Page 87 - 2021 Advanced Ranger First Responder Handbook

CBRN
The goals of Chemical, Biological, Radiological, and Nuclear (CBRN) trauma medicine are to limit and minimize expo-
sure/contamination, treat the immediate life threats, and administer appropriate antidotes or countermeasures. Assess-
ment and treatment of CBRN casualties follows the modified MARCH algorithm (MARCH) 2 . Combat the mentality of
a CBRN patient dipped in agent as a “candied apple.” Instead, think of these patients as stepping in a mud puddle.
Massive hemorrhage, Mask check – control life-threatening bleeding.
Airway, Administer Antidotes (ATNAA, CANA) – establish and maintain a patent airway.
Respiration, Rapid Spot Decontamination (RSDL) – decompress suspected tension pneumothorax, seal sucking chest
wounds, and support ventilation/oxygenation as required.
Circulation, Administer Countermeasures – establish IV/IO access and administer blood products as required to treat
shock.
Head injury/Hypothermia – prevent/treat hypotension and hypoxia to prevent worsening of traumatic brain injury. and
prevent/treat hypothermia.
Use CRESS to quickly determine the agent of concern, conduct triage and recognize symptoms.
C – Consciousness (unconscious, convulsing, altered)
R – Respirations (present, labored, absent)
E – Eyes (pupil size, equal, round, reactive to light)
S – Secretions (absent, normal, increased)
S – Skin (diaphoretic, cyanotic, dry, hot)
CBRN casualties present unique challenges and the medic must constantly ask what is killing the casualty now. These
patients can suffer from trauma, poisoning, or both trauma and poisoning. Always treat the most immediate life threat.
TCCC Application
Hot Zone: Depending on the agent, consider any area with agent to be the same as receiving effective fire. Always
wear multiple sets of nitrile gloves when operating in a CBRN environment. Treatments in this zone are limited to MAR 2 .
Prevention of additional casualties, medic safety, and removing the patient from the area are the highest priorities.
Check and find massive hemorrhage. Only expose on the casualty what is needed to save a life. Use the DRY-WET-DRY
technique and RSDL for decontamination.
Warm Zone: These treatments begin when moved to the Dirty CCP, are in conjunction with decontamination, and con-
sist of CHE 2 . All Hot Zone treatments should be reassessed and possibly replaced with clean ones. Use the command
“Expose to treat” in order to quickly communicate to any assistants the immediate need to decontaminate the head/face
and chest, to facilitate mask removal and for sternal IO placement. This allows ventilatory support and rapid dosing of
countermeasures. Removing contamination by any means available may mean the difference between life and death, as
this limit continued dosing. Do NOT perform any unnecessary procedures in the Warm Zone. Only address immediate
threats to life that cannot wait for decontamination to be completed. The Warm Zone is for DECON, not medical care.

Trauma Assessment Principles
Hot Zone: Tourniquets placed over a CBRN suit are prone to fail. Check the casualty’s mask to ensure it is in place.
Assess the patient’s airway and determine if it makes sense to unmask the casualty to provide an airway in a contami-
nated environment. If the ARFR is breathing filtered air, the casualty should be too. Use a Resuscitator Device Individual
Chemical (RDIC) as needed. Administer antidotes based on the presumed agent. Use ATNAA/CANA for nerve agent and
CyanoKit for cyanide once removed from the exposure. Assess respiratory changes and determine if they are due to an
agent or trauma. Use Rapid Spot Decontamination for any visible agent, around breaches in the suit, and any exposed
skin. Use the DRY-WET-DRY technique and RSDL or soap and water for decontamination.
Warm Zone: Administer countermeasures if required – IV/IO drips, suction, and ventilatory support. Respiratory difficulty
due to poisoning should be treated with ventilatory support if required. Treatment with nebulized albuterol, solumedrol
125mg IV, and/or racemic epinephrine should wait until the Cold Zone. Assess circulation and provide resuscitation if MISC
required. Nerve agent poisonings may require atropine drips for treatment. Preventing hypothermia is critical and decon-
tamination should occur quickly as the patients will be exposed and wet. Manage head wounds as required.

2021 ADVANCED RANGER FIRST RESPONDER HANDBOOK 77