Updates and Announcements

We expect the PFC Podcasts to start being recorded soon and I will do my best to get them up here as soon as possible for the widest dissemination possible.  We will also post relevant articles and recommendations here allowing for discussions, comments and questions.  New Discussion Board posts are summarized automatically on the home page for easy reference.

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Updates to downloadable content

Posted by Paul on August 16, 2014 at 12:35 PM Comments comments (0)

      I will try and remember to post updates we make anywhere on this site or in the community, including the working group, here.  If a link doesn't work leave a comment or send me a message, like someone did recently,  and I'll get it taken care of.  We have added a couple things to the downloadable content tab at teh top of the page.  The first were 2 related position papers that the 10th SFG (A) PFC working group put out.  They were topics initially discussed at SOMSA and were an unofficial basis for many of our recommendations on gear and training.  Now they are official recommendations any medic can quickly read and get a pretty good idea on how to begin packing with what they have available.  It shows what minimum capabilities you should have and the best case capability that many of us may not have but can possibly request or "aquire."  Since I knew what the basic outline of the paper has going to be I made packing lists with pictures for both the folding hanging bag and a large pelican box with equipment already available in the basic TacSet.  Someone asked me for NSNs which is a good idea and I will try and get around to that soon.  It has most all of the recomended capabilities in a way that makes sense to me.  Someone told me that they were going to be going back to Africa and said that they were only being allowed to take 3 pelican or tough boxes.  We talked about it and came up with one box for sick call/ meds and field san things, one box for MasCal that would double as resupply for trauma IFAKs, and the PFC/ Critical care box.  We are also going to sneak on the hanging bag and the usual litters, stands and Skeds,  I think this covers everything a medic might need for a short rotation.  It would be great to have the entire Tribalco kit but as demonstrated this is just not possible every time we go somewhere.  Any comments?  All of these packing lists, pictures and position papers are available on this site. 

PFC Working Group - Airway Recommendations

Posted by medicerik on April 21, 2014 at 9:30 AM Comments comments (0)

Summary comments:


  • Airway management (and subsequent supplemental oxygen, ventilator support, gastric decompression, and a suction device) is a core capability for Prolonged Field Care.
  • Every medic should be trained and maintained with the following airway skills at a minimum: opening and maintaining an airway (with adjunctive NP/OP), bag-valve-mask ventilation, placing a supraglottic airway, and cricothyrotomy.
  • Further training, to include RSI training and advanced ventilator management, can be considered, but require maintenance training beyond current SOF medic training curriculums. Much like ultrasound training, these skills are within the educational reach of most SOF medics, but constant training and maintenance of the skill sets is required to ensure a medic is sustained and able to safely practice them.
  • It is not sufficient to state a SOF medic can safely practice rapid sequence intubation (RSI), to include the administration of paralytic medications, from having initial training alone. Medical Directors (unit medical officers) should establish a maintenance curriculum if they wish to have their medics (or a certain select group of their medics) trained in this skill set. A proper maintenance curriculum should have both recurrent classroom training and supervised intubations on a regular basis
  • Cricothyrotomy training should be included in most medical training. It is considered a final common definitive solution for securing an airway. It allows a cuffed tracheal tube to be placed, and will allow adequate administration of PEEP, and use of a ventilator. Additionally, unlike placing and maintaining an endotracheal tube placed from the oral route (standard orotracheal intubation), maintaining a cric with sedation alone is much more feasible in an austere setting.
  • In a patient who does not require an emergent cricothyrotomy, a reasonable approach might incorporate a supraglottic airway, then controlled cricothyrotomy with both sedation and local anesthesia.
  • It is reasonable to use cricothyrotomy in a medical (non-trauma) patient that requires a cuffed endotracheal tube placed for airway maintenance.
  • Robert Mabry and Richard Levitan (among others) are developing an algorithm that incorporates the recommended decision tree that incorporates the aforementioned techniques, to include a surgical cricothyrotomy.

