Special Operations Command Central

Primary Survey consists of identification and simultaneous management of life threatening conditions.

• Airway maintenance with cervical spine (C-spine) control
• Breathing and ventilation
• Circulation with hemorrhage control
• Disability; neurologic status
• Exposure/environmental control (completely undress the patient, but prevent hypothermia)

• Oxygenation and ventilation are reassessed
• Shock management is initiated and hemorrhage control is re-evaluated
• Volume replacement with crystalloid/blood (if needed) is begun
• Foley and nasogastric tube are placed, if not contraindicated

Secondary Survey does not begin until the primary survey (ABCDE) has been completed and the resuscitation phase has begun. The secondary survey is a head-to-toe evaluation of the casualty. It utilizes the look, listen, and feel techniques in a systematic total body/system evaluation (tubes and fingers in every orifice).

I. Airway and C-spine control. The upper airway is assessed to determine patency. Maneuvers to establish a patent airway with the chin lift or jaw thrust must be aware of the possibility of a C-spine injury. A C-spine injury should be assumed in all patients, especially those with injuries above the clavicle and patients suffering from blast trauma.

A. The most important question to ask a trauma patient is "How are you"? No response implies an altered level of consciousness. Positive, appropriate verbal response indicates a patent airway, intact ventilation and adequate brain perfusion.

B. Maintain an intact airway, protect the airway in jeopardy and provide an airway when none is available. These principles must be applied assuming that a C-spine injury is present with:

1. Chin lift is accomplished with the fingers on one hand placed under the mandible, which is then gently lifted upward to bring the chin anterior. The thumb of the same hand lightly depresses the lower lip to open the mouth. The thumb may also be placed behind the lower incisors and, simultaneously, the chin gently lifted.

2. Grasping the angles of the lower jaw, one hand on each side, and displacing the mandible forward performs jaw thrust maneuver.

The artificial airway must not push the tongue backward and block, rather than clear, the airway. This device must be not be used in the conscious patient because it may induce gagging, vomiting and aspiration.

b. The alternative technique is to insert the oral airway upside-down, so its concavity is directed upward, until the soft palate is encountered. At this point, the airway is rotated 180 degrees, the concavity is directed caudad, and the airway is slipped into place over the tongue. This method should not be used for children, because the rotation of the airway may damage teeth.

a. Inserted in one nostril and passes straight posteriorly and gently into the posterior oropharynx.

1) The nasopharyngeal airway is preferred to the oropharyngeal airway in the

responsive patients because it is better tolerated and less likely to induce vomiting.

1. It should be well lubricated, then inserted into the nostril that appears to be unobstructed.

1. If obstruction is encountered during introduction of the airway, stop and try the other nostril.
2. If the tip of the nasopharyngeal tube is visible in the posterior oropharynx, it may provide safe passage of a nasogastric tube in the patient with facial fractures.

5. Orotracheal intubation is for the unconscious patient who has sustained blunt trauma and the need for definitive airway is anticipated. The procedure for placement is:

a. Assure that adequate ventilation and oxygenation are in progress.

b. Inflate the cuff of the endotracheal tube to establish that the balloon does not leak, then deflate the cuff.

c. Connect the laryngoscope blade to the handle, and check the bulb for brightness.

d. Have an assistant manually immobilize the head and neck. The patient’s neck must not be hyperextended or hyperflexed during this procedure.

e. Hold the laryngoscope in the left hand.

f. Insert the laryngoscope into the right side of the patient’s mouth, displacing the tongue to the left and lift the jaw anteriorly.

g. Visually examine the epiglottis and then the vocal cords.

h. Gently insert the endotracheal tube the trachea without applying pressure on the teeth or oral tissues.

i. Inflate the cuff with enough air to provide an adequate seal. Do not overinflate the cuff.

j. Check the placement of the endotracheal tube by bag-valve-to-tube ventilation.

k. Visually observe lung expansion with ventilation.

l. Auscultate the chest and abdomen with a stethoscope to ascertain tube position.

m. Secure the tube. If the patient is moved, the tube placement must be reassessed.

6. Nasotracheal intubation or blind nasotracheal intubation is indicated for the conscious or breathing unconscious patient and is contraindicated in the apneic patient and whenever severe midface fractures or suspicion of basilar skull fracture exist. The procedures for a nasotracheal intubation are:

a. If a cervical spine fracture is suspected, leave the cervical collar in place to assist in maintaining immobilization of the neck.

b. Assure that adequate ventilation is in progress.

c. Inflate the cuff of the endotracheal tube to ascertain that the balloon does not leak, then deflate the cuff.

d. If the patient is conscious, spray the nasal passage with an anesthetic and vasoconstrictor to anesthetize and constrict the mucosa. If the patient is unconscious, it is adequate to spray the nasal passage only with a vasoconstrictor.

e. Have an assistant maintain manual immobilization of the head and neck.

f. Lubricate the nasotracheal tube with a local anesthetic jelly and insert tube into the nostril.

g. Guide the tube slowly but firmly into the nasal passage, going up for the nostril and then directly posterior and down into the nasopharynx. The curve of the tube should be aligned to facilitate passage along this curved course.

h. Once the tube has entered the pharynx, listen through the tube until the sound of the moving airflow emanating form the endotracheal tube. Advance the tube until the sound of the moving air is maximal, suggesting location of the tip at the opening of trachea. While listening to air movement, determine the point of inhalation and advance the tube quickly. If tube placement is unsuccessful repeat the procedure by applying gentle pressure on the thyroid cartilage. Remember to intermittently ventilate the patient.

i. If an endotracheal stylet is utilized, bend the lower end of the tube and stylet (approximately the last one-fourth) to a near 90^o angle. As the tube is inserted, the end of the tube should be point to the ipsilateral ear. Be sure that the stylet is recessed approximately ½ inch from the end of the tube to prevent trauma during insertion. Gently, yet firmly, guide the tube into the pharynx, and through the glottis and vocal cords. Continue to advance the tube with gentle pressure as you withdraw the stylet.

1. Inflate the cuff with enough air to provide an adequate seal. Avoid overinflation.
2. Check the placement of the endotracheal tube by bag-valve-to-tube ventilation.
3. Visually observe lung expansion with ventilation.
4. Auscultate the chest and abdomen with a stethoscope to ascertain tube position.
5. Secure the tube. If the patient is moved, the tube placement should be reassessed.
6. If endotracheal intubation is not accomplished within 30 seconds or in time required to hold your breath before exhaling, discontinue attempts, ventilate the patient, and try again.

7. Surgical cricothyroidotomy is indicated when there is an inability to intubate the trachea or a contraindication to intubation (severe maxillofacial injuries or larynx fracture). Performing a surgical cricothyroidotomy is accomplished by:

a. Place the patient in a supine position with the neck in a neutral position. Palpate the thyroid notch, cricothyroid interval, and the sternal notch for orientation. Assemble the necessary equipment.

b. Surgically prepare and anesthetize the area locally, if the patient is conscious.

c. Stabilize the thyroid cartilage with the left hand.

d. Make a transverse or longitudinal skin incision over the cricothyroid membrane.

Carefully incise through the membrane.

e. Insert the scalpel handle into the incision and rotate it 90^o to open the airway. A hemostat also may be used instead of the scalpel handle.

f. Insert an appropriately sized, cuffed endotracheal tube into the cricothryoid membrane incision, directing the tube distally into the trachea.

g. Inflate the cuff and ventilate the patient.

h. Observe lung inflations and auscultate the chest for adequate ventilation.

i. Secure the endotracheal tube to the patient to prevent dislodging.

II. Breathing- Expose the patient’s chest and evaluate breathing. Assess respiratory movement and quality of respiration by observing, palpating, and listening. The signs of chest injury or hypoxia that are particularly important and often subtle include an increased rate of breathing and a change in the breathing pattern, especially toward progressively more shallow respirations. Cyanosis is a late sign of hypoxia in the trauma patient. The traumatic conditions that most often compromise ventilation are:

A. Tension pneumothorax develops when a "one-way-valve" air leaks occurs either from the lung or through the chest wall. Air is forced into the thoracic cavity without any means of escape, completely collapsing the affected lung. The mediastinum and trachea are displaced to the opposite lung. A tension pneumothorax requires immediate decompression and is managed initially by rapidly inserting a needle into the second intercostal space in the midclavicular line of the affected hemi-thorax.

