TCCC — PERFORM A TACTICAL COMBAT CASUALTY CARE PATIENT ASSESSMENT

NOTE: During Care Under Fire phase, apply only

... hasty tourniquet(s) high on limb over uniform, to control obvious extremity hemorrhage before moving casualty to cover (Evaluated IAW Control Bleeding Using a Tourniquet task).

NOTE: Despite fire superiority being gained during the care under fire phase of care,

... it does not mean that the enemy threat has been eliminated. You must exercise caution when maneuvering to casualties utilizing available cover, concealment, and suppressive fire. If the tactical situation permits have the casualties move to your position exercising the same caution.

NOTE: Performance steps/measures that are evaluated in other EFMB TCCC tasks (i.e. Control Bleeding Using a Tourniquet task) will not be marked as a NO-GO on this task as long as

... they were attempted at the appropriate phase in the CTL. Performance of a step/measure during the wrong phase (i.e., splinting a fracture in the care under fire phase) or not performing at all will be marked as a NO-GO on this task.

NOTE: For EFMB testing purposes, the host unit may elect for the candidate to only perform

...a detailed physical exam on one casualty due to the time required to perform this portion of the assessment.

NOTE: Once fire superiority has been gained

...begin assessing and treating life threatening hemorrhage.

NOTE: Significant hemorrhage from an extremity wound should be stopped as quickly as possible using a tourniquet. Once the tactical situation permits,

...consideration should be given to applying a pressure type dressing and then loosening the tourniquet.

NOTE: For EFMB testing purposes, the candidate cannot

...direct other individuals or a casualty to perform tasks that he is being evaluated on. This is also applicable for other performance steps/measures within this task. For example, the candidate cannot direct a team member to control bleeding using a tourniquet and only check that it was applied correctly. The candidate must be evaluated on performing each of the TCCC tasks at least once.

NOTE: A casualty with penetrating chest trauma will generally have some degree of

...hemo/pneumothorax as a result of the primary wound.

NOTE: If the casualty has equipment that is essential to the mission,

...move the mission-essential equipment also. Do not try to move equipment that is not mission essential.

NOTE: If multiple casualties exist, at a minimum, the

...primary assessment will be completed on each casualty before moving to the next casualty unless they are expectant.

NOTE: For EFMB testing purposes, the casualty or the evaluator will communicate

...the AMPLE history information to the candidate if properly questioned. If the casualty is unconscious, the candidate can obtain this information from other sources (i.e., check ID tags, medication bracelets, squad members).

NOTE: The chief complaint is

...the casualty's description of the injuries. Life threats are how those injuries threaten the casualty's life (i.e., an open chest wound might lead to a tension pneumothorax, which could lead to cardiac shock).

