TECC Questions and Answers 2023

TECC Questions and Answers 2023 DIRECT THREAT CARE (DTC) / HOT ZONE Guidelines: Mitigate any immediate threat Direct the injured first responder to stay engaged Move patient to a safer position Stop life threatening external hemorrhage Place patient in a position to protect airway INDIRECT THREAT CARE (ITC) / WARM ZONE Guidelines Secure weapons PMARCHP / X-ABCDE Control bleeding Reassess all tourniquets Tourniquets that are determined to be both necessary and effective? Should remain in place if the patient can be evacuated within 2 hours to definitive medical care If existing tourniquet is necessary but ineffective? Either tighten the existing tourniquet further, or apply a second tourniquet, side-by-side and, if possible, proximal to the first to eliminate the distal pulse. If a tourniquet is determined based on wound assessment to not be necessary? Use other techniques to control bleeding and remove the tourniquet Consider tourniquet downgrade/conversion if? There will be a delay in evacuation more than 2 hours. Tourniquet downgrade: Expose the wound fully, identify an appropriate location at least 2-3 inches above the most proximal injury (not over a joint), and apply a new tourniquet directly to the skin. Once properly applied, the prior tourniquet can be loosened but should be left in place. Tourniquet conversion: Expose the wound fully, fully pack the wound with hemostatic or plain gauze, and properly apply a pressure dressing. Once properly applied, the prior tourniquet can be loosened but should be left in place. If the patient is conscious and able to follow commands? Position of comfort If the patient is unconscious or conscious but unable to follow commands: Clear airway Apply basic chin lift or jaw thrust Consider placing a nasopharyngeal airway. Place patient in the recovery position to maintain the open airway. If previous airway measures are unsuccessful Supraglottic Devices Oro/nasotracheal intubation Surgical cricothyroidotomy (with lidocaine if conscious) To cover any open and/or sucking chest wound. Immediately apply a vented or non-vented occlusive seal to cover the defect from Tension pneumothorax presentation Penetrating chest injury with subsequent progressive dyspnea/respiratory distress, hypoxia and/or hypotension, and/or increasing anxiety/agitation, often after the application of a chest seal. If tension pneumothorax is suspected to be developing, Decompress the chest on the side of the injury: ALS providers: Needle decompression should be performed (minimum a 14- gauge, 3.25 inch needle/catheter) at the 2nd intercostal space mid-clavicular lateral to the nipple line and is not directed towards the heart or the 4th/5th intercostal space perpendicular to the chest wall anterior to the mid-axillary line BLS - Burp dressing If suspected severe traumatic brain injury (GCS 9), Apply oxygen if available to maintain saturation 90% and maintain etCO2 in ventilated patient between 35-45 mmHg. Avoid any hyperventilation as evidenced by an etCO2 below 35 mmHg. If available, consider PEEP 5-12 cm H2O. If immediate fluid resuscitation is required and is available, Consider starting at least an 18-gauge IV or obtaining intraosseous (IO) access. If patient has injuries that could potentially require significant blood transfusion Consider administration of 1 gram of TXA as soon as possible. Do not administer TXA later than 3 hours after injury. Assess for shock 90mmHg with/without heart rate 100 bpm If not in shock Patient can drink fluids and establish an saline lock If hemorrhagic shock is present: Fluid Resuscitation Resuscitate using permissive hypotension in the non-head injured patient. Administer IV fluid bolus (per agency protocol) to a goal of improving mental status, radial pulses, or, if available, measured SBP80mmHg. Repeat bolus once after 30 minutes if still in shock. If hemorrhagic shock is present: Calcium If available, infuse 1 gram 10% Calcium chloride or 3 grams of 10% Calcium Gluconate - 1g of CaCl 10% in 10mL is 13.65 meq / 10mL - 1g of CaGlu 10% in 10mL is 4.65 meq/ 10 mL. In a patient who has altered mental status due to suspected or confirmed severe traumatic brain injury (GCS9)? Avoid any hypotension. Maintain BP 110. Elevate head 30 degrees and avoid constricting collars or airway devices. Hypothermia Prevention: Avoid removing all clothing. Keep gear on. Keep PT warm and dry. Place PT on insulated surface. Replace wet clothing. Cover PT with warm clothes/blanket. Give warm IV fluids. Analgesia Adequate pain control can reduce physiologic stress, may decrease post-traumatic stress, and may help to prevent chronic pain syndromes. For mild - moderate pain: Imobilize, positioning. Celecoxib/Acetaminophen For moderate - severe pain: Consider fentanyl, morphine. Have naloxone readily available Ketamine Benzodiazepam Ketamine Analgesic dosages (up to 1mg/kg) When used as a single agent, ketamine does not induce