Tactical Field Care - NAEMT

Tactical Field Care - NAEMT

Tactical Combat Casualty Care November 2009 Tactical Field Care Objectives STATE the common causes of altered states of consciousness on the battlefield.

STATE why a casualty with an altered state of consciousness should be disarmed. DESCRIBE airway control techniques and devices appropriate to the Tactical Field Care phase. 2 Objectives

DEMONSTRATE the recommended procedure for surgical cricothyroidotomy. LIST the criteria for the diagnosis of tension pneumothorax on the battlefield. DESCRIBE the diagnosis and initial treatment of tension pneumothorax on the battlefield. 3 Objectives

DEMONSTRATE the appropriate procedure for needle decompression of the chest. DESCRIBE the progressive strategy for controlling hemorrhage in tactical field care. DEMONSTRATE the correct application of Combat Gauze. 4 Objectives

DEMONSTRATE the appropriate procedure for initiating a rugged IV field setup. STATE the rationale for obtaining intraosseous access in combat casualties. DEMONSTRATE the appropriate procedure for initiating an intraosseous infusion 5

Objectives STATE the tactically relevant indicators of shock in combat settings. DESCRIBE the pre-hospital fluid resuscitation strategy for hemorrhagic shock

in combat casualties. DESCRIBE the management of penetrating eye injuries in TCCC. DESCRIBE how to prevent blood clotting problems from hypothermia. 6 Objectives

DESCRIBE the appropriate use of pulse oximetry in pre-hospital combat casualty Care STATE the pitfalls associated with interpretation of pulse oximeter readings LIST the recommended agents for pain relief in tactical settings along with their indications, dosages, and routes of administration DESCRIBE the rationale for early antibiotic intervention on combat casualties. 7 Objectives

LIST the factors involved in selecting antibiotic drugs for use on the battlefield . DISCUSS the management of burns in TFC EXPLAIN why cardiopulmonary resuscitation is not generally used for cardiac arrest in battlefield trauma care. DESCRIBE the procedure for documenting

TCCC care with the TCCC Casualty Card. 8 Objectives DESCRIBE the appropriate procedures for providing trauma care for wounded hostile combatants. 9 Tactical Field Care

Distinguished from Care Under Fire by: A reduced level of hazard from hostile fire More time available to provide care based on the tactical situation Medical gear is still limited to that carried by the medic or corpsman or unit members (may include gear in tactical vehicles) 10 Tactical Field Care

May consist of rapid treatment of the most serious wounds with the expectation of a reengagement with hostile forces at any moment, or There may be ample time to render whatever care is possible in the field. Time to evacuation may vary from minutes to several hours or longer 11

Battlefield Priorities in Tactical Field Care Phase This section describes the recommended care to be provided TFC. This sequence of priorities shown assumes that

any obvious life-threatening bleeding has been addressed in the Care Under Fire phase by either a tourniquet or self-aid by the casualty. If this is not the case address the massive bleeding first. After that care is provided in the sequence shown. 12 Tactical Field Care Guidelines 1. Casualties with an altered mental status should be disarmed

13 Disarm Individuals with Altered Mental Status Armed combatants with an altered mental status may use their weapons inappropriately. Secure long gun, pistols, knives, grenades, explosives.

Possible causes of altered mental status are Traumatic Brain Injury (TBI), shock, hypoxia, and pain medications. Explain to casualty: Let me hold your weapon for you while the doc checks you out 14 Tactical Field Care Guidelines 2. Airway Management a. Unconscious casualty without airway obstruction: - Chin lift or jaw thrust maneuver - Nasopharyngeal airway

- Place casualty in recovery position 15 Tactical Field Care Guidelines 2. Airway Management b. Casualty with airway obstruction or impending airway obstruction: - Chin lift or jaw thrust maneuver - Nasopharyngeal airway - Allow casualty to assume any position that best protects the airway, to include sitting up. - Place unconscious casualty in recovery position. - If previous measures unsuccessful: - Surgical cricothyroidotomy (with lidocaine

if conscious) 16 Nasopharyngeal Airway The Nose Hose, Nasal Trumpet, NPA

Excellent success in GWOT Well tolerated by the conscious patient Lube before inserting Insert at 90 degree angle to the face NOT along the axis of the external nose Tape it in Dont use oropharyngeal airway (J Tube) Will cause conscious casualties to gag Easily dislodged 17 Nasopharyngeal Airway 18

Nasopharyngeal Airway Whats wrong with this NPA insertion? 19 Maxillofacial Trauma Casualties with severe facial injuries can often protect their own airway by sitting up and leaning forward. 20 Let them do it if they can!

Airway Support Place unconscious casualties in the recovery position after the airway has been opened. 21 Surgical Airway (Cricothyroidotomy)

This series of slides and the video demonstrate a horizontal incision technique for performing a surgical airway. A vertical incision technique is preferred by many trauma specialists and is recommended in the Iraq/ Afghanistan War Surgery textbook. Steps are the same except for the orientation of the incision. Use a 6.0 tube for the airway 22

Surgical Airway (Cricothyroidotomy) 23 Surgical Incision over Cricothyroid Membrane 24 Surgical Airway Incise through the epidermis & dermis

Cricothyroid membrane Epidermis Dermis 25 Surgical Airway Epidermis Cricothyroid membrane 26

Surgical Airway Single stabbing incision through cricothyroid membrane 27 Surgical Airway ***You do not slice, you stab, the membrane*** 28

Surgical Airway Insert the scalpel handle and rotate 90 degrees 29 Surgical Airway Insert Mosquito hemostat into incision and dilate 30 Insert ET Tube

Insert Endotracheal Tube direct the tube into the trachea and towards the chest. 31 Check Placement Misting in tube 32 Inflating the Cuff

Inflate cuff And REMOVE SYRINGE Note: Corpsman/medic may wish to cut ET tube off just above 33 the inflation tube so it wont be sticking out so far. Ventilate Attach Bag 34

Secure the Tube At this point, the tube should be taped securely in place with surgical tape. 35 Dress the Wound Tape a gauze dressing over the surgical airway site. 36

Surgical Airway Video 37 Airway Practical Questions Nasopharyngeal Airway Surgical Airway 38 Tactical Field Care Guidelines

3. Breathing a. In a casualty with progressive respiratory distress and known or suspected torso trauma, consider a tension pneumothorax and decompress the chest on the side of the injury with a 14-gauge, 3.25 inch needle/catheter unit inserted in the second intercostal space at the midclavicular line. Ensure that the needle entry into the chest is not medial to the nipple line and is not directed towards the heart. 39 Tactical Field Care Guidelines

