“That Others May Live”


 Keflex (cephalexin) 117



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 Keflex (cephalexin) 117


 Mefoxin (cefoxitin) 118

 Rocephin (ceftriaxone) 118

 Silvadene cream (silver sulfadiazine) 118

Antihistamines 118

 Benadryl (diphenhydramine) 118

 Phenergan (promethazine) 119

Anti-Inflammatory’s 119

 Decadron (dexamethasone) 119

 Motrin (ibuprofen) 119

 Solumedrol (methylprednisolone) 120

 Toradol (ketorlac tromethamine) 120

Miscellaneous Medications 120

 Afrin nasal spray (oxymetazoline) 120

 Diamox (acetazolamide) 121

 Epinephrine (adrenaline) 121

 Imodium (loperimide) 122

 Mannitol 122

 Lasix (furosemide) 122

 Valium (diazepam) 122

 Zantac (ranitidine) 123

Advanced Cardiac Life Support Drugs* 124

*EMT-P authorized use and/or special mission requirement only

 Adenosine 124

 Atropine 124

 Dopamine 124

 Epinephrine 125

 Lasix (furosemide 125

 Lidocaine 125

 Nitroglycerin 126

 Procainamide 126



Water Purification in the Field 127

Laser Eye Injuries 128

 Amsler Grid Testing 129



9-Line MEDEVAC Request 130

Glossary 133

APGAR Score 134

Mnemonics 134

Conversions 136
MEDICAL COMMAND and CONTROL (MC2)
Care of injured personnel in combat or rescue situations requires medical command and control by licensed medical providers. Paramedical personnel providing care in these situations are acting under the principal of ‘delegated authority’, where the provider (usually a physician) allows appropriately trained personnel to perform specified diagnostic and therapeutic interventions. There are two types of medical control: On-Line and Off-Line
On-Line Medical Control: A physician is either present at the scene and personally directs patient care, or is in contact by radio or other means and able to direct ‘live’ instructions. On-line medical control is the preferred means of medical control for all casualty situations.

Order of precedence for On-Line Medical Control is:


  1. Pararescue/Rescue or Special Tactics Squadron Flight Surgeon present at the scene.

  2. Senior US Military Physician present at scene.

  3. Qualified Allied Country Senior Military Physician, with training equivalent to U.S. physician, present at scene

  4. Qualified civilian physician, with training equivalent to U.S. physician, present at scene. Note: He/she must agree to assume responsibility for care and accompany the patient to a higher level of care.

  5. Senior US Military Physicians Assistant present at the scene.

  6. U.S. Military Physician in direct radio contact.

Off-Line Medical Control: Contact with a control physician is impossible or impractical. Care is administered based on specific physician-approved protocols. In the event On-Line control is not available the following applies:




  1. The PJ Team Leader is responsible for directing medical care at all scenes where On-Line Medical Control is not possible. If the tactical situation requires it, he may delegate medical treatment responsibility to another PJ.

  2. The protocols in this handbook are the approved procedures, medications and techniques for Pararescue Medical Care. Changes to protocols will be approved by the Pararescue Medical Operations Advisory Board (PJ MOAB) in coordination with your MAJCOM Surgeon.

Principles of Combat Casualty Care
Guidelines and Considerations: Care of trauma patients in a combat environment is not the same as care of trauma patients in the civilian environment. While ATLS, BTLS and PHTLS are worthy programs, they were never designed for use on the battlefield. In combat medicine, care of the patient must be modified to fit the situation, tactical or otherwise. Combat casualty care is divided into three phases: 1) Care Under Fire, 2) Tactical Field Care, and 3) Combat Casualty Evacuation (CASEVAC). A synopsis of the level or degree of care rendered during each phase is given below.

Note 1: C-Spine precautions are seldom needed in penetrating neck trauma in combat casualty care. (See spinal injuries and clinical clearing of the cervical spine, pp 46-47)

Note 2: Combat casualties from blast and penetrating trauma who are pulseless and apneic are dead. Attempts to resuscitate these patients are futile.

Caution: These procedures hold for tactical combat casualty care only. Peacetime rescue assumes all patients have a chance to survive. However, in peacetime situations where the rescuer’s lives are in immediate danger (avalanche chutes, etc), these procedures may be needed.
1. Care Under Fire: Care given at the scene of injury while under effective fire. Care is highly limited. The goal is to get the victim out of the fire zone without creating new casualties.
a. Return fire as directed or as required.

b. Try to keep yourself from being injured.

