Over the past decade, combat casualty care (CCC) has rapidly evolved due to the military operations in the Middle East and Afghanistan. During this same period, civilian EMS has encountered domestic terrorist attacks and bombings that have caused civilian EMS to care for combat-type injuries.
Like combat medics, civilian tactical EMS providers are likely to encounter penetrating trauma, blast-related mechanisms of injury, and multiple-casualty incidents while facing more complex casualty evacuation scenarios. Traditional EMS care and training in this new domestic combat environment has resulted in suboptimal safety paradigms and clinical outcomes.[1]
Tactical Combat Casualty Care (TCCC) Guidelines and civilian EMS
The National Association of Emergency Medical Technicians (NAEMT) Tactical Combat Casualty Care (TCCC) course trains the civilian EMS professional to consider and implement the special challenges of triaging and caring for trauma patients who have received combat injuries.[2] The TCCC course is designed to train combat EMS/military personnel deploying to support military operations. However, the course can be adapted for civilian law enforcement special operations officers and EMS professionals. NAEMT also offers a special version for tactical emergency casualty care.
An increased influx of military research affords civilian EMS an effective means to incorporate new evidence-based practice toward leading causes of trauma mortality. Trauma injuries and scene safety challenges seen in domestic attacks and in combat are similar. A safe and responsible civilian EMS approach is reflected in a growing trend to prepare civilian EMS professionals for the domestic combat or tactical environment. This transition continues with application of evidence-based guidelines from the Committee on Tactical Combat Casualty Care (CoTCCC). Here are a few guidelines regarding major causes of preventable combat-related mortality.
Stopping bleeding is essential
The leading cause of death during combat is uncontrolled hemorrhage, followed closely by injuries that affect airway and breathing.[4,5] Recent studies confirm that many of these injuries are preventable if managed correctly. These include:
- Compressible hemorrhage: 60 percent
- Tension pneumothorax: 33 percent
- Airway obstruction and ventilatory compromise: 6 percent.[6]
Evidence suggests that the majority of these hemorrhagic injuries can be successfully managed by using tourniquets in coordination with hemostatic agents.[7,8,9,10]
Tourniquets work by drastically reducing or completely obstructing distal blood flow to the vascular injury of the affected extremity. Optimal use of a limb tourniquet must result in both controlling of hemorrhage and cessation of the distal pulses in the affected extremity.
Junctional bleeding occurs between the trunk and the limbs (high level amputations) and between the pelvic area and legs. The most common type of junctional bleeding is groin hemorrhage. Most commercial tourniquets are unable to be placed in these areas. Junctional tourniquets (also called truncal tourniquets or combat clamps) are fitted with target compression devices that can be specifically positioned over the junctional injury site and pumped up or inflated until the compressions stops the bleeding.
Common uses of junctional tourniquets include controlling inguinal hemorrhage, controlling axilla hemorrhage and stabilizing pelvic fractures. There are many commercial limb and junctional tourniquets available on the market.
CoTCCC guidelines for the use of tourniquets
All sources of bleeding should be controlled. A CoTCCC recommended limb tourniquet should be used to control life-threatening external hemorrhage or for any traumatic amputation. It is recommended to apply the tourniquet directly to the skin two to three inches above the injury. If the bleeding does not stop with the first tourniquet, a second tourniquet should be applied side-by-side with the first. For those injuries in which a limb tourniquet is not possible, a junctional tourniquet should be used.
As with any intervention, it is important to reassess the tourniquet to make sure that it has not slipped out of place or lost constriction integrity. Ensure that the hemorrhage is controlled. If bleeding continues or a distal pulse remains, consider tightening the tourniquet or use an additional tourniquet side-by-side with the first tourniquet. Then reassess to ensure that both bleeding and the distal pulse have ceased.
- Limb and junctional tourniquets should be replaced by hemostatic or pressure dressings as soon as possible if all of the following criteria is met:
- The patient is not in shock
- It is possible to monitor the wound closely for bleeding
- The tourniquet is not being used to control hemorrhage from an amputated extremity
Every effort should be made to convert tourniquets in less than two hours if bleeding can be controlled by other means.[12,13] If possible, clearly mark all tourniquet sites with the time that the tourniquet was applied.
The CoTCCC 2014 guidelines approved the following limb and junctional tourniquets for military use:
- Combat Application Tourniquet (CAT)
- Special Operations Forces Tourniquet-Tactical (SOFTT)
- Emergency and Military Tourniquet
- Combat Ready Clamp (Croc) (junctional)
- Junctional Emergency Treatment Tool (JETT)
- SAM® Junctional Tourniquet.[12]
Managing an open pneumothorax
Research indicates that an open pneumothorax (sucking chest wound) can be treated effectively with an occlusive chest seal.[11] If an open chest wound is not treated correctly, it can develop into a life threatening tension pneumothorax.
An open pneumothorax occurs when the chest wall injury extends through the parietal pleura into the pleural cavity. This creates two openings that allow air into the thorax. During inspiration, air enters the chest through both openings (chest wall and trachea). However, the only way air can enter the alveoli is from the trachea and bronchioles. The extra opening in the chest wall greatly decreases the volume of air available to the alveoli.
