone readily available whenever administering opiates.
- Oral transmucosal fentanyl citrate (OTFC), 800 g transbucally
- Recommend taping lozenge-on-a-stick to casualtys finger as an
added safety measure
- Add second lozenge, in other cheek, as necessary to control
severe pain
OR
- Ketamine 50-100mg IM
- Repeat dose every 30 minutes to 1 hour as necessary to
control severe pain or until the casualty develops nystagmus
(rhythmic eye movement back and forth)
OR
- Ketamine 50 mg intranasal (using nasal atomizer device)
- Repeat dose every 30 minutes to 1 hour as necessary to
control severe pain or until the casualty develops nystagmus

- Repeat dose every 10 minutes as necessary to control severe pain.
OR
- Ketamine 20 mg slow IV/IO push over 1 minute
- Reassess in 5-10 minutes.
- Repeat dose every 5-10 minutes as necessary to control
severe pain or until the casualty develops nystagmus
- Continue to monitor for respiratory depression and agitation

- Promethazine, 25 mg IV/IM/IO every 6 hours as needed for nausea or
for synergistic analgesic effect
13

Note: Narcotic analgesia should be avoided in casualties with respiratory distress,
decreased oxygen saturation, shock, or decreased level of consciousness.

14. Reassess fractures and recheck pulses.

- Moxifloxacin, 400 mg PO once a day
- Cefotetan, 2 g IV (slow push over 3-5 minutes) or IM every 12
hours,
or

16. Burns
(>20%), consider placing the casualty in the Heat-Reflective Shell or
Blizzard Survival Blanket from the Hypothermia Prevention Kit in order
to both cover the burned areas and prevent hypothermia.
resuscitation should be initiated as soon as IV/IO access is established.
Resuscitation should be initiated with Lactated Ringers, normal saline, or
Hextend. If Hextend is used, no more than 1000 ml should be given,
followed by Lactated Ringers or normal saline as needed.
weighing 40-80 kg.
If hemorrhagic shock is also present, resuscitation for hemorrhagic shock
takes precedence over resuscitation for burn shock. Administer IV/IO
fluids per the TCCC Guidelines in Section 5.
e. Analgesia in accordance with TCCC Guidelines in Section 11 may be
administered to treat burn pain.
antibiotics should be given per TCCC guidelines in Section 13 if
a burn casualty.
h. Burn patients are particularly susceptible to hypothermia. Extra
179

ORTHOPEDIC PAIN CONTROL METHODS:

1. R.I.C.E., (Rest, Ice, Compression, Elevation)

2. Splinting

180
COMBAT CASUALTY ASSESSMENT


1. Define the importance of tactics in combat casualty care

2. Name the phases of casualty care and the Warfighters role in each

3. Define what medical interventions are required at each phase of combat casualty
care

4. Demonstrate and explain the process of assessing a combat casualty in the care
under fire phase of combat casualty care

5. Demonstrate and explain the process of assessing a combat casualty in the tactical
field care phase of combat casualty care

6. Perform Warfighter skill assessment lab: C.A.T. tourniquet self application to upper
extremity in thirty seconds

7. Perform Warfighter skill assessment lab: C.A.T. tourniquet self application to lower
extremity in thirty seconds

181
8. Demonstrate and explain techniques used to move casualties in the care under fire
phase

9. Perform care under fire casualty movement practical application lab

10. Perform care under fire rapid casualty assessment practical application lab

11. Perform tactical field care casualty assessment practical application lab

12. Answer all remaining questions regarding casualty assessment in combat casualty
care.

182
Care Under Fire

1. Rescuer performs Care Under Fire (Tactical Initial Assessment)

2. Care Under Fire is care rendered at the point of injury while Warfighter and the
casualty remain under effective hostile fire

Warfighter Self Assessment

1. To provide care under fire, you must ask yourself the following questions:

Can I!.???

2. Remove the threat from the casualty or the casualty from the Threat

3. Quickly and effectively apply a tourniquet (self/buddy)

4. Control bleeding with or without the medic

5. Open and/or protect the casualtys airway

6. Become an effective member of the treatment team and assist the Medic when he is
overwhelmed with casualty care he needs.

183
NOTES:

184
CASCADE OF PERFORMANCE EVENTS

First! win the fight!

