Tactical Combat Casualty Care and Wound Treatment
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CLARIFICATION OF TERMINOLOGY
When used in this publication, words such as "he," "him," "his," and "men"
‘are intended to include both the masculine and feminine genders, unless
specifically stated otherwise or when obvious in context.
USE OF PROPRIETARY NAMES
The initial letters of the names of some products may be capitalized in this
subcourse. Such names are proprietary names, that is, brand names or
trademarks. Proprietary names have been used in this subcourse only to
make it a more effective learning aid. The use of any name, proprietary or
otherwise, should not be interpreted as endorsement, deprecation, or
criticism of a product; nor should such use be considered to interpret the
validity of proprietary rights in a name, whether it is registered or not.
TABLE OF CONTENTS
INTRODUCTION
1 TACTICAL COMBAT CASUALTY CARE
Exercises
2 CONTROLLING BLEEDING FROM AN EXTREMITY
Section I. General
Section II. Controlling External Bleeding From a Wound on an
Extremity
Section III. Applying an Improvised Tourniquet
Section IV. Controlling Bleeding From an Amputation
Section V. Treating Internal Bleeding in an Extremity
Exercises
3 TREATING CHEST INJURIES.
Section I. General
Section II. Treating Open Chest Wounds
Section III. Treating Closed Chest Injuries
Exercises
4 TREATING ABDOMINAL INJURIES
Section I. General
Section II. Treating Open Abdominal Wounds
Section III. Treating an Acute Abdomen
Exercises
5 TREATING HEAD INJURIES
Section I. Open and Closed Head Injuries
Section II. Treating Open Head Wounds
Section III. Treating Other Injuries
Exercises
6 TREATING BURNS
Section I. General
Section II. Treating Thermal Burns
Section III. Treating Electrical Burns
Section IV. Treating Chemical Burns
Section V. Treating Radiant Energy Burns
Exercises
7 TREATING HYPOVOLEMIC SHOCK
Exercises
8 TREATING SOFT TISSUE INJURIES
Exercises
CORRESPONDENCE COURSE OF
THE U.S. ARMY MEDICAL DEPARTMENT CENTER AND
SCHOOL
SUBCOURSE MD0554
TACTICAL COMBAT CASUALTY CARE AND WOUND
TREATMENT
INTRODUCTION
When you have casualties on the battlefield, you must determine the
sequence in which the casualties are to be treated and how to treat their
injuries. This subcourse discusses the procedures for performing tactical
combat casualty care; treating injuries to the extremities, chest, abdominal,
and head; and controlling shock.
Subcourse Components:
This subcourse consists of eight lessons. The lessons are:
Lesson 1, Tactical Combat Casualty Care.
Lesson 2, Controlling Bleeding From an Extremity.
Lesson 3, Treating Chest Injuries.
Lesson 4, Treating Abdominal Injuries.
Lesson 5, Treating Head Injuries.
Lesson 6, Treating Burns.
Lesson 7, Treating Hypovolemic Shock.
Lesson 8, Treating Soft Tissue Injuries.
Here are some suggestions that may be helpful to you in completing this
subcourse:
--Read and study each lesson carefully.
--Complete the subcourse lesson by lesson. After completing each lesson,
work the exercises at the end of the lesson, marking your answers in this
booklet.
--After completing each set of lesson exercises, compare your answers
with those on the solution sheet that follows the exercises. If you have
answered an exercise incorrectly, check the reference cited after the answer
on the solution sheet to determine why your response was not the correct
one.
Credit Awarded:
Upon successful completion of the examination for this subcourse, you
will be awarded 16 credit hours.
To receive credit hours, you must be officially enrolled and complete an
examination furnished by the Nonresident Instruction Section at Fort Sam
Houston, Texas.
You can enroll by going to the web site http://atrrs.army.mil and enrolling
under “Self Development” (School Code 555).
A listing of correspondence courses and subcourses available through the
Nonresident Instruction Section is found in Chapter 4 of DA Pamphlet 350-
59, Army Correspondence Course Program Catalog. The DA PAM is
available at the following website: http://www.usapa.army.mil/pdffiles/p350-
59.pdf.
