TASK: Tactically manage a simulated casualty.
CONDITIONS: Given a written situation concerning tactical combat casualty care and possible responses.
STANDARDS: Select the correct response based upon instruction given in lesson.
REFERENCE: Army’s Combat Lifesaver Course: Student Self-Study (PDF)
In tactical field care, you and the casualty are not under effective enemy fire and you are free to provide care to the best of your ability. However, medical equipment and supplies are limited to that carried into the field by the combat lifesaver and by individual soldiers.
a. Tactical field care covers two situations.
(1) In combat, tactical field care may be given by the combat lifesaver after the casualty has been moved to a safe location. However, the tactical situation can change and you could find yourself back in a care-under-fire situation or even told to stop rendering aid and resume your primary combat functions.
(2) Tactical field care also refers to care rendered by the combat lifesaver when the casualty is not in a care-under-fire situation to begin with, such as a soldier who falls while trying to climb a wall or cliff or a soldier who is injured by an explosion when no enemy troops are in the area.
b. The first situation was covered in Lesson 2. The second will be covered in this lesson. It is assumed that you locate a casualty while you are not in danger from enemy fire and you can render care to the casualty without endangering your mission.
3-2. INFORM YOUR LEADER
When you discover a casualty, communicate the situation to the unit leader as soon as you can. This is done to ensure that the tactical situation allows time to treat the casualty before initiating medical procedures.
a. Send a soldier for medical help (combat medic), if appropriate.
b. Once you have examined the casualty, let the leader know if the casualty will not be able to continue his mission.
c. Once you have treated the casualty, let the unit leader know of any significant change in the casualty’s status.
3-3. APPROACH THE CASUALTY
a. When approaching the casualty, scan the area for potential hazards. Approach the casualty using a safe route. Keep from becoming a casualty yourself.
(1) Survey the area for possible enemy actions, such as small arms fire.
(2) Survey the area for fire or explosive devices and for possible chemical or biological agents.
(3) Survey any nearby buildings for structural stability.
b. As you approach the casualty, form a general impression of the casualty. See if you can anticipate the type of injuries the casualty may have suffered and the type of care you will need to administer.
3-4. CHECK THE CASUALTY FOR RESPONSIVENESS AND LEVEL OF CONSCIOUSNESS
When you reach the casualty, check the casualty for responsiveness and determine the casualty’s level of consciousness.
(1) Upon reaching the casualty, ask in a loud, but calm, voice: “Are you okay?” Gently shake or tap the casualty on the shoulder.
(2) If the casualty is conscious, ask him where it hurts or where his body feels different from usual. This helps to determine the casualty’s level of consciousness and provides you with information that can be used when treating the casualty.
b. Checking Level of Consciousness.
(1) Ask the casualty questions to help determine his level of consciousness. Ask the casualty questions that require more
than a “yes” or “no” answer. Examples of such questions are: “What is your name?”, “What is the date?” and “Where are we?”
(2) If the casualty does not respond, check him for response to pain by rubbing his breastbone (sternum) briskly with your knuckle.
c. Determine Level of Consciousness.
Determine the casualty’s level of consciousness using the AVPU scale discussed below. Changes in the casualty’s AVPU rating may indicate changes in his medical condition, especially if the casualty
has suffered a head injury. Check the casualty’s level of consciousness about every 15 minutes.
(1) A–The casualty is alert (knows who he is, the date, where he is, and so forth).
(2) V–The casualty is not alert, but does responds to verbal (voice)
(3) P–The casualty responds to pain , but not to verbal commands.
(4) U–The casualty is unresponsive (unconscious).
NOTE: A casualty who is yelling at you, telling you what happened, or performing similar actions is alert.
NOTE: If the casualty is alert or responds to voice commands, do not
check the casualty’s response to pain.
3-5. POSITION THE CASUALTY ON HIS BACK
Position the casualty on his back if he is in a prone position. Placing the casualty in a supine position will help you evaluate and treat the casualty. If you turn the casualty, note any injuries that the casualty may have, especially in the chest area. To turn a casualty onto his back, perform the following steps.
a. Kneel beside the casualty with your knees near his shoulders.
b. Raise the casualty’s arm that is nearest to you above the casualty’s head.
c. Adjust the casualty’s legs so that they are together and straight or nearly straight.
d. Place one of your hands under the back of the casualty’s head and neck for support.
e. With your free hand, reach across the casualty’s back and grasp the casualty’s clothing under the arm (far armpit area).
f. Pull steadily and evenly toward yourself, keeping the casualty’s head and neck in line with his torso.
g. Once the casualty is rolled onto his back, place his arms at his sides.
