skills that could be learned by first responders as described in Recommendation 5.1 and summarized in Box 5-2.

The protocol for the treatment of battlefield casualties by a single first responder is presented in the airway-breathing-circulation format. Most of these recommendations represent a departure from traditional therapies administered in the battlefield. There is ample evidence (from experience in civilian emergency medical systems) that nonphysician first responders can be trained to administer aggressive lifesaving therapies in the field. However, these skills must be taught in carefully constructed training courses and administered by simple and clear protocols. Use of these protocols will represent a new era in battlefield therapy.

Hemorrhage

The proposed protocols for the fluid resuscitation of battlefield casualties are based on a modification of those presented by the medical command of the U.S. Navy Seals (Butler et al., 1996). The goal of therapy will be to stop hemorrhage, expand volume rapidly, increase cardiac output, and sustain effective perfusion.

Based on evidence about available resuscitation fluids that is discussed in Chapter 3, taking into consideration the large number of studies that have demonstrated both safety and efficacy, the need for simplicity, the limited volume that can be carried in the field, and relative cost, the committee concluded that 7.5 percent saline should be used for immediate fluid resuscitation on the battlefield.

Recommendation 5.2 The initial fluid resuscitation of the hemorrhaging battlefield casualty should be a 250 ml bolus of 7.5 percent saline delivered by a rapid-infusion system.

First responders in the field should be equipped with a rapid systemic infusion system consisting of a small plastic bag containing a 250 ml bolus of hypertonic (7.5 percent) saline. Both the composition and amount of the initial bolus are based on clinical trials outlined in Chapter 3.

The bag containing hypertonic saline would be placed under low pressure or accompanied by a simple, sturdy pumping device that could be mechanical or electric. Systemic accesses would be achieved via an intraosseous needle (Dubick and Kramer, 1997; Guy et al., 1993), placed into the anterior tibia. In extreme conditions where time and the condition of the wounded combatant dictate, the intraosseous needle with trocar in place could be placed directly through clothing. The possibility of infection is recognized, but this could be treated at a later point. If time and the condition of the wounded combatant allow, clothing could be cut away and a sterile field obtained. Intravenous access



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