WhiskeyMed Protocols 1

68W Scope of Practice 📖

March, 2020
➢ TCCC Guidelines
➢ Clinical Care Protocols
➢ Pharmacology Reference
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Table of Contents
TCCC Study Guide 6-7

TCCC Guidelines 9-32
Garrison Care Protocols 33
➢ Abdominal Pain 34
➢ Allergic Rhinitis/Cold 35
➢ Altitude Illness 36
➢ Anaphylaxis 37
➢ Asthma 38
➢ Back Pain 39
➢ Barotrauma 40
➢ Behavioral Changes 41
➢ Bronchitis/Pneumonia 42
➢ Cellulitis 43
➢ Chest Pain 44
➢ Cold Injury 45-46
➢ Constipation/Fecal Impaction 47
➢ Contact Dermatitis 48
➢ Corneal Abrasion/Corneal Ulcer/Conjunctivitis 49
➢ Cough 50
➢ Cutaneous Abscess 51
➢ Deep Venous Thrombosis (DVT) 52
➢ Dehydration 53
➢ Dental Pain 54
➢ Ear Infection 55
➢ Envenomation (Snakes) 56
➢ Envenomation (Marine) 57
➢ Envenomation (Insects/Arthropods) 58
➢ Envenomation (Scorpion) 59
➢ Epiglottitis 60
➢ Epistaxis 61
➢ Flank Pain 62
➢ Fungal Skin Infection 63
➢ Gastroenteritis 64
➢ Gastroesophageal Reflux Disease (GERD) 65
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➢ Headache 66
➢ Heat Illness 67
➢ Ingrown Toenail 68
➢ Joint Infection 69
➢ Laceration 70
➢ Malaria 71
➢ Meningitis 72
➢ Nausea/Vomiting 73
➢ Pain Management 74
➢ Peritonsillar Abscess 75
➢ Pulmonary Embolism 76
➢ Rhabdomyolysis 77
➢ Seizure 78
➢ Sepsis/Septic Shock 79
➢ Smoke Inhalation 80
➢ Sprain and Strains 81
➢ Subungual Hematoma 82
➢ Syncope 83
➢ Testicular Pain 84
➢ Tonsillopharyngitis 85
➢ Urinary Tract Infection 86
Pharmacology Reference
➢ Acetaminophen (Tylenol) 88
➢ Acetazolamide (Diamox) 89
➢ Acetylsalicylic acid (Aspirin) 90
➢ Albuterol (Proventil, Ventolin) 91
➢ Azithromycin (Zithromax, Z-Pak) 92
➢ Bacitracin 93
➢ Bismuth Subsalicylate (Pepto-Bismol) 94
➢ Benzonatate (Tessalon Perles) 95
➢ Calcium Carbonate (TUMS) 96
➢ Calcium Gluconate (Kalcinate) 97
➢ Ceftriaxone (Rocephin) 98
➢ Cetirizine (Zyrtec) 99
➢ Clindamycin (Cleocin) 100
➢ Clotrimazole (topical) 101
➢ Cyclobenzaprine (Flexeril) 102
➢ Dexamethasone (Decadron) 103
➢ Dextromethorphan (Robitussin DM) 104
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➢ Diazepam (Valium) 105
➢ Diphenhydramine (Benadryl) 106
➢ Epinephrine 107
➢ Ertapenem (Invanz) 108
➢ Fentanyl Oral Lozenges (Actiqu) 109
➢ Fexofenadine (Allegra) 110
➢ Fluconazole (Diflucan) 111
➢ Gatifloxacin (Ophthalmic Solution) 112
➢ Guaifenesin (Mucinex) 113
➢ Hetastarch (Hextend) 114
➢ Hydrocortisone 115
➢ Ibuprofen (Motrin, Advil) 116
➢ Ketamine (Ketalar) 117
➢ Ketorolac (Toradol) 118
➢ Lactated Ringers (LR) 119
➢ Lidocaine (Xylocaine) 120
➢ Loperamide (Imodium) 121
➢ Loratadine (Claritin) 122
➢ Meclizine (Antivert) 123
➢ Malarone (Atovaquone/Proguanil) 124
➢ Meloxicam (Mobic) 125
➢ Methylprednisolone (Solu-medrol) 126
➢ Metronidazole (Flagyl, Metrogel) 127
➢ Midazolam (Versed) 128
➢ Morphine Sulfate (MSO4) 129
➢ Moxifloxacin (Avelox) 130
➢ Mupirocin (Bactroban) 131
➢ Naloxone (Narcan) 132
➢ Nitroglycerin (Nitrostat) 133
➢ Normal Saline (Sodium Chloride 0.9%) 134
➢ Omeprazole (Prilosec) 135
➢ Ondansetron (Zofran) 136
➢ Oxymetazoline (Afrin) 137
➢ Phenylephrine (Sudafed PE) 138
➢ Prednisone (Deltasone) 139
➢ Primaquine 140
➢ Promethazine (Phenergan) 141
➢ Pseudoephedrine (Sudafed) 142
➢ Ranitidine (Zantac) 143
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➢ Tranexamic Acid (TXA, CycloKapron) 144
➢ Trimethoprim-Sulfamethoxazole (TMP-SMZ, Bactrim, Septra) 145
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TCCC
GUIDELINES
⬇⬇⬇⬇⬇⬇⬇
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TCCC Guidelines for Medical Personnel
1 August 2019
RED text indicates new text in this year’s update to the TCCC Guidelines, which includes the
recent changes on extraglottic airways and management of suspected tension pneumothorax.
Basic Management Plan for Care Under Fire

1. Return fire and take cover
2. Direct or expect casualty to remain engaged as a combatant if appropriate
3. Direct casualty to move to cover and apply self-aid if able
4. Try to keep the casualty from sustaining additional wounds
5. Casualties should be extricated from burning vehicles or buildings and moved to places of
relative safety. Do what is necessary to stop the burning process.
6. Stop life-threatening external hemorrhage if tactically feasible:

a. Direct casualty to control hemorrhage by self-aid if able.
b. Use a CoTCCC-recommended limb tourniquet for hemorrhage that is anatomically
amenable to tourniquet use.
c. Apply the limb tourniquet over the uniform clearly proximal to the bleeding site(s). If
the site of the life-threatening bleeding is not readily apparent, place the tourniquet
“high and tight” (as proximal as possible) on the injured limb and move the casualty
to cover
7. Airway management is generally best deferred until the Tactical Field Care phase.
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Basic Management Plan for Tactical Field Care
1. Establish a security perimeter in accordance with unit tactical standard operating procedures
and/or battle drills. Maintain tactical situational awareness.
2. Triage casualties as required. Casualties with an altered mental status should have weapons
and communications equipment taken away immediately.
3. Massive Hemorrhage
a. Assess for unrecognized hemorrhage and control all sources of bleeding. If not already
done, use a CoTCCC-recommended limb tourniquet to control life threatening external
hemorrhage that is anatomically amenable to tourniquet use or for any traumatic amputation.
Apply directly to the skin 2-3 inches above the bleeding site. If bleeding is not controlled with the
first tourniquet, apply a second tourniquet side-by-side with the first.
b. For compressible (external) hemorrhage not amenable to limb tourniquet use or as an
adjunct to tourniquet removal, use Combat Gauze as the CoTCCC hemostatic dressing of choice.
● Alternative hemostatic adjuncts:
⁃ Celox Gauze or
⁃ ChitoGauze or
⁃ XStat (Best for deep, narrow-tract junctional wounds)
- iTClamp (may be used alone or in conjunction with hemostatic dressing or
XStat)
● Hemostatic dressings should be applied with at least 3 minutes of direct pressure
(optional for XStat). Each dressing works differently, so if one fails to control bleeding, it may be
removed and a fresh dressing of the same type or a different type applied. (Note: XStat is not to
be removed in the field, but additional XStat, other hemostatic adjuncts, or trauma dressings may
be applied over it.)
● If the bleeding site is amenable to use of a junctional tourniquet, immediately apply
a CoTCCC-recommended junctional tourniquet. Do not delay in the application of the
junctional tourniquet once it is ready for use. Apply hemostatic dressings with direct
pressure if a junctional tourniquet is not available or while the junctional tourniquet is being
readied for use.
c. For external hemorrhage of the head and neck where the wound edges can be easily
re-approximated, the iTClamp may be used as a primary option for hemorrhage control. Wounds
should be packed with a hemostatic dressing or XStat, if appropriate, prior to iTClamp application.
● The iTClamp does not require additional direct pressure, either when used alone or in
combination with other hemostatic adjuncts.
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● If the iTClamp is applied to the neck, perform frequent airway monitoring and evaluate for
an expanding hematoma that may compromise the airway. Consider placing a definitive airway if
there is evidence of an expanding hematoma.
● DO NOT APPLY on or near the eye or eyelid (within 1cm of the orbit).
4. Airway Management
a. Conscious casualty with no airway problem identified:
● No airway intervention required
b. Unconscious casualty without airway obstruction:
● Place casualty in the recovery position
● Chin lift or jaw thrust maneuver or
● Nasopharyngeal airway or
● Extraglottic airway
c. Casualty with airway obstruction or impending airway obstruction:
● Allow a conscious casualty to assume any position that best protects the
airway, to include sitting up
● Use a chin lift or jaw thrust maneuver
● Use suction if available and appropriate
● Extraglottic airway (if the casualty is unconscious)
● Place an unconscious casualty in the recovery position.
d. If the previous measures are unsuccessful, perform a surgical cricothyroidotomy
using one of the following:
● Cric-Key technique (preferred option)
● Bougie-aided open surgical technique using a flanged and cuffed airway
cannula of less than 10 mm outer diameter, 6-7 mm internal diameter, and 5-8 cm of
intratracheal length
● Standard open surgical technique using a flanged and cuffed airway
cannula of less than 10mm outer diameter, 6-7 mm internal diameter, and 5-8 cm of
intratracheal length (least desirable option)
● Use lidocaine if the casualty is conscious.
e. Cervical spine stabilization is not necessary for casualties who have sustained
only penetrating trauma.
f. Monitor the hemoglobin oxygen saturation in casualties to help assess airway
patency.
g. Always remember that the casualty’s airway status may change over time and
requires frequent reassessment.
Notes:
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* The i-gel is the preferred extraglottic airway because its gel-filled cuff makes it simpler to
use and avoids the need for cuff inflation and monitoring. If an extraglottic airway with an air-filled
cuff is used, the cuff pressure must be monitored to avoid overpressurization, especially during
TACEVAC on an aircraft with the accompanying pressure changes.
* Extraglottic airways will not be tolerated by a casualty who is not deeply unconscious. If
an unconscious casualty without direct airway trauma needs an airway intervention, but does not
tolerate an extraglottic airway, consider the use of a nasopharyngeal airway.
* For casualties with trauma to the face and mouth, or facial burns with suspected
inhalation injury, nasopharyngeal airways and extraglottic airways may not suffice and a surgical
cricothyroidotomy may be required.
* Surgical cricothyroidotomies should not be performed on unconscious casualties who
have no direct airway trauma unless use of a nasopharyngeal airway and/or an extraglottic airway
have been unsuccessful in opening the airway.
5. Respiration/Breathing
a. Assess for tension pneumothorax and treat as necessary.
● Suspect a tension pneumothorax and treat when a casualty has significant torso
trauma or primary blast injury and one or more of the following: ⁃ Severe or progressive
respiratory distress
⁃ Severe or progressive tachypnea
⁃ Absent or markedly decreased breath sounds on one side of the chest
⁃ Hemoglobin oxygen saturation < 90% on pulse oximetry
⁃ Shock
⁃ Traumatic cardiac arrest without obviously fatal wounds
Note:
* If not treated promptly, tension pneumothorax may progress from respiratory distress to
shock and traumatic cardiac arrest.
● Initial treatment of suspected tension pneumothorax:

⁃ If the casualty has a chest seal in place, burp or remove the chest seal. ⁃ Establish
pulse oximetry monitoring.
⁃ Place the casualty in the supine or recovery position unless he or she is conscious
and needs to sit up to help keep the airway clear as a result of maxillofacial trauma.
⁃ Decompress the chest on the side of the injury with a 14-gauge or a 10- gauge,
3.25-inch needle/catheter unit.
⁃ If a casualty has significant torso trauma or primary blast injury and is in traumatic
cardiac arrest (no pulse, no respirations, no response to painful stimuli, no other signs of
life), decompress both sides of the chest before discontinuing treatment.
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Notes:
* Either the 5th intercostal space (ICS) in the anterior axillary line (AAL) or the 2nd ICS in
the mid-clavicular line (MCL) may be used for needle decompression (NDC.) If the anterior (MCL)
site is used, do not insert the needle medial to the nipple line.
* The needle/catheter unit should be inserted at an angle perpendicular to the chest wall
and just over the top of the lower rib at the insertion site. Insert the needle/catheter unit all the way
to the hub and hold it in place for 5-10 seconds to allow decompression to occur.
* After the NDC has been performed, remove the needle and leave the catheter in place.
● The NDC should be considered successful if:

⁃ Respiratory distress improves, or
⁃ There is an obvious hissing sound as air escapes from the chest when NDC is
performed (this may be difficult to appreciate in high-noise environments), or
⁃ Hemoglobin oxygen saturation increases to 90% or greater (note that this may
take several minutes and may not happen at altitude), or
⁃ A casualty with no vital signs has return of consciousness and/or ` radial pulse.
● If the initial NDC fails to improve the casualty’s signs/symptoms from the suspected
tension pneumothorax:
⁃ Perform a second NDC on the same side of the chest at whichever of the two
recommended sites was not previously used. Use a new needle/catheter unit for the
second attempt.
⁃ Consider, based on the mechanism of injury and physical findings, whether
decompression of the opposite side of the chest may be needed.
● If the initial NDC was successful, but symptoms later recur:
⁃ Perform another NDC at the same site that was used previously. Use a new
needle/catheter unit for the repeat NDC.
⁃ Continue to re-assess!
● If the second NDC is also not successful:
⁃ Continue on to the Circulation section of the TCCC Guidelines.
b. All open and/or sucking chest wounds should be treated by immediately applying a
vented chest seal to cover the defect. If a vented chest seal is not available, use a non-vented
chest seal. Monitor the casualty for the potential development of a subsequent tension
pneumothorax. If the casualty develops increasing hypoxia, respiratory distress, or hypotension
and a tension pneumothorax is suspected, treat by burping or removing the dressing or by needle
decompression.
c. Initiate pulse oximetry. All individuals with moderate/severe TBI should be monitored with
pulse oximetry. Readings may be misleading in the settings of shock or marked hypothermia.
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d. Casualties with moderate/severe TBI should be given supplemental oxygen when
available to maintain an oxygen saturation > 90%.
6. Circulation
a. Bleeding
● A pelvic binder should be applied for cases of suspected pelvic fracture:
⁃ Severe blunt force or blast injury with one or more of the following
indications:
◦ Pelvic pain
◦ Any major lower limb amputation or near amputation
◦ Physical exam findings suggestive of a pelvic fracture
◦ Unconsciousness
◦ Shock
● Reassess prior tourniquet application. Expose the wound and determine if a
tourniquet is needed. If it is needed, replace any limb tourniquet placed over the uniform
with one applied directly to the skin 2-3 inches above the bleeding site. Ensure that
bleeding is stopped. If there is no traumatic amputation, a distal pulse should be checked. If
bleeding persists or a distal pulse is still present, consider additional tightening of the
tourniquet or the use of a second tourniquet side-by-side with the first to eliminate both
bleeding and the distal pulse. If the reassessment determines that the prior tourniquet was
not needed, then remove the tourniquet and note time of removal on the TCCC Casualty
Card.
● Limb tourniquets and junctional tourniquets should be converted to hemostatic or
pressure dressings as soon as possible if three criteria are met: the casualty is not in
shock; it is possible to monitor the wound closely for bleeding; and the tourniquet is not
being used to control bleeding from an amputated extremity. Every effort should be made
to convert tourniquets in less than 2 hours if bleeding can be controlled with other means.
Do not remove a tourniquet that has been in place more than 6 hours unless close
monitoring and lab capability are available.
● Expose and clearly mark all tourniquets with the time of tourniquet
application. Note tourniquets applied and time of application; time of re-application; time of
conversion; and time of removal on the TCCC Casualty Card. Use a permanent marker to
mark on the tourniquet and the casualty card.
b. IV Access
● Intravenous (IV) or intraosseous (IO) access is indicated if the casualty is in
hemorrhagic shock or at significant risk of shock (and may therefore need fluid
resuscitation), or if the casualty needs medications, but cannot take them by mouth.
⁃ An 18-gauge IV or saline lock is preferred.
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⁃ If vascular access is needed but not quickly obtainable via the IV route, use
the IO route.
c. Tranexamic Acid (TXA)
● If a casualty is anticipated to need significant blood transfusion (for example:
presents with hemorrhagic shock, one or more major amputations, penetrating torso
trauma, or evidence of severe bleeding):
⁃ Administer 2 gm of tranexamic acid in 100 ml Normal Saline or Lactated
Ringer’s as soon as possible but NOT later than 3 hours after injury. When given,
TXA should be administered over 10 minutes by IV infusion.
d. Fluid resuscitation
● Assess for hemorrhagic shock (altered mental status in the absence of brain injury
and/or weak or absent radial pulse).
● The resuscitation fluids of choice for casualties in hemorrhagic shock, listed from
most to least preferred, are: whole blood*; plasma, red blood cells (RBCs) and platelets in a
1:1:1 ratio*; plasma and RBCs in a 1:1 ratio; plasma or RBCs alone; Hextend; and
crystalloid (Lactated Ringer’s or Plasma-Lyte A). (NOTE: Hypothermia prevention
measures [Section 7] should be initiated while fluid resuscitation is being accomplished.)
⁃ If not in shock:
◦ No IV fluids are immediately necessary.
◦ Fluids by mouth are permissible if the casualty is conscious and can
swallow.
⁃ If in shock and blood products are available under an approved command
or theater blood product administration protocol:
◦ Resuscitate with whole blood*, or, if not available
◦ Plasma, RBCs and platelets in a 1:1:1 ratio*, or, if not available
◦ Plasma and RBCs in a 1:1 ratio, or, if not available
◦ Reconstituted dried plasma, liquid plasma or thawed plasma alone or
RBCs alone
◦ Reassess the casualty after each unit. Continue resuscitation until a
palpable radial pulse, improved mental status or systolic BP of 80-90 is
present.
⁃ If in shock and blood products are not available under an approved
command or theater blood product administration protocol due to tactical or logistical
constraints:
◦ Resuscitate with Hextend, or if not available
◦ Lactated Ringer’s or Plasma-Lyte A
◦ Reassess the casualty after each 500 ml IV bolus.
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◦ Continue resuscitation until a palpable radial pulse, improved mental
status, or systolic BP of 80-90 mmHg is present.
◦ Discontinue fluid administration when one or more of the above end
points has been achieved.
● If a casualty with an altered mental status due to suspected TBI has a weak or
absent radial pulse, resuscitate as necessary to restore and maintain a normal radial pulse.
If BP monitoring is available, maintain a target systolic BP of at least 90 mmHg.
● Reassess the casualty frequently to check for recurrence of shock. If shock recurs,
re-check all external hemorrhage control measures to ensure that they are still effective
and repeat the fluid resuscitation as outlined above.
Note:
* Currently, neither whole blood nor apheresis platelets collected in theater are
FDA-compliant because of the way they are collected. Consequently, whole blood and 1:1:1
resuscitation using apheresis platelets should be used only if all of the FDAcompliant blood
products needed to support 1:1:1 resuscitation are not available, or if 1:1:1 resuscitation is not
producing the desired clinical effect.
e. Refractory Shock
● If a casualty in shock is not responding to fluid resuscitation, consider untreated
tension pneumothorax as a possible cause of refractory shock. Thoracic trauma, persistent
respiratory distress, absent breath sounds, and hemoglobin oxygen saturation < 90%
support this diagnosis. Treat as indicated with repeated NDC or finger thoracostomy/chest
tube insertion at the 5th ICS in the AAL, according to the skills, experience, and
authorizations of the treating medical provider. Note that if finger thoracostomy is used, it
may not remain patent and finger decompression through the incision may have to be
repeated. Consider decompressing the opposite side of the chest if indicated based on the
mechanism of injury and physical findings.
7. Hypothermia Prevention
a. Minimize casualty’s exposure to the elements. Keep protective gear on or with the
casualty if feasible.
b. Replace wet clothing with dry if possible. Get the casualty onto an insulated surface as
soon as possible.
c. Apply the Ready-Heat Blanket from Hypothermia Prevention and Management Kit
(HPMK) to the casualty’s torso (not directly on the skin) and cover the casualty with the
Heat-Reflective Shell (HRS).
d. If an HRS is not available, the previously recommended combination of the Blizzard
Survival Blanket and the Ready Heat blanket may also be used.
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e. If the items mentioned above are not available, use dry blankets, poncho liners, sleeping
bags, or anything that will retain heat and keep the casualty dry.
f. Warm fluids are preferred if IV fluids are required.
8. Penetrating Eye Trauma

