1. 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 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: ml boluses IV, NMT 1L
LR/Plasma-Lyte: ml 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 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 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 g/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 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 kg pt for >15% TBSA, add,100ml/hr for each 10 kg > 80 kg to UOP 30-50ml/hr