Ranger Medic Handbook Draft 2003 - 1

RANGER MEDIC
HANDBOOK
2003
DRAFT
Trauma Management Team
DRAFT
TABLE OF CONTENTS
SECTION SUBJECT PAGE
MEDICAL: RANGER MEDIC SCOPE OF PRACTICE------ 6

PATIENT ASSESSMENT & MANAGEMENT-- 10
PROTOCOLS
OROTRACHEAL INTUBATION--------------------------------- 17
COMBITUBE SA---------------------------------------------------- 18
SURGICAL CRICOTHYROIDOTOMY------------------------- 19
NEEDLE DECOMPRESSION------------------------------------- 20
CHEST TUBE INSERTION---------------------------------------- 21
EXTERNAL JUGULAR CANNULATION---------------------- 22
STERNAL INTRAOSSEOUS INFUSION (FAST-1)---------- 23
ANAPHYLACTIC SHOCK MANAGEMENT-------------------24
BURN MANAGEMENT---------------------------------------------25
HEAD INJURY MANAGEMENT-------------------------------- 26
SPINAL CORD INJURY MANAGEMENT -------------------- 27
HYPOTHERMIA MANAGEMENT ----------------------------- 28
PHARMACOLOGY
PHARMACOLOGY QUICK REFERENCE SHEET------ 29
ACETAMINOPHEN------------------------------------------------ 30
ALBUTEROL--------------------------------------------------------- 31
BACITRACIN-------------------------------------------------------- 32
BENZONATE-------------------------------------------------------- 33
CEFOXITIN----------------------------------------------------------- 34
DEXTROSE 50%----------------------------------------------------- 35
DIAZEPAM----------------------------------------------------------- 36
DIPHENHYDRAMINE---------------------------------------------- 37
EPINEPHRINE-------------------------------------------------------- 38
HETASTARCH------------------------------------------------------- 39
IBUPROFEN---------------------------------------------------------- 40
KETOROLAC-------------------------------------------------------- 41
LIDOCAINE 1%----------------------------------------------------- 42
LOPERAMIDE-------------------------------------------------------- 43
LORATADINE-------------------------------------------------------- 44
MECLIZINE----------------------------------------------------------- 45
MORPHINE----------------------------------------------------------- 46
NALOXONE---------------------------------------------------------- 47
PSEUDOEPHEDRINE---------------------------------------------- 48
PROMETHAZINE--------------------------------------------------- 49
VERSED--------------------------------------------------------------- 50
TACTICAL: TACTICAL COMBAT CASUALTY CARE------ 51
CCP DIAGRAM-----------------------------------------53
PLANNING: MEDICAL EVALUATION CHECKLIST---------54
HAZERDOUS TRAINING CHECKLIST--------- 58
5
DRAFT
RANGER MEDIC SCOPE OF PRACTICE
DEFINITIONS
RANGER FIRST RESPONDER (RFR) – A Ranger who has attended and successfully
completed the Ranger First Responder Course.
SQUAD EMT – A non-medical MOS Ranger currently registered as an EMT-
Basic/Intermediate by the Department of Transportation (DOT). This individual functions
as a bridge between the RFR and the Ranger Medic for tactical and administrative trauma
management.
ADVANCED TRAUMA MANAGER (ATM) - Ranger Medic currently registered as
an EMT-Paramedic by the DOT who has been awarded the identifier W1 (Special
Operations Combat Medic) and has been approved by the Medical Director (Regimental
/ Battalion Surgeon) to function at this advanced level of care.
Standing Orders - Advanced life support interventions which may be undertaken before
contacting on-line medical control.
Protocols - Guidelines for out of hospital patient care. Only the portion of the guidelines
which are designated “standing orders” may be undertaken before contacting on-line
medical control.
Medical Control – A credentialed physician or physician assistant, available on-site or
through established communications, who verbally, or in writing, assumes medical
responsibility and liability,. Medical direction of advanced life-saving activities will be
routed through medical control to assist in providing the best care to all injured Rangers.
Units will establish Medical Control whether the mission is an airfield seizure or
administrative medical coverage of a range. All medical care falls under the licensure
of the Regimental/Battalion Surgeon.
APPLICATION OF PROTOCOLS
These protocols are for use only by Ranger Medical personnel assigned to the 75th
Ranger Regiment while providing BLS, ALS, and TCCC. .
Purpose
The primary purpose of these protocols/standing orders is to serve as a guideline for out-
of-hospital care. Quality out-of-hospital care is the direct result of comprehensive
education, accurate patient assessment, good judgment, and continuous quality
improvement. All Ranger medical personnel will know the Trauma Management Team
Protocols and understand the reasoning behind their employment. Ranger Medics will
not perform any step or steps in a standing order or protocol if they have not been trained
to perform the procedure or treatment in question.
6
DRAFT
Protocols
Ranger medical personnel who are authorized to operate under the Trauma Management
Team guidelines may utilize these standing orders only within the scope of their military
duties. All Ranger medical personnel will adhere to the standards defined in these
protocols orders, or face revocation of privileges by the granting authority if these
standards are violated.
Communications
In case the Ranger Medic cannot contact medical control (ie. acute time-sensitive
injury/illness, mass casualty scenario, or communication difficulties), all protocols
become standing orders. Likewise, in the event that medical control cannot respond to
the radio/telephone within two minutes of the call, the medic will assume that all
protocols are standing orders. In these cases, the senior medic involved will contact
Medical Control as soon as feasible following the incident. Medical Control will review
the record (Trauma SF 600) and countersign as the medical authority to indicate
retroactive approval.
GENERAL GUIDELINES FOR PROTOCOL USAGE

1. Do not obtain a patient history at the expense of the patient. Immediately treat
life-threatening problems detected in the primary survey.
2. Do not treat cardiac arrest due to trauma by medical cardiac arrest protocols.
Promptly transport trauma patients to the previously coordinated Medical
Treatment Facility while conducting CPR, hemorrhage control, cervical spine
immobilization, and other indicated procedures.
3. In patients with non-life-threatening emergencies who require an IV/Saline Lock,
attempt only two IV insertions in the field. Do not delay patient transport to
definitive care for multiple attempts at IV access or advanced medical procedures.
4. Medics will verbally repeat all orders received their execution (i.e. two-man
Trauma Team/RTF Code).
5. Place all patients on a monitor and the following documentation: pulse, blood
pressure, SpO2, and cardiac rhythm.
NEVER HESITATE TO CONTACT THE SURGEON FOR ANY PROBLEM,

QUESTION, OR ADDITIONAL INFORMATION.
7
DRAFT
SPECIAL CONSIDERATIONS
IV Therapy
1. Place at least one, and preferably two, saline locks/IVs in all trauma patients.
2. Trauma patients with controlled bleeding and a systolic blood pressure <90 mm
Hg . Give wide-open fluids (Hextend preferred over normal saline) until the
systolic blood pressure is >90 mm Hg.
3. Trauma patients with controlled bleeding and a systolic blood pressure >90 mm
Hg. Give saline lock only, fluids at a ”to keep open” (TKO) rate, or as directed
in the applicable protocol.
4. Trauma patients with uncontrolled hemorrhage. Give a saline lock only, fluids at
a ”to keep open” (TKO) rate, or as directed in the applicable protocol.
5. All initial IV attempts are peripheral. The external jugular vein is a peripheral
vein. Place a FAST-1, Sternal Intraosseous only in patients who have a life-
threatening emergency where immediate fluid or medication administration
is necessary and a peripheral vein is inaccessible. Only Ranger Medics who
have obtained the required education in sternal intraosseous needle placement and
who have been approved by the Battalion Surgeon may place intraosseous
needles.
6. Each IV bag ill be labeled with the following data:
Time and date of IV start
IV cannula size
Initials of Ranger Medic who started the IV
Combitube Insertion
Confirm and document proper Combitube placement by:
Presence of bilateral breath sounds.
Absence of breath sounds over the epigastrium.
Use of an endotracheal esophageal detector (Tube Check).
Endotracheal Intubation
1. Confirm and document proper endotracheal tube placement by at least three of the
following methods:
Presence of bilateral breath sounds.
Absence of breath sounds over the epigastrium.
Presence of condensation on the inside of the endotracheal tube.
End-tidal carbon dioxide monitoring.
Visualizing the tube passing through the cords.
Use of an endotracheal esophageal detector (Tube Check).
8
DRAFT
2. Following endotracheal intubation, re-verify tube placement every 5-10 minutes by
noting bilateral breath sounds.
Endotracheal Drug Administration
1. Ranger medics may administer the following four drugs via an endotracheal tube:
L - Lidocaine
E - Epinephrine
A - Atropine Sulfate
N – Naloxone
2. When administering drugs via the endotracheal tube, administer 2.0 - 2.5 times the IV
dose diluted in sufficient normal saline to result in a total volume of at least 10 ml.
This facilitates endotracheal instillation and aids in increased drug delivery to the
respiratory tissues.
Patient Information Documentation

Document patient information and procedures utilizing the following:
Tactical – 75th Combat Casualty Card.
Non-Tactical - Trauma SF 600 or Standard SF 600.
RESUSCITATION CONSIDERATIONS
1. Do not attempt resuscitation in the field in cases of:
Rigor mortis
Decapitation
Decomposition
Obvious massive head or chest/abdomen trauma, which is incompatible with
life (provided the patient does not have vital signs)
2. Consider option of “Medical Retirement”. This may require transfer to a military
medical facility, but can provide increased benefits for surviving family members.
3. Consider the potential for organ donation. Patients who have sustained mortal injuries
may still warrant emergent care until a determination can be made whether the patient
may be a potential organ or tissue donor.
4. Consider the application of resuscitation efforts if this is your only patient and the
trauma occurred during training. Fellow Rangers and family members should believe
that every effort was made to sustain life.
5. When possible, place the “quick look” paddles or the ECG leads to confirm asystole
or an agonal rhythm and attach a copy of the strip to the Trauma SF 600.
9
DRAFT
PATIENT ASSESSMENT AND MANAGEMENT
I. Overview
ESTABLISH PRIORITIES
1. Obtain situational awareness, then ensure scene security.
2. Control yourself, then take control of the situation.
3. The senior medic on the scene controls the resuscitation effort and issues all
orders to team members.
PRIMARY SURVEY
During the primary survey, identify life-threatening conditions and begin management.
The primary survey consists of:
A - Airway Maintenance and C-spine stabilization
B - Breathing
C - Circulation with control of massive hemorrhage
D - Disability (mental status)
E - Exposure/Environmental Control [undress patient, but prevent hypothermia]
RESUSCITATION
Aggressive initial resuscitation includes airway establishment and protection, ventilation
and oxygenation, hemorrhage control, IV fluid administration as needed, and
hypothermia prevention. Reassess the patient for changes in status as you perform
resuscitative interventions.
SECONDARY SURVEY
The secondary survey consists of obtaining a brief history and conducting a head-to-toe
evaluation of the trauma patient. This in-depth examination utilizes inspection, palpation,
percussion, and auscultation, to evaluate the body in sections. Examine ach section
individually.
TREATMENT PLAN
First, provide critical resuscitative efforts to resolve potential life-threatening injuries
detected in the primary and secondary survey. Second, determine patient disposition. Is
the patient stable or unstable? What further diagnostic evaluation, operative intervention,
or treatment does the patient need? What level of medical care does the patient need?
When does the patient need evacuation? The senior medic must answer all of these
questions ed in a logical fashion in order to prioritize and mobilize the resources
available.
10
DRAFT
II. The Primary Survey
The primary survey consistes of five major areas: Airway and c-spine control, Breathing,
Circulation, Disability, Exposure/Environment Control.
A. AIRWAY AND C-SPINE

Assess the upper airway to ascertain patency. Chin lift, jaw thrust, or suction may be
helpful in establishing an airway.
Direct specific attention toward the possibility of a cervical spine fracture. Avoid
extending or flexing the patient's head and neck to establish or maintain an airway.
Assume a cervical spine fracture in any patient with an injury above the clavicle as
approximately fifteen percent of patients who have this type of injury will also have a c-
spine injury.
B. BREATHING
Expose the patient’s chest look for symmetrical movement of the chest wall.
Conditions that often compromise ventilation include: MASSIVE HEMOTHORAX,
TENSION PNEUMOTHORAX, OPEN PNEUMOTHORAX, and FLAIL CHEST.
C. CIRCULATION
Circulation consists of two parts: Hemodynamic Status and Hemorrhage Control.
1. Hemodynamic Status
Do not perform a formal blood pressure measurement at this point in the primary
survey. Obtain important information regarding perfusion and oxygenation from
the level of consciousness, pulse, skin color, and capillary refill time. Decreased
cerebral perfusion may cause an altered mental status. Use the patient's pulse as a
rough approximation of the systolic blood pressure.:
RADIAL PULSE: PRESSURE ≥ 80mmHg
FEMORAL PULSE: PRESSURE ≥ 70mmHg
CAROTID PULSE: PRESSURE ≥ 60mmHg
Skin color and capillary refill provide a rapid initial assessment of peripheral
perfusion. Pink skin is a good sign versus the ominous sign of white, ashen, or
gray skin indicating hypovolemia. Pressure to the thumb nail or hypothenar
eminence will cause the underlying tissue to blanch. In a normovolemic patient,
the color returns to normal within two seconds while in the hypovolemic or
hypothermic patient this time period is greater than two seconds.
11
DRAFT
2. Hemorrhage Control
a. EXTERNAL HEMORRHAGE. Identify and control exsanguinating
external hemorrhage in the primary survey. Utilize direct pressure and
pressure bandages to control bleeding. Use tourniquets as needed for
traumatic amputations and in the tactical environment.
b. INTERNAL HEMORRHAGE. Occult hemorrhage into the
thoracic, abdominal, or pelvic regions, or into the thigh surrounding a
femur fracture may account for significant blood loss. If an operating
room is not immediately available, reduce abdominal or lower
extremity hemorrhage by the application of the pneumatic anti-shock
garment.
c. Estimated Fluid and Blood Requirements in Shock (Based on
Patient’s Initial Presentation):
Class I Class II Class III Class IV
Blood Loss (ml) Up to 750 750-1500 1500-2000 > 2000
Blood Loss(%BV) Up to 15% 15-30% 30-40% > 40%
Pulse Rate < 100 > 100 > 120 > 140
Blood Pressure Normal Normal Decreased Decreased
Pulse Pressure Normal or Decreased Decreased Decreased

(mm Hg) increased
Capillary Blanch Test Normal Positive Positive Positive
Respiratory Rate 14-20 20-30 30-40 > 35
Urine Output (mL/hr) > 30 20-30 5-15 Negligible
CNS-Mental Status Slightly Mildly Anxious & Confused-

anxious anxious confused lethargic
Fluid Replacement Crystalloid Crystalloid Crystalloid & Crystalloid &

(3:1 Rule) blood blood
12
DRAFT
D. DISABILITY (MENTAL STATUS)
Utilize a rapid neurological evaluation to determine the patient's pupillary size and
response, as well as the level of consciousness (LOC). Pupils should be equal and
reactive. If the pupils are sluggish or nonreactive to light with unilateral or bilateral
dilation, suspect a head injury and/or inadequate brain perfusion. Describe decreased
mental status through either the AVPU or Glasgow Coma Scale (GCS):
AVPU: A - Alert
V - responds to Verbal stimuli
P - responds only to Painful stimuli
U - Unresponsive to all stimuli
GCS: (15 point scale) Action: Points:
E - Eye Opening: Spontaneous 4
To Speech 3
To Pain 2
None 1
V – Verbal Response: Oriented 5

Confused Conversation 4
Inappropriate Words 3
Incomprehensible Sounds 2
None 1
M – Motor Response: Obeys Commands 6
Localizes Pain 5
Normal Flexion (Withdraws) 4
Abnormal Flexion (Decorticate) 3
Extension (Decerebrate) 2
None (Flaccid) 1
E. EXPOSURE/ENVIRONMENTAL CONTROL
Completely undress the patient (environment permitting) to facilitate thorough
examination and assessment during the secondary survey. Maintain the patient in a
normothermic state. Maintenance of normal body temperature is as important as
any other resuscitation effort.
III. Resuscitation
Resuscitation includes oxygenation, intravenous access, and monitoring.
OXYGEN
Administer supplemental oxygen to all trauma patients via a nonrebreather mask.
IV ACCESS
Start a minimum of two 18 gauge IV/saline locks any multiple trauma patient. Determine
the rate of fluid administration by the patient's hemodynamic status and whether or not
hemorrhage is controlled. Assess fluid resuscitation by improvement in physiologic
parameters such as ventilatory rate, pulse, blood pressure, and urinary output.
13
DRAFT
MONITORING
Continuously monitor all multiple trauma patients for ectopy. Arrhythmias are frequently
associated with blunt chest trauma and should be treated in the same fashion as
arrhythmias secondary to heart disease.
IV. The Secondary Survey

A complete history, physical (head-to-toe examination), and reassessment of vital signs.
HISTORY
Obtain the patient’s pertinent past medical history. A useful mnemonic is the word,
AMPLE.
Allergies
Medications
Past medical illnesses
Last meal
Events associated to the injury
PHYSICAL
The physical exam consists of eight parts: Head, Face, C-Spine and Neck, Chest,
Abdomen, Perineum and Rectum, Musculoskeletal, Neurologic.
1. HEAD
Begin the secondary survey with a detailed examination of the scalp and head
looking for signs of significant injury to include edema, contusions, lacerations,
foreign bodies, and evidence of fracture. Evaluate the eyes for visual acuity,
pupillary size, external ocular muscle function, conjuntival and fundal
hemorrhage, and contact lenses (remove before edema presents).
2. FACE
Treat maxillofacial trauma, unassociated with airway compromise and/or major
hemorrhage, after you have completely stabilized the patient. If the patient has
midface trauma, suspect a cribiform plate fracture, and if required, perform oral
intubation and NOT nasal intubation.
3. C-SPINE/NECK
Suspect an unstable cervical spine injury in patients with blunt head and/or
maxillofacial trauma. Absence of neurological deficit does not rule out cervical
spine injury. Assume a cervical spine injury and immobilize the neck until a
physician clears it. Cervical spine tenderness to palpation and spasm of the
musculature of the neck may indicate a cervical spine injury. The absence of
neck pain and spasm in a patient who is neurologically intact is good evidence
that a C-spine injury does not exist. However, it does not eliminate the need for
14
DRAFT
radiographic cervical spine evaluation. Use neck inspection, palpation, and
auscultation to evaluate for subcutaneous emphysema, tracheal deviation,
laryngeal fracture, and carotid artery injury. In the absence of hypovolemia, neck
vein distension may indicate a tension pneumothorax or cardiac tamponade.
4. CHEST
Perform a complete inspection of the anterior and posterior aspect of the chest to
exclude an open pneumothorax or flail segment. Palpate the entire chest wall (rib
cage, sternum, and clavicles) to reveal fractures or costochondral separation.
Auscultate to evaluate for the alteration of breath sounds denoting a
pneumothorax, tension pneumothorax, or hemothorax. Auscultation of distant
heart sounds may indicate a cardiac tamponade.
5. ABDOMEN
Any abdominal injury is potentially dangerous and, once identified, you must
treat these injuries quickly and aggressively. The specific diagnosis is not as
important as the fact that you recognize the existence of an abdominal injury that
may require surgical intervention. Palpation, close observation, and frequent
reevaluation of the abdomen are essential in the assessment and management of
an intra-abdominal injury. In blunt trauma, the initial examination of the
abdomen may be unremarkable. However, serial exams over time may reveal
increasing signs of tenderness and guarding.
6. RECTUM
A complete rectal examination in a trauma patient is essential and includes an
evaluation for rectal wall integrity, prostate position, sphincter tone, and gross or
occult blood.
7. EXTREMITIES
Inspect the extremities for lacerations, contusions, and deformities. Palpate the
bones, through rotational or three-point pressure, checking for tenderness,
crepitation, or abnormal movements along the shaft, to identify non-displaced or
occult fractures. Apply slight pressure (NO PELVIC ROCK) with the heels of
the hand on the anterior superior iliac spines and on the symphysis pubis to help
identify pelvic fractures. Assess peripheral pulses on all four extremities. The
absence of a peripheral pulse distal to a fracture or dislocation mandates
manipulation toward the position of function. If the pulse is still absent, transport
immediately.
8. NEUROLOGIC EXAMINATION
An in-depth neurologic examination includes motor and sensory evaluation of
each extremity, and continuous re-evaluation of the patient’s level of
consciousness and pupil size and response. Any evidence of loss of sensation,
weakness, or paralysis suggests a major injury either to the spinal column or
15
DRAFT
peripheral nervous system. Immediately establish immobilization using a long
board and a rigid cervical collar and evacuate soon as possible.
V. Reevaluation
Trauma patients require serial exams and reevaluation for change or new signs
and symptoms. Continuous observation, monitoring, vital sign assessment, and
urinary output maintenance (50cc/hour in the adult patient) is also imperative. As
you manage initial life-threatening injuries, other equally life-threatening may
develop. Less severe injuries or underlying medical problems may become
evident. A high index of suspicion facilitates early diagnosis and management.
VI. Summary
Rapidly and thoroughly evaluate the injured Ranger. Develop an outline of
priorities for your patient which includes the primary survey (airway and c-spine
control, breathing, circulation and mental status evaluation).
Begin resuscitation simultaneously with the primary survey including the

management of all life-threatening problems, the establishment of intravenous
access, the placement of EKG monitoring equipment, and the administration of
oxygen.
The secondary survey includes a total evaluation of the injured Ranger from head
to toe. Reassess the ABC’s and the interventions provided during the primary
survey. Document your findings and interventions on a Trauma SF 600 or 75th
CAX card.
16
DRAFT
Orotracheal Intubation
Assure adequate ventilation and
oxygenation are in progress and that
suctioning equipment is immediately
available
APPROVED___________
DATE________________
Check cuff of the ET Tube
Connect the laryngoscope blade to the handle and check bulb for
brightness. Ensure bulb is secure in the blade
Hold Laryngoscope in the left hand
Open patient's mouth with fingers of your right and insert the laryngoscope into
the right side of the patient's mouth, displacing the tongue to the left
Items Needed:
Visually Identify the epiglottis and then the vocal cords · Laryngoscope
· Miller and Macintosh
blades
· ET tubes
Insert the ET tube into the trachea · Suction
· Oxygen source
· Bag-valve-mask
Inflate the cuff · Stethoscope
· Stylet
· Syringe, 10 cc
· Lubricant, water
Confirm proper ET tube placement
soluble
· SpO2 monitor
· Gloves
Secure the tube · Tape
. Tube Check
Document:
· ABCs
· Detailed Assessment
· Vital Signs
· SpO2, ETCO2
· Glasgow Coma Scale
· Tube check results
· Lung Sounds
· Absence of Epigastric
Sounds
· Skin Color
· Teeth to ET Tube Tip
Depth
· Communication with
Medical Control
1 Maintain strict c-spine precautions if potential for c-spine injury exists.
2 Avoid applying pressure on teeth or lips.
4 Never use a prying motion.
5 Advance the ET tube: ensure the tube cuff is 1 to 2.5 cm below the vocal cords (on an adult).
6 Anytime the patient goes 30 seconds without ventilation , stop the procedure and hyperventilate
for 30-60 seconds before procedure is re-attempted.
7 Intubation is only to be attempted twice . After two unsuccessful attempts are made
transition to the COMBITUBE.
Airway
17
DRAFT
COMBITUBE SA
· ABCs
· Oxygen 100%
APPROVED___________
· Assist Ventilations, prn
DATE________________
Assemble & check equipment

Indications:
Place the patient's head in a neutral position
· Endotracheal intubation
cannot be performed
· Jaw-Lift Maneuver · Attempts at endotracheal
· Insert device to the depth indicated by the intubation have been
markings on the tube. The black rings should be unsuccessful
positioned between the patient's teeth. · Direct visualization of the
larynx is inhibited by profuse
Once the COMBITUBE SA is in place: bleeding
Inflate the pharyngeal cuff with 85 ml of air. 1
Inflate the distal cuff with 10 ml of air.

