Tactical

Combat
Casualty Care
Lesson One

MSTC, FT LEWIS WA
 Introduction
Soldiers continue to die on today’s battlefield
just as they did during the Civil War. The
standards of care applied to the battlefield
have always been based on civilian care
principles. These principles while appropriate
for the civilian community, often do not apply
to care on the battlefield.
 Tactical Combat Casualty
Care
► 90% of all battlefield casualties that die,
expire before they reach definitive care.
► Point of wounding care is the responsibility of
the individual soldier, his battle buddy
buddy,, the
Combat Lifesaver, and the Combat Medic.
► Remember in combat, functioning as a
Combat Lifesaver is your secondary mission.
 Tactical Combat Casualty
Care
► Causes of death on the battlefield:
 Penetrating head trauma 31%
 Uncorrectable torso trauma 25%
 Potentially correctable torso trauma 10%
 *Exsanguination from extremity wounds 9%
 Mutilating blast trauma 7%
 *Tension pneumothorax 5%
 *Airway problems 1%
 Tactical Combat Casualty
Care
► Primary causes of preventable death

 Hemorrhage from extremity wounds

 Tension pneumothorax

 Airway problems
 Tactical Combat Casualty
Care

► There needs to be a shift in our thinking, the days of

not providing self aid and laying there and yelling
“Medic” are over. We must have the ability to assess
our own wounds, provide self or buddy aid if needed,
and continue the mission if able. The bottom line is a
soldier capability at the point of wounding, who is
equipped and trained to decrease preventable
battlefield death. This strategy will increase the unit’s
combat effectiveness and it’s survivability. If we could
make some minor changes in our common soldier
medical skills training, we can improve the survival rate
of 15% of all battlefield deaths.
 TC-3 Objectives
►Treat the casualty

►Prevent additional
casualties

►Complete the mission

 Tactical Combat Casualty
Care
►Phases of Care

Care Under Fire

Tactical Field Care

Combat Casualty Evacuation

(CASEVAC) Care
CARE UNDER FIRE
 CARE UNDER FIRE
► “Care Under Fire” is the care rendered by
the soldier medic at the scene of the injury
while they and the casualty are still under
effective hostile fire.
► Self aid/ Buddy aid
 Rapid Casualty Assessment
 Control Hemorrhage
 Treat Penetrating chest trauma
 Maintain airway
 Package casualty for transport
 CARE UNDER FIRE
► M.A.R.C.H. acronym
 M-massive bleeding
 A-airway
 R-respirations
 C-circulation
 H-head injury

HEMORRHAGE CONTROL IS TOP PRIORITY

 CARE UNDER FIRE
► Return fire as directed or required
► Medical personnel’s firepower may be
essential in obtaining tactical fire superiority
► Move the casualty to cover as quickly as
possible
► Direct the casualty to return fire, move to
cover, and conduct self-aid if able
► Stop any life threatening external hemorrhage
with a tourniquet or Emergency Trauma
Dressing.
 CARE UNDER FIRE

► Try to keep yourself from being wounded

► Try to keep the casualty from sustaining addition
wounds
► Suppression of hostile fire may minimize the risk of
injury to personnel and minimize additional injury to
previously injured soldiers
► Have casualty “play dead”
► No immediate management of airway. Airway
management is generally best deferred until the
Tactical Field Care
► Reassure the casualty
 CARE UNDER FIRE
► Do not attempt to salvage a casualty’s
rucksack, unless it contains items
critical to the mission

► Take
the patients weapon and
ammunition if possible to prevent the
enemy from using it against you.
 CARE UNDER FIRE
► Exsanguination from extremity
wounds is the #1 cause of preventable
death on the battlefield
► Injury to a major vessel can result in
hypovolemic shock in a short time frame
► Use of temporary tourniquets to stop the
bleeding is essential in these types of
casualties
 CARE UNDER FIRE

 The need for immediate access to a

tourniquet in such situations makes it
clear that all soldiers on combat
missions have a suitable tourniquet
readily available at a standard location
on their battle gear and be trained in
its use.
TACTICAL FIELD CARE
 TACTICAL FIELD CARE
► “Tactical Field Care” is the care rendered by the
soldier medic once they and the casualty are no
longer under effective hostile fire. It also applies
to situations in which an injury has occurred, but
there has been no hostile fire
► The Tactical Field Care phase is distinguished
from the Care Under Fire phase by having more
time available to provide care and a reduced
level of hazard from hostile fire
TACTICAL FIELD CARE
TACTICAL FIELD CARE
TACTICAL FIELD CARE
 TACTICAL FIELD CARE
► Insome cases, tactical field care may consist of
rapid treatment of wounds with the expectation of
a re-engagement of hostile fire at any moment. In
some circumstances there may be ample time to
render whatever care is available in the field. The
time to evacuation may be quite variable from 30
minutes to several hours.
 TACTICAL FIELD CARE
►Initial assessment consists of
 Airway

 Breathing

 Circulation
 TACTICAL FIELD CARE
► Ifa victim of a blast or penetrating injury is
found without a pulse, respirations, or
other signs of life…
Do Not attempt CPR

