Tactical Combat CBRN Casualty Care + CBRN

Assessment and management of CBRN casualties is complex because it involves not only life-threatening symptoms (some of them rapid onset) but also the threat of contamination of all first responders. An added source of complexity is the frequent mixing of CBRN and penetrating trauma injuries. (Figure 2) Working through this complexity involves a stepwise approach that first rules in or rules out CBRN injuries so that first responders can protect themselves if necessary before rendering aid. The next step integrates assessment and management of both CBRN and traumatic injuries, prioritizing the recognition and management of life-threats first.

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Just as trauma casualties present differently (blunt, trauma, GSW, blasts, etc.), CBRN casualties also have varied presentations. For example, chlorine casualties will require more attention to the toxic inhalation symptoms contrasted with a mustard casualty whose associated trauma may require more prompt intervention than the mustard-specific effects. CBRN casualties can be categorized by circumstances of exposure and presence or absence of trauma and CBRN effects. The acronym CRESS (Consciousness, Respirations, Eyes, Secretions, Skin) is employed to improve rapid identification of the type of chemical agent exposure.

In a CBRN-threat environment, casualties may have traumatic, CBRN or mixed injuries. Before applying TCCC, it is important to identify whether CBRN injuries are present and identify a suspected agent to allow first responders to protect themselves before treating the patient. While this often can be deduced using intelligence reports, technologic agent identification resources, and circumstances of the CBRN event, there will be times when agent identification will need to be made solely based on clinical assessment of symptoms. Some CBRN agents, such as nerve agents, can be rapidly fatal; therefore, recognition of such symptoms is the equivalent of identifying massive hemorrhage in the trauma patient. Clinical clues can be aggregated to identify the most likely agent responsible for symptoms according to the CRESS assessment. Each letter in CRESS corresponds to physical exam findings that can be used to categorize the suspected agent based on the constellation of findings. CRESS findings associated with specific chemical agents are shown in Table 3.

Figure 3. The acronym CRESS

The acronym CRESS is used to differentiate exposures to chemical agents. Exposure to biological agents is unlikely to cause early symptoms. Radiologic exposure may lead to early onset of symptoms (<1 hour post exposure) such as nausea, vomiting, diarrhea, and fever with high dose exposures (>6 Gray). CRESS findings for select chemical agents are summarized in Table 3.

Figure 3. The acronym CRESS
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(MARCHE)2: Integrating TCCC MARCH with CBRN First Response

After initial assessment of casualty in CBRN-threat environment for the presence or absence of CBRN symptoms using the CRESS algorithm (and donning of PPE by first responders if present), the integrated assessment and management of TCCC and CBRN injuries can proceed.

The acronym (MARCHE)2 integrates these two processes using the established TCCC MARCH algorithm (Massive Hemorrhage, Airway, Respirations, Circulation, Hypothermia) with CBRN priorities of Mask, Antidotes, Rapid spot decontamination, Countermeasures, Extraction and Evacuation. Combining these two approaches gives the acronym (MARCHE)2 or “MARCH-squared.”

Similar to TCCC, (MARCHE)2 can be broken into phases of care from highest threat (care under fire or active CBRN threat), to intermediate threat (tactical field care or warm zone casualty management), to lowest threat (PFC/evacuation or care of decontaminated casualties in cold zone). Figure 4 below.

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Putting It All Together, Integrating CRESS and (MARCHE) 2

Step 1: Hot Zone/Care Under Fire

During “hot zone” care, the agent itself is similar to enemy fire. As such, the priorities are protection from and egress away from the threat (CBRN agent) for both casualty and provider. Both casualty and provider should don protective mask. If the casualty is incapacitated, the provider must ensure the casualty’s protective gear is applied and functional.

Only rapid interventions for immediate life-threats should be addressed. Massive hemorrhage, if present, may be the most immediate life threat and control of hemorrhage supersedes other interventions. Massive hemorrhage, if compressible, should be treated according to TCCC guidelines with limb tourniquets.

Perform a rapid assessment of the airway and respirations. Excessive secretions and increased respirations may indicate nerve agent exposure. Completion of the CRESS assessment will help determine if the symptoms are due to trauma or chemical agent exposure. Most airway and respiration interventions should be deferred. Occasionally, such interventions may take priority over mask application, but the decision to unmask a casualty in order to provide the intervention needs to be weighed against the risk of the contaminated environment.

Some CBRN agents are rapid killers. The CRESS assessment will quickly determine whether immediate antidotes are required. If nerve agent exposure is suspected (decreased level of consciousness, increased respirations, constricted pupils, increased secretions, diaphoretic skin) then the provider should direct self-administration of Antidote Treatment Nerve Agent Auto-injector (ATNAA) and Convulsant Antidote for Nerve Agent (CANA) or administer the antidotes for an incapacitated casualty.

