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AIR FORCE SPECIAL OPERATIONS

COMMAND

EMT INTERMEDIATE/PARAMEDIC TREATMENT


PROTOCOLS FOR AIR FORCE SPECIAL
OPERATIONS MEDICAL TECHNICIANS

AFSOC HANDBOOK 48-1


1 JULY 1998
BY ORDER OF THE COMMANDER AFSOC HANDBOOK 48-1
AIR FORCE SPECIAL OPERATIONS COMMAND 1 July 1998

Aerospace Medicine

EMT INTERMEDIATE/PARAMEDIC TREATMENT PROTOCOLS FOR


AIR FORCE SPECIAL OPERATIONS MEDICAL TECHNICIANS
____________________________________________________________________________________
This handbook incorporates requirements, information, and procedures formerly contained in AFSOC SG
policy letters. This Handbook applies to all active duty AFSOC 4F0X1 and 4N0X1 personnel, certified at
the Emergency Medical Technician- Intermediate and Paramedic level, as outlined in AFSOCI 48-101.

OPR: HQ AFSOC/SGPA (SMSgt McGill), 16 OSS/OSM (MSgt Cole)


Certified by: HQ AFSOC/SGA (Lt Col Pollard)
Pages: 53
Distribution: F,X

Page

Medical Control ......................................................................................................................................3

Universal Precautions..............................................................................................................................3

Advanced Cardiac Life Support :


Ventricular Fibrillation/Pulseless Ventricular Tachycardia ..........................................................5
Tachycardia ...............................................................................................................................6
Paroxysmal Supraventricular Tachycardia ..................................................................................7
Cardioversion .............................................................................................................................8
Bradycardia................................................................................................................................9
Asystole ................................................................................................................................... 10
Pulseless Electrical Activity...................................................................................................... 11
Pulmonary Edema .................................................................................................................... 12
Acute Myocardial Infarction/Chest Pain.................................................................................... 13

Medical Emergencies:
Unconscious/Unknown ............................................................................................................. 15
Cerebral Vascular Accident ...................................................................................................... 16
Seizure ..................................................................................................................................... 17
Allergic Reaction...................................................................................................................... 18

Environmental Emergencies:
Heat Emergencies ..................................................................................................................... 20
Hypothermia............................................................................................................................. 21
Drowning ................................................................................................................................. 22
Poisoning/Envenomations ......................................................................................................... 23

Trauma Care/Procedures:
Extremity Trauma .................................................................................................................... 35
Eye Injuries .............................................................................................................................. 36
AFSOCH 48-1, 1 July 1998 2

Burns
Thermal ....................................................................................................................... 37
Electrical ..................................................................................................................... 39
Chemical...................................................................................................................... 40
Thoracic Trauma...................................................................................................................... 42
Open Pneumothorax ................................................................................................................. 43
Hemo/Pneumothorax ................................................................................................................ 44
Needle Thoracentesis ................................................................................................................ 45
Advanced Airway Procedures ................................................................................................... 46
Cricothyroidotomy.................................................................................................................... 49
Venous Cutdown ...................................................................................................................... 50
Nasogastic Tube Placement ...................................................................................................... 51
Urethral Catheter Placement ..................................................................................................... 52
AFSOCH 48-1, 1 July 1998 3

Medical Control

Care of injured personnel in combat or rescue situations requires medical command and control by
licensed medical providers. Paramedical and Emergency Medical Technician-Intermediates providing care
in these situations are acting under the principal of ‘delegated authority’, where the provider(usually a
physician) allows appropriately trained personnel to perform specified diagnostic and therapeutic
interventions. There are several types of medical control:
- On Line Medical Control: A physician is either present on the scene and personally directs
patient care, or is contacted by radio or other means and gives ‘live’ instructions.
-Off Line Medical Control: Contact with a control physician is impossible or impractical, care is
given based on specific physician approved protocols.

The medical control chain for AFSOC medical technicians assigned to Operations Support Squadron
Medical Flights(OSS/OSM) is in the following precedence:
On Line Medical Control:
- Senior AFSOC Flight Surgeon present at the scene.
- Special Tactics Flight Surgeon present at the scene.
- Senior US military physician present at the scene.
- Qualified(training equivalent to US physician) Allied country senior military
physician present at the scene
- Qualified civilian physician(training equivalent to US MD or DO) present at the
scene, provided he/she agrees to assume responsibility for care and accompany
the patient to higher level of care.
- Senior AFSOC Physician Assistant present at the scene
- Any of the above in direct radio contact
Off Line Medical Control:
On line medical control is the preferred means of medical control for all casualty
situations. In the event on line control is not possible the following will apply:
- The Senior medic is responsible for directing medical care at all scenes where on
line control is not possible. He/she will direct medical control in strict adherence
to the established protocols contained herein.
- AFSOC medical technicians assigned to OSS/OSM flights will attempt to contact on
line medical control in all situations prior to reverting to protocol use, with the
exception of an immediate life threat and then will attempt to establish on line control as soon as
possible after the patient is stabilized.

