Abbreviations and Acronyms
Abbreviations and Acronyms
A CPG: clinical practice guideline CPK: creatine phosphokinase ABC: Acinetobacter baumannii-calcoaceticus complex CPNB: continuous peripheral nerve block ABC: airway, breathing, and circulation CPP: cerebral perfusion pressure ABC: assessment of blood consumption CPR: cardiopulmonary resuscitation AC: alternating current CRM: Crew Resource Management ACCP: American College of Chest Physicians CRRT: continuous renal replacement therapy ACH: Army community hospital CSH: combat support hospital ACRM: Anesthesia Crisis Resource Management CSI: cervical spine injury ACS: abdominal compartment syndrome CT: clotting time ACS: acute compartment syndrome CT: component therapy ACTH: adrenocorticotropin CT: computed tomography AE: aeromedical evacuation CVC: central venous catheter AECC: Aeromedical Evacuation Co-ordination Centre CVP: central venous pressure AFRICOM: African Command CVVH: CRRT with a veno-venous technique of hemofiltration AKI: acute kidney injury CXR: chest x-ray ALI: acute lung injury AMEDD C&S: Army Medical Department Center and School D AMPA: alpha-amino-3-hydroxyl-5-methyl-4-isoxazole-propionate AMPLE: allergies, medication, pregnancy, last eaten DLEBT: double-lumen endobronchial tube AMR: advanced medical retrieval DCR: damage control resuscitation APP: abdominal perfusion pressure DLT: double-lumen endobronchial tube APRV: airway pressure-release ventilation DMS: Defence Medical Services (United Kingdom) ARDS: acute respiratory distress syndrome DNBI: disease non-battle-injury APLS: Advanced Paediatric Life Support DoA: depth of anesthesia APS: acute pain service DPL: diagnostic peritoneal lavage APTR: activated partial thromboplastin time ratio DR: disaster relief ATC: acute trauma coagulopathy DVPRS: Defense and Veterans Pain Rating Scale ATICE: Adaptation to the Intensive Care Environment (instrument) DVT: deep venous thrombosis ATLS: Advanced Trauma Life Support ATN: acute tubular necrosis E ATP: adenosine triphosphate EAST: Eastern Association for the Surgery of Trauma AW2: Army Wounded Warrior Program ECCN: en-route critical care nurse B ECG: electrocardiogram ECMO: extracorporeal membrane oxygenation BABT: behind-armor blunt trauma ED: emergency department BAS: battalion aid station EDOCS: expeditionary deployable oxygen concentrator system BATLS: Battlefield Advanced Trauma Life Support EMT-B: emergency medical technician-basic BIPAP: biphasic positive airway pressure ventilation EN: enteral nutrition BK: bradykinin ESBL: extended spectrum β-lactamase BPF: bronchopleural fistula ESPEN: European Society for Parenteral and Enteral Nutrition BVM: bag-valve masks ETCO2: elevated end-tidal carbon dioxide ETT: endotracheal tube C EUCOM: European Command
CMRO2: cerebral metabolic rate of oxygen G: gauge CO: cardiac output Ga: gauge CONUS: continental United States GABA: γ-aminobutyric acid COTS: coagulopathy of trauma shock GAWS: Guardian Angel Weapon System COX: cyclooxygenase GCOs: Clinical Guidelines for Operations CPAP: continuous level of positive airway pressure GCS: Glasgow coma scale
xxv Combat Anesthesia: The First 24 Hours
G6PD: glucose-6-phosphate dehydrogenase MERT(E): medical emergency response team (enhanced) MH: malignant hyperthermia H MILS: manual inline stabilization HA: humanitarian assistance MIST-AT: mechanism of injury, injuries sustained, symptoms and HbCO: carbon monoxide hemoglobin signs, treatment given–age (adult/child) and time of injury HD: hemodialysis MHS: Military Health System HELLP: hemolysis, elevated liver enzymes, and low platelets MODS: multiorgan dysfunction syndrome (syndrome) MRAP: mine-resistant ambush-protected HEMS: Helicopter Emergency Medical System MRI: magnetic resonance imaging HFOV: high-frequency oscillatory ventilation MRSA: methicillin-resistant Staphylococcus aureus HFV: high-frequency ventilation MRSN: Multidrug Resistant Organism Repository and Surveil- HIV: human immunodeficiency virus lance Network HMAP: high mean arterial pressure MTF: medical treatment facility HR: heart rate MTP: massive transfusion protocol I N IAP: intraabdominal pressure NAPQI: N-acetyl-p-benzoquinine imine ICO: infection control officer NASA: National Aeronautics and Space Administration ICP: intracranial pressure NBI: nonbattle injury ICU: intensive care unit NEXUS: National Emergency X-Radiography Utilization Study ID: internal diameter NGF: nerve growth factor IED: improvised explosive device NGO: nongovernmental organization IJV: internal jugular NHS: National Health Service (United Kingdom) iLA: interventional lung assistance NK1: neurokinin-1 ILV: independent lung ventilation NMBA: neuromuscular blocking agent IM: intramuscular NMDA: N-methyl-d-aspartate IMV: intermittent mandatory ventilation NMS: neuroleptic malignant syndrome IN: intranasal NS: normal saline INR: international normalized ratio NSAID: nonsteroidal antiinflammatory drugs IO: intraosseous O IOP: intraocular pressure IPPV: intermittent positive-pressure ventilation OEF: Operation Enduring Freedom IRI: ischemia-reperfusion injury OI: oxygenation index IRT: immediate response team OIF: Operation Iraqi Freedom ISO: International Organization for Standardization OL-ILV: one-lung independent ventilation ISS: injury severity score OR: operating room IV: intravenous OSCAR: High Frequency OSCillation in ARDS (trial) IVC: inferior vena cava OSCILLATE : Oscillation for Acute Respiratory Distress Syn- IVCF: inferior vena cava filter drome Treated Early (trial) OTFC: oral transmucosal fentanyl citrate J P JTTR: Joint Theater Trauma Registry PACCOM: Pacific Command L PAG: periaqueductal grey PCA: patient-controlled analgesia LAST: local anesthetic systemic toxicity PCR: polymerase chain reaction LMA: laryngeal mask airway PD: peritoneal dialysis LMAP: lower mean arterial pressure PE: pulmonary embolism LMWH: low molecular weight heparin PECC: patient evacuation coordination center LOP: limb occlusion pressure PEEP: positive end-expiratory pressure LRMC: Landstuhl Regional Medical Center PetCO : partial pressure of end-tidal carbon dioxide LSI: life-saving intervention 2 PG: propylene glycol LTP: long-term potentiation PICU: pediatric intensive care unit
M PiO2: partial pressure of the inspired oxygen PIS: propofol infusion syndrome MAC: minimum alveolar concentration PLT: platelets MAP: mean arterial pressure PMI: patient movement item MASF: mobile aeromedical staging facilities PMRC: patient movement requirement center MCF: maximum clot firmness PN: parenteral nutrition MDCT: multidetector row spiral computed tomography PO: per os MDR: multidrug-resistant POGS: portable oxygen generator system MEAC: minimum effective analgesic concentration PP: pulse pressures MEDCEN: military medical center PPE: personal protective equipment MEDCOM: US Army Medical Command Ppl: plateau pressure MEDEVAC: medical eva PPV: positive pressure ventilation MERT: medical emergency response team PRBC: packed red blood cells xxvi Abbreviations and Acronyms
PRIS: propofol infusion syndrome U PTSD: posttraumatic stress disorder UFH: unfractionated heparin Q UK: United Kingdom UN: United Nations QEHB: Queen Elizabeth Hospital Birmingham US: ultrasound R USAF: US Air Force USAISR: US Army Institute of Surgical Research RA: regional anesthesia RAAS: rennin-angiotensin-aldosterone system v RAF: Royal Air Force VA: Veterans Affairs (Department) RAP: regimental aid post VAP: ventilator-associated pneumonia RASS: Richmond Agitation-Sedation Scale VAS: visual analog scale RBC: red blood cell VDC: volts direct current RCC: red cell concentrate VGA: volatile gas anesthesia RCDM: Royal Centre for Defence Medicine VILI: ventilator-induced lung injury RCT: randomized controlled trial VITRIS: Vasopressin in Refractory Traumatic Hemorrhagic Shock REBOA: resuscitative endovascular balloon of the aorta (study) rFVIIa: recombinant factor VIIa VRE: vancomycin-resistant Escherichia coli RIFLE: risk, injury, failure, loss, and end-stage disease VRS: verbal rating score ROSC: return of spontaneous circulation Vt: tidal volume RSI: rapid sequence induction VTE: venous thromboemoblism RTD: return-to-duty RRT: renal replacement therapy w RSI: rapid-sequence induction RW: rotary wing WFWB: warm fresh whole blood WHO: World Health Organization S WRAIR: Walter Reed Army Institute of Research SAVe: simplified automated ventilator WWR: Wounded Warrior Regiment SCCM: Society of Critical Care Medicine SCD: sequential compression device SCM: sternocleidomastoid muscle SCV: subclavian
