Fieldcraft 1
what are some distinct characteristics of ballistic injuries?
-caused by projectiles that penetrate casualty (typically bullets or shrapnel and debris from explosions) -causes significant tissue disruption and hemorrhage when a bone is struck -discrete entrance wounds (hard to detect) -irregular, unpredictable wound paths -require assessment for exit wound due to high kinetic energy of projectile
what 4 things does Medical Evacuation (MEDEVAC) encompass?
-collecting wounded -sorting (triage) and prioritizing for evacuation -providing mode of evacuation -performing emergency medical intervention and care en route
what are 4 indications for administering Tranexamic Acid (TXA)?
-hemorrhagic shock -amputation(s) -torso trauma -evidence of severe bleeding
in a combat environment, what 3 non-traumatic disorders should CPR be considered for?
-hypothermia -near-drowning -electrocution
during the primary level of blast injuries, how are hallow organs affected?
-lungs (pulmonary hemorrhage with hypoxia) -colon (ruptured colon with hemorrhage and fecal contamination of peritoneum) -stomach (gastric hemorrhage with shock) -middle ear/ eardrum (tympanic membrane rupture)
what are 2 types of nonstandard medical documentation?
-sharpie on tape -sharpie on casualty's skin
level of care: role 1 -what are their capabilities? -what are the organizations providing the care?
capabilities -self-aid/buddy aid -CLS -medical personnel (combat medic, physician/PA) organizations -battalion aid station (BAS) -medical platoon
when is battlefield CPR *not* appropriate?
casualty has sustained blast or penetrating trauma with no signs of life
when *might* battlefield CPR be appropriate?
casualty loses vital signs and is close to definitive care facility with penetrating trauma (brief periods of CPR may be beneficial)
what happens if you fast push Tranexamic Acid (TXA)?
causes hypotension
what is the opening statement for a 9 line MEDEVAC request?
"I have a 9 line MEDEVAC request, over"
what are the factors that affect coagulopathy?
*B*leeding *A*side *H*arry *H*elp *M*e *B*lood pressure *A*cidosis *H*ypothermia *H*emodilution *M*edication
what are the different types of distributive shock?
*S*eptic *N*eurogenic *A*naphylactic *P*sycholgenic
fluid resuscitation option in order of first choice to last choice
*colloids* (1st choice) 1. whole blood (type O low titer) 2. plasma, RBS, platelets (1:1:1) 3. plasma, RBC (1:1) 4. reconstituted dried plasma, liquid plasma, thawed plasma alone or with RBC 5. hextend *crystalloids* (2nd choice) 6. lactated ringers or plasma-lyte A
what are signs of thoracic injury?
*respiratory rate/effort* -tachypnea/bradypnea -labored breathing -retractions -hemoptysis -1 or 2 word phrases -agitation or air hunger *skin* -diaphoresis -pallor -cyanosis *neck* -trachea deviation -JVD - subcutaneous emphysema (air present under skin) -penetrating wounds *chest* -contusion -tenderness -asymmetry -open wounds -crepitation -flail chest/paradoxical movement -lung sounds (absent/diminished, unilateral/bilateral, bowel sounds in chest) -muffled/distant heart sounds
who is responsible to have casualty delivered to loading site of aircraft
*tactical commander* that initiated evacuation request
what are the brevity codes for line 6 of the 9 line MEDEVAC request?
*wartime:* N - no enemy troops P - possible enemy troops E - enemy troops (approach with caution) X - enemy troops (armed escort required) ex. "line six November (N)" *peacetime:* state injury and blood type ex. "2 gunshot wounds and one compound fracture"
what are the brevity codes for line 9 of the 9 line MEDEVAC request?
*wartime:* N - nuclear B - biological C - chemical -if no CBRN = don't include line 9 ex. "line niner charlie (C)" *peacetime:* terrain description in relation to landing area
what are the 3 most common devices used by the hoist to extract casualties
1. stokes basket 2. jungle penetrator (JP) 3. SKED litter
what size needle is used for NCD?
10 or 14 gauge 3.25in long
what gas is the bloods acid-base balance directly related to?
CO2 produced and CO2 exhaled
what does MTF stand for?
Military Treatment Facility
what's the abbreviation for "right eye"
OD
what's the function of erythrocytes?
carry O2 to tissues (RBC)
what's the function of arteries and arterioles?
carry blood away from heart and to tissue
example of throw bag movement device
kosmo mount lifeline
what are the 2 themes of rescue
simple and complex
Who is responsible and supervises the loading and unloading of an air ambulance?
tactical commander
what are signs and symptoms of tension pneumothorax?
-*progressive respiratory distress* -*diminished/absent breath sound* -*tracheal deviation* -tachypnea -hypotension -JVD -cool, clammy skin
what antibiotic should be administered for casualty that is unconscious, in shock, can't swallow, or can't take medication via PO?
-1g Ertapenem IV/IM once a day OR -2mg Cefotenan slow push 3-5min IV/IM every 12 hours
what analgesics should be administered for casualty in moderate-severe pain *with* signs of shock or respiratory distress?
-20mg Ketamine IV/IO pushed slowly over 1 min every 20 min -50mg Ketamine IN/IM every 30 min
signs/symptoms of cardiogenic shock?
-Chest pain -progressive respiratory distress -weakness -cool, clammy skin -hypotension -tachycardia -tachypnea -rales (CHF) -peripheral edema (CHF)
during combat situations, how does "fight or flight" affect your body
-HR increases -lose fine motor skills -rely on gross motor function
what 2 medications can worsen a sever TBI (traumatic brain injury)?
-Ketamine -OTFC (fentanyl)
signs/symptoms of non-compressible hemorrhage?
-abdominal rigidity/tenderness -ecchymosis (bruising) -hemoptysis (coughing up blood) -hematemesis (vomiting up blood) -hematochezia/melena (rectal bleeding)
2 types of material used for pressure bandaging?
-ace wrap/elastic bandage -emergency bandage
how does acidosis affect coagulopathy?
-anaerobic metabolism creates build up on lactic acid and CO2 which are both acidic -decreased blood pH affects coagulation
what are the contraindications of an NPA?
-basilar skull fracture -maxillofacial trauma -exposed brain matter -CSF from nose, mouth, or ears
hemorrhagic causes of hypovolemic shock
-blood loss (internal or external)
what should you continue to monitor your casualty for after you applied intervention to control bleeding?
