Combat Casualty Care

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TACTICAL COMBAT CASULATY CARE
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• Tactical Combat Casualty Care in Special
  Operations
• CAPT Butler/LTC Hagmann
• Military Medicine Supplement
• August 96

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• 90 of combat deaths occur on the battlefield
  before the casualty ever reaches a medical
  treatment facility.
• COL Ron Bellamy

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Tactical Context

• Incoming fire
• Darkness
• Environmental factors
• Casualty transportation problems
• Delays to definitive care
• Command decisions

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• Two of the obvious differences (in combat
  casualty care) are the adverse conditions of war
  and the fact that under certain tactical
  conditions, the care of the patient is secondary
  to the mission at hand.
• CAPT Byron Holley

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Cocaine Lab Raid

• 32 man Ranger team
• Planned raid on a cocaine lab in dense jungle
• Estimated hostile strength is 8 men with
  automatic weapons
• Insertion from HELO
• 8 Kilometer movement to target

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Cocaine Lab Raid

• As patrol reaches the objective area, a booby
  trap is tripped resulting in a point man without
  pulse or respirations and a squad leader with
  massive trauma to the leg and femoral bleeding
• Heavy incoming fire as hostiles respond
• Planned extraction by boat at point on river 1/2
  mile from target

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Tactical Combat Casualty Care

• Good medicine
• can sometimes be bad tactics!

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Tactical Combat Casualty Care

• Bad tactics can get everyone killed and/or cause
  the mission to fail!

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Tactical Combat Casualty Care

• Casualty scenarios in Ranger operations usually
  entail both a medical problem and a tactical
  problem.
• We want the best possible outcome for both the
  man and the mission.

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Combat Casualty Care Objectives

• Treat the casualty
• Prevent additional casualties
• Complete the mission

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Editorial

• The most important aspect of caring for trauma
  victims on the battlefield is well thought out
  planning for that environment and appropriate
  training of Ranger First Responders and Combat
  Medical Personnel.

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Phases of Care

• Care under Fire
• Tactical Field Care
• Casualty Evacuation (CASEVAC)

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"Care under Fire"

• The care rendered by the RFR/NREMT-B/ Ranger
  Medic at the scene of the injury, while he and
  the casualty are still under effective hostile
  fire.
• Available medical equipment is limited to that
  carried by the individual Ranger or medic in his
  gear.

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"Tactical Field Care"

• Care rendered by the RFR/NREMT-B/ Ranger Medic
  when no longer under effective hostile fire.
• Applies to situations in which an injury has
  occurred on a mission, but there has been no
  hostile fire.
• Available medical equipment limited to that
  carried into the field by mission personnel.

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CASEVAC"

• Care rendered once the casualty (and usually the
  rest of the mission personnel) have been
  extracted by aircraft, vehicle, or boat.
• Personnel and medical equipment previously staged
  in these assets are now available.
• Use "CASEVAC" to describe this phase vs the
  commonly used term "MEDEVAC".

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Basic Tactical Combat Casualty Care Plan
Key Point

• The plan described is presented as a generic
  sequence of steps that will probably require
  modification in some way for almost any casualty
  scenario encountered in Ranger Operations.

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Care under Fire

• Return fire as directed or required
• Try to keep yourself from getting shot
• Try to keep the casualty from sustaining
  additional wounds
• Stop any life-threatening external hemorrhage
  with an Emergency Trauma Dressing and/or
  tourniquet

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Care under Fire

• What does returning fire have to do with medical
  care?

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Care under Fire

• The best medicine on the battlefield is
• Fire Superiority!
• Fire superiority and control of the tactical
  situation is a must. The Tactical Commander (TM
  LDR, SQD LDR, PLT SGT) must have control of the
  situation to effectively manage casualties.

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Care under Fire

• No immediate management of the airway should
  be anticipated at this point because of the need
  to move the casualty to cover as quickly as
  possible.

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Care under Fire

• Exsanguination from extremity wounds is the 1
  cause of preventable death on the battlefield.
• Control of hemorrhage is the top priority!
• Hemorrhage from extremity wounds was the cause of
  death in more than 2500 casualties in Vietnam who
  had no other injuries.

