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Alexander Berk, MD Assistant Clinical Professor Department of Emergency Medicine University of Florida College of Medicine - Jacksonville
I have no association personally or financially with any product or courses referenced in this talk Unfortunately«.
History and current use of tactical emergency medical support (TEMS) Epidemiology of injury in combat/tactical situations Phases of Tactical Combat Causality Care
Care Under Fire (Hot Zone) Tactical Field Care (Warm Zone) CausaltyEvacuation (Cool Zone)
victims/hostages. bystanders and perpetrators .TEMS Tactical Emergency Medical Support Out of hospital system of care dedicated to enhancing the probability of special operations law enforcement mission success and promoting public safety Non-military EMS services that have been modified for the tactical environment TEMS Goals Mission accomplishment Overall team health Care under fire Protection of team members.
EMS vs. TEMS Rescuer Safety Scene Safety Ambulanced based BLS ALS PHTLS Rapid transport Golden hour Mission success Team safety Zones of care TCCC Preventative medicine Health maintenance Delayed transport Golden 5 minutes .
Unique Challenges to TEMS Image of the medical provider Providing care in hostile environments Limited resources No national standards of training Ethics .
000 SWAT missions 3.9 perpetrators injured 7.8 officers injured 21.2 bystanders injured Over 100 Tactical Emergency Medical Support units throughout the US and the world .Is it needed? Per 1.
´ This can be extrapolated to the urban tactical environment .Introduction to Tactical Combat Casualty Care Why are we here? ³90% of combat deaths occur on the battlefield before the casualty ever reaches a medical treatment facility.
US Army Combat Deaths Data 100 90 80 70 60 50 40 30 20 10 0 Battlefield 1st & 2nd Echeons World War Korea Vietnam U. Army Combat Deaths Surg & Gen Hosp Evac & CONUS Hospitals .S.
PERCENTAGE OF TOTAL DEATHS 10 15 20 25 30 35 40 45 0 Imm ediate <5m 5 to < 30m 30m to <2h 5 Time to Death Time to Death TIME TO DEATH KILLED IN ACTION DIED OF Wound 2 to < 6h 6h to <1d 1d to <1w 1w or > .
Introduction to Tactical Combat Casualty Care Conclusion Imperative need to focus on battlefield/tactical medical care during the first 30 minutes after incident. Specialize training ofcombat lifesavers andEMT/paramedicsin Tactical Combat Casualty Care .
Epidemiology of Injury Preventable causes of death Exsanguination from extremity wounds ± 66% Tension pneumothorax ± 30% Airway obstruction ± 4% Blast injuries becoming increasingly more common Basically the biggest bang for your tactical buck .
Tactical Combat Casualty Care In the past. Special Operations combat medical personnel as well as city/county based EMTs and paramedics were trained to manage combat trauma based on the principles of care taught in the ATLS (Advanced Traumatic Life Support) .
Overview PROBLEM: ATLS is not designed to be used in the combat environment. Not intended for combat medics Assumes hospital diagnostic and therapeutic equipment is readily available No tactical context .
Overview What are some tactical considerations? Incoming fire Darkness Environmental factors (cold. heat. sand) Casualty transportation problems Delays to definitive care Command decisions . rain.
HR) Completely expose the patient Secondary survey Does anybody see a problem with doing all of those things in the middle of a firefight? . BP.Overview ATLS CPR C-spine immobilization Primary survey Definitive airway Tourniquets discouraged Two large bore IVs Fluid resuscitation Monitoring (EKG. pulse ox.
Overview Solution: Tactical Combat Casualty Care (TCCC) ± An evolving set of principles guiding trauma in the combat/tactical environment Good medicine can sometimes be bad tactics Bad tactics can get everyone killed and/or cause the mission to fail The best possible outcome for both the personnel and the mission The right things to do AND the right TIME to do them .
Where did TCCC come from?
