Page 32 - PJ MED OPS Handbook 8th Ed

Detailed Aspects of Reassessments and Treatment
1. Airway Management
a. Re-verify airway patency and security in a consistent manner.
b. Suction: Consider periodic low pressure suctioning of the oropharynx and endotracheal tube.
c. Pulmonary toilet: Consider periodic gentle saline flushes (2mL) to clear mucus/blood from
ET tube. Can also drag a Foley with partial inflation from the end of the ET tube to drag out
mucus or clots.
d. Local wound care at cricothyroidotomy site if applicable.
2. Respiratory Management
a. Place a chest tube if patient required more than one needle decompression, or has chest
trauma with decreased breath sounds and signs of hypotension.
b. Apply low pressure suction to chest tube if available. Alternatively, you may attach a one-way
valve and gravity feed into a collection bag.
c. Administer oxygen to maintain O2 saturation >90%.
d. If patient is being ventilated by BVM, maintain strict bagging cycles (1 breath every 6 seconds)
and a tidal volume of approximately 500mL (bag one handed, not a full bag of volume) to al-
low for complete exhalation and avoid stacking breaths. Use the EMMA to guide you further.
e. Use pulse oximetry and capnography to guide ventilator management.
f. Use the DOPE acronym to trouble shoot tube, vent or capnography problems:
i) Displacement: verify tube placement
ii) Obstruction: use suction and flushes, replace tube if necessary
ii) Pneumothorax: use stethoscope, if prior needle decompressions, place chest tube
iv) Equipment: check all equipment, lines, connections, power sources, etc.
g. Use sedation in casualties requiring prolonged intubation/ventilation. If you use sedation
adequately, you should not have to use paralytics.
3. Flail Chest Management
a. Monitor for developing hypoxia secondary to pulmonary contusions.
b. Casualty may require positive pressure ventilation. RR >30, O2 sat <90%.
c. Ensure adequate analgesia.
d. These casualties frequently fatigue and require intubation/definitive airway/ventilation.
4. Fluid Management
a. Conscious: Instruct casualty to drink clear liquids up to 200mL/hr; consider oral electrolyte
supplementation if available (or add a little salt and sugar).
b. Unconscious: Insert Foley catheter and titrate IV/IO/NG crystalloid fluids to maintain mini-
mum urine output of 30–50mL/hr.
i) Clean water ± electrolyte solution may be utilized in lieu of crystalloid for NG infusion.
Bolus 125mL over 5–15 minutes every hour.
ii) If no NG tube, administer fluids by rectum (PR). Maximum PR fluid infusion rate for stable
patients is 200mL/hr.
iii) Maximum PR fluid infusion rate for volume-depleted patients is 500mL/hr.
iv) Notes courtesy of CAN-SOF: NG/OG:
1) Be sure to re-check tube placement (auscultate over epigastrium and aspirate NG for
gastric contents) prior to starting feeds.
2) Keep head of bed elevated >30° during feeds.
3) Tube feed electrolyte solution: (25mL/hr via OG/NG OR 50–100mL q4hr)

30 n Pararescue Medical Operations Handbook / 8th Edition