Слайд 1Introduction to
Tactical Combat Casualty Care
02 June 2014
Слайд 3What is TCCC and Why Do I Need to Learn
about it??
Coalition forces presently have the best casualty treatment and
evacuation system in history.
TCCC is what will keep you alive long enough to benefit from it.
Слайд 4Comparison of Statistics for Battle Casualties, 1941-2005
Holcomb et
al J Trauma 2006
Note: CFR is the Case Fatality Rate
– the
percent of those wounded who die
The U.S. casualty survival rate in Iraq and Afghanistan has been the best in U.S. history.
Слайд 5Why Are We Doing Better?
Improved Personal Protective Equipment
Tactical Combat Casualty
Care
Faster evacuation time
Better trained medics
Holcomb et al J Trauma 2006
Слайд 6TCCC: The New Standard of Care for Managing Trauma on
the Battlefield
Used by Army, Navy, Air Force, Marine Corps, Coast
Guard
Used by most coalition partner nations
Used by NATO
Used by other countries around the world
Слайд 7Objectives
EXPLAIN the differences between military and civilian pre-hospital trauma care
DESCRIBE the key factors influencing combat casualty care
UNDERSTAND how
TCCC developed
DESCRIBE the phases of care in TCCC
Слайд 8Importance of the
First Responder
Almost 90% of all combat deaths
occur before the casualty reaches a Medical Treatment Facility (MTF)
The
fate of the injured often lies in the hands of the one who provides the first care to the casualty.
Corpsman, medic, or pararescueman (PJ)
Combat Lifesaver or non-medical combatant
Слайд 10Berator
Tactical Trauma Care Setting –
Shrapnel Wound in the Hindu Kush
Слайд 11Prehospital Trauma Care:
Military vs. Civilian
Hostile fire
Darkness
Environmental extremes
Different wounding
epidemiology
Limited
equipment
Need for tactical maneuver
Long delays to hospital care
Different medic training and experience
Слайд 12Prior Medical Training
Combat medical training historically was modeled on civilian
courses
Emergency Medical Technician
Advanced Trauma Life Support
Trained to standard of care
in non-tactical (civilian) settings
Tactical elements not considered
Слайд 13Different Trauma Requires Different Care Strategies
It is intuitive that combat
and civilian trauma are different, BUT…
It is difficult to devise
and implement needed changes.
No one group of medical professionals has all of the necessary skills and experience.
Trauma docs and combat medical personnel have different skill sets. Both are needed to optimize battlefield trauma care strategies.
Tourniquets are one striking example of how battlefield trauma care has sometimes been slow to change.
Слайд 14 Tourniquets in WWII
Wolff AMEDD J April 1945
“We
believe that the strap-and-buckle tourniquet in common use is ineffective
in most instances under field conditions…it rarely controls bleeding no matter how tightly applied.”
Слайд 15Over 2500 deaths occurred in Vietnam secondary to hemorrhage from
extremity wounds. These casualties had no other injuries.
Vietnam
Слайд 16Tourniquets in U.S Military
Mid-1990s
Old strap-and-buckle tourniquets were still being issued.
Medics
and corpsmen were being trained in courses where they were taught not to use them.
Слайд 17SOF Deaths in the GWOT
Holcomb, et al
Annals of Surgery
2007
Factors That Might Have Changed Outcomes (82 Fatalities – 12
Potentially Survivable)
Hemostatic dressings/direct pressure (2)
Tourniquets (3)
Faster CASEVAC or IV hemostatic agents (7)
Surgical airway vs. intubation (1)
Needle thoracostomy (1)
PRBCs on helos (2)
Battlefield antibiotics (1)
Слайд 18Tourniquets – Beekley et al
Journal of Trauma 2008
31st CSH in
2004
165 casualties with severe extremity trauma
67 with prehospital tourniquets; 98
without
Seven deaths
Four of the seven deaths were potentially preventable had an adequate prehospital tourniquet been placed
Слайд 19 Tactical Combat Casualty Care in Special Operations
Military Medicine
Supplement
August 1996
Trauma care guidelines
customized for the battlefield
Слайд 20TCCC
Originally a Special Operations research effort
Trauma management plans that take
into account the unique challenges faced by combat medical personnel
Now
used throughout U.S. military and by most allied countries
TCCC has helped U.S. combat forces to achieve the highest casualty survival rate in history.
