Fieldcraft 2
rule of nines / rules of tens
*in book child's legs are 13.5%* round all numbers up to 10 ex. chest burn would be 20% ex. single arm burn would be 10%
When assessing a casualty with an ocular injury, what other type of injury should you also assess for?
-A Head injury -Watch the casualty's LOC -Changes identify an underlying head injury as well
fluid resuscitation for burn casualty
-Administration of IV/IO fluids is needed to prevent a burn casualty from going into hypovolemic shock. -initiate fluid resuscitation as soon as IV/IO access is established -If burns are >20% TBSA, initiate fluid resuscitation as soon as IV/IO access is established -ONLY BURNS: Lactated Ringer's -SHOCK: Low O titer Whole Blood, 1-1-1 Component Therapy, Fresh Frozen Plasma, or Hextend
what's the criteria for administering the Military Acute Concussion Evaluation (MACE) Assessment and when should it be administered
-Any Service Member in a vehicle associated with a blast event, collision or rollover -Any Service Member within 50 meters of a blast (inside or outside) -Anyone who sustains a direct blow to the head -Command directed, such as but not limited to, repeated exposures to blasts -Battalion Aid Station or higher
contraindication of NPA
-Basilar skull fracture(s) -Raccoon Eyes -Battle Signs -Maxillofacial trauma -Exposed brain matter -CSF draining from the nose, mouth, or ears
criteria for mild TBI
-Confused or disoriented state which lasts *less than 24 hours* -Loss of consciousness for *up to 30 minutes* -Memory loss lasting *less than 24 hours* -Structural brain imaging (MRI or CT scan) with normal results -Presentations range from asymptomatic to confusion or amnesia from the event -Usually return to full recovery within weeks after the injury
how to treat corneal abrasions
-Cover the affected eye with a Fox Eye Shield. -Administer combat pill pack. -Evacuate casualty to a MO as soon as possible with glasses
how to treat eyelid lacerations
-Cover the affected eye with a Fox Eye Shield. -Administer combat pill pack. -Evacuate casualty to a MO as soon as possible with glasses, if indicated
how to treat ocular extrusion
-DO NOT attempt to force the eye back into its socket -Shield & gently cup the avulsed eye with moist 4 x 4s -Cover with a loose, moist dressing. -Administer combat pill pack -Evacuate casualty to a MO as soon as possible with glasses, if indicated
how to treat chemical burns
-Remove clothing. -Brush away dry chemicals. -Remove liquid chemicals by flushing with water. -Irrigate eyes
signs and symptoms of musculoskeletal injuries
-Swelling, deformities, crepitus, limited range of motion, and pain. (Once a sign or symptom is found, no additional or repetitive steps should be taken to reproduce it)
basilar skull fractures
-fractures on floor of cranium -*battle's sign* (ecchymosis over mastoid behind ears) -*racoon eyes* (periorbital ecchymosis)
depressed skull fractures
-fragments of bone driven toward or into underlying brain tissue open -possible entry point for bacteria closed -increase risk of intracranial pressure
Cushing's triad
-increased BP -decreased BP -irregular respiration rate indicate increased ICP
what is sepsis
-massive systemic infection -includes hypotension, decreased urine output and AMS
how do burns affect a casualty's chances of becoming hypothermis
-not able to control their own body temperature effectively -possible even in warm weather -prevent by applying Blankets, casualty blankets, clothing
How will circumferential burns of the chest affect a casualty?
By constricting the chest wall. The casualty may suffocate due to an inability to inhale deeply -evacuate as urgent surgical
calculating the rule of tens
[Percentage TBSA (Rounded to the nearest 10%)] X [10 ml per hour (for adults weighing 88-175 pounds)] basically (TBSA) x (10) -for every 25lbs over 175, add 100ml
What is special about white phosphorus and how to treat it
(AKA willie pete) -chemical substance that burns when exposed to oxygen without having to be ignited treat: -Cover the area with water, saline, a wet cloth, or wet mud -Cover with anything that seals the WP from the air. -Maintain the seal until it can be removed.
calculate flow rate
(Volume to be infused in ml) X (gtts/ml of infusion set) / (Total time of infusion in min) (ml) x (gtts/ml) / (min)
mild traumatic brain injury (mTBI)
concussion -can occur even without being knocked out/losing consciousness -can temporarily change the way the brain works Common causes of TBI/ Concussion include: -Blasts, Blow to the head -Vehicle crashes -Being near a blast- projectile -Falls
how to control hemorrhage for soft tissue injuries to head
control significant bleeding with pressure on the edges of the wound (donut gauze)
describe the diaphragm during maximum expiration
extends superiorly to the... -4th intercostal space, anteriorly -6th intercostal space laterally -8th intercostal space posteriorly
bleeding from pelvic fracture can be ___
fatal
what analgesics are used for musculoskeletal injuries? when are they recommended and not recommended?
