Tactical Medicine: Procedures

The Three Rules

1. Scene Safety - Do not become the next casualty. Check for hazards (traffic, fire, downed power lines, attackers)
2. Call for Help - Dial 911 (or local emergency) immediately. Put on speaker if alone
3. Stop the Bleeding - Most preventable deaths are from blood loss. Apply pressure

Initial Assessment (30 Seconds)

1. Are they conscious? Tap shoulder, ask "Are you okay?"
2. Are they breathing? Look at chest, listen, feel for breath
3. Are they bleeding? Look for blood - check under clothes, under body

What to Say to 911

1. Your location (address, landmarks, what you see)
2. What happened (car accident, fall, gunshot, etc.)
3. How many people are injured
4. Are they breathing? Conscious? Bleeding?
5. Your name and phone number

Stay on the line. The dispatcher will guide you.

Stop the Bleed - Three Steps

1. CALL 911 - Get help coming
2. FIND the bleeding - Remove/cut clothing to expose wound
3. STOP the bleeding - Use one of three methods below

Method 1: Direct Pressure

For most wounds:

1. Place clean cloth, gauze, or your bare hand directly on wound
2. Push HARD with both hands - it should hurt them
3. Hold pressure continuously for 10 minutes minimum
4. Do NOT lift to check - you break the clot forming
5. If blood soaks through, add more material ON TOP (do not remove)

Method 2: Wound Packing

For deep wounds (stab, gunshot, severe laceration):

1. Stuff clean cloth or gauze INTO the wound
2. Pack it tight - push material to the bottom of wound first
3. Keep packing until wound is completely full
4. Apply direct pressure on top
5. Hold for 3 minutes minimum

Method 3: Tourniquet

For life-threatening limb bleeding that won't stop:

1. Place 2-3 inches ABOVE the wound (between wound and heart)
2. Wrap tight and secure
3. Twist windlass/stick until bleeding STOPS
4. Secure the windlass in place
5. Note the time - write on patient's forehead if needed

Where NOT to Use Tourniquet

• Neck (use direct pressure only)
• Torso/chest/abdomen (pack wound, apply pressure)
• Groin/armpit (pack wound deeply, apply pressure)

Basic Wound Care Steps

1. Stop bleeding first (if any)
2. Wash your hands or use gloves if available
3. Clean the wound with clean water - flush thoroughly
4. Remove debris gently with clean tweezers if visible
5. Apply antibiotic ointment (optional but helps)
6. Cover with clean bandage

Cleaning Solutions (Best to Worst)

1. Sterile saline or wound wash
2. Clean drinking water (bottled preferred)
3. Tap water (if clean source)
4. Boiled and cooled water
5. Diluted povidone-iodine (Betadine)

Signs of Infection (Watch For)

• Increasing pain after 24 hours
• Redness spreading beyond wound edge
• Warmth and swelling increasing
• Pus or foul-smelling drainage
• Red streaks moving toward heart
• Fever

Any of these = seek medical care immediately.

Sutures/Stitches - When Needed

Seek professional closure if:

• Wound edges won't stay together
• Cut is >1/2 inch deep
• Cut is on face, hands, or over a joint
• Wound is gaping open
• Bleeding won't stop with pressure

Time limit: Stitches work best within 6-8 hours of injury. After 24 hours, most wounds are left open to heal.

Butterfly Strips (Improvised Closure)

1. Clean and dry wound completely
2. Apply benzoin or let skin dry (helps adhesive stick)
3. Place strip on one side of wound, pull edges together, secure other side
4. Space strips 1/4 inch apart
5. Apply strips perpendicular to wound direction

Improvised: Medical tape cut into strips works if nothing else available

Burn Severity

Immediate Burn Care

1. Stop the burning - Remove from heat source, remove hot clothing
2. Cool with water - Run cool (not ice cold) water for 10-20 minutes
3. Remove jewelry - Rings, watches, bracelets before swelling
4. Cover loosely - Clean, dry bandage or cling wrap
5. Pain relief - Ibuprofen or acetaminophen

When to Seek Emergency Care

• Burns larger than palm of hand
• Burns on face, hands, feet, genitals, or over joints
• All electrical burns (damage is internal)
• Chemical burns
• Burns that go all around a limb
• Burns in someone under 5 or over 60
• Difficulty breathing (airway burns)

Chemical Burns

1. Brush off dry chemicals first (before water)
2. Flush with large amounts of water for 20+ minutes
3. Remove contaminated clothing while flushing
4. Continue flushing during transport if possible

Eye exposure: Flush from inner corner outward. Hold eyelids open. Flush for 20+ minutes.

