11/30/2015. Tactical Combat Casualty Care and SOF Tactical Trauma Protocols PFN: SOMTCL03. Terminal Learning Objective. Reason. Hours: 2.

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1 Tactical Combat Casualty Care and SOF Tactical Trauma Protocols PFN: SOMTCL03 Hours: 2.5 Instructor: Slide 1 Terminal Learning Objective Action: Communicate knowledge of Tactical Combat Casualty Care (TCCC) and SOF Tactical Trauma Protocols (TTPs) Condition: Given a lecture in a classroom environment Standard: Received a minimum score of 75% on the written exam and a GO on the practical exam IAW course standards Slide 2 Reason Slide 3 1

2 Agenda Outline the origins, history, and objectives of TCCC and SOF TTPs Identify the three phases of TCCC and SOF TTPs Identify the Care Under Fire treatment priorities Identify the treatment priorities Slide 4 Agenda Identify the SOF TTPs extended Tactical Field Care considerations Identify the Tactical Evacuation Care treatment priorities Slide 5 Origins, History, and Objectives of TCCC and SOF TTPs Slide 6 2

3 Origins, History, and Objectives of TCCC and SOF TTPs Navy initiated TCCC project in 1993 Original guidelines published in 1996 (Journal of Military Medicine) First TCCC course taught in 1996 TCCC incorporated in PHTLS manual 1999 ACSCOT and NAEMT endorsement CoTCCC established in 2001 (meets quarterly) Slide 7 USSOCOM Directive All SOF deploying personnel Trained on current TCCC guidelines ml _curriculum Training completed within 6 months prior to deployment in support of combat operations Slide 8 Origins, History, and Objectives of TCCC and SOF TTPs 90% of combat casualties that die, die before reaching a MTF Slide 9 3

4 Origins, History, and Objectives of TCCC and SOF TTPs Slide 10 Origins, History, and Objectives of TCCC and SOF TTPs Slide 11 Origins, History, and Objectives of TCCC and SOF TTPs Slide 12 4

5 Origins, History, and Objectives of TCCC and SOF TTPs Top three preventable deaths on the battlefield: Hemorrhage from extremity wounds Airway compromise from maxillofacial trauma Tension pneumothorax Slide 13 Origins, History, and Objectives of TCCC and SOF TTPs TCCC objectives Treat the casualty Prevent additional casualties Complete the mission TTP additional options Extended field care Slide 14 Three Phases of TCCC and SOF TTPs Slide 15 5

6 Three Phases of TCCC and SOF TTPs Care Under Fire (CUF) (TFC) Extended Considerations Tactical Evacuation Care (TEC) Slide 16 Care Under Fire Treatment Priorities Slide 17 Care Under Fire Return fire and take cover Direct or expect casualty to remain engaged as a combatant if appropriate Direct casualty to move to cover and apply self aid if able Try to keep casualty from sustaining additional wounds Slide 18 6

7 Care Under Fire 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 Airway management is best deferred until phase Slide 19 Care Under Fire Stop any life threatening external hemorrhage if tactically feasible Direct casualty to control hemorrhage by self aid if able Use a CoTCCC recommended limb tourniquet for hemorrhage that is anatomically amenable to tourniquet use Apply the limb tourniquet over the uniform clearly proximal to the bleeding site If the bleeding site is not apparent place the tourniquet as proximal as possible Slide 20 Treatment Priorities Slide 21 7

8 Casualties with an altered mental status should be disarmed immediately Airway management Unconscious without airway obstruction Chin lift or jaw thrust maneuver Nasopharyngeal airway Place casualty in recovery position Slide 22 Airway management (cont.) Casualty with/or impending airway obstruction Chin Lift or Jaw Thrust maneuver Nasopharyngeal airway Allow casualty to assume any position that best protects the airway, including sitting up Place unconscious casualty in recovery position Protect spine in blunt and blast trauma patients If measures above are unsuccessful: supraglottic airway, intubation or surgical cricothyroidotomy (CricKey, Bougie aided or standard open surgical) Slide 23 Breathing Consider tension pneumothorax and decompress with 14G 3.25 needle/catheter unit if casualty has known or suspected torso trauma and progressive respiratory distress 2 nd ICS, MCL primary 4 th or 5 th anterior axillary line is the alternate Lateral to nipple line and not directed to heart Remove the needle and leave catheter in place Slide 24 8