Contraindications:
· Less than 4 feet tall
Attach the Tube check to Tube 2 and · Patients with a gag reflex
confirm tube placement. · Patients who have ingested a
caustic substance
Begin ventilation through the longer, blue connector
(tube #1).
Lung Gastric Deflate both cuffs and withdraw the

sounds sounds
present No present No tube approximately 3 cm.
? ?
Yes Yes Reinflate both cuffs,
Ventilate through the shorter, reassess lung and
clear connector (tube #2). epigastric sounds 2
Gastric
sounds Add more air to
present Yes
? the distal cuff 2
No Document:
· Tube Markings at Teeth
Continue ventilations · SpO2
through tube #1. · Respiratory Status Before
and After Treatment
Confirm bilateral lung sounds · Lung & Gastric Sounds
& absence of gastric sounds. · Skin Color
· Indications for Use
· Absence of Gag Reflex
Assist Ventilations
· Patient's Age, Height
Reassess Airway Frequently
Transport ASAP
1 This seals the device in the posterior pharynx behind the hard palate. More air may be
added to the pharyngeal cuff if an inadequate seal is detected during ventilation.
2 At no time should the patient's airway or ventilatory status be compromised. If
placement is unsuccessful, remove the device and return to naso/oropharyngeal airway
and assist ventilations via bag-valve-mask.
3. When using a tube check with a Combitube you are confirming that the tube is in the
esophagus (tube check should not re-inflate)
NOTE: This protocol is ONLY to be used with the Combitube SA and does NOT apply
Airway
to the STANDARD Combitube.
18
DRAFT
Surgical Cricothyroidotomy
Prepare RGR CRIC KIT
Select site
APPROVED___________
Cricothyroid membrane: DATE________________
soft aspect just inferior the larynx,
midline, anterior trachea.
Cleanse site with povidine

Indications:
Severe facial injuries with severe
bleeding, anaphylaxis, chemical
Stabilize larynx between thumb and index finger inhalation injury or when other
of non-dominant hand means of establishing an airway
are not adequate.
Palpate cricothyroid membrane Contraindications:
Patients who can be intubated or
Make a transverse skin incision over the airway secured with a combitube
cricothyroid membrane, and carefully incise through
the membrane
Insert a tracheal hook into the cricothyroid

membrane, hook the cricoid cartilage and apply
anterior displacement
Insert a 7-0 ET tube through the midline of the membrane

and direct the tube distally into the trachea
Inflate the cuff of the ET Tube with 10 cc of air

and ventilate the patient
Items needed:
Secure the ET tube to the patient to prevent · Scalpel SZ 10
dislodging · Tracheal Hook
· Povidine solution
· Gloves
Ventilate, as needed 100%Oxygen · Sterile 4x4s
· Bag-valve device
· 7-0mm ET tube
Confirm Proper tube placement
Auscultate breath sounds, monitor SpO2
and/or ETCO2, and chest rise
Airway
19
DRAFT
Needle Decompression
· ABCs
· Oxygen 100%
· Transport ASAP APPROVED___________
DATE________________
Items Needed:
Select site: affected side, 2nd intercostal space, · 10-14g 2.5-3.0 needle with
mid-clavicular line catheter
· Povidine swab
Cleanse site with povidine
Remove the Luer-Lok from the distal end of the

catheter, insert the needle/cath over the rib intothe
intercostal space and puncture the parietal pleura.
Remove the needle from the catheter and

listen for a sudden escape of air.
Leave catheter in place converting the

tension to an open pneumothorax.
Ensure tension has been relieved. If Not

repeat procedure.
Auscultate breath sounds FREQUENTLY and Document:

monitor PT status. · Airway
· Respiratory Status
· SpO2
· Vital Signs
Monitor SpO2, cardiac rhythm and clinical · Cardiac Rhythm
status · Lung Sounds Before
and After Decompression
· Skin Color
· Chest Rise/Excursion
Signs & Symptoms to look for when assessing · Capillary Refill
Tension Pneumothorax · Response to Treatment
· Increases Respiratory Distress · Site Selection
· Unilateral chest movement
· Decreased breath sounds on the affected side
· Distended Neck Veins
· Tracheal Deviation
· Shock
Breathing
20
DRAFT
Chest Tube Insertion

· ABCs
· Oxygen 100%
· Transport ASAP APPROVED___________
DATE________________
Items Needed:
Select site: affected side, 5nd intercostal space, 9" Peans
(nipple level) anterior to the midaxillary line 1-0 Armed Suture
Povidine Solution
# 10 Scalpel
Cleanse site with povidine # 36-38 Chest Tube
Heimlick Valve
Locally anesthetize the skin and rib periosteum 4x4's
Petrolatun Gauze
18 Gauge needle
Make a 2-3 cm horizontal incision at the predetermined
10 cc Syringe
site and bluntly dissect through the subcutaneous tissues
1% Lidocaine
just over the top of the 6th rib
Chux
Punture the parietal pleura with the tip of 2"Tape
the clamp and spread the tissues. Sterile Gloves
With the index finger of the nondominant hand trace the

clamp into the incision to avoid injury to other organs and
clear any adhesions or clots.
With the index finger of the non dominant hand remaining

in place, clamp the proximal end of the chest tube and and
insert into the chest cavity to the desired lenght. Document:
· Airway
· Respiratory Status
Look for "fogging" of the chest tube with · SpO2
expiration. · Vital Signs
· Cardiac Rhythm
· Lung Sounds Before
Connect the end of the chest tube to the heimlick and After Chest Tube
valve. Insertion
· Skin Color
· Chest Rise/Excursion
Suture the tube in place · Capillary Refill
· Response to Treatment
· Site Selection
Apply dressings: wrap tube with pertolatun gauze

then cut 4 x 4's. Tape the tube to the chest
Monitor SpO2, cardiac rhythm and clinical

status
Breathing
21
DRAFT
External Jugular Cannulation

Technique
APPROVED___________
Place patient supine 1 DATE________________
c-spine
precautions Immobilize c-spine
indicated Yes
? Items needed:
No · IV needle/catheter
· IV fluid
Turn patients head slightly to the opposite side · IV tubing/saline lock
· Povidine
· Tegaderm dressing
Cleanse site with povidine · Saline Flush
Align needle/catheter and syringe with saline
flush attached in the direction of the vein with the Document:
tip of the needle aimed toward the ipsilateral 2 · Procedure
nipple · ABCs
· Detailed Assessment
Apply light pressure on the inferior aspect of the · Vital Signs, SpO2
external jugular to create a tourniquet affect 3 · Cardiac Rhythm
· Number of Attempts
Insert needle and enter the vein and · Amount of IV Fluid
aspirate 4 Infused
Note blood return and advance catheter
Withdraw needle/catheter and attach IV

tubing and (or) saline lock. 4
Cover site with tegaderm

dressing
1 Modified Trendelenburg position is an ideal position. This position is not mandatory

yet will help distend the external jugular vein and decrease the likelihood of introducing air
into the vein.
2 Ipsilateral: "on the same side". If you are cannulating the right external jugular vein the
needle should be aimed toward the right nipple.
3 Light pressure below the vein will help distend the vein.
4 Be certain air is not allowed to enter the vein.
Circulation
22
DRAFT
Sternal Intraosseous Infusion

FAST-1
Site Selection
APPROVED___________
DATE________________
Adult Manubrium: Midline on the maubrium, 1.5
cm below the sternal notch.
Indications:
Prepare Site · Inability to attain vascular
access through A/C or external
Local Anesthetic if jugular vein when life saving
conscience fluids and (or) medications are
needed.
Prep site with povidine swab
Use index finger of non-dominant hand to align

the target patch with the patients sternal notch.
Items Needed:
With patch securely attached to PT's skin, the · FAST-1 complete
bone probe cluster is placed in the target zone,
perpendicular to the skin
FAST-1 Insertion
With the introducer in hand, apply steady even

pressure until infusion tube has penetrated the
manubrium
Attach the infusion tube to the right angle female

adapter and secure site with protector dome 2
Attach syringe to the IV insertion site and aspirate bone marrow.
Flush the needle

Aspirates with 5 cc saline flush Flushes Attempt to administer fluid
freely No easily and or medication
No
? ?
Yes Yes
Attach IV tubing/saline
lock
Administer IV fluids, medications as needed
Secure inducer removal device to IV line or patient
Circulation
23
DRAFT
Anaphylactic Shock Management

· ABCs
· Oxygen 100% APPROVED___________
· Transport ASAP 1 DATE________________
Resp
· Oxygen 100%
rate <10 or
>30 Yes · Assist with BVM, prn Signs & Symptoms
? associated with Anaphylaxis:
No S.O.B., wheeze, hoarseness, hives, itching,
Start IV chest tightness, nausea, abdominal cramps,
Normal saline generalized or local edema.
Monitor Cardiac Rhythm, SpO2
Breath Bilateral wheezes, or

sounds diminished or absent
?
Oxygen 100%
Normal
· Epinephrine 1:1,000
0.3 cc SQ or IM 2 3
· Monitor closely
Itching
flushing or Yes
Benadryl 50 mg IM
hives
?
No
· Monitor Closely
· Transport
1 Bee sting: gently remove stinger if still present.

2 Two (2) dilution’s of epinephrine are available: 1:1,000 is appropriate for SQ, IM, or SL
injections, 1:10,000 is for IV or ET use ONLY . Be sure to give the appropriate dilution.
3 Contact Medical Control if symptoms/signs persist.
Anaphylactic Shock Management
24
DRAFT
Burn Management
Scene
Secure the scene 1
secure No
? APPROVED___________
Yes
DATE________________
Stop the
burn process 2
ABCs Types of Burns:

· Thermal
· Airway 3
Remove from environment and
· Breathing extinguish fire
· Circulation 4 · Chemical
Transport ASAP Brush off and/or dilute chemical
Detailed Assessment without exposing rescuer.
Consider need for wearing your
protective mask.
· Electrical
Resp Oxygen 100% Intubate/COMBITUBE Make sure victim is de-energized
distress Assist Ventilations as needed 5
? Yes and suspect internal injuries
No
Evaluate degree of burn
and % body surface area involved 6
7
Critical Transport to the most Start Two IVs
burn Yes appropriate facility Normal Saline 8
?
No Administer IV fluid per
IV NS TKO Parkland Formula
Parkland Formula:
Dress burns IAW SOP · The IV fluid required for the first 24
hours = 4 ml/kg of LR x % area burned.
· Give half of the total fluid within the first
Treat associated injuries 8 hours of the burn. Give the second
half over the next 16 hours.
Consider pain control 9
· Notify receiving facility ASAP Document:

· Prevent hypothermia · Degree of Burn
· Monitor: · % of Body Burned
LOC, Vital Signs, Cardiac Rhythm, · Respiratory Status
SpO2, Respiratory Status · Singed Nares?
· SpO2
1 ensure scene safety . · Type of Burn
2 Remove clothes, flood with water ONLY if flames or smoldering is present.
3 Consider Carbon Monoxide poisoning if victim was within a confined space. If potential for
· Medical History
CO poisoning exists administer Oxygen 100%. · Confined Space yes
4 If shock is present consider underlying causes. or no
5 Consider Surgical cricothyrotomy if unable to intubate due to edema.
6 Note: the patient's palm represents 1% of their BSA. Use this as a reference.
7 Critical burn = · any degree 25% BSA · 3rd degree > 10% · respiratory injury · involvement of
face, hands, feet, or genitalia · circumferential burns · associated injuries · electrical or deep
chemical burns · underlying medical history · age < 10 or > 50 years.
8 Start IVs within unburned areas if possible. Burned areas may be used if needed. Burn Management
9 Morphine 5-10 mg IV (adult)
25
DRAFT
Head Injury Management

· ABCs
· C-spine immobilization
· Oxygen 100% APPROVED___________
· Assist ventilations, prn DATE________________
· Transport ASAP
Calculate
Glasgow Coma Scale
Glasgow Coma Scale

Glasgow See Intubation/COMBITUBE Eye Spontaneous 4
Coma Scale Protocol Opening To Voice 3
? <8
To Pain 2
None 1
<8 Monitor ETCO2 if
Best Oriented 5
PIC is available Verbal Confused 4
Consider Intubation/
Response Inappropriate words 3
COMBITUBE Incomprehensible words 2
None 1
Best Obeys Commands 6
maintain B/P above Motor Localizes Pain 5
Response Withdraws (Pain) 4
100mmHg Flexion 3
Extension 2
Fluid None 1
BP Challenge
? < 100 500cc N/S
mmHG
> 100
mmHG
IV N/S TKO
Document:
Active
Scalp/Face · ABCs
Control Bleeding
Bleed Yes · Detailed Assessment
? · Glasgow Coma Scale
No · Revised Trauma Score
· SpO2, ETCO2, V/S
Monitor: · Cardiac Rhythm
· Vital Signs · Motor/Sensation
· Respiratory Status · Lung Sounds
· LOC · Respiratory Effort
· Cardiac Rhythm · Skin Color
· SpO2 · Mechanism of Injury
Calculate: · Onset & Duration of LOC
1 Oxygen 100% per NRB mask or bag-valve-device as needed.

2 Aggressive airway management may be needed If the patient's ventilations are not effective. Secure the
patient's airway and assist ventilations PRN.
3 Do not let B/P drop below 100mmHg during transport
4 Every head-injured patient who has had a period of unconsciousness must be evaluated at a hospital.
5 End-Tidal CO2 should be maintained between 25-35 mmHg.
6 Hyperventilation is not indicated unless PT shows signs of herniation syndrome
7 Isolated head injuries do not cause shock. If shock is present look for another cause.
8 Isotonic solutions are the only authorized fluids for head injury patients Head Injury Management
26
DRAFT
Spinal Cord Injury Management
· ABCs
· C-Spine stabilization APPROVED___________
· Oxygen DATE________________
· Transport ASAP
Airway See Intubation

patent No protocol
?
Yes Significant findings:
· Significant injury above clavicles
Full spine immobilization · Loss of consciousness
· Paralysis, weakness, numbness,
tingling within extremities
Secondary survey 1
· Point tenderness over spine
Transport
Notify receiving
Paralysis
? Yes hospital ASAP
No
IV N/S TKO
· Supportive Care
· Keep Patient Warm Document:
· Monitor Respiratory Status · Airway
· Vital Signs, SpO2
· Evidence of Paralysis or
Paresthesia
· Loss of Consciousness
· Mechanism of Injury
· Presence or Lack of
Tenderness Over Spine
· Treatment
1 Secondary Survey to include complete neurological check.

Spinal Cord Injury Management
27
DRAFT
Hypothermia Management
· Remove wet clothing APPROVED___________
· Prevent heat loss/wind chill DATE________________
· Maintain horizontal position
· Avoid rough movement
· Monitor core temperature
· Monitor cardiac rhythm
· Airway
· Breathing · Start CPR
· Circulation · Defibrillate VF/VT up to 3 shocks
200j, 300j, 360j
· Intubate
· Establish IV
Pulse &
breathing · Infuse warm normal saline using the
present
No thermal Angel
?
· Place patient in the Ranger Environmental
Yes Protection System (REPS)
34-36ºc Mild Hypothermia

Core · Active external rewarming with
Temp REPS and Warm IV's 1
Core
?
Temp
?
30-34ºc Moderate Hypothermia
· Active external rewarming with
REPS and warm IV's 1
> 30º c < 30º c
<30ºc Severe Hypothermia · Continue CPR · Continue CPR

Active external rewarming with · Withhold IV meds · Give IV meds prn 2
REPS and warm IV's 1 · Limit shocks for · Repeat defibrillation
VF/VT to 3 max for VF/VT as temp
· Transport ASAP rises
Continue active external rewarming
until:
· Core temp >36ºc
· Return of spontaneous circulation
· Patient is turned over to hospital
Document:
· Signs & Symptoms
· Vital Signs, SpO2
· Cardiac Rhythm
· Notify receiving hospital ASAP · Core Temp
· Monitor Cardiac Rhythm, · Mechanism of Injury
Core Temp, VS, SpO2 · Treatment
· Support Respiratory Effort · Response to Treatment
· Transport ASAP
1 Ranger Environmental Protection System

2 Give IV medications at longer than standard intervals.
3 Cardiac irritability begins to fall when temp drops below 33c (91.4F). Hypothermia Management
Ventricular fibrillation becomes increasingly common as temp drops
below 28c (82.4F).
28
DRAFT
PHARMACOLOGY
QUICK REFERENCE
ACETAMINOPHEN (TYLENOL) KETOROLAC (TORADOL)
o 325-650 mg po q4-6h prn o 60 mg IM
ALBUTEROL (PROVENTIL) o 15-30 mg slow IV push
o 2 puffs q4-6h prn LIDOCAINE 1% (XYLOCAINE)
BACITRACIN (Topical) o For local anesthesia, max 3 mg/kg/dose
o AAA bid-tid LOPERAMIDE (IMODIUM)
BENZONATATE (TESSALON PERLES) o 4 mg po initial dose, then 2 mg po after each

loose stool, max 16 mg/day
o 100 mg po tid
LORATADINE (CLARITIN)
CEFOXITIN (MEFOXIN)
o 10 mg po qd
o 2 g IV q6-8h
DEXTROSE 50% MECLIZINE (ANTIVERT)
o 10-20cc slow IV push o 25-50 mg po 1 hour before traveling
DIAZEPAM (VALIUM) MORPHINE
o 5-10 mg slow IV push o 5 mg slow IV push, titrate to effect
DIPHENHYDRAMINE (BENADRYL) NALOXONE
o 25 mg IM/IV o 2 mg IV push, repeat at 2-3 min intervals
o 50 mg PO q4-6h PSEUDOEPHEDRINE (SUDAFED)
EPINEPHRINE (1:1000) o 60 mg po q4-6h
o 0.3 mg SC/IM PROMETHAZINE (PHENERGAN)
HETASTARCH (HESPAN) o 25 mg po q4-6h
o 500-1000 ml IV o 25 mg slow IV push
IBUPROFEN (MOTRIN) SILVER SULFADIAZINE (SILVADENE)
o 800 mg po tid with food or milk o AAA qd-bid
29
DRAFT
Acetaminophen (Tylenol)
Functional Class: Analgesic (non-narcotic), antipyretic Dosage:
Chemical Class: Nonsalicylate, para-aminophenol derivative • PO or PR
Action: • Adult and child > 12 yo:
• May block pain impulses peripherally that occur in o 325-650mg q4-6h prn (max 4 g/day)
response to inhibition of prostaglandin synthesis
• Child < 12 yo:
• Does not possess antiinflammatory properties
o Dose per weight, 10-15mg/kg/q4-6h
• Antipyretic action results from inhibition of
prostaglandins in the CNS (hypothalamic heat-regulating Education:
center
• Do not exceed recommended dose, acute poisoning with
Indications: liver damage may result
• Analgesic: mild-moderate pain (non-rheumatic), • Acute toxicity includes symptoms of nausea, vomiting,
headache and abdominal pain
• Antipyretic: fever (acute and prophylaxis [i.e., Overdose:

vaccinations])
• Drug level, gastric lavage, activated charcoal, administer
Contraindications: oral acetylcysteine (Mucomyst)
• Hypersensitivity
Precautions:
• Pregnancy Category B
• Anemia, hepatic disease, renal disease, chronic

alcoholism, elderly
Adverse Reactions (Side Effects):
• Relatively non-toxic in therapeutic doses
• SKIN: Occasional rash or urticaria
30
DRAFT
Albuterol (Proventil, Ventolin)
Functional Class: Adrenergic β2-agonist Dosage:
Action: • PO or oral inhalation (MDI or NEB)
• Causes bronchodilation by action on β2 (pulmonary) • Adult:

receptors by increasing levels of cAMP, which:
Prevention of exercise induced asthma:
o relaxes smooth muscle
o INH 2 puffs 15 min before exercise
o produces bronchodilation
Bronchospasm:
o produces CNS and cardiac stimulation,
o MDI: 2 puffs q4-6 h
o causes diuresis and gastric secretion
o NEB: 2.5mg (3ml 0.083% soln) qid
Indications:
o PO: 2-4mg qid
• Prevention of exercise induced asthma
• Chilc (age 6-12):
• Prevention and treatment of bronchospasm
Prevention of exercise induced asthma:
Contraindications:
o INH 2 puffs 15 min before exercise
• Hypersensitivity, tachydysrhythmias, severe cardiac
disease Bronchospasm:
Precautions: o MDI: 1-2 puffs q4-6 h
• Pregnancy Category C o NEB: 2.5mg tid/qid
• Cardiac disorders, hyperthyroidism, diabetes mellitus, o PO: 2mg qid (max 12mg/day)
hypertension, prostatic hypertrophy, narrow-angle
glaucoma, seizures • Child (age 2-6):
Adverse Reactions (Side Effects): o Dose per weight, PO: 0.1-0.2 mg/kg/tid
(max 4mg/day)
• CNS: anxiety, dizziness, flushing, hallucinations,
headache, insomnia, irritability, restlessness, stimulation, Education:
tremors
• Demonstrate proper technique for MDI and NEB use
• CV: angina, dysrhythmias, hypertension, hypotension,
• Avoid smoking and caffeine products
palpitations, tachycardia
Overdose:
• EENT: dry nose, irritation of nose and throat
• Administer a β1-adrenergic blocker
• GI: heartburn, nausea, vomiting
• METAB: hypokalemia
• MS: inhibition of uterine contractions, muscle cramps
• RESP: cough
31
DRAFT
Bacitracin (Topical)
Functional Class: Antibiotic (topical) Dosage:
Action: • Topically:
• Interferes with bacterial protein synthesis o Apply to affected areas bid-tid (do not use > 1
week)
Indications:
Education:
• Prevention and treatment of skin infections
• Before each application, cleanse areas with soap and
Contraindications: water; dry well
Precautions:
• Pregnancy Category C
• For external use only
• SKIN: Rash, urticaria, scaling, redness
32
DRAFT
Benzonatate (Tessalon Perles)
Functional Class: Non-narcotic antitussive Dosage:
Action: • PO
• Acts peripherally by anesthetizing the stretch receptors o 100 mg po tid

located in the respiratory passages, lungs, and pleura by
dampening their activity and thereby reducing the cough Education:
reflex at its source.
• Temporary local anesthesia of the oral mucosa can
Indications: predispose to choking.
• Non-productive cough
Contraindications:
Precautions:
• Pregnancy category C
• CNS: Sedation, headache, dizziness, confusion, visual

hallucinations
• GI: Constipation, nausea, GI upset
• SKIN: Pruritis, skin eruptions
33
DRAFT
Cefoxitin (Mefoxin)
Functional Class: Antibiotic Dosage:
Chemical Class: Cephalosporin (2nd Generation) • Adult:
Action: o 2g slow IV push or mixed in 500ml bag of N/S and

infused. Repeat q6-8
• Inhibits bacterial cell wall synthesis, rendering cell wall
osmotically unstable, leading to cell death by binding to
cell wall membrane
Indications:
• INFECTIONS: lower respiratory tract, GU system,
peritonitis, septicemia, skin, bone, joint
• ORGANISMS:
o Gram-negative: H. influenzae, E. coli,
Proteus, Klebsiella, B. fragilis, N. gonorrhoeae,
E. corrodens
o Gram-positive: S. pneumoniae, S. pyogenes, S.
aureus
o Anaerobes: including Clostridium
Contraindications:
• Hypersensitivity, note cross-reactivity with penicillin

allergies
Precautions:
• Pregnancy category B
• Use with caution in patients with penicillin allergy (5-

10% chance of cross-reactivity)
• Dosage modifications are generally only required with

severe renal impairment
• CNS: dizziness, headache, fatigue, fever, chills confusion
• GI: nausea, vomiting, diarrhea, abdominal pain and

cramps, flatulence, colitis, jaundice, increased LFTs
• GU: vaginitis, candidiasis, nephrotoxicity, renal failure
• SKIN: rash, urticaria, Stevens-Johnson syndrome
• HEME: dysfunction of any cell line
34
DRAFT
Dextrose 50% (D-glucose)
Functional Class: Caloric Dosage:
Action: • IV
• Needed for adequate utilization of amino acids; o Administer up to 10 ml/min as required

decreases protein, nitrogen loss; prevents ketosis
Indications:
• Hypoglycemia; Increases intake of calories; increases

fluids in patients unable to take adequate fluids, calories
orally
Contraindications:
• Hyperglycemia, delirium tremens, hemorrhage

