COMBAT

CASUALTY CARE

MANUAL

CIOMR GUIDELINE Following TCCC/CLS principles and conforming to STANAG 2122

V4.4 2021

ALGORITHM details on following pages

- Always think security and call for help ASAP! - Master Drill: under fire / hostile / safe  CUF<>TFC - Multiple casualties: perform triage - Assess / treat individual casualty / casualties (MARCH) M. stop massive external bleeding A. alertness and airway

conscious unconscious (page 4)

airway check mouth / open airway (page 3) listen for passage of air

R. respiration present absent (page 3) maintain airway

(semi?)/permissive non permissive

BLS (page 12) casualty is DEAD if successful: maintain airway C. circulation (page 5)

H. hypothermia prevention & head injury then: - pain relief - antibiotics - eye injuries - burns - fractures - other wounds - communication - continuous re-assessment / treatment / triage - documentation - positioning & preparation for evacuation - evacuation with hand-over 13

BASIC LIFE SUPPORT (BLS) MASTER DRILL is appropriate in SAFE environment; Assess: - under fire (non-permissive) is occasionally considered in hostile environment - hostile/safe environment (semi-permissive/permissive)

Casualty is unresponsive; breathing is absent 1. Under fire / threat (→ Care Under Fire ) (NOTE: “gasping” equals absent breathing) (non-permissive) - win the fight; prevent injuries to self and the casualty

- direct casualty to get under cover and apply self-aid 1. Get help - as directed by commander-on-scene: 2. Place heel of one hand on lower half of breastbone * extricate casualty from burning vehicles/buildings 3. Place 2nd hand on top of 1st hand * move casualty to place of relative safety 4. Compress chest perpendicularly - when feasible: depth: 5-6 cm * stop life threatening external bleeding rate: 100-120/min tourniquet (applied over the uniform 5. After 30 compressions, give 2 rescue breaths - high on the limb (“mouth-to-mouth”) in max. 10 seconds - otherwise 7 cm proximal to a readily visible wound Don’t wait for 2nd exhalation; resume compressions * turn unconscious casualty on belly / side 6. Alternate 30 compressions with 2 breaths - NO FURTHER EXAMINATION or TREATMENT 7. Maintain until: - don’t leave casualty and/or weapons behind - casualty begins to breathe/move - when no longer under fire, re-assess: go to # 2 - exhaustion of caregiver sets in - BLS is taken over by other personnel 2. Hostile / Safe environments (→ Tactical Field Care ) (semi-permissive / permissive) 8. If BLS successful but casualty still unconscious - revert to CUF if tactical situation deteriorates - maintain airway by nasopharyngeal airway - call for help follow NATIONAL guidance - secure the area if necessary - and/or turn casualty on side / in recovery position - use Personal Protective Equipment go to page 3 R. Respiration - enemy casualties: apply flex-cuffs / disarm - move casualties from immediate threats if possible - own troops with altered consciousness: disarm, look / ask for additional weapons, remove comms equipment - assess number of casualties * multiple: triage, assess, treat go to page 2 TRIAGE * single: assess, treat go to page 3 MARCH 12 1

TRIAGE and TREATMENT of MULTIPLE CASUALTIES 5. environmental injuries - hyperthermia (overheating) TRIAGE FIRST, TREAT NEXT (evolving from cramps thru discomfort/headache to

“QUICK”: “Walking” T3; “NOT Walking but shouting” T2; “Silent” T1 loss of consciousness) (until further notice) → move to cool place “FORMAL”: → drinks if conscious → cool actively (fan, rinse, wet sheet) → evacuate if YES WALKING ? INJURED DELAYED T3 unconscious

NO - hypothermia (chill) NOT (evolving from shivering to bizarre behavior to loss INJURED T1 CPR DEAD of consciousness) if available → move to warm place NO OPEN → replace wet clothes BREATHING ? the BREATHING → use buddy heat YES AIRWAY YES turn pt. on side → give warm fluids (NO LIFE alcohol) if conscious YES IMMEDIATE T1 THREATENING → evacuate if unconscious LIMB BLEED ? IMMEDIATE T1 TOURNIQUET 6. battle stress (withdrawn, suspicious, frightened, RESPIRATORY can’t count to 10 IMMEDIATE T1 aroused, talkative, risk taking) DISTRESS ? in 1 breath → disarm NO → ALSO ASSESS

