Page 146 - JSOM Fall 2018

o Resuscitate with whole blood*, or, if not available • End­tidal CO (If capnography is available, maintain
2
o Plasma, RBCs and platelets in a 1:1:1 ratio*, or, between 35–40mmHg)
if not available • Penetrating head trauma (if present, administer
o Plasma and RBCs in a 1:1 ratio, or, if not available antibiotics)
o Reconstituted dried plasma, liquid plasma or • Assume a spinal (neck) injury until cleared.
thawed plasma alone or RBCs alone b. Unilateral pupillary dilation accompanied by a de­
o Reassess the casualty after each unit. Continue creased level of consciousness may signify impending
resuscitation until a palpable radial pulse, im­ cerebral herniation; if these signs occur, take the fol­
proved mental status or systolic BP of 80­90 is lowing actions to decrease intracranial pressure:
present. • Administer 250mL of 3 or 5% hypertonic saline
– If in shock and blood products are not available bolus.
under an approved command or theater blood • Elevate the casualty’s head 30 degrees.
product administration protocol due to tactical or • Hyperventilate the casualty.
logistical constraints: – Respiratory rate 20
o Resuscitate with Hextend, or if not available – Capnography should be used to maintain the
o Lactated Ringer’s or Plasma­Lyte A end­tidal CO between 30–35mmHg
2
o Reassess the casualty after each 500mL IV – The highest oxygen concentration (FIO ) possi­
2
bolus. ble should be used for hyperventilation.
o Continue resuscitation until a palpable radial *Note:
pulse, improved mental status, or systolic BP of Do not hyperventilate the casualty unless signs of impending
80­90mmHg is present. herniation are present. Casualties may be hyperventilated with
o Discontinue fluid administration when one or oxygen using the bag­valve­mask technique.
more of the above end points has been achieved. 7. Hypothermia Prevention
• If a casualty with an altered mental status due to sus­ a. Minimize casualty’s exposure to the elements. Keep
pected TBI has a weak or absent radial pulse, resus­ protective gear on or with the casualty if feasible.
citate as necessary to restore and maintain a normal b. Replace wet clothing with dry if possible. Get the casu­
radial pulse. If BP monitoring is available, maintain alty onto an insulated surface as soon as possible.
a target systolic BP of at least 90mmHg. c. Apply the Ready­Heat Blanket from the Hypothermia
• Reassess the casualty frequently to check for recur­ Prevention and Management Kit (HPMK) to the ca­
rence of shock. If shock recurs, recheck all external sualty’s torso (not directly on the skin) and cover the
hemorrhage control measures to ensure that they are casualty with the Heat­Reflective Shell (HRS).
still effective and repeat the fluid resuscitation as out­ d. If an HRS is not available, the previously recom­
lined above. mended combination of the Blizzard Survival Blanket
Note: and the Ready Heat blanket may also be used.
*Currently, neither whole blood nor apheresis platelets col­ e. If the items mentioned above are not available, use
lected in theater are FDA­compliant because of the way they poncho liners, sleeping bags, or anything that will re­
are collected. Consequently, whole blood and 1:1:1 resusci­ tain heat and keep the casualty dry.
tation using apheresis platelets should be used only if all the f. Use a portable fluid warmer capable of warming all IV
FDA­compliant blood products needed to support 1:1:1 re­ fluids including blood products.
suscitation are not available, or if 1:1:1 resuscitation is not g. Protect the casualty from wind if doors must be kept
producing the desired clinical effect. open.
e. Refractory Shock 8. Penetrating Eye Trauma
• If a casualty in shock is not responding to fluid resus­ a. If a penetrating eye injury is noted or suspected:
citation, consider untreated tension pneumothorax as • Perform a rapid field test of visual acuity and doc­
a possible cause of refractory shock. Thoracic trauma, ument findings.
persistent respiratory distress, absent breath sounds, • Cover the eye with a rigid eye shield (NOT a pres­
and hemoglobin oxygen saturation < 90% support sure patch.)
this diagnosis. Treat as indicated with repeated NDC • Ensure that the 400mg moxifloxacin tablet in the
or finger thoracostomy/chest tube insertion at the 5th Combat Wound Medication Pack (CWMP) is taken
ICS in the AAL, according to the skills, experience, and if possible and that IV/IM antibiotics are given as
authorizations of the treating medical provider. Note outlined below if oral moxifloxacin cannot be taken.
that if finger thoracostomy is used, it may not remain 9. Monitoring
patent and finger decompression through the incision a. Initiate advanced electronic monitoring if indicated
may have to be repeated. Consider decompressing the and if monitoring equipment is available.
opposite side of the chest if indicated based on the 10. Analgesia
mechanism of injury and physical findings. a. Analgesia on the battlefield should generally be achieved
6. Traumatic Brain Injury using one of three options:
a. Casualties with moderate/severe TBI should be moni­ • Option 1
tored for: – Mild to Moderate Pain
• Decreases in level of consciousness – Casualty is still able to fight
• Pupillary dilation o TCCC CWMP
• SBP should be >90mmHg *Tylenol – 650mg bilayer caplet, 2 PO every
• O sat > 90 8 hours
2
• Hypothermia *Meloxicam – 15mg PO once a day

144 | JSOM Volume 18, Edition 3 / Fall 2018