3. Breathing b. All open and/or sucking chest wounds should be treated by immediately applying an occlusive material to cover the defect and securing it in place. Monitor the casualty for the potential development of a subsequent tension pneumothorax. 40 Tension Pneumothorax

Tension pneumothorax is another common cause of preventable death encountered on the battlefield. Easy to treat Tension pneumo may occur with entry wounds in abdomen, shoulder, or neck. Blunt (motor vehicle accident) or penetrating trauma (GSW) may also cause 41 Pneumothorax

A pneumothorax is a collection of air between the lungs and chest wall due to an injury to the chest and/or lung. The lung then collapses as shown. 42 Tension Pneumothorax Side with gunshot wound A tension pneumothorax is worse. Injured lung tissue acts as a one-way valve, trapping more and more air between the lung and the chest wall. Pressure builds

43 up and compresses both lungs and the heart. Tension Pneumothorax Both lung function and heart function are impaired with a tension pneumothorax, causing respiratory distress and shock. Treatment is to let the trapped air under pressure escape Done by inserting a needle into the chest 14 gauge and 3.25 inches long is the

recommended needle size 44 Tension Pneumothorax Question: What if the casualty does not have a tension pneumothorax when you do your needle decompression? Answer:

If he has penetrating trauma to that side of the chest, there is already a collapsed lung and blood in the chest cavity. The needle wont make it worse if there is no tension pneumothorax. If he DOES have a tension pneumothorax, you will save his life. 45 Location for Needle Entry 2nd intercostal space in the Picture midclavicular line of general

2 to 3 finger widths below needle insertion the middle of the collar bone This is a general location for needle insertion

location for 46 Warning! The heart and great vessels are nearby Do not insert needle medial to the nipple line or point it towards the heart. 47 Needle Decompression Enter

Over the Top of the Third Rib Lung Air collection Rib Chest wall Intercostal artery &vein Needle Catheter

48 This avoids the artery and vein on the bottom of the second rib. Remember!!! Tension pneumothorax is a common but easily treatable cause of preventable death on the battlefield.

Diagnose and treat aggressively! 49 Needle Decompression Practical 50 Sucking Chest Wound (Open Pneumothorax) Takes a hole in the chest the size of a nickle or bigger for this to occur.

51 Sucking Chest Wound May result from large defects in the chest wall and may interfere with ventilation Treat by applying an occlusive dressing

completely over the defect during expiration. Monitor for possible development of subsequent tension pneumothorax. Allow the casualty to be in the sitting position if breathing is more comfortable. 52 Sucking Chest Wound (Treated) Key Point: If signs of a tension pneumothorax develop REMOVE the occlusive dressing for a few seconds and allow the tension pneumothorax to decompress!

53 Sucking Chest Wound Video 54 Sucking Chest Wound (Treated) Video 55 Questions?

56 Tactical Field Care Guidelines 4. Bleeding a. Assess for unrecognized hemorrhage and control all sources of bleeding. If not already done, use a CoTCCC-recommended tourniquet to control life-threatening external hemorrhage that is anatomically amenable to tourniquet application or for any traumatic amputation. Apply directly to the skin 2-3 inches above wound. 57

Tactical Field Care Guidelines 4. Bleeding b. For compressible hemorrhage not amenable to tourniquet use or as an adjunct to tourniquet removal (if evacuation time is anticipated to be longer than two hours), use Combat Gauze as the hemostatic agent of choice. Combat Gauze should be applied with at least 3 minutes of direct pressure. Before releasing any tourniquet on a casualty who has been resuscitated for hemorrhagic shock, ensure a positive response to resuscitation efforts (i.e., a peripheral pulse normal in character and normal mentation if there is no traumatic brain injury (TBI). 58

Tactical Field Care Guidelines 4. Bleeding c. Reassess prior tourniquet application. Expose wound and determine if tourniquet is needed. If so, move tourniquet from over uniform and apply directly to skin 2-3 inches above wound. If tourniquet is not needed, use other techniques to control bleeding. 59 Tactical Field Care Guidelines 4. Bleeding d. When time and the tactical situation

permit, a distal pulse check should be accomplished. If a distal pulse is still present, consider additional tightening of the tourniquet or the use of a second tourniquet, side by side and proximal to the first, to eliminate the distal pulse. 60 Tactical Field Care Guidelines 4. Bleeding e. Expose and clearly mark all tourniquet sites with the time of tourniquet application. Use an indelible marker.

61 Tourniquets Points to Remember Damage to the arm or leg is rare if the tourniquet is left on less than two hours. Tourniquets are often left in place for several

hours during surgical procedures. In the face of massive extremity hemorrhage, it is better to accept the small risk of damage to the limb than to have a casualty bleed to death. 62 Tourniquets: Points to Remember

All unit members should have a CoTCCC-approved tourniquet at a standard location on their battle gear. Should be easily accessible if wounded DO NOT bury it at the bottom of your pack When a tourniquet has been applied, DO NOT periodically loosen it to allow circulation to return to the limb. Causes unacceptable additional blood loss It HAS been happening and caused at least one near-fatality in 2005. 63 Tourniquets

Points to Remember Tightening the tourniquet enough to eliminate the distal pulse will help to ensure that all bleeding is stopped and that there will be no damage to the extremity from blood entering the extremity but not being able to get out. 64 Removing the Tourniquet Do not remove the tourniquet if: The extremity distal to the tourniquet has been traumatically amputated

The casualty is in shock The tourniquet has been on for more than 6 hours The casualty will arrive at a medical treatment facility within 2 hours after time of application Tactical or medical considerations make transition to other hemorrhage control methods inadvisable 65 Removing the Tourniquet

Consider removing the tourniquet once bleeding can be controlled by other methods Only a combat medic/corpsman/PJ, a PA, or a physician should loosen tourniquets 66 Removing the Tourniquet

Loosen the tourniquet slowly. Observe for bleeding Apply Combat Gauze to the wound per instructions later in the presentation if wound is still bleeding. If bleeding remains controlled, cover the Combat Gauze with a pressure dressing. Leave loose tourniquet in place or nearby. If bleeding is not controlled without the tourniquet, re-tighten it. 67

TCCC Hemostatic Agent Combat Gauze 68 Combat Gauze Combat Gauze has been

shown in lab studies to be more effective than the previous hemostatic agents HemCon and QuikClot Both Army (USAISR) and Navy (NMRC) studies confirmed 69 Courtesy Dr. Bijan Kheirabadi 70 CoTCCC Recommendation

