TCCC Tier3

What is the goal of management for casualties with suspected head injuries/TBI in TFC?

Prevention of secondary brain injury from hypotension and hypoxia.

What is the definition of shock?

Progressive cellular and tissue hypoxia leading to organ damage and, if not treated, death.

What should you assess before and after splinting?

Pulses, skin color, and sensorimotor function distal to the site of the fracture should be assessed. Once you have applied a splint, be sure to reassess the pulses motor and sensory (PMS) function distal to the fracture, and compare that to the baseline PMS assessment you performed prior to splint application.

What are advantages and disadvantages of two-person carries?

• Advantages: they are useful in situations where drags do not work well and are quicker than most one-person carries. • Disadvantages: they cause the rescuers to have a higher silhouette than most drags, and are hard to accomplish with the added weight of rescuer's and/or the casualty's equipment.

What are the signs of life threatening bleeding?

• Bright red blood is pooling on the ground • The overlying clothes are soaked with blood • There is a traumatic AMPUTATION of an arm or leg • There is pulsatile (pulsing) or steady bleeding from the wound

Name three critical actions in preparing a casualty for evacuation.

• Complete and secure the DD Form 1380 to the casualty. • Secure all loose ends of bandages and wraps. • Secure hypothermia prevention wraps/blankets/straps. • Secure litter straps as required, consider additional padding for long evacuations. • Provide instructions to ambulatory patients as needed.

What signs of hemorrhagic shock are indications that fluid resuscitation is needed?

A casualty with a weak or absent radial pulse, or altered mental status in the absence of traumatic brain injury (TBI), needs fluid resuscitation.

What is the proper distance a deliberate tourniquet should be placed from the bleeding site in TFC?

A deliberate tourniquet placed in TFC should be 2-3 inches above (proximal) to the site of bleeding.

What kind of dressing should be placed on burned areas?

A dry sterile dressing

Why is it important to check the pulse after applying a pressure bandage?

A pressure bandage should not be a tourniquet. It is important to check to ensure a pulse is still present distally after bleeding has been controlled by application of a pressure bandage. If no pulse is present the pressure bandage should be loosened and reapplied.

When should a pressure dressing be used in treating traumatic eye injuries?

A pressure dressing or patch should NEVER be used to treat a traumatic eye injury.

What kind of dressing should be used on penetrating eye trauma with an impaled object?

A rigid eye shield should be used to cover and protect the injured eye. Alternatively, an improvised eye shield (Styrofoam or other cup, etc.) taped over the eye can be used if there is a protruding foreign body in the eye that would extend beyond the rigid eye shield. Tactical protective eyewear can be used to protect the injured eye. A pressure dressing or patch should NOT be used.

True or False: Only the injured eye should be covered with a rigid eye shield?

True. Rigid eye shields should be placed over both eyes ONLY when you are sure or at least strongly suspect that both eyes have been injured. When only one eye has been injured, do not place an eye shield over the unaffected eye to prevent eye movement. Movement has not been shown to worsen the outcome for the injured eye. Blindness, resulting from placing eye shields over both eyes unnecessarily, is psychologically stressful and makes an otherwise ambulatory casualty a litter casualty.

What should you do first when you encounter a casualty with an electrical burn?

Secure the power, if possible; otherwise, remove the casualty from the electrical source using a nonconductive object, such as a wooden stick.

In which phase of care is most of the Tactical Trauma Assessment performed?

Tactical Field Care

What is the best position for a conscious casualty that is breathing on their own?

Allow the conscious casualty that is breathing on their own to assume whatever position allows them to breathe most comfortably.

What anatomical sites can be used to safely administer an intramuscular injection?

The three potential sites are the deltoid, the thigh, and the buttock.

When should you administer antibiotics in the Tactical Field Care phase?

Antibiotics must be given as soon as possible after injury to maximize their ability to prevent wound infections.

What is the most essential treatment task in CUF?

Application of a limb tourniquet to control massive bleeding.

What is the difference between meloxicam and other common NSAID medications?

Unlike the other NSAID medications that inhibit platelet function and can lead to increased bleeding risk, meloxicam is a preferential COX-2 inhibitor that spares platelet function so it does not interfere with hemostasis.

Name three of the four complications of open abdominal wounds.

