abolishingios11

JournalofSpecialOperationsMedicineVolume11,Edition3/Summer/Fall11104TacTicalEmErgEncycasualTycarE(TEcc):guidElinEsforThEProvisionofPrEhosPiTalTraumacarEinhighThrEaTEnvironmEnTsCallawayDW;SmithER;CainJ;ShapiroG;BurnettWT;McKaySD;andMabryRCorrespondingAuthor:DavidW.
Callaway,MDDirector,TheOperationalMedicineInstitute(OMI)AssistantProfessorofEmergencyMedicineCarolinasMedicalCenter1000BlytheBlvdCharlotte,NC28203AuthorsE.
ReedSmith,MDOperationalMedicalDirectorArlingtonCountyFireDepartmentAssistantProfessorofEmergencyMedicineTheGeorgeWashingtonUniversityAddressis1020NorthHudsonStreet,3rdFloorArlington,VA22201JefferyS.
Cain,MDMedicalDirector,McKinneySWAT2804AtwoodDriveMcKinney,TX75070GeoffShapiro,EMT-PCoordinator,OperationalMedicineProgramsTheGeorgeWashingtonUniversity2131KStreet,NWSuite510Washington,DC20037WThomasBurnett,MD,FACEPOperationalMedicineDirectorDepartmentofEmergencyMedicineVirginiaTechCarilionSchoolofMedicineSeanD.
McKay,EMT-PAssociate,AsymmetricCombatInstitute(ACI)115-136WadeHamptonBlvd.
Taylors,SC29687RobertL.
Mabry,MDUnitedStatesArmyInstituteofSurgicalResearch3400RawleyE,ChambersAveFortSamHouston,TX7823420TECC-Summer-Fall11-2_TCCC9/5/116:40PMPage104TacticalEmergencyCasualtyCare(TECC):GuidelinesfortheProvisionofPrehospitalTraumaCareinHighThreatEnvironments105inTroducTionCivilianTacticalEmergencyMedicalSupport(TEMS)hasalonghistoryintheUnitedStates.
Enormousprogresshasbeenmadeduringthepasttenyearsindevelopingprofessionalandoperationalstandardswithinthefield.
However,todate,therestillexistsnostandardofcarewithinTEMSspecifically,andmorebroadlyforhighthreatpre-hospitaltraumacare.
Currentcivilianfirstresponderpracticesandprinciplesdonotadequatelyaddresstheneedforpointofwoundingcareinatypical,highthreatemergencyresponse.
TheenclosedTacticalEmergencyCasualtyCare(TECC)guidelinesarebasedupontheprinciplesofTacticalCombatCasualtyCareandspecificallydesignedtoaddressthisoperationalgap.
1The"holygrail"oftraumacareoutcomesremainseliminatingpreventabledeaths.
In1996,ButlerandHag-mann'sseminalpaperonmodernbattlefieldprehospitalcareexaminedthemannerinwhichpeopledieincombat,dis-cussedthelimitationsofAdvancedTraumaLifeSupport(ATLS)forcombatmedicsandproposedanewsetofprinciplesforhighthreattraumacare:TacticalCombatCasualtyCare(TCCC).
2TheinitialTCCCguidelinesfocusedonthethreemajorpreventablecausesofdeathonthemodernbattlefield:isolatedextremityhemorrhage,tensionpneumothoracesandairwayobstruction.
Perhapsmoreimportantly,TCCCinitiatedaparadigmshiftinprehospitaltraumacare,empha-sizingtacticalconstraints(e.
g.
,incomingfire,light/noisediscipline,andmissionsuccess)asamajordeterminantoftraumaintervention.
Duringthepastdecade,theimplementationofTacticalCombatCasualtyCare(TCCC)hasbeenoneofthemajorfactorsinreducingpreventabledeathonthemodernbattlefield.
3TCCCguidelinesarecreditedwithreducingthecasefa-talityrate(CFR)incurrentcombatoperationsfromapproximately14%inVietnamto7.
4-9.
4%duringOperationIraqiFreedom(OIF)andOperationEnduringFreedom(OEF).
4,5Inamemorandumdated6August2009,theDefenseHealthBoard(DHB)notedthatinseveralSpecialOperationsunitsinwhichallmembersweretrainedinTCCC,noreportedin-cidentsofpreventablebattlefieldfatalitiesoccurredduringtheentiretyoftheircombatdeployments.
Giventhishighrateofefficacy,theDHBnowrecommendsTCCCtrainingforalldeployingcombatantsandmedicaldepartmentpersonnel.
TheprovensuccessofTCCConthebattlefield,ledthecivilianmedicalcommunity,bothtacticalandconven-tional,toexaminecloselythetenantsoftheTCCCdoctrineandintegrateportionsintociviliantraumacare.
Manyagen-cieshavesimplyimplementedTCCCastheirstandardofcare.
Othershaveresisted,citingsemanticconcernsabout"militarylanguage"andoperationalconcernsregardingdifferenceintargetpopulations,resourcelimitations,andlegalconstraints.
Asaresult,civiliantacticalandemergencymedicalelementsstandatthesamecrossroadswheretheSpecialOp-erationsmedicalcommunitystoodinthe1990s.
Rigid,enblocapplicationofTCCCguidelinesincivilianprotocolsisasfundamentallyflawedasutilizingcivilianATLSprinciplesforbattlefieldtraumamanagement.
TCCCiswrittenforthecombatmedicoperatinginacombattheater,notfortheciviliantacticalmedicoperatinginasingle-dwelling,small-scaleurbantacticalenvironment.
Undoubtedly,weaponsandwoundsaresimilarbetweenthetwosettingsandfederalandciviliantacticalteamsareindeed"incombat".
Despitethesesimilarities,justasATLSdidnotaddressmanyoftheuniquefactorsspecifictothemilitarycombatenvironment,TCCCdoesnotaddressthedifferencesbetweenmilitaryandcivil-ianenvironments(Figure1).
figure1:characteristicsthatdistinguishcivilianfrommilitaryhighthreatprehospitalenvironments.
Scopeofpracticeandliability:FederalandcivilianmedicalrespondersmustpracticeunderStateandlocalscopeofpracticeandprotocols,andaresubjecttobothnegligenceandliabilitythatthemilitaryproviderisoftennot.
Patientpopulationtoincludegeriatricsandpediatrics:TCCCdataandresearchwasheavilybasedoffofan18-30yearoldpopulation,notallagegroupsasrepresentedincivilianoperations.
TCCCwaswrittenprimarytoaddressthewoundedcombatantanddoesnotaddresshighthreatcareforinnocentnon-combatants.
Generallyshorterdistancesandgreaterresourcesavailableforevacuationtodefinitivecare.
Differencesinbarrierstoevacuationandcare:Despitethethreatofdynamicterroristattacks,secondaryattacksandarmedresistancetoevacuationisfarlesscommonintheciviliansetting.
Baselinehealthofthepopulation:TheTCCCcombatantpopulationisrelativelyhealthyandphysicallyfitwithoutthehighincidenceofchronicmedicalillnessthatexistsinthecivilianpopulation.
Woundingpatterns:Althoughtheweaponsaresimilarbetweenmilitaryandcivilianscenarios,thewoundingpat-ternsdiffergiventheprevalenceofanddifferencesinprotectiveballisticgear,aswellastheuseofandstrengthofimprovisedexplosivedevicesinthemilitarysetting.
Chronicmedicationuseintheinjured:TCCCdoesnotaccountfororaddresstheeffectsofchronicmedicationuse,suchasbeta-blockersandanti-coagulants.
Specialpopulations:Specialpopulations(e.
g.
pregnantorphysicallydisabled)areprevalentintheciviliansettingandtherequireddifferencesintheircarearerelevantindomesticcounter-terrorismandanti-terrorismresponse.
20TECC-Summer-Fall11-2_TCCC9/5/116:40PMPage105JournalofSpecialOperationsMedicineVolume11,Edition3/Summer/Fall11106TheTECCguidelinesareasetofbest-practicerecommendationsforcasualtymanagementduringhigh-threatciviliantacticalandrescueoperations.
6TheguidelinesarebasedontheprinciplesofTacticalCombatCasualtyCare(TCCC),butaccountfordifferencesinthecivilianenvironmentsuchasallocationandavailabilityofresources,variancesinpatientpopulations,andscopesofpractice.
ThegoalsofTacticalEmergencyCasualtyCareareto:Balancethethreat,civilianscopeofpractice,differencesincivilianpopulations,medicalequipmentlimits,andvariableresourcesforresponsestoatypicalemergencies.
Establishframeworksthatbalancerisk-benefitratiosforallcivilianoperationalmedicalresponseelements.
Provideguidanceonmedicalmanagementofpreventabledeathsatornearthepointofwounding.
Minimizeproviders'riskswhilemaximizingpatients'benefits.
TacTicalEmErgEncycasualTycarE(TEcc)Inconventionalemergencymedicalservices(EMSprotocols,scenesafetyisthefirstpriority.
However,thisal-gorithmictenetdoesnotaccountforunsecurescenes.
Civilianfirstrespondersareincreasinglyrequiredtooperateinhigh-threatenvironments.
Traditionalcareguidelinesareinherentlylimitedinthattheyaresolelypatient-focused,withoutacknowledgementofthesurroundingoperationalortacticalconstraints.
TheTECCprinciplesareasoundcompilationoftraumaguidelines,integratingoperationalandmedicalrequirementsintoaconsolidatedsetofbestpracticesspecifictohigh-threatprehospitalcare.
Aswiththebattle-testedconceptsofTacticalCombatCasualtyCare(TCCC),theTECCprinciplesarejustthat:principles,notinflexibleorrigidprotocols.
InTacticalEmergencyCasualtyCare,operationalscenariosandrelativethreatlevelsdriveclinicalinterventions.
ThethreephasesofTECCaremodeledonTCCC,andrepresenttranslated"lessonslearned"fromcombatandtheirapplica-tiontohigh-threat,civilianpre-hospitalcare.
