DTIC ADA543729: Journal of Special Operations Medicine, Training Supplement. Winter 2011

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1. REPORT DATE 3. DATES COVERED
2011 2. REPORT TYPE 00-00-2011 to 00-00-2011
4. TITLE AND SUBTITLE 5a. CONTRACT NUMBER
Journal of Special Operation Medicine. Training Supplement to Winter
5b. GRANT NUMBER
11. USSOCOM Medic Certification Program
5c. PROGRAM ELEMENT NUMBER
6. AUTHOR(S) 5d. PROJECT NUMBER
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5f. WORK UNIT NUMBER
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United States Special Operations Command ,7701 Tampa Point REPORT NUMBER
Boulevard ,MacDill AFB,FL,33621
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a. REPORT b. ABSTRACT c. THIS PAGE Same as 176
unclassified unclassified unclassified Report (SAR)
Standard Form 298 (Rev. 8-98)
Prescribed by ANSI Std Z39-18
INTRODUCTION
This is the 5th version of the JSOM training supplement. The
guidelines contained in this supplement are reviewed and compiled annu-
ally by a combined group of SOF physicians, ATPs, SOF medical person-
nel from all of the SOCOM component branches, and civilian medical
personnel. The Tactical Medical Emergency Protocols (TMEPS)and Rec-
ommended Drug List (RDL)were created, reviewed, and approved for use
by the Advanced Tactical Practitioner (ATP).
We can also send any of these products to you as a PDF file. Just
request whatever you want via an email to: [email protected]. Please send us
CONSTRUCTIVE comments and recommendations as well. We are al-
ways looking for a good idea or a better way to ensure you have the latest
greatest of information.
LTC Doug McDowell
USSOCOM Chief of Medical Education and Training
Journal of Special Operations Medicine / Training Supplement
NOTES:
Winter2011TMEPS
u.s. SPECIAL OPERATIONS COMMAND
TACTICAL TRAUMA PROTOCOLS ("P)
TACT1CAL MED1C,6.l EMERGENCY PROTOCOLS
RECOMMENDED DRUG LIST
For SPECIAL OPERATIONS ADVANCED TACT1C,6.l PRACT1TIONERS (ATPs)
JANUARY 10, 2011
USSOCOM OFFICE OF THE COMMAND SURGEON
DEPARTMENT OF EMERGENCY MEDICAL SERVICES AND PUaLIC HEALTH
nOl Tampa Point Boulevard
MacOtit Air FOf"C4I a .... , FL 33621
[phone]
Copyright ~2011
JournalofSpecialOperationsMedicine/TrainingSupplement
TABLE OF CONTENTS
SECTION 1: TACTICAL TRAUMA PROTOCOLS (TIPs)
,
TactlcalT'Buma P'otocols· _____________________ ,
,
Care Under Fire
Tactical Field Care:::c::::----------------- •
E.tanded Tactical Field Care
TACEVAC---------------------------------- "
Crush Svndrome "
F ...c lotomv-C-:-C-C,-:--:--::::::---------------- "
Mlid TrJumalic BrJln Injury (mTBII "
MACE~--------~C--C----------------------­ "
Procedural Analgnl. . "
SECTION 2: TACTICAL MEDICAL EMERGENCY PROTOCOLS (TMEPs)
Tactical Medical Emergancv Protocol& (TMEPS) 25
Prelace and Change& 26
Cllnkal Peans 2B
Abdominal Pain 29
AtllIcn& 39
Alle'glc Rhinitis' Hay Fever! Cold-like Symptoms :J.O
Allilude IlInen· 31
Anaphylactic Reaction 33
Asthma (Reactive Airway Dluue) 34
Back PII" 35
hrot/auma 36
Bellavlo,al Cha"ge. (Includes Psychosis. Depression, Sukidallmpulsn) 31
Bla.t Injury s.e Tectical Trauma Protocols
Bronchitis/ PnltUmonia ]8
CeliulltislAbsf;IIu 39
CheSlP,,]n ~
Cold Injury 42
Constlpationl Fecallmpac!lon 44
Contaci Dermatitis 45
Corneal AbrulonJ Corneal Ulcer! Conjunctivitis 46
Cough U
Crusll Syndrome See Taclical Trauma Protocols
Deep Venous Thrombosis (DVT) 43
Dehydration 49
Dental Pain SO
eet.rmlnatlon of Death/Dlsconllnulng Rftulcllalion 5'
Ear InfeC1lon (Includes OUli. Media and Olilis E~te'"'J 52
E,wenomitlon 53
Snakas 53
Marine 54
Insects I Anhropodl 55
Scorpion 56
Eplltull sa
Flank Pain (InclU<les Renal Colic, PyelonephrttJl. Kidney Stonn) 59
Fungal Skin Infecllon 60
GUlroenterlli. 61
Hudache 52
Head lII"d Neck Infection (lncludH Epiglottitis and Perilonsi!l<lr Abscess) 63
Heallllnns 64
HlV Post E.posure Prophylul. 65
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Ingrown T""n311 ____________________
"
Jolnll"fection
1(·9 Evaluation and Trealm.nl------------------- "
K·~ Heal Injuries "
1(·9 High Altitude Sickness and Pulmonary Edema ____________ "
1(·9 Trnum~ Manag"",""" "
1(·9 C-<llngeStlon------------------------ n
M:ldney Slone - See Fl,ok Pain "
Lon of Consciousness (wltholll Selzu,,:ts) "
MACE SO" Tactical Trauma Protocols
Malaria "
Menlnglll$" "
Nil,,"' .nd Vomiting --,-,------------------- "
Otitis blama -See Ear Infection "
Otitis Media - Se" Ear Infection ____________________ "
Pain Mllnall"",ent .".
