HMC Severson Review Flashcards
What is a french word to sort?
Triage
What is the process of prioritizing treatment during a mass casualty event based on their need for or likely benefit from medical attention
Triage
The number of patients and the severities of their injuries DO NOT exceed the resources and capabilities
Multiple casualties
The number of patients and the severities of their injuries DO exceed the resources and capabilities.
Mass Casualties
Five Principles of Triage
(1)Degree of life threat posed by the injuries sustained
(2)Injury severity
(3)Salvageability
(4)Resources
(5)Time, distance, and environment
Triage tags consist of four colors
(a)Black (Deceased/Expectant)
(b)Green (Minimal)
(c)Red (Immediate)
(d)Yellow (Delayed)
What is BICEP in regards to Combat Stress
a)Brief
b)Immediate
c)Central
d)Expectant
e)Proximal
f)Simple
g) Refer
Phases of TCCC
(1)Care under fire
(2)Tactical field care
(3)Tactical evacuation
Quickly choose a casualty collection point based on:
(a)Proximity to patients
(b)Proximity to vehicular access.
(c)Proximity to HLZ
(d)Geography, safety “geographic triage.”
Level (role/echelon) 1
First medical care military personnel receive. Includes immediate life saving measures, disease and non-battle injury prevention and care, combat and operational stress control (COSC), patient location and acquisition
Examples include:
1)Battalion Aid Station
2)Cruisers, Destroyers
Level (role/echelon) 2
Initial resuscitative care is the primary objective of care at this level. Saving life, limb, and when necessary stabilization for evacuation to level 3.
Ex
LHD: Largest medical capability
LHA
CVN
Medical battalion (MEDBN)
Shock trauma platoon (STP):
Forward resuscitative surgical suite (FRSS)
Level (role/echelon) 3
The highest level of care available within a combat zone. Advanced resuscitative care is the primary objective of care
Examples included:
1)Fleet hospitals
2)Hospital ships (USNS Comfort/USNS Mercy)
Level (role/echelon) 4
Definitive medical care is the primary objective at this level
(a)OCONUS Hospital Examples:
1)NH Yokosuka
2)Landstuhl Regional Medical Center
Level (role/echelon) 5
Restorative and rehabilitative care is the primary objective of care at this level
Example:
(a)CONUS hospital examples:
1)NMC SD
2)Walter Reed National Medical Center
MEDEVAC/CASEVAC Priorities
- Urgent: Casualty must be evacuated within 2 hours in order to save life, limb or eyesight
- Priority: Casualty must be evacuated within 4 hours or condition could worsen.
- Routine: Casualty must be evacuated within 24 hours for further care.
Line 1 of 9 Line
(1)Location of pick up site (Grid coordinates).
Line 2 of 9 Line
(2)Frequency/Call sign of pick up site.
Line 3 of 9 Line
Number of patients by precedence:
(a)A- Urgent
(b)C- Priority
(c)D- Routine
Line 4 of 9 Line
Special equipment needed:
(a)A- None
(b)B- Hoist
(c)C- Extraction equipment
(d)D- Ventilator
Line 5 of 9 Line
Number of patients by type
(a)L - # of litter
(b)A- # of ambulatory
Line 6 of 9 Line
Security of pickup site:
(a)N - No enemy
(b)P - Possible enemy
(c)E - Enemy in area
(d)X - Armed escort required
Line 7 of 9 Line
Method of marking pickup site:
(a)A - Panels
(b)B - Pyrotechnics
(c)C - Smoke
(d)D - None
(e)E – Other
Line 8 of 9 Line
Patient nationality and status:
(a)A - US Military
(b)B - US Civilian
(c)C - Non US Military
(d)D - Non U
(e)S Civilian
(f)E – EPW
Line 9 of 9 Line
NBC Contamination:
(a)N- Nuclear
(b)B- Biological
(c)C- Chemical
Mist Report consists of the four following categories
(a)Mechanism of Injury
(b)Injuries Sustained
(c)Signs/Symptoms
(d)Treatment
Energy Levels of Projectiles
(1)Low: Knives, needles, ice picks (hand-driven weapons)
(2)Medium: Firearms with muzzle velocity of less than 1,500 feet second. (.357 magnum, 9 mm, .45auto)
(3)High: Firearms with muzzle velocity of more than 1500 feet per second. (.44 magnum, .50AE)
Blast injuries are subdivided into four categories
- Primary - Effects of Overpressure and Under pressure from a blast wave
- Secondary - Flying Debris/fragments
- Tertiary - Body Displacement
- Quaternary - Burns
TCCC Approved Tourniquets
(a)Combat Application Tourniquet (C.A.T.)