B. Open pneumothorax (Sucking Chest Wound) is a large defect of the chest wall, which remains open, resulting in an open pneumothorax or sucking chest wound. Equilibration between intrathoracic pressure and atmospheric pressure is immediate. If the opening in the chest wall is approximately 2/3 the diameter of the trachea, air passes preferentially through the chest defect with each respiratory effort, because air tends to follow the path of least resistance through the large chest-wall defect. Manage an open pneumothorax by promptly closing the defect with a sterile occlusive dressing, large enough to overlap the wound’s edges, and taped securely on three sides. Taping the occlusive dressing on three sides provides a flutter-type valve effect. As the patient breathes in, the dressing is occlusively sucked over the wound, preventing air from entering. When the patient exhales, the open end of the dressing allows air to escape. A chest tube should be placed remote from the wound as soon as possible. Securely taping all edges of the dressing can cause air to accumulate in the thoracic cavity resulting in a tension pneumothorax unless a chest tube is in place. Any occlusive dressing (plastic wrap, petrolatum gauze, etc.) may be used as a stopgap so rapid assessment can continue.

Chest tube insertion:

1. Determine the insertion site; usually the nipple levels (5^th intercostal space) anterior to the midaxillary line on the affected side. A second chest tube may be needed for a hemothorax or especially large pneumothorax.

2. Make a 2-3 cm transverse (horizontal) incision at the predetermined site and blunt dissect through the subcutaneous tissues, just over the top of the rib (nerves and arteries run inferior to ribs).

3. Puncture the pariental pleura with the tip of a clamp and put a gloved finger into the incision to avoid injury to other organs and to clear any adhesions or clots.

4. Clamp the "suction" end of the thoracostomy tube (minimum #38 French in the adult) and advanced the "drainage" end of the thoracostomy tube into the pleural space to the desired length.

5. Look for "fogging" of the chest tube with expiration or listen for air movement.

6. Connect the "suction" end of the thoracostomy tube to the heimlich valve.

7. Suture the tube in place.

3. Massive hemothorax results from a rapid accumulation of more than 1500 ml of blood in the chest cavity. A penetrating wound that disrupts the systemic or hilar vessels most commonly causes it. It may also be the result of blunt trauma. The blood loss is complicated by hypoxia. The neck veins may be flat secondary to severe hypovolemia or may be distended because of the mechanical effects of intrathoracic blood. This condition is discovered when shock is associated with the absence of breath sounds and/or dullness to percussion on one side of the chest. This condition is managed by large-caliber intravenous lines with rapid crystalloid infusion and a single chest tube (#38 French) is inserted at the nipple level, anterior to the midaxillary line. If 1500 ml is immediately evacuated, it is highly likely that the patient will require an early thoracostomy.
4. Flail chest occurs when a segment of the chest wall does not have bony continuity with the rest of the thoracic cage. This condition usually results from trauma associated with multiple rib fractures. The presence of a flail chest segment results in severe disruption of normal chest wall movement. If the injury to the underlying lung is significant, serous hypoxia may result. The major difficulty in flail chest stems from the injury to the underlying lung. Although chest wall instability leads to paradoxical motion of the chest wall with inspiration and expiration, this defect alone does not cause hypoxia. Associated pain with restricted chest wall movement and underlying lung injury contributes to the patient’s hypoxia. The definitive treatment is to re-expand the lung, ensure oxygenation as completely as possible, administer fluids judiciously, and provide analgesia to improve ventilation.

   E. Cardiac Tamponade most commonly results from penetrating injuries. Blunt injury also may cause the pericardium to fill with blood from the heart, great vessels, or pericardial vessels. The human pericardium sac is a fixed fibrous structure, and only a relatively small amount of blood required to restricted cardiac activity and interfere with cardiac filling. Removal of small amounts of blood or fluid, often as little as 15 ml to 20 ml, by pericardiocentesis may result in immediate hemodynamic improvement. The classic Beck’s triad consist of venous pressure elevation, decline in arterial pressure, and muffled heart tones. Pericardiocentesis is indicated for patients who do not respond to the usual measures of resuscitation for hemorrhagic shock and who have the potential for cardiac tamponade.

   The procedure for a pericardiocentesis is:

   1. Using a #16 or #18 gauge, 6 inch (15 cm) or longer over-the-needle catheter, attach a 35-ml empty syringe with a three-way stopcock.

   2. Puncture the skin 1 to 2 cm inferior to the left of the xypho-chondral junction, at a 45^o angle to the skin.

   3. Carefully advance the needle cephalad and aim toward the tip of the left scapula.

   4. When the needle-tip enters the blood filled pericardial sac, withdraw as much nonclotted blood as possible.

    

   5. After inspiration is completed, remove the syringe, and attach a three-way stopcock, leaving the stopcock closed. Secure the catheter in place.

   6. Should the cardiac tamponade symptoms persist, the stopcock may be opened and the pericardial sac reaspirated. The plastic pericardiocentesis needle can be sutured or taped in place and covered with a small dressing to allow for continued decompression en route to surgery or transfer.

    

    

   III. Circulation

   1. Cardiac output; a rapid assessment can be obtained from:

   1. Pulse- assess:

   4. a. Quality.
   5. b. Rate.
   6. c. Regularity.

   2. Site of palpable pulse is related to systolic blood pressure:

   a. Radial > 80.

   7. b. Femoral > 70.
   8. c. Carotid > 60.

   B. Skin color.

   C. Capillary refill- test on hypothenar (thumb or toenail bed), color should return in two

   seconds.

   D. Bleeding.

   9. 1. Identify exsanguination hemorrhage and control it with direct pressure on the wound.
   10. 2. Pneumatic splints and MAST suits are helpful.
   11. 3. Major intra-thoracic and intra-abdominal bleeding requires rapid operative repair.
   12. 4. The standard individual dressing, when completely soaked, holds less than 250 ml of blood.

    

   IV. Disability/brief neurologic check:

   1. AVPU to determine level of consciousness:
   1. Alert
   2. Vocal stimuli response
   3. Painful stimuli response
   4. Unresponsive

   B. Altered levels of consciousness, TIPPS and the vowels (AEIOU):

   Trauma                  Alcohol

   Infection                Epilepsy

   Psych                      Insulin

   Poison                    Opiates

   Shock                     Urea/metabolic

   C. Pupillary size and reaction.

   D. More detailed evaluation is done during the secondary survey.

   V. Exposure/Environmental control:

   A. Patient should be completely undressed to facilitate a through examination and assessment

   of the patient (cutting clothing in accordance with [IAW] pages 38-39).

   B. Iatrogenic Hypothermia.

   1. It is imperative to cover and protect the patient from becoming hypothermic.

   2. IV fluids must be warmed before administering to the patient if environmental

   conditions are cold/wet (see page 23).

   Resuscitation Phase

   I. After the primary survey is completed, and especially after an adequate airway has been established, the resuscitation phase begins. Hypovolemia and shock (in trauma) is almost always due to blood loss. Access to the circulation for crystalloid therapy or blood resuscitation is mandatory.

   A. IV’s locations order of preference: Forearm/antecubital, Saphenous, Femoral, Jugular and then the Subclavian.

   B. Crystalloid resuscitation is accomplished utilizing isotonic electrolyte solutions is used for initial resuscitation. This type of fluid provides transient intravascular expansion and further stabilizes the vascular volume by replacing accompanying fluid losses into the interstitial spaces. Ringer’s lactate solution is the initial fluid of choice. Normal saline is the second choice.

   1. Although normal saline is a satisfactory replacement fluid in the volumes administered to injured patients, it has the potential to cause hypercholoremic acidosis.  This potential is enhanced if renal function is impaired.
   2. An initial fluid bolus is given as rapidly as possible. Only normal saline can be used in IV lines used for blood.  The usual dose initial infusion is two liters for an adult and 20 cc/kg for a pediatric patient.
   3. The patient’s response is observed during this initial fluid administration; further therapeutic and diagnostic decisions are based on this response. The amount of fluid and blood required for resuscitation is difficult to predict on initial evaluation of the patient. A rough guideline for the total amount of crystalloid volume acutely required is to replace each one milliliter of blood loss with three milliliters of crystalloid fluid, thus allowing for restitution of plasma volume lost into the interstitial and intercellular spaces.

       

       

       

       

      4. Patient’s response to initial fluid resuscitation is the key to determining subsequent therapy.

       

      a. Rapid responses the patient responds and remains stable as fluids are slowed indicates a Class I or less hemorrhages without ongoing losses; no furthers fluid bolus or blood required, but continue with maintenance IV fluid.

      b. Transient response is an initial response but subsequent deterioration indicates a Class II-III hemorrhage and on-going losses; continued fluid administration and initiation of blood transfusion are indicated.

      c. Minimal or no response indicates a Class IV hemorrhage with or without ongoing loss; rapid blood administration and surgical intervention are needed; also consider error in diagnosis (tension pneumothorax, peri-cardial tamponade, or cardiogenic shock).

