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Universal Precautions..............................................................................................................................3
Medical Emergencies:
Unconscious/Unknown ............................................................................................................. 15
Cerebral Vascular Accident ...................................................................................................... 16
Seizure ..................................................................................................................................... 17
Allergic Reaction...................................................................................................................... 18
Environmental Emergencies:
Heat Emergencies ..................................................................................................................... 20
Hypothermia............................................................................................................................. 21
Drowning ................................................................................................................................. 22
Poisoning/Envenomations ......................................................................................................... 23
Trauma Care/Procedures:
Extremity Trauma .................................................................................................................... 35
Eye Injuries .............................................................................................................................. 36
AFSOCH 48-1, 1 July 1998 2
Burns
Thermal ....................................................................................................................... 37
Electrical ..................................................................................................................... 39
Chemical...................................................................................................................... 40
Thoracic Trauma...................................................................................................................... 42
Open Pneumothorax ................................................................................................................. 43
Hemo/Pneumothorax ................................................................................................................ 44
Needle Thoracentesis ................................................................................................................ 45
Advanced Airway Procedures ................................................................................................... 46
Cricothyroidotomy.................................................................................................................... 49
Venous Cutdown ...................................................................................................................... 50
Nasogastic Tube Placement ...................................................................................................... 51
Urethral Catheter Placement ..................................................................................................... 52
AFSOCH 48-1, 1 July 1998 3
Medical Control
Care of injured personnel in combat or rescue situations requires medical command and control by
licensed medical providers. Paramedical and Emergency Medical Technician-Intermediates providing care
in these situations are acting under the principal of ‘delegated authority’, where the provider(usually a
physician) allows appropriately trained personnel to perform specified diagnostic and therapeutic
interventions. There are several types of medical control:
- On Line Medical Control: A physician is either present on the scene and personally directs
patient care, or is contacted by radio or other means and gives ‘live’ instructions.
-Off Line Medical Control: Contact with a control physician is impossible or impractical, care is
given based on specific physician approved protocols.
The medical control chain for AFSOC medical technicians assigned to Operations Support Squadron
Medical Flights(OSS/OSM) is in the following precedence:
On Line Medical Control:
- Senior AFSOC Flight Surgeon present at the scene.
- Special Tactics Flight Surgeon present at the scene.
- Senior US military physician present at the scene.
- Qualified(training equivalent to US physician) Allied country senior military
physician present at the scene
- Qualified civilian physician(training equivalent to US MD or DO) present at the
scene, provided he/she agrees to assume responsibility for care and accompany
the patient to higher level of care.
- Senior AFSOC Physician Assistant present at the scene
- Any of the above in direct radio contact
Off Line Medical Control:
On line medical control is the preferred means of medical control for all casualty
situations. In the event on line control is not possible the following will apply:
- The Senior medic is responsible for directing medical care at all scenes where on
line control is not possible. He/she will direct medical control in strict adherence
to the established protocols contained herein.
- AFSOC medical technicians assigned to OSS/OSM flights will attempt to contact on
line medical control in all situations prior to reverting to protocol use, with the
exception of an immediate life threat and then will attempt to establish on line control as soon as
possible after the patient is stabilized.
Universal Precautions
Universal precautions will be taken appropriately for every situation. They will not be addressed for
each individual protocol.
