Battlefield Critical Care

Steven Podnos MD

Airway Control        

A Safe Airway is more important than possible Cervical Spine injury-oxygenation is what countsBiPAP/Mask/NCannulaLMAETT

Rapid Sequence Intubation-Etomidate 20-30mg plus Succinylcholine 140-200mg IV (70-100kg patient)

Propofol OR Etomidate OR VersedPLUSSuccinycholine

General Evaluation

ABCs  - ATLS  Stop bleeding C Spine control until cleared Secondary survey-log roll with  C Spine protection, look for wounds on back/perineum, check rectal tone if not cooperative/conscious.  Look for torniquets

IV Access, short large bore catheters best

BURNS

Fluid Requirements = TBSA burned(%) x Wt (kg) x 4mL Give 1/2 of total requirements in 1st 8 hours, then give 2nd half over next 16 hours.  Aim lower if possible?

Clean dry sheets

Analgesia

Intubate early for possible laryngeal burns

Chest Wounds

Chest tubes-simple Heimlich valve with finger from glove Three side taped bandage for sucking chest wound.  14g needle for suspected tension PTX (don't wait for CXR) Blast lung may be reflected by delayed hypoxemia

Traumatic Brain Injury-? high ICP

Avoid Hypotension and Hypoxemia Hyperventilation only for impending herniation No role for steroids Can give mannitol or hypertonic saline if you think ICP is highAlso, elevate head of bed, loosen C collar, sedate 

Failure to Ventilate or Oxygenate?        Failure to Ventilate may mean mechanical issues-high airway pressures, vent "Pop offs"  OR progressive hypercapnia.

Hypercapnia is almost always fixed by increasing minute ventilation (resp rate and/or tidal volume)

First step is always to take patient off ventilator and bag them-how hard is it?  Good breath sounds bilat?  Any suggestion of tension pneumothorax?

Think about auto PEEP, mucus plugs, tension PTX, airway misplacement (Look, check capnograph )

SHOCK

All Shock associated with trauma or post surgery is hemorrhagic until proven otherwise. Where can blood loss be hidden?-Chest, Retroperitoneum, Abdomen, Femur Fx, Pelvis, At scene (scalp)

Concept of hypotensive resuscitation until the OR

Palpable pulses may not correlate with systolic BP:

Radial over 80mmFemoral over 70mm

PEA-Causes

• Tension Pneumothorax

• Cardiac Tamponade

• Hypovolemia

• Electrolyte disorder

• Hypothermia

• Pulmonary Embolus

Ventilator Settings

Start with AC 14, TV 500, 100% FIO2, 5 PEEPAdjust to keep sat over 90% and pCO2 30-40Aerosol albuterol for wheezing

If just need for supplemental O2, keep sat over 90% if possible

Intubate for:Failure to protect airway (low GCS)Failure to ventilate (increasing pCO2, resp acidosis)Failure to oxygenate on high flow 02.

Vasopressors

Consider fluid bolus first (except hypotensive resuscitation)

Norepinephrine (Levophed) is always a fine choice.  Alpha stimulation-direct vasoconstrictor.  Beta 1 stimulation-inotrope and chronotropic effect on heart.

High dose Dopamine OK

Phenelephrine-Neosynephrine-pure alpha stim

Norepinephrine - LEVOPHED ®   Alpha receptor & Beta-1 agonist. Used to maintain BP in hypotensive states. Most potent vasoconstrictor (Norepi >>> phenylephrine).

Dosage (initial): 8 to 12 mcg/min -titrate to BP (Usual target: SB:80-100 or MAP=80). Usual maintenance: 2 to 4 mcg/min. Note: doses as high as 0.5 to 1.5 mcg/kg/min for 1-10days have been used in septic shock.

Note: Norepinephrine dosage is stated in terms of norepinephrine base and intravenous formulation is norepinephrine bitartrate. Norepinephrine bitartrate 2 mg = Norepinephrine base 1 mg.