(spinal/cranial), CHF
Precautions:
• Renal, liver, cardiac disease, diabetes mellitus
• Ensure IV Line is Patent
• CNS: Confusion, loss of consciousness, dizziness
• CV: Hypertension, CHF, pulmonary edema
• GU: Glycosuria, osmotic diuresis
• ENDO: Hyperglycemia, rebound hypoglycemia
• SKIN: Chills, flushing, warm feeling, rash, urticaria
35
DRAFT
Diazepam (Valium)
Functional Class: Antianxiety Dosage:
Chemical Class: Benzodiazapine • PO, PR, or IV
Action: • Adult:
• Potentiates the actions of GABA, especially in the limbic o PO 2-10mg tid-qid, taper prn
system, reticular formation; enhances presympathetic
inhibition, inhibits spinal polysynaptic afferent paths Status epilepticus:
Indications: o IV bolus 5-20mg infused at a rate of 2 mg/min;

may repeat every 5-10 min (max 60mg); repeat
• Anxiety in 30 min if seizures reappear
• Sedation Epilepsy:
• Acute alcohol withdrawal o PR 0.2 mg/kg prn
• Anticonvulsant • Geriatric:
• Skeletal muscle relaxant o 2-2.5mg qd-qid, titrated prn
• Pre-surgery/procedure relaxation • Child:
Contraindications: o IV bolus 0.1-0.3 mg/kg (over 3 min); may repeat

q15 min for 2 doses
• Hypersensitivity, psychosis, narrow-angle glaucoma, co-
administration with ketoconazole or itraconazole (P450 Tetanic muscle spasms:
enzyme inhibition)
o Infants >30 days to <5years IM/IV 1-2mg to 5-
Precautions: 10mg q3-4h prn
• Pregnancy category D Anxiety/convulsive disorders:
• Controlled Substance Schedule IV o > 6 months PO 1-2.5mg tid-qid (0.04-0.2 mg/kg

tid-qid prn)
• Elderly, children, debilitated, hepatic disease, renal
disease Adjunct for epilepsy:
o PR: age 2-5 yo 0.5 mg/kg prn; age 6-11 yo 0.3

mg/kg prn; age > 12 yo 0.2 mg/kg prn
• CNS: drowsiness, dizziness, fatigue, confusion,
Education:
depression, blurred vision, headache, stimulation,
insomnia, tremors, nervousness • Avoid driving and activities that require alertness;
drowsiness may occur
• CV: bradycardia, tachycardia, hypertension, hypotension
• Avoid alcohol and other psychotropic medications
• GI: constipation, diarrhea, dry mouth, nausea, vomiting
Overdose:
• SKIN: Rash, dermatitis, itching
• Gastric lavage, monitor VS, supportive care, flumazenil
36
DRAFT
Diphenhydramine (Benadryl)
Functional Class: Antihistamine Dosage:
Chemical Class: H1-receptor antagonist,ethanolamine derivative • PO, IM, or IV
Action: • Adult:
• Acts on blood vessels, GI, respiratory system by o 25-50mg q4-6h (max 400mg/day)
competing with histamine for H1-receptor site;
decreases allergic response by blocking histamine o for sleep, 50mg PO qhs
Indications: • Child:
• Adjunctive therapy for anaphylactic reactions o Dose by weight, 5 mg/kg/day or 150mg per
meter square per day divided q6-8 h (max
• Perenial and seasonal allergic rhinitis, vasomotor 300mg/day)
rhinitis, allergic conjunctivitis; pruritic conditions, mild
urticaria and angioedema Education:
• Motion sickness; sleep aid; cough suppressant • Avoid driving and activities that require alertness;
drowsiness may occur
Contraindications:
• Avoid alcohol and other CNS depressants
• Hypersensitivity, acute asthma attack, lower respiratory
tract disease Overdose:
Precautions: • Ipecac syrup, gastric lavage, diazepam, vasopressors,

barbiturates (short-acting)
• Pregnancy category C; contraindicated while nursing
• Increased intraocular pressure, renal disease, cardiac

disease, hypertension, bronchial asthma, seizure
disorder, hyperthyroidism, prostatic hypertrophy,
bladder neck obstruction, stenosed peptic ulcers
• CNS: anxiety, confusion, dizziness, drowsiness,

euphoria, poor coordination, fatigue, paresthesia,
neuritis
• CV: palpitations, tachycardia
• RESP: increased thick secretions, wheezing, chest

tightness
• EENT: blurred vision, dilated pupils, dry nose, dry

mouth and throat, nasal stuffiness, tinnitis
• GI: nausea, anorexia, diarrhea
• GU: dysuria, frequency, impotence, retention
• HEME: bone marrow suppression, thrombocytopenia,

agranulocytosis, hemolytic anemia
37
DRAFT
Epinephrine
Category: Bronchodilator-adrenergic Dosage:
Functional Class: Catecholamine • Topical, IV, IM, SC, inhalation

Action: • 1mg = 1ml of 1:1000 or 10ml of 1:10,000
• β1- and β2-agonist causing increased levels of cyclic • Adult:
AMP producing bronchodilation, cardiac and CNS
stimulation; large doses cause vasoconstriction; small Anaphylaxis/Allergic Reactions:
doses can cause vasodilation via β2-vascular receptors
o SC/IM (1:1000) 0.2-0.5mg, repeat q10-15 min
Indications: up to 4 hours (single dose max 1mg)
• Anaphylaxis, allergic reactions, acute asthma attacks, Acute Asthma Attack/Bronchodilator:
bronchospasm
o SC/IM (1:1000) 0.2-0.5mg, repeat q10-15 min
• Cardiac arrest, adjunct in anesthesia, vasopressor, up to 4 hours
hemostasis
o IV (1:10,000) 0.1-0.25mg (single dose max
• Nasal congestion, open-angle glaucoma 1mg)
Contraindications:
o NEB instill 8-15 drops into nebulizer reservoir,
• Hypersensitivity, narrow-angle glaucoma administer 1-3 inhalations q4-6h
Precautions: o MDI 1-2 puffs at 1st sign of bronchospasm
• Pregnancy category C; excreted in breast milk, use Cardiac arrest:

caution in nursing mothers
o IV/intracardiac 0.1-1mg (1-10 ml of 1:10,000
• local anesthesia of appendages (nose, toes, fingers, dilution) q3-5 min prn
earlobes, and penis)
o IV intermediate dose 2-5mg q3-5 min;
• Cardiac disorders, hypertension, diabetes, psychosis, escalating dose 1-3-5mg 3 min apart; high dose
hyperthyroidism, prostatic hypertrophy, parkinsonism 0.1 mg/kg q3-5 min
Adverse Reactions (Side Effects): o Intratracheal 1mg q3-5 min (higher doses, eg.
0.1 mg/kg, should be considered only after 1mg
• CNS: anxiety, insomnia, dizziness, confusion, doses have failed)
hallucinations, headache, hemiplegia, subarachnoid
hemorrhage, tremor, weakness, restlessness Hypotension (vasopressor):
• CV: anginal pain, dysrhythmias, increased T wave, o IV Infusion 1-4 mcg/min

hypertension, palpitations, tachycardia
Education:
• GI: nausea, vomiting, anorexia
• For patients with history of hypersensitivity reactions
• GU: urinary retention (hymenoptera, etc) provide Anakit and instruct on use
• RESP: respiratory difficulty, dyspnea Overdose:

• SKIN: pallor, urticaria, wheal • Administer an α-blocker and a β-blocker
38
DRAFT
Hetastarch (Hespan)
Functional Class: Plasma volume expander Dosage:
Chemical Class: Synthetic polymer • IV
Action: o 500-1000 ml, total dose not to exceed 1500

ml/day
• Similar to human albumin, which expands plasma
volume by colloidal osmotic pressure Education:
Indications: • Expands blood volume 1-2 x amount infused.
• Plasma volume expander
Contraindications:
• Hypersensitivity, severe bleeding disorders, renal

failure, severe CHF
Precautions:
• Liver disease, pulmonary edema
• CNS: Headache
• RESP: Wheezing, dyspnea, bronchospasm, pulmonary

edema
• GI: Nausea, anorexia
• EENT: Periorbital edema
• HEME: Decreased hematocrit, platelet function,

increased bleeding and coagulation times, increased sed
rate
• SKIN: Rash, urticaria, pruritis, angioedema, chills,

fever, flushing, peripheral edema
• SYST: Anaphylaxis
39
DRAFT
Ibuprofen (Motrin, Advil)
Functional Class: Nonsteroidal Antiinflammatory Drug (NSAID) Dosage:
Chemical Class: Propionic acid derivative • PO
Action: • Adult:
• Inhibits prostaglandin synthesis by decreasing enzyme o 200-800mg tid-qid (max 3.2g/day)

needed for biosynthesis
• Children:
Indications:
o Dose per weight, 20-40mg/kg/day in divided
• Analgesic: mild-moderate pain (musculoskeletal pain, doses q6-8h
dental procedures, dysmenorrhea)
Education:
• Antiinflammatory: acute inflammation, rheumatoid
arthritis, osteoarthritis, gout • Take with food or milk to decrease GI symptoms; avoid
alcohol and salicylates, bleeding may occur; avoid
• Antipyretic: fevers sunlight
Contraindications:
• Hypersensitivity, asthma, severe renal disease, severe

hepatic disease; aspirin or NSAID-induced nasal polyps,
bronchospasm or angioedema
Precautions:
• Pregnancy Category C
• Bleeding disorders; avoid use with anticoagulants

(warfarin) due to increased bleeding times and potential
for GI bleeding and decreased platelet aggregation.
• CNS: headache, dizziness, drowsiness, fatigue, tremors,

confusion, insomnia, anxiety, depression
• GI: nausea, vomiting, heartburn, dyspepsia, pain,

diarrhea, constipation, flatulence, cramps, peptic ulcer,
bleeding
• CV: tachycardia, peripheral edema, palpitations,

dysrhythmias
• EENT: tinnitis, hearing loss, blurred vision
• GU: nephrotoxicity
• HEME: increased bleeding time
• SKIN: purpura, rash, pruritis, sweating
40
DRAFT
Ketorolac (Toradol)
Functional Class: Non-steroidal antiinflammatory drug (NSAID) Dosage:
Chemical Class: Pyrrolo-pyrrole May be used as a “one time” dose or as “prn” treatment
Action: • PO, IM, or IV
• Inhibits prostaglandin synthesis by decreasing an enzyme • Single-Dose Treatment:

needed for biosynthesis
o IM/IV (<65 yo): 60mg, one dose
Indications:
o IM/IV (>65 yo, with renal impairment or less
• Moderately severe acute pain requiring analgesia at an than 50kg): 30mg, one dose
opioid level; antiinflammatory; antipyretic
• Multi-Dose Treatment:
Contraindications:
o IM/IV (<65 yo): 30mg q6h (max 120mg/day)
• Hypersensitivity, asthma, severe renal disease, severe
hepatic disease, peptic ulcer disease, gastrointestinal o IM/IV (>65 yo, with renal impairment or less
bleeding or perforation, cerebrovascular bleeding, than 50kg): 15mg q6h (max 60mg/day)
hemorrhagic diathesis, incomplete hemostasis, high risk
of bleeding. • Transition from IM/IV to PO:
• Patients currently on aspirin or other NSAIDs o <65 yo: 2 tabs (20mg) first dose, followed by 1
tab (10mg) q4-6h (max 40mg/day)
Precautions:
o >65 yo, with renal impairment or less than 50kg:
• Pregnancy Category C 1 tab (15mg) first dose, followed by 1 tab
(10mg) q4-6h (max 40mg/day)
• Bleeding disorders, GI disorders, cardiac disorders
Education:
• When administering as IM bolus, give slowly and deeply
into muscle tissue; analgesic effects begins at about 30 • Take with food or milk to decrease GI symptoms; avoid
min and peaks at 1-2 hours, with a duration of 2-6 hours. alcohol and salicylates, bleeding may occur
• CNS: dizziness, drowsiness, tremors
• CV: hypertension, flushing, syncope, pallor, edema,

vasodilation
• GI: nausea, dyspepsia, pain, diarrhea, constipation,

flatulence, peptic ulcer, bleeding
• EENT: tinnitus, hearing loss, blurred vision
• GU: nephrotoxicity
• HEME: prolonged bleeding
• SKIN: purpura, rash, pruritis, sweating
41
DRAFT
Lidocaine (Xylocaine)
Functional Class: Local anesthetic Dosage:
Chemical Class: Aminoacyl amide • Injection
Action: • Adult and Child:
• Competes with calcium for sites in nerve membrane that o Varies with procedure, degree of anesthesia
control sodium transport across cell membrane; decreases desired, vascularity of tissue, duration of
rise of depolarization phase of action potential anesthesia required, physical condition of patient
Indications: o Max 3 mg/kg/dose without epi, 5mg/kg/dose

with epi; do not repeat within 2 hours
• Local anesthesia, peripheral nerve block
o Onset < 2 min, duration 30-60 min
Contraindications:
Overdose:
• Hypersensitivity, severe liver disease
• Airway, Oxygen, vasopressor, IVF, anticonvulsant
Precautions:
• Elderly, severe drug allergies
• CNS: anxiety, disorientation, seizures, shivering, tremors,

loss of consciousness
• CV: bradycardia, cardiac arrest, dysrhythmias,

myocardial depression, bradycardia, hypotension,
hypertension
• GI: nausea, vomiting
• EENT: blurred vision, tinnitus, pupil constriction
• RESP: respiratory arrest, status asthmaticus, anaphylaxis
• SKIN: allergic reactions, burning, edema, irritation, rash,

tissue necrosis, urticaria
42
DRAFT
Loperamide (Imodium)
Functinal Class: Antidiarrheal Dosage:
Chemical Class: Piperidine derivative • PO
Action: • Adult:
• Direct action on intestinal muscles to decrease GI o 4mg, then 2mg after each loose stool (max
peristalsis; reduces volume, increases bulk, electrolytes 16mg/day); maintenance for chronic diarrhea
not lost usually 4-8mg daily
Indications: • Child:
• Diarrhea, acute (Traveler’s and non-specific), chronic o <2 years not recommended
(inflammatory bowel disease), and Traveler’s
o On day 1: 13-20 kg, 1 mg tid; 20-30 kg, 2 mg
• Reduction of volume from ileostomy bid; > 30 kg, 2 mg tid
Contraindications: o After day 1: 0.1 mg/kg after each loose stool
• Hypersensitivity, severe ulcerative colitis, acute diarrhea Education:

due to invasive organisms (enteroinvasive E. coli,
Salmonella, Shigella), or pseudomembranous colitis • Avoid driving and activities that require alertness if
drowsiness occurs
Precautions:
• Liver disease, dehydration, bacterial disease, children
• CNS: fatigue, fever, dizziness, drowsiness
• GI: abdominal pain, anorexia, constipation, dry mouth,

nausea, vomiting, toxic megacolon
• RESP: respiratory depression
• SKIN: rash
43
DRAFT
Loratadine (Claritin)
Functional Class: Antihistamine (2nd generation) Dosage:
Chemical Class: Selective histamine (H1)-receptor antagonist • PO
Action: • Adult: 10mg qd
• Binds to peripheral histamine receptors, providing Education:

antihistamine action without sedation
• Effective, but expensive nonsedating antihistamine;
Indications: reserve for patients unable to tolerate sedating
antihistamines like diphenhydramine
• Seasonal rhinitis
• Avoid driving and activities that require alertness if
• Idiopathic chronic urticaria drowsiness occurs
Contraindications:
• Hypersensitivity, acute asthma attacks, lower respiratory

tract disease
Precautions:
• Increased intraocular pressure, bronchial asthma
• CNS: insomnia, sedation, headache
• GI: dry mouth
44
DRAFT
Meclizine (Antivert)
Functional Class: Antiemetic, antihistamine, anticholinergic Dosage:
Chemical Class: H1-receptor antagonist, piperazine derivative • PO
Action: o Vertigo: 25 mg q6hrs
• Acts centrally by blocking chemoreceptor trigger zone, o Motion Sickness: 25-50 mg 1 hr before
which in turn acts on vomiting center traveling
Indications: Education:
• Vertigo, motion sickness • Avoid hazardous activities, activities requiring

alertness.
Contraindications:
• Avoid alcohol and other depressants.
• Hypersensitivity, shock, lactation
Precautions:
• Glaucoma, urinary retention, prostatic hypertrophy, CV

disease, hypertension, seizure disorder
• CNS: Drowsiness, fatigue, restlessness, headache,

insomnia
• CV: Hypotension
• GU: Retention
• GI: Nausea, anorexia
• EENT: Dry mouth, blurred vision
45
DRAFT
Morphine
Functional Class: Narcotic Analgesic Dosage:
Chemical Class: Opiate Administer in smallest effective dose, as infrequently as possible

and titrated to pain control.
Action:
Administer with antiemetic for nausea, vomiting.
• Depresses pain impulse transmission at the spinal cord
level by interacting with opioid receptors Compatible in same IV site with cephalosporins.
Indications: • PO, PR, SC, IM, IV
• Severe, acute pain • Adult:
• Moderate to severe chronic pain o PO: 10-30mg q4h prn
• Anesthesia adjunct for preoperative sedation o PR: 10-20mg q4h prn
Contraindications: o SC or IM: 10mg (range 5-20mg) q4h prn
• Hypersensitivity, addiction (narcotic), hemorrhage, o IV: 2.5-15mg diluted in 4-5 mL sterile water for
bronchial asthma, increased intracranial pressure injection, slowly injected over 4-5 min
Precautions: • Labor anesthesia:
• Pregnancy Category B o 10mg SC or IM
• Addictive personality, acute MI, severe heart disease, Overdose:

elderly, respiratory depression, hepatic or renal disease
• Naloxone (Narcan) 0.2-0.8 mg IV, O2, IV fluids,
• In patients with myocardial infarction, morphine vasopressors
decreases systemic vascular resistance which may lead to
severe hypotension. To minimize, administer minimum Education:
effective dose and elevate patient’s legs.
• Change position slowly, orthostatic hypotension may
• Rapid administration may induce respiratory depression, occur.
therefore monitor patient’s respiratory function.
• Patients will experience CNS effects of drowsiness and
Adverse Reactions (Side Effects): dizziness, therefore use caution with motor vehicle
operation or other hazardous tasks.
• CNS: Drowsiness, dizziness, confusion, headache,
sedation, euphoria • Avoid prolonged, sustained usage to decrease addiction
potential.
• CV: Palpitations, bradycardia, change in blood pressure
• Use with caution with alcohol, CNS depressants.
• EENT: Tinnitus, blurred vision, miosis, diplopia
• Withdrawal symptoms may occur: nausea, vomiting,
• GI: Nausea, vomiting, anorexia, constipation, cramps cramps, fever, faintness, anorexia.
• GU: Urinary retention
• SKIN: Rash, urticaria, bruising, flushing, diaphoresis,

pruritis
• RESP: Respiratory depression
46
DRAFT
Naloxone (Narcan)
Functional Class: Opioid antagonist Dosage:
Chemical Class: Thebaine derivative Duration of action of some narcotics may exceed that of naloxone;
repeat doses prn.
Action:
• SC, IM, IV
• Competes with narcotics at narcotic receptor sites
• Adult:
Indications:
o Narcotic overdose (known or suspected):
• Complete or partial reversal of narcotic depression,
including respiratory depression SC/IM/IV 0.4-2mg initially, repeat at 2-
3 min intervals up to 10mg, if no
• Diagnosis of suspected acute opioid overdose response after 10mg reevaluate
diagnosis
Precautions:
o Postoperative narcotic depression (partial
• Pregnancy category B reversal):
• Narcotic dependency, cardiovascular disease IV 0.1-0.2mg at 2-3 min intervals to

desired level of reversal; repeat doses
Adverse Reactions (Side Effects): may be required within 1-2h intervals
• CNS: Drowsiness, nervousness • Child:
• CV: Hypertension, tachycardia, ventricular dysrhythmia, o Narcotic overdose (known or suspected):
fibrillation
SC/IM/IV 0.01 mg/kg initially, give
• GI: nausea, vomiting subsequent doses of 0.01 mg/kg as
needed at 2-3 min intervals
• RESP: Hyperpnea (deeper and rapid breathing)
o Postoperative narcotic depression (partial
• SKIN: Sweating reversal):
• MISC: Reversal of anesthesia IV 0.005-0.01mg every 2-3 min to

desired degree of reversal
47
DRAFT
Pseudoephedrine (Sudafed)
Functional Class: Adrenergic Dosage:
Chemical Class: Substituted phenylethylamine • PO
Action: • Adult:
• Primary activity through α-effects on respiratory o 60 mg q4-6h

mucosal membranes reducing congestion hyperemia,
edema; minimal bronchodilation secondary to β-effects • Child:
Indications: o 6-12 yo: 30 mg/dose; 2-5 yo: 15 mg/dose
• Nasal decongestant, adjunct in otitis media;with Education:

antihistamines
• Do not use continuously, or more than recommended
Contraindications: dose.
• Hypersensitivity, narrow-angle glaucoma • Rebound congestion may occur.
Precautions: • Avoid taking at bedtime, stimulation may occur.
• Cardiac disorders, hyperthyroidism, diabetes mellitus,

prostatic hypertrophy, lactation, hypertension
• CNS: Tremors, anxiety, insomnia, headache, dizziness,

hallucinations, seizures
• CV: palpitations, tachycardia, hypertension, chest pain,

dysrhythmias
• EENT: Dry nose, irritation of nose and throat
• GI: Nausea, vomiting, anorexia, dry mouth
• GU: dysuria
48
DRAFT
Promethazine (Phenergan)
Functional Class: Antihistamine, H1-receptor antagonist Dosage:
Chemical Class: Phenothiazine derivative • PO, PR, IM, IV
Action: • Adult:
• Acts on blood vessels, GI, respiratory system by o Antihistimine:
competing with histamine for H1-receptor site; decreases
allergic response by blocking histamine PO/PR 12.5mg 3 tid and 25mg qhs
Description: IM/IV 25mg, repeated in 2 hours prn,
convert to PO as soon as possible
• Antihistamine, antiemetic, sedative, antitussive,
antivertigo agent o Antiemetic:
Indications:
PO/IM/IV/PR 12.5-25mg q4h prn
• Antihistamine: Allergy symptoms, rhinitis
• Antiemetic: Nausea, vomiting o Motion sickness:
• Antivertigo: active and prophylactic treatment of motion
sickness PO/PR 25mg 30-60mg prior to
departure, then q12h prn
• Sedative: Preoperative, postoperative, obstetric sedation
• Pain control: Adjunct to use with pain medications o Sedation:
Contraindications:
PO/IM/IV/PR 25-50mg qhs
• Hypersensitivity, acute asthma attack, lower respiratory
tract disease • Child:
Precautions:
• Pregnancy category C o Antihistamine:
• Bladder neck obstruction, prostatic hypertrophy,
PO/PR 0.1 mg/kg/dose q6h during the
predisposition to urinary retention
day and 0.5 mg/kg qhs prn
• Cardiovascular disease, glaucoma, liver disease,
hypertension, history of peptic ulcer, intestinal o Antiemetic:
obstruction, seizure disorder
Adverse Reactions (Side Effects): PO/IM/IV/PR 0.25-1 mg/kg q4-6h prn
• CNS: Dizziness, drowsiness, poor coordination, fatigue,
o Motion sickness:
anxiety, euphoria, confusion, paresthesia, neuritis
• CV: hypotension, palpitations, tachycardia PO/PR 0.5 mg/kg/dose 30-60 min prior
• EENT: Blurred vision, dilated pupils, dry nose, nasal to departure, then q12h as needed
stuffiness, tinnitus
o Sedation:
• GI: anorexia, cholestatic jaundice, constipation, diarrhea,
dry mouth, nausea, vomiting PO/IM/IV/PR 0.5-1 mg/kg/dose q6h
• GU: Retention, dysuria, frequency prn
• HEME: Agranulocytosis, hemolytic anemia,
thrombocytopenia Overdose:
• METAB: Hyperprolactinemia • Administer ipecac syrup or lavage, diazepam,
• RESP: Chest tightness, increased thick secretions, vasopressors, barbiturates
wheezing
Education
• SKIN: photosensitivity, rash, urticaria
• Avoid prolonged sunlight, may cause photosensitivity.
• Avoid driving, other hazardous activity if drowsy.
49
DRAFT
Versed
Category: Dosage:
• General anesthetic Administered intravenously, intramuscularly
Description: • Adult:
• Benzodiazepine sedative o Preoperative sedation:
Indications: IM 70-80 mcg/kg 30-60 minutes before

general anesthesia
• Preoperative sedation (IM)
o Conscious sedation:
• General anesthesia induction, sedation for diagnostic
endoscopic procedures, intubation (IV) IV using 1 mg/ml dilution, titrate slowly
to desired effect; give no more than
Contraindications: 2.5mg over at least 2 minutes; wait at
least 2 minutes to fully evaluate effect;
• Shock, coma, alcohol intoxication administer small doses to appropriate
level of sedation as needed
• Acute narrow-angle glaucoma
o Induction of general anesthesia:
Precautions:
IV 150-350 mcg/kg over 30 seconds,
• Pregnancy category D wait 2 minutes follow with 25% of initial
dose if needed; use lower doses for
• COPD, CHF, chronic renal failure, hepatic disease, elderly patients who are > 55 years age,
premedicated, debilitated, or severe
• Debilitated, myasthenia gravis, other muscular dystrophies systemic disease
and myotonias
• Child:
o Preoperative sedation:
• CNS: anxiety, confusion, euphoria, headache, insomnia,
paresthesia, retrograde amnesia, slurred speech, tremors, IM 80-200 mcg/kg
weakness
o General anesthesia:
• CV: bigeminy, hypotension, nodal rhythm, PVCs,
tachycardia IV 50-200 mcg/kg
• EENT: blocked ears, blurred vision, diplopia, loss of balance,

nystagmus
• GI: hiccups, increased salivation, nausea, vomiting
• RESP: apnea, bronchospasm, coughing, dyspnea,

laryngospasm, respiratory depression
• SKIN: pain, pruritis, rash, swelling at injection site, urticaria
50
DRAFT
TACTICAL COMBAT CASUALTY CARE
Trauma is the leading cause of death in the first four decades of life. Current
protocols in trauma care are based on the Advanced Trauma Life Support (ATLS) course,
which was initially conducted in 1978. Since that time, the ATLS course has been
accepted as the standard for the first hour of trauma management for civilian and military
providers. ATLS is a great approach in the civilian setting; however, it was never
designed for combat application.
The combat environment includes many factors that affect medical care to include
temperature and weather extremes, severe visual limitations, delays in treatment and
evacuation, long evacuation distances, a lack of specialized providers and equipment near
the scene, and the lethal implications of an opposing force. Thus, a modified approach to
trauma management must be utilized while conducting combat operations.
Combat treatment protocols must be directed toward preventable combat death. COL
Ron Bellamy researched how people die in ground combat and developed a list of causes
of death that can be prevented on the battlefield.
How people die in combat Preventable causes of death
KIA: 31% penetrating head trauma 60% Bleeding to death from extremity wounds
KIA: 25% surgically uncorrectable torso trauma 33% Tension pneumothorax
KIA: 10% potentially correctable surgical trauma 6% Airway obstruction (maxillofacial trauma)
KIA: 9% exsanguination from extremity wounds
KIA: 7% mutilating blast trauma
KIA: 5% tension pneumothorax
KIA: 1% airway problems
DOW: 12% (mostly from infections and
complications of shock)
The tactical environment and causes of combat death dictate a different approach for
ensuring the best possible outcome for combat casualties while sustaining the primary
focus of completing the mission. CAPT Frank Butler and LTC John Hagmann proposed
such an approach in 1996. Their article, “Tactical Combat Casualty Care in Special
Operations”, emphasized three major objectives and outlined three phases of care.
Objectives: 3) Combat Casualty Evacuation

(CASEVAC) Care
1) Treat the patient
2) Prevent additional casualties
3) Complete the mission
Phases of Care:
1) Care Under Fire

2) Tactical Field Care
51
DRAFT
1) CARE UNDER FIRE: Care provided at the scene of injury while under effective
enemy fire. Care is limited to the equipment carried by the medical provider. The
major goals are to move the casualty to safety, prevent further injury to the casualty
and provider, stop life threatening external hemorrhage, and most importantly, gain
and maintain fire superiority (The best medicine on the battlefield!). The following
outlines this level of care.
Return fire as directed or required.

