CONSIDERATIONS FOR PROLONGED FIELD CARE

Prolonged field care builds upon the Joint baseline interoperability medical standards listed within the PCC guidelines for advanced trained medical personnel. The following recommendations are intended to assist advanced trained medical personnel with the continuation of more advanced procedures.

SUCTION ADVANCED AIRWAY

Perform advanced airway suction only when needed (e.g., copious secretions, colored secretions, change in oxygenation status, suspected mucus plug). Use sterile technique for advanced airways (e.g., endotracheal tubes) or clean technique for the mouth and throat.

- Minimum: Manual suction device or improvised suction device, such as a 25cm length portion of IV tubing connected to a 60mL syringe
- Better: Open suction tube, suction machine
- Best: Closed inline suction tube, suction machine

Guide for advanced airway suctioning

- Gather necessary equipment.
- Ensure casualty’s head is elevated.
- Perform hand hygiene.
- Place a clean towel under casualty’s chin.
- Don additional PPE based on the casualty’s need for isolation precautions or risk of exposure to bodily fluids.
- Determine the appropriate depth to advance the suction catheter. (Generally, this is the total length of the artificial airway and the adapter.)
- If indicated based on casualty tolerance to procedure, increase Fi02 to 100% for 30 to 60 seconds.
- Insert the suction catheter to the appropriate depth, ensuring that the tip of the catheter does not touch nonsterile surfaces.
- Do not suction while advancing the catheter. Ensure suctioning is performed while withdrawing the catheter for no longer than 15 seconds at a time.
- Allow at least 30 seconds before repeating suctioning, if needed.

FOLEY CATHETER CARE

If possible, remove the catheter. Consider use of a condom catheter (for males) or urinary wicking device (for females).

*External (non-indwelling) catheters may not effectively collect output, since they do not necessarily empty the bladder immediately. Therefore, output measurements may be falsely low if using an external-collection catheter to measure active resuscitation efforts.*

Catheter care should be performed as a part of daily bathing routine, after bowel incontinence, and if secretions build up around the urinary meatus. It should be completed at least every 24 hours. This helps to reduce the risk of catheter-associated urinary tract infection. The drainage bag should be emptied every 24 hours or whenever the main chamber becomes full. A securement device included in the foley bag kit or tape should be used to secure the tubing to the casualty’s thigh to prevent the foley from being accidentally removed if pulled.

Use a basin, warm water, non-irritating soap, and towels to perform catheter every 24 hours.

Guide for performing catheter care:

- Wash hands thoroughly with soap and water, apply gloves, and place a dry towel under the casualty.
- Using mild soap and water, clean genital area.
- For male casualties: retract the foreskin, if needed, and clean the area, including the penis.
- For female casualties: separate the labia and clean the area from front to back.
- Clean urethra (urinary opening), where the catheter enters the body.
- Clean the catheter from where it enters the body and then down, away from urethra. Hold the catheter at the point it enters the casualty so that tension is not placed on it.
- Rinse the area well, dry gently, and remove the towel under the casualty.
- Secure the drainage bag and tubing loop below the level of the bladder. Ensure the tubing is not kinked and nothing is impeding the flow of urine.
- Empty the contents of the drainage bag at least every 24 hours and document the amount of urine output each time.

NUTRITION FOR INTUBATED CASUALTIES

Casualties who are intubated and/or sedated and held at the Role 1 for up to 48-72 hours should receive a feeding tube (nasogastric or orogastric) to initiate enteral nutrition. If there is concern for facial fractures/skull base fracture, place orogastric tube and avoid nasogastric tube placements. Although a controversial topic, feeding at the Role 1 – is possible, as demonstrated by Frizzi, et al.16 Evidence shows that delaying nutrition in large burn patients (≥20% TBSA) increases odds of mortality by 2% for each hour delayed in enteral feeding initiation.17 This translates to an increased mortality risk of 96% in 48 hours, emphasizing the importance of early enteral feeds when possible. Before tube feeds are initiated, it is imperative to ensure proper tube position, with x-ray confirmation being the gold standard. If x-ray is not available and tube feeds are deemed necessary, the following methods should be used to clinically confirm proper position: 1) quickly push air through the tube while auscultating the left upper quadrant (over the stomach) to confirm a “whoosh” AND 2) return of gastric or bile aspirate.

- Better: If casualty is hemodynamically stable, consider placement of a feeding tube and provide trophic feeds using a standard formula (10-20 ml/hr). If enteral formula is not available, an improvised tube feeding can be made by mixing ultra-high temperature milk alone or mixed with the protein drink powder found in Meals-Ready-to-Eat. To maintain tube patency, ensure 30 ml free water flush completed every 4 hours.
- Best: If able and comfortable consider increasing tube feed rate by 10 ml/hr Q4hr until optimal rate of 60 ml/hr is achieved. Provide a polymeric, high-protein enteral nutrition formula, if able; otherwise provide improvised tube feeding.

For enteral nutrition contraindications, please refer to the JTS CPG for Nutritional Support Using Enteral and Parenteral Methods.

***Placement of a feeding tube, particularly in a patient with altered mental status without appropriate confirmation of proper positioning may lead to significant morbidity or mortality from aspiration risk.

ANALGESIA AND SEDATION

Refer to the PCC guidelines and Analgesia and Sedation Management during Prolonged Field Care CPG for a thorough guide to pain and sedation management.

Pearls

- Utilization of a multimodal (i.e., local anesthetics, ketamine, dexmedetomidine, etc.) approach to analgesia in the polytrauma casualty is advised to avoid oversedation and the risk of apnea associated with ever increasing doses of opioids and benzodiazepines.18
- When possible, have on hand reversal agents for opioids (Naloxone) and benzodiazepines (Flumazenil), and be familiar with their dosing.19
- Consider duration of action and the effects of cumulative dosing during procedural sedation; anticipate the need for prolonged monitoring in the post-procedural period.19
- Consider decreasing standard dosing in the shock casualty, and always anticipate potential cardiovascular collapse with drugs that decrease sympathetic tone, particularly in the catecholamine depleted casualty (i.e., the under resuscitated casualty, or one with a prolonged extraction time, etc.).

CHECK BLOOD GLUCOSE LEVEL

If available, check blood glucose level (BGL) every 8 hours or more frequently as dictated by casualty status for casualties that are NPO. A low BGL (less than 80 mg/dL) must be treated immediately with oral sugar, juice, or IV glucose. A high BGL (greater than 200 mg/dL) is less dangerous than low glucose and may be treated if the capability is available.20