AFSOCH 48-1, 1 July 1998 4
Advanced
Cardiac
Life
Support
AFSOCH 48-1, 1 July 1998 5
ABC’s/O2
Perform CPR
Quick Look
1
A ssess vital signs Return of
Supportive care/IV spontaneous circulation
Identify New Rhythm Go to appropriate
give loading dose
rhythm? protocol
of L idocaine
treat as rhythm indicates
Persistent V F/p u l s e l e s s V T
Epinephrine IVP
repeat every 5 min Table 1-1
may give at 1mg every 5 min 1. L i d o c a i n e 1.0-1.5m g / k g r e p e a t i n 3 - 5 m i n
or in intermediate, escalating, or max:3mg/kg
high dose regimen
2. B r e t y l i u m 5 m g / k g I V p u s h
repeat with 10mg/kg IVP q15min up
to 30mg/kg
Reassess patient after each intervention
3. P r o c a i n a m i d e 3 0 m g / m i n
if rhythm changes go to 1
max: 17mg/kg
Continue care
Transport
AFSOCH 48-1, 1 July 1998 6
Tachycardia
ABC’s/O2
IV
ECG monitor/Vital Signs
Are there
serious S& S Yes Prepare for immediate
and pulse c a r d i o v e r s i o n /go to protocol
>150
No
Identify rhythm
Lidocaine Lidocaine
1.0-1.5mg/kg IVP 1.0-1.5mg/kg IVP
Consider Propranolol
Go to PSVT in 5-10 min repeat at in 5-10 min repeat at
1-3mg IV over 2-3min
protocol half dose every 5-10 min half dose every 5-10 min
can be repeated in 2 min
max: 3mg/kg max: 3mg/kg
Procainamide
20-30 mg/min
max: 17mg/kg
Continue care
Transport B r e t y l i u m 5-10 m g/kg
over 8-10 min
max:30mg/kg over 24hrs
Consider TCP
Continue care
Transport
AFSOCH 48-1, 1 July 1998 7
ABC’s/O2
IV
ECG monitor/Vital Signs
R efer to
Is patient stable
No cardioversion protocol
Y es
Vagal Maneuvers
Procainamide
Blood 20-30 mg/min
Pressure? max: 17mg/min
Normal or elevated Low or unstable
Continue care
Consider Propranolol
Transport
1-3mg IV over 2-3min
can be repeated in 2 min
Y es
Does rhythm persist
No
AFSOCH 48-1, 1 July 1998 8
Electrical Cardioversion
A B C ’s/O2/ I n t u b a t e i f n e e d e d
E C G M o n itor Refer to appropriate
IV/Vital signs algorithm
P r e m edicate w i t h 5 m g V a l i u m
o r 5 m g M o r p h ine if poss
C lear Patient
Cardiovert
Bradycardia
ABC’s/O2/Intubate if needed
ECG monitor
IV
V ital Signs
Serious
signs and
symptoms Yes
No
TCP, if available
Yes *Not inflight
TCP, if available
*Not inflight If B/P <100
consider
Dopamine 5-20 mcg/kg/min
Transport to
nearest medical Epinephrine 2-10mcg/min
facility
Transport to
nearest medical
facility
AFSOCH 48-1, 1 July 1998 10
Asystole
ABC’s/O2/Intubate
Perform CPR
ECG monitor
IV
Stop CPR
Confirm asystole in two leads
Start CPR
Consider possible cause
Hypoxia
Hyperkalemia
Preexisting acidosis
Drug overdose
Hypothermia
Consider immediate
TCP
*Not in flight
Transport to
nearest medical
facility
AFSOCH 48-1, 1 July 1998 11
ABC’s/O2/Intubate
Perform CPR
ECG monitor
IV
Continue CPR
Consider treating possible cause
Hypoxia/Hypovolemia
Hyperkalemia/Massive MI
Preexisting acidosis/Cardiac Tamponade
Drug overdose/Tension pneumothorax
Hypothermia/Pulmonary embolism
If relative Bradycardia
A tropine 1mg IVP
max: 0.03-0.04 mg/kg
repeat every 3-5 min
Transport to
nearest medical
facility
AFSOCH 48-1, 1 July 1998 12
Pulmonary Edema
ABC’s/O2
IV
ECG Monitor
Nitroglycerin 0.4 mg SL
if systolic >90mm/hg
Morphine 1-3 mg IV
Titrate to effect
Is
Dopamine 2.5-20 Yes systolic No
mcg/kg/min IV < 100mm/hg?
Titrate to effect
Continue supportive
care
Transport to nearest
medical facility
AFSOCH 48-1, 1 July 1998 13
ABC’s/O2
ECG monitor
IV
Vital Signs
Does
monitor show Yes Go to appropriate
a Tx protocol
rhythm
No
Give Aspirin
325mg PO
If no relief
Morphine 2-5mg IV
every 5 min prn
Supportive care
Transport to
nearest medical
facility
AFSOCH 48-1, 1 July 1998 14
Medical
Emergencies
AFSOCH 48-1, 1 July 1998 15
Unconscious/Unknown
Assess unresponsiveness
AVPU
A B C ’s/02
IV
ECG Monitor
Is
No
Intubate patient GCS
Go to protocol >8?
