2. Introduction
• The three goals of Tactical
Combat Casualty Care (TCCC)
are:
–1. Save preventable deaths
–2. Prevent additional casualties
–3. Complete the mission
3. Introduction
• This approach recognizes a
particularly important principle:
– To perform the correct intervention at the
correct time in the continuum of Tactical
Care
– A medically correct intervention
performed at the wrong time in combat
may lead to further casualties
5. PREVENTABLE CAUSES OF
COMBAT DEATH
• 60% Hemorrhage from extremity wounds
• 33% Tension pneumothorax
• 6% Airway obstruction e.g., maxillofacial
trauma
• * Data is extrapolated from Vietnam to
present day Iraq and Afghanistan
7. STAGES OF CARE:
3 Distinct Phases
• Care Under Fire
• Tactical Field Care
• Tactical Casualty Evacuation
Care (TACEVAC)
8. Care Under Fire
• “Care under fire” is the care
rendered by the Tactical Medic or
Tactical Operator at the scene of
the injury while still under effective
hostile fire
• Available medical equipment is
limited to that carried by the medic
or first responder in his/her aid
bag
9. Tactical Field Care
• “Tactical Field Care” is the care
rendered by the medic once no longer
under effective hostile fire
• Also applies to situations in which an
injury has occurred, but there has
been no hostile fire
• Available medical equipment still
limited to that carried into the field by
medical personnel
• Time to evacuation may vary
considerably
10. TACTICAL EVAC
• “Tactical Evacuation” is the care
rendered once the casualty has
been picked up by evacuation
vehicles
• Additional medical personnel and
equipment may have been prestaged and available at this stage
of casualty management
12. Care Under Fire
• “The best medicine on any
battlefield is fire superiority”
• Medical personnel’s firepower
may be essential in obtaining
tactical fire superiority
• Attention to suppression of hostile
fire will minimize the risk of
additional injuries or casualties
13. Care Under Fire
• Medical personnel may need to
assist in returning fire instead of
stopping to care for casualties
• Wounded operators 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. Self Aide
should be rendered.
14. Care Under Fire
• No attention to airway at this point
because of need to move casualty to
cover quickly
• Control of hemorrhage is essential
since injury to a major vessel can
result in hypovolemic shock in a short
time frame
• Remember the “Average” person can
exsaguinate in 3-5 minutes with a
major vessel injury i.e. Femoral Artery
Disruption
16. Care Under Fire
• Hemorrhage from extremities is
the 1st leading cause of
preventable combat deaths
• Prompt use of tourniquets to
stop the bleeding may be
life-saving in this phase
18. Care Under Fire
• All personnel engaged in High
Threat missions should have a
suitable tourniquet readily
available at a standard location on
their gear and be trained in its use
• The tourniquet should be placed
as high up on the extremity as
possible, ignoring the clothing
20. Care Under Fire
• Conventional litters may not be
available for movement of casualties
• Consider alternate methods to move
casualties such as a SKEDD/Drags
• Smoke, shields and vehicles may act
as screens to assist in casualty
movement
• Armored Vehicles may also be
employed as a means of egress
21. KEY POINTS
•
•
•
•
Return fire as directed or required
If able, the casualty(s) should also return fire
Try to keep from being shot
Try to keep the casualty from sustaining
additional wounds
• Airway management is best deferred until the
Tactical Field Care phase
• Stop any life threatening hemorrhage with a
commercially available tourniquet (CAT)
• Reassure the casualty
23. Tactical Field Care
• Reduced level of hazard from
hostile fire or enemy action
• Increased time to provide care
• Available time to render care may
vary considerably
24. 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 minutes to hours
25. Tactical Field Care
• If a victim of a blast or penetrating
injury is found without a pulse,
respirations, or other signs of life, DO
NOT attempt CPR
• Casualties with confused mental status
should be disarmed immediately of
their weapon.
26. Tactical Field Care
• On going assessment in this phase is:
A.B.C
– Airway
– Breathing
– Circulation
27. Tactical Field Care:
Airway
• Open the airway with a chin-lift
• If unconscious and spontaneously
breathing, insert a nasopharyngeal
airway
• Place the casualty in the recovery
position
30. Tactical Field Care:
Breathing
• Traumatic chest wall defects
should be closed quickly with an
occlusive dressing without regard
to venting one side of the dressing
• Also may use an “Asherman
Chest Seal” or HyFin TM (North American Rescue
Products)
• Place the casualty in the sitting
position or on effected side.
