2012英軍臨床指南

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Emergency Guidelines
Intro
Introduction
Section 1
Preparation
Section 2
Incident management
Section 3
Treatment guidelines
Section 4
Transport
Section 5
Pathways
Supporting Guidelines Clinical Guidelines

Section 6
Toolbox for Operations

Section 7
Operational formulary
Joint Service Publication JSP 999
Section 8
Policies
Section 9
Documentation and audit
Section 10
3
Red Card reporting
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Intro
Contents Contents
Introduction
Introduction
Introduction
Section 1 How to use this document............................................................................................................2
Preparation Title page .............................................................................................................................................4

Authorisation and distribution....................................................................................................5
Section 2 Joint doctrine publications ...........................................................................................................6
Incident management Record of amendments .................................................................................................................7
Preface ..................................................................................................................................................9
Section 3
Emergency guidelines
Section 4
Section 1 Preparation
Transport
Section 2 Incident management
Section 5
Section 3 Treatment guidelines
Pathways
Section 4 Transport
Supporting Guidelines
Section 5 Pathways
Section 6
Toolbox
Supporting guidelines
Section 7
Section 6 Toolbox
Section 7 Operational formulary
Section 8
Section 8 Policies
Policies
Section 9 Documentation and audit
Section 9
Documentation and audit Section 10 Red card reporting
Section 10
Red Card reporting

1st Edition September 2008 1st Edition September 2008
Introduction ii 1 Introduction
JSP 999 JSP 999
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Intro
Using the online JSP 999 Adobe Reader navigation 4
Introduction Explanation Guidelines on navigation Introduction
Section 1 This is the online version of JSP 999. It looks different to the printed document Adobe Readers navigation buttons
but the content is identical. It is an interactive document and has been designed
to be read online. Adobe Readers inbuilt navigation buttons will enable you to move through the document in a
Preparation range of ways.
Printing
Section 2 You will not be able to print this document as it is not Selecting the Click to go to first page in
Click here to print black 21 / 214
suitable for printing. Use this link if you want to print JSP and white JSP 999 document button take you to the beginning of the
Incident management 999 in black & white only.
Click to go to first page in document
document.
Section 3 Navigation 21 / 214

Selecting the Click to go to previous page in
Treatment guidelines Section 6 Clicking on the menu items will take you to the various
Click to go to previous page in document document button will move you back one page.
sections.
Section 4 Toolbox Selecting the Click to go to next page in
21 / 214
document button will will move you forward
Transport Click to go to next page in document
one page.
Selecting a Go to box will take you directly to a
Section 5 1b
Selecting the Click to go to last page in
Go to Treatment
particular procedure or instruction. 21 / 214
guidelines document button will will move you
Pathways Click to go to last page in documen
forward to the final page of your document.
Command 21 / 214
Selecting the Click to return to the
Section 6 C Incident management 1 Clicking on internal menus will take you to specific Click to return to previous page view
chapters. previous page view and the Click to go to
the next page view buttons will will move you
Toolbox Safety
S Incident management 2
back and forth between pages youve viewed. This
21 / 214 is ideal for moving between the main document
Section 7 Communication Click to go to the next page view and hyperlinks.
C
Operational formulary Navigation using Adobe Reader
To make full use of the interactivity and Adobe Readers navigation, you will need to ensure Design of publication
Section 8 that your toolbars are set up correctly. Go to: This online publication has been designed by CGS Media Design Photograpy and Print
Policies Comments or suggestions on the design or functionality are welcomed and should be
directed to:
> View
Section 9 > Toolbars DII CGS MediaCommA-AMC-Des-DesS01
> More Tools T 01264 38 2176
Documentation and audit > Page Navigation
> Tick all Any comments on content should be directed to the sponsor.
Section 10
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Introduction 2 Change 3 September 2012 Change 3 September 2012 3 Introduction
JSP 999 JSP 999
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Intro
How to use this document Informational icons Icons
The icons below are used throughout this document to help communicate important Introduction
Introduction messages. They have been separated into three categories; Medical (green), Informational AUDIT
(blue) and Personal protection/Safety (yellow). The following key explains exactly what these
Section 1 icons represent.
Communication Information Audit
Preparation Medical icons
The Audit icon identifies aspects of care that are readily amenable to audit or where existing
The following three icons are used to denote the practitioner intended to action the guideline: audit standards are in place. However, any aspect of care can be considered for operational
Section 2 audit if highlighted as a potential for improvement.
Incident management Personal protection and safety icons
The following icons are used in conjunction with precautionary text to convey important
Section 3
messages regarding personal safety:
Doctor Nurse Medical Technician /
Treatment guidelines Medical Assistant
The following four icons are used in conjunction with text relating to patient diagnosis
Section 4 and treatment:
Transport
Particulate Mask Gloves Apron Important
mask /
Section 5 Respirator
Pathways The Go to navigation system

Cardiac Patient Medical Treatment
arrest presentation investigation The following navigation system is used for cross-referencing. In the example below the green
Supporting Guidelines lozenge tells you to go to Section 2 by its colour, and the information within the lozenge takes
The following icons are used to denote when transport to the next level of care should you to Incident management 1b which is within Section 2.
Section 6 beconsidered and the means of transport:
1b
Go to Incident
Toolbox management
1a1b
Section 7 You will see the navigational lozenges shown in the example opposite
Incident
throughout this document. They are used to aid general navigation in
management
Operational formulary Ambulance Medical conjunction with the Go to system.
helicopter
Section 8 The treatment timeline
The following icon is used as a treatment timeline indicator. It is representative of time taken
Policies for specific interventions and treatments from arrival at the facility, rather than time from
onset of symptoms.
Section 9
Section 10
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Introduction 4 5 Introduction
JSP 999 JSP 999
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Joint Service Publication 999 Authorisation
Intro
Introduction
Introduction Clinical Guidelines for Operations
Section 1 Joint Service Publication 999 supersedes Joint Doctrine Publication 403.1 (JDP 403.1)
dated September 2008, and is promulgated as directed by the Surgeon General.
Preparation
Authorisation & Distribution
Section 2 JSP 999 (Clinical Guidelines for Operations) is produced on behalf of the Surgeon General (SG)
under the direction of the Joint Medical Command Clinical Committee.
Incident management Director Medical Policy, Defence Medical Services Department HQ SG will make this policy publicly available in accordance with the legislation concerning
Freedom of Information. However, this Policy Letter is not to be published on the Internet without
the express permission of HQ SG (Medical Policy). Where elements of this policy become further
Section 3
incorporated into single Service policies and procedures that might affect individuals from minority
Conditions of release groups, action addressees are to ensure that the information is made available in a culturally
Treatment guidelines 1. This information is Crown copyright and the intellectual property rights for this appropriate manner this includes providing translation where required.
publication belong exclusively to the Ministry of Defence (MOD). No material or In accordance with direction given by SG, action addressees are to ensure that this JSP publication
Section 4 information contained in this publication should be reproduced, stored in a retrieval is promulgated to all medical personnel within their areas of responsibility.
system or transmitted in any form outside MOD establishments except as authorised
by both the sponsor and the MOD where appropriate. Comments on factual accuracy or proposals for amendment are welcomed and should follow the
Transport Red Card Reporting process outlined at the end of this document
2. This information may be subject to privately owned rights. Director Medical Policy,
JSP 999 is only available electronically; users requiring hard copy are responsible for the printing of
Section 5 Defence Medical Services Department these and subsequent maintenance of their currency.
Further advice concerning this policy can be obtained from HQ SG SO2 Medical Policy.
Pathways
List of contributors
Supporting Guidelines Editors 3rd Edition
Lt Col R Russell RAMC, Miss A Bess MIPA
Section 6
Editors & Project Officers 2nd Edition
Toolbox Col T Hodgetts CBE QHP L/RAMC, Col P Mahoney OBE L/RAMC, Lt Col R Russell RAMC,
WO A Carter MBE PMRAFNS, Miss A Bess MIPA
Section 7 List of Contributors 1st edtion
Col T Hodgetts QHP L/ RAMC, Surg Cdr S Bland RN, Lt Col M Byers RAMC, Lt Col P Davis RAMC,
Operational formulary Lt Col P Mahoney OBE RAMC, Lt Col R Russell RAMC, Lt Col M Russell RAMC, Lt Col A Terrell RAMC,
Lt Col D Wilson RAMC, Lt Col L Woolrich-Burt RAMC, Wg Cdr A Green RAF, Lt Cdr A Hoffman QARNNS,
Section 8 Maj M Bailey RAMC, FS A Carter MBE PMRAFNS
Front Cover Illustration: Wing Commander Gora Pathak.
Policies With grateful thanks to everyone who has contributed to Clinical Guidelines to Operations
since their inception and who continue to do so. If certification of contribution is required
Section 9 please contact the Editors
Tel: 0121 415 8848
Documentation and audit DII: SG JMC MEDD-ADMEM Professor PA
Section 10
Designed by CDS, 7 Eastgate, Leeds LS2 7LY www.cds.co.uk email: info@cds.co.uk
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JSP 999 JSP 999
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Intro
Record of amendments Amendments
Introduction
Introduction
Section 1 Change No. Date of Insertion Authority

Preparation 1 May 2010 JMC Med Dir
2 February 2011 JMC Med Dir
Section 2 3 September 2012 JMC Med Dir
Incident management
Section 3
Section 4
Transport
Section 5
Intentionally blank
Pathways
Section 6
Toolbox
Section 7
Section 8
Policies
Section 9
Section 10
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Introduction 8 Change 3 September 2012 9 Introduction
JSP 999 JSP 999
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Intro
Joint Service Publications Preface
Introduction Preface Introduction
Section 1 Purpose
Preparation 1. The primary purpose of JSP1 999 (Clinical Guidelines for Operations) is to improve care at
the point of contact with the patient. It is designed to provide a logical and consistent
Section 2 approach to emergencies in operational medicine and a guide to critical decision making.
2. Clinical care on operations is delivered by a spectrum of care providers within variable
Incident management single Service environments. These providers may be Regular or Reservist military
personnel or civilians under contract. A common understanding is imperative to
Section 3 providing consistent care, both within and between military operations. JSP 999 provides
guidance on the management of predictable clinical conditions for clinicians2 deployed
Treatment guidelines on operations so that the right interventions will be performed at the right time, in the
right sequence, by the right person, and in accordance with Healthcare Governance.
This guidance is supported by evidence and best practice, tempered by operational
Section 4 experience.
Transport 3. The principal target audience for JSP 999 is primary and secondary care clinicians. JSP
999 also has utility for those responsible for medical training, equipment and pan-DLOD3
medical capability development.
Section 5
Intentionally blank
Pathways Scope
4. JSP 999 addresses the actions required when preparing to respond forward to a casualty
Supporting Guidelines or to receive a critically ill/injured casualty in a medical treatment facility. A generic
incident management template provides guidance on the systematic actions at any
Section 6 scene involving casualties, with specific guidance for predictable hazards and action cards
for an incident involving multiple casualties.
Toolbox 5. A common gateway is provided for the treatment and evacuation of all clinical
emergencies across the spectrum of threat that includes trauma4, medical, environmental
Section 7 and toxicological emergencies, in both conventional and CBRN5 settings. The Emergencies
section is supported by a Toolbox of aids to diagnosis and treatment. Treatment is a
Operational formulary continuum from point of wounding or illness, to either resolution or definitive treatment,
with guidelines given as a range of interventions for a given condition at each
echelon of care.
Section 8
Policies
1. Joint Service Publication.
2. For the purposes of this JSP , the term clinicians covers doctors of all specialities, dental personnel, nurses, healthcare assistants
Section 9 and medical assistants/technicians. Some distinctions are made regarding the responsibilities of particular professional groups
but this is not ubiquitous. What is important is that the patient receives the right treatment in an appropriate timescale and that
a clinician only undertakes those medical interventions for which they possess the necessary training, skills and experience.
Documentation and audit 3. Defence Lines of Development.
4. Trauma refers to all injuries (battle and non-battle). The traditional classification into battle injuries and disease/non-battle
injuries, although appropriate for epidemiological and planning work, has no applicability to the clinical management of
Section 10 individual patients; injury and illness share the same initial approach to treatment.
5. Chemical, Biological, Radiation, Nuclear.
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Introduction 10 Change 3 September 2012 11 Introduction
JSP 999 JSP 999
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6. Non-critical conditions are largely excluded from this JSP: it is not intended to be an all-
inclusive textbook of military medicine. The focus is primarily on clinical conditions and Application Preface
Intro
situations where immediate access to supporting guidance will positively impact on the
11. This publication is intended to be referred to by clinicians during the acute Introduction
patient(s) being managed.
Introduction management of the patient. Its design places the highest importance on
7. JSP 999 also includes policy statements, an operational formulary and a Red Card
this user interface: the clinician may progress sequentially through Sections 2 -5 in
Section 1 feedback system to capture continuing experience to inform future structure and content.
an emergency, using the publication as a comprehensive aide memoire, or may simply
Audit tags appear throughout the document where standards are commonly monitored,
select individual guidelines.
Preparation and documentation to assist audit is also included.
12. Trainers will find that existing medical programmes already fit within this structure, but
8. These guidelines do not constitute Patient Group Directions (PGDs) and it remains a Unit
that JSP 951 provides a unique overarching system that links together these component
Section 2 responsibility to have appropriate PGDs in place. Individuals also have a responsibility
fragments 7.
to ensure that they are operating within the scope of their professional practice and
registration. 13. Medical planners will appreciated the importance of preparing to support the spectrum
Incident management of medical conditions and the time imperatives that exist in parallel to established
9. Medical forces on operations are configured to support only the deployed force; any
timelines in major trauma.
Section 3 non-entitled patients are only to be treated within existing capability. However, deployed
clinical personnel are regularly called upon to provide care to the very young. A limited 14. Logisticians will appreciate the stepwise approach within the chain of evacuation to
number of paediatric guidelines have therefore been included; these are consistent with equipment and drugs required, the need to reflect NHS best practice where practical
Treatment guidelines in the operational setting (and its implications with respect to equipment and drugs
extant policy6.
supplied), and the timelines that influence mortality and morbidity.
Section 4
Structure Linkages
Transport
10. The structure of this publication is as follows: 15. JSP 999 was previously JDP 4-03.1 Medical Support to Joint Operations8. Clinically,
this publication flows from the Defence Health Change Programmes Military Medicine
Section 5 Sections 14 Project, and both consolidates and builds on guidelines from a range of national and
Provide a common system for the management of all medical emergencies, international professional organisations and bodies.
Pathways encompassing preparation, incident management, treatment and evacuation.
Section 5
Presents clinical pathways in relation to ballistic, blast, blunt and burn injuries that
Section 6 summarise the key features of management in relation to mechanism of injury and
direct the user to specific, detailed, treatment guidelines.
Toolbox Section 6
Supplements the emergency treatment guidelines with a toolbox of normal values and
Section 7 clinical management support aids, together with Red Card reporting procedures.
Operational formulary Section 7

An operational formulary, providing rapid access to the dose and route of administration
Section 8 of the drugs used in the guidelines.
Section 8
Policies
Contains those policies relevant to the early management of acute illness or injury.
Section 9 Section 9
Contains clinical documentation to facilitate clinical audit against existing best practice
Documentation and audit standards. 6. JSP 950 Chapter 15; leaflet 2-15-1 Treatment of Non-Entitled Children on Operations.
7. JSP 951 links the approaches undertaken in Battlefield Casualty Drills, Military Acute Care, Battlefield Advanced Trauma Life
Support, Advancd Cardiac Life Support, Advanced Burns Life Support, Advanced Paediatric Life Support and Major Incident
Section 10 Medical Management and Support.
8. Which is itself related to AJP 4.10 Allied Joint Medical Support Doctrine and JDP4-00 (3rd Edition) Logistics for Joint Operations.
Red Card reporting

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Intro
Introduction
Section 1
Preparation
Section 2
Incident management
Section 3
Section 4
Transport
Section 5
Pathways

Section 6

Section 7
Section 8
Policies
Section 9 Section 1
Preparation
Section 10
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Intro
Preparation Preparation Contents
Introduction
Preparation
Introduction
PREP Intro.1 PREP Intro.4

Contents
Section 1
Preparation contains guidance on actions Guidance is given on the structure of the
Preparation to take prior to deploying to the incident
scene, supported by a structure for MEDEVAC
Trauma Team with details of individual
responsibilities. This is a best practice model
Actions on alert
Section 2 mission orders (similar in concept to Quick that cannot be replicated when multiple Preparation 1
Battle Orders). patients are received simultaneously: in
Incident management this instance, there will be a serial division
PREP Intro.2
The activation criteria are listed for the
of the Trauma Team under the direction
of the Consultant Emergency Medicine to MEDEVAC mission orders
Section 3
military Trauma Team. Where time is available optimally match the predicted requirements
of individual patients. Trauma Team
Preparation 2
to assemble the team, check equipment
Treatment guidelines resuscitation should utilize the Trauma
and assign roles this is invariably time well
Chart within the Documentation and Audit
Section 4
invested. International standard criteria based
on civilian experience have been enhanced to section of this publication, which indirectly Trauma team activation criteria
acts as a checklist for the Team Leader and
Transport
incorporate elements of the incident history
and anatomical injury that are unique to the is the cornerstone of the continuing audit Preparation 3
military operational setting. of all seriously injured Service personnel on
operations.
Section 5
PREP Intro.3 Trauma team roles & positions
Pathways There are a variety of processes to notify
the Trauma Team in daylight and silent Preparation 4
Supporting Guidelines hours. These include use of a loud-hailer,
vehicle siren, public address system (tannoy),
Section 6 runners, radio pagers, UHF radios and mobile
telephones. The method(s) chosen will
Right turn Resuscitation
Toolbox depend on the size of the hospital footprint Preparation 5
(taking into account if the alert can be
reliably heard around the complex) and
Section 7 the maturity of the operation (early entry
operations are unlikely to have sophisticated
Operational formulary electronic communication systems).
Section 8
Policies
Section 9
Section 10
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Section 1 2 Change 1 May 2010 Change 1 May 2010 3 Section 1
JSP 999 JSP 999
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Intro
Actions on alert 4
1
Preparation 1
Preparation
Introduction
Section 1
Preparation Deployment & Receiving Teams

Section 2
Incident management
Deploying Team Receiving Team
Section 3
Notification/Activation
Section 4
Record full details of task Record full details of incident
Transport Activate personnel Activate personnel
Mission brief (see Trauma Team Activation Criteria)
(see MEDEVAC Mission Orders) Team brief and assign roles
Section 5
Intentionally blank (see Trauma Team Roles)
Pathways
Preparation
Section 6
PPE Medical PPE (gloves, plastic apron,
Medical equipment check lead gown, visor where appropriate)
Toolbox
Weapons and personal military Team brief
Section 7 equipment (helmet/CBA/PLCE) Draw up analgesia +/ anaesthetic
Map/compass/GPS (sanitise kit/ agents +/ antibiotics; run through fluids
Operational formulary delete track history on GPS) Pre-load chest X-ray plate and position
PRR/radio communications portable X-ray machine
Escape plan Order universal donor blood or shock
Section 8
Collect refrigerated items pack if clinical information suggests
immediate transfusion likely
Policies
Prepare ultrasound probe for FAST
Section 9 2d
Go to Section 3 Treatment
Documentation and audit guidelines
Notify CT where available if perceived

requirement
Section 10
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Section 1 4 Change 3 September 2012 5 Section 1
JSP 999 JSP 999
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Intro
MEDEVAC mission orders Trauma team activation 2-3
Introduction Preparation 2 criteria Preparation
Section 1 Preliminaries Preparation 3

Task organisation and call-signs You may only receive a
Mechanism/History
Preparation Ground overview to pickup point (PUP); detail of PUP. Use map/sketch
triage category and a
Penetrating trauma mechanism of injury.
Situation Gunshot or shrapnel wound
Section 2 Casualties: number by priority, clinical detail, CBRN involvement? Blast injury (mine/IED/grenade)
For T1 casualties activate
the Trauma Team
Incident management Enemy: threat en route and at PUP Stab wound
Friendly Forces: MEDEVAC escort/protection Blunt trauma
Section 3 Mission Motor vehicle crash with ejection
MEDEVAC mission statement (repeat this) Motorcyclist or pedestrian hit by vehicle >30km/h
Treatment guidelines Fall >5 metres
Execution
Fatality in the same vehicle
Concept of Ops
Section 4 Entrapment and/or crush injury
Intent effect to be achieved (recovery of any casualties)
Scheme of manoeuvre chronological summary of how MEDEVAC will run Inter-hospital trauma transfer meeting activation criteria
Transport Main effort the activity most crucial to the success of the mission
Section 5
Missions and
To subordinates to allow own planning
Coordinating Instructions Anatomy
Pathways Timings in detail Injury to two or more body regions
Location of forming up point (FUP) e.g. departure HLS Fracture to two or more long bones
Supporting Guidelines Route to FUP (if relevant) and transport details
Spinal cord injury
Action in FUP/loading plan
Section 6 Action at PUP Amputation of a limb
Action on civilian casualties Penetrating injury to head, neck, torso, or proximal limb
Toolbox Action on enemy casualties Burns >15% BSA in adults or >10% in children or airway burns
Action on vehicle/aircraft down Airway obstruction
Section 7 Summary
Execution paragraph to be summarised
Operational formulary Service Support
Essential information or changes to SOPs: dress, equipment, weapon states,
or
Section 8 ammo, rations, water, batteries, personal morphine
Physiology
Special equipment required
Policies Systolic blood pressure <90mmHg or pulse >120bpm (adults)
Command and Signal Respiratory rate <10 or >30 per minute (adults); SpO2 <90%
Section 9 Relevant important locations Depressed level of consciousness or fitting
Code words, CEI changes Deterioration in the Emergency Department
Documentation and audit Synchronise watches Use 9-line information to extract Age >70 years
Questions detail for MEDEVAC Mission Orders Pregnancy >24 weeks with torso injury
Section 10
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Section 1 6 Change 1 May 2010 7 Section 1
JSP 999 JSP 999
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Intro
Trauma team roles & positions 4 Trauma team roles & positions 4 1a
Preparation 4 Preparation 4 (Contd)

Preparation Preparation
Introduction
Section 1 Team Leader (emergency physician)

Controls and manages the resuscitation
Preparation Makes decisions; prioritises investigations and treatment
Airway
Airway Assistant Airway Specialist (anaesthetist)
Section 2 Specialist Responsible for assessment and management of the airway & ventilation
Incident management Counts the initial respiratory rate
Administers oxygen; performs suction; inserts airway adjuncts; endotracheal
intubation (RSI)
Section 3
Maintains cervical spine immobilisation and controls the log roll
Treatment guidelines Takes an initial history (AMPLE)
Radiographer Airway Assistant (ODP or ED nurse)
Section 4 Nurse Assists in preparing equipment for advanced airway intervention
Transport 1 Assists with advanced airway intervention, e.g. applies cricoid pressure
X-Ray This role may be undertaken by Nurse 1
Machine
Section 5 Doctor 1 (emergency physician or surgeon)
Undertakes the primary survey: <C>+B to E
Pathways Clinical findings are clearly spoken to Team Leader and recorded by Scribe
Doctor Doctor Performs procedures depending on skill level and training
1 2
Supporting Guidelines Doctor 2 (GDMO)
Performs procedures depending on skill level and training
Section 6
Nurse
Toolbox 2
All team members are responsible
Section 7 for ensuring their findings and
decisions are correctly recorded
Section 8
This team represents a best practice model
Policies Where there are limited resources
Trauma Team individuals in the team will assume more
Section 9 Scribe than one role and specialist resources
Leader Specialists
Documentation and audit (Nurse/Medic) (e.g. surgeon) may move serially from one
patient to another dependent on the need for
specialist assessment and intervention skills
Section 10
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Intro
Trauma team roles & positions Trauma team roles & positions 4
Preparation 4 (Contd) Preparation 4 (Contd)

Preparation
Introduction
Section 1 Airway Assistant

Applies monitoring equipment
Preparation All team members are responsible
Assists advanced airway intervention
for ensuring their findings and
Assists with procedures
decisions are correctly recorded
Section 2
Nurse 1 (ED Nurse)
Incident management Cut remove clothing
Applying monitoring
Section 3 Mix/administer IV/IM medication
This team represents a best practice model
Where there are limited resources
Treatment guidelines Nurse 2 (ED nurse) individuals in the team will assume more
Cut remove clothing than one role and specialist resources
Section 4 Applies/sets up bair hugger or equivalent (e.g. surgeon) may move serially from one
Transport
Mix/administer IV/IM medication patient to another dependent on the need for
Blood drawn by Dr 2 into blood bottles, istat, BM, labels blood bottles, completes blood specialist assessment and intervention skills
request blood request paperwork (FMed 12A), ensures bloods are sent to labs.
Section 5
Pathways If Massive Transfusion policy activated

Nurse 3
Supporting Guidelines Man Rapid Infuser
Checks and administers blood products with another healthcare professional)
Section 6
N.B. a second rapid infuser may be required: repeat procedure as above.
Toolbox
Scribe (ED nurse or medic or HCA)
Section 7 Collates all information and records decisions on Trauma Chart
Operational formulary Radiographer

X-rays as directed by the Team Leader
Section 8
Hospital specialists
Policies Undertake secondary survey and advanced procedures (e.g. General Surgeon to undertake
secondary survey of the head and torso and Orthopaedic Surgeon to undertake secondary
Section 9 survey of the limbs, pelvis and spine)
Radiologist performs FAST scan, reviews primary images and guides further imaging /
Documentation and audit scanning.
If there is no deployed radiologist FAST may be undertaken by ultrasonographer or suitably
Section 10 trained surgeon, emergency physician or surgeon.
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Section 1 10 Change 3 September 2012 Change 3 September 2012 11 Section 1
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Intro
Right turn Resuscitation 5
Preparation 5
Preparation
Introduction
Section 1 Background
Right turn refers simply to the layout of the field hospital in Camp Bastion:
Preparation It is a left turn into Resuscitation Bay 1, but a right turn into the operating theatre (directly
opposite Resuscitation Bay 1).
Section 2 The term is applied to a casualty who moves directly into the operating theatre on arrival. It
has emerged as an increasingly useful process in the resuscitation of combat casualties who
Incident management are at the very edge of their physiological envelope.
This protocol does not by-pass Emergency Department care as such, as the ED team moves
Section 3 into the operating theatre for the multi-disciplinary resuscitation.
Treatment guidelines Which patients?
Section 4 Surgical time critical

Traumatic cardiac arrest with CPR in progress
Transport Limb trauma
Torso trauma } With signs of critical
hypovolaemia
Section 5
Intentionally blank Decision points
Pathways A decision to right turn can occur at two points:
Receipt of the advance pre-hospital information (JCHAT)
Supporting Guidelines Ambulance bay triage
Section 6 Note: an earlier decision is better as the team can pre-position itself.
Actions
Toolbox
(a) ED Team OR
Team Leader
Section 7
Nurse Level 1 Blood Warmer Teams
Operational formulary (b) Team leadership starts with the Consultant Emergency Medicine (positioned at the
foot end) and is passed on to the Consultant Anaesthetist (at the head end) once rapid
infusion lines are secured, fluid resuscitation with blood products has started, the patient is
Section 8
anaesthetised, and the initial imaging is complete (e.g. FAST scan and/or critical plain films.
Policies (c) Anaesthetists
Manage: A and central access
Section 9 Massive Transfusion Protocol
(d) Surgeons
Surgical intervention will start immediately in cardiac arrest or peri-arrest, if thoracotomy
and aortic cross-clamping is indicated.
Section 10
Red Card reporting

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Intro
Introduction
Section 1
Preparation
Section 2
Incident management
Section 3
Section 4
Transport
Section 5
Pathways

Section 6

Section 7
Section 8
Section 2
Policies
Section 9 Incident
management
Section 10
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Intro
Incident management Incident management Contents
Incident
Introduction Introduction Management
IM Intro.1 IM Intro.4
Generic principles contents
Section 1
The principles of incident management Common message formats are presented
Preparation follow the generic systematic approach to standardize the information passed from
Command
Section 2
encapsulated within the Major Incident
Medical Management and Support
the scene of a multiple casualty incident
(mnemonic METHANE) and at handover of C Incident management 1
(MIMMS) framework. a patient to the next level of care (mnemonic
Incident management MIST). An alphanumeric coded message
IM Intro.2
Safety
sequence is now used extensively for
S
Guidance is given, in the form of action cards, requesting SH for MEDEVAC (9-Line Message).
Section 3
for command of a multiple casualty incident
at both the incident site and the hospital. IM Intro.5 Incident management 2
Algorithms are given to assist the sorting
IM Intro.3 of both adult and paediatric patients into
Section 4 Communication
C
Safety is considered across the hazard priorities for treatment (triage) in both a
conventional and CBRN environment.
Transport
spectrum, taking into account needs that
may be predominantly, although not
Incident management 3
exclusively, single Service (for example rescue
Section 5 from water, actions following a mine strike,
Assessment
A
and actions following an aircraft crash).
Pathways
Section 6 Triage
Toolbox
T Incident management 5
Section 7
Operational formulary T Go to Section 3
Contents
Treatment
guidelines
Section 8
Policies Transport
T Go to Section 4
Contents
Section 9 Transport
Section 10
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Command 1
Intro
C Incident
Introduction Incident management 1 Management
Section 1 Major incident scene

Preparation First medical team at scene
Section 2 Incident management 1a
Incident management Medical Commander

Incident management 1b
Section 3
Scene layout
Treatment guidelines Incident management 1c
Section 4 Triage Officer
Transport Incident management 1d
Section 5
Ambulance parking
Intentionally blank Incident management 1e
Pathways
Ambulance loading
Supporting Guidelines Incident management 1f
Section 6 Casualty clearing
Toolbox Incident management 1g
Section 7 Major incident hospital

Operational formulary Medical Coordinator
Section 8
Incident management 1h
Policies Senior Nursing Officer

Incident management 1i
Section 9
Command Post
Documentation and audit Incident management 1j
Section 10
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Intro
First medical team at scene 1a
Incident
Introduction Incident management 1a Management
Start a log and record time of arrival.

Section 1
Wear protective clothing:
Preparation Helmet
High visibility coat or tabard (civil incident)
Body armour (hostile military incident): as per SOP.
Section 2
Make METHANE assessment, encode as necessary, and send.
Incident management Consider where arriving ambulance vehicles should park.
3
Section 3 Go to Incident
management
Consider where casualty clearing station/RAP should be placed (discuss with
Tactical Commander):
Section 4 safe distance from incident
on vehicle circuit
Transport on hard standing where possible
using available shelter and hard cover.
Section 5 Request/task the Tactical Commander to locate and mark a suitable
Intentionally blank
Emergency Helicopter Landing Site.
Pathways
Contents
Go to Section 4
Supporting Guidelines Transport
Section 6 Continue to assess and communicate with higher formation as details

become available.
Toolbox Continue duties of Medical Commander until relieved.
Section 7 1b
Go to Incident
management
Section 8
Policies
Section 9
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1b Medical Commander Medical Commander 1b
Incident
Introduction Incident management 1b Incident management 1b (Contd) Management
Section 1 Command Assessment

Take command of all medical assets; make key appointments. Identify areas for ambulance parking and CCS; establish an ambulance circuit
Preparation Remain near tactical command element where possible usually at the Incident (liaise with Tactical Commander).
Control Point. Wear a tabard to identify yourself when one is available and it is Identify helicopter landing site and ensure is marked.
Section 2 tactically appropriate. Assess developing hazards to military personnel.
Start a log of your actions, noting the time for each entry: use a nominated scribe
Incident management when resources allow. 4
Go to Incident
Safety management
Section 3
Take responsibility for the safety of all medical personnel at scene, or delegate this to a
Assess need for additional medical personnel and equipment resources;
Safety Officer. Tactical safety will remain the responsibility of the Tactical Commander.
Treatment guidelines liaise with higher formation as necessary.
2 Assess need to rest or relieve medical personnel at scene.
Section 4 Go to Incident
management Triage
Transport Ensure triage is being carried out appropriately; priorities for evacuation may differ
Communications from priorities for treatment at the scene.
Liaise regularly with Tactical Commander and/or commanders of any civil emergency Determine the use of the T4 (Expectant) category.
Section 5
services present.
Pathways Brief all medical personnel on arrival. 5
Go to Incident
Update higher medical formation regularly: pass information to receiving medical management
units in accordance with SOP and Communication Electronic Instruction (CEI).

Supporting Guidelines Treatment
Consider how you will communicate with fixed points at the scene (e.g. CCS,
Section 6 ambulance parking area, ambulance loading) depending on resources (e.g. runner, Establish a casualty clearing station (= casualty collection point/CAP/RAP or equivalent);
radio, loud hailer, hand signals, whistle, field telephone or mobile phone). delegate running of CCS to Medical Officer when available.
Toolbox Provide media brief when instructed by higher formation and with knowledge/ Provide medical personnel to treat patients at point of first contact; bring forward
involvement of Tactical Commander. medical personnel from CCS for specific tasks. Otherwise concentrate medical
Section 7 Follow METHANE and 9-Line message structures. personnel at CCS or deploy as per orders.
Aim to achieve best practice standards, but accept compromise when resources
Operational formulary 3 are overwhelmed.
Go to Incident
management
Contents
Section 8 Go to Section 3 Treatment
guidelines
Policies
Select appropriate transport for individual patients; liaise with loading officer and
Section 9 tactical commander.
Contents
Documentation and audit Go to Section 4 Transport
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Scene layout Triage Officer 1c-d
Incident
Introduction Incident management 1c Incident management 1d Management
Section 1 Primary triage (point of wounding)

Outer cordon (crowd control/force protection/perimeter security) In a military permissive environment, wear a tabard to identify yourself
Preparation as the Triage Officer if available.
Assign priorities and label casualties within the sector designated by the Medical Commander
Section 2 Use the Triage Sieve to initially prioritise adults.
Incident Ambulance
Incident management control point parking 5a
Military Commander Go to Incident
management
Medical Commander
Section 3 +/ Royal Military police
+/ Defence Fire Service
Treatment guidelines Use a Paediatric Triage Tape to initially prioritise children.
Security
5c
Section 4 may Go to
Inner cordon demand
Incident
management
the route
Transport
Patients Casualty in and out Implement the use of the T4 (Expectant) category at the discretion of Medical Commander.
is varied
Section 5 clearing Ambulance Keep a tally of the number of casualties of each priority within your assigned sector;
station loading point report this to the Medical Commander.
Pathways Once primary triage is complete, report to Medical Commander for further tasking.
Secondary triage (treatment facility)
Use the Triage Sort if you have enough time and personnel, otherwise continue with
Section 6 Survivors the Triage Sieve.
5b
Toolbox Go to Incident
management
Section 7
Chemical triage
Operational formulary Follow the Chemical Sieve & Sort.
Return uninjured
Section 8 to fighting role (HLS where permissive) Go to
5de
Incident
management
Policies
Section 9
Consider principles of defence including:
all round defence, mutual support, defence in depth,
and overlapping arcs of fire.
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Ambulance parking Ambulance loading 1e-f
Incident
Introduction Incident management 1e Incident management 1f Management
In militarily permissive environment wear a tabard to identify yourself as the In militarily permissive environment wear a tabard to identify yourself as the
Section 1
Parking Officer. Loading Officer.
Preparation Establish a parking area for ambulances, ideally on hard standing and on/adjacent Work within the CCS (or equivalent).
to vehicle circuit; consider camouflage as tactically required. Establish a holding area for casualties awaiting evacuation. Ensure this area
Section 2 Coordinate ambulance parking. is adequately staffed and equipped (direct your personnel and equipment
Confirm an appropriate Emergency Helicopter Landing Site has been established requirements to CCS commander).
Incident management and marked. Supervise the triage of casualties for evacuation.
Section 3 Contents
Go to
5
Go to Section 4 Transport
Incident
management
Receive medical teams as they arrive and direct them to Medical Commander/ Select appropriate transport and escort for individual casualties, liaising with
Section 4 Incident Control Point for briefing. a CCS doctor or the Medical Commander.
Assess suitability of protective equipment of arriving personnel and inform Liaise with Parking Officer and call forward vehicles as required.
Transport
Medical Commander when clothing is inadequate.
Contents
Section 5 Liaise with Loading Officer for requirement to send vehicles forward to CCS for Go to Section 4 Transport
patient evacuation.
Pathways
Evacuate casualties in priority order, allowing lesser priority casualties to be
evacuated when packaging of higher priority casualties is incomplete.
Ensure patient packaging is adequate (secure lines; limb/spinal immobilisation;
Section 6 adequate fluids and analgesia; documentation accompanying casualty).
Ensure loading of helicopter(s) is supervised by trained staff.
Toolbox
Contents
Go to Section 4
Section 7 Transport
Operational formulary Log the destination of casualties.
Section 8
Policies
Section 9
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Casualty clearing Medical Coordinator 1g-h
Incident
Introduction Incident management 1g Incident management 1h Management
In militarily permissive environment wear a tabard to identify yourself as the The Medical Coordinator is the doctor who leads the clinical response in the field
Section 1
Casualty Clearing Station (CCS) Officer. hospital/PCRF.
Preparation Take command of CCS (or equivalent). This role is logically undertaken by the General Medicine consultant (no immediate
If not already identified, select location with Medical Commander: clinical responsibility with multiple trauma casualties): the background is less important
than the fact it is predetermined and the individual is trained.
Section 2 Hard standing where possible
Close to vehicle circuit The Medical Coordinator is initially best situated in the Reception area to ensure
Incident management preparedness and adequacy of resources: later relocation to the Hospital Squadron
Safe distance from scene hazards office/Hospital Management Cell may be appropriate to coordinate critical transfers
Using available shelter and hard-cover. and casualty flow within the hospital.
Section 3
Clearly mark entrance to CCS and each priority area. The responsibilities of the Medical Coordinator are:
Treatment guidelines Assign staff to do triage: use Triage Sieve until adequate personnel to assist with Start a timed log of information, decisions and actions
Triage Sort. Liaise with OC Hospital Squadron/Command Post (dependent on the size of the
Section 4 hospital) to obtain up-to-date METHANE reports
5
Go to Incident
Liaise with Senior Nursing Officer to determine level of staffing required to meet
Transport management anticipated needs
Allocate medical staff to ED treatment teams and ensure all teams are briefed
Section 5 Place staff in a clinical area appropriate to their training and experience. Ensure minor treatments area is manned and equipped and personnel are positioned
Orientate casualties with head towards the centre of a tent/temporary shelter; do not at Reception to escort the minor injured
Pathways overcrowd a shelter. Ensure ability to rapidly deploy Immediate Response Team (IRT) or Medical
Emergency Response Team (MERT) personnel if requested
Set up equipment dump and delegate management of internal resupply.
Supporting Guidelines Call forward vehicles as required for transport of casualties: liaise with Parking Officer.
Monitor clinical needs during response and report equipment/drug/blood
requirements through command chain together with requirements for in-theatre
Section 6 When CCS overwhelmed with T1 / T2 do not attempt to treat T3 casualties at scene; transfers and CCAST
transport to next Role with medical assistance as escort where possible. T3 casualties may Provide the focus to obtain specialist reach out advice (PJHQ, Poisons Centre, CDC,
Toolbox still undertake self help and buddy aid using their personal medical equipment (this may clinical experts etc)
extend to army team medic capability.) Coordinate return to normal working practices as soon as possible and authorise
Section 7 Start to record destination of casualties treated in CCS and hand this responsibility to major incident stand-down.
Loading Officer.
Operational formulary Liaise with Medical Commander for staff and equipment resources.
These are generic guidelines:
Section 8 improvisation may be required dependent
on the size and nature of the incident
Policies and the available resources
Section 9
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Senior Nursing Officer Command Post 1i-j
Incident
Introduction Incident management 1i Incident management 1j Management
The Senior Nursing Officer (SNO) for the hospital will coordinate the clinical response jointly Maintain a timed log of information, decisions and actions.
Section 1
with the Medical Coordinator: for land operations the SNO may also be OC Hospital Squadron Initiate the clinical response by a predetermined activation system (telephone, tannoy,
Preparation and the established link between the clinical hospital function and CP. vehicle siren) to indicate Major Incident Standby or Major Incident Declared.
The SNO may initially be best situated in the Reception area with the Medical Obtain METHANE report; pass all clinical information and updates to the Medical
Coordinator to ensure preparedness and adequacy of resources: later relocation to the
Section 2 Coordinator and/or Senior Nursing Officer.
Hospital Squadron office/Hospital Management Cell will be appropriate to coordinate
nursing staff resources and casualty flow within the hospital. Determine any requirement for pre-hospital support (IRT/MERT) and deploy on demand.
Incident management
The responsibilities of the Senior Nursing Officer are: Manage information flow from Hospital Squadron to maintain accurate picture of
Start a timed log of information, decisions and actions casualty location, severity and requirements for evacuation.
Section 3
Liaise with Command Post to obtain up-to-date METHANE reports Inform chain of command at intervals regarding casualty numbers and severity,
Treatment guidelines Liaise with Medical Coordinator to determine level of staffing required to meet including all SIL and VSIL listings.
anticipated needs, including temporary relocation of ITU and ward nursing staff to ED Facilitate clinical requests for extraordinary equipment and/or personnel resources
Section 4 Ensure adequate manning to receive casualties at HLS (delegated to Senior Nurse ED) to support the response.
Ensure Senior Nurse ED allocates nursing staff to treatment teams and briefs all teams Ensure catering needs of staff are met where routine mealtimes are interrupted.
Transport Ensure Senior Nurse ED maintains a Casualty State Board to monitor initial flow and
disposition of casualties
Section 5 These are generic guidelines:
Liaise with QM to ensure arrangements to remove personal equipment and weapons
before entering ED improvisation may be required dependent
Pathways Reconfigure wards to generate the bed spaces for the anticipated number of casualties on the size and nature of the incident
Monitor use of equipment and drugs during response and identify requirements and the available resources
Supporting Guidelines for re-supply
Coordinate return to normal nursing shifts as soon as possible.
Section 6
Toolbox These are generic guidelines:

improvisation may be required dependent
Section 7 on the size and nature of the incident
and the available resources
Section 8
Policies
Section 9
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Safety 2
Intro
S Incident
Section 1 Care under fire drill

Preparation Incident management 2a
Section 2
Improvised explosive device
Incident management
Mine
Section 3 Incident management 2c
Treatment guidelines Vehicle accident
Incident management 2d
Section 4
Transport
Water safety
Incident management 2e
Section 5
Intentionally blank Aircraft accident
Pathways Incident management 2f
Supporting Guidelines CBRN/Hazchem safety

Incident management 2g
Section 6
Toolbox
Steep slope rescue
Incident management 2h
Section 7
Confined space
Operational formulary Incident management 2i
Section 8 Collapsed structure
Policies
Incident management 2j
Section 9 This section provides practical guidance on dealing with predictable safety hazards
Documentation and audit It does not replace local Standing Orders, but provides outline guidance
in an emergency when no trained assistance is available
Section 10 Optimal safety procedures demand prior training

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Care under fire drill 2a
Incident
Section 1
This drill should be learned and remembered: if you need to
Preparation read a guideline whilst under fire your training has failed
Section 2
All personnel (including casualties where able) to
Incident management return and maintain fire to suppress the enemy
Section 3
Both medic and Only the casualty
Section 4 casualty in in the open:
Transport
the open medic in cover
Section 5
Intentionally blank
Pathways Deploy smoke upwind If casualty unable to return
if available effective fire, tell them to lie
Supporting Guidelines as still as possible
Section 6
Toolbox
Consider: Plan rescue,
Section 7 considering:
Tourniquet for catastrophic
haemorrhage
Operational formulary Support from friendly
Roll casualty face down forces
(postural airway opening)
Section 8 Use of vehicles
until ready to move
Use of smoke
Policies Best use of cover
Use of rope line
Section 9 Quickest route

Evacuate to cover
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Improvised explosive device Mine 2b-c
Incident
Introduction Incident management 2b Incident management 2c Management
Section 1 (1) Suspected IED: The Four Cs (2) Action on mine find/functioning
On finding anything that is suspected to be an IED, specialist support should immediately Consider (and if possible identify) the kind of mine and fuse involved, to minimise risk
Preparation be sought. No radio/mobile phone transmissions should be made within 15m in order of functioning further mines. Mine fields often have mixes to include antitank and
to minimise risk of triggering electro-explosive devices. antipersonnel mines.
Section 2 Incident Commander should take the following actions: Mines may be located on the surface or buried/camouflaged. Scatterable mines may
a. Confirm. This may be as simple as to visually confirm, from a distance, the presence also be hung overhead (often trail an orientating streamer, which can easily be tangled
Incident management of the item reported. Evaluation of the size of the device (and possible secondary on a branch), so a thorough visual search must be carried out in all directions.
hazards in close proximity) should be made so as to assess the correct cordon distance. A simple procedure may be adopted, as described below, but specialist support should be
Section 3 Consideration should be given to how an EOD Operator or their remote vehicle will gain used wherever possible.
access to the item: what obstacles (e.g. stairs) are present? Do not close and lock doors Procedure, on foot:
that will impede this access.
Treatment guidelines Stop, stand still and alert others (inform command if appropriate by radio, but only if you
b. Clear. Move away from the item, as quickly as practicable, evacuating personnel out
toand beyond the required cordon distance. are standing more than 15m from mines.)
Section 4 Visually check area for trip wires and fuses: a trip wire feeler should be used where possible.
c. Cordon. Create a cordon to keep people at a safe distance. Standard evacuation
distances are a minimum: If specialist support is not available or appropriate, then turn around carefully within your
Transport 100m from small, hand delivered items footprint and retrace footprints to a safe area.
200m from suitcase bombs and small vehicles (cars) If no footprint is visible then look and feel for trip wires and fuses, then prod (see next page)
Section 5 400m from hazardous items including petrol tankers or large vehicles to clear a path until you reach a clear area.
These are minimum distances: where practical a larger area should be secured. If in a group:
Pathways Hazards must be assessed at cordon positions e.g. being out of line of sight is
preferable, but adjacent/below glass (e.g. housing/offices/shops) is not. Due to the Mark footprints for others.
Supporting Guidelines nature of an explosion glass may be shattered and drawn out of a building into the
street by the passage of the shock and pressure waves.
Use On Foot procedure.
Move one at a time.
Section 6 d. Control. Create an Incident Control Point (ICP) to control the cordon, monitoring Maintain 10 metre spacing.
arrival and departure of personnel.
Procedure, in vehicle:
Toolbox e. Check. Ensure that Confirm, Clear, Cordon and Control have been carried out and
the locations of the device, the ICP and a safe route has been passed up the command Stay in vehicle, inform command and request specialist help.
Section 7 chain. If you must leave the vehicle, exit via rear or over roof.
Usually the EOD Operator assumes responsibility for the scene until he/she declares the Visually check area for trip wires and fuses.
Operational formulary area to be safe from risk of explosion. The area is then handed back to the senior military/ Step only into vehicle tracks and follow these to a safe area.
civilian commander. It may be necessary to retain the cordon (possibly at a reduced
Section 8 distance) if the render safe procedure has damaged any of the surroundings and created
a physical hazard. This cordon will also protect the forensic evidence.
In all cases, once clear of danger mark the
Policies area, record it onto maps and report it to
command chain
Section 9
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Mine Vehicle accident 2c-d
Incident
Introduction Incident management 2c (Contd) Incident management 2d Management
Section 1 (2) Action on mine find/functioning (contd)

Vehicle accidents include Road Traffic Collisions and off-road incidents
The area should be first visually searched and then felt to exclude the presence of fuses
Preparation and trip wires indicating a mine (preferably using a trip-wire feeler). All indications of a mine They may involve soft-skin or armoured vehicles, and occupants or pedestrians
being present should be clearly marked for other personnel and avoided. Only after the area
Section 2 is cleared visually should the area be cleared by prodding. Safety of self
2a
Prodding is a systematic search of a lane/area carried out with a non-magnetic material Consider tactical threats first. If under fire, follow Care under fire drill Go to Incident
management
Incident management prodder. A bayonet or similar may be used if no issued mine prodder is available. The Wear suitable Personal Protective Equipment (PPE) if available. Consider:
ground should be probed to a depth of approximately 75mm at an angle of approximately Specialist PPE: e.g. flame retardant high-visibility coveralls
30 to the horizontal with a spacing of 3050mm.
Section 3 Uniform: sleeves rolled down. High-visibility tabard if available. Boots with some toe
Once a solid object or inconsistency in the ground is found then the suspect area should be protection if available
Treatment guidelines marked clearly and avoided. Helmet: hard hat or Kevlar helmet as available.
Gloves: leather gloves to protect from debris, latex or nitrile gloves to protect from body fluids
Section 4 Eyes: visor on helmet, goggles, safety glasses or combination
3050mm Ears: ear defenders, especially if transport in helicopters
Transport Respiratory: dust mask at hand if available (during glass management phase)
30 HAZMAT: See HAZMAT Safety guideline.
4a
Section 5 Approach with care, using the opportunity to read the wreckage Go to Incident
management
Safety of scene
Pathways Mine 75mm Consider tactical threats: think about use of armour, hard cover, and dead ground as
appropriate cover. Consider snatch rescue as part of Care Under Fire.
Supporting Guidelines Control/stop traffic.
Consider parking in fend-off position if on a road. Place traffic cones if available.
Section 6 Direction of serial prodding
Place fire extinguisher in readily available position.
Toolbox If train is involved, think about warning down the line and notifying train operator; use of
Prodding procedure for mine detection short circuit device (Track Operating Clip) to trigger the signal at the rear to red; or rapid
Section 7 extrication as appropriate.
Isolate vehicle battery (consider using electrics to wind down windows first where appropriate
Recovery of a casualty from a mined area
Operational formulary or opening doors in armoured vehicles). As a minimum, turn off ignition.
Follow procedures described above and:
Stabilise vehicle by chocking and consider whether deflating tyres will benefit stability.
Section 8 Continuously reassure casualty
Safety of casualty
Clear and mark exit route from the mined area
Policies Gain rapid access to any casualties.
Re-enter along marked path
Triage casualties.
Clear and mark path to casualty
Section 9 Plan a controlled release, but also plan for snatch rescue in the event a sudden hazard presents.
Clear area around casualty
Think about physical protection for the casualty: eye protection, ear protection (for helicopter
Documentation and audit Administer first aid MEDEVAC or if loud cutting equipment being used), fragment (especially glass) protection
Recover casualty along marked path, provide additional treatment as necessary with improvised shielding, and protection from heat or cold.
Section 10 on reaching safe ground and evacuate.
If you see a hazard that no-one else has shout!
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Water safety: Safety at sea Water safety: Water rescue 2e(i)-(ii) 1a
Incident
Introduction Incident management 2e(i) Incident management 2e(ii) Management
Section 1 The Environment

The fundamentals of safety at sea apply to all HM, RFA or Merchant Ships
Cordon and control: use a physical cordon of at least 3m from the water, and increase
Preparation this if on sloping or unstable ground.
Securing for sea
If the water source is tidal ask, What are the change tide times?
Section 2 Be prepared for sudden movements of the ship even in calm seas. Make sure medical
equipment is properly secured at all times. Remember the physical properties of water. It is:
Incident management Stow away any small items that could otherwise roll into spaces (such as drainage inlets) Relentless
and cause damage. Powerful 1m per sec in knee height water will exert a force of 8kg
(double the speed again and the force is quadrupled)
Section 3 Patients who are turned in must not be left unattended if they cannot look after
themselves, especially in rough weather. If they must be left, make sure they are secure. Predictable hydrology rarely changes.
Treatment guidelines If the ship is on cruising watch, inform the Captain before performing surgical procedures, Water flow:
as he may be able to put the ship onto a steadier course. Spins where there is friction a river embankment re-circulating water back into the
Section 4 main flow
Personal safety
Speeds up on the outside of river bends causing undercuts in the embankment
Transport Ship Knowledge is the key. Be completely familiar with the ships emergency procedures
Tends to travel in straight lines
and evacuation routes especially from where you live and work. Plan in advance how you
would evacuate your patients. Strains and siphons through fences, vehicles, felled tree branches.
Section 5 Dangerous features:
At your place of work and Action Station, know the locations of Emergency Breathing
Apparatus, fire-fighting equipment, first aid kit, and blankets (to prevent smoke ingress). Weirs that have near vertical drops are stoppers they will kill as the water
Pathways
re-circulates pulling the victim back into the white water at the base of the weir
Always have an emergency light source to hand.
Structures that can strain water through, but will entangle and pull down larger
Supporting Guidelines Securing for action objects (i.e. fences, felled trees, branches, vehicles)
Be correctly dressed for the appropriate readiness state. Structures that can cause foot entrapments tree roots, rocks, debris
Section 6
Have your Anti-Gas Respirator, life jacket and survival suit close at hand. Pins large structures mid-flow in water in which water pressure can pin someone
against, eventually submerging them.
Toolbox Be familiar with the layout of your Action Station and how to adopt the Brace position
when ordered to.
Section 7 Priorities
Operational formulary If the ship is hit, fire fighting and damage control take priority over casualty care, until medical
personnel are relieved by the appropriate specialist teams.
Section 8
Policies
Section 9
Section 10
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Water safety: Water rescue Aircraft accident 2e(ii)-f
Incident
Introduction Incident management 2e(ii) (Contd) Incident management 2f Management
Section 1 System of Work Management of the crash site

All personnel within the risk area to be in appropriate PPE Action following an aircraft crash is to take place in 2 phases. The first involves immediate
Preparation Work in pairs, at least
emergency care and making the site safe to prevent further injury, whereas the second involves
investigation of the cause.
Have throw-lines available Crash site hazards include: fire, explosive ordinance, aircraft debris (particularly modern
Section 2
Make use of buoyancy aids (including improvised aids) construction materials, such as Man-Made Mineral Fibres, MMMF).
Incident management Consider the rescue formula: MOs, supported by Command Advisers, must be prepared to give advice on the subject.
Shout: make verbal contact with the victim, instruct them to what you want them to do Phase 1 Immediate response
Section 3 Reach: branches, poles, weapons, stretchers
Live Aircrew
Throw: buoyancy aids, throw lines (not all ropes will float), combat jackets tied
Treatment guidelines together etc Clinical considerations must always dictate how aircrew are handled.
Row: if you have dinghies and the water has been assessed as being suitable for craft Aircrew who have ejected, yet appear uninjured, must still be managed according
Section 4 (not too much white water, current is slow moving, etc) to predetermined policy (AP 1269A 3-03 Annex I).
If you have accidental immersion consider: The PAIME (post-accident initial medical examination) is to be undertaken at an
Transport
Cold water reflex and how to minimise appropriate time, after which uninjured aircrew may be cleared to return to flying
duties immediately.
Section 5 Safe defensive swimming technique lying on back, facing down stream
Emergency signal to make others aware: Fatalities
One arm raised
Pathways Once death has been confirmed, MOs are to resist pressure to move bodies immediately.
Three repeated blasts on a whistle
Bodies provide valuable evidence for the accident investigation and are to be considered
under phase 2 of the post-accident response.
Supporting Guidelines Consider pre-plan do you have a rescue strategy?
Notification
Section 6 CFMO(RAF) is to be notified immediately. He/she will provide advice and notify other
agencies as required.
Toolbox
Phase 2 Management of aircrew following ejection/aircraft accidents
Section 7 or incidents
General considerations
Operational formulary The use of an ejection seat exposes the spine to considerable compression and flexion forces.
In addition, the cervical spine may be exposed to lateral flexion, rotation and traction.
Section 8 These forces may cause spinal compression fractures, rupture of ligaments, and spinal cord
and brain stem lesions. These injuries are often asymptomatic or more severe than mild
Policies symptoms may suggest. Instances have occurred, particularly following ejection at high
aircraft speeds, of potentially lethal cervical spine injury producing minimal symptoms and
Section 9 being undetected by radiography.
Section 10
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Aircraft accident CBRN/Hazchem safety 2f-g
Incident
Introduction Incident management 2f (Contd) Incident management 2g Management
Section 1 Management
Approach from upwind and uphill
It must always be assumed that
Preparation Personnel who have ejected or who have been exposed to high levels of vertical
acceleration have unstable head, neck and spinal injury. They must always be taken Safety of self
Section 2 to hospital for assessment and spinal immobilisation during movement is essential. Personal Protective Equipment
There has been a period, however brief, of loss of consciousness following ejection. Appropriate respirator (note general issue NBC canister will not meet requirements
Incident management Transient loss of consciousness is extremely common following ejection. for many Toxic Industrial Chemicals)
Assessment Safety of scene

Section 3 Respirable atmosphere?
Initial
Other hazards?
Treatment guidelines Full history and physical examination, including detailed neurological assessment
Military imperative?
AP and lateral X-rays of the cervical spine
Safety of casualty
Section 4 Secondary
Personal Protective Equipment
MRI scan
Transport Contamination?
Extractable?
The likelihood of identifying changes in a MRI scan diminishes with time; the MRI scan
Section 5 of the spine should be performed as soon as reasonably practicable following the aircraft Hot zone
accident or ejection. Ideally this should be within 24 hours, but must not be later than 2a
Life saving first aid only: extract along principles of Care under fire drill Go to Incident
Pathways 72 hours after the incident. management
Warm zone
Full casualty decontamination in an area upwind of incident
Supporting Guidelines The following investigations should be undertaken regardless of clinical well-being
Full Personal Protective Equipment for medical personnel
Detailed neurological assessment by a consultant neurologist or neurosurgeon
Section 6 Start therapy
MRI scanning of the whole spine to include the following sequences: Dispose of contaminated equipment in gas-proof bags
Sagittal T1 weighted
Toolbox Do not allow a build up of disposables
Sagittal T2 weighted
Sagittal STIR Cycle staff
Section 7 T1 / T1 casualties with RN (i.e. CBRN) contamination only may be evacuated
A whole body isotope scan 3 to 14 days after injury is desirable. MRI scanning of the brain prior to decontamination
should be limited to those who have, or who are suspected of having, suffered a brain injury.
Operational formulary The threshold level of suspicion for the presence of brain injury should be low, particularly Cold zone
where there has been a loss of consciousness, even for a very short period. Must be a safe area without risk of off-gassing
Section 8 Respiratory protection should be unnecessary
Ophthalmic considerations following aircraft ejection
Policies Injuries may result from canopy disrupting mechanisms and air blast during ejection. Decision
to refer an ejectee for examination by a consultant ophthalmologist should be determined on Notes
clinical grounds. With any evidence that the eyes may have been injured, the individual is to Thickened nerve and mustard agents pose a threat to medics due to long off-gassing
Section 9 duration. Cyanides and other highly volatile agents are less likely to pose a threat to medics
be seen by a consultant ophthalmologist as soon as possible. The individual is not to return to
flying until the MO has discussed the case with CFMO(RAF) and, where necessary, the RAF CA as the agents will probably have dispersed.
in ophthalmology. Irradiated casualties do not pose a threat to medics and contaminated (CBRN) casualties
do not pose a threat if medics wear appropriate Personal Protective Equipment.
Section 10 A build up of CBRN contaminant potentially poses a threat.
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Steep slope rescue Confined space 2h-i
Incident
Introduction Incident management 2h Incident management 2i Management
Section 1 The environment Definition of a confined space

Consider setting up a safety cordon depending on how far the drop and how steep
Preparation the ground. Any place, including any chamber, tank, silo, vat, pit, trench, pipe, sewer, flue, well
Is the rescue taking place near water? Ensure appropriate PPE. or similar space, in which, by virtue of its enclosed nature, there arises a reasonably
foreseeable specified risk.
Section 2
2e
Go to
Incident management Incident
management It often includes a space that is only accessible by a ladder.
The environment
Section 3 What are the conditions underfoot wet, slippery, uneven, crumbling?
Personnel entering the inner cordon to be in correct PPE and to be recorded
Identify an equipment storage area outside the inner cordon. (tagged) going in and out.
Consider weather, wind strength and direction if at height or exposed. What is the size of the space (e.g. a ships hold or engine room)?
Section 4 System of work Consider detection equipment for toxic gases, oxygen levels, excessive heat.
All personnel within the risk area to be in appropriate PPE helmets, gloves, eye protection Consider the ease of entry and exit.
Transport if working face is crumbling. What are you going to encounter within the space (e.g. liquid or solid material
Consider work restraint system using ropes within the inner cordon, either single line that can flow-sludge)?
Section 5 and slack for working within the area (but not near the edge) or double line and tensioned Are there other hazards (electrical, mechanical, noise, asbestos risk)?
for work positioning e.g. observing over the edge.
Pathways System of work
Rope protectors must be used for all ropes over the edge.
Can you access the space?
Single/double line for access (depending on tactical situation), double for rescue
Supporting Guidelines (i.e. where taking another persons load). Does your system allow for retrieval?
Use multiple anchor points, or single bomb proof anchor. Do you need to travel within the space?
Section 6 Do you need to disconnect from your retrieval system?
Consider carefully the method of descent and whether you will need to re-ascend.
Can you add or remove mechanical advantage? Do you need a rapid extrication plan?
Toolbox
Is the rope long enough? Can you or your kit get caught up during entry/exit?
Section 7 Consider depth of field perception concave slopes look shorter! Have you sufficient mechanical advantage to raise the casualty/rescuers?
Can this mechanical advantage be increased/decreased?
Operational formulary Casualty considerations
Do you have appropriate PPE (e.g. S10 Respirator or Breathing Apparatus
Consider method of lowering and/or raising the casualty.
remember that a filtration canister will not correct a hypoxic environment)?
Section 8 Consider using a counter weight.
Lighting what is available and what does the tactical situation allow?
Consider how much medical intervention should be done on first contact with the casualty,
Ensure oxygen delivery equipment is close to the working site.
Policies versus recovering them first.
Isolate electrical equipment where possible.
Consider whether you have enough manpower to move the casualty once rescued.
Section 9 Effective command, control and communications must be maintained throughout.
Think about setting up an Emergency Helicopter Landing Site while the work progresses.
Section 10
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Intro
Collapsed structure Collapsed structure 2j(i)-(ii)
Incident
Introduction Incident management 2j(i) Incident management 2j(ii) Management
Section 1 The environment Rescue Considerations

Why has the structure collapsed?
Preparation Natural: earthquake, tsunami, hurricane?
Section 2
Faulty structure? REPEAT
Deliberate: IED (secondary devices?), bomb, missile, arson etc?
What is the extent of the collapse?
Incident management
Cordon at least 100m around the structure. Control cordon with armed personnel if necessary. R Reconnaissance and survey of the building, putting together a picture of the original use
and shape of the building.
Section 3 All personnel moving through the cordon should be recorded, whether going in or out.
Apply strict hygiene control measures no eating and drinking in cordon. E Elimination of utilities: cutting power, shutting off water mains (drowning a very real
Treatment guidelines problem in recent earthquakes), isolation of gas main.
All personnel inside the inner cordon must wear appropriate PPE helmet, gloves,
respiratory protection, and eye protection. P Primary and surface search and rescue: search the rubble pile:
Section 4 Appropriate equipment for debris removal and casualty extraction e.g. long spinal board, Look: animals will smell victims better than humans; dogs may be aroused by the smell
KED, MIBS stretcher, semi-rigid collar. of open wounds.
Transport Listen: moans, crying, tapping, scratching, scraping. Ensure all personnel stop what they
Significant hazards
are doing when this is done. Must be coordinated with no freelancing taking place.
Section 5 External
E Exploration of voids and spaces if the structure has been supported or shored.
Obstructed access
Pathways Unstable conditions underfoot A Access to the structure by deliberate removal of limited debris.
Restricted vision smoke, dust T Termination of the operation by complete removal of debris to identify any live casualties.
Supporting Guidelines Overhanging hazards
Section 6 Falling objects
Airborne particulates
Toolbox Secondary collapse
Tactical threat/hostile local population
Section 7
Internal
Operational formulary Oxygen deficient atmosphere
Explosive/flammable atmosphere
Section 8 Biological hazards
Leaking gas, exposed electrical wiring
Policies
Asbestos
Sharps glass, nails etc.
Section 9
Section 10
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Communication 3
Intro
C Incident
Section 1 METHANE
Section 2
9-LINE message
Incident management
MIST message
Treatment guidelines NATO phonetic alphabet
Section 4
Transport
Section 5
Intentionally blank
Pathways
Section 6
Toolbox
Section 7
Section 8
Policies
Section 9
Section 10
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Intro
Communication 3a
Incident
Section 1
The METHANE report is designed as an initial report from
Preparation the scene of a major incident involving multiple casualties.
Section 2
Incident management
METHANE
Section 3
M My call-sign, or name and appointment
Treatment guidelines Major incident standby or declared
Section 4 E Exact location

Grid reference, or GPS where available
Transport T Type of incident
Section 5 H Hazards, present and potential

Intentionally blank
A Access to scene, and egress route
Pathways Helicopter landing site location
N Number and severity of casualties
E Emergency services, present and required
Section 6
Toolbox
Section 7
Section 8
Policies
Section 9
Section 10
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Intro
9-LINE message MIST message 3b-c
Incident
Section 1 9-LINE provides the information needed to request MEDEVAC. The MIST message is given at handover
Preparation A MIST message is given at handover between each successive level of care. between each successive level of care.
Section 2
Detail 9 Line Message Add details
as required
Incident management 1 Location (grid of pick up zone) 1

MIST
2 Call sign & frequency 2
Section 3 3 Number of patients / precedence 3
A URGENT P1 IN HOSPITAL (ROLE 2/3) M Mechanism of injury

Treatment guidelines IN 90 MINUTES
IN HOSPITAL (ROLE 2/3)

I Injuries or illness found or suspected
B PRIORITY P2 IN 4 HOURS
Section 4 IN HOSPITAL (ROLE 2/3)

S Signs
C ROUTINE P3 IN 24 HOURS
Respiratory rate
Transport 4 Special equipment 4
SpO2
A None C Extrication A B C D
B Hoist B Ventilator Pulse rate (and rhythm if abnormal)
Section 5 5 Number L Litter (stretcher) 5 L A E Blood pressure
to be A Ambulatory (walking)
carried E Escorts (e.g. children) Glasgow Coma Scale (or AVPU)
Pathways
6 Security at pick up zone
N No enemy P Possible enemy
6
N P E X T Treatment given
Supporting Guidelines E Enemy in area X Hot pick up zone
A Adult/Child
7 Pick up zone marking methods 7
Section 6
A Panels
B Pyro
A B C D T Time
C Smoke
D None E
Toolbox E Other (explain)
8 No. of patients by national status 8 A B C