LESSON ASSIGNMENT
LESSON 1 Tactical Combat Casualty Care.
TEXT ASSIGNMENT Paragraphs 1-1 through 1-5.
When you have completed this lesson, you
LESSON OBJECTIVES
should be able to:
1-1. Identify factors that influence combat
casualty care.
1-2. Identify the stages of care?
1-3. Identify the procedures for care under
fire.
1-4. Identify the procedures for tactical field
care.
1-5. Identify the procedures for casualty
evacuation care.
Work the lesson exercises at the end of this
lesson before beginning the next lesson.
SUGGESTION
These exercises will help you accomplish the
lesson objectives.
LESSON 1
TACTICAL COMBAT CASUALTY CARE
1-1. GENERAL
As a combat medic on today’s battlefield, you will experience a wide
variety of conditions not previously experienced. Your training has prepared
you on standards that apply to the civilian emergency medical service (EMS)
world that may not apply to the combat environment. These tools are a good
basis for sound medical judgment; on today’s battlefield, this judgment
could save the lives of your fellow soldiers. The US Army found the need to
migrate away from the civilian standards and allow the combat medics to
analyze situations in ways not previously thought of. These techniques are
called “tactical combat casualty care” (TC3). These techniques and factors
will be discussed in the following paragraphs. Factors influencing combat
casualty care include the following.
a. Enemy Fire. It may prevent the treatment of casualties and may put you
at risk in providing care under enemy fire.
b. Medical Equipment Limitations. You only have what you carried in
with you in your medical aid bag.
c. A Widely Variable Evacuation Time. In the civilian community,
evacuation can be under 25 minutes; but in combat, evacuation may be
delayed for several hours.
d. Tactical Considerations. Sometimes the mission will take precedence
over medical care.
e. Casualty Transportation. Transportation for evacuation may or may
not be available. Air superiority must be achieved before any air evacuation
assets will be deployed. Additionally, the tactical situation will dictate when
or if casualty evacuation can occur. In addition, environmental factors may
prevent evacuation assets from reaching your casualty.
1-2. STAGES OF CARE
In making the transition from civilian emergency care to the tactical
setting, it is useful in considering the management of casualties that occurs
in a combat mission as being divided into three distinct phases.
a. Care Under Fire. Care under fire is the care rendered by the soldier
medic at the scene of the injury while he and the casualty are still under
effective hostile fire. Available medical equipment is limited to that carried
by the individual soldier or the soldier medic in his medical aid bag.
b. Tactical Field Care. Tactical field care is the care rendered by the
soldier medic once he and the casualty are no longer under effective hostile
fire. It also applies to situations in which an injury has occurred, but there is
no hostile fire. Available medical equipment is still limited to that being
carried into the field by medical personnel. The time needed to evacuate the
casualty to a medical treatment facility (MTF) may vary considerably.
c. Combat Casualty Evacuation Care. Combat casualty evacuation
(CASEVAC) care is the care rendered once the casualty has been picked up
by an aircraft, vehicle, or boat. Additional medical personnel and equipment
may have been pre-staged and are available at this stage of casualty
management.
1-3. CARE UNDER FIRE
a. Medical personnel’s firepower may be essential in obtaining tactical fire
superiority. Attention to suppression of hostile fire may minimize the risk of
injury to personnel and minimize additional injury to previously injured
soldiers. The best offense on the battlefield is tactical fire superiority. There is
little time available to provide care while under enemy fire and it may be
more important to suppress enemy fire than stopping to care for casualties.
The tactical situation will dictate when and how much care you can provide.
