RGR Handbook May 2002 - 1

75th Ranger Regiment
Trauma Management Team
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TABLE OF CONTENTS
SECTION SUBJECT PAGE
MEDICAL: RANGER MEDIC SCOPE OF PRACTICE------ 6

PATIENT ASSESSMENT & MANAGEMENT-- 10
PROTOCOLS
OROTRACHEAL INTUBATION--------------------------------- 17
COMBITUBE SA---------------------------------------------------- 18
SURGICAL CRICOTHYROIDOTOMY------------------------- 19
NEEDLE DECOMPRESSION------------------------------------- 20
CHEST TUBE INSERTION---------------------------------------- 21
EXTERNAL JUGULAR CANNULATION---------------------- 22
STERNAL INTRAOSSEOUS INFUSION (FAST-1)---------- 23
ANAPHYLACTIC SHOCK MANAGEMENT-------------------24
BURN MANAGEMENT---------------------------------------------25
HEAD INJURY MANAGEMENT-------------------------------- 26
SPINAL CORD INJURY MANAGEMENT -------------------- 27
HYPOTHERMIA MANAGEMENT ----------------------------- 28
PHARMACOLOGY
PHARMACOLOGY QUICK REFERENCE SHEET------ 29
ACETAMINOPHEN------------------------------------------------ 30
ALBUTEROL--------------------------------------------------------- 31
BACITRACIN-------------------------------------------------------- 32
BENZONATE-------------------------------------------------------- 33
CEFOXITIN----------------------------------------------------------- 34
DEXTROSE 50%----------------------------------------------------- 35
DIAZEPAM----------------------------------------------------------- 36
DIPHENHYDRAMINE----------------------------------------------37
EPINEPHRINE--------------------------------------------------------38
HETASTARCH------------------------------------------------------- 39
IBUPROFEN---------------------------------------------------------- 40
KETOROLAC-------------------------------------------------------- 41
LIDOCAINE 1%----------------------------------------------------- 42
LOPERAMIDE--------------------------------------------------------43
LORATADINE--------------------------------------------------------44
MECLIZINE-----------------------------------------------------------45
MORPHINE----------------------------------------------------------- 46
NALOXONE---------------------------------------------------------- 47
PSEUDOEPHEDRINE---------------------------------------------- 48
PROMETHAZINE--------------------------------------------------- 49
VERSED--------------------------------------------------------------- 50
TACTICAL: TACTICAL COMBAT CASUALTY CARE------ 51
CCP DIAGRAM-----------------------------------------53
PLANNING: MEDICAL EVALUATION CHECKLIST---------54
HAZERDOUS TRAINING CHECKLIST--------- 58
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RANGER MEDIC SCOPE OF PRACTICE

DEFINITIONS
The following are definitions of frequently used terms:
RANGER FIRST RESPONDER (RFR) – A Ranger who has attended and successfully
completed the Ranger First Responder Course.
SQUAD EMT – A non-medical MOS Ranger currently registered as an EMT-
Basic/Intermediate by the Department of Transportation (DOT). This individual functions
as a bridge between the RFR and the Ranger Medic in respect to tactical and
administrative trauma management.
BASIC TRAUMA MANAGER (BTM) – Ranger Medic currently registered as an
EMT-B/I by the DOT who has been approved by the Medical Director (Battalion
Surgeon) to function at this level of care.
ADVANCED TRAUMA MANAGER (ATM) - Ranger Medic currently registered as
an EMT-Paramedic by the DOT who has been awarded the identifier W1 (Special
Operations Combat Medic) and has been approved by the Medical Director (Regimental
Surgeon) to function at this advanced level of care.
Standing Orders - Advanced life support interventions, which may be undertaken before
contacting on-line medical control.
Protocols - Guidelines for out of hospital patient care. Only the portion of the
guidelines, which are designated “standing orders”, may be undertaken before contacting
on-line medical control.
Medical Control – A credentialed provider, physician or physician assistant, who
verbally, or in writing, states assumption of responsibility and liability, available on-site
or contacted through established communications. Medical direction of advanced life-
saving activities will be routed through medical control to assist in providing the best care
to all injured Rangers. Medical Control is established whether the mission is an airfield
seizure or administrative medical coverage of a range. All medical care falls under the
licensure of the Regimental Surgeon.
APPLICATION OF PROTOCOLS
These standing orders and protocols are only to be used by Ranger Medics assigned to
the 75th Ranger Regiment.
Purpose
These protocols are to be utilized only by Ranger Medical personnel assigned to the
75th Ranger Regiment. The primary purpose of these protocols is to serve as a guideline
for out-of-hospital care. Quality out-of-hospital care is the direct result of comprehensive
education, accurate patient assessment, good judgment, and continuous quality
improvement. All Ranger medical personnel are expected to know the Trauma
Management Team Protocols and understand the reasoning behind their employment.
Ranger Medics should not perform any step or steps in a standing order or protocol if
they have not been trained to perform the procedure or treatment in question.
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Protocols and Standing Orders

These protocols are ONLY for use by Ranger Medics while providing BLS, ALS, and
TCCC. Ranger medical personnel who are authorized to operate under the Trauma
Management Team guidelines may not utilize these standing orders outside of their
military employment. All Ranger medical personnel must adhere to the standards
defined in these protocols, or face revocation of privileges by the granting authority if
these standards are violated.
Communications
In case the Ranger Medic cannot contact medical control (ie. acute time-sensitive
injury/illness, mass casualty scenario, or communication difficulties), all protocols
become standing orders. Likewise, in the event that medical control cannot respond to the
radio/telephone within two minutes of the call, all protocols are considered standing
orders. In the event medical control was not contacted, and treatment protocols were
carried out as standing orders, medical control will be contacted as soon as feasible
following the incident, the record (Trauma SF 600) will be reviewed with medical
control, and medical control will countersign as the medical authority to indicate
retroactive approval.
GENERAL GUIDELINES FOR PROTOCOL USAGE

1. The patient history should not be obtained at the expense of the patient. Life-
threatening problems detected during the primary assessment must be treated
first.
2. Cardiac arrest due to trauma is not treated by medical cardiac arrest protocols.
Trauma patients should be transported promptly to the previously coordinated
Medical Treatment Facility with CPR, control of external hemorrhage, cervical
spine immobilization, and other indicated procedures attempted en route.
3. In patients with non-life-threatening emergencies who require an IV/Saline Lock,
only two attempts at IV insertion should be attempted in the field. Patient
transport to definitive care must not be delayed for multiple attempts at IV
access or advanced medical procedures.
4. Medics will verbally repeat all orders received and given prior to their initiation
(i.e. two-man Trauma Team/RTF Code).
5. All patients that are transported by members of the 3/75 Trauma Management
Team will be placed on a monitor and the following documented: pulse, blood
pressure, SpO2, and cardiac rhythm.
NEVER HESITATE TO CONTACT THE SURGEON FOR ANY PROBLEM,

QUESTION, OR ADDITIONAL INFORMATION.
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SPECIAL CONSIDERATIONS
IV Therapy
1. All trauma patients should receive at least one, and preferably two, Saline
Locks/IVs. Trauma patients with controlled bleeding and a systolic blood
pressure <90 mm Hg should receive wide-open fluids (Hespan preferred over
Normal Saline) until the systolic blood pressure is >90 mm Hg. Trauma patients
with controlled bleeding and a systolic blood pressure >90 mm Hg, or
uncontrolled hemorrhage, should receive a saline lock only, fluids at a ”to keep
open” (TKO) rate, or as directed in the applicable protocol.
2. Sternal Intraosseous (FAST-1) infusion may only be performed on adult patients
who require fluids and or medication to sustain life. This procedure should be
limited to the unconscious, unresponsive patient after at least 2 unsuccessful
peripheral IV attempts when access is absolutely necessary.
3. All initial IV attempts are to be peripheral. The external jugular vein is considered
a peripheral vein. Placement of the FAST-1, Sternal Intraosseous, is only
permitted in patients who have a life-threatening emergency where
immediate fluid or medication administration is necessary and a peripheral
vein is inaccessible. Only Ranger Medics who have obtained the required
education in sternal intraosseous needle placement and who have been approved
by the Battalion Surgeon may place intraosseous needles.
4. Each IV bag should be labeled with the following data:
Time and date of IV start
IV cannula size
Initials of Ranger Medic who started the IV
Combitube Insertion
Proper Combitube placement must be confirmed and documented by at least three
different methods. These include:
Presence of bilateral breath sounds.
Absence of breath sounds over the epigastrium.
Use of an endotracheal esophageal detector (Tube Check).
Endotracheal Intubation
1. Proper endotracheal tube placement must be confirmed and documented by at least
three different methods. These include:
Presence of bilateral breath sounds.
Absence of breath sounds over the epigastrium.
Presence of condensation on the inside of the endotracheal tube.
End-tidal carbon dioxide monitoring.
Visualizing the tube passing through the cords.
Use of an endotracheal esophageal detector (Tube Check).
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2. Following endotracheal intubation, tube placement should be re-verified every 5-10

minutes by noting bilateral breath sounds.
Endotracheal Drug Administration
1. Only the following four drugs can be administered via an endotracheal tube:
L - Lidocaine
E - Epinephrine
A - Atropine Sulfate
N – Naloxone
2. When administering drugs via the endotracheal tube, administer 2.0 - 2.5 times the IV
dose. Also, dilute the drug in sufficient normal saline to result in a total volume of at
least 10 ml. This will facilitate endotracheal instillation and aid in increased drug
delivery to the respiratory tissues.
Patient Information Documentation

Patient information and procedure documentation will take place utilizing the following:
Tactical – 75th Combat Casualty Card.
Non-Tactical - Trauma SF 600 or Standard SF 600.
RESUSCITATION CONSIDERATIONS
1. Resuscitation should not be attempted in the field in cases of:
Rigor mortis
Decapitation
Decomposition
Obvious massive head or chest/abdomen trauma, which is incompatible with
life (provided the patient does not have vital signs)
2. Consider option of “Medical Retirement” prior to pronouncing patient as dead.
This may require transfer to a military medical facility, but can provide increased
benefits for surviving family members.
3. Consider the potential for organ donation. Patients who have sustained mortal injuries
may still warrant emergent care until a determination can be made whether the patient
may be a potential organ or tissue donor.
4. Consider the application of resuscitation efforts if this is your only patient and the
trauma was sustained during training. The perception of fellow Rangers and family
members in this instance should be that every effort was made to sustain life.
5. When possible, place the “quick look” paddles or the ECG leads to confirm asystole
or an agonal rhythm and attach a copy of the strip to the Trauma SF 600.
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PATIENT ASSESSMENT AND MANAGEMENT

I. Overview
ESTABLISH PRIORITIES
1. Obtain situational awareness, then ensure scene security.
2. Control yourself, then take control of the situation. (The senior medic on the
scene needs to control the resuscitation effort. All orders to team members
need to come from one man, the senior medic in charge).
PRIMARY SURVEY
During the primary survey, life-threatening conditions are identified and simultaneous
management is begun. The primary survey consists of:
A - Airway Maintenance and C-spine stabilization
B - Breathing
C - Circulation with control of massive hemorrhage
D - Disability (mental status)
E - Exposure/Environmental Control [undress patient, but prevent hypothermia]
RESUSCITATION
Aggressive initial resuscitation should include airway establishment and protection,
ventilation and oxygenation, hemorrhage control, IV fluid administration as needed, and
hypothermia prevention. As resuscitative interventions are performed, the provider
should reassess the patient for changes in status.
SECONDARY SURVEY
The secondary survey should consist of obtaining a brief history and conducting a head-
to-toe evaluation of the trauma patient. This in-depth examination utilizes inspection,
palpation, percussion, and auscultation, to evaluate the body in sections. Each section is
examined individually.
TREATMENT PLAN
Initially, provide critical resuscitative efforts to resolve potential life-threatening injuries
detected in the primary and secondary survey. Secondly, determine patient disposition. Is
the patient stable or unstable? What further diagnostic evaluation, operative intervention,
or treatment is required? What level of medical care is needed? When does the patient
need to be evacuated? All of these questions must be answered in a logical fashion in
order to prioritize and mobilize the resources available.
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II. The Primary Survey

The primary survey is broken down into five major areas: Airway and c-spine control,
Breathing, Circulation, Disability, Exposure/Environment Control.
A. AIRWAY AND C-SPINE