Usual range: 8-30 mcg/minute. Range used in clinical trials: 0.01-3 mcg/kg/minute. ACLS dosage range: 0.5 to 30 mcg/minute.Administer into large vein to avoid the potential for extravasation.

Calculation of drip rate 8 mg/ 250 ml (ml/hr) = mcg/min x 1.875. Supplied: Injection (soln): 1 mg/ml - 4 ml

Phenylephrine - NeoSynephrine ®  Alpha agonist. May be given IM,SC, IV push, or by continuous infusion.

Treat mild/moderate hypotension, also PSVT.

IV infusion: usual initial rate: 0.1 to 0.18 mg/min (100 to 180mcg/min) (titrate). Usual maintenance rate: 40-60 mcg/min. Maximum rate (range): infusion rates as high as 8 to10 mcg/kg/min may be required in shock.[Usual maximum dosing range reported: 0.4 to 9.1 mcg/kg/minute ].

IV bolus therapy:  0.1 to 0.5 mg/dose every 10-15 minutes as needed (initial dose should not exceed 0.5 mg)  PSVT: 0.5 mg rapid IV push, subsequent doses may be increased in increments of 0.1 to 0.2mg.

Calculation of drip rate (40 mg/250) (ml/hr) = (mg/min) x 375.

Dopamine Used to support BP, CO and renal perfusion in shock.

Dosing (Adult): Refractory CHF: initial dose: 0.5 to 2 mcg/kg/min. Renal: 1 to 5 mcg/kg/min. Severely ill patient: initially 5 mcg/kg/min, increase by 5 to 10 mcg/kg/min (q10 to 30 min) up to max of 50 mcg/kg/min. Cardiac life support (initial): 2 to 5 mcg/kg/min - titrated to effect. Infusion may be increased by 1-4 mcg/kg/minute at 10 to 30 minute intervals until optimal response is obtained. If dosages >20-30 mcg/kg/minute are needed, a more direct-acting pressor may be more beneficial (ie, epinephrine, norepinephrine). [0.5 to 2 mcg/kg/min-dopa; 2-10-dopa/beta; >10-primarily alpha.]

Calculation of drip rate (ml/hr) 400mg/250 ml: wt(kg) x mcg/min x 0.0375.

Sedation

AmnesiaAnalgesiaSedation

Versed-short acting Benzodiazepine-Amnesia and Sedation, mild resp depression at most by itself-2-10mg induction bolus, drip 2-20mg/hour

Fentanyl/Morphine-narcotic-Analgesic- 100 Micrograms of Fentanyl=10 Milligrams of Morphine. Propofol-Sedation, Amnesia only while heavily sedated               Bolus: 1.5‑2.5 mg/kg  continuous propofol infusion of 2.5 mg/kg/hr.                         Etomidate DOSING: ADULTS — Anesthesia: I.V.: Initial: 0.2-0.6 mg/kg over 30–60 seconds for induction of anesthesia; maintenance: 5-20 mcg/kg/minute   

War Surgery in Afghanistan and Iraq, a Series of Cases, 2003-2007 (2008) - describes the management of nearly 100 cases of acute combat trauma, conducted in the forward austere operative environment of war in the 21st century. Presented with vivid surgical photos, the cases encompass the spectrum of trauma that characterizes war today, as well as the medical interventions constantly evolving to treat these wounds. Publisher: Department of Defense, Office of The Surgeon General, US Army, Borden Institute. 2008: 442 p.; ill. Please note: several of the files are large and may take a few minutes to download.Emergency War Surgery (2004) - Although called the 3rd US Revision, this edition of Emergency War Surgery represents an entirely new Handbook. All material is new and revised to reflect lessons learned from ongoing American involvement in Southwest Asia. The Handbook takes a bulleted manual style in order to optimize its use as a rapid reference. Drafted by subspecialty experts, it was then updated by surgeons returned from yearlong deployments in Iraq and Afghanistan. A collaborative effort of the Borden Institute and the AMEDD Center & School, this Handbook is an essential tool for the management of forward combat trauma. MORE INFOEmergency War Surgery zipped file for quick Download

http://www.bordeninstitute.army.mil/other_pub.html