  1. Try to keep the victim from sustaining any further injury.

  2. If the victim is awake and able to function, direct him to take cover and start self-aid.

  3. Airway intervention, if needed, is limited to a NPA. Stop life-threatening hemorrhage with a tourniquet.

  4. Take the casualty with you when you leave.


2. Tactical Field Care: Care is rendered once the operator and casualty are no longer under effective fire. This phase is where the majority of Pararescue medical care will take place.
a. Address the ABCs, replace tourniquets with pressure dressings as appropriate.

  1. Treat wounds with appropriate dressings/splints.

  2. Treat pain and administer antibiotics as required.


3. Combat Casualty Evacuation (CASEVAC): Care given once transport to higher level of medical care has commenced. Usually involves aircraft/boat/vehicle transport, where additional medical equipment may be available.
a. Continue treatment from phase 2, monitor the patient.

  1. Document the care given and prepare to hand-off the casualty to the next echelon of

medical care.


Guidelines for Initiation of Resuscitation
 Medical treatment and resuscitation of victims should be initiated under all circumstances, with the following qualifications:



  1. Combat (Direct Fire):

a. Patient with no pulse, regardless of cause, should not have resuscitation initiated.

  1. Patients with a pulse but no respiration should have resuscitation initiated if it can be

accomplished in relative safety.
Note: Body recovery should be attempted unless the attempt exposes the team to undue danger. If the body cannot be safely recovered the location should be noted as accurately as possible (GPS coordinates preferred) for later recovery efforts. If the body has a set of ID tags that can be safely recovered, leave one with the body, bring the other out.
2) Non-Combat: Decisions to not initiate resuscitation should be discussed with medical control if possible. If contact with medical control is not possible, the following guidelines should be followed:

a. Do not initiate resuscitation if victim is or has:

1) Obviously dead. Characterized by signs such as:

 Obvious decomposition

 Body partially consumed by scavengers

 Dependent lividity

 Rigor mortis (Caution: In hypothermia victims, severe hypothermia may



resemble rigor mortis. Check body core temperature)

2) Decapitated or partially decapitated with no pulse present

3) Dismembered or body is fragmented

5) Open head injury with brain matter exposed and no pulse present

6) Injury to the trunk with chest contents exposed and no pulse present

7) “Frozen” hypothermia victim, e.g., ice formation in the airway, incompressible chest



  1. Total body burns or body carbonization and no pulse present

  2. Suffered massive blunt trauma, e.g., fall of over 100 feet, and has no pulse

b. Decisions to not initiate resuscitation will be completely documented to include:

1) Time/Date of decision, 2) Reason for decision, 3) Name of medical control (if able to contact), and 4) location of victim (GPS coordinates if possible).

  1. The decision to not initiate resuscitation IS NOT a legal declaration of death, unless

a qualified physician declares the patient dead.
Note 1: Body recovery should only be attempted if it can be accomplished with a minimum of risk to the rescue team. If there is any suspicion of death as a result of foul play, or other forensic circumstances (suicide, homicide, neglect, accident, etc) the body and the area around it should be left undisturbed until law enforcement authorities have had an opportunity to examine the scene.
Note 2: In the event of a military aircraft crash, body recovery may be the responsibility of local law enforcement or military authority, depending on the circumstances and location of the mishap. In most circumstances it is best to leave the bodies in position until investigating authorities arrive and survey the site. If the bodies must be moved prior to arrival of the investigative authority, every attempt should be made to record the exact location where the body was found, and the exact position it was in (photographs from multiple angles are helpful).


REFUSAL OF MEDICAL CARE AND/OR TRANSPORT
 In general, Active Duty military members may not refuse life-saving medical care. Mentally competent adult civilians (including dependents, spouses and retired military members) may refuse medical care, even if refusing medical care endangers their lives. PJs should make every effort to insure that patients refusing medical care are aware of the possible consequences of their actions. The patient should be urged to seek other medical care as soon as possible.


  1. If the patient is unconscious, or unable to make a rational decision (secondary to head injury or any other cause of altered mental status) the principal of Implied Consent assumes that a normal, rational person would consent to life-saving medical treatment.



  2. If the patient is a minor or mentally incompetent adult, permission to treat must be obtained from a parent or guardian before treatment can be rendered. If a life-threatening condition exists, and the parent or guardian is unavailable for consent, treatment shall be rendered under the principal of implied consent, as noted above.



