Tactical Emergency Care Military And Operational Out Of Hospital Medicine Pdf

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Tactical Emergency medical services TEMS is out-of-hospital care given in hostile situations by specially trained practitioners.

Brian L. To reveal any potential bias in this publication, and in accordance with Accreditation Council for Continuing Medical Education guidelines, Dr. Dietrich editor in chief , Dr.

Tactical Emergency Medicine

Brian L. To reveal any potential bias in this publication, and in accordance with Accreditation Council for Continuing Medical Education guidelines, Dr. Dietrich editor in chief , Dr.

Springer author , Dr. Verbillion author , Dr. Schwartz peer reviewer , Ms. Behrens nurse reviewer , Ms. Mark executive editor , Ms.

Coplin executive editor , and Ms. Hatcher managing editor report no relationships with companies related to this field of study. Mass casualty shooting events in the United States, although rare, appear to be increasing in frequency.

Active shooter attacks have become a favored means of inflicting terror attacks. This has been a growing trend overseas for some time, with active shooter terrorist teams often carrying explosive devices or explosive suicide vests attacking targets of opportunity.

This article has the purpose of speeding the transition of military medical lessons learned from the battlefield to civilian medical response to high-risk situations. Dietrich, MD, Editor. Trauma care is an evolving specialty that has seen its greatest advances during times of war. The battlefield is an unpleasant arena that pushes the medical community to its limits to decrease the number of casualties.

The combat environment brings many challenges, including hostile fire, impaired visibility, limited resources, widely variable evacuation times, and complex wounds, that make providing quick, efficient, and appropriate medical care difficult.

Over time, it became apparent that ATLS could prove detrimental in the combat setting to both the casualty and medical personnel. New emphasis was placed on hemorrhage cessation, simplified airway control, and rapid evacuation. Tourniquets were re-popularized, and damage-control resuscitation was born.

Despite the severity and complexity of combat injuries, survival rates for combat casualties now are equal to or better than those for civilian trauma. Special Weapons and Tactics SWAT and other law enforcement special operations teams routinely find themselves in hostile environments.

The primary goals of TEMS are mission accomplishment, minimizing injury potential, providing care in unsecured environments, and facilitating evacuation to definitive care. Short periods of intense warfare tend to bring about the greatest advances in surgical and trauma medicine compared to long intervening periods of peace.

The current global war on terrorism has seen survival rates that are equal to or better than civilian trauma care. This would not have been possible without the ultimate sacrifice that many made, the dedication of the military medical community, and the continued research allowing for innovation and advancement of casualty care.

In the mids, using ATLS for treating combat casualties was called into question. While successful in the civilian setting, ATLS does not take into consideration factors such as enemy fire, equipment limitations, delayed evacuation times, temperature and weather extremes, mission considerations, and transport challenges in hostile environments. They compiled a thorough literature review and ran workshops with special operations physicians, corpsmen, and medics.

The result was what is now considered to be the birth of TCCC. The most common mechanism for injury in modern-day warfare is penetrating trauma from explosions and gunshot wounds.

Another astounding statistic from Kelly et al is that exsanguination from isolated extremity wounds caused 7. TCCC divides treatment into three phases of care based on the combat environment: care under fire, tactical field care, and combat casualty evacuation care.

Care Under Fire: Care under fire is rendered by the medic or corpsman at the scene of the injury while both provider and casualty remain under hostile fire. Little medical equipment is available, limited to what can be carried on the individual. Medical care is limited, and obtaining fire superiority needs to be prioritized.

The medic or corpsman should focus on returning fire and maintaining cover, with the goal of keeping the casualty from being wounded further. The only medical care provided during this phase is control of life-threatening hemorrhage with a tourniquet or direct pressure, applied by the casualty if able. Airway management and spinal immobilization are both deferred. Very few injuries approximately 1. Spinal immobilization is time-consuming and likely to be more hazardous to the provider and the casualty than any potential injury.

Tactical Field Care: Tactical field care is rendered once the medic and casualty are no longer under direct hostile fire. The amount of time available to provide medical care is variable, and the tactical field care phase easily can degrade into care under fire. Therefore, situational awareness must be maintained. It is critical to avoid undertaking futile therapeutic measures, such as cardiopulmonary resuscitation CPR , during this phase.

Combat casualties who are in cardiac arrest rarely survive, and CPR diverts resources and care from others with greater likelihood of survival. Major external bleeding sources should be addressed first, and tourniquets, direct pressure, and the use of hemostatic agents are appropriate. Care should be taken to reassess tourniquets applied during care under fire.

Airway interventions such as chin-lift and jaw-thrust are used. If the patient is conscious, allow the patient to assume whatever position allows him or her to best protect the airway. NPAs are tolerated better than oral airways in patients who regain consciousness and are less likely to be dislodged during transport.

After initial interventions, place the casualty in recovery position. In the event of complete airway obstruction or severe respiratory distress requiring a definitive airway, surgical cricothyroidotomy is preferred.

This is in contrast to civilian EMS and emergency department ED management in which cricothyroidotomy is a last resort following failed intubation. Most corpsmen and medics are inexperienced with endotracheal intubation, a technically difficult procedure. Maxillofacial injuries can complicate the potential visibility of the larynx, and esophageal intubations are difficult to recognize in the combat setting.

