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K9 Tactical Emergency Casualty Care Direct Threat Care Guidelines

Lee Palmer, DVM, MS, DACVECC, CCRP, WEMT, NRP, EMT-T, TP-C; Allen Yee, MD, FACEP, FAAEM

The Operational K9—Our companions, our teammates, our defenders— Let’s protect those who protect us.

GOALS a. It is highly recommended that OpK9s operating in a tactical environment wear a body-type harness 1. Accomplish the mission with minimal casualties. to assist in rapid extraction/extrication from the 2. Maintain tactical superiority. hot zone. 3. Expect to keep the canine (K9) team (handler and/or b. K9 handling and restraint K9) maximally engaged in neutralizing the existing i. Any injured or stressed K9 is considered un- threat (e.g., active shooter, structural collapse, con- predictable and may bite, even its own handler. fined space, hazardous materials). ii. Consider applying a muzzle prior to handling 4. Maintain team safety by ensuring, when feasible, a conscious K9 when no contraindications to that the K9 handler is always involved when han- muzzling exist (e.g., upper airway obstruc- dling an injured K9. tion, respiratory complications, severe facial 5. Move the downed K9 team to a safe position and trauma, heat-related injuries, vomiting, coma- prevent any human or K9 casualty from sustaining tose state). additional injuries. iii. Handlers should carry a quick application 6. Treat immediately life-threatening hemorrhage. type of muzzle in a known, easily accessible 7. Minimize public harm. location for expedient handler /team use when and if needed. c. It is strongly urged to have at least two alternate Principles team members or designated first responders (e.g., 1. The term Operational K9 (OpK9) refers to the dis- emergency medical services [EMS], fire depart- tinct subpopulation of elite civilian working K9s that ments) trained in basic K9 handling techniques for operate in high-threat or tactical environments. Ex- situations when the handler is down. amples include K9s that serve federal and local law i. When feasible, these personnel should have enforcement (LE) and force protection agencies (e.g., a well-established and positive rapport with police, Transportation Security Administration, Fed- OpK9s they support. eral Bureau of Investigation, Bureau of Alcohol, Fire- ii. It is recommended that only select members arms, Tobacco, and Explosives, US Marshals Service, are granted this level of rapport to prevent de- US Customs and Border Protection), and search-and- creasing the reliability of the K9 asset. rescue groups (e.g., Federal Emergency Management d. Threat mitigation to rescuer and casualty AL- Agency Urban , various Sheriff’s WAYS takes priority. County search-and-rescue K9 teams). i. DO NOT delay extraction time to a safe zone 2. Establish and maintain tactical control and defer in- for the sole purpose of applying a muzzle on depth medical interventions if engaged in ongoing di- an injured K9. rect threat (e.g., active fire fight, structural collapse, ii. Handler/responder must weigh the benefits dynamic postexplosive scenario). and risks of muzzling the K9 based upon the 3. Threat mitigation techniques will minimize risk to ca- likelihood of a re-emerging threat. sualties and the providers. These should include tech- iii. Consider that in situations where a threat re- niques and tools for rapid casualty access and egress. appears, a muzzled K9 will no longer be able

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to protect the downed handler or continue the 4. K9 handler down. mission. a. When the K9 handler is injured and team mem- 4. should be deferred to a later phase of care. bers and or responders are not close to assist, then Prioritization for extraction is based on available re- the handler (if possible) should: sources and the tactical/operational situation. i. Engage the threat and immediately apply self- 5. Limited first aid at the point of injury is warranted. aid when feasible. 6. Consider deferring airway management until indi- ii. If hostile threat is neutralized, secure the OpK9 rect threat care (ITC), if appropriate based on the by any quick, expedient method. A loose, ag- tactical situation. gressive, or anxious K9 may be a threat to res- 7. Consider hemorrhage control for life-threatening cuers and prevent extraction or provision of bleeding in an injured K9 if tactically feasible. medical aid to the downed handler. a. Direct pressure is the primary medical interven- b. If the K9 team is down and unresponsive, or is re- tion to be considered during direct threat care sponsive but cannot move, the scene commander (DTC) for the K9 casualty. or team leader should weigh the risks and benefits b. Consider securing dressing material in place with of a rescue attempt in terms of manpower, likeli- application of a circumferential pressure bandage hood of success, and mission sustainment. during DTC, if tactically feasible. i. Consider remote medical assessment techniques. c. Consider an improvised tourniquet (ITQ) applica- ii. Recognize that threats are dynamic and may be tion as a last resort for extremity or tail wounds ongoing, requiring continuous threat assessments. involving amputations and for which hemorrhage 5. Stop life-threatening external hemorrhage, if tacti- is not controlled by direct pressure alone. cally feasible. d. Consider quickly placing or allowing the injured a. Remember, the primary goal during DTC is to K9 to remain in a position of comfort that pro- quickly remove the K9 casualty and handler/res- tects the airway, permits ease of respiration, and cuer away from the direct imminent threat (e.g. is least stressful. “Get off the X”). e. Depending on the situation, the position of com- i. Consider moving the K9 casualty to safety fort in most K9s is sternal (i.e., prone) recumbency. (behind cover) before applying direct pressure They may also prefer to sit or stand, which is ac- or a tourniquet (TQ) if the situation allows. ceptable if it is amenable to the tactical situation. b. Direct pressure i. Remains the primary tenet of controlling ex- ternal hemorrhage in K9s under DTC. K9 Tactical Emergency Casualty Care (TECC): c. Wound packing and hemostatic agents DTC Hot Zone Guidelines i. Often not tactically feasible to perform appro- 1. Mitigate any threat (e.g., return fire, use less lethal priately under DTC technology, assume an overwhelming force posture, ii. May consider loosely packing (i.e., wadding extraction from immediate structural collapse or or stuffing) dressing into the wound and then fire, stop the burning process) and move to a safer securing with a quick application pressure position. wrap as situation permits. 2. Keep the K9 casualty or K9 team engaged in any d. Tourniquets: tactical operation, if appropriate and until threat is i. Not considered first-line treatment for control- neutralized. ling extremity hemorrhage in K9s because most 3. K9 casualty extraction: The handler/responder should human commercial, windlass TQs (e.g., Com- secure and extract an injured K9 from the hot zone to bat Application Tourniquet® [Composite Re- a safe location in a way that does not further jeopar- sources Inc.; http://combattourniquet.com/], dize human life (self or team): SOF® Tactical Tourniquet [Tactical Medical a. Avoid exposing themselves or other team mem- Solutions; https://www.tacmedsolutions.com bers to an imminent threat for the sole reason of /product/sof-tactical-tourniquet-wide/]) do not extracting an injured OpK9. work effectively on K9 extremities. b. Engage and neutralize the threat or ensure the ac- ii. Consider TQ application in K9s under the fol- tive threat is neutralized before rendering aid or lowing conditions: extracting the OpK9 casualty. (c) Extremity hemorrhage appears life threat- c. When the handler/responder is already behind ening (e.g., K9 has suffered a complete cover and separated from an injured K9, they traumatic limb or tail amputation), AND should remain under cover and attempt to call (d) Bleeding remains refractory to other and direct the K9 to their location, because some methods of hemostasis (e.g., direct pres- injured OpK9s may remain ambulatory. sure, pressure dressing), AND

