TACTICAL COMBAT CASUALTY

CARE (TCCC)

BY SSGT WASIKE
 OBJECTIVE
By The End Of The Lesson The Student
Should Be Able To Correctly:

1. Explain And Describe The Phases Of

Care In Tactical Combat Casualty Care
(TCCC)

2. Identify The Causes Of Preventable Death

On The Battle Field.
 SCOPE
1. Introduction To (Tccc)

2. Care Under Fire (Cuf)

3. Tactical Field Care ( Tfc)

4 Casualty Packing, Evacuation And

Handover( Prolonged Field Care
(Pfc)

5. Methods Of Carriage
 INTRODUCTION
This Approach Recognizes A
Particularly Important Principle:
⚫ To Perform The Correct Intervention At The
Correct Time In The Continuum Of
Combat Care
⚫ A Medically Correct Intervention
Performed At The Wrong Time In
Combat May Lead To Further Casualties
 INTRODUCTION

Goals Of Tactical Combat Casualty Care (Tccc)

Are:
1. Save Preventable Deaths

2. Prevent Additional Casualties

3. Complete The Mission

 PREVENTABLE CAUSES OF COMBAT
DEATH

 60% Hemorrhage From Extremity

Wounds
 33% Tension Pneumothorax

 6% Airway Obstruction, E.G.,

Maxillofacial Trauma
 FACTORS INFLUENCING
COMBAT CASUALTY
CARE

 Enemy Fire

Medical Equipment Limitations

 Widely Variable Evacuation Time

 IMPORTANCE OF TIME

⚫ The golden hour – where intervention

can make a significant difference
⚫ Platinum 10 minutes – where intervention
can make the most difference
STAGES OF CARE(3 DISTINCT PHASES)

1. Care Under Fire (Cuf)

2. Tactical Field Care ( Tfc)

3. Casualty Packing, Evacuation And

Handover( Prolonged Field Care)
(Pfc)
ANY QUESTION
[Link] UNDER FIRE
 CARE UNDER FIRE

 “The Best Medicine On Any Battlefield

Is Fire Superiority”

 Medical Personnel’s Firepower May

Be Essential In Obtaining Tactical Fire

Superiority
 CARE UNDER FIRE

 Attention To Suppression Of

Hostile Fire Will Minimize The Risk

Of Additional Injuries Or
Casualties
 CARE UNDER FIRE
Prioties.
 Getting the casualty out of killing zone
 Treatment of immediate life threatening
injuries
Safety
self – cover, safe area ppe.
scene – operationally available
e.g. win
firefight
4 c’s (confirm, clear,
cordon, control)
[Link] PACKING, EVACUATION AND
HANDOVER PROLONGED FIELD CARE (PFC)
 CARE UNDER FIRE
CASUALTY ACTION
(If able the casualty needs to)
 Move or crawl to cover
 Self-apply a field dressing
or tourniquet
 Consider retuning fire
 If unable to extract into cover or
return fire stay still to avoid drawing
enemy fire.
 CARE UNDER FIRE

TEAM ACTION
Win the fire fight
Call for help/arrange evacuation
 Vehicle may used to provide
cover (APC)
Extraction plan
 CARE UNDER FIRE
MEDICAL ACTION.
 Find safe cover
 Return fire
 Communicate with the casualty
 Advise to provide self-treatment
May throw tourniquet or
bandage
 Drag harness may be utilized
Move the casualty to cover
when safe.
 CARE UNDER FIRE
Medical Priorities

Dangers- To Yourself Or The Casualty

Safety Win Fire Fight

C-Catastrophic Haemorrhage (tourniquet)

Airway- Does The Casualty Have A Clear

Airway?

Breathing- Is The Casualty Breathing?

 C-CATASTROPHIC HAMORRHAGE
(TOURNIQUET)

 Hemorrhage from extremities is the 1st

leading cause of preventable combat

deaths

 Prompt use of tourniquets to stop the

bleeding may be life-saving in this phase

TOURNIQUETS
 C-CATASTROPHIC HAMORRHAGE
(TOURNIQUET)

Importance

 Understanding catastrophic hemorrhage

 Know how to stop catastrophic

hemorrhage
 C-CATASTROPHIC HAMORRHAGE
TYPES

 Severe

 Sustained

 Uncontrolled

 Life Threatening

 Do Not Sort Out Airway And Breathing While The Tap

Of Life Has Been Turned On And Is Running NO ----

TURN THE TAP OFF
 C-CATASTROPHIC HAMORRHAGE
CONTROL

⚫ Direct Pressure
⚫ Indirect Pressure
⚫ Elevation

⚫ Haemostatic Dressing
⚫ Tourniquet
 C-CATASTROPHIC HAMORRHAGE
(TOURNIQUET)

