algorithm for TCCC - ✔✔MARCH - PAWS - 9 Line tasks in "M" - ✔✔Gain fire superiority/return fire "Are you hurt? Can you fight? Can you treat yourself? Can you move? Tourniquet for massive he... morrhage Move off X check tourniquet sweep all extremites for obvious active bleeds (big pipes/little pipes Steps in Care Under FIre - ✔✔Gain fire superiority/return fire Are you hurt? Can you fight? Can you treat yourself? Can you move yourself? tourniquet for massive bleeds only move off X "M" - ✔✔Care Under fire: -gain fire superiority/return fire Are you hurt? Can you fight? Can you treat yourself? Can you move yourself? Tourniquet for massive hemorrhage only (leave controlled bleeding for later Move off XRecheck tourniquets post movement sweep head/extremities for big pipes/little pipes "A" - ✔✔head tilt/chin lift, jaw thrust look, listen, feel inspect airway for trauma/burns/obstruction/maxillofacial trauma Interventions: NPA, I-Gel, Cri-key best airway if expecting bird transport - ✔✔I-Gel b/c won't expand with elevation due to gas laws best airway if facial burns/swelling - ✔✔cri-key early "R" interventions - ✔✔expose chest, search wounds w/ "tiger claw" or spreading skin **cover sites over nickel in size w/occlusive dressing pelvic stability back side tiger claw/skin spread spine check for stepoffs credit card swipe **cover sites w/occclusive dressing. vented if over a nickel size lay down on litter w/blanket recheck interventions since rolled look listen feel check for pneumo and dart if needed reassess post dart needle size for thoracentesis - ✔✔10 gague or 14 gague3 1/4 inch "C" - ✔✔sweep all limbs again for trauma (DCAPBTLS) combat gauze/wound pack to small active bleeds bilateral pulse check - for shock start IV if shock ruggedized IV, EZ-IO, FAST 1 TXA, IVF when do you start an IV - ✔✔in circulation after the all extremity blood sweep and pulse check identifying shock intervention post starting IV - ✔✔TXA IVF - whole blood, blood products, hextand, LR TXA purpose - ✔✔to preserve clots already formed TXA dose/rate - ✔✔1 gram in 100ml bag over 10 minutes IVF in trauma - ✔✔whole blood other blood products Hextand LR important thing to remember about giving solutions through IV - ✔✔TXA and Hextand aren't compatable crystallizeneed a good flush probably should start second IV "H" - ✔✔Head/Hypothermia "H" interventions - ✔✔DCAPTBLS CSF from nose/ears w/halo test PERRL (pupils equal, round, reactive to light) visual acuity LOBBS (lacerations, obstructions, broken teeth, bleeding, swelling battle signs/raccoon eyes "P" - ✔✔Triple Option 1. Combat Pill Pack (consciuos/can swallow) *TYlenol 1300mg (2tab) Q8hr *Mobic 15mg po QID 2. Fentanyl Lollypop 80mcg 3. Ketamine IM/IN -50mg IM/IN Q30 minutes IV/IO- 20mg Q20 minutes pain options if conscious and can swallow - ✔✔"Combat Pill Pack Tylenol 1300mg (2 650mg tabs) Q8hr MObic 15 mg QID contraindications for fentanyl lollypop - ✔✔shock/high risk of shockrespiratory distress/high risk of respiratory distress unconscious severe TBI/head trauma allergic/narcoti intolerant Ketamine IM/IN - ✔✔50mg q30 minutes Ketamine IV/IO - ✔✔20mg q20 minutes "A" (PAWS) - ✔✔Combat pill pack = Moxifloxacin 400mg po QID Ertapenem 1gram IV/IM QD "A" in PAWS if can tolerate po - ✔✔combat pill pack = Moxifloxacin 400mg QID "A" in PAWS if cannot tolerate po - ✔✔Ertapenem 1gram IV QD "W" - ✔✔treat minor wounds "S" - ✔✔splinting. PMS heck before and after final step of TCCC - ✔✔9 line -Urgent, Priority, Routine -special needs like blood/ventilator/OR capability/Neuro capability -Liter or ambulatory pt www.deployedmedicine.com - ✔✔Deployed Medicine App - ✔✔ Youtube TCCC MARCHPAWS F(nal TEst OUt - ✔✔ benefit of TCCC training - ✔✔documented lower incidents IV cutdown - ✔✔ stopgap - ✔✔ eschelon - ✔✔ common injury from IED attack - ✔✔junctional hemorrhage goals of TCCC - ✔✔Treat the casualty Prevent additional casualties Complete the mission Joint Trauma System - ✔✔ best way to help a person who can't breathe but is conscious - ✔✔let them