hypotension or respiratory depression therefore requires less monitoring. (b) Consider initial dose of 25-50 mg IV, IM or IN titrated every 15 min until pain control. (c) Administering analgesia using a multimodal approach to pain control By using analgesics with different, but potentiating, mechanisms of action, lower doses and therefore less side effects may be used with the same or better pain control than using a single modality alone. Pain management considerations In Traumatic Brain Injury anticipate possible hypotension if opioid analgesics are being used for pain control. Consider co-administering anti-emetic medications with pain medications. Warm Zone CPR - blast, penetrating or blunt trauma who have no pulse, no ventilations, no signs of life. Will likely not be successful and should not be attempted. Consider bilateral needle decompression for? Victims of torso or polytrauma with no respirations or pulse to ensure tension pneumothorax is not the cause of cardiac arrest prior to discontinuation of care. Warm Zone CPR - electrocution or drowning Performing CPR may be of benefit and should be considered in the context of the operational situation. EVAC Guidelines - Initial Reassess / Triage EVAC Guidelines - Airway Consider immobilization, high suspicion with65 with blunt mechanism. Reasess, check seals, burp, repeat needles, add chest tube. Who can benefit from O2? O2 may be of benefit for all traumatically injured patients, Unconscious or altered mental status Torso injuries with dyspnea Chest injury with known/suspected pneumothorax Hemorrhagic shock Patient at altitude EVAC Guidelines - Bleeding Reassess interventions Burn care and resuscitation is consistent with? The principles described in Indirect Threat Care / Warm Zone. Traumatic Brain Injury (TBI) prevention Prevention of hypotension (SBP 110) and hypoxia (SpO2 90%) are critical in management of TBI. EVAC - Guidelines for Analgesia Peripheral nerve blocks (wrist, ankle, digit) can be considered for excellent pain control without causing respiratory depression or change in mentation. Significant symptoms of smoke inhalation and carbon monoxide toxicity should? Be treated with high flow oxygen if available. Significant symptoms of smoke inhalation and cyanide toxicity? Should be considered candidates for cyanide antidote administration. EVAC - Guidelines for TBI For hard physical signs of herniation syndromes, consider: Hypertonic saline 3% - 3 to 5 cc/kg IV bolus. Mannitol 20% - 1g/kg IV bolus. Hyperventilation: PaCO2 30-35 mmHg. EVAC - Guidelines for Cardiopulmonary resuscitation: CPR may have a larger role during the evacuation phase especially for patients with electrocution, hypothermia, non-traumatic arrest or near drowning. Hot Zone Care - Primary Goals: Accomplish the mission with minimal casualties. Prevent any patient from sustaining additional injuries. Keep operational response maximally engaged in addressing the immediate threats Minimize public harm. Hot Zone Care - Operational Principles: 1. Establish operational control of the immediate incident 2. Threat mitigation techniques will minimize risk to casualties and the providers. 3. Triage should be deferred to a later phase of care. 4. Minimal trauma interventions. 5. Consider hemorrhage control before evacuation to a safer area. a. TQ application is the primary "medical" intervention to be considered in this phase of care. Hot Zone Care - Skill Set: Tourniquet Extraction Recovery position WARM ZONE CARE - Goals Same as Hot Stabilize PT Warm Zone Care - Operational Principles: Maintain operational control to stabilize the immediate scenario. Conduct dedicated patient assessment and initiate appropriate life-saving interventions DO NOT DELAY patient extraction for non-life-saving interventions. Consider establishing a CCP Establish communication Prepare casualties for evacuation Warm Zone Care - Triage Unless in a fixed CCP, triage in this phase of care should be limited to the following categories: a. Uninjured b. Deceased / expectant c. All others Indirect Threat / Warm Zone - Hemorrhage Application of direct pressure Application of tourniquet Application of wound packing with gauze or hemostatic agent Application of mechanical or improvised pressure dressing Indirect Threat / Warm Zone - Airway Perform Manual Maneuvers (chin lift, jaw thrust, recovery position) Insert Nasal pharyngeal airway Placement of supraglottic airway Placement of endotracheal tube under direct visualization Perform surgical cricothyrotomy Indirect Threat / Warm Zone - Breathing Application of effective occlusive chest seal Apply oxygen Recognize the symptoms of tension pneumothorax Perform needle thoracentesis Perform manual "burp" of non-vented occlusive dressing Indirect Threat / Warm Zone - Shock Recognize the symptoms of hemorrhagic shock Obtain intravenous and/or intraosseous access Resuscitate hemorrhagic shock using the principles of hypotensive resuscitation