Prolonged Casualty Care Guidelines (Part 2)
To ask

Prolonged Casualty Care Guidelines (Part 2)

Published: 28.11.2023
File size: 2,88 MB

Antibiotics, Sepsis, and Other Drugs - PCC

Background

Complete Basic TCCC Management Plan for Antibiotics then:

Antibiotics should be given immediately after injury or as soon as possible after the management of MARCH and Pain Management and appropriately documented (medication administered, dose, route and time).

Confirm that initial TCCC dose of moxifloxacin (Avelox®) or Ertapenem (Invanz®) have already been given for any penetrating trauma. If available, administer tetanus toxoid IM as soon as possible.

Antibiotics should be given daily for seven to 10 days, depending on the type of antibiotic given (see below tables for antibiotics). When able/available, transition IV/IO antibiotics to PO as soon as possible to conserve supplies and equipment.

Table 11. TCCC Antibiotics

TCCC Antibiotics
Moxifloxacin (Avelox®) Administer 400mg PO daily for 10 days
Ertapenem (Invanz®) Administer 1g daily IV/IO/IM for 10 days
IV/IO to PO transition When transitioning from Ertapenem to Moxifloxacin, begin Moxifloxacin immediately after the final dose of Ertapenem for antibiotic overlap

Table 12. Alternative Antibiotics

(used if supplies of TCCC antibiotics are limited, or as directed by medical control)

Alternative Antibiotics PCC

Sepsis Management

  • Blunt or penetrating injuries may cause sepsis in untreated or undertreated patients.
  • Early recognition of impending sepsis and immediate treatment are imperative to improve changes of survival
  • Maintain a high degree of suspicion for signs of early and/or progressing sepsis while performing continuous triage.
  • Sepsis is defined as suspected or proven infection plus evidence of end organ dysfunction.
  • The National Early Warning Score (NEWS)17 is an aggregate scoring system indicating early physiologic derangements:

Table 13. Physiologic Parameters and NEWS Score

Physiologic Parameters 3 2 1 0 1 2 3
Respiratory Rate ≤8   9-11 12-20   21-34 ≥25
Oxygen Saturation ≤91 92-93 94-95 ≥96      
Temperature ≤35.0   35.1-36.0 36.1-38.0 38.1-39.0 ≥39.1  
Systolic BP ≤90 91-100 101-110 111-219      
Heart Rate ≤40   41-50 51-90 91-110 111-130 ≥131
Level of Consciousness       A     V,P,U
  • For the purposes of this guideline, a NEWS score of >2 is used to increase the sensitivity for detection of and evaluation for sepsis.
  • Early teleconsultations should be used for any signs of sepsis.
  • Additional parenteral antibiotics may be required to treat sepsis as well as vasopressors.
  • All use of pressers should be administered by role-based approved protocols or teleconsultation approval.

NOTE: Surgical telemedicine consultation is highly recommended to guide management of intraabdominal infections (i.e. appendicitis, cholecystitis, diverticulitis, abdominal abscess).

Sepsis Treatment

Table 14. Sepsis Treatments/Interventions

Intervention Paradigm
Antimicrobial Therapy
  • Minimum - Moxifloxacin 400 mg PO daily
  • Better - Ertapenem 1 gram IV/IO every 24 hours OR ceftriaxone 2 grams IV/IO every 24 hrs
  • Best - ceftriaxone 2 grams IV/IO every 24 hrs., PLUS vancomycin 1.5 mg/kg IV/IO every 12 hours, PLUS metronidazole 500 mg IV/PO/IO every 8 hours
Antiparasitic Regimens
  • Minimum - Atovaquone/progauanil (Malarone) 4x3 regimen - 4 tablets PO daily for 3 days
  • Better/Best - Artemether/lumefantrine (Coartem) 4 tablets PO initially, then 4 tablets after 8 hours, then 4 tablets PO twice daily for 2 more days (24 tablets total)
Antifungal Regimens
  • Minimum/Better/Best - Fluconazole 400 mg PO/IV daily
Fluid Resuscitation
  • Minimum - In the absence of IV/IO capability, have the patient drink water
  • If available, include electrolyte oral rehydration solution, especially for patients who cannot consume food
  • Better - IV/IO crystalloids:
    • Initial rapid infusion of 30 ml/kg should be given upon identification of sepsis
    • LR or NS to maintain SBP > 90mmHg or MAP ≥ 65 mmHg
    • If plasma is being given that volume can count toward the 30 ml/kg goal
  • Best - The same fluid resuscitation strategy as above with the addition of a urinary catheter for more precise measuring of UOP
Vasopressors
  • After fluid resuscitation, if there is no observed positive change in SBP, MAP, UOP and/or mental status, vasopressor medications should be given
  • All use of pressers should be administered by role-based approved protocols or teleconsultation approval
  • First-line - norepinephrine infusion
  • Second-line - epinephrine infusion
  • Refer to Drip table below for preparation, starting dose, and drip rates
Additional Medications
  • Consider hydrocortisone or dexamethasone administration for possible adrenal insufficiency if there is a poor response to vasopressor initiation/titration
    • Administer antipyretics (acetaminophen, if available. Non-steroidal anti-inflammatory drugs [NSAIDs] should be avoided as they may impair renal function)

Table 15. Epinephrine 1:10,000 (Adrenaline) or Norepinephrine (Levophed) Drip

0.9% NaCl IVF Bag Size Add to bag: EPI (or NOREPI): 1:10,000 (0.1 mg or 100mcg)/mL Starting Dose (mcg/min) DRIP SET:10gtts (Drops/mL) DRIP RATE: (Drops/min or gtts/min) DRIP SET: 15gtts (Drops/mL) DRIP RATE: (Drops/min or gtts/min)
50 ml 1 ml (100 mcg) 4 mcg/min 20 drops/min 30 drops/min
100 ml 2 ml (200 mcg) 4 mcg/min 20 drops/min 30 drops/min
250 ml 5 ml (500 mcg) 4 mcg/min 20 drops/min 30 drops/min
500 ml 10 ml (1 мг) 4 mcg/min 20 drops/min 30 drops/min
1000 ml (1л) 20 ml (2 мг) 4 mcg/min 20 drops/min 30 drops/min

**This is the least recommended approach as it commits a high volume of epinephrine to a large bag. If the patient’s vital signs (BP/MAP/HR) stabilize, the bag must be discontinued and the medic risks wasting some of their resources – “you can mix a drug in an IV bag, but you can’t take it out.”

