5cc Anesthesia in a Stick Golden Hour TIVA Maintenance drip Tranexamic Acid (TXA) 5cc Anesthesia in a Stick Golden Hour TIVA Maintenance drip Analgesia on the Battlefield 5ML Syringe, 20gu 1.5” needle, Atomizer Mix- Ketamine 50mg/ml (3ml or 150mg) Midazolam 5mg/ml (1ml or 5mg) Fentanyl 50mcg/ml (1ml or 50mcg) Each ml provides- Ketamine 30mg, Midazolam 1mg, Fentanyl 10mcg Sedation- IM/IV/IN- 2ml initial, titrate to nystagmus then 1ml PRN (Consider doubling dose for IM route) Induction for RSI- 5ml syringe then add Paralytic 50 cc Bag of 0.9% NS and + 60 gtt set Mix in- 5cc Anesthesia in a Stick- Ketamine 50mg/ml (3ml or 150mg) Midazolam 5mg/ml (1ml or 5mg) Fentanyl 50mcg/ml (1ml or 50mcg) Infuse at 0.1 to 0.5ml/kg/h Mix- TXA (1gm) in 100cc NS or LR -Give ASAP: <3hrs post injury if significant blood loss anticipated. Give 1stgm over 10min -Begin 2nd infusion of TXA infused over 8 hrs after Hextend or other fluid treatment Mild to Moderate Pain- Casualty is still able to fight - TCCC Combat pill pack - Tylenol 650mg bilayer, 2 PO q 8 hrs - Meloxicam 15mg PO q.d. Moderate to Severe Pain- w/o hemorrhagic shock or resp. distress -Oral transmucosal Fentanyl citrate (OTFC) 800mcg, or IV Morphine 5mg IV/IO Moderate to Severe Pain- Unstable- - Ketamine 50mg IM/IN, or - Ketamine 20mg slow IV/IO Repeat q. 20-30 min Check AVPU and monitor ABC’s End Point is control of pain or development of nystagmus. 5 Hour TIVA Maintenance Drip Fluid Resuscitation 250 cc Bag of 0.9% NS + 60 gtt Mix in- Ketamine 50mg/ml (15ml or 750mg) Midazolam 5mg/ml (5ml or 25mg) Fentanyl 50mcg/ml (5ml or 250mcg) Infuse at 0.1 to 0.5ml/kg/h (if Vecuronium is added to maintenance bag, STOP 15min prior to end of surgery) If in hemorrhagic shock- -Most to least preferred- Whole blood, plasma/RBCs/platelets 1:1:1, plasma/RBCs 1:1, reconstituted dried plasma or liquid plasma or thawed plasma or RBCs alone -Using the ABC score, if massive transfusion indicated, initiate FDP while drawing FWB. -If blood products are not available: -Hextend: 100 - 250ml boluses IV, NMT 1L LR/Plasma-Lyte: 250 - 500ml boluses IV, NMT 2L -Re-assess VS q 3 to 5 min Uncontrolled Hemorrhage: Resusc. until: MAP ~65 (palpable radial pulses with good perfusion [warm hands, feet, CR < 2sec, UOP > 0.5cc/kg/hr, increased mental status] Controlled Hemorrhage: -Resusc. to normal physiology Teleconsult ASAP -For CHI, keep SBP >=90mmHg) - Re-assess frequently to check for re-occurrence of shock. If shock recurs, repeat the fluid resuscitation as outlined above. Paralytic (to complete RSI) Vecuronium 10mg/ml (1ml) IV Rapid Sequence Intubation—6 Steps 1. Pre-oxygenate with 100% Oxygen by mask. 2. Induction agent: 5cc Syringe with Ketamine 50mg/ml (3ml or 150mg) Midazolam 5mg/ml (1ml or 5mg) Fentanyl 50mcg/ml (1ml or 50mcg) 3. Muscle relaxant: Entire Vial- Vecuronium 10mg/ml IV 0.1mg/kg, with an onset of 2-3 min and duration of 30-40 min 4. Cricoid pressure (maintain until ETT placement is confirmed). 5. Laryngoscopy and orotracheal intubation (after 2 min). 6. Verify tube placement. Consider nasogastric or orogastric tube placement after securing airway. Opioid Reversal Agent Naloxone 0.4mg IM/IN/IV for Opioids Benzodiazepine/ Anxiolytic Diazepam 10mg/2ml Dose 2-20 mg IM/IV Moderate Anxiety -2-5mg IV/IM, 2-4 times daily Severe Anxiety/ Muscle Spasm/ Seizures -5-10 mg IM/IV Repeat in 3-4 hrs PRN Midazolam 5mg/ml Seizures lasting > 5-10 min -5-10 mg initially IV>IM repeated q. 10-15 min PRN to Max of 30mg Head Injury GCS, V/S, CN, periph nerve exam, MACE Supplemental O2- SpO2>90% 3% Hypertonic Saline 250ml over 10 min then 50ml/hr Elevate the casualties head 30 degrees Hypervent 1 breath q. 3 sec during HTS admin Mannitol- if hypertonic not available or used 0.25-1g/kg over<20 min then, 0.25g/kg q. 6 hrs Local/ Regional Anesthesia Lido 1% 10mg/ml, Max-300mg(30ml), Lido 2% 20mg/ml, Max-300mg(30ml), Marcaine 0.25% Max-150mg (60ml), Kenalog 40mg/m (duration of action 2-3 weeks) Joint injections- Lido+Marcaine+Kenalog40mg/ml- amount is joint dependent Regional- Superficial cervical plexus block/ Axillary brachial plexus block/ Intravenous RA / Wrist block/ Digital nerve block/ Intercostal nerve block/ Saphenous nerve block/ Ankle block/ Femoral nerve block *Consult Ortho Surgeon before use Penetrating Eye Injury Benzo Reversal Agent Rapid visual acuity Fox/ rigid eye shield Moxifloxacin 400mg PO or Alt Flumazenil 0.5mg/5ml 0.2 mg over 15-30 sec then q. 1 min up to 1mg max Consider BVM assisted respirations for Midazolam OD; wears off in ~ <30 min Anti-emetic Antibiotics Ondansetron 4mg ODT/IV/IO/IM q. 8 hrs PRN for NV - each 8-hr dose can be repeated in 15 min if nausea not improved. - DO NOT give >8mg q. 8 hr Recommended for all combat wounds-- Moxifloxacin 400mg PO q.d. If unable to take PO- Ertapenem 1g IV/IM q.d. Burns Dry sterile dressing, consider Hypothermia Prevention Kit Rule of Tens- 10ml/hr x TBSA for 40-80 kg pt for >15% TBSA, add,100ml/hr for each 10 kg > 80 kg to UOP 30-50ml/hr