⚫ Types of bleeding
 Compressible- Blood Vessels Can Be Pressed
Against An Adjacent Bone To Stem Bleeding .This
Can Be Accomplished On Limb
 Non –Compressible – No Way To Stem Bleeding By

Pressing For Instance Internal Bleeding, Groin Or

Neck
 C-CATASTROPHIC HAMORRHAGE
(TOURNIQUET TIPS)

 Place As Low As Possible

 Think About Other Injuries

 Ensure Tight Enough

 Remember Analgesia

 Note Time – Write On Patient Or Tourniquet

 C-CATASTROPHIC HAMORRHAGE
(TOURNIQUET TIPS)
 Tourniquet Application

 As Close To Wound As Possible

 Can Stay On A Limb For At Least 2 Hours Without

Detriment
 Apply Until Bleeding Is Significantly Reduced

 Tight Application Is Painful

 May Still Be Bleeding From Small Vessels And Bone

 Loosely Applied Can Worsen Bleeding (Stops Venous Return)

 Note Time And Ensure Included In Handover

 Re-assess And Apply Hemorrhage Control Dressing

 A-AIRWAY - IS IT CLEAR?
If The Casualty Is Unresponsive You Must Ensure
The Airway Is Clear Of Any Obstructions

Injury to
the
tongue
A-IRWAY, WITH C -SPINE MANAGEMENT AND OXYGEN
THERAPY
Importance
 Know How To Assess And Threat Airway Problems

 Know When To Consider The Cervical Spine And

How To Manage It
 Know How To Give Oxygen Safely

 If The Casualty Airways Is Blocked They Can

Not Breath
 5-7 Minutes Before Irreversible Brain Damage
Occurs
 A-IRWAY, AIMS OF AIRWAY MANAGEMENT
Open
 Clear

 Maitain

 NB If The Casualty Is Talking , Shouting Or Crying

Then The Airway Is Likely To Be Open , Clear And

Maintained
 A-IRWAY, POSSIBLE CAUSES OF AIRWAY
OBSTRUCTION

 Tongue (Unconscious Casualty)

 Blood, Secretion Or Vomit

 Debris Or Mechanical Obstruction

 Spasm Of The Larynx E.G From Drowning

 Swelling Of The Tongue And Upper Airway E.G

From Burns
 A-IRWAY, RECOGNITION OF AN AIRWAY PROBLEM

 LOOK

 LISTEN

 FEEL
LOOK for chest movement
 A-IRWAY, RECOGNITION OF AN AIRWAY PROBLEM
Look
 Visible Obstruction

 Blood And Vomit

 Respiratory Distress

 Pulling In Of Neck And Chest Muscles

 Casualty Clutching At Throat

 Unconscious

 Severe Facial Trauma

 Facial Airway Burns

LISTEN for breath sounds
 A-IRWAY, RECOGNITION OF AN AIRWAY PROBLEM

Listen
 Snoring

 Noisy Breathing

 Gurgling

 Stridor (Noise On Breathing In)

 Silence (No Breathing)

FEEL for expired air on your cheek
A-IRWAY, AND CERVICAL SPINE MANAGEMENT AND
OXYGEN THERAPY

 Keep It Simple

 Control C –Spine (Manage The

Airway)

C- Spine
 Mechanism Of Injury

 Manual In Line Stabilization

 Later, Collar, Head-block And Tape

 A-IRWAY, AND CERVICAL SPINE MANAGEMENT
AND OXYGEN THERAPY

 Mechanism Of C Spine Injury

 Fall From Height > 2m

 Fall On Head

 Ejection From A Vehicles

 Vehicles Rollover

 High Energy Transfer RTC

 Significant Blunt Trauma Above Clavicles

 Major Trauma
 A-IRWAY, AND CERVICAL SPINE MANAGEMENT

Signs And Symptoms

 Significant Head Injury

 Neck Pain Or Tenderness

 Arms Numbness/Pins Needles

 Arms Weakness
A-IRWAY, AND CERVICAL SPINE MANAGEMENT AND
OXYGEN THERAPY
Oxygen

Oxygen Is A Life –Saving Drug

Oxygen Can Be Used For All Trauma And

Medical Emergencies Especially
 Respiratory Arrest Or Reduced Conscious Level

 Ashma ,Heart Attack, Smoke Inhalation

 Severe Trauma ,Shock

 A-IRWAY, AND CERVICAL SPINE MANAGEMENT AND
OXYGEN THERAPY
How To Use Oxygen
 Check Safe To Use(naked Flames, Smoking, Defibrillation)
 Check Expiry Date
 Turn On Valve
 Check Pressure
 Turn On Flow Regulator
 Check Flow Of Oxygen
 Flow rate should be 10-15 litres per minutes
 Duration = cylinder capacity / flow rate
 Don’t use oil or greases on valves
 A-IRWAY, MANAGEMENT OPTIONS

