C191 w2tc cmast tactical combat casualty care

Tactical Combat Casualty CareTactical Combat Casualty Care((TC-3TC-3))

COMBAT MEDIC ADVANCED SKILLS TRAINING (CMAST)

CMASTCMAST 22

IntroductionIntroduction

Soldiers continue to die on today’s Soldiers continue to die on today’s battlefield just as they did during the Civil battlefield just as they did during the Civil War. The standards of care applied to the War. The standards of care applied to the battlefield have always been based on battlefield have always been based on civilian care principles. These principles civilian care principles. These principles while appropriate for the civilian while appropriate for the civilian community, often do not apply to care on community, often do not apply to care on the battlefield.the battlefield.

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Civilian medical trauma training is Civilian medical trauma training is based on the following principles:based on the following principles:

Emergency Medical Technicians Emergency Medical Technicians Pre-Hospital Trauma Life Support (PHTLS)Pre-Hospital Trauma Life Support (PHTLS) Advanced Trauma Life Support (ATLS)Advanced Trauma Life Support (ATLS)

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Tactical Combat Casualty Care (TC-3) has Tactical Combat Casualty Care (TC-3) has been approved by the American College of been approved by the American College of Surgeons and National Association of Surgeons and National Association of EMTs and is included in the Pre-hospital EMTs and is included in the Pre-hospital Trauma Life Support (PHTLS) manual 5Trauma Life Support (PHTLS) manual 5thth edition.edition.

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Three goals of TC-3:Three goals of TC-3: 1. Treat the casualty1. Treat the casualty 2. Prevent additional casualties2. Prevent additional casualties 3. Complete the mission3. Complete the mission

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This approach recognizes a particularly This approach recognizes a particularly important principle: important principle:

Performing the correct intervention at the Performing the correct intervention at the correct time in the continuum of combat correct time in the continuum of combat care. A medically correct intervention care. A medically correct intervention performed at the wrong time in combat performed at the wrong time in combat may lead to further casualties.may lead to further casualties.

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Pre-hospital care continues to be critically Pre-hospital care continues to be critically important.important.

Up to 90% of all combat deaths occur Up to 90% of all combat deaths occur before a casualty reaches a Medical before a casualty reaches a Medical Treatment Facility (MTF).Treatment Facility (MTF).

Penetrating vs. blunt trauma.Penetrating vs. blunt trauma.

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Factors influencing combat Factors influencing combat casualty care casualty care

Enemy FireEnemy Fire

Medical Equipment LimitationsMedical Equipment Limitations

Widely Variable Evacuation TimeWidely Variable Evacuation Time

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Factors influencing combat Factors influencing combat casualty carecasualty care

Tactical ConsiderationsTactical Considerations

Casualty TransportationCasualty Transportation

CMASTCMAST 1010

Click on picture for video

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Stages of CareStages of Care

Care Under FireCare Under Fire

Tactical Field CareTactical Field Care

Combat Casualty Evacuation CareCombat Casualty Evacuation Care

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““Care under fire” is the care rendered by Care under fire” is the care rendered by the soldier medic at the scene of the injury the soldier medic at the scene of the injury while they and the casualty are still under while they and the casualty are still under effective hostile fire. Available medical effective hostile fire. Available medical equipment is limited to that carried by the equipment is limited to that carried by the individual soldier or soldier medic in their individual soldier or soldier medic in their medical aid bag.medical aid bag.

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Tactical Field CareTactical Field Care ““Tactical Field Care” is the care rendered Tactical Field Care” is the care rendered

by the soldier medic once they and the by the soldier medic once they and the casualty are no longer under effective casualty are no longer under effective hostile fire. It also applies to situations in hostile fire. It also applies to situations in which an injury has occurred, but there which an injury has occurred, but there has been no hostile fire. Available medical has been no hostile fire. Available medical equipment is still limited to that carried into equipment is still limited to that carried into the field by medical personnel. Time to the field by medical personnel. Time to evacuation to an MTF may vary evacuation to an MTF may vary considerably.considerably.

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Combat Casualty Evacuation Combat Casualty Evacuation CareCare

““Combat Casualty Evacuation Care” is the Combat Casualty Evacuation Care” is the care rendered once the casualty has been care rendered once the casualty has been picked up by an aircraft, vehicle or boat. picked up by an aircraft, vehicle or boat. Additional medical personnel and Additional medical personnel and equipment may have been pre-staged and equipment may have been pre-staged and available at this stage of casualty available at this stage of casualty management. management.


