Tactical Field Care 2a: (Based On TCCC-MP Guidelines 180801)

Tactical Combat Casualty Care for Medical
Personnel
August 2018
(Based on TCCC-MP Guidelines 180801)
Tactical Field Care 2a

Circulation - Bleeding
Disclaimer
“The opinions or assertions contained herein are the

private views of the authors and are not to be construed as
official or as reflecting the views of the Departments of the
Army, Air Force, Navy or the Department of Defense.”
- There are no conflict of interest disclosures

LEARNING OBJECTIVES
Terminal Learning Objective
• Perform Hemorrhage Control in Tactical Field
Care.
Enabling Learning Objectives

• Describe the progressive strategies, indications,
and limitations of controlling external
hemorrhage in tactical field care.
• Identify the indications for and application
methods of pelvic binding devices in Tactical
Field Care.
LEARNING OBJECTIVES
Enabling Learning Objectives

• Demonstrate the application of a CoTCCC-
recommended pelvic compression device in
Tactical Field Care.
• Describe the technique for tourniquet
repositioning in Tactical Field Care.
• Identify the indications and methods of
tourniquet conversion in Tactical Field Care.
Tactical Field Care
Guidelines
6. Circulation
a. Bleeding
● A pelvic binder should be applied for cases of
suspected pelvic fracture:
⁃ Severe blunt force or blast injury with one or more
of the following indications:
◦ Pelvic pain
◦ Any major lower limb amputation or near
amputation
◦ Physical exam findings suggestive of a pelvic
fracture
◦ Unconsciousness
◦ Shock
The Bones of the Pelvis
http://www.celebritydiagnosis.com/wp-content/uploads/2015/03/Pelvis.png
Treatment of Suspected Pelvic
Fractures in TCCC
Life-Threatening Pelvic
Fractures
http://www.aast.org/pelvis-injuries
Pelvic Fractures in Combat
Casualties
• Most commonly associated with dismounted IED

attacks accompanied by amputations
• May also occur in severe blunt trauma (such as
motor vehicle crashes, aircraft mishaps, hard
parachute landings, and falls from a height)
• 26% of service members who died in OEF/OIF
had a pelvic fracture.
• Bleeding pelvic fractures with hemodynamic
instability have up to 40% mortality.
Pelvic Fractures and Lower
Limb Amputations due to
Dismounted IEDs
• 77 consecutive patients with traumatic lower limb amputation
after stepping on an IED
• Associated pelvic fracture:
• Unilateral amputation: 10%
• Bilateral amputation: 30%
• Bilateral above-knee amputation: 39%
– Overall, 22% had associated pelvic fractures
• “This study demonstrates a high incidence of pelvic fractures in
patients with traumatic lower limb amputations, supporting
routine pre-hospital application of pelvic binders in this patient
group”
Cross: J R Nav Med Serv, 2014
What Exam Findings Are
Suggestive of a Pelvic Fracture?
Exam Findings:
– Pelvic pain
– Laceration or bruising at bony
prominences of the pelvic ring
– Deformed or unstable pelvis
– Unequal leg length
– Scrotal, perineal, or perianal bruising
– Blood at the urethral meatus
– Massive hematuria
– Blood in the rectum or vagina
– Neurologic deficits in lower extremities
What Type of Pelvic Binding
Device Should Be Used?
There are 3 commercially available pelvic binders:
The Pelvic Binder
The T-POD
The SAM Pelvic Sling II

Two types of junctional tourniquets may also
serve as pelvic binders:
• The SAM Junctional Tourniquet
• The Junctional Emergency Treatment

Tool
• Any of these five devices may be used as a pelvic
binder:
– Pelvic Binder
– T-Pod
– SAM Pelvic Sling II
– SAM Junctional Tourniquet

– Junctional Emergency Treatment Tool
Placement of a Pelvic
Binding Device
• At the level of greater trochanters, NOT the iliac
wings (top of the hip bone.)
Iliac wing – WRONG!
* Note that this

Greater
is also the level of
Trochanters the pubic symphysis.
• In one study 40% of the pelvic binders were placed

too high, resulting in inadequate reduction of the
pelvic fracture and possibly increased bleeding.
Don’t Forget!
• External rotation of the lower extremities is commonly seen

in persons with displaced pelvic fractures.
– This may increase the dislocation of pelvic fragments.
– External rotation can be prevented or reduced by
securing the knees or feet together, improving the effect
achieved by the pelvic binder.
• Don’t logroll casualties with
suspected pelvic fractures –
this may increase internal bleeding.
Don’t Forget!
• Once a binder is on, if additional procedures at the Role II

require access to the abdomen or groin (i.e., REBOA), the
binder may be moved down to the upper thigh.
This will limit external rotation and minimize the
reopening of the pelvis.
• If definitive care is delayed beyond approximately 8-12

hours, the need for a binder should be reassessed and the
binder loosened if the patient remains hemodynamically
stable.
Don’t Forget!
• Pelvic binders may mask the presence of a

pelvic fracture on CT scanning.
Pelvic Binding Device
Practical
DoD Photo by SSgt Ryan Crane, USA