  3. If an alert, oriented patient with normal mental status refuses medical care, then care cannot be rendered. Medical control should be contacted (if possible) if such a situation occurs. If a patient refuses medical care the following statement must be written on the medical treatment form and signed by the patient:


I, THE UNDERSIGNED HAVE BEEN ADVISED THAT MEDICAL ASSISTANCE ON MY BEHALF IS NECESSARY AND THAT REFUSAL OF SAID ASSISTANCE MAY RESULT IN DEATH, PERMANANT INJURY OR IMPERIL MY HEALTH. I REFUSE TO ACCEPT TREATMENT, AND ASSUME ALL RISK AND CONSEQUENCES OF MY DECISION. I RELEASE THE UNITED STATES AIR FORCE AND THE DEPARTMENT OF DEFENSE FROM ANY LIABILITY ARISING FROM MY REFUSAL TO ACCEPT MEDICAL CARE.
Note: The statement must be signed and dated by the patient, and countersigned by a witness. The medical record should completely document that the patient is awake, alert, oriented and has normal mental status. If the patient refuses to sign the form, and still refuses medical care, the patient’s refusal to sign should be documented and signed by the treating PJ and preferably by at least one other witness.

TRAUMA
Trauma patients are not definitively treated in the field, only critical interventions are made. Based on the environmental threat, pararescuemen need to judge the extent patient assessment to be accomplished during initial contact. A more thorough assessment can be accomplished once the patient is removed to a secure area. The following is the conventional approach to a trauma patient. It is not an all-inclusive list. Its purpose is as a reminder only.

Note: For injuries occurring in a combat zone, see Tactical Combat Casualty Care, page 9.
Primary Survey:

Scene SafetyYours? Patients? HAZMAT needed? Universal precautions?

C-SpinePossible injury? MOI? Initial LOC? Stabilize prn.

AirwayClear? Patent? Compromised? .

Treat as needed: OPA/NPA/ETT/Cricothyroidotomy/BVM/O2



 Do not move on to breathing until airway is controlled.

Breathing – Is the Rise and Fall of Chest: Equal & Bi-lateral? Asymmetrical? Is the Respiratory Rate: Rapid? Slow? Equal & Bi-lateral? Asymmetrical? Is the Integrity of the Chest Wall Compromised by: Contusions? Fractures? Crepitus? Penetrating Injuries? Are Breath Sounds: Equal & Bi-lateral? Asymmetrical? Are the Lung Fields: Clear? Distant or Muffled? Are there other Signs & Symptoms: Hyper-resonanance? Hypo-resonanance? JVD? Tracheal Shift? Muffled Heart Sounds? SubQ Emphysema? Pulseless Paradoxisis?

Treat as needed: O2/BVM/Stabilize chest wall/Thoracentesis/Thoracostomy



Circulation - Stop major bleeding. Is Patient in Shock? Determine cause.

Treat as needed: O2/NS or LR/Direct pressure/Pressure dressings/Elevation/

Tourniquets/MAST

Diagnose & Decide - Is pt a Load & Go? Continued decompensation from respiratory &

circulatory compromise? Difficulty with circulation (shock)? Decreased or decreasing LOC?

 Do initial Rx/Evacuate ASAP/Continue Rx. enroute

ExposeExamine pt for additional injuries/Unknown etiology/Obtain initial history
Secondary Survey

Vital Signs - Pulse, Blood Pressure, Respirations, Temperature, O2 Sat, EKG, BGL

Patient History – AMPLE & PQRST

Allergies

Medications

Past medical history (significant)

Last food/fluid intake

Events preceding the injury
Pain: What brought the pain on? How did it start? Is there anything that alleviates/worsens the pain

Quality: How does it feel? Describe it.

Region & Radiation: Where is the pain? Is it local/diffuse/pinpoint? Do you have pain anywhere

else? Does it radiate? (Is pain referred?)



Severity: How bad is pain (scale of 1-to-10)? Can you compare it to anything else?

Time: How long have you had the pain? Is it constant or intermittent? Have you had this pain

before?
Head-to-toe examination – CSM, AVPU, PERLA, Glasgow Coma Scale


Circulation: Patient have distal pulses? Capillary blanch in finger in and toes?

Sensory: Patient feel touch of fingers and toes? Does unconscious patient respond when you

pinch fingers and toes?



