68W STP

Question 1

Adult respirations

Answer 1

12-20 RPM

Question 2

Child (1-10yrs) respirations

Answer 2

15-30 RPM

Question 3

Infant (6-12 month) respirations

Answer 3

25-50 RPM

Question 4

Infant (0-5 month) respirations

Answer 4

25-40 RPM

Question 5

Respiration depth:

Answer 5

Normal: deep, even movement of the chest.

Shallow: minimal rise and fall of the chest and abdomen.

Labored: increased effort to breathe, with possible gasping.

Question 6

Respiration quality:

Answer 6

Normal: effortless, automatic, regular rate, even depth, noiseless, and free of
discomfort.

Dyspnea: difficult or labored breathing.

Tachypnea: rapid respiratory rate; usually is a rate exceeding 24 breaths/min (adult).

Noisy: snoring, rattling, wheezing (whistling), or grunting.

Apnea: temporary absence of breathing.

Question 7

Respiration physical characteristics:

Answer 7

Appearance: the patient may appear restless, anxious, pale, ashen, or cyanotic (blue
skin color).

Position: the patient may alter his position by leaning forward with his hands on his legs
(tripod position) or may be unable to breathe while lying down.

Question 8

Adult pulse:

Answer 8

60-100 BPM

Question 9

Child (1-10yrs) pulse:

Answer 9

70-120 BPM

Question 10

Infant (6-12 month) pulse:

Answer 10

80-140 BPM

Question 11

Infant (0-5 month) pulse:

Answer 11

90-140 BPM

Question 12

What is considered tachycardia in an adult?

Answer 12

100 or more BPM

Question 13

Where to palpate pulse?

Answer 13

Responsive, older than 1yr = radial pulse at wrist.

Unresponsive, older than 1yr = carotid pulse at neck.

Younger than 1yr = brachial pulse at bicep tendon

Question 14

Pulse rhythm:

Answer 14

Regular rhythm.

(1) Usually easy to find.
(2) Has a regular rate and rhythm.
(3) Varies with the individual.

Irregular rhythm (any change from a regular beating pattern).

Question 15

Evaluate pulse strength:

Answer 15

Strong (full) pulse.

(1) Usually easy to find.
(2) Beats evenly and forcefully.

Bounding (stronger than normal) pulse.

(1) Easy to find.
(2) Exceptionally strong heartbeats that make the arteries difficult to compress.

Weak (thready) pulse.

(1) Usually difficult to find.
(2) Weak and thin.

Question 16

What must you explain to patient when taking a BP?

Answer 16

The length of time the procedure will take.

The site to be used.

The physical sensations the patient will feel.

Question 17

Selecting the proper sized sphygmomanometer cuff.

Answer 17

The cuff width should wrap around the arm 1-1.5 times and take up two-thirds of the
upper arm length, if using the brachial artery, and two-thirds of the upper leg length if using the
popliteal artery.

A cuff that is too small may result in falsely high readings; a cuff that is too large may
result in falsely low readings.

Question 18

How to check BP equipment.

Answer 18

Ensure the cuff is completely deflated and fully retighten the one-way valve thumbscrew.

Ensure the sphygmomanometer pressure gauge is reading zero.

Question 19

Describe procedure to obtain a BP from upper arm (brachial artery)

Answer 19

Position the patient and cuff.
Place the patient in a relaxed and comfortable sitting, standing, or lying position.
NOTE: Measuring the blood pressure of a standing patient will result in a slightly higher reading.

With the patient’s arm extended, at approximately heart level and with the palm up, place the cuff over the brachial artery. Ensure the lower edge of the cuff is 1-2 inches above the elbow
and the bladder portion is over the artery.

Wrap the cuff just tightly enough to prevent slippage.

Support the arm so it is in a relaxed state.

Palpate the brachial artery to determine where to place the stethoscope.

Place the stethoscope over the pulse site and hold it
against the artery with nondominant hand.
CAUTION: The cuff should not remain inflated for more than 2 minutes.

With the valve closed tightly, inflate the cuff using the ball-pump until the cuff reads at least 160 mm Hg or until you no longer hear the pulse sounds. Continue
pumping to increase the cuff’s pressure by an additional 30 mm Hg.

Determine the blood pressure reading.
If a stethoscope is used, complete the following steps:
(1) Rotate the thumbscrew in a counter clockwise motion, allowing the cuff to deflate
slowly at about 3 mm Hg per second.
(2) Watch the gauge and listen carefully. Note the patient’s systolic blood pressure as the first distinct “taps” or “thumps” of the pulse waves that can be heard clearly.
(3) Continue to watch the gauge and note the reading where the sound changes again or becomes muffled or disappears. This will be the diastolic blood pressure.
(4) As soon as the pulse sounds cease, open the valve by rotating the thumbscrew and
release the remaining air rapidly.

If a stethoscope is not used, complete the following steps:
NOTE: If in a very noisy environment where hearing the pulse waves is difficult or impossible, the palpation method may be used.
(1) With your nondominant hand, palpate the radial pulse (at the wrist) on the same arm as the cuff.
(2) While palpating the radial pulse, rapidly inflate the cuff until you can no longer feel
the pulse under your fingertips, and then inflate an additional 30 mm Hg above where you last felt the radial pulse.
(3) Rotate the thumbscrew in a counter clockwise motion, allowing the cuff to deflate
slowly at about 3 mm Hg per second.
(4) Watch the gauge, when you again feel the radial pulse return, note the reading on the gauge (systolic blood pressure).
NOTE: The diastolic pressure cannot be determined using this method. If the procedure must be repeated, wait at least 1 minute before repeating the procedure.
(5) As soon as you note the systolic reading, open the valve by rotating the thumbscrew
and release the remaining air rapidly.

Record systolic over diastolic (120/80)
or systolic alone if not using a stethoscope (120/P)

Question 20

Adult BP:

Answer 20

(Systolic) 90-140 mmHg / (Diastolic) 60-90 mmHg

Question 21

Child (1-10yrs) BP:

Answer 21

(Systolic) 80-110 mmHg

Question 22

Infant (0-12 month) BP:

Answer 22

(Systolic) 70 mmHg

Question 23

Hypotension:

Answer 23

BP is lower than the normal range

Question 24

Hypertension:

Answer 24

BP is higher than the normal range

Question 25

Oral temp CAUTIONS:

Answer 25

Do not take an oral temperature when the patient:

1. Has had recent facial or oral surgery.
2. Is unable to follow directions (confused, disturbed, or heavily sedated).
3. Is being administered oxygen by mouth or nose.
4. Is likely to bite down on the thermometer.
5. Has smoked, chewed gum or has eaten or drank anything hot or cold within the last 15 to 30 minutes.

Question 26

Tympanic temp CAUTIONS:

Answer 26

Do not attempt to take a tympanic temperature if the patient has had recent facial or ear surgery or has cerumen (ear wax) impaction.

Question 27

Rectal temp CAUTIONS:

Answer 27

Do not attempt to take a rectal temperature if the patient has had recent rectal
surgery, unless directed to by a medical officer. Do not attempt to take a rectal temperature on an infant unless directed by a medical officer.

Question 28

Temp sites:

Answer 28

Oral: Take an oral temperature if the patient is a conscious adult or child who can follow directions and can breathe normally through their nose.

Tympanic: The tympanic method may be used with conscious or unconscious patients and is the preferred method if the patient has recently had anything to eat or drink.

Rectal: Obtain the patient’s temperature by the rectal method if the oral or tympanic methods are
ruled out by the patient’s condition.

Axillary: Obtain the patient’s temperature by the axillary (least preferred) method if the patient’s condition rules out using the other methods.

Question 29

Select the appropriate thermometer.

Answer 29

Tympanic thermometer.

Oral thermometer: has a blue tip and may be labeled “Oral.”

Rectal thermometer: has a red tip and may be labeled “Rectal.”

Axillary temperatures may be obtained using an oral thermometer.

Question 30

Explain the thermometer procedure and position the patient appropriately

Answer 30

Tympanic method. Position the patient with their head turned to make the ear canal easily accessible.

Oral method. Position the patient seated or lying down.

Rectal method. Position the patient lying on either side with the top knee flexed.

Axillary method. Position the patient either seated or lying face up with the armpit
exposed.

Question 31

How to measure the oral temp?

Answer 31

Oral method. Ensure cover probe is firmly attached to the appropriate probe
attachment. Digital disinfect the thermometer with an alcohol pad. Insert it into the disposable sheath opening; then twist to tear the seal at the dotted line. Pull it apart. Place the thermometer underneath the patient’s tongue. Instruct the patient to close their lips around the instrument firmly but not to bite down.

Question 32

How to measure the rectal temp?

Answer 32

Rectal method. Ensure cover probe is firmly attached to the appropriate probe. In an
adult, insert the thermometer 1 to 2 inches into their rectum. Lift the patient’s upper buttock and ask the patient to take a slow deep breath. This helps relax the anal sphincter to ease insertion of the thermometer.

Question 33

How to measure the tympanic temp?

Answer 33

Tympanic method. Pull the ear pinna upward and rearward; insert the thermometer speculum into the ear canal snugly to create a seal, pointing toward the nose.

Question 34

How to measure the axillary temp?

Answer 34

Axillary method. Pat the armpit dry and place the tip end of an oral thermometer with cover probe firmly attached, in the center of the armpit with the probe attachment tip protruding
to the front of the patient’s body. Place the patient’s arm across his chest.

Question 35

Time requirements for each temp site:

Answer 35

Oral method: must remain in place for at least 3 minutes.
NOTE: If using a digital oral thermometer, leave in place until testing is complete. The digital unit will normally have an audible tone.

Rectal method: must be held in place for at least 2 minutes.

Tympanic method: must remain in place until an audible signal occurs and the patient’s temperature appears on the digital display.

Axillary method: must remain in place for at least 10 minutes.

Question 36

Normal oral temp:

Answer 36

97-99° F.

Question 37

Normal rectal temp:

Answer 37

98-100° F.

Question 38

Normal tympanic temp:

Answer 38

97-99° F.

Question 39

Normal axillary temp:

Answer 39

96-98° F.

Question 40

Record temp to nearest____° F.?

Answer 40

0.2° F.

Question 41

Appropriate oxygen saturation site for adults

Answer 41

Index, middle, ring finger, or toes (if patient has decreased circulation)

Question 42

Appropriate oxygen saturation site for infants

Answer 42

Earlobe clips and neonate sensing probes

Question 43

How to apply O2 saturation sensor?

Answer 43

Wipe selected site with alcohol; apply sensor so that emitting light is directly opposite to detector; attach sensor cable to machine and turn power on.

Question 44

How often should the pulse OX be moved?

Answer 44

2 hours; more adhesive sensors, every 4 hours

Question 45

Explain treatment for respiratory emergency:

Answer 45

Assess the airway and open it, if necessary
(1) Ask the patient a question requiring more than a yes or no answer.
(2) Note whether or not the patient can speak in full sentences.
(3) Look for the presence of drooling that may indicate a partial or complete airway
obstruction.

Assist with artificial ventilations if respiratory effort and rate are inadequate.

(1) Look for the rise and fall of the chest during inspiration and expiration.
(2) Listen for the presence of noisy respirations (e.g., stridor, wheezing).

Apply supplemental oxygen by mask or nasal cannula.

Place the patient in the position of comfort.

Obtain a complete set of vital signs to include pulse oximetry, if available.

Perform a focused physical examination.

a. Listen to the anterior and posterior lung fields with the stethoscope.
b. Look at the chest and abdomen and note the presence of any retractions.
c. Check the skin for the presence of cyanosis.
d. Check the lower extremities for the presence of edema.

Obtain a focused history.

a. Ask the patient if there is an existing condition such as asthma.
b. Ask the patient if he is taking any medications.
c. Question the patient about allergies to medications.
d. Ask the patient if difficulty breathing was of sudden or gradual onset.

