Page 138 - Journal of Special Operations Medicine - Fall 2014

products needed to support 1:1:1 resuscitation are not available, or if 1:1:1 resuscitation is not producing the desired clinical
effect.
8. Prevention of hypothermia
a. Minimize casualty’s exposure to the elements. Keep protective gear on or with the casualty if feasible.
b. Replace wet clothing with dry if possible. Get the casualty onto an insulated surface as soon as possible.
c. Apply the Ready-Heat Blanket from the Hypothermia Prevention and Management Kit (HPMK) to the casualty’s torso
(not directly on the skin) and cover the casualty with the Heat-Reflective Shell (HRS).
d. If an HRS is not available, the previously recommended combination of the Blizzard Survival Blanket and the Ready
Heat blanket may also be used.
e. If the items mentioned above are not available, use poncho liners, sleeping bags, or anything that will retain heat and keep
the casualty dry.
f. Use a portable fluid warmer capable of warming all IV fluids including blood products.
g. Protect the casualty from wind if doors must be kept open.
9. Penetrating Eye Trauma
If a penetrating eye injury is noted or suspected:
a. Perform a rapid field test of visual acuity.
b. Cover the eye with a rigid eye shield (NOT a pressure patch).
c. Ensure that the 400mg moxifloxacin tablet in the combat pill pack is taken if possible and that IV/IM antibiotics are
given as outlined below if oral moxifloxacin cannot be taken.
10. Monitoring
Institute pulse oximetry and other electronic monitoring of vital signs, if indicated. All individuals with moderate/severe TBI
should be monitored with pulse oximetry.
11. Inspect and dress known wounds if not already done.
12. Check for additional wounds.
13. Analgesia on the battlefield should generally be achieved using one of three options:
Option 1
Mild to Moderate Pain
Casualty is still able to fight.
– TCCC Combat pill pack:
– Tylenol - 650mg bilayer caplet, 2 PO every 8 hours
– Meloxicam - 15mg PO once a day
Option 2
Moderate to Severe Pain
Casualty IS NOT in shock or respiratory distress AND
Casualty IS NOT at significant risk of developing either condition.
– Oral transmucosal fentanyl citrate (OTFC) 800μg
– Place lozenge between the cheek and the gum.
– Do not chew the lozenge.
Option 3
Moderate to Severe Pain
Casualty IS in hemorrhagic shock or respiratory distress OR
Casualty IS at significant risk of developing either condition.
– Ketamine 50mg IM or IN;
OR
– Ketamine 20mg slow IV or IO
*Repeat doses q30min prn for IM or IN.
*Repeat doses q20min prn for IV or IO.
*End points: Control of pain or development of nystagmus (rhythmic back-and-forth movement of the eyes)
*Analgesia notes:
a. Casualties may need to be disarmed after being given OTFC or ketamine.
b. Document a mental status exam using the AVPU method prior to administering opioids or ketamine.
c. For all casualties given opiods or ketamine – monitor airway, breathing, and circulation closely.
d. Directions for administering OTFC:
– Recommend taping lozenge-on-a-stick to casualty’s finger as an added safety measure OR utilizing a safety pin and
rubber band to attach the lozenge (under tension) to the patient’s uniform or plate carrier.
– Reassess in 15 minutes.
– Add second lozenge, in other cheek, as necessary to control severe pain.
– Monitor for respiratory depression.
e. IV Morphine is an alternative to OTFC if IV access has been obtained.

130 Journal of Special Operations Medicine Volume 14, Edition 3/Fall 2014