"URGENCIAS SANITARIAS PARA BOMBEROS" Arkaute Akademia. Academia Vasca de Policía y Emergencias.

Manual de Bomberos Operaciones de Salvamento "URGENCIAS SANITARIAS PARA BOMBEROS" Arkaute Akademia

Manual del bombero. Academia Vasca de Policia y Emergencias.

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VOLUMEN 1. OPERACIONES DE SALVAMENTO

1.1 – Rescate en accidentes de tráfico

1.2 – Trabajos y rescates en altura

1.3 – Rescate acuático en superficie

1.4 – Urgencias sanitarias para bomberos

VOLUMEN 2. CONTROL Y EXTINCIÓN DE INCENDIOS

2.1 – Principios de la lucha contra incendios

2.2 – Incendios en interiores

2.3 – Incendios forestales

2.4 – Prevención de incendios

VOLUMEN 3. FENÓMENOS NATURALES Y ANTRÓPICOS. OPERACIONES DE AYUDAS TÉCNICAS

3.1 – Riesgos naturales

3.2 – Riesgo en accidentes con materias peligrosas

3.3 – Redes de distribución e instalaciones

3.4 – Principios de construcción y estabilización de estructuras

VOLUMEN 4. USO DE RECURSOS OPERATIVOS

4.1 – Equipos de protección respiratoria

4.2 – Medios de extinción. Operaciones e instalaciones con mangueras

4.3 – Bombas. Hidráulica básica para bomberos

4.4 – Vehículos de los S.P.E.I.S.

4.5 – Manejo de herramientas y equipos

VOLUMEN 5. ORGANIZACIÓN Y DESARROLLO PROFESIONAL

5.1 – El sistema vasco de atención de emergencias

5.2 – Seguridad y salud laboral

5.3 – Aspectos legales de la intervención. Responsabilidad, deberes y derechos

5.4 – Psicología de emergencias

El manual cuenta con la participación de 52 autores de los distintos servicios de bomberos de Euskadi, del servicio de emergencias Osakidetza, de Cruz Roja, Salvamento Marítimo y la Dirección de Emergencias del Departamento de Interior.

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Tactical Combat Casualty Care TCCC, TC3 by CoTCCC. Guidelines

Tactical Combat Casualty Care TCCC, TC3 by CoTCCC. Guidelines 25 January 2024

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Post by 
Dr. Ramon Reyes, MD 

TCCC Guidelines

Summary of Jan 2024 Changes

4.  Airway Management

Simplifies the airway management sequence in tactical field care.

Better defines the recovery position with head tilted back and chin away from chest.

Eliminates extraglottic airways.

Provides more specific indications for surgical cricothyroidotomy.

Establishes need for frequent reassessment of SpO2, EtCO2, and airway patency. 

5.  Respiration / Breathing in tactical field care

Consideration of a properly-sized Nasopharyngeal Airway when using a BVM.

Ventilate with a 1000ml Bag-Valve-Mask (BVM).

Use continuous EtCO2 and SpO2 monitoring.

adds Moderate and Severe Traumatic Brain Injury to tactical field care.

Pues 4 años más. Instructor/Faculty/Medical Director TCCC-NAEMT Tactical Combat Casualty Care by Dr. Ramon Reyes, MD ∞🧩 𓃗https://emssolutionsint.blogspot.com/2012/01/tactical-combat-casualty-care-tccc.html
TCCC Guidelines by JTS / CoTCCC. FREE pdf / Manual TCCC Español. FREE pdf. Updated TCCC Guidelines Guías " Tactical Combat Casualty Care English/Español
https://emssolutionsint.blogspot.com/2012/07/presentacion-del-programa-phtls-tccc.html
#DrRamonReyesMD ∞🧩 @DrRamonReyesMD
Curso TCC-LEFR Tactical Casualty Care for Law Enforcement First Responders by Dr. Peter Pons, MD Marca Registrada en EUA https://emssolutionsint.blogspot.com/2017/09/curso-tcc-lefr-tactical-casualty-care_4.html

Tactical Combat Casualty Care (TCCC) Guidelines for Medical Personnel

15 December 2021 

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We expect the new TCCC guide in December 2023

Esperamos la nueva guía TCCC en diciembre 2023

No, no es lo mismo leer, no es lo mismo escuchar a un tercero, si lo comparas con ir a quien lo ha escrito, quien lo ha creado. Dr. Frank Butler padre del TCCC y Dr. Ramon Reyes, MD en conversación sobre temas de medicina táctica y el propio TCCC 

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Tactical Combat Casualty Care TCCC, TC3 by CoTCCC. Actualizacion Guias Octubre 2018 

J Spec Oper Med, 18 (4), 37-55 Invierno 2018

Cuidados avanzados de reanimación avanzados en Tactical Combat Casualty Care: TCCC: cambio de las directrices del TCCC 18-01: 14 de octubre de 2018 Frank K Butler Jr, John B Holcomb ... Michael A Weber 