33. Tactical Field Care:
Breathing
• Progressive respiratory distress in the
presence of unilateral penetrating chest
trauma should be considered tension
pneumothorax
• Tension pneumothorax is the 2nd leading
cause of preventable death on the battlefield
• Cannot rely on typical signs such as shifting
trachea (late sign and very difficult to
appreciate)
• Needle chest decompression is life-saving
( 14 gauge 3.25 inch catheter)
35. Tactical Field Care:
Circulation
• Any bleeding site not previously
controlled should now be
aggressively addressed.
• Only the absolute minimum of
clothing should be removed,
although a thorough search for
additional injuries must be
performed
36. Tactical Field Care:
Circulation
• Once the tactical situation permits, a
new tourniquet can be applied 2-3
inches above wound on bare skin.
Distal pulse should be checked, If
present, tighten tourniquet until distal
pulse is absent
• Initiate IV access
37. Hemostatic Dressing
• Apply directly to bleeding site and hold in
place 2 minutes
• 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
• Pack wound with gauze (enough to fill cavity)
• Apply a battle dressing/bandage to secure
hemostatic dressing in place
• If bleeding controlled, do not remove dressing
39. Tactical Field Care: IV
fluids
• FIRST, STOP THE BLEEDING!
• IV access should be obtained using a single
18-gauge catheter because of the ease of
starting. Rapidly consider I/O access
• IV fluids be administered in amounts
enough to maintain systolic B/P between
70-80 mmHg with 0.9 NS (Hextend?)
• A saline lock may be used to control IV
access in absence of IV fluids
• Ensure IV is not started distal to a significant
wound
40. Tactical Field Care:
Additional injuries
• Splint fractures as circumstances
allow while verifying pulse and
prepare for evacuation (SAM
SPLINT)
• Continually reevaluate casualties
for changes in condition while
maintaining situational awareness
• Consider Emergency Airway
42. Tactical EVAC
• At some point in the operation the
casualty will be evacuated
• Time to evacuation may be quite
variable from minutes to hours
• The tactical medic may be among
the casualties or otherwise
debilitated
• A MASS CALSULTY EVENT may
exceed the capabilities of the
medic
43. Tactical EVAC
• Higher level medical personnel MAY
accompany the TAC EVAC vehicle
• Additional medical equipment MAY be
brought in with the TAC EVAC asset,
which may include
– Electronic equipment for monitoring of the
patient’s blood pressure, pulse, and pulse
oximetry
– Oxygen is usually available during this
phase
44. Summary
• There are three categories of
casualties on the battlefield:
1. Operators who will live regardless
2. Operators who will die regardless
3. Operators who will die from preventable
deaths unless proper life-saving steps are
taken immediately (60% Hemorrhage,
33% Tension Pneumo and 6% Airway
Obstruction
• This is the group MEDICS can help the most.
45. Organizations
Recognizing TCCC
• American College of Surgeons (ATLS)
• National Association of EMT’s (found
in PHTLS Manual)
• National Tactical Officers Association(
advocating for a national standardized
curriculum)
• Adopted by US Army and Navy
(Marines) for service wide curriculum
50. Objectives
•
•
•
•
•
•
•
•
Describe the principles of wound healing
Identify the various types and sizes of suture material.
Choose the proper instruments for suturing.
Identify the different injectable anesthetic agents and
correct dosages.
Demonstrate various biopsy methods: punch, excision,
shave.
Demonstrate different types of closure techniques: simple
interrupted, continuous, subcuticular, vertical and
horizontal mattress, dermal
Demonstrate two-handed, one-handed, instrument ties
Recommend appropriate wound care and follow-up.
51. Critical Wound Healing Period
Tissue
Skin
5-7 days
Mucosa
5-7 days
Subcutaneous
7-14 days
Peritoneum
7-14 days
Fascia
14-28 days
0
5 7
14
21
Tissue Healing Time/Days
28
52. Model of Wound Healing
• (1) Hemostasis: within minutes post-injury, platelets aggregate
at the injury site to form a fibrin clot.
• (2) Inflammatory: bacteria and debris are phagocytosed and
removed, and factors are released that cause the migration and
division of cells involved in the proliferative phase.
• (3) Proliferative: angiogenesis, collagen deposition,
granulation tissue formation, epithelialization, and wound
contraction
• (4) Remodeling: collagen is remodeled and realigned along
tension lines and cells that are no longer needed are removed
by apoptosis.
