Клинические протоколы TCCC и Prolonged Field Care (PFC)

Tactical Combat Casualty

Care

(A new way to Triage & Treat Injured Soldiers)

Introduction

Soldiers continue to die on today’s

battlefield just as they did during the

Civil War. The standards of care

applied to the battlefield have always

been based on civilian care principals.

These principals while appropriate for

the civilian community often do not

apply to care on the battlefield.

Introduction

Civilian medical trauma training is

based on the following principles:

Emergency Medical Technicians

(EMT-B,I,P)

Basic Trauma Life Support (BTLS)

Advanced Trauma Life Support (ATLS)

Introduction

Tactical Combat Casualty Care

has been approved by the

American College of Surgeons

and National Association of

EMTs and is included in the Prehospital Trauma Life Support

manual 5th edition.

Introduction

This approach recognizes a

particularly important principle –

Performing the correct intervention

at the correct time in the continuum

of combat care. A medically correct

intervention performed at the wrong

time in combat may lead to further

casualties

Introduction

Three goals of TCCC:

1. Treat the casualty

2. Prevent additional casualties

3. Complete the mission

Introduction

Pre-hospital care continues to

be critically important

Up to 90% of all combat deaths

occur before a casualty

reaches a Medical Treatment

Facility (MTF)

Penetrating vs. Blunt trauma

Combat Deaths

KIA: 31% Penetrating head trauma

KIA: 25% Surgically uncorrectable torso

trauma

KIA: 10% Potentially surgically correctable

trauma

KIA: 9% Hemorrhage from extremity wounds

KIA: 7% Mutilating blast trauma

KIA: 5% Tension pneumothorax

KIA: 1% Airway problems

DOW: 12% Mostly from infections and

complications of shock

Factors Influencing

Combat Casualty Care

Enemy Fire

Medical Equipment Limitations

Widely Variable Evacuation Time

Tactical Considerations

Casualty Transportation

STAGES OF CARE

Care Under Fire

Tactical Field Care

Combat Casualty Evacuation

Care

Care Under Fire

“Care under fire” is the care

rendered by the medic 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 soldier or the

medic in his aid bag.

Tactical Field Care

“Tactical Field Care” is the care

rendered by the 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 hostile fire. Available

medical equipment is still limited to

that carried into the field by medical

personnel. Time to evacuation to a MTF

may vary considerably.

Combat Casualty

Evacuation Care

“Combat Casualty Evacuation

Care” is the care rendered once

the casualty has been picked up

by an aircraft, vehicle or boat.

Additional medical personnel and

equipment may have been prestaged and available at this phase

of casualty management.

Care Under Fire

Manage Apparent Life Threats:

Protect casualty from further

injury

Stop injury process

Control severe bleeding

Care Under Fire

Medical personnel’s firepower

may be essential in obtaining

tactical fire superiority. Attention

to suppression of hostile fire may

minimize the risk of injury to

personnel and minimize additional

injury to previously injured

soldiers.

Care Under Fire

Personnel may need to assist in

returning fire instead of stopping to

care for casualties

Wounded soldiers who are unable to

fight should lay flat and motionless if

no cover is available or move as

quickly as possible to any nearby

cover

Care Under Fire

Medical personnel are limited and if

injured no other medical personnel

may be available until the time of

extraction during the CASEVAC phase

No immediate management of the

airway is necessary at this time due

to movement of the casualty to cover

Care Under Fire

Control of hemorrhage is

important since injury to a major

vessel can result in hypovolemic

shock in a short time frame

Over 2500 deaths occurred in Viet

Nam secondary to hemorrhage

from extremity wounds

Care Under Fire

Use of temporary tourniquets

to stop the bleeding is

essential in these types of

casualties

Care Under Fire

The need for immediate access to

a tourniquet in such situations

makes it clear that all soldiers on

combat missions have a suitable

tourniquet readily available at a

standard location on their battle

gear and be trained in its use.

