Combat medicine

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  • All soldiers should carry a tourniquet that they can quickly and easily reach to use on themselves.Some extremity wounds may be too high on the extremity to control with a tourniquet.
  • Care under Fire does not imply treating in an exposed condition such as in the street. It simply means while your unit is actively engaged with the enemy
  • Tourniquets are routinely used for hours in surgery
  • The wider a tourniquet is, the less force it takes to compress the artery Narrow tourniquets can cut into the casualty and cause additional damageSome commercial tourniquets are not suitable for use in combat
  • 2-3 inches or a hands width above the wound is generally recommended but hard to determine. Utilization of a hands-width as a rough estimate is generally an easier training standard to achieve but students must understand that the place where they see the bleeding (the hole) may NOT be the place where the bleeding is coming from and going higher is a potentially the best answer based on effectiveness.Some wounds are jagged and we must insure that the tourniquet is completely around the limb and not just around the limb on the top
  • You must put a tourniquet on between the wound and the pump in order to stop bleeding.
  • Each unit should have an SOP on where each soldier carries the CATThe CAT should be removed from it’s plastic wrapping since this delays applicationThe CAT can be carried on vest or in IFAK but must be easily accessible
  • Newer models should have threaded windlass and made on dateRods can break especially when exposed to cold weather
  • Loosening tourniquet = losing more blood – do not do this.This soldier will probably require pain management since tourniquet pain can be quite severe.
  • Massive bleeding is an active event and not just an ugly wound
  • This is a photo of an ankle being packed as an example of packing.
  • This bandage is ELASTIC and does NOT require the plastic pressure bar (which breaks) to work effectively. The pressure bar is a technique and people feel that if they don’t have THIS bandage they cannot create a pressure dressing which is incorrect. PRESSURE makes a PRESSURE DRESSING not plastic attachments.
  • Students should try to utilize pressure – either from their own hands or knees – to control bleeding on a wound as they prepare to treat the patient is the best technique. Utilizing a buddy to help bandage is the optimal technique and a pressure bandage MUST have pressure behind it and be secure to work.
  • This is a post mortem x-ray of a tension pneumothorax that resulted from a single gun-shot wound to the left upper chest. Cardiac shadow is now largely on the right side of the chest with free air on the left.
  • This graph represents pre-GWOT data for traumatic deaths over time.The zero to six minute segment represents “instantaneous death” which means 20% of our combat casualties have died in past conflicts in the first six minutes and there was nothing that could be done to prevent these deaths.Arterial bleeding and airway insults cause the most fatalities from that point to one hour to be followed by breathing insults and the results of unresolved shock. After the six hour point there is some stability until the 24 hour mark where infection takes over.
  • Anything can happen on the battlefield and they can happen in conjunction with other injuries or alone.
  • TBI is a major threat on the modern battlefield. Injuries can occur from the blast itself, from shrapnel or debris, or even from the person getting thrown into something or being in a vehicle that rolls over. An open head injury can equalize the pressure building up in the brain but can be rapidly fatal if the brain is penetrated or damaged. Closed head injuries can cause swelling or bleeding of the brain in an enclosed space and, depending on the amount of damage and the speed of swelling or bleeding, can be fast or slow. Casualties with blunt or penetrating wounds of the head where there is obvious massive brain damage and unconsciousness are unlikely to survive with or without emergent evacuation. Casualties with blunt or penetrating wounds to the head where the skull has been penetrated but the casualty is conscious should be evacuated emergently.
  • A casualty with uncontrolled bleeding into the abdomen is Urgent relative to what is happening on the battlefield and how the evacuation assets are arrayed. Uncontrolled bleeding into the abdomen requires rapid surgical intervention and cannot be effectively treated on the battlefield.Exposed abdominal contents by themselves do not pose an immediate threat to life but do cause heat loss, can dry out quickly if left exposed and present a very high risk of infection.
