Tactical Combat Casualty Care 7 December 2012: Current Performance Improvement Issues

Tactical Combat Casualty Care
7 December 2012
Current Performance Improvement

Issues
TCCC Lessons Learned in Iraq
and Afghanistan
• Reports from Joint Trauma System (JTS) weekly

Trauma Telecons – every Thursday morning
– Worldwide telecon to discuss every serious casualty
admitted to a Level III hospital from that week
• Published medical reports
• Armed Forces Medical
Examiner’s Office reports
• Feedback from doctors,
corpsmen, medics,
and PJs
Overcalling CAT A
Evacuations
NATO/ISAF Standard Evacuation
Categories
International Security Assistance Force
SOP #312:
• Governs operations in Afghanistan
• Follows NATO doctrine
• Specifies three categories for casualty
evacuation:
• A - Urgent
• B - Priority
• C - Routine
Categories
• CAT A – Urgent (denotes a critical, life-

threatening injury)
– Significant injuries from a dismounted IED attack
– Gunshot wound or penetrating shrapnel to chest,
abdomen or pelvis
– Any casualty with ongoing airway difficulty
– Any casualty with ongoing respiratory difficulty
– Unconscious casualty
Categories
• CAT A – Urgent (continued)

– Casualty with known or suspected spinal injury
– Casualty in shock
– Casualty with bleeding that is difficult to control
– Moderate/Severe TBI
– Burns greater than 20% Total Body Surface Area
Categories
• CAT B – Priority (serious injury)
– Isolated, open extremity fracture with bleeding
controlled
– Any casualty with a tourniquet in place
– Penetrating or other serious eye injury
– Significant soft tissue injury without major
bleeding
– Extremity injury with absent distal pulses
– Burns 10-20% Total Body Surface Area
Categories
• CAT C – Routine (mild to moderate injury)

– Concussion (mild TBI)
– Gunshot wound to extremity - bleeding controlled
without tourniquet
– Minor soft tissue shrapnel injury
– Closed fracture with intact distal pulses
– Burns < 10% Total Body Surface Area
Training
Train ALL Combatants and
all Operational Medical
Providers in TCCC
• Line commanders must take the lead to have an
effective TCCC training program for all combatants
• Docs, nurses, PAs must know what their combat
medical personnel know about TCCC
Tourniquets Being
Placed Too Proximal and
Not Adjusted during
TFC
E-mail from an orthopedic
surgeon: “…. tourniquet was
applied on the proximal biceps for
a middle finger amputation.”
Care Under Fire Guidelines
7. Stop life-threatening external hemorrhage if

tactically feasible:
– Direct casualty to control hemorrhage by self-aid if
able.
– Use a CoTCCC-recommended tourniquet for
hemorrhage that is anatomically amenable to
tourniquet application.
– Apply the tourniquet proximal to the bleeding site,
over the uniform, tighten, and move the casualty to
cover.
Three Key Points
• “Proximal to the bleeding site” does not

necessarily mean at the upper biceps for
a hand injury or at the upper thigh for
a foot injury
• The tourniquet should be moved to a
skin location 2-3 inches above the
bleeding site during Tactical Field Care.
• Reassess the bleeding site frequently to
ensure that tourniquet is still effective.
Tourniquet Mistakes
to Avoid!
• Not using one when you should
• Using a tourniquet for minimal bleeding
• Putting it on too proximally
• Not taking it off when indicated during TFC
• Taking it off when the casualty is in shock or has
only a short transport time to the hospital
• Not making it tight enough – the tourniquet
should eliminate the distal pulse
• Not using a second tourniquet if needed
• Waiting too long to put the tourniquet on
• Periodically loosening the tourniquet to allow
blood flow to the injured extremity
* These lessons learned have been written in blood. *
Eye Injuries: Recent
Increase in Eye Injuries
from Not Wearing Eye
Protection
Wear Your Eye Protection!
• Jan 2010
• 22 y/o near IED without eye protection
• Now blind in both eyes
• Don’t let this happen to you – see slides below
With eye pro – eyes OK! Without eye pro – both eyes lost
Eye Armor – It Works!
Penetrating Eye Trauma
• Rigid eye shield for obvious or suspected eye wounds - often
not being done – SHIELD AND SHIP!
• Not doing this may cause permanent loss of vision – use a
shield for any injury in or around the eye
• Eye shields not always in IFAKs
• IED + no eye pro + facial wounds = Suspected Eye Injury!
Shield after injury No shield after injury

