PHTLS MILITAR 8 Edição Cap 28

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CHAPTER Scenarios CHAPTER OBJECTIVES At the completion of this chapter, the reader will be able to do the following: Apply and adapt the tenets of Tactical Combat Casualty Care (TCCC) to the care of casualties in the context of realistic combat scenarios.CHAPTER 28 Scenarios 741 Introduction minutes after wounding. Combat medical personnel are critical to this effort. From the lessons learned in the wars in Viet- Combat medical personnel are charged with rapid decision nam, Iraq, and Afghanistan, we now recog- making, immediate action, and competent technical perfor- nize that the leading causes of preventable mance under a wide range of challenging, austere, and danger- combat-related deaths are hemorrhage, airway obstruction, ous conditions. To illustrate the performance of casualty care in and tension pneumothorax. 1-6 The most recent data from Iraq the combat environment, several scenarios will be presented in and Afghanistan found that hemorrhage accounted for 90.9% this chapter. Each scenario presents some of the unique features of preventable prehospital deaths (with truncal being the most of the combat environment and describes the key medical as- common site, followed by junctional and extremity hemor- sessments and interventions performed by combat medical per- rhage), airway obstruction accounted for 7.9% of preventable sonnel. The scenarios are themed in such a way that the focus is deaths, and tension pneumothorax was responsible for the re- on a defined set of clinical problems. Not every Tactical Combat maining Casualty Care (TCCC) principle is highlighted in every scenar- Beyond intervening to prevent imminent death, there are io; rather the scenarios are intended to illustrate how combat a number of combat casualty care conditions requiring imme- medical personnel must combine good medicine with good small diate attention to reduce suffering, morbidity, unit tactics to optimize the care provided to each casualty on the Care for these includes shock management, analgesia, infection battlefield. prophylaxis, spinal cord protection, traumatic brain injury treat- The text in this chapter is not intended to suggest that the ment, and hypothermia prevention. Ensuring the best outcome answers provided are the only acceptable answers. Other an- for the casualty requires that life threats and the other conditions swers may turn out to be just as good or better, depending on the previously listed be addressed rapidly, often within the first few evolving tactical circumstances.742 PREHOSPITAL TRAUMA LIFE SUPPORT, MILITARY EIGHTH EDITION SCENARIO 1 - GUNSHOT WOUND ON NIGHT PATROL You are a medic operating in Afghanistan as part of a combat element on a nighttime direct action mission. While moving by foot along the edge of a cultivated field at night, one man of your four-person team is shot and falls into an irrigation ditch. You and your uninjured teammates take immediate cover and begin returning fire. You call to the wounded man, asking how badly he is hit. He responds, telling you that he has been shot in the left leg just above the knee. He is under effective cover but cannot move. 1. What do you know about the wounded man already? He is alert enough to speak coherently, he probably has an acceptable blood pressure and his airway is open. 2. What do you want to know next? You need to determine how badly he is bleeding and whether he has other injuries. Fire from four hostiles is keeping you and the other two team members very busy, and you cannot leave your cover without getting shot yourself. While you and your other teammates continue the firefight, you ask the casualty if he can tell how much blood is coming out of the wound. He tells you he cannot tell, but his leg is really messed up and he can feel blood on the trousers of his uniform. You ask him if he has been hit anywhere else. He says he does not think so, but his leg really hurts. 3. What do you do next? You tell the casualty to put a tourniquet on his leg and then get back in the fight if he can. In Care Under Fire, the best thing a medic can do for the casualty and the rest of the team may be to take cover and return fire (Figure 28-1). If a medic gets killed trying to get to a casualty, he has done the casualty, the rest of the team, and himself no good. In a situation like this one, the overriding concern is suppression of enemy fire, and ev- ery gun, including the medic's and the casualty's, may be needed. Casualties who are able should remain engaged in the firefight and/or the prosecution of the mission. This casualty was trained and equipped to apply a tourniquet to his own leg. Because his wound was at a site where a tourniquet could be effectively ap- plied above it, he was able to address potentially life-threatening extremity hemorrhage via self-aid. Both he and the medic were able to remain under cover and involved in the fight. In