Ancillary Medications

During PCC, additional medications may be required during the extended treatment of casualties, in addition to pain and antibiotic medications. These medications may have synergistic effects to further reduce pain or fever. Some medications may be utilized to treat side-effects of medications, to include nausea or other GI related issues.

Deep vein thrombosis (DVT) prophylaxis is also recommended for patients that are expected to be in a PCC setting for greater than 48 hours that have achieved hemostasis from wounds or are not at risk for further hemorrhage.

Table 16. Ancillary Medications

Ancillary Medications PCC

*Antipyretic: Use caution with NSAIDs with urgent or priority patients. Ensure patient can void normally (no impaired renal function).

*Link to Infection Prevention in Combat-related Injuries, 27 Jan 2021 CPG18

*Link to Sepsis Management in Prolonged Field Care, 28 Oct 2020 CPG19

Wound Care and Nursing - PCC

Background

Nursing interventions may not appear important to the medical professionals caring for a patient, but such interventions greatly reduce the possibility of complications such as DVT, pneumonia, pressure sores, wound infection, and urinary tract infection; therefore, essential nursing and wound care should be prioritized in the training environment. Critically ill and injured casualties are at high risk for complications that can lead to adverse outcomes such as increased disability and death. Nursing care is a core principle of PCC to reduce the risk of preventable complications and can be provided without costly or burdensome equipment.20

  • Using a nursing care checklist assists with developing a schedule for performing appropriate assessments and interventions.
  • Cross training all team members on these interventions prior to deployment will lessen the demand on the medic, especially when caring for more than one patient.
  • Prolonged Casualty Care Flowsheets, Nursing Care Checklists, Nursing Care Plans, Assessment/Intervention Packing List, and Recommended Nursing Skill Checklist for Clinical Rotations are included as a PCC Guidelines Appendix. (Also located in JTS Nursing Intervention in Prolonged Field Care CPG, 22 Jul 201820)

Pre-deployment, Mission Planning, and Training Considerations

  • Hands-on experience is optimal; simulation is a reasonable substitute
  • Practice with minimal technology so you are prepared when you lose access to electricity, water
  • Regular monitoring, reassessment, and intervention is lifesaving but can be resource-intensive
  • Utilize the Recommended Nursing Skill Checklist for Clinical Rotations included in Appendix B to maximize training opportunities.

Table 17. PCC Role-based Guidelines for Nursing Care and Wound Management

Role-based Guidelines for Nursing Care and Wound Management

*Link to Nursing Intervention in Prolonged Field Care, 22 Jul 2018 CPG20

*Link to Acute Traumatic Wound Care in the Prolonged Field Care Setting, 24 Jul 2017 CPG21

Splinting and Fracture Management - PCC

Table 18. Splinting and Fracture Treatment

Intervention Paradigm
Litter Padding
  • Minimum - Excess uniforms or other textiles
  • Better - Blankets or military sleep pad
  • Best - Blankets or military sleep pad
Splint Placement
  • Minimum - Improvised splints (wood fence, metal plank, etc.)
  • Better - Commercial splinting device (e.g., SAM splint)
  • Best - Commercial splinting device (e.g., SAM splint)
  • Re-check all pulses after splint placement
Pressure Injury Prevention
  • Examine skin, including nares and mouth, for changes and ensure splints are fitted properly and pulses are present below splint.
  • Monitor for allergic reactions to tape, developing erythema, excessive dryness, pressure indenting the skin, cracking, or breakdown.
  • Minimum - As described above, every 2 hours
  • Better - As above, adding padding to elevate bony prominences off of ground/litter/bed
  • Best - As above, adding commercial barrier creams and pressure injury dressings (e.g., Mepilex) to bony prominences
Straps
  • Patient secured for transport with padding/hypothermia considerations
  • All patient care items secured for flight or seaboard transport
    • Waterproof outer shell (HPMK)
    • Packaged to resist heavy wind from rotor wash and wind

*Link to JTS Orthopaedic Trauma: Extremity Fractures CPG, 26 Feb 202022

Burn Treatment - PCC

Background

  • Interrupt the burning process
  • Address any life-threatening process based on MARCH assessment as directed by TCCC.
  • A burned trauma casualty is a trauma casualty first
  • All TCCC skills can be performed through burned tissue

Burn Characteristics

  • Superficial burns (1st degree) appear red, do not blister, and blanch readily.
  • Partial thickness burns (2nd degree) are moist and sensate, blister, and blanch.
  • Full thickness burns (3rd degree) appear leathery, dry, non-blanching, are insensate, and often contain thrombosed vessels

Table 19. PCC Role-Based Guidelines for Burn Management

PCC Role-Based Guidelines for Burn Management

*Link to Burn Wound Management in Prolonged Field Care, 13 Jan 2017 CPG23

Special Considerations in Burn Injuries

Chemical Burns

NOTE: Refer to the JTS Inhalation Injury and Toxic Industrial Chemical Exposure CPG for additional information.

