PHTLS MILITAR 8 Edição Cap 25

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CHAPTER Care Under Fire CHAPTER OBJECTIVES At the completion of this chapter, the reader will be able to do the following: Discuss the impact of the tactical environment on Explain why spinal immobilization is not a critical need the management of combat trauma. in combat casualties with only penetrating trauma. Describe techniques that can be used to quickly Discuss the rationale for early use of a tourniquet move casualties to cover while the unit is engaged to control life-threatening extremity bleeding in a firefight. during the Care Under Fire phase.668 PREHOSPITAL TRAUMA LIFE SUPPORT, MILITARY EIGHTH EDITION SCENARIO Your unit is in a five-vehicle convoy moving through a small Iraqi village when a command-detonated improvised explosive device (IED) explodes under the second vehicle. Moderate sniper fire follows and the rest of the convoy is busily engaged in suppressing it. You are a medic in the disabled vehicle, which is not on fire and is right side up. You are not injured and are able to assist. The person next to you has bilateral midthigh traumatic amputations. There is heavy arterial bleeding from the left stump and only mild oozing of blood from the right stump. The casualty is conscious and in moderate pain. What do you do? 1. What phase of care are you in? 2. What is your immediate concern? 3. Should you treat the casualty or return fire? Why? 4. What is your next action? 5. Should you put a tourniquet on the right stump? Why? 6. What are your next actions? Introduction be especially true in small-unit operations in which friendly fire- power is limited and every weapon in the unit may be needed to As reflected in the Tactical Combat Casualty Care prevail. (TCCC) Guidelines for Care Under Fire shown in Figure 25-1, very limited medical care should be attempted while the casualty and the unit are under effective hostile Moving Casualties in fire. Suppression of hostile fire and moving the casualty to a safe posi- tion are major considerations at this point. Significant delays for a Tactical Settings detailed examination and thorough treatment of all injuries are not In Care Under Fire, the best first step in saving a casualty is usu- advisable while under effective enemy fire. ally to control the tactical situation. An axiom of TCCC is that Casualties who have sustained injuries that are not life "The best medicine on the battlefield is fire superiority." If hos- threatening and that do not preclude further participation in the tile fire cannot be effectively suppressed or the unit is unable to fight should continue to assist the unit in suppressing hostile fire. break contact with the enemy, it may be necessary to move the It may also be critical for the combat medical personnel to help casualty to cover. Casualties whose wounds do not prevent them suppress hostile fire before attempting to provide care. This can from moving themselves to cover should do SO to avoid exposing Figure 25-1 Basic Management Plan for Care Under Fire 1. Return fire and take cover. 2. Direct or expect casualty to remain engaged as a combatant if appropriate. 3. Direct casualty to move to cover and apply self-aid if able. 4. Try to keep the casualty from sustaining additional wounds. 5. Casualties should be extricated from burning vehicles or buildings and moved to places of relative safety. Do what is necessary to stop the burning process. 6. Airway management is generally best deferred until the Tactical Field Care phase. 7. 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 the tourniquet proximal to the bleeding site, over the uniform, tighten, and move the casualty to cover. Source:CHAPTER 25 Care Under Fire 669 the combat medical personnel to unnecessary hazards. If unable clothing, or improvised harness makes the two-person drag eas- to move and unresponsive, the casualty is likely beyond help, ier. However, if those items are not available, then grasping the and risking the lives of rescuers by subjecting them to enemy fire casualty under the arms is all that is necessary to accomplish this in an unprotected area at this point in the engagement is usually drag. A one-person drag can be used for short distances, but it not warranted. is more difficult for the rescuer, is slower, and is less controlled If a casualty is responsive but unable to move, a rescue plan (Figure 25-3). should be developed, as follows: The great disadvantage of dragging is that the casualty is in contact with the ground, and this can cause additional injury 1. Determine the potential risk to the rescuers, keeping in in rough terrain. Carrying the casualty may be a better option mind that