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Tactical Combat Casualty Care 09 SEP 02 Tactical Combat Casualty Care Troy R Johnson, MD MAJ, USA, MC, FS
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Tactical Combat Casualty Care 09 SEP 02 Tactical Combat Casualty Care Troy R Johnson, MD MAJ, USA, MC, FS.

Dec 15, 2015

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Page 1: Tactical Combat Casualty Care 09 SEP 02 Tactical Combat Casualty Care Troy R Johnson, MD MAJ, USA, MC, FS.

Tactical Combat Casualty Care09 SEP 02

Tactical Combat Casualty Care

Troy R Johnson, MDMAJ, USA, MC, FS

Page 2: Tactical Combat Casualty Care 09 SEP 02 Tactical Combat Casualty Care Troy R Johnson, MD MAJ, USA, MC, FS.

Tactical Combat Casualty Care09 SEP 02

Agenda

ObjectivesMortality in CombatPreventable mortalityCare under fireTactical Casualty careEvacuationMilitary vs. Civilian tactical care

Page 3: Tactical Combat Casualty Care 09 SEP 02 Tactical Combat Casualty Care Troy R Johnson, MD MAJ, USA, MC, FS.

Tactical Combat Casualty Care09 SEP 02

Discussion Objectives

1. Identify the top two causes of preventable combat mortality

2. List three methods of controlling hemorrhage in the field

3. Write both two-condition criteria for diagnosis of tension pneumothorax

4. Outline additional equipment and skills available with evacuation assets

5. Compare and contrast civilian and military tactical medical care

Page 4: Tactical Combat Casualty Care 09 SEP 02 Tactical Combat Casualty Care Troy R Johnson, MD MAJ, USA, MC, FS.

Tactical Combat Casualty Care09 SEP 02

Caveats When Applying Civilian

LiteratureDifferent weaponsLess pre-existing dehydrationPre-hospital timeSurgical interventionResourceMonitoringThreat

Page 5: Tactical Combat Casualty Care 09 SEP 02 Tactical Combat Casualty Care Troy R Johnson, MD MAJ, USA, MC, FS.

Tactical Combat Casualty Care09 SEP 02

Combat Mortality

Page 6: Tactical Combat Casualty Care 09 SEP 02 Tactical Combat Casualty Care Troy R Johnson, MD MAJ, USA, MC, FS.

Tactical Combat Casualty Care09 SEP 02

Combat Mortality

Killed in Action(86% KIA)

versus

Died of Wounds(12% DOW)

Page 7: Tactical Combat Casualty Care 09 SEP 02 Tactical Combat Casualty Care Troy R Johnson, MD MAJ, USA, MC, FS.

Tactical Combat Casualty Care09 SEP 02

Combat Mortality

KIA

31% are due to penetrating head

trauma

Page 8: Tactical Combat Casualty Care 09 SEP 02 Tactical Combat Casualty Care Troy R Johnson, MD MAJ, USA, MC, FS.

Tactical Combat Casualty Care09 SEP 02

Combat Mortality

KIA

25% are due to surgically

uncorrectable penetrating torso

trauma

Page 9: Tactical Combat Casualty Care 09 SEP 02 Tactical Combat Casualty Care Troy R Johnson, MD MAJ, USA, MC, FS.

Tactical Combat Casualty Care09 SEP 02

Combat Mortality

KIA

10% are due to potentially correctable

penetrating torso trauma

Page 10: Tactical Combat Casualty Care 09 SEP 02 Tactical Combat Casualty Care Troy R Johnson, MD MAJ, USA, MC, FS.

Tactical Combat Casualty Care09 SEP 02

Combat Mortality

KIA

9% are due to potentially correctable

extremity trauma

Page 11: Tactical Combat Casualty Care 09 SEP 02 Tactical Combat Casualty Care Troy R Johnson, MD MAJ, USA, MC, FS.

Tactical Combat Casualty Care09 SEP 02

Combat Mortality

KIA

7% are due to mutilating blast

injuries

Page 12: Tactical Combat Casualty Care 09 SEP 02 Tactical Combat Casualty Care Troy R Johnson, MD MAJ, USA, MC, FS.