RADIAL PULSE absent on both sides FOR INJURIES IMMEDIATE T1 ? → support by buddies

YES → if ineffective: evacuate doesn’t follow orders IMMEDIATE T1 FOLLOWS ORDERS ? follows orders URGENT T2

NOW assess and treat each individual casualty, in order of T1(Airway), T1(Breathing), T1(Circulation), T1(Disability), T2, T3

go to page 3 MARCH 2 11

FULL EXAMINATION only if feasible (tactical, climate) ASSESSMENT / TREATMENT of EACH CASUALTY

1. wounds (expose; look also for exit wounds !) MARCH (only in TFC !) → cover with dressings M. Massive bleeding (pat casualty down !) (chest: vented/non-vented seal) - Limbs * tourniquet, 7 cm proximal to exposed wound → remove rings * check bleeding and palpable distal pulse protruding gut → do not push back * if necessary: apply 2nd Tq, just proximal to 1st → use wet dressing * then write T+time on strap(s) and/or casualty visible brain → do not compress - Other * direct pressure / hemostatic dressing + 3 foreign objects → do not remove minutes pressure / pressure dressing bones → do not push back (splint as found) A. Airway (+ alertness/level of consciousness+ neck) 2. “hidden injuries” (blast and blunt trauma) Shout chest: shortness of breath, external markings - no reply, eyes closed, no movement abdomen: pain, rigidity, external markings (unconscious casualty) go to page 4 → evacuate - casualty reacts (conscious casualty): 3. spine injuries listen / ask what’s wrong (pain in neck/back, tingling, paralysis) - if voice is clear: go to R. Respiration (unclear in unconscious casualties !) - if voice is hoarse/breathing is noisy: → immobilize spine, if tactical situation * permit casualty’s preferred posture permits and if equipment is available * inspect mouth; clean if necessary NOTE: securing the airway and removing a casualty from * follow NATIONAL guidance on danger has priority over immobilizing the spine ! insertion of nasopharyngeal airway 4. freezing injuries Immobilize neck of casualty (only in blunt trauma) - frost nip go to R. Respiration (pale, no feeling, elastic skin) → rewarm w/ body heat R. Respiration - frost bite (1st, 2nd, 3rd degree) Check rate (pale, no feeling, rigid skin) → cover, no pressure - >30/min or inability to count to 10 in one breath: → evacuate distress  chest injury, blast, shock (get help !) → treatment in MTF - <10/min:  head injury (get help !) - trench foot (pale/blue, blisters) - ASAP apply seal (vented/non-vented/improvised) on → dry, don’t rub ALL chest wounds (also check back !) → do not burst blisters - if casualty deteriorates, remove/burp seal temporarily → evacuate go to page 5 C. Circulation 10 3

UNCONSCIOUS CASUALTY Nine-liner Line 1. Location of the pick-up site Casualty doesn’t react to shouting (no reply, eyes closed, no Line 2. Radio frequency, call sign, and suffix movement) Line 3. Number of patients by precedence: • A – Urgent • B – Urgent Surgical 1. Inspect mouth, remove debris (blood, vomit, teeth) • C – Priority • D – Routine 2. Open airway (chin lift or jaw thrust) • E – Convenience Line 4. Special equipment required: 3. Listen for passage of air (for max 10 seconds) • A – None - present • B – Hoist • C – Extraction equipment * maintain airway by nasopharyngeal airway • D – Ventilator follow NATIONAL guidance Line 5. Number of patients: * and/or turn casualty on side / in recovery position • A – Litter (right now or after completion of MARCH) • B – Ambulatory * if possible, immobilize neck in blunt trauma Line 6. Security at pick-up site: go to page 3 R. Respiration • N – No enemy troops in area • P – Possible enemy troops in area (caution) - absent in non-permissive environment • E – Enemy troops in area (approach with caution) * casualty is most likely DEAD • X – Enemy troops in area (armed escort required) Line 7. Method of marking pick-up site: • A – Panels - absent in semi-permissive environment • B – Pyrotechnic signal * occasionally BLS can be considered • C – Smoke signal * if torso trauma is also present, • D – None follow NATIONAL guidance or refer to Medic for • E – Other potential bilateral needle decompression; Line 8. Patient nationality and status: if breathing returns • A – Coalition Military • B – Coalition Civilian go to page 3 R. Respiration • C – Non – coalition Military • D – Non – coalition Civilian - absent in permissive environment • E – EPW go to page 12 Basic Life Support • F – High Value Target Line 9. Obstacles at pick-up site