sit up/lean forward assume any position that is comfortable what do medics often overlook - ✔✔simple interventions like airway positioning -people have died b/c the medics would not let them assume the most comfortable position = die b/c drown in hemothroax USAISR Report - ✔✔TCCC COmbat Eval 2005TCCC studies - ✔✔ what has made a big difference in battle survival between now and 2001 - ✔✔in 2001, no one in the military carried a tourniquet important thing to remember about medical ethics in combat - ✔✔good medicine can be bad tactics % of combat deaths that are potentially preventable - ✔✔up to 24% of combat deaths are potentially preventable 3 phases of T CCC - ✔✔care under fire Tactile Field Care TACEVAC care second stage of TCCC care - ✔✔tactile field care third stage of TCCC care - ✔✔TACEVAC care only authorized things to do in Care Under Fire - ✔✔gain fire superiority tourniquet for massive bleeding "enemy isn't stupid. wait and detonate. lots of rounds on first responders" aka victim - ✔✔casualty point of injury - ✔✔on teh X on the X - ✔✔point of injurybest way for a casualty to be moved off the X - ✔✔have him move himself Entebbe - ✔✔ intervention if a firefight is actively going on - ✔✔no treatment in care under fire best medicine on the battlefield - ✔✔fire superiority ideal movement - ✔✔casualty moves themself casualty can't move and is unresponsive - ✔✔likely beyond help and moving while under fire might not be worth the risk not worth it to do a "medal of honor" run how to rescue a casualty if they can't move - ✔✔plan in advance -# of rescuers -how to cover -how to move 0-where to cover -use suppression fire/smoke to best advance -recover casualty's weapon if possible what is not performed in care under fire - ✔✔no airway or c-spine interventions if penetrating trauma -yes if blunt trauma like fall intervention if burn - ✔✔stop burning process Nomex material - ✔✔only intervention in Care Under Fire - ✔✔stop life-threatening bleedintg w/tourniquet move off X time it takes to bleed out frtom a femoral artery bleed - ✔✔3 minutes placement of a tourniquet - ✔✔tourniquet should be easily placed on top of pack so casualty can reach it for themself from either hand first choice for bleeding - ✔✔tourniquet when should you not use a tourniquet - ✔✔non=-life threatening bleeds -can use combat gauze/wound pack for other bleeds application of tourniquet and unform - ✔✔apply over uniform in care under fire can cut away clothes later how to place a tourniquet in your pack - ✔✔on top so you can reach it from either hand pulse and tourniquet - ✔✔tourniquet should eliminate pulse how to tell if a tourniquet is working - ✔✔should eliminate pulse stop bleeding completely CAT - ✔✔combat application tourniquet intervention if a CAT tourniquet is too long - ✔✔can't cut excess length b/c the ribbon goes through the entire length. if cut, it becomes as effective as a loose braceletCoTCCC - ✔✔ marking tourniquet time - ✔✔directly on the tourniquet T on the pt's head on the documentation card important thing to remember during Tactical Field Care - ✔✔prepare to reengage w/the enemy transport versus treatment - ✔✔never delay transport for treatment need need eschelon of care more why is preventing hypothermia a priority - ✔✔worsens TBI worsens coagulopathy assumptions you can make if they have an amputation - ✔✔need tourniquet even if not bleeding badly prepare for shock/need for IV access TXA/blood products assume they will become hypothermic usually tapped to be the triage officer - ✔✔Dentists intervention if pt has an altered mental status - ✔✔take weapons and radio devices away causes of trauma altered mental status - ✔✔TBI shock shypoxia pain medications "idiot brain" when they are on the fentanyl lollypoptourniquet conversion - ✔✔convert tourniquet at 2 hours. if conversion fails, keep it on do not convert tourniquet -5 - ✔✔shock traumatic amputation over 6hrs not able to monitor the site will be at the next eschelon of care in under the 2hr mark example of