ScvO2: central venous oxygen saturation SI: sacroiliac SIB: self-inflating bag SIMV/PS: synchronized intermittent mandatory ventilation with pressure support SIRS: systemic inflammatory response syndrome SO: standard operating instruction SOP: standard operating procedures SOUTHCOM: Southern Command STRATEVAC: strategic evacuation SVC: superior vena cava SVR: systemic vascular resistance T TACEVAC: tactical evacuation TARGIT: Triservice Research Group Initiative on TIVA TBI: traumatic brain injury TBSA: total burned surface area TCCC: Tactical Combat Casualty Care TCI: target-controlled infusion TCRA: traumatic cardiorespiratory arrest TD: tracheal disruption TENS: toxic epidermal necrolysis syndrome TIC: toxic industrial chemicals TIVA: total intravenous anesthesia TL-ILV: two-lung independent lung ventilation TLR4: toll-like receptor 4 TRPV: transient receptor potential vallinoid TTE: transthoracic echocardiogram TTP: tactic, technique, or procedure TRALI: transfusion-related acute lung injury TrkA: tyrosine kinase A TSAA: Triservice Anaesthetic Apparatus TST: tuberculin skin testing
xxvii Combat Anesthesia: The First 24 Hours
xxviii Combat Anesthesia: The First 24 Hours Index
Index A pediatric trauma patients, 410 ventilation strategies, 111 ABC score. See Assessment of Blood Consumption score Acute thermal injury, 164–165
xxix Combat Anesthesia: The First 24 Hours Index
surgical considerations, 79 extremity, junctional, and pelvic injury surgical procedures, team considerations, 79 148 Airway trauma, 10 following chemical, biological, radiological, and nuclear expo- ALI. See Acute lung injury sure, 506–521 α2-Adrenergic agonists, 224–225 head trauma and, 127 AmbIT Military PCA Pump, 231 human factors in, 32–34 American College of Surgeons’ Advanced Trauma Life Support, humanitarian operations, 448–457 555 imaging management, 177 Amniotic fluid embolism, 499 intraosseous access, 67–68 “AMPLE” history, 109 local anesthetics, 224–225, 235–236 Amputations monitoring depth of, 187 bilateral above-knee, 35–37 neuraxial anesthesia, 185 considerations, 150 obstetric, 492–502 rapid sequence induction and, 51 pediatric, 470–482 AMR. See Advanced medical retrieval pediatric trauma patient handoff checklist, 405 Analgesia percutaneous central venous access, 64–67 α2-adrenergic agonists, 224 peripheral venous cutdown, 68 abdominal injuries, 207–208, 210 physics of flow, 64 acetaminophen, 223–224 post-anesthesia care of vascular access devices, 69 advanced techniques, 206–207 regional, 148, 179, 185, 242–244 anticonvulsants, 224 for stable casualties, 184–187 basics of, 206 stages of a complex military anesthetic, 61 compartment syndrome, 208–209 target-controlled infusions, 186–187 complex injuries, 209 thoracic injuries, 139 current military practice, 271–272 total intravenous anesthesia, 186–187 frequency of intravenous and oral analgesic administration, training, 61–62 279 ultrasound imaging and, 179 ideal battlefield analgesic, 268 venous access, 179 inhalational analgesia, 270 volatile gas anesthesia, 185 injuries to local nationals, 209–210 Antenatal care, 496 isolated forearm gunshot wound, 210 Antibiotics isolated lower limb injury, 207 infection management, 387–388 isolated upper limb injury, 207 sepsis management, 387–388 ketamine, 270–271 Anticoagulation multimodal applications, 206–210 Factor VIIa effects, 352–353 N-methyl-D-aspartate receptor antagonists, 222–223 hemostatic agents, 17 narcotics, 269 massive transfusion effects, 352–353 nonopioid analgesics, 222–225 prevention of venous thromboembolism, 353–356 nonsteroidal antiinflammatory drugs, 223, 269–270 tranexamic acid effects, 352–353 patient-controlled analgesia, 206, 221–222, 416 Anticonvulsants, 224–225 pediatric patients, 416, 474, 481–482 Antifibrinolytics, 91 penetrating abdominal injuries, 210 Aortic injuries, 136 prehospital medicine, 268–272 Aortocaval compression, 496 simple or single injuries, 207–209 APS. See Acute pain service thoracic injuries, 140, 208 ARDS. See Acute respiratory distress syndrome treatment facilities, 209–210 Arterial access, 68–69 Anaphylaxis, 333, 335 Assessment of Blood Consumption score, 97 Anemia Asthma obstetric considerations, 495 acute management exacerbation algorithm, 406–407 Anesthesia. See also Sedation ATC. See Acute trauma coagulopathy access to vascular space, 49 Atelectasis, 344 acute lung injury, 292 ATICE. See Adaptation to the Intensive Care Environment airway management, 77–79 ATLS. See American College of Surgeons’ Advanced Trauma Life arterial access, 68–69 Support burn injuries, 169–170 ATN. See Acute tubular necrosis catheter and cannula sizes, 64 Atrial cannulation, 68 clinical management, 60–61 Atropine overdose, 518 combat casualties and, 17 Awake fiberoptic intubation, 79 conscious sedation, 185–186 considerations for, 35–38 B for critically injured military patients, 569 damage control philosophy, 61 BABT, 135 decision-making, 60 Back pain. See also Spinal injuries the deployed military anesthesia system, 61 disc lesions, 252 direct atrial cannulation, 68 etiology of, 248–249, 251 elderly populations, 486–490 facet joint pain, 250, 252 equipment, 528–544 mechanical, 248, 250
xxx Combat Anesthesia: The First 24 Hours Index
motions associated with lumbar facet joint strain, 252 pediatric patients, 478 musculature of the back, 250 postoperative care, 170 myofascial pain, 250 procedures outside the operating room, 170–171 nerve root compromise, 253 pulmonary evaluation, 168 nerve root pathology, 249 rule of nines, 422 nonspecific, 248, 250 vascular access, 168 sacroiliac joint pain, 250, 252 spinal stenosis, 253 C treatment options, 255–256 Base deficit correction, 112
xxxi Combat Anesthesia: The First 24 Hours Index
radiologic assessment, 110, 123–124 abdominal trauma, 8 steroids and, 124 aeromedical transport, 5–7 CGOs. See Clinical Guidelines for Operations anesthesia and, 17 Chemical, biological, radiological, and nuclear exposure cardiovascular injuries, 8–10 airway burns, 516 care under fire, 5 airway issues, 512–516 damage control resuscitation, 7 antidotes, 521 extremity injuries and wounds, 8 biological casualties, 516, 518–519 golden hour concept, 4–7 breathing issues, 516–517 hematologic injuries, 16–17 chemical casualties, 517–518 hepatic injuries, 15–16 circulation issues, 517–518 improvised explosive devices injuries, 4 cyanides, 515–516 lethal triad, 4 decontamination, 508, 510 management at role 2 and 3 facilities, 7–8 direct-acting agents, 516–517 management of stable casualties, 182–188 drug contraindications, hazards, and interactions, 520–521 neurologic injuries, 12–13 emergency response, 506–512 outcomes tracking and research, 276–280 hot-zone treatment, 510–512 physiology of, 4 incident management, 506 pulmonary injuries, 10–12 indirect-acting agents, 517 renal injuries, 13–15 inhalational injuries, 515 roles of care, 5–7 initial investigations for casualties, 508 tactical combat casualty care, 4–5 medical hazardous materials site plan, 507 tactical damage control surgery, 7–8 nerve agents, 513–514, 517–519 tactical field care, 5 neurological issues, 518–520 thoracic trauma, 8 personal protective equipment, 507–508 traumatic brain injuries, 7 pulmonary agents, 514–515 Combat casualty care, 43 “Quick Look” assessment, 507, 509 Combat support hospitals, 97 radiological casualties, 516, 518, 519 Command representation, 263 recognizing incidents, 506–507 Compartment syndrome riot control agents, 515–516 abdominal compartment syndrome, 14–15, 298–299 triage, 510–512 early management of, 14, 298–299 vesicants, 514 extremity compartment syndrome, 7 Chest compressions, 557 multimodal analgesia, 208–209 Chest trauma risk factors, 7 chest wall trauma, 10–11 Component therapy, 101, 103–104 pediatric patients, 402–403 Computed tomography imaging Children. See Pediatric trauma cervical spine injuries, 110, 124 Choking agents, 514–515 head trauma, 124–125 Cholecystitis, acalculous, 343 initial trauma assessment, 176–177 Chronic pain Concurrent resuscitation, 49 ascending pain pathways, 247 Conscious sedation, 185–186 back pain, 248–253, 255–256 Continuing Promise mission, 449–450 classification of, 246–248 Continuous peripheral nerve block definition of, 246–248 benefits of, 235 descending modulation, 247 complications, 235–236 interventional procedures, 256 contraindications, 235 neck pain, 253–256 daily rounding considerations, 237–238 neuropathic pain, 246 drugs, 237 treatment options, 255–256 indications, 235 Circulation management infusion settings, 237 critical care, 297–299 isolated upper limb injuries, 207 following chemical, biological, radiological, and nuclear expo- for multiple extremity injuries, 235 sure, 517–518 nursing guidelines, 238 pediatric trauma, 474, 479 securing the catheter, 237 Clinical Guidelines for Operations, 555 when to initiate, 236–237 Clinical practice guideline Continuous renal replacement therapy, 323 acute pain service, 263–264 COTS. See Coagulopathy of trauma shock Clonidine, 364 COX. See Cyclooxygenase CMRO2. See Cerebral metabolic rate of oxygen CPG. See Clinical practice guideline Coagulopathy CPNB. See Continuous peripheral nerve block combat casualties and, 4 CPP. See Cerebral perfusion pressure dilutional, 99 Crew Resource Management, 32–33, 61 Coagulopathy of trauma shock. See also Shock Cricothyroidotomy, 478 Camp Bastion protocol, 242–244 Critical care determining when to use regional anesthesia, 242 acute lung injury, 291–292 Combat application tourniquets, 145 adequacy of resuscitation, 288–289 Combat casualties admission history, 286
