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Ranger medical handbook

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Ranger medical handbook

  1. 1. Ranger MedicRanger MedicHandbookHandbook20072007DOMINATUS COMMINUS REMEMDIUM
  2. 2. 75thRanger Regiment Trauma Management Team (Tactical)Ranger Medic HandbookIn Memoriam to Our FallenRanger Medic Comrades…SFC Marcus V. MurallesKIA – 28 June 2005 – AfghanistanOperation: Enduring FreedomSpecial Operations Flight Medic 2003-2005HHC, 3/160thSpecial Operations Aviation RegimentCompany Senior Medic and Platoon Medic 1999-2003B Co, 3rdBattalion, 75thRanger RegimentCompany Senior Medic and Platoon Medic 1990-1993C Co, 3rdBattalion, 75thRanger RegimentPFC James M. MarkwellKIA – 20 December 1989 – PanamaOperation: Just CausePlatoon Medic 1989C Co, 1stBattalion, 75thRanger Regiment…and one for the Airborne Ranger in the Sky.
  3. 3. 75thRanger Regiment Trauma Management Team (Tactical)Ranger Medic HandbookFORWARDHistorically in warfare, the majority of all combat deaths have occurred prior to acasualty ever receiving advanced trauma management. The execution of the Rangermission profile in the Global War on Terrorism and our legacy tasks undoubtedly willincrease the number of lethal wounds.Ranger leaders can significantly reduce the number of Rangers who die ofwounds sustained in combat by simply targeting optimal medical capability in closeproximity to the point of wounding. Survivability of the traumatized Ranger who sustainsa wound in combat is in the hands of the first responding Ranger who puts a pressuredressing or tourniquet and controls the bleeding of his fallen comrade. Directingcasualty response management and evacuation is a Ranger leader task; ensuringtechnical medical competence is a Ranger Medic task.A solid foundation has been built for Ranger leaders and medics to be successfulin managing casualties in a combat environment. An integrated team response fromnon-medical personnel and medical providers must be in place to care for the woundedRanger. The Ranger First Responder, Squad EMT, Ranger Medic Advanced TacticalPractitioner, and Ranger leaders, in essence all Rangers must unite to provide medicalcare collectively, as a team, without sacrificing the flow and violence of the battle athand.An integrated team approach to casualty response and care will directly translateto the reduction of the died of wounds rate of combat casualties and minimize theturbulence associated with these events in times of crisis. The true success of theRanger Medical Team will be defined by its ability to complete the mission and greatlyreduce preventable combat death. Rangers value honor and reputation more than theirlives, and as such will attempt to lay down their own lives in defense of their comrades.The Ranger Medic will do no less.I will never leave a fallen comrade…Harold R. Montgomery Russ S. Kotwal, MDMSG, USA LTC, MCRegimental Senior Medic Regimental Surgeon1997-Present 2005-PresentRHHC Senior Medic 3/75 Battalion Surgeon1995-1997 1999-20031/75 Plt, Co, BAS NCOIC1990-1995Ranger Medic Handbook 2007 Edition75thRanger Regiment, US Army Special Operations Command
  4. 4. 75thRanger Regiment Trauma Management Team (Tactical)Ranger Medic HandbookRanger Medic Handbook 2007 Edition75thRanger Regiment, US Army Special Operations CommandTable of ContentsSubject PageSECTION ONERMED Mission Statement -------------------------------------------------------------- 1-1RMED Charter ----------------------------------------------------------------------------- 1-2Review Committees----------------------------------------------------------------------- 1-3Editorial Consultants & Contributors -------------------------------------------------- 1-4Key References ---------------------------------------------------------------------------- 1-5RMED Scope of Practice ---------------------------------------------------------------- 1-6RMED Standing Orders & Protocol Guidelines ------------------------------------ 1-8Casualty Assessment & Management ----------------------------------------------- 1-10Tactical Combat Casualty Care (TCCC) --------------------------------------------- 1-17SECTION TWOTactical Trauma Assessment Protocol------------------------------------------------ 2-1Medical Patient Assessment Protocol ------------------------------------------------ 2-2Airway Management Protocol ---------------------------------------------------------- 2-3Surgical Cricothyroidotomy Procedure -------------------------------------- 2-4King-LT D Supralaryngeal Airway Insertion Procedure ----------------- 2-5Orotracheal Intubation Procedure -------------------------------------------- 2-6Hemorrhage Management Procedure ------------------------------------------------ 2-7Tourniquet Application Procedure -------------------------------------------- 2-8Hemostatic Agent Application Protocol --------------------------------------2-9Tourniquet Conversion Procedure --------------------------------------------2-10Thoracic Trauma Management Procedure ------------------------------------------ 2-11Needle Chest Decompression Procedure ---------------------------------- 2-12Chest Tube Insertion Procedure ---------------------------------------------- 2-13Hypovolemic Shock Management Protocol ----------------------------------------- 2-14Saline Lock & Intravenous Access Procedure -----------------------------2-15External Jugular Intravenous Cannulation Procedure ------------------- 2-16Sternal Intraosseous Infusion Procedure ----------------------------------- 2-17Hypothermia Prevention & Management Kit Procedure ---------------- 2-18Head Injury Management Protocol ---------------------------------------------------- 2-19Mild Traumatic Brain Injury (Concussion) Management Protocol ------------- 2-20Seizure Management Protocol --------------------------------------------------------- 2-21Spinal Cord Injury Management Protocol --------------------------------------------2-22Orthopedic Trauma Management Protocol ------------------------------------------2-23Burn Management Protocol ------------------------------------------------------------- 2-24Foley Catheterization Procedure --------------------------------------------- 2-25Pain Management Protocol ------------------------------------------------------------- 2-26Anaphylactic Shock Management Protocol ----------------------------------------- 2-27
  5. 5. 75thRanger Regiment Trauma Management Team (Tactical)Ranger Medic HandbookRanger Medic Handbook 2007 Edition75thRanger Regiment, US Army Special Operations CommandSubject PageSECTION TWO ContinuedHyperthermia (Heat) Management Protocol ---------------------------------------- 2-28Hypothermia Prevention & Management Protocol -------------------------------- 2-29Behavioral Emergency Management Protocol ------------------------------------- 2-30Altitude Medical Emergency Management Protocol ------------------------------ 2-31Acute (Surgical) Abdomen -------------------------------------------------------------- 2-33Acute Dental Pain ------------------------------------------------------------------------- 2-33Acute Musculoskeletal Back Pain ----------------------------------------------------- 2-33Allergic Rhinitis ----------------------------------------------------------------------------- 2-34Asthma (Reactive Airway Disease) --------------------------------------------------- 2-34Bronchitis ------------------------------------------------------------------------------------ 2-34Cellulitis -------------------------------------------------------------------------------------- 2-35Chest Pain (Cardiac Origin Suspected) ---------------------------------------------- 2-35Common Cold ------------------------------------------------------------------------------ 2-35Conjunctivitis -------------------------------------------------------------------------------- 2-36Constipation --------------------------------------------------------------------------------- 2-36Contact Dermatitis ------------------------------------------------------------------------- 2-36Corneal Abrasion & Corneal Ulcer ---------------------------------------------------- 2-37Cough -----------------------------------------------------------------------------------------2-37Cutaneous Abscess ----------------------------------------------------------------------- 2-37Deep Venous Thrombosis (DVT) ------------------------------------------------------ 2-38Diarrhea -------------------------------------------------------------------------------------- 2-38Epiglottitis ------------------------------------------------------------------------------------ 2-38Epistaxis --------------------------------------------------------------------------------------2-39Fungal Skin Infection ---------------------------------------------------------------------- 2-39Gastroenteritis ------------------------------------------------------------------------------ 2-39Gastroesophageal Reflux Disease (GERD) -----------------------------------------2-40Headache ------------------------------------------------------------------------------------ 2-40Ingrown Toenail ---------------------------------------------------------------------------- 2-40Joint Infection ------------------------------------------------------------------------------- 2-41Laceration ----------------------------------------------------------------------------------- 2-41Malaria --------------------------------------------------------------------------------------- 2-41Otitis Externa ------------------------------------------------------------------------------- 2-42Otitis Media --------------------------------------------------------------------------------- 2-42Peritonsillar Abscess --------------------------------------------------------------------- 2-42Pneumonia ---------------------------------------------------------------------------------- 2-43Pulmonary Embolus (PE) ---------------------------------------------------------------- 2-43Renal Colic ---------------------------------------------------------------------------------- 2-43Sepsis / Septic Shock -------------------------------------------------------------------- 2-44Smoke Inhalation -------------------------------------------------------------------------- 2-44Sprains & Strains -------------------------------------------------------------------------- 2-44Subungal Hematoma --------------------------------------------------------------------- 2-45Syncope -------------------------------------------------------------------------------------- 2-45Testicular Pain ------------------------------------------------------------------------------2-45Tonsillopharyngitis -------------------------------------------------------------------------2-46Urinary Tract Infection (UTI) -------------------------------------------------------------2-46
