TREMA e.V.

Guidelines1 for Tactical Combat Casualty Care

Version 1.0 as of: June 2010 In the continuum of tactical combat casualty care, there are 3 different phases: 1. 2. 3. Care Under Fire Tactical Field Care Tactical Evacuation Care

Care Under Fire (CUF)

(Initial care administered under enemy fire, within the immediate danger area, at the site of an attack, away from protective cover

Return fire and take cover. The firepower provided by each individual may be crucial. Direct casualty to remain engaged as a combatant, if appropriate. Or direct casualty to move to cover and apply self-aid, if able. If required, throw medical material to the casualty. Try to keep the casualty from sustaining additional wounds. The best medicine on the battlefield is fire superiority. Extricate casualties from burning vehicles or buildings and / or the danger area as fast as possible while keeping yourself from getting hit. If possible, extinguish fires. Airway management is best deferred until the Tactical Field Care phase (initial treatment at a place away from enemy fire).2

Based on the TCCC guidelines of the Committee of Tactical Combat Casualty Care (CoTCCC). These are recommendations of how to act for users; in individual justified cases, a user has some latitude of decision (act on his / her own responsibility). 22 At best, and depending on the situation, this may be done using a Wendl tube (nasopharyngeal airway) carried on the person at a specified and readily accessible location on the body. Using this measure, though, must not unnecessarily prolong exposure to the threat situation for the casualty or the individual who renders aid.

Stop any critical external bleeding, if tactically feasible under the circumstances: Direct casualty to control bleeding by self-aid (applying a tourniquet) if able. Use a CoTCCC-recommended3 tourniquet at all anatomically amenable body locations. Apply tourniquet proximal to the bleeding site on upper arm / thigh4 over the casualtys garment; tighten sufficiently and move casualty to cover.5

Algorithm: Tourniquet Application6

Care Under Fire Phase

Apply tourniquet proximal to the wound. Check thigh / upper arm above bleeding site.

Check bleeding: Tighten tourniquet until bleeding stops. Apply second tourniquet, if required.

Make mental note of time of application.

Evacuation move casualty to first cover.

Tactical Field Care

Attaching / carrying the tourniquet: Tourniquet at the 2nd line In a standard location (standardized within the team, as a minimum) Easy to see Easily accessible

3 4

Tourniquets recommended by the CoTCCC: C.A.T., SOF-T, EMT. In the CUF phase / as a temporary measure apply as proximal as possible. Quick to apply, with little force required; will reliably stop any distal bleeding. 5 See Algorithm: Tourniquet Application. Be sure to tighten / close sufficiently so as to prevent venous congestion with increased bleeding. 6 In tactical situations or dangerous situations, or when pressed for time, the application of tourniquets is the only, fastest and most effective measure to prevent further loss of blood. Life-saving method with a low incidence of complications in the preclinical application of tourniquets for combat-related injuries.
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Tactical Field Care

(Initial treatment out of reach of the enemy fire, out of the danger area Kill Zone) Examination follows the <C>ABCDE algorithm7 Any measures will depend on the threat situation, scene safety, and MOI8 For example: C-spine control9 in case of a cervical spine trauma. Casualties with an altered or seemingly unnatural mental state must be disarmed immediately.

<C> Critical Bleeding (life-threatening bleeding)

- Unless performed during the Care Under Fire phase, the primary temporary hemostasis of extremity injuries will now be performed by applying a tourniquet.

A Airway (airway management)

- Determine the state of consciousness: AVPU A Alert V Verbal P Pain U Unresponsive - Responsive casualties with facial skull injuries and imminent risk of respiratory tract obstruction: The casualty may assume any posture that keeps his / her respiratory tract open, even sit upright. Measures need to be taken to allow blood to run off to the outside, or the casualty should be instructed accordingly, if able. - Algorithm / escalatory steps for keeping the airway open: Chin lift or jaw thrust maneuver (Esmarch grip) Nasopharyngeal airway (Wendl tube) If possible: recovery position Supraglottal airway devices;10 if required: ETI Invasive Airway: Surgical cricothyroidotomy 11

7 8

See enclosed TREMA e.V. pocket card Initial Assessment. Mechanism of Injury 9 C-spine control: inline stabilization only. According to current recommendations, no axis-aligned longitudinal pulling force must be exerted on the cervical spine. 10 We recommend the application of the LTS-D larynx tube # 4 and 5. Other supraglottal airway devices such as larynx mask and combitube may be used if available and depending on the level of training (ETI = endotracheal intubation). 11 Cric is a means of last resort to be used only if there is and in keeping with an obligatory indication. Proper training is mandatory to perform koniotomy.
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- Surgical cricothyroidotomy cric indications:

Life-threatening glottal / supraglottal obstruction

(facial skull injuries & swelling as a result of anaphylaxy)

Failed application of, or lack of, alternative airway devices

(larynx mask, larynx tube, combitube etc.)