The upper airway should be assessed to ascertain patency. Chin lift, jaw thrust, or suction
may be helpful in establishing an airway.
Specific attention should be directed toward the possibility of a cervical spine fracture.
The patient's head and neck should never be hyper-extended or hyper-flexed to establish
or maintain an airway. One should assume a cervical spine fracture in any patient with an
injury above the clavicle. Approximately fifteen percent of patients who have this type of
injury will also have a c-spine injury.
B. BREATHING
The patient’s chest should be exposed and you should look for symmetrical movement of
the chest wall.
Conditions that often compromise ventilation include: MASSIVE HEMOTHORAX,
TENSION PNEUMOTHORAX, OPEN PNEUMOTHORAX, and FLAIL CHEST.
C. CIRCULATION
Circulation is divided into two parts: Hemodynamic Status and Hemorrhage Control.
1. Hemodynamic Status
A formal blood pressure measurement SHOULD NOT be performed at this point
in the primary survey. Important information can be rapidly obtained regarding
perfusion and oxygenation from the level of consciousness, pulse, skin color, and
capillary refill time. Decreased cerebral perfusion may result in an altered mental
status. The patient's pulse is easily accessible and if palpable, the systolic blood
pressure in millimeters of mercury (mmHG) can be roughly determined as
follows:
RADIAL PULSE: PRESSURE ≥ 80mmHg
FEMORAL PULSE: PRESSURE ≥ 70mmHg
CAROTID PULSE: PRESSURE ≥ 60mmHg
Skin color and capillary refill will provide a rapid initial assessment of peripheral
perfusion. Pink skin is a good sign versus the ominous sign of white or ashen,
gray skin depicting hypovolemia. Pressure to the thumb nail or hypothenar
eminence will cause the underlying tissue to blanch. In a normovolemic patient,
the color returns to normal within two seconds. In the hypovolemic poorly
oxygenated patient and/or hypothermic patient this time period is extended or
absent.
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2. Hemorrhage Control
a. EXTERNAL HEMORRHAGE. Exsanguinating external
hemorrhage should be identified and controlled in the primary survey.
Direct pressure and pressure bandages should be utilized to control
bleeding. Tourniquets should be used as needed for traumatic
amputations and in the tactical environment.
b. INTERNAL HEMORRHAGE. Occult hemorrhage into the
thoracic, abdominal, or pelvic regions, or into the thigh surrounding a
femur fracture can account for significant blood loss. If an operating
room is not immediately available, abdominal or lower extremity
hemorrhage can be reduced by the application of the pneumatic anti-
shock garment.
c. Estimate Fluid and Blood Requirements in Shock (Based on
Patient’s Initial Presentation):
Class I Class II Class III Class IV
Blood Loss (ml) Up to 750 750-1500 1500-2000 > 2000
Blood Loss(%BV) Up to 15% 15-30% 30-40% > 40%
Pulse Rate < 100 > 100 > 120 > 140
Blood Pressure Normal Normal Decreased Decreased
Pulse Pressure Normal or Decreased Decreased Decreased

(mm Hg) increased
Capillary Blanch Test Normal Positive Positive Positive
Respiratory Rate 14-20 20-30 30-40 > 35
Urine Output (mL/hr) > 30 20-30 5-15 Negligible
CNS-Mental Status Slightly Mildly Anxious & Confused-

anxious anxious confused lethargic
Fluid Replacement Crystalloid Crystalloid Crystalloid & Crystalloid &

(3:1 Rule) blood blood
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D. DISABILITY (MENTAL STATUS)

A rapid neurologic evaluation should be utilized to determine the patient's pupillary size
and response, as well as the level of consciousness (LOC). Pupils should be equal and
reactive. If the pupils are found to be sluggish or nonreactive to light with unilateral or
bilateral dilation, one should suspect a head injury and/or inadequate brain perfusion.
LOC can be described through either the AVPU or Glasgow Coma Scale (GCS) method:
AVPU: A - Alert
V - responds to Verbal stimuli
P - responds only to Painful stimuli
U - Unresponsive to all stimuli
GCS: (15 point scale) Action: Points:
E - Eye Opening: Spontaneous 4
To Speech 3
To Pain 2
None 1
V – Verbal Response: Oriented 5

Confused Conversation 4
Inappropriate Words 3
Incomprehensible Sounds 2
None 1
M – Motor Response: Obeys Commands 6
Localizes Pain 5
Normal Flexion (Withdraws) 4
Abnormal Flexion (Decorticate) 3
Extension (Decerebrate) 2
None (Flaccid) 1
E. EXPOSURE/ENVIRONMENTAL CONTROL
The patient should be completely undressed (environment permitting) to facilitate
thorough examination and assessment during the secondary survey. Strive to maintain
the patient in a normothermic state. Hypothermia prevention is as important as any
other resuscitation effort.
III. Resuscitation
Resuscitation includes oxygenation, intravenous access, and monitoring.
OXYGEN
Supplemental oxygen should be administered to all trauma patients in the form of a
nonrebreather mask.
IV ACCESS
A minimum of two 18 gauge IV/saline locks should be started in any multiple trauma
patient. The rate of fluid administration is determined by the patient's hemodynamic
status and whether or not hemorrhage is controlled. Fluid resuscitation is assessed by
improvement in physiologic parameters such as ventilatory rate, pulse, blood pressure,
and urinary output.
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MONITORING
All patients followed for multiple trauma wounds should be continuously monitored for
ectopy. Arrhythmias are frequently associated with blunt chest trauma and should be
treated in the same fashion as arrhythmias secondary to heart disease.
IV. The Secondary Survey

A complete history, physical (head-to-toe examination), and reassessment of vital signs.
HISTORY
A patient’s pertinent past medical history must be obtained. A useful mnemonic is the
word, AMPLE.
Allergies
Medications
Past medical illnesses
Last meal
Events associated to the injury
PHYSICAL
The physical exam can be divided into eight parts: Head, Face, C-Spine and Neck, Chest,
Abdomen, Perineum and Rectum, Musculoskeletal, Neurologic.
1. HEAD
The secondary survey begins with a detailed examination of the scalp and head
looking for signs of significant injury to include edema, contusions, lacerations,
foreign bodies, and evidence of fracture. The eyes should be evaluated for visual
acuity, pupillary size, external ocular muscle function, conjuntival and fundal
hemorrhage, and contact lenses (remove before edema presents).
2. FACE
Maxillofacial trauma, unassociated with airway compromise and/or major
hemorrhage, should be treated after the patient is completely stabilized. If the
patient has midface trauma, suspect a cribiform plate fracture, and if required,
intubation should be performed orally, and NOT via the nasal route.
3. C-SPINE/NECK
Suspect an unstable cervical spine injury in patients with blunt head and/or
maxillofacial trauma. Absence of neurological deficit does not rule out cervical
spine injury. A cervical spine injury should be presumed and the neck
immobilized until cleared by a physician and/or radiographic evaluation. Cervical
spine tenderness to palpation and spasm of the musculature of the neck can be
associated with a cervical spine injury. The absence of neck pain and spasm in a
patient who is neurologically intact is good evidence that a C-spine injury does
not exist. However, it does not eliminate the need for radiographic cervical spine
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evaluation. Neck inspection, palpation, and auscultation should also be used to

evaluate for subcutaneous emphysema, tracheal deviation, laryngeal fracture, and
carotid artery injury. In the absence of hypovolemia, neck vein distension can be
suggestive of tension pneumothorax or cardiac tamponade.
4. CHEST
A complete inspection of the anterior and posterior aspect of the chest must be
performed to exclude an open pneumothorax or flail segment. The entire chest
wall (rib cage, sternum, and clavicles) should be palpated to reveal unsuspected
fractures or costochondral separation. Auscultation should be utilized to evaluate
for the alteration of breath sounds denoting a pneumothorax, tension
pneumothorax, or hemothorax. Auscultation of distant heart sounds may be
indicative of a cardiac tamponade.
5. ABDOMEN
Any abdominal injury is potentially dangerous. Once identified, these injuries
must be treated early and aggressively. The specific diagnosis is not as important
as the fact that an abdominal injury exists which may require surgical
intervention. Palpation, close observation, and frequent reevaluation of the
abdomen are essential in the assessment and management of an intra-abdominal
injury. In blunt trauma, the initial examination of the abdomen may be
unremarkable. However, serial exams over time may reveal increasing signs of
tenderness and guarding.
6. RECTUM
A complete rectal examination in a trauma patient is essential and should include
an evaluation for rectal wall integrity, prostate position, sphincter tone, and gross
or occult blood.
7. EXTREMITIES
Extremities should be inspected for lacerations, contusions, and deformities.
Palpation of bones, through rotational or three-point pressure, checking for
tenderness, crepitation, or abnormal movements along the shaft, can help to
identify non-displaced or occult fractures. Slight pressure (NO PELVIC ROCK)
with the heels of the hand on the anterior superior iliac spines and on the
symphysis pubis can identify pelvic fractures. Peripheral pulses should be
assessed on all four extremities. The absence of a peripheral pulse distal to a
fracture or dislocation mandates manipulation toward the position of function. If
the pulse is still absent, transport immediately.
8. NEUROLOGIC EXAMINATION
An in-depth neurologic examination includes motor and sensory evaluation of
each extremity, and continuous re-evaluation of the patient’s level of
consciousness and pupil size and response. Any evidence of loss of sensation,
weakness, or paralysis suggests a major injury either to the spinal column or
peripheral nervous system. Immobilization using a long board and a rigid
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cervical collar must be immediately established. These patients should be

evacuated as soon as possible.
V. Reevaluation
Trauma patients require serial exams and reevaluation for changed or new signs
and symptoms. Continuous observation, monitoring, vital sign assessment, and
urinary output maintenance (50cc/hour in the adult patient) is also imperative. As
initial life-threatening injuries are managed, other equally life-threatening may
develop. Less severe injuries or underlying medical problems may become
evident. A high index of suspicion facilitates early diagnosis and management.
VI. Summary
The injured Ranger must be rapidly and thoroughly evaluated. You must develop
an outline of priorities for your patient. These priorities include the primary
survey, which looks at airway and c-spine control, breathing, circulation and
mental status evaluation.
Resuscitation should proceed simultaneously with the primary survey. It includes

the management of all life-threatening problems, the establishment of intravenous
access, the placement of EKG monitoring equipment, and the administration of
oxygen.
The secondary survey includes a total evaluation of the injured Ranger from head
to toe. During your evaluation you reassess the ABC’s and the interventions
provided during the primary survey. Ensure to document your finding and
interventions on a Trauma SF 600 or 75th CAX card.
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Orotracheal Intubation
Assure adequate ventilation and
oxygenation are in progress and that
suctioning equipment is immediately
available
APPROVED___________
DATE________________
Check cuff of the ET Tube
Connect the laryngoscope blade to the handle and check bulb for
brightness. Ensure bulb is secure in the blade
Hold Laryngoscope in the left hand
Open patient's mouth with fingers of your right and insert the laryngoscope into
the right side of the patient's mouth, displacing the tongue to the left
Items Needed:
Visually Identify the epiglottis and then the vocal cords · Laryngoscope
· Miller and Macintosh
blades
· ET tubes
Insert the ET tube into the trachea · Suction
· Oxygen source
· Bag-valve-mask
Inflate the cuff · Stethoscope
· Stylet
· Syringe, 10 cc
· Lubricant, water
Confirm proper ET tube placement
soluble
· SpO2 monitor
· Gloves
Secure the tube · Tape
. Tube Check
Document:
· ABCs
· Detailed Assessment
· Vital Signs
· SpO2, ETCO2
· Glasgow Coma Scale
· Tube check results
· Lung Sounds
· Absence of Epigastric
Sounds
· Skin Color
· Teeth to ET Tube Tip
Depth
· Communication with
Medical Control
1 Maintain strict c-spine precautions if potential for c-spine injury exists.
2 Avoid applying pressure on teeth or lips.
4 Never use a prying motion.
5 Advance the ET tube: ensure the tube cuff is 1 to 2.5 cm below the vocal cords (on an adult).
6 Anytime the patient goes 30 seconds without ventilation , stop the procedure and hyperventilate
for 30-60 seconds before procedure is re-attempted.
7 Intubation is only to be attempted twice . After two unsuccessful attempts are made
transition to the COMBITUBE.
Airway
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COMBITUBE SA
· ABCs
· Oxygen 100%
APPROVED___________
· Assist Ventilations, prn
DATE________________
Assemble & check equipment

Indications:
Place the patient's head in a neutral position
· Endotracheal intubation
cannot be performed
· Jaw-Lift Maneuver · Attempts at endotracheal
· Insert device to the depth indicated by the intubation have been
markings on the tube. The black rings should be unsuccessful
positioned between the patient's teeth. · Direct visualization of the
larynx is inhibited by profuse
Once the COMBITUBE SA is in place: bleeding
Inflate the pharyngeal cuff with 85 ml of air. 1
Inflate the distal cuff with 10 ml of air.

