Transcript Combat Casualty Care

TACTICAL COMBAT CASULATY
CARE
Tactical Combat Casualty Care in
Special Operations
CAPT Butler/LTC Hagmann
Military Medicine Supplement
August 96
“90% of combat deaths occur on the
battlefield before the casualty ever
reaches a medical treatment facility.”
COL Ron Bellamy
Tactical Context
Incoming fire
 Darkness
 Environmental factors
 Casualty transportation problems
 Delays to definitive care
 Command decisions

“Two of the obvious differences (in
combat casualty care) are the
adverse conditions of war and the
fact that under certain tactical
conditions, the care of the patient is
secondary to the mission at hand.”
CAPT Byron Holley
Cocaine Lab Raid
32 man Ranger team
 Planned raid on a cocaine lab in dense jungle
 Estimated hostile strength is 8 men with
automatic weapons
 Insertion from HELO
 8 Kilometer movement to target

Cocaine Lab Raid
As patrol reaches the objective area, a
booby trap is tripped resulting in a point
man without pulse or respirations and a
squad leader with massive trauma to the
leg and femoral bleeding
 Heavy incoming fire as hostiles respond
 Planned extraction by boat at point on
river 1/2 mile from target

Tactical Combat Casualty Care
Good medicine
can sometimes be bad tactics!
Tactical Combat Casualty Care
Bad tactics can get everyone killed
and/or cause the mission to fail!
Tactical Combat Casualty Care
Casualty scenarios in Ranger operations
usually entail both a medical problem
and a tactical problem.
 We want the best possible outcome for
both the man and the mission.

Combat Casualty Care Objectives
 Treat
the casualty
 Prevent
additional casualties
 Complete
the mission
Editorial
The most important aspect of caring for
trauma victims on the battlefield is well
thought out planning for that
environment and appropriate training
of Ranger First Responders and Combat
Medical Personnel.
Phases of Care
Care under Fire
Tactical Field Care
Casualty Evacuation (CASEVAC)
"Care under Fire"

The care rendered by the RFR/NREMT-B/
Ranger Medic at the scene of the injury,
while he and the casualty are still under
effective hostile fire.

Available medical equipment is limited to
that carried by the individual Ranger or
medic in his gear.
"Tactical Field Care"
Care rendered by the RFR/NREMT-B/
Ranger Medic when no longer under
effective hostile fire.
 Applies to situations in which an injury has
occurred on a mission, but there has been
no hostile fire.
 Available medical equipment limited to that
carried into the field by mission personnel.

”CASEVAC"
Care rendered once the casualty (and usually
the rest of the mission personnel) have been
extracted by aircraft, vehicle, or boat.
 Personnel and medical equipment previously
staged in these assets are now available.
 Use "CASEVAC" to describe this phase vs the
commonly used term "MEDEVAC".

Basic Tactical Combat
Casualty Care Plan
Key Point:
The plan described is presented as a generic
sequence of steps that will probably require
modification in some way for almost any casualty
scenario encountered in Ranger Operations.
Care under Fire
Return fire as directed or required
 Try to keep yourself from getting shot
 Try to keep the casualty from sustaining
additional wounds
 Stop any life-threatening external
hemorrhage with an Emergency Trauma
Dressing and/or tourniquet

Care under Fire
What does returning fire have to do
with medical care?
Care under Fire
The best medicine on the battlefield is
Fire Superiority!
Fire superiority and control of the tactical
situation is a must. The Tactical Commander
(TM LDR, SQD LDR, PLT SGT) must have
control of the situation to effectively manage
casualties.
Care under Fire
No immediate management of the airway
should be anticipated at this point
because of the need to move the casualty
to cover as quickly as possible.
Care under Fire
 Exsanguination
from extremity wounds
is the #1 cause of preventable death on the
battlefield.