xxxii Combat Anesthesia: The First 24 Hours Index
airway management, 296 CT imaging. See Computed tomography imaging anesthetic considerations for critically injured military pa- CVP. See Central venous pressure tients, 569 CVVH. See Veno-venous technique of hemofiltration breathing management, 296–297 Cyanide antidotes, 521 burn injuries, 164–171 Cyanide poisoning, 515–516 circulation management, 297–299 Cyclooxygenase, 223 compartment syndromes, 298–299 drug administration, 300 D environment considerations, 299–300 ethical issues, 460–467 Damage control resuscitation fluid administration complications, 297–298 acidosis, 90 gastric protection, 300 antifibrinolytics, 91 gut damage control, 300 calcium management, 90 hematology, 288 damage control surgery, 37–38, 88, 293 hemodynamic considerations, 288–291 end points of, 91–92 imaging, 288, 300 evolution of military trauma care, 86–87 intravascular lines, 300 fluids, 38, 88, 89 maintaining blood pressure, 297 hematologic injuries, 16–17 management plans, 288 hemostatic resuscitation, 88–89 management problems following damage control surgery, 293 hypothermia, 90–91 patient discharge, 293 managing the physiology, 89–91 patient transfer, 300 medical adjuncts, 91 pediatrics, 402–424 pathophysiology, 87 physical examination, 286 permissive hypotension, 54, 88 positioning, 300 point-of-care testing, 89 receiving patients, 286–293 point of wounding, 87 record-keeping, 299–300 potassium management, 90 regional techniques, 300 principles of, 87–89 topical negative pressure dressings, 300 recombinant activated factor VII, 91 traumatic brain injury, 299 at role 2 and 3 facilities, 7 venous thromboembolism prophylaxis, 300 specialist retrieval teams, 88 volume status of cardiovascular system, 289–291 Damage control surgery, 37–38, 88, 293 Critical care, perioperative and interoperative DCR. See Damage control resuscitation adjuncts in trauma resuscitation, 114–115 Debridement, 150 admission to intensive care unit, 114–115 Decontamination, 508, 510 airway assessment, 108–110 Deep peripheral nerve block, 243–244 the “AMPLE” history, 109 Deep venous thrombosis, 352–355 assessment regime, 108–112 Defence Medical Rehabilitation Centre, 570 base deficit correction, 112 Defense and Veterans Pain Rating Scale, 278 circulation, 111 Deontology, 460 clearance of cervical spine, 110 Deployed aeromedical team, 263 conditions requiring rapid sequence induction of anesthesia, Deployed pain service 110 clinical practice guideline, 263–264 early enteral nutrition, 115 deployed acute pain service responsibilities, 262 early intensive care requirements for the severely injured, 109 enabling change, 265 end points in resuscitation, 113 governance, 262 fluids in trauma resuscitation, 114 multidisciplinary team, 262–263 fracture fixation, 114 pain education, 264 hypotensive resuscitation, 113–114 predeployment training, 264 immediate requirements and decision points in treating the specialist interest group responsibilities, 262 severely injured, 109 standard operating instruction, 263–264 infection care bundles, 115 team rounds and meetings, 265 initial management, 108 team training, 264 inotropic agents, 114 DeVilbiss Oxygen Concentrator, 536 lactate correction, 112 Dexmedetomidine, 362, 364 patient history, 108 Dilutional coagulopathy, 99 vascular volume status, 111–112 Direct atrial cannulation, 68 vasoactive agents, 114 Direct laryngoscopy, 78 ventilation, 110–111 Disaster relief, 448, 449 Critical Care Air Support Teams, 392, 394–398 Disease non-battle-injuries, 182 Critical Care Air Transport Teams, 6–7, 392–398 Distributive shock, 333–335 CRM. See Crew Resource Management DLEBT. See Double-lumen endobronchial tube CRRT. See Continuous renal replacement therapy DLT. See Double-lumen endobronchial tube Crystalloids, 88, 89, 114 DNBI. See Disease non-battle-injuries CSHs. See Combat support hospitals Dorsal horn, 195–196 CSIs. See Cervical spine injuries Double-lumen endobronchial tube, 139–140, 307 CT. See Component therapy Dräger Fabius Tiro M, 532–533
xxxiii Combat Anesthesia: The First 24 Hours Index
Dräger Narkomed M, 533–536 pumps, 234 Dräger Vamos, 538 securing the catheter, 233–234 Draw-over systems, 528–532 when to initiate, 233 Drug fever, 342–343 Epidural anesthesia Dustoff units, 46–47 pediatric patients, 482 DVPRS. See Defense and Veterans Pain Rating Scale Epinephrine, 557 DVT. See Deep venous thrombosis Equipment airway equipment, 404–406, 470 E anesthesia equipment, 528–544 Belmont Rapid Infuser FMS 2000, 542–543 EAST. See Eastern Association for the Surgery of Trauma guide- Braun Perfusor Compact S, 543–544 lines catheter techniques, 547 Eastern Association for the Surgery of Trauma guidelines, 354 conventional general anesthesia machines, 532–536 ECCNs. See En-route critical care nurses DeVilbiss Oxygen Concentrator, 536 ECGs. See Electrocardiograms Dräger Fabius Tiro M, 532–533 Eclampsia, 498 Dräger Narkomed M, 533–536 ECMO. See Extracorporeal membrane oxygenation draw-over systems, 528–532 Elderly populations electrical nerve stimulator, 546 anesthesia, 488–489 epidural equipment changes, 234 cardiovascular disease, 486–487 expeditionary deployable oxygen concentrator system, 536 considerations for deployed military teams, 489 General Electric Healthcare Datex-Ohmeda S/5 Compact, general anesthesia for internal fixation of fractured femur 537–538 neck, 489 intravenous infusion equipment, 541–544 medications, 487–488 Level 1 H-1200 Fast Flow Fluid Warmer, 541–542 operational factors, 488, 490 medical ultrasound, 546–547 physiology of old age, 486–487 medication delivery systems, 547–549 preoperative assessment, 486 monitors, 537–538 preoperative clinical investigations, 487 needle design, 547 renal disease, 487 nerve localization, 546–547 respiratory disease, 487 obstetric anesthesia, 493–494 Electrical injuries, 171 oxygen supplies, 536–537 Electrical nerve stimulator, 546 patient-controlled analgesia, 206, 221–222, 230–232, 547–549 Electrocardiograms, 135, 556 pediatric trauma, 404–406, 470 Electrolytes personal protective equipment, 507–508 postoperative maintenance for pediatric trauma patients, 412 portable oxygen generator system, 536–537 En-route critical care nurses, 47–48 specialist equipment for pain management, 546–549 End-tidal CO2 Triservice Anesthetic Apparatus, 528–530 methods for measuring, 53 US anesthesia monitoring, 538 tourniquet effects, 157–158 US draw-over system, 531–532 Endotracheal intubation US ventilators, 539–540 estimation of tube size and length in children, 471 Vela, 539 pediatric trauma patients, 477 ventilators, 538–540 Enteral nutrition ESPEN. See European Society for Parenteral and Enteral Nutrition after abdominal surgery, 375 Ethical issues after temporary abdominal closure, 376–377 best interests, 463–464, 465 continuation during repeat operations, 377 culture and autonomy, 465–466 early initiation of, 115 deontology, 460 guidelines for initiating and advancing continuous feeding, before deployment, 466–467 414 dual loyalties, 462–464 immunonutrition, 374–375 in the field hospital, 466 pediatric trauma patients, 414 the “four principles,” 460 postpyloric feeding, 375–376 hypothetical scenarios, 464–465 routes of, 373–374 the law of armed conflict, 461–462 surgical access to the gastrointestinal tract, 376 medical ethics in times of war, 460–462 types of, 374 potential conflict in military critical care, 462–466 Entonox, 496 resource allocation, 462–465 Epidural analgesia reverse triage, 463 benefits of, 233 standards of deployed medical care, 461–462 complications, 233 triage, 462–463 contraindications, 232–233 utilitarianism, 460 daily rounding considerations, 234 European Society for Parenteral and Enteral Nutrition, 372–373, drugs, 234 375 epidural equipment changes, 234 Evacuation indications, 232 buddy-buddy system, 43 infusion settings, 234 chain of survival, 42–43 nursing guidelines, 234 combat casualty care, 5–7, 43 obstetric anesthesia, 496–497 evacuation chain, 42–44
xxxiv Combat Anesthesia: The First 24 Hours Index
