Google Analytics Alternative

Ok

En poursuivant votre navigation sur ce site, vous acceptez l'utilisation de cookies. Ces derniers assurent le bon fonctionnement de nos services. En savoir plus.

13/11/2015

TCCC: Point 2015

tactical-combat-casualty-care-update-2015-1-638.jpg?cb=1422642471

Clic sur l'image pour accéder au document

| Tags : tccc

15/07/2015

Bilan US Afghanistan

 

CT report 2014.jpg

Clic sur l'image pour accéder au document complet

Le résumé:

Introduction

The U.S. has achieved unprecedented survival rates, as high as 98%, for casualties arriving alive to the combat hospital. Our military medical personnel are rightly proud of this achievement. Commanders and service members are confident that if wounded and moved to a Role II or III medical facility, their care will be the best in the world. Combat casualty care however, begins at the point of injury and continues through evacuation to those facilities. With up to 25% of deaths on the battlefield being potentially preventable, the pre-hospital environment is the next frontier for making significant further improvements in battlefield trauma care. Strict adherence to the evidence-based Tactical Combat Casualty Care (TCCC) Guidelines has been proven to reduce morbidity and mortality on the battlefield. However, full implementation across the entire force and commitment from both line and medical leadership continue to face ongoing challenges. This report on pre-hospital trauma in the Combined Joint Operations Area – Afghanistan (CJOA-A) is a follow-on to the one previously conducted in November 2012 and published in January 2013. Both assessments were conducted by the US Central Command (USCENTCOM) Joint Theater Trauma System (JTTS). Observations for this report were collected from December 2013 to January 2014 and were obtained directly from deployed prehospital providers, medical leaders, and combatant leaders. Significant progress has been made between these two reports with the establishment of a Pre-Hospital Care Division within the JTTS; development of a pre-hospital trauma registry and weekly pre-hospital trauma conferences; and CJOA-A theater guidance and enforcement of pre-hospital documentation. Specific pre-hospital trauma care achievements include expansion of transfusion capabilities forward to the point of injury, junctional tourniquets, and universal approval of tranexamic acid. CHANGING OLD PARADIGMS “Treat for shock, but do not waste any time doing it.” Fleet Marine Forces Manual “A tourniquet is a last resort for life-threatening Injuries. Tourniquets cut off blood flow to and from the extremity and are likely to cause permanent damage to vessels, nerves, and muscles.” AMEDDC&S Pamphlet No. 350-10 Saving Lives on the Battlefield (Part II) - One Year Later Unclassified 3 Unclassified

Observations & Discussion

TCCC Guidelines are widely, though not universally, accepted as Authoritative “best practices” for pre-hospital trauma care; however, they are not Directive policy. The high degree of variance amongst deployed unit medical personnel, both in terms of clinical training and operational experience, results in inconsistent application and enforcement of TCCC compliance across the force. Since our line commanders are dependent upon their unit medical personnel to inform their understanding, appreciation, and prioritization of medical support requirements, their TCCC commitment and command emphasis understandably varies as well. In the face of near-term resource constraints, without doctrinal and policy endorsement, the Services will continue to struggle to adequately and fully Organize, Train, and Equip to meet TCCC Guidelines as the standard for pre-hospital care. A previous memorandum and recommendation by the Assistant Secretary of Defense for Health Affairs to train all combatants and deployed medical personnel in TCCC remains incompletely implemented across the DoD. In contrast, US Special Operations Command (USSOCOM) and US Army Special Operations Command (USASOC) have codified TCCC compliance as policy and reduced pre-hospital case fatality rates. We must continue to embrace and explore emerging capabilities to deliver far-forward resuscitative care. Those capabilities that are both responsive and adaptive to the dynamic tactical landscape hold the greatest intrinsic value for our line commanders and their personnel. We must also ensure that our supporting Organize, Train, and Equip functions have the agility to keep pace with these evolving standards of care. We must increase the investment in our medical personnel to develop and retain true expertise in pre-hospital trauma care delivery and oversight. These must become core competencies in the unique domain of operational medical support and we must embrace new medical training paradigms that advance these skills. Finally, officer professional development for both line and medical leaders must emphasize the shared responsibilities for developing and enforcing robust unit commitment to lifesaving pre-hospital trauma care principles.

