Tactical Combat Casualty Care (TCCC)
What kind of scalpel is used with a cricothyroidotomy?
#10
What are the FAST1 flow rates?
- 30-80 ml/min by gravity - 120 ml/min utilizing pressure infusion - 250 ml/min using syringe forced infusion
FAST1 is not recommended for:
- patient w/ weight less than 50 kg (110 lbs) or less than 12 years old - fractured manubrium/sternum: flail chest, tissue damage, trauma, infection, severe osteoporosis - previous sternotomy and/or scar
What are the three CoTCCC-recommended junctional tourniquets?
1. Combat Ready Clamp (CRoC) 2. Junctional Emergency Treatment Tool (JETT) 3. SAM Junctional Tourniquet (SJT)
What are the different ways a surgical cricothyroidotomy can be performed?
1. Cric-Key (preferred) 2. Bougie-aided open surgical technique using flanged and cuffed airway cannula (less than 10 mm outer diameter, 6-7 mm internal diameter, 5-8 cm intratracheal length) 3. standard open surgical technique (least desirable)
What are the types of carries for CUF?
1. One-person drag with/without line 2. Two-person drag with/without line 3. SEAL Team Three Carry (Shoulder-Belt Carry) 4. Hawes Carry (Modified Fireman's Carry or Pack Strap Carry)
When should tourniquets be converted to hemostatic or pressure dressings?
1. The casualty is not in shock 2. It is possible to monitor the wound closely for bleeding 3. The tourniquet is not being used to control bleeding from an amputated extremity
What are the three objectives of TCCC?
1. Treat the casualty 2. Prevent additional casualties 3. Complete the mission
How many cc's of air are used to inflate the cric cuff?
10 cc
What kind of IV catheter is preferred?
18-gauge or saline lock
Damage to the arm or leg is rare if the tourniquet is left on for less than _____ hours.
2
Up to how many combat deaths today are potentially preventable?
24%
How long should you hold direct pressure on a hemostatic agent (e.g. combat gauze)?
3 minutes
What is the failure rate when performing a battlefield cricothyroidotomy?
33%
In one study, how many pelvic binders were placed too high?
40% which resulted in inadequate reduction of the pelvic fracture and possibly increased bleeding
What does the prehospital arm of the Joint Trauma System include?
42 members from all services in DoD and civilian sector; trauma surgeons, emergency medicine, critical care physicians, combatant unit physicians, medical educators, combat medics, corpsmen, PJs; 100% deployed experience as of 2017
What is an acceptable alternate site to treat tension pneumothorax?
4th or 5th intercostal space at the anterior axillary line (AAL) which is at the lateral aspect of the pectoralis major muscle; 5th intercostal space is located at the nipple level in young, fit males
What is the saline lock flushed with?
5cc normal saline (NS) and then every 1-2 hours to keep it open
Do not remove a tourniquet that has been in place more than _____ hours unless close monitoring and lab capability are available.
6
About how much pressure is inserted until the FAST1 releases?
60 pounds
What is normal O2 at 12,000 ft?
86% due to lower oxygen pressure at that altitude
What is normal O2 at sea level?
98% or higher
tension pneumothorax
Air escapes from the injured lung and pressure builds up in the chest which collapses the lung and pushes on the heart. The compressed heart is then not able to pump well.
What is the A in MARCH?
Airway: maintain a patent airway
How can you manage an open pneumothorax?
Apply a vented occlusive dressing completely over the defect at the end of one of the casualty's exhalations. Monitor for possible development of tension pneumothorax. Allow the casualty to sit.
What do you use to prepare the site for a FAST1 insertion?
Betadine and alcohol
What are the three phases of care in TCCC?
Care Under Fire (CUF), Tactical Field Care (TFC), TACEVAC Care
What is the C in MARCH?
Circulation: IV/IO access and administer fluids to treat shock
What is the form name for the TCCC Casualty Card?
DD 1380
How is a tension pneumothorax treated?
Decompress the chest on the side of the injury with a 14-gauge, 3.25 inch needle/catheter inserted in the 2nd intercostal space at the midclavicular line (2-3 finger widths below). Ensure that that the needle is not medial to the nipple line and not directed towards the heart.
Prior to 9/11, what was combat medical training modeled on?
Emergency Medical Technician and Advanced Trauma Life Support
True or False: You should periodically loosen the tourniquet to allow blood flow to the injured extremity
False
What is the H in MARCH?
