Page 122 - Journal of Special Operations Medicine - Winter 2015

level of knowledge and experience where POCT can be b. Measurement is particularly useful in sepsis and
fully employed based solely on clinical judgment. Bio- burn resuscitation
chemical measurements are only a means of quantifying c. Trending during resuscitation provides feedback
the severity of a disorder (e.g., acid-base imbalance, respi- on resuscitation effectiveness
ratory compromise) and the degree of compensation and
for guiding resuscitation in both traumatic and nontrau- Illustrative Case
matic patients. These measurements may lead to a change
in diagnosis, initial triage, and/or initial evacuation prece- A 26-year-old male reservist deploying for the first time
dence. Trending these values may increase the evacuation to sub-Saharan Africa presents with fever and malaise.
precedence and can be relayed to higher medical facilities After a few weeks of questionable compliance with his
to adequately prepare for patient arrival. Similarly, labo- malaria prophylaxis, he is now lying in bed, miserable.
ratory data can influence the decision for transporting a His main complaints are profound malaise and alter-
patient to a host nation medical facility versus waiting nating fevers and chills. A BinaxNOW RDT is posi-
®
for evacuation out of the host country. Finally, labora- tive for Plasmodium falciparum malaria, and his medic
tory measurements may determine the need for high-risk goes with him to seek care at a nearby clinic, where the
medical interventions that may be accomplished via tele- patient is immediately started on an appropriate regi-
medicine or other consultation. men. Over the next 24 hours, he requires minimal in-
travenous fluids to keep his blood pressure, heart rate,
and urine output within normal physiologic parameters.
Recommended Laboratory Tests
His breathing is now unlabored on room air after ini-
The following biochemical measurements can be ap- tially requiring oxygen for mild respiratory distress. On
plied to potentially reduce morbidity, mortality, and/or his second day of bed rest, his fatigue sharply worsens;
conserve resources in a prolonged field care situation. labwork shows his hematocrit has ominously dropped
to 15% overnight. This is communicated via teleconfer-
1. Blood gas (pH, Pco , HCO , Po , base excess/deficit) ence to infectious disease physicians in Germany, and
2
2
3
a. Monitors patient’s ability to ventilate and oxy- prompt transport to Landstuhl Regional Medical Cen-
genate in conjunction with end-tidal (Et)co and ter is arranged. The patient arrives in Germany in less
2
pulse oximetry than 24 hours. Following a prolonged hospital course
b. Measures the effectiveness of mechanical ventila- including more than 1 week in the intensive care unit,
tion (PPV) in correcting respiratory acidosis/alka- he returns to duty several months later.
losis and hypoxia
c. Used in Damage Control Resuscitation Clinical Now, consider this same scenario without the blood
Practice Guideline from the Joint Theater Trauma analysis. How much time could have been lost consid-
Registry (http://www.usaisr.amedd.army.mil/cpgs ering other causes for the new fatigue? Imagine if the
/Damage%20Control%20Resuscitation%20-% transport to definitive care was expected to take 2 days
201%20Feb%202013.pdf) for predictor of mas- or longer. It is not difficult to envision the impact labo-
sive blood transfusion ratory values have on morbidity or mortality. As in this
d. Used as markers to guide resuscitation scenario, medical professionals within Special Opera-
e. Used as potential early physiologic predictor of in- tions Command are expected to deliver phenomenal care
jury severity and intra-abdominal injuries requir- in austere locations across the world. Providers caring
ing surgical repair for SOF personnel in remote areas find themselves with-
2. Electrolytes (Na, K, Cl, etc.) out readily available “first world” hospitals and clinics.
a. Used to diagnose and trend metabolic derangements Similarly, our footprint in Afghanistan is diminished,
b. Used to diagnose and trend primary electrolyte and the medical infrastructure is no exception. This
abnormalities comes at a time in our history when modern medicine
c. Guides the use of hypertonic saline (HTS) therapy relies on a wide range of technology to diagnose, treat,
in closed head injury and monitor medical and surgical conditions. A group
3. Hemoglobin (Hb) of forward looking military physicians, the Prolonged
a. Correlates with signs of shock Field Care (PFC) Working Group, has recognized this
b. Helps guide emergency resuscitation in conjunc- dichotomy and is making an effort to bridge this gap
tion with a patient assessment, blood gases, and through multiple avenues including POCT. 4
lactate
4. Lactate At home, many debate how to cost-effectively manage
a. Serves as quantifiable marker for hypoperfusion, imaging and laboratory services, but few would discount
hypoxemia, reduced oxygen delivery, and predic- the utility of basic blood work in the case of a critically
tor of mortality rate ill patient. The care of traumatically injured patients has

110 Journal of Special Operations Medicine Volume 15, Edition 4/Winter 2015