Page 30 - 2022 Ranger Medic Handbook

Tactical Trauma Assessment
Patient Assessment
Follow TCCC Guidelines of Care Under Fire, Tactical Field Care, and Tactical Evacuation Care.
The acronym MARCH is recommended to guide the priorities in the Care Under Fire (control of life-threatening hemor-
rhage only) and Tactical Field Care phases:
Massive hemorrhage – control life-threatening bleeding.
SECTION 2 Respiration – decompress suspected tension pneumothorax, seal sucking chest wounds, and support ventilation/oxy-
Airway – establish and maintain a patent airway.
genation as required.
Circulation – establish IV/IO access and administer blood products as required to treat shock.
Head injury/Hypothermia – prevent/treat hypotension and hypoxia to prevent worsening of traumatic brain injury
and prevent/treat hypothermia.
TCCC Application
Care Under Fire: Return fire and take cover. Direct or expect casualty to remain engaged as a combatant if appropriate.
Direct casualty to move to cover and apply self-aid if able. Try to keep the casualty from sustaining additional wounds.
Casualties should be extricated from burning vehicles or buildings and moved to places of relative safety. Do what
is necessary to stop the burning process. Tactical patient assessment during this phase is limited to identifying life-
threatening hemorrhage in a rapid head-to-toe survey taking less than 10–15 seconds or as tactically feasible. Airway
management, other than positioning, is generally best deferred until the tactical field care phase. Stop life- threatening
external hemorrhage if tactically feasible with an approved tourniquet.
Tactical Field Care: Consolidate casualties in CCP. Initially, conduct triage to identify which patient needs attention
first and who can wait. Identify any life-threatening hemorrhage not already controlled. In this phase, the first priority is
to conduct a rapid trauma assessment. A more deliberate and traditional head-to-toe MARCH survey is completed on
each casualty after all life threats have been addressed. Casualties with an altered mental status should be disarmed im-
mediately, including communications equipment. Injuries are managed in a head-to-toe-treat-as-you-go manner. Triage
recurs during this entire phase. Delegate treatment of minor injuries to ARFRs or RFRs, freeing the Medic to focus on
more seriously injured. Provide instructions to ARFRs or RFRs if tasked to assist you with multi system trauma casualties.
Communicate casualty status and evacuation requirements to C2. Consolidate medical supplies in CCP. Prepare and
package casualties for evacuation.
Tactical Evacuation: After evacuation movement, reassess patient's mental status, airway, vital signs, and any
interventions.
Trauma Assessment Principles
Massive Hemorrhage: Obvious external sources of bleeding should be controlled with tourniquets, direct pressure, and
pressure dressings. Clamping of injured vessels is not indicated unless the bleeding vessel can be directly visualized.
Sources of internal hemorrhage should be identified. Initial tourniquets are to be placed “high and tight.” Effort should be
made to convert these as distally as possible or to a pressure dressing as soon as the tactical situation allows.
Airway: A conscious and spontaneously breathing patient rarely requires immediate airway intervention. If the patient
is able to talk normally, then his airway is intact. If the patient is semiconscious or unconscious, the tongue is the most
common source of airway obstruction. Patient positioning and airway adjuncts (NPA/OPA) should be the first choice to
maintain a patent airway. Ranger Medics train extensively in order to proficiently conduct a surgical cricothyroidotomy.
This should be the first choice for any patient requiring a definitive airway. Penetrating trauma causing C-spine fractures
is almost universally fatal. One should consider C-spine fracture in blunt trauma and take appropriate precautions.
Respirations: In the conscious patient, who is alert and breathing normally, no interventions are required. If the patient
has an appropriate mechanism of injury and signs of respiratory distress such as tachypnea, dyspnea, or cyanosis,
which may be associated with agitation or decreasing mental status, then a presumption of tension pneumothorax
management is indicated.
Circulation: Important information can be rapidly obtained regarding perfusion and oxygenation from the level of con-
sciousness, pulse, skin color, and capillary refill time. Decreased cerebral perfusion may result in an altered mental
status. Skin color and capillary refill will provide a rapid initial assessment of peripheral perfusion. Pink skin is a good sign
versus the ominous sign of white or ashen, gray skin depicting hypovolemia. Pressure to the thumb nail or hypothenar
eminence will cause the underlying tissue to blanch. In a normovolemic patient, the color returns to normal within 2 sec-
onds. In the hypovolemic, poorly oxygenated patient and/or hypothermic patient, this time period is extended or absent.
Head Injury/Hypothermia: Clothing and protective equipment such as helmets and body armor should only be re-
moved as required to evaluate and treat specific injuries. If the patient is conscious with a single extremity wound, only
the area surrounding the injury should be exposed. Unconscious patients may require more extensive exposure in order
to discover potentially serious injuries but must subsequently be protected from the elements and the environment.
Hypothermia is to be avoided in trauma patients. A brief neurological assessment should be performed, and LOC can be
described through, preferably, AVPU or, alternately, the Glasgow Coma Scale (GCS) method. If the pupils are found to
be sluggish or nonreactive to light with unilateral or bilateral dilation, one should suspect a head injury and/or inadequate
brain perfusion. Assess for any fractures or deformities of extremities or joints.
Vital Signs: Vital signs should be assessed frequently, especially after specific therapeutic interventions, and
before and after moving patients. As a group, Ranger patients are in excellent physical condition and may have
tremendous physiological reserves. They may not manifest significant changes in vital signs until they are in severe
shock. Technology can fail, and Ranger Medics must be capable of obtaining manual vital signs. EtCO 2 monitors
attached to a facemask are inaccurate; the trend is often more important than the number.
16 SECTION 2 PRIMARY TRAUMA PROTOCOLS