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Nota Importante

Aunque pueda contener afirmaciones, datos o apuntes procedentes de instituciones o profesionales sanitarios, la información contenida en el blog EMS Solutions International está editada y elaborada por profesionales de la salud. Recomendamos al lector que cualquier duda relacionada con la salud sea consultada con un profesional del ámbito sanitario. by Dr. Ramon REYES, MD

lunes, 31 de diciembre de 2018

CIRUGÍA DE GUERRA TRABAJAR CON RECURSOS LIMITADOS EN CONFLICTOS ARMADOS Y OTRAS SITUACIONES DE VIOLENCIA VOLUMEN 1 C. Giannou M. Baldan


CIRUGÍA DE GUERRA TRABAJAR CON RECURSOS LIMITADOS EN CONFLICTOS ARMADOS Y OTRAS SITUACIONES DE VIOLENCIA VOLUMEN 1 C. Giannou M. Baldan

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CIRUGÍA DE GUERRA TRABAJAR CON RECURSOS LIMITADOS EN CONFLICTOS ARMADOS Y OTRAS SITUACIONES DE VIOLENCIA VOLUMEN 1 C. Giannou M. Baldan



English Version pdf


Libro Gratuito en PDF Relacionado:

GUÍA PARA EL MANEJO MÉDICO-QUIRÚRGICO DE HERIDOS EN SITUACIÓN DE CONFLICTO ARMADO CICR 



GUÍA PARA EL MANEJO MÉDICO-QUIRÚRGICO DE HERIDOS EN SITUACIÓN DE CONFLICTO ARMADO CICR 
Ministerio de la Protección Social República de Colombia 
COMITÉ INTERNACIONAL DE LA CRUZ ROJA MINISTERIO DE LA PROTECCIÓN SOCIAL 
La cirugía que se realiza en víctimas de una situación de conflicto armado es en general diferente a las que se efectúan en tipos diversos de trauma. Las heridas originadas en conflictos armados son causadas por balas o fragmentos de la explosión de minas o bombas y siempre se consideran lesiones contaminadas. Para estas intervenciones es importante que los médicos cirujanos, anestesiólogos y enfermeras comprendan las particularidades de las heridas generadas en el conflicto y que tengan un rápido acceso a los conocimientos de como proceder en tales casos. Esta Guía aspira contribuir con estos propósitos.

BAJAR PDF GRATIS



MANUALES DE MEDICINA SUTURA, CIRUGIA, CIRUGIA MENOR GRATIS EN PDF


Balística de las heridas: introducción para los profesionales de la salud, del derecho, de las ciencias forenses, de las fuerzas armadas y de las fuerzas encargadas de hacer cumplir la ley http://emssolutionsint.blogspot.com/2017/04/balistica-de-las-heridas-introduccion.html
Guía para el manejo médico-quirúrgico de heridos en situación de conflicto armado by CICR http://emssolutionsint.blogspot.com/2017/09/guia-para-el-manejo-medico-quirurgico.html
CIRUGÍA DE GUERRA TRABAJAR CON RECURSOS LIMITADOS EN CONFLICTOS ARMADOS Y OTRAS SITUACIONES DE VIOLENCIA VOLUMEN 1 C. Giannou M. Baldan CICR http://emssolutionsint.blogspot.com.es/2013/01/cirugia-de-guerra-trabajar-con-recursos.html
Protocolo de cirugía menor en Atención Primaria. PDF Gratis by Gobierno Canario de Salud. España http://emssolutionsint.blogspot.com/2018/06/protocolo-de-cirugia-menor-en-atencion.html
Manual Suturas, Ligaduras, Nudos y Drenajes. Hospital Donostia, Pais Vasco. España http://emssolutionsint.blogspot.com/2017/09/manual-suturas-ligaduras-nudos-y.html
Técnicas de Suturas para Enfermería ASEPEYO y 7 tipos de suturas que tienen que conocer estudiantes de medicina http://emssolutionsint.blogspot.com/2015/01/tecnicas-de-suturas-para-enfermeria.html
Manual Práctico de Cirugía Menor. Grupo de Cirugia Menor y Dermatologia. Societat Valenciana de Medicina Familiar i Comunitaria http://emssolutionsint.blogspot.com/2013/09/manual-practico-de-cirugia-menor.html
Protocolo de Atencion para Cirugia. Ministerio de Salud Publica Rep. Dominicana. Marzo 2016 http://emssolutionsint.blogspot.com/2016/09/protocolo-de-atencion-para-cirugia.html
Manual de esterilización para centros de salud. Organización Panamericana de la Salud http://emssolutionsint.blogspot.com/2016/07/manual-de-esterilizacion-para-centros.html

Articulos relacionados:

Sindrome de Latigazo Cervical 
Compilacion, PDF, Videos e Imagenes by Dr. Ramon Reyes, MDhttp://emssolutionsint.blogspot.com/2016/11/sindrome-de-latigazo-cervical.html

Cinematica de Trauma ATROPELLO, Explosion, Peatones
http://emssolutionsint.blogspot.com.es/2016/07/cinematica-de-trauma-en-peatones.html

Inmovilizacion Espinal en el Paciente de Trauma, Inmovilizacion Selectiva, El NEXUS, El Canadian C-Spine Rule, Consenso Británico http://emssolutionsint.blogspot.com/2016/09/es-necesario-inmovilizar-todos-los.html

MAS LIBROS MEDICINA Y SALUDhttps://www.facebook.com/pg/DrRamonReyesMD/photos/?tab=album&album_id=620883388254594