(b)Special Operations Forces Tourniquet-Tactical (SOFT-T)
(c)Emergency and Military Tourniquet (EMT)
TCCC approved Hemostatic Agent
(a)Combat Gauze
(b)Celox Gauze or Chito Gauze
XStat (Best for deep narrow tract Junctional wounds)
Which TCCC hemostatic agent is FDA-cleared for life threatening junctional bleeds
X Stat
CoTCCC Junctional Tourniquets
(1) Combat Ready Clamp
(2) Junctional Emergency Treatment Tool
(3) SAM Junctional Tourniquet
Tourniquet placement
(a)Apply tourniquet 2 to 3 inches above bleeding site
(b)If unable to identify the site, apply “high and tight.”
(c)If bleeding is still uncontrolled, apply a 2nd tourniquet directly above the first
Insufficient oxygenation; that is decreased partial pressure of oxygen in blood.
Hypoxemia
Indications for Oxygen Therapy.
(1) All trauma causalities should receive appropriate ventilator support with supplemental oxygen to ensure that hypoxia is corrected or averted entirely.
(2) In deciding which method or equipment to use, prehospital care providers should consider the following devices in their respective oxygen concentrations.
(3) If the oxygen saturation is 94% or lower, the patient is hypoxic and needs to be treated quickly.
The following requires what kind of oxygen delivery
(a)Decompression illness (the “bends”)
(b)Carbon monoxide poisoning
(c)Radiation necrosis
(d)Reconstructive surgery
(e)Some infection, wounds
Hyperbaric Oxygen
Manual airway manuevers
- Head Tilt/Chin Lift.
- Jaw Thrust Maneuver
- Sellick’s Maneuver.
- BURP Maneuver.
Which manual air way maneuver?
In casualties with suspected head, neck, or facial trauma, the cervical spine is maintained in a neutral inline position
Jaw Thrust Maneuver.
Which manual air way maneuver?
- Prevention of gastric aspiration is one of the key components in airway maintenance
- particularly during BVM ventilation, aids in preventing aspiration.
Sellick’s Maneuver
Which manual air way maneuver?
The maneuver improves the visualization of the larynx structures and eases the intubation.
BURP Maneuver
What is the most frequently used artificial airway device
Oropharyngeal Airway (OPA).
Contraindications for Oropharyngeal Airway (OPA).
Casualty who is conscious or semiconscious
Complications of OPA
1)Due to gag reflex stimulation,
2)Use of the OPA may lead to gagging, vomiting, and laryngospasmin casualties who are conscious.
Disadvantage of NPA
The risk of nasal bleeding during insertion
Contraindication for NPA
Suspected basilar skull fracture.
preferred supraglottic airway because it makes it simpler to use and avoids the need for cuff inflation and monitoring
I-gel
preferred definitive airway is tracheal intubation through the mouth using direct laryngoscopy
Endotracheal Intubation.
Contraindications for Endotracheal Intubation.
- Lack of training in technique.
- Lack of proper indications.
What airway should be used for trapped patients?
Combitube
What are the 2 basic types of cricothyroidotomy
(a)Needle Cricothyrotomy
(b)Surgical Cricothyrotomy
Indications for Cricothyroidotomy
(1) Massive midface trauma precluding the use of BVM device.
(2) Inability to control the airway using less invasive maneuvers.
