EM Special 9: Military Medicine, part 2

Question 1

the Tactical Combat Casualty Care (TCCC) mainstays of circulation management are

Answer 1

the appropriate use of low-volume resuscitation (also known as permissive hypotension or hypotensive resuscitation) and the preferred resuscitation fluids

Question 2

the first step in circulation management

Answer 2

vascular access
Vascular access is the lifeline for severe combat casualties.

It is critical to firmly secure the catheter in the combat setting.
Use a clear adhesive bandage first; then wrap enough tape to ensure that the catheter will hold in place if you were to throw the IV bag.

Question 3

Ideal site for IO access in the tactical field care

Answer 3

sternum
“Nearly universal use of body armor in the modern tactical environment protects the sternum, so this site is ideal for IO access”

Question 4

Principles of permissive hypotension

Answer 4

The goal is to preserve survival of casualties by maintaining a delicate balance between a blood pressure high enough to provide adequate tissue perfusion but low enough to avoid clot “blow-out” and clotting factor dilution

Current recommendations are to maintain MAP of 60 mm Hg or SBP of approx 80-90 mm Hg

The exception is the multiple trauma casualty with head injury; maintaining a SBP between 90 and 95 mmHg to preserve cerebral blood flow

Question 5

A BP of 80-90 mm Hg is clinically noted by:

Answer 5

a normal level of consciousness and a weakly palpable radial pulse

Question 6

the current resuscitation fluid recommnedations for severe hypovolemic shock [in the tactical field care]

Answer 6

1st choice: fresh whole blood
2nd choice: blood components in 1:1:1 ratio

lactated ringer’s solution is actually 7th choice

Question 7

TCCC primary resuscitation fluid of choice

Answer 7

fresh whole blood
because it has all the required blood components in their natural state and provides a survival advantage to casualties with severe trauma and shock.

Question 8

Using operationally secure identification cards, each prescreened individual can act as a walking blood donor once every

Answer 8

56 days

Question 9

how to give 1:1:1 blood products?

Answer 9

“a unit of plasma is given first, followed by the PRBCs, and then platelets”

Question 10

1 liter of infused lactated Ringer’s results in only _____ of intravascular volume expansion

Answer 10

200 to 250 mL

Question 11

remarks on normal saline

Answer 11

Normal saline is NOT recommended for resuscitation due to the hyperchloremic acidosis it produces.

Additionally, aggressive resuscitation with saline-based resuscitation strategies is associated with a number of adverse effects, including increased bleeding, ARDS, multiorgan failure, ACS, and increased mortality

Question 12

first-line in adjunct therapy in the Joint Trauma System Neurosurgery and Severe Head Injury Clinical Practice Guidline

Answer 12

Hypertonic saline 3%

*Additional options include mannitol or 23.4% saline.

Question 13

When commercial hypertonic saline is not available, providers can:

Answer 13

add 50 mL of 23.4% saline to 500 mL of 0.9% saline to achieve a 2.98% saline solution to simplify dosing options

Question 14

Under TCCC, we prevent hypothermia by

Answer 14

wrapping the patient in a multilayer insulating wrap with a vapor barrier liner

Question 15

Management of head injury

Answer 15

1. patient reclination with head elevated at 30 degrees
2. Give oxygen to maintain O2 Sat 90%
3. Maintain SBP ≥90 mm Hg
4. Adjuncts (HTS, mannitol)
5. Minimize interventions that may cause constriction of venous return in then neck (e.g., cervical collars and endotracheal tube tie systems)

Question 16

the TCCC NSAID of choice

Answer 16

Meloxicam
- has a favorable side effect profile and no effect on platelet function

Question 17

a combat wound medication pack contains

Answer 17

two 500-mg acetaminophen tablets and a meloxicam tablet
- used for lesser injuries with normal mental status
- this combination is effective for moderate pain control, does not affect mental status, and is administered orally

Question 18

these are recommended for more severe pain

Answer 18

oral transmucosal fentanl citrate lozenge (“fentanyl lollipop”)
or ketamine

Question 19

dose of fentanyl

Answer 19

800-mcg fentanyl lozenge
the recommended technique is to tape the lozenge to the patient’s finger, which will deter swallowing and prevent overdosing should the patient become somnolent (as the lozenge attached to the hand will fall from the mouth)

if pain control is not achieved in 15 minutes, a second 800-mcg lozenge can be placed in the other cheek

Question 20

dose of ketamine

Answer 20

Ketamine at subdissociative doses is an effective pain control agent.
initial dose is 50 mg IM or intranasally repeated every 30 minutes and titrated to effect
or 20 mg IV/IO by slow push repeated every 20 minutes and titrated to effect

Question 21

for treatment of nausea, the TCCC now recommends:

Answer 21

ondansetron oral dissolving tablets every 6 hours as needed

Question 22

All war wounds are dirty and contaminated. Early antibiotic use with such wounds may decrease subsequent infection.

For those able to tolerate PO administration, this is recommended:

Answer 22

a single 400-mg dose of oral moxifloxacin (found in the combat wound medication pack)

Question 23

All war wounds are dirty and contaminated. Early antibiotic use with such wounds may decrease subsequent infection.

For casualties with hypotension or an altered level of consciousness, administer:

Answer 23

ertapenem 1 g IV

Question 24

Underresuscitation of burn patients may result in shock and progression into the lethal triad of:

Answer 24

Hypothermia
Acidosis
Coagulopathy

Question 25

remarks on cervical spine immobilization in a combat casualty

Answer 25

Cervical spine immobilization for penetrating injury in a combat casualty is NOT recommended because it will impede the ability to manage the more immediate concerns of a penetrating neck injury.

Blunt head injury should be treated with cervical spine immobilization, situation permitting, as practice in the civilian sector

Question 26

remarks on abdominal trauma in combat

Answer 26

With a significant large-vessel (aorta, IVC, iliac vessels), liver, or splenic injury, there is not much a combat physician can do to save a casualty.

In this situation, stabilize the casualty as best as possible, start an IV, administedr antibiotics, and transport to a higher level of care with surgical capability immediately.

Question 27

what to do if there’s bowel evisceration

Answer 27

replacing the contents will minimize insensible fluid and heat loss and allow for easier casualty movement.

1. remove dirt
2. attempt to replace bowel contents intra-abdoinally
3. cover exposed bowel and abdominal defect with a moist dressing
4. cover with plastic wrap or other fluid-imperfious dressing to minimize insensible fluid loss
5. start an IV and administer IV fluids as needed
6. adminsiter IV antibiotics in preparation for evacuation

Question 28

remarks on pelvic fractures

Answer 28

The practice of “springing” or doing a “pelvic rock” is no longer recommended, because this technique is likely more harmful than beneficial.

perform improvised pelvic splinting with a sheet or use [more superior] commmercially manufactured pelvic splints and binders

Question 29

a partial amputation where the limb is still attached by substantial tissue or bone should be treated how?

Answer 29

the same as an open fracture:
1. hemorrhage control
2. wound debridement and irrigation
3. antibiotic administration
4. splinting in an attempt to savage the limb