      Estimated fluid and blood requirements in shock

      	Class I	Class II	Class III	Class IV
      Blood loss	< 750 cc	750-1500 cc	1500-2000 cc	> 2000 cc
      Blood loss in %	15% or <	15-30%	30-40%	> 40%
      Pulse rate	60-100	> 100	> 120	> 140
      Blood pressure	Normal	Normal	Decreased	Decreased
      Pulse pressure	Normal or increased	Decreased	Decreased	Decreased
      Capillary blanch	Normal	Abnormal	Abnormal	Abnormal
      Respiratory rate	14-20	20-30	30-40	> 35
      Urine output (ml/hr)	30 ml or <	20-30 ml	5-15 ml	Negligible
      Mental Status	Slightly anxious	Mildly anxious	Anxious/ confused	Confused/ lethargic
      Fluid replacement	Crystalloid	Crystalloid	Crystalloid & blood	Crystalloid & blood

      • Pulse pressure is the difference between the systolic and diastolic pressure. A decreased pulse pressure is primarily related to a rise in the diastolic component, because of an elevation in catecholamines, which increases peripheral resistance. A decreased pulse pressure may indicate either shock or cardiac tamponade.
      • 3:1 Rule directs that for every milliliter of blood loss at least 3 milliliter of crystalloid replacement should be given.
      • Shock, always remember the three P’s

      Pipes (blood vessels including the major arteries)

      Pump (the heart)

      Propellant (the circulating blood volume)

      • If no head injury then lift legs, lower head to help profuse the brain for hypotension.
      • If head injury then lower legs, lift head, hyperventilate to decrease perfusion.

      II. Military Anti-Shock Trousers (MAST)

      A. Mechanism of action is translocation of blood from the lower extremities, increased peripheral vascular resistance, increased myocardial afterload; MAST can raise blood pressure but is not a substitute for and should not delay volume replacement. Properly placed MAST can return two units of blood (one unit of blood is equal to 500 ml) to the cardiovascular system.

      B. Indications to utilize MAST are:

      1. Pelvic fractures for splinting and hemorrhage control.
      2. Soft tissue hemorrhage (tamponade).
      3. Leg fractures for stabilization.
      4. Stabilizing circulation for transportation.
      5. Maintaining upper torso perfusion when IV’s or volume replacement is inadequate.

      C. Contraindications to utilizing MAST (first three are absolute) are:

      1. Pulmonary edema.
      2. Circulatory instability due to myocardial dysfunction.
      3. Diaphragmatic rupture.
      4. Intrathoracic bleeding.
      5. Head injuries.
      4. Use:
      1. Remove only after shock state is reversed; deflate gradually with abdominal

      compartment first, then each leg sequentially; if blood pressure falls > five mmHG, reinflate and increase volume resuscitation.

      2. Leave in place once deflated until removed by a physician or physician assistant.

      III. Vital signs are taken every 15-20 minutes.

      A. Rectal temperature at 99.6⁰ Fahrenheit at "+ or – 1^o Fahrenheit".

      1. Mild hypothermia is between 90-95⁰ Fahrenheit (32-35⁰ Celsius).

      2. Moderate hypothermia is between 86-90⁰ Fahrenheit (30-32⁰ Celsius).

      3. Severe hypothermia is below 86⁰ Fahrenheit (< 30⁰ Celsius).

      4. A fever is when the rectal temperature is greater than 100.9⁰ Fahrenheit.

      4. 5. Hyperthermia is > 105.8⁰ Fahrenheit or 41⁰ Celsius.
      5. 6. Oral and axillary temperatures are useless.

      B. Pulse should be between 60-100 beats per minute; check for:

      1. Tachycardia is > 100.

      2. Bradycardia < 60.

      3. Arrhythmias.

      6. C. Respiration should be 12-20 per minute. If > 20, look at the pulmonary system.
      7. D. Blood pressure, if systolic is < 90 mm HG this indicates shock.

       

      Pulse Oximetry

      Ranges	Prehospital care
      Normal is 95-99%
      Mild hypoxia is 91-94%	Give oxygen
      Moderate hypoxia is 86-90%	Give 100% oxygen
      Severe hypoxia is < 85%	100% oxygen, ventilate

      Cold extremities or hypothermia may cause falsely low SpO2 readings.

      Anemia or carbon monoxide poisoning may cause falsely high SpO2 readings.

      If in doubt, give oxygen in spite of a normal SpO_2.

       

       

      

      Oxygen Tank Capacities

      Secondary Survey

      A Head-to-Toe Evaluation

      I. The Secondary Survey does not begin until the Primary Survey (ABCDE) is completed, resuscitation is initiated, and the patient’s ABCDEs are reassessed. Secondary Survey consists:

      A. Head is checked for scalp and bony structures for lacerations, contusions and evidence of fractures.

      B. Ears are checked for Battle’s sign (blood or clear fluids in the ear or bruising behind the ears) which indicate a basilar skull fracture (protect the cervical spine).

      C. Eyes are checked for Raccoon and eye (periorbital bruising) which indicates a cribiform plate fracture. Also check the visual acuity (have the patient read the words on a IV bag or 4 x 4 dressing package), hemorrhages, penetrating injuries, contact lenses and dislocation of lenses.

      D. Nose is checked for bleeding and cerebrospinal fluid. Do not place anything in the patient’s nostrils if blood or cerebrospinal fluid is present.

      E. Mouth is checked for loose or foreign bodies, teeth, vomitus and bleeding or cerebrospinal fluid.

      F. Neck. Patients with maxillofacial or head trauma should be presumed to have an unstable cervical spine injury, and the neck should be immobilized with sandbags (socks filled with sand and dirt) and taped to secure the cervical spine. Cervical spine is inspected for tenderness, stair step deformities, subcutaneous emphysema, tracheal deviation, laryngeal fracture and dilated neck veins.

      G. Chest is visual examined ensuring that the front and back are covered (which will identify must-penetrating trauma). Sucking chest wounds must be covered with Vaseline gauze or treated with a chest tube insertion. Evaluation of ventilatory function is best performed utilizing the stethoscope. A quick check of the neck veins is useful in the assessment of cardiac tamponade.

      H. Abdomen is checked for bowel sounds (5-34 per minute), guarding, masses and evidence of trauma.

      I. Perineum/Rectal/Vagina is checked for urethral bleeding, blood in the scrotum, pregnancy, blood in the vaginal vault and vaginal laceration. A digital exam is performed to assess for presence of blood within the bowel lumen, a high riding prostate, presence of pelvic fractures and quality of sphincter tone.

      J. Musculoskeletal system.

      1. Tenderness, crepitation, abnormal movements along the shafts will identify fractures and for peripheral pulses.

      2. Pelvis is checked for continuity with anterior and posterior pressure with the heels of the hands on both the anterior iliac spines and symphysis pubis.

      3. Blood loss in fractures can be estimated:

      1. Pelvic fracture a patient can lose 1500-2000 cc of blood.
      2. Femur fracture a patient can lose 1500 cc of blood.
      3. Tibia and humerus fractures a patient can lose 750 cc of blood.
      11. Neurologic exam for quick reevaluation of the pupils and assess the level of

      Consciousness.

      Glascow Coma Score (GCS)

      	Response	Score
      Eye opening	Spontanous	4
      	To command	3
      	To pain	2
      	No response	1
      Verbal Response	Oriented	5		Normal	15
      	Confused	4		Mild (coma)	13-14
      	Inappropriate words	3		Moderate (coma)	9-12
      	Incomprehensible words	2		Severe (coma)	6-8
      	No response	1
      Motor Response	Obeys command	6
      	Localizes pain	5		If GCS is:
      	Withdraw from pain	4		< 8 then intubate
      	Flexion (decorticate)	3
      	Extension (decereb.)	2
      	No response	1

      • GCS score equals the sum of the best scores from Eye Opening, Verbal Response and Motor Response. Repeat GCS during serial neurologic examinations; annotate changes in the GCS. Any decreases during serial examinations are a sign of deterioration.

      L. Back/skin are examined with log rolling the patient to inspect and palpate the entire spine

      and back for lacerations or abrasions.

      N. History must be taken on every patient by utilize the pneumonic AMPLE. AMPLE stands for:

      1. Allergies.
      2. Medications currently taking.
      3. Past illnesses.
      4. Last meal.
      5. Event/environment related to the injury.

      II. The medical provider must:

      A. Ensure that AMPLE, vital signs and Glascow Coma Score on the remark section (line #32) of the DD Form 1380 (casualty card).

      B. Re-evaluated the trauma patient constantly to ensure that new findings are not over looked, and to discover deterioration in previously noted symptoms.

      C. Ensure meticulous record keeping since more than one provider will be participating in the care of the patient along the evacuation chain.

