Tactical combat casualty care: Difference between revisions

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==Care Under Fire<ref>Tactical Combat Casualty Care Guidelines; 2 June 2014; http://www.usaisr.amedd.army.mil/</ref>==
==Background==
#Return fire and take cover.
*Tactical Combat Casualty Care (TCCC) is a set of evidence-based guidelines for trauma care in a tactical or combat environment.
#Direct or expect casualty to remain engaged as a combatant if appropriate.
*Developed and updated by the Committee on Tactical Combat Casualty Care (CoTCCC), a division of the US Department of Defense Joint Trauma System (JTS).
#Direct casualty to move to cover and apply self-aid if able.
*Goal is to reduce preventable combat deaths.
#Try to keep the casualty from sustaining additional wounds.
*Guidelines are divided into three "phases of care".
#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.
#Airway management is generally best deferred until the Tactical Field Care phase.
#Stop life-threatening external hemorrhage if tactically feasible:
#*Direct casualty to control hemorrhage by self-aid if able.
#*Use a 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.


==Basic Management Plan for Tactical Field Care==
==Phases of Care==
1. Casualties with an altered mental status should be disarmed
*[[Care under fire]]
immediately.
*[[Tactical field care]]
2. Airway Management
*[[Tactical evacuation care]]
a. Unconscious casualty without airway obstruction:
 