NOTE: This method of rolling the casualty is used to minimize further injury to the casualty’s spine in case he has suffered an injury to the head, neck, or back.
3-6. CHECK FOR MAJOR BLEEDING OF THE EXTREMITIES
Check the casualty for amputation or severe bleeding from the arm, forearm, thigh, or leg. Arterial bleeding from a limb is the leading cause of preventable death on the battlefield.
a. Amputation. If the casualty has an amputation of the arm, forearm, thigh, or leg, apply a tourniquet two to four inches above the amputation site. Do not waste time with lesser measures such as a pressure dressing. Apply a tourniquet even if the amputation does not show severe bleeding. The body’s natural defenses may be controlling the bleeding temporarily, but the wound will soon result in severe arterial bleeding.
CAUTION: DO NOT apply a tourniquet over a joint. The bones of the joint may keep the tourniquet from functioning properly.
NOTE: Amputation of a part of a hand or part of a foot can be controlled using a pressure dressing or other measures.
NOTE: In a complete amputation, the limb part is completely severed from the rest of the body. In a partial amputation, the limb part is still connected to the rest of the body by skin. Treat a partial
amputation as you would a complete amputation.
b. Severe Bleeding. Try to control major bleeding on an extremity using an Emergency Bandage from the casualty’s first aid kit, direct pressure, elevation, Combat Gauze, or other means. If these methods do not control the bleeding, apply a tourniquet two to four inches above the wound to control the bleeding. Methods for controlling bleeding are presented in Lesson 4.
NOTE: Combat Gauze or other hemostatic agent (agent that arrests the flow of blood) and pressure can be used to control bleeding from a wound that is not amenable to the use of a tourniquet, such as bleeding from the axilla, groin, or neck.
3-7. CHECK THE CASUALTY FOR BREATHING
If the casualty is alert, talking, and not in respiratory distress, no airway intervention is needed at this time. However, continue to monitor the casualty’s breathing since his condition could deteriorate.
If the casualty is unconscious or having difficulty breathing, perform the procedures given below. These measures are discussed in greater detail in Lesson 5.
a. Open the casualty’s airway using the head-tilt/chin lift procedure.
NOTE: The muscles of an unconscious casualty’s tongue may have relaxed, causing his tongue to block the airway by sliding to the back of the mouth and covering the opening to the trachea (windpipe). Using the head tilt/chin-lift to move the tongue away from the trachea may result in the casualty breathing on his own.
b. Check the casualty for breathing using the look-listen-feel method (figure 3-1). Place your ear over the casualty’s mouth and nose with your face toward the casualty’s chest while maintaining the casualty’s airway (head-tilt/chin-lift). Look for the rise and fall of the casualty’s chest and abdomen. Listen for sounds of breathing. Feel for his breath on the side of your face.
c. Perform rescue breathing, if needed.
Rescue breathing is performed at the rate of one full breath every five seconds if the casualty is not breathing. Check the casualty’s carotid pulse after 12 ventilations. If the casualty is not breathing on his own and no pulse is detected, move to another casualty. If the casualty is not breathing on his own but has a pulse, continue administering rescue breathing.
d. Insert a nasopharyngeal airway, if needed.
(1) If the casualty is unconscious and breathing on his own, insert a
nasopharyngeal airway (NPA).
(2) If the casualty is conscious but breathing at a rate of less than two respirations every 15 seconds, insert a nasopharyngeal airway.
e. If your evaluation of an unconscious casualty reveals no additional injuries, roll the casualty into the recovery position (on his side) as shown in figure 3-2. This allows accumulated blood and mucus to drain from the casualty’s mouth instead of choking the casualty.
3-8. CHECK THE CASUALTY FOR OPEN CHEST WOUNDS
Check the casualty for wounds that penetrate the chest cavity. Such wounds are called open chest wounds or sucking chest wounds. Left untreated, these wounds can allow air to enter the casualty’s chest and collapse his lung. The following procedures are discussed in greater detail in Lesson 6.
a. Expose the chest and check for equal rise and fall. Remove the minimum of clothing required to expose and treat injuries. Protect the casualty from the environment (heat and cold) as much as possible.
b. Examine the chest for wounds. Check for both entrance and exit wounds.
c. Immediately seal any penetrating injuries to the chest. Place airtight material over the wound (material extends at least two inches beyond wound) when the casualty exhales and tape all sides of the airtight material or apply a commercial chest seal to the casualty’s chest. Then dress and bandage the wounds.
d. After treating a casualty with an open chest wound, allow the casualty to sit up if he has adequate support. If a casualty cannot sit up, place him in the recovery position with his affected (injured) side down. The body pressure acts to “splint” the affected side.