  • Expose body surfaces, brush off dry chemicals, and copiously irrigate with clean water. Large volume (>20L) serial irrigations may be needed to thoroughly cleanse the skin of residual agents. Do not attempt to neutralize any chemicals on the skin.
  • Use personal protective equipment to minimize exposure of medical personnel to chemical agents.
  • White phosphorous fragments ignite when exposed to air. Clothing may contain white phosphorous residue and should be removed. Fragments embedded in the skin and soft tissue should be irrigated out if possible or kept covered with soaking wet saline dressings or hydrogels.
  • Seek early consultation from the USAISR Burn Center (DSN 312-429-2876 (BURN); Commercial (210) 916-2876 or (210) 222-2876; email usarmy.jbsa.medcomaisr.list.armyburncenter@health.mil).

Electrical Burns

  • TCCC ASM and CLS personnel should remove the patient from the electricity source while avoiding injury themselves.
  • For cardiac arrest due to arrhythmia after electrical injury, follow advanced cardiac life support (ACLS) protocol and provide hemodynamic monitoring if spontaneous circulation returns.
  • Small skin contact points (cutaneous burns) can hide extensive soft tissue damage.
  • Observe the patient closely for clinical signs of compartment syndrome.
  • Tissue that is obviously necrotic must be surgically debrided.

NOTE: Escharotomy, which relieves the tourniquet effect of circumferential burns, will not necessarily relieve elevated muscle compartment pressure due to myonecrosis associated with electrical injury; therefore, fasciotomy is usually required.

  • Compartment syndrome and muscle injury may lead to rhabdomyolysis, causing pigmenturia and renal injury.
  • Pigmenturia typically presents as red-brown urine. In patients with pigmenturia, fluid resuscitation requirements are much higher than those predicted for a similar-sized thermal burn.
  • Isotonic fluid infusion should be adjusted to maintain UOP 75-100 mL/hr. in adult patients with pigmenturia.
  • If the pigmenturia does not clear after several hours of resuscitation consider IV infusion of mannitol, 12.5 g per liter of lactated Ringer’s solution, and/or sodium bicarbonate (150 mEq/L in D5W). These infusions may be given empirically; it is not necessary to monitor urinary pH. In patients receiving mannitol (an osmotic diuretic), close monitoring of intravascular status via CVP and other parameters is required.
  • Seek early consultation from the USAISR Burn Center (DSN 312-429-2876 (BURN); Commercial (210) 916-2876 or (210) 222-2876; email usarmy.jbsa.medcomaisr.list.armyburncenter@health.mil).

Pediatric Burn Injuries

  • Children with acute burns over 15% of the body surface usually require a calculated resuscitation.
  • Place a bladder catheter if available (size 6 Fr for infants and 8 Fr for most small children).
  • The Modified Brooke formula (3 mL/kg/%TBSA LR or other isotonic fluid divided over 24 hours, with one-half given during the first 8 hours) is a reasonable starting point. This only provides a starting point for resuscitation, which must be adjusted based on UOP and other indicators of organ perfusion. Goal UOP for children is 0.5-1mL/kg/hr.
  • Very young children do not have adequate glycogen stores to sustain themselves during resuscitation. Administer a maintenance rate of D5LR to children weighing < 20 kg. Utilize the 42-1 rule: 4ml/kg for the first 10kg + 2ml/kg 2nd 10kg + 1ml/kg over 20kg.
  • In children with burns > 30% TBSA, early administration may reduce overall resuscitation volume.
  • Monitor resuscitation in children, like adults, based on physical examination, input and output measurements, and analysis of laboratory data.
  • The well-resuscitated child should have alert sensorium, palpable pulses, and warm distal extremities; urine should be glucose negative.
  • Cellulitis is the most common infectious complication and usually presents within 5 days of injury. Prophylactic antibiotics do not diminish this risk and should not be used unless other injuries require antimicrobial coverage (penetrating injury or open fracture).
  • Most antistreptococcal antibiotics such as penicillin are successful in eradicating infection. Initial parenteral administration is advised for most children presenting with fever or systemic toxicity.
  • Nutrition is critical for pediatric burn patients. Nasogastric feeding may be started immediately at a low rate in hemodynamically stable patients and tolerance monitored. Start with a standard pediatric enteral formula (i.e. Pediasure) targeting 30-35 kcal/kg/day and 2g/kg/day of protein.
  • Children may rapidly develop tolerance to analgesics and sedatives; dose escalation is commonly required. Ketamine and propofol are useful procedural adjuncts.
  • When burned at a young age, many children will develop disabling contractures. These are often very amenable to correction which may be performed in theater with adequate staff and resources.
  • Seek early consultation from the USAISR Burn Center (DSN 312-429-2876 (BURN); Commercial (210) 916-2876 or (210) 222-2876; email burntrauma.consult.army@mail.mil).
  • Opportunities for pediatric surgical care provided by Non-Governmental Organizations (NGOs) may be the best option but require the coordinated efforts of the military, host nation, and NGOs.

Rule of Nines

On the DD Form 1380 the percentage of coverage on the casualty’s body will need to be documented. The Rule of Nines will help with the estimation. The below figure shows the approximation for each area of the body:

  • Eleven areas each have 9% body surface area (head, upper extremities, front and backs of lower extremities, and front and back of the torso having two 9% areas each).
  • General guidelines are that the size of the palm of the hand represents approximately 1% of the burned area.
  • When estimating, it is easiest to round up to the nearest 10.
  • If half of the front or rear area is burned, the area would be half of the area value.
  • For example, if half of the front upper/lower extremity is burned, it would be half of 9%, or 4.5%. If half of the front torso is burned, say either the upper or lower part of the front torso, then it would be half of 18%, or 9%.
  • Remember, the higher the percentage burned, the higher the chance for hypothermia.
  • For children, the percentage of BSA is calculated differently due to the distinctive proportion of major areas.