PMID: 30566723 

Resumen

TCCC ha recomendado previamente intervenciones que pueden prevenir eficazmente 4 de las 5 causas principales de muerte prehospitalarias prevenibles  en combate, hemorragia de extremidades, hemorragia de la unión (Axilas, Ingles Gluteos y Region Inferior del Cuello, obstrucción de las vías respiratorias y neumotórax por tensión, y las muertes por estas causas se han reducido notablemente en heridos en combate de los EE. UU. La hemorragia del torso no comprimible (NCTH, por sus siglas en inglés) (Hemorragia imposible de manejar en la escena con empaquetamiento y compresion por su localizacion anatomica) es la última causa principal de muerte prevenible en el campo de batalla y con frecuencia causa la muerte a los 30 minutos dehaber sufrido la lesion (herida). El  incrementado en utilización de sangre total, incluida la capacidad de transfusión masiva, si está indicada, tiene el potencial de aumentar la supervivencia de las víctimas con hemorragia torácica y / o abdomino-pélvica. Además, la oclusión de la aorta (REBOA) con balón endovascular de reanimación en la zona 1 puede proporcionar un control temporal del sangrado en el abdomen y la pelvis y mejorar la hemodinámia en  víctimas que pueden sufrir parada cardíaca traumática como resultado del shock hemorrágico. Juntas, estas dos intervenciones se designan como Cuidado Avanzado de Reanimación avanzada (CAR) y pueden permitir que las víctimas con NCTH grave sobrevivan el tiempo suficiente para llegar a la atención de un cirujano. Aunque las unidades de Operaciones Especiales ahora están usando la sangre total en atención inicial en el campo, esta capacidad no está presente de manera rutinaria en otras unidades de combate de los EE. UU. y OTAN. por el momento. REBOA no se concibe como un cuidado que podría ser realizado por los Enfermeros de Combate (Combat Medic) de las unidades que trabajan fuera de sus competencias profesionales. Esta intervención debe ser realizada solo por equipos designados de personal médico de combate avanzado con entrenamiento y equipo especial.

Traducción y adaptación by Dr. Ramon REYES, MD

J Spec Oper Med, 18 (4), 37-55 Winter 2018

Advanced Resuscitative Care in Tactical Combat Casualty Care: TCCC Guidelines Change 18-01:14 October 2018

Frank K Butler Jr, John B Holcomb ... Michael A Weber expand

PMID: 30566723

Abstract

TCCC has previously recommended interventions that can effectively prevent 4 of the top 5 causes of prehospital preventable death in combat casualties-extremity hemorrhage, junctional hemorrhage, airway obstruction, and tension pneumothorax- and deaths from these causes have been markedly reduced in US combat casualties. Noncompressible torso hemorrhage (NCTH) is the last remaining major cause of preventable death on the battlefield and often causes death within 30 minutes of wounding. Increased use of whole blood, including the capability for massive transfusion, if indicated, has the potential to increase survival in casualties with either thoracic and/or abdominopelvic hemorrhage. Additionally, Zone 1 Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) can provide temporary control of bleeding in the abdomen and pelvis and improve hemodynamics in casualties who may be approaching traumatic cardiac arrest as a result of hemorrhagic shock. Together, these two interventions are designated Advanced Resuscitative Care (ARC) and may enable casualties with severe NCTH to survive long enough to reach the care of a surgeon. Although Special Operations units are now using whole blood far-forward, this capability is not routinely present in other US combat units at this point in time. REBOA is not envisioned as care that could be accomplished by a unit medic working out of his or her aid bag. This intervention should be undertaken only by designated teams of advanced combat medical personnel with special training and equipment.

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Tactical Combat Casualty Care TCCC Course By TCCC

TCCC Tactical Combat Casualty Care Feb 2016 Trinity, Alabama

This course uses both hands on and highly focused evidence based lecture with real world scenarios that both EMS and Law Enfrocement encounter to include MCI and Active Shooter. This course is battle proven and you will learn skills that will increase patient care and your knowledge base. This course you will get dirty and we will train both in and outdoors regardless of weather. If you would like to train with your own gear please bring it and it will be used in place our supplied gear. If you have a preffered weapon you would like to train with please have it cleared by the instructor if you would like to use it for training.

The Tactical Combat Casualty Care (TCCC) course introduces evidence-based, life-saving techniques and strategies for providing the best trauma care on the battlefield. NAEMT conducts TCCC courses under the auspices of its PHTLS program, the recognized world leader in prehospital trauma education.

NAEMT’s TCCC courses use the PHTLS Military textbook and are fully compliant with the Department of Defense’s Committee on Tactical Combat Casualty Care (CoTCCC) guidelines. It is the only TCCC course endorsed by the American College of Surgeons.

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Dr. Ramon Reyes Diaz, MD 

Almost 90% of American service men and women who die from combat wounds do so before they arrive at a medical treatment facility. This figure highlights the importance of the trauma care provided on the battlefield by combat medics, corpsmen, PJs, and even the casualties themselves and their fellow combatants. With respect to the actual care provided by combat medics on the battlefield, however, J. S Maughon noted in his paper in Military Medicine in 1970 that little had changed in the preceding 100 years. In the interval between the publication of Maughon's paper and the United States’ invasion of Afghanistan in 2001, there was also little progress made. The war years, though, have seen many lifesaving advances in battlefield trauma care pioneered by the Joint Trauma System and the Committee on Tactical Combat Casualty Care. These advances have dramatically increased casualty survival. This is especially true when all members of combat units – not just medics - are trained in Tactical Combat Casualty Care (TCCC.)

Combat medical personnel and non-medical combatants in U.S. and most coalition militaries are now being trained to manage combat trauma on the battlefield in accordance with TCCC Guidelines.

Tactical Combat Casualty Care Guidelines for Medical Personnel

 TCCC Card
Tactical Combat Casualty Care TCCC
Tactical Combat Casualty Care TCCC


03 June 2015
* All changes to the guidelines made since the 140602 annual update are shown in bold text.
* These recommendations are intended to be guidelines only and are not a substitute for clinical judgment.
Basic Management Plan for Care Under Fire

1. Return fire and take cover.

2. Direct or expect casualty to remain engaged as a combatant if appropriate.

3. Direct casualty to move to cover and apply self-aid if able.

4. Try to keep the casualty from sustaining additional wounds.

5. Casualties should be extricated from burning vehicles or buildings and moved to places of relative safety. Do what is necessary to stop the burning process.

6. Airway management is generally best deferred until the Tactical Field Care phase.

7. Stop life-threatening external hemorrhage if tactically feasible:
- Direct casualty to control hemorrhage by self-aid if able.
- Use a CoTCCC-recommended limb tourniquet for hemorrhage that is anatomically amenable to tourniquet use.
- Apply the limb tourniquet over the uniform clearly proximal to the bleeding site(s). If the site of the life-threatening bleeding is not readily apparent, place the tourniquet “high and tight” (as proximal as possible) on the injured limb and move the casualty to cover.