rescuers should not move into a zeroed-in posi- when tactically feasible. The Hawes carry is a one-person tech- tion (i.e., where there is effective concentration of enemy nique that allows for rapid movement (Figure 25-4). If the fire). Did the casualty trip a booby trap or mine? Where is casualty can maintain an upright position, the rescuer stands in fire coming from? Is it direct or indirect (e.g., rifle, machine front of the casualty and squats down. The casualty's arms are gun, grenade, mortar)? Are there electrical, fire, chemical, moved around the neck of the rescuer and held in place. The water, mechanical, or other environmental hazards? rescuer then stands and leans forward, assuming the weight 2. Consider your assets. What can rescuers provide in the of the casualty, and moves to the desired location. Unlike the way of covering fire, screening, shielding, and rescue- applicable equipment? 3. Make sure all mission personnel understand their role in the rescue and which movement technique is to be used (e.g., drag, carry, rope, stretcher). If possible, let the casu- alty know what the plan is SO that the casualty can assist as much as possible by rolling to a certain position, attaching a dragline to his or her web gear, and identifying hazards. 4. Management of the airway is temporarily deferred until the casualty is safe from hostile fire or other hazards. This minimizes the risk to the rescuer and avoids the difficulty of attempting to manage the airway while dragging the casualty. Courtesy of Dr. Mel Otten The fastest method for moving a casualty is dragging along the long axis of the body by two rescuers (Figure 25-2). This drag Figure 25-3 One-person drag. can be used in buildings, shallow water, snow, and down stairs. It can be accomplished with the rescuers standing or crawling. The use of the casualty's web gear, tactical vest, a dragline, poncho, Courtesy of Dr. Mel Otten Figure 25-2 Two-person drag. Figure 25-4 Hawes carry.670 PREHOSPITAL TRAUMA LIFE SUPPORT, MILITARY EIGHTH EDITION fireman's carry, which requires greater lifting effort and requires neck injuries would immobilization of the cervical spine have the rescuer to carry a very heavy load in an awkward position, been of possible Since the time required to accomplish the Hawes carry provides the rescuer greater range of movement cervical spine immobilization was found to be 5.5 minutes, even and the possibility of being able to use his or her firearm. It also when applied by experienced prehospital care providers, the maintains a lower center of gravity for both the casualty and the authors concluded that the potential hazards to both casualty rescuer, thus minimizing the risk of additional injury from falls and combat medical personnel outweighed the potential benefit during the carry. of immobilization. Members of SEAL Team THREE devised and use a two- Kennedy and his coauthors reported similar findings of person carry in which one of the casualty's arms is draped over no cervical spine injuries in 105 victims of gunshot wounds to each of the rescuers' shoulders. Each rescuer uses the hand clos- the Other recent papers examining the value of cervical est to the casualty to lift the casualty by the waist belt. If the spine immobilization in civilian trauma cases have also found casualty is conscious and can hold on to the rescuers' shoulders, little data to support this practice in trauma victims with only a the rescuers may use their free arms to employ their weapons if penetrating mechanism of necessary (Figure 25-5). In casualty scenarios in which the casualty has suffered blunt trauma and is under effective hostile fire (e.g., an ambush Casualty Movement and Spinal in which an improvised explosive device (IED) causes a vehicle to be overturned and the explosion is followed by small arms Immobilization fire), the combat medic, corpsman, or pararescueman must Movement of the casualty will often be the most problematic weigh the risk of injury from hostile fire or vehicle fire secondary aspect of providing TCCC. Although a long-standing principle to the explosion against the risk of worsening any potential spi- of care in the civilian setting is to perform spinal immobiliza- nal cord injury when making decisions about how and when to tion prior to moving a trauma patient with a potential spinal move the casualty to cover. injury, this practice should be re-evaluated in the combat set- The wounding pattern seen in IED injuries depends on ting. Arishita, Vayer, and Bellamy examined the value of cervical whether the explosion occurred when the casualty was riding spine immobilization in penetrating neck injuries in the Vietnam in a vehicle (mounted IED attack) or occurred