TRAUMA ONE // WATCHMAN

◈ TRAUMA PROTOCOLS — GRID DOWN FIELD MEDICINE

These protocols are for use when professional medical care is unavailable. ALWAYS seek modern medical care if accessible. Train with hands-on courses — reading alone is not sufficient preparation.

▶ MARCH PROTOCOL — TACTICAL CASUALTY SEQUENCE▼

MARCH is the tactical order of treatment priorities. Work each phase before moving to the next.

MASSIVE HEMORRHAGE — Control life-threatening bleeding first. Tourniquet, wound packing, direct pressure. Every second counts.
AIRWAY — Establish and protect a patent airway. Head-tilt chin-lift, NPA/OPA, intubation, or surgical airway if needed.
RESPIRATION — Assess breath sounds both sides. Seal open chest wounds. Decompress tension pneumothorax if suspected. Assist ventilations if <8 or >30/min.
CIRCULATION — Treat shock. IV/IO fluids if trained. Monitor pulse, BP, mental status. Maintain systolic >90 mmHg.
HYPOTHERMIA / HEAD INJURY — Wrap patient immediately — hypothermia kills trauma patients. Assess GCS. Elevate head 30° if head injury and no spinal concern.

CARE UNDER FIRE: The ONLY treatment during active fire is tourniquet HIGH AND TIGHT on bleeding extremity. Move to cover FIRST, then treat. Fire superiority is the best medicine on the battlefield.

PRIMARY SURVEY — ABCDE: A = Airway (with C-spine control) • B = Breathing (look, listen, feel) • C = Circulation (hemorrhage, pulse, BP) • D = Disability (GCS, pupils) • E = Expose (remove clothing, check all surfaces, prevent hypothermia)

▶ MASSIVE HEMORRHAGE CONTROL▼

Uncontrolled hemorrhage is the #1 preventable cause of death. Act immediately. The golden hour begins now.

STEP 1 — DIRECT PRESSURE

Don nitrile gloves. Grab a bandanna or cloth if no gloves available — never touch wound with bare hand.
Apply firm, direct pressure to the wound using gauze pads or any clean cloth.
If limb wound, elevate the extremity above the level of the heart while maintaining pressure.
Maintain pressure for a full 5–10 minutes without peeking. If blood soaks through, add more gauze on top — do NOT remove first layer.
If direct pressure slows but does not stop bleeding, locate the pressure point for that region and compress.

KEY PRESSURE POINTS: Brachial artery (mid-upper arm) for arm wounds; Femoral artery (groin crease) for thigh wounds; Popliteal artery (back of knee) for lower leg wounds.

STEP 2 — TOURNIQUET (Extremity Only)

Apply tourniquet when: Direct pressure fails, arterial (spurting) bleeding, amputation, or you are alone and cannot maintain pressure.

Place tourniquet 2–3 inches above the wound (not over a joint). For amputations or unclear wound location, apply high and tight — as high as possible on the limb.
Apply CAT tourniquet: thread limb through loop, tighten strap, twist windlass until bleeding stops and distal pulse is absent.
Lock the windlass in the clip. Secure the strap over the windlass.
WRITE THE TIME on the tourniquet AND on the patient's forehead. Time on tourniquet determines risk of limb loss.
Improvised tourniquet: use a 2–3" wide cloth (belt, bandanna, cravat). Tie around limb, insert a stick, pencil, or pen, twist until bleeding stops. Tie stick in place.
Check the wound at 10-minute intervals. If natural clotting has occurred, release pressure gradually — leave tourniquet in place within reach.

Tourniquet risks: Limb loss after 1–2 hours. Toxic buildup in extremity releases into core upon removal. Do not remove in the field if more than 2 hours applied. Note time — inform any medical personnel.

STEP 3 — WOUND PACKING (Junctional / Non-Compressible)

Use for wounds that cannot be tourniqueted: groin, armpit, neck, shoulder (junctional areas). Also for large lacerations requiring packing.

Open QuikClot or Celox hemostatic gauze. Note: Celox is chitosan-based — avoid if patient has severe shellfish allergy.
Pack the gauze DIRECTLY into the wound, as deep as possible, aiming for the bleeding source. Use your finger to push gauze firmly into the wound cavity.
Continue packing until the wound is filled with gauze. Do not just lay gauze on top — it must be packed in.
Apply firm manual pressure for a minimum of 3–5 minutes (QuikClot) or 3 minutes (Celox). Do not release early.
Apply an Israeli Battle Dressing or pressure bandage over the packed wound to maintain pressure.
If bleeding restarts, do NOT remove existing packing. Add more gauze on top and reapply pressure.

Direct pressure and gauze packing are your first line. Hemostatic agents (QuikClot/Celox) are second line when standard gauze alone fails. Hemostatic agents shelf life: ~3 years; store away from sunlight.

BLOOD LOSS ASSESSMENT

Adult body contains ~10 pints (5 liters) of blood:
• <1.5 pints: Little effect, patient may be asymptomatic
• 1.5–3.5 pints: Rapid heart rate, rapid breathing, pale skin, patient very agitated
• 3.5–4 pints: BP drops, patient confused, very rapid heartbeat
• >4 pints: Very pale, possibly unconscious, dropping heart rate — CRITICAL

▶ AIRWAY MANAGEMENT▼

CONSCIOUS PATIENT — CHOKING / OBSTRUCTION

Ask: "Are you choking?" If they can speak, airway is partially open. Encourage coughing. Do not intervene yet.
If complete obstruction (cannot speak, holding throat, nodding yes): Perform Heimlich maneuver — stand behind patient, make fist above belly button, wrap other arm around patient, thrust sharply upward and inward. Repeat until object dislodged.
If patient loses consciousness: lay flat, straddle hips, give upward abdominal thrusts with heel of palm. Check mouth after each attempt.
INFANT: Place face-down over forearm, give 5 back blows with heel of hand to upper back. Alternate with 5 chest thrusts. Never do abdominal thrusts on infant.

UNCONSCIOUS PATIENT — AIRWAY POSITIONING

Head-Tilt Chin-Lift: Tilt head back, grasp underside of chin and jaw, lift to straighten airway. Use only when NO suspected spinal injury.
Jaw Thrust (spinal precaution): Without tilting head, place fingers behind the angles of the jaw and thrust jaw forward. Use when spinal injury suspected.
Insert oral airway (OPA) if available: size from corner of mouth to earlobe. Insert upside-down in adults, rotate 180° once past teeth. Insert right-side up in children.
Insert nasal airway (NPA) if patient has gag reflex (cannot tolerate OPA): measure from nostril to earlobe, lubricate, insert straight back along floor of nasal passage.
Place unconscious breathing patient in RECOVERY POSITION: on their side, top leg bent forward for stability, head tilted slightly back, mouth down to drain vomit.

EMERGENCY CRICOTHYROIDOTOMY (Last Resort Only): For complete, unrelievable obstruction when Heimlich has failed and patient cannot breathe. Locate Adam's apple, move 1 inch below to cricoid cartilage. Make small horizontal incision in the crease between them. Insert hollow tube (straw, pen casing). Perform CPR rescue breaths through tube if needed. ONLY when patient will otherwise die in minutes.

▶ CPR — CARDIOPULMONARY RESUSCITATION▼

CPR is most effective for: airway obstruction, hypothermia, anaphylaxis, near-drowning, lightning strike. It is of limited value for cardiac arrest from heart disease in grid-down. TRAIN IN PERSON — reading is not enough.

