Army Action Plan: Standard Operating Procedures for Emergency Medical Treatment

EMERGENCY MEDICAL TREATMENT SOPw SOP: 68 Page: 1
I MISSION
To provide gandardized anergent crewman to miliary and detainee personnel secondary to
illness or injury.
II. OVERVIEW
Accident, injury or-illness can

pw occur at any time. By tni
and actions,wlizing a standardized set of treatment
pimples the overall incidence of morbidity and mortality can be reduced. Also, byproviding medical care utilizing protocols anergent boatman can be inated in the absence of a medical officer and can be corninued until a medical provider' is contacted via phone or is present
at the scene.
M. PROCEDURES
1)
All nurses and corpsmen will receive training on protocol usage.
2)
Once initial training is completed, shift nurses will be able approve corpsmen an
usage and medications specifically administered by hospital corps staff. protocol
3) Newly arriving personnel must be approved on .
an emergency response team (Err). wPrig

protocol usage or to being assigned to
4)
Nurses and shift leaders will conduct ongoing protocol and medical refresher training.

Hospital corps staff will have this training annotated in their training record while at
5) GTMO
JTF
Protocols are only in effect in the absence of s credentialed
6) providers
mafical provider. Medical
her care. may modify, supercede or negate any protocol Feat is under his or
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EMERGENCY MEDICAL TREATMENT SOPw
SOP: 61
Page: 2
Auraluzzraluns
.
sismacmir
-ducceto
I ) Assure ABC'sw
• Eausysr
-hafts Overdose
2) Provide supplemental 02 to maintain Sp02 92%w-thumb
-num Taspaatais
3) Obtain vascular access
-bads ObPselinsibumb)
Pkochosods. POI=

-Shock Smoke (CVA)
4) If dehydration or hypoperfusion evident. go to REHYDRATION/SHOCK PROTOCOL
S) Obtain FSBS:
60-300 mg/dl: monitor
300 mg/d1: - give 250 ml NS fluid bolus(*) to maintain SDP 90 mmHg
60 mp/d1• (CY(N) -2
-give 1 tubes oral glucose if alert and able to maintain own airway
-
If unresponsive or unable to maintain own airway:
-give Thisinbu 100 mg IVP (N) if malnourished or pt is on hunger
-DSOW 2S grams IVP (N) or Gloscagoa lung IM (CY(N) if IV not strike
established
6) Nalarone 0.4-2mg IVP (N) dusted to effect for suspected narcotic overdose
7) If seizures evident, go to SEIZURE PROTOCOL
8) Consider Pbeaurearll for barbiturate overdose ••
8) Continue to monitor, transport to clinic, and contact MO for medical ovasight.
*• Contact MO for guidance reputing risk for 'glazes and dosing amounts
EMERGENCY MEDICAL TREATMENT SOPw SOP: 68 Page: 3

ALLEBiagaimanucimaciam
1)ASSAM ABC's
2)Provide supplemental 02 to keep Sp02 92%
3)Obtain vascular access
4)Dipliesthydreabes 50ntsIM (C) or 2S
-SOmg IV? (N)
5)If hypotensive or respiratory distress evident
-EKG monitor
-Epinephrine 1:1000 0.3mg SC (C)/(N) •*

-Atbmserol 2.5mgaoc NS via HHN (cy00
-250 cc NS bolus(a) to maintain SBP 90 mmHg

-Solgramirvi 1 2,img IVP (N)
6) Continue to monitor, transport to clinic, and contact MO for medical oversight
IIHN= hand held nebulize:
** Use Epinephrine with caution in persons with known cardiac history or 40y old
411rp-=-=
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EMERGENCY MEDICAL TREATMENT SOP.
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11/11115
1)Extinguish flames and ensure scene safety.
2)
Go to ADVANCED AIRWAY PROTOCOL if inhalation injury, present
3)Give supplemental 02 to keep Spill 92%

