terminal learning objective - jsomtc · 2015. 11. 30. · 11/30/2015 5 jsomtc, swmg(a) slide 13...

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Slide 1JSOMTC, SWMG(A)

Tactical Combat Casualty Care and SOF Tactical Trauma Protocols

PFN: SOMTCL03Hours: 2.5Instructor:


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


Reason

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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 Tactical Field Care treatment priorities


Agenda

Identify the SOF TTPs extended Tactical Field Care considerations

Identify the Tactical Evacuation Care treatment priorities


Origins, History, and Objectives of TCCC and SOF TTPs

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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)


USSOCOM Directive

All SOF deploying personnel Trained on current TCCC guidelines

• https://mhs.health.mil/References/REF_TCCC.cshtml

• http://www.naemt.org/education/TCCC/guidelines_curriculum

Training completed within 6 months prior to deployment in support of combat operations



90% of combat casualties that die, die before reaching a MTF

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Top three preventable deaths on the battlefield:Hemorrhage from extremity woundsAirway compromise from maxillofacial trauma Tension pneumothorax



TCCC objectives Treat the casualty Prevent additional casualties Complete the mission

TTP additional options Extended field care


Three Phases of TCCC and SOF TTPs

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Three Phases of TCCC and SOF TTPs

Care Under Fire (CUF) Tactical Field Care (TFC) Extended Tactical Field Care Considerations

Tactical Evacuation Care (TEC)


Care Under FireTreatment Priorities


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

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Care Under Fire

Casualties should be extricated from burning vehicles or buildings and moved to places of relative safetyDo what is necessary to stop the burning process

Airway management is best deferred until Tactical Field Care phase


Care Under Fire

Stop any life threatening external hemorrhage if tactically feasibleDirect 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


Tactical Field CareTreatment Priorities

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Tactical Field Care

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


Tactical Field Care

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)


Tactical Field Care

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• 2nd ICS, MCL primary• 4th or 5th anterior‐axillary line is the alternate• Lateral to nipple line and not directed to heart• Remove the needle and leave catheter in place

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Tactical Field Care

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


Tactical Field Care

BleedingAssess 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


Tactical Field Care

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

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Tactical Field Care

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


Tactical Field Care

Prevention of hypothermiaMinimize casualty’s exposure to elements; keep protective gear on or with the casualty

Replace wet clothing with dryGet 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


Tactical Field Care

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

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Tactical Field Care

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


Tactical Field Care

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


Tactical Field Care

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 mmHgNot in hemorrhagic shock

• No IV fluids are immediately necessary• Fluids by mouth are permissible

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Tactical Field Care

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 80‐90 mmHg


Tactical Field Care

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 80‐90 mmHg


Tactical Field Care

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

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Tactical Field Care

Head injury management Fluid resuscitate hypotensionMaintain spo2 > 90%; goal = 95% Controlled mild hyperventilation (20 BPM)Hypertonic saline (3‐5%) 250ml bolus Seizure prophylaxis

• Cerebyx 18 mg/kg IV/IO at 100‐150 mg/min Seizure management

• Valium 5‐10 mg IV/IO q 5 minutes• Versed 5 mg IV/IO q 5 minutes


Tactical Field Care

Head injury management (cont.) Patient positioning

• If CSF present elevate 30‐60 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


Tactical Field Care

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

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Tactical Field Care

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


Tactical Field Care

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


Tactical Field Care

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

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Tactical Field Care

Burns (cont.) Fluid resuscitation (USAISR Rule of Ten)

• Initial IV/IO fluid rate is calculated as %TBSA x 10 ml/hr for adults weighing 40‐80 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 shockAdminister IV/IO fluids per the TCCC Guidelines


Tactical Field Care

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


Tactical Field Care

Inspect and dress known wounds Check for additional wounds Splint fractures and recheck pulses Basic splinting fundamentals apply

Crush injury management Immediately 1000‐1500 ml NS Just before extrication apply tourniquets and give sodium bicarbonate

After extrication monitor for cardiac arrest

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Tactical Field Care

Monitoring Pulse oximetry should be available as an adjunct to clinical monitoring

Readings may be misleading in the settings of shock or marked hypothermia


Tactical Field Care

Analgesia if able to fightMeloxicam (Mobic) 15 mg PO once a dayAcetaminophen 650 mg bilayer caplet, 2 PO every 8 hours


Tactical Field Care

Analgesia if unable to fight without IV/IOHypovolemic shock or respiratory distress

• Ketamine (Ketalar) 50 mg IM or IN• Repeat dose every 15‐30 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

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Tactical Field Care

Analgesia if unable to fight with IV/IOHypovolemic shock or respiratory distress

• Ketamine 20 mg IV/IO over 1 minute repeat dose every 5‐10 min to control pain or until nystagmusoccurs (max of 100mg/hr)

• Consider Versed 1 mg IV for agitationNo hypovolemic shock or respiratory distress

•Morphine 5‐10 mg IV/IO repeat dose every 10 minutes as necessary (monitor for respiratory depression)


Tactical Field Care

Consider an antiemetic for opioid or trauma induced nausea or vomitingOndansetron (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


Tactical Field Care

Antibiotics: recommended for all open combat wounds

Able to take POMoxifloxacin 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

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Tactical Field Care

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


Tactical Field Care

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


SOF TTPs Extended Tactical Field Care Considerations

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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



Respiratory management Perform chest tube and apply chest drain Consider rib blocks for pain managementAdminister 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



Flail chest managementMonitor 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

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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 30‐50 ml per hourClean water may be utilized in lieu of crystalloid for NG/PR infusion



Fluid management (cont.) Critical burn (> 20% TBSA of 2nd/3rd degree burns)• Continue fluid resuscitation according to “The Rule of Ten”

• Insert Foley catheter and adjust fluid rate to maintain urine output of 30‐50 ml per hour

• Oral fluid administration may be acceptable in burns up to 40% TBSA if IV supplies are limited



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

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Analgesia For painful procedures consider the use of procedural anesthesia• Dual agent

Midazolam (Versed) 2 mg IV/IO over 1 minuteKetamine (Ketalar) 20 mg IV/IO over 1 minute

• Single agentMorphine 5 mg IV/IO q 5 min

Consider local blocks for pain management



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



Compartment syndrome management Be suspicious of compartment syndrome in the following conditions• Fractures• Crush injuries• Vascular injuries• Circumferential burns•Multiple penetrating injuries (fragmentation)

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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



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



Blast injuries Tympanic membrane perforation

• Dexamethasone (Decadron) 10 mg IV/IO/IM/PO QD Lungs

•Monitor patient for respiratory deteriorationAbdomen

•Monitor for delayed bowel injury Spine

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Tactical Evacuation CareTreatment Priorities


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



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

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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



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 neededMaintain a normal radial pulse or systolic blood pressure between 80‐90 mmHg



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

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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



Continue analgesia as needed Reassess fractures and recheck pulsesMonitor air pressure in extremity air splints during air evacuation

Start antibiotic therapy if not already done



The Pneumatic Antishock Garment (PASG) may be useful for stabilizing pelvic fractures and controlling pelvic and abdominal bleedingApplication and extended use must be carefully monitored

Contraindicated for casualties with thoracic or brain injuries

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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


Questions?


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

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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 Tactical Field Care treatment priorities


Agenda

Identify the SOF TTPs extended Tactical Field Care considerations

Identify the Tactical Evacuation Care treatment priorities


Reason

terminal learning objective - jsomtc · 2015. 11. 30. · 11/30/2015 5 jsomtc, swmg(a) slide 13...

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