2001: USSOCOM initiated CoTCCC
Physicians (trauma, ER, FP, CC), medics (Rangers, Recon, SEALS, PJs), civilian EMS reps
Coordinated through Naval Operational Medical Institute Continues to evaluate the effectiveness of the TCCC guidelines
Civilian care under fire is still care under fire
Published in the 5th edition of the PHTLS manual
Who is using TCCC
US Navy Corpsmen SEAL Junior Officer Course US Army Rangers USAF PJ School C4 Course (DMRTI) JSOC Medical Readiness Course Over 100 Civilian Law Enforcement Organizations Israeli Defense Forces, British SAS, Canadian Counterterrorism Unit, Belgium, Sweden, Norway, NATO
American College of Surgeons National Association of EMTs Included in the PHTLS course curriculum
Phases of Tactical Combat Care
Different phases of combat care requires different priorities and different skill sets and equipment
1. Care under Fire (Hot Zone) 2. Tactical Field Care (Warm Zone) 3. Casualty Evacuation (CASEVAC) Care (Cold Zone)
August 1996 Think beach scene from Saving Private Ryan . Military Medicine. Available medical equipment is limited to that carried by the individual operator or corpsman/medic in his medical pack´ Tactical Combat Casualty Care in Special Operations. while he and the casualty are still under effective hostile fire. Volume 101. The risk of additional injuries being sustained at any moment is extremely high for both casualty and rescuer.Care Under Fire ³The care rendered by corpsman or buddy at the scene of the injury.
Phase 1 Care Under Fire Overview Keep in mind the environment Night operations No white lights +/.Night vision goggles Active firefight Try to keep from getting shot Try to keep casualty from sustaining more wounds Additional firepower provided by the operator may be imperative for fire superiority First rule of care under fire is to return fire Limited personnel May have only one trained medic .
Phase 1 Care Under Fire Overview Care Under Fire A ± Assess B ± Bleeding C ± Carry / Cover Traditionally A ± Airway B ± Breathing C ± Circulation .
Phase 1 .Care Under Fire Assess Bleeding Carry / Cover .
semiconscious. Can I treat the casualty or do I need to be putting rounds down range? Assess the patient What happened here? Is he injured / bleeding? Is he conscious. or unconscious? Can he safely maintain his weapon? Can I position the casualty so he can get back in the fight or position him for safety? No immediate management of the airway should be anticipated due to the need to quickly move the patient .Phase 1 Care Under Fire Assessment Assess the tactical situation.
Brachial (>70). Radial. Radial (>80) Check respirations (Yes / No ± Labored?) Normal Rate (12-16 per min) Is there active bleeding noted? Can they be put back in the fight? . DISARM! Check for a pulse (Carotid. Femoral) Yes / No Normal Rate (70-100 bpm) Quick BP Check Carotid (>60).Phase 1 Care Under Fire Assessment Alert and Oriented? Is it safe for them to hold a weapon? If not.
Phase 1 .Care Under Fire Assess Bleeding Carry / Cover .
500 casualties in Vietnam who had no other injuries Control of hemorrhage is the TOP PRIORITY .Phase 1 Care Under Fire Bleeding Exsanguination from extremity wounds is the #1 cause of preventable death on the battlefield Hemorrhage was the cause of death in more than 2.
more time consuming measures will have to wait until Phase 2 ± Tactical Field Care. requires close observation/reassessment) Fibrin Dressing / QuikClot (1-3 minutes. minimal attention. requires constant attention) Tourniquet (<20 sec. a combination of these measures is used Direct Pressure Tourniquet + Pressure Dressing Depending on the tactical situation.Phase 1 Care Under Fire Bleeding Hemorrhage Control Agents Direct Pressure (Immediate. requires close observation) Often times. . periodic reassessment) Wound Packing / Pressure Dressing (1-3 minutes.
The Tourniquet Discouraged by ATLS Tactical Combat Casualty Care: It is the most reasonable choice to stop potentially life-threatening bleeding while giving care under fire It is immediate and definitive .
Command Surgeon for Johnson¶s Corps. General Johnson bled to death with the tourniquet in his pocket. Lee¶s senior commanders Dr. David Yandell. directed all troops to carry a tourniquet into battle General Johnson suffered damage to his popliteal artery. an injury that can be controlled by a tourniquet Forgetting that he had one.Historical Fact April 1862 ± The Battle of Shiloh General Albert Sidney Johnson was one of Robert E. .
The Facts About Tourniquets Damage is rare if on for < 1 hour Some orthopedic operations place them for hours If massive extremity hemorrhage. better to risk ischemic damage to limb than bleeding out Non-life threatening bleeding should not receive a tourniquet Apply as close to bleeding site as possible Time should be noted Remove when feasible .
Special Forces One-Handed Tourniquet .
Ranger Ratchet Tourniquet .