4)Remove smoldering clothing and constrictingjewelry
5)Evaluate burn extent using "Rule of Vmes"
6)Attempt to remove offending agent
-Dry chemical: Brush off Irrigate for 20 min with H2O
• Liqtdd chemical: Irrigate for 20 min with H2O
7)Cover with buntAheem or dry, sterile dressing 8)Obtain vascular access
9)2.50 ml NS bolus(s) to maintain SBP 90 mmHg (Keep 110 total for bum formula calculation)

10)Mot/Alms alias. 2-4 mg IM
(C) or IVP (N) q 5 min to a mot of 10mg for pain control. 11)Continue to monitor, transport to clinic, and contact MO ASAP for medical oversight
EMERGENCY MEDICAL TREATMENT SOP w SOP: 68 Page:
1)Assure ABC's
2) If having difficulty breathing, got to DIFFICULTY BREATHING PROTOCOL
3) Give 02 2-4 1pm via NC or u needed to keep Sp02 . 92%
4) 3-lead EKG monitor
5) Obtain W access and draw "Rainbow" lab panel
6)ASA 324 mg PO (CM) X (2) doses. (Chew first dose, swallow second dose)

7)NS 250 ml bolus(s) to maintain SBP 90 mmHg ••
8)Nitroglycerin OA mg SL (CY(N) q S min up to a max of three doses •
9) 12 Lead EKG
10)liforplelno snlphate 2-4 mg NP (N) q $ min (max 10 mg) titrated for pain relief
I 1) Continue to monitor, transport to clinic, and contact MO ASAP for medical oversight

• Check blood pressure in between nitroglycerin doses. Withhold nitroglycerin if
SHP 90nunlig
•• If evidence of right ventricular failure (hypotension, ND, pitting edema), withhold nitroglycerin and morphine. Contact MO ASAP for medical oversight
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EMERGENCY MEDICAL TREATMENT SOPw SOP: 68 Pap: 6
ISID:REtami
1) Assure ABC's
2) Vital signs with Tilts. (A decrease in 10 pts for 13/P or therein of the HR of 20 pointsmeans pt is tOt positive) You mayjust follow HR and response vice complete{ see of tilts.
3)
Draw CBC, and Chem 7 to be seat stet, if detainee does not roped to 2 liters of IVfluids. May DSC labs if detainee is tilt negative. There is no need for IVF.
4) Two liter bolus of NS or
5) Finger stick. If blood glucose is less than 60 then start second N line and infuse D5W
200= / hr for total of 400= and Thiamine 100mg IMIIVPB and call MO.

6) Pulse oz. If pulse ox is less than 95% administer 02 and call MO if hadn't done so
already.
7) May D/C to block if re-tilt is negative. You may re-tilt after first IV bag.
8) If re-tilt positive, call MO if hadn't done so already.
9) Please call MO for any concerns or questions.
EMERGENCY MED
ICAL TREATMENT SOP . SOP: 68 .
Page: 7

plEfliallyzzanim
1)Assure ABC's
2)If respiratory failure is imminent, got to
ADVANCED AIRWAY PROTOCOL 3)Provide supplemental 02 to keep Sp02 92%
4) If anaphylaxis is present got to
ALLERGY/ANAPHYLAXIS PROTOCOL
5) If riles present or history of cardiac/MI:

-EKG monitor
-Obtain vascular access with "RainbovP blood draw

-
Nitrogbearla 44 mgw
SL (CY(N) q 5 min X 3 doses
-Lash I mg/kg IVP (N)
-
Allaaeral 2.5 mg/ Sec NS via /MN if active wheezing present
If history of COPD, asthma, wheezes or diminished breath sounds:

-
Allasterai 2.5 mg/5 cc NS via HIM (C)/(N)
If no improvement

-
Allasterol 2.S nig/Scc NS/ Afro's's( 0.5mg/Scc NS via HHN (C)/(N)
-
Obtain vascular access
-
Eolirme.ls1125 mg IVP (N)
-

