SMOG 2024 (2).pdf

U.S. ARMY AEROMEDICAL EVACUATION STANDARD MEDICAL OPERATING GUIDELINES (SMOG) CY24 Version Published 1 FEB 2024 Table of Contents 1 This is a new document. Updates will be published as required....

U.S. ARMY AEROMEDICAL EVACUATION STANDARD MEDICAL OPERATING GUIDELINES (SMOG) CY24 Version Published 1 FEB 2024 Table of Contents 1 This is a new document. Updates will be published as required. 2  INTRODUCTION The CY 2024 SMOG release marks the beginning of current format. The Aeromedical Evacuation community provided developmental feedback leading to a redesign of current written medical guidance and/or policy. All changes are a result of collaboration between Emergency Medicine professionals, experienced Flight Paramedics, Aeromedical Physician Assistants, Critical Care Nurses, and Flight Surgeons across the Army. There is close coordination in the development of these guidelines with the Joint Trauma System, and the Defense Committees on Trauma. Our shared goal is to ensure the highest quality enroute care possible and to standardize care across all evacuation and emergency medical pre-hospital units. It is our vision that all these enhancements and improvements will advance enroute care across the services and the Department of Defense. Unit Medical Trainers, Medical Standardization Instructors, Medical Flight Instructors and Medical Directors will evaluate Critical Care Flight Paramedics (CCFP), Enroute Critical Care Nurse (ECCN) Aeromedical Physician Assitant (APA), and Flight Surgeon ability to follow and execute the medical instructions herein. These medical guidelines are intended for CCFPs and prehospital professionals who manage emergencies and treat patients in both garrison, humanitarian, and combat theater environments IAW the Aircrew Training Manual Task 2120. Unit medical providers are expected to adjust these guidelines to fit their unit’s mission and medical air crews training/experience. Medical directors or designated supervising physicians will endorse these guidelines upon appropriate adjustment. They will also manage individual unit medical missions within their Critical Care Flight Paramedics, Enroute Critical Care Nurses, and advanced practice aeromedical providers scope of practice. CCFPs should administer medications as listed in the guidelines unless their medical director and/or supervising physician orders deviation. Other medications may be added, so long as the unit supervising physician and/or medical director approves them. This manual also serves as a reference for physicians providing medical direction and clinical oversight to medical personnel. Treatment direction, which is more appropriate to the patient’s condition than the guideline, should be provided by the physician so long as the medical personnel’s scope of practice is not exceeded. Any medical guideline that is out of date or has been found to cause further harm will be updated or removed immediately. The Department of Aviation Medicine (DAM) serves as the managing editor of the SMOG and is responsible for content updates, managing the formal review process, and identifying SMOG Charter members for annual review. The Standard Medical Operating Guidelines provide medical procedural guidance and is in compliment to other Department of Defense and Department of the Army policies, regulatory and doctrinal guidance. Nothing herein overrides or supersedes laws, rules, regulation or policies of the United States, DoD, or DA. 3  MEDICAL DIRECTOR/ UNIT COMMANDER REVIEW AND APPROVAL PAGE The Standard Medical Operating Guideline specifies standard medical treatment guidelines to be used by all Flight Paramedics and Medical Providers performing medical care while serving in this unit in any environment, deployed or otherwise. It is a guideline and not a comprehensive patient care manual. This SMOG and any attached and certified adjustments are hereby established as standard guidelines and protocol for the following unit: Date of Certification and Approval by all of the below: Unit Trainers Review: This document has been reviewed by the below noted individuals for correctness and mission applicability. Unit Standards Officer/NCO: Signature: Date: Unit Training NCO: Signature: Date: Authorization: The Standard Medical Operating Guideline has been reviewed and approved for use by the undersigned. Medical Director/Supervising Physician* Name: Signature of Approval: Date: Unit Commander Name: Signature of Approval: Date: *Additional Medical Director comments and addendums can be attached and should contain counter signature of Unit Commander to be valid. 4  Table of Contents PAGE TOPIC NUMBER COMMANDER / MEDICAL DIRECTOR’S APPROVAL PAGE 4 UNIVERSAL PATIENT CARE 9 TACTICAL EVACUATION 10 GENERAL AIRWAY 11 RAPID SEQUENCE INTUBATION 12 VENTILATOR MANAGEMENT 13 BLOOD 15 TRANSFUSION REACTIONS 16 IV/IO 17 ABDOMINAL INJURY 18 BURN INJURY 19 BURN FLUID RESUSCITATION 20 TRAUMA CHEST 21 CRUSH SYNDROME 22 EXTREMITY 23 EYE 24 HEAD / TBI 25 TRAUMATIC ARREST 26 ABDOMINAL PAIN 27 ALLERGIC REACTION 28 ALTERED MENTAL STATUS 29 BACK / NECK PAIN 30 MEDICAL HYPER / HYPOGLYCEMIA 31 RESPIRATORY DISTRESS (LOWER) 32 RESPIRATORY DISTRESS (UPPER) 33 SEIZURE 34 SEPSIS / FEVER 35 TOXIC INGESTION 36 VOMITING / DIARRHEA 37 BRADYCARDIA w/ PULSE 38 CARDIAC ARREST 39 CARDIAC CHEST PAIN 40 POST – CARDIAC ARREST CARE 41 STROKE / SUSPECTED TIA 42 TACHYCARDIA w/ PULSE 43 PEDIATRIC BRADYCARDIA w/ PULSE 44 5 PEDIATRIC CARDIAC ARREST 45 PEDIATRIC TACHYCARDIA w/ PULSE 46 PEDIATRIC TACHYCARDIA w/ PULSE (POOR PERFUSION) 47 CBRN MARCHE2 48 CHILDBIRTH 49 SPEC POP NEWBORN CARE & DISTRESS 50 OBSTETRIC EMERGENCY 51 PATIENT REFUSAL 52 MWD AIRWAY 53 MWD ANALGESIA / SEDATION 54 WORKING MILITARY MWD CPR 55 DOG MWD GASTRIC DILATION VOLVULUS 56 MWD HEAT INJURY 57 MWD NORMAL PARAMETERS 58 MWD SHOCK FLUID THERAPY 60 ANTIBIOTIC THERAPY CHART 61 COMMON LABORATORY VALUES 62 DA FORM 4700 63 DD FORM 3104 66 REFERENCES DD FORM 3073 (cTCCC) 70 DRUG DILUTION CHART 72 OXYGEN 73 PRE-FLIGHT CHECKLIST 74 FACILITY TRANSFER CHECKLIST 75 PRESSOR PRIORITY CHART 76 STANDING ORDER 77 USEFUL CALCULATIONS 79 Y SITE COMPATABILITY CHART 80 ASSESSMENT REFERENCE CHARTS 81 ALTITUDE ILLNESS 85 ENVIRON MENTAL ANIMAL AND INSECT BITES / STINGS 86 DECOMPRESSION SICKNESS 87 HOT / COLD WEATHER INJURY 88 SUBMERSION INJURY 89 ACETAMINOPHEN 90 ACETAZOLAMIDE 91 MEDICATIONS ACETYLSALICYLIC ACID 92 ACTIVATED CHARCOAL 93 ADENOSINE 94 ALBUTEROL 95 AMIODARONE 96 AMIODARONE CHART 97 ATROPINE SULFATE 98 6 CALCIUM CHLORIDE 99 CALCIUM GLUCONATE 100 DEDICATION PAGE 101 CEFAZOLIN 102 DEXAMETHASONE 103 DEXTROSE 50% 104 DIAZEPAM 105 DILTIAZEM 106 DIPHENHYDRAMINE 107 DOBUTAMINE 108 DOPAMINE 109 DOPAMINE CHART 110 EPINEPHERINE 1:1000 111 EPINEPHERINE 1:1000 DRIP CHART 112 EPINEPHERINE 1:10,000 113 EPINEPHERINE 1:10,000 DRIP CHART 114 ERTAPENEM 115 ETOMIDATE 116 FENTANYL 117 FENTANYL CHART 118 FUROSEMIDE 119 MEDICATIONS GLUCAGON 120 HEPARIN 121 HETASTARCH 122 HYDROMORPHONE 123 HYDROMORPHONE CHART 124 HYDROXOCOBALAMIN 125 KETAMINE 126 KETAMINE CHART 127 KETOROLAC 128 LABETALOL 129 LACTATED RINGERS / DEXTROSE 5% 130 LEVETIRACETAM 131 LIDOCAINE 132 LORAZEPAM 133 MAGNESIUM SULFATE 134 MANNITOL 135 METHYLPREDNISOLONE 136 METOCLOPRAMIDE 137 METOPROLOL 138 MIDAZOLAM 139 MORPHINE 140 MOXIFLOXACIN 141 7 NALOXONE 142 NIFEDIPINE 143 NITROGLYCERIN 144 NOREPINEPHRINE 145 NOREPINEPHRINE CHART 146 NORMAL SALINE / 3% HYPERTONIC SALINE 147 ONDANSETRON 148 MEDICATIONS OXYGEN 149 PHENYLEPHRINE 150 