fentanyl and ketamine recommended: isolated joint and limb injuries not recommended: serious multisystem trauma
when do the most devastating effects of radiation poisoning appear
few hours after initial exposure
What is the most common cause of penetrating injuries in combat?
fragmentation wounds
Hollow vs. Solid Organs
hollow -spill contents into peritoneal cavity and retroperitoneal space -cause peritonitis and sepsis -bleeding is minor -intestine, gallbladder, urinary bladder, stomach solid -vascular -bleed into abdomen when injured -entire circulating BV can be lost into abdominal cavity -Liver, spleen, kidneys, vena cava, descending aorta
3 levels of TBI
mild, moderate, severe
What should the presence of non life-threatening musculoskeletal injuries indicate ?
more serious problems that may have been caused by the same mechanism of injury.
What antibiotic, that is located in the combat pill pack, is one of the few antibiotics that can affect the eye?
moxifloxacin
which antibiotic within the combat pill pack affects the eye
moxifloxacin (Avelox)
what 2 things does damaged muscle tissue release during a crush injury? and what are their affects
myoglobin -damage to kidneys -produce tea or cola colored urine potassium -cardiac arrhythmias
what does Loss of motor and sensory function usually indicate
nerve injury
What is the fluid of choice for a casualty with Crush Syndrome?
normal saline
Double vision is a common complaint with _______?
orbital fracture
what are passive and active protection you can take for your eyes
passive -Take cover & wear eye pro active -Scan with one eye. -Minimizing binoculars use. -Built-in or clip on filters. Smoke screens (Risk of laser injury increases with the use of night vision)
What is the most successful thing to do for Eye injuries?
prevention
significance of foramen magnum
primary opening through which pressure can be released -at base of skull -where SC passes through
3 layers of meninges and it's function
protect cranial nerves and SC -dura mater (superficial) -arachnoid -pia mater (deep)
how to treat orbital fractures
(*may not be able to move eye or focus on objects. Double vision is a common complaint*) -Cover the affected eye with a Fox Eye Shield. -Administer combat pill pack. -Evacuate casualty to a MO as soon as possible with glasses, if indicated
what 4 things can crush syndrome cause
-Damaged muscle tissue releases myoglobin and potassium. -Myoglobin can cause damage to the kidneys. This free myoglobin will produce tea or cola colored urine. -Elevated potassium can cause cardiac arrhythmias. -When the casualty is extricated and the injury is re-perfused, new blood washes the old blood with the accumulated toxins into the system.
What is crush syndrome?
-Damaged muscle tissue releases myoglobin and potassium. -Myoglobin is a storage site within muscle tissue that stores oxygen. -When released from damaged muscle, it can cause damage to the kidneys. -The free myoglobin will produce tea or cola colored urine. -Elevated potassium levels can cause cardiac arrhythmias
Where and when is PMS (CSM) assessed?
-Distal to all extremity injuries -Before and after splinting any extremity
what are some special considerations for impaled objects
-Do not move or remove impaled objects, that job is for the surgeon -Stabilize the object either manually or mechanically with built up bulky dressing -Apply direct pressure with the flat of the hand to control bleeding around the edges of the wound, if necessary -Palpation of the abdomen should NOT be conducted
What type of dressing is used to cover burns?
-Dry sterile dressings -Dry sterile sheets or towels (can be used before transportation) -Additionally, prevent hypothermia
what are some special considerations for evisceration
-Efforts should focus on protecting the protruding segment of intestine or other organs from further damage -Most of the abdominal contents require a moist environment -Apply a clean or sterile dressing that has been moistened with saline (normal saline IV fluid can be used) -Attempts should NOT be made to replace the protruding segment back into the abdominal cavity -Any action that increases intraabdominal pressure such as crying, screaming, coughing, and bearing down can force more of the organs outward
Which burn casualties get transported as Urgent Surgical?
