All cards — Crash Card

O2	SpO2 / PaO2 low	↑ FiO2 then ↑ PEEP
CO2	EtCO2 / pCO2 high	↑ RR then ↑ volume
CO2	EtCO2 / pCO2 low	↓ RR

DOPES

Displaced tube
Obstructed / plugged
Pneumothorax
Equipment failure
Stacked breaths

DOTTS

Disconnect vent
O2 100% · bag by hand
Tube: suction + EtCO2
Tweak settings
Sounds equal

HIGH PRESSURE kink · plug · biting · bronchospasm · PTX
LOW PRESSURE disconnect · cuff leak · extubated

TIDAL VOLUME 6 mL/kg PBW · by height & gender

HT	F mL	M mL
5'0"	275	300
5'2"	300	330
5'4"	330	355
5'6"	355	385
5'8"	385	410
5'10"	410	440
6'0"	440	465
6'2"	465	495
6'4"	495	520

ARDSNET (ARMA)

TV 6 mL/kg PBW · range 4–8
Plat ≤30 · if >30: ↓TV 1 mL/kg → min 4
RR ≤35 · titrate to pH
pH 7.30–7.45 · ≥7.15 tolerated
PaO2 55–80 · SpO2 88–95
ΔP ≤15 (Amato, post-hoc)

PBW derives from height + gender, not weight. 8 mL/kg = table × 1.33.

⚠ STILL HYPOXIC — ESCALATE IN ORDER

1 sedate deeper → 2 paralyze → 3 ↑PEEP (Plat ≤30, ΔP ≤15) → 4 prone if able → 5 accept SpO2 88 / pH ≥7.15 → 6 ECMO call (P/F <80)

High PEEP derecruits in seconds — clamp the tube before ANY circuit break.

FIELD REFERENCE · NOT A PROTOCOLVERIFY LOCALLY

MODES — HAMILTON T1

HAMILTON	EQUIVALENT	FUNCTION
(S)CMV+	Volume AC	every breath gets set volume
PCV+	Pressure AC	every breath gets set pressure
SIMV+	SIMV	set rate + free breaths between
SPONT	PSV / CPAP	patient drives, vent assists
ASV	Adaptive	vent picks rate/volume from %MinVol
DuoPAP	BiPAP / APRV	two pressure levels, spont. on both
NIV	Mask BiPAP	leak-compensated mask ventilation

PRESSORS

AGENT	C	R	V
Norepi	●●	●●	●●
Epi	●●	●●	●●
Vasopressin	●●	●●	●●
Dopamine	●●	●●	●●
Dobutamine	●●	●●	↓
Phenylephrine	●●	↓	●●
Milrinone	●●	●●	↓

C contractility · R rate · V vasoconstriction ●● strong · ● mild · ↓ drops it

SEDATION / PARALYTICS onset → duration

INDUCTION
Etomidate	sec → 3–5m
Ketamine	1m → 10–20m
Propofol	<1m → 3–10m
PARALYSIS
Succinylcholine	45s → 6–10m
Rocuronium	1m → 45–70m

MAINTENANCE
Fentanyl	2m → 30–60m
Midazolam	3m → 1–2h
Dexmedetomidine	slow → short
Propofol gtt	fast on/off
Ketamine gtt	steady

SEDATE BEFORE PARALYZE

rocuronium outlasts induction — re-dose sedation first

VERIFY AGAINST LOCAL PROTOCOL

CC-VT-01ACUTE CARE

Vent Transfer

Gas exchange corrections, DOPES/DOTTS, tidal volume by height, ARDSnet, escalation to ECMO.

$14 In stock

LAB VALUES

CRASH CARDCC-LV-01 · ACUTE CARE 01

BASIC METABOLIC PANEL adult reference

	Na	135–145
▲	K	3.5–5.0
	Cl / CO₂	98–106 / 23–29
	BUN / Cr	7–20 / 0.6–1.2
▲	Glucose	70–100 (fasting)
	Calcium	8.5–10.5
	Mg / Phos	1.7–2.2 / 2.5–4.5

EXTENDED CHEMISTRY

	Anion gap	8–12
	Osmolality	275–295 mOsm/kg
	Ammonia lab-specific	15–45 µg/dL
	Lipase lab-specific	10–140 U/L

ABG arterial · PaCO₂ / PaO₂ mm Hg

	pH	7.35–7.45
	PaCO₂	35–45
	PaO₂	80–100
	HCO₃⁻	22–26 mEq/L
	SaO₂	95–100 %
▲	Lactate	0.5–2.0 · >4 critical mmol/L