junction tourniquet - ✔✔SAM purpose of the blue stripe on combat gauze - ✔✔see on Xray letting up pressure on a wound - ✔✔don't let up direct pressure to check the wound until you are prepared to control the bleeding w/tourniquet or junctional types of gauze to pack wound - ✔✔Combat Gauze (1st choice) Chito gauze/Celox (doesn't cause a shellfish allery problem) how to pack a wound - ✔✔hold pressure against bone towards heart -hold bleeder while youpack. ensure bleed doesn't let up pressure. -cover combat gauze w/pressure dressing how to identify the bleeding vessel when you pack a wound - ✔✔feel for pulsatile vessel. put pressure on bone in direction of heart. then pack with a 1 to 1 swap *if can't identify the site of the bleed, cover potential site w/multiple fingers then let up one at a time to see where it is. then cover that site once you identifyform used to document casualty care - ✔✔DD 1380 how to hold wrap when you are packing a wound - ✔✔don't throw it over shoulder or let it traiil syringe w/sponges - ✔✔Xstat -syringe w/tiny sponges. minisponges rapidly expand on contact w/blood causing a tamponade effect -all sponges have a xray stamp -20seconds contraindications for Xstat - ✔✔Xstat = syringe w/tiny sponges to provide tamponade upon contact w/blood pleural, abd, ... things to remember about Xstat - ✔✔Xstat = syringe w/tiny sponges to provide a tamponade effect upon contact w/blood not popular b/c combat gauze is more versatile significant ccavitation may need 3 syringes injury to expect w/IED blast - ✔✔junctional hemorrhage bifurcate - ✔✔ types of junctional tourniquests - ✔✔SAM, JETT where do you apply the JETT tourniqut - ✔✔apply at teh level of the greater trocanterJETT tourniquet - ✔✔ SAM splint - ✔✔ how to pack a neck wound - ✔✔pack wound, put gauze rap under armpit and over shoulder aka armpitq - ✔✔Ax pocket how to pack an axilla pocket wound - ✔✔make an "X" across the back b/c it will slip if you just wrap around arm. so wrap arm under first then wrap once around back. can put hand in pocket or bind to side for added pressure how to keep wound packing in place if it is at risk for slipping - ✔✔make an "X" to keep high femoral.. neck arm from sliding down -only need to make one X where should you not do wound packing - ✔✔no wound poacking into chest how to do a high femoral wound packing/wrap - ✔✔warp = make an X across the side 1. loose wrap 2. tighter 3. make one X around to hold it all in place 4. go oppoiste direction how to do wound packing to an inguinal space - ✔✔can use a belt/make a diaper suaped differences between the JETT and SAM junctional - ✔✔JETT = moveable pucks SAM - BP cuff bulb to pump up the puckfeature of the JETT junctional - ✔✔has moveable pucks feature of the SAM junctional - ✔✔BP cuff bulb to pump up the pucks semper paratus - ✔✔ "the scene is safe" in TCCC - ✔✔fire superiority hostile combatant is rendered incapacitated and safe by not us Q's to ask ptt - ✔✔"where were you hit" "can you move" **This assesses airway, LOC, if chan moe/shoot, or get them to craw to your, tell them to put direct pressure first preference to move patient - ✔✔crawl to me how to properly do a blood sweep - ✔✔"grip it and rip it" -so fast. not "click" as a distance - ✔✔ where can blood hide on a patient - ✔✔sweep inside body armor b/c it can hide therem overall goals of Care Under Fire - ✔✔fire superiority tourniquet for massive bleeding get them off the Xfirst step after a patient is moved - ✔✔check any tourniquets you may have applied why should you continue to assess "A" if the patient is conscious and talking - ✔✔even if okay "A" and skip over interventiosn like NPA/i-gel/cri-key, if bleeding they may go into shock and loose airway later *trauma adrenaline so airway might start to craump later. if okay to start w/o airwy damage *consider NPA just int case but if talkative, nten not how does an NPA function - ✔✔like a doorstop for tongue to rest on. why arent' OPA's used in TCCC - ✔✔gag dislodge w/movement step prior to inserting NPA - ✔✔90 degree petroleum gelly is thick and gunky so not great. use water soluble or pt spit J. Spec Opermed - ✔✔ insertion of NPA - ✔✔90 degrees bevel to septum rotate if left nare straight back if right *dont' go along the floor b/c it goes straight back then curved. if straight up, then not towards head/brain how is an NPA designed - ✔✔to go into right nostril. if left nostril, rotate and twist intervention not to skip even if pt is talking - ✔✔still check mouth for patency. ask to open even if talking.. might have dip/seeds/gum.