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Perform Tactical Combat

Casualty Care
First Aid 1
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Combat Lifesaver
Functioning as a combat lifesaver is your
secondary mission. Your primary mission is
still your combat duties. Your first priority
while under fire is to take cover, return fire
and kill the enemy. You should render care
to injured soldiers only when such care does
not endanger your primary mission.
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Introduction
About 90 percent of combat deaths occur on
the battlefield before the casualties reach a
medical treatment facility (MTF).
Most of these deaths cannot be prevented
by you or the medic.
Examples: Massive head injury, massive
trauma to the body.
However, a percentage of these deaths can
be prevented.
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Combat Deaths From Vietnam
KIA: 31% Penetrating head trauma
KIA: 25% Surgically uncorrectable torso
trauma
KIA: 10% Potentially surgically correctable
trauma
KIA: 9% Hemorrhage from extremity wounds
KIA: 7% Mutilating blast trauma
KIA: 5% Tension pneumothorax
KIA: 1% Airway problems
DOW: 5% Mostly from infections and
complications of shock
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Primary Injury Site as a Cause of
Death in the Potentially Preventable
Deaths from OIF/OEF
Torso 32%
Extremity
44%
Mult 8%
Head/Neck
16%
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Hemorrhage
81%
CNS
2%
Airway
11%
MSOF
4%
Hemorrhage is the Primary Cause of Death
in Combat
32% Compressible
68% Non-compressible
Other
2%
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Combat Deaths
However, about 15-18 percent of the
casualties who die before reaching a
medical treatment facility can be saved if
lifesaving interventions are performed.
Stop severe bleeding (hemorrhage)
Relieve tension pneumothorax
Restore the airway
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Hemorrhage Deaths
Hemorrhage is by far the leading cause of
death. In the Vietnam conflict, over 2500
Soldiers died due to hemorrhage from
wounds to the arms and legs even though
the Soldiers had no other serious injuries.
These Soldiers could have been saved by
applying hemorrhage control measures to
stop the bleeding.
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Tactical Combat Casualty Care
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Tactical Combat Casualty Care
(cont.)
TCCC can be divided into three phases:
Care Under Fire
Tactical Field Care
Tactical Evacuation Care
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Care Under Fire
The first phase is Care Under Fire. In this
phase, you are under effective hostile fire
and are very limited as to the care you can
provide. Primary objective is to stop life-
threatening bleeding from extremity wounds
by applying a tourniquet to the wounded
limb, and moving yourself and the casualty
to cover.
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Tactical Field Care
The second phase is Tactical Field Care.
In this phase, you and the casualty are no
longer under effective enemy fire and have
more time to provide more care.
Bleeding
Airway
Breathing
Shock
Transport
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Tactical Evacuation Care
The third phase is Tactical Evacuation Care.
In this phase, you render care during
casualty evacuation.
Recheck all previous interventions
Head to toe check, monitor
Document care
Package casualty for transport
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Identify items used in first aid
Field dressing
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Identify items used in first aid
(cont.)
Emergency Bandage
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Identify items used in first aid
(cont.)
Combat Gauze
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Identify items used in first aid
(cont.)
Combat Application Tourniquet
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Gatifloxacin
(antibiotic)
Vioxx
(anti-inflammatory )
Tylenol
(pain reliever)
Identify items used in first aid
(cont.)
Combat Pill Pack
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Identify items used in first aid
(cont.)
Improved First Aid Kit (IFAK)
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Identify items used in first aid
(cont.)
Combat Lifesaver Aid Bag
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Care Under Fire
Take cover and return fire.
Direct or expect casualty to remain engaged
as a combatant, if able.
Direct casualty to move to cover and apply
self-aid if able.
Try to keep the casualty from sustaining any
additional wounds.
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Before Approaching the Casualty
Scan the area for potential danger.
Survey the area for small arms fire.
Detect area for fire or explosive devices.
Survey buildings, if any, for structural
stability.
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Before Approaching the Casualty
(cont.)
Determine the best route of access to the
casualty and the best route of egress. Plan
your evacuation route prior to exposing
yourself to hostile fire.
Request covering fire to reduce the risk to
yourself and the casualty.
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Anticipate the type of injuries the casualty
may have received.
Anticipate what care will probably be
needed.
Did the casualty fall from a wall (fractures)?
Was there an explosion (blast effects)?
Was there small arms fire (bleeding
wounds)?
Before Approaching the Casualty
(cont.)
