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53 An Introduction toTactical Medicine Concepts
463

Circulation (“C”)

Management of circulatory insult includes assessment and control of any non-massive bleeding, vascular access, uid resuscitation, and reassessment of previously placed tourni­quets. Suspicion of occult bleeding into the pelvis, abdomen, thorax, and long bones should be considered in unstable patients without overt bleeding or continued instability despite external hemorrhage control and with pneumothorax ruled out. A high index of suspicion should be maintained for any casualty with a mechanism of injury (MOI) that includes blast exposure, blunt force trauma, and penetrating trauma to the pelvic region. Changes in mental status, tachycardia, or pain are often the only reliable indicators of underlying injury in austere conditions. Rapid application of a pelvic binder is indicated for any suspected pelvic fracture based upon mechanism alone, or in conjunction with clinical nd­ings [38]. Improvised pelvic binding using casualties trou­sers has been shown to be effective [39, 40]. Splint all fractures while maintaining the distal pulse. Folding traction splits are available that can maintain traction as required. Traction provides both hemorrhage control and pain management.
Vascular Access
Continually assess for signs of shock while securing large bore intravenous access early for the administration of analgesia, antibiotics, other drugs, and possible uid resusci­tation. The use of intraosseous access is recommended when peripheral intravenous attempts fail or injuries preclude upper extremity IV sites. Intraosseous has been used with great success in tactical environments for many years [17]. While the intravenous route is preferred, blood transfusion can be administered through intraosseous access with high ow rates [27, 41–43]. Central line access is technically dif­cult and equipment intensive and should be reserved for use in more controlled environments.
Fluid andHemostatic Resuscitation
Fluid resuscitation has undergone drastic change in mili­tary medicine and has prompted a shift in practice in domestic trauma care as well. Early tactical medicine prac­tice employed large volume crystalloid resuscitation, which we now know was a major source of coagulopathy and mortality [44]. The evolution of uid resuscitation then moved to starch-based colloids, thought to give longer duration of intravascular expansion and lower weight as hypertonic solutions allowed for reduced volumes required
for similar effect. 250ml of hypertonic saline and dextran (HSD), for example, has similar vascular expansion to a liter of crystalloid [45, 46]. For the tactical medic, this was appealing from a logistical perspective which meant carry­ing less weight in IV uid. The military experience between 2000 and 2010 fueled a body of evidence to move away from these harmful interventions, and this area of trauma care continues to rapidly evolve [47].
Crystalloid
The use of crystalloid uid should be recognized as harmful in most trauma patients. Exceptions include burn resuscita­tion and head injury management but need to be considered and weighed for risk and benet in multisystem trauma patients including these mechanisms.
When logistics limit uid access to only crystalloid products, a focus should be placed on minimal uid for desired effect, and recognizing that patients with active bleeding have worse outcomes when compared to uid­restricted approaches [3, 44]. Crystalloid infusion should be limited to volume expansion to achieve a perfusing blood pressure, in limited volume [48]. Ideally, some level of blood product, as discussed in the next section, should be employed in all tactical medical trauma care for uid resuscitation.
Blood andProducts
Replacement of lost uid (blood) in trauma has been shown to be best replaced by equivalent uid, thus, replacement with whole blood [49–51]. This has logistical complexity in traditional medicine and is compounded in tactical medical environments. Small, specialized military units employ eld donation and transfusion of fresh whole blood using a buddy transfusion approach. The use of cold-stored low-titer whole blood simplies the eld use of whole blood by eliminating the donor portion of the procedure from the workow of the combat medic and expedites administration when indicated [52]. The logistics of both fresh and cold-stored whole blood remain a signicant limitation for widespread use of blood in tactical environments. 1:1:1 or 1:1 component replacement is thought to be the next best option but still carries logistical and distribution challenges [53, 54]. Current evidence sug­gests in the absence of blood access, dried plasma may be the best option in tactical settings. Table53.2 provides the most recent approach for tactical eld care uid resuscitation. Field resuscitation should target improved LOC, a palpable pulse, and/or systolic blood pressure of 80–90 mmHg or <90mmHg with suspected or conrmed head injury [27].
464
Table 53.2 Preferred resuscitation uids in tactical eld care
Fluid resuscitation in tactical eld care Not in shock IV uids not indicated
Oral rehydration
Shock present
Weak or absent radial pulse and/or altered LOC (shock)
(Order of preference)
1. whole Blood
2. Plasma, RBCs, and platelets (1:1:1)
3. Plasma and RBCs (1:1)
4. RBCs only
5. Dried, liquid, or thawed plasma only
6. Lactated ringers or plasma-lyte A crystalloid
W. Guse et al.
Hemostatic Resuscitation
The evidence in support of tranexamic acid in hemostasis, particularly in the context of massive blood transfusion dur­ing resuscitation, has been well documented. TXA is known to be more effective when given early, less than an hour after injury. Field administration of TXA will ensure that casual­ties are treated within that window [55–57]. Recent studies have pointed to its successful use in traumatic brain injuries and should be considered in these casualties [58]. Early administration in trauma patients is indicated in the tactical environment during tactical eld care via the intravenous or intraosseous routes.
Tourniquet Re-assessment
During the circulatory assessment, reassess applied tourni­quets for effectiveness and the need for re-tightening. Due to uid shifts in the limb compartment under tourniquet, they may need to be re-tightened to ensure efcacy. Inspect the wounds on tourniqueted extremities, especially in cases where the tourniquet was applied during CuF or DTC.Due to the tactical situation, a limb may have been tourniqueted with an otherwise manageable, compressible injury. If the tourniquet has been in place for less than 2hours, these injuries could be converted from tourniquet to other methods of hemorrhage control, including wound packing, hemostatics, and pressure dressings, as the tacti­cal situation or evacuation times allow. Do not attempt tourniquet conversion in the eld setting if the tourniquet has been in place for more than 6 hours, signs of shock are present, or if close monitoring for re-bleeding is not pos­sible. Never remove a tourniquet in cases of, partial or complete, traumatic amputations outside of the OR [19]. While there have been case studies of successful outcomes with extended tourniquet application times, it is generally accepted that the window evacuation for casualties with a tourniquet applied is 2hours [59].