1. Increased risk of hypothermia - insensible heat losses from the evaporative process from the open abdomen 2. Fluid loss - dehydration from the evaporative processes 3. Internal hemorrhage - significant volume of pooled blood or ongoing hemorrhage may not be visible at the surface 4. Infections - both from the nature of the injury and from potential bowel perforation

9-Line

1. Location 2. Call Sign/Freq 3. # of casualties: Urgent/Non-Urgent 4. Special Equipment Needed 5. Type of casualties: Ambulatory/Non-Ambulatory 6. Security at pickup site 7. Marking 8. Nationality of casualties 9. (Wartime) CBRN 9. (Peacetime) terrain

What are the three objectives of TCCC?

1. Treat the casualty 2. Prevent additional casualties 3. complete the mission

What are the four major areas for action in CUF?

1. scene safety 2. casualty movement 3. stop life-threatening external hemorrhage 4. proper communication

Dosage of Meloxicam

15mg tablet once daily

What is the proper protocol for administering tranexamic acid?

2 grams of tranexamic acid should be administered via slow IV or I0 push as soon as possible but NOT later than 3 hours after injury.

Dosage of Acetaminophen

2x 500mg tablets every 8 hours

How long does it take to bleed to death from a complete femoral artery and vein disruption?

3 minutes or less

How long should direct pressure be applied onto packed hemostatic dressings?

3 minutes.

Dosage of Moxifloxacin

400mg tablet once daily

What would be the fluid infusion rate for a 90 kg person with a 40% burn according to the USAISR Rule of Ten?

500ml/hr. The initial IV/O fluid rate is the %TBSA x 10 ml/hr for adults weighing 40-80 kg. For every 10 kg above 80 kg, increase the initial rate by 100 ml/hr. 40% × 10 ml/hr = 400ml/hr 400ml/hr + 100ml/hr = 500m/hr

How should you arrange casualties when staging them at the evacuation site?

At the site, the casualties should be arranged so that they can be loaded in sequence, according to their movement priority and clinical status. This may be dictated by unit procedures, or it may be provided by the evacuation platform personnel. In general, when feasible, ambulatory and routine patients are loaded first, followed by priority casualties, and urgent casualties are loaded last.

What are the differences between the high & tight hasty tourniquets placed in CUF and the deliberate tourniquets placed in TC?

The tourniquets placed in CUF are typically placed over the uniform/clothing as high up on the extremity as possible, as time is very limited and the exact site of bleeding may not have been identified. In contrast, the tourniquets placed in FC are placed more deliberately after uniform clothing has been removed and 2-3 inches above the identified site of bleeding.

How do you care for an amputated body part?

Wrap the amputated body part loosely with moistened gauze. If possible, place it in a plastic bag; if not, wrap it with cravats to cover all of the gauze. Then place the bag, or the cravat-covered body part, in a container with ice, if available.

What is the difference between active and passive hypothermia management?

Active hypothermia treatment uses an external heating source to warm the casualty. Passive hypothermia management strategies will keep the casualty from losing more heat, but will not warm the casualty or reverse the hypothermic process.

What external forces can cause a head injury?

• Involvement in a vehicle blast event, collision, or rollover • The presence within 50 METERS of a blast (inside or outside) • A direct blow to the head or a fall • Gunshot or shrapnel wound to the head, open skull fracture, or witnessed loss of consciousness • Exposure to more than one blast event (the Service member's commander will direct a medical evaluation)

What information does the MIST report contain?

• Mechanism of injury • Injuries • Signs/Symptoms • Treatment

When should you inspect your JFAK, CLS bag, CMC bag and other Service-specific medical kits?

Before, during, and after all training events and missions.

What are the phases of care in TCCC?

Care Under Fire/Threat, Tactical Field Care, and Tactical Evacuation Care.

What goes into selecting a litter?

Choosing a litter may be based solely on equipment availability; but if multiple options are available, then base your decision on a combination of the terrain and tactical considerations, the unit personnel you have to support casualty movement, and the evacuation asset you anticipate using.

Why is it important to document prehospital combat casualty care?

