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Slide 1JSOMTC, SWMG(A)
Tactical Combat Casualty Care and SOF Tactical Trauma Protocols
PFN: SOMTCL03Hours: 2.5Instructor:
Slide 2JSOMTC, SWMG(A)
Terminal Learning Objective
Action: Communicate knowledge of Tactical Combat Casualty Care (TCCC) and SOF Tactical Trauma Protocols (TTPs)
Condition: Given a lecture in a classroom environment
Standard: Received a minimum score of 75% on the written exam and a “GO” on the practical exam IAW course standards
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Reason
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Slide 4JSOMTC, SWMG(A)
Agenda
Outline the origins, history, and objectives of TCCC and SOF TTPs
Identify the three phases of TCCC and SOF TTPs
Identify the Care Under Fire treatment priorities
Identify the Tactical Field Care treatment priorities
Slide 5JSOMTC, SWMG(A)
Agenda
Identify the SOF TTPs extended Tactical Field Care considerations
Identify the Tactical Evacuation Care treatment priorities
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Origins, History, and Objectives of TCCC and SOF TTPs
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Slide 7JSOMTC, SWMG(A)
Origins, History, and Objectives of TCCC and SOF TTPs
Navy initiated TCCC project in 1993 Original guidelines published in 1996 (Journal of Military Medicine)
First TCCC course taught in 1996 TCCC incorporated in PHTLS manual 1999 ACSCOT and NAEMT endorsement CoTCCC established in 2001 (meets quarterly)
Slide 8JSOMTC, SWMG(A)
USSOCOM Directive
All SOF deploying personnel Trained on current TCCC guidelines
• https://mhs.health.mil/References/REF_TCCC.cshtml
• http://www.naemt.org/education/TCCC/guidelines_curriculum
Training completed within 6 months prior to deployment in support of combat operations
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Origins, History, and Objectives of TCCC and SOF TTPs
90% of combat casualties that die, die before reaching a MTF
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Slide 10JSOMTC, SWMG(A)
Origins, History, and Objectives of TCCC and SOF TTPs
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Origins, History, and Objectives of TCCC and SOF TTPs
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Origins, History, and Objectives of TCCC and SOF TTPs
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Slide 13JSOMTC, SWMG(A)
Origins, History, and Objectives of TCCC and SOF TTPs
Top three preventable deaths on the battlefield:Hemorrhage from extremity woundsAirway compromise from maxillofacial trauma Tension pneumothorax
Slide 14JSOMTC, SWMG(A)
Origins, History, and Objectives of TCCC and SOF TTPs
TCCC objectives Treat the casualty Prevent additional casualties Complete the mission
TTP additional options Extended field care
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Three Phases of TCCC and SOF TTPs
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Slide 16JSOMTC, SWMG(A)
Three Phases of TCCC and SOF TTPs
Care Under Fire (CUF) Tactical Field Care (TFC) Extended Tactical Field Care Considerations
Tactical Evacuation Care (TEC)
Slide 17JSOMTC, SWMG(A)
Care Under FireTreatment Priorities
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Care Under Fire
Return fire and take cover Direct or expect casualty to remain engaged as a combatant if appropriate
Direct casualty to move to cover and apply self aid if able
Try to keep casualty from sustaining additional wounds
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Slide 19JSOMTC, SWMG(A)
Care Under Fire
Casualties should be extricated from burning vehicles or buildings and moved to places of relative safetyDo what is necessary to stop the burning process
Airway management is best deferred until Tactical Field Care phase
Slide 20JSOMTC, SWMG(A)
Care Under Fire
Stop any life threatening external hemorrhage if tactically feasibleDirect casualty to control hemorrhage by self aid if able
Use a CoTCCC recommended limb tourniquet for hemorrhage that is anatomically amenable to tourniquet use
