PRINCIPLES OF PROLONGED CARE Flashcards
What is beyond TCCC and exceeds doctrinal planning guidelines, “begins when evac doesn’t”?
Prolonged Field Care (PFC)
What are some reasons for PFC?
- Long evac times
- Indigenous capabilities
- Require different skills
- Different environments
What is RTHP as it involves operation planning and logistics?
- Ruck - gear carried to furthest point usually by medical personnel
- Truck - additional gear carried in vehicles
- House - gear available to IDC/Medical personnel however, can only be maintained at house/tent/FOB or support site “highest level of unit care”
4 Plane - planning stage to consider how casualties will be moved:
a. MEDEVAC (dedicated and equipped)
b. CASEVAC (pre-planed non-medical support)
What are the three phases of PFC?
- Evaluation phase
- Resuscitation phase
- Transport phase
What phase of prolonged field care includes the following?
- Systemic approach priority to treat life threats in order or severity
a. Resuscitation and lifesaving procedures
b. Treat shock
c. Completion or MARCH and
d. Upgrading stopgaps (intubating, cricothyrotomy, chest tubes, etc.)
e. Initiate evacuation plan
Evaluation phase
What phase of prolonged field care includes the following?
- During this time procedures and steps taken to normalize vitals and reverse physiological effects based on skill set available
- Shock
- Lethal triad addressed
- Re-evaluate for life, limb, eyesight conditions and re-evaluate resuscitation efforts
- Nursing care
- Telemedicine
Resuscitation phase
What phase of prolonged field care includes the following?
- Prevent hypothermia
- Secure patient and liter
- Splinting
- Monitor and cuffs
- Emergency meds
- Sedation pain
- Secure tubing
- Documentation of patient condition, response to therapy and treatment rendered
Transport phase
These are all core capabilities of what?
- Monitor - in order to obtain a trend in vital signs
- Resuscitate beyond basic crystalloid
- Ventilate and oxygenate the patient
- Airway management - if patient requires a definitive airway (inflated cuffed tube below the trachea) gain control of the airway and be able to maintain sedation
- Sedation and pain management - In order to provide appropriate long term airway management adequate knowledge and skills to provide sedation and analgesia are required
Core Capabilities of PFC
These are all core capabilities of what?
- Ability to use physical exam and advanced diagnostics to further evaluate
- Nursing care - incorporate hygiene, nursing care, and comfort measures
- Advanced surgical interventions
- Telemedicine consult
- Prepare patient for flight. Imperative to have higher training prior to deployment or mission (joint in-route care course, OJT with ERC nurse)
Core capabilities of PFC
There are no documented cases of permanent tissue damage, nerve damage or vascular injury from properly applied TQ in places for less than __ hours
2 hours
Should tourniquet conversions be attempted if it has been in place for longer than 6 hours?
No, unless it occurs at a definitive care facility
True or False
Tourniquet Conversions
With “Plus 1” (additional not tightened TQ) in place, loosen the first TQ; if no bleeding from the wound is noted, then leave both TQs in place but not tightened and dress the wound
True
Tourniquet Conversions
If bleeding is noted, apply hemostatic agent and hold pressure for ___ to __ minutes. If not further bleeding is noted, leave the loose TQs in place and dress the wound
3 to 5 minutes
True or False
If hemostatic agents fail to control the bleeding, tighten the original TQ in as distal a position as possible to control the bleeding. Leave the “Plus 1” TQ loose and proximal to the tightened TQ
True
Tourniquet Conversions
Should you attempt conversion if TQ is < 2 hours?
yes
Tourniquet Conversions
Should you attempt conversion at 2-6 hours?
Likely safe, attempt conversion
Tourniquet Conversions
If a TQ is in place for > 6 hours should you attempt conversion?
Not advised in PFC
What is the fluid of choice for patients in hemorrhagic shock?
Fresh Whole Blood (FWB)
What is the best fluid in PFC?
THE BEST FLUID IN PFC IS THE ONE YOU HAVE AVAILABLE
What is a very easy tool available to monitor the patient’s response and guide resuscitative efforts?
Urine Output (UOP)
What is the goal for adequate UOP?
0.5-1mg/kg/hr
Reflects adequate kidney perfusion and volume
What is fluid therapy given to achieve adequate end organ function?
Resuscitation fluid
What is fluid therapy that corrects water/electrolyte deficits due to pathologic volume loss, usually given as continuous IV infusion (loss from burns, GI illness, head trauma, DI, chock) ?
Replacement fluid
What fluid therapy is 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
What are made of large molecules that attract fluid into the intravascular space from interstitium?
Colloids
____ml of Hetastarch (common colloid) will give an approximate equivalent volume of 2000ml of NS?
500ml
True or False
Colloids can be used as maintenance fluids
No role for colloids in maintenance fluids as there is a potential risk of complications including kidney disease and induced coagulopathy
What are some general colloid recommendations?
- 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
What fluids work to expand intravascular volume, however only approximately 25% remain within vasculature at 1 hour therefore when given as a resuscitation fluid large volume bolus is required?
Crystalloids
Continuous infusion of ____ are likely to diffuse out into the “third space”
Crystalloids
What are some complications of large volume crystalloid resuscitation?
- Compartment syndrome
- Acute respiratory distress syndrome
- Dilutional coagulopathy
- Acidosis
Caution should be used with crystalloids, NS is an unbalanced fluids with a supraphysiologic concentration of chloride therefore can produce _____, this can worsen inflammation and decrease kidney function.
Hypercholremic Metabolic acidosis
Fresh whole blood (FWB) is the fluid of choice for patients in hemorrhagic shock; to mitigate the risks in PFC the recommendations include what?
- MAP of 65mmHg
- Adequate UOP (at least 0.5cc/kg/hr)
- Adequate mentation
If the patient is UNSTABLE with inadequate intravascular volume, resuscitate with what?
Bolus fluids
If the patient is STABLE with adequate intravascular volume, use what?
Maintenance fluid
General target is to achieve a urine output of at least 0.5ml/kg/hr
A reasonable formulary of “working drugs” for the IDC should include what?
- Morphine
- Fentanyl
- Ketamine
- Midazolam (Versed)
- Adjunctive medications:
a. Narcan
b. Romazicon
c. Antiemetics (zofran)
d. Antihistamines (Claritin, Zyrtec, or Benadryl)
e. Atropine
f. Epinephrine
What are medications given which produce a diminished sensation to pain without producing a loss of consciousness?
Analgesic medications
What is the depression o a patient’s awareness to the environment and reduction of responsiveness, various levels include minimal, moderate, and deep?
Sedation
True or False
Stable patients can get Morphine. Hemodynamically unstable patients should get Fentanyl (or Ketamine).
True
What is the dosage of ketamine for low dose pain?
10-20mg IV titrate to effect repeating dose every 10 minutes as needed for desired effect
What is the ketamine dosage for a patient in High pain dose and they are dissociative?
2.0 mg/kg IV and should also include Versed to avoid vivid dreams which can lead to lifelong dreams and PTSD.
What medication as synergistic effects with opioids and Ketamine and can cause over-sedation, respiratory compromise and drop in BP?
Versed