Assist the patient in using a metered dose inhaler.

a. Perform the five rights of medication usage.
b. Have the patient exhale deeply.
c. Have the patient place his lips around the opening and press the inhaler to activate the spray as he inhales deeply.
d. Instruct the patient to hold his breath as long as possible before exhaling.
e. Repeat steps 4b through 4d.

Document the procedure on FMC

Transport the patient.

Question 46

Initiate a Tactical Combat Casualty Care (TCCC) Card:

Answer 46

1. Remove the Tactical Combat Casualty Card from the casualty’s improved first aid kit
   (IFAK).
2. Complete all entries as fully as possible.
   a. Front of Card.
   (1) Name/Unit-Write the Soldier’s name and unit.
   (2) DTG (date, time, group) - Add date and time and group. For example, 2 PM on 15
   Aug 2010 would be: “151400AAUG2010”.
   (3) Allergies-Write the Soldier’s known medication allergies; if no allergies, record NKDA
   (no known drug allergies).
   (4) Friendly, unknown, NBC- Circle which exposure resulted in this injury (friendly;
   exposure unknown; or NBC (nuclear, biological, chemical).
   (5) TQ (tourniquet) time-If a tourniquet is applied, circle TQ and write the time of the
   tourniquet application.
   (6) Body picture-Mark an “X” at the site of the injury (ies) on the body picture. For burn
   injuries, circle the burn percentage(s) on the figure.
   (7) GSW, BLAST, MVA Other_______- Circle the cause of injury (gunshot wound, blast,
   motor vehicle accident, other, specify).
   (8) Time, AVPU, Pulse, Resp, BP-record the level of consciousness AVPU (alert, verbal
   stimulus, painful stimulus, unresponsive) and vital signs (pulse, respiration, blood pressure) with
   time.
   b. Back of Card.
   (1) A-Circle airway interventions (intact, Adjunct, Cric (cricothyrotomy) Intubated).
   (2) B-Circle breathing interventions (Chest seal, NeedleD (needle decompression, Chest
   Tube).
   (3) C-Circle bleeding control measures addressing Circulation. Don’t forget tourniquet
   time on from of card (TQ (tourniquet), Hemostatic, Packed, PressureDrsg (pressure dressing).
   (4) Fluids-Circle route of fluid (IV (intravenous) or IO (intraosseous)), type (NS (normal saline solution)), LR (lactated ringer’s solution), Hextend® and amount given. Specify other fluids.
   (5) Drugs-Record the type, dose, route of any drugs given (pain medications, ABX
   (antibiotics), or other).
   (6) Other-use the other section to record any other pertinent notes and to explain any
   action that needs clarification.
   (7) Name-The first responder will sign the card.
   NOTE: When more space is needed for documentation, attach another DA Form 7656 to the
   original by safety pin or other means. The second form will be labeled DA Form 7656 #2 and will
   show the Soldier’s name and unit.
3. Attach the completed TCCC Card to the casualty’s belt loop or insert into the left upper arm
   pocket/left lower leg pants pocket, once completed. If attached, keep the TCCC Card in plain
   view.
   NOTE: Do not attach the TCCC Card to the casualty’s body armor as this equipment may will be
   separated from the casualty once they arrive at the medical treatment facility (MTF).

Question 47

Explain assisting in Vaginal Delivery

Answer 47

1. Assist with the first stage of labor.
   NOTE: 1. Scene size-up, initial assessment, focused history, examination, detailed physical
   examination, ongoing assessment, and evacuate assessment steps must be taken to ensure
   that injury(ies) or illness is/are not over looked resulting in further injury to the patient. 2. Evacuate an expecting mother unless delivery is expected within a few minutes.
   a. Interview the pregnant woman. Request health history.
   (1) Present pregnancy history. Is this your first pregnancy? Have there been
   complications during your pregnancy?
   (2) Medical history. Is there a history of diabetes, hypertension, or chronic diseases?
   (3) Obstetric history. How many times have you been pregnant?
   b. Assess general appearance and behavior.
   c. Check vital signs between contractions. If hypotension occurs, place the patient on her
   left side, administer oxygen (if available), and notify the health care provider immediately.
   d. Assess the labor pattern status.
   (1) Contractions-initial onset, frequency, and duration.
   (2) Discomfort or pain.
   e. Assess amniotic membranes status. Inquire if the patient has experienced constant
   leakage or rupture of vaginal fluid.
2. Assist with the second stage of labor.
   a. Assist with delivery of the infant as directed by health care provider.
   NOTE: If the medic is in an isolated environment and is unable to evacuate the patient, the
   medic will deliver the infant.
   b. Determine if the umbilical cord is around the infant’s neck as the infant is being born.
   Place two fingers under the cord at the back of the baby’s neck. Bring the cord forward, over the
   baby’s upper shoulder and head. If you cannot loosen or slip the cord over the baby’s head,
   clamp the cord in two places and, with extreme care, cut the cord between the two clamps and
   unwrap the ends of the cord from around the baby’s neck and proceed with the delivery.
   c. Support the head after the infant’s head is born.
   d. Suction the mouth two or three times and the nostrils. Avoid contact with the back of the
   mouth.
   e. Support the infant with both hands as the torso and full body are born.
   f. Wipe blood and mucus from the mouth and nose with sterile gauze. Suction the mouth
   and nose again.
   g. Clamp, tie, and cut the umbilical cord (between the clamps) as pulsations cease
   approximately four finger widths from the infant.
   h. Wrap the infant in a warm blanket and place on its side, head slightly lower than the
   trunk.
3. Assist with the third stage of labor.
   a. Observe for delivery of the placenta while preparing the mother and infant for
   evacuation.
   b. Place a sterile pad over the vaginal opening and lower the patient’s legs.
   c. Record the time of delivery and evacuate the mother, infant, and placenta to the hospital.
4. Provide initial care for the newborn.
   a. Position, dry, wipe, and wrap the newborn in a blanket and cover the head.
   b. Perform appearance, pulse, grimace, activity, and respirations (APGAR) testing at 1 and
   5 minutes after birth.
   (1) Appearance (color)-no central (trunk) cyanosis.
   (2) Pulse-greater than 100/min.
   (3) Grimace-vigorous and crying.
   (4) Activity-good motion in extremities.
   (5) Respirations, breathing effort-normal, crying.

Question 48

Initiate Treatment for a Poisoned Casualty

Answer 48

1. Determine the type of poisoning.
   a. Ingested poisons.
   (1) Altered mental status.
   (2) Nausea/vomiting.
   (3) Abdominal pain.
   (4) Diarrhea.
   (5) Chemical burns around the mouth.
   (6) Unusual breath odors.
   b. Inhaled poisons.
   (1) Carbon monoxide.
   (a) Headache.
   (b) Dizziness.
   (c) Dyspnea.
   (d) Nausea/vomiting.
   (e) Cyanosis.
   (f) Coughing.
   (2) Smoke Inhalation.
   (a) Dyspnea.
   (b) Coughing.
   (c) Breath that has a smoky smell or the odor of chemicals involved at the scene.
   (d) Black residue in any sputum coughed up by the casualty.
   (e) Nose-hairs singed from super-heated air.
   c. Injected poisons.
   (1) Sympathomimetics (Uppers- example: cocaine).
   (a) Excitement.
   (b) Tachycardia.
   (c) Tachypnea.
   (d) Dilated pupils.
   (e) Sweating.
   (2) Sedative-Hypnotics (downers-example; Valium®, Xanax®).
   (a) Sluggish.
   (b) Sleepy typical coordination of body and speech.
   (c) Pulse and breathing rates are low, often to the point of a true emergency.
   (3) Hallucinogens.
   (a) Tachycardia.
   (b) Dilated pupils.
   (c) Flushed face.
   (d) Often sees or hears things, has very little concept of time.
   (4) Narcotics.
   (a) Reduced rate of breathing.
   (b) Dyspnea.
   (c) Low skin temperature.
   (d) Muscles relaxed.
   (e) Pinpoint pupils.
   (f) Very sleepy.
   d. Absorbed poisons.
   (1) Liquid or powder on the casualty’s skin.
   (2) Burns.
   (3) Itching.
   (4) Irritation.
   (5) Redness.
2. Initiate treatment for the poisoned casualty.
   a. Ingested poisons.
   (1) Maintain the airway.
   (2) Gather all information about the type of ingested poisoning.
   CAUTION: Activated charcoal is contraindicated for casualties that have an altered mental
   status, that you suspect have swallowed acids or alkalis, or that are unable to swallow.
   (3) Administer activated charcoal.
   NOTE: Be prepared to provide oral suctioning if the casualty starts to vomit. All vomitus must be
   saved.
   (a) Adults and children: 1 gram of activated charcoal/kg of body weight.
   (b) Usual adult dose: 25-50 grams.
   (c) Usual pediatric dose-(1-10 years): 12.5-25 grams.
   (4) Give supplemental oxygen.
   (5) Record the name, dose, and time of administration of medication.
   (6) Transport to the nearest medical treatment facility.
   b. Inhaled poisons.
   (1) Remove the casualty from the unsafe environment.
   (a) Maintain the airway.
   (b) Administer high concentrations of oxygen.
   NOTE: This is the most important treatment for inhalation poisoning.
   (2) Transport to the nearest medical treatment facility.
   (3) Document interventions.
   c. Absorbed poisons.
   (1) Remove the casualty from the source.
   (2) Remove contaminated clothing.
   (3) Brush off any powders from the casualty’s skin.
   (4) Flush the skin with large amounts of water for at least 20 minutes.
   d. Injected poisons.
   (1) Maintain the airway and be prepared to provide assisted ventilations.
   (2) Give supplemental oxygen.
   (3) Look for gross soft tissue damage (“tracks”).
   (4) Protect the casualty from harming self and others.
   NOTE: Be prepared to use restraints.
   (5) Transport to the nearest medical treatment facility.
3. Document procedures. (See tasks 081-831-0033 and 081-833-0145.)

Question 49

Change sterile dressing

Answer 49

1. Verify the medical officer’s orders.
2. Identify the patient.
3. Gather the required supplies.
4. Perform a patient care handwash. (See task 081-831-0007.)
5. Explain the procedure to the patient.
6. Prepare the patient.
   a. Expose the wound by moving the patient’s clothing and folding the bed linens away from
   the wound area, if necessary.
   b. Position the patient to provide maximum wound exposure.
   c. Place a protective pad under the patient.
7. Prepare the work area.
   a. Clear the bedside stand or table.
   b. Cut the required tape strips and attach them where they are accessible.
8. Put on a mask and exam gloves.
9. Remove the outer dressing.
   WARNING: Do not peel the tape away from the wound.
   a. Loosen the ends of the tape by peeling toward the wound while supporting the skin
   around the wound.
   b. Grasp the edge of the dressing and gently remove it from the wound.
   c. Note any drainage, color, and odor associated with the dressing.
   d. If the dressing is grossly saturated, discard the dressing and the gloves in a
   contaminated waste container otherwise, dispose of in regular trash.
10. Perform a patient care handwash.
11. Establish a sterile field. (See task 081-833-0007.)
12. Put on a mask and sterile gloves.
13. Remove the inner dressings.
    a. Using forceps, remove the dressings one at a time.
    b. Note any drainage, color, and odor associated with the dressings.
    c. Discard the dressings in a contaminated waste container.
    d. Drop the forceps on the glove wrap.
14. Assess the wound for:
    a. Redness, swelling, foul odor, and/or bleeding.
    CAUTION: Notify the supervisor if any of the above conditions are present.
    b. Drainage that contains blood, serum, or pus (usually yellow but may be blood-tinged,
    greenish, or brown).
    NOTE: If drainage is present, inform the medical officer and request orders to irrigate the
    wound. (See task 081-833-0012.)
15. Clean the wound with sterile gauze soaked with a sterile cleaning solution in accordance
    with (IAW) medical officers orders and/or local standard operating procedure (SOP).
    a. Linear wound.
    (1) First stroke. Clean the area directly over the wound with one wipe and discard the
    gauze.
    (2) Second stroke. Clean the skin area on one side next to the wound with one wipe and
    discard the gauze.
    (3) Third stroke. Clean the skin area on the other side next to the wound with one wipe
    and discard the gauze.
    (4) Continue the procedure alternating sides of the wound, working away from the
    wound until the area is cleaned.
    b. Circular wound.
    (1) First stroke. Start at the center of the wound, wipe the wounded area with an outward
    spiral motion, and then discard the gauze.
    (2) Second stroke. Clean the skin area next to the wound using an outward spiral
    motion, approximately one and one half revolutions, and then discard the gauze.
    (3) Using successive outward, spiral strokes of approximately one and one half
    revolutions, clean the entire area around the wound.
16. Change sterile gloves.
17. Remove adhesive from around the wound, if necessary.
    a. Using a solvent-soaked cotton tipped applicator or gauze pad, rub gently over the
    adhesive residue IAW medical officers orders and/or local SOP.
    b. Observe the skin for signs of irritation.
18. Apply a sterile dressing.
    NOTE: If the wound has a drain inserted, cut the dressing halfway through and position it
    around the drain.
19. Remove sterile gloves and face mask.
20. Secure the dressing with tape.
    NOTE: Write the date and time the dressing was changed on a piece of tape, initial it, and
    secure the tape to the dressing.
    a. Apply tape to the edge of the dressing with half of the tape on the dressing and the other
    half on the skin.
    b. Write the date and time the dressing was changed on a piece of tape, initial it, and
    secure the tape to the dressing.
21. Dispose of contaminated materials in appropriate waste container IAW local SOP.
22. Perform a patient care hand-wash.
23. Record the procedure on the appropriate form IAW local SOP.
    a. Record the date and time of the dressing change.
    b. Document assessment of the wound’s appearance.
    (1) Type and amount of drainage, if any.
    (2) Characteristics of the wound before and after cleaning.

