CMC-TCCC
How fast should a Tourniquet be applied
1 mintute or less
Within what time limit should the bleeding be stopped with a tourniquet
1 minute
When packing a wound with gauze, how far out of the would should the gauze extend
1-2 inches
As a last resort, an improvised tourniquet may be applied as long as it has what three characteristics
1. At least 2 inches wide 2. Sturdy Windlass 3. Fastening devices to prevent loosening
Signs and Symptoms of airway obstruction
1. Casualty is in distress and indicates they can't breathe properly 2. Casualty is making snoring or gurgling sounds 3. Visible blood or foreign objects are present in the airway 4. Maxillofacial trauma (severe trauma to the face is observed)
What steps are taken in Care Under Fire (CUF) before engaging with a casualty
1. Return fire and take cover. 2. Direct the casualty to remain engaged as a combatant if appropriate. 3. Direct the casualty to move to cover and apply self-aid if able. 4. Try to keep the casualty from sustaining additional wounds. 5. Stop life-threatening extremity hemorrhage with a tourniquet if tactically feasible. 6. Move the casualty to cover, if the casualty is unable to move.
What are the three principles of casualty removal/extraction
1. Safety - avoid more casualties and maintain situational awareness. If a threat reemerges you are back in Care Under Fire (CUF) 2. MARCH - TCCC principles still apply. If the situation permits lifesaving measures may be implemented prior to extraction 3. Training - Unit specific training on vehicles and equipment help maintain proficiency
Four major areas for action in Care Under Fire (CUF)
1. Scene Safety 2. Casualty Movement 3. Stop Life Threatening External Hemorrhage 4. Proper Communication
Visual signs of a life threatening bleed
1. There is a traumatic amputation of an arm or leg 2. There is pulsing or steady bleeding from the wound 3. Blood is pooling on the ground 4. Overlying clothes are soaked with blood
When applying a chest seal the edges must extend _______ inches beyond the edge of the wound
2
What are the two sites for performing a Needle Decompression of the Chest (NDC)
2nd Intercostal Space at the Mid Clavicular Line (MCL) 5th Intercostal Space at the Anterior Axillary Line (AAL)
How fast can a patient with damage to a major blood vessel bleed to death
3 Minutes
After packing a wound with a hemostatic dressing how long must direct pressure be maintained
3 minutes
Once a seal is established using the "E-C" technique, the casualty should be ventilated every _________ seconds using a slow steady squeeze over _________ seconds
5-6 1-2
When using supplemental oxygen the goal is to maintain oxygen saturation over ______%
90
What is the only medical intervention that may be performed in Care Under Fire (CUF)
A CoTCCC recommended limb tourniquet placed "high and tight"
Method of assessing altered mental status
AVPU Alert - Casualty is alert Verbal - Responds to verbal commands Pain - casualty responds to painful stimulation Unresponsive - Casualty is unresponsive
Cricothyroidotomy Contraindiciations
Ability to secure less invasive airway
What are the best tactical indicators of hemorrhagic shock
Altered Mental Status in the absence brain injury Weak or absent radial pulse
What is the number one medical priority in Care Under Fire (CUF)
Control of life-threatening external hemorrhage
What is the most important intervention in TCCC
Early control of significant external hemorrhage
Contraindications for establishing Intraosseous (IO) access
Fractures, infections and/or injury at the IO site Osteoporosis Osteogenesis imperfecta Casualties less than 50 kg/110 lbs (FAST1) Scar indicating prior sternotomy
What makes up the three sides of the lethal triad
Hypothermia - Due to environmental factors and physiologic response o blood loss Acidosis - Buildup of Lactic Acid Coagulopathy - Direct Losses of clotting factors and platelets
What is the most common type of shock in the Tactical Field Care (TFC) setting
Hypovolemic shock due to massive blood loss also known as hemorrhagic shock
Roles and Responsibilities: All Service Members (ASM)
Identify and control bleeding, Assess casualty using MARCH, Seek help as directed
Triage Categories
Immediate - Immediate lifesaving intervention required Delayed - Likely to need surgery but general condition permits delay Minimal - Condition does not require immediate lifesaving intervention. "walking wounded" Expectant - Extensive wounds with an unlkikely chance of survival
What is the recommended treatment of suspected tension pneumothorax
Needle Decompression of the Chest (NDC)
Who should the rescuer be communicating with at all times if feasible
Patient, other first responders and tactical leadership
Ways to stay up to date with TCCC
Quarterly reviewed TCCC Guidelines Using training content from deployedmedicine.com
After moving a casualty in Care Under Fire (CUF) what should be done to any applied tourniquets
Reassess
Signs and Symptoms of Open Pneumothorax
Respiratory Distress A "sucking" or "hissing" sound on inhalation A puncture wound of the chest coughing up blood Froth or bubbles around injury Blood tinged sputum
What is the first step in Care Under Fire (CUF)
Return fire and take cover
Role of fire superiority
Return fire and take cover Gain fire superiority
To prevent external rotation of the legs what should be also done when applying a Pelvic Compression Device (PCD)
Secure the knees and/or feet together
What are the initial actions that should be taken in the circulation phase of the MARCH-PAWS sequence
The initial action in this phase should be 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.