Failed endotracheal intubation Cannot ventilate cannot intubate situation!

Algorithm: Surgical Airway Cric:

-

Prepare material (surgical12 or cric-kits) Positioning: overstretch the head (caveat: suspected cervical spine injury) Use left hand to fixate the larynx to the thyroid cartilage from the cranium (top) Use right hand to feel for the ligamentum conicum (local anestheticum or S-ketamine IV / IM) Make longitudinal skin cut above the ligamentum conicum13 Blunt preparation on the ligamentum conicum Make cross cut through the ligamentum conicum Spread the hole (ligamentum conicum) between thyroid and cricoid cartilage with a speculum alternatively with the back part (blade-remote end) of the scalpel or with scissors Insert a 6.0 tube (spiral tube) until the cuff has been placed safely in the trachea Not deeper! (Risk of unilateral ventilation of the right bronchial tubes) Position checking, auscultation, fastening.

Endotracheal intubation (ETI): In the "Tactical Field Care" phase, ETI is not indicated and generally not recommended.14

12

Scalpel #11, 6.0 spiral tube, 10 ml Blocker syringe, ES compresses, means for fastening (tape, gauze dressing), gloves; spreading tools, if required (scissors, clip, nose speculum) 13 Currently, there are different opinions as to the issue of longitudinal cut or cross cut. We recommend the longitudinal cut, as it is considerably safer and better to handle, with a lower risk of cutting through vessels and subsequent bleeding and impairment of visibility (however, if the incision is too far distal, there is a risk of isthmus injury of the thyroid gland). Also, anatomical orientation is clearly better, in particular if the skin is shifted. 14 ETI requires more practicing, more time and more material than supraglottal airway devices; it requires deeper unconsciousness or anesthesia and subsequent respiration of the patient. Normally, it is recommended for the Tactical Evaluation Care phase if the relevant material is available. ETI may be useful, though, depending on the users level of training and practice. Users will need to weigh this against the alternatives.
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B Breathing (chest / breathing)

* All open chest injuries will be closed immediately with a sealing dressing15 that is fastened appropriately. Monitor the casualty for the potential development of a tension pneumothorax and hemorrhagic shock.16 A developing tension pneumothorax needs to be identified at an early stage and relieved by means of a large-lumen needle (14G is recommended).17

Algorithm of Relief Puncture for Decompressing a Tension Pneumothorax:

Puncture with 14G needle (orange 50mm)18 Puncture to be applied on the same side as the injury! Second intercostal space on the medioclavicular line No puncturing medial of the nipple because might puncture the arteria mammaria might injure the heart / vessels Puncturing above the rib (on, at, above) then remove completely19 Penetrating Thorax Injury

Occlusive Dressing Dressing on four / three sides, Asherman, Bolin etc. Assessment Respiratory distress zyanosis unrest. No respiratory sounds on the side affected. Tachypnoea rate of respirations > 30/min Hypotension BP syst. < 80 (radial pulse not palpable) Tachycardia (heart frequency > 100/min (further deterioration / C problem) Late sign: subcutaneous emphysema / cervical vein obstruction / shifted trachea

Needle Decompression

15

It does not matter in which way an occlusive dressing / dressing on three sides / valve dressing is applied. What matters is its effectiveness. It is not possible to recommend a specific product here. Use needs to be made of available material. Intensive training is mandatory. 16 Permissive hypotension is indicated in case of strong bleeding into a cavity (thorax, abdomen or pelvis). See below. 17 A relief puncture will be effective if applied correctly but will only provide for temporary ventilation / pressure relief. Repeat puncture / relief may become necessary if the tension component recurs. 18 The 14G permanent intravenous needle that is normally used may be not be long enough to reach into the pleural cavity. Use of a longer commercial relief-puncture cannula may have to be considered. 19 The cannula used for puncturing may become obstructed / clogged by blood and / or tissue. The cannula will then cease to drain air and may be shifted / bent by the thoracic breathing excursions. Another puncture may become necessary in the process.
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C Circulation (bleedings / circulation / volume)