Bssorai. Guy MD. Mauricio MD. Tali MD. .Tourniquets for Hemorrhage Control on the Battlefield: A 4-Year Accumulated Experience. Tourniquets were applied to 91 (16%) of patients in less than 15 minutes. Abraham. Neurologic complications in seven limbs of five patients. Sokolov. 78% of applications were effective with higher success rates for upper limbs (94%) as compared to lower limbs (71%). Not a single case of death resulting from uncontrolled limb hemorrhage was recorded during the four years.MD 550 soldiers of the IDF were treated in prehospital setting. Amir MD. Dror MD. Lin. Ron Ben. May 2003. 54(5) Supplement:S221-S225. Lakstein. Roni MD. Ischemic time ranged between 109 and 187 minutes. Blumenfeld. Lynn. Journal of Trauma-Injury Infection & Critical Care.
That was then. this is now« .
Black Hawk Down Mogadishu. Corporal Smith succumbs to the wound One of 18 service members lost during fierce fighting between 3 and 4 October 1993. Army Medic Kurt Schmidt and other Rangers present try repeatedly to stop the bleeding using direct pressure and attempts at reaching inside Smith's wound to pinch the artery shut with their fingers Despite the heroic efforts by his fellow Rangers. .S. Somalia Task Force Ranger member Corporal Jamie Smith suffers a severed femoral artery during combat operations U.
QuikClot Provides a hemoconcentration effect in blood that is exiting a wound Accelerates the body¶s natural clotting process by increasing the concentration of platelets and clotting factors at the wound site FDA approved for external use only .
How it works The main component material is called Zeolite Derivative of volcanic rock with many pores Acts as an adsorbent or molecular sieve Captures and holds the water molecules in blood The ability to attract and hold the water molecules is due to electrostatic forces Clotting factors. proteins. and cellular components of the blood are neither attracted nor held They are simply too large to fit in the pore structure .
not chemical or biologic No biological or botanical substances Side Effects? Exothermic reaction 85-90 degrees Celsius possible In vivo studies 37-42 degrees Celsius No danger of allergic reaction Only FDA approved for external use .Product FAQs Allergies? Physical reaction.
Stop pouring promptly when you see a dry layer of QuikClot on wound surface IMMEDIATELY REAPPLY direct pressure or pressure dressing. hold QuikClot package away from face and tear open tabs Package down wind Remove dressings to expose wound and wipe away as much excess blood and water as possible Immediately begin a gradual pour of QuikClot in a back-and-forth motion onto the source of bleeding Try to keep QuikClot in wound ONLY. QuikClot changes from its dry light beige color to a dark color as it absorbs moisture and induces clotting.Phase 1 Care Under Fire Hemorrhage Control: QuikClot Directions Attempt to control bleeding with pressure dressing. If moderate to severe bleeding continues after 90 seconds. .
brush excess granules away or flush gently with water Discard contents once open ± DO NOT REUSE .Phase 1Hemorrhage Control: QuikClot Care Under Fire Precautions Do not use material in the face. drink 2+ glasses of water and seek medical attention immediately If inhaled. move to well-ventilated space Do not use bare hands to apply pressure immediately following application of QuikClot If QuikClot causes heat discomfort to skin. chest or abdomen Do not ingest or inhale QuikClot If ingested. eyes.
Phase 1 Care Under Fire Hemorrhage Control: QuikClot .
. early mortality (180 minutes). metabolic acidosis) were recorded. treatment was provided and limited volume 0. 2003. Llorente. Elena. standard dressing (SD). SD and QuikClot hemostatic agent (QC). Hasan. or SD and TraumaDEX (TDEX). The injury included semitransection of the proximal thigh and complete division of the femoral artery and vein Randomized to (n = 6 animals per group) no dressing (ND). MPH 30 Yorkshire swine (42±55 kg) used to produce uncontrolled hemorrhage. cardiac output.000 mL over 30 minutes) resuscitation was started Blood loss. Peter. Koustova. Gemma. Hancock.Comparative Analysis of Hemostatic Agents in a Swine Model of Lethal Groin Injury. Rhee.. blood pressure. After 5 minutes. Dana.g. Inocencio. Uy. Timothy. Ryan. J Trauma. hemoglobin. and physiologic markers of hemorrhagic shock (e. Anderson.9% saline (1. Orlando.54:1077±1082 Alam. Miller. SD and Rapid Deployment Hemostat (RDH) bandage. MD. Daniel.
Orlando. Hancock. Ryan. J Trauma. Dana. Anderson. Timothy. Miller. 2003.54:1077±1082 Alam. Rhee. Elena. Hasan. Inocencio. MPH Before the application of dressing (first 5 minutes). Gemma. decreased mortality was only statistically significant (p< 0. Llorente. . Uy. Koustova. MD.Comparative Analysis of Hemostatic Agents in a Swine Model of Lethal Groin Injury.4 mL/kg). Daniel. the QC group had the lowest blood loss (4.05) for the QuikClot hemostatic agent group (0% mortality) After application of dressings. Peter. there were no differences in blood loss between the groups After application of wound dressing.4 1.
