Page 124 - Journal of Special Operations Medicine - Summer 2014

• Ketamine works well for tourniquets, long bone frac- Clinic. He added that “improvised tourniquets were
tures due to penetrating trauma, and amputations. uniformly unsuccessful.” Dr. Zeitlow also noted that
• Dosing between 75–100mg works best, but 50mg the Mayo protocol calls for MeansQuikClot Combat
™
IV is a good initial dose when given with midazolam. Gauze to be used only after failure of standard gauze.
• Without midazolam, most patients moved their There are two C-A-T Tourniquets and two packages of
extremities and talked or sang, mostly in incom- Combat Gauze on each prehospital vehicle or aircraft.
prehensible sentences.
• The prehospital combat setting requires a larger
dose of ketamine than would be expected. TCCC Update
• It is difficult to stop patient movement and admin- Dr. Frank Butler
ister more medications. Dr. Butler noted that, by direction of the Acting Un-
– First rotation, we used 50mg/mL, which was dersecretary of Defense (Personnel and Readiness),
not an issue other than the size of the bottle.
– On other rotations, we used 100mg/mL, and the Committee on Tactical Combat Casualty Care
(CoTCCC) was moved to the Joint Trauma System (JTS)/
the bottle was much smaller so we were able to U.S. Army Institute of Surgical Research (USAISR) in
carry two bottles in the medication case.
• Autoinjectors could be beneficial for certain February 2013.
situations.
• When using ketamine, I drew up 200–250mg and There have been four changes to the TCCC Guidelines
approved by the CoTCCC since it has been relocated to
dosed as needed.
• All patients who are critically injured or will need the JTS:
surgery should receive two saline locks.
• Although pain scores were not available on all ca- 1) The TCCC Casualty Card has been updated and a
companion electronic after-action report (AAR) have
sualties, four reported a pain level of 10/10 before been developed and recommended for use as de-
ketamine and, if they recalled, 0/10 after ketamine.
• Ketamine is a safe and effective form of pain man- scribed below.
agement at initial doses of 50–100mg IV. Reference: Kotwal RS, Butler FK, Montgomery HR,
• Midazolam should be used in conjunction with et al. The Tactical Combat Casualty Care Casualty
ketamine if possible. Card. J Spec Ops Med. Summer 2013;13(2):82–86.

2) The TCCC Guidelines now specify the use of a vented
Prehospital Blood and Plasma at the Mayo Clinic
chest seal for the treatment of open pneumothorax.
Dr. Don Jenkins Reference: Butler F, Dubose J, Otten E, et al. Manage-
Dr. Jenkins discussed the prehospital use of plasma and ment of open pneumothorax in Tactical Combat Ca-
platelets at the Mayo Clinic: 479 patients have received sualty Care: TCCC Guidelines Change 13-02. J Spec
thawed plasma to date, and 442 have received packed Oper Med. Fall 2013;13(3):81–86.
red blood cells (PRBCs). This practice is resulting in
improvement in international normalized ratios (INRs) 3) There are now three CoTCCC-recommended junc-
by the time the patients arrive at the hospital. Dr. John tional tourniquets: the Combat Ready Clamp
™
Holcomb noted that liquid plasma (refrigerated imme- (CRoC ), the Junctional Emergency Treatment Tool
®
™
diately after donation, never frozen) is good for 20 days (JETT ), and the Sam Junctional Tourniquet.
and also is a good option for prehospital use. Dr. Jen- Reference: Kotwal RS, Butler FK, Gross KR, et al.
kins also discussed the use of tissue oxygen saturation Management of junctional hemorrhage in Tactical
monitoring as a good method of tracking the adequacy Combat Casualty Care. J Spec Oper Med. Winter
of resuscitation. This new monitoring technology is now 2013;13(4):85–93.
in use at the Mayo Clinic.
4) A new triple-option analgesia plan has been incorpo-
rated into the TCCC Guidelines: (1) oral analgesics
C­A­T Tourniquets and Combat Gauze for less severe pain: (2) oral transmucosal fentanyl
®
™
at the Mayo Clinic
citrate (OTFC) for severe pain in the absence of shock
Dr. Scott Zeitlow or respiratory distress; or (3) ketamine for severe pain
with in the presence of (or with significant potential
Dr. Zeitlow reviewed the prehospital use of tourniquets
(C-A-T Tourniquets used on 73 patients with a 98% suc- for) shock or respiratory distress.
cess rate) and Combat Gauze (used on 52 patients with Reference: Butler FK, Kotwal RS, Buckenmaier CC
a 95% success rate) in the Trauma Service at the Mayo III, et al. A triple-option analgesia plan for Tactical

114 Journal of Special Operations Medicine Volume 14, Edition 2/Summer 2014