* Blood Sweep: Searching / sweeping the entire body of the casualty and stopping of any as yet unrecognized bleeding in accordance with the Initial Assessment algorithm (see pocket card). All bleedings are stopped in the sequence of examination (From head to toe Treat as you go). If not already done, use a CoTCCC-recommended tourniquet to temporarily stop any critical external bleeding that is anatomically amenable to tourniquet application. This will be followed later by the application of definitive hemostatic measures. Compressible bleedings not amenable to tourniquet use will be treated with especially absorbing material20 and hemostyptica21 in accordance with the algorithm listed below. Regardless of the type of hemostyptic available, direct pressure will be applied for at least 3 to 5 minutes to effectively stop the bleeding. It is mandatory that the package be secured by means of a bandage dressing to prevent the package from becoming loose and to prevent further bleeding. During patient evacuation, the bleeding / dressing needs to be checked at regular intervals. Deep wounds which cannot be covered by conventional dressings and wound gauzes need to be tamponed (packing). Absorbing and / or hemostyptic dressing material is placed at the bottom of the wound and the wound cavity is filled completely; then, direct pressure is applied. If the tourniquet is no longer applied in a threat situation or under extreme time pressure, the knot will be twisted tighter until no distal pulse is palpable. A tourniquet already applied in the CUF phase needs to be further tightened if the pulse is still palpable, or needs to be replaced by a second tourniquet. All limbs with applied tourniquets need to be fully examined, which may require clothing to be removed from the areas affected while keeping in mind that the casualtys body warmth needs to be preserved as best and as quickly as possible (for example, by leaving parts of the clothing on the body). Personnel should aim for the tourniquet to be released.

* *

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Particularly absorbing material include Kerlix or abdominal pads, for example. While the new dressings such as the ER dressing or OLEAS dressing have well absorbent pads, their predominant feature is the elastic dressing, which is why it is not possible to use them for packing. Kerlix is particularly suited for this purpose. 21 Applying hemostyptica requires specific training and familiarization with the relevant product to ensure effective and faultless application.
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* Release of the tourniquet:

* After applying a tourniquet as a temporary means to stop the bleeding, the aim is to replace the tourniquet as soon as possible by other means to stop the bleeding.22 Before a tourniquet is removed from a casualty who suffers from a hemorrhagic shock, the casualty must show positive reactions to prior circulation control measures (i.e. normal peripheral pulse and normal mental activity, unless suffering form traumatic brain injury) and effective additional measures must have been taken to stop the bleeding. Checking of existing tourniquets: expose wound, apply an adequate dressing (pressure dressing, to include packing or hemostyptic as required) and verify whether the tourniquet is still needed. If so, the tourniquet is no longer to be placed on the clothing, but rather directly on the skin, about five to ten centimeters above the wound.23

* *

Use a waterproof pen to note the time of tourniquet application clearly and legibly. The time of tourniquet application and the tourniquet location will be recorded on the TREMA e.V. Casualty documentation card; alternatively, for the time being, an expedient means may be used for writing down the information. In case of bleeding limbs, the blood loss may be reduced and coagulation may be enhanced by restraining / immobilizing the limb in addition to applying a wound dressing. Fractures mean additional loss of blood, which often is not visible. Limb or pelvis immobilization and / or axis-aligned positioning will diminish the loss of blood or reduce the bleeding.

22

Time factor: It should be attempted to replace the tourniquet within the first 30 minutes. If evacuation time is less than 30 minutes, the release of the tourniquet is not absolutely necessary. Replacement by other hemorrhage-stopping measures with release of the tourniquet is possible within a period of two hours maximum. If remaining in place for longer periods, a tourniquet should be released only under controlled conditions, possibly in the presence of a physician. It is recommended that a tourniquet whose time of application is not exactly known should be removed only under controlled conditions. 23 It is recommended to use a second tourniquet to avoid loss of blood when releasing and resetting the tourniquet.
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Tactical Field Care Phase

Tourniquet already applied

Bleeding not yet stopped

Reassessment of the bleeding. Can tourniquet be replaced?

Manual pressure on the wound

Apply pressure dressing and / or hemostyptic dressing

Apply pressure dressing

Open tourniquet slowly but completely leave it loosely in place so that it may be tightened again quickly, if required!

- -

Hemostyptic dressing compression

Check dressing regularly; leave loosened tourniquet in place

Close / apply tourniquet. Write down time of application (measure of last resort)

Explanations: + Bleeding successfully stopped

- Bleeding not successfully stopped

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* Non-compressible (cavity) bleeding:

* A cavity bleeding is hard to control, or cannot preclinically controlled at all. Apart from penetrating injuries,24 where the sources of bleeding appear obvious, blunt traumas are treacherous because there is no primary visible bleeding. Explosions may cause penetrating injuries (in particular secondary blast traumas) as well as blunt (particularly primary and tertiary) injuries. Except for pelvis fractures, it is difficult to stop bleeding effectively with the means available on site.25 Permissive hypotension26 is indicated in these cases so as to inhibit further bleeding and to permit hemostasis by the bodys own coagulation mechanism. Likewise, permissive hypotension is indicated for unstoppable / non-compressible bleeding in the trunk of the body.

