PHTLS MILITAR 8 Edição Cap 27

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CHAPTER 27 Tactical Evacuation Care CHAPTER OBJECTIVES At the completion of this chapter, the reader will be able to do the following: Delineate the scope of Tactical Evacuation and equipment that should be available in the (TACEVAC) Care and its inclusion of both Casualty Tactical Evacuation phase as compared to Tactical Evacuation (CASEVAC) and Medical Evacuation Field Care. (MEDEVAC). Define the indications for transfusions in the Describe the additional interventions and modified field, and discuss the requirement to do under management strategies that may be indicated protocol. during TACEVAC given the increased stability of Describe the management of wounded hostile the circumstances and the additional personnel combatants during TACEVAC.CHAPTER 27 Tactical Evacuation Care 727 SCENARIO You are a medic aboard a MEDEVAC Blackhawk that has landed in a secure landing zone (LZ) in the mountains of southeastern Afghanistan to extract a Ranger who has multiple shrapnel wounds from a rocket-propelled grenade (RPG) blast. The LZ altitude is 6,000 feet, and the ambient temperature is 64°F (18°C). The casualty, who has been stabilized by the platoon medic, is able to converse normally and has a tourniquet over his uniform on his upper right thigh. His right shirt sleeve is missing, and there is a pressure dressing around his right upper arm. There is a saline lock in his left antecubital fossa. The platoon medic tells you that the casualty lost a lot of blood from his thigh wound and was drowsy and confused before the tourniquet was applied 30 minutes ago. He received 500 milliliters of Hextend, to which he responded well, and has been stable since. The wound with the pressure dressing was packed with Combat Gauze underneath. He has taken moxifloxacin 400 milligrams by mouth and has an 800-microgram fentanyl lozenge in his right cheek. He has been drinking water from his canteen. 1. What are your considerations for the care of this casualty during the 30-minute helicopter flight back to the Combat Support Hospital? 2. What do you do first? 3. What do you do next? 4. Should you start an intravenous (IV) line through the saline lock in anticipation of the need for a second bolus of Hextend? 5. Should you remove the tourniquet? 6. Should you remove the fentanyl lozenge? 7. What else do you want to do? 8. Is there anything else to attend to during the flight to the Combat Support Hospital? Introduction casualties from the battlefield and moving casualties between medical treatment facilities. The term Casualty Evacuation, or "CASEVAC," Since casualty movement following Tactical Field Care is used to describe the unregulated movement may be either CASEVAC or MEDEVAC, the third phase of of casualties from the point of wounding to care in Tactical Combat Casualty Care (TCCC) is designated the first point of advanced medical care (a Role 2 Forward Sur- Tactical Evacuation (TACEVAC) to encompass both types of gical Team or higher). CASEVAC platforms are typically armed platforms. tactical assets that bear no Red Cross markings. These are of- In contrast, the term aeromedical evacuation is typically ten aircraft, vehicles, or boats of opportunity. During the drive used to describe the aeromedical transfer of casualties between on Baghdad in Operation Iraqi Freedom, some casualties were medical treatment facilities in theater or to the Role 4 hospital moved to the rear on tanks because use of Medical Evacuation in Landstuhl. Aeromedical evacuation is beyond the scope of aircraft and vehicles was not feasible given the tactical circum- TCCC, but will be discussed in the Aeromedical Evacuation in a stances. Combat Theater chapter. En route care is a more general term The term Medical Evacuation, or "MEDEVAC," refers to that includes all of the above types of casualty transport. medically regulated casualty movement using dedicated medi- Evacuation of the wounded from the battlefield using cal evacuation platforms (ground vehicles, rotary wing aircraft, ground, air, or maritime platforms presents an opportunity to etc.). These are crewed by medical attendants and often have bring in additional medical equipment and personnel. This allows more medical treatment equipment available than nonmedical for the expanded monitoring and therapeutic measures outlined assets. MEDEVAC platforms are predesignated assets that bear in the TCCC Guidelines for the TACEVAC phase (Figure 27-1). Red Cross markings and no offensive weaponry such as rockets For example, the TACEVAC provider may have at his or her dis- or missiles. MEDEVAC movements may include both clearing posal more options for airway management, fluid resuscitation,728 PREHOSPITAL TRAUMA LIFE SUPPORT, MILITARY EIGHTH EDITION and prevention of hypothermia than were available in Care Un- administered medications, and other interventions routinely der Fire or Tactical Field Care. As noted in the 2012 TCCC update available for critical The survival advantage has been found to be the greatest, Recent reviews of this topic have offered the possibility for sig- as would be expected, in the subset of casualties with severe but nificant improvements in care through providing evacuation not overwhelming injuries.5 providers trained to at least the critical care flight paramedic The order of the elements of care in TACEVAC listed in level, ensuring that blood and plasma are available for casual- Figure 27-1 presupposes that life-threatening hemorrhage has ties in hemorrhagic shock, using the most capable evacuation been successfully addressed previously in the casualty's care. If platforms available, ensuring TCCC training for all evacuation this is not the case, then hemorrhage control should take first providers, and having advanced airway options, intravenously precedence in TACEVAC as well. Figure 27-1 Basic Management Plan for Tactical Evacuation* Care (October 28th, 2013) 1. Airway Management Casualty in shock a. Unconscious casualty without airway obstruction: Casualty at altitude Chin lift or jaw thrust maneuver d. All open and/or sucking chest wounds should be Nasopharyngeal airway treated by immediately applying a vented chest seal to Place casualty in the recovery position cover the defect. If a vented chest seal is not available, b. Casualty with airway obstruction or impending use a non-vented chest seal. Monitor the casualty for airway obstruction: the potential development of a subsequent tension Chin lift or jaw thrust maneuver pneumothorax. If the casualty develops increasing Nasopharyngeal airway Allow casualty to assume any position that best hypoxia, respiratory distress, or hypotension and a protects the airway, to include sitting up. tension pneumothorax is suspected, treat by burping Place unconscious casualty in the recovery