Universal Precautions

Universal precautions will be taken appropriately for every situation. They will not be addressed for
each individual protocol.
AFSOCH 48-1, 1 July 1998 4

Advanced
Cardiac
Life
Support
AFSOCH 48-1, 1 July 1998 5

Ventricular Fibrillation/Pulseless Ventricular Tachycardia

ABC’s/O2
Perform CPR
Quick Look

Defibrillate w/ 3 stacked shocks


200j, 300j, 300-360j

1
A ssess vital signs Return of
Supportive care/IV spontaneous circulation
Identify New Rhythm Go to appropriate
give loading dose
rhythm? protocol
of L idocaine
treat as rhythm indicates

Persistent V F/p u l s e l e s s V T

Transport to Reassess patient


nearest medical Continue CPR
facility Intubate at once
Initiate IV

Epinephrine IVP
repeat every 5 min Table 1-1
may give at 1mg every 5 min 1. L i d o c a i n e 1.0-1.5m g / k g r e p e a t i n 3 - 5 m i n
or in intermediate, escalating, or max:3mg/kg
high dose regimen
2. B r e t y l i u m 5 m g / k g I V p u s h
repeat with 10mg/kg IVP q15min up
to 30mg/kg
Reassess patient after each intervention
3. P r o c a i n a m i d e 3 0 m g / m i n
if rhythm changes go to 1
max: 17mg/kg

4. Sodium Bicarbonate 1mEq/kg*


if known preexisting acidosis
C irculate for 30-60 seconds i f o v e r d o s e w i t h tricylic a n t i d e p r e s s a n t s
Stop CPR/Defibrillate at 360j
*Requires medical control direction
Continue CPR

Administer medications listed in table 1-1


C irculate each medication for 30-60 seconds
Repeat defibrillation at 360j
Intersperse Epinephrine with additional medications

Continue care
Transport
AFSOCH 48-1, 1 July 1998 6

Tachycardia

ABC’s/O2
IV
ECG monitor/Vital Signs

Are there
serious S& S Yes Prepare for immediate
and pulse c a r d i o v e r s i o n /go to protocol
>150

No

Identify rhythm

Paroxysmal W ide-complex Ventricular


Atrial Fibrillation supraventricular t a c h y c a r d i a of
Atrial Flutter tachycardia
tachycardia uncertain type

Lidocaine Lidocaine
1.0-1.5mg/kg IVP 1.0-1.5mg/kg IVP
Consider Propranolol
Go to PSVT in 5-10 min repeat at in 5-10 min repeat at
1-3mg IV over 2-3min
protocol half dose every 5-10 min half dose every 5-10 min
can be repeated in 2 min
max: 3mg/kg max: 3mg/kg

Adenosine 6mg quick IVP


Consider Verapamil repeat in 1-2 min at
2 . 5 - 5 . 0 m g I V o v e r 1 - 2 m in 12mg rapid IVP
repeat dose of 5-10 m g may repeat one time in 1-2min
q 1 5 m in until effect

Procainamide
20-30 mg/min
max: 17mg/kg
Continue care
Transport B r e t y l i u m 5-10 m g/kg
over 8-10 min
max:30mg/kg over 24hrs

Consider TCP
Continue care
Transport
AFSOCH 48-1, 1 July 1998 7

Paroxysmal Supraventricular Tachycardia

ABC’s/O2
IV
ECG monitor/Vital Signs

R efer to
Is patient stable
No cardioversion protocol
Y es

Vagal Maneuvers

Adenosine 6mg rapid IVP with 10cc bolus


repeat in 1-2 min at
12mg quick IVP with 10cc bolus
may repeat one time in 1-2min

Complex W ide Lidocaine


Width? 1.0-1.5mg/kg IVP
N arrow

Procainamide
Blood 20-30 mg/min
Pressure? max: 17mg/min
Normal or elevated Low or unstable

Consider Verapamil Synchronized cardioversion


2.5-5.0 mg IV over 1-2min R efer to protocol
in 15-30 min
repeat dose of 5-10 min