* * *

Internal Bleeding / Cavity Bleeding

Thorax Abdomen

Pelvis

Extremity

Permissive hypotension*

Permissive hypotension*

Permissive hypotension*

Consider thoracic drainage

Anti-shock trousers (e.g. MAST)

Pelvic sling

*Does not apply to simultaneously occurring severe craniocerebral trauma (GCS < 8)

- Check circulation, motricity, sensibility - axis-aligned positioning / traction in case of fractures, if required - immobilization.

MAST and pelvic sling may be used in combination

Note: MAST Military Anti-Shock Trousers or Pneumatic Anti-Shock Garment (PASG)

24

When treating a penetrating injury, an attempt at internal tamponade may be made, for example using the cuff of a urine catheter. However, this will require practice, experience and precise anatomical knowledge to be able to do this effectively. 25 See Internal Bleeding / Cavity Bleeding algorithm. 26 Permissive hypotension: Administering a restrictive volume and catecholamine dose to keep the systolic blood pressure at about 80mmHg (= radially palpable pulse). Temporary hypotension is accepted in order to promote coagulation and reduce the loss of blood. Any further drop in the blood pressure below 70mmHg must be countered by administering a volume dose, as otherwise cerebral perfusion will be jeopardized.
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* Hemodynamometry
* Expedient blood pressure taking is possible by feeling for the palpable pulse at the large arteries; if the pulse is palpable, this means that the minimum systolic blood pressure is: A. radialis 80 mmHg A. femoralis 70 mmHg A. carotis 60 mmHg For differentiated volume therapy, an effort should be made to take the blood pressure according to Riva Rocci, using a blood pressure meter and a stethoscope, or particularly in a noisy environment to take the blood pressure manually (only systolic BP).27 Depending on the situation and available equipment, this may not always be possible and reasonable. Further symptoms of reduced blood pressure / shock include: * Increased recapillarization time28 Changed mental state reduced vigilance29 unrest Pale, clammy skin Increased heart frequency while peripheral pulse is missing or weak Cyanosis

Intravenous (IV) access

* An early and securely placed IV access may save time in the continuum of the rescue chain if the casualty has not yet been primarily centralized, and may allow for differentiated therapy / possibly save lives. In many cases, though, volume replacement is not primarily indicated. 18G permanent venous catheter are a proven means of IV access. Flow rates are sufficient, with a good probability of succesful puncture of the vene. Primarily, it is recommended to puncture the peripheral veins of the lower arms. If a decision is made to puncture at the wrist or elbow, care should be taken to avoid kinks in the permanent venous catheter during evacuation; if required, the joint should be splinted. Be sure to secure the permanent venous catheter in place. An intraosseous (IO) access is indicated30 if puncture attempts have failed; in centralized patients when volume replacement is mandatory (hemorrhagic shock); or if intravenous analgesia is required (e.g. S-ketamine).

* *

27 28

Electronic blood measuring may make sense in this case; however, these devices are quite susceptible to faults and mean an increased load of equipment. Recapillarization time (capillary refill) may also be prolonged in cases of hypothermia and, in and of itself, must not be rated as a reliable shock symptom. 29 If there is no traumatic brain injury, and if no analgesics or sedatives have been administered. 30 Intraosseous access: Currently, there are two systems available that are recommended by TREMA e.V.: The first one is F.A.S.T. 1 / F.A.S.T. X, which is placed at the sternum; the second is the manually operated EZ-IO system (with a manual turning knob use of a drilling machine is recommended for medical vehicles / special operations vehicles and higher levels); the system may be used for various regions of the body (sternum, tibia, humeral head). Both systems are good usable alternatives to IV access. Familiarization and training are mandatory. A primary injection of 1-2ml of Scandicain / Lidocain 1% is recommended before injecting the actual 10ml bolus in conscious casualties. Tibia injections have shown to be very painful in comparison. A pressure infusion (with cuff, if so required) is necessary in order to achieve an adequate flow.
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Volume replacement
* Assess whether the casualty suffers from a hemorrhagic shock: Changed mental state (if there is no head injury) Weak or missing peripheral pulse (RR < 80mmHg) If the casualty suffers from massive blood loss and shows signs of shock, a 250ml HyperHaes 6% bolus31 is indicated at the beginning of the treatment. A 6% balanced colloidal solution32 is primarily indicated as a volume replacement in case of hemorrhage. Initially, 500ml colloidal, intravenous, as a bolus. Additional infusions up to a total of 1,500ml are possible. HyperHaes 6% is also recommended for severe cases of traumatic brain injury (AVPU: < PU).33 After initial administering of HyperHaes, further volume therapy is indicated with crystalloid34 and colloidal solutions. Stepped-up, sustained volume therapy needs to be weighed against logistical and tactical concerns and the risk of further losses. Volume therapy with more than a maximum of 1,500ml of colloidal and 1,000ml of crystalloid solutions results in a thinning effect with coagulation impairment and needs to be applied with caution35 if the state of shock persists. Depending on the season of the year, an additional supply of liquid administered orally or with crystalloid solutions may be indicated for casualties suffering from dehydration, regardless of any blood loss or trauma.