February 2009 Combat Gauze is the hemostatic agent of choice The previously recommended agent WoundStat has been removed from the guidelines as a result of concerns about its safety. Additionally, combat medical personnel

preferred a gauze-type agent. 71 Combat Gauze Combat GauzeTM demonstrated an increased ability to stop bleeding over other hemostatic agents. No exothermic (heat generating) reaction when

applied. Cost is significantly less than the previously recommended HemCon.TM 72 Combat Gauze NSN 6510-01-562-3325 Combat Gauze is a 3-inch x 4-yard roll of sterile gauze. The gauze is impregnated with kaolin, a material that

causes the blood to clot Has been found in lab studies to control bleeding that would otherwise be fatal Combat Medical Systems, LLC, Tel: 910-426-0003, Fax: 910-426-0009, Website: www.combatgauze.com 73 73 Combat Gauze Directions (1) Expose Wound & Identify Bleeding

Open clothing around the wound If possible, remove excess pooled blood from the wound while preserving any clots already formed in the wound. Locate source of most

active bleeding. Combat Medical Systems, LLC, Tel: 910-426-0003, Fax: 910-426-0009, Website: www.combatgauze.com 74 74 Combat Gauze Directions (2) Pack Wound Completely Pack Combat Gauze tightly into wound and directly onto bleeding source.

More than one gauze may be required to stem blood flow. Combat Gauze may be repacked or adjusted in the wound to ensure proper placement Combat Medical Systems, LLC, Tel: 910-426-0003, Fax: 910-426-0009, Website: www.combatgauze.com 75 75

Combat Gauze Directions (3) Apply Direct Pressure Quickly apply pressure until bleeding stops. Hold continuous pressure for 3 minutes. Reassess to ensure bleeding is controlled. Combat Gauze may be repacked or a second gauze used if initial application fails to provide hemostasis.

Combat Medical Systems, LLC, Tel: 910-426-0003, Fax: 910-426-0009, Website: www.combatgauze.com 76 76 Combat Gauze Directions (4) Bandage over Combat Gauze Leave Combat Gauze in place. Wrap to effectively

secure the dressing in the wound. Although the Emergency Trauma Bandage is shown in this picture, the wound may be secured with any compression 77 bandage, Ace wrap, roller gauze, or cravat. Combat Medical Systems, LLC, Tel: 910-426-0003, Fax: 910-426-0009, Website: www.combatgauze.com 77 Combat Gauze Directions (5) Transport & Monitor Casualty

Do not remove the bandage or Combat Gauze. Transport casualty to next level of medical care as soon as possible. Combat Medical Systems, LLC, Tel: 910-426-0003, Fax: 910-426-0009, Website: www.combatgauze.com 78

78 Combat Gauze Video 79 Direct Pressure

Can be used as a temporary measure. It works most of the time for external bleeding. It can stop even carotid and femoral bleeding. Bleeding control requires very firm pressure. Dont let up pressure to check the wound until you are prepared to control bleeding with a hemostatic agent or a tourniquet! Use for 3 full minutes after applying Combat Gauze. It is hard to use direct pressure alone to maintain control of big bleeders while moving the casualty. 80

Questions? 81 Combat Gauze Practical 82 Tactical Field Care Guidelines 5. Intravenous (IV) access Start an 18-gauge IV or saline lock if indicated.

If resuscitation is required and IV access is not obtainable, use the intraosseous (IO) route. 83 IV Access Key Point NOT ALL CASUALTIES NEED IVs! IV fluids not required for minor wounds IV fluids and supplies are limited save them for the casualties who really need them IVs take time

Distract from other care required May disrupt tactical flow waiting 10 minutes to start an IV on a casualty who doesnt need it may endanger your unit unnecessarily 84 IV Access Indications for IV access Fluid resuscitation for hemorrhagic shock or Significant risk of shock GSW to torso Casualty needs medications, but cannot take them PO: Unable to swallow

Vomiting Shock Decreased state of consciousness 85 IV Access A single 18ga catheter is recommended for access: Easier to start than larger catheters Minimize supplies that must be carried

All fluids carried on the battlefield can be given rapidly through an 18 gauge catheter. Two larger gauge IVs will be started later in hospitals if needed. 86 IV Access Key Points Dont insert an IV distal to a significant wound!

A saline lock is recommended instead of an IV line unless fluids are needed immediately. Much easier to move casualty without the IV line and bag attached Less chance of traumatic disinsertion of IV Provides rapid subsequent access if needed Conserve IV fluids Flush saline lock with 5cc NS immediately and then 87 every 1-2 hours to keep it open Rugged Field IV Setup (1) Start a Saline Lock and Cover with Tegoderm or Equivalent

88 Rugged Field IV Setup (2) Flush Saline Lock with 5 cc of IV Fluid Saline lock must be flushed immediately (within 2-3 minutes) and then flushed every 2 hours if IV fluid is not running. 89 Rugged Field IV Setup (3)

Insert Second Needle/Catheter and Connect IV 90 Rugged Field IV Setup (4) Secure IV Line with Velcro Strap 91 Rugged Field IV Setup (5) Remove IV as Needed for Transport

92 Questions? Questions? 93 93 Intraosseous (IO) Access If unable to start an IV and fluids or meds are needed

94 urgently, insert a sternal I/O line to provide fluids. Pyng FAST IO Device 95 Pyng FAST Warnings PYNG FAST NOT RECOMMENDED IF: Patient is of small stature: Weight of less than 50 kg (110 pounds)

Fractured manubrium/sternum flail chest Significant tissue damage at site Severe osteoporosis Previous sternotomy and/or scar NOTE: PYNG FAST SHOULD NOT BE LEFT IN 96 PLACE FOR MORE THAN 24 HOURS Pyng FAST IO Flow Rates

30 ml/min by gravity 125 ml/min utilizing pressure infusion 250 ml/min using syringe forced infusion 97

Pyng FAST Insertion (1) 1. Prepare site using aseptic technique: Betadine Alcohol 98 Pyng FAST Insertion (2) 2. 3.

4. Finger at suprasternal notch Align finger with patch indentation Place patch 99 Pyng FAST Insertion (3) 5.

6. 7. Place introducer needle cluster in target area Assure firm grip Introducer device must be perpendicular to the surface of the sternum!