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COMMUNICATION C. Circulation - check tourniquets that were applied during CUF METHANE message ( to report and call for help) * expose wounds “Me” (who’s calling) * if still bleeding and/or distal pulse still palpable: Exact location (GPS, map grid, “description”) tighten Tq / apply 2nd Tq Type of incident (firefight, IED, etc) * if not bleeding and transportation time > 2 hours: Hazards (unexploded ordnance, chemicals, etc) move Tq in “2 step” procedure from “high” on limb to Accessibility 7 cm prox. of wound, directly on skin Number and type of casualties/injuries (not for casualty in shock / with traumatic amputation) Expected/required help (helo, armoured ambulance etc) - keep tourniquets visible (not covered by equipment) - check for shock: * weak / absent bilateral radial pulse ATMIST handover (to medical personnel) * ↓ mental status without head injury Adult <>child (age) * sweaty; pale / grey Time of injury * respiratory distress / rate >30/min Mechanism of injury * heart rate >120/min (radial/carotid) Injuries found and/or suspected - assess/stop other external bleeding (check the back!) Signs:airway,respiratory(rate),pulse(rate),consciousness * expose Treatment given * apply direct pressure / elevation / pressure dressing / hemostatic dressing with pressure / (tourniquet) EVACUATION * if tourniquet is used: write T+time on strap / casualty 1. call for evacuation, as early as possible, using NATO : check result / keep Tq visible (nineliner, page 15) or national procedures - stop internal bleeding in fractured limbs by splinting 2. re-examine casualty and re-triage after treatment - NATIONAL guidance on drinking, i.v.access, i.v.fluids 3. evacuate in order of T1 (A,B,C), T2, T3 - refer casualties in shock to Medic 4. unresponsiveness / tourniquet / burnt airway as T1 5. this may be overruled by higher echelon H. Hypothermia prevention - remove wet clothing, if feasible DEATH - cover the casualty; use any available equipment 1. unmistakable signs: decapitation, lividity, decomposition Head injury 2. during treatment: permanent loss of respiratory activity - look for, recognize, report and cardiac activity * altered consciousness, amnesia, disorientation 3. remove tags and personal effects (NATIONAL guidance) * headache, dizziness, nausea, vomiting 4. make every effort not to leave the dead behind * tingling of fingers, ringing in ears Next: 8 5

7. communication 1. pain relief patient (always talk, encourage, explain) - follow NATIONAL guidance leadership (Methane) (page 8) 2. antibiotics evacuation system (9-liner, page 9) or team leader - follow NATIONAL guidance 8. re-examination, re-treatment, re-triage ! 3. penetrating eye injury 9. documentation - do not remove foreign objects - findings and treatment on Casualty Card - cover with hard shield (or own ballistic eye protection) - time of application on tourniquet(s) 4. burns 10. positioning all burns: - follow NATIONAL guidance for fluids rate NOTE: positioning also depends on tactical situation - prevent hypothermia - conscious casualty - estimate total body surface area burned * in general: position preferred by casualty flames: - do not remove adhering clothes * burnt airway: (half) upright position - cool for 10 minutes * injuries to the eye: (half) upright position - large blisters may be burst * chest injuries: (half) upright position - cover burnt area * abdominal injuries: supine, with bent knees (if no - caution: airway burn (see: A Airway) fractures in legs or spine) chemical - remove soaked clothes (caution) - unconscious casualty / casualty in shock - rinse for 30 minutes * recovery position (NATIONAL guidance) - cover burnt area * on injured side, unless foreign object in place phosphorus - rinse * on back with protection of airway (chinlift) - cover with wet dressing (keep dressing wet!) (ONLY in safe environment) 5. fractures - head injured casualty: upper body slightly elevated - give pain relief 11. preparation for evacuation - cover wounds - secure all loose ends of bandages and wraps - immobilize (device or improvised) - secure hypothermia prevention wraps/blankets/straps - check pulse/function before/after - secure litter straps as required 6. other injuries - consider additional padding for long evacuations - expose - provide instructions to ambulatory patients as needed - if necessary cover with appropriate dressing - stage casualties in accordance with unit SOPs (may be overruled by higher echelon) “Full examination” only if feasible (tactical, climate) (page 10) 12. hand-over to medical personnel (AT MIST) (page 8)

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