Contraindications:
· Less than 4 feet tall
Attach the Tube check to Tube 2 and · Patients with a gag reflex
confirm tube placement. · Patients who have ingested a
caustic substance
Begin ventilation through the longer, blue connector
(tube #1).
Lung Gastric Deflate both cuffs and withdraw the

sounds sounds
present No present No tube approximately 3 cm.
? ?
Yes Yes Reinflate both cuffs,
Ventilate through the shorter, reassess lung and
clear connector (tube #2). epigastric sounds 2
Gastric
sounds Add more air to
present Yes
? the distal cuff 2
No Document:
· Tube Markings at Teeth
Continue ventilations · SpO2
through tube #1. · Respiratory Status Before
and After Treatment
Confirm bilateral lung sounds · Lung & Gastric Sounds
& absence of gastric sounds. · Skin Color
· Indications for Use
· Absence of Gag Reflex
Assist Ventilations
· Patient's Age, Height
Reassess Airway Frequently
Transport ASAP
1 This seals the device in the posterior pharynx behind the hard palate. More air may be
added to the pharyngeal cuff if an inadequate seal is detected during ventilation.
2 At no time should the patient's airway or ventilatory status be compromised. If
placement is unsuccessful, remove the device and return to naso/oropharyngeal airway
and assist ventilations via bag-valve-mask.
3. When using a tube check with a Combitube you are confirming that the tube is in the
esophagus (tube check should not re-inflate)
NOTE: This protocol is ONLY to be used with the Combitube SA and does NOT apply
Airway
to the STANDARD Combitube.
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Surgical Cricothyroidotomy
Prepare RGR CRIC KIT
Select site
APPROVED___________
Cricothyroid membrane: DATE________________
soft aspect just inferior the larynx,
midline, anterior trachea.
Cleanse site with povidine

Indications:
Severe facial injuries with severe
bleeding, anaphylaxis, chemical
Stabilize larynx between thumb and index finger inhalation injury or when other
of non-dominant hand means of establishing an airway
are not adequate.
Palpate cricothyroid membrane Contraindications:
Patients who can be intubated or
Make a transverse skin incision over the airway secured with a combitube
cricothyroid membrane, and carefully incise through
the membrane
Insert a tracheal hook into the cricothyroid

membrane, hook the cricoid cartilage and apply
anterior displacement
Insert a 7-0 ET tube through the midline of the membrane

and direct the tube distally into the trachea
Inflate the cuff of the ET Tube with 10 cc of air

and ventilate the patient
Items needed:
Secure the ET tube to the patient to prevent · Scalpel SZ 10
dislodging · Tracheal Hook
· Povidine solution
· Gloves
Ventilate, as needed 100%Oxygen · Sterile 4x4s
· Bag-valve device
· 7-0mm ET tube
Confirm Proper tube placement
Auscultate breath sounds, monitor SpO2
and/or ETCO2, and chest rise
Airway
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Needle Decompression
· ABCs
· Oxygen 100%
· Transport ASAP APPROVED___________
DATE________________
Items Needed:
Select site: affected side, 2nd intercostal space, · 10-14g 2.5-3.0 needle with
mid-clavicular line catheter
· Povidine swab
Cleanse site with povidine
Remove the Luer-Lok from the distal end of the

catheter, insert the needle/cath over the rib intothe
intercostal space and puncture the parietal pleura.
Remove the needle from the catheter and

listen for a sudden escape of air.
Leave catheter in place converting the

tension to an open pneumothorax.
Ensure tension has been relieved. If Not

repeat procedure.
Auscultate breath sounds FREQUENTLY and Document:

monitor PT status. · Airway
· Respiratory Status
· SpO2
· Vital Signs
Monitor SpO2, cardiac rhythm and clinical · Cardiac Rhythm
status · Lung Sounds Before
and After Decompression
· Skin Color
· Chest Rise/Excursion
Signs & Symptoms to look for when assessing · Capillary Refill
Tension Pneumothorax · Response to Treatment
· Increases Respiratory Distress · Site Selection
· Unilateral chest movement
· Decreased breath sounds on the affected side
· Distended Neck Veins
· Tracheal Deviation
· Shock
Breathing
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Chest Tube Insertion

· ABCs
· Oxygen 100%
· Transport ASAP APPROVED___________
DATE________________
Items Needed:
Select site: affected side, 5nd intercostal space, 9" Peans
(nipple level) anterior to the midaxillary line 1-0 Armed Suture
Povidine Solution
# 10 Scalpel
Cleanse site with povidine # 36-38 Chest Tube
Heimlick Valve
Locally anesthetize the skin and rib periosteum 4x4's
Petrolatun Gauze
18 Gauge needle
Make a 2-3 cm horizontal incision at the predetermined
10 cc Syringe
site and bluntly dissect through the subcutaneous tissues
1% Lidocaine
just over the top of the 6th rib
Chux
Punture the parietal pleura with the tip of 2"Tape
the clamp and spread the tissues. Sterile Gloves
With the index finger of the nondominant hand trace the

clamp into the incision to avoid injury to other organs and
clear any adhesions or clots.
With the index finger of the non dominant hand remaining

in place, clamp the proximal end of the chest tube and and
insert into the chest cavity to the desired lenght. Document:
· Airway
· Respiratory Status
Look for "fogging" of the chest tube with · SpO2
expiration. · Vital Signs
· Cardiac Rhythm
· Lung Sounds Before
Connect the end of the chest tube to the heimlick and After Chest Tube
valve. Insertion
· Skin Color
· Chest Rise/Excursion
Suture the tube in place · Capillary Refill
· Response to Treatment
· Site Selection
Apply dressings: wrap tube with pertolatun gauze

then cut 4 x 4's. Tape the tube to the chest
Monitor SpO2, cardiac rhythm and clinical

status
Breathing
21
External Jugular Cannulation

Technique
APPROVED___________
Place patient supine 1 DATE________________
c-spine
precautions Immobilize c-spine
indicated Yes
? Items needed:
No · IV needle/catheter
· IV fluid
Turn patients head slightly to the opposite side · IV tubing/saline lock
· Povidine
· Tegaderm dressing
Cleanse site with povidine · Saline Flush
Align needle/catheter and syringe with saline
flush attached in the direction of the vein with the Document:
tip of the needle aimed toward the ipsilateral 2 · Procedure
nipple · ABCs
· Detailed Assessment
Apply light pressure on the inferior aspect of the · Vital Signs, SpO2
external jugular to create a tourniquet affect 3 · Cardiac Rhythm
· Number of Attempts
Insert needle and enter the vein and · Amount of IV Fluid
aspirate 4 Infused
Note blood return and advance catheter
Withdraw needle/catheter and attach IV

tubing and (or) saline lock. 4
Cover site with tegaderm

dressing
1 Modified Trendelenburg position is an ideal position. This position is not mandatory

yet will help distend the external jugular vein and decrease the likelihood of introducing air
into the vein.
2 Ipsilateral: "on the same side". If you are cannulating the right external jugular vein the
needle should be aimed toward the right nipple.
3 Light pressure below the vein will help distend the vein.
4 Be certain air is not allowed to enter the vein.
Circulation
22
Sternal Intraosseous Infusion

FAST-1
Site Selection
APPROVED___________
DATE________________
Adult Manubrium: Midline on the maubrium, 1.5
cm below the sternal notch.
Indications:
Prepare Site · Inability to attain vascular
access through A/C or external
Local Anesthetic if jugular vein when life saving
conscience fluids and (or) medications are
needed.
Prep site with povidine swab
Use index finger of non-dominant hand to align

the target patch with the patients sternal notch.
Items Needed:
With patch securely attached to PT's skin, the · FAST-1 complete
bone probe cluster is placed in the target zone,
perpendicular to the skin
FAST-1 Insertion
With the introducer in hand, apply steady even

pressure until infusion tube has penetrated the
manubrium
Attach the infusion tube to the right angle female

adapter and secure site with protector dome 2
Attach syringe to the IV insertion site and aspirate bone marrow.
Flush the needle

Aspirates with 5 cc saline flush Flushes Attempt to administer fluid
freely No easily and or medication
No
? ?
Yes Yes
Attach IV tubing/saline
lock
Administer IV fluids, medications as needed
Secure inducer removal device to IV line or patient
Circulation
23
Anaphylactic Shock Management

· ABCs
· Oxygen 100% APPROVED___________
· Transport ASAP 1 DATE________________
Resp
· Oxygen 100%
rate <10 or
>30 Yes · Assist with BVM, prn Signs & Symptoms
? associated with Anaphylaxis:
No S.O.B., wheeze, hoarseness, hives, itching,
Start IV chest tightness, nausea, abdominal cramps,
Normal saline generalized or local edema.
Monitor Cardiac Rhythm, SpO2
Breath Bilateral wheezes, or

sounds diminished or absent
?
Oxygen 100%
Normal
· Epinephrine 1:1,000
0.3 cc SQ or IM 2 3
· Monitor closely
Itching
flushing or Yes
Benadryl 50 mg IM
hives
?
No
· Monitor Closely
· Transport
1 Bee sting: gently remove stinger if still present.

2 Two (2) dilution’s of epinephrine are available: 1:1,000 is appropriate for SQ, IM, or SL
injections, 1:10,000 is for IV or ET use ONLY . Be sure to give the appropriate dilution.
3 Contact Medical Control if symptoms/signs persist.
Anaphylactic Shock Management
24
Burn Management
Scene
Secure the scene 1
secure No
? APPROVED___________
Yes
DATE________________
Stop the
burn process 2
ABCs Types of Burns:

· Thermal
· Airway 3
Remove from environment and
· Breathing extinguish fire
· Circulation 4 · Chemical
Transport ASAP Brush off and/or dilute chemical
Detailed Assessment without exposing rescuer.
Consider need for wearing your
protective mask.
· Electrical
Resp Oxygen 100% Intubate/COMBITUBE Make sure victim is de-energized
distress Assist Ventilations as needed 5
? Yes and suspect internal injuries
No
Evaluate degree of burn
and % body surface area involved 6
7
Critical Transport to the most Start Two IVs
burn Yes appropriate facility Normal Saline 8
?
No Administer IV fluid per
IV NS TKO Parkland Formula
Parkland Formula:
Dress burns IAW SOP · The IV fluid required for the first 24
hours = 4 ml/kg of LR x % area burned.
· Give half of the total fluid within the first
Treat associated injuries 8 hours of the burn. Give the second
half over the next 16 hours.
Consider pain control 9
· Notify receiving facility ASAP Document:

· Prevent hypothermia · Degree of Burn
· Monitor: · % of Body Burned
LOC, Vital Signs, Cardiac Rhythm, · Respiratory Status
SpO2, Respiratory Status · Singed Nares?
· SpO2
1 ensure scene safety . · Type of Burn
2 Remove clothes, flood with water ONLY if flames or smoldering is present.
3 Consider Carbon Monoxide poisoning if victim was within a confined space. If potential for
· Medical History
CO poisoning exists administer Oxygen 100%. · Confined Space yes
4 If shock is present consider underlying causes. or no
5 Consider Surgical cricothyrotomy if unable to intubate due to edema.
6 Note: the patient's palm represents 1% of their BSA. Use this as a reference.
7 Critical burn = · any degree 25% BSA · 3rd degree > 10% · respiratory injury · involvement of
face, hands, feet, or genitalia · circumferential burns · associated injuries · electrical or deep
chemical burns · underlying medical history · age < 10 or > 50 years.
8 Start IVs within unburned areas if possible. Burned areas may be used if needed. Burn Management
9 Morphine 5-10 mg IV (adult)
25
Head Injury Management

· ABCs
· C-spine immobilization
· Oxygen 100% APPROVED___________
· Assist ventilations, prn DATE________________
· Transport ASAP
Calculate
Glasgow Coma Scale
Glasgow Coma Scale

Glasgow See Intubation/COMBITUBE Eye Spontaneous 4
Coma Scale Protocol Opening To Voice 3
? <8
To Pain 2
None 1
<8 Monitor ETCO2 if
Best Oriented 5
PIC is available Verbal Confused 4
Consider Intubation/
Response Inappropriate words 3
COMBITUBE Incomprehensible words 2
None 1
Best Obeys Commands 6
maintain B/P above Motor Localizes Pain 5
Response Withdraws (Pain) 4
100mmHg Flexion 3
Extension 2
Fluid None 1
BP Challenge
? < 100 500cc N/S
mmHG
> 100
mmHG
IV N/S TKO
Document:
Active
Scalp/Face · ABCs
Control Bleeding
Bleed Yes · Detailed Assessment
? · Glasgow Coma Scale
No · Revised Trauma Score
· SpO2, ETCO2, V/S
Monitor: · Cardiac Rhythm
· Vital Signs · Motor/Sensation
· Respiratory Status · Lung Sounds
· LOC · Respiratory Effort
· Cardiac Rhythm · Skin Color
· SpO2 · Mechanism of Injury
Calculate: · Onset & Duration of LOC
1 Oxygen 100% per NRB mask or bag-valve-device as needed.

