Establish a security perimeter in accordance with unit tactical standard operating procedures and/or battle drills. Maintain tactical situational awareness.
Triage casualties as required. Casualties with an altered mental status should have weapons and communications equipment taken away immediately.
a. Assess for unrecognized hemorrhage and control all sources of bleeding. If not already done, use a CoTCCC-recommended limb tourniquet to control life- threatening external hemorrhage that is anatomically amenable to tourniquet use or for any traumatic amputation. Apply directly to the skin 2-3 inches above the bleeding site. If bleeding is not controlled with the first tourniquet, apply a second tourniquet side-by-side with the first.
b. For compressible (external) hemorrhage not amenable to limb tourniquet use or as an adjunct to tourniquet removal, use Combat Gauze as the CoTCCC hemostatic dressing of choice.
c. For external hemorrhage of the head and neck where the wound edges can be easily re-approximated, the iTClamp may be used as a primary option for hemorrhage control. Wounds should be packed with a hemostatic dressing or XStat, if appropriate, prior to iTClamp application.
d. Perform initial assessment for hemorrhagic shock (altered mental status in the absence of brain injury and/or weak or absent radial pulse) and consider immediate initiation of shock resuscitation efforts.
a. Assess for unobstructed airway.
b. If there is a traumatic airway obstruction or impending traumatic obstruction, prepare for possible direct airway intervention.
c. Allow a conscious casualty to assume any position that best protects the airway, to include sitting up and/or leaning forward.
d. Place unconscious casualty in the recovery position, head tilted back; chin away from chest.
e. Use suction if available and appropriate.
f. If the previous measures are unsuccessful, and the casualty’s airway obstruction (e.g. facial fractures, direct airway injury, blood, deformation or burns) is unmanageable, perform a surgical cricothyroidotomy using one of the following:
g. Frequently reassess SpO2, EtCO2, and airway patency as airway status may change over time.
h. Cervical spine stabilization is not necessary for casualties who have sustained only penetrating trauma.
a. Assess for tension pneumothorax and treat as necessary.
NOTE: If not treated promptly, tension pneumothorax may progress from respiratory distress to shock and traumatic cardiac arrest.
NOTE: Either the 5th intercostal space (ICS) in the anterior axillary line (AAL) or the 2nd ICS in the mid-clavicular line (MCL) may be used for needle decompression (NDC). If the anterior (MCL) site is used, do not insert the needle medial to the nipple line.
The needle/catheter unit should be inserted at an angle perpendicular to the chest wall and just over the top of the lower rib at the insertion site. Insert the needle/catheter unit all the way to the hub and hold it in place for 5-10 seconds to allow decompression to occur.
After the NDC has been performed, remove the needle and leave the catheter in place.
b. All open and/or sucking chest wounds should be treated by immediately applying a vented chest seal to cover the defect. If a vented chest seal is not available, use a non-vented chest seal. Monitor the casualty for the potential development of a subsequent tension pneumothorax. If the casualty develops increasing hypoxia, respiratory distress, or hypotension and a tension pneumothorax is suspected, treat by burping or removing the dressing or by needle decompression.
c. Initiate pulse oximetry. All individuals with moderate/severe TBI should be monitored with pulse oximetry. Readings may be misleading in the settings of shock or marked hypothermia.
d. Casualties with moderate/severe TBI should be given supplemental oxygen when available to maintain an oxygen saturation > 90%.
e. If the casualty has impaired ventilation and uncorrectable hypoxia with decreasing oxygen saturation below 90%, consider insertion of a properly sized Nasopharyngeal Airway, and ventilate using a 1000ml resuscitator Bag-Valve-Mask.
f. Use continuous EtCO2 and SpO2 monitoring to help assess airway patency.
OR
1. Cold stored low titer O whole blood
2. Pre-screened low titer O fresh whole blood
3. Plasma, red blood cells (RBCs) and platelets in a 1:1:1 ratio
4. Plasma and RBCs in a 1:1 ratio
5. Plasma or RBCs alone
NOTE: Hypothermia prevention measures [Section 7] should be initiated while fluid resuscitation is being accomplished.
If not in shock:
If in shock and blood products are available under an approved command or theater blood product administration protocol:
Given increased risk for a potentially lethal hemolytic reaction, transfusion of unscreened group O fresh whole blood or type specific fresh whole blood should only be performed under appropriate medical direction by trained personnel.
Transfusion should occur as soon as possible after life-threatening hemorrhage in order to keep the patient alive. If Rh negative blood products are not immediately available, Rh positive blood products should be used in hemorrhagic shock.
If a casualty with an altered mental status due to suspected TBI has a weak or absent radial pulse, resuscitate as necessary to restore and maintain a normal radial pulse. If BP monitoring is available, maintain a target systolic BP between 100-110 mmHg.