ADULT / CHILD CPR

Verify scene safety. Check responsiveness: shake shoulders, call loudly "Are you OK?"
Check for pulse (carotid — neck) and breathing simultaneously for no more than 10 seconds.
No pulse, not breathing (or only gasping): Position patient flat on back on firm surface.
COMPRESSIONS: Place heel of hand on center of chest (lower half of sternum, nipple level). Second hand on top, fingers interlaced. Lock elbows, compress straight down 2 inches (adult) or 1.5 inches (child). Release fully.
Rate: 100–120 compressions per minute. Count aloud to maintain rhythm ("1-and-2-and-3..."). Use "Stayin' Alive" tempo as a mental guide.
After 30 compressions, open airway with head-tilt chin-lift. Give 2 rescue breaths (1 second each, watch chest rise). Pinch nose closed for mouth-to-mouth.
Continue 30:2 cycles. Reassess after 5 cycles (2 minutes). Continue until patient responds, trained help arrives, or 30 minutes without result (pupils dilated and fixed = cessation appropriate).

COMPRESSION-ONLY CPR: If untrained or unwilling to give rescue breaths, continuous compressions at 100/min still provide significant benefit. Better than nothing.

INFANT CPR: Use 2 fingers for compressions, compress 1.5 inches. Ratio 30:2 with 1 rescuer, 15:2 with 2 rescuers. Cover both nose and mouth for rescue breaths.

AED: If available, use immediately. Turn on, attach pads per diagram, follow prompts. Do not touch patient during shock. Resume CPR immediately after shock.

▶ BURN INJURIES▼

BURN CLASSIFICATION

1st Degree (Superficial): Redness, pain, no blistering. Epidermis only. Treat: cool water, aloe vera, OTC pain relief.
2nd Degree (Partial Thickness): Blisters, intense pain, weeping, red/mottled. Epidermis + dermis. Treat: cool water, sterile dressing, do NOT pop blisters.
3rd Degree (Full Thickness): White, brown or black, leathery, may be painless (nerve destruction). All skin layers. Treat: cover sterile dressing, NO cool water (hypothermia risk if large area), urgent care needed.
Inhalation Injury: Singed eyebrows/nasal hair, hoarse voice, soot in mouth. Airway swells — URGENT. Cool moist air, monitor airway closely.

TREATMENT PROTOCOL

Stop the burning: remove patient from source. Remove clothing and jewelry from burned area (unless fused to skin).
Cool the burn: run cool (NOT ice cold) water over burn for 20 minutes. For large burns (>20% body surface), limit cooling to prevent hypothermia.
Do NOT apply butter, oil, toothpaste, or other home remedies — increases infection risk.
Do NOT pop blisters — they are natural sterile barriers.
Cover with clean, non-stick dressing. Wet sterile gauze works well. Wrap loosely.
For 2nd/3rd degree burns: change dressing twice daily with dilute Betadine (1:10 with water) or sterile saline.
Aloe vera (fresh gel from leaf) is an effective natural treatment for 1st and mild 2nd degree burns.
Natural burn treatments: raw honey as antimicrobial dressing, lavender essential oil diluted in carrier oil for minor burns.
Monitor for infection: increasing redness, warmth, swelling, foul odor, fever = begin antibiotics (Amoxicillin or Doxycycline).

Burns >20% body surface = HIGH risk of shock and fluid loss. Push oral fluids aggressively. Burns to face/neck/hands/genitals require priority treatment.

▶ FRACTURES, DISLOCATIONS & SPRAINS▼

FRACTURE IDENTIFICATION

Signs of fracture: Severe pain and tenderness, swelling and bruising, abnormal deformity or angulation, loss of normal function, crepitus (grating sensation), abnormal motion.
Fracture types: Stable (aligned), Open/Compound (bone through skin — HIGH infection risk), Comminuted (shattered), Greenstick (partial break, children).

SPLINTING PROTOCOL

Check CMS BEFORE and AFTER splinting: Circulation (pulse beyond wound site, capillary refill <2 sec), Motor (can patient move fingers/toes?), Sensation (can patient feel touch beyond injury?).
Do NOT attempt to straighten a fractured bone unless circulation is absent (pulseless extremity). If pulse is absent, gentle traction may be necessary to restore flow.
Splint in position of comfort (or the position found). Splint should immobilize the joint ABOVE and BELOW the fracture.
SAM splint: mold to body contour, pad bony prominences, secure with elastic bandage or strips of cloth. If none available, use straight sticks, branches, a rolled magazine — pad them first.
Apply firmly enough to prevent movement but not so tight as to cut circulation. Ensure fingers/toes are visible to monitor.
Elevate the injured extremity above heart level to reduce swelling.
Open fracture: rinse wound thoroughly with sterile water or dilute Betadine (1:10). Cover exposed bone with wet sterile dressing. Do NOT push bone back in. Splint as found. Begin antibiotics immediately (Amoxicillin 500mg TID).

DISLOCATIONS

Check CMS. Shoulder, finger, kneecap, and ankle are most common dislocations in field settings.
Reduction (only if trained): gentle, steady traction along the axis of the limb while assistant stabilizes the proximal segment. Do NOT jerk or force.
If unable to reduce: splint in position found and transport. Successful reduction restores pulse — recheck CMS immediately after.
After reduction: apply ice (if available), sling or splint, rest.

SPRAINS

RICE protocol: Rest, Ice (20 min on/20 min off for first 48 hrs), Compression (elastic bandage), Elevation. Ibuprofen 400-600mg every 6-8 hours for swelling/pain.

▶ HYPOTHERMIA & COLD INJURIES▼

HYPOTHERMIA STAGES

Mild (96–90°F / 35–32°C): Shivering (body's warming mechanism — a GOOD sign), poor coordination, slurred speech, confusion begins.
Moderate (90–82°F / 32–28°C): Shivering STOPS (dangerous — body can no longer warm itself), muscle rigidity, severe confusion, drowsy.
Severe (<82°F / <28°C): Unresponsive, rigid muscles, barely perceptible pulse. May appear dead. "Not dead until warm and dead."

TREATMENT PROTOCOL

Move patient to shelter and out of wind, rain, and cold. Handle gently — rough handling can trigger ventricular fibrillation in severe hypothermia.
Remove wet clothing carefully. Replace with dry insulation. Wrap in sleeping bag, blankets, emergency space blanket (reflective side in).
Protect from ground conduction — always put insulation UNDER the patient (as much heat is lost to ground as to air).
Warm the CORE first: focus heat to armpits, groin, and neck (major blood vessel locations). Use warm water bottles, chemical heat packs, or body heat. Wrap in insulation, not direct high heat.
For mild hypothermia with active shivering: warm sweet liquids (hot cocoa, warm broth). No alcohol.
For moderate/severe: NO oral fluids (aspiration risk). Passive rewarming only unless warm IV saline available.
Monitor breathing. Severe hypothermia — if no pulse or breathing, begin CPR. Continue until patient is rewarmed to at least 86°F (30°C) before calling cessation.
Do NOT rub extremities (releases cold blood from periphery to core too rapidly).