 Postural (Face Down)  Simple Adjucts

 Recovery Position -OP (Oropharyngeal

 Open The Airway Np(nosopharngeal

Head Tilt And Chin Lift  Oxygen

Jaw Trust
 Suction
If casualty is unconscious and breathing
place in the Recovery Position
 AIRWAY

 Open the airway with a chin-lift or

jaw- thrust maneuver

 If unconscious and spontaneously

breathing, insert a nasopharyngeal airway

Position the casualties head Tilt
Nasopharyngeal Airway
ANY QUESTION SO FAR
[Link] FIELD CARE
 TACTICAL FIELD CARE
 Tactical field care is the care rendered by the first

responder or combatant once he and the casualty

are on longer under effective hostile fire.

 It also applies to situations in which an injury has

occurred, but there has been no hostile fire.

 Available medical equipment is still limited to that

carried to the field unit personnel.

 TACTICAL FIELD CARE
⚫ Traumatic Chest Wall Defects Should Be Closed

Quickly With An Occlusive Dressing Without

Regard To Venting One Side Of The Dressing
⚫ Also May Use An “Asherman Chest Seal”

⚫ Place The Casualty In The Sitting Position If

Possible.
 TACTICAL FIELD CARE

A. Casualty With An Altered Mental Status Should

Be Disarmed Immediately
Airway Management
Unconscious Casualty Without Airway Obstructions
C – Catastrophic Hemorrhage
A- Airway
B - Breathing
C - Circulation
D - Disability
E – Exposure/Environment
H – Handover (ATMIST)
CASUALTY PACKING, EVACUATION AND HANDOVER
PROLONGED FIELD CARE (PFC)

⚫ Wound Care
⚫ Fluid Maintenance

⚫ Analgesia And Antibiotics

⚫ Packaging

⚫ Documentation

⚫ Handover
 REVIEW C-A-
C Catastrophic Hemorrhage (Re Check)
A (Not Clear)
Remove Obstruction
Head Tilt
Jaw Thrust
Maintaining Airway( Mention)
NP( Nasopharyngeal)
Op(oropharyngeal )
(LOOK, LISTERN AND FEEL
 TACTICAL FIELD CARE
B. Casualty With Airway Obstructions Or Impending Airway Obstructions.

Airway

C – Catastrophic Hemorrhage

B –Breathing

C –Circulation

D – Disability

E –Exposure

H – Handover (ATMIST)
 B- BREATHING

Check for Breathing

LOOK(movement {chest/abdomen})
LISTEN(breath sounds)
FEEL(breath, movements)
For a maximum of 10 seconds
 B- BREATHING
Life Threatening Injuries
 Airway

 Tension Pneumothorax

 Open Chest Injury (Sucking Chest Wound)

 Massive Haemothorax

 Incursion Flail Chest

 Cardiac Tamponade

 Bomb –Blast Lung

 TENSION PNEUMOTHORAX

⚫ Tension Pneumothorax Is The 2nd Leading Cause

Of Preventable Death On The Battlefield
⚫ Cannot Rely On Typical Signs Such As Shifting
Trachea, Etc.
⚫ Needle Chest Decompression Is Life-saving
 Tension pneumothorax

 Injury Act As Flap –Valve And Air Gradually Fills

The Pleural Space

 Pressure Builds, Reducing Effective Ventilation

 The Lungs Collapses And Pressure Is Placed On Vessels

Returning To Heart
 The Other Lung Becomes Compromised
 B- TENSION PNEUMOTHORAX
 Signs And Symptoms

 Difficulty In Breathing

 Increasing Distress

 Increasing Shock

 Increasing Respiratory Rate

 Chest Wall Over Inflated And Splinted

 Surgical Emphysema

 Percussion Hyper Resonant

 Neck Veins Enlarged(late Sign)

 Trachea Move Away From Injured Side (Late Sign)

 B- TENSION PNEUMOTHORAX

Management
 Release Of Air To Reduce Pressure

 Needle Decompression(large Cannula 14-16g Syringe

 Insert Into 2nd Intercostal Space (Over 3rd Rib)

 Midclavicular Line (Nipple Line)

 Look For Bubbles In The Syringe

 Do Not Remove

 Secure The Cannular

Needle Chest Decompression
 OPEN CHEST INJURY(OPEN
PNEUMOTHORAX)