Tactical Combat Casualty Care09 SEP 02

Combat Mortality

KIA

5% are due to tension

pneumothorax

Page 13: Tactical Combat Casualty Care 09 SEP 02 Tactical Combat Casualty Care Troy R Johnson, MD MAJ, USA, MC, FS.

Tactical Combat Casualty Care09 SEP 02

Combat Mortality

KIA

1% are due to airway

obstruction

(1/2 actual airway)

(1/2 decreased LOC)

Page 14: Tactical Combat Casualty Care 09 SEP 02 Tactical Combat Casualty Care Troy R Johnson, MD MAJ, USA, MC, FS.

Tactical Combat Casualty Care09 SEP 02

Combat Mortality

DOW

12% are mostly due to

complicationsof shock or

late infection

Page 15: Tactical Combat Casualty Care 09 SEP 02 Tactical Combat Casualty Care Troy R Johnson, MD MAJ, USA, MC, FS.

Tactical Combat Casualty Care09 SEP 02

Serious Wounds in Vietnam Surviving to

FacilityFaceEyes 5% Neck

Cervical Spine1%

ThoraxThoracic Spine 5% Abdomen

Lumbar SpinePelvis8%

Head 4%

Extremitiesbony & neural28%

Soft Tissues 44%

Multiple sites with major injuries 5%

Page 16: Tactical Combat Casualty Care 09 SEP 02 Tactical Combat Casualty Care Troy R Johnson, MD MAJ, USA, MC, FS.

Tactical Combat Casualty Care09 SEP 02

PREVENTABLE Mortality

Airway obstruction (6%)

Tension pneumothorax (33%)

Hemorrhage from extremity wounds (60%)

Page 17: Tactical Combat Casualty Care 09 SEP 02 Tactical Combat Casualty Care Troy R Johnson, MD MAJ, USA, MC, FS.

Tactical Combat Casualty Care09 SEP 02

Tactical Combat Casualty Care

Care Under Fire

Tactical Field Care

Evacuation Care

Page 18: Tactical Combat Casualty Care 09 SEP 02 Tactical Combat Casualty Care Troy R Johnson, MD MAJ, USA, MC, FS.

Tactical Combat Casualty Care09 SEP 02

Return fire

Return fire

Return fire

Care Under Fire

Page 19: Tactical Combat Casualty Care 09 SEP 02 Tactical Combat Casualty Care Troy R Johnson, MD MAJ, USA, MC, FS.

Tactical Combat Casualty Care09 SEP 02

Return fire

What does returning fire have to do with medical care?

Care Under Fire

Page 20: Tactical Combat Casualty Care 09 SEP 02 Tactical Combat Casualty Care Troy R Johnson, MD MAJ, USA, MC, FS.

Tactical Combat Casualty Care09 SEP 02

Return fire

What does returning fire have to do with medical care?

Victory is the best medicine !!

Care Under Fire

Page 21: Tactical Combat Casualty Care 09 SEP 02 Tactical Combat Casualty Care Troy R Johnson, MD MAJ, USA, MC, FS.

Tactical Combat Casualty Care09 SEP 02

1. Move the casualty to cover

2. Don’t get shot while trying to do #1

Care Under Fire

Page 22: Tactical Combat Casualty Care 09 SEP 02 Tactical Combat Casualty Care Troy R Johnson, MD MAJ, USA, MC, FS.

Tactical Combat Casualty Care09 SEP 02

Top priority is early control of life-threatening external hemorrhage!Exsanguination from extremity wounds is

the number one cause of preventable death on the battlefield

Hemorrhage from extremity wounds was the cause of death in more than 2500 casualties in Vietnam who had no other injuries

Care Under Fire

Page 23: Tactical Combat Casualty Care 09 SEP 02 Tactical Combat Casualty Care Troy R Johnson, MD MAJ, USA, MC, FS.