this way, the risk of further injury to the casualty, the medic, and the other members of the team was minimized. After several minutes of intense fighting, your team eliminates all hostile fire, and you are able to tend to the casualty. You find him lying on his back in two inches of muddy water at the bottom of the irrigation ditch. He is alert and oriented, but in great pain. He has a strong radial pulse. He tells you again that the gunshot Figure 28-1 Cover and return fire are the priorities in the Care wound to his left leg is his only injury. When you cut open his Under Fire phase. trousers leg, there is an open fracture of his femur. His pain is Source: Courtesy of Lance Cpl James Clark/U.S. Marine Corps great, he stops you from doing a sweep of his leg. 4. What is the greatest tactical need at this point? Your team needs to call for an extract. Since it is difficult to move the casualty and the four hostiles are now neutralized, you elect to call for an evacuation at your current location. 5. What do you need to do for the casualty? Ensure hemorrhage control, rule out other injuries, provide pain relief, administer antibiotics, prepare him to move, and protect him from hypothermia.CHAPTER 28 Scenarios 743 6. How do you do all that? You cannot use a light because the enemy may be nearby, and he will not let you sweep his leg. Since you cannot see or feel well enough to assess for sites of bleeding and amount of blood lost, or to determine if he is still bleeding, you elect to place a second tourniquet higher on his left thigh. You sweep everything other than his left leg and find no other injuries. His clinical status has not changed. You give him the moxifloxacin from his Combat Pill Pack and stick one 800-microgram (mcg) oral transmucosal fentanyl citrate (OTFC) lozenge in his cheek. You gently place a large dressing over the entire wounded area. You splint the casualty's left leg alongside his right. You check to make sure both tourniquets are still tight and in place. The casualty's clinical status has not changed-he is alert and still in severe pain-so you give him a second OTFC lozenge in his other cheek. You have elected to leave his body armor on since you may get into another firefight, SO you put a Ready Heat Blanket over him just below the bottom edge of his armor, placing it on top of his t-shirt to prevent direct contact with the skin, and cover him with the Heat Reflective Shell. 7. What does the casualty need more than anything else at this point? He needs continued control of his bleeding and expedited evacuation. 8. What should you be doing for him until he gets to more advanced care? Continue to monitor his clinical status. You notice that he is drowsy. 9. What is the most significant possible cause of a decline in mental status in this casualty? Ongoing blood loss 10. What else do you want to know? Pulse character? His radial pulse is now rapid and weak. Tourniquets okay? They are both still in place, but you suspect that the wound is still bleeding. Breathing okay? His breathing is slightly rapid but not labored. 11. What is most likely happening? The casualty is going into hemorrhagic shock. 12. What makes you think so? Mental status and radial pulse character have deteriorated. Even though the tourniquets look okay, you suspect continued bleeding. Breathing is slightly rapid. 1,600 mcg of OTFC is not that large of a dose for a young, healthy male in acute pain. It is unlikely that this amount could have caused the change in mental status observed in this casualty. Hemorrhage is the number one cause of preventable combat death. 13. What do you do? You tighten both tourniquets. 14. What else? Because this casualty will need significant blood transfusion due to his hemorrhagic shock, you infuse 1 gram (gm) of tranexamic acid (TXA) in 100 cubic centimeters (cc) of normal saline (NS). It is difficult to start intravenous (IV) therapy at night, you place a sternal intraosseous (IO) device. 15. What next? Next you resuscitate the casualty with 500 milliliters (ml) of Hextend. Ten minutes after the Hextend bolus, the casualty is a lit- tle less drowsy and his radial pulse is a little stronger. You check the tourniquets, and they are still in place and tight. You can detect no bleeding. 16. What next? You complete the TCCC casualty card while waiting for the evac helicopter to arrive.744 PREHOSPITAL TRAUMA LIFE SUPPORT, MILITARY EIGHTH EDITION SCENARIO 2 - PROPELLED GRENADE ATTACK IN AN URBAN ENVIRONMENT While you are on patrol in an urban environment, your squad comes under small arms fire and rocket-propelled grenade (RPG) attack. The point man and a second man are hit. The squad reacts to the contact, rapidly eliminating the ambushing hostiles. There are no other casualties. A secure perimeter is established, and the squad leader instructs you to take care of the casu- alties. You move to Casualty 1 and quickly perform a primary assessment for life-threatening injuries. His mental status is normal and his breathing is rapid but unlabored. You discover a gunshot wound with a small hole that is likely the entrance on his right upper back and what appears to be a larger exit wound in his right armpit. You see pulsatile bleeding from that wound. 