3-9. CHECK FOR OTHER WOUNDS
After you have stopped any serious arterial bleeding from the extremities, checked the airway, and sealed any penetrating chest wounds, continue to evaluate and treat the casualty.
a. Check the casualty for bleeding.
(1) Look for blood-soaked clothes.
(2) Look for entry and exit wounds.
(3) Place your hands behind the casualty’s neck and pass them upward toward the top of the head. Note whether there is blood or brain tissue on your hands from the casualty’s wounds.
(4) Place your hands behind the casualty’s shoulders and pass them
downward behind the back, thighs, and legs. Note whether there is blood on your hands from the casualty’s wounds.
b. Control bleeding using an Emergency Bandage, Combat Gauze, direct pressure, and/or pressure dressing.
(1) If the above methods do not control bleeding from a limb, apply a
tourniquet to the extremity.
(2) Do not apply a tourniquet except to an extremity.
(3) Do not apply a pressure dressing to a head wound. You may apply an Emergency Bandage, but do not tighten it enough to result in a pressure dressing.
(4) If a bone is sticking out of the wound, do not attempt to push the bone back under the skin or to straighten the injured limb. Apply the dressing over the bone and the wound.
3-10. CHECK FOR FRACTURED LIMBS
a. Check the casualty for fractures (broken bones). Some of the signs and symptoms of a fractured limb are given below.
(1) Part of the fractured bone may stick through the skin.
(2) The casualty may have pain, tenderness, swelling, and/or bruising at a particular location. The site of the tenderness or bruise is probably the site of the fracture.
(3) One arm or leg may appear to be shorter than the other or the limb may be in an abnormal position (looks deformed).
(4) The casualty may have difficulty in moving an arm or leg.
CAUTION: Do not have the casualty attempt to move the injured arm or leg to test this symptom. Rely upon what the casualty tells you.
(5) The casualty has massive injury to an arm or leg.
NOTE: Even if the bone is not broken, the pain caused by the wound may be lessened if the arm or leg is splinted after it has been dressed and bandaged.
(6) The casualty may have heard a “snapping” sound at the time of the injury.
b. Splint any fractured limbs using available materials. If available, a universal malleable splint (SAM splint) may be used to splint an arm, forearm, or lower leg. Two rigid objects (such as straight tree limbs, boards, or tent poles) may be used to splint the fractured limb. Materials such as cravats or strips of cloth can be used to secure the rigid objects and keep the fracture immobilized.
c. Applying a splint to a leg.
(1) Push the securing materials under natural body curvatures, such as the knees. Then gently move the securing materials up or down the limb until they are in proper position.
(2) If possible, place at least two cravats above the fracture site and two below the fracture site (above the upper joint, between the upper joint and the fracture, between the fracture and the lower joint, and below the lower joint).
CAUTION: Do not apply a cravat on the suspected fracture site. The pressure caused by the cravat could result in additional injury to
the fracture site.
(3) Place the rigid objects so that one is on each side of the injured leg or thigh. When possible, position the rigid objects so the joint above the fracture and the joint below the fracture will be immobilized. If the fracture is in the lower leg, for example, the splint should extend above the knee and below the ankle. If the fracture is in the thigh, the splint should extend above the hip and below the ankle (hip, knee, and ankle will be immobilized).
CAUTION: Make sure the ends of the splints do not press against the groin. Such pressure could interfere with blood circulation.
(4) Place padding (such as cloth) between the rigid objects and the limb to be splinted. Apply extra padding to joints and sensitive areas such as the groin.
(5) Wrap the securing materials around the rigid objects and limb so that the rigid objects immobilize the limb.
(6) Tie the ends (tails) of each securing cravat in a nonslip knot on the outer rigid object and away from the casualty. (The knots are tied on the outer rigid object to make loosening and retying the cravats easier should that procedure be needed.)
(7) Observe the limb for signs of impaired circulation. The securing material should be tight enough to hold the rigid objects securely in place, but not tight enough to interfere with blood circulation. If you detect signs of poor circulation (such as coolness, numbness, or lack of pulse) loosen the securing materials, make sure the ends of the
rigid objects are not interfering with blood circulation, and retie the cravats.
CAUTION: If the leg still has poor circulation, evacuate the casualty as soon as possible.