2 Aggressive airway management may be needed If the patient's ventilations are not effective. Secure the
patient's airway and assist ventilations PRN.
3 Do not let B/P drop below 100mmHg during transport
4 Every head-injured patient who has had a period of unconsciousness must be evaluated at a hospital.
5 End-Tidal CO2 should be maintained between 25-35 mmHg.
6 Hyperventilation is not indicated unless PT shows signs of herniation syndrome
7 Isolated head injuries do not cause shock. If shock is present look for another cause.
8 Isotonic solutions are the only authorized fluids for head injury patients Head Injury Management
26
Spinal Cord Injury Management
· ABCs
· C-Spine stabilization APPROVED___________
· Oxygen DATE________________
· Transport ASAP
Airway See Intubation

patent No protocol
?
Yes Significant findings:
· Significant injury above clavicles
Full spine immobilization · Loss of consciousness
· Paralysis, weakness, numbness,
tingling within extremities
Secondary survey 1
· Point tenderness over spine
Transport
Notify receiving
Paralysis
? Yes hospital ASAP
No
IV N/S TKO
· Supportive Care
· Keep Patient Warm Document:
· Monitor Respiratory Status · Airway
· Vital Signs, SpO2
· Evidence of Paralysis or
Paresthesia
· Loss of Consciousness
· Mechanism of Injury
· Presence or Lack of
Tenderness Over Spine
· Treatment
1 Secondary Survey to include complete neurological check.

Spinal Cord Injury Management
27
Hypothermia Management
· Remove wet clothing APPROVED___________
· Prevent heat loss/wind chill DATE________________
· Maintain horizontal position
· Avoid rough movement
· Monitor core temperature
· Monitor cardiac rhythm
· Airway
· Breathing · Start CPR
· Circulation · Defibrillate VF/VT up to 3 shocks
200j, 300j, 360j
· Intubate
· Establish IV
Pulse &
breathing · Infuse warm normal saline using the
present
No thermal Angel
?
· Place patient in the Ranger Environmental
Yes Protection System (REPS)
34-36ºc Mild Hypothermia

Core · Active external rewarming with
Temp REPS and Warm IV's 1
Core
?
Temp
?
30-34ºc Moderate Hypothermia
· Active external rewarming with
REPS and warm IV's 1
> 30º c < 30º c
<30ºc Severe Hypothermia · Continue CPR · Continue CPR

Active external rewarming with · Withhold IV meds · Give IV meds prn 2
REPS and warm IV's 1 · Limit shocks for · Repeat defibrillation
VF/VT to 3 max for VF/VT as temp
· Transport ASAP rises
Continue active external rewarming
until:
· Core temp >36ºc
· Return of spontaneous circulation
· Patient is turned over to hospital
Document:
· Signs & Symptoms
· Vital Signs, SpO2
· Cardiac Rhythm
· Notify receiving hospital ASAP · Core Temp
· Monitor Cardiac Rhythm, · Mechanism of Injury
Core Temp, VS, SpO2 · Treatment
· Support Respiratory Effort · Response to Treatment
· Transport ASAP
1 Ranger Environmental Protection System

2 Give IV medications at longer than standard intervals.
3 Cardiac irritability begins to fall when temp drops below 33c (91.4F). Hypothermia Management
Ventricular fibrillation becomes increasingly common as temp drops
below 28c (82.4F).
28
PHARMACOLOGY
QUICK REFERENCE
ACETAMINOPHEN (TYLENOL) KETOROLAC (TORADOL)
o 325-650 mg po q4-6h prn o 60 mg IM
ALBUTEROL (PROVENTIL) o 15-30 mg slow IV push
o 2 puffs q4-6h prn LIDOCAINE 1% (XYLOCAINE)
BACITRACIN (Topical) o For local anesthesia, max 3 mg/kg/dose
o AAA bid-tid LOPERAMIDE (IMODIUM)
BENZONATATE (TESSALON PERLES) o 4 mg po initial dose, then 2 mg po after each

loose stool, max 16 mg/day
o 100 mg po tid
LORATADINE (CLARITIN)
CEFOXITIN (MEFOXIN)
o 10 mg po qd
o 2 g IV q6-8h
DEXTROSE 50% MECLIZINE (ANTIVERT)
o 10-20cc slow IV push o 25-50 mg po 1 hour before traveling
DIAZEPAM (VALIUM) MORPHINE
o 5-10 mg slow IV push o 5 mg slow IV push, titrate to effect
DIPHENHYDRAMINE (BENADRYL) NALOXONE
o 25 mg IM/IV o 2 mg IV push, repeat at 2-3 min intervals up to

10 mg
o 50 mg PO q4-6h
PSEUDOEPHEDRINE (SUDAFED)
EPINEPHRINE (1:1000)
o 60 mg po q4-6h
o 0.2-0.5 mg SC/IM
PROMETHAZINE (PHENERGAN)
HETASTARCH (HESPAN)
o 25 mg po q4-6h
o 500-1000 ml IV
o 25 mg slow IV push
IBUPROFEN (MOTRIN)
SILVER SULFADIAZINE (SILVADENE)
o 800 mg po tid
o AAA qd-bid
29
Acetaminophen (Tylenol)
Functional Class: Analgesic (non-narcotic), antipyretic Dosage:
Chemical Class: Nonsalicylate, para-aminophenol derivative • PO or PR
Action: • Adult and child > 12 yo:
• May block pain impulses peripherally that occur in o 325-650mg q4-6h prn (max 4 g/day)
response to inhibition of prostaglandin synthesis
• Child < 12 yo:
• does not possess antiinflammatory properties
o Dose per weight, 10-15mg/kg/q4-6h
• antipyretic action results from inhibition of
prostaglandins in the CNS (hypothalamic heat-regulating Education:
center
• Do not exceed recommended dose, acute poisoning with
Indications: liver damage may result
• Analgesic: mild-moderate pain (non-rheumatic), • Acute toxicity includes symptoms of nausea, vomiting,
headache and abdominal pain
• Antipyretic: fever (acute and prophylaxis [i.e., Overdose:

vaccinations])
• Drug level, gastric lavage, activated charcoal, administer
Contraindications: oral acetylcysteine (Mucomyst)
• Hypersensitivity
Precautions:
• Pregnancy Category B
• Anemia, hepatic disease, renal disease, chronic

alcoholism, elderly
Adverse Reactions (Side Effects):
• Relatively non-toxic in therapeutic doses
• SKIN: Occasional rash or urticaria
30
Albuterol (Proventil, Ventolin)

Functional Class: Adrenergic β2-agonist Dosage:
Action: • PO or oral inhalation (MDI or NEB)
• Causes bronchodilation by action on β2 (pulmonary) • Adult:

receptors by increasing levels of cAMP, which:
Prevention of exercise induced asthma:
o relaxes smooth muscle
o INH 2 puffs 15 min before exercise
o produces bronchodilation
Bronchospasm:
o produces CNS and cardiac stimulation,
o MDI: 2 puffs q4-6 h
o causes diuresis and gastric secretion
o NEB: 2.5mg (3ml 0.083% soln) qid
Indications:
o PO: 2-4mg qid
• Prevention of exercise induced asthma
• Chilc (age 6-12):
• Prevention and treatment of bronchospasm
Prevention of exercise induced asthma:
Contraindications:
o INH 2 puffs 15 min before exercise
• Hypersensitivity, tachydysrhythmias, severe cardiac
disease Bronchospasm:
Precautions: o MDI: 1-2 puffs q4-6 h
• Pregnancy Category C o NEB: 2.5mg tid/qid
• Cardiac disorders, hyperthyroidism, diabetes mellitus, o PO: 2mg qid (max 12mg/day)
hypertension, prostatic hypertrophy, narrow-angle
glaucoma, seizures • Child (age 2-6):
Adverse Reactions (Side Effects): o Dose per weight, PO: 0.1-0.2 mg/kg/tid
(max 4mg/day)
• CNS: anxiety, dizziness, flushing, hallucinations,
headache, insomnia, irritability, restlessness, stimulation, Education:
tremors
• Demonstrate proper technique for MDI and NEB use
• CV: angina, dysrhythmias, hypertension, hypotension,
• Avoid smoking and caffeine products
palpitations, tachycardia
Overdose:
• EENT: dry nose, irritation of nose and throat
• Administer a β1-adrenergic blocker
• GI: heartburn, nausea, vomiting
• METAB: hypokalemia
• MS: inhibition of uterine contractions, muscle cramps
• RESP: cough
31
Bacitracin (Topical)
Functional Class: Antibiotic (topical) Dosage:
Action: • Topically:
• Interferes with bacterial protein synthesis o Apply to affected areas bid-tid (do not use > 1
week)
Indications:
Education:
• Prevention and treatment of skin infections
• Before each application, cleanse areas with soap and
Contraindications: water; dry well
Precautions:
• Pregnancy Category C
• For external use only
• SKIN: Rash, urticaria, scaling, redness
32
Benzonatate (Tessalon Perles)

Functional Class: Non-narcotic antitussive Dosage:
Action: • PO
• Acts peripherally by anesthetizing the stretch receptors o 100 mg po tid

located in the respiratory passages, lungs, and pleura by
dampening their activity and thereby reducing the cough Education:
reflex at its source.
• Temporary local anesthesia of the oral mucosa can
Indications: predispose to choking.
• Non-productive cough
Contraindications:
Precautions:
• Pregnancy category C
• CNS: Sedation, headache, dizziness, confusion, visual

hallucinations
• GI: Constipation, nausea, GI upset
• SKIN: Pruritis, skin eruptions
33
Cefoxitin (Mefoxin)
Functional Class: Antibiotic Dosage:
Chemical Class: Cephalosporin (2nd Generation) • Adult:
Action: o 2g slow IV push or mixed in 500ml bag of N/S and

infused. Repeat q6-8
• Inhibits bacterial cell wall synthesis, rendering cell wall
osmotically unstable, leading to cell death by binding to
cell wall membrane
Indications:
• INFECTIONS: lower respiratory tract, GU system,
peritonitis, septicemia, skin, bone, joint
• ORGANISMS:
o Gram-negative: H. influenzae, E. coli,
Proteus, Klebsiella, B. fragilis, N. gonorrhoeae,
E. corrodens
o Gram-positive: S. pneumoniae, S. pyogenes, S.
aureus
o Anaerobes: including Clostridium
Contraindications:
• Hypersensitivity, note cross-reactivity with penicillin

allergies
Precautions:
• Pregnancy category B
• Use with caution in patients with penicillin allergy (5-

10% chance of cross-reactivity)
• Dosage modifications are generally only required with

severe renal impairment
• CNS: dizziness, headache, fatigue, fever, chills confusion
• GI: nausea, vomiting, diarrhea, abdominal pain and

cramps, flatulence, colitis, jaundice, increased LFTs
• GU: vaginitis, candidiasis, nephrotoxicity, renal failure
• SKIN: rash, urticaria, Stevens-Johnson syndrome
• HEME: dysfunction of any cell line
34
Dextrose 50% (D-glucose)

Functional Class: Caloric Dosage:
Action: • IV
• Needed for adequate utilization of amino acids; o Administer up to 10 ml/min as required

decreases protein, nitrogen loss; prevents ketosis
Indications:
• Hypoglycemia; Increases intake of calories; increases

fluids in patients unable to take adequate fluids, calories
orally
Contraindications:
• Hyperglycemia, delirium tremens, hemorrhage