100 Pyng FAST Insertion (4) 8. 9. 10. Align introducer perpendicular to the sternum. Insert using increasing pressure

till device releases. (~60 pounds) Maintain 90 degree alignment to the sternum throughout. 101 Pyng FAST Insertion (5) 11. 12. 13.

Following device release, infusion tube separates from introducer Remove introducer by pulling straight back Cap introducer using post-use sharps plug and cap supplied 102

Pyng FAST Insertion (6) 14. 15. 16. Connect infusion tube to tube on the target patch NOTE: Must flush bone plug with 5 cc of fluid to get flow.

Assure patency by using syringe to aspirate small bit of marrow. 103 Pyng FAST Insertion (7) 17.Connect IV line to target patch tube 18. Open

IV and assure good flow 104 Pyng FAST Insertion (8) 19. Place dome to protect infusion site

105 Pyng FAST Insertion (9) Be certain that removal device is attached to casualty. 106 Pyng FAST Insertion (10) Based on combat medical input, the

F.A.S.T. 1 company has modified the packaging so that the removal device is attached to the protective dome. This will ensure that the removal device will always travel with the patient. 107 Pyng FAST Insertion (11) Potential Problems: Infiltration Usually due to insertion not perpendicular to sternum Inadequate flow or no flow

Infusion tube occluded with bone plug Use additional saline flush to clear the bone plug 108 Pyng FAST IO Access Key Points DO NOT insert the Pyng FAST on volunteers

as part of training use the training device provided. Should not have to remove in the field it can be removed at the medical treatment facility. Slides describing the removal process are in the back-up slides for this presentation. BE SURE to keep the removal device with the casualty so that that it will be available for hospital personnel to use. 109 Pyng FAST Insertion Video Key Points Not Shown in Video

Remember to flush the bone plug may cause pain Remember to run IV fluids through the IV 110 line before connecting. Questions Questions? IV/IO Practical 111 Tactical Field Care Guidelines 6. Fluid Resuscitation

Assess for hemorrhagic shock; altered mental status (in the absence of head injury) and weak or absent peripheral pulses are the best field indicators of shock. a. If not in shock: - No IV fluids necessary - PO fluids permissible if conscious and can swallow 112 Tactical Field Care Guidelines 6. Fluid Resuscitation

b. If in shock: - Hextend, 500ml IV bolus - Repeat once after 30 minutes if still in shock. - No more than 1000ml of Hextend 113 Tactical Field Care Guidelines 6. Fluid Resuscitation c. Continued efforts to resuscitate must be weighed against logistical and tactical considerations and the risk of incurring further casualties.

114 Tactical Field Care Guidelines 6. Fluid Resuscitation d. If a casualty with TBI is unconscious and has no peripheral pulse, resuscitate to restore the radial pulse. 115 Blood Loss and Shock What is Shock?

Inadequate blood flow to the body tissues Leads to inadequate oxygen delivery and cellular dysfunction May cause death Shock can have many causes, but on the battlefield, it is typically caused by severe blood loss 116

Blood Loss and Shock Question: How does your body react to blood loss? Answer: It depends on how much blood you lose. 117 Normal Adult Blood Volume 5 Liters 5 Liters Blood Volume 1 liter by

volume 1 liter by volume 1 liter by volume 1 liter by volume

1 liter by volume 118 500cc Blood Loss 4.5 Liters Blood Volume 119 500cc Blood Loss

Mental State: Alert Radial Pulse: Full Heart Rate: Normal or slightly increased Systolic Blood pressure: Normal Respiratory Rate: Normal Is the casualty going to die from this? No 120

1000cc Blood Loss 4.0 Liters Blood Volume 121 1000cc Blood Loss

Mental State: Alert Radial Pulse: Full Heart Rate: 100 + Systolic Blood pressure: Normal lying down Respiratory Rate: May be normal Is the casualty going to die from this? No 122 1500cc Blood Loss 3.5 Liters Blood Volume

123 1500cc Blood Loss Mental State: Alert but anxious Radial Pulse: May be weak Heart Rate: 100+ Systolic Blood pressure: May be decreased

Respiratory Rate: 30 Is the casualty going to die from this? Probably not 124 2000cc Blood Loss 3.0 Liters Blood Volume 125 2000cc Blood Loss

Mental State: Confused/lethargic Radial Pulse: Weak Heart Rate: 120 + Systolic Blood pressure: Decreased Respiratory Rate: >35 Is the casualty going to die from this? Maybe 126

2500cc Blood Loss 2.5 Liters Blood Volume 127 2500cc Blood Loss

Mental State: Unconscious Radial Pulse: Absent Heart Rate: 140+ Systolic Blood pressure: Markedly decreased Respiratory Rate: Over 35 Is he going to die from this? Probably 128 Recognition of Shock on the Battlefield

Combat medical personnel need a fast, reliable, low-tech way to recognize shock on the battlefield. The best TACTICAL indicators of shock are: Decreased state of consciousness (if casualty has not suffered TBI) and/or Abnormal character of the radial pulse (weak or absent) 129 Palpating for the Radial Pulse

130 Fluid Resuscitation Strategy If the casualty is not in shock: No IV fluids necessary SAVE IV FLUIDS FOR CASUALTIES WHO REALLY NEED THEM. PO fluids permissible if casualty can swallow Helps treat or prevent dehydration OK, even if wounded in abdomen Aspiration is extremely rare; low risk in light of benefit

Dehydration increases mortality 131 Hypotensive Resuscitation Goals of Fluid Resuscitation Therapy Improved state of consciousness (if no TBI) Palpable radial pulse corresponds roughly to systolic blood pressure of 80 mm Hg Avoid over-resuscitation of shock from torso wounds. Too much fluid volume may make internal hemorrhage worse by Popping the Clot.