Basic Management Plan for Tactical Field Care

1. Casualties with an altered mental status should be disarmed immediately.

2. Airway Management
a. Unconscious casualty without airway obstruction:
- Chin lift or jaw thrust maneuver
- Nasopharyngeal airway
- Place casualty in the recovery position
b. Casualty with airway obstruction or impending airway obstruction:
- Chin lift or jaw thrust maneuver
- Nasopharyngeal airway
- Allow casualty to assume any position that best protects the airway, to include sitting up.
- Place unconscious casualty in the recovery position.
c. If the previous measures are unsuccessful, perform a surgical cricothyroidotomy using one of the following:
- Cric-Key technique (Preferred option)
- Bougie-aided open surgical technique using a flanged and cuffed airway cannula of less than 10 mm outer diameter, 6-7 mm internal diameter, and 5-8 cm of intratracheal length
- Standard open surgical technique using a flanged and cuffed airway cannula of less than 10mm outer diameter, 6-7 mm internal diameter, and 5-8 cm of intra-tracheal length (Least desirable option)
- Use lidocaine if the casualty is conscious.

3. Breathing
a. In a casualty with progressive respiratory distress and known or suspected torso trauma, consider a tension pneumothorax and decompress the chest on the side of the injury with a 14-gauge, 3.25 inch needle/catheter unit inserted in the second intercostal space at the midclavicular line. Ensure that the needle entry into the chest is not medial to the nipple line and is not directed towards the heart. An acceptable alternate site is the 4th or 5th intercostal space at the anterior axillary line (AAL).
b. All open and/or sucking chest wounds should be treated by immediately applying a vented chest seal to cover the defect. If a vented chest seal is not available, use a non-vented chest seal. Monitor the casualty for the potential development of a subsequent tension pneumothorax. If the casualty develops increasing hypoxia, respiratory distress, or hypotension and a tension pneumothorax is suspected, treat by burping or removing the dressing or by needle decompression.
c. Casualties with moderate/severe TBI should be given supplemental oxygen when available to maintain an oxygen saturation > 90%.

4. Bleeding
a. Assess for unrecognized hemorrhage and control all sources of bleeding. If not already done, use a CoTCCC-recommended limb tourniquet to control life-threatening external hemorrhage that is anatomically amenable to tourniquet use or for any traumatic amputation. Apply directly to the skin 2-3 inches above the wound. If bleeding is not controlled with the first tourniquet, apply a second tourniquet side-by-side with the first.
b. For compressible hemorrhage not amenable to limb tourniquet use or as an adjunct to tourniquet removal, use Combat Gauze as the CoTCCC hemostatic dressing of choice. Celox Gauze and ChitoGauze may also be used if Combat Gauze is not available. Hemostatic dressings should be applied with at least 3 minutes of direct pressure. If the bleeding site is amenable to use of a junctional tourniquet, immediately apply a CoTCCC-recommended junctional tourniquet. Do not delay in the application of the junctional tourniquet once it is ready for use. Apply hemostatic dressings with direct pressure if a junctional tourniquet is not available or while the junctional tourniquet is being readied for use.
c. Reassess prior tourniquet application. Expose the wound and determine if a tourniquet is needed. If it is, replace any limb tourniquet placed over the uniform with one applied directly to the skin 2-3 inches above wound. Ensure that bleeding is stopped. When possible, a distal pulse should be checked. If bleeding persists or a distal pulse is still present, consider additional tightening of the tourniquet or the use of a second tourniquet side-by-side with the first to eliminate both bleeding and the distal pulse.
d. Limb tourniquets and junctional tourniquets should be converted to hemostatic or pressure dressings as soon as possible if three criteria are met: the casualty is not in shock; it is possible to monitor the wound closely for bleeding; and the tourniquet is not being used to control bleeding from an amputated extremity. Every effort should be made to convert tourniquets in less than 2 hours if bleeding can be controlled with other means. Do not remove a tourniquet that has been in place more than 6 hours unless close monitoring and lab capability are available.
e. Expose and clearly mark all tourniquet sites with the time of tourniquet application. Use an indelible marker.


5. Intravenous (IV) access
- Start an 18-gauge IV or saline lock if indicated.
- If resuscitation is required and IV access is not obtainable, use the intraosseous (IO) route.

6. Tranexamic Acid (TXA)
If a casualty is anticipated to need significant blood transfusion (for example: presents with hemorrhagic shock, one or more major amputations, penetrating torso trauma, or evidence of severe bleeding):
– Administer 1 gram of tranexamic acid in 100 cc Normal Saline or Lactated Ringers as soon as possible but NOT later than 3 hours after injury.
– Begin second infusion of 1 gm TXA after Hextend or other fluid treatment.

7. Fluid resuscitation
a. The resuscitation fluids of choice for casualties in hemorrhagic shock, listed from most to least preferred, are: whole blood*; plasma, RBCs and platelets in 1:1:1 ratio*; plasma and RBCs in 1:1 ratio; plasma or RBCs alone; Hextend; and crystalloid (Lactated Ringers or Plasma-Lyte A).
b. Assess for hemorrhagic shock (altered mental status in the absence of brain injury and/or weak or absent radial pulse).
1. If not in shock:
- No IV fluids are immediately necessary.
- Fluids by mouth are permissible if the casualty is conscious and can swallow.
2. If in shock and blood products are available under an approved command or theater blood product administration protocol:
- Resuscitate with whole blood*, or, if not available
- Plasma, RBCs and platelets in a 1:1:1 ratio*, or, if not available
- Plasma and RBCs in 1:1 ratio, or, if not available;
- Reconstituted dried plasma, liquid plasma or thawed plasma alone or RBCs alone;
- Reassess the casualty after each unit. Continue resuscitation until a palpable radial pulse, improved mental status or systolic BP of 80-90 mmHg is present.
3. If in shock and blood products are not available under an approved command or theater blood product administration protocol due to tactical or logistical constraints:
- Resuscitate with Hextend, or if not available;
- Lactated Ringers or Plasma-Lyte A;
- Reassess the casualty after each 500 mL IV bolus;
- Continue resuscitation until a palpable radial pulse, improved mental status, or systolic BP of 80-90 mmHg is present.
- Discontinue fluid administration when one or more of the above end points has been achieved.
4. If a casualty with an altered mental status due to suspected TBI has a weak or absent peripheral pulse, resuscitate as necessary to restore and maintain a normal radial pulse. If BP monitoring is available, maintain a target systolic BP of at least 90 mmHg.
5. Reassess the casualty frequently to check for recurrence of shock. If shock recurs, recheck all external hemorrhage control measures to ensure that they are still effective and repeat the fluid resuscitation as outlined above.

