- 1) Nasogastric or orogastric tube (NG/OGT) should be placed early for gastrointestinal decompression. If medical evacuation is significantly delayed (greater than 24-48 hours), consider starting enteral nutrition.
- 2) Enteral nutrition is contraindicated in hemodynamically unstable patients (i.e. those on high or increasing doses of vasopressors). Low volume tube feeding on patients with stable low doses of vasopressors is generally safe.
- 3) At a minimum, confirm position of gastric tube placement with auscultation over both lung fields and the abdomen along with aspiration of gastric contents. Urinalysis test strips for pH may provide an addition method for NG/OGT placement confirmation in patients not on acid suppressive therapy.
- 4) Goal 25-30 kcal/kg/day + 1-1.2 gm/kg protein; however, this might be difficult, especially in the absence of formal concentrated tube feeds.
- 5) Meal supplement drinks are not sufficient. For example, one Muscle Milk Light bottle contains only 150 kcal and 28 gm protein in 500 mL, which is extremely dilute compared to most tube feeding formulations. This potentially increase extra-vascular lung water (especially in the setting of critical illness) with minimal benefit to nutritional status.
- 6) A more concentrated alternative is to use commercially available protein powder (with similar caloric/protein content per scoop) at 1/4 the recommended concentration and mix in a blender until no clumps are visible. Administer in small volume boluses (e.g., 60mL via Toomey syringe) as tolerated every 2 to 4 hours to a goal of 1 gm/kg/day protein content.
- 7) Further recommendations for enteral nutrition can be found in JTS CPG for Nutritional Support Using Enteral and Parenteral Methods.
- 8) If possible, blood sugar checks should be obtained at least every 6 hours, particularly for those with known diabetes mellitus.
- 9) Venous Thromboembolism (VTE) prophylaxis should be given as long as there are no contraindications. Patients with COVID have demonstrated and increase risk of the formation of thrombus formation, therefore it is recommended to administer Lovenox 30 mg SQ twice daily (avoid if evidence of renal failure) or 7,500 units heparin SQ every 8 hours.
- 10) If pharmacologic prophylaxis is not available, manual ankle plantar/dorsi-flexion range of motion exercises and lower extremity massage every two hours. Consider applying compression stockings if available. DO NOT use ACE wraps.
- 11) Stress-Ulcer Prophylaxis should be given to all intubated patients as long as there are no contraindications. Famotidine 20 mg IV every 12 hours or 20 mg via NG/OGT twice daily, or consider and a proton pump inhibitor, if available (i.e. pantoprazole 40 mg IV daily or omeprazole via NG/OGT daily).
- 12) Ventilator Associated Pneumonia prevention bundle applied to the limitations of an austere environment includes:
  - Head-of-bed elevation to 30 degrees
  - Suction the oropharynx as needed
  - Brush teeth every 12 hours, ideally with commercially prepared Chlorhexidine oral care if available.
- 13) The JTS CPG for Nursing Interventions in Prolonged Field Care provides in-depth discussion of the nursing tasks that may be required if medical evacuation is significantly delayed.