Yes
P e r f o r m G lu c o s e C h e c k
LOW NORMAL
100 mg Thiamine IV
2 mg Naloxone IV
Repeat prn
2 5 g m 5 0 % D extrose IV
Continue
supportive care
Transport to nearest
medical facility
AFSOCH 48-1, 1 July 1998 16
ABC’s/O2/Intubate as needed
ECG monitor
IV
Transport to
nearest
Medical Facility
AFSOCH 48-1, 1 July 1998 17
Seizure
Is
patient No ABC’s/O2
actively IV
seizing? ECG monitor
Yes
Intubate if needed Is
Reassess ABC’s No seizure
IV/ECG monitor lasting
if not completed >10min
Yes
Supportive care
Administer Valium
Transport
5-10 mg slow IVP
Administer 1 amp
25g Dextrose 50% Is
No
Consider 100mg Thiamine glucose
>60mg/dl
Yes
Supportive care
Transport
Has
seizure
activity
stopped? No
Yes
Allergic Reaction
Scene Safety
ABC’s
Severe reaction
pruritis, urtcaria, w h e e z i n g
M ild r e a c t i o n M oderate reaction angioedema, cyanosis,
pruritis, urticaria pruritis, urticaria, w h e e z i n g hypotension, A L O C
IM Benadryl 1mg/kg
max:50mg
Consider steroid use
if transportation is >12hr Yes Is
per medical control Systolic
M o n itor and Transport to >90?
nearest medical facility
No
Environmental
Emergencies
AFSOCH 48-1, 1 July 1998 20
Heat Emergencies
A B C ’s/O 2
ECG Monitor
A ssess Core Temperature/
signs and symptoms
Is
Initiate rapid, aggressive Yes core temp No
> 105 F w/ Have patient rest
external cooling measures
sx’s? in cool area
Does
Is patient Yes
patient No tolerate
actively fluids?
seizing?
No
Yes
Initiate IV NS @ 200cc/hr
Administer 5-10 mg
V a lium IV prn
M onitor core temp
Continue supportive
care
Transport to nearest
medical facility
AFSOCH 48-1, 1 July 1998 21
Hypothermia
ABC’s
O2
M onitor
IV
*Gentle handling
of patient
Is
Start CPR Yes patient
D e f i b /3 shocks
pulseless/
Intubate
apneic?
IV-NS
No
=>30C/
W hat 86F 30-34 C
is Active external rewarming
<30C/ core 34-36 C
86F W hat Temp passive r e w a r m i n g
Continue CPR is
No IV Meds core
Limit to 3 shocks Temp
<30C/86F
=>30C/86F
Warm IV NS Supportive care
Warm O2 Transport
Warm gastric lavage
Continue CPR
Active core IV Meds
rewarming D e f i b as
until >30C/86F core temp rises
Supportive care
Transport
AFSOCH 48-1, 1 July 1998 22
Drowning
Is
ABC’s/O2
patient No IV
still in the
Backboard
water?
ECG monitor
Yes
ABC’s /O2
IV
ECG monitor
Treat as needed
Consider water temp (hypothermia)
Consider down time of patient
No Field
Transport
Conditions?
Yes
If patient revives
Observe for at least
six hours for secondary
drowning
Transport
as needed
AFSOCH 48-1, 1 July 1998 23
A ttem p t to identify
poison/exposure
from call inform ation
A fter
assessm ent of Yes
patient is poison/ G o to appropriate
exposure protocol
known?
No
#1
Acids Alkalis
ABC’s/O2
IV NS
ECG Monitor
Is
Transport rapidly No patient Yes Dilute w/ 200-300ml
to nearest medical conscious? H20/milk PO ONLY w/
facility medical control direction
AFSOCH 48-1, 1 July 1998 25
#2
Hydrocarbons
Cleaning/polishing Agents
Spot Removers
Paints
Cosmetics
Pesticides
Turpentine
Kerosene/Gasoline/Lighter Fluid
ABC’s/O2
IV NS
ECG Monitor
#3
Methanol
Antifreeze
Windshield washer fluid
Paints/Paint removers
Varnishes/shellacs
ABC’s/O2
IV NS
ECG Monitor
Administer 1-2g/kg
Activated Charcoal
Administer
1 mEq/kg
Sodium Bicarbonate
to correct metabolic
acidosis
If available administer
Continue supportive
60 ml of 90% Ethanol
care
or
Transport rapidly to
125 ml of 43% Ethanol
nearest medical
facility
AFSOCH 48-1, 1 July 1998 27
#4
Ethylene Glycol
Windshield De-icers
Detergents
Paints
Radiator Antifreeze/coolants
ABC’s/O2
IV NS
ECG Monitor
Is
Perform gastric lavage Yes ingestion No
***If unconscious intubate time
prior to protect airway < 4hrs?
