Tactical Combat Casualty Care Troy R Johnson MD

Tactical Combat Casualty Care Troy R Johnson, MD MAJ, USA, MC, FS

Agenda t. Objectives t. Mortality in Combat t. Preventable mortality t. Care under fire t. Tactical Casualty care t. Evacuation t. Military vs. Civilian tactical care Tactical Combat Casualty Care 09 SEP 02

Discussion Objectives 1. Identify the top two causes of preventable combat mortality 2. List three methods of controlling hemorrhage in the field 3. Write both two-condition criteria for diagnosis of tension pneumothorax 4. Outline additional equipment and skills available with evacuation assets 5. Compare and contrast civilian and military tactical medical care Tactical Combat Casualty Care 09 SEP 02

Caveats When Applying Civilian Literature t. Different weapons t. Less pre-existing dehydration t. Pre-hospital time t. Surgical intervention t. Resource t. Monitoring t. Threat Tactical Combat Casualty Care 09 SEP 02

Combat Mortality Tactical Combat Casualty Care 09 SEP 02

Combat Mortality Killed in Action (86% KIA) versus Died of Wounds (12% DOW) Tactical Combat Casualty Care 09 SEP 02

Combat Mortality KIA 31% are due to penetrating head trauma Tactical Combat Casualty Care 09 SEP 02

Combat Mortality KIA 25% are due to surgically uncorrectable penetrating torso trauma Tactical Combat Casualty Care 09 SEP 02

Combat Mortality KIA 10% are due to potentially correctable penetrating torso trauma Tactical Combat Casualty Care 09 SEP 02

Combat Mortality KIA 9% are due to potentially correctable extremity trauma Tactical Combat Casualty Care 09 SEP 02

Combat Mortality KIA 7% are due to mutilating blast injuries Tactical Combat Casualty Care 09 SEP 02

Combat Mortality KIA 5% are due to tension pneumothorax Tactical Combat Casualty Care 09 SEP 02

Combat Mortality KIA 1% are due to airway obstruction (1/2 actual airway) (1/2 decreased LOC) Tactical Combat Casualty Care 09 SEP 02

Combat Mortality DOW 12% are mostly due to complications of shock or late infection Tactical Combat Casualty Care 09 SEP 02

Serious Wounds in Vietnam Surviving to Facility Face Eyes 5% Head 4% Neck Cervical Spine 1% Thorax Thoracic Spine 5% Abdomen Lumbar Spine Pelvis 8% Soft Tissues 44% Multiple sites with major injuries 5% Extremities bony & neural 28% Tactical Combat Casualty Care 09 SEP 02

PREVENTABLE Mortality ü Airway obstruction (6%) ü Tension pneumothorax (33%) ü Hemorrhage from extremity wounds (60%) Tactical Combat Casualty Care 09 SEP 02

Tactical Combat Casualty Care Ø Care Under Fire Ø Tactical Field Care Ø Evacuation Care Tactical Combat Casualty Care 09 SEP 02

Care Under Fire t. Return fire Tactical Combat Casualty Care 09 SEP 02

Care Under Fire t. Return fire What does returning fire have to do with medical care? Tactical Combat Casualty Care 09 SEP 02

Care Under Fire t. Return fire What does returning fire have to do with medical care? Victory is the best medicine !! Tactical Combat Casualty Care 09 SEP 02

Care Under Fire 1. Move the casualty to cover 2. Don’t get shot while trying to do #1 Tactical Combat Casualty Care 09 SEP 02

Care Under Fire t. Top priority is early control of lifethreatening external hemorrhage! t. Exsanguination from extremity wounds is the number one cause of preventable death on the battlefield t. Hemorrhage from extremity wounds was the cause of death in more than 2500 casualties in Vietnam who had no other injuries Tactical Combat Casualty Care 09 SEP 02

Care Under Fire t. Top priority is early control of lifethreatening external hemorrhage! t. Exsanguination from extremity wounds is the number one cause of preventable death on the battlefield t. Hemorrhage from extremity wounds was the cause of death in more than 2500 casualties in Vietnam who had no other injuries t. What are the options for control in this setting? Tactical Combat Casualty Care 09 SEP 02

Hemorrhage Control t. Dressing t. Pressure dressing t. Tourniquet Tactical Combat Casualty Care 09 SEP 02

Tourniquets t. Discouraged in the civilian setting t. Most reasonable initial choice to stop life-threatening bleeding t. Direct pressure is hard to maintain during casualty movement t. The risk-benefit ratio Tactical Combat Casualty Care 09 SEP 02