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Medical personnel’s firepower may be Medical personnel’s firepower may be essential in obtaining tactical fire essential in obtaining tactical fire superiority. Attention to suppression of superiority. Attention to suppression of hostile fire may minimize the risk of injury hostile fire may minimize the risk of injury to personnel and minimize additional injury to personnel and minimize additional injury to previously injured soldiers.to previously injured soldiers.

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Care Under FireCare Under Fire Personnel may need to assist in returning Personnel may need to assist in returning

fire instead of stopping to care for fire instead of stopping to care for casualties.casualties.

Wounded soldiers should return fire if Wounded soldiers should return fire if able and or move as quickly as possible to able and or move as quickly as possible to any nearby cover.any nearby cover.

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Medical personnel are limited and if Medical personnel are limited and if injured, no other medical personnel may injured, no other medical personnel may be available until the time of extraction be available until the time of extraction during the CASEVAC phase.during the CASEVAC phase.

No immediate management of the airway No immediate management of the airway is necessary at this time due to limited is necessary at this time due to limited time available and the movement of the time available and the movement of the casualty to cover.casualty to cover.

CMASTCMAST 2222

Care Under FireCare Under Fire Control of hemorrhage is important since Control of hemorrhage is important since

injury to a major vessel can result in injury to a major vessel can result in hypovolemic shock in a short time frame.hypovolemic shock in a short time frame.

Over 2,500 deaths occurred in Viet Nam Over 2,500 deaths occurred in Viet Nam secondary to hemorrhage from extremity secondary to hemorrhage from extremity wounds.wounds.

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Use of temporary tourniquets to Use of temporary tourniquets to stop stop the bleedingthe bleeding is essential in these types is essential in these types of casualties.of casualties.

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Soldier medic first to die;Soldier medic first to die;soldiers: no equipment or training?soldiers: no equipment or training?

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TourniquetTourniquet

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The need for immediate access to a The need for immediate access to a tourniquet in such situations makes it clear tourniquet in such situations makes it clear that all soldiers on combat missions have that all soldiers on combat missions have a suitable tourniquet readily available at a a suitable tourniquet readily available at a standard location on their battle gear and standard location on their battle gear and be trained in its use.be trained in its use.

CMASTCMAST 2727

Combat Application TourniquetCombat Application Tourniquet

WINDLASS

SELF ADHERING BANDWINDLASS STRAP

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Hemorrhage ControlHemorrhage Control If the wound is not an extremity wound If the wound is not an extremity wound

and a tourniquet is not applicable such as:and a tourniquet is not applicable such as:– Neck injuryNeck injury– Axillary injuryAxillary injury– Groin injuryGroin injury– Apply a HemCon hemostatic bandage with Apply a HemCon hemostatic bandage with

pressure to control the bleedingpressure to control the bleeding

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Pressure & HemCon BandagePressure & HemCon Bandage

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Penetrating neck injuries do not require Penetrating neck injuries do not require C-spine immobilization. Other neck C-spine immobilization. Other neck injuries, such as falls over 15 feet, fast-injuries, such as falls over 15 feet, fast-roping injuries or MVAs may require C-roping injuries or MVAs may require C-spine control spine control unlessunless the danger of hostile the danger of hostile fire constitutes a greater threat in the fire constitutes a greater threat in the judgment of the soldier medic.judgment of the soldier medic.

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Care Under Fire Care Under Fire

Conventional litters may not be available Conventional litters may not be available for movement of casualties. Consider for movement of casualties. Consider alternate methods to move casualties such alternate methods to move casualties such as a SKEDas a SKED®® or Talon II or Talon II®® litter. Smoke, CS litter. Smoke, CS and vehicles may act as screens to assist and vehicles may act as screens to assist in casualty movement.in casualty movement.

CMASTCMAST 3232

SKED LitterSKED Litter

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Talon II LitterTalon II Litter

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Care Under FireCare Under Fire Do not attempt to salvage a Do not attempt to salvage a

casualty’s rucksack unless it casualty’s rucksack unless it contains items critical to the contains items critical to the mission.mission.

Take the casualty’s weapon Take the casualty’s weapon and ammunition if possible to and ammunition if possible to prevent the enemy from using prevent the enemy from using them against you.them against you.

