Principles of Prolonged Care

Question 1

Beyond TCCC and exceeds doctrinal planning guidelines. “Begins when evac doesn’t”

Answer 1

Prolonged field care

Question 2

Prolonged field care started in:

Answer 2

2013 with SOMSA extended care working group

Question 3

Reasons for prolonged field care

Answer 3

• Long evac times
• Indigenous capabilities
• Requires different skills
• Different environments

Question 4

Gear carried to furthest point usually by medical personnel

Answer 4

Ruck

Question 5

Additional gear carried in vehicles

Answer 5

Truck

Question 6

Gear available to IDC/Medical personnel however, can only realistically be maintained at house/tent/FOB or support site. “highest level of care unit has”

Answer 6

House

Question 7

Planning stage to consider how casualties will be moved

• MEDEVAC
• CASEVAC

Answer 7

Plane

Question 8

Three phases of prolonged field care

Answer 8

Evaluation phase

Resuscitation Phase

Transport phase

Question 9

During this time procedures and steps taken to normalize vitals and reverse physiological effects based on skill set available

Answer 9

Resuscitation phase

Question 10

Systematic approach priority to treat life threats in order of severity

Answer 10

Evaluation phase

Question 11

10 core capabilities of prolonged field care

Answer 11

• Monitor
• Resuscitate beyond basic crystalloid (FWB)
• Ventilate and Oxygenate the patient
• Airway management
• Sedation and pain management
• Ability to use physical exam and advanced diagnostics to further evaluate
• Nursing care
• Advanced surgical interventions
• Telemedicine consult
• Prepare patient for flight

Question 12

There are no documented cases of permanent tissue damage, nerve damage or vascular injury from properly applied TQ in place for less than __ hours.

Answer 12

2 hours

Question 13

TQ conversion should not be attempted for TQ’s in place longer than __ hours unless it occurs at definitive care facility

Answer 13

6 hours

Question 14

Fluid of choice for patients in hemorrhagic shock as well the capability to provide a transfusion should be a basic capability of any clinician providing PFC.

Answer 14

Fresh whole blood

Question 15

The best fluid in prolonged field care is:

Answer 15

The one that’s available

Question 16

The goal for adequate urine output is:

Answer 16

0.5-1 mg/kg/hr

Question 17

Corrects water/electrolyte deficits due to pathologic volume loss. Usually given as continuous IV infusion (lose from burns, GI illness, head trauma, DI, shock)

Answer 17

Replacement fluid

Question 18

Given as nutrition to provide water/electrolytes lost via ongoing sweat, urination, stool output as well as glucose required mainly for brain metabolism.

Answer 18

Maintenance fluid

Question 19

Made of large molecules that attract fluid into the intravascular space from interstitial.

Answer 19

Colloids

Question 20

500ml of Hetastarch (common colloid) will give approximate equivalent volume of _______ml NS

Answer 20

2000ml NS

Question 21

Will also have longer lasting effect given only 25% of crystalloid will remain intra-vascular at one hour

Answer 21

Colloids (hetastarch)

Question 22

Initial volume expansion in hemorrhagic shock while provision of blood is being arranged

Resuscitation of perfusion to dysfunctional organs or unstable hemodynamics in non-hemorrhagic shock states

Reducing crystalloid requirements in burn patients at risk for over- resuscitation, and peripheral or abdominal compartment syndromes

Answer 22

Colloids

Question 23

Work to expand intravascular volume however only appx 25% remain within vasculature at 1 hour therefore when given as a resuscitation fluid large volume bolus are required.

Answer 23

Crystalloid

Question 24

Complications of large volume crystalloid resuscitation include:

Answer 24

Compartment syndrome

Acute respiratory distress syndrome

Dilutional coagulopathy

Acidosis

Question 25

Caution in resuscitation with crystalloids. “Unbalanced” fluid with a supra-physiologic concentration of chloride therefore can produce hyperchloremic metabolic acidosis. This can worsen inflammation and decrease kidney function

Answer 25

NS

Question 26

Fresh whole blood (FWB) is the fluid of choice for patients in hemorrhagic shock.

To mitigate risks in PFC recommendations are a MAP of ___mmhg

Answer 26

65mmHg

Question 27

If UNSTABLE with inadequate intravascular volume, resuscitate with ____ fluid.

Answer 27

Bolus

Question 28

If STABLE with adequate intravascular volume, use _______ fluid.

A general target is to achieve a urine output of at least 0.5mL/kg/hour

Answer 28

Maintenance

Question 29

Medications given which produce a diminished sensation to pain without producing a loss of consciousness

Answer 29

Analgesic

Question 30

Depression of a patient’s awareness to the environment and reduction of responsiveness. Various levels including minimal, moderate and deep.

Answer 30

Sedation

Question 31

Any procedure that involves sedation should also include monitoring the patient, ideally with:

Answer 31

End-tidal CO2

Pulse Ox

Question 32

PFC medication

Stable patients can get:

Answer 32

Morphine

Question 33

PFC medication

Hemodynamically unstable patients should get:

Answer 33

Fentanyl or ketamine

Question 34

Three ranges of ketamine

Answer 34

Effective pain range with little to no mental status effects

Mid-range; still awake however are agitated and hallucinating

Dissociated range

Question 35

What ketamine range do you want to avoid?

Answer 35

Mid-range

Question 36

Low dose pain range for ketamine

Answer 36

10-20mg IV

Question 37

Mid-range dosing for ketamine (AVOID)

Answer 37

0.3-1mg/kg IV

Question 38

High dose dissociative range for ketamine

Answer 38

2.0 mg/kg IV

Question 39

Has synergistic effect with opioids and Ketamine and can cause over- sedation, respiratory compromise and drop in BP

Answer 39

Versed