Dr. Ramon Reyes, MD 

Les Esperamos en nuestro Grupo en TELEGRAM Soc. IberoAmericana de Emergencias
https://t.me/joinchat/FpTSAEHYjNLkNbq9204IzA

Todos Nuestros VIDEOS en YouTube https://www.youtube.com/c/RamonReyes2015

ALGUNOS VIDEOS EN NUESTRO CANAL DE YOUTUBE

Se merecen mi respeto al mas alto nivel. Con sangre y fluidos por todas partes, sin preocuparse por nada, lo salvaron..Este paciente entró a la emergencia con una herida severa y casi sangró el volumen sanguíneo ...Todos, incluidos los médic@s y enfermer@s, terminaron con la sangre encima, sin preocuparse por contaminación "infección" pero lograron salvar al paciente. by Detcare 👍











CURSO
Libre de Mantenimiento 
El mas ECONOMICO
Vendemos en España y Rep. Dominicana
Hacemos entrega del Sistema Completo

eeiispain@gmail.com

“UNA VIDA NO TIENE PRECIO”



¿Por qué el Desfibrilador TELEFUNKEN?
El DESFIBRILADOR de Telefunken es un DESFIBRILADOR AUTOMÁTICO sumamente avanzado y muy fácil de manejar.
Fruto de más de 10 años de desarrollo, y avalado por TELEFUNKEN, fabricante con más de 80 años de historia en la fabricación de dispositivos electrónicos.
El desfibrilador TELEFUNKEN cuenta con las más exigentes certificaciones.
Realiza automáticamente autodiagnósticos diarios y mensuales.

Incluye bolsa y accesorios.
Dispone de electrodos de "ADULTO" y "PEDIÁTRICOS".
Tiene 6 años de garantía.
Componentes kit de emergencias
Máscarilla de respiración con conexión de oxígeno.
Tijeras para cortar la ropa
Rasuradora.
Guantes desechables.

¿ Qué es una Parada Cardíaca?
Cada año solo en paises como España mueren más de 25.000 personas por muerte súbita.
La mayoría en entornos extrahospitalarios, y casi el 80-90 % ocasionadas por un trastorno eléctrico del corazón llamado"FIBRILACIÓN VENTRICULAR"

El único tratamiento efectivo en estos casos es la "Desfibrilación precoz".
"Por cada minuto de retraso en realizar la desfibrilación, las posibilidades de supervivencia disminuyen en más de un 10%".

¿ Qué es un desfibrilador ?
El desfibrilador semiautomático (DESA) es un pequeño aparato que se conecta a la víctima que supuestamente ha sufrido una parada cardíaca por medio de parches (electrodos adhesivos).

¿ Cómo funciona ?

SU FUNDAMENTO ES SENCILLO:
El DESA "Desfibrilador" analiza automáticamente el ritmo del corazón. Si identifica un ritmo de parada cardíaca tratable mediante la desfibrilación ( fibrilación ventricular), recomendará una descarga y deberá realizarse la misma pulsando un botón.

SU USO ES FÁCIL:
El desfibrilador va guiando al reanimador durante todo el proceso, por medio de mensajes de voz, realizando las órdenes paso a paso.

SU USO ES SEGURO:
Únicamente si detecta este ritmo de parada desfibrilable (FV) y (Taquicardia Ventricular sin Pulso) permite la aplicación de la descarga. (Si por ejemplo nos encontrásemos ante una víctima inconsciente que únicamente ha sufrido un desmayo, el desfibrilador no permitiría nunca aplicar una descarga).

¿Quién puede usar un desfibrilador TELEFUNKEN?
No es necesario que el reanimador sea médico, Enfermero o Tecnico en Emergencias Sanitarias para poder utilizar el desfibrilador.

Cualquier persona (no médico) que haya superado un curso de formación específico impartido por un centro homologado y acreditado estará capacitado y legalmente autorizado para utilizar el DESFIBRILADOR (En nuestro caso la certificacion es de validez mundial por seguir los protolos internacionales del ILCOR International Liaison Committee on Resuscitation. y Una institucion de prestigio internacional que avale que se han seguido los procedimientos tanto de formacion, ademas de los lineamientos del fabricante como es el caso de eeii.edu

