Page 16 - JSOM Summer 2022

radial pulse and is in severe pain. The amount of bleed- explosion occurred, but was struggling to stay on the
ing observed calls for a tourniquet to be applied to the surface of the water without a flotation device. He is
leg. This would ideally have been done by a fellow crew now awake and has no external hemorrhage, but is in
member as soon as the bleeding was noted, since all of moderate respiratory distress. His oxygen saturation is
the crew members are trained to be Tier 1 (All Combat- 62% without supplemental oxygen. There is no sub-
ant) TCCC first responders and tourniquets are present cutaneous emphysema. His breath sounds are present
in the TCCC First Aid Boxes at all Watch Stations. In but diminished bilaterally.
this case, however, no tourniquet has yet been applied to
the bleeding extremity, and his weak, rapid pulse indi- Immediate Actions That Should Be Undertaken by the
cates that he is beginning to go into shock. IDC and the Junior Corpsman
o Casualty 2 is a burn casualty with approximately 50% Casualty 1
Total Body Surface Area (TBSA) partial and full thick- – Since bleeding from the injured extremity is ongoing and
ness burns. The burns are located over most of the pos- life-threatening, this casualty should have a tourniquet ap-
terior surface of his body, with no circumferential burns plied high on the bleeding leg, over his uniform trousers,
noted and strong distal pulses in all extremities. There and tightened until the bleeding has been stopped.
is no external hemorrhage or indication of penetrating – Intravenous (IV) or intraosseous (IO) access should be
injury. There are no facial burns, there is no soot around established.
his mouth, hoarseness, or respiratory distress. He is alert, – The casualty should receive 2g of TXA slow IV or IO push
able to speak clearly, and states that he is in severe pain. since he is in shock.
o Casualty 3 arrives on a litter, conscious but confused.
There is no external hemorrhage and no evidence of Casualty 3 also has life-threatening hemorrhage, but hers is
head trauma. She indicates that she has severe pain in abdominopelvic and noncompressible.
her back, her right hip, and her right leg. She is noted to – Cutting away her trousers reveals an 8-inch contused area
have marked tenderness to palpation in the painful areas adjacent to her right sacroiliac joint and right iliac crest.
of her hip and leg. Her radial pulse is rapid and weak. She has marked tenderness to palpation at that location.
o Casualty 4, who had previously been unconscious im- – This casualty should have a pelvic binder applied imme-
20
mediately following the blast, has suffered tertiary and diately. Since pelvic binders are not yet in the AMAL for
possibly primary blast injury. He is now conscious and this class of ship, the IDC will need to improvise a pelvic
speaking, but is confused and is unable to follow com- binding device, as taught in the TCCC course.
mands. His fronto-temporal scalp laceration is bleeding – The next treatment that should be provided is to establish
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briskly. He has no other external bleeding, does not in- IV or IO access and administer 2g of TXA slow IV push.
dicate any other areas of pain, and has a strong radial TXA is in the medical allowance list for destroyers, but
pulse. only as a single 1g dose. Surface fleet medical directors
o Casualty 5 is awake and stating that she is in moderate should consider making larger quantities of this important
pain. Her clothes are largely burned off. On examina- medication available on Naval vessels within their purview.
tion, she has extensive burns, a mixture of full thickness – Resuscitation with Type O whole blood should also be ini-
and partial thickness in severity, that are estimated to tiated as soon as possible.
cover 90% of her body. She is in less pain than casualty – Also, since this casualty sustained her pelvic and leg injuries
#2 who has much less extensive TBSA burned. She has from a fall, the possibility of cervical and spinal injuries
facial burns, and appears to be in mild respiratory dis- should be considered, and she should have a cervical collar
tress, and has stridor. applied and spinal protection measures should be initiated.
o Casualty 6 was recovered from the water with his life Casualty 4 has external bleeding from the scalp.
jacket on. He was observed to be fully conscious, float- – The scalp bleeding should be addressed with an ITClamp
ing upright and talking prior to the in-water explosion, and possibly Combat Gauze. 22
but became unconscious immediately after that explo- – He also has significant TBI (as indicated by his inability to
sion. He was still unconscious on arrival at the hangar follow commands), so establishing IV or IO access and ad-
bay, but soon regains consciousness. His speech, how- ministering 2g of TXA via slow push is the next priority.
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ever, is slurred and he is not able to move his right arm As noted by Drew et al: “An inability to follow commands,
and right leg. He is also noted to have subcutaneous which represents a GCS motor score of 5 or less, is an effi-
emphysema, moderate respiratory distress, and absent cient way to determine the threshold for TXA administra-
breath sounds on the right side of his chest. tion in the prehospital setting.” 21
o Casualty 7 was recovered from the water after having – Also, since this casualty has sustained a blunt trauma
been exposed to the underwater blast. He is awake tertiary blast injury, the possibility of cervical and spinal
and alert without external hemorrhage or respiratory injuries should be considered. He should have a cervical
distress, but is voicing moderate abdominal pain. The collar applied and spinal protection measures should be
radial pulses are strong but his abdomen is somewhat initiated.
tender to palpation.
o Casualty 8 was recovered from the water after having Casualty 5 has extensive burns, including likely airway burns
been exposed to the underwater blast. He is awake and and is showing signs of airway compromise, likely from a
has no external hemorrhage, but is in moderate respira- combination of thermal injury to airway and possible inhala-
tory distress. His oxygen saturation is 71% without sup- tional injury. Her hemoglobin oxygen saturation is 80%.
plemental oxygen. Breath sounds are present bilaterally. – She should have a surgical airway performed as soon as
o Casualty 9 was recovered from the water without a life feasible. Obtaining an airway is potentially lifesaving if
jacket; he was NOT in the water when the underwater there is thermal injury to airways and airway obstruction

14 | JSOM Volume 22, Edition 2 / Summer 2022