TC3

TC3

1. On the Battlefield, rapid systematic assessment is key

2. Interventions identified as lifesaving measures are initiated immediately

3. Application of TC3 and in Combat

Introduction

Introduction

Today our country is at war –

68Ws Will be called upon to deploy and provide medical care on foreign soil and possibly in a combat zone. You must be able to distinguish between the care provided in the civilian community and the care necessary during hostile actions.

Introduction

Civilian medic training is based on the following principles:

Emergency Medical Technicians (EMT-B – EMT-P)• Basic Trauma Life Support (BTLS)• Pre-Hospital Trauma Life Support (PHTLS)• Advanced Trauma Life Support (ATLS)• Advanced Cardiac Life Support (ACLS)

Battle Field Medicine Currently Soldier Medics are being trained

according to the principles of Tactical Combat Casualty Care (TC-3)

The 3 principles of TC3 are Treat the Casualty Prevent Additional Casualties Complete the Mission.

Introduction

Up to 90% of all combat deaths occur before a casualty reaches a Medical Treatment Facility (MTF)

In Making the Transition from Civilian Emergency Care to

Tactical Combat Casualty Care

• Consider the management of injuries that occur in a combat mission as being divided into 3 distinct phases of care

3 PHASES OF CARE

• Care Under Fire

• Tactical Field Care

• Combat Casualty Evacuation Care

Care under fire” is the care rendered by the medic at the scene of the injury while he and the casualty are still under effective hostile fire. Available medical equipment is limited to that carried by the soldier or the medic in his aid bag.

3 PHASES OF CARETactical Field Care” is the care rendered by the medic once he and the casualty are no longer under effective hostile fire. It also applies to situations in which an injury has occurred, but there has been no hostile fire. Available medical equipment is still limited to that carried into the field by medical personnel. Time to evacuation to a MTF may vary considerably.

• Care Under Fire

• Tactical Field Care

• Combat Casualty Evacuation Care

3 PHASES OF CARE“Combat Casualty Evacuation Care” (CASEVAC) is the care rendered once the casualty has been picked up by an aircraft, vehicle or boat. Additional medical personnel and equipment may have been pre-staged and available at this stage of casualty management.

• Care Under Fire

• Tactical Field Care

• Combat Casualty Evacuation Care

Care Under Fire

Care Under Fire• Priorities

– The number one priority is returning fire• Medics firepower maybe essential• If unable to suppress enemy all may be lost

• Attention to suppression may minimize additional injury to previously wounded Soldiers

– The second priority is treating casualties• Tactical situation dictates when and how

much care is given• Limited number of medics and if inured

there are no immediate replacements• Medics should not take unnecessary risks

– if wounded then there are two casualties to deal with and no medic

Care Under Fire

Care Under Fire• All soldiers need to return fire, even in

wounded.• No immediate management of the airway • Control hemorrhage• Use hasty tourniquets• Penetrating neck injuries do not need a C-

Collar

Care Under Fire

– Wounded unable to fight should• Attempt to crawl, walk or run to cover• If unable to move or fight - lay flat and

motionless

Care Under Fire

No immediate management of the airway is necessary

- Limited time and the need to move casualty to cover

- Airway problems typically play a minimal role in combat casualties

- Only 1% in Viet Nam, mostly from maxillofacial injuries

Care Under Fire

Control of hemorrhage is important since injury to a major vessel can result in hypovolemic shock in a short time frame

Extremity hemorrhage is the leading cause of preventable combat death

Care Under Fire

Use of temporary tourniquets to

stop the bleeding

is essential in these types of casualties

Care Under Fire

Penetrating neck injuries do not require C-spine immobilization. Other neck injuries, such as falls over 15 feet, fast-roping injuries, or MVAs may require C-spine control unless the danger of hostile fire constitutes a greater threat in the judgment of the medic

Scene Size Up

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Scene Size Up

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Scene Size Up

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Scene Size Up

Care Under Fire

• Determine Scene Safety/Security1) When tactical situation allows, assess and treat life

threatening hemorrhage– Triage Casualties, get those that can, back into the fight– Triage the rest for evacuation out of the danger area

Scene Size-up:

Care Under FireScene Safety/Security Cont:Scene Safety/Security Cont:

2) Determine the number of Casualties

If Casualties are in various locations

- Others will need to report to you the number of wounded, their location and the severity of their injuries

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Care Under Fire

Triage Key Points:

Sort Casualties:“If you can hear my Voice”:

“And Can walk – move to me now”(these are the minimal patients)

“And Can’t walk – Raise your hand and let me know and I will come to you”

(these are the delayed patients)