*tell them to spit it out onset of lidocaine for anesthesia - ✔✔ ability to correctly answer the question "Do you have an injury to your legs? - ✔✔ability to answer w/coherentanser means they have LOC/blood to the brain/airway patency most technical skill done by corpsmen/medics - ✔✔33% fail crics b/c shakey, nervous youtube Cri-Key procedure - ✔✔ analogy for the target of cri-key - ✔✔Big mountain valley small mountain how to do surgical cric - ✔✔light finger pressure only to get through skin. wound to chest that indicates an open pneumothorax - ✔✔nickel size or greater needs a vented dressing important thing to remember about tension pneumothorax in the field - ✔✔progressive injury that takes time to develop difference between tension pneumothorax and only having one lung - ✔✔people don't die from 1 bad lung but can from T. pneumo -0die b/c mediastinal shift due to increased pressure. thus, the back up causes distension of JVD so not dumping blood into the heart why does the pressure backup cause JVD in tension pneumothorax - ✔✔backup of blood due to the pressure causes the blood to not dump back into the heartsize of chest wounds - ✔✔open if a nickel or greater = risk t. pneumo and needs a vented dressing smaller than a nickel = closed and can take a regular dressing late signs of t. pneumo - ✔✔anything r/t pressure buildup -JVD from pressure leading to backed up blood -mediastinal shift early signs of t. pneumo - ✔✔unilateral rise/fall of hcest first step of all MARCH steps - ✔✔look for wounds, treat treatment of an open pneumothorax - ✔✔treat w/an occlusive dressing to convert to closed bb/c air can no longer go in/out burping occlusive dressings - ✔✔-burping pneumo dressings degrades teh adhesive -only for open non-vented dressings -NEVER for vented dressings what type of intervention confirmation can't you use on the battlefield - ✔✔auditory confirmation normal SpO2 at 12K feet - ✔✔86% doing a needle decompression when there actually isn't a pneumo - ✔✔okay b/c will seal up like how when you do an IV it seals up. you aren't createing a new pneumo and it will close/heal how to guide 5th ICS - ✔✔pt's hand under armpit. if hand is blown off, measure pt hand to yours and use your hand with their measurementstop two battlefield killers - ✔✔MA of MARCH addressed first open book pelvic fracture - ✔✔ type of pelvic fracture - ✔✔open versus closed book what should you never do with a broken pelvis - ✔✔never rock www.asst.org/pelvis-injury - ✔✔ types of pelvis injuries - ✔✔open book verticle Shear lateral compression causes of pelvic fractures on the battlefield - ✔✔IED MVC parachute landing pelvic fracture s/s - ✔✔external rotation unequal leg length brusise/bleeidnfg lower extremity amputation rotation in a pelvic fracture - ✔✔external rotation legs in pelvic fracture - ✔✔unequal lengthleg is externally rotated - ✔✔suspect pelvic fracture legs are of unequal length - ✔✔suepsect pelvic fracture types of pelvic binders - ✔✔T-pod SAM pelvic sling sheet blouse JETT/SAM can be used as a junctional or pelvic bidner - ✔✔JETT SAM landmark for pelvic binders - ✔✔greater trocanter =level of symphysis pubis NOT ILIAC WINGS!!!! ^in a study, 40% placed too high so inadequate reduction on the pelvic fracuture and possibly increase bleeding common s/s in pelvic frac ture - ✔✔external rotation important step in addition to pelvic binding - ✔✔bindfeet/knees intervention to avoid in pelvic fracture - ✔✔minimize log rolls -you have