* Neither whole blood nor apheresis platelets as these products are currently collected in theater are FDA-compliant. Consequently, whole blood and 1:1:1 resuscitation using apheresis platelets should be used only if all of the FDA-compliant blood products needed to support 1:1:1 resuscitation are not available, or if 1:1:1 resuscitation is not producing the desired clinical effect.

8. Prevention of hypothermia
a. Minimize casualty’s exposure to the elements. Keep protective gear on or with the casualty if feasible.
b. Replace wet clothing with dry if possible. Get the casualty onto an insulated surface as soon as possible.
c. Apply the Ready-Heat Blanket from the Hypothermia Prevention and Management Kit (HPMK) to the casualty’s torso (not directly on the skin) and cover the casualty with the Heat-Reflective Shell (HRS).
d. If an HRS is not available, the previously recommended combination of the Blizzard Survival Blanket and the Ready Heat blanket may also be used.
e. If the items mentioned above are not available, use dry blankets, poncho liners, sleeping bags, or anything that will retain heat and keep the casualty dry.
f. Warm fluids are preferred if IV fluids are required.
9. Penetrating Eye Trauma
If a penetrating eye injury is noted or suspected:
a) Perform a rapid field test of visual acuity.
b) Cover the eye with a rigid eye shield (NOT a pressure patch.)
c) Ensure that the 400 mg moxifloxacin tablet in the combat pill pack is taken if possible and that IV/IM antibiotics are given as outlined below if oral moxifloxacin cannot be taken.

10. Monitoring
Pulse oximetry should be available as an adjunct to clinical monitoring. All individuals with moderate/severe TBI should be monitored with pulse oximetry. Readings may be misleading in the settings of shock or marked hypothermia.

11. Inspect and dress known wounds.

12. Check for additional wounds.

13. Analgesia on the battlefield should generally be achieved using one of three options:
Option 1
Mild to Moderate Pain
Casualty is still able to fight
- TCCC Combat pill pack:
- Tylenol - 650-mg bilayer caplet, 2 PO every 8 hours
- Meloxicam - 15 mg PO once a day
Option 2
Moderate to Severe Pain
Casualty IS NOT in shock or respiratory distress AND
Casualty IS NOT at significant risk of developing either condition
- Oral transmucosal fentanyl citrate (OTFC) 800 ug
- Place lozenge between the cheek and the gum
- Do not chew the lozenge
Option 3
Moderate to Severe Pain
Casualty IS in hemorrhagic shock or respiratory distress OR
Casualty IS at significant risk of developing either condition
- Ketamine 50 mg IM or IN
Or
- Ketamine 20 mg slow IV or IO

* Repeat doses q30min prn for IM or IN
* Repeat doses q20min prn for IV or IO
* End points: Control of pain or development of nystagmus (rhythmic back-and-forth movement of the eyes)

* Analgesia notes
a. Casualties may need to be disarmed after being given OTFC or ketamine.
b. Document a mental status exam using the AVPU method prior to administering opioids or ketamine.
c. For all casualties given opioids or ketamine – monitor airway, breathing, and circulation closely
d. Directions for administering OTFC:
- Recommend taping lozenge-on-a-stick to casualty’s finger as an added safety measure OR utilizing a safety pin and rubber band to attach the lozenge (under tension) to the patient’s uniform or plate carrier.
- Reassess in 15 minutes
- Add second lozenge, in other cheek, as necessary to control severe pain
- Monitor for respiratory depression
e. IV Morphine is an alternative to OTFC if IV access has been obtained
- 5 mg IV/IO
- Reassess in 10 minutes.
- Repeat dose every 10 minutes as necessary to control severe pain.
- Monitor for respiratory depression.
f. Naloxone (0.4 mg IV or IM) should be available when using opioid analgesics.
g. Both ketamine and OTFC have the potential to worsen severe TBI. The combat medic, corpsman, or PJ must consider this fact in his or her analgesic decision, but if the casualty is able to complain of pain, then the TBI is likely not severe enough to preclude the use of ketamine or OTFC.
h. Eye injury does not preclude the use of ketamine. The risk of additional damage to the eye from using ketamine is low and maximizing the casualty’s chance for survival takes precedence if the casualty is in shock or respiratory distress or at significant risk for either.
i. Ketamine may be a useful adjunct to reduce the amount of opioids required to provide effective pain relief. It is safe to give ketamine to a casualty who has previously received morphine or OTFC. IV Ketamine should be given over 1 minute.
j. If respirations are noted to be reduced after using opioids or ketamine, provide ventilatory support with a bag-valve-mask or mouth-to-mask ventilations.
k. Ondansetron, 4 mg ODT/IV/IO/IM, every 8 hours as needed for nausea or vomiting. Each 8­hour dose can be repeated once at 15 minutes if nausea and vomiting are not improved. Do not give more than 8 mg in any 8­hour interval. Oral ondansetron is NOT an acceptable alternative to the ODT formulation.
l. Reassess – reassess – reassess!

