Page 102 - Journal of Special Operations Medicine - Fall 2016

Appendix A Fluid and equipment planning considerations
Only if qualified medical personnel or teleconsul- Best:
tation (ideally with real-time video capability) available. • Fluids: IV fluid to provide 1L/h for 24 to 48 hours
o Then only if wound care available.
o Regional anesthesia with nerve block or IV seda- (depending on evacuation availability)
tion required. • Equipment: ECG, laboratory tests for serum potas-
• Minimum: Cool limb to reduce extremity edema sium and urine myoglobin, Foley catheter with grad-
(evaporative or environmental cooling only, do not uated collection system, tourniquets
pack limb in ice or snow because of risk of further • Medications: hyperkalemia*: calcium gluconate (5 x
tissue damage). 10mL vial or Bristojet), insulin: 1 vial Humulin R
• Pain management: Refer to TCCC Guidelines for an- (500 units; Lilly USA, www.humulin.com), D50
algesia on the battlefield. 28 (120mL), albuterol (24 vials), Kayexalate (360g;
Concordia Pharmaceuticals, http://concordiarx.com)
Infection • Pain: refer to Analgesia, Sedation Clinical Practice
Guidelines (CPG)
For infection due to associated wounds and not crush • Antibiotics: ertapenem
injury itself, follow the Joint Theater Trauma System • Monitoring: Continuous monitoring with portable
Infection Control Guidelines: “Prevent Infection in monitor; 15-minute to hourly vital signs, examina-
Combat-Related Injuries for Extremity Wounds.” 29 tion, urine output documented on flowsheet

Goal: Prevent infection. Communications: real-time video telemedicine
• Best: Ertapenem, 1 gm IV/day (1g, 10 ml saline or consultation
sterile water)
• Better: Cefazolin, 2g IV every 6 to 8 hours; clindamy- Better:
cin (300–450 mg by mouth three times daily or 600 • Fluids: IV fluid to provide 1L/h for 24 to 48 hours
mg IV every 8 hours); or moxifloxacin (400 mg/day; • Equipment: Dipstick urine tests to monitor urine,
IV or by mouth) graduated container to monitor urine output,
• Minimum: Ensure wounds are cleaned and dressed, tourniquets
and hygiene of wounds and patient optimized to the • Medications: hyperkalemia: calcium gluconate (5 x
extent possible given environment. 10mL vial or Bristojet), insulin: 1 vial Humulin R
(500 units), D50 (120mL)
Two appendices accompany this article: Appendix A • Pain medications
presents a summary of fluid and equipment planning • Antibiotics
considerations; Appendix B comprises three tables pre- • Monitoring: 15-minute to hourly vital signs, exami-
senting monitoring and management considerations nation, urine output documented on flowsheet
relative to time.
Communications: telephone, possibly e-mail tele-
References medicine consultation
Minimum:
1. Brochard L, Abroug F, Brenner M, et al. An official ATS/ERS/
ESICM/SCCM/SRLF Statement: prevention and management • Fluids: IV fluid for initial bolus resuscitation (2L),
of acute renal failure in the ICU patient: an international con- then oral or rectal fluid resuscitation with commer-
sensus conference in intensive care medicine. Am J Respir Crit cial or improvised electrolyte solution
Care Med. 2010;181:1128–1155.
2. Greaves I, Porter K, Smith JE, et al. Consensus statement on • Equipment: Guaduated container to monitor urine
the early management of crush injury and prevention of crush output, tourniquets
syndrome. J R Army Med Corps. 2003;149:255–259. • Medications: hyperkalemia: calcium gluconate (5 x
3. Greaves I, Porter KM. Consensus statement on crush injury 10mL vial or Bristojet)
and crush syndrome. Accid Emerg Nurs. 2004;12:47–52.
4. Gunal AI, Celiker H, Dogukan A, et al. Early and vigorous • Pain medications
fluid resuscitation prevents acute renal failure in the crush vic- • Antibiotics
tims of catastrophic earthquakes. J Am Soc Nephrol. 2004;15: • Monitoring: 15-minute to hourly vital signs, exami-
1862–1867.
5. Sever MS, Vanholder R. Management of crush victims in mass nation, urine output documented on flowsheet or
disasters: highlights from recently published recommendations. other written format
Clin J Am Soc Nephrol. 2013;8:328–335.
6. Michell MW, Oliveira HM, Kinsky MP, et al. Enteral resuscita- Communications: telemedicine by telephone
tion of burn shock using World Health Organization oral rehy-
dration solution: a potential solution for mass casualty care. J *Calculated quantities based on treating one patient for 48 hours.
Burn Care Res. 2006;27:819–825.

84 Journal of Special Operations Medicine Volume 15, Edition 3/Fall 2016