A Coalition mil The MIST handover takes no more than 2030 seconds
Section 7 B Civilian with coalition forces
C Non coalition security forces
D Non coalition civilian
D E F All members of the receiving team are to listen
If CPR is in progress, there is catastrophic external bleeding or the
E Opposing forces / PW / Detainee
F Children
9 Pick up zone 9 airway is obstructed allow the clinical care at the next Role to start first
Section 8 Terrain / Obstacles
INCLUDE AN AT MIST REPORT (Details on Smart Triage Tag)

Policies A - Adult/Child T - TimeINCLUDE
M Mechanism I Injury SNSN
Symptoms
A MISTI AT
M - Mechanism REPORT
- Injury S - Symptoms T - Treatment
T Treatment A Adult/Child T Time
: 6545-99-936-355
Section 9 All then encrypted as tactically dictated
Documentation and audit This is a NATO system: priorities at serial 3 do not fit Triage Sieve system.
In formats where additional information is allowed, send MIST message content
Section 10 for individual patients.
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NATO phonetic alphabet Assessment 3d-4
Intro
A Incident
Introduction Incident management 3d Incident management 4 Management
Section 1 The NATO phonetic alphabet is used when spelling Vehicle accident
Preparation
words over the radio Incident management 4a
Section 2
Hazchem recognition
Incident management
alpha juliet sierra Incident management 4b
Section 3 bravo kilo tango

Section 4 charlie lima uniform

Transport
Section 5
delta mike victor
Pathways
echo november whisky
Section 6 foxtrot oscar x-ray
Toolbox
Section 7
golf papa yankee
hotel quebec zulu
Section 8
Policies india romeo

Section 9
Section 10
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Intro
Vehicle accident 4a
Incident
Section 1 Safety
Consider the safety of yourself, the scene and the survivors (injured and uninjured).
Preparation
2
Go to Incident
Section 2 management
Incident management Approach the scene carefully, and avoid a tunnel vision approach to the most obvious
problem.
Section 3
Read the wreckage
Treatment guidelines What happened?
Example: a motorcyclist 20m beyond an accident shows that he/she slowed over that
Section 4 distance this is much less serious than the rider lying 2m away from the foot of a wall.
Transport
Skid marks on road? How long? What direction?
Section 5 Number of vehicles involved?
Intentionally blank Obvious hazards (e.g. fuel spills)?
Pathways Rate of deceleration (much more important than speed of impact)?
How many casualties?
Supporting Guidelines Any pedestrian involvement?
Could anyone be hidden (ditch, hedge, wandered away)?
Section 6 Degree of entrapment?
Has the vehicle rolled (look for damage to the roof)?
Toolbox
Has the vehicle had more than one impact?
What were the force vectors (e.g. was the vehicle hit from front or side)?
Section 7
Were seat belts worn?
Operational formulary Have any airbags or safety systems deployed?
Has the steering wheel been deformed by the drivers chest?
Section 8 Does any windscreen have a bullseye impact from an occupants or pedestrians head
(often small hairs in glass at impact point)?
Policies Is any hair caught on underside of car e.g. sump plug, where a pedestrian is involved,
may demonstrate person has been driven over?
Section 9
Section 10
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Intro
Vehicle accident Hazchem recognition 4a-b
Incident
Introduction Incident management 4a (Contd) Incident management 4b Management
Section 1 Access and triage The recognition and neutralising of hazardous chemicals is a responsibility
of the Fire Service.
Gain rapid access to patient(s) to assess degree of injury, entrapment (real or relative),
Preparation triage for extrication, and immediacy of any clinical problems. A board displaying details of the hazardous chemical is required on all vehicles
on which they are transported.
Plan
Section 2
Plan which casualty needs to come out first and by what means.
UK hazard plate
Incident management Have an A plan urgent but not rushed, for optimal spinal immobilisation.
Emergency action code
Have a B plan for immediate snatch rescue at any point e.g. patient suddenly develops (fire-fighting and protective
Section 3 unmanageable airway, or there is a vehicle fire. Keep B plan in your mind throughout: clothing information)
change it as needed as the structure of the vehicle is altered.
Treatment guidelines Hazard diamond
If the Fire Service is in attendance, discuss the plan: give a realistic time target for the (colour-coded hazard warning)
patient to be released.
Section 4 UN product number
General order and principles of extrication plan Manufacturers contact number
Transport Safety disconnect battery or at least turn off ignition (consider winding down electric
windows first). Deploy fire extinguisher.
Section 5 Vehicle stability chock the vehicle (planks, rocks, sandbags, commercial chock) and
consider deflating tyres.
Pathways UK low hazard UK mixed load
Glass management remove all glass if cutting to occur. With non-bonded windscreens,
remove rubber seal, lift out, and place under vehicle. Where glass needs to be broken, do so
Supporting Guidelines with control using sharp pointed object while protecting patient(s) with improvised shield.
Space making depends on cutting equipment (hand hacksaws or reciprocating saw can
Section 6
be used to remove a roof in a few minutes) and requirement. If posts are to be cut, strip
out fascia and wires first to make cutting easier and to allow saw blade to take easiest route
Toolbox (avoiding safety systems).
Pedals may need to be cut or bent out of the way (use length of seat belt as rope:
Section 7
attach one end to pedal and one end to door. Open door using mechanical advantage
to bend pedal to one side).
Release the casualty extricate, where possible, on a spinal board with longitudinal
movement i.e. along the board. European hazard plate
Section 8
Move the casualty to predetermined treatment area/kit dump for re-assessment, Hazard identification
Policies intervention as required, and packaging for transport. (number series)
Speak to the patient(s) throughout!
Section 9
Documentation and audit UN product number
Section 10
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Triage 5
Intro
T Incident management 5 Incident
Management
Introduction
Section 1 Triage Sieve

Section 2
Triage Sort
Incident management
Paediatric Sieve
Treatment guidelines CBRN (special incident) Triage Sieve
Section 4
Transport
CBRN Triage Sort
Incident management 5e
Section 5
Intentionally blank Chemical primary survey
Pathways 2b
Go to Section 6 Toolbox
Section 6
Toolbox
Section 7
Section 8
Policies
Section 9
Section 10
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Intro
Triage Sieve 5a
Incident
Write
Section 1 Walking yes injured T3
Preparation
no not Or if in combat
O
Survivor
Section 2 injured return to
reception
fighting force
Incident management
Breathing Airway no Under

Section 3
opening effective DEAD
Treatment guidelines no procedures enemy fire
Section 4
yes NOT under effective enemy fire:
OK
Transport Call for assistance to carry out BLS
Section 5
Intentionally blank Starts to breathe: Write T1
Pathways Roll to prone position
Supporting Guidelines Catastrophic

Write
limb bleeding yes use tourniquet T1
Section 6
Toolbox no
Section 7 Write
Breathing rate Under 10 or over 30/min T1
1030/min
Section 8
Policies Write T1
Pulse rate & unconscious or over 120/min
Section 9 response conscious and under 120/min
Write T2
Section 10 Write priority on casualtys cheek or where visible

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Intro
Triage Sort Paediatric Sieve 5b-c
Incident
Section 1 Step 1: calculate the Glasgow Coma Score (GCS)

5080cm (or 310kg)
Preparation E = Eye opening: V = Verbal response: M = Motor response:
spontaneous 4 orientated 5 obeys commands 6
Section 2 to voice 3 confused 4 localises 5 Alert yes T3
Delayed
to pain 2 inappropriate 3 pain withdraws 4
Incident management
none 1 incomprehensible 2 pain flexes 3 no This system is designed for
Section 3 no response 1 pain extends 2 multiple casualty scenarios
no response 1
Breathing no open airway
GCS = E + V + M
Section 4
Step 2: calculate the Triage Sort score yes no DEAD
Transport
Section 5 X = GCS Y = Respiratory rate Z = Systolic BP

Breathing yes T1
1315 4 1029 4 90 or more 4 Immediate
Pathways 912 3 30 or more 3 7689 3
68 2 69 2 5075 2 Respiratory rate Under 20 or over 50/min T1
Supporting Guidelines 45 1 15 1 149 1 Immediate
Section 6 3 0 0 0 0 0 20 to 50 Under 90 or
/ min T1
over 180/min Immediate
Toolbox Triage Sort score = X + Y + Z
Section 7 Step 3: assign a triage priority Pulse rate 90 to 180/min T2
Urgent
12 = T3 Capillary refill no
Section 8 <2 seconds
11 = T2 yes T2
Policies (use forehead) Urgent
10 or less = T1
Section 9
Documentation and audit Step 4: upgrade priority at discretion of senior clinician, dependent on the Send uninjured survivors to Survivor Reception Centre
anatomical injury/working diagnosis
Section 10
Source: Hodgetts T & Porter C: Major Incident Management System. BMJ Publishing (2002) Source: Hodgetts T & Porter C: Major Incident Management System. BMJ Publishing (2002)
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Intro
Paediatric Sieve Paediatric Sieve 5c
Incident
Introduction Incident management 5c (Contd) Incident management 5c (Contd) Management
Section 1
80100cm (or 1118kg) 100140cm (or 1932kg) Use adult triage systems if
Preparation child is longer than 140cm
or heavier than 32kg
Section 2 Alert and moving all limbs yes T3
Delayed
Incident management Alert and moving all limbs yes T3
Delayed
no This system is designed for
Section 3 multiple casualty scenarios no
This system is designed for
Treatment guidelines multiple casualty scenarios
Section 4
Transport yes no DEAD
yes no DEAD
Section 5 T1
Breathing yes
Pathways
Immediate Breathing yes T1
Immediate
Supporting Guidelines Respiratory rate Under 15 or over 40/min T1

Immediate Respiratory rate Under 10 or over 30/min T1
Section 6 Immediate
15 to 40 Under 80 or
/min T1 10 to 30
Toolbox over 160/min Immediate Under 70 or T1
/min over 140/min Immediate
Section 7 Pulse rate 80 to 160/min T2
Urgent Pulse rate 70 to 140/min T2
Operational formulary Urgent
Section 8
Capillary refill no
<2 seconds Capillary refill no
Policies yes T2 <2 seconds
(use forehead) Urgent yes T2
(use forehead) Urgent
Section 9
Documentation and audit Send uninjured survivors to Survivor Reception Centre Send uninjured survivors to Survivor Reception Centre
Section 10
Source: Hodgetts T & Porter C: Major Incident Management System. BMJ Publishing (2002) Source: Hodgetts T & Porter C: Major Incident Management System. BMJ Publishing (2002)
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Intro
CBRN (special incident) CBRN (special incident) 5d(i)-(ii)
Triage Sieve: Hot zone Triage Sieve: Cold zone

Incident
Management
Introduction
Section 1 Incident management 5d(i) Incident management 5d(ii)

Preparation
For hot zone before decontamination For use after decontamination
Section 2
Incident management Walking yes T3 signs of T2 Walking yes T3 signs of T2

Delayed toxicity? Urgent Delayed toxicity? Urgent
Section 3 no
no
no
Section 4
Breathing (after airway
manoeuvres)
DEAD Toxic signs Breathing
no
(after airway DEAD Toxic signs
Transport manoeuvres)
Chemical yes Chemical
yes Where resources permit, Cyanosis
Section 5 Where resources permit, Cyanosis
resuscitation may be Excessive secretions resuscitation may be Excessive secretions
Pathways attempted on cases of Unresponsive attempted on cases of Unresponsive
witnessed respiratory Seizures witnessed respiratory Seizures
arrest with early use of Fasciculations
Supporting Guidelines antidotes (atropine for Non-thermal burns (>3%)
arrest with early use of Fasciculations
antidotes (atropine for Non-thermal burns (>3%)
Section 6 nerve agent toxicity)
Biological nerve agent toxicity)
Biological
Toolbox Temp >39C
Temp >39C
Purpuric rash
Purpuric rash
Section 7 Respiratory T1 Radiation/Nuclear Respiratory <10 or T1
yes >30/min Immediate Radiation/Nuclear
Operational formulary distress Immediate Dose > 0.5v (Gy) rate Dose > 0.5v (Gy)
History of vomiting
History of vomiting
(+diarrhoea) 1030
Section 8 no (+diarrhoea)
Erythema /min
>2secs Erythema
Policies or <40 or
no
>120/min
Section 9
Follows T2 signs of T1 CRT or signs of
Documentation and audit command yes Urgent toxicity? Immediate <2secs or T2 T1
pulse 40120/min Urgent toxicity? Immediate
Section 10
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Intro
CBRN (special incident) Triage Sort
Introduction Incident management 5e
Section 1 For use after decontamination
Preparation
Respiration 1029/min 4
30 or more/min 2
Section 2 30 or more/min + cyanosis 0
9 or less/min 0
Incident management Respiratory arrest Immediate or expectant
Heart rate 600100/min 4

Section 3 4059/min or 101120/min 2
40/min or less 0
More than 120/min 0
Treatment guidelines Cardiac arrest DEAD
Systolic blood pressure 90 or more 4

Section 4 3
7089
6069 2
Transport 149 1
Cardiac arrest DEAD
Section 5 Glasgow Coma Score/ Alert 1315 4 Intentionally blank
AVPU Verbal 912 3
Pathways 68 2
Pain 45 1
Unresponsive 3 or convulsions 0
Fasciculations None 4
Section 6 Local/intermittent 2
General/continuous 0
Flaccidity 0
Toolbox
Biological Any of the following:
Section 7 Temp >39C
Purpuric rash -2
Ascending paralysis
Operational formulary Visual disturbance (bulbar syndrome)
Radiological Any of the following:

Section 8 Vomiting, diarrhoea, erythema -2
Dose >2Sv
Policies
Section 9 Score Category

Total
20 Delayed T3
1819 Urgent T2
Section 10 017 Immediate T1 Out of 20
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Intro
Introduction
Section 1
Preparation
Section 2
Incident management
Section 3
Section 4
Transport
Section 5
Pathways

Section 6

Section 3
Section 7
Section 8
Policies
Section 9
Treatment
Section 10 guidelines
12 3
Red Card reporting
20 e
g
an
Ch
p
Se
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Intro
Treatment guidelines Treatment guidelines Contents
Treatment
Introduction Introduction Guidelines
TG Intro.1 TG Intro.4
Contents
Section 1
Preparation
The treatment of an individual casualty has
been designed with a common gateway for
This is not a textbook of all possible
emergencies. Rather, conditions have
Cardiac arrest Trauma and medical
all emergencies, whether the emergency been selected that are likely to be Treatment guidelines 1
Section 2 is traumatic, medical, toxicological or encountered within the military population
< > Treatment guidelines 2

Catastrophic haemorrhage Trauma and medical
environmental in nature. in the operational setting, or if rare are still
Incident management
TG Intro.2
important clinically and will predictably
require guidance.
C
Section 3 The priorities for treatment are <C>ABCDE.
This is an evolution from previous doctrine
and recognises the requirement to treat A Airway compromise
catastrophic external haemorrhage as the Treatment guidelines 3
Cervical spine trauma
first priority. This is the commonest cause
Section 4 ofavoidable battlefield death.
Transport TG Intro.3 Treatment guidelines 4

Section 5
Evidence-based guidelines are presented
that are tempered with operational
B Difficult or abnormal breathing
Pathways
experience and that have been matched
to the availability of equipment and drugs
Treatment guidelines 5
within the deployed medical modules.
C Shock
Section 6
Chest pain
Toolbox
Section 7 Peri-arrest rhythms
Operational formulary Treatment guidelines 8
Section 8
D Reduced response
Policies
Section 9 E Electrolytes includes poisoning and CW

Environment
Section 10
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Intro F Musculoskeletal Injuries Cardiac arrest 3

1
Treatment guidelines 12 Treatment

Introduction Treatment guidelines 1 Guidelines
Section 1
Acute injury management
Treatment guidelines 13 Adult BLS
Preparation Treatment guidelines 1a
Section 2
Chronic injury management Adult ALS
Treatment guidelines 14 Treatment guidelines 1b
Incident management
Section 3
References Adult choking
Treatment guidelines 15 Treatment guidelines 1c
Paediatric BLS
Section 4 Treatment guidelines 1d
Transport Paediatric ALS
Treatment guidelines 1e
Section 5
Pathways
Child choking
Treatment guidelines 1f
Supporting Guidelines Spare
Section 6 Treatment guidelines 1g
Toolbox Newborn life support
Treatment guidelines 1h
Section 7
Emergency thoracotomy
Treatment guidelines 1i
Section 8 Cardiac Arrest or Cardiovascular Collapse caused
Policies by Local Anaesthetic
Treatment guidelines 1j
Section 9
Section 10
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Intro
Adult BLS 1a
Treatment
Introduction Treatment guidelines 1a Guidelines
Section 1 Check responsiveness

Preparation Shake and shout
Section 2
Incident management If unresponsive get help now

Section 3
Treatment guidelines Open airway

Head tilt /chin lift
Section 4
Transport
Section 5 Check breathing Abnormal or absent

Intentionally blank If unresponsive and breathing place in recoveryposition
Pathways Look, listen and feel. No longer than 10 seconds
Section 6 30 chest compressions
Rate 100/minute
Toolbox
Section 7
2 rescue breaths: 30 compressions
Operational formulary Change rescuer every 2 minutes to prevent fatigue
Section 8
Signs of life No signs of life
Policies
Recovery position Continue resuscitation
Check patient only if they begin 100/minute compressions
Section 9
to breathe normally 30:2 ratio
Section 10 Send or go for help as soon as possible

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Intro
Adult ALS Adult choking 1b-1c
3
Treatment
Introduction Treatment guidelines 1b Treatment guidelines 1c Guidelines
Section 1
Unresponsive Assess severity
Preparation Not breathing or only occasional gasps
Section 2 Call AUDIT

Resuscitation Team
Incident management An audit of process Severe airway Mild airway
CPR 30:2 and outcome of all obstruction obstruction
Section 3 Attach Defibrillator/ cardiac arrest where
Monitor resuscitation is (ineffective cough) (effective cough)
Treatment guidelines Minimise interruptions attempted is desirable
Section 4
Encourage to
Assess
Transport continue
Rhythm
coughing,
Section 5 Shockable VF
or pulseless VT
Non-Shockable
PEA/Asystole
Unconscious Conscious but do
Pathways 5 Back slaps nothing else
During CPR
Correct reversible causes 5 Abdominal thrusts
Supporting Guidelines 1 Shock
1st: 150-200J
if not already (alternate)
biphasic Check electrodes, paddle
Section 6 positions and contact Immediately resume
Subsequent:
150 - 360J Attempt /verify: airway & O2, CPR 30:2 for 2 min
Toolbox IV or IO access
Minimise
BLS
1a
interruptions Go to Treatment
Give adrenaline every 35 min guidelines
Section 7 Immediately resume
CPR 30:2 for 2 min Consider amiodarone,
Minimise atropine, magnesium
Operational formulary Potential reversible causes:
interruptions Consider pacing; buffers
Section 8
ALS
Potential Reversible Causes Immediate post cardiac arrest treatment 1b
Policies Hypoxia Use ABCDE approach Go to Treatment
Hypovolaemia guidelines
Controlled oxigenation and ventilation
Hyper/hypokalaemia & metabolic
Section 9 Hypothermia 12-lead ECG
Tension pneumothorax Treat precipitating cause
Tamponade, cardiac
Documentation and audit Toxic/therapeutic disorders
Temperature control/
therapeutic hypothermia
Thromboembolism
Section 10
Adapted from: Advanced Life Support Guidelines. UK Resuscitation Council (2010) Adapted from: Advanced Life Support Guidelines. UK Resuscitation Council (2010)
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Paediatric BLS Paediatric ALS 1d-1e
3
Treatment
Introduction Treatment guidelines 1d Treatment guidelines 1e Guidelines
Section 1 Stimulate and check

Unresponsive
responsiveness Not breathing or only occasional gasps
Preparation
Section 2 SHOUT Start BLS AUDIT

Call ventilate/oxygenate
Incident management Resuscitation Team An audit of process
Open airway 1min CPR first, and outcome of all
Section 3 Head Tilt, Chin Lift if alone cardiac arrest where
Attach Defibrillator/
(Jaw Thrust) Monitor resuscitation is
Treatment guidelines Minimise interruptions attempted is desirable
Section 4
Check breathing Place inrecovery
Transport Breathing Assess
Look, listen, feel position
Rhythm
Section 5 Shockable Non-Shockable
Not breathing VF/VT Asystole/PEA
Pathways
During CPR
Correct reversible causes
Supporting Guidelines Ventilate If no chest rise Check Electrode/paddle
1 Shock
5 effective breaths Positions and contact
Section 6 reposition airway 4J/Kg
Attempt/verify
reattempt up to 5 times attenuated as Tracheal Intubation
Toolbox appropriate Intraosseous/Vascular access
If no success
Give
Section 7 Assess for signs of life treat as for airway obstruction Uninterrupted compressions
once intubated
Operational formulary Immediately resume Adrenaline every 35 minutes Immediately resume
CPR for 2 min Consider amiodarone, CPR for 2 min
Minimise Minimise
Section 8 interruptions atropine, magnesium interruptions
15 chest compressions
Policies
2 rescue breaths Potential Reversible Causes Immediate post cardiac arrest treatment
15 compressions Hypoxia Use ABCDE approach
Section 9 Hypovolaemia
Controlled oxigenation and ventilation
Hyper/hypokalaemia & metabolic
Hypothermia 12-lead ECG
Documentation and audit Tension pneumothorax Treat precipitating cause
Call resuscitation team after Tamponade, cardiac Temperature control/
Toxic/therapeutic disorders therapeutic hypothermia
Section 10 1 minute then continue BLS Thromboembolism
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Paediatric choking 1f
3
Treatment
Introduction Treatment guidelines 1f Guidelines
Section 1
Assess severity
Preparation
Section 2
Incident management Ineffective cough Effective cough

Section 3
Treatment guidelines Encourage cough

continue to check
Section 4 Unconscious for deterioration
Conscious (toineffective cough)
Transport
5 Back slaps orreliefof obstruction
Section 5 5 Abdominal thrusts

Intentionally blank
(alternate)
Pathways
Open airway chest thrusts for infant
Supporting Guidelines 5 breaths abdominal for child >1
Section 6
Toolbox
BLS
1d
Section 7 Go to Treatment
guidelines
Section 8
Policies
ALS
1e
Go to Treatment
guidelines
Section 9
Section 10
Adapted from: Advanced Life Support Guidelines. UK Resuscitation Council (2010)
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Newborn life support Newborn life support 1h
3
Treatment
Introduction Treatment guidelines 1h Treatment guidelines 1h (Contd) Guidelines
Section 1 A healthy baby will be born blue, will have good tone, will cry within a few seconds of delivery,
Dry the baby will have a good heart rate (about 120150 beats/min) and will rapidly become pink during
Remove any wet towels and cover the first 90 seconds.
Preparation
Start the clock or note the time
A less healthy baby will be blue at birth, will have less good tone, may have a slow heart rate
Section 2 (less than 100 beats/min) and may not establish adequate breathing by 90120 seconds.
An ill baby will be born pale and floppy, not breathing and with a slow or very slow heart rate.
Incident management Assess (tone), breathing and heart rate
Airway
Section 3 Place the baby on his back with the head in the neutral position, place support under
If gasping or not breathing: shoulders but be careful not to overextend the neck.
Treatment guidelines Open the airway Breathing
Give 5 inflation breaths If not breathing adequately by approx 90 seconds give 5 inflation breaths. Aeration of
Section 4 Consider SpO2 monitoring the lungs is likely to require sustained application of pressures of about 30cm of water for
23seconds. Continue to provide regular breaths at a rate of 3040 minutes until the baby
Transport starts to breathe on his own.
Reassess
If no increase in heart rate look for chest movement Chest compressions
Section 5
Two thumbs are placed side by side over the sternum between the nipples and the hands
Pathways encircle the torso. The depth of compression is one third of the anteroposterior diameter
of the chest. At a rate of 3:1 this results in 90 compressions to 30 breaths/min. Pulse rate
If chest not moving: isassessed every 30 seconds.
Supporting Guidelines Recheck head position Drugs
Section 6 Consider 2-person airway control and other airway manoeuvres
Should be delivered via an umbilical venous catheter or intraosseous.
Repeat inflation breaths. Consider SpO2 monitoring
Look for a response. Adrenaline is 10mcg/kg (0.1ml/kg of 1:10000) If not effective a dose of up to 30mcg/kg
Toolbox
(0.3ml/kg of 1:10000) may be tried.
Section 7 Sodium bicarbonate 2 to 4ml/kg of 4.2% bicarbonate solution.

Dextrose recommended is 250mg/kg (2.5ml/kg) of 10% dextrose.
Operational formulary If no increase in heart rate look for chest movement
If there are no signs of life after 10 minutes of continuous and adequate resuscitation then
discontinuation may be justified.
Section 8
When the chest is moving
Policies If heart rate is not detectable or slow (<60 min-1)
Start chest compressions 3 compression to each breath
Section 9

Reassess heart rate every 30s. If heart rate is not detectable
Or slow (<60min-1) consider venous access and drugs
Section 10
Adapted from: Newborn Life Support Guidelines. Resuscitation Council (2010)
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Emergency thoracotomy Cardiac Arrest or Cardiovascular 1i-1j
Collapse caused by Local

Treatment
Introduction Treatment guidelines 1i Guidelines
Section 1
Blunt Chest trauma Penetrating Anaesthetic Treatment guidelines 1j
Preparation It has been recommended that 20% lipid emulsion should be available
wherever patients receive large doses of local anaesthetic (e.g. operating
Section 2 rooms, emergency department, radiology suite)
Signs of life
Incident management
at scene
Section 3
Start CPR using standard guideline
yes no
Signs of life Consider treatment with lipid emulsion
Section 4 Dead no
at scene
Signs of life
Transport on arriving no
Section 5 inED yes Approximate doses are given in red for a 70kg person
no
Give an intravenous bolus injection of Intralipid 20% 1.5ml/kg-1/min
Pathways yes Give a bolus of 100ml
Signs of life Continue CPR
Supporting Guidelines absent Signs of life Start an intravenous infusion of Intralipid 20% at 0.25ml/kg
no on arriving Give at a rate of 400ml over 20min
Section 6 <5 minutes
Repeat the bolus injection twice ar 5 min intervals if an adequate
BATLS inED circulation has not been restored
Toolbox yes
protocols Give two further boluses of 100ml at 5 min intervals
yes After another 5 min, increase the rate to 0.5ml/kg/min if an adequate
Section 7 circulation has not been restored
AUDIT Give at a rate 400ml over 10 min
Emergency
Section 8
Consider thoracotomy Consider Note
Policies Maximum permissible cumulative dose is 12ml / kg
AUDIT Continued CPR throughout treatment with lipid emulsion
Section 9 Infusion of intralipid should be terminated after 25 mins even if CPR is ongoing
In rare circumstances, the equipment and expertise may be
Recovery from LA-induced cardiac arrest may take > 1 h
Documentation and audit available to perform emergency thoracotomy outside a clinical facility:
Propofol is not a suitable substitute for Intralipid
this is only appropriate in penetrating trauma and only if the procedure
Section 10 is performed within 5 minutes of losing vital signs
Resuscitation Council July 2008, The Association of Anaesthetists (AAGBI) 2007
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First aid (all users)
<C> Catastrophic haemorrhage 2 2a
Intro
Treatment guidelines 2a
Treatment Treatment
Introduction Treatment guidelines 2 Guidelines Guidelines
Section 1
First aid (all users)
Catastrophic
haemorrhage
Section 2 Use of Celox
Incident management
Treatment guidelines 2b
Universal donor blood
Section 3 Head, neck, torso Limb(s)
Treatment guidelines 2c
Recombinant factor VIIa
Section 4 Treatment guidelines 2d Field dressing C.A.T.
& pressure
Transport
Section 5
Bleeding
Pathways
Dressing soaked
stops Fails Inappropriate
Supporting Guidelines Celox gauze Celox gauze

Section 6
Toolbox
Bleeding not Bleeding not
Section 7 controlled controlled
Secure dressing
Operational formulary over wound
Section 8 Field dressing(s) Field dressing(s)

& direct pressure & direct pressure
Policies
Section 9
Documentation and audit Continue first aid drills & evacuate T1
Section 10
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Use of Celox 2b
Treatment
Guidelines
Introduction
Section 1
This is ideally a two-person technique
Preparation
Section 2 Operator 1 Operator 2

Incident management
Section 3
Apply pressure Open a fresh field dressing.
into the wound through field
Section 4 dressing Open Celox gauze
Transport
Section 5
Intentionally blank
Pathways Now work closely together
Remove field
Section 6 dressing.
1
Toolbox Unravel and insert
2 Celox gauze packing wound
Section 7 tightly
Apply pressure through a
Operational formulary fresh field dressing for 3 3
minutes
Section 8
Policies
Section 9 Celox
Open headgauze
injury may be used internally
Keep by trained
QuikClot awaysurgeons
from patients
Sucking chest as a temporary haemostatic
wound eyes,nosemeasure
& mouth
Exposed
Expo
p sed abdominal viscera Control spurting blood before using
Small diameter wounds QuikClot
Q uik
ikCl
ik Clott
Section 10
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Universal donor blood Universal donor blood 2c
Treatment guidelines 2c Treatment guidelines 2c (Contd)

Treatment
Guidelines
Introduction
Section 1 Indication Emergency donor panel

Rh D Negative red cells are used as the universal donor group for patients in need of urgent In exceptional circumstances, and only with clearance from the theatre Commander Medical
Preparation blood transfusion when there is no time to cross-match. in consultation with Permanent Joint Headquarters (PJHQ), emergency donor panels may be
Constraint used to provide transfusion support. It is imperative that the use of such emergency donor
Section 2 As only 8% of the population are O RhD Negative, blood of this type is a scarce and panel blood is clearly documented and that the donors are retrospectively tested by the NBS
valuable commodity. for the mandatory microbiological markers. An individual who has been part of an emergency
Incident management donor panel is not to be selected to donate again for at least 12 weeks.
Guideline for use of O RhD negative blood
Follow up action
Section 3 In an emergency setting O RhD Negative cells may be used in all blood types where a delay
in access to blood would threaten life. Once the patients blood group has been established, All individuals who are O RhD Negative and have received O RhD Positive blood in an
a switch to group specific blood is to be made but in all circumstances type specific blood emergency are to have their serum tested for anti-D antibody and other clinically significant
Treatment guidelines blood group antibodies between 36 months post transfusion. If detected, this information
should be used after a maximum of 4 units universal donor blood.
is to be carried by the patient on a NATO Medical Warning Tag.
Section 4 Guideline for use of O RhD positive blood
Policy
To conserve limited stocks of O RhD Negative cells, O RhD Positive blood may be substituted
Transport This guidance is compiled from JSP 950, Leaflet 2-24-3 and National Blood Service (NBS)
as the universal donor type in an emergency setting. The exceptions are:
advice.
Females with child-bearing potential (age <60 years if in doubt) in whom the blood group
Section 5 is unknown unless there is no alternative to save life (presumes O RhD Negative stocks are
exhausted)
Pathways Males with known anti-D antibodies documented on a NATO Medical Warning Tag (there
is no opportunity to test for these antibodies in the field)
Supporting Guidelines If the phenotype of female <60 years is known to be O RhD Negative
Alternative red cells for minority ABO types
Section 6
In the event of shortage of minority blood groups, alternative red cell groups should be
issued according to the following table, unless advised otherwise by the National Blood
Toolbox
Service (NBS):
Section 7 Patient group Preferred alternative group

Operational formulary AB RhD pos A RhD pos
AB or A RhD pos to male/elderly female
AB RhD neg
Section 8 A RhD neg to young female
A RhD pos to male/elderly female
Policies A RhD neg
O RhD neg to young female
B RhD pos to male/elderly female
Section 9 B RhD neg
O RhD neg to young female
Section 10
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Recombinant factor VIIa Airway compromise
A
3
Intro
Treatment guidelines 2d
Treatment
Section 1 Indications
Life-threatening haemorrhage where conventional resuscitation and/or surgical techniques
Preparation have failed. Life-threatening haemorrhage is defined as: Oxygen Therapy
Loss of entire blood volume within 24 hours
Loss of 50% of blood volume within 3 hours Treatment guidelines 3a
Section 2
Blood loss at a rate of 150ml/min
Incident management Blood loss at a rate of 1.5m/kg/min for 20 minutes or more. Universal airway algorithm
In practical terms, rFVIIa should be considered if there is evidence of continued bleeding Treatment guidelines 3b
after 68 units of packed red blood cells and correction of coagulopathy with fresh frozen
Section 3 plasma. Basic airway
The prescription of this drug is restricted to consultants only.
Treatment guidelines Treatment guidelines 3c
Contraindications
Section 4 Do not use if the patient is expected to be unsalvageable despite rFVIIa. Endotracheal intubation
Known or suspected ischemic heart disease. Treatment guidelines 3d
Transport A history of thromboembolic event in the preceding 6 months.
Dose Rapid sequence induction
Section 5
100mcg/kg IV bolus (a dose of 80mcg/kg has been used by Israelis for intraalveolar Treatment guidelines 3e
Pathways haemorrhage in blast lung, but evidence is only anecdotal.)
A second bolus of 100mcg/kg IV may be given after ~20 minutes. RSI supporting drugs
Supporting Guidelines Further doses are unlikely to be beneficial. Treatment guidelines 3f
Adverse effects
Section 6 Thromboembolic events are a theoretical risk, but there has been no increased incidence Surgical airway
within the available published literature when used in the trauma population. Treatment guidelines 3g
Toolbox Disseminated intravascular coagulopathy.
For a full description of potential adverse effects see product data sheet. Pre hospital intubation - MERT protocols
Section 7
Follow up action Treatment guidelines 3h
Operational formulary All uses of rFVIIa will be tracked on the Joint Theatre Trauma Registry at ADMEM, Royal
Centre for Defence Medicine. Ensure all documentation for the Trauma Nurse Coordinator
Section 8 is completed.
Policy
Policies This guideline is in accordance with DMSD/05/01/02 dated 14 June 2007 and DGAMS
Policy Letter 12/05.
Section 9
Section 10
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Oxygen therapy 3a
Treatment
Section 1
Is the casualty walking? yes Oxygen NOT required
Preparation
no
Section 2
Incident management Are they maintaining their

own airway?
Section 3 no
yes
Give
oxygen
Section 4 Normal respiratory rate?
no
(1029 breaths a minute)
Transport
Section 5
Intentionally blank
yes
Use trauma
Pathways mask
Radial pulse present?
or Give minimum
Pulse rate below 120/min? no
Section 6 or (810l/min)
CRT below 2 seconds? to inflate
Toolbox reservoir bag
yes
Section 7
Operational formulary Conscious level (AVPU) V, P or U

Alert
Section 8 Voice
Pain
Policies Unresponsive Those who hit the
criteria first, need
Section 9 Alert oxygen the most
Documentation and audit Re-evaluate
Oxygen NOT required regularly
Section 10
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Universal airway algorithm Basic airway 3b-3c
Treatment
Introduction Treatment guidelines 3c Guidelines
Section 1 Aim Oropharyngeal airway (OPA)

Clear the airway and get oxygen to the cells of the vital organs; provide adequate ventilation The correct sized airway will extend from the centre of the casualtys mouth to the angle of
Preparation the jaw. OPA Technique: Open the casualtys mouth: insert the tip of the airway along the
Methods
roof of the mouth to the soft palate. Rotate the airway 180, directing the concavity of the
Depend on individual skills and available equipment airway towards the feet and slip the airway over the tongue.
Section 2
Incident management Symptoms/signs of airway obstruction

Noise (stridor, snoring)
Section 3 Secretions
Abnormal breathing pattern
Treatment guidelines Patient pale or blue
Looks distressed
Section 4 Cannot speak or difficulty in speaking Nasopharyngeal airway (NPA)
The correct size airway should reach from the patients nostril to the earlobe or the angle of
Transport the jaw. Usually equates to size 6 for female and size 7 for male.
Use when there is oral injury, a fractured mandible or masseter spasm.
Clear and support the airway
Section 5 It is better tolerated than the OPA by the more responsive casualty and is less likely to be
Use simple actions first: suction, jaw thrust, chin lift
dislodged during evacuation. NPA can be used in both sides simultaneously.
Progress to simple adjuncts: NPA, OPA, LMA (as tolerated)
Pathways A suspected fractured base of skull is not an absolute contraindication for use of this airway
Consider using a laryngoscope to improve view for suction (ifavailable) if an oropharyngeal airway cannot be inserted or the airway maintained by other means.
Consider Magill forceps to remove solid debris (if available)
With suspected C-spine injury jaw thrust is preferred to chin lift
Section 6 Support ventilation
Give high concentration oxygen (by mask, or delivered by BVM)
Toolbox Aim for consistent ventilation between 1020/min if RR >30 or <8/min
Section 7
NPA Technique
Airway satisfactory Airway NOT CLEAR Assess the nasal passages for any apparent obstruction (fractures, haemorrhage, polyps).
Choose a nostril that is patent.
Section 8 Consider lateral, prone or head down Consider rapid sequence induction
positions (depending on other injuries) and intubation Select size 6 for an adult female and size 7 for an adult male.
Insert the safety pin across the nostril end of the airway (new devices have an extended
Policies If spinal immobilisation applied, suction should 3e
be available and head down or immediate Go to Treatment
flange) it should be placed laterally to allow a soft suction catheter to pass.
lateral tilt adopted in case of vomiting
guidelines
Lubricate the NPA with a water-soluble lubricant or water.
Section 9 or surgical airway Insert the tip of the airway into the nostril and direct it posteriorly and towards the ear lobe.
Consider the expected clinical course:
can the casualty reasonably be expected (facial injury; airway burns; Gently slide the nasopharyngeal airway through the nostril into the hypopharynx with a
Documentation and audit foreign body stuck in airway; slight rotating motion until the flange rests against the nostril.
to survive the delay to their next point of
care without further airway intervention lack of appropriate training, If an obstruction is encountered try the other nostril or try a smaller nasopharyngeal airway.
Section 10 (cricothyroidotomy or endotracheal intubation)? equipment or drugs for RSI) Trying to force the nasopharyngeal airway past an obstruction may cause severe bleeding.
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Endotracheal intubation Rapid sequence induction 3d-e
Treatment
Introduction Treatment guidelines 3d Treatment guidelines 3e Guidelines
These guidelines are not a substitute for training. Trained anaesthetists and
Section 1
emergency physicians will follow the protocols they are most familiar with. The six Ps Yankauer suction.
Reservoir-Bag-Valve-Mask.
Preparation Medical casualties who are deeply unconscious or unresponsive (cardiac arrest, drowning, Venous/intraosseous access.
overdose) can often be intubated without anaesthetic drugs.
Section 2 Trauma casualties who are deeply unconscious or unresponsive and can be intubated Preparation Allocate team tasks.
Position patient & apply monitoring.
without drugs have a very poor outcome. t-minus 10 min Pharmacy draw up and label all drugs.
Incident management Check and test endotracheal tubes.
Anaesthetic and muscle relaxant drugs have effects
(unless Crash Induction) Check and test laryngoscope blades.
Evaluate for difficult airway.
Section 3 on heart rate, blood pressure andrespiration
They must be used only by trained and experienced individuals
Treatment guidelines 100% O2 with non-rebreather mask.
Do simple airway manoeuvres first (suction, jaw thrust, chin lift, NPA, OPA). Pre-oxygenation If SpO2 <90% provide PPV via
Reservoir-Bag-Valve-Mask with PEEP
Section 4 Give oxygen and support ventilation.
t-minus 5 min valve attached.
GET HELP. Check and prepare equipment for endotracheal intubation: In this case apply cricoid pressure.
Transport
Suction
Airway adjuncts (or escape ventilation) Suspected raised intracranial pressure,
Section 5 Ventilator or BVM
Emergency cricothyroidotomy kit
Pre-medication intraocular hypertension, myocardial
ischaemia or hypertensive emergency:
Pathways t-minus 2 min give fentanyl.
Tube, tape or tie
Heat and Moisture Exchanger (HME) 3f
Supporting Guidelines Endotracheal tube
Go to Treatment
Paralysis
guidelines
Section 6 Drugs Induction.

Cricoid pressure.
Angle piece catheter mount t = zero Neuromuscular blockade.
Toolbox Monitoring, including ETCO2
Stethoscope
Section 7 Elastic bougie Intubate
Laryngoscope
Syringe 10mls
Passage of the Observe passage of ETT between cords.
Consider BURP manoeuvre for poor
endotracheal tube visualisation of cords.
If C-spine immobilisation is in situ this may impede the view with the laryngoscope. If SpO2 <90% STOP! Provide PPV and
Section 8 Apply manual in-line immobilisation, remove the head blocks and tape, and open t-plus 3045 sec O2 until SpO2 >90%.
the cervical collar.
Policies Give RSI drugs in doses appropriate to the patients condition Go to Confirm placement + inflate cuff.
3f
(anaesthetic doses are greatly reduced in shock). Wait for Treatment Detect ETCO2.
guidelines
Section 9 the drugs to work. Cease cricoid pressure + secure tube.

After placing the ETT check the position with a stethoscope and ETCO2 (if available). Post intubation care ABG and CXR.
Reassess oxygen requirements.
If unable to place ETT re-oxygenate the patient with BVM before further attempt. t-plus 45 sec Continue sedation +/ paralysis.
Consider use of a different laryngoscope blade (and use a bougie or introducer if Oro/nasogastric tube and urinary
Section 10 notalready tried). If this fails consider LMA or surgical airway. catheter.
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RSI supporting drugs Surgical airway 3f-g
Treatment
Introduction Treatment guidelines 3f Treatment guidelines 3g Guidelines
Section 1 Pre-induction agents A surgical airway is indicated when:

Fentanyl rapid acting/short lasting opioid. Blunts hypertensive response to laryngoscopy A casualty needing a definitive airway for resuscitation or evacuation is too awake to
Preparation and intubation. tolerate endotracheal intubation without an anaesthetic and specialist anaesthetic support
Indications: haemodynamically stable patients with raised intracranial pressure, is unavailable.
Section 2 hypertensive emergencies, raised intraocular pressure, myocardial ischaemia. A casualty with face and neck burns requires airway protection to pre-empt delayed
Dose: 12 micrograms/kg IV over 60 to 120 seconds. obstruction, but expert anaesthetic help to facilitate intubation is unavailable.
Incident management Induction agents Trauma to the face and neck make endotracheal intubation impossible.
Etomidate favourable haemodynamic profile. Relatively good in hypovolaemic shock. Surgical cricothyroidotomy: procedure
Section 3 Dose: STABLE, 0.3mg/kg IV push (UNSTABLE, 0.15mg/kg IV). Place the casualty supine with the neck in the neutral position.
Ketamine dissociative anaesthetic with excellent analgesic and amnesic properties. If not contraindicated, extend the neck and place a pillow/rolled blanket (or suitable alternative)
Treatment guidelines Potent bronchodilator. Favourable haemodynamic profile with some preservation of under the shoulders: this will bring the landmarks into more prominence.
laryngeal and respiratory reflexes.
Palpate the thyroid notch and cartilage, cricothyroid membrane and cricoid cartilage.
Section 4 Indications: acute severe asthma or COPD with bronchospasm requiring intubation and
ventilation. Haemodynamically unstable patient. Clean the skin and infiltrate with local anaesthetic (unless the casualty is deeply unconscious).
Transport Dose: 0.52mg/kg IV push. Stabilise the thyroid cartilage with the left hand.
Neuromuscular blocking agents Make a horizontal skin incision over the cricothyroid membrane.
Section 5 Suxamethonium Carefully incise through the membrane horizontally; open the incision using artery forceps.
Dose: 1.5mg/kg IV push. Insert a 6mm cuffed tracheostomy tube through the cricothyroid membrane incision,
Pathways Contraindications: history of malignant hyperthermia (personal or family); uncontrolled directing the tube distally into the trachea.
hyperkalaemia; spinal injury >3 days old or denervation illness; crush injury >3 days old or Inflate the cuff. Secure the tube by stitch or tape, or both.
Supporting Guidelines rhabdomyolysis; sepsis >7 days duration; severe burns >24 hours old.
Rocuronium non-depolarising neuromuscular blocking agent. Use in all cases when
Section 6 suxamethonium is contraindicated. Produces adequate paralysis in 4560 seconds.
May be reversed. Insert the airway with the
Toolbox Dose: 1mg/kg IV push. cap open and both balloons
balloons both deflated, using introducer.
deflated
Section 7 Once the airway is successfully
inserted, inflate balloons,
XXX
XX X
close cap and remove
XXX
XXX
introducer.
Section 8
Policies
= Cricothyroid membrane
Section 9
= Cartilage = Muscle
Documentation and audit Put local anaesthetic over balloons
edges of strap muscles both
inflated
marked XXXXXX and not
Section 10 over the membrane
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Pre-hospital intubation Pre-hospital intubation 3h
Introduction MERT Protocols MERT Protocols Treatment

Guidelines
Section 1 Treatment guidelines 3h Treatment guidelines 3h

Preparation Preparation en route Patient
Drugs / Kit Preparation
Section 2
Incident management
Attach pulse oximeter
Section 3 (SpO2 Sats monitoring)
Drugs Kit ASAP
Section 4 Connect Oxygen (15 l/m min) Self-inflating bag ETCO2 monitoring
BLIZZARD HEAT filter catheter mount facemask (+ check for leaks)
Transport Drugs drawn up en route
Remove from Check suction working, and place in easy reach on RHS of patient
Needles removed
packaging Ensure at least one functioning IV/IO line
Section 5 Stoppers placed on
Allow to warm up
syringes
Pathways en route
Unfold onto PLAN A1 PLAN A2
aircraft floor to
Laryngoscope or Airtraq
Supporting Guidelines accept patient
Stretcher loaded
Section 6 directly onto
BLIZZARD 8.0mm GlideRITE COETT for all adults Airtraq channel lubricated inside
Toolbox KETAMINE SUXAMETHONIUM VECURONIUM and outside
Connector pushed fully into tube
200mg/20ml 200mg/5ml 10mg/5ml ETT loaded into channel
Lubricated bougie/stylet preloaded into ETT
Section 7 syringe syringe syringe taking care not to obstruct lens
20 cm protruding from tracheal end.
(4ml of drug)
Operational formulary BREATHING ETT cuff smeared with lubricant
DO NOT TURN ON YET!
CIRCUIT Air filled 10ml syringe pushed fully home
Section 8 Oxygen source into cuff valve
Self-inflating bag
Policies Facemask
Optimise patient positioning
Connecting tubing
Section 9 Place syringes in Ventilator
dedicated holders on Blunt Trauma: Penetrating Trauma:
Documentation and audit Monitoring
Piggot Pouch/on equipment Manual in-line neck stabilization (MILS) Head supported on makeshift pillow
your person and connectors Remove collar pre intubation (if no evidence of spinal deficit)
Section 10
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Intro

Guidelines

Preparation Induction and Muscle Relaxation (Paralysis) Passage of ET Tube
Section 2
Drugs prepared en route Remove facemask from catheter
Incident management (p34) For rapid tranquilisation in mount & place on LHS
combative patient,
Needles removed
Section 3 Stoppers placed on
in order to insert linesor PLAN A1 Plan A2
Bag/ valve >ETCO2 prepare for intubation or
syringes use IV/IO or Intranasal Laryngoscope Airtraq
Treatment guidelines >filter >catheter
Switch on and warm up ketamine.
mount >facemask
Airtraq (if using) (p35) (Use IN only if no IV/IO Laryngoscope to right side of tongue Place Airtraq into mouth in the
system is advised
Section 4 Switch on suction (p35) access) Hold out right hand once glottis viewed midline
(p35)
N.B. Record DO NOT take eyes of glottis Use Back & Up manoeuvre to
Transport Alternate is O2 Pre-sedation GCS optimise view of glottis
Assistant place ETT in right hand
NRBM
Military use masks Preoxygenation
Section 5 with one mushroom GO TO
100mg Nasal via mucosal Glottis
valve only. NO PLAN B (p38) or
Pathways atomization device visualised?
This reduces FiO2 to (MAD) C (p39)
KETAMINE
65% max. 50-200 mg 2ml of 50mg/ml
Supporting Guidelines Place strip of tape on (1-2mg/kg) Ketamine added to 2mls YES
open side to increase IV or IO N/saline
Section 6 FiO2 2mls into each nostril
Pass ETT through glottis
Toolbox Female 22 cm at lips - Male 24 cm at lips
Cricoid Pressure (Assistant) Attach catheter mount onto ETT
Index finger on cricoid cartilage Inflate ETT Cuff
Section 7 Thumb & middle finger either side to stabilise Ventilate manually & check chest movement, breath sounds and ETCO2
Thyroid cartilage manipulation may improve view Ensure ETT cuff seal > Remove cricoid pressure
Operational formulary (B.U.R.P. manoeuvre) Secure ETT with Thomas ET holder or tie
Section 8 VECURONIUM 10mg/5mls

SUXAMETHONIUM~1.5 mg/kg (2
When airway secure
Policies -3mls of 50mg/ml)
Consider placing cervical collar on patient (if not already in use)

Section 9 Suxamethonium takes approx 30-40 to prevent neck movement & movement of ETT
seconds to work
Documentation and audit Watch for muscle twitching (fasiculation)
>relaxation Post Intubation Care p39
Section 10 Maintain cricoid pressure
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Intro

Guidelines

Preparation Plan B Go to Plan C
i-Gel LMA The laryngeal mask (p39)
airway does not fully
Section 2 seal the airway against
regurgitated stomach
Insert i-Gel contents, and so is not
Incident management as safe as a cuffed Surgical Airway
endotracheal tube or
Section 3 surgical airway.
Attach catheter mount to i-Gel
Ventilate manually
Treatment guidelines Check chest movement, breath sounds, ETCO2 & SaO2
Post Intubation Care
Check ETCO2
Section 4
Chest movement, breath sounds and ETCO2 confirmed? NO
Transport Secure tracheal tube Max Fax
Reassess ABC Use of Epistats/ bite
Section 5 blocks and collar
Check LMA position
Pathways Check breathing circuit for leaks, and rectify if found VECURONIUM
Give 10mg 5ml of 2mg/ml
immediately post intubation Extend sedation
Supporting Guidelines Re-check
Chest movement NO Go to Plan C
Section 6 YES
Breath sounds (p39)
ETCO2 Consider placing cervical collar on Max Fax
Toolbox patient (if not already in use) Assess need for
Use of Epistats/ bite
to prevent neck movement & transfusion
blocks and collar
movement of ETT
Section 7 Secure device with Thomas ET holder or tie
Place Blizzard Heat around patient
VECURONIUM 10mg/5mls Post Intubation Care
Section 8 When airway secure
Policies
Triage patient to appropriate facility
Consider placing cervical collar on patient (if not already in use) to
Section 9 prevent neck movement & movement of ETT)
Documentation and audit Head injury? Severe injury?

Need for Right Turn Resus Inform receiving facility
Post Intubation Care p39 Need for Major Transfusion
Section 10
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Intro A Cervical spine trauma 4
Treatment
Section 1
Immobilisation
Section 2 Log roll
Incident management
Spinal clearance
Section 3
Airway issues in C-spine injury
Transport
Section 5
Intentionally blank
Pathways
Section 6
Toolbox
Section 7
Section 8
Policies
Section 9
Section 10
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Immobilisation Log roll 4a-b
Treatment
Introduction Treatment guidelines 4a Treatment guidelines 4b Guidelines
Section 1 Rules of spinal immobilisation The log roll

NEXUS Guidelines: identify those patients who do not require C-spine immobilisation
2
Preparation following blunt trauma. 3
4 1
Section 2 Go to 4c
Treatment
guidelines
Incident management
Care Under Fire/Tactical Field Care: Evacuation to a more secure area takes precedence
over spinal immobilisation.
Section 3
Role 1: Maintain in-line immobilisation and use semi-rigid collar and head blocks to
Treatment guidelines immobilise the neck.
Role 2 Light Manoeuvre: Continue in-line immobilisation and spinal precautions.
Section 4 Role 2 Enhanced/Role 3: Continue in-line immobilisation and spinal precautions until
radiological and clinical clearance.
Transport Exceptions
There is no role for cervical collar immobilisation following penetrating injury. Data does not
Section 5 support the use of collar immobilisation in penetrating trauma and at worst a collar may Three over, three under hand position for the logroll:
mask wounds and haematomata. Position (1) leads the team and controls the head and C-spine
Pathways
The combative patient may not tolerate immobilization in head blocks. To enforce this may Position (2) controls the shoulder, arm and chest
mean the head is pinned down while the rest of the body moves: this is not desirable with a Position (3) controls the pelvis and thigh
Supporting Guidelines potential C-spine injury. Immobilise with semi-rigid collar and repeated reassurance. Position (4) controls the distal lower limb
Where there is concern for raised intracranial pressure (ICP) after a closed head injury,
Section 6 head blocks alone will suffice to immobilise the unresponsive patient. ICP may be further
raised by pressure on the neck veins from semi-rigid collar. Ideally these patients are The log roll is ideally a 4-person technique.
Toolbox also managed 30 degrees head up, which also assists ICP (this may not be possible until Head blocks and cervical collar are removed before the roll when the spine is to be
in a hospital environment). Consider the orientation of head injured casualties when examined (e.g. by a surgeon).
Section 7 transporting in a helicopter, which will fly in a nose-down attitude: if the patients head Position (1) takes control of the head and neck and gives the orders. In-line immobilisation
istowards the aircraft nose this may aggravate a raised ICP. is maintained.
Choose to roll away from the affected side where appropriate. Ensure there is adequate
slack in all lines (IV lines; ventilator tubing; monitoring leads).
Section 8
If the spinal board is to be removed, ensure all straps are taken off the board prior to roll
(otherwise they would be dragged under the patient).
Policies
Position (1) uses the command Ready Brace Roll to ensure synchronous movement
when rolling onto the side.
Section 9
A 5th person must remove/place the spine board and perform a spinal examination
Documentation and audit (including rectal examination at the hospital). Clothing is also removed.
Position (1) uses the command Ready Brace Roll to roll the patient onto their back.
Section 10 Where the spine has not been radiologically and clinically cleared, the cervical spine
immobilisation is re-applied.
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Spinal clearance Airway issues in C-spine 4c-d
injury
Treatment
Introduction Treatment guidelines 4c Guidelines
Section 1 Clearance of the C-spine Treatment guidelines 4d

NEXUS Guidelines from US (National Emergency X-Radiograph Utilization Study, with
Preparation guidelines validated on >30000 patients) are an established framework for clinical Indications for ventilation
clearance of the cervical spine following blunt trauma (99% sensitivity for detecting
Casualties with cervical cord injury above the level of C4 have
Section 2 afracture). The C-spine can be cleared if:
diaphragmatic and intercostal muscle paralysis and rely on accessory
The patient is GCS 15 (normal level of alertness) and muscles for ventilation. They will require early intubation to maintain
Incident management There is no posterior mid-line tenderness and adequate ventilation. Casualties with cord injury between C4 and
There is no distracting injury (other painful injury) and C8 retain the diaphragm function: however, loss of the intercostal
Section 3 There is no focal neurological deficit and muscle function reduces the FVC and tidal volume by up to 60% and
ventilatory support may be required ifthe casualty tires.
There is no intoxication (alcohol or drugs, including iatrogenic).
Treatment guidelines Role 2 Light Manoeuvre: If skills are available endotracheal
Cervical spine X-rays should be performed on all other patients. Three-view plain X-ray
intubation with in-line neck stabilisation should be performed. If
imaging (lateral, AP, peg) is recommended for conscious patients (sensitivity of ~94%
Section 4 advanced airway skills are not available and the casualty requires
for showing fracture in symptomatic patients). A Swimmers view is performed if C7T1
an urgent airway a surgical airway (cricothyroidotomy) should be
junction is not seen on the lateral view. If these images are normal then the casualty can
Transport performed.
be clinically examined and cervical spine precautions removed if she/he is non-tender and
demonstrates a full range of active neck movements. If there is mid-line tenderness then 3e
Section 5 flexion and extension films are used to assess for ligamentous injury. Go to Treatment
guidelines
Where CT is available this should be performed, in preference to x-ray, as part of a trauma
Pathways scan when polytrauma is suspected. Role 2 Enhanced/Role 3: Airway management by endotracheal
Where CT of the brain is undertaken following blunt trauma to the head, and when the intubation.
Supporting Guidelines patient is obtunded, then the cervical injury should be assumed and CT of C-spine included in
Procedure for intubation with concomitant neck injury
the examination.
Section 6 In the presence of a cervical collar, laryngoscopy becomes more
SCIWORA difficult. It is essential tomaximise the opportunity to secure the
Toolbox Spinal Cord Injury Without Radiological Abnormality (SCIWORA) is a rare phenomenon airway on the first attempt at intubation.
(0.08% cervical spine injuries) that occurs in both adults and children. The most common An assistant provides manual in line immobilisation of the cervical
Section 7 injuries (MRI confirmation) are central disc herniation, spinal stenosis, and cord oedema spine.
orcontusion. The equipment stabilizing the C-spine is removed (in the case of a
Operational formulary Clearance of the thoracolumbar spine collar this may mean unfastened and opened rather than completely
removed.)
The thoracolumbar spine is cleared clinically during the log roll and radiologically where
Section 8 symptoms and signs demand imaging. The patient is pre-oxygenated.
A separate assistant applies cricoid pressure.
Policies 4b
Go to Treatment The patient receives anaesthetic drugs and rapid acting
guidelines
neuromuscular blocking drugs.
Section 9
The patients trachea is intubated, the endotracheal tube position is
Documentation and audit checked and the tubesecured.
The stabilizing devices are reapplied.
Section 10 This procedure must include pre-assembling all necessary
Principal source: Hoffman JR et Al: Ann Emergency Med. 32: 461-9 (1998)
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B Difficult or abnormal 5
Difficult or abnormal 5
Intro
B
breathing
Treatment Treatment
Introduction
Guidelines
breathing Guidelines
Section 1 Treatment guidelines 5 Treatment guidelines 5

Preparation
Trauma Medical
Section 2 Breathlessness Anaphylaxis
Treatment guidelines 5a1 Treatment guidelines 5e
Incident management
Tension pneumothorax awake Asthma
Section 3 Treatment guidelines 5a(i) Treatment guidelines 5f
Treatment guidelines Tension pneumothorax ventilated Pulmonary oedema
Treatment guidelines 5a(ii) Treatment guidelines 5g
Section 4
Open pneumothorax Pulmonary embolus & DVT
Transport
Treatment guidelines 5b Treatment guidelines 5h
Section 5 Massive haemothorax Chemicals & poisons Go to 10e
Treatment
Treatment guidelines 5c guidelines
Pathways Trauma or medical

Flail chest Spontaneous pneumothorax
Supporting Guidelines Treatment guidelines 5d
Treatment guidelines 5i
Section 6
Blast Lung
Toolbox Treatment guidelines 5d1
Section 7
Section 8
Policies
Section 9
Section 10
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Breathlessness Tension pneumothorax awake 5a-1-a(i)
Treatment
Introduction Treatment guidelines 5a-1 Treatment guidelines 5a(i) Guidelines
Section 1 Breathlessness is a symptom of Breathlessness - give oxygen Features (may be delayed)

many diseases. It is important Wheeze - give salbutamol (neb/inhaler)
Stridor - get help urgently
Chest pain Hyperinflated hemithorax Splayed ribs
to consider the most dangerous
Preparation Apply monitoring to patient/O including Sats, Extreme respiratory distress (consistent; refractory to reassurance)
causes first and treat these.
BP cuff, cardiac monitor as available Low SpO2 Reduced/absent breath sounds Hyperresonance
Section 2 Reduced/absent movement on affected side
Facial Swelling
Stridor Late signs: hypotension; trachea deviated away from affected side; distended neck/
Incident management Consider Anaphylaxis/ 5e chest/upper arm veins (inconsistent sign if hypovolaemia)
Gasping Breathes Go to Treatment
Hives/itching Allergy guidelines
Needle decompression (affected side)
Section 3 Exposure to allergen
Low Blood Pressure Locate second intercostal space mid-clavicular line on affected side (2nd rib joins the sternum
at the sternal angle; 2nd intercostal space is below this rib).
Increased respiratory rate
Cough (frothy pink/white) 5g
Section 4 Sitting Forward
Consider Cardiogenic Go to Treatment
Hx of trauma/chest pain shock/Heart Failure guidelines
Transport Crackles at bases of lung/chest
Section 5 Chest pain 7a

Breathlessness
FIRST Consider MI/ Go to Treatment
Heart Attack guidelines 2nd intercostal space mid-clavicular line
Pathways bbbb
Hx of immobility/travel 5h Nipple (approximate surface marking)
Go to
Supporting Guidelines Sore Leg
Coughing up blood
Consider PE Treatment
guidelines
5th intercostal space anterior axillary line
Section 6
Increased respiratory rate 5f
Cough (often dry) Consider Asthma Go to
Toolbox Wheeze
Treatment
guidelines
Section 7 Productive cough Insert a large bore cannula perpendicularly into the chest, just above the 3rd rib
Increased respiratory Remove the metal needle and leave the cannula uncapped: air should be heard escaping
Operational formulary Reduced exercise tolerance
Consider Pneumonia Document the procedure (this is important if the cannula is removed/falls out before the
High temperature
Unwell casualty reaches hospital)
Section 8 Crackles over one side of chest
Policies If the technique fails and the diagnosis is certain, the cannula may be too
Breathlessness short. Think laterally and go laterally. Place the cannula in the 5th inter-
Hx of chest trauma (non
Section 9 penetrating) -not always costal space, anterior axillary line or proceed immediately to a chest drain.
required Consider spontaneous 5i
Go to Treatment
(Sometimes) chest pain pneumothorax guidelines
Documentation and audit Increased respiratory rate
Definitive care
Patient sometimes taller than
average A chest drain is required
Section 10
Other causes of breathlessness - lack of fitness, anxiety, exercise, heat injury, other illnesses
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Intro
Tension pneumothorax ventilated Open pneumothorax 5a(ii)-b
Treatment
Introduction Treatment guidelines 5a(ii) Treatment guidelines 5b Guidelines
Section 1 Features (immediate) Features

Low SpO2 Hypotension Surgical emphysema High inflation pressures Low SpO2 Respiratory distress Sucking and bubbling from the wound
Preparation Affected side showing over-expansion (ribs splayed), reduced mobility, reduced/absent Shock Affected side showing reduced movement, absent breath sounds,
breath sounds, increased resonance reduced mobility (under-expansion), increased resonance
Section 2 Late signs: trachea deviated away from affected side First aid
Distended neck/chest/upper arm veins (inconsistent sign if hypovolaemia) Apply Asherman Chest Seal (ACS then reassess).
Incident management Potential for bilateral tension pneumothorax Evacuate as T1
Needle decompression (affected side)
Section 3
Locate second intercostal space mid-clavicular line on affected side (2nd rib joins the sternum Bolin Chest Seal
at the sternal angle; 2nd intercostal space is below this rib).
Treatment guidelines Triple valve
Section 4
Transport
Section 5
2nd intercostal space mid-clavicular line
Pathways
Nipple (approximate surface marking) Adhesive
patch
Supporting Guidelines 5th intercostal space anterior axillary line
Section 6
Toolbox BATLS resuscitation

Insert a large bore cannula perpendicularly into the chest, just above the 3rd rib. Insert a chest drain.
Section 7 Evacuate to definitive care as T1
Remove the metal needle and leave the cannula uncapped: air should be heard escaping.
Document the procedure (this is important if the cannula is removed/falls out before the Give analgesia and antibiotic therapy according to Gunshot Wound (GSW) pathway
casualty reaches hospital.) 1
Go to Section 5
Section 8 Pathways
If the technique fails and the diagnosis is certain, the cannula may be too
Policies short. Think laterally and go laterally. Place the cannula in the 5th inter- Ventilate if respiratory compromise despite chest drain Go to 3cd
(Rapid Sequence Induction of anaesthesia by trained staff only. Treatment
costal space, anterior axillary line or proceed immediately to a chest drain guidelines
Section 9 For haemorrhagic shock Go to 6a

Treatment
Definitive care guidelines
A chest drain is required. Surgical care
Thoracostomy (a surgical hole without placement of a drain) is a temporary option for the This typically involves extending the defect to form a small thoracotomy, excision of the
Section 10 wound edges and partial closure.
ventilated casualty.
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Intro
Massive haemothorax Flail chest 5c-d
Treatment
Introduction Treatment guidelines 5c Treatment guidelines 5d Guidelines
Section 1 Features Features