9 Breathing (cont.) Repeat decompression as required Consider decompression of opposite side if casualty doesn t improve Consider chest tube for ineffective NDC Treat open chest wounds with a vented chest seal (if unavailable use a non vented seal) Monitor the casualty for development of a subsequent tension pneumothorax Slide 25 Bleeding Assess for unrecognized hemorrhage and control all sources of bleeding Use combat gauze for compressible hemorrhage not amenable to tourniquet use Consider a CoTCCC Junctional tourniquet for lower extremity or groin/inguinal wound not amenable to tourniquet use and cannot be controlled with hemostatic dressings Slide 26 Bleeding (cont.) Reassess prior tourniquet application; expose wound and determine is needed If so, place limb tourniquet directly to skin 2 3 above wound If not needed, use other methods to control bleeding Check distal pulse as situation permits If distal pulse is still present consider additional tightening of tourniquet or use of second tourniquet Slide 27 9

10 Bleeding (cont.) Expose and mark all tourniquet sites with time of application using an indelible marker Limb tourniquets and junctional tourniquets should be converted as soon as possible if three criteria are met: casualty is not in shock, wound can be monitored for bleeding, tourniquet is not on an amputation Apply pelvic binder for suspected pelvic fracture Slide 28 Prevention of hypothermia Minimize casualty s exposure to elements; keep protective gear on or with the casualty Replace wet clothing with dry Get the casualty onto an insulated surface (litter) Apply the Ready Heat Blanket on torso (not directly on skin); wrap in HRS or Blizzard Rescue blanket Slide 29 Prevention of hypothermia (cont.) If mentioned gear is not available, use dry blankets, poncho liners, sleeping bags, body bags, or anything that will retain heat and keep the casualty dry Slide 30 10

11 Intravenous (IV) access Start an 18 gauge IV or saline lock if indicated If resuscitation is required and IV access is not obtainable, use the intraosseous (IO) route Slide 31 Tranexamic Acid (TXA) If a casualty is anticipated to need significant blood transfusion Administer 1 gram of Tranexamic Acid in 100 ml Normal Saline or Lactated Ringers over 10 minutes as soon as possible but NOT later than 3 hours after injury Not in same line as Hextend or blood products Begin second infusion of 1 gm TXA after Hextend or other fluid treatment Mark casualty with amount of TXA given on chest Slide 32 Fluid resuscitation (cont.) Assess for hemorrhagic shock Altered mental status in the absence of head injury and/or weak or absent peripheral pulses Systolic blood pressure less than 80 mmhg Not in hemorrhagic shock No IV fluids are immediately necessary Fluids by mouth are permissible Slide 33 11

12 Fluid resuscitation (cont.) In hemorrhagic shock and blood products are available Whole blood Plasma, RBCs and platelets 1:1:1 Plasma and RBCs 1:1 Plasma or RBCs alone Reassess after each unit and continue until a palpable radial pulse, improved mental status or systolic BP between mmhg Slide 34 Fluid resuscitation (cont.) In hemorrhagic shock and blood products are NOT available Hextend Lactated Ringers or Plasma Lyte A Reassess after each 500 ml bolus and continue until a palpable radial pulse, improved mental status or systolic BP between mmhg Slide 35 Fluid resuscitation (cont.) Altered LOC with suspected TBI should be resuscitated to 90 mmhg systolic BP If shock recurs, reassess all external hemorrhage and repeat fluid resuscitation Continued efforts must be weighed against logistical and tactical considerations and the risk of incurring further casualties Warm fluids if possible to prevent hypothermia Slide 36 12