Tourniquets t. Ischemic damage to an extremity is rare if the tourniquet is left in place less than 60 -90 min t. Surgical/anesthesia literature states 5 min off every 30 mins after tourniquet has been on for 120 min t. Risk/Benefit ratio Tactical Combat Casualty Care 09 SEP 02

Care Under Fire t. Return fire t. Don’t be a hero t. Find cover for yourself and your casualty t. Stop any life-threatening external hemorrhage Tactical Combat Casualty Care 09 SEP 02

Questions? Tactical Combat Casualty Care 09 SEP 02

Tactical Field Care t. Reduced risk/warm zone t. Cover/Concealment t. Variable amount of time available t. Mission t. Casualty evacuation t. Field conditions t. Temperature and weather t. Darkness t. Non-sterile environment Tactical Combat Casualty Care 09 SEP 02

External Hemorrhage t. Stop bleeding t. Transport casualty to extraction site t. If tourniquet used earlier t. Consider loosening then reassessing t. Try direct pressure to control bleeding t. May be able to remove tourniquet t. Expose/Environment Tactical Combat Casualty Care 09 SEP 02

Airway Management: Conscious Casualty No attempt at airway intervention if the casualty is conscious and breathing well on his or her own Tactical Combat Casualty Care 09 SEP 02

Airway Management: Altered Mental Status t. Usual cause is hemorrhagic shock or penetrating head trauma t. Manual correction options t. Chin lift/jaw thrust maneuver t. Nasopharyngeal airway t. Gravity positioning t. Low-yield for immobilization of cervical spine Tactical Combat Casualty Care 09 SEP 02

Airway Management: Obstruction t. Liquid removal options t. Gravity t. Suction t. Definitive airway options t. Endotracheal intubation t. Cricothyroidostomy Tactical Combat Casualty Care 09 SEP 02

Breathing t. Tension Pneumothorax t Auscultation t Tracheal deviation t Percussion t JVD Tactical Combat Casualty Care 09 SEP 02

Auscultation t. Seventy-one patients (60%) had a hemothorax, pneumothorax, or hemopneumothorax. Auscultation to detect hemothorax, pneumothorax, or hemopneumothorax had a sensitivity of 58%, a specificity of 98%, and a positive predictive value of 98%. Chen SC. Markmann JF. Kauder DR. Schwab CW. Hemopneumothorax missed by auscultation in penetrating chest injury. Journal of Trauma-Injury Infection & Critical Care. 42(1): 86 -9, 1997 Jan Tactical Combat Casualty Care 09 SEP 02

Auscultation t. Thirty of 71 patients (42%) were found to have pleural space blood or air missed by auscultation. Auscultation missed hemothorax up to 600 m. L, pneumothorax up to 28%, and hemopneumothorax up to 800 m. L and 28%. Chen SC. Markmann JF. Kauder DR. Schwab CW. Hemopneumothorax missed by auscultation in penetrating chest injury. Journal of Trauma-Injury Infection & Critical Care. 42(1): 86 -9, 1997 Jan Tactical Combat Casualty Care 09 SEP 02

Auscultation Tactical Combat Casualty Care 09 SEP 02

Auscultation with Stab Wounds Tactical Combat Casualty Care 09 SEP 02

Auscultation with GSW Wounds Tactical Combat Casualty Care 09 SEP 02

Tension Pneumothorax t. Deceased preload t. Increased afterload t. Mechanical pressure on heart t. Decreased Alveolar surface t. Pleural space agitation Tactical Combat Casualty Care 09 SEP 02

Needle Thoracentesis t. Casualties with penetrating chest trauma will generally have some degree of hemopneumothorax t. Additional trauma from needle thoracentesis will not significantly worsen casualties’ conditions if no pneumothorax present Tactical Combat Casualty Care 09 SEP 02

Needle Thoracentesis t. Emergently decompress affected hemithorax with 14 -gauge needle inserted over 3 rd rib in 2 nd intercostal space at mid-clavicular line Tactical Combat Casualty Care 09 SEP 02

Tube Thoracostomy t. Contraindicated for life-threatening tension pneumothorax t. Difficult to perform t. Infection risk higher when inserting tube in non-sterile conditions t. Prior to Evacuation? Tactical Combat Casualty Care 09 SEP 02

Open Pneumothorax t. Seal defect through which air moving and cover with dressing t. Allow for pressure release t. Difficult to do reliably in tactical setting t. Observe closely for development of tension pneumothorax t. Asherman valve may be option Tactical Combat Casualty Care 09 SEP 02