-Inhalation injuries -2nd Degree burns >20%TBSA and 3rd or 4th degree -Burns to the face, hands, feet, genitalia, perineum or major joints -Electrical and Chemical Burns - Burn casualty with preexisting illnesses -Casualties with burns and trauma -Children -Circumferential Chest burns
what injuries are considered severe TBI
-Intracranial hematoma -epidural hematoma -subdural hematoma -cerebral contusions -subarachnoid hemorrhage
what are mangled extremities and how are they managed
-Involves skin, muscle, tendons, bone, vessels, nerves -Apply tourniquets to control hemorrhage -Evacuate the casualty as an urgent surgical priority
how should eyes be irrigated
-Irrigate affected eyes and lids gently with sterile water or IV solution. (NS or Lactated Ringers) -When irrigating the eyes, ensure the irrigation drainage does not come into contact with the other eye. -How long should chemical burns be irrigated? -*Irrigation should be maintained, for as long as supplies will allow or until the casualty reaches a medical treatment facility* -*irrigate chemical burns at least 20min*
categories of musculoskeletal injuries
-Isolated non life-threatening musculoskeletal trauma (isolated limb fractures). -Non life-threatening musculoskeletal trauma, but with multisystem lifethreatening trauma (life-threatening injuries with limb fractures). -Definite musculoskeletal life-threatening injuries (pelvic and femur fractures with life-threatening blood loss)
What is the correct length and consistency of a splint?
-Long enough to immobilize the joint above and below the injury and rigid enough to keep the bone from moving -use at least four ties (two above and two below the fracture) with nonslip knots to secure the splints -If splinting material is not available, then swathes or a combination of swathes and slings can be used to immobilize an extremity with an anatomic splint
what is the corrective action if you suspect compartment syndrome?
-Loosen tightly applied splints or dressings and reassess for presence of a distal pulse -tighten tourniquets or apply a second tourniquet directly above the first until a distal pulse can no longer be detected
what are the 3 MOIs that you would consider spinal precautions for
-MVC -fall >15ft -IED blast involving MRAP vehicle
what should you gather for an ocular history
-Mechanism of Injury: Blunt, Penetrating, Projectile? Thermal, chemical or laser burn? -Glasses or contact lenses? -Eye disease or previous eye trauma/surgery? -Eye pain or loss of vision? One eye or both?
When using improvised material, what are some general rules to follow and why?
-Narrow materials should not be used to secure a splint. -If raw materials are not available, anatomical splints may be utilized. -Splints should be padded.
What are important indicators for establishing a high index of suspicion for abdominal injuries?
-Obvious signs of trauma -Signs of hypovolemic shock without obvious cause -Degree of shock greater than would be expected by other injuries -Presence of peritoneal signs -Mechanism of injury
Why do we splint musculoskeletal injuries?
-Prevent motion in the broken bone ends. -Not only decreases pain but also eliminates further damage to muscles, nerves, and blood vessels and helps to control hemorrhage
red flags for TBI/head injuries
-Witnessed loss of consciousness (LOC) -Double vision -Two or more blast exposures within 72 hrs -Worsening headache -Amnesia/Memory problems -Weakness -Unusual behavior/combative -Cannot recognize people -Unequal pupils or disoriented to place -Seizures -Unsteady on feet -Repeated vomiting -Abnormal speech
signs/symptoms of TBI
-a transient alteration in neurologic function SYMPTOMS -Headache, Nausea, Vomiting -Dizziness/balance problems -Fatigue -Insomnia/sleep disturbances -Drowsiness -Sensitivity to light/noise Blurred vision -Difficulty remembering/concentrating SIGNS -Vacant stare -Delayed verbal response -Confused and inability to focus attention -Disoriented -Slurred or incoherent speech -Lack of coordination (stumbling/dizzy) -Inappropriate emotions to circumstances -Short-term memory deficits (casualty repeats same questions) -Inability to memorize and recall
criteria for moderate TBI
-admitted or observed because of the potential for deterioration -Confused or disoriented state which *lasts more than 24 hours* -Loss of consciousness for *more than 30 minutes but less than 24 hours* -Memory loss lasting *more than 24 hours, but less than seven days* -Structural brain imaging (MRI or CT scan) with normal or abnormal results
what do you do If distal pulses are absent in a musculoskeletal injury
-apply gentle traction in an attempt to realign it -If resistance is encountered, splint the extremity in the position found.
what can pupil reaction tell us (very important to know)
-difference >1mm in pupil size is abnormal -sluggish or nonreactive pupil is abnormal -both pupils dilated and not reactive to light indicates brainstem injury -injury is reversible if pupils are dilated but react to light -dilated pupils with normal LOC is not dur to head injury
why is Blunt trauma possesses a greater threat to life
-difficult to diagnose -Objective evidence of blunt trauma may not appear on the casualty for hours
inhalation burns -effects on airway patency -sign/symptom -early signs -treatment
-edema of the airway above the vocal cords can occlude the airway sign/symptom -Difficulty breathing (dyspnea) -Coughing, stridor -Breath has "smoky" or "chemical" smell -Black residue in patient's nose and mouth -Nasal or facial hairs are singed -Burns to the head, the face, or the front of the trunk early signs -Facial burns -singed eyebrows -carbonaceous sputum treatment -perform a cricothyroidotomy immediately
nasal fractures
-epistaxis -edema -ecchymosis -nasal deformity -crepitus
mid-face fracutres
-face may appear asymmetrical or flattened -inability to close mouth -face pain and numbness -crepitus
when/how should IV access be obtained for burns
-obtain vascular access for casualties suffering from burns covering greater than 20% of the total body surface area -Immediately begin fluid resuscitation following "The Rule of Tens" -Avoid placement of I.V through burned tissue unless no other site is available -An IO catheter should be placed if IV access cannot be established
What are the five P's of compartment syndrome?
