Page 135 - Journal of Special Operations Medicine - Fall 2014

g. Both ketamine and OTFC have the potential to worsen severe TBI. The combat medic, corpsman, or PJ must consider
this fact in his or her analgesic decision, but if the casualty is able to complain of pain, then the TBI is likely not severe
enough to preclude the use of ketamine or OTFC.
h. Eye injury does not preclude the use of ketamine. The risk of additional damage to the eye from using ketamine is low
and maximizing the casualty’s chance for survival takes precedence if the casualty is in shock or respiratory distress or at
significant risk for either.
i. Ketamine may be a useful adjunct to reduce the amount of opioids required to provide effective pain relief. It is safe to
give ketamine to a casualty who has previously received morphine or OTFC. IV Ketamine should be given over 1 minute.
j. If respirations are noted to be reduced after using opioids or ketamine, provide ventilatory support with a bag-valve-mask
or mouth-to-mask ventilations.
k. Promethazine, 25mg IV/IM/IO every 6 hours may be given as needed for nausea or vomiting.
l. Reassess – reassess – reassess!
14. Splint fractures and recheck pulse.
15. 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
16. 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 Heat-
Reflective Shell or Blizzard Survival Blanket from 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 (TBSA), 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 × 10mL/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 7.
e. Analgesia in accordance with the TCCC Guidelines in Section 13 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 15 if indicated to prevent infection in penetrating wounds.
g. All TCCC interventions can be performed on or through burned skin in a burn casualty.
17. Communicate with the casualty if possible.
– Encourage; reassure.
– Explain care.
18. 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. However, casualties with torso trauma or polytrauma who
have no pulse or respirations during TFC should have bilateral needle decompression performed to ensure they do not have
a tension pneumothorax prior to discontinuation of care. The procedure is the same as described in section 3a above.
19. Documentation of Care
Document clinical assessments, treatments rendered, and changes in the casualty’s status on a TCCC Casualty Card (DD
Form 1380). Forward this information with the casualty to the next level of care.

TCCC Updates 127