TELEFUNKEN en Rep. Dominicana es parte de Emergency Educational Training Institute de Florida. Estados Unidos, siendo Centro de Entrenamiento Autorizado por la American Heart Association y American Safety and Health Institute (Por lo que podemos certificar ILCOR) Acreditacion con validez en todo el mundo y al mismo tiempo certificar el lugar en donde son colocados nuestros Desfibriladores como Centros Cardioprotegidos que cumplen con todos los estanderes tanto Europeos CE como de Estados Unidos y Canada
DATOS TÉCNICOS
Dimensiones: 220 x 275 x 85mm
Peso: 2,6 Kg.
Clase de equipo: IIb
ESPECIFICACIONES
Temperatura: 0° C – + 50° C (sin electrodos)
Presión: 800 – 1060 hPa
Humedad: 0% – 95%
Máximo Grado de protección contra la humedad: IP 55
Máximo grado de protección contra golpes:IEC 601-1:1988+A1:1991+A2:1995
Tiempo en espera de las baterías: 3 años (Deben de ser cambiadas para garantizar un servicio optimo del aparato a los 3 años de uso)
Tiempo en espera de los electrodos: 3 años (Recomendamos sustitucion para mantener estandares internacionales de calidad)
Número de choques: >200
Capacidad de monitorización: > 20 horas (Significa que con una sola bateria tienes 20 horas de monitorizacion continua del paciente en caso de desastre, es optimo por el tiempo que podemos permanecer en monitorizacion del paciente posterior a la reanimacion)
Tiempo análisis ECG: < 10 segundos (En menos de 10 seg. TELEFUNKEN AED, ha hecho el diagnostico y estara listo para suministrar tratamiento de forma automatica)
Ciclo análisis + preparación del shock: < 15 segundos
Botón información: Informa sobre el tiempo de uso y el número de descargas administradas durante el evento con sólo pulsar un botón
Claras señales acústicas y visuales: guía por voz y mediante señales luminosas al reanimador durante todo el proceso de reanimación.
Metrónomo: que indica la frecuencia correcta para las compresiones torácicas. con las Guias 2015-2020, esto garantiza que al seguir el ritmo pautado de compresiones que nos indica el aparato de forma acustica y visual, podremos dar RCP de ALTA calidad con un aparato extremadamente moderno, pero economico.
Normas aplicadas: EN 60601-1:2006, EN 60601-1-4:1996, EN 60601-1:2007, EN 60601-2-4:2003
Sensibilidad y precisión:
Sensibilidad > 90%, tip. 98%,
Especificidad > 95%, tip. 96%,
Asistolia umbral < ±80μV
Protocolo de reanimación: ILCOR 2015-2020
Análisis ECG: Ritmos cardiacos tratables (VF, VT rápida), Ritmos cardiacos no tratables (asistolia, NSR, etc.)
Control de impedancia: Medición9 de la impedancia continua, detección de movimiento, detección de respiración
Control de los electrodos : Calidad del contacto
Identificación de ritmo normal de marcapasos
Lenguas: Holandés, inglés, alemán, francés, español, sueco, danés, noruega, italiano, ruso, chino
Comunicación-interfaz: USB 2.0 (El mas simple y economico del mercado)
Usuarios-interfaz: Operación de tres botones (botón de encendido/apagado , botón de choque/información.
Indicación LED: para el estado del proceso de reanimación. (Para ambientes ruidosos y en caso de personas con limitaciones acusticas)
Impulso-desfibrilación: Bifásico (Bajo Nivel de Energia, pero mayor calidad que causa menos daño al musculo cardiaco), tensión controlada
Energía de choque máxima: Energía Alta 300J (impedancia de paciente 75Ω), Energía Baja 200J
(impedancia de paciente 100Ω)



Medical Doctor for complex and high-risk missions

        
Medicina Bona Locis Malis
EU Medical Doctor / Spain 05 21 04184
Advanced Prehospital Trauma Life Support /Tactical Combat Casualty Care TCCC Instructor and Faculty 
ACLS EP / PALS American Heart Association and European Resucitation Council Instructor and Faculty
Member SOMA Special Operational Medical Association ID Nº 17479 
Corresponding Member Dominican College of Surgeons Book 1  Page M H10

DMO Diving Medical Officer- USA
Air Medical Crew Instructor DOT- USA
Tactical Medical Specialist and Protective Medicine -USA
TECC Tactical Emergency Casualty Care Faculty and Medical Director by C-TECC
MLinkedIn 
Ask about TELEFUNKEN AED 

STAT Tourniquet 21 of 24 applications FAIL by Mike Shertz CRISIS MEDICINE

STAT Tourniquet 21 of 24 applications FAIL by Mike Shertz CRISIS MEDICINE 

Dr. Mike Shertz is the Owner and Lead Instructor at Crisis Medicine. Dr. Shertz spent over 30 years gaining the experience and insight to create and provide his comprehensive, science-informed, training to better prepare everyday citizens, law enforcement, EMS, and the military to manage casualties and wounded in high-risk environments. Using a combination of current and historical events, Dr. Shertz’s lectures include relevant, illustrative photos, as well as hands-on demonstrations to demystify the how, why, when to use each emergency medical procedure you need to become a Force Multiplier for Good. 



STAT Tourniquet 21 of 24 applications FAIL by Mike Shertz CRISIS MEDICINE 


STAT Tourniquet 21 of 24 applications FAIL by Mike Shertz CRISIS MEDICINE 


El uso del torniquete en niños TQ Pediatrico by C-TECC



Existe suficiente científica que habla de la eficiencia del torniquete TQ en adultos, pero encontramos pocos datos sobre su uso en niños.

En un artículo del Boston Children's Hospital, el director del centro de trauma, David Mooney, MD, habló sobre los dos niños a quienes se aplicaron torniquetes después de los atentados de la maratón de Boston. Los torniquetes demostro ser la diferencia entre salvar vidas o perderlas  ese día, y  dos niños que sí tenían torniquetes aplicados hoy continuan vivos.


Lecciones aprendidas de la transferencia del TCCC Tactical Combat Casualty Care:

Después de los tiroteos de la Escuela Primaria Sandy Hook en 2012, el Colegio Cirujanos de los EUA (ACS) reunió al Comité Conjunto para crear una Política Nacional para mejorar la supervivencia de eventos de Heridos en Masa, que se reunieron en Hartford, Connecticut. Las deliberaciones del comité se conocen como Consensos de Hartford, que esencialmente establecen que;

El sangrado incontrolado en extremidades es la causa prevenible más importante de muerte en el ambiente prehospitalario pudiendo alcanzar un 63%.

Esta formacion esta dirigida a todos los actores que  responden profesionales y no profesionales tales como; civiles y fuerzas del orden, para que tengan la educación y el equipo necesario para el control de la hemorragia.

Hartford Consensus apoya firmemente a civiles para que actuen como "respondedores inmediatos".

El Comite  Tactical Emergency Tactical Care (C-TECC) fue convocado para acelerar la transición de las lecciones médicas militares aprendidas del campo de batalla a la respuesta civil para reducir las causas prevenibles de muerte tanto por los servicios de emergencias como por la población civil.

