DOMINATUS COMMINUS REMEMDIUM

Official 2025 Edition

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by the 75th Ranger Regiment
for this publication

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Copyright © 2025 / ISBN 979-8-9902257-5-6

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All rights reserved. No copyrighted part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical
(including photocopy, recording, or any information storage and retrieval system) without permission in writing from the publisher or copyright owner.

Disclaimer: The protocols in this handbook were created by the Ranger Regiment leaders for use ONLY by Ranger Medics while providing emergency
care under the license of their medical director. Ranger Medics who are authorized to operate under the trauma management team guidelines may not
use these standing orders outside of their military employment.

The 2025 Updated Ranger Medic Handbook is a resource for Ranger Medics with advanced skills and knowledge, operating in tactical, remote, or
austere environments. The purpose of the handbook is to provide these medical professionals a resource that outlines the latest techniques and
procedures used in the Special Operations community.

The publisher, Breakaway Media, LLC, makes no representations or warranties of any kind and assumes no liabilities of any kind with respect to
the accuracy or completeness of the contents. The publisher shall not be held liable or responsible to any person or entity with respect to any loss
or incidental or consequential damages caused, or alleged to have been caused, directly or indirectly, by the information contained herein. Loss or
damage includes, but is not limited to, loss of life, limb, eyesight, or mobility. This publication is intended to be used by qualified medical personnel
in the treatment of injuries to persons and working dogs under their care. It is not intended to be used by unqualified persons or persons without
proper medical training.
MEDICAL DIRECTION
Hemorrhage remains the number one cause of preventable death on the battlefield. Evaluate and treat each patient in
accordance with protocols. Ranger Medics must apply thought and cannot blindly follow algorithms. Since hemorrhage
accounts for approximately 90% of potentially survivable battlefield death, always consider and treat for hemorrhagic
shock when in doubt. Although Medics should follow the MARCH algorithm, always ask yourself, “What is killing my
patient now?” Act on that question, regardless of the algorithm if there is a clear cause. Patients may stop breathing
because of hemorrhage.

Treating hemorrhage remains a higher priority than airway control or breathing assistance.

Ranger Medics will always train and master the basics before pursuing more advanced skills, procedures, or techniques.
While these skills are care enhancing, the basics of T
­ actical Combat Casualty Care (TCCC) will save the most lives on
the battlefield.

UPDATES IN THIS ISSUE

1. Rolling a patient with a pelvic binder in place to assess downside wounds is approved so long as the movements
are minimal, controlled, and do not cause further harm to the patient. Hemorrhage control supersedes not rolling
a patient.
2. Expanded explanation on tension physiology onset time, ventilated vs. spontaneous breathing.
3. Medics are approved to slow-push Calcium in the same access port as blood if no other access is available in ex-
treme situations. Medics should always work toward having a dedicated drug port for trauma patients.
4. In extreme deployed situations, Ranger Medics are approved for slow and controlled re-perfusion of partially
filled ­donation bags (deliberate slow infusion due to risk of citrate concentration in blood stream causing cardiac
dysrhythmias).
5. Updates to calcium administration and addition of calcium chloride to the medications.
6. Updates to Pain management protocol
7. Updates to Flail chest management protocol
8. Updates to Anaphylactic shock protocol
9. Separation of UTI and STI protocols
10. Updates to Crush protocols
11. Added Pediatrics TCCC protocols
12. Updates to packing lists
COMMONLY ASKED QUESTIONS
1. TXA may be predrawn into a STERILE 10mL syringe. This should be replaced every 7 days due to bacterial infec-
tion risk.
2. Although the prehospital data is not clear at this time it is likely best practice to administer TXA 2g IV/IO flush as the
initial dose and then do not redose. Ranger Medics are approved to pre-draw 2g TXA and give this as an initial dose.
3. Finger Thoracostomy is a CLEAN procedure. Do not cut into a patient’s chest without cleaning the skin or changing
to clean gloves.
4. Chest Tube is a STERILE procedure. Medics and providers will make every attempt to use sterile gloves, chest
tubes, and peans to decrease our patient’s risk of infection.
5. Backboards are mandated by regulation to carry but have limited proven benefit to spinal patients. Backboards
should be used for patient transfer only. No patient should be on a backboard longer than 10 minutes. A rigid litter
provides the same care without the risks of pressure ulcers.
6. Both Calcium Gluconate and Chloride are approved for use in the Pre-hospital environment. Calcium administration
will be considered after the transfusion of 2 units of blood products and every 4 units after. Calcium should never
be prioritized over Blood and TXA in resuscitation efforts. 1–3g of Calcium will be administered as a slow IV/IO push
over 1–2 minutes or as an infusion in a 100mL or 250mL NaCl bag.
7. Always reassess your patient and treat based on current or trending vital signs.
8. In hemorrhagic shock the priority and focus of the Ranger Medic should be administering blood products; do not
delegate this important task. TXA, calcium, and other adjuncts should not delay blood products.
9. Cold stored blood products will be warmed. In extremis, cold blood is better than no blood, but every attempt must
be made to warm blood. A BLOOD WARMER WILL BE CARRIED.
10. Your medical direction only comes from those within Ranger Regiment. While we appreciate the experts that give
advice and learn from them, they will never dictate your scope of practice. Do not contradict your Ranger medical
leadership by following outside advice.
11. The 75th Ranger Regiment does not promote commercial products or companies. No Medic will be mandated to
carry a specific product unless a clear, overwhelming, significant advantage can be proven.
12. All fluoroquinolones now have a US Black Box Warning due to serious adverse reactions including tendinitis and
tendon rupture, peripheral neuropathy and CNS effects. In some rare cases benefits may outweigh the risks of
fluoroquinolone use. Fluoroquinolone use requires prior approval from unit physician or physician assistant with the
exception of otic or ophthalmic routes. DO NOT PRESCRIBE OR DISPENSE THESE MEDICATIONS WITHOUT
PRIOR APPROVAL!
13. Medics will carry diagnostics equipment (BP Cuff, Stethoscope, EMMA, Pulse Oximetry) and spare batteries for their
equipment. Medics will be trained on troubleshooting issues with electronics and incorporate patient management
should these items fail.
In Memoriam to Our Fallen
Ranger Medic Comrades…
SGT Jonathan K. Peney
KIA – 01 June 2010 – Afghanistan
Operation: Enduring Freedom
Platoon Medic 2007–2010
D Co, 1st Battalion, 75th Ranger Regiment

SFC Marcus V. Muralles

KIA – 28 June 2005 – Afghanistan
Operation: Enduring Freedom
Special Operations Flight Medic 2003–2005
HHC, 3/160th Special Operations Aviation Regiment
Company Senior Medic and Platoon Medic 1999–2003
B Co, 3rd Battalion, 75th Ranger Regiment
Company Senior Medic and Platoon Medic 1990–1993
C Co, 3rd Battalion, 75th Ranger Regiment

PFC James M. Markwell

KIA – 20 December 1989 – Panama
Operation: Just Cause
Platoon Medic 1989
C Co, 1st Battalion, 75th Ranger Regiment

SGT Kevin J. Lannon

KIA – 25 October 1983 – Grenada
Operation: Urgent Fury
Platoon Medic 1981–1983
A Co, 2nd Battalion, 75th Ranger Regiment

. . . and one for the Airborne Ranger in the Sky.

In recognition of the groundbreaking work of the past Ranger Medic Handbook
versions upon which the 2025 version is written.
Chief Editors, 2012
MSG Harold Montgomery, NREMT/ATP
CW4(Ret) William Donovan, PA-C
Chief Editors, 2007
LTC Russ Kotwal, MD
MSG Harold Montgomery, NREMT/ATP
J. Rick Hammesfahr, MD
Chief Editors, 2003
SFC Robert Miller, NREMT-P
SFC Harold Montgomery, NREMT/ATP
Chief Editors, 2001
SFC Robert Miller, NREMT-P
MAJ Russ Kotwal, MD

REVIEW COMMITTEES
2001 SFC Flores (3/75 Battalion Senior Medic)
MAJ Kotwal (3/75 Battalion Surgeon) SSG Odom (3/75 Battalion Senior Medic)
MAJ Meyer (3/75 Battalion PT) SSG Williamson (Regt Med Training NCO)
CPT Detro (3/75 Battalion PA) SSG Medaris (1/75 Company Senior Medic)
SFC Miller (3/75 Battalion Senior Medic) SSG Garcia (2/75 Company Senior Medic)
SFC Montgomery (Regimental Senior Medic) SSG Severtson (2/75 Company Sr Medic)
SSG Flores (3/75 Company Senior Medic)
SSG Gentry (3/75 Company Senior Medic) 2005
SSG Muralles (3/75 Company Senior Medic) LTC Kotwal (Regimental Surgeon)
SSG Odom (3/75 Company Senior Medic) MAJ Matthews (1/75 Battalion Surgeon)
SSG Rothwell (3/75 Company Senior Medic) MAJ McCarver (2/75 Battalion Surgeon)
CPT Sterling (Regimental PA)
2003 CPT Detro (3/75 Battalion PA)
MAJ Wenzel (Regimental Surgeon) CPT Reedy (1/75 Battalion PA)
MAJ Cain (1/75 Battalion Surgeon) CPT Slevin (2/75 Battalion PA)
MAJ Kotwal (3/75 Battalion Surgeon) CPT Grenier (2/75 Battalion PT)
MAJ Sassano (Regt Med Ops Officer) CPT Soliz (3/160 Battalion PA)
SFC Montgomery (Regimental Senior Medic) MSG Montgomery (Regimental Senior Medic)
SFC Miller (Regt Med Plans & Tng NCO) SFC Crays (2/75 Battalion Senior Medic)
SFC Swain (2/75 Battalion Senior Medic) SFC Warren (1/75 Battalion Senior Medic)
SFC Flores (3/75 Battalion Senior Medic) SSG Williamson (Regt Med Plans & Tng NCO)
SSG Odom (3/75 Senior Medic) SSG Gillaspie (2/75 Company Senior Medic)
SSG Williamson (2/75 Company Sr Medic) SGT Kindig (2/75 Company Senior Medic)
SGT Robbins (3/75 Company Senior Medic)
2004 SGT Slavens (3/75 Company Senior Medic)
MAJ Wenzel (Regimental Surgeon) SGT Morissette (3/75 Platoon Medic)
CPT Pairmore (1/75 Battalion PA) SPC Kacoroski (2/75 Platoon Medic)
CPT Nieman (2/75 Battalion PA) SPC Ball (2/75 Platoon Medic)
CPT Kelsey (Regt Med Ops Officer) SPC Lewis (3/75 Platoon Medic)
MSG Montgomery (Regt Senior Medic) SPC Guadagnino (3/75 Platoon Medic)
SFC Crays (2/75 Battalion Senior Medic) SPC Drapeau (3/75 Platoon Medic)
REVIEW COMMITTEES (cont.)
2006 2010
LTC Kotwal (Regimental Surgeon) LTC Chou (Regimental Surgeon)
CPT Redman (1/75 Battalion Surgeon) MAJ Gilpatrick (Regt PA)
CPT Cunningham (2/75 Battalion Surgeon) MAJ Miles (RSTB Battalion Surgeon)
CPT Miles (3/75 Battalion Surgeon) CPT Schaffer (2/75 Battalion Surgeon)
CPT Sterling (Regimental PA) CPT Fisher (1/75 Battalion PA)
CPT Detro (Regimental PA) CPT Dominguez (2/75 Battalion PA)
CPT Fox (3/75 Battalion PA) CPT Morgan (3/75 Battalion PA)
CPT Speer (Regt Med Ops Officer) CPT Menendez (3/75 Battalion PA)
CPT Pollman (3/75 Battalion PT) CPT Brown (Regt Vet)
MSG Montgomery (Regimental Senior Medic) Mr Meyer (Regt PT)
SFC Odom (Regimental Medical Training NCO) MSG Montgomery (Regt Senior Medic)
SSG Veliz (ROC Senior Medic) SFC Kelly (2/75 Bn Senior Medic)
SSG Garcia (2/75 Battalion Senior Medic) SFC Hilyard (Regt Med Tng NCO)
SSG Williamson (3/75 Battalion Senior Medic) SSG Maitha (3/75 Bn Senior Medic)
SSG Gillaspie (2/75 Company Senior Medic) SSG McAdams (Regt Prev Med NCO)
SSG Bernas (2/75 Company Senior Medic)
SSG Chavaree (3/75 Company Senior Medic) 2012
SSG Henigsmith (3/75 Company Senior Medic) LTC Chou (Regimental Surgeon)
SGT Maitha (3/75 Company Senior Medic) MAJ Gilpatrick (Regt PA)
MAJ Miles (RSTB Battalion Surgeon)
2009 MAJ Pollman (Regt PT)
LTC Kotwal (Regimental Surgeon) MAJ Slevin (2/75 Battalion PA)
LTC Chou (incoming RSURG) MAJ Schlanser (Regt VET)
MAJ Gilpatrick (Regt PA) MAJ Hart (1/75 Battalion Surgeon)
MAJ Pollman (Regt PT) MAJ Welde (Regt Med Ops)
MAJ Slevin (2/75 Battalion PA) CPT Manning (Regt Psych)
MAJ Miles (RSTB Battalion Surgeon) CPT Fox (RSTB Battalion PA)
MAJ Montz (Regt OT) CPT McKenna (3/75 Battalion Surgeon)
MAJ Schlanser (Regt VET) CPT Schaffer (2/75 Battalion Surgeon)
CPT Manning (Regt Psych) CPT Fisher (1/75 Battalion PA)
CPT Fox (RSTB Battalion PA) CPT Dominguez (2/75 Battalion PA)
CPT Hart (1/75 Battalion Surgeon) CPT Morgan (3/75 Battalion PA)
CPT Fisher (1/75 Battalion PA) CPT Menendez (3/75 Battalion PA)
CPT McKenna (3/75 Battalion Surgeon) CPT Brown (Regt Veterinarian)
CPT Menendez (3/75 Battalion PA) CPT Odom (1/75 Med Ops)
1LT Odom (1/75 Med Ops) CW4(Ret) Donovan (1/75 PA)
CW4(Ret) Donovan (1/75 PA) LTC(Ret) Meyer (Regt PT)
MSG Montgomery (Regt Senior Medic) MSG Montgomery (Regt Senior Medic)
SFC Kelly (Regt Med Ops) SFC Kelly (2/75 Bn Senior Medic)
SFC Bernas (3/75 Bn Senior Medic) SFC Hilyard (Regt Med Tng NCO)
SFC Conklin (RSTB Bn Senior Medic) SFC Conklin (RSTB Bn Senior Medic)
SFC Schneider (160th Sr Flight Medic) SFC Schneider (160th Sr Flight Medic)
SFC Klagenberg (Regt Vet NCO) SFC Klagenberg (Regt Vet NCO)
SSG Hilyard (1/75 Bn Sr Medic) SFC Hamilton (2/75 Company Senior Medic)
SSG McAdams (1/75 Bn Sr Medic) SFC Bernas (3/75 Bn Senior Medic)
SSG Maitha (Regt Med Force Mod NCO) SFC Morissette (RSTB Co Senior Medic)
SSG Nix (1/75 Company Senior Medic) SFC Maitha (3/75 Bn Senior Medic)
SSG Palmer (1/75 Company Senior Medic) SFC McAdams (Regt Prev Med NCO)
SSG Hamilton (2/75 Company Senior Medic) SFC Ryan (1/75 Bn Senior Medic)
SSG Morissette (RSTB Co Senior Medic) SSG Nix (1/75 Company Senior Medic)
SSG Lewis (RSTB Company Senior Medic) SSG Palmer (1/75 Company Senior Medic)
SPC Dorcus (1/75 Platoon Medic) SSG Lewis (RSTB Company Senior Medic)
SPC Hutchison (1/75 Platoon Medic) SSG Remley (3/75 Company Senior Medic)
SPC Peney (1/75 Platoon Medic) SGT Dorcus (1/75 Platoon Medic)
SPC Vetter (1/75 Platoon Medic) SGT Hutchison (1/75 Platoon Medic)
SPC Peney (1/75 Platoon Medic)
SPC Vetter (1/75 Platoon Medic)
2025 RANGER MEDIC HANDBOOK ACKNOWLEDGEMENTS
2024 MEDICAL DIRECTION 2024 CONTRIBUTING AUTHORS
RMED All Ranger Medics past, present and future
LTC Andrew Oh (Regimental Surgeon) LTC Ryan M. Knight
MAJ Gabe Valdez (Regimental PA) MAJ Donald “Royce” Frazee
MSG Patricio Vasquez (Regimental SEMA) MSG Simon C. Gonzalez
MAJ John Brandsma (Regimental Veterinary Officer) MAJ Joel Daly
CPT Eddie Martinez (Med Ops Officer) SFC Joe Golden (Regimental Med Ops NCO)
MAJ Shawn C. Basinger
RSTB
MAJ Jeremy Noble
MAJ Joel Fahling (Battalion Surgeon)
LTC (Ret) David Meyer (Regimental Physical Therapist)
CPT James Tash (Battalion PA)
MAJ Khalid Rodriguez (Regimental Med Ops Officer)
SFC Sean Collins (Battalion SEMA)
SSG David Pate
1/75 MSG Jeremy Ililau
MAJ Thomas Ulmer (Battalion Surgeon) SSG Colin Vidos (Regimental Med Log NCO)
CPT Bryan Anderson (Battalion PA) MAJ Joseph Shevchik
SFC Patrick Murphy (Battalion SEMA) CPT John Maitha
2LT Greg Gainty (Battalion Med Ops Officer) SFC Cyril Clayton
2/75 MAJ Steven Hunter
MAJ Megan Mahowald (Battalion Surgeon) MAJ Noel Dunn (2/75 Battalion Surgeon)
CPT Adam Sahlberg (Battalion PA) MAJ Jeremiah Beck
SSG Callum Wilkie (Battalion SEMA) SSG Steven Meyer
1LT Ryan Erk (Battalion Med Ops Officer) MAJ Charles Hutchinson
CPT Michael Broussard
3/75 MSG Zachary Conaway
CPT Andrew Withington (Battalion Surgeon) LTC Benjamin Donham, MD
CPT Joshua Milby (Battalion PA) MAJ Jason Barter, MD
SFC Caesar Reyes (Battalion SEMA) SFC Ian Anderson (160th Senior Flight Medic)
CPT Calvin Britt (Battalion Med Ops Officer) MAJ Louis Haase, MD
RMIB MSG Jake Brown, USASOC
MAJ Skyler Brown (Battalion Surgeon) SGM Christopher McNamara, USASOC
SFC Ian Cochran (Battalion SEMA) SGM Justin Ball, USASOC
SFC Devin DeFeo, USASOC
SFC Alan Ginn (Regimental Training NCO)
SFC Nicholas Warner (Regimental Training NCO)
SGM Matt Garrison, USASOC
Dr Bill Knight (Neuro Intensivist)
CPT James Tash (RSTB PA)
SGT Samuel Fredrickson
LTC Jon Bailey
MAJ James Lopata
MAJ Charlie Moore (Regimental Surgeon)
SSG Joshua Seyboth (Regimental Vet Tech)
Contents
SECTION 1 THE RANGER MEDIC & CASUALTY RESPONSE SYSTEMS
Foreword................................................................................................................................................................................ 2
Ranger Medic Charter........................................................................................................................................................... 3
Regimental Medical Charter................................................................................................................................................. 3
Senior Enlisted Medical Advisor (SEMA) Duties & Responsibilities................................................................................... 4
Scope of Practice................................................................................................................................................................ 5
8 Critical RFR Tasks....................................................................................................................................................... 5
Standing Orders and Protocols............................................................................................................................................ 7
Tactical Combat Casualty Care (TCCC)............................................................................................................................. 10
Notes............................................................................................................................................................................ 12