FROSTBITE

Do NOT rewarm if there is any chance of refreezing — a thawed and refrozen extremity suffers far worse damage than frozen tissue.
Rewarm in warm water (100–105°F / 38–41°C) for 20–40 minutes. Protect from direct heat. Very painful — give pain relief.
Do NOT rub frostbitten tissue. Do not walk on frostbitten feet unless no alternative. Cover with clean, dry dressings.
Blisters are protective — do not pop. Elevate extremity. Watch for infection.

▶ SHOCK MANAGEMENT▼

Shock is life-threatening organ failure due to inadequate blood flow. Treat the CAUSE first, then manage the symptoms.

SHOCK TYPES

Hemorrhagic: Blood loss — most common trauma shock. Control bleeding first.
Hypovolemic: Fluid loss (dehydration, burns, vomiting/diarrhea).
Anaphylactic: Severe allergic reaction. Epinephrine immediately.
Septic: Severe infection. Antibiotics, fluids.
Neurogenic: Spinal cord injury. Warm patient, fluids.

SIGNS OF SHOCK

Pale, cool, clammy skin ("cold and clammy") • Rapid weak pulse (>100 bpm) • Rapid shallow breathing (>20/min) • Low BP (systolic <90 mmHg) • Altered mental status: anxious → confused → unresponsive • Capillary refill >2 seconds

TREATMENT PROTOCOL

Control all hemorrhage first. Nothing else matters while blood is pouring out.
Lay patient flat. Elevate legs 12 inches above heart level (the "shock position") unless head injury or chest injury suspected.
Maintain body temperature — cover with blankets. Hypothermia dramatically worsens shock outcomes.
If conscious and no abdominal/chest injury: push oral fluids (water, oral rehydration solution — 200–400 mL/hr).
If IV capable: NS (0.9% NaCl) or Lactated Ringer's (LR preferred for large-volume resuscitation). Target systolic >90 mmHg. Do NOT over-hydrate — "permissive hypotension" in penetrating trauma: target systolic 80–90, not normal.
Monitor mental status, pulse, and respirations every 5 minutes. Any deterioration = escalate treatment.
Do NOT give food or drink if abdominal injury suspected. Do NOT give aspirin or ibuprofen (increase bleeding).

FLUID RESUSCITATION — BY SHOCK CLASS (SOF MEDIC PROTOCOL)

CLASS	BLOOD LOSS	PULSE	BP	FLUID ACTION
I	<750 mL / <15%	<100	Normal	Oral fluids. No IV required unless prolonged.
II	750–1500 mL / 15–30%	100–120	Normal/low	1L NS or LR IV bolus over 30 min. Reassess. Oral ORS if no IV.
III	1500–2000 mL / 30–40%	>120	Dropping	2L NS/LR wide open. Reassess after each liter. Urgent evacuation.
IV	>2000 mL / >40%	>140 or absent	Critical	Maximum IV rate. Field blood transfusion if trained/available. Survival unlikely without surgical intervention.

PERMISSIVE HYPOTENSION: In penetrating trauma with ongoing hemorrhage, target systolic BP 80–90 mmHg — NOT normal. Aggressive fluids before hemorrhage is controlled dilute clotting factors and worsen bleeding. Control the bleed first. This does NOT apply to head injuries — maintain systolic >100 for brain perfusion.

▶ ANAPHYLAXIS — SEVERE ALLERGIC REACTION▼

Anaphylaxis is a medical emergency. Death can occur within minutes from airway obstruction or cardiovascular collapse.

SIGNS: Hives/rash, swelling (face, throat, tongue), difficulty breathing/wheezing, drop in blood pressure, rapid pulse, nausea/vomiting, sense of doom. Can follow insect stings, food (shellfish, nuts), medications.

EPINEPHRINE IMMEDIATELY: Inject EpiPen (0.3mg epinephrine 1:1000) into outer mid-thigh (through clothing if needed). Children <66 lbs: use EpiPen Jr (0.15mg). Hold for 10 seconds.
Call for help / prepare to transport. Epinephrine is temporary — patient needs definitive care.
Position: if breathing difficulty, allow patient to sit up. If low BP/shock, lay flat with legs elevated.
Give Diphenhydramine (Benadryl) 50mg orally — supports Epinephrine but NOT a substitute.
For wheezing: albuterol inhaler if available (2–4 puffs).
Repeat Epinephrine in 5–15 minutes if symptoms not improving. A second EpiPen may be required.
Begin CPR immediately if patient loses pulse or stops breathing. CPR can be successful in anaphylaxis with epinephrine on board.
Monitor for 4–8 hours — biphasic reactions can recur hours later.

▶ HEAD INJURIES▼

Head injuries can deteriorate rapidly and without warning. Frequent monitoring is mandatory.

ASSESSMENT — AVPU SCALE

Alert — fully awake and oriented
Voice — responds to verbal commands
Pain — only responds to painful stimulus
Unresponsive — no response to any stimulus

DANGER SIGNS — SEEK/ESCALATE CARE IMMEDIATELY

• Pupils unequal in size, or not reacting to light (suggests brain herniation)
• Loss of consciousness, or worsening level of consciousness
• Severe headache that is progressively worsening
• Repeated vomiting
• Seizures
• Clear fluid from ears or nose (indicates skull fracture)
• "Battle's sign" — bruising behind ear (suggests basilar skull fracture)

TREATMENT

ABC first — ensure airway is open, patient is breathing, no major bleeding.
Assume spinal injury with all significant head injuries. Use jaw thrust for airway. Log-roll for repositioning.
Elevate head of bed/patient 30 degrees to reduce intracranial pressure — only if no spinal injury concerns OR secured to backboard.
Pain: Acetaminophen ONLY (325–1000mg). NO aspirin or ibuprofen — these increase bleeding risk.
Place vomiting patient in lateral recumbent (recovery) position while maintaining spinal precautions.
Monitor AVPU every 15 minutes. Document any change — deterioration is the key warning sign.
Monitor pupils: check reactivity to light every 30 minutes. Unequal or non-reactive pupils = emergency.
Keep patient awake for first 4–6 hours if concussion suspected. After that, sleep is acceptable — check responsiveness every 2 hours.
Do NOT give fluids excessively — can worsen brain swelling.

▶ WOUND CARE & INFECTION MANAGEMENT▼

WOUND IRRIGATION

After bleeding is controlled: irrigate aggressively with sterile (boiled and cooled) water using a syringe or bulb syringe for pressure. "The solution to pollution is dilution."
First irrigation: dilute Betadine (1 part Betadine to 10 parts water) or Dakin's solution is acceptable.
Subsequent irrigations: plain sterile water — concentrated antiseptics damage new cells and slow healing.
Remove visible debris, dirt, and foreign material with gloved fingers or tweezers. Assume all wounds are dirty.

WOUND CLOSURE DECISION

Close (Primary Intention): Clean, fresh wounds (<6 hours old), low-tension, no signs of infection. Smaller scar but higher infection risk.
Leave Open (Secondary Intention): Bite wounds, dirty/contaminated wounds, puncture wounds, wounds >6 hours old, any signs of infection. Larger scar but safer. Granulation tissue fills in naturally.
RULE: When in doubt — leave it open. Infection in a closed wound is far more dangerous than an open wound healing slowly.

DRESSING CHANGES

Change dressings minimum twice daily, or whenever saturated.
Apply wet-to-dry dressing for open wounds: wet clean gauze with sterile water, wring out, apply to wound. Cover with dry outer dressing.
Triple antibiotic ointment (Neosporin/bacitracin) at wound edges — NOT inside deep wounds.