TCCC vs TECC

Tactical Emergency Casualty Care (TECC) con un conjunto de pautas de atención de trauma basadas en evidencia para entornos prehospitalarios de alta amenaza para civiles. Las directrices se hicieron a partir de las pautas  del TCCC (Tactical Combat Casualty Care).

En resumen, el  (TECC) es la evolución civil y la aplicación de las pautas militares de Cuidado de víctimas de combate táctico (TCCC) y el TCCC como sistema, tiene una aplicación limitada en el ámbito civil.

Los niños no se tienen en cuenta en las pautas de TCCC ya que no están en la población militar desplegada. Como tal, el C-TECC examinó específicamente la investigación y los datos específicos de la población pediátrica y creó un conjunto específico de recomendaciones para niños.

Cuidado pediátrico de urgencias tácticas.

Los puntos clave para el paciente pediátrico incluyen;

El proveedor no debe tardar en aplicar torniquetes a víctimas pediátricas
Aplicar el torniquete TQ sobre la ropa lo más proximal como sea posible en la extremidad. 

Apriete hasta que cese el sangrado (Desaparezca el pulso distal en la extremidad que hemos aplicado el TQ)
.
En cualquier amputación traumática total o parcial, se debe aplicar el torniquete independientemente del sangrado.

Cuando el tiempo y la situación lo permitan, se debe realizar una prueba de pulso distal en cualquier extremidad donde se aplica torniquete. Si todavía hay  pulso distal, considere  aprietar mas el  torniquete o un segundo torniquete, uno al lado del otro y proximal al primero, para eliminar el pulso distal.

Bibliografía
http://www.c-tecc.org/images/content/FINAL_V.1.0_Pediatric_Guidelines.pdf

Adaptado Dr. Ramon REYES, MD
VP Operacional Comite Iberoamericano de Medicina Tactica y Operacional 
Faculty y Medical Director TECC, TCCC
Miembro Grupo Internacional  Comite TECC 

Torniquetes Pediatricos en el Mercado: 

1. S.T.A.T.® Tourniquet 

Pero antes ver estos malos resultados hechos por un profesional de mucho prestigio ante el Comite TECC 

STAT Tourniquet 21 of 24 applications FAIL by Mike Shertz CRISIS MEDICINE 

https://emssolutionsint.blogspot.com/2018/11/stat-tourniquet-21-of-24-applications.html



Torniquete pediátrico para  extremidades pequeñas tanto como unos 20 mm. De fácil aplicación en solo  unos 5 segundos.



2. m2 CHILD Ratcheting Medical Tourniquet EMS World 2015 Top Innovation Award Winner
http://emssolutionsint.blogspot.com/2017/12/m2-ratcheting-medical-tourniquet-rmt.html



















Pediatric Tactical Emergency Casualty Care

DIRECT THREAT CARE (DTC)

Goals:

1.     Accomplish the mission with minimal casualties

2.     Prevent any casualty from sustaining additional injuries

3.     Keep response team maximally engaged in neutralizing the existing threat (e.g. active shooter, unstable building, confined space HAZMAT, etc.)
4.     Minimize public harm


Principles:

1.     Mitigate ongoing direct threat (e.g. active fire fight, unstable building collapse, dynamic explosive scenario, etc.).
2.     Threat mitigation techniques will minimize risk to casualties and the providers. These should include techniques and tools for rapid casualty access and egress.

3.     Minimal trauma interventions are warranted.

4.     Consider hemorrhage control

a.     TQ application is the primary “medical” intervention to be considered in Direct Threat Care.
b.     Consider instructing casualty to apply direct pressure to the wound if no tourniquet available or application is not tactically feasible.

5.     Consider quickly placing or directing casualty to be placed in position to protect airway.

Guidelines:

1.      Mitigate any threat and move to a safer position (e.g. Return fire, utilize less lethal technology, assume an overwhelming force posture, extraction from immediate structural collapse, etc.).
2.      Direct the casualty to move to a safer position and apply self aid if able.

a.      Attention must be paid to the type of instruction that will be presented to this population.
b.      Use of tactile direction, visual signaling and simple language may improve communication.
3.      Casualty Extraction

a.      If a casualty can move to safety, they should be instructed to do so.

Pediatric Tactical Emergency Casualty Care

b.      If a casualty is unresponsive, the scene commander or team leader should weigh the risks and benefits of a rescue attempt in terms of manpower and likelihood of success. Remote medical assessment techniques should be considered.
c.      If the casualty is responsive but cannot move, a tactically feasible rescue plan should be devised.
d.      Recognize that threats are dynamic and may be ongoing, requiring continuous threat assessments.
4.      Stop life threatening external hemorrhage if tactically feasible:

a.      Provider should not hesitate to apply tourniquets to pediatric casualties.

b.      Apply a tourniquet over the clothing as proximal-- high on the limb-- as possible.

c.      Tighten until cessation of bleeding and move to safety. Consider moving to safety prior to application of the TQ if the situation warrants.
d.      Consider instructing casualty to apply direct pressure to the wound if no tourniquet available or application is not tactically feasible
5.      Consider quickly placing casualty, or directing the casualty to be placed, in position to protect airway if tactically feasible


Skill Sets:

1.      Tourniquet application

2.      Consider PACE Methodology- Primary, Alternative, Contingency, Emergency

3.      Commercially available tourniquets

4.      Field expedient tourniquets

5.      Tactical casualty extraction

6.      Rapid placement in recover position

Pediatric Tactical Emergency Casualty Care



INDIRECT THREAT CARE (ITC)

Goals:


1.     Goals 1-4 as above with DTC care

2.     Stabilize the casualty as required to permit safe extraction to dedicated treatment sector or medical evacuation assets

Principles:

1.     Maintain tactical supremacy, mitigate threats and complete the overall mission.

2.     Conduct dedicated patient assessment and initiate appropriate life-saving interventions as outlined in the ITC guidelines. DO NOT DELAY casualty extraction/evacuation for non life-saving interventions.