After applying a pressure bandage what should be assessed
The bleeding is controlled and the distal pulses are present
What is the most essential treatment task in Care Under Fire (CUF)
Applying a limb tourniquet to control massive bleeding
When should you inspect your JFAK, CLS bag or CMC bag
Before, during and after all training events and missions
Treatment of Recurring Tension Pneumothorax
Burp Chest Seal Perform second Needle Decompresion of the Chest (NDC) at the same site lateral to the original NDC If initial NDC does not result in improvement, perform second NDC at the alternate NDC site If again there is no casualty improvement, then move on to the "C" in MARCH.
TCCC phases of care
Care Under Fire (CUF) Tactical Field Care (TFC) Tactical Evacuation Care (TACEVAC)
Nasopharyngeal airway contraindications
Clear fluid coming from the ears Obvious deformities to the nose due to trauma Facial burns Singeing of the nasal hairs Carbonaceous sputum
Nasopharyngeal airway indications
Decreased Level of Consciousness
When applying a deliberate tourniquet in Tactical Field Care (TFC) where should it be applied
Directly to the skin 2-3 inches above the bleeding site
What should you attempt to do when communicating with the casualty
Encourage, Reassure and Explain what you are doing
What is a junctional hemorrhage and how is it treated
External hemorrhage at the junction where an extremity joins the torso that is not amenable to a limb tourniquet. A junctional tourniquet should be applied or the wound packed with hemostatic gauze and a pressure bandage applied. An improvised Pressure Delivery Device (PDD) may be needed to apply direct pressure to the bleeding site
What is the most frequent cause of preventable death on the battlefield
Extremity Hemorrhage
Hasty vs Deliberate Tourniquet
Hasty - Applied "high and tight" over the clothing Deliberate - Applied directly on the skin 2-3 inches above the bleeding site
What two airway maneuvers are used to open and assess a patient's airway
Head-Tilt/Chin-Lift Jaw-Thrust
What is the predominant cause of preventable death in combat fatalities
Hemorrhage
Key Factors influencing TCCC
Hostile fire Tactical considerations Wound patterns Environmental considerations First responder training and experience Equipment contstraints Evacuation delays
If the tactical situation and patient's symptoms permit, what may be used to anesthetize the skin and neck structures prior to performing a cricothyroidotomy
Lidocaine
Factors affecting pulse oximetry readings
Low: Shock, Cold Temperatures High: Carboxyhemoglobinemia (Carbon Monoxide) Impaired readings: Nail polish, very bright environments, skin pigmentation and motion artifact
Importance of TCCC training
Lowest rate of preventable death in history
Combat LifeSaver (CLS) bag contents should be capable of treating what part of MARCHPAWS
M-Massive Bleeding A-Airway R-Respirations C-Circulation H-Hypothermia and Head Injury P-Pain A-Antibiotics W-Wounds S-Splints
Combat Medic Corpsman (CMC) bag contents should be capable of treating what part of MARCHPAWS with more advanced interventions
M-Massive Bleeding A-Airway R-Respirations C-Circulation H-Hypothermia and Head Injury P-Pain A-Antibiotics W-Wounds S-Splints
What does MARCH PAWS stand for
M-Massive Bleeding A-Airway R-Respirations C-Circulation H-Hypothermia and Head Injury P-Pain A-Antibiotics W-Wounds S-Splints
Joint First Aid Kit (JFAK) contents should be capable of treating what parts of MARCHPAWS
M-Massive Bleeding A-Airway R-Respirations P-Pain A-Antibiotics W-Wounds
What is the most common error when performing a cricothyroidotomy
Making the initial incision too small
Leading causes of preventable death in combat trauma
Massive Hemorrhage (Extremity, Junctional), Tension Pneumothorax, Airway Trauma/Obstruction
What is the primary consideration for spinal immobilization
Mechanism of Injury (Explosions, Motor Vehicle Accidents, Falls)
Indications for applying a Pelvic Compression Device (PCD)
Mechanism of Injury (MOI) - Sever blunt force or Blast Injury Pelvic pain Any major lower limb amputation or near amputation Physical exam findings suggestive of a pelvic fracture Unconsciousness Shock
Signs and Symptoms of hypoperfusion (Shock)
Mental confusion or altered mental status in the absence of a head injury Weak or absent radial pulses Tachycardia Tachypnea Excessive thirst Cyanosis with pale, grey, or blotchy blue skin Nausea and/or vomiting Diaphoresis with sweaty, cool, clammy skin
Advantages of One Person Drag/Carry
One rescuer is exposed to enemy/hostile fire
Contraindications for applying a Pelvic Compression Device (PCD)
Open Pelvic Fractures Perineal Lacerations Intraabdominal injuries requiring surgery Burns Severe associated pelvic soft tissue injuries may necessitate external fixation of the pelvis instead of a pelvic binder
Signs of a potentially life threatening chest injury
Penetrating Trauma - Gunshot or shrapnel wound to the chest Blunt Force Trauma - Deformities, Bruising, Swelling, Contusions, Crepitus or any other deformities to the chest
What is Refractory Shock
Persistent hypoperfusion despite fluid resuscitation efforts. Consider unrecognized tension pneumothorax.