  6. 6. 75thRanger Regiment Trauma Management Team (Tactical)Ranger Medic HandbookRanger Medic Handbook 2007 Edition75thRanger Regiment, US Army Special Operations CommandSubject PageSECTION THREEPharmacology Section I: “Proficient and Always Carried” ----------------------- 3-1Pharmacology Section II: “Proficient” ------------------------------------------------- 3-11Pharmacology Section III: “Familiar” -------------------------------------------------- 3-26SECTION FOURRMED Duties & Responsibilities ------------------------------------------------------ 4-1Medical & Casualty Response Planning --------------------------------------------- 4-2Initial Planning / WARNORD --------------------------------------------------- 4-2Tactical Operation Development ---------------------------------------------- 4-3Coordination & Synchronization ----------------------------------------------- 4-6Briefs, Rehearsals, and Inspections ------------------------------------------ 4-6After Action Review in Training or Combat --------------------------------- 4-7Casualty Collection Point (CCP) Operations --------------------------------------- 4-8CCP Duties & Responsibilities ------------------------------------------------- 4-8Casualty Response Rehearsals ----------------------------------------------- 4-9CCP Site Selection --------------------------------------------------------------- 4-9CCP Operational Guidelines --------------------------------------------------- 4-10CCP Building Guidelines -------------------------------------------------------- 4-10Evacuation Guidelines ----------------------------------------------------------- 4-11CCP Layout Templates ---------------------------------------------------------- 4-11General Guidelines for CCP Personnel ------------------------------------- 4-14Casualty Marking & Tagging --------------------------------------------------- 4-14MEDEVAC Request Format ------------------------------------------------------------ 4-16Hazardous Training Medical Coverage ---------------------------------------------- 4-17Pre-Deployment & RRF-1 Assumption Procedures ------------------------------ 4-22Post-Deployment & Recovery Procedures ----------------------------------------- 4-24SECTION FIVERMED Packing Lists ---------------------------------------------------------------------- 5-1RMED RBA/RLCS Minimum Packing List ---------------------------------- 5-1RMED Assault Aid-Bag Minimum Packing List ----------------------------5-2RMED Medications Kit Minimum Packing List -----------------------------5-3Combat Wound Pill Pack (CWPP) Stockage List -------------------------5-3Saline Lock Kit Stockage List -------------------------------------------------- 5-4Chest Tube Kit Stockage List -------------------------------------------------- 5-4Cricothyroidotomy Kit Stockage List ----------------------------------------- 5-4IV Kit Stockage List ---------------------------------------------------------------5-4Minor Wound Care Kit Stockage List ---------------------------------------- 5-5Abbreviation List --------------------------------------------------------------------------- 5-6Conversion Charts ------------------------------------------------------------------------- 5-10The Ranger Medic Code ----------------------------------------------------------------- 5-11The Ranger Creed -------------------------------------------------------------------------5-12
  7. 7. 75thRanger Regiment Trauma Management Team (Tactical)Ranger Medic HandbookSECTION ONEGENERALOVERVIEWRanger Medic Handbook 2007 Edition75thRanger Regiment, US Army Special Operations Command
  8. 8. 75thRanger Regiment Trauma Management Team (Tactical)Ranger Medic HandbookMISSION STATEMENTThe mission of the 75thRanger Regiment TraumaManagement Team (Tactical) is to provide medicalcare and training in accordance with the tenets ofTactical Combat Casualty Care, Tactical MedicalEmergency Protocols, and Pre-Hospital Trauma LifeSupport; in order to provide optimal health care to aJoint Special Operations Task Force conductingmissions in support of U.S. policies and objectives.Ranger Medic Handbook 2007 Edition1-1 75thRanger Regiment, US Army Special Operations Command
  9. 9. 75thRanger Regiment Trauma Management Team (Tactical)Ranger Medic HandbookRANGER MEDIC CHARTER“SOCM ATP”(Special Operations Combat MedicAdvanced Tactical Practitioner)Shoot and engage targets to defend casualties and self.Operate relatively independently with highly-dispersedhighly-mobile combat formations in an austereenvironment.Communicate via secure and non-secure means.Move tactically through unsecured areas.Absolute master of the basics through pre-hospitaltrauma life support and tactical combat casualty care.Timely, consistent, and competent provider of advancedtrauma management within scope of practice.Practitioner who assists licensed medical providers withmedical emergencies and routine care encounteredwhile in garrison, training, and during deployments.1-2 Ranger Medic Handbook 2007 Edition75thRanger Regiment, US Army Special Operations Command
  10. 10. 75thRanger Regiment Trauma Management Team (Tactical)Ranger Medic HandbookREVIEW COMMITTEES2001MAJ Kotwal (3/75 Battalion Surgeon)MAJ Meyer (3/75 Battalion PT)CPT Detro (3/75 Battalion PA)SFC Miller (3/75 Battalion Senior Medic)SFC Montgomery (Regimental Senior Medic)SSG Flores (3/75 Company Senior Medic)SSG Gentry (3/75 Company Senior Medic)SSG Muralles (3/75 Company Senior Medic)SSG Odom (3/75 Company Senior Medic)SSG Rothwell (3/75 Company Senior Medic)2003MAJ Wenzel (Regimental Surgeon)MAJ Cain (1/75 Battalion Surgeon)MAJ Kotwal (3/75 Battalion Surgeon)MAJ Sassano (Regt Med Ops Officer)SFC Montgomery (Regimental Senior Medic)SFC Miller (Regt Med Plans & Trng NCO)SFC Swain (2/75 Battalion Senior Medic)SFC Flores (3/75 Battalion Senior Medic)SSG Odom (3/75 Senior Medic)SSG Williamson (2/75 Company Sr Medic)2004MAJ Wenzel (Regimental Surgeon)CPT Pairmore (1/75 Battalion PA)CPT Nieman (2/75 Battalion PA)CPT Kelsey (Regt Med Ops Officer)MSG Montgomery (Regt Senior Medic)SFC Crays (2/75 Battalion Senior Medic)SFC Flores (3/75 Battalion Senior Medic)SSG Odom (3/75 Battalion Senior Medic)SSG Williamson (Regt Med Training NCO)SSG Medaris (1/75 Company Senior Medic)SSG Garcia (2/75 Company Senior Medic)SSG Severtson (2/75 Company Sr Medic)2005LTC Kotwal (Regimental Surgeon)MAJ Matthews (1/75 Battalion Surgeon)MAJ McCarver (2/75 Battalion Surgeon)CPT Sterling (Regimental PA)CPT Detro (3/75 Battalion PA)CPT Reedy (1/75 Battalion PA)CPT Slevin (2/75 Battalion PA)CPT Grenier (2/75 Battalion PT)CPT Soliz (3/160 Battalion PA)MSG Montgomery (Regimental Senior Medic)SFC Crays (2/75 Battalion Senior Medic)SFC Warren (1/75 Battalion Senior Medic)SSG Williamson (Regt Med Plans & Tng NCO)SSG Gillaspie (2/75 Company Senior Medic)SGT Kindig (2/75 Company Senior Medic)SGT Robbins (3/75 Company Senior Medic)SGT Slavens (3/75 Company Senior Medic)SGT Morissette (3/75 Platoon Medic)SPC Kacoroski (2/75 Platoon Medic)SPC Ball (2/75 Platoon Medic)SPC Lewis (3/75 Platoon Medic)SPC Guadagnino (3/75 Platoon Medic)SPC Drapeau (3/75 Platoon Medic)2006LTC Kotwal (Regimental Surgeon)CPT Redman (1/75 Battalion Surgeon)CPT Cunningham (2/75 Battalion Surgeon)CPT Miles (3/75 Battalion Surgeon)CPT Sterling (Regimental PA)CPT Detro (Regimental PA)CPT Fox (3/75 Battalion PA)CPT Speer (Regt Med Ops Officer)CPT Pollman (3/75 Battalion PT)MSG Montgomery (Regimental Senior Medic)SFC Odom (Regimental Medical Training NCO)SSG Veliz (ROC Senior Medic)SSG Garcia (2/75 Battalion Senior Medic)SSG Williamson (3/75 Battalion Senior Medic)SSG Gillaspie (2/75 Company Senior Medic)SSG Bernas (2/75 Company Senior Medic)SSG Chavaree (3/75 Company Senior Medic)SSG Henigsmith (3/75 Company Senior Medic)SGT Maitha (3/75 Company Senior Medic)1-3 Ranger Medic Handbook 2007 Edition75thRanger Regiment, US Army Special Operations Command
  11. 11. 75thRanger Regiment Trauma Management Team (Tactical)Ranger Medic HandbookEDITORIAL CONSULTANTSExecutive Standing Members:CAPT (Ret) Frank Butler, MDCW4 (Ret) William Donovan, PA-CCOL John Holcomb, MDLTC Russ Kotwal, MD, MPHSFC (Ret) Robert Miller, NREMTMSG Harold Montgomery, NREMTJeffrey Salomone, MDConsulting & Contributing Members:LTC Bret Ackermann, DOMSG Perry Black, NREMTCPT (Ret) Gregory Bromund, PA-CLTC Brian Burlingame, MDMAJ Jeffrey Cain, MDCPT John Detro, PA-CMAJ Arthur Finch, PhDJ.F. Rick Hammesfahr, MDMAJ Shawn Kane, MDMSG(Ret) Cory Lamoreaux, NREMTLTC Robert Lutz, MDMAJ Clinton Murray, MDCPT (Ret) David Nieman, PA-CLTC Kevin O’Connor, DOCPT James Pairmore, PA-CMAJ John Rayfield, MDCPT Raymond Sterling, PA-CRepresentative Organizations:Committee on Tactical Combat Casualty CareDefense and Veterans Brain Injury CenterEmory University Department of Surgery, Atlanta, GAGrady Memorial Hospital, Atlanta, GAJoint Special Operations Medical Training CenterPHTLS Committee of the NAEMTUS Army Institute of Surgical ResearchUS Special Operations Command State Department of EMS and Public Health2007 Edition Chief Editors:LTC Russ Kotwal, MD, MPHMSG Harold Montgomery, NREMT, SOF-ATP1-4 Ranger Medic Handbook 2007 Edition75thRanger Regiment, US Army Special Operations Command
  12. 12. 75thRanger Regiment Trauma Management Team (Tactical)Ranger Medic HandbookKEY REFERENCESTexts:1. Advanced Trauma Life Support for Doctors. 7thEdition, American College ofSurgeons, Mosby, 2004.2. Basic and Advanced Prehospital Trauma Life Support: Military Edition. Revised5thEdition, National Association of Emergency Medical Technicians, Mosby, 2004.3. Emergency Medicine: A Comprehensive Study Guide. 6thEdition, AmericanCollege of Emergency Physicians, McGraw-Hill, 2004.4. Emergency War Surgery. 3rdUS Revision, Borden Institute, 2004.5. Griffith’s Five-Minute Clinical Consult. Lippincott, 2006.6. Guidelines for Field Management of Combat-Related Head Trauma. BrainTrauma Foundation, 2005.7. Prentice Hall Nurse’s Drug Guide. Wilson, Shannon, and Stang, 2007.8. Tactical Medical Emergency Protocols for Special Operations AdvancedTactical Practitioners (ATPs). US Special Operations Command, 2006.9. Tarascon Adult Emergency Pocketbook. 3rdEdition, Tarascon, 2005.10. Tarascon Pocket Pharmacopoeia. Tarascon, 2006.11. The Sanford Guide to Antimicrobial Therapy. 35thEdition, Antimicrobial Therapy,2005.12. Wilderness Medicine. 4thEdition, Mosby, 2001.Articles:1. Bellamy RF. The causes of death in conventional land warfare: implications forcombat casualty care research. Military Medicine, 149:55, 1984.2. Butler FK, Hagmann J, Butler EG. Tactical Combat Casualty Care in SpecialOperations. Military Medicine, 161(3 Suppl):1-15, 1996.3. Butler FK Jr, Hagmann JH, Richards DT. Tactical management of urban warfarecasualties in special operations. Military Medicine, 165(4 Suppl):1-48, 2000.4. Holcomb JB. Fluid resuscitation in modern Combat Casualty Care: lessonslearned from Somalia. Journal of Trauma, 54(5):46, 2003.5. Kotwal RS, O’Connor KC, Johnson TR, Mosely DS, Meyer DE, Holcomb JB. Anovel pain management strategy for Combat Casualty Care. Annals ofEmergency Medicine, 44(2):121-7, 2004.6. Lind GH, Marcus MA, Mears SL, et al. Oral transmucosal fentanyl citrate foranalgesia and sedation in the emergency department. Annals of EmergencyMedicine, 20(10):1117-20, 1991.7. Murray CK, Hospenthal DR, Holcomb JB. Antibiotic use and selection at the pointof injury in Tactical Combat Casualty Care for casualties with penetratingabdominal injury, shock, or inability to tolerate oral agents. Journal of SpecialOperations Medicine, 3(5):56-61, 2005.8. O’Connor KC, Butler FK. Antibiotics in Tactical Combat Casualty Care. MilitaryMedicine, 168:911-4, 2003.1-5 Ranger Medic Handbook 2007 Edition75thRanger Regiment, US Army Special Operations Command
  13. 13. 75thRanger Regiment Trauma Management Team (Tactical)Ranger Medic HandbookSCOPE OF PRACTICERANGER FIRST RESPONDER (RFR) – A Ranger who has successfully completed theRanger First Responder Course. RFRs conduct their scope of practice under thelicense of a medical director. Every Ranger is to be RFR qualified.THE 8 “CRITICAL” RFR TASKS:1) Contain Scene and Assess Casualtieso Return Fire and Secure Sceneo Direct Casualties to Covero Evaluate for Life Threatening Injurieso Triage – Immediate, Delayed, Minimal, Expectanto Call Medical Personnel for Assistance as Required2) Rapidly Identify and Control Massive Hemorrhageo Direct & Indirect Pressureo Tourniqueto Emergency Trauma Dressing3) Inspect and Ensure Patent Airwayo Open and Clear Airwayo Nasopharyngeal Airway4) Treat Life Threatening Torso Injurieso Occlusive Seal Dressingo Needle Decompressiono Abdominal wound management5) Inspect for Bleeding, Gain IV Access, Manage Shocko Head to Toe Blood Sweepso 18 Gauge Saline Locko IV Fluids when dictated by Shocko Prevent Hypothermia6) Control Pain and Prevent Infectiono Combat Wound Pill Pack7) Aid and Litter Teamo Package and Prepare for Transfero SKEDCO, Litters, Manual Carries8) Leader Coordinated Evacuationo Casualty Precedence – Critical (Urgent), Priority, Routineo CASEVAC or MEDEVAC Coordination1-6 Ranger Medic Handbook 2007 Edition75thRanger Regiment, US Army Special Operations Command