- Chin lift or jaw thrust maneuver
==Assessment and Triage==
- Nasopharyngeal airway
*Rather than typical "ABC" approach to trauma assessment, TCCC prioritizes massive hemorrhage
- Place casualty in the recovery position
*MARCH acronym is used to prioritize treatment:
b. Casualty with airway obstruction or impending airway obstruction:
**'''M''' - Massive hemorrhage
- Chin lift or jaw thrust maneuver
***Emphasize early recognition of significant bleeding. Apply limb [[tourniquet]]s high, tight, and early. For junctional injuries, utilize direct pressure or hemostatic agents while waiting for OR.  
- Nasopharyngeal airway
**'''A''' - Airway
- Allow casualty to assume any position that best protects the
***Consider triage given limited management resources. May require surgical airway if significant facial or oropharyngeal injuries are present.  
airway, to include sitting up.
**'''R''' - Respiration
- Place unconscious casualty in the recovery position.
***Recognize and manage pneumothoraces with needle or chest tube thoracostomy. Consider chest seals for chest cavity wounds.  
- If previous measures unsuccessful:
**'''C''' - Circulation
- Surgical cricothyroidotomy (with lidocaine if
***Reevaluate for peripheral pulses, [[tourniquet]]s that need to be replaced, and hemorrhage management deferred during "M." Consider eFAST exam.  
conscious)
**'''H''' - Head/Hypothermia
3. Breathing
***Evaluate for head injury, including mental status and GCS. Treat hypothermia.
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. An acceptable alternate site is the
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th or 5th intercostal space at the anterior axillary line (AAL).
b. All open and/or sucking chest wounds should be treated by
immediately applying a vented chest seal to cover the defect. If a
vented chest seal is not available, use a non-vented chest seal.
Monitor the casualty for the potential development of a subsequent
tension pneumothorax. If the casualty develops increasing hypoxia,
respiratory distress, or hypotension and a tension pneumothorax
is suspected, treat by burping or removing the dressing or by
needle decompression.
c. Casualties with moderate/severe TBI should be given
supplemental oxygen when available to maintain an oxygen
saturation > 90%.
4. Bleeding
a. Assess for unrecognized hemorrhage and control all sources of
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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 CoTCCC
hemostatic dressing of choice. Celox Gauze and ChitoGauze may
also be used if Combat Gauze is not available. Hemostatic
dressings 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 traumatic brain injury (TBI). If the
bleeding site is appropriate for use of a junctional tourniquet,
immediately apply a CoTCCC-recommended junctional tourniquet.
Do not delay in the application of the junctional tourniquet once it
is ready for use. Apply hemostatic dressings with direct pressure
if a junctional tourniquet is not available or while the junctional
tourniquet is being readied for use.
c. Reassess prior tourniquet application. Expose wound and determine if
tourniquet is needed. If so, replace tourniquet over uniform with another
applied 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.
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. 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)
– Administer 1 gram of tranexamic acid in 100 cc Normal Saline
or Lactated Ringers as soon as possible but NOT later than 3
hours after injury.
– Begin second infusion of 1 gm TXA after Hextend or other fluid
treatment.
4
7. Fluid resuscitation
a. The resuscitation fluids of choice for casualties in hemorrhagic
shock, listed from most to least preferred, are: whole blood*;
plasma, RBCs and platelets in 1:1:1 ratio*; plasma and RBCs in
1:1 ratio; plasma or RBCs alone; Hextend; and crystalloid
(Lactated Ringers or Plasma-Lyte A).
b. Assess for hemorrhagic shock (altered mental status in the absence of
brain injury and/or weak or absent radial pulse).
1. If not in shock:
- No IV fluids are immediately necessary.
- Fluids by mouth are permissible if the casualty is
conscious and can swallow.
2. If in shock and blood products are available under an
approved command or theater blood product
administration protocol:
- Resuscitate with whole blood*, or, if not available
- Plasma, RBCs and platelets in a 1:1:1 ratio*, or, if not
available
- Plasma and RBCs in 1:1 ratio, or, if not available;
- Reconstituted dried plasma, liquid plasma or thawed
plasma alone or RBCs alone;
- Reassess the casualty after each unit. Continue
resuscitation until a palpable radial pulse, improved
mental status or systolic BP of 80-90 mmHg is present.
3. If in shock and blood products are not available under an
approved command or theater blood product administration
protocol due to tactical or logistical constraints:
- Resuscitate with Hextend, or if not available;
- Lactated Ringers or Plasma-Lyte A;
- Reassess the casualty after each 500 mL IV bolus;
- Continue resuscitation until a palpable radial pulse,
improved mental status, or systolic BP of 80-90 mmHg
is present.
- Discontinue fluid administration when one or more of
the above end points has been achieved.
4. If a casualty with an altered mental status due to suspected
TBI has a weak or absent peripheral pulse, resuscitate as
necessary to restore and maintain a normal radial pulse. If
BP monitoring is available, maintain a target systolic BP of
at least 90 mmHg.
5. Reassess the casualty frequently to check for recurrence of
shock. If shock recurs, recheck all external hemorrhage
control measures to ensure that they are still effective and
repeat the fluid resuscitation as outlined above.
5
* Neither whole blood nor apheresis platelets as these products are
currently collected in theater are FDA-compliant. Consequently, whole
blood and 1:1:1 resuscitation using apheresis platelets should be used
only if all of the FDA-compliant blood products needed to support 1:1:1
resuscitation are not available, or if 1:1:1 resuscitation is not producing the
desired clinical effect."
8. Prevention of hypothermia
a. Minimize casualty’s 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 casualty’s 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. All
individuals with moderate/severe TBI should be monitored with pulse
oximetry. Readings may be misleading in the settings of shock or marked
hypothermia.
11. Inspect and dress known wounds.
12. Check for additional wounds.
13. Analgesia on the battlefield should generally be achieved using one of
three options:
Option 1
Mild to Moderate Pain
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Casualty is still able to fight
- TCCC Combat pill pack:
- Tylenol - 650-mg bilayer caplet, 2 PO every 8 hours
- Meloxicam - 15 mg PO once a day
Option 2
Moderate to Severe Pain
Casualty IS NOT in shock or respiratory distress AND
Casualty IS NOT at significant risk of developing either condition
- Oral transmucosal fentanyl citrate (OTFC) 800 ug
- Place lozenge between the cheek and the gum
- Do not chew the lozenge
Option 3
Moderate to Severe Pain
Casualty IS in hemorrhagic shock or respiratory distress OR
Casualty IS at significant risk of developing either condition
- Ketamine 50 mg IM or IN
Or
- Ketamine 20 mg slow IV or IO
* Repeat doses q30min prn for IM or IN
* Repeat doses q20min prn for IV or IO
* End points: Control of pain or development of nystagmus
(rhythmic back-and-forth movement of the eyes)
* Analgesia notes
a. Casualties may need to be disarmed after being given OTFC or
ketamine.
b. Document a mental status exam using the AVPU method prior to
administering opioids or ketamine.
c. For all casualties given opiods or ketamine – monitor airway,
breathing, and circulation closely
d. Directions for administering OTFC:
- Recommend taping lozenge-on-a-stick to casualty’s finger as
an added safety measure OR utilizing a safety pin and
rubber band to attach the lozenge (under tension) to the
patient’s uniform or plate carrier.
- Reassess in 15 minutes
- Add second lozenge, in other cheek, as necessary
to control severe pain
- Monitor for respiratory depression
e. IV Morphine is an alternative to OTFC if IV access has been
obtained
- 5 mg IV/IO
- Reassess in 10 minutes.
7
- Repeat dose every 10 minutes as necessary to control
severe pain.
- Monitor for respiratory depression
f. Naloxone (0.4 mg IV or IM) should be available when using opioid
analgesics.
g. Both ketamine and OTFC have the potential to worsen severe TBI.
The combat medic, corpsman, or PJ must consider this fact in his
or her analgesic decision, but if the casualty is able to complain
of pain, then the TBI is likely not severe enough to preclude the
use of ketamine or OTFC.
h. Eye injury does not preclude the use of ketamine. The risk of
additional damage to the eye from using ketamine is low and
maximizing the casualty’s chance for survival takes precedence if
the casualty is in shock or respiratory distress or at significant
risk for either..
i. Ketamine may be a useful adjunct to reduce the amount of opioids
required to provide effective pain relief. It is safe to give ketamine
to a casualty who has previously received morphine or OTFC. IV
Ketamine should be given over 1 minute.
j. If respirations are noted to be reduced after using opioids or
ketamine, provide ventilatory support with a bag-valve-mask or
mouth-to-mask ventilations.
k. Promethazine, 25 mg IV/IM/IO every 6 hours may be given as
needed for nausea or vomiting.
l. Reassess – reassess – reassess!
14. Splint fractures and recheck pulse.
15. Antibiotics: recommended for all open combat wounds
a. If able to take PO:
- Moxifloxacin, 400 mg PO one 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
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
(>20%), consider placing the casualty in the Heat-Reflective Shell
8
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
Ringer’s, normal saline, or Hextend. If Hextend is used, no more
than 1000 ml should be given, followed by Lactated Ringer’s 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 6.
e. Analgesia in accordance with the TCCC Guidelines in Section 12 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 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.
17. Communicate with the casualty if possible.
- Encourage; reassure
- Explain care
18. 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 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.
19. Documentation of Care
Document clinical assessments, treatments rendered, and changes in the
casualty’s status on a TCCC Casualty Card (DD Form 1380). Forward this
information with the casualty to the next level of care.