▲ amber = high-alert analyte — recap on back

FIELD REFERENCE · NOT A PROTOCOLVERIFY LOCALLY

CBC

	WBC	4.5–11 ×10³/µL
	Hgb	M 14–18 / F 12–16 g/dL
	Hct	M 42–52 / F 37–47 %
	Platelets	150–400 ×10³/µL

COAGULATION

	PT	11–13.5 s
▲	INR	0.8–1.1 (therapeutic 2–3)
	aPTT	25–35 s
	Fibrinogen	200–400 mg/dL
	D-dimer lab-varies	<0.5 µg/mL FEU

CARDIAC MARKERS

	Troponin hs vs conventional	<99th %ile · assay-specific
	BNP	<100 pg/mL

LIVER FUNCTION

	AST / ALT	10–40 / 7–56
	Alk Phos	44–147
	T bili / Alb	0.1–1.2 / 3.5–5.0

▲ HIGH-ALERT — FLAGGED ON THIS CARDsame ranges, one glance

K	3.5–5.0
Glucose	70–100 (fasting)
INR	0.8–1.1 (therapeutic 2–3)
Lactate	>4 critical

EDUCATIONAL REFERENCE ONLY

ranges and protocols vary by facility and lab — always follow your institution's policies

RANGES VARY BY LAB · VERIFY LOCALLY

CC-LV-01ACUTE CARE 01

Lab Values

Normal adult ranges for the labs you check most — chemistry, ABG, cardiac — high-alert values in amber.

$14 Ships July 25

ETT SIZING

CRASH CARDCC-ETT-01 · ACUTE CARE 02

PEDIATRIC ETT uncuffed-led · cuffed = −0.5 · depth at lip

AGE	lb	kg	UNCUFF	CUFF	DEPTH cm
Preterm	2–5	1–2.5	2.5–3.0	—	6–8
Newborn	7–11	3–5	3.0–3.5	—	9–10
6 mo	15	7	3.5–4.0	3.0–3.5	10.5–12
1 yr	22	10	4.0–4.5	3.5–4.0	12–13.5
2 yr	26	12	4.5	4.0	13.5
4 yr	35	16	5.0	4.5	15
6 yr	44	20	5.5	5.0	16.5
8 yr	55	25	6.0	5.5	18
10 yr	70	32	6.5	6.0	19.5
12 yr	88	40	7.0	6.5	21
14 yr	110	50	7.0–7.5	6.5–7.0	21

FORMULAS · 1–10 YR

Uncuffed (age÷4)+4
Cuffed (age÷4)+3.5
Depth 3 × tube ID cm
Neonate kg + 6 cm at lip

BLADE

Preterm Miller 0
NB–2 yr Miller 1
2–8 yr Miller / Mac 2
8 yr+ Mac 3 · Mac 4 lg

SUCTION CATH 2 × ETT ID in Fr · 4.0 tube → 8 Fr

GASTRIC / OG 2 × ETT ID in Fr · decompress after BVM

STYLET straight-to-cuff ~35° · tip never past Murphy eye

⚠ FAILED AIRWAY — MOVE, DON'T REPEAT

1 reposition + bougie → 2 size down 0.5 → 3 SGA / LMA → 4 2-person BVM + OPA/NPA → 5 surgical airway — mark cricothyroid early if predicted difficult

Max 2 attempts per operator — SpO2 recovery between every attempt.

FIELD REFERENCE · NOT A PROTOCOLVERIFY LOCALLY

ADULT oral · depth at teeth

Female	7.0–7.5 · 21 cm	Mac 3
Male	7.5–8.0 · 23 cm	Mac 3–4
Nasal route	+2–3 cm	to oral depth
Suction	12–14 Fr	2 × tube ID
Bougie	coudé tip anterior	hold-up ≈ tracheal

LMA BY WEIGHT & difficult airway

SIZE	kg	lb
1	<5	<11
1.5	5–10	11–22
2	10–20	22–44
2.5	20–30	44–66
3	30–50	66–110
4	50–70	110–154
5	70–100	154–220
6	>100	>220

LEMON

Look externally
Evaluate 3-3-2
Mallampati ≥3
Obstruction
Neck mobility

CONFIRMATION every tube · every move

EtCO₂	waveform capnography = standard
Auscultate	equal bilateral · epigastrium silent
Depth	at teeth vs table · note & mark
CXR	tip 2–4 cm above carina
Misting	unreliable · never sole confirmation

⚠ CUFF 20–30 cmH₂O — MANOMETER, NOT FEEL

>30 mucosal ischemia · <20 leak / aspiration · recheck after transport & altitude change

No EtCO₂ waveform → assume misplaced — remove & reconfirm.