Control of hemorrhage is the top priority!
Hemorrhage from extremity wounds was the
cause of death in more than 2500 casualties in
Vietnam who had no other injuries.
Tourniquets

Most reasonable initial choice to stop major
bleeding in the Care Under Fire Phase

Direct pressure is hard to maintain during
casualty transport under fire
Tourniquets
Tissue damage to the limb is rare if the
tourniquet is left in place less than an hour.
 Tourniquets often left in place for several
hours during surgical procedures.
 In the face of massive extremity
hemorrhage, in any event, it is better to
accept the small risk of tissue damage to the
limb than to lose a casualty to bleeding to
death.

Tourniquets
The need for immediate access to a
tourniquet in such situations makes it
clear that all Rangers on combat missions
should have a suitable tourniquet readily
available at a standard location on their
battle gear and be trained in its use.
Questions?
Tactical Field Care
Reduced level of hazard from hostile fire
 Amount of time available extremely variable
 Time prior to extraction may range from
less than a half hour to many hours.
 Limited visibility
 Nonsterile field conditions

Airway Management:
Conscious Patient
No attempt at airway intervention is
required if the patient is conscious and
breathing without difficulty on his own.
Airway Management:
Unconscious Patient
Without airway obstruction
 Usual cause is hemorrhagic shock or
penetrating head trauma
 Chin lift or jaw thrust maneuver
 No need for cervical spine immobilization
 Nasopharyngeal airway if no obstruction

Nasopharyngeal Airway
Better tolerated than an oropharyngeal
airway should the patient subsequently
regain consciousness
 Less likely to be dislodged during patient
transport.

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Suction
If blood or other obstructions are present in
the mouth, they should be removed by hand.
Breathing
 Tension
pneumothorax is the second
leading cause of preventable death on the
battlefield.

Consider progressive, severe respiratory
distress resulting from unilateral chest
trauma to represent a tension
pneumothorax and decompress.
Tension pneumothorax
 Signs/Symptoms
 Decreased
breath sounds
 Tracheal shift
 Hyperresonance to percussion

Difficult to appreciate on the battlefield!
Needle Thoracostomy
Decompress affected side with a 14 gauge
needle inserted at 2nd ICS at MCL.
 A patient with penetrating chest trauma will
generally have some degree of hemothorax or
pneumothorax as a result of the primary
wound.
 Additional trauma from needle thoracostomy
will not significantly worsen patient’s
condition if no tension pneumo.

Needle Thoracostomy

RFR’s, Squad EMT’s, and Medics are
trained in this technique

Technically easy to perform

May be lifesaving if the patient does in fact
have a tension pneumothorax.
Open Pneumothorax
Occlusive dressing
 Not necessary to vent one side of the
wound dressing: difficult to do reliably in a

combat setting

Watch for development of a tension
pneumothorax
 Asherman
Chest Seal is the standard
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Bleeding
Ranger survivability on the battlefield is
measured by immediate control of hemorrhage.
 When tactically feasible consider standard
bleeding control procedures.
 Don’t hesitate to use a tourniquet under more
severe battlefield conditions (Care Under Fire).
 Application of a tourniquet is only acceptable
under extreme circumstances.

Bleeding
Tourniquets are only used to control
serious extremity bleeding by RFR’s
under real world combat conditions.
Bleeding


Remove minimum clothing required to
expose and treat injuries
Emergency Trauma Dressing
 Ranger
Rescue Wrap
Need to protect the patient against the environment
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Ranger Rescue Wrap
IV Therapy

Large IV catheters are needed to administer
large volumes of blood products rapidly

Not a factor in the tactical setting since
blood products will not be available
 18
gauge catheter preferred in the field
setting because of increased success rate
IV Therapy

Larger gauge IVs may have to be started at
MTF

Common practice to discontinue prehospital
IVs upon arrival at MTF because of concern
about contamination of the IV site
IV Therapy

Don't start on an extremity distal to a
significant wound

Saline locks are used (Eliminates the logistical
difficulties of managing the IV bag during
transport)
IV Therapy