Phase 1 Care Under Fire Hemorrhage Control Dressings .
Phase 1 Care Under Fire Hemorrhage Control IFAK Bulky Gauze Dressing Pressure Dressings Tourniquet Burn Dressing Band-Aids Wound Disinfectant Iodine Tablets QuikClot .
Non-life threatening bleeding should be ignored until the Tactical Field Care phase. first line of defense More definitive treatment like pressure dressings and/or QuikClot may be applied given the tactical situation The decision regarding the relative risk of further injury versus that of exsanguination must be made by the operator rendering care.Phase 1 Care Under Fire Hemorrhage Control Review Both the casualty and the corpsman/medic are in grave danger while a tourniquet/dressing is being applied during the Care under Fire phase. Tourniquet is the best. . fastest.
Care Under Fire Assess Bleeding Carry / Cover .Phase 1 .
MVC. significant blast injuries) Only 1.4% of patients with penetrating neck injuries would benefit from CSI. Time to accomplish CSI was found to be 5. fast-roping. .5 minutes. even with experienced EMTs Conclusion: The potential hazards to both patient and provider outweighed the potential benefit of CSI in penetrating neck trauma.Phase 1 Care Under Fire Carry Cervical Immobilization C-spine immobilization (CSI) only needed for high velocity impacts (airborne.
and other types of trauma resulting in midline neck pain OR unconsciousness with CSI unless the danger of hostile fire constitutes a greater risk Fireman carry SHOULD NOT be used if cspine injury is suspected. falls.Phase 1 Care Under Fire Carry Cervical Immobilization Treat parachuting injuries. fast-roping injuries. .
Phase 1 Care Under Fire Casualty Movement .
Phase 1 Care Under Fire Casualty Movement Options Firefighter¶s carry One-person drag Two-person drag Two-person fore-and-aft carry Two-person rifle carry Poncho drag Stokes basket drag Litter Carry (2 man / 4 man) .
Phase 1 Care Under Fire Casualty Movement Fireman¶s Carry .
Phase 1 Care Under Fire Casualty Movement One-Person Drag .
Phase 1 Care Under Fire Casualty Movement Two-Person Drag .
Phase 1 Care Under Fire Casualty Movement Two-Person Fore-and-Aft Carry .
Phase 1 Care Under Fire Casualty Movement Two-Person Rifle or Pack Carry .
Phase 1 Care Under Fire Casualty Movement Poncho Drag .
Phase 1 Care Under Fire Casualty Movement Stoke¶s Basket Drag .
Phase 1 Care Under Fire Casualty Movement Situation dictates method No need to lift casualty No extra gear required Side position from casualty allows for better run/walk Rescuers facing forward to identify threats No need to leave packs or weapons .
N.M.O.Phase 1 Care Under Fire Review TEMS: Advanced medical care in areas unsuitable for conventional EMS Get involved International Tactical EMS Society (ITEMS): http://www.O.c om C.org EMT Tactical:http://www.org International School of Tactical Medicine: http://www.S.us/Course_info.tacticalm edic.casualtycareresear chcenter.htm .T.tems.: http://www.tacticalmedicine.
actively engaged Assess.Phase 1 Care Under Fire Review Situation . Bleeding. pressure dressing. Carry/Cover Expect casualty to stay engaged if possible Return fire as directed/required Airway management is generally best deferred until the Tactical Field Care Phase Stop any life-threatening external hemorrhage Tourniquet. QuikClot Try to keep yourself and casualty from sustaining additional injuries .
Phase 1 Care Under Fire Review Treatment Algorithm Trauma Assessment Airway Breathing Circulation Disability Exposure Rapid Assessment Assess Bleeding (Control) Carry/Cover Phase 2: Tactical Field Care (stay tuned) .
Patterns of Injury and Effects on Delay of Treatment. MPH.Acknowledgements Tactical Combat Casualty Care in Special Operations. and Blast Injuries. CAPT Frank Butler. PhD. Romanosky. MD. HM2(FMF/DV/PJ) Walker. SOMA 2003. MD. MC(UMO/SEAL). Albert J. Tactical Combat Casualty Care ± Update 2003. FACS. Fall 2003 Battlefield Trauma Course. SOMA 2003. HM1(DV/FPJ) Tague. MD. Stephen D. Howard Champion. Explosive Devices. USN. Gieber. Explosions. Journal of Special Operations Medicine. .
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