Findings

1.The lack of standardized TCCC capability may represent a causal factor for the increased killed in action, case fatality rate, and preventable deaths seen in conventional forces when compared to special operations forces. 2. Absent a validated joint requirement which is captured doctrinally, the prevailing resourceconstrained environment will challenge Services to fully Organize, Train, and Equip to TCCC standards. Saving Lives on the Battlefield (Part II) - One Year Later Unclassified 4 Unclassified 3. There is no evidence that the DoD or CJOA-A has policies or procedures in place to validate or enforce pre-hospital care within an organization. Service-specific doctrine requiring Unit Surgeons to each establish a standard of care, allows for variant, non-standard delivery of battlefield trauma care across the force. Furthermore, even within a single command, rotation of Unit Surgeons introduces and magnifies discontinuity of unit trauma care standards. 4. The requirements to perform and support pre-hospital TCCC could be standardized across Services (universally or at the Combatant Command level) with the specific means to achieve these Train & Equip standards left up to the respective Services. 5. As with elements of pre-hospital care, organization structures are highly variant with a number of at-risk forces not having adequately manned/trained/equipped medical support. 6. Units with a tactical evacuation mission requirement should be task organized to be able to provide advanced enroute resuscitative care from the point of injury. 7. Robust training platforms exist for pre-hospital trauma care, though not all course training syllabi keep pace with current best practices. Sufficient information technologies exist to rapidly and widely disperse new TCCC Guidelines as they become immediately available. 8. Unit equipment sets and supporting medical logistics systems have not kept pace with evolving pre-hospital care TCCC guidelines. Out-dated items remain within the supply chain and newly required items have not yet been incorporated into standard configurations. 9. In the absence of a widely mandated policy that establishes TCCC Guidelines as the standard for pre-hospital battlefield care, and accountability for deviations from this standard, the degree of penetrance and acceptance of TCCC Guidelines will remain episodic and dependent upon individual (Surgeon and commander) commitment. 10. Neither line nor operational medical leaders are optimally prepared to recognize the importance of a robust, pre-hospital care system, or equipped with the requisite knowledge, skills, or experience to build or sustain such a system within their unit.

New Recommendations

1. DoD establishes TCCC Guidelines as the DoD standard of care for pre-hospital care. 2. DoD conducts a DOTMLPF-P assessment across Services to assess and implement TCCC Guideline capability. 3. DoD systematically review and correct all pre-hospital care doctrine across the spectrum to accurately represent TCCC Guidelines with the doctrine specifically stating “in accordance with Saving Lives on the Battlefield (Part II) - One Year Later Unclassified 5 Unclassified the current TCCC Guidelines published by the Committee on Tactical Combat Casualty Care” to ensure that the doctrine remains current. 4. Services immediately implement an aggressive transition initiative to update all relevant medical equipment sets and medical logistic policies to ensure units have TCCC Guideline specified medical materials. 5. DoD establishes a Battlefield Pre-Hospital Trauma Care Program Proponent (or equivalent structure) in the DHA. 6. DoD develop and mandate a TCCC Accreditation, Certification, and Recertification program like Basic Life Support, Advanced Trauma Life Support, and Advanced Cardiac Life Support for all military personnel with a requirement for biannual re-certification and as based on level of ability and position (e.g. Non-Medical First Responder, Non-Medical Leader, Medical Provider, Medical Leader). 7. Services require and track TCCC certification for all pre-hospital medical personnel and integrate tracking into combatant Unit Status Reports. 8. Services incorporate TCCC Champion training into all basic and advanced officer and noncommissioned officer professional military development courses. 9. Services incorporate and mandate casualty management and hands on practical exercises into all professional military development courses. 10. DoD updates the Joint Capability Requirement for Tactical Enroute Care to include the ability to provide advanced resuscitative care from the point of injury. 11. As military physicians are ultimately responsible for assuming the role of EMS Director for pre-hospital services if assigned to a combatant unit, the military Services should study and develop career, educational and assignment tracks for operational medical corps officers which includes emphasis upon pre-hospital care delivery.

Conclusion

History teaches that the lessons we have learned regarding combat casualty care may be lost if we fail to attend to them in the coming years. Even in a resource-constrained future, the MHS has the necessary raw materials of personnel, organization, and experience to retain and refine our current best practices. With continued efforts aimed at 1) formalizing TCCC Guideline compliance across the force; 2) embracing evidence-based methods to continually improve upon these Guidelines; and 3) selecting, developing and retaining operational medical personnel dedicated to pre-hospital trauma care, the MHS will ensure an organizational culture that fully embraces pre-hospital combat casualty care as a core competency.

 

| Tags : tccc

10/07/2015

Le point sur la réalité du TCCC US

Saving Lives on the Battlefield I.jpg

clic sur l'image pour accéder au document

14/10/2014

TCCC Mise à jour 06/2014

Tactical Combat Casualty Care Guidelines

2 June 2014

(Includes all changes through #14-01)

 

These recommendations are intended to be guidelines only and are not a substitute for clinical judgment.

  

Basic Management Plan for Care Under Fire

 

  1. Return fire and take cover.

  2. Direct or expect casualty to remain engaged as a combatant if appropriate.

  3. Direct casualty to move to cover and apply self-aid if able.

  4. Try to keep the casualty from sustaining additional wounds.

  5. 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.

  6. Airway management is generally best deferred until the Tactical Field Care phase.

  7. Stop life-threatening external hemorrhage if tactically feasible:

  • Direct casualty to control hemorrhage by self-aid if able.

  • Use a CoTCCC-recommended tourniquet for hemorrhage that is anatomically amenable to tourniquet application.

  • Apply the tourniquet proximal to the bleeding site, over the uniform, tighten, and move the casualty to cover.

Basic Management Plan for Tactical Field Care

 

  1. Casualties with an altered mental status should be disarmed immediately.

  2. Airway Management

    1. Unconscious casualty without airway obstruction:

      • Chin lift or jaw thrust maneuver

      • Nasopharyngeal airway

      • Place casualty in the recovery position

    2. Casualty with airway obstruction or impending airway obstruction:

      • Chin lift or jaw thrust maneuver

      • Nasopharyngeal airway

      • Allow casualty to assume any position that best protects the airway, to include sitting up.

      • Place unconscious casualty in the recovery position.

