EM Special 8: Military Medicine, part 1

Question 1

TCCC

Answer 1

Tactical Combat Casualty Care

Question 2

3 phases of care under TCCC

Answer 2

Care under fire
Tactical field care
Tactical Casualty evacuation

Question 3

The medical actions taken under enemy fire are extremely limited [to]:

Answer 3

applying tourniquet for massive exsanguination
protecting the casualty
moving him or her to safety

Question 4

first-line intervention for massive hemorrhage in a combat setting

Answer 4

tourniquet
If applied before the onset of shock, survival is improved from 17% to 94%

Place about 2 inches proximal to the wound.
Tighten to greater than arterial pressure, because tightening that exceeds venous but not arterial pressure may increase bleeding
If placement of a single tourniquet does not control bleeding, place a second tourniquet immediately adjacent and proximal to the first

Question 5

A wide tourniquet (at least ______ wide) causes less soft tissue damage and is more comfortable for the patient

Answer 5

1.5 inches

Question 6

To control hemorrhage from a large vessel, a tourniquet must have a _______ to gain mechanical advantage when tightening

Answer 6

WINDLASS
Tourniquet without a windlass CANNOT attain sufficient force to stop arterial bleeding.

Question 7

it is recommended to remove a tourniquet within

Answer 7

2 hours

Question 8

at _____ hours with a tourniquet in place, it is probably best not to remove it

Answer 8

6 hours
at this point, the release of potassium, lactate, myoglobin, and other toxins from a severely acidotic limb into the circulation would likely cause more systemic harm then benefit

Question 9

other remarks on posttourniquet care

Answer 9

Once an effective pressure dressing is applied, release but DO NOT REMOVE the tourniquet.
If bleeding recurs, retighten the tourniquet to control bleeding.

Question 10

most common correctable cause of death on the battlefield

Answer 10

massive hemorrhage
- and is the top clinical priority in battlefield trauma care**

Question 11

Airway compromise accounts for relatively few combat deaths, and respiratory difficulties typically progress over time.

This is the reason that TCCC recommends the modified primary survey algorithm of:

Answer 11

MARCH:
Massive hemorrhage
Airway
Respiratory
Circulation
Hypothermia prevention/Head injury

Question 12

used as indicators of peripheral perfusion in injured soldiers

Answer 12

level of consciousness and pulse strength
If the soldier’s peripheral pulse is weak or absent, if the level of consciousness is altered, or if the soldier is not verbally responsive, then immediate intervention is needed before moving down the algorithm

Question 13

remarks on Tranexamic acid

Answer 13

1. Tranexamic acid DECREASES MORTALITY IN TRAUMA.
   It is recommended for use in *all casualties that require significant fluid or blood products, both children and adults.
2. Tranexamic acid is most effective when given within 1 hour of injury and must be given within the first 3 hours

Question 14

dose of tranexamic acid in trauma

Answer 14

1 gram of tranexamic acid in 100 mL of normal saline, infused over 10 minutes

Question 15

If there are no spontaneous respirations after opening the airway, the casualty is triaged to the ______ category in a MASCAL situation

Answer 15

expectant category

MASCAL = Mass Casualty
- defined as more casualties than resources available.

Question 16

other remarks on airway management in MASCAL

Answer 16

If the situation and resources allow, perform advanced airway techniques, including cricothyrotomy, supraglottic airway intubation, and mechanical ventilation.

If space is limited, cricothyrotomy equipment is the most important

Question 17

other remarks on cricothyrotomy

Answer 17

in austere conditions with minimal sedatives and analgesics, proonged evacuation times spanning hours to days, and delayed medical logistical resupply, the threshold for performing a cricothyrotomy should be low.

It is critical to confirm placement and firmly secure the airway.

Question 18

the TCCC minimum standard in needle used in neede decompression

Answer 18

14-gauge, 3-inch-long needle

“In a tactical setting, the threshold to perform a needle decompression is very low, as most casualties with penetrating chest trauma in respiratory distress will have some degree of hemo- or pneumothorax and possible tension pneumothorax”

Question 19

two locations recommended for needle decompression

Answer 19

1.) 2nd ICS, midclavicular line

2.) 4th or 5th ICS, anterior axillary line

Question 20

the updated TCCC standard for open pneumothorax of sucking chest wound

Answer 20

valved/vented chest seal as the first choice

Unvented chest seals require continuous reassessment for possible accumulating tension pneumothorax and need for needle decompression

Question 21

remarks on chest tubes in the tactical field care

Answer 21

The lifesaving intervention for a chest injury in the setting of tactical field care is needle decompression;
a chest tube is NOT immediately required

Needle decompression can be as effective as a chest tube in a patient for up to 4 hours if the patient is not subjected to much movement.
Needle decompression can be repeated as needed