Signs of Fracture

• Pain that increases with movement
• Swelling and bruising
• Deformity (looks wrong compared to other side)
• Unable to bear weight or use limb
• Grinding sensation
• Bone visible through skin (open fracture - emergency)

Basic Splinting Principles

1. Immobilize the joint above AND below the injury
2. Pad bony areas to prevent pressure sores
3. Check circulation before and after - pulse, color, sensation
4. Elevate if possible to reduce swelling
5. Apply ice wrapped in cloth (20 min on, 20 min off)

Improvised Splints

• Arm: Magazines, newspapers, boards, cardboard rolled
• Leg: Boards, ski poles, hiking sticks, another person's leg
• Finger: Popsicle stick, pen, tape to adjacent finger
• Sling: Belt, scarf, shirt tied behind neck

Binding: Torn cloth strips, belts, rope, tape, shoe laces

RICE for Sprains

• Rest - Stop using the injured area
• Ice - 20 minutes on, 20 minutes off
• Compression - Elastic bandage, wrap snug (not tight)
• Elevation - Raise above heart level when possible

Suspected Spine Injury

If mechanism suggests spine injury (fall, dive, car accident):

1. DO NOT MOVE unless immediate danger (fire, collapse)
2. Tell patient not to move their head or neck
3. Place hands on both sides of head to stabilize
4. Keep head, neck, and spine in line
5. Wait for professional help with proper equipment

Hands-Only CPR (Adults)

1. Call 911 (speaker phone)
2. Place heel of hand on center of chest (between nipples)
3. Place other hand on top, fingers interlaced
4. Keep arms straight, shoulders over hands
5. Push HARD - at least 2 inches deep
6. Push FAST - 100-120 compressions per minute (beat of "Stayin' Alive")
7. Let chest fully recoil between compressions
8. Do not stop until help arrives or patient responds

Using an AED

1. Turn on AED (it will give voice instructions)
2. Expose chest completely (dry if wet)
3. Apply pads as shown in pictures on pads
4. Plug in connector if needed
5. "Analyzing" - DO NOT TOUCH patient
6. If shock advised - "Clear!" - push button
7. Immediately resume CPR for 2 minutes
8. Follow AED prompts

Choking - Conscious Adult

If person CAN cough, speak, or breathe: Encourage coughing, do not intervene

If person CANNOT cough, speak, or breathe:

1. Stand behind person, wrap arms around waist
2. Make fist with one hand, place above navel, below ribs
3. Grab fist with other hand
4. Pull sharply inward and upward (J-shaped motion)
5. Repeat until object comes out or person becomes unconscious

Choking - Unconscious Adult

1. Lower person to ground on their back
2. Call 911 if not done
3. Start CPR
4. Before giving breaths, look in mouth for object
5. If visible, sweep out with finger
6. Continue CPR

Choking - Infant (Under 1 Year)

1. Place baby face-down on forearm, head lower than body
2. Support head with hand (jaw, not throat)
3. Give 5 firm back blows between shoulder blades
4. Turn baby face-up on other forearm
5. Give 5 chest thrusts with 2 fingers on breastbone
6. Alternate back blows and chest thrusts until clear

Heat Exhaustion

Signs: Heavy sweating, weakness, cool/pale/clammy skin, fast/weak pulse, nausea, fainting

Treatment:

1. Move to cool area (shade, AC)
2. Lie down, elevate legs
3. Remove excess clothing
4. Apply cool, wet cloths
5. Sip water slowly
6. If vomiting or no improvement in 30 min: call 911

Heat Stroke (EMERGENCY)

Signs: High temp (>103°F), hot/red/dry OR damp skin, fast/strong pulse, confusion, unconsciousness

While waiting:

1. Move to coolest area possible
2. Cool rapidly: cold water immersion is best
3. Or: ice packs to neck, armpits, groin
4. Spray with water and fan
5. Do NOT give fluids if unconscious