      • If previous measures unsuccessful:

      • Surgical cricothyroidotomy (with lidocaine if conscious)

  1. Breathing

a. In a casualty with progressive respiratory distress and known or suspected torso trauma, consider a tension pneumothorax and decompress the chest on the side of the injury with a 14-gauge, 3.25 inch needle/catheter unit inserted in the second intercostal space at the midclavicular line. Ensure that the needle entry into the chest is not medial to the nipple line and is not directed towards the heart. An acceptable alternate site is the 4th or 5th intercostal space at the anterior axillary line (AAL).

  1. All open and/or sucking chest wounds should be treated by immediately applying a vented chest seal to cover the defect. If a vented chest seal is not available, use a non-vented chest seal. Monitor the casualty for the potential development of a subsequent tension pneumothorax. If the casualty develops increasing hypoxia, respiratory distress, or hypotension and a tension pneumothorax is suspected, treat by burping or removing the dressing or by needle decompression.

  2. Casualties with moderate/severe TBI should be given supplemental oxygen when available to maintain an oxygen saturation > 90%.

4. Bleeding

a. Assess for unrecognized hemorrhage and control all sources of bleeding. If not already done, use a CoTCCC-recommended tourniquet to control life-threatening external hemorrhage that is anatomically amenable to tourniquet application or for any traumatic amputation. Apply directly to the skin 2-3 inches above wound.

b. For compressible hemorrhage not amenable to tourniquet use or as an adjunct to tourniquet removal (if evacuation time is anticipated to be longer than two hours), use Combat Gauze as the CoTCCC hemostatic dressing of choice. Celox Gauze and ChitoGauzemay also be used if Combat Gauze is not available. Hemostatic dressings should be applied with at least 3 minutes of direct pressure. Before releasing any tourniquet on a casualty who has been resuscitated for hemorrhagic shock, ensure a positive response to resuscitation efforts (i.e., a peripheral pulse normal in character and normal mentation if there is no traumatic brain injury (TBI). If the bleeding site is appropriate for use of a junctional tourniquet, immediately apply a CoTCCC-recommended junctional tourniquet. Do not delay in the application of the junctional tourniquet once it is ready for use. Apply hemostatic dressings with direct pressure if a junctional tourniquet is not available or while the junctional tourniquet is being readied for use.

c. Reassess prior tourniquet application. Expose wound and determine if tourniquet is needed. If so, replace tourniquet over uniform with another applied directly to skin 2-3 inches above wound. If a tourniquet is not needed, use other techniques to control bleeding.

d. When time and the tactical situation permit, a distal pulse check should be accomplished. If a distal pulse is still present, consider additional tightening of the tourniquet or the use of a second tourniquet, side-by-side and proximal to the first, to eliminate the distal pulse.

e. Expose and clearly mark all tourniquet sites with the time of tourniquet application. Use an indelible marker.

5. Intravenous (IV) Access

a. Start an 18-gauge IV or saline lock if indicated.

b. If resuscitation is required and IV access is not obtainable, use the intraosseous (IO) route.

 

6. Tranexamic Acid (TXA)

a. If a casualty is anticipated to need significant blood transfusion (for example; presents with hemorrhagic shock, one or more major amputations, penetrating torso trauma, or evidence of severe bleeding):

1. Administer 1 gram of tranexamic acid in 100 cc Normal Saline or Lactated Ringer’s as soon as possible but NOT later than 3 hours after injury.

2. Begin second infusion of 1 gm TXA after Hextend or other fluid treatment.

 

7. Fluid Resuscitation

a. The resuscitation fluids of choice for casualties in hemorrhagic shock, listed from most to least preferred, are: whole blood*; plasma, RBCs and platelets in 1:1:1 ratio*; plasma and RBCs in 1:1 ratio; plasma or RBCs alone; Hextend; and crystalloid (Lactated Ringers or Plasma-Lyte A).

b. Assess for hemorrhagic shock (altered mental status in the absence of brain injury and/or weak or absent radial pulse).

1. If not in shock:

- No IV fluids are immediately necessary.

- Fluids by mouth are permissible if the casualty is conscious and can swallow.

2. If in shock and blood products are available under an approved command or theater blood product administration protocol:

- Resuscitate with whole blood*, or, if not available

- Plasma, RBCs and platelets in a 1:1:1 ratio*, or, if not available

- Plasma and RBCs in 1:1 ratio, or, if not available;

- Reconstituted dried plasma, liquid plasma or thawed plasma alone or RBCs alone.

- Reassess the casualty after each unit. Continue resuscitation until a palpable radial pulse, improved mental status or systolic BP of 80-90 mmHg is present.

3. If in shock and blood products are not available under an approved command or theater blood product administration protocol due to tactical or logistical constraints:

- Resuscitate with Hextend, or if not available;

- Lactated Ringers or Plasma-Lyte A.

- Reassess the casualty after each 500 mL IV bolus.

- Continue resuscitation until a palpable radial pulse, improved mental status, or systolic BP of 80-90 mmHg is present.

- Discontinue fluid administration when one or more of the above end points has been achieved.

4. If a casualty with an altered mental status due to suspected TBI has a weak or absent peripheral pulse, resuscitate as necessary to restore and maintain a normal radial pulse. If BP monitoring is available, maintain a target systolic BP of at least 90 mmHg.

