Tactical Combat Casualty Care: Splinting, CPR, MEDEVAC, Evacuation, and Documentation

Fractures: Open vs Closed

• Definition & Identification
• Open fracture – skin is breached; bone communicates with external environment ⇒ high infection risk.
• Closed fracture – skin intact; bone remains internal.
• Typical clinical indicators (multiple may coexist – the more present, the higher the index of suspicion):
• \textbf{Significant\ trauma}+ intense pain.
• \textbf{Marked\ swelling} of the affected limb or joint.
• Audible / patient-reported “snap” at the moment of injury.
• Limb appears a different length or shape (shortening, angulation, rotation).
• Loss of pulse or distal sensation (vascular or neurologic compromise).
• Crepitus – palpable / audible “crunching” on movement.

Splinting: Objectives, Principles & Pitfalls

• Primary objectives
• Prevent any further musculoskeletal & soft-tissue injury.
• Protect neuro-vascular structures coursing near the fracture.
• Make the casualty more comfortable; reduce pain & anxiety.
• Pulse, Motor, Sensory (PMS) checks – mandatory before & after splinting.
• Core principles
• Do a quick head-to-toe sweep for additional injuries before devoting time to the splint.
• Use rigid or bulky material; pad bony prominences when rigid splints are applied.
• Secure with ace wraps, cravats, belts, duct tape – whatever is available.
• Splint prior to moving the casualty whenever tactically feasible to avoid conversion of a closed fracture to open.
• Keep manipulation to an absolute minimum; align only if distal circulation is absent and resistance is not met.
• Immobilize the joint above & below the fracture.
• For arms: the casualty’s own shirt or blouse sleeve can act as an improvised sling/splint.
• Mid-shaft femur → consider traction splint (Thomas, Sager, SKED, etc.).
• Things to avoid
• Excessive manipulation ⇒ iatrogenic vessel / nerve damage.
• Over-tight wraps ⇒ ischemia distal to splint (capillary refill >2 s, cyanosis, paresthesia = warning).

Commercial & Field-Expedient Splints

• Commercial devices
• Pneumatic (air) splints – circumferential support & tamponade.
• SAM® Splint – malleable aluminum core with foam; lightweight, reusable.
• SAN-Splint – similar multilayer concept.
• Field-expedient materials (always pad rigid edges)
• Shirt sleeves + safety pins.
• Weapons (UNLOADED & SAFED first).
• Wooden boards / cardboard boxes / tree limbs.
• Therm-a-Rest® or other camping pads.
• Golden rule – “First, do no harm”: complete PMS checks before / after to confirm no vascular or neurologic insult.

Cardiopulmonary Resuscitation (CPR) in Tactical Settings

• TCCC guidance: NO battlefield CPR for penetrating or blast trauma victims without pulse & respirations – survival = near-zero; resources & lives jeopardised.
• Bilateral needle thoracostomy MUST precede termination of care in torso or poly-trauma to rule out tension pneumothorax (rapidly reversible cause of PEA).
• Historical vignette – 1983 Grenada & Ranger airfield seizure: prolonged futile CPR delayed the mission; highlighted tactical cost.
• Acceptable pre-TACEVAC CPR exceptions (non-traumatic arrests with higher salvage rate):
• \text{Hypothermia}
• Near-drowning
• Electrocution
• Other primary medical causes (e.g., sudden arrhythmia).
• Myocardial infarction seldom occurs mid-operation → not included.
• Case study (Afghanistan 2011): Closed-head injury lost vitals; ER bilateral NCD released air ⇒ ROSC – reinforces “decompress both sides first”.

Tactical Communication & Evacuation Priorities

• Communicate with casualty – reassurance doubles as neurologic assessment (LOA × LOC).
• Keep tactical leadership informed – permits real-time adjustment of fires, positions, extraction.
• Coordinate early with Patient Evacuation Coordination Cell (PECC) or equivalent for TACEVAC asset launch.
• Constantly refine unit-level casualty reports through rehearsal; initiate MEDEVAC (9-Line) without delay.
• Two perspectives:
• Tactical – threat status, impact on weapons coverage, need for repositioning.
• Medical – injuries, triage priority, supplies, equipment, casualty mover logistics.

9-Line MEDEVAC Request (format & rationale)

• Purpose – request rotary / fixed wing or ground evacuation via tactical channels (not direct medical consult).
• Significance – drives asset allocation; minimal medical granularity.
• Lines (transmit in order; lines $$1\text{–}