 

Supraglottic airways:

 

  • Supraglottic airways (SGA) are a reasonable device to provide temporary airway support.
  • Patients may have a hard time tolerating an SGA if they are maintaining any upper airway reflexes. The SGA has been described as “a tennis ball on a stick” in the back of the oropharynx.
  • SGA’s required patent (not massively disrupted) anatomy to obtain an adequate seal. This may not be the case with massive upper airway trauma, as taught in TC3.
  • Characteristics of “ideal” SGA’s are 1) low-pressure cuff, 2) gastric decompression ports, and 3) the ability to provide positive-pressure ventilation. Some available devices currently available on the market, which include these features are, in no particular order: King LT-D, iGel, LMA Supreme, and Cookgas ILA. The PFC Working Group does not endorse a particular product.

 

Sedation for airway maintenance:


  • As previously stated in the PFC analgesia/sedation comments, ketamine is an excellent medication for providing sedation for those patients with potential airway or ventilation compromise. It has the unique characteristic of maintaining airway reflexes and not suppressing ventilatory drive.
  • The combination of medications used for standard RSI (as practiced in an emergency department, or urban EMS systems) includes a paralytic agent. We cannot currently recommend the routine use of paralytic agents in obtaining an initial airway for the SOF medic. See comments above for RSI and advanced ventilator training above. Longer acting paralytics MAY have use after a reasonable airway has been obtained (for instance, in a patient who has had a cric successfully performed).

 

 

 

 

Considerations in Packing The Tactical Aid Bag

Posted by Paul on April 10, 2014 at 9:35 AM Comments comments (4)


Considerations in Packing The Tactical Aid Bag

 

I will preface this article as being very basic knowledge that I wish I would have known when I was starting out 10 years ago.  I hope this will help junior medics make good descisions in preparing equipment and for senior medics in preparing their juniors.  This is not all inclussive or exhaustive by any means, but meant to be a point from which to start.


I have recently been asked about what to pack in an aid bag.  One thing I have learned over many years is that every medic has a different way to pack his aid bag and it is the best way.  I have seen many different aid bags come and go as well as the fanciest new hemostatics and devices.  Instead of dictating a packing list to someone I think explaining the process of choosing the capabilities and categories of equipment would be more beneficial.  An efficient way to start would be to go down the TCCC dictated, SMARCHRV acronym in order to make the best use of space.  SMARCHRV stands for Security, Massivehemorrhage, Airway, Respirations, Circulation, Hypothermia, Reassess andVitals.  The basics for treating the majority of these life threats will normally be included in the kit, commonly referred to as an IFAK (individual first aid kit), every soldier carries.  These can also be items that are carried everyday (EDC) on your person when not deployed to a combat zone.  There have been many lives lost in both overseas deployments and at home due to not having any equipment available.  Some lives however, have been saved when the military medic or corpsman was in the right place at the right time with his aid bag in tow.  Many civilian police departments and sheriffs are finally beginning to adopt the civilian version of TCCC (Tactical Combat Casualty Care) that the armed services have developed.  As a member of the military, once properly trained and while on a military installation or deployment, our scope of practice falls outside the scope of practice of civilian EMS systems.  These include invasive procedures such as cricothyroidotomies, starting IV lines and chest needle decompressions.  The vast majority of Police and EMS systems are only minutes from hospitals and will not allow non-providers the latitude of cutting into a civilian’s neck due to liability issues.  I will not be getting in to the procedures themselves in this article, only how to prepare one’s kit for the possibility of facing these life threatening situation. 


The “S”that stands for security in the acronym encompasses everything to do with security.  When I teach this to soldiers, this includes shooting back.  You cannot effectively treat any injury while being shot at by direct fire.  This may fly in the face of some as having taken the Hippocratic Oath or to those that don’t believe in violence.  I have the luxury of never having taken that oath but would not have a problem with this choice even if I did.  Isn’t preventing injury as important as treating it?  If you sat back and only took care of injury after injury while having the chance to stop the injuries and deaths from occurring wouldn’t that be negligent? Immoral?  I believe it would be.  Imagine a mass school shooting where your children attend.  Were you there withyour aid bag and a gun, what would be the best way to “treat” the injuries happening around you?  Our saying is that overwhelming firepower is the best medicine. This is true on the battlefield and this is true on the streets or at your next mass shooting.  I am a strong advocate of concealed carry for this, of many, reasons. Prevent an injury or illness and you will never have to treat it. Once a threat is mitigated enough that the reward is greater than the risk and the immediate area is secure you can move to the next and most medically preventable cause of death, massive hemorrhage.