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Care Under Fire

Triage Key Points:

• What remains are the Immediate, the Expectant and the Dead

• Determine which are which and go to work• Stop life threatening hemorrhage with tourniquets• Direct treatment and movement to CCP• Defer airway treatment until out of the kill zone

Care Under Fire

Try to have wounded brought to you at a secure/covered location

Avoid working on wounded out in the open area of the kill zone

Call for squad members to assist you, Soldiers in full battle gear are to heavy for one man to lift

Someone may need to retrieve weapons and essential gear If needed, Get Assistance from Combat Life Savers

Request Additional Help

Care Under Fire

Remove casualties from the kill zone quickly Even if the shooting has stopped you are still in

the kill zone Your goal is to get wounded to a covered position Armored vehicle or a secured building is the best

Remove Casualties to CCP/Secure Area

Care Under Fire

The squad may have to retrieve casualties out of a hostile environment

It’s a good idea to use armored vehicles as cover while retrieving casualties

Remove Casualties to CCP/Secure Area

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Care Under Fire

3 basic ways to retrieve casualties- Casualties crawl, walk or run out- Other squad members grab and drag to safety- Retrieve casualties by force

- Team element uses fire and maneuver and takes position past casualties

- Provide covering fire- Recovery team moves in behind to pickup any casualties

Care Under Fire

Make the decision on how to evacuate casualties early Whether by vehicle or a call for a MEDEVAC

helicopter- The longer you wait, the longer it takes to get them out

Reassure casualties during this process- Talk to them in a confident calm tone

Never leave weapons or essential equipment behind

Remove Casualties to CCP/Secure Area

Tactical Field Care

Tactical Field Care

Once in a secure area and no longer receiving enemy fire

Start triaging and treating casualties

with multiple casualties - Should do at least ABC-D on each- Allows the medic to assess and treat the most life

threatening injuries- Allows Prioritization of casualties for evacuation

Tactical Field Care

The Patient Assessment Sequence Sequence is written in an alphabetic A,B,C,

D method- Each letter represents a step- Easy to remember- The sequence is a guideline and a tool to help find and

treat the most life threatening injuries in the order of precedence

- Not expected to be followed line by line in all cases- Modify to treat specific injuries of casualty at hand

Tactical Field Care

The Patient Assessment Sequence On the battlefield standard “ABC” will not provide

optimal care- Maybe appropriate to deviate to “H-ABC” (“H” stands for

Hemorrhage)- Address life threatening hemorrhage and then return to “ABC’s”- Medic can learn to jump in and out of sequence to address life

threats

Therefore the purpose of the sequence is to:- Find and treat life threats- Direct medic so no step is missed or injury gets overlooked

Tactical Field Care

The Patient Assessment Sequence While performing the patient assessment using the

principles of TC3:- You will use many of the skills and techniques learned

in your EMT training

- Add some more advanced skills

Basic principles will remain the same; it is the environment and the MOI that has changed

Tactical Field Care

Sequence

Tactical Field Care

BSI: Put on Gloves Put on Gloves if available Protect medic and patient from infection Wear to pair, blood is slippery and when doing

intricate techniques remove outside pair If not, hands get bloody and then you have to

wipe your hands on your uniform

Tactical Field Care

Initial Assessment: GLC/H-ABC&D G - General Impression:

- Gross observation of patient- Clues to MOI, Age, WT, HT, body position,

appearance/distress, odors (urine, vomit, feces etc)

Gain C-spine control/apply C-collar (if appropriate from MOI)

ESTABLISH C-SPINE CONTROL AT THIS TIME IF NESSESARRY

Tactical Field Care

L: Level of Consciousness- AVPU and A&OX 1,2,3 or 4

C: Chief Complaint/Life Threats

- Chief Complaint is the casualties description of the injuries

- Life Threats are how the patient’s injuries threaten their life

Apparent Life Threats

Tactical Field CareH: Hemorrhage (Treat all major hemorrhage ASAP)

- Reassess any tourniquets or dressings place during Care Under Fire

- Quick visual inspection and blood sweep, looking for major bleeding

- Treat significant hemorrhage when found then continue with remainder of blood sweep

Reassess -This is obviously not working!!!

CHECK FOR MAJOR BLEEDING

• Perform a complete blood sweep• Apply a tourniquet if

indicated• Apply dressings and or

pressure dressings• Only the absolute minimum

of clothing should be removed.

•Significant bleeding should be controlled using a tourniquet as described previously.

