Page 171 - Journal of Special Operations Medicine - Summer 2015

Tactical Combat Casualty Care Guidelines

9 February 2015 chest is not medial to the nipple line and is not directed
towards the heart. An acceptable alternate site is the
*All changes to the guidelines made since those published in 4th or 5th intercostal space at the anterior axillary line
the 2014 Prehospital Trauma Life Support Manual, 8th ed., (AAL).
are shown in bold text. The most recent changes are shown b. All open and/or sucking chest wounds should be treated
in red text. by immediately applying a vented chest seal to cover the
*These recommendations are intended to be guidelines only defect. If a vented chest seal is not available, use a non-
and are not a substitute for clinical judgment. vented chest seal. Monitor the casualty for the potential
development of a subsequent tension pneumothorax. If
the casualty develops increasing hypoxia, respiratory
Basic Management Plan for Care Under Fire distress, or hypotension and a tension pneumothorax is
suspected, treat by burping or removing the dressing or
1. Return fire and take cover.
2. Direct or expect casualty to remain engaged as a combat- by needle decompression.
ant if appropriate. c. Casualties with moderate/severe TBI should be given
3. Direct casualty to move to cover and apply self-aid if able. supplemental oxygen when available to maintain an
4. Try to keep the casualty from sustaining additional wounds. oxygen saturation >90%.
5. Casualties should be extricated from burning vehicles or 4. Bleeding
buildings and moved to places of relative safety. Do what is a. Assess for unrecognized hemorrhage and control all
necessary to stop the burning process. sources of bleeding. If not already done, use a CoTCCC-
6. Airway management is generally best deferred until the recommended limb tourniquet to control life-threaten-
Tactical Field Care phase. ing external hemorrhage that is anatomically amenable
7. Stop life-threatening external hemorrhage if tactically to tourniquet use or for any traumatic amputation. Ap-
feasible: ply directly to the skin 2–3 inches above the wound.
– Direct casualty to control hemorrhage by self-aid if If bleeding is not controlled with the first tourniquet,
able. apply a second tourniquet side-by-side with the first.
– Use a CoTCCC-recommended limb tourniquet for hem- b. For compressible hemorrhage not amenable to limb
orrhage that is anatomically amenable to tourniquet use. tourniquet use or as an adjunct to tourniquet removal,
®
– Apply the limb tourniquet over the uniform clearly use Combat Gauze as the CoTCCC hemostatic dress-
®
®
proximal to the bleeding site(s). If the site of the life- ing of choice. Celox Gauze and ChitoGauze may also
threatening bleeding is not readily apparent, place the be used if Combat Gauze is not available. Hemostatic
tourniquet “high and tight” (as proximal as possible) dressings should be applied with at least 3 minutes of
on the injured limb and move the casualty to cover. direct pressure. If the bleeding site is amenable to use of
a junctional tourniquet, immediately apply a CoTCCC-
recommended junctional tourniquet. Do not delay in
Basic Management Plan for Tactical Field Care the application of the junctional tourniquet once it is
ready for use. Apply hemostatic dressings with direct
1. Casualties with an altered mental status should be dis- pressure if a junctional tourniquet is not available or
armed immediately. while the junctional tourniquet is being readied for use.
2. Airway management c. Reassess prior tourniquet application. Expose the
a. Unconscious casualty without airway obstruction: wound and determine if a tourniquet is needed. If it is,
– Chin lift or jaw thrust maneuver replace any limb tourniquet placed over the uniform
– Nasopharyngeal airway with one applied directly to the skin 2–3 inches above
– Place casualty in the recovery position wound. Ensure that bleeding is stopped. When possible,
b. Casualty with airway obstruction or impending airway a distal pulse should be checked. If bleeding persists or
obstruction: a distal pulse is still present, consider additional tighten-
– Chin lift or jaw thrust maneuver ing of the tourniquet or the use of a second tourniquet
– Nasopharyngeal airway side-by-side with the first to eliminate both bleeding
– Allow casualty to assume any position that best pro- and the distal pulse.
tects the airway, to include sitting up. d. Limb tourniquets and junctional tourniquets should be
– Place unconscious casualty in the recovery position. converted to hemostatic or pressure dressings as soon
– If previous measures unsuccessful: as possible if three criteria are met: the casualty is not
– Surgical cricothyroidotomy (with lidocaine if conscious) in shock; it is possible to monitor the wound closely for
3. Breathing bleeding; and the tourniquet is not being used to con-
a. In a casualty with progressive respiratory distress and trol bleeding from an amputated extremity. Every effort
known or suspected torso trauma, consider a tension should be made to convert tourniquets in less than 2
pneumothorax and decompress the chest on the side of hours if bleeding can be controlled with other means.
the injury with a 14-gauge, 3.25-inch needle/catheter Do not remove a tourniquet that has been in place more
unit inserted in the second intercostal space at the mid- than 6 hours unless close monitoring and lab capability
clavicular line. Ensure that the needle entry into the are available.

Tactical Combat Casualty Care Guidelines 161