Get your gloves ready.  Massive hemorrhage,or bleeding, is not the ugly gash that you can see down to the bone or the eviscerated bowels from an abdominal wound. Those are distraction injuries. Do not get sucked in by those and ignore the rapidly growing pool of blood coming from an upper arm or the audible spurting of blood coming from the femoral artery of the upper leg.  The first life threat is losing too many red blood cells and the best thing you can do for this person is keeping them from losing any more.  Immediately apply more than enough pressure(knees work great for this) just above or directly on the wound.  This buys you time to get to your first IFAKor everyday carry item, the TQ (tourniquet). Tourniquets date back centuries and were carried by some soldiers in the civil war.  Many then, as now, died without having used a TQ on themselves or by applying it incorrectly.  I have been personally present when a soldier did not apply a TQ to himself.  His buddy didn’t either.  All of this after rigorous training and the verbal direction to do so at the time of injury.  You cannot train on these things enough.  The TCCC committee recommends certain TQs over others after extensive study and trials so I won’t recommend one here.  The bottom line is that tourniquet should be on the outer most layer of your medical gear as readily accessible as possible to both hands.  I have one on the shoulder of my body armor one on the outside of my IFAK and 2 rubber banded to the outside of my aid bag.  If in a combat zone without kit, such as on an FOB (Forward Operating Base), I will be sure to have at least 1 TQ in a pocket. You will find a TQ on the inside of my driver’s-side door for quick access and of course there is one in my range bags.  If you are a female and reading this, how easy would it be to keep one in your purse? Sure you could forgo the equipment and just use direct pressure but that is just not always possible.  I have even gone surfing and spearfishing and had a TQ with me, you are never going to get direct pressure while trying to swim and hold your buddy’s head above water.  My job as a medic is to constantly imagine the worst case scenario and mitigate that the best way possible. 


The next component to massive bleeding is the kind that originates in the armpit or just outside the groin.  This is where you will get audible spurting from an arterial bleed and it must be managed immediately.  Apply firm direct pressure immediately.  Using a hemostatic dressing tightly wad up the end and quickly and firmly pack the wad down against the origin of bleeding against the bone.  Continue applying pressure as you pack the remaining tail of the hemostatic into the wound.  The cavity created by the projectile may need more than a single dressing, continue packing gauze or kerlix into the wound until it protrudes from the edges.  The next step is to wrap an elastic bandage, such as an ace wrap or Israeli Dressing, tightly around the affected area while never letting up on the pressure.  This requires much practice,under less than ideal conditions, and having the requisite equipment available; a hemostatic dressing or gauze kerlix and an elastic dressing.  This means that these are the next two items to have readily available in either IFAK or EDC.  It is also prudent to have extra of these in the aid bag for the times when the cavity requires more than a single dressing. 


The next life threat we are concerned with is the airway.  While airway comprises only 1 percent of preventable combat deaths the pathophysiology, the way it kills someone, is much faster than the typical pneumothorax or collapsed lung.  There are different methods to control a man’s airway, each with its own indications or reasons.  While all compromised airways are urgent I would argue that the traumatic injury to the upper airway, mouth and face on an unconscious casualty is the most severe.  This is due to the fact that the casualty’s own body will be trying desperately to inhale while blood and soft tissue are inhaled and the patient will be drowning in his own blood.  If the bleeding is severe enough, spurting,it should be immediately controlled while the equipment for a cricothyroidotomy(cric) is readied.  The equipment required will be a scalpel or extremely sharp knife, a cuffed endotracheal tube with syringe to fill the cuffand a way to properly secure the tube. Other things to take into consideration are a cric hook, easily made by bending the tip of a steel 14g needle and a way to clean the area if time permits along with a needle and suture to close the incision around the tube.  These things should be kept as clean as possible and together a kit for easy retrieval in an outer pocket.  This is a skill that you must train on properly and while under duress.  Again, I will not review the entire procedure but emphasize that it be readily available.  I keep a very small kit in myown EDC/IFAK and am prepared both educationally and mentally, to use it at all times.  Even medics on the battlefield have been apprehensive in performing this procedure, do not be.  Know that you will be saving a life that will soon be lost with your inaction.  It is also worth noting that this is a procedure that will save a life before a person is able to get to an ER but may be completely illegal to perform outside of a deployed theater of operations without the proper credentials.  Know that you could be sued or prosecuted.  My cousin died needing a cric when only a small boy and I will not let another family endure what mine has had to.