-blood visible and spreading on bandage/dressing -signs of entering/progressing into hemorrhagic shock -cessation of bleeding (could still be bleeding internally though)
what are some injuries related to the heart and vessels in the thoracic cavity?
-cardiac contusion -penetrating wounds to heart or BV -pericardial tamponade (cardiac tamponade) -hemothorax
what are the key vessels involved in compressible hemorrhage?
-carotid arteries -internal and external jugular veins -brachial arteries -radial and ulnar arteries -femoral arteries and veins -posterior tibial artery (posterior aspect of medial malleolus)
what are the indications for when a TQ should *not* be converted?
-casualty will arrive at surgical facility in < 2 hours -TQ has been in place > 6 hours -casualty has amputation -casualty is in shock (AMS and absent radial pulses)
what does pneumothorax cause?
-collapsed lung -less available space for respiration (gas exchange) -reduced oxygenation of blood (hypoxia)
why are colloids preferred over crystalloids to expand intravascular volume?
-colloids expand and maintain intravascular volume more -colloids require less volume to be infused (less hemodilution)
what are SJTs designed to do
-control bleeding when CAT, SOFTT, and EMT would be ineffective -may be used to stabilize pelvic Fx
what is this course's standard for improvised TQ?
-cravat wrapped around extremity -8 tongue depressor taped together for windless -another cravat to keep windless from unwinding
what is Lactated Ringer's and it indications?
-crystalloid -pH: 6.2 indications: -burns -dehydration with inability to take fluids PO
what may cause blunt trauma?
-deceleration -compression -bursting or sheering forces
non-hemorrhagic causes of hypovolemic shock
-dehydration due to sweating and insufficient fluid consumption -dehydration due to vomiting/diarrhea -burns (> 20% of body surface area)
characteristics of crystalloids
-do not carry O2 -low pH -do not aid in clotting -do not significantly contribute to long term intravascular volume expansion
what are the indications for TQ conversion?
-evacuation delayed > 2 hours -tactical situation allows for conversion -*wound has been exposed and assessed prior to conversion* -enough time before evacuation for conversion
what is hypotensive resuscitation and why is it done?
-giving fluids to maintain a *low* perfusing BP -lower BP is less likely to dislodge any clots that have formed
when are carries used to evacuate casualties
-greater distance (50m-300m or more depending on carry, strength of bearers, casualty's weight, MOI, terrain) -used for conscious or unconscious casualties -more tiring to bearers -risk of increasing severity of injury
what manual maneuvers might you perform on unconscious casualty to maintain their airway?
-head-tilt, chin-lift -jaw-thrust -recovery position
what are some significant sources of non-compressible hemorrhage?
-heart -lungs (pulmonary arteries/veins) -subclavian vessels -mediastinal vessels (SVC, IVC, aorta) -intercostal vessels (up to 100ml per min each) -abdominal organs and vessels
what methods of bleeding control could be used to convert TQs?
-hemostatic agents -kerlix, compressed gauze, roller gauze -emergency bandage -elastic bandage
how does blood pressure affect coagulopathy?
-higher BP = faster it will bleed -lower BP = hemorrhage slows, allows time for clots to form
what are the 5 types of tourniquets (TQ)?
-improvised TQ -Combat Application Tourniquet (CAT) -Special Operations Forces Tactical Tourniquet (SOFTT) -Emergency Medical Tourniquet (EMT) -SAM Junctional Tourniquet (SJT)
what is the result of tension pneumothorax?
-increased pressure moves mediastinum over, compressing heart and other lung leading to decreased cardia output (decreases pre-load)
what are the contraindications of King LT?
-intact gag reflex -casualty shorter than 4ft -known esophageal disease -ingested caustic (causing burns) substance -inhalation burns
what are the 8 tactical PPE?
-interceptor body armor (IBA) -deltoid and axillary protection system (DAPS) -small arms protective inserts (SAPI plates) -advanced combat helmet (ACH) -army combat shirt (ACS) -gloves -ballistic eye protection (eye pro) -combat earplugs (ear pro)
what are the complications/disadvantages of a cricothyroidotomy?
-invasive procedure -bleeding at incision site (possible aspiration) -misplaced tube -esophageal laceration or intubation (cut too deep) -hematoma -vocal cord injury or paralysis or hoarseness (cut in wrong area)
what are the contraindications of resQGARD
-known dilated cardiomyopathy -left-sided CHF -pulmonary hypertension and/or cardiac stenosis -flail chest -chest pain/ SOB -on-going uncontrolled blood loss
what are the assistant drivers of army ground ambulances responsibilities
-land nav -care en route -loading and unloading casualty -emergency transport or medical supplies/personnel -act as messenger within medical channels
signs/symptoms of hypovolemic shock?
-lose > 20% of body fluid/blood -decreased ability to perfuse body
what causes distributive shock?
-loss of autonomic nervous system control -release of chemical that damage the BV
what is the pleural fluid and its function?
-lubricating fluid between visceral and parietal pleura -creates surface tension that leads to unification of chest wall and surface of lung
what are the indications for using an emergency bandage?
-may be used alone for superficial to moderate injuries -may be used with hemostatic agents or gauze for large deep wounds
what are the complications of an NPA?
-minor facial trauma (epistaxis) -trigger gag reflex if NPA is too long
what are NPAs preferred over OPAs?
-more easily tolerated -less likely to dislodge in transport
Why does spinal immobilization have limited applications in a combat setting
-most ballistic injuries don't require stabilization -limited time
what are 3 tactical indications for spinal immobilization?
-motor vehicle crashes -falls > 15ft -IED blast involving MRAP vehicle MRAP = mine resistant ambush protected (picture)
what are the 2 criteria for starting an new IV site on the same extremity
-must be proximal to old IV site -cannot be distal to an injury
what is a substantial/anchor
-object or structural component that will withstand casualty or rescuers weight during egress (exit) -what you hook the rope up to before you jump off a building
what is a simple theme of rescue
-open fields, vehicles, structures -no hindrances moving casualty
what are the indications to use a SJT?
-pelvic Fx -inguinal injury
what is a deliberate TQ?
-place directly on skin -2-3in above wound -used during tactical field care -check distal pulse -T and time on forehead
what is a hasty TQ?
-placed over clothing -high and tight on extremity -used during care under fire
what are some complications of suctioning?
-prolonged suctioning leads to hypoxemia -cardiac dysrhythmias from arterial hypoxemia -vagal nerve stimulation leading to bradycardia and hypotension
what are the major blood vessles?