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Key PointsKey Points Return fire as directed or required.Return fire as directed or required. The casualty(s) should also return fire if able.The casualty(s) should also return fire if able. Direct casualty to cover and apply self-aid if Direct casualty to cover and apply self-aid if

able.able. Try to keep the casualty from sustaining any Try to keep the casualty from sustaining any

additional wounds.additional wounds. Airway management is generally best deferred Airway management is generally best deferred

until the Tactical Field Care phase.until the Tactical Field Care phase. Stop any life-threatening hemorrhage with a Stop any life-threatening hemorrhage with a

tourniquet or a HemCon bandage if applicable.tourniquet or a HemCon bandage if applicable.


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Is distinguished from the Care Under Fire Is distinguished from the Care Under Fire phase by having more time available to phase by having more time available to provide care. provide care.

A reduced level of hazard from hostile fire. A reduced level of hazard from hostile fire.

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In some cases, tactical field care may In some cases, tactical field care may consist of rapid treatment of wounds with consist of rapid treatment of wounds with the expectation of a re-engagement of the expectation of a re-engagement of hostile fire at any moment. In some hostile fire at any moment. In some circumstances, there may be ample time circumstances, there may be ample time to render whatever care is available in the to render whatever care is available in the field. The time to evacuation may be quite field. The time to evacuation may be quite variable from 30 minutes to several hours.variable from 30 minutes to several hours.

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If a victim of a blast or penetrating injury is If a victim of a blast or penetrating injury is found without a pulse, respirations or other found without a pulse, respirations or other signs of life…signs of life…

DoDo NotNot attempt CPR attempt CPR

Casualties with an altered mental status Casualties with an altered mental status should be disarmed immediately, both should be disarmed immediately, both weapons and grenades.weapons and grenades.

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Initial assessment consists of: Initial assessment consists of:

AirwayAirway

BreathingBreathing

CirculationCirculation

CMASTCMAST 4343


Open the airway with a jaw-thrust Open the airway with a jaw-thrust maneuver; if unconscious insert a maneuver; if unconscious insert a nasopharyngeal airway or Combitube. nasopharyngeal airway or Combitube.

CMASTCMAST 4444

Airway SupportAirway Support Allow a conscious casualty to assume any Allow a conscious casualty to assume any

position that best protects the airway, to position that best protects the airway, to include sitting up.include sitting up.

Place unconscious casualties Place unconscious casualties in the recovery in the recovery position.position.

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NPA or CombitubeNPA or Combitube

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Airway:Airway:

If the casualty is unconscious with an If the casualty is unconscious with an obstructed airway, perform a surgical obstructed airway, perform a surgical cricothyroidotomy.cricothyroidotomy.

CMASTCMAST 4747

CMASTCMAST 4848


CMASTCMAST 4949


Airway:Airway:

Oxygen is usually not available in this Oxygen is usually not available in this phase of care.phase of care.

CMASTCMAST 5050


Breathing:Breathing: Traumatic chest wall defects should be Traumatic chest wall defects should be

closed with an occlusive dressing closed with an occlusive dressing (Vaseline gauze) without regard to venting (Vaseline gauze) without regard to venting one side of the dressing or use an one side of the dressing or use an “Asherman Chest Seal“Asherman Chest Seal®®”. Place the ”. Place the casualty in the sitting position if possible.casualty in the sitting position if possible.

CMASTCMAST 5151


CMASTCMAST 5252


CMASTCMAST 5353

"Asherman Chest Seal""Asherman Chest Seal"

CMASTCMAST 5454


Progressive respiratory distress, secondary Progressive respiratory distress, secondary to a unilateral penetrating chest trauma, to a unilateral penetrating chest trauma, should be considered a tension should be considered a tension pneumothorax and decompressed with a pneumothorax and decompressed with a 14 gauge needle.14 gauge needle.

Tension pneumothorax is the 2Tension pneumothorax is the 2ndnd leading leading cause of preventable death on the cause of preventable death on the battlefield.battlefield.

CMASTCMAST 5555

Tension PneumothoraxTension Pneumothorax

Air pushes over heart and collapses lung

Heart compressed not able to pump well

Air outside lung from wound

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Needle Chest DecompressionNeedle Chest Decompression

CMASTCMAST 5757


Bleeding:Bleeding: Any bleeding site not Any bleeding site not previously controlled should previously controlled should

now be addressed. Only the now be addressed. Only the absolute minimum of absolute minimum of clothing should be removed. clothing should be removed.

CMASTCMAST 5858


Significant bleeding should be controlled Significant bleeding should be controlled using a tourniquet as previously described. using a tourniquet as previously described.

