Tactical Combat Casualty Care (TC3)
I had previously posted this elsewhere on a couple of forums so here it is. Some of it is straight from US Army 68W Combat Medical protocols, some pof it is at the CLS (Combat Lifesaver) level, and there is a bit of opinion thrown in there too…..it is partly excerpted from chapters in Contact and Rapid Fire on Casualties:
Unlike the normal ABC medical protocol that you will have heard about, the combat protocol for trauma situations is H-A-B-C, which puts hemorrhage before Airway, if it is indicated, but still includes circulation for less serious bleeds and IVs. The other big difference is tourniquets: tourniquets used to be considered a tool of last resort. Now they are considered a tool of first resort in a combat environment. The following article does not presume to attempt to give all the answers, but it is a basic summary.
Some procedures that are appropriate in a civilian ambulance situation are not appropriate on the battlefield. Ambulance crews may give fluids to casualties on the way to the hospital, where blood is available. They can, in simple terms, keep putting the fluids in and get definitive care once they arrive at the emergency room. In a battlefield situation, fluids are not given except in specific circumstances. In simple terms, when you go into true shock by losing circulating body fluids (i.e. blood) your blood pressure will drop. As your body responds to the injury and the loss of blood, it will draw blood into the vital organs at the core of the body, at the expense of the limbs. Thus, as blood pressure falls you begin to lose the distal pulses (i.e. in the wrist and foot), then closer and closer to the core until you have no pulses but the heart, and the heart will be the last to give out at the lowest blood pressure. In a combat situation, if you give too much fluid, there is a danger of “blowing the clot” and effectively bleeding out while diluting the blood left in the body, reducing its ability to carry oxygen. Also, fluids frequently given such as Lactated Ringers are rapidly absorbed into tissue so over time they are not really effectively increasing the volume of the blood. Hence the giving of fluids in the ambulance, where in very simple terms you can keep putting it in until you reach the emergency room and blood/plasma products are available. The fluid given for a traumatic wounding on the battlefield is not lactated ringers or similar, but Hextend, which is a starch product. Over roughly an hour, 500cc of Hextend will draw fluids out of surrounding tissue and bulk up to around 800cc. Guidelines state that you can use a maximum of two 500cc bags, 30 minutes apart. The protocol is only to give fluids if there are no radial (or pedal) pulses, which are the pulses in the wrist or foot. The reason is that you want to bring the blood pressure up enough to restore distal circulation to the extremities but no more, because you don’t want to ‘blow any clots’ or cause the casualty to ‘bleed out’. For other injuries such as dehydration other fluids are still given, but not for trauma.
The fact is that a large number of combat injuries are not survivable. Sometimes this will be obvious and the casualty has no chance of survival. Other times, survival will depend on appropriate interventions followed by rapid evacuation and definitive surgical care. There is a difference between being able to keep someone alive at the point of wounding and continuing to keep them alive due to the presence or absence of available definitive care. Do what you can to initially prevent death and get them to someone who can help, or worst case read some books on battlefield surgery and do something yourself, even if it’s just cleaning, debriding and suturing wounds and providing antibiotics, hoping that internal injuries and bleeding are not too severe and will heal in time.
The use of body armor will reduce the incidence of penetrating trauma sustained in combat to the torso and the damage and resulting internal bleeding. Historically, 90% of combat deaths occur before the casualty reaches the treatment facility. The three major, but potentially survivable causes of death on the battlefield are: extremity hemorrhage exsanguination (severe bleeding), tension pneumothorax (oxygen shortage and low blood pressure due to a collapsed lung, a condition that may progress to cardiac arrest if untreated) and airway obstruction. Historically, the most frequent and preventable of these causes of death is extremity bleeding. Most wounds to the extremities will cause death by bleeding out, and this is preventable. Some combat wounds are simply not survivable and will not respond to medical attention i.e. severe internal bleeding or visible brain matter etc.
Care Under Fire:
In this phase the casualty is “on the X” at the point of wounding. This is the point of greatest danger for the CLS. An assessment should be made for signs of life (i.e. is the casualty obviously dead). Cover fire should be given and fire superiority achieved. The casualty should be told, if conscious, to either return fire, apply self-aid, crawl to cover or lay still (don’t tell them to “play dead!”). Once it becomes possible to reach the casualty, the only treatment given in the care under fire phase, if required, is a hasty tourniquet “high and tight” on a limb, over the clothing, in order to prevent extremity bleeding. The casualty should be rapidly moved to cover (drag them).
Tourniquet application: “high and tight” means right up at the top of the leg or arm, right in the groin (inguinal) or armpit (axial) region. The tourniquet needs to be cinched down tight to stop the bleeding. Use/purchase the CAT – Combat Application Tourniquet.
When applying tourniquets, they need to be tight enough to stop the distal pulse i.e. the pulse in the foot or wrist, assuming the limb has not been traumatically amputated. You will not be able to check this pulse at this phase, so just get the tourniquet on tight and check the distal pulse as part of the next phase, tactical field care.