(3) Ongoing tracheobronchial hemorrhage.
Contraindications for cricothyroidotomy
(1) Any casualty who can be safely intubated, either orally or nasally.
(2) Casualties with laryngotracheal injuries
(3) Children under 10 years of age.
(4) Casualties with acute laryngeal disease of traumatic or infectious origin.
(5) Insufficient training
Needle decompression should be performed when the following three criteria are met:
(a)Evidence of worsening respiratory distress or difficulty with BVM device.
(b)Decrease or absent breath sounds
(c)Decompensated shock (SBP <90mm Hg)
Assessment: Casualty may appear in distress with the following signs andsymptoms:
(a)Anxiety / Restlessness
(b)Chest Pain
(c)Tachypnea
(d)Signs of Shock (pallor, confusion, hypotension)
(e)Frothy, Blood Sputum
(f)Diminished Breath Sounds on Affected Side
(g)Tachycardia
(h)Flat Neck Veins
Hemothorax
- occurs when a segment of the chest wall does not have bony continuity with the rest of the thoracic cage.
- The breaking of 2 or more ribs in 2 or more places is termed
Flail Chest
Management of flail chest
1)Adequate ventilation
2)High flow oxygen that may include BVM
3)IV fluids
4)Analgesia to improve ventilation (local anesthetic). If giving IV pain controldo not use pain medication that decreases respiratory drive unless onmechanical ventilation or someone that sole job is bagging the patient.
5)Monitor patients for signs of Pneumothorax or Tension Pneumothorax
6)Use gloved hand as splint till bulky dressing can be put on patient
7)RAPID TRANSPORT to appropriate facility (Level of Care)
it is drawn directly from an on-site donor (Fresh = not refrigerated or stored) and does not undergo processing into separate components(RBCs, plasma, and platelets)
Fresh Whole Blood (FWB)
can receive either O positive or O negative blood at any time
Males
receive O NEGATIVE blood ONLY (unless it is a matter of life and death there is no O negative blood available)
Females of childbearing age
Why can females only receive O neg blood
If the female becomes pregnant with an Rh-positive baby (father has to be Rh- positive), then the Rh-negative mother that was exposed to Rh-positive blood(thus making antibodies against Rh factor) will start to attack the fetal blood cells inducing Hydrops fetalis leading to fetal death
How many units of bood can the liver procvess without needing additional calcium
13 units
How much calcium gluconate should be given if needed
1 amp of calcium gluconate every 4 units of FWB
What should be given prophylactically if they hx of allergies or previous hx of allergic transfusion
Diphenhydramine 25-50mg (IM/PO/IV) through separate line
Does TXA promote new clot formation?
Nope
What effect does TXA have on clots?
It prevents the clots from breaking down by keeping fibrin strands around longer to maintain the clot and thus helps to prevent internal bleeding and ultimately prevent death from hemorrhage
Survival benefit is greatest when TXA is given within
1 hour of injury.
Dosage of TXA
Administer 1 gram of tranexamic acid in 100 ml normal saline or lactated ringers as soon as possible, but not later than 3 hours after injury.
When can a second infusion of TXA be given
A second infusion of 1 gram TXA may be administered after initial fluid resuscitation has been completed
Recommended temperature range for storage of TXA
59-86 degrees F.
IV fluids come in four different forms
(a)Colloids
(b)Crystalloids (Isotonic, Hypotonic, Hypertonic)
(c)Blood and blood products
Which IV fluid?
- Plasma protein fractions, salt poor albumin, dextran, and hetastarch
- do not diffuse out of the vascular space as quickly as crystalloids
- expensive, have specific storage requirements, and have short shelf life.
- More suitable in hospital setting than field use.
Colloids
Which IV fluid?
- Fluids that consist of water and dissolved crystals, such as salts and sugar.
- Used as maintenance fluids to correct body fluids and electrolyte deficit
- contain electrolytes (e.g., sodium, potassium, calcium, chloride) but lack the large proteins and molecules found in colloids.