Once the tactical situation permits, Once the tactical situation permits, consideration should be given to loosening consideration should be given to loosening the tourniquet and using direct pressure or the tourniquet and using direct pressure or hemostatic bandages (HemCon) or hemostatic bandages (HemCon) or hemostatic powder (QuikClot) to control hemostatic powder (QuikClot) to control any additional hemorrhage. any additional hemorrhage.

CMASTCMAST 5959

Tourniquet RemovalTourniquet Removal When? Based on the tactical situation.When? Based on the tactical situation. More time in a safer setting.More time in a safer setting. More help available. More help available. Can you see what you are doing?Can you see what you are doing? Does the casualty need fluid Does the casualty need fluid

resuscitation? If so, do it before the resuscitation? If so, do it before the tourniquet is removed (ensure a positive tourniquet is removed (ensure a positive response is obtained, good peripheral response is obtained, good peripheral pulse mentation).pulse mentation).

CMASTCMAST 6060

Tourniquet RemovalTourniquet Removal DO NOT periodically loosen the tourniquet DO NOT periodically loosen the tourniquet

to get blood to the limb.to get blood to the limb. Can be rapidly fatal.Can be rapidly fatal. Tourniquets are very painful.Tourniquets are very painful. If the tourniquet has been on for > 6hrs, If the tourniquet has been on for > 6hrs,

leave it on.leave it on. If unable to control bleeding with other If unable to control bleeding with other

methods-retighten the tourniquet.methods-retighten the tourniquet.

CMASTCMAST 6161

Hemostatic AgentsHemostatic Agents

HemConHemCon®® Bandage: Bandage:

QuikClotQuikClot®® Powder: Powder:

CMASTCMAST 6262

Chitosan Hemostatic DressingChitosan Hemostatic Dressing

Hold the foil over-pouch so that instructions can be Hold the foil over-pouch so that instructions can be read. Identify unsealed edges at the top of the over-read. Identify unsealed edges at the top of the over-pouch.pouch.

CMASTCMAST 6363


Peel open over-pouch by pulling the unsealed edges Peel open over-pouch by pulling the unsealed edges apart.apart.

CMASTCMAST 6464


Trap dressing between bottom foil and non-Trap dressing between bottom foil and non-absorbable green/black polyester backing with your absorbable green/black polyester backing with your hand and thumb.hand and thumb.

CMASTCMAST 6565


Hold dressing by the non-absorbable polyester Hold dressing by the non-absorbable polyester backing and discard the foil over-pouch. Hands must backing and discard the foil over-pouch. Hands must be dry to prevent dressing from sticking to hands.be dry to prevent dressing from sticking to hands.

CMASTCMAST 6666


CMASTCMAST 6767

Chitosan Hemostatic DressingChitosan Hemostatic Dressing Place the light colored sponge portion of the Place the light colored sponge portion of the

dressing directly to the wound area with the dressing directly to the wound area with the most severe bleeding. Apply pressure for 2 most severe bleeding. Apply pressure for 2 minutes or until the dressing adheres and minutes or until the dressing adheres and bleeding stops. Once applied and in contact bleeding stops. Once applied and in contact with the blood and other fluids, the dressing with the blood and other fluids, the dressing cannot be repositioned.cannot be repositioned.

A new dressing should be applied to other A new dressing should be applied to other exposed bleeding sites. Each new dressing exposed bleeding sites. Each new dressing must be in contact with tissue where bleeding must be in contact with tissue where bleeding is heaviest. Care must be taken to avoid is heaviest. Care must be taken to avoid contact with the casualty’s eyes.contact with the casualty’s eyes.

CMASTCMAST 6868

Chitosan Hemostatic DressingChitosan Hemostatic Dressing If dressing is not effective in stopping If dressing is not effective in stopping

bleeding after 4 minutes, remove original and bleeding after 4 minutes, remove original and apply a new dressing. Additional dressings apply a new dressing. Additional dressings cannot be applied over ineffective dressing.cannot be applied over ineffective dressing.

Apply a battle dressing/bandage to secure Apply a battle dressing/bandage to secure hemostatic dressing in place.hemostatic dressing in place.

Hemostatic dressings should only be Hemostatic dressings should only be removed by responsible persons after removed by responsible persons after evacuation to the next level of care.evacuation to the next level of care.

CMASTCMAST 6969


CMASTCMAST 7070

CMASTCMAST 7171

QuickClotQuickClot

Click in box for video

CMASTCMAST 7272

QuikClot ACSQuikClot ACS®®

CMASTCMAST 7373

Tactical Field CareTactical Field Care IV:IV: IV access must be gained next. The use of IV access must be gained next. The use of

a single 18 gauge catheter is a single 18 gauge catheter is recommended, because of the ease of recommended, because of the ease of starting and also helps to conserve starting and also helps to conserve supplies.supplies.