Continue care
Consider Propranolol
Transport
1-3mg IV over 2-3min
can be repeated in 2 min

Y es
Does rhythm persist

No
AFSOCH 48-1, 1 July 1998 8

Electrical Cardioversion

A B C ’s/O2/ I n t u b a t e i f n e e d e d
E C G M o n itor Refer to appropriate
IV/Vital signs algorithm

Is ventricular rate >150


w / serious signs/symptoms
No
Yes

Check Oxygen saturation,


Suction device, IV line,
Intubation equipment

P r e m edicate w i t h 5 m g V a l i u m
o r 5 m g M o r p h ine if poss

Engage synchronization m ode

Select appropriate energy level


F o r P S V T a n d A trial Flutter start
a t 5 0 J . A l l o t h e r a r r h y t h m ia's start
at 100J

C lear Patient
Cardiovert

Reasses and repeat as needed


Reengage sync each time
Transport ASAP
AFSOCH 48-1, 1 July 1998 9

Bradycardia

ABC’s/O2/Intubate if needed
ECG monitor
IV
V ital Signs

Serious
signs and
symptoms Yes
No

Is rhythm A tropine 1mg IVP


Transport to No Type II 2nd degree max:0.03-0.04 mg/kg
nearest medical heart block or repeat every 3-5 min
facility 3rd degree
heart block

TCP, if available
Yes *Not inflight

TCP, if available
*Not inflight If B/P <100
consider
Dopamine 5-20 mcg/kg/min

Transport to
nearest medical Epinephrine 2-10mcg/min
facility

Transport to
nearest medical
facility
AFSOCH 48-1, 1 July 1998 10

Asystole

ABC’s/O2/Intubate
Perform CPR
ECG monitor
IV

Stop CPR
Confirm asystole in two leads

Start CPR
Consider possible cause
Hypoxia
Hyperkalemia
Preexisting acidosis
Drug overdose
Hypothermia

Consider immediate
TCP
*Not in flight

Epinephrine 1mg IVP


repeat every 3-5 min

Atropine 1mg IVP


max:0.03-0.04 mg/kg
repeat every 3-5 min

Consider termination of efforts


with medical control direction

Transport to
nearest medical
facility
AFSOCH 48-1, 1 July 1998 11

Pulseless Electrical Activity

ABC’s/O2/Intubate
Perform CPR
ECG monitor
IV

Continue CPR
Consider treating possible cause
Hypoxia/Hypovolemia
Hyperkalemia/Massive MI
Preexisting acidosis/Cardiac Tamponade
Drug overdose/Tension pneumothorax
Hypothermia/Pulmonary embolism

Epinephrine 1mg IVP


repeat every 3-5 min

If relative Bradycardia
A tropine 1mg IVP
max: 0.03-0.04 mg/kg
repeat every 3-5 min

Transport to
nearest medical
facility
AFSOCH 48-1, 1 July 1998 12

Pulmonary Edema

ABC’s/O2
IV
ECG Monitor

Assess respiratory status/


vital signs/obtain history

Nitroglycerin 0.4 mg SL
if systolic >90mm/hg

Lasix 0.5-1.0 mg/kg IV

Morphine 1-3 mg IV
Titrate to effect

Is
Dopamine 2.5-20 Yes systolic No
mcg/kg/min IV < 100mm/hg?
Titrate to effect

Continue supportive
care
Transport to nearest
medical facility
AFSOCH 48-1, 1 July 1998 13

Acute Myocardial Infarction/Chest Pain

ABC’s/O2
ECG monitor
IV
Vital Signs

Obtain thorough history

Does
monitor show Yes Go to appropriate
a Tx protocol
rhythm

No

Give Aspirin
325mg PO

Give Nitroglycerin 0.4mg SL


every 5 min x3 PRN if BP stable

If no relief
Morphine 2-5mg IV
every 5 min prn

Supportive care
Transport to
nearest medical
facility
AFSOCH 48-1, 1 July 1998 14

Medical
Emergencies
AFSOCH 48-1, 1 July 1998 15

Unconscious/Unknown

Assess unresponsiveness
AVPU

Ensure spinal im m obilization precautions

A B C ’s/02
IV
ECG Monitor

Perform primary/secondary survey


Treat all presenting conditions

Perform Glasgow Com a Scale

Is
No
Intubate patient GCS
Go to protocol >8?