* * * * * * * *

Hemodynamic Therapy
Bleeding controlled Bleeding uncontrolled

No signs of shock no volume therapy - IV access + mandrins

Signs of shock Restrictive volume therapy Permissive hypotension Aim: RR ~ 80mmHg syst.

Sign of shock Stepped-up volume therapy Aim: RR ~ 100mmHg syst.

CAVEAT:
Severe TBI (GCS <8) or AVPU < PU Aim: RR 120mmHG syst. Volume (HyperHaes)

31

Small volume resuscitation with HyperHaes 6% (a hyperosmolary (contains 7.2% NaCL), colloidal (contains 6% Haes) solution, which generates an effective volume replacement without a considerable thinning effect), promotes microperfusion and increases the perfusion pressure in cases of traumatic brain injury. 32 Currently, a balanced colloidal solution without lactate is recommended, e.g. Vitafusal 6% 130/0.42 or Voluven 6% 130/0.4, which have less blood coagulation-inhibiting properties and a good volume effect (blood loss / colloidal volume effect 1:1.2). 33 According to current data, it may be administered but does not have to be administered. 34 Isotonic balanced solutions without lactate are recommended as a crystalloid solution. Ringers solution (chloride): isotone (309mosm/l) E153 (acetate): isotone (303mosm/l) Jonosteril (acetate): slightly hypotonic (290mosm/l). 35 If evacuation time exceeds 60 minutes, and depending on availability, volume therapy beyond these values may be applied if shock signs persist. Factors to be considered are the means available, the time required for evacuation, and the mission.
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 D Disability (neurolog. status / traumatic brain injury / analgesia) * Neurological Status:

* Determine the state of consciousness in accordance with AVPU36 A Alert (GCS 13-15) V Verbal (GCS 8-12) P Pain (GCS 4-7) U Unresponsive (GCS 3) Alert - Verbal Pain Unresponsive
Eye opening response 6 5 4 3 2 1 spontaneously on request following pain stimulus none fully oriented not fully oriented incoherent unintelligible utterings none Best response to speech Best motoric response

coordinated, on request coordinated, following pain stimulus uncoordinated, following pain stimulus following pain stimulus, flexing synergisms following pain stimulus, stretch synergisms none

Pupils: Assessment in accordance with the PERRLA method: P Pupils E Equal R Round RL React to light A Accommodate37 Preliminary neurological motoric / sensory examination: depending on the accident mechanism Are all limbs moved to the same extent? If casualty is responsive, ask for sensibility disorders. In case of suspected spine trauma perianal sensitivity disorders / uncontrolled faces / urine excretion? the crotch-grab (possibly already during blood sweep) If casualty is unconscious, check pain stimulus on both sides if required.

36

During military operations, the GCS (Glasgow Coma Scale), which is used in the civilian sector, is not user-friendly; it cannot be retrieved in a stressresistant way and cannot be applied safely in tactical situations. The AVPU method provides an approximate, effective and quick impression of the casualtys state of consciousness. 37 To be assessed only if casualty is conscious and responsive.
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* Traumatic Brain Injury (TBI):

If the patient suffers from blunt or penetrating TBI: Regularly check and document state of consciousness Depending on the mechanism of injury, cervical spine immobilization may be indicated38 Elevate upper body 30 degrees Position the head straight in line Keep airways free, if required39 RR syst. goal: 120mmHg40 (with HyperHaes 6%, if required) Adequate analgesia by means of S-ketamine41

* Analgesia:
* * * * * Analgesia by means of a Fentanyl lollipop42 or S-ketamine During military operations, do not take acetylsalicylic acid.43 If opiates are to be administered intravenously, it is recommended to keep Naloxon available. Consider to apply local or regional anesthesia, depending on level of training. Use Fentanyl lollipop 800g for:
38

Casualties with light to medium wounds feeling strong pain Responsive casualties with no signs of shock Casualties without IV / IO access Place Fentanyl lollipop between patients cheek and gum for 15 minutes, then assess pain state again For safety reasons, the Fentanyl lollipop may be taped to the finger of the casualty (may drop out of the casualtys mouth if vigilance is reduced) Watch for shallow breathing and reduced breathing rate