Hypothermia

Signs: Shivering (stops in severe cases), confusion, slurred speech, drowsiness, weak pulse, slow breathing

Treatment:

1. Move to warm area
2. Remove wet clothing
3. Warm center of body first (chest, neck, head, groin)
4. Use skin-to-skin contact under blankets
5. Give warm drinks if conscious (no alcohol)
6. Handle gently - sudden movement can cause cardiac arrest

Frostbite

Signs: White/grayish-yellow skin, waxy feel, numbness, hard or waxy texture

Treatment:

1. Get to warm area
2. Do NOT rub or massage
3. Immerse in warm (not hot) water (100-105°F)
4. Do NOT use dry heat
5. Do NOT walk on frostbitten feet unless necessary
6. Loosely bandage with dry, sterile dressing
7. Seek medical care

Mild Allergic Reaction

Signs: Hives, itching, mild swelling, runny nose

Treatment:

• Remove allergen if possible (stinger, food)
• Antihistamine (Benadryl/diphenhydramine 25-50mg)
• Monitor for worsening

Anaphylaxis (SEVERE - EMERGENCY)

Signs:

• Difficulty breathing, wheezing
• Swelling of throat, tongue, lips
• Widespread hives
• Dizziness, confusion
• Rapid or weak pulse
• Nausea, vomiting
• Feeling of doom

Using an EpiPen

1. Call 911
2. Remove blue safety cap
3. Hold orange tip against outer thigh (through clothes is OK)
4. Push firmly until click
5. Hold for 10 seconds
6. Remove and massage area
7. Note time given
8. Second dose in 5-15 min if no improvement
9. Lay person down, elevate legs (unless breathing trouble)

Bee/Wasp Stings

1. Remove stinger immediately (scrape, don't squeeze)
2. Wash with soap and water
3. Apply cold pack
4. Take antihistamine for itching
5. Watch for signs of anaphylaxis for 30+ minutes

First Steps for Poisoning

1. Call Poison Control: 1-800-222-1222 (US)
2. Identify what was taken, how much, and when
3. Save container/substance if possible
4. Do NOT induce vomiting unless instructed
5. Do NOT give anything by mouth unless instructed

Signs of Poisoning

• Burns or redness around mouth/lips
• Breath smells chemical
• Vomiting, nausea, abdominal pain
• Difficulty breathing
• Confusion, drowsiness
• Seizures
• Open containers nearby

Opioid Overdose

Signs: Pinpoint pupils, unconscious, slow/shallow/no breathing, blue lips

1. Call 911
2. Give Narcan (Naloxone) if available: Nasal: spray one nostril; Inject: IM into outer thigh
3. If no response in 2-3 min, give second dose
4. Start CPR if not breathing
5. Place in recovery position when breathing
6. Stay with them - Narcan wears off

Inhaled Poison (Gas, Fumes)

1. Get to fresh air immediately
2. Open windows/doors if safe
3. Do NOT enter area if you smell gas/fumes
4. Call 911
5. Begin CPR if not breathing

Skin Exposure

1. Remove contaminated clothing carefully
2. Brush off dry chemicals before water
3. Flush skin with large amounts of water for 20+ min
4. Wash gently with soap and water
5. Call Poison Control

Care Under Fire Priorities

1. Return fire and take cover
2. Direct or expect casualty to remain engaged as combatant if appropriate
3. Direct casualty to move to cover and apply self-aid if able
4. Try to keep casualty from sustaining additional wounds
5. Stop life-threatening external hemorrhage if tactically feasible

CUF Assessment

Tactical patient assessment during CUF is limited to:

• Rapid head-to-toe survey (10-15 seconds or as tactically feasible)
• Identifying life-threatening hemorrhage only
• Airway management (other than positioning) deferred to TFC

M - Massive Hemorrhage

CUF Hemorrhage Actions

1. Direct casualty to control hemorrhage by self-aid if able
2. Use a CoTCCC-recommended limb tourniquet
3. Apply tourniquet "High and Tight" (as proximal as possible)
4. Move the casualty to cover

CoTCCC Recommended Tourniquets

Extrication

Casualties should be extricated from:

• Burning vehicles or buildings
• Areas of continued hostile fire
• Hazardous environments (water, chemical, collapse)

Do what is necessary to stop the burning process.