Question 50

Initiate a Field Medical Card

Answer 50

1. Remove the protective sheet from the carbon copy.
   NOTE: FMCs are issued as a pad of 20 cards, each containing an original card, a carbon
   protective sheet, and a duplicate sheet.
2. Complete the minimum required blocks.
   a. Block 1. Enter the casualty’s name, rank, and complete social security number (SSN). If
   the casualty is a foreign military person (including prisoners of war), enter their military service
   number. Enter the casualty’s military occupational specialty (MOS) or area of concentration for
   specialty code. Enter the casualty’s religion and sex.
   b. Block 3. Use the figures in the block to show the location of the injury or injuries. Check
   the appropriate box(es) to describe the casualty’s injury or injuries.
   NOTE: Use only authorized abbreviations. Except for those listed below, however, abbreviations
   may not be used for diagnostic terminology.
   Abr W-Abraded wound.
   Cont W-Contused wound.
   FC-Fracture (compound) open.
   FCC-Fracture (compound) open comminuted.
   FS-Fracture (simple) closed.
   LW-Lacerated wound.
   MW-Multiple wounds.
   Pen W-Penetrating wound.
   Perf W-Perforating wound.
   SL-Slight.
   SV-Severe.
3. When more space is needed, attach another DD Form 1380 to the original. Label the second
   card in the upper right corner “DD Form 1380 #2.” It will show the casualty’s name, grade, and
   SSN.
   c. Block 4. Check the appropriate box.
   d. Block 7. Check the yes or no box. Write the dose administered and the date and time
   that it was administered.
   e. Block 9. Write the information requested. If you need additional space, use Block 14.
   f. Block 11. Initial the far right side of the block.
4. Complete the other blocks as time permits. Most blocks are self-explanatory. The following
   specifics are noted:
   a. Block 2. Enter the casualty’s unit of assignment and the country of whose armed forces
   they are a member. Check the armed service of the casualty, that is, A/T = Army, AF/A = Air
   Force, N/M = Navy, and MC/M = Marine.
   b. Block 5. Write in the casualty’s pulse rate and the time the pulse was measured.
   c. Block 6. Check the yes or no box. If a tourniquet is applied, you should write in the time
   and date it was applied.
   d. Block 8. Write in the time, date, and type of IV solution given. If you need additional
   space, use Block 9.
   e. Block 10. Check the appropriate box. Write the date and time of disposition.
   f. Block 12. Write the time and date of the casualty’s arrival. Record the casualty’s blood
   pressure, pulse, and respirations in the space provided.
   g. Block 13. Document the appropriate comments by the date and time of observation.
   h. Block 14. Document the provider’s orders by date and time. Record the dose of tetanus
   administered and the time it was administered. Record the type and dose of antibiotic
   administered and the time it was administered.
   i. Block 15. The signature of the provider or medical officer is written in this block.
   j. Block 16. Check the appropriate box and enter the date and time.
   k. Block 17. This block will be completed by the Unit Ministry Team. Check the appropriate
   box of the service provided. The signature of the chaplain providing the service is written in this
   block.
   NOTE: As the FMC is the first, and sometimes only, record of treatment of combat casualties,
   accuracy and thoroughness of information provided is of the utmost importance.
5. Attach the completed FMC to the casualty’s uniform by twisting the wire after threading it
   through the top buttonhole of the uniform. Keep the FMC in plain view.
   NOTE: Do not attach the FMC to the casualty’s body armor as this equipment will be separated
   from the casualty once they arrive at the medical treatment facility (MTF).
   Evaluation Preparation:
   Setup: For training and evaluation construct a combat casualty scenario. Have another Soldier
   act as a casualty and have him respond to the Soldier’s questions with personal data according
   to the scenario provided. Ensure the Soldier acting as the casualty has read the scenario
   thoroughly.
   Brief Soldier: Tell the Soldier to complete the FMC by asking appropriate questions of the
   casualty. Tell the casualty to respond to the Soldier’s questions with necessary information
   according to the scenario provided. To test step 2, you may either have the Soldier complete the
   required blocks, or you may require the completion of all blocks. After step 2, ask the Soldier
   what must be done with each copy of the FMC.

Question 51

Administer External Chest Compressions

Answer 51

1. Establish unresponsiveness (gently shake the casualty, asking, “Are you OK?”).
   a. Assess the victim for a response and look for normal or abnormal breathing.
   NOTE: If there is no response and no breathing or no normal breathing (i.e. only gasping), shout
   for help.
   b. Tap the casualty’s shoulder and shout, “Are you all right?”
   c. If the casualty is unresponsive, continue with step 2.
   d. If responsive, continue evaluating the casualty.
2. Activate the Emergency Response System.
3. Check for signs of circulation.
   a. Attempt to palpate the casualty’s carotid pulse (do not take more than 10 seconds).
   b. If the casualty has a carotid pulse but is not breathing, perform rescue breathing. (See
   task 081-831-0048.)
   c. If you do not definitely feel a pulse within 10 seconds, perform 5 cycles of compressions
   and breaths (30:2 ratio) starting with compressions (C-A-B sequence).
4. Begin chest compressions.
   a. Ensure that the casualty is positioned on a hard, flat surface, in a supine position. Kneel
   next to the casualty.
   NOTE: If you suspect the casualty has a head or neck injury, try to keep the head, neck and
   torso in a line when rolling the casualty to a face up position.
   b. Position yourself at the casualty’s side.
   c. Place the heel of one hand on the center of the casualty’s chest on the lower half of the
   breastbone.
   NOTE: You may either extend or interlace your fingers but keep your fingers off the casualty’s
   chest.
   d. Put the heel of your other hand on top of the first hand.
   NOTE: You may either extend or interlace your fingers, but keep your fingers off of the
   casualty’s chest.
   e. Straighten your arms and lock your elbows and position your shoulders directly over your
   hands.
   f. Give 30 compressions.
   (1) Push hard and fast.
   (2) Press down at least 2 inches (5cm) with each compression.
   NOTE: For each chest compression, make sure you push straight down on the casualty’s breast
   bone. This will require hard work. Adequate depth must be attained for at least 23 of the 30
   compressions.
   g. Deliver compressions in a smooth fashion at a rate of at least 100 per minute, (i.e. an
   adequate rate would be 30 compressions in 18 seconds or less).
   h. At the end of each compression, make sure you allow the chest to recoil (re-expand)
   completely.
   CAUTION: Do not move the casualty while CPR (cardiopulmonary resuscitation) is in progress
   unless the casualty is in a dangerous environment, or if you cannot perform CPR effectively in
   the casualty’s present position or location.
   i. Minimize interruptions.
   NOTE: Do not remove the heel of your hand from the casualty’s chest or reposition your hands
   between compressions.
5. Open the airway. (See task 081-831-0018.)
   NOTE: There are two methods of opening the airway to provide breaths, the head tilt-chin lift or
   the jaw thrust.
6. Give two full rescue breaths.
   a. Move quickly to the casualty’s head and lean over his mouth.
   b. Give two full rescue breaths (each lasting 1 second).
   NOTE: Deliver air over one second to make the casualty’s chest rise.
7. Continue to alternate between chest compressions and ventilations (30:2) until:
   a. The casualty is revived.
   b. You are too exhausted to continue.
   c. You are relieved by another health care provider.
   d. The casualty is pronounced dead by an authorized person.
   e. A second rescuer states, “I know CPR,” and joins you in performing two-rescuer CPR.
8. Limit pulse checks.
9. Perform two-rescuer CPR, if applicable.
   NOTE: When performing two-rescuer CPR, the rescuers must change position every 2 minutes
   to avoid fatigue and increase the effectiveness of compressions.
   a. Compressor: Give 30 chest compressions at the rate of 100 per minute.
   b. Compress the chest at least 2 inches (5cm).
   c. Allow the chest to recoil competely after each compression.
   d. Minimize interruptions in compressions, (limit any interruptions to less than 10 seconds).
   e. Count compressions aloud.
   f. Switch duties with the second rescuer every 5 cycles or about 2 minutes, taking less than
   5 seconds to switch.
   g. Ventilator: Maintain an open airway. (See task 081-831-0018.)
   CAUTION: Do not push on the abdomen. If the casualty vomits, turn the casualty on his side,
   clear the airway (suction), and the continue CPR (If you suspect trauma, logroll the patient as a
   unit, clear the airway (suction), and then continue CPR).
   h. Give breaths, watching for chest rise and avoiding excessive ventilation.
   NOTE: If signs of gastric distension are noted, do the following: 1. Recheck and reposition the
   airway. 2. Watch for rise and fall of the chest. 3. Ventilate the casualty only enough to cause the
   chest to rise.
   NOTE: If the casualty is intubated, the ratio of breaths to compressions becomes asynchronous.
   Give 100 compressions per minute with a ventilation rate of approximately 10 to 12 per minute.
   i. Encourage the first rescuer/compressor to perform compressions that are deep enough
   and fast enough to allow complete chest recoil between compressions.
   j. Switch duties with the second rescuer every 5 cycles or about 2 minutes taking less than
   5 seconds to switch.
10. Continue to perform CPR as stated in the task standard.
    NOTE: The rescuer doing rescue breathing should recheck the carotid pulse every 3 to 5
    minutes.
    CAUTION: During evacuation, CPR or rescue breathing should be continued en route if
    necessary.
11. Continue evaluating the casualty when the pulse and breathing are restored. If the
    casualty’s condition permits, place him in the recovery position. (See task 081-831-0018.)
12. Document the procedure on the SF 600.
    Evaluation Preparation:
    Setup: For training and evaluation, a CPR mannequin must be used. Place the mannequin face
    up on the floor (in the supine position). One-Rescuer, Two-Rescuer or a combination of both
    (see NOTE after step 14e) can be evaluated. If two Soldiers are involved, they will be
    designated as “rescuer #1” and “rescuer #2.” Rescuer #1 will start in the chest compression
    position and will be the only one scored during performance of the task. The evaluator will
    ensure that all aspects of the task are evaluated by indicating whether the pulse is present and
    when the rescuers would change positions.
    Brief Soldier: If two Soldiers are involved, tell them about their roles as rescuer #1 and #2. Ask
    rescuer #1 on what type of surface the casualty should be positioned. Then, tell the Soldier(s) to
    perform One-Rescuer or Two-Rescuer CPR as appropriate.