Yes

P e r f o r m G lu c o s e C h e c k

LOW NORMAL

100 mg Thiamine IV
2 mg Naloxone IV
Repeat prn
2 5 g m 5 0 % D extrose IV

Continue
supportive care
Transport to nearest
medical facility
AFSOCH 48-1, 1 July 1998 16

Cerebral Vascular Accident

ABC’s/O2/Intubate as needed
ECG monitor
IV

Perform serum glucose test


Treat as appropriate

Protect patient from injury

Obtain thorough history


and physical exam

Transport to
nearest
Medical Facility
AFSOCH 48-1, 1 July 1998 17

Seizure

Is
patient No ABC’s/O2
actively IV
seizing? ECG monitor

Yes

ABC’s, IV and Monitor when possible


Protect Airway
Protect patient from injury
Prepare for intubation

Intubate if needed Is
Reassess ABC’s No seizure
IV/ECG monitor lasting
if not completed >10min

Yes

Supportive care
Administer Valium
Transport
5-10 mg slow IVP

Perform glucose check

Administer 1 amp
25g Dextrose 50% Is
No
Consider 100mg Thiamine glucose
>60mg/dl

Yes
Supportive care
Transport
Has
seizure
activity
stopped? No
Yes

Supportive care Contact physician


Transport Transport
AFSOCH 48-1, 1 July 1998 18

Allergic Reaction

Scene Safety
ABC’s

Severe reaction
pruritis, urtcaria, w h e e z i n g
M ild r e a c t i o n M oderate reaction angioedema, cyanosis,
pruritis, urticaria pruritis, urticaria, w h e e z i n g hypotension, A L O C

IM Benadryl 1mg/kg O2, Monitor A S A P administer 0.3-0.5mg EPI subq


max:50mg Epi, s u b Q 0.3m g 1:1000 Consider .3-.5mg IV 1:10,000 Epi
w ith medical control direction
O2, EKG monitor, IV,ET if needed or
C ricothyrotom y if needed
IM Benadryl 1mg/kg
max:50mg

IM Benadryl 1mg/kg
max:50mg
Consider steroid use
if transportation is >12hr Yes Is
per medical control Systolic
M o n itor and Transport to >90?
nearest medical facility

No

P lace patient in recumbent position


and elevate legs. G ive fluid challenge
of 500cc LR bolus, may repeat once

M o n itor and transport


Yes Is
to nearest medical facility
Systolic
g i v e 1 2 5 m g s o l u m e d r o l IV
>90?
w ith medical control direction
No
Consider dopamine infusion
5 m c g / k g / m i n titrated to m a intain B /P

M o n itor and transport


to nearest medical facility
g i v e 1 2 5 m g s o l u m e d r o l IV
w ith medical control direction
AFSOCH 48-1, 1 July 1998 19

Environmental
Emergencies
AFSOCH 48-1, 1 July 1998 20

Heat Emergencies

Remove patient from


heat environment

A B C ’s/O 2
ECG Monitor
A ssess Core Temperature/
signs and symptoms

Is
Initiate rapid, aggressive Yes core temp No
> 105 F w/ Have patient rest
external cooling measures
sx’s? in cool area

Initiate IV NS Administer PO fluids


G ive 500cc bolus

Does
Is patient Yes
patient No tolerate
actively fluids?
seizing?

No

Yes
Initiate IV NS @ 200cc/hr

Administer 5-10 mg
V a lium IV prn
M onitor core temp

M onitor core temp

Continue supportive
care
Transport to nearest
medical facility
AFSOCH 48-1, 1 July 1998 21

Hypothermia

ABC’s
O2
M onitor
IV

*Gentle handling
of patient

Is
Start CPR Yes patient
D e f i b /3 shocks
pulseless/
Intubate
apneic?
IV-NS
No

=>30C/
W hat 86F 30-34 C
is Active external rewarming
<30C/ core 34-36 C
86F W hat Temp passive r e w a r m i n g
Continue CPR is
No IV Meds core
Limit to 3 shocks Temp
<30C/86F

=>30C/86F
Warm IV NS Supportive care
Warm O2 Transport
Warm gastric lavage

Continue CPR
Active core IV Meds
rewarming D e f i b as
until >30C/86F core temp rises

Supportive care
Transport
AFSOCH 48-1, 1 July 1998 22

Drowning

Is
ABC’s/O2
patient No IV
still in the
Backboard
water?
ECG monitor

Yes

Ensure open airway prior


to removal from water
Place on backboard

Trained personnel only


remove patient
from water

ABC’s /O2
IV
ECG monitor

Treat as needed
Consider water temp (hypothermia)
Consider down time of patient

No Field
Transport
Conditions?

