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given that some patients may require continued treatment in 4. Ensure presence of normal bowel sounds prior to initiat-
an austere environment, may have preexisting malnutrition, ing any enteral feeding.
or may present for treatment after being septic for a period 5. Enteral feeding is contraindicated in the presence of se-
of time, attention must be paid to the patient’s nutrition as a vere abdominal distention, abdominal pain, and/or gas-
part of a treatment plan. This can be difficult if the patient is trointestinal bleeding.
nauseated and/or vomiting, has an intraabdominal source of 6. Meal supplement drinks are sufficient: 1× Muscle Milk
infection, resources are severely limited, or the patient’s mental Light bottle contains 150kcal and 28g protein in 500mL.
status is not conducive to eating and drinking. 7. A more concentrated alternative is to use commercially
available protein powder (with similar caloric/protein
Most patients do not require nutritional support when evac- content per scoop) at one-fourth the recommended con-
uation is anticipated within 72 hours. When evacuation is centration and mix until no clumps are visible.
delayed beyond 72 hours or not possible, adequate nutrition 8. Administer tube feeds in small volume boluses (e.g.,
should be sustained as outlined below. 60mL via Toomey syringe) 2–4 hours for a goal of 1g/kg/
day protein content.
GOAL: Goal 25–30kcal/kg/day + 1–1.2g/kg protein. Most 9. If vomiting or increased abdominal distension occur, hold
patients with a normal mental status can feed him or herself tube feeds for 6 hours and then try again.
without the placement of a feeding tube. 10. For more information, see JTS Nutrition Support Using
Enteral and Parenteral Methods CPG. 26
1. Enteral nutrition (oral or administered by orogastric or
nasogastric tube) should be withheld in hemodynamically Performance Improvement (PI) Monitoring
unstable patients (i.e., those on high or increasing doses of
vasopressors) due to the risk of causing ischemic GI injury POPULATION OF INTEREST
to include perforation. Casualties receiving PFC or prolonged casualty care (PCC).
2. Nasogastric tube (NGT) should be placed in patients
deemed in critical for gastric decompression. If medical INTENT (EXPECTED OUTCOMES)
evacuation is significantly delayed (>48–72 hours) or the Prehospital documentation is received by JTS on all PFC and
patient has been without significant caloric intake for over PCC patients.
3 days (due to delayed presentation), consider starting en-
teral nutrition (orally if they can take PO safely, via tube if PERFORMANCE/ADHERENCE MEASURES
not). If the patient requires continuous vasopressors, avoid • Sepsis patient with >2 hours prehospital care that ar-
the bolus nutrition sources, and opt for a lower volume rives intubated to Role 2 or 3.
hourly rate of infusion (10–20mL/hr). • Sepsis patient with >2 hours prehospital care requiring
3. At a minimum, confirm presence of gastric placement with dialysis at Role 3 or 4.
auscultation over both lung fields and the abdomen, along • Sepsis patient with >2 hours prehospital care who dies
with aspiration of gastric contents. Best recommendation is within the first 30 days.
obtaining plain film radiography to confirm proper place-
ment PRIOR to instilling any substances through the tube. DATA SOURCES
• Patient Record
• Department of Defense Trauma Registry (DoDTR)
Oral Feed vs Tube Feed • PFC Flowsheet
If a patient has a normal mental status they likely can
take oral nutrition – do not put a tube down their nose. If SYSTEM REPORTING & FREQUENCY
they cannot cooperate or tolerate oral feeds, and evac- The above constitutes the minimum criteria for PI monitor-
uation is not likely or not possible within 72 hours, con- ing of this CPG. System reporting will be performed annually;
sider tube feeds. If tube feeds are initiated without an additional PI monitoring and system reporting may be per-
ability to obtain x-ray verification of placement, monitor formed as needed.
for signs of misplacement or GI obstruction very closely
(e.g., nausea, increasing abdominal distension or pain) The system review and data analysis will be performed by the
and stop feeding if they occur. Patients require contin- JTS Chief and the JTS PI Branch.
uous hydration, but those who receive adequate hydra-
tion will not experience clinically significant adverse RESPONSIBILITIES
effects from starvation for several days to over a week. It is the trauma team leader’s responsibility to ensure famil-
iarity, appropriate compliance and PI monitoring at the local
Severe Malnutrition level with this CPG.
If someone has signs of severe malnutrition (e.g., local
nationals in setting of famine, hostages), obtain tele- References
medicine consultation before starting enteral nutrition. 1. Rhodes A, Evans LE, Alhazzani W, et al. Surviving sepsis cam-
Refeeding syndrome is a life-threatening metabolic and paign: international guidelines for management of sepsis and septic
shock: 2016. Intensive Care Med. 2017;43:304–377.
electrolyte derangement that can develop from feeding 2. Ma XY, Tian LX, Liang HP. Early prevention of trauma-related
severely malnourished patients too much, too quickly. It infection/sepsis. Mil Med Res. 2016;3:33. Published 2016 Nov 8.
is very difficult to detect in the PFC environment. The doi:10.1186/s40779-016-0104-3
first sign may be cardiac collapse from electrolyte de- 3. Chung S, Choi D, Cho J, et al. Timing and associated factors for
rangements which is nearly impossible to resuscitate. sepsis-3 in severe trauma patients: a 3-year single trauma center
experience. Acute Crit Care. 2018;33(3):130-134.

32 | JSOM Volume 20, Edition 4 / Winter 2020