A Heparin or saline lock-type access A Heparin or saline lock-type access tubing should be used unless the casualty tubing should be used unless the casualty needs immediate resuscitation.needs immediate resuscitation.

CMASTCMAST 7474

Saline LockSaline Lock


CMASTCMAST 7575



CMASTCMAST 7676



CMASTCMAST 7777



CMASTCMAST 7878



CMASTCMAST 7979


Soldier Medics should ensure the IV is not Soldier Medics should ensure the IV is not started distal to a significant wound.started distal to a significant wound.

If unable to start an IV, If unable to start an IV, consideration should consideration should be given to starting a be given to starting a sternal I/O line to provide sternal I/O line to provide fluids.fluids.

CMASTCMAST 8080

F.A.S.T. 1F.A.S.T. 1


CMASTCMAST 8181

Tactical Field CareTactical Field Care 1,000 ml of Ringers Lactate (2.4lbs) will 1,000 ml of Ringers Lactate (2.4lbs) will

expand the intravascular volume by 250 ml expand the intravascular volume by 250 ml within 1 hour.within 1 hour.

500 ml of 6% Hetastarch 500 ml of 6% Hetastarch (trade name Hextend(trade name Hextend®®, , weighs 1.3 lbs) will expand weighs 1.3 lbs) will expand the intravascular volume by the intravascular volume by 800ml within 1 hour, and 800ml within 1 hour, and will sustain this expansion will sustain this expansion for 8 hours . for 8 hours .

CMASTCMAST 8282

Tactical Field CareTactical Field Care Algorithm for fluid resuscitation:Algorithm for fluid resuscitation:

BP verses palpable radial pulse and BP verses palpable radial pulse and mentation.mentation.

Superficial wounds (>50% injured); no Superficial wounds (>50% injured); no immediate IV fluids needed. Oral fluids immediate IV fluids needed. Oral fluids should be encouraged.should be encouraged.

CMASTCMAST 8383


Any significant extremity or truncal wound Any significant extremity or truncal wound ( neck, chest, abdomen, pelvis).( neck, chest, abdomen, pelvis).

1. If the casualty is coherent and has a 1. If the casualty is coherent and has a palpable radial pulse, start a saline lock, palpable radial pulse, start a saline lock, hold fluids and reevaluate as frequently as hold fluids and reevaluate as frequently as the situation permits.the situation permits.

CMASTCMAST 8484

Tactical Field CareTactical Field Care Fluids:Fluids: 2. Significant blood loss from any 2. Significant blood loss from any

wound, and the casualty has no radial wound, and the casualty has no radial pulse or is not coherent pulse or is not coherent - - STOPSTOP THETHE BLEEDING BLEEDING -- by whatever means by whatever means available - tourniquet, direct pressure, available - tourniquet, direct pressure, hemostatic dressings, or hemostatic hemostatic dressings, or hemostatic powder etc. Start 500ml of Hextendpowder etc. Start 500ml of Hextend®®. If . If mental status improves and radial pulse mental status improves and radial pulse returns, maintain saline lock and hold returns, maintain saline lock and hold fluids. fluids.

CMASTCMAST 8585


3. If no response is seen, give an 3. If no response is seen, give an additional 500 ml of Hextendadditional 500 ml of Hextend® ® and monitor and monitor vital signs. If no response is seen after vital signs. If no response is seen after 1,000ml of Hextend1,000ml of Hextend®®, consider triaging , consider triaging supplies and attention to more supplies and attention to more salvageable casualties. salvageable casualties.

CMASTCMAST 8686


4. Because of conservation of supplies, 4. Because of conservation of supplies, no casualty should receive more than no casualty should receive more than 1,000 ml of Hextend1,000 ml of Hextend®®. Remember this is . Remember this is the equivalent to more than six liters of the equivalent to more than six liters of Ringers Lactate.Ringers Lactate.

CMASTCMAST 8787


Traumatic Brain Injury (TBI) fluid Traumatic Brain Injury (TBI) fluid resuscitation.resuscitation.

If a casualty is unconscious with a TBI and If a casualty is unconscious with a TBI and no peripheral pulse:no peripheral pulse:

– Resuscitate to restore the peripheral Resuscitate to restore the peripheral pulse. pulse.

