Page 20 - JSOM Summer 2022

and intra-abdominal hemorrhage, although this type of injury A – Urgent Evacuation within 2 hours
43
is uncommon in gastrointestinal barotrauma. He should re- B – Priority Evacuation within 4 hours
ceive parenteral ertapenem, ketamine analgesia, and emergent C – Routine Evacuation within 24 hours
evacuation for exploratory laparotomy on the LHA. He is not The CoTCCC, at the request of then-Deployed JTS Direc-
presently in shock, but he should be monitored closely for de- tor Colonel Stacy Shackelford, provided input about which
velopment of that condition. Note that gastrointestinal baro- injury patterns and physiologic status conditions should be
traumatic injury does not require HBO therapy.
2 included in these various categories. Those recommendations
Casualty 8 can be found in the Ninth Edition (Military) of the Prehospital
This individual has an oxygen saturation of 72% without sup- Trauma Life Support (PHTLS) Textbook. 47
plemental oxygen. There is no subcutaneous emphysema. His
breath sounds are present but diminished bilaterally. He needs Assume that there are two MH-60S Seahawk helicopters trans-
100% oxygen (15L/min via reservoir facemask initially) for porting patients to the LHA. Each aircraft can transport two
his presumed bilateral underwater blast-induced pulmonary litter patients. Nine litter casualties would therefore require
contusions; his target oxygen saturation is 90% or greater. two round trips by each of the two evacuat ing helicopters, as
well as a possible fifth flight for the final patient. The prece-
He could possibly have a developing tension pneumothorax, dence for evacuation is shown below with the casualties listed
but since his breath sounds are equally diminished bilaterally, in order of their priority. The round trip to the LHA is 90 min-
44
the more likely diagnosis is bilateral pulmonary contusions. utes with approximately 15 minutes to unload the aircraft at
If his oxygen saturation continues to decrease, however, or if the LHA. The first four casualties can be transported quickly
he develops shock, bilateral needle decompression might also once the helicopters arrive, but he next four casualties will be
be considered. delayed approximately 2 additional hours while awaiting the
return of the aircraft.
As with gastrointestinal barotrauma — for which he is also at
risk — blast-induced pulmonary contusion does not require The casualties in this scenario, their recommended evacuation
HBO therapy, but, as with Casualties 6 and 7, since he is at categories, and their order of evacuation precedence are:
2
risk for bowel rupture, he should receive parenteral ertapenem.
CAT A – Urgent
Casualty 9 (Denotes a Critical, Life-Threatening Injury)
The casualty’s oxygen saturation improves to 81% on high-
flow oxygen, although he intermittently removes his mask to First Aircraft
cough and has several episodes of sea water emesis. Since he First Priority – Casualty 3 – Pelvic and femur fractures with
is conscious, he should be placed in a sitting position to avoid hemorrhagic shock. She needs emergent surgery for her ab-
23
aspiration in the event of further emesis. His lungs are found dominopelvic NCTH.
to have rhonchi bilaterally. Second Priority – Casualty 6 – Pulmonary barotrauma, CAGE,
Casualty 9 was not in the water when the underwater blast treated tension pneumothorax. Needs a chest tube and emer-
occurred and is therefore not at risk for the severe physiologic gent transport to a hyperbaric treatment facility for HBO 2
derangements that an enhanced underwater blast wave can treatment.
produce. He has, however, experienced a drowning incident Second Aircraft
and is at risk of worsening hypoxemia due to the combined ef- Third Priority – Casualty 1 – Extremity hemorrhage con-
fect of sea water in his lungs, the disruption of his pulmonary trolled by a tourniquet – will likely need a vascular shunting
surfactant, decreased lung compliance, increased capillary- procedure to restore blood flow to the injured leg and possibly
alveolar permeability, an increase in right-to-left shunting a fasciotomy. This casualty will likely be the second patient to
in the lungs, and atelectasis. The primary concerns in this be taken to surgery.
45
casualty are respiratory failure and potentially lethal cardiac
arrhythmias caused by hypoxemia. 45,46 He needs continued Fourth Priority – Casualty 7 – Gastrointestinal barotrauma
oxygen via reservoir mask at 15 liters/min initially with sub- with suspected bowel rupture. Needs an exploratory laparot-
sequent titration based on close pulse oximetry monitoring. omy, but this does not entail the time criticality of controlling
The goal for arterial oxygen saturation per the current Joint Casualty 3’s NCTH or of restoring blood flow to the casualty
Trauma System CPG is 92–96%. 23 with the lower extremity vascular injury.
This casualty also needs to have IV or IO access established, Third Aircraft
but fluid administration should be carried out judiciously, with Fifth Priority – Casualty 8 – Pulmonary barotrauma with sus-
the understanding that drowning victims are at high risk for pected pulmonary contusions and respiratory distress.
pulmonary edema. Over-resuscitation with crystalloid fluids Sixth Priority – Casualty 9 – Drowning casualty with respira-
will increase this risk. The Heimlich Maneuver is not recom- tory distress.
mended for drowning victims because of the risk of aspiration
of sea water regurgitated from the stomach. Fourth Aircraft
Seventh Priority – Casualty 2 – 50% TBSA burns
Priorities for Evacuation to the Eighth Priority – Casualty 4 – Significant TBI
Casualty Receiving and Treatment Ship
During the recent conflicts in Afghanistan and Iraq, medics re- Fifth Aircraft
questing casualty evacuations prioritized their casualties using Ninth Priority – Casualty 5 – 90% TBSA burns
the NATO doctrinal evacuation categorization system. In this
classification system, there are three categories: CAT B – Priority (Serious Injury)
None

18 | JSOM Volume 22, Edition 2 / Summer 2022