position. or removing the dressing or by needle decompression. If above measures unsuccessful: 3. Bleeding Supraglottic airway or a. Assess for unrecognized hemorrhage and control Endotracheal intubation or all sources of bleeding. If not already done, use Surgical cricothyroidotomy (with lidocaine if a CoTCCC-recommended tourniquet to control conscious). C. Spinal immobilization is not necessary for casualties life-threatening external hemorrhage that is anatomically amenable to tourniquet application or with penetrating trauma. for any traumatic amputation. Apply directly to the 2. Breathing skin 2-3 inches above wound. a. In a casualty with progressive respiratory distress and b. For compressible hemorrhage not amenable to known or suspected torso trauma, consider a tension tourniquet use or as an adjunct to tourniquet removal pneumothorax and decompress the chest on the (if evacuation time is anticipated to be longer than side of the injury with a 14-gauge, 3.25 inch needle/ two hours), use Combat Gauze as the hemostatic catheter unit inserted in the second intercostal space at the midclavicular line. Ensure that the needle agent of choice. Combat Gauze should be applied with at least 3 minutes of direct pressure. Before entry into the chest is not medial to the nipple line releasing any tourniquet on a casualty who has been and is not directed towards the heart. An acceptable resuscitated for hemorrhagic shock, ensure a positive alternate site is the 4th or 5th intercostal space at response to resuscitation efforts (i.e., a peripheral the anterior axillary line (AAL). pulse normal in character and normal mentation if b. Consider chest tube insertion if no improvement there is no TBI.) If the bleeding site is appropriate for and/or long transport is anticipated. use of a junctional tourniquet, immediately apply C. Most combat casualties do not require supplemental a CoTCCC-recommended junctional tourniquet. oxygen, but administration of oxygen may be of Do not delay in the application of the junctional benefit for the following types of casualties: Low oxygen saturation by pulse oximetry tourniquet once it is ready for use. Combat Gauze Injuries associated with impaired oxygenation applied with direct pressure should be used if a Unconscious casualty junctional tourniquet is not available or while the Casualty with TBI (maintain oxygen saturation > junctional tourniquet is being readied for use. 90%) (Continues on next page)CHAPTER 27 Tactical Evacuation Care 729 Figure 27-1 Basic Management Plan for Tactical Evacuation* Care (October 28th, 2013) (Continued) C. Reassess prior tourniquet application. Expose wound Elevate the casualty's head 30 degrees. and determine if tourniquet is needed. If so, move Hyperventilate the casualty. tourniquet from over uniform and apply directly to a. Respiratory rate 20 skin 2-3 inches above wound. If a tourniquet is not b. Capnography should be used to maintain the needed, use other techniques to control bleeding. end-tidal between 30-35 d. When time and the tactical situation permit, a distal C. The highest oxygen concentration possible should be used for hyperventilation. pulse check should be accomplished. If a distal pulse is still present, consider additional tightening of the Notes: tourniquet or the use of a second tourniquet, side- Do not hyperventilate unless signs of impending by-side and proximal to the first, to eliminate the herniation are present. distal pulse. Casualties may be hyperventilated with oxygen using e. Expose and clearly mark all tourniquet sites with the bag-valve-mask technique. the time of tourniquet application. Use an indelible 7. Fluid resuscitation marker. Reassess for hemorrhagic shock (altered mental status 4. Intravenous (IV) access in the absence of brain injury and/or change in pulse a. Reassess need for IV access. character.) If (BP) monitoring is available, maintain target If indicated, start an 18-gauge IV or saline lock systolic BP 80-90 mmHg. If resuscitation is required and IV access is not a. If not in shock: obtainable, use intraosseous (IO) route. No IV fluids necessary. 5. Tranexamic Acid (TXA) PO fluids permissible if conscious and can swallow. If a casualty is anticipated to need significant blood b. If in shock and blood products are not available: transfusion (for example: presents with hemorrhagic Hextend 500-mL IV bolus shock, one or more major amputations, penetrating Repeat after 30 minutes if still in torso trauma, or evidence of severe bleeding): Continue resuscitation with Hextend or crystalloid Administer 1 gram of tranexamic acid in 100 CC solution as needed to maintain target BP or clinical improvement. Normal Saline or Lactated Ringers as soon as possible C. but NOT later than 3 hours after injury. If in shock and blood products are available under an Begin second infusion of 1 gm TXA after Hextend or approved command or theater protocol: Resuscitate with 2 units of plasma followed by other fluid treatment. packed red blood cells (PRBCs) in a 1:1 ratio. 6. Traumatic Brain Injury (TBI) If blood component therapy is not available, a. Casualties with moderate/severe TBI should be transfuse fresh whole blood. Continue monitored for: resuscitation as needed to maintain target BP or Decreases in level of consciousness clinical improvement. Pupillary dilation d. If a casualty with an altered mental status due to SBP should be >90 mmHg suspected TBI has a weak or absent peripheral pulse, sat > 90 resuscitate as necessary to maintain a palpable radial Hypothermia pulse. If BP monitoring is available, maintain target 35-40 mmHg) systolic BP of at least 90 mmHg. Penetrating head trauma (if present, administer 8. Prevention of hypothermia antibiotics) a. Minimize casualty's exposure to the elements. Keep Assume a spinal (neck) injury until cleared. protective gear on or with the casualty if feasible. b. Unilateral pupillary dilation accompanied by a b. Replace wet clothing with dry if possible. Get the decreased level of consciousness may signify casualty onto an insulated surface as soon as possible. impending cerebral herniation; if these signs occur, C. Apply the Ready-Heat Blanket from the Hypothermia take the following actions to decrease intracranial Prevention and Management Kit (HPMK) to the pressure: casualty's torso (not directly on the skin) and cover Administer 250 CC of 3% or 5% hypertonic saline the casualty with the Heat-Reflective Shell (HRS). bolus. (Continues on next page)730 PREHOSPITAL TRAUMA LIFE SUPPORT, MILITARY EIGHTH EDITION Figure 27-1 Basic Management Plan for Tactical Evacuation* Care (October 28th, 2013) (Continued) d. If an HRS is not available, the previously recommended Casualty IS at significant risk of developing either combination of the Blizzard Survival Blanket and the condition Ready Heat blanket may also be used. Ketamine 