Documentation of care on the battlefield is not just an administrative requirement. It provides crucial information to other providers in the continuum of care that informs further assessment and treatment. The casualty's level of consciousness and vital signs, when a tourniquet was applied, and if and when analgesics or TXA were administered are examples of information that might directly impact ongoing casualty care. Prehospital documentation becomes part of the casualty's longitudinal medical record, permanently recording injuries and wounds sustained and the care provided.Furthermore, the care and outcomes data captured in prehospital documentation informs evidence-based combat casualty care process improvement and helps to shape the future of battlefield trauma care.

What is an advantage of freeze-dried plasma?

Dried plasma can be stored without refrigeration and may be carried and used by combat medical personnel when transfusion of other blood components is not logistically feasible.

Why is it important to prevent manage hypothermia in a trauma casualty?

Even a small decrease in body temperature can interfere with blood clotting and increase the risk of bleeding to death. Casualties in shock are unable to generate body heat effectively. Avoid the "lethal triad"

What signs or symptoms are suspicious for pelvic instability?

• Pelvic pain • Any major lower limb amputation or near amputation • Physical exam findings suggestive of a pelvic fracture • Unconsciousness • shock

Who should a combat medic corpsman communicate with during the Tactical Field Care phase of care?

• The casualty • Other medical and nonmedical responders • The tactical leadership • The evacuation system

What are the signs of an airway obstruction?

In cases of partial or complete airway obstruction, the casualty may experience agitation, cyanosis, confusion or even unconsciousness, difficulty breathing (dyspnea), or high-pitched breathing noises such as stridor, wheezing, snoring, or gurgling sounds.

Which CoTCCC-recommended analgesia medications can be given by the intranasal route?

In the TFC setting, the medications that are potentially delivered intranasally include: ketamine and naloxone

What type of tourniquet found in the CMC Aid Bag is used to control massive hemorrhage in the axilla that is too proximal for effective limb tourniquet application?

Junctional Tourniquet

Why is it important to perform pre-mission rehearsals of preparation for evacuation?

If the first time that unit members are involved in this process is during an actual evacuation, there is a significant risk that the team will not function well and the evacuation process will be delayed or the transition of care will be less than optimal, which could result in an adverse clinical outcome. These rehearsals not only involve understanding the primary role each participant will be expected to perform, but cross-training unit members so that they can assume the duties of one of the other members.

True or False? Only the Combat Medic Corpsman can document prehospital care for a casualty using the TCCC Card (DD Form 1380?

False. Documentation on the TCCC Card (DD Form 1380) should be completed by whoever is providing care at the point of injury or wounding and updated with any changes in the casualty's status or additional care rendered by all subsequent prehospital providers. Documentation can be completed by nonmedical personnel or the Combat Medic/Corpsman.

True or False? Hypothermia is not an issue in hot operational environments?

False. Even in a hot environment, a trauma or burn casualty can become hypothermic due to hemorrhage and shock. Hypothermia prevention and management is a consideration for all trauma casualties.

True or False: The Snellen Eye Chart is used for performing a rapid field visual acuity test?

False. Rapid visual acuity testing is NOT a formal vision screening with a Snellen Eye Chart. It is a rapid assessment and includes testing the casualty's ability to read print, count fingers, identity hand motion, or differentiate light from dark.

The best medicine on the battlefield is...

Fire superiority

What size burn requires a fluid resuscitation?

For burns > 20% TBSA, initiate fluid resuscitation as soon as IV/O access is established.

Which factors influence TCCC?

Hostile fire, tactical considerations, wounding patterns, environmental considerations, level of first-responder training and experience, equipment constraints and the potential for significant delays in evacuation.

What should you do if you suspect a casualty has a tension pneumothorax?

If a chest seal is in place, burp the seal. If there is no improvement after burping the seal perform a needle decompression of the chest.

What is the pharmacological agent of choice to treat moderate to severe pain in a casualty that is in shock?

If the casualty is in moderate to severe pain, and the casualty is in shock, or at risk of shock or pulmonary compromise, ketamine is the agent of choice.

When should you use ertapenem instead of moxifloxacin as an antibiotic therapy?

If the casualty is in shock or unconscious, or cannot swallow oral medications, they should be given one gram of ertapenem.

What is the oral antibiotic of choice and its dose?

If the casualty is not in shock and can swallow oral medications, they should be given a 400 mg tablet of moxifloxacin.

