Protocols 🤓

Question 1

What are the airway protocols?

Answer 1

2.1 Airway
2.2 SOB Asthma/COPD
2.3 Anaphylaxis <30kg
2.4 Anaphylaxis >30kg

Question 2

What are the signs of severe SOB(as opposed to mild)?

Answer 2

-altered loc -cyanosis -fragmented speech -accessory muscle use -SpO2 <90% -Cant lie supine

Question 3

Difference in Salbutamol dosing Mild vs. Severe SOB?

Answer 3

Both: 4-8 puffs MDI q20min prn x3
or
5mg NEB q20min prn x3 (<30kg 2puffs / 20min)

Question 4

What are the cardiac protocols?

Answer 4

1.1 Suspected Cardiac Chest Pain
1.2 Cardiac Arrest AED
1.3 Post Cardiac Arrest Stabilization
1.4 Discontinue Resuscitation
1.5 VSA - Class B

Question 5

Do not give nitro if?

Answer 5

Not prescribed
BP <90 (or unable to take)
HR <60
Meds: Viagara/Levitra/cialis/staxyn in last 24hrs

Dose: 0.4mg SL q5min max 3 every 30min
(Don’t count self administered doses prior to your arrival)

Question 6

What are the O2 flows?

Answer 6

100% O2 free mask
high flow 6-10L facemask
low flow 2-4L nasal

titrate to 92% SpO2

Question 7

Epi doses?

Answer 7

> 30kg:
Epipen(0.3mg)
or EPI IM 0.3mg q5min prn x3

15-30kg:
Epi Jr (0.15mg)
or EPI IM 0.15mg q5min prn x3

<15kg:
EPI IM 0.01 mg/kg q5min prn x3

Question 8

In 3.3 Hemorrhagic Shock, how much RL or NS to give?

Answer 8

250mL bolus up to 1L max if first shows improvement/no increased hemorrhage except in suspected severe TBI

Question 9

What are the indications for Hemorrhagic shock protocol? Adult and Ped.

Answer 9

Adult: BP <90, HR >110, loss of radial
Ped: BP <70 + 2x age in years

Injury patterns suggest need for transfusion/resus

Question 10

5.1 Hypothermia: what do you do for passive rewarming and active rewarming?

What are the classifications of hypothermia?

Answer 10

Passive: get pt off ground, remove wet clothes, insulating/protect from elements

Active: hot packs to groin, axilla, head, warm iv fluid

Mild: 35-32
Mod: 32-28 confused
Severe: 28-24 shivering stopped
Profound: <24 cardiac arrest

Question 11

5.2 Hyperthermia branches into 2 sections, what are they?

Answer 11

CNS involvement.

No is heat exhaustion. Remove from heat, remove clothes, cool, fluids po.

Yes is heat stroke. Initiate BLS, remove from heat, remove clothing, cool, initiate iv/io, 1 L NS and reassess, urinary catheter for prolonged evac.

Question 12

What are the indications for 5.2 hyperthermia?

What are the stages of hyperthermia per the notes?

Answer 12

Body temp >40’C
or
S/S of hyperthermia

Heat cramps: muscle spasms
Heat exhaustion: nausea, cramps, headache, faint, fatigue, pale, cool, clammy, sweating
Heat stroke: confusion, tachycardia then bradycardia, hypotension, rapid shallow resps, hot skin, no sweating, seizures, coma

Question 13

Describe the MARCH steps in 1.5 VSA? (Class B protocol)

Answer 13

BLS, then
M&CPR: massive hem. control
A: supraglottic airway
R: 100% O2, check CO2 detector, bilat chest decompression in penetrating trauma
C: Bolus NS/RL 1L IV/IO
H: rewarm
Protocol 1.2 Cardiac Arrest until 3 no shock advised (continue in pt with hypothermia, drowning, peds, electrocution)
Contact SMA if cant consider 1.4 Discontinue (or stop per situation)

Question 14

Describe 1.4 Discontinue Resuscitation?

