2
CENTER FOR ARMY LESSONS LEARNED
Airway. A second survivable cause of death at the POI is a non-patent
(closed) airway. Airway injuries typically occur from maxillofacial trauma
or inhalation burns. A conscious and speaking casualty has a patent open
airway. An unconscious casualty who is breathing can benet from the
nasopharyngeal airway (NPA) (see page 8). An unconscious casualty
who is not breathing may require a denitive airway such as a surgical
cricothyroidotomy (see page 11). In a combat setting, endotracheal
intubation is highly difcult, if not impossible.
Respirations. The third potentially survivable cause of death on the
battleeld is the development of a tension pneumothorax (PTX). Air
trapped in the chest cavity begins to displace functional lung tissue and
places pressure on the heart, resulting in cardiac arrest. Seal open chest
wounds with a vented chest seal, decompress a suspected PTX, and
support ventilation/oxygenation, as required. Treat a PTX via needle chest
decompression (NCD) using a 14-gauge, 3.25-inch-long needle with a
catheter (see page 20).
Circulation. Control of bleeding takes precedence over infusing uids.
Only individuals in shock or those who need intravenous (IV) medications
need to have IV access established. Use an 18-gauge catheter and saline
lock in a eld setting. Give tranexamic acid (TXA) as soon as feasible
to casualties in or at risk of hemorrhagic shock. Once a saline lock is
established, secure it with transparent wound-dressing lm. Administer
uids by a second needle and a catheter through the lm dressing. When the
infusion is complete, withdraw the needle, leaving the saline lock in place.
An intraosseous (IO) device is an alternative route for administering uids
when uid resuscitation is required and an IV access cannot be obtained.
Clinical signs of shock on the battleeld are: 1) unconsciousness or altered
mental status not due to coexisting traumatic brain injury (TBI) or drug
therapy; and/or 2) abnormal radial pulse.
Head injury/hypothermia. Hypotension (systolic blood pressure [SBP]
under 90) and hypoxia (peripheral capillary oxygen saturation [SpO2]
under 90) worsen secondary brain injury. Medical personnel identify
mild traumatic brain injury (mTBI) using the Military Acute Concussion
Evaluation (MACE) (more information on MACE is available online at
https://dvbic.dcoe.mil/material/military-acute-concussion-evaluation-
mace-pocket-cards). Non-medical personnel utilize the alert, verbal, pain,
unresponsive (AVPU) scale. Hypothermia is a survivable cause of further
injury and is dened as a whole body temperature below 95 F (35 C).
Hypothermia, acidosis, and coagulopathy constitute the lethal triad in
trauma patients. Hypothermia can occur secondary to blood loss, regardless
of the ambient temperature. The Hypothermia Prevention and Management
Kit (HPMK) is recommended by the CoTCCC for all casualties.