Page 19 - JSOM Summer 2022

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delivered as expeditiously as possible. A delay of 90 minutes CPG. A patient with 90% TBSA will unlikely tolerate
to whole blood resuscitation would likely result in potentially enteral resuscitation, but attempting enteral resuscitation
preventable deaths for many casualties with abdominopelvic in conjunction with IV fluids should be attempted us-
NCTH and hemorrhagic shock. 28,37 ing up to 300mL/hr down a nasogastric tube and closely
following residuals. A urinary catheter is necessary to
Casualty 4
Casualty 4 has had the bleeding from his head wound con- follow urine output. The USAISR Rule of 10s (and all
trolled and has received 2g of IV TXA for his significant the other burn resuscitation formulas) are just a start-
TBI. He remains conscious but confused and unable to fol- ing point for resuscitation. Hourly adjustments in fluids
low commands (GCS Motor Score of 5). Further evaluation administered, in accordance with the JTS CPG Burn Re-
reveals that he has no evidence of other injuries and has a suscitation Flowsheet, are necessary to avoid under and
strong radial pulse. His pupils are round and equal in size at over resuscitation, both of which can be lethal (personal
5 mm bilaterally. There are no lateralizing signs noted. This communication – COL Jennifer Gurney, 7 Nov 2021).
individual should be monitored closely for deterioration of Casualty 6
his mental status that might indicate worsening intracranial This casualty has already had his suspected right-sided ten-
hemorrhage. He should be monitored with pulse oximetry and sion pneumothorax decompressed by needle thoracostomy,
supplemental oxygen given as necessary to maintain his hemo- with an improvement in his oxygen saturation from 76% to
globin oxygen saturation at 90% or higher. His C-collar and 92%. Needle decompression (NDC) is a temporizing measure
spinal protection measures should be continued and the head in treating tension pneumothorax, but one that has proven
of his stretcher should be elevated 30 degrees. very successful since the US Military’s adoption of 14- or
10-gauge, 3.25-inch needles for this procedure. There is con-
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Casualty 5 cern, however, that a tension pneumothorax treated with only
This casualty has burns of life-threatening severity, including NDC may recur in flight during TACEVAC. Simple (finger)
inhalation injury. She has had a cricothyroidotomy success- thoracostomy (ST) is a more reliable method of chest decom-
fully performed and her oxygen saturation has improved to pression and may be used an alternative to needle decompres-
95%. She needs IV access, ketamine for pain, and initiation of sion if the IDC is trained in this procedure, but this procedure
fluid resuscitation with LR administered in accordance with is also a temporizing measure, not definitive treatment, for
the TCCC Guidelines (for a 60-kg woman, the USAISR Rule a tension pneumothorax. Some clinicians recommend that a
of Ten would call for % TBSA of 90% × 10mL/hr = 900mL/ chest tube be inserted before helicopter transport of casualties
hr). She needs a Foley catheter placed to monitor her response with suspected pneumothorax. (See remarks in the Discussion
to fluid resuscitation.
section.) Whichever intervention is chosen, the casualty should
Since her burns are extensive and include circumferential burns be monitored carefully during helicopter transport and further
of all 4 extremities and her torso, her distal extremity pulses interventions undertaken if needed.
should be monitored periodically to ensure that a full-thick-
ness burn eschar is not producing a tourniquet-like effect on The enhanced primary blast wave to which this casualty was
the extremities with resulting distal ischemia. If compromised exposed also caused him to suffer a CAGE secondary to pul-
blood flow is noted, escharotomies should be performed using monary barotrauma. He needs immediate surface oxygen at
ketamine sedation. Likewise, she should be monitored for re- the highest possible inspired fraction. Inspired oxygen frac-
spiratory insufficiency (decreased tidal volumes and increased tions of 90–95% can be achieved by using a reservoir mask
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peak inspiratory pressures) and torso escharotomies should be and an oxygen flow rate of 15L/minute. Note that the goal
performed if respiratory compromise develops. Escharotomies of the supplemental oxygen use in this case is not simply to re-
are not part of current TCCC training, but could be performed duce ischemia in the injured brain tissue, but also to maximize
by the Emergency Medicine physician transported to the ca- the alveolar oxygen concentration in order to accelerate the
sualty ship from the LHA on the first evacuation helicopter. removal of nitrogen dissolved the blood. Hemoglobin oxygen
saturation is not the primary metric here. Prehospital oxygen
She should not have any cold compresses applied, but rather delivery should be followed by hyperbaric oxygen (HBO ) on
2
should have warmed blankets placed over her to prevent hy- a Treatment Table 6 or 6A as specified in Vol 5 of the US Navy
pothermia. There is no need to apply antibiotic creams or oint- Diving Manual. 40
ments at this stage of care.
The ability to provide 100% FIO may be limited by the ability
2
The following additional comments on Casualty 5 were pro- of the delivery system to match the patient’s minute ventila-
vided by COL Jennifer Gurney, a Surgeon at the US Army In- tion. Reservoir non-rebreathing masks should not be taped to
stitute of Surgical Research Burn Center: the face and the ports should remain uncovered.
Burn patients with >40% deep partial thickness or full Casualty 6 is also at risk for bowel or abdominal solid or-
thickness burns will require intubation for pain control gan injury from his gastrointestinal barotrauma and needs to
and secondary to edema causing airway compromise. be evaluated for those two possibilities by the surgeon on the
Burn depth can be challenging to determine initially. Her LHA prior to transport to the chamber. He should also receive
oxygen saturation is 95%, she is mentating and com- parenteral ertapenem as prophylaxis because of the potential
plaining of pain. So, while a 90% burn is almost always for bowel injury.
expectant in a multiple casualty incident, there is not Casualty 7
enough information to determine that this casualty is ex- This casualty’s abdominal pain is indicative of presumed gas-
pectant. She needs intubation, IV access, Foley and naso- trointestinal barotrauma from the underwater blast. This in-
gastric catheters placed, ketamine and narcotics for pain, jury pattern has a high probability of bowel rupture. 41,42 There
and initiation of IV and enteral fluid resuscitation using is also the potential for barotraumatic injury to solid organs
Lactated Ringers and ORS according to the JTS burn

TCCC Maritime Scenario: Shipboard Missile Strike | 17