Question 52

Perform a Medical Patient Assessment

Answer 52

1. Take body substance isolation precautions.
2. Perform scene size-up.
   a. Determine the safest route to access the patient.
   b. Determine the mechanism of injury/nature of illness.
   c. Determine the number of patients.
   d. Request additional help if necessary.
   e. Consider stabilization of the spine.
3. Perform an Initial Assessment.
   a. Form a general impression of the patient and the patient’s environment.
   b. Assess the patient’s mental status using the Alert, Verbal, Pain, Unresponsive (AVPU).
   (1) A-Alert and oriented.
   (2) V-Responsive to verbal stimuli.
   (3) P-Responsive to painful stimuli.
   (4) U-Unresponsive.
   c. Determine the chief complaint/apparent life-threatening condition.
   d. Assess the airway.
   (1) Perform an appropriate maneuver to open and maintain the airway if necessary. (See
   task 081-831-0018.)
   (2) Insert an appropriate airway adjunct, if necessary. (See tasks 081-833-0016, 081-
   833-0142, and 081-833-0169. Also if skill level 30, See task 081-830-3016.)
   e. Assess breathing.
   (1) Determine the rate, rhythm, and quality of breathing.
   (2) Administer oxygen if necessary using the appropriate delivery device. (See tasks
   081-833-0158 and 081-831-0048.)
   f. Assess circulation.
   (1) Check skin color and temperature.
   (2) Assess the pulse for rhythm and force.
   (a) Check the radial pulse in adults.
   (b) Check the radial pulse and capillary refill in children under 6 years old.
   (c) Check the brachial pulse and capillary refill in infants.
   (3) Check for major bleeding.
   (4) Control major bleeding. (See tasks 081-833-0161 and 081-833-0046.)
   (5) Treat for shock. (See task 081-833-0047.)
   g. Identify priority patients and make a transport decision (load and go or stay and play).
   NOTE: High priority conditions that require immediate transport include poor general
   impression, unresponsive, responsive but not following commands, difficulty breathing, shock,
   complicated childbirth, chest pain with systolic blood pressure less than 100, uncontrolled
   bleeding, and severe pain.
4. Conduct a rapid physical exam if the patient is unconscious. Inspect each of the following
   areas for deformities, contusions, abrasions, punctures or penetration, burns, tenderness,
   lacerations, swelling (DCAP-BTLS).
   a. Assess the head.
   b. Assess the neck.
   c. Assess the chest.
   d. Assess the abdomen.
   e. Assess the pelvis.
   f. Assess the extremities.
   g. Assess the posterior.
5. Gather a SAMPLE history from the patient.
   a. Signs and symptoms. Gather history of the present illness (OPQRST) from the patient.
   (1) RESPIRATORY.
   (a) Onset-When did it begin?
   (b) Provocation - What were you doing when this came on?
   (c) Quality-Can you describe the feeling you have?
   (d) Radiation-Does the feeling seem to spread to any other part of your body? Do you
   have pain or discomfort anywhere else in your body?
   (e) Severity On a scale of 1 to 10, how bad is your breathing trouble (10 is worst, 1 is
   best)?
   (f) Time How long have you had this feeling?
   (g) Interventions-Have you taken any medication to help you breathe? Did it help?
   (2) CARDIAC.
   (a) Onset-When did it begin?
   (b) Provocation-What were you doing when this came on?
   (c) Quality-Can you describe the feeling you have?
   (d) Radiation-Does the feeling seem to spread to any other part of your body? Do you
   have pain or discomfort anywhere else in your body?
   (e) Severity-On a scale of 1 to 10, how bad is your breathing trouble (10 is worst, 1 is
   best)?
   (f) Time-How long have you had this feeling?
   (g) Interventions-Have you taken any medication to help you? Did it help?
   (3) ALTERED MENTAL STATUS.
   (a) Description of the episode Can you tell me what happened? How did the episode
   occur?
   (b) Onset-How long ago did it occur?
   (c) Duration-How long did it last?
   (d) Associated symptoms-Was the patient sick or complaining of not feeling well
   before this happened?
   (e) Evidence of trauma Was the patient involved in falls or accidents recently?
   (f) Interventions-Has the patient taken anything to help with this problem? Did it help?
   (g) Seizures-Did the patient have a seizure?
   (h) Fever - Did the patient have a fever? What was the patient’s temperature?
   (4) ALLERGIC REACTION.
   (a) History of allergies-Do you have any allergies?
   (b) What were you exposed to-Is there any chance that you were exposed to
   something that you may be allergic to?
   (c) How were you exposed-How did you come into contact with ___________
   (whatever the patient is allergic to)?
   (d) Effects - What kind of symptoms are you having? How long after you were
   exposed did the symptoms start?
   (e) Progression-How long after you were exposed did the symptoms start? Are they
   worse now than they were before?
   (f) Interventions-Have you taken anything to help? Did it help?
   (5) POISONING/OVERDOSE.
   (a) Substance-What substance was involved?
   (b) When did you ingest/become exposed-When did the exposure/ingestion occur?
   (c) How much did you ingest-How much did the patient ingest?
   (d) Over what time period-Over how long a period did the ingestion occur?
   (e) Interventions-What interventions did the family or bystanders take?
   (f) Estimated weight-What is the patient’s estimated weight?
   (6) ENVIRONMENTAL EMERGENCY.
   (a) Source-What caused the injury?
   (b) Environment-Where did the injury occur?
   (c) Duration-How long were you exposed?
   (d) Loss of consciousness-Did you lose consciousness at any time?
   (e) Effects (general or local)-What signs and symptoms are you having? What effect
   did being exposed have on the patient?
   (7) OBSTETRICS.
   (a) Are you pregnant?
   (b) How long have you been pregnant?
   (c) Are you having pain or contractions?
   (d) Are you bleeding? Are you having any discharge?
   (e) Do you feel the need to push?
   (f) When was your last menstrual period?
   (8) BEHAVIORAL.
   (a) How do you feel?
   (b) Determine suicidal tendencies-Do you have a plan to hurt yourself or anyone
   else?
   (c) Is the patient a threat to self or others?
   (d) Is there a medical problem?
   (e) Interventions?
   b. Allergies.
   c. Medications.
   d. Past pertinent history.
   e. Last oral intake.
   f. Event(s) leading to present illness.
6. Perform a focused physical examination on the affected body part/system.
7. Obtain baseline vital signs. (See tasks 081-831-0013, 081-831-0011, 081-831-0010, and
   081-831-0012.)
8. Provide medication, interventions, and treatment as needed. (See tasks 081-831-0035,
   081-833-0103, 081-833-0116, 081-833-0143, 081-833-0144, 081-833-0159, 081-833-0160,
   081-833-0163, 081-833-0166, 081-833-0054, 081-831-0038, 081-831-0039, 081-833-0031,
   081-833-0073, and 081-833-3206.)
9. Reevaluate the transport decision.
10. Consider completing a detailed physical examination.
11. Perform Ongoing Assessment.
    a. Repeat the initial assessment.
    b. Repeat vital signs.
    c. Repeat the focused assessment regarding the patient’s complaint or injuries.

Question 53

Initiate Treatment for a Near Drowning Casualty

Answer 53

1. Ensure the safety of all rescuers, including yourself, before any water rescue can begin.
2. Recognize the signs and symptoms of near drowning.
   a. Change in level of consciousness.
   b. Restlessness.
   c. Chest pain.
   d. Rales, rhonchi, or wheezing.
   e. Vomiting.
   f. Cyanosis.
   g. Signs of shock (common in near-drowning). When shock is present, try to determine if
   shock is hypovolemic, hypoxic, or neurogenic spinal injury.
   h. Pink froth from nose and mouth.
3. Perform prehospital management for near drowning and aspiration.
   a. Raise the casualty to the surface and remove him from the water as soon as possible.
   NOTE: Cervical or spinal injuries are always a primary concern. You must assume that the
   casualty has a spinal injury and treat accordingly. This means that initial resuscitation and spine
   immobilization must occur while the casualty is still in the water. (See task 081-833-0176.)
   b. Perform an initial assessment. Evaluate the need for suction, ventilation, O2
   administration and basic life support (BLS), if needed.
   c. Float a buoyant backboard under the casualty as ventilation is continued.
   d. Secure the trunk and neck to the backboard to eliminate spine motion. Do not remove
   the casualty from the water until this is done.
   e. Remove casualty from water.
   f. Place the casualty in the lateral recumbent position, with the backboard in place.
   g. Cover the casualty with a blanket.
   h. Administer oxygen by mask.
4. Perform a trauma casualty assessment. (See task 081-833-0155.)
   NOTE: All victims should be hospitalized for at least 24 hours for observation. Common
   complications of near drowning are respiratory failure and circulatory collapse.
5. Record all treatment on the FMC.
6. Evacuate the casualty.

Question 54

Operate an Automated External Defibrillator

Answer 54

1. Take appropriate body substance isolation (BSI) precautions.
2. Briefly question the rescuer about the arrest event.
   a. How long has the patient been in arrest?
   b. How long has CPR been in progress?
   c. Do you know two man CPR?
3. Direct rescuer to stop CPR.
4. Determine need for an AED.
   a. Is patient unresponsive to verbal and painful stimuli?
   b. Is patient apneic?
   c. Is patient pulseless?
5. Direct rescuer to continue CPR.
6. Turn on AED.
   WARNING: Do not attach child pads to an adult patient.
7. Attach the pads to patient’s bare chest.
   NOTE: Follow the AED manufacturer’s guidelines on attaching pads to patient and turning on
   the machine.
   a. The sternum pad is placed on the right upper border of the sternum on the anterior chest
   wall. The top edge should be just below the clavicle. This is the negative electrode.
   b. The apex pad is placed over the left lower ribs at the anterior axillary line. This is the
   positive electrode.
8. Direct rescuer to stop CPR.
   WARNING: The AED will analyize any detectable rythm. If anyone is touching the patient, the
   machine may not recommend a shock.
9. Ensure everyone and everything is clear of the patient.
   a. Gives the order “All Clear”.
   b. Visually checks to ensure no one is in contact with the patient.
   c. Visually checks to ensure nothing is in direct contact with the electrodes such as IV lines,
   monitor wires or a bed frame.
10. Initiate analysis of the rythm.
    NOTE: Certain AEDs have an analyze button that will need to be pressed to analyze the rhythm
    and others will analyze automatically. Refer to the manufacturer’s instructions for the type of
    AED used.
    CAUTION: Do not defibrillate if anyone is touching the patient or the patient is wet (dry the
    patient), touching metal, (move the patient), or wearing a medication patch (remove the patch
    with a gloved hand).
11. Press the shock button if AED indicates shock is advised.
    a. Gives the order “All Clear.”
    b. Visually checks to ensure no one is in direct contact with the patient.
    c. Visually checks to ensure no one is in direct contact with any electrically conductive
    material touching the patient such as IV lines, monitor cables or a bed frame.
12. Direct resumption of CPR.
13. Gather additional information about the arrest event.
14. Confirm effectiveness of CPR.
    a. Check pulse during compressions.
    b. Look for rise and fall of chest during ventilations.
15. Inserts or direct insertion of a simple airway adjunct.
    NOTE: Steps 15 and 16 can be done at any time during the task.
16. Connect oxygen to BVM and turn flow meter to 15 liters per minute (lpm).
17. Ventilate or direct assistant to resume ventilations on the patient.
18. Ensure CPR continues without unnecessary interruptions.
19. Reanalyze rhythm after a full cycle of CPR, (approximately 2 minutes), ensure patient is
    clear.
20. Repeat defibrillator steps 8-12.
21. Transport the patient to a higher level of medical care.