Pneumonia _ $e-Bronchitis ____________________
"
PneumOlhoru, Acutll (AtfllumaUcj "
Pulmonary Embolus - See Chest Pain ----------______ ..
Pyeionephrlll5 -See Flank Pain "
Rima! Colic _ See Flank Pain·· .".
Rhabdomyolysls
Seizure --'--'--::-,------------------------ .".
Sep.lsl Sapllc Sho"_ ____________________ ..
Smoke InhalatlonC- "
Subungual Hematoma ..
TesticL>lar Pain
Traumall" Brain Injury _ Mild (mTBI] 541. Tactical Trauma Protocols
Urinal)! TnlCllnlKllon
SECTION 3:
Recommended O'''g LIB' (ROL) ____________________ ··92
SECTION of:
TaClleal Medical Planning ,nd OperaIlD'" (P50) ------------ '"
SECTION 5:
Bum Quick Refe.ence Guide ____________________
SECTION 6_: __________________________. ..
Ne~.Ch.rt '"
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USSOCOM Tactical Trauma Protocols
Oecember2010
Basic Management Plan for Care Under Fire
1, Retum fife and lake cover.
2. Direct or e~ped casualty to ",,"sin engaged as a ~batant if ablo:!.
3. Olrsct ca&UeKy 10 mewato cover and apply HII·aid If able.
4. Try 10 ~eep the casualty from suslafning &dditior.al wounds.
5. Slop lifa..ti1(f!otening IIII1f11Tlol halllOlfhaga Wt actically faaslble.
a. 0lr8CI casualty to controlllemorrtlBgf! by seW·aid if able.
b. Forllernont\agt! anatomicalty amenable to tourniquet application. U!III a CoTCCC
recommended tourniquel over the uniform proximal 10 the bleeding s~e and move \he
casualty 10 cover.
Basic Management Plan for Tactical Field Care
1. Immediately remove and ISndar lafe the weapons of any casualties with altared meolal statui.
2, If!r1j..nes requiring urgent transport are !dentiliad. requesl casualty evacuation assets as soon as
tile tactical situation pem1itl. Minimizing the time to surgical carals critical 10 lu"';yal for serious
combillll1juries.
3. ThIr acronym MARCH is recommen<l8d to guide the priorities fn the Care Under Fire (CO<lltoi 01'
IWa-threatening hemoohage only) and Tsctlcal Flek:! Care phases:
a. MIISSMt hemootlage - conlrOllife·lIlreatenlng bleeding.
b, AJrway - establish and maintain a patanl airway.
0::. Respiration _ decompress suspected lension pneumothorax. !IIIat open cheIIt wounds. and
&Uppor1 ~eotilat'onlcn,yg.enatlon as required.
d. Cln:Ulalion - IISlabifsh Ivno access and adminis. ... fluids as required 10 \real sI-,ock.
a. Head Injury I Hypo!hermlB - pl'8'lentltreal hypolBnsiol1 af'd hypo>cla to prevenl WOfMnlng 01
traumatic bI;Iin injury and pmvenlltraat hypolhennlB.
4. !Vrwly managem&nt:
a. Consdous CBSuallies:
I. AtIoW conscious casuanln with Impending eirwa, obSlruction 10 assume any posltlon!hat
besl prtltects the airway all<! permits se~o<XIntmj of secrtllions (indudjng sitting up).