as the casualty War and found that in only 1.4% of casualties with penetrating stepped on the IED (dismounted IED attack.) The latter mech- anism of injury was seen in increasing numbers in Afghanistan during the period of 2010 through 2012, and resulted in an injury pattern referred to as Dismounted Complex Blast Injury (DCBI) (see the Tactical Field Care chapter for more information). Spinal injuries may result from either type of IED attack, and this must be considered when treating IED With IED injuries, appropriate spinal precautions should be taken as tactically feasible. Hemorrhage Control In combat casualties, early control of significant external hemor- rhage is the most important intervention. Hemorrhage remains the predominant cause of preventable death in combat fatali- The renewed focus on prehospital tourniquets to prevent death from extremity hemorrhage as emphasized in TCCC was the single most successful battlefield trauma care innovation to come from the wars in Afghanistan and Iraq. Until recently, com- bat medical personnel were taught that a tourniquet should be used only as a last resort to control extremity hemorrhage.9 A study of 2,600 combat fatalities incurred during the Vietnam con- and a study of 982 combat fatalities incurred during the early years of conflict in Afghanistan and reported death rates from extremity hemorrhage of 7.4% and 7.8%, respectively. After the widespread implementation of the tourniquet recom- Figure 25-5 SEAL Team THREE carry. Both rescuers are holding the mendations from the TCCC guidelines, a recent comprehensive casualty by his belt in the rear. study of 4,596 U.S. combat fatalities from 2001 to 2011 noted Source: Courtesy of Dr. Frank Butler. that only 2.6% of total combat fatalities resulted from extremityCHAPTER 25 Care Under Fire 671 hemorrhage. 12 This dramatic decrease in deaths from extremity of concern about ischemic damage to the extremity, this has hemorrhage resulted from the now ubiquitous fielding of modern not been found to be a significant problem when tourniquets tourniquets and aggressive training of all nonmedical personnel have been used appropriately during combat on tourniquet Tourniquets are used frequently during orthopedic surgical pro- Control of significant bleeding from injuries such as scalp cedures and are relatively safe if left on for less than 2 hours. lacerations and external torso injuries is also a high priority, but Prolonged use of a tourniquet can potentially result in the loss the tactical imperative to maintain fire superiority and to move of a limb, but saving the life of the casualty must always take the casualty to cover dictates that only life-threatening extrem- precedence if the tourniquet cannot be removed for tactical ity bleeding should warrant any intervention during Care Under reasons. Fire. Both the casualty and the other unit members should dis- Because of their proven lifesaving value, tourniquets are regard minor wounds insofar as possible during Care Under ubiquitous on the modern Several recent papers Fire, in order to maximize the unit's firepower. If a tourniquet have called for a re-evaluation of tourniquet use in the civilian is required during Care Under Fire, the casualty should apply prehospital environment as Note that every combat- it to himself or herself if at all possible. Tourniquet application ant on the battlefield should be able to apply a tourniquet to should take place under the best cover immediately available to his or her own bleeding extremity or on any unit member that the casualty. requires one. Hemorrhage control by nonmedical personnel has been a key element in reducing preventable deaths on the battlefield. 31 Tourniquets Failure to use tourniquets continued to result in preventable fatalities at the start of the conflicts in Iraq and Afghanistan. Tourniquet Evaluation Colonel John Holcomb, then Commander of the U.S. Army There are currently a variety of tourniquets available on the Institute of Surgical Research, and his coauthors examined market, and some are more effective than others. In a com- all deaths in Special Operations forces from the start of the parative evaluation of tourniquets available at the time, the Global War on Terrorism in 2001 through November 2004, find- U.S. Army Institute of Surgical Research identified three that ing that bleeding from extremity wounds was the cause of 25% were 100% effective in stopping arterial blood flow. 32 These of the potentially preventable deaths in combat were the Combat Application Tourniquet (C-A-T), the SOF Beekley noted that four of the seven deaths that occurred in a Tactical Tourniquet (SOFT-T), and the Emergency and Military series of 165 casualties cared for at the 31st Combat Support Tourniquet (EMT), a pneumatic device. The C-A-T and SOFT-T Hospital in Baghdad could have been prevented by the timely are both windlass-type devices that are lightweight and rela- use of a tourniquet. 