Page 174 - Journal of Special Operations Medicine - Summer 2015

TFC should have bilateral needle decompression per- development of a subsequent tension pneumothorax. If
formed to ensure they do not have a tension pneumotho- the casualty develops increasing hypoxia, respiratory
rax prior to discontinuation of care. The procedure is the distress, or hypotension and a tension pneumothorax is
same as described in section 3a above. suspected, treat by burping or removing the dressing or
19. Documentation of care by needle decompression.
Document clinical assessments, treatments rendered, and 3. Bleeding
changes in the casualty’s status on a TCCC Casualty Card a. Assess for unrecognized hemorrhage and control
(DD Form 1380). Forward this information with the ca- all sources of bleeding. If not already done, use a
sualty to the next level of care. CoTCCC-recommended limb tourniquet to control
life-threatening external hemorrhage that is anatomi-
cally amenable to tourniquet use or for any traumatic
Basic Management Plan for Tactical Evacuation Care
amputation. Apply directly to the skin 2–3 inches
*The term “Tactical Evacuation” includes both Casualty Evac- above the wound. If bleeding is not controlled with the
uation (CASEVAC) and Medical Evacuation ( MEDEVAC) as first tourniquet, apply a second tourniquet side-by-side
defined in Joint Publication 4-02. with the first.
1. Airway management b. For compressible hemorrhage not amenable to limb
a. Unconscious casualty without airway obstruction: tourniquet use or as an adjunct to tourniquet removal,
– Chin lift or jaw thrust maneuver use Combat Gauze as the CoTCCC hemostatic dress-
– Nasopharyngeal airway ing of choice. Celox Gauze and ChitoGauze may also

– Place casualty in the recovery position be used if Combat Gauze is not available. Hemostatic
b. Casualty with airway obstruction or impending airway dressings should be applied with at least 3 minutes
obstruction: of direct pressure. If the bleeding site is amenable to
– Chin lift or jaw thrust maneuver use of a junctional tourniquet, immediately apply a
– Nasopharyngeal airway CoTCCC-recommended junctional tourniquet. Do not
– Allow casualty to assume any position that best pro- delay in the application of the junctional tourniquet
tects the airway, to include sitting up. once it is ready for use. Apply hemostatic dressings
– Place unconscious casualty in the recovery position. with direct pressure if a junctional tourniquet is not
– If above measures unsuccessful: available or while the junctional tourniquet is being
– Supraglottic airway or readied for use.
– Endotracheal intubation or c. Reassess prior tourniquet application. Expose the
– Surgical cricothyroidotomy (with lidocaine if wound and determine if a tourniquet is needed. If it is,
conscious). replace any limb tourniquet placed over the uniform
c. Spinal immobilization is not necessary for casualties with one applied directly to the skin 2–3 inches above
with penetrating trauma. wound. Ensure that bleeding is stopped. When possible,
2. Breathing a distal pulse should be checked. If bleeding persists or
a. In a casualty with progressive respiratory distress and a distal pulse is still present, consider additional tighten-
known or suspected torso trauma, consider a tension ing of the tourniquet or the use of a second tourniquet
pneumothorax and decompress the chest on the side side-by-side with the first to eliminate both bleeding
of the injury with a 14-gauge, 3.25-inch needle/cath- and the distal pulse.
eter unit inserted in the second intercostal space at the d. Limb tourniquets and junctional tourniquets should be
midclavicular line. Ensure that the needle entry into the converted to hemostatic or pressure dressings as soon
chest is not medial to the nipple line and is not directed as possible if three criteria are met: the casualty is not
towards the heart. An acceptable alternate site is the in shock; it is possible to monitor the wound closely for
4th or 5th intercostal space at the anterior axillary line bleeding; and the tourniquet is not being used to con-
(AAL). trol bleeding from an amputated extremity. Every effort
b. Consider chest tube insertion if no improvement and/or should be made to convert tourniquets in less than 2
long transport is anticipated. hours if bleeding can be controlled with other means.
c. Most combat casualties do not require supplemental Do not remove a tourniquet that has been in place more
oxygen, but administration of oxygen may be of benefit than 6 hours unless close monitoring and lab capability
for the following types of casualties: are available.
– Low oxygen saturation by pulse oximetry e. Expose and clearly mark all tourniquet sites with
– Injuries associated with impaired oxygenation the time of tourniquet application. Use an indelible
– Unconscious casualty marker.
– Casualty with TBI (maintain oxygen saturation 4. Intravenous (IV) access
>90%) a. Reassess need for IV access.
– Casualty in shock – If indicated, start an 18-gauge IV or saline lock
– Casualty at altitude – If resuscitation is required and IV access is not ob-
d. All open and/or sucking chest wounds should be treated tainable, use intraosseous (IO) route.
by immediately applying a vented chest seal to cover the 5. Tranexamic acid (TXA)
defect. If a vented chest seal is not available, use a non- If a casualty is anticipated to need significant blood trans-
vented chest seal. Monitor the casualty for the potential fusion (for example: presents with hemorrhagic shock, one

164 Journal of Special Operations Medicine Volume 15, Edition 2/Summer 2015