DEPTH = 3 × TUBE ID

cm at the lip — reassess after every patient move

VERIFY AGAINST LOCAL PROTOCOL

CC-ETT-01ACUTE CARE 02

ETT Sizing

Preterm-to-adult tube sizes and depths, weights in both lb and kg on every pediatric row.

$14 Ships July 25

VASOACTIVE DRIPS

CRASH CARDCC-VD-01 · ACUTE CARE 03

INFUSIONS usual adult IV · titrate to effect

AGENT	RECEPTOR	DOSE	MIX
VASOPRESSORS
Norepinephrine	α₁ > β₁	0.01–0.5 µg/kg/min	4 mg/250 = 16 µg/mL
Epinephrine	β₁β₂ > α₁	0.01–0.5 µg/kg/min	4 mg/250 = 16 µg/mL
Vasopressin	V₁	0.03–0.04 U/min fixed	20 U/100 = 0.2 U/mL
Phenylephrine	α₁ pure	0.5–6 µg/kg/min	10 mg/250 = 40 µg/mL
INOTROPES
Dopamine	D→β₁→α₁	2–20 µg/kg/min	400 mg/250 = 1600
Dobutamine	β₁ > β₂	2–20 µg/kg/min	250 mg/250 = 1000
Milrinone	PDE3	0.375–0.75 µg/kg/min	20 mg/100 = 200

Amber agent = extravasation / high-alert. Dopamine effect is dose-dependent. Milrinone load & peripheral max rates omitted — facility-specific. Verify concentrations locally.

CHOOSE THE PRESSOR first-line by shock type

SEPTIC	Norepi	+ vaso if refractory
CARDIOGENIC	Norepi ± dobutamine	pressure first, then pump
ANAPHYLAXIS	Epi	drip after IM dosing
NEUROGENIC	Norepi / phenylephrine	watch bradycardia
BRADYCARDIC	Epi / dopamine	pace if refractory

LINE SAFETY

CENTRAL preferred for all vasoactives · dedicated pump · labeled line
PERIPHERAL bridge only · large vein · lowest dose · site check q1h

⚠ EXTRAVASATION

1 stop infusion → 2 aspirate via catheter → 3 phentolamine 5–10 mg SC in 10 mL NS around site → 4 new line · restart

Phentolamine reverses α agents — norepi · epi · phenyl · dopamine.

FIELD REFERENCE · NOT A PROTOCOLVERIFY LOCALLY

PUSH-DOSE PRESSORS bridge to the drip

EPI — 10 µg/mL

MIX	1 mL of 0.1 mg/mL + 9 mL NS
YIELDS	10 µg/mL × 10 mL
DOSE	0.5–2 mL (5–20 µg) q2–5 min

PHENYL — 100 µg/mL

MIX	1 mL of 10 mg/mL in 100 mL NS
YIELDS	100 µg/mL — draw 10 mL
DOSE	0.5–2 mL (50–200 µg) q2–5 min

Label every syringe immediately after mixing.

EFFECTS C contractility · R rate · V constriction

AGENT	C	R	V	CAUTION
Norepi	●●	●●	●●	first-line for most shock
Epi	●●	●●	●●	tachyarrhythmia · ↑lactate
Vasopressin	●●	●●	●●	adjunct — fixed, not titrated
Dopamine	●●	●●	●●	arrhythmogenic — avoid if tachy
Dobutamine	●●	●●	↓	may drop BP — pair w/ pressor
Phenylephrine	●●	↓	●●	reflex brady · ok if tachyarrhythmic
Milrinone	●●	●●	↓	long t½ · renal clearance · ↓BP

●● strong · ● mild · ↓ drops it

TITRATION the whole game

TARGET	MAP ≥65 mmHg — or per order · reassess perfusion, not just the number
ADJUST	q2–5 min to response · small steps · one drug at a time
ESCALATE	near max → add second agent, don’t chase one drip forever
MONITOR	art line when able · UOP · mentation · lactate trend
NO RESPONSE	check line · pump · concentration math → then steroids / Ca²⁺ / occult loss
WEAN	taper slowly — never abrupt · vaso last in septic shock

DOSE MATH pump sanity check

µg/min = µg/kg/min × kg
mL/h = µg/min × 60 ÷ conc (µg/mL)

PRESSORS BUY TIME — NOT A FIX

fill the tank, find the cause — reassess volume before every uptitration

VERIFY AGAINST LOCAL PROTOCOL

CC-VD-01ACUTE CARE 03

Vasoactive Drips

The seven infusions you actually hang — receptors, dose ranges, standard mixes, choose-the-pressor.