Apply the limb tourniquet over the uniform clearly proximal to the bleeding site• If the bleeding site is not apparent place the tourniquet as proximal as possible
Slide 21JSOMTC, SWMG(A)
Tactical Field CareTreatment Priorities
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Slide 22JSOMTC, SWMG(A)
Tactical Field Care
Casualties with an altered mental status should be disarmed immediately
Airway management Unconscious without airway obstruction
• Chin lift or jaw thrust maneuver• Nasopharyngeal airway• Place casualty in recovery position
Slide 23JSOMTC, SWMG(A)
Tactical Field Care
Airway management (cont.) Casualty with/or impending airway obstruction
• Chin Lift or Jaw Thrust maneuver• Nasopharyngeal airway• Allow casualty to assume any position that best protects the airway, including sitting up
• Place unconscious casualty in recovery position• Protect spine in blunt and blast trauma patients• If measures above are unsuccessful: supraglottic airway, intubation or surgical cricothyroidotomy(CricKey, Bougie‐aided or standard open surgical)
Slide 24JSOMTC, SWMG(A)
Tactical Field Care
Breathing Consider tension pneumothorax and decompress with 14G 3.25” needle/catheter unit if casualty has known or suspected torso trauma and progressive respiratory distress• 2nd ICS, MCL primary• 4th or 5th anterior‐axillary line is the alternate• Lateral to nipple line and not directed to heart• Remove the needle and leave catheter in place
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Slide 25JSOMTC, SWMG(A)
Tactical Field Care
Breathing (cont.) Repeat decompression as required Consider decompression of opposite side if casualty doesn’t improve
Consider chest tube for ineffective NDC Treat open chest wounds with a vented chest seal (if unavailable use a non‐vented seal)•Monitor the casualty for development of a subsequent tension pneumothorax
Slide 26JSOMTC, SWMG(A)
Tactical Field Care
BleedingAssess for unrecognized hemorrhage and control all sources of bleeding
Use combat gauze for compressible hemorrhage not amenable to tourniquet use
Consider a CoTCCC Junctional tourniquet for lower extremity or groin/inguinal wound not amenable to tourniquet use and cannot be controlled with hemostatic dressings
Slide 27JSOMTC, SWMG(A)
Tactical Field Care
Bleeding (cont.) Reassess prior tourniquet application; expose wound and determine is needed • If so, place limb tourniquet directly to skin 2‐3” above wound
• If not needed, use other methods to control bleeding
Check distal pulse as situation permits • If distal pulse is still present consider additional tightening of tourniquet or use of second tourniquet
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Slide 28JSOMTC, SWMG(A)
Tactical Field Care
Bleeding (cont.) Expose and mark all tourniquet sites with time of application using an indelible marker
Limb tourniquets and junctional tourniquets should be converted as soon as possible if three criteria are met: casualty is not in shock, wound can be monitored for bleeding, tourniquet is not on an amputation
Apply pelvic binder for suspected pelvic fracture
Slide 29JSOMTC, SWMG(A)
Tactical Field Care
Prevention of hypothermiaMinimize casualty’s exposure to elements; keep protective gear on or with the casualty
Replace wet clothing with dryGet the casualty onto an insulated surface (litter)
Apply the Ready‐Heat Blanket on torso (not directly on skin); wrap in HRS or Blizzard Rescue blanket
Slide 30JSOMTC, SWMG(A)
Tactical Field Care
Prevention of hypothermia (cont.) If mentioned gear is not available, use dry blankets, poncho liners, sleeping bags, body bags, or anything that will retain heat and keep the casualty dry
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Slide 31JSOMTC, SWMG(A)
Tactical Field Care
Intravenous (IV) access Start an 18 gauge IV or saline lock if indicated If resuscitation is required and IV access is not obtainable, use the intraosseous (IO) route
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Tactical Field Care