Figure 2. Adult Rule of Nines

Adult Rule of Nines

Figure 3. Pediatric Rule of Nines

Pediatric Rule of Nines

Link to Burn Wound Management in Prolonged Field Care, 13 January 2017 CPG23

Logistics - PCC

Background

Reducing the time to required medical or surgical interventions prevents death in potentially survivable illness, injuries and wounds. When evacuation times are extended, en route care (ERC) capability must be adequately expanded to mitigate the delay. In January 2010, the Joint Force Health Protection Joint Patient Movement Report stated “the current success of the medical community is colored by the valiant ability to overcome deficiencies through ‘just-in-time workarounds;’ many systemic shortfalls are resolved and become transparent to patient outcomes. However, future operations may not tolerate current deficiencies.”24

  • Patient packaging is highly dependent upon the transportation or evacuation platform that is available
  • If possible, rehearse patient packaging internally and with the external resources
  • Train with all possible assets, familiarizing them with standard operating procedures
  • Ensure the patient is stable before initiating a critical patient transfer

Table 20. Logistics Interventions

Intervention Paradigm
Prepare Documentation
  • Minimum - TCCC Card - DA1380
  • Better - Prolonged Field Care Casualty Work Sheet
  • Best - PCC Card with TCCC Card and any additional information, reference DA Form 4700 (SMOG 2021) for transport documentation standard.
Prepare Report
  • Report should give highlights, expected course, and possible complications during transport.
  • The hand-off is the most dangerous time for the patient; it is as important as treatments or medications.
  • If it is rushed, things can easily be missed.
  • Make sure you highlight non-obvious interventions and aspects of care (drugs given, repeat doses, etc.).
  • Minimum - Verbal report describing the patient from head to toe with interventions or a SOAP note.
  • Better - MIST (Mechanism, Interventions, Symptoms, Treatments)
  • Best - MIST with appropriate SBAR (Situation, Background, Assessment, Recommendations) and pertinent labs and other diagnostic information
Prepare Medications
  • Minimum - Prepare medication list with doses and time of next dose.
  • Better - Above with additionally preparing next dose of medication for transport crew appropriately labeled.
  • Best - Above with fresh IV fluids if indicated and fresh bags of drip medications with appropriate labeling and 72 hours of antibiotic for extended transports.
Hypothermia Management
  • Minimum - Blankets
  • Better - Sleep system and blankets.
  • Best - HPMK with Ready Heat or Absorbent Patient Litter System (APLS).
  • If possible, identify with tape the location of interventions or access points on top of hypothermia management to allow transport teams quick identification of location.
Flight Stressor/Altitude Management
  • Minimum - Ear Protection and Eye Protection, if nothing available sunglasses and gauze may be used, if patient is sedated and intubated eyes can be taped shut.
  • Better - Ear Pro and Eye Pro and blankets in all bony areas, Ear Protection and Eye Protection – foam ear plugs or actual hearing protection inserts, goggles.
  • Best - Above with gastric tube (NG/OG) or chest tube for decompression, if indicated. Depending on altitude/platform, consider bleeding air of out bags of fluid.
Secure Interventions and Equipment
  • Minimum – Tape:
    • Securely tape all interventions to include IVs, IOs, airway interventions, gastric tubes and TQs).
    • Oxygen tanks should be placed between the patients’ legs and the monitor should be secured on the oxygen cylinder to prevent injury to the patient.
    • Pumps should be secured to the litter.
  • Better - Additional litter straps to secure equipment and extend the litter with back support as indicated for vented patients to prevent VAP.
  • Best - Above. Use the Special Medical Emergency Evacuation Device (SMEED) to keep the monitor and other transport equipment off patient.
Prepare Dressings
  • AE and Other MEDEVAC assets do not routinely change dressings during transport; therefore, ensure all dressings are changed, labeled, and secured before patient pick up.
  • Minimum - Secure and reinforce dressings with tape, date, and time all dressings.
  • Better - Change dressings within 24 hours of departure, secure as above.
  • Best - Change and reinforce dressings within 4 hours of departure. Ensure additional Class VIII is available for any unforeseen issues in flight.
  • CAUTION - Circumferential/constricting dressings MUST be limited/monitored due to swelling during prolonged aerial transport.
Secure the Patient
  • Minimum - Litter with minimum of 2 litter straps.
  • Better - Litter with padding (example: AE pad or Sleep Mat) with minimum of 3 litter straps.
  • Best - Litter with padding and flight approved litter headrest with minimum of 3 litter straps.
  • Additional litter straps can be used to secure patient or equipment.
Moving a Critical Care Patient
  • Minimum - Two-person litter carry to CASEVAC/MEDEVAC platform.
  • Better - Three-person litter carry to CASEVAC/MEDEVAC platform.
  • Best - Four-person litter carry to CASEVAC/MEDEVAC platform.