  14. 14. 75thRanger Regiment Trauma Management Team (Tactical)Ranger Medic HandbookSQUAD EMT – A non-medical MOS Ranger currently registered as an EMT-Basic/Intermediate by the Department of Transportation (DOT) and designated by thecommand to operate in this capacity. This individual functions as a bridge between theRFR and the Ranger Medic in respect to tactical and administrative traumamanagement. Squad EMTs conduct their scope of practice under the licensure of amedical director.SPECIAL OPERATIONS COMBAT MEDIC ADVANCED TACTICAL PRACTITIONER(SOCM-ATP) – A Ranger Medic currently registered as an NREMT-Paramedic by theDOT and/or USSOCOM State-Paramedic (Advanced Tactical Practitioner) who hasbeen awarded the identifier W1 (Special Operations Combat Medic) and has beenapproved by the unit Medical Director to function at this advanced level of care. ARanger Medic can train and direct routine and emergency medical care, establishcombat casualty collection points, conduct initial surgical and medical patientassessment and management, triage and provide advanced trauma management, andprepare patients for evacuation.Routine garrison care includes assisting unit medical officers with daily sick call andrequires advanced knowledge in common orthopedic problems, respiratory illnesses,gastrointestinal disorders, dermatological conditions, and environmental hazardillnesses. Ranger Medics train non-medical personnel on first responder skills andpreventive medicine. Ranger Medics conduct their scope of practice under the licensureof a medical director and are not independent health care providers. Ranger Medicsshould always obtain medical director advice and supervision for all care provided.However, on rare occasions Ranger Medics may be required to operate relativelyindependently with only indirect supervision in remote, austere, or clandestine locations.In these cases, it is still extremely rare that a Ranger Medic will be unable tocommunicate by radio, phone, or computer.STANDING ORDERS – Advanced life support interventions, which may be undertakenbefore contacting on-line medical control.PROTOCOLS – Guidelines for out of hospital patient care. Only the portions of theguidelines, which are designated as “standing orders”, may be undertaken beforecontacting an on-line medical director.MEDICAL CONTROL / MEDICAL DIRECTOR / MEDICAL OFFICER – A licensed andcredentialed medical provider, physician or physician assistant, who verbally, or inwriting, states assumption of responsibility and liability and is available on-site or can becontacted through established communications. Medical care, procedures, andadvanced life-saving activities will be routed through medical control in order to provideoptimal care to all sick or injured Rangers. Medical Control will always be established,regardless of whether the scenario is a combat mission, a training exercise, or routinemedical care. Note that, ultimately, all medical care is conducted under thelicensure of an assigned, attached, augmenting, or collocated physician.1-7 Ranger Medic Handbook 2007 Edition75thRanger Regiment, US Army Special Operations Command
  15. 15. 75thRanger Regiment Trauma Management Team (Tactical)Ranger Medic HandbookSTANDING ORDERS AND PROTOCOLSThese standing orders and protocols are only to be used by Ranger Medicsassigned to the 75thRanger Regiment.PURPOSEThe primary purpose of these protocols is to serve as a guideline for tactical and non-tactical pre-hospital trauma and medical care. Quality out-of-hospital care is the directresult of comprehensive education, accurate patient assessment, good judgment, andcontinuous quality improvement. All Ranger medical personnel are expected to knowthe Trauma Management Team Protocols and understand the reasoning behind theiremployment. Ranger Medics should not perform any step in a standing order or protocolif they have not been trained to perform the procedure or treatment in question.Emergency, trauma, and tactical medicine continues to evolve at a rapid pace.Accordingly, this document is subject to change as new information and guidelinesbecome available and are accepted by the medical community.STANDING ORDERS AND PROTOCOLSThese standing orders and protocols are ONLY for use by Ranger Medics whileproviding BLS, ACLS, PHTLS, TCCC, and TMEPs. Ranger Medics who are authorizedto operate under the Trauma Management Team guidelines may not utilize thesestanding orders outside of their military employment. All Ranger Medics must adhere tothe standards defined in these protocols. Revocation of privileges will be considered bythe granting authority if these standards are violated.COMMUNICATIONSIn a case where the Ranger Medic cannot contact Medical Control due to an acutetime-sensitive injury or illness, a mass casualty scenario, or communicationdifficulties, all protocols become standing orders. Likewise, in the event thatMedical Control cannot respond to the radio or telephone in a timely fashion required toprovide optimal care to a patient, all protocols are considered standing orders. In theevent that Medical Control was not contacted, and treatment protocols were carried outas standing orders, Medical Control will be contacted as soon as feasible following theincident and the medical record (SF 600 or Trauma SF 600) will be reviewed andcountersigned by Medical Control. Retroactive approval for appropriate care will beprovided through this process.When communicating with medical control, a medical officer or a receiving facility, averbal report will include the following essential elements:1. Provider – name, unit, and call back phone number2. Patient – name, unit, age, and gender3. Subjective – findings to include chief complaint and brief history of event4. Objective – findings to include mental status, vital signs, and physical exam5. Assessment – to include differential diagnosis and level of urgency6. Plan – to include treatment provided, patient response to treatment, and ETAProvide patient status updates as dictated by patient status changes en route.1-8 Ranger Medic Handbook 2007 Edition75thRanger Regiment, US Army Special Operations Command
  16. 16. 75thRanger Regiment Trauma Management Team (Tactical)Ranger Medic HandbookPATIENT CARE DOCUMENTATIONPatient care documentation is of paramount importance and should be performed forevery patient encounter using a JTF Combat Casualty Card, a Trauma SF 600 MedicalRecord, or a SF 600 Medical Record.RESUSCITATION CONSIDERATIONSResuscitation is not warranted in patients who have sustained obvious life-endingtrauma, or patients with rigor mortis, decapitation, or decomposition. However, whenreasonable, consider performing resuscitation efforts when this is your only patient. Theperception of fellow Rangers and family members in this instance should be that everyeffort was made to sustain life. When possible, place “quick look” paddles or EKG leadsto confirm asystole or an agonal rhythm in two leads and attach a copy of this strip tothe medical record. Also note that, technically, only a medical officer can pronounce apatient as deceased.GENERAL GUIDELINES FOR PROTOCOL USAGE1. The patient history should not be obtained at the expense of the patient. Life-threatening problems detected during the primary assessment must be treated first.2. Cardiac arrest due to trauma is not treated by medical cardiac arrest protocols.Trauma patients should be transported promptly to the previously coordinatedMedical Treatment Facility with CPR, control of external hemorrhage, cervical spineimmobilization, and other indicated procedures attempted en route.3. In patients who require a saline lock or intravenous fluids, only two attempts at IVaccess should be attempted in the field. Intraosseous infusion should be consideredfor life-threatening emergencies. However, patient transport to definitive care mustnot be delayed for multiple attempts at IV access or advanced medical procedures.4. Medics will verbally repeat all orders received and given prior to their initiation. It ispreferable that medical personnel work as two-man Trauma Teams wheneverpractical.NEVER HESITATE TO CONTACT A MEDICAL DIRECTOR AT ANY TIME FORASSISTANCE, QUESTIONS, CLARIFICATION, OR GUIDANCE.1-9 Ranger Medic Handbook 2007 Edition75thRanger Regiment, US Army Special Operations Command
  17. 17. 75thRanger Regiment Trauma Management Team (Tactical)Ranger Medic HandbookCASUALTY ASSESSMENT AND MANAGEMENTI. OVERVIEW:ESTABLISH PRIORITIES1. Obtain situational awareness…then ensure scene security.2. Control yourself…then take control of the situation. The senior medical personon the scene needs to control the resuscitation effort. All orders to team membersneed to come from one person, the senior medical person in charge.3. Just remember, there are three groups of casualties that you may encounter. Withthe first group, no matter what you do, they will live. With the second group, nomatter what you do, they may die. With the third group, if you do the right thing, atthe right time, your treatment will be the difference between life and death. Focusyour efforts on this third group.TRIAGE CATEGORIESo Immediate – casualties with high chances of survival who require life-savingsurgical procedures or medical careo Delayed – casualties who require surgery or medical care, but whose generalcondition permits a delay in treatment without unduly endangering the casualtyo Minimal – casualties who have relatively minor injuries or illnesses and caneffectively care for themselves or be helped by non-medical personnelo Expectant – casualties who have wounds that are so extensive that even if theywere the sole casualty and had the benefit of optimal medical resource application,their survival would be unlikelyEVACUATION PRECEDENCES (“CPR”)o Critical (Urgent) – evacuate within 2 HOURS in order to save life, limb, or eyesighto Priority – evacuate within 4 HOURS as critical and time sensitive medical care isnot available locally, the patient’s medical condition could deteriorate, and/or thepatient cannot wait for routine evacuation.o Routine – evacuate within 24 HOURS, as the patient’s medical condition is notexpected to deteriorate significantly while awaiting flightPRIMARY SURVEYDuring the primary survey, life-threatening conditions are identified and simultaneouslymanaged. The primary survey consists of:A - Airway Maintenance and C-spine Stabilization (situation dependent)B - BreathingC - Circulation with Control of Massive Hemorrhage (conducted first in combat setting)D - Disability [mental status]E - Exposure/Environmental Control [prevent hypothermia]1-10 Ranger Medic Handbook 2007 Edition75thRanger Regiment, US Army Special Operations Command