Tranexamic Acid (TXA) If a casualty is anticipated to need significant blood transfusion• Administer 1 gram of Tranexamic Acid in 100 ml Normal Saline or Lactated Ringers over 10 minutes as soon as possible but NOT later than 3 hours after injury
• Not in same line as Hextend or blood products• Begin second infusion of 1 gm TXA after Hextend or other fluid treatment
•Mark casualty with amount of TXA given on chest
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Tactical Field Care
Fluid resuscitation (cont.)Assess for hemorrhagic shock
• Altered mental status in the absence of head injury and/or weak or absent peripheral pulses
• Systolic blood pressure less than 80 mmHgNot in hemorrhagic shock
• No IV fluids are immediately necessary• Fluids by mouth are permissible
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Slide 34JSOMTC, SWMG(A)
Tactical Field Care
Fluid resuscitation (cont.) In hemorrhagic shock and blood products are available •Whole blood• Plasma, RBCs and platelets 1:1:1• Plasma and RBCs 1:1• Plasma or RBCs alone• Reassess after each unit and continue until a palpable radial pulse, improved mental status or systolic BP between 80‐90 mmHg
Slide 35JSOMTC, SWMG(A)
Tactical Field Care
Fluid resuscitation (cont.) In hemorrhagic shock and blood products are NOT available • Hextend• Lactated Ringers or Plasma‐Lyte A• Reassess after each 500 ml bolus and continue until a palpable radial pulse, improved mental status or systolic BP between 80‐90 mmHg
Slide 36JSOMTC, SWMG(A)
Tactical Field Care
Fluid resuscitation (cont.)Altered LOC with suspected TBI should be resuscitated to 90 mmHg systolic BP
If shock recurs, reassess all external hemorrhage and repeat fluid resuscitation
Continued efforts must be weighed against logistical and tactical considerations and the risk of incurring further casualties
Warm fluids if possible to prevent hypothermia
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Slide 37JSOMTC, SWMG(A)
Tactical Field Care
Head injury management Fluid resuscitate hypotensionMaintain spo2 > 90%; goal = 95% Controlled mild hyperventilation (20 BPM)Hypertonic saline (3‐5%) 250ml bolus Seizure prophylaxis
• Cerebyx 18 mg/kg IV/IO at 100‐150 mg/min Seizure management
• Valium 5‐10 mg IV/IO q 5 minutes• Versed 5 mg IV/IO q 5 minutes
Slide 38JSOMTC, SWMG(A)
Tactical Field Care
Head injury management (cont.) Patient positioning
• If CSF present elevate 30‐60 degrees• If IICP only elevate 30 degrees• Don’t elevate the head of a hypovolemic casualty
Sedation of severe TBI after airway established• Versed 1‐2 mg/hour IV/IO
TCCC/SOF TTPs antibiotic prophylaxis should be started
Slide 39JSOMTC, SWMG(A)
Tactical Field Care
Abdominal evisceration Control visible hemorrhage Irrigate and gently reduce if possible Cover and keep warm
Penetrating eye trauma Perform a rapid field test of visual acuity Cover the eye with rigid eye shield (not pressure patch)
Start antibiotics
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Slide 40JSOMTC, SWMG(A)
Tactical Field Care
Burns Facial burns, especially those that occur in closed spaces, may be associated with inhalation injury• Aggressively monitor airway status and oxygen saturation in such patients and consider early surgical airway for respiratory distress or oxygen desaturation
Slide 41JSOMTC, SWMG(A)
Tactical Field Care
Burns (cont.) Estimate total body surface area (TBSA) burned to the nearest 10% using the Rule of Nines
Cover the burn area with dry, sterile dressings• For extensive burns (> 20%), consider placing the casualty in the Blizzard Survival Blanket in the Hypothermia Prevention Kit in order to both cover the burned areas and prevent hypothermia
Slide 42JSOMTC, SWMG(A)
Tactical Field Care
Burns (cont.) Fluid resuscitation (USAISR Rule of Ten)
• If burns are greater than 20% of Total Body Surface Area, fluid resuscitation should be initiated as soon as IV/IO access is established
• Resuscitation should be initiated with Lactated Ringer’s, Normal Saline, or Hextend