       

       

       

       

       

       

       

       

       

       

       

       

       

       

       

       

      Triage

      Emergency War Surgery, 1988

      I. The likely outcome of the individual casualty must be factored into the decision process prior to the commitment of limited medical resources. Casualties are generally sorted into five categories or priorities; these groupings are discussed in decreasing order of surgical urgency.

      A. Urgent group requires urgent intervention if death is to be prevented. This category includes those with asphyxia, respiratory obstruction from mechanical causes, sucking chest wounds, tension pneumothorax, maxillofacial wounds with asphyxia or where asphyxia is likely to develop, exsanguinating internal hemorrhage unresponsive to vigorous volume replacement, most cardiac injuries, and CNS wounds with deteriorating neurological status.

      B. Immediate category is those casualties that present severe, life-threatening wounds that require procedures of moderately short duration. Casualties in this group have a high likelihood of survival. They tend to remain temporarily stable while undergoing replacement therapy and methodical evaluation. The key word is temporary. Examples of the immediate category are unstable chest and abdominal wounds, inaccessible vascular wounds with limb ischemia, incomplete amputations, open fractures of long bones, white phosphorous burns, and 2^nd and 3^rd degree burns of 30-40% or more of the total body surface area.

      C. Delayed category is casualties that can tolerate delay prior to operative invention without unduly compromising the likelihood of a successful outcome. When medical resources are overwhelmed, individuals in this category are held until the urgent and immediate cases are cared for. Examples are stale abdominal wounds with probable visceal injury, but without significant hemorrhage. Other examples include soft-tissue wounds requiring debridement, maxillofacial wounds without airway compromise, vascular injuries with adequate collateral circulation, genitourinary tract disruption, fractures requiring operative manipulation, debridement, external fixation, most eye and CNS injuries.

      D. Minimal or Ambulatory category is comprised of casualties with wounds that are so superficial that they require no more than cleansing, minimal debridement under local anesthesia, tetanus toxoid and first-aid type dressings. They must be rapidly directed away from the triage area to uncongested area where first aid and non-specialty medical personnel are available. Examples include burns of less than 15% total body surface area (with the exception of those involving the face, hands or genitalia). Other examples include upper extremity fractures, sprains, abrasions, early phases of symptomatic but unquantified radiation exposures, suspicion of blast injuries (perforated tympanic membranes).

      E. Expectant category are those casualties that have wounds that are so extensive that even if they were the sole casualty and had the benefit of optimal medical resource application, their survival still would be very unlikely. The expectant casualties should be separated from the view of other casualties; however, they should not be abandoned. Above all, medical personnel attempt to make them comfortable by whatever means necessary. Examples are unresponsive patients with penetrating head wounds, high spinal cord injuries, mutilating explosive wounds involving multiple anatomical sites and organs, 2^nd and 3^rd degree burns in > 60% total body surface area, convulsions and vomiting within 24 hours of radiation exposure, profound shock with multiple injuries, and agonal respirations. At least one medic should constantly attend to the care of the expectant categories.

      II. Triage location should:

      A. Be positioned as far forward as the tactical situation permits, and should be co-located with organic or attached /OPCON security elements.

      B. Have enough space to accommodate multiple vehicles.

      C. Be on high ground with good drainage.

      D. Have evacuation routes with easy to and from roads or trails. If time permits route

      Should be marked or have ground guides.

      E. Have a MEDEVAC LZ within 100-150 meters.

      III. Operations:

      A. Upon arrival all casualties will be re-triaged. This will be done by either the most senior medical personnel or as designated by the senior medical person.

      1. The triage NCO/Officer will ensure that:

      1. All casualties are logged in on an Admissions/Disposition roster.

      2. All casualties have a DD Form 1380 (casualties feeder card) on them, and that the card is filled out correctly.

       

      1. All casualties’ feeder cards are collected.
      2. All casualties are being treated and monitored.
      3. Patients are retriaged and cared for while awaiting evacuation.
      4. Combat Lifesavers (CLS) are being utilized to treat and monitor patients.

      C. Mass casualties:

      1. Defined as three or more patients at one location at the same time.

      2. The battalion aid station (BAS) will be notified as soon as possible (ASAP) of all mass

      Casualty situations so that it can properly prepare personnel and equipment.

      3. Non-organic medical vehicles that are used for the evacuation of patients will be manned with a medic or a CLS.

      IV. Triage color code for chem-lights are:

      

      At no time should the normal progression of care or casualty flow be allowed to have a

      reverse direction. Traffic should not enter and exit through the same portal. Flow against the grain must be held to an absolute minimum. Above, all the dead must not be introduced into the triage area.

       

       

       

       

       

       

       

       

       

       

       

       

       

       

       

       

       

       

       

       

       

       

       

      

      MEDEVAC Request

      Item #9; #9; Explanation #9; #9; Provider #9;

      Medical Evacuation Precedence

      I. Urgent is assigned to emergency cases that should be evacuated as soon as possible and within a maximum of two hours in order to save life, limb or eyesight. This group requires urgent intervention if death is to be prevented. This category includes those with asphyxia, respiratory obstruction from mechanical causes, sucking chest wounds, tension pneumothorax, maxillofacial wounds with asphyxia or where asphyxia is likely to develop, exsanguinating internal hemorrhage unresponsive to vigorous volume replacement, most cardiac injuries and CNS wounds with deteriorating neurological status.

      II. Priority is assigned to sick and wounded personnel requiring prompt medical care. This precedence is used when the individual should be evacuated within four hours or his medical condition could deteriorate to such a degree that he will become an Urgent.

      III. Routine is assigned to sick and wounded personnel requiring evacuation but whose condition is not expected to deteriorate significantly. The sick and wounded in this category should be evacuated within 24 hours.

      IV. The determination to request MEDEVAC and assignment of MEDEVAC the senior military person present makes precedence, based on the advice of the senior medical person at the scene.

       

       

      MEDEVAC & CASEVAC Casualty Capacity Planning Factors

       

       

       

      MEDEVAC/CASEVAC Tracking Chart

       

      

      Note

      SU = Surgical Urgent

      LU = Litter Urgent

      LP = Litter Priority

      WP –Walking Priority

      R = Routine

       

       

       

      Chemical Agents

      Medical Management of Chemical Casualties Handbook, Sept. 95

      I. Nerve Agents (GA/Tabun, GB/Sarin, GD/Soman, GF, VX) mechanism of action inhibits the enzyme acetylcholinesterase is to break down or destroy the chemical acetylcholine. Acetylcholine is a neurotransmitter or messenger chemical, that is released by a nerve to stimulate another nerve, gland or muscle. Under normal conditions, when the required action at each step is completed, the acetylcholine is broken down by the acetylcholinesterase thus stopping the action. But when a nerve agent inhibits acetylcholinesterase, this enzyme can not perform its normal function of breaking down or hydrolyzing the acetylcholine. Acetylcholine is not destroyed and it accumulates along the nerve path; the target organ’s action continues uncontrolled with serious impact to the poisoned person. Muscles become hyperactive and twitch uncontrollably and glands secret copiously.

      1. The parts of the body that are affected by the excessive acetylcholine accumulation are:

      1. Eyes.

      1. 2. Nose (glands).
      2. 3. Mouth (glands).
      3. 4. Respiratory tract.
      4. 5. Gastrointestinal tract.
      5. 6. Sweat glands.
      6. 7. Skeletal muscle.
      7. 8. Central nervous system.
      2. Nerve agent effects with vapor exposure:

      Mild exposure	Organs	Time of onset is seconds to minutes after exposure
      	Eyes	Small pupils (miosis) with dim vision & headache
      	Nose	Runny nose
      	Mouth	Salivation
      	Lungs	Tightness in the chest

      Treatment: 1 Mark I (atropine & 2 PAM Chloride)

      

      Treatment: 3 Mark I’s and Diazepam (CANA) immediately

      3. Nerve agent effects with liquid on the skin:

      

      Treatment: 1-2 Mark I’s depending on the severity of symptoms

      

      Treatment: 3 Mark I’s and Diazepam immediately

      D. Detection with:

      1. M256A1.

      2. CAM.

      3. M8 or M9 paper.

      4. M8A1.

      E. Decontamination with:

      1. M291.

      2. M258A1.

      3. Hypochlorite.

      4. Large amount of water.

      5. M295.

      F. Treatment:

      1. Atropine is the drug of choice for treating nerve agent poisoning. Atropine will dry secretions, reduce bronchoconstriction and decrease gastrointestinal motility. Atropine will have no effect on miosis and will not affect skeletal muscle abnormalities.

      a. Mild symptoms such as rhinorrhea, slight or recovering breathing difficulty or excessive salivation are usually managed with one Mark I. Pain in the eyes, twitching of the eyelids, redness and miosis can be controlled with atropine eye drops.

      b. Severe symptoms usually consist of two or more major systems (gastrointestinal, skeletal muscle, respiratory, etc.); the first step is to administer all three Mark I’s and Diazepam. Diazepam (CANA) should always be administered, when three Mark I’s is given together.

      c. Administer 2 mg of Atropine every five minutes until secretions decrease or until the casualty is breathing easier. A total of 15-20 mg of atropine in the first three hours of the onset of symptoms may be needed.

      d. Atropine administered with the autoinjector will show some effectiveness in three-five minutes.

      e. Discontinue atropine when secretions of the mouth, nose and lungs are minimized.