132 Choice of Resuscitation Fluid in the Tactical Environment Why use Hextend instead of the much less expensive Ringers Lactate used in civilian trauma? 1000ml of Ringers Lactate (2.4 pounds) will yield an expansion of the circulating blood volume of only

about 200ml one hour after the fluid is given. The other 800ml of RL has left the circulation after an hour and entered other fluid spaces in the body FLUID THAT HAS LEFT THE CIRCULATION DOES NOT HELP TREAT SHOCK AND MAY CAUSE OTHER PROBLEMS. 133 Choice of Resuscitation Fluid

500ml of 6% hetastarch (trade name Hextend, weighs 1.3lbs) and will yield an expansion of the intravascular volume of 800ml. This intravascular expansion is still present 8 hours later may be critical if evacuation is delayed. Hextend Less weight to carry for equal effect Stays where it is supposed to be longer and does the casualty more good Less likely to cause undesirable side effects 134

Crystalloid Fluid Shifts VESSEL CELLS W





W W W CELLS INTERSTITIAL LR Water Molecules LR LR Molecules

Small sodium, chloride, potassium, etc. from crystalloids leak through vessel membranes In 1 hour, only 25% of crystalloid fluid is still in the vascular space For a 1000ml bag, thats only 250ml still in the vessels The rest of the fluid diffuses to the interstitial and intracellular space IV


W W W W W Hextend Fluid Shifts

Large Hextend particles remain in the vessels for 12 hours Osmotic pressure pulls additional water from the interstitial and intracellular spaces into the vessels The benefit from 500ml of Hextend is 800ml of blood volume expansion CELLS






W CELLS INTERSTITIAL IV Water Molecules H Hextend MoleculesH W


Compare Fluids Max dose of Hextend is 1,000ml (1,600ml of blood expansion effect) To get the same effect from crystalloid, it requires 7,000ml PER CASUALTY!

Hextend 2.6 lbs Crystalloid Which would you rather carry? 14.4 lbs Hextend is preferred as a weight saving advantage for combat trauma

For hemorrhagic shock, LR is 2nd choice, normal saline is 3rd. Fluid Resuscitation Strategy If signs of shock are present, CONTROL THE BLEEDING FIRST, if at all possible. Hemorrhage control takes precedence over infusion of fluids.

Hextend, 500ml bolus initially If mental status and radial pulse improve, maintain saline lock do not give additional Hextend. 138 Fluid Resuscitation Strategy

After 30 minutes, reassess state of consciousness and radial pulse. If not improved, give an additional 500ml of Hextend. Continued efforts to resuscitate must be weighed against logistical and tactical considerations and the risks of incurring further casualties. Hextend has no significant effects on coagulation and immune function at the recommended maximum volume of 1000 ml (for adults) 139 TBI Fluid Resuscitation If a casualty with TBI is unconscious and has a weak

or absent radial pulse : Resuscitate with sufficient Hextend to restore the radial pulse to normal. Shock increases mortality in casualties with head injuries. Must give adequate IV fluids to restore adequate blood flow to brain. 140 Questions? 141 Tactical Field Care Guidelines

7. Prevention of hypothermia a. Minimize casualtys exposure to the elements. Keep protective gear on or with the casualty if feasible. b. Replace wet clothing with dry if possible. c. Apply Ready-Heat Blanket to torso. d. Wrap in Blizzard Survival Blanket. 142 Tactical Field Care Guidelines 7. Prevention of hypothermia (cont) e. Put Thermo-Lite Hypothermia Prevention System Cap on the casualtys head, under the

helmet. f. Apply additional interventions as needed and available. g. If mentioned gear is not available, use dry blankets, poncho liners, sleeping bags, body bags, or anything that will retain heat and keep the casualty dry. 143 Hypothermia Prevention

Key Point: Even a small decrease in body temperature can interfere with blood clotting and increase the risk of bleeding to death. Casualties in shock are unable to generate body heat effectively. Wet clothes and helicopter evacuations increase body heat loss.

Remove wet clothes and cover casualty with hypothermia prevention gear. Hypothermia is much easier to prevent than to treat! 144 6 Cell 4- Cell Ready-Heat Blanket Ready-Heat Blanket

Apply Ready Heat blanket to torso OVER shirt. 145 Blizzard Survival Blanket Wrap in Blizzard Survival Blanket 146 Hypothermia Prevention and Management Kit

Contents: 1 x Heat Reflective Thermo-Lite Cap 1 x Heat Reflective Shell 1 x Self Heating, Four Cell Shell Liner Dimensions: 7.5 x 9.5 x 3 Weight: 2.5 lbs. Part Number: 80-0027 NSN: 6515-01-532-8056 147 Tactical Field Care Guidelines 8. Penetrating Eye Trauma

If a penetrating eye injury is noted or suspected: a) Perform a rapid field test of visual acuity. b) Cover the eye with a rigid eye shield (NOT a pressure patch.) c) Ensure that the 400 mg moxifloxacin tablet in the combat pill pack is taken if possible and that IV/IM antibiotics are given as outlined below if oral moxifloxacin cannot be taken. 148 Checking Vision in the Field

Dont worry about charts Determine which of the following the casualty can see (start with Read print and work down the list if not able to do that.) Read print Count fingers Hand motion

Light perception 149 Corneal Laceration 150 Small Penetrating Eye Injury 151 Protect the eye with a SHIELD, not a patch! 152

Eye Protection Use your tactical eyewear to cover the injured eye if you dont have a shield. Using tactical eyewear in the field will generally prevent the eye injury from happening in the first place! 153 Both injuries can result in eye infections that cause permanent blindness GIVE ANTIBIOTICS! 154

Tactical Field Care Guidelines 9. Monitoring Pulse oximetry should be available as an adjunct to clinical monitoring. Readings may be misleading in the settings of shock or marked hypothermia. 155 Pulse Oximetry Monitoring

Pulse oximetry tells you how much oxygen is present in the blood Shows the heart rate and the percent of oxygenated blood (O2 sat) in the numbers displayed 98% or higher is normal O2 sat at sea level. 86% is normal at

12,000 feet lower oxygen pressure at altitude 156 Pulse Oximetry Monitoring Consider using a pulse ox for these types of casualties: TBI good O2 sat very important for a good outcome Unconscious Penetrating chest trauma

Chest contusion Severe blast trauma 157 Pulse Oximetry Monitoring Oxygen saturation values may be inaccurate in the presence of:

Hypothermia Shock Carbon monoxide poisoning Very high ambient light levels 158 Tactical Field Care Guidelines 10. Inspect and dress known wounds. 11. Check for additional wounds.

159 Tactical Field Care Guidelines 12. Provide analgesia as necessary. a. Able to fight: These medications should be carried by the combatant and self- administered as soon as possible after the wound is sustained. - Mobic, 15 mg PO once a day - Tylenol, 650-mg bilayer caplet, 2 caplets PO every 8 hours 160 Tactical Field Care Guidelines

12. Provide analgesia as necessary. b. Unable to fight (Does not otherwise require IV/IO access) (Note: Have naloxone readily available whenever administering opiates.) - Oral transmucosal fentanyl citrate (OTFC), 800ug transbuccally - Recommend taping lozenge-on-a-stick to casualtys finger as an added safety measure - Reassess in 15 minutes - Add second lozenge, in other cheek, as necessary to control severe pain. 161 - Monitor for respiratory depression.

