BA

HCB 103.5 – Tactical Combat Casualty Care Vocabulary

Care Under Fire (CUF) Key Points

• Hemostatic agents (e.g.9Combat Gauze) usually NOT feasible in CUF – require 3 min of uninterrupted pressure.
• Non-extremity bleeding sites (neck, axilla, groin) cannot take limb tourniquets.
• Airway interventions are normally deferred:
• Do NOT stop to establish an airway under fire.
• Combat deaths exclusively from airway compromise are infrequent.
• If no airway is present in CUF, survival chances are minimal.

Tactical Field Care (TFC) Overview

• Begins once exposure to hostile fire is reduced and more time/space is available.
• Medical gear still limited to what medics, teammates, or vehicles carry.
• May involve rapid interventions with expectation of re-engagement OR prolonged field care (minutes to hours+).

Battlefield Priorities & M!A!R!C!H Algorithm

• TFC sequencing mirrors USSOCOM Tactical Trauma Protocols.
• Steps:

  1. M – Massive hemorrhage: control life-threatening bleeding.
  2. A – Airway: establish/maintain patency.
  3. R – Respiration: treat sucking chest wounds & suspected tension pneumothorax, support ventilation.
  4. C – Circulation: IV/IO access; resuscitate shock.
  5. H – Head injury/Hypothermia: prevent \text{SBP} < 90\,\text{mmHg} and hypoxia; prevent heat loss.

TFC Guidelines: Security, Triage, Altered Mental Status

• Establish security perimeter per SOP/battle drills; maintain situational awareness.
• Triage as required.
• Casualty with altered mental status:
• Immediately remove weapons, comms, explosives.
• Possible causes: TBI, shock, hypoxia, analgesics.
• Speak calmly: “Let Smith hold your weapon while I check you out.”

Hemorrhage Control in TFC

Limb Tourniquets

• Re-assess for unseen bleeding; apply CoTCCC-recommended limb tourniquet 2–3 in above wound, on skin.
• If bleeding persists, place second tourniquet side-by-side.
• All personnel carry a packaged, unused, mission-ready tourniquet in an accessible, standardized location.
• Do NOT intermittently loosen tourniquets → catastrophic re-bleed documented.

Hemostatic Dressings

• CoTCCC first-line: Combat Gauze (kaolin-impregnated 3 in × 4 yd roll).
• Proven safe via USAISR model; extensive battlefield & civilian data.
• Acceptable alternatives when Combat Gauze unavailable:
• Celox Gauze or ChitoGauze (chitosan-based; coagulation-independent).
• \text{XStat} (mini-sponge injector for deep/narrow junctional tracts).
• iTClamp (mechanical tissue approximation) – primary or adjunct.
• General application rules:
• Pack wound directly onto bleeding source.
• Maintain ≥ 3 min firm pressure (except XStat – self-expanding).
• If first agent fails, remove and re-pack with fresh dressing (XStat never removed in field).

Direct Pressure (without hemostatic)

• Effective for most external bleeds, incl. carotid/femoral, but requires unwavering pressure and is hard during movement.

Wound Packing Steps (Combat Gauze exemplar)

  1. Expose wound; clear pooled blood w/o disturbing clots.
  2. Identify spurting point; pack tightly until filled (may need >1 roll).
  3. Apply continuous pressure ≥ 3 min; reassess.
  4. Secure with compression dressing/ACE/cravat; leave effective packing in place.
  5. Frequent checks for re-bleed; expedite evacuation.

XSTAT 12/30

• Syringe device deploys compressed cellulose mini-sponges that expand on contact with blood for junctional bleeds.
• Temporary (≤ 4 h) bridge until surgery.
• CONTRA-indicated above inguinal ligament, above clavicle, thorax, abdomen, retroperitoneum, sacral space.
• Never remove in field; surgeon must extract after vascular control.

iTClamp – Head/Neck External Hemorrhage

• Closes wound edges; no manual pressure needed once applied.
• Prior hemostatic packing recommended when feasible.
• Monitor airway: expanding hematoma may necessitate definitive airway.
• Apply ≥ 1 cm away from eyelids; can be placed one-handed in ≤ 10 s.

Junctional Hemorrhage

• Regions: groin, buttocks, perineum, axillae, base of neck, proximal extremity beyond limb-tourniquet reach.
• Primarily caused by IEDs & Dismounted Complex Blast Injury (DCBI).
• By 2011, junctional bleeding = #1 cause of preventable exsanguination.
• CoTCCC-approved junctional tourniquets:

  1. Combat Ready Clamp (CROC)
  2. Junctional Emergency Treatment Tool (JETT)
  3. SAM Junctional Tourniquet (SJT)
    • Apply promptly; reassess often – “Apply & never forget.”

Shock Assessment & Immediate Treatment

• Indicators: altered mental status (without TBI) and/or weak/absent radial pulse.
• Begin fluid resuscitation per TCCC guidelines once identified.