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(e) The anatomic site is amenable to TQ Principles application (i.e., mainly limbs and tail 1. Maintain tactical control and complete the overall wounds). mission. iii. When a TQ is warranted (e.g., under Section 2. As applicable, ensure safety of first responders and 4.d.ii.), consider applying an ITQ or wide, elas- K9 casualties by always: tic, nonwindlass TQ (e.g., SWAT-T® [TEMS a. Keeping the K9 handler involved when handling Solutions; http://www.swattourniquet.com/]) or treating an injured K9. (a) ITQs may be constructed from material b. Considering muzzling the K9 when no contraindi- such as a cravat, long-sleeved shirt, or cations to applying muzzle exist (e.g., respiratory back pack strap (at least 3.8cm or 1.5 complications, heat-related injuries, vomiting, co- inches wide). matose state) and if not performed during DTC. (b) A stick, small metal bar, or even a long- c. Considering early use of chemical restraint for bladed knife firmly seated in its sheath injured K9s that are fractious and potentially ag- may be used as the torsion (i.e., windlass) gressive because of pain, stress, and/or fear. device. d. Training medical providers with the likelihood for iv. Apply the ITQ as proximal (i.e., high on the treating injured K9s in safe K9 handling techniques. limb or tail) as possible or at least 2–3 inches 3. Conduct dedicated patient assessment and initiate above the wound. appropriate life-saving interventions as outlined in v. DO NOT apply ITQ directly over a joint or the following ITC guidelines. wound. 4. DO NOT DELAY casualty extraction/evacuation for vi. Tighten until cessation of bleeding AND loss non-lifesaving interventions. of palpable distal pulses. Optimal use of limb 5. Consider establishing a casualty collection point if TQs must result in both multiple casualties are encountered. (a) Cessation of bleeding, AND 6. Unless in a fixed casualty collection point, triage in (b) Loss of distal pulses in the extremity. this phase of care should be limited to the following vii. Expose and clearly mark all TQ sites with an categories: indelible marker. a. Uninjured (a) Indicate date and time of application. b. Deceased/expectant (b) Do not cover a TQ. c. All others e. Immobilize and elevate the area when practi- 7. Establish communication with the tactical and/or cal and feasible. Keep the K9 as calm as possible command element and request or verify initiation of to avoid inadvertent elevations in arterial blood casualty extraction/evacuation. pressure. 8. Prepare casualties for extraction and document care f. Consider quickly placing the K9 casualty in posi- rendered for continuity-of-care purposes. tion to protect airway, if tactically feasible. K9 ITC Warm Zone Guidelines DTC Skill Sets 1. Restraint. Properly restrain K9 per guidelines de- 1. Move to safety. scribed under DTC. 2. Make safe (e.g., muzzle, restrain) the K9, as war- a. Consider the K9’s mouth and teeth as equivalent ranted. to an LE officer’s weapon and, therefore, it should 3. Massive hemorrhage control: be made safe if the K9 is injured and/or the K9 has a. Direct pressure an altered mental status. b. Application of ITQ as last resort for distal extrem- b. Secure once the threat is neutralized. ity or tail hemorrhage c. Consider early use of chemical restraint for in- 4. Casualty movement and extraction jured K9s that are fractious and potentially ag- 5. Rapid placement in recover position gressive because of pain, stress, and/or fear. i. Follow local veterinary-approved protocols or refer to in the K9 TECC Supplement (http:// K9 TECC: ITC Warm Zone www.k9tecc.org/resources.html) for chemical- GOALS restraint protocols. 2. Bleeding. Reassess for massive hemorrhage. 1. Goals 1–6 as above with DTC care a. Reassess interventions applied for massive hemor- 2. Stabilize the K9 casualty as required to permit safe rhage performed during DTC. extraction to dedicated treatment sector or medical b. Assess for and control any other unrecognized evacuation assets sources of major hemorrhage.