Movement Methods

• Fastest: Dragging along the long axis of patient's body (2 rescuers)
• Hasty: Fireman's carry, pack-strap carry
• Equipment: SKEDCO, litter, poncho

Is the casualty conscious? YES: Direct to move to cover and self-aid. NO: Move casualty to cover if tactically feasible.

• M - Massive Hemorrhage
• A - Airway
• R - Respiration
• C - Circulation
• H - Hypothermia/Head

Then PAWS

• P - Pain management
• A - Antibiotics
• W - Wounds (inspect and dress)
• S - Splinting

Initial TFC Actions

1. Establish security perimeter IAW tactical SOPs
2. Consolidate casualties in CCP
3. Conduct triage to identify priority
4. Casualties with altered mental status: disarm, secure weapons and comms
5. Delegate minor injuries to RFRs/ARFRs
6. Communicate casualty status and MEDEVAC requirements to C2

M - Hemorrhage Control

1. Assess for unrecognized hemorrhage and control all life-threatening bleeding
2. Expose wound to assess tourniquet necessity
3. Apply CoTCCC-recommended limb tourniquet if indicated
4. Use hemostatic dressing for compressible hemorrhage not amenable to tourniquet
5. Apply junctional tourniquet for groin/axilla bleeding

Tourniquet Reassessment

• Expose wound - determine if TQ still needed
• If bleeding not controlled: tighten TQ or add second side-by-side
• Mark time of application on TQ and casualty card

Hemostatic Dressings

Junctional Hemorrhage

For groin, axilla, or neck bleeding not amenable to limb tourniquet:

• Combat Ready Clamp (CRoC) - NSN 6515-01-589-9135
• SAM Junctional Tourniquet - NSN 6515-01-618-7475
• JETT - NSN 6515-01-616-5841

Pelvic Binder

Apply for suspected pelvic fracture with:

• Pelvic pain or instability
• Major lower limb amputation/near amputation
• Unconsciousness or shock with pelvic MOI

A - Airway Management

Conscious patient talking normally = airway intact.

Unconscious patient: tongue is most common obstruction.

Unconscious WITHOUT Obstruction

1. Chin lift or jaw thrust maneuver
2. Nasopharyngeal airway (NPA)
3. Place in recovery position

Airway Obstruction or Impending

1. Allow conscious casualty to assume position that protects airway
2. Chin lift or jaw thrust
3. NPA (contraindicated in suspected basilar skull fracture)
4. Suction if available
5. Place unconscious casualty in recovery position

NPA Sizing

• Measure: tip of nose to earlobe
• Common adult sizes: 28F (7.0mm), 32F (8.0mm)
• Lubricate and insert bevel toward septum

Recovery Position

1. Roll casualty onto side (injured side down if possible)
2. Flex upper knee for stability
3. Position upper arm to support head
4. Allows drainage, prevents aspiration

R - Respiration

Progressive respiratory distress + known/suspected torso trauma = consider tension pneumothorax

Tension Pneumothorax Signs

• Difficulty/worsening breathing after chest/abdominal injury
• Decreased SpO2
• Decreased breath sounds on affected side
• Tracheal deviation (late sign)
• JVD (late sign)
• Cyanosis

Needle Chest Decompression

Ensure NOT medial to nipple line and NOT directed toward heart.

Open/Sucking Chest Wound

1. Apply vented chest seal (HyFin, SAM, Bolin)
2. If no vented seal: apply non-vented and monitor closely
3. If breathing worsens: burp seal or perform NCD

C - Circulation

Shock Indicators (Field Assessment):

• Altered mental status (without TBI)
• Weak or absent radial pulse
• Capillary refill >2 seconds
• Cold, pale, clammy skin

Pulse Pressure Estimation

IV/IO Access

• Start 18-gauge IV or saline lock
• If IV not obtainable: use IO (humerus preferred)
• Do NOT delay evacuation for IV access unless lifesaving

TXA (Tranexamic Acid)

Criteria: Hemorrhagic shock, amputations, penetrating torso, severe bleeding, pelvic fracture

Fluid Resuscitation Priority

1. Whole Blood (warmed) - Preferred
2. 1:1:1 Components (Plasma:RBCs:Platelets)
3. LTOWB / ROLO
4. Freeze-Dried Plasma
5. Hextend 500ml bolus
6. Lactated Ringers / Plasma-Lyte A

