Page 136 - Journal of Special Operations Medicine - Fall 2014

Basic Management Plan for Tactical Evacuation Care
1. Airway Management
a. Unconscious casualty without airway obstruction:
– Chin lift or jaw thrust maneuver
– Nasopharyngeal airway
– Place casualty in the recovery position
b. Casualty with airway obstruction or impending airway obstruction:
– Chin lift or jaw thrust maneuver
– Nasopharyngeal airway
– Allow casualty to assume any position that best protects the airway, to include sitting up.
– Place unconscious casualty in the recovery position.
– If above measures unsuccessful:
– Supraglottic airway; or
– Endotracheal intubation; or
– Surgical cricothyroidotomy (with lidocaine if conscious).
c. Spinal immobilization is not necessary for casualties with penetrating trauma.
2. Breathing
a. In a casualty with progressive respiratory distress and known or suspected torso trauma, consider a tension pneumothorax
and decompress the chest on the side of the injury with a 14-gauge, 3.25-inch needle/catheter unit inserted in the second
intercostal space at the midclavicular line. Ensure that the needle entry into the chest is not medial to the nipple line and is
not directed towards the heart. An acceptable alternate site is the 4th or 5th intercostal space at the anterior axillary line
(AAL).
b. Consider chest tube insertion if no improvement and/or long transport is anticipated.
c. Most combat casualties do not require supplemental oxygen, but administration of oxygen may be of benefit for the fol-
lowing types of casualties:
– Low oxygen saturation by pulse oximetry
– Injuries associated with impaired oxygenation
– Unconscious casualty
– Casualty with TBI (maintain oxygen saturation >90%)
– Casualty in shock
– Casualty at altitude
d. All open and/or sucking chest wounds should be treated by immediately applying a vented chest seal to cover the defect.
If a vented chest seal is not available, use a nonvented chest seal. Monitor the casualty for the potential development of a
subsequent tension pneumothorax. If the casualty develops increasing hypoxia, respiratory distress, or hypotension and a
tension pneumothorax is suspected, treat by burping or removing the dressing or by needle decompression.
3. Bleeding
a. Assess for unrecognized hemorrhage and control all sources of bleeding. If not already done, use a CoTCCC-recommended
tourniquet to control life-threatening external hemorrhage that is anatomically amenable to tourniquet application or for
any traumatic amputation. Apply directly to the skin 2–3 inches above wound.
b. For compressible hemorrhage not amenable to tourniquet use or as an adjunct to tourniquet removal (if anticipated
evacuation time is longer than 2 hours), use Combat Gauze as the CoTCCC hemostatic dressing of choice. Celox Gauze
and ChitoGauze may also be used if Combat Gauze is not available. Hemostatic dressings should be applied with at least
3 minutes of direct pressure. Before releasing any tourniquet on a casualty who has been resuscitated for hemorrhagic
shock, ensure a positive response to resuscitation efforts (i.e., a peripheral pulse normal in character and normal mentation
if there is no TBI). If the bleeding site is appropriate for use of a junctional tourniquet, immediately apply a CoTCCC-
recommended junctional tourniquet. Do not delay in the application of the junctional tourniquet once it is ready for use.
Apply hemostatic dressings with direct pressure if a junctional tourniquet is not available or while the junctional tourni-
quet is being readied for use.
c. Reassess prior tourniquet application. Expose wound and determine if tourniquet is needed. If so, replace tourniquet over
uniform with another applied directly to skin 2–3 inches above wound. If a tourniquet is not needed, use other techniques
to control bleeding.
d. When time and the tactical situation permit, a distal pulse check should be accomplished. If a distal pulse is still present,
consider additional tightening of the tourniquet or the use of a second tourniquet, side by side and proximal to the first,
to eliminate the distal pulse.
e. Expose and clearly mark all tourniquet sites with the time of tourniquet application. Use an indelible marker.
4. Intravenous (IV) access

Note: *The term “Tactical Evacuation” includes both Casualty Evacuation (CASEVAC) and Medical Evacuation (MEDEVAC)
as defined in Joint Publication 4-02.

128 Journal of Special Operations Medicine Volume 14, Edition 3/Fall 2014