NOTE: Figure 3-3 shows a splint applied to a fractured thigh.
d. Applying a splint to an arm.
(1) Place the rigid objects so that one is on each side of the injured arm or forearm. When possible, position the rigid objects so the joint above the fracture and the joint below the fracture will be immobilized.
(2) Apply padding between the arm and the splints.
(3) Secure the splints with cravats, strips of cloth, or other securing
materials. If possible, place two cravats above the fracture site and two below the fracture site. Immobilize the joint above the fracture site and the joint below the fracture site.
NOTE: Slings and swathes can be used to immobilize joints.
(4) Check for signs of impaired circulation. If you detect signs of poor circulation (such as coolness, numbness, or lack of pulse) loosen the securing materials, make sure the ends of the rigid objects are not interfering with blood circulation (such as pressing on the armpit), and retie the cravats.
CAUTION: If the arm or forearm still has poor circulation, evacuate the casualty as soon as possible.
(5) If possible, apply a sling to immobilize the forearm.
(6) If possible, apply a swathe (material tied around the injured upper arm and the chest) to immobilize the upper arm. If the upper arm is fractured, apply a swathe above the fracture and a swath below the fracture.
NOTE: Figure 3-4A shows a forearm with a splint applied. Figure 3-4B shows a sling applied to the fractured arm. Figure 3-5 shows a splinted forearm with the casualty’s shirt tail used as a sling (sharp stick stuck through shirt and tail to secure the tail) and a swathe applied.
3-11. ADMINISTER PILL PACK
If the casualty has suffered a wound or fracture, administer the casualty’s combat pill pack (see figure 1-5). Have the casualty
take all four tablets with water from his canteen. The pack contains pain medications and antibiotics to help control infection. Use the casualty’s pack, not your own pack. You need your pack in case you are wounded. This pill pack is not part of the combat lifesaver MES.
3-12. TREAT THE CASUALTY FOR SHOCK
Hypovolemic shock is caused by a sudden decrease in the amount of fluid circulating in the casualty’s blood circulatory system. This is usually caused by severe bleeding, but it can also be caused by severe burns (second and third degree burns on 20 percent or more of the body surface), vomiting, diarrhea, and excessive sweating. Hypovolemic shock can result in the casualty’s death.
NOTE: Hypovolemic shock can also result from blood loss due to internal bleeding (bleeding into the abdominal or chest cavities). You will not be able to treat internal bleeding. This condition requires rapid evacuation.
a. Signs and symptoms of shock include the following.
(1) Sweaty but cool (clammy) skin, pale skin color, and/or blotchy or bluish skin around the mouth.
(3) Anxiety (casualty is restless, nervous, or agitated).
(4) Decrease in the casualty’s level of consciousness (such as mental
confusion or unconsciousness).
(5) Rapid breathing (increased breathing rate).
(6) Unusual thirst.
b. Take the following actions to treat shock.
NOTE: Do not wait for signs and symptoms of shock to occur. The same measures used to treat shock can be applied to help prevent shock from occurring.
(1) If the casualty is conscious, place him in the shock position (on his back with his feet elevated slightly above the level of his heart) (see figure 3-6). This will help his blood circulation. A log, field pack, box, rolled field jacket, or other stable object can be used to elevate his feet. Some exceptions to placing the casualty in the shock
position are given below.
(a) An unconscious casualty should be placed in the recovery position. If the casualty vomits, quickly perform a finger sweep to clear his airway.
(b) A casualty with a suspected spinal fracture or serious head wound should be on his back (feet not elevated). Immobilize his head, neck, and back, if possible.
(c) A casualty with an open abdominal wound should be positioned on his back with his knees flexed to reduce stress to the abdomen and reduce the pain.
(d) A casualty with an open chest wound should be sitting up with his
back to a wall, tree, or other support or in the recovery position with his injured side to the ground. Having the uninjured side up decreases pressure on the uninjured side of the chest and allows the uninjured lung to function easier.
(e) A casualty with a minor head wound should be sitting up with his
back supported or in the recovery position with his wounded side up.
CAUTION: Do not elevate the casualty’s legs until all lower limb fractures have been splinted.
(2) Place a poncho or blanket under the casualty to protect him from the temperature or dampness of the ground (figure 3-6).
(3) Take measures to keep the casualty from overheating or chilling.
(a) In warm weather, keep the casualty in the shade. If natural shade
is not available, erect an improvised shade using a poncho and sticks or other available materials. Fan him if needed to promote the evaporation of perspiration.