3.     Consider establishing a casualty collection point if multiple casualties are encountered

4.     Establish communication with the tactical and/or command element and request or verify initiation of casualty extraction/evacuation.
5.     Prepare casualties for extraction and document care rendered for continuity of care purposes.

Guidelines:

1.      Bleeding:

a.      Assess for unrecognized hemorrhage and control all sources of major bleeding:

i.       If not already done, use a tourniquet for potentially life-threatening bleeding.
i.       Apply the tourniquet over the clothing as proximal-- high on the limb-- as possible. If able and tactical situation permits, consider fully exposing the wound, applying tourniquet directly to the skin.

ii.     For any traumatic total or partial amputation, a tourniquet should be applied regardless of bleeding.
ii.     Apply pressure dressing with deep wound packing to control life-threatening external hemorrhage that is anatomically amenable to such treatment.
b.      For compressible hemorrhage not amenable to tourniquet use, or as an adjunct to tourniquet removal (if evacuation time is anticipated to be longer than two hours),

Pediatric Tactical Emergency Casualty Care

apply a hemostatic agent in accordance with the directions for its use with an appropriate pressure bandage. Before releasing any tourniquet on a casualty who has received IV fluid resuscitation for hemorrhagic shock, ensure a positive response to resuscitation efforts (i.e., a peripheral pulse normal in character and normal mentation).

c.      Reassess all tourniquets that were applied during previous phases of care. Consider exposing the injury. Tourniquets applied hastily during DTC phase that are determined to be both necessary and effective in controlling hemorrhage should remain in place if the casualty can be rapidly evacuated to definitive medical care. If ineffective in controlling hemorrhage or if there is any potential delay in evacuation to care, expose the wound fully, identify an appropriate location immediately proximal to the first tourniquet, and apply a new tourniquet directly to the skin.
d.      When time and the tactical situation permit, a distal pulse check should be accomplished on any limb where a tourniquet is applied. If a distal pulse is still present, consider additional tightening of the tourniquet or the use of a second tourniquet, side by side and proximal to the first, to eliminate the distal pulse.

e.      Expose and clearly mark all tourniquet sites with the time of tourniquet application.
2.      Airway Management:

a.      Unconscious casualty without airway obstruction:

iii.   Chin lift or jaw thrust maneuver

iv.    Nasopharyngeal airway

v.     Place casualty in the recovery position

vi.    Caution advised in patients with suspected C-spine injury.

b.      Casualty with airway obstruction or impending airway obstruction:

i.       Chin lift or jaw thrust maneuver

ii.     Nasopharyngeal airway

iii.   Allow casualty to assume position that best protects the airway- including sitting up
iv.    Place unconscious casualty in the recovery position

c.      If previous measures unsuccessful:

i.       Airway positioning may be enhanced by elevation of the shoulders

Pediatric Tactical Emergency Casualty Care

ii.     Bag mask ventilation is preferred to intubation in the pediatric pre-hospital population with suspected hemorrhagic shock

iii.   Oral/nasotracheal intubation

iv.    Consider surgical/invasive airway

iii.   Needle cricothyroidotomy recommended if signs of puberty are absent
iv.    Surgical cricothyroidotomy only recommended in pediatric patients with signs of puberty
v.     Consider Supraglottic Devices (e.g. King LT or LMA) per protocol.

d.      Apply oxygen if available

3.      Breathing:

e.      In a casualty with progressive respiratory distress and known or suspected torso trauma, consider tension pneumothorax. Needle thoracostomy should be performed on the side of the injury, using the largest gauge (minimum 18-gauge) and the longest length appropriate for body size/chest wall thickness:

vi.    In the second intercostal space at the mid-clavicular line. Ensure that the


needle entry into the chest is lateral to the nipple line and is not directed towards the heart.

vii.  If properly trained, consider a lateral decompression, inserting the needle in the 4-5th intercostals space, anterior to the mid-axillary line on the injured side.
f.       All open chest wounds should be treated by immediately applying an occlusive material to cover the defect and securing it in place. Monitor the casualty for the potential development of a subsequent tension pneumothorax.
4.      Intravascular (IV/IO) access:

a.      If rapid fluid resuscitation is indicated consider primary intraosseous (IO) route (per agency protocol).
b.      Consider IV saline lock

5.      Fluid resuscitation: Assess for hemorrhagic shock; altered mental status (in the absence of head injury) and weak or absent peripheral pulses are the best field indicators of shock.
a.      If not in shock:

i.       No IV fluids necessary

ii.     PO fluids permissible if:

Pediatric Tactical Emergency Casualty Care

v.     Conscious, can swallow, and has no injury requiring potential surgical intervention
vi.    If confirmed long delay in evacuation to care

b.      If in shock:

i.       Administer appropriate IV fluid bolus (20cc/kg NS/LR) and re-assess casualty. Repeat bolus after 30 minutes if still in shock.
ii.     If a casualty with an altered mental status due to suspected TBI has a weak or absent peripheral pulse, resuscitate to mid age-specific systolic blood pressure range, or return of strong peripheral pulse.
6.      Prevention of hypothermia (Note, due to high total body surface area ratio and other physiological variables, children are at high risk of hypothermia):
c.      Initiate all efforts to eliminate heat loss as soon as operationally feasible, after life-saving interventions have been employed.
d.      Minimize casualty’s exposure to the elements.

e.      Replace wet clothing with dry if possible. Place the casualty onto an insulated surface as soon as possible.
f.       Cover the casualty with commercial warming device, dry blankets, poncho liners, sleeping bags, or anything that will retain heat and keep the casualty dry.
g.      Warm fluids are preferred if IV fluids are required.

