TTrraaiinniinngg SSuupppplleemmeenntt WWiinntteerr 1100 JJoouurrnnaall ooff SSppeecciiaall OOppeerraattiioonn MMeeddiicciinnee A Peer Reviewed Journal for SOF Medical Professionals W in t e r 2 0 1 0 S u p p le m e n t t o t h e J o u r n a l o f S p e c ia l O p e r a t io n s M e d ic in e Report Documentation Page Form Approved OMB No. 0704-0188 Public reporting burden for the collection of information is estimated to average 1 hour per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to Washington Headquarters Services, Directorate for Information Operations and Reports, 1215 Jefferson Davis Highway, Suite 1204, Arlington VA 22202-4302. Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to a penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number. 1. REPORT DATE 3. DATES COVERED 2010 2. REPORT TYPE 00-00-2010 to 00-00-2010 4. TITLE AND SUBTITLE 5a. CONTRACT NUMBER Journal of Special Operations Medicine. Training Supplement, Winter 5b. GRANT NUMBER 2010 5c. PROGRAM ELEMENT NUMBER 6. AUTHOR(S) 5d. PROJECT NUMBER 5e. TASK NUMBER 5f. WORK UNIT NUMBER 7. PERFORMING ORGANIZATION NAME(S) AND ADDRESS(ES) 8. PERFORMING ORGANIZATION United States Special Operations Command (USSOCOM),SOC-SG,7701 REPORT NUMBER Tampa Point Blvd,MacDill AFB,FL,33621-5323 9. SPONSORING/MONITORING AGENCY NAME(S) AND ADDRESS(ES) 10. SPONSOR/MONITOR’S ACRONYM(S) 11. SPONSOR/MONITOR’S REPORT NUMBER(S) 12. DISTRIBUTION/AVAILABILITY STATEMENT Approved for public release; distribution unlimited 13. SUPPLEMENTARY NOTES 14. ABSTRACT 15. SUBJECT TERMS 16. SECURITY CLASSIFICATION OF: 17. LIMITATION OF 18. NUMBER 19a. NAME OF ABSTRACT OF PAGES RESPONSIBLE PERSON a. REPORT b. ABSTRACT c. THIS PAGE Same as 184 unclassified unclassified unclassified Report (SAR) Standard Form 298 (Rev. 8-98) Prescribed by ANSI Std Z39-18 INTRODUCTION This is the 4th version of the JSOM training supplement. The guidelines contained in this supplement are reviewed and compiled annu- ally by a combined group of SOF physicians, ATPs, SOF medical person- nel from all of the SOCOM component branches, and civilian medical personnel. The Tactical Medical Emergency Protocols (TMEPS)and Rec- ommended Drug List (RDL)were created, reviewed, and approved for use by the Advanced Tactical Practitioner (ATP). We can also send any of these products to you as a PDF file. Just request whatever you want via an email to: [email protected]. Please send us CONSTRUCTIVE comments and recommendations as well. We are al- ways looking for a good idea or a better way to ensure you have the latest greatest of information. LTC Doug McDowell USSOCOM Chief of Medical Education and Training 2 Journal of Special Operations Medicine U.S. SPECIAL OPERATIONS COMMAND TACTICAL MEDICAL EMERGENCY PROTOCOLS For SPECIAL OPERATIONS ADVANCED TACTICAL PRACTITIONERS (ATPs) January 1, 2010 USSOCOM OFFICE OF THE COMMAND SURGEON DEPARTMENT OF EMERGENCY MEDICAL SERVICES AND PUBLIC HEALTH 7701 Tampa Point Boulevard MacDill Air Force Base, FL 33621 (813) 826-5065 Winter2010TrainingSupplementTMEPS A1 TRAININGSUPPLEMENT TABLEOFCONTENTS PrefaceandChanges 4 ClinicalPearls--------------------------------------------------------------------6 SectionATacticalMedicalEmergencyProtocol(TMEPS) AbdominalPain 7 Abscess-------------------------------------------------------------------------24 AllergicRhinitis/HayFever/Cold-LikeSymptoms 8 AltitudeIllness------------------------------------------------------------------9 AnaphylacticReaction 11 Asthma(ReactiveAirwayDisease)---------------------------------------12 BackPain 13 Barotrauma---------------------------------------------------------------------14 BehavioralChanges(IncludesPsychosis,Depression, SuicidalImpulses) 15 BlastInjuryAssessment-----------------------------------------------------16 Bronchitis/Pneumonia 23 Cellulitis/Abscess------------------------------------------------------------ 24 ChestPain 25 Constipation/FecalImpaction--------------------------------------------27 ContactDermatitis 28 CornealAbrasion/CornealUlcer/Conjunctivitis--------------------- 29 Cough 30 CrushSyndrome------------------------------------------------------------- 31 DeepVenousThrombosis(DVT) 33 Dehydration-------------------------------------------------------------------- 34 DentalPain 35 DeterminationofDeath/DiscontinuingResuscitation----------------36 EarInfection(IncludesOtitisMediaandOtitisExterna) 37 Envenomation-----------------------------------------------------------------38 Epistaxis39 FlankPain(IncludesRenalColic,Pyelonephritis,KidneyStones) 40 FungalSkinInfection 41 Gastroenteritis-----------------------------------------------------------------42 Headache 43 HeadandNeckInfection(IncludesEpiglottitisand PeritonsillarAbscess)------------------------- 44 A2 JournalofSpecialOperationsMedicine HIVPostExposureProphylaxis 45 Hyperthermia--------------------------------------------------------------------47 Hypothermia 48 IngrownToenail----------------------------------------------------------------49 JointInfection 50 