PLASMALYTE-A 149 PROMETHAZINE 151 PROPOFOL 152 PROPOFOL DRIP 153 ROCURONIUM 154 SUCCINYLCHOLINE 155 THIAMINE 156 TRANSEXAMIC ACID (TXA) 157 VASOPRESSIN 158 VECURONIUM 159 Standard Medical Operating Guidelines are found at the following website: https://www.milsuite.mil/book/groups/department-school-of-army-aviation- medicine Also available, along with all fillable evacuation forms and AARs on the Joint Trauma System website: https://jts.amedd.army.mil/index.cfm/PI_CPGs/cpgs https://jts.amedd.army.mil/index.cfm/documents/forms_after_action All comments and/or recommendations should be sent to: [email protected] with the subject line “CCFP-SMOG” 8  TABLE OF CONTENTS UNIVERSAL PATIENT CARE Patient History Key Concepts Age of the patient Use MARCHES for Trauma Patients Chief complaint Massive Bleeding control Timing of events / Event factors Airway Other symptoms or complaints Respiratory Patient’s Past Medical History Circulation Patient Medications and Allergies Hypothermia care Other Pertinent SAMPLE, OPQRST Eye injuries questions Spinal motion restriction Focused primary exam for non- traumatic illness/injury Treatment/Actions Scene safety o Maintain situational awareness o Utilize appropriate PPE Initial assessment o Treat obvious and emergent life threats o MARCHES or Focused Primary Exam o Utilize BLS, ALS, and/or PALS guides as necessary Consider spinal immobilization o Dangerous MOI o Low risk MOI but unable to rotate neck 45o o Does not apply to situations imminent danger exists Record vital signs and make appropriate transport decision Initial Interventions o Supplemental O2 o IV/IO (Saline Lock) as applicable o Medication/fluid administration (as indicated) Secondary assessment o 12 Lead EKG (as applicable) o EtCO2 (applicable) o Secondary interventions o Pain Management Notes, Warnings, Cautions General supportive measures include Airway / Respiratory support, continuous hemodynamic monitoring with SPO2 and EtCO2 as appropriate, Supplemental O2 PRN, IV Fluid boluses, Pain control PRN. All patients should have complete vital signs recorded. All patient encounters should be recorded on appropriate care documentation sheets per theater policies, unit SOPs and/or in accordance with JTS Documentation CPG at end of a patient encounter. Any mishaps / errors should be brought to attention of the medical control ASAP. Contact medical control for any necessary assistance when feasible. Consider spinal immobilization if: Fall from > 1 Meter; Axial Load to Head; High Speed RTC, Rollover, Ejection Motorized Recreational Vehicle; Bicycle Collision; Explosions 9  TABLE OF CONTENTS TACTICAL EVACUATION Ground “Pick-Up” Phase Ground “Pick-Up” Phase Attempt to gain info prior to landing. Goal on ground time < 5 min prior to Ensure 360-degree scene security. wheels up. Collect medical information and If the tactical situation permits, all patient documentation. known preventable causes of death Triage Casualties should be addressed prior to casualty movement. Treat all preventable causes of death IAW TCCC If military working dogs (MWD) are present (injured or uninjured) Package and secure patients for subdue/muzzle MWD first, then treat transport. all human casualties before treating Brief and guide litter teams to aircraft. injured MWDs. Load and secure patients. “In-Flight” Phase Triage Casualties as required: Reassess patients and interventions. Hemorrhage Control o Check/ Add Tourniquet, Pack/Dress Wound, Pressure Dressing, Hemostatic Dressing o Initiate blood (DCR) Airway / Vent Management o Reposition Airway, Nasopharyngeal Airway, RSI (Intubation/BIAD), Cricothyroidotomy o Target SPO2 90-96% Chest Trauma o Vented Occlusive Dressing, Needle Thoracostomy, Finger Thoracostomy, Chest Tube Hypothermia management Head Injury / Altered Mental Status o Monitor and treat for signs and symptoms of ICP (Elevate head, 3% Hypertonic Saline, Target ETCO2) Pain Management Consider Antibiotic Therapy Document Care Notes, Warnings, Cautions Damage Control Resuscitation (DCR) order of precedence: o Control Hemorrhage if able o Administer Blood products. o Consider TXA 2 grams < 3hrs from injury. o Calcium administration during or after 1st unit and after every 4th unit of blood. (Calcium maybe given before TXA) o Consider 125mL bolus Plasmalyte A o Consider Pressors (as a last resort) Notes, Warnings, Cautions Replace any limb tourniquets placed over the uniform with one applied directly to the skin, 2-3 inches above the wound. Maximize blood/fluid therapy prior to considering pressor administration. At any time, patient becomes pulseless and apneic go to traumatic arrest protocol. If tactical situation allows, load deceased patients on a separate transport. Consider full RSI prior to advanced airway management to prevent aspiration. 10  TABLE OF CONTENTS AIRWAY (Adult / Pediatric) Signs and Symptoms of Distress and/or Failure: SPO2 decreasing 35 BPM) I:E: 1:2 (Patients with obstructive lung diseases should have increased I:E around 1:4 or 1:5; if rate > 20 (most children) will need to titrate iTime down to achieve appropriate I:E ratio) FiO2/PEEP (Should be adjusted in concert per the chart below) o Start at 100% (1.0) FiO2 and PEEP of 5; PEEP no higher than 16 on Pediatrics w/out expert consult. o Wait 5 minutes and assess SpO2. o Goal SPO2 90-96% To Achieve Oxygenation Goals, set the FiO2 to 30% and start titration FiO2 and PEEP collectively based on the chart. Go up every 5-10 minutes; quicker if low SpO2 sats develop. NOTE: Hypotensive patients (MAP 25 cm H2O or VT = 6 ml/kg. If Pplat < 30 and breath stacking, or dys-synchrony occurs: may increase VT in 1ml/kg increments to 7 or 8 ml/kg if Pplat remains < 30 cm H2O. Alarm Settings: High Pressure Alarm: 10 cmH2O above peak airway pressure. Low Pressure Alarm: 5 cmH20 below peak 13 airway pressure.  OR High Pressure Alarm: 50% above the baseline PIP (1.5 x current PIP) Low Pressure Alarm: 50% below the baseline PIP (0.5 x current PIP) **Pressures will be determined by placing patient on ventilator for ~ 1-2 minutes and determining intrinsic peak inspiratory pressure. (Labeled as PEAK on 754 Ventilator (top right); Labeled as Ppeak on Hamilton T1 (top left)** Monitor waveform on machine and patient to ensure no breath stacking occurs. If this occurs, a high-pressure alarm may sound. However, if breath stacking suspected even in absence of alarm – disconnect tubing and allow exhalation. Increase I: E. Troubleshooting: Airway compromise or lost airway in-flight. If at any time patient begins to desaturate or develop respiratory problems, immediately disconnect ventilator, and ventilate patient with BVM (with PEEP valve if available) and 100% O2 while correcting issues utilizing the D.O.P.E. algorithm: o Displacement: ETT in place, patient not extubated/ tube did not move during transfer. If advanced – pull back to original length and attempt to bag; if tube has pulled farther out of trachea, DO NOT ATTEMPT TO ADVANCE IT without placement of bougie to verify tracheal placement. When advancing bougie, feel for tracheal rings or carina stop. If in doubt, pull tube and attempt BVM. If this fixes problem, continue to bag patient. Upon stabilization, consider alternative advanced airways (extraglotic airway or cric). **If ETT moves freely, access for ETT bulb rupture. ** o Obstructions: Assess for secretions in ETT. Suction if indicated. o Pressure: Ensure that a tension pneumothorax / hemothorax has not developed (if chest tube in place, ensure it is