14 Kelly noted 77 deaths from extremity tively inexpensive. These tourniquets can be readily applied to hemorrhage in his study of 982 combat fatalities. 11 Colonel one's own or another's extremity and are rugged, reliable, and Brian Eastridge found 131 deaths from extremity hemorrhage small enough to be easily carried. The C-A-T has been desig- in his comprehensive study of 4,596 combat fatalities from nated as an item of individual issue to ground combatants in Afghanistan and all services and has proven effective and reliable in the current As noted above, deaths from extremity hemorrhage (Figure 25-6). can largely be prevented by aggressive use of tourniquets. The other tourniquets found to be effective in the U.S. Army Tourniquets have been in use on the battlefield for centu- Institute of Surgical Research study may also be useful in some and have been shown to clearly save lives in Because of their effectiveness at hemorrhage control and the speed with which they can be applied, tourniquets the best option for temporary control of life-threatening extremity hemorrhage in the tactical environment. Direct pressure and compression dressings are less desirable than tourniquets in this setting because their application at the point of wounding may result in delays in getting the casualty and the rescuer to cover. Also these interventions provide less definitive control of life-threatening hemorrhage, especially while the casualty is being Colonel John Kragh's work has confirmed the lifesaving benefit and low incidence of complications from prehospital tourniquet use in combat Tourniquets are most effective in saving lives when applied before the casualty has gone into shock from blood Although tourniquet use has Figure 25-6 Combat Application Tourniquet (C-A-T). been discouraged by civilian EMS systems in the past because Source: Composite Resources, Inc.672 PREHOSPITAL TRAUMA LIFE SUPPORT, MILITARY EIGHTH EDITION situations. Combat medical personnel experience has found Tourniquet Application that the SOF Tactical Tourniquet (Figure 25-7) may be a better choice if the casualty has large thighs and needs a tourniquet in Tourniquets should be placed clearly proximal to the site of that location. the severe bleeding. They should never be placed directly over The Emergency and Military Tourniquet (Figure 25-8) has a joint. They should also never be placed over a holster or a been found to perform very well in emergency but pocket containing bulky objects that would make tightening the it is more expensive than the C-A-T. Furthermore, its inflatable tourniquet more difficult or more painful for the casualty. cuff may not function if it has had prolonged time in the field or During Care Under Fire, tourniquets should be tightened has been exposed to shrapnel strikes. as necessary to stop bleeding from the distal injury. During this phase, time may not permit exposure of the wound, and the tourniquet may have to be placed over the casualty's uniform. Although this is not an ideal application, it is advisable due to the tactical situation and the need to move both casualty and care provider to cover quickly. If bleeding is not controlled with one tourniquet, a second tourniquet should be applied just proximal to the first. Once time permits in Tactical Field Care, the wound should be exposed and reevaluated, and a replacement tourniquet should be applied directly to the casualty's skin. The time at which a tourniquet is applied should always be noted on the casualty. This has customarily been done by writing the letter "T" on the casualty's forehead along with the time. This should be done with an indelible ink marker to ensure that this important information does not wash or wipe off. Either the involved extremity or a piece of tape applied to the casualty's chest is an alternative location for noting tourni- quet application time. The information should also be record- ed on the individual's TCCC Casualty Card. If the casualty has multiple tourniquets with significantly different times of appli- Courtesy of Tactical Medical cation, this should be noted clearly on the TCCC Casualty Card. Figure 25-7 SOFTM Tactical Tourniquet. See Figures 25-9 and 25-10 for more information on tourniquet Source: Courtesy of Tactical Medical Solutions. application. Hemostatic Agents The requirement to hold direct pressure on the bleeding site after application of a hemostatic agent is tactically infeasible when the casualty and the individual