Do not set the cervical spine orthosis too tight so as not to impede the venous flow. This also applies to the straight positioning of the head. Do not exert traction on the cervical spine. 39 A Wendl tube may also be used for this purpose. Do not use the Wendl tube if suspecting a basilar skull fracture and / or if blood / fluid flows out of the patients nose. 40 RR syst. goal is 120mmHg to maintain a sufficiently high perfusion pressure. The volume substitute of choice is HyperHaes 6% 250ml, administered as a bolus. 41 Analgesia with S-ketamine: Effect: protective reflexes are maintained; increased sympathicus tonus with RR stabilization; respiratory drive is maintained (with subanesthetic dosage, there is a small risk of hypoventilation with hypercapni); possibly neuroprotective properties. 42 Fentanyl lollipop is a colloquial term for a Fentanyl sucking tablet with an applicator much like a tablet on a stick for absorption across the buccal mucosa. It is recommended to swab the applicator on the buccal mucosa. Depending on the case, this may not always be possible, though. In any case, the tablet should not be chewed or swallowed. 43 ASS irreversibly inhibits thrombocyte aggregation and thus critically prevents coagulation in case of wounding.
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If pain continues, place a second Fentanyl lollipop between patients opposite cheek and gum as required.

Use S-ketamine44 for: Casualties with light to medium wounds Casualties who are unable to sit unassisted due to their injuries Casualties with shock symptoms / unstable circulation Casualties with IV / IO access; IM or nasal45 application may be used as an alternative To be administered in combination with initially 1-2mg Midazolam (Dormicum) IV. Further titration of Dormicum up to a maximum of 5mg is possible if unrest persists. Time permitting, Dormicum should be administered before S-ketamine. Talk to the casualty and explain how the medication starts to take effect.46 Dosage47 (for an average soldier with a body weight of about 80kg): IV / IO, initially 20mg S-ketamine; effect sets in within 2 to 3 minutes; then carefully titrate in increments of 10mg48 until the casualty feels no pain. Repeat dosage after approx. 15-20 minutes; titrate in increments of 10mg until patient is free of pain. IM, initially only 80-100mg S-ketamine mono. Effect sets in within 5 to 10 minutes.

Use Midazolam (Dormicum) for: Anxiety, agitation, apprehension, panic In combination with S-ketamine Dosage49 (for an average soldier with a body weight of 80kg): IV / IO 2 mg (titrate as required in increments of 1mg to a maximum of 5mg)

44

S-ketamine is an ataractic analgesic agent. It stabilizes the blood circulation, maintains the protective reflexes, keeps up the respiratory drive if the dosage is subanesthetic, has a highly analgesic effect within a short period of time, and has a short half-life which, however, requires it to be administered in continuing repetition. Caution: Overdosage may result in a brief respiratory depression. 45 Nasal application is an alternative which permits agent absorption through the nasal mucosa. This is still in the trial phase, and exact data as well as experience are not yet available. A dose of 1-2ml of unthinned S-ketamine S with 25mg / ml may be administered as an initial dose for analgesia, in which case the side effects to be considered are the same as for the methods of application. 46 S-ketamine causes ataractic analgesia with a dissociative effect. Casualties may become sensitive to noise and may consider external influences to be unpleasant. Also, there may be unanticipated mental reactions, which is why S-ketamine should not be used for slightly injured, independently mobile casualties. For them, it is recommended to use opiates administered in the form of Fentanyl lollipops (see above). 47 Dosage for S-ketamine in accordance with medical literature: intravenous 0.125-0.25mg / kg of casualtys body weight, and intramuscular 0.25-0.5mg / kg of the casualtys body weight (IM administration may require up to more than 1mg / kg of the casualtys body weight). Caution: Watch for the grade of thinning in available ampules, as ampules with various thinning grades (mg / ml) are on the market. 48 Discontinue S-ketamine administration if nystagmus sets in or if the casualty closes his / her eyes or if the casualty is no longer responsive. 49 Dosage for Midazolam in accordance with medical literature: intravenous 0.025-0.05mg / kg of the casualtys body weight.
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IM initially 10 mg

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E Exposure (further examination, care, warmth retention, antibiosis,

monitoring, documentation) -

Fractures:
Open fractures to be covered with sterile material. Transosseous bleeding may be stopped with a tourniquet only to a certain extent. Only in extreme cases may the temporary application of a tourniquet be indicated until it is replaced by a dressing / hemostyptic. Provide for axis-aligned positioning and immobilization of fractures; use a splint, if possible. Check peripheral pulses before and after splinting.