higher levels of care, 43–44 Fluid resuscitation to higher levels of care, 43–44 complications of administration, 297–298 MEDEVAC, 48–54 damage control resuscitation, 88, 89 medical evacuation assets, 46–48 for multiple injuries, 38 patient evacuation coordination center, 42 trauma resuscitation, 114 self treatment, 43 Focused assessment with sonography for trauma, 97, 176 team medics, 43 Fracture fixation, 114 Expeditionary deployable oxygen concentrator system, 536 Fractures. See Bone fractures Exposure injuries Fresh frozen plasma, 99, 100, 101, 352–353 pediatric patients, 482 Fresh whole blood Extracorporeal membrane oxygenation, 309 dilutional coagulopathy and, 99 Extremity compartment syndrome, 7, 15 military use of, 101, 103–104 Extremity injuries FWB. See Fresh whole blood classification of, 144 combat casualties, 8 G continuous peripheral nerve block, 235 GABA. See γ-aminobutyric acid general operative intervention considerations, 147–149 γ-aminobutyric acid, 361, 363 infection control, 147 Gastric protection, 300 limb injury revascularization, 155–160 Gastrointestinal tract managing reperfusion after tourniquet removal, 155–160 surgical access to, 376 postoperative care, 151–152 GAWS. See Guardian Angel Weapon System prehospital care, 145–146 General anesthesia regional anesthesia, 148 conventional general anesthesia machines, 532–536 role 3 care, 146–147 for internal fixation of fractured femur neck, 489 surgical considerations, 149–150 obstetric anesthesia, 497 tourniquet use, 148–149 General Electric Healthcare Datex-Ohmeda S/5 Compact, 537–538 Extubation Glasgow coma scale, 125, 365, 405, 479–480 pediatric trauma patients, 409 Glial cells, 196 Glucocorticoids, 124 F Golden hour concept, 4–7 Goldman risk factor and score, 486–487 Facet joint pain, 250, 252 Grafts, skin, 166 Facial injuries Guardian Angel Weapon System, 47 airway management, 76 Gunshot wounds pediatric patients, 478 multimodal analgesia, 210 Factor VIIa. See Recombinant activated factor VIIa Gut damage control, 300 FAST. See Focused assessment with sonography for trauma Femoral vein catheterization, 66 H Fentanyl, 496 Fetal monitoring, 497 Hazardous materials site plan, 507 Fever Head trauma. See also Traumatic brain injury acalculous cholecystitis, 343 anesthetic use, 127 atelectasis, 344 assessment of, 124–125 drug fever, 342–343 decreasing cerebral oxygen consumption, 126 empiric therapy, 346 Glasgow coma scale, 125 infectious considerations, 340 imaging, 177–178 malignant hyperthermia, 343–344 intracranial hypertension and, 127 neurogenic fever, 342 management, 125–127 neuroleptic malignant syndrome, 343–344 monitoring, 124–125 noninfectious causes, 341–344 pediatric patients, 417–419 pancreatitis, 343 rapid sequence induction for penetrating injuries, 51 pediatric trauma patients, 419 resuscitation, 127 serotonin syndrome, 344 sedation, 365 treatment of, 346 seizures and, 127 workup of, 344–346 Helicopter Emergency Medical System, 49–50 FFP. See Fresh frozen plasma Hematologic injuries Fiberoptic intubation, 76, 79 anticoagulation, 17 Fiberoptic laryngoscopes, flexible, 78 damage control resuscitation, 16–17 Fibrinolytics hemostatic agents, 17 massive transfusion and, 101 massive transfusion, 16–17 Flexible fiberoptic laryngoscopes, 78 Hematology Fluid management critical care patients, 288 for burn injuries, 165 pediatric trauma patients, 419–421 conservative, 308–309 Hemodynamics mechanical ventilation and, 308–309 pediatric trauma patients, 409–412 pediatric trauma patients, 412–415, 479 Hemorrhage postnatal care, 501 battlefield and preoperative control, 155
xxxv Combat Anesthesia: The First 24 Hours Index
control of catastrophic external hemorrhage, 49 I massive, 471, 474–477 massive hemorrhage protocol, 498–499 ICP. See Intracranial pressure obstetric protocol, 498–499 ICUs. See Intensive care units pediatric anesthesia, 471, 474–477 IED. See Improvised explosive devices preoperative control, 155 iLA. See Interventional lung assist tourniquet use, 155–160 Imaging Hemorrhagic shock, 8–9 anesthesia management, 177 Hemostatic agents, 17 basic radiography, 176 Hemostatic resuscitation, 88–89 cardiac injuries, 178 HEMS. See Helicopter Emergency Medical System cervical spine injuries, 123–124 Hepatic injuries computed tomography, 176–177 liver ischemia reperfusion injury, 16 critical care patients, 288, 300 liver trauma, 15 focused assessment with sonography for trauma, 97, 176 shock liver, 16 future considerations, 179 Hercules helicopters, 47 head injuries, 177–178 HFOV. See High-frequency ocillatory ventilation initial trauma assessment, 176–177 High-frequency ocillatory ventilation, 307–308 interventional radiology, 179 High mean arterial pressure, 113 intraabdominal injuries, 178 HMAP. See High mean arterial pressure musculoskeletal injuries, 179 Hospital ships, 448–449 pelvic injuries, 178 Host nation humanitarian operations, 449–450 thoracic injuries, 178 Hot-zone treatment, 510–512 ultrasound regional anesthesia, 179 Human factors vascular injuries, 178 defense anesthesia and, 32–34 venous access for anesthesia, 179 Human immunodeficiency virus infection Immediate Response Team, 44–46 obstetric considerations, 495 Immune function, 202 Humanitarian operations Immunoglobulin, 386 anesthesia techniques, 455–457 Immunologic complications austere and resource-limited environments, 455–457 massive transfusion and, 99–100 disaster relief, 448, 449 Immunonutrition, 374–375 hospital ships, 448–449 Impact 754 Eagle Univent, 539–540 host nations, 449–450 Improvised explosive devices. See also specific injuries by name humanitarian assistance as a primary mission, 448 injuries, 4 humanitarian assistance as an additional mission, 448 Independent lung ventilation, 306–307 intraoperative anesthesia management, 452–454 Infants. See Pediatric trauma medical personnel, 450 Infection care bundles, 115 mission overview and process, 449 Infection prevention and control nongovernmental organizations, 449–450 acute lung injury, 292 postoperative care, 454–455, 457 antibiotic guidelines, 387–388 preoperative assessment, 451–452 biofilms and, 383–384 surgical services, 450 chemoprophylaxis, 432–434 Hyperkalemia colonization and infection, 382–383 acute management algorithm, 421 common infectious diseases in theater, 437, 441 damage control resuscitation and, 90 extremity, junctional, and pelvic injuries, 147 massive transfusion and, 98 individual interventions, 434–435 medical therapy for, 324 institutional interventions, 435–436 Hyperthermia, malignant, 343–344 intravascular lines and, 383 Hypocalcemia laboratory support, 386–387 damage control resuscitation and, 90 leishmaniasis, 436–440 massive transfusion and, 97–98 malaria, 436 pediatric patients, 482 multidrug-resistant bacteria, 432–441 Hypomagnesemia, 98 operating room procedures, 147 Hypotension pediatric trauma patients, 419 clinical presentation, 328 sources of infection, 382–384 general diagnostic approach, 329–331 tailoring therapy, 386–388 general principles of management, 329, 331–332 ventilators and, 383 pathophysiology of, 328 wounds, 383 Hypotensive resuscitation, 54, 88 Inferior vena cava filters, 355–356 Hypothermia Infusion pumps, 548–549 combat casualties and, 4 Inhalational analgesia, 270 damage control resuscitation and, 90–91 Inhalational injuries, 515 massive transfusion and, 99 Inotropic agents, 114 pediatric patients, 482 Institute of Surgical Research, 101, 103, 565 Hypovolemia Intensive care units effect on systolic pressure variation, 289 admission to, 114–115 pediatric trauma patients, 475 hypotension diagnosis and management, 328–336 Hypovolemic shock, 37, 332 infection management, 382–388 xxxvi Combat Anesthesia: The First 24 Hours Index
