Page 102 - JSOM Summer 2024

common. While most SSTIs are managed on an outpatient
basis, if not recognized and treated appropriately, sepsis and BOX 3 Readily Available Sepsis and Critical Care Management
Resources
life-threatening shock can develop. Cellulitis and abscesses ac- Joint Trauma System (JTS) Clinical Practice Guidelines (CPG).
count for over two-thirds of all active-duty SSTI diagnoses and Most up to date CPGs available at: https://jts.health.mil/index.cfm/
most hospital admissions for SSTI. The most common site is PI_CPGs/cpgs or at https://deployedmedicine.com
the lower extremity (33.6%), followed by the upper extremity • Tactical Combat Casualty Care (TCCC) Guidelines
(28.3%), trunk (14.2%), other or unspecified location (12.4%), • Prolonged Casualty Care Guidelines
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and the head/face/neck region (11.5%). Lower extremity SSTI • Sepsis Management in Prolonged Field Care
are often missed, because caregivers do not examine the lower • Infection Prevention in Combat-related Injuries
legs, feet or between toes during initial physical examinations. • Documentation In Prolonged Field Care
• Airway Management in Prolonged Field Care
• Nursing Intervention in Prolonged Field Care
• Telemedicine Guidance in the Deployed Setting
BOX 2 Potential Causes of Sepsis
Head and neck infections Other Relevant Resources:
• Peritonsillar cellulitis and abscess • Evans L, Rhodes A, Alhazzani W, et al. Surviving Sepsis campaign:
• Submandibular abscess and Ludwig angina International guidelines for management of sepsis and septic
Pulmonary infections shock 2021. Crit Care Med. 2021;49(11):e1063–e1143.
• Bacterial pneumonia • Carr MJ, Maves RC. Infectious disease pearls for maritime surgical
• Coronavirus disease 2019 (COVID-19) teams. In: Tadlock MD, Hernandez AA, eds. Expeditionary
Surgery at Sea: A Practical Approach. Springer; 2023:267–285.
Gastrointestinal infections • Biberston JD, Darling JA, Tripp MS. Maritime prolonged casualty
• Appendicitis care. In: Tadlock MD, Hernandez AA, eds. Expeditionary Surgery
• Sigmoid diverticulitis at Sea: A Practical Approach. Springer; 2023:611–626.
• Cholecystitis • Burkholder T. Alone and unafraid: the independent duty corpsman
• Cholangitis at sea. In: Tadlock MD, Hernandez AA, eds. Expeditionary
Skin and soft tissue infections Surgery at Sea: A Practical Approach. Springer; 2023:173–188.
• Cellulitis
• Abscess
• Pilonidal abscess The patient in this scenario required vasopressor support for
• Perirectal/perianal abscess persistent low blood pressure related to septic shock, despite
• Necrotizing soft tissue infection appropriate crystalloid resuscitation. In this situation, Nor-
Urinary tract infection epinephrine is the first-line vasopressor recommended. Unfor-
• Cystitis tunately, only epinephrine is available on destroyers (in vials
• Pyelonephritis with a 1:1,000 concentration). Therefore, Role 1 maritime
Gynecologic infection caregivers must understand how to mix an epinephrine drip
• Bartholin abscess and estimate the μg/min being administered by calculating the
• Pelvic inflammatory disease (e.g., tubo-ovarian abscess)
drip rate (Table 2). Correctly mixing and administering a va-
sopressor drip by calculating the drip rate requires training
Most SSTIs are caused by Staphylococcus or Streptococcus before deployment. Box 1 lists other necessary procedures in
species, typically acquired when military members live and this scenario that also require specific training before being
work together in deployed or training environments. Risk performed in an austere environment.
factors for SSTI include crowded living conditions, infrequent
bathing and hand washing, trauma (including minor skin While vasopressors are routinely started through peripheral
abrasions), skin colonization, and environmental contamina- IVs in an emergency, central venous access is routinely obtained
tion, all common in the deployed shipboard environment. if prolonged vasopressor use is required. However, in the aus-
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The incidence of SSTI in the deployed maritime environment is tere setting, most Role 1 caregivers lack the supplies and the
not known. However, a 2011 study of 400 Sailors and Marines skillset to obtain central venous access. Therefore, peripheral
during a 3-week underway period found that 49.5% were col- antecubital access is acceptable. However, the access site MUST
onized with Staphylococcus aureus and 3.5% with methicillin- be inspected with every vital sign check for evidence of infiltra-
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resistant S. aureus (MRSA). For comparison, as many as 30% tion of the vasopressor into the surrounding tissues. Infiltration
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of the U.S. population in colonized with S. aureus and MRSA typically manifests as swelling, redness, or induration at the ve-
colonization rates of 1%–3% have been reported in different nous access sight; it can cause permanent damage to the vessel
industrialized countries. 32 or even compartment syndrome to the extremity.
Many potential causes of sepsis (Box 2) require surgical or In addition to norepinephrine, several medications, supplies,
procedural source control, which is typically not possible on and equipment recommended in this scenario are unavailable
Role 1 capable warships and submarines. However, superficial on U.S. Navy destroyers, cruisers, or submarines. These include
skin and soft tissue abscesses, pilonidal abscesses, and peri- ultrasound, electrocardiogram, three-lead cardiac monitor-
rectal abscesses may all be encountered in deployed environ- ing, nasogastric tubes, IV hydrocortisone, and subcutaneous
ments and Role 1 caregivers should be prepared to perform heparin. To prepare Independent Duty Corpsmen to perform
routine incision and drainage either to prevent the progression PCC during LSCO or routine Distributed Maritime Opera-
of infection to sepsis or for possible source control when rapid tions, we identified four changes to the Role 1 capable warship
MEDEVAC is not possible. Box 3 lists the key references used Authorized Medical Allowance List (AMAL) that should be
to develop this scenario for those interested in further reading; considered.
these are easily accessed electronically or via military treat-
ment facility libraries and should be readily available when First, it is hard to argue that norepinephrine or IV hydrocor-
deployed in the austere maritime environment. 3,4,7,10,20,21,33–37 tisone should be included on AMALs, given how infrequently

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