Oxygen often is not available in this phase of care because of the equipment needed to make it a feasible option. If available, it should be given to casualties with moderate to severe traumatic brain injury TBI.

Pulse oximetry monitoring should be used if available. Needle decompression should be considered in any unstable casualty with unilateral chest trauma. The diagnosis of tension pneumothorax on the battlefield is difficult, and the trauma caused by needle decompression is less detrimental to the casualty than an unrecognized tension pneumothorax. Penetrating chest injuries should be covered with commercial vented chest seals or other occlusive dressing.

Intravenous or intraosseous access should be obtained. If a casualty is anticipated to need massive transfusion, has a severe penetrating torso injury, or likely will require major amputation, tranexamic acid TXA should be given within hours of injury. Fluid resuscitation should be limited to casualties in hemorrhagic shock. Whole blood is preferred first line, followed by plasma, packed red blood cells, and platelets in a ratio.

Crystalloids are considered a last-resort resuscitative fluid. Attempts should be made to prevent hypothermia, and analgesia should be given. During Operation Iraqi Freedom and Operation Enduring Freedom, combat pill packs were created and distributed to all combatants. In the event of injury, conscious combatants were instructed to take the entire contents of the package: Tylenol 1, mg, Mobic 15 mg, and moxifloxacin mg. When additional pain control in the form of narcotics is required, the casualty should be disarmed first.

Severe pain can be controlled with transmucosal fentanyl citrate lozenges, which contain an mcg dose. The latter option allows for self-titration; if the casualty loses consciousness, the finger will fall from the mouth. Casualties in respiratory distress or shock should be given ketamine or morphine. Narcan and zofran should be available as needed for severe respiratory depression and vomiting.

Fractures should be splinted and assessed for neurovascular patency. Penetrating eye trauma should be addressed by obtaining visual acuity, administering antibiotics, and applying a rigid eye shield.

All wounds should be dressed, and the patient should be checked for missed wounds. Antibiotics should be prioritized to casualties with abdominal trauma, grossly contaminated wounds, open fractures, and massive soft tissue injuries. Burns present an additional concern in the combat environment. Casualties with burns who are also in hemorrhagic shock should be treated with blood products first.

Additional medical personnel and equipment usually are available during this stage. Much of the care provided mirrors tactical field care, but a few advanced techniques now are recommended based on safety of the environment, available medical personnel, and equipment.

All interventions done prior to receiving the casualty should be reassessed. This includes looking for new bleeding, checking dressings and splints, and providing additional analgesia and antibiotics. Endotracheal intubation and supraglottic airways are options if experienced personnel are available.

Cricothyroidotomy remains an appropriate option if endotracheal intubation fails or cannot be accomplished. Physical examination such as lung or cardiac auscultation is difficult during transport, so electronic monitoring should be applied to track blood pressure, heart rate, pulse oximetry, and capnography during transport.

Oxygen should be provided as needed. Chest tubes should be considered in casualties with continued distress following needle decompression and when long transport times are anticipated. Casualties in hemorrhagic shock should have volume resuscitation, preferably with whole blood. Permissive hypotension, in which fluids are withheld in individuals without signs of shock and only given until restoration of mental status or systolic blood pressure between mm Hg, is encouraged.

TBI casualties should undergo frequent neurologic checks for signs of deterioration; if concerns arise for increasing intracranial pressure, hypertonic saline, elevation of the head of the bed, and hyperventilation are options. Partnerships with other military organizations to assist in advancing TCCC include the Joint Trauma System JTS , which reviews all combat casualties, provides clinical practice guidelines, and provides evidence-based recommendations for trauma care.

TCCC and its phases of care represent a huge paradigm shift in the treatment of combat casualties because they initiate treatment of combat casualties starting at the point of injury, and provides a seamless continuity of medical support all the way to definitive care without any decrease in the level of care. One of the most significant civilian effects that resulted from TCCC and the modernization of military medicine is the creation of tactical emergency medical support TEMS.

TEMS is an out-of-hospital EMS system that focuses on medical support for law enforcement special operations missions. TEMS was designed to fit the distinct needs of high-risk law enforcement operations.

Tactical emergency medical services

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Advance your emergency care training and learn to administer emergency medical care, from hospital to prehospital and nontraditional settings. NAEMT education emphasizes critical thinking skills to obtain the best outcomes for patients. We believe that EMS practitioners make the best decisions on behalf of their patients when given a sound foundation of key principles and evidence-based knowledge. Students learn to recognize and manage common medical crises through realistic case-based scenarios that challenge students to apply their knowledge to highly critical patients.

The Journal of Special Operations medicine peer-reviewed article index displays all of our articles listed in alphabetical order. Simply click on the article that interests you, and you will be taken to the abstract for that article. We hope that you find this list of peer-reviewed tactical medicine journal articles to be a useful tool in your research.

Journal of Special Operations Medicine - Article Index

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Tactical Emergency Medicine

If your institution subscribes to this resource, and you don't have a MyAccess Profile, please contact your library's reference desk for information on how to gain access to this resource from off-campus. Please consult the latest official manual style if you have any questions regarding the format accuracy. The principles of military medical care are applicable to care in civilian mass casualties, in remote settings, for tactical medicine, and in bioterrorism incidents. Advanced trauma life support approaches are well applied in a hospital setting, but in combat, how do you function without ancillary staff? What do you do without ready access to a surgical team?

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