Question 55

Manage a Seizing Patient

Answer 55

1. Identify the type of seizure based upon the following signs and symptoms.
   a. Petit mal.
   (1) Brief loss of concentration or awareness without loss of motor tone.
   (2) Lip smaking or eye blinking.
   (3) Occurs mainly in children and is rarely an emergency.
   b. Grand mal (generalized).
   (1) May be preceded by an aura.
   (2) Has two phases.
   (a) Tonic/Clonic Phase–characterized by rigidity and stiffening of the body, drooling
   and occasional cyanosis around the face and lips.
   (b) Postictal Phase-begins when convulsions stop. The patient may regain
   consciousness and enter a state of drowsiness and confusion or remain unconscious for several
   hours.
   (3) May involve incontinence, biting of the tongue (rare), cyanosis or mental confusion.
   c. Status Epilepticus.
   (1) Two or more seizures without an intervening period of consciousness or a seizure
   lasting more than 30 minutes.
   (2) A medical emergency. If untreated it may lead to:
   NOTE: Mentally note the aspects of seizure activity for recording after the seizure.
   (a) Aspiration of secretions.
   (b) Cerebral or tissue hypoxia.
   (c) Brain damage or death.
   (d) Fractures of long bones.
   (e) Head trauma.
   (f) Injured tongue from biting.
   CAUTION: Never place anything in the mouth of a seizing patient.
2. Maintain the airway of a patient exhibiting tonic-clonic movement.
3. Place the patient on his side if possible.
   a. Observe the patient to prevent aspiration and suffocation.
   CAUTION: Do not elevate the patient’s head and do not restrain the patient’s limbs during
   seizures.
   b. Place patient on high-flow oxygen at 15 L/min via non-rebreathing mask if available.
4. Prevent injury to tissue and bones by padding or removing objects on which the patient may
   injure himself.
5. Manage the patient after the convulsive state has ended.
   a. Place the patient on his side if necessary.
   b. Continue to maintain the patient’s airway.
   NOTE: A patient who has just had a grand mal seizure will sometimes drool and will usually be
   drowsy so you must be prepared to suction if equipment is available.
   c. Administer supplemental oxygen, if available, via non-rebreather mask or bag-valvemask
   if not available earlier.
   CAUTION: Sudden, loud noises may cause another seizure.
   d. If possible, place the patient in a quiet, reassuring atmosphere.
6. Record the seizure activity on SF 600.
   a. Duration of seizure.
   b. Presence of cyanosis, breathing difficulty or apnea.
   c. Level of consciousness before, during and after the seizure.
   d. Whether preceded by an aura, (ask patient).
   e. Muscles involved.
   f. Type of motor activity.
   g. Incontinence.
   h. Eye movement.
   i. Previous history of seizures, head trauma and/or drug or alcohol abuse.
   NOTE: If the seizure is witnessed, be sure to ask if they saw the patient fall, how he landed,
   how the patient was moving during the seizure and how long the seizure lasted.
7. Evacuate the patient on his side in the recovery position.
8. Do not cause further injury to the patient.

Question 56

Bandage an Open Wound

Answer 56

1. Perform an EMT-B trauma assessment. (See task 081-833-0053.)
2. Select the bandaging material for the injury.
3. Explain the procedure to the patient.
4. Ask the patient about any allergies to adhesive tape.
5. Check distal pulses for circulation, sensory and motor (CSM) prior to application of bandage
   to an open wound.
6. Prepare the patient for bandaging by positioning the body part in a position of function, if
   able.
7. Place a waterproof pad (chux) underneath the patient.
8. Apply the dressing to the wound.
   a. The dressing should be large enough to extend beyond the wound on all sides.
   NOTE: If necessary, apply additional dressings to adequately cover the wound.
   b. Avoid touching the dressing in the area that will come in contact with the wound.
   NOTE: If sterile dressings are not available; select the cleanest material available.
   c. Grasp the dressing by the corner, taking it directly from its protective pack and place it on
   the wound.
   WARNING: Do not remove the first dressing if it becomes blood soaked. This dressing is
   helping with the formation of a clot.
   d. If dressing becomes blood soaked, add additional dressings on top.
9. Select the most appropriate size bandage to secure the dressing in place.
   a. Tape may be appropriate for small wounds or wounds to the torso.
   b. For wounds on the head or extremeties, roller gauze or triangular bandages work best.
   NOTE: Point pressure can occur if you bandage around a very small area. Avoid bandaging
   over a joint.
10. Apply the bandage.
    a. For wounds of the hand, maintian position of function during bandaging by placing a roll
    of gauze in the patient’s hand prior to applying the bandage.
    NOTE: When bandaging the hands and feet, if possible, leave the fingers and toes exposed so
    CSM can be assessed.
    b. Start at the narrowest part of the limb and work your way up from there.
    c. To begin the bandage, make two or three wraps directly over one another to ensure a
    firm foundation for the bandage.
    d. Overlap each spiral approximately one-third (1/3) to one-half (1/2) to ensure adequate
    coverage of the dressing.
    e. Secure the self-adhering roller bandage with several overlying wraps.
    f. Overlap the bandage, keeping it snug.
    NOTE: Be careful not to interfere with circulation.
    g. The bandage should extend beyond the dressing on all sides.
    CAUTION: Make sure there are no loose ends of cloth, gauze or tape that could get caught
    when the patient is transported.
    h. Secure the bandage with tape or a square knot.
11. Check circulation after application of the bandage.
    a. Check pulse distal to the wound.
    b. Check CSM function to ensure that the bandage is not too tight.
    c. Check for capillary refill (<2 seconds is normal), if applicable.
    d. Inspect the skin below the bandaging for pale or cyanotic skin.
    e. Ask the patient if they are experiencing any numbness, tingling sensation, coldness in
    the bandaged part or pain.
    NOTE: These are indicators that the bandage may be too tight.
12. Check for irritation.
    a. Ask the patient if the bandage rubs.
    b. Check for bandage wrinkles near the skin surface.
    c. Check for red skin or sores (ulcers) when the bandage is removed.
    d. Remove and reapply only the bandage if necessary.
    NOTE: If appropriate, immobilize the limb and watch to see that the bleeding remains controlled
    and check for edema during transport.
13. Keep the patient at rest.
14. Evacuate the patient if necessary.
15. Record the treatment given on the SF 600.

Question 57

Perform Extrication Using a Seated Device

Answer 57

1. Check for signs and symptoms of a spinal injury.
   NOTE: With unresponsive casualties, you should attempt to identify the mechanism of injury
   (MOI).
   WARNING: If you suspect the casualty has a spinal injury, you must treat them as though they
   have a spinal injury; when in doubt, immobilize.
   a. First you will want to minimize all movement of the spine.
   b. Instruct the responsive casualty to remain as still as possible.
   c. Instruct the responsive casualty to answer your questions with a verbal response only
   and not to shake or nod their head.
2. Instruct the second Soldier to establish and maintain manual inline stabilization of the
   casualty’s spine.
   a. Have your assistant properly position their hands.
   b. Keeping the casualty’s head in a neutral position and the nose in line with the casualty’s
   navel.
   c. Careful movement of the head and neck into a neutral position must be stopped if
   movement results in any of the following:
   (1) Neck muscle spasm.
   (2) Increased pain.
   (3) Increase in numbness, tingling, or loss of motor ability.
   (4) Compromise of the airway or ventilation.
   d. Instruct your assistant to continue manual stabilization until the casualty is secured to a
   long spine board.
   NOTE: Manual stabilization is a method of stabilization where the assistant firmly grasps the
   casualty’s head with both hands and attempts to keep it from moving.
   e. Be gentle when handling the extremities.
   f. If possible, inspect the spine for deformities, contusions, abrasions, punctures or
   penetrations, burns, tenderness, lacerations, and swelling (DCAP-BTLS).
   NOTE: Do not move the casualty in an attempt to elicit a painful response.
   g. You can ask the responsive casualty where the pain is and/or palpate the spine with a
   gloved hand.
   h. Palpate for tenderness, instability, or crepitus (TIC) in the spinal region.
   NOTE: In addition to the normal components of your focused history and physical exam, try to
   pinpoint any pain or tenderness along the spine as best as you can.
3. Apply a rigid cervical collar. (See task 081-833-0177.)
4. Check circulation, sensation,and motor (CSM) function of all extremities.
   NOTE: Advise the casualty of what you are planning to do before moving the limb.
   a. Assess the radial pulse rate, quality, and rhythm. Check both radial pulses at the same
   time in order to compare one against the other.
   b. Assess pain response, light touch response, and grip response in both hands.
   (1) Ask casualty if they can tell you which finger you are touching or gently applying
   slight pressure to a finger.
   NOTE: Casualty is not allowed to look or move head, head must be maintained in neutral in line
   stabilization.
   (2) Place two or three of your gloved fingers into both of casualty’s hands and have them
   squeeze as hard as they can to check grip response.
   c. Assess pedal pulse on each foot at the same time in order to compare one against the
   other for quality and strength.
   WARNING: In some casualties it may be difficult to find pedal pulses in their feet. In cases like
   this, it is a good idea to also check capillary refill as a back-up to the pedal pulses.
   d. Assess plantar flexion and dorsiflexion of each foot.
   e. Ask casualty if they can tell you which toe you are touching.
   NOTE: Must remove casualty’s shoes in order to perform assessment of their feet.
5. Position the immobilization/KED behind the casualty and center it.
   NOTE: Before placing the KED behind the casualty, the two long straps leg straps/groin straps
   are unfastened and placed behind the device.
   a. Properly align the device.
   b. Wrap the vest around the casualty’s torso.
   c. Ensure that the device is tucked well up into the armpits. Adjust as necessary.
   d. Secure the chest/torso straps. Evaluate and adjust the straps as needed.
   NOTE: Chest/torso straps should not inhibit chest rise, resulting in respiratory compromise.
   NOTE: Chest/torso straps must be tight enough so the device does not move up, down, left, or
   right excessively, but not so tight as to restrict the casualty’s breathing.
   e. Secure the leg/groin straps.
   f. Secure the head to the device.
   (1) Apply appropriate padding behind the head to maintain proper alignment.
   (2) Apply velcro head straps.
   NOTE: Head immobilization straps should not allow excessive movement.
   g. Secure the casualty’s wrist together and legs together using cravats.
6. Pivot the casualty onto the backboard/long spine board, while maintaining manual in-line
   neutral stabilization.
   a. Release groin straps once casualty is on backboard/long spine board.
   b. Secure casualty to backboard/long spine board. (See task 081-833-0181.)
7. Reassess CSM function of all extremities.
8. Record procedure and casualty’s tolerance of procedure on FMC.

