Breathing in TACEVAC Watch for tension pneumothorax as casualties with a chest wound ascend to the lower pressure at altitude. Pulse ox readings will become lower as casualty ascends unless supplemental oxygen is added. Chest tube placement may be considered if a casualty with suspected tension pneumo fails to respond to needle decompression Consider tension pneumothorax in casualties with penetrating chest injuries and progressive respiratory distress. Decompress with a needle thoracostomy. Although chest tubes may be considered by trained personnel in long or delayed evacuations, they are considerably more difficult and invasive procedures, and there is no evidence that they are more effective than needle decompression for relieving tension pneumothorax. Supplemental Oxygen in Tactical Evacuation Care Most casualties do not need supplemental oxygen, but have oxygen available and use it for: – Casualties in shock – Low oxygen sat on pulse ox – Unconscious casualties – Casualties with TBI (maintain oxygen saturation > 90%) – Chest wound casualties Oxygen should be pre-positioned on evacuation assets. Oxygen generators or concentrators are preferred over compressed gas cylinders because of the reduced explosive hazard. 5. Tranexamic Acid (TXA) If a casualty is anticipated to need significant blood transfusion (for example: presents with hemorrhagic shock, one or more major amputations, penetrating torso trauma, or evidence of severe bleeding) Administer 1 gram of tranexamic acid (TXA) in 100 cc Normal Saline or Lactated Ringer’s as soon as possible but NOT later than 3 hours after injury. Begin second infusion of 1 gm TXA after Hextend or other fluid treatment. If the casualty meets the criteria for treatment with TXA, and it has not already been given, then give the first dose in Tactical Evacuation Care. Note that TXA should not be initiated if more than three hours have passed since the casualty was injured.
Tactical Evacuation Care Guidelines 6. Traumatic Injury b. Unilateral pupillary dilation accompanied by a decreased level of consciousness may signify impending cerebral herniation; if these signs occur, take the following actions to decrease intracranial pressure: Administer 250cc of 3% or 5% hypertonic saline bolus Elevate the casualty’s head 30 degrees Continued… Read text Rising ICP may lead to cerebral herniation. When signs of herniation are present in a brain-injured casualty, rapid reduction is the ICP is needed. Hypertonic saline may help decrease ICP and improve cerebral perfusion pressure and brain tissue oxygen levels. Elevation of the casualty’s head may help reduce ICP. Tactical Evacuation Care Guidelines 6. Traumatic Brain Injury b. (Continued) 3) Hyperventilate the casualty Respiratory rate 20 Capnography should be used to maintain the end-tidal CO2 between 30-35 mmHg The highest concentration of oxygen (FIO2) possible should be used for hyperventilation Continued… Read text Hyperventilation leads to reduced levels of CO2 in the blood that, in turn, can contribute to cerebral vasoconstriction and lowered ICP. Therefore, hyperventilation can be used as a temporary measure to lower ICP in brain-injured casualties exhibiting signs of cerebral herniation. If capnography is available, it should be used to monitor end-tidal CO2 levels. The target range for CO2 is slightly lower than normal. Hyperoxia also contributes to cerebral vasoconstriction that will reduce cerebral blood flow which may help reduce elevated ICP. However, because of the increased amount of oxygen carried by the blood when hyperoxic, it will improve cerebral tissue oxygenation even while reducing cerebral blood flow. If oxygen is available, the highest concentration that can be delivered should be delivered. Tactical Evacuation Care Guidelines 6. Traumatic Brain Injury Notes: Do not hyperventilate unless signs of impending herniation are present. Casualties may be hyperventilated with oxygen using the bag-valve-mask technique. Read text The hypocarbia and cerebral vasoconstriction that result from hyperventilation may be harmful to a brain-injured casualty who is not herniating. These casualties need to maintain their cerebral perfusion. Accordingly, hyperventilation should only be used in casualties who display signs of cerebral herniation, and who need emergent reduction in ICP.
Convoy IED Scenario Recap from TFC The last medical interventions during TFC were: – Placed tourniquet on both bleeding stumps – Disarmed – Placed NPA – Established IV – Administered 1 gm TXA and I unit whole blood – IV antibiotics – Provided hypothermia prevention • Your helo has now arrived at the HLZ Read text OK – let’s go back to our scenario that we started in Care Fire. Your element was in a five-vehicle convoy moving through a small Iraqi village when a command-detonated IED exploded under the second vehicle. The person next to you sustained bilateral mid-thigh amputations. He had heavy arterial bleeding from the left stump, and the right stump was only mildly oozing blood. The care you rendered during Tactical Field Care is shown here. The time in flight to the hospital will be 30 minutes. Convoy IED Scenario What’s Next? • Casualty is now conscious but is confused • Reassess casualty for ABCs – NPA still in place – Tourniquets in place, no significant bleeding • Attach electronic monitoring to casualty – Heart rate 140; systolic BP 70 – O2 sat = 90% Read text Convoy IED Scenario What’s next? Supplemental Oxygen Why? Casualty is still in shock What’s next? Continue fluid resuscitation with plasma and RBCs in a 1:1 ratio Why? Casualty is still in shock Read text