-pain (early sign) -paresthesia (burning, prickling, pins and needles, itching, or tingling of the skin) -pulselessness (late sign) -pallor (late sign) -paralysis (late sign)
how to conduct gross visual acuity test
-read or identify information on a near card. Or any printed material you may have with you. -Count how many fingers are held up and record the furthest distance the fingers can be counted correctly. -Assess ability to detect hand motion 1-2 in. in front of the eye. -Test for light perception. (if they can tell when the light is turned on & off)
how to transport a casualty with a TBI
-supine -facial wound present: tilt casualty towards side of injury to allow for drainage -cerebral perfusion may be jeopardized when head is elevated > 30 degrees
mandible fractures
-teeth no longer fit together properly or may be missing -crepitus or step off
what are the three elements of smoke inhalation
-thermal injury -asphyxiation -toxin-induced lung injury (leading cause of death in fires is not thermal injuries but the inhalation of toxic smoke)
criteria for severe TBI
-two types: Closed and Open -Confused or disoriented state lasting *more than 24 hours* -Loss of consciousness for *more than 24 hours* -Memory loss lasting *more than seven days* -Structural brain imaging (MRI or CT scan) with normal or abnormal results. -Accounts for 8% of head injuries. -The mortality approaches 40% with deaths usually occurring within 48 hours -Long term disability is common
what are the most dangerous aspects of abdominal trauma that have immediate consequences to life
-uncontrolled hemorrhage -time
linear skull fractures
-usually no bone displacement -*account for 80% of skull fractures*
how much blood can one femur fracture lose
1-2 L
how much fluid can the peritoneal cavity hold before evidence of distention is apparent
1.5 L
what percent of stab wounds compared to gunshot wounds require surgical intervention
15% stab wounds 85% GSW
if casualty if showing signs of increased ICP what rate should you ventilate them at
20 bpm and SPO2 >90%
What percentage of penetrating trauma in the gluteal area is associated with significant intraabdominal trauma?
50%
what is crush syndrome
Damaged muscle tissue that releases myoglobin and potassium
should morphine be administered to casualty with suspected TBI
Due to Morphine's effect on ICP and pupillary response, it is NOT recommended in patients with a suspected brain injury
what are the different degrees of burns and explain them
FIRST degree -epidermis -heals in 3-6 days SECOND degree -epidermis and part of dermis -mottles, red, blisters -painful -surgical repair or graft may be required -heal in 2-4 weeks THIRD degree -all layers of epidermis and dermis -charred, translucent, pearly white that's dry with thrombosed (clotted) BV -pain (3rd degree burns surrounded by 2nd degree burns) -surgical repair with skin grafting and rehab is necessary FOURTH degree -damages skin and underlying layers of subcutaneous tissue, muscle, bone, or internal organs
What type of VA can be completed on the battlefield?
Gross Vision Examination
The most reliable indicator of intraabdominal bleeding is?
Hypovolemic shock from an unexplained source
How should musculoskeletal trauma be treated in the following circumstances: -If the tactical situation and the casualty's condition allows? -In a life-threatening situation? -In a hostile environment?
If the tactical situation and the casualty's condition allows? -Splint suspected musculoskeletal injuries. In a life-threatening situation? -Injuries may be splinted while the casualty is being transported. In a hostile environment? -There may not be time to splint an injury.
How is a gross visual acuity test completed?
In order, ask to read near card, count fingers at a distance, asses ability to detect hand motion, turn off all light and test eyes for light perception
what is peritonitis
Inflammation of peritoneum or ABD lining
Why is normal saline the solution of choice for crush injuries instead of lactated ringers?
Lactated ringers contains potassium which is also released from the damaged muscle tissue and can cause cardiac arrthymias
What type of physical exam should be completed on a combat casualty with an abdominal injury?
Light palpation for TRDP -deep palpation may dislodge blood clots, promote existing hemorrhage and increase spillage of contents of the GI tract
What information is necessary to assume the casualty is suffering from an abdominal injury due to blunt trauma?