Слайд 21TCCC Approach
Identify the causes of preventable death on
the battlefield
Address them aggressively
Combine good medicine with good tactics
Слайд 22(Data based on the Wound Data Munitions Effectiveness Team (WDMET)
during the Vietnam War between 1967 and 1969)
NEXT
Слайд 23Potentially Preventable
Deaths (232) in OIF and OEF
From evaluation of 982
casualties, and casualties could have more than 1 cause of
death. (Kelly J., J Trauma 64:S21, 2008)
Слайд 24Preventable Death on the Battlefield: OEF and OIF
Eastridge 2012 Study:
4,596 U.S. deaths
87% pre-hospital deaths
24% of pre-hospital
deaths were potentially survivable
Holcomb, et al, 2005 – US SOF Preventable Deaths = 15%
Kelly, et al, 2008 – US Military Preventable Deaths = 24%
Eastridge, et al, 2011, 2012 – US Military Preventable Deaths = 27.6%
4
Unclassified
Слайд 25Point of Wounding Care
Causes of preventable death on the battlefield
today:
Hemorrhage from extremity wounds
Junctional hemorrhage (where an arm or leg
joins the torso, such as in the groin area after a high traumatic amputation)
Non-compressible hemorrhage (such as a gunshot wound to the abdomen)
Tension pneumothorax
Airway problems
Слайд 26Junctional Hemorrhage
These types of wounds are often caused by IEDs
and may result in junctional hemorrhage.
Слайд 27Extremity Hemorrhage
Click on picture to start video
Слайд 28Tension Pneumothorax
Air escapes from injured lung – pressure builds
up
in chest
Heart compressed - not able to pump well
Air pressure
collapses lung
and pushes on
heart
Слайд 30Three Objectives of TCCC
Treat the casualty
Prevent additional casualties
Complete the mission
Слайд 31 TCCC Guidelines 1996
Tourniquets
Aggressive needle thoracostomy
Nasopharyngeal airways
Surgical airways for maxillofacial
trauma
Tactically appropriate fluid resuscitation
Battlefield antibiotics
Improved battlefield analgesia
Combine good tactics and
good medicine
Scenario-based training
Combat medic input to guidelines
Слайд 32Changes in TCCC:
How Are They Made?
The Committee on Tactical Combat
Casualty Care
Слайд 33 Committee on Tactical
Combat Casualty Care
Part of
the Joint Trauma System
42 members from all services in the
DoD and civilian sector
Trauma Surgeons, ER and Critical Care physicians, operational physicians; medical educators; combat medics, corpsmen, and PJs
100% deployed experience
Meet periodically; update TCCC as needed
Слайд 34 TCCC Now:
Additional Interventions
Hemostatic dressings
Intraosseous infusion devices
Hypotensive
resuscitation
Fentanyl lozenges for severe pain
Ketamine as an analgesic option
Junctional hemorrhage
control devices and TXA
Hypothermia prevention
Management of wounded hostile
combatants
Слайд 35TCCC: How Do We
Know That it’s Working?
Слайд 36TCCC
“I am writing to offer my congratulations for the recent
dramatic advances in prehospital trauma care delivered by the U.S.
military. Multiple recent publications have shown that Tactical Combat Casualty Care is saving lives on the battlefield.”
Dr. Jeff Salomone
American College of Surgeons Committee on Trauma
Chairman of Prehospital Trauma Subcommittee
Letter to ASD Health Affairs
10 June 2008
Слайд 37Mabry and McManus
AMEDD Center and School
“The new concept of Tactical
Combat Casualty Care has revolutionized the management of combat casualties
in the prehospital tactical setting.”