$14 Ships July 25

RSI · AIRWAY

CRASH CARDCC-RSI-01 · ACUTE CARE 04

PREPARE before the first attempt

Pre-oxygenate	100% O₂ ≥3 min or 8 VC breaths
Apneic O₂	NC 15 L/min — on through attempt
Position	ear-to-sternal-notch · ramp if obese
Backup	suction on · bougie · SGA at hand
Pressor	push-dose epi drawn up before drugs
Plan	verbalise A→B→C · assign roles

INDUCTION → PARALYSIS IV · mg/kg

AGENT	mg/kg	ONSET	DURATION	HEMODYN.
INDUCTION
Etomidate	0.3	30–60s	3–10m	neutral
Ketamine	1–2	30–60s	5–15m	↑BP ↑HR
Propofol	1.5–2.5	<60s	5–10m	↓↓BP
Midazolam	0.1–0.3	60–90s	15–30m	↓BP · slow
PARALYSIS
Succinylcholine	1.5	45–60s	6–10m	↑K⁺
Rocuronium	1.2 RSI	45–60s	30–60m	neutral

ROC 1.2 intubating conditions ≈ sux speed · plan for 30–60 min down
NO ANALGESIA etomidate / midazolam — pair with fentanyl

NO SUX — USE ROC

Hyperkalemia known / suspected
Burns / crush >72 h out
Denervation GBS · ALS · SCI
MH history personal / family

SHOCK / LOW BP

SI ≥1 → ketamine or etomidate
cut induction dose 25–50%
avoid propofol
push-dose epi 5–20 µg q2–5m

FIELD REFERENCE · NOT A PROTOCOLVERIFY LOCALLY

FAILED AIRWAY change something every attempt

Each attempt	blade · bougie · position · operator
SpO₂ falling	stop → 2-hand BVM + OPA/NPA
BVM fails	supraglottic (i-gel / LMA)

⚠ CAN'T INTUBATE · CAN'T OXYGENATE

1 ≤3 attempts total → 2 declare CICO aloud → 3 last SGA try → 4 scalpel–bougie–tube cric → 5 confirm EtCO₂

Decide to cut while SpO₂ still >80 — fixation on the tube kills.

QUICK DOSES mg by weight · midpoint doses

WT kg	ETOM 0.3	KETA 1.5	SUX 1.5	ROC 1.2
50	15	75	75	60
60	18	90	90	72
70	21	105	105	84
80	24	120	120	96
90	27	135	135	108
100	30	150	150	120
110	33	165	165	132

POST-INTUBATION confirm → sedate

CONFIRM EtCO₂ waveform · equal sounds · secure depth
HYPOTENSIVE fluids · push-dose epi 5–20 µg q2–5m

PUSH — RE-SEDATE
Fentanyl	25–100 µg IV
Midazolam	1–2 mg IV
WATCH
Propofol	↓BP
Dexmedetomidine	↓HR

DRIPS
Fentanyl	25–200 µg/h
Propofol	5–50 µg/kg/min
Midazolam	1–5 mg/h
Ketamine	0.5–2 mg/kg/h
Dexmedetomid.	0.2–0.7 µg/kg/h

SEDATE BEFORE PARALYZE

roc 30–60 min outlasts every induction agent — re-dose sedation first

VERIFY AGAINST LOCAL PROTOCOLCC-RSI-01

CC-RSI-01ACUTE CARE 04

RSI & Airway Drugs

Pre-oxygenation through failed airway: induction and paralytic doses, onset, duration, hemodynamics.

$14 Ships July 25

PEDIATRIC EMERGENCY

CRASH CARDCC-PED-01 · ACUTE CARE 05

WEIGHT & VITALS APLS wt (age+4)×2 kg · 1–10 y

AGE	~KG	HR	RR	SBP ≥
Neonate	3.5	100–180	30–60	60
Infant <1 y	4–10	100–160	30–60	70
Toddler 1–3 y	10–14	90–150	24–40	72–76
Preschool 3–6 y	14–20	80–140	22–34	76–82
School 6–12 y	20–40	70–120	18–30	82–90
Adolescent >12 y	>40	60–100	12–20	90

SBP floor 1–10 y = 70 + 2×age · a "normal" BP does not rule out shock

ARREST weight-based · IV/IO

Epi 0.1 mg/mL	0.01 mg/kg = 0.1 mL/kg q3–5m · max 1 mg
Defibrillate	2 J/kg → 4 J/kg · max 10 J/kg or adult dose
Cardioversion	0.5–1 J/kg → 2 J/kg · synchronized
Amiodarone	5 mg/kg · max 300 mg · may repeat ×2
Adenosine	0.1 → 0.2 mg/kg rapid · max 6 → 12 mg
Compressions	100–120/min · ⅓ AP depth · 15:2 two-rescuer