Yes

If patient revives
Observe for at least
six hours for secondary
drowning

Transport
as needed
AFSOCH 48-1, 1 July 1998 23

Poisoning and Envenomation

A ttem p t to identify
poison/exposure
from call inform ation

Ensure scene safety


Don protective
equipm ent
and clothing

C o n tact M ed/Poison Control


G o to specific protocol:
Is 1. A c ids/A lkalis
exposure Yes 2. H ydrocarbons
known? 3. M ethanol
4. E thylene glycol
5. Isopropanol
6. C y a n ide
No 7. Spiders/Scorpions
A B C ’s/O 2 8. Snakes
IV
E C G M o n itor
VS/AVPU

A fter
assessm ent of Yes
patient is poison/ G o to appropriate
exposure protocol
known?

No

Treat sym p tom atically C o n tinue supportive


C o n tact M e d ical C o n t r o l care
C o n tact Poison C o n trol if possible Transport to nearest
m e d ical facility
AFSOCH 48-1, 1 July 1998 24

#1

Acids Alkalis

Hydrochloride acids: Sodium Hydroxide:


-metal cleaners -washing powders
-pool cleaners -paint removers
-toilet bowl cleaners Disk batteries
Sulfuric acids: Bleach
-battery acid Ammonias:
-toilet bowl cleaners -jewelry cleaners
Phenol -hair dyes/tints
Acetic Acid Toilet bowl cleaners
Bleach

ABC’s/O2
IV NS
ECG Monitor

Is
Transport rapidly No patient Yes Dilute w/ 200-300ml
to nearest medical conscious? H20/milk PO ONLY w/
facility medical control direction
AFSOCH 48-1, 1 July 1998 25

#2

Hydrocarbons

Cleaning/polishing Agents
Spot Removers
Paints
Cosmetics
Pesticides
Turpentine
Kerosene/Gasoline/Lighter Fluid

ABC’s/O2
IV NS
ECG Monitor

Perform gastric emptying of amounts


>1 ml/kg of petroleum products containing:
Camphor/Benzene/Organophosphates/
Arsenics/Lead/Mercury
ONLY w/ Medical Control direction
***Intubate prior to attempting to protect airway

Continue supportive care


Transport rapidly to nearest
medical facility
AFSOCH 48-1, 1 July 1998 26

#3

Methanol

Antifreeze
Windshield washer fluid
Paints/Paint removers
Varnishes/shellacs

ABC’s/O2
IV NS
ECG Monitor

Perform gastric lavage Is


***If unconscious intubate Yes ingestion No
prior to protect airway time < 4 hrs?

Administer 1-2g/kg
Activated Charcoal

Administer
1 mEq/kg
Sodium Bicarbonate
to correct metabolic
acidosis

If available administer
Continue supportive
60 ml of 90% Ethanol
care
or
Transport rapidly to
125 ml of 43% Ethanol
nearest medical
facility
AFSOCH 48-1, 1 July 1998 27

#4

Ethylene Glycol
Windshield De-icers
Detergents
Paints
Radiator Antifreeze/coolants

ABC’s/O2
IV NS
ECG Monitor

Is
Perform gastric lavage Yes ingestion No
***If unconscious intubate time
prior to protect airway < 4hrs?

Administer
1 mEq/kg
Sodium Bicarbonate
to correct metabolic
acidosis

Continue supportive
If available administer
care
60 ml of 90% Ethanol
Transport rapidly to
or
nearest medical
125 ml of 43% Ethanol
facility
AFSOCH 48-1, 1 July 1998 28

#5

Isopropanol
Rubbing Alcohol
Disinfectants
Degreasers
Industrial cleaning agents

ABC’s/O2
IV NS
ECG Monitor

Perform gastric lavage


***If unconscious intubate
prior to protect airway

Continue supportive
care
Transport rapidly to
nearest medical
facility
AFSOCH 48-1, 1 July 1998 29

#6

Cyanide

Remove patient
from source

ABC’s/O2
IV NS
ECG Monitor

Administer Amyl Nitrate


for 15 of every 30
seconds

Administer 300mg
Sodium Nitrate slow IVP over no less than 5 min

Administer 12.5 g
Sodium Thiosulfate IV

Continue supportive
care
Transport rapidly to
nearest medical
facility
AFSOCH 48-1, 1 July 1998 30