Hypothermia Prevention/Head Injury (“H”)

Hypothermia Management
Aggressive hypothermia management is a cornerstone of trauma care and is of paramount importance in austere medi­cine. Even in the hot climates of Iraq and Afghanistan, casu­alties become hypothermic, especially when exposed to higher altitudes and onboard evacuation platforms. The more severely injured casualty is at greater risk of hypothermia, and an associated increase in mortality and increases the incidence of trauma-induced coagulopathies [60]. The body loses heat through four primary means: evaporation, radia­tion, conduction, and convection. Hypothermia management should be a combination of active and passive measures to combat these heat loss avenues. Examples of passive mea­sures include, but are not limited to: early use of a litter (con­duction), windproof emergency blankets (radiation and convection), removing blood-soaked clothes, and drying the casualty while packaging (evaporation). Active measures are the use of rewarming blankets and warm uids. There are a multitude of well-thought-out active rewarming kits avail­able; even a simple wool blanket can sufce in Prolonged Field Care. Aggressive hypothermia management is effective to disrupting the “Lethal Triad” [27, 61–64]. Strategies to avoid hypothermia and its treatments are discussed further.
Traumatic Brain Injury
In recent conicts, the asymmetrical threat of improvised explosive devices (IEDs) has grown in prevalence; the inci­dence of traumatic brain injury (TBI) has increased as well, with mild TBIs being the most common in large cohort studies [65]. Casualties with a suspected TBI with oxygen saturation below 90% should be administered oxygen as soon as it is available and tactically feasible. TBI casualties are an exception for crystalloid uid resuscitation in eld settings where blood is not available. In these patients,
53 An Introduction toTactical Medicine Concepts
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maintaining a target of 90mmHg systolic blood pressure or palpable radial pulse is recommended [66]. The use of Ringer’s Lactate is associated with decreased mortality over normal saline [67]. Casualties that present with a severe or worsening TBI, pupillary dilation, and decreasing mental status, a 250ml bolus of 3% hypertonic saline is indicated. HSD is preferred over mannitol in TFC/ITC as it avoids the diuretic effects which are more difcult to man­age in an operational setting [66, 68]. Hyperventilation (targeting end-tidal CO2 between 30 and 35 mmHg or a ventilatory rate of 16 when capnometry is unavailable) should be used as a temporizing measure only when there are observable signs of cerebral herniation [66]. In law enforcement and for paramedics responding to intentional mass casualty events, such as the Boston Marathon Bombing, the military experiences with IEDs and TBIs should be considered.
Eyes andEverything Else (“E”)
This portion of the MARCH approach catches the remaining goals and interventions the tactical medical provider should consider. Getting this far in the treatment algorithm will be dependent upon the environment, number and severity of casualties, and time with the patient.
Eye Injuries
While the use of ballistic-rated glasses and goggles has sig­nicantly reduced globe injuries, these injuries remain a source of morbidity [69, 70], and there remains a reasonable threat of open globe injuries in any combat environment. Treatment in the eld should include a baseline visual acuity test, a rigid shield type dressing, and early prophylaxis with an appropriate antibiotic if transport is prolonged. In civilian emergency care, both eyes are usually dressed to avoid ocu­lar movement increasing damage. This may not be appropri­ate in a tactical setting as the patient then becomes completely dependent upon others in a dangerous environment.
Monitoring andVital Signs