I. Chin 1111 or jaw thrust mal'l8ll'lM
iii. Nascpharyngeal airway
b. Uooonsclous casualties:
r. Chin HII or jaw thrust maneuver
iI. Nasopharyngeal airway
iii. Pbw;e unoonscious casually Into recovBry posilion. Preted s;1ine In bIOi'll and ~a$1
trauma .,atienls.
c. If preceding me81Uf88 are unsuccessful and airway prtll8Clion Is lequired:
I. Normal anatomy. Consider supraglottic a'i-way de\iicll or endotracheal intubation.
i.. Abnormal anatomy: Surgical <ri;nIhymidotomy (with IKIocafne ~ conscic>us).
iii. Us, !he dellnili"" airway with which yoo are /11051 BlCperienced to Increase likeUhood of
success.
d. Failed airway: Surgical cricoth)Toidotomy arnl/or other r"!!CUII airway procedure.
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e. Verity OOfrect airway placement ar>d patency.
I. Coofirmalion with an 8ndotract\eal tube inlfOducer (bougie).
l SeK.,nflating bulb syringe (e.g., EIO~eallntubalion Detector).
iii, Cok>rimetnc. end tidal C02 dele<;fOr.
iv. End IKiaI C02 mooito+".
v. 00 001 rely 00 auscultaOon PI' "lSual misting !rr the ET lube to confrrm pj.acement
00 001 rel~ on the GIIsualty 10 breathe Independently through It>e aifway ~ .... ice. Support
ventilation using a tIag ~'(Y8 mask (BVM) de\l1ce. Au10matic Ye<ltilation dG'lices ere en
acceptable aHemalM! ~ avaliabIB.
5. Brealhing:
a. Coosid .... a tension pneum<.>ll!omx In an)' r.asuaKy with respiralory dis\reli.S PI' hypotension
Boa koown PI' suspected lorso Irauma.
I, FO( suspected tension prreumolhoru, decomPl'ess the chest on the sideo/ the1nJury with
a 14--gauge. l.25lnc:h r>IIedIeJCMhet&r un~ ,nserted inlo the second intM:oStalspuca at
!he mrd-davlCUlar Nne.
(a) Ensure lllat needle entry into the chest is not mad"'lto the nipple line.
(OJ E"sure!le8'l~ 1$ not ~ted towaros me tleart
(cj RerTlOYe needle end leave catheter in place.
l If unable t<I penetrate tile antoriorchetot WIP w~h Ihe needle. consider tile ,,"' or 5'"
fnl. .r eo.slal .pace 01 tIlo antenor a.Ulary l'n9 00 tile attocled side as an allemate
decom~ion ,~e.
11/. Repeat deoomprassioll as IeQUlted fO+" W(lJ1.8J"Iing PI' racoo!og symptomsls!gn.
ill Consider ImaN QaU{llllhomoo~lOmy device or chesl lube Wo eeole decompression is'
unsuccessful alter two attempts at each,slte.
b. T",81 B~ opf,!n an!lfor sucking chest wounds by Immoolalely applyong an occIus,ve maleriollo
cover the deleel and HCUring It In pliJCe. Closely monJtor lila casually lor tho! POlential
dew!!opment 01 a subMqu,,", lon.ion pne<lmolhorax.
6. Bleeding;'
a. A&o6S11 for un"""'llnized tIomorThagtlllnd IlOI1trol aH S""1'C8S 01 b4e<lding. If notalreJJ(!~
dOne. usa • CoT CCC recommenoed toum;quet 10 conltcllrtMhre8\e<ling ex'emal
IIemorrllage in 8nBlomocall~ amenable S;18S '" for ooy trnuma~c af1.IpUlaIlOfl.
b. FO( signil"ocant 8xle"'oll1em~ nol amenable to toorniQuet application, usa an epproved
hernQSt8tie llgent with iI pre.sura dressing
C. Reassess priol t<lurnJquel appjicabon.
Ilir"tialloumiquet1s Over un,form and J1O\ functioning pJOp6Ily, apply .. sec:onfI toumiquel
dlreclfy 10 s~in pJ'Olljrnallo Iha origInal ene.
It Tigh'"" loumOquet until distal puiS<! is absent
iii. Add -another toum<Qu01 PfOxrmall~ ~ one tourn,quet 00 $Ie", cIo<!s nol control b!eed;og.
Iv Expose and clearly mllr~ 1111 tourniquet sites with tile lime o/appliciltlon USIflll an lJ>delible
maIlee,
v. tf other \ed1ruqoos (e.g.: hemoslaticPl' pressure dmsshg);I(e adequ~le 10 control
llII.!ed(ng. r. .m ove pre"iou51~ apploed !ournOqu8ts. Tnep is to remove tourniquels
"";11><" 2 hoors ~ OO$siblo.
d. Apply peIvfC D>ncJef fOl treatment of $U$peeled pe{vlc If3oCtJJre.
