could be provided also, but the committee concluded that the intraosseous route would be easier to teach to nonmedical combatants.

The use of hypertonic saline is recommended only as the initial intervention until definitive fluid resuscitation can be provided by more skilled medical personnel (again, consistent with the approaches used in clinical trials). If future research justifies it, additional compounds, such as those that carry oxygen or other novel therapies (see Chapter 4), could be added to the hypertonic saline solution.

Repeat Administration of Hypertonic Saline

Repeat administration of hyper-tonic saline would depend on the environment and the wounded combatant's physical condition. Regardless, an established limit as to the total amount of hypertonic saline that is infused would be necessary to avoid the complications that could occur with large infusions (Dubick and Wade, 1994; Lyons, 1996; Vassar et al., 1990). It is recommended that a total limit of 500 ml be set, and that the second bolus be given only if there is extended time to evacuation. Since the typical combatant will be a young healthy male, the likelihood is reduced that he will be highly sensitive to perturbations that might occur from a second bolus of hypertonic saline.

Airway and Breathing

The success of any fluid resuscitation depends on continued breathing and oxygenation. Although airway maintenance was not part of the charge to this committee, it was still felt that recommendations to ensure the integrity of the airway and breathing should be made. Without such efforts, any fluid resuscitation protocol would be futile. To this end, first responders should be instructed in securing the airway by administering chin lift, jaw thrust, and the use of adjuncts such as the intubating laryngeal mask airway (LMA). The LMA has been used in Europe for a number of years (Benumof, 1992; Davies et al., 1990; Martin et al., 1993; Pennant and Walker, 1992; Pennant and White, 1993; Reinhart and Simmons, 1994; Smith and Joshi, 1993; Somerson and Sicilia, 1993; Stone et al., 1994; Tolley et al., 1992; Walker et al., 1993). Its use can rapidly be taught to lay personnel, and the success rate maintained at a high level (Davies et al., 1990; Tolley et al., 1992; Walker et al., 1993). Recent work has indicated that after 5 minutes of training, lay personnel trained to use the intubating LMA on mannequins had a 90 percent success rate, a rate maintained over a period of at least 1 week (Richard Levitan, personal communication). Proper placement should be confirmed with an inexpensive disposable end tidal carbon dioxide (CO2) device (Goldfarb and Cohen, 1990; Vukmir et al., 1991).

Tension pneumothorax is a relatively common problem in combat casualties, accounting for 10 percent of the deaths in the battlefield during the Vietnam conflict (Figure 1-2). A substantial number of civilian paramedic systems in the United States have trained their medics to recognize the major signs of a tension

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