Fall - United States Special Operations Command

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Tactical Field Care. Furthermore, there are now several small, light commercial IV fluid warmers that can readily be carried in vehicle kits and helicopters for use in TACEVAC care. A Proposed Change – Fluid Resuscitation in TACEVAC was presented by CAPT Jeff Timby. CAPT Timby pointed out in his position paper on changing the fluid resuscitation guidelines in Tactical Evacuation Care that the current recommendations: 1) do not call for use of blood pressure measurements where these may be available during TACEVAC; 2) could be interpreted to call for use of more than 1000ml of Hextend when this has not been recommended; 3) do not reflect the current theater practice of giving PRBCs and thawed plasma in a 1:1 ratio; 4) call for Hextend to be used initially instead of plasma and PRBCs if both are available; and 5) should be modified to base decisions on fluid resuscitation in casualties with TBI on pulse character or measured blood pressure, not mental status. Wednesday 4 August The Committee revisited the preferred features for cricothyroidotomy sets, and approved the following clarifications to the list: - The set or its individual components must be FDA-approved - Scalpel: #10 blade - Should include a trach hook or other instrument to help define and expose the opening - Tube features: 6-7 mm internal diameter Balloon cuff Flanged 5-8cm intratracheal length - 5cc syringe to inflate cuff - Ruggedized IAW Mil Std 8.10G The Committee also revisited the preferred features for chest seals and approved the following clarifications to the list: - FDA-approved - Ruggedized IAW Mil Std 8.10G - Non-valved - Packaged two per package The Potential Changes to the CoTCCC Guidelines were discussed by Dr. Frank Butler. 1) Maximum amount of Hextend to be used: Several committee members noted that the evidence that 1000ml is the maximum volume of Hextend that can be used without risking a Hextend-related coagulopathy is limited – the paper by Gan et al., suggests that larger volumes might be safe. Dr. Butler noted that the patients in the Gan paper may have received blood component therapy in addition to the reported volumes of Hextend. 2) Fluid resuscitation in controlled vs uncontrolled hemorrhage: Drs. Otten and Gandy noted that a specific goal for fluid resuscitation in controlled hemorrhage should be established. The best example of this type of hemorrhage on the battlefield is isolated extremity hemorrhage that has been effectively controlled with a tourniquet. Dr. Champion noted that shock may be considered to exist at a blood pressure lower than 105 systolic in trauma patients. 3) King LT Airways: An e-mail was received from LTC Marty Schreiber, the Deployed Director of the Joint Theater Trauma System (JTTS) asking that the CoTCCC review the possible use of the King LT airway in light of the failed surgical airways that have been noted in the weekly JTTS Trauma Teleconferences. Surgical airways have emerged as the most technically challenging lifesaving intervention that medics and corpsmen (and other prehospital providers) are undertaking on the battlefield at present. Committee members noted that while the King LT has been found to be effective in cardiac arrest patients in the civilian sector, most airway deaths in combat casualties are related to maxillofacial and/or neck trauma and that the efficacy of the King LT in preventing deaths in these types of casualties has not been established. Casualties who are not unconscious from profound hypovolemic shock or severe head trauma do not tolerate King LTs well. MAJ Mabry also noted that there is a significant incidence of trismus in traumatic brain injury (TBI) casualties that makes insertion of the King LT difficult. Proposed actions included: a) modifying the Lessons Learned presentation in the TCCC curriculum to emphasize that unconsciousness alone is not an indication for a surgical airway and that in casualties who have sustained maxillofacial trauma and are having trouble maintaining their airway, the first measure that should be used, if feasible, is the sit-up and lean-forward airway position; b) CoTCCC tracking of surgical airways in the weekly Trauma teleconferences; and c) a research effort was proposed to evaluate various train- 84 Journal of Special Operations Medicine Volume 10, Edition 4 / Fall 10
ing methodologies for surgical airways with successfully accomplished cadaver procedures to be used as the definitive outcome measure. 4) Pyng FAST-X: HMCM Sine noted that the Pyng FAST-X might be a preferred IO device once it is approved by the FDA. The Preferred Features – Intraosseous Devices was revisited by the committee. The following features were approved: - FDA approved - Sternal insertion site as the primary (Clearly labeled for site of insertion and needle size) - Big bone insertion site if desired as a backup (Clearly labeled for site of insertion and needle size) - Easily inserted without the need for powered devices - Supports infusion of all prehospital resuscitation fluids - Latex-free - Minimum flow rate of 125cc/min - Self-retaining once inserted - Able to be removed without the need for a removal tool - Easily trained for battlefield or simulated battlefield environments - Compatible with other systems via a standard luer-lock - Able to be left in place for up to 24 hours - Sterile, trauma-resistant packaging - Meets MILSTAN 8.10G - Shelf life: three years minimum; five years goal - Used with high