a. If a penetrating eye injury is noted or suspected:
● Perform a rapid field test of visual acuity and document findings.
● Cover the eye with a rigid eye shield (NOT a pressure patch.)
● Ensure that the 400 mg moxifloxacin tablet in the Combat Wound Medication Pack
(CWMP) is taken if possible and that IV/IM antibiotics are given as outlined below if oral
moxifloxacin cannot be taken.
9. Monitoring a. Initiate advanced electronic monitoring if indicated and if monitoring equipment is

available.
10. Analgesia a. Analgesia on the battlefield should generally be achieved using one of three
options:
● Option 1
⁃ Mild to Moderate Pain
- Casualty is still able to fight
◦ TCCC Combat Wound Medication Pack (CWMP)
* Tylenol – 650 mg bilayer caplet, 2 PO every 8 hours
* Meloxicam - 15 mg PO once a day
● Option 2
⁃ Moderate to Severe Pain
- Casualty IS NOT in shock or respiratory distress AND
- Casualty IS NOT at significant risk of developing either condition
◦ Oral transmucosal fentanyl citrate (OTFC) 800 µg
* Place lozenge between the cheek and the gum
* Do not chew the lozenge
● Option 3
- Casualty IS in hemorrhagic shock or respiratory distress OR
- Casualty IS at significant risk of developing either condition
◦ Ketamine 50 mg IM or IN Or
◦ Ketamine 20 mg slow IV or IO
* Repeat doses q30min prn for IM or IN
* Repeat doses q20min prn for IV or IO
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* End points: Control of pain or development of nystagmus (rhythmic
back-and-forth movement of the eyes)
Analgesia notes:
a. Casualties may need to be disarmed after being given OTFC or ketamine.
b. Document a mental status exam using the AVPU method prior to administering opioids
or ketamine.
c. For all casualties given opioids or ketamine – monitor airway, breathing, and circulation
closely
d. Directions for administering OTFC:
● Recommend taping lozenge-on-a-stick to casualty’s finger as an added safety
measure OR utilizing a safety pin and rubber band to attach the lozenge (under tension) to
the patient’s uniform or plate carrier.
● Reassess in 15 minutes
● Add second lozenge, in other cheek, as necessary to control severe pain
● Monitor for respiratory depression
e. IV Morphine is an alternative to OTFC if IV access has been obtained
● 5 mg IV/IO
● Reassess in 10 minutes.
● Repeat dose every 10 minutes as necessary to control severe pain.
● Monitor for respiratory depression.
f. Naloxone (0.4 mg IV or IM) should be available when using opioid analgesics. g. Both
ketamine and OTFC have the potential to worsen severe TBI. The combat medic,
corpsman, or PJ must consider this fact in his or her analgesic decision, but if the casualty
is able to complain of pain, then the TBI is likely not severe enough to preclude the use of
ketamine or OTFC.
h. Eye injury does not preclude the use of ketamine. The risk of additional damage to the
eye from using ketamine is low and maximizing the casualty’s chance for survival takes
precedence if the casualty is in shock or respiratory distress or at significant risk for either.
i. Ketamine may be a useful adjunct to reduce the amount of opioids required to provide
effective pain relief. It is safe to give ketamine to a casualty who has previously received
morphine or OTFC. IV Ketamine should be given over 1 minute. j. If respirations are noted
to be reduced after using opioids or ketamine, provide ventilatory support with a
bag-valve-mask or mouth-to-mask ventilations. k. Ondansetron, 4 mg Orally Dissolving
Tablet (ODT)/IV/IO/IM, every 8 hours as needed for nausea or vomiting. Each 8-hour dose
can be repeated once at 15 minutes if nausea and vomiting are not improved. Do not give
more than 8 mg in any 8-hour interval. Oral ondansetron is NOT an acceptable alternative
to the ODT formulation.
l. Reassess – reassess – reassess!
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11. Antibiotics: recommended for all open combat wounds
a. If able to take PO meds:
⁃ Moxifloxacin (from the CWMP), 400 mg PO once a day
b. If unable to take PO meds (shock, unconsciousness):
⁃ Ertapenem, 1 gm IV/IM once a day
12. Inspect and dress known wounds.
13. Check for additional wounds.
14. 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.
c. Cover the burn area with dry, sterile dressings. For extensive burns (>20%), consider
placing the casualty in the Heat-Reflective Shell or Blizzard Survival Blanket from the Hypothermia
Prevention Kit in order to both cover the burned areas and prevent hypothermia.
d. Fluid resuscitation (USAISR Rule of Ten)
● If burns are greater than 20% of TBSA, fluid resuscitation should be initiated as
soon as IV/IO access is established. Resuscitation should be initiated with Lactated
Ringer’s, normal saline, or Hextend. If Hextend is used, no more than 1000 ml should be
given, followed by Lactated Ringer’s or normal saline as needed.
● Initial IV/IO fluid rate is calculated as %TBSA x 10 ml/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).
e. Analgesia in accordance with the TCCC Guidelines in Section (10) may be administered
to treat burn pain.
f. Prehospital antibiotic therapy is not indicated solely for burns, but antibiotics should be
given per the TCCC guidelines in Section (11) if indicated to prevent infection in penetrating
wounds.
g. All TCCC interventions can be performed on or through burned skin in a burn casualty.
h. Burn patients are particularly susceptible to hypothermia. Extra emphasis should be
placed on barrier heat loss prevention methods.
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15. Splint fractures and re-check pulses.
16. Communication
a. Communicate with the casualty if possible. Encourage, reassure and explain care.
b. Communicate with tactical leadership as soon as possible and throughout casualty
treatment as needed. Provide leadership with casualty status and evacuation requirements to
assist with coordination of evacuation assets.
c. Communicate with the evacuation system (the Patient Evacuation Coordination Cell) to
arrange for TACEVAC. Communicate with medical providers on the evacuation asset if possible
and relay mechanism of injury, injuries sustained, signs/symptoms, and treatments rendered.
Provide additional information as appropriate.
17. Cardiopulmonary resuscitation (CPR)

a. 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. However, casualties with torso trauma or polytrauma who have no pulse or
respirations during TFC should have bilateral needle decompression performed to ensure they do
not have a tension pneumothorax prior to discontinuation of care. The procedure is the same as
described in section (5a) above.
18. Documentation of Care

a. Document clinical assessments, treatments rendered, and changes in the casualty’s
status on a TCCC Card (DD Form 1380). Forward this information with the casualty to the next
level of care.
19. Prepare for Evacuation.

a. Complete and secure the TCCC Card (DD 1380) to the casualty.
b. Secure all loose ends of bandages and wraps.
c. Secure hypothermia prevention wraps/blankets/straps.
d. Secure litter straps as required. Consider additional padding for long evacuations.
e. Provide instructions to ambulatory patients as needed.
f. Stage casualties for evacuation in accordance with unit standard operating procedures.
g. Maintain security at the evacuation point in accordance with unit standard operating
procedures.
20
Basic Management Plan for Tactical Evacuation Care
* The term “Tactical Evacuation” includes both Casualty Evacuation (CASEVAC) and Medical
Evacuation (MEDEVAC) as defined in Joint Publication 4-02.
1. Transition of Care
a. Tactical force personnel should establish evacuation point security and stage casualties
for evacuation.
b. Tactical force personnel or the medic should communicate patient information and status
to TACEVAC personnel as clearly as possible. The minimum information communicated should
include stable or unstable, injuries identified, and treatments rendered.
c. TACEVAC personnel should stage casualties on evacuation platforms as required.
d. Secure casualties in the evacuation platform in accordance with unit policies, platform
configurations and safety requirements.
e. TACEVAC medical personnel should re-assess casualties and re-evaluate all injuries
and previous interventions.
2. Massive Hemorrhage
a. Assess for unrecognized hemorrhage and control all sources of bleeding. If not already
done, use a CoTCCC-recommended limb tourniquet to control life-threatening external
hemorrhage that is anatomically amenable to tourniquet use or for any traumatic amputation.
Apply directly to the skin 2-3 inches above the bleeding site. If bleeding is not controlled with the
first tourniquet, apply a second tourniquet side-by-side with the first.
b. For compressible (external) hemorrhage not amenable to limb tourniquet use or as an
adjunct to tourniquet removal, use Combat Gauze as the CoTCCC hemostatic dressing of choice.
● Alternative hemostatic adjuncts:
⁃ Celox Gauze or
⁃ ChitoGauze or
⁃ XStat (Best for deep, narrow-tract junctional wounds)
- iTClamp (may be used alone or in conjunction with hemostatic dressing or
XStat)
● Hemostatic dressings should be applied with at least 3 minutes of direct pressure
(optional for XStat). Each dressing works differently, so if one fails to control bleeding, it
may be removed and a fresh dressing of the same type or a different type applied. (Note:
XStat is not to be removed in the field, but additional XStat, other hemostatic adjuncts, or
trauma dressings may be applied over it.)
● If the bleeding site is amenable to use of a junctional tourniquet, immediately apply
a CoTCCC-recommended junctional tourniquet. Do not delay in the application of the
21
junctional tourniquet once it is ready for use. Apply hemostatic dressings with direct
pressure if a junctional tourniquet is not available or while the junctional tourniquet is being
readied for use.
c. For external hemorrhage of the head and neck where the wound edges can be easily
re-approximated, the iTClamp may be used as a primary option for hemorrhage control. Wounds
should be packed with a hemostatic dressing or XStat, if appropriate, prior to iTClamp application.
● The iTClamp does not require additional direct pressure, either when used alone or in
combination with other hemostatic adjuncts. ● If the iTClamp is applied to the neck, perform
frequent airway monitoring and evaluate for an expanding hematoma that may compromise the
airway. Consider placing a definitive airway if there is evidence of an expanding hematoma.
● DO NOT APPLY on or near the eye or eyelid (within 1cm of the orbit).
3. Airway Management
a. Conscious casualty with no airway problem identified:
● No airway intervention required
b. Unconscious casualty without airway obstruction:
● Place casualty in the recovery position
● Chin lift or jaw thrust maneuver or
● Extraglottic airway
c. Casualty with airway obstruction or impending airway obstruction:
● Allow a conscious casualty to assume any position that best protects the
airway, to include sitting up
● Use a chin lift or jaw thrust maneuver
● Use suction if available and appropriate
● Extraglottic airway (if the casualty is unconscious)
● Place an unconscious casualty in the recovery position.
d. If the previous measures are unsuccessful, assess the tactical and clinical
situations, the equipment at hand, and the skills and experience of the person
providing care, and then select one of the following airway interventions:
● Endotracheal Intubation or
● Perform a surgical cricothyroidotomy using one of the following:
- Cric-Key technique (preferred option)
- Bougie-aided open surgical technique using a flanged and cuffed airway
cannula of less than 10 mm outer diameter, 6-7 mm internal diameter, and 5-8 cm of
intratracheal length
22
-Standard open surgical technique using a flanged and cuffed airway cannula
of less than 10mm outer diameter, 6-7 mm internal diameter, and 5-8 cm of
intratracheal length (least desirable option)
-Use lidocaine if the casualty is conscious.
e. Cervical spine stabilization is not necessary for casualties who have sustained
only penetrating trauma.
f. Monitor the hemoglobin oxygen saturation in casualties to help assess airway
patency.
g. Always remember that the casualty’s airway status may change over time and
requires frequent reassessment.
Notes:
* The i-gel is the preferred extraglottic airway because its gel-filled cuff makes it simpler to
use and avoids the need for cuff inflation and monitoring. If an extraglottic airway with an air-filled
cuff is used, the cuff pressure must be monitored to avoid overpressurization, especially during
TACEVAC on an aircraft with the accompanying pressure changes.
* Extraglottic airways will not be tolerated by a casualty who is not deeply unconscious. If
an unconscious casualty without direct airway trauma needs an airway intervention, but does not
tolerate an extraglottic airway, consider the use of a nasopharyngeal airway.
* For casualties with trauma to the face and mouth, or facial burns with suspected
inhalation injury, nasopharyngeal airways and extraglottic airways may not suffice and a surgical
cricothyroidotomy may be required.
* Surgical cricothyroidotomies should not be performed on unconscious casualties who
have no direct airway trauma unless use of a nasopharyngeal airway and/or an extraglottic airway
have been unsuccessful in opening the airway.
4. Respiration/Breathing
a. Assess for tension pneumothorax and treat as necessary.
● Suspect a tension pneumothorax and treat when a casualty has significant torso
trauma or primary blast injury and one or more of the following: ⁃ Severe or progressive
⁃ Severe or progressive tachypnea
⁃ Absent or markedly decreased breath sounds on one side of the chest
⁃ Hemoglobin oxygen saturation < 90% on pulse oximetry
⁃ Shock
⁃ Traumatic cardiac arrest without obviously fatal wounds
Note:
* If not treated promptly, tension pneumothorax may progress from respiratory distress to
shock and traumatic cardiac arrest.
23
● Initial treatment of suspected tension pneumothorax:
⁃ If the casualty has a chest seal in place, burp or remove the chest seal. ⁃ Establish
pulse oximetry monitoring.
⁃ Place the casualty in the supine or recovery position unless he or she is conscious
and needs to sit up to help keep the airway clear as a result of maxillofacial trauma.
⁃ Decompress the chest on the side of the injury with a 14-gauge or a 10- gauge,
3.25-inch needle/catheter unit.
⁃ If a casualty has significant torso trauma or primary blast injury and is in traumatic
cardiac arrest (no pulse, no respirations, no response to painful stimuli, no other signs of
life), decompress both sides of the chest before discontinuing treatment.
Notes:
* Either the 5th intercostal space (ICS) in the anterior axillary line (AAL) or the 2nd ICS in
the mid-clavicular line (MCL) may be used for needle decompression (NDC.) If the anterior (MCL)
site is used, do not insert the needle medial to the nipple line.
* The needle/catheter unit should be inserted at an angle perpendicular to the chest wall
and just over the top of the lower rib at the insertion site. Insert the needle/catheter unit all the way
to the hub and hold it in place for 5-10 seconds to allow decompression to occur.
* After the NDC has been performed, remove the needle and leave the catheter in place.
● The NDC should be considered successful if:

⁃ Respiratory distress improves, or
⁃ There is an obvious hissing sound as air escapes from the chest when NDC is
performed (this may be difficult to appreciate in high-noise environments), or
⁃ Hemoglobin oxygen saturation increases to 90% or greater (note that this may
take several minutes and may not happen at altitude), or
⁃ A casualty with no vital signs has return of consciousness and/or ` radial pulse.
● If the initial NDC fails to improve the casualty’s signs/symptoms from the suspected
tension pneumothorax:
⁃ Perform a second NDC on the same side of the chest at whichever of the two
recommended sites was not previously used. Use a new needle/catheter unit for the
second attempt.
⁃ Consider, based on the mechanism of injury and physical findings, whether
decompression of the opposite side of the chest may be needed.
● If the initial NDC was successful, but symptoms later recur:
⁃ Perform another NDC at the same site that was used previously. Use a new
needle/catheter unit for the repeat NDC.
⁃ Continue to re-assess!
24
● If the second NDC is also not successful:
⁃ Continue on to the Circulation section of the TCCC Guidelines.
b. Initiate pulse oximetry if not previously done. All individuals with moderate/severe TBI
should be monitored with pulse oximetry. Readings may be misleading in the settings of shock or
marked hypothermia.
c. Most combat casualties do not require supplemental oxygen, but administration of
oxygen may be of benefit for the following types of casualties:
● Low oxygen saturation by pulse oximetry
● Injuries associated with impaired oxygenation
● Unconscious casualty ● Casualty with TBI (maintain oxygen saturation > 90%)
● Casualty in shock
● Casualty at altitude
● Known or suspected smoke inhalation
d. All open and/or sucking chest wounds should be treated by immediately applying a
vented chest seal to cover the defect. If a vented chest seal is not available, use a non-vented
chest seal. Monitor the casualty for the potential development of a subsequent tension
pneumothorax. If the casualty develops increasing hypoxia, respiratory distress, or hypotension
and a tension pneumothorax is suspected, treat by burping or removing the dressing or by needle
decompression.
e. Initiate pulse oximetry. All individuals with moderate/severe TBI should be monitored with
pulse oximetry. Readings may be misleading in the settings of shock or marked hypothermia.
f. Casualties with moderate/severe TBI should be given supplemental oxygen when
available to maintain an oxygen saturation > 90%.
5. Circulation
a. Bleeding
● A pelvic binder should be applied for cases of suspected pelvic fracture:
⁃ Severe blunt force or blast injury with one or more of the following
indications:
◦ Pelvic pain
◦ Any major lower limb amputation or near amputation
◦ Physical exam findings suggestive of a pelvic fracture
◦ Unconsciousness
◦ Shock
● Reassess prior tourniquet application. Expose the wound and determine if a
tourniquet is needed. If it is needed, replace any limb tourniquet placed over the uniform
with one applied directly to the skin 2-3 inches above the bleeding site. Ensure that
bleeding is stopped. If there is no traumatic amputation, a distal pulse should be checked. If
25
bleeding persists or a distal pulse is still present, consider additional tightening of the
tourniquet or the use of a second tourniquet side-by-side with the first to eliminate both
bleeding and the distal pulse. If the reassessment determines that the prior tourniquet was
not needed, then remove the tourniquet and note time of removal on the TCCC Casualty
Card.
● Limb tourniquets and junctional tourniquets should be converted to hemostatic or
pressure dressings as soon as possible if three criteria are met: the casualty is not in
shock; it is possible to monitor the wound closely for bleeding; and the tourniquet is not
being used to control bleeding from an amputated extremity. Every effort should be made
to convert tourniquets in less than 2 hours if bleeding can be controlled with other means.
Do not remove a tourniquet that has been in place more than 6 hours unless close
monitoring and lab capability are available.
● Expose and clearly mark all tourniquets with the time of tourniquet
application. Note tourniquets applied and time of application; time of re-application; time of
conversion; and time of removal on the TCCC Casualty Card. Use a permanent marker to
mark on the tourniquet and the casualty card.
b. IV Access
● Intravenous (IV) or intraosseous (IO) access is indicated if the casualty is in
hemorrhagic shock or at significant risk of shock (and may therefore need fluid
resuscitation), or if the casualty needs medications, but cannot take them by mouth.
⁃ An 18-gauge IV or saline lock is preferred.
⁃ If vascular access is needed but not quickly obtainable via the IV route, use
the IO route.
c. Tranexamic Acid (TXA)
● If a casualty is anticipated to need significant blood transfusion (for example:
presents with hemorrhagic shock, one or more major amputations, penetrating torso
trauma, or evidence of severe bleeding):
⁃ Administer 2 gm of tranexamic acid in 100 ml Normal Saline or Lactated
Ringer’s as soon as possible but NOT later than 3 hours after injury. When given,
TXA should be administered over 10 minutes by IV infusion.
d. Fluid resuscitation
● Assess for hemorrhagic shock (altered mental status in the absence of brain injury
and/or weak or absent radial pulse).
● The resuscitation fluids of choice for casualties in hemorrhagic shock, listed from
most to least preferred, are: whole blood*; plasma, red blood cells (RBCs) and platelets in a
1:1:1 ratio*; plasma and RBCs in a 1:1 ratio; plasma or RBCs alone; Hextend; and
crystalloid (Lactated Ringer’s or Plasma-Lyte A). (NOTE: Hypothermia prevention
measures [Section 7] should be initiated while fluid resuscitation is being accomplished.)
26
⁃ If not in shock:
◦ No IV fluids are immediately necessary.
◦ Fluids by mouth are permissible if the casualty is conscious and can
swallow.
⁃ If in shock and blood products are available under an approved command
or theater blood product administration protocol:
◦ Resuscitate with whole blood*, or, if not available
◦ Plasma, RBCs and platelets in a 1:1:1 ratio*, or, if not available
◦ Plasma and RBCs in a 1:1 ratio, or, if not available
◦ Reconstituted dried plasma, liquid plasma or thawed plasma alone or
RBCs alone
◦ Reassess the casualty after each unit. Continue resuscitation until a
palpable radial pulse, improved mental status or systolic BP of 80-90 is
present.
⁃ If in shock and blood products are not available under an approved
command or theater blood product administration protocol due to tactical or logistical
constraints:
◦ Resuscitate with Hextend, or if not available
◦ Lactated Ringer’s or Plasma-Lyte A
◦ Reassess the casualty after each 500 ml IV bolus.
◦ Continue resuscitation until a palpable radial pulse, improved mental
status, or systolic BP of 80-90 mmHg is present.
◦ Discontinue fluid administration when one or more of the above end
points has been achieved.
● If a casualty with an altered mental status due to suspected TBI has a weak or
absent radial pulse, resuscitate as necessary to restore and maintain a normal radial pulse.
If BP monitoring is available, maintain a target systolic BP of at least 90 mmHg.
● Reassess the casualty frequently to check for recurrence of shock. If shock recurs,
re-check all external hemorrhage control measures to ensure that they are still effective
and repeat the fluid resuscitation as outlined above.
Note:
* Currently, neither whole blood nor apheresis platelets collected in theater are
FDA-compliant because of the way they are collected. Consequently, whole blood and 1:1:1
resuscitation using apheresis platelets should be used only if all of the FDAcompliant blood
products needed to support 1:1:1 resuscitation are not available, or if 1:1:1 resuscitation is not
producing the desired clinical effect.
e. Refractory Shock
27
● If a casualty in shock is not responding to fluid resuscitation, consider untreated
tension pneumothorax as a possible cause of refractory shock. Thoracic trauma, persistent
respiratory distress, absent breath sounds, and hemoglobin oxygen saturation < 90%
support this diagnosis. Treat as indicated with repeated NDC or finger thoracostomy/chest
tube insertion at the 5th ICS in the AAL, according to the skills, experience, and
authorizations of the treating medical provider. Note that if finger thoracostomy is used, it
may not remain patent and finger decompression through the incision may have to be
repeated. Consider decompressing the opposite side of the chest if indicated based on the
mechanism of injury and physical findings.
6. Traumatic Brain Injury