14. Splint fractures and re-check pulses.

15. Antibiotics: recommended for all open combat wounds
a. If able to take PO:
- Moxifloxacin, 400 mg PO one a day
b. If unable to take PO (shock, unconsciousness):
- Cefotetan, 2 g IV (slow push over 3-5 minutes) or IM every 12 hours
or
- Ertapenem, 1 g IV/IM once a day

16. Burns
a. Facial burns, especially those that occur in closed spaces, may be associated with inhalation injury. Aggressively monitor airway status and oxygen saturation in such patients and consider early surgical airway for respiratory distress or oxygen desaturation.
b. Estimate total body surface area (TBSA) burned to the nearest 10% using the Rule of Nines.
c. Cover the burn area with dry, sterile dressings. For extensive burns (>20%), consider placing the casualty in the Heat-Reflective Shell or Blizzard Survival Blanket from the Hypothermia Prevention Kit in order to both cover the burned areas and prevent hypothermia.
d. Fluid resuscitation (USAISR Rule of Ten)
– If burns are greater than 20% of Total Body Surface Area, fluid resuscitation should be initiated as soon as IV/IO access is established. Resuscitation should be initiated with Lactated Ringer’s, normal saline, or Hextend. If Hextend is used, no more than 1000 ml should be given, followed by Lactated Ringer’s or normal saline as needed.
– Initial IV/IO fluid rate is calculated as %TBSA x 10cc/hr for adults weighing 40- 80 kg.
– For every 10 kg ABOVE 80 kg, increase initial rate by 100 ml/hr.
– If hemorrhagic shock is also present, resuscitation for hemorrhagic shock takes precedence over resuscitation for burn shock. Administer IV/IO fluids per the TCCC Guidelines in Section 7.
e. Analgesia in accordance with the TCCC Guidelines in Section 13 may be administered to treat burn pain.
f. Prehospital antibiotic therapy is not indicated solely for burns, but antibiotics should be given per the TCCC guidelines in Section 15 if indicated to prevent infection in penetrating wounds.
g. All TCCC interventions can be performed on or through burned skin in a burn casualty.

17. Communicate with the casualty if possible.
- Encourage; reassure
- Explain care

18. Cardiopulmonary resuscitation (CPR)
Resuscitation on the battlefield for victims of blast or penetrating trauma who have no pulse, no ventilations, and no other signs of life will not be successful and should not be attempted. However, casualties with torso trauma or polytrauma who have no pulse or respirations during TFC should have bilateral needle decompression performed to ensure they do not have a tension pneumothorax prior to discontinuation of care. The procedure is the same as described in section 3a above.

19. Documentation of Care
Document clinical assessments, treatments rendered, and changes in the casualty’s status on a TCCC Casualty Card (DD Form 1380). Forward this information with the casualty to the next level of care.
Basic Management Plan for Tactical Evacuation Care

* The term “Tactical Evacuation” includes both Casualty Evacuation (CASEVAC) and Medical Evacuation (MEDEVAC) as defined in Joint Publication 4-02.

1. Airway Management
a. Unconscious casualty without airway obstruction:
- Chin lift or jaw thrust maneuver
- Nasopharyngeal airway
- Place casualty in the recovery position
b. Casualty with airway obstruction or impending airway obstruction:
- Chin lift or jaw thrust maneuver
- Nasopharyngeal airway
- Allow casualty to assume any position that best protects the airway, to include sitting up.
- Place unconscious casualty in the recovery position.
- If the previous measures are unsuccessful, assess the tactical and clinical situations, the equipment at hand, and the skills and experience of the person providing care, and then select one of the following airway interventions:
- Supraglottic airway, or
- Endotracheal intubation or
- Perform a surgical cricothyroidotomy using one of the following:
- Cric-Key technique (Preferred option)
- Bougie-aided open surgical technique using a flanged and cuffed airway cannula of less than 10mm outer diameter, 6-7mm internal diameter, and 5-8 cm of intra-tracheal length
- Standard open surgical technique using a flanged and cuffed airway cannula of less than 10mm outer diameter, 6-7mm internal diameter and 5-8cm of intra-tracheal length (Least desirable option)
- Use lidocaine if the casualty is conscious.
c. Spinal immobilization is not necessary for casualties with penetrating trauma.

2. Breathing
a. In a casualty with progressive respiratory distress and known or suspected torso trauma, consider a tension pneumothorax and decompress the chest on the side of the injury with a 14-gauge, 3.25 inch needle/catheter unit inserted in the second intercostal space at the midclavicular line. Ensure that the needle entry into the chest is not medial to the nipple line and is not directed towards the heart. An acceptable alternate site is the 4th or 5th intercostal space at the anterior axillary line (AAL).
b. Consider chest tube insertion if no improvement and/or long transport is anticipated.
c. Most combat casualties do not require supplemental oxygen, but administration of oxygen may be of benefit for the following types of casualties:
- Low oxygen saturation by pulse oximetry
- Injuries associated with impaired oxygenation
- Unconscious casualty
- Casualty with TBI (maintain oxygen saturation > 90%)
- Casualty in shock
- Casualty at altitude
d. All open and/or sucking chest wounds should be treated by immediately applying a vented chest seal to cover the defect. If a vented chest seal is not available, use a non-vented chest seal. Monitor the casualty for the potential development of a subsequent tension pneumothorax. If the casualty develops increasing hypoxia, respiratory distress, or hypotension and a tension pneumothorax is suspected, treat by burping or removing the dressing or by needle decompression.