FLUIDS

Bolus 10–20 mL/kg isotonic
reassess after each bolus
Blood 10 mL/kg
Neonate/CHD 10 mL/kg

GLUCOSE rule of 50

D10 5 mL/kg · D25 2 mL/kg
D50 1 mL/kg (% × mL/kg = 50)
low: <60 child · <45 neonate
recheck 10–15 min after dose

⚠ NORMAL-LOOKING LOWS — HYPOTENSION IS LATE

Children compensate: tachycardia · cool/mottled skin · cap refill >2 s · narrow pulse pressure with SBP intact. Falling BP = decompensation — act before it.

Tachycardia out of proportion + poor perfusion = shock with a "normal" BP.

FIELD REFERENCE · NOT A PROTOCOLVERIFY LOCALLY

AIRWAY cuffed ETT = age/4 + 3.5

AGE	ETT cuffed	DEPTH cm	BLADE
Neonate	3.0	9	Miller 0–1
1 y	3.5–4.0	10.5–12	Miller 1
2 y	4.0	12	Miller 1–2
4 y	4.5	13.5	Miller/Mac 2
6 y	5.0	15	Mac 2
8 y	5.5	16.5	Mac 2
10 y	6.0	18	Mac 2–3
12 y	6.5	19.5	Mac 3

depth at lip = 3 × ETT size · uncuffed = age/4 + 4 · confirm with EtCO2

SEIZURE · ANAPHYLAXIS · RSI

Midazolam	0.1 IV / 0.2 IM/IN mg/kg · max 5 IV / 10 IM
Epi IM 1 mg/mL	0.01 mg/kg max 0.3–0.5 mg · thigh · q5–15m
Ketamine	1–2 mg/kg IV · 4 mg/kg IM
Fentanyl	1–2 mcg/kg IV/IN · slow push
Rocuronium	1 mg/kg IV
Atropine	0.02 mg/kg · max 0.5 mg · symptomatic brady
Naloxone	0.1 mg/kg IV/IO/IN · max 2 mg · repeat prn

NEONATE QUICK

warm · dry · stimulate · suction prn
apneic/gasping → PPV 40–60/min
HR <60 + poor perfusion →
compressions 3:1
epi 0.01–0.03 mg/kg IV (0.1 mg/mL)
no chest rise → MR SOPA corrections
SpO2 target 85–95% by 10 min

FIRST MOVES

estimate kg first — every dose needs it
check glucose in any sick child
brady → oxygenate + ventilate first
IO early if no IV in ≤2 attempts
length-based tape > age formulas
keep warm — cold worsens everything

BRADYCARDIA = HYPOXIA

until proven otherwise — fix airway & oxygenation before drugs

VERIFY AGAINST LOCAL PROTOCOL

CC-PED-01ACUTE CARE 05

Pediatric Emergency

Weight and vitals by age band, arrest doses, airway sizing, seizure/anaphylaxis/RSI drugs.

$14 Ships July 25

BURN ASSESSMENT

CRASH CARDCC-BRN-01 · ACUTE CARE 06

%TBSA — RULE OF NINES 2°/3° only · peds deltas amber

REGION	ADULT	PEDS
Head / neck	9	18
Arm (each)	9	9
Leg (each)	18	14
Trunk — anterior	18	18
Trunk — posterior	18	18
Perineum	1	–

PALM RULE patient's palm including fingers ≈ 1% TBSA — scattered / irregular burns

DEPTH exam findings

SUPERFICIAL	epidermis · red, dry, blanches · painful · no blisters · not counted in TBSA
SUPERF. PARTIAL	papillary dermis · wet, blisters, brisk blanch · very painful
DEEP PARTIAL	reticular dermis · mottled, sluggish / no blanch · ↓ pinprick sensation
FULL	all layers · leathery, waxy, charred · no blanch · painless to touch

FLUID RESUSCITATION LR · count 2°/3° only

Parkland	4 mL × kg × %TBSA · LR · total / 24 h
Modern start	≈2 mL/kg/%TBSA · initial rate, then titrate
Peds	+ D5 maintenance gtt · alongside resus fluid

⚠ HALF IN FIRST 8 h — FROM TIME OF BURN

0–8 h first half → 8–24 h second half — clock starts at the burn, not arrival

Subtract prehospital fluid already given from the first-half volume.