Thephasesaredynamic,occasionallyoverlapping,andrarelylinear.
Itisofutmostimportancetorecognizethatthethreatzonesaresituational,notgeographic.
Thisconceptisacriticalcompo-nentoftheapplicationofTECCinrealworldsettings.
ThethreephasesofTECCare:DirectThreatCare/CareUnderFire(DT/CUF)IndirectThreatCare/TacticalFieldCare(ITC/TFC)Evacuation/TacticalEvacuation(EVAC/TACEVAC)dirEcTThrEaTcarE/carEundErfirEDirectThreat/CareUnderFire(DT/CUF)describesactionstakeninresponsetoacasualtywheretheexternal,on-goingthreattolifeisasdangerous,ormoredangerous,thantheinjurysustained.
Veryminimal"medical"interventionisgenerallywarranted.
Theriskoffurtherinjuriestothecasualtyandtherescuerisextremelyhighwhileunderdirecthos-tilethreatinhigh-riskenvironments.
ExamplesofDT/CUFincludealawenforcementofficershotinthedoorwayofanapartmentduringahigh-riskwarrantsearchorafirefighterrapidinterventionteam(RIT)memberencounteringaninjuredteammateduringimminentstructuralcompromise.
Availablemedicalequipmentisoftenlimitedandthetacticalscenariodictatesmedicalinterventions.
Themilitaryadagethat"thebestmedicineonthebattlefieldisfiresuperiority"hascausedsignificantconcernintheapplicationofTCCCtocivilianhigh-threatenvironments.
First,lawenforcementpersonnelmustdeployabroaderspec-trumofoptionstosubduethreatsthanthemilitary.
Forexample,theyarerarelyabletoconduct"reconbyfire,"arelim-itedintheapplicationof"suppressivefire,"andevenunderdirectthreat,havewiderresponsibilitiesbeyondtheirownprotectionandthatoftheirteam,includingtheprotectionofvictimsandpreservationofthecommunity.
Second,TECCappliesbeyondSpecialOperationslawenforcement;itisapplicabletoallhigh-riskprehospitalproviders.
TheconceptsofTECCaresalienttoEMSpersonnelrespondingtoanundergroundsubwayblast,afirefighterrapidinterventionteam(RIT)memberinastructuralcollapse,oramedicrespondingtoadynamicschoolshooting.
However,theconceptofbal-ancingthebenefitofimmediatetraumainterventionwiththethreatposedbyanongoingdirectthreatappliesacrossallofthesedisciplines.
Whileunderdirectthreat,TECCprioritiesaretopreventthecasualtyandresponderfromsustainingadditionalin-juries,keeptheresponseteamengagedinneutralizingthethreat,minimizepublicharm,andcontrollife-threateningex-tremityhemorrhage.
Ifinjuredwhileunderdirectthreat,casualtiesshouldattempttoremaininthefight,takecover,providetheirowninitialcare,andcontrolseverehemorrhage.
Theyshouldthenre-engageandassisttheirunitwithneutralizingcontinuedactivethreats.
Teammembersandmedicsinthisphasecanassistcasualtiesinseekingcover,andmayrenderself-aidorbuddy-aidtocontrolseverehemorrhagewhileutilizingtacticsthatminimizethechancethatothermembersoftheteamwillsustainadditionalcasualties.
20TECC-Summer-Fall11-2_TCCC9/5/116:40PMPage106TacticalEmergencyCasualtyCare(TECC):GuidelinesfortheProvisionofPrehospitalTraumaCareinHighThreatEnvironments107CasualtyextractionCasualtyextractionisacriticalprincipleinTECCguidelines,fromthepointofwoundingthroughoutvariousphasesofcare.
Whenexaminingtheevidencebasedtreatmentmodalities,itiscrucialtoremembertheseshouldnotbeperformeduntilthecasualtyandrescuerarebehindcover.
Theadage"wedon'ttreatinthestreet"issometimeslostinthechaosofthemoment;failuretoadheretothiswarningexposescasualtiesandrescuerstofurtherharm.
Effectivepoint-of-woundingex-tractiontechniquesarecriticallinksinthechainofsurvivalforcasualtiesinjuredinhigh-threatenvironments.
Inrealworldevents,theneedforunconventionalextractioncontinuesthroughoutallphasesofcare,toeventualcasualtyhand-offtohigherechelonsofcare.
Thiscouldincludethecapabilityofbreachingintolockdownsituationsforcasualtycollectionpoints(CCP)acquisition,breachingforcasualtyegressthroughrestrictedarea(padlocksystems,drywall,concreteblockwalls,etc),hastymechanicaladvantageorloweringsystemsforcasualtyremovalfrommulti-storystructures,expedientconfinedspace/structuralcollapseresponse,andrescuetactics,techniques,andprocedures(TTPs)forchemical,biological,radiological,nu-clear,andexplosive(BRNE)eventswhenoperationsdictateself-containedbreathingapparatuses(SCBA)utilization.
Whencreatingtheserescueguidelines,itisimportanttofullyunderstandtherelevanceandshortcomingsofcivilian-basedrescuecapabilities,andiftheseelementsareabletodynamicallyadapttoenvironmentalvariableswithonlyorganicassets.
HemorrhagecontrolEarlyhemorrhagecontroliscriticalinoperationalmedicineandtraumamanagement.
Inthehigh-threatenviron-ment,thismedicalfactmustbebalancedwithoperationalriskassessments.
Accordingly,TECCrecommendsrapidlycon-trollingpotentiallylife-threateningextremityhemorrhage.
Tourniquetsarethemosteffective,rapidinterventionavailable.
Hemostaticdressingsrequire3-5minutesofcontinuouspressureandshouldbedeferreduntiltheIndirectThreatCare/Tac-ticalFieldCarephase.
UncontrolledextremityhemorrhagewastheleadingcauseofpreventabledeathinVietnam(9%oftotalcasualties)andremainssointhecurrentconflictsinIraqandAfghanistan(2-3%oftotalcasualties).
7-9Extremitytraumaandexsan-guinationisalsoamajorcauseofpreventabledeathinciviliantrauma.
10,11Increasingly,civilianEMSandhigh-riskmed-icalteamsaredeployingtourniquetsforroutineutilizationindailyoperations.
Thereisstrongevidencesupportingtheefficacyoftourniquetsincontrollinglife-threateninghemorrhage,12,13theimportanceoftourniquetplacementpriortopro-gressiontostatesofshock,andthesafetyoftourniquetuseforperiodslessthan2-4hours.
14TheU.
S.
ArmyInstituteofSurgicalResearch(USAISR)conductedanextensiveseriesoflaboratoryandfieldtourniquetstudiestoidentifytheidealcharacteristicsforafieldtourniquetaswellasdeterminethemosteffectiveexistingcommercialoptions.
ThecriteriaforthetourniquetsaredescribedinTable1.
15Currently,theCombatApplicationTourni-quet(CAT)andtheSpecialOperationsTacticalTourniquet(SOFT-TWide)arethetwomostcommonlyutilizedanddemon-strablyeffectiveoptionsforhigh-riskprehospitalenvironments.
Bothcanbeappliedwithoneortwohandsandhaveshown100%efficacyinabolishingradialandfemoralpulses.
16Othercommercialtourniquetsareavailable,butshouldbeutilizedwithcautionandafterthoroughinvestigation.
DuringtheDT/CUFphaseofCTECC,thetourniquetshouldbeappliedasproximalaspossibleonthelimbtofacilitatespeedandefficacy.
Itmaybeplacedovertheuniform,butcautionshouldbeexercisedtoin-surenoobjectsobstructthecompressionband(e.
g.
,knivesinpocketsordropholster).
Thetimeoftourniquetapplicationshouldbeclearlymarkedonthecasualtyandcommunicatedtoacceptingprovidersduringtransfer.
AirwaymanagementInTCCC,airwaymanagementisdeferreduntilTacticalFieldCare.
However,severalOperatorsandmedicsfeltthatplacingthecasualtyintherecoverypo-sition(i.
e.
,onrightorleftside)toreducelikelihoodofairwayobstructionwasarapidinterventionthatshouldbeconsideredifjudgednecessaryandiftacticallyfeasi-ble.
Anillustrativeexamplewouldbeacombinedshoot-ingandblastincidentwithongoingactiveshooterresponse.
Victimsmaybesufferingfromfacialtraumaandairwayobstructionorbeunconsciousfromblastinjury.
Asthecontactteammovestowardthetarget,rapidlyplacingthecasualtiesintherecoverypositionmaybeaworthwhileinterventionthatquicklysaveslivesbypreventingairwayobstruction.
Table1:characteristicsoftourniquetsutilizedintacticalandhigh-threatenvironments(adaptedfromtheu.
s.
armyinstituteofsurgicalresearch)1.
Completeocclusionofarterialbloodflowinthigh2.
Capableofeasyreleaseandre-application3.
Applicationtime=60seconds4.
Cost:1.
5–2.
0"11.
Shelflifeof10yr20TECC-Summer-Fall11-2_TCCC9/5/116:40PMPage107JournalofSpecialOperationsMedicineVolume11,Edition3/Summer/Fall11108SpinalImmobilizationInisolatedpenetratinginjuriesoftheneck,spinalimmobilizationisrarelyuseful.
17However,therescuershouldbecognizantofcervicalspineprotectionduringextractionifthereisasignificantbluntmechanisminjurysuchasblast,fall,orstructuralcollapse.
Thetacticalsituationshoulddictaterescueractions,andtheriskofimmediatedeathtotherescuershouldbeweighedagainsttheriskoffurtherspinalcordinjuryfromnon-stabilizedextractionofcasualties.
indirEcTThrEaTcarE/TacTicalfiEldcarE(iTc/Tfc)TheITC/TFCarticulatesasetoftraumacareprioritiesrelevantduringhigh-riskoperationsduringperiodswhenthecasualtyandtheproviderareinanareaofhighersecurity,suchasacasualtycollectionpoint(CCP)withcoverand/orconcealment.