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Tourniquets

• Most reasonable initial choice to stop major
  bleeding in the Care Under Fire Phase
• Direct pressure is hard to maintain during
  casualty transport under fire

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Tourniquets

• Tissue damage to the limb is rare if the
  tourniquet is left in place less than an hour.
• Tourniquets often left in place for several
  hours during surgical procedures.
• In the face of massive extremity hemorrhage, in
  any event, it is better to accept the small risk
  of tissue damage to the limb than to lose a
  casualty to bleeding to death.

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Tourniquets

• The need for immediate access to a tourniquet
  in such situations makes it clear that all
  Rangers on combat missions should have a suitable
  tourniquet readily available at a standard
  location on their battle gear and be trained in
  its use.

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Questions?
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Tactical Field Care

• Reduced level of hazard from hostile fire
• Amount of time available extremely variable
• Time prior to extraction may range from less than
  a half hour to many hours.
• Limited visibility
• Nonsterile field conditions

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Airway Management Conscious Patient

• No attempt at airway intervention is required
  if the patient is conscious and breathing without
  difficulty on his own.

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Airway Management Unconscious Patient

• Without airway obstruction
• Usual cause is hemorrhagic shock or penetrating
  head trauma
• Chin lift or jaw thrust maneuver
• No need for cervical spine immobilization
• Nasopharyngeal airway if no obstruction

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Nasopharyngeal Airway

• Better tolerated than an oropharyngeal airway
  should the patient subsequently regain
  consciousness
• Less likely to be dislodged during patient
  transport.

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Suction

• If blood or other obstructions are present in
  the mouth, they should be removed by hand.

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Breathing

• Tension pneumothorax is the second leading cause
  of preventable death on the battlefield.
• Consider progressive, severe respiratory distress
  resulting from unilateral chest trauma to
  represent a tension pneumothorax and decompress.

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Tension pneumothorax

• Signs/Symptoms
• Decreased breath sounds
• Tracheal shift
• Hyperresonance to percussion
• Difficult to appreciate on the battlefield!

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Needle Thoracostomy

• Decompress affected side with a 14 gauge needle
  inserted at 2nd ICS at MCL.
• A patient with penetrating chest trauma will
  generally have some degree of hemothorax or
  pneumothorax as a result of the primary wound.
• Additional trauma from needle thoracostomy will
  not significantly worsen patients condition if
  no tension pneumo.

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Needle Thoracostomy

• RFRs, Squad EMTs, and Medics are trained in
  this technique
• Technically easy to perform
• May be lifesaving if the patient does in fact
  have a tension pneumothorax.

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Open Pneumothorax

• Occlusive dressing
• Not necessary to vent one side of the wound
  dressing difficult to do reliably in a combat
  setting
• Watch for development of a tension pneumothorax
• Asherman Chest Seal is the standard

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Bleeding

• Ranger survivability on the battlefield is
  measured by immediate control of hemorrhage.
• When tactically feasible consider standard
  bleeding control procedures.
• Dont hesitate to use a tourniquet under more
  severe battlefield conditions (Care Under Fire).
• Application of a tourniquet is only acceptable
  under extreme circumstances.

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Bleeding

• Tourniquets are only used to control serious
  extremity bleeding by RFRs under real world
  combat conditions.

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Bleeding

• Remove minimum clothing required to expose and
  treat injuries
• Emergency Trauma Dressing
• Ranger Rescue Wrap
• Need to protect the patient against the
  environment

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Ranger Rescue Wrap
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IV Therapy

• Large IV catheters are needed to administer large
  volumes of blood products rapidly
• Not a factor in the tactical setting since blood
  products will not be available
• 18 gauge catheter preferred in the field setting
  because of increased success rate

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IV Therapy

• Larger gauge IVs may have to be started at MTF
• Common practice to discontinue prehospital IVs
  upon arrival at MTF because of concern about
  contamination of the IV site

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IV Therapy

• Don't start on an extremity distal to a
  significant wound
• Saline locks are used (Eliminates the logistical
  difficulties of managing the IV bag during
  transport)

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IV Therapy

• Extremity (Upper gt Lower) vein first choice
• External jugular vein next option
• Sternal Intraosseous is last option

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Fluid Resuscitation

• 1. Controlled bleeding/ no shock
• Saline lock, NO IV fluids required
• 2. Controlled bleeding/shock
• Saline lock, IV Hespan 500 - 1000cc
• 3. Uncontrolled bleeding
• Saline lock, NO IV fluids

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Fluid Resuscitation

• Despite its widespread use, the benefit of
  prehospital fluid resuscitation in trauma
  patients has not been established.