-pulmonary artery and vein -aorta -superior/inferior vena cava
what are the advantages of army ground ambulances
-readily available when needed -not limited by inclement weather -used to evacuate casualties form front line
when are drags used to evacuate casualties
-removal from dangerous situations or hostile environments -allows for low profile -short distances up to 50m
what are some common misplacements of a cricothyroidotomy?
-right main-stem bronchi intubation (advance tube too far) -tube directed cephalically (towards head instead of towards lungs) how to fix it: remove tube and try agian
what is normal saline solution and it indications?
-same amount of Na+ and Cl- as found in plasma -9g NaCl per 1000ml of water pH: 5.9 indications: -only used in conjunction with blood transfusion -NOT used to restore lost fluid
what positions of comfort might a casualty position themselves in to maintain their airway?
-sitting upright/forward -tripod position -recovery position
what are the side effects/complications of King LT?
-sore throat -dysphagia -upper airway hematoma -esophageal rupture (rare) -vomiting
what is a complex theme of rescue
-structural ingress (entrance) or egress (exit) (ex. vertical casualty movement) -vehicle extraction (ex. doors, hatches, window, hasty stabilization) -tactical search and rescue (ex. collapsed building)
how does hemodilution affect coagulopathy?
-too much IV crystalloid fluid has been given (normal saline or lactated ringers) -clotting proteins, platelets, RBC have been "washed out"
what are the indications for IO venular access
-trauma to extremities -2 unsuccessful IV attempts, AMS, and absent radial pulses -not recommended for dehydrated casualties (even after 2 failed IV attempts)
what are the indications of an NPA?
-unconscious with spontaneous respirations and no respiratory distress -unconscious without airway obstruction -AMS with intact gag reflex (every unconscious casualty gets an NPA)
what are the indications of King LT?
-unconscious without gag reflex -respiratory arrest -respiratory rate <8 or >30 -near drowning -electrocution -drug overdose
what is the loading sequence of 4 litter casualties
1 upper right 2. lower right 3. upper left 4. lower left
what is your 1st, 2nd, and 3rd choice for selecting a vein for vascular access
1. *m*edian cubital vein (middle) - least apt to roll 2. *c*ephalic vein (lateral) 3. *b*asilic vein (medial) - most prominent, rolls easy (Mcdonalds Cheese Burgers)
what are the 3 phases of TCCC?
1. Care Under Fire (CUF) 2. Tactical Field Care (primary) 3. Combat Casualty Evacuation Care (secondary)
after gaining vascular access, what do you do next?
1. TXA infusion (1g TXA in 100ml IV solution over 10min) 2. flush with 5ml NS 3. administer blood products or Hextend 4. after completion of giving fluids, administer 2nd dose of TXA
what are 2 end-point indications of Ketamine administration?
1. control of pain 2. development of nystagmus (rhythmic back and forth movement of eyes)
what are 5 sources of chest trauma?
1. diaphragmatic tear - tear in diaphragm 2. simple rib Fx - break in one or more ribs 3. flail chest - break in 2 or more consecutive ribs in 2 or more places 4. traumatic asphyxia - intense compression of thoracic cavity, ruptures BV 5. tracheal bronchial tree injry - tear in trachea or bronchi or tissue lining trachea
what are 5 factors influencing care on the battlefield?
1. enemy fire 2. limited medical equipment 3. widely variable evacuation times 4. tactical considerations 5. casualty transportation
what are 3 locations of wounds on battlefield and the percentages of each one
1. extremities (60%) 2. head/neck (25%) 3. torso (9%)
what are 3 preventable causes of death on battlefield?
1. hemorrhage (90% died from) 2. tension pneumothorax (2% died from) 3. airway obstruction (8% died from)
how should you treat a casualty that develops reoccurrence of progressive respiratory distress after insertion of NCD?
1. if you have another 14 gauge 3.25in needle... -insert second needle directly lateral of first attempt 2. if you do not have another 14 gauge 3.25in needle... -flush first attempt needle with 1-2ml of sterile IV solution
what are 5 safety procedures of loading a UH-60A blackhawk
1. keep low silhouette, keep clear of main and tail rotators 2. do not approach until signaled to do so 3. approach at 90 degrees form front 4. if on hill, approach from downhill side 5. no smoking within 50 ft of aircraft
when the body shunts to compensate for shock, which organs are 1. least important 2. less important 3. most important
1. least important - skin, muscle, bone 2. less important - intestines, liver, stomach, spleen 3. most important - brain, heart, lungs, kidneys
what is each line of the 9 line MEDEVAC request?
1. location of pickup site 2. radio freq, call sign, suffix 3. # patients by precedence 4. special equipment 5. #patient by type 6. *wartime* security of pickup site 6. *peacetime* # and type of wound, injury, illness 7. method of marking pickup site 8. nationality and status 9. *wartime* NBC contamination 9. *peacetime* terrain description
what skills is a soldier trained with Warrior Tasks capable of performing?
1. open airway by positioning 2. insert NPA 3. hemorrhage control
what skills is a soldier trained with Combat Life Saver (CLS) capable of performing?
1. open airway by positioning 2. insert NPA 3. hemorrhage control 4. occlusive dressing and perform needle chest decompression (must go through 40hr course)
what is you first and second choice of treatment for penetrating thoracic wounds?
1. vented chest seal 2. non-vented chest seal
what does each of the following blood products provide 1. whole blood 2. 1:1:1 PRBC 3. Hextend 4. crystalloids
1. whole blood -volume expander -clotting factors, platelets -O2 carrying capacity 2. 1:1:1 PRBC -volume expander -clotting factors, platelets 3. Hextend -volume expander 4. crystalloids -volume expander -low pH
how much blood can an adult bleed into the abdomen?
10L of blood and IV fluid (body only has about 6L of blood)
how much blood can be lost before BP drops?
1500ml
how much blood can an adult bleed into *each side* of the chest?
1500ml into each side (AKA 3000ml in entire chest)
what is the size of the needle for vascular access
18 gauge 1.25 in
how much blood can an adult bleed into *each* thigh?
1L in *each* thigh (AKA 2L total for both thighs combined)
how far past the edges of the wound should an occlusive dress extent?
