Page 111 - JSOM Summer 2022

hemorrhage, airway, respiratory, circulatory, hypothermia the urinary output of these patients early in order to prevent
(MARCH) algorithm used to guide the initial care of patients fluid overload which can cause significant harm.
who have suffered a blast injury. Be aware of items that could
amplify the effects of the blast wave and cause a primary blast The treatment of positive-pressure pulmonary edema, inhala-
injury (i.e., an enclosed space, distance from epicenter and size tion injury, and ARDS in the PFC environment is first and
of explosion, etc.). It is important to be suspicious for sec- foremost a PFC problem. As good TCCC care was the founda-
ondary (shrapnel), tertiary (patient propelled into structures tion for the successful treatment of ALIs in the tactical setting,
or objects) and quaternary (inhalation trauma and toxin expo- good PFC basics are the foundation of these protocols.
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sure) blast injuries. In the case of positive pressure pulmonary
edema, the onset time of symptoms will indicate the severity of In order to most effectively manage a patient suffering from
the injury. Initial treatments should include patient positioning ALIs or ARDS, a SOF medic needs a PFC equipment load-
to optimize respiration, supplemental O if available, and a out that includes advanced vitals monitoring, an ISTAT or
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rapid evacuation to a higher level of care. In the severely injured equivalent for field labs, and a fully adjustable ventilator such
patient, early and aggressive airway management is required as the IMPACT (Soma Technology, https://www.somatech-
in addition to positive pressure ventilations. This should be nology.com/Ventilators/Impact-Univent-754.aspx). The PFC
accomplished ideally with a pediatric bag-valve mask (BVM), treatment protocol is designed as a continuation of that from
otherwise use an adult BVM equipped with a PEEP valve. TCCC. Treatment should follow the principle of least invasive
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The initial RR should be 12, the initial PEEP should be 5. to most invasive, with the provider “escalating force” based
Field SpO will be the primary diagnostic tool used to drive on the how patient’s condition and vital signs are trending.
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treatment, with the end goal being an SpO of 90–94%. Field Initial management should focus on patient positioning, sup-
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EtCO can also be used with a goal of 35–45mmHg. Increase plemental O , establishing multiple IV/IO access points, and
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the RR and the PEEP gradually until the patient is within the reaching out early for expert guidance via telemedicine. Pa-
90–94% SpO range. If the patient deteriorates and falls out of tient positioning is a key early intervention that can help de-
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tolerance, continue to increase both values to bring them back lay the onset of more severe symptoms, allowing more time
within range. Do not exceed an RR of 20 and a PEEP of 10. to organize evacuation and prepare advanced interventions.
If available broad-spectrum antibiotics should also be initiated Placing patients in different positions maximizes oxygenation
in accordance with specific unit protocols. in different parts of the lungs (Figure 4).
A unique consideration when dealing with BLI in the tactical
setting is the risk of encountering a closed tension pneumo-
thorax caused by the overpressure of the blast wave. The best
way to differentiate between the two injuries is to auscultate
for lung sounds. In BLI there will be abnormal lung sounds
throughout all lung fields. In a closed tension pneumothorax,
you will have absent lung sounds on the affected side. If un- FIGURE 4 Placing
able to auscultate for lung sounds, look for bilateral versus patients in different
positions maximizes
unilateral rise and fall of the chest. BLI will also have a slower oxygenation in different
progression in all but the most severe cases, which will be ac- parts of the lungs.
companied by frothy, blood-tinged sputum. When in doubt
always defer to treating for a tension pneumothorax since that
is the more immediate life threat.

Inhalation injury in a tactical environment is managed in much
the same way as positive pressure pulmonary edema. Apply
the principles of TCCC and use the MARCH algorithm to
conduct your initial assessment and treatments. Be suspicious Utilize patient assessments and SpO monitoring to find the
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of cutaneous burns in a patient with an inhalation injury and positions that allow for the greatest oxygenation of the pa-
vice versa. Where an inhalation injury has occurred second- tient and cycle between these positions. Change the patient’s
ary to a blast, be suspicious of potential blast injuries being position approximately every eight hours. If the patient does
present. In the case of an inhalation injury due to prolonged not tolerate the position they will need to be changed sooner
smoke exposure, be aware of the potential for cyanide and/ or they will become a non-responder in that position. Broad-
or CO poisoning. Treatment for a suspected inhalation injury spectrum antibiotics should also be started in accordance with
is identical to BLI. Initial treatments are still patient position- specific unit protocols, along with IV dexamethasone, with an
ing, supplemental O , and rapid evacuation. Be prepared to initial dose of 20mg/day for the first 5 days and then 10mg/
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aggressively manage the airway and provide positive pressure day until day 10.
ventilations using the same protocol as BLI.
If the patient continues to deteriorate, the SOF medic will
An important consideration is fluid resuscitation in a patient have to escalate to more invasive interventions. This deterio-
with inhalation injury and significant cutaneous burns. Studies ration will be marked by an increasing RR, heart rate (HR),
have shown that burn patients with an inhalation injury will blood pressure and dyspnea along with patient anxiety and
require more overall fluid volume than patients without inha- discomfort as they become both hypoxic and hypercapnic.
lation injury. Therefore, in the tactical setting, apply normal SpO , blood pH, and PaCO are the primary diagnostic val-
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fluid resuscitation protocols for burn patients with inhalation ues that will be used to drive treatment along with the pa-
injuries. However, it is vital to begin monitoring and titrating tient’s mental status. The Horowitz Index can also be used to
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