50 mg IM or IN e. If the items mentioned above are not available, use Or poncho liners, sleeping bags, or anything that will Ketamine 20 mg slow IV or IO retain heat and keep the casualty dry. Repeat doses q30min prn for IM or IN f. Use a portable fluid warmer capable of warming all Repeat doses q20min prn for IV or IO End points: Control of pain or development of IV fluids including blood products. nystagmus g. Protect the casualty from wind if doors must be kept (rhythmic back-and-forth movement of the eyes) open. *Analgesia notes 9. Penetrating Eye Trauma a. Casualties may need to be disarmed after being If a penetrating eye injury is noted or suspected: given OTFC or ketamine. a. Perform a rapid field test of visual acuity. b. Document a mental status exam using the AVPU b. Cover the eye with a rigid eye shield (NOT a pressure method prior to administering opioids or ketamine. patch). C. For all casualties given opiods or ketamine - monitor C. Ensure that the 400 mg moxifloxacin tablet in the airway, breathing, and circulation closely combat pill pack is taken, if possible, and that IV/IM d. Directions for administering OTFC: antibiotics are given as outlined below if oral Recommend taping lozenge-on-a-stick to casualty's moxifloxacin cannot be taken. finger as an added safety measure OR utilizing a 10. Monitoring safety pin and rubber band to attach the lozenge Institute pulse oximetry and other electronic monitoring (under tension) to the patients uniform or plate of vital signs, if indicated. All individuals with moderate/ carrier. severe TBI should be monitored with pulse oximetry. Reassess in 15 minutes 11. Inspect and dress known wounds if not already done. Add second lozenge, in other cheek, as necessary 12. Check for additional wounds. to control severe pain 13. Analgesia on the battlefield should generally be Monitor for respiratory depression achieved using one of three options: e. IV Morphine is an alternative to OTFC if IV access has been obtained Option 1 5 mg IV/IO Mild to Moderate Pain Reassess in 10 minutes. Casualty is still able to fight Repeat dose every 10 minutes as necessary to TCCC Combat pill pack: control severe pain. Tylenol - 650-mg bilayer caplet, 2 PO every 8 hours Monitor for respiratory depression Meloxicam - 15 mg PO once a day f. Naloxone (0.4 mg IV or IM) should be available when using opioid analgesics. Option 2 g. Both ketamine and OTFC have the potential to Moderate to Severe Pain worsen severe TBI. The combat medic, corpsman, Casualty IS NOT in shock or respiratory distress AND or PJ must consider this fact in his or her analgesic Casualty IS NOT at significant risk of developing decision, but if the casualty is able to complain of either condition Oral transmucosal fentanyl citrate (OTFC) 800 ug pain, then the TBI is likely not severe enough to Place lozenge between the cheek and the gum preclude the use of ketamine or OTFC. Do not chew the lozenge h. Eye injury does not preclude the use of ketamine. The risk of additional damage to the eye from Option 3 using ketamine is low and maximizing the casualty's Moderate to Severe Pain chance for survival takes precedence if the casualty Casualty IS in hemorrhagic shock or respiratory is in shock or respiratory distress or at significant risk distress OR for either. (Continues on next page)CHAPTER 27 Tactical Evacuation Care 731 Figure 27-1 Basic Management Plan for Tactical Evacuation* Care (October 28th, 2013) (Continued) i. Ketamine may be a useful adjunct to reduce the resuscitation for burn shock. Administer IV/IO amount of opioids required to provide effective fluids per the TCCC Guidelines in Section 7. pain relief. It is safe to give ketamine to a casualty e. Analgesia in accordance with TCCC Guidelines in who has previously received morphine or OTFC. IV Section 13 may be administered to treat burn pain. Ketamine should be given over 1 minute. f. Prehospital antibiotic therapy is not indicated solely j. If respirations are noted to be reduced after using for burns, but antibiotics should be given per TCCC opioids or ketamine, provide ventilatory support with guidelines in Section 15 if indicated to prevent a bag-valve-mask or mouth-to-mask ventilations. infection in penetrating wounds. k. Promethazine, 25 mg IV/IM/IO every 6 hours may be given as needed for nausea or vomiting. g. All TCCC interventions can be performed on or Reassess - reassess - reassess! through burned skin in a burn casualty. 14. Reassess fractures and recheck pulses. h. Burn patients are particularly susceptible to 15. Antibiotics: recommended for all open combat wounds hypothermia. Extra emphasis should be placed on a. If able to take PO: barrier heat loss prevention methods and IV fluid Moxifloxacin, 400 mg PO once a day warming in this phase. b. If unable to take PO (shock, unconsciousness): 17. The Pneumatic Antishock Garment (PASG) may be useful Cefotetan, 2 gm IV (slow push over 3-5 minutes) for stabilizing pelvic fractures and controlling pelvic and or IM every 12 hours, abdominal bleeding. Application and extended use must or be carefully monitored. The PASG is contraindicated for Ertapenem, 1 gm IV/IM once a day 16. Burns** casualties with thoracic or brain injuries. a. Facial burns, especially those that occur in closed 18. CPR in TACEVAC Care spaces, may be associated with inhalation injury. a. Casualties with torso trauma or polytrauma who Aggressively monitor airway status and oxygen have no pulse or respirations during TACEVAC should saturation in such patients and consider early surgical have bilateral needle decompression performed to airway for respiratory distress or oxygen desaturation. ensure they do not have a tension pneumothorax. b. Estimate total body surface area (TBSA) burned to The procedure is the same as described in section the nearest 10% using the Rule of Nines. 