2 in
what is the casualty carrying capacity of... MaxPro MRAP ambulance
2 litters or 3 ambulatory
what is the casualty carrying capacity of... HAGA MRAP ambulance
3 litters or 6 ambulatory
what is the casualty carrying capacity of... M113
4 litters or 10 ambulatory or combination of the 2
what is the casualty carrying capacity of... M1133 (stryker light armored vehicle)
4 litters or 6 ambulatory or combination of the 2
what is the casualty carrying capacity of... M997 (used WITHIN base)
4 litters or 8 ambulatory or 2 litter and 4 ambulatory
what is the casualty carrying capacity of... armored medical evacuation vehicle (AMEV)
4 litters and 8 ambulatory (looks like m113 but has larger enclosed top and more heavy duty)
where is the roller clamp placed
4-6in below the drip chamber
what antibiotic should be administered for casualty that can swallow and take medication via PO?
400mg Moxifloxacin PO once a day
One of the members of your team collapsed while on foot patrol in a mountainous regions of Afghanistan in over 100 degree heat. After evaluating the casualty for traumatic injuries, you believe his condition and his altered mental status is due to heat exhaustion. What is the fluid of choice for this patient?
5% dextrose and water
where is the secondary insertion site for NCD?
5th intercostal space, above 6th rib on the anterior axillary line (AAL)
what is the max time you should spend on the "X"?
60 sec
what size diameter tube is required to allow spontaneous breathing and adequate oxygenation in adult through cricothyroidotomy?
6mm internal diameter
what is the bloods normal pH range required for coagulation?
7.35-7.45
what systolic BP is needed to perfuse vital organs?
80mmHg
what systolic BP is high enough to dislodge any blood clots
> 93mmHg
what are the brevity codes for line 4 of the 9 line MEDEVAC request?
A - none B - hoist C - extraction equipment D - ventilator ex. "line fower alpha wun (A1)"
what are the brevity codes for line 7 of the 9 line MEDEVAC request?
A - panels B - pyrotechnic signal C - smoke signal D - none E other ex. "line seven November (N)"
what are the brevity codes for line 3 of the 9 line MEDEVAC request?
A - urgent B - urgent-surgical C - priority D - routine E - convenience ex. "line tree bravo too (B2)"
what are the brevity codes for line 8 of the 9 line MEDEVAC request?
A - us military B - us civilian C - non-us military D - non-us civilian E - enemy prisoner of war (EPW) ex. "line ait echo (E)"
when triaging patients, patients presenting with what 3 things should be treated first?
AMS, absent radial pulses, shock
where is the cricothyroid membrane located?
Above the first cricoid cartilage ring and below the thyroid cartilage
what are the bronchioles?
Airways in the lungs that lead from the bronchi to the alveoli.
what are some medications that affect coagulopathy?
Aspirin (ASA), ibuprofen, naproxen, warfarin (coumadin)
what's the abbreviation for "below knee amputation"
BKA
what is the standard TQ in the IFAK?
CAT (combat application TQ)
what are the classifications of hemorrhage
CLASS 1 vol. - <750ml % - 15% HR - normal RR - normal systolic BP - normal CLASS 2 vol. - 750-1500ml % - 15-30% HR - >100 RR - 20-30 systolic BP - normal CLASS 3 vol. - 1500-2000ml % - 30-40% HR - >120 RR - 30-40 systolic BP - decreased CLASS 4 vol. - >2000ml % - >40% HR - >140 RR - >35 systolic BP - greatly decreased
what are the Tactical Combat Casualty Care goals? (TCCC or TC3)
CPT "captain" -*C*omplete the mission (most important) -*P*revent additional casualties -*T*reat the casualty
what is a type of standard medical documentation?
DD Form 1380, TCCC
what's the abbreviation for "diagnosis"
Dx
what's the abbreviation for "fracture"
Fx
what's the abbreviation for "gun shot wound"
GSW
what's the abbreviation for "history of"
H/O
in the absence of blood product, what is the pre-hospital fluid of choice
Hextend
what's the abbreviation for "history"
Hx
what's the abbreviation for "intravenous"
IV
if IV access has been attained, what is an alternative to OTFC?
IV morphine -15mg diluted in 5cc's of sterile solution repeated every 10 min
If a casualty is dehydrated but alert, able to swallow, has a present radial pulse, and not experiencing nausea how should he be treated?
IV of NaCl
what tactical PPE will stop 9mm bullets and contains panels covering front, back, sides, neck, and join
Interceptor body armor (IBA)
what are 2 supraglottic airway devices?
King LT and I-GEL
what are the brevity codes for line 5 of the 9 line MEDEVAC request?
L - litter A - ambulatory ex. "line fife lima ait break alpha wun (L8, A1)"
what's the abbreviation for "laceration"
Lac
what fluid is administered to burn casualties
Lactated Ringer's
what is the nasal cavity?
Large air filled space above and behind the nose
what are the bronchi?
Large airways leading from the trachea to the bronchioles
what's the abbreviation for "left"
Lt
MEDEVAC vs CASEVAC
MEDEVAC - evacuation of casualty via medical mode of transportation CASEVAC - evacuation of casualty via non-medical mode of transportation
When does the MEDEVAC begin and end
MEDEVAC begins when medical personnel receive injured or ill Soldiers and continues as far rearward as the casualties medical condition warrants or the military situation requires
what is the temporary treatment for a thoracic wound and how long does it last?
NCD - lasts up to 4 hours
what tactical PPE offers some protection to hands against flame
Nomex gloves
what tactical PPE protects neck torso and arms against flame
Nomex or Kevlar army combat shirt (ACS)
what's the abbreviation for "left eye"
OS
what's the abbreviation for "both eyes"
OU
what's the abbreviation for "by mouth"
PO
what are the 4 P's of wound packing?
Peel, Push, Pile, Pressure (always check for exit wounds)
what is a sucking chest wound?
Penetrating injury to chest that produces hole 2/3 size of trachea presenting with sucking sound (avg trachea about 1 in)
what's the abbreviation for "rule out"
R/O
what's the abbreviation for "right"
Rt
what is over-classification?
Tendency to classify a wound as more severe than it actually is
After placing an ET tube into your casualty's trachea, you notice your casualty has unilateral rise and fall of the chest and diminished breath sounds on the left side. What is your casualty's problem?
The ET tube was inserted too far and is in the right main stem bronchi
what is the oral cavity?
The part of the mouth behind the gums and teeth that is bounded above by the hard and soft palates and below by the tongue and by the mucous membrane connecting it with the inner part of the mandible.
how should an IV you started be written on casualty documentation
The type of administration set used along with the location and size of the catheter and the type and amount of fluid, if any was given
what is the only injectable hemostatic agent?