INFECTION SIGNS — ESCALATE ANTIBIOTICS

Increasing redness spreading from wound • Warmth • Swelling • Pus or foul-smelling discharge • Red streaking spreading up limb (cellulitis/sepsis) • Fever (>100.4°F) • Swollen lymph nodes

Red streaking up limb = potential blood poisoning (sepsis). This is life-threatening. Begin antibiotics immediately: Amoxicillin 500mg TID or Doxycycline 100mg BID for 7–10 days.

DAKIN'S SOLUTION (Field Antiseptic)

Dissolve ½ tsp baking soda in 4 cups boiled water. Add bleach per desired strength: 3 tsp = mild (clean wounds), 3 tbsp = moderate (infected wounds). Store in dark container at room temperature. Make fresh every 2–3 days — loses potency quickly.

▶ TENSION PNEUMOTHORAX & OPEN CHEST WOUNDS▼

Tension pneumothorax is rapidly fatal. It is a clinical diagnosis — do NOT wait for confirmation. Treat based on signs.

RECOGNIZE — TENSION PNEUMOTHORAX

Mechanism: Penetrating or blunt chest trauma → air enters pleural space → lung collapses → pressure builds → heart and great vessels shift away (mediastinal shift) → drops venous return → cardiac arrest.

Signs (MATCH): Absent breath sounds on injured side • Tracheal deviation AWAY from injury (late sign) • Respiratory distress — severe, worsening • Cyanosis • Hypotension despite fluid

Rule: If penetrating chest trauma + respiratory distress + decreased breath sounds on one side = decompress immediately.

NEEDLE DECOMPRESSION (Tension Pneumothorax)

Identify the affected side — no breath sounds, patient deteriorating. If unsure: decompress the side of injury.
Landmark: 2nd intercostal space (ICS), midclavicular line (MCL). Find the clavicle, go 2 ribs down, at the midpoint of the clavicle.
Prep skin with Betadine or alcohol wipe if time permits. Glove up.
Insert a 14-gauge (or largest available) IV catheter-over-needle PERPENDICULAR to the chest wall, immediately ABOVE the 3rd rib (to avoid the neurovascular bundle running under each rib).
A rush of air = correct placement. Tension is relieved. Advance catheter, remove needle. You will hear/feel the pressure release.
Leave catheter in place — do NOT remove. Attach a 3-way stopcock or finger of a glove with a hole cut in the tip (one-way valve) to prevent re-accumulation.
Reassess breath sounds and vital signs immediately. Patient should improve within seconds to minutes.
This is a bridge — patient needs a chest tube as soon as possible. Evacuate urgently.

If no large-bore IV catheter: a 16–18 gauge will work but may kink. A 3.5" or longer needle is required for obese or muscular patients — standard 1.5" may not reach pleural space.

OPEN CHEST WOUND (Sucking Chest Wound)

Any chest wound larger than 2 cm that makes a sucking or bubbling noise with breathing. Air enters through the wound instead of through the airway — lung collapses. Risk of converting to tension pneumothorax.

Apply a vented chest seal (Hyfin or Bolin) directly over the wound. Remove packaging, dry skin first — seal must be airtight. Center over wound.
Vented seals allow air OUT but not IN — this prevents tension buildup. Commercial preferred; improvise if unavailable.
Improvised chest seal: petroleum gauze or plastic wrap (from an MRE bag, IV bag, or wrapper) taped on THREE sides only — leave one side open to vent. Check: does it flutter out on exhale? Good.
If patient deteriorates after sealing (increasing respiratory distress, dropping BP) — LIFT one edge of the seal to release pressure. This indicates tension pneumothorax is building. Proceed to needle decompression.
If exit wound present: seal BOTH entry and exit wounds.
Place patient in position of comfort — sitting up or semi-reclined if breathing is easier that way.
Monitor continuously. Evacuate urgently.

▶ PRIMARY & SECONDARY SURVEY — PATIENT ASSESSMENT▼

Perform in this exact order on every trauma patient. Primary Survey identifies life threats. Secondary Survey finds everything else. Do not proceed to secondary until primary threats are controlled.

PRIMARY SURVEY — ABCDE (Life Threats Only)

AIRWAY with C-spine control. Is airway open and clear? Can patient speak? Gurgling = fluid, needs suctioning. Stridor = partial obstruction. If unconscious: chin-lift (no trauma) or jaw thrust (trauma). Insert OPA/NPA. Intubate or cric if needed.
BREATHING. Look: chest rise — symmetric? Wounds? Look, listen, feel. Rate and depth. Absent breath sounds one side = pneumothorax. Seal open wounds. Decompress tension pneumo. Assist ventilations if <8 or >30 breaths/min.
CIRCULATION. Control all external hemorrhage NOW — tourniquet, wound packing, pressure. Check radial pulse: rate, quality, present/absent. Capillary refill (normal <2 sec). Skin: pale, cool, clammy = shock. Estimate blood loss. Start IV/IO if trained.
DISABILITY. Rapid neurological assessment. AVPU: Alert, Voice, Pain, Unresponsive. Pupils: equal and reactive? Glasgow Coma Scale if time. Any limb weakness or paralysis?
EXPOSE / ENVIRONMENT. Cut away clothing — look at entire body. Back, armpits, groin, scalp. Find EVERY wound. Cover with blanket immediately after — prevent hypothermia.

Treat life threats AS YOU FIND THEM — do not complete the survey before acting. Airway before breathing before circulation. But a tourniquet applied in seconds before the survey is always correct for exsanguinating extremity hemorrhage.

SECONDARY SURVEY — HEAD TO TOE

Only begin after primary threats are controlled. Systematic head-to-toe exam to find all injuries.

HEAD: Scalp — feel for lacerations, depressions, boggy areas. Pupils equal and reactive. Ears — blood or CSF fluid (clear). Battle's sign behind ear (bruising = basilar skull fracture, late). Mouth — airway clear, teeth intact.
NECK: Tracheal position — midline? Midline deviation = tension pneumo or large hematoma. Jugular veins — distended? (tension pneumo, tamponade). Cervical spine tenderness — maintain precautions if suspected.
CHEST: Feel every rib — crepitus, step-off, tenderness. Auscultate both sides. Look for paradoxical movement (flail chest). Bruising, seat belt marks.
ABDOMEN: Gently palpate all four quadrants. Rigid = blood/peritonitis. Guarding. Bruising (especially flank — kidney/spleen). Do NOT repeat palpation — once is enough.
PELVIS: Compress inward on both iliac crests once only. Movement or pain = pelvic fracture (life-threatening hemorrhage). Do NOT repeatedly rock — worsens bleeding.
EXTREMITIES: Palpate long bones for fracture. Check CMS (Circulation/Motor/Sensation) distal to each injury. Deformity, swelling, crepitus. Log-roll patient — check entire back, buttocks, posterior thighs.
REASSESS: Repeat primary survey after secondary. Patient status changes. Document all findings and times.

▶ SURGICAL AIRWAY — CRICOTHYROIDOTOMY▼

Last-resort airway. Perform when: cannot intubate, cannot ventilate, complete airway obstruction unrelieved by Heimlich. Death in minutes without action. Two methods: Needle (faster, temporary) and Surgical (definitive field airway).