  18. 18. 75thRanger Regiment Trauma Management Team (Tactical)Ranger Medic HandbookRESUSCITATIONAggressive initial resuscitation should include hemorrhage control, airway establishmentand protection, ventilation and oxygenation, IV fluid administration as needed, andhypothermia prevention. As resuscitative interventions are performed, the providershould reassess the patient for changes in status.SECONDARY SURVEYThe secondary survey should consist of obtaining a brief history and conducting acomplete head-to-toe evaluation of the trauma patient. This in-depth examinationutilizes inspection, palpation, percussion, and auscultation, to evaluate the body insections. Each section is examined individually.TREATMENT PLANInitially, provide critical resuscitative efforts to resolve potential life-threatening injuriesdetected in the primary and secondary survey. Secondly, determine the patientdisposition. Is the patient stable or unstable? What further diagnostic evaluation,operative intervention, or treatment is required? What level of medical care is needed?When does the patient need to be evacuated? All of these questions must be answeredin a logical fashion in order to prioritize and mobilize the resources available.II. THE PRIMARY SURVEYThe primary survey is broken down into five major areas: Airway and C-Spine Control,Breathing, Circulation, Disability, Exposure/Environment Control.o During combat operations, while operating under the auspices of TacticalCombat Casualty Care (TCCC), the primary survey is conducted as C-A-B-D-Einstead of A-B-C-D-E.o Hemorrhage control is the most common cause of preventable death incombat and thus takes priority over airway management in this environment.A. AIRWAY AND C-SPINEThe upper airway should be assessed to ascertain patency. Chin lift, jaw thrust, orsuction may be helpful in reestablishing an airway. Specific attention should be directedtoward the possibility of a cervical spine fracture. The patients head and neck shouldnever be hyper-extended or hyper-flexed to establish or maintain an airway. One shouldassume a c-spine fracture in any patient with an injury above the clavicle. Approximatelyfifteen percent of patients who have this type of injury will also have a c-spine injury.Quick assessment of Airway & Breathing can be observed by the patient’s ability tocommunicate and mentate.B. BREATHINGThe patient’s chest should be exposed and you should look for symmetrical movementof the chest wall. Conditions that often compromise ventilation include: MASSIVEHEMOTHORAX, TENSION PNEUMOTHORAX, OPEN PNEUMOTHORAX, and FLAILCHEST.1-11 Ranger Medic Handbook 2007 Edition75thRanger Regiment, US Army Special Operations Command
  19. 19. 75thRanger Regiment Trauma Management Team (Tactical)Ranger Medic HandbookC. CIRCULATIONCirculation is divided into two parts: Hemodynamic Status and Hemorrhage Control.1. Hemodynamic StatusA formal blood pressure measurement SHOULD NOT be performed at this point in theprimary survey. Important information can be rapidly obtained regarding perfusion andoxygenation from the level of consciousness, pulse, skin color, and capillary refill time.Decreased cerebral perfusion may result in an altered mental status. The patients pulseis easily accessible, and if palpable, the systolic blood pressure in millimeters ofmercury (mm HG) can be roughly determined as follows:RADIAL PULSE: PRESSURE ≥ 80 mm HgFEMORAL PULSE: PRESSURE ≥ 70 mm HgCAROTID PULSE: PRESSURE ≥ 60 mm HgSkin color and capillary refill will provide a rapid initial assessment of peripheralperfusion. Pink skin is a good sign versus the ominous sign of white or ashen, gray skindepicting hypovolemia. Pressure to the thumb nail or hypothenar eminence will causethe underlying tissue to blanch. In a normovolemic patient, the color returns to normalwithin two seconds. In the hypovolemic, poorly oxygenated patient and/or hypothermicpatient this time period is extended or absent.2. Hemorrhage Control (Conducted first in Combat Setting)o EXTERNAL HEMORRHAGE. Exsanguinating external hemorrhage should beidentified and controlled in the primary survey. Direct pressure, indirect pressure,elevation, tourniquets, hemostatic agents, and pressure dressings should beutilized to control bleeding. Note that tourniquets should be used as a primaryadjunct for massive or arterial bleeding until controlled by dressings orhemostatic agents.o INTERNAL HEMORRHAGE. Occult hemorrhage into the thoracic, abdominal, orpelvic region, or into the thigh surrounding a femur fracture, can account forsignificant blood loss. If an operating room is not immediately available,abdominal or lower extremity hemorrhage can be reduced by hemostatic agents,wound packing, ligation, and clamping.Estimate of Fluid and Blood Requirements in Shock:Class I Class II Class III Class IVBlood Loss (ml) Up to 750 750-1500 1500-2000 > 2000Blood Loss(%BV) Up to 15% 15-30% 30-40% > 40%Pulse Rate < 100 > 100 > 120 > 140Blood Pressure WNL WNL Decreased DecreasedPulse Pressure (mmHg) WNL/increased Decreased Decreased DecreasedCapillary Blanch Test Normal Positive Positive PositiveRespiratory Rate 14-20 20-30 30-40 > 35Urine Output (mL/hr) > 30 20-30 5-15 NegligibleCNS-Mental Status Slightly anxious Mildly anxious Anxious/confused Confused/lethargicFluid Replacement Saline Lock Saline Lock Colloid / Blood Colloid / Blood1-12 Ranger Medic Handbook 2007 Edition75thRanger Regiment, US Army Special Operations Command
  20. 20. 75thRanger Regiment Trauma Management Team (Tactical)Ranger Medic HandbookD. DISABILITY (MENTAL STATUS)A rapid neurologic evaluation should be utilized to determine the patients pupillary sizeand response, as well as the level of consciousness (LOC). Pupils should be equallyround and reactive to light. If the pupils are found to be sluggish or nonreactive to lightwith unilateral or bilateral dilation, one should suspect a head injury and/or inadequatebrain perfusion. LOC can be described through either the AVPU or Glasgow ComaScale (GCS) method:A ALERTV Responds to VERBAL stimuliP Responds to PAINFUL stimuliAVPU:U UNRESPONSIVE to stimuliE EYE OPENINGSpontaneousTo speechTo painNone4321V VERBAL RESPONSEOrientedConfusedInappropriate WordsIncomprehensible SoundsNone54321GCS:(15 point scale)M MOTOR RESPONSEObeys CommandsLocalizes PainWithdraws (Normal Flexion)Decorticate (Abnormal Flexion)Decerebrate (Extension)None (Flaccid)654321E. EXPOSURE / ENVIRONMENTAL CONTROLThe patient should be completely undressed (environment permitting) to facilitatethorough examination and assessment during the secondary survey. Strive to maintainthe patient in a normothermic state. Hypothermia prevention is as important as anyother resuscitation effort.III. RESUSCITATIONResuscitation includes oxygenation, intravenous access, and monitoring.OXYGEN AND AIRWAY MANAGEMENTSupplemental oxygen should be administered to all trauma patients in the form of anonrebreather mask if available. A bag-valve-mask (BVM) should be readily availableand used when needed. Definitive airways can be provided through cricothyroidotomyand endotracheal intubation. Endotracheal intubation must be confirmed anddocumented by at least three of the following methods: 1) visualization of the tubepassing through cords, 2) endotracheal esophageal detector (Tube Check), 3) bilateral1-13 Ranger Medic Handbook 2007 Edition75thRanger Regiment, US Army Special Operations Command
  21. 21. 75thRanger Regiment Trauma Management Team (Tactical)Ranger Medic Handbookbreath sounds and absence of epigastric sounds, 4) condensation inside theendotracheal tube, and 5) end-tidal carbon dioxide monitoring.IV ACCESSA minimum of two 18 gauge IV/saline locks should be started in all multiple traumapatients. The rate of fluid administration is determined by the patients hemodynamicstatus and whether or not hemorrhage is controlled. Fluid resuscitation is assessed byimprovement in physiologic parameters such as the ventilatory rate, pulse, bloodpressure, and urinary output. Trauma patients should receive 1-2 peripheral IV accesssaline locks. Trauma patients who have controlled bleeding and a Systolic BP <90mm Hg should receive Hextend until the Systolic BP is >90 mm Hg up to a maximum of1000 ml. Trauma patients with controlled bleeding and a systolic blood pressure >90mm Hg, or uncontrolled hemorrhage, should receive a saline lock only and fluids TKO.Note that the external jugular vein is considered a peripheral vein. When peripheralaccess is inaccessible after a minimum of two unsuccessful peripheral IV attempts, asternal intraosseous “FAST-1” device can be performed on adults who require life-saving fluids and/or medications. When practical, use a permanent marker to label eachIV bag with the time initiated and completed, medications placed in the bag, allergies tomedications, and the number of IV bags received.MONITORINGAll patients followed for multiple trauma wounds should be continuously monitored forvital sign instability. Dysrhythmias are frequently associated with blunt chest traumaand should be treated in the same fashion as arrhythmias secondary to heart disease.IV. The Secondary SurveyThis survey should include a complete history, a head-to-toe physical examination, anda reassessment of vital signs.HISTORYA patient’s pertinent past medical history must be obtained. A useful mnemonic is theword “AMPLE”.AllergiesMedications and nutritional supplementsPast medical illnesses and injuriesLast mealEvents associated to the injuryPHYSICALThe physical exam can be divided into eight parts: Head, Face, C-Spine and Neck,Chest, Abdomen, Perineum and Rectum, Musculoskeletal, and Neurological.1. HEADThe secondary survey begins with a detailed examination of the scalp and head lookingfor signs of significant injury to include edema, contusions, lacerations, foreign bodies,evidence of fracture, CSF leak, or hemotympanum. The eyes should be evaluated for1-14 Ranger Medic Handbook 2007 Edition75thRanger Regiment, US Army Special Operations Command
  22. 22. 75thRanger Regiment Trauma Management Team (Tactical)Ranger Medic Handbookvisual acuity, pupillary size, external ocular muscle function, conjunctival and fundalhemorrhage, and contact lenses (remove before edema presents).2. FACEMaxillofacial trauma, unassociated with airway compromise and/or majorhemorrhage, should be treated after the patient is completely stabilized. If the patienthas midface trauma, suspect a cribiform plate fracture. If intubation is required in thisscenario then it should be performed orally and NOT via the nasal route.3. C-SPINE/NECKSuspect an unstable cervical spine injury in patients with blunt head or maxillofacialtrauma and/or mechanism of injury (static-line or freefall jump incident, fastrope orrappelling incident, aircraft mishap, motor vehicle collision, blast injury, fall > 20 feet). Anabsence of neurological deficits does not rule out spinal injuries. A cervical spine injuryshould be presumed and the neck immobilized until cleared by a physician and/orradiographic evaluation. Cervical spine tenderness to palpation and spasm of themusculature of the neck can be associated with a cervical spine injury. The absence ofneck pain and spasm in a patient who is neurologically intact is good evidence that a C-spine injury does not exist. However, it does not eliminate the need for radiographiccervical spine evaluation. Neck inspection, palpation, and auscultation should also beused to evaluate for subcutaneous emphysema, tracheal deviation, laryngeal fracture,and carotid artery injury. In the absence of hypovolemia, neck vein distension can besuggestive of a tension pneumothorax or cardiac tamponade.4. CHESTA complete inspection of the anterior and posterior aspect of the chest must beperformed to exclude an open pneumothorax or flail segment. The entire chest wall (ribcage, sternum, clavicles, and posterior and axillary regions) should be palpated toreveal unsuspected fractures or costochondral separation. Auscultation should beutilized to evaluate for the alteration of breath sounds denoting a pneumothorax, tensionpneumothorax, or hemothorax. Auscultation of distant heart sounds may be indicativeof a cardiac tamponade. Percussion of hypertympanic sounds may indicate tensionpneumothorax.5. ABDOMENAny abdominal injury is potentially dangerous. Once identified, these injuries must betreated early and aggressively. The specific diagnosis is not as important as the factthat an abdominal injury exists which may require surgical intervention. Palpation, closeobservation, and frequent reevaluation of the abdomen are essential in the assessmentand management of an intra-abdominal injury. In blunt trauma, the initial examination ofthe abdomen may be unremarkable. However, serial exams over time may revealincreasing signs of tenderness, rebound pain, guarding, and loss of bowel sounds.6. RECTUMA complete rectal examination in a trauma patient is essential and should include anevaluation for rectal wall integrity, prostate position, sphincter tone, and gross or occultblood.1-15 Ranger Medic Handbook 2007 Edition75thRanger Regiment, US Army Special Operations Command