SECTION 2 PRIMARY TRAUMA PROTOCOLS

Triage................................................................................................................................................................................... 14
Tactical Triage Protocol............................................................................................................................................... 15
Tactical Trauma Assessment.............................................................................................................................................. 16
Tactical Trauma Assessment....................................................................................................................................... 17
Hemorrhage Management.................................................................................................................................................. 18
Hemorrhage Control Protocol..................................................................................................................................... 19
Tourniquet Application Procedure.............................................................................................................................. 20
Tourniquet Conversion Procedure.............................................................................................................................. 21
Airway Management........................................................................................................................................................... 22
Airway Management Protocol..................................................................................................................................... 23
Surgical Cricothyroidotomy Procedure...................................................................................................................... 24
Thoracic Trauma Management........................................................................................................................................... 25
Thoracic Trauma Management Protocol.................................................................................................................... 26
Needle Chest Decompression Procedure.................................................................................................................. 27
Chest Tube Insertion and Finger Thoracostomy Protocol......................................................................................... 28
Tactical Damage Control Resuscitation............................................................................................................................. 29
Tactical Damage Control Resuscitation Protocol...................................................................................................... 30
Shock Management............................................................................................................................................................ 31
Saline Lock & Intravenous Access Procedure............................................................................................................ 32
External Jugular Intravenous Cannulation Procedure............................................................................................... 33
Sternal Intraosseous Infusion Procedure................................................................................................................... 34
Intraosseous Infusion Procedure (Non-Sternal)......................................................................................................... 35
Hypothermia Prevention & Management Kit Procedure............................................................................................ 36
Head Trauma....................................................................................................................................................................... 37
Head Trauma Management Protocol.......................................................................................................................... 38
Concussion.......................................................................................................................................................................... 39
Concussion Management Protocol............................................................................................................................ 40
Abdominal Trauma.............................................................................................................................................................. 41
Abdominal Trauma Management Protocol................................................................................................................. 42
Blast Injury Assessment..................................................................................................................................................... 43
Eye Injury............................................................................................................................................................................. 44
Eye Injury Management Protocol................................................................................................................................ 45
Lateral Canthotomy..................................................................................................................................................... 46
Seizures............................................................................................................................................................................... 47
Seizure Management Protocol.................................................................................................................................... 48
Spinal Cord Injury Management......................................................................................................................................... 49
Spinal Cord Injury Management Protocol.................................................................................................................. 50
Orthopedic Trauma............................................................................................................................................................. 51
Orthopedic Trauma Management Protocol................................................................................................................ 52
Burn Management............................................................................................................................................................... 53
Burn Management Protocol........................................................................................................................................ 54

vii
Pain Management............................................................................................................................................................... 55
Pain Management Protocol......................................................................................................................................... 56
Procedural Analgesia................................................................................................................................................... 57
Regional Anesthesia........................................................................................................................................................... 58
Austere Extended Care....................................................................................................................................................... 59
Austere Extended Care Protocol................................................................................................................................. 61
Blood Transfusion............................................................................................................................................................... 62
Fresh Whole Blood Transfusion (Donor Procedure)................................................................................................... 63
Fresh Whole Blood Transfusion (Recipient Procedure)............................................................................................. 64
Foley Catheterization Procedure................................................................................................................................. 65
Crush Syndrome Management.......................................................................................................................................... 66
Crush Protocol............................................................................................................................................................. 67
Evacuation........................................................................................................................................................................... 68
Evacuation Protocol..................................................................................................................................................... 69
NATO MEDEVAC Request........................................................................................................................................... 70
MIST Report................................................................................................................................................................. 70
SIT Report.................................................................................................................................................................... 70
Evacuation Patient Packaging..................................................................................................................................... 71
Evacuation Patient Handover...................................................................................................................................... 72
Skedco Horizontal Hoist Procedure........................................................................................................................... 73
Skedco Vertical Hoist Procedure................................................................................................................................ 74
CBRN................................................................................................................................................................................... 75
CBRN CCP................................................................................................................................................................... 76
TICs/TIMs Toxic Inhalation/Eye Exposure Box.......................................................................................................... 77
Toxic Industrial Chemicals/Materials Inhalation Injury Treatment SOP.................................................................... 77
TIC/TIMS Eye Injury Treatment SOP........................................................................................................................... 77
Chemical Casualty Triage Table.................................................................................................................................. 78
CBRN – Nerve Agents....................................................................................................................................................... 79
CBRN – Vesicant Agents................................................................................................................................................... 80
CBRN – Cyanide Agents................................................................................................................................................... 80
CBRN – Pulmonary Agents............................................................................................................................................... 81
CBRN Quick Reference Cards.................................................................................................................................... 82
Chemical Agent Treatment Guide............................................................................................................................... 85
Notes............................................................................................................................................................................ 86

SECTION 3 TACTICAL MEDICAL EMERGENCY PROTOCOLS (TMEPs) & SICK CALL

Medical Patient Assessment.............................................................................................................................................. 88
Medical Patient Assessment Protocol........................................................................................................................ 89
Abdominal Pain (Includes Surgical Abdomen, GERD, Dyspepsia).................................................................................. 90
Allergic Rhinitis/Hay Fever Protocol................................................................................................................................... 90
Altitude Medical Emergencies............................................................................................................................................ 91
Altitude Medical Emergency Management Protocol................................................................................................. 92
Anaphylactic Reaction Emergencies................................................................................................................................. 93
Anaphylactic Shock Management Protocol............................................................................................................... 94
Asthma (Reactive Airway Disease)..................................................................................................................................... 95
Barotrauma.......................................................................................................................................................................... 95
Behavioral Emergency Management (Includes Psychosis, Depression, Suicidal Impulses)........................................ 96
Behavioral Emergency Management Protocol........................................................................................................... 97
Assessment & Management of Suicidal Risk.................................................................................................................... 98
Assessment & Management of Suicidal Risk Protocol............................................................................................ 101
Leader’s Suicide Risk Assessment Tool (L-SRAT)................................................................................................... 102
Bronchitis........................................................................................................................................................................... 104
Cellulitis/Cutaneous Abscess.......................................................................................................................................... 105
Chest Pain......................................................................................................................................................................... 106
Compartment Syndrome.................................................................................................................................................. 107
Conjunctivitis..................................................................................................................................................................... 107
Constipation/Fecal Impact............................................................................................................................................... 108

viii CONTENTS
Contact Dermatitis............................................................................................................................................................ 108
Corneal Abrasions/Corneal Ulcers.................................................................................................................................. 109
Cough................................................................................................................................................................................ 109
Deep Vein Thrombosis (DVT) ............................................................................................................................................110
Dehydration........................................................................................................................................................................110
Dengue Fever.....................................................................................................................................................................110
Dental Pain.........................................................................................................................................................................111
Determination of Death......................................................................................................................................................111
Electrocution......................................................................................................................................................................111
Envenomation – Arthropod (Spider & Scorpion)..............................................................................................................112
Envenomation – Insect, Hymenoptera (Bee, Wasp, Hornet)............................................................................................112
Envenomation – Marine.....................................................................................................................................................113
Envenomation – Snake.......................................................................................................................................................114
Epistaxis.............................................................................................................................................................................115
Flank Pain (Includes Renal Colic, Pyelonephritis, Kidney Stones)..................................................................................115
Frostbite & Frostnip............................................................................................................................................................116
Fungal Skin Infection..........................................................................................................................................................117
Gastroenteritis (Diarrhea/Nausea/Vomiting)....................................................................................................................117
Headache............................................................................................................................................................................118
Headache (Migraine Origin)...............................................................................................................................................118
HIV Post-Exposure Prophylaxis........................................................................................................................................119
Hyperthermia..................................................................................................................................................................... 120
Hyperthermia (Heat) Management Protocol............................................................................................................. 121
Hypothermia Management............................................................................................................................................... 122
Hypothermia Prevention & Management Protocol................................................................................................... 123
Ingrown Toenail................................................................................................................................................................. 124
Insomnia............................................................................................................................................................................ 125
Joint Infection.................................................................................................................................................................... 125
Laceration.......................................................................................................................................................................... 126
Loss of Consciousness (without Seizures)/Syncope...................................................................................................... 126
Malaria............................................................................................................................................................................... 127
Meningitis.......................................................................................................................................................................... 128
Motion Sickness & Prevention.......................................................................................................................................... 128
Nausea & Vomiting............................................................................................................................................................ 129
Otitis Externa (Outer Ear Infection or Swimmer’s Ear).................................................................................................... 129
Otitis Media (Middle Ear Infection)................................................................................................................................... 130
Pharyngitis Protocol (Oral Pharyngeal Infections including Viral, Strep, Epiglottitis,
Peritonsillar Abscess, Mononucleosis)..................................................................................................................... 131
Pneumonia......................................................................................................................................................................... 132
Pulmonary Embolism (PE) ............................................................................................................................................... 132
Rabies Post-Exposure Prophylaxis.................................................................................................................................. 133
Rectal Bleeding................................................................................................................................................................. 133
Rhabdomyolysis................................................................................................................................................................ 134
Sepsis/Septic Shock......................................................................................................................................................... 134
Smoke Inhalation............................................................................................................................................................... 135
Spontaneous Pneumothorax............................................................................................................................................ 135
Subungal Hematoma........................................................................................................................................................ 136
Testicular Pain................................................................................................................................................................... 136
Upper Respiratory Infection/Common Cold.................................................................................................................... 137
Urinary Tract Infection...................................................................................................................................................... 137
Sexually Transmitted Infection......................................................................................................................................... 137
Notes.......................................................................................................................................................................... 138

SECTION 4 RANGER MEDIC PHARMACOLOGY & FORMULARY

Pharmacology Standards & Guidelines........................................................................................................................... 140
Acetaminophen (Tylenol).................................................................................................................................................. 142
Acetazolamide (Diamox)................................................................................................................................................... 142

CONTENTS ix
Acetylsalicylic Acid (Aspirin)............................................................................................................................................. 143
Albuterol (Proventil)........................................................................................................................................................... 143
Aluminum Hydroxide, Magnesium Hydroxide (Maalox).................................................................................................. 144
Amoxicillin/Clavulanate (Augmentin)................................................................................................................................ 144
Atovaquone-Proguanil (Malarone)................................................................................................................................... 144
Atropine Sulfate................................................................................................................................................................. 145
Azithromycin (Zithromycin, Z-Pak)................................................................................................................................... 145
Bacitracin........................................................................................................................................................................... 145
Benzathine-Penicillin G (Bicillin)....................................................................................................................................... 146
Benzonatate (Tessalon Perles)......................................................................................................................................... 146
Bisacodyl (Dulcolax)......................................................................................................................................................... 146
Blood.................................................................................................................................................................................. 147
Bupivacaine (Marcaine)..................................................................................................................................................... 147
Calcium Chloride............................................................................................................................................................... 147
Calcium Gluconate............................................................................................................................................................ 148
Cefazolin Sodium (ANCEF)............................................................................................................................................... 148
Ceftriaxone (Rocephin)..................................................................................................................................................... 148
Cetirizine (Zyrtec).............................................................................................................................................................. 149
Cimetidine (Tagamet)........................................................................................................................................................ 149
Ciprofloxacin (Cipro)......................................................................................................................................................... 150
Clindamycin (Cleocin)....................................................................................................................................................... 150
Cyclobenzaprine (Flexeril)................................................................................................................................................ 151
Dexamethasone (Decadron)............................................................................................................................................. 151
Dextrose (D50)................................................................................................................................................................... 152
Diazepam (Valium)............................................................................................................................................................. 152
Diphenhydramine (Benadryl)............................................................................................................................................ 153
Docusate (Colace)............................................................................................................................................................. 154
Doxycycline....................................................................................................................................................................... 154
Epinephrine (Including Epi-Pen)....................................................................................................................................... 155
Ertapenem (Invanz)........................................................................................................................................................... 155
Erythromycin Ophthalmic Ointment................................................................................................................................. 155
Eszopiclone (Lunesta)....................................................................................................................................................... 155
Fentanyl............................................................................................................................................................................. 156
Fexofenadrine (Allegra)..................................................................................................................................................... 156
Fluconazole (Diflucan)....................................................................................................................................................... 157
Fluticasone (Flonase)........................................................................................................................................................ 157
Gatifloxacin Ophthalmic Solution (Zymar)....................................................................................................................... 158
Guaifenesin........................................................................................................................................................................ 158
Hydrocortisone Cream...................................................................................................................................................... 158
Hydromorphone (Dilaudid)............................................................................................................................................... 159
Ibuprofen (Motrin, Advil)................................................................................................................................................... 159
Ketoconazole..................................................................................................................................................................... 160
Ketamine............................................................................................................................................................................ 160
Ketorolac (Toradol)............................................................................................................................................................ 161
Lactated Ringer’s (LR)...................................................................................................................................................... 161
Levetiracetam (Keppra)..................................................................................................................................................... 161
Levofloxacin (Levoquin).................................................................................................................................................... 162
Lidocaine (Xylocaine)........................................................................................................................................................ 162
Loperamide (Imodium)...................................................................................................................................................... 163
Loratadine (Claritin)........................................................................................................................................................... 163
Meclizine (Antivert)............................................................................................................................................................ 164
Melatonin........................................................................................................................................................................... 164
Meloxicam (Mobic)............................................................................................................................................................ 164
Methocarbomol (Robaxin)................................................................................................................................................ 165
Methylprednisolone (Solu-Medrol)................................................................................................................................... 165
Metronidazole (Flagyl, MetroGEL).................................................................................................................................... 166
Midazolam (Versed).......................................................................................................................................................... 166