Eye Protection
• Use your tactical eyewear to cover the injured eye if you

don’t have a shield.
• Using tactical eyewear in the field will generally prevent
the eye injury from happening in the first place!
JTTS Trauma Telecon
9 Sept 2010
• Recent case of endophthalmitis (blinding infection
inside the eye)
• Reminder – shield and moxifloxacin in the field
for penetrating eye injuries – combat pill pack!
• Also – need to continue
moxi both topically and
systemically in the MTFs
• Many antibiotics do not
penetrate well into the
eye
Patched Open Globe
22 July 2010
• Shrapnel in right eye from IED
• Had rigid eye shield placed
• Reported as both pressure patched and as having a
gauze pad placed under the eye shield without
pressure – NO pressure patches on eye injuries
• Extruded uveal tissue (intraocular contents) noted at
time of operative repair of globe
• Do not place gauze on injured eyes! COL Robb
Mazzoli: Gauze can adhere to iris tissue and cause
further extrusion when removed even if no pressure
is applied to eye.
• At least two other recent occurrences of patching
Pressure Dressings on
Eye Injuries
The wrong thing to do – makes a bad situation

potentially much worse – SHIELD ONLY
Battlefield Analgesia
NO Narcotic Analgesia for
Casualties in Shock
• Narcotics (morphine and fentanyl) are

CONTRAINDICATED for casualties
who are in shock or who are likely to
go into shock; these agents may worsen
their shock and increase the risk of death
• Four casualties in two successive weekly telecons
were noted to have gotten narcotics and were in shock
during transport or on admission to the MTFs
• Use ketamine for casualties who are in shock or at
risk of going into shock but are still having
significant pain
Case Report
September 2012
• Male casualty with GSW to thigh
• Bleeding controlled by tourniquet
• In shock – alert but hypotensive
• Severe pain from tourniquet
• Repeated pleas to PA to remove the tourniquet
• PA did not want to use opioids because of the shock
• Perfect candidate for ketamine analgesia
• Not fielded at the time with this unit
Platelet-Inhibiting Drugs
in the Battle Space
First – Do No Harm
Harris et al – Mil Med 2012
• Platelets help to keep you from bleeding to death if you

are wounded. Some drugs keep them from working.
• Survey of 175 Soldiers at a FOB in SE Afghanistan
• “Do you take over-the-counter or prescription
NSAIDs?”
• If so, how often?
Recommendations:
• Earlier platelets in DCR
• Consider restricting NSAIDs in theater
• Other analgesic choices: acetaminophen,
cox-2 selective NSAIDs, tramadol
Note that other drugs
and some nutritional
supplements may inhibit
platelets as well. Check
with your doc on this!
Documentation of TCCC
Care
TCCC Card –
Fill It Out!
• You’re not done taking care of your casualty

until this is done
• Mission Commanders – this is a leadership
issue!
Questions?

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Tactical Combat Casualty Care 7 December 2012: Current Performance Improvement Issues

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Tactical Combat Casualty Care

Current Performance Improvement

• Reports from Joint Trauma System (JTS) weekly

• CAT A – Urgent (denotes a critical, life-

• CAT A – Urgent (continued)

• CAT C – Routine (mild to moderate injury)

7. Stop life-threatening external hemorrhage if

• “Proximal to the bleeding site” does not

Shield after injury No shield after injury

• Use your tactical eyewear to cover the injured eye if you

The wrong thing to do – makes a bad situation

• Narcotics (morphine and fentanyl) are

• Platelets help to keep you from bleeding to death if you

• You’re not done taking care of your casualty

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