Burns: Facial burns (in particular those sustained in closed spaces or in a deflagration / explosion) will often be accompanied by inhalation traumata. Check the respiratory system at increased intervals. Observe pulse oxymetry. Consider creating a surgical airway if upper airways are obstructed.

Determine burnt body surface using the Rule of Nines. Cover burns with dry, sterile dressings.50 There is an increased risk of hypothermia for burn victims. Warmth retention is to be considered at all times.51 Adequate analgesia (as per the paragraph on analgesia; see above). Volume replacement52 with more than 20 per cent body surface intravenously or intraossarily: Initially, 1,000ml of a balanced crystalloid solution in the first hour53 In case of additional hemorrhagic shock, follow the above mentioned pattern, with primary focus on volume therapy.

50

Metalline dressings are recommended. Sterile compresses or commercial dressings such as the ER dressing may also be used if there are no special wound contact layers available. It is important to prevent any further contamination of the wound! 51 Use of the gold / silver or olive / silver Bundeswehr / civilian rescue blanket is urgently recommended. Other recommendable variants that are commercially available: Blizzard Survival Blanket / Blizzard Rescue Blanket. 52 Baxters Parkland formula: burnt body surface in % x 4 ml/h x kg body weight within 24 hours. 50 per cent in the first 8 hours, 25 per cent each in the following 2 x 8 hours. This formula provides just a rough orientation and is to be used only for long routes of evacuation. 53 Jonosteril, E153
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Penetrating Eye Injury: Perform a quick vision check. Cover eye with a rigid eye patch. Do not exert pressure on the injured eye. Do not use compresses. Do not locally apply medication / ointments.

Remember to administer adequate analgesia. Take local anesthetica54 into consideration. Administer oral antibiotics (Moxifloxacin / Ciprofloxacin 400mg).

Hypothermia55
Try to minimize the casualtys exposure to the effects of weather.56 Leave as much protective clothing on the casualty as is practicable. Isolate the casualty from the ground at an early stage (place the casualty on a carry sheet or on an isolating mat, if possible). Use thermal / insulation blankets.57 Protect the casualtys head from chilling. If possible, remove casualtys wet clothes and replace with dry clothes. Use any material that will keep the casualty warm and dry.

Antibiotics:
Administration of antibiotics is indicated for all58 open combat related injuries. Consider the risk of anaphylactic reaction to antibiotics; cf. Anaphylaxis. If the casualty is responsive and if it is possible to administer oral medication: Moxifloxacin / Ciprofloxacin 1 x 400mg p.o. If oral administration is not possible or if an IV / IO access exists: Tazobac59 1x 4.5g IV

54

Instill local anesthetic eye drops, such as Ophtacain-N (Tetracain) single dose 1 to 2 drops per eye into the conjunctival sac; may be administered over longer periods of time if pain recurs. 55 Hypothermia is part of the lethal triad, together with coagulopathy and acidosis. Also, coagulation is critically dependent on the body temperature. Coagulation capability is reduced with every degree of the body temperature. Thus, hypothermia prevention also serves to stop the bleeding. 56 Wind, rain, and cold (especially from the ground). 57 Rescue blanket, blizzard rescue blanket, chemical thermal blankets (e.g. Ready Heat), poncho liner, sleeping bag, cold weather protection gear, clothes etc. 58 In this context, all open injuries does not refer to minor injuries (such as small cuts or bruises). Such minor injuries are to be discussed with the appropriate physician; in most cases, local treatment will suffice. 59 Tazobac 3 x 4.5 g/day (Piperacillin and Tazobactam). This covers gram-positive and gram-negative pathogens and anaerobes (primarily in the preclinical stage it is no longer necessary to administer Metronidazol). Currently, this particularly applies to Afghanistan. Other antibioses may be recommendable, depending on the area of operation and the range of pathogens.
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Anaphylaxis: Stop the supply of the allergen, if possible.60 If the casualty is responsive, ask for possible allergies. In case of circulatory insufficiency (tachycardia > 100; hypotension < 80mmHg) Suprarenin 0.5mg IM IV access available: 0.1mg Suprarenin IV (1:10,000)

Administration of a generous volume (500-1,000 ml)of a balanced crystalloid solution Further therapy measure: IV administration of H161 and H2 antagonists as well as cortisone (SDH) 250-1,000mg IV Check airway at regular intervals for swelling of the mucous membranes bronchospasm.

If upper airway is obstructed, establish surgical airway as required.