providing care are under Figure 25-9 Tourniquet Application Mistakes Mistakes to avoid when applying tourniquets include: Not using a tourniquet when you should Using a tourniquet for minimal bleeding Putting the tourniquet on too proximally Not making the tourniquet tight enough to effectively stop the bleeding Not using a second tourniquet if needed Waiting too long to put the tourniquet on Periodically loosening the tourniquet to allow blood Courtesy of Delfi Medical Innovations, Inc. flow to the injured extremity Figure 25-8 Emergency and Military Tourniquet. Source: Courtesy of Delfi Medical Innovations, Inc.CHAPTER 25 Care Under Fire 673 applied to the bleeding site. This subject is discussed more fully Figure 25-10 Tourniquet Tips in the Tactical Field Care chapter. All manufactured tourniquets are designed for a single use. A separate group of tourniquets should be Airway used for training, and training tourniquets should not No immediate management of the airway should be anticipated subsequently be issued to individuals for use in combat. during Care Under Fire because of the need to move the casualty Many military units have evolved to a single-tour, single- to cover as quickly as possible. Since most preventable deaths use policy for tourniquets. on the battlefield are caused by hemorrhage, addressing any sig- nificant external hemorrhage that may be present will hopefully prevent the casualty from going into hypovolemic shock and requiring airway management. An injury that is severe enough effective hostile fire. Therefore, the use of hemostatic agents to result in immediate loss of consciousness during Care Under during Care Under Fire is not However, when Fire, such as penetrating head trauma, will have a high proba- its application can be achieved in a safer setting, a hemo- bility of proving fatal. Airway control should be deferred until static dressing can be a highly effective option for controlling Tactical Field Care and until after all major external hemorrhage a life-threatening hemorrhage when a tourniquet cannot be has been addressed. Summary In Care Under Fire, the need for medical care must be weighed against the need to move to cover and to suppress hostile fire rapidly. During Care Under Fire, very limited medical care should be attempted while under effective hostile fire. Suppression of hostile fire and moving the casualty to cover are priorities. Casualties who are able to should remain engaged as combatants during Care Under Fire. Combat medical personnel may have to help suppress hostile fire before providing care to casualties. If the casualty is unable to move and is unresponsive, he or she is likely beyond help. Risking additional lives by exposure to fire in the open in order to move the casualty to cover during Care Under Fire may not be warranted. If the casualty is responsive and able to move to cover, he or she should do SO immediately. If the casualty is responsive but unable to move to cover, a rescue plan should be implemented as outlined in this chapter. The fastest method for moving a casualty is dragging him or her along the long axis of the body by two rescuers. One-person drags are slower than two-person drags, but have the advantage of exposing only one rescuer to additional risk. The Hawes carry can be used by one person and may be useful in some situations. A two-person carry used by SEAL Team THREE requires that one of the casualty's arms be draped over each of the rescuers' shoulders with the rescuers grasping the casualty by his or her waist belt. This is a useful option for a two-person carry. With penetrating injury to the head or neck, immobilization of the cervical spine during Care Under Fire is not warranted unless blunt injury is present as well. In combat casualties with known or possible blunt neck or spine trauma, the first responder must weigh the risk of injury from hostile fire to the casualty and the responder while immobilizing the spine against the risk of causing or worsening a spinal cord injury. The wounding pattern of IED injuries is characterized by penetrating injuries superimposed on blast injury from the explosion and possibly blunt injury from motor vehicle trauma. In these settings, injury to the spine is more common and appropriate precautions should be taken when tactical conditions allow. Immediate control of extremity hemorrhage with a tourniquet is the most important lifesaving intervention in Care Under Fire and is generally the only medical care that should be undertaken before the casualty is moved to cover. Tourniquets save lives in combat when used appropriately. They are most effective when applied before the casualty has gone into shock from blood