Motor: Patient move fingers and toes? Arms? Legs? Equal & Bi-Lateral muscle strength?
Alert: Patient is A & O person/place/date/time

Verbal: Patient responds properly to verbal stimuli

Pain: Patient responds to painful stimuli (withdraws from stimulus)

Unconscious: Patient is unresponsive
Pupils

Equal

Reactive

Light

Accommodating
Perform field treatment of findings from secondary exam.
Continuously monitor the patient. Be prepared to correct ABCs if they deteriorate.


Glasgow Coma Scale

Eye Opening

Spontaneous

To voice


To pain

None


4

3

2



1

Verbal Response

Oriented Confused Inappropriate sounds Incomprehensible sounds

None


5

4

3



2

1


Motor Response

Obeys command Localizes pain

Withdraws (pain) Flexion (pain) Extension (pain) None



6

5

4



3

2

1



Score of 8 or less, or deteriorating score indicates serious head injury.

Additional Notes:

SHOCK
Shock is defined as tissue perfusion that is not adequate to meet metabolic needs. There are several types of shock; but all are based on the underlying mechanism causing inadequate perfusion. The major types of shock that Pararescuemen are concerned with are: Hypovolemic, Cardiogenic, Anaphylactic, Septic, and Neurogenic.

Hypovolemic/Hemorrhagic Shock
Guidelines & Considerations: The treatment of hemorrhagic shock with large amounts of fluids in the field is controversial. Hemorrhage control takes precedence over starting fluid administration. In cases where bleeding is internal (abdominal or chest wounds), fluid resuscitation prior to surgical control of bleeding may actually make things worse. In cases of internal bleeding, fluid resuscitation should be titrated to a blood pressure between 90-100 mmHg systolic. In cases where the bleeding has been controlled (for example extremity wounds), then fluid resuscitation to higher blood pressures is acceptable.
Signs & Symptoms:

 Apprehensive/restlessness


 Hyperventilation

 Muscle weakness and fatigue

 Decreased level of consciousness

 Cool, pale moist skin

 Weak, rapid, thready pulse

 Decreasing blood pressure

 Narrowing pulse pressure less than 30mmHg


Rapid field estimate of BP:

 Palpable radial pulse = Minimum of 90 mm Hg systolic

 Palpable femoral pulse = Minimum of 60 mm Hg systolic

 Palpable carotid pulse = Minimum of 40 mm Hg systolic


Treatment:

1. Assess Airway, Breathing and Circulation. CONTROL BLEEDING.

2. Start Large Bore IV's with Normal Saline or Ringers Lactate.

 Saline lock with a large bore IV catheter is also acceptable.



3. Administer oxygen 4 to 8 LPM.

4. Place patient is shock position.

5. Keep warm and covered.

6. Monitor V.S. q 5-15 minutes.

7. Adjust IV flow rate to maintain systolic blood pressure between 90-100mmHg and/or minimal BP necessary to maintain a good carotid pulse.

Cardiogenic Shock
Signs & Symptoms:

Abnormal pulse: Irregular, rapid and/or weak pulse

 Decrease in blood pressure 30mmHg or more from normal (less than 90mmHg systolic)

 Chest pain


 Nausea and vomiting

 Pallor, cold clammy skin

 Muscular weakness
Treatment:

1. Assess airway and circulation status first, treat appropriately.

2. Complete rest.

3. Administer oxygen 4 to 8 LPM.

4. Start IV and titrate to maintain 90-100 mm Hg systolic BP.

5. Monitor Vital Signs q 15 minutes to 1-4 hours PRN. Auscultate lungs with every 250 cc’s of fluids administered IV.

6. Evacuate ASAP.

Anaphylactic Shock
Signs & Symptoms:

 Hives


 Apprehension

 Hyperventilation

 Laryngeal edema

 Reddened skin or numerous blotchy red areas

 Itching

Angio-edema

 Tachycardia

 Wheezing

 Respiratory distress

 Hypotension

 Airway obstruction/shock
Treatment: See Anaphylaxis Protocol, page 115

Septic Shock (Hyperdynamic & Hypodynamic)
Hyperdynamic Shock (Early, Warm)

Signs & Symptoms:

 Fever


 Altered mentation

 Shaking, chills

 Rapid bounding pulse

 Blood pressure increase-normal-decreases

 Decreased urinary output
Hypodynamic Shock (Late, Cool)

Signs & Symptoms:

 Skin cold, clammy

 Blood pressure decreases further

 Pulse raid, weak, irregular

 Edema

Treatment: (Septic Shock)

1. Start Large Bore IV with crystalloid solution

2. Administer oxygen 4-8L/min

3. Begin antibiotic therapy

4. Drain abscesses, clean and drain wounds. Debride as required

5. Adjust IV fluid rate to maintain a minimum BP of 90-100 mm Hg systolic

Neurogenic Shock

Note: Isolated head injuries do not cause shock. If shock is present in such a patient, search for other causes of shock.