 Signs And Symptoms

 Open Wound

 Bleeding

 Air May Be Bubbling In/ Out

 Depth Uncertain

 Patient’s Conditions May Vary

 OPEN CHEST INJURY(OPEN
PNEUMOTHORAX)
Management
 Proprietary Chest Seal ( E.G Russell Chest Seal)

 Seal Taped On Three Sides

 Complete Occlusion

 Reassess Regularly

 Risk Of Tension Pneumothorax

 MASSIVE HAEMOTHORAX
Sign And Symptoms
 Diffcult To Tell Apart From Pneumothorax

 Usually Air And Blood

 Patient May Become Increasingly Shocked

Management Requires

Chest Drain(only If Respiratory Compromise)

 FLAIL CHEST

Signs And Symptoms

 Multiple Fractures Leaving Free Segment

 May Have Paradoxical Movement

 Difficulty Breathing

 Increased Rate

 Tender Chest Wall

 Lots Of Pain
 FLAIL CHEST

Management
 Oxygen

 Analgesia

 Position on side of flail segment

 Ventilator support
 CARDIAC TAMPONADE
Sign And Symptoms
 A Build Up Blood Or Fluids In The Pericardial Sac,
Which Puts Pressure On The Heart
 This May Prevent Effective Pumping
Management
 Thoracotomy Within 10 Mins (I.E Expert Medical
Care)
 Evacuate Urgently
 BLAST LUNG

Sign And Symptoms

 Widespread Injury
 Likely To Cause Other Traumatic Injury
May Be Delayed Signs And

Symptoms Management
 CABC And Oxygen
 May Need Ventilator Support
 Basic Assessment Of Breathing(risen Twelve
And Fall)
Basic Assessment Of Chest(risen Twelve And Fall)
Rate – Respiratory Rate=breaths Per Minutes
15 Secs*4
10secs*6
30secs*2
60sec
Goal Post Of Life( 10-30) Count Per Minutes
Injuries –Front Side Back Armpits, Bruising, And
Wounds.
 Basic Assessment Of Breathing
(Risen Twelve And Fall)
Symmetry-Movement, sides equal

Effort of breathing- shortness of breath difficult in

breathing.
Neck signs
Trachea central
Wounds
Emphysema
(crunchy
feeding)
Larynx injury
 BREATHING Chest Assessment

F- Feel-normal Expansion, Tenderness.

A - Assess – Resonance, Dull, And Hyper
Resonant L – Listening To Born Side. Normal
Breathing.
L – Look- At The Back.
ANY question
C- CIRCULATION
 C- CIRCULATION
The Clotting System
Circulation
 Review Earlier
Management (I.E.
CAB )
 Look For Signs Of
Bleeding
 Control Bleeding
Where Possible
 C- CIRCULATION
 Any Bleeding Site Not Previously

Controlled Should Now Be

Addressed
 Only The Absolute Minimum Of

Clothing Should Be Removed, Although A

Thorough Search For Additional Injuries
Must Be Performed
 C- CIRCULATION
Assess Circulatory Statu

Pulses(radial Pulse)

Count The Rate

Pulse Rate = Heart Rate Normally

60-100/Min Effective Goal Posts Of Life 40-

120/Min
Presence Of Radial Pulse Means That Systolic
BP >90

Capillary Refill Time(CRT)

Forehead, Nail

Press For 5 Sec Colour Returns

<2sec Mental State

 C- CIRCULATION
CIRCULATION (Blood On The Floor And Four More.)

Look For Signs Of Bleeding

Types Of Bleeding

Capillaries ---Oozing

Veins---- Steady Flow

Of Dark Blood

Arteries----rapid Flow Or Spurting Of Bright

Blood The Clotting System

Vasospasm Constriction Of Blood Vessels

Platelets

Clotting Factor
 C- CIRCULATION
(Blood On The Floor And Four More.)

1. Chest – Injuries, Reduced Air Entry,

Dull Percussion

2. Abdomen –Bruising, Tender, Rigid

Swelling

3. Pelvis- Injuries Hip/ Low Back Pain

4. Long Bones Fractures Pain

Deformity Swelling
 C- shock
 Shock Occurs Because Of A Lack Of Circulating

Fluids Volume Or Pressure

 Bleeding-in Trauma, Hemorrhage Is The Most Likely

Causes Of Shock
 Shock –Inadequate Tissue Perfusion( I.E. Insufficient

Oxygen And Glucose)

 Untreated, It Will Lead To Organ Failure And Death
 Control Bleeding Where Possible
 C- shock
Signs And Symptoms
 Mental State (Confusion, Agitated, Drowsy)

 Colour (Pale, Blue Lips ? Sweating)

 Pulse Rate (Fast, Then Slow)

 Blood Pressure ( Low)

 Capillary Refill Time ( CRT Prolonged)

 Respiratory Rate (High , Then Low)

 C- shock
Signs And Symptoms
 He Might Feel Cold And Clammy When You Touch His
Skin.
 He Might Be Pale And Looking Anxious

 There Might Be A Blue Tinge To Extremities Such As

His Nose, Ears And Fingers.
 His Pulse Might Be Weak And Fast.

