Current Performance Improvement Issues Tactical Combat Casualty Care 7 December 2012.

Current Performance Improvement Issues

Tactical Combat Casualty Care7 December 2012

TCCC Lessons Learned in Iraq and Afghanistan

• Reports from Joint Trauma System (JTS) weekly Trauma Telecons – every Thursday morning–Worldwide telecon to discuss every serious casualty

admitted to a Level III hospital from that week• Published medical reports• Armed Forces Medical Examiner’s Office reports• Feedback from doctors, corpsmen, medics, and PJs

Overcalling CAT A Evacuations

NATO/ISAF Standard Evacuation Categories

International Security Assistance Force

SOP #312:• Governs operations in Afghanistan • Follows NATO doctrine • Specifies three categories for casualty

evacuation:• A - Urgent• B - Priority• C - Routine

• CAT A – Urgent (denotes a critical, life-threatening injury)

– Significant injuries from a dismounted IED attack– Gunshot wound or penetrating shrapnel to chest,

abdomen or pelvis– Any casualty with ongoing airway difficulty– Any casualty with ongoing respiratory difficulty– Unconscious casualty

NATO/ISAF Standard Evacuation Categories

• CAT A – Urgent (continued)

– Casualty with known or suspected spinal injury– Casualty in shock – Casualty with bleeding that is difficult to control–Moderate/Severe TBI– Burns greater than 20% Total Body Surface Area

NATO/ISAF Standard Evacuation Categories

• CAT B – Priority (serious injury)– Isolated, open extremity fracture with bleeding

controlled– Any casualty with a tourniquet in place– Penetrating or other serious eye injury– Significant soft tissue injury without major

bleeding– Extremity injury with absent distal pulses – Burns 10-20% Total Body Surface Area

NATO/ISAF Standard Evacuation Categories

• CAT C – Routine (mild to moderate injury)

– Concussion (mild TBI)

– Gunshot wound to extremity - bleeding controlled without tourniquet

–Minor soft tissue shrapnel injury

– Closed fracture with intact distal pulses

– Burns < 10% Total Body Surface Area

NATO/ISAF Standard Evacuation Categories

Training

Train ALL Combatants and all Operational Medical

Providers in TCCC• Line commanders must take the lead to have an

effective TCCC training program for all combatants• Docs, nurses, PAs must know what their combat

medical personnel know about TCCC

Tourniquets Being Placed Too Proximal and

Not Adjusted during TFC

E-mail from an orthopedic surgeon: “…. tourniquet was applied on the proximal biceps for a middle finger amputation.” 

Care Under Fire Guidelines

7. Stop life-threatening external hemorrhage if tactically feasible:– Direct casualty to control hemorrhage by self-aid

if able. – Use a CoTCCC-recommended tourniquet for

hemorrhage that is anatomically amenable to tourniquet application.

– Apply the tourniquet proximal to the bleeding site, over the uniform, tighten, and move the casualty to cover.

Three Key Points

• “Proximal to the bleeding site” does not necessarily mean at the upper biceps for a hand injury or at the upper thigh for a foot injury

• The tourniquet should be moved to a skin location 2-3 inches above the bleeding site during Tactical Field Care.

• Reassess the bleeding site frequently to ensure that tourniquet is still effective.

Tourniquet Mistakesto Avoid!

• Not using one when you should• Using a tourniquet for minimal bleeding• Putting it on too proximally• Not taking it off when indicated during TFC• Taking it off when the casualty is in shock or has

only a short transport time to the hospital• Not making it tight enough – the tourniquet

should eliminate the distal pulse• Not using a second tourniquet if needed• Waiting too long to put the tourniquet on• Periodically loosening the tourniquet to allow

blood flow to the injured extremity* These lessons learned have been written in blood. *

Eye Injuries: Recent Increase in Eye Injuries from Not Wearing Eye

Protection

Wear Your Eye Protection!

• Jan 2010• 22 y/o near IED without eye protection• Now blind in both eyes• Don’t let this happen to you – see slides below

With eye pro – eyes OK! Without eye pro – both eyes lost

Eye Armor – It Works!

Penetrating Eye Trauma

• Rigid eye shield for obvious or suspected eye wounds - often not being done – SHIELD AND SHIP!

• Not doing this may cause permanent loss of vision – use a shield for any injury in or around the eye

• Eye shields not always in IFAKs• IED + no eye pro + facial wounds = Suspected Eye Injury!

Shield after injury No shield after injury

• Use your tactical eyewear to cover the injured eye if you don’t have a shield.• Using tactical eyewear in the field will generally prevent the eye injury from happening in the first place!

Eye Protection

JTTS Trauma Telecon9 Sept 2010

• Recent case of endophthalmitis (blinding infection inside the eye)• Reminder – shield and moxifloxacin in the field for penetrating eye injuries – combat pill pack!• Also – need to continue moxi both topically and systemically in the MTFs• Many antibiotics do not penetrate well into the eye

Patched Open Globe 22 July 2010

• Shrapnel in right eye from IED• Had rigid eye shield placed• Reported as both pressure patched and as having a

gauze pad placed under the eye shield without pressure – NO pressure patches on eye injuries

• Extruded uveal tissue (intraocular contents) noted at time of operative repair of globe

• Do not place gauze on injured eyes! COL Robb Mazzoli: Gauze can adhere to iris tissue and cause further extrusion when removed even if no pressure is applied to eye.

• At least two other recent occurrences of patching

Pressure Dressings on Eye Injuries

The wrong thing to do – makes a bad situation potentially much worse – SHIELD ONLY

Battlefield Analgesia

NO Narcotic Analgesia for Casualties in Shock

• Narcotics (morphine and fentanyl) are CONTRAINDICATED for casualties

who are in shock or who are likely to go into shock; these agents may worsen their shock and increase the risk of death• Four casualties in two successive weekly telecons

were noted to have gotten narcotics and were in shock during transport or on admission to the MTFs

• Use ketamine for casualties who are in shock or at risk of going into shock but are still having significant pain

Case ReportSeptember 2012

• Male casualty with GSW to thigh• Bleeding controlled by tourniquet• In shock – alert but hypotensive• Severe pain from tourniquet• Repeated pleas to PA to remove the tourniquet• PA did not want to use opioids because of the shock• Perfect candidate for ketamine analgesia• Not fielded at the time with this unit

Platelet-Inhibiting Drugs in the Battle Space

First – Do No HarmHarris et al – Mil Med 2012

• Platelets help to keep you from bleeding to death if you are wounded. Some drugs keep them from working.• Survey of 175 Soldiers at a FOB in SE Afghanistan• “Do you take over-the-counter or prescription NSAIDs?”• If so, how often?

First – Do No HarmHarris et al – Mil Med 2012

First – Do No HarmHarris et al – Mil Med 2012

Recommendations:• Earlier platelets in DCR• Consider restricting NSAIDs in theater• Other analgesic choices: acetaminophen, cox-2 selective NSAIDs, tramadol

Note that other drugs and some nutritional

supplements may inhibit platelets as well. Check with your doc on this!

Documentation of TCCC Care

TCCC Card –Fill It Out!

• You’re not done taking care of your casualty until this is done

• Mission Commanders – this is a leadership issue!

Questions?