Question 58

Initiate Treatment for a Head Injury

Answer 58

1. Take appropriate body substance isolation (BSI) precautions.
2. Check for the signs and symptoms of head injuries.
   WARNING: Brain injury, leading to a loss of function or death, often occurs without evidence of
   a skull fracture or scalp injury. Because the skull cannot expand, swelling of the brain or a
   collection of fluid pressing on the brain can cause pressure. This can compress and destroy the
   brain tissue.
   a. Closed head injury–caused by a direct blow to the head.
   (1) Deformity of the head.
   (2) Clear fluid or blood escaping from the nose and/or ear(s).
   (3) Periorbital discoloration (raccoon eyes).
   (4) Bruising behind the ears, over the mastoid process (battle sign).
   (5) Lowered pulse rate if the casualty has not lost a significant amount of blood.
   (6) Signs of increased intracranial pressure.
   (a) Headache, nausea, and/or vomiting.
   (b) Possible unconsciousness.
   (c) Change in pupil size or symmetry.
   (d) Lateral loss of motor nerve function-one side of the body becomes paralyzed.
   NOTE: Lateral loss may not happen immediately but may occur later.
   (e) Change in the casualty’s respiratory rate or pattern.
   (f) A steady rise in the systolic blood pressure if the casualty hasn’t lost significant
   amounts of blood.
   (g) A rise in the pulse pressure (systolic pressure minus diastolic pressure).
   (h) Elevated body temperature.
   (i) Restlessness-indicates insufficient oxygenation of the brain.
   b. Concussion-caused by a violent jar or shock.
   NOTE: A direct blow to the skull may bruise the brain.
   (1) Temporary unconsciousness followed by confusion.
   (2) Temporary, usually short term, loss of some or all brain functions.
   (3) The casualty has a headache or is seeing double.
   (4) The casualty may or may not have a skull fracture.
   c. Contusion-an internal bruise or injury. It is more serious than a concussion. The injured
   tissue may bleed or swell. Swelling may cause increased intracranial pressure that may result in
   a decreased level of consciousness and even death.
   d. Open head injury.
   (1) Penetrating wound-an entry wound with no exit wound.
   (2) Perforating wound-the wound has both entry and exit wounds.
   (3) Visibly deformed skull.
   (4) Exposed brain tissue.
   (5) Possible unconsciousness.
   (6) Paralysis or disability on one side of the body.
   (7) Change in pupil size.
   (8) Lacerated scalp tissue-may have extensive bleeding.
3. Direct manual stabilization of the casualty’s head.
4. Assess the casualty’s level of consciousness (LOC) by the following methods.
   a. AVPU Method.
   (1) Does the casualty know their name, date or time; location and events leading up to
   the injury, (Alert and oriented (A&O) x four)?
   (2) Does the casualty respond to verbal stimuli/commands?
   (3) Does the casualty respond to painful stimlus?
   (4) Is the casualty unconscious?
   b. Glasgow Coma Scale (GCS).
   NOTE: The Glasgow Coma Scale (GCS) score is calculated by using the best response noted
   while evaluating the casualty’s eyes, verbal response and motor response. A baseline GCS
   should be calculated to assess the casualty’s LOC accurately. The highest possible score a
   casualty can receive is 15 and the lowest possible score is 3.
   (1) Eye opening.
   (2) Verbal response.
   (3) Motor response.
5. Initiate treatment for the head injury.
   a. Superficial head injury.
   (1) Apply a dressing.
   (2) Observe for abnormal behavior or evidence of complications.
   b. Head injury involving trauma.
   (1) Maintain a patent airway using the jaw thrust maneuver. (See task 081-831-0018.)
   (2) If the casualty is unconscious, insert an oropharyngeal airway without
   hyperextending the neck. (See task 081-833-0016.)
   (3) Administer high concentration oxygen by bag valve mask (see task 081-833-0158), if
   airway is not patent. If airway is patent, administer oxygen by non-rebreather mask. (See task
   081-833-0017.)
   (4) Observe the size of each pupil by shining a light in each eye to observe the pupillary
   reaction to the light.
   NOTE: The pupils should constrict promptly when exposed to bright light. Failure of the pupils to
   constrict may indicate brain injury.
   (5) Apply a cervical collar. (See task 081-833-0177.)
   (6) Dress the head wound(s).
   WARNING: Do not apply pressure to or replace exposed brain tissue.
   (7) Control bleeding. (See task 081-833-0124.)
   (8) Treat for shock.
   (9) Monitor the casualty for convulsions or seizures. (See task 081-831-0035.)
   (10) A casualty with no suspected c-spine injury can have the head elevated 6 inches to
   assist with drainage of blood from the brain.
   CAUTION: Do not give the casualty anything by mouth (NPO).
   (11) A casualty with a suspected c-spine injury should be placed on a long spine board.
   (See task 081-833-0181.)
6. Monitor unstable casualties every 5 minutes and document findings.
   a. Level of consciousness.
   b. Pupillary responsiveness and equality.
   c. Vital signs.
   d. Motor functions.
   (1) Evaluate the casualty’s strength, mobility, coordination and sensation.
   (2) Document any complaints, weakness, or numbness.
7. Record the treatment on the FMC.
8. Evacuate the casualty.
   NOTE: Casualty should be facing you during transport. It is much easier to monitor and manage
   their airway if you can see it all times. Have suction readily available. (See task 081-833-0021.)

Question 59

Initiate Treatment for Foreign Bodies of the Eye

Answer 59

1. Perform visual acuity testing. (See task 081-833-0193.)
2. Assess eyes: pupils, equal, round, reactive to light (PERRL).
3. Locate the foreign body.
   a. Method one.
   (1) Pull the lower lid down.
   (2) Tell the casualty to look up and to both sides and check for foreign bodies.
   (3) Pull the upper lid up.
   (4) Tell the casualty to look down and to both sides and check for foreign bodies.
   b. Method two.
   (1) Tell the casualty to look down.
   (2) Grasp the casualty’s upper eyelashes and gently pull the eyelid away from the
   eyeball.
   (3) Place a cotton-tipped swab horizontally along the outer surface of the upper lid and
   fold the lid back over the swab.
   CAUTION: If the foreign bodies cannot be located, bandage both eyes and seek further medical
   aid immediately.
   (4) Look for the foreign bodies or damage on the globe.
   CAUTION: Do not put pressure on the globe.
4. Remove the foreign body.
   a. Small foreign body on an anterior surface.
   (1) Hold the casualty’s eye open.
   (2) Irrigate the eye. (See task 081-833-0054.)
   b. Foreign body stuck to the cornea or lying under the upper or lower eyelid.
   (1) For a foreign body under the lower eyelid, pull the lower lid down.
   (2) For a foreign body under the upper eyelid, pull the upper lid up.
   CAUTION: Bandage both eyes if foreign bodies are not easily removed by these methods or if
   there is pain or loss of vision in the eye. Seek further medical aid immediately.
   (3) Remove the foreign body with a moistened, sterile cotton-tipped swab.
   NOTE: In hazardous conditions, leave the good eye uncovered long enough to ensure the
   casualty’s safety.
   CAUTION: Do not attempt to remove a foreign body stuck to or sticking into the eyeball. A
   medical officer must remove such objects.
   c. Foreign body stuck or impaled in the eye.
   (1) Apply dry sterile dressings to build around and support the object.
   NOTE: This will help prevent further contamination and minimize movement of the object.
   (2) Cover the injured eye with a paper cup or cardboard cone.
   (3) Cover the uninjured eye with a dry dressing or eye patch.
   (4) Reassure the casualty by explaining why both eyes are being covered.
   NOTE: The eyes move together. If the casualty uses (moves) the uninjured eye, the injured eye
   will move as well. Covering both eyes will keep them still and will prevent undue movement on
   the injured side.
   (5) Seek further medical aid immediately.
5. Obtain details about the injury.
   a. Source and type of the foreign bodies.
   b. Whether the foreign bodies were wind-blown or high velocity.
   c. Time of onset and length of discomfort.
   d. Any previous injuries to the eye.
6. Record the procedure on the FMC.
7. Evacuate the casualty, as required.
8. Do not cause additional injury to the eye.
   a. Do not probe for foreign bodies.
   b. Do not put pressure on the globe.
   c. Do not remove an impaled object.

Question 60

Initiate Treatment for Lacerations of the Eyelid

Answer 60

1. Position the casualty and remove his headgear, if necessary.
   a. Conscious casualty will be placed in a seated position.
   b. Unconscious casualties will be placed in a supine position with the head slightly
   elevated.
2. If conscious, perform visual acuity testing. (See task 081-833-0193.)
3. Assess eyes: pupils, equal and round, regular in size, and react to light (PERRL).
4. Examine the eyes for the following:
   a. Objects protruding from the globe.
   b. Look for foreign bodies or damage on the globe.
   c. Swelling or lacerations on the globe.
   d. Bloodshot appearance of the sclera.
   e. Bleeding.
   (1) Surrounding the eye.
   (2) Inside the globe.
   (3) Coming from the globe.
   f. Contact lenses. Ask the casualty if he is wearing contact lenses but do not force the
   eyelids open. Record that they are being worn, if appropriate.
5. Categorize the injury.
   a. Injury to the tissue surrounding the eye (lacerations and contusions).
   b. Injury to the globe.
   c. Extrusion.
   d. Foreign bodies. (See task 081-833-0039.)
   e. Protruding (impaled) objects.
6. Treat the injury.
   NOTE: Torn eyelids should be handled carefully. Wrap any detached fragments in a separate
   moist dressing and evacuate with the casualty.
   a. Control bleeding with light pressure from a dressing; use no pressure at all if you suspect
   that the eyeball itself has been injured.
   b. Cover the eyelid with sterile gauze soaked in saline to keep the wound from drying.
   c. Preserve any avulsed skin and transport it with the casualty for possible grafting.
   d. If penetrating eyeball injury is not suspected, cover the injured eyelid with cold
   compresses to reduce swelling.
   e. Cover the uninjured eye with a bandage to decrease movement, and transport.
   NOTE: In hazardous conditions, leave the good eye uncovered long enough to ensure the
   casualty’s safety.
7. Record the procedure on the FMC.
8. Evacuate the casualty.
   a. Transport the casualty on his back, with the head elevated and immobilized.
   b. Evacuate eyeglasses with the casualty, even if they are broken.
9. Did not cause additional injury to the eye.

Question 61

Initiate Treatment for Extrusions of the Eye

Answer 61

1. Position the casualty and remove his headgear, if necessary.
   a. Conscious-seated.
   b. Unconscious-lying on his back with the head slightly elevated.
2. If conscious, perform visual acuity testing. (See task 081-833-0193.)
3. Assess eyes: pupils, equal and round, regular in size, and react to light (PERRL).
4. Examine the eyes for the following:
   a. Objects protruding from the globe.
   b. Swelling or lacerations on the globe.
   c. Bloodshot appearance of the sclera.
   d. Bleeding.
   (1) Surrounding the eye.
   (2) Inside the globe.
   (3) Coming from the globe.
   e. Contact lenses. Ask the casualty if he is wearing contact lenses but do not force the
   eyelids open. Record that they are being worn, if appropriate.
   f. Extrusion (the eye is protruding from the socket).
   CAUTION: Do not attempt to reposition the globe or replace it in the socket.
5. Treat the injury.
   a. Position the casualty face up.
   b. Cut a hole in several layers of dressing material, and then moisten it. Use sterile liquid, if
   available.
   c. Place the dressing so the injured globe protrudes through the hole, but does not touch
   the dressing. The dressing should be built up higher than the globe.
   NOTE: If available, place a paper cup or cone-shaped piece of cardboard over the eye. Do not
   apply pressure to the injury site. Apply roller gauze to hold the cup in place.
   d. Cover the uninjured eye to prevent sympathetic eye movement.
   NOTE: In hazardous conditions, leave the good eye uncovered long enough to ensure the
   casualty’s safety.
6. Record the procedure on the FMC.
7. Evacuate the casualty.
   a. Transport the casualty on his back, with the head elevated and immobilized.
   b. Evacuate eyeglasses with the casualty, even if they are broken.
8. Do not cause further injury to the casualty.