x CONTENTS
Modafinil (Provigil)............................................................................................................................................................. 167
Morphine Sulfate (MSO4)................................................................................................................................................... 167
Moxifloxacin (Avelox)........................................................................................................................................................ 168
Mupirocin (Bactroban)...................................................................................................................................................... 168
Naloxone (Narcan)............................................................................................................................................................. 169
Naphazoline (Naphcon-A, Vascon, Clear Eyes).............................................................................................................. 169
Naproxen (Naprosyn)........................................................................................................................................................ 170
Nitrofurantoin (Macrobid).................................................................................................................................................. 170
Ofloxacin Otic (Floxin)....................................................................................................................................................... 170
Omeprazole (Prilosec)....................................................................................................................................................... 171
Ondansetron (Zofran)........................................................................................................................................................ 171
Oxymetazoline (Afrin)........................................................................................................................................................ 171
Plasma-Lyte A................................................................................................................................................................... 172
Polyethylene Glycerol (MiraLAX)...................................................................................................................................... 172
Prednisone......................................................................................................................................................................... 172
Primaquine......................................................................................................................................................................... 173
Promethazine (Phenergan)............................................................................................................................................... 173
Pseudoephedrine (Sudafed)..............................................................................................................................................174
Rabeprazole (Aciphex).......................................................................................................................................................174
Rizatriptan (Maxalt)........................................................................................................................................................... 175
Scopolamine (Transderm Scop)....................................................................................................................................... 175
Sodium Chloride, 0.9% (Normal Saline).......................................................................................................................... 176
Sodium Chloride, 3% or 23.4% (Hypertonic Saline)....................................................................................................... 176
Sufentanil (Dsuvia)............................................................................................................................................................ 176
Sumatriptan (Imatrex)........................................................................................................................................................ 177
Terbinafine (Lamisil).......................................................................................................................................................... 177
Tetracaine Ophth............................................................................................................................................................... 177
Tranexamic Acid (TXA)...................................................................................................................................................... 178
Trimethoprim-Sulfamethoxazole (TMP-SMZ, Bactrim, Septra)...................................................................................... 178
Zolpidem (Ambien)............................................................................................................................................................ 179
Tylenol (see Acetaminophen)............................................................................................................................................ 142
Valium (see Diazepam)...................................................................................................................................................... 152
Versed (see Midazolam).................................................................................................................................................... 166
Zithromycin/Z-Pak (see Azithromycin)............................................................................................................................. 145
Zofran (see Ondansetron)................................................................................................................................................. 171
Drug Quick Reference............................................................................................................................................... 181
Ketamine Drip Tables................................................................................................................................................. 181
Pharmacology Notes................................................................................................................................................. 182

SECTION 5 SPORTS MEDIC SCOPE OF PRACTICE

Shoulder – Traumatic & Acute Pain.................................................................................................................................. 184
Arm/Elbow – Traumatic & Acute Pain............................................................................................................................... 185
Hand/Wrist – Traumatic & Acute Pain.............................................................................................................................. 186
Hip – Traumatic & Acute Pain........................................................................................................................................... 187
Leg – Traumatic & Acute Pain........................................................................................................................................... 188
Knee – Traumatic & Acute Pain......................................................................................................................................... 189
Ankle – Traumatic & Acute Pain........................................................................................................................................ 190
Clearing the Spine and Joint for Mechanical Issues at The Joint of Pain...................................................................... 191
Notes.......................................................................................................................................................................... 194

SECTION 6 MPC/CANINE TRAUMA & TACTICAL MEDICAL EMERGENCY PROTOCOLS

Canine Patient Assessment.............................................................................................................................................. 196
Canine Trauma & Shock Management............................................................................................................................. 197
Canine Field Blood Transfusion Procedure..................................................................................................................... 202
Canine Injection & IV Sites......................................................................................................................................... 203
Canine Tactical Medical Emergencies............................................................................................................................. 204

CONTENTS xi
Canine Heat Injury....................................................................................................................................................... 204
Canine Gastric Dilatation Volvulus (GDV)................................................................................................................... 205
Canine Altitude Sickness and Pulmonary Edema...................................................................................................... 205
Canine Seizure Management...................................................................................................................................... 205
Canine Toxicities – Explosives, Others....................................................................................................................... 206
Canine CBRNE............................................................................................................................................................. 207
MPC Reference Card................................................................................................................................................... 213

SECTION 7 PEDIATRIC TACTICAL COMBAT CASUALTY CARE

Pediatric Tactical Combat Casualty Care Guidelines..................................................................................................... 215
Class VIII Considerations and Modifications from Adult Equipment............................................................................. 217
Notes.......................................................................................................................................................................... 219

SECTION 8 MEDICAL PLANNING & CASUALTY COLLECTION OPERATIONS

Casualty Response Planning Overview........................................................................................................................... 221
Ranger Casualty Response Planning .............................................................................................................................. 221
Predeployment Requirements.......................................................................................................................................... 222
Medical Threat Assessment............................................................................................................................................. 222
Higher Headquarters Orders and Guidelines.................................................................................................................. 223
Determine Medical Assets................................................................................................................................................ 224
Tactical Medical Support Plan Development.................................................................................................................. 229
QRF Capabilities and Integration..................................................................................................................................... 233
Briefs, Rehearsals, and Precombat Inspections............................................................................................................. 233
Sustained Combat Operations & Time-Sensitive Targets.............................................................................................. 235
Casualty Collection Point Operations.............................................................................................................................. 238
Relief-in-Place Operations............................................................................................................................................... 245
Notes.......................................................................................................................................................................... 246

SECTION 9 HAZARDOUS TRAINING MEDICAL COVERAGE

Hazardous Training Medical Coverage Duties & Responsibilities................................................................................. 248
Hazardous Training Medical Coverage Planning............................................................................................................ 249
Equipment Requirements............................................................................................................................................ 250
Medical Coverage During Tactical Exercises............................................................................................................. 250
Pre-Coverage Inspections.......................................................................................................................................... 250
Pre-Coverage Rehearsals........................................................................................................................................... 250
Hazardous Training Medical Coverage Checklist........................................................................................................... 251

SECTION 10 PACKING LISTS

Kit/Aid Bag Minimum Stock.............................................................................................................................................. 253
Advanced Ranger First Responder Medical Kit Contents.............................................................................................. 254
Ranger Bleeder Control Kit Contents.............................................................................................................................. 254

SECTION 11 REFERENCES & ABBREVIATIONS

Abbreviations & Acronyms............................................................................................................................................... 256
MACE 2.............................................................................................................................................................................. 262
Reference Charts.............................................................................................................................................................. 276
Conversion Charts............................................................................................................................................................ 277
Neuro Exam Reference Chart........................................................................................................................................... 278
ARDSnet Vent Settings..................................................................................................................................................... 279
Ranger Casualty Card....................................................................................................................................................... 281
Prolonged Field Care Card............................................................................................................................................... 282
TBI RTD Card..................................................................................................................................................................... 284
Notes.......................................................................................................................................................................... 287

xii CONTENTS
SECTION 1
SECTION 1

THE RANGER MEDIC &

CASUALTY RESPONSE SYSTEMS

1
Foreword
SECTION 1

The 75th Ranger Regiment has been continuously engaged in combat operations since the beginning of the Global War
on Terrorism. Since Oct 2001, the Regiment has remained the standard for prehospital care. Ranger medics continue to
be at the cutting edge of battlefield medicine driving changes to TCCC. Given the Ranger mission, life-threatening injuries
will still be encountered as we continue prosecuting our nation’s enemies.

Though we have lost too many Ranger brethren, executing the fundamentals of the unit’s casualty response and medi-
cal programs has produced astounding results. Based on the principles that have evolved in the last two decades, the 75th
Ranger Regiment’s standard of medical care is zero preventable battlefield deaths. This hallmark is a direct result of the
mastery of the medical fundamentals of individual Rangers, Ranger leaders, and Ranger medical personnel.

The success of Ranger medicine is the success of the 75th Ranger Regiment. The Ranger First Responder, Advanced
Ranger First Responder, Ranger Medic, and Ranger leaders integrate casualty scenarios into battle drills. Preventing death
does not depend solely on the Ranger Medic but on the effectiveness of the Ranger team to respond to a fallen comrade.
The chain of survival starts in training and allows for both success of the mission and care for the casualty.

“Mastery of the Fundamentals” is and always has been a standard to live by within the 75th Ranger Regiment. The
mastery of casualty response and medical skills at all levels has saved numerous Ranger lives. Rangers are continuously
self-critical and use every training or real casualty scenario to improve themselves. The unit also looks for emerging tech-
nology and techniques and swiftly adapts them to the combat environment.

The foundation of the unit’s medical programs remains based on the integrated tenets of Tactical Combat Casualty
Care (TCCC), innovative medical planning, and casualty response training for Ranger leaders, and when employed to their
fullest, saves lives on the battlefield. Through the continuous evolution of our training and equipment programs, the Regi-
ment will always strive to be the tip-of-the-spear for developing the battlefield medicine standard of care for the Infantry
and Special Operations communities.

The 75th Ranger Regiment and Ranger Medical Team will continue to hold true the Ranger Creed and the unit charters
and complete any mission placed before it.

I will never leave a fallen comrade…

2 SECTION 1 THE RANGER MEDIC & CASUALTY RESPONSE SYSTEMS

Ranger Medic Charter

SECTION 1
Operate as a combat multiplier in highly mobile Ranger units in austere environments, engaging the enemy to
protect both casualties and self while enhancing overall mission effectiveness.

A master of the medical fundamentals and skilled practitioner of point-of-injury trauma care, Ranger medics
leverage tactical combat casualty care protocols and an advanced skill set to stabilize and evacuate casualties.

An Advanced Tactical Paramedic who assists licensed medical providers with medical emergencies and routine
healthcare encountered while in garrison, in training, and during deployments.

Regimental Medical Charter

Provide optimal tactical healthcare support in accordance with TCCC and the Ranger Medic Handbook.

“Absolute Mastery of the Basics”

Train and operate medics who are relatively independent with highly dispersed highly mobile combat forma-
tions in an austere environment.

“Advanced skills within a Scope of Practice”

Train and operate medics to move tactically through unsecured areas who can communicate, engage targets,
and remain a combat multiplier.

“Be a Ranger on the Battlefield”

Provide training to individual Rangers and leaders to provide first responder care and command/control of
casualty response operations.

“Teach and mentor Rangers and Leaders in Combat Medicine”

Evaluate and develop casualty response tactics, techniques, equipment, and procedures as the standard
bearer of tactical medicine for the armed forces.

“Set the Standard for the Armed Forces in Tactical Medicine”

2025 RANGER MEDIC HANDBOOK 3

Senior Enlisted Medical Advisor (SEMA) Duties & Responsibilities
SECTION 1

The SEMA is customarily known as a battalion senior medic and traditionally functions in the capacity of a platoon
sergeant. However, in the context of the Ranger Medic Handbook, the senior medic duty description will be used to
define the responsibilities of the highest ranking and most experienced medic present at any given location and time.
This medic is designated as the “senior medic” at that specific location and thus is responsible for the duties and re-
sponsibilities as listed below.

■ Principal medical advisor to the commander and senior enlisted advisor

■ Provide and supervise advanced trauma management within protocols and sick call within scope-of-practice

■ Lead, supervise, and train junior medics

➣ Individual training
➣ Health and welfare
➣ Development and counseling
➣ Troop leading procedures and precombat inspections (PCIs)

■ Plan, supervise, and conduct casualty response training for Rangers and leaders
➣ Ranger first responder (RFR)
➣ Casualty Response Training for Ranger Leaders (CRTRL)
➣ Opportunity training/spot-checking

■ Maintain company/platoon-level medical equipment and supplies

➣ Accountability/inventory
➣ Maintenance/serviceability
➣ PCI of individual Ranger bleeding control kits
➣ PCI of squad casualty response kits
➣ Requisition and receive Class VIII from appropriate source

■ Plan, coordinate, and execute medical planning for company-level operations

➣ Task organization of company medics
➣ On-target casualty response plan
➣ CASEVAC from target to next higher medical capability

■ Conduct after action reviews and report and archive medical lessons learned

■ Monitor the status of health in the unit/element

➣ Physically limiting profiles
➣ Command health reporting and tracking
➣ MEDPROS data entry and information review

4 SECTION 1 THE RANGER MEDIC & CASUALTY RESPONSE SYSTEMS

SCOPE OF PRACTICE

SECTION 1
CASUALTY RESPONSE SYSTEM – The Regiment’s solution for managing combat casualties is to recognize that the
problem is solved by the entire unit, not just medics, and that a casualty can occur during any phase of an operation.
The principles of the casualty response system are the first responder to a casualty can be any Ranger in the unit; that
medical personnel manage casualty care; and that leaders run the mission. When a casualty is incurred, it immediately
becomes a component of the unit’s mission to extract, treat, and evacuate the casualty while still completing the assigned
combat mission as an integrated team. Thus, every member of the unit must maintain first responder medical skills, med-
ics must be highly proficient, and leaders must know how to properly integrate casualty management into any phase of
an operation.

RANGER FIRST RESPONDER (RFR) – An RFR is the baseline for all Rangers. This level of training equips all Rangers with
treatment skills as a secondary mission to their primary mission role. The RFR medical capability provides a tactical com-
bat casualty care skillset with specific trauma skills. An RFR is always trained and employed in conjunction with a Platoon
Medic or higher but has the skillset to provide basic medical interventions independent of any trained medical personnel.
This skillset will be trained and verified annually.

The 8 Critical RFR Tasks

Contain Scene and Assess Casualties
CARE UNDER FIRE

° Return fire and secure scene

° Direct casualties to cover
° Evaluate for life-threatening injuries
° Triage – immediate, delayed, minimal, expectant
° Call medical personnel for assistance as required
Rapidly Identify and Control Massive Hemorrhage
° Direct & indirect pressure
° Tourniquet
° Emergency trauma dressing
TACTICAL FIELD CARE

Inspect and Ensure Patent Airway

° Open and clear airway
° Nasopharyngeal airway
Treat Life-Threatening Torso Injuries
° Occlusive seal dressing
° Needle decompression
° Abdominal wound management
Inspect for Bleeding, Gain IV Access, Manage Shock
° Head-to-toe blood sweeps
° 18-Gauge saline lock
° IV fluids when dictated by shock
TACTICAL EVACUATION

° Prevent hypothermia
Control Pain and Prevent Infection
° Combat wound pill pack
Aid and Litter Team
° Package and prepare for transfer
° SKEDCO, litters, manual carries
Leader Coordinated Evacuation
° Command & control of casualty evacuation integrated with ongoing combat operation
° Request & coordinate evacuation asset and establish evacuation site (HLZ)
° Casualty precedence – critical (urgent), priority, routine CASEVAC or M
­ EDEVAC coordination

2025 RANGER MEDIC HANDBOOK 5

ADVANCED RANGER FIRST RESPONDER (ARFR) – The ARFR medical capability is a nonmedical Ranger trained on
SECTION 1

specific first responder medical skills beyond the RFR level, to provide a higher level of trauma response during Ranger
operations. This is the highest level of capability for nonmedical Rangers. The ARFR is expected to provide limited scope
trauma and emergency care in a tactical or austere setting; they may work independently or in support of a medical pro-
vider. They are proficient at advanced medical procedures and basic medication administration.

PLATOON MEDIC – The Ranger Platoon Medic is the minimum standard for an individual serving as sole medical support
for a Ranger mission. The Ranger Platoon Medic is a Special Operations-Advanced Tactical Paramedic (SO-ATP). The
Ranger Platoon Medic provides advanced emergency medical care for critical and emergent casualties in a tactical setting
with a specific focus on trauma for patient care less than 4 hours duration. These personnel are employed in disaggregated
operations to ensure tactical elements have adequate advanced trauma medical capabilities. The Ranger Platoon Medic
also provides medical support to the platoon outside of tactical operations, is able to treat basic medical conditions inde-
pendently and difficult medical conditions with oversight or medical direction. Ranger Platoon Medics are responsible for
training and validating Ranger First Responders.

