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Tactical Combat Casualty Care Guidelines

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 apply 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 a tourniquet for hemorrhage that is anatomically amenable to tourniquet

application.

·  Apply the tourniquet proximal (3 fingers above)  the bleeding site, over the uniform, tighten, and move the casualty to cover.

             

Basic Management Plan for Tactical Field Care and Tactical Evacuation 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.

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, 8 cm needle/catheter unit inserted in the second intercostal space at the 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 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 if necessary by needle decompression.

4.  Bleeding

a.  Assess for unrecognized hemorrhage and control all sources of bleeding. If not already done, use a tourniquet to control life-threatening external hemorrhage if possible. Apply directly to the skin 2-3 inches (three fingers) 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 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. If hemostatic gauze is not available then pack the wound with any sterile dressings available.

c.  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 is present and consistent. If the bleeding site is junctional apply hemostatic dressings with direct pressure.

d.  Reassess prior tourniquet application (this may include loosening the tourniquet to see if bleeding has stopped). Expose wound and determine if                 tourniquet is needed. If so, replace tourniquet over uniform with another applied directly to skin 6-8cm (3 fingers) above wound. If a tourniquet is not                 needed, use other techniques to control bleeding. 

e.  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.

f.    Expose and clearly mark all tourniquet sites with the time of tourniquet application. Use an indelible marker.

5.  Fluid resuscitation

a.  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 administration protocol:

·   Resuscitate with Lactated Ringers or Normal Saline if LR is not available;

·   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.

3.    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.

4.    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.

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.  Cover the casualty with a Heat-Reflective Shell (HRS). 

d.  If HRS is not available, use dry blankets, poncho liners, sleeping bags, or anything that will retain heat and keep the casualty dry.

e.  Oral warm fluids for the conscious patients are preferred

9.     Penetrating Eye Trauma

      If a penetrating eye injury is noted or suspected:                  

a. Perform a rapid field test to see if vision has been affected.

b. Cover the eye with a rigid eye shield.

c. Ensure no pressure is applied.

d. Ensure that the Co-Amoxiclav, 825 mg tablet in the combat pill pack is taken if  

  possible.

10.  Inspect and dress known wounds.

11.  Check for additional wounds.

12.  Splint fractures and recheck pulse distal to injury.

13.  Analgesia and infection prevention on the battlefield should generally be achieved using the TCCC Combat pill pack: 

·         Paracetemol (Pain control) – 1000 mg by mouth

·         Diclofenac (Pain control) – 100 mg by mouth

·         Ciproflocacin (Antibiotic) – 1000 mg by mouth

14. Burns

a.  Facial burns, especially those that occur in closed spaces, may be      associated with inhalation injury. Aggressively monitor airway status      in such patients for respiratory distress.

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 or Blizzard Survival Blanket in order to both cover the burned areas and prevent hypothermia. 

e.  Analgesia in accordance with the TCCC Guidelines may be administered to treat burn pain. 

f.    All interventions can be performed on or through burned skin in a burn casualty.

15. Communicate with the casualty if possible.

-  Encourage; reassure

-  Explain care

16. 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 multiple trauma 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. 

17. Documentation of Care

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