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MEDICAL - TACTICAL & LONG RANGE MEDICAL GUIDELINES

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THE ART OF WAR - Part II - Waging War
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Tactical & Long Range Surveillance (LRRP) Medical Guidelines. These guidelines may not be updated or form the current basis of treatment with the Tactical Combat Causality Care Curriculum.
 

A. Scene Size-Up

 

1. Area security (scene safety) is the primary concern. You may be under hostile fire at this point-return fire and gain fire superiority (the best medicine on the battlefield is fire superiority). The medic must assess for safety and security when you arrive or realize aid is needed. Any condition (environmental or tactical) that can be considered harmful to either the patient or the medic must be addressed and corrected to produce the safest scene possible. Protect your patient from further injury. You do not want to get shot so find cover. If no cover is available, the casualty should not move and make as little noise as possible so as to not draw fire.  Sometimes the best and only way to evaluate your patient is to do it from a distance with a pair of bino’s. 

 

2. When the area is safe and secure the medic will simultaneously get a history, determine the number of patients, and begin assessing the patient’s responsiveness.  Attempt to get a history from anyone that may be present or had visual contact when the patient went down. After the medic receives the history he will act accordingly (i.e. GSW, explosion, fall from great height, burn, etc.) If the medic does not receive a response, an assessment and treatments will continue according to patient injuries.  Remember you must still provide return fire and security for you and your patient.  If your patient is able to return fire and watch for security threats then let them while you are attending to their injuries.

 

3. For situations with more than one patient, the medic will need to do a rapid triage to determine the most critical patient. In many instances dead casualties will have to be "triaged out" in order to properly identify those in most need of emergent care.

 

4. Additional help may be needed to position, extricate, triage, assist management or secure the scene.  Deciding how to move the patient should be in the team mission plan (SOP-Standard Operating Procedure). All available assistants will perform perimeter security until the medic requires or asks for help. Once the assistants are done they should move back to the perimeter to pull security—Remember SECURITY!

 

5. The medic should treat the C-spine with respect to the injury or the patient’s signs or symptoms (unexplained neurological deficit).  A general guideline is to determine if the MOI is capable of causing C-spine injury and if there are no injuries above the clavicles.  However in a tactical setting, the C-spine is not of the greatest concern. In penetrating neck injuries sustained in Vietnam, only 1.4% of patients would have benefited from immobilization. The average time it takes to immobilize a casualty is 5.5 minutes. In a tactical scenario this is not feasible—hazards far outweigh the gains.  In-line stabilization should be maintained until the C-spine can be palpated for abnormalities and pain with palpation or movement. The medic should elect to employ or for-go C-spine immobilization based on his clinical findings.

 

B Initial Assessment

 

1. Make a general impression of the patient based on visible injuries, skin color, level of responsiveness, or symptoms and history. Remember your overall impression of the casualty (ex: is the patient’s condition critical, poor, does he have a chest wound or obvious respiratory distress).

 

2. Determine the patient’s responsiveness: AVPU. As the medic you will need to be conscious of the response received from the patient.

 

3. Rapidly examine the patient from head to toe, visually. Attempt to locate apparent life threats (massive arterial bleeding, sucking chest wounds). Particular attention and aggressive management of external massive bleeding must be accomplished since this is the most frequent cause of death in military casualties. Control major bleeding to extremity with a tourniquet (team medic should assign standard location of team member tourniquet. Ex: right cargo pocket or left side of web gear).

 

4. Airway Assessment and Management.

 

a. Open airway – Use a modified jaw thrust to open the airway.

 

b. Look in the mouth and clear any potential obstructions. Attempts to manually clear obstructions with the fingers should be made first. This is best accomplished by rolling the patient on his side (Remember C –spine control) and finger sweeping from top to bottom. Suction may be required to remove blood and other debris. A laryngoscopic exam with Magill forceps or a Heimlich maneuver can remove larger obstructions.