COMPANY SENIOR MEDIC – The Company Senior Medic is a Ranger Medic serving in the capacity of Provider-Extender
Primary Medic for a Special Operations maneuver element. The Company Senior Medic is expected to independently man-
age multiple complex traumatic and medical problems on the modern battlefield and in remote or austere conditions. While
deployed, the Company Senior Medic independently delivers a selected level of healthcare normally provided by mid-level
practitioners. The Company Senior Medic is expected to manage and lead the company level casualty collection point (CCP).
The Company Senior Medic is responsible for training and validating Ranger Platoon Medics and Advanced Ranger First
Responders.

BATTALION SENIOR ENLISTED MEDICAL ADVISOR – The Battalion SEMA is a Ranger Medic capable of providing
critical care and advanced resuscitative care to a Ranger maneuver element. He is an integral member of the Ranger
Resuscitation Team who provides far forward critical care for complex trauma and medical patients. The Battalion SEMA
is expected to manage and lead the battalion-level CCP. He also trains, validates, and employs all Ranger Medics and
nonmedic providers.

DAMAGE CONTROL RESUSCITATION TEAM – The Damage Control Resusitation Team provides a team-based ap-
proach capable of providing critical care and advanced procedures during SOF missions. The team is composed of a
medical provider and senior medic. The team can care for two critical care patients simultaneously for up to 6 hours while
providing advanced airway interventions, ventilation, cardiovascular support, and advanced hemorrhage control.

Ranger Medics provide routine garrison care to include assisting unit medical officers with daily sick call. This requires
advanced knowledge in common orthopedic problems, respiratory illnesses, gastrointestinal disorders, dermatological
conditions, and environmental hazard illnesses. Ranger Medics train nonmedical personnel on first responder skills and
preventive medicine. Ranger Medics conduct their scope of practice under the licensure of a medical director and are not
independent healthcare providers. Ranger Medics should always obtain medical director advice and supervision for all
care provided. However, on rare occasions Ranger Medics may be required to operate relatively independently with only
indirect supervision in remote, austere, or clandestine locations. In these cases, it is still extremely rare that a Ranger Medic
will be unable to communicate by radio, phone, or computer.

STANDING ORDERS – Advanced life support interventions, which may be undertaken before contacting online medical
control.

PROTOCOLS – Guidelines for out-of-hospital patient care when a medical director is not locally available. Only the por-
tions of the guidelines that are designated as “standing orders” may be undertaken before contacting an online medical
director.

MEDICAL CONTROL/MEDICAL DIRECTOR/MEDICAL OFFICER – This is a licensed and credentialed medical provider,
physician or physician assistant, who verbally, or in writing, states assumption of responsibility and liability and is available
on-site or can be contacted through established communications. Medical care, procedures, and advanced life-saving
activities will be routed through medical control in order to provide optimal care to all sick or injured Rangers. Medical
Control will always be established, regardless of whether the scenario is a combat mission, a training exercise, or routine
medical care. Note that, ultimately, all medical care is conducted under the licensure of an assigned, attached,
augmenting, or co-located PHYSICIAN.

6 SECTION 1 THE RANGER MEDIC & CASUALTY RESPONSE SYSTEMS

STANDING ORDERS AND PROTOCOLS

SECTION 1
As published, these standing orders and protocols will be used ONLY by Ranger Medics
currently assigned to the 75th Ranger Regiment who have demonstrated competency through
Ranger Medic Assessment & Validation (RMAV) and expressly given a scope of practice by
their supervising Medical Director.

Purpose
The primary purpose of these protocols is to serve as a guideline for tactical and nontactical pre-hospital trauma and medi-
cal care. Quality out-of-hospital care is the direct result of comprehensive education, accurate patient assessment, good
judgment, and continuous quality improvement. The protocols contained within this handbook make the following specific
assumptions on when and how they are employed.

Ranger Medics may often find themselves in austere tactical environments where evacuation of a unit member to a medical
treatment facility for a medical emergency would entail either significant delays to treatment or compromise the unit’s mis-
sion. The disorders chosen have one of the following properties in common: they are relatively common, acute in onset; the
Ranger Medic is able to provide at least initial therapy that may favorably alter the eventual outcome; the condition is either
life-threatening or could adversely affect the mission readiness of the injured or ill Ranger; immediate evacuation may not
be possible and, even if it is, may still entail significant delays to definitive treatment; and the medical problem may worsen
significantly if treatment is delayed. The Ranger Medic will contact a consulting physician as soon as feasible. Treatment
will be done under the appropriate protocol.

Medical Director approved medication regimens are designed to provide the Ranger Medic the ability to manage multiple
conditions without compromising standards of care. Appropriate documentation of diagnosis and treatment rendered in
the patient’s medical record will be accomplished when the unit returns to their forward operating base.

Unit Protocols are not designed to conduct Medical/Civic Action (MEDCAP) missions independently. Evacuation recom-
mendations are based on the appropriate therapy per protocol being initiated on diagnosis. The definitions of urgent, prior-
ity, and routine evacuations are based on the times found in Joint Publication 4-02.2 of 2, 4, and 24 hours, respectively.

Unit medical officers use protocols to develop the knowledge base and capability of Ranger Medics during unit sick call.
Ranger Medics should not perform any step in a standing order or protocol if they have not been trained to perform the
procedure or treatment in question.

Emergency, trauma, and tactical medicine continues to evolve at a rapid pace. Accordingly, this document is subject to
change as new information and guidelines become available and are accepted by the medical community. The Ranger
Medic must continuously expand and sustain his knowledge base.

Standing Orders and Protocols

These standing orders and protocols are for use ONLY by Ranger Medics while providing emergency care under
the license of their medical director. Ranger Medics who are authorized to operate under the trauma management
team guidelines may not use these standing orders outside of their military employment. Revocation of privileges
will be considered by the granting authority if these standards are violated.

2025 RANGER MEDIC HANDBOOK 7

Communication
SECTION 1

In a case where the Ranger Medic cannot contact medical control due to an acute time-sensitive injury or illness,
a mass casualty scenario, or communication difficulties, all protocols become standing orders. Likewise, in the
event that medical control cannot respond to the radio or telephone in a timely fashion required to provide optimal care to
a patient, all protocols are considered standing orders. In the event that medical control was not contacted, and treatment
protocols were carried out as standing orders, Medical control will be contacted as soon as feasible following the incident
and the medical record (Casualty Card, SF 600 or Trauma SF 600) will be reviewed and countersigned by medical control.
Retroactive approval for appropriate care will be provided through this process.

When communicating with medical control, a medical officer, or a receiving facility, a verbal report will include the following
essential elements:
1. Provider – name, unit, and callback phone number
2. Patient – name, unit, age, and gender
3. Subjective – findings to include chief complaint and brief history of event
4. Objective – findings to include mental status, vital signs, and physical exam
5. Assessment – to include differential diagnosis, presumed diagnosis, and level of urgency
6. Plan – to include treatment provided, patient response to treatment, and patient status updates

NEVER HESITATE TO CONTACT A MEDICAL DIRECTOR AT ANY TIME FOR ASSISTANCE,

QUESTIONS, CLARIFICATION, OR GUIDANCE THROUGH ANY COMMUNICATIONS MEANS AVAILABLE.

Patient Care Documentation

Patient care documentation is of paramount importance and will be performed for every patient encounter using a Tactical
Combat Casualty Card, Trauma SF 600 Medical Record, SF 600 Medical Record, or designated electronic health record
and transported with the patient to a medical treatment facility or provider. Lack of a card or form is not an excuse for lack
of documentation. Rangers Medics will use all resources available to attempt documentation for the next-level provider.
Documentation by writing on dressings, tape, or even the patient is completely acceptable if other resources are not avail-
able. If time constraints that might delay the evacuation of the patient prevent real time documentation, then the Ranger
Medic will document at the first available opportunity.

Medical Personal Protective Equipment (PPE) And Universal Precautions

Medical PPE and the concepts of universal precautions will be used whenever possible and indicated. When the circum-
stances allow, use a minimum of nonsterile exam gloves. If possible, actions normally considered sterile procedures will
be conducted in as clean an environment as can be maintained. Awareness of patient protection from infection must be
maintained during the execution of any protocol or procedure. Ranger Medics will conduct precombat inspections of all
invasive or sterile materials prior to every mission and replace accordingly.

Resuscitation Considerations
Resuscitation is not warranted in patients who have sustained obvious life-ending trauma or patients with rigor mortis,
decapitation, decomposition, or mass casualty situations. When reasonable, consider performing resuscitation efforts
when this is your only patient. The perception of fellow Rangers and family members in this instance should be that every
effort was made to sustain life.

When possible, use ultrasound to confirm no cardiac activity, or place ECG leads to confirm asystole in three leads and
attach a copy of this strip to the medical record. Also note that, technically, only a medical officer can pronounce a patient
as deceased. Refer to the protocol Determination of Death/Discontinuing Resuscitation.

8 SECTION 1 THE RANGER MEDIC & CASUALTY RESPONSE SYSTEMS

General Guidelines For Protocol Usage

SECTION 1
1. Documentation should not delay the treatment of the injured patient. Life-threatening problems detected during the
primary assessment must be treated first.
2. Cardiac arrest due to trauma is not treated with medical cardiac arrest protocols. Trauma patients should be transported
promptly to the previously coordinated medical treatment facility with control of external hemorrhage, blood product
resuscitation, bilateral finger thoracostomies, and other indicated procedures attempted en route. CPR should be a
last resort.
3. In patients who require a saline lock or intravenous fluids, only two attempts at IV access should be attempted in the
field, then proceed immediately to intraosseous infusion for life-threatening emergencies. Patient transport to definitive
care must never be delayed for multiple attempts at IV access or other advanced medical procedures.
4. Medics will verbally repeat all orders received and given prior to their initiation. It is preferable that medical personnel
work as trauma teams whenever practical.
5. Due to the high level of physical fitness of Rangers and Special Operations personnel, there may be a prolonged period
of mental lucidity and apparent stable vital signs despite a severe injury. Always treat the injury at hand and be prepared
under the assumption that the patient’s condition will worsen.
6. Oxygen is indicated only for respiratory distress or SpO2 desaturations, and rarely available during a ground tactical
operation. If oxygen is available and indicated, the expectation is that a Medic will administer it appropriately.
7. Highly trained Ranger Medics have a clear understanding of the circumstances to determine the appropriate level of
protocol usage. During combat operations in an austere environment, a medic will fully utilize the protocols contained
within this handbook and within his scope of practice. In the non deployed training environment within CONUS, a
Ranger Medic is expected to implement the US standards of care and evacuate to an appropriate medical treatment
facility as previously planned. However, whether executing protocols in an austere environment or at a training exercise
on a military installation, the goal of the Ranger Medic is to provide the most up-to-date standard of care.

After Action Reviews (AAR) And

Ranger Prehospital Trauma Registry (PHTR)
In accordance with RTC 350-29, Ranger medical personnel will submit a casualty after action review for any injury/illness
that occurs on a combat target. The timeframe for reporting begins on departing the staging base, through the combat
operation, and ends on return to staging base.

Medical personnel are required to submit the casualty AAR no later than 72 hours post mission. Casualty AARs will also be
completed for injuries that occurred during the mission but are not reported or observed until after returning to the stag-
ing base. All casualty AARs are to be self-critical and lead to medical education. No comments in an AAR will be used in
disciplinary matters against a medic.

2025 RANGER MEDIC HANDBOOK 9

TACTICAL COMBAT CASUALTY CARE (TCCC)
SECTION 1

Trauma is the leading cause of death in the first four decades of life. Current protocols for civilian trauma care in the US
are based on the Advanced Trauma Life Support (ATLS) course, which was initially conducted in 1978. Since that time,
ATLS protocols have been accepted as the standard of care for the first hour of trauma management that is taught to both
civilian and military providers. ATLS is a great approach in the civilian setting; however, it was never designed for combat
application.

Historically, most combat-related deaths have occurred in close proximity to the point of injury, prior to a casualty reaching
an established medical treatment facility. The combat environment has many factors that affect medical treatment, includ-
ing temperature and weather extremes, severe visual limitations, delays in treatment and evacuation, long evacuation
distances, a lack of specialized providers and equipment near the scene, and the lethal implications of combat weapons.
Thus, a modified approach to trauma management must be used while conducting combat operations.

The tactical environment and causes of combat death dictate a different approach for ensuring the best possible outcome
for combat casualties while sustaining the primary focus of completing the mission. CAPT Frank Butler and LTC John
Hagmann proposed such an approach in 1996. Their article, “Tactical Combat Casualty Care in Special Operations,”
emphasized three major objectives and outlined three phases of care.

Objectives: Phases of Care:

 Treat the patient 1. Care under fire

 Prevent additional casualties 2. Tactical field care

 Complete the Mission 3. Combat casualty evacuation (CASEVAC) care

The 75th Ranger Regiment adopted the principles of TCCC in the late 1990s and institutionalized them with training pro-
grams prior to combat operations in Afghanistan and Iraq. Today, mastering the basics of TCCC remains the bedrock of
the Ranger Medic. This, along with casualty response training for Ranger leaders and dedication to meticulous medical
planning, produces astounding casualty survival rates on the modern battlefield.

10 SECTION 1 THE RANGER MEDIC & CASUALTY RESPONSE SYSTEMS

Care Under Fire

SECTION 1
Care under fire is the care rendered by the first responder or combatant at the scene of the injury while they are still
under effective hostile fire. Available medical equipment is limited to that carried by the individual or by the medical
provider in their aid bag.

Major goals of CUF are to move the casualty to safety, prevent further injury to the casualty and provider, stop life-
threatening external hemorrhage, and gain and maintain fire superiority – the best medicine on the battlefield!

Tactical Field Care

Tactical field care is the care rendered by the first responder or combatant once they are no longer under effective hostile
fire. TFC may consist of rapid treatment of the most serious wounds with the expectation of a re-engagement with hos-
tile forces at any moment, or there may be ample time to render whatever care is possible in the field. It also applies to
situations in which an injury has occurred but there has been no hostile fire. Available medical equipment is still limited
to that carried into the field by unit personnel. Time to evacuation to a medical treatment facility may vary considerably.
Remember – effective hostile fire could resume at any time.

Tactical Evacuation Care

Tactical evacuation care is the care rendered once the casualty has been picked up by an aircraft, vehicle, or boat. Ad-
ditional medical personnel and equipment that may have been pre-staged should be available in this phase of casualty
management. The term “tactical evacuation” encompasses both casualty evacuation (CASEVAC) and medical evacu-
ation (MEDEVAC).

TCCC Concepts
Casualty scenarios in combat usually entail both a medical problem and a tactical problem. We want the best possible
outcome for both the casualty and the mission. Good medicine can sometimes be bad tactics; bad tactics can get
everyone killed or cause the mission to fail. Doing the RIGHT THING at the RIGHT TIME is critical.

Hypotensive Resuscitation
Goals of Fluid Resuscitation Therapy: (1) improved state of consciousness, (2) palpable radial pulse, and (3) avoid over
resuscitation of shock. Basing the titration of fluids upon a monitored physiologic response may avoid the problem of
excessive blood pressure elevation and fatal rebleeding from previous clotted injury sites. BLOOD and blood products
are the only fluids for trauma resuscitation.

Preventing the Trauma Lethal Triad

Hypothermia is a significant concern in any trauma victim because it leads to hypothermia-
induced coagulopathy by both decreasing platelet function and slowing enzyme activity in
the coagulation cascade.

Prevention of hypothermia, along with hemorrhage control and fluid resuscitation, will help
maintain the casualty’s ability to generate heat. HYPOTHERMIA

DEATH

COAGULOPATHY ACIDOSIS

2025 RANGER MEDIC HANDBOOK 11

NOTES
SECTION 1

12 SECTION 1 THE RANGER MEDIC & CASUALTY RESPONSE SYSTEMS

SECTION 2
SECTION 2

PRIMARY TRAUMA
PROTOCOLS

13
Triage
Triage is the process of sorting casualties into groups based on their need for or likely benefit from immediate medical
treatment. Obviously, all casualties need treatment. However, accurate triage aids the provider in deciding which casualties
have the greatest likelihood of survival if immediate care is rendered and which casualties can wait until the immediate care
is completed. Triage ensures the greatest care for the greatest number and the maximal utilization of medical personnel,
equipment, evacuation, and facilities. At any location or CCP, the most experienced provider assumes the role of triage
SECTION 2

officer. All casualties, including traumatic brain injury, must be assumed to have multisystem trauma until proven otherwise
Triage is a dynamic and continuous process that must continue as the casualty’s status changes.