Casualty should also return fire if able.
Try to keep yourself from getting shot.
Try to keep the casualty from sustaining additional injuries.
Stop any life threatening external hemorrhage with a tourniquet.
Take the casualty with you when you leave.
2) TACTICAL FIELD CARE: Care rendered once the casualty is no longer under
effective enemy fire or when conducting a mission without hostile fire (ie, a soldier is
injured on an airborne insertion). Do not attempt CPR on the battlefield for victims
of blast or penetrating trauma who have no pulse, respirations, or other signs of life.
Airway.
Nasopharyngeal airway for unconscious casualty without obstruction.
Cricothyroidotomy for airway obstruction.
No C-Spine immobilization for penetrating trauma.
Breathing.
If respiratory distress following unilateral blunt or penetrating chest trauma,
presume tension pneumothorax and decompress.
Circulation.
Control any remaining bleeding with tourniquet, dressing or direct pressure.
Initiate 18-gauge saline lock or IV.
• Controlled hemorrhage without shock: NO FLUIDS
• Controlled hemorrhage with shock: Hespan 1000cc
• Uncontrolled hemorrhage with shock: Hypotensive Resuscitation (Use
mentation coupled with weak radial pulses to judge fluid
resuscitation)
Other.
Wounds: inspect and dress; check for additional wounds.
Fractures: splint and recheck pulse.
Analgesia: Morphine 5mg IV; repeat after 10 minutes if needed.
Antibiotics: Cefoxitin 2g IVP (over 3-5 min)
Environment: Undress casualty to extent needed; prevent hypothermia.
3) COMBAT CASUALTY EVACUATION (CASEVAC): The medical care provided

during the evacuation of the casualty. Continue or initiate care as per previous phase.
Pre-staged medical assets on CASEVAC should be utilized to provide the same or
higher level of care rendered during the mission.
Initiate or continue care as per previous phase.
52
DRAFT
Evaluate and refine care.
Airway: Provide combitube or endotracheal intubation as needed.
Breathing: Administer oxygen; provide chest tube if indicated.
Circulation: Remove tourniquets and use direct pressure if possible.
Other: Institute electronic monitoring
12
Security Security
Aid & Litter MINIMAL / EXPECTANT Aid & Litter
Team 2 (Blue Chemlights) Team 3
CAX CAX
Gear Gear
Medic Chaplain EMT

Medical
Equipment
Bundle
S4 Rep
9 Medical 3
IMRed Ch
ts )
Augmentation
ml D
(
ME eml
Team
he E
igh
n C AY
DI ights )
(G EL
AT
D
ree
E
Medical Officer Medics

Medical NCO EMT
Medical OIC
Security Security
Aid & Litter Aid & Litter
Team 1 CP CCP PL Team 4
PJLNO
6 S1/CAX Rec
TRIAGE RTO
Vehicle
Holding Area CHOKE POINT
Route of Incoming Vehicles
IR
Chemlights
Route of Outgoing Vehicles
53
DRAFT
TACTICAL MEDICAL EVALUATION CHECKLIST
EVENT RESPONSIBILITY GO NO-GO
PLANNING / PRE-DEPLOYMENT PHASE
Combat Health Support Planning
Medical Threat Assessment (SRP Status versus Threat)
Determine medical assets (Organic, Attached, Air, Ground,

Theater, JTF, Host Nation, ISB/FSB, etc…)
Gather higher HQ medical guidelines & requirements
Familiarization with adjacent unit medical operations
Submit medical RFIs
Request maps, imagery and medical intelligence
Understand the tactical commander’s plan & concept of the
operation
Conduct a casualty estimation based off of the commander’s
concept of the operation by phase, objective, or event
Determine key locations & designate a primary/alternate if
appropriate: Unit objectives, Plt/Co/Bn CCPs, HLZs,
AXPs, COB/EPW/NEO collection points, etc…
Determine the casualty flow from point of injury to tertiary
fixed MTF (Key locations, distances, link-ups, etc…)
Plan for air CASEVAC (Dedicated assets, assets on-call,
HLZs, request & launch methods, etc…)
Plan for ground CASEVAC (Dedicated assets, assets on-call,
routes, AXPs, request & launch methods, etc…)
Determine medical communications requirements (Requesting
and directing CASEVAC, casualty reporting, resupply
requests, and Medical call signs/frequencies on SOI)
Coordinate the Casualty Reporting / Regulating System
Synchronize medical events and systems into the unit’s tactical

synch matrix and execution checklist
Determine Class VIII resupply requirements, methods,
distribution, locations, packing lists, etc…(Synchronize with
the unit’s overall resupply system)
Determine Preventive Medicine requirements (Before, during
and after the deployment)
Determine area medical support requirements at staging bases
(Lab, X-ray, PM, etc…)
Schedule and coordinate CHS rehearsals with higher, adjacent,
and subordinate elements (CCP Ops, CASEVAC Ops,
vehicle and aircraft loading/unloading)
Determine Admin Med Coverage requirements and integrate
based on the tactical mission and SOPs
Conduct Pre-Combat Checks

Back-brief medical mission to higher medical authority,
commanders, and leaders
Draw / Perform Checks & Maintenance on Combat Equipment
Weapons Protective Masks
Night Vision Communications
Mission Specific
54
DRAFT
Pack / Re-Pack Trauma Assault Packs
Select appropriate aidbag or rucksack
Ensure packing of recommended DOS stockage
Attend COMMEX
Ensure proper COMSEC
Check/Confirm frequencies & call signs
Verify and maintain copy of Battle Roster / Manifest
Co Sr Medics should have a Co Battle Roster
Bn CCP should have a Bn or TF Battle Roster
Infil/Exfil Manifests as appropriate
Check combat elements (Squads/Platoons/Companies)
All Rangers - Bleeding Control Kits
Designated Rangers - RFR Aid Bags, SKEDCO Litters
All Medics - Med Supplies, Drugs, & Casualty Cards
Verify dissemination of medical plan to the lowest level
CASEVAC procedures
Medical Locations
Rehearse and conduct CASEVAC drills with combat elements
Pack/Re-Pack/Stage Medical Re-Supply

Battalion Medical ISU-90/Pallet
Company Deployment Chests
Reconfigure per mission specifics
Speedballs, Bundles, Pull-Offs configured as required
Draw / Perform checks on MEDSOV and Quad
PMCS Vehicle
Load required medical equipment
Litters (NATO, Sked, Isr) Vehicle OVM/Tools
O2 Straps & Tie-Downs
Suction and BVM Trauma Assault Packs
Re-Supply Bundles Mission Specifics
Gather Operational Required Items
Maps, Imagery, Overlays (Routes, CCPs, HLZs, AXPs
AAs, Fighting Positions, Objectives, Phase Lines)
Communications SOI and COMSEC
Conduct CHS Rehearsals
CHS Operations Order / Briefing (to all CHS participants)
Medical Threat / Intelligence
Medical Concept of the Operation & Casualty Flow
Key Locations
Requesting Procedures (CASEVAC, Re-Supply, etc…)
Medical Communications
Casualty Tracking
CCP Operations
CCP Assembly, Security & Movement Plan
Casualty Movement and Aid & Litter Team Plan
Marking, Vehicle Parking, Link-up Procedures
Casualty Tracking & Recording
Triage, Treatment & Management of Casualties
CASEVAC Drills
Care Under Fire Drills
Air CASEVAC Request & Loading
Ground CASEVAC Request & Loading
55
DRAFT
EXECUTION PHASE
Care Under Fire
Return Fire / Control Situation / Recover Casualty
Provide Immediate Life-Saving Measures
Bleeding Control
Communicate Situation
Tactical Field Care
Evacuate Casualty to CCP or Secure Location
Conduct Triage in a Multiple Casualty Situation
Conduct a Rapid Trauma Assessment
Treat Life-Threatening Injuries / Gain IV Access
Prep for Evacuation
Secure Bandages, Immobilize as required, Prep evac- related
equipment (litters, straps, etc…)
Request Evacuation & Re-Supply (as required)
Triage into a Casualty Collection Point
Perform Detailed Physical Examination
Definitive Management of ABCs
Request Further Evacuation & Re-Supply
Treat Minor Injuries (non-life threatening) as time permits
CCP Internal Evaluation/CASEVAC PREP
CCP Element Assembly & Link-Up (75% Assembled within 30
min of Airdrop)
CCP is established IAW the tactical timeline at the designated
location. If CCP is established at alternate location or any
other deviation in the plan, disseminate to units. Cover and
concealment is utilized to the fullest extent possible.
CCP Security is established and maintained throughout op.
All pax maintain security/situational awareness at all times.
CCP Pax conduct appropriate noise, light, trash discipline at
CCP sites for duration of op.
Communications with C2 elements and units are established.
Execution checklist calls are made if required.
Communication is established with company medics, 1SGs,
and evac vehicles.
If marking devices are utilized, they are employed IAW SOP or
the coordinated plan.
Triage point is identified, marked, and used IAW SOP
Casualties triaged into CCP by treatment category.
Casualties recorded as they enter the CCP and reported to the
TOC/CP/1SG/Head DACO as appropriate.
Casualties are treated to the maximum available medical care
standard as possible while in the CCP. Casualties
reassessed every 5 minutes or as the situation permits while
in the CCP. Casualties are protected from the environment
and covered/concealed as much as the situation permits.
Evac from CCP is coordinated through appropriate C2 element
EPW, COB, or NEO casualties are treated and evacuated IAW
the Geneva Convention, SOP, or established plan
Casualties have documentation/casualty card prior to evac from
CCP (NLT evac from Bn level CCP)
CCP personnel and casualties are extracted/recovered
56
DRAFT
CASEVAC Operations
Evac requests submitted IAW SOP or coordinated plan
Vehicle movements coordinated through C2 elements
CEPs, AXPs, HLZs, and link-ups are conducted IAW SOP or
coordinated plan
Air and ground evac ops are coordinated through C2 elements
IAW SOP or coordinated plan
Casualties evacuated by category (Urgent, Priority, Routine, or
Convenience)
Casualty Treatment Evaluation (individual casualty trauma
patient assessment)
Determine Responsiveness / Level of Consciousness
Assess Airway & Breathing
Assessment / Patency
Assures adequate Ventilation, Breathing Rate and Quality
Manages Injuries related to airway and breathing
Manages Airway (J-Tube / Nasopharyngeal / Suction / BVM
/ ET-tube / Surgical Airway)
Administers Oxygen if appropriate and available
Manage C-Spine* if indicated (as situation permits)
Assess Circulation
Assess for and controls life threatening bleeding
Assess Pulse Rate and Quality
Assess Skin (color, temperature and condition)
Triages into evacuation or treatment category
Conducts Rapid or Focused Trauma Assessment/Survey and
treats life threatening injuries appropriately
Treat for Shock
Establishes Vascular Access (IV fluids or Saline Lock)
Obtains Baseline Vital Signs
Obtains a Patient History (Secondary Survey as situation
permits)
SAMPLE History
Self-Aid/Buddy-Aid/RFR care previously rendered?
Previous Interventions rendered?
Conducts a Detailed Physical Assessment (as situation permits)
(Inspect/Palpate/Auscultate OR Pain/Blood/Deformity)
Assess Head (scalp, ears, eyes/pupils, oro-nasal
Assess Neck (inspect, JVD, tracheal deviation)
Assess Chest (inspect, palpate, auscultate )
Assess Abdomen/Pelvis/Genitalia (palpate/auscultate)
Assess Extremities (pain, blood, deformity, pulses,
motor/sensory)
Assess Posterior (sweep of back)
Manages Secondary Injuries & Wounds (as situation permits)
Records Patient Information/Treatment/Interventions on
Casualty Card (NLT Bn level CCP)
57
DRAFT
75th RANGER HAZARDOUS TRAINING CHECKLIST (ADMIN MEDICAL) AS OF 9APRIL 2002
CHECKLIST INITIALS REMARKS

VEHICLE DISPATCHED AND FUELED CAUTION: DO NOT RETURN AMBULANCE TO MOTOR POOL
(CIRCLE) AMB TRK VAN WITH LESS THAN ½ TANK OF GAS.
PMCS TURN 2404 IN WITH DISPATCH. NOTE ANY PROBLEMS.

(AMBULANCE ONLY)
APPROPIATE ADMIN MEDICAL COVERAGE 350-2 (ASOP)
REQUIREMENTS FB 40-2 (MED COVERAGE)
COMMUNICATIONS APPROPIATE NUMBER AND TYPE OF COMMUNICATIONS
AVAILABLE FOR MISSION SUPPORT. COMMO CHK WITH
OIC/DZSTL, MEDICS, DRIVER, HOSP AND AIREVAC
DISPATHER PRIOR TO P-HOUR/HIT TIME.
MEDICAL EQUIPMENT CAUTION: ACCOUNT FOR AND TEST ALL EQUIPMENT
BEFORE AND AFTER MISSION.
BACKBOARD WITH STRAPS (min. 4 ea.)
CERVICAL STABILIZER
C-COLLAR
BVM (bag, mask, reservoir and tubing)
O2 COMPLETE (regulator, tank, non-rebreather mask and case)
PSI:________________
SUCTION (battery and manual)
MAST PANTS
PRO SPLINT SET (complete)
KED/OREGON SPINE SPLINT
RANGER TRAUMA PACK (PER SOP)
BLANKETS/RESCUE WRAP W/ HEATER
VITAL SIGNS MONITOR (CIRCLE) PROPAQ PIC W/ 2 BATTERIES
REEL/HARE TRACTION SPLINT
SITE SURVEY (MEDICAL) OFF POST ONLY
EVAC CHECKLIST AND TRAUMA 600’s
MAP W/ GPS MILITARY AND STRIP MAP (STRIP MAP FOR OFF POST ONLY)
SEN MEDIC CONFIRM GRID YOURSELF
RANGER MEDICAL PROTOCOL BOOK REVIEW PRIOR TO COVERAGE
ADMIN HEAD LIGHT
NIGHT VISION GOGGLES POTENTIAL FOR NEED Y N
EVACUATION BY AIR/GROUND
RESPONSIBILITIES OF THE MEDIC (S), DZSTL/ OIC PRI HLZ (GRID/LANDMARK): ____________________
AND DRIVER REVIEWED, REHERSED AND ALT HLZ (GRID/LANDMARK): ___________________
UNDERSTOOD BY ALL MENTIONED PAX.
METHOD OF MARKER:
DZSTL/OIC NAME: ________________________ DAY: ___________________
SIGNATURE: _____________________________ NIGHT: _________________
MEDIC: ________________________________
UNIT __________________________________
ABN OP FAST ROPE LFX DEMO WATER OP OTHER __________
AAR COMMENTS ON BACK
58
DRAFT
ABBREVIATION LIST
AAS acute abdominal series
ABD abdomen
ABG arterial blood gas
AC before eating (ante cibium)
ACLS Advanced Cardiac Life Support
A&O X - alert and oriented times orientation
AF afebrile
AKA above-the-knee amputation
AP anteroposterior
ASA acetylsalicylic acid (aspirin)
AT/NC atraumatic, normocephalic
bid twice a day
BKA below-the-knee amputation
BM bowel movement
BP blood pressure
BPM beats per minute
BRBPR bright red blood per rectum
BS bowel sounds
Bx biopsy
c with (cum)
CAD coronary artery disease
CAT computed axial tomography
CBC complete blood count
CC chief complaint
CHI closed head injury
C/O complaining of
CPR cardiopulmonary resuscitation
CTA clear to auscultation
CXR chest x-ray
D/C discontinue or discharge
DDx differential diagnosis
DOA dead on arrival
DOB date of birth
DOE dyspnea on exertion
DPL diagnostic peritoneal lavage
DPT diphtheria, pertussis, tetanus
DTR deep tendon reflex
DVT deep venous thrombosis
Dx diagnosis
EBL estimated blood loss
ECG electrocardiogram
EDC estimated date of confinement
EMG electromyelogram
EMS emergency medical system
EOMI extraocular muscles intact
ET endotracheal
ETOH ethanol
FB foreign body
F&D fixed and dilated
FamHx family history
F/C fevers, chills
F/U follow-up
Fx fracture
GERD gastroesophageal reflux disease
GI gastrointestinal
GSW gunshot wound
gtt drops
GU genitourinary
HA headache
59
DRAFT
Hct hematocrit
HEENT head, eyes, ears, nose, throat
Hgb hemoglobin
HPI history of present illness
HR heart rate
HS bed time (hours of sleep)
HSV herpes simplex virus
HTN hypertension
Hx history
I&D incision and drainage
IM intramuscular
I&O intake and output
IV intravenous
JVD jugular venous distention
L left
LA lymphadenopathy
lac laceration
LBP low back pain
LE lower extremities
LIH left inguinal hernia
LLL left lower lobe
LMP last menstrual period
LOC loss of consciousness
LP lumbar puncture
LLQ left lower quadrant
LUL left upper lobe
LUQ left upper quadrant
MAST military antishock trousers
MI myocardial infarction
MOI mechanism of injury
MMR measles, mumps, rubella
MRI magnetic resonance imaging
MVA motor vehicle accident
NAD no acute distress
NKDA no known drug allergies
NPO nothing by mouth (nil per os)
NS normal saline
NSAID nonsteroidal antiinflammatory drug
NSR normal sinus rhythm
NTG nitroglycerin
N/V/D nausea, vomiting, diarrhea
OB obstetrics
OD right eye (oculus dexter), overdose
OE otitis externa
OM otitis media
OPV oral polio vaccine
OS left eye (oculus sinister)
PC after eating (post cibum)
PCN penicillin
PE physical exam, pulmonary embolism
PEA pulseless electrical activity
PERRL pupils equal, round, reactive to light
PFT pulmonary function test
PMHx past medical history
PMI point of maximal impulse
PO by mouth (per os)
PPD purified protein derivative
PR per rectum
PRN as often as needed (pro re nata)
PSHx past surgical history
Pt patient
PUD peptic ulcer disease
60
DRAFT
q every (quaque)
qd every day
qh every hour
q _h every _ hours
qid four times a day (quater in die)
qod every other day
R right
RBC red blood cell
RDA recommended dietary allowance
RIH right inguinal hernia
RLL right lower lobe
RLQ right lower quadrant
RML right middle lobe
R/O rule out
ROM range of motion
ROS review of systems
RUL right upper lobe
RUQ right upper quadrant
RR respiratory rate
RRR regular rate and rhythm
RTC return to clinic
Rx prescription, treatment
s without (sine)
SEM systolic ejection murmur
SL sublingual
Sn signs
SocHx social history
SOB shortness of breath
SQ subcutaneous
STD sexually transmitted disease
Sx symptoms
Td tetanus-diphtheria toxoid
tid three times a day (ter in die)
TKO to keep open
TM tympanic membrane
TNTC to numerous to count
TTP tenderness to palpation
Tx treatment
ud as directed (ut dictum)
UE upper extremities
URI upper respiratory tract infection
UTI urinary tract infection
VA visual acuity
VD venereal disease
VSS vital signs stable
WBC white blood cell
WD well developed
WN well nourished
WNL within normal limits
YO years old
>,<,= greater than, less than, equal
61
Tactical Combat Casualty Care
Prehospital Care in the Tactical Environment
The Committee on Tactical Combat Casualty Care
For Chapter 17: Military Medicine, in The Prehospital Trauma Life

Support Manual, Fifth Edition
10 Feb 2003 Draft
1
The Committee on Tactical Combat Casualty Care: 2002
U.S. Special Operations Command/U.S. Navy Bureau of Medicine and Surgery
Chairman – CAPT Stephen Giebner