- the mainstay of IV therapy in prehospital settings
Crystalloids
When the crystalloid contains the same amount of electrolytes as the plasma, it is referred to as
Isotonic
Common isotonic solutions
a)Lactated Ringers (LR) (which contain sodium chloride, potassium,calcium and lactate)
b)Normal Saline Solution (NSS) (0.9% sodium chloride solution)
c)5% Dextrose in water (D5W)
If a crystalloid contains more electrolytes than the body plasma, it is more concentrated and referred to as
hypertonic
The procedure must be performed under sterile conditions to avoid causing osteomyelitis (infection of the bone).
Intraosseous (IO) Infusion
Intraosseous (IO) Contra-indications
(1) Ipsilateral fracture or crush injury of an extremity (increases the risk ofsubcutaneous extravasation, so another extremity should be used)
(2) Previous orthopedic procedure near the selected insertion site
(3) Previous IOVA attempts in the same bone (even if IOVA was obtained, fluid would leak out of the previously attempted site)
(4) Infection at the selected insertion site
(5)Inability to locate landmarks (e.g., excessive tissue over the insertion site
(5) Brittle bones (e.g., osteogenesis imperfect or anything increasing risk of fracture)
TCCC Combat Wound Medication Pack (CWMP)
- Tylenol: 625 mg bilayer caplet, 2 tablets PO every 8 hours. Max of 4 gram over a 24-hour period.
- Meloxicam: 7.5 to 15 mg PO daily
What pain management should be given if casualty IS NOT in shock or respiratory distress and casualty is NOT at significant risk of developing either.
- Oral Transmucosal Fentanyl Citrate (OTFC): 800 mg. Place between cheek and the gum, instruct the patient to not chew.
What pain management should be given if casualty IS in shock or respiratory distress OR casualty is at significant RISK ofeither developing either condition
- Ketamine: 50 mg IM or IN (Intranasal) with repeat dose every 30 minutes or 20mg IV or IO with repeat dose every 20 minutes. *note: end point is control of pain or development of nystagmus
What pain management should be given as an alternative to OTFC if IV access has been established
Morphine: 5 mg IV/IO. Max of 15 mg. Reassess in 10 minutes and repeat asnecessary to control severe pain. Ensure to monitor for respiratory depression
Nalaxone dose
- IV, IM, SubQ: Initial: 0.4 to 2 mg; may need to repeat doses every 2 to 3minutes.
- lower initial dose (0.1 to 0.2 mg) should be considered for patients withopioid dependence to avoid acute withdrawal or if there are concerns regardingconcurrent stimulant overdose
TCCC recommendations for antibiotics
- Moxifloxacin: 400 mg IV/PO q 24 hours
- Ertapenem (Invanz): 1-gram IV q24 hours
- Ceftriaxone (Rocephin): 2 grams IV every 12 hours
Math for MAP
Mean arterial pressure (MAP) = (systole +diastole x2/3) or diastole + 1/3 pulse pressure
Math for CPP
CPP = MAP-ICP
What brain injury is the following?
(a)Bleeding between skull and Dura Mater
(b)1-2% of TBI patients
(c)Usually low velocity blow to temporal bone
(d)Pathognomonic history is patient has head trauma with a brief LOC, regainsconsciousness (lucid interval), then experiences rapid decline in consciousness
(e)Due to the location of the bleed the patient have a great recovery if rapid surgical intervention is performed
(f)Watch for dilated, sluggish non-reactive pupil
Epidural hematoma
What brain injury?
(a)Account for 30% of severe brain injuries
(b)Generally results from venous bleed
(c)Bridging veins are torn during blow to the head
(d)Blood collects between Dura and Arachnoid membrane
(e)Typically results from relatively rapid accumulation of blood in the subdural space and rapid onset of mass effect
Subdural hematomas
What brain injury?
1)Severe HA
2)Nausea & vomiting
3)Dizziness
4)May have meningeal signs
5)Seizures
Subarachnoid Hemorrhage (SAH)
After a mild TBI/concussion, what is the minimum recovery period?