functioning/ not kinked or clamped). If tension pneumo / hemothorax suspected, perform immediate needle thoracostomy. Assess the need for escharotomy if circumferential burn. Consider additional paralysis and sedation if patient does not tolerate ventilation. o Equipment: Ensure that vent did not fail; O2 tank not empty. If ventilator is operational, trace all tubes to the patient connection (airway tube, transducer line, exhalation line) ensuring patency and connections. High pressure alarms / Peak airway pressure alarms (Peak pressure >35 cm H2O): Correct problems causing increased airway resistance and decreased lung compliance, including pneumothorax or pulmonary edema. Check ventilator to make sure prescribed tidal volume is being delivered. Check for linked/crushed tubing. Air leaks causing low pressure alarms / volume loss: Assess, correct air leaks in endotracheal tube, tracheostomy cuff, ventilator system; recheck ventilator to make sure prescribed tidal volume is delivered. Ventilator desynchrony: Agitation and respiratory distress that develop in a patient on a mechanical ventilator who has previously appeared comfortable represents an important clinical circumstance that requires a thorough assessment and an organized approach. The patient should not always be automatically re-sedated but must instead be evaluated for several potentially life-threatening developments that can present in this fashion. Lung hyperinflation (air trapping) and auto-PEEP: Dynamic hyperinflation is associated with positive end- expiratory alveolar pressure, or auto-PEEP. The physiologic effects include decreased cardiac preload because of diminished venous return into the chest. The reduced cardiac output that results from the reduction in preload can lead to hypotension and, if severe, to Pulseless Electrical Activity and cardiac arrest. Dynamic hyperinflation can also lead to local alveolar overdistention and rupture. Prevent, manage lung hyperinflation by decreasing tidal volume, changing inspiratory and expiratory phase parameters, switching to another mode, and correcting physiological abnormalities that increase airway resistance. Document procedure, results, and vital signs. Ventilator Transfer Procedure 1. Ensure endotracheal tube is secure, document size and position of ETT at the teeth. Clamp tube before disconnecting patient from vent if PEEP is greater than 5 or PEEP recruitment maneuvers are being conducted to maintain PEEP and un- clamp only after connected to new vent circuit. 2. Ventilator settings should be coordinated with the transferring physician, anesthesia provider or respiratory therapist. Verify settings, review arterial blood gas (ABG) analysis, and current SPO2 and ETCO2 readings. Place those setting on transport vent and place patient on transport vent early to verify patient tolerance and compatibility. 3. ABG should be done within 30 minutes of flight. If time allows, patient should be on transport ventilator for at least 15 minutes prior to transport. 4. Ventilator settings for en-route care team should initially be matched to those of the transferring facility. Adjust settings PRN in order to maintain appropriate clinical parameters listed on first page of ventilator management protocol or transferring physician orders. 5. Ensure adequate sedation and analgesia medications are on hand. CPG IDs: CPG 27 Mechanical Ventilation Basics; CPG 48 Mechanical Ventilation During CCAT 14  TABLE OF CONTENTS BLOOD AND COMPONENT USE IMMEDIATE CLINICAL INDICATIONS in trauma patients with SERIOUS INJURIES and evidence of hemorrhage / shock: Systolic 100 or higher and/or one or more amputations Clinical Indications: Uncontrolled hemorrhage or evidence of hemorrhagic shock, trauma patients with amputation (complete or partial with distal circulation compromise), non- compressible penetrating thoracic, abdominal, and transitional zone injuries (significant mechanism of injury), clinical signs of coagulopathy (tachycardia, tachypnea, fever, altered mentation, hypoxemia, and severe hypothermia associated with blood loss Treatment Maximal hemorrhage control, treatment of suspected tension pneumothorax, patent airway or airway control, IV/IO access and hypothermia prevented and/or treated. Order of precedence: Resuscitate with Whole Blood Plasma, RBCs, Platelets in a 1:1:1 Ratio (no particular order) Plasma and RBCs in a 1:1 Ratio Plasma (thawed, liquid, reconstituted) alone or RBCs alone Document all items on the SF 518 (only authorized document for blood products aboard Army Aeromedical Evacuation platforms). o Two person verification of patient and blood products given matching SF 518. Observe units of blood (look for gas, discoloration, clots, and sediment) and verify that the Safe-T-Vue is white. Initiate large bore IV (18G min, 14G preferred) or IO access (Lidocaine 2% (2-3 mL) flush in IO sites provides analgesia and increases compliance) All blood and blood products will be administered through a dedicated line of NS using Y-tubing with filter. Transfuse blood through an approved fluid warming device if available. o Rapid transfusion can be achieved via pressure bag at least 300 mmHg and 60 ml syringe or manual pressure can also be utilized in the event a pressure infuser is not available. Consider slowing all other concurrent infusions unless they are TXA or RFVIIa. Resuscitation Goal: until palpable radial pulse, improved mental status or SBP 100 (SBP >110 w/ head injury) and MAP >60 mmHg. 30 ml of 10% calcium gluconate or 10 ml of 10% calcium chloride IV/IO should be given to patients in hemorrhagic shock during or immediately after transfusion of the first unit of blood product and with ongoing resuscitation after every 4 units of blood products. Ionized calcium should be monitored and calcium should be given for ionized calcium less than 1.2mmol/L. o Monitor patient every 5 minutes and document any patient signs and symptoms consistent with a transfusion reaction. 15  TABLE OF CONTENTS TRANSFUSION REACTIONS STOP THE TRANSFUSION! If a blood transfusion reaction is suspected Treatment Apply O2 (if hypoxic), IV/IO and cardiac monitor. Establish Advanced Airway per individual competencies, contraindications, and/or attempt failures. Maintain SPO2 >90% Anaphylaxis: o 500ml NS (if not started already) o Epinephrine 0.5mg IM o Diphenhydramine 50mg IV/IO/IM/PO o Methylprednisone 125mg IV/IO o Consider Albuterol 90mcg (2 puffs or 2.5-5mg nebulized) Febrile Non-hemolytic Transfusion Reaction (FNHTR) o Acetaminophen 500mg PO or 1G IV Acute Hemolytic Reaction (AHTR) o Draw blood from adjacent limb. o 100-200ml/hour NS to support UOP of 100-200ml/hr Continue to reassess the patient and ensure to document on SF 518 Notify blood bank of all transfusion reactions. Notes, Warnings, Cautions GENERAL RULES: o Stop the transfusion. o Keep the intravenous line open with saline. o Identify and treat cause of the reaction. o Re-institute the transfusion only if it is deemed to be clinically essential. Before initiating IVF bolus, ensure IV tubing is new. DO NOT USE existing Y- tubing from blood administration set. The most common transfusion reaction is a febrile, non-hemolytic transfusion reaction. These are mostly benign with no lasting sequelae. Treatment consists of antipyretics. (Acetaminophen 500mg PO every 4 hours.) TRALI is the leading cause of transfusion-related mortality and commonly occurs is patients who have undergone recent surgery, massive blood transfusion, or who have an active infection. Goal of treatment is supportive and aimed at maintaining oxygenation and reducing respiratory distress. TACO is essentially pulmonary edema secondary to congestive heart failure usually occurring in elderly, small children, and those with compromised cardiac function. Large volumes of fluid given rapidly are a common precursor to this reaction. Goal is aimed at mobilizing fluids (diuretics) and treating underlying condition. Both TACO and TRALI require immediate resuscitation by an advanced level practitioner. o A unit of packed cells should be given at a rate of 2.5-3.0 mL/kg per hour. Mechanical-caused hemolysis is commonly caused by rapid transfusion, poor collection, and storage, or heating the blood above 42°C during transfusion. 