RESUSCITATION

Large bore IV access is one of the most critical components of initial resuscitation. With the IV stick, blood is used for Typing on an Eldon Card. All team members should be proficient in peripheral IV and IO placement. Initial resuscitation through an IO can be a bridge to IV placement. The DCR CPG algorithm should be followed for resuscitation. See the JTS Damage Control Resuscitation, 12 Jul 2019.72 Ultrasound guided peripheral IV placement is another useful option. Additionally, it is recommended to become familiar with conversion of peripheral IV catheters to Rapid Infusion Catheters (Arrow RIC®). Central line access should be considered only when peripheral IV or IO access is limited or when multiple sites for infusion are not readily available. The majority of patients can be rapidly resuscitated through large bore peripheral IV or IO access. Rapid blood typing as part of the Walking Blood Bank, blood product storage, transfusion, and efficient blood warming are essential capabilities of ARSC teams.

BURNS

Protect the airway early; early intubation is necessary in patients with >40% TBSA burns, facial burns or this there is any concern for inhalation injury. Video laryngoscopy (i.e. GlideScope®) should be heavily utilized to obtain and early definitive airway and may help diagnose inhalational injuries in patients with facial burns. Burn resuscitation should be started as early as possible using the rule of 10s. See JTS Burn Care CPG, 11 May 2016.73 The volume of IV resuscitation fluid available may be limited. Plasma may be used to supplement resuscitation fluid. Significant burns should be transferred rapidly to the next level of care. Maintain a low threshold to perform escharotomy early in the transport process, especially with circumferential full-thickness burns. Silverlon® is a lightweight burn dressing that can stay in place 3-5 days and is useful for other abrasions and shallow wounds as well. When burn dressings are not available, avoid debridement of blistered partial thickness burns and cover burns with dry sterile dressings. Maintain normothermia as burn patients are susceptible to hypothermia even in the warmest environments. Notify the USAISR Burn Center as early as possible (DSN 312-429-2876) or email: usarmy.jbsa.medcom-aisr.list.armyburncenter@health.mil.

HYPOTHERMIA

Maintenance of normothermia is crucial for survival of combat casualties. Active warming or cooling devices such as heaters or air conditioners have significant electrical power or fuel requirements and will not be available in the ARSC environment. Hypothermia management kits (HPMKs) should be frequently used, they contain chemical warming blankets that generate heat on exposure to air—these blankets should not be placed directly on the skin due to the risk of thermal burns. Hypothermia in the trauma patient is directly related to degree of blood loss. Hypothermia will continue until adequate blood volume is restored.

PEDIATRICS

ARSC teams may be required to care for pediatric patients including neonates, depending on the Medical Rules of Eligibility. This is a significant challenge for these teams; however, even though non-doctrinal, the unique mission requirements of these teams may result in them caring for pediatric patients. If this is the case, ensure age-specific medical supplies and equipment are available such as pediatric monitors, lines, tubes, and medications. While a Broselow bag may be too large to carry in this environment, they can be broken down and specific elements such as airway adjuncts and a BroselowTM tape can be carried to assist with caring for the pediatric population.

OBSTETRICS

Pregnant patients may present who meet medical rules of engagement for care. ARSC providers should be familiar with the anatomical changes that occur during pregnancy due to the gravid uterus. Ultrasound can be used to evaluate the fetus. Fetal distress is associated with a fetal heart rate of less than 100 beats per minute and is an indication of the need for continued maternal resuscitation, or even emergent fetal delivery. ARSC providers should be familiar with emergent obstetric procedures including cesarean section and surgical management of post-partum hemorrhage. ARSC providers should contact an obstetrician for guidance as able.

K9 DAMAGE CONTROL

Injured military working dogs (MWD) may require urgent surgical stabilization. The MWD CPG, 12 Dec 2018.74 outlines the unique clinical considerations for these patients. Always apply a muzzle (or improvised muzzle) early for safety. Consider having hair clippers and larger ET tubes (9-11 Fr) available for canine use as well as larger laryngoscopes (i.e. Miller blade size 4). The canine handler, unless injured, will help manage the care and will have a card with weight-based medication doses specific to their canine. Standard tourniquets may be used for severe canine limb injuries, however elastic pressure dressings are typically effective and in some cases the tourniquets may not adjust to a small enough circumference to occlude blood flow. Predeployment MWD specific medical training is strongly recommended and in currently is a CENTCOM theater requirement. New recommendation regarding the K9 WBB exist and these teams (as well as all Role 2 and Role 3) should contact a theater Veterinarian when arriving in theater. If K9 blood is held on sight, then it must be in a separate cooler and location than human blood.

VENTILATOR MANAGEMENT

All team members should be facile with the use of the particular ventilator available. Refillable oxygen storage (liquid or gas) are heavy and a challenge to maintain and refill. Portable battery powered oxygen concentrators are an option but require power for continuous use. Additional ventilator management such as setting up an oxygen reservoir for a ventilator will be addressed in a future Austere Anesthesia CPG.

IMAGING

X-ray or cross-sectional imaging may not be available in the austere environment. Portable sonography may be the only imaging tool and miniaturized devices are available. Readiness and training for this skillset are required prior to deploying to an ARSC environment. Ultrasound will provide the ability to evaluate the torso for injuries (E-FAST), guide resuscitation, guide vascular access, assess for vascular flow, and to perform regional anesthetic techniques.

EXTERNAL ELECTRICAL POWER

The ability to provide quality care will depend heavily on electrical power. Early initiation of warmed blood products and patient normothermia are vital components of a successful trauma resuscitation. Maintenance of blood refrigeration and active warming and cooling devices (e.g., heaters, air-conditioners, blood warmers, plasma thawing devices) draw significant electrical power requirements. Regular maintenance and fuel requirements for power generators must be preplanned and communicated with the ground force commander, but are ultimately the responsibility of the surgical team.

CHEMICAL, BIOLOGICAL, RADIOLOGICAL AND NUCLEAR (CBRN)

ARSC teams should be prepared to protect and decontaminate themselves and there must be a plan for the patients and incoming casualties. While ARSC teams must have a treatment plan in place should they encounter a CBRN patient, they may not be equipped to manage this patient population. It is imperative to communicate this with the Operational Command that an ARSC team is not equipped or staffed for large scale patient decontamination that care timelines will extend during a CBRN event, and triage decisions may change significantly. See table below.

Table 1: CBRN Considerations for ARSC teams