Care Under Fire

Penetrating neck injuries do not

require C-spine immobilization.

Other neck injuries, such as falls

over 15 feet, fast-roping injuries, or

MVAs may require C-spine control

unless the danger of hostile fire

constitutes a greater threat in the

judgment of the medic

Care Under Fire

Conventional litters may not be

available for movement of

casualties. Consider alternate

methods to move casualties such

as a SKED® or Talon II® litter.

Smoke, CS, and vehicles may act

as screens to assist in casualty

movement.

Care Under Fire

Do not attempt to salvage a

casualty’s rucksack, unless it

contains items critical to the mission

Take the patient’s weapon and

ammunition if possible to prevent

the enemy from using it against

you.

KEY POINTS

Return fire as directed or required

The casualty(s) should also return fire if able

Try to keep yourself from being shot

Try to keep the casualty from sustaining any

additional wounds

Airway management is generally best

deferred until the Tactical Field Care phase

Stop any life threatening hemorrhage with a

tourniquet

Reassure the casualty

Tactical Field Care

The Tactical Field Care phase is

distinguished from the Care Under

Fire phase by having more time

available to provide care and a

reduced level of hazard from

hostile fire. The times available to

render care may be quite variable.

Tactical Field Care

In some cases, tactical field care may

consist of rapid treatment of wounds

with the expectation of a reengagement of hostile fire at any

moment. In some circumstances there

may be ample time to render whatever

care is available in the field. The time

to evacuation may be quite variable

from 30 minutes to several hours.

Tactical Field Care

If a victim of a blast or penetrating

injury is found without a pulse,

respirations, or other signs of life,

Do Not attempt CPR

Casualties with altered mental status

should be disarmed immediately,

both weapons and grenades

Tactical Field Care

Initial assessment consists of

Airway

Breathing

Circulation

Tactical Field Care

Airway

Open the airway with a jaw thrust

maneuver, if unconscious insert a

nasopharyngeal airway or

Combitube, and place the casualty

in the recovery position

Tactical Field Care

Airway

If the casualty is unconscious

with an obstructed airway,

perform a surgical

cricothyroidotomy

Tactical Field Care

Airway

Oxygen is usually not available

in this phase of care

Tactical Field Care

Breathing

Traumatic chest wall defects

should be closed with an occlusive

dressing without regard to venting

one side of the dressing or use an

“Asherman Chest Seal®”. Place the

casualty in the sitting position if

possible.

Tactical Field Care

Breathing

Progressive respiratory distress

secondary to a unilateral

penetrating chest trauma should be

considered a tension pneumothorax

and decompressed with a 14 gauge

needle

Tension pneumothorax is the 2nd

leading cause of preventable death

on the battlefield

Tension Pneumothorax

Air pushes over

heart and

collapses lung

Heart compressed

not able to pump

Air

outside

lung

from

wound

Tactical Field Care

Bleeding

Any bleeding site not

previously controlled should

now be addressed. Only the

absolute minimum of clothing

should be removed.

Tactical Field Care

Bleeding cont’d

Significant bleeding should be controlled

using a tourniquet as described previously.

Once the tactical situation permits,

consideration should be given to loosening

the tourniquet and using direct pressure or

hemostatic dressings (HemCon®) or

hemostatic powder (QuikClot®) to control

any additional hemorrhage

Chitosan Hemostatic

Dressing

Hold the foil over-pouch so that

instructions can be read. Identify unsealed

edges at the top of the over-pouch

Chitosan Hemostatic

Dressing

Peel open over-pouch by pulling the

unsealed edges apart

Chitosan Hemostatic

Dressing

Trap dressing between bottom foil and

non-absorbable green/black polyester

backing with your hand and thumb

Chitosan Hemostatic

Dressing

Hold dressing by the non-absorbable polyester

backing and discard the foil over-pouch. Hands

must be dry to prevent dressing from sticking to

hands.