2 above. C. Cover the burn area with dry, sterile dressings. For b. CPR may be attempted during this phase of care if the extensive burns (>20%), consider placing the casualty casualty does not have obviously fatal wounds and in the Heat-Reflective Shell or Blizzard Survival Blanket will be arriving at a facility with a surgical capability from the Hypothermia Prevention Kit in order to both within a short period of time. CPR should not be cover the burned areas and prevent hypothermia. d. Fluid resuscitation (USAISR Rule of Ten) done at the expense of compromising the mission or If burns are greater than 20% of Total Body Surface denying lifesaving care to other casualties. Area, fluid resuscitation should be initiated as soon 19. Documentation of Care as IV/IO access is established. Resuscitation should Document clinical assessments, treatments rendered, and be initiated with Lactated Ringer's, normal saline, or Hextend. If Hextend is used, no more than 1000 ml changes in the casualty's status on a TCCC Casualty should be given, followed by Lactated Ringer's or Card (DD Form 1380). Forward this information with normal saline as needed. the casualty to the next level of care. Initial IV/IO fluid rate is calculated as for adults weighing 40-80 kg. *The new term "Tactical (TACEVAC) includes For every 10 kg ABOVE 80 kg, increase initial rate both Casualty Evacuation (CASEVAC) and Medical Evacuation by 100 ml/hr. (MEDEVAC) as defined in Joint Publication 4-02. If hemorrhagic shock is also present, resuscitation *See the Treatment of Burn Casualties in Tactical Combat for hemorrhagic shock takes precedence over Casualty Care, for discussion of this guideline. This material is written and published by the Committee on Tactical Combat Casualty Care. It is available at732 PREHOSPITAL TRAUMA LIFE SUPPORT, MILITARY EIGHTH EDITION Airway unfavorable SO casualties with moderate to severe TBI should be given supplemental oxygen, when available, to The opportunity to carry additional equipment and work in maintain an oxygen saturation of greater than Furthermore, a more secure environment allows for an expanded range of hyperoxia causes cerebral vasoconstriction independently of the therapeutic airway interventions. Endotracheal intubation and effects of hypocapnia and therefore may help to reduce intra- supraglottic airways (SGAs)8-10 are all potentially feasible airway cranial pressure. Hyperoxia has also been shown to increase alternatives in this phase if the nasopharyngeal airway is insuffi- cerebral tissue and to improve cerebral metabo- cient to manage the airway. SGAs may be especially useful in the lism in casualties with severe head injury.18-20 For casualties with subset of patients who are unconscious, but have no direct max- moderate to severe TBI, then, supplemental oxygen should be illofacial trauma that results in airway obstruction. Schwartz given at the highest inspired fraction of oxygen achievable as and colleagues reported success in performing endotracheal early in the continuum of care as intubation with the aid of night-vision goggles. Most airway fa- talities in combat are related to maxillofacial trauma, and airway problems in this setting may be best managed by allowing the ca- Bleeding sualty to maintain the sit-up-and-lean-forward position, as men- Hemorrhage is the leading cause of preventable death in tioned in the Tactical Field Care chapter, unless requirements combat casualties. Early and definitive control of external for spinal immobilization preclude this option. A surgical airway hemorrhage using TCCC principles has been shown to produce remains a valuable option if the individual providing care has the dramatic reductions in preventable The TACEVAC requisite skill and the other measures previously described have phase usually offers an opportunity to reassess the casualty failed or are not in a more controlled and stable environment. Assessment of Decreased pressure at altitude will result in an increase in wounds and hemorrhage control should be a priority in this the volume of gas enclosed in spaces with flexible walls, such phase as it may be the first opportunity to fully assess the se- as air-filled cuffs in endotracheal tubes and SGAs. Saline should verity and extent of wounds managed rapidly during the Care be used to inflate cuffs on devices used in casualties who will Under Fire and Tactical Field Care phases. To the extent pos- be transported in unpressurized aircraft. Medical providers on sible, all areas of the casualty's body should be examined for evacuation aircraft should check to ensure that this has been additional wounds, and the adequacy of hemorrhage control done, and relieve any altitude-related overpressure in cuffs that measures previously employed should be reassessed. The same may have been filled with air by ground medics. Note that SGAs principles of hemorrhage control should be employed, includ- such as the I-Gel that have a gel-filled cuff do not require venting ing the use of tourniquets and Combat Gauze. at altitude. In the TACEVAC phase, it is appropriate to reassess for the continued need of a tourniquet to achieve or maintain hemor- rhage control. As noted previously, the presence of shock or an Breathing anticipated time of 2 hours or less from tourniquet placement un- Any gas trapped in the pleural space will also expand at altitude, til arrival at a medical treatment facility are contraindications to thus increasing the risk of a tension pneumothorax. Casualties tourniquet removal in the field. If tourniquet removal is indicat- with chest trauma should be watched for respiratory distress, ed, the wound should be exposed and Combat Gauze should be hypoxia, and/or hypotension with a high index of suspicion for applied with direct pressure as outlined in the Tactical Field Care tension pneumothorax. This is especially true for any casualty chapter. If a tourniquet remains necessary, it should be removed who has been treated for a sucking chest wound or has already from over the uniform after replacing it with another tourniquet been treated with needle thoracostomy. The use of vented chest applied directly to the skin 2 to 3 inches above the wound. seals as now recommended by TCCC should help to reduce the As time and the tactical situation permit, a distal pulse risk of tension pneumothorax in sucking chest wounds that have check should be accomplished. If there is ongoing hemorrhage been treated with a chest seal. or a persistent distal pulse, the tourniquet should be tightened or Oxygen is often available on TACEVAC platforms. Many a second tourniquet applied just proximal to the first. casualties do not require supplemental oxygen, but some con- The TACEVAC phase may also provide the first opportunity ditions may warrant its use. Casualties with injuries that impair to employ junctional hemorrhage control devices as discussed in ventilation (unconsciousness) or gas exchange (inhalation injury the Tactical Field Care or exposure to smoke or toxic fumes), casualties with blunt or penetrating pulmonary injury, casualties in shock, or any casu- Tranexamic Acid alty with low oxygen saturation on pulse oximetry may benefit from supplemental oxygen. 