  • Combat medicine

    1. 1. Battlefield Direct Triage Training Introduction to Tactical Combat Casualty Care
    2. 2. Goals of TCCC• Three Goals of TCCC – Treat the casualty – Prevent additional casualties – Complete the mission• Relative priority determined by tactical situation
    3. 3. Casualty Assessment Techniques M-A-R-C-H-(E) – Massive Hemorrhage – Airway – Respirations – Circulation – Hypothermia – (Evacuation)
    4. 4. Phases of Care• Care Under Fire• Tactical Field Care• Tactical Evacuation Care
    5. 5. Care Under Fire Principles1. Return fire/take cover2. Direct/expect casualty to remain engaged as a combatant, if appropriate3. Direct casualty to move to cover/apply self aid if able4. Try to keep the casualty from sustaining additional wounds5. Airway management is generally best deferred until the Tactical Field Care phase
    6. 6. Care under Fire Principles6. Stop life-threatening external hemorrhage if tactically feasible: - Direct casualty to control bleeding by self-aid if able (one handed tourniquet use) - Use a tourniquet for extremity hemorrhage (if possible)
    7. 7. Care Under Fire Principles• Don’t try to treat casualty in the Kill Zone!• Suppression of enemy fire and moving casualties to cover are the most important factors• The best medicine on the battlefield is Fire Superiority
    8. 8. Care Under Fire Principles• Don’t take time to establish an airway• Defer airway treatment until you have moved casualty to cover• Hemorrhage is the greatest threat to life• If casualty has no airway or respirations in the Care Under Fire phase, chances for survival are minimal• CPR is not indicated on the battlefield
    9. 9. Tactical Field Care Principles• Re-inspect for bleeding control and treat as needed• Conduct a complete assessment of casualty to identify all wounds – treat as you go (ABC or MARCH-E)• Prepare casualty as a “package” for evacuation and be ready to move• Casualties who have lost blood must be kept warm (hypothermia)
    10. 10. Tactical Field Care Summary• Check Head to toe – treating as you go• Simultaneously preparation of casualty for evacuation• Be prepared to move on short notice• Constantly re-inspect treatments and patient status (level of consciousness, radial pulse)• Changes in status change evacuation priority• Transfer information to next level of care• Keep patient warm
    11. 11. Tactical Evacuation care• Provide care during evacuation• Having more supplies on vehicles as part of plan is key
    12. 12. Tactical Combat Casualty Care Summary• The three leading preventable causes of death on the battlefield that TCCC is focused on reducing are: – Uncontrolled hemorrhage – Tension pneumo-thorax – Airway• As the combat situation changes, your treatments change
    13. 13. Tactical Combat Casualty Care Summary• Always maintain a tactical advantage and mission focus during casualty care• Care under fire is focused on moving the casualty to cover and preventing death from blood loss• Stop any life threatening extremity bleeding with a tourniquet• Tactical Field Care is where airway management is done and where chest and other injuries are treated• Always be prepared to move as you treat• Keep the casualty warm• Transfer treatment information
    14. 14. Hemorrhage Control on the Battlefield
    15. 15. Hemorrhage Control – Stop the Bleeding• Early control of severe hemorrhage is critical – Extremity hemorrhage is the most frequent cause of preventable battlefield deaths – Over 2500 deaths occurred in Vietnam due to hemorrhage from extremity wounds – Injury to a major vessel can quickly lead to shock and death
    16. 16. Hemorrhage Control Frequently Asked Question• How long does it take to bleed to death from a severed femoral artery?• Hint: The large blood vessel in your thigh• Answer: – Casualties with such an injury can bleed to death in as little as 3 minutes
    17. 17. Hemorrhage Control• When a tourniquet can be applied, it is the first choice for to control massive bleeding in extremity wounds for combat casualties
    18. 18. Hemorrhage Control Frequently Asked Question• If I put a tourniquet on a casualty, is he going to lose that limb?• Answer: No. The amputations that occur in combat are generally due to the degree of damage and not the tourniquet use.