to chec the back b/c have to r/o major killers -even if they have apelvic fracture, they get 1 log roll to r/o injury to backmovement and pelvic fractures - ✔✔minimize log rolls even if they have a pelvic fracture, they get at least 1 log roll to r/o injury to back what must tourniquets do - ✔✔eliminate distal pulse stop bleeding rare injury w/tourniquet use - ✔✔damage to extremities is rare if a tournique is on for under 2 hrs first thing given through an IV in trauma - ✔✔TXa purpose of TXA - ✔✔helps preserve clots already formed. need to be abel to clot properly prior to vollumizing battlefield s/s of shock - ✔✔decreased LOC w/o TBI weak/absent radial pulse IV on the battlefield - ✔✔no IV w/o indication only for shock b/c need TXA/blood/hextand/ABX Rx -unable to swallow, decreased LOC, vomiting IV placement if wounds - ✔✔no IV distal to wounds indication for TXA - ✔✔suspicion of shock from internal bleeding how to give TXA - ✔✔1gram 10 minutes 100ml bagimportant thing to remember when giving TXA plus other products - ✔✔TXA and Hextand are incompatable crystallize needs good flush most desired IVF on battlefield - ✔✔whoel blood only reason you get IVF on battlefield - ✔✔hemorrhagic shock end point for IVF on battlefield - ✔✔SNP over 80-90 increased LOC problem of too much IVF in trauma - ✔✔pop a clot when doesn't a casualty get IVF - ✔✔no IVF if no shock -may po hydrate if tolerate even if likely OR or trauma to abd po hydration in battlefield trauma - ✔✔if LOC and patent airway, may have po hydration no matter what. even if GSW to abdomen or suspect immediate OR options for IV access on the battlefield - ✔✔ruggardized IV EZ-IO FAST 1 ruggardized IV - ✔✔ EZ-IO - ✔✔ FAST 1 - ✔✔site of FAST 1 - ✔✔manubrium (head of sternum) pressure needed for FAST 1 - ✔✔60 lbs of pressure how to identify site for FAST 1 - ✔✔sternal notch place sticker w/target site will be the manubrium (head of sternum) contraindications for FAST 1 - ✔✔under 50kg/110lbs under 12yo previous sternal injury/surgery tissue damage severe osteoprosis time a FAST 1 can be in place - ✔✔24 horus IO options - ✔✔FAST 1 ESZ-IO important thing to remember about the EZ-IO - ✔✔use correct EZ-IO based on the anatomical position when can you po hydrate - ✔✔if LOC and can swallow regardless of injuries SOLO program by SEALS - ✔✔ size of IVF boluses - ✔✔500ml then reasesss (they recommend 250ml then reassess)Far Forward - ✔✔ Far Forward battlefield blood programs - ✔✔SOLO = SEALS Valkarye -= Camp Pendleton Marines = in progress *walking blood banks *medic carries a chart of who cna donate to who *SEALS can do it in 11 minutes w/o battlefield stresses consideration of high volume IVF - ✔✔makes internal hemorrhage worse by poppoing a clot goal of IVF - ✔✔improve radial puse palpable radial pusle SBP 80-90 improve LOC ways to warm fluids on the battlefield - ✔✔blankets, under armpit, in cargo pockets fluid coming from nose/ears - ✔✔halo test takes 2 minutes LOBBS - ✔✔Lacerations Odor Broken Teeth Blood Swelling important thing to remember about eye injuries - ✔✔eye injuries are disteracting.protuding eyeballs are addressed in "H", not earlier so the only thing we intervene on in "H" head - ✔✔feel for deformities CSF leak eye acuity/PERRL cover w/rigid eye patch trauma visual acuity - ✔✔read my name tape read this package how many fingers follow my fingers light versus dark PERRL using eye shield on battlefield - ✔✔only put the eye shield on the injured eye. other eye is uncovered. blindness = increses anxiety, turns pt into a liter patient, blindness is psychologically anxiety compartment syndrome in the eye - ✔✔retrobulbar hemorrhage retrobulbar hemorrhage - ✔✔compartment syndrome in teh eye bleeding has nowhere to go so inc4reases pressure eyeball moves forward blood, blind, blind needs eye doc to cut ligament intervention for retrobulbar hemorrhage - ✔✔needs eye doc to cut the ligament to relieve the pressureposition of hte eyeball in a retrobulbar hemorrhage - ✔✔compartment syndrome in the eye. increases