TCCC Combat Casualty Care – Key Vocabulary

Far-Forward Whole-Blood & 1:1:1 Resuscitation

• Fresh, low-titer type O whole blood (FWB) is a battlefield alternative when component therapy is unavailable or failing.
• 75th Ranger Regiment ROLO (Ranger O-Low-titer) program:
• Identifies pre-screened donors with Type O, low anti-A/anti-B titers.
• Screens for blood type, infectious diseases, antibody titers before deployment.
• Donor pool is on-hand; blood drawn and transfused immediately to casualties in hemorrhagic shock.
• Regulatory status:
• In-theater collected whole blood and apheresis platelets are NOT FDA-compliant (collection environment, documentation).
• Use ONLY when FDA-approved products for 1:1:1 component therapy (PRBCs : Plasma : Platelets) are:
• Unavailable, OR
• Available but clinically ineffective.
• Ethical / practical implication – balancing immediate lifesaving need vs. regulatory compliance.

Hypothermia Prevention (TCCC §103.5.4.6)

• Guiding principle – even mild hypothermia impairs coagulation ➜ exacerbates bleeding.
• Early, aggressive prevention for ALL trauma & burn casualties.

Field Measures

• Minimize exposure: cold ground, wind, precipitation, rotor-wash.
• Insulate beneath casualty ASAP (poncho liner, foam pad, litter insulation).
• Replace wet clothing; keep protective gear if feasible (adds insulation, prevents secondary injury).
• Active external heat:
• Place approved heating blanket on anterior torso & axillae; NEVER directly on skin.
• Enclose:
• Start with impermeable bag (e.g., HPMK heat-reflective shell).
• Upgrade to insulated hooded sleeping bag inside vapor-barrier shell when possible.
• Pre-stage kits: insulated enclosure + external heat source for hand-off / evacuation phase.
• Warm IV fluids with battery device rated to 150\ \text{mL·min}^{-1} delivering 38^{\circ}\text{C}.
• Protection continues on evacuation platforms (doors off helicopters create major convective loss).

Key Take-Home Points

• Shocked patients cannot self-generate heat.
• Wet clothes & helo flight exponentially increase cooling.
• Prevention is vastly easier than re-warming.

Penetrating Eye Trauma (TCCC §103.5.4.7)

Immediate Actions

• Suspect open globe if projectile, blast, or sharp object involved.
• Rapid visual-acuity check – descending order:

1. Read printed text
2. Count fingers
3. Detect hand motion
4. Light perception
   • Document result.
   • Apply rigid eye shield ONLY – NO pressure patches.
   • Prevents extrusion of ocular contents.
   • Shields should be standard in IFAK/medic kits; tactical eye-pro acceptable substitute.

Antibiotics & Infection Control

• Open globe ➜ high risk of endophthalmitis ➜ give systemic antibiotics.
• Prefer moxifloxacin 400\,\text{mg} PO from Combat Wound Medication Pack (CWMP).
• If unable to take PO, use IV/IM per systemic infection protocol.

Why Avoid Shielding Uninjured Eye

• No evidence that conjugate eye movement worsens outcome.
• Bilateral patching converts ambulatory patient into litter patient & creates psychological stress.

Retrobulbar Hemorrhage (RBH)

• Orbit = closed compartment; bleeding raises pressure ➜ optic-nerve ischemia.
• S/S: pain, proptosis, decreased vision (“bloody, blind, bulging”).
• Requires emergent evacuation; definitive field intervention = lateral canthotomy.
• Cut lateral canthal tendon, decompresses orbit.
• Must be done within minutes to save vision.

Monitoring & Triple-Option Analgesia (TCCC §103.5.4.8)

Battlefield Monitoring

• Use electronic monitors (pulse ox, EtCO₂, BP) when gear & situation permit.

Analgesia Goals

1. Preserve fighting force (casualty able to continue mission if possible).
2. Provide rapid, maximal pain relief.
3. Minimize adverse effects (respiratory depression, hypotension, cognitive impairment).

Simplified 3-Option Scheme

• All doses may be repeated as directed; always reassess pain & vitals.
• Contraindications for opioids (morphine, fentanyl): hypovolemic shock, respiratory distress, unconsciousness, severe TBI.

OPTION 1 – Mild/Moderate Pain, Casualty Fighting
• CWMP:
• Acetaminophen 500\,\text{mg} ×2 PO q8h (extended release =1000\,\text{mg}).
• Meloxicam 15\,\text{mg} PO once daily.
• Does NOT impair platelets (unlike other NSAIDs).

OPTION 2 – Moderate/Severe Pain, NO shock/respiratory risk
• Oral transmucosal fentanyl citrate (OTFC) 800\,\mu\text{g} between cheek & gum.
• Repeat once after 15 min if needed.
• Admin hacks: tape lozenge to casualty’s finger or safety-pin to uniform ➜ if they become obtunded, drug falls out.
• Monitor respiration; if depression occurs: establish IV, deliver naloxone 0.4\,\text{mg}, assist ventilations.
• Alternative if IV established: Morphine 5\,\text{mg} IV/IO q10 min PRN (TCCC slide shows 1.5 mg; many units use 5 mg – follow local SOP).

OPTION 3 – Moderate/Severe Pain WITH shock, respiratory risk, or likely to deteriorate
• Ketamine (favorable hemodynamic profile).
• IM/IN: 50{-}100\,\text{mg} (≈0.5{-}1\,\text{mg·kg}^{-1}) q20–30 min PRN.
• IV/IO: 30\,\text{mg} (≈0.3\,\text{mg·kg}^{-1}) over 1 min; repeat q20 min PRN.
• End-points = adequate pain control OR nystagmus.
• Safety: wide margin; maintains airway reflexes; stimulates cardiac output; rare apnea if pushed too fast (bag for a few breaths).
• Useful adjunct after opioids; safe sequential use.