TCCC Application
Care Under Fire: CUF is primarily self-aid and buddy-aid. If a patient is conscious, then direct to seek cover and provide
self-treatment. If a patient is nonresponsive, when tactically feasible, move the patient to cover. Address only immediate
life­threatening hemorrhage if possible. Continue the mission/fight. Leave a Ranger buddy or report the GPS location of
any patients who are separated from the maneuver element for later recovery.
Tactical Field Care: Direct all casualties through a choke point and triage into the CCP to provide appropriate treatment
and accountability. Perform initial tactical trauma assessments on casualties. Separate casualties into four distinct cat-
egories using the UPR method. If a casualty can walk and talk (can follow instructions or describe injuries), then they are
most likely going to be categorized as “routine.” Routine casualties should tend to their own wounds if possible. Routine
casualties may also assist with other casualties. If a casualty has obvious signs of death, then they should be categorized
as “expectant.” Casualties who require life-saving interventions, cannot obey simple commands, have abnormal (or no)
radial pulses, or are in respiratory distress are categorized as “urgent.” All others will most likely fall into the “priority”
category. As soon as initial triage is completed, the primary effort is the life-saving interventions for the urgent casualties.
When moving from patient to patient, each is rendered a complete trauma assessment in a head-to-toe-treat-as-you-go
manner. When the provider has completed with one category group, he moves to the next. The provider should return to
the urgent category group routinely, or after each other group is completed, to assess and provide continued resuscita-
tion as needed. When all category casualties have been completed, the provider starts over with the urgent group and
cycles back through all casualties in each category. Triage is a constantly continuing process until all casualties have been
evacuated. In some cases, depending on injuries, interventions completed, or emerging complications, a casualty may be
downgraded to a lower category or upgraded to a higher category. There may be instances of a small number of casual-
ties in which a single patient is obviously expectant while others are obviously minimal. In this case, a patient normally
classified as expectant may be the focus of your attention. This action is for the benefit of the patient’s comrades in that
you attempted everything possible to save his life. Expectant casualties receive comfort measures and pain medications.
Tactical Evacuation: Triage is again conducted as casualties are packaged and prepared for evacuation. In this phase,
triage is categorized into evacuation precedence of urgent, priority, or routine. Urgent casualties are those who require
surgical or advanced medical intervention within 2 hours to save life, limb, or eyesight. Priority casualties are those who
require evacuation to a higher level of care within 4 hours. Routine casualties are those who remain including minimal,
expectant, and depending on the tactical situation, KIA, or DOW. Some minimal casualties may not require evacuation
and can exfiltrate with the unit for further medical treatment upon return to base. It is critical that the Medic has a good
understanding of the evacuation assets/capabilities and receiving facility’s capabilities. When evacuation is imminent,
casualties should be arranged in evacuation precedence keeping in mind the capability of the evacuation asset. In cases
of a small asset (MEDEVAC or MH60) that can carry only a few of your casualties, then urgent casualties are loaded
and evacuated first while remaining casualties are evacuated on subsequent turns of the asset. In cases of a large as-
set (MH47), then priority litter casualties are loaded first followed by urgent litter casualties. This is so that the urgent
casualties will be the first unloaded at the receiving facility. Minimally or walking wounded are loaded last. In all cases,
the evacuation medical provider will override the ground Medic in casualty loading based on placement of resuscitation
equipment on the vehicle or aircraft.
Extended Care: Triage continues through extended care as casualty conditions may improve or deteriorate and require
less or more medical care over time. TCCC management does not stop until a casualty is turned over to an equal or
higher level of care.

Triage Categories & Evacuation Precedence

Urgent: This category includes those casualties who require an immediate life-saving intervention or surgery. Example
casualties include those who are hemodynamically unstable and those who have airway complications, chest or abdom-
inal injuries, massive external hemorrhage, shock, or burns > 20% TBSA. Casualties require evacuation within 2 hours.
Priority: This category includes those wounded who may need surgery but whose condition permits delay in treatment
without unduly endangering life, limb, or eyesight. Example casualties include those with no evidence of shock, large
soft tissue wounds with controlled bleeding, fracture s of major bones, torso wounds with controlled bleeding, or burns
< 20% TBSA. Casualties require evacuation within 4 hours.
Routine: This category is for casualties often referred to as the walking wounded. These casualties have minor injuries
such as small burns, lacerations, abrasions, and small bone fractures. Casualties require evacuation within 24 hours.
Expectant (Routine): This category is for casualties who have wounds so extensive that even if they were the only
casualty, they would have little hope for survival. Examples of expectant casualties are those who are unresponsive with
massive penetrating head trauma, massive torso trauma, or no signs of continued life.

14 SECTION 2 PRIMARY TRAUMA PROTOCOLS

Tactical Triage Protocol

SECTION 2

2025 RANGER MEDIC HANDBOOK 15

Tactical Trauma Assessment
Patient Assessment
Follow TCCC Guidelines of Care Under Fire, Tactical Field Care, and Tactical Evacuation Care.
The acronym MARCH is recommended to guide the priorities in the Care Under Fire (control of life-threatening hemor-
rhage only) and Tactical Field Care phases:
SECTION 2

Massive hemorrhage – control life-threatening bleeding.

Airway – establish and maintain a patent airway.
Respiration – decompress suspected tension pneumothorax, seal sucking chest wounds, and support ventilation/
oxygenation as required.
Circulation – establish IV/IO access and administer blood products as required to treat shock.
Head injury/Hypothermia – prevent/treat hypotension and hypoxia to prevent worsening of traumatic brain injury
and prevent/treat hypothermia.

TCCC Application
Care Under Fire: Return fire and take cover. Direct or expect casualty to remain engaged as a combatant if appropriate.
Direct casualty to move to cover and apply self-aid if able. Try to keep the casualty from sustaining additional wounds.
Casualties should be extricated from burning vehicles or buildings and moved to places of relative safety. Do what
is necessary to stop the burning process. Tactical patient assessment during this phase is limited to identifying life-
threatening hemorrhage in a rapid head-to-toe survey taking less than 10–15 seconds or as tactically feasible. Airway
management, other than positioning, is generally best deferred until the tactical field care phase. Stop life-­threatening
external hemorrhage if tactically feasible with an approved tourniquet.
Tactical Field Care: Consolidate casualties in CCP. Initially, conduct triage to identify which patient needs attention
first and who can wait. Identify any life-threatening hemorrhage not already controlled. In this phase, the first priority is
to conduct a rapid trauma assessment. A more deliberate and traditional head-to-toe MARCH survey is completed on
each casualty after all life threats have been addressed. Casualties with an altered mental status should be disarmed im-
mediately, including communications equipment. Injuries are managed in a head-to-toe-treat-as-you-go manner. Triage
recurs during this entire phase. Delegate treatment of minor injuries to ARFRs or RFRs, freeing the Medic to focus on
more seriously injured. Provide instructions to ARFRs or RFRs if tasked to assist you with multi­system trauma casualties.
Communicate casualty status and evacuation requirements to C2. Consolidate medical supplies in CCP. Prepare and
package casualties for evacuation.
Tactical Evacuation: After evacuation movement, reassess patient’s mental status, airway, vital signs, and any interventions.

Trauma Assessment Principles

Massive Hemorrhage: Obvious external sources of bleeding should be controlled with tourniquets, direct pressure, and
pressure dressings. Clamping of injured vessels is not indicated unless the bleeding vessel can be directly visualized.
Sources of internal hemorrhage should be identified. Initial tourniquets are to be placed “high and tight.” Effort should be
made to convert these as distally as possible or to a pressure dressing as soon as the tactical situation allows.
Airway: A conscious and spontaneously breathing patient rarely requires immediate airway intervention. If the patient
is able to talk normally, then his airway is intact. If the patient is semiconscious or unconscious, the tongue is the most
common source of airway obstruction. Patient positioning and airway adjuncts (NPA/OPA) should be the first choice to
maintain a patent airway. Ranger Medics train extensively in order to proficiently conduct a surgical cricothyroidotomy.
This should be the first choice for any patient requiring a definitive airway. Penetrating trauma causing C-spine fractures
is almost universally fatal. One should consider C-spine fracture in blunt trauma and take appropriate precautions.
Respirations: In the conscious patient, who is alert and breathing normally, no interventions are required. If the patient
has an appropriate mechanism of injury and signs of respiratory distress such as tachypnea, dyspnea, or cyanosis,
which may be associated with agitation or decreasing mental status, then a presumption of tension pneumothorax
management is indicated.
Circulation: Important information can be rapidly obtained regarding perfusion and oxygenation from the level of con-
sciousness, pulse, skin color, and capillary refill time. Decreased cerebral perfusion may result in an altered mental
status. Skin color and capillary refill will provide a rapid initial assessment of peripheral perfusion. Pink skin is a good sign
versus the ominous sign of white or ashen, gray skin depicting hypovolemia. Pressure to the thumb nail or hypothenar
eminence will cause the underlying tissue to blanch. In a normovolemic patient, the color returns to normal within 2 sec-
onds. In the hypovolemic, poorly oxygenated patient and/or hypothermic patient, this time period is extended or absent.
Head Injury/Hypothermia: Clothing and protective equipment such as helmets and body armor should only be re-
moved 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 injuries but must subsequently be protected from the elements and the environment.
Hypothermia is to be avoided in trauma patients. A brief neurological assessment should be performed, and LOC can be
described through, preferably, AVPU or, alternately, the Glasgow Coma Scale (GCS) method. If the pupils are found to
be sluggish or nonreactive to light with unilateral or bilateral dilation, one should suspect a head injury and/or inadequate
brain perfusion. Assess for any fractures or deformities of extremities or joints.
Vital Signs: Vital signs should be assessed frequently, especially after specific therapeutic interventions, and
before and after moving patients. As a group, Ranger 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. Technology can fail, and Ranger Medics must be capable of obtaining manual vital signs. EtCO2 monitors
attached to a facemask are inaccurate; the trend is often more important than the number.

16 SECTION 2 PRIMARY TRAUMA PROTOCOLS

Tactical Trauma Assessment

SECTION 2

2025 RANGER MEDIC HANDBOOK 17

Hemorrhage Management
Hemorrhage Control
Extremity trauma hemorrhage is the most frequent cause of preventable combat death, which can generally be pre-
vented by the early use of a tourniquet. The use of compression dressings and/or hemostatic agents to control bleeding
or convert tourniquets is imperative in continued casualty management. For internal or uncontrollable hemorrhage of
SECTION 2

the chest or abdomen, the most crucial life-saving intervention is rapid evacuation to a surgical capability. Measures
that will enhance the possibility of survival of these casualties are early resuscitation with blood products, avoidance of
aggressive crystalloid/colloid fluid resuscitation, prevention of clotting dysfunction caused by hypothermia and acidosis,
and avoidance of platelet-impairing medications.

TCCC Application
Care Under Fire: Stop life-threatening external hemorrhage if tactically feasible. Direct casualty to control hemorrhage
by self-aid/buddy-aid if able. Use a CoTCCC-recommended tourniquet for hemorrhage that is anatomically amenable
to tourniquet application. Apply the tourniquet proximal to the bleeding site, over the uniform, tighten, and move the
casualty to cover. Initial tourniquet placement should be as high as possible on the limb.

Tactical Field Care & Tactical Evacuation: Assess for unrecognized hemorrhage and control all sources of bleeding. If
not already done, use a CoTCCC-recommended tourniquet to control life-threatening external hemorrhage that is ana-
tomically amenable to tourniquet application or for any traumatic amputation. Apply directly to the skin 2–3 inches above
wound and never over a joint. For compressible hemorrhage not amenable to tourniquet use or as an adjunct to tour-
niquet removal (if evacuation time is anticipated to be longer than 2 hours), use a pressure dressing with a hemostatic
agent. Hemostatic gauze should be packed into cavitation of wound with at least 3 minutes of direct pressure. Before
releasing any tourniquet on a casualty who has been resuscitated for hemorrhagic shock, ensure a positive response to
resuscitation efforts (i.e., a peripheral pulse normal in character and normal mentation if there is no traumatic brain in-
jury). Reassess prior tourniquet application. Expose wound and determine if tourniquet is needed. If so, move tourniquet
from over uniform and apply directly to skin 2–3 inches above wound. If a tourniquet is not needed, use other techniques
to control bleeding. When time and the tactical situation permit, a distal pulse check should be accomplished. If a distal
pulse is still present, consider additional tightening of the tourniquet or the use of a second tourniquet, side by side and
proximal to the first, to eliminate the distal pulse. Expose and clearly mark all tourniquet sites with the time of tourniquet
application. Use a permanent marker.
a. Reassess patient and verify bleeding is controlled.
b. Verify distal pulses are absent in extremities with tourniquets.
c. Reassess if tourniquet is required or other hemorrhage control means are appropriate.

Advanced Hemorrhage Control: Consider the early use of a junctional tourniquet for high femoral or axillary bleeding
not amendable to tourniquet application. Any improvised junctional technique must be trained and practiced to ensure
proper application. Other advanced hemorrhage control techniques such as REBOA should only be performed by those
with extensive training and experience in the individual tasks required to successfully complete the procedure.

Extended Care
Tourniquet Conversions: If a tourniquet is applied, loosened, or reapplied, ensure the approximate time is recorded on
the tourniquet and the casualty card. Reevaluate all applied tourniquets for efficacy and further need. Perform tourniquet
conversion procedure as applicable, as early as possible, and if hemorrhage control is achieved otherwise. This has
never been more important given extended casualty evacuation times.

Wound Management: Change and/or reinforce all hemorrhage control dressings as applicable and dependent on medi-
cal supplies. Irrigate and redress wounds (any potable water can be used for irrigation). Debride only obviously devital-
ized tissue. Change dressings every 24 hours or as needed. Consider converting to silver impregnated dressings to
reduce frequency of dressing changes. Continue antibiotics. Repeat moxifloxacin 400mg PO or ertapenem 1g IV/IO/IM
q24hr.

Abdominal Injuries: Control any visible hemorrhage from bowel. Irrigate gross debris off of exposed bowel. Attempt to
gently reduce bowel back into abdominal cavity. If bowel is reduced, approximate skin (sutures or staples) and cover
abdominal wound with dressing. If bowel is unable to be reduced, cover bowel with moist dressing and keep covered.

18 SECTION 2 PRIMARY TRAUMA PROTOCOLS

Hemorrhage Control Protocol

SECTION 2

2025 RANGER MEDIC HANDBOOK 19

Tourniquet Application Procedure
SECTION 2

20 SECTION 2 PRIMARY TRAUMA PROTOCOLS

Tourniquet Conversion Procedure

SECTION 2

2025 RANGER MEDIC HANDBOOK 21

Airway Management
Airway management must be of prime concern for any trauma casualty. The setting, conditions, and injuries must be
taken into account for every casualty. In the tactical setting, hemorrhage control and shock resuscitation are more im-
portant than definitive airway management. Aggressive airway management is warranted in some casualties. However,
in many casualties, simple repositioning of an airway may solve airway, breathing, and oxygenation problems. Assess
SECTION 2

every patient’s airway based on the setting, patient condition, and patient’s pending condition and take the appropriate
action. A patient who can breathe on his own should be allowed to breath on his own unless the injury pattern or
predicted clinical course warrants a more aggressive action.

TCCC Application
Care Under Fire: Airway management, other than patient positioning, is generally best deferred until the Tactical Field
Care phase.
Tactical Field Care:
Unconscious casualty without airway obstruction:
■ Inspect oropharynx and remove any foreign body from airway or lip. Do not conduct blind finger sweeps.
■ Chin-lift or jaw-thrust maneuver
■ Nasopharyngeal airway
■ Place casualty in the recovery position

Casualty with airway obstruction or impending airway obstruction:

■ Inspect oropharynx and remove any foreign body from airway or lip. Do not conduct blind finger sweeps.
■ Chin-lift or jaw-thrust maneuver
■ Nasopharyngeal airway
■ Allow casualty to assume any position that best protects the airway, including sitting up
■ Place an unconscious casualty in the recovery position.
■ If previous measures are unsuccessful: surgical cricothyroidotomy (with pain control if conscious)

Tactical Evacuation: With every evacuation movement of a casualty, confirm airway placement and reassess airway
patency.
Unconscious casualty without airway obstruction:
■ Inspect oropharynx and remove any foreign body from airway or lip. Do not conduct blind finger sweeps.
■ Chin-lift or jaw-thrust maneuver
■ Nasopharyngeal airway
■ Place casualty in the recovery position

Casualty with airway obstruction or impending airway obstruction:

■ Inspect oropharynx and remove any foreign body from airway or lip. Do not conduct blind finger sweeps.
■ Chin-lift or jaw-thrust maneuver
■ Nasopharyngeal airway
■ Allow casualty to assume any position that best protects the airway, to include sitting up
■ Place unconscious casualty in the recovery position
■ If above measures are unsuccessful:
➣ Surgical cricothyroidotomy (with pain control if conscious)
➣ Supraglottic airway
Spinal immobilization is not necessary for casualties with penetrating trauma.