14 Casualties being transported by air Administration of tranexamic acid (TXA) has been shown to confer should be monitored for a drop in oxygen saturation due to the a survival benefit in bleeding patients. TXA should be administered lower oxygen partial pressures at altitude. as soon as possible when indicated, but not more than 3 hours after As noted in the Tactical Field Care chapter, hypoxia in ca- the injury was indications and directions for use sualties with traumatic brain injury (TBI) is associated with are outlined in the Tactical Field Care chapter.CHAPTER 27 Tactical Evacuation Care 733 Fluid Resuscitation Transport container to be used Transport container handling instructions Recent experience in resuscitating severely injured casualties Storage temperature requirements who require massive transfusions (10 or more units of packed red Storage temperature documentation requirements blood cells [PRBCs]) has shown that infusing freshly thawed plas- Disposition of unused units upon return of containers ma and PRBCs in a 1:1 ratio increases survival. Early (within Maximum time allowed for transport in a container the first 6 hours after injury) administration of freshly thawed Number and types of units to be transported plasma is critical to maximize casualty survival. 24 This practice Indications for transfusion (known as Damage Control Resuscitation (DCR)) helps to re- Procedure for transfusion store clotting factors lost due to bleeding and to improve coagu- Equipment required lation status as well as to restore oxygen-carrying Pretransfusion check of units Fluid resuscitation recommendations for TACEVAC were Protective equipment required updated in 2010. For casualties who are in shock, the resusci- Transfusion rate tation option of choice is plasma and PRBCs administered in a Transfusion pressure 1:1 ratio, when use of these products is logistically Warming of units Both PRBCs and plasma are now routinely carried by the British Monitoring during transfusion Medical Emergency Rescue Teams (MERTs). PRBCs are carried End points of resuscitation and used by U.S. Air Force Pararescue teams (PEDRO) and by Management of transfusion reactions some U.S. Army MEDEVAC (DUSTOFF) For many casu- Documentation of transfusion alties, use of these products has improved hemodynamic stabil- ity during transport. The use of PRBCs and whole blood has a If plasma and PRBCs are not available, hypotensive good safety profile in the deployed resuscitation with Hextend should be carried out with an initial Although the literature on DCR often discusses the use of 500-mL bolus, followed by a second bolus in 30 minutes if clin- platelets in addition to PRBCs and plasma, the use of platelets ically indicated, as outlined in the Tactical Field Care in the prehospital setting is not feasible given the blood-banking If necessary, resuscitation may be continued with crystalloid techniques currently present in theater. Blood component ther- solutions or additional Hextend in a casualty who has already apy initiated in the TACEVAC phase may be a factor in the in- received two 500-ml boluses of Hextend. Both Hextend and creased survival noted in critically injured casualties in two crystalloids replace intravascular volume but do not replace studies on TACEVAC care and Decreased use of crys- oxygen-carrying capacity or clotting factors. They also contrib- talloids in resuscitation has been associated with improved out- ute to dilutional coagulopathy. comes. Combat medical personnel should always recognize the In order to administer blood component therapy safely and importance of hypotensive resuscitation in the setting of uncon- effectively, the following elements must be in place: trolled hemorrhage and avoid over-resuscitation. Blood pressure monitoring will typically be present on TACEVAC platforms. Re- 1. Obtaining PRBCs and plasma for transport into prehos- gardless of the fluids used, resuscitation should be titrated to a pital settings must be logistically feasible in the area of target systolic blood pressure (BP) of 80 to 90 milliliters of mer- operations. cury (mm Hg). If the casualty has sustained a TBI, however, the 2. A protocol must be in place that has been coordinated target systolic BP is at least 90 mm Hg.39 with the appropriate blood-banking facilities and approved by both theater and unit medical leadership. 3. Combat medical personnel must be well trained in the Electronic Monitoring transfusion protocol. Casualty assessment is typically difficult inside TACEVAC plat- The details of the protocol may vary depending on the ma- forms due to high noise and vibration levels and the need to turity of the theater, service guidelines, the specific tactical sce- avoid using lights at night for tactical safety reasons. For in- nario(s) envisioned, and the blood-banking logistics in the area stance, helicopter transport impairs or precludes the ability of of operations. In general, though, the following items should be combat medical personnel to auscultate the lungs and even addressed: to palpate the carotid pulse. 45 To provide for reliable assess- ment of the casualty's status during transport under such con- Training of combat medical personnel in the protocol ditions, electronic monitoring should be available in this phase Documentation of this training of TCCC. Electronic monitoring systems capable of reporting Retraining interval BP, heart rate, pulse oximetry, and capnography are commer- Determination of which blood products will be used cially available and should be used during TACEVAC for se- (PRBCs, plasma) riously injured casualties. As an example, the presence of an Ratio of plasma and platelets to PRBC units infused esophageal intubation will need to be determined by a decrease Blood type (ABO and Rh) compatibility issues in oxygen saturation or an absence of expired carbon dioxide734 PREHOSPITAL TRAUMA LIFE SUPPORT, MILITARY EIGHTH EDITION since it will be impossible to hear breath sounds inside a noisy Note that the highest oxygen concentration possible should aircraft or vehicle. be used for hyperventilation. Do not hyperventilate casualties un- A national sample of 250 air transport agencies reported less signs of impending herniation are present. Casualties may be that more than 75% of these agencies monitored oxygenation and hyperventilated with oxygen using a bag-mask. ventilation during The significant effect of altitude on oxygenation (Figure 27-2) must be considered when inter- preting pulse oximetry readings while operating in mountainous Prevention of regions and during aircraft evacuation in airframes with unpres- surized cabins. 