Deployed medicine "Module 5 Tactical Trauma Assessment"

communicating with the casualty allows you to assess their

mental status and identify any changes over time that might lead you to an early reassessment of the casualty's status.

During TFC what kind of blood sweep is conducted and what equipment is available to use

physical blood sweep, ready to immediately apply a tourniquet, hemostatic dressing, pressure dressing, or junctional tourniquet, as appropriate, to control massive hemorrhage

During CUF what kind of blood sweep is conducted and what equipment is available to use

visual blood sweep, and only use CoTCCC tourniquet

What are the groups you communicate with and what do you communicate in TTA

1. Communicate with the casualty, if possible 2. Communicate with tactical leadership and report lines 3, 4, and 5 of the MEDEVAC report (if not already done) 3. Communicate/transmit the MEDEVAC information with the evacuation system and arrange for Tactical Evacuation Care 4. Communicate with other medical providers and relay MIST report

What is the TFC steps of progression

1. Establish security perimeter/maintain tactical situational awareness 3. Triage casualties as required 3. Use body substance isolation precautions, if tactical situation permits 4. Assess responsiveness using the AVPU (alert, verbal, pain, unresponsive) process and mental status. If unresponsive, assess for presence of carotid pulse and respirations. If unresponsive with pulses and respirations or if responsive with an altered mental status, take weapons/communication equipment from casualties 5. Communicate with casualty throughout the tactical trauma assessment process

What are the steps of preparing a casualty for evacuation

1. Place and secure casualty on evacuation device, and attach DD FORM TCCC Casualty Card onto casualty if not done already 2. Secure all loose bandages, equipment, blankets, etc. 3. Secure hypothermia prevention wraps/blankets/straps 4. Secure litter straps as required; consider additional padding, as needed 5. Provide instructions to ambulatory casualties as needed 6. Stage casualties for evacuation and identified litter team(s) 7. Maintain security/safety at the evacuation point

What are the steps preparing for evacuation 3

1. Prepare the casualty to be evacuated (securing loose bandages, equipment, blankets, etc.) and place them on a litter appropriate for the type of evacuation. 2. Prepare the site by directing the supporting personnel to establish security and a casualty movement process (often with litter-bearer teams), and by staging the casualties in the correct priority for evacuation. 3. Prepare the incoming evacuation assets by communicating with them about the casualty status and anticipated requirements during the evacuation.

These three efforts will help in the success in ensuring the best possible outcome for your casualty

1. Relay required MEDEVAC request information to the tactical leader in accordance with unit standard operating procedures 2. REASSESS all lifesaving interventions (MARCH sequence) and continue with the PAWS portion if time permits 3. INITIATE ELECTRONIC MONITORING if indicated and equipment is available

Several non-life-threatening wounds can result in significant long-term disability or deteriorate into life-threatening complications and need to be addressed as soon as possible, examples of these injuries are

1. abdominal injuries 2. burns 3. any soft tissue injuries 4. fractures

What does TTA involve

1. assessing injuries 2. prioritizing treatments 3. coordinating the care of a combat casualty

What are the key parts of communicating to a patient

1. encourage 2. reassure 3. explain

Altered mental status has several potential causes such as

1. metabolic 2. toxic 3. infectious Note: but in the combat or trauma environment, the principal causes are traumatic brain injury, hypoxia, and hypovolemia from blood loss. Note: hypothermia, although not typically a primary cause, can exacerbate mental status changes.

What is a blood sweep?

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

Describe the steps of progression in "A" for PAWS

ADMINISTER ANTIBIOTICS 1. Check for drug allergy(ies) before administration 2. Administer CWMP antibiotics (moxifloxacin) to conscious casualty able to swallow for all open combat wounds 3. If unable to take oral meds (shock, unconsciousness), give ertapenem IV or IM