 His Breathing Might Be Shallow And Rapid.

 He Might Be Thirsty.
 C- shock

Signs And Symptoms

 He Might Complain Of Feeling Weak, Faint

And Giddy With Blurred Vision.

 He Might Be Semi-conscious Or Unconscious.

 C- shock
Management
 Control Hemorrhage

 Oxygen

 Fracture Management

 Evacuate To Definitive Care

FRACTURES
 FRACTURES
 A Fracture Is A Broken Or Cracked Bone in

the continuity of the bone.

 Correctly Treating A Casualty With A Fracture

Helps To Reduce The Pain And Prevents Further

Damage Being Caused By The Broken Bone.
 The Bone Can Be Fractured At The Point Of

Impact.
 Tactical Field Care: Additional
injuries fractures

⚫ Splint Fractures As Circumstances

Allow While Verifying Pulse And
Prepare For Evacuation
⚫ Continually Re-evaluate Casualties For
Changes In Condition
 Tactical Field Care: Additional
injuries fractures

Signs and symptoms

⚫ Pain

⚫ Loss of function

⚫ Deformity

⚫ Swelling

⚫ Tenderness
 INJURIES FRACTURES
Principles Of Fracture Splintage
 Pain Relief

 Reduce Blood Loss

 Realignment

 Minimize Movement

 Reduce Tissue Damage

 Prevent Vessel And Nerve Damage

 Assist With Evacuation

 CLOSED FRACTURE

A closed fracture is when there is no break in the surface

of

the skin over the fracture.

 Tactical Field Care: Additional
injuries fractures
Soft Tissues Injury(muscle /Tendon)
 Protection
 Rest
 Ice (Not Direct Contact, 10 Mins/Hr
 Compression
 Elevation

Dislocation (is bone displaced out of joint

Shoulder,fingers,ankles,patella (knee cap)
 C- CIRCULATION
General Assessment

Radial Pulse-pulse Rate( Heart Rate) Normally 60-100/Min

Effective Goal Posts Of Life 40-120/Min

Rates Reflects CABCD Problems

Presence Of A Radial Pulse Means Systolic BP Is Less

Than 90

Capillary Refill Time-

Forehead, Nail Bed (Press For 5 Sec Color Returns For 2

Sec)
 CHECKING CIRCULATION

⚫ Circulation (Blood On The Flour And Four More)

⚫ Purse Rate Goal Post (40-120)
⚫ Capillary Refill Time 5sec Refill 2sec
⚫ Four More(check)
⚫ Chest
⚫ Pelvic
⚫ Abdomen
⚫ Long Bones
ANY question
 DISABILITY (neurological ,head injury)

 The Brain Is A Delicate And Sensitive Structure

 Injury Occurs From Lack Of Oxygen,

Blood Supply Or Damange From Pressure
Effects
 Assessment Is As Part OF CABCDE

 Treatment Is Best Achieved By Providing Oxygen

And Managing CABCDE

 D-DISABILITY(HEAD INJURIES)
Head Injury Signs And Symptoms
 Confusion

 Memory Loss(retrograde/Anterograde)

 Loss Of Consciousness

 Blurred Vision

 Impaired Ability To Concentrate

 Fatigue/Tiredness/Sleep Disturbance

 Headache

 Dizziness/Nausea

 Fluid From Nose And Ears

D Disability (Head Injuries) assessment

A-alert
V-voice
P-pain
U-
unresp
onsive
 HEAD INJURY (AVPU AND PUPILS)
A-alert
V- Responsive To Voice
P-responsive To Pain
U-unresponsive
Pupils Assessment
P-pupils
E-equal
A-and
R-reactive To
L-light
Neurological Assessment Loss Of Consciousness
Arms Or Legs
 D-DISABILITY(HEAD INJURIES)
Management And
Monitoring
 Airway Open Clear And Maintained
 Oxygen
 Chest Injuries Are Managed
 Hemorrhage Is Controlled
 CABCDE
 Pulse
 Conscious Level
 Pupils
ANY QUESTION SO FAR
[Link] PACKING, EVACUATION AND
HANDOVER PROLONGED FIELD CARE (PFC)
 E-EVACUATIONS CONSIDERATION
⚫ AvailabilityOf Resources
⚫ Hostile Or Non Hostile Environment