 

c. Assess the airway, "look, listen, and feel" for a minimum of 5 seconds. You’re mainly concerned about the quality and adequacy of ventilation’s at this point. Exact rate is not important and a waste of precious time. Is the airway open and adequate to support life YES or NO?

 

d. Insert a nasopharyngeal airway if the patient is unable to maintain his own airway, not breathing spontaneously, or in respiratory distress. For burns with suspected inhalation injury or severe facial trauma, consider inserting an ET-Tube or Surgical cricothyrotomy.

 

e. Always reassess the patients airway, (LLF to obtain an approximate rate and rhythm), after inserting the nasopharyngeal airway or after intubation.

 

NOTE: A system of reassessing any intervention after a placement or implementation of an intervention should become standard procedure for all SOF operators. Movement’s cause changes to your interventions-check them. If you do something for your patient, make sure it works!

 

 f. Ensure adequate ventilation if necessary by BVM or Mouth to Mask. This can generally be done by "guesstimating." Is the rate to slow or to fast (Rate <10 or Greater than 28>)? If oxygen is available, administer at 15 LPM so as to obtain 100% saturation.

 

5. Breathing Assessment/Management.

 

a. Inspect the thorax for life threatening injuries:

 

(1) Bilateral rise and fall of the thorax during respirations.

 

(2) Flail segments in the chest wall (one section of the chest rises and falls while the rest of the chest rises and falls in symmetry).

 

(3) Trauma – Sucking chest wounds, Penetrating chest wounds, large bruises.

 

b. Treat all anterior injuries.

 

(1) Apply three-sided occlusive dressings to open chest wounds (Using plastic and tape, or petroleum gauze), use needle decompression to treat pneumothorax.

 

(2) Treat all other injuries according to protocol.

 

c. Auscultate the thorax for:

 

(1) Bilateral breath sounds.

 

(2) Rales, rhonchi, wheezing (Traumatic asphyxia, blast lung).

 

d. Palpate the anterior thorax.

 

(1) Flail segments.

 

(2) Crepitus (Rib Fx).

 

(3) Subcutaneous Emphysema (Lung injury, mediastinal compromise).

 

e. Palpate the posterior thorax by sliding hands as far under the body as possible without causing spinal manipulation. Remember that a missile needs to exit somewhere—always check the down side of any wound.

 

(1) Identify all life threatening posterior injuries.

(2) Treat posterior sucking chest wounds with three sided occlusive dressings. Temporary measures can be an IV bag or an abdominal dressing (still wrapped in plastic), placed between the wound and the ground. When the patient is lifted for movement, occlude with a three-sided dressing, and stabilize penetrating impaled objects.

 

NOTE: Treat all life threatening problems as they are found.

 

6. Circulatory Assessment/Management

 

a. Assess for a pulse. (Carotid/Femoral/Radial) Note the rate and strength. The location will give you a minimum baseline systolic BP. A simultaneous check for both the carotid and radial pulse will give you a quick reference for both BP and heart rate. Patients without radial pulses and a rapid carotid pulse are usually decompensating and require aggressive management with IV fluids.

 

b. Assess for peripheral perfusion. This can be simply done by noting skin color and temperature. Pinching the capillary bed of the finger and toenails is also acceptable.

 

c. Identify and control severe bleeding.

 

(1) Remember life over limb (if movement of a limb is necessary to stop bleeding). Severely angulated compound fractures are difficult to gain hemorrhage control. Angulation creates a cavity and the artery cannot be pressured against a bone to control bleeding.

 

(2) Identify exactly where the bleeding is coming from, not just the injury (If you identify an injury near the bleeding, that injury may not be the cause of the hemorrhage, look for other injuries in the area).

 

(3) Control of massive bleeding should begin simultaneously in the assessment of the airway and breathing.

 

(4) Apply the appropriate dressing, (field, pressure, tourniquets, or hemostats) when necessary.

 

(5) Tourniquets are placed on amputations. (Do not forget to dress the end of the stump during your rapid trauma assessment).