54. Common Patient
Factors
• Age
• Blood supply to the
area
• Nutritional status
• Tissue quality
• Revision/infection
• Compliance
•
•
•
•
•
Weight
Dehydration
Chronic disease
Immune response
Radiation therapy
55. CDC Surgical Wound Classification
• Clean: (1-5% risk of infection) uninfected operative
wounds in which no inflammation is encountered and the
respiratory, alimentary, genital, or uninfected urinary tracts are
not entered. In addition, clean wounds are primarily closed, and
if necessary, drained with closed drainage. Operative incisional
wounds that follow nonpenetrating (blunt) trauma should be
included in this category if they meet the criteria.
• Clean-contaminated: (3-11% risk) operative wounds in
which the respiratory, alimentary, genital, or urinary tract is
entered under controlled conditions and without unusual
contamination. Specifically, operations involving the biliary tract,
appendix, vagina, and oropharynx are included in this category,
provided no evidence of infection or major break in technique is
encountered.
56. CDC Surgical Wound
Classification
• Contaminated: (10-17% risk) open, fresh, accidental
wounds, operations with major breaks in sterile technique or
gross spillage from the gastrointestinal tract, and incisions in
which acute, nonpurulent inflammation is encountered.
• Dirty or infected: (>27% risk) old traumatic wounds
with retained devitalized tissue and those that involve existing
clinical infection or perforated viscera. This definition suggests
that the organisms causing postoperative infection were
present in the operative field before the operation.
58. Suture Materials
• Criteria
– Tensile strength
– Good knot security
– Workability in handling
– Low tissue reactivity
– Ability to resist bacterial infection
59. Types of Sutures
•
•
•
•
Absorbable or non-absorbable (natural or synthetic)
Monofilament or multifilament (braided)
Dyed or undyed
Sizes 3 to 12-0 (numbers alone indicate
progressively larger sutures, whereas numbers
followed by 0 indicate progressively smaller)
• New antibacterial sutures
60. Non-absorbable
• Not biodegradable
and permanent
– Nylon
– Prolene
– Stainless steel
– Silk (natural, can
break down over
years)
Absorbable
• Degraded via
inflammatory
response
– Vicryl
– Monocryl
– PDS
– Chromic
– Cat gut (natural)
61. Natural Suture
Synthetic
• Biological
• Cause inflammatory
reaction
– Catgut (connective
from cow or sheep)
– Silk (from silkworm
fibers)
– Chromic catgut
• Synthetic polymers
• Do not cause
inflammatory
response
– Nylon
– Vicryl
– Monocryl
– PDS
– Prolene
62. Monofilament
• Single strand of suture
material
• Minimal tissue trauma
• Smooth tying but more
knots needed
• Harder to handle due to
memory
• Examples: nylon,
monocryl, prolene, PDS
Multifilament (braided)
• Fibers are braided or
twisted together
• More tissue resistance
• Easier to handle
• Fewer knots needed
• Examples: vicryl, silk,
chromic
64. Suture Selection
• Do not use dyed sutures on the skin
• Use monofilament on the skin as
multifilament harbor BACTERIA
• Non-absorbable cause less scarring but
must be removed
• Plus sutures (staph, monocryl for E. coli,
Klebsiella)
• Location and layer, patient factors, strength,
healing, site and availability
65. Suture Selection
• Absorbable for GI, urinary or biliary
• Non-absorbable or extended for up to
6 mos for skin, tendons, fascia
• Cosmetics = monofilament or
subcuticular
• Ligatures usually absorbable
67. Surgical Needles
• Wide variety with different company’s
naming systems
• 2 basic configurations for curved
needles
– Cutting: cutting edge can cut through
tough tissue, such as skin
– Tapered: no cutting edge. For softer
tissue inside the body
71. Anesthetic Solutions
• Lidocaine
(Xylocaine®)
– Most commonly used
– Rapid onset
– Strength: 0.5%, 1.0%,
& 2.0%
– Maximum dose:
• 5 mg / kg, or
• 300 mg
– 1.0% lidocaine = 1 g
lidocaine / 100 cc =
1,000mg/100cc
– 300 mg = 0.03 liter =
30 ml
• Lidocaine
(Xylocaine®) with
epinephrine
–
–
–
–
–
Vasoconstriction
Decreased bleeding
Prolongs duration
Strength: 0.5% & 1.0%
Maximum individual
dose:
• 7mg/kg, or
• 500mg
72. Anesthetic Solutions
• CAUTIONS: due to its vasoconstriction
properties never use Lidocaine with
epinephrine on:
– Eyes, Ears, Nose
– Fingers, Toes
– Penis, Scrotum
75. Injection Techniques
• 25, 27, or 30-gauge
needle
• 6 or 10 cc syringe
• Check for allergies
• Insert the needle at
the inner wound
edge
• Aspirate
• Inject agent into
tissue SLOWLY
• Wait…
• After anesthesia
has taken effect,
suturing may begin
77. When to Refer
• Deep wounds of hands or feet, or unknown
depth of penetration
• Full thickness lacerations of eyelids, lips or
ears
• Injuries involving nerves, larger arteries,
bones, joints or tendons
• Crush injuries
• Markedly contaminated wounds requiring
drainage
• Concern about cosmesis
79. Closure Types
• Primary closure (primary intention)
– Wound edges are brought together so that they are adjacent
to each other (re-approximated)
– Examples: well-repaired lacerations, well reduced bone
fractures, healing after flap surgery
• Secondary closure (secondary intention)
– Wound is left open and closes naturally (granulation)
– Examples: gingivectomy, gingivoplasty,tooth extraction
sockets, poorly reduced fractures
• Tertiary closure (delayed primary closure)
– Wound is left open for a number of days and then closed if it
is found to be clean
– Examples: healing of wounds by use of tissue grafts.