Answer 14

BLS
No pulse after 30 min CPR with normal body temp
(Ensure other interventions have been attempted, continue in hypothermia, drowning, peds, electrocution)

Question 15

2.4 Anaphylaxis <30kg pt, what is considered hypotension?

How much NS to give

Answer 15

1 month to 1 year: <70mmHg
1-10years:
70mmHg + (2 x age)
Ex. 5 years old = 80mmHg

20mL/kg NS IV/IO x 2prn

Ex. 45lb child = 20kg x 20mL =400mL
Note: massive fluid shifts occur due to increased vascular permeability transfer up to 35% intravascular V to extravascular in minutes. If pt not responsive to IM Epi may require large fluid resus.

Question 16

1.3 Post Cardiac Arrest Stabilization how long to monitor closely for?

Answer 16

10 minutes, obtain vitals every 5 minutes

Question 17

Steps for 1.1 Cardiac Chest Pain?

Answer 17

BLS
O2 (aim >92%)
ASA 160mg PO
Initiate Med Evac
Saline Lock
If BP <90 give 250mL NS IV repeat x4 every 10 min if BP <90
If BP >90 give Nitro .4mg q5min(dont give if HR<60)
If no pain relief after 3 doses and bp>90 Cpl can give Morphine and Dimenhydrinate
Monitor pt and contact SMA

Question 18

What is considered KIA?

Answer 18

No pulse, no resp, following blast/trauma in combat

Also obvious death is decapitation, head trauma with brains out, rigor mortis, decomposition

Question 19

iGel indications? Contraindications? Cautions?

Answer 19

Indications: pt cant maintain patent airway(GCS<8 and absence of gag reflex), cardioresp arrest
Contraindications: gag reflex, trismus/abcess/trauma/mass obstruction, liklihood of having full stomach(upper GI conditions, pregnancy, obesity)
Cautions: dont allow peak airway pressure ventilation to exceed 40cm H2O, dont use excessive force, intended to be left for up to 4 hours, do not reuse

Question 20

How do you confirm placement of a supraglottic airway?

Answer 20

Auscultate epigastric region, auscultate breaths for bilateral entry, confirm thorax rises evenly, CO2 detector

Question 21

3.9 Chest Trauma Management: How to burp? When to needle d?

Answer 21

Expose and rake, cover holes with gloved hand, apply chest seal(use vented if available).
If tension pneumo suspected, peel back seal, align tissues and press downward on patient expiration, replace seal before inspiration. Attempt 2x. Then do needle d if in an operational environment(class b for pte).

Question 22

1.2 Cardiac Arrest AED Protocol, what are the 3 cautions?

Answer 22

Hypothermia: defib wont be effective until >30’C, focus on rewarming and CPR
Asphyxiation: focus on good oxygenation and CPR before AED
Trauma: cardiac arrest due to trauma low probability of survival, consider resources/op requirements

Question 23

3.1 Massive External Hemorrhage, order of control methods to consider?

Answer 23

Direct pressure
Limb tq?
Wound pack with hemostatic dressing(not in abdomen,thoracic,cranial cavities)
Junctional tq?
Pressure and hemostatic dressing
Wet check if not yet done, 3.11 Other sources of Significant Hemorrhage, consider Pelvic Binder(pelvic trauma, unexplained hypotension in blast/blunt trauma, blast with lower limb amp, pelvic pain)

Question 24

3.2 TQ Assessment, Conversion, Removal, indications, and describe process?

Answer 24

Indications: can be controlled by other means, replace strap with pneumatic, replace a Tq places in CUF over clothing

Contraindications to converting to dressing:
-complete amp -hemorrhagic shock -tq on >4hours - cant be monitored -bleeding cant be controlled

Attempt to convert to dressing if possible within 2hours of tq.