Airway Management in TFC

Decision Logic

• Conscious & able to protect airway: none needed.
• Unconscious, no obstruction: recovery position ± chin lift/jaw thrust; NPA; extraglottic airway.
• Conscious with impending obstruction: allow self-positioning (sit/lean forward); suction; chin lift/jaw thrust; NPA; deep unconscious → extraglottic.
• Fails → Surgical cricothyroidotomy.
• Penetrating trauma alone does NOT mandate cervical spine stabilization.
• Pulse oximetry aids ongoing airway assessment (target \text{SpO}_2 > 90\%).

Recovery Position

• Side-lying with head dependent after airway opened; reduces aspiration risk.

Nasopharyngeal Airway (NPA)

• 90° insertion relative to face, along nasal floor.
• Lubricate; gentle back-and-forth if resistance; switch nostril if needed; tape secure.
• Better tolerated than oropharyngeal in awake casualties.

Extraglottic Airway

• Preferred: i-gel (gel cuff, no inflation needed).
• Air-cuff devices require cuff-pressure monitoring, especially during altitude change.
• Only for deeply unconscious patients; otherwise gag reflex.
• If not tolerated, revert to NPA.

Maxillofacial Trauma

• Allow patient to sit forward if self-maintaining airway.
• Severe face burns/injuries may necessitate early surgical cricothyroidotomy.

Surgical Cricothyroidotomy

• High failure (~33 %) in medics → demands repetitive, realistic training (≥ 5 live simulations).
• Cric-Key technique – CoTCCC preferred:
• 19 cm curved introducer with anterior tip, matched to 5.0 mm cuffed Melker cannula.
• Combines hook, stylet, dilator, bougie.
• Key procedural steps:

  1. Prep kit; identify landmarks (thyroid cartilage “Adam’s apple” → cricoid; incision over cricothyroid membrane).
  2. Vertical skin incision, blunt dissect, horizontal membrane cut.
  3. Insert Cric-Key + cannula, verify tracheal rings, avoid skin tenting.
  4. Remove stylet; inflate cuff (10 mL air).
  5. BVM ventilate; auscultate bilaterally; secure tube.

Respiration Management – Tension Pneumothorax

Pathophysiology Review

• Pneumothorax = air between lung & chest wall; lung collapses.
• Tension pneumo: injured tissue forms 1-way valve; pressure shifts mediastinum → impairs lungs & heart → shock → traumatic arrest.
• Unaddressed tension pneumo is a common, yet easily treatable, cause of battlefield death.

Indications to Suspect & Treat

• Significant torso/blast trauma AND ≥ 1 of:
• Severe/progressive respiratory distress or tachypnea.
• Unilateral absent/decreased breath sounds.
• \text{SpO}_2 < 90\% at sea level.
• Signs of shock.
• Traumatic arrest without obviously lethal injury.

Immediate Actions

  1. If chest seal present – burp/remove.
  2. Apply pulse oximetry.
  3. Position supine or recovery; conscious with face trauma may sit.
  4. Needle Decompression (NDC): 14-G or 10-G, 3.25 in catheter.
    • Insert perpendicular, just above lower rib margin.
    • Hold 5–10 s; remove needle, leave catheter.
  5. Traumatic arrest → decompress both sides before ceasing resuscitation.

Acceptable NDC Sites

• Lateral: 5th ICS, Anterior Axillary Line (AAL)
• Males: nipple level.
• Females: infra-mammary fold; 4 finger-breadths below axilla; or 2 finger-breadths below axillary hairline.
• Anterior: 2nd ICS, Mid-Clavicular Line (MCL)
• 2–3 finger-widths below mid-clavicle.
• Never medial to nipple line; do not aim toward heart.

Success Criteria for NDC

• Improved breathing or audible hiss or \text{SpO}_2 \uparrow \rightarrow ≥ 90\% or ROSC in arrest.
• If failure: 2nd attempt at alternate site; consider opposite lung.
• Recurrence: repeat NDC at same site with new catheter.

Chest Seals – Open Pneumothorax

• Sucking chest wound: ≥ nickel-sized defect; air enters pleural space via wall defect.
• Apply vented occlusive dressing at end-expiration. If none available, use unvented.
• Monitor closely; if tension develops, "burp" or temporarily remove seal or perform NDC.
• Emerging evidence: vented seals prevent tension pneumo more reliably than unvented.

Pulse Oximetry Monitoring

• Normal \text{SpO}_2 at sea level ≈ 98\%; at 12,000 ft ≈ 86\%.
• Indications: severe chest trauma, TBI, unconscious, suspected pneumo.
• Caveats: readings skewed by hypothermia (cold limb ↓), carbon monoxide (false ↑), intense ambient light, or shock.

Training & Operational Notes

• Hemostatic dressings: leave in manufacturer packaging until use; harsh climate degrades exposed tourniquets/dressings.
• Training tourniquets are NOT mission tourniquets