• If Hextend is used, no more than 1000 ml should be given, followed by Lactated Ringer’s or Normal Saline as needed
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Slide 43JSOMTC, SWMG(A)
Tactical Field Care
Burns (cont.) Fluid resuscitation (USAISR Rule of Ten)
• Initial IV/IO fluid rate is calculated as %TBSA x 10 ml/hr for adults weighing 40‐80 kg
• For every 10 kg ABOVE 80 kg, increase initial rate by 100 ml/hr
• If hemorrhagic shock is also present, resuscitation for hemorrhagic shock takes precedence over resuscitation for burn shockAdminister IV/IO fluids per the TCCC Guidelines
Slide 44JSOMTC, SWMG(A)
Tactical Field Care
Burns (cont.)Analgesia in accordance with the TCCC guidelines may be administered to treat burn pain
Prehospital antibiotic therapy is not indicated solely for burns, but antibiotics should be given per the TCCC guidelines if indicated to prevent infection in penetrating wounds
All TCCC interventions can be performed on or through burned skin in a burn casualty
Slide 45JSOMTC, SWMG(A)
Tactical Field Care
Inspect and dress known wounds Check for additional wounds Splint fractures and recheck pulses Basic splinting fundamentals apply
Crush injury management Immediately 1000‐1500 ml NS Just before extrication apply tourniquets and give sodium bicarbonate
After extrication monitor for cardiac arrest
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Slide 46JSOMTC, SWMG(A)
Tactical Field Care
Monitoring Pulse oximetry should be available as an adjunct to clinical monitoring
Readings may be misleading in the settings of shock or marked hypothermia
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Tactical Field Care
Analgesia if able to fightMeloxicam (Mobic) 15 mg PO once a dayAcetaminophen 650 mg bilayer caplet, 2 PO every 8 hours
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Tactical Field Care
Analgesia if unable to fight without IV/IOHypovolemic shock or respiratory distress
• Ketamine (Ketalar) 50 mg IM or IN• Repeat dose every 15‐30 min• Controls pain or nystagmus occurs
No hypovolemic shock or respiratory distress• Fentanyl Citrate (OTFC) 800 ug transbuccally• Reassess in 15 minutes•Monitor for respiratory depression
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Slide 49JSOMTC, SWMG(A)
Tactical Field Care
Analgesia if unable to fight with IV/IOHypovolemic shock or respiratory distress
• Ketamine 20 mg IV/IO over 1 minute repeat dose every 5‐10 min to control pain or until nystagmusoccurs (max of 100mg/hr)
• Consider Versed 1 mg IV for agitationNo hypovolemic shock or respiratory distress
•Morphine 5‐10 mg IV/IO repeat dose every 10 minutes as necessary (monitor for respiratory depression)
Slide 50JSOMTC, SWMG(A)
Tactical Field Care
Consider an antiemetic for opioid or trauma induced nausea or vomitingOndansetron (Zofran)
• 4 mg ODT/IV/IO/IM every 8 hours• Can be repeated once at 15 min•Max 8mg in any 8 hour period
Promethazine (Phenergan)•Must be diluted and given slowly• Has a synergistic effect• Use only if Zofran is not available
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Tactical Field Care
Antibiotics: recommended for all open combat wounds
Able to take POMoxifloxacin 400 mg PO one a day
Unable to take PO Ertapenem 1 g IV/IM once a day Cefotetan 2g IV (slow push over 3‐5 minutes) or IM every 12 hours
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Slide 52JSOMTC, SWMG(A)
Tactical Field Care
Communicate with patient if possible Encourage and reassure Explain care
Cardiopulmonary resuscitation Resuscitation 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 and should not be attempted
Slide 53JSOMTC, SWMG(A)
Tactical Field Care
Bilateral needle decompression For casualties with torso or multisystem trauma and no pulse or respirations during TFC phase
Document Clinical assessments, treatments rendered, and changes in casualty’s status on a TCCC Casualty Card
Forward this Information with the casualty to the next level of care
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SOF TTPs Extended Tactical Field Care Considerations
