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– Reassess the casualty after each unit. Continue re- g. Prestage an insulated hypothermia enclosure system
suscitation until a palpable radial pulse, improved with external active heating for transition from the
mental status or systolic BP of 100mmHg is present. noninsulated hypothermia enclosure systems; seek to
– Discontinue fluid administration when one or improve upon existing enclosure system when possible.
more of the above end points has been achieved. h. Use a battery-powered warming device to deliver
– If blood products are transfused, administer 1g IV resuscitation fluids, in accordance with current
of calcium (30mL of 10% calcium gluconate or CoTCCC guidelines, at flow rate up to 150mL/min
10mL of 10% calcium chloride) IV/IO after the with a 38°C output temperature.
first transfused product. i. Protect the casualty from exposure to wind and pre-
• Given increased risk for a potentially lethal hemo- cipitation on any evacuation platform.
lytic reaction, transfusion of unscreened group O 8. Penetrating Eye Trauma
fresh whole blood or type specific fresh whole blood • If a penetrating eye injury is noted or suspected:
should only be performed under appropriate medical – Perform a rapid field test of visual acuity and doc-
direction by trained personnel. ument findings.
• Transfusion should occur as soon as possible after – Cover the eye with a rigid eye shield (NOT a pres-
life-threatening hemorrhage in order to keep the sure patch).
patient alive. If Rh-negative blood products are not – Ensure that the 400mg moxifloxacin tablet in the
immediately available, Rh-positive blood products Combat Wound Medication Pack (CWMP) is taken
should be used in hemorrhagic shock. if possible and that IV/IM antibiotics are given as
• If a casualty with an altered mental status due to sus- outlined below if oral moxifloxacin cannot be
pected TBI has a weak or absent radial pulse, resus- taken.
citate as necessary to restore and maintain a normal 9. Monitoring
radial pulse. If BP monitoring is available, maintain a • Initiate advanced electronic monitoring if indicated
target systolic BP between 100 and 110mmHg. and if monitoring equipment is available.
• Reassess the casualty frequently to check for recur- 10. Analgesia
rence of shock. If shock recurs, recheck all external a. TCCC nonmedical first responders should provide an-
hemorrhage control measures to ensure that they are algesia on the battlefield achieved by using:
still effective and repeat the fluid resuscitation as out- • Mild to moderate pain
lined above. • Casualty is still able to fight
f. Refractory Shock – TCCC Combat Wound Medication Pack (CWMP)
• If a casualty in shock is not responding to fluid resus- ■ Acetaminophen – 500mg tablet, 2 PO every
citation, consider untreated tension pneumothorax as 8 hours
a possible cause of refractory shock. Thoracic trauma, ■ Meloxicam – 15mg PO once a day
persistent respiratory distress, absent breath sounds, b. TCCC Medical Personnel:
and hemoglobin oxygen saturation <90% support Option 1
this diagnosis. Treat as indicated with repeated NDC • Mild to moderate pain
or finger thoracostomy/chest tube insertion at the fifth • Casualty is still able to fight
ICS in the AAL, according to the skills, experience, and – TCCC Combat Wound Medication Pack
authorizations of the treating medical provider. Note (CWMP)
that if finger thoracostomy is used, it may not remain ■ Acetaminophen – 500mg tablet, 2 PO every
patent and finger decompression through the incision 8 hours
may have to be repeated. Consider decompressing the ■ Meloxicam – 15mg PO once a day
opposite side of the chest if indicated based on the Option 2
mechanism of injury and physical findings. • Mild to moderate pain
7. Hypothermia Prevention • Casualty IS NOT in shock or respiratory distress
a. Take early and aggressive steps to prevent further body AND casualty IS NOT at significant risk of devel-
heat loss and add external heat when possible for both oping either condition.
trauma and severely burned casualties. – Oral transmucosal fentanyl citrate (OTFC) 800μg
b. Minimize casualty’s exposure to cold ground, wind, and ■ May repeat once more after 15 minutes if
air temperatures. Place insulation material between the pain uncontrolled by first
casualty and any cold surface as soon as possible. Keep TCCC combat paramedics or providers:
protective gear on or with the casualty if feasible. – Fentanyl 50μg IV (0.5–1μg/kg
c. Replace wet clothing with dry clothing, if possible, and ■ May repeat q 30 min
protect from further heat loss. – Fentanyl 100μg IN
d. Place an active heating blanket on the casualty’s ante- ■ May repeat q 30 min
rior torso and under the arms in the axillae (to prevent Option 3
burns, do not place any active heating source directly on • Moderate to severe pain
the skin or wrap around the torso). • Casualty IS in hemorrhagic shock or respiratory
e. Enclose the casualty with the exterior impermeable en- distress OR
closure bag. • Casualty IS at significant risk of developing either
f. As soon as possible, upgrade hypothermia enclosure sys- condition:
tem to a well-insulated enclosure system using a hooded – Ketamine 30mg (or 0.3mg/kg) slow IV or IO
sleeping bag or other readily available insulation inside push
the enclosure bag/external vapor barrier shell. ■ Repeat doses q 20 min PRN for IV or IO

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