H - Hypothermia Prevention

Prevention Measures

• Minimize environmental exposure
• Keep protective equipment on if feasible
• Replace wet clothing
• Get casualty onto insulated surface ASAP
• Use HPMK (Hypothermia Prevention Management Kit)
• If unavailable: dry blankets, poncho liner, sleeping bag
• Warm IV fluids preferred

HPMK Components

• Ready-Heat Blanket (apply to torso, NOT directly on skin)
• Heat-Reflective Shell (HRS)
• Self-heating fluid warmer

Head Injury / TBI

• Maintain SBP >90 mmHg (target >110 mmHg)
• Maintain SpO2 >90%
• Prevent hypothermia
• Elevate head 30° if no spinal concern
• Document GCS/AVPU

P - Pain Management

Mild-Moderate (able to fight):

Moderate-Severe (NOT in shock):

Moderate-Severe (IN shock):

See Pharmacology App for details

A - Antibiotics

Recommended for ALL open combat wounds.

W - Wounds

• Inspect and dress all known wounds
• Full body sweep for additional wounds
• Document on casualty card

S - Splinting

• Splint fractures and dislocations
• Check pulses before and after splinting
• Pad bony prominences
• Immobilize joint above and below fracture

Burns

• Facial burns: aggressively monitor airway (edema risk)
• Estimate TBSA (Rule of Nines)
• Cover with dry, sterile dressings
• >20% TBSA: IV fluids per Rule of Ten

Tactical Force Actions

• Establish evacuation point security
• Stage casualties for evacuation
• Communicate patient status to TACEVAC personnel
• Consolidate medical supplies

SIT Report Method

1. Identify receiving care provider on evac platform
2. Establish direct contact (radio/eye/hand)
3. Provide SIT status (most serious first):

Casualty Documentation

• Complete DD Form 1380 (Tactical Combat Casualty Care Card)
• Document all interventions with times
• Document vital signs
• Attach to casualty (do not lose)

After Movement Reassessment

After every evacuation movement, reassess:

• Mental status (AVPU)
• Airway patency
• Vital signs
• All interventions (TQs, chest seals, airways, IVs)
• Bleeding control

DOPE Troubleshooting

For ventilation problems with advanced airway:

• D - Dislodgement: Check tube position
• O - Obstruction: Suction
• P - Pneumothorax: Consider NCD
• E - Equipment failure: Disconnect vent, use BVM

TBI Severity

TBI Management Goals

• SBP >110 mmHg
• SpO2 >90%
• Prevent hypothermia
• Elevate head 30° (if no spinal concern)
• PCO2 35-40 mmHg (if capnography)
• Document serial neuro exams

CPR May Be Attempted If:

• Casualty does NOT have obviously fatal wounds
• Quickly arriving at surgical capability
• Resources available and mission allows

Before Discontinuing Care

Casualties with torso/polytrauma and no pulse should receive:

• Bilateral needle decompression
• Assess for reversible causes

Equipment

• Scalpel (#20 or #10)
• Tracheal hook or bougie
• 6.0-7.0 cuffed ET tube or cric-specific tube
• 10cc syringe
• BVM
• Securing device/tape
• Antiseptic, gloves

Procedure

1. Position supine, head/neck midline
2. If conscious: Ketamine sedation, lidocaine to site
3. Identify cricothyroid membrane (soft depression below thyroid cartilage)
4. Stabilize larynx with non-dominant hand
5. Make VERTICAL skin incision (3-4cm)
6. Make HORIZONTAL incision through membrane
7. Insert tracheal hook on inferior border, apply anterior traction
8. Insert bougie or tube (6.0-7.0)
9. Inflate cuff (10cc)
10. Confirm placement (ETCO2, misting, auscultation, SpO2)
11. Secure tube
12. Ventilate: 1 breath every 6-8 seconds

Equipment

• 14G, 3.25" needle/catheter (minimum)
• Antiseptic

Site Selection

NOT medial to nipple line. NOT directed at heart.

Procedure

1. Select site based on injury pattern
2. Clean site
3. Insert needle perpendicular (90°) to chest wall
4. Advance over superior border of rib (avoid neurovascular bundle)
5. Puncture parietal pleura (may feel "pop")
6. Hold 5-10 seconds
7. Remove needle, leave catheter in place
8. Reassess patient

Effectiveness Check

• Improved breathing
• Increased SpO2
• Improved breath sounds
• Rush of air on insertion

If ineffective: Repeat at alternate site or consider finger thoracostomy.