3. Bleeding
a. Assess for unrecognized hemorrhage and control all sources of bleeding. If not already done, use a CoTCCC-recommended limb tourniquet to control life-threatening external hemorrhage that is anatomically amenable to tourniquet use or for any traumatic amputation. Apply directly to the skin 2-3 inches above the wound. If bleeding is not controlled with the first tourniquet, apply a second tourniquet side-by-side with the first.
b. For compressible hemorrhage not amenable to limb tourniquet use or as an adjunct to tourniquet removal, use Combat Gauze as the CoTCCC hemostatic dressing of choice. Celox Gauze and ChitoGauze may also be used if Combat Gauze is not available. Hemostatic dressings should be applied with at least 3 minutes of direct pressure. If the bleeding site is amenable to use of a junctional tourniquet, immediately apply a CoTCCC-recommended junctional tourniquet. Do not delay in the application of the junctional tourniquet once it is ready for use. Apply hemostatic dressings with direct pressure if a junctional tourniquet is not available or while the junctional tourniquet is being readied for use.
c. Reassess prior tourniquet application. Expose the wound and determine if a tourniquet is needed. If it is, replace any limb tourniquet placed over the uniform with one applied directly to the skin 2-3 inches above wound. Ensure that bleeding is stopped. When possible, a distal pulse should be checked. If bleeding persists or a distal pulse is still present, consider additional tightening of the tourniquet or the use of a second tourniquet side-by-side with the first to eliminate both bleeding and the distal pulse.
d. Limb tourniquets and junctional tourniquets should be converted to hemostatic or pressure dressings as soon as possible if three criteria are met: the casualty is not in shock; it is possible to monitor the wound closely for bleeding; and the tourniquet is not being used to control bleeding from an amputated extremity. Every effort should be made to convert tourniquets in less than 2 hours if bleeding can be controlled with other means. Do not remove a tourniquet that has been in place more than 6 hours unless close monitoring and lab capability are available.
e. Expose and clearly mark all tourniquet sites with the time of tourniquet application. Use an indelible marker.

4. Intravenous (IV) access
a. Reassess need for IV access.
- If indicated, start an 18-gauge IV or saline lock
- If resuscitation is required and IV access is not obtainable, use intraosseous (IO) route.

5. Tranexamic Acid (TXA)
If a casualty is anticipated to need significant blood transfusion (for example: presents with hemorrhagic shock, one or more major amputations, penetrating torso trauma, or evidence of severe bleeding)
– Administer 1 gram of tranexamic acid in 100 cc Normal Saline or Lactated Ringers as soon as possible but NOT later than 3 hours after injury.
– Begin second infusion of 1 gm TXA after Hextend or other fluid treatment.

6. Traumatic Brain Injury
a. Casualties with moderate/severe TBI should be monitored for:
1. Decreases in level of consciousness
2. Pupillary dilation
3. SBP should be >90 mmHg
4. O2 sat > 90
5. Hypothermia
6. PCO2 (If capnography is available, maintain between 35-40 mmHg)
7. Penetrating head trauma (if present, administer antibiotics)
8. Assume a spinal (neck) injury until cleared.
b. Unilateral pupillary dilation accompanied by a decreased level of consciousness may signify impending cerebral herniation; if these signs occur, take the following actions to decrease intracranial pressure:
1) Administer 250 cc of 3 or 5% hypertonic saline bolus.
2) Elevate the casualty’s head 30 degrees.
3) Hyperventilate the casualty.
a) Respiratory rate 20
b) Capnography should be used to maintain the end-tidal CO2 between 30-35 mmHg
c) The highest oxygen concentration (FIO2) possible should be used for hyperventilation.

*Notes:
- Do not hyperventilate unless signs of impending herniation are present.
- Casualties may be hyperventilated with oxygen using the bag-valve-mask technique.

7. Fluid resuscitation
a. The resuscitation fluids of choice for casualties in hemorrhagic shock, listed from most to least preferred, are: whole blood*; plasma, RBCs and platelets in 1:1:1 ratio*; plasma and RBCs in 1:1 ratio; plasma or RBCs alone; Hextend; and crystalloid (Lactated Ringers or Plasma-Lyte A).
b. Assess for hemorrhagic shock (altered mental status in the absence of brain injury and/or weak or absent radial pulse).
1. If not in shock:
- No IV fluids are immediately necessary.
- Fluids by mouth are permissible if the casualty is conscious and can swallow.
2. If in shock and blood products are available under an approved command or theater blood product administration protocol:
- Resuscitate with whole blood*, or, if not available
- Plasma, RBCs and platelets in a 1:1:1 ratio*, or, if not available
- Plasma and RBCs in 1:1 ratio, or, if not available;
- Reconstituted dried plasma, liquid plasma or thawed plasma alone or RBCs alone;
- Reassess the casualty after each unit. Continue resuscitation until a palpable radial pulse, improved mental status or systolic BP of 80-90 mmHg is present.
3. If in shock and blood products are not available under an approved command or theater blood product administration protocol due to tactical or logistical constraints:
- Resuscitate with Hextend, or if not available;
- Lactated Ringers or Plasma-Lyte A;
- Reassess the casualty after each 500 mL IV bolus;
- Continue resuscitation until a palpable radial pulse, improved mental status, or systolic BP of 80-90 mmHg is present.
- Discontinue fluid administration when one or more of the above end points has been achieved.
4. If a casualty with an altered mental status due to suspected TBI has a weak or absent peripheral pulse, resuscitate as necessary to restore and maintain a normal radial pulse. If BP monitoring is available, maintain a target systolic BP of at least 90 mmHg.
5. Reassess the casualty frequently to check for recurrence of shock. If shock recurs, recheck all external hemorrhage control measures to ensure that they are still effective and repeat the fluid resuscitation as outlined above.

* Neither whole blood nor apheresis platelets as these products are currently collected in theater are FDA-compliant. Consequently, whole blood and 1:1:1 resuscitation using apheresis platelets should be used only if all of the FDA-compliant blood products needed to support 1:1:1 resuscitation are not available, or if 1:1:1 resuscitation is not producing the desired clinical effect.