Shock (tachycardia and hypotension) Severe chest pain Paradoxical movement
of the flail segment
Preparation Affected side showing: reduced breath sounds, dullness to percussion, under-expansion Extreme respiratory distress
and reduced mobility External signs of blunt chest injury
Section 2 Respiratory distress (mild severe) (bruising/swelling/seatbelt marks)
The stethoscope is a blunt tool, but should yield useful information in massive haemothorax. Crepitus: fractured ribs/surgical emphysema
Incident management CXR will reliably detect massive haemothorax however, it takes ~500ml fluid to produce Paradoxical movement of the flail segment
detectable changes on erect CXR and when supine up to 1000ml may be present in a (see diagram, may be subtle),
Section 3 hemithorax without marked radiological signs. Extended FAST performed by radiologist, orhypomobility
ultrasonographer or trained clinician is a quick, sensitive tool which can easily be performed in Low SpO2
Treatment guidelines resus. CT is the most sensitive diagnostic tool where available at Role 2 Enhanced/Role 3. Signs from associated haemothorax
First aid may be present
Section 4 No specific treatment First aid
Evacuate as T1 Evacuate T1 with affected side down
Transport
BATLS resuscitation (will offer some splinting of segment).
Section 5 Consider inserting a chest drain. Balance the benefit of improving ventilation with BATLS resuscitation
precipitating further blood loss that cannot be replaced when forward of a Role 2/3 Critical decision: exclude or treat associated
Pathways with surgical capability. A chest drain at Role 1 may convert such a patient from being tension (key indicator is over-inflation
critically stable to being precipitously unstable. of hemithorax). Remember that needle
Consider a thoracostomy instead of a chest drain when the patient is ventilated and decompression in absence of tension might
Supporting Guidelines rapid packaging for transport is essential (e.g. primary retrieval from point of wounding): make the patients condition worse.
remember that blood drained from an open thoracostomy cannot be measured. A chest drain (technically may be difficult)
Section 6
Research (animal studies of haemothorax) has shown no benefit from clamping will be needed for failed decompression,
a chest drain. large simple pneumothorax or prolonged
Toolbox
Evacuate to definitive care as T1 transport to R2E. There is a low threshold
Give analgesia and antibiotic therapy according to Gunshot Wound (GSW) pathway. for post-ventilation chest drain because
Section 7 of the risk oftension pneumothorax.
Antibiotics do not appear to reduce the risk of secondary empyema.
Continuing treatment is principally directed towards the underlying contusion. Where there is
Operational formulary 1
respiratory compromise (hypoxia and/or hypercapnia) on blood gases proceed to ventilation
Go to Section 5 Pathways
(Rapid Sequence Induction of anaesthesia by trained staff only). Go to 3cd
Section 8 Ventilate if respiratory compromise despite chest drain (Rapid Sequence Induction Treatment
guidelines
of anaesthesia by trained staff only). Go to 3cd
Policies Treatment
Ventilation may be avoided by effective analgesia (including intercostal nerve blocks
guidelines or thoracic epidural): realistically, this is a technique that will be undertaken at a Role 2
6a Enhanced or a Role 3 facility, unless the Medical Officer is extremely isolated.
Section 9 For haemorrhagic shock Go to
Treatment
guidelines
Definitive care
Documentation and audit Complications
Evacuation will be required to Role 4. Dependent on the degree of underlying contusion
Empyema (risk after chest drain for all indications is 125%) and respiratory failure this may require ventilation and a critical care transfer. CPAP is a
Section 10 Fibrothorax (rare) widely used option.
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Intro
Blast lung Blast lung 5d-1
Treatment
Introduction Treatment guidelines 5d-1 Treatment guidelines 5d-1 Guidelines
Ventilation strategy Pursue a strategy of

Section 1 Features The aim is to oxygenate the patients vital organs but minimise further permissive hypercapnia
An injury where there is initially diffuse bleeding with the lung (causing hypoxia), which damage to the lungs from the ventilator. This is achieved using Target pH to 7.25
Preparation progresses to an inflammatory state with the lung. approaches that have benefit in ARDS. Plateau airway pressure not
Use FiO,in combination with appropriate levels of PEEP to achieve adequate above 30 cm H2O
Blast Lung Hypoxia can get rapidly worse: or develop over 24-48 hours. oxygenation in accordance with: Tidal volume 6-8ml/kg [no
Section 2 Small number of these patients present with severe refractory hypoxia very soon after injury Fi02 FI 0.4 0.5 0.8 0.9 1.0 more than 8 ml/kg] (lean
body weight)
PEEP 1
5 to 8 8 to 10 10 to 14 14 to 16 16 16 to 18 If hypercapnia difficult
Incident management Look for, manage and/or exclude pneumothoraces and undertake to control, increase the
endotracheal intubation if oxygenation is difficult to maintain or achieve
Clinical Symptoms Those at risk are: respiratory rate (up to 35
breaths/minute) in preference
Endobronchial toilet in the presence of pulmonary haemorrhage is
Section 3 include: Those exposed to significant blast. hazardous but may be required if clot obstruction is contributing to to increases in tidal volume
Shortness of breath Those within an enclosed space (vehicle or hypoxaemia. Segmental obstruction on chest x-ray or CT should prompt In presence of a significant
Treatment guidelines Haemoptysis building).
careful consideration of the potential risks and benefits of performing metabolic acidosis, ensure
endobronchial suction. PaCO2 not less than 6.5 kPa
Cough Those with signature injuries associated with Permissive hypercapnia may represent a reasonable strategy in the (see footnotes)
Section 4 blast (e.g. limb amputation). presence of severe lung injury. Consider sodium bicarbonate
If High Frequency Oscillatory Ventilation (HFOV) is available, along with if pH drops below 7.1
the skills and experience to use it, consider its role if the above measures Active cooling to target a
Transport prove inadequate. core temperature of 35C
Consider alveolar recruitment manoeuvres if HFOV is unavailable and should be considered if other
Guidance for Management oxygenation cannot be achieved or maintained, but this must only strategies are inadequate
Section 5 be performed with caution. but may not be practical if
Initial resuscitation follows standard
Prone positioning may be of benefit if the appropriate use of FiO, PEEP, patient is coagulopathic.
DMS <C>ABC protocol
Pathways recruitment manoeuvres, tracheal and endobronchial toilet and the use of
Think blast lung if X-ray &/or CT show neuromuscular blockade has failed to achieve adequate oxygenation.
any thoracic abnormality In the presence of Consider use of recombinant Factor VIIA (rVIIa) in blast lung
Supporting Guidelines Management of blast lung is similar confirmed blast lung, Factor VIIa has been used in a small number of patients to treat the diffuse haemorrhage of early blast
to that of pulmonary contusion fluid (crystalloid) lung and to treat other haemorrhagic lung disease. At present there is no specific therapy to modify
the progression of blast lung, although there is limited anecdotal evidence of rFVIIa having a possible
Section 6 Give high flow oxygen to maintain resuscitation can therapeutic effect in some UK casualties by slowing the injury progression and some cases series evidence of
SaO2 over 95% rFVIIa use in other haemorrhagic lung conditions.
Toolbox exacerbate This is currently under investigation at DSTL Porton Down.
Actively exclude pneumothorax and
haemothorax
acute lung injury. In most cases the UK military experience has been as part of a massive transfusion protocol but rFVIIa has
been used specifically to manage the lung injury in some patients where there was rapid deterioration in their
Section 7 Intubate and ventilate as required for: lung function. This is an off licence use, and has been agreed by the Advisory Group on Military Medicine
Consider early use (AGoMM, Aug 2010) and is subject to ongoing audit and review.
Surgery for other injuries
Operational formulary of blood and blood Examples of dose regimes used successfully include:
rFVIIa 100 micrograms per Kg given early in resuscitation intravenously in presence of severe refractory
Hypoxaemia (PaO2< 8 kPa)
components. hypoxia, dose repeated 20-30 minutes later.
Signs of pulmonary, cerebral or cardiac A small number of casualties have been given a further 2 or 3 doses over the following 4 to 6 hours.
Section 8 micro-embolisation (high CVP but poor Other Considerations
cardiac performance, confusion, The patient should still have enteral feeding unless contra indicated.
Policies haemodynamic instability) The time frame when the haemorrhagic element of blast lung stops is uncertain-and may be between 6 to 48 hours.
This is the subject of ongoing work at DSTL. The risk of VTE and the use of Low Molecular Weight Heparins and other
If micro-embolisation is suspected ventilate pharmacological VTE prophylaxis needs to be balanced against the risk of ongoing lung injury- so alternative methods of
Section 9 with 100% oxygen until signs subside or VTE prophylaxis should be considered.
for up to 24 hours, otherwise adjust the FiO2 Patients with Blast Lung Injury are a significant issue for aeromed transport: speak to the CCAST team early.
Advice From QEHB Critical Care Re: Target PaCO2. In the presence of metabolic acidosis the degree of respiratory acidosis
Documentation and audit to achieve a PaO2 of between 8 and 9 kPa. cannot be determined and therefore cannot be used to titrate alveolarminute volume. There is a survival advantage associated
withrespiratory acidosis, and so the only way of ensuring at least a modestdegree of respiratory acidosis in the presence
of a metabolic acidosis is toensure that the PaCO2 is not driven down into the normal range. If acidaemiaper se becomes
Section 10 haemodynamically compromising, the answer is to administerbicarbonate, rather than increase alveolar minute volume
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Anaphylaxis (adult) Anaphylaxis (child) 5e
Treatment
Introduction Treatment guidelines 5e Treatment guidelines 5e (Contd) Guidelines
Section 1
Actions at Role 13 Actions at Role 13
Consider when compatible history of severe allergic-type Consider when compatible history of severe allergic-type
Preparation Time reaction with respiratory difficulty and/or hypotension, Time reaction with respiratory difficulty and/or hypotension,
especially if skin changes present especially if skin changes present
Section 2
Incident management
High flow oxygen treatment High flow oxygen treatment
Section 3
Treatment guidelines Stridor, wheeze, respiratory distress Stridor, wheeze, respiratory distress
or clinical signs of shock or clinical signs of shock
Section 4
Transport Adrenaline (epinephrine) 1:1000 solution

Adrenaline (epinephrine) >12 years: 500 micrograms IM (0.5ml)
Section 5 1:1000 solution, 300 micrograms if child is small
0.5ml (500 micrograms) IM 612 years: 300 micrograms IM (0.3ml)
Pathways Repeat in 5 minutes <6 years: 150 micrograms IM (0.15ml)
if no clinical improvement Repeat in 5 minutes if no clinical improvement
Section 6
Antihistamine (chlorpheniramine)
Antihistamine (chlorpheniramine) >12 years: 10mg IM or slow IV
Toolbox 10mg IM/or slow IV 612 years: 5mg IM or slow IV
6mths6 years: 2.5mg IM or slow IV
Section 7
<6 months: 250 micrograms/kg
Operational formulary In addition 15 mins
20 mins
In addition
Section 8
For all severe or recurrent If clinical manifestations of
Policies reactions and patients with shock do not respond to drug
For all severe or recurrent reactions If clinical manifestations of
asthma give hydrocortisone treatment give 5001000ml
and patients with asthma give shock do not respond to drug
Section 9 200mg IM/or slowly IV crystalloid fluid by rapid infusion
hydrocortisone >12 years: treatment give 20ml/kg IV
612 years: 100mg IM or slow IV crystalloid fluid by rapid
Documentation and audit 6 mths6 yrs: 50mg IM or slow IV infusion. One repeat dose
<6 months: 25mg IM or slow IV maybe necessary
Section 10
Adapted from: Advanced Life Support Algorithm (January 2008) Adapted from: Advanced Life Support Algorithm (January 2008)
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Asthma (adult) Asthma (adult) 5f
Treatment
Introduction Treatment guidelines 5f Treatment guidelines 5f (Contd) Guidelines
Section 1 Actions at Role 1 Observations Actions at Role 2/3

Preparation Assess and record Measure PEFR and SaO2 or ABG
Time Time
Peak expiratory flow (PEFR)
Section 2 Symptoms and response to
Moderate or severe asthma Life threatening asthma
salbutamol inhaler Ventolin inhaler
Incident management Pulse & respiratory rate PEFR 3375% best or predicted PEFR <33% best or predicted
SpO2 (features as at Role 1)
Section 3 SpO2 <92%
5 mins Silent chest, cyanosis or poor
5 mins
Give salbutamol nebuliser 5mg respiratory effort
Bradycardia or hypotension
Exhaustion, confusion, coma
Section 4 Moderate Acute severe Life threatening
Obtain senior help NOW
asthma asthma asthma
Transport PEFR 5075% PEFR <50% or
PEFR >50% best PEFR 3350% best PEFR <33% best Repeat nebuliser life-threatening
salbutamol 5mg features Immediate management
Section 5 or predicted or predicted or predicted High flow oxygen
Prednisolone
4050mg orally Nebuliser
Pathways salbutamol 5mg
Speech normal Cant complete sentences SpO2 <92% 1530
Resp <25/min Resp 25/min Silent chest mins ipratropium 0.5mg
Supporting Guidelines Pulse <110/min Pulse 110/min Cyanosis
Prednisolone 4050mg PO or
hydrocortisone 100mg IV
Feeble respiratory rate PEFR 5075% PEFR <50% or
Section 6 signs of severe
Observe in oreffort
Hypotension asthma
Toolbox primary health ABG markers of severity
until PEFR >75% Bradycardia Normal or raised PaCO2
Section 7 Exhaustion, confusion 60 mins Observe: PaCO2 >4.6kPa; 35mmHg
SpO2 Severe hypoxia
Operational formulary Further Pulse PaO2 <8kPa; 60mmHg
Arrange transfer to next Role Low pH
15 mins treatment Resps
Section 8 120
mins
Policies Oxygen 100% Consider After 15 minutes:
Continuous salbutamol repeat salbutamol 5mg/
Prednisolone 4050mg nebs(510mg/hr) ipratropium 0.5mg neb
Section 9 Magnesium sulphate Correct fluids/electrolytes
If appropriate
Nebuliser (1.22g IV over 20 mins) Chest X-ray
Salbutamol 5mg Salbutamol IV 250mcg over
Ipratropium 0.5mg 10 mins followed by IV infusion
Section 10
In accordance with: British Thoracic Society Guidelines (May 2008) In accordance with: British Thoracic Society Guidelines (May 2008)
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Intro
Asthma (child under 2 years) Asthma (child over 2 years) 5f
Treatment
Introduction Treatment guidelines 5f (Contd) Treatment guidelines 5f (Contd) Guidelines
Section 1
Actions at Role 13 Actions at Role 1
Preparation Assess asthma severity Assess asthma severity

Time Time
Section 2
Moderate Severe Moderate Severe Life threatening
Incident management
SpO2 92% SpO2 <92% SpO2 >92% SpO2 <92% SpO2 <92%
Section 3 Audible wheeze Cyanosis Able to talk Too breathless to talk Silent chest
Using accessory muscles Marked respiratory distress Heart rate 130/min Heart rate >130/min Cyanosis
Still feeding Too breathless to feed
Section 4
Transport Life threatening features include apnoea, Salbutamol inhaler Salbutamol inhaler
bradycardia and poor respiratory effort 410 puffs via spacer 10 puffs via spacer
Section 5
5 mins Consider soluble
Pathways prednisolone 20mg
Immediate management: age 25 years, or
oxygen via close fitting face mask or nasal prongs Salbutamol nebuliser
Supporting Guidelines 3040mg >5 years 2.5mg 25 years
2.5mg >5 years
Section 6
Salbutamol inhaler up to 10 puffs or
Toolbox via spacer (volumatic) and face 5mg terbutaline
mask or salbutamol 2.5mg neb or Soluble prednisolone
Section 7 terbutaline5mg neb 20mg 25 years
Repeat every 14 hours 3040mg >5 years
Operational formulary if responding Add ipratropium bromide
0.25mg neb
Section 8 If poor response:
1530 mins
Policies Add ipratropium bromide 0.25mg Actions at Roles 2 & 3
nebuliser en route tohospital
Soluble prednisolone 10mg IV salbutamol 15mcg/kg of 200mcg/ml over 10 minutes
Section 9
Chest X-ray and ABGs
Documentation and audit Role 3 only Consider bolus IV infusion magnesium sulphate 40mg/kg
IV hydrocortisone 4mg/kg (max 2g) over 20 minutes
20 mins
Section 10
In accordance with: British Thoracic Society Guidelines (May 2008) In accordance with: British Thoracic Society Guidelines (May 2008)
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Intro
Pulmonary oedema Pulmonary embolus & DVT 5g-h
Treatment
Introduction Treatment guidelines 5g Treatment guidelines 5h Guidelines
Section 1 Role 1 Role 1

Preparation Signs of shock (clammy, anxious) Time Suspected Symptoms & signs of DVT
Dyspnoea/difficulty talking DVT or PE? Pain & swelling to leg
Section 2 Usually unilateral
Tachycardic/tachypnoeic
yes May be bilateral
Incident management Pink frothy sputum
Crackles or wheeze
Section 3 Signs of exhaustion/reduced level of Symptoms & signs of PE
Immediate Actions Breathlessness*
consciousness
Treatment guidelines High Flow O2 Tachypnoea >20/min
Pleuritic chest pain
Monitor pulse, RR, BP, SpO2
Haemoptysis
Section 4 ABG *Breathlessness +/or RR are
Immediate treatment almost always present
Transport
If conscious sit up
PLUS
Section 5 100% oxygen Signs of Massive PE
Furosemide 5 mins Signs of Massive PE?
If wheezing give salbutamol nebuliser Syncope/shock
50mg IV
Pathways 2.55mg SpO2 <92%
Pulse Rate >120
Monitor resps, pulse, BP yes no RR >29
Section 6 Immediate
Evacuate
evacuation
Toolbox
Section 7 Role 2 & 3

Operational formulary Investigations Treatment
FBC, U&Es, glucose Nitrates (buccal suscard 25mg
Section 8 ABG or nitrate infusion if systolic BP
Chest X-ray >90mmHg)
Policies Morphine 2.55mg IV
12-lead ECG
Role 2 & 3 Role 2 & 3
Section 9
Furosemide 50mg IV
see
Metoclopramide 10mg IV or
cyclizine 50mg IV
60
Risk of cardiac arrest over
Systolic BP <100mmHg = treat mins
Section 10 for shock Adapted from: British Thoracic Society Guidelines on the Management of Pulmonary Embolism (2003)
& Auckland City Hospital VTE Investigation Algorithm (2005)
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Intro
Pulmonary embolus & DVT Pulmonary embolus & DVT 5h
Treatment
Introduction Treatment guidelines 5h (Contd) Treatment guidelines 5h (Contd) Guidelines
Section 1 Wells score for risk stratification Thromboprophylaxis: general

Venous thromboembolic (VTE) disease (deep vein thrombosis, DVT, +/ pulmonary embolic
Preparation Wells score for DVT disease, PED), is a major contributor to morbidity and mortality in hospital admissions
A Score of 2 or more = probability of DVT 28% (likely) across all specialities. Studies have shown that 0.9% of all hospital admissions will die of
Section 2 A Score <2 = probability of DVT 5% (unlikely) PED, 10% of all hospital deaths are due to PED and the risk of VTE rises tenfold in patients
hospitalised after trauma, surgery or immobilising medical illness.1, 2
Clinical Characteristic Score
Incident management Active cancer (receiving treatment within 6 month or palliation) 1
VTE thromboprophylaxis is to be given unless there is a clear indication to the contrary.
Thedecision NOT to give prophylaxis should be made by a senior clinician and reasons
Paralysis, paresis or recent POP lower extremities 1 forthis decision recorded in the clinical notes.
Section 3 Bedridden for 3 or more days, major surgery within 12 weeks 1
Localised tenderness line of the deep veins 1 Trauma Prophylaxis
Treatment guidelines Entire leg swollen 1
Multiple trauma, major lower limb fractures, Full length GECS + LMWH (enoxaparin
Calf swelling at least 3cm more than the other side 1
Section 4 head or spinal cord trauma without 40mg SC once daily)
(measured 10cm below tibial tuberosity)
significant risk of bleeding Full length GECS alone until
Pitting oedema confined to the symptomatic leg 1
Transport Collateral superficial veins (non-varicose) 1 As above but with bleeding risk from head haemodynamically stable: then add
Previous documented DVT 1 trauma or blast lung enoxaparin 40mg SC once daily
Section 5 Alternative diagnosis at least as likely as DVT 2 Surgical patients Full length GECS + LMWH (enoxaparin
40mg SC once daily)
Reference: N Engl J Med 349 (13) Sept 25, 2003. 12271235 Major surgery (>1 hour and/or patient
Pathways Full length GECS alone until
>40yrs)
Wells score for PE haemodynamically stable: then add
As above but with significant bleeding risk
Supporting Guidelines A Score of >4 = > probability of PE 41% (likely) enoxaparin 40mg SC once daily
A Score < or =4 = > probability of PE 8% (unlikely) Medical patients Full length GECS + LMWH (enoxaparin
Section 6 Patients who are likely to be immobile in 40mg SC once daily)
Clinical Characteristic Score
Clinical signs and symptoms of DVT 3 bed for >72 hours (e.g. MI, pneumonia)
Toolbox GECS = Graduated Elasticated
(Minimum of leg swelling and pain on palpation of deep veins)
Compression Stockings
Alternative diagnosis less likely than PE 3
Section 7 Heart Rate >100 1.5
LMWH = Low Molecular Weight Heparin
Immobilisation or surgery in the previous 4 weeks 1.5

Previous documented DVT/PE 1.5
Haemoptysis 1 Notes
Section 8 Malignancy (Treated within 6 months or palliative) 1 AUDIT
Below-knee GECS are NOT to be used
Policies Reference: Thromb Haemost 2000; 83: 41620 LMWH does not require coagulation monitoring
Vidas D-Dimer has a low specificity in older patients, in trauma, post operative states, Aspirin not suitable for prophylaxis as of unproven efficacy2
Section 9 inflammation, infection and malignancy. Duration of therapy is until fully mobile or discharge from hospital
It should not be used as a routine screen for venous thromboembolism in patients
Documentation and audit who are likely to have a positive test for another reason.
1 Scottish Intercollegiate Guidelines Network: Prophylaxis of Venous Thromboembolism, National Clinical Guideline.
Section 10 Adapted from: British Thoracic Society Guidelines on the Management of Pulmonary Embolism (2003) SIGN. Edinburgh (2002)
& Auckland City Hospital VTE Investigation Algorithm (2005) 2 British Committee for Standards in Haematology: Guidelines on the Use and Monitoring of Heparin. BCSH (2005)
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Intro
Spontaneous pneumothorax C Shock 5i-6
3
Treatment
Introduction Treatment guidelines 5i Treatment guidelines 6 Guidelines
Section 1 Features
Pneumothorax may occur spontaneously in the absence of trauma.
Hypovolaemic shock
Pneumothorax may also be secondary to asthma, pneumonia or TB.
Section 2
Sudden onset unilateral pleuritic chest pain
Septic shock
Dyspnoea +/ cough.
Incident management Depending on size of pneumothorax there may be tachypnoea and tachycardia and
percussion may be normal or hyperresonant.
Cardiogenic shock
Section 3 Investigations
CXR is essential to diagnose small pneumothoraces: the stethoscope is only a crude
Treatment guidelines diagnostic aid. Neurogenic shock
Monitor SpO2.
Measure ABG when there is dyspnoea and/or reduced SpO2.
Transport ECG when the prominent symptom is chest pain. Intraosseous Access
Treatment Treatment guidelines 6e
Section 5 Aspiration is recommended for spontaneous pneumothorax:
infiltrate with local anaesthetic, insert a 16G IV cannula in the 2nd intercostal space
Pathways inthe mid clavicular line
attach three way tap and aspirate with a 50ml syringe
Supporting Guidelines continue aspiration until patient coughs excessively or until 2.5 litres of air is removed.
If aspiration unsuccessful insert a chest drain.
Section 6
Toolbox Where no chest X-ray capability is available, the patient is symptomatic

and clinically there is a pneumothorax, insert a chest drain
Section 7
Operational formulary Note

Ultrasound can be used successfully to detect a pneumothorax.
Section 8
Policies
Section 9
Section 10
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Intro
Hypovolaemic shock 6a
Treatment
Section 1 Step 1
Stop external bleeding Go to 2ab
Preparation Treatment
guidelines
Step 2
Section 2 Assess the cause of the hypovolaemic shock:
haemorrhage (trauma and non-trauma)
Incident management plasma (burns)
electrolyte solution (diarrhoea and/or vomiting).
Section 3
Step 3
Treatment guidelines Estimate the degree of hypovolaemic shock from the table:
Section 4 Class of I II III IV

Shock
Up to 750ml 7501500ml 15002000ml >2000ml
Transport Blood loss <15% lost 1530% lost 3040% lost >40% lost
Section 5 Heart rate <100/min >100/min 120140/min >140/min

Intentionally blank
Decreased/
Pathways Systolic BP Normal Normal Decreased
unrecordable
Very narrow/
Supporting Guidelines Pulse pressure Normal Narrowed Narrowed
absent
Section 6 Capillary Prolonged/
Normal Prolonged Prolonged
Refill Absent
Toolbox Respiratory
1420/min 2030/min >30/min >35/min
Rate
Section 7 Urine output >30ml/hr 2030ml/hr 520ml/hr Negligible
Operational formulary Cerebral Normal/

Anxious/
Anxious/ Confused/
Frightened/
function slightly anxious Hostile Confused unresponsive
Section 8
Policies Step 4
Replace fluid intravenously for Class II, III and IV shock (see over).
Section 9 Step 5
Splint unstable pelvic fractures.
Apply a traction splint for fractured femur.
Section 10
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Intro
Hypovolaemic shock Septic shock 6a-b
Treatment
Introduction Treatment guidelines 6a (Contd) Treatment guidelines 6b Guidelines
Section 1 Fluid replacement Actions at Role 1 See also Neurology

Haemorrhage + Fever guideline
Preparation The endpoint for resuscitation for non-compressible haemorrhage (chest or abdomen) Time Hypotension usually
is a systolic BP of 90mmHg. Where SBP cannot be measured, use the presence of a accompanied by: fever/ 9d
Section 2 radial pulse to indicate adequate volume replacement (but this can over-estimate SBP). other features of sepsis/ Go to Treatment
guidelines
Give 0.9% NaCl (normal saline) or Hartmanns solution in 250ml aliquots. warm peripheries
Incident management If there is continuing evidence of shock after 2L crystalloid then blood is needed.
For patients with Class III shock ask for group compatible blood to be available within
Section 3 15 minutes (a full cross match cannot give you blood in the Resuscitation Room in Consider:
under 45minutes). Meningitis if meningism + photophobia purpuric rash
Treatment guidelines For patients with Class IV shock use universal donor blood. Go to 2d Meningococcal septicaemia if purpuric rash only
Treatment
guidelines Endocarditis
Section 4 Use fresh frozen plasma in parallel to packed red cells to restore clotting factors Severe pneumonia including atypical organisms
When more than 68 units of packed cells are needed Biliary or renal tract infection
Transport consider recombinant Factor VIIa . Go to 2e Wound infection or bowel perforation if penetrating injuries
Treatment
Necrotising fasciitis if soft tissue affected surgical review
Monitor the effect of volume resuscitation using the pulse rate, pulse pressure, Malaria if exposure within 2 years do antigen card test
Pathways blood pressure, respiratory rate and hourly urine output (urometer). Typhoid/typhus/leptospirosis if deployed overseas
Burns
Supporting Guidelines Estimate the size of the burn using the Rule of Nines or the Lund and Browder Chart.
1ab Cefotaxime IV or IM 2g (50mg/kg in children)
Section 6 Go to Section 6 Toolbox
or if severe penicillin allergy give
chloramphenicol IV 25mg/kg
Estimate the weight of the patient to the nearest 10kg. with
Toolbox
Estimate the time since the injury to the nearest hour. 100% oxygen + IV fluid resuscitation
Now use the Burns calculator to determine the fluid requirement.
Section 7 Fluidis replaced as N/Saline solution only pre-hospital. Once at hospital use Hartmanns.
1c
Operational formulary Go to Section 6
Toolbox
Diarrhoea and/or vomiting
Section 8 Start fluid resuscitation with 0.9% NaCl (normal saline) or Hartmanns solution. If risk or features of malaria quinine IV 20mg/kg up to 1400mg
Refer to Compendium for specific treatment of infectious causes of D&V. If risk or features of typhus doxycycline PO 200mg (not in children)
Policies Consider Septic shock Go to 6b If risk or features of listeriosis amoxicillin IV 2g (100mg/kg in children)
Treatment
guidelines
Section 9
Related guidelines
Documentation and audit Heat illness Go to 11c 15 mins
Treatment
Beware of hypoglycaemia with quinine

guidelines
Section 10
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Intro
Septic shock Septic shock 6b
Treatment
Introduction Treatment guidelines 6b (Contd) Treatment guidelines 6b (Contd) Guidelines
Section 1 Actions at Role 2 & 3 See also Neurology Intensive care (care may start in the ED)
+ Fever guideline
Preparation Time GCS <15 or other acute Two or more of the following
neurological features 9d Temp >38.3 or <36C
+ Go to
Section 2 Treatment
Suspected Heart rate >90/min
fever or other features of sepsis guidelines
Reassess no yes
infection? Resp rate >20 or
Incident management PaCO2 <4.2Kpa
WBC >12K or <4K or
Consider yes >10% immature cells
Section 3
Meningitis if meningism + photophobia purpuric rash
Treatment guidelines Encephalitis or septicaemia if no meningism or photophobia
Cerebral malaria if exposure within 2 years do antigen card test
Obtain Check
appropriate lactate
Section 4 cultures
Transport If features of meningitis then consider lumbar puncture (LP) unless
signs of ICP or laboratory investigations unavailable Systolic BP<90 Lactate >4mmol
Section 5 Do not delay antibiotics for >30 minutes in order to do LP after fluid bolus no or no Sepsis
(20mls/kg) >1 organ failure
Pathways
Cefotaxime 2g IV or IM (50mg/kg in children) or if severe penicillin yes yes
Supporting Guidelines allergy give chloramphenicol IV 25mg/kg with 100% oxygen + IV
fluid resuscitation + review by intensive care unit team
Antibiotics
Section 6 Septic Severe and
Shock Sepsis re-assess
Toolbox Cefotaxime 2g IV or IM (50mg/kg in children) or
if severe penicillin allergy give chloramphenicol IV
Section 7 25mg/kg with 100% oxygen + IV fluid resuscitation Early goal directed therapy
+ review by intensive care unit team (Role 3 ED/ITU) Continue to
Operational formulary Give broad spectrum antibiotics
Insert CVP line
follow ITU
If CVP <8mmHg give 500mls bolus crystalloid care pathway
Section 8 If risk or features of septicaemia gentamicin IV 57mg/kg
If SBP <90mmHg (after fluid replacement) start
If risk or features of malaria quinine IV 10mg/kg up to 1400mg
noradrenaline
Policies If risk or features of typhus doxycycline PO 200mg (not children) If Hb <10 or Hct <30 give packed red cells
If risk or features of listeriosis amoxicillin IV 2g (100mg/kg in children) Pre-emptive intubation & ventilation
Section 9 1 hour 5d
Tight glycaemic control Go to Section 5 Pathways
In refractory circulatory failure,
Documentation and audit Notes corticosteroid therapy may be beneficial
Beware of hypoglycaemia with malaria + quinine 9d
F Med 85 notification to communicable disease control team
Section 10 Treatment
See also Meningitis Research Foundation Guidelines Go to guidelines Adapted from: The Surviving Sepsis Campaign (2005), UHCW (2005) & the Meningitis Research Foundation (2004)
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Intro
Cardiogenic shock Neurogenic shock 6c-d
3
Treatment
Introduction Treatment guidelines 6c Treatment guidelines 6d Guidelines
Section 1 Definition Definition

Cardiogenic shock is defined clinically as a poor cardiac output plus evidence of tissue hypoxia Neurogenic shock is a form of distributive shock where loss of vascular tone leads to
Preparation that is not improved by correcting reduced intravascular volume. When a pulmonary artery amal-distribution of blood flow.
catheter is used, cardiogenic shock may be defined as a cardiac index below 2.2L/minute/m2
Aetiology and pathophysiology
Section 2 despite an elevated pulmonary capillary wedge pressure (>15mmHg).
Injury to the spinal cord may interrupt the sympathetic chain resulting in vasodilation
Aetiology with hypotension and warm peripheries. Symptoms are more severe with high cervical
Incident management
Acute myocardial infarction is the most likely cause. Cardiogenic shock occurs in about cord lesions whereas lesions below T6 would rarely produce shock.
7% of patients admitted with AMI and typically may be present acutely or develop within Loss of sympathetic innervation to the heart results in unopposed parasympathetic
Section 3 2448 hours. Major risk factors for developing cardiogenic shock with AMI are tachycardia activity with resultant bradycardia.
or bradycardia, hypotension, diabetes and previous MI.
Treatment guidelines Patients who have lost sympathetic tone also lose some ability to thermoregulate:
Treatment they donot sweat in the heat and they cannot vasoconstrict in the cold.
Section 4 Thrombolysis is unlikely to be beneficial in these cases and RCT has found no significant Treatment
difference in mortality at 21 days.
Beware attributing hypotension to spinal cord injury in the initial phases of resuscitation:
Transport Medical supportive treatment can be provided with vasopressors, inotropes and a patient with spinal cord injury may have warm extremities, a bradycardia and a soft
vasoconstrictors. abdomen despite having a significant haemoperitoneum. Presume hypotension is
Section 5 A large RCT has identified that early invasive cardiac revascularisation will reduce mortality due to blood loss and search for a source of bleeding (CXR, Pelvis XR, FAST scan of
compared to medical treatment alone. This will require judgement regarding the availability abdomen, CT clinical examination of long bones, catheter to exclude haematuria from
Pathways of local resources (Host Nation and/or Neighbouring Nation) or the suitability for CCAST retroperitoneal bleed).
evacuation to Role 4. Monitor the patients temperature: if the Resus Room is hot (desert environment) be
Supporting Guidelines prepared to spray with water and fan to cool; if the room is cold cover with blankets and
usethe hot air warming blanket.
Section 6 Use atropine for bradycardia.
Toolbox Go to
6b
Treatment
guidelines
Section 7
This may be ineffective as the underlying pathophysiology is absence of sympathetic
Operational formulary tone rather than excessive parasympathetic tone. If atropine fails use vasopressors
(e.g. norepinephrine) under the direction of an intensivist and progress to cardiac
Section 8 pacing (external pacing available through the defibrillator). Bradycardia typically
resolves at
Policies 35 weeks.
Section 9
Section 10
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Intro
Intraosseous Access Intraosseous Access 6e
3
Treatment
Section 1 The EZ-IO is indicated for immediate vascular access in emergencies.
Preparation
Section 2
Incident management Sites:

Tibia
Section 3 Humerous
Figure 3 Tibial site demonstrated
Section 4
Transport
Section 5
Figure 1 EZ-10 Power Driver and Needle sets
Pathways Tibial Techniques
Check skin, adipose and muscle thickness before insertion (see Figure 2).
Figure 4 Figure 5
Supporting Guidelines Use aseptic technique.
Insert EZ-IO needle set.
Section 6
IMPORTANT: Do not touch the needle set with your hands or fingers.
Toolbox
Section 7
Operational formulary Position Driver at insertion site with needle

set at a 90-degree angle to the bone.
Section 8 Gently power or press needle set until
needle set touches bone.
Policies Figure 2
Open the pouch and prepare equipment (including a 50ml syringe).
Section 9 Prepare IV fluids. Prime 3 way tap and EZ connector with fluid.
Check the patency of the chosen limb. Figure 6
Clean insertion site with alcohol swab (see Figure 3). IMPORTANT: Control the patients movement prior to and during needle set insertion.
Section 10 Choose appropriate size needle and attach to driver. Ensure the driver and needle are
securely seated.
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Intro
Intraosseous Access Intraosseous Access 6e
3
Treatment
Introduction Treatment guidelines 6e (Contd) Treatment guidelines 6e (Contd) Guidelines
Section 1
Remove Power Driver and Stylet (Figure 8).
Preparation
Confirm metal catheter stability.
Attach primed extension set to catheter hubs
Section 2 Luer lock. (Figure 9)
Incident management
Do not attach a syringe directly to the EZ-IO Figure 8
Section 3 catheter hub
Aspirate a small amount of marrow to confirm

Treatment guidelines placement.
Flush the EZ-IO catheter with 10 ml of Normal
Section 4 Saline.
Transport
Section 5 Note: frequently monitor the insertion site for

extravasation. Figure 9
Pathways Figure 7 Ensure at least 5mm of the catheter is visible
Penetrate bone cortex by squeezing the drivers trigger and applying gentle, steady To remove catheter from patient attach Luer
Section 6 downward pressure. lock syringe, continuously rotate clockwise
while slowly and gently applying traction to
Toolbox catheter.
Release Drivers trigger and stop insertion process when: Do not rock or bend the catheter during removal
1. A sudden give or pop is felt upon entry into the medullary space. (figure 10).
Section 7 2. The desired depth is obtained.
Dress site as appropriate. Figure 10
Operational formulary IMPORTANT: use gentle-steady pressure. DO NOT USE EXCESSIVE FORCE. Allow the
needle set rotation and downward pressure to provide the penetrating action.
Section 8 Note: If the Driver stalls and will not penetrate the bone you may be applying too much
pressure.
Policies
IMPORTANT: use gentle-steady pressure. DO NOT USE EXCESSIVE FORCE. Allow the
needle set rotation and downward pressure to provide the penetrating action.
CAUTION: Do not leave the catheter >24 hours
Section 9
Note: If the Driver stalls and will not penetrate the bone you may be applying too much
Documentation and audit pressure.
Section 10
Adapted from manufacturers directions for use 2008 With permission of Vidacare
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Intraosseous Access Chest pain 7
Intro
C Treatment
Introduction Treatment guidelines 6e (Contd) Treatment guidelines 7 Guidelines
Section 1
Humeral Intraosseous Myocardial infarction & Acute Coronary
Preparation Patient supine on stretcher Syndromes
(Patients) hand over testicles
Section 2 Trace clavicle from sternum to ac-
romion
Incident management 2 finger widths down
Thrombolysis
Feel the tubercle Treatment guidelines 7b
Section 3 Drill into the patient/floor
Use a YELLOW needle for servicemen
Section 4
Transport
Section 5
Pathways
Section 6
Toolbox Acromion
Section 7
Greater
Operational formulary tubercle
Section 8
Policies
Distance between
Section 9 2 points is 34.6mm
Section 10
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Intro Myocardial infarction & ACS 7a

3
Treatment
Section 1
Actions at Role 1
Preparation Time Assess and record
Pain: character, site, radiation, intensity
Section 2 Time of onset of pain & duration
Incident management Symptoms of SOB, sweating, nausea, palpitations
Section 3
Observations Make the diagnosis
Treatment guidelines Pulse Typical chest pain: severe, crushing central
BP chest pain radiating to left arm +/or jaw
Respiratory rate Beware: atypical pain presenting as
Section 4 SpO2 indigestion, right arm pain or jaw pain only
Transport
Section 5 Immediate Treatment

Intentionally blank Aspirin 300mg STAT
Pathways GTN spray (2 puffs)
Oxygen
Supporting Guidelines 5 mins
Section 6 Morphine 2.55mg IV
(repeat as required to
Toolbox controlpain)
Section 7
Operational formulary Transfer immediately
AUDIT
Section 8
Myocardial infarction is time critical
Policies Outcome is proportional to the time taken to access
thrombolysis
All suspected MI or ACS must be evacuated T1
Section 9
A standard of 30 minutes from time of diagnosis at
Documentation and audit Role 2 & 3 Role 1 to reaching a facility with thrombolysis is to be
adopted for audit
30 mins
Section 10 Adapted from: The National Service Framework for Coronary Heart Disease (2000, updated 2005) &
ESC Guidelines, European Heart Journal (2011)32, 2999-3054
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Intro
Myocardial infarction & ACS Thrombolysis 7a-b
Treatment
Section 1
Actions at Role 2 & 3 Tenecteplase is the first choice of thrombolytic agent if the patient:
Is <75 years old with anterior infarction, and presents within six hours of the onset ofpain
Preparation Time Assess and record as per Role 1 Observations
Has had previous streptokinase or is allergic to streptokinase
Pain: character, site, radiation, intensity Pulse
Is profoundly hypotensive (BP <90mmHg)
Section 2 Time of onset of pain & duration BP
Otherwise use streptokinase
Symptoms of SOB, sweating, nausea, palpitations Resps
SpO2
Incident management
Administration of Tenecteplase (Metalyse):
Immediately
Section 3 12 lead ECG Tenecteplase given as directed
Repeat GTN sublingual; consider GTN infusion Investigations Enoxaparin:
Ensure aspirin 300mg has been given
Treatment guidelines Oxygen CK Glucose Give 1mg/kg sc immediately post thrombolysis and then 1 mg/kg every 12 h until for a
5
mins Morphine 2.55mg aliquots IV if still in pain U&Es BM minimum of 48 hours and max of 8 days and at least until the completion of transfer
Section 4 Clopidogrel 300mg FBC Chest X-ray to onward receiving hospital.
Enoxaparin 1mg/kg bd s/c LFTs In patients >75 years, start with first s.c. dose of 0.75 mg/kg with a maximum of 75 mg
Transport for the first two s.c. doses.
In patients with creatinine clearance of <30 mL/min, regardless of age, the s.c. doses
Section 5 are repeated every 24 h
Definite STEMI MI Non STEMI MI/ACS Possible MI/ACS (low risk)
Typical chest pain If clexane not available or allergy then use:
Pathways Does not fulfil criteria V heparin bolus of 60 U/kg with a maximum of 4000 U followed by an i.v. infusion
>20minutes in last
12hours for thrombolysis of 12 U/kg with a maximum of 1000 U/h for 2448 h. Target APTT: 5070 s to be
Supporting Guidelines and Admit to medical ward monitored at 3, 6, 12, and 24 h.
ST elevation >1mm Perform Troponin T Troponin T 12 hours
Section 6 in 2 limb leads On admission after most intense pain Administration of streptokinase:
or 12 hours after most 1500000 units over 60 minutes
Toolbox ST elevation >2mm intense pain Should be given within 12 hours of onset of pain
in 2 chest leads Reduce dosage if patient weighs <70kg
or Best practice is
Section 7 LBBB Aspirin 75mg OD toconsider Absolute contradictions to thrombolysis:
20 GTN Infusion Transfer for PTCA Active peptic ulcer
Operational formulary mins Clopidogrel 75mg od Gp IIb/IIIa Major surgery within past ten days
Continue enoxaparin inhibitor Bleeding diathesis
Section 8 1mg/kg bd (onlyat Role 4)
Thrombolysis CVA within previous six months
within 20 minutes
Policies of arrival Relative contraindications to thrombolysis:
Continuing pain? yes Prior arterial puncture
Section 9 Anticoagulant therapy
AUDIT Traumatic CPR
no
Documentation and audit Head injury/serious trauma (within last 12 months)
Admit to critical care area for Door-to-needle Pregnancy
serial ECGs and monitoring time <20 mins Uncontrolled hypertension
Section 10
Adapted from: The National Service Framework for Coronary Heart Disease (2000, updated 2005) &
ESC Guidelines, European Heart Journal (2011)32, 2999-3054
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Intro
Thrombolysis C Peri-arrest rhythms 8
Treatment
Introduction Treatment guidelines Cont 7b Treatment guidelines 8 Guidelines
Section 1
Patient monitoring:
Preparation Record BP every 15 minutes Broad complex tachycardia
If side effects occur, STOP infusion and inform doctor
Restart after 15 minutes if condition stabilises Treatment guidelines 8a
Section 2
Adjunctive therapy:
Narrow complex tachycardia presumed
Incident management
GTN infusion if SBP >90mmHg supraventricular tachycardia)
Start -blocker within 36 hours of MI (as soon as possible in ACS) Treatment guidelines 8b
Section 3 Start ACE Inhibitor on day 310 (if no contraindications)
Lipid testing and statins are not available in the field
Bradycardia
Adapted from: The National Service Framework for Coronary Heart Disease (2000, updated 2005) & from the
Section 4 ESC Guidelines, European Heart Journal (2011) 32, 2999-3054
Complete heart block
Transport
Treatment guidelines 8d
Section 5 ECG diagnosis
Pathways Go to Section 6
3c
Toolbox
Section 6
Toolbox
Section 7
Section 8
Policies
Section 9
Section 10
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Broad complex tachycardia 8a
Treatment
Section 1 With pulse Support ABCs: give oxygen; cannulate

Monitor ECG, BP SpO2
Preparation Record 12-lead ECG if possible; if not record rhythm strip
Identify and treat reversible causes (e.g. electrolyte abnormalities)
Section 2
Incident management
Is patient stable?
Section 3 Signs of instability include:
unstable 1. Reduced conscious level 2. Chest pain
Treatment guidelines 3. Systolic BP <90mmHg 4. Heart failure
(Rate-related symptoms uncommon at less than 150 beats/min)
Section 4
Synchronised DC shock DC shock is always given under stable
Transport Up to 3 attempts sedation/general anaesthesia,
100, 150, 200j.
Section 5
Intentionally blank Amiodarone 300mg IV over 1020 mins
Pathways and repeat shock; followed by: Is QRS narrow (<0.12 sec)?
Amiodarone 900mg over 24 hours
Section 6 irregular Broad QRS: regular
Is QRS regular?
Toolbox
If Ventricular Tachycardia
Section 7 Seek expert help (or uncertain rhythm):
Amiodarone 300mg IV over
Operational formulary 2060 min; then 900mg over 24 hrs
If previously confirmed SVT
Section 8 Possibilities include:
With bundle branch block:
Give adenosine as for regular
AF with bundle branch block treat as
Policies for narrow complex
narrow complex tachycardia
Pre-excited AF consider amiodarone
Section 9 Polymorphic VT (e.g. torsade de pointes
give magnesium 2g over 10 min) These are UK national guidelines
Documentation and audit Not all drug choices are available in
deployed modules.
Section 10
Adapted from: Advanced Life Support Guidelines. UK Resuscitation Council (2005)
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Intro
Narrow complex tachycardia Bradycardia 8b-c
Treatment
Introduction Treatment guidelines 8b Treatment guidelines 8c Guidelines
Section 1 If appropriate give oxygen, establish venous access and record a 12-lead ECG
With pulse Support ABCs: give oxygen; cannulate
Monitor ECG, BP SpO2
Preparation Record 12-lead ECG if possible; if not record rhythm strip Adverse signs?
Identify and treat reversible causes (e.g. electrolyte abnormalities) Systolic BP <90mmHg
Section 2 yes Heart rate <40 beats/min no
Ventricular arrhythmias
Incident management Is patient stable?
Signs of instability include: compromising BP
Section 3
unstable 1. Reduced conscious level 2. Chest pain Heart failure
3. Systolic BP <90mmHg 4. Heart failure Atropine
(Rate-related symptoms uncommon at less than 150 beats/min) 500mcg IV
Section 4 Synchronised DC shock DC shock is always given under

Up to 3 attempts sedation/general anaesthesia, stable
100, 150, 200j. Satisfactory
Transport response? yes
Amiodarone 300mg IV over 1020 mins
Section 5 no
and repeat shock; followed by: Is QRS narrow (<0.12 sec)?
Amiodarone 900mg over 24 hours Risk of asystole?
Pathways
yes Recent asystole
Mbitz II AV block
Supporting Guidelines regular Narrow QRS:
irregular Complete heart block
Is QRS regular?
Section 6 Interim measures: with broad QRS
Atropine 500mcg IV repeat Ventricular pause >3s
Toolbox Use vagal manoeuvres Irregular narrow
Adenosine 6mg rapid IV bolus:
to maximum of 3mg
complextachycardia
if unsuccessful give 12mg; Probable atrial fibrillation. Control ratewith: Adrenaline 210mcg min no
Section 7 if unsuccessful give further 12mg -blocker IV or digoxin IV Alternate drugs
Monitor ECG continuously If onset <48 hours consider:
Operational formulary or
Amiodarone 300mg IV 2060 min; Observe
then900mg over 24 hours Transcutaneous pacing
Section 8 Normal sinus rhythm restored?
Alternatives include
Policies yes no Aminophylline
Seek expert help Seek expert help Isoprenaline
Section 9 Dopamine
Probable re-entry PSVT: Arrange transvenous Glucagon (if beta-blocker or calcium-
Record 12-lead ECG in sinus rhythm
If recurs, give adenosine again & consider
pacing channel blocker overdose)
Possible atrial flutter Glycopyrrolate can be used instead
choice of antiarrhythmic prophylaxis Control rate (e.g. -blocker) ofatropine
Section 10
Adapted from: Advanced Life Support Guidelines. UK Resuscitation Council (2005) Adapted from: Advanced Life Support Guidelines. UK Resuscitation Council (2005)
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Complete heart block D Reduced response 8d-9
Treatment
Introduction Treatment guidelines 8d Treatment guidelines 9 Guidelines
Section 1 Features
Complete heart block (CHB) occurs when there is total failure of conduction of electrical
Trauma
Preparation activity from atria to ventricles. Head injury
CHB can be due to disease at AV node or bundle of His level.
Section 2 Treatment guidelines 9a
If nodal level block the escape rhythm will be narrow complex, stable, and usually fast
Incident management
enough to support an adequate circulation. ECG diagnosis Go to Section 8 1
Policies
If block is at the bundle of His the escape rhythm will be slow, unreliable and broad complex
Section 3
with an increased risk of major symptoms. Medical
The unreliable escape rhythm may fail either briefly, leading to Stokes-Adams syncope,
Treatment guidelines orcompletely causing ventricular standstill and cardiac arrest. Fitting (convulsions)
Treatment Treatment guidelines 9b
Section 4 Broad complex complete heart block will require cardiac pacing.
Glycaemic emergencies
Non-invasive pacing techniques
Transport Treatment guidelines 9c
Percussion pacing comprises of the delivery of a series of gentle blows over the precordium
lateral to the lower left sternal edge. The hand should fall a few inches only and the blows
Section 5 should be gentle enough to be easily tolerated by a conscious patient. If percussion pacing Infection
does not produce a pulsed rhythm rapidly then orthodox CPR should be used without
Pathways further delay. Neurology + fever
Transcutaneous pacing can be established very quickly. The electrodes of a multifunction Treatment guidelines 9d
Supporting Guidelines pacing-defibrillator can be placed in the anterior-posterior position, but during cardiac arrest
Section 6
it is more convenient to use an anterior-lateral configuration so chest compressions are not Meningococcal disease
interrupted:
Select the demand mode and adjust the ECG gain to ensure sensing of any intrinsic Treatment guidelines 9e
Toolbox QRScomplexes.
Select an appropriate pacing rate (6090 for adults). Encephalitis
Section 7 Select the lowest pacing current setting and gradually increase while observing the Treatment guidelines 9f
patient and the ECG.
Operational formulary Increase the current until electrical capture occurs (in the range of 50100mA). Malaria
A palpable pulse confirms the presence of mechanical capture with contraction of the Treatment guidelines 9g
Section 8 myocardium. Failure to achieve mechanical capture in the presence of good electrical
Policies
capture indicates a non-viable myocardium.
Vascular
Subarachnoid haemorrhage
Section 9
Cerebrovascular accident
Section 10 Treatment guidelines 9i
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Intro
Head injury 9a
Treatment
Section 1
Severe head injury Penetrating head injury?
Preparation
1
Go to Section 5 Pathways
Section 2
<C>ABCDE approach
Incident management
Indication for CT Scan?
Section 3 1
Go to Section 8 Policies
Treatment guidelines C-spine at risk?
Immobilise
Section 4 4a
Go to Treatment
guidelines
Transport
Section 5
Intentionally blank
Pathways GCS 8 or less: airway at risk
Indicators for
Supporting Guidelines surgical intervention
Unilateral pupil dilation
Section 6 (in context of coma
Incident/Role 1
Lateral position following injury)
Toolbox
Development of
Suction
Section 7 lateralising signs
NP airway
Compound depressed
Operational formulary Oxygen skull fracture
Evacuate Open injury
Section 8
Policies
Role 2/Role 3
Section 9 Rapid Sequence Induction
3ae
Documentation and audit Go to Treatment
guidelines
Section 10
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Head injury Fitting (convulsions) 9a-b
3
Treatment
Section 1 Head injuries indications for neurosurgical referral

Criteria for urgent neurosurgical consultation are the presence of one or more of the following:
Role 1 ADULT
Preparation
Fractured skull in combination with: Time critical features
Either
Section 2 Any major <C>ABCD problems
Confusion or other depression of the level of consciousness Do not attempt an
Or Serious head injury oropharyngeal airway
Incident management Focal neurological signs Underlying infection (meningitis)
Or Nasopharyngeal airway
Fits Other important causes may be useful
Section 3
Confusion or other neurological disturbance persisting for more than 4 hours even if there Hypoxia
3f
Treatment guidelines isno skull fracture Hypotension Go to Treatment
guidelines
Coma continuing after resuscitation Hypoglycaemia
Section 4 Suspected open injury of the vault or the base of the skull Electrolyte imbalance
ce
Depressed fracture of the skull Alcohol withdrawal 100% oxygen
Transport
Neurological deterioration
Diazepam 10mg rectal
Section 5 Head injuries indications for CT Obtain IV access if possible
As for consultation with a neurosurgeon above. Check BM to exclude
Pathways
In addition: hypoglycaemia
Skull fracture or fit following head trauma
Unstable haemodynamic status precluding transfer to a Neurosurgical unit, where CT
Section 6 isavailable in the field hospital
Diagnostic uncertainty
Toolbox Uncertain level of consciousness in intubated and ventilated patients
Detailed guidance on indications for CT scanning is given in Section 8 Policies Role 2 & 3
Section 7
1 Gain IV access
Operational formulary Go to Section 8 Policies If fitting repeatedly or one fit lasting 5 mins
give diazemuls 10mg IV; may be repeated
Section 8 Phenytoin infusion (loading dose: 15mg/kg
ata rate not exceeding 50mg/min)
Policies
Do not use if bradycardia or heart block
Lorazepam
Section 9 Anaesthetise (thiopentone) and ventilate
(0.05mg/kg,
If CT facility available pre and post maximum 4mg)
Documentation and audit intravenous contrast studies should be is a first line
performed. alternative to
Section 10 Establish and treat the cause diazemuls
In accordance with National Institute for Health and Clinical Excellence Head Injury Guidelines (September 2007)
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Glycaemic emergencies Glycaemic emergencies 9c
Treatment
Introduction Treatment guidelines 9c Treatment guidelines 9c (Contd) Guidelines
Section 1 Hypoglycaemia Diabetic ketoacidosis & HONK

Preparation Time Consider hypoglycaemia in any patient with acute agitation, Time
Symptoms & signs Observations Causes
abnormal behaviour or impaired consciousness Thirst Infection
Pulse
Polyuria Infarction
Section 2 Kussmauls
RR
BP Insufficient insulin
hyperventilation Intercurrent illness
Incident management BM
Symptoms & signs Observations Odour of acetone on
Skin cold/ clammy Respiratory Rate breath
Dehydration
Section 3 Tachycardia Pulse
Drowsiness BM >14mmol/l
Restlessness BP Coma
Treatment guidelines Irrational or violent BM
Confusion High flow oxygen Normal blood glucose
Trembling Decision to 1 litre 0.9% NaCl STAT is 3.65.8mmol/l
Section 4 5 Coma evacuate
mins 10
Transport mins Role 2 & 3
Hypoglycaemic if BM <3.0mmol/l
Section 5 Diabetic ketoacidosis (DKA) Hyperosmolar non-ketotic
Hyperglycaemia (>14mmol/l) coma (HONK)
Pathways Conscious & cooperative Unconscious/semi conscious Metabolic acidosis (pH <7.35 Blood glucose is often higher
Give 515g of fast acting oral Glucagon 1mg IM or SC if IV or bicarbonate <15mmol/l) (>33mmol/l)
Supporting Guidelines carbohydrate: accessdifficult High anion gap: [(sodium +
potassium) bicarbonate]
No acidosis
34 dextrose tablets Give 500ml Glucose 10% IV Na+ often high (>150mmol/l)
Section 6 4 tsp sugar in 150ml warm water (add50ml 50% glucose to 500ml Ketonaemia
Cola 90mls 0.9%NaCl)
Then give oral carbohydrate when Observations
Toolbox
awake BM ABG MSU
U&Es Urine for ketones ECG
Section 7 Blood glucose Blood cultures Chest X-ray
15
Operational formulary mins
Immediate treatment
Section 8 High flow oxygen
Repeat as necessary Maintain <C>ABC Blood glucose >20mmol/l 6u actrapid IV stat
Policies after 1015 minutes Monitor IV fluid: 0.9% NaCl
Repeat BM 1 litre STAT add K+ to bag
1 litre over 1 hour 1
according to Go to Sec 7
Section 9 Role 2 & 3 1 litre over 2 hours
1 litre over 4 hours
plasma level
Operational
formulary
Documentation and audit Obtain a laboratory glucose within 1 hour of presentation 5d

45 90% of patients recover fully within 20 minutes Start insulin as per sliding scale Go to Sec 5
mins 30 Pathways
mins
Section 10
Adapted from: West Mercia Clinical Guidelines (2004), Oxford Handbook of Accident and Emergency Medicine (2005)
Adapted from: West Mercia Clinical Guidelines (2004) and Oxford Handbook of Accident and Emergency Medicine (2005)
and the British National Formulary (2004)
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Neurology + fever Neurology + fever 9d
Treatment
Introduction Treatment guidelines 9d Treatment guidelines 9d (Contd) Guidelines
Section 1 Actions at Role 1 See also Actions at Role 2 & 3 See also
Preparation meningococcal meningococcal
Time GCS <15 or other acute Time GCS <15 or other acute neurological features disease
disease +
Section 2 neurological features 9e
+ 9e fever or other features of sepsis Go to Treatment
Go to guidelines
Incident management fever or other features of sepsis Treatment

guidelines
Consider:
Section 3 Meningitis if meningism + photophobia purpuric rash
Consider: Encephalitis or septicaemia if no meningism or photophobia
Treatment guidelines Meningitis if meningism + photophobia purpuric rash Cerebral malaria if exposure within 2 years do antigen card test
Encephalitis or septicaemia if no meningism or photophobia
Section 4 Cerebral malaria if exposure within 2 years do antigen card test
If features of meningitis consider CT head scan and lumbar puncture
Transport (LP) unless signs of ICP or laboratory investigations unavailable
Benzylpenicillin IV or IM 1200mg (600mg in children) Do not delay antibiotics for >30 minutes in order to do LP
Section 5 or if severe penicillin allergy use chloramphenicol IV 25mg/kg
with
Pathways 100% oxygen + IV fluid resuscitation Cefotaxime 2g IV or IM (50mg/kg in children)
or if severe penicillin allergy use
chloramphenicol IV 25mg/kg
Supporting Guidelines 100% oxygen + IV fluid resuscitation + review
by intensive care unit team
Section 6
Toolbox If risk or features of malaria quinine IV 10mg/kg up to 1400mg

If risk or features of meningitis dexamethasone IV 0.15mg/kg
If risk or features of typhus doxycycline PO 200mg (not in children)
If risk or features of encephalitis acyclovir IV 10mg/kg
Section 7 If risk or features of listeriosis amoxicillin IV 2g (100mg/kg in children) If risk or features of septicaemia gentamicin IV 57mg/kg
If risk or features of malaria quinine IV 10mg/kg up to 1400mg
Operational formulary If risk or features of typhus doxycycline PO 200mg (not in children)
15 If risk or features of listeriosis amoxicillin IV 2g (100mg/kg in children)
Section 8 mins
1 hour
Policies Notes
Notes
Beware of rabies as a cause of encephalitis
Beware of rabies as a cause of encephalitis
Section 9 Beware of hypoglycaemia with malaria + quinine
Beware of hypoglycaemia with malaria + quinine
F Med 85 notification to communicable disease control team
Documentation and audit see also Meningitis Research Foundation guidelines (following pages)
Sources: Meningitis Research Foundation Guidelines, 2nd Ed (2005) www.meningitis.org Sources: Meningitis Research Foundation Guidelines, 2nd Ed (2005) www.meningitis.org
Section 10 British National Formulary, Journal of Infection (2005;50:3734) and J Neurol Neurosurg Psychiatry (2004;75:29)
British National Formulary, Journal of Infection (2005;50:3734) and J Neurol Neurosurg Psychiatry (2004;75:29)
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Meningococcal disease Meningococcal disease 9d
Treatment
Section 1 Role 1 Roles 2 & 3

Preparation Time Patient presents with: Septicaemia Adverse signs
Fever Petechial/purpuric non-blanching Rapidly progressive rash
Section 2 rash (may be absent or atypical at Poor peripheral perfusion (CRT >4s),
Vomiting presentation) oliguria & systolic BP <90mmHg
Incident management Lethargy Meningitis RR <8 or >30/minute
Neck stiffness may be absent in 30% Pulse rate <40 or >140/minute
Section 3 of cases GCS <12
Non-specific Suspect meningococcal Suspect Immediate assessment:

Treatment guidelines Immediate investigations:
signs/symptoms Septicaemia if: meningitis if: Airway
FBC; U&Es; LFTs; Blood sugar, CRP
Breathing: RR, SpO2
Section 4 Purpuric rash Severe Clotting profile
Circulation: pulse, capillary refill time
Signs of shock headache Blood gases
Transport Urine output
Neck stiffness Microbiology
Evacuate Mental status
for further Photophobia Neurology
Blood culture
Section 5 Throat swab
evaluation Drowsiness
Secure airway Clotted blood
Pathways 100% O2 Save EDTA blood for polymerase chain
IV access fluid resuscitation reaction confirmatory diagnosis
Immediately
Section 6 give benzylpenicillin Predominantly Predominantly meningitis
Adult 1200mg IV or IM septicaemia Perform LP only if confident ICP
Toolbox Child (19yrs) 600mg IV or IM Do not attempt is not raised Give antibiotics
Cefotaxime 2g IV (adult) if LP is delayed
Infant 300mg IV or IM lumbar puncture
Section 7 Consider corticosteroids >30 minutes
Cefotaxime 2g
or IV (adult) Careful volume resuscitation
Operational formulary Chloramphenicol if penicillin allergy Manage in 30 head elevation Dexamethasone
Adult 1g critical care area Manage in critical care area 0.15mg/kg QDS
Child (19yrs) 12.5mg/kg (max 1g) Low threshold for elective intubation for 4days
Section 8 & ventilation (cerebral protection)
Policies Think of sepsis
Careful monitoring Think of meningitis
Section 9 Administer oxygen 100% Repeated review Careful monitoring
15 IV colloid bolus 20ml/kg Follow sepsis Repeated review
Documentation and audit mins algorithm Isolate patient for 24 hours
Section 10
Adapted from: The Meningitis Research Foundation www.meningitis.org Meningitis Research Foundation Guidelines, 2nd Ed (2005) www.meningitis.org, Journal of Infection (2005;50:3734)
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Meningococcal disease Encephalitis 9e-f
Treatment
Introduction Treatment guidelines 9e (Contd) Treatment guidelines 9f Guidelines
Section 1 Children Viral encephalitis