Tranexamic Acid (TXA) -1g TXA via IV diluted in 100cc of saline pushed slowly over 8-10min within first 3 hours of initial injury
what is the primary air ambulance
UH-60A balckhawk
what's the abbreviation for "wounded in action"
WIA
what medication can be administered as needed for nausea or vomiting?
Zofran (Ondansetron) -4-8mg every 6 hours IV/IO/IM
how is an IV flow rate calculated
[(volume infused in ml)x(drops per ml of infusion set in gtts/ml)]/ (total infusion time in min)
what is the trachea?
a tube that connects the nose and mouth to lungs
a penetrating abdominal wound above what landmark is considered a thoracic and abdominal injury?
abdominal wound above level of umbilicus
what an indication for fluid resusciatation?
absent radial pulses
what tactical PPE provides ballistic, fragmentation, and impact protection for head
advanced combat helmet (ACH)
who is responsible for supervising loading of aircraft
aeromedical evacuation personnel
when and where are TQ applications documented?
after checking distal pulse, on casualty's forehead *and* DD form 1380 prior to securing casualty
when are medical personnel required to complete a medical AAR on DA form 4700 04.1 filled out
after the medical incident occurs
when triaging patients, patients presenting with what should be treated last/not at all?
agonal respirations = "a goner" = dead
what does AXP stand for?
air/ambulance exchange point
signs/symptoms of anaphylactic shock?
allergic rxn - "hypertensive reaction to the antigen" - envenomation, compromised airway, wheezing, hypotension, tachycardia, abdominal cramping, edema
what does a needle chest decompression do?
allow air under pressure to escape pleural cavity *does NOT "re-inflate" lung*
Why would an emergency cricothyroidotomy be preferred over an intermediate airway?
allows direct ventilation of lungs
what is a saline lock used for
allows ready access to cardiovascular system without having to administer fluids
how is the administration of fluids documented pre-hospital
amount and type of fluid
what type of medication is Tranexamic Acid (TXA)?
antifibrinolytic (prevents breakdown of clots)
when is an IV catheter considered a "dirty stick"
any catheter placed in pre-hospital setting
where does compressible hemorrhage occur?
arms, legs, axilla, groin, neck, superficial injuries to head and torso
when should prevention of hypothermia begin?
as soon as the casualty is identified
what other area besides inguinal could SJT be used
axillary by using an extender to the target compression device (TCD)
what tactical PPE protects eyes form burns and penetrating trauma
ballistic eye protection (eye pro) on the list of Authorized Protective Eyewear List (APEL)
what are 2 types of significant penetrating trauma MOIs?
ballistics and blast injuries
why must you hold the NCD in place with the needle still inside the catheter for 10sec after insertion?
because the needle maintains the shape of the catheter as the thoracic muscles briefly contract after insertion (removal of needle too soon will cause muscle contractions to occlude catheter)
at what body temp are clotting factors affected?
below 93 degrees F
at what body temp is a casualty considered to be hypothermic?
below 95 degrees F
what is non-compressible hemorrhage?
bleeding *can't* be compressed with direct pressure, wound packing, or pressure dressings
what is compressible hemorrhage?
bleeding *can* be compressed with direct pressure, wound packing, pressure dressings, or tourniquets
what fluid is given to burn casualties with absent radial pulses
blood and blood products or Hextend
what's the difference between blue and black CATs?
blue = training black = carried in combat
what are civilian wounds are predominantly due to?
blunt trauma
what type of trauma distributes a force of injury over a larger area?
blunt trauma
what causes closed pneumothorax?
blunt trauma causing tear in visceral pleura allowing positive pressure air to fill pleural cavity
what's the abbreviation for "with"
c
what's the abbreviation for "complaint of"
c/o
level of care: role 2 -what are their capabilities? -what are the organizations providing the care?
capabilities -advanced trauma management and TCCC -provide packed RBC -limited x-ray -clinical laboratory -operational dental support organizations -medical company - brigade support battalion (assigned to brigade) -medical company - area support (aid to units) -forward surgical team (FST)
level of care: role 3 -what are their capabilities? -what are the organizations providing the care?
capabilities -resuscitation -initial wound surgery -damage control surgery -postoperative treatment organizations -combat support hospital
how should a casualty be carried on a litter and what are the exceptions to this rule?
carried feet first exceptions: -going up hill/stairs head first -lower extremity injury - feet first uphill and head first down hill to prevent weight of body from pressing on injury
what's the function of veins and venules?
carry blood back to heart
how should fluids be administered to dehydrated casualty, able to swallow, has radial pulses, not nauseated? does the treatment chang if the casualty also has an amputation?
casualty can drink fluids by mouth -other injuries don't change administration of fluids by mouth
what is the anchor point for inguinal wounds?
casualty's thigh, buttocks, or *belt*
infection: cause signs/symptoms corrective actions preventive measures
cause -use of contaminated equipment -poor venipuncture equipment -contaminated site -IV equipment not changed regularly signs/symptoms -redness, swelling, soreness -c/o chills, fever, malaise -sudden rise in temp and pulse -purulent (pus-like) drainage form IV site corrective actions -discontinue IV -use aseptic technique to clean and dress wound -report it, document it preventive measures -used strict aseptic techniques when starting IVs -clean site when initiating IV -anchor catheter and tubing securely -check site at least daily for signs of inflammation
hemostatic agent(s) that turn into super glue like material and cover the hole in the bleeding vessel
celox gauze and chito gauze
what is the definitive treatment of a thoracic wound?
chest tube
where does non-compressible hemorrhage occur?
chest, abdomen, pelvis (internal bleeding)
what are the 4 basic steps of coagulation?
clotting: 1. injury 2. factors activated 3. vasoconstriction 4. formation of platelet plug
what's the function of thrombocytes?
coagulation - form clots over damaged BV (platelets)
hemostatic agent(s) that stimulate clotting when placed in wounds
combat gauze
what is the hemostatic agent of choice?
combat gauze
what is the preferred hemostatic agent?
combat gauze
who is responsible for the ambulance at all times and driver maintenance of the ambulance?
combat medic
example of webbing/handle movement device
combat rescue sling
when is a special operations forces tactical TQ (SOFTT) used?