*Link to Interfacility Transport of Patients between Theater Medical Treatment Facilities, 24 Apr 2018 CPG

Appendix A: TCCC Guidelines

TCCC Guidelines

Open the attachment on the side menu or open the below link to print or fill out electronically.

https://deployedmedicine.com/market/31/content/40

Appendix B: Airway Resources

Nursing Care Checklist

Open the attachment on the side menu or open the below link to print or fill out electronically.

https://prolongedfieldcare.org/wp-content/uploads/2018/05/PFC-Nursing-Care-Plan_.pdf

Appendix C: MASCAL Resources

Triage Guiding Principles

  • Priorities change based on time from injury
  • Activities in first hour are CRITICAL
  • Don’t waste time with formal triage tools. Just extricate/stop threat, stop external bleeding, clear airway
  • Transfusion and ventilator support within the first hour identify a resource-intensive patient
  • Damage control surgery has little impact after the first hour

Figure 4. TRIAGE cheat cards START

TRIAGE cheat cards START

Table 21. Triage Assessment

Each Patient Triage Assessment Should Be Complete in Less Than 60 Seconds
Category Examples
Category I: Immediate (red chemlite)
  • (Any MARCH issue)
  • Airway obstruction
  • Flail/open chest wound
  • Tension- Pneumothorax/hemothorax
  • Massive hemorrhage
  • 20-70% Burns
  • Unstable Vital Signs
  • Severe TBI (unconscious alive Pt)
Category II: Delayed (green chemlite)
  • Open fractures w/PMS intact
  • Soft tissue injuries
  • Moderate TBI (stable vital signs)
  • Open abdominal wounds
*Category III: Minimal (no chemlite) remain armed continue to engage
  • Minor abrasions, burns, sprains lacerations
  • Moderate/Mild anxiety
  • Fractures/dislocations w/PMS
  • Mild TBI
**Category IV: Expectant or Hero (blue chemlite)
  • Massive head or spinal injury
  • Third degree burns > 70% BSA
  • Injuries incompatible with life

*In combat, it is assumed that minimals will continue to stay armed/engaged if no mental status altering pharmaceuticals are given for pain.

**Expectant category is ONLY used in combat operations and/or when the requirements to adequately treat these patients exceed the available resources. In peacetime, it is generally assumed that all patients have a chance of survival.

Source: Special Operations Force Medic Handbooks (PJ, Ranger)

Triage Class 1 (MASCAL)

Adequate medics to treat critical patients and handle the rest

  • Many casualties
  • Threat controlled
  • Resources not severely limited
  • Medical personnel can arrive
  • Evacuation possible

Table 22. Triage Class 1 Actions and Goals

<1 Hour After Injury 1 – 4 Hours After Injury >4 Hours After Injury
Goals Goals Goals
  • Eliminate Threat
  • Establish CCP
  • Blood transfusion within 30 minutes
  • Evacuate to DCR/DCS within 1 hour
  • DCR/DCS as soon as possible
  • Use advanced resuscitation to “extend the Golden Hour”
Evacuate
Actions Actions Actions
  • Stop external bleeding
  • Clear airway
  • Ensure ventilation
  • Formal triage
  • Transfuse
  • MARCH PAWS
  • Transfuse
Use prolonged care to optimize outcomes

Triage Class 2 (MASCAL)

Unable to manage the number of critical patients

  • Numerous casualties or MASCAL (i.e. < 100 Casualties)
  • Threat has been controlled or partially controlled
  • Resources are very limited
  • Medical personnel can arrive (may be delayed > 1 hour)
  • Evacuation is possible (may be delayed > 1 hour)

Table 23. Triage Class 2 Actions and Goals

<1 Hour After Injury 1 – 4 Hours After Injury >4 Hours After Injury
Goals Goals Goals
  • Eliminate threat
  • Get medical personnel on scene
  • Begin evacuation of urgent but survivable patients
  • Evacuate urgent and priority patients
  • DCR/DCS as soon as possible
Evacuate remainder of patients
Actions Actions Actions
  • Stop external bleed
  • Clear airway
  • Reserve intubation/transfusion
  • CCP if able, otherwise get a count
  • Formal triage
  • MARCH PAWS if able
  • Transfuse
  • Establish CCP
  • Utilize minimals/returns to duty
  • Re-triage
  • Complete MARCH PAWS
  • Use prolonged care to optimize outcomes
  • Wound/fracture management

Triage Class 3 (Ultra-MASCAL)

Absolutely overwhelming number of casualties

  • Ultra-MASCAL (i.e. >100, possibly thousands of casualties)
  • Threat is ongoing
  • Resources are severely limited
  • Medical personnel unable to arrive in < 1 Hour
  • Evacuation not possible in < 1 Hour

Table 24. Triage Class 3 Actions and Goals

<1 Hour After Injury 1 – 4 hours After Injury >4 Hours After Injury
Goals Goals Goals
  • Respond to threat
  • Self-aide, buddy care
  • Separate ambulatory/ non-ambulatory
  • Eliminate threat
  • Get medical personnel on scene
  • Begin evacuation
  • Evacuate
  • Distribute patients
Actions Actions Actions
  • Stop external bleed
  • Clear airway
  • Reverse intubation/ transfusion
  • Get a count
  • Stop external bleed
  • Reserve intubation/transfusion
  • Begin to establish CCPs
  • Utilize minimals/return to Duty
  • Formal triage
  • Use prolonged care to optimize outcomes
  • Wound/fracture management
  • Utilize minimals/return to duty

MASCAL/Austere Team Resuscitation Record

Open the attachment on the side menu or open the below link to print or fill out electronically.

https://jts.amedd.army.mil/assets/docs/forms/MASCAL_Austere_Trauma_20_Jan_2020.pdf

Instructions: https://jts.amedd.army.mil/assets/docs/forms/MASCAL_Form_Instructions.pdf

Tactical Triage Protocol (algorithm)

Figure 5. Tactical Triage Protocol

Tactical Triage Protocol

Appendix D: Documentation Resources

The following resources and associated links are included in this CPG as attachments.

