106 Tactical medicine and Field Sanitation

Question 1

History of TCCC

Answer 1

Historical data shows that 90% of combat wound fatalities die on the battlefield before reaching a military treatment facility. TCCC guidelines are currently used throughout the US Military and various allied countries. TCCC guidelines were first introduced in 1996 for use by Special Operations Corpsmen, Medics, and Pararescumen (PJs)

Question 2

Triage

Answer 2

Triage is a French word meaning “to sort”, is the process of quickly assessing patients in a multiple casualty incident and assigning patients a priority (or classification) for receiving treatment according to the severity of the illnesses or injuries. Triage is a dynamic (ongoing) process, and a patient’s priority is subject to change to reflect situational changes.

Question 3

Three phases of TCCC

Answer 3

Care under fire
Tactical Field Care
Tactical Evacuation

Question 4

Care under fire

Answer 4

Care rendered by the first responder or combatant at the scene of the injury while under hostile fire

Question 5

Tactical Field Care

Answer 5

Care rendered by the first responder or combatant when no longer under effective hostile fire.

Question 6

Tactical Evacuation

Answer 6

Care rendered once the casualty has been picked up by an aircraft, ground vehicle or boat.
**Note: The term “Tactical Evacuation” encompasses both Casualty Evacuation (CASEVAC) and Medical Evacuation (MEDEVAC).

Question 7

Casualty management CUF

Answer 7

Maintain fire superiority and take cover. Fire supremacy is the key to preventing combat trauma.
 If able, casualty should stays engaged as a combatant.
 Instruct casualty to move to cover and apply self-aid if possible.
 Keep casualty from sustaining additional wounds.

Question 8

Treatment plan CUF

Answer 8

Stop any life-threatening external hemorrhage from extremities with a tourniquet over the uniform (if tactically feasible).
 If not tactically feasible (e.g. fire superiority has not been obtained), do not try to treat the casualty in the kill zone. Application of a tourniquet may be deferred until patient has been moved to safety.
**NOTE: The decision regarding the relative risk of further injury versus that of bleeding to death must be made by the person rendering care.
 Non-life threatening bleeding should be deferred until Tactical Field Care.
 Move casualty to cover as quickly as possible utilizing an evacuation plan.

Question 9

Mental Status

Answer 9

Determine responsiveness using AVPU acronym. Check if casualty is Alert, responsive only to Vocal commands, responsive only to Pain, or Unresponsive.
 Any casualty with an altered mental status should be disarmed immediately.

Question 10

Airway management

Answer 10

Anatomical Structures
 Airway consists of nose, mouth, throat, voice box, and wind pipe.
 Air is diverted to the left and right lungs at the bronchial tree, the bottom of the wind pipe.
 Lungs are elastic organs composed of thousands of small air spaces and covered by an airtight membrane.
 The rib cage protects the lungs.
 The diaphragm is a large dome-shaped muscle that separates the bottom of the lungs from the abdominal cavity. General guidelines:
 Assess the airway by using the look, listen and feel technique for 5 to 10 seconds.
 Open airway using modified jaw thrust or chin lift techniques.
 Look for foreign obstructions and clear if possible.
 Insert a nasopharyngeal airway (NPA) if required (Do not use an NPA if a facial fracture is suspected).
 Reassess airway after any interventions

Question 11

Breathing Assessment

Answer 11

Inspect the anterior thorax for bilateral rise and fall and for possible penetrating trauma.
 Auscultate the chest, bad side then good side.
 Palpate in order to feel any abnormalities.
 Treat all life-threatening penetrating injuries of the chest, such as a sucking chest wound, with an occlusive dressing.
 Perform a needle thoracentesis (needle decompression) if a pneumothorax is suspected.
 Repeat the assessment on the posterior thorax by carefully performing a log roll.

Question 12

Circulatory Assessment

Answer 12

 Check for a carotid pulse
 Perform a blood sweep by sweeping the downside of each limb in order to identify wounds and bleeding.
 If blood is found, gain control of any life-threatening hemorrhage with a tourniquet or hemostatic agent.
 Assess the radial pulses for rate (beats per minute) and quality (strong, weak, thread). Estimated blood pressure (BP). Blood pressure can be estimated based on the presence of a casualty’s heart rate. Below are the parameters for estimating blood pressure:
 Radial pulse detected – 80/P
 Femoral pulse detected – 70/P
 Carotid pulse detected – 60/P
 Normally, a BP reading consists of 2 numbers, but if assessing BP by palpation (touch); “P” is substituted for the second number to denote that it was determined by palpation.
 Assess peripheral perfusion by checking:
 Skin color (pale/flushed/normal)
 Skin temperature (cold/cool/warm/hot)
 Skin condition (dry/moist)
 Check for capillary refill and ensure it is less than three seconds.