⚫ Terrain

⚫ Distance And Time

⚫ Stretcher Or Sitting

⚫ Type Of Injuries

⚫ Number Of Casualties

⚫ Severity Of Casualties
 H-HARDOVER (ATMIST)
A –Age/ At For Location
(Grid) T-time
M –Mechanism Of Injury
I- Injuries
Apparent
Suspected
S-signs And Symptoms ON ARRIVA
/LCURRENT C Tourniquet
(Applied)
A. Open And Maintained
B. RR (10-30),chest
C. PR(40-120)CRT Four More
D. AVPU, PEARL
METHODS OF CASUALTY
TRASPORTATION
SUPPORT CARRY

⚫ Human Crutch
⚫ Stand At The Casualty
Injured Side, Places
His Nearer Arm
Around Your Neck And
Hold His Hand
With Your Free Hand.
⚫ Put Your Other Hand
Round His Waist And
Grasp His Clothing At
The Hip.
⚫ The Casualty Can Be
Given Additional
Support An
Improvised Walking
Stick
FIREMAN’S CARRY

⚫ Fireman’s Lift
⚫ Help The Casualty To
Stand Up
⚫ Grasp The Casualty
Right Wrist Your
Left Hand
⚫ Taking The Weight On
Your Right Should
Stand And Gently Pull
The Casualty A Cross
Both Shoulder.
SADDLEBACK CARRY
 PISTOL BELT DRAG

⚫ Dragging. When dragging a casualty: Fold

the casualty’s arms across his
⚫ chest. Grasp his smock, webbing straps or
grab handle on his body armour and
drag
⚫ him along the ground.
 NECK DRAG

• Neck Drag. To Carry Out The Neck Drag:

• Place The Casualty On His Back And Fix His Wrists
Together Firmly (Egplasticuffs).
• Kneel Astride The Casualty And Place His Tied Hands Over
Your Head.
Take The Casualty’s Weight On Your Neck And Crawl
Forward, Dragging Him
PACK STRAP CARRY
Two-Man Arms Carry
Improvised Litter with Poncho
and Poles
Free edges of poncho are
folded over the second pole.
ATMIST SENARIOS
 TRIAGE ( MULTIPLE CASUALTY)
⚫ To do the most , for the most
⚫ To sieve or priorities
⚫ First priority in major incident support
⚫ Aim is to deliver the right patient to the
right place at the right time
⚫ Used whenever patients needing
immediate help outnumber helpers
 TRIAGE
Major incident priorities
Management
Command
Safety
Communication
Assessment
Support
Triage
Treatment
transport
 TRIAGE

Priority categories
P1 immediate life saving procedure

P2 urgent intervention (4-6 hrs)

P3 delay intervention (walking wounded)

dead
MASTER DRILL
 MULTIPLE CASUALTIES
You Must Triage All 1. Assess The Priority
Casualties Before 2. Write It On Casualty’s Check Or Where Visible
Treatment 3. Move To The Next Casualty

Write T3
Walking ? YE
S
NO

Breathing Airway opening

NO procedures
STILL
DEAD
NONE
YES Starts
breathing
 MULTIPLE CASUALTIES

You Must Triage All Casualties 1. Assess The Priority

Before Treatment 2. Write It On Casualty’s Check Or Where Visible
3. Move To The Next Casualty

Airway opening STILL

Breathing NO procedures DEAD
NONE

YES Starts
breathing
Catastrophic limb bleedi ng T1
¾ prone position
NO T1
Use tourniquet

Breathing rate Under 10 or over 30/min T1

Pulse rate& Under 40 over 120/min T1

AVPU Go to drill 2
ANY QUESTION SO FAR
MASTER DRILL SENARIOS
Cardiopulmonary resuscitation

SECONDARY SURVEY
 MASTER DRILL (BLS)
STOPPAGE OF BREATHING CAN BE CAUSED BY;

 Choking.

 Suffocation.

 Swelling of the airway.

 The tongue falling back in unconsciousness.

 MASTER DRILL
(BLS)
STOPPAGE OF BREATHING CAN BE CAUSED BY
 Electric shock.

 Drowning in water, blood or vomit.

 Heart attack.

 Drugs overdose.