Caution: Neurogenic shock may mask intra-abdominal, pelvic and lower extremity injury. A careful survey of the entire patient is mandatory in patients with this condition.
Signs & Symptoms:

 MOI consistent with probability of spinal cord injury

 Increased pulse (may also have normal pulse or bradycardia)

 Decreased blood pressure less than 80mmHg systolic

 Flaccid, paralysis

 Incontinent of urine and/or feces

 Abnormal reflexes

 Spasticity

 Paralysis and loss of sensation

 Point tenderness/pain, deformity of spine.


Treatment:

1. Assess airway and circulation status first, treat appropriately. Immobilize spine.

2. Start IV with normal saline or ringers lactate, titrate to maintain minimum BP of 100 mm Hg systolic.

3. Administer oxygen 4-8L/min

4. Institute other shock modalities as directed
Additional Notes (Shock):

SPINAL INJURIES
Guidelines and Considerations:

Note: If patient is unconscious, assume spinal injury. The spine-injured patient, even if awake, may not complain of pain. Use correct technique (in-line stabilization) and enough people to move the patient without manipulating the C spine.
There are Five Basic Groups of Spinal Injuries:

1. Muscular or ligamentous strains or contusions (e.g.,lumbosacral strain or cervical whiplash)

2. Intervertebral disc injuries

3. Vertebral fracture/dislocation without any involvement of the spinal cord

4. Vertebral fracture/dislocation with injury to the spinal cord

5. Penetrating injuries to the spinal cord and its surrounding tissue
Mechanism of Injuries (MOI):

 Direct trauma to head, neck, face

 Falls or dives into shallow water

 Acceleration/deceleration injuries

 Ejections

 Blunt trauma

 Penetrating injury

 Blast Injury


Treatment:

1. Maintain Airway.

2. Immobilize Neck - C-collar, spine board (do not restrict breathing).

3. Perform primary and secondary surveys.

4. Palpate entire spine for point tenderness.

5. Perform sensory/motor function check.

6. Oxygen 8 liters per minute.

7. IV normal saline or ringers lactate and titrate, or saline lock.

8. Clean and dress open wounds.

9. Urethral catheterization, monitor urine output.

10. Place NG tube if patient is unconscious. Consider NG even if patient is awake. Caution: Be prepared

for vomiting, prevent aspiration.



11. Check neurological function q 15-30 min and record.

12. Note: Consider antibiotics if open wounds are associated with the injury and evacuation is delayed.
Solu-Medrol Protocol for Blunt (Non-Penetrating) Spinal Cord Trauma.

Note: This protocol is controversial, and should only be initiated after consultation with medical control.
Guidelines and Considerations: To be used only in cases of blunt trauma with signs and symptoms of spinal cord injury. It is most effective when started as soon as possible after the injury occurs.
Initial dose: 30 mg/Kg Solu-Medrol IV push, give over 1-2 minutes.

Maintenance dose: 5.4 mg/Kg/hour by continuous IV drip for 23 hours.

 If the protocol is started more than 6 hours after the original injury, continue the IV drip for

48 hours.

 All persons started on the Solu-Medrol protocol should also receive ulcer prophylaxis: Zantac,

50 Mg IV or IM every 6-8 hours, or 150 Mg orally every 12 hours.

Example Solu-Medrol Protocol Calculation: A 100 Kg person requires an initial bolus of 3 GRAMS of Solu-Medrol, followed by an IV drip giving 540 mg of Solu-Medrol per hour for the next 23-48 hours.
Clinical Clearing of the Cervical Spine: In some rescue or combat situations, the risks incurred by taking the time to do complete cervical spine immobilization, or of transporting an otherwise ambulatory patient with C-spine precautions are significant. In these situations, the following protocol can be used to determine if the patient requires c-spine immobilization.
1. Combat or Rescue Situation: Note: Accomplished when C-spine precautions will adversely affect the ability to accomplish the mission AND all of the following conditions are met and documented:
a) The patient is fully awake and alert with no alcohol or medications on board that might

alter his sensorium or level of consciousness.