#7

Black Widow Spider

ABC’s/O2
IV NS
ECG Monitor

Clean affected area w/


saline
Cover w/ sterile dressing

If symptoms are moderate


to severe administer
5 mg Valium IV

Continue supportive
care
Transport rapidly to
nearest medical
facility
AFSOCH 48-1, 1 July 1998 31

#7

Brown Recluse Spider

ABC’s/O2
IV NS
ECG Monitor

Apply cold compresses/


sterile dressing to
affected area

Continue supportive
care
Transport rapidly to
nearest medical
facility
AFSOCH 48-1, 1 July 1998 32

#7

Scorpion Stings

ABC’s/O2
IV NS
ECG Monitor

Apply ice to affected area


to relieve localized pain

Consider 5 mg Valium IV
for apprehension

Consider 25-50 mg Demerol IV


for pain control

Are
Yes No
symptoms
severe?

Is
patient No
convulsing?

Yes
Continue supportive
care
Adminster 5 mg Valium IV over Transport rapidly to
2 min q 10-15 min prn
nearest medical
facility
AFSOCH 48-1, 1 July 1998 33

#8

Snake Envenomantion

ABC’s/O2
IV NS
ECG Monitor

Calm/reassure patient Splint extremity at


Keep patient still heart level

Examine snake if it
can
be done safely to *Check distal pulses
determine type frequently
*Do not remove until
reach medical facility
Remove all devices which may
become tourniquets, ie; Rings/
watches, etc.
Administer appropriate
antivenin ONLY w/
Clean wound w/ saline M edical Control
direction

Apply Sawyer Extractor


Pump if available
*Most effective if applied Continue supportive
w/in 3 minutes care
Repeat suction prn until evac Transport rapidly to
nearest medical
facility

Determine type of snake and/or


evaluate signs/symptoms

Elapidae/Sea Snake Crotalidae/Viper


Unknown snake w/ no Unknown snake w/
significant local pain significant local pain

*Apply ace wrap *Apply proximal


compression bandage constriction band
AFSOCH 48-1, 1 July 1998 34

Trauma
Care/
Procedures
AFSOCH 48-1, 1 July 1998 35

Extremity Trauma

ABC’s
Vital signs
IV as needed

Perform Manual Stabilization

Remove all clothing from area.


Remove any restricting items.

Assess distal neurovascular status

If there is any neurovascular compromise


and transport is >60min attempt
to realign once ONLY.

Dress any open wounds

Apply padding to any bony prominences

Apply gentle traction


Apply traction splint
Immobilize the joints above and below.

Reassess distal neurovascular status

Consider 4mg IV Morphine and


transport ASAP
AFSOCH 48-1, 1 July 1998 36

Eye Injuries

Scene Safety
ABC’s / O2
M onitor

Obtain baseline visual acuity


except in chemical or corrosive burns

Burn Foreign Body Trauma

Attempt to remove any obvious Cover both eyes


Penetrating trauma
loose foreign bodies, with a with a loose moist
What type dressing
moist cotton applicator
of
burn?
Stabilize object
Flash Chemical and Transport to
burn dress both eyes
Evert upper lid nearest medical
and examine for facility
foreign body
Cover eyes with
Irrigate ASAP
loose dressing
Transport to
nearest medical
Irrigate and facility
cover both eyes
Transport to Determine type of
nearest medical chemical.
facility continue irrigating
1
Transport to
nearest medical
facility Laser injury
Transport to
nearest medical
facility. Continue
irrigating Obtain visual
acuity

Amsler grid

Transport to
nearest medical
facility
AFSOCH 48-1, 1 July 1998 37

Thermal Burns

Scene Safety
ABC’s/O2
Monitor

Stop burning process

Is Is
there Yes transport
evidence of time
inhalation >10min?
injury? No Yes

No
Consider Transport immediately
intubation If sx progress rapidly
Removed any
intubate as needed
clothing/jewelry

Determine % BSA burned


and
degree of burns

Are there
3rd degree >10% BSA
Apply dry
2nd degree >20% BSA No
sterile dressings
2nd/3rd degree >15%
to burns
Suspected inhalation
injury

Transport to
Yes nearest medical
facility

1
AFSOCH 48-1, 1 July 1998 38

Thermal Burns

1
Yes

Start IV at 2-4ml of LR
X Kg body weight X
% BSA burned.
Give half of this in the first
8 hrs, second half over the next
16 hrs

Cover large burns with dry sterile dressings.