a. Casualties with moderate/severe TBI should be monitored for:
● Decreases in level of consciousness
● Pupillary dilation
● SBP should be >90 mmHg ● O2 sat > 90
● Hypothermia
● End-tidal CO2 (If capnography is available, maintain between 35-40 mmHg)
● Penetrating head trauma (if present, administer antibiotics)
● Assume a spinal (neck) injury until cleared.
b. Unilateral pupillary dilation accompanied by a decreased level of consciousness may

signify impending cerebral herniation; if these signs occur, take the following actions to
decrease intracranial pressure:
● Administer 250 ml of 3 or 5% hypertonic saline bolus.
● Elevate the casualty’s head 30 degrees.
● Hyperventilate the casualty.
⁃ Respiratory rate 20
⁃ Capnography should be used to maintain the end-tidal CO2 between 30-35
mmHg
⁃ The highest oxygen concentration (FIO2) possible should be used for
hyperventilation.
*Note: Do not hyperventilate the casualty unless signs of impending herniation are present.
Casualties may be hyperventilated with oxygen using the bag-valve-mask technique.
7. Hypothermia Prevention
a. Minimize casualty’s exposure to the elements. Keep protective gear on or with the
casualty if feasible.
28
b. Replace wet clothing with dry if possible. Get the casualty onto an insulated surface as
soon as possible.
c. Apply the Ready-Heat Blanket from the Hypothermia Prevention and Management Kit
(HPMK) to the casualty’s torso (not directly on the skin) and cover the casualty with the
Heat-Reflective Shell (HRS).
d. If an HRS is not available, the previously recommended combination of the Blizzard
Survival Blanket and the Ready Heat blanket may also be used.
e. If the items mentioned above are not available, use dry blankets, poncho liners, sleeping
bags, or anything that will retain heat and keep the casualty dry.
f. Use a portable fluid warmer capable of warming all IV fluids including blood products.
g. Protect the casualty from wind if doors must be kept open
8. Penetrating Eye Trauma

a. If a penetrating eye injury is noted or suspected:
● Perform a rapid field test of visual acuity and document findings.
● Cover the eye with a rigid eye shield (NOT a pressure patch.)
● Ensure that the 400 mg moxifloxacin tablet in the Combat Wound Medication Pack
(CWMP) is taken if possible and that IV/IM antibiotics are given as outlined below if oral
moxifloxacin cannot be taken.
9. Monitoring a. Initiate advanced electronic monitoring if indicated and if monitoring equipment is

available.
10. Analgesia a. Analgesia on the battlefield should generally be achieved using one of three
options:
● Option 1
⁃ Mild to Moderate Pain
- Casualty is still able to fight
◦ TCCC Combat Wound Medication Pack (CWMP)
* Tylenol – 650 mg bilayer caplet, 2 PO every 8 hours
* Meloxicam - 15 mg PO once a day
● Option 2
- Casualty IS NOT in shock or respiratory distress AND
- Casualty IS NOT at significant risk of developing either condition
◦ Oral transmucosal fentanyl citrate (OTFC) 800 µg
* Place lozenge between the cheek and the gum
* Do not chew the lozenge
● Option 3
29
- Casualty IS in hemorrhagic shock or respiratory distress OR
- Casualty IS at significant risk of developing either condition
◦ Ketamine 50 mg IM or IN Or
◦ Ketamine 20 mg slow IV or IO
* Repeat doses q30min prn for IM or IN
* Repeat doses q20min prn for IV or IO
* End points: Control of pain or development of nystagmus (rhythmic
back-and-forth movement of the eyes)
Analgesia notes:
a. Casualties may need to be disarmed after being given OTFC or ketamine.
b. Document a mental status exam using the AVPU method prior to administering opioids
or ketamine.
c. For all casualties given opioids or ketamine – monitor airway, breathing, and circulation
closely
d. Directions for administering OTFC:
● Recommend taping lozenge-on-a-stick to casualty’s finger as an added safety
measure OR utilizing a safety pin and rubber band to attach the lozenge (under tension) to
the patient’s uniform or plate carrier.
● Reassess in 15 minutes
● Add second lozenge, in other cheek, as necessary to control severe pain
● Monitor for respiratory depression
e. IV Morphine is an alternative to OTFC if IV access has been obtained
● 5 mg IV/IO
● Reassess in 10 minutes.
● Repeat dose every 10 minutes as necessary to control severe pain.
● Monitor for respiratory depression.
f. Naloxone (0.4 mg IV or IM) should be available when using opioid analgesics. g. Both
ketamine and OTFC have the potential to worsen severe TBI. The combat medic,
corpsman, or PJ must consider this fact in his or her analgesic decision, but if the casualty
is able to complain of pain, then the TBI is likely not severe enough to preclude the use of
ketamine or OTFC.
h. Eye injury does not preclude the use of ketamine. The risk of additional damage to the
eye from using ketamine is low and maximizing the casualty’s chance for survival takes
precedence if the casualty is in shock or respiratory distress or at significant risk for either.
i. Ketamine may be a useful adjunct to reduce the amount of opioids required to provide
effective pain relief. It is safe to give ketamine to a casualty who has previously received
morphine or OTFC. IV Ketamine should be given over 1 minute. j. If respirations are noted
30
to be reduced after using opioids or ketamine, provide ventilatory support with a
bag-valve-mask or mouth-to-mask ventilations. k. Ondansetron, 4 mg Orally Dissolving
Tablet (ODT)/IV/IO/IM, every 8 hours as needed for nausea or vomiting. Each 8-hour dose
can be repeated once at 15 minutes if nausea and vomiting are not improved. Do not give
more than 8 mg in any 8-hour interval. Oral ondansetron is NOT an acceptable alternative
to the ODT formulation.
l. Reassess – reassess – reassess!
11. Antibiotics: recommended for all open combat wounds

a. If able to take PO meds:
⁃ Moxifloxacin (from the CWMP), 400 mg PO once a day
b. If unable to take PO meds (shock, unconsciousness):
⁃ Ertapenem, 1 gm IV/IM once a day
12. Inspect and dress known wounds.
13. Check for additional wounds.
14. 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.
c. Cover the burn area with dry, sterile dressings. For extensive burns (>20%), consider
placing the casualty in the Heat-Reflective Shell or Blizzard Survival Blanket from the Hypothermia
Prevention Kit in order to both cover the burned areas and prevent hypothermia.
d. Fluid resuscitation (USAISR Rule of Ten)
● If burns are greater than 20% of TBSA, fluid resuscitation should be initiated as
soon as IV/IO access is established. Resuscitation should be initiated with Lactated
Ringer’s, normal saline, or Hextend. If Hextend is used, no more than 1000 ml should be
given, followed by Lactated Ringer’s or normal saline as needed.
● Initial IV/IO fluid rate is calculated as %TBSA x 10 ml/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).
31
e. Analgesia in accordance with the TCCC Guidelines in Section (10) may be administered
to treat burn pain.
f. Prehospital antibiotic therapy is not indicated solely for burns, but antibiotics should be
given per the TCCC guidelines in Section (11) if indicated to prevent infection in penetrating
wounds.
g. All TCCC interventions can be performed on or through burned skin in a burn casualty.
h. Burn patients are particularly susceptible to hypothermia. Extra emphasis should be
placed on barrier heat loss prevention methods.
15. Splint fractures and re-check pulses.
16. Communication
a. Communicate with the casualty if possible. Encourage, reassure and explain care.
b. Communicate with tactical leadership as soon as possible and throughout casualty
treatment as needed. Provide leadership with casualty status and evacuation requirements to
assist with coordination of evacuation assets.
c. Communicate with the evacuation system (the Patient Evacuation Coordination Cell) to
arrange for TACEVAC. Communicate with medical providers on the evacuation asset if possible
and relay mechanism of injury, injuries sustained, signs/symptoms, and treatments rendered.
Provide additional information as appropriate.
17. CPR in TACEVAC Care

a. Casualties with torso trauma or polytrauma who have no pulse or respirations during
TACEVAC should have bilateral needle decompression performed to ensure they do not have a
tension pneumothorax. The procedure is the same as described in Section (4a) above.
b. CPR may be attempted during this phase of care if the casualty does not have obviously
fatal wounds and will be arriving at a facility with a surgical capability within a short period of time.
CPR should not be done at the expense of compromising the mission or denying lifesaving care to
other casualties.
18. Documentation of Care

a. Document clinical assessments, treatments rendered, and changes in the casualty’s
status on a TCCC Card (DD Form 1380). Forward this information with the casualty to the next
level of care.
32
Garrison Care
Protocols
⬇⬇⬇⬇⬇⬇⬇
33
Abdominal Pain
Definition
Acute onset of abdominal pain in the absence of external injury. Common causes in young healthy adults
include appendicitis, cholecystitis, pancreatitis, perforated ulcer, diverticulitis, or constipation/fecal
impaction. If begins within 72 hours of a blast injury, consider bowel perforation.
Signs and Symptoms

➔ Severe, persistent or worsening abdominal pain; rigid abdomen, rebound tenderness, fever,
uncontrollable vomiting, absent bowel sounds, blood vomitus/stools, black tarry stools, coffee
ground vomitus
Management
1. Keep patient NPO, except for water and meds
2. Start IV, administer 1L Normal Saline bolus followed by 150mL/hr if needed.
3. If there is a potential for infection, administer ONE of the following:
● Ertapenem (Invanz) 1gm IV/IM daily x 5-14 days
● Ceftriaxone (Rocephin) 1gm IV daily w/ Metronidazole (Flagyl) 500mg PO q8hr
4. Treat per Pain Management Protocol. (DO NOT GIVE NSAIDS!)
5. Treat per Nausea/Vomiting Protocol
Disposition
➢ Urgent evacuation to facility with surgical capability
34
Allergic Rhinitis/Cold-Symptoms
Definition
Allergic Rhinitis is an inflammation of the nasal passages due to environmental allergens. The Common
Cold is the inflammation of nasal passages due to a respiratory virus.
Signs and Symptoms

➔ Rhinorrhea with clear discharge, boggy or inflamed nasal mucosa, +/- nasal congestion, sneezing,
nasal pruritis; +/- concurrent watery, pruritic, or red eyes; history of environmental allergy
Management
1. Fluticasone (Flonase) 2 sprays in each nostril daily
2. Antihistamines prn. Choose one! Examples:
● Diphenhydramine (Benadryl): 25-50mg PO q 4-6hr
● Cetirizine (Zyrtec): 10mg PO daily
● Loratadine (Claritin): 10mg PO daily
● Fexofenadine (Allegra): 60mg PO bid or 180mg PD qd
3. Decongestants prn. Choose one! Examples:
● Pseudoephedrine (Sudafed): 60mg PO q4-6hr
● Oxymetazoline (Afrin): 2-3 sprays intranasally q12hrs. Not to exceed 3 days
● Phenylephrine (Sudafed PE): 10mg q4hrs prn
4. Increase PO fluid intake
Disposition
➢ Evacuation usually not required
35
Altitude Illness
Definition
Occurs at altitudes of 8,000 ft or higher. Conditions include Acute Mountain Sickness (AMS), High Altitude Cerebral Edema (HACE), and High
Altitude Pulmonary Edema (HAPE)
Signs and Symptoms

➔ AMS: generally benign and self-limiting; diagnosed as headache w/ one or more additional symptoms (anorexia, nausea, vomiting,
insomnia, dizziness, lassitude, or fatigue.
➔ HACE: Unsteady, wide, and unbalanced (ataxic) gait and altered mental status are hallmark signs
➔ HAPE: Dyspnea at rest is hallmark signs. Other symptoms include cough, crackles upon auscultation, tachypnea, tachycardia, fever,
central cyanosis, or low oxygen saturation disproportionate to the elevation level.
Management
1. Halt ascent. Immediately descent at least 3,000 ft. if tactically feasible
2. If AMS symptoms present:
● Acetazolamide (Diamox) 250mg PO bid UNLESS PATIENT IS ALLERGIC TO SULFA
● Dexamethasone (Decadron) 4mg PO q6hr if patient is allergic to sulfa
○ If administered, no further ascent until asymptomatic for 24 hours after last Dexamethasone dose.
3. If HACE symptoms present:
● Administer supplemental oxygen to bring Spo2 above 90%
● Dexamethasone (Decadron) 8mg IV/IM, then 4mg IV/IM q6hrs
○ Individuals with HACE should not be left alone and especially not be allowed to descend alone.
4. If HAPE symptoms present:
● Administer supplemental oxygen to bring Sp02 above 90%
● Nifedipine (Procardia) 30mg SR q12hr or 20mg SR q8 if blood pressure is stable
○ If not available, give sildenafil (Viagra) 50mg q8hr, or tadalifil (Cialis) 10mg q12hr
● Minimize exertion to avoid exacerbation of symptoms
5. Treat per Pain Management protocol, but avoid narcotics
6. Treat per Nausea/Vomiting protocol
7. Treat per Dehydration protocol
8. For signs or symptoms of either HAPE or HACE: If immediate descent is not tactically feasible and a GAMOW bag is available, use a GAMOW
bag in 1 hour treatment sessions with bag inflated to a pressure of 2psi (approximately 100mmHg) above ambient pressure. Four or five sessions
are typical for effective treatment. GAMOW BAG TREATMENT IS NOT A SUBSTITUTE FOR DESCENT!
Disposition
➢ Most cases of AMS are relatively mild, resolve in 2-3 days, and do not require evacuation
➢ Priority evacuation for AMS patients that worsen despite therapy
➢ Urgent evacuation for patients with suspected HACE or HAPE
36
Anaphylaxis
Definition
An acute, widely distributed form of shock caused by an extreme response to an allergen. Primary causes include
insect envenomation, medications, and food allergies. Death can result from airway compromise, inability to ventilate,
or cardiovascular collapse
Signs and Symptoms

➔ Wheezing (bronchospasm), dyspnea, stridor (laryngeal edema), angioedema, urticaria (hives), hypotension,
tachycardia
Management
1. For patients w/ airway involvement and/or circulatory collapse, administer ONE of the following:
● Epi-Pen: Single auto injector dose of 0.3mg
● Epinephrine: 0.5mg (0.5mL of 1:1000 IM) DO NOT USE INTRAVENOUSLY!
○ Repeat epinephrine q5min prn
2. Oxygen with pulse oximetry monitoring
3. If severe respiratory distress exists, aggressive airway management with bag-valve-mask and airway adjuncts (oral
and nasopharyngeal airways). Intubate early if no response to epinephrine.
4. IV normal saline TKO (saline lock)
● Administer 1-2L normal saline bolus for hypotension:
● Titrate to establish systolic blood pressure >90mmHg or palpable radial pulse if BP cuff not available
5. In addition, administer each of the following:
● Diphenhydramine (Benadryl) 50mg IV/IM/PO/SL
● Dexamethasone (Decadron) 10mg IV/IM/PO
● Ranitidine (Zantac) 150mg PO bid
6. If wheezing is present, administer:
● Albuterol (Ventolin) 2-3 puffs q5min, repeat up to 3 times
Disposition
➢ Urgent evacuation
37
Asthma
Definition
Inflammatory disorder of the airway with bronchial hyper-responsiveness and narrowing of the distal
airways; acute exacerbation seen with change in environment or level of allergen or irritant
Signs and Symptoms

➔ Wheezing, dyspnea, chest tightness, decreased oxygen saturation, respiratory distress, difficulty
speaking in full sentences
Management
1. Albuterol (Proventil) MDI 2-3 puffs q5min. Repeat up to 3 times (works best w/ spacer)
2. If no response, administer:
● Epinephrine 0.5mg (0.5ml of 1:1000 solution) IM, repeat ONCE in 5-10 minutes if needed
● Dexamethasone (Decadron) 10mg IV/IM/PO
3. Establish IV access
4. Oxygen w/ pulse oximetry monitoring
5. If fever, chest pain, and productive cough, consider and treat as per Bronchitis protocol or Pneumonia
protocol
Disposition
➢ If patient responds to management, observe for 4 hours.
○ Return To Duty if there is now wheezing or dyspnea and normal oxygen saturation.
Continue albuterol q6hr and re-evaluate in 24 hours. Continue dexamethasone 10mg IM
daily for 4 days.
➢ Urgent evacuation, if poor response to treatment
38
Back Pain
Definition
Refers to musculoskeletal back pain due to mechanical stress or functional demands. THIS PROTOCOL
IS NOT FOR ACUTE SPINAL TRAUMA INJURIES!
Signs and Symptoms

➔ Acute or gradual onset of back pain that can be severe and debilitating; with or without radiation;
aggravated by movement or certain positions, alleviated with rest
➔ Usually history of previous back pain; may radiate to legs
Management
1. Treat per Pain Management Protocol
2. Apply cold compress to painful area for 20-25 min tid
3. Encourage fluid hydration, avoid bed rest, use ice pack if acute or heat pack if subacute, stretch as
tolerated
4. In addition, you may administer the following muscle relaxer:
● Cyclobenzaprine (Flexeril) 10 mg PO tid
5. For additional analgesia, you may also consider the following:
● Diazepam (Valium) 5- 10mg IM/IV/PO, and repeat once in 6-8h prn
● Trigger point injections with local anesthetic (IF TRAINED!). Lidocaine 1-2mL per trigger point.
May repeat daily for 2 days
6. Refer to Flank Pain protocol if back pain is accompanied by fever and/or urinary symptoms.
Disposition
➢ Evacuation usually not required;
➢ Routine evacuation for severe cases not responding to therapy
➢ Urgent if neurological involvement (weakness, numbness, bowel/bladder dysfunction, saddle
anesthesia)
39
Barotrauma
Definition
Refers to pulmonary barotrauma, middle ear barotrauma, and paranasal sinus barotrauma. May occur from
blast overpressure or ascent from depth if compressed air was used.
Signs and Symptoms

➔ Middle Ear/Paranasal sinus barotrauma: pain in the ear(s), sinuses, and/or teeth
➔ Pulmonary barotrauma: chest pain, dyspnea, mediastinal emphysema, subcutaneous emphysema,
pneumothorax, or arterial gas embolism (AGE). Symptoms of AGE include unconsciousness,
paralysis, weakness, fatigue, large areas of abnormal sensations, and convulsions. Usually occurs
within 10 minutes of surfacing after a dive or shortly after overpressure exposure (blast injury).
Associated pneumothorax is a potential complication.
Management
1. If flying, descend to altitude until relief is felt (if feasible)
2. For Middle Ear barotrauma, provide the following treatments:
● Protect ear from water or further trauma (if tympanic membrane is ruptured)
● Moxifloxacin (Avelox) 400mg PO daily if contamination is suspected
● Pseudoephedrine (Sudafed) 60mg PO q4-6hr prn
● DO NOT use ear drops!
3. For Paranasal Sinus barotrauma, provide the following treatments:
● Pseudoephedrine (Sudafed) 60mg PO q4-6hr prn
4. For Pulmonary barotrauma, provide the following treatments:
● If there is no respiratory distress, monitor the patient closely. Use pulse oximetry if available
● If respiratory distress occurs, treat as a pneumothorax
● For severe symptoms or signs of AGE, administer 100% oxygen, 1L normal saline IV (150mL/hr)
and evacuation to recompression chamber.
5. If an unpressurized airframe is used, avoid altitude exposure greater than 1000ft.
6. Treat per Pain Management protocol. Avoid narcotics
Disposition
➢ Routine evacuation for mild-moderate middle ear, sinus, or pulmonary barotraumas without
respiratory distress.
➢ Urgent evacuation for cerebral arterial gas embolus, pneumothorax, or any pulmonary barotrauma
with respiratory distress.
40
Behavioral Changes
Definition
Includes psychosis, depression, and suicidal impulses. Etiologies are numerous and will often dictate the management; thus
mental status changes could be caused by head trauma, metabolic and endocrine disease processes, environmental toxins,
infections, combat stress disorder, hypoxia, hyperthermia, pharmaceutical agent use (ex. mefloquine) or withdrawal. Consider
diabetic hypoglycemia as a cause of altered mental status.
Signs and Symptoms