nutritional support, 372–377 regional anesthesia, 148 receiving patients, 286–293 role 3 care, 147 sedation use, 360–366 surgical considerations, 150–151 sepsis management, 382–388 tourniquet use, 148–149 shock diagnosis and management, 328–336 Intermittent positive-pressure ventilation, 557 K Internal jugular vein catheterization, 65–66 Interoperative critical care Ketamine adjuncts in trauma resuscitation, 114–115 prehospital analgesia, 270–271 admission to intensive care unit, 114–115 suggested doses for acute pain control, 223 assessment regime, 108–112 suggested doses in acute severe pediatric trauma, 474 base deficit correction, 112 Kidney injury. See Acute kidney injury circulation, 111 early enteral nutrition, 115 L early intensive care requirements for the severely injured, 109 Lactate correction, 112 end points in resuscitation, 113 Landstuhl Regional Medical Center fluids in trauma resuscitation, 114 current capabilities, 562–563 fracture fixation, 114 history of, 562 hypotensive resuscitation, 113–114 specialty services, 563 immediate requirements and decision points in treating the surgical specialties, 563 severely injured, 109 Laryngoscopes, flexible fiberoptic, 78 infection care bundles, 115 Laryngoscopy, 78 initial management, 108 LAST. See Local anesthetic systemic toxicity inotropic agents, 114 Lead clinicians, 263 lactate correction, 112 Leishmaniasis, 436–440 vascular volume status, 111–112 “LEMON” airway assessment, 408 vasoactive agents, 114 Level 1 H-1200 Fast Flow Fluid Warmer, 541–542 ventilation, 110–111 Ligands, 194 Interventional lung assist, 111 Limb injuries. See Extremity injuries Interventional radiology, 179 Limb occlusion pressure, 159–160 Intraabdominal injuries, 178 Lipolysis, 201 Intracranial hypertension, 127 Liver injuries, 15–16 Intracranial pressure, 12–13, 125–127, 365, 417–419 Liver ischemia reperfusion injury, 16 Intraosseous vascular access, 67–68, 411, 475 LMAP. See Lower mean arterial pressure Intrathoracic airway injuries, 134–135 LMWH. See Low-molecular weight heparin Intravascular lines Local anesthetic systemic toxicity, 235–236 infection prevention, 300, 383 Local anesthetics, 224–225, 235–236 Intravenous infusion equipment, 541–544 Local nationals injuries, 209–210 Intubation Log roll, 49 blind nasal intubation, 79 LOP. See Limb occlusion pressure cervical spine injuries and, 122–123 Lorazepam, 362–363 confirmation of endotracheal tube position, 52–53 Low-molecular weight heparin, 353–355 drugs used with, 51–52 Lower limb injuries failed intubation drills, 53 multimodal analgesia, 207 fiberoptic, 79 Lower mean arterial pressure, 113 improving success rate of, 52 LRMC. See Landstuhl Regional Medical Center initial indications for mechanical ventilation, 406 LTV 1000 Series ICU Ventilator, 540 management algorithm, 408 Lund-Browder charts, 422 methods for measuring end-tidal CO2, 53 Lung injuries, 136–137. See also Pulmonary injuries pediatric trauma patients, 406, 408 resuscitation guidelines, 557 M success rates for Medical Emergency Response Teams, 52 Inverse-ratio ventilation, 306 MAAS. See Motor Activity Assessment Scale IPPV. See Intermittent positive-pressure ventilation Macronutrients IRT. See Immediate Response Team postoperative maintenance for pediatric trauma patients, 413 Ischemia-reperfusion injury, 9, 16. See also Vascular reperfusion Malaria, 436, 495 IVC. See inferior vena cava filters Malignant hyperthermia, 343–344 Manual inline stabilization, 122–123 J MAP. See Mean arterial pressure Massive hemorrhage. See Hemorrhage Joint Theater Trauma Registry, 277 Massive transfusion JTTR. See Joint Theater Trauma Registry acidosis and, 98–99 Junctional injuries anticoagulation and, 17 classification of, 144–145 complications of, 97–100 general operative intervention considerations, 147–149 considerations during military operations, 100–101 infection control, 147 dilutional coagulopathy and, 99 postoperative care, 151–152 effects of, 352–353 prehospital care, 145–146 example of, 16
xxxvii Combat Anesthesia: The First 24 Hours Index
fibrinolytics, 101 evolution of, 44–45 hemostatic agents and, 17 in-theater training, 45–46 hyperkalemia and, 98 intubation success rates, 52 hypocalcemia and, 97–98 patient movement concepts, 394 hypomagnesemia and, 98 predeployment preparation, 45 hypothermia and, 99 Medical evacuation assets immunologic complications, 99–100 CASEVAC, 4–7, 46, 394 initiation protocols, 96–97 MEDEVAC, 46–54, 393–394 military use of fresh whole blood, 101, 103–104 US Air Force pararescue, 47–48 recombinant factor VIIa, 101 Medical hazardous materials site plan, 507 UK operational protocol, 100, 102–103 Medical ultrasound, 546–547 US military protocol, 100–101, 104 MERT. See Medical Emergency Response Team Massive transfusion protocol, 96–97 MHS. See Military Health System McGill questionnaire, 215 Midazolam, 361–362 MDCT. See Multidetector computed tomography Military Health System, 565 MDR. See Multidrug-resistant bacteria Military hospitals Mean arterial pressure, 156–157, 417 Landstuhl Regional Medical Center, 562–563 Mechanical ventilation in the United States, 564–566 acute lung injuries and, 291–292 Military medical activities, 565 adjuncts to, 308–309 Military medical centers, 564–565 asymmetrical pulmonary pathologies, 307 Military pain scoring systems, 215–216 for bronchopleural fistula, 316–318 Military treatment facilities, 43–44 conservative fluid management, 308–309 MILS. See Manual inline stabilization drugs used with, 51–52 Minimum alveolar concentration, 481 extracorporeal membrane oxygenation, 309 MODS. See Multiorgan dysfunction syndrome the first 24 hours, 304–310 Monitors, 537–538 high-frequency ventilation, 307–308 Morphine, 496 independent lung ventilation, 306–307 Motor Activity Assessment Scale, 361 infection issues, 383 MTFs. See Military treatment facilities inverse-ratio ventilation, 306 MTP. See Massive transfusion protocol mode of, 305–308 Multidetector computed tomography, 177 monitoring and optimizing ventilation, 304–305 Multidisciplinary trauma team, 34–35 neuromuscular blocking agents, 308 Multidrug-resistant bacteria nitric oxide and, 308 antibiotic guidelines, 387 pediatric trauma patients, 402–409, 406–409 chemoprophylaxis, 432–434 positive end-expiratory pressure, 305 common infectious diseases in theater, 437, 441 prehospital procedures, 53 individual interventions, 434–435 pressure-preset ventilation, 305–306 infection from, 382 principles of safe ventilation, 304–305 institutional interventions, 435–436 prone positioning, 308 leishmaniasis and, 436–440 recruitment maneuvers, 308 malaria and, 436 resuscitation guidelines, 557 organism surveillance, 434 spontaneous ventilation, 306 Multimodal analgesia thoracic injuries and, 140 advanced techniques, 206–207 tidal volume, 304 basics of, 206 for tracheal disruption, 316–318 compartment syndrome, 208–209 transfer ventilators, 309–310 complex injuries, 209 volume-preset ventilation, 305 injuries to local nationals, 209–210 MEDCENs. See Military medical centers isolated forearm gunshot wound, 210 MEDEVAC isolated lower limb injury, 207 access to vascular space, 49 isolated upper limb injury, 207 capabilities, 47 multimodal applications, 207–210 care during, 48–54 penetrating abdominal injuries, 210 concurrent resuscitation, 49 simple or single injuries, 207–209 control of catastrophic external hemorrhage, 49 thoracic injuries, 208 drugs used with intubation and ventilation, 51–52 treatment facilities, 209–210 en-route care, 46–47 Multiorgan dysfunction syndrome, 112–113, 115 intubation, 52–53 Musculoskeletal injury imaging, 179 the log roll, 49 Myofascial pain, 250 patient movement concepts, 393 rapid sequence induction, 49–51 N resuscitation, 53–54 thoracostomy, 53 N-methyl-D-aspartate receptor antagonists, 222–223 training, 46 Narcotics. See also specific drugs by name ventilation, 53 prehospital analgesia, 269 Medical Emergency Response Team NASA. See National Aeronautics and Space Administration combat casualty retrieval, 46 Nasal intubation, blind, 79 composition of, 45 National Aeronautics and Space Administration, 32 xxxviii Combat Anesthesia: The First 24 Hours Index
National Emergency X-Radiography Utilization Study, 123–124 postoperative pediatric trauma patients, 412–415 National Health Service, 32–33 postpyloric feeding, 375–376 Neck injuries surgical access to the gastrointestinal tract, 376 airway management, 76–77 types of enteral feed preparations, 374 whiplash injuries, 254–255 Neck pain O cervical myelopathy, 254 cervical radiculopathy, 254 Obstetric anesthesia occipital neuralgia, 254 anemia and, 495 prevalence of, 253 antenatal care, 496 treatment options, 255–256 cardiac disease and, 494–495 whiplash injuries, 254–255 challenges in the deployed environment, 492–495 Needle design, 547 civilian best practice, 501 Neonatal care, 501 current civilian best practice, 495–501 Nerve agents, 513–514, 517–519 deployed civilian experience, 501 Nerve blocks environmental considerations, 493 needle design, 547 equipment considerations, 493–494 pediatric patients, 481 fetal monitoring, 497 Nerve localization, 546–547 high-risk conditions, 498–500 Nerve stimulator, electrical, 546 human immunodeficiency virus infection and, 495 Neuraxial anesthesia, 185 malaria and, 495 Neuraxial blockade, 355 massive hemorrhage protocol, 498–499 Neurogenic fever, 342 military experience, 501 Neurogenic shock, 10, 335 neonatal care, 501 Neuroleptic malignant syndrome, 343–344 normal labor, 493, 496–497 Neurologic injuries obstetric experience of deployed surgeons, 493 cerebral perfusion pressure, 12–13 operative interventions, 493, 497–498 following chemical, biological, radiological, and nuclear expo- pain relief during labor, 496–497 sure, 518–520 patient information, 495–496 intracranial pressure, 12–13 postnatal care, 501 pediatric patients, 479–480 preexisting indigenous standards of care, 492–493 prophylaxis for severe traumatic brain injury, 13 preexisting pathology in the pregnant patient, 493–495 Neurological