Page 20 - 2022 Spring JSOM

Prolonged Casualty Care Guidelines

21 December 2021

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Michael Remley, USA, NRP ; Paul Loos, SO-ATP ; Dan S. Mosely III, MD ; Jamie Riesberg, MD *
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Prolonged Casualty Care Background The guidelines are a consolidated list of casualty-centric knowledge,
skills, abilities, and best practices are the proposed standard of care
Prolonged Casualty Care (PCC) for developing and sustaining DoD programs required to enhance
The need to provide patient care for extended periods of time when confidence, interoperability, and common trust among all PCC-adept
evacuation or mission requirements surpass available capabilities and/ personnel across the Joint force.
or capacity to provide that care.
The JTS CPGs are foundational to the PCC guidelines and will be
The PCC guidelines are a consolidated list of casualty-centric knowl- referenced throughout this document in an effort to keep these guide-
edge, skills, abilities, and best practices intended to serve as the DoD lines concise. General information on the Joint Trauma System is
baseline clinical practice guidance (CPG) to direct casualty manage- available on the JTS website
ment over a prolonged period of time in austere, remote, or expedi- (https://jts.amedd.army.mil) MARC H -PAWS-L
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tionary settings, and/or during long-distance movements. These PCC and links to all of the CPGs Massive Hemorrhage/MASCAL
guidelines build upon the DoD standard of care for non- medical and are also available by using
medical first responders as established by the Committee on Tactical the following link: https://jts. Airway
Combat Casualty Care (CoTCCC), outlined in the Tactical Combat amedd.army.mil/index.cfm/ Respirations
Casualty Care (TCCC) guidelines, and in accordance with (IAW) PI_CPGs/cpgs. Circulation
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DoDI 1322.24. Communication
The TCCC guidelines are in- Hypothermia/Hyperthermia
The guidelines were developed by the PCC Work Group (PCC WG). cluded in these guidelines as Head Injury
The PCC WG is chartered under the Defense Committee on Trauma an attachment because they Pain Control
(DCoT) to provide subject matter expertise supporting the Joint are foundational AND pre- Antibiotics
Trauma System (JTS) mission to improve trauma readiness and out- requisite to effective PCC. Wounds (+ Nursing/Burns)
comes through evidence-driven performance improvement. The PCC Remember, the primary goal Splinting
WG is responsible for reviewing, assessing, and providing solutions in PCC is to get out of PCC!!! Logistics
for PCC- related shortfalls and requirements as outlined in DoD In-
struction (DoDI) 1322.24, Medical Readiness Training, 16 Mar 2018, PCC Principles
under the authority of the JTS as the DoD Center of Excellence pursu- The principles and strategies of providing effective prolonged casualty
ant to DoDI 6040.47, JTS, 05 Aug 2018.
care are meant to help organize the overwhelming amount of critical
Operational and medical planning should seek to avoid categorizing information into a clear clinical picture and proactive plan regardless
PCC as a primary medical support capability or control factor during of the nature of injury or illness. The following steps can be imple-
deliberate risk assessment; however, an effective medical plan always mented in any austere environment from dispersed small team oper-
includes PCC as a contingency. Ideally, forward surgical and critical ations in permissive environments to large scale combat operations to
care should be provided as close to casualties as possible to optimize make the care of a critically ill patient more efficient for the medic and
survivability. DoD units must be prepared for medical capacity to their team. These mimic the systems and processes in typical intensive
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be overwhelmed, or for medical evacuation to be delayed or com- care units without relying on technology while leaving the ability to
promised. When contingencies arise, commanders’ casualty response add technological adjuncts as they become available. The following
plans during PCC situations are likely to be complex and challeng- checklist is meant to emphasize some of the most important principles
ing. Therefore, PCC planning, training, equipping, and sustainment in efficient care of the critically ill patient (see Figure 1).
strategies must be completed prior to a PCC event. The following ev- 1. Perform initial lifesaving care using TCCC guidelines and continue
idence-driven PCC guidelines are designed to establish a systematic resuscitation.
framework to synchronize critical medical decisions points into an The foundation of good PCC is mastery of TCCC and a strong
executable PCC strategy, regardless of the nature of injury or illness, foundation in clinical medicine.
to effectively manage a complex patient and to advise commanders of 2. Delineate roles and responsibilities, including naming a team leader.
associated risks. A leader should be appointed who will manage the larger clinical
picture while assistants focus on attention intensive tasks.
The guidelines build upon the accepted TCCC categories framed in 3. Perform comprehensive physical exam and detailed history with
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the novel MARC H -PAWS-L treatment algorithm, (Massive Hemor- problem list and care plan.
rhage/MASCAL, Airway, Respirations, Circulation, Communications, After initial care and stabilization of a trauma or medical patient,
Hypo/Hyperthermia and Head Injuries, Pain Control, Antibiotics, a detailed physical exam and history should be performed for the
Wounds (including Nursing and Burns), Splinting, Logistics). purpose of completing a comprehensive problem list and corre-
The PCC guidelines prepare the Service Member for “what to consider sponding care plan.
next” after all TCCC interventions have been effectively performed 4. Record and trend vital signs.
and should only be trained after having mastering the principles and Vital signs trending should be done with the earliest set of vital signs
techniques of TCCC. taken and continued at regular intervals so that the baseline values
can be compared to present reality on a dedicated trending chart.
*Correspondence to jamie.c.riesberg.mil@army.mil
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1 MSG Michael Remley is affiliated with the US Army. Paul Loos, SO-ATP, and COL Jamie Riesberg are affiliated with the Defense Committee
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on Trauma Prolonged Casualty Care Working Group. Dr Dan S. Mosely III is associated with the Joint Trauma System.
† Section lead authors are listed within the section titles; see complete list of authors on page 47.
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