7.      Penetrating Eye Trauma: If a penetrating eye injury is noted or suspected:

a.      Perform a rapid field test of visual acuity.

b.      Cover the eye with a rigid eye shield (NOT a pressure patch). If a commercial eye shield is not available, use casualty’s eye protection device or anything that will prevent external pressure from being applied to the injured eye.
8.      Reassess casualty:

a.      Complete secondary survey checking for additional injuries. Inspect and dress known wounds that were previously deferred.
b.      Consider splinting known/suspected fracture to include applying pelvic binding techniques for suspected pelvic fractures.
9.      Provide analgesia as necessary.

a.      Consider oral or rectal (if available) non-narcotic medications such as Tylenol for mild to moderate pain.


Pediatric Tactical Emergency Casualty Care

b.      Avoid the use of non-steroidal anti-inflammatory medications (e.g. aspirin, ibuprofen, naproxen, ketorolac, etc) in the trauma patient as these medications interfere with platelet functioning and may exacerbate bleeding.
c.      Narcotic pain medications should be utilized per protocol. Consider utilization of mucosal atomizer devices (MAD). Exercise caution when using narcotic medications (e.g. fentanyl citrate.) and/or Ketamine for moderate to severe pain in pediatric patients due to their higher volumes of distribution.

i.       Consider adjunct administration of anti-emetic medicines

ii.     Have naloxone readily available whenever administering opiates

iii.   Monitor for adverse effects such as respiratory depression or hypotension.

10.   Antibiotics: Consider initiating antibiotic administration for casualties with open wounds and penetrating eye injury when evacuation to definitive care is significantly delayed or infeasible. This is generally determined in the mission planning phase and requires medical oversight.

11.   Burns:

a.      Facial burns, especially those that occur in closed spaces, may be associated with inhalation injury. Look for singed nasal hairs or facial hair or soot in and around the nares which may indicate possible inhalational injury. Aggressively monitor airway status and oxygen saturation in such patients and consider early definitive airway management for respiratory distress or oxygen desaturation.

b.      Smoke inhalation, particularly in a confined space, may be associated with significant carbon monoxide and cyanide toxicity. Patients with signs of significant smoke inhalation plus:
i.       Significant symptoms of carbon monoxide toxicity should be treated with high flow oxygen if available
ii.     Significant symptoms of cyanide toxicity should be considered candidates for cyanide antidote administration
c.      Estimate total body surface area (TBSA) burned to the nearest 10% using the appropriate locally approved burn calculation formula.
d.      Cover the burn area with dry, sterile dressings and initiate measures to prevent heat loss and hypothermia.
e.       If burns are greater than 20% of Total Body Surface Area, fluid resuscitation should be initiated under medical control as soon as IV/IO access is established. If


Pediatric Tactical Emergency Casualty Care

hemorrhagic shock is also present, resuscitation for hemorrhagic shock takes precedence over resuscitation for burn shock as per the guidelines.

f.       All previously described casualty care interventions can be performed on or through burned skin in a burn casualty.
g.      Analgesia in accordance with TECC guidelines may be administered.

h.      Aggressively act to prevent hypothermia for burns greater than 20% TBSA.

12.   Monitoring: Apply appropriate monitoring devices and/or diagnostic equipment if available. Obtain and record vital signs.
13.   Prepare casualty for movement: Consider environmental factors for safe and expeditious evacuation. Secure casualty to a movement assist device when available. If vertical extraction required, ensure casualty secured within appropriate harness, equipment assembled, and anchor points identified.

14.   Communicate with the casualty if possible. Encourage, reassure and explain care.

15.   Cardiopulmonary resuscitation (CPR) within a tactical environment 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 unless appropriate manpower is available. However, consider bilateral needle decompression for victims of torso or polytrauma with no respirations or pulse to ensure tension pneumothroax is not the cause of cardiac arrest prior to discontinuation of care.

a.      In certain circumstances, such as electrocution, drowning, atraumatic arrest, or hypothermia, performing CPR may be of benefit and should be considered in the context of the tactical situation.
16.   Documentation of Care: Document clinical assessments, treatments rendered, and changes in the casualty’s status in accordance with local protocol. Consider implementing a casualty care card that can be quickly and easily completed by non-medical first responders. Forward this information with the casualty to the next level of care.


Skill set:

1.     Hemorrhage Control:

a.     Apply Tourniquet

b.     Apply Direct Pressure

c.     Apply Pressure Dressing

d.     Apply Wound Packing

e.     Apply Hemostatic Agent

2.     Airway:

Pediatric Tactical Emergency Casualty Care

a.     Apply Manual Maneuvers (chin lift, jaw thrust, recovery position, shoulder elevation)

b.     Insert Nasal pharyngeal airway

c.     Insert Supraglottic Device (LMA, King-LT, etc)

d.     Perform Tracheal Intubation

e.     Perform Surgical Cricothyrotomy (Not recommended for under 10 yrs)

f.      Perform Needle Cricothyrotomy

3.     Breathing:

a.     Application of effective occlusive chest seal

b.     Assist Ventilations with Bag Valve Mask

c.     Apply Oxygen

d.     Apply Occlusive Dressing

e.     Perform Needle Chest Decompression

4.     Circulation:

a.     Gain Intravascular Access

b.     Gain Intraosseous Access

c.     Apply saline lock

d.     Administer IV/IO medications and IV/IO fluids

e.     Administer blood products

5.     Wound management:

a.     Apply Eye Shield

b.     Apply Dressing for evisceration

c.     Apply Extremity Splint

d.     Apply Pelvic Binder

e.     Initiate Basic Burn Treatment

f.      Initiate Treatment for Traumatic Brain Injury

6.     Prepare Casualty for Evacuation:

a.     Move Casualty (drags, carries, lifts)

b.     Apply Spinal Immobilization Devices

c.     Secure casualty to litter

d.     Initiate Hypothermia Prevention

7.     Other Skills:

a.     Perform Hasty Decontamination

a.     Initiate Casualty Monitoring

b.     Establish Casualty Collection Point

c.     Perform Triage

Pediatric Tactical Emergency Casualty Care

EVACUATION CARE (EVAC):

Goals:

1.      Maintain any life saving interventions conducted during DTC and ITC phases

2.      Provide rapid and secure extraction to a appropriate level of care

3.      Avoid additional preventable causes of death


Principles:

1.      Reassess the casualty or casualties

2.      Rapidly evacuate patients/casualties is critical

3.      Utilize additional resources to maximize advanced care

4.      Avoid hypothermia

5.      Communication is critical, especially between tactical and non tactical EMS teams.

Guidelines:

1.      Reassess all interventions applied in previous phases of care. If multiple wounded, perform primary triage.
2.      Airway Management:

a.      The principles of airway management in Evacuation Care are similar to that in ITC with the addition of increased utility of supraglottic devices and endotracheal intubation.
b.      Unconscious casualty without airway obstruction:

i.       Chin lift or jaw thrust maneuver

ii.     Nasopharyngeal airway

iii.   Place casualty in the recovery position

iv.    Caution advised in patients with suspected C-spine injury

b.     Casualty with airway obstruction or impending airway obstruction:

i.       Recovery position

ii.     Naso/oropharyngeal airway

iii.    Airway positioning may be enhance by elevation of shoulders

iv.    Bag mask ventilation is equivalent to intubation in the pediatric pre-hospital setting

Pediatric Tactical Emergency Casualty Care

v.      If previous measures unsuccessful, it is prudent to consider supraglottic Devices (King LT, LMA, etc), endotracheal intubation with Rapid Sequence Intubation.
vi.    Needle cricothyroidotomy recommended if signs of puberty are absent

vii.  Surgical cricothyroidotomy only recommended in patients with signs of puberty
c.      Following intubation, continuously monitor for ETT dislodgment, obstruction and equipment failure.
d.      If attached to a mechanical ventilator, consider lung protective strategies and reassess for respiratory decline in patients with potential pneumothoraces.
e.      Use of end-tidal CO2 monitoring is recommended when available.

f.       Prophylactic hyperventilation is not recommended

3.      Breathing:

a.      Reassess casualties who have had chest seals applied or had needle thoracostomy. If there are signs of continued or progressive respiratory distress:
i.       Consider repeating needle decompression. If this results in improved clinical status, the decompression can be repeated multiple times.
ii.     If appropriate provider scope of practice and approved local protocol, consider placing a chest tube if no improvement of respiratory distress after decompression if long duration or air transport is anticipated.
b.     All open chest wounds should be treated by immediately applying an occlusive material to cover the defect and securing it in place. Monitor the casualty for the potential development of a subsequent tension pneumothorax. Tension pneumothoraces should be treated as described in ITC.

c.      Administration of oxygen may be of benefit (absent an environmental risk for fire or explosion) for all traumatically injured patients, especially for the following types of casualties:
i.       Low oxygen saturation by pulse oximetry

ii.     Injuries associated with impaired oxygenation

iii.    Unconscious casualty

iv.    Casualty with TBI (maintain oxygen saturation > 90%)

v.      Casualty in shock


Pediatric Tactical Emergency Casualty Care

vi.    Casualty at altitude

vii.  Casualties with pneumothoraces

4.      Bleeding:

a.      Fully expose wounds to reassess for unrecognized hemorrhage and control all sources of major bleeding.
b.     If not already done, use a tourniquet or an appropriate pressure dressing with deep wound packing to control life-threatening external hemorrhage that is anatomically amenable to such treatment. For any traumatic total or partial amputation, a tourniquet should be applied regardless of bleeding.

c.      Reassess all tourniquets that were applied during previous phases of care. Expose the injury and determine if a tourniquet is needed.
i.       Tourniquets applied in prior phases that are determined to be effective in controlling hemorrhage should remain in place if the casualty can be rapidly evacuated to definitive medical care.
ii.     If ineffective in controlling hemorrhage or if there is any potential delay in evacuation to care, apply a new tourniquet immediately above the first.
iii.    If delay to definitive care longer than 2 hours is anticipated and wound for which tourniquet was applied is anatomically amenable, attempt a tourniquet downgrade as described in ITC (this should be a paramedic or MD action).

iv.    A distal pulse check should be performed on any limb where a tourniquet is applied. If a distal pulse is still present, consider additional tightening of the tourniquet or the use of a second tourniquet, side by side and proximal to the first, to eliminate the distal pulse.

v.      Expose and clearly mark all tourniquet sites with the time of tourniquet application. Use an indelible marker.
5.       Fluid resuscitation:

a.      If casualty displays signs of shock (altered mental status in the absence of brain injury, weak or absent peripheral pulses, and/or change in pulse character) resuscitation should be directed towards restoration of peripheral pulses and improvement of mental status.

b.     If BP monitoring is available, maintain target systolic BP 70mmHg or Mean Arterial Pressure greater than 60 mm Hg in children under 10 (minimum normal systolic BP = 70 + (Age x 2).