Rapid spot decontamination of skin or wounds is indicated when there is gross contamination on the skin or wounds or when protective gear is breached. If wound contamination with chemical agent is suspected, immediately expose the wound to perform rapid spot decontamination. This step is necessary even in a contaminated environment and may be lifesaving.

Treatment for cyanide can be considered in the hot zone, but the need to establish IV/IO access to administer hydroxocobalamin makes this a judgment call weighed against the time needed to reach the warm zone and the ongoing threat in the hot zone location. Naloxone 2 mg intramuscular or intranasal for opioid incapacitating agents may also be considered for life-threatening respiratory depression. As in TCCC, non-essential interventions should be deferred until the next phase of care.

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Step 2: Warm Zone/Tactical Field Care

In the warm zone, or tactical field care phase, attention is given to decontamination and reassessment of the casualty. This phase occurs at a dirty CCP (hotline) and requires personnel dedicated to triage, decontamination, and patient treatment. At this phase, interventions may have altered the clinical presentation of the casualty (e.g., the patient may have decreased secretions and reduced airway resistance from use of the ATNAA), so it is important to take into account prior interventions and changes in the clinical status of the casualty. However, the goal is to quickly transition the casualty to the cold zone for definitive care, so only life-saving treatments should be done in the warm zone.

Decontamination and treatment can be synchronous processes. Medical personnel will need to clearly communicate with non-medical personnel responsible for decontamination. “Expose to treat” is used by decontamination personnel when the provider deems it in the best interest of the casualty to remove PPE to provide life-saving medical intervention. For example, the mask may be removed and the head, face, and chest quickly decontaminated so that the provider can ventilate the casualty and insert a sternal IO if parenteral antidotes, blood product or fluid resuscitation or countermeasures are immediately indicated. It would also be appropriate to prioritize decontamination of an arm to establish an IV or proximal humerus IO access.

Circulation should be assessed to identify external hemorrhage and shock. The provider can assess the effects of both CBRN agents and antidotes on the patient’s circulatory status. As decontamination ensues, dirty treatments are replaced with clean. Due to cold water and the need to fully expose the casualty in order to conduct thorough decontamination, hypothermia is a significant risk. Ensure rapid transit through the decontamination line with careful attention to hypothermia mitigation in order to prevent iatrogenic injury from the decontamination process. Additionally, personnel working within the warm zone in full protective gear are at risk of heat injury and stressors associated with operating in PPE, which must be recognized and mitigated

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Step 3: Cold Zone/Tactical Evacuation Care/Prolonged Field Care

Once the decontaminated casualty has passed into the cold zone, they should be re-evaluated and receive needed interventions to include tactical evacuation or prolonged field care. The decontamination process alone can result in significant change in the casualty’s condition, so re-triage and reassessment are the first priority. If a secondary survey has not been performed, it should be done immediately after re-assessment of the primary survey. Documentation throughout the phases of care is vital to facilitate information transfer as the patient transits from one phase to another. The CBRN casualty card (Appendix B) is a useful tool to ensure comprehensive documentation relevant to the CBRN casualty. In the absence of a CBRN casualty card, the TCCC casualty card is sufficient if duration of care before transfer is short and patient is relatively stable. If handoff to higher echelon of care is delayed or patient is unstable, PFC documentation will likely be necessary. (Loos 2018)

It is important to take into consideration that receiving providers at all roles of care may have minimal to no experience with CBRN patients. Communication is crucial to ensure receiving providers understand previous decontamination and care and exposures that may be suspected. This can prevent delays in patient care caused by unnecessary repetitive decontamination or redundant treatments.

Casualties that reach the cold zone have been decontaminated and are now suitable for the full spectrum of care appropriate to the clinical environment and capabilities. There are however, some unique concerns to address in a combination CBRN/trauma casualty. While thorough decontamination and complete removal of a casualty’s clothing eliminates almost all debris, it is possible the casualty may have retained foreign material or contaminated dressings in wounds. Such material may pose risk to treating personnel from off-gassing or secondary contamination. Additionally, this residual contamination may represent a continuing source of exposure to the patient via a route that bypasses the normal barriers of the skin resulting in rapid systemic distribution of the agent. Larger fragments should be removed from the wound using a “no touch” technique with surgical instruments, followed by placing the material and instrument in a sealed container with hypochlorite solution, minimizing the risk to providers. When possible, the contaminated wound should be further irrigated with clean water. Providers dealing with contaminated foreign material or dressings can wear 3 pairs of nitrile gloves. The outer glove should be discarded every 20 minutes. In the absence of suspected retained debris, the fully decontaminated patient in the cold zone can be treated as all other patients at that level of care. The extent of wound care provided will depend on prehospital resources available and transport time to surgical care.