At this stage of care, regular monitoring of vitals and inter­ventions should be started. Tactical medical operators will be limited in their diagnostic equipment. Most will have a pulse oximeter, stethoscope, and blood pressure cuff [6]. However, the background sounds of operations may preclude the effec­tive use of hearing-based diagnostic equipment. More tactile and visual techniques can be used in those cases, such as the presence of distal pulses and mental status assessment to
assess end-organ perfusion. All injuries, interventions, time of interventions, and results of intervention need to be docu­mented [27].
Analgesia
Pain management is addressed in a tiered system. In a mili­tary setting, casualties with minor injuries who can still ght may need to remain engaged or be used for security of the casualty collection point (CCP). A 1 gram dose of acet­aminophen in conjunction with an appropriate oral antibi­otic is all that is indicated. For patients with moderate injuries that cannot remain operational and are not exhibit­ing the signs of shock or respiratory distress, oral transmu­cosal fentanyl citrate lozenges (OTFC) have become the standard of care in many military medical units. OTFC has demonstrated excellent efcacy in recent conicts and when administered with the lozenge taped to the patient’s thumb, has a self-limiting administration. For patients in severe pain, ketamine is used both for pain management and sedation. Sedation should be considered prior to inva­sive procedures, securing the airway, and if the casualty is a danger to themselves or operational success. The use of benzodiazepines is not routinely used in a eld environ­ment. They should be considered in sedation and violent patient interventions (a law enforcement consideration). Naloxone should be included in any pain management plan for management of both overdose and iatrogenic overad­ministration. As in many other settings, pain is often under­managed in austere settings [71–73].
Secondary Survey
A full secondary survey should be completed, time permit­ting. Fractures, not splinted already, should be splinted, and distal perfusion reassessed and documented. Burns should be assessed using the Rule of Tens. The Rule of Tens is simply the Rule of Nines rounded up to the nearest percent and is easier in a chaotic environment. Burns should be dressed with a dry sterile dressing. Fluid resuscitation using Ringer’s Lactate or other balanced crystalloid should be initiated accordingly guided by the modied Parkland formula [74,
75]. Abdominal eviscerations should be reduced into the
abdominal cavity to protect viability and maximize splanch­nic circulation [27]. If the evisceration cannot be reduced, the eviscerated organs should be covered and secured with moist sterile dressings or a water impermeable non-adhesive material. All minor wounds should be inspected and dressed. All ndings and interventions should be added to the current documentation.
466
W. Guse et al.
Antibiotic Administration
With the rates of open orthopedic trauma in tactical oper­ations and the realities of unhealthy, austere environ­ments where they are conducted, prophylactic antibiotic administration, based on local flora, should be consid­ered in any tactical medicine plan. The current CoTCCC guidelines recommend that all open combat wounds receive point-of- wounding prophylaxis. When the envi­ronment, wound modalities, and delayed time to care are considered, this is a prudent response [76–80]. In a law enforcement setting with rapid evacuation and less aus­tere conditions available, this will require the input of the physician in a medical director role. However, vast areas of North America where law enforcement conducts oper­ations would still be considered austere and have extended evacuation times. Prudent stewardship of antibiotics is important but not all law enforcement operations take place in urban areas.