  23. 23. 75thRanger Regiment Trauma Management Team (Tactical)Ranger Medic Handbook7. EXTREMITIESExtremities should be inspected for lacerations, contusions, and deformities. Palpationof bones (through rotational or three-point pressure) checking for tenderness,crepitation, or abnormal movements along the shaft, can help to identify non-displacedor occult fractures. Slight pressure (NO PELVIC ROCK) with the heels of the hand onthe anterior superior iliac spines and on the symphysis pubis can identify pelvicfractures. Peripheral pulses should be assessed on all four extremities. The absence ofa peripheral pulse distal to a fracture or dislocation mandates manipulation toward theposition of function; if the pulse is still absent, transport immediately.8. NEUROLOGICAL EXAMINATIONAn in-depth neurological examination includes motor and sensory evaluation of eachextremity, and continuous re-evaluation of the patient’s level of consciousness and pupilsize and response. Any evidence of loss of sensation, weakness, or paralysis suggestsa major injury either to the spinal column or peripheral nervous system. Immobilizationusing a long board and a rigid cervical collar must be immediately established. Thesepatients should be evacuated as soon as possible. Additionally, consider treating patientas a spinal cord injury if distracting injury and consistent with mechanism of injury.V. REEVALUATIONTrauma patients require serial exams and reevaluation for changed or new signs andsymptoms. Continuous observation, monitoring, vital sign assessment, and urinaryoutput maintenance (an average of > 30cc/hour in the adult patient) is also imperative.As initial life-threatening injuries are managed, other equally life-threatening problemsmay develop. Less severe injuries or underlying medical problems may becomeevident. A high index of suspicion facilitates early diagnosis and management.VI. SUMMARYThe injured Ranger must be rapidly and thoroughly evaluated. You must develop anoutline of priorities for your patient. These priorities in combat include the primarysurvey which includes evaluation of circulation, airway and c-spine control, breathing,disability (mental status), and exposure/environment.Resuscitation should proceed simultaneously with the primary survey. It includes themanagement of all life-threatening problems, the establishment of intravenous access,the placement of EKG monitoring equipment, and the administration of oxygen.The secondary survey includes a total evaluation of the injured Ranger from head totoe. During your evaluation you reassess the ABC’s and the interventions providedduring the primary survey. Ensure to document your finding and interventions on aTrauma SF 600 or JTF Casualty Card.1-16 Ranger Medic Handbook 2007 Edition75thRanger Regiment, US Army Special Operations Command
  24. 24. 75thRanger Regiment Trauma Management Team (Tactical)Ranger Medic HandbookTACTICAL COMBAT CASUALTY CARE (TCCC)Trauma is the leading cause of death in the first four decades of life. Current protocolsfor civilian trauma care in the US are based on the Advanced Trauma Life Support(ATLS) course, which was initially conducted in 1978. Since that time, ATLS protocolshave been accepted as the standard of care for the first hour of trauma managementthat is taught to both civilian and military providers. ATLS is a great approach in thecivilian setting; however, it was never designed for combat application.Historically, most combat-related deaths have occurred in close proximity to the point ofinjury prior to a casualty reaching an established medical treatment facility. The combatenvironment has many factors that affect medical care to include temperature andweather extremes, severe visual limitations, delays in treatment and evacuation, longevacuation distances, a lack of specialized providers and equipment near the scene,and the lethal implications of an opposing force. Thus, a modified approach to traumamanagement must be utilized while conducting combat operations.Combat treatment protocols must be directed toward preventable combat death. COLRon Bellamy researched how people die in ground combat and developed a list ofcauses of death that can be prevented on the battlefield.How people die in combatKIA: 31% penetrating head traumaKIA: 25% surgically uncorrectable torso traumaKIA: 10% potentially correctable surgical traumaKIA: 9% exsanguination from extremity woundsKIA: 7% mutilating blast traumaKIA: 5% tension pneumothoraxKIA: 1% airway problemsDOW: 12% (mostly from infections andcomplications of shock)Preventable causes of death60% Bleeding to death from extremity wounds33% Tension pneumothorax6% Airway obstruction (maxillofacial trauma)The tactical environment and causes of combat death dictate a different approach forensuring the best possible outcome for combat casualties while sustaining the primaryfocus of completing the mission. CAPT Frank Butler and LTC John Hagmann proposedsuch an approach in 1996. Their article, “Tactical Combat Casualty Care in SpecialOperations”, emphasized three major objectives and outlined three phases of care.Objectives:Treat the patientPrevent additional casualtiesComplete the missionPhases of Care:1. Care Under Fire2. Tactical Field Care3. Combat Casualty Evacuation (CASEVAC) Care1-17 Ranger Medic Handbook 2007 Edition75thRanger Regiment, US Army Special Operations Command
  25. 25. 75thRanger Regiment Trauma Management Team (Tactical)Ranger Medic HandbookOver the past decade, numerous military and civilian medical providers and multiplearticles in the medical literature have endorsed the tenets of Tactical Combat CasualtyCare (TCCC). TCCC was integrated into the 4thand subsequent editions of thePrehospital Trauma Life Support (PHTLS) textbook that is authored by the NationalAssociation of Emergency Medical Technicians in cooperation with the AmericanCollege of Surgeons Committee on Trauma.In 2002, the Committee on Tactical Combat Casualty Care (COTCCC) was establishedby the US Special Operations Command. Since then, the COTCCC has met on aregular basis in order to evaluate, modify, and make recommendations for TCCCprotocols, procedures, and guidelines.The following is a summary of the phases of care which includes updates from theCOTCCC through 2006:PHASES OF CARE:1. CARE UNDER FIRECare provided at point of injurywhile under effective enemyfire, limited by equipmentcarried by provider.Major goals are to movecasualty to safety, preventfurther injury to the casualtyand provider, stop lifethreatening externalhemorrhage, and gain andmaintain fire superiority –the best medicine on thebattlefield!Return fire and take cover, direct casualty to return fire and takecoverKeep yourself from getting shot and prevent additional woundsto casualtySelf aid if able and buddy aid if availableTreat life threatening external hemorrhage with a tourniquetIf bleeding continues, also use a hemostatic agent and pressuredressing2. TACTICAL FIELD CARECare rendered once casualtyis no longer under effectiveenemy fire or when conductinga mission without hostile fire.Do not attempt CPR on thebattlefield for victims of blast orpenetrating trauma who haveno pulse, respirations, or othersigns of life.Disarm casualties with alteredmental status, place weaponon safe and clear, take radioaway from casualty.AIRWAY• Chin-lift or jaw-thrust maneuver, recovery position, andnasopharyngeal airway for unconscious patients• Cricothyroidotomy for airway obstruction• No C-Spine immobilization for penetrating traumaBREATHING• If torso trauma and respiratory distress, presume tensionpneumothorax and needle decompress• Treat sucking chest wounds with three-sided dressing duringexpiration, and monitor for tension pneumothorax• Administer chest tube when needed1-18 Ranger Medic Handbook 2007 Edition75thRanger Regiment, US Army Special Operations Command
  26. 26. 75thRanger Regiment Trauma Management Team (Tactical)Ranger Medic HandbookCIRCULATION• Assess and control bleeding with tourniquet, hemostaticagent, pressure dressing• Initiate 18-gauge saline lock (IV); use IO as requiredo Controlled hemorrhage, no shock: NO FLUIDSo Controlled hemorrhage, shock: Hextend 500-1000cco Uncontrolled hemorrhage, no shock: NO FLUIDS• PO fluids permissible if consciousENVIRONMENT• Prevent hypothermia, minimize exposure, external warmingdevices, IVF warmersWOUNDS• Inspect, dress, and check for additional woundsFRACTURES• Check pulse, inspect, dress, splint, and recheck pulseMEDICATIONS (Analgesia and Antibiotics)• Oral Wound Pill Packs: Mobic 15 mg, Tylenol 650 mg,Moxifloxacin 400 mg• OTFC: Fentanyl lozenge 800 mcg• IV Pain Management: Morphine 5 mg IV repeated every 10minutes as needed for pain; Promethazine 25 mg IV fornausea and synergistic analgesic effect• IV Antibiotic: Cefotetan 2g q12h or Ertapenem 1 g q24hMONITOR• Vital signs and pulse oximetryDOCUMENT• Casualty Card3. COMBAT CASUALTY EVACUATION (CASEVAC)The medical care providedduring the evacuation of thecasualty. Continue or initiatecare as per previous phase.Pre-staged medical assets onCASEVAC should be utilizedto provide the same or higherlevel of care rendered duringthe mission.INITIATE AND CONTINUE CARE AS PER PREVIOUS PHASEEVALUATE AND REFINE CAREAirway: Consider combitube or laryngeal mask airway orendotracheal intubationBreathing: Consider oxygen if availableCirculation: Convert tourniquets as possibleEnvironment: Adjust temperature in vehicle or aircraft1-19 Ranger Medic Handbook 2007 Edition75thRanger Regiment, US Army Special Operations Command
  27. 27. 75thRanger Regiment Trauma Management Team (Tactical)Ranger Medic HandbookSECTION TWOPART ATRAUMAPROTOCOLSRanger Medic Handbook 2007 Edition75thRanger Regiment, US Army Special Operations Command
  28. 28. Tactical Trauma AssessmentEnsure Scene SecurityReturn FireContinue MissionPrevent additional injuriesCAREUNDERFIREPHASETACTICALFIELDCAREPHASE CasualtyConscious orUnconscious?Direct casualty to moveto covered position,Buddy-Aid aspossibleUnder covering fire,move casualty to acovered positionConduct Rapid Head-to-Toe Surveyto identify Immediate LifeThreatening InjuriesManual Airway PositioningNasopharyngeal Airway (NPA)Emergency CricothyroidotomyThoracic TraumaQuick Occlusive DressingNeedle DecompressionSecure Position or CCPTriage Multiple Casualties as requiredMajor Bleeding?Re-AssessHemorrhage ControlIAW ProtocolRe-Assess AirwayManagement IAWProtocolTreat Other Injuries IAWAppropriate ProtocolUNCONSCIOUS CONSCIOUSYESNOYESDirect / Guide casualty torender self-aidDirect casualty to providesecurity/return fire asrequiredAssess ResponsivenessConduct Primary Survey & InitiateMonitoring of Vital Signs/SpO2When tacticalsituation permits,move casualty toCCPChestInjury?Re-Assess ThoracicManagement IAWProtocolS/Sx ofShock?Refer to Hypovolemic ShockManagement ProtocolCare Under Fire PhaseTactical Field Care PhseCare Under Fire PhaseTactical Field Care PhseYESNOYESNOHemorrhage ControlControl Massive ExternalBleeding with a TourniquetSimple Manual Airwaypositioning as requiredConscious withSpontaneousRespirations(RR >8 or <30 )?Apply / Re-Apply TourniquetApply Hemostatic DressingApply Pressure DressingPack and Dress WoundsDetailed Secondary SurveyInitiate IV AccessAdminister Combat Wound Pill Packif able to tolerate POMonitor IAW ProtocolAntibiotics as requiredPain Management as requiredContact/Report to Medical OfficerOxygen if possibleDocumentEvacuate IAW ProtocolTactical CasualtyAssessmentCIRCULATIONAIRWAYBREATHINGDISABILITYEXPOSENOAPPROVEDDATE: 01 OCT 06Dr KotwalDr RedmanDr CunninghamDr MilesRanger Medic Handbook 2007 Edition75thRanger Regiment, US Army Special Operations Command2-1