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c. Direct pressure: mentation and peripheral femoral pulses are i. If not already done, apply direct pressure and normal). pressure dressing with deep-wound packing to v. When time and the tactical situation permit, control life-threatening external hemorrhage. a distal pulse check should be accomplished d. Wound packing: on any extremity on which a TQ remains in i. Consider controlling junctional hemorrhage place. To eliminate a distal pulse or visual (inguinal or axillary) or other deep, compress- hemorrhage, if still present, consider: ible hemorrhaging wounds if the bleeding site (a) Additional tightening of the TQ, and/or is not controlled by direct pressure applica- (b) Use of a second juxtaposed TQ, side by tion alone. side and proximal to the first. (a) Performed for major junctional hemorrhage vi. Reasons to consider NOT removing TQ and upper extremity wounds above the el- include: bow and stifle (i.e., triceps, caudal thigh) (a) The distal extremity or tail is a complete (b) Not very effective or necessary on most amputation K9 distal limb wounds (i.e., below elbow (b) The K9 casualty remains in shock or is and knee/stifle) because of lack of signifi- suffering traumatic brain injury (TBI). cant musculature (c) The TQ has been on for >6 hours. ii. Impregnated hemostatic dressing or standard (d) Medical treatment facility is within 2 roll gauze may be used for wound packing. hours after time of application. (a) Topical hemostatic agents are to be ap- (e) Considered inadvisable to transition to plied in the form of an impregnated gauze other hemorrhage control methods on ba- dressing. Apply in accordance with manu- sis of the tactical or medical situation. facturer’s guidelines. vii. Expose and clearly mark all TQ sites with the (b) DO NOT apply powdered or granular time of TQ application. forms of hemostatic agents directly to the f. Consider using a junctional TQ for difficult-to- wound. control junctional hemorrhages (e.g., axilla and iii. Refer to K9 TECC Supplement or local vet- inguinal placements) in K9s. Note: The Abdomi- erinary-approved protocols for guidance on nal Aortic Junctional Tourniquet (AAJT™; Com- deep-wound packing for K9s (e.g., types of pression Works; http://compressionworks.com) material, wound packing protocol). has not been evaluated in K9s, but has been evalu- e. Tourniquet: ated in swine models and shown effective. i. Reassess all TQs that were applied during pre- g. Immobilize (i.e., splint) and elevate the injured vious phases of care by exposing the injury area whenever feasible. and determining if a TQ is needed. h. Reassess frequently for evidence of rebleeding. ii. TQs applied hastily during DTC phase that 3. Airway management. are determined to be both necessary and effec- a. Unconscious casualty without airway obstruction: tive in controlling hemorrhage should remain i. Place the K9 casualty in the recovery posi- in place if the casualty can be rapidly evacu- tion, this typically is in a sternal (i.e., prone) ated to definitive veterinary care. position. iii. Consider conversion to pressure or hemostatic ii. Extend the head and neck into a straight in- dressing and bandage if: line position. (a) TQ is deemed ineffective for controlling iii. Physically open the mouth and pull tongue hemorrhage forward to help open the airway and allow (b) Bleeding can be controlled by other meth- examination of the mouth and pharyngo- ods, such as with direct pressure, pressure laryngeal area. bandage, and/or deep-wound packing (a) Consider using a roll of tape or syringe (c) If there is any potential delay in evacua- tube casing (without a plunger) as a tion to care (>2 hours), expose the wound mouth gag to keep the mouth open. fully and reassess need for TQ around the b. K9 casualty with airway obstruction or impending 2-hour time point airway obstruction: (d) Refer to K9 TECC Supplement for guid- i. Clinical signs: Pawing at mouth, gagging, ex- ance on TQ conversion. cessive drooling, frequent swallowing motions,­ iv. Before releasing a TQ on a casualty that has extended head and neck, elbows and upper received intravenous (IV) fluid resuscitation legs held out from the chest (i.e., “tripod po- for hemorrhagic shock, ensure a positive re- sition”), reluctant to lie down, and cyanosis sponse to resuscitation efforts (e.g., improving­ (bluish gums) as a late sign.

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ii. Evaluation: airway obstruction. DO NOT delay on- (a) It is not advised to stick your hand into scene time. the mouth of a conscious K9. Consider c. Advanced airway techniques: If previous mea- team safety for not suffering bite wounds: sures are unsuccessful at clearing the airway, the 1) Use a leash, rope, or roll gauze looped provider is properly trained, and the intervention behind the upper canine teeth to pry is within the provider’s scope of practice, then the mouth open. perform: 2) If in your scope of practice, con- i. Orotracheal (OTT)/endotracheal intubation sider sedating the K9 in accordance (ETT): with local veterinary-approved pro- (a) Preferred technique in K9s for gaining tocols or refer to in the K9 TECC patent airway, because of ease of ETT Supplement for chemical-restraint placement as compared to humans recommendations. (b) To facilitate ETT placement, ensure head (b) Position the K9 in any position that allows and neck are extended (not flexed) and in the K9 to breath with minimal restriction line. This will allow a direct line of sight or of air flow and protects the airway, even if path from the oral cavity through the pha- that involves a sitting position. ryngolaryngeal area and into the trachea. (c) Observe for bilateral chest rise and fall. (c) A laryngoscope is not often required for (d) Listen for labored or noisy breathing (e.g., K9 OTT/ETT, but it is helpful. stridor, stertor) (d) Common sizes for a 25–30kg K9 are (e) Palpate throat and trachea. 9–11mm internal diameter. (f) Open airway as described in paragraph ii. Blind insertion airway device: 3.a.ii (a) Not considered first line. ETT placement iii. Intervention: is preferred, but consider if ETT is not (a) For patients with an observable ob- available. struction, quickly remove any obvious (b) Consider placing a 37–41F Comitube moveable foreign material from the oro- (Medtronic, http://www.medtronic.com/ pharyngolaryngeal area. us-en/index.html). (b) BE CAREFUL not to push the object (c) King laryngeal tubes (Ambu, http://www. down further into the airway. ambu.com) and I-Gel® (Intersurgical Ltd.; 1) If foreign material is not readily vis- http://www.intersurgical.com/info/igel) ible, DO NOT perform blind two-fin- have not been clinically evaluated in K9s; ger sweep of the mouth and pharynx. laryngeal mask airways often become dis- (c) Consider abdominal thrusts (i.e., Heim- lodged during movement. lich maneuver) for moveable foreign bod- ii. Needle or surgical cricothyrotomy: ies. NOTE: NEVER attempt abdominal (a) Use the same procedure as described for thrusts if sharp objects such as sticks or humans. bones are present. (b) Use chemical restraint in accordance with (d) If attempts to clear or remove the object approved veterinary guidelines or K9 or obstruction from the airway have failed TECC Supplement, and local lidocaine, if and the K9 collapses, consider initiating: conscious. 1) Direct visualization and removal with iii. Needle or surgical tracheostomy: Magill forceps or similar instrument (a) Not recommended over cricothyrotomy 2) Chest compressions (100–120 compres- because it is more invasive, time consum- sions/min) ing, and has a higher rate of complications. 3) Artificial ventilation via bag-mask- (b) Use chemical restraint (see K9 TECC Sup- valve technique or mouth to snout at plement or local veterinary approved pro- a rate of 8–10/min tocols) and local lidocaine if conscious. 4) If within scope of practice and iv. NOTE: If cervical spinal cord injury is sus- training, pursue advanced airway pected, try to maintain the head and neck in a techniques (e.g., needle or surgical neutral, in-line position; avoid excessive flex- cricothyrotomy) ion or extension of the neck. (e) If partial airway obstructions (i.e., some d. Consider administering oxygen supplementation, air is able to flow into the lungs), trans- if available. port as soon as possible and continuously e. If no spontaneous ventilations, provide artificial monitor for progression to complete respirations at 8–10/min.