ANATOMY LANDMARK

Feel the Adam's apple (thyroid cartilage). Move finger DOWN — feel the soft depression between thyroid and cricoid cartilage. This is the cricothyroid membrane. It is your target. It is about 1 inch below the Adam's apple.

METHOD 1 — NEEDLE CRICOTHYROIDOTOMY (Faster, Buys Time)

Position patient supine. Place roll under shoulders to hyperextend neck (unless C-spine suspected).
Locate cricothyroid membrane — firm landmark palpation, then prep with Betadine/alcohol.
Attach a 14-gauge IV catheter to a 10cc syringe. Nick skin with #11 blade if available.
Insert needle at 90° to skin, applying suction on syringe. When air freely enters syringe — you are in the trachea. STOP advancing needle.
Angle needle toward feet at 45°. Hold needle steady; advance catheter off needle all the way to the hub. Remove needle.
Confirm placement: attach syringe, inject air — should flow freely. If resistance: reposition.
Secure catheter with suture or tape. Connect to oxygen at 15 L/min or provide manual ventilations via syringe (plunger removed, attached to catheter).
This provides approximately 30–45 minutes of oxygenation. Proceed to surgical cric as soon as able.

METHOD 2 — SURGICAL CRICOTHYROIDOTOMY (Definitive)

Locate and prep membrane as above. Sterile gloves if available.
Stabilize larynx with non-dominant hand — pinch between thumb and middle finger. Do NOT let it slip.
Make a 1-inch horizontal skin incision over the membrane with #10 or #11 scalpel. Cut ONLY through skin — not membrane yet.
Relocate membrane by touch. Make a second 1-inch horizontal incision THROUGH the cricothyroid membrane. A rush of air confirms entry. Do NOT cut vertically — avoid cricothyroid arteries.
Insert hemostat into incision and dilate opening by spreading. Or hook index finger into incision to maintain opening.
Insert ET tube (size 6–7) or smallest available airway tube through the opening, directed toward feet. Inflate cuff.
Confirm placement: bilateral breath sounds, chest rise. Secure tube with tape or suture. Connect BVM.
Ventilate at 12–16 breaths/min for adult. Monitor SpO2 if oximeter available. Reassess every 5 minutes.

No ET tube available: a ballpoint pen casing, IV tubing, or any non-collapsible hollow tube can maintain a surgical airway temporarily.

▶ PAIN CONTROL — FIELD ANALGESIC LADDER▼

Uncontrolled pain worsens shock, impairs cooperation, and reduces survival. Treat pain aggressively but safely. Assess pain on a 0–10 scale before and after treatment. Reassess every 30 minutes.

NEVER give opioids to: unconscious patients, respiratory rate <12, SBP <90 mmHg, suspected head injury, bowel obstruction. Never give aspirin or ibuprofen in active hemorrhage or shock.

STEP 1 — MILD PAIN (1–4): NON-OPIOID FIRST LINE

Acetaminophen: 650–1000mg orally q6h. Maximum 4g/day. Preferred for head injury. No anti-inflammatory effect.
Ibuprofen: 400–800mg orally q6–8h with food. Maximum 3200mg/day. Anti-inflammatory. Do NOT use with active bleeding, shock, kidney injury.
Aspirin: 325–650mg orally q4–6h. Avoid with bleeding — inhibits platelet function for 7–10 days.
Non-medication: splint fractures, elevate injured extremity, ice (first 48h), positioning of comfort, reassurance.

STEP 2 — MODERATE PAIN (5–7): ADD KETOROLAC

Ketorolac (Toradol): 15–30mg IM or IV q6h. Maximum 5 days continuous use. Powerful NSAID — better than morphine for kidney stone, fracture, dental pain. Do NOT use with active bleeding.
Combine with acetaminophen for additive effect — different mechanisms, no interaction.

STEP 3 — SEVERE PAIN (8–10): OPIOID (IF TRAINED AND AUTHORIZED)

Morphine: 2–4mg IV/IM slowly q4h. Start low; titrate to effect. Monitor respirations — if <12/min, hold next dose.
Oral Morphine (if no IV): 5–10mg orally q4h. Slower onset (30–60 min) but effective for field use.
Have reversal agent: Naloxone (Narcan) 0.4–2mg IV/IM — reverses opioid overdose within 2 minutes. Essential if morphine is in your cache.
Document dose, time, route, and patient response. Monitor every 15 minutes after opioid administration.

NON-DRUG ADJUNCTS

Wound immobilization reduces pain significantly — properly splinted fractures require less medication. Psychological support: calm voice, explain what you are doing, patient advocacy. Cold therapy: ice wrapped in cloth, 20 min on/20 off, first 48 hours only.

▶ INFECTED WOUND MANAGEMENT▼

In a grid-down scenario, wound infections are common and life-threatening. The sooner infection is recognized and treated, the better the outcome. A wound that was clean yesterday can be life-threatening tomorrow.

INFECTION PROGRESSION — RECOGNIZE THE STAGES

Stage 1 — Local inflammation (Days 1–3, Normal): Mild redness, warmth, swelling at wound edges. Small amount of clear/pale yellow fluid. This is normal healing — do NOT over-treat.

Stage 2 — Local infection (Days 2–5): Increasing redness spreading beyond wound edges. Warmth. Swelling. Pus — thick, yellow-green. Foul odor. Patient may have low-grade fever. BEGIN ANTIBIOTICS NOW.

Stage 3 — Spreading infection / Cellulitis: Red streaking spreading UP the limb from the wound (following lymph channels). Firm, hot, red skin. Fever >101°F. Patient feels ill, fatigued. URGENT — spreading sepsis. Escalate antibiotics, consider evacuation.

Stage 4 — Sepsis / Systemic: High fever OR hypothermia. Rapid heart rate (>100). Rapid breathing (>20). Confusion. Patient very ill. LIFE-THREATENING. Maximum antibiotics, urgent evacuation, IV fluids.

TREATMENT PROTOCOL — INFECTED WOUND

Drain it: Infected closed wounds MUST be opened. If there is an abscess (fluctuant, pus-filled swelling): incise with scalpel at the most dependent point. Drain pus completely. Do not stitch it shut.
Irrigate aggressively: High-pressure irrigation with 60mL syringe. Use sterile water or Dakin's solution (mild concentration: 3 tsp bleach per 4 cups boiled water + ½ tsp baking soda). Minimum 500mL per wound.
Pack the wound open: Use wet gauze (moistened with sterile water or Dakin's). Pack loosely into wound cavity. Cover with dry outer dressing. Do NOT stitch infected wound closed.
Change dressings twice daily: Remove packing, re-irrigate, re-pack. Each change: assess for improvement or worsening. Wet-to-dry packing debrides the wound with each change.
Antibiotics: Skin/soft tissue: Amoxicillin 500mg TID x10 days. Deep wound/spreading: Amoxicillin 875mg BID or add Metronidazole 500mg TID (covers anaerobes in deep/contaminated wounds). Red streaking: Doxycycline 100mg BID.
Elevate: Keep infected limb elevated above heart level. Reduces swelling and promotes drainage.
Mark the margin: Use a permanent marker to draw a line at the edge of redness. Check every 4 hours — if redness expanding beyond the line, infection is spreading, escalate treatment.
Track temperature: Check every 4–6 hours. Rising fever = worsening. Falling after antibiotics = improving.