COL Robert Allen
COL Frank Anders
CPT Steve Anderson
COL James Bagian
COL Ron Bellamy
1LT Bart Bullock
CAPT Frank Butler
Dr. Howard Champion
TSGT George Cum
CAPT Roger Edwards
LTC Stephen Flaherty
CDR Scott Flinn
MAJ John Gandy
CAPT Larry Garsha
COL John Holcomb
Dr. David Hoyt
LTC Donald Jenkins
Dr. Jay Johannigman
MSG John Kennedy
CPT Robert Mabry
Dr. Norman McSwain
SFC Robert Miller
MAJ Kevin O'Connor
CAPT Edward Otten
LTC Tyler Putnam
CDR Peter Rhee
CAPT Larry Roberts
CDR Jeff Timby
HMCM Gary Welt
Executive Assistants: LT David Anderson, Ms. Shannon Addison
2
General Considerations
Throughout their careers, military medical personnel may be called upon to treat trauma
victims in two types of situations – in combat, and in routine life on or off military installations.
For non-combat situations, such as motor vehicle accidents, training accidents on the base, falls
at home, and civilian acts of violence, the PHTLS guidelines described elsewhere in this manual
apply. These guidelines should be followed and the appropriate EMS system activated. This
chapter deals specifically with military combat trauma, and the recommendations herein apply
solely to the tactical prehospital setting.
Ninety per cent of combat wound fatalities die on the battlefield before reaching a medical
treatment facility. (1) This fact of war emphasizes the need for continued improvement in combat
prehospital care. Trauma care training for military corpsmen and medics has been based primarily
on the principles taught in the Advanced Trauma Life Support (ATLS) course. (2) ATLS provides
a standardized approach to the management of trauma that has proven very successful when used in
the setting of a hospital emergency department. The value of at least some aspects of ATLS in the
prehospital setting, however, has been questioned, even in the civilian sector. (3-23) Military
authors have voiced additional concerns about the applicability of ATLS in the combat setting. (24-
31) Mitigating factors such as darkness, hostile fire, resource limitations, prolonged evacuation
times, unique battlefield casualty transportation issues, command and tactical decisions affecting
healthcare, hostile environments, and provider experience levels pose constraints different from the
hospital emergency department. These differences are profound, and must be carefully reviewed
when trauma management strategies are modified for combat application.
For example, Zajtchuk, Jenkins, Bellamy and their colleagues recommended combat
casualty care guidelines for U.S. Army combat medics prior to the Gulf War that differed somewhat
from ATLS guidelines. (25) Butler’s “Tactical Combat Casualty Care in Special Operations” paper
in 1996 provided a comprehensive review of prehospital care in the Special Operations tactical
setting along with a set of recommended Tactical Combat Casualty Care (TCCC) guidelines for use
by Special operations corpsmen, medics and pararescuemen (PJs). (31) These TCCC guidelines
were published in the Fourth Edition of the Prehospital Trauma Life Support Manual. (32)
Additionally, civilian medical organizations like the Wilderness Medical Society have published
their own recommendations for the care of trauma patients in environments of interest to their
members. (33) The ATLS course and its principles are well accepted as the standard of care once
the patient reaches the Emergency Department of an MTF. Difficulties arise, however, as civilian
ATLS principles are extrapolated onto the battlefield setting. This chapter addresses those
difficulties, in light of the requirement to best achieve all three goals of TCCC: 1) Treat the
casualty; 2) Prevent additional casualties; and 3) Complete the mission.
3
The Committee on Tactical Combat Casualty Care
Like all medical management strategies, the TCCC guidelines require periodic review and
updating. Establishing a standing multi-service Committee on Tactical Combat Casualty Care
(COTCCC) was first stated as a requirement by the Commander of the Naval Special Warfare
Command. (34) This Committee was founded in 2002 by the U.S. Special Operations Command,
and continued support of this effort has been approved by the Navy Bureau of Medicine and
Surgery (BUMED). The committee comprises a tri-service group of trauma specialists, operational
medical officers, and combat medical personnel. It will continue to monitor developments in the
field of TCCC and propose changes to the guidelines as appropriate. The updated TCCC guidelines
in Tables 1-3 and the explanatory text in this chapter are the results of the efforts of the COTCCC
during workshops held in 2002.
Stages of Care in TCCC

Casualty management during combat missions can be divided into three distinct phases as
described below. (31) This approach recognizes a particularly important principle – performing the
correct intervention at the correct time in the continuum of field care. A medically correct
intervention performed at the wrong time in combat may lead to further casualties.
1. "Care Under Fire" refers to care rendered at the scene of the injury while both the medic
and the casualty are under effective hostile fire. The risk of additional injuries being sustained at
any moment is extremely high for both casualty and rescuer. Available medical equipment is
limited to that carried by each operator and the medic.
2. "Tactical Field Care" is the care rendered once the casualty and his unit are no longer
under effective hostile fire. It also applies to situations in which an injury has occurred on a
mission, but hostile fire has not been encountered. Medical equipment is still limited to that carried
into the field by mission personnel. Time prior to extraction may range from a few minutes to many
hours.
3. "Combat Casualty Evacuation Care" (CASEVAC) is the care rendered while the casualty
is being evacuated by an aircraft, ground vehicle, or boat for transportation to a higher echelon of
care. Any additional personnel and medical equipment pre-staged in these assets will be available
during this phase. The term "CASEVAC" should be used to describe this phase since the Air Force
reserves "MEDEVAC" to describe a non-combat medical transport.
Basic TCCC Management Plan

An updated basic management plan for each of the three phases of TCCC is presented in
Tables 1, 2, and 3. This plan is a generic sequence of steps that serves as a starting point from
which development of tailored, scenario-based management plans may begin. A detailed rationale
for each step outlined in the basic management plan was presented in the fourth edition of this
publication. (32) Modifications to the TCCC guidelines by the COTCCC are discussed below. As
4
before, treatment principles in the ATLS course have been followed except where specific tactical
considerations require a departure.
Care Under Fire

Very limited medical care should be attempted while the casualty and his unit are under
effective hostile fire, as reflected in Table 1. Suppression of hostile fire and moving the casualty to
a safe position are major considerations at this point. Significant delays for a detailed examination
or consummate treatment of all injuries are ill advised while under effective enemy fire. Casualties
who have sustained injuries that are not life threatening, and that do not preclude further
participation in the fight, should continue to assist the unit in suppressing hostile fire, and in any
other way possible to achieve mission success. It may also be critical for the combat medic or
corpsman to help suppress hostile fire before attempting to provide care. This can be especially true
in small unit operations where friendly firepower is limited, and every man’s weapon may be
needed to prevail. If hostile fire is not effectively suppressed, it may be necessary to move the
casualty to cover. Casualties whose wounds do not prevent them from moving themselves to cover
should do so to avoid exposing the medic or other aid givers to unnecessary hazard. Management
of an impaired airway is temporarily deferred until the patient is safe, thereby minimizing the risk to
the rescuer and avoiding the difficulty of managing the airway while dragging the casualty. Further
discussion of casualty movement is presented in Figure 1.
The temporary use of a tourniquet to manage life-threatening extremity hemorrhage is

recommended. This principle is supported by the wealth of Vietnam conflict combat casualty data
indicating that exsanguinations from extremity injuries represented the number one etiology of
preventable battlefield deaths (35). Direct pressure and compression dressings are less desirable
than tourniquets in this setting because their application at the site of injury may result in delays
getting the casualty and the rescuer to cover, and they may provide poorer control of hemorrhage
while the casualty is being moved. Mabry et al reported on the lives saved in Mogadishu in 1993 by
properly applied tourniquets. (36) In recent experience by the Israeli Defense Force (IDF), the use
of tourniquets in combat settings confirmed that they are effective and safe even when their use is
prompted by tactical rather than clinical indications. There were very few and minimal
complications resulting from their use. (37) The standard “web belt through the buckle” tourniquet
issued by the military for many years has not been well received by the combat medic community.
Combat medics have often carried makeshift tourniquets composed of an encircling soft bandage
tightened by a makeshift windlass. Some commercially available tourniquets were tested in a study
sponsored by the U.S. Special Operations Command, and found to be unsatisfactory. (38) Several
newly designed tourniquets are now being field tested by the U.S. Army, including a double-buckle
tourniquet designed for ease of self-application with one hand in the event of a traumatic amputation
of a hand or arm, and a ratchet design. Whatever tourniquet is selected must be both effective in
controlling arterial bleeding and quickly applied under field conditions.
First responders can also achieve hemostasis in some cases of non-extremity hemorrhage
using hemostatic agents in conjunction with direct pressure, if the site of the bleeding is
accessible without surgical incision. A number of external agents have been approved by the U.S.
Food and Drug Administration (FDA) for this indication, and have recently been evaluated in a
5
standardized fashion in tactically relevant animal models. The Rapid Deployment Hemostat®
(RDH) bandage is a proprietary formulation of poly-N-acetyl glucosamine that has not proven as
efficacious as other options in trials at the United States Army Institute of Surgical Research
(USAISR).(39) TraumaDex is a starch polymer that has been shown to reduce bleeding in some
trauma models, but has not been proven at this time to equal the other options in severe bleeding
models. (40) QuickClot ™ is an FDA-approved powder of proprietary formulation. This agent
was introduced by the Marine Corps in mid-2002; the first combat test and evaluation of an
active hemostatic agent by the U.S. Armed Forces. QuickClot ™ has been found effective in
severe bleeding models (41), but when not meticulously applied, it can produce an exothermic
reaction with temperatures up to 90oC. The heat produced under this circumstance could potentially
cause pain and collateral tissue damage. (42) To minimize the risk posed by this exothermic
potential, excess blood and fluid must first be removed from the application site. The powder
format may prove difficult to apply properly on the battlefield, especially at night. In November
2002, another active hemostatic agent, the HemCon® dressing, was approved by the FDA for
external use. The HemCon® dressing is another proprietary formulation of poly-N-acetyl
glucosamine that has proven effective in a severe bleeding model in trials at the USAISR. (43)
Recombinant Factor VIIa is another hemorrhage control agent currently under evaluation in a multi-
center trial. It has anecdotally proven efficacious in cessation of bleeding in trauma patients with
severe bleeding and acquired coagulopathies. (44) It is currently not recommended for field use, but
may ultimately prove valuable in forward surgical units for some patients.
Further evaluation and development will yield more information on currently approved
external hemostatic agents, and intense research in the area of other agents that can control
hemorrhage in the field is underway. New agents are likely to be available soon. Efficacy will be
demonstrated in severe hemorrhage models, and in the durability, ease of use, cost, tactical
relevance, and shelf life of the product. As of this writing, there is currently no direct data to
demonstrate that either QuickClot ™ or the HemCon® dressing is more effective at achieving
hemostasis. However, because of its safety and ease of application, the HemCon® dressing
represents the best current option for external hemostasis on the battlefield in casualties whose
bleeding sites are not amenable to the use of a tourniquet.
A casualty may exsanguinate before any medical help arrives (45), so the importance of
achieving rapid, definitive control of life-threatening hemorrhage on the battlefield cannot be
overemphasized. Furthermore, standard field dressings and direct pressure may not work reliably to
control exanguinating extremity hemorrhage. (45) Therefore, every combatant should carry both a
tourniquet and a hemostatic dressing as part of his personal gear loadout, and should be trained in
their use.
There is no requirement to immobilize the spine prior to moving a casualty out of a firefight
if he has sustained only penetrating trauma. Arishita, Vayer, and Bellamy examined the value of
cervical spine immobilization in penetrating neck injuries in Vietnam. They determined that only
1.4% of patients with penetrating neck injuries might have benefited from cervical immobilization
(24). Hostile fire poses a much more significant threat in this setting, to both casualty and rescuer,
than spinal cord injury from failure to immobilize the C-spine. (24) For casualties with significant
blunt trauma in the Care Under Fire phase, the risk of spinal cord injury remains a major
6
consideration. (36) In this circumstance, the risk of cord injury from neck movement must be
weighed against the risk of additional hostile fire injuries while immobilizing the C-spine.
Combat is a frightening experience, and being wounded, especially seriously, can generate
tremendous anxiety and fear. Engaging a casualty with reassurance is therapeutically beneficial,
and communication is just as important in patient care on the battlefield as it is in the MTF.
Tactical Field Care

Recommended guidelines for this phase of care are shown in Table 2.
In the combat setting, there are four primary reasons for an individual to exhibit an altered
state of consciousness: traumatic brain injury, pain, shock, and analgesic medications. An armed
combatant suffering an altered state of consciousness poses a serious threat of injury to others in his
unit should he employ his weapons inappropriately. Anyone noted to have an altered state of
consciousness should be disarmed immediately, to include secondary weapons and explosive
devices. (46)
Unconscious casualties should have their airways opened with the chin-lift or jaw thrust
maneuvers. If spontaneous respirations are present and there is no respiratory distress, further
airway management is best achieved with a nasopharyngeal airway. It is more easily tolerated than
an oropharyngeal airway if the patient suddenly regains consciousness (2), and it is probably less
likely to be dislodged during transport. (31) These casualties should be placed in the semiprone
recovery position (Figure 2) to prevent aspiration of blood, mucous, or vomitus.
Should an airway obstruction develop or persist despite the use of a nasopharyngeal airway,
a more definitive airway will be required. The ability of experienced paramedical personnel to
perform endotracheal intubation has been well documented. (6,47-56) Most studies reported use of
cadaver training, operating room intubations, supervised initial intubations, or a combination of
these methods in teaching the skill. They also stressed the importance of continued practice to
maintain proficiency. This technique may be prohibitively difficult in the tactical environment,
however, for a number of reasons (31): 1) there have been no studies examining the ability of well-
trained but relatively inexperienced military medics to accomplish endotracheal intubation on the
battlefield; 2) many corpsmen and medics have never performed an intubation on a live patient or
even a cadaver; 3) standard endotracheal intubation techniques entail the use of a tactically
compromising white light in the laryngoscope; 4) endotracheal intubation can be extremely difficult
in a casualty with maxillofacial injuries (25); and 5) esophageal intubations are probably much less
recognizable on the battlefield. Endotracheal intubation may be difficult to accomplish even in the
hands of more experienced paramedical personnel under less austere conditions. (57) One study,
which examined first-time intubationists trained with mannequin intubations alone, noted an initial
success rate of only 42% in the ideal confines of the operating room with paralyzed patients. (54)
Another study examined basic EMTs who had been trained in intubation and found that only 53 of
103 patients were successfully intubated. (58) Even in civilian settings with experienced
paramedical personnel, another report documented that in 27 of 108 prehospital intubations, the tube
was misplaced upon arrival in the Emergency Department. (59) Some reports of successful
7
intubation by military combat medical personnel use mannequin intubation by just-trained
corpsmen as an outcome measure (60), which may not be an accurate indicator of success under
actual battlefield conditions. The usefulness of this procedure was further questioned in a study in
which prehospital endotracheal intubation was not found to improve outcome in patients with
severe head injuries. (61)
Significant airway obstruction in the combat setting is likely to be the result of penetrating
wounds of the face or neck in which blood or disrupted anatomy precludes good visualization of the
vocal cords. Cricothyroidotomy is therefore preferable to intubation in these cases, if the combat
corpsman or medic has been trained in this procedure. (25,31) Cricothyroidotomy has been
reported safe and effective in trauma victims (62), but is not without complications (63,64). Even
so, it is felt to provide the best chance for successful airway management in this setting.
Furthermore, it can be performed under local anesthesia with lidocaine in an awake patient.
Thermal or toxic gas injuries are important considerations in certain tactical situations.
Airway edema is aggravated by fluid administration, and this may lead to acute upper airway
obstruction. Airway burns should be suspected if fire occurs within a confined space, the patient
has cervicofacial burns, singeing of the nasal hairs, carbonaceous sputum or complaints of sore
throat, hoarseness or wheezing. Cricothyroidotomy is the airway of choice in the Tactical Field
Care Phase for these casualties.
A presumptive diagnosis of tension pneumothorax should be made when significant

respiratory distress develops in the setting of torso trauma. The diagnosis of tension pneumothorax
on the battlefield should not rely on such typical clinical signs as decreased breath sounds, tracheal
deviation, or hyperresonance to percussion because these signs may not always be present (65), and
even if they are, they may be exceedingly difficult to appreciate on the battlefield. A patient with
penetrating chest trauma will generally have some degree of hemo/pneumothorax as a result of his
primary wound, and the additional trauma caused by a needle thoracostomy would not be expected
to significantly worsen his condition should he not actually have a tension pneumothorax. (56)
Paramedics are authorized to perform needle thoracentesis in some civilian emergency medical
services. (51,56) Combat corpsmen and medics should also be proficient in this technique. Chest
tubes are not recommended in this phase of care for the following reasons: 1) they are not needed to
provide initial treatment for a tension pneumothorax; 2) they are more difficult and time-consuming
for relatively inexperienced medical personnel, especially in the austere battlefield environment; 3)
chest tube insertion is probably more likely to cause additional tissue damage and subsequent
infection than needle thoracostomy; and 4) no documentation of benefit from battlefield tube
thoracostomy by paramedical personnel was found in the literature. (31) Tube thoracostomy is
generally not part of the paramedic's scope of care in civilian EMS settings (51,56), and no studies
were found that address the use of this procedure by corpsmen and medics in combat settings.
Needle thoracentesis with a 14-gauge needle was found to rapidly relive elevated
intrapleural pressure in a swine model of traumatic tension pneumothorax. (66) The therapeutic
effect was sustained for 4 hours, and this procedure was found to be equivalent to tube
thoracostomy with a 32F chest tube for the observation period. (66) The ease and speed of
performance, and the decreased likelihood of complications make needle thoracentesis the
procedure of choice for relieving tension pneumothorax on the battlefield. Cannula length is an
8
important consideration here (67), as the pectoral muscles must be penetrated, and in young
soldiers, they can be very thick. Even though it may be difficult to appreciate in field settings, if
there is no rush of air when the needle is inserted, then either it didn’t go in far enough, or there was
no tension pneumothorax there. Medics of the 75th Ranger Regiment currently pack 10ga 3-inch
needle/catheters for this procedure. (Personal communication – SFC Rob Miller) Any patient who
has undergone needle thoracentesis for relief of tension pneumothorax must be continually re-
assessed. Catheters used for this purpose are subject to occlusion by clotting and kinking.
An open pneumothorax (sucking chest wound) may result from large defects in the chest
wall, and may interfere with respiration. These wounds are treated by applying a vaseline gauze
during expiration, covering the gauze with tape or a field dressing, placing the casualty in the sitting
position, and monitoring for the possible development of a tension pneumothorax.
Tourniquets applied during the Care Under Fire phase should be replaced with direct
pressure and/or HemCon® dressings when the tactical situation allows, with care to assure
continued hemostasis.
Although ATLS teaches starting two large bore (14- or 16-gauge) intravenous catheters for
fluid resuscitation in trauma cases (2), the 18-gauge catheter is preferred in the field setting because
of the ease of cannulation. (31) Crystalloid and colloid solutions can be administered rapidly
through an 18-gauge catheter and blood products requiring the larger cannulae aren’t given in the
field (68,69). Blood products may be administered in the CASEVAC phase or later at an MTF, but
field-placed IV cannulae will normally be replaced there anyway due to the risk of contamination.
(70)
Despite its ubiquity, the benefit of prehospital fluid resuscitation in trauma patients has not
been established. (3,6-8,10-12,14,16,19,21,25,71) The ATLS course proposes initial fluid
resuscitation with two liters of a crystalloid. Other options are no fluid resuscitation until
hemorrhage is definitively controlled, or limited (hypotensive) resuscitation to achieve a perfusing
systolic blood pressure of about 70 mm Hg. Additionally there has been controversy over the fluid
to be used. Choices have included crystalloid, colloid, synthetic colloid, blood products, and the
new hemoglobin solutions. The beneficial effect from crystalloid and colloid fluid resuscitation in
hemorrhagic shock has been demonstrated largely in animal models where the volume of
hemorrhage is controlled experimentally and resuscitation is initiated after the hemorrhage has been
stopped. (21,22) Multiple studies using uncontrolled hemorrhagic shock models have found that
aggressive fluid resuscitation before surgical repair of a vascular injury is associated with either no
improvement in survival or increased mortality when compared to no resuscitation or hypotensive
resuscitation. (9,10,15,17-21,72,73) This lack of benefit is presumably due to interference with
vasoconstriction as the body attempts to adjust to the loss of blood, and interference with hemostasis
at the bleeding site. Two studies were found in which aggressive fluid resuscitation improved the
outcome of uncontrolled hemorrhagic shock. (74,75) Both of these studies used rat tail amputation
models, which may not correlate well with uncontrolled hemorrhage on the battlefield from intra-
thoracic and intra-abdominal injuries. Some studies have noted that fluid resuscitation proved to be
of benefit only after previously uncontrolled hemorrhage was stopped. (76-78)
9
Three studies were found which address this issue in humans. One large study of 6,855
trauma patients found that although hypotension was associated with a significantly higher mortality
rate, the administration of prehospital IV fluids did not reduce this mortality. (14) A retrospective
analysis of patients with ruptured abdominal aortic aneurysms showed a survival rate of 30% for
patients who were treated with aggressive preoperative colloid fluid replacement in contrast to a
77% survival rate for patients in whom fluid resuscitation was withheld until the time of operative
repair. (79) The author strongly recommended that aggressive fluid resuscitation be withheld until
the time of surgery in these patients. Bickell and colleagues published a large prospective trial
examining this issue in 598 victims of penetrating torso trauma. (4,13) They found that aggressive
prehospital fluid resuscitation of hypotensive patients with penetrating wounds of the chest and
abdomen was associated with a higher mortality than seen in those for whom aggressive volume
replacement was withheld until the time of surgical repair. Further analysis of this data found that
this difference was most significant in those patients with wounds of the chest, with abdominal
wounds showing little difference in survival between early and delayed fluid resuscitation. (80)
Although confirmation of these findings in other randomized, prospective human studies has not yet
been obtained, no human studies were found which demonstrated any benefit from fluid
replacement in patients with ongoing hemorrhage. Continuing hemorrhage must be suspected in
battlefield casualties with penetrating abdominal or thoracic injury until surgical repair is effected.
Hespan (6% hetastarch) was recommended in the 1996 TCCC paper as better alternative for
fluid resuscitation in the Tactical Field Care phase than lactated ringer's (LR) solution. (31) LR is a
crystalloid, which means that the primary osmotically active particle is sodium. Since the sodium
ion distributes throughout the entire extracellular fluid compartment, LR moves rapidly from the
intravascular space to the extravascular space. This shift has significant implications for fluid
resuscitation. For example, if a trauma patient is infused with 1000 cc of LR, only 200cc of that
volume will remain in the intravascular space one hour later. (81-83) This is not a problem in the
civilian setting, since the average time for transport of the patient to the hospital in an ambulance is
less than 15 minutes (13,14), after which surgical control of hemorrhage can be rapidly achieved. In
the military setting, however, where several hours may elapse before a casualty arrives at an MTF,
effective volume resuscitation may be difficult to sustain with LR.
In contrast, the large hetastarch molecule is retained in the intravascular space and there is
no loss of fluid into the interstitium. Hetastarch osmotically promotes fluid influx into the vascular
space from the interstitium such that an infusion of 500cc of Hetastarch results in an intravascular
volume expansion of almost 800cc (83), and this effect is sustained for eight hours or longer. (84)
Although concerns have been voiced about coagulopathies and changes in immune function
associated with the use of hetastarch (23,85-88), these effects are not seen with infusions of less
than 1500cc. (86-90) Several papers have found hetastarch to be a safe and effective alternative to
LR in resuscitating patients with controlled hemorrhagic shock. (91,92) Hetastarch is also felt to be
an acceptable alternative to LR for intraoperative fluid replacement. (93)
The 1993 Ben Taub study mentioned previously (4) found that aggressive prehospital
fluid resuscitation of hemorrhagic shock resulting from penetrating trauma to the chest or
abdomen produced a greater mortality than KVO fluids only. This resulted in a recommendation
in the original TCCC paper to withhold aggressive fluid resuscitation from individuals with
penetrating torso trauma. (31) At the 1998 Special Operations workshop on Urban Warfare
10
casualties, however, there was a clear consensus among the panelists that should a casualty with
uncontrolled hemorrhage have mental status changes or become unconscious (correlating to a
blood pressure of 50 systolic or less), he should be given enough fluid to resuscitate him to the
point where his mentation improves (correlating to a systolic blood pressure of 70 or above.)
Panel members stressed the importance of not trying to aggressively administer IV fluids with
the goal of achieving "normal" blood pressure in casualties with penetrating truncal injuries. (46)
The consensus conferences held in 2001 and 2002 under the sponsorship of the Office of
Naval Research and other agencies (94) promoted the concepts of minimal fluid resuscitation in
the setting of uncontrolled hemorrhage and the use of alternative fluids that yield logistical
advantages of lighter weight and smaller volume in the ruck sack. The report from the Institute
of Medicine in 1999 titled “Fluid resuscitation; state of the science for treating Combat
Casualties and Civilian injuries” recommended that 7.5% hypertonic saline be initially used for
fluid resuscitation. The rationale for this recommendation was that Lactated Ringers has been
shown to have detrimental immunological effects and that further research was needed to find
the optimal resuscitation fluid. (95-112) HTS was recommended as it has been used in
numerous clinical trails with minimal consequences and in patients with traumatic brain injury, it
may have potential benefits. HTS has also been shown to be immunosuppressive which may
effect the complications (such as ARDS) often seen after massive resuscitation. However, the
main reason for the recommendation of HTS was due to its logistical advantage. The problem
with the use of 7.5% HTS is that it is not currently manufactured and so is not available.
Therefore, in the consensus conferences in 2001 and 2002, the recommendation was that a
colloid solution such as hetastarch be used until HTS is more readily available. It is also unclear
if the resuscitative effect of a single infusion of HTS lasts as long as that of a comparable
infusion of a colloid solution, and this point deserves further investigation.
A technique of minimal fluid resuscitation in the field in casualties with uncontrolled

