Results and discussion

TERMINAL LEARNING OBJECTIVE: Given a simulated casualty in a simulated combat environment, treat the casualty in accordance with the references. (FMST.07.15)

ENABLING LEARNING OBJECTIVES:

(1) Without the aid of references, choose from a given list the three correct phases of care of tactical casualty management, in accordance with the references. (FMST.07.15a)

(2) Without the aid of references, given a simulated casualty and the necessary equipment, conduct combat casualty care, in accordance with the references. (FMST.07.15b)

OUTLINE

1. Summary of Findings and Recommendations.

a. Pre-hospital care of combat casualties is divided into three phases: (FMST.07.15a) 1. Care under Fire.

2. Tactical Field Care

3. Combat Casualty Evacuation (CASEVAC) Care.

b. Suppression of hostile fire may take temporary precedence over the rendering of care in the Care under Fire phase.

c. Cervical spine immobilization is not required for victims of penetrating head or neck trauma.

d. CPR should not be attempted on the battlefield for victims of blast or penetrating trauma who have no pulse, respirations, or other signs of life.

e. The use of tourniquets is encouraged in the Care under Fire phase. The tourniquet is removed and bleeding controlled with direct pressure in subsequent phases when feasible.

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f. The nasopharyngeal airway is the airway of first choice for unconscious patients until the CASEVAC phase.

g. For patients with airway obstruction in the Tactical Field Care phase unrelieved by a nasopharyneal airway, the next airway maneuver is cricothyroidotomy.

h. Endotracheal intubation is not the standard of care until the CASEVAC phase.

i. Evaluation of the laryngeal mask airway and the Combitube for use by SOF corpsmen and medics is recommended.

j. Progressive, severe respiratory distress in the setting of unilateral blunt or penetrating chest trauma on the battlefield should result in a presumptive diagnosis of tension pneumothorax and decompression of that hemithorax with needle thoracostomy.

k. Chest tube insertion is not indicated until the CASEVAC phase of care.

l. Oxygen is not expected to be carried onto the battlefield, but CASEVAC assets should have it.

m. No IV fluids are to be given until the CASEVAC phase unless the patient is in hypovolemic shock from a bleeding site which has now been controlled. Fluid

resuscitation is not necessary for patients who are not in shock and not appropriate for patients in hypovolemic shock from uncontrolled hemorrhage (penetrating wounds of the chest and abdomen).

n. Saline locks may be used instead of IV's if fluid resuscitation is not required.

o. 18 gauge catheters may be used instead of 14 or 16 gauge.

p. Hespan (1000cc) is the fluid of choice for initial resuscitation of patients with controlled hemorrhagic shock.

q. Morphine is to be used IV (5mg) instead of IM.

r. IV cefoxitin is to be used as soon as possible for patients with penetrating abdominal trauma, grossly contaminated wounds, massive soft tissue trauma, open fractures, or any patient in whom a long delay until definitive treatment is expected.

s. Casualties should not be completely undressed for a secondary survey in the field.

Removal of clothing should be limited to that necessary to expose known or suspected wounds.

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6-t. More specific combat casualty care planning should be carried out and based on specific mission-oriented scenarios.

u. The establishment of Combat Casualty Transport Teams and their use on CASEVAC assets is recommended.

v. Electronic monitoring should be routinely used on CASEVAC assets unless conditions prohibit.

w. MAST trousers are not recommended as a standard of care in any phase.

2. Phases of Care:

a. Phase One: Care Under Fire

1. Return fire as directed or required.

2. Keep yourself from getting shot.

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

4. Stop any massive external hemorrhage with a tourniquet.

5. Take the casualty with you when you leave.

b. Phase Two: Tactical Field Care 1. Airway management

- Unconscious casualty without airway obstruction: > Nasopharyngeal airway.

- Unconscious casualty with airway obstruction: > Cricothyroidotomy.

- Cervical spine immobilization is not necessary for casualties with penetrating head or neck trauma.

2. Breathing

- Consider tension pneumothorax and decompress with needle

thoracostomy if a casualty has unilateral penetrating chest trauma and progressive respiratory disstress.

3. Bleeding

- Control any remaining bleeding with a tourniquet or direct pressure.

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6-4. IV

- Start an 18 gauge IV or saline lock.

5. Fluid Resuscitation

- Controlled hemorrhage without shock: > No fluids necessary.

- Controlled hemorrhage with shock: > Hespan 1000cc

- Uncontrolled (infra-abdominal or thoracic) hemorrhage: > No IV fluid resuscitation.

6. Inspect and dress wound.

7. Check for additional wounds.

8. Analgesia as necessary: > Morphine (5mg) IV, wait 5minutes, repeat as necessary.

9. Splint fractures and recheck pulses.

10. Antibiotics

Cefoxitin 2gm slow IV push (over 3-5 minutes) for penetrating abdominal trauma, grossly contaminated wounds, massive soft tissue trauma, open fractures, or any patient in whom a long delay until CASEVAC or definitive treatment is expected.

11. Cardiopulmonary Resuscitation

CPR on the battlefield for victims of blast or penetrating trauma who have no pulse, no respirations, and no other signs of life will not be successful if attempted.

c. Phase Three: Combat Casualty Evacuation (CASEVAC) Care 1. Airway management

Unconscious casualty without airway obstruction: > Nasopharyngeal airway, endotracheal intubation, Combitube or laryngeal mask airway.

Unconscious casualty with airway obstruction: > Cricothyroidotomy if endotracheal intubation and/or other airway devices are unsuccessful.

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6-2. Breathing

Consider tension pneumothorax or hemothorax and decompress with needle thoracostomy if a casualty has unilateral penetrating chest trauma and progressive respiratory distress.

Consider chest tube insertion if a suspected tension pneumothorax is not relieved by needle thoracostomy

Oxygen.

3. Bleeding

Consider removing tourniquets and using direct pressure to control bleeding if possible.

4. IV

Start an 18 gauge IV or saline lock if not already done.

5. Fluid resuscitation

No hemorrhage or controlled hemorrhage without shock: > Lactated Ringer's at 250cc/hr.

Controlled hemorrhage with shock: > Hespan 1000cc initially.

Uncontrolled (infra-abdominal or thoracic) hemorrhage: > No IV fluid resuscitation.

Head Wound patient: > Hespan at KVO unless there is concurrent controlled hemorrhagic shock.

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6-UNITED STATES MARINE CORPS Mountain Warfare Training Center Bridgeport, California 93517-5001

FMST.07.37 04/01/02 STUDENT HANDOUT