NECROTIZING FASCIITIS (Flesh-Eating Infection): Severe pain out of proportion to appearance. Skin may look normal but tissue is dying underneath. Spreading rapidly — hours, not days. Gray/brown skin discoloration. Crepitus (crackling under skin = gas-producing bacteria). THIS IS A SURGICAL EMERGENCY. Antibiotics alone will not save the patient. Evacuate immediately.

▶ DENTAL EMERGENCIES▼

⚕ A dedicated dental module — IVORY — is part of the WATCHMAN Command Suite and covers the full scope of field dentistry: examination, diagnosis, local anesthesia, cement fillings, extractions, and long-term dental care planning. The protocols below cover immediate emergencies only.

In Vietnam, half of all sick call was dental. Dental pain incapacitates. In prolonged grid-down, dental emergencies are inevitable. These protocols do not require dental training.

TOOTHACHE — DIAGNOSIS

Identify the bad tooth: touch each tooth in the area with something cold. The bad one will be very sensitive.
Touch the same tooth with something warm. If it hurts with heat AND the pain continues 10 seconds after removing the heat source: the nerve is irreversibly damaged. This tooth requires extraction — it cannot be saved without a root canal.
If sensitive to cold only (not heat): the tooth is likely saveable. Pain relief and antibiotics may buy time.
Look for: visible cavity (dark hole), broken tooth, swelling at the gum line (abscess), pus.

TOOTHACHE — TREATMENT (Without Extraction)

Pain: Ibuprofen 400–800mg q6–8h + Acetaminophen 500–1000mg q6h (can alternate for better control).
Clove oil (Eugenol): Natural dental anesthetic — soak a small cotton ball and pack gently into the cavity. Provides significant temporary relief. Do not apply to gums — causes irritation.
Temporary filling: Zinc oxide eugenol (IRM powder) mixed to putty consistency fills the cavity. Dental cement (Cavit or Dycal) also works. Keeps air and debris out of the nerve.
Infection / Abscess: Amoxicillin 500mg TID x7 days. Metronidazole 500mg TID if no improvement in 48 hours. Penicillin-allergic: Clindamycin 300mg TID.
Warm salt water rinses 4x daily — reduces inflammation and keeps area clean.

KNOCKED-OUT TOOTH (AVULSION) — TIME CRITICAL

Re-implantation success drops 1% per minute the tooth is out of the socket. Act immediately.

Pick up tooth by the CROWN (white part) — do NOT touch the root.
If dirty: rinse gently with clean water for 10 seconds. Do NOT scrub.
Storage if not re-implanting immediately: place tooth in milk (best), or between the patient's cheek and gum, or in sterile saline. Do NOT use tap water — kills root cells.
If tooth has been out <15 minutes: attempt re-implantation. Rinse socket gently. Insert tooth firmly with steady pressure in correct orientation. Have patient bite down on gauze.
Splint to adjacent teeth: use dental wax, soft orthodontic wax, or carefully applied thin wire secured with dental cement or superglue. Patient on soft diet.
Antibiotics: Amoxicillin 500mg TID x7 days. Pain: Ibuprofen + Acetaminophen.
After 2 hours out: root cells are dead. Re-implantation still possible but pulp will decay. Treat it as a dental implant — it may scar into position.

DENTAL ABSCESS — FIELD DRAINAGE

A dental abscess that is not draining can spread to the jaw, neck, and airway. Airway compromise from dental infection is fatal. If swelling is closing the throat — evacuate immediately.

Identify abscess: swelling at gum line near a tooth, fluctuant (soft and pus-filled when pressed), patient has severe pain, fever, swollen lymph nodes in neck.
Begin Amoxicillin 500mg TID immediately. Add Metronidazole 500mg TID for more severe cases.
If abscess is pointing (skin is thinned, feels like it wants to burst): drain it. Clean with Betadine. Small stab incision with #11 blade at the most fluctuant point. Allow pus to drain. Do not pack dental abscesses.
Warm salt water rinses every 2 hours encourage continued drainage.
Monitor for airway involvement: difficulty swallowing, difficulty opening mouth (trismus), swelling spreading toward the neck or under the chin. Any of these = evacuate urgently.

EVACUATION CRITERIA

Evacuate for dental emergency when: airway compromise, swelling spreading to neck or floor of mouth, jaw cannot open (trismus), not responding to antibiotics in 48 hours, or patient cannot maintain hydration due to pain.

▶ EVACUATION CRITERIA — WHEN TO MOVE▼

In a grid-down scenario where resources are limited, the evacuation decision is one of the hardest and most important you will make. Evacuate too early and you expend resources and risk en route. Evacuate too late and the patient dies of something treatable. This guide establishes objective criteria.

EVACUATE IMMEDIATELY — MINUTES MATTER

▸ Uncontrolled hemorrhage despite tourniquet and wound packing
▸ Tension pneumothorax not fully relieved by needle decompression
▸ Airway obstruction not resolved by basic maneuvers or surgical airway
▸ Suspected internal abdominal bleeding (rigid abdomen, falling BP, mechanism of injury)
▸ Shock Class III–IV not responding to fluids
▸ Altered mental status after head injury (any deterioration from baseline)
▸ Anaphylaxis not responding to epinephrine
▸ Cardiac arrest with reversible cause (hypothermia, drowning, anaphylaxis)
▸ Burns >20% body surface area, or any burns to face/airway
▸ Dental/soft tissue infection spreading to neck or floor of mouth

EVACUATE URGENTLY — HOURS MATTER

▸ Open fractures (bone through skin) — infection risk escalates hourly
▸ Compartment syndrome — fasciotomy window is 6 hours
▸ Eye injuries with vision loss
▸ Suspected spinal injury with neurological deficits
▸ Infection with red streaking (lymphangitis) or spreading cellulitis
▸ High fever (>103°F) not responding to antipyretics and antibiotics
▸ Diabetic crisis not responding to glucose management
▸ Seizures in a patient with no known seizure history
▸ Wound not improving after 48–72 hours of antibiotic therapy
▸ Inability to maintain oral hydration (vomiting everything)

TREAT IN PLACE — MONITOR CLOSELY

▸ Minor lacerations healing normally
▸ Closed fractures, properly splinted, CMS intact
▸ Mild-to-moderate infections responding to oral antibiotics within 48 hours
▸ First/second degree burns <10% body surface, not on face or hands
▸ Sprains and minor musculoskeletal injuries
▸ Mild dehydration responding to oral rehydration
▸ Stable chronic conditions (managed blood pressure, managed diabetes)
▸ Dental pain controlled with medication, no spreading infection

TRANSPORT PRECAUTIONS

Stabilize BEFORE moving: hemorrhage controlled, airway secured, fractures splinted, patient packaged for transport.
Spinal precautions: if spinal injury suspected, log-roll onto rigid surface. Maintain neutral alignment throughout transport.
Position by injury: head injury = slight elevation (30°). Shock = flat, legs elevated. Chest injury = semi-reclined. Unconscious = recovery position. Spinal = supine, neutral.
Assign a dedicated attendant for transport — monitoring vital signs, airway, and consciousness level every 5 minutes en route.
Document: injury, treatments given, medications (name, dose, time, route), vital signs trend, current status. This travels with the patient.