(spinal/cranial), CHF
Precautions:
• Renal, liver, cardiac disease, diabetes mellitus
• Ensure IV Line is Patent
• CNS: Confusion, loss of consciousness, dizziness
• CV: Hypertension, CHF, pulmonary edema
• GU: Glycosuria, osmotic diuresis
• ENDO: Hyperglycemia, rebound hypoglycemia
• SKIN: Chills, flushing, warm feeling, rash, urticaria
35
Diazepam (Valium)
Functional Class: Antianxiety Dosage:
Chemical Class: Benzodiazapine • PO, PR, or IV
Action: • Adult:
• Potentiates the actions of GABA, especially in the limbic o PO 2-10mg tid-qid, taper prn
system, reticular formation; enhances presympathetic
inhibition, inhibits spinal polysynaptic afferent paths Status epilepticus:
Indications: o IV bolus 5-20mg infused at a rate of 2 mg/min;

may repeat every 5-10 min (max 60mg); repeat
• Anxiety in 30 min if seizures reappear
• Sedation Epilepsy:
• Acute alcohol withdrawal o PR 0.2 mg/kg prn
• Anticonvulsant • Geriatric:
• Skeletal muscle relaxant o 2-2.5mg qd-qid, titrated prn
• Pre-surgery/procedure relaxation • Child:
Contraindications: o IV bolus 0.1-0.3 mg/kg (over 3 min); may repeat

q15 min for 2 doses
• Hypersensitivity, psychosis, narrow-angle glaucoma, co-
administration with ketoconazole or itraconazole (P450 Tetanic muscle spasms:
enzyme inhibition)
o Infants >30 days to <5years IM/IV 1-2mg to 5-
Precautions: 10mg q3-4h prn
• Pregnancy category D Anxiety/convulsive disorders:
• Controlled Substance Schedule IV o > 6 months PO 1-2.5mg tid-qid (0.04-0.2 mg/kg

tid-qid prn)
• Elderly, children, debilitated, hepatic disease, renal
disease Adjunct for epilepsy:
o PR: age 2-5 yo 0.5 mg/kg prn; age 6-11 yo 0.3

mg/kg prn; age > 12 yo 0.2 mg/kg prn
• CNS: drowsiness, dizziness, fatigue, confusion,
Education:
depression, blurred vision, headache, stimulation,
insomnia, tremors, nervousness • Avoid driving and activities that require alertness;
drowsiness may occur
• CV: bradycardia, tachycardia, hypertension, hypotension
• Avoid alcohol and other psychotropic medications
• GI: constipation, diarrhea, dry mouth, nausea, vomiting
Overdose:
• SKIN: Rash, dermatitis, itching
• Gastric lavage, monitor VS, supportive care, flumazenil
36
Diphenhydramine (Benadryl)
Functional Class: Antihistamine Dosage:
Chemical Class: H1-receptor antagonist,ethanolamine derivative • PO, IM, or IV
Action: • Adult:
• Acts on blood vessels, GI, respiratory system by o 25-50mg q4-6h (max 400mg/day)
competing with histamine for H1-receptor site;
decreases allergic response by blocking histamine o for sleep, 50mg PO qhs
Indications: • Child:
• Adjunctive therapy for anaphylactic reactions o Dose by weight, 5 mg/kg/day or 150mg per
meter square per day divided q6-8 h (max
• Perenial and seasonal allergic rhinitis, vasomotor 300mg/day)
rhinitis, allergic conjunctivitis; pruritic conditions, mild
urticaria and angioedema Education:
• Motion sickness; sleep aid; cough suppressant • Avoid driving and activities that require alertness;
drowsiness may occur
Contraindications:
• Avoid alcohol and other CNS depressants
• Hypersensitivity, acute asthma attack, lower respiratory
tract disease Overdose:
Precautions: • Ipecac syrup, gastric lavage, diazepam, vasopressors,

barbiturates (short-acting)
• Pregnancy category C; contraindicated while nursing
• Increased intraocular pressure, renal disease, cardiac

disease, hypertension, bronchial asthma, seizure
disorder, hyperthyroidism, prostatic hypertrophy,
bladder neck obstruction, stenosed peptic ulcers
• CNS: anxiety, confusion, dizziness, drowsiness,

euphoria, poor coordination, fatigue, paresthesia,
neuritis
• CV: palpitations, tachycardia
• RESP: increased thick secretions, wheezing, chest

tightness
• EENT: blurred vision, dilated pupils, dry nose, dry

mouth and throat, nasal stuffiness, tinnitis
• GI: nausea, anorexia, diarrhea
• GU: dysuria, frequency, impotence, retention
• HEME: bone marrow suppression, thrombocytopenia,

agranulocytosis, hemolytic anemia
37
Epinephrine
Category: Bronchodilator-adrenergic Dosage:
Functional Class: Catecholamine • Topical, IV, IM, SC, inhalation

Action: • 1mg = 1ml of 1:1000 or 10ml of 1:10,000
• β1- and β2-agonist causing increased levels of cyclic • Adult:
AMP producing bronchodilation, cardiac and CNS
stimulation; large doses cause vasoconstriction; small Anaphylaxis/Allergic Reactions:
doses can cause vasodilation via β2-vascular receptors
o SC/IM (1:1000) 0.2-0.5mg, repeat q10-15 min
Indications: up to 4 hours (single dose max 1mg)
• Anaphylaxis, allergic reactions, acute asthma attacks, Acute Asthma Attack/Bronchodilator:
bronchospasm
o SC/IM (1:1000) 0.2-0.5mg, repeat q10-15 min
• Cardiac arrest, adjunct in anesthesia, vasopressor, up to 4 hours
hemostasis
o IV (1:10,000) 0.1-0.25mg (single dose max
• Nasal congestion, open-angle glaucoma 1mg)
Contraindications:
o NEB instill 8-15 drops into nebulizer reservoir,
• Hypersensitivity, narrow-angle glaucoma administer 1-3 inhalations q4-6h
Precautions: o MDI 1-2 puffs at 1st sign of bronchospasm
• Pregnancy category C; excreted in breast milk, use Cardiac arrest:

caution in nursing mothers
o IV/intracardiac 0.1-1mg (1-10 ml of 1:10,000
• local anesthesia of appendages (nose, toes, fingers, dilution) q3-5 min prn
earlobes, and penis)
o IV intermediate dose 2-5mg q3-5 min;
• Cardiac disorders, hypertension, diabetes, psychosis, escalating dose 1-3-5mg 3 min apart; high dose
hyperthyroidism, prostatic hypertrophy, parkinsonism 0.1 mg/kg q3-5 min
Adverse Reactions (Side Effects): o Intratracheal 1mg q3-5 min (higher doses, eg.
0.1 mg/kg, should be considered only after 1mg
• CNS: anxiety, insomnia, dizziness, confusion, doses have failed)
hallucinations, headache, hemiplegia, subarachnoid
hemorrhage, tremor, weakness, restlessness Hypotension (vasopressor):
• CV: anginal pain, dysrhythmias, increased T wave, o IV Infusion 1-4 mcg/min

hypertension, palpitations, tachycardia
Education:
• GI: nausea, vomiting, anorexia
• For patients with history of hypersensitivity reactions
• GU: urinary retention (hymenoptera, etc) provide Anakit and instruct on use
• RESP: respiratory difficulty, dyspnea Overdose:

• SKIN: pallor, urticaria, wheal • Administer an α-blocker and a β-blocker
38
Hetastarch (Hespan)
Functional Class: Plasma volume expander Dosage:
Chemical Class: Synthetic polymer • IV
Action: o 500-1000 ml, total dose not to exceed 1500

ml/day
• Similar to human albumin, which expands plasma
volume by colloidal osmotic pressure Education:
Indications: • Expands blood volume 1-2 x amount infused.
• Plasma volume expander
Contraindications:
• Hypersensitivity, severe bleeding disorders, renal

failure, severe CHF
Precautions:
• Liver disease, pulmonary edema
• CNS: Headache
• RESP: Wheezing, dyspnea, bronchospasm, pulmonary

edema
• GI: Nausea, anorexia
• EENT: Periorbital edema
• HEME: Decreased hematocrit, platelet function,

increased bleeding and coagulation times, increased sed
rate
• SKIN: Rash, urticaria, pruritis, angioedema, chills,

fever, flushing, peripheral edema
• SYST: Anaphylaxis
39
Ibuprofen (Motrin, Advil)

Functional Class: Nonsteroidal Antiinflammatory Drug (NSAID) Dosage:
Chemical Class: Propionic acid derivative • PO
Action: • Adult:
• Inhibits prostaglandin synthesis by decreasing enzyme o 200-800mg tid-qid (max 3.2g/day)

needed for biosynthesis
• Children:
Indications:
o Dose per weight, 20-40mg/kg/day in divided
• Analgesic: mild-moderate pain (musculoskeletal pain, doses q6-8h
dental procedures, dysmenorrhea)
Education:
• Antiinflammatory: acute inflammation, rheumatoid
arthritis, osteoarthritis, gout • Take with food or milk to decrease GI symptoms; avoid
alcohol and salicylates, bleeding may occur; avoid
• Antipyretic: fevers sunlight
Contraindications:
• Hypersensitivity, asthma, severe renal disease, severe

hepatic disease; aspirin or NSAID-induced nasal polyps,
bronchospasm or angioedema
Precautions:
• Pregnancy Category C
• Bleeding disorders; avoid use with anticoagulants

(warfarin) due to increased bleeding times and potential
for GI bleeding and decreased platelet aggregation.
• CNS: headache, dizziness, drowsiness, fatigue, tremors,

confusion, insomnia, anxiety, depression
• GI: nausea, vomiting, heartburn, dyspepsia, pain,

diarrhea, constipation, flatulence, cramps, peptic ulcer,
bleeding
• CV: tachycardia, peripheral edema, palpitations,

dysrhythmias
• EENT: tinnitis, hearing loss, blurred vision
• GU: nephrotoxicity
• HEME: increased bleeding time
• SKIN: purpura, rash, pruritis, sweating
40
Ketorolac (Toradol)
Functional Class: Non-steroidal antiinflammatory drug (NSAID) Dosage:
Chemical Class: Pyrrolo-pyrrole May be used as a “one time” dose or as “prn” treatment
Action: • PO, IM, or IV
• Inhibits prostaglandin synthesis by decreasing an enzyme • Single-Dose Treatment:

needed for biosynthesis
o IM/IV (<65 yo): 60mg, one dose
Indications:
o IM/IV (>65 yo, with renal impairment or less
• Moderately severe acute pain requiring analgesia at an than 50kg): 30mg, one dose
opioid level; antiinflammatory; antipyretic
• Multi-Dose Treatment:
Contraindications:
o IM/IV (<65 yo): 30mg q6h (max 120mg/day)
• Hypersensitivity, asthma, severe renal disease, severe
hepatic disease, peptic ulcer disease, gastrointestinal o IM/IV (>65 yo, with renal impairment or less
bleeding or perforation, cerebrovascular bleeding, than 50kg): 15mg q6h (max 60mg/day)
hemorrhagic diathesis, incomplete hemostasis, high risk
of bleeding. • Transition from IM/IV to PO:
• Patients currently on aspirin or other NSAIDs o <65 yo: 2 tabs (20mg) first dose, followed by 1
tab (10mg) q4-6h (max 40mg/day)
Precautions:
o >65 yo, with renal impairment or less than 50kg:
• Pregnancy Category C 1 tab (15mg) first dose, followed by 1 tab
(10mg) q4-6h (max 40mg/day)
• Bleeding disorders, GI disorders, cardiac disorders
Education:
• When administering as IM bolus, give slowly and deeply
into muscle tissue; analgesic effects begins at about 30 • Take with food or milk to decrease GI symptoms; avoid
min and peaks at 1-2 hours, with a duration of 2-6 hours. alcohol and salicylates, bleeding may occur
• CNS: dizziness, drowsiness, tremors
• CV: hypertension, flushing, syncope, pallor, edema,

vasodilation
• GI: nausea, dyspepsia, pain, diarrhea, constipation,

flatulence, peptic ulcer, bleeding
• EENT: tinnitus, hearing loss, blurred vision
• GU: nephrotoxicity
• HEME: prolonged bleeding
• SKIN: purpura, rash, pruritis, sweating
41
Lidocaine (Xylocaine)
Functional Class: Local anesthetic Dosage:
Chemical Class: Aminoacyl amide • Injection
Action: • Adult and Child:
• Competes with calcium for sites in nerve membrane that o Varies with procedure, degree of anesthesia
control sodium transport across cell membrane; decreases desired, vascularity of tissue, duration of
rise of depolarization phase of action potential anesthesia required, physical condition of patient
Indications: o Max 3 mg/kg/dose without epi, 5mg/kg/dose

with epi; do not repeat within 2 hours
• Local anesthesia, peripheral nerve block
o Onset < 2 min, duration 30-60 min
Contraindications:
Overdose:
• Hypersensitivity, severe liver disease
• Airway, Oxygen, vasopressor, IVF, anticonvulsant
Precautions:
• Elderly, severe drug allergies
• CNS: anxiety, disorientation, seizures, shivering, tremors,