Question 13

Assess for Shock

Answer 13

Shock is an abnormality of the circulator system that results in an inadequate amount of blood flow and oxygen to organs and tissues.
 Hemorrhagic shock is the most common form of shock encountered in the battlefield.

Question 14

Anatomy of the cardiovascular system

Answer 14

 Pump
 Heart (Contains 4 chambers)
 Container
 Arteries, veins, and capillaries
 Fluid
 Blood and blood plasma

Question 15

Signs and symptoms of shock

Answer 15

 Heart rate: Greater than 100 beats per minute
 Respirations: Greater than 20 beats per minute
 Capillary Refill: Greater than 3 seconds
 Skin: Cool, clammy, pale, or cyanotic
 Mental Status: Restless, disoriented, lethargic, or unconscious

Question 16

Treatments of shock

Answer 16

 Control life-threatening extremity hemorrhage and non-life-threatening hemorrhage with hemostatic agents and pressure dressings.
 Provide supportive care for internal bleeding
 Maintain the patient’s airway
 Keep patient warm to prevent hypothermia
 Reassess interventions and monitor vital signs.
 TACEVAC.

Question 17

management of burns

Answer 17

The severity of all burns will vary depending on the source of the burn, duration of exposure, and location of the burn.
Anatomy of the Skin:
 The most important function is to form a protective barrier against the external environment.
 Skin also prevents fluid loss, regulates body temperature, and allows for sensation.

Question 18

Three layers of skin

Answer 18

Epidermis
Dermis
Subcutaneous

Question 19

Burn Classifications

Answer 19

Burn Classifications
Burns are classified by the depth of the burn and the extent of the total body surface area (TBSA) of the burn.
First-Degree Burns/Superficial Thickness Burns
 Involves only the epidermis.
Signs & Symptoms:
 Dry, red and inflamed skin.
 Painful.
 The burned area blanches (whites out) under firm pressure.
 Typically will heal within one week.
Second-Degree Burns/Partial Thickness Burns
 A burn in which the surface (epidermis) is destroyed and various portions of the dermis are damaged.
Signs & Symptoms:
 Skin will appear glistening or have a wet appearance.
 Blisters or open weeping wounds
 Deep, intense pain
 Typically will heal in two to three weeks.
 Fluid loss may be significant depending on the extent of the burn.
Third-Degree Burn/Full Thickness Burn
 All three layers of the skin are damaged.
Signs & Symptoms:
 Skin has a dry, leathery appearance.
 The skin can range in color from white, yellow, cherry red, brown, or charred black.
 First and second-degree burns surround the third degree burn.
 Severe pain around periphery of burn, but little to no pain near center of burn.
Fourth-Degree Burns
 A burn that not only encompasses all three layers but also includes underlying fat, muscles, bone, or internal organs

Question 20

Types of burns

Answer 20

 Thermal
 Most common type of burn, generally from fire or excessive heat.
 Electrical
 These are often more serious than they appear. Entrance and exit wounds may be small but the electricity burns a large area as it travels through the body.
 Chemical
 Occurs when skin comes in contact with various caustic agents  Radiation
 Associated with nuclear blasts and other forms of radiation.

Question 21

Treatment of burns

Answer 21

Thermal/Radiation Burns
 Stop the burning process
 Remove all clothing and jewelry; however do not pull away clothes that are stuck to skin.
 Wrap the burn loosely with a dry sterile dressing.
 Keep the casualty warm as the casualty will not be able to maintain their body temperature.
 Provide pain relief
 Electrical Burns
 Stop the electrical source
 Use a nonconductive item, such as a wooden beam to disengage the casualty from the source.
 Wrap the burn loosely with a dry sterile dressing.
 Chemical Burns
 Flush the affected area with large amounts of water.
 Brush dry chemicals off away from both yourself and the casualty.
 For a confirmed acid burn. Irrigate the area for 15 minutes.
 Wrap the burn loosely with a dry sterile dressing.
 Prevent Hypothermia
 Ensure all hemorrhage is controlled.
 Keep patient warm by wrapping in available material