80. Wound Preparation
• Most important step for reducing the risk of wound
infection.
• Remove all contaminants and devitalized tissue
before wound closure.
– IRRIGATE w/ NS or TAP WATER (AVOID
H2O2, POVIDONE-IODINE)
– CUT OUT DEAD, FRAGMENTED TISSUE
• If not, the risk of infection and of a cosmetically poor
scar are greatly increased
• Personal Precautions
83. Principles And
Techniques
• Minimize trauma in skin
handling
• Gentle apposition with
slight eversion of wound
edges
– Visualize an
Erlenmeyer flask
• Make yourself comfortable
– Adjust the chair and the
light
• Change the laceration
– Debride crushed tissue
84. Types of Closures
● Simple interrupted closure – most commonly used, good for
shallow wounds without edge tension
● Continuous closure (running sutures) – good for hemostasis
(scalp wounds) and long wounds with minimal tension
● Locking continuous - useful in wounds under moderate tension
or in those requiring additional hemostasis because of oozing
from the skin edges
● Subcuticular – good for cosmetic results
● Vertical mattress – useful in maximizing wound eversion,
reducing dead space, and minimizing tension across the wound
● Horizontal mattress – good for fragile skin and high tension
wounds
● Percutaneous (deep) closure – good to close dead space and
decrease wound tension
85. Simple Interrupted
Suturing
• Apply the needle to the needle driver
– Clasp needle 1/2 to 2/3 back from tip
• Rule of halves:
– Matches wound edges better; avoids dog
ears
– Vary from rule when too much tension
across wound
88. Suturing
• The needle enters
the skin with a 1/4inch bite from the
wound edge at 90
degrees
– Visualize Erlenmeyer
flask
– Evert wound edges
• Because scars
contract over time
89. Suturing
• Release the needle from the needle driver, reach into
the wound and grasp the needle with the needle
driver. Pull it free to give enough suture material to
enter the opposite side of the wound.
• Use the forceps and lightly grasp the skin edge and
arc the needle through the opposite edge inside the
wound edge taking equal bites.
• Rotate your wrist to follow the arc of the needle.
• Principle: minimize trauma to the skin, and don’t bend
the needle. Follow the path of least resistance.
90. Suturing
• Release the needle and grasp the portion of
the needle protruding from the skin with the
needle driver. Pull the needle through the
skin until you have approximately 1 to 1/2inch suture strand protruding form the bites
site.
• Release the needle from the needle driver
and wrap the suture around the needle
driver two times.
91.
92. Simple Interrupted Suturing
• Grasp the end of the suture material with the needle
driver and pull the two lines across the wound site in
opposite direction (this is one throw).
• Do not position the knot directly over the wound
edge.
• Repeat 3-4 throws to ensuring knot security. On
each throw reverse the order of wrap.
• Cut the ends of the suture 1/4-inch from the knot.
• The remaining sutures are inserted in the same
94. The trick to an
instrument tie
• Always place the suture holder parallel to
the wound’s direction.
• Hold the longer side of the suture (with the
needle) and wrap OVER the suture holder.
• With each tie, move your suture-holding
hand to the OTHER side.
• By always wrapping OVER and moving the
hand to the OTHER side = square knots!!
107. Suturing - finishing
• After sutures placed, clean the site
with normal saline.
• Apply a small amount of Bacitracin or
white petroleum and cover with a
sterile non-adherent compression
dressing (Tefla).
108. Suturing - before you go…
• Need for tetanus globulin and/or vaccine?