Equipment

• Scalpel (#10)
• Kelly clamp / Peans forceps
• Chest tube (28-36 Fr) - optional
• Heimlich valve - if using tube
• Antiseptic, gloves, suture

Site

Procedure

1. Clean site, local anesthesia if time permits
2. 2-3cm horizontal incision parallel to ribs
3. Blunt dissect through tissue to pleura (over top of 6th rib)
4. Puncture pleura with clamp tip, spread
5. Insert finger to confirm entry and sweep for adhesions
6. FINGER THORACOSTOMY: Can stop here if no tube
7. If tube: insert with finger guidance, attach Heimlich valve
8. Secure with suture and occlusive dressing

Site Priority (Best Flow First)

Procedure (EZ-IO)

1. Clean site
2. Stabilize limb on flat surface
3. Insert at 90° with steady pressure
4. Stop when you feel "give" or "pop"
5. Remove stylet
6. Attach primed extension set
7. Aspirate (may get marrow)
8. Flush with 5-10ml NS
9. Lidocaine 40mg slow IO for pain (conscious patient)
10. Secure and infuse

Site Selection

• Antecubital fossa (AC)
• Forearm
• Dorsum of hand
• External jugular (EJ) - alternate

Procedure

1. Apply tourniquet proximal to site
2. Select vein (palpate, visible)
3. Clean site
4. Insert catheter at 15-30° angle, bevel up
5. Advance until flash
6. Lower angle, advance catheter
7. Remove needle
8. Release tourniquet
9. Attach saline lock or IV tubing
10. Flush with 5-10ml NS
11. Secure with Tegaderm

Application

1. Place 2-3" above wound (or high and tight if bleeding source unknown)
2. Pull strap tight
3. Turn windlass until bleeding stops
4. Lock windlass
5. Secure remaining strap
6. Mark time on TQ and casualty card

Verification

• Bleeding stopped
• Distal pulse absent
• If bleeding continues: tighten or add second TQ side-by-side

Conversion (TFC Phase)

Consider conversion if ALL criteria met:

• TQ in place <2 hours
• Casualty NOT in shock
• Can monitor wound closely
• NOT an amputation

Conversion Procedure:

1. Apply direct pressure / pressure dressing distal to TQ
2. Slowly release TQ
3. Monitor for bleeding x 2 minutes
4. If bleeding: reapply TQ immediately
5. If no bleeding: leave loosened TQ in place

9-Line MEDEVAC Request

Line 3 - Precedence

Line 4 - Special Equipment

• A: None
• B: Hoist
• C: Extraction equipment
• D: Ventilator

Line 5 - Type

• L: Litter
• A: Ambulatory

Line 6 - Security

• N: No enemy
• P: Possible enemy
• E: Enemy in area
• X: Armed escort required

MIST Report Format

Example

M: GSW to right thigh, 1423 hrs

I: Through-and-through right thigh, no bone involvement

S: A+Ox4, HR 98, BP 118/72, SpO2 98%

T: TQ right thigh 1425, wound packed w/ combat gauze, 1g TXA IV

IMMEDIATE (T1) - RED

Requires immediate intervention. Will die without treatment.

• Airway obstruction
• Tension pneumothorax
• Massive hemorrhage
• Shock

DELAYED (T2) - YELLOW

Needs treatment but can wait without life threat.

• Large wounds without shock
• Fractures (stable)
• Burns <20% TBSA

MINIMAL (T3) - GREEN

"Walking wounded" - minor injuries.

• Minor lacerations
• Sprains
• Small burns

EXPECTANT (T4) - BLACK

Injuries incompatible with survival given resources.

• Massive head trauma with brain matter
• Burns >85% TBSA
• Prolonged cardiac arrest

Still provide comfort measures.

Normal Adult Vitals

AVPU Scale

• A - Alert
• V - Responds to Voice
• P - Responds to Pain
• U - Unresponsive

Glasgow Coma Scale

Total: 3-15 | Severe: 3-8 | Moderate: 9-12 | Mild: 13-15

Tourniquets

Hemostatic Agents

Chest Seals

Airway