  29. 29. Medical Patient Assessment ProtocolIndication for aMedical PatientAssessmentSceneSecure?Ensure Scene Securityor Refer to TacticalAssessment ProtocolProvider PrecautionsPrimary SurveyA – Airway / C-SpineB – BreathingC – CirculationD – DisabilityE – Expose/EnvironmentDetailed Assessment& DocumentatonComplete Vital SignsSOAP FormatContinuousMonitoringRequired?Consider:Cardiac MonitoringPulsoximetryGlucometryIV AccessFocused ExaminationBased on ChiefComplaints)Apply appropriate protocolsbased on Primary, Detailedand Focused AssessmentsDocument allfindingsYESNOAVPU Responsiveness AssessmentALERTVERBAL – Responds to verbal stimuliPAIN – Responds to painful stimuliUNCONSCIOUS – Does not respond to any stimuliAMPLE Patient HistoryA – AllergiesM – MedicationsP – Past Medical HistoryL – Last MealE – Events AssociatedOPQRST Patient HistoryChief ComplaintO – OnsetP – ProvocationQ – QualityR – RadiationS – SeverityT – TimeNormal Adult Vital SignsSystolic Blood Pressure:Male: 120-140Female: 110-130Pulse Rate: 60-80Respiratory Rate: 12-20Body Temperature: 98.6Abnormal Finding: Eyes, Ears, NoseCerebral Spinal FluidBattle’s SignRaccoon eyesPupil InequalityAbnormal gazeDoll’s eye responseAbnormal Finding: NeckJugular vein distentionTracheal deviationSubcutaneous emphysemaAbnormal Finding: Chest & Breath SoundsRetractionsUnequal excursionSubcutaneous emphysemaErythemaParadoxical motionAbnormal breath soundsRalesRhonchiWheezingStridorKussmaul respirationsCheyne-stokes patternAbnormal Finding: AbdominalPulsationsGuardingPainTendernessRebound tendernessMassesAbsent bowel soundsSigns of Extremity Vascular CompromiseAbsent or diminshed pulseCool extremitySlow or absent capillary refillCyanosisDislocationInappropriate AnglesSwellingDiscolorationNOYESMonitor IAW ProtocolAntibiotics as requiredPain Management as requiredContact/Report to Medical OfficerOxygen if possibleDocumentEvacuate IAW ProtocolSOAP FormatS – Age/SexChief ComplaintHistory of Present IllnessAllergiesMedicationsPast Medical HistoryPast Surgical HistorySocial HistoryO – Complete Vital SignsPhysical ExaminationA – Differential DiagnosisP – Immediate PlanMonitoring MedicationsFluids DiagnosticsProcedures ReferralsTransportAPPROVEDDATE: 01 OCT 06Dr KotwalDr RedmanDr CunninghamDr MilesGlasgow Coma ScaleEye Spontaneous 4Opening To Voice 3To Pain 2None 1---------------------------------------------------------Verbal Oriented 5Response Confused 4Inappropriate Words 3Incomprehensible Words 2None 1---------------------------------------------------------Motor Obeys Commands 6Response Localizes Pain 5Withdraws (Pain) 4Flexion 3Extension 2None 1---------------------------------------------------------Document as: E___ + V____+ M____=____Ranger Medic Handbook 2007 Edition75thRanger Regiment, US Army Special Operations Command2-2
  30. 30. DO NOT usenasopharyngeal airwayif basal skull fractureis suspected.AirwayPatent?Definitive AirwayEstablished?YESNONOTrauma AssessmentYESNOReposition Airway Manually(jaw-thrust if c-spine injury)Sweep & Suction as neededHeimlich Maneuver if indicatedEstablish More Definitive AirwayAs Required IAW Procedures1. Crycothyroidotomy2. King-LT AirwaySee ProceduresMonitorRe-check airway every 5 minSweep & Suction as neededSupplemental O2 if possibleAssist ventilation w/BVM as neededRestart Protocol if problems ariseEvac - PriorityConsider Immediate Cricothyroidotomy as dictated by:1. Maxillofacial Trauma2. Tactical Situation3. Any other Failed IntubationRe-Assess Interventions ProvidedConsider other causes of HypoxiaAirway Management ProtocolIs SpO2>90%?Assist ventilations with BVM as requiredThoracicTrauma?Refer to ThoracicTrauma ManagementICW this protocolYESYESNOYESNOSupplemental O2 if possibleGenerally, unless a patient has aGCS of <8, intubation will bedifficult. The medic shouldconsider immediatecricothyroidotomy to establish adefinitive airway.Indications forAirway Management1. Airway Obstruction due to trauma, edema, excesssecretions, foreign body, or tongue2. Apnea3. Excess work of breathing as indicated by accessorymuscle use, fatigue, diaphoresis, or tachypnea whenresp failure is imminent4. Decreased LOC (GCS<8)5. Hypoxia (SpO2 <90%)6. Shock7. Patients not meeting the above criteria may stillrequire airway protection preceding long transportConscious withSpontaneousRespirations(RR <8 or >30 )?Insert Nasopharyngeal AW (NPA)Consider & Implement ImmediateEvacuation as requiredMonitor IAW ProtocolAntibiotics as requiredPain Management as requiredContact/Report to Medical OfficerOxygen if possibleDocumentEvacuate – UrgentMonitor Airway ContinuouslySweep & Suction as requiredRestart Protocol if respiratory problems arriseAPPROVEDDATE: 01 OCT 06Dr KotwalDr RedmanDr CunninghamDr MilesGlasgow Coma ScaleEye Spontaneous 4Opening To Voice 3To Pain 2None 1---------------------------------------------------------Verbal Oriented 5Response Confused 4Inappropriate Words 3Incomprehensible Words 2None 1---------------------------------------------------------Motor Obeys Commands 6Response Localizes Pain 5Withdraws (Pain) 4Flexion 3Extension 2None 1---------------------------------------------------------Document as: E___ + V____+ M____=____AVPU Responsiveness AssessmentALERTVERBAL – Responds to verbal stimuliPAIN – Responds to painful stimuliUNCONSCIOUS – Does not respond to any stimuliRanger Medic Handbook 2007 Edition75thRanger Regiment, US Army Special Operations Command2-3
  31. 31. 1. Maintain strict C-Spine precautions if potential for C-Spine Injury exists.2. Anytime the patient goes 30 seconds without ventilation, stop the procedure andhyperventilate for 30-60 seconds before procedure is re-attempted.Patient AssessmentIndication for SurgicalCricothyroidotomySurgical Cricothyroidotomy ProcedurePrepare Cric-KitSecure the tube to the patient toprevent dislodgingEQUIPMENT NEEDED:- Scalpel, Sz 10- Tracheal Hook- Povidine Solution/Swab- Gloves- Sterile 4X4 Sponge- 7.0mm ET Tube- Bag-Valve-Mask (BVM)DOCUMENTATION:- ABC’s- Detailed Assessment- Vital Signs- SpO2- Glasgow Coma Scale- Tube Check Results- Lung Sounds- Absence of Epigastric Sonds- Skin Color- Complications EncounteredIdentify Crycothyroid membrane:Soft aspect just inferior to the larynx, midline, anteriortracheaCleanse the site with PovidineStabilize larynx between thumb andindex finger of non-dominant handMake a VERTICAL skin incision over thecrycothyroid membrane, and carefullyincise through the membraneInsert a tracheal hook onto the crycothyroidmembrane, hook the crycoid cartilage andapply anterior displacementInsert a 6.0 to 7.0 ET Tube or Cric-specifictube through the midline of the membraneand direct the tube distally into the tracheaInflate the cuff of the ET Tube with 10cc of airAttach BVM and ventilate the patientVentilate as needed with 100% O2 (if possible)Confirm tube placement and adequateventilationAuscultate Breath SoundsMonitor SpO2Chest Rise and FallMonitor ContinuouslyAntibiotics as requiredPain Management as requiredContact/Report to Medical OfficerOxygen if possibleDocumentEvacuate IAW ProtocolEnsure adequate ventilation with BVM(12 to 20 breaths per minute)APPROVEDDATE: 01 OCT 06Dr KotwalDr RedmanDr CunninghamDr MilesGlasgow Coma ScaleEye Spontaneous 4Opening To Voice 3To Pain 2None 1---------------------------------------------------------Verbal Oriented 5Response Confused 4Inappropriate Words 3Incomprehensible Words 2None 1---------------------------------------------------------Motor Obeys Commands 6Response Localizes Pain 5Withdraws (Pain) 4Flexion 3Extension 2None 1---------------------------------------------------------Document as: E___ + V____+ M____=____Ranger Medic Handbook 2007 Edition75thRanger Regiment, US Army Special Operations Command2-4
  32. 32. 1. CONTRAINDICATION: The King-LT-D does not protect the airwayfrom the effects of reguritation or aspiration. Be prepared to suctionas needed.2. REMOVAL:a. Suction above the cuff in the oral cavity if indicatedb. Fully deflate both cuffs before removal of the devicec. Remove the King LT-D when protective reflexes have returnedPatient AssessmentIndication forSupralaryngealAirwayKing-LT D Supralaryngeal Airway Insertion ProcedureEQUIPMENT NEEDED:- King LT-D Airway Device (siz 4 or 5)- 90cc syringe (accompanying)- Gloves- Bag-Valve-Mask (BVM)- Oxygen if availableDOCUMENTATION:- ABC’s- Detailed Assessment- Vital Signs- SpO2- Glasgow Coma Scale- Lung Sounds- Absence of Epigastric Sonds- Skin Color- Complications EncounteredAirway Management in patients over 4 ft in heightControlled or Spontaneous VentillationApply chin-lift and introduceKing-LT-D into corner of mouthWhile holding the King-LT-D inthe dominant hand, advance tipunder base of tongue, whilerotating tube to midline (the blueline faces the chin)Without excerting excessiveforce, advance tube until base ofconnector is aligned with teeth orgumsInflate cuffs:Size 4 or 5 – 80 mlAttach BVM. While bagging,slowly withdraw tube untilventilation is easy and free-flowingOxygen 100% if availableBag-valve-mask ventilationsas requiredCheck for breath sounds andabsence of epigastric soundsTest cuff inflationsystem for air leakApply water-solublelubricant to distal tipAdjust cuff inflation asnecessary to obtain a seal ofthe airway at the peakventilatory pressure employedMonitor ContinuouslyAntibiotics as requiredPain Management as requiredContact/Report to Medical OfficerOxygen if possibleDocumentEvacuate IAW ProtocolEnsure adequate ventilation with BVM(12 to 20 breaths per minute)APPROVEDDATE: 01 OCT 06Dr KotwalDr RedmanDr CunninghamDr MilesGlasgow Coma ScaleEye Spontaneous 4Opening To Voice 3To Pain 2None 1---------------------------------------------------------Verbal Oriented 5Response Confused 4Inappropriate Words 3Incomprehensible Words 2None 1---------------------------------------------------------Motor Obeys Commands 6Response Localizes Pain 5Withdraws (Pain) 4Flexion 3Extension 2None 1---------------------------------------------------------Document as: E___ + V____+ M____=____Ranger Medic Handbook 2007 Edition75thRanger Regiment, US Army Special Operations Command2-5