•Once the tactical situation permits, consideration should be given to loosening the tourniquet and replacing with a dressing and bandage

•Consider a hemostatic dressings or hemostatic powder (QuikClot) to control any additional hemorrhage

Tactical Field Care Bleeding cont’d

A – Airway• A: Airway: There are 2 parts to airway

1) Patency – Open the airway and check for patency using appropriate methods i.e. head-tilt-chin-lift or jaw thrust etc.

2) Airway Adjunct - Consider an airway adjunct. Nasopharyngeal Airway (NPA), a Combitube or an emergency Cricothyrotomy and then reassess the airway immediately to determine if the airway is still patent (assess-treat-reassess)

A – Airway• Unconscious casualties – insert NPA or Combitube• NPA is better tolerated than an OPA should casualty

become conscious• If a more advanced airway is needed use a Combitube• Allow a conscious pt to assume a position that best protects

the airway i.e. sitting up• A casualty with maxillofacial injuries should never be

transported in a supine position • If all other methods fail then perform an emergency

cricothyrotomy.

NPA In Place

Then Reassess!

Combitube

A – Airway• NOTE: If an emergency cricothyrotomy or a

Combitube was done then someone has to constantly monitor that casualty and suction the airway from time to time.

• It may be necessary to use a BVM to ventilate the pt if respiratory rate falls

• If the pt is moved or log-rolled then these devices have to be reassessed to ensure they did not become dislodged

B – Breathing: 4 parts

IAPO = Inspect, Auscultate, Palpate, Oxygen1) Inspect: Expose the chest and Inspect for (DCAP

BLS) and equal rise and fall of the chest If a penetrating wound is discovered, immediately seal

with an occlusive dressing and inspect for an exit wound

2) Auscultate: Carefully listen to 4 fields for equality and presence of respirations

B – Breathing: 4 parts

IAPO = Inspect, Auscultate, Palpate, Oxygen

3) Palpate: Palpate both anterior and posterior of the chest, feeling for TIC

4) Oxygenate/BVM: Always consider oxygen and apply O2 therapy if it is available and use BVM if needed for ventilation

NOTE: Oxygen may not be available in this phase of care but always consider it, otherwise when it is available you will may forget to use it

Keep in mind both FLAs and M113s can carry oxygen

Tactical Field Care Breathing

Tactical Field Care

Progressive respiratory distress secondary to a unilateral penetrating chest trauma should be considered a tension pneumothorax and decompressed with a 14 gauge needle

Tension pneumothorax is the 2nd leading cause of preventable death on the

battlefield

TENSION PNUEMOTHORAX• Required as a consideration by any or all of the following

– Decreased or absent breath sounds

– Decreased LOC

– Absent radial pulses

– Dropping blood pressure

– Cyanosis

– JVD

– Tracheal Deviation

– Bad bag compliance

INDICATIONS TO DECOMPRESS TENSION PNEUMOTHORAX

• Needle Chest Decompression• Insert 2nd ICS/MCL on the same side as the

chest wound!

• Indications– Simply: Any pt displaying respiratory distress

following a chest injury

Assess Circulation

C – Circulation: 5 parts 1) Assess & treat life threatening bleeding.

– If this step was completed in “H” reassess all treatments and go on to check pulses, if not done perform:

– Visual inspection– Perform a blood sweep– Control hemorrhage

2) Check Pulses― this is a gross pulse check (present or not), do not count the rate― start with radial pulses first, if absent, check for a carotid pulse― Purpose 1st are they alive? 2nd is B/P sufficient to perfuse the brain

(>80 systolic)

C – Circulation: 5 parts

―Finding the strongest palpable pulse is important when considering casualty’s circulatory status and level of shock. For reference:

Radial pulse = 80 systolicFemoral pulse = 70 systolicCarotid pulse = 60 systolic

Tactical Field CareCirculation

Key Point:

If the radial pulses are absent then the BP is less than 80 and the casualty’s brain is not being perfused with O2

C – Circulation: 5 parts 3) Skin Temperature, Color and Condition

– Temperature: Cool, warm or hot– Color: Pink, pale or cyanotic – Condition: Moist “clammy” or dry

• Normal skin should be pink and either dry or moist• Abnormal skin is pale, cool and clammy (shock) and

with hypoxia the skin can become cyanotic (blue)• Red, hot and dry skin is a sign that the body has lost

the ability to regulate heat

C – Circulation: 5 parts

4) Identify the Signs and Symptoms of Shock― Think about pt’s overall conditionExample: Cool, clammy skin; altered mental status; rapid

weak pulse or absent radial pulse

Treat for shock – keep pt warm, elevate feet, place in position of comfort. Other treatments for shock come later, such as: IV fluids (if needed), splinting fractures and medications