Tactical Combat Casualty Care09 SEP 02

Top priority is early control of life-threatening external hemorrhage!Exsanguination from extremity wounds is

the number one cause of preventable death on the battlefield

Hemorrhage from extremity wounds was the cause of death in more than 2500 casualties in Vietnam who had no other injuries

What are the options for control in this setting?

Care Under Fire

Page 24: Tactical Combat Casualty Care 09 SEP 02 Tactical Combat Casualty Care Troy R Johnson, MD MAJ, USA, MC, FS.

Tactical Combat Casualty Care09 SEP 02

Hemorrhage Control

Dressing

Pressure dressing

Tourniquet

Page 25: Tactical Combat Casualty Care 09 SEP 02 Tactical Combat Casualty Care Troy R Johnson, MD MAJ, USA, MC, FS.

Tactical Combat Casualty Care09 SEP 02

Discouraged in the civilian settingMost reasonable initial choice to

stop life-threatening bleedingDirect pressure is hard to maintain

during casualty movementThe risk-benefit ratio

Tourniquets

Page 26: Tactical Combat Casualty Care 09 SEP 02 Tactical Combat Casualty Care Troy R Johnson, MD MAJ, USA, MC, FS.

Tactical Combat Casualty Care09 SEP 02

Ischemic damage to an extremity is rare if the tourniquet is left in place less than 60-90 min

Surgical/anesthesia literature states 5 min off every 30 mins after tourniquet has been on for 120 min

Risk/Benefit ratio

Tourniquets

Page 27: Tactical Combat Casualty Care 09 SEP 02 Tactical Combat Casualty Care Troy R Johnson, MD MAJ, USA, MC, FS.

Tactical Combat Casualty Care09 SEP 02

Return fireDon’t be a heroFind cover for yourself and your

casualtyStop any life-threatening external

hemorrhage

Care Under Fire

Page 28: Tactical Combat Casualty Care 09 SEP 02 Tactical Combat Casualty Care Troy R Johnson, MD MAJ, USA, MC, FS.

Questions?

Page 29: Tactical Combat Casualty Care 09 SEP 02 Tactical Combat Casualty Care Troy R Johnson, MD MAJ, USA, MC, FS.

Tactical Combat Casualty Care09 SEP 02

Reduced risk/warm zoneCover/ConcealmentVariable amount of time

availableMissionCasualty evacuation

Field conditionsTemperature and weatherDarknessNon-sterile environment

Tactical Field Care

Page 30: Tactical Combat Casualty Care 09 SEP 02 Tactical Combat Casualty Care Troy R Johnson, MD MAJ, USA, MC, FS.

Tactical Combat Casualty Care09 SEP 02

Stop bleedingTransport casualty to extraction

siteIf tourniquet used earlier

Consider loosening then reassessingTry direct pressure to control bleedingMay be able to remove tourniquet

Expose/Environment

External Hemorrhage

Page 31: Tactical Combat Casualty Care 09 SEP 02 Tactical Combat Casualty Care Troy R Johnson, MD MAJ, USA, MC, FS.

Tactical Combat Casualty Care09 SEP 02

No attempt at airway intervention if the casualty is conscious and breathing well on his or her own

Airway Management:Conscious Casualty

Page 32: Tactical Combat Casualty Care 09 SEP 02 Tactical Combat Casualty Care Troy R Johnson, MD MAJ, USA, MC, FS.

Tactical Combat Casualty Care09 SEP 02

Usual cause is hemorrhagic shock or penetrating head trauma

Manual correction optionsChin lift/jaw thrust maneuverNasopharyngeal airwayGravity positioning

Low-yield for immobilization of cervical spine

Airway Management:Altered Mental Status

Page 33: Tactical Combat Casualty Care 09 SEP 02 Tactical Combat Casualty Care Troy R Johnson, MD MAJ, USA, MC, FS.

Tactical Combat Casualty Care09 SEP 02

Liquid removal optionsGravitySuction

Definitive airway optionsEndotracheal intubationCricothyroidostomy

Airway Management:Obstruction

Page 34: Tactical Combat Casualty Care 09 SEP 02 Tactical Combat Casualty Care Troy R Johnson, MD MAJ, USA, MC, FS.