AssessmentandtreatmentprioritiesaresimilartothoseunderTCCCTFC:MajorHemorrhagecontrol,Air-way,Breathing/Respirations,Circulation,Head&Hypothermia,andEverythingElse(MARCHE).
Althoughthehigherdegreeofsecurityforthecasualtyandtherespondergenerallyallowforamoredeliberateapproachtoprovidingcasu-altycare,thefirstrespondermustremaincognizantthatatacticaloperationrepresentsadynamicprocessandscenese-curitycanchangeinstantly.
Firstrespondersmustweighthepotentialbenefitsofprovidingmedicalcareagainsttherisksoftheongoingtacticaloperationand/ordelayingopportunitytoevacuatethecasualtyfromthescene.
DisarmtheCasualtyAnimportantaspectofconductingacasualtyassessmentisensuringthatthecasualtydoesnotposeathreattohimselfortherescuer.
Ifthecasualtyhasanydegreeofalteredmentalstatus,ensurecasualtyandrescuersafetybyclear-ingtheirweaponsinanapprovedmethod,orremovingtheirweaponfromtheirpersonentirely.
Respondersshouldmain-tainhighvigilanceforsafetywhendistractiondevicesorotherexplosivedevicesarepresentonthecasualty'skit.
MajorHemorrhageControlMassivehemorrhageistheprimarythreattolifeinmosttraumapatients,andgainingrapidhemorrhagecontrolisthefirstpriority.
Aggressivelyapplyfirmdirectpressuretoawoundsitewhiletheinjuryisexposed,asdirectpres-sureisthemosteffectivemethodforcontrollingbleeding.
Iftherescuercannotholddirectpressureforanextendedpe-riodoftime,othermeasuresofhemorrhagecontrolshouldbeapplied.
AsdiscussedundertheDT/CUFsection,appropriatetourniquetdevicesrepresentthemostrapidandeffectiveoptionforcontrollingextremityhemorrhage.
IfatourniquetwasappliedduringtheDT/CUFphase,itshouldbere-assessedduringtheITC/TFCphaseforeffectivenessornecessity.
Tourniquetsappliedhastilyoveruniformclothingmaynotachieveadequatepressuretooccludearterialbloodflow.
Ahastilyconductedaggressivecasualtymovementfromthepointofinjurytoamoresecurelocationmaydislodgeanotherwiseadequatetourniquet.
Additionally,astourniquetsareappliedmoreliberallyintacticalsituationsforwoundswithapparentsignificanthemorrhage,somewillbeappliedtowoundsthatdonotactuallyrequiretourniquetsfordefinitivehemorrhagecontrol.
Ifthetrainedmedicexaminesthewoundundermoresecureconditionsanddeterminesatourniquetisnotrequired,heorsheshouldapplyanappropriatepressuredressingandreleasethetourniquetslowly,andcarefullyassesstheextremityforappropriatereperfusionand/orsignsofcompartmentsyndromeorvascularcom-promise.
ForongoingextremityhemorrhagenotaddressedduringtheDT/CUFphasethatisamenabletotourniquetap-plication,applythetourniquetdirectlyovertheskinproximaltotheinjuryandtightenuntiladistalpulseisnolongerpalpable.
Eliminatingasmuchdistalbloodflowaspossibleisimportanttoprevent(oratleastminimizepotentialfor)developmentofcompartmentsyndrome.
18-20Softtissueinjuriescanappearmoresevere,butarerarelylife-threateningifexpeditiouslytreated.
Withoutmajorvasculardisruption,manybleedingsofttissueinjuriescanbeadequatelymanagedthroughapplyingappropriatepressuredressings.
Medicaldirectorsshouldstronglyconsiderincorporatingwoundpackingintotheseprotocols,aspackingwithsterilegauzeinadditiontocompressivebandagesprovidesmoresignificanthemorrhage-controlcapabil-itiesthantopicallyapplieddressingsalone.
Majorvascularinjurieswithintheneck,axilla,andgroin(i.
e.
,junctionalzones)arenotamenabletotourniquetapplicationandeffectivepressuredressingsareoftenextremelydifficulttoapply.
Hemostaticdressingsusedbymili-taryforcesdemonstratesuccessfulbleedingcontrolinthesetypesofinjuries.
CombatGauze,akaolin-impregnatedgauzepackingagent,istheprimaryhemostaticagentrecommendedbytheCommitteeonTacticalCombatCasualtyCare.
Manyunitsareutilizingoneoftwochitosan-basedgauzeproducts(ChitogauzeandCeloxGauze)withequallysuc-cessfulresults.
Medicaldirectorsmustensurethatappropriatetacticalprotocolsincorporatingwoundpackingareinplacewhenconsideringtheadditionofthesehemostaticagents,astheyarenotintendedforsimpletopicalapplications.
Somevascularinjurieswithinthesejunctionalzonescannotbecontrolledwithtourniquets,pressuredressings,orhemostaticagents.
Whentacticalsituationsprecluderescuersfrommaintainingprolongeddirectmanualpressure,con-20TECC-Summer-Fall11-2_TCCC9/5/116:40PMPage108TacticalEmergencyCasualtyCare(TECC):GuidelinesfortheProvisionofPrehospitalTraumaCareinHighThreatEnvironments109siderusingmechanicaldevicestoachieveprolongeddirectpressure.
Whenconsideringaddingthesemechanicaldevicestoexistingprotocols,werecommendselectingdevicesthathavebeenclinicallyevaluatedandreceivedFoodandDrugAdministration(FDA)approval.
BreathingCombatdata,aswellascivilianpolicedata,indicatesthattensionpneumothorax,althoughrelativelysimpletotreat,remainsasignificantcauseofpreventabledeath.
21AspartoftheinitialassessmentinITC/TFC,thechestshouldbeex-posedandexaminedthoroughlyforanyopenchestwoundnotpreviouslyaddressed.
InITC/TFC,operationallimitationsoftenmakeitdifficulttoproperlymonitorfordevelopingtensionpneumothoraxusingthetraditionalphysicalsignsofhy-poxia,narrowingpulsepressure,tachycardia,andtrachealdeviation.
Instead,inITC/TFCandotherhigh-riskprehospitalsettings,anypatientwithpenetratingchesttraumathathasprogressiverespiratorydistressshouldbeassumedtohaveade-velopingtensionpneumothoraxandshouldbetreatedwithneedledecompression.
Leavingthecatheterinplaceversusre-movingitafter1-2minutesisamatteroflocalprotocolandpreference.
Inmostcasesthecatheterwillclotoffinafewminutesmakingitnolongereffectiveinevacuatingair.
Theargumentforremovingtheneedleistopreventprovidersfromassumingthatatensionpneumothoraxcannotdevelopbecausethecatheteriscontinuouslyventingthespace.
Theargu-mentagainstremovingthecatheteristhatitisaquickvisuallandmarktoallowforsubsequentneedledecompressions.
Thereisnoneedtoplaceafluttervalveonthecatheterifleftinplace,asitwillnotcreateanopenpneumothorax.
There-sistancecreatedbythesmallinternaldiameterofthe14-gaugecatheterissuchthatairwillmoveinandoutofthelargerdiametermouthandtracheainsteadofthe14-gaugecatheter.
Thepatientwithapenetratingchestwoundneedstobecloselymonitoredfordevelopmentoftensionpneumothorax,especiallyifhe/sherequiredneedledecompression.
TheTECCguidelineappendixdescribestwodifferenttechniquesforneedledecompression.
Circulation/ResuscitationIntravenousfluidresuscitationremainscontroversial,despitegrowingevidencethatusingnon-bloodproductsasprimaryresuscitationfluidsforhemorrhagichypovolemiacontributestoincreasedmorbidityandmortality.
22-25Thedeci-siontoinitiateIVresuscitationshouldbebaseduponthecasualty'sdegreeofbloodlossandshock,aswellasotherfactorssuchasevacuationtimetoadefinitivecarefacility.
Ingeneral,young,healthyadulttraumapatientswithapalpableradialpulseandnormalmentationafterhemorrhagecontroldonotrequireemergentIVfluidtherapy.
PermissivehypovolemicIVfluidresuscitationprotocolshavebeenusedwithgreatsuccessbyseveralmilitaryforcesthroughoutongoingmultipleglobalconflicts.
Arisk-versus-benefitanalysispriortoadministeringIVfluidsshouldbeconductedforanytraumaca-sualty.
ThecurrentCoTCCCguidelinesareincludedasanexampleofahypovolemicprotocolonly.
TheU.
S.
militaryrec-ommendsHextendastheirIVfluidofchoiceasprimarilyforlogisticaladvantages.
Formilitaryforceslackingimmediateresupplycapabilitywhomayexperiencedelaysincasualtyevacuationrangingfrommultiplesofhourstodays,thebene-fitofthedurationoftheintravascularvolumeexpansionseenwiththathetastarch-basedfluidenablestheirpersonneltoop-timizecarriedmedicalsupplies26-28Intheciviliansetting,thesignificantlyhighercostofcolloidsolutionsmustbebalancedagainstthelimitedmedicalbenefits.
HypothermiapreventionandcasualtypackagingHypothermiaintraumapatientsresultsindysfunctionalclottingcascades,acidosisandsubsequentincreasedmor-tality.
HypothermiapreventionbeginsduringITC/TFC.
Casualtiesshouldbemovedtoawarmedlocationifpossible.
Ifpossible,thecasualtyshouldbepackagedutilizingaheatretentionsystematminimum.
Incoldenvironments,theuseofactiveexternalrewarmingmaybebeneficial.
Thereareseveralcommercialheat-producinghypothermiakitsavailableandinusecurrentlybythemilitarythatcanbeconsidered.
Ifunavailable,anythingthatwillretainheat(e.
g.
,dryblankets,bodybags,sparegortexjacket,etc.
)shouldbeapplied.
Inmasscasualtyscenarios,oncethepatienthasbeenmovedtoanareawherethereisnodirectorindirectexter-nallifethreat,primarytriagecanoccurtoidentifycriticalpatientsandsortpatientsintogroupsaccordingtotheirneedforimmediateresources.
