Page 124 - 2022 Ranger Medic Handbook

Dental Pain
DEFINITION: Most common causes are deep decay, fractures of tooth crown/root, acute periapical (root end) abscesses, or
pericoronitis (pain associated with an impacted wisdom tooth).
S/Sx: Intermittent or continuous pain (usually intense), heat or cold sensitivity; visibly broken/cracked tooth; severe pain
on percussion; intraoral swelling/abscess; partially erupted wisdom tooth.
MANAGEMENT:
1. Treat per Pain Management Protocol. Consider application of clove oil–soaked gauze for pain relief.
2. If signs and symptoms of infection are present, administer amoxicillin/clavulanic acid 875mg PO bid for 7 days OR
ceftriaxone 1g IV/IM qd × 7 days OR if previous unavailable, then azithromycin 500mg PO initially followed by 250mg
PO qd × 4 days.
3. If gums appear swollen and red, encourage increased oral hygiene and warm saline rinses bid. Consider local or
SECTION 3 DISPOSITION: Evacuation usually not necessary. Routine evacuation if not responding to therapy or requiring IV antibiotics.
regional anesthesia if trained.

Determination of Death
DEFINITION: Immediate determination of death is appropriate in a trauma patient without pulse or respirations in the
setting of multiple casualties when resuscitative efforts would hinder the care of more viable patients. It is assumed that
personnel do not have access to ECG, or other monitoring equipment to evaluate heart rhythm, or deliver countershocks.
S/Sx: Obvious death – persons who, in addition to absence of respiration, cardiac activity and neurologic reflexes have
one or more of the following: decapitation; massive crushing and/or penetrating injury with evisceration of the heart,
lung, or brain; incineration; decomposition of body tissue; rigor mortis or post-mortem lividity.
MANAGEMENT:
1. In the setting of obvious death, resuscitative efforts should not be initiated.
2. If resuscitative efforts have been initiated, discontinuation should be considered: After 15 minutes (if the cause is un-
known or due to trauma) or after 30 minutes (when the cause is due to hypothermia, electrical injury, lightning strike,
cold water drowning, or other cause known to require a prolonged resuscitative effort) when: There is persistent
absence of pulse and respirations despite assuring airway and ventilation as well as administration of resuscitative
fluids and medications; no response to deep pain above or below the clavicles; absence of SpO 2 and EtCO 2 , from a
correctly placed endotracheal tube or alternative airway.
3. If there is any question as to the discontinuation of resuscitative efforts, continue ACLS/ALS treatment protocol and
then a medical officer should be contacted for guidance.
4. In traumatic arrest, consider and as tactically feasible, conduct bilateral finger thoracostomy and airway maneuver or
advanced airway placement with re-evaluation prior to discontinuing resuscitation.
DISPOSITION: Evacuation of the remains when tactically feasible. In the event of return of spontaneous circulation,
Urgent evacuation.
SPECIAL CONSIDERATIONS: Patients that are struck by lightning, have hypothermia, cold-water drowning, or intermit-
tent pulses may require extended cardiopulmonary resuscitation.

Electrocution
DEFINITION: Death or serious injury caused by electric shock, electric current passing through the body. Injury can occur
through both direct electrocution and from blast/blunt trauma injuries.
MANAGEMENT: Follow Tactical Trauma Assessment Protocol with additional key notes outlined in this Protocol. Light-
ning strikes deliver direct current (DC) electrocution and domestic electrocution is classically alternating current (AC).
Maximal injury due to DC is usually cardiac and respiratory arrest, and AC injury can cause ventricular fibrillation. Fixed
and dilated pupils are often due to transient autonomic disturbance, but be sure to rule out closed head injury first.
Rhabdomyolysis and compartment syndrome can develop. For lightning strike casualties conduct reverse triage as
apnea/asystole is commonly transient and can resolve with BLS/ACLS support until return of respirations and pulse.
DISPOSITION: Evacuate any patients with systemic symptoms to higher level of care.

110 SECTION 3 TACTICAL MEDICAL EMERGENCY PROTOCOLS (TMEPs) & SICK CALL