Extended Care
1. Monitoring: Maintain continuous pulse oximetry and EtCO2; document serial vital signs.
2. Verify airway patency and with any evacuation or movement of the patient.
3. Suction: Consider periodic suctioning of the oropharynx and established airway tube.
4. Ventilation: The SAVe II Ventilator is a small, lightweight ventilator that automatically recommends ARDSnet lung protec-
tive settings based on the patient’s height. The default settings do not have PEEP and Medics must manually set the
vent to a PEEP of 5 at a minimum. The SAVe II does not require an external O2 source, but supplemental O2 can be
attached and set at no higher than 6L/m, which provides 62% oxygen. Any ventilator battery lasts for a limited amount
of time. For extended periods, consider alternating between a ventilator and BVM assisted ventilations with an attached
PEEP valve. Keep in mind that positive pressure ventilation is a known cause of tension pneumothorax.
5. Consider local wound care and further securing of cricothyroidotomy site if applicable.

22 SECTION 2 PRIMARY TRAUMA PROTOCOLS

Airway Management Protocol

SECTION 2

2025 RANGER MEDIC HANDBOOK 23

Surgical Cricothyroidotomy Procedure
SECTION 2

24 SECTION 2 PRIMARY TRAUMA PROTOCOLS

Thoracic Trauma Management
Thoracic Trauma
Penetrating and blunt chest trauma remains a threat regardless of the use of body armor. The primary life-threat that is
preventable is tension pneumothorax. Always consider presumptive diagnosis of tension pneumothorax when progres-
sively worsening respiratory distress develops in a casualty with a known or suspected torso trauma. The late signs of
decreased breath sounds, tracheal deviation, and jugular vein distention may not always be present and may be difficult

SECTION 2
to assess on the battlefield. Relief of tension pneumothorax requires release of air under pressure within the chest cavity.
Constant reassessment of patients with chest trauma is imperative to identify progression or reemergence of tension
pneumothorax. The management of an open chest wound with an occlusive dressing sealing the wound may lead to the
development of a pneumothorax. Once sealed, patients must be monitored for development of tension pneumothorax.
Continued assessment for hemothorax, flail segments, or cardiac tamponade should follow management of tension.

TCCC Application
Care Under Fire: No specific action.
Tactical Field Care: In a casualty with progressive respiratory distress and known or suspected torso trauma, consider
a tension pneumothorax and decompress the chest on the side of the injury with at least a 14-G, 3.25-inch needle/
catheter inserted in the 5th intercostal space, anterior axillary line (preferred), or second intercostal space, mid clavicular
line (secondary site). Ensure that the needle entry into the chest is not medial to the nipple line and is not directed toward
the heart. All open and/or sucking chest wounds should be treated by immediately applying an occlusive material to
cover the defect and securing it in place. Monitor the casualty for the potential development of a subsequent tension
pneumothorax. Casualties with evidence of torso trauma and no vital signs should have bilateral needle decompression
or finger thoracostomy (preferred) performed to ensure they do not have a tension pneumothorax prior to all resuscita-
tion efforts being halted.
Tactical Evacuation: Consider finger thoracostomy or chest tube insertion if multiple needle decompressions, no im-
provement, life-threatening complications and/or long transport is anticipated. Most combat casualties do not require
supplemental oxygen, but administration of oxygen may be of benefit for the following types of casualties: low oxygen
saturation, injuries associated with impaired oxygenation, casualties with TBI (maintain oxygen saturation > 95%), cas­
ualties in shock, and casualties at altitude.

Extended Care
Reassess patient for development of tension pneumothorax. Consider finger thoracostomy or chest tube if: patient
requires multiple needle decompressions OR no improvement with needle decompression OR evacuation time is pro-
longed (> 1 hour) OR evacuation requires transport at high altitude in unpressurized aircraft. If available, provide oxygen
as needed to maintain O2 saturation > 90% (> 95% and < 100% for TBI). Apply negative pressure to chest tube if avail-
able, not exceeding –20cm H2O. Consider rib blocks for pain management. If patient is being ventilated, maintain strict
bagging cycles (1 breath every 5 seconds) and a tidal volume of approximately 500mL to allow for complete exhalation
and avoid stacking breaths. Always use a PEEP valve when bagging. Consider the use of a ventilator if available and add
physiologic PEEP (3–5cm H2O). Consider sedation for casualties requiring prolonged intubation/ventilation if no shock
or hypotension. If a sufficient supply of chest seals are available, then consider removing seals, “burping” wounds, and
resealing with a new occlusive dressing. Resuscitative fluids should be managed very conservatively unless there is
significant blood lost from other injuries. Regardless, manage resuscitation fluids only to maintain a systolic pressure of
90–100mmHg, radial pulse, and/or mentation.
Flail Chest Management: Casualties with flail chest can present with tachypnea and eventual hypoxia due to shallow
breaths. The primary treatment for flail chest is PAIN CONTROL to allow the casualty enough relief for sufficient inspira-
tion and oxygenation. This will prevent respiratory fatigue. If unable to improve vitals with pain management, consider
alternate etiology for symptoms (pneumothorax, hemorrhagic shock, hemothorax etc). If alternate etiologies for respira-
tory distress have been ruled out and/or treated, and casualty continues to demonstrate signs of severe fatigue, consider
systemic analgesic and sedation, placement of a surgical airway, and mechanical ventilation.
Hemothorax: Identification of hemothorax is difficult to assess in the field. MOI, reduced breath sounds, difficulty
breathing, and unexplained shock should lead to suspicion of hemothorax. Rapid evacuation to surgical capability, ven-
tilation support, judicious fluid therapy, and chest tube are indicated for hemothorax. If continuous output from the chest
tube is > 200–250cc/hr over the first 4 hours, there is a very high likelihood of intrathoracic vascular injury that requires
surgical intervention. If evacuation capabilities are significantly delayed or blood products are limited, high output chest
tube drainage may require re-triage of casualty and consideration for transition to expectant/palliative care.
Cardiac Tamponade: Bleeding or fluid collection into the pericardium may often be expected from hard frontal trauma
to the chest or small puncture wounds creating compression on the heart. Little can be accomplished in the field if this
injury is suspected. The suspicion of this injury should elevate the urgency of evacuation and should be communicated
to receiving facility if possible. If properly trained, a pericardiocentesis may be performed in extremis situations.
Cardiac Dysrhythmias: If patient is being monitored with ECG capability, cardiac dysrhythmias with chest trauma (es-
pecially blunt trauma) may occur. Manage any such dysrhythmias as with any such cardiac patient IAW ACLS guidelines.
Accompanying Abdominal Injuries: Any injury between the nipple and the navel may be assumed to be a thoraco­
abdominal injury. Consider the use of occlusive dressings over these wounds if concerned for tension pneumothorax.
Subsequently, assess patient for development of tension pneumothorax physiology. Diaphragmatic rupture or injuries
may occur and have a significant effect on respiratory effort. Control any visible hemorrhage from bowel using approved
hemostatic agent or gauze. Irrigate gross debris off of exposed bowel. Attempt to gently reduce bowel back into ab-
dominal cavity. If bowel is reduced, approximate skin (sutures or staples) and cover abdominal wound with an occlusive
dressing. If bowel is unable to be reduced, cover bowel with moist dressing.

2025 RANGER MEDIC HANDBOOK 25

Thoracic Trauma Management Protocol
SECTION 2

26 SECTION 2 PRIMARY TRAUMA PROTOCOLS

Needle Chest Decompression Procedure

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2025 RANGER MEDIC HANDBOOK 27

Chest Tube Insertion and Finger Thoracostomy Procedure
SECTION 2

28 SECTION 2 PRIMARY TRAUMA PROTOCOLS

Tactical Damage Control Resuscitation
Prevention of hypovolemic shock (inadequate tissue perfusion) is critical in a trauma casualty. Shock can be thought
of as a pause in the act of dying and requires aggressive actions to prevent its progression. Once a casualty has pro-
gressed to shock, he is susceptible to the lethal triad of coagulopathy, hypothermia, and acidosis. Early preventative
actions can delay hypothermia. Controlling blood loss and appropriate blood product administration can delay the

SECTION 2
progress of coagulopathy.

TCCC Application
Care Under Fire: Stop life-threatening bleeding.
Tactical Field Care: The first priority is to stop any active hemorrhage. Initiate intravenous (IV) access if indicated. Start
an 18-G or larger IV or saline lock. If resuscitation is required and IV access is not obtainable, use the intraosseous
(IO) route. Assess for hemorrhagic shock; decreased mental status (in the absence of head injury) and weak or absent
peripheral pulses are the best field indicators of shock. If indicated by assessment, initiate fluid resuscitation. If not in
shock, resuscitation is not necessary. If in shock, administer whole blood or blood products in a 1:1:1 ratio. Repeat if
still in shock. Warm fluids are preferred if IV fluids are required. Be aware of warmer constraints as applying pressure to
increase flow may cause ineffective warming and cell lysis. Continued efforts to resuscitate must be weighed against
logistical and tactical considerations and the risk of incurring further casualties. If a casualty with TBI is unconscious
and has no peripheral pulse, resuscitate to restore the radial pulse. Prevention of hypothermia is critical in a shock
patient. Minimize casualty’s exposure to the elements. Keep protective gear on or with the casualty if feasible. Replace
wet clothing with dry if possible. Get the casualty onto an insulated surface as soon as possible. Apply the Ready-Heat
Blanket from the Hypothermia Prevention and Management Kit (HPMK) to the casualty’s torso (not directly on the skin)
and cover the casualty with the Heat-Reflective Shell (HRS). If an HRS is not available, the combination of any blanket
and the Ready-Heat Blanket may also be used. If the items mentioned above are not available, use dry blankets, poncho
liners, sleeping bags, or anything that will retain heat and keep the casualty dry.
TXA Administration: If a casualty is anticipated to need a blood transfusion (e.g., presents with hemorrhagic shock, one
or more major amputations, penetrating torso trauma, or evidence of severe bleeding), administer 2g of tranexamic acid
(TXA) as an IV/IO flush as soon as possible but not later than 3 hours after injury. If initial dose of TXA was 1g, administer
second infusion of 1g TXA after the first unit of blood or blood product treatment. Record on CAX Card “2g TXA given”.
Drug must be properly maintained at 15–30°C/59–86°F. Do not delay blood product resuscitation for a trauma pa-
tient in shock in order to administer TXA and/or calcium.
Calcium Administration: Many patients who require Blood resuscitation will present with hypocalcemia. Calcium ad-
ministration will be considered after the 2nd unit of blood and again after every 4th unit of blood. Unless tactically unfea-
sible, calcium will be administered using a secondary IV/IO site. Do not delay blood product resuscitation for trauma
patients in shock in order to administer Calcium.
Tactical Evacuation: Reassess need for IV access if not previously established. Reassess for hemorrhagic shock. If not
in shock, then no IV fluids are necessary. Avoid PO fluids for casualties requiring surgical intervention. Continue resuscita-
tion with whole blood, packed red blood cells (PRBCs), plasma, and platelets in a 1:1:1 ratio as indicated. If a casualty
with TBI is unconscious and has a weak or absent peripheral pulse, resuscitate as necessary to maintain a systolic blood
pressure of 110mmHg or above. Prevention of hypothermia is even more critical for a trauma patient in moving vehicles or
aircraft. Keep protective gear on or with the casualty if feasible. Remove and replace wet clothing with dry if possible. Get
the casualty onto an insulated surface as soon as possible. Apply external warming devices as depicted in tactical field
care if not already accomplished. Use a portable fluid warmer capable of warming all IV fluids including blood products.
Protect the casualty from wind if doors must be kept open.

Extended Care
Fluid Management: Continue resuscitation with whole blood or blood products as indicated. Maintain a palpable radial
pulse or systolic blood pressure of 90–100mmHg in all unconscious patients with noncompressible, internal hemor-
rhage. Maintain a normal radial pulse character or systolic blood pressure > 110mmHg in TBI patients with altered
mental status. If available, insert Foley catheter and titrate IV/IO/NG/PR crystalloid fluids to maintain urine output of
30–50mL/hr.
ROLO Transfusion: All lifesaving TCCC protocols and procedures should be completed while ARFRs obtain blood for
transfusion. Evacuation should not be delayed for field transfusions. ROLO may be considered for trauma casualties
showing signs of hemorrhagic shock; shock from internal, noncompressible, or uncontrollable bleeding; massive blood
loss with tachypnea, tachycardia, systolic hypotension and altered mental status; or extended evacuation.

2025 RANGER MEDIC HANDBOOK 29

Tactical Damage Control Resuscitation Protocol
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30 SECTION 2 PRIMARY TRAUMA PROTOCOLS

Shock Management
Hypotensive Resuscitation
The employment of hypotensive resuscitation is meant to avoid over resuscitation of shock. Basing the titration of fluids
on a monitored physiologic response may avoid the problem of excessive blood pressure elevation and fatal rebleeding
from previously clotted injury sites.

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Shock Assessment
Important information can be rapidly obtained regarding perfusion and oxygenation from the level of consciousness,
pulse, skin color, and capillary refill time. Mental status is the most important indicator of shock. Decreased cerebral
perfusion may result in an altered mental status. The patient may progress from anxious to confused to unresponsive.
Beware of the patient with an impending sense of doom. The patient’s pulse is easily accessible, and if palpable, the
systolic blood pressure in millimeters of mercury (mmHg) can be roughly estimated as follows:

RADIAL PULSE: PRESSURE 80mmHg

FEMORAL PULSE: PRESSURE 70mmHg
CAROTID PULSE: PRESSURE 60mmHg

It is important to state that the above pressure ranges are merely quick estimates of systolic blood pressures
and are generally OVERESTIMATED and inaccurate. They are to be used during the rapid initial assessment of
a trauma patient. Actual blood pressure measurement and a complete patient assessment should direct your
trauma and shock management decisions.

Narrowed pulse pressure, < 30mmHg (decreased difference between systolic and diastolic pressures) are extremely
sensitive and specific for identifying shock early, and they should trigger consideration for blood product resuscitation
and advanced care.

Skin color and capillary refill will provide a rapid initial assessment of peripheral perfusion. Pink skin is a good sign versus
the ominous sign of white or ashen, gray skin depicting hypovolemia. Pressure to the thumb nail or hypothenar eminence
will cause the underlying tissue to blanch. In a normovolemic patient, the color returns to normal within 2 seconds. In the
hypovolemic, poorly oxygenated patient and/or hypothermic patient, this time period is extended or absent.

The classic classes of shock are inaccurate and misleading but are often referred to in trauma literature. Ranger Medics
should consider mechanism of injury, mental status, pulse, and other signs when making decisions on triage, treatments,
and evacuation priority.

The following table is provided for educational purposes only and should not be relied on.

Estimate of Fluid and Blood Requirements in Shock*

Class I Class II Class III Class IV
Blood loss (mL) Up to 750 750–1,500 1,500–2,000 > 2,000
Blood loss (%BV) Up to 15% 15–30% 30–40% > 40%
Pulse rate < 100 > 100 > 120 > 140
Blood pressure (mmHg) WNL WNL Decreased Decreased
Pulse pressure (mmHg) WNL/increased Decreased Decreased Decreased
Capillary blanch test Normal Positive Positive Positive
Respiratory rate 14–20 20–30 30–40 > 35
Urine output (mL/hr) > 30 20–30 5–15 Negligible
CNS mental status Slightly anxious Mildly anxious Anxious/confused Confused/lethargic
*Modified from ATLS.