If an impaled object is on an extremity, what do you need to do in addition to stabilizing the object?

If the impalement is on an extremity, treat it like a fracture and stabilize the joint above and below the location of the object with splints.

Which lines of a MEDEVAC must be transmitted for an asset to be launched?

Lines 1-5 are enough information to initiate a MEDEVAC depending upon pre-planning and coordination between tactical and evacuation units. Lines 6-9 can be transmitted while the evacuation asset is en route.

What does MARCH PAWS stand for?

Massive bleeding, airway, respirations (breathing), circulation, and hypothermia AND head injury, pain, antibiotics, wounds, and splints.

After applying pressure to stop bleeding, if necessary, what is the next step in treating a minor wound?

Next, irrigate and clean wounds with either sterile water, if it is available, or even clean water if your supplies are limited or you have no access to sterile water.

Should you establish IV access on all casualties in case they deteriorate?

Not every casualty needs an IV, and some of them will be able to tolerate oral fluid replacement therapy, saving limited I fluids and blood products for others.

When would you use an extraglottic airway?

On a casualty who is deeply unconscious and needs an advance airway to ventilate (on their own or with assistance).

What are contraindications to converting a tourniquet to wound packing and a pressure bandage?

Shock, Inability to closely monitor for rebleeding, or Amputation

What should you do first when you encounter a casualty with a thermal burn?

Stop the source of the burn

What is every first responder's role in CUF?

Suppress hostile fire and/or establish scene safety, assist in self-aid, and assist in moving casualties

What does AVPU stand for?

The AVPU method, or Alert, Verbally responsive, Pain responsive, or Unresponsive, provides responders the information they need to make decisions.

What is the difference between the TCCC Card (DD Form 1380) and the TCCC After Action Report (AAR)?

The TCCC Card (DD Form 1380) is filled out in realtime by whoever is providing the care at point of wounding or injury. The card may be filled out by nonmedical personnel or a Combat Medic/Corpsman. The TCCC Card will become a permanent part of the Service member's longitudinal medical record. The TCCC After Action Report is completed retrospectively after the mission is complete and the first responder has returned to base. This electronic AAR is intended to be completed by whoever rendered the care after the first responder or Combat Medic/Corpsman completes the mission. Submitted electronically by the Combat Medic/Corpsman via the Joint Trauma System website within 72 hours following the mission.

What are the contraindications of using the oral transmucosal fentanyl citrate (OTFC) lozenges for the management of moderate pain?

The contraindications for opioids, including fentanyl, are hypovolemic shock, respiratory distress, unconsciousness, or severe head injury.

What are the advantages of using an oral antibiotic over a parenteral antibiotic?

The logistical issues associated with carrying, reconstituting, and then injecting or infusing parenteral medications makes use of oral antibiotics the preferred route, when oral administration is possible.

Why do the TCCC Guidelines recommend checking a radial pulse?

The presence or absence of radial pulses is used as a sign of hypotension for determining shock and recommending fluid resuscitation.

What are the three objectives of fracture management and splinting?

The primary objectives of fracture management and splinting are to prevent further injury to local tissues or organs, to protect the nerves and vessels that run parallel to bones, and to make the casualty more comfortable by relieving some pain.

Why is it important to assess the casualty's mental status?

They may need to be disarmed and to have communications equipment removed. Following their mental status throughout the assessment may help responders identify changes in clinical status, leading to early casualty reassessment.

Injectable hemostatic agent is contraindicated in which types of wounds?

This device is not indicated for use in thorax, pleural cavity, mediastinum, abdomen, retroperitoneal space, sacral space, above the inguinal ligament, and tissues above the clavicle

What condition warrants oxygenation in TFC according to the TCCC Guidelines?

Traumatic brain injury; maintain an oxygen saturation >90%

How should you treat an open chest wound?

Treat open chest wounds by applying a vented chest seal completely over the wound during expiration.

What is the importance of following trends in vital signs?

Trends in vital signs provide insight into the casualty's clinical course that help the responder identify the need for interventions or assessments earlier than would happen with a single set of vital signs.

True or False: During TFC, the tactical situation could change back to CUF again at any time?

True

True or False: When applying a splint, ensure the joints above and below the fracture are immobilized in the splint whenever possible.

