Transcript Document

Tactical Combat Casualty Care
7 December 2012
Current Performance Improvement
Issues
TCCC Lessons Learned in Iraq
and Afghanistan
• Reports from Joint Trauma System (JTS) weekly
Trauma Telecons – every Thursday morning
– Worldwide telecon to discuss every serious casualty
admitted to a Level III hospital from that week
• Published medical reports
• Armed Forces Medical
Examiner’s Office reports
• Feedback from doctors,
corpsmen, medics,
and PJs
Overcalling CAT A
Evacuations
NATO/ISAF Standard Evacuation
Categories
International Security Assistance Force
SOP #312:
• Governs operations in Afghanistan
• Follows NATO doctrine
• Specifies three categories for casualty
evacuation:
• A - Urgent
• B - Priority
• C - Routine
NATO/ISAF Standard Evacuation
Categories
• CAT A – Urgent (denotes a critical, lifethreatening injury)
– Significant injuries from a dismounted IED attack
– Gunshot wound or penetrating shrapnel to chest,
abdomen or pelvis
– Any casualty with ongoing airway difficulty
– Any casualty with ongoing respiratory difficulty
– Unconscious casualty
NATO/ISAF Standard Evacuation
Categories
• CAT A – Urgent (continued)
– Casualty with known or suspected spinal injury
– Casualty in shock
– Casualty with bleeding that is difficult to control
– Moderate/Severe TBI
– Burns greater than 20% Total Body Surface Area
NATO/ISAF Standard Evacuation
Categories
• CAT B – Priority (serious injury)
– Isolated, open extremity fracture with bleeding
controlled
– Any casualty with a tourniquet in place
– Penetrating or other serious eye injury
– Significant soft tissue injury without major
bleeding
– Extremity injury with absent distal pulses
– Burns 10-20% Total Body Surface Area
NATO/ISAF Standard Evacuation
Categories
• CAT C – Routine (mild to moderate injury)
– Concussion (mild TBI)
– Gunshot wound to extremity - bleeding controlled
without tourniquet
– Minor soft tissue shrapnel injury
– Closed fracture with intact distal pulses
– Burns < 10% Total Body Surface Area
Training
Train ALL Combatants and
all Operational Medical
Providers in TCCC
• Line commanders must take the lead to have an
effective TCCC training program for all combatants
• Docs, nurses, PAs must know what their combat
medical personnel know about TCCC
Tourniquets Being
Placed Too Proximal and
Not Adjusted during
TFC
E-mail from an orthopedic
surgeon: “…. tourniquet was
applied on the proximal biceps for
a middle finger amputation.”
Care Under Fire Guidelines
7. Stop life-threatening external hemorrhage if
tactically feasible:
– Direct casualty to control hemorrhage by selfaid if able.
– Use a CoTCCC-recommended tourniquet for
hemorrhage that is anatomically amenable to
tourniquet application.
– Apply the tourniquet proximal to the bleeding
site, over the uniform, tighten, and move the
casualty to cover.
Three Key Points
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“Proximal to the bleeding site” does not
necessarily mean at the upper biceps for
a hand injury or at the upper thigh for
a foot injury
The tourniquet should be moved to a
skin location 2-3 inches above the
bleeding site during Tactical Field Care.
Reassess the bleeding site frequently to
ensure that tourniquet is still effective.
Tourniquet Mistakes
to Avoid!
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Not using one when you should
Using a tourniquet for minimal bleeding
Putting it on too proximally
Not taking it off when indicated during TFC
Taking it off when the casualty is in shock or has
only a short transport time to the hospital
Not making it tight enough – the tourniquet
should eliminate the distal pulse
Not using a second tourniquet if needed
Waiting too long to put the tourniquet on
Periodically loosening the tourniquet to allow
blood flow to the injured extremity
* These lessons learned have been written in blood. *
Eye Injuries: Recent
Increase in Eye Injuries
from Not Wearing Eye
Protection
Wear Your Eye Protection!
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Jan 2010
22 y/o near IED without eye protection
Now blind in both eyes
Don’t let this happen to you – see slides below
With eye pro – eyes OK!
Without eye pro – both eyes lost
Eye Armor – It Works!
Penetrating Eye Trauma
• Rigid eye shield for obvious or suspected eye wounds - often
not being done – SHIELD AND SHIP!
• Not doing this may cause permanent loss of vision – use a
shield for any injury in or around the eye
• Eye shields not always in IFAKs
• IED + no eye pro + facial wounds = Suspected Eye Injury!
Shield after injury
No shield after injury
Eye Protection
• Use your tactical eyewear to cover the injured eye if you
don’t have a shield.
• Using tactical eyewear in the field will generally prevent
the eye injury from happening in the first place!
JTTS Trauma Telecon
9 Sept 2010
• Recent case of endophthalmitis (blinding infection
inside the eye)
• Reminder – shield and moxifloxacin in the field
for penetrating eye injuries – combat pill pack!
• Also – need to continue
moxi both topically and
systemically in the MTFs
• Many antibiotics do not
penetrate well into the
eye
Patched Open Globe
22 July 2010
• Shrapnel in right eye from IED
• Had rigid eye shield placed
• Reported as both pressure patched and as having a
gauze pad placed under the eye shield without
pressure – NO pressure patches on eye injuries
• Extruded uveal tissue (intraocular contents) noted at
time of operative repair of globe
• Do not place gauze on injured eyes! COL Robb
Mazzoli: Gauze can adhere to iris tissue and cause
further extrusion when removed even if no pressure
is applied to eye.
• At least two other recent occurrences of patching
Pressure Dressings on
Eye Injuries
The wrong thing to do – makes a bad situation
potentially much worse – SHIELD ONLY
Battlefield Analgesia
NO Narcotic Analgesia for
Casualties in Shock
• Narcotics (morphine and fentanyl) are
CONTRAINDICATED for casualties
who are in shock or who are likely to
go into shock; these agents may worsen
their shock and increase the risk of death
• Four casualties in two successive weekly telecons
were noted to have gotten narcotics and were in shock
during transport or on admission to the MTFs
• Use ketamine for casualties who are in shock or at
risk of going into shock but are still having
significant pain
Case Report
September 2012
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Male casualty with GSW to thigh
Bleeding controlled by tourniquet
In shock – alert but hypotensive
Severe pain from tourniquet
Repeated pleas to PA to remove the tourniquet
PA did not want to use opioids because of the shock
Perfect candidate for ketamine analgesia
Not fielded at the time with this unit
Platelet-Inhibiting Drugs
in the Battle Space
First – Do No Harm
Harris et al – Mil Med 2012
• Platelets help to keep you from bleeding to death if you
are wounded. Some drugs keep them from working.
• Survey of 175 Soldiers at a FOB in SE Afghanistan
• “Do you take over-the-counter or prescription
NSAIDs?”
• If so, how often?
First – Do No Harm
Harris et al – Mil Med 2012
First – Do No Harm
Harris et al – Mil Med 2012
Recommendations:
• Earlier platelets in DCR
• Consider restricting NSAIDs in theater
• Other analgesic choices: acetaminophen,
cox-2 selective NSAIDs, tramadol
Note that other drugs
and some nutritional
supplements may inhibit
platelets as well. Check
with your doc on this!
Documentation of TCCC
Care
TCCC Card –
Fill It Out!
• You’re not done taking care of your casualty
until this is done
• Mission Commanders – this is a leadership
issue!
Questions?