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Anticipate how your actions will affect the
enemy's fire.
Can the casualty move to cover on his own?
Plan what you will do to help the casualty
before you go to the casualty's aid (control
life threatening bleeding).
Before Approaching the Casualty
(cont.)
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If under effective hostile fire, return fire as
directed or required. Do not expose yourself
to enemy fire in order to provide care.
If possible, determine if casualty is alive or
dead. Provide lifesaving care to the live
casualty.
Before Approaching the Casualty
(cont.)
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Suppress enemy fire. Reducing enemy fire
may be more important to the casualty's
survival than the treatment you can
provide.
If the casualty can function, direct him to
return fire, move to cover, and administer
self-aid.
If the casualty is unable to return fire or
move to safety and you cannot assist him,
tell the casualty to lay still.
Before Approaching the Casualty
(cont.)
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When the combat situation allows you to
safely assist the casualty:
Approach the casualty by the safest route.
Form a general impression as you approach
the casualty (extent of injuries, chance of
survival, and so forth).
If you decide to move the casualty (and
yourself) to a safer location, take the
casualty's weapon and other mission-
essential equipment with you.
Before Approaching the Casualty
(cont.)
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Care Under Fire (cont.)
Airway management is generally best deferred
until the Tactical Field Care phase
Stop life-threatening external hemorrhage if
tactically feasible:
- Direct casualty to control hemorrhage by self-
aid if able.
- Use a tourniquet for hemorrhage that is
anatomically amenable to tourniquet application.
Apply tourniquet high on injured limb, over the
uniform, tighten it, and move casualty to cover.
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Care Under Fire (cont.)
If the casualty cannot seek safety on his
own and you can safely assist him, do so.
Communicate the medical situation to the
team leader.
If the casualty has severe bleeding from a
limb or has an amputation, apply a
tourniquet. Do not worry about the
casualty's breathing at this time.
Use Tactical Casualty Movement techniques
to move yourself and the casualty to cover.
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Combat Application Tourniquet
(CAT)
WINDLASS
OMNI TAPE BAND
WINDLASS STRAP
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Tourniquet
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Tactical Casualty Movement
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Tactical Casualty Movement (Drags)
One-man drag Two-man drag Cradle drop drag
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Tactical Casualty Movement (Carries)
Hawes carry
One-man
support carry
Modified two-man,
fore-and-aft carry
Two-man support carry
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Tactical Field Care
The tactical situation has changed and you
are no longer under enemy fire.
This gives you more time and more safety to
perform more medical interventions.
However, the tactical situation can change
again and you may find yourself back in the
Care Under Fire phase.
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Tactical Field Care (cont.)
Perform tactical field care when you and the
casualty are no longer under direct enemy
fire. That is, the casualty has moved, or
been moved to a safe location, enemy fire
has been suppressed, or you are protected
from direct enemy fire, or the casualty was
already in a safe location.
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Quiz
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Tactical Field Care
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Tactical Field Care (cont.)
Form a general impression of the casualty
as you approach
If the casualty has suffered from a blast or
penetrating trauma and has no signs of life
(no pulse and no respirations), do not
perform cardiopulmonary resuscitation
(CPR). The casualty will probably not
survive and you may expose yourself to
enemy fire.
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Check the Casualty for
Responsiveness
If the casualty is conscious, ask where it
hurts or where his body feels different than
usual. This provides you information you
can use in evaluating and treating the
casualty.
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Tactical Field Care (cont.)
Determine the casualty's level of
consciousness. Ask questions that require
more than a "yes" or "no" answer.
Examples of such questions are:
What is your name?
What is the date?
Where are we?
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Tactical Field Care (cont.)
A--The casualty is alert, knows who he is,
the date, where he is, and so forth
V--The casualty is not alert, but does
responds to verbal commands.
P--The casualty responds to pain, but not
verbal commands.
U--The casualty is unresponsive
(unconscious).
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Reassess Hemorrhage
Reassess prior hemorrhage control
measures
Expose and assess wound
If tourniquet is needed apply directly on the
skin 2-4 inches above wound
Apply hemostatic agent (Combat Gauze)
and pressure if wound not amenable to
tourniquet (axilla, groin, neck)
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Hemorrhage Control
After tourniquet application and tactical
situation permits, check distal pulse. If pulse
is present tighten existing tourniquet more or
add a second tourniquet above the first one
side by side and tighten it (controlling
arterial blood flow will prevent a
compartment syndrome in the distal limb).