Repeat Alkuiesal 2.5 mWScc NS via HHN (CY(N) 6) Continue to
monitor, transport to clinic, and contact MO for medical oversight
HHN.. Hand Held Nebulizer
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EMERGENCY MEDICAL 'TREATMENT SOPw
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2131Efinpicaungunga
1)Au= ABC's
2)Obtain diving history:

-depth of dive
-total diving time (time leering surface anti! time reaching surfacer. total dive time)
time spelt at bottom
ascent time

-type of mixture (sir, N1TROX, helium/oxygen mixture, etc.)
-
any complications during dive 3)NRB 10-15 1pm 02 4)Obtain IV seem
S) Transport supine on spine board to NH OTMO for eval
Important Numbers: Dive Locker: Dive '
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EMERGENCY MEDICAL TREATMENT SOPw
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IIMIBLCALIKaarilkaltill=
1) Ensure scene safety 2) Assure ABC's 3) Consider spinal immobilization
4) If cardiac arrest or bradycardia present, refer to appropriate protocol S) 3-lead EKG monitor
6) Obtain vascular access with "Rainbow" lab draw 7) 250 ml NS bolus(s) to maintain SHP 90 mmHg 8) 12-Lead EKG
9) If burn injury present, go to BURN PROTOCOL 10) Continue to monitor, transport to ea*, and contact MO for Medical oversight
005132

EMERGENCY MEDICAL TREATMENT SOPw SOP: 68 Page: 10
1) Assure ABC's

2) If respiratory failure is imminent, go to ADVANCED AIRWAY PROTOCOL
3) Remove from environment
4) Provide supplemental 02 to maintain Sp02 92%
5) If altered LOC or rectal temp 104 F:

-FSBS (if less than 60 mg/dl, got to ALTERED MENTAL STATUS PROTOCOL)
- obtain vascular access with "Rainbow" Wood draw
-Inane 2 L IV NS bolus (C)/(N)

-Aggressive cooling measures (ice to um pits and groin, water and direct wind from fa,
etc.)
-Discontinue aggressive cooling measures when cue temp reaches 101 degrees F
Heat Exhaustion
-Place in air-conditioned environment

-Infuse 2L N NS bolus (c)I(N)
Heat Cramps:
• -Encourage PO intake
-Educate need for increase fluid requirements while operating in hot environment
6) 250m1 NS bolus(s) to maintain SBP 90 mmHg 7)Continue to monitor, transport to clinic, and contact MO for medical oversight
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NAUSEA AND VOMITING 1)Assure ABC's 2)Provide supplemental 02 to keep Sp02 92% 3)If dehydration or bypoperfusion evident, go to REHYDRATION/SHOCK PROTOCOL 4)Obtain vascular access as needed 5)If active nausea and yanking present
-Phourzaa 25mg IM (cy(N) cc 12.5-25mg IVP (N)
or

-Zofran 4mg IVP (N) 6)Continue to monitor, transport to clinic, and contact MO ASAP for medical ovasight

00E134
EMERGENCY MEDICAL TREATMENT SOP w
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POLSONING/OVERDOSI
I) Assure ABC's
2) Obtain hisony:
-type and amount of poison
-route (invited, inhaled, injected or through skin who contamination)
-time poisoned
-has patient vomited? When?
• history
-PMH of drug or ETOH usage?
3) In unresponsive or altered mental status, got to ALTERED MENTAL STATUS
PROTOCOL

4) If seizing, got to SEIZURE PROTOCOL
5) If anaphylaxis or-allergic reaction suspected, go to ANAPHYLAXIS/ALLERGIC
REACTION PROTOCOL

6)If inhaled poison:
-expose to fresh air/remove from environment
-administer 100% 02 via NRB
7) If skin surface conminhiated:
Dry Chemical

-brush off particles
-bristle with H2O for 20 min
Liquid Chemical
-irrigate area with 1120 for 20 min
8) Ingested poison (non acid, alkali, or other caustic substance):
-if acid, alkali or other caustic substance, proceed to step 9
-if 30 min after poison ingestion, give 1 gram/kg Activated Charcoal PO (if tolerated)