loss of consciousness
• CV: bradycardia, cardiac arrest, dysrhythmias,

myocardial depression, bradycardia, hypotension,
hypertension
• GI: nausea, vomiting
• EENT: blurred vision, tinnitus, pupil constriction
• RESP: respiratory arrest, status asthmaticus, anaphylaxis
• SKIN: allergic reactions, burning, edema, irritation, rash,

tissue necrosis, urticaria
42
Loperamide (Imodium)
Functinal Class: Antidiarrheal Dosage:
Chemical Class: Piperidine derivative • PO
Action: • Adult:
• Direct action on intestinal muscles to decrease GI o 4mg, then 2mg after each loose stool (max
peristalsis; reduces volume, increases bulk, electrolytes 16mg/day); maintenance for chronic diarrhea
not lost usually 4-8mg daily
Indications: • Child:
• Diarrhea, acute (Traveler’s and non-specific), chronic o <2 years not recommended
(inflammatory bowel disease), and Traveler’s
o On day 1: 13-20 kg, 1 mg tid; 20-30 kg, 2 mg
• Reduction of volume from ileostomy bid; > 30 kg, 2 mg tid
Contraindications: o After day 1: 0.1 mg/kg after each loose stool
• Hypersensitivity, severe ulcerative colitis, acute diarrhea Education:

due to invasive organisms (enteroinvasive E. coli,
Salmonella, Shigella), or pseudomembranous colitis • Avoid driving and activities that require alertness if
drowsiness occurs
Precautions:
• Liver disease, dehydration, bacterial disease, children
• CNS: fatigue, fever, dizziness, drowsiness
• GI: abdominal pain, anorexia, constipation, dry mouth,

nausea, vomiting, toxic megacolon
• RESP: respiratory depression
• SKIN: rash
43
Loratadine (Claritin)
Functional Class: Antihistamine (2nd generation) Dosage:
Chemical Class: Selective histamine (H1)-receptor antagonist • PO
Action: • Adult: 10mg qd
• Binds to peripheral histamine receptors, providing Education:

antihistamine action without sedation
• Effective, but expensive nonsedating antihistamine;
Indications: reserve for patients unable to tolerate sedating
antihistamines like diphenhydramine
• Seasonal rhinitis
• Avoid driving and activities that require alertness if
• Idiopathic chronic urticaria drowsiness occurs
Contraindications:
• Hypersensitivity, acute asthma attacks, lower respiratory

tract disease
Precautions:
• Increased intraocular pressure, bronchial asthma
• CNS: insomnia, sedation, headache
• GI: dry mouth
44
Meclizine (Antivert)
Functional Class: Antiemetic, antihistamine, anticholinergic Dosage:
Chemical Class: H1-receptor antagonist, piperazine derivative • PO
Action: o Vertigo: 25 mg q6hrs
• Acts centrally by blocking chemoreceptor trigger zone, o Motion Sickness: 25-50 mg 1 hr before
which in turn acts on vomiting center traveling
Indications: Education:
• Vertigo, motion sickness • Avoid hazardous activities, activities requiring

alertness.
Contraindications:
• Avoid alcohol and other depressants.
• Hypersensitivity, shock, lactation
Precautions:
• Glaucoma, urinary retention, prostatic hypertrophy, CV

disease, hypertension, seizure disorder
• CNS: Drowsiness, fatigue, restlessness, headache,

insomnia
• CV: Hypotension
• GU: Retention
• GI: Nausea, anorexia
• EENT: Dry mouth, blurred vision
45
Morphine
Functional Class: Narcotic Analgesic Dosage:
Chemical Class: Opiate Administer in smallest effective dose, as infrequently as possible

and titrated to pain control.
Action:
Administer with antiemetic for nausea, vomiting.
• Depresses pain impulse transmission at the spinal cord
level by interacting with opioid receptors Compatible in same IV site with cephalosporins.
Indications: • PO, PR, SC, IM, IV
• Severe, acute pain • Adult:
• Moderate to severe chronic pain o PO: 10-30mg q4h prn
• Anesthesia adjunct for preoperative sedation o PR: 10-20mg q4h prn
Contraindications: o SC or IM: 10mg (range 5-20mg) q4h prn
• Hypersensitivity, addiction (narcotic), hemorrhage, o IV: 2.5-15mg diluted in 4-5 mL sterile water for
bronchial asthma, increased intracranial pressure injection, slowly injected over 4-5 min
Precautions: • Labor anesthesia:
• Pregnancy Category B o 10mg SC or IM
• Addictive personality, acute MI, severe heart disease, Overdose:

elderly, respiratory depression, hepatic or renal disease
• Naloxone (Narcan) 0.2-0.8 mg IV, O2, IV fluids,
• In patients with myocardial infarction, morphine vasopressors
decreases systemic vascular resistance which may lead to
severe hypotension. To minimize, administer minimum Education:
effective dose and elevate patient’s legs.
• Change position slowly, orthostatic hypotension may
• Rapid administration may induce respiratory depression, occur.
therefore monitor patient’s respiratory function.
• Patients will experience CNS effects of drowsiness and
Adverse Reactions (Side Effects): dizziness, therefore use caution with motor vehicle
operation or other hazardous tasks.
• CNS: Drowsiness, dizziness, confusion, headache,
sedation, euphoria • Avoid prolonged, sustained usage to decrease addiction
potential.
• CV: Palpitations, bradycardia, change in blood pressure
• Use with caution with alcohol, CNS depressants.
• EENT: Tinnitus, blurred vision, miosis, diplopia
• Withdrawal symptoms may occur: nausea, vomiting,
• GI: Nausea, vomiting, anorexia, constipation, cramps cramps, fever, faintness, anorexia.
• GU: Urinary retention
• SKIN: Rash, urticaria, bruising, flushing, diaphoresis,

pruritis
• RESP: Respiratory depression
46
Naloxone (Narcan)
Functional Class: Opioid antagonist Dosage:
Chemical Class: Thebaine derivative Duration of action of some narcotics may exceed that of naloxone;
repeat doses prn.
Action:
• SC, IM, IV
• Competes with narcotics at narcotic receptor sites
• Adult:
Indications:
o Narcotic overdose (known or suspected):
• Complete or partial reversal of narcotic depression,
including respiratory depression SC/IM/IV 0.4-2mg initially, repeat at 2-
3 min intervals up to 10mg, if no
• Diagnosis of suspected acute opioid overdose response after 10mg reevaluate
diagnosis
Precautions:
o Postoperative narcotic depression (partial
• Pregnancy category B reversal):
• Narcotic dependency, cardiovascular disease IV 0.1-0.2mg at 2-3 min intervals to

desired level of reversal; repeat doses
Adverse Reactions (Side Effects): may be required within 1-2h intervals
• CNS: Drowsiness, nervousness • Child:
• CV: Hypertension, tachycardia, ventricular dysrhythmia, o Narcotic overdose (known or suspected):
fibrillation
SC/IM/IV 0.01 mg/kg initially, give
• GI: nausea, vomiting subsequent doses of 0.01 mg/kg as
needed at 2-3 min intervals
• RESP: Hyperpnea (deeper and rapid breathing)
o Postoperative narcotic depression (partial
• SKIN: Sweating reversal):
• MISC: Reversal of anesthesia IV 0.005-0.01mg every 2-3 min to

desired degree of reversal
47
Pseudoephedrine (Sudafed)
Functional Class: Adrenergic Dosage:
Chemical Class: Substituted phenylethylamine • PO
Action: • Adult:
• Primary activity through α-effects on respiratory o 60 mg q4-6h

mucosal membranes reducing congestion hyperemia,
edema; minimal bronchodilation secondary to β-effects • Child:
Indications: o 6-12 yo: 30 mg/dose; 2-5 yo: 15 mg/dose
• Nasal decongestant, adjunct in otitis media;with Education:

antihistamines
• Do not use continuously, or more than recommended
Contraindications: dose.
• Hypersensitivity, narrow-angle glaucoma • Rebound congestion may occur.
Precautions: • Avoid taking at bedtime, stimulation may occur.
• Cardiac disorders, hyperthyroidism, diabetes mellitus,

prostatic hypertrophy, lactation, hypertension
• CNS: Tremors, anxiety, insomnia, headache, dizziness,

hallucinations, seizures
• CV: palpitations, tachycardia, hypertension, chest pain,

dysrhythmias
• EENT: Dry nose, irritation of nose and throat
• GI: Nausea, vomiting, anorexia, dry mouth
• GU: dysuria
48
Promethazine (Phenergan)
Functional Class: Antihistamine, H1-receptor antagonist Dosage:
Chemical Class: Phenothiazine derivative • PO, PR, IM, IV
Action: • Adult:
• Acts on blood vessels, GI, respiratory system by o Antihistimine:
competing with histamine for H1-receptor site; decreases
allergic response by blocking histamine PO/PR 12.5mg 3 tid and 25mg qhs
Description: IM/IV 25mg, repeated in 2 hours prn,
convert to PO as soon as possible
• Antihistamine, antiemetic, sedative, antitussive,
antivertigo agent o Antiemetic:
Indications:
PO/IM/IV/PR 12.5-25mg q4h prn
• Antihistamine: Allergy symptoms, rhinitis
• Antiemetic: Nausea, vomiting o Motion sickness:
• Antivertigo: active and prophylactic treatment of motion
sickness PO/PR 25mg 30-60mg prior to
departure, then q12h prn
• Sedative: Preoperative, postoperative, obstetric sedation
• Pain control: Adjunct to use with pain medications o Sedation:
Contraindications:
PO/IM/IV/PR 25-50mg qhs
• Hypersensitivity, acute asthma attack, lower respiratory
tract disease • Child:
Precautions:
• Pregnancy category C o Antihistamine:
• Bladder neck obstruction, prostatic hypertrophy,
PO/PR 0.1 mg/kg/dose q6h during the
predisposition to urinary retention
day and 0.5 mg/kg qhs prn
• Cardiovascular disease, glaucoma, liver disease,
hypertension, history of peptic ulcer, intestinal o Antiemetic:
obstruction, seizure disorder
Adverse Reactions (Side Effects): PO/IM/IV/PR 0.25-1 mg/kg q4-6h prn
• CNS: Dizziness, drowsiness, poor coordination, fatigue,
o Motion sickness:
anxiety, euphoria, confusion, paresthesia, neuritis
• CV: hypotension, palpitations, tachycardia PO/PR 0.5 mg/kg/dose 30-60 min prior
• EENT: Blurred vision, dilated pupils, dry nose, nasal to departure, then q12h as needed
stuffiness, tinnitus
o Sedation:
• GI: anorexia, cholestatic jaundice, constipation, diarrhea,
dry mouth, nausea, vomiting PO/IM/IV/PR 0.5-1 mg/kg/dose q6h
• GU: Retention, dysuria, frequency prn
• HEME: Agranulocytosis, hemolytic anemia,
thrombocytopenia Overdose:
• METAB: Hyperprolactinemia • Administer ipecac syrup or lavage, diazepam,
• RESP: Chest tightness, increased thick secretions, vasopressors, barbiturates
wheezing
Education
• SKIN: photosensitivity, rash, urticaria
• Avoid prolonged sunlight, may cause photosensitivity.
• Avoid driving, other hazardous activity if drowsy.
49
Versed
Category: Dosage:
• General anesthetic Administered intravenously, intramuscularly
Description: • Adult:
• Benzodiazepine sedative o Preoperative sedation:
Indications: IM 70-80 mcg/kg 30-60 minutes before

general anesthesia
• Preoperative sedation (IM)
o Conscious sedation:
• General anesthesia induction, sedation for diagnostic
endoscopic procedures, intubation (IV) IV using 1 mg/ml dilution, titrate slowly
to desired effect; give no more than
Contraindications: 2.5mg over at least 2 minutes; wait at
least 2 minutes to fully evaluate effect;
• Shock, coma, alcohol intoxication administer small doses to appropriate
level of sedation as needed
• Acute narrow-angle glaucoma
o Induction of general anesthesia:
Precautions:
IV 150-350 mcg/kg over 30 seconds,
• Pregnancy category D wait 2 minutes follow with 25% of initial
dose if needed; use lower doses for
• COPD, CHF, chronic renal failure, hepatic disease, elderly patients who are > 55 years age,
premedicated, debilitated, or severe
• Debilitated, myasthenia gravis, other muscular dystrophies systemic disease
and myotonias
• Child:
o Preoperative sedation:
• CNS: anxiety, confusion, euphoria, headache, insomnia,
paresthesia, retrograde amnesia, slurred speech, tremors, IM 80-200 mcg/kg
weakness
o General anesthesia:
• CV: bigeminy, hypotension, nodal rhythm, PVCs,
tachycardia IV 50-200 mcg/kg
• EENT: blocked ears, blurred vision, diplopia, loss of balance,

nystagmus
• GI: hiccups, increased salivation, nausea, vomiting
• RESP: apnea, bronchospasm, coughing, dyspnea,

laryngospasm, respiratory depression
• SKIN: pain, pruritis, rash, swelling at injection site, urticaria
50
TACTICAL COMBAT CASUALTY CARE

