We are continuing to cover the TCCC “MARCH” Field Care. Yesterday, we covered the “M” representing Massive Hemorrhage. Today, we’ll continue with the A-R-C-H portions and more details to conclude the Tactical Combat Casualty Care Lessons.
AIRWAY
Head tilt/chin lift and jaw thrust are still recommended, as are nasopharyngeal airway (NPA) use. NPAs are preferred over OPA’s (nose vs mouth), because they do not stimulate a gag reflex. I like NPAs because they are a bit more forgiving when it comes to size (nose to ear!) in that fewer sizes fit a wider range of people, and they provide a quick and dirty responsiveness scale. If the patient accepts an NPA without a blink, that is usually not a good sign. A recent change in the airway guidelines has also been to allow a patient with facial trauma (think about a jaw shot off or other injury) to maintain their own airway, if possible, by sitting up and leaning forward. Two soldiers with facial trauma died from blood asphyxiation during drug-assisted intubation attempts after being laid down, and in both instances, they had been able to maintain an airway while leaning forward and sitting up. Don’t fight gravity if you do not have to.
Surgical crics. Even on a loved one, what is the highest level of care you are capable of delivering after the cric? I’m not advocating against learning all you can, but realize the limitations of a SHTF world, and accept the fact that death may be a blessing in some cases.
RESPIRATION
Tension Pnuemothorax-
Any penetrating chest trauma has the potential to cause a pneumothorax. This is when air is inside of the chest but outside of the lung. Air follows the path of least resistance. Respiration is a passive process, in that when the diaphragm retracts, it creates negative pressure in the lungs. This negative pressure pulls air into the lungs. If air has another way into your chest besides through your mouth, it will follow the path of least resistance and take it. If enough air pressure builds up inside of the chest cavity, it can create a tension pneumothorax, where the pressure collapses the lung and inhibits blood flow in the heart, causing death.
An occlusive dressing is an airtight dressing that is placed over a wound to keep any further air from getting in. If you suspect that a pnuemo could develop, use an occlusive dressing. A lot of higher abdominal wounds have the potential to cause a pnuemo, especially if the angle is right, so if the chance is there, be safe and use one. There are commercially available occlusive dressings. I like the Halo chest seals. They come in a resealable Ziploc style pouch, and they come with two in a pouch for entry and exit wounds. They have had no trouble sticking to any chest wounds I have dealt with, assuming you can wipe off the majority of the blood and sweat. Every manufacturer makes one. HyFins are popular as well. Some, like the Asherman Chest seal, come with a built in valve with the idea that it will let any trapped air out, reducing the pressure. However, this valve does not work 100% of the time. Expedient occlusive dressings can also be used. We have used the wrapper on a SWAT-T over the wound and then used the SWAT-T to hold it on. I have heard of IV bag wrappers being used after being taped on, as well as saran wrap being wrapped around a patient. AED pads have been used with very good success, as well.
I am a huge believer in thinking on your feet in a pinch. I am also a huge believer in being prepared. A chest seal is $10 or so. They are worth it. In the second you need one, it is much easier knowing you can go to your IFAK and grab one, instead of having to think of how to construct one. There will be other things to be doing instead of trying to unroll the folded up length of duct tape you have in order to tape something on. A few seals, like the H and H, are semi rolled up. Most other ones are flat, and they can be a problem to carry. I carry my seals in my vest carrier under the panel. It keeps them flat and accessible. There really is no training on occlusive dressings. It’s like putting on a big sticker, but I would encourage you to buy an extra and play with it. Become familiar with it.
In addition to penetrating trauma, chest trauma of any type can cause a pneumo. If anyone with chest trauma, such as a broken rib, is having difficulty breathing, be alert for a pneumo.
The field solution to a tension pneumothorax is a needle decompression. Needle decompression is not covered under any good Samaritan laws and is being presented as a informational study only. So when do you do it? In addition to overall patient deterioration, you will notice lung sounds are greatly diminished or absent on the injury side, as well as a drop in oxygen saturation. This means a lung has collapsed or is in the process of collapsing. (You do have a pulse oximeter and a stethoscope, right?) Do not wait for tracheal tug to alert you to the presence of a tension pneumo, or it may be too late.