5. Reassess the casualty frequently to check for recurrence of shock. If shock recurs, recheck all external hemorrhage control measures to ensure that they are still effective and repeat the fluid resuscitation as outlined above.

 

* Neither whole blood nor apheresis platelets as these products are currently collected in theater are FDA-compliant. Consequently, whole blood and 1:1:1 resuscitation using apheresis platelets should be used only if all of the FDA-compliant blood products needed to support 1:1:1 resuscitation are not available, or if 1:1:1 resuscitation is not producing the desired clinical effect.

8. Prevention of Hypothermia

a. Minimize casualty’s exposure to the elements. Keep protective gear on or with the casualty if feasible.

b. Replace wet clothing with dry if possible. Get the casualty onto an insulated surface as soon as possible.

c. Apply the Ready-Heat Blanket from the Hypothermia Prevention and Management Kit (HPMK) to the casualty’s torso (not directly on the skin) and cover the casualty with the Heat-Reflective Shell (HRS).

d. If an HRS is not available, the previously recommended combination of the Blizzard Survival Blanket and the Ready Heat blanket may also be used.

e. If the items mentioned above are not available, use dry blankets, poncho liners, sleeping bags, or anything that will retain heat and keep the casualty dry.

f. Warm fluids are preferred if IV fluids are required.

9. Penetrating Eye Trauma

a. If a penetrating eye injury is noted or suspected:

1. Perform a rapid field test of visual acuity.

2. Cover the eye with a rigid eye shield (NOT a pressure patch.)

3. Ensure that the 400 mg moxifloxacin tablet in the combat pill pack is taken if possible and that IV/IM antibiotics are given as outlined below if oral moxifloxacin cannot be taken.

10. Monitoring

Pulse oximetry should be available as an adjunct to clinical monitoring. All individuals with moderate/severe TBI should be monitored with pulse oximetry. Readings may be misleading in the settings of shock or marked hypothermia.

 

11. Inspect and dress known wounds.

 

12. Check for additional wounds.

 

13. Analgesia on the battlefield should generally be achieved using one of three options:

Option 1

Mild to Moderate Pain

Casualty is still able to fight

- TCCC Combat pill pack:

- Tylenol - 650-mg bilayer caplet, 2 PO every 8 hours

- Meloxicam - 15 mg PO once a day

Option 2

Moderate to Severe Pain

Casualty IS NOT in shock or respiratory distress AND

Casualty IS NOT at significant risk of developing either condition

- Oral transmucosal fentanyl citrate (OTFC) 800 ug

- Place lozenge between the cheek and the gum

- Do not chew the lozenge

Option 3

Moderate to Severe Pain

Casualty IS in hemorrhagic shock or respiratory distress OR

Casualty IS at significant risk of developing either condition

- Ketamine 50 mg IM or IN

Or

- Ketamine 20 mg slow IV or IO

 

* Repeat doses q30min prn for IM or IN

* Repeat doses q20min prn for IV or IO

* End points: Control of pain or development of nystagmus (rhythmic back-and-forth movement of the eyes)

 

* Analgesia notes

a. Casualties may need to be disarmed after being given OTFC or ketamine.

b. Document a mental status exam using the AVPU method prior to administering opioids or ketamine.

c. For all casualties given opioids or ketamine – monitor airway, breathing, and circulation closely

d. Directions for administering OTFC:

- Recommend taping lozenge-on-a-stick to casualty’s finger as an added safety measure OR utilizing a safety pin and rubber band to attach the lozenge (under tension) to the patient’s uniform or plate carrier.

- Reassess in 15 minutes

- Add second lozenge, in other cheek, as necessary to control severe pain

- Monitor for respiratory depression

e. IV Morphine is an alternative to OTFC if IV access has been obtained

- 5 mg IV/IO

- Reassess in 10 minutes.

- Repeat dose every 10 minutes as necessary to control severe pain.

- Monitor for respiratory depression

f. Naloxone (0.4 mg IV or IM) should be available when using opioid analgesics.

g. Both ketamine and OTFC have the potential to worsen severe TBI. The combat medic, corpsman, or PJ must consider this fact in his or her analgesic decision, but if the casualty is able to complain of pain, then the TBI is likely not severe enough to preclude the use of ketamine or OTFC.

h. Eye injury does not preclude the use of ketamine. The risk of additional damage to the eye from using ketamine is low and maximizing the casualty’s chance for survival takes precedence if the casualty is in shock or respiratory distress or at significant risk for either.

i. Ketamine may be a useful adjunct to reduce the amount of opioids required to provide effective pain relief. It is safe to give ketamine to a casualty who has previously received morphine or OTFC. IV Ketamine should be given over 1 minute.

j. If respirations are noted to be reduced after using opioids or ketamine, provide ventilatory support with a bag-valve-mask or mouth-to-mask ventilations.

k. Promethazine, 25 mg IV/IM/IO every 6 hours may be given as needed for nausea or vomiting.

l. Reassess – reassess – reassess!