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Slide 55JSOMTC, SWMG(A)
SOF TTPs Extended Tactical Field Care Considerations
Airway Suction
• Consider periodic suctioning of the oropharynx and endotracheal tube
Pulmonary toilet• Consider periodic saline flushes (2 ml) to clear mucus/blood from ET tube
Local wound care at cricothyroidotomy site if applicable
Slide 56JSOMTC, SWMG(A)
SOF TTPs Extended Tactical Field Care Considerations
Respiratory management Perform chest tube and apply chest drain Consider rib blocks for pain managementAdminister oxygen if available Consider the use of a ventilator/assist device if available
Consider sedation with midazolam (Versed) 1‐2 mg/hour IV/IO for prolonged intubation
Slide 57JSOMTC, SWMG(A)
SOF TTPs Extended Tactical Field Care Considerations
Flail chest managementMonitor for developing hypoxia secondary to pulmonary contusions
Casualty may require positive pressure ventilation
Ensure adequate analgesia• Consider rib blocks for pain management
These casualties frequently fatigue and require intubation/definitive surgical airway
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Slide 58JSOMTC, SWMG(A)
SOF TTPs Extended Tactical Field Care Considerations
Fluid management Conscious
• Instruct casualty to drink clear liquids up to 1 liter per hour; consider oral electrolyte supplementation if available
Unconscious• Insert Foley catheter and titrate IV/IO/NG/PR crystalloid fluids to maintain urine output of 30‐50 ml per hourClean water may be utilized in lieu of crystalloid for NG/PR infusion
Slide 59JSOMTC, SWMG(A)
SOF TTPs Extended Tactical Field Care Considerations
Fluid management (cont.) Critical burn (> 20% TBSA of 2nd/3rd degree burns)• Continue fluid resuscitation according to “The Rule of Ten”
• Insert Foley catheter and adjust fluid rate to maintain urine output of 30‐50 ml per hour
• Oral fluid administration may be acceptable in burns up to 40% TBSA if IV supplies are limited
Slide 60JSOMTC, SWMG(A)
SOF TTPs Extended Tactical Field Care Considerations
Wound care management Irrigate and redress wounds (any potable water can be used for irrigation)
Debride only obviously devitalized tissue Change dressings every 24 hours
• Consider converting to silver impregnated dressings to reduce frequency of dressing changes
Continue antibiotics• Repeat moxifloxacin (Avelox) 400 mg PO or ertapenem (Invanz) 1 gm IV/IO/IM every 24 hours
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Slide 61JSOMTC, SWMG(A)
SOF TTPs Extended Tactical Field Care Considerations
Analgesia For painful procedures consider the use of procedural anesthesia• Dual agent
Midazolam (Versed) 2 mg IV/IO over 1 minuteKetamine (Ketalar) 20 mg IV/IO over 1 minute
• Single agentMorphine 5 mg IV/IO q 5 min
Consider local blocks for pain management
Slide 62JSOMTC, SWMG(A)
SOF TTPs Extended Tactical Field Care Considerations
Nutrition management Consider oral nutrition if evacuation will be delayed by over 24 hours
Orthopedic injury management Traction splints as needed Reassess fractures and adjust splints as needed
Slide 63JSOMTC, SWMG(A)
SOF TTPs Extended Tactical Field Care Considerations
Compartment syndrome management Be suspicious of compartment syndrome in the following conditions• Fractures• Crush injuries• Vascular injuries• Circumferential burns•Multiple penetrating injuries (fragmentation)
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Slide 64JSOMTC, SWMG(A)
SOF TTPs Extended Tactical Field Care Considerations
Clinical signs of compartment syndrome Pain out of proportion to injury Pain with passive motion of muscles in the involved compartment
Pallor Paresthesias Pulselessness
Consider use of compartment pressure monitor if available and trained in its use
Slide 65JSOMTC, SWMG(A)
SOF TTPs Extended Tactical Field Care Considerations
Compartment syndrome management Reevaluate every 30 minutes for first two hours then once every hour
Maintain extremity at heart level Loosen encircling dressings Fasciotomy