16  TABLE OF CONTENTS IV / IO PROTOCOL Assess need for IV Intraosseous Device for o Emergent or potentially Life/limb threatening. emergent medical or trauma condition. IO should only be considered Peripheral IV x 2 first if patient is deemed o Catheter > 18ga difficult to gain IV access. o Two failed attempts or > If IV/IO access unsuccessful 90 secs proceed to IO. attempt EJ IV Cannulation. Sternal IO Devices: Correct needle size for EZ-IOTM o Yellow - 45mm for humerus o Fast-1TM and *heavy sternal o EZ T.A.L.O.NTM o Blue - 25mm for adult o EZ-IOTM *sternum/tib o Pink - 15mm for children and *sternal/tib Locations for EZ T.A.L.O.N.TM and EZ-IOTM by precedence o Bilateral Proximal *NOTE: Use of EZ-IO in sternal is off label Humerus emergency procedure only o Bilateral Proximal Tibia o Bilateral Distal Tibia Notes, Warnings, Cautions GENERAL RULES: o GAIN VASCULAR ACCESS where available based upon patient. o Any pre-hospital fluids or medications approved for IV use may be given through an intraosseous line, including blood products. o All trauma patients or potentially ill patients should have at least two functioning IV / IO lines whenever possible. o Upper extremity IV sites are preferable to lower extremity IV sites. o Pressure infusion bag is recommended for IO starting at 300mmHg. o Following IV attempt failure and IO attempt failure, external jugular lines can be attempted for life-threatening events with no peripheral access. o Ensure open and functioning fluid bolus per specific protocol. At a minimum, maintain a slow “to-keep-open” (TKO) drip. 17  TABLE OF CONTENTS ABDOMINAL INJURY Signs and Symptoms Altered Mental Status Tachycardia Absence of palpable pulses Pale, moist, mottled skin Poor peripheral pulses Hypotension Hematuria Pain, tenderness, distention, dissymmetry Absent/diminished bowel sounds Grey-Turner sign Cullen sign Kehr’s sign Treatment Blunt Abdominal/Pelvic Injury o Serial Physical Exams/Reassessment o Pelvic Binder o Conduct FAST exam if possible* o Focus on resuscitation Penetrating Abdominal/Pelvic Injury o Hemostatic Dressing/ Pack Pelvic Cavity o Pressure Dressing o Direct and Indirect pressure o Abdominal Dressing o Pelvic Binder o AAJT- uncontrolled pelvic bleed Damage Control Resuscitation o Consider implementation of DCR if indications are met (SBP100) (penetrating abdominal injuries) Notes, Warnings, Cautions Pregnant patient o Increased risk of Aspiration and gastric acidity o Patient should receive max O2 due to increased O2 consumption and depleted reserves o Consider warm LR before crystalloids to better restore fetal oxygenation o >20 weeks gestation, tilt at least 15 degrees to prevent Vena Cava Syndrome * FAST exam cannot reliably exclude significant injury but may provide indication of intra-abdominal injury. Lateral contusions (seatbelt sign) associated with a 20% occurrence of internal injury. Presence of pregnant uterus should be determined. Some changes can mimic shock (heart rate can increase by 20 BPM, blood volume increases by 50% during mid-pregnancy, and can experience relative anemia from hemodilution.) Due to the increase in blood flow to the uterus, risk of massive blood loss is greatly increased with trauma to the bony pelvis 18  TABLE OF CONTENTS BURN INJURY History Burn Center: DSN: 312-429-2876 (429-BURN) How long ago was the injury? Comm: 210-916-2876 or 210-222-2876 Any signs of airway involvement? How big/small of a space was the patient in during the incident? STOP the burning process/remove patient from electrical source. Ensure your safety first! (inhalation/carbon monoxide) Are there other traumatic injuries associated? Differential Diagnosis: cardiac arrest, environmental exposure, seizure, burns Any spinal immobilization needed? (chemical, electrical, thermal, radiation), (fall from a significant height, blast, multiple trauma, carbon monoxide toxicity. etc.) Treatment Access for additional injuries and treat life threats (DO NOT overlook TRAUMA), IV/IO, O2, and monitor (electrical injuries must have 12 lead EKG completed to access for Arrythmia’s) Electrical: If arrythmia is present, go to appropriate Cardiac protocol Remove any constricting items i.e., rings and bracelets Access airway, if suspected airway involvement move to Airway Guideline. Indications for endotracheal intubation include comatose patient, symptomatic inhalation injury, deep facial burns, and burns over 40% Total Body Surface Area (TBSA). Requires large ETT size 8 adult. Thermal/Electric burn: If able, remove burning/charred clothing and cover with dry, sterile sheets/dressings. Chemical burn: Brush off dry chemicals, cut off contaminated clothing, flush area with saline 10-15 minutes. o Eyes: flush with saline for 30 minutes. o Hydrofluoric Acid- Arterial infusion over 4hrs (40mL of D5W with 10mL of 10% calcium gluconate). o Tear Gas- rinse skin and eyes with NS. o Alkali Burns to eye- 1-2 L of NS each eye for 30 minutes. Determine/start fluid replacement for burn fluid resuscitation. Manage pain and prevent hypothermia. KEEP WARM! Monitor urinary output, if able Consider prophylactic escharotomy prior to transport or emergency inflight escharotomy if circumferential burns, especially to the chest that compromise ventilation Notes, Warnings, Cautions Urinary output is the MOST reliable guide for adequate resuscitation: Adult 0.5ml/kg/hr (75-100ml/hr electrical burn) Children: 40KG Burns: 10mL/hr x %TBSA (estimate to nearest 10%); patients weighing more than 80kg, add 100 ml/hr to IV fluid rate for each 10 kg > 80 kg. Re-evaluate every 1-2 hours. Adjust IV rate to UOP goal 30-50mL. Adjust IV rate up or down by 20-25%. High Voltage Injury: 10mL/hr x %TBSA (estimate to nearest 10%); patients weighing more than 80kg, add 100 ml/hr to IV fluid rate for each 10 kg > 80 kg. Re-evaluate every 1-2 hours. Adjust IV rate to UOP goal 75-100mL. Adjust IV rate up or down by 20-25% PEDIATRIC 20%, may require acute fluid resuscitation in prehospital: LR (best)>NS (2nd best)>Hextend (only to 1L) Notes, Warnings, Cautions It is worth your time and effort to accurately estimate burn surface area, ideal body weight, then calculate and administer appropriate fluids while the patient is under your care. Infants and young children should also receive LR with 5% Dextrose at a maintenance rate and monitor for hypoglycemia. Reference CPG ID: 12 (Burn Care); JTS Burn Resuscitation Flow Sheet 20  TABLE OF CONTENTS CHEST TRAUMA Signs and Symptoms Signs and Symptoms Difficulty breathing Open wound/impalement over Rapid respirations with SPO2 the Thorax decreasing or 90% (goal 93-95%) and PaO2>80mmHg  ETCO2-35-40mmHg (suspected herniation 30-35 mmHg) No Obvious Airway Compromise o Jaw Thrust o NPA o Supplemental O2 