-place NG tube if unable to tolerate PO
-if 30 min since ingestion, moor and proceed to step 9

9) Contact Poison•Control Center or obtain MSDS sheets as needed
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EMERGENCY MEDICAL TREATMENT SOP
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10) Continue to monitor, transport to clinic, contact MO ASAP for medical oversight

slams
1)Assure ABC's
2)Protect patient from injury

3)If respiratory failure is imminent, proceed to ADVANCED AIRWAY PROTOCOL 4)Obtain FSBS. If less than 60 mg/dl, go to
ALTERED MENTAL STATUS PROTOCOL 5)If patient is actively seizing 10 min:
-obtain vascular access
-
Diazepam 2-10mg IVP (N) " or Lora 2-5 mg NP (N)** 6) Continue to monitor, transport to clinic, and contact MO ASAP for medical oversight
0* If unable to obtain N access, may administer Diazepam via rectum
005126
EMERGENCY MEDICAL TREATMENT SOP w SOP: 68 Page: 14
°MakielallAZIME2014
1)Assure scene
2) Perform primary assessment:
A
-ensure open airway with c-spine control
-if respiratory failure irmninent, go to ADVANCED AIRWAY PROTOCOL
B
-ZAP? and ensure adequate respiratory !baton
-peovide supple:mute/ 02 to keep Sp02 92%
-if S/S of tenslon poeuoniothorax evident, perform needle thouncentesis
-stop all life-threatening hemorrhage
-perform "blood sweep"
D AVPU or OCS
- ongoing mental status checks

E expose all suspected injury areas
-prevent hypothermia and shock from excessive lure
F.
-full set of vital signs (including Sp02 and pain aaessment)
-EBL to detamine blood loss
3) Secure airway using ADVANCED AIRWAY PROTOCOL if needed
4) Obtain venous access and intim NS via bolu(s) to maintain SBP 90 mmHg
5) Perform secondary assessment and treat all associated injuries
6) Morphine sulfite
titrated to effect 2-5mg 1M (CY(N) or 2-5mg W (N) PRN for lain (maximum I Ding)
7)
Continue to monitor, transport to clinic, and contact MO ASAP for medical oversight
CARDIAC ARREST
PROTOCOL FOR NON-
ACLS PROVIDERS

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EMERGENCY MEDICAL TREATMENT SOP w
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AUTOMATED EXTERNAL DEFIBRILLATION (AED) FOR NON-ACLS PERSONNEL
I) Establish painlessness
2) Contact Delta Clinic or Detention Hospital and all "Code Blue"
3) Start CPR utilizing BVM and 100% 02.
4) Turn AED on
5) Attach electrodes

6) Analyze rhythm
If shock indicated:
-give (3) "stacked shocks"
-continue CPR for (1) minute

-maintain airway crattrol utilizing ADVANCED AIRWAY PROTOCOL and establish
PI access
-Epinephrine 1:10,000 Img IVP (N) or 2.5 mg ETT (N) q 3-5 min

-analyze rhythm
-give (3) "stacked shocks" if needed

-continue CPR for (1) minute LIdocabut 1-1.5 mg/kg NP (N) or 2-3 mg ETT (N) to a maximum of 3 mg/kg
-analyze rhythm
-give (3) "stacked shocks' if needed
-continue CPR, monitoring and delivering drug, shock, drug, shock, etc.