ThismayoccurduringtheITC/TFCorduringearlystagesoftheEVAC/TACEVACdependinguponthetacticalscenario.
EvacuaTioncarE/TacTicalEvacuaTioncarE(Evac/TacEvac)EvacuationCare/TacticalEvacuationCare(EVAC/TACEVAC)describesactionstakentocontinueprovidingap-propriatetraumacareduringtransporttodefinitivemedicalcarewhenthereisgenerallyreducedthreattothepatientandmedicalprovider.
AnexampleofEVAC/TACEVACCarewouldbethecareprovidedintheTriage/Treatmentareaorase-cureCCPduringamasscasualtyeventwhilethepatientsarewaitingfortransporttoahigherlevelofcare.
Inmanycivilianscenarios,thisphaseofcaremaybelimitedintheprehospitalsetting.
Alargepercentageofcivil-ianhigh-riskscenarioswillhaveresourcesandcircumstancesthatallowforthepatienttoberapidlytransferredwithout20TECC-Summer-Fall11-2_TCCC9/5/116:40PMPage109JournalofSpecialOperationsMedicineVolume11,Edition3/Summer/Fall11110scenedelaydirectlytoahighlevelfixedmedicalcenter.
Inthesecases,thepatientessentiallymovesfromITC/TFCdi-rectlyintothetraumabay.
However,ifthereisanydelayintransferduetothetacticalscenario,logistics,orsheervol-umeofpatients(e.
g.
,mass-casualtyincidents(MCI)oriftheactualtransferrequiresalongtransittime,thentheapplicationoftheguidelinesofEVAC/TACEVACbecomeevenmoreimportantProvidersinemergencydepartmentsandtraumacentersshouldbefamiliarwiththeEVAC/TACEVACguide-lines.
Thereareanecdotalpublishedcasereportsofpre-hospitalprovidersusingappropriateequipmentandinterventions,suchasacommercialtourniquet,thataremetwithdisbeliefandconfusiononthepartofthecivilianclinicalstaffinthetraumabay.
Theseprovidersmusthavebaselinefamiliaritywiththeguidelinesandproceduresoccurringoutsideoftheirfacility,andmusthaveanunderstandingofhowtoassessandutilizeprehospitalinterventions.
Intheciviliansetting,evacuationisgenerallyviagroundorhelicopter-basedEMS/criticalcareplatforms.
De-spitetheusualmethods,EVAC/TACEVACmustaccountforhastyevacuationwithvehiclesofopportunity(e.
g.
,policecar,sportutilityvehicle(SUV),armoredvehicle,etc.
).
Thissectionprimarilydiscussesoptionsforcareonplatformswitheithersecurespaceoradditionalcapabilities.
IndividualunitsshouldevaluatetheirevacuationassetsandcustomizetheirTTPstoaccountformission-specificlimitations.
Re-assessthecasualtyImmediatelyassessthepatientandre-assessallinterventionsthatwereappliedinpreviousphasesofcare.
Theinterventionswerelikelyappliedinahastyfashion,mayhaveloosenedduringmovementofthepatient,andmaynolongerbeeffective.
TheproviderinEVAC/TACEVACshouldtakethetimetolookatallinterventionsandimmediatelyaddressanythatappeartobeineffectiveandcreatingalife-threateningsituation,orasituationthatcanleadtore-injuryorden-igrationinclinicalcondition.
AirwayInEVAC/TACEVAC,ifallmajorlifethreateninghemorrhagehasbeencontrolledinITC/TFC,theprovidershouldmovedirectlytocontrollingandmaintainingtheairway.
Withdecreasedexternalrisktotheproviderandpatient,thisphaseofcarecanbeapproachedinamoretraditionalsenseofAirway-Breathing-Circulation.
Thebasicairwayin-terventionsremainthesamehereasinpreviousphases,withtheadditionalconsiderationforrapidsequenceintubation(RSI).
TheuseofRSIandendotrachealintubationaretimeandresourceintensive.
Theprocessrequiresthattheproviderconcentratesontheprocedureandairway,sacrificingsituationalawareness.
Thus,itisonlyintroducedasatreatmentconsiderationinthisphasewhentheexternalthreatriskismitigated.
Thisinterventionismostlikelytoonlybeavail-ableifthecasualtyistransportedonaplatformstaffedwithadvancedproviders(i.
e.
,physicians,criticalcarenurse,orparamedics).
SpinalimmobilizationmayhaveamoreimportantroleinEVAC/TACEVAC.
InEVAC/TACEVAC,therisk-benefitratioforspinalimmobilizationleanstowardbenefit;thus,ifavailableimmobilizationshouldbeimplementedforanypatientwithhardphysicalsignsofneurologicinjuryandforanypatientwithahigh-riskmechanism.
Inthisphase,considerationshouldbegiventoclearingthec-spineclinicallyusingeithertheNEXUSorCanadianc-spinecriteria.
Thiseasilyappliedcriterionhasbecomestandardofcareinemergencydepartmentsandcanidentifypatientsthatdonotneedimmobilizationwithalmost100%sensitivity.
Cautionshouldbeusedwhenapplyingthecriteriatopatientsovertheageof65years,asthereisahigherriskofoccultinjuryinthisagegroup.
Whiletreatmentwillbeguidedbylocalprotocols,delayingevacuationforpatientsinextremiswithpenetratingneckinjureswhileperformingmeticulousspinalimmobilizationmustbebalancedagainstgettingthepatienttodefinitivecare.
BreathingTheinterventionsfromITC/TFCarecontinuedintoEVAC/TACEVAC.
Duringevacuation,additionalmoni-toringsuchaspulseoximetryaremoreroutinelyavailable.
Theseadjunctsshouldbeusedtoprovideadditionalinfor-mationontherespiratorystatusofthecasualty.
Notethatoxygendesaturationisarelativelylatesignofrespiratorycompromise,andnewertechniquessuchasnasalendtidalCO2mayprovidemoretimelyinformation.
Althoughmanytraumapatients,suchasthosewithisolatedmusculoskeletalinjury,donotrequiresupplemen-taloxygen,inthisphaseoxygenshouldbereadilyavailableinalmostallcivilianoperationalsettingsandshouldbelib-erallyapplied.
Inmasscasualtysettingswhereresourcesarescarce,supplementaloxygencanbereservedforpatientswithinjuriestotherespiratorysystemcausingimpairedoxygenation,casualtiesinshock,casualtieswithheadinjury,un-consciouscasualties,andanycasualtywithlowoxygensaturationbypulseoximetry.
Chesttubeplacementshouldbeconsideredonanypatientwhorequiresrepeatedneedledecompressions,isbeingairevacuated,orifthereisalongdelayintransporttodefinitivecare.
Thisisanadvancedsurgicalprocedurethatrequirespropertraining,medicaloversightandappropriatelocalprotocols.
Chesttubesalwaysrequireaone-wayvalve.
20TECC-Summer-Fall11-2_TCCC9/5/116:40PMPage110TacticalEmergencyCasualtyCare(TECC):GuidelinesfortheProvisionofPrehospitalTraumaCareinHighThreatEnvironments111BleedingInEVAC/TACEVACphase,allwoundsshouldbefullyexposedandevaluatedtoassessforefficacyofinterven-tionsappliedinpriorphasesofcare.
Thepatientshouldbeexposed,includingremovalofprotectivegearifpresent,toallowthoroughevaluationformissedwounds.
Thegearshouldbeexaminedforsignsofdamageandkeptwiththepatient.
At-tentionmustbepaidtopreventhypothermia.
Anyuntreatedmajorextremitywoundoranyextremitywoundwithbleed-inguncontrolledbypriorinterventionsshouldbetreatedusingatourniquetapplied2-3inchesabovethewoundorbyusinganappropriatepressuredressingwithdeepwoundpacking.
Alltourniquetsshouldbere-evaluatedbothforefficacyandfornecessity.
Thecomplicationsoftourniquetsarealldirectlyrelatedtolengthoftimeinplace;thus,thesoonertheycanberemoved,thelowerthecomplicationrates.
Sev-eralstudiesshownocomplicationsintourniquetsleftinplaceupto120minutes.
29Althoughtherearecertainlymassca-sualtyandausterescenariosinwhichtheremaybeadelaytodefinitivecareofgreaterthan120minutes,inhighriskscenarioswithalimitednumberofcasualties,thepatientshouldbeindefinitivecareatafixedfacilitywellwithinthetwohourwindow.
Thedecisioninthisphasethusbecomeswhethertoattempttodowngrade/removethetourniquetortoleavewellenoughaloneuntildefinitivecare.
Ifthetourniquetisnecessaryandeffective,andthecasualtywillbequicklyevac-uatedtoadefinitivecarefacility,itshouldremaininplace.
However,ifthereisananticipatedsignificantdelayintrans-fertodefinitivecare,considertransitioningthetourniquettoapressuredressing.
BeforeanyeffectivetourniquetisremovedonapatientwhohasreceivedIVfluidforshock,thepatientmustbeassessedclinicallyforpositiveresponsestointerventions.
Tomoveatourniquetdistallytoasite2-3inchesabovethewound,anewtourniquetshouldbeplacedinthenewlocation.
Onceproperlyapplied,thepriortourniquetcanbeloos-ened.
Todowngradeatourniquettoapressuredressing,anappropriatepressuredressingwithhemostaticornon-hemo-staticdeepwoundpackshouldbeappliedtothewound.
Onceapplied,thetourniquetshouldbeloosenedandthewoundshouldbeexaminedforsignsofbleeding.
Ifbleeding,thetourniquetisre-tightenedandthepressuredressingisrein-forced.
Ifbleedingoccurswhenthetourniquetisloosenedafterreinforcement,thetourniquetisreappliedandleftinplace.
Ifthereisnobleedingoncethetourniquetisloosened,itisleftinplace.