hemorrhage was promoted in a recent paper by Holcomb. (113) Whereas the 1996 TCCC
guidelines called for Special Operations medics to give 1000 ml of Hespan® to all casualties
meeting the requirement for resuscitation, Holcomb proposed the that all casualties in shock (as
defined by absent peripheral pulses or altered mental status in the absence of brain injury) be
given a 500cc bolus of Hextend. If no improvement is noted in 30 minutes, the bolus is repeated
once. This modification has several advantages: 1) logistics: not all casualties will require 1000
ml of hetastarch, thus saving fluid and time for other casualties; 2) rebleeding; titration of fluids
based upon a monitored physiologic response may avoid the problem of excessive blood
pressure elevation and fatal rebleeding from previously clotted sites; 3) training; basing the fluid
therapy on the premise of responders vs. nonresponders follows the lead of the ACS Committee
on Trauma in the ATLS course, and allows for a single approach to patients with both controlled
and uncontrolled hemorrhage. Interestingly, this recommendation for “hypotensive”
resuscitation is a rebirth of similar principles employed in World War II by Beecher. (114)
Although hetastarch has a theoretical advantage over crystalloids for resuscitating combat
casualties on the battlefield because of its sustained intravascular presence, there is little
convincing clinical evidence in trauma patients that any one crystalloid or colloid works better
than others. However, a multifold reduction in medical equipment weight is achieved by
substitution of hetastarch solution for LR (31), and this is clearly of logistical benefit to military
11
medics, enabling them to carry the smallest volume and weight of resuscitation fluid consistent
with effective practice. (113, 115)
The Hextend® formulation of hetastarch has not been widely used as a front-line
resuscitation fluid, thus clear evidence of its superiority is lacking. However, hetastarch
solutions mixed in saline (Hespan®) increase blood loss compared to the identical hetastarch
mixed in a balanced electrolyte solution, a lactate buffer, and physiological levels of glucose
(Hextend®). (116) A protective influence of Hextend against multiple organ injury after
hepatoenteric ischemia-reperfusion has been reported, and the effect attributed to a potential anti-
oxidant effect of the hetastarch molecule. (117) For the near future, hypertonic saline dextran is
not available, so Hextend is the recommended resuscitation fluid for the Tactical Field Care
phase. The 500cc boluses recommended should be administered as rapidly as possible using
manual pressure on the IV bag or inflatable IV bag cuffs.
The most significant concern with the proposed battlefield resuscitation algorithm is that
it cannot be rigorously evaluated in clinical trials. It is based upon a combination of historical
information, recent animal studies, civilian and military trauma experience, and expert opinion.
The realities of war prevent prospective randomized blinded resuscitation studies on the
battlefield, so now, as in the past, insightful recommendations from those knowledgeable in
trauma physiology and experienced in trauma care must provide the basis for military medical
doctrine. (114, 118, 119) Further modification will be warranted as ongoing research and
development efforts yield new and relevant information. This issue was extensively discussed
during the combat fluid resuscitation conferences (94), with unanimous agreement that this
approach is sound. Optimally, future analysis will also include review of injury data
prospectively collected in a military trauma registry.
It may be difficult to establish intravenous access in casualties in shock. A sternal

intraosseous (IO) device offers an alternative route for administering fluids and medications in
this situation. (120, 121) This allows the medic to avoid more difficult and invasive techniques
like central venous cannulation or saphenous cutdown. IO access is far easier to obtain in the
dark, and requires minimal aseptic technique.
An additional change from the previous recommendations entails the administration of

oral fluids to casualties with penetrating trauma. This recommendation is based upon
observations from trauma surgeons attached to forward-deployed MTFs, noting that many
casualties are kept NPO for prolonged periods in anticipation of eventual surgery. With
transportation delays superimposed upon the dehydration often present in combat operations
before wounding, these casualties come to surgery markedly dehydrated. This may adversely
affect their chance of survival, and the observed risk of emesis and aspiration is remarkably low.
Under the new guidelines, therefore, PO fluids are recommended for all casualties with a normal
state of consciousness, including those with penetrating torso trauma.
The last recommended change to the fluid resuscitation guidelines is a modified fluid
regimen for an individual with traumatic brain injury (TBI) and shock. In this individual,
decreased state of consciousness may be due to either the TBI or hemorrhagic shock from
associated injuries. Hypotension in the presence of brain injury has been found to be associated
12
with a significant increase in mortality. (122) Because of the need to ensure adequate cerebral
perfusion pressure, this casualty should receive IV or IO fluids until he has a palpable radial
pulse, commensurate with a systolic blood pressure of at least 80 mm Hg.
The optimal resuscitation fluid for use by combat medics remains an open question and is
currently a topic of great interest in military medical research. Studies planned in the near future
at the USAISR and other laboratories will evaluate hetastarch solutions, crystalloids, 5%
hypertonic saline, and hemoglobin-based oxygen carrying solutions in combat-appropriate
trauma models. Animal models used in studies performed to address fluid resuscitation issues on
the battlefield should include a significant delay to surgical repair to simulate the prolonged
evacuation times combat operations often entail. Care should be taken in attempting to
extrapolate the results of resuscitation fluid studies in the civilian sector to the battlefield, since
average prehospital time in urban areas is usually very short. However, civilian studies may
provide all the available human trauma data. Additionally, resuscitation studies must address
both controlled and uncontrolled hemorrhagic shock as the pre-operative clinical objectives may
be different.
It is common for intravenous lines started in the field to become dislodged during casualty
transport. One system for securing IV lines that has proven useful in TCCC is inserting an 18-
gauge 1¼” catheter along with a saline lock. The saline lock is then secured with Tegoderm®
over the site. Fluids and medications are then given by inserting a second 18-gauge 1¼“ needle
and catheter through the lock, and withdrawing the needle. The catheter is left in place and
secured with a circumferential velcro wrap (Linebacker®) to prevent it from being dislodged.
(Personal communication – SFC Rob Miller – 75th Ranger Regiment).
As in civilian settings, the type of analgesic given in TCCC depends on the severity of the
casualty’s pain. Beecher noted in his WWII survey (123) that many men were fairly unruffled by
seemingly horrific wounds sustained in battle, though the same wounds in a civilian setting would
be expected to produce agonizing pain. If the wounds are not significantly painful, no analgesia is
indicated. For mild to moderate pain, 50 mg of rofecoxib po qd and 1000 mg of acetaminophen po
q6h are given with the goal of preserving normal sensorium and allowing the casualty to continue as
a combatant. Rofecoxib (Vioxx®) is a cyclo-oxygenase-2 (Cox-2) inhibitor and does not cause the
platelet dysfunction seen with non-selective NSAIDs. (124, 125) It also provides a more favorable
side effect profile than seen with other Cox-2 inhibitors. It does not exhibit the same
hypersensitivity responses in sulfa-sensitive individuals that have been reported with valdecoxib
(Bextra®) (126) and celecoxib (Celebrex®) (127), and carries no such contraindication. It is
important to realize that platelet dysfunction is an important consideration even for individuals with
relatively minor wounds until they have been evacuated to a medical treatment facility or their
operating base. The first wounds sustained by a casualty in combat may not, unfortunately, be the
last.
If the casualty’s wounds require more potent analgesia (bony injuries and burns are
typically the most painful), it should be achieved with morphine, preferably administered
intravenously. (31) Intravenous administration allows for much more rapid onset and more accurate
titration of narcotic dose than the intramuscular route. An initial dose of 5 mg is given and repeated
at 10-minute intervals until adequate analgesia is achieved. It is common for individuals who have
13
received high doses of morphine to experience nausea and vomiting, so promethazine 25 mg
IV/IM/IO should be given to prevent this side effect.
Infection is an important late cause of morbidity and mortality in battlefield wounds.

Cefoxitin was previously proposed (31) because of its excellent spectrum of action, low incidence
of side effects, and low cost. Several significant changes in the antibiotics used in TCCC have
recently been proposed by O’Connor and Butler. (128)
The logistical burden of reconstituting and injecting parenteral medications makes the use
of oral antibiotics an attractive alternative when possible. In some casualties, oral antibiotics are
clearly not an option (penetrating abdominal trauma, unconsciousness, shock). In patients
without contraindications, however, oral antibiotic prophylaxis is feasible. The USSOCOM-
sponsored workshop on Tactical Management of Urban Warfare Casualties held in Tampa in
December, 1998 focused on the Battle of Mogadishu, and identified a number of potential
improvements in the battlefield care of combat casualties (46). Participants in this workshop
noted that an orally administered antibiotic would have several advantages. Giving antibiotics to
a wounded teammate would require no more than having him swallow a tablet with a gulp of
water from a canteen, and would eliminate the need for mixing and parenteral administration.
With a long-acting oral antibiotic, SOF combat medics could easily carry an adequate supply of
antibiotics to cover the entire unit for several days.
Penicillins are not a good choice in this setting because they: 1) cause too many severe
allergic reactions; 2) require too frequent dosing, and 3) are not active against most gram-
negative organisms. The fluoroquinolones, on the other hand, have an excellent spectrum of
antibacterial action. Ciprofloxacin has good coverage against Pseudomonas species (129), but
little activity against anaerobes. (129,130) Levofloxacin has more action against gram-positive
organisms than ciprofloxacin, but is less effective against Pseudomonas, and is also not reliably
effective against anaerobes. Levofloxacin does have some activity against Pseudomonas and is
indicated for urinary tract infections caused by this organism. (131) Trovafloxacin is effective
against gram-positive, gram-negative, and anaerobic organisms. (129) Moxifloxacin and
gatifloxacin are also fourth generation fluoroquinolones that have an enhanced spectrum of
activity. Trovafloxacin, gatifloxacin, and moxifloxacin yield low minimum inhibitory
concentrations against most groups of anaerobes. (130,132) One study found that
moxifloxacin’s activity against Clostridium and Bacteroides species was in the same range as
metronidazole’s, and superior to that of clindamycin. (133) Another study found that “In
general, moxifloxacin was the most potent fluoroquinolone for gram-positive bacteria while
ciprofloxacin, moxifloxacin, gatifloxacin, and levofloxacin demonstrated equivalent potency
against gram negative bacteria. (134) A third study found that moxifloxacin was almost as active
as trovafloxacin, as active as gatifloxacin, and more active than levofloxacin and ciprofloxacin
against the anaerobes tested, including Clostridium species. (135) Blood levels of the
fluoroquinolones achieved with oral dosing are similar to those achieved with IV dosing, so oral
administration does not significantly reduce the bioavailability of these agents.
Use of a fourth generation fluoroquinolone has an additional benefit for use in Special
Operations. Since these operations often entail immersion in sea or fresh water, infections with
pathogens found in these environments must be considered as well. Wounds contaminated with
14
seawater are susceptible to infections with Vibrio species, gram negative rods that can result in
an overwhelming gram-negative sepsis with 50% mortality. (138) Contamination of wounds
with fresh water may result in infections with Aeromonas species, also a gram negative rod.
(136) The excellent gram negative coverage of fourth generation fluoroquinolones makes them a
good choice in these circumstances.
In addition to the advantage of oral administration, the fluoroquinolones require less

frequent dosing. Both moxifloxacin and gatifloxacin are given as a single daily 400mg dose.
Imagine a SOF unit with 3 seriously wounded individuals that cannot be extracted for 48 hours.
To maintain antibiotic coverage with cefoxitin for all 3 casualties would require 24 doses – a
quantity that Special Operations medics are not likely to carry. In contrast, 6 tablets of one of the
fluoroquinolones would suffice for the same period.
The fluoroquinolones also have an excellent safety profile. A review in the October 1999
Mayo Clinic Proceedings states that the they are tolerated as well or better than any other class of
antibacterial agents. (129) The best-known toxic effect of the fluoroquinolones has been the
severe hepatotoxicity seen with trovafloxacin use, but this was seen in only 140 patients out of
2.5 million prescriptions, and was usually seen after long-term (more than 28 days) use of the
medication. Another disadvantage of trovafloxacin is that its absorption is delayed by morphine,
which may be used in combat casualties. (129) Gastrointestinal upset is seen in about 5% of
patients treated with fluoroquinolones, and mild allergic reactions (rash, urticaria, and
photosensitivity) are seen in 1-2% of patients. Mild CNS symptoms (headache and dizziness)
are also encountered in 5-10% of patients treated with the fluoroquinolones. (129)
One of the considerations in a medication chosen for use by ground troops in the field is
its ability to maintain its activity in hot and cold environments. The recommended storage
temperature for gatifloxacin is 77o F with 59o F to 86o F listed as the acceptable temperature
range. If true, this would limit the drug’s usefulness to ground combat troops. Correspondence
on this issue with the manufacturer, Bristol-Myers Squibb, has indicated that gatifloxacin tablets
have excellent stability at higher temperatures with documented maintenance of efficacy for 6
months at 104o F and 3 months at 122o F (personal correspondence – Mr. Brett Schenk and Mr.
Steve Sharpe, BMS).
Gatifloxacin is a good choice for single-agent therapy based on its excellent spectrum of
coverage, good safety profile, and once-a-day dosing. Moxifloxacin would be an acceptable
second choice. A third choice might be levofloxacin, but since levofloxacin has only limited
activity against anaerobes, another drug must be added to achieve coverage against these
organisms. The most active drugs for the treatment of anaerobic infections are clindamycin and
metronidazole. (137) Relatively few anaerobes are resistant to clindamycin, and few, if any, are
resistant to metronidazole. (137) Metronidazole has the advantage of having a less severe side
effect profile than clindamycin.
Based on the discussion above, either moxifloxacin or gatifloxacin would be a good

choice for an oral antibiotic for use on the battlefield. A cost comparison of these two agents
performed by the Naval Hospital Pensacola pharmacy in August of 2002 found that the cost to
the U.S. government for a single dose of moxifloxacin was $5.09 while a single dose of
15
gatifloxacin was only $1.86. This cost comparison is based on DOD-wide pricing schedules
(personal communication – LT Roger Bunch and LCDR Tony Capano). Based on the much
lower cost of gatifloxacin with other factors being approximately equal, gatifloxacin emerges as
the best choice for an oral antibiotic.
The use of oral antibiotics is not advisable in some casualties. An unconscious casualty
is not able to take the medication. An individual in shock will have a reduced mesenteric blood
flow that might interfere with absorption of an oral agent. Casualties with penetrating abdominal
trauma may have a mechanical disruption of the GI tract that would impede absorption of an oral
antibiotic. Effective antibiotic prophylaxis is especially important in this group of patients. A
large group of patients (338) with penetrating trauma to the abdomen was reported by Dellinger
et al. (138) Even in this civilian trauma center setting, 24% of patients developed wound
infections and nine died as a result.
Use of cefotetan as an alternative to cefoxitin as a battlefield antibiotic was first proposed

by O’Connor. (139) Cefotetan is a similar medication with the same broad spectrum of action,
but with a longer half-life that allows q 12 hour dosing. Both cefoxitin and cefotetan were
recommended by Osmon as prophylactic agents for adults undergoing colorectal surgery (140)
and by Conte for trauma victims with a ruptured viscus. (141)
Luchette et al published a meta-analysis of antibiotic prophylaxis in penetrating trauma in

2000. (142) The more successful regimens included: cefoxitin, gentamycin with clindamycin,
tobramycin with clindamycin, cefotetan, cefamandole, aztreonam, and gentamycin alone.
Nichols and colleagues compared cefoxitin to a gentamycin/clindamycin combination in
penetrating abdominal trauma and found them to be equivalent. (143) Jones and colleagues
compared cefoxitin, cefamandole and a tobramycin/clindamycin combination in patients with
penetrating colon trauma. (144) They concluded that both cefoxitin and the
tobramycin/clindamycin combination were superior to cefamandole. In 1992, Fabian compared
cefoxitin to cefotetan directly. His study included 515 patients, and he found no difference in
efficacy between the two agents. (145)
While cefoxitin and cefotetan appear to be equal in efficacy, the longer half-life and
comparable cost make cefotetan a better choice. Cefoxitin remains a viable alternative and a
good second choice.
Cardiopulmonary resuscitation of a battlefield casualty who has suffered blast or penetrating

trauma is not appropriate. (31,146) Prehospital resuscitation of trauma patients in cardiac arrest has
been fraught with futility even in urban settings where the victim is in close proximity to trauma
centers. For example, Branney and colleagues reported a 2% survival rate (14 of 708) among
patients receiving emergency department thoracotomy who arrived at the emergency department
with absent vital signs. (147) In a more recent study, Rosemurgy, Norris, et al reported no survivors
out of 138 trauma patients who suffered a prehospital cardiac arrest in whom resuscitation was
attempted. (148) The authors recommended that resuscitation of trauma victims in
cardiopulmonary arrest not be attempted even in the civilian prehospital setting, primarily because
of the large economic cost entailed in these uniformly unsuccessful attempts. In the tactical combat
setting, the cost of attempting to resuscitate patients with inevitably fatal wounds will be measured
16
in additional lives lost as combat medical personnel are exposed to hostile fire during resuscitation
efforts, and care is withheld from casualties with potentially survivable wounds. Successful
completion of the unit’s mission may also be unnecessarily jeopardized by these efforts. Only in the
case of non-traumatic disorders such as hypothermia, near drowning, or electrocution, should
cardiopulmonary resuscitation be performed in the tactical prehospital setting.
CASEVAC Care
The use of a CASEVAC asset to evacuate the wounded from the battlefield presents the
opportunity to bring in additional medical equipment and personnel to treat the casualties. This
opportunity led to the recommendation to establish designated Combat Casualty Transportation
Teams for Special Operations forces. (31) This additional medical expertise and equipment will
allow for the expanded diagnostic and therapeutic measures outlined in Table 3 for the CASEVAC
phase of care.
Care in this phase more closely approximates ATLS guidelines. The opportunity to carry
additional equipment and a (possibly) more favorable environment in which to work make a more
varied selection of airway management interventions possible. Endotracheal intubation, the
laryngeal mask airway (149), the intubating laryngeal mask airway (150), and the esophageal-
tracheal combitube (151) are all potentially feasible alternatives in this phase if the nasopharyngeal
airway is insufficient to manage the airway. Schwartz and his colleagues reported success in
performing endotracheal intubation with the aid of night vision goggles. (152) Surgical
cricothyroidotomy remains a valuable option if needed. (153)
Several improvements in fluid resuscitation may be possible in the CASEVAC phase.