If no shock indicated:
-continue CPR
-maintain airway control and establish N access
-Epburplirbso 1:10,000 'mg IVP (N) or 2.5mg ETT (N) q 3-5 min
-continue CPR
-Atropine 1mg NP (N) or 2mg ETT (N) q 5min (max of 3mg)

-continue CPR, monitoring with AED and proceed to if shock indicated" if shock
7) If spontaneous return of pulse, got to POST RESUSCITATION PROTOCOL
8) Continue to monitor, transport to clinic, and contact MO ASAP for medical oversight
oosias

EMERGENCY CARDIAC
CARE PROTCOLS FOR
ACLS PROVIDERS

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I ) Establish unresponsiveness . • Myocardial Wanda:Acidosis Tarim Encomollann
2) Begin CPR with BVM and 100% 02 abilidallimWHYP":1111
• HYodurada
3) 3-lead EKG monitor 4) Maintain airway utilizing ADVANCED AIRWAY PROTOCOL • *Pah - Cardiac lampoloda- Emboli . Drag °modals
5) Obtain vascular access
6) Ephuphrins 1:10,000 lmg IVP (N) or 2mg ETT (Cy(N) q 3-5min
7) Continue CPR
8) ilfropine lms IVP or 2mg ETT (C)/(N) q 3-5 min (max 3 mg)
9) Continue CPR

10) If spontaneous return of pulse, go to POST RESUSCITATION PROTOCOL 11) Continue to monitor, transport to clinic, and contact MO ASAP for medical oversight
0 0 514 J.
EMERGENCY MEDICAL TREATMENT SOPw
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latinfatam
1) Assure ABC's 2) Provide supplemaual 02 to keep Sp02 92% 3) EXGRIOnitOr
4) If ri degree Type II or 34 degree Heart Block present with signs of hypoperfusion, consider
early nanscutaneous pacing (TCP)
5) Obtain vascular acceu
6) Atropine 0.5-1 mg IVP (N) titrated to effect (maximum 3mg)
7) If patient fails to respied to atropine, consider transcutaneous pacing (TCP)
8) Continue to monitor, transport to clinic, and contact MO ASAP for medical oversight

0051A2
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ZEUEUENIUmicatkicnyinam
1) Establish *salesmen

2) Begin CPR with BVM and 100% 02
3) Maintain airway utilizing ADVANCED AIRWAY PROTOCOL
4) Obtain vascular access

5) Epinephrine 1:10,000
Img JVP (N) or 2mg ETT (C)/(N) q 3-5 min
6) Continue CPR

7) Atropine lragIVP (N) or 2mg ETT (C)/(N) q 3.5 min (maximum 3mg) ** 8) Continue CPR
9) Rule out causes of PEA and treat according to appropriate protocol 10) If spontaneous return of pulse, got to POST RESUSCITATION PROTOCOL 11) Continue to monitor, transport to clinic, and contact MO ASAP for medical oversight
Give atropine for electrical heart rate 60 bpm
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1) Assure ABC's
2) Provide supplemental 02 to keep Sp02 92%
3) 3-lead EKG monitor
4)

If pulse 150 bpm with signs of altered mental status or hypperibsion:
ynd
-snonized cardioversion (1001, 2004 3, 360)) •
-if
pulseless got to appropriate protocol
5) Obtain vascular access
6) 12 Lead EKGw
7)

If pulse 150 bpm and without signs of hypoperfission, attempt vagal maneuver ••
8) Ifsigns of deteriorating mental status or hypoperfusion present

-synchronized cardioversion (1004 200J, 3001, 36111) •••
-if pulseless go to appropriate protocol
9) Continue to monitor, transport to clinic, and contact MO ASAP for medical oversight

• May stan at 501 for Atrial Flutter
** Vagal maneuvers should not be attempted on the following:
-phistory
revi of transient ischemic attack (TIAY cerebral vascular accident (CVA)
-wous neck surgery
-neck cancer
-history of &or& stenosis

-known carotid artery blockage
••* If possible, provide sedation with analgesia: -
Seemed 1-2mg IVP (N)
-iforphine Sarno 2-4mg IVP (N)
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16Car-CARDI&ZIPLCQMPLEI
1) Assure ABC's
2) Provide supplemental 02 to keep Sp02 92%
3) 3-lead EKG monitor

4) If pulse 150 bpm with signs of altered mental status or hypoperfusion:
-synchronized eardioversion (1004 2004 3001. 3601) •
5) Obtain vascular access
6) 12 Lead EKG

