Fall - United States Special Operations Command

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- IV or IO access obtained: - Morphine sulfate, 5mg IV/IO - Reassess in 10 minutes. - Repeat dose every 10 minutes as necessary to control severe pain. - Monitor for respiratory depression - Promethazine, 25mg IV/IM/IO every 6 hours as needed for nausea or for synergistic analgesic effect 13. Splint fractures and recheck pulse. 14. Antibiotics: recommended for all open combat wounds a. If able to take PO: - Moxifloxacin, 400mg PO one a day b. If unable to take PO (shock, unconsciousness): - Cefotetan, 2g IV (slow push over 3-5 minutes) or IM every 12 hours or - Ertapenem, 1g IV/IM once a day 15. Burns a. Facial burns, especially those that occur in closed spaces, may be associated with inhalation injury. Aggressively monitor airway status and oxygen saturation in such patients and consider early surgical airway for respiratory distress or oxygen desaturation. b. Estimate total body surface area (TBSA) burned to the nearest 10% using the Rule of Nines. c. Cover the burn area with dry, sterile dressings. For extensive burns (>20%), consider placing the casualty in the Blizzard Survival Blanket in the Hypothermia Prevention Kit in order to both cover the burned areas and prevent hypothermia. d. Fluid resuscitation (USAISR Rule of Ten) – If burns are greater than 20% of Total Body Surface Area, fluid resuscitation should be initiated as soon as IV/IO access is established. Resuscitation should be initiated with Lactated Ringer’s, normal saline, or Hextend. If Hextend is used, no more than 1000ml should be given, followed by Lactated Ringer’s or normal saline as needed. – Initial IV/IO fluid rate is calculated as %TBSA x 10cc/hr for adults weighing 40- 80kg. – For every 10kg ABOVE 80kg, increase initial rate by 100ml/hr. – If hemorrhagic shock is also present, resuscitation for hemorrhagic shock takes precedence over resuscitation for burn shock. Administer IV/IO fluids per the TCCC Guidelines in Section 6. e. Analgesia in accordance with the TCCC Guidelines in Section 12 may be administered to treat burn pain. f. Prehospital antibiotic therapy is not indicated solely for burns, but antibiotics should be given per the TCCC guidelines in Section 14 if indicated to prevent infection in penetrating wounds. g. All TCCC interventions can be performed on or through burned skin in a burn casualty. 16. Communicate with the casualty if possible. - Encourage; reassure - Explain care 17. Cardiopulmonary resuscitation (CPR) Resuscitation on the battlefield for victims of blast or penetrating trauma who have no pulse, no ventilations, and no other signs of life will not be successful and should not be attempted. 18. Documentation of Care Document clinical assessments, treatments rendered, and changes in the casualty’s status on a TCCC Casualty Card. Forward this information with the casualty to the next level of care. Basic Management Plan for Tactical Evacuation Care * The new term “Tactical Evacuation” includes both Casualty Evacuation (CASEVAC) and Medical Evacuation (MEDEVAC) as defined in Joint Publication 4-02. 1. Airway Management a. Unconscious casualty without airway obstruction: - Chin lift or jaw thrust maneuver - Nasopharyngeal airway - Place casualty in the recovery position b. Casualty with airway obstruction or impending airway obstruction: - Chin lift or jaw thrust maneuver 88 Journal of Special Operations Medicine Volume 10, Edition 4 / Fall 10
- Nasopharyngeal airway - Allow casualty to assume any position that best protects the airway, to include sitting up. - Place unconscious casualty in the recovery position. - If above measures unsuccessful: - Laryngeal Mask Airway (LMA)/intubating LMA or - Combitube or - Endotracheal intubation or - Surgical cricothyroidotomy (with lidocaine if conscious). c. Spinal immobilization is not necessary for casualties with penetrating trauma. 2. Breathing a. In a casualty with progressive respiratory distress and known or suspected torso trauma, consider a tension pneumothorax and decompress the chest on the side of the injury with a 14-gauge, 3.25 inch needle/catheter unit inserted in the second intercostal space at the midclavicular line. Ensure that the needle entry into the chest is not medial to the nipple line and is not directed towards the heart. b. Consider chest tube insertion if no improvement and/or long transport is anticipated. c. Most combat casualties do not require supplemental oxygen, but administration of oxygen may be of benefit for the following types of casualties: - Low oxygen saturation by pulse oximetry - Injuries associated with impaired oxygenation - Unconscious casualty - Casualty with TBI (maintain oxygen saturation > 90%) - Casualty in shock - Casualty at altitude d. All open and/or sucking chest wounds should be treated by immediately applying an occlusive material to cover the defect and securing it in place. Monitor the casualty for the potential development of a subsequent tension pneumothorax. 