Place urinary catheter/Monitor urine output
Maintain 100cc/hr output
Keep patient warm
Place NG tube, especially for airevac

4-6 mg IV morphine for pain control


Titrate to effect
Silvadene dressings for transport >12hrs

Transport to nearest
burn center if pt is stable
or to nearest medical
facility
AFSOCH 48-1, 1 July 1998 39

Electrical Burns
Scene Safety
ABC’s/O2
ECG Monitor
IV

Life
Threatening Yes
Refer to appropriate algorithm
arrhythmia
present?

No

Apply long backboard


with cervical collar
and treat all burns

Place urinary catheter


to monitor urine output

Is Yes Increase fluid administration


Continue IV fluid and transport No the Urinary output should be
Transport to burn center if
urine at least 100ml/hr
available
dark?

Administer 25gm mannitol to


first bag and 12.5gm of mannitol
Does No Is nearest
be added to subsequent liters of No urine clear medical
fluid with Medical Control Direction
with ^ facility
Continue IV fluid and transport
fluid <1hr
Transport to burn center if
available away

Yes
Yes

Continue IV fluid and transport


Transport to burn center if
available
AFSOCH 48-1, 1 July 1998 40

Chemical Burns

Scene Safety
ABC’s/O2

Determine type of
chemical involved

Is Immediately brush dry


dry powder Yes
powder from skin before
present on irrigating skin
the skin?

No

Immediately flush away the chemical


with large amounts of water for at
least 20-30 mins.

Is
there Yes Refer to appropriate
involvement
algorithm for eye injuries
of the eyes

No

Remove any contaminated


clothing. Keep patient warm

1
AFSOCH 48-1, 1 July 1998 41

Chemical Burns

Irrigate exposed area


Irrigate Exposed area No Yes
Is >20% G ive 2-4ml of LR X Kg body
Start IV KVO with LR
BSA weight X %BSA burned. Give
D ress all burns with dry
involved? half of this in the first 8 hours,
sterile dressing
the rest over the next 16 hrs.

Transport to nearest
burn center if pt is stable Transport to nearest
or to nearest medical burn center if pt is stable
facility or to nearest medical
facility
AFSOCH 48-1, 1 July 1998 42

Thoracic Trauma

ABC’s/O2
IV
C-spine precautions
ECG monitor

Expose chest completely. Evaluate for


quality of breath sounds/signs of
chest injuries

Resp distress, tachycardia Large defect present Pt in shock with absent Paradoxical motion of the
hypotensive, tracheal on chest wall w/ breath sounds and/or chest wall
deviation, unilateral resp distress dullness to percussion Crepitus w/ palpation
breath sounds, cyanosis, on one side of chest of ribs

Possible Open
Pneumothorax Possible Flail chest
Go to appropriate Possible Hemothorax
Go to appropriate Go to appropriate
algorithm algorithm
algorithm

No
Hyperresonsant Possible Cardiac
percussion? Tamponade

Yes

Possible Tension
Pneumothorax
Go to appropriate
algorithm
AFSOCH 48-1, 1 July 1998 43

Open Pnuemothorax

ABC’s/O2
IV
C-spine precaution
ECG monitor

Promptly place an occlusive


material taped on 3 sides
over defect

Insert a chest tube remote from the


site as soon as possible.
Go to appropriate protocol

Continue supportive
care
Observe for improvement/
development of tension
pneumothorax

Transport to
nearest medical
facility
AFSOCH 48-1, 1 July 1998 44

Massive Hemo/Pneumothorax
ABC’s/O2
IV
C-spine precaution
ECG monitor

Insert chest tube

Locate 5th intercostal space


midaxillary line
affected hemithorax

Cleanse/Anesthetize
as appropriate

Make incision
Perform blunt dissection

Penetrate thorax w/ hemostat


Sweep digitally to ensure organs/
clots are away from site

Introduce chest tube


Clamp Tube w/Hemostat
Observe for misting
Advance to appropriate location
Attach Heimlich Valve

Suture in place w/
occlusive dressing

Transport
Observe for improvement
to nearest medical
Continue supportive
facility
care
Take altitude precautions
while inflight
AFSOCH 48-1, 1 July 1998 45

Needle Thoracentesis

ABC’s/O2
IV
C-spine precaution
ECG monitor

Perform needle thoracentesis

Locate 2nd intercostal space


affected hemithorax

Select site @ MCL


Cleanse appropriately

Insert 14 ga needle
Attach flutter device
Secure in place

Does
patient
condition
Yes improve No

Prepare for Consider Cardiac Tamponade


chest tube insertion
if indicated by sx’s
Go to appropriate
protocol

Transport
to nearest
medical facility
AFSOCH 48-1, 1 July 1998 46

Advanced Airway Procedures

#1
Perform ABC’s

***
Is No
Stridor/snoring resps
airway
Cyanosis Go to #2
open?
Gurgling
Frothy sputum
Unequal rise/fall chest
D ecreased breath sounds
Suspect M echanism of Injury Y es
U se of accessory muscles

Is
No
patient Open airway using
spontaneously appropriate manuveur
breathing?