commonly used in theater
describe the 2 stages of shock
compensated -heart is stimulated to increase cardiac output -peripheral BV constrict (shunting) -anaerobic metabolism (causes acidosis) decompensated -compensating mechanisms fail -falling BP (major indicator)
how does a rescuer gain leverage dragging casualties
create a distance of 2-3 feet between you and the casualty (can lean back creating a counter balance)
what fluid should not be administered pre-hospital in combat setting for intravascular volume expansion
crystalloids
how does hypothermia affect coagulopathy
decrease in temp prevents chemical reactions needing for clotting to occur
what does a cricothyroidotomy decrease the risk of?
decreased risk of gastric insufflation and aspiration
infiltration: definition cause signs/symptoms corrective actions preventive measures
definition -accumulation of fluid in tissue surrounding IV needle site cause -penetration of vein wall (catheter no longer in vein) signs/symptoms -slow/stopped flow rate -cool, hard, pale, swollen infusion site -pain, tenderness, burning, irritation at infusion site -*fluid leaking around infusion site* corrective actions -check patency of IV -stop infusion and remove needle/catheter -evaluate extremity -apply warm compress to encourage absorption -report it, document it, restart IV preventive measures -tape catheter hub and tubing securely to limb
circulatory overload: definition cause signs/symptoms corrective actions preventive measures
definition -increased vascular volume resulting from excessive IV fluid infused too rapidly cause -fluid delivered too fast -reduced kidney fuction -CHF or cardiac insufficiency signs/symptoms -elevated BP -JVD -tachypnea, SOB, tachycardia, rhonchi, rales -fluid intake > uriniary output -peripheral edema corrective actions -decrease flow rate -position of comfort -report it, document it preventive measures -frequently check flow rate to maintain desired rate
phlebitis: definition cause signs/symptoms corrective actions preventive measures
definition -inflammation of wall of veiin (phleb- means vein) cause -injury to vein during puncture -irritation to vein due to... --long-term therapy --irritating or incompatible additive --large-bore catheter --lower extremity IV site --infection signs/symptoms -slow flow rate -swelling around infusion site -pain, tenderness -redness along vein (redlines) and warmth at infusion site corrective actions -stop IV -report it, document it, restart IV preventive measures -infuse at prescribed rate -select large vein for irritating drugs/fluids -change solutions and dressing (24hrs) -change tubing (48hrs) -change IV site (72hrs)
air embolism: definition cause signs/symptoms corrective actions preventive measures
definition -obstruction of BV by air carried via bloodstream cause -failure to remove air from tubing or by injecting air into IV port signs/symptoms -*abrupt drop in BP* -weak, rapid pulse -cyanosis -*chest pain* corrective actions -place casualty on left side with feet elevated (allow pulmonary artery to absord air) -administer O2 -report it preventive measures -clear air fromIV tubing -monitor solution levels and change before they are empty -check that all connections are secure
what tactical PPE attaches to the IBA to protect shoulders and axilla
deltoid and axillary protection system (DAPS)
what is inhalation?
diaphragm contracts (active process) creating negative pressure insides lungs that pulls air into lungs
what is exhalation?
diaphragm relaxes (passive process) and air leaves the lungs
why do most soldiers die in combat?
die within minutes due to penetrating trauma and hemorrhage
what are the distal and proximal ends of the IV tubing set
distal - gain access or spike the IV bag proximal - connect to catheter hub
example of integrated harness/webbing loops movement device
dragon handle/harness system and combat rescue sling
what's the abbreviation for "dressing"
drsg
what is the preferred advanced airway in combat environments?
emergency surgical cricothyroidotomy
what is the most significant obstacle a combat medic faces?
enemy fire
what is the purpose of the Medical Evacuation System?
ensure sick and injured are moved quickly into and through the combat health support system
when can a SKED movement device be used
evacuate casualty over land or rescue casualty from water
how often is an IV bag replaced?
every 24 hours -don't allow bag to run completely empty before changing it
how often should IV tubing be replaced?
every 48 hours
how often should IV catheter be replaced?
every 72 hours -change IV site at same time as bag and tubing if possible
where on the body are the majority of combat wounds suffered?
extremities
what is the only thing that should be treated during care under fire? how is it treated? why is it the only thing treated?
extremity bleeding with hasty CAT to maintain firepower supremacy
what's the function of leukocytes?
fight infection, consume dead tissue, produce antibodies (WBC)
when should antibiotics be administered?
for all open wounds
where should medic get supplies from to treat casualty and why?
get supplies from casualties IFAK to decrease load medic must carry in aid bag
what is the greatest concern with inhalation burns?
greatest concern is airway edema (be prepared to perform surgical cricothyroidotomy)
what's the difference between the green and yellow side of combat earplugs?
green end visible on outside of ear when worn -protect during weapon fire but can still hear tactically relevant sounds yellow side visible on outside of ear when worn -provide maximum protection against eardrum damage for noise in/around aircraft, vehicles, watercraft, ect.
what's the abbreviation for "drops"
gtts
which direct are casualties loaded into vehicles
head first -reduce motion sickness -less noise from opening and closing of doors -less danger of further injury from rear collision
how are casualties loaded on UH-60A balckhawk
head towards cabin: left side: loaded head first right side: loaded feet first
what does HLZ stand for?
helicopter landing zone
what is the leading cause of death on battlefield and the percentages of each category?
hemorrhage is leading cause of death categories of hemorrhage -extremity (13.5%) -junctional (19.2%) -truncal (67.3%)
how does hypothermia affect the casualty in hot vs cold environments?
hypothermia occurs equally in both hot and cold temps
what is the lethal triad
hypothermia, acidosis, coagulopathy
level of care: role 4 -where is it located?
in CONUS (within continental US)
what are the indications of a cricothyroidotomy?
inability to ventilate any other way due to... -sever maxillofacial trauma -airway obstruction -structural deformities of airway -inhalation burns/edema -unconscious and unable to maintain own airway
what results from increased CO2 levels in body?
increased respiration rate to get rid of excess CO2
after 2 failed attempt of gaining vascular access, what do you do next?
initiate sternal IO line to provide fluids
what do you do if the initial NCD was unsuccessful?
insert second attempt laterally next to first attempt
what are the 2 types of extracellular fluid
interstitial - surrounds tissue cells (includes CSF and synovial fluid) intravascular - in vessels (plasma)
how much fluid is intracellular and extracellular?
intracellular - 2/3 extracellular - 1/3
what causes cardiogenic shock?