      2. Pralidoxime Chloride (2-PAMCL) in the autoinjector (600-mg/2 cc) is the second drug for use in nerve agent poisoning cases. The 2-PAMCL removes nerve agent from the enzyme acetylcholinesterase as long as irreversible bonding (aging) has not occurred. 2-PAMCL must be used as early as possible, which is why the 2-PAMCL was included in the Mark I. Only three 2-PAMCL can be given every hour. Discontinue use of the 2-PAMCL after symptoms of respiratory distress have eased.

      3. Diazepam or CANA (Convulsive Antidote Nerve Agent) comes as a 10 mg autoinjector adopted by the US military for use in controlling convulsing patients. The key to increasing the effectiveness of the Diazepam is that it must be used before convulsions begin. When two or more organ systems become involved, one Diazepam injector should be administered along with the three Mark I’s to lessen the convulsive activity the soldier may experience. If patient is still convulsing after 10 minutes give a second Diazepam injector. If still convulsing after 5-10 minutes give a third Diazepam autoinjector.

      

      4. Aggressive airway maintenance and the use of assisted ventilation will increase the casualties with severe symptoms will require ventilator support.

      5. Pyridostigmine Bromide (P.B. tabs) pretreatment was adopted primarily for use against GD nerve agent’s "aging" effect on acetylcholinesterase. The pretreatment has no effect on someone exposed to the nerve agent GB, GF or VX does not increase the effectiveness of the treatment for these agents. Within two minutes after GD inhibits acetylcholinesterase, the GD becomes irreversibly bound (aging) to the enzyme and can not be stripped off the enzyme by the oxime 2-PAMCL in the Mark I.

      a. The dosage of 30 mg of pyridostigmine is the maximum concentration within the body, will reversibly inhibit approximately 30% of the blood’s acetylcholinesterase. A level lower than the maximum will be consistently maintained al long as the eight-hour oral dosage is continued. The pretreatment taken by itself will not protect the soldier and does not reduce the effects from the nerve agent.

      b. The pretreatment is not an antidote, but when used in conjunction with the Mark I, the pyridostigmine enhances the effects of the Mark I only against GD. Each package is a blister pack of 21 tablets with each tablet containing 30 mg of pyridostigmine.

      c. On order, one tablet is taken orally every eight hours. If a scheduled dose is missed

      it will not be made up; the soldier will take one tablet at the earliest opportunity to begin the next eight-hour interval. The soldier will discontinue taking the tablets on order from their unit commander. The pretreatment should not be taken on a continuous basis for longer than 14 days. The pretreatment should only be started upon on order of the unit commander.

      II. Mustard (HD and H) and Lewisite (L) are mustards that rapidly penetrates the skin causing both cellular damage and systemic damage. The true deadly nature of the agent’s effects is that any individuals exposed to large amounts of mustard in either liquid or vapor form, faces a total systemic assault. Death occurs because of the failure of the body’s immune system (sepsis and infection are the major contributing causes to death) and pulmonary damage.

      A. Detection is made with:

      1. An odor of garlic, horseradish or mustard.
      2. Visual observation.
      3. M8 or M9 paper.
      4. M256A1 CK.
      5. CAM.
      1. Treatment:
      1. The eyes need dexamethasone sodium phosphate-neomycin ophthalmic ointment to  decrease inflammation and for its antibacterial effects. For any eye pain utilize a systemic narcotic analgesics is recommended. Under no circumstances should the eyes be bandaged. Bandaging the eyes of a blister agent casualty will allow the eyelids to stick together and the secretions will not have any means to drain.

         2. Skin blisters the size of a quarter or smaller should be left intact if possible. Large blisters should be deroofed with blisters which have broken should have the ragged roof of the blister removed. The area of the open blister should be cleaned with tap water or saline and a petrolatum gauze bandage applied. The individual should be given a tropical antibacterial cream such as sliver sulfadiazine burn cream and instructed to apply a 1/8-inch layer to the blister (s) four times per day. A petrolatum gauze bandage must cover the area.

         3. The individual who presents with any sign or symptom of respiratory exposure must be evacuated promptly.

          

          

          

          

          

          

          

         III. Cyanide (AC and CK) is a blood agent with the basic physical action of disrupting oxygen utilization at the cellular level.

         A. Detection is made only with the M256A1.

         2. Decontamination consist of:

         1. Removing the contaminated clothing.

         1. Underlying skin is decontaminated with copious amount of water.

          

         

         

          

          

          

          

          

          

          

          

          

          

          

          

          

          

         Field Management of Contaminated Casualties

         Medical Management of Chemical Casualties Handbook, Sept. 95

         I. Key Elements for planning:

         1. Wind direction and speed.
         2. Security of the decon site.
         3. Access control to decontamination site with:

         1. An entry control point (ECP) must be established to control movement of all vehicles

         into the Medical Decontamination and Treatment Facility (MTF).

         2. The ECP should be located at a distance far enough from the MTF to minimize any vapor hazard that may occur from contaminated vehicles stopping at this point.

         D. Equipment and supplies.

         E. Personnel requirements.

         F. Work and rest considerations.

         G. Establish a patient decontamination station.

         1. H. Litter casualty decontamination procedures.
         2. I. Ambulatory casualty decontamination procedures.
         3. J. Disestablishment of the decontamination station.
         4. K. Destruction of contaminated waste (clothing, medical supplies, etc.).
         5. L Disposition of contaminated and deceased individuals.
         6. M. Location of dirty and clean helicopter PZ/LZs.

          

          

          

          

          

          

          

         II. MOPP levels:

         MOPP Ready	Mask carried/worn. 1st set IPE available within 2 hours.
         	2nd set available within 6 hours
         MOPP 0	Mask carried/worn. IPE immediately available.
         MOPP I	Mask carried/worn. Protective suit worn, boots & gloves carried.
         MOPP II	Mask carried/worn. Suit & boots worn, gloves carried.
         MOPP III	Mask worn. Suit & boots worn, gloves carried.
         MOPP IV	Mask worn. Suit, boots & gloves worn.
         Mask only	Guidance establishing appropriate situations when soldiers
         	can safely operate with no other protective clothing
         	***Never used with a blister agent***

         III. Establish the treatment site:

         A. Outside a one kilometer stand off distance from the edge of the predicted downwind hazard area that:

         1. All personnel can remain in MOPP 2 during the set up of the decontamination site.

         2. One soldier will be in MOPP 4 conducting continuous monitoring during site set up.

         This soldier should use both the M8A1 (ACAA) and the M256A1 chemical detection kit regardless of what agent has been reported.

         3. As long as the monitor continues to report no contact with chemical agent vapors, all 

         personnel can remain in MOPP 2 until such time that the first casualties are 5-10 minutes away.

         B. If the selected site is within the one kilometer stand off distance or within the predicted downwind vapor hazard area, then:

         1. All personnel must be in MOPP 3 or MOPP 4 during site set up.

         2. If the site must be set up inside the vapor hazard area, it is critical that the selected site be free of liquid contamination.

         3. As long as the team sent to the selected site remains completely outside the predicted liquid hazard area, and optimally outside the stand off distance, then a point chemical survey should take no longer than a few minutes using the M8 chemical paper.

          

          

         IV. Site preparation phase:

         1. Will consist of at least a ground recon prior to site activation.

         B. All vehicle movement routes must be driven and points along the route requiring direction 

         indicators identified and any ground obstacles identified for removal.

         C. The arrival/triage area must be surveyed to insure it can handle the evacuation vehicles

         moving into and out of the area plus the activities of the triage officer and the litter teams.

         D. Site must be evaluated for night operations.

         E. When setting up in a forest location, it may become necessary to clear low hanging branches, brush or other ground obstacles.

         F. Only the minimum amount of medical supplies needed to support the contaminated emergency treatment point should be set out.