Encephalitis means inflammation of the brain and is usually the result of a viral illness.
Preparation Estimate of childs weight (110 years) There are 2 main types (i) acute viral encephalitis, and (ii) post-infectious encephalitis
Weight (kg) = 2 x (age in years + 4) (anautoimmune condition).
Section 2 Symptoms
Systolic blood pressure = 80+ (age in years x 2)
Encephalitis may begin with a flu-like illness or headache, progressing to confusion,
Incident management N.B. low BP is a pre-terminal sign in children drowsiness, altered level of response, fits and coma.
Observe HR, RR, BP, perfusion, conscious level Photophobia and neck stiffness may occur, as in meningitis, but symptoms that help
Section 3 discriminate encephalitis include dysphasia, sensory changes, loss of motor control and
Cardiac monitor and pulse oximetry
uncharacteristic behaviour.
Treatment guidelines Take blood for glucose FBC, Clotting, U&E, Ca2+, Mg2+, PO4, blood cultures, blood gas,
Some symptoms are attributable to a rise in intracranial pressure (severe headache,
cross-match
dizziness, confusion and fits).
Section 4 Colloid bolus (20ml/kg) Diagnosis
4.5% Human Albumin Solution (or Fresh Frozen Plasma or Hemaccel/Gelofusine) There is no useful field diagnostic test for viral encephalitis: diagnosis will be on the clinical
Transport IV or IO (intraosseous) presentation. Polymerase chain reaction is sensitive for diagnosing HSV-1 should blood
samples be returned to UK.
Section 5 Inotropes
Treatment
Dopamine or Dobutamine at 1020mcg/kg/min:
Pathways make up 3x weight (kg) mg in 50ml 5% dextrose and run at 10ml/hr = 10mcg/kg/min In most cases treatment is symptomatic and is not amenable to antiviral therapy. Herpes
(these dilute solutions can be used via a peripheral vein) simplex encephalitis (HSE) and varicella zoster encephalitis may respond to acyclovir 10mg/
kg IV every 8 hours. If given in the first few days of illness the mortality can be reduced from
Supporting Guidelines Start adrenaline via a central line only at 0.1mcg/kg/min:
~80% to ~25%. Treatment may often have to be continued beyond the standard 10 day
make up 300mcg/kg in 50ml of saline at 1ml/hour = 0.1mcg/kg/min
regimen (potentially for up to 21 days).
Section 6
Intubate Tick-borne encephalitis (TBE)
Toolbox Atropine 20mcg/kg (max 600mcg) and thiopentone 35mg/kg This is caused by TBE virus (of the family Flaviviridae) and is spread by the ixodid tick, endemic
and suxamethonium 2mg/kg (caution when high potassium). in Europe, former Soviet Union and Asia. The incubation period is 714 days after which there
ETT size = [age/4 +4]; ETT length (oral) = [age/2 +12]. is a 24 day viraemic phase followed by a remission (of ~8 days) then a second febrile
Section 7 illness in 2030% characterised by symptoms encephalitis, meningitis or both. Treatment
Then: morphine (100mcg/kg) + midazolam (100mcg/kg) every 30 minutes
is symptomatic and the disease is rarely fatal (12%) although sequelae are common.
Operational formulary Hypoglycaemia (glucose <3mmol/l)
5ml/kg 10% dextrose bolus IV, then dextrose infusion at 80% of maintenance
Section 8 requirements over 24 hours
Policies If K+ <3.5mmol/l
Give 0.25mmol/kg over 30 mins IV with ECG monitoring caution if anuric
Section 9
Section 10
Adapted from: The Meningitis Research Foundation (2004) www.meningitis.org
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Malaria Subarachnoid haemorrhage 9g-h
Treatment
Introduction Treatment guidelines 9g Treatment guidelines 9h Guidelines
Section 1 Presentation
Consider subarachnoid haemorrhage in any worst ever
Specific
Preparation or sudden onset headache: Sudden agonizing headache
Fever (characteristically cyclical)
is subarachnoid haemorrhage until proven otherwise
Additional features
Section 2 History of poor compliance with malaria prophylaxis History
Incident management Rigors, headache, vomiting, diarrhoea, sweating +++, prostration Most bleeds follow rupture of saccular (berry) aneurysms in the Circle of Willis.
Abdominal pain, jaundice, hepatosplenomegaly Patients report sudden onset and worst ever headache.
Section 3 Increasing haemolytic anaemia Often described as like a blow to the back of the head.
P.falciparum severe signs: cerebral malaria, shock, DIC, renal impairment, Accompanied by neck pain, photophobia and vomiting.
Treatment guidelines haemoglobinuria, pulmonary oedema, hyperpyrexia
May present after collapse or fits.
Differential diagnosis Drowsiness and confusion may occur.
Section 4 Consider malaria in all patients with febrile illness, including heat illness, and any
patient with symptoms of septicaemia.
Investigation
Transport This may need to proceed alongside resuscitation.
Investigations Venous access and check glucose, FBC, clotting screen, U&E.
Microscopy of thick and thin films
Section 5 CXR may show changes of neurogenic pulmonary oedema.
Plasmodium and falciparum antigen tests (available in field laboratory) ECG may demonstrate ischaemic changes.
Pathways FBC (look for anaemia, and decreased platelets) Urgent CT head scan to detect intracranial blood (if operationally possible; maximally
U&E ( Na and urea) and urinalysis; glucose ( ); LFTs ( AST/ALT) sensitive within 12 hours). If CT negative do LP to detect xanthochromia.
Supporting Guidelines Treatment Treatment
Supportive: rehydration, antipyretics, analgesia Provide adequate analgesia and antiemetic:
Section 6
Codeine 3060mg PO
Uncomplicated cases Complicated cases Paracetamol 1g PO/IV and/or NSAID
Toolbox P.falciparum: Malarone Quinine 20mg/kg IV (max 1.4g) Morphine titrated.
4 tablets OD for 3 days infused over 4 hours then after If severely agitated or combative intubate and ventilate.
Section 7 P.vivax/P.ovale/P.malariae: 812 hours give 10mg/kg (max
Maintain MAP c.90mmHg.
chloroquine (base) 600mg 700mg) infused over 4 hours
Operational formulary PO then 300mg after 6 hours then repeat every 812 hours Maintain normal PaO2 with supplemental oxygen.
then 300mg OD for 2 days If quinine resistance known or Give at least 3L maintenance fluids/24hrs IV (more if vomiting).
Section 8 Primaquine required for P.vivax/ suspected follow with Fansidar Aim to evacuate to neurosurgical unit within 24 hours of haemorrhage.
P.ovale after chloroquine (3 tablets) stat or doxycycline
Further treatment options
Policies 7/7 course
Nimodipine 60mg PO every 4 hours or 1mg/hr IV (not on deployed module scale).
Section 9 Alternative therapeutic regimens may be acceptable or desirable,

but are not supported within the current module scaling
Communication
Section 10 Inform Chain of Command
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Cerebrovascular accident E Electrolytes 9g-h
Treatment
Introduction Treatment guidelines 9i Treatment guidelines 10 Guidelines
Section 1 In cases of suspected ischaemic stroke, the patients survival and functional recovery may
depend on prompt recognition and treatment.
Hyperkalaemia
Preparation Immediate general assessment
Section 2
First 10 minutes after arrival to the hospital Hypokalaemia
Assess the airway, breathing, circulation, and vital signs.
Incident management Provide oxygen by mask, obtain venous access.
Take blood samples (FBC, U&Es, coagulation studies). Hypocalcaemia during massive transfusion
Section 3 Check blood glucose (BM Stix): provide treatment if indicated.
Obtain a 12-lead ECG: check for arrhythmias.
Treatment guidelines Perform a mini-neurological assessment including Glasgow Coma Scale. Hyponatraemia
Immediate neurological assessment Treatment guidelines 10d
Section 4
First 25 minutes after arrival to the hospital
Transport Review the patients history. Acute renal failure
Establish onset (<3 hours required for thrombolytics). Treatment guidelines 10e
Section 5 Perform a full physical examination.
Perform a full neurological examination. Determine stroke severity.
Pathways Obtain urgent non-contrast CT scan (door-to-CT scan civilian performance indicator is Chemicals & poisoning includes CW agents
<25minutes from arrival) where available (door-to-CT scan read civilian performance
Supporting Guidelines indicator is <45 minutes after arrival).
Section 6
Management Biological agents & toxins includes BW agents
CT scan is undertaken to rule out non-ischaemic causes of stroke (e.g. SAH, tumour, Treatment guidelines 10g
traumatic haemorrhage).
Toolbox
If CT negative, review thrombolytic exclusions and review risk and benefits of thrombolytic
therapy for patient.
Radiation casualties
Section 7 If elect for thrombolytic therapy door-to-treatment goal is <60 minutes. Treatment guidelines 10h
Operational formulary Management of irradiated casualties
Note: 9
Section 8 The use of thrombolytic therapy for acute ischaemic stroke is not yet routine in UK Go to Section 8 Policies
civilian practice and the decision to use this therapy must rest with the deployed
Policies consultant physician.
CBRN triage
Section 9 5de
Go to Section 2 Incident
management
Section 10
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Intro
Hyperkalaemia 9i-10
Treatment
Section 1 K+ 7.0mmol/L Immediate treatment

K+ 6.06.9mmol/L + ECG changes Immediate treatment
Preparation
K+ 5.35.9mmol/L Recheck +/ enteral
Section 2
Incident management
ECG Tented T-wave
Broad QRS
changes Flattened/absent P-wave
Section 3
Immediate treatment
Treatment guidelines Stop any potassium supplements (IV/PO)
Give 10ml 10% calcium gluconate IV
Section 4 Start salbutamol nebuliser 5mg (2.5mg if ischaemic heart disease)
Give 25ml 50% dextrose + 10iu Actrapid insulin IV over 15 minutes
Transport
Give 50100mmol sodium bicarbonate IV
50100mls 8.4% over 30 minutes via central line or
Section 5 200400ml 2.1% over 30 minutes via peripheral line
Intentionally blank
Pathways Continuing treatment
Do blood gasses
Supporting Guidelines Consider repeat doses of calcium gluconate every 1020 minutes until ECG normal or to
maximum of 50ml
Section 6 Consider 1 litre 20% glucose + 100iu Actrapid at 2ml/kg/hour
Enteral treatment
Toolbox
Consider calcium resonium 30g enema, followed by 15g PO TDS in water with oral lactulose
1020ml (up to QDS)
Section 7
Dialysis requirements
Operational formulary Persistent K+ >7.0mmol/L
Fluid overload (pulmonary oedema)
Section 8 Symptomatic uraemia (urea likely >45mmol/L)
Acidosis, pH <7.1
Policies Pericarditis
Section 9
Documentation and audit Recheck potassium hourly

until <6.0mmol/L (unless chronic)
Section 10
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Intro
Hypokalaemia Hypocalcaemia during 10b-c
massive transfusion
Treatment
Introduction Treatment guidelines 10b Guidelines
Section 1 Severe <2.5mmol/L Treatment guidelines 10c

Replace intravenously, 40mmol/hour maximum, ideally via central line. Use ECG monitoring.
Preparation Continuing therapy will be determined by response. Definition
Hypocalcaemia is a corrected serum calcium less than 2.20mmol/L, or an ionized calcium
Section 2 Moderate 2.53.0mmol/L <1.0mmol/L.
If receiving digoxin or ECG changes (u waves) replace intravenously, 40mmol/hour
maximum (40mmols in 100mls sodium chloride/dextrose over 1hour, ideally via central line) . The normal range for total serum calcium is 2.20-2.65mmol/L and the measured value
Incident management requires to be corrected for the albumin concentration:
Use ECG monitoring.
Section 3 If not receiving digoxin give Sando-K, 4 tablets stat. Correction factor (serum calcium concentration [mmol/L]):
Continuing therapy will be determined by response and estimation of ongoing losses. +0.02 for every 1.0g/L albumin below 40g/L
Treatment guidelines Mild >3.0mmol/L requiring replacement -0.02 for every 1.0g/L albumin above 40g/L
Give Sando-K, 2 tablets stat. The normal range for serum ionized (free) calcium is 1.0-1.3mmol/L.
Section 4 Continuing therapy will be determined by response and estimation of ongoing losses. Symptomatic or severe hypocalcaemia
Transport Symptoms usually occur with total serum calcium levels of less than 1.8mmol/L (ionized
calcium less than 0.7mmol/L).
Section 5 Acute hypocalcaemia causes neurological excitability with:
Peri-oral or peripheral paraesthesia
Pathways Hyperreflexia
Tetany, muscle cramps, seizures
Supporting Guidelines Chvosteks sign: tap over the facial nerve in the parotid gland, approximately 2cm anterior
to the tragus of the ear
Section 6 Twitching at the angle of the mouth
Trousseaus sign: inflate blood pressure cuff to above the systolic pressure for about 2
Toolbox minutes (obstructs the brachial artery and causes ulnar and median nerve ischaemia and
results in carpal spasm)
Section 7 Complications include:
Hypotension, bradycardia, cardiac failure
Prolonged Q-T interval, arrhythmias
Intellectual deterioration
Section 8
Laryngospasm
Policies Bronchospasm
Intravenous calcium supplementation
Section 9 10% calcium gluconate solution is the first choice.
10% calcium chloride may be used, but can cause tissue necrosis if extravasated.
Give 10mls calcium gluconate slowly over 10-20 minutes, with continuous ECG monitoring.
Section 10 Ionized calcium should be monitored and this is available on ISTAT EG7 cartridge from an
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Intro
Hypocalcaemia during Hyponatraemia 10c-d
massive transfusion
Treatment
Introduction Treatment guidelines 10d Guidelines
Section 1 Treatment guidelines 10c (Contd) Diagnostic features

Mild hyponatraemia is commonly seen in soldiers excessively drinking water.
Preparation arterial blood sample.
Confusion and irritability occur with serum levels ~120mmol/L.
Consider the need for further calcium after each 4 units of stored red cells transfused:
Coma, fits and death occur with serum levels ~110mmol/L.
Section 2 determine the requirement by regular monitoring of ionized calcium levels and clinical
symptoms/signs. Assessment of volume status helps diagnosis and management.
Incident management Cautions Management
Undiluted calcium should not be used as it causes thrombophlebitis. Exclude pseudohyponatraemia. Lipaemic serum, hyperglycaemia, and mannitol (et al)
Section 3 give a falsely low reading. Calculate the osmolarity [2 x (Na+ + K+) + urea + glucose] and
Calcium must not be given through the same line as NaHCO3 (sodium bicarbonate) as this
compare with the measured osmolarity. Is there an osmolar gap?
will result in precipitation of calcium carbonate.
Treatment guidelines If coma or fits. Start infusion of 0.9% sodium chloride ~500ml/hour until hypertonic
Monitor saline available. Give 1.8% sodium chloride at 70mmol Na+/hour until serum sodium
ECG >120mmol/L.
Section 4
Improvement in clinical signs and symptoms If volume depleted (dehydrated). Start 0.9% sodium chloride infusion. Add colloid if
Transport Serial blood levels (ionized calcium). hypotensive. Monitor urine output and CVP. Beware of cardiac failure.
If not dehydrated. For patients with SIADH restrict input to 8001000ml/24hour.
Source If Na+ <125mmol/L and unresponsive to fluid restriction consider demeclocycline
Section 5
Guideline adapted from National Library for Health, Map of Medicine, dated 29 Jan 2009. 300mg tds PO. Seek expert help early.
Pathways
Also see Cardiac Arrest or Cardiovascular Collapse caused by local The diagnosis of the cause of hyponatraemia and its
Supporting Guidelines Anaesthetic (Treatment Guidelines 1c) and Management of Massive management is a complex issue, requiring the early involvement
Haemorrhage on Operations Policies 10 of the appropriate consultants
Section 6
Toolbox
Osmotic demyelination, caused by too rapid an elevation
Section 7 of serum sodium in established hyponatraemia is
oftenirreversible
Section 8
Policies
Section 9
Section 10
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Intro
Acute renal failure Chemicals & poisons 10e-f
Treatment
Introduction Treatment guidelines 10e Treatment guidelines 10f Guidelines
Section 1 Assess renal reserve

Estimated glomerular filtration rate (eGFR) can be derived from serum creatinine (preferred to
Drugs in overdose
Preparation urea as it is independent of dietary protein intake) by the Cockcroft-Gault equation:
eGFR in males = [140 Age(yrs)] x Wt(kg)/[serum creatinine (mol/l) x 0.814]
Poisoning: general
Section 2 eGFR in females: multiply the result of the above equation by 0.85. Treatment guidelines 10f(i)
Incident management Normal eGFR is ~120mls/min. Critical minimum=20ml/min. A rising creatinine and falling
eGFR indicates a potential need for renal replacement treatment. Seek advice from a
nephrologist if management is uncertain.
Chemical weapons
Section 3
Causes of impaired renal function Cyanide
Treatment guidelines These are classified into three groups: Treatment guidelines 10f(ii)
Pre-renal = poor renal perfusion (best sign: hypotension especially if this is postural)
Section 4 Renal = nephritis (best sign: urinary dipsticks show blood, protein or both) Incapacitating agents
Post-renal = obstruction (best sign: obstruction on ultrasound). Treatment guidelines 10f(iii)
Transport
Indications for renal replacement treatment
Section 5 (haemofiltration, dialysis etc) Inhalational
There are four indications for renal replacement. The presence of any one that fails to respond Treatment guidelines 10f(iv)
Pathways to conservative measures qualifies:
Fluid overload (pulmonary oedema) Methaemoglobinaemia
Supporting Guidelines Hyperkalaemia ([K+]>6.5mmol/l) Treatment guidelines 10f(v)
Urea>40mmol/l
Section 6 Metabolic acidosis ([HCO3-]<12mmol/l). Organophosphates
Toolbox Diagnosis and treatment of oliguric acute renal failure Treatment guidelines 10f(vi)
Most causes are medical, usually due to reduced renal perfusion following hypotension
Section 7 (secondary to absolute or relative hypovolaemia), but nephritis is a possibility. Vesicants
Normal urine output is about 1500mls/24hrs = 60ml/hr Treatment guidelines 10f(vii)
Operational formulary Acute renal failure = 400ml/24hrs = 18.5ml/hr
Hourly urine output and renal function tests (especially serum creatinine) should be
monitored regularly in seriously ill patients as soon as medical assessment commences,
Phosgene
Section 8 Treatment guidelines 10f(viii)
especially in patients who have suffered trauma, burns or infection who are at particular
risk. In these patients, attention should be paid to restoration of peripheral oxygen delivery
Policies
(increasing pulmonary arterial oxygenation and peripheral blood flow).
Section 9
Section 10
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Intro
Poisoning: general 10f(i)
Treatment
Introduction Treatment guidelines 10f(i) Guidelines
Section 1 General care

All patients who show features of poisoning should generally be admitted.
Preparation If possible, identify the type and quantity of poison and the time at which taken.
Most poisoning cases are treated by managing symptoms as they arise.
Section 2
Respiration
Incident management Respiration is often impaired in unconscious patients; most poisons that impair consciousness
also depress respiration. Respiratory stimulants do not help and should be avoided.
Section 3 Give high concentration oxygen, especially with carbon monoxide poisoning or inhalation
of irritant gases. Avoid oxygen in paraquat poisoning.
Treatment guidelines Support airway and breathing as required.
3 5
Go to and
Section 4 Treatment
guidelines
Treatment
guidelines
Transport Blood pressure

Hypotension is common in severe poisoning with central nervous system depressants.
Section 5 Support blood pressure with a combination of head-down positioning and the use of
Intentionally blank
intravenous crystalloids (e.g. 0.9% NaCl).
Pathways Hypertension is less common and is usually transient: it may be associated with illicit
sympathomimetic drugs (e.g. amphetamines and cocaine).
Supporting Guidelines Heart
Section 6 Conduction defects and arrhythmias can occur, notably with tricyclic antidepressants, some
antihistamines, and coproxamol. Treatment is targeted at correcting hypoxia and acidosis
or other biochemical abnormality rather than antiarrhythmic drugs.
Toolbox
Body temperature
Section 7 Hypothermia is common in unconscious patients. Core temperature should be monitored
and managed.
Operational formulary Hyperthermia can occur after ingestion of some CNS stimulants. Cool with tepid sponging
and a fan to aid evaporation: do not use iced water.
Section 8 Convulsions
Short lived convulsions do not require treatment.
Policies
For protracted convulsions:
9b
Section 9 Go to Treatment
guidelines
Section 10
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Intro
Poisoning: general Cyanide 10f(i)-(ii)
Treatment
Introduction Treatment guidelines 10f(i) (Contd) Treatment guidelines 10f(ii) Guidelines
Section 1 Removal from gastrointestinal tract Specific agents Contamination PPE

Induction of vomiting is not indicated. Hydrogen Cyanide (AC) Personal protective Decontamination (warm) team
Preparation Cyanogen Chloride (CK) equipment decontamination IPE (4R)
Gastric lavage is only indicated where the following are true: Nitrile compounds Limited requirement
Medical (warm) team
Life threatening amount of drug has been ingested in the last hour Hydrogen Sulphide (HS) due to vapour
IPE (4R) and surgical gloves
Section 2 Airway can be adequately protected Dilution of any liquid
(change every 1015 minutes
contamination
Poison cannot be adsorbed by charcoal (e.g. iron or lithium).
Incident management
Prevention of absorption using activated charcoal Signs and symptoms (onset seconds to minutes)
Section 3 Activated charcoal can bind to poisons and reduce absorption. Airway Breathing Circulation Disability Exposure/ Other
The sooner it is given, the more effective it is (but may still be effective up to an hour Odour bad Pink skin (early) Arterialised Loss of skin Metabolic
Treatment guidelines or more after ingestion of the poison). eggs (HS) Cyanosis (late) venous blood consciousness acidosis
Respiratory Seizures Lactate
It is particularly useful where small amounts of drug are toxic, e.g. antidepressants: distress
Section 4 Adult: 50g initially, repeated if necessary Apnoea Bicarbonate
Significant poisoning after 15 minutes is unlikely, unless continuing or further exposure.
Child under 12yrs: 25g (50g in severe poisoning).
Transport Charcoal should not be used when poisoned with:
Petroleum distillates Treatment 100% Oxygen
Section 5 Corrosive substances Role 1 and beyond Serum lactate & bicarbonate
and IV/IO (where available at Role 3)
Alcohol access
Pathways Severity
Iron Mild
Lithium. Dizziness, anxiety, tachycardia,
Supporting Guidelines nausea, drowsiness. mild Severity? moderate/severe
Resources for further information Moderate
Section 6 www.spib.axl.co.uk (TOXBASE) is available to registered users. loss of consciousness, convulsions,
vomiting, cyanosis.
National Poisons Information Service: phone numbers are listed inside the cover of the Severe Supportive management
Toolbox British National Formulary (0870 600 6266 via Whitehall Operator). Deep coma, fixed unreactive pupils, andmonitoring
cardiorespiratory failure, cardiac
arrhythmias and pulmonary oedema.
Section 7 Symptoms
Haemodynamically unstable
yes possible due to cyanide
or significant blood loss?
Operational formulary poisoning?
no
definite
Section 8 yes Possible CO poisoning?
Policies no
Sodium thiosulphate Sodium nitrite Dicobalt edetate

Section 9 only (see note) 10mls of 3% solution (300mg) IV over 300mg IV over one
25mls of 50% solution 520 minutes, followed by Sodium minute followed by a
(12.5mg) IV over 10 minutes Thiosulphate 25mls of 50% solution further 300mg if response
Documentation and audit (12.5mg) IV over 10 minutes (see note) does not occur after
one minute, followed
by dextrose (50mls of
Section 10 Note: only sodium nitrite is required for HS poisoning 50%dextrose solution)
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Intro
Incapacitating agents Inhalational 10f(iii)-(iv)
Treatment
Introduction Treatment guidelines 10f(iii) Treatment guidelines 10f(iv) Guidelines
Section 1 Specific agents Contamination PPE Specific agents Contamination PPE

Atropine Personal protective Decontamination team Chlorine Personal protective Decontamination team
Preparation BZ (Agent 15) equipment decontamination IPE (4R) Phosgene equipment decontamination IPE (4R)
Nerve agents Detergent solution Medical team Smoke inhalation (Cyanide Ensure no liquid hazard Medical team
Other incapacitating agents Hypochlorite (0.5%) solution IPE (4R) and surgical gloves /carbon monoxide/nitrous (unlikely unless in very IPE (4R) and surgical gloves
Section 2 Biological agent (encephalic Copious water (change every 1015 minutes fumes) cold climate) (change every 1015 minutes)
syndrome) and caution with Lewisite)
Incident management Illicit drug use
Signs
g and symptoms
y p (dependent
p on causation)
Section 3 Signs and symptoms (dependent on causation) Airway Breathing Circulation Disability Exposure/skin Other
Rhinorrhea Dyspnoea/ Possible Chemical burns Respiratory
Nuclear/Radiological Significant irradiation dose >0.5Gy, nausea and vomiting, diarrhoea Mucosal coughing hypovolemia Frost bite, alkalosis
Treatment guidelines Chemical (nerve agent) Pinpoint pupils, dimness of vision, increased secretions, wheezing, irritation Pulmonary if exposed to Metabolic
excessivesweating Laryngeal oedema pressurised liquid acidosis
Chemical (atropine/BZ) Dry mouth, dilated pupils, dry skin Mad as a hatter, blind as a bat, dry as a bone, oedema Cyanosis (2 to hypoxia or
Section 4 red as a beet, hot as hell Chest pain hyperchloraemia)
Chemical (opiate) Pinpoint pupils, respiratory depression Initial symptoms may be experienced in chlorine exposure (stinging eyes, lacrimation and blepharospasm).
Transport Biological/Medical Delirium, pyrexia, encephalitic syndrome Phosgene symptoms may be delayed and in the absence of initial signs of exposure.
Conventional injury Head injury, barotrauma, deafness, shock, hypoxia Differential diagnosis
Cardiogenic pulmonary oedema, pneumonia, secondary drowning.
Section 5
Differentiation and treatment of psychiatric symptoms
Pathways Treatment Symptomatic treatment Oxygen therapy
General Management Role 1 Dyspnoea Supportive management:
Supporting Guidelines Rest, cooling, fluids sedation
Avoid physical restraint
Tachypnoeic Bronchodilators
Frothy sputum or cough (salbutamol)
Desaturating (<93%) (where measurable) Avoid exertion
Section 6
Medical cause?
Toolbox Airway Secretions?
yes Severity? moderate
Role 2 and mild/
Breathing Wheezing? beyond Severity? moderate
Reassess
severe Chlorine: for at least 24 hours
Section 7 Pupils Pinpoint or dilated?
Phosgene: for at least 72 hours
Skin Excessive sweating? Supportive Pulmonary oedema
Operational formulary Dry skin? management
Rash? Consider: andmonitoring
Temp Pyrexial? chemical restraint Respiratory support Oxygen therapy
Section 8 Trauma? (humidified)
Benzodiazepine titrated CPAP (if available)
Visual hallucinations? and repeated as necessary or Supportive management:
Policies (avoidpolypharmacy) Beware Intubation and mechanical Bronchodilators
no Treat underlying cause in hyperpyrexia ventilation (with PEEP) (salbutamol)
accordance with CGOs For phosgene exposure: Avoid exertion
Section 9 Treat temp >39C consider N-acetylcysteine nebulisers Monitoring:
as heat injury (Sciuto et al, 1995) ABGs
Documentation and audit CXR
Psychological 11c
For cases of possible cyanide:
consider sodium thiosulphate alone
Section 10 screening? Treatment
guidelines iaw Cyanide Guideline or
Hydroxycobalamin (Vitamin B12)
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Intro
Methaemoglobinaemia Organophosphates 10f(v)-(vi)
Treatment
Introduction Treatment guidelines 10f(v) Treatment guidelines 10f(vi) Guidelines
Section 1 Specific agents Contamination PPE Specific agents Contamination PPE

Amyl/sodium nitrite Personal protective equipment Decontamination team Tabun (GA) Personal protective equipment Decontamination team
Preparation (cyanide antidote kit) decontamination Dependent on agent

Sarin (GB)
Soman (GD)
decontamination IPE
Toxic Industrial Chemicals Dependent on causation Dilution and open-air circulation Medical team
Medical team GF
Local anaesthetics Detergent solution IPE (4R) and surgical gloves
Dependent on team Vx Hypochlorite (0.5%) solution
Section 2 (G6PDdeficiency) Organophosphates
(changeevery 10 15 minutes)
Incident management Signs

g and symptoms
y p (dependent
p on causation) Signs
g and symptoms
y p (dependent
p on causation)
Airway Breathing Circulation Disability Exposure/skin Other Airway Breathing Circulation Disability Exposure/ Other
Section 3 Cyanosis Chocolate coloured Confusion Cyanosis Increased Bronchoconstriction Bradycardia Pinpoint pupils skin Decreased
secretions Respiratory distress (miosis) Sweating urinary output
(unresponsive venous blood Seizures
Dimmed vision
Treatment guidelines to oxygen) Dysrhythmias Rhinorrhoea andfailure
Bronchorrhoea Apnoea
Fasciculation Gastric stasis
Loss of consciousness Paralysis
Dyspnoea Cardiac ischemia Seizures
Abnormal pulse
Section 4 oximetry
1520% may be asymptomatic, with possible cyanosis
Treatment
Transport Death at ~70% MetHb
Differential diagnosis Combopen (IM) Oxygen and IV/IO access
Carbon monoxide poisoning (concurrent) 2mg Atropine
Section 5 Cyanide poisoning (arterialised venous blood) 500mg Pralidoxime (P2S)
5mg Diazepam (equivalent) Ageing
Up to 3 Combopens given GA 46 hours
Pathways
Treatment Oxygen therapy
GB
GD
5 hours
2 minutes
Assessment VX >48 hours
Supporting Guidelines Supportive management
and monitoring
Section 6 Fasciculation or seizures? yes Diazepam
510mg IV titrated and
no
Toolbox mild/moderate Severity? repeated as required
severe Signs of toxicity

Section 7 Bronchospasm and/or Bronchorrhoea Full atropinisation
(suspect if high ventilation pressures) Suggested by:
or bradycardia
Operational formulary Methylene blue Drying of secretions
Reduction in airway pressures
12mg/kg IV Reversal of bradycardia
(except in case of G6PD deficiency)
Section 8 Atropine
Continued
Flushed dry skin
12mg atropine End tidal CO2 (Role 2/3)
Expect response in 2060 IV/IO atropine
(Dilated pupils are an unreliable
Policies minutes. In absence of being (every 515 requirement? sign of full atropinisation)
minutes)
able to quantify a MetHb
Section 9 level, initially use 1mg/kg,
repeatedasrequired. Pralidoxime (P2S)
In cases of Oxime GA GB GD GF
P2S +
Documentation and audit 2g or 30mg/kg IV total over 510 minutes
slow response
Obidoxime + +
(or Tabun
Improvement should be within 30 minutes H16 + +
exposure), start
Section 10 (repeat doses 0.51g at 46 hourly intervals)
Reassess NB 500mg of P2S per Combopen
Obidoxime + = Effective = Not effective
= Sometimes effective
(where available)
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Intro
Vesicants Phosgene 10f(v)-(vi)
Treatment
Introduction Treatment guidelines 10f(vii) Treatment guidelines 10f(viii) Guidelines
Section 1 Specific agents Contamination PPE Inhalation of phosgene results in a fulminating pulmonary oedema that is incapacitating
Mustard (H) (Sulphur/Nitrogen) Personal protective equipment Decontamination team and may be fatal.
Preparation Lewisite (L) decontamination IPE (4R) caution with
Phosgene Oxime (CX) Hypochlorite (0.5% solution) corrosive agents Signs
g and symptoms
y p (dependent
p on causation and exposure)
p
Corrosives including: Copious water Medical team
Section 2 Acids (esp. HF) Copper sulphate solution IPE (4R) Airway Breathing Circulation Disability Exposure/skin Other
Alkali (for phosphorous) Rhinorrhoea Dyspnoea Possible Chemical burns Respiratory
Phosphorus Mucosal Coughing hypovolaemia Frost bite, if exposed alkalosis
Incident management irritation Pulmonary to pressurised liquid Metabolic
Laryngeal oedema acidosis
Signs
g and symptoms
y p (dependent
p on causation) oedema Cyanosis
Section 3 Chest pain
Airway Breathing Circulation Disability Exposure/skin Other
Burning Pulmonary Hypovolaemic Burning eyes Erythema Arsenic poisoning Expiratory
Treatment guidelines mucosa oedema shock Burns (Lewisite) wheeze
(Lewisite) Cardiac Necrosis Hypocalcaemia (HF)
dysrhythmia
Section 4 (HF burns and After a latency period of 6 to 12 hours, acute pulmonary oedema becomes clinically
intoxication) apparent resulting in severe respiratory distress.
Transport Death may occur from anoxia 6 to 24 hours after exposure.
Differentiation and treatment of skin symptoms Diagnosis
Section 5 Onset Delayed (hours) There are few signs or symptoms for up to six hours post exposure. A high index of
Mustard
suspicion
Supportive management
Pathways Immediate (<30 minutes)
Treat as thermal burns is required.
Monitor airway if mucosal injuries Symptoms
Sweat areas (i.e. groin, armpits,
Supporting Guidelines Distribution? neck, face, webspaces)
(Monitor bone marrow suppression)
Initially a dry cough, then chest tightness and/or dyspnoea.
Section 6 Non-specific or open areas Signs

Phosgene oxime Expiratory wheeze or tachypnoea (little else in early stages).
Toolbox Lesion Urticaria/wheal, necrosis later Supportive management
Debride necrotic areas
Other (i.e. grey lesion, eschar, saponification
Section 7
Operational formulary Other CW agent? Industrial? Consider: Munitions? Consider:

Lewisite (arsenical) Acid Phosphorus (red and white)
Supportive management: Dilute with copious Smother fragments with water
Section 8 Skin/Eyes: Topical British Anti-Lewisite amounts of water. or wet cloth. Decontaminate by
(BAL)/Dimercaprol (if available) Hydrofluoric acid (HF) burns: keeping the substance stable in
Policies Systemic features and indications: Topical HF antidote water. Also phosphoric acid burns.
Pulmonary oedema (calcium gluconate) gel Do not allow substance to come
Burn size >1% (palm size) Local infiltration with into contact with air
Section 9 Skin contamination with calcium gluconate solution
Skin and eyes: Neutralise with
immediate (within 30 minutes) reaction Treat systemic toxicity
1.0% copper sulphate solution.
Prolonged QT and dysrhythmias (hypocalcaemia) with IV
Documentation and audit Systemic treatment/chelation: calcium chloride
Wounds: 0.10.2% copper
sulphate solution.
IM 10% BAL in oil (dose 3mg/kg), specific Alkali
regime. (Significant side effects noted) Remove copper sulphate solution
Dilute with copious
Section 10 Oral DMSA 30mg/kg/day, and based on amounts of water.
ASAP with copious water.
confirmation of diagnosis
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Intro
Biological agents & toxins 10g
Treatment
Introduction Treatment guidelines 10g Guidelines
Section 1 Anthrax
Preparation Treatment guidelines 10g(i)
Section 2
Botulinum toxin
Treatment guidelines 10g(ii)
Incident management
Marine envenomation
Section 3 Treatment guidelines 10g(iii)
Treatment guidelines Plague
Treatment guidelines 10g(iv)
Section 4
Transport
Plants & mushroom
Treatment guidelines 10g(v)
Section 5
Intentionally blank Q-Fever
Pathways Treatment guidelines 10g(vi)
Supporting Guidelines Ricin

Treatment guidelines 10g(vii)
Section 6
Toolbox
Smallpox
Treatment guidelines 10g(viii)
Section 7
Staphylococcal toxin
Operational formulary Treatment guidelines 10g(ix)
Section 8 Tularaemia
Policies Treatment guidelines 10g(x)
Section 9
Viral haemorrhagic fever
Treatment guidelines 10g(xi)
Vomiting & diarrhoea
Section 10 Treatment guidelines 10g(xii)
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Intro
Anthrax 10g(i)
3
Treatment
Introduction Treatment guidelines 10g(i) Guidelines
Section 1 Personal protection for body

Preparation
standard handling
Section 2 precautions or high
particulate
Incident management Secretions and lesions Corpses are highly infectious (release filter mask
are infectious of spores): use a non-porous body bag
Section 3
Presentation
Treatment guidelines Cutaneous anthrax:
Rapidly growing painless papule (ulcerates, becoming a dry black scab with
Section 4 surrounding purple vesicles-eschar)
Local oedema + regional lymphadenopathy
Transport Pus indicates secondary infection
Associated rigors, headache, vomiting
Section 5
Intentionally blank Low mortality
Pathways Pulmonary anthrax:
Abrupt onset; may be brief initial improvement before sudden worsening
Supporting Guidelines Rigors, dyspnoea, cyanosis
High mortality, even with ICU support
Section 6 Gastrointestinal anthrax:
Fever, toxaemia, nausea, vomiting, anorexia, haemolytic colitis
Toolbox High mortality secondary to ingested spore
Investigations
Section 7
Chest x-ray and CT chest if available to provide baseline cross-sectional imaging
Operational formulary Microscopy of vesicle fluid from under eschar/lymph node exudates
Culture blood, CSF, lymph node exudates
Section 8 Chest X-ray in pulmonary anthrax shows mediastinal widening (not always)
Sputum is often negative for bacilli
Policies
Treatment
Ciprofloxacin 400mg IV BD or 500mg PO BD or
Section 9
Doxycycline 200mg IV/PO stat then 100mg IV/PO BD
Documentation and audit The route of administration is determined by the severity of infection
Communication
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Intro
Botulinum toxin Marine envenomation 10g(iii)-(iii)
Treatment
Introduction Treatment guidelines 10g(ii) Treatment guidelines 10g(iii) Guidelines
Section 1 Specific agents Contamination PPE Assess and record Nematocyst = tentacle
Botulinum toxin (of Universal precautions Decontamination Team & Signs and symptoms (banded ladder appearance)
Preparation biological origin, from
Clostridium botulinum)
Decontamination:
Soap and water
Medical Team to wear surgical
mask, gloves and apron
Tetanus status
When and where injured
Role 1
Caution with body fluids
Section 2 Not contagious Marine envenomation
Painful, pruritic or visible lesion
Incident management
Signs and symptoms (onset hours to days)
g symptoms
Anticholinergic y p without CNS features Puncture wounds Urticaria/Vesicles
Section 3
Airway Breathing Circulation Disability Exposure/skin Other
Dry mouth Dyspnoea ALERT Dry skin Nausea &
Treatment guidelines Dysphagia Respiratory Cranial nerve palsies vomiting Hydroid Sponge
Dysphasia paralysis Blurred vision Urinary retention Fire coral Bristleworm
Dilated pupils Constipation
Section 4 Diplopia Nematocyst Jellyfish
Sea snake Starfish removal Anemone
Descending flaccid
Octopus Sea urchin
Transport paralysis
Cone shell Stingray
Differential diagnosis:
Scorpionfish
Guillain-Barr (Miller-Fisher) syndrome: characterised by ascending paralysis
Catfish Spicule or bristle
Section 5 Tetanus look for involuntary muscle spasms
Weaverfish Apply 5% extraction with
Nerve agent produces cholinergic toxidrome (increased secretions + CNS involvement) acetic acid adhesive tape/
Atropine poisoning: produces anticholinergic toxidrome + CNS involvement
Pathways solution rubber cement
to one
Supporting Guidelines Treatment Supportive management

Symptoms
worsen/
Role 1 Increased pain
Section 6 Symptoms
Pressure Hot water improve Acetic acid 5%
mild/moderate Severity? occlusion immersion application
Toolbox dressing (90min)
severe Irrigate Apply baking
Local/regional soda slurry for
Section 7 anaesthesia Apply 5% 10minutes
Role 2 and Aggressive respiratory solution to all
Operational formulary beyond support nematocysts Treat allergic
reactions
Section 8
Continuing no Supportive care
Apply shaving
Policies deterioration? foam and scrape
off with dull edge
yes Consider systemic
Section 9 steroids
Give supportive care
Documentation and audit Antitoxin

Give 1 vial of polyvalent botulinum antitoxin
Check preparation for specific precautions
Section 10 Only effective if circulating toxin present
Evacuate Evacuate
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Intro
Marine envenomation Plague 10g(iii)-(iv)
3
Treatment
Introduction Treatment guidelines 10g(iii) (Contd) Treatment guidelines 10g(iv) Guidelines
Section 1 Roles 2 & 3 Investigations Personal protection

Preparation Assess and record FBC, PT, APTT & FDPs
or if
Site and extent of injury U&E, glucose & CK high particulate respiratory symptoms
Section 2 Give tetanus if required Urine diptest filter mask + visor (pneumonic plague)
(myoglobinuria)
Incident management Give 3rd generation

cephalosporin
Look for signs of Signs of envenomation
+ + isolate pneumonic plague cases
Section 3
envenomation Any degree of paralysis
Treatment guidelines Carry out investigations INR >2.0 Person-to-person spread via respiratory droplets or contact with pus from buboes
CK >500iu/l or
Section 4 myoglobinuria Sporadic cases endemic in some geographical areas; spread by fleas from
Creatinine rising or >normal rodentvector
Transport Other marine Jellyfish Unconscious or fitting BW cases will be pneumonic, rapidly progressive, and highly infectious
animals
Section 5 Systemic symptoms Presentation
Initially non-specific symptoms: high fever, chills, myalgia, headache.
Pathways no yes Pneumonic plague: cluster of pneumonia cases (aerosolised deliberate attack)
X-ray for spines Clean and dress with bloody sputum, mediastinitis + pleural effusion. Short incubation period
Supporting Guidelines and remove wounds (~2 days)
Section 6
Give Sporadic plague: affects lymph nodes (e.g. inguinal nodes) which become
tender & swollen, and may suppurate (buboes). Secondary symptoms are cough
anti venom and haemoptysis
Toolbox Surgically remove blisters
and excise around site of Differential diagnosis
envenomation Acute respiratory infections, including anthrax
Section 7
Investigations
Operational formulary Microscopy and culture of sputum or bubo aspirate
Clean and dress wounds
Continue to monitor ICT Chest to assess lungs and mediastinum early
Section 8 Acute and convalescent sera (send to UK)
Chest X-ray: pneumonia with mediastinal lymphadenopathy +/ pleural effusion
Policies
Further management Management
Section 9 Repeat investigations every 24 hours Ciprofloxacin 400mg IV BD or 500mg PO BD or
Regular observations Doxycycline 200mg IV stat then 100mg IV BD or 100mg PO BD
Documentation and audit Source isolation in the hospital environment
Discharge patient if fit and well after 24 hours
Consider need for ventilation if paralysis Communication
Section 10
Inform Chain of Command
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Intro
Plants & mushroom Plants & mushroom 10g(v)
Treatment
Introduction Treatment guidelines 10g(v) Treatment guidelines 10g(v) (Contd) Guidelines
Section 1 Role 1 Roles 2 & 3

Preparation Assess and record Blood
Save the plant if possible for the identification Time of ingestion and onset FBC & coagulation screen
Section 2 symptoms U&E, LFT
Pulse and BP Glucose
Incident management Respiratory rate Group & Save
GCS and pupil response
Continuous ECG monitoring
Section 3 Assess and record Bloods (4 hourly) Repeated doses activated charcoal
Time of ingestion Consider telemedicine photo of plant Regular bloods (above)
Treatment guidelines Pulse and BP
Fluid replacement to maintain high
urine output (monitor by urometer)
Respiratory rate Gastrointestinal symptoms Beware multi-organ failure
Section 4
GCS and pupil response
Transport Blood glucose (BM Stix) Place in darkened room
Hallucinogenic
Provide reassurance
Section 5 Benzodiazepine PO/IV
Muscarinic symptoms
Pathways Salivation Defaecation Consider atropine and -agonists
Give activated charcoal 1g/kg PO Lacrimation GI hypermotility
Supporting Guidelines (if within one hour of poison ingestion) Urination Emesis
Supportive care
Consider physostigmine if severely
Section 6 Anticholinergic symptoms symptomatic
Tachycardia
Toolbox Hypertension
Gain IV access Regular bloods
Warm dry skin Repeated doses activated charcoal
Section 7 Start maintenance fluids (crystalloid)
Careful fluid and electrolyte
balance
Operational formulary Digitalis effect Consider Digoxin Fab fragments
Ventricular extrasystoles and/or (but unlikely to be available)
conduction block
Section 8
Arrange evacuation with ECG monitoring Nausea & vomiting
Ensure plant sample goes with patient Hyperkalaemia
Policies Yellow visual haloes (xanthopsia) Local and systemic steroid
Antihistamines
Section 9 Bathing
Dermatitis Calamine lotion
Section 10
Beware of liver and renal failure
(especially when symptoms start 6 or more hours after ingestion)
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Intro
Q-Fever Ricin 10g(vi)-(vii)
3
Treatment
Introduction Treatment guidelines 10g(vi) Treatment guidelines 10g(vii) Guidelines
Section 1 Consider
Personal protection Personal protection
Preparation external
DECON if
Section 2
+ + contaminated
standard precautions standard precautions by aerosol
Incident management
No isolation required
Toxin from castor oil plant, and forms 510% of waste in engine oil production
Section 3 Effective as aerosol, or injected, or most likely as food/water contaminant
Rickettsial disease (Coxiella burnetti) caused by inhalation of infected particles,
Treatment guidelines not a tick bite
Presentation
Acute & chronic forms: endocarditis + hepatitis more common in chronic form
Mortality is generally low (<1%) Inhalation
Section 4
Weakness, fever, cough and pulmonary oedema occur 1824 hours after inhalation;
Presentation severe respiratory distress and death from hypoxia follow in 3672 hours
Transport 1. Entry
Initial flu-like symptoms, with Aerosol from infected Ingestion
dry cough + pleuritic chest pain sheep, goats or cattle
Section 5 Severe gastrointestinal symptoms including GI haemorrhage (+ liver, spleen,
at 45 days
2. Spread kidney necrosis) followed by vascular collapse and death
Fever, severe retrobulbar
Pathways headache, myalgia, anorexia,
Haematogenous Parenteral (injected)
(through blood) Local muscle + lymph node necrosis, progressing to organ involvement and death
weakness, profuse sweats,
Supporting Guidelines nausea, vomiting and diarrhoea 3. Disease Differential diagnosis
Aseptic meningitis occurs in 1% Pneumonitis
Respiratory: pulmonary anthrax (mediastinitis on CXR); pneumonic plague;
Section 6 Endocarditis
phosgene (ARDS mediated by exertion)
Investigations Granulomas
No acute field test is available Gastrointestinal: salmonellosis; shigellosis; cholera; staphylococcal enterotoxin B
Toolbox 4. Exit (would not expect life-threatening clinical presentation)
to assist diagnosis
Usually none Dermal injection: necrotising fasciitis
FBC is normal in 70% acute
Section 7 in man
cases ( wbc in 30%) Investigations
LFTs show transaminases No acute field test is available to assist diagnosis
Operational formulary Monitor FBC ( wbc), U&E, glucose, clotting, arterial blood gases (hypoxia)
x23, but normal bilirubin
CT chest early if abnormal CXR
CXR may range from normal to widespread pneumonitis
Section 8 CXR may show infiltrates or ARDS, but no mediastinitis
Liver ultrasound granulomatous hepatitis; ECHO valve vegetations Blood for acute and convalescent sera should be sent to UK
Policies Blood for acute and convalescent sera should be sent to UK
Treatment
Treatment There is no specific treatment or antidote
Section 9 Doxycycline 200mg IV/PO stat then 100mg IV/PO BD (can be doubled in severe Consider skin (hypochlorite solution) or gut (charcoal) decontamination
infection) for 1014 days; reinstitute if a relapse occurs Volume replacement +/ vasoconstrictors (noradrenaline) will be required
Documentation and audit Treat symptomatically, including any pulmonary oedema
Communication
Section 10 Inform Chain of Command Communication
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Intro
Smallpox Smallpox 10g(viii)
Treatment
Introduction Treatment guidelines 10g(viii) Treatment guidelines 10g(viii) (Contd) Guidelines
Section 1 Investigations
Personal protection There is no useful field diagnostic test
Preparation Diagnosis can be confirmed by electron microscopy and PCR (UK reference
or if
high particulate filter mask any symptoms of smallpox infection laboratory investigation of index case)
Section 2 + visor Management
Supportive care
Incident management
+ + isolate patient

Source isolation in the hospital environment
Immediate ring vaccination for all exposed personnel, if not already immunised
Section 3
Exercise care when disposing of bedding and/or clothing
Spread is via aerosol, droplets and
Treatment guidelines Smallpox is highly infectious
direct contact with vesicle fluid Communication
Section 4
Patients are infectious until all
Transport scabs have separated
Strict quarantine must be
applied to all contacts for a
Section 5 minimum of 16 days following
exposure
Pathways
Section 6 Presentation
Toolbox Prodromal phase
Malaise, fever, rigors, headache, vomiting & backache (15% may have delirium)
Section 7 An erythematous rash will be seen early on Caucasian skin
Rash
Operational formulary Starts at 23 days from onset of prodrome and spreads centrally
Lesions change from macules to papules to pustules
Section 8 Lesions are more abundant on the extremities
Lesions remain synchronous in their stage of development
Policies Scabs form 814 days after onset of rash
Outcome: significant mortality
Section 9 Differential diagnosis
Documentation and audit Any other infections that cause vesicular rashes, e.g. chickenpox
Important diagnostic features that suggest smallpox are the distribution
(spreading from periphery towards centre), the synchronicity of lesions, and
Section 10
lesions that are located more deeply in the dermis than chickenpox
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Intro
Staphylococcal toxin Tularaemia 10g(ix)-(x)
Treatment
Introduction Treatment guidelines 10g(ix) Treatment guidelines 10g(x) Guidelines
Section 1
Personal protection Personal protection
Preparation
Section 2
+ + + universal precautions
standard precautions
Incident management Hand to eye inoculation may occur
Body fluids are infectious
causing oculoglandular tularaemia
The toxin that most commonly causes sporadic endemic food poisoning
Section 3 In BW context it is an incapacitating agent, although rarely at high doses it
couldcause multi-organ failure and death (can be easily aerosolised and is Franciscella tularensis is a naturally occurring disease of wild mammals
Treatment guidelines highlystable) (e.g. rabbits) and birds (animal infection spread by ticks/lice/fleas/flies)
Human infection may be acquired from bites of infected animals or insects
Section 4 Presentation or by ingestion or inhalation
Inhalation
Presentation
Transport Symptoms within 16 hours: fever, shortness of breath and severe retrosternal
chest pain. In high dose can cause ARDS General
Section 5 Fever, chills, headache, exhaustion, and pain in the extremities
Ingestion
Symptoms within 18 hours, rarely up to 18 hours post-exposure: nausea, vomiting, Respiratory
Pathways cramping abdominal pain, then urgency and profuse non-bloody diarrhoea. Retrosternal discomfort and non-productive cough; atypical pneumonia: cluster of
Normally resolves in 1224 hours. Debilitation can last as long as 2 weeks cases will raise suspicion of BW (onset within 35 days)
Supporting Guidelines Differential diagnosis Ulceroglandular
Small round structured virus (Norwalk-like virus: winter vomiting disease) Local ulcer and regional lymphadenopathy
Section 6
Investigations Other
Toolbox Diagnosis is largely clinical Untreated mortality ~40%; generally low mortality in treated cases
Diarrhoea is negative for blood on diptest Differential diagnosis
Section 7 FBC shows neutrophil leucocytosis Malaria; infectious mononucleosis; Q-Fever; brucellosis; actinomycosis
Theoretically, toxin can be detected on nasal swab within 1224 hours Investigations
Operational formulary ofexposure to aerosol (but field technology cannot support this)
Microscopy: can be directly identified from secretions or tissue if fluorescent
Section 8 Treatment marked antibodies or immunohistochemical colours available
There is no specific treatment Secretion/tissue culture is difficult
Policies Treat vomiting and dehydration symptomatically Serology (ELISA) and PCR are ultimately diagnostic: send blood to UK
Communication CXR for atypical pneumonia
Section 9 Inform Chain of Command Treatment
Documentation and audit Gentamicin 5mg/kg IV per day for at least 10 days
Communication
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Intro
Viral haemorrhagic fever Vomiting & diarrhoea 10g(xi)-(xii)
Treatment
Introduction Treatment guidelines 10g(xi) Treatment guidelines 10g(xii) Guidelines
Section 1 Personal protection Personal protection

Preparation or if
Section 2
high particulate filter mask
+ visor
haemorrhage; diarrhoea or vomiting;
cough; taking or handling blood samples
+ + universal precautions
Incident management Decontaminate
+ + isolate samples
Hand washing before and after seeing the patient
Use alcohol hand rub as additional infection control measure
Ensure appropriate disposal of clinical waste
Section 3
Treatment guidelines Scrupulous clinical waste Corpses are highly infectious Outbreaks of diarrhoea and vomiting are common in military populations
Small round structured virus (Norwalk-like virus) should be considered in
Section 4 outbreaks: secretions (especially vomitus) are highly infectious
Wide group of unrelated viral infections
Presentation
Transport Includes Ebola, Lassa Fever, Congo-Crimean Haemorrhagic Fever, Hanta virus
Acute onset vomiting, diarrhoea, stomach cramps
Most infections arise from blood/body fluid contact (e.g. vomit or urine)
Blood in stools of salmonella, shingella and campylobacter cases
Section 5 Pre-terminal stages are haemorrhage and multi-organ failure
Differential diagnosis
Presentation
Pathways May be prodrome for many other diseases
Fever, malaise, pharyngitis, abdominal pain, nausea and vomiting, constipation Consider malaria if fever
or diarrhoea, haemorrhage, haemodynamic collapse
Supporting Guidelines Differential diagnosis
Investigations
Microscopy: stool (and diptest for blood)
Malaria
Section 6 Culture: stool, and blood if systemic symptoms
Can mimic acute surgical abdomen (appendicitis)
Serology
Toolbox Other conditions that present with fever, septicaemia and shock
Virology: if clusters consider sending sample to UK (will allow diagnosis by PCR
(e.g. meningococcal septicaemia)
and ELISA: electron microscopy requires fresh stool sample and can only be done
Section 7 Investigations if patient is in UK)
Discuss with laboratory prior to sampling any body fluids Treatment
Operational formulary Exclude malaria in malaria endemic areas Rehydration according to need (oral where possible)
Treatment No routine antibiotics
Section 8 Largely supportive: give fluid replacement by mouth where possible (organisms Campylobacter enteritis: ciprofloxacin or erythromycin
can be aerosolised around an IV entry site when the line is agitated) Salmonellosis or shigellosis: ciprofloxacin or trimethoprim
Policies Specific treatment with ribavirin where available [30mg/kg IV stat, then
Communication
15mg/kg IV QDS 4/7, then 2.5mg/kg IV tds 6/7] may have some effect in
Section 9 Lassa Fever and CCHF if administered early For routine cases complete F Med 85 only
Use FFP to correct deranged clotting when there is haemorrhage For outbreaks Inform Chain of Command
Communication
Section 10
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Intro
Radiation casualties E Environment 10h-11
Treatment
Introduction Treatment guidelines 10h Treatment guidelines 11 Guidelines
Section 1
Role 1 Role 2 Role 2 Role 4
Preparation Enhanced/Role 3 Hypothermia
Section 2 POW Gross Full decontamination Surgical Medical Transfer
Incident management
decontamination
Life saving 1st Aid

Nasal swabs
Debridement
Surgical
Management
Transfer Frost bite
BATLS
Dose estimate Decontamination Anti-infectives
Ciprofloxacin 1g Treatment guidelines 11b
Section 3 Primary closure if Acyclovir
Nasal blows vomit within 4 hrs
Heat illness
800mg
of exposure Fluconazole
Treatment guidelines Nasal swabs
200mg
Section 4
FBC as
appropriate Chelating Agents Treatment guidelines 11c
Cytokines
Transport Bowel Stimulants Bites & stings

Section 5 Irradiated only Treatment guidelines 11d
Pathways Ondansetron
or Granisetron
Sample Collection:
Altitude emergencies
FBC/Leucocytes 6 hourly/HLA tissue typing/Dicentrics at 24 hrs
Supporting Guidelines Decontamination (blood for chromosomal studies) Treatment guidelines 11e
Section 6
Diving emergencies
24 hour Urine/Faeces/Vomit
Toolbox Dressings and discarded clothes

Section 7
Note the requirement for transfer to Role 4
Operational formulary for continuing tests and treatment Near drowning
Treatment guidelines 11g
Section 8
Policies Electrical & lightning

Section 9 See Policies for
9
Go to Section 8
further direction
Acute pain
Policies
Section 10 Treatment guidelines 11i

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Intro
Hypothermia 11a
Treatment
Section 1 Actions at Role1

Preparation ASSESS <C>ABCD
Follow common emergency treatment pathway
Section 2
Incident management Is the casualty hypothermic? (cold to touch and/or T <35oC)
Section 3 yes
Is the casualty shivering?
Section 4 no yes
Transport
Reduce environmental
Hypothermia influences Hypothermia
Section 5 is severe is mild
Intentionally blank Remove wet clothing
Pathways Lie on insulated surface
Is the casualty Cover with blankets Rewarm
Supporting Guidelines conscious? Use rewarming kits passively
Section 6 (HPMK or Blizzard
Blanket)**
Toolbox yes no Evacuate
Are there signs of life?
Section 7
yes no
Section 8 Handle gently to avoid Start CPR

precipitating VF Avoid rough handling &
Policies be cautious of intubation:
you may induce VF
Section 9 Insulate from further
heat loss and evacuate
** Rewarming blankets take >10mins to reach maximum
Section 10 temperature: active when en route to patient if possible
Adapted from: JSP 539
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Intro
Hypothermia Frost bite 11a-b
Treatment
Section 1 Actions at Role2 & 3 Emergency treatment

Preparation ASSESS <C>ABCD
Follow common emergency treatment pathway In the open
Section 2 Move out of the wind/drink warm fluids
Incident management Investigations Remove boots oedema may hinder replacement
Rectal temp with a low reading Remove wet clothes: change for dry
Section 3 thermometer
Warm foot in buddys armpit/groin for 10 minutes
BP, pulse, resps, BM
Treatment guidelines Give aspirin (600mg) or ibuprofen (600800mg)
U&Es, FBC, clotting, amylase,
blood cultures If sensation returns can continue to walk
Section 4 ABG
Transport ECG At high altitude give oxygen
Section 5
At established camp
Pathways Management Remove boots and change wet clothing for dry
Humidified oxygen warmed to 4246C Warm fluids to drink
Supporting Guidelines (active internal rewarming)
Warm air duvet (bear hugger) Give aspirin (5001000mg)
Section 6
(active external rewarming) Rapid rewarming:
Toolbox Monitor ECG Immerse part in warm water at 37C
Monitor temp every 30 mins until >36C Rewarm for one hour
Section 7 If hypoglycaemia present correct with
Dry, apply loose bandaging and elevate
IV50% glucose
Operational formulary Consider active internal Evacuation is mandatory
rewarming for profound
Section 8 hypothermia:
Warmed fluid lavage;
Policies Investigations
intravesical; nasogastric;
Do not
Drug metabolism is and unpredictable Rub
extrapleural;
Section 9 Avoid drugs until core temp >30C intraperitoneal. Rewarm one part if the
Then give drugs with dosage intervals casualty is hypothermic
Consider CVP line and urinary catheter Rewarm if there is a
inunstable patients possibility of refreezing
Section 10
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Intro
Heat illness Heat illness 11c
Treatment
Introduction Treatment guidelines 11c Treatment guidelines 11c (Contd) Guidelines
Section 1 First aid Role 1 Symptoms

Preparation Agitation
Symptoms: agitation, nausea or vomiting, staggering Airway/Breathing/Circulation Nausea or vomiting
Section 2 or loss of coordination, cramps, disturbed vision, Axilla or ideally core temperature Cramps
confusion, dizziness, collapse or loss of consciousness must be recorded
Incident management Staggering or loss of
Pulse/Resps/BP/GCS coordination
100% oxygen Disturbed vision/
Section 3
IV access 1 litre normal saline headache
Stop Maintain cooling procedure Dizziness
activity Confusion
Section 4 Collapse or loss of
consciousness
Transport
Lie the casualty down in the shade
Section 5
Elevate feet if conscious Complications
Pathways Strip to underwear Cardiac arrest
Sponge or spray casualty with cool water and fan the skin Go to
Supporting Guidelines 1
Treatment
guidelines
Section 6
Role 2 & 3 Fitting
Toolbox Go to 9b
Give water to drink if the Place the unconscious Re-assess ABC Treatment
guidelines
Section 7 casualty is conscious casualty in the recovery Pulse/Resps/BP/BM/ECG
position Hypoglycaemia
Rectal temperature
Operational formulary Go to 9c
Consider intubation and ventilation Treatment
ABGs guidelines
Section 8
Urinary catheter/NG tube/ Hyperkalaemia
Policies CVP line/Arterial line Go to
Evacuate to medical 10a
FBC, U&Es, LFTs, CK, clotting screen,
care as quickly as
Treatment
guidelines
Section 9 myoglobin clearance and lactate
possible Acute renal failure
Documentation and audit Go to 10d
Treatment
guidelines
Section 10
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Intro
Bites & stings: spider Bites & stings: spider 11d
Treatment
Introduction Treatment guidelines 11d Treatment guidelines 11d (Contd) Guidelines
Section 1 Role 1 Lie patient down Role 2 & 3 Lie patient down
Preparation FBC
In all patients PT, APTT & FDPs
Section 2 Observe for at least 24 hours U&Es, Glucose & CK
Assess and record Repeat investigations every 24 hours Urine diptest
Incident management When and where bitten Monitor wound
Description of spider Give analgesics and anxiolytics
Section 3
Any symptoms Give tetanus if required
Treatment guidelines Pulse & respiratory rate Consider use of anti venom
Use of anti venom
BP and GCS
Section 4 Measure circumference of affected limb
Mark area of oedema Other spiders
Transport Widow spider
Record tetanus status Fasciculation
Systemic envenomation
Section 5 Marked salivation/
Severe pain
lacrimation
Pathways Hypertension
Localised pain Other bites yes Tachycardia
Supporting Guidelines Local sweating If patient
Dyspnoea
Piloerection clinically stable
Section 6 Decreased GCS
Toolbox yes
Assume Widow spider Pressure Observe
Section 7
immobilise limb
Operational formulary Use anti venom
If patient systemically Have anaphylaxis kit ready
Section 8 Management
well for 24 hours
If respiratory distress give oxygen Do not
Policies Gain IV access Feed patient
Consider IV crystalloid if hypotension Also consider
Section 9 Allow them to Discharge patient
Analgesia as needed walk around Assisted ventilation
back to unit Need for renal dialysis
Documentation and audit Elevate limb
Debridement of necrotic
Arrange transfer Wash the limb
Section 10 tissue
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Intro
Bites & stings: snake/scorpion Bites & stings: snake/scorpion 11d
Treatment
Introduction Treatment guidelines 11d (Contd) Treatment guidelines 11d (Contd) Guidelines
Section 1 Role 1 Lie patient down Role 2 & 3 Investigations

FBC
Preparation
PT, APTT & FDPs
In all patients U&E, Glucose & CK
Section 2 Observe for at least 24 hours Urine diptest
Assess and record Repeat investigations every 24 hours Group and Save serum
Incident management When and where bitten Monitor wound 20 mins whole blood clotting test
Description of snake Give analgesia (not NSAID) and anxiolytic
Section 3 Give tetanus toxoid if required Signs of envenomation
Any symptoms
X-ray wound for fangs/barbs Local swelling around wound
Treatment guidelines Heart & respiratory rate
Look for signs of envenomation Tender regional lymph nodes
BP and GCS
Any degree of paralysis (earliest
Section 4 Measure circumference of affected limb sign is ptosis)
Mark area of oedema/discolouration Spontaneous systemic bleeding
Transport (e.g. gums or nose)
Look for and document spontaneous bleeding
No signs of INR >2.0
Section 5 Look for and document paralysis (ptosis is early sign) envenomation CK >5000u/l or myoglobinuria
Check tetanus status Creatinine rising or >normal
Pathways Unconscious or fitting
Systemic symptoms
Supporting Guidelines If patient systemically
Management well for 24 hours
Section 6 Pressure immobilisation (elapid snakes only: see following guidance) For severe symptoms use
antivenom (locally raised
Splint limb anti venom is best)
Toolbox
Gain IV access
Section 7 Arrange transfer Discharge patient
Consider IV crystalloid if hypotension back to unit (beware
wound infection) If using polyvalent or multiple dose of
Operational formulary If respiratory distress give oxygen monovalent pre-medicate the patient
with antihistamine and hydrocortisone.
Section 8 Have anaphylaxis kit ready
Favirept anti venom
Policies Appropriate use of pressure
immobilisation as a first aid technique
Do not If progressive neurotoxic envenoming,
giverepeat dose in 1 hour
implies an understanding of the effects Feed patient If coagulopathy, assess need for further Also consider/use of:
Section 9
of snake venom and the ability to Allow them to walk around anti venom at 6 hours Assisted ventilation
Documentation and audit reliably identify snake species. Refer to individual data sheet for Renal dialysis
Elevate limb
recommended dose and dose intervals FFP if coagulopathy
Section 10 Wash the limb ofeach brand of anti venom. Antibiotics for wound
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Intro
Bites & stings: snake/scorpion Altitude emergencies 11d-e
Treatment
Introduction Treatment guidelines 11d (Contd) Treatment guidelines 11e Guidelines
Section 1 HACE Headache HAPE

Preparation
Pressure Immobilisation

Severe headache
Incoordination
Difficulty breathing
(Elapid envenomation only e.g. cobras) Disorientation
Reduced exercise
Simple analgesia tolerance
Section 2 This technique slows systemic absorption of snake venom Hallucination
Cough may be wet
Apply a firm bandage to whole length of affected limb Lower consciousness
Blood stained sputum
Coma
Incident management Capillary refill and arterial pulses must be maintained in the extremity. AMS
Thebandage must not be too tight you should be able to slip a finger Headache
+
Section 3 behind the bandage one of following
Descend Descend
The limb can be further immobilised in a full length cast Oxygen
Loss of appetite Oxygen
Treatment guidelines Nausea
The patient must rest only minimal active movement Dexamethasone (8mg Sit upright
Vomiting Carry if possible
Do not remove the pressure immobilisation until in the resuscitation IM/IV initially then
Section 4 4mg 6 hourly)
Lethargy Keep warm
facility, after IV access has been obtained in another limb and anti venom Sleep disturbance
Portable hyperbaric Nifedipine (20mg SR
Transport isavailable Dizziness orally 6 hourly)
chamber to facilitate
descent Consider adding
Section 5 dexamethasone (4mg
Stop ascent orally 6 hourly) if
Pathways Rest HACE is not excluded
Simple analgesia
Antiemetic
Section 6 Worsens No improvement
Toolbox 1. Locate area of bite or sting 2. Apply a firm bandage, not 3. Apply bandage to whole Descend Descend and
and prepare bandage. too tight you should be length of affected limb.
Oxygen continue treatment
Section 7 able to slip a finger behind
Acetazolamide (250mg
the bandage.
orally 8 hourly)
Operational formulary Dexamethasone (4mg orally
6 hourly)
Section 8 Portable hyperbaric chamber
to facilitate descent
Policies
Section 9 Descend
to below altitude where symptoms first occurred
Documentation and audit 4. The limb can be immobilised 5. The limb can be further 6. The patient must rest. Only
using a splint. immobilised in a full length minimal active movement
cast. should be allowed. Key HAPE High Altitude Pulmonary oEdema
Section 10 HACE High Altitude Cerebral oEdema AMS Acute Mountain Sickness
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Intro
Diving emergencies Near drowning 11f-g
Treatment
Introduction Treatment guidelines 11f Treatment guidelines 11g Guidelines
Section 1 Dived on compressed air

Also consider:
Actions at Role 1
underwater in last 48 hours
Preparation
Oxygen toxicity ASSESS <C>ABCD
follow common emergency treatment pathway
Section 2 Nitrogen narcosis
Incident management History or Symptoms suggesting Barotrauma
decompression illness
Section 3 Spontaneous Cardiac arrest Cardiac arrest
respiration Warm Hypothermia
Section 4 Assess <C>ABCD Consider and treat:

Lie supine & horizontal Immersion Syndrome
Transport Administer 100% oxygen Dysrhythmias BLS/ALS BLS/ALS
Establish IV access Pneumothorax High flow O2 Go to
1
Go to
1
Treatment Treatment
Section 5 Hypothermia Transport to hospital guidelines guidelines
Administer fluids
Transport to hospital Transport to hospital
Pathways
Cardiac Arrest
Section 6 Transfer to nearest Recompression Chamber 1
Go to Treatment
Maintain altitude less than 300m during flight guidelines
Toolbox Maintain 100% oxygen

Maintain supine horizontal position
Section 7 Beware concomitant injuries, especially spinal injuries. These may occur for instance after
Entonox is not to be administered for analgesia
aircraft crashes or parachuting incidents into water
Operational formulary Maintain horizontal posture to avoid post-immersion cardiovascular collapse, especially
during rescue
Section 8 Sudden or frequent changes in posture may precipitate VF in the cold, bradycardic patient
Mild symptoms Serious symptoms Employ warming measures early. In practice it is very difficult to rewarm pre-hospital,
Policies but it is vital to prevent further heat loss
Fatigue Weakness Visual disturbance
Postural drainage of aspirated fluid does not improve oxygenation and may further
Section 9 Skin rash Joint pains Ataxia compromise the airway or the cervical spine
Itching Paraesthesia Paralysis or hemiplegia Convey all patients to hospital unless submerged >3 hours
Documentation and audit Dizziness Decreased level of Hospital admission for 24 hours is mandatory in near drowning
Dyspnoea consciousness Anecdotal reports of secondary drowning reflect late manifestations
Section 10 ofpulmonaryinsufficiency
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Intro
Near drowning Electrical & lightning 11g-h
Treatment
Introduction Treatment guidelines 11g (Contd) Treatment guidelines 11h Guidelines
Section 1 Actions at Role 2 & 3 Role 1

Preparation Ensure electrical
Suspect cervical spine injury Is it safe to approach casualty? no
isolation
Section 2 Primary and secondary survey yes
Incident management Treat associated injuries If no cardiorespiratory 1
Treat specific complications output follow Cardiac Go to Treatment
Assess <C>ABC arrest guideline guidelines
Section 3
Treatment guidelines Investigations Pulmonary support