CMASTCMAST 8888


Dress wounds to prevent further Dress wounds to prevent further contamination and help hemostasiscontamination and help hemostasis

(Emergency Trauma Dressing(Emergency Trauma Dressing®®)) Check for additional wounds (exit)Check for additional wounds (exit) Protect the patient from Hypothermia Protect the patient from Hypothermia

(Blizzard Survival Blanket).(Blizzard Survival Blanket).

CMASTCMAST 8989

Why does Hypothermia Happen?Why does Hypothermia Happen?

CMASTCMAST 9090

Blizzard Survival WrapBlizzard Survival Wrap

CMASTCMAST 9191

6 – Cell

“Ready-Heat” Blanket

4- Cell

“Ready-Heat” Blanket

Blizzard “Survival Blanket”

CMASTCMAST 9292

Hypothermia Prevention and Hypothermia Prevention and Management KitManagement Kit ™ ™

Dimensions: 7.5” x 9.5” x 3” Weight: 2.5 lbs.Part Number: 80-0027NSN: 6515-01-532-8056

Contents:1 x Heat Reflective Skull Cap1 x Self Heating, Four Cell Shell Liner 1 x Heat Reflective Shell

North American Rescue Products

CMASTCMAST 9393

Hypothermia Prevention and Hypothermia Prevention and Management Kit Management Kit ™™

North American Rescue Products

CMASTCMAST 9494

Field Expedient WarmingField Expedient Warming

CMASTCMAST 9595

MonitoringMonitoring Pulse oximetry may be available as an Pulse oximetry may be available as an

adjunct to clinical monitoring. Readings adjunct to clinical monitoring. Readings may be misleading in the settings of shock may be misleading in the settings of shock or marked hypothermia.or marked hypothermia.

CMASTCMAST 9696

Tactical Field CareTactical Field Care Pain Control:Pain Control: Able to fight -Able to fight -

– Meloxicam (MobicMeloxicam (Mobic®®) 15mg po initially ) 15mg po initially – Acetaminophen 650 mg Bi-layered caplet Acetaminophen 650 mg Bi-layered caplet 2 po q8hr2 po q8hr

Unable to fight -Unable to fight -– Morphine 5 mg IV / IOMorphine 5 mg IV / IO– PhenerganPhenergan®® 25mg IV, IM 25mg IV, IM

CMASTCMAST 9797

Combat Pill PackCombat Pill Pack

CMASTCMAST 9898

Tactical Field CareTactical Field Care Pain Control:Pain Control: Pain control should be achieved by Pain control should be achieved by

intravenous morphine, if possible.intravenous morphine, if possible. 5mg IV morphine may be given every 10 5mg IV morphine may be given every 10

minutes until adequate pain control is minutes until adequate pain control is achieved. If a saline lock is used it should achieved. If a saline lock is used it should be flushed with 5ml of sterile solution be flushed with 5ml of sterile solution (saline, LR etc.) after morphine (saline, LR etc.) after morphine administration.administration.

CMASTCMAST 9999


Phenergan should be used with Morphine Phenergan should be used with Morphine to reduce nausea and vomiting.to reduce nausea and vomiting.

Ensure some visible indication of time Ensure some visible indication of time and amount of morphine given.and amount of morphine given.

Soldiers who administer Soldiers who administer morphine should also be trained morphine should also be trained in its side effects and in the use in its side effects and in the use of Naloxone.of Naloxone.

CMASTCMAST 100100

Future Pain ReliefFuture Pain Relief

Fentanyl Transmucosal Lozenge

CMASTCMAST 101101

Fentanyl Transmucosal Fentanyl Transmucosal LozengeLozenge

Dosage:Dosage: 1- 400 mcg lozenge orally initially. 1- 400 mcg lozenge orally initially.

Recommend taping it to casualty's finger Recommend taping it to casualty's finger as an added safety measure.as an added safety measure.

Reassess in 15 min.Reassess in 15 min. Add a second lozenge in other cheek if Add a second lozenge in other cheek if

necessary.necessary. Monitor for respiratory depression.Monitor for respiratory depression.

CMASTCMAST 102102

Future Pain ReliefFuture Pain Relief

Intranasal Ketamine

CMASTCMAST 103103


Pain Control:Pain Control:

Soldiers should avoid aspirin and other Soldiers should avoid aspirin and other nonsteroidal anti-inflammatory medicines nonsteroidal anti-inflammatory medicines while in a combat zone because of while in a combat zone because of detrimental effects on hemostasis. detrimental effects on hemostasis.