Question 62

Perform an EMT-B Trauma Assessment

Answer 62

1. Take BSI precautions.
2. Perform a Scene Size-Up.
   a. Determine the safest route to access the casualty.
   b. Determine the mechanism of injury (MOI).
   c. Determine the number of casualties.
   d. Request additional help, if necessary.
   e. Consider the need for spinal stabilization.
   NOTE: If the MOI is significant, direct another Soldier to provide manual, in-line stabilization of
   the cervical spine.
3. Perform an Initial Assessment.
   NOTE: Life threatening injuries should be managed as they are identified.
   a. Form a general impression (global overview) of the casualty’s condition and environment.
   b. Determine the chief complaint.
   c. Assess the airway.
   (1) Perform appropriate maneuver to open and maintain the airway. (See task 081-831-
   0018.)
   (2) Insert an appropriate airway adjunct, if necessary. (See tasks 081-833-0016, 081-
   833-0142, and 081-833-0169. Also if skill level 30, See task 081-830-3016.)
   d. Assess breathing.
   (1) Determine the rate, depth and ease of respirations, (breathing).
   (2) Administer supplemental oxygen by non-rebreathing mask, if available. (See tasks
   081-833-0158 and 081-831-0048.)
   e. Assess circulation.
   (1) Skin color, condition, and temperature (CCT).
   (2) Assess the pulse for rate, rhythm, and strength.
   (a) Check the radial pulse in adults.
   (b) Check the radial pulse and capillary refill in children.
   NOTE: Capillary refill should only be checked in children less than 6 years old.
   (c) Check the brachial pulse and capillary refill in infants.
   (3) Check for significant hemorrhage (bleeding).
   (4) Control bleeding. (See tasks 081-833-0161 and 081-833-0212.)
   (5) Treat for shock. (See task 081-833-0047.)
   f. Assess the casualty’s mental status using the Alert, Verbal, Pain, Unresponsive (AVPU)
   scale.
   (1) A - Alert and oriented (eyes open spontaneously as you approach; casualty appears
   aware and responsive to the environment).
   (2) V - Responsive to verbal stimuli (sound).
   (3) P - Responsive to painful stimuli (touch, such as tapping the casualty on the shoulder
   or pinching the casualty’s ear).
   (4) U - Unresponsive (does not respond to any stimuli).
   g. Determine casualty priority and make a transport decision.
   NOTE: High priority conditions that require immediate transport include a poor general
   impression, unresponsive, responsive but not following commands, difficulty breathing, shock,
   complicated childbirth, chest pain with systolic blood pressure less than 100 mm Hg,
   uncontrolled bleeding, and severe pain.
4. If the MOI is significant, perform a Rapid Trauma Assessment.
   NOTE: A significant MOI includes ejection from a moving vehicle, death in the same passenger
   compartment, falls greater than 20 feet, rollover of vehicle, high-speed vehicle collision, vehiclepedestrian
   collision, motorcycle crash, trauma resulting in a loss of consciousness or altered
   mental status, and penetrations of the head, chest, abdomen (e.g., stab and gunshot wounds)
   or pelvis, and significant blunt trauma to the head, chest, abdomen, or pelvis. Additional
   significant MOI for a child include falls from more than 10 feet, bicycle collision, and vehicles in
   medium speed collision.
   a. Head.
   (1) Inspect for deformities, contusions, abrasions, punctures or penetration, burns,
   tenderness, lacerations, and swelling (DCAP-BTLS).
   (2) Palpate for tenderness, instability, or crepitus (TIC).
   b. Neck.
   (1) Inspect for DCAP-BTLS.
   (2) Palpate spinal step-offs.
   (3) Inspect for jugular vein distention (JVD).
   (4) Inspect to ensure the trachea is midline (without deviation).
   (5) Apply a cervical collar, if necessary.
   c. Chest.
   (1) Inspect for DCAP-BTLS.
   (2) Palpate for TIC.
   (3) Inspect for the presence of paradoxical motion.
   (4) Auscultate (listen) for breath sounds (present, diminished, absent, equal).
   d. Abdomen.
   (1) Inspect for DCAP-BTLS.
   (2) Palpate for tenderness, rigidity, and distension and pulsating masses (TRDP).
   CAUTION: Do not “log roll” casualties suspected of having a pelvic fracture.
   e. Pelvis.
   NOTE: If a conscious casualty complains of pain or if an unconscious casualty responds as if in
   pain at any time during the assessment, do not continue the exam. Treat for pelvic fracture.
   (1) Inspect for DCAP-BTLS.
   (2) Gently compress (downward or inward) to detect TIC.
   (3) Inspect for priapism (male casualties only), wetness which may be caused by blood
   or loss of bladder control.
   f. Extremities.
   (1) Inspect for DCAP-BTLS.
   (2) Palpate for TIC.
   (3) Assess the hands and feet for circulation, sensation and motor function (CSM).
   g. Posterior.
   NOTE: The casualty must be “log rolled” to do this portion of the assessment. If necessary, the
   casualty should be placed on a long spine board after assessment. If the Pneumatic Anti-shock
   Garment (PASG) is deemed necessary, it should be positioned on the long spine board before
   casualty placement. If the casualty has a suspected pelvic fracture or bilateral femoral fractures,
   lift the casualty using a scoop stretcher, assess the posterior and place the casualty on the long
   spine board.
   (1) Inspect for DCAP-BTLS.
   NOTE: If penetrating wounds were noted during the anterior assessment, check for posterior
   exit wounds while the casualty is log-rolled/lifted with the scoop stretcher.
   (2) Inspect for wetness which can be caused by loss of bladder control and rectal
   bleeding.
5. If there is no significant MOI, perform a Focused History and Physical Exam.
   a. Based on chief complaint.
   b. Focus on the areas the casualty tells you are painful or that you suspect may be painful
   due to the MOI.
6. Obtain a baseline set of vital signs. (See tasks 081-831-0010, 081-831-0011, 081-831-
   0012, and 081-831-0013.)
7. Obtain a SAMPLE history.
   a. Signs/symptoms.
   (1) Ask the casualty what is wrong.
   (2) Observe the casualty.
   b. Allergies.
   (1) Ask the casualty if there are any allergies to medications, foods, or environment.
   (2) Look for a medical identification tag.
   c. Medications.
   (1) Ask the casualty if he is taking any medications (prescription, over the counter, or
   illegal).
   (2) Search for an identification tag with medications on it or medications in the area.
   d. Pertinent past history.
   (1) Ask the casualty if there are any medical problems (past and present).
   (2) Ask the casualty if he has been feeling ill.
   (3) Ask the casualty about recent surgery or injuries.
   (4) Ask the casualty if he is currently under the care of a medical officer and, if so, what’s
   their name and what type of care is being provided.
   e. Last oral intake.
   (1) Ask the casualty when his last meal or drink was.
   (2) Ask the casualty what he ate or drank.
   f. Events leading to the injury or illness.
   (1) Ask about the sequence of events that led up to the current event.
   (2) If the casualty is unable to answer, search the scene for anything that may indicate
   what occurred.
8. Perform a detailed physical examination.
   a. Assess the scalp and cranium.
   (1) Inspect for DCAP-BTLS.
   (2) Palpate for TIC.
   b. Assess the ears.
   (1) Inspect for DCAP-BTLS.
   (2) Inspect for drainage.
   (a) Blood or serous fluids.
   (b) Clear fluids.
   c. Assess the face for DCAP-BTLS.
   d. Assess the eyes.
   (1) Inspect for DCAP-BTLS.
   (2) Inspect for discoloration.
   (3) Inspect for unequal pupils.
   (4) Inspect for foreign bodies.
   (5) Inspect for blood in anterior chamber.
   e. Assess the nose.
   (1) Inspect for DCAP-BTLS.
   (2) Inspect for drainage of blood and/or clear fluid.
   f. Assess the mouth.
   (1) Inspect for DCAP-BTLS.
   (2) Inspect for loose or broken teeth.
   (3) Inspect for objects that could cause obstruction.
   (4) Inspect for swelling or laceration of the tongue.
   (5) Inspect for unusual breath odor (alcohol, acetone, etc.).
   g. Assess the neck.
   (1) Inspect for DCAP-BTLS.
   (2) Inspect for JVD.
   (3) Inspect to ensure the trachea is still midline (without deviation).
   (4) Palpate for TIC.
   h. Reassess the chest.
   (1) Inspect for DCAP-BTLS.
   (2) Palpate for TIC.
   (3) Auscultate breath sounds.
   (4) Assess for flail chest.
   i. Reassess the abdomen.
   (1) Inspect for DCAP-BTLS.
   (2) Palpate for TRDP.
   j. Reassess the pelvis.
   (1) Inspect for DCAP-BTLS.
   (2) Inspect for TIC.
   k. Reassess the extremities.
   (1) Inspect for DCAP-BTLS.
   (2) Palpate for TIC.
   (3) Check the CSM.
   l. Reassess the posterior.
   NOTE: If the casualty is secured to a long spine board, do not remove from the board.
   Reassess the flanks and as much of the spine as you can without moving the casualty
   unnecessarily.
   (1) Inspect for DCAP-BTLS.
   (2) Inspect for wetness which can be caused by loss of bladder control and rectal
   bleeding.
   833-0046, 081-833-0049, 081-833-0050, 081-833-0052, 081-833-0056, 081-833-0057, 081-
   833-0058, 081-833-0060, 081-833-0062, 081-833-0064, 081-833-0154, and 081-833-3011.)
   n. Reassess the casualty’s vital signs every 5 minutes (if unstable), every 15 minutes (if
   stable).
9. Document all assessment findings and care provided on the FMC. (See task 081-831-
   0033.)
   Evaluation

Question 63

Apply an Improvised Tourniquet

Answer 63

1. Take BSI precautions.
   CAUTION: A tourniquet should be applied just proximal to the hemorrhaging wound. Leave the
   tourniquet in open view so it can be monitored for recurrent hemorrhage. Do not place an
   improvised tourniquet directly over a joint.
2. Expose the wound.
3. Place the prepared cravat and windlass 2-3 inches above the wound and secure the cravat
   tightly against the extremity with a full non-slip knot.
   CAUTION: A tourniquet should be applied tight enough to block arterial flow.
4. Twist the windlass until the bleeding stops.
5. While holding tension on the windlass, place the windless inside the half knot of the second
   cravat proximal to the tourniquet (if possible).
6. Tighten the second cravat around the windless and secure the second cravat to the
   extremity with a full non-slip knot.
7. Assess for absence of a distal pulse.
   NOTE: Checking for a distal pulse in not indicated for amputations.
   CAUTION: In preparation for transport, ensure the improvised tourniquet is in open view at all
   times for monitoring purposes.
8. Place a “T” and the time of application on the casualty’s forehead.
9. Secure the tourniquet in place with tape.
10. Reassess that bleeding is controlled.
11. Record the treatment on the FMC.
12. Evacuate the casualty.
    Evaluation Preparation: None.

