Principles of Prolonged Care Flashcards
Beyond TCCC and exceeds doctrinal planning guidelines. “Begins when evac doesn’t”
Prolonged field care
Prolonged field care started in:
2013 with SOMSA extended care working group
Reasons for prolonged field care
- Long evac times
- Indigenous capabilities
- Requires different skills
- Different environments
Gear carried to furthest point usually by medical personnel
Ruck
Additional gear carried in vehicles
Truck
Gear available to IDC/Medical personnel however, can only realistically be maintained at house/tent/FOB or support site. “highest level of care unit has”
House
Planning stage to consider how casualties will be moved
- MEDEVAC
- CASEVAC
Plane
Three phases of prolonged field care
Evaluation phase
Resuscitation Phase
Transport phase
During this time procedures and steps taken to normalize vitals and reverse physiological effects based on skill set available
Resuscitation phase
Systematic approach priority to treat life threats in order of severity
Evaluation phase
10 core capabilities of prolonged field care
- Monitor
- Resuscitate beyond basic crystalloid (FWB)
- Ventilate and Oxygenate the patient
- Airway management
- Sedation and pain management
- Ability to use physical exam and advanced diagnostics to further evaluate
- Nursing care
- Advanced surgical interventions
- Telemedicine consult
- Prepare patient for flight
There are no documented cases of permanent tissue damage, nerve damage or vascular injury from properly applied TQ in place for less than __ hours.
2 hours
TQ conversion should not be attempted for TQ’s in place longer than __ hours unless it occurs at definitive care facility
6 hours
Fluid of choice for patients in hemorrhagic shock as well the capability to provide a transfusion should be a basic capability of any clinician providing PFC.
Fresh whole blood
The best fluid in prolonged field care is:
The one that’s available
The goal for adequate urine output is:
0.5-1 mg/kg/hr
Corrects water/electrolyte deficits due to pathologic volume loss. Usually given as continuous IV infusion (lose from burns, GI illness, head trauma, DI, shock)
Replacement fluid
Given as nutrition to provide water/electrolytes lost via ongoing sweat, urination, stool output as well as glucose required mainly for brain metabolism.
Maintenance fluid
Made of large molecules that attract fluid into the intravascular space from interstitial.
Colloids
500ml of Hetastarch (common colloid) will give approximate equivalent volume of _______ml NS
2000ml NS
Will also have longer lasting effect given only 25% of crystalloid will remain intra-vascular at one hour
Colloids (hetastarch)
Initial volume expansion in hemorrhagic shock while provision of blood is being arranged
Resuscitation of perfusion to dysfunctional organs or unstable hemodynamics in non-hemorrhagic shock states
Reducing crystalloid requirements in burn patients at risk for over- resuscitation, and peripheral or abdominal compartment syndromes
Colloids
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.
Crystalloid
Complications of large volume crystalloid resuscitation include:
Compartment syndrome
Acute respiratory distress syndrome
Dilutional coagulopathy
Acidosis
Caution in resuscitation with crystalloids. “Unbalanced” fluid with a supra-physiologic concentration of chloride therefore can produce hyperchloremic metabolic acidosis. This can worsen inflammation and decrease kidney function
NS
Fresh whole blood (FWB) is the fluid of choice for patients in hemorrhagic shock.
To mitigate risks in PFC recommendations are a MAP of ___mmhg
65mmHg
If UNSTABLE with inadequate intravascular volume, resuscitate with ____ fluid.
Bolus
If STABLE with adequate intravascular volume, use _______ fluid.
A general target is to achieve a urine output of at least 0.5mL/kg/hour
Maintenance
Medications given which produce a diminished sensation to pain without producing a loss of consciousness
Analgesic
Depression of a patient’s awareness to the environment and reduction of responsiveness. Various levels including minimal, moderate and deep.
Sedation
Any procedure that involves sedation should also include monitoring the patient, ideally with:
End-tidal CO2
Pulse Ox
PFC medication
Stable patients can get:
Morphine
PFC medication
Hemodynamically unstable patients should get:
Fentanyl or ketamine
Three ranges of ketamine
Effective pain range with little to no mental status effects
Mid-range; still awake however are agitated and hallucinating
Dissociated range
What ketamine range do you want to avoid?
Mid-range
Low dose pain range for ketamine
10-20mg IV
Mid-range dosing for ketamine (AVOID)
0.3-1mg/kg IV
High dose dissociative range for ketamine
2.0 mg/kg IV
Has synergistic effect with opioids and Ketamine and can cause over- sedation, respiratory compromise and drop in BP
Versed