Tactical Field Care Guidelines 12. Provide analgesia as necessary. b. Unable to fight - IV or IO access obtained: - Morphine sulfate, 5 mg IV/IO - Reassess in 10 minutes. - Repeat dose every 10 minutes as necessary to control severe pain. - Monitor for respiratory depression - Promethazine, 25 mg IV/IM/IO every 6 hours as needed for nausea or for synergistic analgesic effect 162

Pain Control Pain Control When Able to fight: Mobic and Tylenol are the medications of choice Both should be packaged in a COMBAT PILL PACK and taken by the casualty as soon as feasible after wounding. Mobic and Tylenol DO NOT cause a decrease

in state of consciousness and DO NOT interfere with blood clotting. Medications like aspirin, Motrin, and Toradol DO interfere with blood clotting and should not be used by combat troops in theater. 163 Pain Control Fentanyl Lozenge Pain Control - Unable to Fight If casualty does not otherwise require IV/IO access Oral transmucosal fentanyl citrate, 800 g (between cheek and gum)

VERY FAST-ACTING; WORKS ALMOST AS FAST AS IV MORPHINE VERY POTENT PAIN RELIEF 164 Pain Control Fentanyl Lozenge Dosing and Precautions Tape fentanyl lozenge on a stick to casualtys finger as an added safety measure

Re-assess in 15 minutes Add second lozenge in other cheek if needed Respiratory depression very unlikely especially if only 1 lozenge is used Monitor for respiratory depression and have naloxone (Narcan) (0.4 - 2.0mg IV) ready to treat 165 Pain Control Fentanyl Lozenges Safety Note:

There is an FDA Safety Warning regarding the use of fentanyl lozenges in individuals who are not narcotic-tolerant. Multiple studies have demonstrated safety when used at the recommended dosing levels, BUT NOTE: DONT USE TWO WHEN ONE WILL DO! 166 Pain Control

Pain Control - Unable to Fight If Casualty requires IV/IO access Morphine 5 mg IV/IO Repeat every 10 minutes as needed IV preferred to IM because of much more rapid onset of effect (1-2 minutes vice 45 minutes) Phenergan 25mg IV/IM as needed for N&V

Monitor for respiratory depression and have naloxone available 167 Morphine Carpuject for IV (Intravenous) Use 168 Morphine: IM Administration

IV/IO morphine given by medic/corpsman/PJ is preferred to IM pain relief is obtained in 1-2 min instead of 45 minutes IM Intramuscular injection is an alternative if no medic/corpsman/PJ is available to give it IV. Initial dose is 10 mg (one autoinjector) Wait 45 to 60 minutes before additional dose Attach auto injectors or put M on forehead to note each dose given

169 Morphine Injector for IM (intramuscular) Injection 170 IM Morphine Injection Target Areas Triceps 171

IM Morphine Injection Target Areas Buttocks Upper/ outer quadrant to avoid nerve damage Anterior thigh 172

IM Morphine Injection Technique Tips Expose injection site Clean injection site if feasible Squeeze muscle with other hand Auto-inject Hold in place for 10 seconds

Go all the way into the muscle as shown 173 Warning: Morphine and Fentanyl Contraindications Hypovolemic shock

Respiratory distress Unconsciousness Severe head injury DO NOT give narcotics to casualties with these contraindications. 174

Pain Medications Key Points! Aspirin, Motrin, Toradol, and other nonsteroidal anti-inflammatory medicines (NSAIDS) other than Mobic should be avoided while in a combat zone because they interfere with blood clotting. Aspirin, Motrin, and similar drugs inhibit platelet

function for approximately 7-10 days after the last dose. You definitely want to have your platelets working normally if you get shot. Mobic and Tylenol DO NOT interfere with platelet function this is the primary feature that makes them the non-narcotic pain medications of choice. 175 Tactical Field Care Guidelines 13. Splint fractures and recheck pulse. 176

Fractures: Open or Closed Open Fracture associated with an overlying skin wound Closed Fracture no overlying skin wound Open fracture Closed fracture

177 Clues to a Closed Fracture Trauma with significant pain AND Marked swelling

Audible or perceived snap Different length or shape of limb Loss of pulse or sensation distal Crepitus (crunchy sound) 178

Splinting Objectives Prevent further injury Protect blood vessels and nerves - Check pulse before and after splinting Make casualty more comfortable 179

Principles of Splinting Check for other injuries Use rigid or bulky materials Try to pad or wrap if using rigid splint Secure splint with ace wrap, cravats, belts, duct tape

Try to splint before moving casualty 180 Principles of Splinting Minimize manipulation of extremity before splinting Incorporate joint above and below Arm fractures can be splinted to shirt using sleeve

Consider traction splinting for midshaft femur fractures Check distal pulse and skin color before and after splinting 181 Things to Avoid in Splinting

Manipulating the fracture too much and damaging blood vessels or nerves Wrapping the splint too tight and cutting off circulation below the splint 182 Commercial Splints 183

Field-Expedient Splint Materials Shirt sleeves/safety pins Weapons Boards

Boxes Tree limbs ThermaRest pad 184

Dont Forget! Pulse, motor and sensory checks before and after splinting 185 Tactical Field Care Guidelines 14. Antibiotics - recommended for all open combat wounds: a. If able to take PO meds: - Moxifloxacin, 400 mg PO one a day b. If unable to take PO (shock, unconsciousness): - Cefotetan, 2 g IV (slow push over 3-5 minutes) or IM every 12 hours

or - Ertapenem, 1 g IV/IM once a day 186 Outcomes: Without Battlefield Antibiotics Mogadishu 1993 Casualties: 58 Wound Infections: 16 Infection rate: 28%

Time from wounding to Level II care 15 hrs Mabry et al J Trauma 2000 187 Outcomes: With Battlefield Antibiotics Tarpey AMEDD J 2005: 32 casualties with open wounds All received battlefield antibiotics

None developed wound infections Used TCCC recommendations modified by availability: Levofloxacin for an oral antibiotic IV cefazolin for extremity injuries IV ceftriaxone for abdominal injuries. 188 Outcomes: With Battlefield Antibiotics

MSG Ted Westmoreland Special Operations Medical Association presentation 2004 Multiple casualty scenario involving 19 Ranger and Special Forces WIA as well as 30 Iraqi WIA 11- hour delay to hospital care