Pediatric Tactical Emergency Casualty Care

c.      Establish intravascular access if not performed in ITC phase. Consider primary intraosseous access in Pediatric population
d.     Management of resuscitation as in ITC with the following additions:

i.       If in shock and blood products are not available or not approved under scope of practice/local protocols resuscitate as in ITC.
ii.     If in shock and blood products are available with an appropriate provider scope of practice under an approved medical protocol:
1.      Resuscitate with 10-15 cc/kg of plasma (FFP) and 10-15 cc/kg of packed red blood cells (PRBCs) in a 1:1 ratio.
2.      If blood component therapy is not available, and appropriate training, testing and protocols are in place, consider transfusing fresh whole blood.
3.      Continue resuscitation as needed to maintain target BP or clinical improvement.
iii.    If a casualty with an altered mental status due to suspected TBI has a weak or absent peripheral pulse, resuscitate as necessary to maintain mid age-specific systolic blood pressure range, or a strong peripheral pulse.
iv.    If suspected TBI and casualty not in shock, raise the casualty’s head to 30 degrees and maintain MAP > 60mm Hg with volume resuscitation or vasopressor medications, if indicated and approved under scope of practice/local protocols.

6.      Prevention of hypothermia:

a.      Continue all efforts to eliminate heat loss as operationally feasible, after life-saving interventions have been employed.
b.     Minimize casualty’s exposure to the elements. Move into a medic unit, warmed vehicle, or warmed structure if possible. Ensure transport vehicle climate control system does not worsen hypothermia.
c.      Replace wet clothing with dry if possible. Place the casualty onto an insulated surface as soon as possible.
d.     Cover the casualty with commercial warming device, dry blankets, poncho liners, sleeping bags, or anything that will retain heat and keep the casualty dry.
e.      Warm fluids are preferred if IV fluids are required.

7.      Monitoring


Pediatric Tactical Emergency Casualty Care

a.      Institute electronic monitoring if available, including pulse oximetry, cardiac monitoring, etCO2 (if assisted ventilation or altered mental status), and blood pressure.
b.     Obtain and record vital signs.

8.      Reassess casualty:

a.      Complete secondary survey checking for additional injuries. Inspect and dress known wounds that were previously deferred.
b.     Determine mode and destination for evacuation to definitive care.

c.      Splint known/suspected fractures and recheck pulses.

d.      Apply pelvic binding techniques for suspected pelvic fractures.

e.      Consider the mechanism of injury and the need for spinal immobilization. Spinal immobilization is not necessary for casualties with penetrating trauma if the patient is neurologically intact. Patients may be clinically cleared from spinal immobilization under a locally approved protocol if they have none of the following:

i.       Midline c-spine tenderness

ii.     Neurologic impairment

iii.    Altered mental status

iv.    Distracting injury

9.      Provide analgesia as necessary.

a.      Mild pain:

i.       Consider oral non-narcotic medications

ii.     Avoid the use of non-steroidal anti-inflammatory medications (e.g. aspirin, ibuprofen, naproxen, ketorolac, etc) in the trauma patient as these medications interfere with platelet functioning and may exacerbate bleeding

b.     Moderate to severe pain:

i.       Narcotic pain medications should be utilized per protocol. Consider utilization of mucosal atomizer devices (MAD). Exercise caution when using narcotic medications (e.g. fentanyl citrate.) and/or Ketamine for moderate to severe pain in pediatric patients due to their higher volumes of distribution.


Pediatric Tactical Emergency Casualty Care

i.       Place patient on appropriate monitor

ii.     Consider adjunct administration of anti-emetic medicines

iii.   Have naloxone readily available whenever administering opiates
iv.    Monitor for adverse effects such as respiratory depression or hypotension.

10.   Burns:

c.      Burn care is consistent with the principles described in ITC.

d.      Smoke inhalation, particularly in a confined space, may be associated with significant carbon monoxide and cyanide toxicity. Patients with signs of significant smoke inhalation plus:
ii.     Significant symptoms of carbon monoxide toxicity should be treated with high flow oxygen if available
iii.   Significant symptoms of cyanide toxicity should be considered candidates for cyanide antidote administration
e.      Be cautious of off-gassing from patient in the evacuation vehicle if there is suspected chemical exposure (e.g. cyanide) from the fire.
f.       Consider early airway management if there is a prolonged evacuation period and the patient has signs of significant airway thermal injury (e.g. singed facial hair, oral edema, carbonaceous material in the posterior pharynx and respiratory difficulty).

11.   Prepare casualty for movement: Consider environmental factors for safe and expeditious evacuation. Secure casualty to a movement assist device when available. If vertical extraction required, ensure casualty secured within appropriate harness, equipment assembled, and anchor points identified.

12.   Communicate with the casualty, transporting crew and with the accepting facility. Encourage, reassure and explain care to patient and parents.
13.   Cardiopulmonary resuscitation (CPR) may have a larger role during the evacuation phase especially for patients with electrocution, hypothermia, non traumatic arrest or near drowning.
a.      Consider rescue breaths in small children with deteriorating cardiopulmonary status.

Pediatric Tactical Emergency Casualty Care

b.      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.
14.   Documentation of Care: Continue or initiate documentation of clinical assessments, treatments rendered, and changes in the casualty’s status in accordance with local protocol. Forward this information with the casualty to the next level of care.