If tourniquet is not necessary, apply
hemostatic agent and pressure bandage
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Tactical Field Care
Check the casualty's airway.
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Tactical Field Care
Head Tilt Chin Lift
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Nasopharyngeal Airway
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Tactical Field Care
Recovery position
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Tactical Field Care
Check for open chest wounds.
A penetrating wound to the chest can result in the
collapse of the casualty's lung.
Seal the open chest wound with an occlusive
(airtight material) bandage.
Have the casualty exhale and apply the material,
tape on all four sides.
Seal both entrance and exit wounds, place
casualty in sitting position.
Transport casualty with injured side down.
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Asherman Chest Seal
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Other Chest Seals
HyFin
TM
Chest Seal Bolin Chest Seal
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Tension Pneumothorax
Monitor casualtys respiration
If progressive respiratory distress develops
this is a tension pneumothorax
Perform needle chest decompression
Insert 14 gauge 3.25 in needle catheter into
2
nd
ICS MCL all the way to the hub
Remove needle and tape catheter to chest
Monitor respirations
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Needle Decompression Lines
MCL
AAL
MAL
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Needle Chest Decompression
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Tactical Field Care
Take measures to control bleeding.
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Tactical Field Care
Apply an emergency bandage and direct
pressure to a severely bleeding wound.
If conventional methods of controlling
severe bleeding do not control the bleeding
on an extremity, apply a tourniquet.
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Tactical Field Care
Apply a tourniquet to a major amputation
of the extremity.
If not already done.
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Tactical Field Care
Take measures to control shock.
Hypovolemic shock results when there is a
sudden decrease in the amount of fluid
circulating in the casualty's circulatory
system. Although heat stroke, diarrhea, and
dysentery can also cause hypovolemic
shock, we are chiefly concerned about
hypovolemic shock due to blood loss from a
wound.
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Tactical Field Care
The first step in preventing or controlling
shock is to stop the bleeding. You have
already taken steps to control bleeding by
applying dressings and tourniquets as
needed to control external bleeding, that is,
bleeding that you can see on the outside of
the body. The casualty may also have
internal bleeding, such as bleeding into the
abdominal or chest cavities, which you
cannot treat. This requires rapid evacuation.
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Preventing/Treating Shock
Position casualty on back or position of
comfort (chest wound)
Elevate legs slightly higher than level of
heart
Do not elevate legs if:
They are unsplinted
Suspected spinal injury
Open chest wound casualty may feel better
sitting up or on side
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Preventing/Treating Shock
(cont.)
Do not elevate legs if:
Abdominal wound (flex knees)
Head injury
Casualty is unconscious
Cover entire casualty with blanket to keep
warm (Blizzard Blanket, Ready Heat
Blanket).
Reassure Casualty.
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Blizzard Blanket & Ready-Heat
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Splint Fractures
Splint fractures as circumstances allow,
insuring pulse, motor, and sensory checks
before and after splinting.
Be aware of
compartment
syndrome in
blast injuries.
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Penetrating Eye Trauma
Penetrating Eye Trauma
If a penetrating eye injury is noted or
suspected:
a) Perform a rapid field test of visual acuity.
b) Cover the eye with a rigid eye shield (NOT a
pressure patch.)
c) Ensure that the 400 mg moxifloxacin tablet in
the combat pill pack is taken if possible.
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Checking Vision in the Field
Dont worry about charts.
Determine which of the following the
casualty can see (start with Read print and
work down the list if not able to do that).
Read print
Count fingers
Hand motion
Light perception
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Eye Protection
Use your tactical eyewear to cover the
injured eye if you dont have a shield.
Using tactical eyewear in the field will
generally prevent the eye injury from
happening in the first place!
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TCCC Lessons Learned: Iraq
and Afghanistan
Shield for open globes often not being done
Preventable loss of vision
Eye shields not in IFAKs
Shield after injury No shield after injury
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Tactical Field Care
Treat other injuries.
Splint any obvious long bone fractures.
Administer the soldier's combat pill pack, if
available.
Mobic 15mg
Tylenol 2 650mg Caplets
Moxifloxacin 400mg
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Obtain Medical Care for Soldiers
Who Have Been Subjected to Blasts
All Soldiers who have been subjected to
blasts must be referred to medical personnel
All personnel in any damaged vehicle (e.g., blast,
accident, rollover)
All dismounted Soldiers
within 50 meters of a blast
All within a structure hit by
an explosive device
Anyone who sustains a
direct blow to the head or loss of consciousness
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Tactical Field Care
Communicate.