CMASTCMAST 104104


Splint fractures as circumstances allow, Splint fractures as circumstances allow, ensuring pulse, motor and sensory (PMS) ensuring pulse, motor and sensory (PMS) checks before and after splinting.checks before and after splinting.

CMASTCMAST 105105


Antibiotics should be considered in any Antibiotics should be considered in any wound sustained on the battlefield. wound sustained on the battlefield.

CMASTCMAST 106106


Casualties who are awake and alert, Casualties who are awake and alert, Gatifloxacin 400 mg, one tablet Q day.Gatifloxacin 400 mg, one tablet Q day.

Casualties who are unconscious: Casualties who are unconscious: Cefotetan-2 gm IV / IM q 12 hours.Cefotetan-2 gm IV / IM q 12 hours. Ertapenum 1 gm IV / IM QD.Ertapenum 1 gm IV / IM QD. IV requires 30 infusion time.IV requires 30 infusion time. IM should be diluted with lidocaine.IM should be diluted with lidocaine.

CMASTCMAST 107107

Ertapenum InvanzErtapenum Invanz®®

Reconstitute the contents of a 1 gm vial of INVANZ Reconstitute the contents of a 1 gm vial of INVANZ with 3.2 ml of 1.0% lidocaine HCl injection with 3.2 ml of 1.0% lidocaine HCl injection ** **

( ( without epinephrine without epinephrine ). Shake vial thoroughly to ). Shake vial thoroughly to form solution. form solution.

Immediately withdraw the contents of the vial and Immediately withdraw the contents of the vial and administer by deep intramuscular injection into a administer by deep intramuscular injection into a large muscle mass (such as the gluteal muscles or large muscle mass (such as the gluteal muscles or lateral part of the thigh). lateral part of the thigh).

The reconstituted IM solution should be used within 1 The reconstituted IM solution should be used within 1 hour after preparation. hour after preparation. NOTE: THE NOTE: THE RECONSTITUTED SOLUTION SHOULD NOT BE RECONSTITUTED SOLUTION SHOULD NOT BE ADMINISTERED INTRAVENOUSLY. ADMINISTERED INTRAVENOUSLY.

CMASTCMAST 108108

AntibioticsAntibiotics

Patients with allergies to flouroquinolones, Patients with allergies to flouroquinolones, penicillin's, cephalosporins, or other beta-penicillin's, cephalosporins, or other beta-lactam antibiotics may need alternate lactam antibiotics may need alternate antibiotics which should be selected during antibiotics which should be selected during the pre-deployment phase. the pre-deployment phase.

CMASTCMAST 109109

ReassuranceReassurance

Combat is a very frightening experience.Combat is a very frightening experience. Even more so if injured and especially if Even more so if injured and especially if

injured severely.injured severely. Simple reassurance is as effective as Simple reassurance is as effective as

giving morphine.giving morphine. Explain care that is being given.Explain care that is being given.

CMASTCMAST 110110

DocumentationDocumentation

Document clinical assessments, treatment Document clinical assessments, treatment rendered and changes in the casualty's rendered and changes in the casualty's status.status.

Forward with casualty Forward with casualty to next level of care. to next level of care.

Casevac CareCasevac Care

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At some point in the operation, the At some point in the operation, the casualty will be scheduled for evacuation. casualty will be scheduled for evacuation. Time to evacuation may be quite variable Time to evacuation may be quite variable from minutes to hours.from minutes to hours.

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There are only minor differences in care There are only minor differences in care when progressing from the Tactical Field when progressing from the Tactical Field Care phase to the Casevac phase.Care phase to the Casevac phase.

1. Additional medical personnel may 1. Additional medical personnel may accompany the evacuation asset and accompany the evacuation asset and assist the soldier medic on the ground. assist the soldier medic on the ground. This may be important for the following This may be important for the following reasons: reasons:

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The soldier medic may be among the The soldier medic may be among the casualties.casualties.

The soldier medic may be dehydrated, The soldier medic may be dehydrated, hypothermic or otherwise debilitated.hypothermic or otherwise debilitated.

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Casevac CareCasevac Care The evacuation asset’s medical equipment The evacuation asset’s medical equipment

may need to be prepared prior to may need to be prepared prior to evacuation.evacuation.

There may be multiple casualties that There may be multiple casualties that exceed the capability of the soldier medic to exceed the capability of the soldier medic to care for simultaneously.care for simultaneously.

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2. Additional medical equipment can be 2. Additional medical equipment can be brought in with the evacuation asset to brought in with the evacuation asset to augment the equipment the soldier medic augment the equipment the soldier medic already has.already has.