➔ Acute behavioral changes including withdrawal, depression, aggression, confusion, or other behavioral patterns atypical
for the individual.
➔ Psychosis is an acute change in mental status characterized by altered sensory perceptions that are not congruent with
reality (Ex. auditory and/or visual hallucinations, violent/paranoid behavior, disorganized speech patterns, severe
withdrawal from associates)
Management
1. Remove all weapons or potential weapons from patient AND treating Medic
2. Check pulse oximetry
3. Place patient in safe environment under continuous surveillance
4. Place either 1 tube of glutose (oral glucose gel) or contents of one packet of sugar in the buccal mucosal region for possible
hypoglycemia.
5. Take Temperature
● If temperature is below 95 degrees, treat per Cold Injury protocol
● If temperature is above 101 degrees, treat per Meningitis protocol
● If temperature is above 103 degrees, treat per Meningitis & Heat Illness protocol
○ If Meningitis is suspected or if there is a decrease in mental status, use valium with caution due to possible
respiratory depression, hypotension, and masking of progression of disease related altered mental status
6. For acute agitation, combativeness, or violent behavior, restrain patient with at least 4 individuals and give Ketamine (Ketalar)
4-5mg/kg for a max dose of 500mg IM
7. Apply physical restraints once patient is chemically restrained with ketamine, then establish IV access. If emergence reaction
occurs in the form of combativeness, give Midazolam (Versed) 1-2mg IV OR Diazepam (Valium) 2mg IV. Repeat after 3-5min prn
for a max dose of 4mg of midazolam or 5mg of diazepam.
8. If sedated or restrained, maintain constant vigilance for a change in the hemodynamic status or loss of airway reflexes.
Disposition
41
Bronchitis/Pneumonia
Definition
● Bronchitis: lower respiratory infection primarily involving inflammation of the bronchi; viruses are the
most common cause
● Pneumonia: lower respiratory infection primarily involving inflammation of the alveoli; can be caused
viruses, bacteria, or fungi
Signs and Symptoms

➔ Bronchitis: Preceding URI symptoms, cough (initially unproductive, then productive), fatigue, +/-
fever > 100.4, +/- dyspnea, erythematous pharynx
➔ Pneumonia: Fever, productive cough (especially with dark yellow, red tinged, or greenish sputum,
chest pain, rhonchi/decreased breath sounds, dyspnea
Management
1. Albuterol (Proventil) MDI 2-4 puffs q4-6hr
2. Treat symptoms with antitussives, decongestants, expectorants, as needed
3. Treat per Pain Management protocol
4. If signs and symptoms are severe (ex. Temperature >100 degrees, RR > 25/min, myalgias), administer
ONE of the following:
● Azithromycin (Zithromax) 500mg PO first dose then 250mg daily for 4 days
● Moxifloxacin (Avelox) 400mg PO daily for 7 days
5. If unable to tolerate PO intake, administer ONE of the following:
● Ertapenem (Invanz) 1g IV/IM daily
● Ceftriaxone (Rocephin) 1 g IV daily
6. If febrile, administer:
● Acetaminophen 1g PO q6hr prn
Disposition
➢ Observation o
r Routine evacuation as necessary
➢ Urgent evacuation for severe dyspnea or hypoxia
42
Cellulitis
Definition
Acute superficial spreading bacterial skin infection due to trauma or scratching of other lesions. Generally
begins about 24 hours following a break in the skin, but more serious types of cellulitis may be seen as
early as 6-8 hours following animal or human bites.
Signs and Symptoms

➔ Local warmth, pain, erythema, swelling with well-demarcated borders, +/- fever/chills, +/-
lymphadenopathy.
Management
1. Administer ONE of the following:
● Moxifloxacin (Avelox) 400mg PO qd for 10 days
● Amoxicillin/Clavulanic acid (Augmentin) 875mg PO bid for 10 days
2. PLUS, ONE of the following:
● TMP-SMZ (Septra DS) 1 tab PO bid for 10 days
● Rifampin (Rifadin) 600mg PO bid for 10 days
4. Clean/dress wound and surrounding area
5. Use marker to demarcate infection border
6. Limit activity as feasible
7. Reevaluate at least daily
8. Identify and drain abscess if present
9. If worsening at 24 hours or no improvement after 48 hours, use ONE of the following:
● Ceftriaxone (Rocephin) 1g IV/IM qd and continue PO antibiotics
● Ertapenem (Invanz) 1g IV/IM X 7-14 days and continue PO antibiotics
10. If rapidly spreading and very painful consider necrotizing fasciitis (life-threatening deep tissue infection)
and treat per Sepsis/Septic Shock protocol
Disposition
➢ Priority evacuation if infection fails to improve or worsens within 24-48hrs on antibiotics
43
Chest Pain
Definition
Possible myocardial infarction (heart attack) or other acute coronary syndrome. Consider the possibility of
other chest pain causes such as pulmonary embolism, pericarditis, spontaneous pneumothorax, and
esophageal rupture. Consider pulmonary embolism if patient has localized chest pain with a history of DVT
or prolonged sedentary periods.
Signs and Symptoms

➔ Usually in patients over 40; history of hypertension, diabetes, smoking, elevated cholesterol,
obesity; family history of MI at a young age
➔ Substernal pressure/squeezing chest pain +/- radiation to left arm or jaw, dyspnea, diaphoresis
(sweating). May present with bilateral rales/crackles in the lungs on auscultation or
hypertension/hypotension.
Management
1. Initiate “MONA” treatment:
● Morphine Sulfate (MSO4) 5mg IV initially then 2mg IV q10-15min prn for pain
● Oxygen (if available and only if SpO2 is less than 94%)
● Nitroglycerin: 0.4mg SL initially, repeat q5min for a total of 3 doses
● Acetylsalicylic Acid (Aspirin) 325mg PO
2. Establish IV access
3. Avoid all exertion
3. Pulse oximetry and cardiac monitor (if available)
Disposition
➢ Urgent evacuation on platform with ACLS personnel, medications, and equipment
44
Cold Injury
Definition
Includes non-freezing cold injury (frostnip, chilblains, and trench foot), freezing cold injury (frostbite), and hypothermia.
Signs and Symptoms

➢ Non-Freezing Cold Injury (frostnip, chilblains, trench foot)
○ Itching; pale, cool, blotchy wet skin; mild ulcerations may be present; numbness and tingling sensations
➢ Freezing Cold Injury (Frostbite)
○ Superficial-Skin is firm, but not hard; painful, red skin
○ Deep-Painless, gray appearing skin. Skin is hard, white, gray, ashen, waxy in appearance.
➢ Hypothermia (Decreased core temperature)
○ Mild-Shivering, poor coordination
○ Moderate-Cessation of shivering, disorientation, slurred speech, confusion
○ Severe-Unconscious
Management
1. For Non-Freezing Cold Injury:
● Gently dry, do not rub the involved area. Elevate feet, warm torso, hydrate orally, dry socks. NSAIDS may help.
Evacuation depends on ambulatory ability
2. For Freezing Cold Injury:
● Do not walk on frozen feet/toes unless necessary for the preservation of life.
● Do not rub with snow/ice
● Do not vigorously massage tissue
● Do not use space heaters or dry heat sources (fire, MRE heaters, hand-warmers, etc.)
● If thawed, refreezing will most likely result in amputation
● Once thawing has occurred, expect intense pain requiring narcotic use. Follow Pain Management p rotocol
● If refreezing likely:
○ Do not attempt to thaw frostbitten tissue
○ Protect tissue from further injury by wrapping with dry Kerlix (separate digits w/ dressing)
● If refreezing not likely
○ Superficial
■ Warm water immersion
■ Warm extremity in axilla or groin
■ Drainage of clear blisters may be considered
■ Apply soft Kerlix type dressing
○ Deep
■ Warm water immersion until tissue is soft (approximately 30 min)
■ Apply loose dry dressing prior to transport
■ Do not drain hemorrhagic blisters
3. For Hypothermia:
● Move to a warm environment, remove any wet clothing and begin rewarming (Blizzard Blanket, Ranger Rescue Wrap,
etc.)
● Shield from wind
● If able to tolerate PO, provide food and hydrate patient
● Mild: exercise in place
● Moderate/Severe:
○ Do not exercise the patient. Maintain supine position on insulation.
45
○ Do not give patients food or oral fluids
○ If IV fluids are indicated, administer glucose-containing IV fluids warmed to 101.6 degrees or 1 amp of D50
○ Begin active rewarming (Blizzard Blanket, Ranger Rescue Wrap, etc.)
● If unconscious:
○ Avoid sudden movements and rough handling due to increased ventricular fibrillation risk
○ Assure airway patency
○ Check for 60 seconds for pulse and respirations due to bradycardia
○ If not breathing, begin ventilations
○ If no pulse, begin chest compressions only if patient will not arrive in medical facility in 3 hours
Disposition
➢ Evacuation not necessary for cases of nonfreezing ambulatory cold injuries
➢ Routine evacuation for cases of nonfreezing cold injury which are non ambulatory
➢ Priority evacuation for cases of freezing cold injuries (Frostbite)
➢ Urgent evacuation for moderate/severe hypothermia cases to a facility capable of active rewarming and resuscitation
46
Constipation/Fecal Impaction
Definition
Constipation is defined as infrequent or hard, dry stools; Fecal Impaction occurs when a mass of stool
becomes lodged inside the patient’s rectum and is unable to be passed without intervention.
Signs and Symptoms

➔ Infrequent, hard, dry stools with possible pain/straining with defecation, abdominal fullness, and
poorly localized cramping abdominal pain
➔ If pain becomes severe with N/V and lack of flatus or stools consider bowel obstruction.
Management
1. Increase PO fluids and fiber – fruits, bran, vegetables
2. Bisacodyl (Dulcolax) 10mg PO tid prn
3. Treat per Pain Management protocol (no narcotics – they cause constipation!),
4. If impacted or no response give 500cc Normal Saline enema per rectum (lubricate IV tubing)
5. If continued no response, perform digital rectal exam (DRE) and digital disimpaction
6. If severe pain, rigid board-like abdomen, fever, and/or rebound tenderness develop, or moderate to large
amounts of blood are present in the stool, then treat per Abdominal Pain protocol
Disposition
➢ Routine e
vacuation if no response to treatment
➢ Urgent evacuation if acute abdominal etiology suspected
47
Contact Dermatitis
Definition
Inflammation of the skin due to a reaction with an external substance (plants, metals, chemicals, topical
medications)
Signs and Symptoms

➔ Acute onset of skin erythema and pruritus; may see edema, papules, vesicles, bullae, and possible
discharge and crusting
Management
1. Remove offending agent and evaluate pattern
2. Wash area with soap and water
3. Change and/or wash clothes
4. Topical cold wet compress AAA
5. Topical calamine lotion AAA
6. Topical 1% Hydrocortisone AAA qid until dermatitis resolves.
7. Cover with dry dressing to help prevent spread to other parts of the body or clothing.
8. Administer:
● Diphenhydramine (Benadryl) 25-50mg PO qid prn for pruritus, if tactically feasible
9. Then, if severe, Administer ONE of the following steroids:
● Methylprednisolone (Solu-Medrol) 125 mg IM
● Dexamethasone (Decadron) 10mg IM daily x 5 days
● Prednisone 60mg PO daily x 5 days burst or taper dose down every 3 days for a 14-21 day course
Disposition
➢ Priority evacuation if severe, eye or mouth involved, or > 50% BSA involved
48
Corneal Abrasion/Corneal Ulcer/Conjunctivitis
Definition
Corneal Abrasion: A scratch on the surface of the cornea. Corneal Ulcer: Erosion or open sore on the
surface of the cornea, often caused by infection. Conjunctivitis: inflammation of the conjunctiva, often
caused by allergies or viral/bacterial infection.
Signs and Symptoms

➔ Corneal Abrasion: pain, redness, light sensitivity, feeling of “something in the eye”. Positive
fluorescein stain/cobalt blue light
➔ Corneal Ulcer: intense pain, white/gray spot on cornea, vision loss
➔ Conjunctivitis: itchy/ watery eyes, possible yellow-greenish discharge
Management
1. Remove any contact lenses and examine the eye using fluorescein to enhance visualization.
2. Check for foreign bodies, perform eyelid inversion. Irrigate with normal saline prn.
3. For corneal ulcer or bacterial conjunctivitis, administer:
● Gatifloxacin (Zymar) 0.3% 1 drop in affected eye qid until after 24h fluorescein negative (q2h if
corneal ulcer)
4. For pain, administer:
● Tetracaine 0.5% 2 drops in the affected eye for pain (do not give bottle to patient)
● In addition, treat per Pain Management protocol
5. No patching
6. Reduce light exposure/stay indoors/wear sunglasses as feasible
7. Monitor daily with fluorescein. Should get progressively smaller. Continue antibiotic drops until 24 hours
after cornea becomes fluorescein negative (no bright yellow spot)
Disposition
➢ Routine evacuation if not improving
➢ Priority evacuation if corneal ulcer
➢ Urgent evacuation and eye shield if ruptured globe suspected or LASIK flap dislocation
49
Cough
Definition
Usually viral etiology, but may occur with high altitude pulmonary edema (HAPE), pneumonia, GERD, and
smoking history
Signs and Symptoms

➔ Cough with or without scant sputum production, often accompanied by other URI S/S (sore throat,
rhinorrhea, post-nasal drip)
Management
1. If the cough is productive, do not treat unless the cough is restricting sleep
2. Increase PO hydration
3. Avoid respiratory irritants (smoke, aerosols, etc)
4. Administer the following for sore throat/mild cough:
● Cepacol Lozenges: 1 lozenge q2hr prn
5. For additional cough suppression, you may administer ONE of the following:
● Benzonatate (Tessalon perles) 100mg PO tid
● Dextromethorphan (Robitussin DM) 30mg PO bid prn cough
6. If needed, administer:
● Albuterol (Proventil) MDI 3-4 puffs q4h can help if cough continues
7. Treat per Bronchitis/Pneumonia protocol if fever, chest pain, dyspnea, colored sputum (green, dark
yellow, red-tinged)
Disposition
50
Cutaneous Abscess
Definition
A localized collection of pus in the skin and may occur on any skin surface
Signs and Symptoms

➔ Focal pain, erythema, warmth, tenderness, swelling, and fluctuance
Management
1. Administer ONE of the following antibiotics:
● Clindamycin (Cleocin) 300-450mg PO q6h X 21 days
● TMP-SMZ (Septra) DS 1 tab PO bid x 10 days
● Moxifloxacin (Avelox) 400mg PO qd x 10 days
● Azithromycin (Zithromax) 250mg PO 2 tabs PO day 1 then 1 tab PO day 2-5
2. I&D if not on eyelid, face, or neck (sterilize site with betadine, anesthetize with 1% Lidocaine, incise
parallel to skin tension lines with scalpel and make an opening large enough to allow purulence to drain,
pack with iodoform gauze or nugauze, cover with loose bandage; check, redress, and wick q12-24hrs); Do
not suture, drainage is the key to treatment!
Disposition
➢ Evacuation usually not required;
➢ Priority evacuation if condition worsens; treat per Cellulitis protocol
51
Dental Pain
Definition
Common causes are deep decay, fractures of tooth crown or root, pericoronitis (pain from impacted
wisdom tooth), periapical abscess, or barodontalgia
Signs and Symptoms

➔ Intermittent or continuous pain; heat or cold sensitivity; visibly broken/cracked tooth;
➔ Severe pain on percussion; swelling or abscess; lost filling; partially erupted wisdom tooth
Management
2. If signs and symptoms of infection, administer one of the following:
● Clindamycin (Cleocin) 300-450mg PO q6h x 10 days
● Amoxicillin/Clavulanic Acid (Augmentin) 875mg PO bid x 7 days
● Ceftriaxone (Rocephin) 1gm IV/IM daily x 7days
Disposition
➢ Routine evacuation if no response to therapy
52
Dehydration
Definition
Deficit of total body water; accompanying a disruption of metabolic processes. May be caused by acute
diarrhea, viral/bacterial infections, or environmental factors (heat stress or strenuous activity)
Signs and Symptoms

➔ Lightheadedness (worse with sudden standing, headache, nausea/vomiting
➔ Dry mucosa, decreased urinary frequency and volume, dark urine, degradation in performance
Management
1. Increase oral fluids if tolerated
a. If available, use carbohydrate/electrolyte drink mixes for fluid replacement diluted to a 1:4
solution
b. Avoid fluids containing caffeine
2. If unable to tolerate PO fluids, use an initial bolus of 1L normal saline IV, followed by repeat attempt
at PO hydration. If still unable to tolerate PO hydration, repeat 1L bolus of normal saline IV. If
normal saline is not available, use available IV fluids.
Disposition
➢ Priority evacuation if dehydration persists after treatment
53
Deep Vein Thrombosis (DVT)
Definition
Potentially life-threatening condition in which a clot is present in the large veins of the leg and may dislodge
and localize in the pulmonary arteries, becoming a pulmonary embolism (PE)
Signs and Symptoms

➔ History of recent trauma, air travel, altitude exposure, birth control pills, or family history of DVT;
➔ Pain, swelling, and warmth seen in legs (usually calf), but may occur in any deep vein; palpable
venous “cord”; pain with passive stretching or dorsiflexion of the foot
Management
1. Acetylsalicylic acid (Aspirin) 325mg PO
2. Immobilize and do not allow to walk on affected extremity
3. Monitor with pulse oximetry (sudden decrease suggests PE), if tachypnea, tachycardia, respiratory
distress, and chest pain develop, treat per Chest Pain p
rotocol
Disposition
➢ Priority evacuation
➢ Urgent if PE suspected
54
Ear Infection
Definition
Includes Otitis Media (middle ear infection) and Otitis Externa (external ear infection). Otitis Media is
typically viral or bacterial in etiology; often precipitated by upper respiratory infection/eustachian tube
dysfunction. Otitis Externa is also known as “Swimmer’s ear”; typically caused by bacterial or fungal
infection.
Signs and Symptoms

➔ Otitis Media: Ear pain, decreased hearing, inflamed/bulging eardrum
➔ Otitis Externa: Ear canal drainage, pain on motion of tragus (outer ear), cracked/red/inflamed
external auditory canal
Management
1. For Otitis Media, Administer ONE of the following:
● Moxifloxacin (Avelox) 400mg PO daily for 10 days
● Azithromycin (Z-pac) 500mg PO initially followed by 250mg PO daily x 4 days
2. For Otitis Externa, Administer:
● Gatifloxacin (Zymar) 5 drops tid-qid until symptoms remain resolved for 48 hours
Disposition
➢ For uncomplicated cases, no evacuation is necessary
➢ Routine evacuation for complicated cases not responding to therapy
(Normal Ear) (Otitis Media) (Otitis Externa)
55
Envenomation (Snakes)
Definition
Refers to poisonous snake bites, particularly from Crotalidae (pit vipers, rattlesnakes, moccasins,
bushmaster) or Elapids (Coral snake, sea snake, mamba, cobra, taipan, kraits). Only a minority of
snakebites from toxic snakes involve severe, life-threatening envenomations. May cause life threatening
anaphylaxis.
Signs and Symptoms

➔ Crotalidae: Sudden pain, erythema, ecchymosis, hemorrhagic bullae, bleeding from site, metallic
taste, hypotension, shock, swelling/edema
➔ Elapids: Cranial nerve dysfunction (ptosis, difficulty swallowing, etc.), paresthesias, fasciculations,
weakness, altered mental status.
Management
1. If signs and symptoms of anaphylaxis present, treat per Anaphylaxis protocol
2. Treat per Pain Management protocol using narcotics. Avoid NSAIDS!
4. Perform the following:
● Minimize activity and place on litter
● Remove all constricting clothing
● Start IV in unaffected extremity
● Monitor and record vital signs and extent of edema every 15-30min
● Give IV crystalloid for hypotension as necessary
● Immobilize affected limb in neutral position
● Compression wrap (proximal to distal) may be helpful with an elapidae (neurotoxic snake), but is not
indicated for a crotalidae (pit viper) bite.
Disposition
➢ Evacuation not required for crotalidae bites if signs and symptoms do not indicate anaphylaxis or
development of severe envenomation after 4 hours of observation.
➢ Urgent evacuation for anaphylaxis, elapidae bites, or signs/symptoms of severe envenomation
(systemic signs/symptoms, progressive ascending edema) exists.
56
Envenomation (Marine)
Definition
Envenomation via marine life. Categorized into three types: Stings (Jellyfish, Sea Wasp), Bites (Sea
snakes, blue ringed octopus), and punctures (Sea urchin, stingray, fish spines, and bristle worms). Likely
to occur in intertidal regions, reefs, and surf zones.
Signs and Symptoms