13 Head injury management Fluid resuscitate hypotension Maintain spo2 > 90%; goal = 95% Controlled mild hyperventilation (20 BPM) Hypertonic saline (3 5%) 250ml bolus Seizure prophylaxis Cerebyx 18 mg/kg IV/IO at mg/min Seizure management Valium 5 10 mg IV/IO q 5 minutes Versed 5 mg IV/IO q 5 minutes Slide 37 Head injury management (cont.) Patient positioning If CSF present elevate degrees If IICP only elevate 30 degrees Don t elevate the head of a hypovolemic casualty Sedation of severe TBI after airway established Versed 1 2 mg/hour IV/IO TCCC/SOF TTPs antibiotic prophylaxis should be started Slide 38 Abdominal evisceration Control visible hemorrhage Irrigate and gently reduce if possible Cover and keep warm Penetrating eye trauma Perform a rapid field test of visual acuity Cover the eye with rigid eye shield (not pressure patch) Start antibiotics Slide 39 13

14 Burns Facial burns, especially those that occur in closed spaces, may be associated with inhalation injury Aggressively monitor airway status and oxygen saturation in such patients and consider early surgical airway for respiratory distress or oxygen desaturation Slide 40 Burns (cont.) Estimate total body surface area (TBSA) burned to the nearest 10% using the Rule of Nines Cover the burn area with dry, sterile dressings For extensive burns (> 20%), consider placing the casualty in the Blizzard Survival Blanket in the Hypothermia Prevention Kit in order to both cover the burned areas and prevent hypothermia Slide 41 Burns (cont.) Fluid resuscitation (USAISR Rule of Ten) If burns are greater than 20% of Total Body Surface Area, fluid resuscitation should be initiated as soon as IV/IO access is established Resuscitation should be initiated with Lactated Ringer s, Normal Saline, or Hextend If Hextend is used, no more than 1000 ml should be given, followed by Lactated Ringer s or Normal Saline as needed Slide 42 14

15 Burns (cont.) Fluid resuscitation (USAISR Rule of Ten) Initial IV/IO fluid rate is calculated as %TBSA x 10 ml/hr for adults weighing kg For every 10 kg ABOVE 80 kg, increase initial rate by 100 ml/hr If hemorrhagic shock is also present, resuscitation for hemorrhagic shock takes precedence over resuscitation for burn shock Administer IV/IO fluids per the TCCC Guidelines Slide 43 Burns (cont.) Analgesia in accordance with the TCCC guidelines may be administered to treat burn pain Prehospital antibiotic therapy is not indicated solely for burns, but antibiotics should be given per the TCCC guidelines if indicated to prevent infection in penetrating wounds All TCCC interventions can be performed on or through burned skin in a burn casualty Slide 44 Inspect and dress known wounds Check for additional wounds Splint fractures and recheck pulses Basic splinting fundamentals apply Crush injury management Immediately ml NS Just before extrication apply tourniquets and give sodium bicarbonate After extrication monitor for cardiac arrest Slide 45 15

16 Monitoring Pulse oximetry should be available as an adjunct to clinical monitoring Readings may be misleading in the settings of shock or marked hypothermia Slide 46 Analgesia if able to fight Meloxicam (Mobic) 15 mg PO once a day Acetaminophen 650 mg bilayer caplet, 2 PO every 8 hours Slide 47 Analgesia if unable to fight without IV/IO Hypovolemic shock or respiratory distress Ketamine (Ketalar) 50 mg IM or IN Repeat dose every min Controls pain or nystagmus occurs No hypovolemic shock or respiratory distress Fentanyl Citrate (OTFC) 800 ug transbuccally Reassess in 15 minutes Monitor for respiratory depression Slide 48 16