loss. Tourniquets have been shown to be safe when applied for less than 2 hours.674 PREHOSPITAL TRAUMA LIFE SUPPORT, MILITARY EIGHTH EDITION Two tourniquets have been shown to be 100% effective in stopping arterial blood flow and are recommended for use on the battlefield: the Combat Application Tourniquet (C-A-T), and the SOF Tactical Tourniquet (SOFT-T) Tourniquets should be placed proximal to the site of the hemorrhage. Tourniquets should never be placed directly over a joint or over pockets containing bulky items. The time of tourniquet application should be noted both on the tourniquet itself and on the TCCC Casualty Card. The use of hemostatic agents in Care Under Fire is not recommended because of the requirement to hold direct pressure on the bleeding site for 3 minutes after application. This is an unacceptably long period during Care Under Fire. Airway management is usually best deferred until Tactical Field Care, and until after major external hemor- has been addressed. SCENARIO RECAP Your unit is in a five-vehicle convoy moving through a small Iraqi village when a command-detonated IED explodes under the second vehicle. Moderate sniper fire follows and the rest of the convoy is busily engaged in suppressing it. You are a medic in the disabled vehicle, which is not on fire and is right side up. You are not injured and are able to assist. The person next to you has bilateral midthigh traumatic amputations. There is heavy arterial bleeding from the left stump and only mild oozing of blood from the right stump. The casualty is conscious and in moderate pain. What do you do? SCENARIO SOLUTION 1. What phase of care are you in? You are in the Care Under Fire phase. 2. What is your immediate concern? The casualty may exsanguinate quickly from arterial bleeding. 3. Should you treat the casualty or return fire? Why? You should treat the casualty's extremity hemorrhage. The rest of the convoy is providing suppressive fire, and applying a tour- niquet is a fast and easy lifesaving intervention. 4. What is your next action? Place a tourniquet on the stump of the left thigh. 5. Should you put a tourniquet on the right stump? Why? No. The bleeding from the right stump is minimal at this point. Wait until Tactical Field Care, but recheck often. 6. What are your next actions? Drag the casualty out of the vehicle and move to the best cover. Return fire if needed. Communicate the casualty's status to the team leader.CHAPTER 25 Care Under Fire 675 References 16. Mabry RL, Holcomb JB, Baker A, et al. U.S. Army Rangers in Somalia: an analysis of combat casualties on an urban battlefield. J Trauma. 1. Butler FK, Hagmann J, Butler EG. Tactical Combat Casualty Care in 2000; 49:515. Special Operations. Mil Med. 1996; 17. Mucciarone JJ, Llewellyn CH, Wightman JM. Tactical Combat 2. Arishita GI, Vayer JS, Bellamy RF. Cervical spine immobilization of Casualty Care in the assault on Punta Paitilla Airfield. Mil Med. 2006; penetrating neck wounds in a hostile environment. J Trauma. 1989; 171(8):687-690. 29:332-337. 18. Beekley AC, Starnes BW, Sebesta JA. Lessons learned from modern 3. Kennedy FR, Gonzalez P, Beitler A, et al. Incidence of cervical spine military surgery. Surg Clin N Am. 2007; 87:157-184. injury in patients with gunshot wounds to the head. South Med J. 19. Tarpey MJ. Tactical combat casualty care in Operation Iraqi 1994; 87:621-623. Freedom. U.S. Army Medical Dept J. April-June 2005:38-41. 4. Stuke L, Pons P, Guy J, et Prehospital spine immobilization for 20. Tien HC, Jung V, Rizoli SB, Acharya SV, MacDonald JC. An evalu- penetrating trauma-review and recommendations from the Prehos- ation of Tactical Combat Casualty Care interventions in a combat pital Trauma Life Support Executive Committee. J Trauma. 2011; environment. J Am Coll Surg. 2008; 207:174-178. 71:763-770. 21. Carey ME. Analysis of wounds incurred by U.S. Army Seventh Corps 5. Lustenberger T, Talving P, Lam L, et al. Unstable cervical spine frac- personnel treated in corps hospitals during Operation Desert Storm, ture after penetrating neck injury: a rare entity in an analysis of 1,069 February 20 to March 10, 1991. J Trauma. 1996; 40:S165-S169. patients. J Trauma. 2011; 70:870-872. 22. Kragh JF, Walters TJ, Baer DG, et al. Practical use of emergency 6. Caravalho J. OTSG Dismounted Complex Blast Injury Task Force; tourniquets to stop bleeding in major limb trauma. J Trauma. 2008; Final Report. June 18, 2011:44-47. 64:S38-S50. 7. Comstock S, Pannell D, Talbot M, et al. Spinal injuries after impro- 23. Kragh JF, Walters TJ, Baer DG, et al. Survival with emergency tour- vised explosive device incidents: implications for Tactical Combat niquet use to stop bleeding in major limb trauma. Ann Surg. 2009; Casualty Care. J Trauma. 