47,48 Hypothermia Efforts to minimize heat loss should continue during TACEVAC Traumatic Brain Injury Care. Given the potential for heat loss due to wind chill and the lower temperatures encountered at altitude, the casualty must in TACEVAC Care be aggressively protected against cold stress during evacua- Prevention of hypoxia and hypotension is especially important in tion. Hypothermia may occur rapidly in conditions that expose casualties with TBI because these conditions may result in second- the casualty to water, wind, and cold surfaces, such as the floor ary injury to the traumatized brain. Casualties with moderate to of a vehicle or aircraft in cooler environments (Figure 27-3). severe TBI should be monitored carefully for: Even in warm ambient temperatures, it is possible for the casualty to become significantly hypothermic if appropriate Decreases in level of consciousness measures to preserve core temperature are not employed. Pupillary dilation Hypothermia prevention measures are discussed in the Tacti- Systolic BP maintained at greater than 90 mm Hg cal Field Care chapter. Casualties in shock are at increased risk Oxygen saturation maintained at greater than 90% of hypothermia since they are not able to generate body heat Hypothermia at a normal rate. Partial pressure of carbon dioxide maintained within 35 to 40 mm Hg (if capnography is available) If penetrating head trauma is present, antibiotics should be administered. Combat medical personnel should assume a cervi- cal spine injury, until cleared, in TBI casualties when the mecha- nism of injury includes blunt 20 Unilateral pupillary dilation accompanied by a decreased level of consciousness may signify impending cerebral hernia- tion; if these signs occur, take the following actions to decrease intracranial pressure: Administer 250 cc of 3% or 5% hypertonic saline bolus. Elevate the casualty's head 30 degrees. Hyperventilate the casualty. Maintain a respiratory rate of 20 if capnography is not available. If capnography is available, maintain the end-tidal carbon dioxide between 30 and 35 mm Hg Altitude Oxygen Saturation Sea level 97% 5000 feet 96% 8000 feet 93% 12,000 feet 86% Figure 27-2 Approximate Pulse Oximetry Values for Healthy Figure 27-3 If helicopter doors stay open during flight, wind could Volunteers at Altitude cause casualties to become hypothermic during transport. Source: Courtesy of Dr. Frank Butler Source: U.S. Navy photo by Petty Officer Daniel Gay.CHAPTER 27 Tactical Evacuation Care 735 Analgesia fatal wounds and will be arriving at a facility with a surgical ca- pability within a short period of time. CPR should not be done at The use of appropriate analgesics should be continued in the the expense of compromising the mission or denying lifesaving TACEVAC phase of care. Remember that medications that im- care to other pair platelet function should not be used in combat casualties. If the evacuation platform has the appropriate personnel Oral transmucosal fentanyl citrate is a good option when the and equipment, resuscitative thoracostomy may be indicated casualty is not in Remember also that opioids are if the casualty has a cardiopulmonary arrest during transport. contraindicated in casualties in hemorrhagic shock or with re- A recent study noted that of 29 patients who arrested en route, spiratory difficulty. Ketamine is a good option for casualties 13 (44.8%) had a transient return of spontaneous circulation, whose pain is severe but in whom opioids should not be with three 30-day survivors Casualty Movement Care for Wounded Conventional litters should be available during TACEVAC. The Hostile Combatants casualty should be made as comfortable as possible on a litter and kept warm and dry. If an improvised litter is used, it should In the TACEVAC phase, the principles of care are the same for be padded, and any field-expedient materials used to treat the ca- wounded hostile combatants as for coalition forces AFTER the sualty should be replaced with conventional splints, tourniquets, prisoner security measures described in the Tactical Field Care and dressings as soon as feasible. chapter have been accomplished. The rules of engagement may dictate the evacuation process for wounded hostile combatants, but proper prisoner-handling procedures must be maintained Cardiopulmonary throughout, with particular attention to restraint and security. Resuscitation During Remember that each hostile combatant in custody represents a TACEVAC potential threat not only to combat medical personnel, but to the entire unit. Speed wounded enemy combatants to the rear as fast The prognosis for trauma patients with prehospital cardiac ar- as medically and tactically feasible. rest is very poor. As noted in the Tactical Field Care chapter, In an era in which hostile forces routinely use suicide bomb- casualties with torso trauma or polytrauma who lose their pulse er tactics, the concealment of improvised explosive devices or respirations during TACEVAC should have bilateral needle (IEDs) on hostile combatant casualties or even on apparently decompression performed to ensure they do not have a tension friendly local national casualties is an additional concern. This pneumothorax. has led some evacuation units to require that all noncoalition ca- Cardiopulmonary resuscitation (CPR) may be attempted sualties be searched thoroughly for IEDs before they are loaded during this phase of care if the casualty does not have obviously onto an evacuation platform.54 Summary Additional medical equipment and personnel should be provided in the Tactical Evacuation (TACEVAC) phase. This allows for an enhanced level of medical care compared to Care Under Fire and Tactical Field Care. Casualties with torso trauma should be monitored for respiratory distress with a high index of suspicion for tension pneumothorax. Expansion of intrapleural gas due to the lower pressure at altitude may result in a tension pneumothorax. Casualties with injuries that interfere with breathing, or who have a low oxygen saturation on pulse oxim- etry, or those who are in shock should be given oxygen during TACEVAC, if it is available. During the TACEVAC phase, a thorough examination for additional wounds should be performed. The adequacy of hemorrhage control measures previously employed should be reassessed and replaced or enhanced as needed. Fluid resuscitation should be continued as needed with the goal of maintaining a palpable peripheral pulse and normal mentation. If electronic blood pressure (BP) monitoring is available, resuscitate to a systolic BP of 80 to 90 mm HG. Plasma and packed red blood cells (PRBCs) administered in a 1:1 ratio should be used in this phase of care, if logistically feasible.736 PREHOSPITAL TRAUMA LIFE SUPPORT, MILITARY EIGHTH EDITION Blood products, if used, must be administered by combat medical personnel trained in blood transfusion and under a preapproved protocol. Electronic monitoring systems capable of reporting BP, heart rate, pulse oximetry, and capnography should be used during evacuation. If a casualty with traumatic brain injury (TBI) is unconscious and has a weak or absent peripheral pulse, resuscitate as necessary to maintain a systolic BP of at least 90 mm Hg. Altitude significantly affects oxygenation in aircraft with unpressurized cabins, and this should be consid- ered when interpreting pulse oximetry readings. Casualties with moderate to severe TBI should be monitored carefully for signs of impending cerebral her- niation, and steps should be taken to lower intracranial pressure if decreasing level of consciousness and unilateral papillary dilation are noted. Casualties should be aggressively protected