o Consider RSI if treating single Urgent Casualty Evidence of Elevated ICP: o Target Vital Signs: SBP>110, SPO2> 90% (goal 93-95%), PaCO2> 80mmHg, ETCO2 35-40mmHg, CCP60 (CCP=MAP – ICP) o Elevate head of bed to 30-60 deg o 3% Hypertonic Saline 250 mL bolus followed by 50-100 mL/hr. infusion. Evidence of Impending Herniation (e.g., unilateral/bilateral dilated or fixed pupil, presence of Cushing’s triad) [Cushing’s triad = (relative) bradycardia, hypertension/widening pulse pressures, irregular respirations]: o Target ETCO2 30-35mmHg Notes, Warnings, Cautions Ensure Continuous monitoring q5-10 min GCS 110: consider LR/NS bolus Avoid Hypo/Hyper-capnea through dedicated closely managed ventilation Reference CPG ID: 30 (TBI and Neurosurgery in the Deployed Enviroment: 63 (TBI Management in PFC) 25  TABLE OF CONTENTS TRAUMATIC ARREST History History (Differential)) Evidence of trauma without a pulse Medical cause of arrest preceding Unresponsive to external stimuli trauma Tension pneumothorax Hypovolemia Cardiac Tamponade Treatment Determine if injuries are incompatible with life. o Do not resuscitate if injuries are incompatible with life. Begin CPR Address all known points of hemorrhage. o Initiate blood products o TXA 2gm IV/IO Place advanced airway o Start supplemental O2 Bilateral needle thoracostomy Consider Advances Procedures o Finger Thoracostomy o Tube Thoracostomy o Pericardiocentesis Place monitor on patient: Prepare Defibrillator o Determine Rhythm: Pulse return? ROSC not Achieved o Continue CPR o Continue Blood / IV Fluids o Reduce Long Bone Fractures o Reduce Pelvic Fracture o Reassess known hemorrhage points ROSC Achieved o Return to Tactical Evacuation or Previous Guideline Notes, Warnings, Cautions Injuries obviously incompatible with life include decapitation, massively deforming head / chest injury, traumatic hemi-corpectomy or total body disruption, incineration, lividity/ rigor mortis. If unsure if arrest due to trauma or medical cause, initiate ALS guideline for any arrhythmias following optimization of hemostasis (in trauma patients, volume loss must be corrected 1st, consider blood admin above all else) CPR without addressing massive hemorrhage, blood volume resuscitation, tension pneumothorax, and pericardial tamponade will be ineffective. *Consider severe hypocalcemia if blood products have recently been transfused due to calcium chelation and evidence of poor cardiac activity/contractility. 26  TABLE OF CONTENTS ABDOMINAL PAIN (Adult) Signs and Symptoms Potential Causes Pain (RUQ, RLQ, LUQ, LLQ) Migration / Radiation) Tenderness Nausea / Vomiting Diarrhea (Bloody?) Dysuria Constipation Vaginal Bleeding / Discharge Distention Guarding / Rigidity Associated symptoms: Fever, Headache, Weakness, Malaise / Fatigue, Myalgia, Cough, Mental Status Changes, Rash Rule out MOI as a differential diagnosis. Universal Patient Care Guideline, O2 (if Hypoxemic), IV / IO Guideline, Cardiac Monitor12 Lead ECG (>40yo) Trauma Considerations Medical Considerations MOI- Blunt force or penetrating Identify potential causes of abdominal trauma pain (refer to chart above) Obstetric Patient trauma- follow O/B Tachycardia / Hypotension / Emergency Guideline Orthostatic BP consider 500ml bolus per (IV/IO Blood Products guideline) Significant Pain Persistent or Worsening Signs of Hypovolemic Shock (Tachycardia, pain management guideline Hypotension, Pulse Pressure) Cardiac Emergencies cardiac pain guideline) Rigid Distended Abdomen and/or Nausea or Vomiting Known: AAA, GI Bleed, or Ruptured 500ml IVF Bolus Ectopic / Abruption Promethazine 12.5-25mg IV Reassess unstable patients every 5 Ondansetron 4-8mg IV min; Stable patients every 15 min. Notes, Warnings, Cautions Maintain a high index of suspicion for ectopic pregnancy as a cause of abdominal pain in childbearing age. Antacids should be avoided in patients with renal disease. Patients older than 50 are at an increased risk for life-threatening diagnosis. Appendicitis presents with vague, periumbilical pain that migrates to the RLQ. This classic presentation may not be present in some patients. Repeat vital signs after each intervention. In non-traumatized patients, may repeat fluid bolus PRN depending on patient condition and vital signs. In trauma patients, fluid bolus should be used in accordance with hypotensive resuscitation guideline. Conservative approach with lower promethazine dosage for patients likely to experience sedative effects (e.g., elderly patients). 27  TABLE OF CONTENTS ALLERGIC REACTION (Adult) (Pediatric) Signs and Symptoms Differential Diagnosis Itching or Hives Urticaria (rash only) Cough / Wheeze / Resp. Distress Anaphylaxis (2 or more systems) Chest/Throat tightness Shock (other than anaphylactic) Difficulty Swallowing Angioedema Hypotension or Shock Aspiration / Airway Obstruction Edema Asthma or COPD Nausea / Vomiting Pulmonary Edema / CHF *Rule out MOI as a differential diagnosis. Universal Patient Care Guideline, O2 (if Hypoxemic), IV / IO Guideline, Cardiac Monitor (ASAP)* ADULT PEDIATRIC Hives / Rash Only Hives / Rash Only No Resp. Complaint No Resp. Complaint Administer Diphenhydramine 25-50mg Administer Diphenhydramine IV/ IO/ IM/ PO 25-50mg IV/ IO/ IM/ PO Administer Methylprednisolone 2mg/kg Administer Methylprednisolone 2mg/ IV/IO kg IV/IO Shock / Unresponsive or Respiratory Shock / Unresponsive or Respiratory Distress / Failure Distress / Failure Epinephrine-Pen or Epinephrine Epinephrine-Pen (Jr for 50yo, pregnant, have a history of ischemia – all patients should be on cardiac disease, or have HR >150. monitors and have 12- lead ECG. Epinephrine can precipitate dysrhythmias / ischemia – all patients should be on The shorter the interval from contact to monitors and have 12-lead ECG. symptoms, the more severe the reaction. Epinephrine: IM: 0.3-0.5mg (0.3-0.5 mL Arrhythmia- See pediatric cardiac guideline 1:1000) or EpiPen® IV Bolus: 100 mcg over for bradycardia, cardiac arrest, and 5-10 min; mix 0.1mg (0.1 mL of 1:1000 in tachycardia with a pulse. 10mL NS, and infuse over 5-10 min) IV Infusion: Start at 1 mcg/min; mix 1mg (1 mL Non-arrhythmia- See hypotension guideline of 1:1000 in 500 mL NS, and infuse at 0.5 or respiratory distress guideline. mL/min; titrate as needed 28  TABLE OF CONTENTS ALTERED MENTAL STATUS Signs and symptoms Differential diagnosis Any signs of head trauma/injuries? Any Head trauma/psychiatric disorders AMS? Thyroid dysfunction Any pertinent medical conditions or Hyper/hypoglycemia medical history? Diabetic ketoacidosis/toxic Ingestion Are there any bystanders that can Environment (hyper/hypothermia) provide information about the patient? Is Hypoxia this abnormal behavior? Safety of the helicopter/crew/other patients take PRIORITY! Treatment Does the patient have a head injury, unable to protect their airway (GCS3 ft. Fall directly onto head / neck Arrhythmia History of back / neck arthritis plus Bradycardia with Pulse Guideline Tachycardia with Pulse Guideline Cardiac Arrest Guideline (VF / Pulseless VT or Asystole / PEA) Notes, Warnings, Cautions EXAMINE: Mental Status, HEENT, neck, chest, abdomen, back, extremities and neurologic. Abdominal Aortic Aneurysm is a concern in hypertensive / diabetic / >50y populations- feel for pulsatile abdominal mass. Symptoms may mimic kidney stones. Patients with trauma and midline tenderness should be immobilized. Any bowel/ bladder incontinence is significant and may represent a true medical emergency. 