pressure w/ nowhere to go. eye moves forward s/s of retrobulbar hemorrhage - ✔✔bloody blind bulgin what do you twist on a CAT tourniquet - ✔✔windlass downrange - ✔✔ full algorithm of TCCC - ✔✔MARCH-PAWS - 9 Line purpose of the order of the TCCC algorithm - ✔✔ranked based on major battlefield inbjuries that kill what might be d/c in upcoming TCCC editions - ✔✔Hextand what rx should you not take in teh 8-10 days prior to a known mission/battle - ✔✔no NSAID/asprin/toradol -inhibits plt function for 8-10 days -b/c interferes w/clotting factors option for pain control if fentanyl lozange is given - ✔✔okay to give Ketamine what should you remember in terms of the medications and the environment - ✔✔for temperature extremes, know the temperature ranges of all rx *examplke, Fentanyl needs 80-86F so might be ineffective for pt and need multiple characteristics of Ketamine - ✔✔-unique b/c maintains pharyngela reflex-less risk of respiratory depression -giving to pt w/traumatic amputation helps them forget the event so less PTSD later 0heart stimulated, not depressed HR in ketamine - ✔✔unlike other pain rx, HR is stimulated not depressed Ketamine and respiratory - ✔✔unique b/c the pharyngeal reflex is maintained less risk for R. depression than opiates too rapid = respiratory depression and apnea so prepare BVM too rapid Ketamine - ✔✔give over 1 minute too rapid = respiratory depression and apnea so preapare BVM what is in the Combat Pill Pack - ✔✔Tylenol total 1300mg Mobic Moxifloxacin book Black Hawk Down by Mark BOwden - ✔✔ interventions and burned skin - ✔✔all TCCC interventions can go through burned skin how to think about burn pts - ✔✔they are trauma casualties w/burns NOT burns w/trauma cravat - ✔✔ when would you use a traction splint - ✔✔traction splint for mid-shaft femur **NEED TRAINING**traction splints for mid-shaft femur *need training** - ✔✔ interventions before/after splints - ✔✔PMS = pusle, motor, sensory best Youtube for TCCC = ANderson Strickland - ✔✔ SAM wesbsite for product training videos - ✔✔ recommended wrapping technique for burns - ✔✔Z wrap -dry wrap in a Z pattern allows for swelling best communication - ✔✔clear, short, concise TACEVAC - ✔✔ reports in TACEVAC stage - ✔✔MIST & casualty card important thing to remember about the person receiving the 9 Line Call - ✔✔person receiving the call is probably a marine on radio watch so not medical. DO NOT use medical jargon how to identify yourself/casualty over the radio - ✔✔your special number usually initial/last 4 combo BD9738 how to think about the 9 Line Evacuation - ✔✔"calling a Cab" NOT direct communication w/medical9 -LIne Line 1= - ✔✔pickup location LIne 2= - ✔✔radio frequency, call sign, suffix LIne 3= - ✔✔#pt by prescedence (urgent, priority, routine) Line 4 - ✔✔special equipment (none, hoist, extraction, ventilator, blood, specialty location like neuro/OR/eye doc Line 5 - ✔✔# casualties b y type L= litter A- ambulatory Line 6 - ✔✔seccurity at pickup site Line 7 - ✔✔markings at pickup site panels, pyrotechnical signal, smoke signal, none, other Line 8 - ✔✔casualty nationality/status 4 types of casualty for evacuation purposes - ✔✔urgent priority routine convenienceLine 9 - ✔✔CBRNE in wartime terrain descripotion in peacetime 4 TCCC reports - ✔✔MIST = medical information (keep it simple) 9 LIne = tactical non-medical for evacuation purposes DD1380 for tactical field care intervetions After Action Report what should not be delayed in TCCC - ✔✔evacuation what guides Tactical Evacuation - ✔✔Rule of 9's important thing to remember about soft tissue inuuries - ✔✔DISTRACTIONS! common, look bad, but usually dont' kill unless associated w/shock cause rescuer to feel disoriented and freeze *take a deep breath, look around to get out of the tunnel vision tactical restraints on a mission - ✔✔ important thing to remember about evacuation delays - ✔✔evacuation delays should not increase mortality if bleeding is controlled [Show More]
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