Chitosan Hemostatic

Dressing

Place the light colored sponge portion of

the dressing directly to the wound area with

the most severe bleeding. Apply pressure

for 2 minutes or until the dressing adheres

and bleeding stops. Once applied and in

contact with the blood and other fluids, the

dressing CANNOT be repositioned.

A new dressing should be applied to other

exposed bleeding sites Each new dressing

must be in contact with tissue where

bleeding is heaviest. Care must be taken to

avoid contact with the patient’s eyes.

Chitosan Hemostatic

Dressing

If dressing is not effective in stopping

bleeding after 4 minutes, remove

original and apply a new dressing.

Additional dressings cannot be

applied over ineffective dressing

Apply a battle dressing/bandage to

secure hemostatic dressing in place

Hemostatic dressings should only be

removed by responsible persons after

evacuation to the next level of care

HERE

'-tEAE

QuikClo€

Adsorbent Hemostatic Agent,

Controls Moderate to Severe Blood Loss

by Promoting Coagulation

For Ernergencyf External Use

as a

-Temporary Traumatic Wound+Treatment

To Stop Moderate-tO-Severe Bleeding

SEE DIRECTEONS ON BACK

Z-MEDICA

Tactical Field Care

IV

IV access must be gained next. The use

of a single 18 gauge catheter is

recommended, because of the ease of

starting and also helps to conserve

supplies.

A Heparin or saline lock-type access

tubing should be used unless the

patient needs immediate resuscitation.

Tactical Field Care

IV

Medics should insure the IV is not

started distal to a significant wound.

If unable to start an IV consideration

should be given to starting a sternal

I/O line to provide fluids

Tactical Field Care

Fluids

1000ml of Ringers Lactate (2.4lbs)

will expand the intravascular volume

by 250ml within 1 hour

500ml of 6% Hetastarch (trade

name Hextend®, weighs 1.3lbs) will

expand the intravascular volume by

800ml within 1 hour, and will sustain

this expansion for 8 hours

Tactical Field Care

Fluids

Algorithm for fluid resuscitation

BP verses palpable radial pulse and

mentation

Superficial wounds (>50% injured); no

immediate IV fluids needed. Oral fluids

should be encouraged.

Tactical Field Care

Fluids

Any significant extremity or truncal

wound ( neck, chest, abdomen,

pelvis)

1. If the soldier is coherent and has a

palpable radial pulse, start a saline

lock, hold fluids and reevaluate as

frequently as the situation permits

Tactical Field Care

Fluids

2. Significant blood loss from any

wound, and the soldier has no radial

pulse or is not coherent-STOP THE

BLEEDING- by whatever means

available- tourniquet, direct

pressure, hemostatic dressings, or

hemostatic powder etc. Start 500ml

of Hextend®. If mental status

improves and radial pulse returns,

maintain saline lock and hold fluids

Tactical Field Care

Fluids

3. If no response is seen give an

additional 500ml of Hextend® and

monitor vital signs. If no response is

seen after 1000ml of Hextend®,

consider triaging supplies and attention

to more salvageable casualties

Tactical Field Care

Fluids

4. Because of coagulation

concerns, no casualty should

receive more than 1000 ml of

Hextend®.

Tactical Field Care

Wounds

Dress wounds to prevent further

contamination and help

hemostasis

(Emergency Trauma Dressing®)

Check for additional wounds (exit)

Tactical Field Care

Pain Control

Able to fight

– Rofecoxib (vioxx®) 50 mg po qd

– Acetaminophen 1000 mg po q6hr

Unable to fight

– Morphine 5 mg IV / IO

– Phenergan® 25mg IV, IM

Combat

the event

all four pilis with water.

Pill Pack

'RANGER

Pain Management and Infection Control

For Combat Casualties

"Just Got Easier To Swallow"

Tactical Field Care

Pain Control

Pain control should be achieved by

intravenous morphine, if possible

1. 5mg IV morphine may be given

every 10 minutes until adequate pain

control is achieved. If a saline lock is

used it should be flushed with 5ml of

sterile solution (saline, LR etc.) after

morphine administration.