Thank You!
Questions?20
Tactical Field Care
Guidelines
6. Circulation
a. Bleeding (continued)
● Reassess prior tourniquet application. Expose the wound
and determine if a tourniquet is needed. If it is needed,
replace any limb tourniquet placed over the uniform with
one applied directly to the skin 2-3 inches above the
bleeding site. Ensure that bleeding is stopped. If there is no
traumatic amputation, a distal pulse should be checked. If
bleeding persists or a distal pulse is still present, consider
additional tightening of the tourniquet or the use of a second
tourniquet side-by-side with the first to eliminate both
bleeding and the distal pulse. If the reassessment determines
that the prior tourniquet was not needed, then remove the
tourniquet and note time of removal on the TCCC Casualty
Card.
Tourniquets:
Points to Remember
Tightening the tourniquet enough to eliminate
the distal pulse will help to ensure that all
bleeding is stopped, and that there will be no
damage to the extremity from blood entering
the extremity
but not being
able to get out.
Photo courtesy Dr. Warren Dorlac

Tourniquet Repositioning
Tourniquet Repositioning
• It is better to wait to route the self-adhering

strap of the second tourniquet through its
securing clips and securing it with the safety
strap until you have loosened the first
tourniquet and assured the bleeding is
controlled by the second tourniquet.
– You may have to further tighten the second
tourniquet.
Comments on the Video from the CoTCCC Staff

Tourniquets:
Points to Remember
• Damage to the arm or leg is rare if the

tourniquet is left on for less than two hours.
• Tourniquets are often left in place for
several hours during surgical procedures.
• In the face of massive extremity
hemorrhage, it is better to accept the small
risk of damage to the limb than to have a
casualty bleed to death.
Tactical Field Care
Guidelines
6. Circulation
● Limb tourniquets and junctional tourniquets should be
converted to hemostatic or pressure dressings as soon
as possible if three criteria are met: the casualty is not
in shock; it is possible to monitor the wound closely for
bleeding; and the tourniquet is not being used to
control bleeding from an amputated extremity. Every
effort should be made to convert tourniquets in less
than 2 hours if bleeding can be controlled with other
means. Do not remove a tourniquet that has been in
place more than 6 hours unless close monitoring and
lab capability are available.
Tourniquets:
Points to Remember
• Every effort should be made to convert tourniquets in
less than 2 hours if bleeding can be controlled by
other means. If bleeding remains controlled with
Combat Gauze, leave the loosened tourniquet in
place. If the bleeding is not controlled with Combat
Gauze, re-tighten the tourniquet until bleeding stops.
• Restoring blood flow to the limb by transitioning to
Combat Gauze at the 2-hour mark will minimize the
chance of ischemic damage due to the tourniquet.
Tourniquet Conversion
1. Expose the wound(s).

2. Apply Combat Gauze and a pressure

dressing.
3. Loosen “high-and-tight” tourniquet and

move it down to just above the pressure
dressing. (Leave it loose here just in case
it’s needed later.)
4. Monitor for re-bleeding.
Tourniquets:
Points to Remember
• If the transition to Combat Gauze at 2 hours failed,

try again at 6 hours using the steps outlined in the
previous slides.
• Do not release the tourniquet after 6 hours of

application unless close monitoring and lab support
are available to evaluate for metabolic
complications of prolonged tourniquet use.
Tourniquets:
Points to Remember
Do not convert the tourniquet if:
– The casualty is in shock.
– You cannot closely monitor the wound for re-bleeding.
– The extremity distal to the tourniquet has been
traumatically amputated.
– The tourniquet has been on for more than 6 hours.
– The casualty will arrive at a medical treatment facility
within 2 hours after time of application.
– Tactical or medical considerations make transition to other
hemorrhage control methods inadvisable.
Tourniquets:
Points to Remember
• Only medics, physician assistants, or

physicians should re-position or convert
tourniquets.
Tactical Field Care Guidelines
6. Circulation
- Expose and clearly mark all tourniquets with the time
of tourniquet application. Note tourniquets applied
and time of application; time of re-application; time of
conversion; and time of removal on the TCCC
Casualty Card. Use a permanent marker to mark on
the tourniquet and the casualty card.
Questions?

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Tactical Combat Casualty Care for Medical

Tactical Field Care 2a

“The opinions or assertions contained herein are the

- There are no conflict of interest disclosures

Enabling Learning Objectives

Enabling Learning Objectives

• Most commonly associated with dismounted IED

The Pelvic Binder

The SAM Pelvic Sling II

• The Junctional Emergency Treatment

– SAM Junctional Tourniquet

* Note that this

• In one study 40% of the pelvic binders were placed

• External rotation of the lower extremities is commonly seen

• Once a binder is on, if additional procedures at the Role II

• If definitive care is delayed beyond approximately 8-12

• Pelvic binders may mask the presence of a

DoD Photo by SSgt Ryan Crane, USA

Photo courtesy Dr. Warren Dorlac

• It is better to wait to route the self-adhering

Comments on the Video from the CoTCCC Staff

• Damage to the arm or leg is rare if the

1. Expose the wound(s).

2. Apply Combat Gauze and a pressure

3. Loosen “high-and-tight” tourniquet and

• If the transition to Combat Gauze at 2 hours failed,

• Do not release the tourniquet after 6 hours of

• Only medics, physician assistants, or

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