2025 RANGER MEDIC HANDBOOK 31

Saline Lock & Intravenous Access Procedure
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32 SECTION 2 PRIMARY TRAUMA PROTOCOLS

External Jugular Intravenous Cannulation Procedure

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2025 RANGER MEDIC HANDBOOK 33

Sternal Intraosseous Infusion Procedure
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34 SECTION 2 PRIMARY TRAUMA PROTOCOLS

Intraosseous Infusion Procedure (Non-Sternal)

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2025 RANGER MEDIC HANDBOOK 35

Hypothermia Prevention & Management Kit Procedure
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36 SECTION 2 PRIMARY TRAUMA PROTOCOLS

Head Trauma
Open head injury results from application of force with penetration of the skull. The most common agents are missiles
and blunt instruments. The lethality is proportional to the energy of the missile (which in turn is proportional to the
square of the velocity). Injuries caused by blunt instruments can cause open depressed skull fractures but are usually
of relatively low energy and cause only local injury to the brain. Nonetheless, these are serious wounds and have a high

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potential for infection.

Closed head injury results from application of force to the head that does not involve penetration of the skull but may
involve scalp lacerations and facial fractures. The degree of injury to the brain is dependent on the energy transferred to
the brain as a result of the force applied to the head. Closed head injury most often results from falls and motor vehicle
accidents, even in an operational environment. Alteration of consciousness is the hallmark of brain injury and may be
mild or severe, immediate or delayed, brief or permanent. Delayed deterioration of consciousness may occur as a result
of hematoma formation within the skull or worsening swelling of the brain. The mechanism for this impairment of con-
sciousness is increasing intracranial pressure, with subsequent impairment of brain perfusion (blood flow).

Assessment & Management

Generally, with head injuries the primary damage is done and there is little that can be done to correct that dam-
age. The primary goal of head injury management is to identify or rule out intracerebral hemorrhage and then pre-
vent secondary injuries associated with hypoxia, hypotension, anemia, hyperthermia, and hypothermia. This equates
to aggressive bleeding control and airway management. Avoid hypoxia (any SpO2 < 90%) and hypotension (any SBP
< 100), and react to the signs of brain edema, herniation, or seizures.

The hallmark of head injury is alteration of consciousness. This is best assessed using the Glasgow Coma Scale. Pupil-
lary function is also important to assess, and this can be done with any light source. In bright sunlight conditions, closing
the eye for 30 seconds and observing while quickly opening demonstrate pupillary reactivity. Regular reassessment, as
the tactical situation permits, is critical as a neurologic status may vary significantly over time.

Inspection: Vital signs should be assessed in any patient with a head injury and patency of the airway confirmed.
The head should be inspected for signs of open injury or skull fracture. Open injury will be accompanied by a defect,
and basal skull fracture may be associated with Battle’s sign (retroauricular ecchymosis) or raccoon eyes (periorbital
­ecchymoses). Leakage of cerebrospinal fluid from the ears or nose may also be present. The pupils should be inspected
for equality and/or reactivity. Unequal or nonreactive pupils in an unconscious patient are ominous signs.

Auscultation: Auscultation is generally not helpful in the evaluation of the head injury itself, but in a patient with impaired
consciousness, a full exam, including auscultation of the lungs, should be performed.

Palpation: Palpation of the head may reveal an underlying closed depressed skull fracture (an “ashtray” feel). The
cervical, thoracic, and lumbar spine should be palpated to assess for tenderness or deformity, possibly indicating an
associated spinal injury.

MANAGEMENT: Treatment involves securing the airway, maintaining systolic blood pressure > 110, maintaining oxygen
saturation > 92% and < 100%, stabilizing the cervical spine (C-spine) if indicated, dressing any wound, and establishing
an intravenous line. Prevent seizures IAW Seizure Protocol and treat, if indicated, with hypertonic saline.

Extended Care
Key aspects of field management of severe TBI are the prevention of hypoxia and hypotension. Ensure early establishment
of a definitive airway, aggressively treat respiratory compromise, administer oxygen if available (to maintain saturation
> 92% and < 99%), and fluid resuscitate hypotension. DO NOT hyperventilate unless indicated for signs of herniation.
Controlled hyperventilation may be considered as a temporizing measure for evidence of increasing intracranial pres-
sure (ICP) and herniation (deteriorating mental status, unequal pupils, posturing). For impending herniation, ventilate to
achieve EtCO2 of 25–30mmHg for 15–20 minutes. Otherwise, and without impending herniation, maintain EtCO2 of 35–
40mmHg. If EtCO2 monitor is not available, ventilate at a rate of 20/min and a tidal volume of approximately 500mL. Pre-
vent seizures as per Seizure Protocol. Administer with 4g of levetiracetam for seizure prophylaxis if available. Elevate the
head 30 degrees. Prevent hypo/hyperthermia. Antibiotic prophylaxis for penetrating head trauma: c ­ eftriaxone 2g IV/IO.
Ensure casualty is evacuated to a facility with a neuro­surgeon available.

2025 RANGER MEDIC HANDBOOK 37

Head Trauma Management Protocol
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38 SECTION 2 PRIMARY TRAUMA PROTOCOLS

Concussion
A concussion is a blow or jolt to the head or a penetrating head injury that disrupts the function of the brain. Not all blows
or jolts to the head cause a brain injury. In combat, concussions are usually caused by a bullet, fragment, blast, fall, direct
impact, or motor vehicle crash. Some, but not all, persons with a concussion lose consciousness.

S/Sx: Headache; fatigue; sensitivity to noise and light (phonophobia and photophobia); difficulty concentrating; loss of

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balance; nausea/vomiting; insomnia/sleep disturbances; vision changes/blurred vision; ringing ears; excessive tired-
ness; dizziness; drowsiness; difficulty remembering; confusion; irritability.

TCCC Application
Care Under Fire: Manage life-threatening hemorrhage. No specific action for TBI/concussion.

Tactical Field Care: Treat other injuries in accordance with TCCC guidelines. For patients with S/Sx of traumatic brain
injury or potential for blast injury, assess for RED FLAG symptoms, and conduct neurological evaluation.

S/Sx of RED FLAG Evacuation:

Tactical Evacuation: Evacuate based on appropriate protocol of other injuries or red flag symptoms.

Special Considerations
Mandatory events requiring MACE 2:
a. Personnel in a vehicle associated with a blast, collision, or rollover
b. Personnel within 150 meters of a blast
c. Personnel with a direct blow to the head
d. Command directed evaluation

All return-to-duty must be evaluated and approved by an MD/PA.

Concussion is primarily a clinical diagnosis. If you do not feel that a patient is back to their baseline, do not allow them
to RTD and re consult your medical provider.

Management
1. Consider concussion in anyone who is dazed, confused, “saw stars,” lost consciousness (even if just momentarily),
or has memory loss that results from a fall, explosion, motor vehicle crash, or any other event involving abrupt head
movement, a direct blow to the head, or other head injury.
2. Triage and treat other injuries as required. As soon as tactically feasible, evaluate for concussion.
3. If red flags are present – consult with medical provider for possible urgent evacuation.
4. Administer MACE 2, initiate 24-hour rest and consult with medical provider.
5. Treatment: Treat symptoms with acetaminophen, NSAIDs, and ondansetron as needed. DO NOT use narcotics or
tramadol for symptom management. Not all symptoms will respond to conservative management as the brain heals.
This is to be expected. Refer to the Ranger mTBI Return to Duty Protocol for clearance.

Extended Care
All patients with TBI/concussion injuries are to be evaluated by an MD/PA as soon as tactically feasible. If evacuation is
delayed, then remove patient from an active tactical role. If no RED FLAG indications, then place patient in a limited duty
role that will allow for rest and sleep if possible. Identify a Ranger buddy who will remain in close proximity and monitor
patient status – DO NOT allow patient to be left alone while remaining in a tactical situation. Medical personnel should
assess patient frequently for general responsiveness, vital signs, and any indication of red flag symptoms. Explain to
patient and Ranger buddy the importance of alerting medical personnel of any red flag symptoms. If possible, rest will
be the best recovery. Ensure patient remains well hydrated as dehydration will aggravate recovery. Allow patient to eat
small, light meals if not affected by nausea or vomiting. Avoid exertion and any kind of strenuous events or situations
that will hinder healing. Limit work to mundane tasks that are not critical to tactical situation but still allow a feeling of
importance.

2025 RANGER MEDIC HANDBOOK 39

Concussion Management Protocol
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40 SECTION 2 PRIMARY TRAUMA PROTOCOLS

Abdominal Trauma
Penetrating abdominal injuries are characterized by a violation of the peritoneal or retroperitoneal spaces by any variety
of low- to high-velocity objects. Injuries represent a spectrum that includes impalement with foreign objects or stab,
gunshot, and fragment wounds. Tissues are crushed and torn by the penetrating missile, or they are injured indirectly
by stretching and cavitation. Multiple abdominal organs are commonly damaged as a result of penetrating trauma. The

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management of abdominal trauma in the field centers on adequate resuscitation, pain control, and intravenous antibiot-
ics with the goal of evacuating the patient to a location where surgical care is available. Wound care and other supportive
measures should also be given.

Initial Assessment & Management

Visible evidence of abdominal trauma may not always be immediately present (especially when associated with blunt
MOIs). Abdominal pain is not always a reliable indicator of abdominal injury as it may be mimicked by fractures of the
ribs and pelvis or not be readily evident because of decreased mental status due to associated head or spinal cord
injury. Furthermore, severe pain from other injures such as extremity fractures may mask the patient’s perception of pain
in the abdominal area.

Inspect for: Entrance and exit wounds, contusions and abrasions, distention, protruding bowel or omentum, gastro­
intestinal hemorrhage (bloody emesis or rectal bleeding), hematuria, and signs of shock.

Palpation: Palpation of the abdomen can reveal tenderness, guarding, and rigidity. Assess all abdominal quadrants for
superficial, deep and rebound tenderness. If an obvious evisceration is present, palpation should be deferred. Involun-
tary guarding is a reliable sign of peritoneal irritation. Pelvic stability should be assessed especially when blunt trauma is
the mechanism of injury. A pelvis that is determined to be unstable should not be subjected to repeated manipulation to
test for stability. If possible, a rectal examination should be done in all patients with suspected abdominal injuries. Gross
blood indicates gastrointestinal hemorrhage or perforation of the bowel, a high riding prostate is suspicious for urethral
injury, and poor rectal tone indicates neurological injury.

Auscultation: Auscultation is difficult and misinterpreted in the tactical setting and should not be used as a singular
diagnostic measure. Absent or decreased bowel sounds are commonly associated with injury to abdominal viscera.
However, patients with audible bowel sounds can still have significant underlying abdominal injuries. Auscultation of
bowel sounds in the thorax is suggestive of diaphragmatic injury.

Control any visible hemorrhage from bowel using approved hemostatic agent or gauze. Irrigate gross debris off of ex-
posed bowel. Attempt to gently reduce bowel back into abdominal cavity. If bowel is reduced, approximate skin
(adhesive dressing, sutures, or staples) and cover abdominal wound with dressing. If bowel has been penetrated
or fecal matter is present, do not attempt to reduce back into abdomen. If bowel is unable to be reduced, cover bowel
with a non-adherent and water impermeable dressing. If uncontrolled abdominal hemorrhage is suspected, immediately
begin resuscitation with whole blood or blood products in a 1:1:1 ratio. Resuscitation efforts should be directed at
maintaining cerebral perfusion as indicated by patient’s mental status if there is no associated head injury. If there is no
associated head injury, a systolic blood pressure of 90–100mmHg is adequate and will prevent rebleeding from over-
resuscitation. The patient who is hemodynamically unstable and requires ongoing large-­volume resuscitation is probably
bleeding from an intra-abdominal or intrathoracic source.

Extended Care
Eviscerated bowel and omentum should be covered with a non-adherent and water-impermeable dressing. The wound
should be reassessed and remoistened every 1–2 hours. Clamps for hemorrhage control should be applied only to easily
seen bleeding vessels. Do not attempt to pull out more bowel or omentum. A nasogastric (NG) tube should be placed
to decompress the stomach in order to decrease the risk of vomiting and aspiration. The NG tube may be reserved
for those patients who are vomiting or have a distended abdomen. A Foley catheter may be useful in patients who are
unstable in order to monitor urine output and to obtain urine samples to evaluate for blood. Worsening pain or worsen-
ing signs of shock, peritonitis, or sepsis indicate deterioration and should accelerate efforts to evacuate the patient
to a location where surgical care is available. Anti­biotic therapy should be initiated as soon as a penetrating injury is
suspected. Administer ertapenem 1g IV.

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Abdominal Trauma Management Protocol
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42 SECTION 2 PRIMARY TRAUMA PROTOCOLS

Blast Injury Assessment
TCCC Application
INITIAL EVALUATION AND TREATMENT PER APPROPRIATE TRAUMA PROTOCOL
All unit members exposed to blast will be assessed for blast injuries as soon as tactically feasible, with documentation
if possible. Any indications or complications from blast injuries should warrant immediate evacuation for evaluation at

SECTION 2
a more capable facility.

Blast injuries have a wide range from minor tympanic membrane (TM) ruptures to hollow organ overpressure injuries. All
personnel must be evaluated and monitored for at least 6 hours for injuries. Submersion or confined space environments
significantly increase the incidence of injury. Special caution should be taken when examining these patients.

Signs & Symptoms

HEENT – Careful inspection for TM rupture during examination. Intact TMs do NOT exclude significant blast injury to
other parts of the body. Check for ear discharge, tinnitus, and hearing loss.
Pulmonary – Evaluate for shortness of breath and abnormal breath sounds.
Neurologic – Evaluate for TBI with MACE 2 and neurological exam.
Abdomen – Monitor until 48–72 hours post injury.

Management
1. All asymptomatic patients should be monitored for at least 6 hours after the event to rule out late presenting
complications.
2. TM: Keep ear canal dry/covered (use cotton balls if possible) in case of TM rupture. Refer to ENT for evaluation when
possible.
3. MACE 2 examination needs to be accomplished on all personnel affected by the blast.
4. Pulmonary decompensation: High-flow O2 if available. Use caution with high-pressure ventilation; this may worsen
the patient’s condition. Follow rules for hypovolemic resuscitation given risk for pulmonary edema. Have high suspi-
cion for tension pneumothorax. Be prepared for needle decompression. Consider tube thoracostomy: recurrence or
persistence of respiratory distress after two needle decompressions OR evacuation time > 1 hour OR patient requires
positive pressure ventilation. For air evacuation, fly at the lowest tactically feasible altitude.
5. Abdomen: Any abdominal pain or tenderness within 48–72 hours of a blast exposure should be presumed to be a
bowel perforation and warrants urgent surgical evaluation. Follow Abdominal Pain Protocol for urgent evacuation.
6. Consider possibility of arterial gas embolism (AGE) in patients with focal neurological deficits after pulmonary blast
injury. AGE may require recompression therapy. See Barotrauma Protocol.
7. Spine injury: Patients involved in vehicular blasts or thrown by explosions are at high risk for spinal injury. Maintain
a high index of suspicion for spinal injury, especially in unconscious patients. Manage IAW Spinal Trauma Protocol.

Disposition & Evacuation

1. TM rupture without complications – RTD after 6 hours of observation
2. TM rupture with hearing loss – Routine evacuation
3. Neurologic Injury – Urgent for neurosurgical evaluation
4. Pulmonary complications – Urgent evacuation
5. Abdominal pain – Urgent evacuation
6. AGE or barotrauma – Urgent evacuation
7. Spinal injury – Urgent evacuation to neurosurgical capability

2025 RANGER MEDIC HANDBOOK 43

Eye Injury
Penetrating injuries to eye globe or fracture of the orbit must be assessed with any facial trauma in the combat setting.
In the combat setting, penetrating wounds of the eye may be very common from shrapnel and debris. Blunt trauma that
may disrupt the integrity of the globe may be seen during facial trauma from falls, PLF, FRIES landings, hand-to-hand
combat, or MVA-type collisions. The primary management in any setting includes a rigid eye shield that does not put
SECTION 2

pressure on the globe of the eye. Avoid any manipulation of eye or eye globe if penetrating injury is suspected. Infec-
tion may cause later permanent loss of vision, so early broad-spectrum systemic antibiotic therapy is critical to prevent
post-traumatic endophthalmitis.

TCCC Application
Care Under Fire: Stop life-threatening bleeding.
Tactical Field Care/Tactical Evacuation: If a penetrating eye injury is noted or suspected: Perform a rapid field test of
visual acuity and document findings. Cover the eye with a rigid eye shield (NOT a pressure patch). Give ondansetron
4–8mg IV/IM/ODT/PO to prevent vomiting and the subsequent increase in IOP. Ensure that the 400mg moxifloxacin
tablet in the combat pill pack is taken if possible. If able to take PO: moxifloxacin, 400mg PO once a day. If unable to
take PO: ertapenem, 1g IV/IM once a day.