2. Perform tactical field care procedures.

a. Establish a security perimeter. b. Immediately remove the weapon and communication equipment from any casualty with an altered mental status. c. Communicate updates to the medical situation to the unit leader (Evaluated IAW Triage Casualties task). d. Take body substance isolation (BSI) precautions. e. Perform a primary assessment. (1) Develop a general impression of the patient. NOTE: A general impression is the observation of the casualty. Note clues to the patient's mechanism of injury, the patient's approximate age, height, weight, body position, appearance, signs of distress and any odors present (i.e., urine, vomit, feces). (2) Determine the patient's responsiveness using the AVPU scale. (a) A - Alert and oriented. (b) V - Responsive to verbal stimuli. (c) P - Responsive to painful stimuli. (d) U - Unresponsive. (3) Determine the patient's chief complaint and life threats. (4) Assess for Massive Hemorrhage. (a) Reassess any treatment for hemorrhage performed during the care under fire phase. (b) Perform a blood sweep to identify any life threatening hemorrhage. (c) Immediately treat life threatening hemorrhage, if present. (i) Apply a deliberate tourniquet to any new wounds discovered on extremities (Evaluated IAW Control Bleeding Using a Tourniquet task). (ii) For wounds treated with a hasty tourniquet during Care Under Fire Phase, apply a deliberate tourniquet then loosen the hasty tourniquet (Evaluated IAW Control Bleeding Using a Tourniquet task). (iii) For hemorrhage that cannot be controlled with a tourniquet, apply a Hemostatic Device (Evaluated IAW Control Bleeding of a Junctional Wound with Hemostatic Device task). (5) Assess the Airway. (a) Perform appropriate maneuver to open and maintain the airway. (b) Determine if the airway is patent or not. Look, listen and feel to ensure the patient's airway is patent and not compromised. (c) Insert a nasopharyngeal airway adjunct, if required (Evaluated IAW Insert a Nasopharyngeal Airway task). (6) Assess Respiration/Breathing. (a) Inspect the chest. (i) Open body armor (if present) and expose the chest. (ii) Inspect for any penetrating chest wounds, deformities, contusions, abrasions, punctures or penetration, burns, tenderness, lacerations, swelling (DCAP-BTLS) and equal bilateral rise and fall of the chest. (iii) If a penetrating chest wound is present, apply an occlusive dressing to both entrance and exit wound if present (Evaluated IAW Treat a Penetrating Chest Wound task). (b) Palpate the anterior area of the chest feeling for tenderness, instability and crepitus (TIC). (c) Observe for adequate respiratory effort and progressive respiratory distress. EVALUATOR STATES: "RESPIRATION RATE IS BELOW 8 BREATHS PER MINUTE" or "RESPIRATION RATE IS ABOVE 30 BREATHS PER MINUTE" (i) If respirations are less than 8 or greater than 30 breaths per minute, utilize a bag valve mask to perform manual ventilation NOTE: Candidate will apply proper placement of bag valve mask on casualty and direct CLS to administer one ventilation every 5-6 seconds to achieve a ventilation rate of 10-12 breaths per minute. NOTE: Progressive respiratory distress secondary to unilateral chest trauma should be considered a tension pneumothorax and requires needle decompression. (f) Perform needle chest decompression, if necessary (Evaluated IAW Perform Needle Chest Decompression task). (7) Assess Circulation. (a) Perform blood sweep for any additional hemorrhages. (i) Control bleeding, if present, with direct pressure, pressure bandage, elevation, hemostatic device, or tourniquet (Evaluated IAW appropriate Control Bleeding tasks). (ii) Convert to pressure dressing or use hemostatic device to control bleeding and then loosen tourniquet, if appropriate (Evaluated IAW appropriate Control Bleeding tasks). (b) Check for pulses. (i) Check the radial pulse, if present the blood pressure is at least 80mmHg. (ii) If radial pulse is not present, check for the carotid pulse. If present, the blood pressure is at least 60mmHg. (c) Assess the skin's color, condition, and temperature (CCT). (d) Identify signs and symptoms of shock, if present. (i) Weak or absent radial pulses. (ii) Altered mental status. (iii) Pale, cool and clammy skin. (e) Initiate hypotensive fluid protocol (Evaluated IAW Initiate a Saline Lock and IV task). (i) Initiate fluids only if in hypovolemic shock. (ii) (Verbalize) Give 1gram Tranexamic Acid (TXA) in 100 cc Normal Saline or Lactated Ringer's as soon as possible but NOT later than 3 hours after injury. When given, TXA should be administered over 10 minutes by IV infusion. (ii) Give Hextend 500-ml IV bolus. (iii) Repeat after 30 minutes if casualty is still in shock (8) Prevent hypothermia and treat for shock, if applicable (Evaluated IAW Initiate Treatment for Hypovolemic Shock and Prevent Hypothermia task). (9) Determine the patient's evacuation priority and make a MEDEVAC decision. f. Perform a Detailed Physical Exam. (1) Assess the head. (a) Inspect for *deformities, contusions, abrasions, punctures or penetration, burns, tenderness, lacerations, and swelling* (DCAP-BTLS). (b) Palpate for tenderness, instability, and crepitus (TIC). (c) Use pen light to inspect eyes for pupils equal round and reactive to light (PERRL). (d) Inspect for raccoon eyes and battle sign behind ears. (e) Inspect the mouth for broken teeth or airway obstructions. (f) Inspect the nose, mouth and ears for cerebral spinal fluid (CSF) and/or blood. (g) Treat an open head wound, if present (Evaluated IAW Treat an Open Head Wound task). (h) Treat lacerations, contusions, and extrusions of the eye (Evaluated IAW Treat Lacerations, Contusions, and Extrusions of the Eye task). (2) Assess the neck. (a) Inspect for DCAP-BTLS. (b) Palpate C-spine for TIC and step-offs. (c) Inspect for jugular vein distention (JVD). (d) Inspect for tracheal deviation. (e) Apply cervical collar, if necessary. (3) Assess the chest. (a) Inspect for DCAP-BTLS and equal bilateral rise and fall of the chest. (b) Auscultate at least four fields for equality and presence of respirations. (c) Palpate the anterior area of the chest feeling for TIC. (e) Observe for progressive respiratory distress. (f) Perform needle chest decompression, if necessary (Evaluated IAW Perform Needle Chest Decompression task). (4) Assess the abdomen. (a) Inspect for DCAP-BTLS. (b) Treat an open abdominal wound, if present (Evaluated IAW Treat an Open Abdominal Wound task). (c) Palpate for tenderness, rigidity and distention (TRD) if no open abdominal wound exist. (5) Assess the pelvis. (a) Inspect for DCAP-BTLS. (b) Gently compress to detect TIC if no signs and symptoms of trauma exist. (c) Inspect genitalia and perineum (6) Assess the lower extremities. (a) Inspect for DCAP-BTLS. (b) Palpate for TIC. (c) Check for pulse, motor, and sensory (PMS). (7) Assess the upper extremities. (a) Inspect for DCAP-BTLS. (b) Palpate for TIC. (c) Check for PMS. (d) Immobilize a suspected fracture of the arm, if present (Evaluated IAW Immobilize a Suspected Fracture of the Arm task). NOTE: The casualty should be log rolled to do this portion of the assessment, unless contraindicated by injuries. (8) Assess the posterior. (a) Inspect for DCAP-BTLS. (b) Palpate the long spine for TIC and step-offs. (c) Inspect for rectal bleeding. (d) Log roll patient onto litter/stretcher. (e) Reassess all life-saving interventions or treatments to ensure they have not been compromised due to the movement of the patient.

1. Perform care under fire procedures.

a. Take cover. Return fire as directed or required before providing medical treatment. b. Direct the casualties to return fire, move to cover, and apply self aid if able. c. Determine the scene safety/security. d. Determine the number and location of the injured and severity of their injuries (Evaluated IAW Triage Casualties task). e. Direct team members/combat life savers to assist, if available. f. Assess the casualties for life threatening extremity hemorrhage. (1) If the casualty is unresponsive or unable to move and has severe extremity bleeding, administer life-saving hemorrhage control before moving the casualty. (a) Use a tourniquet for hemorrhage that is anatomically amenable to tourniquet application (Evaluated IAW Control Bleeding with Tourniquet task). g. Communicate the medical situation to the team leader, the evaluator for EFMB testing purposes (Evaluated IAW Triage Casualties task). h. Tactically transport the casualty, their weapon, and mission-essential equipment to cover, as required (Evaluated IAW Evacuate Casualties tasks). j. Recheck the bleeding control measures as the tactical situation permits.