    19. 19. Tourniquet Function Principles• Tourniquet must occlude artery in both an arm and a leg (stop pulse and blood flow)• Tourniquet must be locked into place once tightened to prevent accidental release• The band or strap that is routed around the extremity should be at least one inch wide• Tourniquets do not work on or near joints• Tourniquets can be improvised but it takes time to do so
    20. 20. Tourniquet Application Principles• Identify the injury: massive bleeding from arm or leg• Put tourniquet on above the wound *and tighten (take out the slack)• Turn windlass rod or tourniquet device until bleeding stops• Secure tourniquet (i.e windlass rod) for transport (no quick releases)• Annotate time and monitor patient
    21. 21. Tourniquet Application Principles• Apply above wound without delay to control massive bleeding in arms and legs• Do not “treat in the street” – find cover• The casualty, the person applying the tourniquet, and the entire element are in grave danger during Care under fire phase (i.e. while in a firefight)
    22. 22. Recommended Tourniquet• The Committee for Tactical Combat Casualty Care recommends that all combat personnel should carry a C.A.T and be trained in its use – This tourniquet was designed to be applied with one hand in order to meet USSOCOM requirement – Soldiers should be able to easily reach own tourniquet quickly – Should be carried by unit SOP
    23. 23. Combat Application Tourniquet
    24. 24. Tourniquet Application Principle• DO NOT periodically loosen the tourniquet to get blood to the limb - Can be rapidly fatal• Tourniquets are very painful• If bleeding re-occurs after tourniquet is applied – attempt to retighten the tourniquet• If bleeding still occurs or a pulse is present, you should apply another TQ above first TQ
    25. 25. Summary Tourniquet Application• Immediately put on above extremity wound in order to control massive bleeding• Tighten tourniquet until bleeding stops• Mark time of application• Do not loosen or remove without a medic• Tourniquets are very painful
    26. 26. Some extremity wounds will not require a tourniquet
    27. 27. Wound Packing Principles• Pack cavities that are bleeding to the bone (deep)• Layer gauze in – do not stick in entire roll even into large cavities• Create a pressure cone from the inside out and then apply a pressure bandage and hold pressure to control bleeding
    28. 28. Wound Packing Function• Combat injuries form cavities of all shapes and sizes• Packing gauze deep into these cavities creates a “pressure cone”• Proper wound packing technique can control arterial bleeding in areas where you cannot use a tourniquet
    29. 29. Example Wound Packed With Kerlix
    30. 30. Wound Packed with Kerlix
    31. 31. Pressure Bandage Function Principles• Pressure is an essential component to hemorrhage control• Pressure on an artery above a wound can slow down or sometimes temporarily stop blood flow• A pressure bandage is applied to help slow down bleeding so that the blood can clot – it is not meant to be a tourniquet• Pressure bandages can be easily improvised
    32. 32. Pressure Bandage Application Principles• Pressure is the key component in a pressure bandage - be prepared to improvise• Place it on the wound, wrap it until it is effective, and secure it so it doesn’t come loose• If applying a pressure bandage to a cavity, pack the cavity with gauze first to create pressure cone
    33. 33. Evacuation Principles for Hemorrhage Control• Mark time of tourniquet application and transfer knowledge of treatment to evacuation asset• Some bleeding you cannot see so monitor level of consciousness - decreases in level of consciousness or loss of radial pulse are categorized as urgent• Tourniquet and hemostatic effectiveness must be constantly re-assesed during movement and evacuation
    34. 34. Hemorrhage Control Summary• Apply tourniquet to control massive bleeding on arms and legs• Use Combat Gauze in wounds that are massively bleeding but on which a tourniquet cannot be used• Pack wounds in layers NOT rolls• Use pressure dressings to secure treatments, help slow down bleeding, and treat minor wounds• Know the equipment your unit is using, where it is located on each soldier and vehicle, and train to use it in the combat environment
    35. 35. Airway and Breathing
    36. 36. Airway Anatomy
    37. 37. Airway Principles• When managing airway problems in combat the least invasive and simplest techniques work best• Airways in casualties require constant monitoring and reassessments• Inhalation airway burns and some trauma (i.e. blast and bleeding) can be very dangerous and must be identified quickly because they often require more advanced airway interventions
    38. 38. Airway Management• Positioning (self performed) – Conscious casualties will find a way to breath –allow them to do so – Decreased state of consciousness or unconscious casualties need your help• Recovery position if unconscious – Maintain casualty on side to allow drainage and gravity to move anatomy to keep airway open – Casualties often vomit (blast; morphine)• Head tilt-Chin lift• NPA - (Nose-Hose)
    39. 39. Airway problems• Airway obstructions occurs in three categories of combat related patients: – Facial and neck trauma – Unconscious patients – Inhalation Burns
    40. 40. Airway Management• Place unconscious casualties in the recovery position
    41. 41. Airway burns • Progressive development • Medical intervention is require to secure and maintain airway
    42. 42. Nasopharyngeal Airway (NPA) Nose-Hose• Open the airway with a head tilt- chin lift maneuver, if unconscious insert a nasopharyngeal airway. Any airway device must be at least 6mm in diameter to allow spontaneous respiration.
