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reinforces that a casualty’s airway status may change over time RS, Littlejohn LF, Martin MJ, Mazuchowski EL, Otten EJ,
and that he or she should be frequently reassessed. Polk T, Rhee P, Seery JM, Stockinger Z, Torrisi J, Yitzak A,
Zafren K, Zietlow SP
Keywords: extraglottic airway; i-gel; TCCC; Tactical Combat
Casualty Care; guidelines ABSTRACT: This change to the Tactical Combat Casualty
Care (TCCC) Guidelines that updates the recommendations
2017;17(4):80–84 for management of suspected tension pneumothorax for com-
Efficacy of the Mnemonic Device “MARCH PAWS” as a bat casualties in the prehospital setting does the following
Checklist for Pararescuemen During Tactical Field Care and things: (1) Continues the aggressive approach to suspecting
Tactical Evacuation Kosequat J, Rush SC, Simonsen I, Gallo and treating tension pneumothorax based on mechanism of
I, Scott A, Swats K, Gray CC, Mason B injury and respiratory distress that TCCC has advocated for
in the past, as opposed to waiting until shock develops as a
ABSTRACT: Background: The application of Tactical Com- result of the tension pneumothorax before treating. The new
bat Casualty Care (TCCC) represents evidence-based medicine wording does, however, emphasize that shock and cardiac
to improve survival in combat. Over the past several years, US arrest may ensue if the tension pneumothorax is not treated
Air Force Pararescuemen (PJs) have expanded the mnemonic promptly. (2) Adds additional emphasis to the importance
device “MARCH” to “MARCH PAWS” for use during tactical of the current TCCC recommendation to perform needle de-
field care and tactical evacuation (TACEVAC). The mnemonic compression (NDC) on both sides of the chest on a combat
stands for massive bleeding, airway, respiration, circulation, casualty with torso trauma who suffers a traumatic cardiac
head and hypothermia, pain, antibiotics, wounds, and splint- arrest before reaching a medical treatment facility. (3) Adds
ing. We undertook this performance improvement project to a 10-gauge, 3.25-in needle/ catheter unit as an alternative to
determine the efficacy of this device as a treatment checklist. the previously recommended 14-gauge, 3.25-in needle/cathe-
Methods: The mission reports of a 16-PJ combat rescue de- ter unit as recommended devices for needle decompression. (4)
ployment to Operation Enduring Freedom (OEF) from Jan- Designates the location at which NDC should be performed as
uary through June 2012 were reviewed. The triage category, either the lateral site (fifth intercostal space [ICS] at the ante-
mechanism of injury, injury, and treatments were noted. The rior axillary line [AAL]) or the anterior site (second ICS at the
treatments were then categorized to determine if they were in- midclavicular line [MCL]). For the reasons enumerated in the
cluded in MARCH PAWS. Results: The recorded data for mis- body of the change report, participants on the 14 December
sions involving 465 patients show that 45%, 48%, and 7%, 2017 TCCC Working Group teleconference favored including
were in category A, B, and C, respectively (urgent, priority, both potential sites for NDC without specifying a preferred
routine); 55% were battle injuries (BIs) and 45% were non- site. (5) Adds two key elements to the description of the NDC
battle injuries (NBIs). All treatments for BI were accounted for procedure: insert the needle/catheter unit at a perpendicular
in MARCH PAWS. Only 9 patients’ treatments with NBI were angle to the chest wall all the way to the hub, then hold the
not in MARCH PAWS. Conclusion: This simple mnemonic needle/catheter unit in place for 5 to 10 seconds before remov-
device is a reliable checklist for PJs, corpsmen, and medics to ing the needle in order to allow for full decompression of the
perform TACEVAC during combat Operations, as well as care pleural space to occur. (6) Defines what constitutes a success-
for noncombat trauma patients. ful NDC, using specific metrics such as: an observed hiss of air
Keywords: Tactical Combat Casualty Care; survival; Parares- escaping from the chest during the NDC procedure; a decrease
cuemen; mnemonic; MARCH PAWS; tactical field care; tac- in respiratory distress; an increase in hemoglobin oxygen sat-
tical evacuation uration; and/or an improvement in signs of shock that may
be present. (7) Recommends that only two needle decompres-
2018;18(1):15–18 sions be attempted before continuing on to the “Circulation”
(Case Reports) Military Prehospital Use of Low Titer Group portion of the TCCC Guidelines. After two NDCs have been
O Whole Blood Warner N, Zheng J, Nix G, Fisher AD, John- performed, the combat medical provider should proceed to the
son JC, Williams JE, Northern DM, Hellums JS fourth element in the “MARCH” algorithm and evaluate/treat
the casualty for shock as outlined in the Circulation section
ABSTRACT: The military’s use of whole-blood transfusions is of the TCCC Guidelines. Eastridge’s landmark 2012 report
not new but has recently received new emphasis by the Tactical documented that noncompressible hemorrhage caused many
Combat Casualty Care Committee. US Army units are imple- more combat fatalities than tension pneumothorax. Since
1
menting a systematic approach to obtain and use whole blood the manifestations of hemorrhagic shock and shock from
on the battlefield. This case report reviews the care of the first tension pneumothorax may be similar, the TCCC Guidelines
patient to receive low titer group O whole blood (LTOWB) now recommend proceeding to treatment for hemorrhagic
transfusion, using a new protocol. shock (when present) after two NDCs have been performed.
Keywords: blood transfusion; group O whole blood; Tactical (8) Adds a paragraph to the end of the Circulation section of
Combat Casualty Care the TCCC Guidelines that calls for consideration of untreated
tension pneumothorax as a potential cause for shock that
2018;18(2):19–35 has not responded to fluid resuscitation. This is an import-
Management of Suspected Tension Pneumothorax in Tacti- ant aspect of treating shock in combat casualties that was not
presently addressed in the TCCC Guidelines. (9) Adds finger
cal Combat Casualty Care: TCCC Guidelines Change 17-02 thoracostomy (simple thoracostomy) and chest tubes as addi-
Butler FK, Holcomb JB, Shackelford S, Montgomery HR, An- tional treatment options to treat suspected tension pneumo-
derson S, Cain JS, Champion HR, Cunningham CW, Dorlac thorax when further treatment is deemed necessary after two
WC, Drew B, Edwards K, Gandy JV, Glassberg E, Gurney J, unsuccessful NDC attempts-if the combat medical provider
Harcke T, Jenkins DA, Johannigman J, Kheirabadi BS, Kotwal
has the skills, experience, and authorizations to perform these

22 | JSOM Volume 20, Edition 4 / Winter 2020