 

d. Identify the patients that will require more advance medical care for survival. These patients are considered your priority patients and need to be evacuated as soon as possible (tactical situation, terrain). Depending on the mode of evacuation and the number of patients you may have to triage the patients for evacuation.

 

C. Rapid Trauma Assessment (Reassessment/Resuscitative Phase).

 

1. Reassess the ABCs.

 

a. LLF for a minimum of 5 seconds (obtain a rate and rhythm). If the patient is being ventilated, remove the AMBU-bag. If the patient’s airway and respiration’s are adequate, complete the steps for airway assessment prior to intubation.

 

b. Intubate/Cric/Management – Intubate the patient if he is unconscious and does not have the presence of gag reflex and needs assistance in ventilation (patient is breathing less than 10 or more than 28). Remember: GSC less than 8, you better intubate!

 

c. Assess the pulses and distal circulation. Reassess all your treatment. If you had to move the patient for any reason (tactical situation, scene hazards), ensure that no dressings came loose and that hemorrhage control was not lost. Compound fractures commonly bleed severely prior to being immobilized and may require to be re-dressed or re-aligned. Pay particularly close attention to your occlusive dressings.

 

2. Assess the head.

 

a. You are basically looking for penetrating trauma, signs of basal skull fracture, and signs of increased intracranial pressure. You will need to look for things that will kill your patient.

 

b. Assess the pupils for PEARL. (Windows to the brain).

 

c. Assess the mouth, nose, and ears for potential airway compromising injuries, blood and cerebral spinal fluid.

 

3. Assess the neck.

 

a. Look for obvious injuries.

 

b. Inspect for JVD and tracheal deviation.

 

c. Inspect/Palpate/Treat the C-spine.

 

d. Dress any injuries prior to applying C-collar.

 

e. Apply a C-collar (PRN).

 

4. Assess the chest.

 

a. Inspect the anterior thorax for:

 

(1) Bilateral rise and fall of the thorax during respirations.

 

(2) Wounds that may have been missed during the initial assessment or dressings that may have been dislodged during the movement.

 

(3) Treat all anterior sucking chest wounds with a three-sided occlusive dressing.

 

(4) Assess the effectiveness of the chest dressings applied.

 

b. Auscultate.

 

(1) Lung fields at the apices, center, and bases (X3) bilaterally (note findings: rate, rhythm and depth).

 

(2) Auscultate heart sounds (note findings: rate, rhythm, and character).

 

c. Percuss the lung at the apices, center, and bases (X3) bilaterally for hypo/hyper resonance.

 

d. Palpate for flail segments, crepitus (Rib Fx), and subcutaneous emphysema.

 

5. Assess the abdomen/pelvis.

 

a. Look at the abdomen for obvious injuries. Penetrating trauma, distention, ecchymosis.

 

b. Look at the pelvis for obvious deformities. DO NOT PALPATE THE PELVIS IF DEFORMITY IS NOTED. Palpate for stability and note the patient’s response. Potential pelvis fractures should not be examined repeatedly.

 

6. Assess the extremities. Lower and upper.

 

a. Look for major injuries. Fracture and hemorrhage (uncontrolled arterial and major venous).

 

b. Treat all potentially life-threatening injuries and reassess all previous treatments for effectiveness.

 

7. Assess the posterior.

 

a. Log roll the patient (Conscious of C-spine at all times).

 

(1) Maintain C-spine and L-spine alignment.

 

(2) With the help of an assistant the medic will log roll the patient over and inspect and palpate the patient’s posterior. (Don’t forget your patient’s injuries! Log roll to the appropriate side.)

 

b. Palpate the long spine for step-offs, deviations, and lacerations. Treat all posterior injuries on the thorax with four sided occlusive dressings.

 

c. Inspect for Bright Red Blood from the Rectum. (BRBR).

 

d. Assess the back of the lower extremities for injuries.

e. After completion of the posterior exam, log roll the patient back into the lateral recumbent position. (Onto the field litter.)

 

f. Reassess the patient after completion of the log roll. Reassess and Tighten dressings and tourniquets (PRN).