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Fluid Resuscitation Uncontrolled Bleeding

• Several studies noted that only after
  previously uncontrolled hemorrhage was stopped
  did fluid resuscitation prove to be of benefit.

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Fluid Resuscitation Uncontrolled Bleeding(Human)

• World War I combat trauma patients
• Concluded that initiating IV fluid replacement
  without first obtaining surgical hemostasis
  promoted further hemorrhage.
• Cannon

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Fluid Resuscitation Uncontrolled Bleeding

• Weight of evidence at this time favors
  withholding aggressive IV fluid resuscitation in
  patients with uncontrolled hemorrhage from
  penetrating thoracic or abdominal trauma until
  the time of surgical intervention.

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Fluid Resuscitation Controlled Bleeding

• Immediate fluid resuscitation is still
  recommended for casualties on the battlefield
  whose hypovolemic shock is the result of bleeding
  from an extremity wound which has been controlled.

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• Comments/Questions?

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Inspect and Dress Wound

• Minimize further contamination
• Promote hemostasis

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Check for Additional Wounds

• A careful check for additional wounds should be
  made, since high velocity projectiles from
  assault rifles will tumble and take erratic
  courses when travelling through tissue.
• Exit sites are often remote from the entry wound.

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Splint Fractures and Recheck Pulse

• Check distal pulses both before and after
  splinting
• Remedy any decrease in the pulse caused by
  splinting by adjusting the position of the splint

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Cardiopulmonary Resuscitation (CPR)

• Battlefield CPR for victims of blast or
  penetrating trauma who have no pulse, no
  respirations, and no other signs of life, will
  not be successful and should not be attempted.
• Attempts to resuscitate trauma patients in arrest
  have been futile even in the urban setting where
  the victim is in close proximity to a trauma
  center.

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Cardiopulmonary Resuscitation

• The battlefield cost of attempting to perform
  CPR on casualties with what are inevitably fatal
  injuries will be measured in additional lives
  lost as care is withheld from patients with less
  severe injuries and as Rangers are exposed to
  additional hazard from hostile fire because of
  their attempts.

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CardiopulmonaryResuscitation

• Only in the case of nontraumatic disorders
  such as hypothermia, near drowning, or
  electrocution should CPR be considered prior to
  the CASEVAC phase.

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CASEVAC Care

• Two significant differences will be present in
  progressing from the Tactical Field Care phase to
  the CASEVAC phase
• Additional medical personnel may accompany the
  evacuating asset.
• Additional medical equipment may be pre-staged
  on the evacuating asset.

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CASEVAC Care Monitoring

• Helicopter transport impairs or precludes the
  provider's ability to auscultate the lungs or
  even to palpate the carotid pulse
• Electronic monitoring systems capable of
  providing blood pressure, heart rate, pulse
  oximetry, and capnography are commercially
  available and needed for air medical transport

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Recommendations

• 1. Base planning for Ranger combat casualties
  should be incorporated into specific mission
  scenarios to aid in identifying the unique
  medical and tactical requirements that will have
  to be addressed in that scenario.

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Recommendations

• 2. On combat missions, all Rangers should have a
  suitable tourniquet readily available at a
  standard location on their battle gear.
• 3. All Rangers should be trained to use a
  tourniquet.

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Recommendations

• 4. Designate and train Combat Casualty Transport
  Teams.
• 5. In the event of a conflict, assign these
  teams to the JSOTF commander.

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Vision Statement

• We must also have the intellectual agility to
  conceptualize creative, useful solutions to
  ambiguous problems.this means training and
  educating people on
• how to think, not just what to think.
• Gen Peter Schoomaker
• Commander-in-Chief

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Questions?