Tuesday, February 19, 2013

Lesson Eighteen: TCCC TFC

Following on immediately after Care Under Fire, Tactical Field Care begins whenever things calm down enough to allow this level of care in the field. The fight may be over, there may be a lull, it may re-commence at any moment, and/or you may have a place of security and cover from immediate battlefield actions where secondary care of a casualty or casualties is appropriately rendered. You may have minutes to hours for this phase. Work like it was minutes. The tactical and medical situation may change at any moment, so work your casualties rapidly through the steps, and move on to the next one, and/or re-evaluate the ones you have, with a view towards getting any patients ready for the next, Evacuation, phase of care.

Casualties with an altered mental status should be disarmed immediately, before further care. Rifles, pistols, knives, grenades, pyro and demo. Everything. “Hey buddy, let me hold onto this for you while the doc checks you out” is a good way to approach it with conscious patients. At any rate, it’s embarrassing to have a patient who’s not in his normal state of mind attack your doc or others because you didn’t take away his toys. And if he’s later being evacuated, that gear is going to need to be re-distributed anyway.
TFC starts with M-A-R-C-H. The acronym is broken down as follows:

Massive hemorrhage control. If tourniquet(s) were applied during CUF, drive on. If not, apply any you need to. And if one wasn’t enough, a second CAT may be applied above the first one to control further bleeding from the already once-tourniquetted extremity.
Airway Management

You next want to establish and maintain a patent airway.
Conscious patients, esp. those with trauma to face, jaw, and upper airway, may be able to self-manage by sitting up and leaning forward. Let them.

Unconscious patients get the chin lift jaw thrust maneuver. If that isn’t enough, and they have no facial/airway trauma, deploy the “Nose Hose”, a nasopharyngeal (NP) airway. It looks like a trumpet. Lube it first, slide it into either nostril at a 90 degree angle, twist it into place, and tape it in place. It’s mildly uncomfortable, but tolerated, even by conscious patients. If one nostril won’t take it, try the other side. Don’t force it. Slow is better than trying to ram it in in a hurry. If the patient gags once it’s inserted to the flared end, it’s probably hitting the back of their throat and triggering the gag reflex. Withdraw it slightly, and resecure it.
Once either of these airways are accomplished, assess the patient for adequate breathing.

If both of these fail, the next option is a cricothyroidotomy. Describing this is fine, but you need to review diagrams to understand how to perform this intervention. (And if your patient is still conscious, some injectable lidocaine local anesthetic is a great idea!)
On males, there’s a prominent hump at the Adam’s apple. This is the thyroid cartilage. Just below this, there’s a depression (it’s roughly diamond shaped), then there’s another smaller harder ring, which is the cricoid cartilage. The flat diamond-shaped depression is the intended site for performing a “crike”. After prepping the patient’s skin with Betadine, a sterile scalpel should be used to make a vertical incision (that means from top to bottom) about ½ to ¾ of an inch long. You should be able to insert your gloved finger and/or a hemostat (scissor-looking clamp for non-medical types) to spread the opening slightly. If you have an 6.0 ET tube, insert it. If not, that failed nasal trumpet, or a fresh one, will also work. Once you’ve placed either into the hole, the patient should now have a new way to suck air and blow off CO2 if you did it right. Put some sterile gauze around the outside of the new wound you created to help stop any bleeding, and secure your new airway device with tape to keep it in place.

Place unconscious patients in the recovery position: Rolled onto left side, head resting on extended left arm, right arm and right leg drawn up and across the left limbs. This way, if they vomit, or have blood draining into their airway, they won’t choke on either.

Decompress tension pneumothorax. Anyone with penetrating chest or upper back trauma may have an air leak. The lungs work as a closed system. When air leaks in from outside, it gets between the lung and the chest wall, preventing full inflation. Eventually, the lung on the injured side will collapse, with the other lung pulling their airway structures to the better side. This is a tension pneumothorax.
To decompress the built up air inside the chest cavity, insert a 14G 3 ¼ “ needle catheter on the injured side* on the mid clavicular line (an imaginary up-and-down line halfway between the sternum and the shoulder), which is roughly above and slightly outside of the nipple, at the 2nd intercostal space (over the top of the second rib down from the collarbone). Ribs have their nerves, arteries, and veins in a notch underneath each rib, so by inserting over the top of the 2nd rib, you won’t hit these structures. The needle goes in at 90 degrees, and not pointed towards the heart. Air and/or fluid and blood may be ejected with pressure when this is done. If you have goggles or other eye protection, pop them on first if you hadn’t already been wearing them. Once the needle is in place, it should allow the trapped air out. Remove the inner metal needle, leaving the hollow tube (the catheter) in place, and tape the hub in place to continue doing its job.

Seal open chest wounds with an occlusive dressing.