14. Splint fractures and recheck pulses.

15. Antibiotics: recommended for all open combat wounds

a. If able to take PO:

1. Moxifloxacin, 400 mg PO one a day

b. If unable to take PO (shock, unconsciousness):

1. Cefotetan, 2 g IV (slow push over 3-5 minutes) or IM every 12 hours

or

2. Ertapenem, 1 g IV/IM once a day

16. Burns

a. Facial burns, especially those that occur in closed spaces, may be associated with inhalation injury. Aggressively monitor airway status and oxygen saturation in such patients and consider early surgical airway for respiratory distress or oxygen desaturation.

b. Estimate total body surface area (TBSA) burned to the nearest 10% using the Rule of Nines.

c. Cover the burn area with dry, sterile dressings. For extensive burns (>20%), consider placing the casualty in the Heat-Reflective Shell or Blizzard Survival Blanket from the Hypothermia Prevention Kit in order to both cover the burned areas and prevent hypothermia.

d. Fluid resuscitation (USAISR Rule of Ten)

  1. If burns are greater than 20% of Total Body Surface Area, fluid resuscitation should be initiated as soon as IV/IO access is established. Resuscitation should be initiated with Lactated Ringer’s, normal saline, or Hextend. If Hextend is used, no more than 1000 ml should be given, followed by Lactated Ringer’s or normal saline as needed.

  2. Initial IV/IO fluid rate is calculated as %TBSA x 10cc/hr for adults weighing 40- 80 kg.

  3. For every 10 kg ABOVE 80 kg, increase initial rate by 100 ml/hr.

  4. If hemorrhagic shock is also present, resuscitation for hemorrhagic shock takes precedence over resuscitation for burn shock. Administer IV/IO fluids per the TCCC Guidelines in Section 7.

e. Analgesia in accordance with the TCCC Guidelines in Section 13 may be administered to treat burn pain.

f. Prehospital antibiotic therapy is not indicated solely for burns, but antibiotics should be given per the TCCC guidelines in Section 15 if indicated to prevent infection in penetrating wounds.

g. All TCCC interventions can be performed on or through burned skin in a burn casualty.

17. Communicate with the casualty if possible.

a. Encourage; reassure

b. Explain care

18. Cardiopulmonary Resuscitation (CPR)

Resuscitation on the battlefield for victims of blast or penetrating trauma who have no pulse, no ventilations, and no other signs of life will not be successful and should not be attempted. However, casualties with torso trauma or polytrauma who have no pulse or respirations during TFC should have bilateral needle decompression performed to ensure they do not have a tension pneumothorax prior to discontinuation of care. The procedure is the same as described in Section 3 above.

19. Documentation of Care

Document clinical assessments, treatments rendered, and changes in the casualty’s status on a TCCC Casualty Card (DD Form 1380). Forward this information with the casualty to the next level of care.

 

Basic Management Plan for Tactical Evacuation Care

Note: The term “Tactical Evacuation” includes both Casualty Evacuation (CASEVAC) and Medical Evacuation (MEDEVAC) as defined in Joint Publication 4-02.

 

1. Airway Management

a. Unconscious casualty without airway obstruction:

      1. Chin lift or jaw thrust maneuver

      2. Nasopharyngeal airway

      3. Place casualty in the recovery position

b. Casualty with airway obstruction or impending airway obstruction:

        1. Chin lift or jaw thrust maneuver

        2. Nasopharyngeal airway

        3. Allow casualty to assume any position that best protects the airway, to include sitting up.

        4. Place unconscious casualty in the recovery position.

        5. If above measures unsuccessful:

  • Supraglottic airway or

  • Endotracheal intubation or

  • Surgical cricothyroidotomy (with lidocaine if conscious).

c. Spinal immobilization is not necessary for casualties with penetrating trauma.

 

2. Breathing

a. In a casualty with progressive respiratory distress and known or suspected torso trauma, consider a tension pneumothorax and decompress the chest on the side of the injury with a 14-gauge, 3.25 inch needle/catheter unit inserted in the second intercostal space at the midclavicular line. Ensure that the needle entry into the chest is not medial to the nipple line and is not directed towards the heart. An acceptable alternate site is the 4th or 5th intercostal space at the anterior axillary line (AAL).

b. Consider chest tube insertion if no improvement and/or long transport is anticipated.

c. Most combat casualties do not require supplemental oxygen, but administration of oxygen may be of benefit for the following types of casualties:

- Low oxygen saturation by pulse oximetry

- Injuries associated with impaired oxygenation

- Unconscious casualty

- Casualty with TBI (maintain oxygen saturation > 90%)

- Casualty in shock

- Casualty at altitude

d. All open and/or sucking chest wounds should be treated by immediately applying a vented chest seal to cover the defect. If a vented chest seal is not available, use a non-vented chest seal. Monitor the casualty for the potential development of a subsequent tension pneumothorax. If the casualty develops increasing hypoxia, respiratory distress, or hypotension and a tension pneumothorax is suspected, treat by burping or removing the dressing or by needle decompression.