➔ Stings: immediate, intense pain followed by local, linear erythematous eruption
➔ Punctures: immediate, intense pain out of proportion, may result in several puncture wounds, may
involve systemic symptoms.
➔ Bites: Often painless, symptoms are variable but may be extreme (paralysis, altered mental status,
Management
1. For Stings (Jellyfish, Sea Wasp)
● Remove stinger, tentacles, etc. if possible with gloved hand, forceps, or tape
● Immediately flush with vinegar, isopropyl alcohol, or seawater. NOT FRESH WATER!
● Apply topical lidocaine and/or topical steroids
2. For Bites (Sea snakes, blue ringed octopus)
● Follow Envenomation (Snakes) protocol
3. For Punctures (Sea urchin, stingray, fish spines, bristle worms)
● Remove all penetrating foreign bodies with gloved hand, forceps, or tape
● Irrigate w/sea water
● Soak the affected area in non-scalding water (110-115 degrees) for 30-90 minutes to inactivate
toxins
● Ultrasound or X-ray (if available for retained foreign body
4. Follow Pain Management p rotocol
Disposition
➢ Evacuation not required if signs and symptoms do not indicate severe envenomation after 24 hours
of observation (cardiovascular collapse, anaphylaxis, paralysis, ascending edema of limb)
➢ Urgent evacuation if evidence of severe envenomation
57
Envenomation (Insect/Arthropod)
Definition
Refers to bites from Hymenoptera (Bee, wasp, hornet) and Arthropods (Spiders)
Signs and Symptoms

➔ Hymenoptera: Pain, swelling/edema, puncture sites from stingers or fangs, warmth, erythema
➔ Arthropods: Pinching bite, local swelling, burn sensation, muscle spasms, abdominal pain/rigidity,
nausea/vomiting, diaphoresis, hypertension, tachycardia
Management
1. For Hymenoptera (Bee, Wasp, Hornet)
● If signs and symptoms of anaphylaxis present, treat per Anaphylaxis protocol
● Remove stinger by scraping from side
● Apply ice or cold water
● Apply Topical 1% Hydrocortisone cream
● Apply topical lidocaine
● Ibuprofen (Motrin) 800mg PO tid x 7days
● Diphenhydramine (Benadryl) 25-50mg q6hr prn PO/IV
2. For Spiders (Black widow, brown recluse)
● Elevate the bite site and avoid strenuous activity
● Treat per Pain Management protocol (narcotic analgesia)
● Diphenhydramine (Benadryl) 25-50mg q6hr prn PO/IV
● Diazepam (Valium) 2-10mg PO q6-8hr or 5-10mg IV/IM, if muscle spasms occur
● Use an antibiotic appropriate for MRSA if cellulitis occurs.
Disposition
➢ Evacuation typically not required for localized insect stings
➢ Routine evacuation for tissue necrosis of brown recluse bite
➢ Urgent evacuation for anaphylaxis, abdominal rigidity, or development of systemic signs
58
Envenomation (Scorpions)
Definition
Stings from venomous species of scorpions
Signs and Symptoms

➔ Local pain, swelling, erythema, nausea/vomiting, paresthesias, tongue fasciculations, seizures,
agitation, blurry vision/rotary eye movements,
➔ Sympathetic overdrive (tachycardia, hypertension, hyperthermia) or parasympathetic overdrive
(hypotension, bradycardia, hypersalivation, incontinence)
Management
2. Treat per Nausea/Vomiting p rotocol
3. Apply ice packs to bite site
4. Diphenhydramine (Benadryl) 25-50mg q6hr prn PO/IV
Disposition
➢ Evacuation typically not required for localized insect stings
➢ Routine evacuation for tissue necrosis of brown recluse bite
➢ Urgent evacuation for anaphylaxis, abdominal rigidity, or development of systemic signs
59
Epiglottitis
Definition
Rapidly progressive infection of the epiglottis and adjacent tissues usually caused by bacteria; may cause
airway obstruction and result in death without emergent intervention.
Signs and Symptoms

➔ Sore throat, difficulty speaking and swallowing, drooling, respiratory distress
➔ Erythematous pharynx is the first symptom of severe sore throat that progresses to epiglottal
swelling and potential for airway obstruction
Management
1. Place patient in sitting or comfortable position
2. IV access, Pulse oximetry, and O2 if available
● Ceftriaxone (Rocephin) 1gm IV/IM daily for 7 days
● Amoxicillin/clavulanic acid (Augmentin) 875mg PO bid for 7 days
4. In addition, administer:
● Dexamethasone (Decadron) 10mg IV/IM x 1
5. Do not manipulate airway unless required, let the patient protect his own airway
6. If definitive airway is needed, make one attempt at intubation, and if failed, perform a cricothyroidotomy
Disposition
60
Epistaxis
Definition
“Nosebleed”. Most commonly occurs as a result of trauma or drying of the nasal mucosa (common at high
altitudes or desert environments). Further defined as anterior (most common) or posterior (typically seen in
older, hypertensive patients).
Signs and Symptoms

➔ Bleeding may be bright or dark red, but slow.
➔ Anterior and posterior bleeds will present similarly, but posterior bleeds will not respond well to
initial treatment. Bleeding may cause respiratory distress if blood drains into the airway.
Management
1. Clear airway by having patient sit up and lean forward
2. Administer Oxymetazoline (Afrin) 2-3 sprays intranasally and pinch anterior area of the nose firmly for
full 10 minutes without releasing pressure. Have the patient blow their nose prior to administering.
3. If bleeding continues, insert Afrin-soaked nasal sponge along floor of nasal cavity, remove 30 minutes
after bleeding is controlled, and apply Mupirocin (Bactroban) or Bacitracin bid-tid
4. If severe nosebleeds and bleeding continues, suspect posterior epistaxis and initiate saline lock or
Normal Saline TKO. Consider inserting 14 French Foley catheter intranasally for 72h
5. If packing and/or catheter required for > 12h, treat with Moxifloxacin (Avelox) 400mg PO qd
Disposition
➢ Evacuation not required for mild, anterior, and resolving epistaxis
➢ Priority evacuation for severe epistaxis not responding to therapy or if Foley used
61
Flank Pain
Definition
Includes pyelonephritis (kidney infection) and renal colic (spasmodic pain in the ureters typically caused by
kidney stones. Pyelonephritis may be associated with a preceding lower urinary tract infection (UTI) or
obstruction. May proceed to life-threatening systemic infection. Flank pain may also be associated with
testicular torsion. Ensure a normal external GU exam first.
Signs and Symptoms

➔ Back pain, flank pain, nausea/vomiting, CVAT, fever, chills,
➔ Frequency, urgency, dysuria, polyuria, and hematuria.
Management
1. If fever present, administer ONE of the following:
● Moxifloxacin (Cipro) 400mg PO daily
● Amoxicillin/clavulanic acid (Augmentin) 875mg PO bid x 7-14days
2. If PO antibiotics not tolerated, administer ONE of the following:
● Ceftriaxone (Rocephin) 2g IV/IM q12h x 7-10days
● Ertapenem (Invanz) 1g IV/IM daily x 14days
Disposition
➢ Priority evacuation; may progress to life-threatening systemic infection and septic shock
62
Fungal Skin Infection
Definition
Superficial infection caused by an overgrowth of fungi on the skin. Infections are most commonly acquired
from humans, but may also be acquired from the soil and animals. Differential diagnosis includes eczema,
insect bites, cellulitis, and contact dermatitis
Signs and Symptoms

➔ Scaling plaques, erythema, pruritic, slow spreading, irregular or circumferential borders; often
initially diagnosed as contact dermatitis but gets worse with steroid cream;
➔ Most common sites of infection are feet (“athlete’s foot” or tinea pedis), groin (“jock itch” or tinea
cruris), scalp (tinea capitus), and torso or extremities (“ringworm” or tinea corporis)
Management
1. Antifungal cream (Ex. Clotrimazole) AAA tid until one week after lesion resolves
2. In moderate to severe cases, administer the following:
● Fluconazole (Diflucan) 150 mg PO qwk x 2 wks
Disposition
➢ Evacuation not usually required
63
Gastroenteritis
Definition
Inflammation of the gastrointestinal tract. Usually due to an acute viral infection of the GI tract, but bacteria
or parasite infections are common in deployed environments
Signs and Symptoms

➔ Sudden onset of N/V/D, abdominal cramping, +/- fever
Management
1. Administer:
● Loperamide (Imodium) 4mg PO initially, then 2mg after every loose BM, max of 16mg/day (do not
use if bloody stools or fevers)
2.Treat per Nausea/Vomiting protocol
3.Treat per Dehydration protocol
4. If diarrhea is moderate-severe (3-5 loose stools per day), administer ONE of the following:
● Azithromycin (Zithromax) 500mg PO daily X 3 days
● Moxifloxacin (Avelox) 400mg PO daily X 3 days
5. If diarrhea persists after 3 days of therapy, or diarrhea develops while already on antibiotics, administer:
● Metronidazole (Flagyl) 500mg PO tid x 10 days
Disposition
➢ Routine evacuation if diarrhea develops while already on antibiotics
➢ Priority evacuation if dehydration despite therapy or antibiotic-related diarrhea
➢ Urgent evacuation if grossly bloody stools or circulatory compromise
64
Gastroesophageal Reflux Disease (GERD)
Definition
Reflux of acidic gastric contents into esophagus due to improper lower esophageal sphincter relaxation
Signs and Symptoms

➔ “Heartburn”, chest pain, regurgitation, dysphagia
Management
1. Avoid high-fat food, onion, tomato, chocolate, peppermint, citrus, tobacco, coffee, alcohol
2. Elevate head on bed when sleeping, do not eat just before bedtime, do not sleep on right side
● Ranitidine (Zantac) 150mg PO qd prn
● Omeprazole (Prilosec) 20mg PO qd or bid prn
4. If on Doxycycline for malaria chemoprophylaxis, take the doxy early in the day with a meal
Disposition
65
Headache
Definition
Pain associated with any region of the head. May be further defined as Primary (Tension-type, Migraine,
Cluster) or Secondary (headache secondary to dehydration, sinus congestion, illness, etc.)
Signs and Symptoms

➔ Tension headaches are typically band-like, bilateral, mild-moderate, and no neurological symptoms.
➔ Cluster headaches include deep, severe, episodic, unilateral pain behind the eye that may be
accompanied by runny/stuffy nose.
➔ Migraines are typically unilateral, painful/painless, may be associated with neurological symptoms
and/or nausea/vomiting. Secondary headache symptoms will vary by type.
Management
1. If the patient has fever, nuchal rigidity, photophobia, petechial rash, severe nausea/vomiting, preceding
seizures, or mental status changes, treat per Meningitis Protocol
4. For secondary headaches, treat the underlying condition (hydration for dehydrated patients,
decongestants for sinus headaches, caffeine for caffeine withdrawal, etc.)
Disposition
➢ Evacuation usually not required if headache responds to therapy
➢ Urgent evacuation if suspected meningitis.
66
Heat Illness
Definition
Refers to heat exhaustion and heat stroke. Generally involves physical collapse or debilitation during or
immediately following exertion in the heat. Heat stroke is a life-threatening effect of hyperthermia and
characterized by altered mental status and a core temperature of >104 degrees F. These patients are at
risk for multisystem organ failure; careful monitoring is essential even after return to normothermia
Signs and Symptoms

➔ Heat Exhaustion: Temperature generally ≤ 104 degrees F. Headache, dizziness, nausea,
tachycardia, and normal mental status
➔ Heat Stroke: Temp generally > 104 degrees F, above symptoms and altered mental status
(delirium, stupor, coma)
Management
1. Early rapid cooling reduces mortality and morbidity! Initiate prior to transport!
● Full body ice immersion while keeping head elevated out of water (Best approach)
● Continual dousing of cold water or ice water soaked towels
● Spray patient with water w/ rapid air movement provided by fan
2. Place 1 tube Glutose (oral glucose gel) or 1 packet of sugar in buccal mucosal region
5. For cola-colored urine or severe muscle pain, treat per Rhabdomyolysis protocol
Disposition
➢ Routine evacuation or observation for Heat Exhaustion
➢ Urgent evacuation for Heat Stroke
67
Ingrown Toenail
Definition
Occurs when nail growth cuts into one or both sides of the paronychium or nail bed; usually big toe; caused
by trimming nails in curved fashion, nail deformity, tight fitting shoes, and rotational toe deformity
Signs and Symptoms

➔ Pain, edema, erythema, hyperkeratosis at lateral nail fold; pressure on nail margin increases pain
Management
1. Partial toenail removal: clean site with soap, water, and betadine; local anesthesia through digital block
using 1% lidocaine without epinephrine; apply tourniquet at base; remove lateral ¼ of nail toward cuticle,
using sharp scissors; separate nail from the underlying matrix and remove; curette posterior and lateral nail
grooves to remove debris; rub matrix with silver nitrate stick;
2. Apply Mupirocin (Bactroban) and cover with non adherent dry sterile dressings; wash, clean, recheck
wound and change dressing daily
4. Systemic antibiotics usually not needed, however you may administer ONE of the following:
● Moxifloxacin (Avelox) 400mg PO qd x 10d
● Azithromycin (Zithromax) 250mg 2 tabs PO day 1 then 1 tab PO day 2-5 if in tactical setting or
infection (increasing pain, redness, and swelling)
Disposition
68
Joint Infection
Definition
Bacterial joint infection, also known as “septic arthritis” or “septic joint” ; may result from penetrating trauma
(animal or human bite), gonorrhea, or iatrogenic causes (ex. Attempted aspiration of joint effusion)
Signs and Symptoms

➔ Fever and red swollen painful joint; pain with axial load; inability to straighten joint
Management
1. Immobilize joint
● Ertapenem (Invanz) 1gm IV/IM daily
● Ceftriaxone (Rocephin) 2gm IV/IM bid
Disposition
➢ Priority evacuation
69
Laceration
Definition
Skin laceration
Signs and Symptoms

➔ Simple uncomplicated laceration of skin without involvement of deeper structures
Management
1: Irrigate and clean wound thoroughly
2. Prepare area in sterile fashion
3. Provide local anesthesia with 1% Lidocaine
4. Close with absorbable suture, non-absorbable suture, dermabond, or steri-strips as dependent on depth
of wound
5. If dirty wound or environment, administer ONE of the following:
● Clindamycin (Cleocin) 300-450mg PO q6h X 10 days
● TMP-SMZ (Septra) DS 1 tab PO bid x 10 days
● Moxifloxacin (Avelox) 400mg PO qd x 10 days
6. Check tetanus status and treat as needed; do not suture if wound is > 12 h old (> 24 h on face), or if
puncture/bite wound
Disposition
70
Malaria
Definition
Protozoan infection transmitted by Anopheles mosquito; prevention through personal protective measures
is the key (anti-malarial meds, DEET, permethrin, minimize exposed skin). May present like pneumonia or
gastroenteritis. The use of chemoprophylaxis does NOT rule out malaria.
Signs and Symptoms

➔ History of travel to malaria-endemic area, non-compliance with anti-malarial meds and/or personal
protective measures;
➔ Malaise, fatigue, and myalgia followed by recurrent episodes of fevers, chills, rigors, profuse
sweats, headache, backache, nausea, vomiting, diarrhea; tachycardia, orthostatic hypotension,
tender hepatomegaly, moderate splenomegaly, and delirium
Management
1. Malarone (Atovaquone) 4 tabs daily X 3 days w/ food PLUS Primaquine 30mg daily X 14 days
● Must rule out G6PD deficiency before giving Primaquine
2. Acetaminophen (Tylenol) 1000mg PO q6h prn fever
Disposition
➢ Routine evacuation for uncomplicated cases
➢ Urgent e
vacuation if cerebral, pulmonary, or vital sign instability
71
Meningitis
Definition
Life-threatening inflammation of the meninges (tissue surrounding the brain and spinal cord). Caused by
bacterial, viral, or fungal pathogens. May cause death in hours if not treated aggressively.
Signs and Symptoms

➔ Severe headache, high fever, altered mental status, photophobia, nausea/vomiting, malaise,
seizures.
➔ Positive Brudzinski’s sign (pain with head and neck flexion) and Kernig’s sign (neck pain with hip
flexion and knee extension) signs
Management
1.Initiate immediate IV access
2. Administer BOTH of the following
● Dexamethasone (Decadron) 10mg IV/IM q6hr
● Ceftriaxone (Rocephin) 2g IV q12hr (IM route possible alternative, but prefer IV route)
4. Treat per Nausea/Vomiting P rotocol
5. If seizures occur, treat per Seizure Protocol
6. Moxifloxacin (Avelox) 400mg PO once OR Ceftriaxone (Rocephin) 250mg IM for prophylaxis of close
contacts
Disposition
72
Nausea/Vomiting
Definition
Non-specific nausea/vomiting. Common causes in the soldier population include gastroenteritis, motion
sickness, dehydration, headaches, etc.
Signs and Symptoms

➔ Pallor, lethargy, abdominal pain, dizziness
Management
1. If nausea/vomiting is mild or indigestion-related, administer the following:
● Calcium Carbonate (TUMS) 2-4 500mg tablets
○ Max 15 tablets in 24 hours
● Bismuth Subsalicylate (Pepto-Bismol) 2 tablets/tablespoons q30min prn
○ Max 8 doses in 24 hours
2. If nausea/vomiting is caused by vertigo or motion sickness , ONE of administer the following:

● Diphenhydramine (Benadryl) 25-50mg IV/IM/PO q6hr prn
● Meclizine (Antivert) 25-50mg PO 1hr before travel, may repeat q24hr for duration of journey
3. If nausea/vomiting is moderate-severe, administer ONE of the following:

● Ondansetron (Zofran) 4-8mg IV/IM bid or 8mg PO q8hr prn
● Promethazine (Phenergan) 25mg IV/IM/PO q6hr prn
Disposition
➢ Evacuation per protocol for underlying condition
73
Pain Management
Definition
Pain as it pertains to injuries and illnesses in the garrison setting
Management
1. Acetaminophen (Tylenol) 1000mg PO q6hr prn
2. Nonsteroidal anti-inflammatory drugs (NSAIDS) (CHOOSE 1 ONLY)

a. Meloxicam (Mobic) 15mg PO daily prn
b. Ibuprofen (Motrin) 800mg PO q8hr prn
c. Ketorolac (Toradol) 30mg IM q6hr prn
i. Consider 10mg PO q8hr prn for prolonged use
3. Narcotic Medications (CHOOSE 1 ONLY)

a. Fentanyl Lozenge (Actiq Lozenge) 800mcg orally over 15 min (may repeat dose)
b. Morphine Sulfate: 5mg IV initial dose then 5mg IV q10min for max dose of 30mg. Repeat
as necessary q30-60min.
4. Treat per Nausea/Vomiting Protocol
Disposition
➢ Consider underlying cause to determine evacuation priority. Patients receiving IV/IM opiates should
most likely be evacuated
74
Peritonsillar Abscess
Definition
Infection with abscess formation and pus collection between anterior and posterior tonsillar pillars, usually
following acute episode of tonsillopharyngitis
Signs and Symptoms

➔ Extreme sore throat or neck pain, dysphagia, dysphonia, fever, erythema, edema, asymmetry of
oropharynx with deviation of uvula
Management
● Clindamycin (Cleocin) 300-450mg PO q6h X 21d
● Amoxicillin/Clavulanic Acid (Augmentin) 500/125mg PO tid 875/125mg PO bid
● Ceftriaxone (Rocephin) 1gm IV/IM daily x 7d
3. If unresolving or worsening symptoms to include airway obstruction, the patient must be evacuated for
needle aspiration or I&D (caution must be used to avoid carotid artery perforation)
Disposition
➢ Routine evacuation
➢ Priority evacuation if airway obstruction
75
Rhabdomyolysis
Definition
Condition caused by extensive injury to skeletal muscles, resulting in the leakage of large quantities of
potentially toxic intracellular contents (myoglobin, potassium, etc.) into the bloodstream. Common
causative injuries include crush injuries, snake bites, severe muscle strains, electrical/thermal burns,
carbon monoxide poisoning, blunt trauma, severe physical exertion.
Signs and Symptoms