systems, 202 resources for the deploying anesthesiologist, 501 Neuromuscular blocking agents, 308 risk factors, 493 Neuropathic pain, 246 sexual violence and, 495 NEXUS. See National Emergency X-Radiography Utilization tocolysis, 498 Study trauma management principles, 499–500 NHS. See National Health Service Obstructive shock, 10, 335–336 Nitric oxide Occipital neuralgia, 254 mechanical ventilation and, 308 OL-ILV. See One-lung independent ventilation NMDA. See N-methyl-D-aspartate receptor antagonists One-lung independent ventilation, 140 Nociceptor receptors, 194 Operating room procedures Nongovernmental organizations, 449–450 amputation, 150 Nonopioid analgesics, 222–225 communication, 147 Nonsteroidal antiinflammatory drugs, 223, 225, 269–270 debridement, 150 Nonthermal skin diseases, 171 extremity injuries, 149–150 Novel hybrid resuscitation, 54 general principles for surgical management of battlefield NSAIDs. See Nonsteroidal antiinflammatory drugs wounds, 149 Nuclear exposure. See Chemical, biological, radiological, and infection control, 147 nuclear exposure junctional injuries, 150–151 Nurses patient positioning, 147 continuous peripheral nerve block guidelines, 238 pelvic injuries, 151 en-route critical care nurses, 47–48 regional anesthesia, 148 epidural analgesia guidelines, 234 set-up for burn injuries, 166–167 pain nurses, 263 tourniquet use, 148–149 patient-controlled analgesia guidelines, 232 vascular surgery, 149–150 ward nurses, 263 Operation Smile, 450 Nutritional support Opioids acute lung injuries and, 292 adverse events, 222 burn injuries and, 168–169 intravenous administration, 220–222 continuation of enteral nutrition during repeat operations, 377 pain regimen based on injury severity, 221 enteral feeding after abdominal surgery, 375 per os administration, 220 enteral nutrition after temporary abdominal closure, 376–377 side effects, 231 enteral route, 373–377 Orthopedic injuries, 149 immunonutrition, 374–375 Oxygen supplies, 536–537 initiation of, 372–373 nutritional requirements, 372 parenteral route, 373–377
xxxix Combat Anesthesia: The First 24 Hours Index
P key hormones released, 200 lipolysis, 201 Packed red blood cells, 97, 99 metabolic responses, 200–202 Pain, acute. See also Acute pain service neurological systems response, 202 basic concepts, 194 patient outcomes, 203 descending modulatory pathways, 196 protein catabolism, 200 dorsal horn, 195–196 psychological responses, 202 measuring pain, 277–278 respiratory response, 202 pain matrix, 196–197 system responses, 202 pain mechanisms, 194–197 water and electrolyte balance, 201–202 pain perception in higher centers, 196–197 Pain scoring pain transmission, 195–196 difficulties with, 214 peripheral nociceptors, 194 importance of, 214 role of the glia, 196 military scoring systems, 215–216 transient receptor potential vallinoid channel subtypes, 195 scoring effects of pain, 215 WHO pain ladder, 207, 277–278 scoring pain intensity, 215 Pain, chronic when to score pain, 217 ascending pain pathways, 247 Pain service back pain, 248–253, 255–256 clinical practice guideline, 263–264 classification of, 246–248 deployed acute pain service responsibilities, 262 definition of, 246–248 enabling change, 265 descending modulation, 247 governance, 262 interventional procedures, 256 multidisciplinary team, 262–263 neck pain, 253–256 pain education, 264 neuropathic pain, 246 predeployment training, 264 treatment options, 255–256 specialist interest group responsibilities, 262 Pain management standard operating instruction, 263–264 catheter techniques, 547 team rounds and meetings, 265 communication and, 278 team training, 264 continuous peripheral nerve block, 235–238 Pancreatitis, 343 electrical nerve stimulator, 546 Pararescuemen, 47–48 epidural analgesia, 232–234 Parenteral nutrition future of pain management on the battlefield, 279–280 immunonutrition, 374–375 history of, 276–277 initiation and advancement of, 414 measuring pain, 277–278 pediatric trauma patients, 414–415 medical ultrasound, 546–547 postpyloric feeding, 375–376 medication delivery systems, 547–549 recommendations for nutrition components, 415 needle design, 547 routes of, 373–374 nerve localization, 546–547 surgical access to the gastrointestinal tract, 376 obstetric anesthesia, 496–497 Patient-controlled analgesia, 547–549 pain management champions, 263 benefits of, 206, 230 patient-controlled analgesia, 206, 221–222, 230–232, 547–549 complications, 230–231 pediatric trauma patients, 415–417 contraindications, 230 postnatal care, 501 indications, 230 roles of care, 278 nursing guidelines, 232 specialist equipment for, 546–549 opioid administration, 221–222 Pain medications pediatric trauma patients, 416 acetaminophen, 223–225 pump settings, 231 adverse events, 222 types of drugs, 230 anticonvulsants, 224 when to initiate, 232 frequency of intravenous and oral analgesic administration, Patient evacuation coordination center, 42 279 Patient movement requirement centers, 396 intravenous administration, 220–222 Patient positioning local anesthetics, 224–225 airway management, 77–78 N-methyl-D-aspartate receptor antagonists, 222–223 critical care, 300 nonopioid analgesics, 222–225 mechanical ventilation and, 308 nonsteroidal antiinflammatory drugs, 223, 225 operating room procedures, 147 opioids, 220–222 percutaneous central venous access, 65, 66 pain regimen based on injury severity, 221 prone positioning, 308 per os administration, 220 Patient transfer, 300 α2-adrenergic agonists, 224–225 Patient transport. See also Aeromedical transport Pain nurses, 263 pediatric trauma patients, 423 Pain relief Pave Hawk helicopters, 47–48 carbohydrate metabolism, 201 PCA. See Patient-controlled analgesia cardiovascular response, 202 PECC. See Patient evacuation coordination center immune function response, 202 Pediatric Advanced Life Support algorithm, 554 initial stress response, 200 Pediatric trauma
xl Combat Anesthesia: The First 24 Hours Index
acute management of asthma exacerbation algorithm, 406–407 anterior posterior compression, 145 acute management of hyperkalemia algorithm, 421 classification of, 145 airway equipment, 404–406, 470 general operative intervention considerations, 147–149 airway management, 477–478 imaging, 178 analgesia, 481–482 infection control, 147 analgesic drug doses, 474 lateral compression, 145 anatomy and physiology, 403, 473–474 management strategy for fractures, 150–151 anesthesia, 470–482 postoperative care, 151–152 anesthesia handoff checklist, 405 prehospital care, 145–146 blood product dosing guidelines, 420 regional anesthesia, 148 breathing management, 478–479 role 3 care, 147 burn care, 421–423 surgical considerations, 151 caudal anesthesia, 482 tourniquet use, 148–149 chest trauma, 402–403 vertical shear, 145 circulation management, 474, 479 Percutaneous central venous access commonly used analgesics, 416 complications of, 67 disability, 479–482 femoral vein, 66 dosing for commonly used medications, 428 history of, 64–65 dosing for single-injection peripheral nerve block, 481 internal jugular vein, 65–66 emergency resuscitation dosing, 427 patient positioning, 65, 66 enteral feeding, 414 pediatric trauma patients, 412, 427, 475–477 epidural anesthesia, 482 subclavian vein, 65 equipment, 404, 470 tasks to be completed on arrival of patient, 65 estimated blood volumes, 420 techniques, 65, 66 estimation of endotracheal tube size and length in children, ultrasound-guided, 66–67 471 Perioperative critical care exposure, 482 adjuncts in trauma resuscitation, 114–115 fever, 419 admission to intensive care unit, 114–115 fluid management, 412–415, 479 airway assessment, 108–110 Glasgow coma scale, 405, 479–480 the “AMPLE” history, 109 head trauma, 417–419 assessment regime, 108–112 hematologic issues, 419–421 base deficit correction, 112 hemodynamic principles, 409–412 circulation, 111 infection, 419 clearance of cervical spine, 110 initial ventilator settings, 409 conditions requiring rapid sequence induction of anesthesia, intraosseous insertion, 411 110 massive hemorrhage, 471, 474–477 early enteral nutrition, 115 mechanical ventilation, 402–409 early intensive care requirements for the severely injured, 109 minimum alveolar concentration, 481 end points in resuscitation, 113 neurologic injuries, 479–480 fluids in trauma resuscitation, 114 normal physiological values for children, 470 fracture fixation, 114 nutritional support, 412–415 hypotensive resuscitation, 113–114 pain management, 415–417 immediate requirements and decision points in treating the parenteral feeding, 414 severely injured, 109 patient-controlled analgesia, 416 infection care bundles, 115 pediatric parameters, 404 initial management, 108 physiologic considerations, 403, 473–474 inotropic agents, 114 preparation, 470–471 lactate correction, 112 pulmonary support, 402–409 patient history, 108 rapid sequence induction, 420, 477–478 vascular volume status, 111–112 receiving pediatric critical care patients, 402 vasoactive agents, 114 recommended extubation criteria, 409 ventilation, 110–111 refeeding syndrome, 415 Peripheral nerve blocks resuscitation, 412, 427, 475–477 needle design, 547 sedation management, 415–417, 480 pediatric patients, 481 spinal cord trauma, 417–419 Peripheral nociceptors, 194 thermoregulation, 474 Peripheral venous cutdown, 68 transport principles, 423 Peritoneal dialysis, 325 trauma considerations, 471–473 Permissive hypotension, 54, 88 vascular access, 410–412, 475 Personal protective equipment, 507–508 vasoactive agents, 411 Pethidine, 496 ventilator-associated pneumonia bundle, 410 Pharmacists ventilatory management techniques, 406–410 acute pain service responsibilities, 263 weight estimation for Afghanistan local national children, 471 Physical examinations, 286 Pedro helicopters, 47 Physiotherapists, 263 PEEP. See Positive end-expiratory pressure PIS. See Propofol infusion syndrome Pelvic injuries PMRCs. See Patient movement requirement centers