 Hypothermia
Cardiopulmonary resuscitation

⚫ Victims Of Blast Or Penetrating Trauma Who Has No Pulse

Should Not Be Attempted( CPR)
Cardiopulmonary resuscitation
 If Circulation Present Continue AV

 If Circulation Absent Commence CPR

 Continue Av’s At Rate Of 10 A Minute

 Casualty Breathes Place In Recovery Position

 Secondary Survey
Cardiopulmonary resuscitation
 Circulation Is Absent If The Casualty
Is:

 Not Breathing

 Not Moving

 Not Coughing
Cardiopulmonary resuscitation
 If there are NO signs of circulation or if you are unsure

start External Chest Compressions (CPR)

 CHECK FOR CIRCULATION FOR A

MAXIMUM OF TEN SECONDS

Cardiopulmonary resuscitation
 Find Base Of The Sternum (Breast Bone)

 Place The Heel Of One Hand TWO Finger Widths

Up From The Base Of The Sternum

 Cover The First Hand And Interlock The Fingers

 Kneel Close, Arms Straight, Shoulders Over

The Sternum And Press Down Vertically 4 To 5

Cms
Cardiopulmonary resuscitation
 Compressions Should Be At A Rate Of

Approximately 100 Per Minute

 Carry Out Cpr At A Ratio Of: 30 Ecc To 2av

Cardiopulmonary resuscitation
Continue CPR Until:

I. Qualified Help Arrives And Takes Over

Ii. Casualty Shows Signs Of Life

Iii. You Become Exhausted

Cardiopulmonary resuscitation
 If the casualty starts to breath place in the Recovery

Position
 Carry out Secondary Survey

 Remember CPR should continue until – Qualified help

arrives, Casualty shows Signs of Life, You become

exhausted
Cardiopulmonary resuscitation
Cardiopulmonary resuscitation
Cardiopulmonary resuscitation
SECONDARY SURVEY
INTRA –VENOUS CANNULATION IV
 INTRA –VENOUS CANNULATION IV

 Intravenous Therapy (Iv Therapy ) Is The Infusion

Of Liquid Substances Directly Into A Vein.

 Intravenous Means --- Within Vein

 ItThe Fastest Way To Deliver Fluids And

Medications Throughout The Body

 INTRA –VENOUS CANNULATION IV

Preferred Sites
 Hard; Dorsal Arch Veins
 Wrist; Volar Aspect

 Cubital Fossa

 Foot ;Dorsal Arch

 Scalp; Scalp Veins Should Only Be Used Once The

Alternatives Are Exhausted
INTRA –VENOUS CANNULATION( IV)

VEINS OF THE HAND

1. Digital dorsal veins
2. Dorsal metacarpal veins
3. Dorsal venous veins
4. Cephalic vein
5. Basilic vein
INTRA –VENOUS CANNULATION IV

VEINS OF THE
FOREARM
1. Cephalic vein
2. Median cubital veins
[Link] cephalic vein
4. Basilic vein
5. Cephalic vein
6. Median Antebrachial
vein
 INTRA –VENOUS CANNULATION IV
Why Gain Access

[Link]

 Catastrophic Bleeding

 Multiple Injuries

 Pelvic Fractures

 Internal Bleeding

2. Administration Of Drugs

3. Illness

 Heat Illness

 Diahoria And Vomiting

 Cholera
 INTRA –VENOUS CANNULATION IV
When To Give Fluids
 Severe Dehydration
 If “No Radial Pulse” Can Be Felt In A Trauma Victim
 In Penetrating Torso Trauma The Presence Of
A Central Pulse (Carotid ) Should Be
Considered Adequate.
 Head Injury
 Give 250 Ml Boluses (Sodium Chloride 0.9%) Until
Pulse Returns And Then Monitor And Titrate As
Required
 INTRA –VENOUS CANNULATION IV
REASONS WHY FLUID ARE GIVEN -IV
 For Hydration
 To Balance The Electrolytes In The Body
 With Gun Shot Wounds
 Patients Who Have Been Operated On (Surgery)
 Given To Expectant Mothers After Delivery
 Given To RTA Victims
 Given To Drunkers Who Are Unconscious
IV-GAIN
 Ways To Gain Haemorrhage Control
 Stop External Bleeding
 Reduce Fractures
 Minimal Casualty Movement
 Prevent Hypothermia
 INTRA –VENOUS CANNULATION IV
Why Hypotensive Resuscitation
 Fluids Raise The Blood Pressure Bursting
Formed Clots
 Cool The Blood And Dilute Clotting Factors

 Resulting In Increased Bleeding

 Fluids Should Only Be Given When Major

Organ Perfusion Is Impaired
 INTRA –VENOUS CANNULATION IV
TIPS IN IV PROCEDURE
 Ensure use of tourniquet which is quick release ( use gloves)
 Stay clam and be prepared ( ensure patient is comfortable and
sufficiently warm to prevent vasoconstriction )
 Grain confidence , re assure the patient
 Access the vein –ensure vein is visible, straight easly
compressed and not over the joint
 Feel rather than look
 Use an appropriate cannular size
 First quenching an un quenching
 INTRA –VENOUS CANNULATION IV