☐ MEDICAL SUPPLY INVENTORY

TIER	ITEM	CATEGORY	ON HAND	NEEDED	STATUS	EXPIRY	LOCATION / CACHE	ACTIONS

No supplies logged.

📋 PATIENT LOG — SOAP FORMAT

ID / NAME	DATE	CHIEF COMPLAINT	ASSESSMENT	STATUS	CAREGIVER	ACTIONS

No patient records. Add a patient to begin tracking.

◈ START TRIAGE BOARD

Simple Triage And Rapid Treatment — Assess RPM: 30 (respirations) — 2 (CRT seconds) — Can Do (follows commands). 30 sec per patient. Triage only — do NOT treat unless stopping massive bleeding, opening airway, or treating shock.

🔴 IMMEDIATE (RED) 0

NEEDS IMMEDIATE CARE / WILL NOT SURVIVE IF UNTREATED

🟡 DELAYED (YELLOW) 0

NEEDS CARE WITHIN 2–4 HRS / STABLE FOR NOW

🟢 MINIMAL (GREEN) 0

WALKING WOUNDED / MINOR INJURIES ONLY

⬛ EXPECTANT (BLACK) 0

DECEASED OR UNSURVIVABLE WITHOUT ADVANCED CARE

🏥 MEDICAL ASSETS

⚕ WHAT IS THIS?
Medical infrastructure pushed from the Area Intel Map. Hospitals, urgent care, EMS stations, pharmacies, and fire / first-responder nodes within evacuation distance of your AO. Pre-event: evacuation planning, treatment-tier reference, regional capability awareness. Post-event: track facility degradation, plan alternates, identify which assets remain operational. Per Alton (Survival Medicine Handbook): the absence of advanced prehospital care converts otherwise-survivable trauma into mortalities at ~3x baseline rate. Knowing what existed and what remains is mission-critical.

No medical assets logged yet. Push hospitals, urgent care, EMS, pharmacies, or fire stations from the Area Intel Map to populate this list.

📖 QUICK REFERENCE

⊕ VITAL SIGNS — NORMAL RANGES

AGE GROUP	PULSE (BPM)	RESP RATE (/MIN)	BP SYSTOLIC	TEMP (°F)	O₂ SAT
Adult (18+)	60–100	12–20	90–140	97–99	>95%
Child (6–12)	70–120	18–25	80–120	97–99	>95%
Child (1–5)	80–130	22–30	75–115	97–99	>95%
Infant (<1 yr)	100–160	30–40	70–100	97–99	>95%

Tachycardia (>100 bpm) = pain, fever, shock, dehydration, anxiety. Bradycardia (<60) = severe hypothermia, head injury, medications, athletes (normal). RR >30 or <8 = emergency. Any temp >103°F or <95°F = urgent action.

⊕ RULE OF NINES — BURN SURFACE AREA ESTIMATION

ADULT

Head & Neck9%

Each Arm (entire)9%

Chest (front)9%

Abdomen (front)9%

Upper Back9%

Lower Back9%

Each Thigh9%

Each Lower Leg9%

Perineum1%

CHILD (MODIFIED)

Head & Neck18%

Each Arm9%

Chest (front)9%

Abdomen (front)9%

Back (entire)18%

Each Leg (entire)13.5%

Perineum1%

Burns >20% body surface = HIGH shock risk. Burns to face/hands/feet/genitals always require aggressive treatment. 2nd/3rd degree burns over 10%+ in field = urgent.

PALM METHOD: Patient's own palm (fingers together) = approximately 1% body surface area. Useful for irregular burn patterns.

⊕ HEMORRHAGIC SHOCK — CLASS STAGING

CLASS I — Compensated (<750 mL / <15%)
Pulse <100, BP normal, RR normal, mental status normal. Skin normal. Minimal symptoms.

CLASS II — Mild (750–1500 mL / 15–30%)
Pulse 100–120, BP normal or slightly low, RR 20–30, anxious/agitated. Skin pale, cool, clammy.

CLASS III — Moderate (1500–2000 mL / 30–40%)
Pulse >120, BP dropping (systolic 70–90), RR 30–40, confused. Skin pale/mottled, CRT >2 sec.

CLASS IV — Severe (>2000 mL / >40%)
Pulse >140 (or absent), BP systolic <70, RR >35 or agonal, lethargy/unresponsive. Death imminent without immediate intervention.

⊕ MEDICATION REFERENCE — FIELD USE

MEDICATION	USE	ADULT DOSE	NOTES / CAUTIONS
Ibuprofen (Advil/Motrin)	Pain, inflammation, fever	200–800mg q6–8h (max 3200mg/day)	Do NOT use for head injuries, GI bleeding, shock, or kidney disease. Take with food.
Acetaminophen (Tylenol)	Pain, fever	325–1000mg q4–6h (max 4000mg/day; 3g if elderly)	Preferred for head injuries. Do NOT exceed dose — liver damage. Avoid with alcohol.
Aspirin	Cardiac event, anti-platelet, pain	325mg chewable (cardiac); 81mg daily (prevention)	Do NOT give to children (<16) — Reye's syndrome risk. Avoid if bleeding, head injury.
Diphenhydramine (Benadryl)	Allergic reactions, anaphylaxis support, sleep aid	25–50mg q4–6h (max 300mg/day)	ADJUNCT to Epinephrine for anaphylaxis — never sole treatment. Causes drowsiness.
Epinephrine 1:1000 (EpiPen)	Anaphylaxis, cardiac arrest	0.3mg IM outer mid-thigh. Repeat in 5–15 min if needed.	Children <66 lbs: 0.15mg (EpiPen Jr). Refrigerate; expires ~1–2 years. Auto-injector preferred.
Amoxicillin (Fish-Mox Forte)	Wound infection, cellulitis, dental	500mg 3x/day (TID) for 7–10 days	Penicillin family. Avoid if PCN allergic. Good for skin/soft tissue infections.
Doxycycline (Bird-Biotic)	Infections (Lyme, respiratory, wound)	100mg 2x/day (BID) for 7–14 days	Do NOT give to children <8 or pregnant women. Take with full glass water. Sun sensitivity.
Ciprofloxacin	Gram-negative infections, UTI, some wound infections	500mg 2x/day (BID) for 7–14 days	Avoid in children and pregnancy. Reserve for resistant infections.
QuikClot / Celox	Hemostatic agent — hemorrhage control	Pack directly into wound, apply firm pressure 3–5 min	Celox: chitosan (shrimp-based) — caution if severe shellfish allergy. QuikClot: kaolin-based.
Oral Rehydration (ORS)	Dehydration, shock support, diarrhea	Drink to thirst; 200–400mL/hr if dehydrated	Make: 1L water + ½ tsp salt + 6 tsp sugar. Electrolytes critical for recovery.

⊕ PEDIATRIC CONSIDERATIONS

Airway: Smaller, softer, more anterior. Even slight obstruction is dangerous. Use smaller OPA/NPA. Sniffing position to open airway (not full head tilt).

CPR: 2-finger compressions (infant), one-hand for small child. Rate 100–120/min. Depth 1.5" (infant) to 2" (child). AED: use pediatric pads for <55 lbs.

Hypothermia: Children lose heat much faster — smaller mass relative to surface area. Dry immediately, wrap with adult bodies if needed.

Burns: Use modified Rule of Nines. Children are more susceptible to dehydration and burn shock. Aggressive oral hydration.

