Page 114 - JSOM Spring 2020

o Reassess the MWD after each 500mL IV/IO *NOTE: Ketamine can cause nystagmus and increased intra-
bolus. ocular pressure in an MWD. Therefore consider alternative
o Continue resuscitation until a palpable femoral sedatives or analgesics in MWDs with penetrating eye traumas
pulse, improved mental status, or systolic BP of unless other alternatives are unavailable or are ineffective.
80–90mmHg is present. 9. Monitoring
o Discontinue fluid administration when one or a. Initiate advanced electronic monitoring, if indicated
more of the listed end points has been achieved. and if monitoring equipment is available.
■ If an MWD with an altered mental status due to b. Monitors of choice include pulse oximetry (placed
suspected TBI has a weak or absent femoral pulse, on the lip, tongue, or prepuce) and capnography, if
resuscitate as necessary to restore and maintain a intubated.
normal femoral pulse. If BP monitoring is available, 10. ANALGESIA
maintain a target systolic BP of ≥90mmHg. a. Analgesia on the battlefield should generally be
■ Reassess the MWD frequently to check for recurrence achieved using one of three options:
of shock. If shock recurs, recheck all external hem- Option 1
orrhage control measures to ensure they are still ef- ■ Mild to Moderate Pain
fective and repeat the fluid resuscitation as outlined. o Meloxicam: one-half of a 7.5mg tablet (0.1mg/
■ Refractory Shock kg) orally once a day
o If an MWD in shock is refractory to fluid re- o DO NOT give acetaminophen (e.g., Tylenol) or
suscitation and canine blood products are not ibuprofen to an MWD.
available, consider: Option 2
®
◆ Using synthetic colloids (Hextend [Pfizer, ■ Moderate to Severe Pain
https://www.pfizer.com/] and/or Hespan [B. MWD is NOT in shock or respiratory distress
®
Braun Medical Inc. https://www.bbraunusa. AND MWD is NOT at significant risk of develop-
com/en.html) – 150–200mL bolus IV/IO. ing either condition:
Can repeat if shock state is not resolved. o Do not attempt to give oral transmucosal fen-
o Untreated tension pneumothorax as a possible tanyl citrate to an MWD. Rather, administer
cause of refractory shock. Thoracic trauma, ONE of the following options:
persistent respiratory distress, absent breath ◆ Morphine: 0.25–0.5mg/kg IM (equivalent
33
sounds, and hemoglobin oxygen saturation to one 10mg morphine autoinjector), or
<90% support this diagnosis. Treat as indicated ◆ Hydromorphone: 0.1mg/kg IV/IO/IM, or
33
above with repeated C-NDC or finger thoracos- ◆ Fentanyl (injectable) every 20–30 minutes at:
tomy/chest tube insertion. Note: If finger tho- 2–5µg/kg IV/IO, or 10µ/kg IM, or 4µ/kg
33
33
racostomy is used, it may not remain patent and intranasally (IN). 34
finger decompression through the incision may *NOTE: Morphine and hydromorphone often cause vomiting
have to be repeated. In MWDs, always consider in dogs, so handlers and medics should be prepared to remove
decompressing both sides of the chest as de- the muzzle after administration of an opioid. Hydromorphone
scribed in Section 5. causes excessive panting; use caution with head injuries and
7. Hypothermia Prevention respiratory disease.
a. Minimize MWD’s exposure to the elements. Option 3
b. Remove any wet outer wear (e.g., vests, harnesses, boo- ■ Moderate to Severe Pain
ties). GENTLY pat dry any wet tissues or hair coat. MWD is in hemorrhagic shock or respiratory dis-
c. Place the MWD on an insulated surface as soon as tress OR MWD is at significant risk of developing
possible. either condition:
d. Apply a ready-heat blanket from the HPMK to the o Ketamine: 2–5mg/kg (60–90mg) IV/IO/IM/IN 13,35
MWD’s torso (not directly on the skin) and cover the o If possible, to improve analgesia or sedation,
MWD with the heat-reflective shell (HRS). strongly consider combination therapy when-
e. If an HRS is not available, the combination of the ever using ketamine in MWDs. Suggested proto-
Blizzard Survival Blanket (Blizzard Protection Systems cols include combining 50mg of ketamine with
Ltd., https://www.blizzardsurvival.com/) and a ready- either an/a:
heat blanket may also be used. ◆ Opioid (5mg of morphine OR 3mg of hydro-
f. If these items are not available, use dry blankets, pon- morphone OR 150µg fentanyl), OR
cho liners, sleeping bags, or anything that will retain ◆ Benzodiazepine (10mg of midazolam or
heat and keep the MWD dry. diazepam). 13,36
g. Warm fluids are preferred if IV/IO fluids are required. *End points: Control of pain and appropriate level of seda-
8. Penetrating Eye Trauma tion. MWD should be generally recumbent but responsive and
a. If a penetrating eye injury is noted or suspected: breathing voluntarily and comfortably.
■ Place muzzle on MWD, if practical, before exam- Analgesia Notes:
ining the eye. a. Document mental status in MWD before administer-
■ DO NOT attempt to bandage or cover the eye. Make ing opioids or ketamine.
every effort to prevent MWD from scratching at the b. For all casualties given opioids or ketamine, monitor
eye. Consider sedation as outlined in Section 10. airway, breathing, and circulation closely.
■ If possible, gently rinse the eye with clean water. c. Consider adjunct administration of antiemetics (on-
■ Ensure that oral or IV or intramuscular (IM) antibi- dansetron 8–16mg IV or 24mg orally) 37,38 before ad-
otics are given as outlined under Antibiotics. ministering opioids.

108 | JSOM Volume 20, Edition 1 / Spring 2020