17 Analgesia if unable to fight with IV/IO Hypovolemic shock or respiratory distress Ketamine 20 mg IV/IO over 1 minute repeat dose every 5 10 min to control pain or until nystagmus occurs (max of 100mg/hr) Consider Versed 1 mg IV for agitation No hypovolemic shock or respiratory distress Morphine 5 10 mg IV/IO repeat dose every 10 minutes as necessary (monitor for respiratory depression) Slide 49 Consider an antiemetic for opioid or trauma induced nausea or vomiting Ondansetron (Zofran) 4 mg ODT/IV/IO/IM every 8 hours Can be repeated once at 15 min Max 8mg in any 8 hour period Promethazine (Phenergan) Must be diluted and given slowly Has a synergistic effect Use only if Zofran is not available Slide 50 Antibiotics: recommended for all open combat wounds Able to take PO Moxifloxacin 400 mg PO one a day Unable to take PO Ertapenem 1 g IV/IM once a day Cefotetan 2g IV (slow push over 3 5 minutes) or IM every 12 hours Slide 51 17

18 Communicate with patient if possible Encourage and reassure Explain care Cardiopulmonary resuscitation Resuscitation on the battlefield 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 Slide 52 Bilateral needle decompression For casualties with torso or multisystem trauma and no pulse or respirations during TFC phase Document Clinical assessments, treatments rendered, and changes in casualty s status on a TCCC Casualty Card Forward this Information with the casualty to the next level of care Slide 53 SOF TTPs Extended Tactical Field Care Considerations Slide 54 18

19 SOF TTPs Extended Tactical Field Care Considerations Airway Suction Consider periodic suctioning of the oropharynx and endotracheal tube Pulmonary toilet Consider periodic saline flushes (2 ml) to clear mucus/blood from ET tube Local wound care at cricothyroidotomy site if applicable Slide 55 SOF TTPs Extended Tactical Field Care Considerations Respiratory management Perform chest tube and apply chest drain Consider rib blocks for pain management Administer oxygen if available Consider the use of a ventilator/assist device if available Consider sedation with midazolam (Versed) 1 2 mg/hour IV/IO for prolonged intubation Slide 56 SOF TTPs Extended Tactical Field Care Considerations Flail chest management Monitor for developing hypoxia secondary to pulmonary contusions Casualty may require positive pressure ventilation Ensure adequate analgesia Consider rib blocks for pain management These casualties frequently fatigue and require intubation/definitive surgical airway Slide 57 19

20 SOF TTPs Extended Tactical Field Care Considerations Fluid management Conscious Instruct casualty to drink clear liquids up to 1 liter per hour; consider oral electrolyte supplementation if available Unconscious Insert Foley catheter and titrate IV/IO/NG/PR crystalloid fluids to maintain urine output of ml per hour Clean water may be utilized in lieu of crystalloid for NG/PR infusion Slide 58 SOF TTPs Extended Tactical Field Care Considerations Fluid management (cont.) Critical burn (> 20% TBSA of 2 nd /3 rd degree burns) Continue fluid resuscitation according to The Rule of Ten Insert Foley catheter and adjust fluid rate to maintain urine output of ml per hour Oral fluid administration may be acceptable in burns up to 40% TBSA if IV supplies are limited Slide 59 SOF TTPs Extended Tactical Field Care Considerations Wound care management Irrigate and redress wounds (any potable water can be used for irrigation) Debride only obviously devitalized tissue Change dressings every 24 hours Consider converting to silver impregnated dressings to reduce frequency of dressing changes Continue antibiotics Repeat moxifloxacin (Avelox) 400 mg PO or ertapenem (Invanz) 1 gm IV/IO/IM every 24 hours Slide 60 20

21 SOF TTPs Extended Tactical Field Care Considerations Analgesia For painful procedures consider the use of procedural anesthesia Dual agent Midazolam (Versed) 2 mg IV/IO over 1 minute Ketamine (Ketalar) 20 mg IV/IO over 1 minute Single agent Morphine 5 mg IV/IO q 5 min Consider local blocks for pain management Slide 61 SOF TTPs Extended Tactical Field Care Considerations Nutrition management Consider oral nutrition if evacuation will be delayed by over 24 hours Orthopedic injury management Traction splints as needed Reassess fractures and adjust splints as needed Slide 62 SOF TTPs Extended Tactical Field Care Considerations Compartment syndrome management Be suspicious of compartment syndrome in the following conditions Fractures Crush injuries Vascular injuries Circumferential burns Multiple penetrating injuries (fragmentation) Slide 63 21