Prolonged Field Care

Prolonged eld care includes nursing and critical care inter­ventions beyond the interventions discussed previously in tactical eld care and following the MARCHE algorithmic approach. Situations where evacuation is delayed, the need for ongoing management of critical trauma patients can occur in both military and law enforcement settings and need to be a consideration in medical planning. Remote and tele­medicine support care be a signicant force multiplier in extending critical care far forward, where expert guidance can be directed where tactical medical providers may require consultation. For teams where the threat of prolonged evacu­ation is high, additional training, planning, and equipment are required [81].
The tactical medical provider kit can then be focused on carrying advanced procedure equipment in a rst-line medi­cal bag, in addition to a second-line treatment bag or various mission-specic kits or components tailored to different mis­sions and medical threats [84, 85]. Additional equipment for re-supply or mass-casualty or disaster events can be pre­positioned in team vehicles or other pre-planned caches. Careful consideration to medical bag packing needs to be considered as weight and space are at a premium. Consideration for multi-use items and reducing redundancy where able are strategies to minimize the medic load. As noted above, spreading kit among the team also expands the supplies available, while keeping the medical provider light and agile in order to function well.
Drone technology has evolved rapidly, and drone use for equipment deployment for supplies, medications, or just-in­time blood product delivery is within operational reach with this technology [86].
Less-Lethal andChemical Munitions
The injury patterns, decontamination, and management asso­ciated with less-lethal impact and energy weapons and chemical agents require a subset of knowledge for the tacti­cal medical provider. These devices and agents are com­monly employed in law enforcement, and weaponized chemicals and biologic agents pose threats in both military and law enforcement operations. Understanding energy weapons such as the Taser™, various types and sizes of impact projectiles, distraction devices, oleoresin capsicum spray, and CS gas which are commonly employed in tactical operations is important [87, 88] (Fig.53.3).
Chemical, biological, radiological, nuclear, and explo­sive (CBRNE) weapon effects and associated medical man-
Medical Equipment inTactical Medical Care
The medical interventions reviewed herein require signi­cant logistical and equipment investment. Especially in a mass-casualty event, the tactical medical provider’s medical kit can be quickly exhausted [82]. By contrast, the tactical medical provider can quickly become overloaded with equip­ment, impeding their ability to move and work effectively. Layered positioning of medical supplies is advantageous in planning for casualties and can ensure the medical providers are not overloaded, while also ensuring required equipment is available when needed. Each operator or team member should carry basic medical equipment including tourniquet, packing gauze and bandage, and chest seal in an individual rst aid kit (IFAK) [83].
Fig. 53.3 40mm less-lethal projectile baton. (File photo, S.Cowan)
53 An Introduction toTactical Medicine Concepts
467
agement present yet another specialized area of knowledge the tactical medical provider should be versed in. The breadth of this topic is vast and will be covered further in Chaps. 56 and 57 [89, 90].
Environmental andOperational Dierences: TCCC Versus TECC
Military Tactical Combat Casualty Care is conducted in non- permissive or semi-permissive austere environments and primarily involves treatment of young, t operators with minimal comorbidities. Military humanitarian mis­sions can quickly become a tactical medicine situation with attacks on NGOs being commonplace. Depending on the enemy, the use of CBRNE agents may complicate the battlespace further.
The Geneva Convention (GC) allows military medics, persons tasked to medical units and evacuation platforms to be armed for self-defense, the defense of their casualties, and defense of the medical unit, if required [91]. In recent con­icts, asymmetrical threats are not signatories to the GC and have been specically targeting medical personnel and facil­ities [92]. Military Medics are embedded with combat units and in many instances come under re (self-defense) and move forward with their engaged units. An armed medic can participate, if required, in protecting themselves but runs the risk of being actively engaged and may be unable to move to render aid to casualties. An unarmed medic, by contrast,
could be a hindrance to a unit engaged in active combat requiring a guardian from the embedded unit.
Tactical Emergency Casualty Care is conducted in permis­sive and semi-permissive environments. Operations can be non-austere and austere depending on the region of the coun­try. TECC casualties include the general population with all the variances in age ranges, infant, pediatric, adult, and geri­atric, with all the expected comorbidities and physiological conditions. Due to the permissive nature of these operations, follow on medical assets and evacuation to denitive trauma care are more readily available (Fig.53.4). Active shooter and intentional mass casualty events do occur. In these specic incidences, TECC providers would typically advance and position themselves similar to military medics [93].
Law enforcement teams can have armed providers, unarmed providers, or a combination in their resources. Many times, armed tactical medical operators are sworn ofcers or constables with specialty medical training. In some agencies, specic paramedics are recruited and trained in tactics and rearms and then added to the team. In other agencies, unarmed medics are used and staged in the Yellow or Warm Zone and brought forward when the objective is secured. These teams should train their non­medical operators to the TECC First Responder standard to provide Red or Hot Zone Care for the possibility of a pro­tracted operation. Training physicians and advanced care paramedics to give solid medical direction and advice over communications is an excellent tool to mitigate liability in protracted or austere operations.
Fig. 53.4 Handover of a trauma patient in a law enforcement tactical simulation. (File photo: S.Cowan)
468
W. Guse et al.
There are distinct differences between law enforcement and military operations. Unfortunately, with asymmetrical threats of the last decade, the lines have blurred and there can be signicant overlap. The differences between TCCC and TECC need to be balanced by any physician tasked as LE medical director or any military physician.