Anydistalpulsenotedinalimbwithaneededtourniquetinplaceshouldbeaddressedbyadditionaltighteningorbyapplicationofasecondtourniquetside-by-side(ideallyproximaltothefirsttourniquet)tothefirstinordertoapplyawiderbaseofpressuretothesupplyingvasculature.
Alltourniquetsneedtobeclearlymarkedwithindeliblemarkershow-ingthetimeofapplication.
Hemostaticagentsshouldbeutilizedasinpriorphasesforanysignificantbleedinginwoundslocatedinanatomicareasnotamenabletotourniquetplacement,orfordowngradingoftourniquets.
Thecurrent,recommendedfourth-gener-ationhemostaticagentsareprimarilyintheformofimpregnatedgauze.
IntravenousaccessandresuscitationAllpatientswithtruncalinjury,shockorsignsofimpendingshockshouldhavean18-gaugeIVsalinelockplaced.
Theflowratesthroughan18-gaugearenotsignificantlylowerthanthe16-or14-gaugeIVneedlesandareeasiertoplaceinthehypotensivecasualtyintheuncontrolledfieldsetting.
Thecasualtyshouldbeassessedforhemorrhagicshock,ei-therwithbloodpressuremonitoringor,ifunavailable,withassessmentofmentalstatusandperipheralpulses.
Mentalsta-tus,intheabsenceoftraumaticheadinjury,isthemosteffectivemarkerofperfusionandshock;this,alongwiththepresenceandcharacterofperipheralpulsesprovidesthecaregiverwithanexcellentmethodtomonitorforhemorrhagicshock.
Ifthepatientisnotinshock,noIVfluidsareimmediatelynecessary.
Oralfluidsmaybeconsideredincasualtieswhoareconscious,canswallow,andhasnoinjurythatwouldrequireemergentsurgery.
Oralfluidsshouldalsobecon-sideredifthereisasignificantdelayinevacuationtocare,astheywillhelpcomfortthepatient.
Forcasualtiesexhibitingsignsofhemorrhagicshock,bloodproductsshouldbeconsideredifreadilyavailablewithanappropriateproviderandapprovedmedicalprotocol.
Severalstudiesoncombatwoundedhaveshownthesuperioref-fectofresuscitationwithbloodproductsina1:1ratioofplasmatopackedredbloodcellsand/orwholebloodwhencom-paredtotraditionalresuscitationwithintravenousfluids.
30,31Plasmarapidlyaddressesthecoagulopathyoftrauma,essentiallyaddressingonearmofthelethaltriadofhypothermia-coagulopathy-acidosis.
Althoughmorestudiesareneededinthecivilianpre-hospitalsetting,themilitarydataisstrongenoughtoendorsethisrecommendation.
32,33Ifbloodprod-uctsarenotavailableornotapprovedunderlocalprotocols,useofHextendcolloidorappropriatecrystalloidin500ccbo-lusesevery30minutestomaintainhypotensiveresuscitationisrecommended.
Thegoalsystolicis80-90mmHgandimprovementandmentalstatus.
Hextendshouldbelimitedto1000cctotal.
Hypotensiveresuscitationshouldbeavoidedincasualtieswithconcomitantheadinjury.
InTBI,resuscitativefluidblousesshouldbeadministeredtomaintainthegoalsystolicbloodpressureofatleast90mmHgorpalpableradialpulse.
Anypatientwithasuspectedtraumaticbraininjurywhoisnotinshockshouldbepositionedwiththeheadelevatedto30degrees.
20TECC-Summer-Fall11-2_TCCC9/5/116:40PMPage111JournalofSpecialOperationsMedicineVolume11,Edition3/Summer/Fall11112PreventionofhypothermiaAlleffortsshouldbemadeinEVAC/TACEVACphasetopreventthedevelopmentofhypothermiawhilepack-agingcasualtiesandduringtransporttodefinitivecare.
Wetclothingshouldberemovedandreplacedwithdryclothing(ifavailable),andthepatientshouldbeplacedonavaporbarriertopreventconductiveheatlosstothegroundorothersurfaces.
WarmedIVfluidsarepreferredforresuscitation.
Itisimportantforproviderstomaintainthisvigilanceagainsthypothermiawhileenroutetodefinitivecare,especiallyduringairtransportwherecabintemperaturesareoftenlowerthanthetemperatureatthepointofcasualtycollection.
MonitoringAvailablemonitoringincludingend-tidalCO2forintubatedpatientsshouldbeinstitutedwhilewaitinganddur-ingtransporttodefinitivecare.
Allvitalsignsshouldberecordedfortrendingandcontinuityofcare.
Withmultipleca-sualtiesornoisyenvironments,pulseoximetrycanbeausefuladjuncttogiveacontinuousvisualreportingofpulse(aswellasoxygensaturation).
Providersshouldensurethatpulseoximetryismeasuredonunaffectedoruninjuredlimbstogainaccuratereadings.
Re-assessandre-triageAstimepermits,aproperhead-to-toe,front-to-backsecondarysurveyshouldbeperformed.
Anysignificantin-juriesnotpreviouslyaddressedshouldbetreatedincludingsplintingoflongboneorjointinjuriesandapplicationofpelvicbindingtechniques.
Asecondarytriageofthepatientshouldbepreformedtodeterminemodeanddestinationforevacuationtodefinitivecare.
AnalgesiaandantibioticsInEVAC/TACEVAC,considerationsforthecasualtytocontinuethemissionarelesssignificant.
However,incertainscenarios,itmaybenecessaryforthecasualtytomaintainmentalfacultiesandremainoperationallyactive.
Inthesescenariosandincaseswherethecasualtyisexperiencingonlymildtomoderatepain,oralorIVnon-narcoticmed-icationsareappropriate.
Incasesofmoderatetoseverepain,inadditiontooralandIVnon-narcoticanalgesics,narcoticsareappropri-ateandshouldbeadministeredinanyformandthentitratedtoeffect.
Itisimportanttonotethattheonsetofactionforintramuscular(IM)injectionofnarcoticscanbeupto45-60minutessothemedicshouldexercisecautionandavoidstacking.
Ifutilizingnarcotics,theprovidermustmonitorcloselyforadverseeffectsandshouldhavenaloxoneavailable.
Additionally,considerationshouldbegiventohavinganti-emeticsavailablewhenusingnarcoticsforpaincontrol.
Dur-ingevacuation,itisprudentutilizeavailableelectronicnon-invasivemonitoringifdeliveringnarcoticanalgesia.
Theadministrationofantibioticsisnotatraditionalpre-hospitalintervention.
However,inhigh-riskopera-tionalsettingssuchaswildernessrescueorausterescenarioswheretheremaybeaverysignificantdelayinevacuationtocare,earlyadministrationofantibioticsforpenetratingwoundsandeyeinjuriesmaybebeneficialtooutcomes.
Inthesespecificcases,thepotentialneedshouldbeanticipatedandappropriatemedicaloversightshouldbeinvolved.
BurnsBurncareinEVAC/TACEVACphaseisacontinuationofcareinitiatedinITC/TFCphase.
Earlyaggressiveair-waycontroland/orRSIshouldbeinitiatedforanycasualtywithsignsofinhalationalinjury.
TotalBodySurfaceArea(TBSA)shouldbecalculatedandthepatientshouldbecoveredwithdry,steriledressings.
Ifpossible,dressingsandcon-certedeffortstopreventhypothermiashouldbeinitiated.
Inmasscasualtysituationswheredelaytoevacuationmaybesignificant,considerationmaybegiventoutilizingcommercialburndressingsforpaincontrolincasualtieswithburnslessthan20%TBSA.
Theriskofinducedhypothermiafromcommercialburndressingsincreaseswithlargerburnsandthusshouldbeavoided.
Burnresuscitationshouldbeinitiatedaccordingtolocalprotocol.
Althoughburnpatientswilleventuallyrequiresignificantamountsoffluids,thecalculatedrequirementsareforthefirst8and24hoursandcanbeeasilymadeupusinghighvolumeinfusersoncethepatienthasreacheddefinitivecare;thus,excessivefluidsdonotneedtobeimmediatelyinitiatedintheEVAC/TACEVACphase.
Preventionofhypothermiaandhypotensiveresuscita-tionforhemorrhagicshocktakesclearprecedenceoverburnfluidresuscitationinthefield.
Aggressiveanalgesicuseforburncasualtiesisappropriate.
AdditionalprioritiesTherescuermustpreparecasualtiesformovementwithconsiderationsgiventoenvironmentalfactorsandotherevacuationproceduressuchasverticallifts.
AtallpointsthroughoutthecareofthepatientintheEVAC/TACEVACphase,thecasualtyshouldbeencouragedandreassured,eveniftheyareunconscious.
Allinformationandproceduresshouldbeexplainedinrealtime,andemphasisshouldbeplacedonkeepingthecasualtyfullyinformed.
20TECC-Summer-Fall11-2_TCCC9/5/116:40PMPage112TacticalEmergencyCasualtyCare(TECC):GuidelinesfortheProvisionofPrehospitalTraumaCareinHighThreatEnvironments113Documentationofcareneedstobecompletedinaccordancetolocalprotocols,ideallyintheformofanapprovedstandardizedlocalcasualtycarecardforconsistency.
Allassessments,treatmentsandmedicationsrendered,trendsandchangesinpatientstatusneedtobeaccuratelydocumentedandpassedtothedefinitivecarefacilitytoprovideeffectivecon-tinuityofcare.
Cardiopulmonaryresuscitation(CPR)mayhavealargerroleduringtheevacuationphaseespeciallyforpatientswithelectrocution,hypothermia,non-traumaticarrestorneardrowning.
Ifresourcesareavailableandtransittimeisshort,CPRmaybeappropriateintheabovesettings.
conclusionTheTacticalEmergencyCasualtyCare(TECC)guidelinesofferasetofprinciplesfortraumamanagementinhigh-threatprehospitalenvironmentsbaseduponthehardlessonslearnedfromadecadeofwar.