    43. 43. Identifying the Airway problem• How would you determine if a person has an airway problem?• Casualties with altered level of consciousness should be disarmed immediately.
    44. 44. Evacuation Principles for Airway Casualties• Casualties with penetrating facial trauma bleed profusely and can die from either blood loss or aspiration of blood (drowning)• Unconscious litter patients with facial injuries should NOT be transported on their backs unless a medical provider has established an advanced definitive airway
    45. 45. Evacuation Principles for Airway Casualties• Transport casualties with massive facial wounds either on their sides or on their stomachs with their heads turned to the side• This allows fluids (blood/vomit) to drain out of the mouth and keeps the tongue from falling back• Casualties that have a decreased level of consciousness should be evacuated with an NPA• Casualties with compromised airways are urgent
    46. 46. Airway Summary• Use least invasive technique first• Positioning alone may be all you need• Remember to protect casualties airway during evacuation and constantly monitor• Airway injuries always require positional airway and may require advanced medical airways• Airway treatments are not done in danger areas (Care Under Fire)
    47. 47. BREATHING• All holes in the chest – defined as between the neck and navel - should be closed with an occlusive dressing (tape on 4 sides)• Chest normally has a negative intra-thoracic pressure• After perforation of the chest wall, the pressure becomes positive and causes the lung to collapse
    48. 48. Chest Physiology• If hole is larger than 2cm (.7 in) then air may enter and exit through that hole instead of through the trachea (sucking chest wound). This will rob air from the remaining good lung and compound the hypoxia already present.• Sealing the hole must be the first priority
    49. 49. Tension Pneumothroax
    50. 50. Tension Pneumothorax• Signs and symptoms of tension: – Difficulty breathing – No breath sounds on affected side – Hyperresonate to percussion (sounds like drum) – Hypotensive (low blood pressure) – Jugular (neck) vein distention (enlargement) – Tracheal shift• Can you detect these at night, in combat??
    51. 51. Tension Pneumothorax• Why is tension pneumothorax rapidly fatal?? – Pressure in chest pushes heart and large vessels against good lung causing collapse – Great vessels are crimped and blood flow to and from heart is compromised – Heart is unable to provide adequate circulation
    52. 52. Chest Seal problems • Poor Adhesive, doesnt stick when body is sweaty or bloody. – Wipe away blood, sweat and other funk • Insure that your treatment is effective. – Reassess the patient.
    53. 53. Breathing Principle• Progressive respiratory distress secondary to a penetrating chest wound should be considered a tension Pneumothorax• A suspected tension Pneumothroax should be decompressed with a 14 gauge 3.25 in. needle/catheter• Tension Pneumothorax is one of the preventable causes of death on the battlefield
    54. 54. Needle / Chest Decompression (NCD)• What are the sites for NCD?• Primary: 2nd intercostal space (ICS) mid clavicular line (MCL)• Why?• Alternate sites:• 3rd, 4th, 5th, ICS AAL, MAL
    55. 55. Needle / Chest Decompression Steps• Identify second intercostal space (ICS) along the mid- clavicular line (MCL)• Over the top of the third rib insert a 14 ga 3.25 in needle/catheter unit at a 90 degree angle to the chest wall.• Insert needle all the way to the hub. Listen for a hiss of escaping air. This indicates you have entered the chest cavity.