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f. Monitor oxygen saturation (if available). Normal (e) Once in the pleural space, direct the needle values are >94% on room/atmospheric air. ventrally (i.e., toward the sternum) and the i. Pulse oximetry probe placement in order of lay the needle against the thoracic wall. preference: tongue (if unconscious), lip, ear 1) Ensure the bevel of the needle faces pinna, prepuce (male) or vulva (female). away from the inner thoracic wall. 4. Respiration. (f) Once air is evacuated, remove both the sty- a. All open and/or sucking chest wounds should be let and catheter. DO NOT leave in place. treated by immediately applying a gloved hand 1) The increased elasticity of the K9’s over wound, followed by a vented or nonvented skin prevents adequate securing of the occlusive seal to cover the defect. catheter and/or stylet and, thus, in- i. Rapidly clip hair (if feasible; this is not neces- creases the risk of further lung trauma sary) around the wound, to allow the seal to if the stylet/catheter is left in place. become airtight. Note: Clipping is often not (g) Consider decompressing the chest on both a necessary step, because of the elasticity of sides (left and right): K9s have a fenes- K9 skin. trated /communicating mediastinum that ii. If hair clippers are not available, place a allows air to infiltrate both sides. ­water-soluble lubricant (or other water-­ e. Penetrating thoracic foreign body (e.g., knife, ar- soluble medium, e.g., blood) on the under- row, rebar): side of the chest seal to form an occlusive i. If still in place, DO NOT REMOVE but SE- seal between the skin and the chest seal. CURE object in place. Only consider remov- iii. Secure in place on all four-sides (vented or ing impaled object if it: nonvented) with adhesive tape. (a) Interferes with establishing a patent air- b. Monitor the casualty for the potential develop- way or performing cardiopulmonary re- ment of a subsequent tension pneumothorax suscitation (CPR); (T-PTX). (b) Cannot be adequately secured it in place c. Consider the presence of a T-PTX in the setting of for evacuation or transport; or known or suspected thoracic trauma AND include (c) Cannot be removed from the scene or trans- progressive respiratory distress and increasing re- ported with the K9 (e.g., K9 impaled on re- spiratory rate, with the following clinical signs: bar sticking out from a concrete flooring). i. Rapid, shallow, and open-mouth breathing ii. Place occlusive seal (e.g., saran wrap, meal ii. Acting agitated or unable to get comfortable ready-to-eat wrapper, commercial chest seal) iii. Head and neck extended and elbows and up- around the impaled object and seal edges of per front legs held out away from body (i.e., occlusive seal with adhesive tape. tripod position) iii. Stabilize and secure (e.g., with bandaging) the iv. Asynchronous breathing pattern (i.e., abdo- foreign body to prevent further injury. men and chest move in opposite directions iv. Perform needle decompression as needed if T- during inspiration) PTX develops. v. Barrel-chested with minimal chest excursion v. Transport (injury up) as soon as possible with (more abdominal component) no pressure on penetrating object. vi. Lack of drive and response to even basic 5. Circulation (IV/interosseous [IO] access). commands, unwillingness to move a. If evacuation to definitive care is >30 minutes, vii. Reluctance to lie down consider placing at least an 18-gauge IV catheter viii. Cyanotic (blue) gums (a late finding) (or larger bore) in at least one peripheral vein (the ix. Collapse cephalic vein in either front leg is preferred). d. If T-PTX is present or develops, consider: b. If resuscitation is required and IV access is not i. “Burping” the occlusive chest seal, AND/OR obtainable, use the IO route (per agency protocol ii. Needle decompression (if within scope of and training). Recommended IO locations in the practice and training) K9, in order of preference: (a) Performed with a 14-gauge, 2- to 3.25- i. Flat anteromedial surface of the proximal tibia inch (8cm) needle/catheter (1–2cm distal to the tibial tuberosity; pre- (b) Insert in the seventh to ninth intercostal ferred route, because of ease of placement and space midway up the lateral thoracic wall. location of landmark; 15–25 mm IO catheters (c) Ensure that the needle enters cranially often work well. (i.e., toward the head) of the rib. ii. Greater tubercle of the humerus. (Similar in- (d) Insert the needle perpendicular to the sertion technique as humans). Often requires chest wall. an adult-length IO catheter.

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6. Tranexamic acid (TXA) or epsilon-aminocaproic 9. Hypothermia. acid (EACA). a. Minimize casualty’s exposure to the cold a. If casualty is anticipated to need significant blood elements. transfusion (e.g., presents with hemorrhagic b. Move patient from cold environment or element shock, one or more amputations, penetrating torso to warm shelter. trauma, or evidence of severe bleeding) consider c. Transport patient in a horizontal/sternal position. administration of one of the following as soon as d. Remove any wet outer wear (e.g., vests, har- possible and NO LATER than 3 hours postinjury: nesses, booties). i. 10 mg/kg TXA in 100mL normal saline (NS) e. Gently pat dry any wet tissues or hair coat. Avoid or lactated Ringer’s solution (LR) IV slowly vigorous rubbing. over 15 minutes. f. Place the casualty on an insulated surface as soon ii. 150mg/kg EACA in 100mL NS or LR slowly as possible. over 15 minutes; may continue as an infusion g. Cover the casualty with a commercial warm- at 15–20mg/kg/h for 8 hours. ing device, dry blankets, poncho liners, sleeping b. NOTE: Evidence supporting the appropriate dos- bags, or anything that retains heat and keeps the age of TXA or EACA in K9s is currently limited. casualty dry. Studies are being conducted. h. ALWAYS handle markedly hypothermic patients 7. Fluid resuscitation. (i.e., < 86°F [30°C]) gently to avoid triggering a. Assess for hemorrhagic shock cardiac dysrhythmias. i. Altered mental status (in the absence of head i. Primary efforts should concentrate on treating injury) and weak/absent peripheral femoral and preventing hypothermia (as described above) pulses are the best field indicators of shock. and transporting patient gently to a medical care ii. Abnormal vital signs: facility. (a) Systolic blood pressure (SBP) <90mmHg 10. Ocular (eye) trauma. and heart rate >140 bpm, or a shock in- a. Consider flushing the affected eye and adjacent dex (HR/SBP) >1. tissues with copious amounts of sterile saline or (b) Refer to K9 TECC Supplement or K9 ophthalmic rinse. TECC resources page (http://www.k9tecc b. Nonpenetrating injuries: .org/resources.html) for expected changes i. Protect the eye from further injury. in K9 vital parameters. ii. If available, place a commercial or impro- b. NOT in shock: vised (e.g., bucket with bottom cut out) i. No IV fluids necessary. Elizabethan-type collar on the K9 to prevent ii. Per os (PO) fluids permissible if: self-trauma. (a) Conscious, able to swallow, and has no iii. Consider covering the uninjured eye to re- injury requiring potential surgical inter- duce the level of anxiety as well as reduce vention, AND “sympathetic” movement of the injured eye. (b) Confirmed long delay in evacuation to care. c. Penetrating eye trauma: 8. If in shock: i. If a penetrating eye injury is noted or sus- a. Goal is to maintain perfusion, not necessarily to pected, protect the eye from external pres- restore to normal perfusion values. sure and stabilize any impaled object to b. Administer appropriate IV fluid bolus and reas- prevent movement during extraction. sess casualty’s perfusion parameters (in accor- d. Refer to K9 TECC Supplement or local veterinary- dance with local veterinary-approved protocols or approved guidelines under “Ocular Trauma” for refer to the K9 TECC Supplement for fluid resus- further guidance. citation protocols). 11. Reassess casualty. i. Repeat bolus as appropriate based on clinical a. Perform secondary survey (head-to-tail full-body response. examination), checking for additional injuries. c. If K9-specific blood products are available, con- Reassessment includes: sider resuscitation with fresh-frozen plasma (FFP) i. Inspection (visual observation), and packed red blood cells (PRBCs) in a 1:1 ratio. ii. Palpation (hands-on assessment), and d. If a K9 casualty with an altered mental status due iii. Auscultation (auditory assessment). to suspected TBI has a weak or absent peripheral b. Consider focused assessment of identified local- pulse, resuscitate as necessary to maintain a de- ized injured areas. sired SBP ≥90mmHg or a strong palpable femoral c. Reassess vital parameters (e.g., heart rate, respi- pulse. Avoid restoring SBP >120mmHg with sus- ratory rate, pulse quality, capillary refill). pected TBI. 12. Wounds and fractures.

