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Tactical Combat Casualty Care

Operational medicine overview

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Operational medicine overview

Tactical Combat Casualty Care


Operational Emergency Medical Skills Course Manual, LTC (Ret) J. Hagmann, M.D., 2004

Tactical Combat Casualty Care, Committee on Tactical Combat Casualty Care, Government Printing Agency, Feb 2003

Tactical Combat Casualty Care in Special Operations, CPT Frank Butler, Jr., MC, USN; LTC John Hagmann, MC, USA; ENS George Butler, MC, USN, Military Medicine, Vol. 161, Supp 1, 1996

3 environments for care





Primarily deals with blunt trauma

Access to full range of specialist Physicians

Resource intensive

Advanced trauma care facilities, Intensive care units

ATLS procedures

Pre-surgical evaluation with access to full labs, blood banks, etc.


Primarily deals with blunt trauma

Rapid response times

Well equipped and supported, utilizes EMT trained personnel

Advanced life support capabilities

Rapid transport and access to ambulances, helicopters, etc.

Short evacuation times (usually less than 1 hour away from hospital)

Strict medical control and use of protocols


Most significant difference between this and the above are evacuation times of greater than 1 hour

Primarily deals with penetrating trauma

Independent providers

Austere environments

Echeloned care

May have delayed initial medical access (scene safety important)

In most cases limited to what medic can carry in aid-bag

Often pre-injury stressor is present (e.g. dehydration, sleep deprivation, stress of mission)

Operational field care
3 distinct areas

Care under fire


Limited to what is carried by medic and soldiers

Care based on MARCH acronym

M – Massive Bleeding

A – Airway

R – Respirations

C – Circulation

H – Head

Tactical field care

More secure

More Resources … still resource limited

ABC’s and Rapid Trauma Assessment

IV’s and Fluid Resuscitation

Dressings, Splints and Meds

CPR – Resuscitation on the battlefield for victims of blast or penetrating trauma who have no pulse, no respirations, and no other signs of life will not be successful and should not be attempted.

C-spine precautions

C-spine control: even with the neck supported in a C-collar, you do not prevent all neck injury

For penetrating trauma, C-spine control is unnecessary (blunt trauma tears vertebral ligaments requiring support). Penetrating injury blasts away ligaments, so if there is penetrating trauma then you already have C-spine trauma

Value – no one has shown conclusively that C-spine control can reduce the number of people who become paralyzed. For example, in Austria, an EMS system was established in the 1980’s using C-spine control but no differences were detected in numbers of patients who developed paralysis before and after introduction (does not mean it isn’t there).

C-spine control tends to be very resource intensive (manpower and medical management) that we do not use it except for very specific injuries where you think that there is a C-spine injury.

Standard medical procedures have been developed for the treatment of patients in the traditional pre-hospital and hospital environments where evacuations are usually achieved in less than 1 hour. These procedures are not always applicable to your work environment.


Mortality curve

Following trauma, the chances of a casualty surviving are dependant upon numerous variables, including the speed at which appropriate medical treatment is administered. During this discussion, we will look at the factors that can affect the chances of a casualty surviving as injury symptoms developing from initial penetrating trauma, through hemorrhage and/or respiratory compromise, to shock and infection.

Mortality curve
penetrating trauma

Lifesaving Measures

Hemorrhage Control

Airway management


Hemorrhage control

Tourniquet vs. Field Dressing

Alternate Means


Hemcon Dressing

Fibrin Bandage

Airway management

Resource Intensive methods v. Less intensive methods

Allow patient to sit up and manage own airway

O2 delivery

Naso v. Oral

Surgical Cricothyroidotomy v. Intubation

Needle Cric


Shock is initially a physiological protection response that occurs in response to injury

Not a state your body slowly goes into because of injury






Operational Environment is different from civilian pre-hospital environment.

Know your mission profile and understand your resources.

Right intervention at the Right time.

Regardless of Echelon assigned to… we ALL are Echelon I medics!


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