➔ Acute muscle pain (myalgias), muscle weakness, fever, malaise, nausea/vomiting, tea-colored
urine, oliguria/anuria, dipstick positive for blood, but no intact RBC on a spun specimen
Management
1. Normal saline 1-2L bolus IV/IO followed by 500mL-1L/hr (Avoid Lactated Ringers due to potassium
content)
● Titrate to achieve a target urine output of > 200mL/hr (measure with Foley Catheter)
2. Consider urinary alkalinization to achieve urine pH > 6.5
● Mix Sodium Bicarbonate 40mEq (1 ampule/bristojet) in 500mL normal saline. Run at 100mL/hr
3. If signs of Hyperkalemia occur(noted on cardiac monitor), administer:
● Calcium Gluconate: 1 gram (10mL of a 10% solution) IV/IO
● Sodium Bicarbonate: 40mEq (1 ampule) IV/IO
4. If signs and symptoms of Hypocalcemia occur (perioral tingling, muscle tetany, QT prolongation), STOP
sodium bicarbonate infusions.
Disposition
76
Seizure
Definition
Uncontrolled electrical activity in the brain, which may produce physical convulsions, minor physical signs,
thought disturbances, or a combination of symptoms. May be caused by injury, high fever, alcohol
withdrawal, drug use, toxins, and structural abnormalities of the central nervous system (CNS).
Signs and Symptoms

➔ Involuntary repetitive muscle movements that are abrupt in onset, associated unresponsiveness,
typically lasts 90-120 seconds, followed by a period of confusion and somnolence (postictal state)
➔ Evidence of seizure activity may include urinary incontinence and acute intraoral trauma (ex.
Tongue biting)
Management
1. Place the patient in the left lateral recumbent position. DO NOT PLACE ANYTHING IN PATIENTS
MOUTH!
2. Support and maintain airway and ventilation as needed to include SpO2.
3. If actively seizing, administer ONE of the following:
● Diazepam (Valium) 5-10mg IV/IO q5min to a maximum dose of 20mg
● Midazolam (Versed) 5mg q5min or 5-10mg IM/IN q15min (no maximum dose)
4. If seizures are accompanied by a fever:
● Consider meningitis and treat per Meningitis protocol
● Consider malaria if in malaria endemic area and treat per Malaria protocol
Disposition
77
Sepsis/Septic Shock
Definition
Severe life-threatening bacterial blood infection; rapid onset; death may occur within 4-6 hrs without
antibiotic therapy
Signs and Symptoms

➔ Hypotension, fever, chills, tachycardia, altered mental status, dyspnea, possible purpuric skin rash
Management
1. IV or IO access
● Ertapenem (Invanz) 1gm IV/IM daily
● Ceftriaxone (Rocephin) 2gm IV/IM daily,
3. If hypotensive, give 1L NS or LR bolus (if unavailable, give 500mL Hextend). Repeat bolus if needed to
maintain systolic BP >90 mmHg or palpable radial pulse.
4. If hypotension continues, administer:
● Epinephrine (1:100,000, 10mcg/mL). Administer via push dose of 0.5-2mL (5-20mcg) IV/IO to
maintain radial pulse or SBP > 90 mmHg
6. If hypotension persists after fluids and epinephrine, administer:
● Dexamethasone (Decadron) 10mg IV
7. Monitor for decreased mental status and be prepared to manage airway
Disposition
78
Smoke Inhalation
Definition
Common after closed space exposure to fire; consider airway burns, carbon monoxide poisoning, other
toxin inhalation, and need for hyperbaric oxygen
Signs and Symptoms

➔ History of smoke exposure, burns, singed nares, facial burns, coughing, respiratory distress (may
be delayed onset)
Management
1. Refer to Airway Management protocol and consider early cricothyroidotomy or intubation
2. Administer the following:
● Oxygen if available
● Albuterol (Proventil) MDI 2-4 puffs q4-6h
● Dexamethasone (Decadron) 10mg IV/IM daily x 2 days
3. Limit patient exertion and activity
Disposition
➢ Priority evacuation if significant inhalation suspected
➢ Urgent evacuation if in respiratory distress
79
Sprains and Strains
Definition
Sprain or strain of musculoskeletal structures
Signs and Symptoms

➔ Swelling, pain, erythema, ecchymosis, tenderness, decreased range of motion
Management
1. “RICE” (Rest, Ice, Compression, Elevation)
2. Orthosis/splint/crutches for pain relief and stability
4. If no fracture, initiate rehab immediately; active range of motion exercises as tolerated; encourage weight
bearing as tolerated; suspect occult fracture if no improvement within one week
Disposition
80
Subungual Hematoma
Definition
Collection of blood under the nail; typically occurs after trauma to fingernail or toenail
Signs and Symptoms

➔ Pain and purplish-black discoloration under the nail
Management
1. Decompress nail with large gauge needle introduced through nail over discolored area with a gentle but
sustained rotating motion until underlying blood and pressure is relieved; gentle pressure to the nail
immediately after the procedure may evacuate additional blood
3. Tape/splint if fracture suspected
Disposition
81
Syncope
Definition
A brief loss of consciousness and postural tone that resolves spontaneously with a return to baseline
neurological function within seconds or a few minutes. Most common causes include vasovagal
stimulus, orthostatic hypotension, cardiac arrhythmias, medications, or neurological etiologies
Signs and Symptoms

➔ Sudden and brief loss of consciousness; without seizures; return to normal mentation; physical
injuries from fall may occur.
Management
1. Supportive care; place in supine position and ensure airway is open, should regain consciousness within
a few seconds
2. Check blood glucose; correct hypoglycemia prn
3. Check vitals; stabilize with oxygen or fluid resuscitation prn
4. If no response, consider heat injury, anaphylaxis, cardiac, and pulmonary etiologies and treat as per
protocol
5. Cardiac monitoring
Disposition
➢ Evacuation usually not required; unless other diagnosis or symptoms continue/recur
82
Testicular Pain
Definition
Testicular pain due to torsion, epididymitis, orchitis, STIs, hernias, masses, and trauma
Signs and Symptoms

➔ Torsion: sudden onset of pain, pain-induced nausea/vomiting, swelling, abnormal lie of testicle,
symptoms increase with elevation, associated with activity, loss of cremasteric reflex;
➔ Epididymitis: gradual onset of worsening pain, +/- fever, +/- dysuria, +/- trauma
Management
1. If torsion suspected, manually detorse by rotating outward “open the book”, if pain increases attempt
once to rotate in opposite direction
2. If other cause suspected, consider and treat as per Urinary Tract Infection protocol and treat pain as
per Pain Management protocol
Disposition
➢ Urgent e vacuation for testicular torsion even if manually relieved with detorsion. For other causes
of testicular pain, treat the cause and consider evacuation if symptoms persist more than 3 days,
and if the patient is operationally compromised.
83
Tonsillopharyngitis
Definition
Acute bacterial or viral infection/inflammation of the pharynx, palatine tonsils, or both. 30% of cases are
caused by Group A Beta Hemolytic Streptococcus (GABHS) bacteria
Signs and Symptoms

➔ Sore throat, enlarged and edematous tonsils, erythema and exudates, palatal petechiae, anterior
cervical lymphadenopathy
➔ Fever > 102.5 suggestive of bacterial cause; throat culture is most accurate test for GABHS
Management
1. Salt water gargles
2. For fever, administer:
● Acetaminophen (Tylenol) 1000mg PO q6h
3. If bacterial suspected, administer
● Azithromycin (Zithromax) 500mg PO daily x 3 days
4. Observe and treat as per Peritonsillar Abscess protocol as required
5. Consider concurrent infection with Ebstein-Barr virus (Infectious Mononucleosis)
Disposition
84
Urinary Tract Infection (UTI)
Definition
Bacterial infection along the urinary tract (Urethritis, Prostatitis, Cystitis, or Pyelonephritis); most common in
females or in the tactical setting where dehydration can occur. Renal colic (kidney stones) is also
associated with UTI. May be confused with sexually transmitted infections.
Signs and Symptoms

➔ Frequency, urgency, dysuria; possible cloudy malodorous or dark urine, suprapubic discomfort
➔ CVAT or back/flank pain, fever, nausea/vomiting are more likely to occur with Pyelonephritis.
Management
1. Administer ONE of the following antibiotics:
● Ceftriaxone (Rocephin) 1g IV/IM
● TMZ-SMP (Septra) 1 PO bid x 3 days
2. In addition administer:
● Azithromycin 1g PO once
4. PO hydration
5. If fever, CVAT, back pain, or flank pain, suspect pyelonephritis or renal colic and treat per Flank Pain
protocol.
Disposition
➢ Evacuation usually not required for lower urinary tract infections
➢ Routine evacuation if symptoms worsen or no resolution
85
Pharmacology
Reference
⬇⬇⬇⬇⬇⬇⬇
86
ACETAMINOPHEN (TYLENOL)
Class
CNS agent – non-narcotic, analgesic, antipyretic
Action
Analgesia action possibly through peripheral nervous system; fever reduction through direct action on the
hypothalamus heat-regulating center resulting in peripheral vasodilation, sweating, and dissipation of heat;
has minimal effect on platelet aggregation, bleeding time, and gastric bleeding
Indications Contraindications
➢ Mild Pain ➢ Hypersensitivity to drug

➢ Fever ➢ Caution with history of excess alcohol use
➢ Chronic Liver Damage
Dose
❏ TCCC: 650mg bilayer caplet, 2 PO q8hr
❏ Pain Management: 1000mg PO q6h (max: 4 g/d)
Side Effects Adverse Reactions

➔ Rash ➢ Hemolytic Anemia
➔ Urticaria ➢ Liver Damage
87
ACETAZOLAMIDE (DIAMOX)
Class
CNS Agent – carbonic anhydrase inhibitor; diuretic, anticonvulsant
Action
Diuretic effect due to inhibition of carbonic anhydrase activity in proximal renal tubule, preventing formation
of carbonic acid; anticonvulsant action effect thought to involve inhibition of CNS carbonic anhydrase,
retarding abnormal paroxysmal discharge from CNS neurons
➢ Prevention/treatment of acute mountain ➢ Sulfa allergy

sickness
➢ Acute High Altitude Illness
Dose
❏ Altitude Illness:
❏ Pretreatment: 125mg PO bid 24 hours before ascent
❏ Treatment: 250mg PO bid

➔ Paresthesia in extremities ➢ Transient Myopia (usually resolves with
➔ Hearing dysfunction/tinnitus discontinuation of drug)
➔ Loss of appetite ➢ Hematuria
➢ Flaccid Paralysis
➢ Convulsions
88
ACETYLSALICYLIC ACID (ASPIRIN)
Class
CNS agent – NSAID; salicylate; anti-inflammatory, analgesic, antipyretic
Action
Inhibits prostaglandin synthesis involved in the production of inflammation, pain, and fever; enhances
antigen removal and reduces spread of inflammation; peripheral analgesic action with limited CNS action in
the hypothalamus; antipyretic by indirect centrally mediated peripheral vasodilation and sweating;
powerfully inhibits platelet aggregation and ability of blood to clot; high levels can impair hepatic synthesis
of blood coagulation factors VII, IX, and X, possibly by inhibiting the action of vitamin K
➢ Myocardial Infarction prophylaxis (reduce ➢ Hypersensitivity to aspirin

risk of death and/or nonfatal MI) ➢ Hypersensitivity to nonsteroidal
➢ Mild to moderate pain relief anti-inflammatory drugs (NSAIDs)
➢ History of GI bleeding
➢ Fever
➢ Patients w/ bleeding disorders (ex. hemophilia)
➢ Patient age < 16 years old
Dose
❏ Chest Pain protocol: 324mg PO
❏ Deep Venous Thrombosis (DVT) protocol: 324mg PO

➔ Gastrointestinal symptoms ➔ Interacts w/ NSAIDS, coumadin, heparin
➔ Gastrointestinal bleeding
89
ALBUTEROL (Proventil, Ventolin)
Class
Autonomic nervous system agent – sympathomimetic, beta-adrenergic agonist, bronchodilator
Action
Acts more prominently on beta2 receptors (particularly smooth muscles of bronchi, uterus, and vascular
supply to skeletal muscles) than on beta1 (heart) receptors; minimal or no effect on alpha-adrenergic
receptors; inhibits histamine release by mast cells; produces bronchodilation by relaxing the smooth
muscles of the bronchial tree which decreases airway resistance, facilitates mucus drainage, and increases
vital capacity
➢ Relief of bronchospasm ➢ Known hypersensitivity to Albuterol

➢ Pregnancy
Dose
❏ Asthma protocol: 2-3 puffs q5min
❏ Bronchitis/Pneumonia protocol: 2-4 puffs q4-6hrs
❏ Cough protocol: 3-4 puffs q4hr
➔ Tremor ➔ Hypertension
➔ Nausea ➔ Angina
➔ Nervousness ➔ Vertigo
➔ Palpitations ➔ CNS stimulation
➔ Sleeplessness
90
AZITHROMYCIN (ZITHROMAX, Z-Pak)
Class
Antimicrobial – antibiotic; macrolide
Action
Reversibly binds to 50S ribosomal subunit of susceptible organisms inhibiting protein synthesis; effective
against mild to moderate infections caused by pyogenic streptococci, Streptococcus pneumoniae,
Haemophilus influenzae, Mycobacterium avium–intracellulare, and Staphylococcus aureus
➢ Acute bacterial sinusitis ➢ Known allergy to azithromycin

➢ Mild community-acquired pneumonia ➢ Pregnancy
➢ Chancroid ➢ Patients receiving Astemizole or Cisapride
➢ Pharyngitis
➢ Uncomplicated skin infections
➢ Urethritis
Dose
❏ Bronchitis/Pneumonia, Ear Infection, Cutaneous Abscess, Ingrown Toenail:
❏ 500mg PO first dose then 250mg daily for 4 days
❏ Gastroenteritis, Tonsillopharyngitis 500mg PO daily X 3 days
❏ Urinary Tract Infection 1g PO once
➔ Nausea/vomiting ➔ Angioedema
➔ Diarrhea ➔ Cholestatic jaundice
➔ Abdominal pain
91
BACITRACIN
Class
Antimicrobial – antibiotic
Action
Polypeptide derived from Bacillus subtilis culture; bactericidal/bacteriostatic that appears to inhibit cell wall
synthesis; activity similar to penicillin; active against many gram-positives including Streptococci,
Staphylococci, Pneumococci, Corynebacteria, Clostridia, Neisseria, Gonococci, Meningococci,
Haemophilus influenzae, and Treponema pallidum; ineffective against most other gram-negatives
➢ Superficial skin infections ➢ Atopic individuals

➢ Pregnancy category C
Dose
❏ Epistaxis: AAA bid-tid
❏ General cuts/scapes: AAA bid-tid, clean affected area prior to application
➔ No remarkable side effects noted ➔ Bacitracin hypersensitivity (erythema,

anaphylaxis)
92
BISMUTH SUBSALICYLATE (PEPTO-BISMOL)
Class
Antacid- Anti-diarrheal
Action
As an antidiarrheal, the exact mechanism has not been determined. Bismuth subsalicylate may exert its
antidiarrheal action not only by stimulating absorption of fluid and electrolytes across the intestinal wall
(antisecretory action) but also, when hydrolyzed to salicylic acid, by inhibiting the synthesis of
prostaglandins responsible for intestinal inflammation and hypermotility.
➢ Diarrhea ➢ Salicylate allergy

➢ Nausea/Vomiting ➢ Peptic Ulcers
Dose
❏ Nausea/Vomiting: 2 tablets/tablespoons q30min prn
❏ Max 8 doses in 24 hours
➔ Darkening of stools ➔ Hearing loss

➔ Black tongue ➔ Gastrointestinal bleeding
93
BENZONATATE (TESSALON PERLES)
Class
ENT agent – antitussive
Action
Nonnarcotic antitussive chemically related to tetracaine; does not inhibit respiratory center at
recommended doses; decreases frequency and intensity of nonproductive cough
➢ Non-productive cough in acute and chronic ➢ Pregnancy category C

respiratory conditions
Dose
❏ Cough: 100mg PO tid
➔ Drowsiness ➔ Rash
➔ Sedation ➔ Pruritus
➔ Headache
94
CALCIUM CARBONATE (TUMS)
Class
Antacid
Action
Calcium carbonate is an inorganic salt used as an antacid. It is a basic compound that acts by neutralizing
hydrochloric acid in gastric secretions. Subsequent increases in pH may inhibit the action of pepsin.
➢ Nausea ➢ Kidney disease

➢ GERD ➢ Hypercalcemia
Dose
❏ Nausea/Vomiting: 2-4 500mg tablets
❏ Max 15 tablets in 24 hours
➔ Constipation ➔ Renal issues

➔ Gas ➔ Mood changes
95
CALCIUM GLUCONATE (KALCINATE)
Class
Calcium Salt
Action
Calcium increases the threshold potential, thus restoring the normal gradient between threshold potential
and resting membrane potential, which is abnormally elevated in hyperkalemia.
➢ Acute Hyperkalemia ➢ Hypercalcemia

➢ Acute hypocalcemia ➢ Renal or cardiac disease
Dose
❏ Rhabdomyolysis: 1 gram (10mL of a 10% solution) IV/IO
➔ Extravasation may cause tissue ➔ N/A

damage/necrosis
➔ Rapid injection may cause vasodilation,
hypotension, or dysrhythmia
96
CEFTRIAXONE (ROCEPHIN)
Class
Antimicrobial – antibiotic; third-generation cephalosporin
Action
Preferentially binds to penicillin-binding proteins (PBP) and inhibits bacterial cell wall synthesis; effective
against most Enterobacteriaceae, gram-positive aerobic cocci, Neisseria meningitides and gonorrhea;
some effect against Treponema pallidum
➢ Pneumonia ➢ Penicillin allergy

➢ UTI ➢ Hepatic/liver dysfunction
➢ Skin infections
➢ Abdominal infections
Dose
❏ Urinary Tract Infection: 1 gram IV/IM
❏ Abdominal Pain, Bronchitis/Pneumonia, Cellulitis, Dental Pain:
❏ 1 gram IV/IM daily (typically 4-14 days)
❏ Epiglottitis, Peritonsillar Abscess: 1 gram IV/IM daily X 7 days
❏ Sepsis: 2 grams IV/IM daily
❏ Flank Pain, Meningitis, J oint Infection: 2 grams IV/IM q12hrs
➔ Headaches ➔ Eosinophilia
➔ Dizziness ➔ Thrombocytosis
➔ Nausea/Vomiting
➔ Diarrhea
➔ Urticaria
➔ Increased Temperature
97
CETIRIZINE (ZYRTEC)
Class
ENT agent – H1-receptor antagonist; non-sedating antihistamine
Action
Potent H1-receptor antagonist and antihistamine; low lipophilicity and H1-receptor selectivity and thus no
significant anticholinergic or CNS activity; reduces local and systemic effects of histamine release
➢ Mild allergy symptoms (runny nose, ➢ Known hypersensitivity to cetirizine or

watery/itchy eyes, sneezing, hives) hydroxyzine
Dose
❏ Allergic Rhinitis/Cold-like Symptoms: 10mg PO qdaily
➔ Side effects less likely than other first ➔ Stomach Pain

generation antihistamines ➔ Nausea/Vomiting
➔ Drowsiness
➔ Tiredness
➔ Dry Mouth
98
CLINDAMYCIN (CLEOCIN)
Class
Antimicrobial – Lincosamide/lincomycin antibiotic
Action
Suppresses protein synthesis by binding to 50 S subunits of bacterial ribosomes; effective against strains
of anaerobic streptococci, Bacteroides (especially B. fragilis), Fusobacterium, Actinomyces israelii,
Peptococcus, Clostridium sp, and aerobic gram-positive cocci, including Staphylococcus aureus,
Staphylococcus epidermidis, Streptococci (except S. faecalis), and Pneumococci
➢ Dental infections ➢ Clindamycin or lincomycin hypersensitivity

➢ Lacerations ➢ Ulcerative colitis
➢ Peritonsillar abscess
Dose
❏ Dental Pain, Laceration: 300-450mg PO q6hrs X 10 days
❏ Cutaneous Abscess, Peritonsillar Abscess: 300-450mg PO q6hrs X 21 days
➔ Nausea/Vomiting ➔ Hypotension
➔ Diarrhea ➔ Jaundice
➔ Stomach or joint pain ➔ Dark Urine
99
CLOTRIMAZOLE (Topical)
Class
Topical antifungal cream
Action
Clotrimazole is an imidazole derivative which works by inhibiting the growth of individual Candida or fungal

ermeability of the fungal cell wall. It
cells by altering the p binds to phospholipids in the cell membrane and
rgosterol and other s terols required for c ell membrane production. Clotrimazole
iosynthesis of e
inhibits the b
may s low fungal growth or result in fungal cell death
➢ Mild fungal skin infections ➢ Hypersensitivity to clotrimazole
Dose
❏ Fungal Skin Infection: AAA tid until one week after lesion resolves
➔ Redness ➔ N/A
➔ Blistering
➔ Itchiness
100
CYCLOBENZAPRINE (FLEXERIL)
Class
Autonomic nervous system agent – central acting; skeletal muscle relaxant
Action
Structurally and pharmacologically related to TCAs; relieves skeletal muscle spasm of local origin without
interfering with muscle function; believed to act primarily within CNS at brain stem with some action at
spinal cord level; depresses tonic somatic motor activity, although both gamma and alpha motor neurons
are affected; increases circulating norepinephrine by blocking synaptic reuptake, thus producing
antidepressant effect; has sedative effect and potent central and peripheral anticholinergic activity
➢ Short term relief of muscle spasm ➢ Cardiac arrhythmias