Tactical Combat Casualty Care09 SEP 02

Breathing

Tension PneumothoraxAuscultationTracheal deviationPercussionJVD

Page 35: Tactical Combat Casualty Care 09 SEP 02 Tactical Combat Casualty Care Troy R Johnson, MD MAJ, USA, MC, FS.

Tactical Combat Casualty Care09 SEP 02

AuscultationSeventy-one patients (60%) had a

hemothorax, pneumothorax, or hemopneumothorax. Auscultation to detect hemothorax, pneumothorax, or hemopneumothorax had a sensitivity of 58%, a specificity of 98%, and a positive predictive value of 98%.

Chen SC. Markmann JF. Kauder DR. Schwab CW. Hemopneumothorax missed by auscultation in penetrating chest injury. Journal of Trauma-Injury Infection & Critical Care. 42(1):86-9, 1997 Jan

Page 36: Tactical Combat Casualty Care 09 SEP 02 Tactical Combat Casualty Care Troy R Johnson, MD MAJ, USA, MC, FS.

Tactical Combat Casualty Care09 SEP 02

Auscultation

Thirty of 71 patients (42%) were found to have pleural space blood or air missed by auscultation. Auscultation missed hemothorax up to 600 mL, pneumothorax up to 28%, and hemopneumothorax up to 800 mL and 28%.

Chen SC. Markmann JF. Kauder DR. Schwab CW. Hemopneumothorax missed by auscultation in penetrating chest injury. Journal of Trauma-Injury Infection & Critical Care. 42(1):86-9, 1997 Jan

Page 37: Tactical Combat Casualty Care 09 SEP 02 Tactical Combat Casualty Care Troy R Johnson, MD MAJ, USA, MC, FS.

Tactical Combat Casualty Care09 SEP 02

Auscultation

Page 38: Tactical Combat Casualty Care 09 SEP 02 Tactical Combat Casualty Care Troy R Johnson, MD MAJ, USA, MC, FS.

Tactical Combat Casualty Care09 SEP 02

Auscultation with Stab Wounds

Page 39: Tactical Combat Casualty Care 09 SEP 02 Tactical Combat Casualty Care Troy R Johnson, MD MAJ, USA, MC, FS.

Tactical Combat Casualty Care09 SEP 02

Auscultation with GSW Wounds

Page 40: Tactical Combat Casualty Care 09 SEP 02 Tactical Combat Casualty Care Troy R Johnson, MD MAJ, USA, MC, FS.

Tactical Combat Casualty Care09 SEP 02

Tension Pneumothorax

Deceased preloadIncreased afterloadMechanical pressure on heartDecreased Alveolar surfacePleural space agitation

Page 41: Tactical Combat Casualty Care 09 SEP 02 Tactical Combat Casualty Care Troy R Johnson, MD MAJ, USA, MC, FS.

Tactical Combat Casualty Care09 SEP 02

Casualties with penetrating chest trauma will generally have some degree of hemopneumothorax

Additional trauma from needle thoracentesis will not significantly worsen casualties’ conditions if no pneumothorax present

Needle Thoracentesis

Page 42: Tactical Combat Casualty Care 09 SEP 02 Tactical Combat Casualty Care Troy R Johnson, MD MAJ, USA, MC, FS.

Tactical Combat Casualty Care09 SEP 02

Emergently decompress affected hemithorax with 14-gauge needle inserted over 3rd rib in 2nd inter-costal space at mid-clavicular line

Needle Thoracentesis

Page 43: Tactical Combat Casualty Care 09 SEP 02 Tactical Combat Casualty Care Troy R Johnson, MD MAJ, USA, MC, FS.

Tactical Combat Casualty Care09 SEP 02

Contraindicated for life-threatening tension pneumothorax

Difficult to performInfection risk higher when inserting

tube in non-sterile conditionsPrior to Evacuation?

Tube Thoracostomy

Page 44: Tactical Combat Casualty Care 09 SEP 02 Tactical Combat Casualty Care Troy R Johnson, MD MAJ, USA, MC, FS.