         G. The emergency treatment area and litter decontamination area will need:

         Emergency Treatment Area Equipment

         Item #9; #9; Amount

         Litter Decontamination Area Equipment

         Item #9; #9; Amount

         V. Emergency medical treatment will consist of:

         A. Administration of Mark 1’s and Diazepam.

         B. Application of pressure dressings.

         C. Establishing a patent airway.

         D. Starting an intravenous infusion.

         E. All personnel rendering medical assistance will be in MOPP IV.

         VI. Chloride solution:

         A. 0.5% chlorine solution is used for all skin decontamination.

         B. 5% chlorine solution is used to decontaminate the casualty’s protective mask, hood, scissors, TAP aprons, litters and the gloves on personnel working in the patient decontamination area plus litters.

         C. The buckets should be marked to indicate 0.5% and 5% chlorine solution.

         D. Preparation of the 0.5% and 5% hypochlorite solutions will require mixing the solutions in a container which can be closed after completion. By closing the container the solution will remain at the required strength far longer than if allowed to stand in an open container. The recommended mixing container is the five-gallon water can. When mixing the calcium hypochlorite granules, the granules must be completely dissolved into the water. The most effective method for mixing is to agitate the granules as they are poured into the water and then allow the solution to sit for 20 minutes to ensure the granules are dissolved.

         E. For the 0.5% hypochlorite solution:

         1. Use 6 ounce bottles of calcium hypochlorite granules found in the Chemical Agent Patient Decon MES and mix one of the six ounce bottle into five gallons of water.

         2. When using a bulk package of calcium hypochlorite from a bulk package, retain one empty six ounce bottle from the Chemical Agent Patient Decon MES to measure the correct amount of dry calcium hypochlorite granules (mix as listed above).

         3. Household bleach (Clorox or Purex) use two quarts with four and half gallons of water.

         F. For the 5% hypochlorite solution:

         1. Use six ounce bottles of the calcium hypochlorite granules and mix eight of the six ounce bottles of calcium hypochlorite into the five gallon container of water.

         2. If using calcium hypochlorite from the bulk package retain one of the empty six ounce bottles to measure the correct amount of dry calcium hypochlorite granules.

         3. Household bleach (Clorox or Purex) use the bleach straight from the bottle, do not mix with water.

         VII. Clothing removal:

         1. Decontaminate the hood:

         1. Cover inlet valve covers to prevent wetting by the 5% chlorine solution.

         2. Sponge down the voicemitter, eyelets outserts, sides and top of the hood with the 5%

         chlorine solution.

         3. When the 5% chlorine solution is not available, use the M291 SDK or the M258A1 SDK reversing the order of the wipes, wipe number two then wipe number one.

         4. Immerse and scrub scissors in a 5% chlorine solution. After ever two to three cuts, the scissors must be immersed, along with the gloved hands of the soldier doing the cutting.

         5. Cut the zipper cord, neck draw cord and then the hood shoulder straps.

         1. Unzip the hood zipper.

         7. Cut the zipper below the voicemitter.

         8. Proceed cutting upward towards the inlet valve covers. Cut close to the covers and

         proceed towards the eyelets outsert.

         9. Cut upward to the top of the eyelets outsert.

         10. Cut across the forehead to the outer edge of the next eye outsert.

         11. Cut downward towards the patient’s shoulder staying close to the remaining eyelets outsert and inlet valve cover.

         12. Cut across the lower part of the voicemitter to the zipper.

         1. 13. Immerse and scrub scissors in a 5% chlorine solution.
         2. 14. Cut from the center of the forehead over the top of the head.
         3. 15. Fold left and right sides of the hood to the side of the patient’s head, laying the sides

         on the litter.

         4. 16. Use 0.5% chlorine solution, M291 or the M258A1.

         a. Cover inlet valve covers to prevent wetting by 0.5% chlorine solution.

         5. b. Wipe external portions of the mask.

         c. Wipe exposed areas of patient’s face (i.e. chin, neck and back of ears).

         8. Cut Field Medical Card (FMC):

         A. The medic should view the 1380 FMC prior to removal.

         1. Allow FMC to fall into a zip-lock plastic bag.
         2. Seal plastic bag and wash with 0.5% chlorine solution.
         3. Place plastic bag under back of head harness straps.
         4. If possible, complete a new FMC from the old FMC and place the new FMC in a plastic

         Bag under the headharness.

          

         IIX. Remove personal articles from the pockets of BDO and:

         1. Place in zip-lock plastic bags.
         2. Mark the bags and remove to the contaminated holding area.

         IX. Cut casualty’s BDO, cut the overgarment around the tourniquets, bandages and splints. Two persons will be cutting the BDO at the same time.

         A. Unfasten velcro closure at wrist and cut from wrist area of sleeves along the inseam of the sleeve, up to armpits and then to neck area.

         B. Repeat cutting procedure for the other side of the jacket.

         C. Starting at jacket drawstring, cut drawstring, unfasten velcro closures moving from waist to neck and then unzip jacket.

         D. If the casualty is able, instruct the casualty to hold arms up and away from the body and drape the left and right chest sections of the jacket over the outside of the litter.

         E. Direct casualty to hold arms away from the upper body until told otherwise.

         F. If the casualty is unable to perform this instruction, then one augmentee holds the casualty’s gloved hand and performs this action for the casualty. Another augmentee folds the section over the outside of the litter.

         G. Remove the BDO trousers by cutting the leg closure cord at the cuff.

         H. Cut along the inseam of the left trouser leg until the crotch area is reached then cut across into the zipper.

         I. Cut along the inseam of the right trouser leg until the crotch area is reached and then go sideways into the first cut.

         J. Unsnap the trouser waistband and unzip the trouser zipper.

         11. Allow trouser halves to drape over side of the litter.

         L. Tuck the remaining cloth between the legs down between the legs insuring only the black

         BDO lining is showing.

         X. Remove outer gloves:

         A. Do not remove inner gloves.

         B. Decontaminate the casualty’s gloves with a 5% chlorine solution.

         1. C. Instruct the casualty to hold his arms away from the litter and upper body or if the

         casualty can not comply with instructions, hold the casualty’s gloves by the fingers.

         2. D. Always remove the gloves over the sides of the litter.
         3. E. Grasp the cuff of the glove.
         4. F. Pull the cuff over the fingers and turning the glove inside out.
         5. G. Tell casualty to carefully lover his arm (s) across the chest after the glove (s) is removed.

         If the casualty is unable to do this, decontaminate your chemical gloves and do this for him.

         6. H. Do not allow the arms to contact the exterior (camouflage) side of the overgarment.
         7. I. Dispose of contaminated gloves by placing them in a plastic trash bag.
         8. J. Immerse and scrub your own gloves in 5% chlorine solution.

         XI. Remove chemical protective overboots:

         9. A. Cut laces.
         10. B. Fold lacing eyelets flat outward.
         11. C. Hold heel with one hand.
         12. D. Pull overboot downward over the heel with other hand.
         13. E. Pull towards you until removed.
         14. F. Place overboots in contaminated plastic trash bag with casualty’s gloves.

         XII. Remove combat boots:

         15. A. Cut boot laces along the tongue.
         16. B. Pull boots downward and towards you until they are removed.
         17. C. Place boots in plastic trash bag with chemical overboots and gloves.

          

          

         XIII. Remove inner clothing:

         A. Cut or unbuckle belt.

         B. Cut BDU pants following same procedures as for overgarment trousers.

         18. C. Cut BDU jacket following same procedures as for overgarment jacket.

         D. Remove undergarments following same procedure as for fatigues. If patient is wearing a brassiere, it is cut between the cups. Both shoulder straps are then cut where they attach to cups and laid back off shoulders.

         E. Remove socks.

         F. Remove inner gloves.

         19. G. A three-person patient lift is now used to remove the nude patient from the contaminated

         clothing with removal from contaminated litter and place the patient on a clean decontamination litter.

         1. The three workers lifting the patient slide their cleaned arms under the patient in a forklift fashion supporting the casualties neck, torso/lower back and distal legs while using the straight-back and knee-lift technique.

         2. After the casualty is lifted up the casualty is rolled slightly inward against the lifters’ chest to make holding up the casualty less of an effort. If decontaminatable litters are not available, use a plastic covered canvas litter (or at a lesser degree of desirable, a single use of an uncovered canvas litter).

         XIV. Skin and wound decontamination:

         A. Decontaminate the casualty entire skin surface by lightly wiping the skin with a sponge with 0.5% chlorine solution.

         B. The casualty is washed from the midline outward constantly washing from clean to dirty and not placing a dirty sponge back on a clean area without first rinsing it in the 0.5% chlorine solution.

         C. The complete topside of the casualty is washed in this manner paying particular attention to hairy areas of the body (the groin and axillary regions) and sweaty area; i.e. the belt-line, just above the boots and the crease of the buttock and wrists.

         D. The backside of the casualty will be washed after the casualty is log rolled onto their side.

         E. The casualty’s back is washed from the shoulders to over halfway down the backside

         taking care not to miss any areas.