7) Lklocalme 1-1.5 mg/kg slow IVP (N) over 2 min *10
8) If rhythm does not spontaneously convert to sinus within 10 min:

•
LIdocalse 0.5-0.75 mg/kg slow IVP (N) over 2 min •• 9) If patient becomes pulseless, go to VENTRICULAR FTBRILLATION/PULSELESS VENTRICULAR TACHYCARDIA, PROTCOL 10) If patient develops sign of altered mental status or hypoperfusion:
-synchronized cardioversion (1004 2001, 3001, 36W) • 11) if patient converts to sinus rhythm, start Lleadne drip 2-4 mg/min
0 Continue to monitor, transport to clinic, and contact MO ASAP for medical oversight
* If possible, provide sedation with analgesic
-
Versed 1-2mg IV? (N)
Morphise Sulfite 2-4mg IVP (N)

** Give 55 dose in patients with impaired liver function, left ventricular dysfunction or 70 yo
005145
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VENTRICULAR FIBRILLATION/PULSELESS VENTRICULAR TACHYCARDIA
1) Establish *niceness

2) Contact Delta Clinic or Detention Hospital and all "Code Blue"
3) EICCimoniter
4) Defibrillate at 2004 300.1, 3603

5) CPR with 13VM and 100%02
6) Maintain airway utiliabqg ADVANCED AIRWAY PROTOCOL
7) Obtain venous 'coat

Efileepierise 1:10,000
IV? (N) or 2mg ETT (C), N) q 3-5min 9) Continue CPR 10) Defibrillate at 3603 11) Llibeelne 1-1.5mg1kg IV? (N) or 3mg/kg ETT (Cy(N) • 12) Continue CPR 13)Defibrillate at 3601
14)Wotan 1.5rag/kg IVP (N) or 3mg/kg ETT (CY(N) • (maim= 3neglkg) 15) Continue CPR 16) Defibrillate 3603
16) Continua "drukshoer sequence with delibrilhuian every 30-60 seconds after drug
administration 17) If spontaneous return of pub*, got to POST RESUSCITATION PROTOCOL 18)Continue to monitor, transport to clinic, and all MO ASAP for medical oversight
• Give Si dose in patients with impaired liver function, left ventricular draction or 70 yo
005146
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EMERGENCY MEDICAL TREATMENT SOP w
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POST RESUSCITTATION
1) Assure ABC's
2) Assess heart rate:
-if bean rate 60 bpm, got to BRADYCARDIA PROTOCOL if batt rate 150, go to NARROW or WIDE TACHYCARDIA PROTOCOL
3) If patient is hypotensive and lung sounds are clean
-give 250m1 NS bolus(s) to maintain SBP 90 mmHg
-consider Armadas 5­
10 meg/kg/min to maintain SBP 90 mmHg if unresponsive tofluid bolus(s)
4) [fluting V-FIB or V-TACH dining resuscitation: -
give lideatine 13 mg/kg slow !VP (N) over 2 minutes (if not previously given) •
start Lidearae drip at 2-4 mg/min
5) Continue to monitor, transport to clinic, and contact MO ASAP for medical oversight
• Give Y3 dose in patients with impaired liver function, left vermicular dysftinction or 70 yo
005147
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STANDARD OPERATING PROCEDURES Detention Hospital Guantanamo Bay, Cuba REVIEWED AND APPROVED BY:
Officerin Chwge Date
IMPLEMENTED BY:
Director for Administration
Date
$enior Enlisted Advisor Datg
ANNUAL REVIEW LOG:
By:w Brw By:w By:w By:w By:w Data Date:----Date: Date:w Data Date:
SOP REVISION LOG:
Revision to Page:w Revision to Page:w Revision to Page:w Revision to Page:. Revision to Pagew Revision to Page: w Date: Datc Date: wDate: Date: ., Date:
ENTIRE SOP SUPERSEDED BY:
Titlew
SOP NO: Date:

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