Electronic monitoring, if available, may yield a better understanding of the casualty’s status.
Casualties with traumatic brain injuries should be maintained with a systolic blood pressure of 90
mmHg or higher in this phase. Asanguinous fluids restore blood volume, but do not replace
oxygen-carrying capacity. When logistically feasible, O-positive or negative packed red blood cells
should be available in this phase for use when indicated and under appropriate protocols. Rhesus
factor compatibility is an issue only in females with reproductive capability. Both the British
Special Air Service (personal communication – Dr. John Naevin, former 22cd SAS Regimental
Surgeon) and the IDF (154) have used PRBCs successfully in casualty transport platforms. Israeli
medical personnel store the PRBCs in a special field refrigerator that maintains a temperature
between 1o C and 6o C, and expand them with 250 ml of saline solution before administration. (154)
Use of PRBCs in the field has had an excellent safety record in the IDF. (154)
The potential for casualties to develop hypothermia and a secondary coagulopathy (155)
makes adequate warming an important function in preparation for and during CASEVAC.
Concomitant use of the Thermal AngelTM device, the Rescue WrapTM, and gel heaters has been
employed in combat operations in both fixed-wing and rotary aircraft. This combination has proven
able to increase a casualty’s temperature in ambient temperatures below freezing. (Personal
communication – TSgt Steve Cum)
17
The proposal for Combat Casualty Transportation Teams and the additional care that they
provide should be evaluated by the conventional forces for applicability in their units.
Scenario-Based Training
Despite the effort that has gone into developing a combat-appropriate trauma
management plan, the bottom line remains that no single plan will suffice for all situations. This
realization led to the concept of scenario-based management plans (31). Representative
scenarios are presented in Figures 3-10. The medical and tactical issues to be addressed in most
of these scenarios have been addressed previously (156, 157). Figures 3 and 4 are from the
Mogadishu action on 3 October 1993. This engagement resulted in the greatest number of US
casualties in a single firefight since Vietnam (18 dead, 73 wounded). In addition, there was a
delay of 15 hours before the first wounded were evacuated to a Combat Support Hospital.
Scenarios like these, based on actual past events, help to raise the level of interest in ensuing
discussions.
Figures 5-7 deal with a parachute insertion and subsequent land warfare phase, with
injuries of different magnitudes sustained upon landing. The medical care of these casualties is
relatively straightforward, but they require difficult tactical decisions of the mission commander.
Figures 8-10 deal with casualty scenarios that occur during diving operations. This is a
very important aspect of the training for SEAL and Marine Reconnaissance mission commanders
because the underwater environment has such a large impact on casualty management, and
because this area is not addressed in civilian medical literature.
As one examines these scenarios, it becomes apparent that the appropriate care for a
casualty may vary based on how critical the mission is, the anticipated time to evacuation, and
the environment in which the casualty occurs. Any management plan for a combat casualty
discussed in the planning phase should be considered advisory rather than directive in nature,
since only infrequently will an actual casualty situation unfold exactly as anticipated. It is
obviously not possible to plan for every casualty scenario that may occur, but review of several
casualty scenarios most appropriate for an impending operation is a valuable exercise in the
planning process.
TCCC Skills List
Individuals other than medics may be called upon to provide medical care on the battlefield.
Each combatant should be able to perform life-saving interventions such as the application of a
tourniquet, and simple tasks such as self-administration of oral antibiotics and analgesics. This is
the goal of an Army program called “Combat Lifesaver” in which non-medics receive basic medical
training in specified life-saving skills. A list of each type of potential first responder, and the skills
that each should possess is provided in Table 4.
18
Tactical Medicine for Small Unit Mission Commanders
Although the TCCC protocol is gaining increasing acceptance throughout the U.S.
Department of Defense and allied military forces (158-165), this protocol by itself is not
adequate training for the management of combat trauma in the tactical environment. Since
casualty scenarios in small-unit operations entail tactical problems as well as medical ones, the
appropriate management plan for a particular casualty must be developed with an appreciation
for the entire tactical situation. (31) This approach has been developed through a series of
workshops carried out by SOF medical personnel in association with appropriate medical
specialty groups such as the Undersea and Hyperbaric Medical Society, the Wilderness Medical
Society, and the Special Operations Medical Association. (156, 157, 46)
The most recent of these workshops, which addressed the Tactical Management of Urban
Warfare Casualties in Special Operations, noted that several of the casualty scenarios studied
from the Mogadishu action in 1993 (166) had very important tactical implications for the mission
commanders. (46) The unconscious fast-rope fall victim in Figure 3 resulted in a decision by the
mission commander to split the forces in his ground convoy, detaching 3 of the 12 vehicles to
take the casualty back to base immediately, leaving the remaining 9 to extract the rest of the
troops. The helicopter crash described in Figure 4 resulted in the pilot’s body being trapped in
the wreck. Several discrete elements from the target building suffered multiple casualties as they
moved towards the crash site to assist. The casualties eventually outnumbered those who were
able to maneuver, forcing the elements to remain stationary, and preventing them from
consolidating their forces. When a rescue convoy finally reached the embattled troops at the
crash site, there was a delay of approximately 3 hours while the force worked feverishly to free
the trapped body. Several hundred troops and over 25 vehicles were vulnerable to counterattack
during this period. These scenarios made it obvious to members of the workshop panel that
training only combat medics in tactical medicine is not enough. McRaven has compiled
accounts of a number of special operations that may be used for scenario development. (167) If
tactical medicine involves complex decisions about both tactics and medicine, then we must train
the tactical decision makers – the mission commanders - as well as combat medical personnel in
this area. (46) A customized course in Tactical Medicine for SEAL and Ranger Mission
Commanders has been developed and incorporated into the training for mission commanders in
those units. The Tactical Medicine course provides a rationale for why mission commanders
need training in this area. While it is true that the combat medic takes care of the casualty, the
mission commander runs the mission, and what’s best for the casualty and what’s best for the
mission may be in direct conflict. The question is often not just whether or not the mission can be
completed successfully without the wounded individual(s); the issue may well be that continuing
the mission will adversely affect the outcome for the casualty. If the mission is to be successfully
accomplished, the mission commander may have to make some very difficult decisions about the
care and movement of casualties. Additional reasons to train mission commanders in tactical
medicine include: 1) the importance of having the commander know that the care provided in
TCCC may be substantially different than the care provided for the same injury in a non-combat
setting; 2) the unit may be employed in such a way that there is no corpsman, medic, or PJ
19
immediately available to the injured individual; and 3) the corpsman, medic or PJ may be the first
team member shot.
Although the use of helmets and body armor are not feasible for every combat operation,
the Mogadishu experience documents the efficacy of individual protective clothing in preventing
potentially lethal injuries. (36) Tactical Medicine training should emphasize the benefits of these
devices where operationally feasible.
Acknowledgments
The authors express their appreciation to the many individuals, both military and civilian,
who have assisted with this project. Special thanks are also extended to the Special Operations
corpsmen, PJs, and medics who will risk their lives in future conflicts while using these
guidelines to save their wounded teammates.
Thanks also to the Naval Operational Medical Institute that conducted this research effort,
the U.S. Special Operations Command Biomedical Initiatives Steering Committee for its
sponsorship of the COTCCC in 2002/2003, and the Navy Bureau of Medicine and Surgery for its
planned future sponsorship of this effort.
20
References
1. Bellamy, RF. The causes of death in conventional land warfare: implications for combat casualty
care research. Mil Med. 1984; 149:55-62
2. Alexander RH, Proctor HJ. Advanced Trauma Life Support 1993 Student Manual. Chicago, IL:
1993. American College of Surgeons
3. Krausz MM. Controversies in shock research: Hypertonic Resuscitation - Pros and Cons. Shock
1995; 3:69-72
4. Bickell WH, Wall MJ, Pepe PE, et al. Immediate versus delayed fluid resuscitation for
hypotensive patients with penetrating torso injuries. NEJM. 1994; 331: 1105-1109
5. Honigman B, Rohwder K, Moore EE, et al. Prehospital advanced trauma life support for
penetrating cardiac wounds. Ann Emerg Med. 1990; 19:145-150
6. Smith JP, Bodai BI. The urban paramedic's scope of practice. JAMA. 1985; 253:544-548
7. Smith JP, Bodai BI, Hill AS, et al. Prehospital stabilization of critically injured patients: a failed
concept. J Trauma 1985; 25:65-70
8. Dronen SC, Stern S, Baldursson J, et al. Improved outcome with early blood administration in a
near-fatal model of porcine hemorrhagic shock. Amer J Emerg Med. 1992; 10: 533-537
9. Stern SA, Dronen SC, Birrer P, et al. Effect of blood pressure on hemorrhage volume and
survival in a near-fatal hemorrhage model incorporating a vascular injury. Ann Emerg Med. 1993;
22:155-163
10. Chudnofsky CR, Dronen SC, Syverud SA, et al. Early versus late fluid resuscitation: lack of
effect in porcine hemorrhagic shock. Ann Emerg Med. 1989; 18:122-126
11. Bickell WH. Are victims of injury sometimes victimized by attempts at fluid resuscitation? Ann
Emerg Med. 1993; 22: 225-226
12. Chudnofsky CR, Dronen SC, Syverud SA, et al. Intravenous fluid therapy in the prehospital
management of hemorrhagic shock: improved outcome with hypertonic saline/6% Dextran 70 in a
swine model. Am J Emerg Med. 1989; 7:357-363
13. Martin RR, Bickell WH, Pepe PE, et al. Prospective evaluation of preoperative fluid
resuscitation in hypotensive patients with penetrating truncal injury: a preliminary report. J Trauma
1992; 33:354-361
21
14. Kaweski SM, Sise MJ, Virgilio RW. The effect of prehospital fluids on survival in trauma
patients. J Trauma 1990; 30: 1215-1218
15. Gross D, Landau EH, Klin B, et al. Treatment of uncontrolled hemorrhagic shock with
hypertonic saline solution. Surg Gyn Obst. 1990;170:106-112
16. Deakin CD, Hicks IR. AB or ABC: prehospital fluid management in major trauma. J Accid
Emerg Med. 1994; 11: 154-157
17. Bickell WH, Bruttig SP, Millnamow GA, et al. Use of hypertonic saline/Dextran versus lactated
ringer's solution as a resuscitation fluid after uncontrolled aortic hemorrhage in anesthetized swine.
Ann Emerg Med. 1992; 21: 1077-1085
18. Dontigny L. Small-volume resuscitation. CJS. 1992; 35: 31-33
19. Krausz MM, Bar-Ziv M, Rabinovici R, et al. "Scoop and run" or stabilize hemorrhagic shock
with normal saline or small-volume hypertonic saline? J Trauma 1992; 33:6-10
20. Gross D, Landau EH, Assalia A, et al. Is hypertonic saline resuscitation safe in uncontrolled
hemorrhagic shock? J Trauma 1988; 28:751-756
21. Kowalenko J, Stern S, Dronen S, et al. Improved outcome with hypotensive resuscitation of
uncontrolled hemorrhagic shock in a swine model. J Trauma 1992; 33:349-353
22. Krausz MM, Klemm O, Amstislavsky T, et al. The effect of heat load and dehydration on
hypertonic saline solution treatment on uncontrolled hemorrhagic shock. J Trauma 1995; 38:747-
752
23. Napolitano LM. Resuscitation following trauma and hemorrhagic shock: Is hydroxyethyl starch
safe? Critical Care Med. 1995; 23:795-796
24. Arishita GI, Vayer JS, Bellamy RF. Cervical spine immobilization of penetrating neck wounds
in a hostile environment. J Trauma 1989; 29:332-337
25. Zajtchuk R, Jenkins DP, Bellamy RF, et al, eds: Combat casualty care guidelines for Operation
Desert Storm. Washington, DC: 1991. Office of the Army Surgeon General Publication
26. Bellamy RF. How shall we train for combat casualty care? Mil Med.1987; 152:617-622
27. Baker MS. Advanced Trauma Life Support: Is it adequate stand-alone training for military
medicine? Mil Med. 1994; 159:587-590
28. Wiedeman JE, Jennings SA. Applying ATLS to the Gulf War. Mil Med. 1993; 158:121-126
29. Heiskell LE, Carmona RH. Tactical emergency medical services: an emerging subspecialty of
Emergency Medicine. Ann Emerg Med. 1994; 23:778-785
22
30. Ekblad GS. Training medics for the combat environment of tomorrow. Milit Med. 1990;
155:232-234
31. Butler FK, Hagmann J, Butler EG. Tactical Combat Casualty Care in Special Operations. Mil
Med. 1996; 161: Supplement 1-16
32. McSwain N, ed: Military Medicine. Prehospital Trauma Life Support, 4th ed. St Louis, MO:
Mosbey; 1999:316-331
33. Practice Guidelines for Wilderness Medical Emergencies. Wilderness Medical Society.
Indianapolis, Indiana; 1995
34. Commander, Naval Special Warfare Command letter of 29 May 1997
35. Maughon JS. An inquiry into the nature of wounds resulting in killed in action in Vietnam. Mil
Med. 1970; 135:8-13
36. Mabry RL, Holcomb JB, Baker A, Uhorchak J, Cloonan C, Canfield AJ, Perkins D,
Hagmann J. US Army Rangers in Somalia: An analysis of combat casualties on an urban
battlefield. J Trauma. 2000; 49:515-529
37. Lakstein D, Blumenfeld A, Sokolov T, Lin G, Bssorai R, Lynn M, Ben Abraham R.

Tourniquets for Hemorrhage Control in the Battlefield – A Four Year Accumulated Experience.
Accepted for publication, J Trauma
38. Calkins MD, Snow C, Costello M, Bentley TB. Evaluation of possible battlefield tourniquet
systems for the far-forward setting. Mil Med 2000; 165: 379-384
39. Sondean, JL, Pusateri, AE, Coppes, VG, Gaddy, CE, and Holcomb, JB. Comparison of ten
different hemostatic dressings in an aortic injury. Accepted for publication, J Trauma
40. Alam HB, Gemma B, Miller D, Koustova E, Hancock T, Inocencio R, Anderson D, Llorente O,
and Rhee P. Comparative Analysis of Hemostatic Agents in a Swine Model of Lethal Extremity
Injury. Accepted for publication in J Trauma
41. Pusateri AE, Wright J. United States Army Institute of Surgical Research. Unpublished data
42. Pusateri AE, Wright J. United States Army Institute of Surgical Research. Unpublished data
43. Pusateri AE, McCarthy SJ, Gregory KW, Harris RA, Cardenas L, McManus AT, Goodwin
CW. Effect of a Chitosan-based Hemostatic Dressing on Blood Loss and Survival in a Model of
Severe Venous Hemorrhage and Hepatic Injury in Swine. Accepted for publication in J Trauma
23
44. Martinowitz U, Kenet G, Segal E, Luboshitz J, Lubetsky A, Ingerslev J, Lynn M.
Recombinant Activated Factor VII for Adjunctive Hemorrhage Control in Trauma. J Trauma
2001; 51: 431-439
45. Carey ME. Analysis of wounds incurred by U.S. Army Seventh Corps personnel treated in
corps hospitals during Operation Desert Storm, February 20 to March 10, 1991. J Trauma 1996;
40: S165-S169
46. Butler FK, Hagmann JH, et al. Tactical Management of Urban Warfare Casualties in Special
Operations. Mil Med, 2000; 165 (4, supp: 1-48)
47. Sladen A. Emergency endotracheal intubation: Who can - who should? Chest 1979; 75:535-536
48. Stewart RD, Paris PM, Winter PM, et al. Field endotracheal intubation by paramedical
personnel: success rates and complications. Chest 1984; 85:341-345
49. Jacobs LM, Berrizbeitia LD, Bennet B, et al. Endotracheal intubation in the prehospital phase of
emergency medical care. JAMA. 1983; 250:2175-2177
50. Pointer JE. Clinical Characteristics of paramedics' performance of endotracheal intubation. J

Emerg Med. 1988; 6:505-509
51. Lavery RF, Doran J, Tortella, BJ, et al. A survey of advanced life support practices in the United
States. Prehosp and Disaster Med. 1992; 7:144-150
52. DeLeo BC. Endotracheal intubation by rescue squad personnel. Heart & Lung 1977; 6:851-854
53. Stratton SJ, Kane G, Gunter CS, et al. Prospective study of manikin-only versus manikin and
human subject endotracheal intubation training of paramedics. Ann Emerg Med. 1991; 20: 1314-
1318
54. Trooskin SZ, Rabinowitz S, Eldridge C, et al. Teaching endotracheal intubation using animals
and cadavers. Prehosp and Disaster Med. 1992; 7:179-182
55. Stewart RD, Paris PM, Pelton GH, et al. Effect of varied training techniques on field
endotracheal intubation success rates. Ann Emerg Med. 1984; 13:1032-1036
56. Cameron PA, Flett K, Kaan E, et al. Helicopter retrieval of primary trauma patients by a
paramedic helicopter service. Aust NZ J Surg. 1993; 63:790-797
57. Reinhart DJ, Simmons G. Comparison of placement of the laryngeal mask airway with
endotracheal tube by paramedics and respiratory therapists. Ann Emerg Med 1994; 24: 260-263
58. Sayre MR, Sakles JC, Mistler AF, Evans JL, Kramer AT, Pancioloi AM. Field trial of
endotracheal intubations by basic EMTs. Ann Emerg Med 1998; 31:228-233
24
59. Katz SH, Falk JL. Misplaced endotracheal tubes by paramedics in an urban emergency
medical services system. Ann Emerg Med 2001; 37: 32-37
60. Calkins MD, Robinson TD. Combat trauma airway management: endotracheal intubation
versus laryngeal mask airway versus combitube use by SEAL and reconnaissance combat
corpsmen. J Trauma 1999; 46: 927-932
61. Murray JA, Demetriades D, Berne TV, et al. Prehospital intubation in patients with severe
head injury. J Trauma 2000; 49: 1065-1070
62. Salvino CK, Dries D, Gamelli R, et al. Emergency cricothyroidotomy in trauma victims. J
Trauma 1993; 34: 503-505
63. McGill J, Clinton JE, Ruiz E. Cricothyroidotomy in the emergency department. Ann Emerg
Med. 1982; 11:361-364
64. Erlandson MJ, Clinton JE, Ruiz E, et al. Cricothyroidotomy in the emergency department
revisited. J Emerg Med. 1989; 7: 115-118
65. Mines D. Needle thoracostomy fails to detect a fatal tension pneumothorax. Ann Emerg Med.
993; 22:863-866
66. Holcomb JB, Pusateri AE, Kerr SM, Macaitis JM, Cardenas L, Harris RA. Initial efficacy and
function of needle thoracentesis versus tube thoracostomy in a swine model of traumatic tension
pneumothorax. Accepted for publication in J Trauma
67. Britten S, Palmer SH, Snow TM. Needle thoracocentesis in tension pneumothorax: insufficient
cannula length and potential failure. Injury. Dec 1996; 27(10): 758
68. Aeder MI, Crowe JP, Rhodes RS, et al. Technical limitations in the rapid infusion of intravenous
fluids. Ann Emerg Med. 1985; 14:307-310
69. Hoelzer MF. Recent advances in intravenous therapy. Emerg Med Clin of North America 1986;
4:487-500
70. Lawrence DW, Lauro AJ. Complications from IV therapy: results from field-started and
emergency department-started IV's compared. Ann Emerg Med. 1988; 17:314-317
71. Kramer GC, Perron PR, Lindsey DC, et al. Small volume resuscitation with hypertonic saline
dextran solution. Surgery 1986; 100:239-245
72. Shaftan GW, Chiu C, Dennis C, et al. Fundamentals of physiological control of arterial
hemorrhage. Surgery 1965; 58:851-856
73. Milles G, Koucky CJ, Zacheis HG. Experimental uncontrolled arterial hemorrhage. Surgery
1966; 60:434-442
25
74. Krausz MM, Horne Y, Gross D. The combined effect of small-volume hypertonic saline and
normal saline in uncontrolled hemorrhagic shock. Surg Gyn Ob. 1992; 174:363-368
75. Sindlinger JF, Soucy DM, Greene SP, et al. The effects of isotonic saline volume resuscitation
in uncontrolled hemorrhage. Surg Gyn Ob 1993; 177: 545-550
76. Landau EH, Gross D, Assalia A, et al. Treatment of uncontrolled hemorrhagic shock by
hypertonic saline and external counterpressure. Ann Emerg Med. 1989; 18:1039-1043
77. Rabinovici R, Krausz MM, Feurstein G. Control of bleeding is essential for a successful
treatment of hemorrhagic shock with 7.5 percent NaCl solution. Surg Gynecol Obstet. 1991;
173:98-106
78. Landau EH, Gross D, Assalia A, et al. Hypertonic saline infusion in hemorrhagic shock treated
by military antishock trousers (MAST) in awake sheep. Crit Care Med. 1993; 21:1554-1561
79. Crawford, ES. Ruptured abdominal aortic aneurysm: an editorial. J Vasc Surg. 1991; 13:348-
350
80. Wall, M. AAST presentation; 1994
81. Rainey TG, Read CA. The pharmacology of colloids and crystalloids. In The Pharmacologic
Approach to the Critically Ill Patient, pp 219-240. Edited by Chernow B. Baltimore, Williams and
Wilkens, 1988
82. Carey JS, Scharschmidt BF, Culliford AL, et al. Hemodynamic effectiveness of colloid and
electrolyte solutions for replacement of simulated blood loss. Surg Gynecol Obstet 1970; 131: 679
83. Marino PL. Colloid and crystalloid resuscitation. In: The ICU Book. Malvern PA: Lea and
Febiger; 1991: 205-216
84. Mortelmans Y, Merckx E, van Nerom C, et al. Effect of an equal volume replacement with 500
cc 6% hydroxyethyl starch on the blood and plasma volume of healthy volunteers. Eur J Anesth.
1995; 12: 259-264
85. Lucas CE, Denis R, Ledgerwood AM, et al. The effects of Hespan on serum and lymphatic
albumin, globulin, and coagulant protein. Ann Surg. 1988; 207:416-420
86. Sanfelippo MJ, Suberviola PD, Geimer NF. Development of a von Willebrand-like syndrome
after prolonged use of hydroxyethyl starch. Am J Clin Path. 1987; 88:653-655
87. Strauss RG. Review of the effects of hydroxyethyl starch on the blood coagulation system.
Transfusion 1981; 21: 299-302
26
88. Dalrymple-Hay MB, Aitchison R, Collins P, et al. Hydroxyethyl starch-induced acquired Von
Willebrand's disease. Clin Lab Haemat. 1992; 14:209-211
89. Macintyre E, Mackie IJ, Ho D, et al. The haemostatic effects of hydroxyethyl starch (HES) used
as a volume expander. Intensive Care Med. 1985; 11:300-303
90. Via D, Kaufman C, Anderson D, Stanton K, Rhee P. Effect of hydroxyethyl starch on

coagulopathy in a swine model of hemorrhagic shock resuscitation. J Trauma 2002; 50: 1076-
1082
91. Falk JL, O'Brien JF, Kerr R. Fluid resuscitation in traumatic hemorrhagic shock. Crit Care
Clin 1992 Apr;8(2): 323-40
92. Shatney CH, Krishnapradad D, Militello PR, et al. Efficacy of hetastarch in the resuscitation of
patients with multisystem trauma and shock. Arch Surg.1983; 118:804-809
93. Ratner LE, Smith GW. Intraoperative fluid management. Surgical Clinics of North America
1993; 73:229-241
94. Champion HR. The Combat Fluid Resuscitation Conferences. Accepted for publication in J
Trauma
95. Rhee P., Koustova E., Alam H.B. Searching for the optimal resuscitation method:
Recommendations for the initial fluid resuscitation of combat casualties. Accepted for
publication in J Trauma
96. Rhee P., Burris D., Kaufmann C., Pikoulis M., Austin B., Ling G., Harviel D., Waxman K.
Lactated Ringers Resuscitation Causes Neutrophil Activation After Hemorrhagic Shock. J
Trauma, 1998, 44:313-319
97. Burris D., Rhee P., Kaufmann C., Pikoulis M., Austin B., Leppäniemi A.K. Controlled
Resuscitation in Uncontrolled Hemorrhagic Shock. J Trauma, 1998, 46:216-223
98. Deb S., Martin B., Sun L., Ruff P., DeBraux S., Austin B., Rich N.M., Rhee P. Lactated
Ringer’s Resuscitation in Hemorrhagic Shock Rats Induces Immediate Apoptosis. J Trauma,
1999, 46:582-589
99. Sun L., Ruff P., Austin B., Deb S., Martin, B., Burris D., Rhee P. Early Upregulation of
ICAM-1 and VCAM-1 Expression in Rats with Hemorrhagic shock and Resuscitation. Shock,
1999, 11:416-422
100. Rhee P., Wang D., Ruff P., Wolcott K., DeBraux S., Austin B., Burris D., Sun, L. Human
Neutrophil Activation and Increased Adhesion by Various Resuscitation Fluids. Critical Care
Medicine, 2000, 28:74-78
27
101. Alam H.B., Sun L., Deb S., Martin B., Ruff P., Rhee P. Increase in E and P selectin
expression is immediate and depends on the fluid used for resuscitation in rats. 5th International
Congress on Trauma, Shock, Inflammation and Sepsis 2000; 331-335
102. Alam H.B., Austin B., Koustova E., Rhee P. Ketone Ringer’s solution attenuates
resuscitation induced apoptosis in rat lungs following hemorrhagic shock. 5th International
Congress on Trauma, Shock, Inflammation and Sepsis 2000;63-66
103. Deb S., Sun L., Martin B., Talens E., Burris D., Kaufmann C., Rich N, Rhee P.
Resuscitation with Hetastarch and Lactated Ringers Induces Early Apoptosis in the Lung through
the Bax Protein following Hemorrhagic Shock. J Trauma, 2000,49:47-55
104. Rhee P., Morris J., Durham R., Hauser C., Luchette F., Cipolle M. Miller R. Ascending
Dose, Parallel Group, Double-blind, Placebo-controlled, Dose finding Study of rhu MAB CD18
in Patients with Traumatic Hemorrhagic Shock. J Trauma, 2000;49:611-620
105. Alam H.B., Austin B., Koustova E., Rhee P. Resuscitation induced pulmonary apoptosis
and Intracellular Adhesion Molecule-1 expression are attenuated by the use of Ketone Ringer’s
solution in rats. Surgical Forum 2000; LI:181-183
106. Alam H.B., Sun L., Ruff P., Austin B., Burris D., Rhee P. E- and P-Selectin Expression
Depends on the Resuscitation Fluid used in Hemorrhaged Rats. J Sug Res, 2000;94:145-152
107. Alam HB, Austin B, Koustova E, Rhee P. Resuscitation induced pulmonary apoptosis and
intracellular adhesion molecule-1 expression are attenuated by the use of ketone ringer’s solution
in rats. J Amer Col Surg. 2001;193(3):255-63
108. Lieberthal W., Fuhro R., Alam H., Rhee P., Szebeni J., Hechtman H.B., Favuzza J., Valeri
C.R., Comparison of a 50% Exchange-transfusion with albumin, hetastarch, and Modified
Hemoglobin Solutions. Shock. 2002:7:61-69
109. Gushchin V., Stegalkina S., Alam H.B., Kirkpatrick J.R., Rhee P.M., Koustova E.
Cytokine Expression Profiling in Human Leukocytes after Exposure to Hypertonic and Isotonic
Fluids. J Trauma. 2002:52:867-871
110. Koustova E., Stanton K., Gushchin V., Alam H.B., Stegalkina S., Rhee P. Effects of
lactated Ringer’s solutions on human leukocytes. J Trauma. 2002:52:872-878
111. Alam H.B., Stegalkina S., Rhee P., Koustova E. cDNA array analysis of gene expression
following hemorrhagic shock and resuscitation in rats. Resuscitation 2002;54(2):189-200
112. Alam H., Koustova E., Stanton K., Anderson D., Burris D., Rich N., Rhee P. Differential
effects of various resuscitation fluids on neutrophil activation following hemorrhagic shock in
swine. Submitted to Shock
28
113. Holcomb JB. Fluid resuscitation in modern combat casualty care: lessons learned from
Somalia. Accepted for publication in J Trauma
114. Beecher HK. The management of traumatic shock. In Beecher HK ed. Resuscitation and
anesthesia for wounded men. Springfield, IL: Banerstone House; 1949:123-127
115. Pearce FJ, Lyons WS. Logistics of parenteral fluids in battlefield resuscitation. Mil Med
1999; 164: 653-655
116. Gan TJ, Bennett-Guerrero E, Phillips-Bute B, Wakeling H, Moskowitz DM, Olufolabi Y,

