Page 232 - 2025 Ranger Medic Handbook

Figure 2: AVPU Mental Status Exam
AVUP: A quick method to evaluate pediatric mental status, Alert = best, Unresponsive = worst.
The four possible recordable outcomes are as follows:
■ Alert: The patient is fully awake but may not necessarily be oriented. The child will spontaneously open eyes,
respond to voice (may be confused), and have bodily motor function.
■ Verbal: When you talk to the child, they respond in some manner, categorized as any measures of eyes, voice or
motor response. For example, the response by eyes opening, moaning/grunting, or slight movement of extremity.
■ Pain: The child responds to pain stimulus through any measures of eyes, voice, or motor response.
■ Unresponsive: No response to verbal or pain stimulus.
Figure 3: FLACC-R Pain Assessment
0 1 2
Face Smile or no expression Occasional grimace, Frequent or constant chin
withdrawn, disinterested, quivering, clenched jaw,
appears worried panicked expression
Legs Normal position, relaxed, Uneasy, restless, tense, Kicking or legs drawn up,
normal tone occasional tremors constant tremors
Activity Lying quietly, normal Squirming, shifting, tense, Arched, rigid or jerking, gasping
position, moves easily, shallow respirations respirations or breath holding
breathing normally
Cry No cry Moans or whimpers, occasional Crying steadily, screams, sobs,
complaints frequent complaints
Consolability Content, relaxed Reassured by occasional Difficult to console, resists
touching or talking, distractible comfort attempts
0–3 = mild pain; 4–6 = moderate pain; 7–10 = severe pain.
FLACC-R = Face, Legs, Activity, Cry, and Consolability scale (revised).
SECTION 7 Resuscitation Analgesia/sedation
Commonly Used Weight-Based Medications

Whole blood 10–20mL/kg IV/IO Ketamine
Analgesia • 0.5mg/kg IV
Plasma 10–20mL/kg IV/IO • 1mg/kg IM/IN*
Tranexamic acid 15mg/kg IV/IO Sedation • 1–1.5mg/kg IV
Calcium gluconate 60mg/kg IV/IO • 4–5mg/kg IM*
Calcium chloride 20mg/kg IV/IO
Opioid analgesia Sedation
++
Fentanyl • 0.5–1µg/kg IV + Midazolam • 0.05–0.1mg/kg IV
• 2µg/kg IN* (first dose max 2.5mg)
Hydromorphone 0.01–0.015mg/kg IV + • 0.05–0.15mg/kg IM*
• 0.2–0.3mg/kg IN*
+ Given higher concentrations of opioid analgesia commonly available through the military Authorized Medical Allowance List, dilution
with normal saline may be necessary to obtain appropriate dose.
*All intranasal/intramuscular administration of medications, use the highest concentration available. If > 0.5mL of total IN volume, split the
dose between nostrils, as too much volume in a single nostril will not be absorbed but swallowed.
++ Start all pediatric single doses no more than 2.5mg and repeat every 3–5 minutes as necessary, to maximum of 10mg.
IM = intramuscular, IN = intranasal, IO = intraosseous, IV = intravenous.

218 SECTION 7 PEDIATRIC TACTICAL COMBAT CASUALTY CARE