8. Prevention of hypothermia
a. Minimize casualty’s exposure to the elements. Keep protective gear on or with the casualty if feasible.
b. Replace wet clothing with dry if possible. Get the casualty onto an insulated surface as soon as possible.
c. Apply the Ready-Heat Blanket from the Hypothermia Prevention and Management Kit (HPMK) to the casualty’s torso (not directly on the skin) and cover the casualty with the Heat-Reflective Shell (HRS).
d. If an HRS is not available, the previously recommended combination of the Blizzard Survival Blanket and the Ready Heat blanket may also be used.
e. If the items mentioned above are not available, use poncho liners, sleeping bags, or anything that will retain heat and keep the casualty dry.
f. Use a portable fluid warmer capable of warming all IV fluids including blood products.
g. Protect the casualty from wind if doors must be kept open.

9. Penetrating Eye Trauma
If a penetrating eye injury is noted or suspected:
a) Perform a rapid field test of visual acuity.
b) Cover the eye with a rigid eye shield (NOT a pressure patch).
c) Ensure that the 400 mg moxifloxacin tablet in the combat pill pack is taken if possible and that IV/IM antibiotics are given as outlined below if oral moxifloxacin cannot be taken.

10. Monitoring
Institute pulse oximetry and other electronic monitoring of vital signs, if indicated. All individuals with moderate/severe TBI should be monitored with pulse oximetry.

11. Inspect and dress known wounds if not already done.

12. Check for additional wounds.

13. Analgesia on the battlefield should generally be achieved using one of three options:
Option 1
Mild to Moderate Pain
Casualty is still able to fight
- TCCC Combat pill pack:
- Tylenol - 650-mg bilayer caplet, 2 PO every 8 hours
- Meloxicam - 15 mg PO once a day
Option 2
Moderate to Severe Pain
Casualty IS NOT in shock or respiratory distress AND
Casualty IS NOT at significant risk of developing either condition
- Oral transmucosal fentanyl citrate (OTFC) 800 ug
- Place lozenge between the cheek and the gum
- Do not chew the lozenge
Option 3
Moderate to Severe Pain
Casualty IS in hemorrhagic shock or respiratory distress OR
Casualty IS at significant risk of developing either condition
- Ketamine 50 mg IM or IN
Or
- Ketamine 20 mg slow IV or IO

* Repeat doses q30min prn for IM or IN
* Repeat doses q20min prn for IV or IO
* End points: Control of pain or development of nystagmus (rhythmic back-and-forth movement of the eyes)

* Analgesia notes
a. Casualties may need to be disarmed after being given OTFC or ketamine.
b. Document a mental status exam using the AVPU method prior to administering opioids or ketamine.
c. For all casualties given opioids or ketamine – monitor airway, breathing, and circulation closely
d. Directions for administering OTFC:
- Recommend taping lozenge-on-a-stick to casualty’s finger as an added safety measure OR utilizing a safety pin and rubber band to attach the lozenge (under tension) to the patient’s uniform or plate carrier.
- Reassess in 15 minutes
- Add second lozenge, in other cheek, as necessary to control severe pain
- Monitor for respiratory depression
e. IV Morphine is an alternative to OTFC if IV access has been obtained
- 5 mg IV/IO
- Reassess in 10 minutes.
- Repeat dose every 10 minutes as necessary to control severe pain.
- Monitor for respiratory depression.
f. Naloxone (0.4 mg IV or IM) should be available when using opioid analgesics.
g. Both ketamine and OTFC have the potential to worsen severe TBI. The combat medic, corpsman, or PJ must consider this fact in his or her analgesic decision, but if the casualty is able to complain of pain, then the TBI is likely not severe enough to preclude the use of ketamine or OTFC.
h. Eye injury does not preclude the use of ketamine. The risk of additional damage to the eye from using ketamine is low and maximizing the casualty’s chance for survival takes precedence if the casualty is in shock or respiratory distress or at significant risk for either.
i. Ketamine may be a useful adjunct to reduce the amount of opioids required to provide effective pain relief. It is safe to give ketamine to a casualty who has previously received morphine or OTFC. IV Ketamine should be given over 1 minute.
j. If respirations are noted to be reduced after using opioids or ketamine, provide ventilatory support with a bag-valve-mask or mouth-to-mask ventilations.
k. Ondansetron, 4 mg ODT/IV/IO/IM, every 8 hours as needed for nausea or vomiting. Each 8­hour dose can be repeated once at 15 minutes if nausea and vomiting are not improved. Do not give more than 8 mg in any 8­hour interval. Oral ondansetron is NOT an acceptable alternative to the ODT formulation.
l. Reassess – reassess – reassess!

14. Reassess fractures and recheck pulses.

15. Antibiotics: recommended for all open combat wounds
a. If able to take PO:
- Moxifloxacin, 400 mg PO one a day
b. If unable to take PO (shock, unconsciousness):
- Ertapenem, 1 g IV/IM once a day

16. Burns
a. Facial burns, especially those that occur in closed spaces, may be associated with inhalation injury. Aggressively monitor airway status and oxygen saturation in such patients and consider early surgical airway for respiratory distress or oxygen desaturation.
b. Estimate total body surface area (TBSA) burned to the nearest 10% using the Rule of Nines.
c. Cover the burn area with dry, sterile dressings. For extensive burns (>20%), consider placing the casualty in the Heat-Reflective Shell or Blizzard Survival Blanket from the Hypothermia Prevention Kit in order to both cover the burned areas and prevent hypothermia.
d. Fluid resuscitation (USAISR Rule of Ten)
– If burns are greater than 20% of Total Body Surface Area, fluid resuscitation should be initiated as soon as IV/IO access is established. Resuscitation should be initiated with Lactated Ringer’s, normal saline, or Hextend. If Hextend is used, no more than 1000 ml should be given, followed by Lactated Ringer’s or normal saline as needed.
– Initial IV/IO fluid rate is calculated as %TBSA x 10cc/hr for adults weighing 40- 80 kg.
– For every 10 kg ABOVE 80 kg, increase initial rate by 100 ml/hr.
– If hemorrhagic shock is also present, resuscitation for hemorrhagic shock takes precedence over resuscitation for burn shock. Administer IV/IO fluids per the TCCC Guidelines in Section 7.
e. Analgesia in accordance with the TCCC Guidelines in Section 13 may be administered to treat burn pain.
f. Prehospital antibiotic therapy is not indicated solely for burns, but antibiotics should be given per the TCCC guidelines in Section 15 if indicated to prevent infection in penetrating wounds.
g. All TCCC interventions can be performed on or through burned skin in a burn casualty.
h. Burn patients are particularly susceptible to hypothermia. Extra emphasis should be placed on barrier heat loss prevention methods and IV fluid warming in this phase.