The next important piece of equipment essential to the airway kit is universally found in the IFAK, the Nasopharyngeal Airway adjunct or NPA and some call it the nose trumpet. I have 1 in the IFAK and a couple in the aid bag as backups.  This is a small item and can normally be squeezed into most small spaces.  Be sure to have a small packet of surgi-lube to go with it or you will have to make do with the patient’s own bodily fluids. This can be inserted into any patient with an altered mental status, especially an unconscious one.  The other temporary airway adjunct is the oralpharyngeal airway or OPA.  This is to be used on a casualty who is  unconscious and without a gag reflex.  It can also be used as a bite block in the patient needing a definitive airway such as an ET tube.  An OPA is not normally carried in an IFAK but can be if so desired. 


As a medical provider it will beyour responsibility to be completely prepared for any procedure you are trained in.  If you can do a rapid sequence induction (RSI) you should have the needed drugs along with the ET tube,stylet, bougie and your laryngoscope set. In order to check proper placement you should have a Bag Valve Mask(BVM), stethoscope and at least one other device to double check.  In the case of a failed intubation, having a cric kit ready at your side will be crucial. I keep all of these things in a single pouch apart from the main compartment easily accessible from the outside of the bag.  The decision to RSI a patient should not be made lightly. Unless you are absolutely certain of success and completely prepared for failure you should not begin to consider the procedure.  You must be well practiced and equipped to maintain sedation and control of the airway until you can safely extubate or pass him to the next level of care.  While oxygen may not be necessary it is nice to have and the advent of oxygen concentrators and disposable O2 Packs has made this capability safer to transport.  All of these things come at a price in the form of money, space and weight. 


At some point you have to take into the consideration of planning for evacuation of the patient to the next higher echelon of care and then on to a rehab site or facility.  Many of us have taken this for granted for years with the astoundingly fast transport times in two theaters of war.  This is also true for many of the street medics who patrol our neighborhoods.  We in the military are coming to a point where this will more often be the exception than the rule. On the civilian side preparing for rural or mass casualty events will always be prudent.


The next step will be to thoroughly assess the chest from the neck to the navel for any punctures.  If even the smallest protrusion is found it should immediately be covered by an occlusive dressing.  Standard sizes should be available in the IFAK but the larger ones may need to be stored in the aid bag so they don’t get folded.  Folding greatly reduces the efficacy of the dressing.  Besides the Halo XL dressing, surgical ioban makes a great occlusive dressing for massive, gaping thoracic wounds.  Once the sucking chest wound is completely occluded you must be ready to treat a pneumothorax.  This is when air has been sucked in to the space between the lung and the chest wall.  This must be treated before it gets worse and progresses into a tension pneumothorax, pressure collapsing the lung and pressing on the heart and major vessels. The treatment for this is a needle thoracentisis.  The smallest recommended size needle for this is a 14 gauge, 3.25” needle catheter although many medics are moving to the larger 10g needle catheter.  This also should be kept in the IFAK with spares available in the aid bag. 


The definitive treatment for a pneumothorax is a chest tube.  I won’t go into when and where you should so this as it is still hotly contested by physicians in this community.  The basic items you will need are the chest tube, sterile gloves, one way Heimlich valve,large curved Kelly forceps, a scalpel, an antiseptic to clean the area, lidocaine, needle and suture and needle and syringe.  There are all inclusive sterile kits available, but these things can also be obtained separately.  If you decide to do this, you should be as aseptic as possible as the rate of contamination and subsequent infection are high enough to make the pros hesitant in a forward situation.  This would best be kept in the trained medic’s aid bag and not in the IFAK.