TECCdefineswhatshouldbedoneandwhenitshouldbedonetostabilizethecasualtyinthecivilianarenauntiltheriskcanbeeliminatedandthecasualtycanbetreatedatadefinitivecarefacility.
TheTECCguidelinesrepresentatreatmentframeworkthatacceptsmit-igatedriskwhileprovidingasignificantlifesavingbenefit.
BaseduponthehardworkoftheCommitteeforTCCCandthesacrificesofAmericanwarfighters,theindicationsandapplicationsforTECCextendwellbeyondtacticallawenforcement.
'Tactical'shouldnotimplythattheguidelinesareonlyforLawEnforcementoperations.
Tacticalinthissensemeansoperational,astacticsareperformedonthefiregroundandinotheroperationalsettingseveryday.
TheLawEnforcement(LE)andspecialweaponsandtactics(SWAT)operationsareacriticalareaforimplementation.
But,theyarenottheonlyend-users.
TECCshouldbeutilizedinanyhighriskand/oraustereoperationalsettingwheretherisk-benefitratiotoprovidersandpatientsdrivesdecision-making,in-cluding,butnotlimitedto:activeshooterresponse,improvisedexplosivedevice(IED)andblastresponse,CBRNEandter-rorism-relatedevents,anymasscasualty,wildernessandausteresettingsandrescue,andevenintraditionaltraumaresponse.
TheinitialTECCguidelinesarebaseduponanecdotalexperiencefromwarriors,best-practicerecommendationsfromcombatmedics,inputfromphysicians,discussionswithdomesticfirstrespondersandscientificevaluationfromouracademicinstitutions.
AswithTCCC,theTECCguidelineswillevolve.
TheCommitteeforTacticalEmergencyCasualtyCarewillcontinuetoupdatetheguidelinesthroughJournalofSpecialOperationsMedicine,theC-TECCwebsiteandincollaborationwiththeSpecialOperationsMedicalAssociation(SOMA).
SpecialThankstoCAPTFrankButlerforhisguidance,theCoTCCCfortheircontinueddedicationtothewarfighter,andtothemenandwomeninharm'sway;onthebattlefieldandinourstreets.
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20TECC-Summer-Fall11-2_TCCC9/5/116:40PMPage114TacticalEmergencyCasualtyCare(TECC)Guidelines115TacTicalEmErgEncycasualTycarE(TEcc)guidElinEsdirEcTThrEaTcarE/carEundErfirE(dT/cuf)goals:1.
Accomplishthemissionwithminimalcasualties2.
Preventthecasualtyfromsustainingadditionalinjuries3.
Keepresponseteammaximallyengagedinneutralizingtheexistingthreat(e.
g.
activeshooter,unstablebuilding,confinedspaceHAZMAT,etc.
)4.
MinimizepublicharmPrinciples:1.
Establishtacticalsupremacyanddeferindepthmedicalinterventionsifengagedinongoingdirectthreat(e.
g.
,activefirefight,unstablebuildingcollapse,dynamicexplosivescenario,etc.
).
2.
Threatmitigationtechniqueswillminimizerisktocasualtyandtoprovider.
3.
Minimaltraumainterventionsarewarranted.
4.
Considerhemorrhagecontrola.
TQapplicationistheprimary"medical"interventiontobeconsideredinCUF/DirectThreat.
b.
Considerinstructingcasualtytoapplydirectpressuretothewoundifnotourniquetavailableorapplicationisnottacticallyfeasible.
5.
Considerquicklyplacingordirectingcasualtytobeplacedinpositiontoprotectairway.
guidelines:1.
Mitigatethethreatandtakecover(e.
g.
Returnfire,utilizelesslethaltechnology,assumeanoverwhelmingforcepos-ture,extractionfromimmediatestructuralcollapse,etc.
).
2.
Directthecasualtytostayengagedinoperationifappropriate.
3.
Directthecasualtytomovetocoverandapplyselfaidifable.
4.
CasualtyExtractiona.
Ifacasualtycanmovetosafety,theyshouldbeinstructedtodoso.
b.
Ifacasualtyisunresponsive,thescenecommanderorteamleadershouldweightherisksandbenefitsofarescueattemptintermsofmanpowerandlikelihoodofsuccess.
Remotemedicalassessmenttech-niquesshouldbeconsidered.
c.
Ifthecasualtyisresponsivebutcannotmove,atacticallyfeasiblerescueplanshouldbedevised.
d.
Recognizethatthreatsaredynamicandmaybeongoing,requiringcontinuousthreatassessments.
5.
Stoplifethreateningexternalhemorrhageiftacticallyfeasible:a.
Directcasualtytoapplyeffectivetourniquetifableb.
Applythetourniquetovertheclothingasproximal—highonthelimb—aspossible.
c.
Tightenuntilcessationofbleedingandmovetosafety.
ConsidermovingtosafetypriortoapplicationoftheTQifthesituationwarrants.
d.
Tourniquetshouldbereadilyavailableandaccessiblewitheitherhande.
Considerinstructingcasualtytoapplydirectpressuretothewoundifnotourniquetavailableorapplicationisnottacticallyfeasiblef.
Considerquicklyplacingcasualty,ordirectingthecasualtytobeplaced,inpositiontoprotectairwayiftacticallyfeasibleskillsets:1.
Tourniquetapplicationa.
ConsiderPACEMethodology-Primary,Alternative,Contingency,Emergencyb.
Commerciallyavailabletourniquetsc.
Fieldexpedienttourniquets2.
Tacticalcasualtyextraction3.
Rapidplacementinrecoverposition20TECC-Summer-Fall11-2_TCCC9/5/116:40PMPage115JournalofSpecialOperationsMedicineVolume11,Edition3/Summer/Fall11116indirEcTThrEaTcarE/TacTicalfiEldcarE(iTc/Tfc)goals:1.
Goals1-4aswithDT/CUFcare2.
Stabilizethecasualtyasrequiredtopermitsafeextractiontodedicatedtreatmentsectorormedicalevacuationassets.
Principles:1.
Maintaintacticalsupremacyandcompletetheoverallmission.
2.
Asapplicable,ensuresafetyofbothfirstrespondersandcasualtiesbyrenderingweaponssafeand/orrenderinganyad-juncttacticalgearsafeforhandling(flashbangs,gascanisters,etc).
3.
Conductdedicatedpatientassessmentandinitiateappropriatelife-savinginterventionsasoutlinedintheITC/TFCguidelines.
DONOTDELAYcasualtyextraction/evacuationfornon-lifesavinginterventions.
4.
Considerestablishingacasualtycollectionpointifmultiplecasualtiesareencountered.
5.
Establishcommunicationwiththetacticaland/orcommandelementandrequestorverifyinitiationofcasualtyextrac-tion/evacuation.
6.
Preparecasualtiesforextractionanddocumentcarerenderedforcontinuityofcarepurposes.
guidelines:1.
LawEnforcementCasualtiesshouldhaveweaponsmadesafeoncethethreatisneutralizedorifmentalstatusisaltered.
2.
Bleeding:a.
Assessforunrecognizedhemorrhageandcontrolallsourcesofmajorbleeding:i.
Ifnotalreadydone,useatourniquetoranappropriatepressuredressingwithdeepwoundpackingtocontrollife-threateningexternalhemorrhagethatisanatomicallyamenabletosuchtreatment.
-Applythetourniquetovertheclothingasproximal—highonthelimb—aspossible,orifabletofullyexposeandevaluatethewound,applydirectlytotheskin2-3inchesabovewound.
-Foranytraumatictotalorpartialamputation,atourniquetshouldbeappliedregardlessofbleeding.
b.
Forcompressiblehemorrhagenotamenabletotourniquetuse,orasanadjuncttotourniquetremoval(ifevacuationtimeisanticipatedtobelongerthantwohours),applyahemostaticagentinaccordancewiththedirectionsforitsuseandanappropriatepressurebandage.
Beforereleasinganytourniquetonacasu-altywhohasreceivedIVfluidresuscitationforhemorrhagicshock,ensureapositiveresponsetoresusci-tationefforts(i.
e.
,aperipheralpulsenormalincharacterandnormalmentation).
c.
Reassessalltourniquetsthatwereappliedduringpreviousphasesofcare.
Considerexposingtheinjuryanddeterminingifatourniquetisneeded.
TourniquetsappliedhastilyduringDT/CUFphasethatarede-terminedtobebothnecessaryandeffectiveincontrollinghemorrhageshouldremaininplaceifthecasu-altycanberapidlyevacuatedtodefinitivemedicalcare.
Ifineffectiveincontrollinghemorrhageorifthereisanypotentialdelayinevacuationtocare,exposethewoundfully,identifyanappropriatelocation2-3inchesabovetheinjury,andapplyanewtourniquetdirectlytotheskin.
Onceproperlyapplied,thepriortourniquetcanbeloosened.
Ifatourniquetisnotneeded,useothertechniquestocontrolbleedingandremovethetourniquet.
d.
Whentimeandthetacticalsituationpermit,adistalpulsecheckshouldbeaccomplishedonanylimbwhereatourniquetisapplied.
Ifadistalpulseisstillpresent,consideradditionaltighteningofthetourni-quetortheuseofasecondtourniquet,sidebysideandproximaltothefirst,toeliminatethedistalpulse.
e.
Exposeandclearlymarkalltourniquetsiteswiththetimeoftourniquetapplication.
3.
AirwayManagement:a.
Unconsciouscasualtywithoutairwayobstruction:i.
Chinliftorjawthrustmaneuverii.
Nasopharyngealairwayiii.
Placecasualtyintherecoverypositionb.
Casualtywithairwayobstructionorimpendingairwayobstruction:i.
Chinliftorjawthrustmaneuverii.
Nasopharyngealairwayiii.
Allowcasualtytoassumepositionthatbestprotectstheairway-includingsittingupiv.
Placeunconsciouscasualtyintherecoveryposition20TECC-Summer-Fall11-2_TCCC9/5/116:40PMPage116TacticalEmergencyCasualtyCare(TECC)Guidelines117c.