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a. Important: Handle an injured K9 with a fracture d. NOTE: Ertapenem: Currently, there are no phar- with extreme care and proper restraint. Consider macokinetic data on this antibiotic use in K9s. administering a chemical restraint and analgesia Because of the very limited information available before manipulating the fractured site. (Refer to regarding its use in K9s, it is considered an inves- K9 TECC Supplement for drug protocols.) tigational treatment. If this is the only antibiotic b. Inspect for and dress additional closed or open available, then suggested dosage is to use the hu- wounds and fractures: man pediatric dose of 15mg/kg IV or IM every 12 i. Consider splinting known or suspected frac- hours, not to exceed a daily dosage of 1g (e.g., tures if time and resources permit. 25kg OpK9 = 375mg dose). ii. Rapidly identify and attend to open abdomi- 15. Burns. nal wounds. a. Important: Analgesia in accordance with K9 c. Refer to K9 TECC Supplement or follow local TECC guidelines should be considered for all K9 veterinary-approved guidelines for wound and burn casualties. fracture management protocols. b. Consider burns may not be readily evident in 13. Analgesia/sedation. K9s because their hair coat covers skin lesions a. Provide adequate analgesia as necessary for the effectively. injured K9. i. Hot liquids seep under hair coat and, there- b. For K9s able to continue mission: fore, only an area of wet, oily, or greasy hair i. DO NOT use any human-derived nonste- may be present. roidal antiinflammatory medications (e.g., ii. A K9 often reacts to a painful burn by dis- aspirin, ibuprofen, naproxen, ketorolac) in playing agitation and continually biting, lick- K9s. ing, or rubbing the affected area. Look for ii. When available, consider: tramadol 3–5mg/ these behavioral signs to help support any kg every 6–8 hours PO (75–125mg for a suspicion that a K9 may have been burned. 25kg K9). c. Immediately remove the K9 from the burning iii. Use caution when attempting to administer source and stop the burning process. oral medications to an injured K9 in pain. i. Remove all harnesses, collars, vest, booties, c. For K9s unable to continue mission: and so forth. Avoid pulling away any items i. Consider narcotic (opiate) medications. that are melted and have stuck to the K9’s (a) IV, IO, or intramuscular (IM) pure mu skin. (μ)-agonist opiates (e.g., morphine, fen- d. Consider inhalational/airway injury in any K9 tanyl, hydromorphone) are the most trapped in a confined-fire environment and with effective. any one of the following clinical signs: carbona- (b) NOTE: Oral opiates are not effective ceous sputum, singed facial or nasal hairs, facial and intranasal/transmucosal fentanyl burns, oropharyngeal edema, vocal changes (stri- (e.g., lozenges) have not been fully eval- dorous), or altered mental status. uated in K9s. i. Facial burns, especially those that occur in ii. Consider ketamine (at analgesic dosages) for closed spaces, may be associated with inhala- moderate to severe pain. tion and corneal injuries. (a) Ketamine must be combined with a ben- ii. Aggressively monitor airway status and oxy-

zodiazepine (e.g., midazolam, diazepam, gen saturation (Spo2) in such patients and lorazepam) in K9s. consider early definitive airway manage- iii. Consider adjunct administration of anti- ment for respiratory distress or oxygen de-

emetic medications (e.g., ondansetron). saturation. Note: Consider Spo2 may appear d. Refer K9 TECC Supplement or local veterinary- normal because most devices do not differ- approved guidelines for analgesia protocols. entiate between carbon monoxide (CO) and 14. Antibiotics. oxyhemoglobin. a. Consider initiating antibiotic administration for e. Consider treating ocular/corneal injuries (e.g., K9 casualties with open wounds or fractures, or flushing eyes, applying topical nonpreserved penetrating eye injury when evacuation to defini- lubricant). tive care is significantly delayed or infeasible. f. Smoke inhalation, particularly in a confined b. This is generally determined in the mission plan- space, may be associated with significant CO ning phase and requires medical oversight. and cyanide toxicity. Patients with signs of sig- c. If antibiotics are warranted, select either a cephalo- nificant smoke inhalation plus: sporin or potentiated penicillin (e.g., amoxicillin- i. Significant symptoms of CO toxicity should clavulanic acid, cephalexin). be treated with high-flow oxygen, if available.