EXAMPLE 70 kg × 40% → 11.2 L / 24 h · ≈700 mL/h × 8 h · then titrate to UOP

FIELD REFERENCE · NOT A PROTOCOLVERIFY LOCALLY

INHALATION INJURY airway closes fast

⚠ RED FLAGS → INTUBATE EARLY

enclosed-space fire · carbonaceous sputum · singed nares / facial burns · stridor · hoarseness

Edema peaks over hours — secure the airway before it does.

CO · CYANIDE same fire, both possible

CARBON MONOXIDE

SpO₂ unreliable — reads normal
100% O₂ NRB · co-oximetry
t½ 4–5 h air → ~1 h on O₂
HBO: AMS · pregnancy · COHb >25%

CYANIDE

enclosed space + AMS + ↑lactate
soot + hypotension / arrest → treat
hydroxocobalamin 5 g IV
peds 70 mg/kg · don't wait on labs

ELECTRICAL surface underestimates depth

Dysrhythmia	continuous ECG + 12-lead · monitor ≥12–24 h if abnormal
Rhabdo	dark / tea urine → UOP 75–100 mL/h until clear
Deep injury	serial compartment checks · entry/exit wounds mislead
Labs	trend CK · K⁺ — treat hyperkalemia early

BURN CENTER TRANSFER any one criterion

01 partial >10% TBSA
02 any full thickness
03 face · hands · feet · genitalia · joints

04 electrical or chemical
05 suspected inhalation injury
06 extremes of age

ESCHAROTOMY burn-team call

Indication	circumferential full thickness — limb, chest, neck
With	poor distal perfusion · restricted chest excursion / ↑PIP

TITRATE TO UOP — NOT THE FORMULA

adult 0.5 mL/kg/h · child 1 mL/kg/h · electrical 75–100 mL/h — reassess hourly

VERIFY AGAINST LOCAL PROTOCOL

CC-BRN-01ACUTE CARE 06

Burn Assessment

Rule of Nines with peds deltas, palm rule, depth tiers, Parkland fluids, toxic and electrical flags.

$14 Ships July 25

TRAUMA / SHOCK

CRASH CARDCC-TRM-01 · ACUTE CARE 07

HEMORRHAGIC SHOCK I–IV classic cutoffs · 70 kg

CLASS	LOSS	HR	SBP	PP	RR	MENTAL
I	<15%	<100	nl	nl	14–20	sl. anxious
II	15–30	>100	nl	↓	20–30	anxious
III	30–40	>120	↓	↓	30–40	confused
IV	>40%	>140	↓↓	↓	>35	lethargic

Narrowing pulse pressure is the earliest vital-sign change — BP holds until class III.
HR masked by β-blockers · elderly · pacemaker · athletes — don't trust a normal rate.

SHOCK TYPE exam hallmark → first move

TYPE	HALLMARK	FIRST MOVE
HYPOVOL	flat neck veins · cool · clammy	blood · find bleed
CARDIOG	JVD + rales · cool	inotrope · no bolus
OBSTRUCT	JVD + clear lungs	decompress / drain
DISTRIB	warm · wide pulse pressure	pressor + fluids

TARGETS

PERMISSIVE HYPOTENSION

SBP 80–90 · palpable radial
only until surgical hemostasis
bolus to target, not to normal
reassess after every unit

TBI EXCEPTION

SBP 90–100 minimum
one hypotensive episode
doubles TBI mortality
GCS ≤8 → secure airway

SHOCK INDEX = HR ÷ SBP · >0.9 occult shock · >1.0 think blood + MTP

⚠ BLEEDING CONTROL — IN ORDER

1 direct pressure → 2 pack wound + pressure → 3 tourniquet high & tight — mark time → 4 junctional device / 2nd TQ above 1st

TQ not controlling → second tourniquet proximal, side by side.

FIELD REFERENCE · NOT A PROTOCOLVERIFY LOCALLY

MASSIVE TRANSFUSION trigger early — ratios save

Ratio	1:1:1 PRBC : FFP : platelets
Trigger	SI >1 · ≥2 of: penetr · +FAST · SBP<90 · HR>120
TXA load	1 g IV over 10 min · ≤3 h from injury
TXA maintenance	then 1 g IV over 8 h (CRASH-2)
Calcium	citrate binds Ca → replace early w/ transfusion

Hypocalcemia kills: hypotension refractory to blood · coagulopathy · arrest.

LETHAL DIAMOND each arm feeds the others

Hypothermia <35 °C
Acidosis pH <7.2
Coagulopathy
Hypocalcemia

KEEP THEM WARM

strip wet · wrap · cover head
fluids + blood warmed
heat the cabin, not you

REASSESS is resuscitation working?