(b) In cool weather, cover the casualty with a Blizzard survival blanket (combat lifesaver MES), blanket, poncho, or other available materials to keep him warm and dry (figure 3-7).
NOTE: Blood loss can cause a significant drop in body temperature, even in hot weather.
NOTE: Do not cover a tourniquet. Leave it so medical personnel can see it easily.
(4) Loosen any binding clothing, including boots. Tight clothing can
interfere with blood circulation.
CAUTION: Do not loosen or remove the casualty’s clothing if you are in a chemical agent environment.
(5) Reassure the casualty and keep the casualty calm. Tell the casualty that you are helping him. Be confident in your ability to help the casualty and have a “take charge” attitude. Your words and actions can do much to reassure the casualty and reduce his anxiety. Be careful of any comments you make regarding the casualty’s condition.
(6) Send someone to obtain medical help. The casualty may need intravenous infusion (IV) to replace lost fluid volume. Combat medics carry IV fluids and the supplies to administer the fluid. If you must leave the casualty alone in order to seek help, tell him you are going to get medical help and will return. Turn the casualty’s head to one side before you leave. This will help to keep the casualty from choking should he vomit.
(7) Small sips of water are permitted if the casualty is conscious.
(8) Evacuate the casualty if medical help is not available.
3-13. MONITOR THE CASUALTY
Monitor the casualty’s level of consciousness and breathing rate.
a. Check the casualty’s level of consciousness every 15 minutes. A decrease in AVPU status could indicate that the casualty’s condition is becoming worse.
b. Monitor the casualty’s respirations. If the casualty has suffered thoracic trauma, progressive severe respiratory distress (breathing that becomes more labored and faster) may indicate tension pneumothorax. Decompress the affected chest side by inserting the needle/catheter from your combat lifesaver aid bag into the second
intercostal space (ICS) on the mid-clavicular line (MCL). This procedure (described in Section II of Lesson 6) will allow the air trapped in the casualty’s chest to escape and let the casualty breathe easier.
c. If a casualty becomes unconscious or his breathing rate drops below two respirations every 15 seconds, insert a nasopharyngeal airway.
d. Monitor the casualty’s wounds. If a tourniquet has been applied, make sure that arterial bleeding is controlled. If a pressure dressing is not controlling arterial bleeding, consider applying a tourniquet.
Reinforce dressings, if needed. Recheck your interventions every time you move the casualty.
3-14. PREPARE THE CASUALTY FOR EVACUATION
A casualty with a tourniquet, open chest wound, or other serious or life-threatening injury should be evacuated as soon as possible. If medical help is not available, prepare the casualty for evacuation. Prepare the casualty so that he is protected from becoming chilled during transport.
a. Initiate a DD Form 1380, U. S. Field Medical Card, or a Tactical Combat Casualty Care Card. Attach the card to the casualty’s clothing or place it in a pocket, as appropriate (see Lesson 7). This will provide medical personnel with a history of the casualty’s injury and treatment.
b. Use the radio to make a request for medical evacuation (Lesson 8), if appropriate. A medical evacuation vehicle (ground or air ambulance) will have medical personnel to care for the casualty during transport.
c. If the casualty is to be transported by non-medical means, prepare a litter, if appropriate (Lessons 9 and 10).
Use a non-medical military vehicle to transport the casualty to a medical treatment facility or collection point, if possible.
(1) Continue to monitor the casualty during transport. Perform additional care (open the airway, insert a nasopharyngeal airway, perform needle chest decompression, and so forth) as needed. Monitor wounds and take measures to control additional bleeding. Reinforce existing dressings with additional dressings and bandages as needed.
(2) If an amputation is involved, evacuate the amputated part with the casualty. If possible, rinse amputated part free of debris, wrap it loosely in saline-moistened gauze, seal the amputated part in a
plastic bag or cravat, and place it in a cool container.
Do not freeze the amputated part.
Do not place amputated part in water.
Do not place the amputated part directly on ice.
Do not use dry ice to cool the amputated part.
Do not place the amputated part so that it is in view of the casualty.
(3) If the casualty has been treated for an open chest wound, transport the casualty with the affected (injured) side down, if possible.
d. If you are to be the leader of a litter team, position yourself at the casualty’s left shoulder. This is the best position to monitor the casualty while transporting the casualty by litter. The litter bearers position themselves with the knee nearest the litter on the ground and grasp the litter handles (figure 3-8A). Upon command of the leader, the four litter bearers lift the litter in unison (figure 3-8B). Upon command of the leader, the bearers move forward in unison and move the casualty to the aid station or collection point.