Tactical Trauma Assessment

This module is an overview of tactical trauma assessment (TTA). The skills practice will take place near the end of the course after you have learned ALL of the skills.

Tactical Combat Casualty Care is broken up into four roles of care. The most basic is taught to All Service Members (ASM), which is designed to instruct in the absolute basics of hemorrhage control and to recognize more serious injuries.

You are in the Combat Lifesaver (CLS) role. This teaches you more advanced care to treat the most common causes of death on the battlefield, and to recognize, prevent, and communicate with medical personnel the life-threatening complications of these injuries.

The Combat Medic/Corpsman (CMC) role includes much more advanced and invasive care requiring significantly more medical knowledge and skills.

Finally, the last role, Combat Paramedic/Provider (CPP) is for Combat paramedics and advanced providers, to provide the most sophisticated care to keep our wounded warriors alive and get them to definitive care.

Your role as a CLS is to treat the most common causes of death on the battlefield, which are massive hemorrhage and airway/respiratory problems. Also, you are given the skills to prevent complications and treat other associated but not immediately life-threatening injuries.

The Tactical Trauma Assessment (TTA) module has three cognitive learning objectives and five performance learning objectives. The cognitive learning objectives are to identify the:

1. Common causes of altered mental status in combat or noncombat environments
2. Importance of disarming and securing communications equipment of a casualty with altered mental status
3. Importance and techniques of communicating with a casualty in TFC

The performance learning objectives are to demonstrate:

1. Techniques used to assess a casualty for responsiveness
2. Communication with a casualty in Tactical Field Care
3. Application of body substance isolation (BSI) in TFC
4. TTA in the proper order using the MARCH PAWS sequence in accordance with CoTCCC guidelines
5. Appropriate actions and interventions used during a casualty assessment to render aid to the casualty in accordance with CoTCCC Guidelines.

The critical aspects are to identify the importance of and demonstrate the systematic approach for assessment and interventions in providing lifesaving care to a casualty following the MARCH PAWS sequence in accordance with the CoTCCC guidelines.

A full tactical trauma assessment should follow the MARCH PAWS sequence.

- Massive bleeding
- Airway
- Respiration/breathing
- Circulation
- Hypothermia/Head injuries

- Pain
- Antibiotics
- Wounds
- Splinting

We will cover the interventions and procedures of MARCH PAWS in more detail in later modules

Pay attention to this video. You will be expected to perform a full TTA upon completion of this training.

# TACTICAL TRAUMA ASSESSMENT HOW-TO (VIDEO)

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# COMBAT SPEED TTA "FIRE FIGHT CONSCIOUS CASUALTY" (VIDEO)

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# COMBAT SPEED TTA "EXPLOSION" UNCONSCIOUS CASUALTY (VIDEO)

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Whenever possible, the responder/CLS should don latex-free gloves as a BSI precaution.

Gloves are provided in the JFAK and CLS bags.

Your initial casualty evaluation should be a rapid head-to-toe check for any unrecognized life-threatening bleeding (a blood sweep).

This blood sweep should include a visual and hands-on (palpation) inspection of the front and back of the casualty from head to toe, including neck, armpits, groin, etc.

This blood sweep is a systematic way to ensure rapid identification of any unrecognized life-threatening bleeding.

If you identify life-threatening bleeding that was missed in the Care Under Fire phase, immediately apply a tourniquet or hemostatic dressing, and/or pressure dressing.

If a tourniquet was previously applied but bleeding is not controlled, apply a second tourniquet side-by-side with the original tourniquet, preferably higher on the injured limb, if possible, to control the bleeding. This is the “M” of MARCH PAWS.

Evaluate the casualty’s airway and ensure the airway is open. LOOK (for rise and fall of the chest), LISTEN (for sounds of breathing), and FEEL (breath on your cheek) for indications of trouble breathing, snoring or gurgling sounds, visible objects obstructing the airway, and any severe trauma to the face.

Do not do a blind finger sweep.

If a casualty is unconscious, the tongue may have relaxed, causing an airway blockage. Use the head-tilt chin-lift or jaw-thrust method to open the airway. Important note: If a neck or spinal injury is suspected, use the jaw-thrust method to open the airway.

This is the first “A” of MARCH PAWS.

NOTE: Once the airway has been opened using one of these maneuvers, the casualty may require repeated/continued maneuvers to maintain an open airway.

If the casualty is unconscious or semiconscious but breathing on their own AND you do not identify an airway obstruction, you may be able to better support airway management through the use of a nasopharyngeal airway (NPA). This can help open/maintain a conscious or unconscious casualty’s airway.

Note any clear fluid coming from the nose or ears. This may be cerebrospinal fluid, which indicates a possible skull fracture. Do not attempt to place an NPA if clear fluid is coming from the nose or ears.

If airway maneuvers and nasopharyngeal airway are ineffective at opening or maintaining an open airway, notify medical personnel.

If the casualty is conscious, allow them to assume any position that best protects the airway and allows them to breath easily, including sitting up.

Place an unconscious casualty in the recovery position. If an NPA was inserted into the right nostril, place the casualty on their right side, if possible.

LOOK (for rise and fall of the chest), LISTEN (for sounds of breathing), and FEEL (breath on your cheek) for indications of trouble breathing (as noted for airway previously).