Let your unit leader know the casualty's
condition. Will the casualty be able to return
to duty? Does the casualty require medical
evacuation to save life or limb? Is something
else appropriate, such as evacuation by
non-medical vehicle?
Initiate a Casualty Card.
Monitor the casualty.
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Tactical Evacuation Care
If the casualty requires evacuation, prepare
the casualty for evacuation.
Make sure that the casualty is covered with
a blanket if you need to keep him warm.
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Tactical Evacuation Care
If the casualty is to be evacuated by medical
transport, you may need to prepare and
transmit a MEDEVAC request (separate
lesson).
If the casualty has to be moved to a
collection point for evacuation, you may
need to prepare a SKED

litter, a Talon
litter, or improvised litter, place the casualty
on the litter, and evacuate the casualty to
the collection point.
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Tactical Evacuation Care
Talon

Litter SKED

Litter
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Tactical Evacuation Care
If an unconscious casualty is being
evacuated on a non-medical vehicle, the
combat lifesaver may need to accompany
the casualty and render additional care as
needed.
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Summary
The fate of the wounded rests in the hands of the
ones who apply the first dressing.
LTC Nicholas Senn, Wisconsin Army National Guard
Founder of the Association of Military Surgeons of the United States
(1898)
If during 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.
CAPT (Ret.) Frank Butler, M.D., USN
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Initiating a Field Medical
Card
1
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Purpose of the US Field
Medical Card (DD Form 1380)
Provides medical personnel with essential
information about the casualtys injury and
treatment given
Used in forward combat areas by North Atlantic
Treaty Organization (NATO) troops
Instructions in French and English
Prepared on any casualty treated within a
theater of operations
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US Field Medical Card (DD Form 1380)
Issued in a pad
Pad contains 10 sets
Set consists of card with attached wire,
protective sheet, and duplicate paper form
Blocks 1, 3, 4, 9, 11 (primary information)
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Block 1
Name Enter casualtys name in last name, first name, middle initial format
Rank Enter abbreviation of casualtys rank (SGT, CPT)
SSN Enter Casualtys social security number. If the casualty is a member
of a foreign military, or prisoner of war, enter military service number
instead. Leave blank if not in military
MOS Enter casualtys military occupation specialty (MOS) code if enlisted
or area of concentration (AOC) if an officer in the box titled SPECIALTY
CODE/GPM
Sex Mark the appropriate box to the left of MALE / HOMME FEMALE /
FEMME
Religion Enter the casualtys religious preference in box titled RELIGION
Smith, John D. SGT
123-45-6789 11 B Religion
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Block 3
If casualty is suffering trauma (battle
casualty), mark box BC/BC
If nuclear, biological, or chemical
casualty, mark box NBC/NBC
If casualty is ill and is not classifiable
as one of the other three categories,
mark box DISEASE/MALADE
If casualty is suffering from combat
stress or other psychological injury,
mark box PSYCH/PSYCH
Mark figures to show location of
injuries (entry and exit)
Mark appropriate box or boxes to
describe casualtys injuries
If OTHER is marked, explain injuries
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Block 4
Check appropriate box for level of consciousness
AVPU system
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Block 9
Enter a brief description of the treatment given
Use approved abbreviations if possible
If needed, use block 14 for additional space
Tourniquet applied to R leg above knee. IV (Hextend)
L forearm, 16ga, wide open. Bandage applied over
stump. Pt. states allergy to PCN.