  33. 33. 1. Maintain strict C-Spine precautions if potential for C-Spine Injury exists.2. Avoid applying pressure on the teeth or lips. Never use a prying motion.3. anytime the patient goes 30 seconds without ventilation, stop the procedureand hyperventilate for 30-60 seconds before procedure is re-attempted.4. Intubation is to be only attempted twice. After two unsuccessful attempts aremade, transition to a surgical cricothyroidotomy.5. If assistance is available, use Selick’s maneuver to assist visualization ofepiglottis and vocal cords.6. Inflate with 10cc of normal saline OR only 5cc of air for high altitudeenvironment or high altitude aeromedical evacuation.Patient AssessmentIndication forOrotracheal IntubationOrotracheal Intubation ProcedureAssure adequate ventilation and oxygenation are inprogress and that suctioning equipment isimmediately availableCheck cuff of ET Tube and lubricate tubeConnect the laryngoscope blade to the handle andcheck bulb for brightness. Ensure bulb is secure inthe bladeHold laryngoscope in the Left handOpen patient’s mouth with fingers of your Right handand insert the laryngoscope into the right side of thepatient’s mouth, displacing the tongue to the Left.Visually identify the epiglottis and the vocal cords* Use Selick’s Maneuver if assistance is availableInsert and advance the ET Tube into the tracheaensuring the cuff is at least 1 to 2.5 cm below thevocal cordsApply upward and outward pressure (lifting thelaryngoscope) on the mandibleDO NOT leverage off of the teethInflate the cuff on the ET Tube with air using a 10ccsyringe (*see Note 6)Initially Confirm tube placementTube Check – Bulb should inflate if the ET Tbe isproperly placed in the trachea. The bulb will notinflate if the tube is misplaced into the esophagusAuscultation – Bilateral breath soundsshould be heard upon inhalation and/orsqueezing of the BVM or epigastric soundsAttach BVM with supplemental O2 (if available)Secondary confirmation of tube placementSecure the TubeEQUIPMENT NEEDED:- Laryngoscope- Miller and Macintosh Blades- ET Tube (7.0 or 7.5mm)- Suction (Manual or Mechanical)- Oxygen Source (if available)- Bag-Valve-Mask (BVM)- Stylet- Stethoscope- Syringe, 10cc- Lubricant (Water Soluble)- Tube Check Bulb- Pulsoximeter- Gloves- TapeDOCUMENTATION:- ABC’s- Detailed Assessment- Vital Signs- SpO2- Glasgow Coma Scale- Tube Check Results- Lung Sounds- Absence of Epigastric Sonds- Skin Color- Teeth to ET Tube Tip depth- Complications EncounteredAPPROVEDDATE: 01 OCT 06Dr KotwalDr RedmanDr CunninghamDr MilesMonitor ContinuouslyAntibiotics as requiredPain Management as requiredContact/Report to Medical OfficerOxygen if possibleDocumentEvacuate IAW ProtocolEnsure adequate ventilation with BVM(12 to 20 breaths per minute)Glasgow Coma ScaleEye Spontaneous 4Opening To Voice 3To Pain 2None 1---------------------------------------------------------Verbal Oriented 5Response Confused 4Inappropriate Words 3Incomprehensible Words 2None 1---------------------------------------------------------Motor Obeys Commands 6Response Localizes Pain 5Withdraws (Pain) 4Flexion 3Extension 2None 1---------------------------------------------------------Document as: E___ + V____+ M____=____Ranger Medic Handbook 2007 Edition75thRanger Regiment, US Army Special Operations Command2-6
  34. 34. 1. If bleeder is visualized or palpated, apply hemostatic agent directly to site.2. For truncal bleeding, assume the possibility of intra-abdominal and thoracic injury.TraumaAssessmentAssess Bleeding& LocationExtremity Truncal HeadMassiveUncontrolledExtremityBleeding?HypovolemicShock?BleedingContinues?NONONOYESYESPenetratingThoracic?Refer to ThoracicTrauma ProtocolICW this protocolPenetratingAbdominal?Considerimmediate evacRefer to AirwayMgmt ProtocolICW this protocolHemorrhage Management Protocol1. Apply Hemostatic Agent2. Pack Wound3. Pressure DressingApply Direct Pressure&Indirect PressurePack WoundPressure DressingConsider tourniquet conversionby med personnel IAW procedureRe-Apply TourniquetMonitorPain ControlAntibioticsDocumentEvac -RoutinePackWoundPressureDressingHypovolemicShock?NOYESRefer toHypovolemicShockProtocolYESNOYESNOYESNOMaxillofacialInjury?Pack Wound with airwaymanagement awarenessYESNO1. Hemostatic Agent2. Pack Wound3. Pressure DressingGCS<8?Refer to AirwayManagementProtocol ICW thisprotocolYESYESNOAirway Patent &SpontaneousRR >8 and <30?Refer to Head InjuryManagement ProtocolICW this protocolScalplacerationbleeding?Consider quickclosure of lacerationswith staples orsuturesTourniquetApplied IAWprocedure?Apply or tightenTourniquetApply HemostaticAgentYESNOIf bleeding continues, considerclamping or ligationMonitor IAW ProtocolAntibiotics as requiredPain Management as requiredContact/Report to Medical OfficerOxygen if possibleDocumentEvacuate – Urgent SurgicalRestart Protocol if problems arriseAssess for ShockYESNO1. Hemostatic Agent2. Pack Wound3. Pressure DressingAPPROVEDDATE: 01 OCT 06Dr KotwalDr RedmanDr CunninghamDr Miles1. Apply Hemostatic Agent2. Pack Wound3. Pressure DressingRanger Medic Handbook 2007 Edition75thRanger Regiment, US Army Special Operations Command2-7
  35. 35. Patient AssessmentIndication forTourniquetApplicationTourniquet Application ProcedureDOCUMENTATION:- ABC’s- Detailed Assessment- Vital Signs- SpO2- ComplicationsEncounteredMassive External ExtremityBleedinguncontrolled by direct orindirect pressureAmputationCombat ApplicationTourniquet(CAT)RatchetTourniquetWindlass(Sticks & Rags)LowerExtremityUpperExtremityRoute band around legand pass the free-runningend through the bucklePass band through theoutside slit of the buckleand pull the band tightSecurely fasten the bandback on itselfTwist the Windlass Roduntil arterial bleeding hasstoppedLock the Windlass Rodwith the clip and secureRod with friction adapterstrapInsert the wounded armthrough the loop of thebandPull the band tightly andsecure the band back onitself and around the arm**DO NOT adhere theband past the WindlassClipTwist the Windlass Roduntil arterial bleeding hasstoppedLock the Windlass Rodwith the clip and secureRod with friction adapterstrapInsert the woundedextremity through theloop of the devicePull excess strap astightly as possibleRatchet maneuverthe device untilarterial bleeding hasstoppedLock the ratchet onitself and wrapexcess webbingaround the ratchetdeviceDocument the location and time thetourniquet was appliedDo not cover the tourniquet if possibleApply the tourniquet to proximalaspect of femur or humerosUsing a cravat or cloth stripapproximately 2" wide and24" lengthTie a tight half-knot andplace a stick over the knotTie a tight full-knot over thestickTwist the stick until arterialbleeding has stoppedLoop the cravat or clotharound the wounded extremityUsing the remaining cravator cloth ends, tightly securethe stick into placeConsider Tourniquet Conversion if:1. Bleeding Controlled2. Hemostatic Dressing effective3. Extended Evacuation time4. Re-locating tourniquet distallyRefer to TourniquetConversion Procedure1. Tourniquet Conversion is to only be performedby a Ranger Medic or Medical Officer. Non-medical personnel are not authorized toconvert tourniquets.2. Tourniquets are to be placed as high aspossible on long bones of extremities toensure adequate hemorrhage control.3. Tourniquet Pain is difficult to manage – Titrateto appropriate effect.Monitor IAW ProtocolAntibiotics as requiredPain Management as requiredContact/Report to Medical OfficerOxygen if possibleDocumentEvacuate IAW ProtocolAPPROVEDDATE: 01 OCT 06Dr KotwalDr RedmanDr CunninghamDr MilesRanger Medic Handbook 2007 Edition75thRanger Regiment, US Army Special Operations Command2-8
  36. 36. Patient AssessmentIndication forApplication ofHemostatic AgentHemostatic Agent Application ProcedureMassive External Extremity Bleeding uncontrolled by direct,indirect pressure or tourniquet.Massive truncal bleeding uncontrolled by pressure, ligatiing orclampingAmputationChitosan(Hemcon)DressingCeloxQuik-ClotDocument the location and time thehemostatic agent was appliedAssess casualty for HypovolemicShock IAW protocolApply direct, firm pressureto wound using steriledressing or kerlex gauzeCut dressing to appropriatesize as indicated by thesize of the woundApply dressing firmly for 1to 2 minutes to bleedingsite until dressing adheresand bleeding stopsPack wound with KerlexgauzeApply outer bandage tosecure dressing on woundsite**AVOID contact with wetskin on provider or patient.Avoid breathing productdust or getting in eyes**Use gauze, sterile spongeor suction to wipe excessblood and moisture fromwound areaImmediately start a slowpour of Quik-Clot granulesdirectly into the woundStop pouring as soon asdry granules cover thewounded area. Use onlyenough to stop bleedingRe-Apply firm pressureusing sterile gauze ordressingApply outer bandage tosecure wound siteMonitor IAW ProtocolAntibiotics as requiredPain Management as requiredContact/Report to Medical OfficerOxygen if possibleDocumentEvacuate IAW ProtocolBlot away excessblood from woundwith gauzeImmediately pourentire contents ofCelox pouch directlyinto woundUsing gauze, applyFIRM pressure to thewound for 5 minutesIf bleeding persists,apply direct pressurefor an additional 5minutesCover wound withtrauma dressing andmanintain pressureon woundEmerging orAlternativeProductAPPROVEDDATE: 01 OCT 06Dr KotwalDr RedmanDr CunninghamDr MilesRanger Medic Handbook 2007 Edition75thRanger Regiment, US Army Special Operations Command2-9
  37. 37. PatientAssessmentIndication forTourniquetConversionTourniquet Conversion ProcedureEQUIPMENT NEEDED:- TourniquetDOCUMENTATION:- ABC’s / Airway Status- Detailed Assessment- Vital Signs- Date/Time of procedure- Skin Color- Capillary Refil- Response to procedure- Complications EncounteredBleeding ControlledHemostatic Dressing effectiveExtended evacuation time/distanceRe-locating Tourniquet distallyLoosen ProximalTourniquetBleedingControlled?Continue to observe for bleedingRe-apply ProximalTourniquetApply 2ndTourniquet2-4" Above WoundRe-Assess for tourniquet re-application as neededLoosen ProximalTourniquetBleedingControlled?Continue to observefor bleedingRe-Assess for tourniquetre-application as neededRe-apply ProximalTourniquetConsider CyclingTourniquet for capillaryperfusion as neededYESNOYESNOMonitor IAW ProtocolAntibiotics as requiredPain Management as requiredContact/Report to Medical OfficerOxygen if possibleDocumentEvacuate IAW Protocol1. Tourniquet Pain is difficult to manage – Titrate to appropriate effectAPPROVEDDATE: 01 OCT 06Dr KotwalDr RedmanDr CunninghamDr MilesRanger Medic Handbook 2007 Edition75thRanger Regiment, US Army Special Operations Command2-10
  38. 38. S/Sx of Chest InjMech of InjHemorrhage?Refer to HemorrhageControl Protocol(Truncal Branch)ANDHypovolemic ShockProtocol1. Re-Assess after each intervention.2. If in a multiple casualty situation, consider needle decompression onall significant chest injury casualties.PENETRATING BLUNTIdentifyMechanismOPEN IMPALEMENTTension orSimplePneumothoraxSuspected?HemothoraxSuspected?HemothoraxSuspected?Consider Evacversus Chest TubeYES YESYESYESNONONONOFlail SegmentSuspected?YESNOThoracic Trauma Management ProtocolSpinal InjurySuspected?ConsiderSplinting &Pain ControlStabilize Object & ApplyOcclusive DressingApply Occlusive DressingNeedle DecompressionProcedureChest Tube Procedure(as required)Refer to SpinalManagementProtocolYESNOTension orSimplePneumothoraxTension orSimplePneumothoraxSuspected?Repeat Needle Decompression asoften as necessaryChest Tube / Pleurovent Decision Criteria:1. Multiple Unsuccessful NeedleDecompressions2. Extended time before evacuation occurs3. Extended evacuation distance/timeAssess effectiveness of decompression,breath sounds, and RRConscious withSpontaneous &Respirations(RR >8 or <30 )?Refer to AirwayManagementProtocol ICW thisprotocolNOPenetrating orBlunt Trauma?RespiratoryDistress?NOYESMonitor IAW ProtocolAntibiotics as requiredPain Management as requiredContact/Report to Medical OfficerOxygen if possibleDocumentEvacuate – Urgent SurgicalRe-Assess for Tension PneumothoraxYESNOYESAPPROVEDDATE: 01 OCT 06Dr KotwalDr RedmanDr CunninghamDr MilesRanger Medic Handbook 2007 Edition75thRanger Regiment, US Army Special Operations Command2-11
  39. 39. 1. The provider will make determination on site selection based on injurypattern and overall patient condition.2. If using, povidine-iodine, wait 2 min before continuing with procedurePatient AssessmentIndication for NeedleChest DecompressionNeedle Chest Decompression ProcedureEQUIPMENT NEEDED:- 10G to 14G 2.5" to 3" Needle with catheter- Povidine Solution/swab- Asherman Chest SealDOCUMENTATION:- ABC’s / Airway Status- Detailed Assessment- Vital Signs- SpO2- Lung Sounds before and after decompression- Chest rise/excursion- Skin Color- Capillary refill- Response to treatment- Complications EncounteredABC’sOxygen 100% if availableAssist Ventilations as neededSelect Site:1. Affected side, 2ndor 3rdintercostal space, mid-clavicular lineOR2. Affected side, 5thintercostal space, mid-axillary lineCleanse site with povidine solution/swab and wait 2 minORCleanse with AlcoholRemove the leur-lok from the distal end of thecatheter, insert the needle/cath over the rib into theintercostal space and puncture the parietal pleuraRemove the needle from the catheterand listen for the sudden escape of airLeave the catheter in place convertingtension to an open pneumothoraxEnsure tension has been relieved. If not,then repeat procedureAuscultate breath sounds frequentlyand monitor patient statusApply Asherman Chest Seal (ACS) over catheterhub so that flutter valve protects catheterMonitor IAW ProtocolAntibiotics as requiredPain Management as requiredContact/Report to Medical OfficerOxygen if possibleDocumentEvacuate IAW ProtocolAPPROVEDDATE: 01 OCT 06Dr KotwalDr RedmanDr CunninghamDr MilesRanger Medic Handbook 2007 Edition75thRanger Regiment, US Army Special Operations Command2-12