 Types Of Fluids
 Normal Saline
 Dextrose 5% ,10% ,50%
 Ringers Lactate (RL)
 Flagyl
 Paracetarmol
 Blood Products
 INTRA –VENOUS CANNULATION IV

IV EQUIPMENT
 Alcohol prep
 Tourniquet
 Iv cannula
 Iv giving set
 Tape/iv dressing
 Gloves
 Bag of iv fluid
 gauze
 INTRA –VENOUS CANNULATION IV

Types of Cannulars

G 22 ( 25mm) Blue

G20 ( 32 Mm) Pink

G18 (32mm) Green

G 16 (19 Mm ) Grey
INTRA OSSEOUS (IO )
 INTRA OSSEOUS INFUSION
(IO )
 This Is The Process Of Injecting Directly Into The

Marrow Of A Bone To Provide A Non Collapsible

Entry Point Into The Systemic Venous System
 Technique Is Used To Provide Fluids And Medication

When Intravenous Access Is Not Available Or Not

Feasible
 INTRA OSSEOUS INFUSION
(IO ) WHO NEEDS AN IO
 Acute patients
 Have limited or no vascular access
 Have an immediate need for drugs of fluids
 Require multiple iv sticks to obtain vascular access for
medication or fluid infusion
 Need access in emergencies
 Are in cardiac or respiratory arrest
 IV AND IO SUMMARY
 Prevention Of Bloods Loss First

 Hypotensive Resuscitation

 Preparation Of Equipment Is Essential

 Find Your Landmark

 Be Awere Of Complications

 Discontinue If And When Required

ANY QUESTION SO
FAR
REMOTE ROAD TRAFFIC
COLLISION
 REMOTE ROAD TRAFFIC
COLLISION
⚫ Safety, safety, safety
⚫ Assess the scene ,read the
wreckage
⚫ make plan
 early rapid access
 Vehicle stabilization
 Glass management
 Space making
 extrication
⚫ CABCDE
⚫ Command, control and
communication
 REMOTE ROAD TRAFFIC
COLLISION
Casualty extrication
⚫ Self extrication –casualty get out of the vehicle
on their own
⚫ Assisted extrication –casualty is heiped or
got out by others
⚫ Relative entrapment –casualty in pain
or doors jammed
⚫ Extrication planning –safe extrication planned
in line with casualty and situational
needs
 REMOTE ROAD TRAFFIC
COLLISION
Causes of entrapment
⚫ Unwillingness to come out
⚫ Door locked or deformed
⚫ Lack of access
⚫ Passenger cell intrusion
⚫ Pedals
⚫ Unconscious
⚫ Injuries
⚫ pain
 REMOTE ROAD TRAFFIC
COLLISION
Method of extrication
By breaking spreading, cutting
removing, The glass,taigate
dashboard
S
a
f
e
t
y
(
 REMOTE ROAD TRAFFIC
COLLISION
⚫ Assessing the scene and reading the wreckage
⚫ Scene safety and treatment of casualties
will be enhanced by understanding what
has happened
⚫ Assessing the scene
⚫ Reading the wreckage
Look at the overall scene
Indicators of rate of
deceleration Specific
damage to the vehicle Think
about mechanism of injury
 REMOTE ROAD TRAFFIC
COLLISION
Early rapid acess
Quick
assessment
Triage
Assisting in
planning
Extrication plan
A plan –
controlled
release
B plan-snatch rescue if situation
 REMOTE ROAD TRAFFIC
COLLISION
⚫ Extrication management
[Link] assessment and scene
safety 360 [Link] and
casualty access
[Link] A- non time critical
Plan B- emergency action plan
[Link] creation
[Link] access (let vehicle work
for you) [Link] and
extrication
ANY QUESTION SO FAR
REMOTE ROAD TRAFFIC COLLISION
SENARIOS
 OBJECTIVE
By the end of the lesson the
student should be able to
correctly:
1. Explain and describe the phases
of care in tactical combat casualty
care (TCCC)
2. Identify the causes of
preventable death on the battle
field.
SUMMARY
Q/A
REFERENCE:
1. PROMETHEUS MEDICAL LTD
COURSE WORKBOOK PAGE 3-47

2. PROMETHEUS MEDICAL LTD

CORE SKILLS IN PRE- HOSPITAL CARE COURSE
WORK BOOK PAGE 4-22
LINK UP.
TCCC PRACTICALS