Page 34 - JSOM Summer 2020

This is a significant challenge for these teams; however, even External Electrical Power
though nondoctrinal, the unique mission requirements of The ability to provide quality care will depend heavily on elec-
these teams may result in them caring for pediatric patients. trical power. Early initiation of warmed blood products and
If this is the case, ensure age-specific medical supplies and patient normothermia are vital components of a successful
equipment are available, such as pediatric monitors, catheters, trauma resuscitation. Maintenance of blood refrigeration and
tubes, and medications. Although a Broselow bag may be too active warming and cooling devices (e.g., heaters, air condi-
large to carry in this environment, the contents can be bro- tioners, blood warmers, plasma thawing devices) draw signif-
ken down and specific elements such as airway adjuncts and icant electrical power requirements. Regular maintenance and
a Broselow tape can be carried to assist with caring for the fuel requirements for power generators must be preplanned
™
pediatric population. and communicated with the ground-force commander, but are
ultimately the responsibility of the surgical team.
Obstetrics
Pregnant patients may present who meet medical rules of en- Chemical, Biological, Radiological, and Nuclear
gagement for care. ARSC providers should be familiar with ARSC teams should be prepared to protect and decontam-
the anatomic changes that occur during pregnancy due to the inate themselves, and there must be a plan for the patients
gravid uterus. Ultrasound can be used to evaluate the fetus. and incoming casualties. Although ARSC teams must have a
Fetal distress is associated with a fetal heart rate of fewer treatment plan in place should they encounter a patient with
than 100 bpm and is an indication of the need for continued chemical, biological, radiological, and nuclear (CBRN) expo-
maternal resuscitation or even emergent fetal delivery. ARSC sure, they may not be equipped to treat this patient popula-
providers should be familiar with emergent obstetric proce- tion. It is imperative to communicate with the Operational
dures, including cesarean delivery and surgical management of Command that an ARSC team is not equipped or staffed for
postpartum hemorrhage. ARSC providers should contact an large-scale patient decontamination, that care timelines will
obstetrician for guidance as able. extend during a CBRN event, and triage decisions may change
significantly (Table 1).
K9 Damage Control
Injured military working dogs (MWDs) may require urgent TABLE 1 CBRN Considerations for Austere Resuscitative and
surgical stabilization. The MWD CPG outlines the unique Surgical Care Teams
74
clinical considerations for these patients. Always apply a muz- • Develop a hasty and deliberate decontamination plan (on arrival
zle (or improvised muzzle) early for safety. Consider having to a new site with all parties).
hair clippers and larger endotracheal tubes (9Fr–11Fr) avail- • Conduct individual and team drills to practice donning personal
able for canine use, as well as larger laryngoscopes (e.g., protective equipment.
Miller blade size 4). The canine handler, unless injured, will • May use nitrile gloves x3 for protection; change outer glove if it
help manage the care and will have a card with weight-based becomes sticky or gummy.
medication doses specific to their canine. Standard tourni- • Identify the nearest resource that has CBRN detection
quets may be used for severe canine limb injuries; however, capabilities.
elastic pressure dressings are typically effective and, in some • Identify a large water source (55-gal drum or similar, with hose).
cases, the tourniquets may not adjust to a small enough cir- • Ample supply of rapid skin-decontamination lotion
cumference to occlude blood flow. Predeployment, MWD- • Do not bring casualty into clinical facility until decontamination
specific medical training is strongly recommended and cur- is complete. This is an element of proper triage. Anticipate
rently is a Central Command theater requirement. New rec- loss of supplies and equipment used on patients before
ommendations regarding the K9 WBB exist and these teams decontamination, and plan accordingly.
(as well as all Role 2 and Role 3) should contact a theater • See JTS CBRN Injury Part I: Initial Response to CBRN Agents
CPG
75
veterinarian when arriving in theater. If K9 blood is held on-
site, it must be in a separate cooler and location than human Abbreviations: CBRN, chemical, biological, radiological, and nuclear;
CPG, clinical practice guideline; JTS, Joint Trauma System.
blood.
Ventilator Management Blood Use in the ARSC Environment
All team members should be facile with the use of the partic- Blood is a resource that cannot be improvised and must be
ular ventilator available. Refillable oxygen storage containers communicated to operational leadership as a mission-critical
(liquid or gas) are heavy and a challenge to maintain and refill. requirement. Logistical factors with the ARSC team must be
Portable battery-powered oxygen concentrators are an option considered even more so than at the Role 2 or Role 3. ARSC
but require power for continuous use. Additional ventilator teams do not have dedicated personnel to manage the blood
management, such as setting up an oxygen reservoir for a ven- supply, storage, temperature regulation, accounting, and re-
tilator, will be addressed in a future Austere Anesthesia CPG. supply. Blood supply and resupply must be considered early
and often. This is often managed through medical operations
Imaging channels and requires close coordination with the combatant
X-ray or cross-sectional imaging may not be available in the command blood program and regional blood logistic process.
austere environment. Portable sonography may be the only Maintaining stored blood products within a narrow tempera-
imaging tool and miniaturized devices are available. Readiness ture range and subsequently warming them in a timely manner
and training for this skill set are required before deploying to are two of the greatest challenges of austere trauma medi-
an ARSC environment. Ultrasound will provide the ability to cine. 13,50 In an unstable and critically ill combat casualty, early,
evaluate the torso for injuries (E-FAST), guide resuscitation, balanced blood resuscitation (ideally, whole blood) improves
guide vascular access, assess for vascular flow, and perform 72-hour mortality rate. 4,13,76–79 ARSC teams must anticipate
regional anesthetic techniques. blood requirements, work with the theater blood program

32 | JSOM Volume 20, Edition 2 / Summer 2020