    56. 56. Needle Decompression Lines MCL AAL MAL
    57. 57. Needle / Chest Decompression
    58. 58. Needle Decompression• Remove needle and tape catheter in place – If possible allow the casualty to sit up• In animal studies this technique was effective for up to four hours
    59. 59. Needle Decompression Frequently Asked Question• What if casualty doesnt have a tension pneumothorax and you perform Needle Decompression? – Already has hole in chest that is probably larger than diameter of 14 ga needle – No additional damage
    60. 60. Needle Decompression Frequently Asked Question• Can needle decompression be repeated if the patients respiratory distress returns? – Yes, repeat as needed
    61. 61. Needle Decompression Frequently Asked Question• Does the needle/catheter need a glove finger or three-way-stopcock to prevent air from re-entering the chest cavity? – No, the diameter of the 14 ga. Catheter is too small to allow air to re-enter the chest.
    62. 62. Needle Decompression Frequently Asked Question• Will lung re-inflate after pressure is released from chest cavity? – No - To re-inflate lung you must have a chest tube with suction and or positive pressure ventilation – We are converting a tension pneumothorax to a standard pneumothorax. – This is a much more survivable injury than a tension pneumothorax
    63. 63. Needle Decompression Frequently Asked Question• If you do not have the ability to perform needle decompression, how would you treat a casualty who develops a tension pneumothorax? – Remove part of the bandage and attempt to burp the wound – If that is not effective, put on a glove and stick your finger into the wound
    64. 64. Evacuation Principle• Casualties with breathing difficulty must be carefully positioned and often feel the need to move to breath• If the casualty is conscious try and sit them up partially - Place a rucksack or blankets behind them• If the casualty is unconscious place them injured side down to allow the good lung to ventilate easier
    65. 65. Evacuation Principle• Once a person develops a tension they will probably develop another in a matter of time so they require constant monitoring• If you left a catheter in place and the casualty re- develops respiratory distress the catheter may have become clogged or dislodged• If a patient shows signs of progressive respiratory distress AFTER 1st needle they get another needle• A casualty with a tension is urgent
    66. 66. Breathing Principles - Summary• Cover all holes between neck and navel• Constantly monitor for signs of respiratory distress• Progressive / worsening respiratory distress and a penetrating injury to the chest are the indications for a needle decompression – even if you have given one already• Attempt to burp wound if there is no needle• Transport in best possible position or injured side down
    67. 67. Other Battlefield Injuries
    68. 68. Casualty Mortality Curve Airway Arterial Arterial Bleeding Airway Breathing Infection Shock
    69. 69. Management of Battlefield Injuries• Head• Abdominal• Burns• Fractures
    70. 70. TBI• Mechanism of Injury – Blast – Penetrating Trauma• Open vs Closed• Can occur from one exposure or multiple events
    71. 71. Abdominal Treatment• Protect the contents• Attempt to gently replace (medic) or cover and keep moist (all)• Dessication (drying of bowel) leads to removal of bowel• Bleeding into the abdomen can be from multiple locations and is non-compressible• Relative Evacuation Priority for someone who is bleeding into belly?
    72. 72. Burns• Can impact airway and be emergent• Can affect patients body temp regulation• Can cause great amounts of pain or no pain at all depending on degree• Can cause swelling• Can cause of death
    73. 73. Burns• Do not wrap with gauze: Stays in wound and has to be removed by scrubbing• Can cover with burn wraps or plastic but do not wrap too tightly b/c of swelling• Give pain meds IV/IO - covering will help with pain• Cover casualty• Evacuate
    74. 74. Fractures Open or Closed• Open Fracture – associated with an overlying skin wound• Closed Fracture – no overlying skin wound Open fracture Closed fracture
    75. 75. Splinting Objectives• Prevent further injury• Protect arteries and nerves 1.Check pulse before and after splinting• Make casualty more comfortable
    76. 76. Principles of SplintingRule of Two’s – Two Pulses – Two Joints (immobilize) • One above the injury • One below the injury – Two Ties • One tie above the fracture • One tie below the fracture • One tie above the joint • One tie below the joint
    77. 77. Things to Avoid in Splinting• Manipulating the fracture too much and damaging blood vessels or nerves• Wrapping the splint too tight and cutting off circulation below the splint
    78. 78. Splinting Materials• Commercial• Field expedient• Other leg
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