Question 25

3.5 Burn Management, indications? Describe?

Answer 25

Indications: 2nd and 3rd degree burns >20% BSA Stop burning process. Assess airway and O2. Hypothermia prevention and active rewarming. If bp<90 and no hemorrhage(if so refer to 3.3 Hemorrhagic Shock) give 500ml RL bolus prnx4. If bp>90 continue with burn management (dry sterile dressing/cellophane, dont wrap tight anticipate swelling) Calculate BSA burn IV/IO USAISR Rule of Ten Burn Protocol(parkland formula for peds) Pain Protocol 3.6 Foley Catheter (aim for 30-50mL/hour or 0.5ml/kg/hr, if under or over readjust IV fluid rate by 25% for an hour and reassess) Evac/SMA

Question 26

What % TBSA for fluid resus? Preferably with what? Alternatives?

Answer 26

20% RL-if hemorrhage ruled out give 500mL bolus prnx4 until BP>90 and titrate per urine output Alternatives: NS, or by PO with TBSA<30% give oral rehydration solution or 1L water with 6teaspoons sugar and 0.5teaspoon salt

Question 27

TBSA estimates: adult (front and back)?

Answer 27

Head: 9% Torso: 32% Arm: 9% Leg: 18% Genitals: 1%

Question 28

TBSA estimates: child?

Answer 28

Head: 14% Torso: 32% Arm: 9% Leg: 16%

Question 29

TBSA estimates baby?

Answer 29

Head: 18% Torso: 32% Arm: 9% Leg: 14%

Question 30

CUF steps?

Answer 30

Tactical awareness Return fire and cover Direct casualty to remain engaged if possible When feasible move pt to cover(tactical rescue) Keep casualty from sustaining more wounds Establish TFC Bubble as permitted Remove casualties from Burning vehicles/buildings/stop burning process Stop hemmorhage: direct casualty to self aid, tq, either proximal or high and tight Airway best for TFC, but put in recovery position if altered LOC Steps 1-3

Question 30

Yellow box? Blue box?

Answer 30

Yellow: Cpl Blue: class b performed in named operational environment with signed authority from sma

Question 31

MOI to consider SMR?

Answer 31

High Speed MVC Fall >3x height no FFO Fall >1m with FFO Axial Load Diving Penetrating Wound In/Near Spinal Sports Injury Head/Neck Unconscious Trauma Hx Blast With s/s spinal pain, abnormal motor/sensory Or unreliable pt(brain injury, altered LOC, intoxication, distracting injury) *not recommended in tactical environment

Question 32

Conditions to satisfy TFC Bubble establishment?

Answer 32

1. Engaged in CUF 2. Care provider not required for combat 3. Care provider and casualty in adequate cover 4. Casualty will likely benefit from TFC interventions

Question 33

3.6 Pain?

Answer 33

Assess Saline lock Severe pain: Cpl can give ketamine(class b) or morphine, pte can give fentanyl 800ug lolly and another after 15 min (class b) Prep: ondanestron or dimenhydrinate for nausea Naloxone for resp distress Mod pain: ibuprofen 800mg q8h, or meloxicam 15mg PO once, and/or Acetaminophen 1g PO q6h Child 4-16: ibuprofen 10mg/kg PO q8h and/or acetaminophen 15mg PO q6h

Question 34

3.7 mTBI?

Answer 34

Indications: head injury with altered LOC, or common symptoms. Neuro exam(GCS, pupils, gross focal neuro deficits) If GCS <8 go to 3.10 sTBI Stabilize immediate life threats and assess red flags(if yes pri1 evac) MACE eval Report any abnormal findings do med tech management Exertional testing and repeat MACE 24hr supervises rest, consult sma for RTD

Question 35

3.8 Eye Injury?

Answer 35

Open globe? Rigid eye shield, for adults give Moxifloxacin 400mg PO and if CPL give Ondansetron 8mg prn Foreign body? Tetracaine 1-2gtts Irrigation Remove if cant rigid eye shield If no foreign body give tetracaine 1-2gtts and if Cpl stain with fluorescein to check for corneal abrasion

