BOLD Text indicates recommendations that are significantly different from human TCCC
Basic Management Plan for Care Under Fire
* NOTE: CoTCCC recommended human-designed windlass limb tourniquets are generally ineffective in canines due to conformational differences; Limb tourniquets are, generally, not warranted to abate extremity hemorrhage in canines.
Establish a security perimeter in accordance with unit tactical standard operating procedures and/or battle drills. Maintain tactical situational awareness.
Triage casualties as required. Human casualties should always be given priority over MWD casualties.
* CoTCCC recommended windlass, limb tourniquets designed for humans (e.g. C-A-T, SOFTT-W) tend to slip distally and generally fail on MWDs due to conformational differences and should not be used as first line therapy for hemorrhage control in MWDs.
* The only tourniquet that should be considered for use on a massive extremity hemorrhage in a MWD’s is a stretchable and elastic tourniquet such as the SWAT-T. This type of material allows it to mold to nearly any limb size and conformation in conjunction with its wide design, allows it to serve as an effective circumferential pressure bandage on an MWD’s limb.
*Junctional tourniquets have not been evaluated in dogs and are not recommended at this time.
a. Conscious MWD with no airway problems identified:
b. Unconscious casualty without airway obstruction:
c. Conscious MWD with airway obstruction or impending airway obstruction:
d. If attempts to clear or remove the airway obstruction have failed or the MWD collapses or becomes unconscious consider one of the following techniques:
NOTE: intubation of the MWD is most easily performed with the dog in sternal or prone position (but can be performed in lateral), head and neck extended, and tongue pulled forward. Capnometer reading >10 mmHg also verifies correct placement.
If necessary assisted ventilation via an Ambu-bag can be performed at a rate of 8-10 breaths per minute.
* Blind Insertion Airway Device / Nasopharyngeal airways / Extraglottic Airway Devices have not been evaluated in canines and should not be utilized in MWDs.
e. Cervical Spinal stabilization is not necessary for MWDs suffering only penetrating trauma.
f. Monitor hemoglobin saturation (SpO2) and capnography when available, to help assess airway patency
g. Always remember that the MWD’s airway status may change over time and requires frequent reassessment.
a. All Open and/or Sucking chest wounds should be treated by immediately applying gloved hand over the wound/defect, followed by placement of a vented or non-vented occlusive seal to cover the defect.
b. Monitor /assess the MWD for development of tension pneumothorax and treat as necessary (see section d below).
c. Suspect a tension pneumothorax in the setting of known or suspected torso trauma or primary blast injury and one or more of the following:
d. Initial treatment of suspected tension pneumothorax consider:
Note: Re-positioning the canine into lateral may allow air to redistribute, rise and accumulate to the highest point on the affected side.
e. When available, initiate pulse oximetry and monitor pulse oximetry in all MWDs suffering moderate to severe TBI. The presence of circulatory shock or marked hypothermia (< 95°F / 35°C) may adversely influence readings.
f. Consider administering oxygen supplementation when SpO2 < 94% on room/atmospheric and when available.
* Note: Pelvic binders have not been evaluated in dogs. However because pelvic fractures in dogs are very unlikely to result in life threatening hemorrhage, pelvic binders are not recommended in MWDs at this time.
b. IV/IO Access
c. Tranexamic Acid (TXA)
d. Fluid resuscitation
*Note: DO NOT administer human blood products to a canine. Human blood products have a high probability of causing a hemolytic reaction when transfused into a canine.
e. Refractory Shock
a. Minimize MWD’s exposure to the elements.
b. Get the MWD onto an insulated surface as soon as possible.
c. Apply the Ready-Heat Blanket from the Hypothermia Prevention and Management Kit (HPMK) to the MWD’s torso (not directly on the skin) and cover the MWD with the Heat-Reflective Shell (HRS).
d. If an HRS is not available, the previously recommended combination of the Blizzard Survival Blanket and the Ready Heat blanket may also be used.
e. If the items mentioned above are not available, use dry blankets, poncho liners, sleeping bags, or anything that will retain heat and keep the MWD dry.
f. Warm fluids are preferred if IV fluids are required.
If a penetrating eye injury is noted or suspected:
NOTE: Ketamine can cause nystagmus and increased intraocular pressure in a MWD. Therefore consider alternative sedatives/analgesics in MWDs with penetrating eye traumas unless other alternatives do not exist or are ineffective.
Initiate advanced electronic monitoring if indicated and if monitoring equipment is available.
a. Analgesia on the battlefield should generally be achieved using one of three options:
* Morphine and hydromorphone often causes vomiting in dogs so handlers and medics should be prepared to remove the muzzle after administration of an opioid. Hydromorphone causes excessive panting; use caution with head injuries and respiratory disease.