Head injury/Hypothermia: prevent/treat hypotension and hypoxia to prevent worsening of TBI
What often causes a junctional hemorrhage?
IEDs
How tight should the tourniquet be?
It should stop the bleeding and eliminate the distal pulse.
How was TCCC used early in the Iraq and Afghanistan conflicts?
It was not widely used at the start of the wars, but increased in use by both Special Operations and conventional units beginning in 2005.
What should you do if signs of tension pneumothorax develop in a treated sucking chest wound?
Lift one edge of the seal and allow the tension pneumothorax to decompress ("burping").
What is the M in MARCH?
Massive hemorrhage: control life-threatening bleeding
Do penetrating head and neck injuries require C-spine stabilization?
No
Where is the limb tourniquet placed?
Over the uniform clearly proximal (2-3 inches) to the bleeding site, but if it is not obvious, place the tourniquet "high and tight" (as proximal as possible) on the injured limb.
What is the "Triple Option" for battlefield analgesia?
PO meds, OTFC, ketamine
What are the three commercially available pelvic binders?
Pelvic Binder, T-POD, SAM Pelvic Sling II
If the first tourniquet fails to control the bleeding, what should be done?
Place a second tourniquet just above (proximal) the first.
What is the R in MARCH?
Respiration: decompress tension pneumothorax, seal open chest wounds, support ventilation/oxygenation
What two types of junctional tourniquets may also serve as pelvic binders?
SAM Junctional Tourniquet and Junctional Emergency Treatment Tool
How does the XSTAT 12 work?
Syringe-like applicator injects 38 compressed minisponges into deep wounds which rapidly expand to 10-12 times their volume on contact with blood within 20 seconds, compressing the wound to stop bleeding
What types of casualties should you consider using a pulse ox for?
TBI (good O2 sat of >90% is very important for a good outcome); unconscious; penetrating chest trauma; chest contusion; severe blast trauma
During which phase should airway management be performed?
Tactical Field Care phase
What should be done with the pelvic binder if definitive care is delayed beyond 8-12 hours?
The need for a binder should be reassessed and the binder loosened if the patient remains hemodynamically stable.
How does a pneumothorax occur?
There is a collection of air between the lung and chest wall due to an injury to the chest and/or lung. The lung then collapses. Normally, the lung fills up the entire chest cavity, but with injury, the air is inside the chest but outside the lung.
chitosan
a mucoadhesive whose function is independent of coagulation cascade; does not cause reactions in people allergic to shellfish; has been used in combat with hemostatic dressings since 2004 with no safety issues reported
What is inserted into the XSTAT 12 applicator to deploy the minisponges into a wound?
a plunger
Celox Gauze/ChitoGauze
active ingredient is chitosan; as effective as Combat Gauze at hemorrhage control; neither have been tested in the USAISR safety model
nasopharyngeal airway (NPA)
also called "nose hose" and "nasal trumpet"; well tolerated by conscious patient but will gag; don't use an oropharyngeal airway (J tube) with it; easily dislodged
If the transition from tourniquet to Combat Gauze at 2 hours failed, when should you try again?
at 6 hours
Where should the pelvic binder be placed?
at the level of greater trochanters, NOT iliac wings (top of hip bone)
junctional hemorrhage
bleeding from wounds to the groin, buttocks, perineum, axillae, base of neck, extremities at sites too proximal for a limb tourniquet
When should the minisponges from the XSTAT 12 be removed?
by a surgeon after achieving proximal and distal vascular control
When should you not convert the tourniquet?
casualty in shock; you cannot closely monitor the wound for re-bleeding; the extremity distal to the tourniquet has been amputated; it has been on more than 6 hours; casualty will arrive at an MTF within 2 hours; tactical or medical considerations make transition inadvisable
How should you handle an unconscious casualty without airway obstruction?
chin lift/jaw thrust, nasopharyngeal airway, place casualty in recovery position
What are the three hemostatic dressings recommended in the TCCC guidelines?
combat gauze, Celox gauze, ChitoGauze
What is XStat best for?
deep, narrow-tract junctional wounds
Where should a tourniquet not be placed?
directly over the knee, elbow, a holster, cargo pocket that contains bulky items
Don't insert an IV _____ to a significant wound.
distal
What is the number one medical priority in CUF?
early control of severe hemorrhage
Why is a saline lock recommended instead of an IV line unless fluids are needed immediately?