Supplemental Oxygen t. Controversial the tactical environment t. Cylinders of compressed gas heavy and risky for tactical operations t. Transportation of casualty difficult without vehicle Tactical Combat Casualty Care 09 SEP 02

Shock Management t. Shock is a state of inadequate organ perfusion t. Diagnosed by noting end-organ dysfunction t. Altered mental status t. Poor peripheral perfusion t. Anxiety Tactical Combat Casualty Care 09 SEP 02

Shock Management t. Therapeutic goals t. Increase oxygenation of blood t. Increased trans-alveolar oxygen t. Increased hemoglobin concentration t. Increase cardiac output t. Increased preload t. Increased stroke volume Tactical Combat Casualty Care 09 SEP 02

Intravenous Access t. IV access t. Cleaning the skin before venipuncture t. Saline lock should be used unless casualty requires immediate fluid resuscitation t. Flushing the lock with 5 m. L of normal saline every 2 hours will usually keep it open Tactical Combat Casualty Care 09 SEP 02

Controlled Hemorrhage: Without Shock t. NO immediate fluid resuscitation t. Save IV fluids for those who really need them t. No unnecessary tactical delays – do not wait 5 minutes to start an IV in this patient Tactical Combat Casualty Care 09 SEP 02

Controlled Hemorrhage: With Shock t. Administer IV fluids in boluses to correct end-organ dysfunction t 0. 9% (normal) or 3% saline solutions t. Lactated Ringer’s solution t 6% hetastarch [Hespan®] t. DO NOT use normal vital signs as endpoints for fluid resuscitation t. Increased blood pressure t. Hemoglobin, platelets, and clotting factors Tactical Combat Casualty Care 09 SEP 02

Uncontrolled Hemorrhage: With or Without Shock t. NO immediate fluid resuscitation t. Spend time controlling exsanguination t. External t. Internal t. Save IV fluids t. Permissive hypotension Tactical Combat Casualty Care 09 SEP 02

Cardiopulmonary Resuscitation Only in cases of nontraumatic cardiac arrest should CPR be considered prior to Evacuation t. Electrocution t. Hypothermia t. Near-drowning Tactical Combat Casualty Care 09 SEP 02

Additional Considerations t Minimize further contamination t Promote hemostasis t Check for additional wounds t Exit sites may be remote from entry t Some sites are easily overlooked t Splint fractures and recheck distal pulses t Analgesic medications t Antibiotic medications Tactical Combat Casualty Care 09 SEP 02

Questions? Tactical Combat Casualty Care 09 SEP 02

Evacuation

CASEVAC versus MEDEVAC t. CASEVAC t. Casualty evacuation from the battlefield t. MEDEVAC t. Medical evacuation of casualties Tactical Combat Casualty Care 09 SEP 02

CASEVAC Care t. Medical personnel may accompany evacuating asset t. No reliance on field personnel providing care t. Medical personnel operating in tactical vehicle t. Additional medical equipment may be available on evacuation platform t. Variable Tactical Combat Casualty Care 09 SEP 02

CASEVAC Care t Primary focus is clearing casualties off the battlefield and not medical care enroute t Adaptability is key t Maximize your mission within the CASEVAC mission Tactical Combat Casualty Care 09 SEP 02

CASEVAC Care t Tactical aircraft/vehicles have restrictions against white light t Laryngoscopes t Blood identification t Wound identification t Black out sheets Tactical Combat Casualty Care 09 SEP 02

MEDEVAC Care t. Medical personnel part of asset t. Medical personnel operating vehicle designed for them t. Additional medical equipment available on evacuation platform t. Oxygen t. Suction t. Monitoring t. Positioning Tactical Combat Casualty Care 09 SEP 02

MEDEVAC Care t. Difficult to get far-forward t. No part of assault planning t. Communications Tactical Combat Casualty Care 09 SEP 02

MEDEVAC Care t. FLA t. UH-60 Q t. Combat medic t. Augmentation t. CCATT t. Strategic MEDEVAC Tactical Combat Casualty Care 09 SEP 02

Questions? Tactical Combat Casualty Care 09 SEP 02

Military vs Civilian Tactical Medical Support Tactical Combat Casualty Care 09 SEP 02

Military vs. Civilian Tactical Medical Support t. Lines are purling t. Proximity to Tertiary level of care t. Additional resources t. Acceptance of casualties t. Philosophy t. Offense vs. defense t. Containment vs. destruction Tactical Combat Casualty Care 09 SEP 02

Questions ? Tactical Combat Casualty Care 09 SEP 02