Question 22

Management of Fractures

Answer 22

In an open fracture there is a break in the skin, while in a closed fracture the skin remains intact.
Signs & Symptoms:
 Deformity
 Crepitus
 Pain with or without movement
 Inability to move extremity
 Protruding bone
 Swelling
 Obvious Injury
Splints are used to immobilize a fracture.
 Rigid Splints: cannot be changed in shape.
 Formable Splints: can be molded in various shapes.
 Improvised Splints: made from any available material such as a stick or branch.
 Anatomical Splints: the casualty’s body is used as a splint.
 Sling: used to Support an upper extremity.
 Swath: used to immobilize a fracture.
Guidelines for splinting:
 Control hemorrhage and treat for shock.
 Establish distal pulse prior to splinting.
 Expose fracture site.
 If bone is exposed, ensure to cover the ends with sterile dressing prior to splinting  Splint fracture in position found.
 Attempt to straighten a deformed limb only if it is a closed injury with no distal pulses.
 Do not try to reposition or put back an exposed bone.
 Move the fractured part as little as possible while applying the splint.
 Pad the splint at any bony prominence points (elbow, wrist or ankle).
 Immobilize the splint above and below the fracture.
 Reassess distal pulses after splint is secured.
 When in doubt, treat all injuries as a possible fracture.

Question 23

Administration of Medications

Answer 23

 Utilize the combat pill pack in the treatment of all wounds. Combat pill pack contains:
 Moxifloxacin: One 400mg tablet PO; used as an antibiotic.
 Mobic: One 15mg tablet PO; used for pain management.
 Tylenol: Two 650mg tablets PO; for pain management.
Document Baseline Vital Signs
 Respiratory Rate
 Pulse Rate
 Estimated blood pressure

Question 24

Casualty Movement Technique Considerations

Answer 24

assistance as opposed to an unconscious one.
 Location of nearest cover
 Best way to move patient to cover
 Risk to rescuer: Some carries may expose rescuer to enemy fire.
 Weight differences: A heavier casualty may be more difficult to maneuver.
 Distance covered: A faster carry might be used as opposed to a carry that produces a smaller targe

Question 25

TACEVAC priorties

Answer 25

Urgent Evacuation
 Evacuation to the next higher echelon of medical care is needed to save life or limb.
 Must occur within 2 hours
Priority Evacuation
 Evacuation to the next higher echelon of medical care is needed or the patient will deteriorate into the URGENT category.
 Must occur within 4 hours
Routine evacuation
 Evacuation to the next echelon of medical care is needed to complete medical treatment.
 Must occur within 24 hours

Question 26

Purify water with iodine tablets

Answer 26

 Fill the canteen with the cleanest water available.
 Add two tablets for a one-quart canteen (four tablets for a two quart canteen).
 Replace the cap and wait 5 minutes.
 Shake the canteen.
 Loosen the cap and tip the canteen over to allow leakage around the canteen
threads.
 Tighten the cap and wait another 25 minutes before drinking.
**NOTE: Tincture of Iodine 2% can be substituted for Iodine tablets. Five drops
are equivalent to one Iodine tablet

Question 27

Purifying water by boiling

Answer 27

Boiling is a means of disinfecting small quantities of water when no other
means are available.
 Boiling water has the following disadvantages:
 Fuel is needed to boil water.
 Water can take a long time to boil and must cool before drinking.
 Must be kept in a covered, uncontaminated container.
 Water must be held at a rolling boil for at least 5 minutes at sea level to
make it safe for drinking.
**Note: The command surgeon may prescribe longer boiling times at higher
altitudes and in areas where certain heat-resistant organisms are prevalent.

Question 28

Dispose human waste

Answer 28

The methods for disposing of human waste in the field varies with the tactical
situation, soil conditions, water table, weather conditions, availability of materials,
and local environmental regulations. The following need to be taken into
consideration when choosing a waste disposal method and location:
 Must be 50 feet from berthing areas
 Must be 100 feet from nearest natural water source
 Must be 300 feet from food service areas
Cat Hole
 Approximately 1-foot wide and 1-foot
deep.
 Used when on the march.
 Packed down with dirt after each use.
Straddle Trench
 Approximately 4-feet long, 2 ½ feet deep, and 1-
foot wide (Additional trenches must be 2 feet
apart).
 Used for 1 – 3 day bivouac sites.
 Serves 25 people, accommodating 2 at a time.
 Packed with dirt after each bivouac site or when
trench is filled to within one foot