Ifpreviousmeasuresunsuccessful:i.
Surgicalcricothyroidotomy(withlidocaineifconscious)ii.
Oro/nasotrachealintubationiii.
ConsiderSupraglotticDevices(e.
g.
KingLT,CombiTube,orLMA)perprotocol.
d.
Considerapplyingoxygenifavailable4.
Breathing:a.
Allopenand/orsuckingchestwoundsshouldbetreatedbyimmediatelyapplyinganocclusivematerialtocoverthedefectandsecuringitinplace.
Monitorthecasualtyforthepotentialdevelopmentofasubsequenttensionpneumothorax.
b.
Inacasualtywithprogressiverespiratorydistressandknownorsuspectedtorsotrauma,consideraten-sionpneumothoraxanddecompressthechestonthesideoftheinjurywitha14-gauge,3.
25inchnee-dle/catheterunitinserted:i.
Inthesecondintercostalspaceatthemidclavicularline.
Ensurethattheneedleentryintothechestislateraltothenipplelineandisnotdirectedtowardstheheart.
ii.
Ifproperlytrained,consideralateraldecompression,insertingtheneedleinthe2-4thintercostalsspace,anteriortothemid-axillarylineontheinjuredside.
5.
Intravenous(IV)access:a.
Startan18-gaugeIVsalinelockifindicatedb.
IfresuscitationisrequiredandIVaccessisnotobtainable,usetheintraosseous(IO)route(peragencyprotocol).
6.
Fluidresuscitation:Assessforhemorrhagicshock;alteredmentalstatus(intheabsenceofheadinjury)andweakorabsentperipheralpulsesarethebestfieldindicatorsofshock.
a.
Ifnotinshock:i.
NoIVfluidsnecessaryii.
POfluidspermissibleif:a.
Conscious,canswallow,andhasnoinjuryrequiringpotentialsurgicalinterventionb.
Ifconfirmedlongdelayinevacuationtocareb.
Ifinshock:i.
AdministerappropriateIVfluidbolus(500ccNS/LR/Hextend)andre-assesscasualty.
Repeatbolusonceafter30minutesifstillinshock.
ii.
IfacasualtywithanalteredmentalstatusduetosuspectedTBIhasaweakorabsentperipheralpulse,resuscitateasnecessarytomaintainadesiredsystolicbloodpressureof90mmHgorapalpableradialpulse.
7.
Preventionofhypothermia:a.
Minimizecasualty'sexposuretotheelements.
Keepprotectivegearonorwiththecasualtyiffeasible.
b.
Replacewetclothingwithdryifpossible.
Placethecasualtyontoaninsulatedsurfaceassoonaspossi-ble.
c.
Coverthecasualtywithcommercialwarmingdevice,dryblankets,poncholiners,sleepingbags,oranythingthatwillretainheatandkeepthecasualtydry.
d.
WarmfluidsarepreferredifIVfluidsarerequired.
8.
PenetratingEyeTrauma:Ifapenetratingeyeinjuryisnotedorsuspected:a.
Performarapidfieldtestofvisualacuity.
b.
Covertheeyewitharigideyeshield(NOTapressurepatch).
Ifacommercialeyeshieldisnotavail-able,usecasualty'seyeprotectiondeviceoranythingthatwillpreventexternalpressurefrombeingap-pliedtotheinjuredeye.
9.
Reassesscasualty:a.
Completesecondarysurveycheckingforadditionalinjuries.
Inspectanddressknownwoundsthatwerepreviouslydeferred.
b.
Considersplintingknown/suspectedfracturetoincludeapplyingpelvicbindingtechniquesforsus-pectedpelvicfractures.
10.
Provideanalgesiaasnecessary.
a.
Abletocontinuemission:i.
Consideroralnon-narcoticmedicationssuchasTylenolb.
Unabletocontinuemission:i.
Consideroralnon-narcoticmedicationsformildtomoderatepain20TECC-Summer-Fall11-2_TCCC9/5/116:40PMPage117JournalofSpecialOperationsMedicineVolume11,Edition3/Summer/Fall11118ii.
Consideruseoforal/intra-nasal/IV/IOnarcoticmedications(hydrocodone,oxycodone,transmucosalfentanylcitrate,etc.
)formoderatetoseverepainiii.
Consideradjunctadministrationofanti-emeticmedicinesNote:Havenaloxonereadilyavailablewheneveradministeringopiatesiv.
Monitorforadverseeffectssuchasrespiratorydepressionorhypotentension.
11.
Antibiotics:Considerinitiatingantibioticadministrationforcasualtieswithopenwoundsandpenetratingeyeinjurywhenevacuationtodefinitivecareissignificantlydelayedorinfeasible.
Thisisgenerallydeterminedinthemissionplanningphaseandrequiresmedicaloversight.
12.
Burns:a.
Facialburns,especiallythosethatoccurinclosedspaces,maybeassociatedwithinhalationinjury.
Ag-gressivelymonitorairwaystatusandoxygensaturationinsuchpatientsandconsiderearlydefinitiveair-waymanagementforrespiratorydistressoroxygendesaturation.
b.
Estimatetotalbodysurfacearea(TBSA)burnedtothenearest10%usingtheappropriatelocallyap-provedburncalculationformula.
c.
Covertheburnareawithdry,steriledressingsandinitiatemeasurestopreventheatlossandhypother-mia.
d.
Ifburnsaregreaterthan20%ofTotalBodySurfaceArea,fluidresuscitationshouldbeinitiatedundermedicalcontrolassoonasIV/IOaccessisestablished.
Ifhemorrhagicshockisalsopresent,resuscita-tionforhemorrhagicshocktakesprecedenceoverresuscitationforburnshockaspertheguidelines.
e.
Allpreviouslydescribedcasualtycareinterventionscanbeperformedonorthroughburnedskininaburncasualty.
f.
AnalgesiainaccordancewithTECCguidelinesmaybeadministered.
g.
Aggressivelyacttopreventhypothermiaforburnsgreaterthan20%TBSA.
13.
Monitoring:Applyappropriatemonitoringdevicesand/ordiagnosticequipmentifavailable.
Obtainandrecordvitalsigns.
14.
Preparecasualtyformovement:Considerenvironmentalfactorsforsafeandexpeditiousevacuation.
Securecasu-altytoamovementassistdevicewhenavailable.
Ifverticalextractionrequired,ensurecasualtysecuredwithinap-propriateharness,equipmentassembled,andanchorpointsidentified.
15.
Communicatewiththecasualtyifpossible.
Encourage,reassureandexplaincare.
16.
Cardiopulmonaryresuscitation(CPR)withinatacticalenvironmentforvictimsofblastorpenetratingtraumawhohavenopulse,noventilations,andnoothersignsoflifewillnotbesuccessfulandshouldnotbeattempted.
Incer-taincircumstance,suchaselectrocution,drowning,atraumaticarrest,orhypothermia,performingCPRmaybeofbenefitandshouldbeconsideredinthecontextofthetacticalsituation.
17.
DocumentationofCare:Documentclinicalassessments,treatmentsrendered,andchangesinthecasualty'sstatusinaccordancewithlocalprotocol.
Considerimplementingacasualtycarecardthatcanbequicklyandeasilycompletedbynon-medicalfirstresponders.
Forwardthisinformationwiththecasualtytothenextlevelofcare.
skillset:1.
hemorrhagecontrol:a.
ApplyTourniquetb.
ApplyDirectPressurec.
ApplyPressureDressingd.
ApplyWoundPackinge.
ApplyHemostaticAgent2.
airway:a.
ApplyManualManeuvers(chinlift,jawthrust,recoveryposition)b.
InsertNasalpharyngealairwayc.
InsertSupraglotticDevice(LMA,King-LT,Combitube,etc)d.
PerformTrachealIntubatione.
PerformSurgicalCricothyrotomy3.
Breathing:a.
Applicationofeffectiveocclusivechestsealb.
AssistVentilationswithBagValveMaskc.
ApplyOxygen20TECC-Summer-Fall11-2_TCCC9/5/116:40PMPage118TacticalEmergencyCasualtyCare(TECC)Guidelines119d.
ApplyOcclusiveDressinge.
PerformNeedleChestDecompression4.
circulation:a.
GainIntravascularAccessb.
GainIntraosseousAccessc.
Applysalinelockd.
AdministerIV/IOmedicationsandIV/IOfluidse.
Administerbloodproducts5.
Woundmanagement:a.
ApplyEyeShieldb.
ApplyDressingforeviscerationc.
ApplyExtremitySplintd.
ApplyPelvicBindere.
InitiateBasicBurnTreatmentf.
InitiateTreatmentforTraumaticBrainInjury6.
PreparecasualtyforEvacuation:a.
MoveCasualty(drags,carries,lifts)b.
ApplySpinalImmobilizationDevicesc.
Securecasualtytolitterd.
InitiateHypothermiaPrevention7.
otherskills:a.
PerformHastyDecontaminationb.
InitiateCasualtyMonitoringc.
EstablishCasualtyCollectionPointd.
PerformTriageNote:Therecommendedskillsetsarebasedupon10yearsofongoingcombat.
CareprovidedwithintheITC/TFCguidelinesisbaseduponindividualfirstrespondertraining,availableequipment,localmedicalprotocols,andmed-icaldirectorapproval.
EvacuaTion/TacTicalEvacuaTioncarE(Evac/TacEvac):goals:1.
MaintainanylifesavinginterventionsconductedduringDTC/CUFandITC/TFCphases2.
Providerapidandsecureextractiontoaappropriatelevelofcare3.
AvoidadditionalpreventablecausesofdeathPrinciples:1.
Reassessthecasualtyorcasualties2.
Utilizeadditionalresourcestomaximizeadvancedcare3.
Avoidhypothermia4.
Communicationiscritical,especiallybetweentacticalandnontacticalEMSteams.
guidelines:1.
Reassessallinterventionsappliedinpreviousphasesofcare.
Ifmultiplewounded,performprimarytriage.
2.
AirwayManagement:a.
