Tactical Field Care

Tactical Field Care

Tactical Combat Casualty Care for Medical Personnel August 2018 (Based on TCCC-MP Guidelines 180801) Tactical Field Care 3c Communication, Evacuation Priorities and CPR in Tactical Field Care Disclaimer

The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Departments of the Army, Air Force, Navy or the Department of Defense. - There are no conflict of interest disclosures . LEARNING OBJECTIVES

Terminal Learning Objective Communicate combat casualty care items effectively in Tactical Field Care. Enabling Learning Objectives Identify the importance and techniques of communication with a casualty in Tactical Field Care. Identify the importance and techniques of

communicating casualty information with unit tactical leadership. LEARNING OBJECTIVES Enabling Learning Objectives Identify the importance and techniques of

communicating casualty information with evacuation assets or receiving facilities. Identify the relevant tactical and casualty data involved in communicating casualty information. Identify the evacuation urgencies recommended in the TCCC TACEVAC Nine Rules of Thumb and the JTS evacuation guidelines Identify the information requirements and format of the 9-Line MEDEVAC Request.

LEARNING OBJECTIVES Terminal Learning Objective Describe cardiopulmonary resuscitation (CPR) considerations in Tactical Field Care. Enabling Learning Objectives

Identify considerations for cardiopulmonary resuscitation in tactical field care. Describe why cardiopulmonary resuscitation is not generally used for traumatic cardiac arrest in battlefield trauma care. Identify the conditions in which CPR should be considered in tactical field care. Tactical Field Care Guidelines

16. Communication a. Communicate with the casualty if possible. Encourage, reassure and explain care Tactical Field Care Guidelines 16. Communication (cont) b. Communicate with tactical leadership as soon as possible and throughout casualty treatment as needed. Provide leadership with casualty status and evacuation requirements to assist with

coordination of evacuation assets. Tactical Field Care Guidelines 16. Communication (cont) c. Communicate with the evacuation system (the Patient Evacuation Coordination Cell) to arrange for TACEVAC. Communicate with medical providers on the evacuation asset if possible and relay mechanism of injury, injuries sustained, signs/symptoms, and

treatments rendered. Provide additional information as appropriate. Talk to the Casualty Encourage, reassure and explain care. Talking with the casualty helps assess his mental status. Talking through procedures helps maintain your own confidence and the casualtys confidence in you.

Talk to Leadership Communicate with tactical leadership ASAP and throughout the treatment process. Provide the casualtys status and evacuation requirements. Develop unit-level casualty reports and rehearse them frequently. Initiate the MEDEVAC request.

Tactical Casualty Information Tactical Data Threat Identification Casualty Identification Casualty Location Casualty Weapon Systems Can casualty shoot, move, communicate? Does casualty need assistance?

C2 notification Medical Data Injuries? Conscious/Unconscious? Treatment rendered / required? Get Medic to Casualty OR Casualty to Medic? Evacuation requirements? Triage for multiple

casualties? Casualty evac category? Need more Class VIII? Communicate with Evac System Evacuation Request (9-Line MEDEVAC) MIST Report 9-Line Evacuation Request Required if you need to have a casualty evacuated by

another unit. 9-Line Evacuation Request Request for resources through tactical aircraft channels. NOT a direct medical communication with medical providers Significance Determines tactical resource allocation DOES NOT convey much useful medical information

9-Line Evacuation Request Line 1: Pickup location Line 2: Radio frequency, call sign and suffix Line 3: Number of patients by precedence (evacuation category): A Urgent B Urgent-Surgical C Priority D Routine E Convenience

9-Line Evacuation Request Line 4: Special equipment required A None B Hoist C Extraction equipment D Ventilator * Blood 9-Line Evacuation Request Line 5: Number of casualties by type

L Number of litter patients A Number of ambulatory patients Line 6: Security at pickup site N No enemy troops in area P Possible enemy troops in area (approach with caution) E Enemy troops in area (approach with caution) X Enemy troops in area (armed escort required) 9-Line Evacuation Request Line 7: Method of marking pickup site

A Panels B Pyrotechnic signal C Smoke signal D None E Other - specify Line 8: Casualtys nationality and status A US military B US civilian C Non-US Military D Non-US civilian

E Enemy prisoner of war 9-Line Evacuation Request Line 9 (Wartime): CBRN Contamination C Chemical B Biological R Radiological N - Nuclear Line 9 (Peacetime): Terrain Description

MIST Report Conveys additional evacuation information that may be required by theater commanders. A MIST report is supplemental to a MEDEVAC request, and should be sent as soon as possible. MEDEVAC missions should not be delayed while waiting for MIST information. MIST information helps the receiving MTF better prepare for the specific casualties inbound. MIST Report

M: Mechanism of injury I: Injury type(s) S: Signs & Symptoms T: Treatment Tactical Evacuation:

Nine Rules of Thumb TACEVAC 9 Rules of Thumb: Assumptions These Rules of Thumb are designed to help the corpsman or medic determine the true urgency for evacuation. They assume that the decision is being made at 1530 minutes after wounding. They also assume that care is being rendered per the TCCC guidelines. These considerations are most important when

there are tactical constraints on evacuation: Interferes with mission High risk for team High risk for TACEVAC platform TACEVAC Rule of Thumb #1 Soft tissue injuries are common and may look bad, but usually dont kill unless associated with shock. TACEVAC Rule of Thumb #2

Bleeding from most extremity wounds should be controllable with a tourniquet or hemostatic dressing. Evacuation delays should not increase mortality if bleeding is fully controlled. TACEVAC Rule of Thumb #3 Casualties who are in shock should be evacuated as soon as possible. Gunshot wound to the abdomen a common

cause of shock in combat casualties. TACEVAC Rule of Thumb #4 Casualties with penetrating wounds of the chest who have respiratory distress unrelieved by needle decompression of the chest should be evacuated as soon as possible. TACEVAC Rule of Thumb #5 Casualties with blunt or penetrating trauma

of the face associated with airway difficulty should have an immediate airway established, and should be evacuated as soon as possible. REMEMBER to let the casualty sit up and lean forward if that helps him or her to breathe better! TACEVAC Rule of Thumb #6 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. TACEVAC Rule of Thumb #7 Casualties with blunt or penetrating wounds to the head - where the skull has been penetrated but the casualty is conscious - should be evacuated emergently.

TACEVAC Rule of Thumb #8 Casualties with penetrating wounds of the chest or abdomen who are not in shock at their 15-minute evaluation have a moderate risk of developing late shock from slowly bleeding internal injuries. They should be carefully monitored and evacuated as soon as feasible. TACEVAC Rule of Thumb #9

Casualties with TBI who display red flag signs - witnessed loss of consciousness, altered mental status, unequal pupils, seizures, repeated vomiting, visual disturbance, worsening headache, unilateral weakness, disorientation, or abnormal speech require urgent evacuation to a medical treatment facility. JTS-Recommended Standard

Evacuation Categories Specifies three categories for casualty evacuation: A - Urgent B - Priority C Routine JTS-Recommended Standard Evacuation Categories CAT A Urgent (denotes a critical, lifethreatening injury) Significant injuries from a dismounted IED

attack Gunshot wound or penetrating shrapnel to chest, abdomen or pelvis Any casualty with ongoing airway difficulty Any casualty with ongoing respiratory difficulty Unconscious casualty JTS-Recommended Standard Evacuation Categories CAT A Urgent (continued) Casualty with known or suspected spinal injury

Casualty in shock Casualty with bleeding that is difficult to control Moderate/Severe TBI Burns greater than 20% Total Body Surface Area JTS-Recommended Standard Evacuation Categories CAT B Priority (serious injury) Isolated, open extremity fracture with bleeding

controlled Any casualty with a tourniquet in place Penetrating or other serious eye injury Significant soft tissue injury without major bleeding Extremity injury with absent distal pulses Burns 10-20% Total Body Surface Area JTS-Recommended Standard Evacuation Categories CAT C Routine (mild to moderate injury)

Concussion (mild TBI) Gunshot wound to extremity - bleeding controlled without tourniquet Minor soft tissue shrapnel injury Closed fracture with intact distal pulses Burns < 10% Total Body Surface Area Questions? Tactical Field Care Guidelines

17. Cardiopulmonary resuscitation (CPR) a. 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 5.a. above. CPR NO battlefield CPR CPR in Civilian Trauma This is a series of 138 trauma patients with prehospital cardiac arrest and in whom resuscitation was attempted. There were no survivors. The authors recommended that trauma patients in

cardiopulmonary arrest not be transported emergently to a trauma center even in a civilian setting due to large economic cost of treatment without a significant chance for survival. Rosemurgy et al. J Trauma 1993 The Cost of Attempting CPR on the Battlefield CPR performers may get killed Mission gets delayed

Casualty stays dead CPR on the Battlefield (Ranger Airfield Operation in Grenada)

Airfield seizure operation. A Ranger was shot in the head by a sniper. Casualty had no pulse or respirations. CPR attempts were unsuccessful. The operation was delayed while CPR was performed. Ranger PA finally intervened: Stop CPR and move out! CPR in Tactical Settings Only in the case of cardiac arrest due to:

Hypothermia Near drowning Electrocution Other non-traumatic causes should CPR be considered prior to the

Tactical Evacuation Care phase. Traumatic Cardiac Arrest in TCCC

Mounted IED attack in March 2011 Casualty unconscious from closed head trauma Lost vital signs prehospital CPR on arrival at hospital Bilateral needle decompression done in ER Rush of air from left-sided tension pneumothorax Return of vital signs life saved This procedure is routinely performed by Emergency Medicine physicians and Trauma Surgeons for trauma

victims who lose their pulse and heart rate in the hospital Emergency Department. Questions?

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