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immediately available, Rh positive blood products if possible and that IV/IO/IM antibiotics are given as
should be used in hemorrhagic shock. outlined below if oral moxifloxacin cannot be taken.
• If a casualty with an altered mental status due to sus- 9. Monitoring
pected TBI has a weak or absent radial pulse, resus- • Initiate advanced electronic monitoring if indicated
citate as necessary to restore and maintain a normal and if monitoring equipment is available.
radial pulse. If BP monitoring is available, maintain a 10. Analgesia
target systolic BP between 100–110mmHg. a. TCCC non-medical first responders should provide
• Reassess the casualty frequently to check for recurrence analgesia on the battlefield achieved by using:
of shock. If shock recurs, re-check all external hemor- • Mild to Moderate Pain
rhage control measures to ensure that they are still effec- • Casualty is still able to fight
tive and repeat the fluid resuscitation as outlined above. – TCCC Combat Wound Medication Pack (CWMP)
f. Refractory Shock ■ Acetaminophen – 500mg tablet, 2 PO every
• If a casualty in shock is not responding to fluid resus- 8 hours
citation, consider untreated tension pneumothorax as ■ Meloxicam – 15mg PO once a day
a possible cause of refractory shock. Thoracic trauma, b. TCCC Medical Personnel:
persistent respiratory distress, absent breath sounds, Option 1
and hemoglobin oxygen saturation < 90% support • Mild to Moderate Pain
this diagnosis. Treat as indicated with repeated NDC • Casualty is still able to fight
or finger thoracostomy/chest tube insertion at the 5 – TCCC Combat Wound Medication Pack
th
ICS in the AAL, according to the skills, experience, and (CWMP)
authorizations of the treating medical provider. Note ■ Acetaminophen – 500mg tablet, 2 PO every
that if finger thoracostomy is used, it may not remain 8 hours
patent and finger decompression through the incision ■ Meloxicam – 15mg PO once a day
may have to be repeated. Consider decompressing the Option 2
opposite side of the chest if indicated based on the • Mild to Moderate Pain
mechanism of injury and physical findings. • Casualty IS NOT in shock or respiratory distress
7. Hypothermia Prevention AND Casualty IS NOT at significant risk of devel-
a. Take early and aggressive steps to prevent further body oping either condition.
heat loss and add external heat when possible for both – Oral transmucosal fentanyl citrate (OTFC)
trauma and severely burned casualties. 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 50 mcg IV/IO 0.5–1 mcg/kg
c. Replace wet clothing with dry clothing, if possible, and – May repeat q 30 min
protect from further heat loss. – Fentanyl 100 mcg 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 20–30mg (or 0.2–0.3mg/kg) slow IV
sleeping bag or other readily available insulation inside or IO push
the enclosure bag/external vapor barrier shell. ■ Repeat doses q20 min prn for IV or IO
g. Pre-stage an insulated hypothermia enclosure system ■ End points: Control of pain or development
with external active heating for transition from the of nystagmus (rhythmic back-and-forth move-
non-insulated hypothermia enclosure systems; seek to ment of the eyes).
improve upon existing enclosure system when possible. – Ketamine 50–100mg (or 0.5–1mg/kg) IM or IN
h. Use a battery-powered warming device to deliver IV/IO ■ Repeat doses q20–30 min prn for IM or IN
resuscitation fluids, in accordance with current CoTCCC Option 4
guidelines, at flow rate up to 150mL/min with a 38°C TCCC Combat Paramedics or Providers:
output temperature. • Sedation required: significant severe injuries requir-
i. Protect the casualty from exposure to wind and precipi- ing dissociation for patient safety or mission success
tation on any evacuation platform. or when a casualty requires an invasive procedure;
8. Penetrating Eye Trauma must be prepared to secure the airway:
• If a penetrating eye injury is noted or suspected: – Ketamine 1–2mg/kg slow IV/IO push initial dose
– Perform a rapid field test of visual acuity and docu- ■ Endpoints: procedural (dissociative) anesthesia
ment findings. – Ketamine 300mg IM (or 2–3mg/kg IM) initial
– Cover the eye with a rigid eye shield (NOT a pressure dose
patch). ■ Endpoints: procedural (dissociative) anesthesia
– Ensure that the 400mg moxifloxacin tablet in the ◆ If an emergence phenomenon occurs, con-
Combat Wound Medication Pack (CWMP) is taken sider giving 0.5–2mg IV/IO midazolam.

14 | JSOM Volume 22, Edition 1 / Sping 2022