Advanced Airway Induction TIVA Maintenance Ketamine drip (for Sedation) CRIC IS THE PREFERED DIFINITIVE AIRWAY IN A PROLONGED FIELD CARE EVENT. For SHORT TERM DIFINITIVE AIRWAY consider RSI as an alternative. Can use either PROCEDURAL SEDATION or 5cc ANESTHSEIA IN A STICK for induction. Sedation loading dose first (1 mg/kg IV/IO over 60 seconds). MIX: 750 mg (1.5 vials of 500mg/5ml) in 250 mL of normal saline (3mg/mL solution). Initial Drip Dose: Best: Using an IV pump, set to mcg/kg/min dose desired. Increase or decrease dose by 5-10 mcg/kg/min increments. Better: Using a dial flow adaptor, initial drip rate in mL/hr equals the casualty’s weight in kg divided by 2 (see table). Minimum: Count drip rate. Increase or decrease rate by 1-2 drips/min (very slowly) to achieve goal. Drip adjustments: Increase or decrease drip by 0.25 mg/kg/hr (1 row) Procedural Sedation 5cc Anesthesia in a Stick Step 1: Bolus (1.0-2.0 mg/kg) 80-160 mg ketamine IV/IO over 60 second (250-400 mg IM if necessary). Step 2: Consider adding (start low, give more): 25-100 mcg fentanyl IV/IO 1-4 mg midazolam IV/IO Step 3: May need to repeat doses as below if procedure lasts more than 10-15 min. Ketamine every 10-15 min Fentanyl every 15-30 min Midazolam every 30-60 min 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) Ketamine Drip Rate Chart for Sedation Ketamine drip rate for dial flow or IV pump (starting dose highlighted) Dose 40 kg 60 kg 80 kg 100 kg 0.5 mg/kg/hr 8 mcg/kg/min 7 ml/hr* 10 ml/hr 13 ml/hr 17 ml/hr 0.75 mg/kg/hr 13 mcg/kg/min 15 ml/hr 20 ml/hr 25 ml/hr 1.0 mg/kg/hr 17 mcg/kg/min 27 ml/hr 33 ml/hr 1.25 mg/kg/hr 21 mcg/kg/min 34 ml/hr 42 ml/hr 1.5 mg/kg/hr 25 mcg/kg/min 30 ml/hr 40 ml/hr 50 ml/hr 1.75 mg/kg/hr 29 mcg/kg/min 24 ml/hr 35 ml/hr 47 ml/hr 59 ml/hr 2.0 mg/kg/hr 33 mcg/kg/min 53 ml/hr 67 ml/hr *dial flow adaptor not accurate for rate < 10 ml/hr, use drip count Ketamine drip count for 15 drips/mL tubing (starting dose highlighted) 0.5 mg/kg/hr 1/35 sec 1/24 sec 1/18 sec 1/9 sec 1/27 sec 1/14 sec 1/8 sec 1.0 mg/kg/hr 1/12 sec 1/7 sec 1/15 sec 1/10 sec 1/6 sec 1.5 mg/kg/hr 1/5 sec 1/11 sec 2.0 mg/kg/hr 1/4 sec Add 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. Maintain MAP >55mmHg to ensure proper end organ perfusion. Local / Regional Anesthesia Lido 1% 10mg/ml, Max-300mg(30ml), Lido 2% 20mg/ml, Max-300mg(15ml), 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 Ref: TCCC (June 2016); JTC Clinical Practice Guidelines; Management of Analgesia and Sedation during Prolonged Field Care (Jeremy Pamplin, MD, et al.); Emergency War Surgery Manual (3rd US Revision)

Hemorrhage Management Analgesia on the Battlefield Seizures / Anxiety Crush Injury - IAW CPG Tranexamic acid: Give ASAP: <3hrs post injury if significant blood loss anticipated. TXA (1gm) in 100cc NS or LR, given over 10min. -Begin 2nd infusion of TXA if pt continues to show signs of ongoing hemorrhage. Infuse over 8 hrs after Hextend or other fluid treatment. 