Page 15 - 2021 Advanced Ranger First Responder Handbook

Tactical Trauma Assessment
Tactical Patient Assessment
Follow TCCC Guidelines of Care Under Fire, Tactical Field Care, and Tactical Evacuation Care. TCCC
The acronym MARCH is recommended to guide the priorities in the Care Under Fire (control of life-threatening hemor-
rhage only) and Tactical Field Care phases:
Massive hemorrhage – control life-threatening bleeding.
Airway – establish and maintain a patent airway.
Respiration – decompress suspected tension pneumothorax, seal sucking chest wounds, and support ventilation/oxy-
genation as required.
Circulation – establish IV/IO access and administer blood products as required to treat shock.
Head injury/Hypothermia – prevent/treat hypotension and hypoxia to prevent worsening of traumatic brain injury and
prevent/treat hypothermia.
TCCC Application
Care Under Fire: Return fire and take cover. Direct or expect casualty to remain engaged as a combatant if appropriate.
Direct casualty to move to cover and apply self-aid if able. Try to keep the casualty from sustaining additional wounds.
Casualties should be extricated from burning vehicles or buildings and moved to places of relative safety. Do what is
necessary to stop the burning process. Tactical patient assessment during this phase is limited to identifying life threat-
ening hemorrhage in a rapid head-to-toe survey taking < 10–15 seconds or as tactically feasible. Airway management,
other than positioning, is generally best deferred until the TFC phase. Stop life-threatening external hemorrhage if tacti-
cally feasible with an approved tourniquet.
Tactical Field Care: Consolidate casualties in CCP. Initially, conduct triage to identify which patient needs attention
first and who can wait. Identify any life-threatening hemorrhage not already controlled. In this phase, the first priority is
to conduct a rapid trauma assessment. A more deliberate and traditional head-to-toe MARCH survey is completed on
each casualty after all life threats have been addressed. Casualties with an altered mental status should be disarmed
immediately, including communications equipment. Injuries are managed in a head-to-toe-treat-as-you-go manner. Tri-
age reoccurs during this entire phase. Delegate treatment of minor injuries to RFRs, freeing the ARFR to focus on more
seriously injured. Provide instructions to ARFRs or RFRs if tasked to assist you with multisystem trauma casualties.
Communicate casualty status and evacuation requirements to C2. Consolidate medical supplies in CCP. Prepare and
package casualties for evacuation.
Trauma Assessment Principles
Massive Hemorrhage: Obvious external sources of bleeding should be controlled with tourniquets, direct pressure, and
pressure dressings. Clamping of injured vessels is not indicated unless the bleeding vessel can be directly visualized.
Sources of internal hemorrhage should be identified. Initial tourniquets are to be placed “high and tight.” Effort should be SECTION 6
made to convert these as distally as possible or to a pressure dressing as soon as the tactical situation allows.
Airway: A conscious and spontaneously breathing patient rarely requires immediate airway intervention. If the patient
is able to talk normally, then his airway is intact. If the patient is semiconscious or unconscious, the tongue is the
most common source of airway obstruction. Patient positioning and airway adjuncts (nasopharyngeal airway [NPA]/
oropharyngeal airway [OPA]) should be the first choice to maintain a patent airway. Ranger Medics train extensively
in order to proficiently conduct a surgical cricothyroidotomy. This should be the first choice for any patient requiring a
definitive airway. Penetrating trauma causing C-spine fractures is almost universally fatal. One should consider C-spine
fracture in blunt trauma and take appropriate precautions.
Respirations: In the conscious patient who is alert and breathing normally, no interventions are required. If the patient
has an appropriate mechanism of injury and signs of respiratory distress such as tachypnea, dyspnea, or cyanosis,
which may be associated with agitation or decreasing mental status, then a presumption of tension pneumothorax
management is indicated.
Circulation: Important information can be rapidly obtained regarding perfusion and oxygenation from the level of con-
sciousness, pulse, skin color, and capillary refill time. Decreased cerebral perfusion may result in an altered mental
status. Skin color and capillary refill will provide a rapid initial assessment of peripheral perfusion. Pink skin is a good sign
versus the ominous sign of white or ashen, gray skin depicting hypovolemia. Pressure to the thumb nail or hypothenar
eminence will cause the underlying tissue to blanch. In a normovolemic patient, the color returns to normal within 2 sec-
onds. In the hypovolemic, poorly oxygenated patient, and/or hypothermic patient, this time period is extended or absent.
Head Injury/Hypothermia: Clothing and protective equipment such as helmets and body armor should be removed
only as required to evaluate and treat specific injuries. If the patient is conscious with a single extremity wound, only
the area surrounding the injury should be exposed. Unconscious patients may require more extensive exposure in order
to discover potentially serious injuries but must subsequently be protected from the elements and the environment.
Hypothermia is to be avoided in trauma patients. A brief neurological assessment should be performed, and loss of con-
sciousness (LOC) can be described preferably through the “alert, verbal, pain, unresponsive” (AVPU) scale. If the pupils
are found to be sluggish or nonreactive to light with unilateral or bilateral dilation, one should suspect a head injury and/
or inadequate brain perfusion. Assess for any fractures or deformities of extremities or joints.
Vital Signs: Vital signs should be assessed frequently, especially after specific therapeutic interventions, and before and
after moving patients. As a group, Ranger patients are in excellent physical condition and may have tremendous physi-
ological reserves. They may not manifest significant changes in vital signs until they are in severe shock. Technology can
fail and ARFRs must be capable of obtaining manual vital signs.
2021 ADVANCED RANGER FIRST RESPONDER HANDBOOK 5