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TACTICAL EMS PROTOCOLS face and scalp in this category.21 In such situations, consideration should be given to the use of hemostatic agents.16 These unique dressings possess properties that contribute to clot formation through alter- native means (e.g., mobilization of clot- ting components) and should be used in addition to direct pressure and pressure bandages.8 SHOCK MANAGEMENT Shock management has been researched for decades and signifi cant breakthroughs have come about as a result of lessons learned in Operation Iraqi Freedom.22 rhage in the trauma patient, the manage- ment of shock becomes paramount. This should be accomplished through fl uid administration when indicated. Fluid resuscitation in the tactical environment takes a "hypotensive resuscitation" approach.10 Fluid should be administered in individuals with an altered level of consciousness secondary to hypovolemia. Additionally, the absence of a palpable radial pulse is an indication for fluid administration with the return of palpable radial pulses as an endpoint.14 The standard of care described by ACEP distinguishes between controlled and uncontrolled hemorrhage when considering fluid resuscitation. ACEP recommends the administration of 20 ml/kg of normal saline (0.9% NaCl) following control of hemorrhage. In the event that hemorrhage has not been controlled, ACEP recommends limiting fluid administration to a quantity capable of maintaining peripheral perfusion.21 AIRWAY MANAGEMENT Airway dysfunction occurs less frequently in the tactical setting than in a conventional EMS setting.15 Studies indicate that airway adjuncts are often effective, in the absence of traumatic airway obstruction, and the need for an advanced airway is less common. Consideration should also be given to the decreased ability to monitor a patient during the CUF and TFC phases. Very few patients in this setting experi- ence a primary life-threatening airway or breathing problem.13 30 FEBRUARY 2012 | EMSWORLD.com Pneumothorax: Tension pneumo- Following control of hemor- thorax is the second-leading cause of reversible and preventable combat death. Tactical medics must be prepared to effectively seal any open chest wound. Less importance is placed on the use of a relief valve as paramedics are trained to recognize and treat any tension pneumo- thorax that may subsequently develop.14 Tactical medics must maintain a high index of suspicion when managing pene- trating trauma to the chest, and a diag- nosis of pneumothorax should be made in any case involving progressive respi- ratory distress following penetrating or blunt chest trauma.16 The typical clinical indicators of tension pneumothorax can be difficult to appreciate in the tactical environment. Thus care in the tactical environment dictates more aggressive treatment for this condition. For this reason, needle decompression should be performed in the presence of torso trauma with respiratory distress, regard- less of progression.10 This differs from many civilian prehospital protocols that require clinical signs of hemodynamic instability prior to performing needle decompression. Advanced airway options: An anal- ysis of combat fatalities found that only a small percentage of combat deaths were attributable to airway compromise, with most of those cases being asso- ciated with significant maxillofacial trauma.23 Intubation was found to be extremely difficult during these situa- tions. Additionally, the white light emitted during laryngoscopy could potentially give away one's position when working in low ambient light conditions. If a more definitive airway is necessary, many experts recommend surgical cricothy- rotomy as the procedure of choice.14 Endotracheal intubation should only be considered in the tactical environment when a patient is experiencing a respi- ratory compromise directly associated with airway obstruction as a result of trauma.15 An additional challenge of placing an advanced airway in the tactical environ- ment is confirming tube placement. It is not practical to carry expensive equip- ment in this environment but simple colorimetric devices may work.24 While these devices are suitable for confirma- tion of intubation, they are not accept- able for physiologic monitoring. Another option for airway manage- ment in the tactical environment is the use of blind insertion airway devices. The American College of Surgeons recommends the use of a multilumen esophageal airway device, such as the Combitube, or a laryngeal tube airway, such as the King LT.13 These devices can be inserted without violating light disci- pline, and their correct placement can more easily be confirmed. Conclusion Much of what has been learned in battlefield medicine can be applied to the civilian prehospital setting. It is inef- fective, and potentially dangerous, to attempt to apply standard prehospital practices to the civilian tactical envi- ronment. For civilian tactical medics to operate successfully in this unique environment they must have TEMS- specific protocols in place to justify their actions. These protocols can be effectively designed based on the TCCC guidelines with modifications to accom- modate jurisdictional and environmental Training is a critical component of tactical EMS response. Here, participants in Urban Shield 2011, an advanced homeland security training event, discuss operations. Photo by John Erich