➢ Recovery of MI (heart attack
Dose
❏ Back Pain: 10mg PO tid (no longer than 2-3 weeks)
➔ Dry mouth ➔ Tongue/Face edema

➔ Dizziness ➔ Heart palpitations
➔ Fatigue ➔ Muscle twitching
101
DEXAMETHASONE
Class
Hormones and synthetic substitutes – steroid; adrenocorticoid; glucocorticoid
Action
Long-acting synthetic adrenocorticoid with intense glucocorticoid activity and minimal mineralocorticoid
activity; Antiinflammatory and immunosuppressive properties; prevents accumulation of inflammatory cells
at sites of infection; inhibits phagocytosis, lysosomal enzyme release, and synthesis of selected chemical
mediators of inflammation; reduces capillary dilation and permeability
➢ Emergency treatment of AMS, HACE, ➢ Use caution in patients with a history of

HAPE ○ Diabetes
➢ Inflammatory conditions ○ Hypertension
➢ Allergic conditions ○ Ulcers
Dose
❏ Altitude Illness (AMS): 4mg PO q6hr
❏ Altitude Illness (HACE): 8mg IV/IM, then 4mg IV/IM q6hrs
❏ Anaphylactic Reaction, Asthma, Epiglottitis: 10mg IV//IM/PO
❏ Smoke Inhalation: 10mg IV/IM daily x 2days
❏ Contact Dermatitis: 10mg IM daily X 5 days
➔ Delayed wound healing ➔ Psychotic behavior

➔ Acne ➔ Congestive heart failure
➔ Edema ➔ Hypertension
102
DEXTROMETHORPHAN (ROBITUSSIN DM)
Class
ENT agent – Antitussive
Action
Nonnarcotic derivative that depresses the cough center in the medulla; chemically related to morphine but
without central hypnotic or analgesic effect or capacity to cause tolerance or addiction; antitussive activity
comparable to that of codeine but is less likely than codeine to cause constipation, drowsiness, or GI
disturbance
➢ Temporary relief of non-productive cough ➢ Asthma

➢ Persistent cough
➢ Liver impairment
Dose
❏ Bronchitis/Pneumonia, Cough: 30mg PO bid
➔ Dizziness ➔ CNS depression w/ high doses

➔ Drowsiness ➔ Excitability
➔ Nausea/Vomiting
103
DIAZEPAM (VALIUM)
Class
CNS agent – benzodiazepine; anticonvulsant; anxiolytic
Action
Anticonvulsant and antianxiety psychotherapeutic drug with action at both limbic and subcortical levels of
CNS; increases total sleep time, but shortens REM and stage 4 sleep
➢ Acute anxiety ➢ Hypotension

➢ Seizures ➢ Administration of other respiratory
➢ Relaxation of skeletal muscles depressants (morphine, fentanyl, etc.)
Dose
❏ Behavioral Changes: 2mg IV, repeat q3-5min prn for a max dose of 5mg
❏ Envonomation (Insect/Arthropod): 2-10mg PO q6-8hr or 5-10mg IV/IM
❏ Back Pain: 5-10mg IM/IV/PO, repeat prn q6-8hr
❏ Seizure: 5-10mg IV/IO q5min or 10mg IM q15min, max dosage: 20mg
➔ Hypotension ➔ Bradycardia
➔ Decreased respiration ➔ Cardiovascular collapse
➔ Drowsiness ➔ Amnesia
104
DIPHENHYDRAMINE (BENADRYL)
Class
ENT agent – H1-blocker; antihistamine
Action
H1-receptor antagonist and antihistamine as it competes for H1-receptor sites on effector cells; significant
central anticholinergic activity as it prolongs action of dopamine by inhibiting its reuptake and storage, thus
decreasing parkinsonism and drug-induced extrapyramidal symptoms
➢ Mild-moderate allergic symptoms ➢ Asthma

➢ Dystonic Reaction ➢ Pregnant or lactating females
Dose
❏ Allergic Rhinitis/Cold-like Symptoms, Envenomation (insect/arthropod or Scorpions):
❏ 25-50mg PO q4-6hr
❏ Contact Dermatitis: 25-50mg PO qid prn for pruritus, if tactically feasible
❏ Nausea/Vomiting: 25-50mg IV/IM/PO
❏ Anaphylactic Reaction: 50mg IV/IM/PO/SL
➔ Sedation ➔ Insomnia
➔ Blurred vision ➔ Vertigo
➔ Nausea/Vomiting ➔ Palpitations
105
EPINEPHRINE
Class
Autonomic nervous system agent – natural and synthetic catecholamine; alpha- and beta-adrenergic
agonist; bronchodilator
Action
Sympathomimetic that acts directly on both alpha and beta receptors; the most potent activator of alpha
receptors; strengthens myocardial contraction; increases systolic but may decrease diastolic blood
pressure; increases cardiac rate and output; constricts bronchial arterioles and inhibits histamine release,
thus reducing congestion and edema and increasing tidal volume and vital capacity
➢ Anaphylaxis ➢ 1:1,000 is NOT given IV

➢ Asthma ➢ Use caution in patients w/ history of heart
disease or over the age of 40
Dose
❏ Sepsis: 0.5mg IM (0.5mL of 1:1000)
❏ Asthma: 0.5mg IM (0.5mL of 1:1000). Repeat ONCE in 5-10min if needed
❏ Anaphylactic Reaction: 0.5mg IM (0.5mL of 1:1000). Repeat q5min prn
➔ Hypertension ➔ Uncontrolled effects on myocardium and

➔ Cardiac arrhythmias arterial system
➔ Nausea/Vomiting
106
ERTAPENEM (INVANZ)
Class
Antimicrobial – antibiotic, carbapenem, beta-lactam
Action
Broad-spectrum antibiotic that inhibits cell wall synthesis of gram-positive and gram-negative bacteria by its
strong affinity for bacterial cell wall penicillin-binding proteins (PBPs); highly resistant to most bacterial
beta-lactamases; effective against most Enterobacteriaceae, Pseudomonas aeruginosa, and Acinetobacter
spp; poorly effective against Enterococci, particularly vancomycin-resistant strains
➢ Complicated intra-abdominal infections ➢ Hypersensitivity to ertapenem or other

➢ Pneumonia carbapenems
➢ Complicated UTI/Pyelonephritis ➢ Penicillin allergy with documented severe
➢ Penetrating battlefield trauma reaction
Dose
❏ TCCC (all open injuries): 1gram IV/IM daily (Until further care)
❏ Abdominal Pain, Joint Infection: 1gram IV/IM daily X 5-14 days
❏ Cellulitis: 1 gram IV/IM daily X 7-14 days
❏ Bronchitis/Pneumonia, Flank Pain: 1 gram IV/IM daily X 10-14 days
(For IV reconstitute with 10mL NS; for IM reconstitute with 3.2mL 1% lidocaine w/o epinephrine)
➔ Diarrhea ➔ Seizures
➔ Infused vein phlebitis/thrombophlebitis
➔ Nausea/Vomiting
107
FENTANYL ORAL LOZENGES (ACTIQ)
Class
CNS agent - potent narcotic (opiate) agonist
Action
Action similar to morphine with more rapid and less prolonged analgesia and sedation, but less emetic
effect
➢ Moderate-severe battlefield related trauma ➢ Known allergy to medication

pain ➢ Head injury
Dose
❏ TCCC, Pain Management: 800mcg orally over 15min, repeat prn. Max 1600mcg/day
❏ Place lozenge between cheek and lower gum. DO NOT CHEW!
➔ Nausea/Vomiting ➔ Laryngospasm
➔ Hypotension ➔ Convulsions
➔ Respiratory Depression ➔ Chest wall skeletal muscle rigidity (high or
rapid IV dose)
108
FEXOFENADINE (ALLEGRA)
Class
ENT agent – H1-receptor antagonist; non-sedating antihistamine
Action
Competitively antagonizes histamine at the H1-receptor site; does not bind with histamine to inactivate it;
not associated with anticholinergic or sedative properties; inhibits antigen-induced bronchospasm and
histamine release from mast cells
➢ Allergic Rhinitis ➢ Known hypersensitivity

➢ Chronic urticaria ➢ Pregnancy Category Cf
Dose
❏ Allergic Rhinitis/Cold-like Symptoms: 60mg PO bid or 180mg PD qd
➔ Headache ➔ N/A
➔ Drowsiness
➔ Fatigue
109
FLUCONAZOLE (DIFLUCAN)
Class
Synthetic triazole antifungal agent
Action
Its mechanism of action, like that of other azoles, involves interruption of the conversion of lanosterol to
ergosterol via binding to fungal cytochrome P-450 and subsequent disruption of fungal membranes.
➢ Fungal skin infection ➢ Hypersensitivity to fluconazole

➢ Vaginal candidiasis
➢ Oropharyngeal candidiasis
Dose
❏ Fungal Infection: 150 mg PO qwk x 2 wks
➔ N/A ➔ Steven-Jonson syndrome

➔ Toxic epidermal necrosis
110
GATIFLOXACIN (Ophthalmic Solution)
Class
Antimicrobial – antibiotic; quinolone
Action
Broad spectrum bactericidal agent that inhibits DNA-gyrase topoisomerase II, an enzyme necessary for
bacterial replication, transcription, repair and recombination; effective against methicillin-resistant
Staphylococcus aureus (MRSA), penicillin resistant Streptococcus pneumoniae, Pseudomonas aeruginosa,
and cocci resistant to other quinolones
➢ Eye infections ➢ Hypersensitivity to any component of

➢ May be used for outer ear infections product
Dose
❏ Corneal Abrasion/Corneal Ulcer/Conjunctivitis:
❏ 0.3% 1 drop in the affected eye qid until after 24h fluorescein negative (q2h if corneal ulcer)
❏ Ear Infection (Otitis Externa)
❏ 5 drops tid-qid until symptoms remain resolved for 48 hours
➔ Temporary blurring of vision or stinging ➔ Skin rash

➔ Lid margin crusting ➔ Corneal staining
➔ Bitter taste ➔ Tearing and photophobia
111
GUAIFENESIN (MUCINEX)
Class
ENT agent –expectorant
Action
Enhances reflex outflow of respiratory tract fluids by irritation of gastric mucosa; aids in expectoration by
reducing adhesiveness and surface tension of secretions
➢ Relief of dry, non-productive coughs ➢ Guaifenesin hypersensitivity

➢ Pregnancy category C
Dose
❏ Bronchitis/Pneumonia: 600mg-1200mg PO q12hr prn
➔ Nausea ➔ N/A
➔ Drowsiness
112
HETASTARCH (HEXTEND)
Class
Plasma volume expander – colloid; synthetic starch resembling human glycogen
Action
Increases colloidal osmotic pressure and expands plasma volume similar to albumin, but with less potential
for anaphylaxis or interference with cross matching or blood typing procedures; remains in the intravascular
space increasing arterial and venous pressures, heart rate, cardiac output, urine output; not a blood or
plasma substitute
➢ Treatment of shock secondary to ➢ Known bleeding disorders or uncontrolled

hemorrhage hemorrhage
➢ Congestive heart failure
➢ Renal impairment
Dose
❏ TCCC: 500mL bolus. Continue resuscitation until a palpable radial pulse, improved mental status or
systolic BP of 80-90 is present. No more than 1000mL for burns.
❏ Sepsis/Septic Shock: 1L bolus, prn for hypotension. Max dose 1500mL/day
➔ Nausea/Vomiting ➔ Severe anaphylaxis (rare)

➔ Peripheral or facial edema
➔ Urticaria
113
HYDROCORTISONE
Class
Skin and mucous membrane agent – synthetic hormone; adrenal corticosteroid, glucocorticoid,
mineralocorticoid, antiinflammatory
Action
Stabilizes leukocyte lysosomal membranes, inhibits phagocytosis and release of allergic substances,
suppresses fibroblast formation and collagen deposition
➢ To reduce inflammation in various skin ➢ Steroid hypersensitivity

conditions ➢ Viral/bacterial infections of the skin
➢ Pregnancy Category C
Dose
❏ Contact Dermatitis, Envenomation (Insect/Arthropod):
❏ Apply AAA qid daily until dermatitis resolves
➔ Skin thinning/atrophy ➔ Anaphylactoid reaction

➔ Aggravation or masking of infections ➔ Petechiae
➔ Impaired wound healing ➔ Hyper/hypopigmentation
114
IBUPROFEN (MOTRIN, ADVIL)
Class
CNS agent – NSAID (cox-1); anti-inflammatory, analgesic, antipyretic
Action
Propionic acid inhibitor prototype that blocks prostaglandin synthesis, modulates T-cell function, inhibits
inflammatory cell chemotaxis, decreases release of superoxide radicals or increases scavenging of these
compounds at inflammatory sites, inhibits platelet aggregation and prolongs bleeding time
➢ Mild-moderate pain ➢ History of aspirin sensitivity or asthma

➢ Arthritis ➢ Suspected internal bleeding
➢ Penetrating trauma
➢ Pregnancy
Dose
❏ Pain Management : 800mg PO q8hrs prn
➔ Nausea/Vomiting ➔ Prolonged bleeding time

➔ Dizziness ➔ Tinnitus
➔ Drowsiness ➔ Peptic ulcer
115
KETAMINE (KETALAR)
Class
Rapid acting general sedative and analgesic
Action
NMDA receptor antagonist with potent anesthetic effects.
➢ Moderate-severe pain ➢ Hypersensitivity to ketamine

➢ Anesthetic agent for procedures ➢ Eye globe injury
Dose
❏ TCCC:
❏ 50 mg IM/IN or 20 mg slow IV/IO
❏ Repeat q30min prn for IM/IN or q20min IV/IO prn
➔ Emergence reactions (delirium, ➔ Apnea

hallucinations, confusion) ➔ Laryngeal spasm
➔ Hypertension
➔ Nystagmus
116
KETOROLAC (TORADOL)
Class
CNS agent – NSAID; anti-inflammatory, analgesic, antipyretic
Action
inhibition of prostaglandin synthesis by competitive blocking of the enzyme cyclooxygenase
(COX). Ketorolac is a non-selective COX inhibitor. It is considered a first-generation NSAID.
➢ Mild-moderate pain ➢ Known hypersensitivity to NSAIDS

➢ Fever (if ASA or Acetaminophen not ➢ Any active internal bleeding
available) ➢ Extreme caution in those with heart or
vascular diseases
Dose
❏ Pain Management: 30mg IM q6hr prn
➔ Gastrointestinal symptoms ➔ N/A

➔ Stomach pain
➔ Heartburn
117
LACTATED RINGER’S (LR)
Class
Plasma volume expander – crystalloid; isotonic salt solution
Action
Each liter contains 6.0 g Sodium Chloride (Na+ 130 mEq/L, Cl¯ 109 mEq/L) and other electrolytes (K+ 4
mEq/L, Ca++ 3 mEq/L, Lactate 28 mEq/L, and 9 kcal/L); pH 6.4; remains in the intravascular space for only
a very limited time as it diffuses rapidly throughout the extracellular space
➢ Fluid replacement when blood/plasma not ➢ Do not use with blood products
available in TCCC ➢ Congestive heart failure
➢ Hypovolemia from sepsis, burns,
dehydration, etc.
Dose
systolic BP of 80-90 is present
➔ Hypertension ➔ N/A
➔ Edema
➔ Electrolyte imbalance
118
LIDOCAINE (XYLOCAINE)
Class
Amide-type local anesthetic; cardiovascular agent; class IB antiarrhythmic
Action
Anesthetic effect similar to procaine; class IB antiarrhythmic action by suppressing automaticity in the
His-Purkinje system and by elevating the electrical stimulation threshold of ventricles during diastole
➢ Local anesthetic (Suturing, debridement, ➢ Hypotension

nerve blocks, etc.) ➢ 2nd-3rd degree AV block
➢ Cardiac use for ACLS
Dose
❏ Back Pain: 1-2mL per trigger point. May repeat daily for 2 days
❏ General local anesthesia: To desired effect. Max dose 4.5mg/kg or 300mg
❏ 15mL of 2% solution is 300mg
➔ Slurred speech ➔ Dermatological reaction

➔ Altered mental status ➔ Status asthmaticus
➔ Tinnitus ➔ Anaphylaxis
119
LOPERAMIDE (IMODIUM)
Class
GI agent – antidiarrheal
Action
Synthetic piperidine derivative that inhibits GI peristaltic activity by direct action on circular and longitudinal
intestinal muscles; prolongs intestinal content transit time, increases consistency of stools, and reduces
fluid and electrolyte loss
➢ Acute diarrhea ➢ Acute dysentery

➢ Not for use in children < 12 years old
Dose
❏ Gastroenteritis: 4mg PO initially, then 2mg after every loose BM, max of 16mg/day (do not use if
bloody stools or fevers)
➔ Abdominal pain ➔ Hypersensitivity

➔ Nausea/Vomiting
➔ Drowsiness/Dizziness
120
LORATADINE (CLARITIN)
Class
ENT agent – H1-receptor antagonist – non-sedating antihistamine
Action
Long-acting histamine antagonist with selective peripheral H1-receptor sites that blocks histamine release;
disrupts capillary permeability, edema formation, and constriction of respiratory, GI, and vascular smooth
muscle
➢ Allergic rhinitis ➢ Known hypersensitivity

➢ Chronic urticaria ➢ Pregnancy Category B
Dose
❏ Allergic Rhinitis/Cold-like Symptoms: 10mg PO daily, take on an empty stomach
➔ Dizziness ➔ Hypertension
➔ Dry mouth ➔ Angina
➔ Fatigue ➔ Vertigo
➔ CNS stimulation
➔ Sleeplessness
121
MECLIZINE (ANTIVERT)
Class
H1-Receptor antagonist; antihistamine, anti-vertigo agent
Action
Long-acting piperazine antihistamine with marked effect in blocking histamine-induced vasopressive
response, but only slight anticholinergic action; marked depressant action on labyrinthine excitability and on
conduction in vestibular-cerebellar pathways; exhibits CNS depression, antispasmodic, antiemetic, and
local anesthetic activity
➢ Nausea/Vomiting associated with vertigo or ➢ Known hypersensitivity

motion sickness ➢ Pregnancy Category B
Dose
❏ Nausea/Vomiting: 25-50mg PO 1hr before travel, may repeat q24hr for duration of journey
➔ Dizziness ➔ N/A
➔ Dry mouth
➔ Fatigue
122
MALARONE (Atovaquone/Proguanil)
Class
Antimalarials
Action
The constituents of MALARONE, atovaquone and proguanil hydrochloride, interfere with 2 different
pathways involved in the biosynthesis of pyrimidines required for nucleic acid replication. Atovaquone is a
selective inhibitor of parasite mitochondrial electron transport. Proguanil hydrochloride primarily exerts its
effect by means of the metabolite cycloguanil, a dihydrofolate reductase inhibitor. Inhibition of dihydrofolate
reductase in the malaria parasite disrupts deoxythymidylate synthesis.
➢ Prophylaxis and treatment of Plasmodium ➢ Hypersensitivity to atovaquone, proguanil

falciparum malaria ➢ Severe renal impairment
Dose
❏ Malaria: 4 tabs daily X 3 days w/ food
➔ Headache ➔ Liver transaminase elevations

➔ Abdominal Pain ➔ Seizures
➔ Nausea/vomiting/diarrhea ➔ Psychotic episodes
123
MELOXICAM (MOBIC)
Class
CNS agent – NSAID; anti-inflammatory, analgesic, antipyretic
Action
inhibits prostaglandin synthetase (cylooxygenase 1 and 2) enzymes leading to a decreased
synthesis of prostaglandins, which normally mediate painful inflammatory symptoms.7 As
prostaglandins sensitize neuronal pain receptors, inhibition of their synthesis leads to analgesic
and inflammatory effects. Meloxicam preferentially inhibits COX-2, but also exerts some activity
against COX-1, causing gastrointestinal irritation.
➢ Mild-moderate pain ➢ Allergy to NSAID class of drugs, aspirin

➢ Osteoarthritis and rheumatoid arthritis
Dose
❏ TCCC, Pain Management: 15mg PO daily prn
➔ Allergic reaction ➔ Anaphylactoid reaction

➔ Face edema
➔ Fatigue
➔ Fever
124
METHYLPREDNISOLONE (SOLU-MEDROL)
Class
Hormones and synthetic substitutes – adrenal corticosteroid, glucosteroid, antiinflammatory
Action
Intermediate-acting synthetic steroid with less sodium and water retention effects than hydrocortisone;
inhibits phagocytosis and release of allergic substances; modifies immune response to various stimuli;
antiinflammatory and immunosuppressive
➢ Acute asthma attack ➢ Systemic fungal infections