MOI and pain
When should pain management be considered for musculoskeletal injuries?
Once the injury is splinted
What is the goal of burn wound care?
Prevent shock, infection and minimize disfiguration
What is the definitive treatment facility for a casualty suffering from a head injury?
Role 3 with neurosurgical capabilities
how to treat the 3 types of foreign bodies in an ocular injury
Superficial Foreign Bodies -Irrigate and cover affected eye with a Fox Eye Shield Embedded or Penetrating Foreign Bodies -Do not attempt to remove the object -Stabilize the object, if necessary -Cover affected eye with a Fox Eye Shield, if possible Foreign Body No Longer Present -Cover affected eye with a Fox Eye Shield for all, administer combat pill pack and Evacuate casualty to a MO as soon as possible with glasses, if indicated
How does this swelling affect extremities in burn casualties?
Swelling and edema, especially with circumferential burns of extremities, can compromise distal circulation therefore, be prepared to monitor extremity pulses
how to treat thermal, laser, and chemical burns
THERMAL and LASER -Stop the burning -Cover affected eye with dry sterile dressing. -Follow burn protocols. -Pain management? -*Combat pill pack (don't administer if only suffering from thermal burns)* -Evacuate casualty. CHEMICAL (*irrigate first* before performing VA and physical assessment) -Immediately irrigate the eyes. -Administer combat pill pack. -Evacuate casualty
What is the primary factor in assessing abdominal trauma?
The determination that an abdominal injury does exist
cribriform plate
The horizontal plate of the ethmoid bone separating the cranial cavity from the nasal cavity.
How does placing musculoskeletal injuries in categories help?
These categories will help you understand the priority of care.
During pregnancy, how long is the uterus protected by the pelvis?
Until about the 12th week
You have a casualty with an open skull fracture. You should?
apply sufficient pressure
What is the most common cause of compartment syndrome in combat casualties?
arterial blood flow continues into an extremity, but venous flow is restricted from returning to the system
what is APEL
authorized protective eyewear list
when should you achieve vascular access and contact MO for musculoskeletal injuries
before extrication
why is covering both eyes during combat not recommended
casualty with both eyes covered is rendered defenseless against the enemy and is completely dependent on others
3 brain hemispheres and their functions
cerebrum (largest) -sensory function -motor function -higher intellectual function -intelligence -memory cerebellum -primitive functions -coordination -balance brainstem -vital body function -cardio-respiratory function
which eye injury must be flushed before conducting a visual acuity assessment
chemical burns
when should pressure dressing not be used for head injuries
do not apply pressure dressings to open or depressed skull fractures
What is a common complaint for a patient that has an orbital fracture?
double vision
according to DA PAM 40-506 2 June 2003, para 4.13. c when will contact lenses not be worn
during BCT, field exercises, gas chamber exercises, developments, combat -wearing contact lenses will worsen chemical exposures of eye and corneal injuries such as corneal foreign bodies, laceration, ulcers, or infections
cerebral perfusion may be jeopardized when head is elevated how far
elevated greater than 30 degrees
How are circumferential burns treated
escharotomy performed by MO at Battalion Aid Station or FMSC, NOT by a 68W -an incision made through burned skin to help with healing (the scab or crust that forms after a third degree burn is called 'eschar')
what analgesics can worsen a moderate-sever TBI
ketamine and OCTF
For mild TBI what pain control can be administered?
ketamine and fentanyl
how should casualty with abdominal injury be transported
knees bent (to relax abdominal muscles)
How should an obviously pregnant female be transported?
left side, right leg elevated -left side, tilt the right side of the spine board, elevate the casualty's right leg or manually displace the uterus to the left to relieve supine hypotension
how to manage shock If the casualty has an altered mental status due to suspected TBI *and* has weak or absent radial pulse?
resuscitate as necessary to restore and maintain a normal radial pulse -target systolic BP of at least 90mmHg
what does Loss of motor, sensory, and pulse usually indicate
serious arterial and nerve injury
how to control hemorrhage for complex scalp injuries to head
several gauze pads held in place by an elastic roller bandage creates an effective pressure dressing to control significant bleeding
electrical burns -what is the significance of them -indications
significance -more serious than they appear due to damage to deep tissue along unpredictable path -can cause dysrhythmias or loss of pulse -consider AED use indications: -Ruptured tympanic membranes -fractures to multiple areas of the spine and long bones
What is the first intervention provided for a casualty suffering from ocular burns?
stop the burning process
in Tactical Field Care What is the first step for burns?
stop the burning process