Possibility C-spine yes Immobilise in collar
FBC, electrolytes, serum glucose Supplemental oxygen on all patients
andhead blocks
Section 4 ABG Maintain PO2 >60mmHg in adults
Coagulopathy screen Maintain PO2 >80mmHg in children no
Transport Urinalysis If PO2 not maintained then initiate
CXR anaesthesia/intubation/ventilation +PEEP
ECG Trial of CPAP is permissible in alert, Assess and record
Section 5 Blood cultures if febrile non-vomiting patients
Type of electricity involved (high/
Pathways low voltage and AC/DC)
Supportive care Whether patient was wet/dry
Nasogastric tube
Supporting Guidelines Urinary catheter
Tetanus status
Pulse and respiratory rates
Section 6
Entry/exit wounds/burns
Therapeutics GCS and pupil response
Toolbox Treat hypovolaemia with crystalloid
Metabolic acidosis will improve in line with oxygenation and perfusion Any paralysis/neurovascular deficit
Section 7 Electrolyte disturbances are rarely significant and do not require therapeutic correction
Systemic steroids have no effect on outcome
Operational formulary Lung infection is common secondary to aspiration
Brain abscess and systemic aspergillosis have been reported Treatment A patient may be discharged
Beware leptospirosis from contaminated or stagnant water Give high flow oxygen if Low voltage (<600v)
Section 8
Continuous pulse oximetry/ and No history vertical current
Policies Rewarming Poor prognostic signs ECG monitoring and Dry skin at time incident
Rewarm patients with T <35C CPR >25/min without ROSC Gain IV access and start IV fluids and No loss of consciousness
Section 9 Hypothermic patients in cardiorespiratory arrest Other features such as unreactive (noton injured limb) and No amnesia
must be rewarmed to 32C before resuscitation pupils are unreliable prognostic Dress wounds with paraffin tulle
Documentation and audit is abandoned indicators and No altered mental status
Consider therapeutic hypothermia (3234C)
Arrange evacuation except for those and No symptoms or signs of
for 12 hours following VF arrest whom it is safe to discharge complications
Section 10
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Electrical & lightning Acute pain 11h-i
Treatment
Introduction Treatment guidelines 11h (Contd) Treatment guidelines 11i Guidelines
Section 1 Roles 2 & 3 Oral analgesia

Oral analgesia will be adequate for mild or moderate pain
Preparation (see later in this guideline).
Assess and record
Investigation
Pulse and respiratory rates Splintage
Section 2 ECG
Entry/exit wounds/burns Splintage will reduce the pain from a fractured limb or digit. Splints can be
Urinalysis
GCS and pupil response improvised from clothing. A broad arm sling is effective for most upper limb
Incident management C-spine films as required
Any paralysis/neurovascular deficit injuries and when folded into a broad band can be used to splint the lower limbs
and the pelvis.
Section 3 A traction splint is advised for a suspected fracture of the femoral shaft. The
Sager splint can immobilize and provide traction to both legs if required. Apply
Treatment guidelines Evidence of 7kg (~14lbs) of traction, but do not use the Sager splint if there is a suspected
Investigation
High voltage injury unstable fracture/open book fracture of the pelvis (the counter-traction point
yes U&Es, calcium, CK
Section 4 Extensive cutaneous burns isthe symphysis pubis).
FBC
Systemic injury A SAM splint is useful for immobilising upper limbs in the position in which they
Transport are found (for example, a deformed forearm fracture) if the capability does not
exist to perform analgesia-controlled realignment in the pre-hospital setting.
Section 5 A box splint or neoprene splint is an alternative to SAM to immobilise a limb
Evidence of intra-abdominal Investigation and offers additional padding plus integral Velcro strap securing mechanism.
yes
injury LFTs and amylase
Pathways Entonox
Entonox is a mixture of 50% oxygen and 50% nitrous oxide. It is a rapid onset
Supporting Guidelines analgesic that may be used by a cooperative patient: offset is also rapid once the
Evidence of myoglobinuria Investigation mask or mouthpiece is removed by the patient. Contraindications are suspected
Section 6 (+ve dipstick and no RBC yes Maintain high urine pneumothorax (a tension pneumothorax may be produced), suspected open
on microscopy) output (100mls/hr) head injury (a pneumocephalus may be produced) or suspected decompression
Toolbox sickness. In the cold, the gases will separate and the cylinder must be repeatedly
inverted before use.
Investigation
Section 7 Altered level of consciousness yes Opiates
Perform CT head
Intramuscular morphine is available for first aid use, but it is relatively slow
Operational formulary inonset and has unpredictable absorption in the shocked patient.
Admit for period observation if General action Intravenous morphine is the benchmark analgesic for use in the operational setting.
Section 8 High voltage (>600v) Give tetanus as required Titrate against the pain in 2.55mg aliquots (0.1mg/kg in children). The peak
Symptoms suggestive of systemic injury Consider tetanus Ig if extensive effect may not be seen for 1020 minutes so if immediate analgesia is essential
Policies muscle damage and soil (for example to reduce a dislocated ankle to restore a distal pulse) use fentanyl
Evidence of neurovascular deficit
contamination no matter what or ketamine as an alternative where available (Medical Officers only).
Burns with subcutaneous damage
Section 9 the immune status
Arrhythmia or ECG abnormality For Paediatric Pain Assessment
Documentation and audit High risk exposure
5b
Associated injuries requiring admission Consider other investigations Go to Section 6 Toolbox
Section 10 Co-morbid disease asindicated
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Acute pain Acute pain 11i
Treatment
Introduction Treatment guidelines 11i (Contd) Treatment guidelines 11i (Contd) Guidelines
Section 1 Ketamine Pain: continuing requirements

Ketamine is a powerful, rapid onset (some effect after about 15 seconds when Pain Score
Preparation given IV, but worth waiting 12 minutes for peak effect), short acting analgesic
that has particular application to assist painful procedures (including facilitating 0 = No pain on rest or movement
Section 2 rapid extrication from entrapment and realigning fractured/dislocated limbs). It is 1 = No pain on rest, mild on movement
a dissociative analgesic, so patients will appear detached and unresponsive but 2 = Mild pain on rest, moderate on movement
Incident management will moan or cry out when the procedure is performed.
3 = Continuous pain on rest, severe on movement
Caution must be exercised when used by non-anaesthetists, but it is a generally
Section 3 safe drug ifsimple rules are followed:
Mild Pain Pain Assessment Score 1
Use a dose of 0.250.5mg/kg IV for analgesia (24mg/kg IM is an alternative).
Treatment guidelines If the patient is shocked, start with the lower dose Regular paracetamol 1g QDS (maximum 4g/day)
Have suction available in the event the patient salivates excessively + (if not contraindicated) add regular ibuprofen 400mg
Section 4 (unlikely at the low analgesic doses). TDS or diclofenac 50mg TDS (maximum 150mg/day)
Emergence delirium is also uncommon at low doses and additional
Transport benzodiazepine IV is not required when used for analgesia. Moderate Pain Pain Assessment Score 2
Local anaesthesia Paracetamol 1g QDS + codeine 3060mgs QDS
Section 5
Local anaesthetic nerve blocks provide a means for complete pain relief (when fully + (if not contraindicated) regular ibuprofen 400mg
Pathways effective) that may facilitate extrication from entrapment (e.g. fingers caught in TDS or diclofenac 50mg TDS
Wound
machinery), assist in manipulation of a limb (e.g. realignment of a fractured femur)
suture: and optimise ventilation (e.g. for conscious patients with multiple rib fractures,
Supporting Guidelines thereby potentially avoiding elective ventilation). The most common use in the
Severe Pain Pain Assessment Score 3
operational setting is to support the pain-free suturing of wounds Morphine hourly IM/IV/oral regime
Section 6
Lignocaine has historically been the standard agent as 1% or 2% solution: or Patient Controlled Analgesia of morphine
clinical effect is immediate, but the duration is limited to less than 1 hour.
Toolbox or continuous infusion of morphine
The combination of adrenaline with lignocaine is useful as an adjunct to
haemostasis while suturing (and/or to increase the safe total dose administered), These can be given with regular paracetamol 1g QDS +/ regular ibuprofen 400mg TDS
Section 7 but this combination must not be used to anaesthetise fingers or toes. ordiclofenac 50mg TDS (if not contraindicated).
Levo-bupivicaine represents current best clinical practice: it has a perceived
Operational formulary improved safety profile over bupivicaine and an extended duration of action Ensure appropriate antiemetic (and laxative where
overlignocaine, although the onset of peak action is often >5 minutes. appropriate with repeat doses ofopiate) are prescribed.
Section 8 Topical local anaesthetic (lignocaine gel) is used prior to male urinary
catheterization, or to anaesthetise the cornea (amethocaine drops)
Policies priortoexamination and/or removal of aforeign body. For Paediatric Pain Assessment
5b
Section 9 Go to Section 6
For side effects and total safe drug doses Toolbox
Documentation and audit refer to British National Formulary (BNF)

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Local Anaesthetic Toxicity F Musculoskeletal Injuries Contents
Treatment
Introduction Treatment guidelines 11j Treatment Guidelines 12 guidelines
Section 1 In general the Central Nervous System (CNS) is more sensitive to local anaesthetics than the
Cardiovascular System (CVS). Signs and symptoms of acute MSK injury
Preparation
CNS signs and symptoms Treatment guidelines 12a
Early or mild toxicity: light headedness, dizziness, tinnitus, circumoral numbness, abnormal
Section 2
taste, confusion and drowsiness. Management of acute MSK injury
Incident management Severe toxicity: tonic clonic convulsion leading to progressive loss of consciousness, coma,
respiratory depression and respiratory arrest.
Section 3
Note: depending on the drug and the speed of the rise in blood level the patient may
go from awake to convulsing within a very short time.
Pain Relief
Section 4 Drugs to stop fitting such as Diazepam 0.2 0.4mg/kg intravenously slowly over 5 minutes
repeated after 10 minutes if required, or 2.5mg 10mg rectally. CASEVAC decision points
Transport CVS signs and symptoms Treatment guidelines 12d
Early or mild toxicity: tachycardia and rise in blood pressure. This will usually only occur if
Section 5 there is adrenaline in the local anaesthetic. If no adrenaline is added then bradycardia with
hypotension will occur. General advice
Pathways
Severe toxicity: usually about 4 7 times the convulsant dose needs to be injected Treatment guidelines 12e
before cardiovascular collapse occurs. Collapse is due to the depressant effect of the local
Supporting Guidelines anaesthetic acting directly on the myocardium. Bupivacaine is considered to be more
cardiotoxic than lignocaine.
Section 6 Also see Treatment Guideline 1b and 10d
Toolbox
Section 7
Section 8
Policies
Section 9
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Intro
Introduction Introduction
Treatment
Introduction Treatment Guidelines 12 Guidelines
Section 1 Purpose
Musculoskeletal (MSK) Clinical Guidelines for Operations (CGOs) are intended to guide
Preparation primary care clinicians in the management of common clinical conditions arising from injury
to the musculoskeletal system. This guidance is based on evidence-based best practice
Section 2 and addresses the challenges of delivering the most appropriate management within the
constraints of the operational environment.
Incident management
Target Audience
The target audience is the primary care team: medical technicians (CMTs/MAs), nurses and
Section 3
doctors working in primary care who may only have had limited training in managing these
conditions. It will guide them when they do not have early access to the rehab team, to ensure
Treatment guidelines the patients get the right early management and assist with decision-making on whether to
move the patient on or manage locally.
Section 4
Structure
Transport The structure of this document is as follows:
Section 12 covers generic principles of MSK injury management and operational constraints.
Section 5 Intentionally blank Section 13 covers the clinical care pathways for the main acute MSK injuries.
Pathways Section 14 covers the clinical care pathways for the common chronic MSK conditions
presenting on operations.
Supporting Guidelines Section 15 gives you the background references for these guidelines.
How to use these guidelines
Section 6
Musculoskeletal injuries are the commonest presentation to the primary care team on
operations or exercise. Many patients, if managed early and appropriately, can remain in the
Toolbox
field and fit for role.
Section 7 Section 12
Gives you the background and general information on managing MSK injuries and
Operational formulary presentations:
The signs and symptoms of an acute injury.
Section 8
Principles of managing acute MSK injuries in the field.
Policies Which pain relief to use and when.
What you need to consider before requesting a CASEVAC.
Section 9 Generic exercise advice.
Section 10
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Section 13
Focuses on the four commonest areas of acute MSK injury: ankle, knee, back and shoulder.
Signs and symptoms of acute 12a
MSK injury
Treatment
What to consider and to look for. Guidelines
Introduction How best to manage them.
Section 1
Exercise programme to advise.
Section 14
Treatment Guidelines 12a
Preparation Covers the commonest chronic MSK presentations on operations. Many of these conditions An acute injury is a new injury or a new episode of an old injury. When
may be chronic, but the demands of the operational environment may stir them up. Early managing these injuries, you should consider the following.
Section 2 treatment and advice will maximise their chances of staying on the ground and fulfilling
their role.
Incident management Mechanism of injury Heat
Section 15
Most joints have a recognised pattern of Acute injury causes bleeding within the
Gives you the references should you want further information on any of the content in injury that will result in damage to soft area of the injury and this produces heat.
Section 3 these guidelines. tissues around the joint. Beware the injuries Remember infection also causes heat.
caused by significant trauma or force.
Section 4
Deformity Redness / colour
Transport
This can be a sign of either severe soft Often associated with acute injury will
tissue injury (as in a dislocation) or of be a change in colour of the skin. A red
Section 5 bony injury. No deformity is a good sign. area (erythema) will be associated with
increased heat as well.
Pathways
Pain Range of movement
Section 6
Acute injuries are almost always associated Acute injuries are often stiff so there may
with sudden onset of pain around the injury. be a reduced range of movement.
Toolbox Pain can be severe initially but then settle
quite quickly. Some movements of an injured
joint will be more painful than others.
Section 7
Swelling Gait
Section 8 Swelling can occur either within the soft An injury will often cause the patient to limp
tissues (soft-tissue swelling) or within a joint with a painful gait.
Policies (effusion). Early joint swelling often means
significant internal damage.
Section 9
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Management of acute MSK injury Pain relief 12b-c
Treatment
Introduction Treatment Guidelines 12b Treatment Guidelines 12c Guidelines
Section 1 Acute MSK injuries will be painful, often swell and will limit use. Best practice is to apply the PARACETAMOL
P.R.I.C.E GUIDELINES below for any acute injury, with the aim of preventing swelling, reducing
Is a good, safe drug for pain relief (analgesia).
Preparation pain and speed up healing.
NSAIDS (NON-STEROIDAL ANTI-INFLAMMATORY DRUGS)
Section 2 Ibuprofen and Diclofenac are no better for pain relief in most MSK injuries than Paracetamol
Apply P.R.I.C.E. ....... and avoid H.A.R.M. and have a higher side-effect profile. NSAIDs have other properties that can be useful in some
Incident management MSK injuries (when it is beneficial to modulate the inflammatory response).
Section 3 and remember..NO NSAIDs on an empty stomach

P.R.I.C.E. guidelines avoid H.A.R.M
This table will help you to select the most appropriate pain relief:
PROTECT NO HEAT
Section 4
Protect the injured area and This will encourage
Transport prevent further injury. bleeding, not reduce it. Type of Injury Recommended Avoid
Section 5 REST NO ALCOHOL
Pathways Relative rest of the injured joint/ This will also make Acute joint injuries NSAIDs COX-2s
muscle will reduce blood flow and any bleeding into the
Supporting Guidelines swelling. injury worse.
Acute tendon injury NSAIDs
Section 6 ICE NO RUNNING
Toolbox Cooling an injury will help prevent This will delay healing Muscle Injury Paracetamol NSAIDs
swelling by reducing blood flow. and make the injury
Section 7 worse.
COMPRESSION Back Pain Paracetamol and NSAIDs
Applying a firm, elastic bandage NO MASSAGE
will compress the injured area, Massage and heat
Section 8 Fractures Paracetamol or stronger NSAIDs
again with the aim of preventing rubs will also make the
Policies swelling. bleeding worse in the
first two days.
Chronic Tendinopathy Paracetamol NSAIDs
Section 9 ELEVATION
Documentation and audit Elevate the injured area, ideally
above the level of the heart. DOMS (Muscle soreness) NSAIDs
Section 10
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CASEVAC decision points General exercise advice 12d-e
Treatment
Introduction Treatment Guidelines 12d Treatment Guidelines 12e Guidelines
Section 1 Factors that you should consider before requesting a CASEVAC. Each section has specific exercise advice for that injured part of the body.
Preparation
Section 2 IMMEDIATE ACTION The following generic

DRILLS advice can however be If symptoms improve with
Incident management
applied to all patients you the exercises, gradually
Patients unable because of injury progress as advised, and
Section 3 see with MSK injuries:
to perform Immediate Action Drills you can do more.
should be considered for early All exercises must only be
Treatment guidelines performed within a pain free
CASEVAC.
range:
Section 4 WEAPON HANDLING
Go to pain, not through
Transport Can the patient handle their personal pain.
weapon safely and effectively?
Section 5 SUSPICION OF INFECTION If stretching tight muscles, If symptoms do not
warm them up first. improve, but more
Pathways Any patient with a systemic infection importantly do not get
(any cause) and a hot swollen joint If trying to improve range
any worse, continue with
Supporting Guidelines (in the absence of a clear mechanism of movement in a tight joint
the exercises.
of injury) should be considered for (eg ankle), ICE first, as it will
Section 6 help with the pain.
CASEVAC urgently.
Toolbox HELICOPTER/TRANSPORT Try and get the patients
AVAILABILITY walking normally as early as
Section 7
Is CASEVAC transport available within possible.
Operational formulary the 3 days? Make a decision on Advise all patients to do If symptoms worsen,
whether patient should leave location balance exercises, as early either during or after
Section 8 early. exercise, stop doing that
as possible.
specific exercise.
Policies ROLE
When advised to do an
Is the individual in a role that can be exercise slowly, unless
Section 9
undertaken despite injury? Discuss specifically advised;
Documentation and audit with Chain of Command and RMO or hold for a count of ten.
senior medic.
Section 10
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Intro F Acute injury management Contents
Treatment
Section 1
Ankle
Section 2
Knee
Incident management Treatment guidelines 13b
Section 3
Back
Section 4
Shoulder
Transport Treatment guidelines 13d
Section 5 Intentionally blank
Pathways
Section 6
Toolbox
Section 7
Section 8
Policies
Section 9
Section 10
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Intro
Acute ankle injury Acute ankle injury 13a
Treatment
Introduction Treatment Guidelines 13a Treatment Guidelines 13a Guidelines
Section 1 MILD MODERATE/SEVERE

Preparation
MECHANISM OF TREATMENT
INJURY Pain 1-10 1-3 4-10
Section 2 Commonly an inversion PROTECT
injury (sole of foot turns Functional immobilisation with Swelling Mild Moderate / severe
Incident management a rigid ankle brace (eg Aircast
inwards - going over
your ankle). Air-Stirrup) if available and Gait Normal/mild limp Limp/unable to walk
Section 3
crutches may be required.
Treatment guidelines PAIN Movement Mild loss Moderate/severe loss
range
Felt immediately on REST
Section 4 injury and usually Limit weight bearing, avoid
localised to the outside HARM, try not to walk too much. Consider
Transport early
(lateral) of the ankle. For CASEVAC -
severe injuries pain may ICE see
Section 5
also be felt on the inside 10 mins of ice, 10 mins off, decision
Pathways (medially). points
10 mins on (intermittent
application) repeat every 2
Supporting Guidelines SWELLING hours if possible, but at least 4 x
Can be localised to the daily. Use any of the ice options Start PRICE treatment & exercises on page 184
Section 6 area of injury but often available. Improvise.
Toolbox the whole ankle will be
enlarged and swollen. COMPRESSION
Section 7 Use a non-adhesive elasticated Reassess - 3 days
COLOUR CHANGE
Operational formulary bandage on 50% stretch (75%
Bruising can occur stretch over ankle), from toes to
rapidly after injury and just below knee.
Section 8
will form around the
ankle, in the sole of the
Policies ELEVATION
foot and down to the Improved No change
toes. Often an area of Raise above chest height when
Section 9
redness will occur over sitting down. Lying on your
Documentation and audit the lateral ankle within front with knees bent is good for
24 hours. ankles. Continue ankle exercises CASEVAC when available
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Acute ankle injury Acute ankle injury 13a
Treatment
Section 1 Ankle: Dorsiflexion / Plantarflexion Ankle: Strengthening

Preparation Remember..go to pain, not through pain. Remember..go to pain, not through pain.
Section 2
Incident management
Section 3
Section 4
Starting position Action Starting position Action
Transport Lying or sitting, leg supported. Hold the stretch for 5 secs. Lying or sitting and improvise with a Hold the stretch for 5 secs.
Slowly pull the foot up towards you. Slowly push the foot down - hold for 5 secs. towel or t-shirt to pull against. Slowly push the foot down - hold for 5 secs.
Section 5 Progression Reps/Sets Progression Reps/Sets

Push a little further each set and use 3 x 10 Repetitions. Push your injured foot against your 3 x 10 Repetitions.
Pathways a strap under the ball of the foot to At least 4 times daily. At least 4 times daily.
good foot if no towel available.
assist pull up.
Supporting Guidelines Ankle: Dorsiflexion / Plantarflexion Ankle: Knee to wall stretch

Starting Action
Section 6 position Keeping your
Stand heel down,
Toolbox facing a push your
wall. Injured knee over
Section 7 leg forward. your toes
Can be done towards
Operational formulary with boot on the wall.
if necessary.
Section 8
Starting position Action
Policies Lying or sitting, leg supported. Turn the sole of the foot in
Slowly pull the foot up towards you. then out.
Section 9 Progression Reps/Sets
Push a little further each set and use a strap 3 x 10 Repetitions.
Documentation and audit under the ball of the foot to assist pull up. At least 4 times daily. Progression Reps/Sets
Push a little further each set and use a strap 3 x 5 Repetitions. At least 4 times daily.
Section 10 under the ball of the foot to assist pull up. Hold for 10 seconds each time.
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Acute knee injury Acute knee injury 13b
Treatment
Introduction Treatment Guidelines 13b Treatment Guidelines 13b Guidelines

Preparation
MECHANISM OF PROTECT
Immobilisation is usually not Pain 1-10 1-3 4-10
INJURY
Section 2 required as swelling will limit
Often a twisting injury, Swelling None / Mild Moderate / severe
range of movement. Crutches
Incident management
knee bent sideways or
may be required.
knee bent backwards Gait Normal / Mild limp Limp / unable to walk
Section 3 (hyperextended).
REST Movement Mild loss Moderate / severe loss
Limit weight bearing. Position of range
Treatment guidelines PAIN
Immediately on injury comfort (usually supported with Locking None Yes
Giving way
Section 4
and usually deep a slight bend) Encourage gentle
within the knee. Once movement within the painfree Consider
Transport range. early
swollen the patient will CASEVAC
Section 5 describe a constant see
throbbing pain. ICE decision
Pathways 10 mins of ice, 10 mins off, points
SWELLING 10 mins on (intermittent

Supporting Guidelines If swollen within 2 application) repeat every
2 hours if possible, but at least Start PRICE treatment & exercises on page 190
Section 6 hrs suspect serious
4 x daily. Use any of the ice
internal knee injury.
Toolbox options available. Improvise.
Little or no swelling is
a good sign.
Section 7 COMPRESSION Reassess - 3 days
COLOUR CHANGE If compression can be applied
immediately after injury then it
Early bruising is rare
may prevent significant swelling.
Section 8 but redness may occur.
50% stretch above and below
Policies knee, 75% stretch over knee.
HEAT Improved No change
Section 9 Acute swollen knee will ELEVATION
be warm to touch.
Documentation and audit Elevate in position of comfort
(patient will need to lie flat). Continue knee exercises CASEVAC when available
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Acute knee injury Acute knee injury 13b
Treatment
Section 1 Knee: Heel glides - lying Knee: Strengthening - static quads

Section 2
Incident management
Section 3
Section 4
Transport Sit with injured leg straight out in front. Slowly bend knee, dragging heel towards you, Lying with knee supported on rolled up towel Tighten the thigh (quads)
Use a smooth surface and a rolled tubigrip then slowly push foot away. Finish with knee or sitting. muscles to straighten the knee.
(or similar) under the foot. as straight as possible again. Progression Reps/Sets
Section 5
Progression Reps/Sets Tighten quads and then raise leg 3 x 15 repetitions.
Pathways Try and increase the bend with each set. 3 x 10 Repetitions. if not too painful. At least twice daily.
At least 4 times daily.
Supporting Guidelines Ankle: Heel glides - sitting Knee: Prone lying - bending knee against gravity
Section 6
Toolbox
Section 7
Section 8
Policies Same exercise as above, but start sitting on a Slowly slide the foot Lie on your front with your thigh supported Bend your knee as far as possible
chair. Sit forward in the chair if possible. back and forwards. on a rolled up towel/pillow. Allow gravity to and then allow slowly
Section 9 straighten your knee. to straighten again.
Progression Reps/Sets
Try and increase the weight through the knee 3 x 10 Repetitions. Progression Reps/Sets
Documentation and audit on each set. At least 4 times daily. Bend the knee a bit more each time. 3 x 10 Repetitions.
At least twice daily.
Section 10
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Acute back injury Acute back injury 13c
Treatment
Introduction Treatment Guidelines 13c Treatment Guidelines 13c Guidelines
Section 1
MILD MODERATE SEVERE
Preparation
MECHANISM OF PROTECT / REST
INJURY Position of comfort may be Pain 1-10 1-3 4-6 7-10
Section 2 lying on front or side lying with
Often a twisting or
knees bent to chest. Regular Movement
Incident management
lifting injury, but may range Mild stiffness Moderate loss Unable to
periods of rest to unload spine. move
be after a bad fall
Avoid long periods of sitting and Radiation of Thighs / Severe often
Section 3 from height. pain Local pain only
buttocks down leg
aggravating movements.
Treatment guidelines PAIN Gait Slow Painful Unable to walk
ICE
Sudden onset of
Section 4 Ice can help but this is the Red Flags None None Any
pain during lifting or
ONE time when HEAT can
Transport twisting activity. Can
reduce muscle spasm and pain.
be localised to low
Improvise.
Section 5 back either centrally or
on either side. Reassess - 3 days
Pathways COMPRESSION
SWELLING Compression is not possible, but
Supporting Guidelines None visible. taping may provide support to
the lower back & help relieve pain. Start PRICE treatment & exercises on page 192
Section 6
COLOUR CHANGE
Toolbox ANALGESIA
Rarely, although may
Early pain relief - regular
Section 7
be late bruising.
Paracetamol and NSAIDs
encourage early movement
Operational formulary STIFFNESS Improving No change
An acute back will
Section 8 often stiffen very
quickly.
RED FLAGS
Policies Requiring early CASEVAC:
Continue knee exercises CASEVAC when available
Section 9 Difficulty passing urine / faecal
incontinence Consider early
Documentation and audit Pins & needles between legs CASEVAC
Severe pain down both legs see
Section 10 decision points
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Acute back injury Acute back injury 13c
Treatment
Section 1 Spine: Humps and dumps Spine: Flexion in lying

Preparation
Section 2
Incident management
Section 3
Section 4 Starting position Action Starting position Action:

On your hands and knees. Slowly push your belly button towards the Lie on your back, knees slightly bent. If very Slowly bring your knees up to your chest
floor. Then move in the other direction stiff, use heat on spine first to ease spasm.
Transport Progression using your arms to assist.
and tuck your tailbone underneath you Improvise. Gradually move them back down.
Push a little further each set as pain allows.
and suck your belly button in. Progression
Section 5 Reps/Sets:
Reps/Sets Try and move a bit further each time but
3 x 5 -10 as pain allows. 3 x 5 -10 repetitions as pain allows.
Pathways avoid pain.
At least twice daily. At least twice daily.
Spine: Rotation in lying Spine: Extensions (over towel)

Section 6
Toolbox
Section 7
Section 8
Policies Lie on your back, knees slightly bent. Roll your legs/knees slowly to one side Lie on your front with a towel under your Slowly straighten your arms,
Keep your feet on the floor/cot bed. then the other side. pelvis. Place your hands ready to keeping your pelvis on the floor
Always pause in the middle. do a press-up. and your buttocks relaxed.
Section 9 Progression
Roll your legs/knees further each set. Reps/Sets Progression Reps/Sets
Documentation and audit 3 x 5 -10 repetitions as pain allows. Push a little further each set and 3 x 5 - 10 repetitions as pain allows.
At least twice daily. remove the towel. At least 4 times daily.
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Acute shoulder injury Acute shoulder injury 13d
Treatment
Introduction Treatment Guidelines 13d Treatment Guidelines 13d Guidelines

Preparation
MECHANISM OF TREATMENT
INJURY Pain 1-10 1-3 4-10
Section 2
Fall on outstretched PROTECT / REST
arm/ shoulder, arm Immobilisation in position of Swelling Mild / none Moderate / none
Incident management forced back (when comfort (forearm across chest).
overhead), or direct fall You may have to improvise a Movement
Mild loss Moderate/severe loss
Section 3 onto shoulder). sling to support the arm.
range
Treatment guidelines DEFORMITY Deformity None Obvious

Acromio-clavicular ICE
Section 4 joint (ACJ) may be 10 mins of ice, 10 mins off,
more prominent or 10 mins on (intermittent Consider
Transport early
flattening of shoulder application) repeat every CASEVAC -
Section 5 if shoulder dislocated 2 hours if possible, but at least 4 see
(compare with other x daily. Use any of the ice options decision
Pathways shoulder). Check distal available. Improvise. points
pulses if dislocated.
Supporting Guidelines PAIN COMPRESSION
Immediately on injury Not possible. Start PRICE treatment & exercises on page 196
Section 6
and usually deep
Toolbox within the shoulder. ELEVATE
Try and keep upright and
Section 7 SWELLING avoid lying down. Reassess - 3 days
Only swelling visible
Operational formulary will be over ACJ.
Section 8 COLOUR CHANGE
Early bruising is rare.
Policies
Redness may occur. Improved No change
Section 9
HEAT
Documentation and audit Acute swollen shoulder
may be warm to touch. Continue ankle exercises CASEVAC when available
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Acute shoulder injury Acute shoulder injury 13d
Treatment
Section 1 Shoulder: Pendular exercises Shoulder: Resisted movements

Preparation Starting Action
position Slowly swing
Sit or stand, your arm
Section 2
leaning forwards and
forward. back, side to
Incident management
Let your side or make
arm drop circles. Let
Section 3 below you. gravity help.
Section 4 Starting position Action

Stand against a wall with Gentle push against the wall.
injured arm straight.
Transport Reps/Sets
Progression 3 x 10 repetitions.
Section 5 Bend elbow and try and rotate the arm At least twice daily.
Progression Reps/Sets outwards. Repeat for inwards. Hold for 10 seconds.
Gradually increase the size of the circles 2 x 1 minute in each direction as pain allows.
Pathways
and /or swing. At least 4 times daily
Supporting Guidelines Shoulder: Active assisted movement Shoulder: 4-point kneeling

Section 6
Toolbox
Section 7
Section 8
Policies Starting position Action Starting position Action

Take hold of a stick/pole in both hands, With help from the good arm, On hands and knees with Gradually transfer weight
keeping your elbows straight. Just clasp slowly lift your injured arm straight arms. onto the injured arm.
Section 9 injured arm with good hand if necessary. forward or sideways.
Documentation and audit Progression Reps/Sets Try lifting all weight off 3 x 5-10 repetitions.
Try and increase the movement 3 x 10 repetitions. your good arm. At least twice daily.
with each set. At least 4 times daily.
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Intro F Chronic injury management Contents
Treatment
Section 1
Ankle / Achilles
Preparation
Ankle bracing and taping
Section 2 Treatment guidelines 14a
Incident management
Knee
Section 3 Treatment guidelines 14b
Back
Section 4 Treatment guidelines 14c
Transport
Shoulder
Section 5 Intentionally blank Treatment guidelines 14d
Pathways
Section 6
Toolbox
Section 7
Section 8
Policies
Section 9
Section 10
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Chronic ankle / achilles pain Chronic ankle / achilles pain 14a
Introduction
Treatment Guidelines 14a Treatment Guidelines 14a
Treatment
Guidelines
Section 1 Ankle: Resisted plantarflexion

Preparation
HISTORY TREATMENT Remember..go to pain, not through pain.
Mild acute injury in
Section 2 the past which has ACTIVITIES
not got better. Avoid aggravating
Incident management activities if possible.
No swelling or only
mild swelling.
Section 3
Painful Achilles or PAIN RELIEF
Treatment guidelines pain in the ankle. Start pain relief. See chart on
page 177.
Section 4 Not keen to squat
but can walk OK. Starting position Action
Transport
EXERCISE Lying or sitting leg supported. Push your foot down against resistance.
May feel unstable. Start exercise programme. Slowly push the foot down.
Progression
Section 5 Increase the resistance that you are applying Reps/Sets
SO WHAT MIGHT Inform patient to stop if any 3 x 10 Repetitions. Twice daily.
through the band.
BE GOING ON? exercises are too painful or make
Pathways
their symptoms worse. Ankle: Calf stretches
Achilles
Supporting Guidelines Tendinopathy
(pain at the back of
TAPING
Section 6 Try taping is ankle unstable
the ankle).
or weak.
Toolbox Chronic lateral ankle
sprain (pain at
Section 7 the side/deep pain).
Section 8 Starting position Action

Standing leaning against a wall. Hold the stretch and
Policies Injured leg to the rear. Keep your then bend your knee
back leg straight with your heel down. and drop down.
Hips forward. Reps/Sets
Section 9
Progression Hold stretch for 10 seconds
Documentation and audit Repeat with both knee straight and repeat 5 times.
and knee bent. At least 4 times per day.
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Chronic ankle / achilles pain Chronic ankle / achilles pain 14a
Treatment
Section 1 Ankle: Calf Raise Ankle: Balance

Section 2
Incident management
Section 3
Section 4
Transport Standing with weight on painful leg only. Raise up onto your toes. Standing on the painful leg Use your uninjured leg to slowly
Progression Reps/Sets place a few objects on the floor. reach out to the objects.
Section 5 Perform the exercise at a slower speed. 3 x 15 Repetitions. Progression Reps/Sets

Do not bounce. Twice daily. Move the objects 5 minutes.
Pathways further away. At least twice daily.
Ankle: Knee to wall stretch Achillies loading: Double leg

Starting Action
Section 6 position Keeping your
Stand facing heel down,
Toolbox a wall. push your
Injured leg knee over
forward. your toes
Section 7
Can be done towards
the wall.
Operational formulary with boot on
if necessary.
Section 8
Policies Standing with toes on the edge of a step. Slowly lower your heels towards the floor.
Section 9 Repeat with knees bent also. 3 x 10 repetitions.
Do not bounce. At least twice daily.
Documentation and audit Progression Reps/Sets
Move toes further from wall. 3 x 5 repetitions.
Section 10 At least 4 times daily.
Hold for 10 seconds each time.
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Chronic ankle / achilles pain Ankle bracing and taping 14a
Treatment
Section 1 Ankle: Balance

Remember..go to pain, not through pain. Acute ankle
Preparation
For acute ankle injuries (P 10), the best
ankle brace is the Aircast Air-Stirrup TM.
Section 2
This can be applied early in the first few
Incident management
days after an acute injury to help
Section 3
restrict sideways movement
(particularly inversion), but should not
Treatment guidelines restrict other ankle movements.
Section 4 It can be applied over a compression

Starting position Action bandage but it is too bulky to get inside
Stride standing as shown. Slowly lower your back knee
Transport a military boot.
Injured leg forward. towards the floor
Section 5 Progression Reps/Sets Chronic ankle

Perform the movement 3 x 10 - 12.
more slowly. At least twice daily.
For chronic ankle injuries that are
Pathways unstable (ie they keep going over them),
Achillies loading: Single leg bracing or taping the ankle can keep the
Supporting Guidelines patient mobile and doing their job.
Section 6 The best brace for these ankles is the
Toolbox Aircast Sport-Stirrup TM. This can be
applied directly onto skin and can be
Section 7 worn inside a military boot.
Operational formulary Remember to continue the exercises

(particularly for balance), even when
Section 8 wearing the brace.
Policies Standing on injured leg Slowly lower your heel to the floor. Ankle taping
with toes on edge of step. Use your good leg to come back up.
Taping can be very effective in
Section 9 Progression Reps/Sets supporting an unstable ankle and
Repeat with knees bent also. 3 x 10 repetitions.
Documentation and audit At least twice daily. allowing the patient to continue
in their role.
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Ankle bracing and taping Chronic knee pain 14a-b
Treatment
Introduction Treatment Guidelines 14a Treatment Guidelines 14b Guidelines
Section 1
KEY THINGS TO STEP 1
Preparation REMEMBER Prepare and If a patient TREATMENT
position presents with
WITH TAPING ACTIVITIES
Section 2 Dry skin and shave chronic knee pain,
Some people are if hairy
consider Avoid aggravating
Incident management allergic to tape so check Keep foot in neutral,
first pulling toes up the following: activities if possible.
Section 3 The best size of tape for STEP 2 HISTORY PAIN RELIEF
most adult ankles is 3.8 Anchor
Treatment guidelines Tape to tape Gradual onset but Start pain relief. See chart on
cm (1 1/2) may be required no acute injury. page 177.
Section 4 Tape does not stick to if sweaty/damp
No swelling or only
Transport
wet or moist skin (but STEP 3 mild swelling. EXERCISE
tape sticks well to tape!) Apply two or Start exercise programme.
Pain but not giving
Section 5 Tape will stick to hairs three stirrups
way or locking. Inform patient to stop if any
so shave the area Start on the inside
exercises are too painful or make
Pathways before if possible Take care not to Not keen to squat
have but can walk OK. their symptoms worse.
Tape can remain on the any folds in the tape
skin for up to three days Lift tape up to SO WHAT MIGHT
Section 6 but the skin may begin anchor
BE GOING ON?
to degrade STEP 4 (Optional)
Toolbox Anterior knee pain
Take care when Add a Figure 6 for
extra support (patella-femoral
Section 7 removing tape: joint or patellar
Start on the inside
Apply counter-traction again tendinopathy).
with your other hand on Once under foot, Runners knee
the skin come across the
(Ilio-tibial band
Section 8 front of ankle
Do not just pull the back to where you friction syndrome).
Policies tape off or you will started
Cartilage (meniscal)
remove skin as well STEP 5 tear, if mild.
Section 9
Tape can be applied on Final anchor
Documentation and audit top of an elasticated This will hold all the
bandage if required tape in place
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Chronic knee pain Chronic knee pain 14b
Treatment
Section 1 Knee: Quadriceps stretch Knee: Single leg squat

Section 2
Incident management
Section 3
Section 4
Transport Standing and holding foot and Slowly pull your heel towards Standing with weight Keeping your back straight slowly
ankle behind you. your bottom. on painful leg only. bend your knee. Keep you hips level and
Progression Reps/Sets Progression avoid twisting your leg.
Section 5
Try and increase the stretch 5 Repetitions of 10 second holds. Gradually add weight if pain free Reps/Sets
Pathways with each repetition. Every two hours (when possible). (2.5kg at a time). 3 x 12 - 15 repetitions.
Twice daily.
Knee: Double leg squat Knee: Step downs
Starting
Section 6 position
Standing
Toolbox with feet
just under
shoulder
Section 7
width apart.
Section 8
Action
Policies Keeping your back straight bend both knees.
Stand on a step. With your good leg out in front slowly bend
Keep your weight towards you heels.
Progression your standing leg until your good leg almost
Section 9 Reps/Sets touches the floor. Keep your back straight.
Move toes further from wall.
3 x12-15 repetitions.
Reps/Sets
Documentation and audit Progression Twice daily.
3 x 12 - 15 repetitions.
Gradually add weight if pain free Twice daily.
Section 10 (2.5kg at a time).
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Chronic back pain Chronic back pain 14c
Treatment
Section 1 Spine: Abdominal strengthening

Preparation
If a patient TREATMENT Remember..go to pain, not through pain.
presents with
Section 2 chronic back pain, ACTIVITIES
consider Avoid aggravating
Incident management
the following: activities if possible.
Section 3
HISTORY PAIN RELIEF
Treatment guidelines Gradual onset but Start pain relief. See chart on
no acute injury. page 177.
Section 4
Stiffness which Starting position Action
Transport improves with EXERCISE Lying on your back with knees bent and your Slowly slide your hands towards your knees
exercise / mild Start exercise programme. hands on your thighs. tightening your abdominals as you do so.
Section 5 activity. Inform patient to stop if any Progression Reps/Sets
Try to reach past your knees 3 x 10 - 15 repetitions.
Pain on movement. exercises are too painful or make and sit up higher. Once daily.
Pathways
Not keen to bend their symptoms worse.
Supporting Guidelines forwards/backwards, Spine: Back strengthening
but can walk OK.
Section 6
Exclude Red Flags
Toolbox (see Acute Back Pain
P190).
Section 7
SO WHAT MIGHT
BE GOING ON?
Section 8 Mechanical low back
pain (in most cases). Starting position Action
Policies Lying on your back with Tighten bum muscles and lift hips off the floor.
Pain from a small
your knees bent. Try and keep your spine straight.
Section 9
tear in a disc.
Hold for a bit longer 3 x 10 repetitions.
Documentation and audit each time. Once daily.
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Chronic back pain Chronic back pain 14c
Treatment
Section 1 Spine: Humps and dumps Spine: Flexion in lying

Section 2
Incident management
Section 3
Section 4
Starting position Action Starting position Action:
Transport On your hands and knees. Slowly push your belly button towards the Lie on your back, knees slightly bent. If very Slowly bring your knees up to your chest
Progression floor. Then move in the other direction stiff, use heat on spine first to ease spasm. using your arms to assist.
and tuck your tailbone underneath you Improvise. Gradually move them back down.
Section 5 Push a little further each set as pain allows.
and suck your belly button in. Progression Reps/Sets:
Pathways Reps/Sets Try and move a bit further each time but
3 x 5 -10 as pain allows. 3 x 5 -10 repetitions as pain allows.
avoid pain.
At least twice daily. At least twice daily.
Supporting Guidelines Spine: Extensions (over towel)
Spine: Rotation in lying
Section 6
Toolbox
Section 7
Section 8
Policies Starting position Action Starting position Action

Lie on your back, knees slightly bent. Roll your legs/knees slowly to one side Lie on your front with a towel under your Slowly straighten your arms,
Section 9 Keep your feet on the floor/cot bed. then the other side. pelvis. Place your hands ready to keeping your pelvis on the floor
Always pause in the middle. do a press-up. and your buttocks relaxed.
Progression
Documentation and audit Roll your legs/knees further each set. Reps/Sets Progression Reps/Sets
3 x 5 -10 repetitions as pain allows. Push a little further each set and 3 x 5 - 10 repetitions as pain allows.
Section 10 At least twice daily. remove the towel. At least 4 times daily.
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Chronic shoulder pain Chronic shoulder pain 14d
Treatment
Section 1 Shoulder: Elevation Stretch

Preparation
If a patient TREATMENT Remember..go to pain, not through pain.
presents with
Section 2 chronic shoulder ACTIVITIES
pain, consider Avoid aggravating
Incident management
the following: activities if possible.
Section 3
HISTORY PAIN RELIEF
Treatment guidelines Gradual onset but Start pain relief. See chart on
no acute injury. page 177.
Section 4
No swelling or only Starting position Action
Transport mild swelling above EXERCISE On all fours with hands Slowly move you weight over your legs
the ACJ. Start exercise programme. shoulder width apart. keeping your hands still.
Section 5 Progression Reps/Sets
Pain at extremes of Inform patient to stop if any Try to stretch further with each repetition. 3 x 5 repetitions. Hold for 20 seconds.
movement or when exercises are too painful or make Do not bounce. At least twice daily.
Pathways
carrying. their symptoms worse.
Supporting Guidelines Not keen to raise Shoulder: Rotation Stretch
arm above head.
Section 6
SO WHAT MIGHT
Toolbox
BE GOING ON?
Section 7 Shoulder instability
(rotator cuff
Operational formulary weakness).
Section 8 Impingement
secondary to Starting position Action
Policies shoulder instability. Sitting or standing. Use a pole/stick to rotate your
injured shoulder outwards. Ensure that you
Section 9
Chronic ACJ sprain. Progression
keep your elbow at your side.
Try and stretch further with each repetition.
Reps/Sets
Documentation and audit 3 x 5 repetitions. Hold for 20 seconds.
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Chronic shoulder pain Chronic shoulder pain 14d
Treatment
Section 1 Shoulder: Rotation Stretch 2 Shoulder: Strengthening

Section 2
Incident management
Section 3
Section 4
Transport Sitting or standing. Use a towel/stick to pull your painful arm Sitting or standing with arm horizontal and Use a bandage or towel to resist
Progression behind your back. elbow bent. as you rotate your arm forwards.
Section 5 Try and stretch further Reps/Sets Progression Reps/Sets
with each repetition. 3 x 10 repetitions. Hold for 5 seconds. Use anything with a bit of stretch to pull 3 x 10 repetitions.
Pathways At least twice daily. against. Gradually increasing. Hold for 5 seconds.
Supporting Guidelines Shoulder: Posterior Stretch Shoulder: Strengthening
Section 6
Toolbox
Section 7
Section 8
Policies Sitting or standing with injured arm across Gradually increase the stretch by pulling up In four point kneeling (as shown) with weight Transfer your weight onto your injured arm
chest. Support with good arm. and across with the good arm. over arms. and lift your uninjured arm off the bed/floor.
Section 9 Progression Reps/Sets Progression Reps/Sets
Hold the stretch a bit longer Hold for 20 seconds. Use a bandage or towel to resist as you lift 3 x 10 repetitions.
Documentation and audit each time. At least twice daily. your arm up. This can be repeated with both Hold for 5 seconds.
arms weightbearing.
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Intro F References 15
Treatment
Section 1
References
Preparation Treatment guidelines 14
Section 2
Incident management
Section 3
Section 4
Transport
Section 5 Intentionally blank
Pathways
Section 6
Toolbox
Section 7
Section 8
Policies
Section 9
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References
Introduction Treatment Guidelines 15
Section 1
Preparation
REFERENCES
Non-steroidal anti-inflammatory drugs in sports medicine: guidelines
for practical but sensible use.
Section 2 J A Paoloni, C Milne, J Orchard, B Hamilton. Br J Sports Med 2009;43:863-
Incident management 865.
Cyclo-oxygenase-2 inhibitors; Beneficial or detrimental for athletes
Section 3 with acute musculoskeletal injuries?
S J Warden. Sports Med 2005;35(4):271-283.
Cryotherapy for acute ankle sprains: a randomised controlled study of
two different icing protocols.
Section 4
C M Bleakley, S M McDonough, D C MacAuley. Br J Sports Med
Transport 2006;40:700-705.
Effect of accelerated rehabilitation on function after ankle sprain:
Section 5 randomised controlled trial. Intentionally blank
C M Bleakley, S R OConner, M A Tully, L G Rocke, D C MacAuley, I Bradbury,
Pathways S Keegan, S M McDonough. BMJ 201;340:c1964 doi:10.1136/bmj.c1964
A systematic review on the effectiveness of external ankle supports
Supporting Guidelines in the prevention of inversion ankle sprains among elite and
Section 6 recreational players.
Dizon JM, Reyes JJ. J Sci Med Sport. 2010 May;13(3):309-17.
Toolbox DDR Best Practice Guidelines;
http://defenceintranet.diiweb.r.mil.uk/DefenceIntranet/
Section 7 Teams/BrowseTeamCategories/Orgbased/Centre/
DirectorateOfDefenceRehabilitationddr.htm
ACKNOWLEDGEMENTS
Section 8 We would like to thank everyone involved for their feedback in developing
these guidelines, especially the clinical teams at RRU Edinburgh and RRU
Policies
Catterick. For further feedback, please email: Alastair.nicol700@mod.uk
Section 9 Lt Col A M Nicol FFSEM(UK) RAMC
Consultant Sport and Exercise Medicine DMRC Headley Court
Documentation and audit Maj J G Watson MCSP RAMC
OC RRU Edinburgh
Section 10
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Introduction
Section 1
Preparation
Section 2
Incident management
Section 3
Section 4
Transport
Section 5
Pathways

Section 6

Section 7
Section 8
Policies
Section 9 Section 4
Transport
Section 10
12 3
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Intro
Transport Transport Contents
Introduction
Transport
Introduction
TRA Intro.1 TRA Intro.3

Contents
Section 1
This section grades the dependency of This section details the criteria for an
Preparation patients for their needs during inter-unit
transport, and identifies the minimal level
improvised helicopter landing site for
situations where personnel specifically
Inter-unit transfer
Section 2 of professional competence to support trained in this procedure are unavailable. Transport 1
these needs.
Incident management TRA Intro.4
TRA Intro.2
Support Helicopters (SH) are a fundamental
Safety when approaching SH to load or
unload a casualty is paramount. This section
Helicopter landing site
Section 3
component of patient transportation either describes the configuration and approach Transport 2
as a vehicle for primary retrieval of the procedures of SH regularly encountered by
undifferentiated casualty from point of UK DMS personnel on operations.
Section 4
wounding/illness, or for the secondary
transport of casualties to a facility for further Aircraft drills: CH47
Transport
investigation and/or treatment. These
functions require a different skill set for the
Transport 3
clinical staff involved. Primary retrieval requires
Section 5 clinicians with resuscitation skills focused on
the <C>ABCDE paradigm together with skills Aircraft drills: Puma
Pathways in incident scene management and patient
extrication. Secondary retrieval demands Transport 4
intensive care skills to manage the post-
Supporting Guidelines operative and/or anaesthetised patient with
Section 6
a higher level of invasive monitoring and
often multiple infusions of fluids and/or drugs.
Aircraft notes (alphabetical)
Toolbox Transport 5
Section 7
Section 8
Policies
Section 9
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Inter-unit transfer 1
Transport 1
Transport
Introduction
Section 1 Levels of dependency

There are four levels of dependency for transport:
Preparation
1. Critical Care High Dependency
Section 2 2. Critical Care Medium Dependency
Incident management 3. Non-Critical Care Low Dependency
4. Non-Critical Care Minimal Dependency
Section 3
Level 1: High dependency
Treatment guidelines These are patients who require intensive support during transit including any combination
of ventilation (with SpO2 and End Tidal CO2 monitoring), arterial monitoring for Mean
Arterial Pressure, ECG monitoring of cardiac dysrhythmia, and monitoring of core temperature.
Section 4
Thesepatients may be unconscious or sedated/anaesthetised.
Transport An intensivist is required to provide this level of care, supported by a nurse
trained in both critical care and in-transit care.
Section 5
Intentionally blank
Level 2: Medium dependency
Pathways These are patients who do not require intensive support, but do still demand regular monitoring
and whose condition may deteriorate during transport. Patients include those requiring a
Supporting Guidelines combination of oxygen administration, one or more intravenous infusions (including syringe
driven drug and fluid administration), and multiple drains or catheters.
Section 6 An intensivist is required to provide this level of care, supported by a nurse
trained in both critical care and in-transit care.
Toolbox
Level 3: Low dependency
Section 7
These are patients whose condition is not expected to deteriorate during transit, but who require
Operational formulary nursing care or management of simple oxygen therapy, continuation of an intravenous infusion,
and/or a urinary catheter.
Section 8 Medical technicians and non-specialist nursing staff are suitable for this task.
Policies Level 4: Minimal dependency

These are patients who do not require nursing attention in-transit, but who might need
Section 9 assistance with mobility or bodily functions.
Documentation and audit Medical technicians and non-specialist nursing staff are suitable for this task.
Section 10 Principal source: Army Medical Directorate Doctrine Note 335 Medical Evacuation Regiment (V)
(this updates AMS Core Doctrine Volume 4, Part 1 Pre-Hospital Care)
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Helicopter landing site Helicopter landing site 2
Transport 2 Transport 2 (Contd)

Transport
Introduction
Section 1 Selection Marking by day
Preparation This is the recommended landing site preparation H

when the exact details of the aircraft are unknown
Section 2
Incident management
Section 3
Section 4
Transport will be visible)

securely OR (vehicle roof beacons
OR
Section 5 60m
15m
Pathways 100m
Section 6
Toolbox
Section 7
Section 8 1 metre = 1 pace

All areas must be cleared
Policies of loose objects
OR OR
Section 9
Documentation and audit Ideally ground should be level:

if sloping, slope should be
Section 10 uniform and <10
Reference: Hodgetts T, Porter C: Major Incident Management System. BMJ Books. London (2002)
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Helicopter landing site Aircraft drills: CH47 2-3
Transport 2 (Contd) Transport 3

Transport
Introduction
Section 1 Marking by night Peacetime configuration

When used for casualty transfer in peace a stretcher fit will be used.
Preparation
24 stretcher casualties may be transported in this role.
Section 2 Operational configuration

10m Approach When used for emergency CASEVAC stretchers are placed on the floor and secured by
Incident management strops.
10m 10m
path
A maximum of 10 stretcher casualties may be transported in this role (but less if
Wind
Section 3 X acombination of stretcher and walking/sitting patients are transported).
10m 5m
Light
Section 4
Transport
X Touchdown
Use lights (torches, chemiluminescent light-sticks but
Load
not blue light) of equal intensity to form a letter T
Section 5 1 metre = 1 pace
Pathways
Supporting Guidelines 1 metre = 1 pace
Section 6 Approaching the aircraft

Toolbox Approach path 35m
Follow the instructions from the Loadmaster
35m
Wind Approach the rear of the aircraft

Section 7 Standard approach on operations is 45 & 78 oclock
Section 8
Policies or use vehicles (cars, not lorries) with beam headlights
Section 9
In an emergency a light-stick (infrared in tactical situations) can be
Documentation and audit attached to a long string and swung overhead to create a buzz saw
effect visible from the air
Section 10
Reference: Hodgetts T, Porter C: Major Incident Management System. BMJ Books. London (2002)
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Aircraft drills: Puma Aircraft notes (alphabetical) 4-5
Transport 4 Transport 5
Transport
Introduction
Section 1 Peacetime configuration Blackhawk

When used for casualty transfer in peace a stretcher fit will be used. Medical teams need to be familiar with all helicopters supporting them, including those
Preparation 6 stretcher casualties may be transported in this role. of coalition forces. One of the most commonly encountered by UK forces is the
Blackhawk.
Section 2 Operational configuration
The Blackhawk may be fitted for dedicated CASEVAC role, in which case it will have a
When used for emergency CASEVAC the stretchers are placed on the floor and secured stretcher carousel which can take six stretchers (and one seated casualty). The aircraft
Incident management by strops. can be awkward to load if unfamiliar with the process. Medics should closely follow the
A maximum of 3 stretchers may be transported in this role (but if walking patients are instructions given by the crew. Once the carousel is loaded and doors closed, it may be
Section 3 on board only 1 stretcher can be transported). impossible to move from one side of the carousel to the other. It is therefore crucial that
some thought is given to where the individuals of a medical team position themselves
Treatment guidelines for flight.
Blackhawks without the stretcher carousel fitted will take fewer casualties (usually four
Section 4 stretcher or up to seven seated casualties), being limited by the aircrafts specific role
at the time of tasking.
Transport Chinook (CH47)
The Chinook is a tandem rotored medium lift helicopter designed to operate in all weather
Section 5
conditions. It has multiple uses and configurations. With removal of seats, up to ten
stretchers can be secured directly to the floor although in practice this leaves minimal
Pathways room to move around and work effectively. Of particular note with the Chinook are the
following points:
Supporting Guidelines 10 oclock At the front of the aircraft, the front rotor disc can drop as low as 1.3m on level
ground.
Section 6 The exhaust gases from the engine and auxiliary power unit are very hot and are
Approaching the aircraft blown directly to the rear of the aircraft. Loading and unloading is therefore in the
Toolbox 2 oclock 4/5 oclock and 7/8 oclock positions, 6 oclock being avoided where possible.
Wait for the thumbs up sign
The Chinook is a particularly noisy aircraft and hearing protection is a must for all
Section 7 from the Pilot or Loadmaster passengers, including casualties.
before approaching from the
Operational formulary 10 or 2 oclock position Gazelle
The Gazelle is a single rotored helicopter, most commonly used in surveillance role
Section 8 operationally. It can be fitted to carry a single stretcher casualty, although the medical
carer has very poor access during flight. It takes time to configure the aircraft for the
Specific hazards stretcher role (port side pilots seat and flying controls need to be removed). The Gazelle
Policies
Left or right mounted door gun can alternatively take three sitting casualties.
Section 9 Rear-mounted chaff and flares Lynx

The Lynx is a single rotored helicopter with a number of operational roles. It can carry
Documentation and audit up
to nine seating casualties if troop carrying seats are fitted or up to three stretcher
Section 10 casualties, usually on the floor. Space is very limited when carrying stretchers and in
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Aircraft notes (alphabetical)
Introduction Transport 5 (Contd)
practice it is difficult to carry, and work on, any more than two stretcher cases. Further
Section 1
restriction occurs if door guns are fitted.
Preparation Merlin
The Merlin is a single main rotored medium support helicopter. It can carry up to 16
Section 2 stretcher casualties or 24 walking casualties.
Incident management Puma

The Puma is a single main rotored helicopter. Its main role is to provide tactical support
Section 3 but it is often used in CASEVAC role. This extremely versatile aircraft can usually
accommodate two stretchers (although it can take three), six walking casualties or a
Treatment guidelines combination thereof.
Sea King
Section 4 The Sea King is a single main rotor, all weather support helicopter. The aircraft is
extremely versatile with many operational roles. In the rapid reaction role, up to six
Transport stretchers can be secured to the floor, although operationally four is more normal. Do
not approach the aircraft during engine shutdown as the blades drop dangerously low
Section 5 when not at full power.
Intentionally blank
Pathways
Section 6
Toolbox
Section 7
Section 8
Policies
Section 9
Section 10
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Intro
Introduction
Section 1
Preparation
Section 2
Incident management
Section 3
Section 4
Transport
Section 5
Pathways

Section 6

Section 7
Section 8
Policies
Section 9 Section 5
Pathways
Section 10
12 3
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Intro
Pathways Pathways Contents
Introduction Introduction Pathways
PATH Intro.1
Contents
Section 1
Pathways contains overarching guidance
Preparation for specific patterns of injury. The experienced
user (e.g. the Team Leader) may prefer this
Ballistic
Section 2 often single page aide memoire approach, Pathways 1
with cross references to other relevant sections
Incident management should additional guidance be needed.
PATH Intro.2 Blast

Section 3
This section also include a series of critical Pathways 2
care pathways designed to aid a systematic
approach to common clinical problems
Section 4
encountered on the intensive care unit.
Blunt trauma
Transport Pathways 3
Section 5
Burn
Pathways
Thermal ....... Pathways 4a
Supporting Guidelines Electrical...... Pathways 4b
Section 6 Chemical ......Pathways 4c
Toolbox
Section 7
Common critical care pathways
ICU ventilator care bundle ............... Pathways 5a
ICU neuro care bundle ....................... Pathways 5b
Section 8 Enteral feeding protocol .....................Pathways 5c
Policies Bath insulin protocol version 5.4.... Pathways 5d
Section 9 Bowel management flow chart .......Pathways 5e
Section 10
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Intro Pathways Ballistic: Role 1 1
Introduction Pathways 1 Pathways
Contents (Contd)
Section 1
Penetrating head injury
Interventions
Preparation Genitourinary Trauma and Catheters <C>ABCDE approach
Low GCS = airway at risk:
3
Go to Sec 3
Section 2 Genitourinary Trauma Role 2 & 3 ... Pathways 6a Treatment
guidelines
Incident management Genitourinary Trauma Role 4 ........... Pathways 6b Limbs

Lateralising signs = need
surgical assessment.
Urinary Catheters ..................................Pathways 6c Haemorrhage control Antibiotics
Benzylpenicillin1.2g IV/IM
Section 3 2
Go to Sec 3 Treatment
Airway injury
Medical Ethics
guidelines
If appropriate to Above cricothyroid membrane
re-examine wounds prior think cricothyroidotomy:
Section 4 Medical Ethics ........................................... Pathways 7 to surgery, redress with
3e
iodine soaked gauze and Go to Sec 3 Treatment
Transport secure with crepe bandage guidelines
Splint long bone injuries Below cricothyroid membrane

Section 5 Safe Transfusion Practice Analgesia think tracheostomy and
evacuate to surgeon
Aide Memoire for
11i
Pathways Go to Sec 3 Treatment
guidelines Chest
Safe Transfusion Practice ...................... Pathways 8 Antibiotics Pneumothorax?
Supporting Guidelines Benzylpenicillin1.2g IV/IM Haemothorax?
5ac
Fluid resuscitation Go to Sec 3
Section 6 Treatment
. Go to Sec 3
6a
Treatment Antibiotics
guidelines
Toolbox guidelines
Section 7 Abdomen
Penicillin allergy
Internal bleeding?
Clindamycin 600mg IV qds
Operational formulary Evacuate for surgery.
Consider need for NG tube.
Section 8 Antibiotics
Critical decisions
Policies
Identify time-critical injuries
Section 9
(non-compressible haemorrhage) Caveats
requiring urgent evacuation for surgery Check front and back
Documentation and audit C-collar is not required for penetrating of casualty
neck injury unless there are signs of Bullets and fragments
Section 10 abnormal neurology cross cavities
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Ballistic: Roles 2 & 3 Blast 1-2
Introduction Pathways 1 (Contd) Pathways 2 Pathways
Section 1 Perforated ear drums

Interventions Penetrating head injury Management Perforated TMs are not
Preparation Follow guidelines for Role 1
<C>ABCDE approach <C>ABCDE approach a reliable indicator that
Plus consider RSI: blast lung will develop
3c Hearing loss and/or
Section 2 Go to Sec 3
Penicillin allergy Treatment
guidelines ICRC (International balance disorder requires
Clindamycin 600mg IV qds Committee of the urgent ENT assessment
Incident management Obtain CT unless expectant (T4)
Antibiotics: cefotaxime 1g IV; Red Cross) describe
Section 3 Limbs add metronidazole 500mg IV 3 injury patterns for Pattern 3
Follow guidance for Role 1
if air sinus or middle ear an antipersonnel mine. From handling mines: deminers
clinically breached removing mines or children
Treatment guidelines plus antibiotics: Source: BMJ 1991;303:150912.
Co-amoxiclav 1.2g IV playing with them. Severe
Airway injury head, face, eye injuries
(instead of benzylpenicillin)
Section 4 Above cricothyroid membrane
or alternatively think cricothyroidotomy: Blast lung Pattern 2
cefuroxime 1.5g IV for fractures Is uncommon in
Transport + metronidazole 500mg IV for Go to Sec 3
3e Multiple fragments from mine
Treatment survivors who reach
complex compound fracture guidelines triggered near casualty
hospital
Injuries to face, head, chest,
Section 5 with soft tissue injury Below cricothyroid membrane May develop over abdomen and limbs
think tracheostomy: 2448 hours
Pathways move to emergency surgery.
Fluid resuscitation Consider rFVIIa
Chest In suicide IED consider
2d
Supporting Guidelines Go to Sec 3
6a
Treatment
Follow guidelines for Role 1 Go to Sec 3 Treatment blood sample for
guidelines Plus antibiotics guidelines
Hep B immunoglobin/
Section 6 Tetanus prophylaxis Co-amoxiclav 1.2g IV immunisation
(instead of benzylpenicillin) Pattern 1
for the non-immune HIV PEP
Usually from standing on
Toolbox Urinary catheter Abdomen buried mine
with hourly measurement Internal bleeding? Usually sustain traumatic
Section 7 for critical patients Confirm with FAST USS or DPL amputation of foot or leg Associated ballistic
Antibiotics Other leg often affected injury?
Operational formulary Co-amoxiclav 1.2g IV
One or both legs may need 1
(instead of benzylpenicillin)
amputation
Go to Pathways
Section 8 Injuries to genitalia are