intrinsic causes -heart muscle damage -dysrhythmia -valvular disruption extrinsic -cardiac tamponade -tension pneumothorax
Why does amputation with no bleeding require immediate tourniquet application?
it's not bleeding due to arteries/arterioles constricting and temporarily preventing hemorrhage, but BV will eventually tire and dilate
what is the fluid of choice for casualties suffering from non-hemorrhagic causes of shock
lactated ringer's
when would an improvised TQ be used?
last resort if manufactured TQ is not available
how do you position a casualty with penetrating chest trauma?
lateral recumbent with injured side down to alleviate pressure on uninjured lung to allow it to breathe better
what position should you NOT force a conscious casualty into to maintain their airway?
laying supine
how do you avoid complications of suctioning?
limit suctioning to no longer than 15sec (15sec rule)
which 2 lines of the 9 line MEDEVAC request change depending on wartime or peacetime?
line 6 and 9
what is the saying to remember the 9 line MEDEVAC
lines 1-5 -Low Flying Pilots Eat Tacos lines 6-9 -Some Might Nibble Cheese
which lines of the nine line are decided by the medic?
lines 3-5
example of rigid litter movement device
litter and talon II
what 2 things are taken into consideration when deciding how to pack a wound?
location and depth
how does resQGARD work
makes it harder to inhale and increases negative pressure in chest pulling more blood into heart which increases cardiac output elevating the BP
what is the purpose of an NPA?
manage/maintain airway patency
how do you maintain a patent airway on a unconscious casualty?
manual maneuvers
location of IO vascular access
manubrium
what is the parietal pleura?
membrane lining inside of pleural cavity (chest wall)
what is the visceral pleura?
membrane lining surface of lung
when is an emergency medical TQ (EMT) used?
most effective emergency department TQ
which casualty is loaded last and why
most significant injured is loaded last so they are the first to be off loaded
do motionless or moving objects experience more friction?
motionless objects experience more friction -require more force to put object in motion than to keep object in motion
when is the rescuer at the greatest vulnerability
moving the casualty off the "X" (CUF)
what are the indications for suctioning?
mucus, vomitus, blood in airway
what is the time limit for sending lines 1-5?
must be sent within 25sec
what type of shock can casualties present with normal signs
neurogenic
Should antibiotics be given to casualty that only has burns?
no
what is the casualty carrying capacity of... UH-60A blackhawk
normal: 4 litter and 1 ambulatory max: 6 litter and 1 ambulatory or 7 ambulatory
when would a combat medic use resQGARD
on casualty that's spontaneously breathing, absent radial pulses, significant MOI, AMS, and... 1. medic *does not have time, supplies, or equipment to gain vascular access* 2. cold weather where fluid is too cold to infuse
What causes a tension pneumothorax?
one-way valve only allowing air into pleural space trapping air in pleural space
what is the anchor point for axillary wounds?
over opposite shoulder against neck
which populations should you be very careful with when administering IV fluids
pediatrics, geriatrics, or casualties experiencing CHF, kidney failure, pulmonary edema -are at increased risk of cardiac overload
what are combat wounds are predominantly due to?
penetrating trauma
what type of trauma distributes a force of injury over a smaller area?
penetrating trauma
what causes open pneumothorax?
penetrating wound where projectile enters chest allowing positive pressure are to fill pleural cavity
how should you treat a casualty presenting with torso trauma and no pulse or respirations?
perform bilateral NCDs to ensure they don't have bilateral tension pneumothoracies
what is shunting?
peripheral vasoconstriction forcing blood towards central circulation to perfuse vital organs
what does PZ stand for?
pickup site
who is responsible for ensuring the litter squad follows the prescribed methods for loading and securing litter and equipment on aircraft
pilot
who is responsible for making the final decision on how many casualties can safely be loaded in aircraft
pilot-in-command (PIC)
how do you maintain a patent airway on a conscious casualty?
position of comfort
how are IVs documented pre-hospital and in hospital?
pre-hospital -size and location of IV catheter hospital -dat and time of access -size of catheter
what are 2 major indications to treat for tension pneumothorax
presence of *BOTH* progressive respiratory distress *and* torso trauma
describe the levels of blast injuries
primary -*due to wave itself* secondary -*caused by debris or shrapnel from explosion* tertiary -*impact with another object* -casualty blown into a solid object and suffers blunt force trauma
what's the abbreviation for "as needed"
prn
after applying a chest seal to a thoracic wound, what should you continue to monitor for?
progressive respiratory distress
what is the goal of medical documentation?
provide *written* record of assessment findings and treatments given
what's the function of plasma?
provide fluid environment for other blood components
What is cardiogenic shock?
pump failure
why do pressure bandages work?
puts external pressure on wounds
how does gauze packing work to control bleeding?
puts focal pressure on bleeding BV to promote clotting by slowing bleeding
what are the palpable blood pressures?
radial - 80mmHg femoral - 70mmHg carotid - 60mmHg
what are ways to reduce friction
reduce body surface contact points -place different material between casualty and ground -change the angle of the casualty (raise one end of body to reduce total surface area contacting ground)
what's the purpose of TQ conversion?
reduce unnecessary damage to extremity
why don't you remove a TQ if it's been in place > 6 hours?
removal could cause death due to... -release of micro-emboli resulting in PE or stroke -release and recirculation of acidotic blood, metabolic waste, and toxins from non-perfused tissue
what should you do if bandage becomes soaked with blood?
removed ALL packing and start over because it was clearly ineffective the first time
example of webbing/hands-free movement device
rescue assault tether and combat rescue sling
what is the effects of administering 500ml Hextend and how long do the effects last
results in 800ml of intravascular fluid expansion and can be maintained for 8 hours or longer
what are the indications for stopping fluid resuscitation
return of palpable radial pulse *or* improved mental status *or* systolic BP of 80-90mmHg -reassess casualty after each 500ml IV bolus
what are the indications, contraindications, and complications of an I-GEL?
same as King LT
where is the primary insertion site for NCD?
second intercostal space, above 3rd rib on the midclavicular line (MCL) lateral to the nipple line to avoid puncturing mediastinum
what are the indications for gaining vascular access with saline lock and pushing fluids
significant MOI with absent radial pulses and AMS
what are the indications for only gaining vascular access with saline lock
significant MOI with present radial pulses and normal mental status
what tactical PPE are placed in front and back of IBA for enhanced protection adding significant bulk and weight to IBA
small arms protective inserts (SAPI)
which soldiers are subject to increased evacuation times?