1. What is your immediate concern? The bleeding is life threatening. A lifesaving intervention is urgently needed. 2. How do you handle it? You immediately expose the area, pack Combat Gauze into the wound, and hold direct pressure for 3 minutes. While you are performing these actions, you are talking to the casualty in order to check both his airway and his mental status. After 3 minutes, the external bleeding appears controlled, you build a pressure dressing over the Combat Gauze. This dressing also covers the entrance wound. You notice the casualty is more anxious and short of breath. You recheck for other sources of bleeding and find none. Suddenly, the casualty becomes unresponsive. His left radial pulse is not palpable. His breathing grows very rapid and shallow. 3. What do you think is going on? Given the location of the chest wound and the sudden decompensation, you suspect a tension pneumothorax. 4. What are you going to do about it? You perform a needle decompression of the right chest and hear the soft hiss of escaping air. The casualty becomes conscious again and you note improvement in the rate and depth of his respirations. 5. What next? Recheck the casualty's pulse. The radial pulse is now normal. 6. What next? You move to Casualty 2, who reports that he was hit on his right side. He denies loss of consciousness, and his mental status is normal. He complains of shortness of breath and appears anxious. Upon examination, the only injury you find is a shrapnel wound in the midaxillary line on his right side at nipple level. The wound is about the size of a quarter. A piece of shrapnel apparently slipped between the plates of his armor. Sucking and hissing sounds are coming from the wound. 7. What is the diagnosis? Open pneumothorax (or sucking chest wound) 8. How can you help this man? You apply a vented chest seal over the wound and the casualty's breathing quickly improves. 9. What else do you want to know? Exit wound? You can't find one. Cardiovascular status? He is alert and oriented, and his radial pulses are strong. Neurologic status? He is alert and oriented, he moves all his extremities, and he has no gross sensory abnormalities. Other injuries? You find none.CHAPTER 28 Scenarios 745 Medical Evacuation (MEDEVAC) for the two casualties is requested from headquarters. In anticipation of a he- licopter evacuation (Figure 28-2), you prepare the ca- sualties for flight, including saline locks, antibiotics, and analgesia. 10. Which analgesic would you use? Casualty 1 is not complaining of severe pain, you elect to defer analgesic medications. You use ketamine for Casualty 2 because he has an injury that might impair respiration. You place them in Hypothermia Prevention and Manage- ment Kits (HPMKs) to ensure that the cold environment of helicopter flight does not induce hypothermia. You plan to remind the flight paramedic to keep the doors Figure 28-2 Evacuation by air requires special considerations. closed during the flight if possible. Source: Courtesy of Kimberly Lamb, U.S. Army. 11. What do you do next? You complete TCCC casualty cards while waiting for the evac helicopter to arrive. The casualties are picked up by an Army DUSTOFF helicopter. Immediately after takeoff, the casualty with the back-to-right axillary gunshot wound develops sudden-onset shortness of breath and hypoxemia as measured by pulse oximetry. The flight paramedic recalls Boyle's law, by which gas expands at altitude, thus potentially causing air trapped in the pleural space to ex- pand and convert a simple pneumothorax to a tension pneumothorax. She responds by immediately inserting a second needle for decompression. The casualty's condition improves immediately. 12. What should the flight paramedic do now? Continue to monitor both casualties' respirations, blood pressure, and oxygen saturation as well as watch for any signs of external hemorrhage. The DUSTOFF unit delivers both casualties to the Role 3 medical treatment facility and communicates their clinical histories to the emergency medical staff.746 PREHOSPITAL TRAUMA LIFE SUPPORT, MILITARY EIGHTH EDITION 3 - ROCKET-PROPELLED GRENADE ATTACK DURING A CONVOY You are riding with a squad in the back of a cargo Humvee along a road at the outskirts of a small Afghani village. When you stop at an intersection, a lone attacker located about 50 meters away takes aim with an RPG and fires the rocket. The warhead explodes right front wheel. The vehicle sustains moderate damage to its right side and veers into a concrete barrier. Small flames erupt from the engine compartment. Everyone in the vehicle is shaken, but all are alert and responsive at first and scramble to exit the vehicle. You grab your rifle and medical kit and hit the ground running. However, the front right passenger makes it only a few meters from the Humvee and then falls to the ground. Before you are able to reach cover, the unit begins to take small arms fire from several locations. 