3. Bleeding a. Assess for unrecognized hemorrhage and control all sources of bleeding. If not already done, use a CoTCCC- recommended tourniquet to control life-threatening external hemorrhage that is anatomically amenable to tourniquet application or for any traumatic amputation. Apply directly to the skin 2-3 inches above wound. b. For compressible hemorrhage not amenable to tourniquet use or as an adjunct to tourniquet removal (if evacuation time is anticipated to be longer than two hours), use Combat Gauze as the hemostatic agent of choice. Combat Gauze should be applied with at least 3 minutes of direct pressure. Before releasing any tourniquet on a casualty who has been resuscitated for hemorrhagic shock, ensure a positive response to resuscitation efforts (i.e., a peripheral pulse normal in character and normal mentation if there is no TBI.) c. Reassess prior tourniquet application. Expose wound and determine if tourniquet is needed. If so, move tourniquet from over uniform and apply directly to skin 2-3 inches above wound. If a tourniquet is not needed, use other techniques to control bleeding. d. When time and the tactical situation permit, a distal pulse check should be accomplished. If a distal pulse is still present, consider additional tightening of the tourniquet or the use of a second tourniquet, side by side and proximal to the first, to eliminate the distal pulse. e. Expose and clearly mark all tourniquet sites with the time of tourniquet application. Use an indelible marker. 4. Intravenous (IV) access a. Reassess need for IV access. - If indicated, start an 18-gauge IV or saline lock - If resuscitation is required and IV access is not obtainable, use intraosseous (IO) route. 5. Fluid resuscitation Reassess for hemorrhagic shock (altered mental status in the absence of brain injury and/or change in pulse character.) If BP monitoring is available, maintain target systolic BP 80-90mmHg. a. If not in shock: - No IV fluids necessary. - PO fluids permissible if conscious and can swallow. b. If in shock and blood products are not available: - Hextend 500ml IV bolus - Repeat after 30 minutes if still in shock. - Continue resuscitation with Hextend or crystalloid solution as needed to maintain target BP or clinical improvement. TCCC Updates 89
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Volume 10, Edition 4 // Fall 10 Jou
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Fall 10 Volume 10, Edition 4 FEATUR
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From the Editor III
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MSgt Mike Maroney renders a salute
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medical system. 14 Although there a
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were collected using the University
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of VO 2max at lactate threshold (%V
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Figure 4: Anatomic location of the
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Warrior Model for Human Performance
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pacity testing should be incorporat
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During the O-Course training, physi
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triathletes was approximately seven
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52. Myer GD, Ford KR, Barber Foss K
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Jennifer B. Deluzio, MS Neuromuscul
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such isolated training increase the
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panied by an improvement in the fle
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Warrior Model for Human Performance
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sessions) with a range of 54-100%.
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side of daily Army PT. Finally, it
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musculoskeletal overuse injuries. A
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War on Terrorism, which lists as it
Page 43 and 44: MATERIEL AF PM has the most of the
Page 45 and 46: failed to reach the summit. All mem
Page 47 and 48: Scapula Fracture Secondary to Stati
Page 49 and 50: Image 2: Scapular-Y view taken appr
Page 51 and 52: Public Health Foodborne Illness Cas
Page 53 and 54: 1. Determine that an outbreak has o
Page 55 and 56: INTRODUCTION Traumatic Brain Injury
Page 57 and 58: There are four computer-based model
Page 59 and 60: Figure 4: Casualty 1 Composite Scor
Page 61 and 62: testing over 450 Soldiers in less t
Page 63 and 64: Reply from ANDRE PENNARDT, MD, FACE
Page 65 and 66: LTC Coppedge was an energetic, as w
Page 67 and 68: of these twelve week courses was si
Page 69 and 70: 3. Interview with Colonel (COL) Hel
Page 71 and 72: had values above the 95th percentil
Page 73 and 74: Special Ops Crew Recognized For Lif
Page 75 and 76: Dawn Over Baghdad: How the U.S. Mil
Page 77 and 78: Peter J. Benson, MD COL, USA Comman
Page 79 and 80: for our Partner Nations (PN). In 20
Page 81 and 82: Neuro-cognitive Assessment Metrics
Page 83 and 84: Warner D. “Rocky”Farr, MD COL U
Page 85 and 86: LTC Craig A. Myatt, PhD HQ USSOCOM
Page 87 and 88: Excerpts from the Committee on Tact
Page 89 and 90: guidelines also support IO as the p
Page 91 and 92: ing methodologies for surgical airw
Page 93: d. When time and the tactical situa
Page 97 and 98: 14. Burns a. Facial burns, especial
Page 99 and 100: Tactical Combat Casualty Care Burn
Page 101 and 102: 7. All TCCC interventions can be pe
Page 103 and 104: Critical Care Credentials for the S
Page 105 and 106: Meet Your JSOM Staff EXECUTIVE EDIT
Page 107 and 108: Special Forces Aidman's Pledge As a
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Fall - United States Special Operations Command

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