Page 29 - JSOM Summer 2020

the Operational Command and ARSC team to make timely focus damage-control principles as the primary approach for
decisions to accomplish objectives and maximize critical care all surgical procedures, which minimizes time, resources, and
capabilities. personnel. This mindset and approach should be used for pa-
tient with traumatic injury and those without (e.g., appendici-
tis). There may be scenarios in which the ARSC team will be
Tactical Combat Casualty Care
the definitive level of care for host-nation patients; however
The TCCC guidelines are foundational knowledge for aus- decision-making is still constrained by resource availability
tere providers at all levels of training, and, as of 2019, TCCC and by operational mission requirements. 24
training is a requirement for all medical providers. Thorough
knowledge of current TCCC guidelines not only will help sur- In most cases, emergency surgery for acute surgical diseases
gical teams understand care provided at point of injury but (e.g., acute cholecystitis and appendicitis) that do not clini-
also provide battle-tested options for care that are appropriate cally require a damage-control strategy should be temporized
in austere environments, even for surgical teams. A thorough with antibiotics and expeditiously transferred to a higher level
understanding of tourniquets, their associated complications, of care. If operational considerations require patients be held
and recommendations for conversion to pressure dressings longer than 24 hours, or if the patient presents with sepsis
and removal in the austere environment is fundamental to or hemodynamic instability due to an intraabdominal source,
TCCC and is not common knowledge for providers without surgery may be indicated.
prior tactical medical experience. TCCC airway management,
pain management, and resuscitation recommendations have For elective or semi-urgent cases, the evacuation chain should
been implemented with a high degree of success. be used in communication with the operational commander
and the theater trauma director. Give the significant resource
Mass casualty (MASCAL) scenarios are especially challenging limitations, only true emergencies should be considered at this
in resource-limited environments. A few casualties can quickly level of care.
turn into a MASCAL for the austere team. Mastery of the con-
cepts of TCCC will save lives in this setting. 17–23 Principles of Anesthesia and Intraoperative Monitoring
dynamic triage must be used during all phases of care, includ-
ing intraoperatively, and not be limited to the initial evalua- Delivering safe anesthesia in the austere environment must
tion. Proper triage results in the greatest good for the greatest account for available medical capabilities and the tactical
13
number. This cannot be overstated. The burden of these deci- situation.
sions is heavy. Redundancy in triage and clinical skills is espe-
cially necessary for ARSC teams given that they do not have all Patient Monitoring
the resources of a standard Role 2 and because every member Monitoring under anesthesia ideally includes understanding
will be task saturated. Realistic, challenging MASCAL and tri- normal physiology of a patient and using your hands and eyes
age scenarios should be trained during predeployment to work to monitor your patient. Adjuncts in this environment are ad-
through difficult decisions based on limited resources. ditional cardiac monitoring, blood pressure, pulse oximetry,
temperature, and, for a patient receiving ventilatory support,
Austere teams should maximize the use of limited resources inspired oxygen analysis and end-tidal carbon dioxide (Etco )
2
by restricting surgical interventions to damage control only, measurement. A range of devices are available to monitor
25
particularly when evacuation timelines are short. When evac- vital signs with minimal space and maintenance. However,
uation timelines are delayed, more definitive or repeated sur- honing clinical skills to manually assess vital signs is import-
geries may be required. For example, a vascular shunt may ant because monitoring devices may not always be available.
temporize arterial injury, but when evacuation is delayed
beyond 24 hours, definitive vascular reconstruction or am- Etco : Etco monitoring is an important capability as a phys-
2
2
putation may be indicated. When transferring patients to a iologic indicator, even at the initial levels of care. The Etco
2
host-nation facility, the capability for definitive surgical care value is relevant during resuscitation and in patients with trau-
may be absent or unknown. This highlights the wide and com- matic brain injury, in addition to its established role in veri-
plex spectrum of clinical care in the austere setting and em- fying airway placement and monitoring ventilation. Under
25
phasizes the importance of understanding time and distance to controlled ventilation, the Etco level can also be used to esti-
2
the next level of care with a clear knowledge of the transport mate changes in cardiac index or cardiac output over time.
26
capability and the receiving facility’s capability. This knowledge can be applied within the clinical context and
can be used in cardiopulmonary resuscitation to predict pa-
When evacuation is delayed and patients are held by a surgical tients who are more likely to achieve return of spontaneous
team after the initial resuscitative care, the surgeon must weigh circulation (Etco pressure >10mmHg). As such, knowing
26
2
the risks of definitive surgery against the risks of ischemia and the Etco can be useful during triage.
2
infection. There are currently not enough outcome data avail-
able to make firm recommendations for patients being treated Ultrasound: The presence of sonographically identified car-
for longer than 72 hours in an austere environment. diac activity at any point during trauma bay or intraoperative
resuscitation is associated with increased survival to hospital
admission. 27
Damage Control Procedures
ARSC teams exist for unstable patients who cannot tolerate Invasive pressure monitoring: Small in-line devices (e.g.,
transport to a Role 2 (or next level of care); their function in Centurion Compass ; Centurion Medical Products, http://
®
the battlefield continuum of care is for the provision of early compass.centurionmp.com/) have been used successfully for
damage-control resuscitation and surgery. ARSC teams should monitoring aortic occlusion during resuscitative endovascular
Austere Resuscitative and Surgical Care Guidelines | 27