7. Vnclllor eoc<l;SS:
a. SIM an 18-gauge IV or satine lOck ifindlcaled.
b n msu$Citatlon b reQuil"1Kland IV access b unol>lainable. use the I"trn""soou, (10) leule
8. Fluid resuseltatlo,,:
a Assess 10< hemorrhagoc,hOd< Altered mentat SJatu, (fn the absence oIlIead injury) and
"",a~ or 8bsani periphofal PlJI&es lire the besl field IodrcaloJS IPI' sl>ocO.,
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b. If not in &hock:
L No IViID nuids required.
~. PO fluids permissible If !he Cilsualt~ is COIlscious and abla to swallow.
c. II In shock:
L InltTale IV~O He><lend aod titrate 10 effect.
(II) 10 !he absenca of traumatlc brain Injury (TBI), use noonull!lfll1ta1 statu!! as end point
lor resuscila\loo.
(b) In lhe presance trnumalic bra.in Injury (TBI), use reslorntico 01 radial po~ or SBP"
90 mm Hg 85 end point for resuscitalion.
H. 1"lIlata resuscitatiorl With 2 units 01 plasma II blood com~ts a(9l1vaDa~e. Continue
nt9<lscitation with Packed Red Blood Cells and pla8/l18 in B 1,1 ratio as required.
lv, Fresh whole blood may be used if componool therapy iii notavallable.
v. In the almlnceof blood products. use Hextand
Yl. In the absence of blood prodllCls and He~lend. use ayslalloid.
d, Continued resUllcilalion efforts must be weighed agaln&! Ioglstic:al and tactical considerations
and \I>e risk 01 incurring further ca5UIIll>es. The goal of contlnued resusdtalion is !he
restoration of noonal l'italllgns In the sailing 01 controlled hemontlage.
9. Head InJUI'} management:
e. KeV aspeCIS of field msnagemltflt 01 severe TBI are the pnlven\iOn of h\'PO~la and
hypotension, Ensure alll1y establl$hmenl 01 II dllflnlliw airway, aggressively Imat ,esplllltory
compromise, admlnlster oxygen if available (10 maintain satura110n " 95%), aod nuk!
resuscitate h)'pOleosion.
b. Routine hype<V8lltila\lOn Is NOT reoommeoded.
c. Controlled hype<VtH1Wation may be considIHad 85 a temporizing moaSlfte lor evidence or
Increeslr.g InllllCnlnlal PflIs:wre (ICP) and herniation (e.g., deteriorating mental statUI.
unequal pupi15, pasturing, and irregular respiratory pattem).
t, 1\ end tid.1 COl monitor is lIYa~able. venblale to ad!Ieve pCOlol 3OmmHg.
ii. II end tidal CO:!. monitor .. not a.a~able ...... ntilet. at a rat. ollO pet minute and" tidal
volume or approximatefy 500m1.
d. Hypertonic nr.ne (3%) for evidence oIJncreased ICP:
I. 1soIal8d TBI (hemodynamic8l1~ stable) - adminIster 3% HS 500mIIVIlO.
il. TBI w~ controlled 8lO;temai MmOI'I'h8{/8 -administer 3% HS SOOmIIVIIO plus
He.tend/other ftuld5 as per Be (shock) if ,equinK!
e. Seizure J>I"OPhyiaxis for penetrating head tra-umaldepressed skull fractufes:
I, =:,nytoin (Cereb~J 18mg/lcg IV~O al tOO-t5Omglm1n (sklw IVPj irav.llable.
&:
00 not administer In ter than l5Om1llmin sInce this ma~ ..a ult In
hypotenllon.
H. Repllatl00mg IVIIO Q8H lor maintenance.
I. SeizLl/"fl mllllHll"""'"t:
L OOazepam (Vlllium«l) S-tOmg Iv/IO q 5 min to maximum do5II ollOmg.
l OR Mldamlam (Ver!li8d®) 5mIlIVIlO q 5 min (no maximum dose).
1If, Moottor casualty closely lor apnea when admlnlatertr.g benzodfaz8p1nes.
IV. Fosphenytoln (Ce ..b ~) 18mgJkg IViIO al l00-15Omg/mln (a","" IVP) ifavailable for
seizures refractory to benzodiazeplnM.
III:
00 not administer laster thin 150mglmln since this mly result In
hypotenSion.
g. If cerebrospfnlll ftuld (CSF) Is identified leaklnll trom the ears and/or nose, elavate the head
30-60 deg'8e9 11 tha calua~y's Othllf injurles perm~ and \lie casuatty is hemodynamically
stable.
h. 1\ the casually e.hib~s signs or InCfeased ICP and is hemod)'ll8mic:aHy stable, conlicler
t.ll.e.v.;lti ng !he h8ad l(}"30 degrees to Impro. .... 1'8I1<IU& outfloW !rom the brain and decrease
ICP. 00 not tllevate the head or a h)'lXWOlemk; casually B1nce this win reduce cerebrnl bir.>od
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