Dehydration signs: Sunken fontanelle (infant), dry mouth, no tears, no urine for >8 hours, sunken eyes.

Medications: Ibuprofen 5–10mg/kg q6–8h. Acetaminophen 10–15mg/kg q4–6h. No aspirin under 16. Diphenhydramine 1mg/kg up to 25mg.

⊕ START TRIAGE — RPM QUICK REFERENCE

STEP	ASSESS	RESULT	TAG
1. RESP	Is patient breathing?	Not breathing after airway repositioned	BLACK
		Starts breathing after airway opened	RED
		Respirations >30/min	RED
2. PERF	Radial pulse + CRT?	No radial pulse OR CRT >2 sec	RED
2. PERF	Radial pulse + CRT?	Pulse present AND CRT ≤2 sec	→ Check Mental Status
3. MENTAL	Follows simple commands?	Unresponsive or disoriented	RED
		Can follow commands but cannot get up	YELLOW
		Follows commands AND can walk	GREEN

When in doubt between categories — always tag the HIGHER priority. In START, only three interventions are permitted: stop massive bleeding, open airway, elevate legs for shock.

⊕ 9-LINE MEDEVAC REQUEST — RADIO FORMAT

For HAM/radio-equipped MAGs. Transmit in order. "BREAK" between categories on Line 3 and 5 if mixed. Encrypt grid on Line 1 per unit SOP.

LINE	ITEM	BREVITY CODES / FORMAT
1	Location of pickup site	Grid coordinates (encrypt if COMSEC active)
2	Radio frequency & callsign	Pickup site radio freq + callsign (can send in clear)
3	Patients by precedence	A=Urgent (2hr) • B=Urgent-Surgical • C=Priority (4hr) • D=Routine (24hr) • E=Convenience
4	Special equipment	A=None • B=Hoist • C=Extraction equipment • D=Ventilator
5	Patients by type	L=Litter (non-ambulatory) • A=Ambulatory (walking)
6	Security of pickup site	N=No enemy • P=Possible enemy • E=Enemy present • X=Armed escort required
7	Method of marking LZ	A=Panels • B=Pyrotechnic signal • C=Smoke (state color) • D=None • E=Other
8	Patient nationality/status	A=US Military • B=US Civilian • C=Non-US Military • D=Non-US Civilian • E=POW/EPW
9	NBC contamination	N=Nuclear • B=Biological • C=Chemical • None=Routine (omit if not contaminated)

Example call: "ALPHA BASE, this is SUTTON ONE requesting 9-Line MEDEVAC. Line 1: [grid]. Line 2: [freq] SUTTON ONE. Line 3: Alpha, one urgent. Line 4: Alpha. Line 5: Litter, one. Line 6: November. Line 7: Charlie, purple smoke. Line 8: Alpha. Line 9: None. OVER."

⊕ GLASGOW COMA SCALE (GCS)

RESPONSE	DESCRIPTION	SCORE
EYE OPENING (E)
Spontaneous	Opens without stimulation	4
To voice	Opens to verbal command	3
To pain	Opens to painful stimulus	2
None	No response	1
VERBAL (V)
Oriented	Knows person, place, date	5
Confused	Converses but disoriented	4
Inappropriate	Random words, no conversation	3
Incomprehensible	Moaning, groaning only	2
None	No verbal response	1
MOTOR (M)
Obeys commands	Follows verbal instructions	6
Localizes pain	Moves toward painful stimulus	5
Withdraws	Pulls away from pain	4
Flexion	Abnormal flexion (decorticate)	3
Extension	Abnormal extension (decerebrate)	2
None	No motor response	1

INTERPRETATION (E+V+M = TOTAL)

15 — Normal, fully conscious

13–15 — Mild TBI / Concussion

9–12 — Moderate TBI

3–8 — Severe TBI / Deep coma

3 — Deepest coma (minimum possible)

Any downward trend in GCS = URGENT. A drop of 2+ points from baseline = immediate escalation. Reassess every 15 min for head injury patients.

AVPU quick field check: Alert (GCS ~15) • Voice (GCS ~12) • Pain (GCS ~8) • Unresponsive (GCS 3–5)

⊕ ANTIBIOTIC SELECTION GUIDE — GRID DOWN

Use the narrowest effective antibiotic. Overuse breeds resistance. Always complete the full course. Discontinue only if confirmed allergy or clear adverse reaction.

INFECTION TYPE	FIRST CHOICE	SECOND CHOICE	IF PCN ALLERGIC	DURATION
Skin / Soft Tissue (wound, cellulitis)	Amoxicillin 500mg TID	Doxycycline 100mg BID	Clindamycin 300mg TID	7–10 days
Spreading / Red Streak (lymphangitis)	Amoxicillin 875mg BID	Doxycycline 100mg BID	Clindamycin 300mg TID	10–14 days
Dental / Oral Abscess	Amoxicillin 500mg TID + Metronidazole 500mg TID	Amoxicillin 500mg TID alone	Clindamycin 300mg TID	7 days
Respiratory (mild) (bronchitis, sinusitis)	Azithromycin 500mg Day 1, 250mg Days 2–5	Doxycycline 100mg BID	Azithromycin (already OK)	5–7 days
Respiratory (severe) (pneumonia)	Doxycycline 100mg BID + Azithromycin	Ciprofloxacin 500mg BID	Ciprofloxacin 500mg BID	10–14 days
Urinary Tract (UTI)	Ciprofloxacin 500mg BID	Doxycycline 100mg BID	Ciprofloxacin (OK)	7 days (3d uncomplicated)
Deep / Anaerobic (abdominal, bite wound)	Amoxicillin 500mg TID + Metronidazole 500mg TID	Ciprofloxacin 500mg BID + Metronidazole	Clindamycin 300mg TID + Metronidazole	10–14 days
Lyme Disease	Doxycycline 100mg BID	Amoxicillin 500mg TID	Azithromycin 500mg QD	21 days (full course critical)
Animal / Human Bite	Amoxicillin 875mg BID	Doxycycline 100mg BID	Clindamycin 300mg TID + Ciprofloxacin 500mg BID	10–14 days

Metronidazole: do NOT consume alcohol during treatment — severe reaction. Doxycycline: avoid in pregnancy and children <8. Sun sensitivity — cover up. Ciprofloxacin: avoid in children, pregnancy; reserve for resistant cases.

★ TRAINING LOG — GROUP MEDICAL CERTIFICATIONS

Key certifications for grid-down preparedness: Stop the Bleed, TCCC (Tactical Combat Casualty Care), Wilderness First Aid, CPR/AED, WEMT, Combat Lifesaver, CERT (Community Emergency Response Team), PHTLS.

MEMBER	CERTIFICATION / COURSE	LEVEL	DATE COMPLETED	EXPIRY DATE	CERT STATUS	ISSUING ORGANIZATION	ACTIONS

No training records. Log group medical certifications to track readiness.

⚗ TOOLS — FIELD CALCULATORS

▶ PEDIATRIC DOSE CALCULATOR▼

For use when standard medical care is unavailable. Always verify weight before dosing. When in doubt, use the lower dose range. Never dose by age alone — use weight.

PATIENT WEIGHT

lbs kg

MEDICATION

Enter patient weight and select medication to calculate dose.

◈ GROUP MEDICAL READINESS

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