Page 34 - 2022 Spring JSOM

o Early teleconsultations should be used for any signs of sepsis Wound Care and Nursing – LT Dana Flieger, LTC Chris
o Additional parenteral antibiotics may be required to treat sep- VanFosson, MAJ Sabas Salgado, CPT Jeff Maler
sis as well as vasopressors.
o All use of pressers should be administered by role-based ap- Background
proved protocols or teleconsultation approval. Nursing interventions may not appear important to the medical pro-
NOTE: Surgical telemedicine consultation is highly recommended to fessionals caring for a patient, but such interventions greatly reduce
guide management of intra- abdominal infections (i.e., appendicitis, cho- the possibility of complications such as DVT, pneumonia, pressure
lecystitis, diverticulitis, abdominal abscess) (see Table 13). sores, wound infection, and urinary tract infection; therefore, essential
nursing and wound care should be prioritized in the training environ-
ment. Critically ill and injured casualties are at high risk for compli-
Sepsis Treatment (see Tables 14 and 15)
cations that can lead to adverse outcomes such as increased disability
Ancillary Medications and death. Nursing care is a core principle of PCC to reduce the risk
During PCC, additional medications may be required during the of preventable complications and can be provided without costly or
extended treatment of casualties, in addition to pain and antibiotic burdensome equipment (see Table 17). 20
medications. These medications may have synergistic effects to further ■ Using a nursing care checklist assists with developing a schedule
reduce pain or fever. Some medications may be utilized to treat side- for performing appropriate assessments and interventions.
effects of medications, to include nausea or other GI related issues. ■ Cross training all team members on these interventions prior to
deployment will lessen the demand on the medic, especially when
Deep vein thrombosis (DVT) prophylaxis is also recommended for caring for more than one patient.
patients that are expected to be in a PCC setting for greater than 48 ■ Prolonged Casualty Care Flowsheets, Nursing Care Checklists,
hr that have achieved hemostasis from wounds or are not at risk for Nursing Care Plans, Assessment/Intervention Packing List, and
further hemorrhage (see Table 16).
Recommended Nursing Skill Checklist for Clinical Rotations are
TABLE 13 Physiologic Parameters and NEWS Score
Physiologic Parameters 3 2 1 0 1 2 3
Respiratory Rate ≤8 9–11 12–20 21–34 ≥25
Oxygen Saturation ≤91 92–93 94–95 ≥96
Temperature ≤35.0 35.1–36.0 36.1–38.0 38.1–39.0 ≥39.1
Systolic BP ≤90 91–100 101–110 111–219
Heart Rate ≤40 41–50 51–90 91–110 111–130 ≥131
Level of Consciousness A V,P,U

TABLE 14 Sepsis Treatments/Interventions
Intervention Paradigm
Antimicrobial Therapy • Minimum – Moxifloxacin 400mg PO daily
• Better – Ertapenem 1g IV/IO every 24 hr OR ceftriaxone 2g IV/IO every 24 hr
• Best – ceftriaxone 2g IV/IO every 24 hr, PLUS vancomycin 1.5mg/kg IV/IO every 12 hr, PLUS metronidazole 500mg IV/PO/IO
every 8 hr
Antiparasitic Regimens • Minimum – Atovaquone/progauanil (Malarone) 4x3 regimen – 4 tablets PO daily for 3 days
• Better/Best – Artemether/lumefantrine (Coartem) 4 tablets PO initially, then 4 tablets after 8 hr, then 4 tablets PO twice daily for
2 more days (24 tablets total)
Antifungal Regimens • Minimum/Better/Best – Fluconazole 400mg PO/IV daily
Fluid Resuscitation • Minimum – In the absence of IV/IO capability, have the patient drink water
• If available, include electrolyte oral rehydration solution, especially for patients who cannot consume food
• Better – IV/IO crystalloids:
o Initial rapid infusion of 30mL/kg should be given upon identification of sepsis
o LR or NS to maintain SBP > 90mmHg or MAP ≥ 65mmHg
o If plasma is being given that volume can count toward the 30mL/kg goal
• Best – The same fluid resuscitation strategy as above with the addition of a urinary catheter for more precise measuring of UOP
Vasopressors • After fluid resuscitation, if there is no observed positive change in SBP, MAP, UOP and/or mental status, vasopressor medications
should be given
• All use of pressers should be administered by role-based approved protocols or teleconsultation approval
• First-line – norepinephrine infusion
• Second-line – epinephrine infusion
• Refer to Drip table below for preparation, starting dose, and drip rates
Additional Medications • Consider hydrocortisone or dexamethasone administration for possible adrenal insufficiency if there is a poor response to
vasopressor initiation/titration
• Administer antipyretics (acetaminophen, if available. Non-steroidal anti-inflammatory drugs [NSAIDs] should be avoided as they
may impair renal function)

TABLE 15 Epinephrine 1:10,000 (Adrenalin) or Norepinephrine (Levophed) Drip
Add to bag: DRIP SET:10gtts (Drops/mL) DRIP DRIP SET: 15gtts (Drops/mL)
0.9% NaCl IVF EPI (or NOREPI): 1:10,000 Starting Dose RATE: DRIP RATE:
Bag Size (0.1 mg or 100mcg)/mL (mcg/min) (Drops/min or gtts/min) (Drops/min or gtts/min)
50mL 1mL (100mcg) 4mcg/min 20 drops/min 30 drops/min
100mL 2mL (200mcg) 4mcg/min 20 drops/min 30 drops/min
250mL 5mL (500mcg) 4mcg/min 20 drops/min 30 drops/min
500mL 10mL (1mg) 4mcg/min 20 drops/min 30 drops/min
1000mL (1L) 20mL (2mg)* 4mcg/min 20 drops/min 30 drops/min
*This is the least recommended approach as it commits a high volume of epinephrine to a large bag. If the patient’s vital signs (BP/MAP/HR) stabilize, the bag must
be discontinued and the medic risks wasting some of their resources – “you can mix a drug in an IV bag, but you can’t take it out.”

32 | JSOM Volume 22, Edition 1 / Sping 2022