Trauma is the leading cause of death in the first four decades of life. Current
protocols in trauma care are based on the Advanced Trauma Life Support (ATLS) course,
which was initially conducted in 1978. Since that time, the ATLS course has been
accepted as the standard for the first hour of trauma management that is taught to both
civilian and military providers. ATLS is a great approach in the civilian setting;
however, it was never designed for combat application.
The combat environment includes many factors that affect medical care to include
temperature and weather extremes, severe visual limitations, delays in treatment and
evacuation, long evacuation distances, a lack of specialized providers and equipment near
the scene, and the lethal implications of an opposing force. Thus, a modified approach to
trauma management must be utilized while conducting combat operations.
Combat treatment protocols must be directed toward preventable combat death. COL
Ron Bellamy researched how people die in ground combat and developed a list of causes
of death that can be prevented on the battlefield.
How people die in combat Preventable causes of death
KIA: 31% penetrating head trauma 60% Bleeding to death from extremity wounds
KIA: 25% surgically uncorrectable torso trauma 33% Tension pneumothorax
KIA: 10% potentially correctable surgical trauma 6% Airway obstruction (maxillofacial trauma)
KIA: 9% exsanguination from extremity wounds
KIA: 7% mutilating blast trauma
KIA: 5% tension pneumothorax
KIA: 1% airway problems
DOW: 12% (mostly from infections and
complications of shock)
The tactical environment and causes of combat death dictate a different approach for
ensuring the best possible outcome for combat casualties while sustaining the primary
focus of completing the mission. CAPT Frank Butler and LTC John Hagmann proposed
such an approach in 1996. Their article, “Tactical Combat Casualty Care in Special
Operations”, emphasized three major objectives and outlined three phases of care.
Objectives: 3) Combat Casualty Evacuation

(CASEVAC) Care
1) Treat the patient
2) Prevent additional casualties
3) Complete the mission
Phases of Care:
1) Care Under Fire

2) Tactical Field Care
51
1) CARE UNDER FIRE: Care provided at the scene of injury while under effective
enemy fire. Care is limited to the equipment carried by the medical provider. The
major goals are to move the casualty to safety, prevent further injury to the casualty
and provider, stop life threatening external hemorrhage, and most importantly, gain
and maintain fire superiority (The best medicine on the battlefield!). The following
outlines this level of care.
Return fire as directed or required.

Casualty should also return fire if able.
Try to keep yourself from getting shot.
Try to keep the casualty from sustaining additional injuries.
Stop any life threatening external hemorrhage with a tourniquet.
Take the casualty with you when you leave.
2) TACTICAL FIELD CARE: Care rendered once the casualty is no longer under
effective enemy fire or when conducting a mission without hostile fire (ie, a soldier is
injured on an airborne insertion). Do not attempt CPR on the battlefield for victims
of blast or penetrating trauma who have no pulse, respirations, or other signs of life.
Airway.
Nasopharyngeal airway for unconscious casualty without obstruction.
Cricothyroidotomy for airway obstruction.
No C-Spine immobilization for penetrating trauma.
Breathing.
If respiratory distress following unilateral blunt or penetrating chest trauma,
presume tension pneumothorax and decompress.
Circulation.
Control any remaining bleeding with tourniquet, dressing or direct pressure.
Initiate 18-gauge saline lock or IV.
• Controlled hemorrhage without shock: NO FLUIDS
• Controlled hemorrhage with shock: Hespan 1000cc
• Uncontrolled hemorrhage with shock: Hypotensive Resuscitation (Use
mentation coupled with weak radial pulses to judge fluid
resuscitation)
Other.
Wounds: inspect and dress; check for additional wounds.
Fractures: splint and recheck pulse.
Analgesia: Morphine 5mg IV; repeat after 10 minutes if needed.
Antibiotics: Cefoxitin 2g IVP (over 3-5 min)
Environment: Undress casualty to extent needed; prevent hypothermia.
3) COMBAT CASUALTY EVACUATION (CASEVAC): The medical care provided

during the evacuation of the casualty. Continue or initiate care as per previous phase.
Pre-staged medical assets on CASEVAC should be utilized to provide the same or
higher level of care rendered during the mission.
Initiate or continue care as per previous phase.
52
Evaluate and refine care.

Airway: Provide combitube or endotracheal intubation as needed.
Breathing: Administer oxygen; provide chest tube if indicated.
Circulation: Remove tourniquets and use direct pressure if possible.
Other: Institute electronic monitoring
12
Security Security
Aid & Litter MINIMAL / EXPECTANT Aid & Litter
Team 2 (Blue Chemlights) Team 3
CAX CAX
Gear Gear
Medic Chaplain EMT

Medical
Equipment
Bundle
S4 Rep
9 Medical 3
IMRed Ch
ts )
Augmentation
ml D
(
ME eml
Team
he E
igh
n C AY
DI ights )
(G EL
AT
D
ree
E
Medical Officer Medics

Medical NCO EMT
Medical OIC
Security Security
Aid & Litter Aid & Litter
Team 1 CP CCP PL Team 4
PJLNO
6 S1/CAX Rec
TRIAGE RTO
Vehicle
Holding Area CHOKE POINT
Route of Incoming Vehicles
IR
Chemlights
Route of Outgoing Vehicles
53
TACTICAL MEDICAL EVALUATION CHECKLIST

EVENT RESPONSIBILITY GO NO-GO
PLANNING / PRE-DEPLOYMENT PHASE
Combat Health Support Planning
Medical Threat Assessment (SRP Status versus Threat)
Determine medical assets (Organic, Attached, Air, Ground,

Theater, JTF, Host Nation, ISB/FSB, etc…)
Gather higher HQ medical guidelines & requirements
Familiarization with adjacent unit medical operations
Submit medical RFIs
Request maps, imagery and medical intelligence
Understand the tactical commander’s plan & concept of the
operation
Conduct a casualty estimation based off of the commander’s
concept of the operation by phase, objective, or event
Determine key locations & designate a primary/alternate if
appropriate: Unit objectives, Plt/Co/Bn CCPs, HLZs,
AXPs, COB/EPW/NEO collection points, etc…
Determine the casualty flow from point of injury to tertiary
fixed MTF (Key locations, distances, link-ups, etc…)
Plan for air CASEVAC (Dedicated assets, assets on-call,
HLZs, request & launch methods, etc…)
Plan for ground CASEVAC (Dedicated assets, assets on-call,
routes, AXPs, request & launch methods, etc…)
Determine medical communications requirements (Requesting
and directing CASEVAC, casualty reporting, resupply
requests, and Medical call signs/frequencies on SOI)
Coordinate the Casualty Reporting / Regulating System
Synchronize medical events and systems into the unit’s tactical

synch matrix and execution checklist
Determine Class VIII resupply requirements, methods,
distribution, locations, packing lists, etc…(Synchronize with
the unit’s overall resupply system)
Determine Preventive Medicine requirements (Before, during
and after the deployment)
Determine area medical support requirements at staging bases
(Lab, X-ray, PM, etc…)
Schedule and coordinate CHS rehearsals with higher, adjacent,
and subordinate elements (CCP Ops, CASEVAC Ops,
vehicle and aircraft loading/unloading)
Determine Admin Med Coverage requirements and integrate
based on the tactical mission and SOPs
Conduct Pre-Combat Checks

Back-brief medical mission to higher medical authority,
commanders, and leaders
Draw / Perform Checks & Maintenance on Combat Equipment
Weapons Protective Masks
Night Vision Communications
Mission Specific
54

Pack / Re-Pack Trauma Assault Packs
Select appropriate aidbag or rucksack
Ensure packing of recommended DOS stockage
Attend COMMEX
Ensure proper COMSEC
Check/Confirm frequencies & call signs
Verify and maintain copy of Battle Roster / Manifest
Co Sr Medics should have a Co Battle Roster
Bn CCP should have a Bn or TF Battle Roster
Infil/Exfil Manifests as appropriate
Check combat elements (Squads/Platoons/Companies)
All Rangers - Bleeding Control Kits
Designated Rangers - RFR Aid Bags, SKEDCO Litters
All Medics - Med Supplies, Drugs, & Casualty Cards
Verify dissemination of medical plan to the lowest level
CASEVAC procedures
Medical Locations
Rehearse and conduct CASEVAC drills with combat elements
Pack/Re-Pack/Stage Medical Re-Supply

Battalion Medical ISU-90/Pallet
Company Deployment Chests
Reconfigure per mission specifics
Speedballs, Bundles, Pull-Offs configured as required
Draw / Perform checks on MEDSOV and Quad
PMCS Vehicle
Load required medical equipment
Litters (NATO, Sked, Isr) Vehicle OVM/Tools
O2 Straps & Tie-Downs
Suction and BVM Trauma Assault Packs
Re-Supply Bundles Mission Specifics
Gather Operational Required Items
Maps, Imagery, Overlays (Routes, CCPs, HLZs, AXPs
AAs, Fighting Positions, Objectives, Phase Lines)
Communications SOI and COMSEC
Conduct CHS Rehearsals
CHS Operations Order / Briefing (to all CHS participants)
Medical Threat / Intelligence
Medical Concept of the Operation & Casualty Flow
Key Locations
Requesting Procedures (CASEVAC, Re-Supply, etc…)
Medical Communications
Casualty Tracking
CCP Operations
CCP Assembly, Security & Movement Plan
Casualty Movement and Aid & Litter Team Plan
Marking, Vehicle Parking, Link-up Procedures
Casualty Tracking & Recording
Triage, Treatment & Management of Casualties
CASEVAC Drills
Care Under Fire Drills
Air CASEVAC Request & Loading
Ground CASEVAC Request & Loading
55

EXECUTION PHASE
Care Under Fire
Return Fire / Control Situation / Recover Casualty
Provide Immediate Life-Saving Measures
Bleeding Control
Communicate Situation
Tactical Field Care
Evacuate Casualty to CCP or Secure Location
Conduct Triage in a Multiple Casualty Situation
Conduct a Rapid Trauma Assessment
Treat Life-Threatening Injuries / Gain IV Access
Prep for Evacuation
Secure Bandages, Immobilize as required, Prep evac- related
equipment (litters, straps, etc…)
Request Evacuation & Re-Supply (as required)
Triage into a Casualty Collection Point
Perform Detailed Physical Examination
Definitive Management of ABCs
Request Further Evacuation & Re-Supply
Treat Minor Injuries (non-life threatening) as time permits
CCP Internal Evaluation/CASEVAC PREP
CCP Element Assembly & Link-Up (75% Assembled within 30
min of Airdrop)
CCP is established IAW the tactical timeline at the designated
location. If CCP is established at alternate location or any
other deviation in the plan, disseminate to units. Cover and
concealment is utilized to the fullest extent possible.
CCP Security is established and maintained throughout op.
All pax maintain security/situational awareness at all times.
CCP Pax conduct appropriate noise, light, trash discipline at
CCP sites for duration of op.
Communications with C2 elements and units are established.
Execution checklist calls are made if required.
Communication is established with company medics, 1SGs,
and evac vehicles.
If marking devices are utilized, they are employed IAW SOP or
the coordinated plan.
Triage point is identified, marked, and used IAW SOP
Casualties triaged into CCP by treatment category.
Casualties recorded as they enter the CCP and reported to the
TOC/CP/1SG/Head DACO as appropriate.
Casualties are treated to the maximum available medical care
standard as possible while in the CCP. Casualties
reassessed every 5 minutes or as the situation permits while
in the CCP. Casualties are protected from the environment
and covered/concealed as much as the situation permits.
Evac from CCP is coordinated through appropriate C2 element
EPW, COB, or NEO casualties are treated and evacuated IAW
the Geneva Convention, SOP, or established plan
Casualties have documentation/casualty card prior to evac from
CCP (NLT evac from Bn level CCP)
CCP personnel and casualties are extracted/recovered
56