True. Always incorporate the joint proximal and the joint distal to the site of the fracture in your splint.

True or False? A combat casualty with 25% TSA burns would be evacuation category A?

True. If the burns were less than 20% but more than 10% it would be Category B.

What is a blood sweep?

a rapid visual and palpable head-to-toe check of the front and back of the casualty for any unrecognized life-threatening bleeding.

What is tension pneumothorax?

air enters the chest cavity through the wound with every inspiration, but doesn't leave with expiration and is trapped, so every breath adds more air to the air space inside the rib cage and outside the lung, and the pressure inside the chest builds up and causes the lung to collapse. Injured lung tissue acts as a one-way valve, trapping more and more air between the lung and the chest wall. Pressure builds up and compresses both lungs and the heart.

What are the most reliable indicators of shock in a TFC setting?

altered mental status in the absence of head injury and an absent or weak radial pulse.

What is inguinal junctional hemorrhage and how is it treated?

bleeding from the large blood vessels at the junction where the lower extremities join the torso. Injuries to these junctional areas are typically not amenable to a limb tourniquet and require other intervention. If available a CoTCCC-recommended junctional tourniquet should be applied. If not available, the wound should be packed with hemostatic gauze and direct pressure applied to the wound. Application of an improvised pressure delivery device may be needed to apply additional, targeted, and sustained pressure to control hemorrhage.

How do you prevent dislocation of pelvic fragments from external rotation of the lower extremities?

by tying the casualty's knees and/or feet together.

What is Care Under Fire?

care given by the first responder at the scene of the injury while they and the casualty are still under effective hostile fire or near the threat.

What is the difference between TFC and CUF?

care rendered once the combat medic/corpsman and casualty are no longer under direct threat from effective enemy fire. This allows for the time and the relative safety for a more deliberate approach to casualty assessment and treatment.

What is the primary role in TFC?

casualty assessment and treatment

If all hemorrhage control measures have been applied and fluid resuscitation does not improve shock (refractory shock), what potentially unrecognized injury should be considered, and how would you treat it?

consideration of an unrecognized tension pneumothorax should be suspected. Treatment with a needle decompression of the chest (NDC) should be considered. And, if two NDCs have failed to provide improvement, it may be necessary to perform a finger thoracostomy or insert a chest tube.

Where should you apply a deliberate tourniquet when replacing one that was placed over the uniform, like a high and tight tourniquet from Care Under Fire?

directly on the skin, 2-3 inches above the wound.

What is the number one medical priority in CUF?

early control of life-threatening external hemorrhage

What is a CCP?

location on the battlefield for the triage, treatment and monitoring, and the packaging/staging of casualties for evacuation. The CCP should be established reasonably close to the fight where casualties are likely to occur, be near natural "lines of drift", provide relative cover and concealment from the enemy whenever possible, and have access to evacuation routes.

What are common errors when performing a cricothyroidotomy?

making the initial incision too small, thereby limiting the ability to clearly visualize the cricothyroid membrane; identifying the landmarks properly is difficult and commonly leads to incorrect placement; "stabbing" when incising; not inserting a finger, once the membrane has been incised, to manually feel for the lumen and tracheal rings.

Leading causes of preventable death due to traumatic injuries include?

massive hemorrhage, tension pneumothorax, and airway trauma/obstruction

What are the critical observations or red flags that may prompt urgent evacuation to a higher level of medical care for trauma casualties with a suspected head injury, in accordance with the Military Acute Concussive Evaluation 2

• Deteriorating level of consciousness • Double vision • Increased restlessness; combative or agitated behavior • Repeat vomiting • Results from a structural brain injury detection device (if available) • Seizures • Weakness or tingling in arms or legs • Severe or worsening headache

What is triage?

the deliberate sorting of casualties and allocation of limited treatment resources according to a system of priorities designed to maximize the number of survivors on the battlefield.

What are the initial actions that should be taken in the circulation phase of the MARCH-PAWS sequence?

to ensure that there are no untreated sources of massive bleeding and reassess all previously applied tourniquets and dressings with pressure bandages to ensure bleeding is still being controlled.

What are advantages and disadvantages of one-person drags?

• Advantages: only one rescuer is exposed to enemy fire. • Disadvantages: they are difficult to perform and can cause the rescuer to tire quickly.