Summary

Tactical medicine combined the dynamic and hazardous environments of military and law enforcement operations with the complexity of modern trauma care. Simply practic­ing in-hospital style medicine in these environments is dan­gerous and requires the tactical medical provider to balance the requirements of the operation and tactical environment with the medical needs of patients during operations. Initial and ongoing individual and team training and experience in this nuanced eld of trauma care have been demonstrated to improve outcomes and have become a standard of care.
Key Points
• Tactical medicine is not simply transferring tradi­tional trauma care into a law enforcement or mili­tary environment.
• Tactical medicine is driven by environmental con­straints and requires an understanding of evidence from conict-related injury research.
• Training to safely provide tactical medicine is broad and multifaceted.
• Specic interventions, approached in an algorith­mic fashion, must be tailored to the incidence of injury and environment.

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Hypothermia andtheTrauma Team
SusanMarjorieRoberts, SeanLynch, DeanGubler, andAnthonyJ.LaPorta
54

Introduction

Normal human body temperature is thermoregulated in the range of 36.4–37.5°C [1, 2]. Signicant changes to the core body temperature can lead to potentially fatal systemic effects. Hypothermia can occur as a consequence of trau­matic injury and can be inuenced by predisposing risk fac­tors, including care provided by the medical team [3, 4]. Attention to preventing hypothermia is critical throughout all phases of trauma care. Hypothermia is common in severely injured patients, but further decrease in temperature can be prevented by the trauma team taking certain pertinent actions [1]. It is critical to effectively manage hypothermia, due to hypothermia’s relationship to worsening coagulopathy and effect on organ function. The trauma team must be able to both recognize and treat hypothermia to decrease the associ­ated morbidity and mortality and increase the patient’s likeli­hood of survival [5].

Hypothermia

Denition
Diagnosing hypothermia requires measurement of the core body temperature. Special thermometers capable of reading low temperatures are necessary to diagnose moder­ate and severe hypothermia. Temperatures can vary accord­ing to location, perfusion, and ambient temperature [3]. Locations to measure temperature include forehead, mouth, esophageal, ear, pulmonary artery (most reliable), axillary, and rectal. In situations where core body temperatures are difcult to measure, such as in the rescue zone, hypothermia can be staged according to clinical signs based on the Swiss staging system [6]. The Swiss system divides hypothermia into grades with corresponding correlation to estimated core body temperature. Mild hypothermia is grade 1 (35–32°C) and is associated with a conscious patient who is shivering. Moderate hypothermia is grade 2 (32–28°C) and is associ­ated with a drowsy patient who is not shivering. Grave hypo­thermia is grade 3 (28–24 °C) and is associated with an unconscious patient who still has vital signs. Deep hypother­mia is grade 4 (24–13.7°C) and irreversible hypothermia is grade 5 (13.7–<9°C).
Prevalence ofHypothermia After Trauma
The 2018 Advanced Trauma Life Support (ATLS) guidelines dene hypothermia as any core body temperature less than 35°C [1]. Without any associated traumatic injury, hypother­mia can further be divided into mild hypothermia at 35–32°C, moderate hypothermia at 32–28 °C, and severe hypothermia <28 °C. With traumatic injury the classica­tions of hypothermia are modied: mild hypothermia at 36°C, moderate hypothermia at 36–32°C, and severe hypo­thermia <32 °C. Trauma patients are more susceptible to hypothermia, and it can be detrimental to these patients.
Accurately determining the prevalence of hypothermia after traumatic injury can be difcult due to variations in methods of recording core body temperature, variable accuracy of measurement tools, inconsistent documentation, and variabil­ity of cut-off levels for hypothermia classes [3]. Hypothermia occurs more frequently in severely injured patients, such as trauma patients (30–50%). Hypothermia, a component in the lethal triad (or more recently lethal diamond), can progress to increased mortality and organ failure [1].
Etiology
S. M. Roberts (*) · S. Lynch · D. Gubler · A. J. LaPorta Rocky Vista University College of Osteopathic Medicine, Englewood, CO, USA e-mail: dgubler@rvu.edu
© Springer Nature Switzerland AG 2025 L. Marshall Gillman, S. Widder (eds.), Trauma Team Dynamics, https://doi.org/10.1007/978-3-031-86312-7_54
Many factors are involved in a patient developing hypother­mia after a traumatic injury [3]. Signicant risk factors for
473
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