1. Those who are risk of dying immediately would likely die if the injury occurred in a
hospital.

2. Others can self-care until it is safe to take time away from the fight to help them.

3. Obtaining further casualties while trying to render aid will only worsen the situation.

4. Return fire as directed or required.

5. Try to keep yourself from getting shot.

6. Try to keep the casualty from sustaining additional wounds.

7. Stop any life-threatening extremity hemorrhage with a tourniquet.

8. Take the casualty with you when you leave

185
Specific Considerations

1. Greater than 10% mortality rate due to massive hemorrhage and lack of airway in.

2. Hemorrhage is the most preventable cause of death in the first hour.

3. Airway must be addressed early.

4. Casualties will maintain their airway long enough to control hemorrhage.

186
INITIAL CONTACT WITH DOWN WARFIGHTER

SHOUT!,SHAKE!, SEEK!

SHOUT

1. Establishes open airway/level of consciousness

2. Count 1 to 10 and do it now"..

SHAKEEstablishes level of consciousness

SEEKAGGRESSIVELY SEEK OUT INJURIES

1. Blood on the floor"and 4 more

2. Blood sweep"

a. Chest

b. Abdomen

c. Pelvis

d. Long Bones

TACTICAL FIELD CARE ASSESSMENT

187
Tactical Field care is care rendered when no longer under effective hostile fire or when
a casualty is encountered in the field

Remember"Reassess!Reassess!Reassess!

Warfighter Skills for Tactical Field Care

# Identify life and limb threatening conditions

# Treat/or assist the medic in treatment of the casualty

# Recognize the signs of worsening casualty status, and deliver appropriate care

# Recognize when summoning the medic is critical

# Communicate evacuation needs

# Safely move the casualty to a treatment location

# Assist the medic with the movement of the casualty and eventual evacuation

Tactical Field Care Principles

# Examine and determine the severity of injuries

# Intervene in a step wise approach

# Realize the situation can quickly change back to Care under Fire

# Be prepared to move

# Continually communicate with your team

# Maintain awareness of tactical situation

# Get help when feasible

# Be diligent in reassessing earlier interventions

a. After major movements

b. After re-engaging a threat

c. As often as possible

188
Look at the interventions you performed while under fire. These interventions were
made in haste and must be reevaluated.

Prolonged Firefight

Tactical Field care and Care Under Fire may overlap

Imperative that providing medical care does not risk sustaining further casualties

Tactical Field Care Considerations

Respiratory and circulatory injuries will start to become fatal in this phase of care.

Non-medic contributions are very important here

Preventable deaths from respiratory compromise requires recognition by the non-
medical Warfighter"this will allow for swift life-saving interventions

M.A.R.C.H. Massive Bleeding

Reassess previous interventions

Ensure rebleeding has not occurred

Repeat full blood sweep

M. A. R. C. H. Airway

Reassess airway and make manual adjustments as needed

Ensure you have the ability to maintain an open airway for the long term

Ensure that the medic is notified of any airway condition you are not able to manage

M.A.R.C.H. Respiration

Provide Rescue breaths and ventilation as needed

Check for signs of respiratory distress

Check for chest wall integrity

Needle decompression of chest as required

Consider Ventilation:

189
a. Apnea (temporary inability to breath)

b. Respiratory distress

c. Out of It

M.A.R.C.H. Circulation

Check pulses

Carotid "neck (Notify medic in carotid pulse is lost)

Radial"wrist (Notify medic in radial pulse is lost)

Femoral"groin

Consider giving PO fluids or obtaining IV access depending on casualty status

M.A.R.C.H. Head to Toe (Neuro)

Assessment of Level of Consciousness (LOC)

AVPU

Alert

Responsive to verbal stimuli

Responsive to painful stimuli

Unresponsive"strong indicator of significant head injury, Remember!airway!

Tactical Field Care Continuum

Complete head-toe assessment and institute management of medical issues

Replace clothing and PPE after assessing/treating casualty

190
MARCH PNEUMONIC

NOTES:

Head & Neck
!
#
$ %
&
191

Skull

Fractures/step-off (linear fractures)

Raccoons Eyes/Battles Sign

Scalp lacerations

Eyes

Pupillary reflexes

Conjunctiva hemorrhages (Blast Eye)

Enucleation

Ears

Bleeding (ruptured TM)

CSF leakage (clear fluid)

Nose

Bleeding

CSF leakage

Septal deviation

Face & Jaw

Mid-face instability

Jaw fractures

Cervical Spine

Palpation tenderness

Bony step-off

Pain/paraesthesia/paralysis

*Note: Casualty must be fully awake to participate in examination!
192

Cervical Spine Penetrating Injury

1. There is no requirement to immobilize the spine prior to moving a casualty out of a
firefight if he has only sustained a penetrating injury.