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ii. Significant symptoms of cyanide toxicity 17. Prepare K9 casualty for movement. should be considered candidates for cyanide a. Consider environmental factors for safe and ex- anti­dote administration, if available (see peditious evacuation. K9 TECC Supplement for cyanide antidote b. Secure casualty to a movement-assist device, options). when available. g. Estimate total body surface area (TBSA) burned c. If vertical extraction is required, ensure casualty to the nearest 10%, using the appropriate, lo- is secured within appropriate harness, equipment cally approved burn TBSA estimate calculation is assembled, and anchor points are identified. (see K9 TECC Supplement or see www.k9tecc 18. Communicate with the K9 casualty to provide .org/resources for K9 Casualty Care Card). reassurance. h. Local and minor burns (i.e., superficial or par- a. If available, ensure K9 handler travels with the tial thickness <15% TBSA): Consider cooling K9 to provide restraint, comfort, and reassur- burned skin with cool to cold water (sterile fluid, ance (this is important for both the handler and if available) within 20 minutes of burn incident. the K9). i. Avoid actively cooling (e.g., irrigation, appli- b. Encourage and provide positive reassurance to cation of ice) burns >15% TBSA to prevent the injured K9 by stroking the K9’s hair coat inducing hypothermia. and/or patting the K9 on the head if they are not ii. Cover the burn area with dry, sterile dress- aggressive. ings and initiate measures to prevent heat 19. Cardiopulmonary resuscitation. loss and hypothermia once cool irrigation is a. CPR within a tactical or high-threat environ- completed (if performed). ment for victims of blast or penetrating trauma i. For moderate to severe burns (i.e., >20% TBSA) who have no pulse, no ventilations, and no other or any full-thickness burn (i.e., third or fourth signs of life is not often successful and, therefore, degree): should not be attempted during ITC. May have i. Fluid resuscitation should be initiated as a greater role for consideration during the evacu- soon as IV/IO access is established. (Refer to ation phase. K9 TECC Supplement under “Burns.”) b. May benefit those patients suffering cardiopul- ii. If hemorrhagic shock is also present, resus- monary arrest (CPA) after electrocution, hypo- citation for hemorrhagic shock takes pre- thermia, atraumatic arrest, or submersion injury cedence over resuscitation for burn shock. and, therefore, should be considered in the con- (Refer to K9 TECC Supplement under text of the tactical situation. “Shock – Fluid Resuscitation” or locally ap- c. Consider bilateral needle decompression for K9 ca- proved veterinary guidelines.) sualties suffering torso or polytrauma with no res- iii. DO NOT actively cool by applying ice and/ pirations or pulse to ensure T-PTX is not the cause or water to burned area. of cardiac arrest before discontinuation of care. iv. Cover the burn area with dry, sterile dress- d. Refer to K9 TECC Supplement or K9TECC re- ings and initiate measures to prevent heat sources (www.k9tecc.org/resources) for veterinary loss and hypothermia once cool irrigation is CPR guidelines. completed, if performed. 20. Documentation of care. v. Aggressively act to prevent hypothermia for a. Document clinical assessments, treatments ren- burns >0% TBSA. dered, and changes in the casualty’s status in ac- j. All previously described casualty care interven- cordance with local protocol. tions can be performed on or through burned b. Forward this information with the casualty to skin for a burn casualty. the next level of care. 16. Monitoring. c. Consider implementing a K9 Casualty Care Card a. Periodically, obtain and record vital signs (i.e., tem- (located in K9 TECC Supplement and at www perature, pulse, respiration, pulse quality, mucous .k9tecc.org/resources) that can be quickly and membrane color, capillary refill time, mentation). easily completed by a nonmedical first responder. b. If available electronically, monitor: i. Spo via tongue (if unconscious), lip, ear 2 ITC Warm Zone Skill Set pinna, prepuce or vulva, rectum (if rectal probe available) 1. Hemorrhage control. ii. Electrocardiogram a. Apply direct pressure.

iii. End-tidal carbon dioxide (ETCO2) level (if b. Apply pressure dressing. intubated) c. Apply wound packing. iv. Noninvasive blood pressure d. Apply hemostatic agent.

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e. Apply/reassess improvised or elastic tourniquet 3. Use additional resources to maximize advanced care. (last resort). 4. Avoid hypothermia. 2. Airway. 5. Communication is critical, especially between tac- a. Apply manual maneuvers (position head and neck, tical and nontactical EMS teams and veterinary re- straight and in line). sources. b. Perform endotracheal intubation. 6. Maintain situational awareness. In dynamic events, c. Perform needle or surgical cricothyrotomy/ there are NO threat-free areas (e.g., green or cold zone) tracheotomy. 3. Breathing. Guidelines a. Application of effective occlusive chest seal b. Assist ventilations with bag-valve-mask. 1. Primary goal. c. Apply oxygen. a. The M2ARCH2 principles performed during ITC d. Apply occlusive dressing. are similar in evacuation care. e. Perform needle chest decompression (consider b. Reassess all interventions applied in previous bilateral). phases of care, DTC, and ITC. 4. Circulation. c. If multiple wounded (humans and K9s), perform a. Gain intravascular access. primary triage for priority AND destination. b. Gain IO access. d. Consider using the traditional approach to pri- c. Administer IV/IO medications and IV/IO fluids. mary assessment by evaluating airway and breath- d. Administer blood products. ing before bleeding/circulation. e. Keep warm. 2. Airway management. 5. Wound management. a. Unconscious K9 without airway obstruction: a. Protect the injured eye. Same as ITC. b. Apply dressing for evisceration. b. Downed K9 with airway obstruction or impend- c. Apply extremity splint. ing airway obstruction: d. Initiate basic burn treatment. i. Initially, same as ITC e. Initiate treatment for TBI. ii. If previous measures unsuccessful, it is pru- 6. Prepare casualty for evacuation. dent to consider OTT/ETT or needle/surgical a. Move casualty (e.g., drag, carry, lift). cricothyrotomy or tracheostomy (with lido- b. Apply spinal immobilization devices. caine, if conscious). c. Secure casualty to . c. If intubated, reassess for respiratory decline in pa- d. Initiate hypothermia prevention. tients with potential pneumothoraces 7. Other skills. d. Consider the mechanism of injury and the need for a. Perform hasty decontamination. spinal immobilization. (See Neurological Trauma b. Initiate casualty monitoring. below). c. Establish casualty collection point. i. Consider most conscious K9s may need chem- NOTE: Care provided within the ITC guidelines is ical restraint to remain immobilized. (Refer based on individual first responder training and scope of to K9 TECC Supplement or locally approved practice, available equipment, local medical protocols, veterinary protocols.) and approval. ii. Spinal immobilization may not be necessary for downed K9s with penetrating trauma if K9 TECC: Cold Zone Evacuation the K9 appears neurologically intact. 3. Breathing. GOALS a. Immediately apply an occlusive bandage to all 1. Maintain any lifesaving interventions conducted open and/or sucking chest wounds that were not during DTC and ITC phases. treated before transport. 2. Provide rapid and secure extraction to an appropri- b. Monitor the K9 for the potential development of ate level of care. a subsequent T-PTX. Clinical signs of a T-PTX in 3. Avoid additional preventable causes of death. K9s include, for example, progressive respiratory distress, hypoxia, and/or hypotension in the set- ting of known or suspected thoracic trauma). Principles c. Treat T-PTX as described in ITC (i.e., “burping” 1. Reassess the casualty or casualties. chest seal or needle decompression). Repeat steps 2. Use a triage system or criteria per local policy that as needed to mitigate respiratory distress. consider priority AND destination and includes both i. ALWAYS consider decompressing both left human and K9 casualties. and right sides of the chest in K9s