K-9EvaluationandTreatment-----------------------------------------------51 K-9HeatInjuries 54 K-9HighAltitudeSicknessandPulmonaryEdema-------------------55 K-9TraumaManagement 57 KidneyStone–SeeFlankPain----------------------------------------------40 LossofConsciousness(withoutSeizures) 60 MACE-----------------------------------------------------------------------------17 Malaria 61 Meningitis----------------------------------------------------------------------- 62 NauseaandVomiting 63 OtitisExterna–SeeEarInfection------------------------------------------ 37 OtitisMedia–SeeEarInfection 37 PainManagement------------------------------------------------------------ 64 Pneumonia–SeeBronchitis 23 PulmonaryEmbolus–SeeChestPain------------------------------------25 Pyelonephritis–SeeFlankPain 40 RenalColic–SeeFlankPain------------------------------------------------40 Seizure 65 Sepsis/SepticShock--------------------------------------------------------66 SmokeInhalation 67 SpontaneousPneumothorax-----------------------------------------------68 SubungualHematoma 69 TesticularPain----------------------------------------------------------------- 70 TraumaticBrainInjury–Mild(mTBI) 71 UrinaryTractInfection------------------------------------------------------- 73 SectionBTacticalMedicalEmergencyProtocolDrugList 77 SectionCTacticalMedicalEmergencyProtocol PlanningandOperations 154 SectionDBurnCharts 174 SectionENerveCharts 178 Notes Winter2010TrainingSupplementTMEPS A3 PREFACE Management of medical emergencies is best accomplished by appropriately trained physicians in an Emergency Department setting. Special Operations Combat Medics (SOCMs), however, may often find themselves in austere tactical environments where evacuation of a teammate to an MTF for a medical emergency would entail either significant delays to treatment or compromise the unit’s mission. Although SOCM trained medics are not routinely authorized by the services to treat non-traumatic emergencies, in many SOF situations, training SOCMs to treat at least some medical emergencies may result in both improved outcome for the individual and an improved probability of mission success. The disorders chosen have one of the following properties in common: they are relatively common; they are acute in onset; the SOCM is able to provide at least initial therapy that may favorably alter the eventual outcome; and the condition is either life-threatening or could adversely affect the mission readiness of the SOF operator. The Protocols outlined in the following pages carry the following assumptions: A. The SOCM medic is in an austere environment where a medical treatment facility or a unit sick call capability is not available. If a medical treatment facility or a medic authorized to treat patients independently is available, then the patient should be seen in those settings rather than by a SOCM medic. B. Immediate evacuation may not be possible and, even if it is, may still entail significant delays to definitive treatment. The medical problem may worsen significantly if treatment is delayed. C. The SOCM will contact a consulting physician as soon as feasible. D. SOCM treatment will be done under the appropriate Protocol. E. Medication regimens are designed to minimize the number of medications the SOCMs are required to learn and carry. Medications have been used for multiple conditions when feasible without compromising care. F. Appropriate documentation of diagnosis and treatment rendered in the patient’s medical record will be accomplished when the unit returns to forward operating base. G. Note these Protocols are not designed to allow SOCM medics to conduct Medical/ Civic Action (MEDCAP) missions independently. H. Evacuation recommendations are based on the appropriate therapy per Protocol being initiated on diagnosis. I. The definitions of Urgent, Priority, and Routine evacuations are based on the times found in Joint Publication 4-02.2 of 2, 4, and 24 hours respectively. J. For any infection, limit contact and use universal precautions. Changes for 2007: A. The changes in the combat pill pack (Moxifloxacin (Avelox) and meloxicam), as recommended by the Committee on Tactical Combat Casualty Care (CoTCCC), have been changed in the TME Protocols. (2007) B. The Fentanyl oral dosage of 800 mcg, as recommended by the CoTCCC has been incorporated into the Pain Protocol. (2007) C. The change in the IV antibiotics has also been changed to reflect medication availability. D. When possible, alternate antibiotics or anti-emetics have been listed. Changes for 2008: A. The Cellulitis and Cutaneous Abscess Protocols were combined. B. An Altitude Illness Protocol was created, combining AMS, HACE, and HAPE. C. The Chest Pain was expanded to provide more guidance. D. The following new protocols were added: Determination of Death and Envenomation. E. The following medication changes were made: the use of Zithromax was decreased; Keflex, Quinine, Doxycycline and Corticosporin Otic were removed. F. The following medications were added: Amoxicillin/Clavulanic Acid (Augmentin), Rabeprazole (Aciphex), Septra DS, Salmeterol (Serevent), Rifampin, Toradol, and Benadryl Quikstrips. G. The Meningitis Disposition typo error from 2007 was corrected. H. Modifications were made to most of the TMEPS with respect to further refinement in recommendations. I. The “Clinical Pearls” section was added. A4 JournalofSpecialOperationsMedicine Changes for 2009: A. Crush Protocol added B. Blast Protocol added C. MACE added D. Traumatic Brain Injury – Mild (mTBI) Protocol added E. Bronchitis/Pneumonia: Disposition changed. F. Flank Pain: antibiotics modified (order of preference) G. Joint Infection: antibiotics modified (order of preference) H. Spontaneous Pneumothorax: indications for tube thoracostomy added I. Urinary Tract Infections: antibiotics modified J. Drugs added: Calcium Chloride, Calcium Gluconate, Sodium Bicarbonate, Mannitol K. HIV PEP Protocol updated with new medications added: Atripla, Truvada, Viread, Kaletra L. Behavioral Changes Protocol changed and midazolam (Versed) added. M. Seizure Protocol changed and midazolam (Versed) added. Changes for 2010: A. K-9 Protocols added B. Drugs added: tadalafi (Cialis), sildenafil (Viagra) C. Altitude Illness changed to add tadalafi (Cialis) and sildenafil (Viagra) Winter2010TrainingSupplementTMEPS A5 Don’t Forget… (Clinical Pearls) When IV route is recommended, but not obtainable, consider IO, IM, or PO unless contraindicated. Currently available SL medication formulations include: Benadryl Quikstrips, Sudafed PE SL, Zofran ODT. If crystalloids (normal saline or lactated Ringer’s) are recommended but not available, substitute Hextend or Hespan if available. DO NOT give epinephrine IV unless given under the ACLS protocols All IV medications may be given slow IV push with the exception of antibiotics which should be in a drip, unless otherwise specified. Remember to document dose and time of all medications so the receiving facility may be informed. Do not use local anesthetic with epinephrine on the ears, nose, digits, and penis. When oxygen is called for in the Protocols, the authors realize that it is recommended, but may not be available. Due to the high level of physical fitness of SOF personnel, there may be a prolonged period of mental lucidity and apparent stable vital signs despite a severe injury. Treat the injury, not the Operator! MedicalDocumentation (SOAP note): In order to ensure proper care and medical information transfer during patient treatment a standardize format for medical documentation is required. The standard format is the SOAP note (Subjective, Objective, Assessment, and Plan). Subjective: In the patient’s own words, describe the chief complaint. At a minimum you need to include the OPQRST (Onset, Palliative or Provocative, Quality, Radiation, Severity, and Timeline of symptoms). AMPLE (Allergies, Medication, Past Medical and Surgical history, Last meal, and Events leading up to this condition) history is also included in this section Objective: Vital signs and physical examination findings. At a minimum you need to document pertinent positives and negatives, and measurements of injuries or lesions. Be as detailed as possible. Assessment: A brief summary of your medical decision making to include what you think it is and what it is not. Include your differential diagnosis list in this section. Plan: Your course of treatment to include any medications, additional studies, consultation, rehabilitation, evacuation category, and disposition of the patient. A6 JournalofSpecialOperationsMedicine ABDOMINAL PAIN SPECIAL CONSIDERATIONS: 1. Common causes in young healthy adults include appendicitis, cholecystitis, pancreatitis, perforated ulcer, and diverticulitis. 2. Consider constipation/ fecal impaction as a potential cause of abdominal pain. SIGNS AND SYMPTOMS SUGGESTIVE FOR CONTINUED OBSERVATION: 1. Epigastric burning pain 2. Present bowel sounds 3. Nausea and/ or vomiting 4. Absence of rebound tenderness 5. If diarrhea is present,treat per Gastroenteritis Protocol. MANAGEMENT: 1. Antacid of choice 2. Ranitidine (Zantac) 150mg PO bid OR Rabeprazole (Aciphex) 20mg PO qd OR Proton Pump Inhibitor of choice 3. PO hydration DISPOSITION: 1. Observation and re-evaluation. 2. Priority evacuation if symptoms not controlled by this management within 12 hours. SIGNS AND SYMPTOMS SUGGESTIVE FOR URGENT EVACUATION: 1. Severe, persistent, or worsening abdominal pain is the key sign. 2. Rigid abdomen 3. Rebound abdominal tenderness 4. Fever 5. Absence of bowel sounds 6. Focal percussive tenderness 7. Uncontrollable vomiting 8. Presence of bloody vomitus or stools 9. Presence of black tarry stools 10. Presence of coffee ground vomitus MANAGEMENT: 1. Start IV with normal saline (NS), 1 liter bolus, followed by NS 150cc/hr. Keep NPO except for medications or PO hydration. 2. Ertapenem (Invanz) 1gm IV qd 3. OR Ceftriaxone (Rocephin) 1gm IV qd. plus Metronidazole (Flagyl) 500mg PO q 8h 4. Treat per Pain Protocol 5. Treat per Nausea and Vomiting Protocol DISPOSITION: Urgent evacuation to a surgical facility. Winter2010TrainingSupplementTMEPS A7