Chest seals work by closing the chest wall opening, allowing air to enter the chest through its normal pulmonary route. Traditional three-sided dressings have shown to be ineffective in preventing conversion of an open pneumothorax to a tension pneumothorax.[11] Vented chest seals allow for the release of accumulated air or evacuation of blood and are effective in preventing the re-entry of air through the open chest wound. Non-vented chest seals adhere to the chest, creating a tight seal and do not allow air to escape or re-enter.
There are many commercial chest seals available on the market. They provide an effective rugged adherence property that allows them to stay in place in the presence of sweat, soil, air, or blood.
CoTCCC guidelines and the chest seal
Development of a tension pneumothorax is a common life threatening complication of an open chest wound. All open chest wounds should be treated by immediate application of a vented chest seal to cover the defect. If a vented chest seal is not available, use a non-vented chest seal.
Monitor the patient for the potential complication of a tension pneumothorax. If the patient develops increasing hypoxia, respiratory distress, or hypotension due to a tension pneumothorax, treat by removing or “burping” the dressing or by performing a needle decompression.[11]
In summary, EMS professionals must realize the value of military research and incorporate the latest evidence-based practice regarding the use of tourniquets and chest seals. As the potential for domestic combat injuries remains high, prehospital professionals must focus on those preventable causes of combat death and implement the latest guidelines to improve patient outcome. EMS professionals serve a pivotal role as active participants in the development of protocols involving domestic combat injuries.
References
1. Butler, F. (2003). Tactical combat casualty care: Combining good medicine with good tactics. Journal of Trauma, 54((5Suppl)), S2-3.
2. Tactical Combat Casualty Care. (2014, November 1). Retrieved March 6, 2015, from http://www.naemt.org/education/TCCC/tccc.aspx CDC. Ten Leading Causes of Death and Injury. (2014, November 14). Retrieved March 6, 2015, from http://www.cdc.gov/injury/wisqars/leadingcauses.html
3. Eastridge, B. J., Hardin, M., Cantrell, J., Oetjen-Gerdes, L., Zubko, T., Mallak, C., . . . Blackbourne, L. H. (2011). Died of Wounds on the Battlefield: Causation and Implications for Improving Combat Casualty Care. The Journal of Trauma: Injury, Infection, and Critical Care, 71(Supplement), S4-S8. doi:10.1097/TA.0b013e318221147b
4. Kotwal, R. S., Butler, F. K., & Edgar, B. P. (2013). Saving lives on the battlefield: A joint trauma system review of pre-hospital trauma care in combined joint operating area–Afghanistan (CJOA-A). 1, 1-49. Retrieved January 30, 2015, from https://tacticalelement.files.wordpress.com/2012/12/01-30-2013_centcom_final_report_pre-hospital_trauma_care_assessment_team.pdf.
5. Eastridge, B., Mabry, R., & Sequin, P. (2012). Death on the battlefield (2001-2011): Implications for the future of combat casualty care. Trauma and Acute Care Surgery, 73, S431-S437.
6. Kragh, J. F., Walters, T. J., Baer, D. G., Fox, C. J., Wade, C. E., Salinas, J., & Holcomb, J. B. (2008). Practical Use of Emergency Tourniquets to Stop Bleeding in Major Limb Trauma. The Journal of Trauma: Injury, Infection, and Critical Care, 64(Supplement), S38-S50. doi:10.1097/TA.0b013e31816086b1
7. Kragh, J. F., O’Neill, M. L., Walters, T. J., Dubick, M. A., Baer, D. G., Wade, C. E., . . . Blackbourne, L. H. (2011). The Military Emergency Tourniquet Program’s Lessons Learned With Devices and Designs. Military Medicine, 176(10), 1144-1152. doi:10.7205/MILMED-D-11-00114
8. Naval Operational Medical Lessons Learned, Feedback to the Field #11: Application of the Combat Action Tourniquet. (2012, February). Retrieved April 9, 2015, from https://www.dmsb.mil/jmteLinksResources.asp
9. Kling, D. R., Vander Wilden, G., Kragh, J. F., & Blackbourne, L. H. (2012). Forward assessment of 79 prehospital battlefield tourniquets used in the current war. Journal of Special Operations Medicine, Winter(12), 33-38.
10. Butler, F. K., Dubose, J. J., Otten, E. J., Bennett, D. R., Gerhardt, R. T., & Kheirabadi, B. S. (2013). Management of open pneumothorax in tactical combat casualty care: TCCC guidelines change 13-02. Journal of Special Operations Medicine, 13(3), 81-86.
11. Shackelford, S. A., Butler, F. K., Kragh, J. F., Stevens, R. A., Seery, J. M., & Parson, D. L. (2014). Optimizing the use of limb tourniquets in tactical casualty care: TCCC guidelines change 14-02. 1-41. Retrieved April 10, 2015, from http://www.vighter.com/wp-content/uploads/2015/01/Position-Paper.pdf
12. Kragh, J. F., Walters, T. J., Westmoreland, T., Miller, R. M., Mabry, R. L., Kotwal, R. S., & Ritter, B. A. (2013). Tragedy into Drama: An American history of tourniquet use in the current war. Journal of Special Operations Medicine, 13, 5-25.