         F. The upper side of the litter is deconned prior to laying the casualty back down.

         G. The opposite side of the casualty is washed in exactly the same manner and the litter is deconned once more.

         8. A medical personnel then removes dressing and replace them only if necessary.

         I. Superficial (not body cavities, eyes or nervous tissue) wounds are then flushed with the

         0.5% chlorine solution with new dressings applied if needed.

         J. Cover massive wounds with plastic.

         K. The medic places new tourniquets 0.5-1 inch proximal to the original tourniquet and then removes the old tourniquet.

         L. Splints are not removed but are saturated to skin with 0.5% chlorine solution.

         M. If the splint cannot be saturated (i.e. air-splints or canvas splints), it must be removed sufficiently so that everything under the splint can be saturated with the 0.5% chlorine solution.

         N. Final check for completeness of decontamination with the CAM or M8 paper.

          

          

          

          

          

          

          

          

          

          

          

          

          

          

          

          

          

          

          

          

          

         

         Analgesics and Antibiotics in Trauma

         I. Analgesics for relief of moderate to severe pain in trauma:

         1. Meperidine (Demerol) is:

         1. Given at 30-50 mg intravenously.

         2. Given at 75-mg intramuscular injection.

         3. Beware of Meperidine’s respiratory depression.

         4. Synthetic narcotic analgesic similar to morphine.

         2. Morphine (primary analgesic of choice) is:

         1. Given at 3-5 mg intravenously for a 70 kilogram soldier.

         2. Given at 5-15 mg intramuscular injection.

         3. Beware of Morphine’s cerebral and respiratory depression, and pupillary

         constriction.

         4. Always have Narcan on hand to reverse the effects.

          

         Dosage

         		Dosage interval	Onset of action	Duration of action
         Meperidine	I.M. 75 mg	3-4 hours	10-15 minutes	2-4 hours
         	I.V. 30-50 mg	3-4 hours	1 minutes	2-4 hours
         Morphine	I.M. 5-15 mg	4 hours	30-60 minutes	4-5 hours
         	I.V. 3-5 mg	4 hours	20 minutes	4-5 hours

          

          

          

          

          

          

          

          

          

         Quantity of Issue

         	Trauma Team	Senior Aidmen	Aidmen
         Morphine	5 boxes per team	2 boxes	1 box
         10 mg tubex,
         10 tubexs in a box
         Narcan	5 vials	2 vials	1 vial
         1 vial/10 ml
         Meperdine	5 boxes	None	None
         50 milligram tubex in
         a box of 10's
         Tylenol & codiene	1 bottle	None	None
         bottle of 500's tab.
         Valium	10 bottle	None	None
         10mg injectable at
         5 mg/1cc, 10 tubex

         II. A review of infections following soft-tissue limb wounds in soldiers injured during the Falkland Campaign indicated that a delay in surgery and a delay in antibiotic administration were the most important factors related to the subsequent development of infection. When surgical delay was unavoidable, the delaying antibiotic administration assumed an even greater importance. That study showed a greater incidence of septic complications when debridement was delayed more than six hours; it also showed an increased incidence of infectious complication when the time from wounding to antibiotic administration exceed six hours.

          

         Agent	Mode of action	Antibacterial spectrum
         Cefoxitin	Cell wall synthesis inhibitors	Gram-negative anaerobes especially
         2nd generation of	stable to staphylococcal beta	Bacteroides Fragilis. Also effective
         Cephalosporin	lactamases	against several protozoa.

         • Cefoxitin is given 2 grams every 12 hours either I.M. or I.V. route.

          

          

         Tetanus Immunization

         I. Previously immunized individuals.

         A. A fully immunized individual is an individual that the attending physician/physician assistant has determined to have been previously and fully immunized, and the last dose of toxoid was given within the last ten years. Treatment consists of:

         1. Administered 0.5 ml of absorbed toxoid for tetanus-prone wounds (if more than five years has elapsed since the last dose).

         1. The booster may be omitted if excessive toxoid injections have been given before.
         2. A partially immunized individual is an individual who has received two or more

         injections of toxoid and the last dose was received more than ten years ago, 0.5 ml absorbed toxoid is administered for both tetanus-prone and none tetanus-prone wounds. Passive immunization is not necessary.

         II. Individuals that are not adequately immunize are those patients that have received:

         1. Only one or no prior injections of toxoid.
         2. The toxoid or the immunization history is unknown.
         3. Treatment:
         1. Nontetanus-prone wounds are administered 0.5 ml of absorbed toxoid.
         2. Tetanus-prone wounds are administered:
         1. 0.5 ml absorbed toxoid.
         2. 250 units of Tetanus Immune Globulin.
         3. Consider administering antibiotics (although their effectiveness for prophylaxis of

         Tetanus remains unproved).

         4. Administered medication using different syringes and sites for injections.

         III. Immunization schedule for adults:

         1. Series of three injections of toxoid.

         B. Booster every 10 years.

         Fractures

         I. Types of fractures:

         1. Closed fracture in that the overlying skin remains intact.
         2. Open fracture (the overlying skin and soft tissue have been damaged):

         1. Type I with the wound < 1 cm long with no evidence of contamination.

         2. Type II with the wound > 1 cm long with no soft tissue stripped from the bone.

         3. Type IIIA with a large wound with adequate soft tissue coverage of bone.

         1. Type IIIB with a large wound with periosteal stripping and bone exposure.

         

         Closed fracture with #9; #9; Open fracture with Intraarticular fracture

         large hemotoma #9; #9; external bleeding #9; #9; with hemarthrosis

         II. Fracture patterns:

         1. Transverse
         2. Oblique
         3. Spiral
         4. Comminuted fracture has more than two fracture fragments.
         5. Segmental fracture is a comminuted fracture with three large, well-identified fragments in

         the shaft of a long fracture.

         6. Impacted fracture is when two fracture fragments are telescoped onto one another.

         G. Avulsions fracture results from a sudden muscle pull that tears the musculotendinous

         with attached bony fragment from the bone.

         8. Compression fracture is common in vertebrae.

         

         Segmental #9; #9; Impacted Avulsion

          

         III. Principles of splinting:

         A. A dry, sterile compression dressing is applied to all open wounds to control bleeding and prevent further contamination, minimizing the risk of infection.

         B. The splint should incorporate the joints above and below the fracture bone and splint the fracture in place.

         C. Splinting demands constant monitoring of neurovascular function of distal limb (capillary refill, pulse, gross sensation and motor function).

         1. Splinting must be completed before moving patient.

         E. If fracture causes significant deformity of long bone (i.e. femur), limb may be realigned

         with gentle traction and maintained in this position during splinting.

         IV. Fractures of the upper extremities:

         A. Shoulder injuries:

         1. Most injuries around the shoulder (including acromioclavicular separations) as well as

         fractures of the clavicle, proximal humerus, and scapula, can be immobilized with a sling and swathe. The elbow should be well supported in the sling and the knot tied securely to one side of the neck. One or two swathes are then applied over the arm in the sling to bind the arm firmly, but not to tightly, to the chest wall, preventing the limb from swinging freely. The hand is left free to facilitate monitoring of the neurovascular function of the limb.

         Position of arm & forearm #9; #9; Immobilization technique

         2. The only shoulder injury that cannot be effectively immobilized in a simple sling and swathe is the common anterior dislocation of the shoulder joint. Following this injury, the arm is locked in moderate abduction and cannot be brought comfortably against the chest wall (as is needed for the application of a simple sling and swathe). An anteriorly dislocated shoulder must be splinted in the abducted position in which it is found.

         B. Humerus fractures. Following fracture of the shaft of the humerus, muscle spasm often produces a significant deformity. If angulation is apparent, applying longitudinal traction to the distal fragment can restore the general alignment of the arm. This is best accomplished by grabbing the condyles of the humerus with one hand, supporting the fracture site with the other hand, and gently but firmly pulling the arm distally until the arm is aligned against the chest wall. One person must maintain this alignment while a padded board splint is applied, adding stability to the lateral aspect of the arm. The entire injured limb and the splint are then incorporated into a sling and swathe.

         C. Injuries of the elbow range from non-displaced fractures to complete dislocations and severe limb-threatening injuries, such as the displace supracondylar fracture. The injured elbow must be splinted in the position in which it is found because manipulation or application of traction in this region may cause or aggravate a preexisting nerve or vessel injury. A Sam splint with an ace wrap, and the splinted limb is then supported with a sling.

         D. Forearm and hand fractures:

         1. Although significant angulation often occurs, most of these fractures can be well stabilized with an air splint without manipulation or traction. An air splint gently compresses the injury site and effectively immobilizes the fracture fragments. Two individuals are needed to apply an air splint properly:

         a. One to support the injured limb at all times.

         b. The other to put on the splint.

         c. The splint is inflated once it is in place.