 

8. Immobilize all long bone fractures at this time. Fracture immobilization is considered part of hemorrhage control due to associated blood loss caused by sharp edges and the close proximity of large blood vessels.

 

9. Identify all other injuries – All active bleeding should be identified and managed by this point of the rapid trauma assessment. Treatment of non-life and limb threatening injuries maybe deferred to the detailed physical exam.

 

NOTE: The patient can be exposed as needed throughout the initial and rapid trauma assessment.

 

10. Full set of vital signs.

 

a. Heart rate--include rate, character, and rhythm.

 

b. Respirations--include rate, character, and rhythm.

 

c. Blood pressure can be estimated using pulses however an accurate BP using a BP cuff is recommended.

 

d. All vital signs must be annotated for future reference (I normally place a strip of 3" tape on the casualties chest or leg and jot down time, HR, respirations, and BP).

 

11. At this point a decision must be made regarding the need for evacuation versus the patient’s need for fluid therapy. This decision is made based on the patient’s vital signs, tactical situation, distance to be moved, and risks factors in all of the previously listed categories if that particular category were to be delayed.

 

D. Initiate 2 large bore IVs.

 

1. The medic will start the first IV in an uninjured extremity of their choice. Properly secured the IV and make sure it is patent—remember that you may have to move the patient through the brush.

 

2. After the first IV has been initiated, reassess the patient’s ABC (this is a quick reassessment i.e. check for signs of life, if the patient is being ventilated, look for rise and fall of the chest. Quickly look at the patient’s bleeders for further hemorrhage.

 

3. Initiate a second peripheral IV on the patient.

 

NOTE: As a last resort, (All other sites are compromised) the medic may use a limb with a fracture or amputation, as long as the IV site is proximal of the injury.

 

4. Consider the use of analgesics for the patient if a long or far movement is expected or in cases of severe pain (Abdominal Wounds).

 

5. Caution should be used with patients that may have an uncontrolled internal hemorrhage. These patients should be kept in a state of "controlled shock" by giving only enough fluid to provide perfusion of the brain. This is usually accomplished by maintaining a systolic BP between 60-70 mm Hg. (Carotid Pulse).


E. Patient movement.

 

1. The medic will move the patient to a designated safe area for extraction and perform the detailed physical exam.

 

2. The patient must be moved safely and with caution given to his current injuries.

 

3. Rapid reassessment upon completion of movement.

 

a. Complete a gross inspection of the overall patient to ensure that all injuries are treated and that proper hemorrhage control has been achieved.

 

b. Check the patient’s IV’s and ensure that they have not been compromised during movement, that they are viable and not infiltrating, and that they are properly functioning and not empty.

 

c. Titrate the flow after adequate fluid replacement has been accomplished (IAW patient’s vital signs).

 

F. Detailed Physical Exam.

 

1. ABCs and treatment reassessment.

 

a. Airway – reassess the patient’s airway – LLF, obtain rate, character, and rhythm. Check placement and patency of the ET-Tube. (re-intubate patient PRN).

 

b. Breathing – Check any occlusive dressings on the chest to ensure they are still working effectively. Ensure the patient has bilateral breath sounds and did not develop a tension pneumothorax during movement.

 

c. Circulation – Confirm presence of pulse’s, obtain rate, character, and rhythm. Rapidly assess dressings for hemorrhage control and ensure they have not loosened during movement of the patient.

 

2. Head – Complete examination and treatment of all injuries found. Inspect for injuries using DCAPBTLS.

 

a. Deformities.

 

b. Contusions (bruises).

 

c. Abrasions.

 

d. Penetrations.

 

e. Burns.

 

f. Tenderness.

 

g. Lacerations.

 

h. Swelling.

 

i. Thoroughly inspect and palpate the scalp and skull running fingers through the hair to insure you find all injuries/lacerations or foreign bodies.

 

j. Palpate all facial bones (zygomatic, maxilla, mandible, nasal and orbital ridges).