Extremity (Upper > Lower) vein first choice

External jugular vein next option

Sternal Intraosseous is last option
Fluid Resuscitation
1. Controlled bleeding/ no shock:
Saline lock, NO IV fluids required
2. Controlled bleeding/shock:
Saline lock, IV Hespan 500 - 1000cc
3. Uncontrolled bleeding:
Saline lock, NO IV fluids
Fluid Resuscitation
Despite its widespread use, the benefit of
prehospital fluid resuscitation in trauma
patients has not been established.
Fluid Resuscitation:
Uncontrolled Bleeding
Several studies noted that only after
previously uncontrolled hemorrhage was
stopped did fluid resuscitation prove to
be of benefit.
Fluid Resuscitation:
Uncontrolled Bleeding
(Human)

World War I combat trauma patients

Concluded that initiating IV fluid
replacement without first obtaining
surgical hemostasis promoted further
hemorrhage.
 Cannon
Fluid Resuscitation:
Uncontrolled Bleeding
Weight of evidence at this time favors
withholding aggressive IV fluid resuscitation
in patients with uncontrolled hemorrhage
from penetrating thoracic or abdominal
trauma until the time of surgical intervention.
Fluid Resuscitation:
Controlled Bleeding
Immediate fluid resuscitation is still
recommended for casualties on the
battlefield whose hypovolemic shock is
the result of bleeding from an extremity
wound which has been controlled.
Comments/Questions?
Inspect and Dress Wound

Minimize further contamination

Promote hemostasis
Check for Additional Wounds

A careful check for additional wounds
should be made, since high velocity
projectiles from assault rifles will tumble
and take erratic courses when travelling
through tissue.

Exit sites are often remote from the entry
wound.
Splint Fractures and Recheck Pulse

Check distal pulses both before and after
splinting

Remedy any decrease in the pulse caused
by splinting by adjusting the position of
the splint
Cardiopulmonary
Resuscitation (CPR)
Battlefield CPR 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.
 Attempts to resuscitate trauma patients
in arrest have been futile even in the
urban setting where the victim is in close
proximity to a trauma center.

Cardiopulmonary
Resuscitation
The battlefield cost of attempting to perform
CPR on casualties with what are inevitably
fatal injuries will be measured in additional
lives lost as care is withheld from patients
with less severe injuries and as Rangers are
exposed to additional hazard from hostile
fire because of their attempts.
Cardiopulmonary
Resuscitation
Only in the case of nontraumatic disorders
such as hypothermia, near drowning, or
electrocution should CPR be considered
prior to the CASEVAC phase.
CASEVAC Care
Two significant differences will be present
in progressing from the Tactical Field Care
phase to the CASEVAC phase:
Additional medical personnel may accompany
the evacuating asset.
 Additional medical equipment may be prestaged on the evacuating asset.

CASEVAC Care: Monitoring

Helicopter transport impairs or precludes the
provider's ability to auscultate the lungs or
even to palpate the carotid pulse

Electronic monitoring systems capable of
providing blood pressure, heart rate, pulse
oximetry, and capnography are commercially
available and needed for air medical transport
Recommendations
1. Base planning for Ranger combat casualties
should be incorporated into specific mission
scenarios to aid in identifying the unique
medical and tactical requirements that will
have to be addressed in that scenario.
Recommendations
2. On combat missions, all Rangers should
have a suitable tourniquet readily
available at a standard location on their
battle gear.
3. All Rangers should be trained to use a
tourniquet.
Recommendations
4. Designate and train Combat Casualty
Transport Teams.
5. In the event of a conflict, assign these
teams to the JSOTF commander.
Vision Statement
“We must also have the intellectual
agility to conceptualize creative, useful
solutions to ambiguous problems.…this
means training and educating people on
how to think, not just what to think.”
Gen Peter Schoomaker
Commander-in-Chief
Questions?