Describe the steps of progression in "A" for MARCH

ASSESS AND SECURE THE AIRWAY 1. If conscious allow casualty to assume any position of comfort that facilitates breathing and protects the airway 2. For an unconscious casualty without airway obstruction place in the recovery position. If needed use the head tilt chin lift or jaw thrust maneuver to open airway. 3. If the casualty is unconscious or semi-conscious, insert a nasopharyngeal airway (NPA) or extraglottic if indicated 4. For an unconscious casualty with an obstructed or impending obstructed airway clear any excess secretions using mechanical or manual suctioning, if indicated 5. In an unconscious casualty with an obstructed airway insert an extraglottic airway 6. If previous measures are unsuccessful, in an unconscious casualty with upper airway obstruction perform a cricothyroidotomy and secure it 7. Monitor the casualties pulse oximetry to help assess airway patency

Describe the steps of progression in "M" for MARCH

ASSESS AND TREAT MASSIVE HEMORRHAGE 1. Assess for unrecognized hemorrhage and control all sources of bleeding 2. Apply a tourniquet directly to the skin, 2-3 inches above the bleeding site, if not previously done in CUF 3. Apply a second tourniquet side-by-side, proximal to the first, if bleeding is not controlled with the initial tourniquet 4. Assess effectiveness of previously placed tourniquets, if ineffective, tighten tourniquets further; if still bleeding, apply second tourniquet proximal to first or apply a deliberate tourniquet 2-3 inches above the bleeding site 5. If wound or wounds is not amenable to a limb tourniquet (neck, axillary and/or inguinal wounds, etc.), apply hemostatic dressing/adjuncts (for hemostatic dressing(s) hold pressure for 3 minutes) 6. Perform a blood sweep (neck, axillary, and inguinal regions, anterior and posterior trunk, and all extremities) to exclude unrecognized life-threatening bleeding sources 7. When appropriate, apply junctional hemorrhage control techniques using a wound packing or a junctional tourniquet 8. Perform initial assessment for hemorrhagic shock (altered mental status in the absence of brain injury and/or weak or absent radial pulse) and consider immediate initiation of shock resuscitation efforts

Describe the steps of progression "C" for MARCH

ASSESS CIRCULATION 1. Assess for pelvic fracture, and if suspected, use a CoTCCC-recommended pelvic compression device 2. Expose wound(s) and reassess any previously applied tourniquets to determine if a tourniquet is indicated 3. If ineffective, tighten further or place and tighten an additional tourniquet directly above and next to the deliberate tourniquet 4. If indicated, and time permits, convert the high and tight tourniquet to a deliberate tourniquet (2-3 inches above the wound) 5. If tourniquet was not indicated, convert high and tight tourniquet and/or junctional tourniquet to other bleeding control means (wound packing and pressure bandage) 6. Expose and reassess any previously placed tourniquets, clearly mark all tourniquets with the time of tourniquet application 7. Treat any significant nonpulsatile bleeding with hemostatic agent (hold pressure for 3 minutes) and apply a pressure bandage 8. Reassess junctional (neck, axillary, inguinal) wound(s) packing, if present Assess for hemorrhagic shock (checking for radial pulses) 9. If radial pulse is present with normal mental status and significant injuries, insert saline lock (If vascular access is needed but not quickly obtainable via the IV route, use the IO route) 10. If altered mental status in the absence of brain injury and/or weak or absent radial pulse:| Establish IV or IO, Administer tranexamic acid by slow IV/IO push, as well if the casualty has signs or symptoms of significant TBI or has altered mental status associated with blast injury or blunt trauma. Administer blood products, giving 1 gm of calcium after the first unit and continuing reassessment until a palpable radial pulse, improved mental status, or systolic BP of 100 mmHg is present 11. Assess for refractory shock if not responding to fluid resuscitation and consider untreated tension pneumothorax as possible cause (NDC, if indicated)

Describe the steps of progression in "R" for MARCH

ASSESS RESPIRATION 1. Remove body armor 2. Assess for signs of tension pneumothorax 3. Inspect torso for wounds (front and back) 4. Assess breathing, initiate pulse oximetry (if available) 5. Apply a vented chest seal to all open chest wound(s) 6. If present, burp and/or remove and reapply any chest seal previously placed 7. If present without chest seal, or if chest seal burp did not resolve tension pneumothorax signs, perform needle decompression of the chest (NDC) 8. Reassess to confirm NDC was successful 9. Support with manual ventilations (bag valve mask, if available) if respiratory effort is inadequate 10. If no injuries, drape body armor over the casualty's torso