2. Arishita, Vayer, and Bellamy examined the value of cervical spine immobilization in
penetrating neck injuries in Vietnam. They determined that only 1.4% of patients with
penetrating neck injuries might have benefited from cervical immobilization. Hostile fire
poses a much greater threat in this setting, to both casualty and rescuer, than spinal
cord injury from failure to immobilize the spine.

Cervical Spine Blunt Trauma

1. For casualties with significant blunt trauma in the Care Under Fire phase, the risk of
spinal cord injury remains a major consideration.

2. In this circumstance, the risk of cord injury from neck movement must be weighed
against the risk of additional hostile fire injuries while immobilizing the C-spine.
193
Thorax

Visualize

1. Obvious penetrating or sucking chest wound

2. Chest wall excursion/symmetry

3. Respiratory rate/quality

4. Paradoxical movement

5. Bruising/marks

Feel

1. Axilla/clavicle/sternum"work down

2. Assess above and below nipple lines on both sides

3. Assess for rib fractures

4. Check for subcutaneous air (rice crispies)

5. Check Back! (Blood sweep)

Note: Percussion and auscultation limited value in noisy environment!

194
Abdomen

Visualize

1. Obvious wounds/marks/bruising

2. Distension (late sign)

3. Eviscerations

Feel

1. Pain

2. Muscle guarding/rigidity

Pelvis

1. Pain/instability/crepitance

2. Inspect groin for bruising/blood at meatus

3. Associated injuries: femur/knee fractures

4. Unexplained shock

Pelvic Fractures

1. Pain in the pelvis with movement of the legs or deformity of the upper legs = Pelvic
Fracture.

2. This can easily be life-threatening (>2+ L blood loss). Closing and stabilizing the
pelvis may help.
195

Extremities

Visualize

1. Penetrating wounds/deformity/loss of function/amputation

Feel

1. Point tenderness/swelling/bruising/crepitance/instability

Modalities of Management

1. Hemorrhage control (M)

2. Assess and secure airway (A)

3. C-Spine control/precautions as required

4. Immediately seal open chest injuries (R) with an Asherman Chest Seal/4 sided
occlusive dressing (ie: HALO)

5. Decompress affected hemi-thorax in tension pneumothorax with needle
decompression (R)

196
6. Initiate IV access/PO fluids depending on casualtys hemodynamic and mental status
(C)

7. Splint/stabilize long bone/suspected pelvic fractures (H)
8. Package casualty for transport/evacuation (H:Handling with care)

9. Continue to reassess casualty! (FULL M.A.R.C.H. Assessment)

a. Every 10 minutes or after long movement

b. After making movement

c. After engaging the threat

d. As often as possible

197
MAXIMIZING OPERATIONAL PERFORMANCE

1. Operational performance maintenance is the job of the individual Warfighter.

2. There are several field practical methods of maintaining your best possible physical
condition while deployed.

Areas of Concern:

a. Sleep: _________________________________________________________

b. Hydration: ______________________________________________________

c. Nutrition: _______________________________________________________

Sleep Hygiene:

a. Dark, quiet place: ________________________________________________

b. Use sleep area only for sleeping: ____________________________________

c. Sleep cues: ____________________________________________________

d. Routine: _______________________________________________________

e. Place: _________________________________________________________

f. Position: _______________________________________________________

g. Attire: _________________________________________________________

h. Avoid exercise right before sleep: ___________________________________

i. Avoid alcohol, caffeine and tobacco before sleep: _______________________

Hydration:

a. Body losses water by: ____________________________________________

b. Sweating: ______________________________________________________

c. Urination: ______________________________________________________

d. Breathing: ______________________________________________________

e. Bleeding: ______________________________________________________
198

f. All lost water must be replaced: _____________________________________

g. Electrolytes must be replaced: ______________________________________

h. Sodium: _______________________________________________________

i. Potassium: _____________________________________________________

j. Many others: ____________________________________________________

k. ORS replace needed electrolytes: ___________________________________

Nutrition

a. Operational needs require more than the basal metabolic calorie needs:
________________________________________________________________

b. 100 additional calories per mile traveled on foot:
________________________________________________________________

c. Per-mission meal must be high in complex carbohydrates:
________________________________________________________________

d. Support long term exertion with same meals (Energy bars and gels):
________________________________________________________________

e. Recovery food is needed after exertion:

NOTES:

199

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