easier to move; less chance of traumatic disinsertion; provides rapid access; conserves IV fluids
What may cause tension pneumothorax?
entry wounds in the abdomen, shoulder, or neck; blunt (motor vehicle accident) or penetrating trauma (GSW)
Combat Gauze
first choice for hemostatic dressing; a 3 in. x 4 yd. roll of sterile gauze impregnated with kaolin, a material that causes blood to clot
XSTAT 12
first expanding wound dressing FDA-cleared for life-threatening junctional bleeding in the groin or axilla not amenable to tourniquet application; a temporary device for use up to 4 hours
What are the indications for IV access?
fluid resuscitation for hemorrhagic shock or risk of shock; casualty needs meds but cannot take them by mouth; unable to swallow; vomiting; decreased state of consciousness; absent/weak radial pulses
Open Book Pelvis Injury
front of the pelvis opens like a book; results in tears of the strong pelvic ligaments that hold the pelvis bones together at the symphysis pubis and the sacroiliac joints
Lateral Crush Injury
half of the pelvis is crushed either inward or outward
What is the leading cause of preventable death on the battlefield?
hemorrhagic shock
When may oxygen saturation values be inaccurate?
hypothermia, shock, carbon monoxide poisoning, very high ambient light levels
When can you go the IO route?
if vascular access is needed but not quickly obtainable via the IV route
If a person has suffered a maxillofacial trauma but his/her _____ are intact, he/she may do well.
larynx and trachea
If the casualty is conscious when performing a cricothyroidotomy, what should you use?
lidocaine
If you must move a casualty under fire, what should be considered?
location of nearest cover; how best to move him/her; risk to rescuers; weight of casualty and rescuer; distance to be covered; use suppression fire and smoke to best advantage; recover casualty's weapons if possible
What can a tension pneumothorax impair?
lung function and heart function, causing respiratory distress and shock
What does the radiopaque marker embedded into each of the minisponges of the XSTAT 12 do?
makes them detectable by X-ray
Who are the only people allowed to reposition or convert tourniquets?
medics, physician assistants, physicians
Vertical Shear Pelvis Injury
one half of the pelvis is forcefully shifted upward
How many deaths occurred in Vietnam secondary to hemorrhage from extremity wounds?
over 2500
Pelvic binders may mask the presence of a _____ on CT scanning.
pelvic fracture
What exam findings are suggestive of a pelvic fracture?
pelvic pain; laceration/bruising at bony prominences of pelvic ring; deformed/unstable pelvis; unequal leg length; scrotal, perineal, or perianal bruising; blood at urethral meatus; massive hematuria; blood in rectum/vagina; neurologic deficits in lower extremities
Where is external rotation of the lower extremities commonly seen in?
people with displaced pelvic fractures; may increase the dislocation of fragments; can be prevented/reduced by securing the knees or feet together
All individuals with moderate/severe TBI should be monitored with _____.
pulse oximetry
What are signs of life threatening bleeding?
pulsing or steady bleeding from the wound; blood is pooling; clothes soaked with blood; bandages covering the wound are ineffective and steadily becoming soaked with blood; traumatic amputation of arm or leg; there was prior bleeding and patient is now in shock
What will minimize the chance of ischemic damage due to a tourniquet?
restoring blood flow to the limb by transitioning to Combat Gauze at the 2-hour mark
pelvic binder
should be applied for cases of suspected pelvic fracture
What are the major concerns of CUF?
suppression of enemy fire and moving casualties to cover
What is the second leading cause of preventable death on the battlefield?
tension pneumothorax
What should be considered in a casualty with progressive respiratory distress and known/suspected torso trauma?
tension pneumothorax
The higher the sponge density in the wound cavity -
the higher the pressure exerted on the damaged vessel
What is MARCH?
the sequence of care in TFC
What size does a hole in the chest have to be for a sucking chest wound (open pneumothorax) to occur?
the size of a nickel or bigger
What is the XSTAT 12 not indicated for use in?
thorax, pleural cavity, mediastinum, abdomen, retroperitoneal space, sacral space, tissues above inguinal ligament, tissues above clavicle
Having _____ XSTAT 12 applicators available at the point of injury is recommended by the manufacturer.
three
What are the surface landmarks for a cricothyroidotomy?
thyroid cartilage, thyroid prominence (Adam's apple in males), cricothyroid membrane, cricoid cartilage
How do you stop burning in CUF?
with any non-flammable fluids, by smothering, or by rolling on the ground