24 hours
If symptom free during exertional testing and this is their first concussion in the past 12 months then
Return to duty
If symptom free during exertional testing and this is their second concussion in the past 12 months then
stay at stage 2 light routine activity for the next 5 days and perform NSI screening questionnaire daily
If symptoms develop/return during any of the above TBI recovery stages then
go back to stage1 (Rest), provide symptom management, refer to rehabilitation provider for daily monitored progressive return to activity processes
Hypothermia is defined as a core temperature below
95
Hypothermia Temperature stages
a)Mild - 90-95ºF
b)Moderate - 82-90ºF
c)Severe below 82ºF
Which stage of hypothermia?
(1Alert, but mental status may be altered
(2Shivering present
(3Not functioning normally
(4Not able to care for self
(5Estimated core temperature 32 to 35°C (90 to 95°)
- demonstrates tachypnea, tachycardia, initial hyperventilation, ataxia, dysarthria, impaired judgment, shivering, and so-called “cold diuresis
Mild hypothermia
Which stage of hypothermia?
(1Decreased level of consciousness
(2Conscious or unconscious, with or without shivering
(3Estimated core temperature 28 to 32°C (82 to 90°F)
(a)CNS depression, drop in heart rate and cardiac output, hypoventilation, andhyporeflexia
(b)At lower ends of temp, loss of shivering, dysrhythmias (A fib), and dilated pupils below 29ºC
Moderate hypothermia
Which stage of hypothermia?
(1Unconscious
(2Not shivering
(3Estimated core temperature <28°C (<82°C)
(a)Pulmonary edema, oliguria, hypotension, bradycardia, ventricular dysrhythmias.(V fib/tach/asystole)
(b)Loss of oculocephalic reflexes
Severe/Profound hypothermia
Lab studies for hypothermia
(a)Fingerstick glucose *
(b)Electrocardiogram (ECG) * (Osborne Waves)
Mild hypothermia is treated with what kind of rewarming
passive external rewarming
Moderate and refractory mild hypothermia are treated with what kind of warming
external rewarming
Severe (and some cases of refractory moderate) hypothermia is treated with what kind of rewarming
with active internal rewarming and possibly extracorporeal rewarming
In general, loss of up to 15 percent (about 750 mL) of circulating blood volume and is tolerated well in healthy patients
Class I
Blood loss of 15 to 30 percent (about 750 to 1500 mL) of total blood volume generally results in tachycardia and narrowed pulse pressure.
(class II hemorrhage)
As blood loss increases beyond 30 percent (1500 mL) there is worsening hypotension, tachycardia, peripheral hypo perfusion, and decline in mental status.
(class III hemorrhage)
At greater than 40 percent (2 Liters) blood loss the ability of the body to compensate has reached its limits and hemodynamic decompensation is imminent without effective resuscitation
class IV hemorrhage
The patient’s pulse is easily accessible, and if palpable, the systolic blood pressure in millimeters of mercury (mm Hg) can be roughly determined as followed in hemodynamic patients.
(1Radial Pulse: pressure ≥ 80 mmHg
(2Femoral Pulse: pressure ≥ 70 mmHg
(3Carotid Pulse: pressure ≥ 60 mmHg
A GSC score of ___ indicates severe head injury/coma
≤ 8
patient’s pertinent past medical history must be obtained. A useful mnemonic is the word “AMPLE”
(1) Allergies
(2) Medications and nutritional supplements
(3) Past medical illnesses and injuries
(4) Last meal
(5) Events associated to the injury
Bleeding from the scalp can be masked by what which can cause a significant amount of blood may be lost before adequate evaluation is performed.