17. The Pneumatic Antishock Garment (PASG) may be useful for stabilizing pelvic fractures and controlling pelvic and abdominal bleeding. Application and extended use must be carefully monitored. The PASG is contraindicated for casualties with thoracic or brain injuries.

18. CPR in TACEVAC Care
a. Casualties with torso trauma or polytrauma who have no pulse or respirations during TACEVAC should have bilateral needle decompression performed to ensure they do not have a tension pneumothorax. The procedure is the same as described in section 2a above.
b. CPR may be attempted during this phase of care if the casualty does not have obviously fatal wounds and will be arriving at a facility with a surgical capability within a short period of time. CPR should not be done at the expense of compromising the mission or denying lifesaving care to other casualties.

19. Documentation of Care
Document clinical assessments, treatments rendered, and changes in the casualty’s status on a TCCC Casualty Card (DD Form 1380). Forward this information with the casualty to the next level of care.

Tactical Combat Casualty Care Curriculum

The NAEMT Prehospital Trauma Life Support (PHTLS) Committee is pleased to host the Committee on Tactical Combat Casualty Care’s (CoTCCC) updated curriculum for the Tactical Combat Casualty Care (TCCC) course.

The TCCC course is the military counterpart to the PHTLS course. It is designed for military medics, corpsmen, and pararescuemen who are preparing to deploy in support of combat operations. Casualty care on the battlefield must be the best possible combination of good medicine and good small-unit tactics.

The specifics of casualty care in the tactical setting will depend on the tactical situation, the injuries sustained by the casualty, the knowledge and skills of the first responder, and the medical equipment at hand. In contrast to a hospital Emergency Department setting where the patient IS the mission, on the battlefield, care of casualties sustained is only PART of the mission. TCCC recognizes this fact and structures its guidelines to accomplish three primary goals:

1. Treat the casualty
2. Prevent additional casualties
3. Complete the mission

The TCCC program was developed to customize the principles of good trauma care for successful use on the battlefield.

The need for a standing committee to ensure that the TCCC guidelines are updated as necessary to reflect both new advances in prehospital medicine and battlefield experience with TCCC was identified in the original 1996 TCCC paper. The CoTCCC was established in 2001 and is now part of the Defense Health Board.

The TCCC guidelines are published every 4 years in the Prehospital Trauma Life Support manual. It has been recognized that TCCC guidelines and curriculum will need to change more often than the 4-year cycle of the PHTLS textbook publication. NAEMT will include the updated TCCC guidelines and curriculum on its website as they are approved as a way to help get this new information out to the combat medical personnel in the military who need it.  


TCCC Guidelines in pdf

Tactical Combat Casualty Care (TCCC) and Tactical Emergency Casualty Care (TECC) Courses By NAEMT PreHospital Trauma Life Support (PHTLS)
Dr. Ramon Reyes Diaz, MD with Dr. Frank : Butler, Jr, MD

Frank K. Butler, Jr., MD PHTLS Consultant to the Committee on Military Medicine Email: Frank.Butler@med.navy.mil Frank K. Butler, Jr., MD, is retired as Captain, Medical Corps, U.S. Navy and is staff ophthalmologist for the Naval Hospital, Pensacola, Fla. He currently chairs the Committee on Tactical Combat Casualty Care and serves as a medical consultant for the Navy Medical Lessons Learned Center. He also serves as president of DSO Medical Consultants, LLC, and as a member of the board of the Undersea and Hyperbaric Medical Society. In addition to serving as a member of the PHTLS Executive Council, Butler is a member of the NOAA Diving Medical Review Board and an ophthalmology consultant for Diver’s Alert Network. Previously, Butler was command surgeon for the United States Special Operations Command; editor, Journal of Special Operations Medicine; and chair, USSOCOM Biomedical Initiatives Steering Committee. He served as a surgeon through the Joint Task Force Five in Afghanistan in 2003 and as Biomedical Research Director for Naval Special Warfare Command. He’s also worked as Chief of Ophthalmology, Naval Hospital Pensacola; Diving Medical Research Officer, Navy Experimental Diving Unit; Platoon Commander for SEAL Team One and Platoon Commander for Underwater Demolition Team Twelve. After attending the Georgia Institute of Technology and earning his M.D. from the Medical College of Georgia, Butler worked as an intern in family practice at the Navy Regional Medical Center, Jacksonville, Fla., from 1980-1981. He completed his ophthalmology residency at the National Naval Medical Center, Bethesda, Md., and served as chief resident, Undersea Medical Officer Training, Navy Undersea Medical Institute. Butler is a Fellow of the American Academy of Ophthalmology and a member of the Undersea and Hyperbaric Medical Society, Special Operations Medical Association, Association of Military Surgeons of the United States, American Medical Association and Wilderness Medical Society. He has published in more than 20 publications, textbooks and symposiums, including for the Undersea Medical Society, Ophthalmology, and the Annals of Surgery.

Tactical Combat Casualty Care (TCCC) and Tactical Emergency Casualty Care (TECC) Courses By NAEMT PreHospital Trauma Life Support (PHTLS)

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Tactical Combat Casualty Care (TCCC) and Tactical Emergency Casualty Care (TECC) Courses By NAEMT PreHospital Trauma Life Support (PHTLS)

TERRORISMO Y SALUD PÚBLICA - "GESTIÓN SANITARIA DE ATENTADOS TERRORISTAS POR BOMBA"

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