xli Combat Anesthesia: The First 24 Hours Index
Pneumonia R ventilator-associated pneumonia bundle, 410 Pneumothorax, 67 RAAS. See Rennin-angiotensin-aldosterone system Point-of-care testing, 89 Radiologic assessment. See also Imaging Portable oxygen generator system, 536–537 cervical spine injuries, 123–124 Positioning. See Patient positioning Radiological exposure. See Chemical, biological, radiological, and Positive end-expiratory pressure, 111, 292, 305–306 nuclear exposure Postnatal care, 501 RAP. See Regimental aid posts Postoperative care Rapid sequence induction burn injuries, 170 airway management, 79, 122–123 extremity injuries, 151–152 care during MEDEVAC, 49–51 junctional injuries, 151–152 indications for, 50–51 pediatric trauma patients, 412–415 medications commonly used for, 420 pelvic injuries, 151–152 pediatric trauma patients, 420, 477–478 Postpyloric feeding, 375–376 risks during MEDEVAC flight, 50 Posttraumatic stress disorder RASS. See Richmond Agitation-Sedation Scale pain response, 202 RBCs. See Red blood cells Potassium management RCC. See Red cell concentrate damage control resuscitation and, 90 RCDM. See Royal Centre for Defence Medicine massive transfusion and, 98 Recombinant activated factor VIIa PRBCs. See Packed red blood cells damage control resuscitation and, 91 Preeclampsia, 498 effects of, 352–353 Prehospital medicine massive transfusion and, 101 analgesia, 268–272 Record-keeping, 299–300 care during MEDEVAC, 48–54 Recruitment maneuvers, 308 considerations for the future, 54 Red blood cells, 98 evacuation chain, 42–44 Red cell concentrate, 100 extremity, junctional, and pelvic injuries, 145–146 Refeeding syndrome, 415 Medical Emergency Response Team, 44–46 Regimental aid posts, 43 medical evacuation assets, 46–48 Regional anesthesia prehospital resuscitation guidelines, 555–556 Camp Bastion protocol, 242–244 Pressure-preset ventilation, 305–306 continuum of risk, 243 PRIS. See Propofol infusion syndrome determining when to use, 242 Project HOPE, 450 for extremity, junctional, and pelvic injury surgical procedures, Prone positioning, 308 148 Propaq, 538 obstetric anesthesia, 497 Propofol, 362–364 pediatric patients, 480–481 Propofol infusion syndrome, 126, 363–364 potential benefits of, 242 Protein catabolism, 200 for stable casualties, 185 PTSD. See Posttraumatic stress disorder ultrasound imaging and, 179 Pulmonary agents, 514–515 venous access, 179 Pulmonary embolism, 335 Remifentanil, 496 Pulmonary injuries. See also Respiratory disease Renal disease acute respiratory distress syndrome, 12 elderly populations and, 487 airway trauma, 10 Renal failure chest wall trauma, 10–11 etiology of, 322 lung injuries, 136–137 incidence of, 322 pediatric trauma patients, 402–409 Indications for renal support, 322–323 pulmonary contusion, 291 management options, 323–324 pulmonary trauma, 10–11 outcomes, 324 prevention of, 322 Q “RIFLE” classification, 322–323 Renal injuries Q fever, 341, 437, 441 abdominal compartment syndrome, 14–15 QEHB. See Queen Elizabeth Hospital Birmingham acute kidney injury, 14, 322–324 Queen Elizabeth Hospital Birmingham compartment syndrome, 14 anesthetic considerations for critically injured military pa- extremity compartment syndrome, 15 tients, 569 renal replacement therapy, 15 clinical and anesthetic considerations for patients admitted to “RIFLE” criteria for acute renal failure, 15 the military trauma ward, 569 risk factors for acute renal failure, 13 coordinating clinical care, 569–570 Renal replacement therapy, 15, 322–325 essential requirements for receiving casualties at Role 4, 568 Renal support external relationships, 570 constructing a field-expedient peritoneal dialysis system, 325 operating room activity, 570 etiology of injuries, 322 patient admissions and disposition, 568–569 history of, 322 “Quick Look” assessment, 507, 509 incidence of injuries, 322 indications for, 322–323
xlii Combat Anesthesia: The First 24 Hours Index
management options, 323–324 Sedation. See also Anesthesia modes of, 324 acute lung injury, 292 outcomes, 324 benzodiazepines, 361 prevention of acute kidney injury and renal failure, 322 conscious sedation, 185–186 Rennin-angiotensin-aldosterone system, 290–291 daily interruption of sedation, 365–366 Reperfusion. See also Vascular reperfusion dexmedetomidine, 362, 364 ischemia-reperfusion injury, 9, 16 head injuries, 365 Respiratory disease. See also Pulmonary injuries pediatric trauma patients, 415–417, 480 elderly populations and, 487 pharmacology of sedatives, 362 Goldman risk factor and score, 486–487 propofol, 362–364 Respiratory system restraints and, 366 pain response, 202 sedation scales, 360 Restraints sedatives, 361–364, 417 sedation and, 366 Seizures Resuscitation. See also Damage control resuscitation head trauma and, 127 adequacy of resuscitation, 288–289 Sepsis areas of controversy, 557 antibiotic guidelines, 387–388 blood product administration, 53–54 diagnosis of, 333 capnometry as a guide to resuscitation, 557 goal-directed therapy, 334 cardiac arrest guidelines, 552 immunoglobulin doses, 386 chest compressions, 557 laboratory support, 386–387 concurrent, 49 patient management, 333, 384 end points, 113 the resuscitation bundle, 384–385 epinephrine, 557 the sepsis management bundle, 385–386 evidence for military traumatic cardiorespiratory arrest, supportive therapy, 385 556–557 tailoring therapy, 386–388 guidelines, 552–558 Sequential compression device, 354 head trauma, 127 Serotonin syndrome, 344 hypotensive resuscitation, 54 Sexual violence, 495 ideal goals of, 113 Shock intubation, 557 adrenal crisis, 335 novel hybrid resuscitation, 54 anaphylaxis, 333, 335 obstetric algorithm, 500 cardiac tamponade, 336 pediatric emergency resuscitation dosing, 427 cardiogenic shock, 332–333 pediatric trauma patients, 412, 427, 475–477 categories of, 328–329 prehospital resuscitation guidelines, 555–556 clinical presentation, 328 the resuscitation bundle, 384–385 coagulopathy of trauma shock, 242–244 trauma resuscitation guidelines, 552–555 combat casualties and, 8–10 vasopressors, 557 distributive shock, 333–335 ventilation, 557 hypovolemic shock, 37, 332 Return of spontaneous circulation, 556–557 management of, 332–336 Richmond Agitation-Sedation Scale, 292, 360–361 neurogenic shock, 335 “RIFLE” criteria, 15, 322–323 obstructive shock, 335–336 Riot control agents, 515–516 pathophysiology of, 328 Roles of care pulmonary embolism, 335 acute pain services at role 3 facilities, 278–279 sepsis, 333–334 burn casualties at role 3 facilities, 164–171 traumatic shock, 8–9 for combat casualties, 5–7 Shock liver, 16 combat casualty management at role 2 and 3 facilities, 7–8 SIRS. See Systemic inflammatory response syndrome damage control resuscitation at role 2 and 3 facilities, 7 Situational awareness essential requirements for receiving casualties at Role 4, 568 trauma teams and, 34 extremity injury management at role 3 facilities, 146–147 Skin diseases, nonthermal, 171 junctional injury management at role 3 facilities, 147 Skin grafts, 166 pelvic injury management at role 3 facilities, 147 Society of Critical Care Medicine, 360, 365 Royal Air Force Sodium maintenance, 412–413 Critical Care Air Support Teams, 392 SOI. See Standard operating instruction Royal Centre for Defence Medicine, 568 SOP. See Standard operating procedures RRT. See Renal replacement therapy Specialist retrieval teams, 88 RSI. See Rapid sequence induction Spinal-epidural analgesia, 497 Rule of nines, 422 Spinal injuries. See also Back pain airway management, 122–123 S Canadian C-Spine Rule, 123–124 CT imaging, 110 Sacroiliac joint pain, 250, 252 epidemiology, 122 SCCM. See Society of Critical Care Medicine injury patterns, 122 SCD. See Sequential compression device pediatric patients, 417–419 Scoring pain. See Pain scoring radiologic assessment, 110, 123–124