Once the chest including the armpits, front and back are completely assessed you can move directly into the head-to-toe blood sweep as the first part of the C in SMARCHRV, Circulation.  At this point you are looking for any bleeding that you may have missed initially.  Start at the head and work systematically down toward the feet making sure not to miss anything.  This means removing the casualty’s clothes and equipment as much as the situation permits. Trauma shears make this much easier and safer than using a knife of some kind.  Keep a pair everywhere; the aid bag, IFAK, on your person, they will disappear when you need them most.  Be as thorough and methodical as possible.  You don’t want to overlook something that could have improved the patient’s life or chances ofnliving.  This means that if it is dark oreven low light you should have a hands free flashlight available such as a headlamp.  Don’t try and use a tactical red lens for this as it will filter out the blood, making it invisible.  I use a blue or green lens for this and it will make the blood jump out at you.  If able log roll the patient toward you and inspect everything on the backside of the patient.  Have a litter and casualty blanket ready to roll the patient onto so that you don’t have to keep manipulating him.  In the litter kit should be a hypothermia prevention kit and some kind of bag to hold all of the patient’s equipment and cut up clothing.


The litter should be a reminder for you to call for help if you or anyone else hadn’t done this already.  This could mean a military medevac or simply calling 911.  All of the preventable life threats should have been treated by now except for hypothermia.  This is absolutely one of the most important steps in this sequence due to the effect on the clotting cascade.  Once the core temp of the body falls a few degrees the blood will stop spontaneously clotting and any internal bleeding could very well kill the patient.  You must get the blanket on the patient as early as possible and be very aggressive in preventing hypothermia.  It is extremely difficult to rewarm a patient even a couple degrees in the best of conditions so your best bet is going to be prevention.  I even keep a beanie cap in my aid bag in colder environments.  After rolling the patient back onto his back but before getting the patient all tightly wrapped up, quickly reassess each individual treatment. This is the R in the acronym, Reassess. 


This should be done after each time the casualty is moved.  Use the entire SMARCH acronym to re-check everything. Start with the security situation as before.  Make sure the TQ is still tight and there is no blood creeping through any pressure dressing.  Check the occlusive dressings to make sure they are still occlusive and that the needle decompressions are still patent.  This can be done by using a simple syringe with saline or sterile water or without if not available.  Attach it to the catheter and pull back.  If you get a couple bubbles or it easily pulls air it should be good for the time being. If it is not you will feel it pulling suction and can pull it out, force flush it and re-insert another or you can use the needle you should have savedfrom the original procedure.  You cannot afford to use a new needle every single time, especially with multiple patients.  Each patient will now have their own set of needles, syringes and instruments to be saved for use on them only. 


Vitals need to be taken and recorded early in order to begin the process of trending.  You must have a baseline as early as possible in order to compare later sets of vital signs. The basic vital signs will be heart rate, which may be elevated becauseof adrenaline, blood pressure and rhythm, rate and quality of breathing.   Pulse oximetry may also be of use.  So for these things you will need a BP cuff, Stethoscope, watch or timer and a pulse ox if you can get one.  These things will be kept inside the larger aid bag if available.  If not you can use the presence of the patient’s pulse as an indicator that he has a blood pressure at the moment.  The actual pulseis easily counted also.  These are all basic things that each team member, if you have any, should be able to accomplish if you asked them.  You have enough other things going on without having to do this every 5-15 mins.  If you are using an automatic BP cuff like you get a Walgreens, be sure to have the patient’s wrist you are using on the same spot each time such as laying on his chest near his heart.  They are not entirely accurate but will work for trending if done this way.   


Once the patient is on the litter and has been reassessed with vital signs taken you can begin a thorough head to toe exam looking for everything else that may be affecting the patient.  This is a detailed exam and will include everything from fractures to burns and abrasions and bruises.  Treat each of these things as you find them and be sure to fill out a casualty card, patient care flow sheet or even just write these things down on a piece of paper or tape if that is all you have. 


