Page 148 - 2025 Ranger Medic Handbook

Rhabdomyolysis
DEFINITION: Breakdown or necrosis of skeletal muscle cells that release cellular contents into the circulation. Typical
causes: Limb ischemia, carbon monoxide poisoning, electrical or thermal burns, blunt trauma or crush injury, snake Bite,
hyperthermia, hypothermia, and physical exertion.
S/Sx: Acute muscle pain (myalgias); muscle weakness; fever; malaise; nausea or vomiting; tea-colored urine; oliguria/
anuria; dipstick positive for blood, but no intact RBC on a spun specimen (due to myoglobin in urine).
MANAGEMENT: Aggressive hydration is the cornerstone of treatment.
1. Crystalloid solution 1–2L bolus IV/IO followed by 500mL–1L/hr. In a patient making urine, any isotonic fluid is accept-
able (you do not need to avoid potassium containing fluids if patient is making urine). Titrate fluids to achieve target
SECTION 3 2. Monitor intake/output hourly.
urine output of > 200mL/hr.
3. If unable to monitor due to clinical condition, insert Foley catheter to facilitate measuring urine output.
4. Reassess vital signs and mental status frequently. Utilize cardiac monitoring if available.
Potential Problems/Complications:
a. Cardiac dysrhythmia treatment: 1g calicum chloride or 3g calcium gluconate q5 minutes until arrhythmia has
resolved, then adminster glucose+insulin.
b. If dysrhythmia occurred, loop diuretics may be needed to eliminate potassium.
c. Persistent oliguria despite adequate fluid resuscitation.
d. Avoid loop diuretics such as furosemide, which may increase myoglobin precipitation in kidneys and provoke
acute renal failure.
e. Compartment syndrome: see Compartment Syndrome Protocols.
DISPOSITION: Priority evacuation

Sepsis / Septic Shock
DEFINITION: Severe life-threatening condition resulting from the presence of harmful microorganisms in the blood or
other tissues and the body’s response to their presence, potentially leading to the malfunctioning of various organs,
shock, and death.
S/Sx: Hypotension; fever; tachycardia; altered mental status; dyspnea
MANAGEMENT: Do not attempt to treat without contacting a medical officer.
1. Obtain IV/IO access.
2. Ertapenem 1g IV/IO qd OR ceftriaxone 2g IV/IO qd.
3. If patient is hypotensive, give 1L crystalloid solution fluid bolus. Consider additional fluids if still hypotensive, then an
additional liter titrated to maintain systolic blood pressure > 90mmHg or palpable radial pulse. Maintain aggressive
fluid management.
4. Initiate vasopressor medications if persistent hypotension despite > 2L IVF boluses. (norepinephrine or epinephrine).
Epinephrine (1:100,000) 0.5–2mL q5–15 minutes or drip prn. Epinephrine 10μg in large IV q5–15min if persistent
hypotension despite > 2L IVF boluses. Initiate evacuation.
5. Upon consultation with medical officer, consider stress dose steroids (hydrocortisone 200mg IV daily) for septic
shock refractory to vasopressors.
6. Monitor for decreased mental status and be prepared to manage airway.
DISPOSITION: Urgent evacuation
SPECIAL CONSIDERATIONS:
1. Ensure complete medical history and documentation of any preceding events are sent to medical provider.

134 SECTION 3 TACTICAL MEDICAL EMERGENCY PROTOCOLS (TMEPs) & SICK CALL