Blast Injury at the Breach Point
You are staged with a tactical team for a dynamic entry on a small apartment. The breach uses a flash-bang and a small explosive charge on the door. As the team enters, the sole occupant detonates an improvised device in a 3-by-4-meter room. The scene is now secure but smoke-filled, and the structure has visible ceiling damage. Two casualties: the suspect has traumatic bilateral above-knee amputations and an unstable pelvis; an officer has a bloody cough, expanding neck veins, and decreased breath sounds on the right. At the casualty collection point 30 meters away: suspect HR 140, weak radial pulse, RR 34, SpO2 88% on room air, GCS 10; officer HR 118, RR 28, SpO2 91%, systolic BP 88. Ground transport to a trauma center is 25 minutes; a helicopter is 8 minutes out but not yet on station. You have two tourniquets, chest seals, needle decompression kits, TXA, and cold-stored low-titer O whole blood.
1. Lay out the first five minutes of tactical field care for both casualties. Explain how you sequence MARCH across two patients with limited supplies.
Read the worked answer
At the CCP I do a rapid MARCH on both, but hemorrhage comes first for both before I get pulled into the officer's chest. For the suspect: two tourniquets, one on each above-knee amputation, placed high and tight; pelvic binder for the unstable pelvis; then cover with a blanket. For the officer: expose the chest, apply a vented chest seal to any open wound, and perform right-sided needle decompression for the hypotension, distended neck veins, and absent right breath sounds. Then I cycle back: both get TXA, the suspect gets blood as soon as I have access, and both get hypothermia prevention. With limited supplies, I do not chase perfect care on one patient; I treat the lethal problems in sequence and reassess. The officer is more likely to survive with rapid thoracic and blood-pressure correction, but the suspect's junctional and pelvic hemorrhage will kill him in minutes if I do not place those tourniquets first. Two tourniquets, one pelvic binder, one needle, then blood.
2. Justify your thoracic decisions for the officer and the suspect. Include what findings would make you repeat a needle decompression and why blast lung changes your threshold.
Read the worked answer
The officer has the classic tension pneumothorax triad of hypotension, distended neck veins, and absent unilateral breath sounds, so I needle-decompress the right chest without waiting for imaging. I use the 4th or 5th intercostal space at the anterior axillary line with a 14-gauge, 3.25-inch needle or a commercial decompression device, and I reassess for improved blood pressure, breath sounds, and work of breathing. If there is no improvement, I repeat at the same or a second site, because a standard needle may not reach the pleural space in a muscular chest. I also place a chest seal on any external wound. The suspect is different: blast lung means pulmonary contusion, and a chest seal or positive-pressure ventilation can create or worsen a tension pneumothorax. I decompress him only for signs of tension such as worsening hypotension, absent breath sounds, tracheal deviation, or rising airway pressure, not prophylactically. I monitor both closely because tension can recur during evacuation; a recurrence in flight is a reason to repeat decompression.
3. Choose the evacuation platform and describe your resuscitation targets and blood and TXA plan en route. Address permissive hypotension.
Read the worked answer
The helicopter is faster once it is on station, but it is not there yet. I start ground movement immediately and request the aircraft to rendezvous at the landing zone or intercept en route; waiting on the pad with two unstable patients wastes the 8-minute advantage. My targets are permissive hypotension until hemorrhage is controlled, with systolic around 80-90 mmHg or a palpable radial pulse and intact mental status. However, the officer may have a brain injury from the blast, so I do not allow profound hypotension in him; I target a higher pressure if his GCS is depressed. I give whole blood as the primary resuscitation fluid, 1-2 units, and avoid large crystalloid boluses. TXA 1 gram IV over 10 minutes within 3 hours. I keep both warm, monitor for recurrent tension, and reassess tourniquets. If the suspect remains pulseless or the officer's saturation falls despite decompression, I escalate to the aircraft or a closer facility rather than continuing a long ground ride.