With all of these major life threats that you may possibly encounter the thing I invariably use the most  small wound kit; band aids, bacitracin, sutures, stapler and maybe some burn gel.  People do dumb things and usually it is not life threatening.  You should still expect it and be prepared for it. Along this line is the very small drug box that must be brought out every other day with simple items in it like Benadryl, Imodium, Motrin, Tylenol and the like.  Since Benadryl was brought up you may as well have an epi-pen or two and an albuterol asthma inhaler.  Both can be life savers but without them you are left to much more drastic measures. An eye kit with lidocaine or tetracaine, erythromycin ointment, fluorescein strips and a small cobalt pen light does not take up much space.  All of these things I have used while on patrols in the desert.  Another thing I now carry after a bad experience on a flight of all places is the small over the counter dental kit.  The guy next to me broke 4 of his front teeth off when biting into an apple and I had to sit next to him the entire 19 hour flight unable to provide much relief at all.  He could not eat, he could not drink water and he could only breathe shallowly as anything passing over the exposed roots and nerves caused excruciating pain.  I’ll be ready if that ever happens again.  We ended up holding him down (at his request) and painting regular old finger nail polish on the roots to give him some relief. Not something I want to ever repeat.

 

 

 

SOCOM PFC WG Analgesia/Sedation Comments(February, 2014)

Posted by Paul on February 21, 2014 at 6:20 PM Comments comments (0)

This just came out this month by he primary SOCOM Prolonged Field Care Working group.  I am posting it here in it's entirety so that everyone will see it.  I also posted it as a download.  The infusion package at the bottom is perfect for keeping most patients sedated for up to 8 hours.


SOCOM PFC WG Analgesia/Sedation Comments(February, 2014)

The following comments are summarized from a sub-group expert panel of the SOCOMPFC working group.  They should be considered in the context of the South Sudan Case Studies recently circulated.

Please use these comments when considering case discussions and training of medics.

Allcomments are directed at the level of the SOF medic, and their training.

GENERALCOMMENTS:

PFC pharmacology is a core concept to be discussed in any training session.

Anydiscussion of PFC pharmacology should include a discussion about the CONCEPT Sof analgesia, amnesia/anxiolysis, and sedation.

Areasonable formulary of “working drugs” for the SOF medic should include:morphine, Fentanyl, ketamine, and midazolam (Versed).  Adjunctive medications could include: narcan,romazicon, antiemetics, antihistamines, atropine and others.

Thefirst time a medic administers these drugs should NOT be on a sick (unstable orcomplicated) patient.   Practice withtheir use.

As withany medication, a medic should be able to demonstrate an active knowledge ofthe pharmacology of any medication they are allowed to carry.    This should include: indications,therapeutic dosages, half-life, time for peak effect, contraindications, adverseeffects, usual concentrations, pitfalls, and your personal strategy fordilution and administration.

Any procedure that involves sedation should also include monitoring the patient,ideally with end-tidal CO2 (with a waveform), and at a minimum, have oxygen saturation (pulse ox) monitoring.  Also, airway adjuncts, to include suction, BVM with oxygen source, and advanced airway equipment, should be available.

If apatient is too unstable, pain control and sedation should be withheld until the patient can be stabilized.

COMMENTSABOUT THE AGENTS (in the context of the case study):

-Thereis a difference between analgesia (pain control) and sedation.  Some patients who appear to only need pain control MAY need sedation in order to perform prolonged evacuations (travelover rough roads, for instance).  Other examples of clinical scenarios that may require sedation include: chest tube insertion, cricothyrotomy, reduction of fractures or dislocations, large burn debridements, surgical procedures such as fasciotomies, and rapid sequenceinduction for intubations.

-The reason opioids have been around for centuries is they work.  This is in the case of the need for analgesia.  It is perfectly reasonable to treat >80% of patients with morphine.  Stable patients can get morphine.

-Hemodynamically unstable patients should get Fentanyl (or ketamine at pain control doses).  Remember, fentanyl and ketamine have very short half-lives and will need to be dosed and re-dosed.  A drip for analgesia can be very problematic and is NOT advised. 

-Fentanyl lollipops are effective and easy to administer.  1 x 800mcg lollipop,in its entirety, which has about 50% bioavailability, would be the equivalentof approximately 400mcg IV.  Do notdiscount this when adding drugs that are synergistic.  A major side effect of the lollipops isnausea.

-Get away from IM and go to IV meds as quickly as feasible.  There is a time for non-IV/IO administration, but that time ends with the establishment of IV's and acouple of minutes to think through the process. In these cases (South Sudan case studies), the patients received two different drugs through delivery mechanisms that make them very difficult to titrate. 