Place OPA/NPA
Y es
A ssess respiratory
A ttach BVM to high
effort
flow O2
Begin appropriate
ventilations

Is
rate No A ssess breath sounds/
>10 or adequacy of ventilations
<28?

Prepare for intubation


Y es while ventilating

A re
there
Y es Go
No signs of
Place Non Rebreather to
respiratory
w / high flow O2 #3
distress?
***

Supportive
care
Transport
AFSOCH 48-1, 1 July 1998 47

#2

Perform B L S
procedures to
attem p t airw ay
clearing

Yes
Go to #1 Successful?

No

D irectly visualize
a ir w a y w /
laryngoscope

Are Is
Prepare
No vocal No Foreign Yes Remove FB
for
cords Body w / M agill Go to #1
cricothyroidotom y
v isible? v isible? forceps
Go to Protocol

Yes

Go to #3
AFSOCH 48-1, 1 July 1998 48

#3

Remove OPA/NPA

D irectly visualize
vocal cords
w / laryngoscope

Are
vocal No Perform
cords digital
visible? intubation

Yes

Introduce appropriately
sized Endotracheal T u b e
w / or w/out stylet

V isualize tube
passing cords

R e m o v e stylet

Inflate cuff

Auscultate all lung


fields and epigastrium
to confirm p r o p e r
tube placement

Reposition No Yes Ventilate


Confirmed?
accordingly Secure tube
Mark Placement
P lace O P A
AFSOCH 48-1, 1 July 1998 49

Cricothyroidotomy

Select site
Orient to structures

Cleanse/anesthetize
area as appropriate

Stabilize thyroid cartilage w/ left hand

Make transverse incision


over cricothryroid membrane
Incise through membrane

Insert scalpel handle into


incision and rotate 90 degrees
to open airway

Insert ET Tube distally


Inflate cuff
Check bilateral breath sounds

Ventilate patient
Secure ET Tube in place
AFSOCH 48-1, 1 July 1998 50

Venous Cutdown

Select site
Usually saphenous vein

Cleanse/anesthetize as appropriate

Make full thickness


transverse incision

Identify vein
Perform blunt dissection
to free from all structures

Ligate distal portion of vein


Leave suture in place for
traction and securing

Pass a tie under proximal


portion of vein

Make small transverse venotomy


Gently dilate venotomy w/
catheter introducer

Introduce catheter into vein


using introducer as support

Secure w/ suture left in place

Attach IV tubing to catheter


Adjust flow rate as desired
Secure in place

Close incision w/ interrupted sutures


Apply dressing over site
AFSOCH 48-1, 1 July 1998 51

Nasogastric Tube Insertion


ABC’s/O2
IV
ECG Monitor

Measure NG Tube from


tip of nose to ear lobe to xiphoid process

Inspect to ensure patent nostril

Lubricate tube

Insert through nostril


with angle of tube horizontally
or slightly downward

When distal tip reaches


posterior pharynx, slightly
flex patient’s neck and instruct
to swallow

Insert tube to predetermined length

Confirm placement by inserting tube air


into tube and auscultating over epigastrium

Is
tube No
placement Reposition accordingly
confirmed?

Yes

Secure tube
Proceed w/ lavage
AFSOCH 48-1, 1 July 1998 52

Urethral Catheterization

Check patency of catheter balloon

Drape between penis and scrotum

Grasp penis w/ 4X4


and retract foreskin

Cleanse head of penis w/ betadine

Lubricate 5 inches of catheter end

Grasp and hold penis at 60 degree angle

Slowly insert catheter until resistance is felt

Apply gentle pressure to pass catheter


through bladder sphincter muscle
*DO NOT FORCE*

After urine flow insert 1/2 inch farther

Inflate balloon w/ 5-10cc of sterile fluid

Wrap area w/ sterile dressing and bacitracin ointment


AFSOCH 48-1, 1 July 1998 53

RODGER D. VANDERBEEK, Col, USAF, MC, SFS


Command Surgeon