30  TABLE OF CONTENTS HYPERGLYCEMIA/HYPOGLYCEMIA Hyperglycemia S/S Hypoglycemia S/S BLOOD GLUCOSE >250 BLOOD GLUCOSE 60mg/dl. Consider Intubation for patients with AMS.  If IV access unobtainable, administer Glucagon 1mg IM. Nausea or vomiting present, administer: Recheck 15 minutes after  Promethazine 12.5-25mg IV OR administration. Ondansetron 4-8mg IV  Patients with NO AMS:  Administer oral glucose gel or equivalent until glucose level is >70mg/dL. Notes, Warnings, Cautions Notes, Warnings, Cautions If insulin is available, treat with low dose If administering Dextrose, obtain infusion, 0.1 units/kg/hr. blood glucose sample from contralateral arm. Too rapid drop in blood glucose can cause Hypoglycemia may be detrimental to patients hypoglycemia. at risk for cerebral ischemia, such as victims of stroke, cardiac arrest, and head trauma. Rapid drop in blood glucose levels can lead to shifts extracellular osmolality which can lead Hypoglycemic patients must be alert enough to cerebral edema. to swallow and protect airway. 31  TABLE OF CONTENTS LOWER RESP DISTRESS Signs and Symptoms Potential Causes Shortness of Breath Asthma Pursed Lip Breathing Anaphylaxis / Allergy Decreased Ability to Speak Aspiration Tachypnea / Hyperpnea COPD Pleural Effusion Wheezing / Rhonchi / Rales Pneumonia Use Accessory Muscles Congestive Heart Failure / Cardiac Fever / Cough Pulmonary Embolus Tachycardia Pneumothorax Absent Breath Sounds Pericardial Tamponade Hyperventilation Toxic Inhalation (e.g., Cyanide, CO) WHEEZES RALES/CHF ADULT Monitor O2 and ETCO2 Monitor O2 and ETCO2 Place on 100% oxygen via NRB. Provide PPV/NIPPV Administer Albuterol 90-180mcg MDI 2 (CPAP/BIPAP) with 100% puffs or 2-5mg nebulized oxygen support. Monitor for allergic reactions: Initiate IV/IO Access o Consider Epinephrine 1:1,000 0.3- Administer nitroglycerin SL 0.5mg IM (EPI PEN) 0.4mg q5min if SBP>90. Initiate IV/IO Access o Failure to improve: Administer Methylprednisolone 125mg IV administer Furosemide Consider Magnesium Sulfate 2G IV over 60-80mg IV slow push, 20min. place foley if possible. As a last resort, administer Ketamine 1mg/kg IV slow push. PEDIATRIC Place on 100% oxygen via NRB. Administer Albuterol 90mcg MDI 2 puffs or 2.5-5mg Monitor O2 and ETCO2 nebulized) (Max 12 doses per 24hrs) Provide PPV (if tolerated) with Monitor for allergic reactions: 100% oxygen support OR 100% o Consider Epinephrine (1:1000) NRB if PPV is not tolerated. o 15- 30kg.15mg IM (EPIPEN JR) Failure to improve: administer o 30kg> 0.3mg IM (EPIPEN) OR Furosemide 1mg/kg IV slow o 0.01mg/kg IM (max 0.3mg) push, place foley if possible. Administer Methylprednisolone 1-2mg/kg IV. Administer Magnesium Sulfate 25-75mg/kg IV over 30min (Max 2G) with 20ml/kg crystalloid. Last resort, administer Ketamine 0.5mg/kg IV slow push. Notes, Warnings, Cautions SPO2 0.3mg IM (EPIPEN) OR o 1:1000 0.01mg.kg IM (max 0.3mg) Administer Methylprednisolone 1-2mg/kg IV. Notes, Warnings, Cautions SPO2 90 Keys to Success: BP < 90, RR >20/min. 1. Early recognition Altered Mental Status 2. Identification of the cause of shock Decreased Urine output 3. Early, decisive treatment of the cause and initiation of cause- Rash(s), Purpura specific resuscitation. Immunosuppressed Treatment Initiate Monitoring: ECG, NIBP, SPO2, ETCO2, Temp Supplemental O2, Goal > 90% Check Glucose ( 90 or MAP >65 or 30ml/kg. Initiate/Monitor Foley. UOP 0.3-0.5ml/kg/hr. Temperature >100.4°F / 38°C consider Acetaminophen 1gram PO/IV (if not provided in the last 6 hours) Persistent or Refractory Hypotension after 2L NS/LR, unable to maintain SBP > 90 or MAP > 65? o Administer Norepinephrine 2-12mcg/min IV. o Add Vasopressin 0.04 units/min SBP < 90 or MAP < 65. o Add Epinephrine 2-20 mcg/min SBP < 90 or MAP < 65. Consider Antibiotic Therapy Ceftriaxone 2 g slow IV push or in 100 cc NS flow to gravity (immunocompetent) or Cefepime 2 g IV in 100 cc NS flow to gravity (immunocompromised) Contact Medical Control for further if able. Notes, Warnings, Cautions Consider adding Vasopressin when titrating above 8-10 mcg/min IV norepinephrine. Continue it once started and decrease norepinephrine to MAP goal > 65. Monitor overall respiratory status. Many patients who are critically ill with sepsis will need ventilatory support at some point in their management. Record urine output if foley in place. Decreased urine output is an indicator of patient deterioration. Fever may not be present in immunocompromised, elderly, or those on immunosuppressive drugs. All fever is not due to infection – evaluate for environmental / thyroid / toxic etiology. In Trauma Sepsis, Blood is Preferred Caution in over-resuscitation >.5ml/kg/hr UOP, wet lungs, increased work of breathing. 35  TABLE OF CONTENTS TOXIC INGESTION Poison Control Number (in US): +1(800)222-1222 Signs and Symptoms Differential Diagnosis Mental Status Changes Cyclic Antidepressants Hypo/Hypertension Acetaminophen Respiratory Depression Depressants Tachycardia/Arrythmias Stimulants Seizure Anticholinergic Cardiac Medications Solvents/Cleaners ADULT Treatment Blood Sugar 60: Activated Charcoal 1g/kg PO (If alert and 100 or Hypotensive?  Sodium Bicarbonate 1mEq/kg  100-150 mEq in 1L D5/NS @ 100-200ml/hr Organophosphate: Atropine 2mg IV/IO q5 + 2-PAM 600mg IV/IM o Seizure - Midazolam 2.5-5mg IV/IM PEDIATRIC Treatment Blood Sugar 60: Activated Charcoal 1g/kg PO (If alert and 100 or Hypotensive?  Sodium Bicarbonate 1mEq/kg  100-150 mEq in 1L D5/NS @ 100-200ml/hr Organophosphate: Atropine 0.02mg/ IV/IO q5 + 2-PAM 25mg/kg IV/IM o Seizure - Lorazepam 0.1mg/kg IV Notes, Warnings, Cautions Anticholinergic: Altered mental status, hyperthermia, mydriasis, flushing, anhidrosis, full bladder. o Follow TriCylcic dosing o Lorazepam for agitation and seizures Beta Blockers watch for Hypoglycemia Calcium Channel Blockers watch for Hyperglycemia Cyclic Antidepressants signs: Hypotension, depressed mental status, respiratory depression, and cardiac arrythmias Opiod signs: Depressed mental status, pinpoint pupils, N/V, Respiratory depression, hypotension Organophosphate signs: Salivation, Lacrimation, Urination, Diarrhea, Emesis, Altered Mental Status 36  TABLE OF CONTENTS VOMITING AND DIARRHEA Signs and Symptoms Differential Diagnosis Pain CNS Injury / Infection Abdominal Distention Myocardial Infection Constipation Drugs / Toxins Diarrhea Pregnancy Anorexia Gastroenteritis Fever Appendicitis Rash Bowel Obstruction ADULT Treatment IV - O2 - Monitor Blood Glucose 15min. o Prolonged code with no response - >3 rounds of medications, 30min of resuscitation. o All patients should get a glucose check, at least 1L fluid bolus, and ultimately bilateral needle decompression (especially in Trauma) before discontinuation of efforts. o Should take at least 1min to check for pulse in hypothermic patients. 