3. Bleeding

a. Assess for unrecognized hemorrhage and control all sources of bleeding. If not already done, use a CoTCCC-recommended tourniquet to control life-threatening external hemorrhage that is anatomically amenable to tourniquet application or for any traumatic amputation. Apply directly to the skin 2-3 inches above wound.

b. For compressible hemorrhage not amenable to tourniquet use or as an adjunct to tourniquet removal (if anticipated evacuation time is longer than two hours), use Combat Gauze as the CoTCCC hemostatic dressing of choice. Celox Gauze and ChitoGauze may also be used if Combat Gauze is not available. Hemostatic dressings should be applied with at least 3 minutes of direct pressure. Before releasing any tourniquet on a casualty who has been resuscitated for hemorrhagic shock, ensure a positive response to resuscitation efforts (i.e., a peripheral pulse normal in character and normal mentation if there is no TBI.) If the bleeding site is appropriate for use of a junctional tourniquet, immediately apply a CoTCCC-recommended junctional tourniquet. Do not delay in the application of the junctional tourniquet once it is ready for use. Apply hemostatic dressings with direct pressure if a junctional tourniquet is not available or while the junctional tourniquet is being readied for use.

c. Reassess prior tourniquet application. Expose wound and determine if tourniquet is needed. If so, replace tourniquet over uniform with another applied directly to skin 2-3 inches above wound. If a tourniquet is not needed, use other techniques to control bleeding.

d. When time and the tactical situation permit, a distal pulse check should be accomplished. If a distal pulse is still present, consider additional tightening of the tourniquet or the use of a second tourniquet, side-by-side and proximal to the first, to eliminate the distal pulse.

e. Expose and clearly mark all tourniquet sites with the time of tourniquet application. Use an indelible marker.

4. Intravenous (IV) Access

a. Reassess need for IV access.

1. If indicated, start an 18-gauge IV or saline lock

2. If resuscitation is required and IV access is not obtainable, use intraosseous (IO) route.

5. Tranexamic Acid (TXA)

a. If a casualty is anticipated to need significant blood transfusion (for example; presents with hemorrhagic shock, one or more major amputations, penetrating torso trauma, or evidence of severe bleeding):

1. Administer 1 gram of tranexamic acid in 100 cc Normal Saline or Lactated Ringers as soon as possible but NOT later than 3 hours after injury.

2. Begin second infusion of 1 gm TXA after Hextend or other fluid treatment.

6. Traumatic Brain Injury

a. Casualties with moderate/severe TBI should be monitored for:

1. Decreases in level of consciousness

2. Pupillary dilation

3. SBP should be >90 mmHg

4. O2 sat > 90

5. Hypothermia

6. PCO2 (If capnography is available, maintain between 35-40 mmHg)

7. Penetrating head trauma (if present, administer antibiotics)

8. Assume a spinal (neck) injury until cleared.

b. Unilateral pupillary dilation accompanied by a decreased level of consciousness may signify impending cerebral herniation; if these signs occur, take the following actions to decrease intracranial pressure*:

1. Administer 250 cc of 3 or 5% hypertonic saline bolus.

2. Elevate the casualty’s head 30 degrees.

3. Hyperventilate the casualty:

  • Respiratory rate 20.

  • Capnography should be used to maintain the end-tidal CO2 between 30-35.

  • The highest oxygen concentration (FIO2) possible should be used for hyperventilation.

 

* Notes:

Do not hyperventilate unless signs of impending herniation are present.

Casualties may be hyperventilated with oxygen using the bag-valve-mask technique.

7. Fluid Resuscitation

a. The resuscitation fluids of choice for casualties in hemorrhagic shock, listed from most to least preferred, are: whole blood*; plasma, RBCs and platelets in 1:1:1 ratio*; plasma and RBCs in 1:1 ratio; plasma or RBCs alone; Hextend; and crystalloid (Lactated Ringers or Plasma-Lyte A).

b. Assess for hemorrhagic shock (altered mental status in the absence of brain injury and/or weak or absent radial pulse).

1. If not in shock:

  • No IV fluids are immediately necessary.

  • Fluids by mouth are permissible if the casualty is conscious and can swallow.

2. If in shock and blood products are available under an approved command or theater blood product administration protocol:

  • Resuscitate with whole blood*, or, if not available

  • Plasma, RBCs and platelets in a 1:1:1 ratio*, or, if not available;

  • Plasma and RBCs in 1:1 ratio, or, if not available;

  • Reconstituted dried plasma, liquid plasma or thawed plasma alone or RBCs alone.

  • Reassess the casualty after each unit. Continue resuscitation until a palpable radial pulse, improved mental status or systolic BP of 80-90 mmHg is present.

3. If in shock and blood products are not available under an approved command or theater blood product administration protocol due to tactical or logistical constraints:

  • Resuscitate with Hextend, or if not available;

  • Lactated Ringers or Plasma-Lyte A;

  • Reassess the casualty after each 500 mL IV bolus;

  • Continue resuscitation until a palpable radial pulse, improved mental status, or systolic BP of 80-90 mmHg is present.

  • Discontinue fluid administration when one or more of the above end points has been achieved.

4. If a casualty with an altered mental status due to suspected TBI has a weak or absent peripheral pulse, resuscitate as necessary to restore and maintain a normal radial pulse. If BP monitoring is available, maintain a target systolic BP of at least 90 mmHg.

5. Reassess the casualty frequently to check for recurrence of shock. If shock recurs, recheck all external hemorrhage control measures to ensure that they are still effective and repeat the fluid resuscitation as outlined above.

 

* Neither whole blood nor apheresis platelets as these products are currently collected in theater are FDA-compliant. Consequently, whole blood and 1:1:1 resuscitation using apheresis platelets should be used only if all of the FDA-compliant blood products needed to support 1:1:1 resuscitation are not available, or if 1:1:1 resuscitation is not producing the desired clinical effect.