TheprinciplesofairwaymanagementinEvacuationCarearesimilartothatinITC/TFCwiththeaddi-tionofincreasedutilityofsupraglotticdevicesandendotrachealintubation.
b.
Unconsciouscasualtywithoutairwayobstruction:SameasITC/TFCc.
Casualtywithairwayobstructionorimpendingairwayobstruction:i.
Initially,sameasITC/TFCNaso/oropharyngealairwayii.
Ifpreviousmeasuresunsuccessful,itisprudenttoconsidersupraglotticDevices(KingLT,CombiTube,LMA,etc),endotrachealintubation/RapidSequenceIntubationorsurgicalcricothyroidotomy(withlidocaineifconscious).
20TECC-Summer-Fall11-2_TCCC9/5/116:40PMPage119JournalofSpecialOperationsMedicineVolume11,Edition3/Summer/Fall11120d.
Ifintubatedandattachedtoamechanicalventilator,considerlungprotectivestrategiesandreassessforrespiratorydeclineinpatientswithpotentialpneumothoraces.
e.
Considerthemechanismofinjuryandtheneedforspinalimmobilization.
Spinalimmobilizationisnotnecessaryforcasualtieswithpenetratingtraumaifthepatientisneurologicallyintact.
Maintainhighclinicalsuspicionforcasualtiesoverageof65yowithbluntmechanism.
Additionally,patientsmaybeclinicallyclearedfromspinalimmobilizationunderalocallyapprovedprotocoliftheyhavenoneofthefollowing:-Midlinec-spinetenderness-Neurologicimpairment-Alteredmentalstatus-Distractinginjury-Intoxication3.
Breathing:a.
Allopenand/orsuckingchestwoundsshouldbetreatedbyimmediatelyapplyinganocclusivematerialtocoverthedefectandsecuringitinplace.
Monitorthecasualtyforthepotentialdevelopmentofasubsequenttensionpneumothorax.
TensionpneumothoracesshouldbetreatedasdescribedinITC/TFC.
b.
Reassesscasualtieswhohavehadchestsealsappliedorhadneedledecompression.
Iftherearesignsofcontinuedorprogressiverespiratorydistress:i.
Considerrepeatingtheneedledecompression.
Ifthisresultsinimprovedclinicalstatus,thedecompressioncanberepeatedmultipletimes.
ii.
Ifappropriateproviderscopeofpracticeandapprovedlocalprotocol,considerplacingachesttubeifnoimprovementofrespiratorydistressafterdecompressioniflongdurationorairtrans-portisanticipated.
c.
Administrationofoxygenmaybeofbenefitforalltraumaticallyinjuredpatients,especiallyforthefollow-ingtypesofcasualties:-Lowoxygensaturationbypulseoximetry-Injuriesassociatedwithimpairedoxygenation-Unconsciouscasualty-CasualtywithTBI(maintainoxygensaturation>90%)-Casualtyinshock-Casualtyataltitude-Casualtieswithpneumothoraces4.
Bleeding:a.
Fullyexposewoundstoreassessforunrecognizedhemorrhageandcontrolallsourcesofmajorbleed-ing.
b.
Ifnotalreadydone,useatourniquetoranappropriatepressuredressingwithdeepwoundpackingtocontrollife-threateningexternalhemorrhagethatisanatomicallyamenabletosuchtreatment.
i.
Applythetourniquetdirectlytotheskin2-3inchesabovewound.
ii.
Foranytraumatictotalorpartialamputation,atourniquetshouldbeappliedregardlessofbleed-ing.
c.
Reassessalltourniquetsthatwereappliedduringpreviousphasesofcare.
Exposetheinjuryanddeter-mineifatourniquetisneeded.
i.
Tourniquetsappliedinpriorphasesthataredeterminedtobebothnecessaryandeffectiveincon-trollinghemorrhageshouldremaininplaceifthecasualtycanberapidlyevacuatedtodefinitivemedicalcare.
ii.
Ifineffectiveincontrollinghemorrhageorifthereisanypotentialdelayinevacuationtocare,identifyanappropriatelocation2-3inchesabovetheinjury,andapplyanewtourniquetdirectlytotheskin.
Onceproperlyapplied,thepriortourniquetcanbeloosened.
iii.
Ifdelaytodefinitivecarelongerthan2hoursisanticipatedandwoundforwhichtourniquetwasappliedisanatomicallyamenable,attemptatourniquetdowngradeasdescribedinITC/TFC.
d.
Adistalpulsecheckshouldbeperformedonanylimbwhereatourniquetisapplied.
Ifadistalpulseisstillpresent,consideradditionaltighteningofthetourniquetortheuseofasecondtourniquet,side-by-sideandproximaltothefirst,toeliminatethedistalpulse.
e.
Exposeandclearlymarkalltourniquetsiteswiththetimeoftourniquetapplication.
Useanindeliblemarker.
20TECC-Summer-Fall11-2_TCCC9/5/116:40PMPage120TacticalEmergencyCasualtyCare(TECC)Guidelines1215.
Fluidresuscitation:Reassessforhemorrhagicshock(alteredmentalstatusintheabsenceofbraininjury,weakorabsentperipheralpulses,and/orchangeinpulsecharacter).
IfBPmonitoringisavailable,maintaintargetsystolicBP80-90mmHg.
a.
EstablishintravenousorintraosseousaccessifnotperformedinITC/TFCphaseb.
ManagementofresuscitationasinITC/TFCwiththefollowingadditions:i.
Ifinshockandbloodproductsarenotavailableornotapprovedunderscopeofpractice/localprotocolsresuscitateasinITC/TFC.
ii.
Ifinshockandbloodproductsareavailablewithanappropriateproviderscopeofpracticeunderanapprovedmedicalprotocol:-Resuscitatewith2unitsofplasma(FFP)and2unitsofpackedredbloodcells(PRBCs)ina1:1ratio.
-Ifbloodcomponenttherapyisnotavailable,andappropriatetraining,testingandproto-colsareinplace,considertransfusingfreshwholeblood.
-ContinueresuscitationasneededtomaintaintargetBPorclinicalimprovement.
iii.
IfacasualtywithanalteredmentalstatusduetosuspectedTBIhasaweakorabsentperipheralpulse,resuscitateasnecessarytomaintainadesiredsystolicbloodpressureof90mmHgorapalpableradialpulse.
iv.
IfsuspectedTBIandcasualtynotinshock,raisethecasualty'sheadto30degrees.
6.
Preventionofhypothermia:a.
Minimizecasualty'sexposuretotheelements.
Moveintoamedicunit,vehicle,orwarmedstructureifpossible.
Keepprotectivegearonorwiththecasualtyiffeasible.
b.
Replacewetclothingwithdryifpossible.
Placethecasualtyontoaninsulatedsurfaceassoonaspossi-ble.
c.
Coverthecasualtywithcommercialwarmingdevice,dryblankets,poncholiners,sleepingbags,oranythingthatwillretainheatandkeepthecasualtydry.
d.
WarmfluidsarepreferredifIVfluidsarerequired.
7.
Monitoring:a.
Instituteelectronicmonitoringifavailable,includingpulseoximetry,cardiacmonitoring,etCO2(ifin-tubated),andbloodpressure.
b.
Obtainandrecordvitalsigns.
8.
Reassesscasualty:a.
Completesecondarysurveycheckingforadditionalinjuries.
Inspectanddressknownwoundsthatwerepreviouslydeferred.
b.
Determinemodeanddestinationforevacuationtodefinitivecare.
c.
Splintknown/suspectedfracturesandrecheckpulses.
d.
Applypelvicbindingtechniquesforsuspectedpelvicfractures.
9.
Provideanalgesiaasnecessary:a.
Mildpain:i.
Consideroralnon-narcoticmedicationsb.
Moderatetoseverepain:i.
Consideruseoforal/intra-nasal/IV/IOnarcoticmedications(hydrocodone,oxycodone,transmucosalfentanylcitrate,morphine,etc.
)ii.
Consideradjunctadministrationofanti-emeticmedicinesiii.
Havenaloxonereadilyavailablewheneveradministeringopiatesiv.
Monitorforadverseeffectssuchasrespiratorydepression,hypotentension10.
Burns:a.
BurncareisconsistentwiththeprinciplesdescribedinITC/TFC.
b.
Becautiousofoff-gassingfrompatientintheevacuationvehicleifthereissuspectedchemicalexpo-sure(e.
g.
cyanide)fromthefire.
c.
Considerearlyairwaymanagementifthereisaprolongedevacuationperiodandthepatienthassignsofsignificantairwaythermalinjury(e.
g.
singedfacialhair,oraledema,carbonaceousmaterialintheposteriorpharynxandrespiratorydifficulty.
)11.
Preparecasualtyformovement:Considerenvironmentalfactorsforsafeandexpeditiousevacuation.
Securecasu-altytoamovementassistdevicewhenavailable.
Ifverticalextractionrequired,ensurecasualtysecuredwithinap-propriateharness,equipmentassembled,andanchorpointsidentified.
12.
Communicatewiththecasualtyifpossibleandwiththeacceptingfacility.
Encourage,reassureandexplaincare.
20TECC-Summer-Fall11-2_TCCC9/5/116:40PMPage121JournalofSpecialOperationsMedicineVolume11,Edition3/Summer/Fall1112213.
Cardiopulmonaryresuscitation(CPR)mayhavealargerroleduringtheevacuationphaseespeciallyforpatientswithelectrocution,hypothermia,nontraumaticarrestorneardrowning.
14.
DocumentationofCare:Continueorinitiatedocumentationofclinicalassessments,treatmentsrendered,andchangesinthecasualty'sstatusinaccordancewithlocalprotocol.
Forwardthisinformationwiththecasualtytothenextlevelofcare.
skills:1.
Familiarizationwithadvancedmonitoringtechniques2.
Familiarizationwithtransfusionprotocols3.
Ventilatorandadvancedairwaymanagement20TECC-Summer-Fall11-2_TCCC9/5/116:40PMPage122