C – Circulation: 5 parts 5) Gain Intravenous Access―The use of a single 18ga cath. is preferred in the field

setting because of ease of starting―Saline lock should be used unless pt needs immediate

fluid resuscitation―Do not initiate IV distal to significant injury―Consider Intraosseous if IV fails―Make the fluid decision (Hextend vs. LR) based on

injuries and Hypotensive Fluid Protocol/burn formula

Tactical Field Care FluidsRemember:

1000ml of Ringers Lactate (2.4lbs) will expand the intravascular volume by 250ml within 1 hour

500ml of 6% Hetastarch (trade name Hextend, weighs 1.3lbs) will expand the intravascular volume by 800ml within 1 hour, and will sustain this expansion for 8 hours

D – Decision:

Tactical Field Care

D – Decision:― Make evacuation category decision based on the

casualty’s present condition and call in a 9 line MEDEVAC request

― Do not delay calling in the 9 line, waiting will delay life saving treatment and may add to a bad outcome

1) Prepare the 9-line or have some on do it for you2) Ensure that the 9-line was called in

Tactical Field Care

D – Decision:1) Categories are listed below for reference:

― Priority I: URGENT― Priority IA: URGENT SURGICAL― Priority II: PRIORITY― Priority III: ROUTINE― Priority IV: CONVIENCE

NOTE: Evacuation categories, not Triage categories

*** END OF THE INITIAL ASSESSMENT

• Used to further evaluate the casualty for other life-threatening conditions, not as obvious as hemorrhage

• Start at the head and work to the feet, assessing and treating as you go

• Simultaneously prepare for transport

Tactical Field CareE: Expose/Evaluate

The Rapid Trauma Assessment (Head to Toe, Treat As You Go)

• Key Points:

• Similar to a blood sweep but inspect and palpate for fractures and other underlying Life-Threats

• Logroll and inspect the pt’s posterior

• Bandage and splint remaining wounds as you find them to speed up packaging the pt for MEDEVAC

Tactical Field CareRapid Trauma Assessment

Review of Acronyms used:• DCAP-BLS – Used for inspection and palpation.

– Deformities, Contusions, Abrasions, Punctures, Burns, Lacerations, Swelling

• TIC – Used for palpation (esp. fx) – Tenderness, Instability, Crepitus

• TRD – (TURD) Used for palpating the abd– Tenderness, Rigidity, Distension

• JVD – Jugular Vein Distension• PMS – Pulse, Motor, Sensory

Tactical Field CareRapid Trauma Assessment

• HEAD:• First reassess GLC, airway and need for advanced

airway• Inspect:

– DCAP-BLS – Use a penlight – Check the eyes for PERRL– Check for Battle sign and raccoon eyes– Look for blood & CSF from the eyes, ears, nose and mouth.– look in the mouth for any broken teeth or other airway

obstructions

• Palpate: the bones of the face and skull for TIC

Tactical Field CareThe Rapid Trauma Assessment

• Neck:Inspect: For wounds (DCAP-BLS), Tracheal deviation and JVDPalpate: Vertebrae C-2 to T-1 for TIC– Apply C-collar if appropriate

• Chest: Reassess IAPOInspect: Equal rise and fall of chest, DCAP-BLSAuscultate: 4 fields for presence and quality of respirationsPalpate: skip is done before, it will not change

Oxygenate: Reconsider O2 if available and consider using a BVM to ventilate the pt if needed

Tactical Field CareThe Rapid Trauma Assessment

• Abdomen:Inspect: For wounds (DCAP-BLS)

Palpate: TRD

• Pelvis: Inspect: DCAP-BLS

Palpate: Pelvic Rock for TIC

NOTE: Do not perform pelvic rock if any s/s of fx

Tactical Field CareThe Rapid Trauma Assessment

• Lower Extremities:

Inspect: DCAP-BLS

Palpate: Palpate for TIC and check PMS

Tactical Field CareThe Rapid Trauma Assessment

• Upper Extremities:

Inspect: DCAP-BLS

Palpate: Palpate for TIC and check PMS

• Posterior: Logroll

Tactical Field CareThe Rapid Trauma Assessment

• Posterior: Logroll

Inspect: DCAP-BLS

Palpate: Palpate the long spine for TIC

- Secure to stretcher

- After the logroll reassess the pt’s ABCs, bandages and IVs (airways dislodge and bandages and IVs can get pulled off)

Tactical Field CareThe Rapid Trauma Assessment

1) Full set of Vitals: Pulse, blood pressure, respirations, skin (TCC), Pulse oximetry and Pupils (PERRL)

2) AMPLE History:

A = AllergiesM = Medications P = Prior med hx (significant)L = Last mealE = Events leading up to the injury

3) Complete The Field Medical Card

Tactical Field Care F: Full Set Of Vital Signs

3 Steps – Vital Signs/AMPLE/FMC

GIVE: Give appropriate medications―Administer analgesics and antibiotics ―Finish packaging the pt for MEDEVAC―Tie up loose ends, document medications

in FMC and reinforce dressings

Tactical Field Care G: Give and GO:

GO: Transport and Ongoing Assessment

Tactical Field Care

GO: Transport and Ongoing Assessment― Repeat all below every 5 min for unstable pt and every 15 min for a stable pt until MEDEVAC arrives

Repeat Initial assessment including GLC/ABCs― Is the pt getting better or worse?

Repeat a full set of vital signs and document each set in the FMC

Repeat or reassess any interventions― Airway adjuncts, bandages, tourniquets, IVs and fluids, occlusive dressings, splints along with distal

circulation

Re-evaluate your evacuation category― The pt’s condition can change over time and you may have to move up or back in the order of

evacuation precedence

*** END OF TACTICAL FIELD CARE

Tactical Field Care

NOTE:

• The Soldier Medic should constantly be talking and reassuring the casualty• Recheck the ABCs every few min. to ensure the pt is still “with” you• If you spend a few min. performing a treatment go back and check ABCs before

moving on

Example of a quick reassessment:

The pt is talking so he has an airway, he can speak in full sentences so his breathing is good, I note his bandage is still dry so I have hemostasis, I can see his IV is still running and I see no infiltration at the IV site.

Tactical Field Care

Casevac Care

Combat Casualty Evacuation Care

Combat Casualty Evacuation Care: The care rendered once the casualty has been placed by an aircraft, vehicle or boat

• Additional medical personnel and equipment may have been pre-staged and are available at this phase of casualty management

Casevac Care

At some point in the operation, the casualty will be scheduled for evacuation. Time to evacuation may be quite variable from minutes to hours.

Casevac Care

There are a multitude of factors that will affect the ability to evacuate a casualty

Availability of aircraft or vehicles, weather, tactical situation and mission may all effect the ability of or inability to evacuate casualties

Casevac Care

There are only minor differences in care when progressing from the Tactical Field Care phase to the Casevac phase

Additional medical personnel may accompany the evacuation asset and assist the soldier medic on the ground. This may be important for the following reasons:

Additional medical personnel

may accompany the evacuation asset

Casevac Care

The soldier medic may be among the casualties.

The soldier medic may be dehydrated, hypothermic or otherwise debilitated.

Casevac Care The evacuation asset’s medical equipment may

need to be prepared prior to evacuation.

There may be multiple casualties that exceed the capability of the soldier medic to care for simultaneously.

Casevac Care

Additional medical equipment can be brought in with the evacuation asset to augment the equipment the soldier medic already has.

This equipment may include:

Casevac Care

Electronic monitoring equipment capable of measuring a casualty’s blood pressure, pulse and pulse oximetry.

Oxygen should be available during this phase.

Casevac Care

Ringers Lactate at a rate of 250 ml per hour for casualties not in shock should help to reverse dehydration.

Blood products may be available during this phase of care.

Casevac Care

Thermal Angel® fluid warmers.

PASG, if available, may be beneficial in pelvic fractures and helping to control pelvic and abdominal bleeding (they are contraindicated in thoracic and brain injuries).

Summary How people die in ground combat: 31% penetrating head trauma.

25% surgically uncorrectable torso trauma.

10% potentially correctable surgical trauma.

Summary

9% Exsanguination from extremity wounds: (1st)

7% mutilating blast trauma. 5% tension pneumothorax: (2nd) 1% airway problems: (3rd) 12% died of wounds (mostly infections and

complications of shock).

SummaryIf during the next war you could do only two

things,

(1) put a tourniquet on

(2) relieve a tension pneumothorax

then you can probably save between 70 and 90 percent of all the preventable deaths on the battlefield.

SummaryFOLLOW THE ALPHEBETFOLLOW THE ALPHEBET

H- HemorrhageA- AirwayB - BreathingC- CirculationD - DecisionE – Expose/ evaluateF – Full set of VS, SAMPLE, FMCG – Give & GO This will minimize missing important information and will assist

you in Conserving the Fighting Force

Summary

Medical care during combat differs significantly from the care provided in the civilian community.

New concepts in hemorrhage control, fluid resuscitation, analgesia, and antibiotics are important steps in providing the best possible care to our combat soldiers.

These timely interventions will be the mainstay in decreasing the number of combat fatalities on the battlefield.

Questions?