Question 64

Perform a Combat Casualty Assessment

Answer 64

1. Perform care under fire.
   NOTE: Care under fire is care rendered at the scene of the injury while the combat medic and
   the casualty are still under effective hostile fire.
   a. Return fire as directed before providing medical treatment. This may include wounded
   Soldiers still able to fight.
   b. Provide care to casualty tactically.
   (1) Suppress enemy fire.
   (2) Use cover or concealment (smoke).
   (3) If casualty is unresponsive, move casualty and his equipment to cover as the tactical
   situation permits.
   (4) Direct casualty to return fire, move to cover, and administer self-aid, (stop bleeding) if
   possible. If unable to move casualty to cover and still under direct enemy fire, tell the casualty
   not to move.
   (5) Keep the casualty from sustaining additional wounds.
   (6) Reassure the casualty.
   c. Administer only life-saving care while still under enemy fire.
   (1) Identify and control life-threatening hemorrhage with a tourniquet.
   (2) Cervical spine control is not necessary.
   NOTE: The combat medic rendering care decides treatment on the basis of the relative risk of
   further injury versus that of exsanguination.
   d. Communicate medical situation to team leader.
   e. Tactically transport casualty, his weapon, and mission-essential equipment to cover.
   f. Recheck bleeding control measures as the tactical situation permits.
2. Perform tactical field care.
   NOTE: Tactical field care is care rendered by the medic when no longer under effective hostile
   fire. Tactical field care also applies to situations in which an injury has occurred on a mission but
   there has been no hostile fire. Available medical equipment is limited to that carried into the field
   by the combat medic and mission personnel.
   a. In the following situations, communicate medical situation to patrol leader.
   (1) Upon determining that casualty will not be able to continue mission.
   (2) Before initiating any medical procedures (ensure tactical situation allows for time
   required).
   (3) Upon any significant change in casualty’s status.
   b. Note general impression of the casualty by determining responsiveness or level of
   consciousness (AVPU).
   (1) A - Alert.
   (2) V - Responds to verbal commands.
   (3) P - Responds to painful stimuli.
   (4) U - Unresponsive.
   NOTE: If the casualty has suffered from a blast or penetrating trauma and has no signs of life
   (no pulse, no blood pressure, no respirations), do not perform CPR. These casualties will not
   survive and you may expose yourself to enemy fire and delay care to other casualties.
   c. Assess and secure the airway.
   (1) If the casualty is conscious and not in respiratory distress, do not administer airway
   intervention.
   (2) If the casualty is unconscious, use a chin-lift or jaw-thrust to open the airway. Use a
   nasopharyngeal airway (NPA) to maintain the airway.
   (3) Roll the casualty into the recovery position. This allows for accumulated blood and
   mucus to drain and not choke the casualty.
   (4) For an unconscious casualty with an obstructed airway or severe maxillofacial
   trauma, perform a surgical cricothyroidotomy. (See task 081-833-3005.)
   d. Assess the chest and perform medical care to correct problems in breathing or
   respiration.
   (1) Immediately seal any penetrating injuries to the chest with a four-sided occlusive
   dressing, or apply a commercial device such as the Asherman®, Hyphen®, or Bolin® Chest
   Seals.
   (2) Monitor casualty for progressive severe respiratory distress (breathing becomes
   more labored and faster).
   (3) If respiration becomes progressively worse, consider this a tension pneumothorax
   and decompress affected chest side with a 14 gauge 3-1/4 inch catheter-over-needle inserted at
   second intercostal space (ICS) at midclavicular line (MCL). Secure the catheter in place with
   tape.
   e. Identify and control major bleeding not previously controlled.
   (1) Apply direct pressure and/or an emergency trauma bandage, as appropriate.
   (2) If a tourniquet was previously applied, consider changing the tourniquet to a pressure
   dressing and/or using a hemostatic bandage to control bleeding.
   (3) Leave the tourniquet in place while doing this. Loosen it, but do not remove it.
   (4) If the wound continues to bleed, retighten the tourniquet until bleeding stops.
   f. Determine if the casualty requires fluid resuscitation.
   (1) A palpable radial pulse and normal mental status should be used to determine who
   needs fluid resuscitation. These can be determined in the typical noisy and chaotic battlefield
   environment. Blood pressure measurement is not necessary. If a casualty has a radial pulse, his
   equivalent blood pressure is at least 80 mmHg.
   (2) If the casualty has a superficial wound, IV resuscitation is not necessary but oral fluid
   hydration should be encouraged.
   (3) If the casualty has a significant wound, either extremity or truncal (neck, chest,
   abdomen, or pelvis), and the casualty is coherent and has a palpable radial pulse:
   (a) Start an 18 gauge IV catheter and place a saline lock. Hold fluids but reevaluate
   as frequently as the tactical situation allows. If unable to start a peripheral IV, consider starting a
   F.A.S.T. 1 sternal intraosseous line. (See task 081-833-0185.)
   (b) Upper extremity is first choice. Do not start an IV on an extremity distal to a
   significant wound.
   (c) If the casualty does not have a radial pulse, ensure that the bleeding has stopped
   using whatever means available–direct pressure, pressure dressings, hemostatic bandage, or
   tourniquets as needed.
   (d) Once the bleeding has stopped, give 500 ml of Hextend® as rapidly as possible.
   Recheck in 30 minutes. If the radial pulse has returned, do not give any additional fluids but
   monitor as frequently as possible.
   (e) If the radial pulse does not return, give an additional 500 ml of Hextend®.
   (f) Recheck in 30 minutes. If the radial pulse returns, hold additional fluids and
   evacuate ASAP. If the radial pulse does not return, then triage your supplies and equipment to
   other casualties.
   g. Expose any wounds.
   (1) Remove the minimum amount of clothing required to expose and treat injuries. Dress
   the wounds to prevent contamination and help with hemostasis. An emergency bandage is ideal
   for this. Search for exit wounds.
   (2) Always check for exit wounds.
   (3) Protect the casualty against the environment.
   h. Splint obvious fractures. (See task 081-833-0263.)
   i. Administer pain medications as needed to any Soldier wounded in combat.
   (1) If the casualty is still able to fight, Mobic® 15 mg po qd with two 650 mg caplets of
   acetaminophen every 8 hours, will control mild to moderate pain and not cause drowsiness.
   These medications and an antibiotic make up the “Combat Pill Pack”, and should be issued to
   each Soldier prior to deployment.
   (2) If the casualty is unable to fight–
   (a) Morphine 5 mg given IV (through the saline lock) and repeated every 10 minutes
   as necessary is very effective in controlling severe pain. If a saline lock is used, it should be
   flushed with 5 ml of saline after the morphine administration.
   (b) Phenergan 25 mg IV or IM may be necessary to combat the nausea and vomiting
   associated with morphine.
   NOTE: Medics who carry morphine must be familiar with its side effects and trained in the use
   of Naloxone to counter these side effects.
   (c) Pain relief can also be attained with the use of fentanyl transmucosal lozenges.
   These lozenges are placed between the cheek and gum and will be absorbed through the oral
   mucosa. This method allows for narcotic pain control without IV access.
   (d) Ensure there is visible evidence of the amount and time of pain medication given.
   (3) Soldiers should avoid aspirin and some of the older anti-inflammatory medications
   because of their detrimental effects on blood clotting.
   (4) Antibiotics should be considered in all Soldiers wounded in combat who have a 3
   hour delay in evacuation time since these wounds are prone to infection.
   (a) In Soldiers who are awake and alert, give an oral antibiotic.
   (b) In unconscious Soldiers or those who may not be able to take an oral antibiotic, IV
   antibiotics may be given through the saline lock every 12 hours.
   NOTE: Soldiers who may have allergies to these medications must be identified in the predeployment
   planning phase and alternate medications provided.
   j. Initiate medical evacuation request lines 1 through 5 (lines 6 through 9, as appropriate).
   k. Complete FMC.
   l. Transport the casualty to the site where evacuation is anticipated.
3. Perform combat casualty evacuation care (CASEVAC). Care in the CASEVAC phase does
   not differ significantly from the tactical field care phase. However, there are two significant
   differences.
   a. Additional medical personnel may accompany the evacuation asset to assist the medic.
   b. Additional medical supplies and equipment may also accompany the evacuation asset.
   This equip may consist of:
   (1) Oxygen.
   (2) Electronic monitoring devices.
   (3) Additional IV fluids.
   (4) Blood (may be available)

Question 65

Apply a Cervical Collar

Answer 65

1. While your assistant is stabilizing the casualty’s cervical spine, complete an initial
   assessment and care for all life-threatening injuries before applying the cervical collar.
   WARNING: If you suspect the casualty has a spinal injury, treat him as though he has a spinal
   injury.
2. Use the mechanism of injury, level of responsiveness, and location of injuries to determine
   the need for cervical immobilization.
3. While maintaining manual cervical spine stabilization and neutral neck alignment, assess
   the casualty’s neck prior to placing the collar. Once the collar is in place, you will not be able to
   assess or palpate the back of the neck.
4. Reassure the casualty and explain the procedure to him.
5. Determine the size of collar to apply.
   a. The front height of the collar should fit between the point of the chin and the chest at the
   suprasternal notch.
   b. Once in place, the collar should rest on the shoulder girdle and provide firm support
   under both sides of the mandible without obstructing the airway or any ventilation efforts.
   c. If the collar is too large, the casualty’s neck may be placed in hyperextension.
   d. If the collar is too small, the casualty’s neck may be placed in hyperflexion.
6. Apply the collar to a seated casualty, if applicable.
   a. Have the other Soldier apply in-line stabilization of the head and neck from behind the
   casualty.
   b. Place the chin support first.
   c. Wrap the collar around the neck.
   d. Secure the Velcro® strap in place.
   e. Maintain manual stabilization of the head and neck until the casualty is immobilized on a
   long spine board.
   NOTE: Cervical collars do not fully immobilize the cervical spine; therefore, you must maintain
   manual stabilization of the casualty’s neck until the casualty is fully immobilized on a long spine
   board. (See task 081-833-0181.)
7. Apply the collar to a supine casualty, if applicable.
   a. Have the other Soldier kneel at the casualty’s head and manually apply in-line
   stabilization of the head and neck.
   b. Set the collar in place around the neck.
   c. Secure the Velcro strap in place.
   d. Maintain manual stabilization of the head and neck until the casualty is immobilized on a
   long spine board.

Question 66

Apply a Long Spine Board

Answer 66

1. Check for the signs and symptoms of a spinal injury.
   a. Spinal deformity. Its presence indicates a severe spinal injury, but its absence does not
   rule one out.
   b. Tenderness and/or pain in the spinal region.
   (1) Detect it by palpation or ask the casualty.
   (2) The presence of any pain is sufficient cause to suspect the presence of a spinal
   injury.
   c. Lacerations and/or contusions in the spinal region indicate severe trauma and usually
   accompany a spinal injury.
   NOTE: The absence of lacerations and/or contusions does not rule out a spinal injury.
   d. Weakness, loss of sensation, and/or paralysis.
   (1) A neck level (cervical) spine injury may cause numbness or paralysis in all four
   extremities.
   (2) A waist level spinal injury may cause numbness or paralysis below the waist.
   (3) Ask the casualty to try to move the fingers and toes to check for paralysis.
2. Place the casualty on a long spine board.
   NOTE: If a spine board is not available, utilize a standard litter or improvised litter made from a
   board or door. A hard surface is preferable to one that gives with the casualty’s weight.
   a. The log roll technique.
   (1) Place the spine board next to, and parallel with, the casualty.
   (2) Immobilize the casualty’s head and neck using manual stabilization.
   (a) Place your hands on both sides of the casualty’s head, cradling the skull with your
   hands.
   (b) Maintain manual stabilization until the casualty has been secured on the spine
   board.
   (3) Apply a cervical collar, if available, or improvise one. (See task 081-833-0177.)
   (4) Brief each of the three assistants on their duties and instruct them to kneel on the
   same side of the casualty, with the spine board on the opposite side of the casualty
   (a) First assistant. Place the near hand on the shoulder and the far hand on the waist.
   (b) Second assistant. Place the near hand on the hip and the far hand on the thigh.
   (c) Third assistant. Place the near hand on the knee and the far hand on the ankle.
   (5) On your command, and in unison, the assistants roll the casualty slightly toward
   them. Turn the casualty’s head, keeping it in a straight line with the spine.
   (6) Instruct the assistants to reach across the casualty with one hand, grasp the spine
   board at its closest edge, and slide it against the casualty. Instruct the second assistant to reach
   across the board to the far edge and hold it in place to prevent board movement.
   (7) Instruct the assistants to slowly roll the casualty back onto the board. Keep the head
   and spine in a straight line.
   (8) Place the casualty’s wrists together at the waist and tie them together loosely.
   NOTE: If the cervical collar or improvised collar does not fit flush with the spine board, place a
   roll in the hollow space between the neck and board. The roll should only be large enough to fill
   the gap, not to exert pressure on the neck.
   b. The straddle-slide technique.
   NOTE: Use this method when limited space makes it impossible to use the log roll technique
   (such as fractured pelvis).
   (1) Stand at the head of the casualty with your feet wide apart.
   (2) Apply stabilization to the casualty’s head and apply a cervical collar.
   (3) Instruct the first assistant to stand behind you (facing your back), to line up the spine
   board, and to gently push the spine board under the casualty at your command.
   (4) Instruct the second assistant to straddle the casualty while facing you and gently
   elevate the shoulders so that the spine board can be slid under them.
   (5) Instruct the third assistant (facing you) to carefully elevate the hips while the spine
   board is being slid under the casualty.
   WARNING: Complete all movements simultaneously, keeping the head and spine in a straight
   line.
   NOTE: If the cervical collar or improvised collar does not fit flush with the spine board, place a
   roll in the hollow space between the neck and board. The roll should only be large enough to fill
   the gap, not to exert pressure on the neck.
   (6) Instruct the fourth assistant (facing you) to carefully elevate the legs and ankles while
   the board is being slid into place under the casualty.
3. Secure the casualty to the long spine board.
   a. Secure the casualty’s torso and lower extremities with straps across the chest, hips,
   thighs, and lower legs.
   NOTE: Include the arms if the straps are long enough. If the spine board is not provided with
   straps and fasteners, use cravats or other long strips of cloth.
   WARNING: Do not release manual stabilization until the cravats or head straps are firmly in
   place.
   b. Secure the casualty’s head and head supports to the board with straps or cravats.
   (1) Apply head supports.
   (2) Use two rolled towels, blankets, boots, or similar material. (Do not use sandbags.)
   (3) Place one close to each side of the head.
   (4) Using a cravat-like material across the forehead, make the supports and head one
   unit by tying to the board.
4. Record the treatment on the FMC.
5. Evacuate the casualty.
6. Do not cause further injury to the casualty.