1. What should you do to help the casualty who is lying out in the open? Do your best to eliminate hostile fire. Minimize unit exposure to hostile fire. 2. What can you do at this point to protect the casualty from being shot? Eliminate hostile fire and direct the casualty to move to the nearest cover. You drop behind cover that gives you a hasty fighting position and start firing back at the enemy. The casualty takes cover behind the Humvee. After a 5-minute firefight, hostile fire is eliminated. The squad sets up a perimeter, and the squad leader gives you the go-ahead to care for the casualty. Because there may still be a risk of sniper fire, you want to relocate the casualty to cover behind a low stone wall nearby. He is still alert but in acute respiratory distress and is unable to walk at this point. 3. How do you move him? You use the one-person drag. 4. Why do you choose this method? You do not have help since the other squad members are providing security. The ground you have to cross is fairly smooth. You can stabilize the casualty's cervical spine (blunt trauma) by cradling his head and neck with your forearms. In your initial assessment, you find the casualty has a disfigured right zygomatic arch and a broken jaw, and there is blood in his mouth. You note swelling, bruising, and abrasions over the right side of his neck. There is no obvious life-threatening external bleeding. He is not talking and does not respond to questions about neck pain. He responds to deep pain with barely audible moaning. His radial pulse is strong. His breathing is shallow, slow, and sonorous. Opening his body armor and blouse, you observe that the rise and fall of his chest are symmetrical, but there is little excursion. 5. What is your primary concern? The casualty may still be breathing spontaneously, but his respiratory effort is weak. The disrupted anatomy and bleeding from injuries to his lower face and neck could be blocking his airway. 6. What do you do? The casualty's clinical status and the mechanism of his injuries make it impossible to rule out a spinal injury. Taking care to keep his neck stable, you do a chin lift and notice that the casualty's respirations get a little deeper. Next, you inset a nasopharyngeal airway. The casualty's breathing is still weak and noisy. His oxygen saturation isCHAPTER 28 Scenarios 747 7. What next? You judge that the casualty does not yet have an ad- equate airway and elect to do a cricothyroidotomy. As you perform this procedure (Figure 28-3), you give the squad leader the information he needs for a 9-line MEDEVAC request. He lets you call over one of the Com- bat Lifesavers in the squad to help you out. After the procedure is performed, the casualty becomes alert and his oxygen saturation improves to You secure the cricothyrotomy tube Your squad leader tells you to pre- pare for MEDEVAC by helicopter in 30 minutes. 8. What else do you want to do for this casualty? Stabilize his cervical spine. 9. How do you do that? Figure 28-3 Addressing acute breathing problems is usually best You do not have a cervical collar (C-collar) with you, deferred until the Tactical Field Care or Tactical Evacuation Care phase. you use manual in-line stabilization. The MEDEVAC heli- Source: Courtesy of U.S. Army Medical Department. copter will have a C-collar and spine board. 10. What else should you consider? Rule out unrecognized bleeding? You have another squad member check for bleeding and he finds find none. TXA? Not indicated because the radial pulse is normal. IV/IO fluids? Not indicated at this point. Hypothermia prevention? Yes, this is very important. Analgesia? The casualty cannot speak but appears uncomfortable and indicates "yes" when asked if he is in pain. You give him 50 milligrams of ketamine intramuscularly (IM). Antibiotics? Yes, you administer 1 gm of ertapenem IM. 11. What next? You complete the TCCC casualty card while waiting for the evac helicopter to arrive. When the MEDEVAC helicopter arrives, you, the Combat Lifesaver, and the flight paramedic place the casualty on a spine board and apply a C-collar. You brief the flight paramedic on the casualty's course far and give him the casualty's TCCC card.748 PREHOSPITAL TRAUMA LIFE SUPPORT, MILITARY EIGHTH EDITION SCENARIO 4 - DISMOUNTED IMPROVISED EXPLOSIVE DEVICE ATTACK You are a medic in a 12-man Marine squad moving into a small village. One patrol member steps on a pressure-plate activated improvised explosive device (IED). Three patrol members are injured. Unhurt members of the patrol form a protective perimeter around the casualties. There is no follow-on hostile fire, at least for the moment. 