Administer
1 mEq/kg
Sodium Bicarbonate
to correct metabolic
acidosis
Continue supportive
If available administer
care
60 ml of 90% Ethanol
Transport rapidly to
or
nearest medical
125 ml of 43% Ethanol
facility
AFSOCH 48-1, 1 July 1998 28
#5
Isopropanol
Rubbing Alcohol
Disinfectants
Degreasers
Industrial cleaning agents
ABC’s/O2
IV NS
ECG Monitor
Continue supportive
care
Transport rapidly to
nearest medical
facility
AFSOCH 48-1, 1 July 1998 29
#6
Cyanide
Remove patient
from source
ABC’s/O2
IV NS
ECG Monitor
Administer 300mg
Sodium Nitrate slow IVP over no less than 5 min
Administer 12.5 g
Sodium Thiosulfate IV
Continue supportive
care
Transport rapidly to
nearest medical
facility
AFSOCH 48-1, 1 July 1998 30
#7
ABC’s/O2
IV NS
ECG Monitor
Continue supportive
care
Transport rapidly to
nearest medical
facility
AFSOCH 48-1, 1 July 1998 31
#7
ABC’s/O2
IV NS
ECG Monitor
Continue supportive
care
Transport rapidly to
nearest medical
facility
AFSOCH 48-1, 1 July 1998 32
#7
Scorpion Stings
ABC’s/O2
IV NS
ECG Monitor
Consider 5 mg Valium IV
for apprehension
Are
Yes No
symptoms
severe?
Is
patient No
convulsing?
Yes
Continue supportive
care
Adminster 5 mg Valium IV over Transport rapidly to
2 min q 10-15 min prn
nearest medical
facility
AFSOCH 48-1, 1 July 1998 33
#8
Snake Envenomantion
ABC’s/O2
IV NS
ECG Monitor
Examine snake if it
can
be done safely to *Check distal pulses
determine type frequently
*Do not remove until
reach medical facility
Remove all devices which may
become tourniquets, ie; Rings/
watches, etc.
Administer appropriate
antivenin ONLY w/
Clean wound w/ saline M edical Control
direction
Trauma
Care/
Procedures
AFSOCH 48-1, 1 July 1998 35
Extremity Trauma
ABC’s
Vital signs
IV as needed
Eye Injuries
Scene Safety
ABC’s / O2
M onitor
Amsler grid
Transport to
nearest medical
facility
AFSOCH 48-1, 1 July 1998 37
Thermal Burns
Scene Safety
ABC’s/O2
Monitor
Is Is
there Yes transport
evidence of time
inhalation >10min?
injury? No Yes
No
Consider Transport immediately
intubation If sx progress rapidly
Removed any
intubate as needed
clothing/jewelry
Are there
3rd degree >10% BSA
Apply dry
2nd degree >20% BSA No
sterile dressings
2nd/3rd degree >15%
to burns
Suspected inhalation
injury
Transport to
Yes nearest medical
facility
1
AFSOCH 48-1, 1 July 1998 38
Thermal Burns
1
Yes
Start IV at 2-4ml of LR
X Kg body weight X
% BSA burned.
Give half of this in the first
8 hrs, second half over the next
16 hrs
Transport to nearest
burn center if pt is stable
or to nearest medical
facility
AFSOCH 48-1, 1 July 1998 39
Electrical Burns
Scene Safety
ABC’s/O2
ECG Monitor
IV
Life
Threatening Yes
Refer to appropriate algorithm
arrhythmia
present?