This equipment may include:This equipment may include:

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Electronic monitoring equipment capable Electronic monitoring equipment capable of measuring a casualty’s blood pressure, of measuring a casualty’s blood pressure, pulse and pulse oximetry.pulse and pulse oximetry.

Oxygen should be available during this Oxygen should be available during this phase.phase.

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Ringers Lactate at a rate of 250 ml per Ringers Lactate at a rate of 250 ml per hour for casualties not in shock should hour for casualties not in shock should help to reverse dehydration.help to reverse dehydration.

Blood products may be available during Blood products may be available during this phase of care.this phase of care.

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Thermal AngelThermal Angel®® fluid warmers. fluid warmers.

PASG, if available, may be beneficial in PASG, if available, may be beneficial in pelvic fractures and helping to control pelvic fractures and helping to control pelvic and abdominal bleeding (they are pelvic and abdominal bleeding (they are contraindicated in thoracic and brain contraindicated in thoracic and brain injuries).injuries).

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SummarySummary How people die in ground combat:How people die in ground combat:

31% penetrating head trauma.31% penetrating head trauma. 25% surgically uncorrectable torso 25% surgically uncorrectable torso trauma.trauma. 10% potentially correctable surgical 10% potentially correctable surgical

trauma.trauma.

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SummarySummary

9% exsanguination from extremity 9% exsanguination from extremity wounds: wounds: (1(1stst))

7% mutilating blast trauma.7% mutilating blast trauma. 5% tension pneumothorax: 5% tension pneumothorax: (2(2ndnd)) 1% airway problems: 1% airway problems: (3(3rdrd)) 12% died of wounds (mostly infections and 12% died of wounds (mostly infections and

complications of shock).complications of shock).

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SummarySummary Three categories of casualties on the Three categories of casualties on the

battlefield.battlefield. Soldiers who will do well regardless of Soldiers who will do well regardless of

what we do for them.what we do for them. Soldiers who are going to die regardless of Soldiers who are going to die regardless of

what we do for them.what we do for them. Soldiers who will die if we do not do Soldiers who will die if we do not do

something for them (now 7-15%).something for them (now 7-15%).

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SummarySummary

““If during the next war you could do only If during the next war you could do only two things, (1) put a tourniquet on and (2) two things, (1) put a tourniquet on and (2) relieve a tension pneumothorax then you relieve a tension pneumothorax then you can probably save between 70 and 90 can probably save between 70 and 90 percent of all the preventable deaths on percent of all the preventable deaths on the battlefield.” the battlefield.”

COL Ron Bellamy 1993COL Ron Bellamy 1993

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SummarySummary Medical care during combat differs Medical care during combat differs

significantly from the care provided in the significantly from the care provided in the civilian community. New concepts in civilian community. New concepts in hemorrhage control, fluid resuscitation, hemorrhage control, fluid resuscitation, analgesia, and antibiotics are important analgesia, and antibiotics are important steps in providing the best possible care to steps in providing the best possible care to our combat soldiers.our combat soldiers.

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SummarySummary

These timely interventions will be the These timely interventions will be the mainstay in decreasing the number of mainstay in decreasing the number of combat fatalities on the battlefield.combat fatalities on the battlefield.

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National Stock NumbersNational Stock NumbersCombat Application TourniquetCombat Application Tourniquet®® 6515-01-521-7976 6515-01-521-7976 HextendHextend® ® Fluid 6505-01-498-8636Fluid 6505-01-498-8636 F.A.S.T.1F.A.S.T.1®® 6515-01-453-0960 6515-01-453-0960 Emergency BandageEmergency Bandage®® 6510-01-492-2275 6510-01-492-2275 HemCon Chitosan DressingHemCon Chitosan Dressing®® 6510-01-502-6938 6510-01-502-6938 Sked LitterSked Litter®® 6530-01-260-1222 6530-01-260-1222 Talon II LitterTalon II Litter®® 6530-01-452-1651 6530-01-452-1651 Blizzard Rescue WrapBlizzard Rescue Wrap®® 6532-01-524-6932 6532-01-524-6932 Ready Heat Medical BlanketsReady Heat Medical Blankets®® 6532-01-525-4062 6532-01-525-4062 Adjustable C-Collar w/head wedge 6515-01-516-3115Adjustable C-Collar w/head wedge 6515-01-516-3115

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Questions?Questions?

Health & Medicine

C191 w2tc cmast tactical combat casualty care