Traumatic amputation: get the tourniquet on high and tight and tighten it until the bleeding stops. Note: in some circumstances there will be pulsating arterial bleeding and severe venous bleeding, but other times it is possible that there may be less bleeding initially as the body reacts in shock and “shuts down” the extremities, but bleeding will resume when the body relaxes. So get that tourniquet on tight.
Compartment Syndrome: you don’t want to be feeling sorry for the casualty and trying to cinch the tourniquet down ‘only just enough’. Tighten it to stop the distal pulse. If you don’t, the continuing small amount of blood circulation into the limb can cause compartment syndrome, which is a build-up of toxins: when the tourniquet is removed, these toxins flood into the body and can seriously harm the casualty.
For an improvised tourniquet, make sure the strap is no less than 2 inches wide, to prevent it cutting into the flesh of the limb.
Tactical Field Care:
Once the casualty is no longer “on the X”, CLS can move into the Tactical Field Care phase. This is where the CLS conducts the assessment of the casualty and treats the wounds as best as possible according to H-A-B-C:
Hemorrhage: During the Tactical Field care phase, any serious extremity bleeding (arterial or serious venous) on a limb, including traumatic amputation, is treated with a tourniquet 2-3 inches above the wound. Axial (armpit), inguinal (groin) and neck wounds are treated by packing with Kerlix or combat gauze (treated with hemostatic agent, commercially available from Quickclot) and wrapping up with ACE type bandage.
Once you have dragged the casualty to cover, you will conduct a blood sweep of the neck, axial region, arms, inguinal region and legs. This can be done as a pat down, a “feel” or “claw”, or simply ripping your hands down the limbs. Debate exists as to the best method. Conduct the blood sweep and look at your hands at each stage to see if you have found blood. Once a wound is found, check for exit wounds. Ignore minor bleeds at this stage: you are concerned about pulsating arterial bleeds and any kind of serious bleed where you can see the blood rapidly running out of the body.
Beware of deliberate tourniquet application to the lower limbs, below the knee and elbows. The two small bones there may cause problems, particularly with traumatic amputation, and the tourniquet may either not be effective or cause further harm to the casualty. Assess it. Also, if the injury is, for example, below the knee, then don’t put the tourniquet over a joint (i.e. knee), put it above the joint.
Airway: CLS can aid the airway by positioning (i.e. head tilt/chin lift to open the airway) and use of the NPA. An NPA should be used for any casualty who is unconscious or who otherwise has an altered mental status.
· Consider use of an OPA/NPA and suction. You need to be trained on these items.
· Combat medics are trained to carry out a crycothyroidotomy (“crike”) to place a breathing tube though the front of the airway. This is an effective way of quickly opening the airway on the battlefield, particularly for facial trauma of burns to the face and airway.. If you are trained and have the equipment you can use patent airways that insert into the mouth and are of the types that paramedics are be trained to use: Combi-tubes and King Airways.
· A crike will save life but assumes that you are heading to a hospital for treatment and repair. The tube will go through the membrane and this will need to be repaired. However, if it is your option to save life, do it and figure out the details later.
Breathing: Occlusive (airtight) dressings are used to close any open chest wounds. Check for exit wounds! Check the integrity of the chest: ribs and breast bone. You will have to open body armor to do this. If signs of a pneumo/hemo-thorax develop (progressive respiratory distress, late stages would be a deviated trachea (windpipe) in the neck as a result of the whole lung and heart being pushed to one side by the pressure of the air build up in the chest cavity) then needle chest decompression can be performed (NCD).
· If you don’t have a specific occlusive dressing, use something like plastic (or the pressure dressing packet) and tape it down over the chest wound. The Old school method was to tape three sides to let air escape, current thinking is to tape all four sides down to seal the wound.
· NCD involves placing a 14 gauge needle, at least 3.25 inches long, into the second intercostal rib space (above the third rib) in the mid-clavicular line (nipple line). This is basically a little below the collar bone, in line above the nipple. The needle is withdrawn and the cannula is left open to air (tape it in place). An immediate rush of air out of the chest indicates the presence of a tension pneumothorax. The manoeuver effectively converts a tension pneumothorax into a simple pneumothorax.
o The definitive treatment is to get a chest tube in, in the side of the chest (eighth intercostal space); to drain the blood and air that is filling the chest cavity.
You then move on to Circulation (including bleeds and administering a saline lock or fluids), any pain meds you have and that are appropriate, and then the full assessment, which is not covered in detail here. For wounds that do not need a tourniquet or the tourniquet can be converted, then pack the wound and use something like a pressure bandage/Israeli dressing to stop the bleeding. Once you have treated the H-ABCs and conducted the assessment and any interventions you should cover the casualty with a thermal blanket to retain body heat and reduce the risk of hypothermia. You will continue to monitor the casualty and perform interventions as necessary both prior to and during the evacuation.