8. Prevention of Hypothermia

a. Minimize casualty’s exposure to the elements. Keep protective gear on or with the casualty if feasible.

b. Replace wet clothing with dry if possible. Get the casualty onto an insulated surface as soon as possible.

c. Apply the Ready-Heat Blanket from the Hypothermia Prevention and Management Kit (HPMK) to the casualty’s torso (not directly on the skin) and cover the casualty with the Heat-Reflective Shell (HRS).

d. If an HRS is not available, the previously recommended combination of the Blizzard Survival Blanket and the Ready Heat blanket may also be used.

e. If the items mentioned above are not available, use poncho liners, sleeping bags, or anything that will retain heat and keep the casualty dry.

f. Use a portable fluid warmer capable of warming all IV fluids including blood products.

g. Protect the casualty from wind if doors must be kept open.

9. Penetrating Eye Trauma

a. If a penetrating eye injury is noted or suspected:

1. Perform a rapid field test of visual acuity.

2. Cover the eye with a rigid eye shield (NOT a pressure patch).

3. Ensure that the 400 mg moxifloxacin tablet in the combat pill pack is taken if possible and that IV/IM antibiotics are given as outlined below if oral moxifloxacin cannot be taken.

 

10. Monitoring

Institute pulse oximetry and other electronic monitoring of vital signs, if indicated. All individuals with moderate/severe TBI should be monitored with pulse oximetry.

 

11. Inspect and dress known wounds if not already done.

 

12. Check for additional wounds.

 

13. Analgesia on the battlefield should generally be achieved using one of three options:

Option 1

Mild to Moderate Pain

Casualty is still able to fight

- TCCC Combat pill pack:

- Tylenol - 650-mg bilayer caplet, 2 PO every 8 hours

- Meloxicam - 15 mg PO once a day

Option 2

Moderate to Severe Pain

Casualty IS NOT in shock or respiratory distress AND

Casualty IS NOT at significant risk of developing either condition

- Oral transmucosal fentanyl citrate (OTFC) 800 ug

- Place lozenge between the cheek and the gum

- Do not chew the lozenge

Option 3

Moderate to Severe Pain

Casualty IS in hemorrhagic shock or respiratory distress OR

Casualty IS at significant risk of developing either condition

- Ketamine 50 mg IM or IN

Or

- Ketamine 20 mg slow IV or IO

 

* Repeat doses q30min prn for IM or IN

* Repeat doses q20min prn for IV or IO

* End points: Control of pain or development of nystagmus (rhythmic back-and-forth movement of the eyes)

 

* Analgesia notes

a. Casualties may need to be disarmed after being given OTFC or ketamine.

b. Document a mental status exam using the AVPU method prior to administering opioids or ketamine.

c. For all casualties given opioids or ketamine – monitor airway, breathing, and circulation closely

d. Directions for administering OTFC:

- Recommend taping lozenge-on-a-stick to casualty’s finger as an added safety measure OR utilizing a safety pin and rubber band to attach the lozenge (under tension) to the patient’s uniform or plate carrier.

- Reassess in 15 minutes

- Add second lozenge, in other cheek, as necessary to control severe pain

- Monitor for respiratory depression

e. IV Morphine is an alternative to OTFC if IV access has been obtained

- 5 mg IV/IO

- Reassess in 10 minutes.

- Repeat dose every 10 minutes as necessary to control severe pain.

- Monitor for respiratory depression

f. Naloxone (0.4 mg IV or IM) should be available when using opioid analgesics.

g. Both ketamine and OTFC have the potential to worsen severe TBI. The combat medic, corpsman, or PJ must consider this fact in his or her analgesic decision, but if the casualty is able to complain of pain, then the TBI is likely not severe enough to preclude the use of ketamine or OTFC.

h. Eye injury does not preclude the use of ketamine. The risk of additional damage to the eye from using ketamine is low and maximizing the casualty’s chance for survival takes precedence if the casualty is in shock or respiratory distress or at significant risk for either.

i. Ketamine may be a useful adjunct to reduce the amount of opioids required to provide effective pain relief. It is safe to give ketamine to a casualty who has previously received morphine or OTFC. IV Ketamine should be given over 1 minute.

j. If respirations are noted to be reduced after using opioids or ketamine, provide ventilatory support with a bag-valve-mask or mouth-to-mask ventilations.

k. Promethazine, 25 mg IV/IM/IO every 6 hours may be given as needed for nausea or vomiting.

l. Reassess – reassess – reassess!

14. Reassess fractures and recheck pulses.

 

15. Antibiotics: recommended for all open combat wounds

a. If able to take PO:

1. Moxifloxacin, 400 mg PO one a day

b. If unable to take PO (shock, unconsciousness):

1. Cefotetan, 2 g IV (slow push over 3-5 minutes) or IM every 12 hours

or

2. Ertapenem, 1 g IV/IM once a day

16. Burns

a. Facial burns, especially those that occur in closed spaces, may be associated with inhalation injury. Aggressively monitor airway status and oxygen saturation in such patients and consider early surgical airway for respiratory distress or oxygen desaturation.

b. Estimate total body surface area (TBSA) burned to the nearest 10% using the Rule of Nines.

c. Cover the burn area with dry, sterile dressings. For extensive burns (>20%), consider placing the casualty in the Heat-Reflective Shell or Blizzard Survival Blanket from the Hypothermia Prevention Kit in order to both cover the burned areas and prevent hypothermia.

d. Fluid resuscitation (USAISR Rule of Ten)

  1. If burns are greater than 20% of Total Body Surface Area, fluid resuscitation should be initiated as soon as IV/IO access is established. Resuscitation should be initiated with Lactated Ringer’s, normal saline, or Hextend. If Hextend is used, no more than 1000 ml should be given, followed by Lactated Ringer’s or normal saline as needed.