  • DD 1380 TCCC Card and accompanying POI TCCC After Action Report
  • DD 3019 Resuscitation Record
  • DA 4700 TACEVAC form
  • Nursing care grid (See Appendix B.)
  • Teleconsultation Script

DD 1380 TCCC Card

Open the attachment on the side menu or open the below link to print or fill out electronically.

https://jts.health.mil/index.cfm/documents/forms_after_action

DD 1380 - POI TCCC After Action Report

Open the attachment on the side menu or open the below link to print or fill out electronically.

https://jts.health.mil/index.cfm/documents/forms_after_action

DD 3019 Resuscitation Record

Open the attachment on the side menu or open the below link to print or fill out electronically.

https://www.esd.whs.mil/Portals/54/Documents/DD/forms/dd/dd3019.pdf

DA 4700 TACEVAC Form

Open the attachment on the side menu or open the below link to print or fill out electronically.

Instructions: https://jts.health.mil/index.cfm/documents/forms_after_action

Prolonged Field Care Casualty Card v22.1, 01 Dec 2020

Open the attachment on the side menu or open the below link to print or fill out electronically.

https://jts.health.mil/assets/docs/forms/Prolonged_Field_Care_Casualty_Card-Worksheet.pdf

Virtual Critical Care Consultation Guide

Guide is to be used with the Prolonged Field Care Card.

PCC Virtual Critical Care Consultation Guide

Appendix E: TBI Resources

Neurological Examination

  1. MENTAL STATUS

    Level of Consciousness: Note whether the patient is:

    • Alert/responsive
    • Not alert but arouses to verbal stimulation
    • Not alert but responds to painful stimulation
    • Unresponsive

    Orientation: Assess the patient’s ability to provide:

    • Name
    • Current location
    • Current date
    • Current situation (e.g., ask the patient what happened to him/her)

    Language: Note the fluency and appropriateness of the patient’s response to questions. Note patient’s ability to follow commands when assessing other functions (e.g., smiling, grip strength, wiggling toes). Ask the patient to name a simple object (e.g., thumb, glove, watch).

    Speech: Observe for evidence of slurred speech.

  2. CRANIAL NERVES

    All patients:

    • Assess the pupillary response to light.
    • Assess position of the eyes and note any movements (e.g., midline, gaze deviated left or right, nystagmus, eyes move together versus uncoupled movements).

    Noncomatose patient:

    • Test sensation to light touch on both sides of the face.
    • Ask patient to smile and raise eyebrows, and observe for symmetry.
    • Ask the patient to say “Ahhh” and directly observe for symmetric palatal elevation.

    Comatose patient:

    • Check corneal reflexes; stimulation should trigger eyelid closure.
    • Observe for facial grimacing with painful stimuli.
    • Note symmetry and strength.
    • Directly stimulate the back of the throat and look for a gag, tearing, and/or cough.
  3. MOTOR

    Tone: Note whether resting tone is increased (i.e. spastic or rigid), normal, or decreased (flaccid).

    Strength: Observe for spontaneous movement of extremities and note any asymmetry of movement (i.e. patient moves left side more than right side). Lift arms and legs, and note whether the limbs fall immediately, drift, or can be maintained against gravity. Push and pull against the upper and lower extremities and note any resistance given. Note any differences in resistance provided between the left and right sides.

    (NOTE: it is often difficult to perform formal strength testing in TBI patients. Unless the patient is awake and cooperative, reliable strength testing is difficult.)

    Involuntary movements: Note any involuntary movements (e.g., twitching, tremor, myoclonus) involving the face, arms, legs, or trunk.

  4. SENSORY

    If patient is not responsive to voice, test central pain and peripheral pain.

    Central pain: Apply a sternal rub or supraorbital pressure, and note the response (e.g., extensor posturing, flexor posturing, localization).

    Peripheral pain: Apply nail bed pressure or take muscle between the fingers, compress, and rotate the wrist (do not pinch the skin). Muscle in the axillary region and inner thigh is recommended. Apply similar stimulus to all four limbs and note the response (e.g., extensor posturing, flexor posturing, withdrawal, localization).

    NOTE: In an awake and cooperative patient, testing light touch is recommended. It is unnecessary to apply painful stimuli to an awake and cooperative patient.

  5. GAIT

    If the patient is able to walk, observe his/her casual gait and note any instability, drift, sway, and so forth.

Ultrasonic Assessment of Optic Nerve Sheath Diameter

If a patient is unconscious (i.e. does not follow commands or open eyes spontaneously), they may have elevated ICP. There is no reliable test for elevated ICP available outside of a hospital; however, optic nerve sheath diameter (ONSD) measurement is a rapid, safe, and easy-to-perform ultrasonographic assessment that may help identify elevated ICP when more definitive monitoring devices are not available.

  • The optic nerve sheath directly communicates with the intracranial subarachnoid space. Increased ICP, therefore, displaces cerebrospinal fluid along this pathway. Normal ONSD is 4.1–5.9mm.30
  • A 10–5-MHz linear ultrasound probe can be used to obtain ONSDs. ONSD is measured from one side of the optic nerve sheath to the other at a distance of 3mm behind the eye immediately below the sclera.31
  • In general, ONSDs >5.2mm should raise concern for clinically significant elevations in ICP in unconscious TBI patients.5,32 The ONSD can vary significantly in normal individuals, so one single measurement may not be helpful; however, repeated measurements that detect gradual increases in ONSD over time may be more useful than a single measurement.
  • NSD changes rapidly when the ICP changes, so it can be measured frequently.33 If ONSD is used, it is best to check hourly along with the neurologic examination.