What is Direct Pressure and when should it be used
Pressure applied directly over the bleeding site can be used temporarily until a tourniquet or dressing is in place
What is indirect pressure and when should it be used
Pressure applied to a vessel proximal to the bleeding site temporarily until a tourniquet or pressure bandage can be applied
Early Signs of Tension Pneumothorax
Severe or progressive respiratory distress Severe or progressive tachypnea - abnormally rapid breathing Absent or markedly decreased breath sounds on one side of the chest Hemoglobin oxygen saturation < 90% on pulse oximetry Shock - If not treated promptly, tension pneumothorax may progress from respiratory distress to shock and traumatic cardiac arrest. Traumatic cardiac arrest without obviously fatal wounds
Contraindications for Tourniquet Conversion
Shock Inability to closely monitor for rebleeding Amputation Tourniquet has been in place for more than 6 hours
Indications for establishing Intravenous (IV) access
Shock, Significant risk of developing shock, cannot take medications orally
Roles and Responsibilites: Combat Medic Corpsman (CMC)
Suppress hostile enemy fire, assume primary role in performing casualty assessment using MARCH PAWS, Manage emergency response using all available responders, Reassess casualties and communicate with TACEVAC medical personnel.
Roles and Responsibilities: Combat LifeSaver (CLS)
Suppress hostile enemy fire, perform assessment and treat using MARCH PAWS, assist the Combat Medic Corpsman (CMC) as directed
A tourniquet applied "high and tight" in Care Under Fire (CUF) should be reassessed in what phase of TCCC
Tactical Field Care (TFC)
What technique is used for maintaining a seal with the Bag Valve Mask (BVM)
The "E-C" Technique
What is a Casualty Collection Point (CCP)
The Casualty Collection Point (CCP) is a location on the battlefield for the triage, treatment and monitoring, and the packaging/staging of casualties for evacuation
What are the anatomical landmarks when applying a Pelvic Compression Device (PCD)
The Greater Trochanters
Unconscious casualties not in shock or conscious casualties that can tolerate any position should be placed in what position to maintain their airway
The Recovery Position
When reassessing a previously placed tourniquet what should be checked for
The bleeding has been stopped and distal pulses are absent
What is the preferred airway opening maneuver in case of suspected spinal injuries
The jaw-thrust method
Conscious patients should be allowed to remain in what position to maintain their airway
The position of maximal comfort (DO NOT force a patient that is sitting up into the supine position if it causes more difficulty in breathing)
Disadvantages of One Person Drag/Carry
They are difficult to perform and can cause the rescuer to tire quickly
Advantages of Two Person Drag/Carry
They are useful in situations where drags do not work well and are quicker than most one-person carries.
Disadvantages of Two Person Drag/Carry
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
Injectable hemostatic agent (X-STAT) 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
If a tourniquet is reassessed and is not effective what action should be taken
Tighten the tourniquet if able and reassess or apply a second tourniquet side-by-side with the first
Indications for Tourniquet Replacement
Tourniquets applied over the uniform Tourniquets applied to proximal on the extremity (greater than 3" above the wound) Greater than 2 hours to surgery
Late Signs of Tension Pneumothorax
Tracheal deviation Jugular vein distention Subcutaneous emphysema Shift of the mediastinal contents away from the side of the tension pneumothorax
Contraindications for establishing Intravenous (IV) access
Trauma (vascular injury or fracture) proximal to IV site
Oxygen use indications
Traumatic Brain Injury (TBI) Refractory Shock
What are the principal causes of altered mental status in TCCC
Traumatic Brain Injury (TBI), Hypoxemia (low blood oxygen level) and Hypovolemia due to massive blood loss
Three Objectives of TCCC
Treat the Casualty Prevent additional casualties Complete the Mission
Signs of Respiratory Distress
Tripod Positioning Nasal Flaring Intercostal Retractions Confusion/Lightheaded/Agitation (Lack of Oxygen) Tachypnea Dyspnea Cyanosis Pulse Oximetry less than 90%
Indications for establishing Intraosseous (IO) access
Two failed peripheral vascular access attempts IV access was difficult or unattainable
Cricothyroidotomy Indications
Unsuccessful airway management with less invasive airway maneuvers Maxillofacial injuries to include partial or complete airway obstruction Thermal and toxic gas injuries
Evacuation Categories
Urgent - Evacuation within 2 hours Priority - Evacuation within 4 hours Routine - Evacuation within 24 hours
What items should be taken away from a casualty with altered mental status
Weapons and Communication Equipment
Can the principles of TCCC be applied to non combat settings?
Yes. Motor Vehicle Accidents, Active Shooter, Workplace Accident.
What is every responder's role in Care Under Fire (CUF)
suppress hostile fire/establish scene safety, assist in self aid, assist in moving casualties, if feasible.
What type of chest seal is recommended for open or sucking chest wounds
vented chest seal. (If a vented chest seal is not available, a non-vented chest seal should be used)