Critical decisions Investigations common Associated blunt
injury?
Policies FBC
Consider absolute requirement for surgery Cross match blood Go to
3
at Role 2 Enhanced, or whether transfer Blood gases (I-STAT) Have a high index of suspicion for bowel Pathways
Section 9 to Role 3 is more appropriate for critical patients injury clinical diagnosis, ultrasound
Urea & electrolytes Associated burn?
Documentation and audit Decision must be tempered by casualtys and CT can be inconclusive: diagnostic
where indicated 4
condition, timeline to next Role, and peritoneal lavage may reveal vegetable Go to
Plain radiology/USS/CT
Section 10 anticipation of further casualties inbound where indicated matter and raised amylase/white count Pathways
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Intro
Blunt trauma Burn: Thermal 3-4a
Introduction Pathways 3 Pathways 4a Pathways
Section 1
Interventions
Blunt head injury
Low GCS = airway at risk:
Role 1 Obtain Accurate History Including
Preparation <C>ABCDE approach 3
Time of Burn Mechanism of Injury
guidelines Any First Aid Risk of inhalation Injury
Section 2 Lateralising signs = need
C-spine
surgical assessment.
Incident management Collar + head blocks
if suspect spine injury Fractured base of skull Minor burn Large burn >5% Inhalation injury
CSF leak/ panda eyes/
suspected
Section 3 Spinal injury bruised mastoid
History of exposure to fire
Loss of motor power? Special Areas BATLS primary assessment
Treatment guidelines Loss of sensation?
Airway (basic) & smoke in an enclosed
Record level NP airway can be used Face Administer high flow O2 space
Evacuate with full in head injury Evacuate T2 Site wide bore IV cannulae Hoarseness or change in
Section 4 immobilisation voice
3f Hand Administer IV morphine
Foot 1mg/ml titrated to effect Harsh cough
Transport Pelvic injury
guidelines
Perineum Stridor
Improvise a binder Airway injury
Section 5 Ex fix unstable injuries Over Moving Burns to face
Above cricothyroid membrane Assess total body surface
think cricothyroidotomy: Joint Singed nasal hairs
Limbs area (TBSA) affected
Pathways 3e
Deep burns Soot in saliva or sputum
using Rule of Nines
Haemorrhage control Go to Sec 3 Treatment
guidelines
Inflamed oropharynx
Supporting Guidelines Go to Sec 3
2
Treatment
Below cricothyroid membrane
guidelines think tracheostomy: Remaining Calculate (from time of High flow O2
Section 6 If appropriate to move to emergency surgery. minor burns burn) & initiate IV fluid Nurse sitting up
re-examine wounds prior If superficial & resuscitation using modified Monitor resp rate & SaO2
Toolbox to surgery, redress with Chest considered within Parkland Formula
iodine soaked gauze and Pneumothorax? capabilities,
secure with crepe bandage Haemothorax? dress & review
Section 7 Splint long bone injuries Flail chest? If any degree of upper
as outpatient Dress burns with clingfilm airway obstruction is present,
Analgesia 5ac Do not wrap around limbs
Operational formulary Go to Sec 3 Treatment
airway must be secured by
Lay longitudinally
Caveats
11i guidelines intubation or surgical airway
Section 8 prior to evacuation
guidelines
Check front and Abdomen
Antibiotics
For compound fractures back of casualty Internal bleeding? Evacuate
Perform BATLS secondary survey
Policies for FAST USS +/ surgery
Log roll If considered safe to transfer
Consider need for NG tube.
unintubated, nurse sitting up
Section 9 Fluid resuscitation
Evacuate >25% TBSA T1
Critical decisions
6a
Documentation and audit Go to Sec 3 Treatment
Contents
>15% TBSA T2 Evacuate T1 A
Trauma Team Activation Go to Sec 1
guidelines
Preparation
Section 10 Criteria and Roles >5% TBSA T3
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Burn: Thermal Burn: Thermal 4a
Introduction Pathways 4a (Contd) Pathways 4a (Contd) Pathways
Section 1 Role 2 Obtain accurate history including Role 3 Obtain accurate history including
Preparation Time of burn Mechanism of injury Time of burn Mechanism of injury
Any first aid Risk of inhalation injury Any first aid Risk of inhalation injury
Section 2
Incident management Minor burn Inhalation injury

Minor burn Large burn Inhalation injury Large burn suspected
suspected
Section 3 As per Role 2
As per Role 1 Special Areas
Special Areas BATLS primary survey Face
Treatment guidelines BATLS primary survey
Face Evacuate T2
Evacuate T2 Hand Thorough inspection of
Section 4 Administer high flow O2 oropharynx for damage
Ensure high flow O2 in situ Foot
Hand Nurse sitting up
Cannulated with large bore Perineum Ensure high flow O2 in situ
Transport Foot Monitor resp rate, Over Moving
IV cannulae Cannulated with large bore IV cannulae
Perineum SaO2 & ABGs Joint Administer high flow O2
Adequately analgesed using Adequately analgesed using
Over Moving Deep burns Nurse sitting up
Section 5 morphine 1mg/ml, titrated to effect
morphine 1mg/ml, titrated to effect
Joint Monitor resp rate,
Deep burns If any degree of upper Remaining minor burns SaO2 & ABGs
Pathways airway obstruction is If superficial & considered Baseline CXR
Reassess total body surface area present, airway must be Monitor FBC, U&Es, Glucose & ABGs
within capabilities, dress & Measure
Supporting Guidelines Remaining
(TBSA) affected using Rule of Nines secured by intubation review as outpatient in line For deep burns >20% hove cross Carboxyhaemoglobin
or surgical airway prior with theatre holding policy matched blood available
Section 6 minor burns to evacuation
If superficial & Monitor FBC, ABGs & U&Es Bronchoscopy
Toolbox considered within ifavailable
Catheterise patients with Burns >20 In an environmentally controlled theatre @ approx 28C
capabilities, If considered safe to Pressure support
Reassess total area burnt using Lund & Browder chart, including burn
dress & review transfer unintubated, ventilation at
Section 7 as outpatient
depth
Review Parkland Formula & nurse sitting up Escharotomies if indicated by a skilled surgeon using cutting diathermy early stages
of pulmonary
Operational formulary titrate fluid resus to urine output, Thoroughly clean wound using warm aqueous based antiseptic solution failure
haematocrit & base deficit Dress with flammacerium, paraffin gauze & gamgee secured with
Section 8 Evacuate T1 A netelast
Urgent
Policies Assess peripheral circulation
Aeromed
in affected limbs perform
Evacuate Monitor efficacy of modified Urgent Aeromed Evacuation
escharotomies if full surgical
Section 9 Parkland resuscitation regime, Evacuation
facilities available & >25% TBSA T1 titrating to urine output,
Burns >25% TBSA
Documentation and audit Evacuate T1 haematocrit & base deficit
>15% TBSA T2 Escharotomies
Monitor urine for evidence of Clinical evidence of SIRS
Redress burns with clingfilm
>5% TBSA T3 acute tubular necrosis & inc. UO Deep burns >5%
Section 10 applied longitudinally to 1.52ml/kg/hr if indicated Burns to special areas
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Intro
Burn: Electrical Burn: Electrical 4b
Introduction Pathways 4b Pathways 4b (Contd) Pathways
Section 1 Role 1 Obtain accurate history including Role 2 As RAP

Preparation Time of burn
Any first aid Confirm high flow O2
Section 2 Approx voltage Adequate IV access
Efficacy of IV analgesia
Incident management
Section 3 Full BATLS primary survey Assess arterial blood gasses, FBC, U&Es
High incidence of concurrent injury Catheterise if TBSA >15%
Section 4 Administer high flow O2

Assess efficacy of fluid resuscitation titrated against
urine output >2ml/kg/hr, haematocrit and base deficit
Transport Site wide bore IV cannulae
Administer IV morphine 1mg/m titrated to effect
Section 5 Perform 12 lead ECG and initiate continuous monitoring if abnormalities are detected
Pathways
As thermal 4a Monitor peripheral circulation in affected limbs
Go to Perform escharotomies if indicated as long as surgeon and theatre facilities available
Supporting Guidelines burn Pathways
High index of suspicion for compartment syndrome
Section 6
Assess peripheral circulation of affected limbs
Toolbox Evacuate T1 or T2 dependent on physiological parameters
Section 7
Dress burns with cling film applied Monitor FBC, U&Es, glucose, ABGs and have cross-matched blood available
Operational formulary longitudinally and elevate limbs
Section 8 Assess efficacy of fluid resuscitation against urine output,

haematocrit, base deficit, and titrate as necessary
BATLS secondary survey
Policies
Review by surgeon in a temperature controlled theatre. Electrical burns have
Section 9 potential for extensive deep tissue damage between entry and exit point
Evacuate T1 or T2 High index of suspicion for compartment syndrome in affected limbs
dependent on physical parameters /
total body surface area affected
Section 10 Monitor urine for evidence of myoglobinurea aim for urine output of > 2ml/kg/hr
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Burn: Chemical Common critical care pathways: 4c-5a
Introduction Pathways 4c ICU ventilator care bundle Pathways
Section 1
All Roles Obtain accurate history including the
Pathways 5a
Preparation agent causing the burn Is the patient ventilated and admitted to ICU?
Section 2
Nurse the patient in Contraindications/exclusions?
Incident management a semi-recumbent Spinal injury:
Phosphorus Chemical Vesicant position 40 See spinal management protocol
Section 3 4
At Role 1 All staff to wear All staff to wear
Treatment guidelines guidelines
Visible lumps removed protective equipment protective equipment

Patients requiring prone positioning
and the area irrigated BATLS primary survey BATLS primary survey
Section 4 Neuroscience patients
with H2O High Flow O2 High Flow O2 Patients with acute pelvic injury
Transport Soaked dressings Site wide bore IV Site wide bore IV
applied cannulae & administer Commence enteral
cannulae & administer
Section 5 Evacuate IV Morphine 1mg/ml IV Morphine 1mg/ml feeding at earliest
titrated to effect opportunity Contraindications?
titrated to effect
Pathways aim <12 hours Commence H2 antagonist
At Surgical Facility
Supporting Guidelines 1% Copper Sulphate
Remove visible powder / Decontaminate Patient
lumps; and maintaining prior to admission into
Soln. increases visibility
Section 6 environmental control the Medical facility Go to Section 5
5d
Remove particles irrigate thoroughly, Maintain tight Pathways
Toolbox then thoroughly flush treating used irrigant glycaemic control

Copper sulphate from as contaminated Glycaemic control protocol for ICU patients
the wound Remove Blisters and
Section 7 Alkalis require longer irrigate with a weak
irrigation than acid hypochlorite solution
Operational formulary 5h
Treat as thermal burn Administer DVT Go to Section 3 Treatment
guidelines
once decontaminated prophylaxis
Section 8 Assess efficacy of irrigation Treat as thermal burn
with litmus paper once decontaminated Low molecular weight heparin
Policies
Section 9 Treat as thermal burn

once decontaminated Maintain optimum sedation 2ab
Documentation and audit levels at all times appropriate Go to Section 7 Operational
formulary
Go to
4a to clinical condition and
Section 10 Pathways environmental circumstances Sedation guidelines
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Common critical care pathways: Common critical care pathways: 5b-c
Introduction ICU neuro care bundle Enteral feeding protocol

Incident
Section 1 Pathways 5b Pathways 5c

Preparation Is there a severe head injury and a suspicion of raised ICP? Key points
1. Use a large bore nasogastric feeding tube (NGT) when commencing enteral feeding.
Section 2
Nurse the patient in Maintain neutral head alignment, 2. Introduce feed gradually and according to flow diagram.
Incident management a head up or head avoid hip and knee flexion 3. Once feeding is established, aspirate NGT minimum of once daily.
tilt position >15 <30 4. Critically ill patients should commence feeding as soon as possible.
Section 3 5. Perform blood glucose monitoring 4 hourly.
6. Any drugs administered by NGT should be liquid and given separately from the feed
Treatment guidelines Turn patient using log roll technique to with flushing before and after with water.
ensure neutral head alignment at all times 7. To minimise aspiration, patients should be fed sat at 30 or greater.
Section 4
Transport Start feed @ 30mls/hr for 4 hours
For ventilated patients

Section 5 follow ventilator care bundle 5a
Go to
(with the exception of
Aspirate
Pathways
Pathways
semi-recumbent position)
Supporting Guidelines More than 200mls? Less than 200mls?
Section 6
Maintain PcCO2 at 4.5Kpa
Toolbox
Maintain PaO2 > 10Kpa Replace 200mls and Replace aspirate
discard the rest Increase rate by 2530mls
Section 7
for 4 hours
Maintain MAP >90mmhg Noradrenaline may be required
Section 8 (in absence of 2a Continue to feed at 30mls/hr
Go to Section 7
ICP monitoring) Operational
until 2 consecutive aspirations Aspirate 4 hourly
Policies formulary
are <200mls Increase rate by

Aspirate 4 hourly 2540mls/4 hours until
Section 9
If this does not occur prescribed rate achieved
Documentation and audit Actively cool patients to maintain
Maintain core temperature within 24 hours consider
optimum temperature ensuring
between 3637c gastric motility drugs
Section 10 peripheral shutdown is avoided
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Common critical care pathways: Common critical care pathways: 5d
Introduction Bath insulin protocol version 5.4 Bath insulin protocol version 5.4 Incident
Section 1 Pathways 5d Pathways 5d (Contd)

Preparation Exclusions
What is the latest blood glucose?
Check glucose in 30 mins.
This protocol is not suitable for patients with diabetic ketoacidosis, patients who are
Section 2 Start again from red box eating
Less than Stop Give 20ml of for next blood glucose. or children under the age of 16.
Incident management 3 mmol/L insulin 50% glucose Discuss with doctor Start protocol immediately if blood glucose rises above 7mmol/L for two consecutive
hours, or of there is a single blood glucose above 8mmol/L.
Section 3 Insulin infusion
33.9 Halve insulin Check glucose in 30 mins.
mmol/L infusion rate Start again from red box Use Insulin Actrapid 50iU in 50ml 0.9% NaCl running through a dedicated cannula or
Treatment guidelines for next blood glucose central like lumen. Round insulin infusion rate to the nearest 0.5ml/hr.
Starting rate for insulin infusion
Section 4
>2 mmol/L Inc. insulin by 1 iU/hr Blood Glucose Rate (ml/hr)
Blood glucose
Transport increased by... >12 4
12 mmol/L Inc. insulin by iU/hr
7.112 2
Section 5
<1 mmol/L No change 37 0
How much has
Pathways 47 blood glucose <3 Give 20ml 50% glucose, recheck glucose in 30 mins, discuss with doctor
mmol/L changed from <1 mmol/L No change
Supporting Guidelines previous value?
12 mmol/L Dec. insulin by iU/hr
Blood glucose testing
Test blood glucose each hour if blood glucose is more than 7mmol/l.
Section 6 Use the same blood glucose testing machine each time.
2.14 mmol/L Dec. insulin by 1 iU/hr
Blood glucose
If blood glucose is stable between 4 and 7 and the insulin dose has only changed by
Toolbox decreased by...
>4 mmol/L Dec. insulin by 2 iU/hr 1ml/hr or less in the last 2 hours, blood glucose can be measured every 2 hours.
Feeding
Section 7
Continuous feeding is recommended with this protocol. If enteral feeding is stopped,
>4 mmol/L Inc. insulin by 4 iU/hr halve the insulin infusion and measure blood glucose hourly.
Operational formulary Blood glucose
increased by...
24 mmol/L Inc. insulin by 2 iU/hr
When enteral feed is restarted, measure the blood glucose hourly and simply follow the
protocol (i.e. do not automatically increase insulin infusion when feed goes on).
Section 8
<2 mmol/L Inc. insulin by 1 iU/hr Stop protocol when patient takes food orally (even if NG supplements being given at
How much has night). Consider if insulin necessary by another route.
Policies More than blood glucose
<1 mmol/L Inc. insulin by 1 iU/hr
Other infusions (especially antibiotics)
7 mmol/L changed from
Section 9 previous value? Should be made up with water or saline if possible, or if not, with the minimum volume
12 mmol/L No change of glucose. Immunoglobulin infusion may cause over reading of blood glucose with
Documentation and audit Advantage II glucometer.
Blood glucose
2.14 mmol/L Dec. insulin by 1 iU/hr Ward discharge
Section 10 decreased by... Patients should be converted to a standard sliding scale before ward discharge. This
>4 mmol/L Dec. insulin by 2 iU/hr should always run with a glucose or TPN infusion.
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Common critical care pathways: Genitourinary Trauma Role 2 & 3 5e-6a
Introduction Bowel management flow chart Pathways 6a Pathways
Section 1 Pathways 5e Unilateral Testicular Injury

Preparation Limited debridement avoid orchidectomy
Establish feeding Perform rectal examination within 24 hours of Vaseline gauze dressing
regime admission & document in care plan
Section 2 Testes
Bilateral Testicular Injury
Incident management Impacted Soft Empty Avoid debridement or orchidectomy
Gentle saline wash + vaseline guaze dressing
Section 3
Commence senna 10ml nocte Distal Injury
Treatment guidelines Assess effect after 3 days Debridement
Urinary Diversion urethral catheter
Bowels not open Bowels open (suprapubic catheter if urethral difficult
Section 4 Penis &
Transport Urethra Proximal Injury
Perform rectal examination
Debridement
Section 5 Urinary Diversion suprapubic catheter
Impacted Soft Empty
Pathways
Debridement
Bladder & Urinary Diversion suprapubic catheter
Supporting Guidelines Continue senna
Give 4g glycerine suppository Prostate Intraperitoneal urinary extravasation
Section 6 Assess after 24 hours requires urgent closure of bladder injury
Toolbox Bowels not open Bowels open

Partial injury or small defect (<2cm)
Primary anastomosis (at laparotomy)
Section 7 Ureter
Perform rectal examination Rectum empty
Impaction regime Extensive ureteric loss/defect
1. Microlax enema Rectum full Exteriorise proximal ureter with 6-8 F NG tube
2. Phosphate enema Seek medical advice if
Section 8 no sign of obstruction
Assess after each
Stable patient
intervention
Policies CT scan conservative management
Increase senna to 20ml nocte Communicate injury grade to role 4
Section 9 Give 4g glycerine suppository Kidney
Assess after 24 hours Unstable patient
Documentation and audit nephrectomy
Seek further Bowels not open
Section 10 medical advice Bowels open
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Genitourinary Trauma Role 4 Urinary Catheters 6b-c
Introduction
Pathways 6b Pathways 6c Pathways
Section 1
Requirement for Urethral Catheter
Preparation Assessment/debridement with consultant Urologist on call
Section 2 Testes Embryologist to assist with sperm retrieval

Critically ill patient Genitourinary trauma Suspected genitourinary trauma
Endocrinologist to advise on androgen replacement (often associated with pelvic #)
Incident management
Section 3 Assessment/debridement with consultant Urologist on call Urethra Urethra ? Urethral ? Bladder
intact not intact Trauma Trauma
Treatment guidelines Penis & Formal imaging ascending and descending urethrogram
or pericathetheter urethrogram (MRI)
Urethra
Section 4 Check urinary diversion functioning urethral or
suprapubic catheter Trial of catheter (16F) (Stress
Transport gentle with lots of Cystogram)
lubricationg jelly
Assessment/debridement with consultant Urologist on call
Section 5
Formal imaging stress cystogram (MRI)
Pathways Bladder & Check urinary diversion (suprapubic catheter) functioning Extraperitoneal
failure success Intraperitoneal
Prostate and repair bladder neck injury if present bladder injury bladder injury
Supporting Guidelines If persistent urinary leakage then consider bilateral
nephrostomies (interventional radiology)
Section 6
16F Silicone 16F Silicone Pericatheter 16F Silicone Laparotomy
Toolbox Urethral catheter Suprapubic Urethrogram Urethral Bladder repair
Ureteric stenting or formal ureteric reconstruction
Ureter catheter At Role 4 catheter 16F Urethral
Section 7 If delay or kidney drainage inadequate - nephrostomy catheter + drain
Conservative management Role 4
Section 8 Kidney Repeat CT scan depending on original injury (grade 4 5) If urinary catheterisation is prolonged, then daily clamping for 2-3 hours by nursing staff
should be commenced as soon as it is clinically safe.
Policies Explore nephron sparing options if necessary embolisation,
percutaneous drainage/stenting If the patient is alert and able to use his upper limbs, then he should be converted to a flip
flow valve as soon as it is clinically safe.
Section 9
The catheter should be cleaned daily with an aseptic technique and changed every six
weeks.
All casualties with genitourinary trauma should be referred to the Military Genitourinary
All cases referred to Genitourinary reconstruction team at RCDM
Section 10 Reconstruction team.
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Intro
Medical ethics Medical ethics 7
Introduction
Pathways 7 Pathways 7 Pathways
Step 2: QUADRANT 2: PATIENT PREFERENCES

Section 1 Step 1: Step 3: What does/would the patient want?
Moral perception Quadrant 1 Quadrant 2 Recommended
Preparation (identification of Medical Patient Moral Action:
ASCERTAIN if possible
moral issue) Indications Preferences Act SUMMARY
Is patient competent/capable of making decision?
Section 2 Start here........ End here. If so what does the patient want? Is the patients right to
Has he expressed prior preferences? choose
Incident management Is patient aware of benefits/risks? being respected to the
Does he understand? extent possible in ethics
Quadrant 3 Quadrant 4 & law?
Section 3 Has he given consent
Quality of Contextual
Life Factors
Treatment guidelines QUADRANT 3: QUALITY OF LIFE
What sort of life is likely with the proposed treatment?
Section 4
Quadrant 1: Medical Indications ASCERTAIN if possible
Transport QoL before the accident
What sound clinical judgement determines
is physiological & medically appropriate Anticipated physical, mental & socials deficits if
Section 5 treatment successful Components of QoL
Functioning after treatment-continued life
judged desirable? (identify value judgment) Cognitive/cerebral function
Pathways Physical disabilities
What physical/mental/social deficits likely if
Ascertain if possible Summary treatment works? Pain & suffering associated
Supporting Guidelines Extent & severity of injury/diagnosis Can medical intervention benefit this Biases that may prejudice providers evaluation with the disease
Prognosis patient overall and how can harm be of QoL Burdens of the treatment
Section 6 Acute/Chronic/Reversible? minimised? Is present or future condition such that
Identify value judgements, consult with continued life be judged undesirable?
Options for treatment, risks & benefits
Toolbox others if possible If so, consider & plan for palliative care
Probability of success
Plan for therapeutic failure
Section 7
QUADRANT 4: CONTEXTUAL ISSUES
PHYSIOLOGICAL FUTILITY
No chance of achieving chosen Contextual Features
Section 8 MEDICAL goal THIS IS MORE OBJECTIVE Resources issues
Situation QUANTITATIVE FUTILITY
Law
Policies Guidelines
futile? Very low chance of achieving chosen MEDICAL goal Impact on others e.g. morale
QUALITATIVE FUTILITY Local context e.g. facilities, cultural beliefs / QoL tied to surroundings
Section 9 MEDICAL goal if reached is so undesirable, Family issues
treatment not indicated Physician/nurse issues
Documentation and audit Financial/economics factors inc. resource allocation
With grateful thanks to Dr Daniel K Sokol, Honorary Senior Lecturer in Medical Ethics, Imperial College London,
and Member of MOD research Ethics Committee References: Jonsen, A. R.,Siegley, M., Winslade, W., (2002) Clinical Ethics : a practical Religious/cultural factors
Section 10 approach to ethical decisions in Clinical Medicine, McGraw-Hill / Lantos, J.D., Meadow, W., (2006) Neonatal Bioethics: the moral Conflicts of interest / HCW or institutions
challenges of medical innovation, The John Hopkins University Press
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Intro
Policies
Toolbox
Transport
Pathways
Section 7
Section 9
Section 5
Section 4
Section 3
Section 6
Section 1
Section 8
Section 2
MENU
Section 10
Preparation
Introduction
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Incident management

This is an Aide Memoire and does not replace training. Staff who may be involved in the transfusion process
MUST complete basic transfusion competencies within their NHS trust via the MDHU PD departments before
JSP 999
deployment. Staff should comply with all appropriate safety measures.
Section 5
BLOOD TRANSFUSIONS REQUESTS CASUALTY BLOOD SAMPLING COLLECTION OF BLOOD
Pathways
Request Blood Components/Blood Identify patient before collecting blood COMPONENTS

y 8
grouping/ Crossmatch using FMED 12A sample for transfusion. All patients to have Collect identification of casualty e.g. Trauma
FMED 12A must be signed by the requesting name band or Hosp No attached e.g. to an Pack label or drug chart.
clinician AND by the phlebotomist/ endo-tracheal tube, before blood is taken. Run for only ONE casualty at a time.
healthcare worker drawing the blood. Draw sample into transfusion EDTA sample Date, time and sign for SHOCK PACKS and
Complete FMED 12A with patient identifiers tubes (Pink) and mix by inverting 5 times. include TRAUMA NUMBER on shock pack
Note: Stickers (pre-printed labels) are Label sample at patients bedside issue form.
acceptable on request forms but must be immediately. When collecting patient specific
signed to confirm correct label. Note: Label pre-transfusion sample by hand. components:
MINIMUM dataset for a Transfusion request Stickers (pre-printed labels) are not Check expiry date of blood component
is: acceptable on samples. Ensure Unique Blood Component Pack
26
Trauma number and sex MINIMUM dataset for Emergency Number and Hospital Number of casualty
Time and date of sample Samples is: matches:
Add nationality (if known) and approximate Trauma Number and Sex Numbers stated on the blood compatibility
age (if a child) to allow selection of special Time and Date of sample label (FMed 692)
requirements. Initials of phlebotomist Blood issue paperwork
Add recorded blood group if available. MINIMUM dataset for Non-Urgent Date, time and sign for each individual
Include both ABO and RhD e.g. A pos. Samples is : blood component (Laboratory record)
Collect Patient Transfusion Form if
State type and quantity of components Hospital Number and Sex
provided (provided with first unit)
required and degree of urgency. Full Name (if known)
Deliver blood components and paperwork,
Date of Birth (if known)
directly to (registered) Healthcare
Time and date of sample
Aide Memoire for Safe Transfusion Practice
Practitioner responsible for casualty.

Initials of phlebotomist
Seal sample in completed FMed 12A and
send to lab as soon as possible.
NOTE: THE LABORATORY MUST NOT
ACCEPT INCOMPLETELY LABELLED
SAMPLES AND WILL DISCARD THEM
Change 3 September 2012

1st Edition September 2008
BLOOD TRANSFUSIONS ADMIN
Secure adequate venous access. Prepare
patient and clinical area
Prepare paperwork including Massive BLOOD OBSERVATIONS
Transfusion Flow sheet if used
Perform and record blood observations up
If transfusion takes place during initial to 60 minutes before transfusion. Baseline
resuscitation, do not spike unit until directed observations should include:
Pathways 8
1st Edition September 2008

Change 3 September 2012 i.e. after patient has arrived.
Temperature
Give blood components using a blood Pulse
administration set which incorporates a Respirations POST-TRANSFUSION ACTIVITY
170-200 micron filter. Only red cells and FFP Blood Pressure Complete prescription chart/flowchart with
may be infused through rapid infusers. Observe patient closely for first 30 min. transfusion start time and completion time.
Blood Components should not be spiked Ensure patient can be seen throughout
Complete Pink and Blue section labels of
until the TWO pre-transfusion checks transfusion.
FMED 692 for each blood component with:
have been carried out by TWO registered Note: Many patients are under continuous
Healthcare Practitioners (note local policy Hospital Number / Trauma Number
observation throughout initial resuscitation.
may apply). Surname / Forename (if known)
27
Perform and record observations 15 min Start Date and Time of Transfusion
Complete Blood Component checks as after starting transfusion (unless already Sign labels. Labels must be signed by
follows: recorded), and within 60 minutes of bothstaff administering transfusion.
Visibly inspect bag and contents completion of the transfusion.
Return completed Pink label to the
Check that Blood Components have not Recognise, manage, record and report laboratory/BMS/BDSS trained personnel
passed expiry date. transfusion reactions. providing blood (Local protocol may apply).
Check that Unique Blood Pack Number,
Stop transfusion Complete Blue label. Attach to Record of
Hospital Number and Casualtys Name
Inform MO/Trauma lead Transfusion form. Retain in medical notes.
(if stated) matches:
Keep venous access open
Details on blood compatibility label (FMed Include transfusion details in handover
Repeat pre-transfusion checks
692)
Inform the laboratory/BMS if deployed.
Details on paperwork from laboratory.
Aide Memoire for Safe Transfusion Practice
Manage reaction
Complete Patient Check as follows:
Restart transfusion as directed
Check Patients details on name band
matches the details on the Blood
Components. Note: In addition, check
details with casualty if conscious.
Pathways
8
Section 5
JSP 999
MENU
Intro
Introduction
Section 1
Preparation
Section 2
Incident management
Section 3
Section 4
Transport
Section 5
Pathways

Section 6

Section 7
Section 8
Policies
Section 9 Section 6
Toolbox
Section 10
12 3
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an
Ch
p
Se
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Intro Toolbox Contents
Toolbox
Introduction
Contents
Section 1
Preparation
Burns
Rule of Nines............................................................. Toolbox 1a
Section 2
Lund and Browder chart ...................................... Toolbox 1b
Burns calculator ........................................................Toolbox 1c
Incident management
CW agent differentiation
Section 3 Quick look features ................................................. Toolbox 2a
Chemical primary survey ..................................... Toolbox 2b
Section 4
ECG and rhythm recognition
Cardiac arrest rhythm ........................................... Toolbox 3a
Transport Peri-arrest rhythm ................................................... Toolbox 3b
Heart block .................................................................Toolbox 3c
Section 5 Myocardial infarct.................................................. Toolbox 3d
Intentionally blank
Pathways
Normal values
Supporting Guidelines Biochemistry ........................................................ Toolbox 4a
Haematology and coagulation ..................... Toolbox 4b
Section 6 Recognising acid base disorders ....................Toolbox 4c
Toolbox
Urinalysis and cardiac enzyme markers..... Toolbox 4d
Section 7 Paediatrics
Assessment of the sick child ............................... Toolbox 5a
Operational formulary Assessment of pain ................................................ Toolbox 5b
Managing severe pain in children.....................Toolbox 5c
Section 8
Policies
Glasgow Coma Scale
Adult ............................................................................. Toolbox 6a
Section 9 Child ............................................................................. Toolbox 6b
Documentation and audit Calculating drip rates ....................... Toolbox 7
Section 10 Early warning score..........................Toolbox 8
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Intro Toolbox Burns: Rule of Nines 1a
Toolbox 1a
Toolbox
Introduction
Contents (Contd)
Section 1
Preparation
Asthma management...................Toolbox 9
18% 18% front
Military Medical 9%
18% back
Section 2
Listing Categories .........................Toolbox 10
Incident management 9% 9%
Section 3
Treatment guidelines 18% front

1%
18% back
Section 4
14% 14%
Transport
9% 9%
Section 5
Pathways
Supporting Guidelines 1%
Section 6
Toolbox 18% 18%
Section 7
Section 8
Policies
Section 9
Section 10
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Intro
Burns: Lund and Browder chart Burns: Burns calculator 1b-c
Toolbox 1b Toolbox 1c
Toolbox
Introduction
Section 1 Instructions
A. Fluid deficit after burn
Preparation A A 1. Calculate total burn area (Rule of Nines; Lund and Browder Chart). Round to nearest
1 10%.
Section 2 1 2. Estimate/measure the patients weight and round to nearest 10kg.
3. Read off the fluid deficit (in millilitres white section) from time elapsed since burn
Incident management (inhours grey section).
2 13 2 2 13 2 4. Deduct the volume of any fluid already administered.
Section 3 5. Replace deficit with Hartmanns solution only.
Treatment guidelines 1.5 1.5 1.5 1.5 B. Maintenance fluid after burn
1. Read the hourly maintenance requirement (ml) from the purple section and replace as
Section 4 Hartmanns solution.
1.5 1 1.5 1.5 2.5 2.5 1.5 2. Start this replacement at the same time the deficit is replaced.
Transport 3. Note that the hourly requirement changes after 8 hours from the burn.
B B B B 4. Colloid is required after the first 8 hours following burn for children and after the first
Section 5 24 hours for adults.
time elapsed from burn in hours fluid deficit in millilitres

Pathways
C C C C
Supporting Guidelines 40 PER CENT BURNS
Weight (kg) 10 20 30 40 50 60 70 80 90 100
Section 6 8 940 1600 2100 2600 4000 4800 5600 6400 7200 8000
1.75 1.75 1.75 1.75 7 825 1400 1840 2275 3500 4200 4900 5600 6300 7000
Toolbox
Time Post Burn (Hours)

6 710 1200 1575 1950 3000 3600 4200 4800 5400 6000
Fluid 5 590 1000 1315 1625 2500 3000 3500 4000 4500 5000
Section 7 Ignore simple erythema Region % Deficit 4 470 800 1050 1300 2000 2400 2800 3200 3600 4000
Head 3 355 600 790 975 1500 1800 2100 2400 2700 3000
Operational formulary Partial thickness Neck 2 235 400 525 650 1000 1200 1400 1600 1800 2000
Trunk (anterior) 1 120 200 265 325 500 600 700 800 900 1000
Section 8 Full thickness
Trunk (posterior) Fluid 08 120 200 265 325 500 600 700 800 900 1000
Maintenance 924 ! ! ! ! 250 300 350 400 450 500
Policies Age A% B% C% Arm (right)
0 9.5 2.75 2.5 Arm (left)
Section 9 1 8.5 3.25 2.5 Buttocks hourly maintenance requirement in millilitres
5 6.5 4 2.75 Genitalia
Documentation and audit 10 5.5 4.5 3 Leg (right)
15 4.5 4.5 3.25 Leg (left) Specialist burns advice essential
Section 10 Adult 3.5 4.75 3.5 TOTAL
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Burns: Burns calculator Burns: Burns calculator 1c
Toolbox 1c (Contd) Toolbox 1c (Contd)

Toolbox
Introduction
Section 1 10 PER CENT BURNS 40 PER CENT BURNS

Weight (kg) 10 20 30 40 50 60 70 80 90 100 Weight (kg) 10 20 30 40 50 60 70 80 90 100
Preparation 8 590 1000 1315 1625 8 940 1600 2100 2600 4000 4800 5600 6400 7200 8000
7 515 875 1150 1425 7 825 1400 1840 2275 3500 4200 4900 5600 6300 7000
Section 2

6 440 750 985 1220 6 710 1200 1575 1950 3000 3600 4200 4800 5400 6000
Fluid 5 370 625 820 1020 ORAL FLUIDS ONLY Fluid 5 590 1000 1315 1625 2500 3000 3500 4000 4500 5000
Incident management Deficit 4 295 500 655 815 Deficit 4 470 800 1050 1300 2000 2400 2800 3200 3600 4000
3 220 375 500 600 3 355 600 790 975 1500 1800 2100 2400 2700 3000
Section 3 2 150 250 330 400 2 235 400 525 650 1000 1200 1400 1600 1800 2000
1 75 125 165 200 1 120 200 265 325 500 600 700 800 900 1000
Treatment guidelines Fluid 08 75 125 165 200 Fluid 08 120 200 265 325 500 600 700 800 900 1000
Maintenance 924 ! ! ! ! Maintenance 924 ! ! ! ! 250 300 350 400 450 500
Section 4
20 PER CENT BURNS 50 PER CENT BURNS
Transport Weight (kg) 10 20 30 40 50 60 70 80 90 100 Weight (kg) 10 20 30 40 50 60 70 80 90 100
8 705 1200 1575 1950 2000 2400 2800 3200 3600 4000 8 1060 1800 2360 2925 5000 6000 7000 8000 9000 10000
Section 5 7 620 1050 1380 1710 1750 2100 2450 2800 3150 3500 7 925 1575 2065 2560 4375 5250 6125 7000 7875 8750

6 530 900 1180 1460 1500 1800 2100 2400 2700 3000 6 795 1350 1770 2195 3750 4500 5250 6000 6750 7500
Pathways
Fluid 5 440 750 985 1220 1250 1500 1750 2000 2250 2500 Fluid 5 660 1125 1475 1830 3125 3750 4375 5000 5625 6250
Deficit 4 350 600 790 975 1000 1200 1400 1600 1800 2000 Deficit 4 530 900 1180 1460 2500 3000 3500 4000 4500 5000
Supporting Guidelines 3 265 450 590 730 750 900 1050 1200 1350 1500 3 400 675 885 1100 1875 2250 2625 3000 3375 3750
2 180 300 395 490 500 600 700 800 900 100 2 265 450 590 730 1250 1500 1750 2000 2250 2500
Section 6
1 90 150 200 245 250 300 350 400 450 500 1 130 225 295 365 625 750 875 1000 1125 1250
08 90 150 200 245 250 300 350 400 450 500 08 130 225 295 365 625 750 875 1000 1125 1250
Toolbox Fluid Fluid
Maintenance 924 ! ! ! ! 125 150 175 200 225 250 Maintenance 924 ! ! ! ! 315 375 440 500 565 625
Section 7
30 PER CENT BURNS 60 PER CENT BURNS
Operational formulary Weight (kg) 10 20 30 40 50 60 70 80 90 100 Weight (kg) 10 20 30 40 50 60 70 80 90 100
8 825 1400 1840 2275 3000 3600 4200 4800 5400 6000 8 1175 2000 2625 3260 6000 7200 8400 9600 10800 12000
Section 8 7 720 1225 1575 2075 2625 3150 3675 4200 4725 5250 7 1030 1750 2300 2850 5250 6300 7350 8400 9450 10500

6 620 1050 1380 1780 2250 2700 3150 3600 4050 4500 6 880 1500 1970 2445 4500 5400 6300 7200 8100 9000
Policies Fluid 5 515 875 1150 1420 1875 2250 2625 3000 3375 3750 Fluid 5 735 1250 1640 2040 3750 4500 5250 6000 6750 7500
Deficit 4 410 700 920 1140 1500 1800 2100 2400 2700 3000 Deficit 4 590 1000 1310 1630 3000 3600 4200 4800 5400 6000
Section 9 3 310 525 690 855 1125 1350 1575 1800 2025 2250 3 440 750 985 1220 2250 2700 3150 3600 4050 4500
2 210 350 460 570 750 900 1050 1200 1350 1500 2 295 500 655 815 1500 1800 2100 2400 2700 3000
Documentation and audit 1 105 175 230 285 375 450 525 600 675 750 1 150 250 330 410 750 900 1050 1200 1350 1500
Fluid 08 105 175 230 285 375 450 525 600 675 750 Fluid 08 150 250 330 410 750 900 1050 1200 1350 1500
Section 10 Maintenance 924 ! ! ! ! 190 225 260 300 340 375 Maintenance 924 ! ! ! ! 375 450 525 600 675 750
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Burns: Burns calculator Burns: Burns calculator 1c
Toolbox 1c (Contd) Toolbox 1c (Contd)

Toolbox
Introduction
Section 1 70 PER CENT BURNS 100 PER CENT BURNS

Weight (kg) 10 20 30 40 50 60 70 80 90 100 Weight (kg) 10 20 30 40 50 60 70 80 90 100
Preparation 8 1295 2200 2890 3575 7000 8400 9800 11200 12600 14000 8 1645 2800 3675 4550 10000 12000 14000 16000 18000 20000
7 1130 1925 2530 3180 6125 7350 8575 9800 11025 12250 7 1440 2450 3150 3985 8750 10500 12250 14000 15750 17500
Section 2

6 970 1650 2170 2680 5250 6300 7350 8400 9450 10500 6 1235 2100 2755 3415 7500 9000 10500 12000 13500 15000
Fluid 5 810 1375 1805 2235 4375 5250 6125 7000 7875 8750 Fluid 5 1030 1750 2300 2845 6250 7500 8750 10000 11250 12500
Incident management Deficit 4 650 1100 1445 1790 3500 4200 4900 5600 6300 7000 Deficit 4 825 1400 1840 2275 5000 6000 7000 8000 9000 10000
3 485 825 1085 1345 2625 3150 3675 4200 4725 5250 3 620 1050 1380 1710 3750 4500 5250 6000 6750 7500
Section 3 2 325 575 725 900 1750 2100 2450 2800 3150 3500 2 410 700 920 1140 2500 3000 3500 4000 4500 5000
1 160 290 360 450 875 1050 1225 1400 1575 1750 1 210 350 460 570 1250 1500 1750 2000 2250 2500
Treatment guidelines Fluid 08 160 290 360 450 875 1050 1225 1400 1575 1750 Fluid 08 210 350 460 570 1250 1500 1750 2000 2250 2500
Maintenance 924 ! ! ! ! 440 525 615 700 790 875 Maintenance 924 ! ! ! ! 625 750 875 1000 1125 1250
Section 4
80 PER CENT BURNS
Transport Weight (kg) 10 20 30 40 50 60 70 80 90 100
8 1410 2400 3160 3900 8000 9600 11200 12800 14400 16000
Section 5 7 1235 2100 2765 3415 7000 8400 9800 11200 12600 14000
6 1060 1800 2370 2925 6000 7200 8400 9600 10800 12000
Pathways
Fluid 5 880 1500 1975 2440 5000 6000 7000 8000 9000 10000
Deficit 4 705 1200 1580 1950 4000 4800 5600 6400 7200 8000
Supporting Guidelines 3 530 900 1185 1465 3000 3600 4200 4800 5400 6000
2 335 600 790 975 2000 2400 2800 3200 3600 4000
Section 6
1 175 300 395 490 1000 1200 1400 1600 1800 2000
08 175 300 395 490 1000 1200 1400 1600 1800 2000
Toolbox Fluid
Maintenance 924 ! ! ! ! 500 600 700 800 900 1000
Section 7
90 PER CENT BURNS
Operational formulary Weight (kg) 10 20 30 40 50 60 70 80 90 100
8 1530 2600 3415 4225 9000 10800 12600 14400 16200 18000
Section 8 7 1340 2275 2990 3700 7875 9450 11025 12600 14175 15750
6 1150 1950 2490 3170 6750 8100 9450 10800 12150 13500
Policies Fluid 5 960 1625 2135 2640 5625 6750 7875 9000 10125 11250
Deficit 4 765 1300 1710 2115 4500 5400 6300 7200 8100 9000
Section 9 3 575 975 1280 1585 3375 4050 4725 5400 6075 6750
2 380 650 855 1055 2250 2700 3150 3600 4050 4500
Documentation and audit 1 190 325 430 530 1125 1350 1575 1800 2025 2250
Fluid 08 190 325 430 530 1125 1350 1575 1800 2025 2250
Section 10 Maintenance 924 ! ! ! ! 565 675 790 900 1015 1125
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CW agent differentiation: CW agent differentiation: 2a-b
Introduction Quick look features Chemical primary survey Toolbox
Section 1 Toolbox 2a Toolbox 2b

Preparation Airway
Increased? Nerve Agent
Secretions
Section 2 Nerve agent Cyanide Decreased? Atropine/BZ
Skin: Sweaty, Skin: Dry, pink or Secretions Bad Eggs? Hydrogen Sulphide
Incident management
cyanosed, fasciculation cyanosed
Breathing
Bronchospasm? Nerve Agent
Section 3 Pupils: Pinpoint Pupils: Normal or large Breathing
Cough and Lung damager
Treatment guidelines Respiration: Respiration: frothy Sputum?
Bronchoconstriction, Initial respiratory
rapid, shallow, stimulation then slow, Cyanosis? Cyanide Methaemoglobinaemia
Section 4 wheezing deep, irregular Skin colour
Pink? Cyanide Carbon Monoxide
Transport Secretions: Secretions: Circulation
Excessive salivation/ Normal
Section 5 bronchial secretions Heart rate Bradycardia? Nerve Agent
Chocolate Methaemoglobinaemia
Pathways coloured blood?
Venous blood
Arterialised Cyanide
Supporting Guidelines venous blood?
Section 6 Disability
Pinpoint? Nerve Agent Opiate
Pupils
Toolbox Dilated? Botulin Atropine/BZ
Section 7 CNS involvement confusion, coma Nerve Agent Atropine/BZ
Operational formulary Exposure

Immediate (<1 hr)? Hydrofluoric acid Lewisite
Erythema/
Section 8 Burns Delayed (>1 hr)? Mustard
Policies Fasciculation? Nerve Agent

Muscle
Flaccid Paralysis? Botulin Concurrent with
Section 9 BATLS Primary
Excessive sweating? Nerve Agent Survey (includes
Documentation and audit Skin biological toxins)
Dry? Atropine/BZ
Section 10 The list is not exclusive but highlights signs and symptoms more specific
to CW & Toxic industrial chemicals with specific and antidotal treatment
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Intro
ECG and rhythm recognition: ECG and rhythm recognition: 3a-b
Introduction Cardiac arrest rhythm Peri-arrest rhythm Toolbox
Section 1 Toolbox 3a Toolbox 3b

Preparation >100 = tachycardia
Is there electrical activity? no Asystole What is the ventricular rate?
Count the small squares between <60 = bradycardia
Section 2 two R waves and divide into 300
Incident management yes
Are there P waves? no Regular broad complex

Section 3 tachycardia?
VT with pulse
Is the activity chaotic? yes Ventricular Fibrillation yes
Section 4
Transport no
Section 5 Irregular rhythm?

Atrial fibrillation
Pathways
Is there a broad yes Ventricular Tachycardia
Supporting Guidelines complex tachycardia?
Section 6
no One P per QRS?
Toolbox
Sinus rhythm
Section 7
Operational formulary Pulseless Electrical Activity

[any rhythm during cardiac arrest other than asystole, VF or VT]
Section 8
P wave ~300/min
Policies Atrial flutter
Section 9 More Ps than QRS?

Heart block
1
See cardiac arrest Go to Section 3 Treatment
Look at the PR and RR intervals
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ECG and rhythm recognition: ECG and rhythm recognition: 3c-d
Introduction Heart block Myocardial infarct Toolbox
Section 1 Toolbox 3c Toolbox 3d

Preparation First degree heart block A myocardial infarction is principally recognised from the history and ECG changes
Section 2 History
Incident management The characteristic history is central chest pain (tightness/crushing) +/ radiation to the jaw or
arm(s) that lasts >20 minutes, is unrelieved by rest or GTN, and is accompanied by nausea/
vomiting and sweating. Not all of these features need be present.
Section 3 This is simply a prolongation of PR interval >0.12ms (3 small squares)
ECG
If there are more P waves than QRS complexes this is 2nd or 3rd degree heart block
Treatment guidelines The characteristic change on the ECG is a raised ST segment (pericarditis also causes a raised
ST segment, but has a different morphology and tends to give more generalised lead changes).
Section 4 Look at the PR and RR intervals
Transport To diagnose MI there must be 2mm of ST elevation

PR variable RR variable 2nd degree type I
in an inferior lead (II, III, AVF) and/or 1mm of ST
Section 5
PR constant 2nd degree type II elevation in 2 or more consecutive chest leads (V1 V6)
Pathways PR variable RR constant 3rd degree (complete)
Supporting Guidelines 2nd degree type I (Wenkebach) Anterior MI manifests in V2, V3, V4 and indicates a left coronary artery/left anterior
descending (LAD) artery occlusion.
Section 6 Anterolateral MI manifests in I, AVL, V3 V6 and indicates LAD, diagonal, circumflex and
marginal branch occlusion.
Toolbox Anteroseptal MI manifests in V1V4 and indicates LAD occlusion.
Inferior MI manifests in II, III and AVF and indicates right coronary artery occlusion.
Section 7 Lateral MI manifests in I, AVL, V5V6 and indicates circumflex branch of left coronary
2nd degree type II artery occlusion.
Operational formulary Posterior MI manifests in V8V9 (reposition V1V2 more laterally) and indicates right
coronary artery or circumflex branch occlusion. In V1V4 the R wave is greater than the
Section 8 S wave and in V1V2 there is ST segment depression: the T wave is elevated.
Policies
7a-b
3rd degree (complete heart block) See Thrombolysis Go to Section 3
Section 9 Treatment
guidelines
Section 10
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Normal values: Biochemistry Normal values: Haematology 4a-b
Introduction Toolbox 4a and coagulation Toolbox
Section 1 Biochemistry Toolbox 4b

Preparation Test Conventional units SI units Haematology
Section 2 Albumin 3.55g/dl 3550g/L

Test Conventional units SI units
Incident management Alkaline phosphatase 45115IU/ml 45115U/L
Male: 4.25.4 x 106/mm3 4.25.4 x 1012/L
RBCs
Male: 1040U/L 0.170.68kat/L Female: 3.65 x 106/mm3 3.65 x 1012/L
Section 3 ALT
Female: 735U/L 0.120.60kat/L
Male: 1417.4g/dl 140174g/L
Hb
Treatment guidelines Amylase 26102U/L 0.41.74kat/L
Female: 1216g/dl 120160g/L
Section 4 Male: 42%52% 0.420.52

Anion gap 814mEq/L 814mmol/L Hct
Female: 36%48% 0.360.48
Transport AST 1231U/L 0.210.53kat/L Lymphocytes 25%40% 0.250.40
B lymphocytes 270640/mm3
Section 5 Bilirubin, total 0.21mg/dl 3.517mol/L T lymphocytes 1,4002,700/mm3
Pathways BUN 820mg/dl 2.97.5mmol/L Monocytes 2%8% 0.020.08
Supporting Guidelines Calcium (Ca2+) 8.210.2mg/dl 2.052.54mmol/L Neutrophils 54%75% 0.540.75
Section 6 Chloride (Cl) 100108mEq/L 100108mmol/L Platelets 140000400000/mm3 140400 x 109/L
Toolbox Male: 55170U/L 0.942.89kat/L Male: 10mm/hr 010mm/hr

Creatine Kinase ESR
Female: 30135U/L 0.512.3kat/L Female: 20mm/hr 020mm/hr
Section 7
Male: 0.81.2mg/dl 62115mol/L
Creatinine Coagulation
Operational formulary Female: 0.60.9mg/dl 5397mol/L
Glucose 70100mg/dl 3.96.1mmol/L

Section 8 Test Conventional units SI units
Policies Potassium (K+) 3.55mEq/L 3.55mmol/L INR (target therapeutic) 2.03.0 2.03.0
Sodium (Na+) 135145mEq/L 135145mmol/L PTT 2135 sec 2135 sec

Section 9
Documentation and audit Fibrinogen 200400mg/dl 24g/L
Section 10 D-Dimer <250mcg/L <1.37nmol/L
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Normal values: Recognising Normal values: Urinalysis and 4c-d
Introduction acid base disorders cardiac enzyme markers Toolbox
Section 1 Toolbox 4c Toolbox 4d

Preparation Recognising acid-base disorders Urinalysis
Section 2 Disorder ABG findings Possible causes Test Conventional units SI units
Incident management Respiratory Acidosis pH <7.35 Central nervous system depression Colour Straw to dark yellow
(excess CO2 retention) HCO3- >26mEq/L from drugs, injury, ordisease
Section 3 (if compensating) Hypoventilation from respiratory, Specific gravity 1.0051.035
PaCO2 >45mm Hg cardiac, musculoskeletal, or
Treatment guidelines neuromuscular disease pH 4.58
Respiratory alkalosis pH >7.45 Hyperventilation due to anxiety, Glucose None

Section 4
(excess CO2 loss) HCO3- <22mEq/L pain, or improper ventilator
settings Sodium 40220mEq/L/24hr 40220mmol/day
Transport (if compensating
PaCO2 <35mm Hg Respiratory stimulation from drugs,
disease, hypoxia, fever, orhigh Potassium 25125mmol/24hr 25125mmol/day
Section 5
room temperature
Chloride 110250mEq/24hr 110250mmol/day
Pathways Gram-negative bacteraemia
Protein 5080mg/24hr 5080mg/day
Metabolic acidosis pH <7.35 Depletion of HCO3- from renal
Supporting Guidelines (HCO3- loss or acid HCO3- <22mEq/L disease, diarrhoea, or
Osmolality 501,400mOsm/kg
retention) PaCO2 <35mm Hg small-bowel fistulas
Section 6 Excessive production of organic
(if compensating)
acids from hepatic disease, Cardiac enzyme markers
Toolbox endocrine disorders such as
diabetes mellitus, hypoxia, shock,
Enzyme Conventional SI Initial Peak Time to
Section 7 or drug toxicity
units units evaluation return to
Inadequate excretion of acids due normal
Operational formulary to renal disease
Troponin-I < 0.35mcg/L <0.35mcg/L 46 hours 12 hours 310 days
Section 8 Metabolic alkalosis pH >7.45 Loss of hydrochloric acid from
(HCO3- retention or HCO3- >26mEq/L prolonged vomiting or gastric Troponin-T <0.1mcg/L <0.1mcg/L 48 hours 1248 hours 710 days
Policies acid loss) PaCO2 >45mm Hg suctioning
(if compensating) Loss of potassium from increased Male: 55170U/L 0.942.89kat/L
renal excretion (as in diuretic CK
Section 9 Female: 30135U/L 0.512.3kat/L
therapy) or corticosteroid overdose
Documentation and audit Excessive alkali ingestion CKMB <5% <0.05 48 hours 1224 hours 7296 hours
Section 10 Myoglobin 00.9mcg/ml 570mcg/L 24 hours 810 hours 24 hours
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Intro
Paediatrics: Assessment Paediatrics: Assessment of pain 5a-b
Introduction of the sick child Toolbox 5b

Toolbox
Section 1 Toolbox 5a QUESTT

Preparation The response of a pre-school child to serious illness can be deceptive and unpredictable.
Section 2
Non-specific symptoms and signs are important early indicators of serious underlaying illness.
A structured clinical assessment and interpretation of vital signs that cover several body QUESTT
systems can be identify children who may be seriously ill.
Incident management Except when very high (>41c), fever poses no threat to the child but may be a marker of
overwhelming sepsis, localised infection, occult bacteraemia, or benign illness.
Q Question the patient
Section 3 Key observations provide an overall appraisal of illness severity U Use pain rating scale
Ask about E Evaluate behaviour and physiological signs

Behaviour Irritable, not responsive to parents, drowsy, difficult to wake S Secure familys involvement
Section 4 Feeding >50% reduction in intake; fatigue/sweating with feeds
Dehydration Reduced urine output T Take cause of pain into account
Transport Gastrointestinal Vomiting bile or blood, >3 vomits in 24 hrs, >5 watery stools in 24 T Take action and assess effectiveness
hrs, or blood in stools
Risk factors <3 months, chronic underlaying disease, immune deficiency
Section 5
Vital signs (see table for approx. range of normal) Signs identifying an infant/small child in pain
Pathways Temperature <35.5C, >39.5C
Respiratory rate Hypoventilation, tachypnoea
Supporting Guidelines Heart rate Bradycardia, tachycardia
Section 6

Blood pressure
Oxygen saturation
Hypo/hypertension, pulse pressure
<95%
Forehead Brows
Bulge between brows & Lowered and
Toolbox Age (Years) <1 25 512 > 12 vertical furrows drawn together
Pulse (beats/min) 110160 95140 80120 60100
Section 7 Resps (breaths/min) 3040 2530 2025 1520
Syst BP (mmHg) 7090 80100 90110 100120
Nose Eyes
Look/Listen/Feel Broadened and bulging Tightly closed
Section 8 Breathing Grunting, rapid rate, irregular, nasal flaring, tracheal tug,
sternal recession, exhausted
Policies Circulation Capillary refill >2 sec, cool peripheries
Dehydration Dry oral mucosa, sunken eyes, reduced skin turgor
Section 9 Skin Rash, mottled, pallor, cyanosed Mouth See next
Cry Persistent, inconsolable, weak, high-pitched Open and squarish page for
Documentation and audit Eye contact No eye contact, glassy stare, unresponsive to visual stimuli pain scales
Consciousness Lethargic, abnormal tone/posture, only rousable to pain,
Section 10 unresponsive
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Intro
Paediatrics: Assessment of pain Paediatrics: Managing severe 5c
Introduction Toolbox 5b (Contd) pain in children Toolbox
Section 1 Use one of the following pain rating scales Toolbox 5c

Preparation Intranasal Diamorphine in Children
Wong-Baker FACES Pain Rating Scale
Section 2 Cautions:
Indications: Dose:
Severe pain Head injury
Incident management Beware respiratory
0.1 ml/kg (100mcg/kg)
Child must be >10kg diamorphine
depressant
Section 3
Treatment guidelines 0 2 4 6 8 10 Record pain score before & after administration (speed of onset usually 5 mins)
No Hurts Hurts Hurts Hurts Hurts
Section 4 hurt little bit little more even more whole lot worse
Transport INTRANASAL DIAMORPHINE
In a 1ml syringe, using a
Section 5 or 5mg vial of diamorphine
powder, make up to
0.5ml with 0.5 ml water
Weight
DILUTION CHART
Discarded Administered
Dose of
Diamorphine
(kg) Volume (ml) Volume (ml)
Pathways (mg)
10kg 0.4 0.1 1.0
Supporting Guidelines Visual Analogue Scale 15kg 0.35 0.15 1.5

20kg 0.3 0.2 2.0
Section 6 Discard excess to leave
25kg 0.25 0.25 2.5
30kg 0.2 0.3 3.0
Toolbox 0 1 2 3 4 5 6 7 8 9 10 0.01ml.kg (see table)
35kg 0.15 0.35 3.5
40kg 0.1 0.4 4.0
Section 7 No Worst 45kg 0.05 0.45 4.5
pain pain 50kg 0 0.5 5.0
Attach syringe firmly to
Section 8 mucosal atomization device
Policies
Section 9
Spray solution into the clearer
Documentation and audit Nostril:
On one side only if <0.2ml
If >0.2ml spray half volume
Section 10 From: Hockenberry MJ, Wilson D, Winkelstien ML: Wongs Essentials of Paediatric Nursing, edition7, p.1259. into each nostril
St Louis (2005) Used with permission. Copyright, Mosby.
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Intro
Glasgow Coma Scale: Adult 5b-6a
Toolbox 6a
Toolbox
Introduction
Section 1 Add the scores for the best response in each category to achieve the total score
Preparation
Test Score Patients response
Section 2
Eye opening
Incident management Spontaneously 4 Opens eyes spontaneously
To speech 3 Opens eyes to verbal command

Section 3
To pain 2 Opens eyes to painful stimulus
None 1 Doesnt open eyes in response to stimulus
Section 4
Motor response
Transport Obeys 6 Reacts to verbal command
Section 5 Localizes 5 Attempts to remove source of pain

Intentionally blank
Pathways Withdraws 4 Flexes and withdraws from painful stimulus
Supporting Guidelines Abnormal flexion 3 Flexes, but does not localize pain
Section 6 Abnormal extension 2 Extends limbs
Toolbox None 1 No response; just lies flaccid
Section 7 Verbal response

Oriented 5 Is oriented and converses
Confused 4 Is disoriented and confused
Section 8
Inappropriate words 3 Replies randomly with incorrect words
Policies
Incomprehensible 2 Incomprehensible sounds
Section 9 None 1 No response
Documentation and audit Total score

Section 10
Adapted from: The Joint Royal Colleges Ambulance Service Liaison Committee (JRCALC) (October 2006)
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Glasgow Coma Scale: Child Calculating drip rates 6b-7
Toolbox 6b Toolbox 7
Toolbox
Introduction
Section 1 Modification of Glasgow Coma Scale for children under 4 years old When calculating the flow rate of IV solutions, remember that the number of drops required
to deliver 1ml varies with the type of administration set youre using. To calculate the drip
Preparation rate, you must know the calibration of the drip rate for each specific manufacturers product.
Test Score
As a quick guide, refer to the chart below.
Section 2 As per
Eye opening
adult scale
Incident management
As per Ordered volume
Motor response
adult scale
Section 3
Best verbal response 500ml/ 1000ml/ 1000ml/ 1000ml/ 1000ml/ 1000ml/
Treatment guidelines Appropriate words or social smiles, 24hr 24hr 20hr 10hr 8hr 6hr
fixes on and follows objects 5 or or or or or or
Section 4 Cries, but is consolable 4 21ml/hr 42ml/hr 50ml/hr 100ml/hr 125ml/hr 167ml/hr
Persistently irritable 3
Transport Restless, agitated 2 Drops/ml Drops/minute to infuse
Silent 1
Section 5 Macrodrip
Pathways 10 4 7 8 17 21 28
15 5 11 13 25 31 42
20 7 14 17 33 42 56
Section 6
Microdrip
Toolbox
60 21 42 50 100 125 167
Section 7
Section 8
Policies
Section 9
Section 10
Adapted from: The Joint Royal Colleges Ambulance Service Liaison Committee (JRCALC) (October 2006) Adapted from: Weinstock D (Ed): Critical Care Facts. Lippincott, Williams & Wilkins (2005)
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Early Warning Score Asthma management 8-9
Toolbox 8 Toolbox 9
Toolbox
Introduction
Section 1 Follow this early warning score to activate a medical emergency team for a deteriorating Peak expiratory flow in normal adults
patient, then follow evidence-based treatment guidelines (CGOs).
Preparation NEW symptoms 4 3 2 1 0 1 2 3 4
660 660
75 190
650 650
Nurse concerned NEW 183
72
Section 2 Chest pain NEW 640
175 MEN
640
69
AAA pain NEW 630 630
Incident management SOB NEW 620 66 167 620

Physiology 610 63 160 610
Ht. Ht.
Pulse changes <45 4549 5054 5560 9099 100119 120139 >139 (ins)
Section 3 600 (cms) 600
Temp-core <34 34.034.5 34.635.0 35.135.9 38.539.9 40.040.4 >40.4 590 590
(rectal/tympanic)
Treatment guidelines RR (adult) <8 89 1011 2125 2630 3136 >36 580 580
SpO2 (O2) <88 8891 9295 570 570
Section 4 SpO2 (Air) <85 8689 9093 9496 560 560

falls to falls to falls to rises by rises by rises by
NORMAL RANGE
SBP (mmHg) <90 9099 100110 2029 3040 >40
550 550
Transport falls falls by falls by

Pulse Pulse 540 540
or >40 3140 2030
pressure pressure
530 530
narrows 10 narrows >10
Section 5 GCS changes <13 1314
confused or
agitated
PEF 520 520
L/min 510 510
<10mls/hr <20mls/hr
Urine output >250mls/hr
Pathways for 2 hours for 2 hours 500
69
500
175 WOMEN
Biochemistry 490 490
K+ <2.5 2.53.0 5.65.9 6.06.2 >6.2 66
167
480 480
Na+ <120 120125 126129 146147 148152 153160 >160
470
63 160
470
pH <7.21 7.217.25 7.267.30 7.317.34 7.467.48 7.497.50 7.517.60 >7.60 60
Section 6 pCO2 (acute changes) <3.5 3.53.9 4.04.4 6.16.9 >6.9
460 152 460
450 57 145 450
SBE <-5.9 -4.9 to -5.8 -3.8 to -4.8 -3 to -3.7 Ht. Ht.
Toolbox pO2 (acute changes) <9.0 9.09.4 9.59.9 1011 440 (ins) (cms)
440
Creatinine 121170 171299 300440 >440 430 430
Section 7 Hb <80 8089 90100 420 420

Urea <2 2.02.4 7.620 2130 3140 >40 410 410
Operational formulary 400 400
MET scoring system 390 390
Section 8 Score Action

380 380
1 Observe
Policies 15 20 25 30 35 40 45 50 55 60 65 70
23 Repeat TPR, BP, GCS, calculate urine output last 2 hours (if known)
Age in Years
Now recalculate score (if same, observe closely)
Section 9 Standard deviation men = 48 litres/min In men, values of PEF up to 100 litres/min, less than
4 Bleep patients SHO (to attend within 30 minutes) predicted, and in women less than 85 litres/min, less
Standard deviation women = 42 litres/min
than predicted are within normal limits
Documentation and audit 57 Confirm with Senior Nurse then 333 SHO of patients speciality
8 or more Inform Senior Nurse then
Section 10 Nunn AJ, Gregg I: New Regression Equations for Predicting Peak Expiratory Flow in Adults. BMJ 1989;298;1068
Activate MET 70.
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Military Medical Listing Categories
Introduction Toolbox 10
Section 1
Preparation 1. Very Seriously Ill (VSI). A patient is termed very seriously ill when his/her
illness or injury is of such severity that life or reason is immediate endangered. An example
Section 2 would be a casualty who requires ventilation following injury.
Incident management
2. Seriously Ill (SI). A patient is termed seriously ill when his/her illness or injury is
Section 3 of such severity that there is cause for immediate concern, but there is no imminent danger
to life. An axample would be a patient who is extubated post - operatively, but has required a
Treatment guidelines limb amputation.
Section 4
3. Ill. This category applies to an individual whose illness or injury requires hospitalisation,
whose condition does not warrant classification as VSI or SI.
Transport
Section 5 Unlisted Casualties (UL). An individual whose illness or injury requires Intentionally blank
hospitalisation but whose condition does not warrant classification as VSI, SI or ILL.
Pathways
Section 6
Toolbox
Section 7
Section 8
Policies
Section 9
Section 10
JSP 751. Joint Casualty & Compassionate Policy & Procedures. Issue 8, May 2009
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Intro
Introduction
Section 1
Preparation
Section 2
Incident management
Section 3
Section 4
Transport
Section 5
Pathways

Section 6

Section 7
Section 8
Section 7
Policies
Section 9 Operational
formulary
Section 10
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Intro Operational formulary 1
Operational
formulary
Introduction
Contents
Section 1
Preparation Emergency drugs formulary

Section 2 Operational formulary 1
Incident management
Critical care
Section 3
IV drug infusions .........Operational formulary 2a
Sedation guidelines ...Operational formulary 2b
Section 4
Transport Sedation scoring

Operational formulary 3
Section 5
Intentionally blank
Pathways
Antibiotic prescribing guidelines
Supporting Guidelines Operational formulary 4
Section 6
Toolbox
Section 7
Section 8
Policies
This formulary is restricted to drugs that are included within
the emergency treatment guidelines in this publication.
Section 9
Details of interactions, contraindications and adverse effects
Documentation and audit are not given. This information is available by referring to the
British National Formulary in hard copy or online at www.bnf.org.
Section 10
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Emergency drugs formulary 1
Operational
Introduction Operational formulary 1 formulary
Section 1
Drug Dose Interval
Preparation Acetazolamide
Altitude emergencies 250mg PO 8 hourly
Section 2
Acyclovir
Encephalitis 10mg/kg IV Every 8 hours
Incident management
Actrapid
Section 3 Diabetic ketoacidosis 6u IV Stat
6u/hr IV If blood sugar >14mmol/L
Treatment guidelines 3u/hr IV If blood sugar <14mmol/L
or use a sliding scale of insulin instead of an infusion:
Section 4 Insulin infusion With infections or
Hourly BM rate (U/hr) Insulin resistance
Transport
03.9 0.5 1
4.07.9 1.0 2
Section 5 8.011.9 2.0 4
Intentionally blank
12.016.0 3.0 6
Pathways >16 4.0 8
Switch to 5% dextrose when BM < 11

Hyperkalaemia 10u IV Over 15 minutes with glucose
Section 6
Adenosine
Toolbox Narrow complex tachycardia 6mg IV stat dose and follow with up to 3 doses of
12mg every 12 minutes
Section 7
Adrenaline (epinephrine)
Cardiac arrest (adult) 1:10000 10ml 3 minutes
Pre-filled syringe
Cardiac arrest (child) 10 mcg/kg 3 minutes
Section 8 (0.1ml/kg of 1 in
10000 solution)
Policies
Adrenaline (epinephrine)
Anaphylaxis (adult) 1:1000 0.5ml IM Can repeat after 5 minutes
Section 9 Bradycardia 210mcg/min IV
Section 10
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Emergency drugs formulary Emergency drugs formulary 1
Operational
Introduction Operational formulary 1 (Contd) Operational formulary 1 (Contd) formulary
Section 1 Drug Dose Interval Drug Dose Interval

