Page 3 - 2022 Ranger Medic Handbook

MEDICAL DIRECTION
Hemorrhage remains the number one cause of preventable death on the battlefield. Evaluate and treat each patient in
accordance with protocols. Ranger Medics must apply thought and cannot blindly follow algorithms. Since hemorrhage
accounts for approximately 90% of preventable battlefield death always consider and treat for hemorrhagic shock
when in doubt. Although Medics should follow the MARCH algorithm always ask yourself, “What is killing my patient
now?” Act on that question regardless of the algorithm if there is a clear cause. Patients may stop breathing because
of hemorrhage.
Treating hemorrhage remains a higher priority than airway control or breathing assistance.
Ranger Medics will always train and master the basics before pursuing more advanced skills, procedures, or techniques.
While these skills are care enhancing the basics of Tactical Combat Casualty Care (TCCC) will save the most lives on
the battlefield.

UPDATES IN THIS ISSUE
1. Refined wording and terminology of many sections to include the composition of Damage Control Resuscitation
Teams.
2. Included consideration for massive internal hemorrhage in addition to massive external hemorrhage in protocols.
3. Removed GCS as an airway assessment, added EtCO 2 range to airway protocol and consideration for second NPA,
added maintain O 2 saturation < 100%.
4. Refined wording in the Tourniquet Conversion Protocol.
5. Refined the Thoracic Trauma Management Protocol with focus to rapidly assess for and rule out tension pneumo-
thorax; for refractory shock, rapidly initiate blood product resuscitation and Tactical Damage Control Resuscitation
Protocol.
6. NCD for pneumothorax should only be inserted to full depth at anterior sites.
7. Added narrowed pulse pressure description to assist in identifying early shock in Tactical Damage Control Resus-
citation Protocol.
8. Refined wording in the head trauma and concussion protocols, authorized administration of 30mL 23.4% NS via
slow push IV/IO in impending herniation, but be prepared to lose IV.
9. Changed dressing type for abdominal trauma to a nonadherent and water impermeable dressing.
10. Adjusted seizure treatment doses to midazolam 5mg IV/IO q2–3 min/10mg IM q15 min or diazepam 5mg IV/IO
q5–10 min/10mg IM q15 min for 2 doses.
11. Refined severe pain management ketamine dosing to 0.3mg/kg rather than procedural sedation dosing and moder-
ate pain dosing with 600mg ibuprofen.
12. Adjusted Damage Control Resuscitation systolic BP goal to 90–100mmHg.
13. In the Crush Syndrome Management Protocol edited for a patient making urine, physiologic isotonic fluids (Plasma-
Lyte or Ringer's lactate) are the fluid of choice to prevent worsening acidosis and worsen hyperkalemia.
14. Shortened cellulitis antibiotic course to 7 days.
15. In the Determination of Death Protocol added, in traumatic arrest, consider and, as tactically feasible, conduct
bilateral finger thoracostomy and airway maneuver or advanced airway placement with reevaluation prior to dis-
continuing resuscitation.
16. Added prophylaxis and postexposure prophylaxis information in the Malaria Protocol.
17. Shortened Pneumonia antibiotic course to 5 days.
18. In the Rhabdomyolysis Protocol added, in a patient making urine, any isotonic fluid is acceptable (you do not need
to avoid potassium containing fluids if patient is making urine).
19. Updated sexually transmitted infection antibiotic dosing.
20. Refined Pharmacology standards to Proficient and Trained, Proficient, and Familiar.
21. Updated FDA pregnancy categories for medication and drug quick reference card.
22. Updated Medical Operations section with current doctrine and crisis response considerations.
23. Added blood containers to aid bag and ARFR packing list