There are two locations for needle insertion. First, the needle goes on the injury side. The first location is the second intercostal space, along the midclavicular line. Feel for the middle of your collar bone. Go down to the space between your first and second rib. This is the first intercostal space. Feel and go over the second rib, to between the second and third rib. This is the target. You want to be equal/lateral to the nipple, and angled slightly down on insertion (roughly aimed for the bottom of the shoulder blade) but not towards the heart. You may or may not hear air escape, depending on how loud things are. Another acceptable location is the 4th or 5th intercostal space at the anterior axillary line. (Nurses will recognize this as the location for a chest tube, which is another skill to cross train on.) This is roughly where a vertical line at the front of the armpit and a horizontal line at male nipple level intersect. There are nerves and blood vessels that run on the bottom of each rib. The goal is to skim the needle over the top of the rib. If you strike a rib during insertion, adjust the angle up slightly and try again. Sometimes you can do this without removing the needle fully. Insert as far as it will go. After insertion is made, pull out the needle and leave the catheter. If you have to insert a second or third needle, go right next to the first. A quick and dirty method to get you real close to the first insertion location is to form a ”C” with your hand, and hook the collar bone with your thumb. Your index finger will land pretty close to the second intercostal space.
So what needle do you use? The military did a study of chest wall thickness and found that a 3.25” needle will cover 99% of people. Most companies make a 14 gauge 3.25” needle for this purpose. You can find them for around $11-12, if you shop around. These have a stiffer catheter that is more kink resistant than a normal IV. If all you have are standard IV needles, choose the biggest (gauge and length) that you have and use the secondary location on the anterior axillary line. Length is more important than gauge, if you have to choose. (A 2” 18 gauge is preferred over a 1.25” 14 gauge.)
Needle decompression is scary the first time you do it. The needle is huge. Realize that the person will die if you don’t, and most people will thank you after you do save them. Also, if for some freak chance you were wrong, and they didn’t have a tension pneumo, all you did was cause a minor pneumo that will hurt a little but won’t kill anyone.
So, how do you train for this? We honestly use baby back ribs, with a layer of flank steak over them. We got this idea from a CE at the hospital. The flank steak approximates the chest tissue, so the ribs take a little work to feel beneath, like a real person’s upper chest. It is very similar, and it provides realistic resistance. While you are at it, try intentionally striking a rib, and walking the needle up and over so you are familiar with this. Use a large gauge needle for this, but don’t waste the expensive ones.
CIRCULATION
TCCC takes a slightly different approach to this than most are used to.
CPR– CPR is not part of TCCC, nor should it be. Realize that there are two basic types of cardiac arrest. The first is sometimes called a witnessed cardiac event. Uncle Joe grabs his chest and suddenly falls over. There are multiple causes for this, but the most easily fixable one is a dysrhythmia. Imagine the heart quivering, instead of beating. CPR is started, and blood is circulated long enough to maintain perfusion until an AED or defibrillator gets on the scene, at which point the heart is shocked and the rhythm converts and Uncle Joe is saved. The second type of arrest is a trauma arrest. This is when the heart stops beating because of some external factor that caused it, whether hypovolemia, a bullet in the ventricle, or something else. All of the CPR and shocks on scene will never fix this, because it is not a problem with the heart. Even if this happened on the operating room floor, the outlook is very grim. Field survival rates are virtually nil. TCCC does not advocate wasting energy or risking the mission or further lives to try to save someone who is unsavable.
As a side note, you may want to consider an AED as a group purchase for your retreat.
The circulation intervention for TCCC is IV fluids for prevention of shock. All parties that are injured should be pre-emptively treated for shock. Prevention is much easier and has higher survival rates than waiting to treat. If you wait for dropping blood pressure, it is too late. Altered mental status or tachycardia is often the first clue. The person may be able to answer everything, but responses may be delayed. It could be repetitive questioning. Be alert for minor changes.
TC3 is geared for a small squad unit with limited supplies. This is very appropriate for a SHTF world with no restock. If someone is alert and able to drink fluids by mouth, let them. Don’t waste an IV bag if you don’t have to. On that same note, consider stocking 2x500ml bags vs 1x1000ml bags. During the past year there was a nationwide IV fluid shortage. We were able to still get 500ml bags, so most of our patients got treated with these and saline locks, which is pretty much a temporary port for medication or fluids as needed. There were no issues with this.
There is new update called a ”ruggedized IV.” This is a saline lock that is attached to a standard IV catheter. This is then covered with a large tegaderm dressing. The port is secure and sterile but can be accessed directly through the dressing if it is needed in a hurry. If meds are needed, the needle of the syringe can go directly into the port. If IV fluids are needed, a new needle and catheter are inserted, and the needle is removed, leaving the catheter in place through the dressing and into the port. If you have a casualty who is able to take fluids by mouth, let him, but start a ruggedized IV and establish venous access now, in case it is needed later. In tests, fluid administration was delayed using this set up. In a standard IV set up, a 500 ml bolus took 10 minutes to give. Through the ruggedized IV set up, it took 15 minutes. Using a pressure bag brought the ruggedized IV time down to 12 minutes. If you do not have a pressure bag, a BP cuff or someone squeezing the bag will have the same effect.