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ii. For situations with prolonged transport times 5. TXA or EACA. that require multiple decompressions, consider a. If casualty is anticipated to need significant blood placing a thoracostomy tube (again, pending transfusion (i.e., presents with hemorrhagic shock, the provider experience and scope of practice). one or more amputations, penetrating torso trauma, d. If available, consider administration of oxygen to or evidence of severe bleeding), consider adminis-

maintain Spo2 at approximately 94% for all trau- tration of one of the following as soon as possible matically injured K9s and any K9 with: and NO LATER THAN 3 hours postinjury:

i. Low Spo2 by pulse oximetry (<94%) i. 10mg/kg TXA in 100mL NS or LR IV slowly ii. Injuries associated with impaired oxygenation over 15 minutes (e.g., pulmonary contusion, smoke inhalation) ii. 150mg/kg EACA in 100mL NS or LR slowly iii. Unconsciousness over 15 minutes; after initial bolus, may con-

iv. TBI (maintain Spo2 >90%) sider continued infusion at 15–20mg/kg/h for v. Circulatory shock 8 hours vi. Casualties with pneumothoraces 6. Circulation. 4. Bleeding. a. Reassess casualty for hemorrhagic shock (i.e., al- a. Reassess all interventions and sources of major tered mental status in the absence of brain injury, hemorrhage for bleeding. weak or absent peripheral pulses, and/or change b. Control all sources of major bleeding with appro- in pulse character). priate use of direct pressure, deep-wound packing, b. Establish IV or IO access, if not performed al- and pressure bandages. ready performed in ITC. c. Avoid use of TQs as first-line intervention in K9s c. Restore perfusion as recommended in ITC. (Re- to control bleeding, except for: fer to K9 TECC Supplement for shock and fluid i. Situations in which hemorrhage remains resuscitation.) uncontrolled despite application of direct d. If BP monitoring is available, maintain a SBP of pressure dressing, hemostatic agents, or deep- 80–90mmHg. wound packing i. For a K9 casualty with an altered mental sta- ii. Areas that are anatomically appropriate (limb tus due to suspected TBI, maintain a desired or tail) for TQ application SBP ≥90mmHg or a strong palpable femoral iii. A traumatic total or partial amputation of an pulse. extremity (a) For TBI, consider using a low-volume d. Reassess all TQs that were applied during previ- fluid strategy comprising hypertonic sa- ous phases of care. Expose the injury and deter- line combined with a synthetic colloid. mine if a TQ is needed. ii. If in shock and K9-specific blood products are e. Tourniquets applied in prior phases that are de- available, with appropriate provider scope of termined to be both necessary and effective in practice/local protocols, resuscitate with 1:1 controlling hemorrhage should remain in place if ratio of PRBCs to FFP. the casualty can be rapidly evacuated to definitive (a) If K9 blood-component is not medical care. available, consider collecting and trans- f. If TQ is ineffective in controlling hemorrhage or if fusing fresh whole blood, if veterinary- there is any potential delay in evacuation to care, approved protocols, appropriate training, identify an appropriate location 2–3 inches above and methods of compatibility testing are in the injury, and apply a new TQ. place. g. If delay to definitive care longer than 2 hours is e. Further administration of IV fluids to maintain anticipated and the wound for which TQ was hemodynamic stability must take into the con- applied is anatomically amenable, attempt a TQ sideration transport time as well as the adverse downgrade. Refer to K9 TECC Supplement for ­effects on the patient that may be invoked by us- guidance on TQ conversion. ing large-volume fluid resuscitation. h. A distal pulse check should be performed on any i. If transport times are anticipated to exceed 2 limb on which a TQ is applied. If a distal pulse or hours, consider administering small aliquots active bleeding is still present, consider: of fluids to maintain targeted BP/clinical i. Additional tightening of the original TQ, or ­perfusion parameters or consider starting a ii. The use of a second TQ, juxtaposed (i.e., side low-rate infusion of: by side) and proximal to the first (a) Synthetic colloids (low-molecular weight, i. Expose and clearly mark all TQ sites with the preferred) at 1mL/kg/h, OR date and time of TQ application. Use an indelible (b) Isotonic crystalloids at 2mL/kg/h marker. 7. Prevention of hypothermia.

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a. Minimize casualty’s exposure to the elements; c. If antibiotics are warranted, select either a move into medic unit, vehicle, or warmed struc- cephalosporin or potentiated penicillin (e.g., ture, if possible. ­amoxicillin-clavulanic acid, cephalexin). b. If not performed already during previous phases 12. Burns. of care: a. Consider burns may not be readily evident in i. Remove any wet overgarments and dry the K9s because their hair coat covers cutaneous le- casualty. sions effectively. ii. Place the casualty on an insulated surface as b. Burn care is consistent with the principles de- soon as possible. scribed in ITC. For recommended interven- iii. Cover the casualty with commercial warming tions refer to the “Burns” section in K9 TECC device, dry blankets, poncho liners, sleeping Supplement. bags, or anything that will retain heat and c. Smoke inhalation, particularly in a confined keep the casualty dry. space, may be associated with significant CO c. If available and required to maintain perfusion, and cyanide toxicity. Patients with signs of sig- provide warm IV fluids. nificant smoke inhalation plus: 8. Monitoring. i. Significant symptoms of CO toxicity should a. Periodically, obtain and record vital signs (i.e., be treated with high-flow oxygen, if available. temperature, pulse, respiration, pulse quality, ii. Significant symptoms of cyanide toxicity mucous membrane color, capillary refill time, should be considered candidates for cyanide mentation) antidote administration. (Refer to K9 TECC b. If available, electronically monitor: Supplement for cyanide antidote options.) i. Pulse oximetry d. Be cautious of off-gassing from patient in the ii. Electrocardiogram evacuation vehicle if there is suspected chemical