MARKER	TREND TO SEE
Lactate	clearing >10–20% / 2 h → normal <2
Base deficit	mild 2–5 · mod 6–9 · severe ≥10
Pulse pressure	widening = volume responding
Urine output	≥0.5 mL/kg/h after hemostasis
EtCO2	rising with perfusion · <25 = low flow

WHERE THEY BLEED OUT floor + four more

SPACE	HOLDS	MOVE
Chest	1.5 L / side	decompress · chest tube
Abdomen	liters	FAST → surgery, not fluids
Pelvis	>2 L	binder at greater trochanters
Femur	1–1.5 L each	traction splint
External	—	ladder on front face

FIX THE BLEEDING, NOT THE NUMBER

crystalloid dilutes, cools, and dilutes clot — blood replaces blood

VERIFY AGAINST LOCAL PROTOCOL

CC-TRM-01ACUTE CARE 07

Trauma & Shock

Hemorrhagic shock classes I–IV, shock-type differentiator, massive transfusion and reassessment.

$14 Ships July 25

ELECTROLYTES

CRASH CARDCC-LYT-01 · ACUTE CARE 08

REPLACEMENT DOSING adult IV · severity-tiered

K⁺ POTASSIUM3.5–5.0 mEq/L

3.0–3.4 · asymptomatic	20–40 mEq PO/IV
<3.0 / symptomatic	40–80 mEq IV · divided
Rate · peripheral	≤10 mEq/h · monitor ≥10

central max per facility policy · 10 mEq ↑ K ~0.1 mEq/L

Mg²⁺ MAGNESIUM1.7–2.2 mg/dL

Repletion	1–2 g IV over 30–60 min
TORSADES	2 g IV over 1–2 min

PO₄ PHOSPHORUS2.5–4.5 mg/dL

Mild–mod	0.08–0.16 mmol/kg IV
Severe <1.5	0.16–0.32 mmol/kg IV

Infuse over 4–6 h · K-phos if K low, else Na-phos

Ca²⁺ CALCIUMiCa 1.1–1.3 mmol/L

Gluconate	1–2 g IV · peripheral OK
Chloride	1 g = 3× elemental · CENTRAL

NEVER

K⁺ IV push — ever
CaCl periph — necrosis
Rapid Mg unless torsades
Ca + phos same line — precipitates

CO-REPLACEMENT

Mg first — K won't hold
K-phos counts toward K
Recheck before re-dose
PO route preferred if able

Mg BEFORE K

hypomagnesemia makes K repletion refractory — replete Mg first

FIELD REFERENCE · NOT A PROTOCOLVERIFY LOCALLY

ECG BY DERANGEMENT

Δ	FINDINGS
↑K⁺	peaked T → PR↑ · flat P → wide QRS → sine wave
↓K⁺	U waves · ST↓ · flat T · ectopy
↓Mg²⁺	↑QT · torsades risk · worse with ↓K
↑Mg²⁺	↓DTRs → PR↑ · wide QRS → block / arrest
↓Ca²⁺	long QT · tetany · Chvostek / Trousseau
↑Ca²⁺	short QT · bradycardia · lethargy

⚠ HYPERKALEMIA — EMERGENT · ECG Δ OR K ≥6.5

1 STABILIZE Ca gluconate 1 g IV over 2–3 min → 2 SHIFT insulin 10 U reg IV + D50 25 g · albuterol 10–20 mg neb / 10 min → 3 ELIMINATE dialysis · K binders · loop diuretic

Calcium protects the myocardium only — serum K unchanged. Track glucose after insulin.

EXPECT IT situation → derangement

Massive transfusion	↓iCa (citrate) — give Ca
DKA on insulin	K · Phos crash — replete early
Refeeding	↓Phos · ↓K · ↓Mg
Crush · rhabdo · burns	↑K — anticipate, monitor
Diuretics · NG losses	↓K · ↓Mg
CKD · oliguria	↑K risk — replete cautiously

RECHECK after dose

K⁺	1–2 h after IV dose
Mg²⁺	6–12 h after dose
PO₄ Phos	6 h after infusion
iCa	6 h after repletion

CORRECTIONS

Corr Ca = Ca + 0.8 × (4 − alb)

iCa preferred when available

Total Ca misleads in hypoalbuminemia — trust ionized.

TREAT THE ECG, NOT THE NUMBER

ECG changes at any K — calcium first, then shift, then eliminate

VERIFY AGAINST LOCAL PROTOCOL

CC-LYT-01ACUTE CARE 08

Electrolyte Replacement

Severity-tiered IV repletion for K, Mg, phos, and calcium with the critical rate limits in amber.