xliii Combat Anesthesia: The First 24 Hours Index
steroids and, 124 Thoracotomy, 137–138, 556 Spinal stenosis, 250, 253 Thromboembolic disease Spontaneous ventilation, 306 chemical prophylaxis, 354–355 Stable casualties Factor VIIa effects, 352–353 choosing anesthetic technique, 184–187 inferior vena cava filters, 355–356 classification of, 182 massive transfusion effects, 352–353 common operations, 183–184 mechanical prophylaxis, 354 conscious sedation, 185–186 neuraxial blockade, 355 monitoring depth of anesthesia, 187 pathophysiology of venous thromboembolism, 352–353 neuraxial anesthesia, 185 prevalence of venous thromboembolism, 353 perioperative considerations, 184 prevention of venous thromboembolism, 353–356 population at risk, 182–183 prophylaxis, 300 regional anesthesia, 185 tranexamic acid effects, 352–353 special considerations, 183 Tidal volume, 304 total intravenous anesthesia, 186–187 TIVA. See Total intravenous anesthesia volatile gas anesthesia, 185 TL-ILV. See Two-lung independent ventilation Standard operating instruction Tocolysis, 498 acute pain service, 263–264 Topical negative pressure dressings, 300 Standard operating procedures TOSC. See Return of spontaneous circulation trauma teams and, 33–34 Total intravenous anesthesia, 186–187 Steroids Tourniquets spinal injury use, 124 cardiovascular effects, 156–157 Strategic evacuation, 394, 397 combat application tourniquet, 145 STRATEVAC. See Strategic evacuation complications association with, 148 Subclavian vein catheterization, 65 extremity injuries and, 148–149 Superficial peripheral nerve block, 244 junctional injuries and, 148–149 Supraglottic airways, 78 managing reperfusion after removal, 155–160 Surgical principles, 149. See also Operating room procedures metabolic effects, 159 Surviving Sepsis Campaign, 333, 384 neurologic effects, 158 SVR. See Systemic vascular resistance pelvic injuries and, 148–149 Systemic inflammatory response syndrome, 115 physiologic effects, 156–160 Systemic vascular resistance, 156–157 respiratory effects, 157 safety of, 159–160 T tourniquet pain, 158–159 Tracheal disruption TACEVAC. See Tactical evacuation aeromedical evacuation, 316–317 Tactic, technique, or procedure calls, 47 diagnosis of, 316 Tactical Combat Casualty Care, 4–5, 48, 271 postoperative care, 316–317 Tactical damage control surgery, 7–8 preventing further injury, 316–317 Tactical evacuation, 394, 397 ventilation considerations, 316–317 TAP block. See Transversus abdominis plane block ventilator settings, 316–317 Target-controlled infusions, 186–187 Tracheostomy, 478 TBI. See Traumatic brain injury TRALI. See Transfusion-related acute lung injury TCCC. See Tactical Combat Casualty Care Tranexamic acid, 352–353 TCI. See Target-controlled infusions Transfer ventilators, 309–310 TCRA. See Traumatic cardiorespiratory arrest Transfers, patient, 300 Team medics, 43 Transfusion, massive. See Massive transfusion Thermal injury, acute, 164–165 Transfusion-related acute lung injury, 100 Thermoregulation Transient receptor potential vallinoid, 194–195 pediatric trauma patients, 474 Transport, patient. See also Aeromedical transport Thoracic injuries pediatric trauma patients, 423 analgesia principles, 140 Transversus abdominis plane block, 207–108 anesthesia principles, 139 Trauma shock aortic injuries, 136 coagulopathy of trauma shock, 242–244 blunt injuries, 135 Trauma team cardiac injuries, 135–136 communication, 33 combat casualties, 8 considerations for, 35–38 imaging, 178 crew resource management, 33–34 intrathoracic airway injuries, 134–135 familiarization with environment and equipment, 34 lung injuries, 136–137 leadership and followership, 34 multimodal analgesia, 208 multidisciplinary trauma team, 34–35 operative intervention, 137–139 roles of, 36 pathophysiology, 134–137 situational awareness, 34 penetrating injuries, 134 training, 35 practical conduct of anesthesia, 139–140 use of standard operating procedures, 33–34 ventilation strategies, 140 Traumatic brain injury Thoracostomy, 53 anesthetic use, 127
xliv Combat Anesthesia: The First 24 Hours Index
assessment of, 124–125 pediatric trauma patients, 410–412, 475 critical care, 299 percutaneous central venous access, 64–67 decreasing cerebral oxygen consumption, 126 peripheral venous cutdown, 68 Glasgow coma scale, 125 physics of flow, 64 intracranial hypertension and, 127 post-anesthesia care of vascular access devices, 69 management, 125–127 Vascular injuries monitoring, 124–125 imaging, 178 neuroprotective measures, 13 surgical considerations, 149–150 prophylaxis for, 13 Vascular reperfusion, 155–160 resuscitation, 127 Vasoactive agents, 114, 411 seizures and, 127 Vasopressors, 557 tactical damage control surgery, 7 Vela ventilators, 539 Traumatic cardiorespiratory arrest, 552, 556–557 Veno-venous technique of hemofiltration, 323–324 Traumatic shock, 8–9 Venous thromboembolism Triage chemical prophylaxis, 354–355 ethical issues, 462–463 factor VIIa effects, 352–353 following chemical, biological, radiological, and nuclear expo- inferior vena cava filters, 355–356 sure, 510–512 massive transfusion effects, 352–353 Triservice Anesthetic Apparatus, 528–530 mechanical prophylaxis, 354 TRPV. See Transient receptor potential vallinoid neuraxial blockade, 355 TTPs. See Tactic, technique, or procedure calls pathophysiology of, 352–353 Tuberculin skin testing, 437 prevalence of, 353 Two-lung independent ventilation, 140 prevention of, 353–356 prophylaxis, 300 U tranexamic acid effects, 352–353 Ventilation, mechanical UFH. See Unfractionated heparin acute lung injuries and, 291–292 Ultrasound, medical, 546–547 adjuncts to, 308–309 Unfractionated heparin, 353–355 asymmetrical pulmonary pathologies, 307 United Kingdom for bronchopleural fistula, 316–318 buddy-buddy system, 43 conservative fluid management, 308–309 Defence Medical Services, 32 drugs used with, 51–52 massive transfusion operational protocol, 100, 102–103 extracorporeal membrane oxygenation, 309 Medical Emergency Response Team, 44–46 the first 24 hours, 304–310 Queen Elizabeth Hospital Birmingham, 568–571 high-frequency ventilation, 307–308 team medics, 43 independent lung ventilation, 306–307 United Kingdom Defence Medical Services infection issues, 383 pain scoring systems, 215–216 inverse-ratio ventilation, 306 United States mode of, 305–308 combat casualty care, 43 monitoring and optimizing ventilation, 304–305 massive transfusion military protocol, 100–101, 104 neuromuscular blocking agents, 308 medical evacuation assets, 46–48 nitric oxide and, 308 military anesthesiologists, 32 pediatric trauma patients, 406–410 military hospitals, 564–566 positive end-expiratory pressure, 305 Upper limb injuries prehospital procedures, 53 multimodal analgesia, 207 pressure-preset ventilation, 305–306 US Air Force principles of safe ventilation, 304–305 Critical Care Air Transport Teams, 6–7, 392 prone positioning, 308 pararescue, 47–48 recruitment maneuvers, 308 US anesthesia monitoring, 538 resuscitation guidelines, 557 US Army’s Institute of Surgical Research, 101, 103, 565 spontaneous ventilation, 306 US draw-over system, 531–532 thoracic injuries and, 140 US ventilators, 539–540 tidal volume, 304 USAF, Form 3899, Aeromedical Evacuation Patient Record, 397 for tracheal disruption, 316–318 USAISR. See US Army’s Institute of Surgical Research transfer ventilators, 309–310 USNS Comfort, 448–449, 450, 452, 454 volume-preset ventilation, 305 USNS Mercy, 448, 452 Ventilator-associated pneumonia, 383 Utilitarianism, 460 Ventilators, 538–540 V Vesicants, 514 Veterans Affairs Medical Centers, 565–566 VAP. See Ventilator-assiciated pneumonia Video laryngoscopy, 78 Vascular access Virchow triad, 352 access to vascular space, 49 Visual analogue pain scale, 215 arterial access, 68–69 Volatile gas anesthesia, 185 catheter and cannula sizes, 64 Volume-preset ventilation, 305 direct atrial cannulation, 68 VTE. See Venous thromboembolism intraosseous access, 67–68
xlv Combat Anesthesia: The First 24 Hours Index
W Walter Reed Army Institute of Research, 437–440 Ward nurses, 263 Water/electrolyte balance, 201–202 Whiplash injuries, 254–255 World Health Organization pain ladder, 207, 277–278 surgical checklist, 33 WRAIR. See Walter Reed Army Institute of Research Z Zygopaphyseal joint pain, 250
xlvi Combat Anesthesia: The First 24 Hours Index
MERT Head Out Again by Tony Green, acrylic on paper, 2009. Art: Courtesy of Tony Green.
xlvii Combat Anesthesia: The First 24 Hours Index
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