If possible, strongly consider combination therapy whenever using ketamine in MWDs. Suggest a combination of 50 mg ketamine with either an opioid (5 mg of morphine OR 3 mg of hydromorphone OR 150 mcg fentanyl) OR a benzodiazepine (10 mg of midazolam or diazepam) to improve analgesia and sedation
* End points: Control of pain and appropriate level of sedation. MWD should be generally recumbent but responsive and breathing comfortably
b. For all casualties given opioids or ketamine – monitor airway, breathing, and circulation closely
c. Consider adjunct administration of antiemetics (Ondansetron 8-16 mg IV or 24 mg PO) prior to administering opioids.
d. Naloxone should be available when using opioid analgesics.
e. Both ketamine and opioids have the potential to worsen severe TBI. The combat medic, corpsman, or PJ must consider this fact in his or her analgesic decision, but if the MWD is vocalizing and demonstrating painful behaviors, then the TBI is likely not severe enough to preclude the use of ketamine or opioids.
f. Ketamine may be a useful adjunct to reduce the amount of opioids required to provide effective pain relief. It is safe to give ketamine to a MWD who has previously received morphine. IV Ketamine should be given over 1 minute.
g. If respirations are noted to be reduced after using opioids or ketamine, provide ventilatory support with a bag-valve-mask or mouth-to-mask ventilations.
h. Reassess, reassess, reassess
a. Antibiotics are recommended for all open combat wounds.
b. Recommended antibiotics in order of preference are:
- Moxifloxacin (from the CWMP), 400 mg PO once a day
Inspect and dress known wounds.
Check for additional wounds
a. 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 intubation or surgical airway for respiratory distress or oxygen desaturation.
b. Estimate total body surface area (TBSA) burned to the nearest 10% using the Rule of Nines.
c. Cover the burn area with dry, sterile dressings. For extensive burns (>20%), consider placing the casualty in the Heat-Reflective Shell or Blizzard Survival Blanket from the Hypothermia Prevention Kit in order to both cover the burned areas and prevent hypothermia.
d. Fluid resuscitation (extrapolated from the USAISR Rule of Ten)
e. Analgesia in accordance with the K9TCCC Guidelines in Section (10) may be administered to treat burn pain.
f. Prehospital antibiotic therapy is not indicated solely for burns, but antibiotics should be given per the K9TCCC guidelines in Section (11) if indicated to prevent infection in penetrating wounds.
g. All K9TCCC interventions can be performed on or through burned skin in a burn casualty.
h. Burn patients are particularly susceptible to hypothermia. Extra emphasis should be placed on barrier heat loss prevention methods.
a. Important: Handle an injured canine with a fracture with extreme care and proper restraint and muzzling, if appropriate. Consider sedation and analgesia before manipulating the fractured site (see Section 10).
b. SAM splints and spoon splints can be applied below the knee or below the elbow. Ensure sufficient padding is in place along pressure points when applying these splints to minimize the risk of further injuries.
a. Communicate consistently with the canine handler or assigned escort. Explain care provided and request support required for canine management and positioning. Handler and canine should travel together whenever feasible to facilitate handling and comfort of the MWD.
b. Communicate with tactical leadership as soon as possible and as needed during the treatment process. Provide leadership with casualty status on a regular basis and evacuation requirements to assist with coordination of evacuation and dedication of on-site support assets. Include canine handler or escort in evacuation planning for casualty management.
c. Communicate with the established evacuation system for that specific locale to arrange TACEVAC. Provide mechanism of injury, injuries sustained, identified signs/symptoms, current status, and treatments/medications administered to medical providers on evacuation platform. Ensure receiving medical providers are aware of the need to have canine Handler or assigned escort accompany the casualty for management.
a. CPR within a tactical or high-threat environment for victims of blast or penetrating trauma who have no pulse, no ventilations, and no other signs of life is not often successful
b. Bilateral needle decompression (See section 3) for MWDs suffering torso or polytrauma with no respirations or pulse should be performed to verify that tension pneumothorax is not the cause of cardiac arrest. This should be completed prior to determining if CPR should be initiated or continued
a. Complete the Canine Tactical Combat Casualty Care Card. Request general information from Handler or assigned escort. Document evacuation category, evacuation type, mechanism of injury, treatments, and medications administered.
b. Update the signs and vital parameters every five minutes for critical/unstable MWD casualties an every 15 minutes for stable, non-critical canine casualties.
c. Document any additional information that would be beneficial for higher level of care under NOTES portion.
a. Complete and secure the canine TCCC Card to the MWD. If available, use Canine Deployment Medical Card for missing information.
b. Secure Canine Deployment Medical Card to canine.
c. Verify placement and efficacy of all interventions.
d. Secure all loose ends of bandages and wraps.
e. Secure litter straps based on configuration requirements if applicable. Consider padding for extended evacuations.
f. Stage casualty for evacuation based on unit standard operating procedures.
g. Position canine handler or assigned escort at the head of the MWD.
h. Protect artificial airway, if present, from excessive wind, dirt, foreign objects.
i. Maintain security at the evacuation point in accordance with unit standard operating procedures.
j. Transport injured MWD requiring emergent surgery to the closest surgical team regardless if there is a veterinary team at that location