No
Yes
Yes
Chemical Burns
Scene Safety
ABC’s/O2
Determine type of
chemical involved
No
Is
there Yes Refer to appropriate
involvement
algorithm for eye injuries
of the eyes
No
1
AFSOCH 48-1, 1 July 1998 41
Chemical Burns
Transport to nearest
burn center if pt is stable Transport to nearest
or to nearest medical burn center if pt is stable
facility or to nearest medical
facility
AFSOCH 48-1, 1 July 1998 42
Thoracic Trauma
ABC’s/O2
IV
C-spine precautions
ECG monitor
Resp distress, tachycardia Large defect present Pt in shock with absent Paradoxical motion of the
hypotensive, tracheal on chest wall w/ breath sounds and/or chest wall
deviation, unilateral resp distress dullness to percussion Crepitus w/ palpation
breath sounds, cyanosis, on one side of chest of ribs
Possible Open
Pneumothorax Possible Flail chest
Go to appropriate Possible Hemothorax
Go to appropriate Go to appropriate
algorithm algorithm
algorithm
No
Hyperresonsant Possible Cardiac
percussion? Tamponade
Yes
Possible Tension
Pneumothorax
Go to appropriate
algorithm
AFSOCH 48-1, 1 July 1998 43
Open Pnuemothorax
ABC’s/O2
IV
C-spine precaution
ECG monitor
Continue supportive
care
Observe for improvement/
development of tension
pneumothorax
Transport to
nearest medical
facility
AFSOCH 48-1, 1 July 1998 44
Massive Hemo/Pneumothorax
ABC’s/O2
IV
C-spine precaution
ECG monitor
Cleanse/Anesthetize
as appropriate
Make incision
Perform blunt dissection
Suture in place w/
occlusive dressing
Transport
Observe for improvement
to nearest medical
Continue supportive
facility
care
Take altitude precautions
while inflight
AFSOCH 48-1, 1 July 1998 45
Needle Thoracentesis
ABC’s/O2
IV
C-spine precaution
ECG monitor
Insert 14 ga needle
Attach flutter device
Secure in place
Does
patient
condition
Yes improve No
Transport
to nearest
medical facility
AFSOCH 48-1, 1 July 1998 46
#1
Perform ABC’s
***
Is No
Stridor/snoring resps
airway
Cyanosis Go to #2
open?
Gurgling
Frothy sputum
Unequal rise/fall chest
D ecreased breath sounds
Suspect M echanism of Injury Y es
U se of accessory muscles
Is
No
patient Open airway using
spontaneously appropriate manuveur
breathing?
Place OPA/NPA
Y es
A ssess respiratory
A ttach BVM to high
effort
flow O2
Begin appropriate
ventilations
Is
rate No A ssess breath sounds/
>10 or adequacy of ventilations
<28?
A re
there
Y es Go
No signs of
Place Non Rebreather to
respiratory
w / high flow O2 #3
distress?
***
Supportive
care
Transport
AFSOCH 48-1, 1 July 1998 47
#2
Perform B L S
procedures to
attem p t airw ay
clearing
Yes
Go to #1 Successful?
No
D irectly visualize
a ir w a y w /
laryngoscope
Are Is
Prepare
No vocal No Foreign Yes Remove FB
for
cords Body w / M agill Go to #1
cricothyroidotom y
v isible? v isible? forceps
Go to Protocol
Yes
Go to #3
AFSOCH 48-1, 1 July 1998 48
#3
Remove OPA/NPA
D irectly visualize
vocal cords
w / laryngoscope
Are
vocal No Perform
cords digital
visible? intubation
Yes
Introduce appropriately
sized Endotracheal T u b e
w / or w/out stylet
V isualize tube
passing cords
R e m o v e stylet
Inflate cuff
Cricothyroidotomy
Select site
Orient to structures
Cleanse/anesthetize
area as appropriate
Ventilate patient
Secure ET Tube in place
AFSOCH 48-1, 1 July 1998 50
Venous Cutdown
Select site
Usually saphenous vein
Cleanse/anesthetize as appropriate
Identify vein
Perform blunt dissection
to free from all structures
Lubricate tube
Is
tube No
placement Reposition accordingly
confirmed?
Yes
Secure tube
Proceed w/ lavage
AFSOCH 48-1, 1 July 1998 52
Urethral Catheterization