Technique

  1. Check to make sure there is no eye injury. A penetrating injury to the eyeball is an absolute contraindication to ultrasound because it puts pressure on the eye.
  2. Ensure the head and neck are in a midline position. Gentle sedation and/or analgesia may be necessary to obtain accurate measurements.
  3. Ensure the eyelids are closed.
  4. If available, place a thin, transparent film (e.g., Tegaderm; 3M, http://www.3m.com) over the closed eyelids.
  5. Apply a small amount of ultrasound gel to closed eyelid.
  6. Place the 10(–5) MHz linear probe over the eyelid. The probe should be applied in a horizontal orientation (Figure 1) with as little pressure as possible applied to the globe.
  7. Manipulate the probe until the nerve and nerve sheath are visible at the bottom of screen. An example of a proper ultrasonagraphic image of the optic nerve sheath can be seen in Figure 2.
  8. Once the optic nerve sheath is visualized, freeze the image on the screen.
  9. Using the device’s measuring tool, measure 3mm back from the optic disc and then obtain a second measurement perpendicular to the first. The second measurement should cover the horizontal width of the optic nerve sheath (Figure 2). An abnormal ONSD is shown in Figure 3.
  10. Repeat the previous sequence in the opposite eye. Annotate both ONSDs on the PFC Casualty Card.
  11. ONSDs should be obtained, when possible, at regular intervals to help assess changes in ICP, particularly when the neurologic examination is poor and/or unreliable (i.e. with sedation). Serial measurements with progressive diameter enlargement and/or asymmetry in ONSDs should be considered indicative of worsening intracranial hypertension.

CAUTION: ONSD measurements are contraindicated in eye injuries. NEVER apply pressure to an injured eye.

Figure 1. Appropriate placement of the linear probe. Figure 2. An ultrasonographic view of a normal eye and optic nerve sheath. Figure 3. Ultrasound image of the right optic nerve sheath of a 61-year-old man with a traumatic subdural hematoma.

Appropriate placement of the linear probe

An ultrasonographic view of a normal eye and optic nerve sheath

Ultrasound image of the right optic nerve sheath of a 61-year-old man with a traumatic subdural hematoma

 

Ultrasound gel is placed over a closed eyelid and the probe placed horizontally over the eyelid, applying as little pressure to the globe as possible. If available, Tegaderm or other thin covering (e.g., Latex glove) should be placed over a closed eyelid for further protection. To measure ONSD, apply the ultrasound measuring device to the optic disc and measure back 3mm along the length of the optic nerve. A second, perpendicular measurement is obtained at the previously measured point that spans the horizontal width of the optic nerve sheath. In this image, ONSD was determined to be 5.1mm, a normal value. The optic nerve sheath measured 6.8mm in diameter. Elevated ICP was subsequently confirmed (26mmHg) after the placement of an ICP bolt monitor.

Spontaneous Venous Pulsations

  • Spontaneous venous pulsations (SVPs) are subtle, rhythmic variations in retinal vein caliber on the optic disc and have an association with ICP.
  • It is difficult to see SVPs without advanced equipment; however, if a handheld ophthalmoscope is available, it is worth an attempt to visualize the retinal veins.
  • Don’t worry if you cannot see SVPs; this may actually be normal. However, if you do see them, it is very reassuring that ICP is normal.10
  • If SVPs are initially present and can no longer be seen on subsequent examinations, the provider should be concerned for increasing ICP.

Technique

  1. Gently lift the eyelid until the pupil is in view.
  2. Using a handheld ophthalmoscope, the provider should maneuver himself or herself to a position where the optic disc can be visualized.
  3. Identify the retinal veins as they emerge from the optic disc. Retinal veins are typically slightly larger and darker than retinal arteries. Figure at right demonstrates the typical appearance of the retina.
  4. Observe the retinal veins for pulsations. Note the presence or absence of spontaneous venous pulsations.
  5. Repeat the step 1–4 sequence in the contralateral eye.

Figure 6. Typical appearance of a healthy retina

Typical appearance of a healthy retina

The retinal vessels can be seen emerging from the optic disc. Retinal veins can be identified by their slightly larger, thicker size and darker color. Retinal arteries are small, thin, and lighter in color than retinal veins.

Glasgow Coma Scale

TBI severity classification using the GCS score:

  • Mild: 13–15
  • Moderate: 9–12
  • Severe: 3–8
Eye Opening Verbal Response Motor Response

4 – Spontaneous

3 – To verbal command

2 – To painful stimuli

1 – No response

5 – Oriented

4 – Confused

3 – Inappropriate words

2 – Incomprehensible sounds

1 – No response

6 – Obeys commands

5 – Localizes to painful stimuli

4 – Withdraws from pain

3 – Flexion to pain

2 – Extension to pain

1 – No response

Richmond Agitation Sedation Scale (RASS)

Richmond Agitation Sedation Scale (RASS)

Signs and Symptoms of Elevated Intracranial Pressure

  • GCS<8 and suspected TBI
  • Rapid decline in mental status
  • Fixed dilated pupils(s)
  • Cushing’s triad hemodynamics (hypertension, bradycardia, altered respirations)
  • Motor posturing (unilateral or bilateral)
  • Penetrating brain injury and GCS <15
  • Open skull fracture

Hypertonic Saline (HTS) Protocol (goal Na 140-165 meq/L)

  • 3% HTS: 250-500 cc bolus, then 50 ml/hr infusion, rebolus as needed for clinical signs.
  • 7.5% HTS: decrease above doses by 50%.
  • 23.4%: dilute to 3% and use as above. If unable to dilute, can be given as 30 ml bolus and redose as needed.
  • Central venous line (CVL) preferred for 3% (can be given initially via peripheral IV/IO).
  • CVL REQUIRED for 7.5% or higher concentration.