•Only consider if evacuation is delayed over 6 hours• Only perform if within your scope of practice
Slide 66JSOMTC, SWMG(A)
SOF TTPs Extended Tactical Field Care Considerations
Blast injuries Tympanic membrane perforation
• Dexamethasone (Decadron) 10 mg IV/IO/IM/PO QD Lungs
•Monitor patient for respiratory deteriorationAbdomen
•Monitor for delayed bowel injury Spine
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Slide 67JSOMTC, SWMG(A)
Tactical Evacuation CareTreatment Priorities
Slide 68JSOMTC, SWMG(A)
Tactical Evacuation Care
Airway management Continue to monitor the casualty’s airway and upgrade as needed
Consider replacing advanced airway bulbs with saline prior to aircraft CASEVAC
Breathing Continue to reassess Perform thoracostomy if needed Provide oxygen if available
Slide 69JSOMTC, SWMG(A)
Tactical Evacuation Care
Bleeding Reassess patient and verify bleeding is controlled
Verify distal pulses are absent in extremities with tourniquets
Reassess if tourniquet is required or other hemorrhage control means are appropriate
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Slide 70JSOMTC, SWMG(A)
Tactical Evacuation Care
Hypothermia management Continue hypothermia prevention management or initiate if not already started
Utilize heating system on evacuation platform and avoid wind exposure
Use an IV warming device for all fluid administration
Slide 71JSOMTC, SWMG(A)
Tactical Evacuation Care
Intravenous (IV) access Reassess IV patency Flush IV lines and saline locks as required
TXA If needed and not already started
Fluid resuscitation Continue resuscitation as neededMaintain a normal radial pulse or systolic blood pressure between 80‐90 mmHg
Slide 72JSOMTC, SWMG(A)
Tactical Evacuation Care
Burn Treatment Continue fluid resuscitation with Rule of Tens Consider urinary catheter to monitor output
Head injury management Continue to prevent hypotension and hypoxia Controlled mild hyperventilation
• If CO2 monitor available pCO2 of 30 mmHg• If no CO2 monitor 20 BPM
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Slide 73JSOMTC, SWMG(A)
Tactical Evacuation Care
Penetrating eye trauma Cover with rigid eye shield if not already done
Monitoring Institute pulse oximetry and other electronic monitoring of vital signs, if indicated
Inspect and dress known wounds if not already done
Check for additional wounds
Slide 74JSOMTC, SWMG(A)
Tactical Evacuation Care
Continue analgesia as needed Reassess fractures and recheck pulsesMonitor air pressure in extremity air splints during air evacuation
Start antibiotic therapy if not already done
Slide 75JSOMTC, SWMG(A)
Tactical Evacuation Care
The Pneumatic Antishock Garment (PASG) may be useful for stabilizing pelvic fractures and controlling pelvic and abdominal bleedingApplication and extended use must be carefully monitored
Contraindicated for casualties with thoracic or brain injuries
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Slide 76JSOMTC, SWMG(A)
Tactical Evacuation Care
Document Clinical assessments, treatments rendered, and changes in casualty’s status on a TCCC Casualty Card
Forward this Information with the casualty to the next level of care
Slide 77JSOMTC, SWMG(A)
Questions?
Slide 78JSOMTC, SWMG(A)
Terminal Learning Objective
Action: Communicate knowledge of Tactical Combat Casualty Care (TCCC) and SOF Tactical Trauma Protocols (TTPs)
Condition: Given a lecture in a classroom environment
Standard: Received a minimum score of 75% on the written exam and a “GO” on the practical exam IAW course standards
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Slide 79JSOMTC, SWMG(A)
Agenda
Outline the origins, history, and objectives of TCCC and SOF TTPs
Identify the three phases of TCCC and SOF TTPs
Identify the Care Under Fire treatment priorities
Identify the Tactical Field Care treatment priorities
Slide 80JSOMTC, SWMG(A)
Agenda
Identify the SOF TTPs extended Tactical Field Care considerations
Identify the Tactical Evacuation Care treatment priorities
Slide 81JSOMTC, SWMG(A)
Reason