1. What phase of care are you in right now? You are in the Tactical Field Care phase because there is no incoming fire at present, but the patrol is alert for any hostile fire that may ensue. 2. What do you do first? You perform a rapid assessment of the casualties. Casualty 1 is obviously dead from a devastating head wound. Casualty 2 has multiple small fragment wounds to the back of his arms and legs, and to his buttocks, but there is no obvious major hemorrhage. He is alert and oriented. Casualty 3 has sustained a traumatic amputation of his left leg just below the hip, with additional pelvic and inguinal wounds. He is bleeding heavily from multiple points in and around the amputation site. He is agitated, making loud but incomprehensible sounds, and is weakly thrashing about with his remaining extremities. 3. How do you begin caring for the casualties? You divide the labor. You direct a squad Combat Lifesav- er to evaluate the casualty with the shrapnel wounds, Casualty 2. You take Casualty 3, the casualty with the amputation, and apply a tourniquet above the amputa- tion site (Figure 28-4). 4. Whose Combat Application Tourniquet are you using? One of your own. You would normally use the casual- ty's, but you are in a real hurry and do not have time to inspect the casualty's tourniquet to make sure it was not damaged in the blast. 5. Where do you apply it? You apply the tourniquet as high on the femoral stump as you can. You continue to tighten the tourniquet but Figure 28-4 Traumatic amputations require the application of a tourniquet. cannot get a good purchase on the stump, and there is still significant bleeding, from both the amputation site Source: Courtesy of Lori Newman/U.S. Army. and the inguinal wound. 6. What now? You break out your Combat Gauze and, with help from another patrol member, apply it to the bleeding sites with 3 minutes of firm direct pressure. The bleeding is still not controlled. 7. What next? You break out your Combat Ready Clamp (CRoC) and quickly assemble it. You apply the to the casualty's right groin and achieve control of the hemorrhage. The squad sends in the 9-line MEDEVAC request and alerts them of the RPG hazard in the nearby village. The squad is then directed to move the casualties on foot to a landing zone (LZ) in an open area 1 kilometer away from the village. Casualty 2 takes his Combat Pill Pack. He continues to be a functioning unit member and assists with the mission. However, Casualty 3 is now conscious but confused. His radial pulse is not palpable and his carotid pulse is thready and rapid. 8. What is the most likely diagnosis for Casualty 3? Hemorrhagic shockCHAPTER 28 Scenarios 749 9. What treatment do you provide Casualty 3? You place a sternal device and infuse 1 gm of TXA in 100 CC of normal saline, flush the IO line, and follow that with a 500-cc bolus of Hextend. When the bolus is in, the casualty's carotid pulse gets a little stronger, and his radial pulse is now palpable. He is alert but confused. He is breathing adequately and is not complaining of pain at the moment. 10. Now that you have IO access, are there other meds you would give? Yes, IV antibiotics via slow IV push. 11. What further care is required? Place a pulse oximeter on Casualty 3. His oxygen saturation is 95%. The mission commander gives the order to move out for the designated LZ. The deceased casualty is moved with a two-person drag. Casualty 3 is moved using a three-person car- ry. The Marines carrying Casualty 3 monitor the site of the previous hemorrhage to ensure that it does not begin to bleed again. The other five patrol members provide security during the movement to the LZ. The patrol arrives at the LZ. The helicopter is 10 minutes out. It has been about 45 minutes since the first bolus of Hextend went in, and Casualty 3's status is the same. 12. What next? You infuse a second 500-ml bolus of Hextend into Casualty 3. 13. What else do you want to do? You thoroughly reassess Casualty 2 and Casualty 3 and find no new conditions requiring immediate treatment. You place Casualty 3 in an HPMK after rechecking to ensure that his previous hemorrhage remains controlled. 14. What next? You complete TCCC casualty cards while waiting for the evac helicopter to arrive. 15. In addition to monitoring for continued hemorrhage control, what is Casualty 3 likely to need during the 20-minute MEDEVAC flight? He may need further fluid resuscitation, preferably with plasma and packed red blood cells if available. High-flow supplemental oxygen should be started using a reservoir mask. If his mental status continues to improve and pain becomes an issue, he may need ketamine.750 PREHOSPITAL TRAUMA LIFE SUPPORT, MILITARY EIGHTH EDITION SCENARIO 5 FAST-ROPING CASUALTY IN AN URBAN ENVIRONMENT A 14-man Special Operations assault team fast-ropes from a helicopter hovering about 25 meters (80 feet) above the ground for a building assault in a high-threat urban environment. On exiting, one of the last members of the team loses his grip and falls to the ground (Fig- ure 28-5). The helicopter, unable to loiter at the scene or evacuate the casualty, departs quickly with its escort gunship. You, one of two medics on the team, attend immediately to the casualty. The mission commander instructs the rest of the team to form a defensive pe- rimeter. There are hostiles all around you in the streets, and the unit begins to take sporadic fire from several directions. The casualty is unconscious. 