– Dirty (playground nail) vs clean (kitchen knife)
– Immunization history (>10 yrs need booster or >5 yrs if
contaminated)
• Tell pt to return in one day for recheck, for signs of
infection (redness, heat, pain, puss, etc), inadequate
analgesia, or suture complications (suture strangulation or
knot failure with possible wound dehiscence)
• It should be emphasized to patients that they return at the
appropriate time for suture removal or complications may
arise leading to further scarring or subsequent surgical
removal of buried sutures.
109. Patient instructions and follow up care
• Wound care
– After the first 24-48 hours, patients should gently
wash the wound with soap and water, dry it
carefully, apply topical antibiotic ointment, and
replace the dressing/bandages.
– Facial wounds generally only need topical
antibiotic ointment without bandaging.
– Eschar or scab formation should be avoided.
– Sunscreen spf 30 should be applied to the wound
to prevent subsequent hyperpigmentation.
110. Suture Removal
• Average time frame is 7 – 10 days
–
–
–
–
–
–
FACE: 3 – 5 d
NECK: 5 – 7 d
SCALP: 7 – 12 days
UPPER EXTREMITY, TRUNK: 10 – 14 days
LOWER EXTREMITY: 14 – 28 days
SOLES, PALMS, BACK OR OVER JOINTS: 10 days
• Any suture with pus or signs of infections
should be removed immediately.
111. Suture Removal
•
•
•
•
Clean with hydrogen peroxide to remove
any crusting or dried blood
Using the tweezers, grasp the knot and snip
the suture below the knot, close to the skin
Pull the suture line through the tissue- in the
direction that keeps the wound closed - and
place on a 4x4. Count them.
Most wounds have < 15% of final wound
strength after 2 wks, so steri-strips should
be applied afterwards.
112. Topical Adhesives
• Indications: selection of approximated, superficial,
clean wounds especially face, torso, limbs. May be
used in conjunction with deep sutures
• Benefits: Cosmetic, seals out bacteria, apply in 3 min,
holds 7 days (5-10 to slough), seal moisture, faster,
clear, convenient, less supplies, no removal, less
expensive
• Contraindicated with infection, gangrene, mucosal,
damp or hairy areas, allergy to formaldehyde or
cryanoacrylate, or high tension areas
113. Dermabond®
• A sterile, liquid topical skin
adhesive
• Reacts with moisture on skin
surface to form a strong, flexible
bond
• Only for easily approximated
skin edges of wounds
– punctures from minimally
invasive surgery
– simple, thoroughly cleansed,
lacerations
114. Dermabond®
•
•
•
•
Standard surgical wound prep and dry
Crack ampule or applicator tip up; invert
Hold skin edges approximated horizontally
Gently and evenly apply at least two thin
layers on the surface of the edges with a
brushing motion with at least 30 s between
each layer, hold for 60 s after last layer until
not tacky
• Apply dressing
http://www.youtube.com/watch?v=oa13wriWTus&feature=related
http://www.youtube.com/watch?v=YhyPxFsYtXk&NR=1
115. Follow Up Care with
Adhesives
• No ointments or medications on dressing
• May shower but no swimming or scrubbing
• Sloughs naturally in 5-10 days, but if need to remove
use acetone or petroleum jelly to peel but not pull
apart skin edges
• Pt education and documentation
117. References
•
•
•
•
•
•
•
•
•
http://depts.washington.edu/uwemig/media_files/EMIG%20Suture%20Han
dout.pdf
Thomsen, T. Basic Laceration Repair. The New England Journal of
Medicine. Oct. 355: 17.
Edgerton, M. The Art of Surgical Technique. Baltimore, Williams & Wilkins,
1988.
www.uptodateonline.com; 2009, topic lacerations, etc.
http://dermnetnz.org/procedures/pdf/suturing-dermnetnz.pdf
http://www.mnpa.us/handouts/Session%2005%20%20%20%20Basic%20Suturing%20%202010%20MNPA.pdf
http://www.practicalplasticsurgery.org/docs/Practical_01.pdf
http://health.usf.edu/NR/rdonlyres/ABB54A41-80A1-4E2B-8AE87EB5D06CE8DF/0/wound_healing_manual.pdf
Jackson, E. Wound Care – Suture, Laceration, Dressing: Essentials for
Family Physicians. AAFP Scientific Assembly. 2010.
http://www.aafp.org/online/etc/medialib/aafp_org/documents/cme/courses/c
onf/assembly/2010handouts/071.Par.0001.File.tmp/071-072.pdf