39  TABLE OF CONTENTS CHEST PAIN Signs and Symptoms: Differential Diagnosis: Differential Diagnosis: Chest Pain Angina Aortic Dissection / Radiation of Pain Acute MI Aneurysm Location of Pain Pericarditis GERD Pale / Diaphoretic / Lightheaded Pulmonary Embolism Esophageal Spasm Nausea / Vomiting Asthma / COPD Esophageal perforation Shortness of Breath Pneumothorax Chest Wall Injury / Pain Universal Patient Care Protocol O2 If.12sec): Wolf-Parkinson-White Syndrome (rate typically >150/min) Artifact / Device Failure Valvular Heart Disease Conscious, Rapid Pulse Cardiac Sick Sinus Syndrome Chest Pain / Shortness of Breath Endocrine / Metabolic Myocardial Infarction Palpitations Hyperkalemia Electrolyte Imbalance Dizziness Drugs Sinus Tachycardia / Atrial Flutter Anxiety Pulmonary Hypoxia Drug Overdose / Toxin Hyperthyroidism Universal Patient Care Guideline METOPROLOL DILTIAZEM ADENOSINE O2 (if Hypoxemic) 5mg IV q5min X 3 20mg (0.25mg/kg) IV over 1st Dose: 6mg rapid IV IV / IO Guideline Hold if SBP 10 y/o lower limit = 90mmHg >10 y/o 60 - 100 Acutely Altered Mental Status Typical Sinus Tachycardia Rates o GCS 3 rounds of medications, 30min of resuscitation o All patients should get a glucose check, at least 20ml/kg fluid bolus of NS, and ultimately bilateral needle decompression (Trauma) before discontinuation of efforts 45  TABLE OF CONTENTS PEDIATRIC TACHYCARDIA with Pulse and Adequate Perfusion Typical HR/min Indicators of CARDIOPULMONARY COMPROMISE Newborn 85 - 205 Hypotension 3mth – 2y/o 100 - 190 o 1-10 y/o lower limit = 70+(years old x 2)mmHg 2y/o to 10y/o 60 -140 o >10 y/o lower limit = 90mmHg >10y/o 60 - 100 Acutely Altered Mental Status Typical Sinus Tachycardia Rates o GCS 10 y/o lower limit = 90mmHg >10 y/o 60 - 100 Acutely Altered Mental Status Typical Sinus Tachycardia Rates o GCS 180/min If Regular Rhythm (R-R) and Search for and Treat NO o Constant Rate w/o variability on 6 second strip QRS Monomorphic: Underlying Causes o Abrupt Rate changes between tachy and normal Adenosine IV / IO Rapid Push P waves absent or abnormal? 1st 0.1mg/kg (max 6mg) Vague history inconsistent with known cause 2nd 0.2mg/kg (max12mg) YES Treatable causes: Probable Amiodarone 5mg/kg over 20- Check & Treat compromise in ABCs Supraventricular Tachycardia 60 minutes IV / IO Hypoglycemia Consider Vagal Maneuvers o D25 2mL/kg slow IV (max 25mL) with NO delay to next step OR o Glucagon 0.025mg/kg IM (max 1mg) Procainamide 15mg/kg over Tension Pneumothorax 30-60 minutes Adenosine IV / IO Rapid Push OVERDOSE (Breastfeeding Mother): 1st 0.1mg/kg (max 6mg) B-blocker (atenolol, metoprolol, labetalol): 2nd 0.2mg/kg (max12mg) o Glucagon 0.05mg/kg (3-10mg) IV – pretreat with ondansetron (0.15mg/kg – max 2mg) for nausea if possible If no IV / IO access or adenosine fails Calcium channel blocker (dilitiazem, verapamil, nifedipine) Synchronized Cardioversion o Calcium chloride 10% 0.2ml/kg slow IV push 1st 0.5-1J/kg, if fails then 2J/kg Narcotic (Sedation w/o delay to Cardioversion: o Naloxone 0.1mg/kg IV/IM (max 2mg) Midazolam 0.05-0.1mg/kg IV / IO) Pearls: Vagal maneuvers: blow through 18ga IV catheter, ice pack on forehead, carotid massage (unilateral only – listen for bruits prior to performing), or having patient blow against closed glottis (“bear down”). Adenosine should be given with the “2 syringe technique” – one with adenosine and the other with the saline flush. These should be attached to a 2 port IV adapter and flush should immediately follow drug. o All patients should be warned of discomfort / feeling of heart stopping before adenosine administration. 47  TABLE OF CONTENTS CBRN MARCHE2 After initial assessment of casualty in CBRN-threat environment for the presence or absence of CBRN symptoms using the CRESS algorithm, the integrated assessment and management of TCCC and CBRN injuries can proceed. MARCHE2 integrates the TCCC MARCH algorithm with the priorities of CBRN treatment. MARCHE2 is further broken down into phases similar to TCCC. The “Hot Zone” should be considered as care under fire, addressing only immediate life threats, “Warm Zone” is tactical field care and “Cold Zone” as tactical evacuation care. MARCHE2 Algorithm TCCC MARCH CBRN MARCHE2 CRESS Assessment MASSIVE HEMORHORAGE Mask HASTY tourniquets in the HOT ZONE Consciousness: MASK or CHECK MASK SEAL as immediate Transition to DELIBERATE tourniquets during Conscious, Unconscious, depressed HOT ZONE treatment DECON in WARM ZONE consciousness, AMS, seizures, agitation, normal Antidote AIRWAY Respirations: Utilize CRESS to differentiate chemical agent Normal, increased, decreased, exposure RAPID IDENTIFICATION OF Assess – excessive secretions indicate CHEMICAL WARFARE AGENT NERVE AGENT distress, delayed onset, apneic, tachypnea, wheezing, immediate ATNAA (x3)/CANA (x1) for NERVE AGENT Defer most interventions - consider risks in NAXOLONE (2mg IM) for OPIOID active HOT ZONE of remove mask to access irritation INCAPATICITATING AGENT airway Eyes: Can consider Cyanokit® in HOT ZONE for BLOOD AGENT if symptoms are severe, first Normal, constricted (Miosis), dilated Respirations action should be removal from area of exposure (Mydriasis), irritated, painful, and rapid spot decontamination Increased respirations consider ATNAA/CANA NERVE AGENT GUIDELINE Secretions: Rapid Spot Decontamination Depressed respirations consider NAXOLONE None, Increased, Decreased Copious INCAPACITATING AGENT GUIDELINE Secretions (salivation, lacrimation, Indicated for gross contamination on skin and/or Other than antidotes – respiratory interventions rhinorrrhea, bronchorrhea), wounds or if protective gear is breached is best deferred to WARM ZONE Rapid exposure and decontamination of contaminated wounds is necessary Skin: lifesaving procedure in the HOT ZONE Circulation Normal, Dry and Hot, Flushed, Apply RSDL, M100, M295, Sorbent, tech Erythema, Diaphoresis, Cyanotic, Circulation intervention should be deferred Blisters, Pain wipe, etc. to WARM ZONE CRESS must be reassessed Assess for shock Countermeasures IV/IO GUIDELINE regularly, during zone transitions HYPOTENSION/SHOCK GUIDELINE and at each transfer, to monitor for Appropriate therapy based on type of agent delayed onset of life threatening exposure, post initial antidote administration symptoms, and analyze antidote or Deferred to WARM ZONE countermeasure effectiveness Hypothermia Prevention & Head Injury Protect from lethal triad: HYPOTHERMIA, acidosis and coagulopathy through HOT/WARM/COLD ZONES Active warming or HPMK post decontamination and packaging for further evacuation Determine if altered mental status is due to chemical agent or trauma, if trauma HEAD INJURY/TBI GUIDLINE Extricate and Evacuate EXTRICATE: egress patient from threat, agent contact, HOT ZONE Evacuate: to WARM ZONE – Dirty CCP for decontamination COUNTERMEASURES and appropriate supportive care starts in WARM ZONE and continues during Evacuation/COLD ZONE Notes, Warnings, Cautions Treatment goals of CBRN is give antidote, extricate from exposure area, conduct spot decontamination, provide airway support. 48  TABLE OF CONTENTS CHILDBIRTH Signs and Symptoms Possible Complications Preterm labor Primi/Gravida/Para? Spontaneous vaginal delivery Any pregnancy complications? Placenta previa Vaginal fluid/bleeding? Uterine contractions/back Prolapsed cord pain/stomach pain? Abnormal presentations (i.e., Duration of contractions and time breech) between Crowning/urge to push? Any complications expected with the newborn? Treatment O2 if hypoxemic, IV/IO, cardiac monitor, and blood glucose check. Place in left lateral decubitus or pad under right hip. Hyper or hypotensive? Any abnormal bleeding? Refer to obstetric emergency. Visually inspect to see if patient is crowning, if crowning is present, assist with the birth of the child. If no, continue to monitor, re access, and transport patient to nearest MTF. Position mother, prepare 2 sets of hemostats and scissors / scalpel, umbilical cord clamp if available, bulb suction. Suctioning of nose and mouth with bulb aspirate recommended if obvious obstruction from secretions. Use slight downward pressure to deliver superior shoulder, then slight upward pressure to deliver lower shoulder. Clamp cord after 1-3 minutes with 2 hemostats and cut between clamps. Wrap infant to prevent hypothermia and give to mother. Deliver placenta, do not pull. Keep placenta for evaluation by MTF. “Externally” massage uterus to encourage contraction/limit bleeding. Continue to monitor and re access mother and neonate enroute to nearest MTF and refer to newborn guideline. Notes, Warnings, Cautions If umbilical cord around neck, attempt to reduce manually prior to delivery of head (should feel rope-like structure around neck). As last resort, and if unable to keep pressure off of the cord, clamp and cut cord when unable to manually reduce. If umbilical cord seen, elevation of presenting part with vaginal hand and maintain elevation until delivery via C-section. *Do not place pressure on the cord or monitor pulse via the cord. If neonate appears to be stuck in the birth canal (i.e., turtling of the head), flex the mother’s hips (both knees to chest). 