► Casualtieswith altered mental status

should be disarmed immediately, both
weapons and grenades
 TACTICAL FIELD CARE
►Traumatic chest wall defects should
be closed with an occlusive
dressing without regard to venting
one side of the dressing or use an
“Asherman Chest Seal®”. Place the
casualty in the sitting position if
possible.
 TACTICAL FIELD CARE
►Progressive respiratory distress
secondary to a unilateral penetrating
chest trauma should be considered a
tension pneumothorax and
decompressed with a 14 gauge needle
►Tension pneumothorax is the 2nd
leading cause of preventable death on
the battlefield
 TACTICAL FIELD CARE
► Bleeding
 Significant bleeding should be controlled using a
tourniquet as described previously.
 Any bleeding site not previously controlled
should now be addressed. Only the absolute
minimum of clothing should be removed.
 Once the tactical situation permits, consideration
should be given to loosening the tourniquet and
using direct pressure or hemostatic bandages
(HemCon®) to control any additional hemorrhage.
 TACTICAL FIELD CARE
► Tourniquet Removal
 When? Based on the Tactical Situation
 More time in a safer setting
 More help available
 Does the casualty need fluid resuscitation?
 If so, do it before the tourniquet is removed
 TACTICAL FIELD CARE
► Tourniquet Removal (cont’d)
 Take great precaution when loosening the tourniquet. Normally
under medical supervision.
 DO NOT periodically loosen the tourniquet to get blood to the
limb.
 Can be rapidly fatal.
 Tourniquets are very painful.
 If the tourniquet has been on for > 6hrs, leave it on.
 If unable to control bleeding with other methods-retighten the
tourniquet
 TACTICAL FIELD CARE
► Initiate an IV via heplock or saline lock
► 1000ml of Ringers Lactate (2.4lbs) will expand the
intravascular volume by 250ml within 1 hour
► 500ml of 6% Hetastarch (trade name Hextend®,
weighs 1.3lbs) will expand the intravascular
volume by 800ml within 1 hour, and will sustain
this expansion for 8 hours
► While in garrison, remove Hetastarch solution from
CLS bag
 TACTICAL FIELD CARE
► Significantblood loss from any wound, and the
soldier has no radial pulse or is not coherent-
STOP THE BLEEDING- by whatever means
available- tourniquet, direct pressure, hemostatic
dressings, or hemostatic powder etc. Start 500ml
of Hextend®. If mental status improves and
radial pulse returns, maintain saline lock and
hold fluids
 TACTICAL FIELD CARE
► If no response is seen give an additional 500ml of
Hextend® and monitor vital signs. If no response is
seen after 1000ml of Hextend®, consider triaging
supplies and attention to more salvageable
casualties
► Because of conservation of supplies, no
casualty should receive more than 1000 ml of
Hextend®. Remember this is the equivalent to
six liters of Ringers Lactate.
 TACTICAL FIELD CARE
►Splint fractures as circumstances
allow, insuring pulse, motor, and
sensory checks before and after
splinting
 TACTICAL FIELD CARE
► Antibiotics
should be considered in any
wound sustained on the battlefield.
 TACTICAL FIELD CARE
► Combat Pill Pack
 Tylenol 1000mg (Pain Medication)
 Mobic 15mg (Pain Medication)
 Gatifloxacin 400mg (Antibiotic)
CASualty EVACuation
 CASEVAC Care
► At some point in the operation, the casualty
will be scheduled for evacuation. Time to
evacuation may be quite variable from
minutes to hours.
► “Combat Casualty Evacuation Care” is the
care rendered once the casualty has been
picked up by an aircraft, vehicle or boat.
Additional medical personnel and equipment
may have been pre-staged and available at
this stage of casualty management.
 CASEVAC Care
► Many of the same principles of care outlined in the
Tactical Field Care phase will also apply to the
CASEVAC phase
► There are only minor differences in care when
progressing from the Tactical Field Care phase to the
Casevac phase.
 Additional medical personnel may accompany the
evacuation asset and assist the medic on the ground.
 Additional medical equipment may be pre-staged on the
evacuating asset
 CASEVAC Care
► Priority
is to move urgent casualties to
medical treatment facilities via fastest
means available to you
 Tactical situation and resources available
are factors used to make this decision
CASEVAC Care
CASEVAC Care
CASEVAC vs MEDEVAC: The
Battle of the Ia Drang Valley
► 1st Bn, 7th Cavalry in Vietnam
► Surrounded by 2000 NVA - heavy
casualties
► Called for MEDEVAC
► Request refused because LZ not secure
► Eventual pickup by 229th Assault Helo
Squadron after long delay
 CASEVAC vs MEDEVAC
► Use the term "Combat Casualty Evacuation" or
“CASEVAC” to eliminate any misunderstanding of the
mission required
► CASEVAC
 Nonstandard vehicle, NO ENROUTE CARE
 May already be there or very close by
► MEDEVAC
 Dedicated vehicle with en-route care
 May take longer
 Evacuation Care in the
Past
► Medicalcare during CASEVAC expected to
be rendered by the medic present on the
mission phase of the operation.
►Why is this a problem?
 The medic may be among the casualties.
 The medic may be dehydrated, hypothermic, or
otherwise debilitated.
 There may be multiple casualties which exceed
the ability of the medic to care for
simultaneously.
CASEVAC Care
CASEVAC Care
 Recommendations
1. Base planning for combat casualties should be
incorporated into specific mission scenarios to aid in
identifying the unique medical and tactical requirements
that will have to be addressed in that scenario.

2. On combat missions, all soldiers should have a suitable

tourniquet readily available at a standard location on their
battle gear.

3. All soldiers should be trained to use a tourniquet.

4. Designate and train Combat Casualty Transport Teams

 Summary
► Three most common combat injuries on
the battlefield
► Soldiers who will do well regardless of
what we do for them
► Soldiers who are going to die regardless of
what we do for them
► Soldiers who will die if we do not do
something for them Now (7-15%)
 Summary
►Ifduring the next war you could do only
two things, (1) put a tourniquet on and (2)
relieve a tension pneumothorax then you
can probably save between 70 and 90
percent of all the preventable deaths on
the battlefield. COL Ron Bellamy 1993
Questions????