CASEVAC Operations
Evac requests submitted IAW SOP or coordinated plan
Vehicle movements coordinated through C2 elements
CEPs, AXPs, HLZs, and link-ups are conducted IAW SOP or
coordinated plan
Air and ground evac ops are coordinated through C2 elements
IAW SOP or coordinated plan
Casualties evacuated by category (Urgent, Priority, Routine, or
Convenience)
Casualty Treatment Evaluation (individual casualty trauma
patient assessment)
Determine Responsiveness / Level of Consciousness
Assess Airway & Breathing
Assessment / Patency
Assures adequate Ventilation, Breathing Rate and Quality
Manages Injuries related to airway and breathing
Manages Airway (J-Tube / Nasopharyngeal / Suction / BVM
/ ET-tube / Surgical Airway)
Administers Oxygen if appropriate and available
Manage C-Spine* if indicated (as situation permits)
Assess Circulation
Assess for and controls life threatening bleeding
Assess Pulse Rate and Quality
Assess Skin (color, temperature and condition)
Triages into evacuation or treatment category
Conducts Rapid or Focused Trauma Assessment/Survey and
treats life threatening injuries appropriately
Treat for Shock
Establishes Vascular Access (IV fluids or Saline Lock)
Obtains Baseline Vital Signs
Obtains a Patient History (Secondary Survey as situation
permits)
SAMPLE History
Self-Aid/Buddy-Aid/RFR care previously rendered?
Previous Interventions rendered?
Conducts a Detailed Physical Assessment (as situation permits)
(Inspect/Palpate/Auscultate OR Pain/Blood/Deformity)
Assess Head (scalp, ears, eyes/pupils, oro-nasal
Assess Neck (inspect, JVD, tracheal deviation)
Assess Chest (inspect, palpate, auscultate )
Assess Abdomen/Pelvis/Genitalia (palpate/auscultate)
Assess Extremities (pain, blood, deformity, pulses,
motor/sensory)
Assess Posterior (sweep of back)
Manages Secondary Injuries & Wounds (as situation permits)
Records Patient Information/Treatment/Interventions on
Casualty Card (NLT Bn level CCP)
57
75th RANGER HAZARDOUS TRAINING CHECKLIST (ADMIN MEDICAL) AS OF 9APRIL 2002
CHECKLIST INITIALS REMARKS

VEHICLE DISPATCHED AND FUELED CAUTION: DO NOT RETURN AMBULANCE TO MOTOR POOL
(CIRCLE) AMB TRK VAN WITH LESS THAN ½ TANK OF GAS.
PMCS TURN 2404 IN WITH DISPATCH. NOTE ANY PROBLEMS.

(AMBULANCE ONLY)
APPROPIATE ADMIN MEDICAL COVERAGE 350-2 (ASOP)
REQUIREMENTS FB 40-2 (MED COVERAGE)
COMMUNICATIONS APPROPIATE NUMBER AND TYPE OF COMMUNICATIONS
AVAILABLE FOR MISSION SUPPORT. COMMO CHK WITH
OIC/DZSTL, MEDICS, DRIVER, HOSP AND AIREVAC
DISPATHER PRIOR TO P-HOUR/HIT TIME.
MEDICAL EQUIPMENT CAUTION: ACCOUNT FOR AND TEST ALL EQUIPMENT
BEFORE AND AFTER MISSION.
BACKBOARD WITH STRAPS (min. 4 ea.)
CERVICAL STABILIZER
C-COLLAR
BVM (bag, mask, reservoir and tubing)
O2 COMPLETE (regulator, tank, non-rebreather mask and case)
PSI:________________
SUCTION (battery and manual)
MAST PANTS
PRO SPLINT SET (complete)
KED/OREGON SPINE SPLINT
RANGER TRAUMA PACK (PER SOP)
BLANKETS/RESCUE WRAP W/ HEATER
VITAL SIGNS MONITOR (CIRCLE) PROPAQ PIC W/ 2 BATTERIES
REEL/HARE TRACTION SPLINT
SITE SURVEY (MEDICAL) OFF POST ONLY
EVAC CHECKLIST AND TRAUMA 600’s
MAP W/ GPS MILITARY AND STRIP MAP (STRIP MAP FOR OFF POST ONLY)
SEN MEDIC CONFIRM GRID YOURSELF
RANGER MEDICAL PROTOCOL BOOK REVIEW PRIOR TO COVERAGE
ADMIN HEAD LIGHT
NIGHT VISION GOGGLES POTENTIAL FOR NEED Y N
EVACUATION BY AIR/GROUND
RESPONSIBILITIES OF THE MEDIC (S), DZSTL/ OIC PRI HLZ (GRID/LANDMARK): ____________________
AND DRIVER REVIEWED, REHERSED AND ALT HLZ (GRID/LANDMARK): ___________________
UNDERSTOOD BY ALL MENTIONED PAX.
METHOD OF MARKER:
DZSTL/OIC NAME: ________________________ DAY: ___________________
SIGNATURE: _____________________________ NIGHT: _________________
MEDIC: ________________________________
UNIT __________________________________
ABN OP FAST ROPE LFX DEMO WATER OP OTHER __________
AAR COMMENTS ON BACK
58
ABBREVIATION LIST
AAS acute abdominal series
ABD abdomen
ABG arterial blood gas
AC before eating (ante cibium)
ACLS Advanced Cardiac Life Support
A&O X - alert and oriented times orientation
AF afebrile
AKA above-the-knee amputation
AP anteroposterior
ASA acetylsalicylic acid (aspirin)
AT/NC atraumatic, normocephalic
bid twice a day
BKA below-the-knee amputation
BM bowel movement
BP blood pressure
BPM beats per minute
BRBPR bright red blood per rectum
BS bowel sounds
Bx biopsy
c with (cum)
CAD coronary artery disease
CAT computed axial tomography
CBC complete blood count
CC chief complaint
CHI closed head injury
C/O complaining of
CPR cardiopulmonary resuscitation
CTA clear to auscultation
CXR chest x-ray
D/C discontinue or discharge
DDx differential diagnosis
DOA dead on arrival
DOB date of birth
DOE dyspnea on exertion
DPL diagnostic peritoneal lavage
DPT diphtheria, pertussis, tetanus
DTR deep tendon reflex
DVT deep venous thrombosis
Dx diagnosis
EBL estimated blood loss
ECG electrocardiogram
EDC estimated date of confinement
EMG electromyelogram
EMS emergency medical system
EOMI extraocular muscles intact
ET endotracheal
ETOH ethanol
FB foreign body
F&D fixed and dilated
FamHx family history
F/C fevers, chills
F/U follow-up
Fx fracture
GERD gastroesophageal reflux disease
GI gastrointestinal
GSW gunshot wound
gtt drops
GU genitourinary
HA headache
59
Hct hematocrit
HEENT head, eyes, ears, nose, throat
Hgb hemoglobin
HPI history of present illness
HR heart rate
HS bed time (hours of sleep)
HSV herpes simplex virus
HTN hypertension
Hx history
I&D incision and drainage
IM intramuscular
I&O intake and output
IV intravenous
JVD jugular venous distention
L left
LA lymphadenopathy
lac laceration
LBP low back pain
LE lower extremities
LIH left inguinal hernia
LLL left lower lobe
LMP last menstrual period
LOC loss of consciousness
LP lumbar puncture
LLQ left lower quadrant
LUL left upper lobe
LUQ left upper quadrant
MAST military antishock trousers
MI myocardial infarction
MOI mechanism of injury
MMR measles, mumps, rubella
MRI magnetic resonance imaging
MVA motor vehicle accident
NAD no acute distress
NKDA no known drug allergies
NPO nothing by mouth (nil per os)
NS normal saline
NSAID nonsteroidal antiinflammatory drug
NSR normal sinus rhythm
NTG nitroglycerin
N/V/D nausea, vomiting, diarrhea
OB obstetrics
OD right eye (oculus dexter), overdose
OE otitis externa
OM otitis media
OPV oral polio vaccine
OS left eye (oculus sinister)
PC after eating (post cibum)
PCN penicillin
PE physical exam, pulmonary embolism
PEA pulseless electrical activity
PERRL pupils equal, round, reactive to light
PFT pulmonary function test
PMHx past medical history
PMI point of maximal impulse
PO by mouth (per os)
PPD purified protein derivative
PR per rectum
PRN as often as needed (pro re nata)
PSHx past surgical history
Pt patient
PUD peptic ulcer disease
60
q every (quaque)
qd every day
qh every hour
q _h every _ hours
qid four times a day (quater in die)
qod every other day
R right
RBC red blood cell
RDA recommended dietary allowance
RIH right inguinal hernia
RLL right lower lobe
RLQ right lower quadrant
RML right middle lobe
R/O rule out
ROM range of motion
ROS review of systems
RUL right upper lobe
RUQ right upper quadrant
RR respiratory rate
RRR regular rate and rhythm
RTC return to clinic
Rx prescription, treatment
s without (sine)
SEM systolic ejection murmur
SL sublingual
Sn signs
SocHx social history
SOB shortness of breath
SQ subcutaneous
STD sexually transmitted disease
Sx symptoms
Td tetanus-diphtheria toxoid
tid three times a day (ter in die)
TKO to keep open
TM tympanic membrane
TNTC to numerous to count
TTP tenderness to palpation
Tx treatment
ud as directed (ut dictum)
UE upper extremities
URI upper respiratory tract infection
UTI urinary tract infection
VA visual acuity
VD venereal disease
VSS vital signs stable
WBC white blood cell
WD well developed
WN well nourished
WNL within normal limits
YO years old
>,<,= greater than, less than, equal
61

RGR Handbook May 2002 - 1

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RGR Handbook May 2002 - 1

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75th Ranger Regiment

Trauma Management Team

MEDICAL: RANGER MEDIC SCOPE OF PRACTICE------ 6

TACTICAL: TACTICAL COMBAT CASUALTY CARE------ 51

PLANNING: MEDICAL EVALUATION CHECKLIST---------54

HAZERDOUS TRAINING CHECKLIST--------- 58

RANGER MEDIC SCOPE OF PRACTICE

Protocols and Standing Orders

GENERAL GUIDELINES FOR PROTOCOL USAGE

NEVER HESITATE TO CONTACT THE SURGEON FOR ANY PROBLEM,

2. Following endotracheal intubation, tube placement should be re-verified every 5-10

Patient Information Documentation

PATIENT ASSESSMENT AND MANAGEMENT

II. The Primary Survey

A. AIRWAY AND C-SPINE

Class I Class II Class III Class IV

Blood Loss (ml) Up to 750 750-1500 1500-2000 > 2000

Blood Loss(%BV) Up to 15% 15-30% 30-40% > 40%

Blood Pressure Normal Normal Decreased Decreased

Pulse Pressure Normal or Decreased Decreased Decreased

Capillary Blanch Test Normal Positive Positive Positive

Respiratory Rate 14-20 20-30 30-40 > 35

Urine Output (mL/hr) > 30 20-30 5-15 Negligible

CNS-Mental Status Slightly Mildly Anxious & Confused-

Fluid Replacement Crystalloid Crystalloid Crystalloid & Crystalloid &

D. DISABILITY (MENTAL STATUS)

V – Verbal Response: Oriented 5

IV. The Secondary Survey

evaluation. Neck inspection, palpation, and auscultation should also be used to

cervical collar must be immediately established. These patients should be

Resuscitation should proceed simultaneously with the primary survey. It includes

Hold Laryngoscope in the left hand

Assemble & check equipment

Inflate the distal cuff with 10 ml of air.

Lung Gastric Deflate both cuffs and withdraw the

Cleanse site with povidine

Insert a tracheal hook into the cricothyroid

Insert a 7-0 ET tube through the midline of the membrane

Inflate the cuff of the ET Tube with 10 cc of air

Remove the Luer-Lok from the distal end of the

Remove the needle from the catheter and

Leave catheter in place converting the

Ensure tension has been relieved. If Not

Auscultate breath sounds FREQUENTLY and Document:

Chest Tube Insertion

With the index finger of the nondominant hand trace the

With the index finger of the non dominant hand remaining

Apply dressings: wrap tube with pertolatun gauze

Monitor SpO2, cardiac rhythm and clinical

External Jugular Cannulation

Note blood return and advance catheter

Withdraw needle/catheter and attach IV

Cover site with tegaderm

1 Modified Trendelenburg position is an ideal position. This position is not mandatory

Sternal Intraosseous Infusion

Prep site with povidine swab

Use index finger of non-dominant hand to align

With the introducer in hand, apply steady even

Attach the infusion tube to the right angle female

Attach syringe to the IV insertion site and aspirate bone marrow.

Flush the needle

Administer IV fluids, medications as needed

Secure inducer removal device to IV line or patient