2011; 71:S413-S417. 249:1-7. 8. Eastridge BJ, Mabry R, Seguin P, et al. Pre-hospital death on the 24. Butler FK, Holcomb JB, Giebner SG, McSwain NE, Bagian J. Tactical battlefield: implications for the future of combat casualty care. Combat Casualty Care 2007: evolving concepts and battlefield expe- J Trauma Acute Care Surg. 2012; rience. Mil Med. 2007; 172(S):1-19. 9. Butler FK, Blackbourne LH. Battlefield trauma care then and now: 25. Lakstein D, Blumenfeld A, Sokolov T, et al. Tourniquets for hemor- a decade of Tactical Combat Casualty Care. J Trauma Acute Care rhage control on the battlefield: a four-year accumulated experience. Surg. 2012; J Trauma. 2003; 54:S221-S225. 10. Maughon JS. An inquiry into the nature of wounds resulting in killed 26. Kalish J, Burke P, Feldman J, et al. The return of tourniquets. J Em in action in Vietnam. Mil Med. 1970; 135:8-13. Med Serv. 2008; 33(8):45-53. 11. Kelly JF, Ritenhour AE, McLaughlin DF, et al. Injury severity 27. Dorlac WC, Debakey ME, Holcomb JB, et al. Mortality from isolated and causes of death from Operation Iraqi Freedom and Opera- civilian penetrating extremity injury. J Trauma. tion Enduring Freedom: 2003-2004 versus 2006. J Trauma. 2008; 28. Doyle GS, Taillac PP. Tourniquets: a review of current use with pro- 64:S21-S27. posals for expanded prehospital use. Prehosp Emerg Care. 2008; 12. Kotwal RS, Butler FK, Edgar EP, Shackelford SA, Bennett DR, Bailey 12:241-256. JA. Saving lives on the battlefield: a joint trauma system review 29. Markov N, Dubose J, Scott D, et al. Anatomic distribution and mor- of pre-hospital trauma care in combined joint operating area- tality of arterial injury in the wars in Afghanistan and Iraq with com- Afghanistan (CJOA-A) Executive Summary. J Spec Oper Med. 2013; parison to a civilian benchmark. J Vasc Surg. 2012; 56(3):728-736. 13(1):77-85. 30. Butler F, Carmona R. Tactical combat casualty care: from the battlefields 13. Holcomb JB, McMullen NR, Pearse L, et al. Causes of death in Spe- of Afghanistan to the streets of America. Tactical Edge. Winter 2012. cial Operations Forces in the Global War on Terror. Ann Surg. 2007; 31. Kotwal RS, Montgomery HR, Kotwal BM, et al. Eliminating prevent- 245:986-991. able death on the battlefield. Arch Surg. 2011; 146:1350-1358. 14. Beekley AC, Sebesta JA, Blackbourne LH, et al. Prehospital tourni- 32. Walters TJ, Wenke JC, Greydanus DJ, Kauvar DS, Baer DG. Labo- quet use in Operation Iraqi Freedom: effect on hemorrhage control ratory evaluation of battlefield tourniquets on human volunteers. and outcomes. J Trauma. 2008; 64:S28-S37. U.S. Army Institute of Surgical Research Technical Report 2005-05. 15. Mabry RL. Tourniquet use on the battlefield. Mil Med. 2006; 171:352-356. September 2005.676 PREHOSPITAL TRAUMA LIFE SUPPORT, MILITARY EIGHTH EDITION SPECIFIC SKILLS Combat Application Tourniquet (C-A-T°) One-Handed Self-Application to an Arm 1 Insert the wounded extremity through the loop 2 Pull the self-adhering band tight, and securely of the self-adhering band. fasten it back on itself. Source: Composite Resources Inc. Source: Composite Resources Inc. (1) 3 Adhere the band around the arm. Do not adhere 4 Twist the windlass rod until the bleeding stops. the band past the clip. Source: Composite Resources Inc. Source: Composite Resources Inc.CHAPTER 25 Care Under Fire 677 SPECIFIC SKILLS Combat Application Tourniquet (continued) Lock the rod in place with the windlass clip. 6 Adhere the band over the windlass rod. For small extremities, continue to adhere the band around the extremity. Source: Composite Resources Inc. Source: Composite Resources Inc. 7 Secure the rod and band with the windlass strap. Grasp the strap, pull it tight, and adhere it to the opposite hook on the windlass clip. Source: Composite Resources Inc.678 PREHOSPITAL TRAUMA LIFE SUPPORT, MILITARY EIGHTH EDITION Combat Application Tourniquet (continued) Application to a Leg Pass the self-adhering band through the inside 2 Pass the band through the outside slit of the slit of the friction adaptor buckle. friction adaptor buckle, which will lock the band in place. Source: Composite Resources Inc. Source: Composite Resources Inc. 3 Pull the self-adhering band tight, and securely 4 Twist the windlass rod until the bleeding stops. fasten the band back on itself. Source: Composite Resources Inc. Source: Composite Resources Inc.CHAPTER 25 Care Under Fire 679 Combat Application Tourniquet (continued) 5 Lock the rod in place with the windlass clip. 6 Secure the rod with the windlass strap. Grasp the strap, pull it tight, and adhere it to the opposite hook on the windlass clip. Source: Composite Resources Inc. Source: Composite Resources Inc.