iii. ETCO2 (if intubated) exposure (e.g., cyanide) from the fire. iv. Noninvasive blood pressure e. Consider early airway management if there is a 9. Reassess patient. prolonged evacuation period and the patient has a. Perform secondary survey to check for addi- signs of significant airway thermal injury (e.g., tional injuries. singed facial hair, oral edema, carbonaceous ma- b. Inspect/dress known wounds and splint known/ terial in the posterior pharynx, and respiratory suspected fractures that were previously deferred. difficulty). Recheck pulses/warmth of bandaged limbs. f. Provide adequate analgesia for all burn patients. c. Attend to any suspected or known blunt or pen- g. Aggressively act to prevent hypothermia for etrating eye injuries: burns >20% TBSA. i. Protect the eye from external pressure. 13. Prepare K9 casualty for movement. ii. Stabilize any impaled object to prevent a. Consider environmental factors for safe and ex- movement during transport and movement. peditious evacuation. d. Important: Handle an injured K9 with a fracture b. Secure casualty to a movement-assist device with extreme care and proper restraint. Consider when available. administering a chemical restraint and analgesia c. If vertical extraction is required, ensure casualty before manipulating the fractured site. is secured within appropriate harness, equipment e. Refer to K9 TECC Supplement for Wound and is assembled, and anchor points are identified. Ocular Trauma Management and recommended 14. Communicate with the K9 casualty to provide analgesia/chemical restraint protocols. reassurance. 10. Analgesia/sedation. a. If available, ensure K9 handler travels with the K9 a. Provide adequate analgesia as necessary as de- to provide restraint, comfort, and reassurance (this scribed under ITC and K9 TECC Supplement. is important for both the handler and the K9). b. DO NOT use any human-derived nonsteroidal b. Encourage and provide positive reassurance to antiinflammatory medications (e.g., aspirin, ibu- the injured K9 by stroking the K9’s hair coat and profen, naproxen, ketorolac) in K9s. or patting the K9 on the head if the K9 is not 11. Antibiotics. aggressive. a. Consider initiating antibiotic administration for 15. CPR. K9 casualties with open wounds/fractures and a. May have a beneficial role for patients suffering penetrating eye injury when evacuation to de- CPA from electrocution, hypothermia, nontrau- finitive care is significantly delayed or infeasible. matic arrest, or drowning b. This is generally determined in the mission plan- b. Note: Consider bilateral needle decompression ning phase and requires medical oversight. for casualties with thoracic or blunt polytrauma

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with no respirations or pulse to ensure T-PTX is for nonveterinary licensed personnel to practice veteri- not the cause of CPA before discontinuation of nary medicine without the direct or indirect supervision care. from a licensed veterinarian. The available resources c. For CPR guidelines in K9s, see recommendations are, rather, intended to be used as a template and/or listed in K9 TECC Supplement, under CPR. reference to assist each EMS/Fire/LE agency in develop- 16. Documentation of care. ing their own prehospital protocols and standing orders a. Contact and relay the following information to for rendering emergency lifesaving preveterinary care to the receiving veterinary facility: OpK9s injured in the line of duty. i. Estimated time of arrival ii. Mechanisms of the injury sustained (e.g., Further the K9 TECC working group advises: smoke inhalation, blunt versus penetrating 1. Each agency’s guidelines and standing orders should trauma) be developed in collaboration and partnership with a iii. Index of suspicion for the seriousness of un- veterinarian licensed in their state or region. seen injuries 2. These resources are intended to be used ONLY: iv. Initial and trends in vital parameters a. For rendering emergency lifesaving care to OpK9s v. K9’s known or suspected injuries injured in the line of duty when licensed veteri- vi. Overall condition or status (e.g. vital signs, nary professionals are not readily available to ren- mentation, neurological) der care, AND vii. Interventions performed b. By licensed or certified EMS paraprofessionals viii. Patient’s response to interventions (EMTs, advanced EMTs, ), LEOs, and/ b. Continue or initiate documentation of clinical or K9 handlers in accordance with the level of their assessments, treatments rendered, and changes legal scope of practice for providing medical care in the casualty’s status, in accordance with local to human casualties, and by their respective state’s: protocol. i. Veterinary Practice Act or statutes regulating c. Transfer information with the casualty to the the practice of , AND next level of care either verbally or in writing. ii. Practice acts or statutes of their respective pro- d. Considering implementing a K9 Casualty Care fession (e.g. state EMS statutes) Card (see K9 TECC Supplement). c. By the aforementioned personnel that have re- ceived training in K9 anatomy, K9 first responder SKILL SET: care, and K9 TECC procedures under the direc- tion of a licensed veterinary professional or a 1. Familiarization with advanced monitoring techniques professional training organization that employs a 2. Familiarization with transfusion protocols licensed veterinarian as a medical director to over- 3. Advanced airway management see their training curriculum. K9 TECC DISCLAIMER: The practice of veterinary medicine is defined and gov- The information and resources made available by the erned on a state-by-state basis. The requirements and K9 TECC working group do not provide authorization exemptions for practicing veterinary medicine may be

K9 TECC Skill Set Based on Provider Level Pressure Bandage + Hemostatic Needle Surgical Provider Level Wound Packing Agents TQs Decompression ETT Airway K9 handler X X X LEO (nonhandler) X X X EMR or equivalent X X X X* EMT or equivalent X X X X* X* Advanced EMT or X X X X X* X* equivalent X X X X X* X* EMR, emergency medical responder; EMT, emergency medical technician; LEO, law enforcement officer. *Only with special training, specialized protocol, and agency/OMD approval. Ideally, this skill set should be performed by all providers, but need to prove safety and efficacy before inclusion of additional provider levels. Other EMS/medical-related skills such as patient assessment, chest seal placement, splinting, and hypothermia management, should be considered standard for all levels of providers. Additional skills can be considered with agency approval.

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