$14 Ships July 25

MARCH FIELD CARE

CRASH CARDCC-MFC-01 · FIELD OPS

M · MASSIVE HEMORRHAGE before anything else

TOURNIQUET	high & tight · tighten until bleeding + distal pulse stop
TIME	write on TQ and casualty forehead
PACK	wound packing + 3 min direct pressure
JUNCTIONAL	junctional TQ / pack + pressure groin · axilla · neck
2ND TQ	side-by-side, proximal to first, if bleeding continues

A · AIRWAY

Position · chin lift / jaw thrust
unconscious → recovery position
NPA · tolerated semiconscious
Cric · surgical, if trained + failed above
burns / inhalation → airway early

R · RESPIRATION

Vented chest seal on open wounds
Needle decomp 10–14 ga · ≥3.25 in
5th ICS AAL pref · 2nd ICS MCL
tension recurs — re-dart if needed
burp / replace clotted seal

C · CIRCULATION blood > crystalloid

SHOCK SIGN	↓ mental status · weak / absent radial pulse
ACCESS	18 ga IV · IO if ×2 fail or no time
TXA	2 g IV/IO slow push · ≤3 h (was 1 g + 1 g)
FLUIDS	whole blood > components > crystalloid
BP TARGET	permissive: SBP 80–90 / radial pulse
TBI EXCEPT.	keep SBP 100+ (newer trend 110+)

H · HYPOTHERMIA / HEAD

STRIP	wet clothing off · insulate from ground
WRAP	heat blanket + vapor shell + cap
FLUIDS	warm IV fluids when able
TBI	avoid hypoxia SpO2 ≥90 · SBP 100+
RECHECK	AVPU / pupils with every set of vitals

FIELD REFERENCE · NOT A PROTOCOLVERIFY LOCALLY

TQ CONVERSION if evac delayed

2 h	reassess every TQ · convert if criteria met
CONVERT IF	bleeding controlled · no shock · not an amputation · can monitor
METHOD	pressure dressing on · loosen slowly · leave TQ in place, ready
≥6 h	NEVER remove — surgical setting only

ONGOING CARE PAWS · TCCC triple-option analgesia

FIGHTING	acetaminophen 1 g PO + meloxicam 15 mg still mission-capable
MOD-SEV	ketamine 20–30 mg slow IV/IO · 50–100 mg IM/IN
OPIOID	fentanyl OTFC 800 µg buccal not in shock / resp distress
ABX	moxifloxacin 400 mg PO · ertapenem 1 g IV/IM if no PO
WOUNDS	expose · dress · recheck every prior bleed
SPLINT	splint fractures · pulse check before + after

EVAC PRIORITY MEDEVAC categories

URGENT	≤1 h · life / limb / eyesight · airway, tension, shock, TBI ↓
PRIORITY	≤4 h · stable but will deteriorate untreated
ROUTINE	≤24 h · stable, treated, holding

DOCUMENTATION

TQ time on device + forehead
casualty card stays with patient
meds: drug · dose · route · time
every intervention timed

MIST HANDOFF

Mechanism of injury
Injuries found / suspected
Signs — last set of vitals
Treatments given + times

⚠ REASSESS AFTER EVERY INTERVENTION — AND EVERY MOVE

1 bleeding / TQ → 2 airway → 3 chest / re-tension → 4 mental status → 5 warmth

Needle decompression buys minutes, not hours — tension pneumo comes back.

MARCH IN ORDER — BLEEDING KILLS FIRST

restart the sequence from M after every reassessment

VERIFY AGAINST CURRENT TCCC GUIDELINES

CC-MFC-01FIELD OPS 01

MARCH Field Care

The full MARCH sequence — hemorrhage, airway, respiration, circulation, hypothermia — TCCC-derived.

$14 Ships July 25

WT kg	ETOM 0.3	KETA 1.5	SUX 1.5	ROC 1.2
50	15	75	75	60
60	18	90	90	72
70	21	105	105	84
80	24	120	120	96
90	27	135	135	108
100	30	150	150	120
110	33	165	165	132

WT kg	ETOM 0.3	KETA 1.5	SUX 1.5	ROC 1.2
50	15	75	75	60
60	18	90	90	72
70	21	105	105	84
80	24	120	120	96
90	27	135	135	108
100	30	150	150	120
110	33	165	165	132

WT kg	ETOM 0.3	KETA 1.5	SUX 1.5	ROC 1.2
50	15	75	75	60
60	18	90	90	72
70	21	105	105	84
80	24	120	120	96
90	27	135	135	108
100	30	150	150	120
110	33	165	165	132