b) The patient has no painful ‘distracting’ injuries (such as femur fracture, pelvic fracture, and long bone fracture or significant chest/abdominal injury). No significant head or facial trauma.
c) The patient has a completely normal motor and sensory neurological examination, and does not have any significant neck pain or any midline or paraspinous muscle spasm.
d) There is no pain or tenderness to palpation of the posterior cervical spine, and no palpable

step-offs of the cervical spine. No muscle spasm in midline or paraspinous muscles.


e) The patient has no other injury that might require long-board immobilization (thoracic or

lumbar spine injury, pelvic fracture).


f) The patient has no pain on unassisted range of motion of the neck.
g) Low suspicion of cervical spine injury based on mechanism of injury.
Note: This protocol does not fully clear the cervical spine. However, if properly done, this protocol will insure that the chance of missing a clinically significant cervical spine injury is minimal.

Caution: Documentation of all of the above criteria being met is MANDATORY. If in doubt, immobilize the cervical spine.
2. Combat situations only: Penetrating trauma to the neck alone does not absolutely require

C-spine immobilization. However, minimize motion of the neck as much as possible. DO NOT stop to perform cervical spine immobilization while under direct fire. (See Tactical Combat Trauma Care, page 9).


Dermatome Chart
Sensory Level Determination:



Motor Level Determination:
Decorticate Posturing: Arms flexed, Legs extended = lesion at or above upper brainstem.

Decerebrate Posturing: Arms and legs extended = lesion in the brainstem

Flaccid Paralysis: Usually indicates spinal cord injury.

HEAD INJURIES
Guidelines and Considerations:

All patients with significant Head/Face injuries have a spinal injury until proven otherwise.

 Use in-line stabilization & enough people to move pt w/out manipulating C -Spine.

 Maintain airway. Do not obstruct breathing

 Maintain a high index of suspicion for cerebral insult until proven otherwise.

The most important element in assessment of head injury is LOC and noted changes.

Serial Glasgow Coma Scale readings should be accomplished on all head injury patients.

Note: Isolated head injuries do not cause shock. If shock is present in such a patient, search for

other causes of shock.


Physical Findings and Indications
Primary Survey:

ABCs: An open and secure airway is critical.

 Patients with head injuries commonly vomit or patients tongue blocks airway.


Level of Consciousness: AVPU (see page 41)
Glasgow Coma Scale: (see page 42)
Vital Signs: Observe and record every 5 minutes.

Observe Blood Pressure for: Increasing Intracranial Pressure (ICP); Increasing BP; Widening

pulse pressure. If possible, maintain BP between 100-140 mmHg systolic.

 Pain and fear can also increase BP

Observe Pulse for: ICP with decreasing pulse rate; slowing of pulse rate (strong/steady/bounding)

Observe Respirations for: Increasing, decreasing and/or become irregular; Cheyne-Stokes

 Fear, hysteria, chest injuries, etc. also affect respiratory rate (not as reliable as other VS)

Observe for Cushing’s Reflex: Slowing pulse rate, deep erratic respirations, and increasing blood pressure.


Secondary Survey:

1. Obtain a history if possible to determine the MOI.

2. Maintain cervical spine immobilization.

3. Examine the scalp for evidence of bleeding, swelling and deformity.

4. Examine the nose and ears for blood and cerebral spinal fluid.

5. Gently palpate the skull (don't press on depressed areas or explore open wounds.)

6. Observe pupillary reaction

7. Record all findings and continue with remainder of secondary assessment.
Treatment:

1. Secure airway, ensure breathing and circulation

2. Maintain cervical spinal immobilization

3. Oxygen 4-8L/min (If evidence of increased intracranial pressure, see next section)

4. IV normal saline, titrate appropriately (If shock develops give adequate fluid volume to maintain systolic

blood pressure at 100). Saline lock is an excellent alternative to having a running IV in place.



5. Gently dress all scalp wounds (If there is concern of underlying fracture, do not apply pressure)

6. Consider antibiotics (Rocephin) in an open skull injury if more than 4 hours to higher level care

7. Transport ASAP. If possible, elevate the head of the patient by raising the head end of the litter 1-2 feet

higher than the foot end of the litter.