Preparation Amiodarone Diamorphine
Cardiac arrest 300mg IV Pre-filled syringe Myocardial infarction 2.55mg IV PRN for pain
Broad complex tachycardia 300mg IV over 1020 minutes Pulmonary oedema 2.55mg IV PRN
Section 2
900mg IV over 24 hours
Diazepam (rectal)
Atrial fibrillation 300mg IV over 2060 minutes
Incident management Fitting 10mg PR (adults) PRN
Aspirin
Myocardial infarction & ACS 300mg chewed Single dose Diazepam
Section 3 (emulsion, Diazemuls)
Atropine Fitting 1020mg IV (adults) 3060 minutes PRN
Treatment guidelines Cardiac arrest 3mg IV Single dose
Diclofenac 11i
Bradycardia 500mcg IV Repeat to max 3mg
Section 4 Benzylpenicillin guidelines
Meningococcal disease 1200mg (adult) IV/IM Digoxin

Transport 600mg (child) IV/IM Atrial fibrillation 0.751mg IV over at least 2 hours (emergency)
300mg (infant) IV/IM 11.5mg PO in divided doses over 24 hours (rapid)
Section 5 Calcium gluconate Dobutamine
Hyperkalaemia 10ml 10% IV Repeat every 10 minutes Meningococcal disease child 1020mcg/kg/min [make up with 50ml 5% dextrose
Pathways as required, max 50ml and run at 10mcg/kg/min]
Cefotaxime
Supporting Guidelines Sepsis 12g IV TDS
Doxycycline
Non-gonococcal urethritis 100mg BD for 7 days
Meningococcal disease 12g IV TDS Typhus 100mg BD
Section 6
Chloramphenicol Etomidate 3d
Toolbox Sepsis 25mg/kg IV If penicillin allergy Go to Section 3 Treatment
guidelines
Meningococcal disease 25mg/kg IV If penicillin allergy
Section 7 Chlorpheniramine 1020mg IM/ Single dose Fentanyl Analgesic; 3d
Anaphylaxis (adult) slow IV pre-induction agent Go to Section 3 treatment
guidelines
Clarithromycin 250mg PO BD for 7 days Furosemide
Antimicrobial recommendations 500mg IV BD Pulmonary oedema 50mg IV PRN
Section 8
Codeine 11i Gentamicin
Policies Go to Section 3 Treatment Septicaemia 2mg/kg IV Over at least 3 minutes
guidelines
Glucagon
Section 9 Dexamethasone
Hypoglycaemia 1mg IM Stat
Septic shock 0.15mg/kg IV QDS
Documentation and audit Meningococcal disease 0.15mg/kg IV QDS Glucose
Altitude emergencies 4mg PO 6 hourly Hypoglycaemia 50% 25ml IV Stat
Section 10
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Emergency drugs formulary Emergency drugs formulary 1
Operational
Section 1 Drug Dose Interval Drug Dose Interval

Preparation Glyceryl trinitrate (buccal) Naloxone
Pulmonary oedema 25mg buccal Titrate vs BP Opiate overdose 0.42mg IV Every 2 minutes PRN
Acute coronary syndrome 25mg buccal Titrate vs pain/BP 0.8mg IM PRN
Section 2
Glyceryl trinitrate (spray) 400mcg PRN Nifedipine
Incident management Angina, acute attack under tongue Altitude emergencies 20mg SR PO 6 hourly
1 Nimodipine
Section 3 Heparin Go to Section 7 Operational Tenecteplase
formulary Subarachnoid haemorrhage 60mg PO 4 hourly
Hydrocortisone 1mg/hr IV
Treatment guidelines Anaphylaxis 100500mg IM/IV Stat Paracetamol 11i
Asthma adult 100mg IV Stat Go to Section 3 Treatment
Section 4 Asthma child 4mg /kg IV Stat guidelines
Ipratropium (nebuliser) Phenytoin (infusion)

Transport Fitting 15mg/kg Loading dose
Asthma (adult) 0.5mg NEB QQH PRN
(rate not exceeding 50mg/min)
Section 5 Isosorbide dinitrate (infusion)
Angina 210mg/hr Titrate vs pain/BP Potassium chloride
Pathways Pulmonary oedema 210mg/hr Titrate vs BP Hypokalaemia Up to 60mmol 30mmol/hr max
Ketamine Plasma potassium Potassium added to bag
3d
Supporting Guidelines Anaesthesia 2mg/kg IV Go to Section 3 Treatment
guidelines
mmol/L mmol/L
<2 40
Section 6 Analgesia 0.250.5mg/kg IV Go to Section 3
11i
Treatment 34 30
45 20
guidelines
Toolbox Lidocaine hydrochloride >5 None

Broad complex tachycardia 50mg IV Repeat every 5 mins as required
Prednisolone
Section 7 (max dose 200mg) Max dose 200mg
Asthma adult 40mg PO Reducing dose daily
Local anaesthesia 1% solution Max dose 200mg
Operational formulary (10mg/ml) Quinine
Malaria 20mg/kg IV Max dose 1400mg
Magnesium sulphate
Section 8 Asthma (adult) 1.22g IV Over 20 minutes Recombinant Factor VIIa
Broad complex tachycardia 50% 5ml IV In 30 minutes (consultant use only)
Policies Intractable haemorrhage 100mcg/kg IV Stat dose:
Metoclopramide
Can repeat after 20 minutes
Nausea/vomiting 10mg IV/IM 8 hourly max
Blast lung 80mcg/kg (Anecdotal evidence only for
Section 9
Midazolam benefit)
Sedation 210mg IV (adults) Titrated
Documentation and audit Paralysing agent when suxamethonium contraindicated Go to Section 3
3d
treatment
Morphine 11i
guidelines
Section 10 Myocardial infarction & ACS 510mg IV Go to Section 3 Treatment

guidelines
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Emergency drugs formulary Critical care: IV drug infusions 1-2a
Operational
Introduction Operational formulary 1 (Contd) Operational formulary 2a formulary
Section 1 Drug Dose Interval

Actrapid 50iu made to 50mls with 0.9% NaCl
Preparation Salbutamol (nebuliser) 5mg NEB QQH PRN Infuse via peripheral or central line Change infusion line 24 hours
Asthma (adult)
Section 2 Salbutamol (infusion) Adrenaline 4mg made up to 50mls with 5% dextrose
Asthma adult 5mg in 500ml sodium chloride 0.9% or glucose 5%
Incident management Infuse via central line Change infusion line 72 hours
Dose (mcg/min) 3 4 5 6 7 8 9 10 11 Continuous blood pressure and
cardiac monitoring required
Section 3 Infusion rate (ml/min) 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 1.1
Pump rate (ml/hr) 18 24 30 36 42 48 54 60 66 Alfentanil 50mg made up to 50mls with 0.9% NaCl
Dose (mcg/min) 12 13 14 15 16 17 18 19 20 Infuse via peripheral or central line Change infusion line 72 hours
Section 4 Infusion rate (ml/min) 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 2
Amiodarone Loading dose infused over 1 hour
Transport Pump rate (ml/hr) 72 78 84 90 96 102 108 114 120
300mg in 100mls of 5% dextrose
Table adapted from West Mercia Clinical Guidelines
Maintenance dose infused over 24 hours
Section 5 900mg made to 500mls with 5% dextrose
Streptokinase
Thrombolysis 1500000 units IV Over 60 minutes (21mls/hr)
Pathways
Suxamethonium 3d Infuse via central line. Change infusion line 204 hours
Paralysing agent for RSI Go to Section 3 Continuous cardiac and blood
Supporting Guidelines Treatment
guidelines
pressure monitoring required
Section 6 Tenecteplase
During cardiac arrest or treatment
Thrombolysis 500600mcg/kg Stat
of VT with pulse amiodarone may
Toolbox Follow Tenecteplase with heparin as specified below: be given via peripheral line using
pre-filled syringe
Weight kgs Weight stones Dose Reconstituted volume
Section 7
Less than 60kgs Less than 9st 6lb 30mg 6mls Dobutamine 250mg made to 50mls with 5% dextrose
Operational formulary 6070kgs 9st 7lb to 11st 35mg 7mls Infuse via central line.
7080kgs 11st 1lb to 12st 8lb 40mg 8mls Continuous blood pressure and
Section 8 8090kgs 12st 9lb to 14st 2lb 45mg 9mls
cardiac monitoring required
Policies over 90kgs over 14st 3lb 50mg 10mls

Dopamine 200mg made to 50mls with 5% dextrose
Maintenance infusion
Infuse via central line. Change infusion line 72 hours
Section 9 Weight Heparin bolus (concentration 1000 units per ml)
Continuous blood pressure and
Less than 67kgs 4000 units 0.8ml per hour (800 units per hour) cardiac monitoring required
67kgs or above 5000 units 1ml per hour (1000 units per hour)
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Critical care: IV drug infusions Critical care: Sedation guidelines 2a-b
Operational
Introduction Operational formulary 2a (Contd) Operational formulary 2b formulary
Section 1 Key points

Furosemide 50mg made to 50mls with 0.9% NaCl Sedation must be managed effectively.
Preparation Infuse via peripheral or central line Change infusion line 72 hours When commencing a sedative infusion administer a loading dose (bolus) titrated to effect.
When increasing a sedative infusion administer a bolus titrated to effect and then increase
Section 2 Magnesium sulphate 10mls (5g) made to 50mls with 0.9% NaCl. the infusion by a small increment and reassess.
Infuse over 1 hour
Incident management Combinations of sedatives that act via different mechanisms are more effective than single
Infuse via peripheral or central line Change line 72 hours agents at high doses.
Section 3 Tolerance to sedatives develops more quickly at high doses.
Midazolam 50mg made to 50mls with 0.9% NaCl
Treatment guidelines Infuse via peripheral or central line Change line 72 hours
Section 4 Morphine 50mg made to 50mls with 0.9% NaCl

Infuse via peripheral or central line Change line 72 hours
Transport
Section 5 Noradrenaline 4mg made to 50mls with 5% dextrose

Infuse via central line. Continuous Change line 72 hours
Pathways blood pressure and cardiac
monitoring required
Potassium chloride 39mmols in 100mls 0.9% NaCl
Section 6 given over 12 hours
Infuse via central line. Continuous
Toolbox cardiac monitoring required
Section 7 Propofol 1% undiluted

Section 8 Streptokinase 1.5 million units in 100mls 0.9% NaCl

over 1 hour
Policies Continuous cardiac monitoring
Section 9 Vecuronium 50mg in 50mls of water for injections

(powder reconstituted with water)
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Sedation scoring Antibiotic prescribing guidelines 3-4
Operational
Introduction Operational formulary 3 Operational formulary 4 formulary
Section 1 The patients sedation level should be assessed and documented hourly.
Key points Key Points from Antibiotic Policy
The score can be used as an objective measurement in order to promote effective
Preparation management of sedation. Right Drug, Right Place, Right Route
The desired level of sedation (i.e. Sedation score) must be considered for each individual Appropriate Dose (high enough)
Section 2 patient according to circumstance. STOP when no longer indicated
There will always be exceptions and some patients to whom the scoring is not applicable. Target drug whenever possible to likely pathogen(s)
Incident management
Section 3 Score Sedation level Guidelines
Treatment guidelines Operation Restraints

3 Agitated and restless Give a bolus. Start or increase infusion Knowledge of local microbial epidemiology is helpful
Section 4 Apply to Military & Civilian patients
2 Awake and uncomfortable Give a bolus. Start or increase infusion Modify treatment once microbiology results available
Transport OR with clinical microbiology/infectious disease advice
Therapeutic drug monitoring is NOT available
Section 5 1 Aware but calm No change
Multi-drug resistant organisms ARE important in
Pathways deployed facilities, and antibiotic policies are integral
0 Roused by voice Try decreasing infusion rate part of infection control
-1 Roused by touch Try decreasing infusion rate
Section 6
Toolbox -2 Roused by painful stimuli Stop infusion Empiric Antibiotic Therapy Guidelines (Role 3)
First Line Therapy Penicillin Allergy Additional Notes
Section 7 Restart infusion at lower rate when sedation
-3 Unrousable CNS Infection
score is at the desired level
Operational formulary Bacterial Meningitis Ceftriaxone 2g 12 hrly Meropenem 2g iv 8 hrly
(see notes on Penicillin allergy)
If the patient is considered at
risk of Penicillin / Cephalosporin
resistant pneumococcal infection
A Natural sleep then additional therapy will be
Section 8 required pending CSF culture &
sensitivity results.
Policies P Paralysed Suggested therapy :

add Linezolid 600mg iv 12 hrly
to standard regimen
Section 9 Cerebral Abscess Ceftriaxone 2g daily
+ Metronidazole 500mg iv 8 hrly
Documentation and audit + Flucloxacillin 1-2g iv 6 hrly
Viral Encephalitis Aciclovir 10mg/kg iv 8 hrly
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Antibiotic prescribing guidelines Antibiotic prescribing guidelines 3-4
Operational
Section 1 Empiric Antibiotic Therapy Guidelines (Role 3) Empiric Antibiotic Therapy Guidelines (Role 3)
First Line Therapy Penicillin Allergy Additional Notes First Line Therapy Penicillin Allergy Additional Notes
Preparation
Respiratory Tract Skin & Soft
Infection Tissue Infection
Section 2 Hospital Acquired Co-amoxiclav 1.2g iv 8 hrly Levofloxacin 500mg The treatment of ventilator associated Cellulitis Flucloxacillin 1-2g iv 6 hrly Management of skin & soft tissue infections may
Pneumonia po / iv once daily pneumonia (VAP) should be guided be affected by consideration of both meticillin-
Abscess(es) / Flucloxacillin 1-2g iv 6 hrly
Incident management Onset <5 days: Piperacillin/Tazobactam 4.5g iv Levofloxacin 500mg
wherever possible by the results of
surveillance cultures. Furunculosis
resistance and/or the possible presence of the
Panton-Valentine Leucocidin (PVL) gene. As
8 hrly po / iv once daily Empiric treatment of VAP occurring within Clindamycin 300-600 resistance patterns vary greatly between strains,
Acute Flucloxacillin 2g iv 6 hrly mg po 6 hrly
+/- Teicoplanin 400mg 12 hrly +/ - Teicoplanin 400mg 12 48 hrs of intubation should be treated treatment should be guided by culture results
Section 3 for 3 doses then once daily hrly for 3 doses then once as for early onset hospital acquired
Osteomyelitis /
Pyogenic discitis /
(if staphylococcal infection
confirmed on culture suggest
wherever possible
thereafter daily thereafter (only if pneumonia. Empirical treatment of VAP Healthcare associated MRSA
Septic Arthritis add Rifampicin 300-600mg
Onset >5days: (only if patient considered at risk patient considered at risk occurring >48 hrs post-intubation should Suggested therapy
Treatment guidelines of MRSA infection* ) of MRSA infection*) be treated as for late onset hospital
po 12 hourly)
Linezolid 600mg po/iv 12 hrly
acquired pneumonia. Peri-orbital Co-amoxiclav 1.2g 8 hrly Community associated MRSA (+/- PVL)
(* the risk of MRSA colonisation (* the risk of MRSA cellulitis Suggested therapy
Section 4 / infection should be assessed colonisation / infection mild infections : - Doxycycline 100mg 12
with due consideration of both should be assessed with Diabetic foot Co-amoxiclav 1.2g iv 8 hrly hrly + Rifampicin 300mg po 12 hrly
local epidemiology and patient due consideration of both infections severe infections: - Linezolid 600mg po/iv
Transport factors). local epidemiology and 12 hrly + Clindamycin 1.2-1.8g 6 hrly
patient factors). + Rifampicin 600mg iv 12 hrly
MSSA (+PVL)
Aspiration Co-amoxiclav 1.2g iv 8 hrly Clindamycin 300-600mg Depending upon the material aspirated,
Section 5 Pneumonia po 6 hrly and severity of illness penicillin allergic
Suggested therapy
mild infections: - Flucloxacillin 500mg 1g
patients may require additional po/iv 6 hrly
Gram-negative antibiotic cover e.g.
Pathways Ciprofloxacin. Clindamycin 150-
severe infections: - Finezolid 600mg po/iv
12 hrly + Clindamycin 1.2-1.8g 6 hrly
300mg po 6 hrly + Rifampicin 600mg iv 12 hrly
Post-influenza Co-amoxiclav 1.2g iv 8 hrly Levofloxacin 500mg po Bacterial super-infections with
+/- Ciprofloxacin 500mg Septic arthritis in young people is commonly due
Supporting Guidelines pneumonia once daily Staphylococcus aureus, Streptococcus
pneumoniae and Haemophilus influenzae
po 12 hrly to staphylococcal infection. More rarely gonococcal
and meningococcal infection may be the
have all been described as pathogens
aetiology. In patients with severe sepsis or where
Section 6 post-influenza.
In patients with severe, necrotising
early Gram-stain fails to rule-out possible infection
with Gram negative diplococci, then appropriate
pneumonia complicating a recent flu-like
antibiotic treatment should be initiated pending
Toolbox illness, treat as for PVLstaphylococcal
pneumonia pending cultures.
culture results.
Suggested therapy:
Ceftriaxone 2g iv 12 hrly
Section 7 Exacerbation COPD Doxycycline 200mg po stat, Lumbar discitis in the elderly or those with
previous urinary tract sepsis may be associated
100mg daily thereafter.
with gram negative pathogens.
Operational formulary Suggested therapy:
Ceftriaxone 2g iv daily.
Necrotising Soft Linezolid 600mg iv 12 hrly The key treatment for necrotising soft tissue infections is aggressive surgical
Section 8 Tissue Infection + Meropenem 1g iv 8 hrly treatment. The first line regimen suggested will also provide good coverage
+ Clindamycin 900mg iv of resistant Gram-positive organisms including PVL-associated staphylococcal
6 hrly infections. This regimen is also appropriate for those with penicillin allergy.
Policies Consider patient isolation pending culture results liaise with infection control
team.
Section 9 Bite injuries Co-amoxiclav 1.2g iv 8 hrly Doxycycline 200mg

po stat, 100mg daily
All animal bites must be risk assessed for possibility
of rabies and tetanus and managed appropriately.
thereafter
Documentation and audit + Metronidazole 500mg
po 8 hrly
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Antibiotic prescribing guidelines Antibiotic prescribing guidelines 4
Operational
Section 1 Empiric Antibiotic Therapy Guidelines (Role 3) Empiric Antibiotic Therapy Guidelines (Role 3)
First Line Therapy Penicillin Allergy Additional Notes First Line Therapy Penicillin Allergy Additional Notes
Preparation
Skin & Soft Severe Sepsis -
Tissue Infection community
Section 2 Uncomplicated Trimethoprim 200mg po The treatment of all urinary tract infections should
acquired
Lower UTI 12 hrly be guided by urine culture whenever possible. No localising signs Ceftriaxone 2g once Meropenem 1g 8 hrly Patients presenting from the community without
Incident management Complicated Lower Co-amoxiclav 1.2g 8 hrly
There is increasing recognition of community-
onset urinary tract infections caused by coliforms
daily (see notes on Penicillin
allergy)
localising signs or symptoms may require empiric
broad spectrum antibiotic therapy. Malaria must
UTI +/- single dose of Gentamicin carrying extended-spectrum be excluded. Causes of this syndrome include
5mg/kg stat (max dose 500 beta-lactamase (ESBL) enzymes. Patients with meningococcal disease, invasive pneumococcal disease,
Section 3 / Acute mg) a history of ESBL-carriage or who are deemed staphylococcal bacteraemia, Group A beta-haemolytic
Pyelonephritis Ciprofloxacin 500mg po streptococcal bacteraemia and more rarely enteric
at high risk of carriage and who require empiric
12 hrly fever and leptospirosis. The recommended antibiotics
antibiotic therapy should receive a carbapenem.
Treatment guidelines This group of patients often have a history of provide adequate initial cover for these pathogens. If
persistent / recurrent urinary tract infection which a rickettsial infection or Q-fever is epidemiologically
is poorly responsive to first-line oral therapy. plausible then additional antibiotic therapy should be
Section 4 Suggested therapy: Meropenem 1g 8 hrly iv given pending culture results.
Suggested therapy:
add Doxycycline 100mg 12 hrly po
Transport Intra-abdominal
CVS Infection
Infection
Native valve Acute presentation:
Section 5 endocarditis Flucloxacillin 2g iv 4 hrly
Teicoplanin 10mg/kg
12 hrly for 3 doses, then
Biliary Tree Co-amoxiclav 1.2g 8 hrly Patients presenting
Infection i. during hospital admission with intra-abdominal
10mg/kg daily infection, or
Indolent presentation:
Pathways Benzylpenicillin 1.2g iv 4 hrly
+ Rifampicin 600mg iv
12 hrly
Peritonitis Co-amoxiclav 1.2g 8 hrly ii. with severe sepsis arising from community
secondary to onset intra-abdominal infections, should
Teicoplanin 400mg 12
stomach receive more potent broad spectrum antibiotic
hrly for 3 doses, then
Supporting Guidelines /proximal small
bowel perforation
once daily thereafter
+ Ciprofloxacin 400mg
therapy.
Suggested therapy:
12 hrly iv Piperacillin/Tazobactam 4.5g iv tds.
Section 6 Peritonitis Co-amoxiclav 1.2g 8 hrly +/- Metronidazole
Whilst Co-amoxiclav and Piperacillin/Tazobactam
secondary to 500mg 8hrly iv
provide sufficient anaerobic cover in most instances,
distal small bowel
Toolbox perforation / large
the addition of Metronidazole may be an option in the
presence of extensive faecal soiling.
bowel perforation
/ complicated There is no indication for the empiric use of anti-MRSA
Section 7 appendicitis or anti-fungal agents in the absence of ositive cultures.
Bacterial Ciprofloxacin 500mg Antibiotic therapy is not indicated in the majority of

Operational formulary Gastroenteritis po bd patients with uncomplicated diarrhoeal illness.
In patients with signs of sepsis, diarrhoea may be due
to a non-enteric source of bacteraemia / parasitaemia.
Section 8 Exclude malaria and consider treating as for

Sepsis no localising signs - pending cultures.
Policies
Section 9
Section 10
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Antibiotic prescribing guidelines
Introduction Operational formulary 4 (Contd)
Section 1 Empiric Antibiotic Therapy Guidelines (Role 3)
First Line Therapy Penicillin Allergy Additional Notes
Preparation
Fungal Infection
Section 2 Suspected
candidaemia
Fluconazole 12mg/kg stat
iv then 6mg/kg iv/po
Therapy with Liposomal Amphotericin may be
appropriate;
(or deep-seated once daily iii. In patients with suspected or confirmed
Incident management Candida infection) candidaemia or deep-seated fungal infection
with exposure to Fluconazole in the previous 4
weeks.
iv. In patients with candidaemia or deep-seated
Section 3 Candida infection due to a non-albicans
Candida species
Suggested therapy:
Treatment guidelines AmBisome) 1 mg/kg once daily increasing to 3mg/
kg daily.
The management of all patients with possible or
Section 4 confirmed invasive fungal infection should be discussed
with a clinical microbiologist.
Transport
Section 5
Intentionally blank
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Section 6
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Section 6

Section 7
Section 8
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Section 9 Section 8
Policies
Section 10
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Policies Policies Contents
Introduction
Policies
Introduction
POL Intro.1
Contents
Section 1
All clinicians are to be familiar with the Clinical CT guidelines ...............................................................Policies 1
Preparation content of CJOs Clinical Governance
Directive which encompasses all relevant Clinical Governance in the Defence Medical Services....Policies 2
Section 2 aspects of the various central and single
Service policies identified below.
Clinical operational infection control
Incident management These polices are extracts of selected
JSP 950 Medical Policy Leaflets that at Role 2e/Role 3 ........................................................................Policies 3
Section 3 are specifically relevant to the deployed
clinician, or provide a basis for policy in Communicable disease control ...........................................Policies 4
areas uncovered by SGPL.
Confidentiality & protection of patient information.....Policies 5
Section 4
Consent for examination and treatment Policies 6
Transport
Immunological protection of military personnel .........Policies 7
Section 5
Inoculation accidents to staff ..............................................Policies 8
Pathways
Management of irradiated and contaminated
Supporting Guidelines casualties ................................................................................. Policies 9
Section 6
Massive Transfusion Protocol ........................................... Policies 10
Toolbox
Medical support to persons detained by UK Forces ... Policies 11
Section 7
Prevention, identification, referral & follow up
Operational formulary of Leishmaniasis ..................................................................... Policies 12
Section 8 Preventing malaria in military populations ................. Policies 13
Policies
Religious beliefs guidelines ................................................. Policies 14
Section 9
Deaths on operations .......................................................... Policies 15
Treatment of Non Entitled Children on Operations ... Policies 16
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Clinical CT guidelines X
1
Policies 1
Policies
Introduction
A CT scanner may be available in a deployed medical unit. These guidelines specify the
Section 1 indications for a CT examination.
Preparation All requests for CT must be made only on the specific instruction of a consultant.
The CT scanner is to be used for emergency indications only or where the result will alter
Section 2 management or evacuation plans for the patient only. Under no circumstances is it to be
used for routine, non emergency cases.
Incident management If there is any doubt as to the appropriateness of the referral the Duty Radiologist is to be
contacted (maybe deployed or UK based)
Section 3 Pre-authorised indications1
CT may be undertaken for the following indications without prior discussion with the
Treatment guidelines Duty Radiologist.
Section 4 Acute stroke A policy of CT for most strokes as soon as reasonably possible is
to be encouraged, but at least within 48 hours, as this will ensure
Transport accurate diagnosis of the cause, site, and appropriate primary
treatment and secondary prevention.
Section 5 Headache: CT will provide evidence of haemorrhage in up to 98% of patients
Intentionally blank acute, severe; with SAH if performed within the first 48 hours of ictus. A lumbar
Pathways subarachnoid puncture should still be performed on all patients (delayed 12 hours
haemorrhage after ictus for xanthochromia) with suspected SAH, but with
(SAH) negative CT. CT is indicated in patients with acute onset headache
Supporting Guidelines with focal neurological signs, nausea or vomiting, or GCS (Glasgow
Coma Score) below 14.
Section 6
Head injury Any of the following clinical features indicates that there is a risk of a
Toolbox clinically significant brain injury requiring neurosurgical intervention:
GCS <13 at any point since the injury
Section 7 GCS 13 or 14 with failure to regain GCS 15 within 2 hours of injury
Suspected open or depressed skull fracture
Operational formulary Any sign of basal skull fracture (haemotympanum, racoon eyes,
CSF otorrhoea, Battles sign)
Section 8 More than one episode of vomiting
Age >64 years
Policies Post-traumatic seizure
Coagulopathy, including anticoagulant therapy
Section 9 Focal neurological deficit
Documentation and audit Contd on next page
Section 10 1 Modified from Royal College of Radiologists: Making the Best Use of a Department of Clinical Radiology: Guidelines for Doctors.
Fifth edition
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Clinical CT guidelines Clinical CT guidelines X
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Policies 1 (Contd) Policies 1 (Contd)

Policies
Introduction
Section 1 Head injury (Contd) The following two features in the absence of any of the above Indications requiring radiological approval
indicates a risk of a clinically significant brain injury that does CT for the following indications may only be undertaken after discussion with the Duty
Preparation not require neurosurgical intervention: Radiologist (may be deployed or UK based).
Retrograde amnesia of greater than 30 minutes
Dangerous mechanism of injury: pedestrian struck by motor
Section 2 vehicle, occupant ejected from a motor vehicle, fallfrom a Altered level of Enhanced CT of the brain may be of value in detecting
height >3 feet or 5 stairs consciousness without cerebral abscess or tumour. Contrast should not be given
Incident management Cervical spine in CT may be used as an alternative to XR, and is essential ifthe
trauma ifacute stroke is suspected.
unconscious patient cervico-thoracic junction is not clearly seen on XR. Acute abdominalpain CT should not be used as a screening tool for undiagnosed
Section 3 with head injury CT of the whole cervical spine at the time of brain scan. warranting hospital abdominal pain. The most clinical benefit will be gained from
admission for a request which poses a particular diagnostic question, and
Treatment guidelines Thoracic spine trauma Detailed analysis of bone injury is achieved with CT axial considerationof which has been preceded by both a thorough clinical appraisal
images and reconstructions. surgery of the patient and plain films of the abdomen and erect chest.
Section 4 Lumbar spine trauma Detailed analysis of bone injury is achieved with CT axial Pancreatitis: acute CT with IV contrast enhancement is used early in severe cases
images and reconstructions. to assess the extent of necrosis, which is helpful in prognosis.
Transport
Major trauma: Sensitive and specific. Indicated unless patients condition is Pelvis: fall with inability CT can be useful when reported XR is normal or equivocal.
abdomen/pelvis too unstable. Ultrasound can show free fluid, but is less sensitive to weight-bear
Section 5 at identifying solid organ damage.
Urethral bleeding and Delayed post-contrast CT should be considered if urethra is
Pathways Major trauma: chest Especially useful to exclude mediastinal haemorrhage and pelvic injury normal and haematuria is present to assess for other urinary
aortic injury. tract injuries.
Supporting Guidelines Chest pain: aortic CT with IV contrast is the most reliable and practical technique. Soft tissue neck injury May be valuable when there is penetrating
dissection or complex trauma.
Section 6
Complex limb trauma CT to show complex fracture and/or vascular damage Facial trauma CT is indicated with major facial trauma where the
Toolbox isindicated. investigation will affect immediate management.
Polytrauma CT Head, neck, chest, abdomen and pelvis +/- CT angiography
Section 7 is indicated in cases of polytrauma particularly blast related Other indications
injuries due risk of significant occult injury. All other requests for CT must be discussed with the Duty Radiologist.
Operational formulary Pulmonary embolism Indicated only when clinical probability is high (see below). Referrals from outside Field Hospital
Spiral CT is as accurate as pulmonary angiography in the Direct referrals for CT from outside the Field Hospital will not be accepted. All potential
Section 8 detection of pulmonary emboli and reliably excludes clinically referrals must be discussed with the relevant Field Hospital consultant. If the consultant
important pulmonary embolism. considers it to be an appropriate case they are to arrange the CT examination. The Field
Policies Hospital consultant is responsible for the care of the patient whilst on site and is responsible
Suspected ureteric CT is indicated as an alternative to IVU as it is more sensitive
to ensure that appropriate action is taken with the scan result.
colic and specific. Dose is 1.5 times greater than a 5 film IVU.
Section 9
Paediatric Contrast Dose
Documentation and audit Clinical probability is defined by (A) breathlessness and tachypnoea, with or without The volume of intravenous contrast administered in paediatric patients depends on
chest pain or haemoptysis that occurs (B) in the absence of another reasonable estimated weight. A guideline dose of 2ml of contrast per Kg.
explanation and (C) in the presence of a major risk factor. A + B + C = high probability;
Section 10 A + either B or C = intermediate probability; A without either B or C = low probability.
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Clinical Governance in the Clinical operational infection 2-2e-3
Introduction Defence Medical Services control at Role 2e/Role 3 Policies
Section 1 Policies 2 Policies 3

Preparation Clinical Governance (CG) definition Infection control
Infection control comprises prevention and control of infectious disease both communicable
Section 2 A framework through which health care organisations are accountable for continually and non-communicable.
improving the quality of their services and safeguarding high standards of care by
Incident management creating an environment in which excellence in clinical care will flourish.2 Universal precautions are to be used to minimise the risk of cross infection between
patients and health care workers (HCWs).
Section 3 Within the Role 2 Enhanced/Role 3 clinical setting universal precautions should be used by
The Defence Medical Services (DMS) aspires to match the same standards of care and
all HCWs regardless of the known infectious state of a patient and are to be adopted when
supervision as provided by the NHS.
handling blood, body fluids, secretions, excretions and contaminated items.
Treatment guidelines Good practice, evidence based medicine and audit are to be systematically adopted.
All those involved in health care delivery are to work in teams to a consistently high Hands
Section 4 standard and identify ways to provide safer and better care for their patients. Hands of HCWs are the most common vehicle by which microorganisms are transmitted.
Risks and hazards to patients are to be reduced to as low a level as possible, creating Effective hand decontamination by HCWs is the single most effective action that can be
Transport asafety culture throughout the health care system. taken to prevent the spread of infection.
Patient-centred care is at the heart of health care provision. Patients must be kept fully Alcohol gel and antiseptic hand scrubs should be available in conjunction with soap and
Section 5 informed and given the opportunity to participate in their care and the development/ water and their use should be confined to clinical areas only.
implementation of CG.
Pathways Developing and implementing effective CG will significantly reduce the risk of an adverse PPE
event for the patient, and significantly reduce the risk of litigation for the practitioner/ PPE should be used by all HCWs where any direct contact with body fluids from patients
Supporting Guidelines commander. is anticipated. PPE comprises the following: gloves, apron, mask and eye protection.
The aims of CG are as follows: Sharps comprise needles (hollow bore or suture), scalpels, stitch cutters, glass ampoules,
Section 6 sharp instruments and bone/tooth fragments. Sharps safety within the clinical
To ensure that systems to monitor the quality of clinical practice are in place and are
functioning correctly. environment is paramount and extreme care must always be taken.
Toolbox
To ensure that clinical practice is reviewed and improved where appropriate. Clinical waste
Section 7 To ensure that clinical practitioners meet standards, such as those issued by the national Clinical waste consists of waste generated from patient care and comprises five groups:
professional regulatory bodies. Group A consists of soiled surgical dressings, swabs and all other contaminated waste
Operational formulary To identify points of accountability and responsibility throughout the Chain of Command. from clinical areas. It also includes materials other than reusable linen from cases of
infectious disease, all human tissue from hospitals or laboratories and all related swabs
The Joint and Operational environment and dressings.
Section 8 PJHQ is responsible for the coordination and implementation of CG in the Joint and
Group B consists of discarded syringes, needles, cartridges, broken glass and any other
Operational environment.
Policies contaminated disposable sharp instrument or item.
PJHQ is responsible for directing local Commanders Medical to implement and report Group C consists of clinical laboratory waste.
on CG within their areas of responsibility and for directing how CG is to operate in these
Section 9 environments through CJOs CG Directive.
Group D consists of drugs or pharmaceutical waste.
Group E consists of items used to dispose of urine, faeces and other bodily secretions
They, in turn, will be supported by designated senior medical and dental officers.
Documentation and audit orexcretions not found in Group A.
Section 10
2 Clinical Governance in Action: Quality in the new NHS. HSC 199/065. DH, London (1999)
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Clinical operational infection Communicable disease control 3-4
Introduction control at Role 2e/Role 3 Policies 4

Policies
Section 1 Policies 3 (Contd)

Preparation All clinical/domestic waste bags and sharps boxes must be secured and marked with the PJHQ is responsible for the provision of deployment-specific preventive medicine advice.
ward/department they have originated from. There is a statutory requirement to notify designated infectious diseases.
Section 2 All used linen (lightly soiled or not) from a patient not suspected to be infected, should be This is a responsibility of medical personnel in primary and secondary care units.
placed into a white plastic laundry bag. PJHQ is responsible for promulgating Medical Warning Notices based on Medical Intelligence
Incident management Linen heavily blood stained or soiled and/or from an infected patient should be placed in a Assessments, detailing the particular preventive medical requirements for joint deployments.
water-soluble bag and then inside a red plastic bag and marked with the ward/department Formal notification is only part of communicable disease surveillance and does not include
Section 3 it has originated from. some diseases whose importance reflects their potential severity, or on the management of
Blood spills incidents occurring on operations or other joint deployments.
Blood spills may expose HCWs to blood borne viruses (BBV) or other pathogens. Successful communicable disease control depends on the adoption of appropriate
preventive measures and training to minimise the risks of incidents. Once an incident has
Section 4 The cleaning of blood spill can be carried out more safely if any pathogens in the spillage
occurred, timely diagnosis and reporting (even if the diagnosis is only provisional) is an
are first destroyed by a disinfectant.
essential factor in the identification of the problem and the institution of control measures.
Transport The two methods of achieving this are by the use of high concentration granules
or a hypochlorite solution of 10000 parts per million (ppm).
Section 5 Service sources for communicable disease advice
Isolation & Cohort Nursing
Pathways Isolation & Cohort Nursing is required to prevent the transfer of microorganisms from Royal Navy
infected patients to other patients and/or staff. There are two types of isolation nursing: Telephone: Civilian 02392 768101 Military 93806 8101
Supporting Guidelines Source Isolation/Cohort Nursing. This confines the infection by nursing the infected
patient away from other non-infected patients and thus preventing transmission by
DII: INM-OMS-PHCons
Section 6 blocking the routes of spread.

Army
Protective Isolation. This confines the susceptible immunosuppressed patient(s) away
from other patients, thus preventing exposure to microorganisms and infection by various Telephone: Civilian 01276 412937 Military 94261 2937
Toolbox
routes. DII: AMD-AD Health and Assurance
Section 7 The Role 2 Enhanced/Role 3 hospital should have a designated isolation ward. This ward will
have to instigate source isolation/cohort nursing. Royal Air Force
Operational formulary Telephone: Civilian 01494 494333 Military 95381 4333
DII: Air-Health-Health Protection SO1
Section 8
HQ Surgeon General
Policies Telephone: Civilian 01543 34120 Military 94422 4120
DII: SG ACDS MedOpCap-CDS SO1
Section 9
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Confidentiality & protection Consent for examination 5-6
Introduction ofpatient information or treatment Policies
Section 1 Policies 5 Policies 6

Preparation All patients have the right to expect that information held about them will be kept in Consent from patients
confidence and will not be used or revealed inappropriately. In this respect, the rights
1. Consent needs to be obtained before you examine, treat or care for patients.
Section 2 ofService personnel are identical to those enjoyed by civilians.
2. Adults are always assumed to be competent unless demonstrated otherwise. The question
Confidentiality is defined as the statutory and professional duty to safeguard personal
Incident management to ask if you have any doubts about their competence is, Can this patient understand and
information by preventing its improper disclosure.
weigh up the information needed to make the decision?
Confidentiality is an essential component of the clinical consultation, and any perception
Section 3 3. Patients may be competent to make some health care decisions, even if they are not
that personal information may be improperly disclosed will seriously undermine the trust
competent to make others.
between the patient and health care professional. However the sharing of information
Treatment guidelines is integral to the auditing of clinical practice and the planning of health services. It is 4. Patients can change their minds and withdraw consent at any time.
important that the boundaries between patients expectations of confidentiality and the 5. Young people aged 16 and 17 are presumed to have the competence to give consent
Section 4 information needs of both the health care provider and the organisation are clearly defined. forthemselves.
Protection against improper disclosure of personal information and informed 6. Younger children who understand fully what is involved in the proposed procedure can also
Transport consent to appropriate disclosure underpin the principles of medical confidentiality. give consent. In other cases, someone with parental responsibility must give consent on
Information concerning the physical or mental health of an individual has the legal status the childs behalf, unless they cannot be reached in an emergency.
Section 5 of sensitive personal data under the provisions of the Data Protection Act 1998 and must 7. It is always best practice for the person actually treating the patient to seek the patients
be safeguarded in accordance with the Act. consent.
Pathways Caldicott Report3 set out the principles under which each organisation should handle 8. Patients need sufficient information before they can decide whether to give their consent.
confidential patient information: The patients consent may not be valid if they are not offered as much information
Supporting Guidelines Justify the purpose(s). as they reasonably need to make their decision, and in a form they can understand.
Do not use patient-identifiable information unless it is absolutely necessary. Alltreatment options discussed must be documented in the notes.
Section 6
Use the minimum necessary patient-identifiable information. 9. Consent must be given voluntarily: not under any duress or undue influence from health
Access to patient-identifiable information should be on a strict need to know basis. professionals, family or friends.
Toolbox
Everyone should be aware of their responsibilities. 10. Consent can be written, oral or non-verbal. A signature on a consent form does not in itself
Section 7 Understand and comply with the Law. prove the consent is valid the point of the form is to record the patients decision, and
also increasingly the discussions that have taken place.
Personal information may not be disclosed to a patients employer without the patients
Operational formulary explicit consent. In exceptional circumstances only, this may be over-ridden by health and 11. Competent adult patients are entitled to refuse treatment, even where it would clearly
safety, operational, legal or security considerations. benefit their health.
Section 8 12. No-one can give consent on behalf of an incompetent adult. However, you may still treat
such a patient if the treatment would be in their best interests.
Policies
Section 9
Section 10 Source: Department of health 12 key points on consent. For more detail consult the Reference guide to consent
3 Report on the Review of Patient-Identifiable Information. NHS Executive (1997) for examination or treatment, available at www.doh.gov.uk/consent
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Immunological protection Inoculation accidents to staff 7-8
Introduction of military personnel Policies 8

Policies
Section 1 Policies 7
Preparation Wound contamination
Incidents where multiple casualties arise from a single contact such as IED, increase the Inoculation injury Sharps injury
Section 2 possibility of casualtys wounds being contaminated with blood, other body fluids or tissue Caused by needle, scalpel blade,
sharps injury bone or tooth fragments, and other
from another. This introduces the risk of transmission of blood borne viruses (particularly
Incident management Hepatitis B, Hepatitis C, and HIV). Where such an incident has occurred a risk assessment body fluid splash sharp objects contaminated with
should be undertaken to determine the correct course of action after the event. The risk human bite/scratch body fluids
Section 3 assessment should take into account the type of wound, level of tissue contamination and Splashes
source. A knowledge of the prevalence of BBV in the resident population is also required as is, Splashes of blood/body fluid into
Treatment guidelines for hepatitis B, prior vaccination status. Where post exposure action is required the following the eye or mouth, open cuts or
action is to be taken:
lesions on the skin
Section 4 a. HIV Wash and make wound bleed
One Combivir tablet (300mg zidovudine + 150mg lamivudine) b.d., and two Kaletra tablets Bites/scratches
under running water.
(200mg lopinavir + 50mg ritonavir) b.d. There is also a requirement to assess whether Human bites or scratches
Transport Splashes to the eyes/mouth
repatriation should occur in order to complete HIV PEP, counselling and follow up care.
should be washed with copious
Section 5 b. Hepatitis B amounts of water
Post exposure prophylaxis is required if there is no history of previous vaccination. If the
Pathways source is known to be HBsAG positive then the accelerated vaccination course at zero, one
month and 2 months should be given. In addition HBIG should be given. If the source is
felt to be at high risk but hepatitis B status is unknown, only the accelerated course should
Supporting Guidelines be given. A shorter accelerated course may be given to those over the age of 18. Engerix
B vaccine is the only vaccine licensed for this indication and should be given at day zero, Immediately MOD 2000 accident/incident form
Section 6 7and 21 days. must be completed
Inform head of department
c. Hepatitis C
Toolbox
There is currently no post exposure prophylaxis for hepatitis C. If hepatitis C is suspected,
then a baseline blood sample should be taken for serological testing. Repeat samples need
Section 7 to be taken at 3 and 6 months post exposure.
Operational formulary Service sources of advice on immunisations Identify whether or not the Obtain injured employee consent
source patient is an HIV/ for 10ml clotted blood to be tested
Defence Medical Services Department Hepatitis B/Hepatitis C risk for anti-HBS and stored
Section 8
Telephone: Civilian 020 7218 1433 Military 96218 1433
Policies Royal Navy
Telephone: Civilian 02392 625583 Military 93832 5583
Section 9 Army
Obtain source patient consent If a significant injury occurs from
Telephone: Civilian 01276 412938 Military 94261 2938
Documentation and audit Obtain 10ml clotted blood sample a known HIV source, prophylaxis
Royal Air Force for Hepatitis B/C and/or HIV within one hour should be offered
Telephone: Civilian 01494 494332 Military 95221 4332 after appropriate counselling
Section 10
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Management of irradiated Management of irradiated 9
Introduction and contaminated casualties and contaminated casualties Policies
Section 1 Policies 9 Policies 9 (Contd)

Preparation The early management of irradiated casualties can be divided into acute care, emergency Acute Radiation Syndrome
care and intensive care. Definitive care at Role 4 should involve pre-designated hospitals
Acute Radiation Syndrome (ARS) is an acute illness caused by irradiation of the body by a high
Section 2 with experience whenever possible.
dose of penetrating radiation in a very short period of time. The major cause of this syndrome
The basic principles of radiation management (time, distance, shielding) coupled with is depletion of immature parenchymal stem cells in specific tissues5.
Incident management the basic principles of casualty management (<C>ABCDE and CSCATTT) are enduring
The three traditional ARS Syndromes6
alongside the specialist aspects of radiation medicine.
Bone marrow syndrome (sometimes referred to as haematopoietic syndrome) the full
Section 3 This guidance provides a template of care from POW to Role 4 for operational radiation syndrome will usually occur with a dose between 0.7 and 10Gy though mild symptoms
exposures in remote locations where definitive/expert medical help is unobtainable for up may occur as low as 0.3 Gy. Survival rate of patients with this syndrome decreases with
Treatment guidelines to 48 hours. In all circumstances clinicians must use their clinical judgement and take advice increasing dose. The primary cause of death is the destruction of the bone marrow,
from SME whenever possible. The Institute of Naval Medicine maintains a 24 hour SME resulting in infection and haemorrhage.
Section 4 service contactable via +44 2392 768020.
Gastrointestinal (GI) syndrome: the full syndrome will usually occur with a dose between
Casualties may be conventional, irradiated, contaminated (externally or internally) or may 10 and 100Gy, but some symptoms may occur as low as 6Gy. Survival is extremely unlikely
Transport suffer combined wounds. Casualties with combined wounds have a significantly worse with this syndrome. Destructive and irreparable changes in the GI tract and bone marrow
prognosis. usually cause infection, dehydration, and electrolyte imbalance. Death usually occurs within
Section 5 Radiation produces deterministic (threshold effects) as well as stochastic (probability based) 2 weeks.
effects. For a given dose of radiation the risk/benefit of any therapy needs to be considered, Cardiovascular (CVS)/Central Nervous System (CNS) syndrome: the full syndrome will
Pathways and the long term psychological welfare of an individual must also be considered. usually occur with a dose greater than 50Gy, but some symptoms may occur as low as
Broadly speaking deterministic effects occur over 500mSv with 5% of individuals suffering 20Gy. Death occurs within 3 days. Death is likely due to collapse of the circulatory system
acute nausea and vomiting over 750mGy. Time to emesis provides a fair approximation of as well as increased pressure in the confining cranial vault as the result of increased fluid
Supporting Guidelines dose and prognosis above this level4. content caused by oedema, vasculitis, and meningitis.
Section 6 The three stages of ARS
Dose Relative Hazard
Prodromal stage: The characteristic symptoms for this stage are nausea, vomiting, and
Toolbox About 10 milli-Gray No acute effects possibly diarrhoea (depending on dose) that occur from minutes to days following
About 0.1 Gray No acute effects, subsequent additional risk of cancer about 0.5%, exposure. The symptoms may last up to several days.
Section 7 dependent upon dose rate Latent stage: In this stage the patient looks and feels generally healthy for a few hours or
even up to a few weeks.
About 1 Gray N & V possible, mild bone marrow depression, subsequent risk of
Operational formulary cancer 5%, dependent upon dose rate Manifest illness stage: In this stage the symptoms depend on the specific syndrome and last
from hours up to several months. Most patients who do not recover will die within several
Greater than 2 Gray Definite nausea, vomiting, medical evaluation and treatment required months of exposure. The recovery process lasts from several weeks up to two years.
Section 8
Policies
Section 9

5 CDC: Acute radiation syndrome www.bt.cdc.gov/radiation/index.asp
Section 10
4 IAEA: Diagnosis and Treatment of Radiation injuries. Safety Report, Series 2. Vienna (1998) 6 CDC: Radiation Emergencies (fact sheet) www.bt.cdc.gov/radiation/index.asp
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Intro
Management of irradiated Management of irradiated 9
Introduction and contaminated casualties and contaminated casualties Policies
Section 1 Policies 9 (Contd) Policies 9 (Contd)

Preparation Roles of care Dose estimation
Management is based on roles of care. Dose estimation will not initially be possible, and can often prove to be inaccurate.
Section 2 Anestimate can be extrapolated from the time to vomiting:
Role 1: This is based on <C>ABCDE. Exposed individuals should evacuate the area and
decontaminate themselves as early as possible. Radiation dose is directly related to
Incident management
radioactivity and exposure time and inversely proportional to distance from the source. Estimation of Dose Related to Onset
Casualties should undergo normal trauma management and early decontamination. Use of Vomiting (Single Acute Exposure)7
Section 3 antiemetics symptomatically and other countermeasures with SME advice.
<10 minutes >8Gy
Role 2: The management continues along <C>ABCDE pathway. Irradiated troops need to
Treatment guidelines be decontaminated, receive resuscitative treatment and be evacuated to specialist care. 1030 minutes 68Gy
Medical Triage: It is necessary to assess traumatic injury and medical conditions prior <1 hour 46Gy
Section 4
to consideration of radiation exposure. See Triage algorithms in Incident Management 12 hours 24Gy
guidelines.
Transport >2 hours <2Gy
5
Go to Section 3 Incident
Section 5 management
Alternative methods use lymphocyte counts at 6 hourly intervals utilising calibrated graphs,
Rapid Radiological Triage: and DNA dicentric counts in specialist laboratories.
Pathways Time to vomiting <4hours: Refer for immediate evaluation. Management of casualties initial
Time to vomiting >4hours: Refer for delayed evaluation (2472 hours) if no concurrent injury.
Supporting Guidelines Role 3: Continued medical management and surgical care as required. If available,
Initial management of casualties should be on <C>ABCDE principles. Triage should be
for conventional injury initially. Radiation doses sufficient to disable an individual within
consideration should be given to the use of appropriate chelating agents and cytokines. 14 hours signify a high and potentially fatal dose that requires assessment (or use of T4
Section 6
Role 4: Definitive care provided by Radiation Medicine specialists. category in MASCAL). If radiological contamination is considered likely no mouth-to-mouth
Toolbox or mouth-to-nose resuscitation should occur (even with a face shield device).
Radiation induced nausea and vomiting is a debilitating feature of acute radiation syndrome.
Nausea is controlled by the automatic nervous system, and vomiting by the vomit centre and Gross decontamination should occur at the earliest opportunity, but should not delay life
Section 7 Chemoreceptor Trigger Zone (CTZ). Radiation causes nausea and vomiting by either direct saving treatment. The removal of outer cloths will reduce contamination by 8590%.
effects on the brain or by release of serotonin and histamines: Contamination of casualties will not pose an immediate threat to medical personnel if
Operational formulary Nausea and vomiting associated with radiation usually occurs 30 minutes to several hours correctly managed from first principles. Decontamination teams should be supervised to
after exposure. ensure that they receive the lowest possible dose.
Section 8 5-HT receptor blockers have been shown to be effective against radiation-induced nausea The collection of samples to assist in dose estimation and further casualty management
and vomiting. has a high priority even in the early stages of treatment. These include wound swabs, nasal
Policies swabs, urine and faces (after 12 to 24 hours).
Section 9
Section 10
7 From IAEA Safety Report, Series 2, Table 8
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Management of irradiated Massive Transfusion Procotol 9-10
Introduction and contaminated casualties Policies 10

Policies

Preparation Management of casualties surgical Definition of massive transfusion
Surgical care should proceed routinely. Surgical decontamination may be necessary in a Massive transfusion is defined as:
Section 2 small number of cases (those with incorporated emitting foreign bodies). To achieve this The replacement of an equivalent amount of blood to an entire circulating blood volume
wound probes and portable ultrasound devices may be required. ofthe patient within 24 hrs; or
Incident management
Effective wound debridement is important as primary closure offers significant survival More than 10 units of red blood cells within 24 hours (which ever comes first).
advantages over delayed primary closure, but this window of opportunity closes between
Section 3 3648 hours. After this time surgery should be delayed until the recovery of the immune The military operational setting
system. Surgeons must use their best judgement as to which approach should be used. In the acute military operational setting, additional criteria include:
Treatment guidelines Visible radioactive particles should be removed, and a search made for beta and gamma The transfusion of over 4 units of red cells in 1 hour; or
emitters using a contamination probe in the wound. Alternatively, the wound should be
Section 4 swabbed and the swab exposed to a contamination probe until contamination levels are The replacement of 50% of the total blood volume in 3 hours; or
minimized. A rate of loss of >150ml/min.
Transport
Continuing medical care Principles of the DMS Operational Massive Transfusion Protocol (MTP)
Section 5 For casualties with a significant dose of radiation, the use of selective anti-infective therapy Activate avoidance of hypothermia by the use of fluid warmers and rapid infusion devices.
needs to be considered. A balance must be drawn between the inappropriate use of
Maintain the Hct at 35%.
Pathways antibiotics to reduce gut microbial load and the appropriate use in an infected casualty
whowill be at risk of overwhelming infection due to a radiation induced fall in leucocytes. Use of FFP to RCC in a 1:1 ratio as soon as practicable. Note that once patient is stable,
component therapy should be guided by laboratory and point of care testing.
The use of cytokine therapy should be considered in any casualty with a dose greater than
Supporting Guidelines 2Gy. This is a specialist field and will usually take place at Role 4. It involves the potential use Early use of cryoprecipitate in order to maintain the level of fibrinogen above 1.5g/l.
of a granulocyte-macrophage colony-stimulating factor.
Section 6 Early intervention with platelet support to maintain the platelet count above 100 x 109/l
The use of appropriate chelating agents should also be considered, especially Prussian Blue using UK (or more local source if appropriate) derived platelet components, or platelets
Toolbox and Ca-DPTA. This should ideally be given at the earliest opportunity particularly within the donated using field apheresis, both in preference to whole blood from the Emergency
first 46 hours8. These drugs appear to have few side effects and should be given to patients Donor Panel (EDP).
with a significant incorporated load. This will be assessed on clinical grounds, using judgement,
Section 7 Frequent measurement of FBC and coagulation studies to confirm successful application
the time of emesis, and the isotope as a guide. However, as identification of isotopes, body ofthe MTP.
burden and potential future risk vs treatment benefit may be difficult to calculate in the field,
Operational formulary these casualties may require urgent return to Role 4. The use of chelating agents will be at the Frequent measurement of calcium and potassium levels in order to identify the presence
direction of Radiation Medicine Specialists from the Institute of Naval Medicine. ofhyperkalaemia or hypocalcaemia so that appropriate therapy can be commenced.
Section 8 Appropriate intervention with rFVIIa in accordance with current military guidelines. It
Casualties should be evacuated at the earliest opportunity to a Role 4 hospital with
allspecimens to allow dose estimation and continued care. should be noted that rFVIIa should rarely be required
Policies
Regular assessments of the base deficit in order to monitor (along with hypothermia and
coagulopathy) the lethal triad associated with massive trauma.
Section 9
Section 10 8 The Radiation Emergency Assistance Centre www.orau.gov/reacts
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Massive Transfusion Procotol Massive Transfusion Procotol 10

Policies
Introduction
Section 1
Preparation
Prepare for Baseline
Control bleeding Prevent
Section 2 Massive ROTEM FBC, clotting,
Biochemical
Check/ Apply Tourniquets MAJOR TRAUMA Transfusion Fibrinogen, Ca 2+
disturbance
Incident management / Pelvic Binder (NAMEBAND) Chemistry + ABG
Repeat at intervals
Section 3
Shock Pack 1 Hypocalcaemia
Treatment guidelines 4+4 or 2+2 RCC Give 10mls 10% Titrate treatment to
+ FFP Calcium Chloride recommended goals.
Control Airway Call for
Section 4 for every Shock Pack Hct >0.3
Give oxygen SHOCK PACK (or equivalent) Plt >100 x 109/l
Transport Consider using early if Fibrinogen >1.5g/ l
Shock Pack 2 Pre-hospital blood Ionised Ca >1 mmol/L
Section 5 4+4+Platelets Temp >36oC
(consider Cryo) Locally defined CA and
Pathways MCF (ROTEM)
Assess and Resuscitate (Early Patient Shocked or Hyperkalaemia Stop non-surgical
surgery) Recognized Injury Pattern Consider Dextrose bleeding
Supporting Guidelines Shock Pack 3 Insulin Infusion
+ 1 Platelets + 1
Section 6
Pool Cryo
Toolbox Resistant coagulopathy
IO / IV Access. Consider:
Section 7 Maintain normal body Large bore central IV access Titrate treatment Further
temperature Baseline bloods incl Blood Group Resuscitation
Operational formulary Send to Lab More components
TXA if fibrinolysis
1. Confirm identifier and process baseline bloods NovoSeven
Section 8 ASAP
Fresh Whole Blood
Policies 2. Record nationality and age of patient at request
1g Tranexamic Acid bolus 3. Use group specific components and goal directed
Minimum ROTEM set =
(if < 3hr) (may be given treatment ASAP
Section 9 EXTEM, FIBTEM, APTEM pre-hospital) followed by 4. Resuscitate less severe trauma clinically with
1g infusion in 8hr fluids and or red cells
UK Platelets = dose of 4
US platelets = dose of 6 5. Guidelines are not a substitute for good clinical
UK Cryoprecipitate (cryo) = 5 judgement.
Section 10
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Medical support to persons Medical support to persons 11
Introduction detained by UK forces detained by UK forces Policies

Preparation Questioning of patients should not normally take place within a medical facility, or
JDP 1-10, 2nd edition contains the paramount doctrine for this subject matter. This during acute medical treatment. Commanders may request access to CPERS undergoing
Section 2 document is a distillation of that doctrine, designed as a quick reference for clinicians treatment for questioning. The request should be directed to the Medical Commander
on the ground. Clinicians are to ensure that they are fully conversant with JDP 1-10, 2nd of the relevant medical facility, who will take advice from the responsible physician. They
Incident management edition with particular reference to Chapter 2 (Standards of Treatment) and Chapter 3 should consider whether questioning could cause harm to the patients physical or mental
(Medical Support to CPERS) prior to deployment. In the case of any doubt or discrepancy, health. If they feel that it will, the request should be denied. The Formation Commander has
the full JDP should be consulted and takes precedence. the authority to overrule the Medical Commander, and order that access for questioning
Section 3 be given. Should this occur, the order should be in writing and the facts reported up the
medical chain of command.
Treatment guidelines All Captured Persons (CPERS) will be referred to as such, regardless of their specific legal
classification. Minimum Standards
The legal and ethical principles of medical care to CPERS are covered by a number of CPERS held by UK forces have the right to seek medical attention if they wish, and must not
Section 4 national and international legal standards. In addition to these, all clinicians remain bound be prevented from doing so at any time.
by their normal standards of professional conduct, and will be judged against these.
Transport Health professionals must remain clearly focussed on the provision of clinical care, for the Interpreters must be provided if needed.
sole purpose of evaluating, protecting or improving physical and mental health of patients. The services of a qualified general practitioner and dentist must be available to all
Section 5 Medical care should be provided impartially, and solely on the basis of need. Medical staff detention facilities.
should at all times remain mindful of their duty to act in the best interests of their patients.
Pathways CPERS are entitled to the same standard of medical care as would be provided to UK Forces In addition, all CPERS must be offered a medical examination as follows:
personnel in the same location.
Supporting Guidelines As early as reasonably practicable and in any case within 4 hours of capture unless
Certain acts, specifically prohibited by Medical Personnel, are as follows: there are compelling circumstances making such examination impossible. The
Section 6 Questioning CPERS on non-medical matters. examination should be by the most medically qualified person available. If the 4 hour
Certifying CPERS fit for questioning, captivity or punishment. This is a decision for time-line cannot be met, the reason(s) should be recorded in writing in the F Med 1026
Toolbox commanders in which medical staff have no part. (Medical Examination for CPERS).
Using medical skills or knowledge to assist in questioning of CPERS. The Commander responsible for the CPERS facility must ensure that interrogation
Section 7 Restraining CPERS, other than that needed for the protection of their physical or (as distinct from tactical questioning) does not take place until the CPERS has been
mental health, or that of other persons. The restraint must be proportionate, and the medically examined by a qualified doctor.
Operational formulary minimum needed.
Photographing CPERS. Forensic photography is the responsibility of the Service The purpose of this examination is to identify any health needs the CPERS may have, and
Section 8 Police. Clinical photography may, however, be required in some circumstances. This should be documented on F Med 1026 (Medical Examination for CPERS). The CPERS has the
requires written consent from the CPERS and Commander Medicals authority. The right to decline medical examination, and this should be recorded.
Policies photographs must remain in the medical records, and be protected as such. This will
not normally happen outside of hospital. Should a CPERS be held for prolonged periods, regular medical examinations should
Section 9 be conducted as laid down in JDP 1-10 at least monthly, preferably once weekly and
even more frequently as the clinical situation merits as decided by the responsible
Medical staff can, and should, feel free to recommend to commanders that a CPERS medical officer.
is medically unfit for a specified activity. This may include questioning or captivity. CPERS held in isolation, or who are felt to be at increased risk to health for any reason,
The commander must decide whether or not to accept this recommendation. The must be seen daily.
Section 10 recommendation and decision should both be recorded in the patients clinical record.
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Medical support to persons Medical support to persons 11
Introduction detained by UK forces detained by UK forces Policies
Section 1 Policies 11 (Contd) Policies 11 (Contd)

Preparation Medical staff should be prepared to see any CPERS who requests assistance, or to whom In addition, Medical staff are to examine all ranks of prisoners of war before they commence
their attention is directed. CPERS should be notified that they have the right to request work and thereafter at least once a month. Medical staff are to grade prisoners of war as a
Section 2 medical attention, and should be advised how to do so. result of these inspections as either:
Incident management If a CPERS requires admission to hospital: Fit for heavy work, fit for light work or not permitted to work
He should be transported to the Emergency Department.
Section 3 An escort should be provided from the holding facility, and the CPERS should be In accordance with good medical practice, documentation of this examination is to be
supervised by them at all times during the inpatient stay. regarded as medical records and treated accordingly in terms of storage and confidentiality.
Treatment guidelines Difficulties in proving an appropriate escort must not delay medical treatment. Clearly, if there is a change in the medical condition of the CPERS, a further examination
The Medical Commander of the medical facility at which the CPERS is being treated should be conducted to determine fitness for employability and the medical records updated
should be informed immediately the CPERS enters the facility and preferably before accordingly.
Section 4
arrival to allow for appropriate preparation.
Transport Hygiene
It is a responsibility of commanders to provide CPERS with clean and sanitary facilities, as
well as adequate food and water. Medical staff may be requested to advise in this, and
Section 5 If a CPERS requires outpatient treatment:
have a duty to inform commanders if they feel the facilities are substandard. Environmental
The time, date and location of the appointment should be communicated to the health assistance should also be requested if required. Matters of concern should always and
Pathways responsible commander. immediately be documented and brought to the attention of the responsible commander
It is the duty of the commander to ensure that the appointment is kept. and medical chain of command.
Confidentiality and Consent
Section 6 Special Categories Such information as injuries, distinguishing marks, immunisation history, blood group
Special procedures and heightened health surveillance may be required for some CPERS and allergies will be regarded as confidential if obtained through a medical examination
Toolbox categories - especially children, juveniles, pregnant women, nursing mothers and vulnerable and consultation. If it is in the interests of the CPERS to divulge this information then
people. They should be provided with culturally and medically appropriate care, including ante they should be encouraged to do so. For example, an immunisation history will help
Section 7 and post natal care if required. ensure necessary immunisation cover as required and a declaration of allergy status
The following definitions are applicable within JDP1-10: would be beneficial to avoid exposure to allergens whilst a CPERS is held in captivity.
Operational formulary Sex, age, height, weight, eyes, skin and hair descriptions are not regarded as medically
confidential information because identification is in the patients best interest if being
A vulnerable CPERS is defined as an treated within legitimate legal authority, and these factors are obvious within any
Section 8 normal social contact. In cases of doubt concerning the release of medical information,
individual who by reason of mental
Captured or other disability, age or illness, the supervising medical officer or the medical chain of command is to be consulted.
Policies Captured children Non-medical personnel should not be present during consultations, unless required for
juveniles are is or may be unable to take care
are defined as all protection of medical staff and in an interpreter capacity.
defined as all of himself or is unable to protect
Section 9 CPERS under the
CPERS aged 15, himself against significant harm
age of 15. Where medical information is required in completion of CPERS Administrative Forms,
16 or 17 or exploitation or is dependent
Documentation and audit on others for assistance in the DMS staff may wish to insert the words: Refer to F Med 1026 Part 2 for medical care
performance of basic physical instructions. Detailed information held in F Med 1026: Part 1 and other Defence Medical
functions. Services CPERS Medical Records.
Section 10
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Prevention, identification, referral Prevention, identification, referral 12
Introduction & follow up of Leishmaniasis & follow up of Leishmaniasis Policies