against hypothermia during evacuation. Proper prisoner-handling procedures should be maintained throughout the treatment and evacuation of wounded hostile combatants. All noncoalition casualties should be searched thoroughly for improvised explosive devices (IEDs) before being loaded onto an evacuation platform. SCENARIO RECAP You are a medic aboard a MEDEVAC Blackhawk that has landed in a secure LZ in the mountains of southeastern Afghanistan to extract a Ranger who has multiple shrapnel wounds from an RPG blast. The LZ altitude is 6,000 feet, and the ambient temperature is 64°F (18°C). The casualty, who has been stabilized by the platoon medic, is able to converse normally and has a tourniquet over his uniform on his upper right thigh. His right shirt sleeve is missing, and there is a pressure dressing around his right upper arm. There is a saline lock in his left antecubital fossa. The platoon medic tells you that the casualty lost a lot of blood from his thigh wound and was drowsy and confused before the tourniquet was applied 30 minutes ago. He received 500 milliliters of Hextend, to which he responded well, and has been stable since. The wound with the pressure dressing was packed with Combat Gauze underneath. He has taken moxifloxacin 400 milligrams by mouth, and has an 800-microgram fentanyl lozenge in his right cheek. He has been drinking water from his canteen. SCENARIO SOLUTION 1. What are your considerations for the care of this casualty during the 30-minute helicopter flight back to the Combat Support Hospital? This casualty is now apparently stable, but had been noted to be in hemorrhagic shock earlier. 2. What do you do first? You check all the pressure dressings and see no signs of bleeding from these wounds. You ensure that there are no other sites of major bleeding. 3. What do you do next? You next confirm that he is responsive; he answers questions appropriately and has a good radial pulse. 4. Should you start an intravenous (IV) line through the saline lock in anticipation of the need for a second bolus of Hextend? Yes, it is probably a good idea to start an IV line through the saline lock. You can run crystalloid at a keep-vein-open rate to keep the line open.CHAPTER 27 Tactical Evacuation Care 737 5. Should you remove the tourniquet? No, you should not remove the tourniquet. Even though pressure dressings over Combat Gauze are present on the distal wounds, you will risk further bleeding by releasing the tourniquet's pressure, and the casualty will be at the emergency department within 2 hours of the tourniquet's application. It is better at this point not to remove the tourniquet. If feasible, you may replace it with another tourniquet applied directly to the skin 2 to 3 inches proximal to the site of the bleeding. 6. Should you remove the fentanyl lozenge? You should remove the fentanyl lozenge, since the casualty was previously in shock. If the casualty's pain level requires an- algesia, ketamine is a better analgesic option in casualties who are in or at risk for hemorrhagic shock. 50 Opiates may cause cardiorespiratory depression and must be used with caution in casualties who have recently been hypotensive or who are in danger of going into shock. 7. What else do you want to do? You also want to establish electronic monitoring of the casualty. You place a pulse oximeter from the PROPAC on board the helicopter on a finger of the casualty's left hand. Pulse rate is 100 beats per minute, and oxygen saturation is 8. Is there anything else to attend to during the flight to the Combat Support Hospital? Yes, you should be concerned about this level of oxygen saturation, but this decrease in oxygen saturation is likely due to the altitude. You will keep a careful eye on this during the flight. Administer supplemental oxygen as needed to maintain an oxygen saturation of 90% or higher. You should also keep the casualty warm during the flight to the Combat Support Hospital.738 PREHOSPITAL TRAUMA LIFE SUPPORT, MILITARY EIGHTH EDITION References 18. Tolias C, Reinert M, Seiler R, et al. Normobaric hyperoxia-induced improvement in cerebral metabolism and reduction in intracranial 1. Butler FK, Blackbourne LH. Battlefield trauma care then and now: pressure in patients with severe head injury: a prospective historical a decade of Tactical Combat Casualty Care. J Trauma Acute Care cohort-matched study. J Neurosurg. 2004;101(3):435-444. Surg. 2012;73(suppl):S395-S402. 19. Tolias CM, Kumaria A, Bullock MR. Hyperoxia and traumatic brain 2. Mabry RL. Memorandum for Record, United States Central Command injury. J Neurosurg. 2009;110(3):607-609. Joint Theater Trauma System, After Action Report for MEDCOM 20. Dickey N. Management of traumatic brain injury in Tactical Combat Tasker 1039.01C, February 7, 2011. http://www.michaelyon-online Casualty Care. Defense Health Board Memo. July 26, 2012. http:// health.mil/dhb/recommendations/2012/2012-04.pdf Accessed .pdf. Accessed May 7, 2013. May 7, 2013. 3. Caravalho J. OTSG Dismounted Complex Blast Injury Task Force: 21. Dickey N, Jenkins D. Combat Ready Clamp addition to the Final Report. June 18, 2011:44-47. Tactical Combat Casualty Care Guidelines. Defense Health Board 4. Mabry R, Apodaca A, Penrod J, Orman J, Gerhardt R. Impact of Memo. September 23, 2011.http://health.mil/dhb/recommenda- critical care trained flight paramedics on casualty survival during tions/2011/2011-07.pdf. Accessed May 7, 2013. helicopter evacuation in the current war in Afghanistan. J Trauma 22. Eastridge BJ, Mabry R, Seguin P, et al. Pre-hospital death on the Acute Care Surg. 2012;73(suppl): S32-S37. battlefield: implications for the future of combat casualty care. 5. Morrison JJ, Oh J, Dubose JJ, O'Reilly DJ, et al. En-route care J Trauma Acute Care Surg. capability from point of injury impacts mortality after severe 23. Kotwal RS, Montgomery HR, Kotwal BM, et al. Eliminating prevent- wartime injury. Ann Surg. 2013;257:330-334. able death on the battlefield. Arch Surgery. 2011;146:1350-1358. 6. Apodaca A, Olson CM, Bailey J, Butler FK, Eastridge BJ, Kuncir E. 24. Tovmassian RV, Kragh JF, Dubick MA, Baer DG, Blackbourne LH. Com- Performance improvement evaluation of forward aeromedical evac- bat Ready Clamp medic technique. J Spec Ops Med. 2012;12:72-78. uation platforms in Operation Enduring Freedom. J Trauma Acute 25. Dubick M, Kragh JF. Evaluation of the Combat Ready Clamp to con- Care Surg. trol bleeding in human cadavers, manikins, swine femoral artery 7. Dickey N, Jenkins D, Butler F. Tactical Evacuation Care im- hemorrhage model and swine carcasses. U.S. Army Institute of provements within the Department of Defense. Defense Health Surgical Research Technical Report. June 2012. Board Memo. August 8, 2011. http://health.mil/dhb/recommenda- 26. Dickey N, Jenkins D. Recommendations regarding the addition of tions/2011/2011-03.pdf. Accessed May 7, 2013. tranexamic acid to the Tactical Combat Casualty Care Guidelines. 