-Mantra should be “titrate to effect,” as there is a range for every patient and tolerance.

-Ketamine, in general, is an excellent medication if you understand its effects and pitfalls.  There are three ranges: effective pain range with little or no mental status effects (start with 10-20mg IV and titrate to effect), the mid-range where they’re still awake but agitated and actively hallucinating (0.3-1.0 mg/kg; 30-80mg IV), and the dissociated range wherethey’re sedated and dissociated: 1.0-2.0 mg/kg IV.  Decide ahead of time if you’re going high or low, but don’t get stuck in the middle.  This is also an excellent medication to induce unconsciousness prior to RSI (rapid sequence induction) prior to intubation(1.0 mg/kg IV push).  PLEASE NOTE:these are all IV/IO dosages, NOT IM. IM dose for initial administration is 4X the IV/IO dose.

-Versed (and other benzodiazepines) is a great drug.  Great for the correct indication, but there can be some serious pitfalls with its use, especially when added to other potent drugs. Understand the synergy of benzodiazepines and opioids (synergistic effect).  Occasionally, it can drop bloodpressures or over-sedate your patient.

Below is a recommendation for a sedation (not pure analgesia) mix that can be used to prepare and administer an infusion over time:

Basic principle: ketamine/versed drip with IV fentanyl bumps if needed.

Mix: 250ml bag of NS, filled with750mg ketamine and 25mg Versed. The initial drip rate is KG body weight/2 =cc/hr. For example a 100kg patient would be started at 50cc/hr drip rate.  At this rate, you can calculate the baglasting about five hours. In practice, it is observed that the majority of thetime, the drip rate could be cut in half after 20-30min, and the bag may last8-9 hrs.  (For reference, the initial doses are: ketamine: 1.5 mg/kg/hr, and Versed: 0.05mg/kg/hr).

Remember, there is NO such thing as a cookbook.  BE VIGILANT and titrate the drugs to effect

Romazicon should be available with this drip combination in the event that the entire bagis infused mistakenly as a bolus.  There is a large safety margin with inadvertent high doses of ketamine, but this dose of Versed would be problematic.

For reference, many sedation procedures in anesthesia are a combination of 2-3mgVersed followed by 50-100mcg of fentanyl and then 20mg bumps of ketamine untilthe patient has nystagmus (normally 60-80mg of ketamine).

For the sedation infusion combination above, some units package it and seal/band it to distribute as a complete kit.  This helps with both accountability of the various medications and operational medical planning (one small package for the purpose of sedating one critical casualtyfor approximately 8 hours).

 

Open Discussion "community" now on Google+

Posted by Doc Keenan on January 31, 2014 at 8:30 AM Comments comments (0)

Everyone, the PFC Working Group from SOCOM has opened an open community on Google+.  The intent is to open a wide base of interest with discussions that can drive further educational initiatives, training and knowledge.  I do not see this "competing" with this site, but rather this site as being one of the repositories of knowledge that medics can tap into.  The benefits of Google+ is that it is a little more secure than Facebook and there are many medical communities already there and they give it much better reviews than Facebook.  Also, users don't need to apply for membership, which, I realize, is both good and bad.  In any posts there, you can point back to references or discussions here, since there is obviously quite a bit of good stuff here.  In the not-too-distant future, we're planning educational podcasts, and an "official" website that we, the working group, can hang products.  Discussions are ongoing with JSOMTC and SOMA as potential hosts.  More to follow...

Tribalco Integrated Casualty Solution, TICS, CASEVAC Set

Posted by Paul on January 26, 2014 at 8:15 PM Comments comments (1)

This set includes the Tempus and although it is huge with all of it's components, it is a much better starting point to make an extended care packing list than the TacSet.  TICS CASEVAC Set  I look forward to seeing what comes from the med shops.

EZ IO shortage

Posted by Tm medic on January 21, 2014 at 7:10 PM Comments comments (3)

As our EZ IO needle's expiration date draw near, I started looking for vendors. The price on them increased about 300%. They are a little pricey to begin with, about 120.00 per needle, now they are appox 400.00 EACH!!!!  we don't like the Sternal IOS. now we find out they are a sole source company not using distributors. Any one use anything else?



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