General Analgesia Rules

• Disarm casualty after potent analgesic/dissociative agent.
• Document mental status (AVPU) pre-drug.
• Monitor ABCs continuously after opioids, ketamine, or benzos.
• Ondansetron 4\,\text{mg} ODT/IV/IM q8h PRN nausea (may repeat once at 15 min; max 8\,\text{mg}/8 h). Replaces promethazine (safer, non-sedating).
• Benzodiazepines NOT routine; reserve for procedural sedation or ketamine emergence. Avoid opioid + benzo combination.

NSAID Caveats

• Avoid aspirin, ibuprofen, naproxen, ketorolac in combat zone – inhibit platelet function for 7{-}10 days.
• Meloxicam & acetaminophen spare platelet function ⇨ preferred.

Antibiotic Prophylaxis for Open Wounds (TCCC §103.5.5.1)

• Give ASAP after life-threat conditions controlled; delays ↑ infection risk.

If casualty CAN take PO:
• Moxifloxacin 400\,\text{mg} PO once daily (from CWMP).

If casualty CANNOT take PO (shock, unconscious):
• Ertapenem 1\,\text{g} IV over 30 min OR IM once daily.
• IV prep: reconstitute vial in 10\,\text{mL} NS, transfer to 50\,\text{mL} NS.
• IM: dissolve in 3.2\,\text{mL} lidocaine 1% (no epi).

Combat Wound Medication Pack Contents (unit-dose blister):

1. Moxifloxacin 400\,\text{mg}
2. Meloxicam 15\,\text{mg}
3. Acetaminophen 1000\,\text{mg} (2 × 500\,\text{mg} ER)

Medication Allergy Screening
• Identify aspirin/NSAID allergies ⇨ no Meloxicam.
• Fluoroquinolone, penicillin, cephalosporin allergies need alternate antibiotics (coordinate pre-deployment).

Wound Care – Abdominal Evisceration Highlights

• Control bleeding: irrigate, apply hemostatic gauze to sources.
• Cover exposed bowel with moist sterile dressing, then water-impermeable layer (transparent preferred: IV bag, food-wrap, chest seal).
• ONE gentle attempt at reduction allowed; if successful, close skin (e.g., chest-seal) to prevent re-evisceration.
• Do NOT force actively bleeding or non-reducible viscera back inside.
• Hypothermia risk ↑ (bowel evaporative loss) – monitor.
• In prolonged field care (>hours) odds of late reduction success LOW; may elect to leave external under protective dressing.
• Always inspect for additional wounds.

Burn Management (TCCC §103.5.5.2)

Initial Approach

• Treat as trauma patient with burns (hemorrhage control & airway come first).
• Facial burns in closed space ➜ high suspicion for inhalation injury ➜ monitor SpO₂, consider early surgical airway.

Estimate Size – Rule of Nines

• Calculate TBSA to nearest 10\%; exclude superficial (1st-degree) burns.
• Degrees:
• 1° – erythema only.
• 2° – partial-thickness (blistering).
• 3° – full-thickness (leathery, insensate).
• 4° – extends to muscle/bone.

Cover & Prevent Heat Loss

• Dry sterile dressings; if >20\% TBSA, consider placing casualty into heat-reflective shell / Blizzard blanket (combats hypothermia & covers wounds).

Fluid Resuscitation – USAISR Rule of Ten

• Initiate if >20\% TBSA AND IV/IO available.
• Use LR, NS, or Hextend (≤1000\,\text{mL} of Hextend; thereafter crystalloid).
• Initial hourly rate:
\text{Rate (mL·hr}^{-1}) = (\%\text{TBSA}) \times 10
• ADD 100\,\text{mL·hr}^{-1} for every 10\,\text{kg} above 80\,\text{kg} body weight.
• Example: 30\% TBSA, 100\,\text{kg} patient → 30\times10=300; +200 (two tens over 80 kg) → 500\,\text{mL·hr}^{-1}.
• If hemorrhagic shock present, prioritize damage-control resuscitation per §103.5.4.5; treat burn shock second.
• Burns ≤30\% TBSA & conscious: may use oral fluids if tactical situation allows.

Analgesia & Antibiotics

• Follow TCCC triple-option analgesia (above) for burn pain.
• Routine prophylactic antibiotics NOT indicated solely for burns; give per open-wound guideline if penetrating wounds exist.

Hypothermia Emphasis

• Burn skin loses thermoregulation; combine enclosure bags, reflective shells, active warming.
• ALL TCCC interventions (tourniquet, IV, IO, chest seal) can be performed through burn skin if necessary.

Inter-Topic Connections & Practical Insights

• Hypothermia prevention, hemorrhage control, and analgesia form a triad that directly affects coagulation, hemodynamics, and casualty survivability.
• Eye shields, tactical eyewear, and burn dressings all underscore the preventive value of personal protective equipment (PPE).
• Whole-blood programs (ROLO) highlight need for unit-level medical planning (pre-screening, training donors) paralleling antibiotic allergy screening and CWMP issuance.
• The triple-option analgesia algorithm exemplifies escalation-of-care principles also seen in burn fluid resuscitation (oral → IV → damage-control priorities).
• Ethical implications: non-FDA-compliant products and off-label drug routes (IN ketamine) are justified under combat necessity, demanding clear SOPs and documentation.

REASSESS – REASSESS – REASSESS ➜ Every intervention above requires continuous monitoring for effectiveness & complications.