  40. 40. Ranger Medic Handbook 2007 Edition75thRanger Regiment, US Army Special Operations Command2-13Patient AssessmentIndication forChest TubeChest Tube Insertion ProcedureEQUIPMENT NEEDED:- 9" Peans Forceps (clamp)- 1-0 Armed Suture- Povidine Solution/swabs- Scalpel, #10- 36 Fr to 38 Fr Chest Tube- Heimich Valve- Sterile 4X4 Sponges- Petrolatum Gauze- 18G Needle- Syringe, 10cc- Chux- Lidocain Inj, 1%- Tape, 2"- Sterile GlovesDOCUMENTATION:- ABC’s / Airway Status- Detailed Assessment- Vital Signs- SpO2- Lung Sounds before and after tube insertion- Chest rise/excursion- Skin Color- Capillary refill- Response to treatment- Complications EncounteredABC’sOxygen 100% if availableAssist Ventilations asneededSelect Site: Affected side, 5thintercostal space (nipplelevel), anterior to midaxillary lineCleanse site with povidine solution/swabLocally anesthetize the skin, rib periosteum, and pleuraMake a 2-3 cm horizontal incision parallel to ribs at thepredetermined site and bluntly dissect through thesbcutaneous tissues just over the top of the 6thribINDICATIONS:1. Multiple Unsuccessful Needle Decompressions2. Extended time before evacuation occurs3. Extended evacuation distance/timePuncture the parietal pleura with the tip of the clamp (9"Peans) and spread the tissuesWith the index finger of the non-dominant hand, tracethe clamp into the incision to avoid injury to otherorgans and clear any adhesions or clotsWith the index finger of the non-dominant handremaining in place, clamp the proximal end of the chesttube and insert into the chest cavity to the desiredlengthLook for “fogging” of the chest tube with expirationConnect the end of the chest tube to the Heimlich valveSecure the tube in placeSuture the tube in place using purse-string techniqueORStaple the tube in placeORSlide tube through ACS valve and apply ACS to chest wallWrap the tube with petrolatum gauzeApply cut 4X4 sponge twice around the tubeTape the dressings in placeTape the tube to the chestPrepare EquipmentMonitor IAW ProtocolAntibiotics as requiredPain Management as requiredContact/Report to Medical OfficerOxygen if possibleDocumentEvacuate IAW ProtocolAPPROVEDDATE: 01 OCT 06Dr KotwalDr RedmanDr CunninghamDr Miles
  41. 41. 1. Fluid of choice for shock resuscitation is Colloids. Do not exceed 1000cc of colloids.2. Normal saline is the preferred crystalloid over Lactated Ringers because it mixes with allmedications & blood products.3. Foley catheters should be packed in vehicle-based trauma bags and utilized based onextended evacuation time4. Patient Warming procedures are to be initiated as soon as possible ICW fluid challenges.TraumaAssessmentHemorrhageControl ProtocolBleedingControlled orUncontrolled?Controlled Bleeding Uncontrolled BleedingAssessResponseRapidResponseBP >90BP>90BP<90Hypovolemic Shock Management ProtocolInitiate Vascular Access1. Peripheral Saline Lock2. Second Attempt Peripheral Saline Lock3. External Jugular Access4. Intraosseous Device AccessFluid Challenge # 1500cc Colloid (1stChoice)Or 1000cc CrystalloidTransient orNo Response(after 30 min)Fluid Challenge # 2500cc Colloid (1stChoice)Or 1000cc CrystalloidAssessResponseIV TKORe-Assess all Treatments andInterventionsAssessResponseBP>90BP<90Assess & Continue Fluid ratesat TKO until EvacuationContinue to Identify and Manage CauseInitiate Vascular Access1. Peripheral Saline Lock2. Second Attempt Peripheral Saline Lock3. External Jugular Access4. Intraosseous Device AccessIV TKO (Colloid or Crystalloid)DO NOT Fluid ChallengePatient Warming ProceduresPatient Warming ProceduresAltered Mental Status w/o head injuryWeak/Absent Peripheral PulsesTachycardiaAnxietyDiaphoresisIncreased Resp RateCapillary Refill >2 secDecreased BPConfusionUnconsciousnessDecrease Urine OutputPalpable Pulses = Estimated Systolic BPRadial Pulse: >80mmHgFemoral Pulse: >70mmHgCarotid Pulse: >60mmHgS/Sx ofHypovolemicShock?YESNOEstablish IV AccessNo IV Fluids RequiredPO Fluids PermissableRefer to appropriate injury protocolMonitor & Evac as neededCalculate Estimated FluidLoss and DocumentMonitor IAW ProtocolAntibiotics as requiredPain Management as requiredContact/Report to Medical OfficerOxygen if possibleDocumentEvacuate – Urgent SurgicalMonitor IAW ProtocolAntibiotics as requiredPain Management as requiredContact/Report to Medical OfficerOxygen if possibleDocumentEvacuate – Urgent Surgical5-15Colloid ColloidColloid &BloodColloid &BloodEstimated Fluid & Blood Loss (Modified from ATLS)APPROVEDDATE: 01 OCT 06Dr KotwalDr RedmanDr CunninghamDr MilesRanger Medic Handbook 2007 Edition75thRanger Regiment, US Army Special Operations Command2-14
  42. 42. Patient AssessmentIndication for SalineLock and/or IV InfusionSaline Lock & Intravenous Access ProcedurePrep Equipment & Don GlovesEQUIPMENT NEEDED:- Constricting Band- Povidine-Iodine Swab- 2 X 18-G IV Catheter/Needle- 10 cc Syringe- Saline Lock- Tegaderm (at least 2.5" X 2.5")- IV Tubing (10 gtts/ml)- Raptor/Linebacker IV securing device- Tape, 2"- Appropriate IV Fluids- GlovesDOCUMENTATION:- ABC’s- Detailed Assessment- Vital Signs- SpO2- IV Site- IV Gauge- Date/Time Started- Fluids Infused / rate- Complications EncounteredApply constricting bandCleanse / Prep Site with Povidine SwabInsert catheter/needleAdvance catheter and remove needleAttach Saline LockRelease Constricting BandApply Tegaderm over entire site(including the saline lock hub)Flush with 5-10ml Normal SalineIndication for IV InfusionPrep IV EquipmentApply pressure proximal to saline lockInsert catheter/needle into the salinelock portAdvance catheter into the saline lockport and remove needleAttach IV tubing and release pressureOpen IV Fluids line and ensureadequate flowSecure IV tubing with Tape/Raptor/LinebackerAdminister IV fluids IAW appropriateprotocolSupport splint extremity as neededIndication rapid removalof IV from saline LockMonitor IAW ProtocolAntibiotics as requiredPain Management as requiredContact/Report to Medical OfficerOxygen if possibleDocumentEvacuate IAW ProtocolIV Drip RatesUnsecure IV Tubing from PT and turn off the IV flowGently remove the IV tubing catheter from thesaline lock** DO NOT REMOVE THE SALINE LOCK**Discard IV Bag/Tubing as appropriateAPPROVEDDATE: 01 OCT 06Dr KotwalDr RedmanDr CunninghamDr MilesRanger Medic Handbook 2007 Edition75thRanger Regiment, US Army Special Operations Command2-15
  43. 43. Patient AssessmentIndication for ExternalJugular IntravenousCannulationExternal Jugular Intravenous Cannulation ProcedurePrep Equipment and don glovesPlace patient in supine position ormodified Trendelenberg positionC-spine precautions as requiredTurn the patients head to the opposite sideCleanse the site with povidine solution/swabApply light pressure on the inferior aspect of theexternal jugular to create a tourniquet affectAlign needle/catheter/syringe in the direction of thevien with the tip of the needle generally aimedtoward the “same-side” nippleAttach a 10 cc syringe filled with normalsaline to catheter/needleInsert the catheter/needle into the vein and aspirate**NOTE BLOOD RETURN WHEN ASPIRATING****DO NOT ALLOW AIR TO ENTER THE VEIN**Advance catheter and withdraw needle/syringeAttach saline lock and flush withnormal salineApply Tegaderm covering entire site(including saline lock portEQUIPMENT NEEDED:- Constricting Band- Povidine-Iodine Swab- 2 X 18-G IV Catheter/Needle- 10 cc Syringe- Saline Lock- Tegaderm (at least 2.5" X 2.5")- IV Tubing (10gtts/ml)- Raptor/Linebacker securing device- Tape, 2"- Appropriate IV Fluids- GlovesDOCUMENTATION:- ABC’s- Detailed Assessment- Vital Signs- SpO2- IV Site- IV Gauge- Date/Time Started- Fluids Infused / rate- Complications EncounteredMonitor IAW ProtocolAntibiotics as requiredPain Management as requiredContact/Report to Medical OfficerOxygen if possibleDocumentEvacuate IAW ProtocolAPPROVEDDATE: 01 OCT 06Dr KotwalDr RedmanDr CunninghamDr MilesRanger Medic Handbook 2007 Edition75thRanger Regiment, US Army Special Operations Command2-16
  44. 44. Patient AssessmentIndication for SternalIntraosseous InfusionSternal Intraosseous Infusion ProcedurePrep EquipmentEQUIPMENT NEEDED:- FAST-1 Sternal Intraosseous(Complete)(6515-01-453-0960)DOCUMENTATION:- ABC’s- Detailed Assessment- Vital Signs- SpO2- ComplicationsEncounteredInability to attain vascular accessthrough peripheral extremity orexternal jugular when life-savingfluids or medications are neededSite Selection:Adult Manubrium – Midline on the manubrium,1.5 cm below the sternal notchPrepare site with local anesthetic if PT is consciousCleanse site with povidine solution/swabUse index finger of non-dominant hand to alignthe target patch with the patient’s sternal notchVerify Target Zone is on the midline over the manubriumApply PatchWith patch securely attached to the patient’s skin, thebone probe cluster is placed in the target zone,perpendicular to the skinFAST-1 InsertionWith the introducer in hand, applysteady even pressure until infusiontube has penetrated the manubrium(release is felt)Attach the infusion tube to the rightangle female adapter and secure withprotector domeAttach syringe to the IV insertion siteand aspirate bone marrowMarrowAspiratesFreely?Flush the needle with5 cc Normal SalineFlushesEasily?Discontinue Procedureand find an alternatemeans of vascularaccessAttach IV Tubing and/or saline lockAdminister IV Fluids and/or MedicationsIAW appropriate protocolSecure Inducer Removal Package to theIV Line and/or PatientYESNOYESNOPush needles of inducer into theaccompanying sharps plugMonitor IAW ProtocolAntibiotics as requiredPain Management as requiredContact/Report to Medical OfficerOxygen if possibleDocumentEvacuate IAW ProtocolAPPROVEDDATE: 01 OCT 06Dr KotwalDr RedmanDr CunninghamDr MilesRanger Medic Handbook 2007 Edition75thRanger Regiment, US Army Special Operations Command2-17
  45. 45. Patient AssessmentIndication forHypothermia Prevention& Management KitHypothermia Prevention & Management Kit ProcedureEQUIPMENT NEEDED:- NARP Hypothermia KitDOCUMENTATION:- ABC’s- Detailed Assessment- Vital Signs- SpO2- Skin Color- Complications EncounteredPrevention of Heat Loss in a Trauma CasualtyActive Re-Warming of a Hypothermia PatientEnsure hemorrhage is controlledand other injuries managed IAWappropriate protocolsPlace the heat reflective skullcap on the patient’s headOpen the heat reflective shelland place on a litterPlace the patient inside thereflective shellRemove any wet clothing(Replace with dry clothes ifpossible)Place the self-heating, four cellshell liner on the torso.**Ensure that there is an article ofclothing between the casualty andthe self-heating shell liner**Wrap and secure the reflectiveshell around the casualtyMonitor IAW ProtocolAntibiotics as requiredPain Management as requiredContact/Report to Medical OfficerOxygen if possibleDocumentEvacuate IAW ProtocolAPPROVEDDATE: 01 OCT 06Dr KotwalDr RedmanDr CunninghamDr MilesRanger Medic Handbook 2007 Edition75thRanger Regiment, US Army Special Operations Command2-18

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