7-3
After sources of hemorrhage are identified and controlled, the need for intravenous access should be
considered. If the patient has an isolated extremity wound, the bleeding has been controlled and there are
no signs of shock, there is no need for immediate intravenous fluid resuscitation. Intravenous access with a
saline lock should be considered for all casualties with significant injuries. If there is a truncal injury and if
signs of shock are present, or if blood pressure continues to drop, intravenous access should be obtained
with a 16 or 18-gauge catheter followed by a 1-2 liter bolus of normal saline or lactated Ringers, or 500
milliliters of Hespan. If the patient has improvement of the clinical signs of shock following the initial bolus,
subsequent intravenous fluids should be titrated to achieve only a good peripheral pulse and an improvement
in sensorium rather than to normalize blood pressure. If there is no clinical improvement following the
initial IV fluid bolus, the possibility of severe uncontrolled intra-abdominal or intrathoracic bleeding should be
considered. Further fluid resuscitation in uncontrolled hemorrhage is not indicated, may be harmful, and may
waste the limited fluids available to the SOF medic.
Cardiopulmonary arrest from hemorrhage has a very high mortality in the hospital setting. Attempting to
resuscitate patients who are in cardiac arrest secondary to hemorrhage while in the field will almost certainly
be futile.
Disability: A brief neurological assessment should be performed using the AVPU scale:
A-Alert
V-Responds to verbal stimuli
P-Responds to painful stimuli
U-Unresponsive
Exposure: Clothing and protective equipment such as helmets and body armor should only be removed
as required to evaluate and treat specific injuries. If the patient is conscious with a single extremity
wound, only the area surrounding the injury should be exposed. Unconscious patients may require more
extensive exposure in order to discover potentially serious injures but must subsequently be protected from
the elements and the environment. Hypothermia is to be avoided in trauma patients.
Vital Signs: Vital signs should be assessed frequently, especially after specific therapeutic interventions,
and before and after moving patients. The SOF medic should be sensitive to subtle changes in vital signs
in wounded SOF operators. As a group these patients are in excellent physical condition and may have
tremendous physiological reserves. They may not manifest significant changes in vital signs until they are
in severe shock. The vital signs include:
Pulse: The rate and character of the pulse should be evaluated. A weak, rapid, barely palpable radial
pulse indicates the presence of hemorrhagic shock.
Respiration: Respiratory rate can be an extremely sensitive indicator of physiologic stress. Resting
tachypnea should be considered abnormal and should prompt investigation if there is no obvious cause.
Blood Pressure: The SOF medic is not expected to carry a sphygmomanometer during combat
operations. Palpation of distal and central pulses provides a rough guide to systolic blood pressure.
Radial- at least 70 mmHg
Femoral- at least 60 mmHg
Carotid- at least 50 mmHg
Temperature: Only if hypo or hyperthermia are suspected. Hypothermia is an often unrecognized and yet
significant contributor to traumatic death.
Secondary Survey
During the Secondary Survey, a more methodical search for non-life threatening injuries is conducted. These
injuries should be treated as they are encountered. Like the Primary Survey above, the Secondary Survey
may need to be modified and adapted according to the tactical situation and the number and type of
casualties encountered. The vast majority (75%) of casualties who are wounded in action (WIA) will have
isolated penetrating trauma to the extremities. These patients do not require a detailed head to toe exam