Respiration rate (breaths per minute) and quality (shallow, labored, etc.) should be noted.

Indications of respiratory distress include:

- Breathing that is progressively difficult
- Decreased breathing sounds
- Distended neck veins
- Opposed to “progressive” respiratory distress
- Hunched over; they need to be in the “position of comfort”
- Agitation due to a lack of oxygen
- High pulse

This is the “R” of MARCH PAWS.

Common causes of chest injuries include gunshot, stab, or shrapnel wounds to chest and blunt-force trauma.

Note obvious signs of penetrating trauma, bruising, swelling, crackling/popping (on palpation), or other deformities of the chest. Check the casualty’s respiration and ability to breathe. All open and/or sucking chest wounds should be treated by immediately applying a vented chest seal to cover the defect.

For respiratory distress not resolved by a chest seal or in a casualty with known or suspected chest or back trauma without an open and/or sucking chest wound, consider a tension pneumothorax, and perform a needle decompression of the chest.

Injuries to the chest are very serious and can be life-threatening. The casualty’s condition can change quickly with a chest injury.

This is the “C” in MARCH PAWS. The casualty should be reassessed for life-threatening hemorrhage (including effectiveness of prior interventions-TQs, pressure bandages, etc.).

Is there an obvious pelvic or femur fracture? If so, a medic should be informed immediately. Assess the radial pulse.

If the pulse is absent or weak, shock should be suspected and a medic should be informed immediately.

The CLS should be familiar with the signs/symptoms of shock. In the combat environment, shock is assumed to be due to blood loss.

If untreated, shock could lead to death. If shock is suspected, a medic should be informed immediately.

Prevent hypothermia by minimizing the casualty’s exposure to the elements and applying active hypothermia prevention measures, when possible.

If no rewarming equipment is available, then use dry blankets, poncho liners, sleeping bags, or anything that will retain heat and keep the casualty dry. Make sure you assess for hemorrhagic shock and ensure bleeding is controlled.

Perform rapid field test of visual acuity (e.g., read Meals Ready to Eat (MRE) label, or name tag).

If the casualty has any penetrating injuries, they should take the antibiotic in the Combat Wound Medication Pack (CWMP). Cover eye with rigid shield, not pressure patch. Do not cover both eyes unless both are injured and you are sure the casualty will not return to the fight.

The CWMP contains drugs for mild to moderate pain (meloxicam and acetaminophen) and an antibiotic specific for penetrating wounds (moxifloxacin).

A CWMP can give significant pain relief for mild to moderate pain and will not alter the casualty’s mental status. It also includes antibiotics for preventing/treating infections after traumatic injuries, such as penetrating wounds, eye injuries, and burns.

This is the “P” and “A” of MARCH PAWS.

This is the “W” in MARCH PAWS.

All other wounds (burns, fractures, other soft tissue wounds, etc.) should be addressed with splinting, dressings, etc. as appropriate. This will be covered in more detail in a later module.

Note: Reassess pulses after all dressings are placed to ensure that they are not too tight. Do not ever apply one and forget it!

Stop the burning process by extracting the casualty from the source, and cover the burned areas with dry, sterile dressings.

If the burn is caused by white phosphorus, submerse the affected area in water, if possible; otherwise, the dressing must be wet. Advise medical personnel immediately.

Remember to prioritize assessing MARCH before addressing burns. This is part of the “W” of MARCH PAWS.

Assess for any fractures, and if present, splint the fracture using whatever materials are available, making sure to immobilize the joint above and the joint below the fracture.

Check pulse(s) before and after applying splints. Treat open fractures with meds (for pain and to prevent infection) with meds from the CWMP.

This is the “S” of MARCH PAWS.

Communicate with the casualty by reassuring them and telling them about procedures being performed.

Communicate with medical personnel and your tactical leadership, and relay casualty status and evacuation needs.

Document all assessment and care on a DD Form 1380 TCCC card. Every Service member will carry their own DD Form 1380 in their JFAK. If possible, use a permanent marker (such as a Sharpie) to make entries on the card. When rendering care or assisting medical personnel, include as much information as you can on the card.

This is the official record of the care provided and should go with the casualty when care is handed off to a medic or at the time of evacuation.

Communication includes the MIST report and 9-line MEDEVAC request.

At this time we will break for a trainer-led demonstration on TTA.

In this module, we discussed the TTA. We identified the common causes of altered mental status in combat or noncombat environments, the importance of disarming and securing the communications equipment of a casualty with altered mental status, and techniques for communicating with a casualty in TFC. We also demonstrated techniques for assessing a casualty for responsiveness, applying body substance isolation, conducting a TTA in the proper order using the MARCH PAWS sequence, and using appropriate actions and interventions in a casualty assessment to render aid in accordance with CoTCCC Guidelines.

To close out this module, check your learning with the questions below (answers under the image).

# Answers

### In which phase of care is the TTA performed?

- TFC

### What pneumonic is used to prioritize care in the TTA?

- MARCH PAWS

### What is a blood sweep?

- A blood sweep is your initial casualty evaluation. It should be a rapid head-to-toe check for any unrecognized life-threatening bleeding.