Question 36

4.3 Antibiotic?

Answer 36

Indications: contaminated open wound with delayed evac(2-4hours), penetrating eye injury, bowel injury, orofacial infections, burn with infection Assess IV Adult: Moxifloxacin 400mg PO q24hrs or if cant PO and cpl, Cefoxitin 2g IV/IO/IM q8h or Clindamycin(if penicillin allergy) 600mg IV/IO/IM q8h Child: no moxi, need cpl, cefoxitin 30mg/kg IV/IO/IM max 2g or Clindamycin if penicillin allergy 10mg/kg IV/IO/IM max600mg q8h

Question 37

4.4 Hostile-class b?

Answer 37

Assess for other medical reasons Verbal deescalation CPL: haloperidol and midazolam repeat 10min if pt danger

Question 38

4.5 Hypoglycemic?

Answer 38

Indications: diabetic pts >3yo with decreasedLOC Bls Bgl If <4.0mmol/L give liquid glucose PO, iv, adult: D10W 100ml IV/IO, ped: D10W 2ml/kg IV/IO max 100ml If bgl still <4 give anither dose D10W and recheck after 10min(15-20 for children), if still low reduce flow to 100ml/hr(or convert to saline for children) Consider other causes if decreased LOC, if bgl>4 discontinue D10W recheck bgl q30min If cant IV, give Glucagon 3mg intranasally repeat after 5min, give carbs when pt responsive or give dextrose IV/IO

Question 39

4.6 Unconscious NYD?

Answer 39

BLS & Initiate transport Bgl<4? Hypoglycemic protocol Give naloxone 0.4mg IV/IO or 0.8mg IM/SC or 0.4mg IN if successful switch to narcotic OD protocol If BP<90 initiate Hem Shock Protocol

Question 40

5.1 Hypothermia?

Answer 40

Indications: temp <35’C or symptoms Assess Handle gently ABCs Hypoglycaemia? If yes go to Hypoglycaemic Protocol Saline Lock Prevent further heat loss(off ground, remove wet clothing, shield) Passive rewarming(dry warm clothes) Active rewarming(hot packs) Sma Foley Catheter Transport

Question 41

5.2 Hyperthermia?

Answer 41

Indications: >40’C or symptoms Assess CNS? If no its heat cramps, or heat exhaustion(nausea, headache, clammy, sweating). Remove from heat, cool, PO fluids. If yes its heat stroke(>40’C, tachycardia then brady), IV/IO for fluids, urinary catheter in prolonged evac

Question 42

Start Triage Order:

Answer 42

“Walk to me” - GREEN Go to massive hem and tq. Leave all in recovery position or position of comfort if alert. Breathing? If no, reposition if that works they are RED If fails EXPECTANT Rate? >30 RED Radial? No = RED Mental-obeys? No=RED Yes ‘why didn't you come?’ YELLOW or GREEN if didn't hear

Question 43

3.5 Blood Protocol: indications? Contra? What is the order of best fluids to administer?

Answer 43

Indications: -penetrating trauma to chest/abdo/junctional Or -suspected pelvic hemm. Or -above knee amp/multiple amps AND -altered LOC Or -no radial AND HR>120 Or -bp<100 AND HR>120 No contra-life threat, caution common rxns within 4 hours are fever>38, uticaria, dyspnea hypotension<100, if so send blood and tubing with pt. Give women <45yo priority for O-. Blood uses 18g, use warming device, only compatible with NaCl, is not compatible with meds so start second IV, and change tubing every 4 hours or 4 units. Pt will need 1g CaCl or 3g Calcium Gluconate given by PCP at first unit and every 4th. Best fluids: -Low titre group O Whole Blood -Group O packed RBC -Group AB Plasma -NS 250mL max 500mL

Question 44

What do you look for in the quality of blood pack when administering blood?

Answer 44

Clotting Black means infection Hemolysis(layer that cant get manipulated out) Particulates Lipemia (high cholesterol) Also check info(expiry is 21 days), temperature remained within 1-6’(did not break cold chain), blood type, matches doc. Fill out form CF2061