8. If bleeding from scalp wounds is not controlled by pressure, consider suturing with 0-nylon or use skin

staples to close. Caution: If brain tissue is seen in the wound, DO NOT irrigate with dilute betadine

solution: Irrigate with normal saline only.
Increased Intracranial Pressure (ICP): Increased ICP can be the result of several different types of intracranial processes. Some, such as subdural or epidural hematoma can only be managed definitively by surgical intervention. Diffuse brain injury causing swelling of the brain itself can be treated to some extent in the field. As the brain swells, a herniation syndrome can result, where the intracranial contents shift and herniate through the cranial foramen.
Signs& Symptoms:

 GCS less than or equal to 10, or deteriorating GCS.

Asymmetric Pupils: Classically a large, fixed pupil suggests herniation, usually with the expanding mass on the same side as the fixed & dilated pupil. Typically, changes progress from sluggish pupil odd-shaped pupil fixed/dilated pupil. Asymmetrical pupil size, responsiveness or size differences of

1.5 mm are considered pathological until proven otherwise.

Note: Approximately 3% of the population have asymmetric pupils normally (anisocoria) and that

some eye surgery can result in odd-shaped and fixed pupils.

 Motor examination showing decreased strength, localized weakness or abnormal motor posturing.

(decorticate or decerebrate posturing).

 Abnormal cranial nerve examination (especially decreasing gag reflex), pupillary response or corneal

reflexes.

 Decreasing LOC or other neurological deterioration in the setting of acute head injury.
Treatment:

1. Hypotension is rarely caused by isolated head injury. Regardless of cause, hypotension must be treated

aggressively in the setting of acute head injury. Keep systolic BP above 95 mmHg by stopping bleeding

and appropriate fluid resuscitation.

2. Caution: Prolonged Hyperventilation of the patient in the field is no longer appropriate treatment. Vasoconstriction resulting from hyperventilation can Increase cerebral damage by reducing cerebral blood flow.

3. Mannitol: This is an osmotic diuretic that can decrease cerebral edema. It takes effect within minutes of

administration and can last 6-8 hours. Use mannitol ONLY if there is evidence of increased ICP. Note: Mannitol increases urine flow (making this an unreliable indicator of resuscitation) and causes dehydration.

Increase IV fluids to compensate.

GCS of 9 or below: 1.0 mg/Kg not to exceed 100 grams IV bolus.



4. Elevate the patient’s head higher than his feet by 1-2 feet. The patient should be kept flat: Elevate the

head of the stretcher/stokes litter to accomplish this.



5. Note: Steroids such as Solu-Medrol and Decadron are ineffective in treating traumatically induced

cerebral edema, and should NOT be used in the setting of trauma-induced increased ICP.

6. Seizure in the setting of acute head injury is a serious sign, and should be treated aggressively. Insure

the patient is being adequately oxygenated, and give Diazepam, 0.1 mg/Kg up to 5 mg IV every 5

minutes (up to a max dose total of 20 mg).
FACIAL AND EYE TRAUMA
Airway Obstruction From:

Posterior Tongue Displacement:

Unconscious patient: Jaw thrust or chin lift.

Conscious patient: Most common cause is bilateral mandible fracture. Have patient bend

forward (Caution: C-spine control) and pull tongue forward or insert airway adjunct.


Oropharyngeal Bleeding:

 Rotate supine patient to the side. Allow for drainage. (Caution: C-spine control)

 Suction & direct pressure if possible.
Edema:

 Early intubation if possible

 If unable to intubate, cricothyroidotomy may be needed
Blood Loss from Facial Trauma:

 Pressure dressing to most areas of face.

Specific locations:

 Severe Tongue Laceration: If pressure unsuccessful, a few sutures may be needed.

 Gingiva, Floor of Mouth, Buccal Mucosa: Pressure dressing with roll of sterile gauze.

Have patient bite on roll or hold in place with pressure.



Epistaxis (Nasal Bleeding):

1. Direct pressure: Pinch anterior portion of nose between fingers for a minimum of 5 minutes.

2. Packing: Anterior or Posterior. Note: All patients who have had nasal packing should be given

antibiotics (Keflex, 500 mg q. 6 hours or Cefotan, 1 gram IV or IM q. 12 hours). Caution: DO NOT

attempt to pack a nose if a cerebral spinal fluid (CSF) leak is suspected.

Anterior Pack: Layer strips of petrolatum gauze in one or both nostrils.

Posterior Pack: Used if bleeding persists in the nasopharynx after the anterior packing.