1. What is the first priority? Provide cover for the team, including the casualty. 2. Why? There are many armed hostiles in street crowds all around you. It is unlikely that the team can eliminate all hostile fire. The best way to deal with injuries is to prevent them, the team takes cover behind a nearby low wall. 3. How do you move the casualty? You and the team member move him using a two-man carry, taking care to minimize head and neck movement. 4. The low wall provides effective cover from incom- ing fire. What phase of care are you in? You are in the Tactical Field Care phase, but a very high- risk version of it. 5. What do you do next? Safely behind cover, you begin your assessment of the Figure 28-5 Not all combat-related trauma involves weapons. casualty. He is still unresponsive; you find no signs of Falls represent an important mechanism of injury on the battlefield. external hemorrhage. He has a patent airway, adequate Source: Courtesy of Sgt. Timothy Kingston/US Army. breathing, and a strong radial pulse. You note bilateral open femur fractures and are aware of the high incidence of spinal and pelvic fractures in high falls. While maintaining im- provised cervical stabilization, you remove his weapons, helmet, and body armor to facilitate your examination. Your further assessment reveals symmetrical and responsive pupils and ecchymosis at the left mastoid area (Battle's sign). The casualty remains unresponsive. You place a pulse oximeter on his finger; his oxygen saturation is 94%. 6. What is the diagnosis? Traumatic brain injury due to blunt trauma, and bilateral open femur fractures. You cannot rule out spinal injury, and he may have noncompressible abdominal or thoracic hemorrhage. You inform the team leader of the urgency of the casualty's condition. The team leader reports back that the mission has been altered to accommodate the casualty and four armored Humvees have been dispatched for evacuation. Their estimated time of arrival is 15 minutes. Two of the vehicles have litters, but one of the team members finds a door nearby and you use it as an improvised rigid litter that you can minimize the time required on-scene once the vehicles arrive.CHAPTER 28 Scenarios 751 7. What do you do next? While continuing to monitor him, you apply the C-collar that you thought to bring for this type of mission, and you insert a nasopharyngeal airway. (Note that a field-expedient cervical collar can also be made from a SAM splint.) You then insert a saline lock. 8. Does the casualty need any meds? Because of the high probability of noncompressible hemorrhage in a fall of this magnitude, you elect to administer TXA. The casualty remains unconscious, he does not need analgesics. He has open femur fractures, you administer IV antibiotics after the TXA is in. 9. What do you do next? The door effectively splints the femur fractures after you secured his legs to the door with tactical tape and covered the wounds with sterile dressings. You put a Ready Heat Blanket over the casualty's t-shirt and place him into a Heat Reflective Shell. You then put his helmet back on and lay his body armor over him. The vehicles were due to arrive 10 minutes ago but have not yet done The team members continue to maintain security and minimize incoming hostile fire. 10. What next? You reassess the casualty and note his respirations have become very shallow and the left pupil is now dilated. He remains unresponsive. 11. What is happening clinically with this casualty? Cerebral herniation 12. What can you do about it? You have no oxygen in TFC. You use a bag-mask device to ventilate the casualty. Capnography is not available, you use a ventilation rate of 20 breaths/minute. You elevate the head of the improvised rigid litter 30 degrees. You would give 250 ml of 3% saline IV if you had it, but you do not. You monitor his oxygen saturation with a pulse oximeter, and it remains above 13. What next? You complete the TCCC casualty card while waiting for the evac vehicles to arrive. The vehicles arrive shortly thereafter. You have unit members help you carefully move the casualty into the vehicles and secure the improvised litter as best you can. Everyone else mounts up in the other vehicles, and the convoy moves out.752 PREHOSPITAL TRAUMA LIFE SUPPORT, MILITARY EIGHTH EDITION References 6. Deal VT, McDowell D, Benson P, Iddins B, et al. Tactical Com- bat Casualty Care February 2010. Direct from the Battlefield: 1. Gerhardt RG, Mabry RL, De Lorenzo RA, Butler FK. 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