soldiers on dispersed and nonlinear battlefields
how does medication affect coagulopathy?
some meds inhibit formation of clots by deactivating platelets (anticoagulants)
what is the pleural cavity?
space between visceral and parietal pleura
signs/symptoms of septic neurogenic?
spinal injury - hypotension, neuro deficit, *bradycardia, warm dry skin, alert and lucid when supine*
what are the indications of resQGARD
spontaneously breathing with hypotension due to... -orthostatic intolerance (fainting) -hypovolemia -cardiogenic shock -dialysis -blood donation
example of poleless litter movement device
stingray poleless litter, tactical extrication device, and combat rescue sling
what is your first intervention for hemorrhagic shock?
stop bleeding
what is the purpose of a constricting band
stops venous return while still allowing arterial flow
why are veins used for vascular access
superficial, larder, easy to see and feel
signs/symptoms of psychogenic shock?
syncopal - increased stimulation vagus nerve causes hypotension, vasodilation, decreased cardia output, *vasovagal syncope*
signs/symptoms of septic shock?
systemic infection - hypotension, decreased urine output, AMS, *fever*, *rigors* (shaking chills), *petechiae* (small, purple hemorrhagic spots on skin)
what phase of the CCA is management of an impaired airway addressed?
tactical field care
when is the greatest amount of treatment for your casualty given?
tactical field care
who decides if casualties will be evacuated?
tactical leader
who determines the request for MEDEVAC?
tactical leader
who makes the decision to use MEDEVAC or CASEVAC?
tactical leader
how many sides should you tape down on an improved chest seal
tape all 4
what is the major concern with pneumothorax?
that it will progress into tension pneumothorax
what should you assume about all penetrating thoracic wounds?
that they have some variation of pneumothorax and hemothorax (hemopneumothorax)
What is the mediastinum?
the cavity between the lungs containing heart and greater vessels (SVC/IVC/aorta) -AKA cardiac box
in what order do you treat penetrating torso trauma?
the first wound you find is the first wound you treat
what must the person that fills out the TCCC also include on the casualty's TCCC?
the person filling it out must put their battle roster # (first and last initial and last 4) ex. John Doe 123-12-1234 = JD1234
Whose call sign and radio frequency is provided in Line 2 of the 9 line MEDEVAC request
the person that will be at the receiving site
what does the "x" refer to?
the place where casualty went down or was wounded in battle (AKA "hot spot" or "point of wounding" or immediate danger area)
what is battlefield documentation a part of?
the soldiers official and permanent medical record
what is significantly different about emergency medical TQs?
they're pneumatic (inflatable) - but can rupture and deflate
a penetrating thoracic wound below what landmark is considered an abdominal and thoracic injury?
thoracic wound below 4th intercostal space (nipple line) or lower
what is the evacuation time and criteria for urgent-surgical precedence?
time - max 1 hour criteria - requires far forward surgical intervention (uncontrollable bleeding, head injury)
what is the evacuation time and criteria for urgent precedence?
time - max 1 hour criteria - to save life, limb, eyesight, or to avoid permanent disability (severe burns)
what is the evacuation time and criteria for routine precedence?
time - max 24 hours criteria - sick and wounded with condition not expected to deteriorate rapidly
what is the evacuation time and criteria for priority precedence?
time - max 4 hours criteria - suffer unnecessary pain or disability or condition could deteriorate changing precedence to urgent
what is the evacuation time and criteria for convenience precedence?
time - no time limit criteria - matter of medical convenience rather than necessity
what are the alveoli?
tiny circular sacs where external respiration occurs
what is a medics best tool for internal bleeding?
tranexamic acid (TXA)
what secures parts of the IV or saline lock while still allowing visualization of the access site?
transparent dressing
what treatment occurs during the care under fire phase of TCCC?
treatment limited to control of obvious extremity bleeding with a hasty tourniquet
after 1 failed attempt of gaining vascular access, what do you do next?
try gaining access on the other arm
what is the anchor point for neck wounds?
under axilla opposite of wound
how long does aspirin (ASA) deactivate thrombocytes?
up to 5-10 days
what is distributive shock?
vasodilation leading to decreased cardiac output
what is the difference between a vented and unvented occlusive dressing?
vented allows for one-way air movement out of pleural cavity. unvented doesn't allow any air movement in or out of pleural cavity
what is a WALK and where is it stored?
warrior aid and litter kit, stored on ground vehicles
how should you treat a casualty that develops reoccurrence of progressive respiratory distress after application of occlusive dressing?
when you don't have a 14 gauge 3.25in needle... 1. burp the wound (lift occlusive dressing, wipe area with gauze to remove any clots prevent release of air, reseal) if tension remains after burping... 2. place gloved finger into wound in attempt to dislodge any clots prevent release of air and then reseal occlusive dressing
when would you not expose your team or compromise the mission to extract a casualty until the threat is eliminated?
when you see obvious signs *not* consistent with life (ex. brain matter, absent rise/fall of chest)
what's the function of capillaries?
where O2 and CO2 gas exchange occurs (internal respiration/cellular respiration)
what is the "holy grail" of pre-hospital fluid resuscitation
whole blood (type O low titer)
Should antibiotics be given to casualty that has burns and penetrating trauma?
yes
can both sides of a blackhawk be loaded with casualties
yes
can a cricothyroidotomy be preformed on a conscious or AMS casualty? if so how?
yes, under local anesthesia using lidocaine
what treatment occurs during the tactical care evacuation phase of TCCC?
-care rendered once casualty has been evacuated -treatment options increase but are still limited to equipment and personnel available
what analgesics should be administered for casualty in mild-moderate pain?
-650ml Tylenol PO 2 pills every 8 hours -15mg Mobic PO once a day
what analgesics should be administered for casualty in moderate-severe pain *without* signs of shock or respiratory distress?
-800ug Fentanyl (OTFC) transbuccally
you should remove the casualty's weapon from them after the administration of what 3 medications?
-OTFC -Ketamine -Morphine
what are the 3 TCCC principles?
-address initial lifesaving care provided at point of wounding -army wide implementation -completing the card (soldiers info pre-filled out and placed in IFAK)
what treatment occurs during the tactical field care phase of TCCC?
-assess for and treat preventable causes of death or disability -non-life threatening injuries may be treated during this phase (if time and resources permit it)