Konstadt SN, Bradford C, Glass PS, Machin SJ, Mythen MG. Hextend, a physiologically
balanced plasma expander for large volume use in major surgery: a randomized phase III clinical
trial. Hextend Study Group. Anesth Analg 1999 May; 88(5): 992-8
117. Nielsen VG, Tan S, Brix AE, Baird MS, Parks DA. Hextend (hetastarch solution) decreases
multiple organ injury and xanthine oxidase release after hepatoenteric ischemia-reperfusion in
rabbits. Crit Care Med 1997; 25: 1565-1574
1118. Debakey ME. Surgery in World War II: Vol II. General Surgery. Government Printing
Office, 1956
119. Churchill ED. Surgeon to Soldiers. Philadelphia J.B. Lippincott 1972
120. Dubrick MA, Holcomb JB. A review of intraosseous vascular access: current status and
military application. Mil Med 2000; 165: 552-559
121. Calkins MD, Fitzgerald G, Bentley TB, Burris D. Intraosseous infusion devices: a
comparison for potential use in Special Operations. J Trauma 2000; 48: 1068
122. Manley G, Knudson MM, Morabito D, Damron S, Erickson V, Pitts L. Hypotension,

hypoxia, and head injury. Arch Surg 2001; 136: 1118-1123
123. Beecher HK. Pain in men wounded in battle. Ann Surg 1946; 123:96-105
124. Buttar N, Wang K. The “aspirin” of the new millennium: cyclooxygenase-2 inhibitors.
Mayo Clin Proc 2000; 75: 1027-1038
125. McCrory C, Lindahl SGE. Cyclooxygenase inhibition for postoperative analgesia. Anesth
Analg 2002; 95: 169-176
126. FDA, Phermacia update Bextra label with new warnings. FDA Talk Paper, T02-43, Nov.
15, 2002
127. PDR 56th ed. 2002, Product information: Celebrex®; Contraindications. 2780-84
29
128. O’Connor K, Butler FK. Antibiotics in Tactical Combat Casualty Care 2002. Accepted for
publication in Mil Med
129. Walker RC. The fluoroquinolones. Mayo Clin Proc 1999; 74: 1030-1037
130. Appelbaum PC. Quinolone activity against anaerobes. Drugs 1999; 58 Suppl 2: 60-64
131. Mosby’s GeneralRx 11th Edition. 2001. Quoted on MD Consult Website.
132. Hoellman DB, Kelly LM, Jacobs MR, Appelbaum PC. Comparative antianaerobic activity
of BMS 284756. Antimicrob Agents Chemother 2001; 45: 589-592
133. Seciale A, Musumeci R, Blandino G, Milazzo I, Caccamo F, Nicoletti G. Minimal

inhibitory concentrations and time-kill determination of moxifloxacin against aerobic and
anaerobic isolates. Int J Antimicrob Agents 2002; 19: 111-118
134. Mather R, Karenchak LM, Romanowski EG, Kowalski RP. Fourth generation
fluoroquinolones: new weapons in the arsenal of ophthalmic antibiotics. Am J Ophthalmol 2002;
133: 463-466
135. Ackerman G, Schaumann R, Pless B, Claros MC, Goldstein EJ, Rodloff. Comparative
activity of moxifloxacin in vitro against obligately anaerobic bacteria. Eur J Clin Microbiol
Infect Dis 2000; 19: 228-232
136. Auerbach PS, Halstead B. Injuries from non-venomous aquatic animals. In, Auerbach PS,
ed: Wilderness Medicine. St Louis, Mosby, Fourth Edition, 2001: 1418-1449
137. Brooks GF, Butel JS, Morse SA. Infections caused by anaerobic bacteria. In, Medical
Microbiology. Lange Medical Books, New York; 2001; 268-269
138. Dellinger EP, Oreskovich MR, Wertz MJ. Risk of infection following laparotomy for
penetrating abdominal injury. Arch Surg 1984; 119: 20
139. O’Connor, Kevin. War Wound Prophylaxis. Special Operations Medical Association
Presentation; December, 2000
140. Osmon DR. Antimicrobial prophylaxis in adults. Mayo Clinic Proc 2000; 75: 98-109
141. Conte JE. Manual of antibiotics and infectious diseases. Williams and Wilkins; Baltimore,
Eighth Edition; 1995
142. Luchette FA, Borzotta AP, Croce MA, et al. Practice management guidelines for
prophylactic antibiotic use in penetrating abdominal trauma: The EAST practice management
guidelines work group. J Trauma 48:508-518, 2000
30
143. Nichols RL, Smith JW, Klein DB, et al. Risk of infection after penetrating abdominal
trauma. NEJM 311:1065-1070, 1984
144. Jones RC, Thal ER, Johnson NA, Gollihar LN. Evaluation of antibiotic therapy following
penetrating abdominal trauma. Ann Surg 201:576-585, 1985
145. Fabian TC, Croce MA, Payne LW, Minard G, Pritchard FE, Kudsk KA. Duration of
antibiotic therapy for penetrating abdominal trauma: a prospective trial. Surgery 112:788-795,
1992
146. Battistella FD, Nugent W, Owings JT, Anderson JT. Field triage of the pulseless trauma
patient. Arch Surg 1999; 134: 742-746
147. Branney SW, Moore EF, Feldhaus KM, et al. Critical analysis of two decades of experience
with postinjury emergency department thoracotomy in a regional trauma center. J Trauma45:87,
1988
148. Rosemurgy AS, Norris PA, Olson SM, et al. Prehospital cardiac arrest: the cost of futility. J
Trauma 1993;35:468-473
149. Martin SE, Ochsner G, Jarman RH, Agudelo WE, Davis FE. Use of the laryngeal mask
airway in air transport when intubation fails. J Trauma 1999; 47: 352-357
150. Joo HS, Kapoor S, Rose DK, Naik VN. The intubating mask airway after induction of
general anesthesia versus awake fiberoptic intubation in patients with difficult airways. Anesth
Analg 2001; 92: 1342-1346
151. Blostein PA, Koestner AJ, Hoak S. Failed rapid sequence intubation in trauma patients:
esophageal tracheal combitube is a useful adjunct. J Trauma 1998; 44: 534-537
152. Schwartz RB, Gillis WL, Miles RJ. Orotracheal intubation in darkness using night vision
goggles. Mil Med 2001; 166: 984-986
153. Fortune JB, Judkins DG, Scanzaroli D, McLeod KB, Johnson SB. Efficacy of prehospital
surgical cricothyrotomy in trauma patients. J Trauma 1997; 42: 832-836
154. Barkana Y, Stein M, Maor R, Lynn M, Eldad A. Prehospital blood transfusion in prolonged
evacuation. J Trauma 1999; 46: 176-180
155. Holcomb JB, Pusateri A, Harris RA, Reid TJ, Beall LD, Hess JR, MacPhee MJ. Dry fibrin
sealant dressings reduce blood loss, resuscitation volume, and improve survival in hypothermic
coagulopathic swine with Grade V liver injuries. J Trauma 1999; 47: 233-242
156. Butler FK, Smith DJ, eds: Tactical Management of Diving Casualties in Special Operations.
Bethesda, Undersea and Hyperbaric Medical Society Workshop Report, 1998
31
157. Butler FK, Zafren K, eds: Tactical Management of Wilderness Casualties in Special
Operations. Wilderness and Environmental Medicine 1998; 9: 62 -117
158. Richards TR. Commander, Naval Special Warfare Command letter 1500 Ser 04/0341; 9 April
1997
159. Allen RC, McAtee JM. Pararescue Medications and Procedures manual. Air Force Special
Operations Command Publication; January 1999
160. Krausz MM. Resuscitation Strategies in the Israeli Army. Presentation to the Institute of
Medicine Committee on Fluid Resuscitation for Combat Casualties. 17 September 1998
161. Pappas CG. The Ranger medic. Mil Med 2001 May;166(5):394-400
162. Malish RG. The preparation of a Special Forces company for pilot recovery. Mil Med 1999;
164: 881-884
163. De Lorenzo RA. Medic for the millennium: the U.S. Army 91W health care specialist. Mil
Med 2001;166(8):685-8
164. Naevin J, Dunn RLR. The Combat Trauma Life Support Course: resource-constrained first
responder trauma care for special forces medics. Mil Med 2002; 167: 566-572
165. Butler FK. Tactical medicine training for SEAL mission commanders. Mil Med.
2001;166(7):625-31
166. Bowden M. BlackHawk Down. New York, Atlantic Monthly Press, 1999
167. McRaven W. Spec Ops – Case Studies in Special Operations Warfare: Theory and Practice.
Novato CA, Presidio Press, 1995
32
Table 1

Care Under Fire
1. Expect casualty to stay engaged as a combatant if appropriate
2. Return fire as directed or required
3. Try to keep yourself from being shot
4. Try to keep the casualty from sustaining additional wounds
5. Airway management is generally best deferred until the Tactical

Field Care phase
6. Stop any life-threatening external hemorrhage:

- Use a tourniquet for extremity hemorrhage
- For non-extremity wounds, apply pressure and/or a HemCon® dressing
7. Communicate with the patient if possible

- Offer reassurance, encouragement
- Explain first aid actions
33
Table 2

Tactical Field Care
1. Casualties with an altered mental status should be disarmed immediately
2. Airway management
- Unconscious casualty without airway obstruction:
Chin-lift or jaw-thrust
Nasopharyngeal airway
Place casualty in recovery position
- Casualty with airway obstruction or impending airway obstruction
Surgical cricothyroidotomy (with lidocaine if conscious) if above
measures unsuccessful
- Spinal immobilization is not necessary for casualties with penetrating trauma
3. Breathing
- Consider tension pneumothorax and decompress with needle thoracostomy if
casualty has torso trauma and respiratory distress
- Sucking chest wounds should be treated by applying a vaseline gauze during
expiration, covering it with tape or a field dressing, placing the casualty in
the sitting position, and monitoring for development of a tension
pneumothorax
4. Bleeding
- Assess for unrecognized hemorrhage and control all sources of bleeding
- Assess for discontinuation of tourniquets after application of hemostatic dressing
(HemCon®) or a pressure dressing
5. IV
- Start an 18-gauge IV or saline lock, if indicated
- If resuscitation is required and IV access is not obtainable, use the intraosseous
route
34
Table 2

Tactical Field Care
(continued)
6. Fluid resuscitation
Assess for hemorrhagic shock; altered metal status in the absence of head injury
and weak or absent peripheral pulses are the best field indicators of shock
- If not in shock:
No IV fluids necessary
PO fluids permissible if conscious
- If in shock:
Hextend 500cc IV bolus
Repeat once after 30 minutes if still in shock
No more than 1000cc of Hextend
- Continued efforts to resuscitate must be weighed against logistical and tactical
considerations and the risk of incurring further casualties
- If a casualty with TBI is unconscious and has no peripheral pulse, resuscitate to
restore the radial pulse
7. Inspect and dress known wounds
8. Check for additional wounds
9. Analgesia as necessary
- Able to fight:
Rofecoxib 50mg po qd
Acetaminophen 1000mg po q6h
- Unable to fight:
Morphine 5 mg IV/IO
Reassess in 10 minutes
Repeat dose q10min as necessary to control severe pain
Monitor for respiratory depression
Promethazine 25 mg IV/IO/IM q4h
10. Splint fractures and recheck pulse
11. Antibiotics: Recommended for all open combat wounds

- Gatifloxacin 400 mg PO qd
- If unable to take PO (shock, unconscious, or penetrating torso injuries)
cefotetan 2 gm IV (slow push over 3-5 minutes) or IM q12 hours
35
Table 2

Tactical Field Care
(continued)
12. Communicate with the patient if possible

- Encourage, reassure
- Explain care
13. Cardiopulmonary resuscitation

Resuscitation on the battlefield for victims of blast or penetrating trauma who have
no pulse, no respirations, and no other signs of life will not be successful and should
not be attempted.
36
Table 3

Combat Casualty Evacuation (CASEVAC) Care
1. Airway management
- Unconscious casualty without airway obstruction:
- Casualty with airway obstruction or impending airway obstruction:
or
Laryngeal mask airway/ ILMA
or
Combitube
or
Endotracheal intubation
or
Surgical cricothyroidotomy (with lidocaine if conscious)
- Spinal immobilization is not necessary for casualties with penetrating trauma
2. Breathing
- Consider tension pneumothorax and decompress with needle thoracostomy if
casualty has torso trauma and respiratory distress
- Consider chest tube insertion if no improvement and/or long transport anticipated
- Most combat casualties do not require oxygen, but administration of oxygen may
be of benefit for the following types of casualties:
- Low oxygen saturation by pulse oximetry
- Injuries associated with impaired oxygenation
- Unconscious patient
- TBI patients (maintain oxygen saturation > 90)
- Sucking chest wounds should be treated with a vaseline gauze applied during
expiration, covering it with tape or a field dressing, placing the casualty in
the sitting position, and monitoring for the development of a tension
pneumothorax
3. Bleeding
- Reassess for unrecognized hemorrhage and control all sources of bleeding
- Assess for discontinuation of tourniquets after application of hemostatic dressing
(HemCon®) or a pressure dressing
37
Table 3

(continued)
4. IV
- Reassess need for IV access
- If indicated, start an 18-gauge IV or saline lock
- If resuscitation is required and IV access is not obtainable, use intraosseous
route
5. Fluid resuscitation
- Reassess for hemorrhagic shock
Altered mental status (in the absence of brain injury) and/or abnormal vital
signs
- If not in shock:
IV fluids not necessary
PO fluids permissible if conscious
- If in shock:
Hextend 500cc IV bolus
Repeat after 30 minutes if still in shock
Continue resuscitation with PRBC, Hextend, or LR as indicated
- If a casualty with TBI is unconscious and has no peripheral pulse, resuscitate as
necessary to maintain a systolic blood pressure of 90mm Hg or above
6. Monitoring
- Institute electronic monitoring of pulse oximetry and vital signs if indicated
7. Inspect and dress wound if not already done
8. Check for additional wounds
9. Analgesia as necessary
- Able to fight:
Rofecoxib 50mg po qd
Acetaminophen 1000mg po q6h
- Unable to fight:
Morphine 5 mg IV/IO
Reassess in 10 minutes
Repeat dose q10min as necessary to control severe pain
Monitor for respiratory depression
Promethazine 25 mg IV/IO/IM q4h
10. Reassess fractures and recheck pulses
38
Table 3

(continued)
11. Antibiotics: Recommended for all open combat wounds

- Gatifloxacin 400 mg PO qd
- If unable to take PO (shock, unconscious, or penetrating torso injuries)
IV cefotetan 2 gm IV (slow push over 3-5 minutes) or IM q12 hours
12. MAST trousers may be useful for stabilizing pelvic fractures and controlling pelvic
and abdominal bleeding. Their application and extended use must be carefully
monitored. They are contra-indicated for casualties with thoracic and brain injuries.
39
Table 4
Tactical Combat Casualty Care Skills List
Individual Combat
Skill Operator Lifesaver Medic
Overview of Tactical X X X
Medicine Training
Hemostasis
Apply tourniquet X X X
Apply direct pressure X X X
Apply HemCon® dressing X X X
Apply MAST trousers X
Casualty Transport X X X
Techniques
Airway
Chin-lift/Jaw-thrust X X X
Nasopharyngeal airway X X X
Cricothyroidotomy X
ILMA X
Endotracheal Intubation X
Combitube X
Breathing
Needle thoracostomy X X
Treat open pneumothorax X X X
Chest tube X
Administer oxygen X
Intravenous access/therapy
Assess for shock X X X
Start an IV/saline lock X X
Obtain intraosseous access X
IV fluid resuscitation X X
IV analgesia X
IV antibiotics X
Administer PRBCs X
40
Table 4
Tactical Combat Casualty Care Skills List

(continued)
Individual Combat
Skill Operator Lifesaver Medic
Intramuscular therapy
IM morphine X X X
IM antibiotics X
Oral antibiotics X X X
Oral analgesia X X X
Fracture management
Splinting X X X
Traction splinting X X
Electronic monitoring X
41
Figure 1
Movement of Casualties
Care Under Fire
Usually, the best first step in saving a casualty is to control the tactical situation.
Casualties who are able to, should move to cover without assistance so as not to expose a rescuer
to unnecessary risk. If a casualty is unable to move and is unresponsive, he is likely beyond
help, and risking the lives of rescuers is not warranted. If a casualty is responsive and unable to
move, then a rescue plan should be developed. First, determine the potential risk to the rescuers,
keeping in mind that rescuers should not move into a zeroed-in position. Did the casualty trip
a booby trap or mine? Where is fire coming from? Is it direct or indirect (i.e. rifle, machinegun,
grenade, mortar, etc.)? Are there electrical, fire, chemical, water, mechanical, or other
environmental hazards? Next, consider assets. What can rescuers provide in the way of
covering fire, screening, shielding, and rescue-applicable equipment?. Third, make sure
everyone understands their role in the rescue and which movement technique is to be used, i.e.
drag, carry, rope, stretcher, etc. If possible, let the casualty know what the plan is so that he can
assist as much as possible by rolling to a certain position, attaching a drag line to web gear,
identifying hazards, etc. The fastest method for moving a casualty is dragging along the long
axis of the body by two rescuers. This drag can be used in buildings, shallow water, snow, and
down stairs. It can be accomplished with the rescuers standing or crawling. The use of the
casualty’s web gear, tactical vest, a drag line, poncho, clothing or improvised harness makes this
method easier. However, holding the casualty under the arms is all that is necessary. A one-
rescuer drag can be used for short distances, but is more difficult for the rescuer, is slower, and is
less controlled. The great disadvantage of dragging is that the casualty is in contact with the
ground, and this can cause additional injury in rough terrain. The fireman’s carry can be used,
but it may expose too much of the rescuer and the casualty to hostile fire. Otherwise, it can be
used over rough terrain with potentially less injury to the casualty from contact with the ground.
Tactical Field Care
Once the tactical situation is controlled or the casualty has been moved to cover, further
movement should be easier. The casualty can be disarmed, and mission essential gear distributed
to other team members. Here again, the fireman’s carry can be used for short distances, but is
very exhausting for both the casualty and the rescuer. If the casualty is conscious, a saddleback
carry can be used. It, however, is less stable and more difficult for the rescuer. The two-man
carry is accomplished by having the casualty sit on a rifle, board, pack-frame or other object,
which is then carried by a rescuer on either side. If the casualty can hold on to the rescuers, then
each rescuer will have one arm free to fire a weapon or move obstacles. If the casualty cannot
hold on, then the rescuers can take turns holding the casualty. The two-man fore-and–aft carry
can be used in narrow areas, but it does not allow either rescuer a free hand. For longer
distances, a conventional or improvised litter should be used. Either the Sked™ or Stokes™
basket make better litters for rough terrain, building interiors, or areas where the litter must be
raised or lowered more than 3 meters. These litters can be dragged by two rescuers if necessary,
42
Figure 1
Movement of Casualties
(continued)
rather than carried by four. The folding litter or a body bag are the next best options, but have
little or no support for the casualty’s spine, and are difficult to drag by two rescuers. The Army
litter has no good way to restrain the casualty and is difficult to use over rough terrain. An
improvised litter can be made from a poncho, poncho liner, blanket, field jackets, doors, or many
other materials that may be available. If the casualty is a victim of blunt trauma and spinal injury
is suspected, then rigid support may be better than non-rigid. A cervical collar can be
improvised from a SAM splint or other material and applied to the casualty before moving.
When moving casualties long distances, tourniquets, dressings, splints and IV lines should be
checked periodically to assure they are intact. Casualties should be protected as much as
possible from the elements (sun, rain, wind, cold, snow, blowing sand, insects) during transport,
and observed for signs of hypothermia, dehydration and heat illness.
CASEVAC Care
Conventional litters should be available during this phase. The casualty should be made
as comfortable as possible, and kept warm and dry. If an improvised litter is used, it should be
padded and field expedient material replaced with conventional splints, tourniquets, dressings,
etc. as soon as feasible. If decontamination is needed, it should be carried out prior to
evacuation, if tactically feasible.
43
Figure 2
The semiprone recovery position.
44
Figure 3
Urban Warfare Scenario – Fast Rope Casualty
• 16 man Ranger team – security element for building assault

• 70 foot fast rope insertion
• One man misses rope and falls
• Unconscious
• Bleeding from mouth and ears
• Taking fire from all directions from hostile crowds
• Anticipated extraction by ground convoy in 30 minutes
45
Figure 4
Urban Warfare Scenario - Helo Hit by RPG Round
• Hostile and well-armed (AK-47s, RPG) enemy in urban environment

• Building assault to capture members of a hostile clan
• In Blackhawk helicopter trying to cover helo crash site
• Flying at 300 foot altitude
• Left door gunner with 6 barrel M-134 minigun (4000 rpm)
• Hit in hand by ground fire
• Another crew member takes over mini-gun
• RPG round impacts under right door gunner
• Windshields blown out
• Smoke filling aircraft
• Right minigun not functioning
• Left minigun without a gunner and firing uncontrolled
• Pilot
Transiently unconscious - now becoming alert
• Co-pilot
Unconscious - lying forward on helo’s controls
• Crew Member
Leg blown off
Lying in puddle of his own blood
Femoral bleeding
46
Figure 5
Tib/Fib Fracture on Parachute Insertion
• Twelve man SF team

• Interdiction operation for weapons convoy
• Night parachute jump from a C-130
• 4-mile patrol over rocky terrain to the objective
• Planned helicopter extract near target
• One jumper sustains an open fracture of his left tibia and fibula
on landing
47
Figure 6
Multiple Trauma from Parachute Collapse
• 16 man SF team
• Interdiction operation on a weapons convoy
• Night static line jump from C-130
• 4 mile patrol over rocky terrain to objective
• Planned helicopter extraction near target
• One jumper has canopy collapse 40 feet above the drop zone
Open facial fractures with blood and teeth in the oropharynx
Bilateral ankle fractures
Open angulated fracture of the left femur
48
Figure 7
Fatality from Parachute Malfunction
• 16 man SF team
• Interdiction operation on a weapons convoy
• Night static line jump from C-130
• 4 mile patrol over rocky terrain to objective
• Planned helicopter extraction near target
• One jumper has streamer
Obviously dead on DZ
49
Figure 8
Underwater Explosion on Ship Attack
• Ship attack
• Launch from PC 12 miles out
• One hour transit in two Zodiacs
• Seven SEAL swim pairs
• Zodiacs approach to within one mile from the harbor
• Turtleback half mile, then purge and go on bag
• Charge dropped in water by hostile forces at target ship
• Swim buddy unconscious
50
Figure 9
CNS Oxygen Toxicity during Ship Attack
• Launch from PC 12 miles out

• One hour transit in two Zodiacs
• Seven SEAL swim pairs
• Zodiacs approach to within one mile from the harbor
• 78 degree water - wet suits
• Turtleback half-mile, then go on bag
• Very clear, still night - transit depth 25 feet
• Diver notes that buddy is disoriented and confused with arm twitching
51
Figure 10
Gunshot Wound Prior to SEAL Delivery Vehicle Extraction
• Two SEAL Delivery Vehicle operation

• Insertion from Dry Deck Shelter with two-hour transit to beach
• Target is a heavily defended harbor in a bay
• 43 degree water - divers wearing dry suits
• Air temperature 35 degrees
• Boats bottomed for across-the-beach radio beacon placement
• One man shot in chest at the objective
• Hostile forces in pursuit
52

Ranger Medic Handbook Draft 2003 - 1

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Ranger Medic Handbook Draft 2003 - 1

Uploaded by

Copyright:

Available Formats

RANGER MEDIC

MEDICAL: RANGER MEDIC SCOPE OF PRACTICE------ 6

TACTICAL: TACTICAL COMBAT CASUALTY CARE------ 51

PLANNING: MEDICAL EVALUATION CHECKLIST---------54

HAZERDOUS TRAINING CHECKLIST--------- 58

RANGER MEDIC SCOPE OF PRACTICE

GENERAL GUIDELINES FOR PROTOCOL USAGE

NEVER HESITATE TO CONTACT THE SURGEON FOR ANY PROBLEM,

Patient Information Documentation

A. AIRWAY AND C-SPINE

Class I Class II Class III Class IV

Blood Loss (ml) Up to 750 750-1500 1500-2000 > 2000

Blood Loss(%BV) Up to 15% 15-30% 30-40% > 40%

Blood Pressure Normal Normal Decreased Decreased

Pulse Pressure Normal or Decreased Decreased Decreased

Capillary Blanch Test Normal Positive Positive Positive

Respiratory Rate 14-20 20-30 30-40 > 35

Urine Output (mL/hr) > 30 20-30 5-15 Negligible

CNS-Mental Status Slightly Mildly Anxious & Confused-

Fluid Replacement Crystalloid Crystalloid Crystalloid & Crystalloid &

V – Verbal Response: Oriented 5

IV. The Secondary Survey

Begin resuscitation simultaneously with the primary survey including the

Hold Laryngoscope in the left hand

Assemble & check equipment

Inflate the distal cuff with 10 ml of air.

Lung Gastric Deflate both cuffs and withdraw the

Cleanse site with povidine

Insert a tracheal hook into the cricothyroid

Insert a 7-0 ET tube through the midline of the membrane

Inflate the cuff of the ET Tube with 10 cc of air

Remove the Luer-Lok from the distal end of the

Remove the needle from the catheter and

Leave catheter in place converting the

Ensure tension has been relieved. If Not

Auscultate breath sounds FREQUENTLY and Document:

Chest Tube Insertion

With the index finger of the nondominant hand trace the

With the index finger of the non dominant hand remaining

Apply dressings: wrap tube with pertolatun gauze

Monitor SpO2, cardiac rhythm and clinical

External Jugular Cannulation

Note blood return and advance catheter

Withdraw needle/catheter and attach IV

Cover site with tegaderm

1 Modified Trendelenburg position is an ideal position. This position is not mandatory

Sternal Intraosseous Infusion

Prep site with povidine swab

Use index finger of non-dominant hand to align

With the introducer in hand, apply steady even

Attach the infusion tube to the right angle female

Attach syringe to the IV insertion site and aspirate bone marrow.

Flush the needle

Administer IV fluids, medications as needed

Secure inducer removal device to IV line or patient

Anaphylactic Shock Management

Monitor Cardiac Rhythm, SpO2

Breath Bilateral wheezes, or

1 Bee sting: gently remove stinger if still present.

ABCs Types of Burns:

· Notify receiving facility ASAP Document:

Head Injury Management

Glasgow Coma Scale