Battlefield antibiotics given Negligible incidence of wound infections in this group. 189 Battlefield Antibiotics Recommended for all open wounds on the battlefield! 190 Battlefield Antibiotics If casualty can take PO meds

Moxifloxacin 400 mg, one tablet daily Broad spectrum kills most bacteria Few side effects Take as soon as possible after life-threatening conditions have been addressed Delays in antibiotic administration increase the risk of wound infections 191 Combat Pill Pack Mobic 15mg Tylenol ER 650mg, 2 caplets

Moxifloxacin 400mg 192 Battlefield Antibiotics Casualties who cannot take PO meds Ertapenem 1 gm IV/IM once a day IM should be diluted with lidocaine (1 gm vial ertapenem with 3.2cc lidocaine without epinephrine)

IV requires a 30-minute infusion time NOTE: Cefotetan is also a good alternative, but has been more difficult to obtain through supply channels 193 Medication Allergies

Screen your units for drug allergies! Patients with allergies to aspirin or other nonsteroidal anti-inflammatory drugs should not use Mobic. Allergic reactions to Tylenol are uncommon. Patients with allergies to flouroquinolones, penicillins, or cephalosporins may need alternate antibiotics which should be selected by unit medical personnel during the pre-deployment phase. Check with your unit physician if unsure. 194 Treatment of Burns in TCCC

15. Burns a. Facial burns, especially those that occur in closed spaces, may be associated with inhalation injury. Aggressively monitor airway status and oxygen saturation in such patients and consider early surgical airway for respiratory distress or oxygen desaturation. b. Estimate total body surface area (TBSA) burned to the nearest 10% using the Rule of Nines. (see next slide) 192195 Three Degrees of Burns 196196

Degrees of Burns First-degree burn Second-degree burn Third-degree burn 197197 Rule of Nines for Calculating Burn Area 198198 Treatment of Burns in

TCCC 15. Burns (cont) c. Cover the burn area with dry, sterile dressings. For extensive burns (>20%), consider placing the casualty in the Blizzard Survival Blanket in the Hypothermia Prevention Kit in order to both cover the burned areas and prevent hypothermia. 199199 Treatment of Burns in TCCC 15. Burns (cont) d. Fluid resuscitation (USAISR Rule of Ten)

If burns are greater than 20% of Total Body Surface Area, fluid resuscitation should be initiated as soon as IV/IO access is established. Resuscitation should be initiated with Lactated Ringers, normal saline, or Hextend. If Hextend is used, no more than 1000 ml should be given, followed by Lactated Ringers or normal saline as needed. 200200 Treatment of Burns in TCCC 15. Burns (cont) Initial IV/IO fluid rate is calculated as %TBSA x 10cc/hr for adults weighing 40-80 kg. For every 10 kg ABOVE 80 kg, increase initial rate by 100 ml/hr.

If hemorrhagic shock is also present, resuscitation for hemorrhagic shock takes precedence over resuscitation for burn shock. Administer IV/IO fluids per the TCCC Guidelines in Section 6. 201201 Treatment of Burns in TCCC 15. Burns (cont) e. Analgesia in accordance with TCCC Guidelines in Section 12 may be administered to treat burn pain. f. Prehospital antibiotic therapy is not indicated solely for burns, but antibiotics should be given

per TCCC guidelines in Section 14 if indicated to prevent infection in penetrating wounds. 202202 Treatment of Burns in TCCC 15. Burns (cont) g. All TCCC interventions can be performed on or through burned skin in a burn casualty. These casualties are Trauma casualties with burns - not the other way around US Army ISR Burn Center

203203 Tactical Field Care Guidelines 16. Communicate with the casualty if possible. - Encourage; reassure - Explain care 204 Tactical Field Care Guidelines 17. Cardiopulmonary resuscitation (CPR): Resuscitation on the battlefield for victims of blast or penetrating

trauma who have no pulse, no ventilations, and no other signs of life will not be successful and should not be attempted. 205 CPR NO battlefield CPR 206 CPR in Civilian Trauma

138 trauma patients with prehospital cardiac arrest and in whom resuscitation was attempted. No survivors Authors recommended that trauma patients in cardiopulmonary arrest not be transported emergently to a trauma center even in a civilian setting due to large economic cost of treatment without a significant chance for survival. Rosemurgy et al. J Trauma 1993 207

The Cost of Attempting CPR on the Battlefield CPR performers may get killed Mission gets delayed Casualty stays dead 208 CPR on the Battlefield (Ranger Airfield Operation in

Grenada) Airfield seizure operation Ranger shot in the head by sniper No pulse or respirations CPR attempts unsuccessful Operation delayed while CPR performed Ranger PA finally intervened: Stop CPR

and move out! 209 CPR in Tactical Settings Only in the case of cardiac arrests from: Hypothermia Near-drowning Electrocution

Other non-traumatic causes should CPR be considered prior to the Tactical Evacuation Care phase. 210 Tactical Field Care Guidelines 18. Documentation of Care: Document clinical assessments, treatments rendered, and changes in the casualtys status on a TCCC Casualty Card. Forward this information with the casualty to the next level of care.

211 TCCC Casualty Card Designed by combat medics Used in combat since 2002 Replaces DD Form 1380

Only essential information Can by used by hospital to document injuries sustained and field treatments rendered Heavy-duty waterproof or laminated paper 212 TCCC Casualty Card DA Form 7656 Thanks to the 75th Ranger Regiment 213

TCCC Casualty Card This card is based on the principles of TCCC. The TCCC Casualty Card addresses the initial lifesaving care provided at the point of wounding. Filled out by whomever is caring for the casualty. Its format is simple with a circle or X in

the appropriate block. 214 TCCC Casualty Card Front Back 215 Instructions

Follow the instructions on the following slides for how to use this form. This casualty card should be in each individuals Individual First Aid Kit. Use an indelible marker to fill it out Attach it to the casualtys belt loop, or place it in their upper left sleeve, or the left trouser cargo pocket

Include as much information as you can 216 TCCC Card Front Individuals name and allergies should already be filled in. This should be done when placed in IFAK. 217

TCCC Card Front Add date-time group Cause of injury, and whether friendly, unknown, or NBC. 218

TCCC Card Front Mark an X at the site of the injury/ies on body picture. Note burn Percentages on figure 219 TCCC Card Front Record casualtys

level of consciousness and vital signs with time. 220 TCCC Card Back Record airway interventions. 221

TCCC Card Back Record breathing interventions. 222 TCCC Card Back Record bleeding control measures, dont forget tourniquet time on front of card.