Preparation MCL should be considered in military personnel who have a mucosal lesion (usually
Leishmaniasis is a parasitic infection that is usually affecting the nose, mouth or ears) that:
transmitted by the bite of an infected sandfly Appears as a chronic ulcer, area of mucosal destruction or raised lesion.
Section 2
Leishmaniasis may present with lesions of the skin (cutaneous leishmaniasis), mucous Persists for greater than two weeks duration.
Incident management membranes (mucocutaneous leishmaniasis) or internal organs (visceral leishmaniasis). Is refractory to appropriate antibiotic therapy for bacterial infections of mucosa.
Its presentation varies enormously dependent on a number of parasite and host factors. Dental Presentations: If a Dental Officer suspects that a persistent intraoral lesion may
Section 3 Cutaneous leishmaniasis (CL) and its possible recurrence as mucocutaneous leishmaniasis be Leishmaniasis he should consult with the Medical Officer before determining the
(MCL), also known as espundia, are the forms of greatest concern to the Armed Forces. appropriate management of the case.
Treatment guidelines Prevention Any suspected case of CL or MCL is to be notified by the Medical Officer who first sees the
Education of military personnel. patient. Notification is to be carried out by both F Med 85 form and telephone or electronic
Section 4 Bite avoidance measures. communication with the appropriate single Service focal point for communicable disease
control.
Sandfly vector control.
Transport Reservoir host control. It is essential that all suspected CL or MCL cases are referred for specialist tropical disease
opinion and diagnostic testing. As management of leishmaniasis is highly specialised and
Section 5 Sandfly vector control varies according to mode of presentation and species of parasite involved, treatment is not
Where operationally possible, the control of sandfly vector populations is an essential part of to be initiated by non-tropical medicine specialists.
Pathways leishmaniasis prevention. The methods available include the use of knockdown and residual In deployed situations: If the Medical Officer has direct communications with the centres,
insecticides, to which sandflies are extremely susceptible, by suitably trained personnel. direct referral should be made with Aeromed being arranged according to extant procedures.
Supporting Guidelines Reservoir host control It is unlikely that Aeromed will be required as a priority.
Where operationally and environmentally possible, the control of potential reservoir hosts
Section 6 (e.g. dogs and rodents) should be considered, although this may not be feasible. Contact details for key military communicable
Management disease control appointments
Toolbox
The successful management of suspected cases of CL and MCL depends upon six key principles: Royal Navy Army Royal Air Force
Section 7 Identification of suspected cases. SO1 PHM, Office of the Army Health Unit, Officer Commanding,
Notification of suspected cases. Medical Director General Army Medical Directorate, Communicable Disease
Operational formulary Referral of suspected cases. (Naval), Room 139, Former Army Staff College, Control Wing,
Diagnosis of suspected cases. Victory Building, Slim Road, Camberley, RAF Centre of Aviation
HM Naval Base, Surrey GU15 4NP. Medicine, RAF Henlow,
Section 8 Treatment of confirmed cases.
Portsmouth P01 3LS. Bedfordshire, SG16 6DN.
Follow-up confirmed cases.
Telephone: Telephone: Telephone:
Policies Identification Civilian 02392 723934 Civilian 01276 412931 Civilian 01462 851515
CL should be suspected in military personnel who have a localised skin lesion that: Military 93802 3934 Military 94261 2931 Military 95381 6359
Section 9 Occurs within two years of visiting an area where leishmaniasis is endemic CHOtS: CASH:
as indicated by the Medical Intelligence Assessment for the country involved. 2SL-MDGN-S01PHM AMD-Med Int SO2
Documentation and audit Appears as a chronic ulcer or crusting lesion.
E-mail: E-mail: E-mail:
Persists for greater than two weeks duration. so1phm@dial.pipex.com zorria@amd.mod.uk occdc@rafcam.mod.uk
Section 10 Is refractory to appropriate antibiotic therapy for bacterial skin infections.
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Preventing malaria in Preventing malaria in 13
Introduction military populations military populations Policies

Preparation Protection follows the principles of awareness through education, bite prevention and Early diagnosis and treatment on deployment
chemoprophylaxis. A fourth principle, which is specific to the military, is the role of the chain
Medical personnel to whom individuals present with a history of feverish or flu-like illness
Section 2 ofcommand in the integration of malaria protection measures into plans and risk assessments.
ina malaria risk area are to be considered to have malaria until otherwise proven.
Chain of command Equipment to enable near-to-patient blood testing for malaria is to be deployed in support
Incident management
The chain of command is to identify where compliance cannot be achieved for operational of all deployments to malaria-endemic areas. In the context of current practice the two
reasons and is to acknowledge the risk that needs to be managed. Under these test kits that are issued are the ICT pF (NSN 6550-99-244-9080) and Optimal
Section 3 circumstances it is the responsibility of medical staffs to support the commander fully (NSN 6550-99-191-1311).
by developing appropriate contingencies to minimise the effects of any future malarial In the event of near-to-patient diagnostic tests being unavailable, the theatre medical
Treatment guidelines outbreak. instruction is to detail the location of the nearest appropriate laboratory services for
Awareness and education microscopic investigation.
Section 4
Military personnel are to be briefed regularly on the risks of malaria. In particular, they are If a diagnosis is made in theatre, medical staffs are to initiate treatment without delay in
to be briefed on protective measures before deployment on operations or exercises and the accordance with Clinical Guidelines for Operations (Treatment Guideline 9g) or alternative
Transport
message is to be reinforced whilst deployed. advice from CCDC issued in the theatre medical instruction or after direct consultation.
Section 5 Bite avoidance 9g

Go to Section 3
Bite avoidance measures include the wearing of appropriate clothing in malarial areas, Treatment
guidelines
Pathways using bed-nets, door and window screens and insecticide sprays. Clothes and bed nets
provide better protection when treated with insecticide. Once a diagnosis has been made, the patient is to be evacuated to the home base, or a
Supporting Guidelines Vector control
designated regional destination for further treatment and observation. The priority for
evacuation is to be based on clinical need. Advice and direction can be obtained from
Section 6 The reduction of the vector population at all stages of its life cycle, where operationally Aeromed staffs.
possible, remains an essential part of malaria prevention.
Toolbox Chemoprophylaxis
Chemoprophylaxis refers to the use of drugs to prevent malaria. Aircrew Divers
Section 7 DDAvMed Department of Underwater Medicine
Prior to and during any deployments, personnel are to take their antimalarial drugs exactly
HQ Personnel and Training Command Institute of Naval Medicine
Operational formulary as directed in the deployment medical instruction.
RAF Innsworth INM Alverstoke
Should personnel at any time experience what they believe to be Adverse Drug Events Gloucester Hampshire
Section 8 (ADEs) from their antimalarial drugs, they are to seek medical advice as soon as possible, Gloucestershire PO1 2DL
but are not to stop their antimalarial drugs without first obtaining such advice. GL3 1EZ
Policies Telephone: Telephone:
Monitoring of adverse drug effects Civil Voice: 01452 712612 Civil Voice: 02392 768026
Section 9 Extn 5816
Medical officers are to report any unexpected and/or severe adverse reactions to
antimalarial drugs to the Committee on Safety of Medicines, using the yellow card system. Civil Fax: 01452 510841 Civil Fax: 02392 504832
Documentation and audit Military Voice: 95471 5816 Military Voice: 93806 8026
Military Fax: 95471 5977
Section 10
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Preventing malaria in Religious beliefs guidelines 13/14
Introduction military populations Policies 14 Policies
Section 1 Policies 13 (Contd) This guidance presumes that the body/body parts are not part of
forensic evidence that may alter the availability to release for burial.
Preparation Malarial chemoprophylaxis and aircrew
There are a number of drugs that can be used for the chemoprophylaxis of malaria in
Section 2 Christianity Muslim Jewish Sikh
aircrew. The particular drug chosen from this list should be appropriate for the area to
bevisited and should be selected using the guidelines. The dying May wish to receive The patient needs Where operationally The patient should
Incident management patient the sacrament of to repeat or hear available the receive Spiritual
Drugs that may be used by aircrew for malaria chemoprophylaxis are as follows: the sick. repeatedly from Synagogue should comfort from
Chloroquine other Muslims the be informed in readings from
Section 3 Proguanil Shahada. accordance with the Holy Scriptures
Malarone (Proguanil 100mg and Atovaquone 250mg) patient/relatives performed by a
The patient should
Treatment guidelines Doxycycline extend his/her index
wishes. relative or by a
Granthi.
finger to signify his/
her continuing belief
Section 4 Aircrew likely to take Malarone, are to have a one-off trial period of the drug in the Shahada.
during a non-flying phase.
Members of the
Transport Aircrew are not to take mefloquine (Larium) as there is a small, but significant, family should sit with
risk of side-effects, which could degrade concentration and coordination. the patient to pray
Section 5 There is also a risk of cardiac conduction defects with this drug. and recite verses
from the Quran.
Aircrew who inadvertently take mefloquine, are to be grounded and made
Pathways unfit flying for a period of 3 months after the last dose of mefloquine. Death Routine Last Rites There should be There should be The family must be
are appropriate for minimal handling minimal handling asked if they wish
all Christians. of the body by of the body by to wash and lay
Supporting Guidelines Malarial chemoprophylaxis and divers nursing staff. Gloves
must be worn.
nursing staff. Gloves
must be worn.
out the body.
Divers may be prescribed Mefloquine if the risk assessment indicates it is the preferred The five Ks must be
Section 6 prophylaxis, however, they are to be made temporarily unfit for diving for 3 weeks. If they Deceased males The deceased will respected and left
should be attended not require full last with the deceased.
have experienced no side effects during this time, they may recommence diving while to by male staff offices as this will be
Toolbox continuing to take Mefloquine after consultation with a Medical Officer. and females by performed by the
Kesh (uncut hair)
female staff. Chevra Kedisha once Kanga (comb)
Divers who suffer adverse drug effects (ADE) while taking Mefloquine should be made Kara (iron bangle)
the body has left the
Section 7 temporarily unfit for diving until 4 weeks after their last dose and only recommence diving The body should
hospital.
be straightened Kachhera
after consultation with a Medical Officer. (undergarments)
immediately after Jewish Religious
Divers may be prescribed Malarone if the risk assessment indicates it is the preferred death, arms and Law requires burial Kirpan (a sword,
prophylaxis. However, they are to be made temporarily unfit to dive for 3 days. If they have fingers straight, to take place within if present to be left)
Section 8 experienced no ADE during this time they may recommence diving after consultation with ankles fastened 2472 hours of Cremation should
together with a death occurring.
a Medical Officer. Divers who suffer ADE whilst taking Malarone should stop diving until take place as soon
bandage.
Policies reviewed by a medical officer who should seek advice from a diving medical specialist at as possible.
Full last offices will
INM. Alternative malaria chemoprophylaxis is doxycycline. not be performed
Section 9 as this will be done
once the body has
left the hospital.
Post-mortem No religious Potential religious Potential religious Potential religious
objection objection objection objection
Section 10
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Deaths on operations Deaths on operations 15
Introduction Policies 15 Policies 15 (Contd) Policies
Section 1 Death on operations falls under the remit of the Coroners Office and may require post-mortem/
inquest following repatriation of the body. The following advice is to enable medical personnel
Preparation to assist in the preservation of evidence, thereby facilitating the forensic process. However, it is
emphasised that preservation of life takes priority over preservation of forensic evidence at Circumstances General advice Labelling
all times.
Section 2 Apparent Do not clean body after life extinct Label: Name/Rank/
natural causes/ pronounced. Number of casualty
Incident management Circumstances General advice Labelling sudden death If resuscitation attempt made cap off lines if known.
and tubes, which should remain in situ. Two labels should
Section 3 Body parts Do not clean. Label each part, if
Package body in body bag. be attached one
Clothing to remain in situ. determinable with
Clothing: Package separately. If items are on wrist and one on
Package individual parts separately the Name/Rank/
Treatment guidelines Number of casualty wet, place in separate polythene bags, if ankle. Labels should
unless certain from same body. be tied to body, not
where known. dry place in separate brown paper bags,
Use body bags. Plastic bags may be used to clothing.
Section 4 label and hand to Investigating Officer.
for individual parts and placed in body Include the Name/
Name/Rank/Number
bags. Rank/Number of the Suspicious Do not clean body after life extinct
Transport Medical Practitioner
of the Medical
circumstances pronounced. Practitioner who
who pronounced life If resuscitation attempt made cap off lines
Section 5 (A) On scene pronounced life
extinct. and tubes, which should remain in situ. extinct along with
Dead on arrival Do not clean. Label: Name/Rank/ Body should not be moved and medical date and time.
Pathways
Clothing to remain in situ. Number of casualty team should await Investigating Officer
Package in body bag. if known. unless operational environment dictates
Supporting Guidelines Two labels should otherwise.
To be evacuated with helmet and body
Section 6 armour inside body bag (for forensic be attached one If body moved:
examination). on wrist and one on Clothing: if already removed, package
ankle. Labels should separately. If items are wet, place in
Toolbox
be tied to body, separate polythene bags, if dry place in
Death after Body: do not clean after life extinct not to clothing. separate brown paper bags, label and
Section 7 medical pronounced; cap off lines and tubes hand to Investigating Officer.
Name/Rank/Number
which should remain in situ. Package Body: Package body in body bag.
intervention of the Medical
Operational formulary body in body bag.
Practitioner who Suspicious Do not clean body after life extinct
Clothing: if already removed, package pronounced life
separately. If items are wet, place in circumstances pronounced.
Section 8 extinct along with
separate polythene bags, if dry place in (B) Medical If resuscitation attempt made cap off lines
date and time.
Policies separate brown paper bags, label and facility and tubes, which should remain in situ.
hand to Investigating Officer. Body should not be packaged but left for
Section 9 the Investigating Officer unless there will
be a delay.
Removal of clothing:
Documentation and audit Any clothing removed should be packaged
If possible clothing should be cut around any entry or exit holes, however, in separate polythene bags, labelled and
Section 10 preservation of evidence should not compromise medical care at any time. handed to Investigating Officer.
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Deaths on operations Deaths on operations 15

Policies
Introduction
Section 1
Preparation Siting of graves

Weapon (all circumstances)
Graves are to be sited in accordance with the following guidelines:
Section 2 If a weapon accompanies the body, make safe
Graves should be as near to the scene of death as possible and should ensure ease of
Package and label with Name/Rank/Number of individual who carried out subsequent recovery and identification. Graves should, where possible, be sited out of sight
Incident management procedure along with time/date ofother troops. All graves should be placed in order to provide protection from water egress.
Where practical the same individual to remain with weapon until handed to Graves should be dispersed and where practical, individual remains should be buried
Section 3 Investigating Officer; if not feasible, sign into Armoury or secure place to ensure separately.
chain of evidence is preserved
Treatment guidelines With the exception of temporary burial sites (outlined above) the minimum depth of a
grave is to be one metre and the body is to be buried clothed and enclosed in a porous
body bag, poncho or cloth cover. Sleeping bags, plastic bags and other impervious
Section 4 wrappings should only be used as a last resort.
If any doubt exists as to the handling of a dead body advice should be
Transport sought from Forensic Dept HQ SIB (UK): 01980 673666 or 673643 Marking of graves
For aircraft crashes contact the Air Investigation Branch All graves are to be marked as follows:
Section 5 (Centre of Aviation Medicine) on 01462 851515 ext 8035 Individual graves
Pathways An appropriate religious marker, high enough to be seen, is to be placed on the grave.
Field burials At its base a bottle, can or other suitable container is to be half buried, open end downwards.
General This is to contain the following info written clearly in pencil or indelible ink on paper or card
Supporting Guidelines Where possible dead will be recovered for internment in a cemetery. If this is not possible an and then wrapped in polythene:
emergency burial will be performed. Initial burial of own and enemy dead should take place Service Number, rank, surname, forename or initials and sex.
Section 6
at the earliest opportunity at or near the place of death. Sub-unit 2iCs are responsible for National force, unit and date and place of birth if available.
ensuring that all burials are conducted in the correct manner and are documented. Date and cause of death.
Toolbox
Date and by whom buried.
Types of burial
Section 7 Religious faith, if known.
Individual burial
Each identified remains is buried in an individual grave. Trench/group burial
Operational formulary For these types of burial a marker or row identification stake is to be placed at the beginning
Group burial
Group burial uses a common grave for 2 or more individually identified remains. of each row and a list that coincides with the sequences of the bodies is to be maintained.
Section 8 One copy is to be attached to the Emergency Burial Report (F/CAS/753) and one copy is to
Trench burial beplaced in a suitable container at the base of the row marker.
Policies Trench burial is only to be used for mass casualties. A trench is prepared and individual remains
are laid in it side by side, thus obviating the necessity of digging and filling individual grave.
Section 9 Temporary burial
If no refrigeration is available, but the aim is to repatriate, the body can be placed into bags
Documentation and audit and buried to slow down decomposition, preventing further damage by the elements and
animal/insect activity. The body can then be recovered when appropriate. The recommended
depth of a temporary burial is between 4050cm, and it is further recommended to place a
Section 10
tarpaulin or similar covering over the burial site.
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Deaths on operations Treatment of Non Entitled 15/16
Introduction Policies 15 (Contd) Children on Operations Policies
Section 1 Policies 16
Preparation Burial services Medical forces on operations are configured to support only the deployed force and medical
manpower and material is scaled to that end.
Whenever practicable, a brief burial service of the appropriate religion is to be held. Examples
Section 2 of approved burial services for Christian, Jewish, Hindu, Islamic and Buddhist religions can be Current doctrine provides that the medical force can deliver support to non combatants in
found at Annexes A and E of Chapter 56 to the Guide to the Administration of personnel in War a disaster relief capacity or as part of the overall campaign. Doctrine specifies that any care
Incident management (AC 63481), which is to be carried by Coy Cps and BGLogO. given must be within existing capability, must not impact on the mission, and must not
create a dependency among the local population. This doctrine fully recognises the duty
Emergency burial report under Common Article 3 of the Geneva Conventions requiring that the wounded and sick be
Section 3
An Emergency Burial Report (F/CAS/753) is to be completed for each emergency grave by the collected and cared for but does not fully acknowledge the moral and ethical imperative to
2iC of the Coy responsible for the burial. Once completed it is to be passed to RAOWO in B Ech render all necessary care to any individuals who might present at military medical facilities
via BG MAIN. The RAOWO is responsible for copying each report and sending one copy to whether or not it is within deployed capability.
Field Records (P20(Fd)) and retaining the other. While acknowledging an ethical obligation to treat civilians, defence doctrine remains that
Section 4
Personal effects deployed military medical facilities are configured to support the deployed force.
Transport All personal effects are to be removed and marked using one ID disc; the other is to be buried This policy provides a framework to help clinicians to identify at which point their clinical
with the body. An inventory is to be made (AFW 3190 in triplicate) and signed by an officer. responsibilities have been discharged and what actions need to be taken to ensure that
Section 5 One copy should be placed with the effects, the second forwarded to the Field Records civilian paediatric cases are retuned either to the local health economy or NGO facilities at the
through the RAOWO who is to retain the third. earliest opportunity that their condition allows.
Pathways Projectiles and fragmentation Ethical Rationale
Any projectiles and/or fragmentation should be recovered, if they are loose and on the surface It is accepted that medical support to the deployed force will continue to be configured
Supporting Guidelines of the body in order that they are not lost. They should be packaged in plastic containers, with to provide only acute services and that all post acute and chronic care and long term
padding, and handed to the RMP CSI on arrival. rehabilitation will be undertaken in the home base. Implicit in this is that a wounded
Section 6
member of the deployed force, who has completed the acute phase of his care but who has
Toolbox ongoing treatment needs, will be transferred from acute hospital care into the rehabilitation
phase of their treatment in the UK.
Section 7 Consistent with this principle, a wounded member of the local population, if admitted to a
UK Medical treatment facility, would also transfer from an acute Service facility to a chronic
Operational formulary provider in their home base no later than the point at which they had reached the end
of the acute component of their care pathway. Where this care is not available clinicians
Section 8 and commanders need to consider the best course of action on a case by case basis. For
example in the presence of a devastating brain injury or a high spinal cord transection
Policies
where the likely outcome is very poor it may be inappropriate to start critical care. Such
considerations are made by NGO. providers such as the International Committee of the Red
Section 9
Cross (ICRC) which does not usually provide ventilation for intensive care patients.
Documentation and audit Where cases have come to the end of the acute phase of their care and are ready for
transfer to a post acute or chronic care setting, it is acknowledged that in many operational
Section 10 theatres such a setting will be within the family/community or in medical facilities which
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Treatment of Non Entitled 16
Introduction Children on Operations Policies

Preparation may have significant capability and capacity shortcomings and may be associated with
greater risks of morbidity and mortality. Medical staffs must come to terms with this reality
Section 2 of modern expeditionary campaigning where our own treatment capability and ethical and
moral codes are at odds with the tactical reality of overwhelming demand.
Incident management Effects Based Operations (EBO)
DMS accepts the ethical and moral imperative to provide urgent life saving care to all those
Section 3 in need and inevitability that such cases will present to deployed medical treatment facilities
from primary care posts through the IRT to the deployed emergency room.
Treatment guidelines Principles
The current spectrum of operations imposes a specified and implied task on DMS personnel
Section 4 to manage and treat civilians from outside their core areas of practice e.g. children, the
elderly and pregnant women.
Transport The balance of clinical activity will always be in favour of treating the military population.
However, where personnel do become involved in treating paediatric cases, training
Section 5 and equipment will be provided to allow them to undertake a suite of additional clinical
interventions which will be required to meet the different clinical needs of these patients. Intentionally blank
Pathways There is a requirement for deployed personnel to be able to access paediatric advice from
specialists in the UK and this will best be achieved using current telemedicine capability.
Supporting Guidelines On operations where genuinely unforeseen crises arise for which material and equipment
has not been supplied or for which deployed clinical staff have not had basic training, MOD
Section 6 will still support and indemnify its practitioners who operate in a Good Samaritan capacity
using the skills, equipment and material to hand.
Toolbox Command Implications
In addition to providing care to civilian populations, there is a requirement for Force and
Section 7 Medical Commanders to be pro-active in identifying and liaising with key community
leaders and any deployed NGO healthcare providers who will be involved in the provision
Operational formulary of post-acute care. This includes local medical providers, members of the family of the
casualty and community leaders who will need to be advised as to what care is going to be
Section 8 provided within the military treatment facility, at which point that care will come to an end
and, most importantly, informing them when a casualty has reached the end of the acute
Policies care pathway and is ready for discharge, or transfer to a local medical facility.
Commanders must also provide appropriate moral support to clinical staffs to help them
overcome any negative feelings that they may have when discharging patients into an
Section 9
uncertain clinical setting.
Section 10
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Introduction
Section 1
Preparation
Section 2
Incident management
Section 3
Section 4
Transport
Section 5
Pathways

Section 6

Section 7
Section 8
Section 9
Policies
Section 9 Documentation
and audit
Section 10
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Intro Documentation Contents
Documentation
and audit
and audit
Introduction
Section 1
Preparation Contents
Section 2
Major trauma audit data collection
Incident management
Documentation and audit 1
Section 3
Treatment guidelines Major Trauma Data Analysis

Documentation and audit 2
Section 4
Transport
Standard documentation
Section 5
Intentionally blank UK Defence Medical Services Pre-hospital Report
Pathways Form
UK Defence Medical Services Trauma Resuscitation
Chart
Section 6
Operational Trauma Audit Form
Toolbox
Emergency Department Clinical Record
Section 7
Section 8
Policies
Section 9
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Intro
Major trauma audit X
1
data collection
Documentation
and audit
Introduction
Section 1 Documentation and audit 1

Preparation Collection of data is crucial for an effective audit cycle of major trauma systems. If there is
no written evidence that care has been provided then legally it must be assumed that it was
Section 2 not given. Documentation is a vital part of patient care and remains a priority even in high
intensity operations. Data collection needs to be done while the case notes are still available
Incident management and is best started as soon as possible by a trained individual who has experience in care of
the major trauma patient.
Section 3 The Operational trauma audit data collection form is reproduced in this JTTP as a
fail-safe for copying and operational use. Optimally effective major trauma audit requires
Treatment guidelines training in data collection and use of these forms. Training for Major Trauma Audit is
available to units via DMETA and consists of one day to be completed by personnel who
willbe taking on this responsibility during deployment.
Section 4
Deploying TNCs spend 2 days pre-deployment training with ADMEM at the Royal Centre for
Transport Defence Medicine and an additional 1 day at DSTL, Porton Down.
Monthly returns from theatre are required. The completed forms should be returned
Section 5 toRCDM for analysis, with nil returns also required.
Intentionally blank
Pathways
Section 6
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Section 7
Section 8
Policies
Section 9
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Major Trauma Data Analysis Major Trauma Data Analysis 2
Documentation
Introduction Documentation and audit 2 Documentation and audit 2 (Contd) and audit
Section 1 Aim Abbreviated injury scale

Major Trauma Audit for Clinical Effectiveness (MACE) has one principal aim: The Abbreviated Injury Scale (AIS) is a directory that codes every injury by anatomical
Preparation description and severity. The severity codes range from 1 minor to 6 fatal.
To improve the care of the seriously injured patient from the point Injury severity score
Section 2
of injury to the point of discharge from hospital treatment The Injury Severity Score (ISS) is an anatomical scoring system that can be used to predict
Incident management probability of survival (Ps) following injury. The score ranges from zero (no injury) to 75
(injuries incompatible with life), although the probability of survival does not fall in a linear
Meeting clinical governance needs fashion with a rising score. An ISS of 16 is associated with a mortality of ~10%. For this reason
Section 3
MACE follows on from the successful Major Trauma Clinical Effectiveness Project established it has been used as the benchmark to identify cases of major trauma (ISS 16 or more).
in MDHU Frimley Park Hospital in 1997 and critically appraises the clinical management of
Treatment guidelines The ISS will not recognise multiple injuries within the same body region. For example, a
the seriously injured patient. MACE has evolved to evaluate practice on military operations patient with a single fractured femur will have the same score as a patient with bilateral
using the same standards as those applied to the seriously injured within a civilian best fractured femurs. A patient with an extradural haematoma in isolation may score the same
Section 4 practice setting. Clinical management is judged against predetermined standards as a patient with a combined extradural, subdural, and intracerebral haemorrhage. It takes
(performance indicators) in four areas of activity pre-hospital care, resuscitation, definitive little imagination to see that the second patient has less chance of survival, or if they do
Transport care, and documentation. Areas of strength are identified and reinforced as good practice. survive will have a worse morbidity.
Any failure to meet an individual standard is investigated and education provided to avoid
Section 5 recurrences. In particular, trends in poor management are sought which demand a change Additionally, an isolated closed head injury with a maximum AIS score of 3 will have an
in the system of care. ISS of 9. But these patients often die. They would not be included in any major trauma
outcome statistics which are compiled using ISS.
Pathways Functions of operational data collection & analysis
The New Injury Severity Score (NISS) overcomes many of the criticisms of ISS and is the
Analyse the epidemiology of the seriously injured treated at a deployed hospital, for preferred anatomical scoring system within DMS. NISS takes account of multiple injuries
Supporting Guidelines example age and sex distribution, the place and mechanism of injury, and the nationality within the same body region. It is simpler to calculate and more predictive than the ISS. It
(including civilian or military). is unlikely to completely replace the ISS until the TRISS methodology is widely superseded
Section 6 (see later TRISS is a formula to estimate probability of survival, which incorporates the
Calculate the severity of injury using accepted international models.
Injury Severity Score).
Toolbox Calculate the probability of survival to identify unexpected survivors (markers of best
practice) and unexpected deaths (markers of poor practice).
Section 7 Provide education through regular multidisciplinary clinical case conferences to improve
local standards of care.
Operational formulary Facilitate the comparison of standards of trauma care in peace with those in a military
operational setting.
Section 8 Provide a record of experience of clinical lessons for future operations.
Policies The models for data analysis are described: in an operational setting it is realistic to use the
Abbreviated Injury Scale, Injury Severity Score and New Injury Severity Score as tools to
assist early feedback to clinicians through regular trauma clinical case conferences.
Section 9
Section 10
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Major Trauma Data Analysis Major Trauma Data Analysis 2
Documentation
Introduction Documentation and audit 2 (Contd) Documentation and audit 2 (Contd) and audit
Section 1 Probability of survival (Ps) E value & SMR

Wessons Criteria is a crude methodology for evaluating the clinical effectiveness
Preparation Probability of survival (Ps) outcome measures are designed to identify both unexpected survivors
(who are markers of good practice) and unexpected deaths (who are markers of poor practice). (or E value) of a trauma system. It is a simple formula:
Probability of survival can be estimated using measures of anatomical injury severity, measures
Section 2 of the bodys response to injury (changing physiological signs) or a combination of these. E= Salvageable patients who survived x 100
The most accurate predictive methods combine anatomy with physiology. Salvageable patients who survived and died
Incident management
Anatomical methods
These are the Injury Severity Score (ISS) and the New Injury Severity Score (NISS), and A salvageable major trauma patient is one with an Injury Severity Score of 1659. Patients
Section 3 with very high scores of 6075 are excluded, which includes those with AIS 6 in any body
aredescribed on the previous page.
region. Patients with a head injury of AIS 5 are also considered unsalvageable and are
Treatment guidelines An ISS of 16 equates to a mortality of ~10%. It is for this reason that an ISS of 16 has been excluded.
adopted as the benchmark to identify major trauma.
The Standardised Mortality Ratio (SMR) is the ratio of observed deaths to expected deaths
Section 4 Physiological methods using TRISS-generated survival probabilities. An SMR >1.0 implies reduced performance,
The most robust of these is the Revised Trauma Score (RTS). It is a retrospective audit tool and <1.0 improved performance compared to Major Trauma Outcome Study norms.
Transport
and is not used prospectively to predict the survival of a patient at the roadside or in the SMR is a very crude measure. Where the number of cases in a study is comparatively
resuscitation room. small (often so in recent military operations) any unexpected death will alter the SMR
Section 5 disproportionately. Remember, the limitations of ISS are transferred to TRISS and therefore
TRISS methodology
to limitations of the SMR. If a patient is underscored on ISS (compared to NISS) then the
Pathways This probability of survival estimate is based on a combination of the Revised TRauma
probability of survival is artificially inflated on TRISS.
Score (RTS) and the Injury Severity Score (ISS) hence TRISS. It is a more reliable
predictor than RTS or ISS alone. A crude account is taken of the patients age (above or
Supporting Guidelines below 55 years old). A series of coefficients is used in the calculation, and these differ for Term (abbreviation) Definition
blunt or penetrating injury.
Section 6 Revised Trauma Score Systolic blood pressure, respiratory rate and Glasgow Coma Score
ASCOT (RTS) are each coded from 14, multiplied by a weighting coefficient
Toolbox The limitations of ISS have been described. If ISS has limitations, then so will TRISS. A that relates to their prognostic power, then summed.
further refinement in estimating the probability of survival has been the development of Abbreviated Injury A directory that codes every injury by anatomical description and
Section 7 ASeverity Characterisation Of Trauma (ASCOT). This includes an assessment of injury Scale (AIS) severity (severity codes range from 1 minor to 6 fatal).
severity by body region, and has an improved classification to take account of the patients
age. Italso uses a series of coefficients that differ for blunt or penetrating injury. Injury Severity Score A score that takes account of up to three injuries from three
Operational formulary (ISS) separate body regions (most severe AIS codes are squared then
summed). Score ranges from 1 to 75.
Section 8
Major trauma An Injury Severity Score of 16 or more1.
Policies New Injury Severity A score that takes account of up to three injuries from any body
Score (NISS) region (most severe AIS codes are squared then summed). Score
Section 9 ranges from 1 to 75. More reliable than ISS.
TRISS A complex formula using Naperian logarithms that combines
Documentation and audit RTS and ISS to predict probability of survival.
Section 10
1 A score of 16 equates to a mortality of 10%.
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Major Trauma Data Analysis UK DEFENCE MEDICAL SERVICES PREHOSPITAL REPORT FORM
Team Physician: Nurse:
Annex A to ASOP 1 Dated 1 Nov 10
Fourth/Paramedic:
Introduction Documentation and audit 2 (Contd) Date

Surname
Time of Arrival
First Name
Theatre
Service No
Hospital Number
Nationality
Age DOB Sex Male Female Unit / Ship Service
Time of Injury Time of Arrival on Scene Rank BI DNBI
Section 1 Term (abbreviation) Definition PRE-HOSPITAL FREE TEXT: CAT
M: (Times: )
I:
Preparation Probability of Survival A prediction used to describe unexpected deaths and S:
(Ps) unexpected survivors that encourages a specific case to be T:
MECHANISM
reviewed to identify system weaknesses or strengths. IED (Circle as appropriate) PPIED/CWIED/SBIED/VBIED Dismounted/Mounted Vehicle Type:
Section 2 Mines GSW IDF Fragments (RPG/Airburst) Burns Fall ht. [ m] Other Battle Injury state: [ ]
A Severity An alternative complex formula to TRISS using both MVC/IED Mounted Driver Ejected Rear Seat Top Cover Rollover Wearing Seat Belt Trapped duration: [ ]
Incident management Characterisation of physiological and anatomical data to predict probability of Body Armour Type: Osprey Version: CBA: Helmet Type: Mk6a/Mk7 Ballistic Goggles
DNBI (Insert Diagnosis): Surgical: Medical: Orthopaedic: Environmental/Other:
Trauma (ASCOT) survival. Believed to overcome some of the limitations of ISS. INJURIES
Section 3 Wessons Criteria2 (E) This is a crude evaluation of system effectiveness.
Treatment guidelines E= Salvageable patients who survived x 100

Salvageable patients who survived and died
Section 4 An unsalvageable patient has ISS 6075, or has an isolated
head injury with Abbreviated Injury Scale 5 (ISS 25).
Transport
Standardised Mortality SMR = observed deaths
Ratio (SMR) expected deaths (TRISS)
Section 5
SMR >1.0 implies reduced performance against the norm.
Pathways
Section 6
Indicate motor/sensory
Toolbox Free Text level by shading
Section 7
Section 8
Policies
Section 9 Time Life Pronounced Extinct

Primary Survey Pt Name PRF No:
Section 10
2 Wesson D et al: J Trauma; 28:12661231 (1988)
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Cat Haemorrhage Y / N C.A.T Time:[ ] Site: [ ] C.A.T Time:[ ] Site: [ ] C.A.T Time:[ ] Site: [ ]
UK DEFENCE MEDICAL SERVICES TRAUMA RESUSCITATION CHART Emergency Department (Ver 1.8H) Aug 2011
Intro Airway
Haemostatic Agent Type: [ ] Time:[
Clear Obstructed Suction OPA Size:[
] FFD Sites: [
] NPA Size:[ ]
] No: [ ]
Date Time of Arrival Theatre HERRICK
Hospital
RSI (Document Below) Indication: Number
Surgical Airway Type Size Indication:
Introduction C-Spine Manual Immobilisation Collar Head Blocks Spinal Board Not Tolerated Surname First Name Service No Nationality
Airway RSI (Drugs used documented above)Intubated Pre-MERT Free Text
Pre-O2 with BVM Cricoid Pressure Blade Size: Mac 2 3 4 Airtraq Age DOB Sex Male Female Unit / Ship Service
ETT Size:[ ] Cuffed Uncuffed Bougie Style t
Section 1 Time of Injury
Time of Arrival
on Scene
Rank BI DNBI
Grade I Grade II Grade III Grade IV PRE-HOSPITAL CARE HISTORY (MIST)

Preparation If involved
Driver Front Seat Rear Seat Top Cover Wearing Seat Belt
vehicle type
Mechanism of
Mines IED GSW RPG Projectile Explosive Stabbing Protection:
Injury
Section 2 Fall Height Other Explain CBA Eye Protection Helmet
Incident management Injuries
Vital Signs Pulse RR BP Sa02 % 02 l/m GCS A V P U

Section 3 Airway soiled No of attempts EasiCap Oesophageal Intubation Detector ETCO2
Bilateral chest expansion Tube tie Tape Thomas ETT holder MERT Pedro BLM
Treatment
Breathing
Normal Difficulty No Spont Resps BVM required ETCO2 Dustoff Mission #
BolinR L Needle DecompressionR L
Chest-drainR L ThoracostomyR L ThoracostomyIndication: ASSESSMENT PRIMARY SURVEY RESUSCITATION
Circulation Suction OPA NPA ET Tube
C/Thyrotomy

Section 4 ext. bleed Site [ ] Int. Bleed Location: [ Chest Abdo Pelvis Femur ]
Radial pulse Femoral Pulse Carotid Pulse No Pulse CPR Pre-MERT Y/N Time Commenced:
Airway Clear Obstructed No intervention Adjunct Airway
LMA RSI time ETT size cm at teeth
IV /I O Site: [ ] Size: [ ]
IV /I O Site: [ ] Size: [ ] C-Spine Normal Possible Injury Clinically Cleared C-Spine Manual immobilisation Collar / Head blocks
Transport IV /I O Site: [ ] Size: [ ] Pelvic Sling
Breathing Normal Abnormal Oxygen
l/min
Mask BVM
Chest Seal R L
Disability A V P U GCS Total: (E= V= M= )Pupils equal Unequal R [ ] L[ ] Posture:
Breath Sounds Clear Equal Abnormal Breathing N/Decompression R Tension L Tension
Section 5 Exposure
OBS (Time)
Log Roll: Y/N Temp: Cold / Hot / Normal Blizzard: Y/N
Thorascostomy R Tension L Tension
Reduced air entry R L Chest drain R Tension L Tension
Drugs Route Dose Time Signature
Pathways HR (/min)
External Bleeding Internal Bleeding IV / IO 1 Site Size
Chest Abdomen Pelvis Femurs Circulation IV / IO 2 Site Size

RR (/Min) Circulation
Head Upper Extremity IV / IO 3 Site Size
Supporting Guidelines BP (mmHg) Lower Extremity Haemostatics FFD HemCon Celox Other
SpO2 (%) Radial Pulse Present Absent Tourniquet Type Site Time
Section 6 GCS / AVPU Femoral Pulse Present Absent Tourniquet Type Site Time
Carotid Pulse Present Absent Tourniquet Type Site Time

Pupils
Toolbox ETCO2
Disability A V P U Abdomen Ears: Tympanum
Pupils Equal & reactive Abnormal Soft Firm R L

Pain Score/3
Section 7
R Upper Limb L Upper Limb Flat Distended Eyes: Size
Movement Present
BLOOD AND IV FLUIDS R Lower Limb R Upper Limb Tender R L
Fluid Start Finish Signed Fluid Start Finish Signed
Normal Flexor Extensor NonTender FROEM
Lateralising Signs
Operational formulary 1 5 No response to pain Eviscerated Penetrating Injury R L
2 6 Fully undress patient Reduce fractures Site

Logroll patient / dislocations Site
Section 8 3 7
Back without obvious injury Apply splints
4 8 Penetrating wound to back Pelvic
1 Sagar

2 Sam

3 Box-splint

4 Kendrick
5 Other

Policies H/O Time Triage Category (Circle)

T1 T2 T3 D
Disposal
Hospital: [ ]
Disposal
ED
MERT Aircraft
Type
Exposure Blunt trauma (bruising / contusion)
Suspected spinal injury
Site
Site
Type
Type
Theatre
Hospital No: Mortuary PR examination Deferred Pulse / Sensation post splinting: No change Improved
Section 9 Completed By Name Rank Signature Clinical Lead Initials Anal tone: Normal Decreased
Saddle sensation: Normal Decreased
Pain Score
/3 BM
Active warming Active cooling
mmol/L
Section 10
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Name Hospital Number Name Hospital Number
Intro History (AMPLE) Pain / tenderness P
Abrasion A
Introduction
Allergies Medications Past Medical History
Bruising //////
Last food Last drink Events leading to injury Exposure to hazardous materials (CBRN) Fracture: Open Closed #
Section 1
Laceration +++
Imaging Time Prelim Results Imaging Time Prelim results I Stat Venous Arterial Puncture / stab O
GSW entry E
Preparation
Fast Positive Negative R L Wrist pH Na
GSW exit X
Chest XR Normal R L Hand pCO2 K
Burns partial
Pelvis XR Normal P02 iCa
Burns full thickness
Section 2 R L Femur BE Hct First field dressing applied FFD
R L Tib / Fib HC03 Hb Heamostatic applied HM
Incident management R L Ankle To CT Head C-spine TC02 FBC U&E Amputation ^^^
Fragmentation
R L Foot From CT Traumagram s02 Coags CK
See attached burn chart (>20%)
Section 3
R L Humerus Chest
Adb/pelvis

Cross-match
R L Forearm Blood to lab at Group & save

In Volume Out Volume
Time Notes / Narrative Summary of Injuries to be completed by team leader
Crystalloid Urine
Blood Chest drain 1
Chest drain 2
Section 4 Estimate #s
Total in ml Total out ml
Transport INPUT OUTPUT
R Chest drain time Catheter time
Section 5 S e e M a s s i v e Tr a n s f u s i o n W o r k s h e e t L Chest drain time Gastric tube time
Time Fluid Volume Time Fluid Volume Time Fluid Volume
Pathways
Drugs Dose Route Prescribed by Given by Time
Section 6
Toolbox
Section 7
Evidence of biological shrapnel?

Consider blood borne virus prophylaxis
Team Leader = TL Apppointment Scribe = S Anaesthesia = A Nurse - N1, N2 Primary Assessment = Doc 1
Section 8 Rank Name Apppointment Rank Name Apppointment
1 6
Policies 2 7
3 8
4 9
Section 9 5 10
Section 10
Red Card reporting

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Name Hospital Number Operational Trauma Audit Form Trauma form Version 5.2 Oct 11
Intro History (AMPLE)
RESTRICTED MEDICAL (when completed)
Introduction
Allergies Medications Past Medical History
Trauma Audit Form Version 5.2 Oct. 2011 Scored Database Completed DB No.
Last food Last drink Events leading to injury Exposure to hazardous materials (CBRN)
DEPLOYED TNCs
Section 1 Imaging Time Prelim Results Imaging Time Prelim results I Stat Venous Arterial USE THIS FORM FOR
ALL Patients who have been the subject of a Trauma Call
Preparation
Fast Positive Negative R L Wrist pH Na
Chest XR Normal R L Hand pCO2 K

ANY UK Service person who is to be evacuated to RCDM for in-patient care
Pelvis XR Normal P02 iCa
following a traumatic injury (Hostile or Non-Hostile)
Section 2 R L Femur BE Hct DEMOGRAPHICS Op Theatre Herrick Country
R L Tib / Fib HC03 Hb Medical Treatment Facility Region
Incident management R L Ankle To CT Head C-spine TC02 FBC U&E If other, state: City
R L Foot From CT Traumagram s02 Coags CK

Role of MTF 3
Force Supplying Country Designation
Section 3
R L Humerus Chest
Adb/pelvis

Cross-match
R L Forearm Blood to lab at Group & save Regt/Corps Service No. Rank Gender
Time Notes / Narrative Summary of Injuries to be completed by team leader Surname First Name DOB Age
Treatment guidelines F/Med 830 No. Trust ID
INJURY Date of injury Scoring Cat: Environment Military
Section 4 Time hrs Intent
Injury Type: Blast Blunt Penetrating Thermal Other Blast Exposure Suspected
Transport Mechanism of Injury Location of Incident
Trapped: How Long min Circumstances of Injury
Section 5 Body Armour more more
If other, state: Visibly Damaged
Helmet If other, state: Visibly Damaged
Pathways Eye Protection If other, state: Visibly Damaged
Genital Protection If other, state: Visibly Damaged
Hearing Protection If other, state: Visibly Damaged
Gloves If other, state: Visibly Damaged
Section 6 Localisation of Victim When Injured
Toolbox Vehicle Information

Vehicle more more If other, state:
Location Restraint
Section 7
Environmental Information
Evidence of biological shrapnel?

Consider blood borne virus prophylaxis Temperature (oC) Humidity (%) Rain Snow Altitude (m) CBRN Information
Team Leader = TL Apppointment Scribe = S Anaesthesia = A Nurse - N1, N2 Primary Assessment = Doc 1 Brief incident history (including any delay in evacuation with reason):
Section 8 Rank Name Apppointment Rank Name Apppointment
1 6
Policies 2 7
3 8
4 9
Section 9 5 10
Section 10 RESTRICTED MEDICAL (when completed)
Red Card reporting

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Operational Trauma Audit Form (Contd) Operational Trauma Audit Form (Contd)
Intro
RESTRICTED MEDICAL (when completed) RESTRICTED MEDICAL (when completed)
Introduction
PRE-HOSPITAL / ROLE 1 Unit providing treatment: MERT / BLM Unit providing treatment:
Section 1 Nationality of Unit: Nationality of Unit:

Time at scene Time left scene Transport: (If other, state: ) Time at scene Time left scene
Preparation Treatment by: MO Nurse Paramedic CMT/MA Team Medic Buddy Other (state) Vehicle wheels tracked Adverse events during transport:
Triage Category Vitals: GCS Total / 15 Medical material on vehicle: Oxygen Mattress
Interventions: E /4 V /5 M /6 Treatment by: MO Nurse Paramedic CMT/MA Team Medic Buddy Other (state)
Section 2 Airway #1 Airway #2 AVPU A V P U Interventions: (GCS prior ) Vitals: GCS Total / 15
Airway #3 Airway #4 BP / mmHg Airway #1 Airway #2 E /4 V /5 M /6
Incident management Airway #5 Airway #6 Capillary Refill Time (secs) Airway #3 Airway #4 AVPU A V P U
Airway #7 Airway #8 Pulse Rate Radial Airway #5 Airway #6 BP / mmHg
Airway Obstruction Extraction of object in the mouth: Time Femoral Airway #7 Airway #8 Pulse Rate Radial
Section 3 Asherman Chest Seal: Time Bolin Chest Seal: Time Carotid Extraction of object in the mouth: Time Femoral
Needle Decompression: Time Was tension pneumothorax present? Asherman Chest Seal: Time Bolin Chest Seal: Time Carotid
Treatment guidelines ICD: L R Thoracostomy: Time Thoracotomy: Time Needle Decompression: Time Was tension pneumothorax present?
Morphine IV mg IM mg ICD: L R Thoracostomy: Time Thoracotomy: Time
Access: IV Central IO Resp Rate
Section 4 Access: IV Central IO Resp Rate
SPO2 % Temp C
CPR: Start Time End Time SPO2 % Temp C
Spinal Immobilisation: Collar Head blocks Long board Pain score before CPR: Start Time End Time Pain score before
Transport Limb traction: Sager splint Box splint Neoprene splint Sam splint Pain score after Spinal Immobilisation: Collar Head blocks Long board Pain score after
Sam Pelvic sling Other Splint Limb traction: Sager splint Box splint Neoprene splint Sam splint
Section 5 Exposure Intervention: Blizzard blanket Other Sam Pelvic sling Other Splint
Pupil reaction (left) Pupil size (left) Pupil reaction (left) Pupil size (left)
Pathways Pupil reaction (right) Pupil size (right) Pupil reaction (right) Pupil size (right)
Haemorrhage: Active Bleeding: Time rFVIIa: Time Celox Gauze: Time Haemorrhage: rFVIIa: Time Celox Gauze: Time FFD: Time
FFD: Time Compressive Dressing: Time Compressive Dressing: Time
Supporting Guidelines 1st Tourniquet applied to Time applied Time released 1st Tourniquet applied to Time applied Time released
2 nd
Tourniquet applied to Time applied Time released 2nd Tourniquet applied to Time applied Time released
Section 6 3rd Tourniquet applied to

th
Time applied Time released 3rd Tourniquet applied to
th
Time applied Time released
4 Tourniquet applied to Time applied Time released 4 Tourniquet applied to Time applied Time released
Toolbox Pre-Hospital drugs Pre-Hospital fluids (enter blood products later): In-transit drugs In-transit fluids (enter blood products later):
Drug Name Dose Route Fluid Name Volume Drug Name Dose Route Fluid Name Volume
mls mls
Section 7 mls mls
mls mls
Operational formulary mls mls
mls mls
Section 8 mls mls

mls mls
mls mls
Policies mls mls
Section 9
Documentation and audit RESTRICTED MEDICAL (when completed)

Section 10
Red Card reporting

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Intro
Introduction Other fluids given
FD HOSPITAL RESUS Date Time Trauma Team Called Yes No
mls
Section 1 Trauma Team Leader: Reason for Trauma Call: Right Turn
mls
Triage Category on Arrival Vitals: GCS Total / 15
mls
Preparation Interventions: (GCS prior ) E /4 V /5 M /6
mls
Surgical Instrument Applied: Time BP / mmHg
mls
Airway #1 Airway #2 Pulse Rate
Section 2 Airway #3 Airway #4
Airway #5 Airway #6
Incident management Airway #7 Airway #8 Resp Rate

SPO2 % Temp C
Extraction of object in the mouth: Time
Needle Decompression: Time Was tension pneumothorax present? Pain score on arrival ED
Section 3 ICD: L R Thoracostomy: Time Thoracotomy: Time Pain score depart ED
White cell count
Treatment guidelines Access: IV Central IO

CPR: Start Time End Time
Spinal Immobilisation: Collar Head blocks Long board
Section 4 Limb traction: Sager splint Box splint Neoprene splint Sam splint
Sam Pelvic sling Other Splint
Total Blood products given (units)
Transport Pupil reaction (left) Pupil size (left)
Emergency Donor Panel
Pupil reaction (right) Pupil size (right)
Blood(RCC) FFP Cryo Platelets Whole Blood Platelets
Section 5 Haemorrhage: Celox Gauze: Time Compressive Dressing: Time
Role1
1st Tourniquet applied to Time applied Time released
2 nd
Tourniquet applied to Time applied Time released MERT
Pathways 3rd Tourniquet applied to Time applied Time released Resus
th
4 Tourniquet applied to Time applied Time released Initial Theatre
Supporting Guidelines rFVIIa (complete the following if administered) Other

1st dose mg Time Temp. pH PO2 PCO2 BE Where Total
Section 6 2nd dose mg Time Temp. pH PO2 PCO2 BE Where

Massive transfusion protocol initiated FAST US: Time
Disposal: Ward Surgery ITU/HDU Mortuary Disposal Date: Time:
Toolbox CT: Time X-Ray: Time

RTU External Transfer Unknown
Progress Notes:
Head Chest Abdo Pelvis Limbs Skull Chest Abdo Pelvis Limbs
Section 7 C Spine T Spine L Spine Spine
FD Hospital Resus Drugs Total fluids given during ED resus
Operational formulary Drug Name Dose Route Length of

course of
Fluid Name Volume
treatment
Section 8 Total Crystalloids-Isotonic given mls

Total Colloids given mls
Policies
Total fluids given during Immediate Surgery
Total Crystalloids-Isotonic given mls
Section 9 Total Colloids given mls
Section 10
Red Card reporting

JSP 999 JSP 999
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Intro
Introduction Red Cross Wound Classification: Classify the 2 most serious injuries prior to surgery and in conjunction with surgical opinion, refer to explanatory notes Performance Indicators appropriate to patient pathway Pre-Hospital ED Theatre Critical Care Ward Burns
Tick those areas where the patient has been treated and record the appropriate performance indicators by speaking to staff in those areas.
Injury No. E X C F V M G
Section 1 Injury No. E X C F V M G

below
KIA DOW WIA KNEA DNEA WNEA
Date Injuries AIS 05 Code
Preparation 1
2
Pre-Hospital Care Performance Indicators Yes No NA Comments
Section 2 3 Time from point of wounding to BATLS skills <1 hour?
4 Time from point of wounding to appropriate surgical care <2 hours?
IV fluid boluses given to maintain radial pulse?
GCS measured prior to intubation?
6 Was ETCO2 measured if the patient was intubated?
7 Hypothermia mitigation equipment used where appropriate?
Section 3 8
Full spinal immobilisation used where appropriate?
Vital signs recorded to a minimum standard (RR, SpO2, PR, radial pulse present, AVPU, pain score)?
9 Pain score <3 after analgesia.
Treatment guidelines 10 Did the patient receive antibiotics within 1 hour of wounding?
Long bone fractures stabilised <1 hour of injury?
11 MIST handover performed at the ED?
Section 4 12 Emergency Department Performance Indicators

Temperature >36C on arrival?
Yes No NA Comments
ISS NISS RTS TRISS ASCOT
Vital signs recorded on arrival (minimum data: RR, SPO2, BP, PR, GCS, pain score, blood gases, BM Stix)?
OPERATIONS PERFORMED Surgeon(s):
Transport Repeat vital signs recorded every 10 minutes in 1st hour (minimum data: RR, SPO2, BP, PR, GCS, pain
score)?
Date Procedure: Commenced Finished Lowest &
GCS <9 - RSI/ETT completed within 10 minutes of arrival in ED?
Highest Temp
ETCO2 recorded every 10 minutes in all patients ventilated in ED?
1
Section 5 2
/
/
Emergency thoracotomy for patients in extremis <10 minutes of arrival in the ED?
Surgical airway secured (if required) within 10 minutes of arrival in the ED?
GCS <9 with isolated closed head injury - CT head performed <1 hour minutes arrival?
3 /
Pathways 4 /
Penetrating extremity wounds x-rayed pre-debridement?
Betadine soaked dressing applied to wounds within 1 hour of arrival in ED?
5 / Tetanus IgG given in heavily contaminated wounds within 4 hours of arrival in ED?
Indications for novel haemostatic use clearly documented?
6 /
Tourniquet (if used) reviewed by a surgeon within 2 hours of application?
Pain score maintained at 2 or below?
CK measured for crush and burns patients and/or when CAT applied for above 1 hour?
Section 6 Theatre Performance Indicators Yes No NA Comments
Penetrating abdominal injury with BP <90 Systolic undergo laparotomy <30 minutes from arrival in ED?
Toolbox
Urgent thoracotomy performed for shocked patients with penetrating chest injury <1 hour of arrival in the ED?
Casualties with continuing haemorrhage with shock taken to theatre <30 minutes from arrival in ED?
Damage control laparotomy (if performed) performed in <90 minutes from ED arrival?
Was the laparotomy if performed therapeutic?
Section 7 Fasciotomies performed for confirmed vascular injuries?
Acute compartment fasciotomies performed <1 hour of arrival in ED?
Revascularisation surgery performed <6 hours of injury?
Operational formulary Decompressive craniotomy/craniectomy performed <4 hours of a blunt head injury?
Closure of penetrating head injuries performed <6 hours of injury?
All wounds photographed pre and post debridement with copies available in UK?
Section 8 All wounds ICRC scored at initial surgery?

Limb salvage scoring performed pre amputation (2 surgeon agreement)?
Appropriate initial wound surgery performed <6 hours of injury?
Policies Bacteriological specimens taken pre and post each debridement with results available to clinicians?
Appropriate antibiotics commenced within 6 hours of open fracture?
Off table temperature >34C?
Nutritional assessment plan documented post surgery?
Section 9

Section 10
Red Card reporting

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Intro
Introduction COMPLICATIONS Were there any complications yes/no/unknown (see complication list)
Critical Care Performance Indicators Yes No NA Comments Date/Time Details Code
Minimum monitoring standards followed during anaesthesia?
Section 1 Hb maintained >8 g/dL during hospital admission and AEROMED?
Pre Hospital
Airway
Glycaemic level 4-8mmol/L sustained during admission and AEROMED?
Preparation
30 degree head up maintained on ITU & during AEROMED (ventilated patient)? Fluids
ITU patients evacuated within 48 hours of admission to ITU?
Post-operative period Performance Indicators Yes No NA Comments Miscellaneous
No CSF leak post neurosurgery?
Section 2 No missed penetrating/sight threatening ocular injury? Hospital
No missed eardrum injury? Airway
No unplanned re-laparotomies or re-thoracotomies?
Incident management No unplanned admission to critical care? Pulmonary
Post operative temperature maintained > 34C?
Cardiovascular
Full tertiary survey (including spine) carried out <24 hours of arrival in ED?
Section 3 LMWH started within 24 hours of admission?

TED stockings fitted?
GIT
Ward Performance Indicators Yes No NA Comments Hepatic

Treatment guidelines Waterlow score performed on admission to ward?
Haematological
Follow-up Performance Indicators Yes No NA Comments
Case discussed at a weekly MDT meeting?
Infection
Section 4
Significant events fed back to the theatre of operation?
Case discussed at a 6 monthly morbidity and mortality meeting?
Renal / GU
Burns Performance Indicators Yes No NA Comments
Transport BSA, location, depth estimate and fluid resuscitation begun <1 hour of burn?
Inhalation/airway injury identified <1 hour following burn?
Musculoskeletal
Formal burn assessment (dressing and accurate fluid resuscitation) performed <4 hours following burn? Neurological
Limb escharotomy within <4 hours of burn?
Section 5 NG feeding begun within 6 hours of burns >15% BSA?
Vascular
Ophthalmology
Pathways Psychiatric
Other
Supporting Guidelines Provider
Section 6 DISCHARGE / TRACKING Aeromed Priority P1 P2 P3 CCAST N/A

Date Admitted Location Date Discharged / Transferred Length of stay (days)
Toolbox
Section 7
Section 8 On Completion of this form please return to: Trauma Nurse Coordinator, Academic Department of Military Emergency
Medicine, Royal Centre for Defence, Medicine Institute of Research And Development, Birmingham Research Park, Vincent
Drive, Edgbaston, Birmingham, B15 2SQ.
Policies
Section 9 RESTRICTED MEDICAL (when completed)
Section 10
Red Card reporting

JSP 999 JSP 999
MENU
Intro EMERGENCY DEPARTMENT Receiving medical unit:
CLINICAL RECORD Hospital number:

Operation name:
Introduction
Surname: Service number:
Section 1 First name(s): Rank:
Sex: Male Female Date of birth:
Preparation Status: UK Service personnel Service: Royal Navy
UK Civilian Army
Coalition forces/other Royal Air Force
Section 2 Coalition/contractors/NGO Unknown
Local national
Incident management Enemy prisoner of war
Unit in theatre: Unit in UK/BFG:
Section 3 PRESENTATION
Allergies:
Treatment guidelines Date of arrival: Time of arrival: Attendance No:
Mode of arrival: Ambulance Helicopter Escort unit & No:
Self IRT
Section 4 Other ........................................................................
Presenting complaint:
Transport Date & time of incident/onset of symptoms: No. casualties in incident:
Activity (tick one box) RTA Vehicle Mechanism (tick one box)
Section 5 1 Unintentional injury (tick one box, if appropriate) 1 Fall
Intentionally blank 2 Suspected intentional self harm (Patients vehicle OR mode of transport) 2 Blunt force (struck, crashed)
3 Alleged/suspected assault 1 Pedestrian 3 Gunshot
Pathways 4 Operations of war or civil conflict 2 Bicycle 4 Piercing force (stab, bite, cut, shot)
5 Disease/illness 3 Two-wheel motor vehicle 5 Explosive blast (improvised device)
6 Sport 4 6 Explosive blast (other)
Supporting Guidelines 98 Unknown 5
Car or van
Lorry or bus 7 Traffic injury
6 Green fleet 8 Poisoning
Section 6 Appropriate PPE (tick one box)
7 White fleet 9 Burn (flame/cold/chemical)
(eye protection/CBA/seat belt etc) 8 Armoured vehicle 10 Environmental
97 Other (heat stress/hypothermia)
Toolbox 1 Worn
98 Unknown 97 Other
2 Not worn
7 Unavailable 98 Unknown
Section 7 98 Unknown 99 Not applicable
RTA Circumstances
99 Not applicable
(tick all appropriate)
Operational formulary 1 Single vehicle involved
Alcohol involvement 2 Multiple vehicles involved
(tick one box) 3 Vehicle rolled over
Section 8 Y Suspected of confirmed 4 Patient was ejected
N No/information unavailable 5 Top cover
Policies
Section 9
Section 10
Red Card reporting

Section 9 26 Change 3 September 2012 Change 1 May 2010 27 Section 9
JSP 999 JSP 999
MENU
Attach copies of blood results, ECG, etc. here
BASELINE OBSERVATIONS X
Intro TREATMENTS
GCS Blood Pulse Resp. Saturation Temperature BM Documentation
Date Time Drug Dose Route Doctor Nurse Pressure Rate O2 and audit
Introduction
Section 1
main 2nd 3rd
Preparation URINALYSIS (initial each performed)
Diagnosis
Body part NAD: Protein: Ketones: Leukocytes:
Section 2 Write up to 3 different diagnoses. giving diagnosis code and body part codes. See lists of code below RBCs: Nitrites: Urobilinogen:
Treatment (tick all applicable) Investigations Injury conditions
Incident management 1 Analgesia (tick all applicable) 1 Fracture ASSESSMENT NOTES
2 Antibiotics 1 Bacteriology 2 Musculoskeletal
2 Biochemistry (muscle, tendon, ligament injuries) Name:
3 Bandage
Section 3 4 Central line 3 CT 3 Wound
(including bite, cut, abrasion, laceration)
5 Chest drain 4 Cross match
4 Bruise or superficial injury
5 ECG
Treatment guidelines 6 Crutches
7 Defibrillation/pacing
6 ED observation
5
6
Burn
Concussion
7 Haematology 7 Organ system injury
8 Dressing
8 Histology 8 Other injury
Section 4 9 Emergency contraception
10 Eye ointment/drops
9 MRI 9 Unknown
10 Ultrasound
11 Guidance 11 Urine Non-injury conditions
Transport 12 I & D (Incision & Drainage) 12 X-ray 20 Allergy (including anaphylaxis)
13 Intubation 97 Other 21 Cardiac
14 Irrigation 98 None 22 Central nervous system
Section 5 15 IV therapy (excluding strokes)
16 Local anaesthesia 23 Cerebrovascular
Head & neck Upper Limb 24 Dermatological Time: Signature:
17 Minor surgery
Pathways 18 Nebuliser
1 Brain 10 Shoulder 25 Diabetes & other endocrinological
19 Observation
2 Head 11 Axilla 26 ENT CLINICAL NOTES
3 Face 12 Upper arm 27 Faciomaxillary
20 Occupational therapy 4 Eye 13 Elbow 28 Gastrointestinal
Supporting Guidelines 21 Parenteral drugs 5
7
Nose
Mouth, jaw,
14
15
Forearm
Wrist
29 Gastroenteritis
Time seen: Clinician: Grade:
22 Physiotherapy 30 General surgical
23 Plaster of Paris teeth 16 Hand 31 GUM
Section 6 24 Prescription 8 Throat 17 Digit 32 Gynaecological
9 Neck 33 Haematological
25 Reduction
34 Heat illness
Toolbox 26 Removal of foreign body
Trunk Lower Limb 35 Infectious disease
27 Resuscitation 18 Cervical spine 28 Hip 36 Local infection
28 Sling 19 Thoracic 29 Groin 37 Obstetric
Section 7 29 Splint 20 Lumbosacral 30 Thigh 38 Ophthalmological
30 Sutures spine 31 Knee 39 Psychiatric
31 Tetanus & diphtheria toxoid 21 Pelvis 32 Lower leg 40 Respiratory
Operational formulary 32 Tetnaus immunoglobulin 22 Chest 33 Ankle 41 Rheumatological
33 Thrombolytic 23 Breast 34 Foot 42 Septicaemia
24 Abdomen 35 Toe 43 Urological (including cystitis)
34 Urinary Catheter
25 Back/buttocks 97 Multiple site 44 Vector-borne illness
Section 8 35 Wound closure 26 Ano/rectal 98 Unknown or 45 Other vascular
97 Other 27 Genetalia not relevant 97 Other condition
98 None 99 Nothing abnormal detected
Policies
Section 9
Section 10
Red Card reporting

JSP 999 JSP 999
MENU
CLINICAL NOTES (Contd)
Intro
Introduction
Section 1
Preparation
Section 2
Incident management
Section 3
Section 4
Transport
Section 5
Intentionally blank
Pathways
Section 6
Speciality Time of referral: Immediate disposal
Toolbox (tick one box) (tick one box)
1 ED 1 RTU
Section 7 2 Orthopaedics 2 Primary Health care
3 Surgery 3 Planned review
Operational formulary Time of departure:
4 Medicine 4 Ward:
97 Other 5 Theatre
Section 8 6 HDU or ITU
7 Mortuary
Policies
Section 9
Section 10
Red Card reporting

MENU
Intro
Introduction
Section 1
Preparation
Section 2
Incident management
Section 3
Section 4
Transport
Section 5
Pathways

Section 6

Section 7
Section 8
Section 10
Policies
Section 9 Red card

reporting
Section 10
12 3
Red Card reporting
20 e
g
an
Ch
p
Se
JSP 999 JSP 999
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Intro Red card reporting 1
Red card
reporting
Introduction Introduction
Section 1 Development of Clinical Guidelines for Operations requires feedback
Preparation from clinicians using the guidelines in practice
The following are to be reported through the command chain to Commander
Section 2 by completing the submission form:
Conditions that are not included in the guidelines where guidance is perceived
Incident management to be required
Instances where the guideline does not give enough depth of guidance for
Section 3 aspecificcondition
Perceived errors of fact.
For the submission form
Section 4 2
Go to Red card reporting
Transport
Section 5 Commander Medical is to forward suggestions to PJHQ who are to inform:

Intentionally blank RCDM, Academic Department of Military Emergency Medicine (guideline initiator)
Pathways SO2 Clinical Policy, HQ Surgeon Generals Dept, DMS(OW).
Section 6
Toolbox
Section 7
Section 8
Policies
Section 9
Section 10
Red Card reporting

JSP 999 JSP 999
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Intro Red card reporting 2
Red card
reporting
Introduction Submission form
Section 1
Preparation Reporting officer (all fields are mandatory)

Number Rank Name
Section 2
Unit
Incident management
Operational deployment..
Section 3 Role & Capability where guideline applied (e.g. Role 2/Nurse).
Treatment guidelines Guideline
Section 4 Number
or
Transport Condition not covered
Section 5
Intentionally blank Reason for reporting
Pathways (give as much detail as possible)
Section 6
Toolbox
Section 7
Section 8
Policies
Section 9

Signature Date
Section 10
Red Card reporting


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2012英軍臨床指南

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Supporting Guidelines Clinical Guidelines

Toolbox for Operations

Documentation and audit

Section 1 How to use this document............................................................................................................2

Preparation Title page .............................................................................................................................................4

Documentation and audit Section 10 Red card reporting

Red Card reporting

Introduction Explanation Guidelines on navigation Introduction

Section 3 Navigation 21 / 214

Red Card reporting

Pathways The Go to navigation system

Documentation and audit

Red Card reporting

Red Card reporting

Section 1 Change No. Date of Insertion Authority

Documentation and audit

Red Card reporting

Introduction Preface Introduction

Red Card reporting

Operational formulary Section 7

Red Card reporting

Supporting Guidelines Clinical Guidelines

Toolbox for Operations

PREP Intro.1 PREP Intro.4

Documentation and audit

Red Card reporting

Preparation Deployment & Receiving Teams

Notify CT where available if perceived

Red Card reporting

Introduction Preparation 2 criteria Preparation

Section 1 Preliminaries Preparation 3

Red Card reporting

Preparation 4 Preparation 4 (Contd)

Section 1 Team Leader (emergency physician)

Red Card reporting

Preparation 4 (Contd) Preparation 4 (Contd)

Section 1 Airway Assistant

Pathways If Massive Transfusion policy activated

Operational formulary Radiographer

Red Card reporting

Section 4 Surgical time critical

Red Card reporting

Supporting Guidelines Clinical Guidelines

Toolbox for Operations

Documentation and audit

Red Card reporting

Section 1 Major incident scene

Incident management Medical Commander

Section 7 Major incident hospital

Policies Senior Nursing Officer

Red Card reporting

Start a log and record time of arrival.

Section 6 Continue to assess and communicate with higher formation as details

Documentation and audit

Red Card reporting

Section 1 Command Assessment

units in accordance with SOP and Communication Electronic Instruction (CEI).

Red Card reporting

Section 1 Primary triage (point of wounding)

Red Card reporting

Operational formulary Log the destination of casualties.

Documentation and audit

Red Card reporting