Tactical Combat Casualty Care09 SEP 02

Seal defect through which air moving and cover with dressingAllow for pressure releaseDifficult to do reliably in tactical settingObserve closely for development of

tension pneumothorax

Asherman valve may be option

Open Pneumothorax

Page 45: Tactical Combat Casualty Care 09 SEP 02 Tactical Combat Casualty Care Troy R Johnson, MD MAJ, USA, MC, FS.

Tactical Combat Casualty Care09 SEP 02

Controversial the tactical environment

Cylinders of compressed gas heavy and risky for tactical operations

Transportation of casualty difficult without vehicle

Supplemental Oxygen

Page 46: Tactical Combat Casualty Care 09 SEP 02 Tactical Combat Casualty Care Troy R Johnson, MD MAJ, USA, MC, FS.

Tactical Combat Casualty Care09 SEP 02

Shock Management

Shock is a state of inadequate organ perfusion

Diagnosed by noting end-organ dysfunctionAltered mental statusPoor peripheral perfusionAnxiety

Page 47: Tactical Combat Casualty Care 09 SEP 02 Tactical Combat Casualty Care Troy R Johnson, MD MAJ, USA, MC, FS.

Tactical Combat Casualty Care09 SEP 02

Shock Management

Therapeutic goalsIncrease oxygenation of blood

Increased trans-alveolar oxygenIncreased hemoglobin concentration

Increase cardiac outputIncreased preloadIncreased stroke volume

Page 48: Tactical Combat Casualty Care 09 SEP 02 Tactical Combat Casualty Care Troy R Johnson, MD MAJ, USA, MC, FS.

Tactical Combat Casualty Care09 SEP 02

IV accessCleaning the skin before

venipunctureSaline lock should be used unless

casualty requires immediate fluid resuscitation

Flushing the lock with 5 mL of normal saline every 2 hours will usually keep it open

Intravenous Access

Page 49: Tactical Combat Casualty Care 09 SEP 02 Tactical Combat Casualty Care Troy R Johnson, MD MAJ, USA, MC, FS.

Tactical Combat Casualty Care09 SEP 02

Controlled Hemorrhage: Without

ShockNO immediate fluid resuscitationSave IV fluids for those who

really need themNo unnecessary tactical delays –

do not wait 5 minutes to start an IV in this patient

Page 50: Tactical Combat Casualty Care 09 SEP 02 Tactical Combat Casualty Care Troy R Johnson, MD MAJ, USA, MC, FS.

Tactical Combat Casualty Care09 SEP 02

Controlled Hemorrhage: With

ShockAdminister IV fluids in boluses to

correct end-organ dysfunction0.9% (normal) or 3% saline solutionsLactated Ringer’s solution6% hetastarch [Hespan®]

DO NOT use normal vital signs as endpoints for fluid resuscitationIncreased blood pressureHemoglobin, platelets, and clotting factors

Page 51: Tactical Combat Casualty Care 09 SEP 02 Tactical Combat Casualty Care Troy R Johnson, MD MAJ, USA, MC, FS.

Tactical Combat Casualty Care09 SEP 02

Uncontrolled Hemorrhage: With or

Without ShockNO immediate fluid resuscitationSpend time controlling

exsanguinationExternalInternal

Save IV fluidsPermissive hypotension

Page 52: Tactical Combat Casualty Care 09 SEP 02 Tactical Combat Casualty Care Troy R Johnson, MD MAJ, USA, MC, FS.

Tactical Combat Casualty Care09 SEP 02

Only in cases of nontraumatic cardiac arrest should CPR be considered prior to EvacuationElectrocutionHypothermiaNear-drowning

Cardiopulmonary Resuscitation

Page 53: Tactical Combat Casualty Care 09 SEP 02 Tactical Combat Casualty Care Troy R Johnson, MD MAJ, USA, MC, FS.

Tactical Combat Casualty Care09 SEP 02

Minimize further contaminationPromote hemostasisCheck for additional wounds

Exit sites may be remote from entrySome sites are easily overlooked

Splint fractures and recheck distal pulses

Analgesic medicationsAntibiotic medications

Additional Considerations

Page 54: Tactical Combat Casualty Care 09 SEP 02 Tactical Combat Casualty Care Troy R Johnson, MD MAJ, USA, MC, FS.

