Page 117 - Journal of Special Operations Medicine - Spring 2016
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(i) The Warm Zone typically exists between 5. Vascular injuries in the neck,
the Hot Zones and Cold Zones, but is not groin, and axilla (i.e., junctional
geographic and depends on the evolving zones) are not amenable to tra-
situation. ditional extremity tourniquets. In
(ii) Responders must remain cognizant that addition, effective pressure dress-
scene security can change instantly. ings are often extremely difficult
(iii) A focused and deliberate approach to pro- to apply. Hemostatic impregnated
viding patient care should occur. dressings with direct pressure
(iv) The potential benefits of providing medi- (minimum 5 minutes with contin-
cal care in these zones must outweigh the uous pressure is preferred) have
risks of the ongoing tactical operation shown useful in such situations.
and/or delaying opportunity to evacuate b. A – Airway management
the patient. i. Patients in the Warm Zones with
(v) Care in the Warm Zone typically occurs airway issues are high priority for
at or near the point of injury once scene evacuation due to their often intense
stabilizing measures have occurred. Care resource requirements
may also take place at a casualty collec- ii. Consider applying oxygen if avail-
tion point (CCP). able and indicated.
(vi) A CCP is a location concealed and covered iii. Unconscious casualty without air-
from immediate threat where victims can way obstruction:
be assembled for movement from areas of 1. Chin lift or jaw thrust maneuver
risk to the triage/treatment area. Multiple 2. Nasopharyngeal airway
CCPs may be required, which may be lo- 3. Place casualty in the recovery
cated in the Warm or Cold Zone. CCPs position
should be established and locations com- iv. Casualty with airway obstruction or
municated as early as possible through impending airway obstruction:
operations to ALL responders. 1. Chin lift or jaw thrust maneuver
(vii) If possible, an abbreviated triage system 2. Nasopharyngeal airway
should be set up to identify the priority 3. Allow casualty to assume posi-
for the extrication of patients. The use tion that best protects the airway,
of ribbons or markers to clearly identify including sitting up or leaning
immediate and delayed (red and yellow, forward
respectively) patients is highly recom- 4. Place unconscious casualty in
mended. Deceased individuals should also the recovery position
be labeled/tagged appropriately to prevent v. If previous measures unsuccessful, if
repeat assessments by multiple providers. time and resources permit, consider
(viii) Medical care in the Warm Zone should be per protocol:
limited to essential interventions only and 1. Supraglottic Devices (e.g., King
is guided by the mnemonic “MARCHED” LT , EASYTube , or Combi Tube ).
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a. M – Massive Hemorrhage Control 2. Oro/nasotracheal intubation
i. Massive hemorrhage remains the 3. Surgical cricothyroidotomy
greatest threat to life in most trauma c. R – Respirations
patients. Attaining hemorrhage con- i. The chest/upper abdomen should be
trol is the top priority. assessed for any evidence of an open
ii. Tourniquets remain the preferred chest wound and an occlusive dress-
means of hemorrhage control for ing should be applied accordingly.
life-threatening bleeding in this ii. Tension pneumothorax remains a
environment. significant cause of preventable death
1. If a tourniquet was applied in the in trauma patients.
Hot Zone, it should be reassessed. 1. In suboptimal environments that
2. Tourniquets applied over cloth- interfere with complete physi-
ing are not as effective and may cal assessment, any patient with
need to be adjusted. significant blunt or penetrating
3. Tourniquets should only be dis- chest trauma who displays dys-
continued by an appropriately pnea should be treated as a de-
trained ALS provider in consul- veloping tension pneumothorax
tation with medical control. and receive needle decompres-
4. Other methods of hemorrhage sion, if appropriate.
control include deep wound 2. To be effective, needle decom-
packing with either sterile gauze pression needs to be performed
or hemostatic impregnated gauze. using at least a 3.25 inch, 14g
Threat-Based EMS Protocol in Volatile Environment 101