 

k. Reassess the eyes for PERRL and injuries.

 

l. Assess the mouth, nose, and ears for blood/CSF, or battle sign. Ensure ET Tube is properly secured.

 

m. Treat and note all injuries encountered.

 

3. Neck

 

a.  If C-collar is in use (If the mechanism of injury led to the suspicion of a C-spine injury), do not remove for the purposes of performing this exam. Examine as much as possible without having to remove the C-collar.

 

b. Check the C-spine and re-enforce any dressings.

 

c. Assess for tracheal deviation, and jugular vein distention (JVD).

 

4. Shoulder girdle

 

a.  Inspect and palpate the clavicles and compress the shoulder girdle to assess stability. Splint appropriately.

 

5. Chest.

 

a. Inspect the chest for bandages that may have come off due to movement or the patient’s sweating. Symmetrical rise and fall of the chest. (Re-enforce all that are necessary).

 

b. Auscultate for breath sounds in all lung fields bilateral. Elicit a heart rate and state the rate, character, and rhythm.

 

c. Percuss for abnormal (hypo-hyper) resonance in all lung fields bilaterally.

 

d. Palpate for flail segments, fractured ribs, and/or any other abnormalities.

 

6. Abdomen.

 

a. Inspect for any abnormalities, previous injuries, or bruising that may indicate internal hemorrhage.

 

b. Palpate both lightly and deeply (except in evisceration), report tenderness, guarding, etc.

 

c. Treat all injuries and reinforce all dressings/treatments.

 

7. Extremities.

 

a. Inspect and palpate all extremities.

 

b. Assess distal neurovascular status.

 

c. Dress all wounds, immobilize and splints all fractures, amputations.

 

d. Reassess IVs and splints positional IVs sites.

 

8. Vital signs

 

a. The medic should take a set of vital signs at a minimum of every 5-15 minutes (Respiration’s, heart rate, and BP. Document the time taken).

 

NOTE: The patient should be ready for evacuation at this point if a CASEVAC has been called (which should have been done shortly after the injury occurred) in or on stand by.

 

G. Preparation for transport/evacuation. (MEDEVAC)

1. Call for a MEDEVAC using the Army nine-line format upon arrival to the extraction site or when you have stabilized your patient.

 

2. Upon notification of inbound aircraft or ambulance complete the following before loading the patient for transport.

 

a. Quick check of patient’s ABCs.

 

b. Ensure IVs are free flowing and have enough fluid for transport.

c. Reassess all treatments given.

 

d. Get a transport set of vital signs.

 

e. Complete patient assessment form or use SOAP format. Consider the use of analgesics for the patient if a long transport time is expected in cases of severe pain (Abdominal Wounds).


TRIAGE and MEDEVAC PROCEDURES

 

1.  Triage Codes

 

RED                               Immediately life threatening but treatable conditions.  These are the most critically injured patients, who could die within minutes if not treated.

 

YELLOW                   Serious but not immediately life threatening conditions.  These less critically injured patients could suffer serious disability or die if not treated within hours.

 

GREEN                      Minor conditions that can wait for hours to days to be treated.  They have non life or limb threatening injuries or illnesses and are generally the last to be transported.  This includes most of the patients who were separated from the seriously injured group at the beginning of the triage process by the fact that they could walk.

 

 

BLACK                      Non-salvageable conditions.  The black designation refers to patients who are dead or dying.  It may include those who still have vital signs or who might be resuscitated in a single patient scenario, but who cannot be treated in an MCI without  pulling resources away from patients with better chances of survival.

 

MEDEVAC CATEGORIES

 

Respiratory and Chest Trauma

Shock

Internal Injuries       

Multiple system trauma                                          

2nd & 3rd degree burns greater than 30%            

Amputation or non controllable bleeding         

Eye injuries    

Head / spinal injuries                                             

Extended extraction / transport

FOR LIKE MINDED PATRIOTS WHO WANT TO SURVIVE ANY AND ALL SITUATIONS THAT THEY MAY FACE.