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Authorized Abbreviations
Abraded wound Abr W
Contused wound Cont W
Fracture (compound) open FC
Fracture simple (closed) FS
Fracture (compound) open comminuted - FCC
Gun shot wound GSW
Lacerated wound LW
Multiple wounds MW
Penetrating wound Pen W
Perforating wound Perf W
Severe SV
Slight - SL
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Block 11
Enter your initials (not your name) in the far right of the
signature box of Block 11
This will let medical personnel know who initially treated
the casualty and still leave room for the medical officer to
sign the card
MN
07/01/30
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Secondary Information
(Front of Form)
If you have time, you can also fill out some
of the other blocks on the front of the form
after you have filled in the primary five
blocks
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Block 2
Enter the casualtys unit
Enter the casualtys country, for example USA
Check the appropriate armed service element. Mark the
A/T box for Army, AF/A for Air Force, N/M for Navy,
and MC/M for Marine Corps
A Co. 187
th
Med Bn
USA
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Block 5/6
Skip Block 5 since you have not been taught to take an
accurate pulse and record it properly
BLOCK 6: If a tourniquet was applied, mark the YES
block. If not applied, leave blank
If you checked YES, enter date in YY/MM/DD format and
the time in 24-hour time that the tourniquet was applied
07/01/30 14:24
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Block 7
Skip this block
Used by Combat Medic to record the administration of
Morphine
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Block 8
If an intravenous infusion (IV) has been initiated:
Write the type of IV fluid (Hextend) in the IV/IV box
Write the date and time that the IV solution was begun in
the TIME/HEURE box. Write the date in YY/MM/DD
format and the time in 24-hour time format
Hextend
07/01/30 14:27
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Block 10
Check the box in front of the appropriate disposition
(Return to Duty or Evacuated)
Enter the date (YY/MM/DD) and time (military) of the
disposition in the TIME/HEURE box
07/01/30 14:40
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Reverse Side of the Field Medical Card
The reverse side of the Field Medical Card
is normally filled out by medical personnel
or other personnel once the casualty
reaches a medical treatment facility, such
as a battalion aid station (BAS). Your self-
study book contains a discussion on these
blocks. Since you will not be involved in
filling them out, they will not be covered in
this lesson.
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TACTICAL COMBAT
CASUALTY CARE (TCCC)
CARD
DA FORM 7656
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Point of Injury (POI)
Documentation of Care
Most casualties injured on the battlefield do
not have their initial care documented prior
to evacuation.
DD form 1380 is an outdated cumbersome
form to fill out. Much of the information is
unnecessary.
Electronic forms are not compatible with the
battlefield environment.
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TCCC Casualty Card
A new casualty card is available to help
document the care for injured Soldiers at the
point of wounding. This card is based on the
principles of TCCC.
This new card addresses the initial
lifesaving care provided at the point of
wounding.
Its format is simple with a circle or X in the
appropriate block.
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TCCC Card
Front Back
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Instructions
Follow the instructions on the following
slides for how to use this form.
This casualty card will be found in each
Soldiers IFAK.
Use an indelible marker to fill it out.
Attach it to the casualtys belt loop, or place
it in their upper left sleeve, or the left trouser
cargo pocket.
Include as much information as you can.
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TCCC Card Front
Individuals name
and allergies
should already be
filled in. This
should be done
when placed in
IFAK.
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TCCC Card Front (cont.)
Add date-time
group (DTG)
Cause of injury,
and whether
friendly,
unknown, or
NBC.
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TCCC Card Front (cont.)
Mark an X at the
site of the injury/ies
on body picture.
Note burn
percentages on
figure.
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TCCC Card Front (cont.)
Record casualtys
level of consciousness
and vital signs with
time.
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TCCC Card Back
Record airway
interventions.
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TCCC Card Back (cont.)
Record breathing
interventions.
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TCCC Card Back (cont.)
Record bleeding
control measures.
Dont forget
tourniquet time on
front of card.
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TCCC Card Back (cont.)
Record route of fluid,
type, and amount
given.
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TCCC Card Back (cont.)
Record any drugs
given: pain meds,
antibiotics, or other.
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TCCC Card Back (cont.)
Record any pertinent
notes.
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TCCC Card Back (cont.)
Sign card.
Does not have to be
a medic to sign.
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Documentation
Record each specific intervention in each
category.
If you are not sure what to do, the card will
prompt you where to go next.
Simply circle the intervention you performed.
Explain any action you want clarified in the
remarks area.
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Documentation (cont.)
You may not be able to perform all the
interventions on the card or that the casualty
needs.
However, when the medic is available he
can add additional treatments to the card.
This card can be filled out in less than two
minutes.
It is important that we document the care
given to the casualty.
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TCCC Card Abbreviations
DTG = Date-time group (e.g. 160010Oct2009)
NBC = Nuclear, Biological, Chemical
TQ = Tourniquet
GSW = Gunshot Wound
MVA = Motor Vehicle Accident
AVPU = Alert, Verbal stimulus, Painful stimulus, Unresponsive
Cric = Cricothyroidotomy
NeedleD = Needle decompression
IV = Intravenous
IO = Intraosseous
NS = Normal Saline
LR = Lactated Ringers
ABX = Antibiotics
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