  2. Initial IV/IO fluid rate is calculated as %TBSA x 10cc/hr for adults weighing 40- 80 kg.

  3. For every 10 kg ABOVE 80 kg, increase initial rate by 100 ml/hr.

  4. If hemorrhagic shock is also present, resuscitation for hemorrhagic shock takes precedence over resuscitation for burn shock. Administer IV/IO fluids per the TCCC Guidelines in Section 7.

e. Analgesia in accordance with the TCCC Guidelines in Section 13 may be administered to treat burn pain.

f. Prehospital antibiotic therapy is not indicated solely for burns, but antibiotics should be given per the TCCC guidelines in Section 15 if indicated to prevent infection in penetrating wounds.

g. All TCCC interventions can be performed on or through burned skin in a burn casualty.

h. Burn patients are particularly susceptible to hypothermia. Extra emphasis should be placed on barrier heat loss prevention methods and IV fluid warming in this phase.

17. The Pneumatic Antishock Garment (PASG) may be useful for stabilizing pelvic fractures and controlling pelvic and abdominal bleeding. Application and extended use must be carefully monitored. The PASG is contraindicated for casualties with thoracic or brain injuries.

18. CPR in TACEVAC Care

a. Casualties with torso trauma or polytrauma who have no pulse or respirations during TACEVAC should have bilateral needle decompression performed to ensure they do not have a tension pneumothorax. The procedure is the same as described in Section 2 above.

b. CPR may be attempted during this phase of care if the casualty does not have obviously fatal wounds and will be arriving at a facility with a surgical capability within a short period of time. CPR should not be done at the expense of compromising the mission or denying lifesaving care to other casualties.

19. Documentation of Care

Document clinical assessments, treatments rendered, and changes in the casualty’s status on a TCCC Casualty Card (DD Form 1380). Forward this information with the casualty to the next level of care.

 

| Tags : tccc

04/09/2014

Remplissage vasculaire: Evolution majeure du TCCC

Fluid Resuscitation for Hemorrhagic Shock in Tactical Combat Casualty Care
 

L'emploi préhospitalier de la transfusion de globules rouges et de plasma était évoqué de manière anecdotique. Une évolution importante survient dans la procédure américaine du TCCC (1, 2). Cette pratique est en passe de devenir une recommandation protocolée de théâtre pour les blessés en état de choc (Pas de pouls radial et conscience altérée el l'absence de traumatisme crânien)  hémorragique avec notons le recours au Plyo du CTSA.

" Tactical Field Care and TACEVAC Care

7. Fluid resuscitation

a. The resuscitation fluids of choice for casualties in hemorrhagic shock, listed from most to least preferred, are: whole blood*; plasma, RBCs and platelets in 1:1:1 ratio*; plasma and RBCs in 1:1 ratio; plasma or RBCs alone; Hextend; and crystalloid (Lactated Ringers or Plasma-Lyte A).

b. Assess for hemorrhagic shock (altered mental status in the absence of brain injury and/or weak or absent radial pulse).

1. If not in shock:

- No IV fluids are immediately necessary.

- Fluids by mouth are permissible if the casualty is conscious and can swallow.

2. If in shock and blood products are available under an approved command or theater blood product administration protocol:

- Resuscitate with whole blood*, or, if not available

- Plasma, RBCs and platelets in a 1:1:1 ratio*, or, if not available

- Plasma and RBCs in 1:1 ratio, or, if not available;

- Reconstituted dried plasma, liquid plasma or thawed plasma alone or RBCs alone;

- Reassess the casualty after each unit. Continue resuscitation until a palpable radial pulse, improved mental status or systolic BP of 80-90 mmHg is present.

3. If in shock and blood products are not available under an approved command or theater blood product administration protocol due to tactical or logistical constraints:

- Resuscitate with Hextend, or if not available;

- Lactated Ringers or Plasma-Lyte A;

- Reassess the casualty after each 500 mL IV bolus;

- Continue resuscitation until a palpable radial pulse, improved mental status, or systolic BP of 80-90 mmHg is present.

- Discontinue fluid administration when one or more of the

above end points has been achieved.

4. If a casualty with an altered mental status due to suspected TBI has a weak or absent peripheral pulse, resuscitate as necessary to restore and maintain a normal radial pulse. If BP monitoring is available, maintain a target systolic BP of at least 90 mmHg.

5. Reassess the casualty frequently to check for recurrence of shock. If shock recurs, recheck all external hemorrhage control measures to ensure that they are still effective and repeat the fluid resuscitation as outlined above.

* Neither whole blood nor apheresis platelets as these products are currently collected in theater are FDA-compliant. Consequently, whole blood and 1:1:1 resuscitation using apheresis platelets should be used only if all of the FDA-compliant blood products needed to support 1:1:1 resuscitation are not avalaible