Describe the steps of progression in "P" for PAWS

CONTROL PAIN 1. Check for drug allergy(ies) before administration 2. Disarm casualties before administering any drug that can alter mental status 3. Administer appropriate pain management 4. CWMP (acetaminophen and meloxicam) analgesics for conscious casualty who can swallow 5. Oral transmucosal fentanyl citrate (OTFC), for a casualty with mild to moderate pain, not in shock or respiratory distress 6. Ketamine IV/IO for moderate to severe pain for a casualty in shock or respiratory distress (may repeat every 20 min for severe pain) 7. Ketamine 50-100 mg (or 0.5-1 mg/kg) IM or IN Repeat doses q20-30 min prn for IM or IN 8. For nausea or vomiting, administer ondansetron 9. Administer naloxone, as indicated for opioid overdoses 10. Document a mental status exam using the AVPU method prior to administering opioids or ketamine.

for pulseless casualty without respirations what do you consider

Considered bilateral NDC

Once you have completed MARCH & PAWS on all patients and time permits what is done next in patient care

If time and tactical situation permit, perform a detailed examination and secondary assessment. This is most commonly done from head to toe to ensure that the examination is complete and nothing is overlooked. This includes the head, neck, chest, abdomen, pelvis, groin, perineum, lower extremities, upper extremities, posterior thorax, lumbar, and buttocks. If you find any minor injuries, treat them as appropriate and document.

What pneumonic is used to prioritize care in the Tactical Trauma Assessment?

MARCH PAWS

Describe the steps of progression in the last "H" for MARCH

PREVENT AND ACTIVELY/PASSIVELY TREAT HYPOTHERMIA 1. Minimize casualty exposure to the environment 2. Employ active warming measures, if available 3. Enclose the casualty with an exterior impermeable enclosure bag ASSESS FOR HEAD INJURY 4. Check for signs and symptoms of head and/or penetrating eye injury 5. Prevent secondary head injury by treating hypoxia and hypotension 6. Manage any eye injury(ies) appropriately 7. Perform a visual acuity test; cover eye injury(ies) with a rigid eye shield(s 8. Administer oral antibiotic from Combat Wound Medication Pack (CWMP) for penetrating injury(ies) 9. Time permitting, review Military Acute Concussion Evaluation 2 screening questions 10. Manage any head injury(ies) appropriately

Explain how TTA is conducted

Remember that when performing an assessment, you will need to go back and forth from assessing the need for an intervention to performing a skill, and then return to assessing for the next potential injury. So, although we call this an assessment, the entire process is a combination of an assessment and a treatment plan being executed simultaneously

Describe the steps of progression in "S" for PAWS

SPLINT ANY FRACTURES WITHOUT DISRUPTING ANY IMPALED OBJECTS

Describe the steps of progression in "W" for PAWS

TREAT ADDITIONAL WOUNDS 1. Reassess any and all medical interventions 2. Inspect, assess, and treat burns with dry, sterile dressings and hypothermia prevention 3. Assess for other wounds and, if indicated, apply dressing(s) for abdominal evisceration(s), dressing(s) to stump(s), dressing(s) to any impaled object(s)

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

Tactical Field Care

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

What areas do you check in a physical blood sweep

This blood sweep is a visual and hands-on (palpating) inspection of the front and back of the casualty from head to toe, including the neck, axillae, groin, arms, legs, abdomen, chest and back

The initial rapid assessment of a casualty's mental status comes from

communicating with the casualty by asking them to follow commands and to answer questions.

See PDF TACTICAL TRAUMA ASSESSMENT CHECKLIST ABBREVIATED for

complete assessment algorithm steps

When conducting AVPU and the patient seems to be altered what in addition should be considered as well

access the mechanism of injury (Blast, MVAs, Direct blow to the head)

If a casualty is not responding appropriately to your questions or statements (noticed by observing their verbal and nonverbal responses), this is a sign of an

altered mental status

When do you obtain an AVPU from a patient in TTA

during the "H" of head injury evaluation, you will assess them using the AVPU technique.

When should you remove weapons and equipment of a casualty

they have an altered mental status or show or combat incapable