Military Acute Concussion Evaluation 2 (MACE 2) Form, 2021

Open the attachment on the side menu or open the below link to print or fill out electronically.

https://www.health.mil/Reference-Center/Publications/2020/07/30/Military-Acute-ConcussionEvaluation-MACE-2

MHS Progressive Return to Activity Following Acute Concussion/Mild TBI

Open the attachment on the side menu or open the below link to print or fill out electronically.

https://jts.health.mil/index.cfm/documents/forms_after_action

Appendix F: Logistics Resources

Prolonged Field Care – Patient Packaging, 11 Aug 2021

Patient packaging is highly dependent upon the Casualty Evacuation (CASEVAC) / Medical Evacuation (MEDEVAC) platform that is operationally available. If possible, rehearse patient packaging internally and with the external resources. Train with MEDEVAC assets understand transporting teams’ standard operating procedures in order to best prepare the patient for transport. (Example some teams want to secure the patient and interventions themselves while others may be okay with a fully wrapped patient).

Ensure the patient is stable before initiating a critical patient transfer. For POI/unstable patients ensure the appropriate transport team (MEDEVAC with en route critical care nurse or advanced provider). Interfacility transfers should meet the following minimum:

  1. Hemorrhage control
  2. Resuscitation adequate (SBP 70-80 mmHg, MAP >60, or UOP >0.5ml/kg/hr)
  3. Initial post-op recovery as indicated
  4. Stabilization of fractures

Prepare Documentation

  • Good: TCCC Card - DA1380
  • Better: Prolonged Field Care Casualty Work Sheet
  • Best: PFC Card with TCCC Card and any additional information, reference DA Form 4700 (SMOG 2021) for transport documentation standard

*preference: secure to patient strip of 3in Tape with medications administered attached to blanket or HPMK

Prepare Report

Report should give highlights, expected course, and possible complications during transport. The handoff is the most dangerous time for the patient it is as important as treatments or medications. If it is rushed things can easily be missed.

  • Good: Verbal report describing the patient from head to toe with a SOAP note.
  • Better: MIST (Mechanism, Interventions, Symptoms, Treatments).
  • Best: MIST with appropriate SBAR (Situation, Background, Assessment, Recommendations) and pertinent labs and other diagnostic information.

Prepare Medications

  • Good: Prepare medication list with doses and time of next dose.
  • Better: Above with additionally preparing next dose of medication for transport crew appropriately labeled.
  • Best: Above with fresh IV fluids if indicated and fresh bags of drip medications with appropriate labeling and 72 hours of antibiotic for extended transports.

Hypothermia Management

  • Good: Blankets.
  • Better: Sleep system and blankets.
  • Best: HPMK with Ready Heat or Absorbent Patient Litter System (APLS).

Flight Stressor/ Altitude Management

  • Good: Ear Protection and Eye Protection, if nothing available sunglasses and gauze may be used, if patient is sedated and intubated eyes can be taped shut.
  • Better: Ear Pro and Eye Pro and blankets in all bony areas, Ear Protection and Eye Protection – foamies or actual hearing protection inserts, goggles.
  • Best: Above with gastric tube (NG/OG) or chest tube for decompression, if indicated. Depending on altitude/platform, consider bleeding air of out bags of fluid.

Secure Interventions and Equipment

  • Good: Tape (securely tape all interventions to include IVs, IOs, Airway interventions, Gastric Tubes and TQs). Oxygen tanks should be placed between the patients legs and the monitor should be secured on the oxygen cylinder to prevent injury to the patient. Pumps should be secured to the litter.
  • Better: Additional litter straps to secure equipment and extend the litter with back support as indicated for vented patients to prevent VAP.
  • Best: Above and use the SMEED to keep the monitor and other transport equipment off patient.

*if possible, identify with tape the location of interventions or access points on top of hypothermia management to allow transport teams quick identification of location.

Prepare Dressings

Air Evacuation and other MEDEVAC assets do not routinely change dressings during transport; therefore, ensure all dressings are changed, labeled, and secured before patient pick up.

  • Good: Secure and reinforce dressings with tape, date, and time all dressings.
  • Better: Change dressings within 24 hours of departure, secure as above.
  • Best: Change and reinforce dressings within 4 hours of departure. Ensure additional Class VIII is available for any unforeseen issues in flight.

Secure the Patient

  • Good: Litter with minimum of 2 litter straps.
  • Better: Litter with padding (example: AE pad or Sleep Mat) with minimum of 3 litter straps.
  • Best: Litter with padding and flight approved litter headrest with minimum of 3 litter straps (additional litter straps can be used to secure patient or equipment)

Moving a Critical Care Patient

  • Good: Two person little carry to CASEVAC/MEDEVAC platform.
  • Better: Three person little carry on a rickshaw to CASEVAC/MEDEVAC platform.
  • Best: Four person little carry on a rickshaw to CASEVAC/MEDEVAC platform.

Prolonged Casualty Care Patient Packaging Flowchart

Prolonged Casualty Care Patient Packaging Flowchart

Pearls:

  • Document all times – TCCC Card or DA4700.
  • Assist Ensure the patient is stable before initiating a critical patient transfer.
  • POI/unstable patients ensure the appropriate transport team (MEDEVAC W/ECCN or Advanced provider).
  • Interfacility transfers should meet the following minimum:
    • Hemorrhage control
    • Resuscitation adequate (SBP 70-80 mmHg, MAP >60, or UOP >0.5ml/kg/hr)
    • Initial post-op recovery as indicated
    • Stabilization of fractures

You can discuss this material on the TSSS forum

Ask a question

⚠️ The TCCC (Tactical Combat Casualty Care) medical guidelines posted on this site are helpful to all tactical medical care providers. But they DO NOT REPLACE PRACTICAL TRAINING and the getting of the practical skills.

By closing this block, you agree that you are aware of the need to take practical courses in providing medical care during military operations.

Clicky