         2. Wrist and hands injuries can be immobilized with a bulky hand dressing and a palmar padded board splint. Injured hands are placed in the position of function, with the wrist dorsiflexed about 30 degrees and the fingers flexed slightly into a position that would comfortably hold softball. A roll of soft gauze is then placed in the palm of the hand, and a Sam splint is placed along the palmar aspect of the hand, wrist and forearm. The entire limb below the elbow is secured to the Sam splint with an ace wrap. While the patient is being transported the splinted hand should be elevated in a sling.

         V. Fractures of the lower extremities:

         A. Hip fractures. Displaced hip fractures cause an obvious shortening and external rotation of the injured limb. Because the fracture lies so close to the hip joint, the pelvis as well as the entire leg should be immobilized to prevent movement at the fracture site. A long board or a scoop stretcher provides support and stabilizes the pelvis and the entire injured limb.

         B. Femur fractures. Fracture of the femoral shaft usually occurs as the result of a high-velocity injury. Muscle spasm and the loss of stability of the underlying femur usually create significant deformity. Traction splints are used for fractures of the femoral shaft:

         1. First, the limb is realigned with manual traction by one medic.

         2. Another medic places the traction splint under the injured limb, secures it with straps, and uses a ratchet mechanism to maintain the needed continuous traction on the ankle and foot.

         3. Patients with femoral fractures may also have associated pelvic or spinal injury and therefore should be transported on a spine board.

         C. Injuries to the knee range from ligament sprains or ruptures to severe fracture/dislocations. Because the risk of neurovascular injury is extremely high in this region, the injured knee must be splinted in the position in which it is found.

         1. When the knee is found extended, two padded boards splints (one on the medial and one on the lateral aspects of the injured limb) from the groin to the ankle joint, secured with several cravats; provide adequate immobilization of the knee joint.

         2. When the knee is found in the flexed position, padded board splints are placed on the medial and lateral aspect of the limb in a "A" frame configuration. The splints should extend from the upper end of the femur to the lower end of the tibia.

         C. Tibia and fibula fractures are often associated with significant deformity. Severely displaced fractures of the tibia and fibula should be realigned with longitudinal traction and splinted with a long leg air splint or padded board splints that extend above the knee. The knee joint must be completely immobilized.

         D. Ankle and foot fractures. The pillow splint is one of the many splinting devices used to immobilize an injured ankle or foot. A standard pillow can be wrapped around the injured ankle and foot and secured snugly with safety pins or an ace wrap. The pillow readily conforms to the shape of the injured part. Toes are exposed for assessment of distal neurovascular function.

         VII. Fractures of the spine:

         A. Complete immobilization of the injured spine prior to transportation to the hospital has significantly reduced the incidence of quadriplegia and paraplegia following major trauma. Proper splinting of the unstable spine greatly decreases the risk of spinal cord impingement by the unstable bony elements. Splinting is mandatory for all patients with a suspected spinal injury (i.e. patients involved in motor vehicle accidents, falls from a height that are hard like a helicopter landing or those with either face or head injuries).

         1. The only indication for realignment of the injured spine is an inadequate airway, which is a life-threatening problem and therefore always takes precedence in the initial patient care protocols.

         2. The purpose of spinal immobilization is to provide a single solid unit of the head, trunk and pelvis so that one segment does not move in relation to the other two.

         3. A cervical collar is first placed on the cervical spine to provide initial and partial immobilization, however, a cervical collar alone cannot completely eliminate movement of the head and truck.

         4. The trunk and then the head are secured to the immobilization device with straps.

         5. The patient is rotated as a unit, laid on a long spin board, and secured to it with long straps.

         6. After the head, spine and pelvis are fully immobilize, other limb injuries are splinted as well, and the patient is transferred on a long board.

         7. Be sure the patient can be rolled as a unit to clear the airway since vomiting is a common reaction following a back fracture.

         VIII. Fractures of the pelvis. Because the pelvis lies in the retroperitoneal space, in close proximity to several large blood vessels, pelvic fractures may lead to hypovolemic shock. The MAST and long board are most effective for immobilization of the pelvis and preventing hypovolemia. Inflation of the MAST stabilizes the pelvic fracture and decreases bleeding at the fracture sites. Sections of the MAST are inflated gradually while the patient’s blood pressure is continually monitored. Because severe, irreversible hypovolemic shock may ensue when a MAST is deflated, deflation should take place in a trauma center (i.e. a Level II medical company or combat support hospital).

          

          

          

          

          

          

          

          

         SAM^r Splint

         

          

         I. The secret to using the SAM Splint properly is to curve it lengthwise. The longitudinal bend gives the splint its strength.

          

          

          

         

         II. Double the SAM Splint or

         create a t-bend for extra strength.

         

         III. Curve the outside edges the opposite

         direction to make it even stronger.

          

         IV. Fold the SAM Splint around the thumb and over the wrist to stabilize thumb injuries.

          

         

         V. Place the curved splint

         under the forearm to treat

         a lower arm fracture or sprain.

         

         VI. Wrap the SAM Splint around the

         elbow to splint the wrist or forearm.

          

          

         

         VII. For injuries to fingers, fold up

         the end for extra protection.

          

          

          

          

         IIX. For dislocated shoulders, fold the splint

         in threes to form a triangular ‘Airplane’ splint. Create

         curves to strengthen.

          

          

          

         

         IX. To splint the upper arm, double-fold one

         end, and shape as a cup to support the elbow.

         Use gauze, kling or wrap to keep the splint securely

         in place. Finish with a sling or ace wrap to provide additional support.

         

         X. Stabilize the ankle with a single splint, folded

         under the foot, and applied to each side of the leg. Use

         two splints, one on each side of the leg, and curve under

         the foot to immobilize the knee or leg.

          

          

         XI. Use the SAM Splint as a cervical collar if one is not available.

         A. Begin by making a bend at one end; flare the upper end to support the chin.

         

          

         1. Beginning at the chin, wrap the free end loosely

         Around the neck, bringing it obliquely down to the chest.

          

          

         

          

          

         C. Squeeze in the sides to create lateral wings for stability and to take up the slack.

         Burn Injuries

         I. The first priority in the management of the burn patient is maintenance of the airway, control of hemorrhage, and prompt institution of resuscitative therapy (ABCDE).

         1. Remove all constricting articles, such as rings, bracelets, wristwatches, belts and boots.

         B. The patient is not undressed unless the injury has been caused by a chemical agent, in

         which case all contaminated clothing must be removed.

         C. The patient should be covered with a clean sheet and a blanket, if appropriate, to maintain body temperature and prevent gross contamination during transport to a treatment facility. Burn dressings can be used or initial wound coverage.

         D. Patency of the airway is assured.

         E. Hemorrhage should be controlled.

         F. Fractures should be splinted.

         G. Intravenous pathway should be established in a unburned are (if available) and in an

         upper extremity veins if there are associated abdominal wounds. A burn area may be used.

         H. Patients with extensive partial-thickness burns may have considerable discomfort, which can be relieved by appropriate doses of morphine or meperidine administered intravenously. Subcutaneous or intramuscular injections of analgesics should not be used since they will not be

         mobilized during the period of edema formation (and will therefore be ineffective in pain control).

         Rule of Nines for Estimating Extent of Burns

         Region	Percentage
         Head	9%
         Chest & abdomen	18%
         Upper and lower back	18%
         Arms	9%
         Upper leg	9%
         Lower leg	9%
         Genitalia and perineum	1%

         To estimate the extent of irregularly disposed burns, on can make use of the fact that one surface of the casualty’s hand represents approximately 1% of his total body surface. Small burns of the face, hands, feet and perineum will require hospitalization, even if these limited areas are the only sites of a burn injury.

          

         

         Evaluating Depth of Burns

         Criteria	Partial-thickness burn	Full-thickness burn
         	(Second-degree burn)	(Third-degree burn)
         Cause	Very deep sunburn, contact with	Fire, prolonged exposure to
         	hot liquids, or flash burns from	hot liquids, contact with hot
         	Gasoline flame.	objects or electricity.
         Color	Pink or mottled red	Pale white or charred
         		appearance and leathery.
         Surface	Blisters and broken epidermis.	Dry and inelastic, broken skin with
         	Sensitive to cold air.	fat exposed
         Pin prick	Painful	Painless, insensitive to pin prick.
         Severity	Critical: burns complicated by	Critical: burns complicated
         	respiratory tract injury/fractures	by respiratory tract injury or fractures.
         	and/or covering 15-30% body	Burns involving the critical areas
         	surface area.	of the face, hands, feet and/or
         		perineum. Burn covering > 10%
         		of BSA
         	Moderate: burns of 15-30% of