Page 115 - JSOM Spring 2020

d. Naloxone should be available when using opioid an- K9TCCC guidelines in Section 11, if indicated, to pre-
algesics. Recommended doses are 2mg IV/IO or 4mg vent infection in penetrating wounds.
IM/IN. Repeat as needed. 39 g. All K9TCCC interventions can be performed on or
e. Ketamine and opioids have the potential to worsen se- through burned skin in a burn casualty.
vere TBI. The Combat Medic, Corpsman, or Parares- h. Burn patients are particularly susceptible to hypother-
cueman must consider this fact in his or her analgesic mia. Extra emphasis should be placed on barrier heat-
decision, but if the MWD is vocalizing and demonstrat- loss prevention methods.
ing painful behaviors, then the TBI is likely not severe 15. SPLINT FRACTURES and recheck pulses.
enough to preclude the use of ketamine or opioids. a. Important: Handle any injured MWD with a fracture
f. Ketamine may be a useful adjunct to reduce the with extreme care and proper restraint and muzzling,
amount of opioids required to provide effective pain if appropriate. Consider sedation and analgesia before
relief. It is safe to give ketamine to an MWD who has manipulating the fractured site (see Section 10).
previously received morphine. IV Ketamine should be b. SAM splints (SAM Medical, https://www.sammedical.
given over 1 minute. com/) and spoon splints can be applied below the knee
g. If respirations are noted to be reduced after using opi- or below the elbow of an MWD. Ensure sufficient pad-
oids or ketamine, provide ventilatory support with a ding is in place along pressure points when applying
bag-valve-mask or mouth-to-mask ventilations. these splints to minimize the risk of additional injuries.
h. Reassess, Reassess, Reassess! 16. Communication
11. ANTIBIOTICS: a. Communicate consistently with the MWD handler
a. Recommended for all open combat wounds or assigned escort. Explain care provided and request
b. Recommended antibiotics in order of preference are: support required for MWD management and position-
■ Ceftriaxone sodium, 25mg/kg, IV/IM every 12 hours 40 ing. Handler and MWD should travel together when-
■ Cefotaxime sodium, 25mg/kg, IV/IM every 8 hours 40 ever feasible to facilitate handling and comfort of the
■ Ertapenem, 15–30mg/kg, IV or subcutaneously ev- MWD.
ery 8 hours 41 b. Communicate with tactical leadership as soon as
■ If able to take medications orally, consider: possible and as needed during the treatment process.
■ Moxifloxacin (from the Combat Wound Medica- Provide leadership with casualty status regularly and
tion Pack), 400mg orally once a day evacuation requirements to assist with coordination of
12. Inspect and dress known WOUNDS. evacuation and dedication of onsite support assets. In-
13. Check for ADDITIONAL WOUNDS. clude canine handler or escort in evacuation planning
14. BURNS for casualty management.
a. Facial burns, especially those that occur in closed c. Communicate with the established evacuation sys-
spaces, may be associated with inhalation injury. Ag- tem for that specific locale to arrange tactical evac-
gressively monitor airway status and oxygen satura- uation. Provide to medical providers on evacuation
tion in such patients and consider early intubation platform the mechanism of injury (MOI), injuries sus-
or surgical airway for respiratory distress or oxygen tained, identified signs and symptoms, current status,
desaturation. and treatments and medications administered to the
b. Estimate total body surface area (TBSA) burned to the MWD. Ensure receiving medical providers are aware
nearest 10% using the Rule of Nines. of the need to have canine handler or assigned escort
c. Cover the burn area with dry, sterile dressings. For accompany the casualty for management.
extensive burns (>20%), consider placing the casualty d. K9TCCC recommends the use of S-MIST reporting for
in the heat-reflective shell or Blizzard Survival Blanket MWD casualties. The MIST report is not a formal part
from the HPMK to both cover the burned areas and of the US Standard Medical Evacuation (MEDVAC) re-
prevent hypothermia. quest. It is supplemental to a MEDEVAC request and
d. Fluid resuscitation (extrapolated from the US Army should be sent as soon as possible but should not de-
Institute of Surgical Research Rule of Ten) lay the MEDEVAC mission. The MIST report is also a
■ If burns are >20% of TBSA, fluid resuscitation verbal exchange between the current provider and the
should be initiated as soon as IV/IO access is es- next level of care. For example, when a ground Medic
tablished. Initiate resuscitation with (in order of hands a patient off to a flight Medic, he gives the MIST
preference): lactated Ringer’s, Plasma-Lyte A/Nor- report along with the TCCC/canine TCCC card.
mosol-R, normal saline, or Hextend; if Hextend is ■ S-MIST is a simple yet thorough and efficient way
used, no more than 20mL/kg (500–800mL) should to convey the salient details of a patient’s status.
be given, followed by lactated Ringer’s or normal Stated another way, it is a succinct format to com-
saline, as needed. municate the status and treatment performed so the
■ Initial IV/IO fluid rate is calculated as %TBSA × next Role of care knows what they need to provide
10mL/h. immediate treatment.
■ If hemorrhagic shock is also present, resuscitation ■ S-MIST Report:
for hemorrhagic shock takes precedence over re- o S – Stable or Unstable
suscitation for burn shock. Administer IV/IO fluids o M – Mechanism of Injury: A brief description of
per the K9TCCC Guidelines in Section 6. the MOI and time of injury (if known)
e. Analgesia in accordance with the K9TCCC Guidelines o I – Injury or Illness: A brief description of the
in Section 10 may be administered to treat burn pain. injuries sustained, starting with the most serious
f. Prehospital antibiotic therapy is not indicated solely first. Highlight life-threatening injuries.
for burns, but antibiotics should be given per the o S – Symptoms and Vital Signs:

K9TCCC Guidelines | 109