49  TABLE OF CONTENTS NEWBORN CARE AND DISTRESS Signs and symptoms Full term delivery? Meconium staining of amniotic fluid? Any signs of Dehydration? (sunken fontanelles, tearless, decreased UOP, and dry mouth, skin and tongue) Fluid Overload? (SOB, ankle/sacral edema, increased JVP, and crackles in lungs Determine after 1st 60 seconds of care and repeat q5 min. Score of 6 or less=IMMEDIATE RESUSCITATION! Severely depressed: 0-3 Moderately depressed: 4-6 Excellent condition: 7-10 Treatment Does the patient have good tone? Is the airway open? (Breathing/Crying) o Use bulb syringe to clear mouth/nose, dry and stimulate (foot tap/back rub), keep warm, find APGAR score, and monitor SpO2 and treat hypoglycemia (glucose 90 mmHg. Neonatal or pediatric blood pressure cuffs must be used. CPG ID: K9 CPG; K9 TCCC 60  TABLE OF CONTENTS ANTIBIOTIC THERAPY CHART *Post-injury antimicrobial agents are recommended to prevent early post-traumatic infectious complications, including sepsis, secondary to common bacterial flora. Selection is based on narrowest spectrum and duration required to prevent early infections prior to adequate surgical wound management. This narrow spectrum is selected to avoid selection of resistant bacteria. The antimicrobials listed are not intended for use in established infections, where multidrug-resistant (MDR) or other nosocomial pathogens may be causing infection. Injury Preferred Agent Frequency Duration Extremity Wounds Skin, soft tissue, without open fractures Cefazolin 2g q 6-8hrs 24 hours 24 hours, then with Skin, soft tissue, with open fractures, exposed each subsequent Cefazolin 2g q 6-8hrs bone, or open joints I&D until soft tissue coverage Thoracic Wounds Penetrating chest injury Cefazolin 2g q 6-8hrs 24 hours Abdominal Wounds Penetrating abdominal injury with Stop 24 hours after suspected/known hollow viscus injury and Cefazolin, 2g IV q 6-8hrs control of soilage; may apply to rectal/perineal injuries as PLUS metronidazole 500 mg IV q 8-12hrs contamination well Maxillofacial And Neck Wound Open maxillofacial fractures, maxillofacial Cefazolin 2g g q 6-8hrs 24 hours fractures with foreign body or fixation device Central Nervous System Wounds 5 days or until CSF Cefazolin, 2g IV q 6-8hrs leak is Penetrating brain injury PLUS (consider) metronidazole closed, whichever 500 mg q 8-12 hrs is longer Cefazolin, 2g IV q 6-8hrs Penetrating spinal cord injury PLUS (consider) metronidazole 500 mg Q 8-12 hrs Eye Wounds q 6hrs Erythromycin ophthalmic Until epithelium ointment healed. Eye injury, burn or abrasion or PRN for Or No systemic symptomatic Bacitracin ophthalmic ointment treatment required relief 7 days or until Levofloxacin 750 mg IV/PO q 24 hrs evaluated by an Eye injury, penetrating PLUS vancomycin 15-20 mg/kg q 8-12hrs ophthalmologist. IV No topical agents. Burns Pre hospital Not indicated Delayed Evacuation to Surgical Care Moxifloxacin 400 mg PO x 1 PO tolerable X 1 dose dose. Single dose therapy Or Not PO tolerable X 1 dose Ertapenem 1 g IV/ IM 61  TABLE OF CONTENTS COMMON LAB VALUES Chemistry Laboratory Conventional SI Units Anion Gap 8-16 mEq/L 8-16 mmol/L BUN 8-25 mg/100mL 2.9-8/9 mmol/L Calcium 8.5-10.5 mg/100mL 2.1-2.6 mmol/L Carbon Dioxide 24-30 mEq/L 24-30 mmol/L Creatine Male 0.2-0.5 mg/dL Female 0.3-0.9mg/dL Creatine Kinase Male 17-40 U/L Female 10-79 U/L Creatinine 0.6-1.5 mg/100L 53-133 Glucose 70-110 mg/100mL 3.9-5.6 mmol/L Sodium 135-145 mEq/L Potassium 3.5-5.0 mEq/L 3.5-5.0 mmol/L Hematology Hemoglobin Male 13-18 g/100 mL Female 12-16 g/100mL Hematocrit Male 41-50% Female 36-44% Platelets 140,000-450,000/ml Cardiac Markers Troponin I* Onset 4-6 hrs. Peak 12-24 hrs. Troponin T* Onset 3-4 hrs. Peak 10-24 hrs. Male 10-95 ng/ml Female 10-65 ng/ml Myoglobin Onset 1-3 hrs. Peak Peak: 6-10 hrs. INR only if Tx for DVT 0.8-1.2 2.0-3.0 Normal Blood Gasses pH 7.35-7.45 Pco2 35-45 mm Hg HCO3 22-26 mmol/L Base excess (-2)-(+2) mEq/L CO2 19-24 mEq/L SaO2 96-100% *Troponin assays are becoming more analytically sensitive. Each device has different reference ranges associated. Correlate cTn with reference lab. Point of care readers are less sensitive. 62  MEDICAL RECORD-SUPPLEMENTAL MEDICAL DATA For use of this form, see AR 40-66; the proponent agency is the Office of the Surgeon General REPORT TITLE Tactical Evacuation After Action Report & Patient Care Record, Page 1 63  MEDICAL RECORD-SUPPLEMENTAL MEDICAL DATA For use of this form, see AR 40-66; the proponent agency is the Office of the Surgeon General REPORT TITLE Tactical Evacuation After Action Report & Patient Care Record, Page 2 PREPARED BY (Signature & Title) 64  TACTICAL EVACUATION-AFTER ACTION REPORT & PATIENT CARE RECORD Page 3 IAW AR 40-68 (RAR) 22 May 2009 Paragraph 3–7. This page is a quality assurance document. Do not file in medical records. Casualty's Protective Equipment (Check all worn) The National Defense Authorization Act for fiscal year 1987 (Public Law (PL) No. 99-661), section 1102, Title 10, (10USC 1102) this document was created by or for the DOD in a medical QA program and is confidential and privileged. PL 99-661 and subsequent guidance predicated on this law (10 USC 1102) preclude disclosure of, or testimony about, any records or findings, recommendations, evaluations, opinions, or actions taken as part of a QA program except in limited situations. Under the provisions of 10 USC 1102, this information is exempt from release in accordance with Exemption 3 of the FOIA. Additional detailed information regarding the confidentiality of QA documents and records is contained in appendix B. 65  Reset Form EVACUATION PATIENT CARE RECORD Page of Medical Record Supplemental Medical Data: AR 40-66 and DHA-PM 6025.02 Volume 1 govern the use of this form. Read Privacy Act statement in its entirety before completing this form Injury Event Date Time Zone L Z Country Region State Mission # Tail to tail YES NO Leg# of 9-line Time Wheels-up Time Platform Dispatch Cat: URG PRI ROUT Assessed Cat: URG PRI ROUT Dispatch information (M.I.S.T., MOI/NOI, Injuries, Disease Diagnosis, etc.) Pickup: Arrival Time Role/Facility/POI Location Departure Time Dropoff: Arrival Time Role/Facility/T2T Location Departure Time INTERVENTIONS INJURY LOCATOR Massive Hemorrhage (TQ/Hemostatic Adjunct) MOI Medical Time Location Type Time off (AMP)utation (BL)eeding Time Location Type Time off (B)urn % TBSA Time Location Type Time off (C)repitus (D)eformity Time Location Type Time off (DG)Degloving Airway (E)cchymosis (FX)Fracture Time Type Size Depth @ (GSW)Gunshot Wound Time Type