➢ Contact dermatitis ➢ Pregnancy category C
➢ Severe allergic reactions
Dose
❏ Contact Dermatitis: 125mg IM
➔ Nausea/vomiting ➔ Delayed wound healing

➔ Heartburn ➔ Spontaneous fractures
➔ Headache
125
METRONIDAZOLE (FLAGYL, METROGEL)
Class
Antimicrobial – nitroimidazole antibiotic, antitrichomonal, amebicide
Action
Synthetic compound with direct trichomonacidal, amebicidal, and antibacterial activity (anaerobic bacteria
and some gram-negative bacteria); effective against Trichomonas vaginalis, Entamoeba histolytica, Giardia
lamblia, obligate anaerobic bacteria, gram-negative anaerobic bacilli, and Clostridia; microaerophilic
Streptococci and most aerobic bacteria are resistant
➢ Gastroenteritis presumed due to Giardia ➢ Hypersensitivity to metronidazole or other

nitroimidazole derivatives
➢ Caution in patients with CNS diseases or
blood dyscrasias
Dose
❏ Abdominal Pain: 500mg PO q8hrs in conjunction w/ Ceftriaxone
❏ Gastroenteritis: 500mg PO q8hrs X 3days
➔ Flushing ➔ Seizures
➔ Palpitation ➔ Peripheral neuropathy
➔ Tachycardia ➔ Patients with undiagnosed candidiasis may
➔ Refrain from alcohol use within 3 days after present with more prominent symptoms
treatment to reduce side effects.
126
MIDAZOLAM (VERSED)
Class
CNS agent – benzodiazepine; anticonvulsant; anxiolytic
Action
Anticonvulsant and antianxiety psychotherapeutic drug with action at both limbic and subcortical levels of
CNS; increases total sleep time, but shortens REM and stage 4 sleep
➢ Sedation for short, painful procedures ➢ Known hypersensitivity to midazolam

➢ Active seizures ➢ Hypotension
➢ Agitated patients ➢ Acute narrow angle glaucoma
Dose
❏ Behavioral Changes: 1-2mg IV. Max dose 4mg
❏ Seizures: 5mg IV/IO q5min or 5-10mg IM q15min (no maximum dose)
➔ Hallucination ➔ Cardiovascular or Respiratory depression

➔ Bradycardia
➔ Retrograde amnesia
127
MORPHINE SULFATE (MSO4)
Class
CNS agent – narcotic (opiate) agonist; analgesic
Action
Natural opium alkaloid with agonist activity as it binds with 3 types of the same receptors as endogenous
opioid peptides; analgesia at supraspinal level, euphoria, respiratory depression and physical dependence;
sedation and miosis; dysphoria, hallucinogenic, and cardiac stimulant effects
➢ Severe Pain ➢ Respiratory depression

➢ Pain from cardiac ischemia ➢ Hypotension
➢ Head injury
Dose
❏ TCCC: 5mg IV/IO, repeat q10min prn
❏ Chest Pain: 5mg IV initially then 2mg IV q10-15min prn for pain
❏ Pain Management: 5mg IV initial dose then 5mg IV q10min for max dose of 30mg. Repeat as
necessary q30-60min.
➔ Decreased respiratory rate ➔ Seizures with large doses

➔ Hypotension ➔ Constipation
➔ Bradycardia ➔ Urinary retention
➔ Nausea/vomiting
128
MOXIFLOXACIN (AVELOX)
Class
Antimicrobial – antibiotic; fluoroquinolone
Action
Broad spectrum bactericidal agent that inhibits DNA-gyrase topoisomerase II, an enzyme necessary for
bacterial replication, transcription, repair and recombination; effective against gram-positive and gram
negative organisms, Staphylococcus aureus, Streptococcus pneumonia, Haemophilus influenzae,
Klebsiella pneumoniae, Moraxella catarrhalis, Chlamydia pneumoniae, Mycoplasma pneumoniae, and
other microbes
➢ Pneumonia ➢ Hypersensitivity to fluoroquinolones

➢ Penetrating trauma ➢ Patients <18 years old
➢ Complicated skin infections ➢ Pregnancy and lactation
➢ Complicated intra-abdominal infections ➢ Uncorrected hypokalemia
Dose
❏ Meningitis (prophylaxis): 400mg PO once
❏ TCCC, Barotrauma, Epistaxis, Flank Pain: 400mg PO qd (until transferred to higher care)
❏ Gastroenteritis: 400mg PO qd x 5-14 days
❏ Bronchitis/Pneumonia: 400mg PO qd x 7 days
❏ Cellulitis, Cutaneous Abscess, Ear infection, Ingrown Toenail, Laceration
❏ 400mg PO qd x 10 days
➔ Headache ➔ Tendon ruptures

➔ Nausea ➔ Use cautiously with NSAIDS due to
➔ Diarrhea increased CNS stimulation
➔ Photosensitivity ➔ Abnormal dreams
129
MUPIROCIN (BACTROBAN)
Class
Antimicrobial – antibiotic; pseudomonic acid
Action
Topical antibacterial produced by fermentation of Pseudomonas fluorescens; inhibits protein synthesis by
binding with bacterial transfer-RNA; effective against Staphylococcus aureus [including methicillin-resistant
(MRSA) and beta-lactamase-producing strains], Staphylococcus epidermidis, Staphylococcus
saprophyticus, and Streptococcus pyogenes
➢ Impetigo ➢ Should NOT be used with open wounds

➢ Topical skin infection
Dose
❏ Epistaxis, Ingrown Toenail: Topically AAA tid-qid x 1-2 weeks
➔ Burning/stinging pain at application site ➔ Dry skin

➔ Nausea ➔ Tenderness
➔ Systemic reactions (rare)
130
NALOXONE (NARCAN)
Class
CNS agent – narcotic (opiate) antagonist
Action
A "pure" narcotic antagonist, essentially free of agonistic (morphine-like) properties; thus, produces no
significant analgesia, respiratory depression, psychotomimetic effects, or miosis when administered in the
absence of narcotics and possesses more potent narcotic antagonist action
➢ Known or suspected narcotic induced ➢ Known allergy to medication

respiratory depression
Dose
❏ TCCC: 0.4mg IV/IM/IN. Repeat q2-3min prn. Max dose 10mg
❏ Keep available whenever using opiate medications in any protocol
➔ In narcotic dependent patient, withdrawal ➔ Nausea/Vomiting

symptoms may be precipitated ➔ Tachycardia
➔ Hypertensions
131
NITROGLYCERIN (NITROSTAT)
Class
Nitrate - Vasodilator
Action
The principal pharmacological action of nitroglycerin is relaxation of v ascular smooth muscle. Although
venous effects predominate, nitroglycerin produces, in a dose-related manner, d ilation of both arterial and
venous beds. Dilation of postcapillary vessels, including large veins, promotes peripheral pooling of blood,
decreases venous return to the heart, and reduces left ventricular end-d iastolic pressure (preload).
➢ Ischemic chest pain ➢ Recent erectile dysfunction drug use

(Viagra, Cialis, etc.)
➢ Hypotension
Dose
❏ Chest Pain: 0.4mg SL initially, repeat q5min for a total of 3 doses
➔ Headache ➔ Syncope
➔ Dizziness ➔ Heart palpitations
132
NORMAL SALINE (SODIUM CHLORIDE 0.9%)
Class
Plasma volume expander – crystalloid; isotonic salt solution
Action
Each mL contains 9 g sodium chloride (Na+ 154 mEq/L; Cl¯ 154 mEq/L); pH 5.7; expands circulating
volume by approximating sodium content of the blood; but, it remains in the intravascular space for only a
very limited time as it diffuses rapidly throughout the extracellular space
➢ Hypovolemia from non-hemorrhagic ➢ Hemorrhagic shock

conditions (burns, sepsis, dehydration, etc.) ➢ Congestive Heart Failure
Dose
systolic BP of 80-90 is present
❏ Dehydration: 1L bolus, repeat prn
❏ Rhabdomyolysis: 1-2L bolus, followed by 500mL-1L/hr
➔ Fluid overload ➔ N/A

➔ Edema
➔ Electrolyte imbalance
133
OMEPRAZOLE (PRILOSEC)
Class
GI agent – proton pump inhibitor (PPI)
Action
Antisecretory compound that is a gastric acid pump inhibitor; suppresses gastric acid secretion by inhibiting
the H+ , K+ -ATPase enzyme system [the acid (proton H+ ) pump] in the parietal cells which relieves
gastrointestinal distress and promotes ulcer healing
➢ Gastroesophageal reflux disease (GERD) ➢ PPI hypersensitivity

➢ Duodenal and gastric ulcers ➢ GI bleeding
Dose
❏ Gastroesophageal Reflux Disease (GERD): 20mg PO qd or bid prn
➔ Headache ➔ N/A
➔ Abdominal pain
➔ Nausea/Vomiting
134
ONDANSETRON (ZOFRAN)
Class
GI agent – 5-HT3 antagonist, antiemetic
Action
Selective serotonin (5-HT3) receptor antagonist, acting centrally in the chemoreceptor trigger zone (CTZ)
and peripherally on vagal nerve terminals; serotonin is released from the wall of the small intestine,
stimulates the vagal efferents through the serotonin receptors, and initiates the vomiting reflex
➢ Prevention of nausea/vomiting ➢ Hypersensitivity to product
Dose
❏ TCCC: 4mg ODT/IV/IO/IM q8hr prn
❏ Nausea/Vomiting: 4-8mg IV/IM bid or 8mg PO q8hr prn
➔ Anxiety ➔ Elevated liver transaminases

➔ Dizziness ➔ Anaphylaxis
➔ Arrhythmias ➔ Syncope
135
OXYMETAZOLINE (AFRIN)
Class
Nasal decongestant
Action
Oxymetazoline is a sympathomimetic that selectively agonizes α1 and, partially, α2 adrenergic
receptors[11] Since vascular beds widely express α1 receptors, the action of oxymetazoline results in
asoconstriction of vessels results in relief of nasal congestion in two ways: first, it
vasoconstriction. V
increases the diameter of the airway lumen; second, it reduces fluid exudation from postcapillary venules.
It can reduce nasal airway resistance (NAR) up to 35.7% and reduce nasal mucosal blood flow up to 50%.
➢ Sinus Congestion ➢ Hypertension

➢ Epistaxis ➢ Thyroid conditions
Dose
❏ Epistaxis: 2-3 sprays intranasally and pinch anterior area of nose firmly for full 10 minutes without
releasing pressure.
❏ Allergic Rhinitis/Cold Symptoms, Bronchitis/Pneumonia:
❏ 2-3 sprays intranasally q12hrs. Not to exceed 3 days
➔ Burning ➔ Serious allergic reaction

➔ Tingling
136
PHENYLEPHRINE (SUDAFED PE)
Class
Vasoconstrictor - nasal decongestant
Action
Sympathomimetic drug, which means that it mimics the actions of epinephrine (commonly known as
adrenaline) or norepinephrine. Phenylephrine selectively binds to alpha-1 receptors which cause blood
vessels to constrict.
➢ Nasal congestion ➢ Overactive thyroid

➢ Hypotension ➢ Hypertension
Dose
❏ Allergic Rhinitis/Cold Symptoms, Bronchitis/Pneumonia: 10mg q4hrs prn
➔ Anxiety ➔ Rebound congestion

➔ Hypertension
➔ Headache
137
PREDNISONE (DELTASONE)
Class
Synthetic glucocorticoid- anti-inflammatory
Action
Decreases inflammation via suppression of the migration of polymorphonuclear leukocytes and reversing
increased capillary permeability. It also suppresses the immune system by reducing the activity and the
volume of the immune system.
➢ Dermatitis ➢ Tuberculosis
➢ Asthma/COPD ➢ Osteoporosis
➢ Inflammatory Conditions
Dose
❏ Contact Dermatitis: 60mg PO daily x 5 days burst or taper dose down every 3 days for a 14-21
day course
➔ Insomnia ➔ Allergic reactions

➔ Decreased wound healing ➔ High blood sugar
➔ Nausea/Vomiting
138
PRIMAQUINE
Class
Antimicrobial – antimalarial
Action
Acts on primary exoerythrocytic forms of Plasmodium vivax and Plasmodium falciparum by an incompletely
known mechanism. Destroys late tissue forms of P. vivax and thus effects radical cure (prevents relapse).
➢ To prevent relapse/attacks from P. vivax ➢ Rheumatoid arthritis

and P. ovale malaria ➢ Pregnancy
Dose
❏ Malaria: 30mg daily x 14days
➔ Darkening of urine ➔ Visual disturbances

➔ Fevers ➔ Hypertension
➔ Chills ➔ Anemia/leukopenia
139
PROMETHAZINE (PHENERGAN)
Class
GI agent – phenothiazine; antiemetic, antivertigo
Action
Long-acting phenothiazine derivative with prominent sedative, amnesic, antiemetic, and anti-motion
sickness actions and marked antihistamine activity; antiemetic action due to depression of CTZ in medulla;
as with other antihistamines, it exerts antiserotonin, anticholinergic, and local anesthetic action
➢ Nausea/Vomiting ➢ Children < 2 years old

➢ Motion Sickness ➢ Asthma
➢ Allergic reactions ➢ Vomiting of unknown etiology in children
➢ Comatose states
➢ Use caution when administering IV due
tissue injury from extravasation
Dose
❏ Nausea/Vomiting: 25mg IV/IM/PO q6hr prn
➔ Sedation/sleepiness ➔ Lowers seizure threshold

➔ Anticholinergic effects (dry mouth, urinary ➔ Extrapyramidal symptoms (dystonia)
retention, constipation, etc.) ➔ Arrhythmias
➔ Bradycardia
140
PSEUDOEPHEDRINE (SUDAFED)
Class
Autonomic nervous system agent–sympathomimetic; alpha/beta-adrenergic agonist, decongestant
Action
Sympathomimetic amine that, like ephedrine, produces decongestion of respiratory tract mucosa by
stimulating the sympathetic nerve endings including alpha-, beta-1 and beta-2 receptors; unlike ephedrine,
also acts directly on smooth muscle and constricts renal and vertebral arteries; has fewer adverse effects,
less pressor action, and longer duration of effects than ephedrine
➢ Nasal decongestant ➢ Hypersensitivity

➢ Adjunct in otitis media ➢ Narrow angle glaucoma
Dose
❏ Allergic Rhinitis/Cold-Like Symptoms, Bronchitis/Pneumonia, Barotrauma:
❏ 60mg PO q4-6hrs prn
➔ CNS: Tremors, anxiety ➔ Rebound congestion if used more than the

➔ CV: Palpitations, tachycardia recommended dose
➔ EENT: Dry nose, irritation of nose/throat
➔ GI: Nausea/Vomiting
141
RANITIDINE (ZANTAC)
Class
GI agent – antisecretory H2-receptor antagonist
Action
Antihistamine with high selectivity for reversible competitive inhibition of histamine H2-receptors on parietal
cells of the stomach (minimal effect on H1-receptors) and thus decreases gastric acid secretion, raises the
pH of the stomach, and indirectly reduces pepsin secretion
➢ GERD ➢ Known/suspected liver disease

➢ Gastric or peptic ulcers
➢ Adjunct in the treatment of allergic reactions
Dose
❏ Gastroesophageal Reflux Disease (GERD): 150mg PO qd prn
❏ Anaphylactic Reaction: 150mg PO bid
➔ Headache ➔ Thrombocytopenia
➔ Diarrhea ➔ Liver toxicity
➔ Constipation
142
TRANEXAMIC ACID (TXA, CYKLOKAPRON)
Class
Antifibrinolytic agent
Action
TXA is a synthetic reversible competitive inhibitor to the Lysine receptor found on plasminogen. The
binding of this receptor prevents plasmin (activated form of plasminogen) from binding to and ultimately
stabilizing the fibrin matrix.
➢ Casualties at high risk for massive blood ➢ Greater than 3hr after injury
transfusions (hemorrhagic shock, ➢ Active intravascular clotting
penetrating torso trauma, major ➢ Known hypersensitivity
amputations, etc.)
Dose
❏ TCCC: 2 grams in 100 ml Normal Saline or Lactated Ringer’s as soon as possible but NOT later
than 3 hours after injury. When given, TXA should be administered over 10 minutes by IV infusion.
➔ Chest pain ➔ Hypotension (From rapid administration)

➔ Blurred division
➔ Nausea/vomiting
143
TETRACAINE (ALTACAINE)
Class
Antimicrobial – antibacterial, sulfonamide
Action
Fixed combination of TMP and SMZ, synthetic folate antagonists and enzyme inhibitors that prevent
bacterial synthesis of essential nucleic acids and proteins; effective against Pneumocystis carinii
pneumonitis, Shigellosis enteritis, most strains of Enterobacteriaceae, Nocardia, Legionella micdadei, and
Legionella pneumophila, and Haemophilus ducreyi
➢ Cellulitis ➢ TMP-SMZ, sulfonamide, or bisulfite

➢ Enteritis hypersensitivity
➢ Urinary tract infections ➢ Group A beta-hemolytic streptococcal
pharyngitis
➢ Pregnancy
➢ Use caution with severe allergy or asthma
Dose
❏ Urinary Tract Infection: 1 tab PO x 3 days
❏ Cellulitis, Cutaneous Abscess, Laceration: 1 tab PO x 10 days
❏ (1 tab = 160mg TMP/800mg SMZ)
➔ Nausea/vomiting ➔ Rash
➔ Diarrhea ➔ Toxic epidermal necrolysis
➔ Pseudomembranous enterocolitis
144
TRIMETHOPRIM-SULFAMETHOXAZOLE (TMP-SMZ,
BACTRIM, SEPTRA)
Class
Antimicrobial – antibacterial, sulfonamide
Action
Fixed combination of TMP and SMZ, synthetic folate antagonists and enzyme inhibitors that prevent
bacterial synthesis of essential nucleic acids and proteins; effective against Pneumocystis carinii
pneumonitis, Shigellosis enteritis, most strains of Enterobacteriaceae, Nocardia, Legionella micdadei, and
Legionella pneumophila, and Haemophilus ducreyi
➢ Cellulitis ➢ TMP-SMZ, sulfonamide, or bisulfite

➢ Enteritis hypersensitivity
➢ Urinary tract infections ➢ Group A beta-hemolytic streptococcal
pharyngitis
➢ Pregnancy
➢ Use caution with severe allergy or asthma
Dose
❏ Urinary Tract Infection: 1 tab PO x 3 days
❏ Cellulitis, Cutaneous Abscess, Laceration: 1 tab PO x 10 days
❏ (1 tab = 160mg TMP/800mg SMZ)
➔ Nausea/vomiting ➔ Rash
➔ Diarrhea ➔ Toxic epidermal necrolysis
➔ Pseudomembranous enterocolitis
145
146
147

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68W Scope of Practice 📖

TCCC Study Guide 6-7

Basic Management Plan for Care Under Fire

2. Direct or expect casualty to remain engaged as a combatant if appropriate

3. Direct casualty to move to cover and apply self-aid if able

4. Try to keep the casualty from sustaining additional wounds

6. Stop life-threatening external hemorrhage if tactically feasible:

● Initial treatment of suspected tension pneumothorax:

● The NDC should be considered successful if:

8. Penetrating Eye Trauma

9. Monitoring a. Initiate advanced electronic monitoring if indicated and if monitoring equipment is

12. Inspect and dress known wounds.

13. Check for additional wounds.

17. Cardiopulmonary resuscitation (CPR)

18. Documentation of Care

19. Prepare for Evacuation.

● The NDC should be considered successful if:

6. Traumatic Brain Injury

b. Unilateral pupillary dilation accompanied by a decreased level of consciousness may

8. Penetrating Eye Trauma

9. Monitoring a. Initiate advanced electronic monitoring if indicated and if monitoring equipment is

11. Antibiotics: recommended for all open combat wounds

12. Inspect and dress known wounds.

13. Check for additional wounds.

15. Splint fractures and re-check pulses.

17. CPR in TACEVAC Care

18. Documentation of Care

Signs and Symptoms

Signs and Symptoms

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Signs and Symptoms

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Signs and Symptoms

Signs and Symptoms

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Signs and Symptoms

Signs and Symptoms

Signs and Symptoms

Signs and Symptoms

Signs and Symptoms

Signs and Symptoms

Signs and Symptoms

Signs and Symptoms

Signs and Symptoms

Signs and Symptoms

Signs and Symptoms

Signs and Symptoms

(Normal Ear) ​(Otitis Media) ​(Otitis Externa)

Signs and Symptoms

Signs and Symptoms

Signs and Symptoms

Signs and Symptoms

Signs and Symptoms

Signs and Symptoms

Signs and Symptoms

Signs and Symptoms

Signs and Symptoms

(Normal Ear) (Otitis Media) (Otitis Externa)

2. If nausea/vomiting is caused by vertigo or motion sickness , ONE of administer the following:

3. If nausea/vomiting is moderate-severe, administer ONE of the following:

4. Treat per Dehydration protocol

4. Treat per Nausea/Vomiting Protocol