Note: Observe patient closely. If the pack becomes loose it can easily obstruct the airway.

a) Remove packing. Insert foley catheter through the nose until it is visualized in the

pharynx.



b) Inflate balloon with approx. 15cc of fluid. Put traction on the catheter, setting the

balloon into the back of the nose. Once in place, pack around the catheter with

petrolatum gauze and maintain traction.

c) If there are no contraindications, patients who require a posterior pack should receive

sedation.



Ocular Trauma:

Guidelines and Considerations:

1. Obtain history of injury, pre-existing conditions, i.e. contact lens use. If chemically induced, type of

chemical, treatment, visual disturbance, pain, any other associated injuries.



2. Time of injury.

3. Obtain gross visual acuity and record. Visual acuity can be as simple as light perception, count fingers

at three feet, read this book at 2 feet, etc.



Note: Always obtain a visual acuity with ocular injuries! (Before and after treatment, if possible)

Caution: In cases of chemical splash injury to the eye, begin irrigation immediately!

Physical Examination
Eyelids: Assess for: Edema, bruising, burns, movement and strength, ptosis, foreign bodies impacting the globe.

Orbital rim: Gently palpate for: Depressed fractures or loss of sensation to the skin above and below the globe.

Globe: Retract lids without applying pressure to globe. Examine for: Forward or retro displacement of the globe. Assess for: Normal movement and double vision at the extremes of gaze and integrity of the globe. Examine for: Foreign body or obvious damage.

Conjunctiva: Assess for: Signs of infection, evidence of subconjunctival air, hemorrhage, or foreign bodies.

Cornea: Assess for: Tears, abrasions and clarity.

Pupils: Assess for: Red light reflex, reactivity to light, and shape.

Anterior chamber: Assess for: Blood and dislocation of lens.

Lens: Examine for: Clarity and position.

Specific Injuries and Treatment:

Lid: Examine for: Foreign bodies. Invert lid to examine globe for laceration, penetrating injury, and impaled object. Treatment: Apply dressing and transport. DO NOT suture laceration.
Corneal Abrasion: Examine for: pain, foreign body sensation, and photophobia. Treatment: Instill antibiotic ointment, transport.

Foreign Body: Examine for: Pain, foreign body sensation. Treatment: Irrigate eye and treat as for corneal abrasion. If foreign body is still present instill antibiotic ointment. Patch both eyes to prevent eye movement. Transport.

Caution: If it appears the foreign body has penetrated into the anterior or posterior chamber: Do not patch and do not use ointment. Shield eye and transport.
Blood in Anterior Chamber (Hyphema): A sign of possibly severe eye injury.

Treatment: Keep patient as still as possible, maintain sitting position and immediate transport.
Iritis: May present as: Constricted, dilated or irregular pupil; hyphema or severe photophobia.

Treatment: Rest and transport.
Lens: About the only lens injury you may be able to assess will be anterior dislocation.

Treatment: Rest and transport.

Vitreous: Blood in the posterior chamber, interfering with light transfer through the vitreous may be assessed with a black rather than a red fundoscopic reflex. Treatment: Rest and transport.
Globe: Possible ruptured globe; Possible marked visual impairment. Vitreous may be seen extruding from the globe. Globe may be soft and anterior chamber flat or shallow.

Caution: Palpation of globe may cause increased loss of vitreous.

Treatment: Eye shield (no pressure applied to globe) and moist dressing. Immediate transport. Cipro, 500 mg b.i.d.

Chemical Injuries: History and physical examination. Treatment: Copious irrigation for at least 30 minutes prior to or during transport. Use water, normal saline or lactated ringers.

Note: Any water will do in a pinch.
Caution: If the victim has had an alkali compound (such as lye or ammonia) splashed into the eye, irrigation must begin AT ONCE. This is the only time you do not take the time to evaluate the visual acuity prior to starting treatment. Continue irrigation for a minimum of 60 minutes or until directed to stop by medical control.
Traumatic Enucleation: Globe displaced from orbit.

Treatment: Protect globe with moist sterile gauze, shield globe and immediate transport.


REDUCED SNELLEN CHART
E ------------------200

N Z -----------------120

Y L S ----------------80

U F V P --------------60

N S T R F ---------------40

R O L C T B -----------30

M E V P T R U -----------20

Designation at side of line represents Visual Acuity in Snellen notation for 16’’ viewing distance



CHEST TRAUMA
Guidelines and Considerations



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