Questions?

Page 55: Tactical Combat Casualty Care 09 SEP 02 Tactical Combat Casualty Care Troy R Johnson, MD MAJ, USA, MC, FS.

Tactical Combat Casualty Care09 SEP 02

Evacuation

Page 56: Tactical Combat Casualty Care 09 SEP 02 Tactical Combat Casualty Care Troy R Johnson, MD MAJ, USA, MC, FS.

Tactical Combat Casualty Care09 SEP 02

CASEVACCasualty evacuation from the battlefield

MEDEVACMedical evacuation of casualties

CASEVAC versus MEDEVAC

Page 57: Tactical Combat Casualty Care 09 SEP 02 Tactical Combat Casualty Care Troy R Johnson, MD MAJ, USA, MC, FS.

Tactical Combat Casualty Care09 SEP 02

Medical personnel may accompany evacuating assetNo reliance on field personnel providing

careMedical personnel operating in tactical

vehicle

Additional medical equipment may be available on evacuation platformVariable

CASEVAC Care

Page 58: Tactical Combat Casualty Care 09 SEP 02 Tactical Combat Casualty Care Troy R Johnson, MD MAJ, USA, MC, FS.

Tactical Combat Casualty Care09 SEP 02

CASEVAC Care

Primary focus is clearing casualties off the battlefield and not medical care enroute

Adaptability is key

Maximize your mission within the CASEVAC mission

Page 59: Tactical Combat Casualty Care 09 SEP 02 Tactical Combat Casualty Care Troy R Johnson, MD MAJ, USA, MC, FS.

Tactical Combat Casualty Care09 SEP 02

CASEVAC Care

Tactical aircraft/vehicles have restrictions against white lightLaryngoscopesBlood identificationWound identification

Black out sheets

Page 60: Tactical Combat Casualty Care 09 SEP 02 Tactical Combat Casualty Care Troy R Johnson, MD MAJ, USA, MC, FS.

Tactical Combat Casualty Care09 SEP 02

MEDEVAC Care

Medical personnel part of assetMedical personnel operating vehicle

designed for them

Additional medical equipment available on evacuation platformOxygenSuctionMonitoringPositioning

Page 61: Tactical Combat Casualty Care 09 SEP 02 Tactical Combat Casualty Care Troy R Johnson, MD MAJ, USA, MC, FS.

Tactical Combat Casualty Care09 SEP 02

MEDEVAC Care

Difficult to get far-forwardNo part of assault planningCommunications

Page 62: Tactical Combat Casualty Care 09 SEP 02 Tactical Combat Casualty Care Troy R Johnson, MD MAJ, USA, MC, FS.

Tactical Combat Casualty Care09 SEP 02

MEDEVAC Care

FLA UH-60QCombat medicAugmentationCCATTStrategic MEDEVAC

Page 63: Tactical Combat Casualty Care 09 SEP 02 Tactical Combat Casualty Care Troy R Johnson, MD MAJ, USA, MC, FS.

Questions?

Page 64: Tactical Combat Casualty Care 09 SEP 02 Tactical Combat Casualty Care Troy R Johnson, MD MAJ, USA, MC, FS.

Tactical Combat Casualty Care09 SEP 02

Military vs Civilian Tactical Medical Support

Page 65: Tactical Combat Casualty Care 09 SEP 02 Tactical Combat Casualty Care Troy R Johnson, MD MAJ, USA, MC, FS.

Tactical Combat Casualty Care09 SEP 02

Military vs. Civilian Tactical Medical

SupportLines are purlingProximity to Tertiary level of careAdditional resourcesAcceptance of casualtiesPhilosophy

Offense vs. defenseContainment vs. destruction

Page 66: Tactical Combat Casualty Care 09 SEP 02 Tactical Combat Casualty Care Troy R Johnson, MD MAJ, USA, MC, FS.

Tactical Combat Casualty Care09 SEP 02

Questions ?


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