Page 62 - JSOM Summer 2018

TABLE 1 Comparison of John Turner Caddy’s 1855 Injury and Treatment Guidelines, With Evolving Standards of Emergent TCCC
Urgency of prompt hemorrhage control
Caddy 1855 ‘There is high authority for stating “that a Maughon 1970 ‘Many of the 193 deaths due to wounds of the
large proportion of the killed in every great battle perish of extremities . . . might be alive today if the thought were firmly
haemorrhage. . . . embedded to staunch the flow of blood at all times . . .’
“In every wound, the bleeding demands the earliest attention; Bellamy 1984 ‘A cursory inspection reveals that a substantial
every other consideration may be deferred’. number of casualties . . . exsanguinated from arterial wounds at sites
where simple first aid measures . . . might have been able to control
hemorrhage, at least temporarily.’
Butler et al. 1996 ‘It is very important, however, to stop major
bleeding as quickly as possible, since injury to a major vessel may
result in the very rapid onset of hypovolemic shock. The importance
of this step requires emphasis in light of reports that hemorrhage from
extremity wounds was the cause of death in more than 2,500 casualties
in Vietnam who had no other injuries. These are preventable deaths.’
TCCC 2014 ‘A casualty may exsanguinate before any medical help
arrives, so the importance of achieving rapid, definitive control of life
threatening hemorrhage on the battlefield cannot be over-emphasized.’
Massive hemorrhage
Caddy 1855 ‘In conversation it has soon proclaimed itself, that Maughon 1970 ‘Control of hemorrhage depends on knowledge of
the prompt application of the tactile extremities of the fingers is arterial pressure points, how to apply a pressure dressing, and how and
far from being properly appreciated. If there be bleeding from a when to use a tourniquet’.
wound, the fingers of either hand should, without hesitation, be CFA, TCCC, TACMED 2011 ‘Stop major hemorrhage with pressure,
immediately and firmly placed against the bleeding part to stanch tourniquet and wound packing with hemostatic agent ‘
the sudden hemorrhage. . . . The bleeding from veins is generally to
be checked with a wetted compress and a bandage’. . . . TCCC 2014 ‘Use a CoTCCC-recommended tourniquet to control
life-threatening external hemorrhage that is anatomically amenable to
‘Every sailor has a tourniquet at hand in his clasp- knife and its tourniquet application. . . .”
laniard, and its application is easily to be learned. No man would,
by timely warning, neglect the necessary addenda of a compress ‘For compressible hemorrhage not amenable to tourniquet use or as
and bandage. . . .’ an adjunct to tourniquet removal. . . . Hemostatic dressings should be
applied with at least 3 minutes of direct pressure.’
Traumatic amputation
Caddy 1855 ‘If the arm or the leg be knocked off by a cannon- TCCC 2014 ‘use a CoTCCC-recommended tourniquet . . . for any
shot, &c., . . . . the broken limb should be immediately grasped by traumatic amputation.’
the hands, thus to restrain spasm, a tourniquet should be placed to
control the main artery of the thigh or upper arm. . . .’
Fractures
Caddy 1855 ‘If . . . the bones be fractured, with much laceration Butler et al 1996 ‘Fractures should be splinted as circumstances
of soft parts, the broken limb should be immediately grasped by allow, ensuring that peripheral pulses are checked both before and
the hands, thus to restrain spasm, a tourniquet should be placed to after splinting and that any decrease in the pulse caused by the splinting
control the main artery of the thigh or upper arm, and the lacerated is remedied by adjusting the position of splint.’
soft parts should be washed, and laid in as natural a position as TCCC 2014 Splint fractures and recheck pulse
possible, covered with wet linen.
. . . If the thigh or the lower leg be fractured, the bones must be
placed in position as nearly as possible approaching the direction
and appearance of the limb uninjured. . . .
If the patient has to be conveyed any considerable distance, splints
should be constructed of any material at hand; even a couple
of walking sticks, of sufficient length and firmness, may be no
contemptible substitute.’
Penetrating wounds
Caddy 1855 ‘In penetrating chest wounds, the patient should be Maughon 1970 ‘All individuals should be trained . . . to give
placed to lie on the wounded side, to give the sound lung the better emergency care to certain special wounds, such as sucking wounds
opportunity of acting . . . A large compress, firmly secured, should of the chest and jaw injuries which cause respiratory obstruction.’
be placed over penetrating wounds of the chest, to prevent the TCCC 2014 Maintain airway with chin lift/jaw thrust, NPA, airway
ingress of the external air. . . . recover position. Identify and decompress tension pneumothorax.
‘In penetrating belly wounds, any protruded intestine should be Apply occlusive dressing (with periodic venting) for sucking chest
cleaned of dirt, and returned and secured within the abdominal wounds.
walls by a compress and a wide roller, and the thighs should be [treatment of evisceration injuries not specifically mentioned]
bent on the belly.’
Shock and hypothermia
Caddy 1855 ‘. . . nervous symptoms, varying in degree according TCCC 2014 ‘Fluids by mouth are permissible if the casualty is
to the severity of the injury, and the previous health of the patient, conscious and can swallow’
may be treated with wine or spirit, and external heat to epigastrium IV fluid resuscitation is indicated for controlled hemorrhage with
and feet. shock.
These nervous symptoms, or the shock, are known by the paleness ‘Prevention of heat loss should start as soon after wounding as the
of the surface, the cold and clammy perspiration, faintness, tactical situation permits.’ Remedies include dry clothes, external
trembling, imperceptible pulse, mental confusion and alarm. . . . rewarming, and blanketing.
‘In wounds of the intestines, unless by sanction of a medical officer,
fluids are inadmissible.’
(continues)

60 | JSOM Volume 18, Edition 2/Summer 2018