22 SOF TTPs Extended Tactical Field Care Considerations Clinical signs of compartment syndrome Pain out of proportion to injury Pain with passive motion of muscles in the involved compartment Pallor Paresthesias Pulselessness Consider use of compartment pressure monitor if available and trained in its use Slide 64 SOF TTPs Extended Tactical Field Care Considerations Compartment syndrome management Reevaluate every 30 minutes for first two hours then once every hour Maintain extremity at heart level Loosen encircling dressings Fasciotomy Only consider if evacuation is delayed over 6 hours Only perform if within your scope of practice Slide 65 SOF TTPs Extended Tactical Field Care Considerations Blast injuries Tympanic membrane perforation Dexamethasone (Decadron) 10 mg IV/IO/IM/PO QD Lungs Monitor patient for respiratory deterioration Abdomen Monitor for delayed bowel injury Spine Slide 66 22

23 Tactical Evacuation Care Treatment Priorities Slide 67 Tactical Evacuation Care Airway management Continue to monitor the casualty s airway and upgrade as needed Consider replacing advanced airway bulbs with saline prior to aircraft CASEVAC Breathing Continue to reassess Perform thoracostomy if needed Provide oxygen if available Slide 68 Tactical Evacuation Care Bleeding Reassess patient and verify bleeding is controlled Verify distal pulses are absent in extremities with tourniquets Reassess if tourniquet is required or other hemorrhage control means are appropriate Slide 69 23

24 Tactical Evacuation Care Hypothermia management Continue hypothermia prevention management or initiate if not already started Utilize heating system on evacuation platform and avoid wind exposure Use an IV warming device for all fluid administration Slide 70 Tactical Evacuation Care Intravenous (IV) access Reassess IV patency Flush IV lines and saline locks as required TXA If needed and not already started Fluid resuscitation Continue resuscitation as needed Maintain a normal radial pulse or systolic blood pressure between mmhg Slide 71 Tactical Evacuation Care Burn Treatment Continue fluid resuscitation with Rule of Tens Consider urinary catheter to monitor output Head injury management Continue to prevent hypotension and hypoxia Controlled mild hyperventilation If CO2 monitor available pco2 of 30 mmhg If no CO2 monitor 20 BPM Slide 72 24

25 Tactical Evacuation Care Penetrating eye trauma Cover with rigid eye shield if not already done Monitoring Institute pulse oximetry and other electronic monitoring of vital signs, if indicated Inspect and dress known wounds if not already done Check for additional wounds Slide 73 Tactical Evacuation Care Continue analgesia as needed Reassess fractures and recheck pulses Monitor air pressure in extremity air splints during air evacuation Start antibiotic therapy if not already done Slide 74 Tactical Evacuation Care The Pneumatic Antishock Garment (PASG) may be useful for stabilizing pelvic fractures and controlling pelvic and abdominal bleeding Application and extended use must be carefully monitored Contraindicated for casualties with thoracic or brain injuries Slide 75 25

26 Tactical Evacuation Care Document Clinical assessments, treatments rendered, and changes in casualty s status on a TCCC Casualty Card Forward this Information with the casualty to the next level of care Slide 76 Questions? Slide 77 Terminal Learning Objective Action: Communicate knowledge of Tactical Combat Casualty Care (TCCC) and SOF Tactical Trauma Protocols (TTPs) Condition: Given a lecture in a classroom environment Standard: Received a minimum score of 75% on the written exam and a GO on the practical exam IAW course standards Slide 78 26

27 Agenda Outline the origins, history, and objectives of TCCC and SOF TTPs Identify the three phases of TCCC and SOF TTPs Identify the Care Under Fire treatment priorities Identify the treatment priorities Slide 79 Agenda Identify the SOF TTPs extended Tactical Field Care considerations Identify the Tactical Evacuation Care treatment priorities Slide 80 Reason Slide 81 27