8. Martin SE, Ochsner G, Jarman RH, et al. Use of the laryngeal Defense Health Board Memo. September 23, 2011. http://health.mil/ mask airway in air transport when intubation fails. J Trauma. dhb/recommendations/2011/2011-06.pdf. Accessed May 7, 2013. 1999;47(2):352-357. 27. Morrison JJ, Dubose JJ, Rasmussen TE, Midwinter MJ. Military 9. Joo HS, Kapoor S, Rose DK, Naik VN. The intubating mask air- application of tranexamic acid in trauma emergency resuscitation way after induction of general anesthesia versus awake fiber study (MATTERs). Arch Surg. 2012;147(2):113-119. optic intubation in patients with difficult airways. Anesth Analg. 28. CRASH-2 Collaborators. The importance of early treatment with 2001;92(5):1342-1346. tranexamic acid in bleeding trauma patients: an exploratory anal- 10. Blostein PA, Koestner AJ, Hoak S. Failed rapid sequence intubation ysis of the CRASH-2 randomized controlled trial. Lancet. 2011;377: in trauma patients: esophageal-tracheal Combitube is a useful ad- 1096-1101. junct. J Trauma. 1998;44:534-537. 29. Holcomb JB, Wade CE, Michalek JE, et al. Improved plasma and 11. Dickey N. Supraglottic airway use in Tactical Evacuation Care. De- platelet to red blood cell ratios improves outcome in 466 massively fense Health Board Memo. September 17, 2012. http://health.mil transfused civilian trauma patients. Ann Surg. 2008;248(3):447-458. /dhb/recommendations/2012/2012-06.pdf Accessed May 7, 2013. 30. Streets CG. Lessons from the battlefield in the management of major 12. Schwartz RB, Gillis WL, Miles RJ. Orotracheal intubation in darkness trauma. Br J Surg. 2009;96(8):831-832. using night vision goggles. Mil Med. 2001;166:984-986. 31. Hess JR, Holcomb JB. Transfusion practice in military trauma. 13. Fortune JB, Judkins DG, Scanzaroli D, et al. Efficacy of prehos- Transfus Med. 2008;18(3):143-150. pital surgical cricothyrotomy in trauma patients. J Trauma. 32. Beekley AC, Starnes BW, Sebesta JA. Lessons learned from modern 1997;42(5):832-836. military surgery. Surg Clin N Am. 2007;87(1):157-184. 14. Grissom CK, Weaver LK, Clemmer TP, Morris AH. Theoretical ad- 33. Borgman MA, Spinella PC, Perkins JG, et al. The ratio of blood prod- vantage of oxygen treatment for combat casualties during medical ucts transfused affects mortality in patients receiving massive trans- evacuation at high altitude. J Trauma. 2006;61(2):461-467. fusions at a combat support hospital. J Trauma. 63(4):805-813. 15. Chi JH, Knudson MM, Vassar MJ, et al. Prehospital hypoxia affects 34. Zink KA, Sambasivan CN, Holcomb JB, Chisholm G, Schreiber MA. outcome in patients with traumatic brain injury: a prospective multi- A high ratio of plasma and platelets to packed red blood cells in the center study. J Trauma. 2006;61(5):1134-1141. first 6 hours of massive transfusion improves outcomes in a large 16. Floyd T, Clark J, Gelfand R, et al. Independent cerebral vasoconstric- multicenter study. Am J Surg. 2009;197(5):565-570. tive effects of hyperoxia and accompanying arterial hypocapnia at 1 35. Holcomb JB, Spinella PC. Optimal use of blood in trauma patients. ATA. J Appl Physiol. 2003;95(6):2453-2461. Biologicals. 2010;38(1):72-77. 17. Tisdall M, Taylor C, Tachtisidis I, et al. The effect of cerebral tissue 36. Holcomb JB. Damage control resuscitation. J Trauma. 2007;62: oxygenation index of changes in the concentrations of inspired oxy- S36-S37. gen and end-tidal carbon dioxide in healthy adult volunteers. Anesth 37. Holcomb JB. Optimal use of blood products in severely injured trau- Analg. 2009;109(3):906-913. ma patients. Hematology. 2010;2010:465-469.CHAPTER 27 Tactical Evacuation Care 739 38. Hetzler MR, Risk G. Damage control resuscitation for the Special 46. Perez L, Klofas E, Wise L. Oxygenation/ventilation of transported Forces medic: simplifying and improving prolonged trauma care: intubated adult patients: a national survey of organizational practic- parts one and two. J Spec Oper Med. 2009;9(3):14-21, 53-62. es. Air Med J. 2000;19(2):55-58. 39. Lednar WM, Poland GA, Holcomb JB, Butler FK. Recommendations 47. Pilmanis AA. USSOCOM Biomedical Initiatives Steering Committee regarding the Tactical Combat Casualty Care Guidelines on fluid interim report. August 2004 (unpublished data). resuscitation. Defense Health Board Memo. December 10, 2010. http:// 48. Luks AM, Swenson ER. Pulse oximetry at high altitude. High Alt Med health.mil/dhb/recommendations/2010/2010-06.pdf Accessed May 7, Biol. 2011;12:109-119. 2013. 49. Kotwal R, O'Connor KC, Johnson TR, Mosely DS, Meyer DE, Hol- 40. Kotwal RS, Butler FK, Edgar EP, Shackelford SA, Bennett DR, Bai- comb JB. A novel pain management strategy for combat casualty ley JA. Saving lives on the battlefield: a joint trauma system review care. Ann Emerg Med. 2004;44:121-127. of pre-hospital trauma care. in combined joint operating area- 50. Wedmore IS, Kotwal RS, McManus JG, et al. Safety and efficacy of Afghanistan (CJOA-A) Executive Summary. J Spec Oper Med. oral transmucosal fentanyl citrate for prehospital pain control on the 2013;13(1):77-85. battlefield. J Trauma Acute Care Surg. 41. Duke MD, Guidry C, Guice J, et al. Restrictive fluid resuscitation in 51. Dickey N. Prehospital use of ketamine in battlefield analgesia. combination with damage control resuscitation: time for adaptation. Defense Health Board Memo. March 8, 2012. http://health.mil/dhb J Trauma Acute Care Surg. 2012;73:674-678. /recommendations/2012/2012-03.pdf. Accessed May 8, 2013. 42. Morrison CA, Carrick MM, Norman MA, et al. Hypotensive resusci- 52. Dickey N. Needle decompression of tension pneumothorax- tation strategy reduces transfusion requirements and severe post- Tactical Combat Casualty Care recommendations 2012-5. Defense operative coagulopathy in trauma patients with hemorrhagic shock: Health Board Memo. July 7, 2012 preliminary results of a randomized controlled trial. J Trauma. 53. Morrison J, Poon H, Rasmussen T, et al. Resuscitative thoracotomy fol- 2011:70:652-663. lowing wartime injury. J Trauma Acute Care Surg. 2013;74(3):825-829. 43. Fromm RE Jr, Varon J. Air medical transport. J Fam Pract. 54. Kotwal RS, Butler FK, Edgar EP, Shackelford SA, Bennett DR, Bailey 1993;36(3):313-318. JA. Saving lives on the battlefield: a joint trauma system review 44. Fromm RE Jr, Dellinger RP. Transport of critically ill patients. of pre-hospital trauma care in combined joint operations area- J Intensive Care Med. 1992;7(5):223-233. Afghanistan (CJOA-A). Final report of the U.S. Central Command 45. Hunt RC, Carroll RG, Whitley TW, Bryan-Berge DM, Dufresne DA. Pre-Hospital Trauma Care Assessment Team dated 30 January 2013. Adverse effect of helicopter flight on the ability to palpate carotid pulses. Ann Emerg Med. 1994;24(2):190-193. Accessed May 8, 2013.