Tactical Field Care

Pain control

2. Insure some visible indication of

time and amount of morphine given.

3. Soldiers who administer morphine

should also be trained in its side

effects and in the use of Naloxone

Tactical Field Care

Pain Control

Soldiers should avoid aspirin and

other nonsteroidal antiinflammatory medicines while in a

combat zone because of

detrimental effects on hemostasis.

Tactical Field Care

Fractures

Splint fractures as

circumstances allow, insuring

pulse, motor, and sensory

checks before and after

splinting

Tactical Field Care

Antibiotics

Antibiotics should be

considered in any wound

sustained on the battlefield.

Tactical Field Care

Casualties who are awake and alert,

Gatifloxacin 400 mg, one tablet Q

day with increased fluids

Casualties who are unconscious,

Cefotetan 2gms IV push over 3-5

minutes, may be repeated at 12

hour intervals.

Personnel with allergies to

Fluoroquinolones or Cephalosporins,

consider other broad spectrum

antibiotics in the planning phase.

Casevac Care

At some point in the operation

the casualty will be scheduled

for evacuation. Time to

evacuation may be quite

variable from minutes to hours.

Casevac Care

There are only minor differences in care

when progressing from the Tactical

Field Care phase to the Casevac phase.

1. Additional medical personnel may

accompany the evacuation asset and

assist the medic on the ground. This

may be important for the following

reasons:

Casevac Care

The medic may be among the

casualties

The medic may be dehydrated,

hypothermic, or otherwise

debilitated

Casevac Care

The Evac asset’s medical

equipment may need to be

prepared prior to evacuation.

There may be multiple casualties

that exceed the capability of the

medic to care for simultaneously.

Casevac Care

2. Additional medical

equipment can be brought in

with the EVAC asset to

augment the equipment the

medic already has.

This equipment may include:

Casevac Care

Electronic monitoring equipment

capable of measuring a

patient’s blood pressure, pulse,

and pulse oximetry.

Oxygen should be available

during this phase

Casevac Care

Ringers Lactate at a rate of

250ml per hour for patients not

in shock should help to reverse

dehydration.

Blood products may be available

during this phase of care.

Summary

How people die in ground combat:

31% Penetrating Head Trauma

25% Surgically Uncorrectable

Torso Trauma

10% Potentially Correctable

Surgical Trauma

Summary

9% Exsanguination from Extremity

Wounds 1st

7% Mutilating Blast Trauma

5% Tension Pneumothorax 2nd

1% Airway Problems 3rd

12% Died of Wounds (Mostly infections

and complications of shock)

Today < 5 %

Summary

Three categories of casualties on

the battlefield:

Soldiers who will do well regardless

of what we do for them

Soldiers who are going to die

regardless of what we do for them

Soldiers who will die if we do not do

something for them NOW (7-15%)

Summary

“If during the next war you could

do only two things, (1) put on a

tour-niquet and (2) relieve a

tension pneumothorax then you

can prob-ably save between 70

and 90 per-cent of all the

preventable deaths on the

battlefield.”

COL Ron Bellamy

Summary

Medical care during combat differs

significantly from the care provided

in the civilian community. New

concepts in hemorrhage control,

fluid resuscitation, analgesia, and

antibiotics are important steps in

providing the best possible care to

our combat soldiers.

Summary

These timely interventions

will be the mainstay in

decreasing the number of

combat fatalities on the

battlefield.

National Stock

Numbers

One handed tourniquet 6515-01-504-0827

Hextend® Fluid 6505-01-498-8636

FAST 1® 6515-01-453-0960

Emergency Trauma Dressing® 6510-01-4922275

HemCon Chitosan Dressing® 6510-01-5026938

Sked Litter® 6530-01-260-1222

Talon II Litter® 6530-01-452-1651