Thick hair
What injury is the following:
1)Most commonly injured organ in blunt trauma
2)Often associated with other injuries
3)Left lower rib pain may be indicative
4)Often can be managed non-operatively
Splenic Injuries
What injuries are the following:
1)Second most common solid organ injury
2)Can be difficult to manage surgically
3)Often associated with other abdominal injuries
Liver injuries
What injuries are the following
1)Injury can involve stomach, bowel, or mesentery
2)Symptoms are a result from a combination of blood loss and peritonealcontamination
3)Small bowel and colon injuries result most often from penetrating trauma
4)Deceleration injuries can result in bucket-handle tears of mesentery
5)Free fluid without solid organ injury is a hollow viscous injury until proven otherwise
Hollow Viscous Injuries
The three basic regions of the abdomen are the
- peritoneal cavity
- the retroperitoneum
- the pelvic portion
Signs and symptoms of anaphylaxis begin within how many minutes of exposure
60 minutes
Second line therapy for anaphylaxis
Methylprednisolone (Solumedrol) 125mg IM/IV daily x 2 days
Carbon monoxide haan affinity for hemoglobin how many times greater than oxygen?
260
Injuries most often involved in blunt abdominal trauma include
a)Spleen 40-55%
b)Liver 35-45%
c)Small bowel 5-10%
GSW most commonly injure
1)Small bowel (50%)
2)Colon (40%)
3)Liver (30%)
4)Abdominal vessels (25%)
What are the most common signs of compartment syndrome?
(a)Paresthesia’s (most common)
(b)Pain (most common) pain often described as out of proportion
Forearm degloving occurs at what level
Subcutaneous level
What is the gold standard imaging for Pelvic fracture
CT scan
Zone of coagulation – central zone
Region of greatest destruction resulting in Necrosis and not capable of repair.
Region of greatest destruction resulting in Necrosis and not capable of repair.
1)Cells are injured but not irreversible.
2)Will become necrotic if deprived of blood flow.
3)Timely burn care and resuscitation will preserve blood flow and oxygendelivery.
Zone of hyperemia – outermost zone.
1)Minimal cellular injury and characterized by increased blood flow secondary to inflammatory reaction initiated by the burn injury.
What kind of burn?
(a)Historically referred to as first degree.
(b)Involve ONLY EPIDERMIS.
(c)Red and painful.
(d)Rarely clinically significant except in the situation of large sunburns which canincrease the risk of dehydration
(e)Heal well within a week without scar.
(f)Not included when calculating the percentage of total body surface area of burns.
Superficial Burns
What kind of burn?
(a)Once referred to as second degree.
(b)Involve epidermis and varying portions of the DERMIS.
(c)Can be classified as superficial or deep.
(d)Will appear as BLISTERS or “denuded” burned areas with glistening or wetappearing base.
(e)Zone of necrosis involves entire epidermis and varying depths of superficial dermis, can progress to full thickness if not properly treated
Partial thickness burns
What kind of burn
(a)May have several appearances
(b)Most often appear thick, dry, white, and leathery regardless of skin color.
(c)Thick leathery damaged skin referred to as eschar.
(d)Common, misconception that these burns are pain free because nerve endingsare destroyed. These patients have varying degrees of pain, surrounding areashave superficial and partial thickness burns. These nerves are intact. These burns can be disabling and life threatening.
Full thickness
Starting rate for fluid resuscitation for burns?
Starting rate 500ml/hr for adults.
Initial hourly fluid rate for burns
1)Initial hourly rate = %TBSA Burn x 10 ml/hr
Target UOP for burns
0.5ml/kg/hr
Reason for PFC
(a)Long evac times
(b)Indigenous capabilities
(c)Requires different skills
(d)Different environments
Three Phases of PFC
- Evaluation phase
- Resuscitation Phase
- Transport Phase
Goal UOP in PFC
UOP of 0.5-1 mg/kg/hr
Crystalloid fluids increase intravascular volume how?
Work to expand intravascular volume however only appx 25% remain within vasculature at 1 hour therefore when given as a resuscitation fluid large volume bolus are required.
Fresh whole blood (FWB) is the fluid of choice for patients in hemorrhagic shock. To mitigate risks in PFC recommendations are as follows
a)MAP of 65mmhg
b)Adequate UOP (at least 0.5cc/kg/hr)
c)Adequate mentation