Monitoring of vital signs:

Consciousness / vigilance Breathing rate Heart frequency Blood pressure Skin color / recapillarization time Pulse oxymetry62

Documentation:
All observed vital signs, clinical findings (injuries), any action taken, and any changes in the casualtys condition need to be documented. Expedient means may be used for the purpose (piece of paper, docutape etc.) or, preferably, use is made of the TREMA e.V. Doku-Karte documentation card (see annex), which permits all important information to be documented easily and close to the patient. Important information to be documented: Tourniquet: place and time of application Identified injuries Applied hemostyptica Vital parameters in the course of time Administered medication (infusions, analgesics, antibiotics) Action taken (e.g. relief puncture)

60 61

Discontinue antibiotics or HAES infusion. Remove venomous sting or similar. H1 antagonist, e.g. Dimetindene (Fenistil) 8mg (two ampules) + H2 antagonist, e.g. Ranitidine (Zantic) 50mg (1 ampule) 62 Pulse oxymetry is an indicator of oxygen saturation of the hemoglobin in ones blood. The standard value is 95-99%, which is reduced if there is a lack of oxygen. Disruptive factors are bad peripheral perfusion (due to centralization resulting from shock or hypothermia), the surrounding light, movement artefacts or contaminations. A high content of MetHb or COHb (methemoglobin or carboxyhemoglobin) will lead to erroneously high values. Caution: Pulse oxymetry values may lag behind the incident if there are changes in saturation (e.g. rapid change with tension pneumothorax).
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Basic Response Rules for Tactical Evacuation Care63

(Casualty care during tactical evacuation)

Prior to evacuation, a check will be conducted to verify whether the casualty and the material are ready for transport:
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Is the airway unobstructed and / or are airway protection measures, if any, still sufficient? Are all dressings still sufficient? Is the infusion / IV / IO access secured? Is the casualty protected from potential injury in transit (head, limbs)? Has all the material been collected? (Avoid leaving traces) Has sufficient documentation been prepared?

During evacuation, it is mandatory to regularly assess / examine the casualty and to revise any action taken in accordance with the ABCDE pattern. Algorithms and recommendations as described above for the Tactical Field Care phase shall apply. During evacuation, it is recommended to monitor vital signs by means of appropriate monitoring systems (pulse oxymetry, ECG etc.) if and when such systems are available. Most of the casualties will not require additional oxygen. In the following situations, however, it may be helpful to administer oxygen:
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Reduced oxygen saturation (< 90% in pulse oxymetry) Injuries resulting in insufficient oxygen intake Unconscious casualties Casualties suffering from traumatic brain injury (keep oxygen saturation at a value above 90%) Casualties in shock Casualties at high altitudes

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The new concept of Tactical Evacuation Care comprises the measures of Casualty Evacuation (CASEVAC) (expedient evacuation of casualties) as well as the measures of Medical Evacuation (MEDEVAC) (evacuation of casualties by qualified medical staff) as defined in Joint Publication 4-02.

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In case of an existing penetrating thorax injury (with or without tension component and performed relief puncture), the use of a thorax drainage should be considered, in particular if the casualtys condition does not improve and / or if the duration of the evacuation is expected to be prolonged. The pneumatic military anti-shock trousers (MAST)64 may be helpful in controlling any hemorrhage in the pelvis and the abdomen. If a pelvis fracture has been stabilized by a pelvic sling, an additional benefit may be achieved by combining the sling with a MAST. Donning the MAST, its use for prolonged periods of time, and its removal need to be monitored carefully. As for casualties suffering from thorax or craniocerebral injuries, use of the anti-shock trousers is contra-indicated. Documentation of all observed vital signs, clinical findings (injuries), any action taken, and changes in the casualtys condition on the TREMA e.V. Doku-Karte documentation card (see annex). Preparation of casualty transfer to the next person / unit / level for further treatment:
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Patient (age, name, unit) Injury pattern (what, caused by what, when) Current clinical status (vigilance, BP, HF, RR, SpO2) Action taken (hemostasis, volume therapy, medication administration, splints, dressings) Additional information (allergies, previous diseases, medication, special circumstances SAMPLE) Handover of documentation Wait for questions.

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The use of the MAST is currently the subject of controversial debate. Because of its size, its use is rather impracticable prior to Role 1 but may be suitable for the Tactical Evacuation Care Phase at the Mobile Emergency Physician Team or in a Role 2 shock room. After donning the MAST, abrupt opening is to be avoided. It is recommended to provide for constant release of pressure using vasopressors if required while monitoring the casualtys blood pressure. On principle, this should be done only at a hospital (mobile surgical hospital / field hospital) because of unpredictable consequences.
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Annex: TREMA e.V. Initial Assessment Pocket Card

TREMA e.V. Casualty Documentation Card

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