Administer fluid boluses as needed to maintain radial pulses. Permissive hypertension may be something to think about, depending on what resources you have available. I suggest you read up on it. It’s worth a separate article, but it’s basically allowing low blood pressure rather than bolusing to get it high at risk of blowing out any clots.
HYPOTHERMIA/HEAD INJURY
Like blood, heat is easier to maintain than replace. All casualties need to be kept warm. Survival blankets are often called casualty blankets for this reason. The body has a fairly narrow range for operating temperature and pH. If either gets too far out of homeostasis, key body processes (like blood clotting factors) may not work. Pre-emptively treat, in this case. If someone gets shot, put them in a blanket and a beanie hat until they get to higher care. You do not want to be behind “the 8 ball” with treating hypothermia and shock. If you live in a cold area, consider keeping heating pads or hand warmers with you. The other ways to treat for shock are to elevate the feet and provide oxygen (along with fluids, as stated above). For head injuries (altered mental status with no signs or mechanism of shock), you need to keep their blood pressure above 90 to maintain brain perfusion and keep oxygen saturation above 90%, as well. This will not undo a brain injury, but it will prevent secondary injury to the brain.
The last aspect of TCCC is medevac or casualty evacuation. Something to work on in this realm is to get geared up, then try to drag and carry each other around. It is not easy. When you are familiar with it, try dragging someone as they or you are shooting. Be sure to remember all of your gun safety; a few dry fire runs should be done first. A couple of points to consider: Drag straps on most vests are nothing more than carrying handles. They rip. Do not rely on them. In a pinch, grabbing the strapping over a shoulder is going to be sturdier. We pre-load a length of rope through the back of our vests, if we think it may be needed. It is thick rope, with a loop on one end and a carabiner on the other, and it’s about 48” long. It can be figure-eighted around arms and shoulders, left in place to disperse the load to the entire back of the vest, or slip knotted around someone’s feet and clipped to your vest. Have some method in place that you have trained on to get someone out of somewhere in a hurry. Be sure to check interventions (tourniquets, dressings, and so forth) after moving someone, as they can come loose or come off.
We have also used casualty bags as lifters/carriers in a pinch as well, and although they’re uncouth they do work.
OTHER ITEMS
One of the most difficult bleeds to control is a high hip arterial bleed. You cannot tourniquet at this location, and it is hard to manually apply enough pressure with the artery at the depth it is. The military solution to this is the CROC clamp that some medics carry. This is pretty much a folding C-clamp, with a flat board for under the buttocks of the victim and a rubber ball at the business end of the clamp. The ball is placed above the site where pressure is wanted, and it is screwed down until the desired effect is reached. It is very difficult to move a patient with this on, as you are pretty much limited to using a backboard to a helicopter and that’s it. We have played around with grip-tightened wood clamps– the quick release ones that clamp down as you pull the trigger– with some success . It worked to occlude blood flow, but it did not stay on well, and we had to modify the clamp ends. Also, do you have a surgical option to fix this injury?
The IFAK contains a rigid eye shield. With eye injuries, pressure is the enemy. You cannot put eye jelly back in. Pressure dressings can squeeze fluid from the eye, making the injury worse. A pressure dressing can also adhere to the eye, causing more damage upon removal. Even a bandage wrapped loosely can cause unsafe pressures. The eye shield is designed to protect the eye without putting pressure on it. One company makes a multipurpose pressure dressing where part of the pressure bar is removable for use as a rigid eye shield. If you can, cover both eyes. Eye movement is reciprocal, so whatever the good eye does, the injured eye does as well. With eyes, prevention truly is the best medicine. Wear protective eyewear anytime you think you may need them. Look up some of the pictures of IED victims where the outline of where their glasses were is all that is intact. The thought of losing sight post-SHTF is pretty horrendous.
The current antibiotic in the IFAK is 400 mg of moxifloxacin. This is a broad spectrum antibiotic. It should be taken ASAP after any penetrating injury with the potential for infection. Moxifloxacin has some mixed side effects. It is not available as a fish antibiotic. It is a member of the Quinolone family of antibiotics. Cipro is part of the quinolone family as well, and is available in a fish form (Fish Flox, or Fish Flox Forte). I am not specifically advocating either, but I am providing a starting point for your own research. Since infection is going to be a killer, I recommend carrying some antibiotic to be taken prophylactically. There is a large inverse correlation between severity of infection and post injury time of first dose.