So find the original cause of the problem, and apply an Asherman Chest Seal (ACS) or similar device, or an air-occlusive dressing, over the wound(s).
*Note that patients can get wounded on both sides, get tension pneumothorax on both sides, even from one wound, and/or need multiple chest decompressions on the injured side(s) and multiple chest seals/occlusive dressings. All of these are appropriate field medical interventions under combat conditions to prevent treatable causes of death.

Assist breathing/oxygenation.  Place unconscious patients in the recovery position. Conscious patients may wish to sit upright. If you have supplemental oxygen or bag valve masks, serious airway injury patients may require assisted ventilations, from an uninjured/less-injured buddy when possible to allow you to deal with other casualties.

Assess any issues with bleeding, and tourniquet and Combat Gauze placement.

Mark the time the tourniquet was applied indelibly on the CAT. A proper tourniquet should completely occlude pulses beyond where it is placed. Don’t loosen tourniquet once applied. Never remove a tourniquet on an amputated limb, or if the casualty is in shock, or if they will get to treatment in 2 hours or less, or if the tourniquet has been in place for 6 hours or longer.
If casualties have torso wounds not suited for treatment with the CAT, now’s the time to break out your Combat Gauze and stuff it into any open wounds. Apply direct pressure for at least 3 minutes once the gauze is applied. Do NOT remove pressure of the gauze to “check” to see if it’s working. You’ll only waste the gauze, and have to re-start the whole process. That'll be a problem if things get sporty again, so do it right the first time.

Once the time is up, observe for continued bleeding. If it continues, more gauze. Then pressure wrap with a field dressing, an Israeli 4” or 6” bandage, and/or ACE wraps or Coban-style self-adhering bandages.

Remember you’re treating notable hemorrhaging, not applying bandaids and 4x4s to superficial wounds at this point.

Any casualties in shock, or seriously at risk for it, like torso GSWs or major wounds, should get IV/IO access and fluids. I’m not covering this here and now, beyond telling you yet again that you need serious training to learn this beyond what a post on the internet can accomplish. Not least of which is the required hands-on supervised practice that can, in a couple of hours, get you to where you could start an IV if you had to, and none of which I can provide online in a blog. TAKE A SERIOUS CLASS.

The takeaway point I can give you is that the best way to treat shock due to blood loss is to prevent the blood loss in the first place. Dumping Hextend and LR into a patient who’s entering shock are a distant second to stopping the bleeding in the first place.
Aggressive early treatment vastly outperforms aggressive late treatment.

Head Injury/Hypothermia
Head injury patients need their O2 saturation maintained at greater than 90%. Whether you’re bagging them, or adding supplemental oxygen, keep their sats up. This is also why you need a pulse oximeter, even one of the $50 specials from the drugstore.

Remove wet clothing, and cover the casualty, top and bottom, to prevent heat loss. Shock and hypothermia are a lethal combination.
Other considerations

Eye trauma
WEAR YOUR FRIGGIN’ EYE PROTECTION, and avoid the problem. For those who didn’t, the injured eye should be covered with a rigid shield (not a pressure dressing, which can squeeze the fluid out of an injured eye and result in  loss of the eye.

Monitor pulse ox in patients with brain injury, major trauma, airway compromise, shock, or unconsciousness or altered mental status. Know that altitude decreases normal sea level pulse ox from 98% @ sea level to 86% @ 12K’ altitude in normal healthy individuals, and the decrease in available oxygen for the body is real. Casualties at altitude are thus at greater risk for notable hypoxia.
After MARCH, assess and treat all other wounds on all casualties. Expose the casualty using trauma shears to remove clothing, and check for wounds all over, top, bottom, and sides.

Patients capable of self-care may self-medicate with Mobic (if carried) and Tylenol, per TCCC dosages and guidelines. Aspirin and ibuprofen decrease clotting for 7 days after taking, and should be avoided for combat personnel for this reason.
Patients out of the fight are normally cared for using Rx IM/IV medication requiring diligent monitoring by the medic, per protocols.

Splint fractures and check pulses afterwards. SAM splints are your friend.
Burns Cover with dry sterile dressing, wrap with hypothermia blankets, treat for pain, and initiate fluid therapy for burns greater than 20% body surface area.

NO battlefield CPR. 100% failure rate for CPR, even for civilians with traumatic full arrest in non-combat environment. Dead is dead. Focus medical care efforts and resources on the salvageable living patients. Exceptions: hypothermia, electrocution, near-drowning. Bilateral needle decompression for tension pneumothorax rule-out is advised, may save a life, and won’t do any harm to a fully arrested patient.
Communicate with your patients, and reassure them as you reassess them.

Document patient condition, care and treatments rendered, and ensure the record gets passed along to higher levels of care when the patient is evacuated.

{Note: I won't be covering the Casualty Evacuation phase. If you're in the military, the training you receive on CASEVAC will be far more thorough than anything you'll find here. If you're not, casevac consists of using commercial or improvised litters until you get to a pack mule, truck, van, or phone to call for an ambulance, so going into 9-line medevac requests is kind of pointless. If you're hung up about it, take the class.}

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