Finally, when a medical evacuation (MEDEVAC) is requested, the tactical
situation may not safely allow the air asset to respond.
b. Personnel may need to assist in returning fire instead of stopping to
care for casualties. This may include wounded soldiers that are still able to
fight.
c. Wounded soldiers who are unable to fight and who are exposed to
enemy fire should move as quickly as possible to any nearby cover. If no
cover is available or the wounded soldier cannot move to cover, he should lie
flat and motionless (play dead).
d. Figure 1-1 depicts a tragic situation. A wounded Marine is down in the
street. A colleague attempts to come to his rescue along with a second
Marine. Enemy fire continues in the area and the first rescuer is critically
wounded. The second rescuer returns behind cover. Eventually, after enemy
fire is contained, the first wounded Marine is rescued and the initial rescuer
is permanently disabled. The point is, when under enemy fire, we cannot
afford to rush blindly into a danger area to rescue a fallen comrade. If we do,
there may be additional soldiers wounded or killed attempting to rescue our
wounded.
Figure 1-1. Soldier and rescuers wounded.
e. Medical personnel are limited and, if they are injured, no other medical
personnel will be available until the time of evacuation during the
CASEVAC phase.
f. No immediate management of the airway is necessary at this time due
to the limited time available while under enemy fire and during the
movement of the casualty to cover. Airway problems typically play a
minimal role in combat casualties. Wounding data from Viet Nam indicates
airway problems were present in only about one percent of combat
casualties, mostly from maxillofacial injuries.
g. The control of hemorrhage (major bleeding) is important since injury
to a major vessel can result in hypovolemic shock in a short time frame.
Extremity hemorrhage is the leading cause of preventable combat death.
NOTE: Over 2,500 deaths occurred in Viet Nam secondary to hemorrhage
from extremity wounds; these casualties had no other injuries.
h. The use of temporary tourniquets to stop the bleeding is essential in
these types of casualties. If the casualty needs to be moved, as is usually the
case, a tourniquet is the most reasonable initial choice to stop major
bleeding. Ischemic damage to the limb is rare if the tourniquet is left in place
for less than one hour (tourniquets are often left in place for several hours
during surgical procedures). In addition, the use of a temporary tourniquet
may allow the injured soldier to continue to fight. Both the casualty and the
soldier medic are in grave danger while applying the tourniquet and non-
life-threatening bleeding should be ignored until the tactical field care
phase.
i. The need for immediate access to a tourniquet in such situations makes
it clear that all soldiers on combat missions have a suitable tourniquet, such
as the Combat Application Tourniquet (CAT) shown in figure 1-2, readily
available at a standard location on their battle gear and that soldiers be
trained in its use.
Figure 1-2. The Combat Application Tourniquet (CAT).
j. Penetrating neck injuries do not require cervical spine (C-spine)
immobilization. Other neck injuries, such as falls over 15 feet, fast roping
injuries, or motor vehicle collisions (MVC), may require C-spine
immobilization unless the danger of hostile fire constitutes a greater threat
in the judgment of the soldier medic. Studies have shown that, with
penetrating neck injuries being only 1.4 percent of the injured, few would
have benefited from C-spine immobilization. Adjustable rigid cervical colors
(C-collars) should be carried in the soldier medic’s medical aid bag. If rigid
C-collars are not available, a SAM splint from the aid bag can be used as a
field expedient C-collar.
k. Litters may not be available for movement of casualties.
(1) Consider alternate methods to move casualties, such as ponchos,
pole-less litters, SKEDCO or Talon II litters, discarded doors, dragging, or
manual carries).
(2) Smoke, CS (2-chlorobenzalmalononitrile, a type of riot control gas),
and vehicles may act as screens to assist in casualty movement.
l. Do not attempt to salvage a casualty’s rucksack unless it contains items
critical to the mission. Take the casualty’s weapon and ammunition, if
possible, to prevent the enemy from using them against you.
m. Key points.
(1) Return fire as directed or required.
(2) The casualty should also return fire if able.
(3) Direct the casualty to cover and apply self-aid, if able.
(4) Try to keep the casualty from sustaining any additional wounds.
(5) Airway management is generally best deferred until the tactical
field care phase.
(6) Stop any life-threatening hemorrhage with a tourniquet or a
HemCon™ Bandage, if applicable.
1-4. TACTICAL FIELD CARE
The "tactical field care" phase is distinguished from the "care under fire"
phase by having more time available to provide care and a reduced level of
hazard from hostile fire.
a. The time available to render care may be quite variable. In some cases,
tactical field care may consist of rapid treatment of wounds with the