rate of success in battlefield reports when available - Includes attachments and instructions to facilitate training - High rate of user acceptance when data is available - Device facilitates ease of use in low light environments - Minimal chance for provider injury - Minimal chance for retained parts of device after removal - Unlikely to be traumatically displaced - Bag friendly – minimal weight and cube - malleable - Low rate of complications from battlefield use Additional comments from the group on this topic were: - It is more important that the device stay in than that it be easily removed; - Other sites besides the sternum should be included as options; - The provider may be unsuccessful in his first attempt and should have an alternate site as a backup; - The casualty’s body armor must be removed in order to use a sternal IO insertion site; - Tibial IOs are very painful during fluid infusion; - It is harder for medics to do tibial insertions than sternal insertions; - There have been multiple reports from AFME of tibial IO placements being done in the wrong location; - Humeral IO devices are more likely to be traumatically displaced than sternal IOs; - There will not be any power drills in my aid bag. Proposed Change - Hypothermia Prevention was discussed by the Committee and the following changes to the TCCC Guidelines were approved by a unanimous vote: (changes in bold red text on page 87 &90) g. Protect the casualty from wind if doors must be kept open. Proposed Change – Fluid Resuscitation in TACEVAC presented by CAPT Jeff Timby. The Committee unanimously approved the following changes to the TCCC Guidelines: (changes in bold red text on page 87 & 90) For the following supporting attachments please go to the PHTLS website at http://www.naemt.org/education/PHTLS/TCCC.aspx. 1) Position Paper for Hypothermia Prevention Change to the TCCC Guidelines 2) Position Paper for Fluid Resuscitation Change to the TCCC Guidelines TCCC Updates 85
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Volume 10, Edition 4 // Fall 10 Jou
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Fall 10 Volume 10, Edition 4 FEATUR
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From the Editor III
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MSgt Mike Maroney renders a salute
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medical system. 14 Although there a
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were collected using the University
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of VO 2max at lactate threshold (%V
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Figure 4: Anatomic location of the
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Warrior Model for Human Performance
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pacity testing should be incorporat
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During the O-Course training, physi
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triathletes was approximately seven
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52. Myer GD, Ford KR, Barber Foss K
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Jennifer B. Deluzio, MS Neuromuscul
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such isolated training increase the
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panied by an improvement in the fle
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Warrior Model for Human Performance
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sessions) with a range of 54-100%.
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side of daily Army PT. Finally, it
Page 39 and 40: musculoskeletal overuse injuries. A
Page 41 and 42: War on Terrorism, which lists as it
Page 43 and 44: MATERIEL AF PM has the most of the
Page 45 and 46: failed to reach the summit. All mem
Page 47 and 48: Scapula Fracture Secondary to Stati
Page 49 and 50: Image 2: Scapular-Y view taken appr
Page 51 and 52: Public Health Foodborne Illness Cas
Page 53 and 54: 1. Determine that an outbreak has o
Page 55 and 56: INTRODUCTION Traumatic Brain Injury
Page 57 and 58: There are four computer-based model
Page 59 and 60: Figure 4: Casualty 1 Composite Scor
Page 61 and 62: testing over 450 Soldiers in less t
Page 63 and 64: Reply from ANDRE PENNARDT, MD, FACE
Page 65 and 66: LTC Coppedge was an energetic, as w
Page 67 and 68: of these twelve week courses was si
Page 69 and 70: 3. Interview with Colonel (COL) Hel
Page 71 and 72: had values above the 95th percentil
Page 73 and 74: Special Ops Crew Recognized For Lif
Page 75 and 76: Dawn Over Baghdad: How the U.S. Mil
Page 77 and 78: Peter J. Benson, MD COL, USA Comman
Page 79 and 80: for our Partner Nations (PN). In 20
Page 81 and 82: Neuro-cognitive Assessment Metrics
Page 83 and 84: Warner D. “Rocky”Farr, MD COL U
Page 85 and 86: LTC Craig A. Myatt, PhD HQ USSOCOM
Page 87 and 88: Excerpts from the Committee on Tact
Page 89: guidelines also support IO as the p
Page 93 and 94: d. When time and the tactical situa
Page 95 and 96: - Nasopharyngeal airway - Allow cas
Page 97 and 98: 14. Burns a. Facial burns, especial
Page 99 and 100: Tactical Combat Casualty Care Burn
Page 101 and 102: 7. All TCCC interventions can be pe
Page 103 and 104: Critical Care Credentials for the S
Page 105 and 106: Meet Your JSOM Staff EXECUTIVE EDIT
Page 107 and 108: Special Forces Aidman's Pledge As a
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Fall - United States Special Operations Command

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