Reassess the casualty frequently to check for recurrence of shock. If shock recurs, re-check all external hemorrhage control measures to ensure that they are still effective and repeat the fluid resuscitation as outlined above.
a. Take early and aggressive steps to prevent further body heat loss and add external heat, when possible, for both trauma and severely burned casualties.
b. Minimize casualty’s exposure to cold ground, wind and air temperatures. Place insulation material between the casualty and any cold surface as soon as possible. Keep protective gear on or with the casualty if feasible.
c. Replace wet clothing with dry clothing, if possible, and protect from further heat loss.
d. Place an active heating blanket on the casualty’s anterior torso and under the arms in the axillae (to prevent burns, do not place any active heating source directly on the skin or wrap around the torso).
e. Enclose the casualty with the exterior impermeable enclosure bag.
f. As soon as possible, upgrade hypothermia enclosure system to a well-insulated enclosure system using a hooded sleeping bag or other readily available insulation inside the enclosure bag/external vapor barrier shell.
g. Pre-stage an insulated hypothermia enclosure system with external active heating for transition from the non-insulated hypothermia enclosure systems; seek to improve upon existing enclosure system when possible.
h. Use a battery-powered warming device to deliver IV/IO resuscitation fluids, in accordance with current CoTCCC guidelines, at flow rate up to 150 ml/min with a 38°C output temperature.
i. Protect the casualty from exposure to wind and precipitation on any evacuation platform.
(unable to follow commands with either evidence of head trauma or a blunt/blast mechanism)
a. Prevent hypoxemia (goal SpO2 >90-95%)
b. Prevent hypotension – maintain SBP 100-110 mmHg. Transfuse whole blood or plasma preferentially if casualty is in hemorrhagic shock. Otherwise use 1-2 L bolus of crystalloid if no evidence of hemorrhage or hemorrhagic shock.
c. Identify and treat herniation (declining neurologic status with asymmetric or fixed/dilated pupil(s), or posturing):
a. If a penetrating eye injury is noted or suspected:
a. Initiate advanced electronic monitoring if indicated and if monitoring equipment is available.
TCCC non-medical first responders should provide analgesia on the battlefield achieved by using:
TCCC Medical Personnel:
Option 1
Option 2
TCCC Combat Paramedics or Providers:
Option 3
Option 4
TCCC Combat Paramedics or Providers:
If an emergence phenomenon occurs, consider giving 0.5-2 mg IV/IO midazolam.
If continued dissociation is required, move to the Prolonged Casualty Care (PCC) analgesia and sedation guidelines.
Analgesia and sedation notes:
Antibiotics: recommended for all open combat wounds
a. If able to take PO meds:
b. If unable to take PO meds (shock, unconsciousness):
Check for additional wounds
a. Assess and treat as a trauma casualty with burns and not burn casualty with injuries.
b. 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 surgical airway for respiratory distress or oxygen desaturation.
c. Estimate total body surface area (TBSA) burned to the nearest 10% using the Rule of Nines.
d. 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.
e. Fluid resuscitation (USAISR Rule of Ten)
f. Analgesia in accordance with the TCCC Guidelines in Section (10) may be administered to treat burn pain.
g. Prehospital antibiotic therapy is not indicated solely for burns, but antibiotics should be given per the TCCC guidelines in Section (11) if indicated to prevent infection in penetrating wounds.
h. All TCCC interventions can be performed on or through burned skin in a burn casualty.
i. Burn patients are particularly susceptible to hypothermia. Extra emphasis should be placed on barrier heat loss prevention methods.
Splint fractures and re-check pulses.
a. Resuscitation on the battlefield for victims of blast or penetrating trauma who have no pulse, no ventilations, and no other signs of life will not be successful and should not be attempted. However, casualties with torso trauma or polytrauma who have no pulse or respirations during TFC should have bilateral needle decompression performed to ensure they do not have a tension pneumothorax prior to discontinuation of care. The procedure is the same as described in section (5a) above.
a. Communicate with the casualty if possible. Encourage, reassure and explain care.
b. Communicate with tactical leadership as soon as possible and throughout casualty treatment as needed. Provide leadership with casualty status and evacuation requirements to assist with coordination of evacuation assets.
c. Communicate with the evacuation system (the Patient Evacuation Coordination Cell) to arrange for TACEVAC. Communicate with medical providers on the evacuation asset if possible and relay mechanism of injury, injuries sustained, signs/symptoms, and treatments rendered. Provide additional information as appropriate.
a. Document clinical assessments, treatments rendered, and changes in the casualty’s status on a TCCC Card (DD Form 1380).
b. Forward documentation with the casualty to the next level of care.
a. Complete and secure the TCCC Card (DD 1380) to the casualty.
b. Secure all loose ends of bandages and wraps.
c. Secure hypothermia prevention wraps/blankets/straps.
d. Secure litter straps as required. Consider additional padding for long evacuations.
e. Provide instructions to ambulatory patients as needed.
f. Stage casualties for evacuation in accordance with unit standard operating procedures.
g. Maintain security at the evacuation point in accordance with unit standard operating procedures.