223 TCCC Card Back Record route of fluid, type, and amount given. 224 TCCC Card Back Record any drugs given:

pain meds, antibiotics, or other. 225 TCCC Card Back Record any pertinent notes. 226

TCCC Card Back Sign card. Does not have to be a medic or corpsman to sign 227 Documentation

Record each specific intervention in each category. If you are not sure what to do, the card will prompt you where to go next. Simply circle the intervention you performed. Explain any action you want clarified in the remarks area. 228 Documentation

The card does not imply that every casualty needs all of these interventions. You may not be able to perform all of the interventions that the casualty needs. The next person caring for the casualty can add to the

interventions performed. This card can be filled out in less than two minutes. It is important that we document the care given to the casualty. 229 TCCC Card Abbreviations

DTG = Date-Time Group (e.g. 160010Oct2009) NBC = Nuclear, Biological, Chemical TQ = Tourniquet GSW = Gunshot Wound MVA = Motor Vehicle Accident AVPU = Alert, Verbal stimulus, Painful stimulus, Unresponsive Cric = Cricothyroidotomy

NeedleD = Needle decompression IV = Intravenous IO = Intraosseous NS = Normal Saline LR = Lactated Ringers ABX = Antibiotics 230 Questions ? 231 Further Elements of Tactical Field Care

Reassess regularly Prepare for transport Minimize removal of uniform and protective gear, but get the job done Replace body armor after care, or at least keep it with the casualty. He or she may need it again if there is additional contact. 232

Further Elements of Tactical Field Care Casualty movement in TFC may be better accomplished using litters. 233 Litter Carry Video

Secure the casualty on the litter Bring his weapon Click to start video 234 Summary of Key Points

Still in hazardous environment Limited medical resources Hemorrhage control Airway management Breathing Remove the tourniquet when possible Hypotensive resuscitation for hemorrhagic shock Hypothermia prevention 235 Summary of Key Points

Shield and antibiotics for penetrating eye injuries Pain control Antibiotics Reassure casualties No CPR

Documentation of care 236 Questions? Wear your body armor! 237 Management of Wounded Hostile Combatants 238

Objectives DESCRIBE the considerations in rendering trauma care to wounded hostile combatants. 239 Care for Wounded Hostile Combatants

No medical care during Care Under Fire Though wounded, enemy personnel may still act as hostile combatants. May employ any weapons or detonate any ordnance they are carrying Enemy casualties are hostile combatants until they: Indicate surrender Drop all weapons Are proven to no longer pose a threat 240 Care for Wounded Hostile

Combatants Combat medical personnel should not attempt to provide medical care until sure that wounded hostile combatant has been rendered safe by other members of the unit. Restrain with flex cuffs or other devices if not already done.

Search for weapons and/or ordnance. Silence to prevent communication with other hostile combatants. 241 Care for Wounded Hostile Combatants

Segregate from other captured hostile combatants. Safeguard from further injury. Care as per TFC guidelines for U.S. forces after above steps are accomplished. Speed to the rear as medically and tactically feasible 242 QUESTIONS ? Convoy IED Scenario

Recap from Care under Fire Your last medical decision during Care Under Fire: Placed tourniquet on bleeding stump You moved the casualty behind cover and returned fire. If it was possible, you provided an update to your mission commander

244 Convoy IED Scenario Assumptions in discussing TFC care in this scenario: Effective hostile fire has been suppressed. Team Leader has directed that the unit will move. Pre-designated HLZ for helicopter evacuation is 15 minutes away.

Flying time to hospital is 30 minutes. Ground evacuation time is 3 hours. Enemy threat to helicopter at HLZ estimated to be minimal. 245 Convoy IED Scenario Next decision? How to evacuate casualty? Helicopter

Longer time delay for ground evacuation Enemy threat at HLZ acceptable 246 Convoy IED Scenario Next decision? Load first and treat enroute to HLZ or treat first and load after? Load and Go Why?

Can continue treatment enroute Avoid potential second attack at ambush site 247 Convoy IED Scenario Next decision? Do you need spinal immobilization? Not unless casualty has neck or back pain Why? No vehicle roll over

Low expectation of spinal cord injury in the absence of direct head/neck blunt trauma Speed is critical 248 Convoy IED Scenario Casualty and medical provider are in vehicle enroute to HLZ. Next action? Reassess casualty

Casualty is now unconscious No bleeding from first tourniquet site Other stump noted to have severe bleeding 249 Convoy IED Scenario Next action? Place tourniquet on 2nd stump Next action? Remove any weapons or ordnance that the casualty may be carrying.

Next action? Place nasopharyngeal airway Next action? Make sure hes not bleeding heavily elsewhere Check for other trauma 250 Convoy IED Scenario

Next action? Establish IV access - need to resuscitate for shock Next action? Infuse 500cc Hextend Next actions Hypothermia prevention IV antibiotics Pulse ox monitoring Continue to reassess casualty 251

Remember The TCCC guidelines are not a rigid protocol. The tactical environment may require some modifications to the guidelines. Think on your feet! 252 Questions?

253 Back-Up Slides 254 Pyng FAST Removal (1) 1. 2. Stabilize target patch

with one hand Remove dome with the other 255 Pyng FAST Removal (2) 3. 4. Terminate IV fluid flow

Disconnect infusion tube 256 Pyng FAST Removal (3) 5. 6. 7. 8.

Hold infusion tube perpendicular to manubrium Maintain slight negative pressure on infusion tube Insert remover while continuing to hold infusion tube Advance remover 257 Pyng FAST Removal (4)

9. 10. 11. 12. This is a threaded device Turn it clockwise until remover no longer turns This engages remover into metal (proximal) end of the infusion tube Gentle counterclockwise

movement at first may help in seating remover 258 Pyng FAST Removal (5) 13. 14. 15. 16. Remove infusion tube

Use only T shaped knob and pull perpendicular to manubrium Hold target patch during removal DO NOT pull on the Luer fitting or the tube itself 259 Pyng FAST Removal (6)

17. Remove target patch 260 Pyng FAST Removal (7) 18. 19. Dress infusion site using aseptic technique

Dispose of remover and infusion tube using contaminated sharps protocol 261 Pyng FAST Removal (8) Problems encountered during removal Performed properlyshould be none!

If removal fails or proximal metal ends separate: Make incision Remove using clamp This is a serious injury as defined by the FDA and is a reportable event 262

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