250ml / 10min = 25ml / min. 10gtt/ml = 4gtt / sec 15gtt/ml = 6gg / sec 20gtt/ml = 8gtt / sec 100ml / 10min = 10ml / min. 10gtt/ml = 1.6gtt / sec 15gtt/ml = 2.5gtt / sec 20gtt/ml = 3gtt / sec 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. 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 Apply 2x tourniquets side by side and proximal to the injury before extrication. Start IV/IO Crystalloids administration IMMEDIATELY (before extrication). Initial bolus, 2L; initial rate: 1L/h, adjust to urine output (UOP) goal of >100–200mL/h. Monitor UOP for myoglobinuria (red, brown, or black), cont. IV/IO fluids until clear UOP. Record vitals q15min for signs of cardiac arrhythmias, for 1-2h or until clear UOP. Treat for Hyperkalemia if signs of cardia arrhythmias present: Administer 10 mL (10%) Calcium Gluconate or Calcium Chloride IV over 2–3 minutes, q30-60mins. + Insulin (regular) 10 units IV push + 50mL D50 Albuterol (2.5mg/3mL vial), 10mg in nebulizer. Kayexalate 15-30g, mixed in 50-100ml liquid, taken oral/rectal. 250 ML / 10 MINS 10gtt/ml Drip Set: 4gtt/sec 15gtt/ml Drip Set: 6gtt/sec 20gtt/ml Drip Set: 8gtt/sec 100 ML / 10 MINS 1.6gtt/sec 2.5gtt/sec 3gtt/sec Benzo Reversal Agent Fluid Resuscitation 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. 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. Opioid Reversal Agent Naloxone 0.4mg IM/IN/IV for Opioids. Head Injury - IAW CPG GCS, V/S, CN, periph nerve exam, MACE Supplemental O2- SpO2>90% Steroids should be avoided . Maint. systolic PB >90mmHg. Intracranial Hypertension: 3% Hypertonic Saline 250ml bolus. then infuse at 50-100ml/hr. Elevate the casualties head 30 degrees Hyperventilate 1 breath q. 3 sec during HTS admin. Mannitol- if hypertonic not available. 1g/kg bolus IV followed by 0.25g/kg IV push q4 hrs. Avoid Mannitol in hypotensive pt. Burns Management – IAW CPG Infection Prevention – IAW CPG Dry sterile dressing. Consider Hypothermia Prevention Kit. Secure advanced airway if: comatose patient, symptomatic inhalation injury, deep facial burns, and burns over 40% Total Body Surface Area. Calculate TBSA, if >20% start fluid resuscitation for 24-48h. Rule of Tens: 10ml/hr x TBSA for 40-80 kg pt. For all pts. >80kg, add 100ml/hr for each 10 kg >80 kg. Place foley. Monitor UOP to achieve 30-50ml/hr. Increase/decrease fluid rate by 20-25%/hr to achieve 30-50ml/h UOP. AVOID over-resuscitation, may contribute to edema and respiratory distress. Combat wounds / Point of Injury: Moxifloxacin 400mg PO. If penetrating abdominal injury, shock, or unable to tolerate PO Ertapenem 1g IV/IM. Combat wound / Clinical Care: Cefazolin, 2 gm IV q6-8h OR Clindamycin 600 mg IV q8h . + Metronidazole 500mg IV q8-12 when injury includes: Penetrating abdominal injury w/ suspected/known hollow viscus injury and soilage. Penetrating brain/spinal cord injury. Eye injury, burn or abrasion: Topical Erythromycin or Bacitracin ophthalmic ointment QID. Eye injury, penetrating: NO TOPICAL, Levofloxacin 500 mg IV/PO qDay. Penetrating Eye Injury Anti-emetic SHIELD AND SHIP Rapid visual acuity. Fox / rigid eye shield. Moxifloxacin 400mg PO or Alt 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