==See Also==
==See Also==
*[[Combat triage]]
*[[Nine line CASEVAC]]
*[[Military emergency medicine]]
==External Links==
*[http://cotccc.com/ Committee on Tactical Combat Casualty Care (CoTCCC)]


==References==
==References==
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[[Category:EMS]]
[[Category:EMS]]
[[Category:Milmed]]
[[Category:Military]]

Latest revision as of 22:15, 16 February 2018

Background

  • Tactical Combat Casualty Care (TCCC) is a set of evidence-based guidelines for trauma care in a tactical or combat environment.
  • Developed and updated by the Committee on Tactical Combat Casualty Care (CoTCCC), a division of the US Department of Defense Joint Trauma System (JTS).
  • Goal is to reduce preventable combat deaths.
  • Guidelines are divided into three "phases of care".

Phases of Care

Assessment and Triage

  • Rather than typical "ABC" approach to trauma assessment, TCCC prioritizes massive hemorrhage
  • MARCH acronym is used to prioritize treatment:
    • M - Massive hemorrhage
      • Emphasize early recognition of significant bleeding. Apply limb tourniquets high, tight, and early. For junctional injuries, utilize direct pressure or hemostatic agents while waiting for OR.
    • A - Airway
      • Consider triage given limited management resources. May require surgical airway if significant facial or oropharyngeal injuries are present.
    • R - Respiration
      • Recognize and manage pneumothoraces with needle or chest tube thoracostomy. Consider chest seals for chest cavity wounds.
    • C - Circulation
      • Reevaluate for peripheral pulses, tourniquets that need to be replaced, and hemorrhage management deferred during "M." Consider eFAST exam.
    • H - Head/Hypothermia
      • Evaluate for head injury, including mental status and GCS. Treat hypothermia.

See Also

External Links

References

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