Critical Care Medicine
July 2008
Слайд 38USMC Casualty
Scenario 2008
CoTCCC gets input directly from combat
medics,
corpsmen, and USAF pararescuemen (PJs)
15 casualties
- 4 tourniquets applied
3 lives saved - 4th casualty died from chest wound
Слайд 39Tourniquets – Kragh et al:
Two Landmark Papers
Published in 2008/2009
Tourniquets are saving lives on the battlefield
31 lives
saved in 6 months by tourniquets
Author estimates 2000 lives saved with tourniquets
in this conflict up to that date (2009)
No arms or legs lost because of tourniquet use
Слайд 40What Do the Soldiers Say?
A recent U.S. Army Training and
Doctrine Command survey of Soldiers in combat units found that
TCCC is the second most valued element of their training, exceeded only by training in the use of their individual weapon.
COL Karen O’Brien
TRADOC Surgeon
CoTCCC Meeting April 2010
Слайд 41Eliminating Preventable
Death on the Battlefield
TCCC in the 75th
Ranger Regiment
All Rangers and docs trained in TCCC
Ranger
preventable death incidence: 3%
Overall U.S. military preventable deaths: 24%
Слайд 42Hartford Consensus
2 April 2013
Working group organized by American College
of Surgeons Board of Regents and FBI
In response to Sandy
Hook shootings
Excerpt from findings:
Слайд 43ASDHA TCCC Letter
14 February 2014
Слайд 44USFOR-A FRAGO 14-067
21 March 2014
All physicians, physician assistants, nurse practitioners,
medics, corpsmen, parajumpers (PJs) and nurses in CJOA-A (Afghanistan) will
be trained in TCCC
Training will be done in accordance with current TCCC Guidelines (found on Joint Trauma System website)
Curriculum to support this training is found on the Military Health System website
Training is reportable to the chain of command
Units will field equipment to perform TCCC
Слайд 45Phases of Care in TCCC: Timing Is Everything
Casualty scenarios in
combat usually entail both a medical problem and a tactical
problem.
We want the best possible outcome for both the casualty and the mission.
Good medicine can sometimes be bad tactics; bad tactics can get everyone killed or cause the mission to fail.
Doing the RIGHT THING at the RIGHT TIME is critical
Слайд 46TCCC Phases of Care
TCCC divides care into 3 phases based
on the tactical situation.
During the gunfight, attention is focused
primarily on eliminating the threat.
As the threat decreases, increasing focus is applied to providing the best possible medical care for the casualties.
Слайд 47Phases of Care in TCCC
Care Under Fire
Tactical Field Care
Tactical
Evacuation Care
Слайд 48Care Under Fire
Care under fire is the care rendered
by the first responder or combatant at the scene of
the injury while he and the casualty are still under effective hostile fire. Available medical equipment is limited to that carried by the individual or by the medical provider in his or her aid bag.
Слайд 49Tactical Field Care
Tactical Field Care is the care rendered
by the first responder or combatant once he 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. Available medical equipment is still limited to that carried into the field by unit personnel. Time to evacuation to a medical treatment facility may vary considerably.
Слайд 50Tactical Evacuation Care
Tactical Evacuation Care is the care rendered
once the casualty has been picked up by an aircraft,
ground vehicle or boat. Additional medical personnel and equipment that may have been pre-staged should be available in this phase of casualty management.
Слайд 51Summary of Key Points
Prehospital trauma care in tactical settings is
very different from civilian settings.
Tactical and environmental factors have a
profound impact on trauma care rendered on the battlefield.
Good medicine can be bad tactics.
Up to 24% of combat deaths today are potentially preventable.
Good first responder care is critical.
TCCC will give you the tools you need!
Слайд 52Summary of Key Points
Three phases of care in TCCC
Care Under
Fire
Tactical Field Care
TACEVAC Care
Слайд 53Summary of Key Points
TCCC – designed for combat
NOT designed for
civilian trauma settings
But may have applicability in some cases