Extended Care
Retrobulbar Hematoma: Blunt or penetrating periocular trauma may result in orbital bleeding. As the pressure in the
orbital compartment is progressively elevated, the intraocular pressure will also rise. If intraocular pressure rises to a
sufficiently high level (> 21mmHg), either central retinal artery occlusion or damage to the optic nerve may ensue and
vision may be permanently lost in the eye. Signs and symptoms of retrobulbar hemorrhage include pain, periorbital ec-
chymosis, progressive proptosis (bulging forward of the eye), decreased vision, diffuse subconjunctival hemorrhage, and
an afferent papillary defect. Optic nerve ischemia can develop as quickly as 45–90 minutes after onset of hematoma. The
definitive management for this disorder is a lateral canthotomy.

Rapid Field Visual Acuity Test Eye Examination (TRAUMA)

Visual acuity is the vital sign of the Inspect surrounding structures: Inspect the symmetry of the eyes,
eye in your assessment. Vision in eyebrows, and orbital area for any abnormalities.
affected eye should be checked Eyelids: Inspect the patient’s lightly closed eyelids for symmetry,
with unaffected eye closed. A fasciculation, tremors, and presence of eyelashes. While closed, look to
simple quantification is from best ensure eyelids close completely.
to worst:
Pupils: PERRLA, distortion, size
1. Able to read print Iris: Details clear, blood in anterior chamber, evidence of iris tissue in
2. Can count the number of fingers cornea or limbus, laceration or indication of penetrating trauma
held up
Sclera: Obvious lacerations, dark iris or uveal tissue, redness,
3. Can see hand motion
subconjunctival hemorrhage
4. Can see light
Cornea: Obvious defects (laceration or penetration), iris tissue in cornea
Document the finding on
Ocular motion: Inability to move eye
Casualty Card.

Standard Visual Acuity Test

Distant visual acuity is tested using a Snellen chart with patient 20 ft away in a well-lighted area. Test each separately,
with one eye being covered while testing the opposite eye. Allow a few moments for eyes to adjust between tests. If
patient wears corrective vision, record two separate tests: one with and one without correction. Documentation is re-
corded as a fraction in which the numerator indicates the distance from the chart (20), and the denominator indicates the
distance at which the average eye can read the line (i.e., 20/40 indicates the patient is reading at 20 ft what the average
eye can read at 40 ft). Tell patient to read the line most clear to them and then proceed to the next distance level. Record
the distance in which the patient can still accurately read the text.
Near visual acuity is tested using the same principles as distant vision, but with Rosenbaum pocket vision screener. The
patient holds the card approximately 14 inches from the eye and reads the smallest line possible.
Peripheral visual acuity is tested using the confrontation test. Stand facing the patient at eye level and test each eye
separately. While the patient covers one eye, you cover the opposing eye (patient, left; examiner, right). Fully extend your
arm midway between yourself and the patient and then move it centrally with the fingers moving. Have the patient tell
you when the moving fingers are first seen. Compare the patient’s response with your response in the upper, lower, left,
and right spectra. Record as the estimated degrees of vision, with directly ahead being 0 degrees.

44 SECTION 2 PRIMARY TRAUMA PROTOCOLS

Eye Injury Management Protocol

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2025 RANGER MEDIC HANDBOOK 45

Lateral Canthotomy
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46 SECTION 2 PRIMARY TRAUMA PROTOCOLS

Seizures
A seizure is an uncommon event that can be caused by many different ailments and processes. Not all convulsions be-
come an epileptic condition, and most are brief and self-limited. Seizures are characterized by abrupt onset of abnormal
muscle activity or a prodrome of confusion, peculiar behavior, automatisms, or vivid sights/smells.

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Assessment & Management
Assessment: May have sudden onset of loss of consciousness, followed by abnormal motor activity such as tonic
rigidity, clonic rhythmic movements of the limbs, urinary incontinence, frothing at the mouth, and biting the tongue and
mouth; may last seconds to minutes and is usually followed by a period of weakness, somnolence, and confusion (post-
ictal state). Seizures will often spontaneously stop without any intervention after a few minutes. The differential diagnosis
of a convulsive event is extensive: idiopathic epilepsy, alcohol or drug associated seizures, post concussive syndrome,
convulsive syncope, heat stroke, infection (meningitis), brain mass lesions, nerve gas exposure, metabolic abnormalities,
and eclampsia in pregnancy. Wellbutrin, INH, tramadol, and other medications may lower seizure threshold.

Management: Remove the patient from an area where he could injure himself or others. Keep sharp and breakable
objects away from the patient. Pad objects to avoid injury. Do not put anything in the patient’s mouth. Never put your
fingers in the patient’s mouth.

Medications are rarely required to break a first-time seizure. After the seizure, evacuate the patient to an appropriate
treatment facility for a neurological examination and further evaluation. The exam will usually be normal, other than
confusion and somnolence in the immediate postictal period, which may last for hours. After focal motor seizures,
there may be a period of Todd’s paralysis, which is focal weakness of the affected limb. If seizure lasts longer than
5 minutes, then it is considered status epilepticus. These seizures must be stopped ASAP. This is a life-threatening event
and may produce significant brain injury if the patient survives. Emergency medical assistance and intervention must be
rapidly sought. Begin an IV access line. Administer benzodiazepines until the seizure stops or the patient requires airway
management. Midazolam 5mg IV/IO q2–3min/10mg IM q15 min or diazepam 5mg IV/IO q5–10min/10mg IM q15min
for 2 doses. For persistent seizures despite adequate treatment above, confirm no secondary medical cause, continue
benzodiazepines and be prepared to secure airway IAW Airway Management protocol. Evacuate for further imaging and
EEG monitoring if available.

If available, after seizure has stopped, administer a loading dose of levetiracetam 4g IV over 5–15 minutes to prevent
seizure recurrence. If evacuation is delayed > 12 hours after loading dose, administer 1g IV levetiracetam every 12 hours
until patient reaches higher level of care.

Extended Care
Attempt to identify and manage underlying condition prompting the seizure activity. NO DRIVING, WEAPONS HAN-
DLING, OR OTHER DANGEROUS ACTIVITIES UNTIL MEDICALLY CLEARED. Urgent evacuation is not normally
required for a patient with a single seizure that spontaneously resolved. Patients should ultimately be referred for a
nonemergent, ROUTINE neurological consultation.

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Seizure Management Protocol
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48 SECTION 2 PRIMARY TRAUMA PROTOCOLS

Spinal Cord Injury Management
While cervical spine (C-spine) injuries are relatively common in major trauma, they receive less attention in the combat
environment due to the prevalence of penetrating injury mechanisms. With the high incidence of explosive injury in pres-
ent conflicts, providers must pay attention to the indications for and methods of ruling out cervical or spinal injury. IED
blasts and jump injuries have a high risk for lumbar fractures. Physical exam is essential for C-spine clearance, but most

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patients will require some form of imaging.
Spine boards have never been proven to provide any benefit to the patient and often cause harm through prolonged
pressure. Even patients with suspected spinal injuries are best cared for on a rigid litter and not on a spine board. If used,
patients should spend no more than 10 minutes on a spine board as they make transferring/moving patients easier.
Remove the patient as soon as possible from a spine board and place on a padded rigid litter. Do not place a suspected
spine-injured patient on a SKEDCO or other flexible litter.
Likewise, cervical collars are also known to cause harm by interfering with lifesaving interventions and hiding other inju-
ries. Use NEXUS Criteria to aid in C-spine clearance and only place a collar when necessary. Penetrating trauma patients
rarely require cervical collars. If required, perform all lifesaving interventions with an assistant preventing unnecessary
C-spine movement prior to placing a cervical collar.

TCCC Application
Care Under Fire: Manage life-threatening hemorrhage. No specific action. On the battlefield, preservation of the life of
the casualty and Medic is of paramount importance. In these circumstances, evacuation to a more secure area takes
precedence over spine immobilization.
Tactical Field Care: Medics should consider cervical collar placement on all patients who have sustained injuries
through the following mechanisms if the tactical situation allows: major explosive or blast injury; mechanism that pro-
duces a violent impact on the head/neck; mechanism that creates sudden acceleration/deceleration or lateral bending
forces on the neck; fall from height (vs. fall from standing); and ejection or fall from any motorized vehicle. Autopsy data
show patients with penetrating cervical injury in war almost never survive the injury. Therefore, spinal stabilization should
only be performed after all other lifesaving interventions. All providers must be aware that the collar may hide other
injuries, increase the difficulty of airway management, and mask developing pathology such as expanding hematoma.
Patients with isolated penetrating cervical injury who are conscious and have no neurological signs should not have a
cervical collar placed in the prehospital environment. Patients with isolated penetrating brain injury do not require a cer-
vical collar unless the trajectory suggests C-spine involvement. Field expedient cervical immobilization methods include
IV bags, rolled poncho liner, stacked/taped MRE package, rolled up uniform shirt, or snivel gear.
Tactical Evacuation: Evacuate as determined by other significant injury protocols. Evacuate as Urgent patients with
gross neurological deficits. Evacuate as Priority patients without other significant injuries or without neurological deficit.
Consider padding of litter for extended distance evacuations. Ensure hypothermia prevention measures are rendered.

Extended Care
In the event of extended care, there is little that can be done for known spinal injuries. If possible, avoid repeated litter
movements of the casualty. If extended spinal immobilization is expected, then attempt to pad the litter prior to place-
ment of the patient to reduce the risk of development of pressure ulcers. Attempt to pad any areas near bony promi-
nences. Immobilized patients are at risk of aspiration. Be prepared for emergency suction and/or the ability to tip the
immobilized patient if vomiting is imminent. Use prophylactic antiemetics to help reduce risk. High spinal cord injuries
may affect the diaphragm and put the patient at risk for respiratory failure. Be prepared for ventilation procedures. These
patients may also display hypotension (from neurogenic shock) and bradycardia. Fluid challenge within normal guide-
lines. If tachycardia is present, then assume hypovolemic shock and attempt to determine cause.
Patient comfort while immobilized will become a greater concern as time passes. Urination may be controlled by use of
Foley catheterization or tipping the immobilized casualty.

Spinal Injury Assessment

1. Do not administer procedural sedation until after completion of neurovascular check and assessment of GCS.
2. Report & document GCS, paralysis, and any neurological deficit.
3. Concerning MOIs:
a. Any mechanism that produced a violent impact to the head, neck, torso, or pelvis.
b. Incidents producing sudden acceleration, deceleration or lateral bending forces to neck.
4. Distracting injuries are any injury that may potentially impair the patient’s ability to recognize other injuries or neuro-
logical deficit.

2025 RANGER MEDIC HANDBOOK 49

Spinal Cord Injury Management Protocol
SECTION 2

50 SECTION 2 PRIMARY TRAUMA PROTOCOLS

Orthopedic Trauma
Trauma to the extremities is common and can range from simple sprains to massive soft tissue injury and bony destruc-
tion associated with explosive devices. The sensation of a “pop” or “crack” is often misleading and should not be relied
on. The patient’s exam is often the key to diagnosis and initiating proper treatment. Any bleeding, even a small amount,
should indicate an open fracture. Examine joints for dislocation and splint any obvious deformity in two planes.

SECTION 2
TCCC Application
Care Under Fire: Control massive life-threatening hemorrhage.

Tactical Field Care: Initially splint any fractures in position of function or immobilize in current position. Generally, splint-
ing in position of function will reduce overall pain to patient. Use traction on indicated fractures but stop if it is causing
worse pain. By splinting and reducing fractures, attempt to restore any vascular compromise. If possible, clean and irri-
gate any gross contaminated wounds/fractures. If conscious, administer combat wound pill pack. Administer antibiotics:
ertapenem 1g IV/IM qd OR ceftriaxone 2g IV q24hr. Reassess neurovascular status every 5–10 minutes and document
changes. Dislocations with distal pulse may be reduced based on evacuation time and training/experience in procedure.
Consider pain management, local/regional anesthesia, or dissociative agents prior to manipulating dislocations. Splint
and/or sling/swathe as appropriate.

Tactical Evacuation: Reassess splints, interventions, and neurovascular status after any evacuation movements. If
previously unable to provide traction or adequate splinting, apply as appropriate.

Extended Care
Orthopedic injuries often accompany other significant injuries. Prioritize patient management based on severity of
multiple injuries. Vital signs should be monitored regularly to include color, temperature, motor and sensory function.
Conduct repeat motor and sensory exams in conjunction with vital sign checks. IV fluids administered to maintain SBP
of 90–100mmHg or as indicated by other conditions. Focus extended care efforts on extremity perfusion. Splinting in
anatomical position of function will optimize improved blood flow. If tourniquets have been applied, consider tourniquet
conversion if hemorrhage can be controlled through other means.

Consider patient comfort for extended timeframes and re-splint as necessary. Use hematoma blocks, local, or regional
anesthesia for pain control. Consider padding points of contact on splinting devices. Treat IAW Pain Management Pro-
tocol; consideration of effect on other injury patterns. Contaminated wounds should be flushed with normal saline or
clean water. The intent is to remove gross contamination such as dirt and debris.

Monitor for development of compartment syndrome. Be suspicious of compartment syndrome in the following con-
ditions: fractures, crush injuries, vascular injuries, or multiple penetrating injuries (fragmentation). The classic clinical
signs of compartment syndrome: pain out of proportion to injury, pain with passive motion of muscles in the involved
compartment, pallor, paresthesia, and pulselessness are late findings. Be aware that peripheral pulses are present in
90% of patients with compartment syndrome. Monitor closely and be aware of any pain out of proportion. Compart-
ment syndromes make take hours to develop. For patients with suspected compartment syndrome, reevaluate every 30
minutes for 2 hours, then every hour for 12 hours, then every 2 hours for 24 hours, then every 4–6 hours for 48 hours.
Extremity compartment syndromes may occur in the thigh, lower leg/calf, foot, forearm, and hand.

Compartment syndrome management: maintain extremity at level of heart. Do not elevate. Loosen encircling
dressings. Urgent evacuation. Only attempt fasciotomy if evacuation is delayed 6 hours or longer and with online
medical direction. Fasciotomy is not within the independent scope of the Ranger Medic.

2025 RANGER MEDIC HANDBOOK 51

Orthopedic Trauma Management Protocol
SECTION 2

52 SECTION 2 PRIMARY TRAUMA PROTOCOLS

Burn Management
TCCC Application
Care Under Fire: Casualties should be extricated from burning vehicles or buildings and moved to places of relative
safety. Do what is necessary to stop the burning process.
Tactical Field Care: Facial burns, especially those that occur in closed spaces, may be associated with inhalation injury

SECTION 2
and/or carbon monoxide inhalation. Aggressively monitor airway status and oxygen saturation in such patients and
consider early surgical airway for respiratory distress or oxygen desaturation. Estimate total body surface area (TBSA)
burned to the nearest 10% using the rule of nines. Cover the burn area with dry, sterile dressings. For extensive burns
(> 20%), if available, consider placing the casualty in a ready-heat blanket from the Hypothermia Prevention and Man-
agement Kit to both cover the burned areas and prevent hypothermia. Initiate fluid resuscitation (USAISR Rule of Ten):
If burns are greater than 20% of TBSA, fluid resuscitation should be initiated as soon as IV/IO access is established.
Resuscitation should be initiated with crystalloids. Do not use more than 3L of NS due to the risk of causing hyperchlore-
mic metabolic acidosis. Initial IV/IO fluid rate is calculated as %TBSA × 10mL/hr for adults weighing 40–80 kg. For every
10 kg ABOVE 80 kg, increase initial rate by 100mL/hr. If available, a balanced crystalloid like Plasmalyte or Osmolyte
is ideal for burn resuscitation. Lactated Ringer is the preferred crystalloid if Plasmalyte/Osmolyte is not available. Only
use Normal Saline if no other options are available due to resulting hyperchloremic metabolic acidosis. If hemorrhagic
shock is also present, resuscitation for hemorrhagic shock takes precedence over resuscitation for burn shock. Treat
the burn patient IAW the Pain Management Protocol. Prehospital antibiotic therapy is not indicated solely for burns,
but antibiotics should be given as indicated for other traumatic injuries. All TCCC interventions can be performed on or
through burned skin in a burn casualty.
Tactical Evacuation: Initiate any tactical field care interventions not previous performed. Burn patients are particularly
susceptible to hypothermia. Extra emphasis should be placed on barrier heat loss prevention methods and IV fluid
warming in this phase.

Extended Care
Extended care in the prehospital environment will remain focused on prevention of hypothermia, airway, and vital sign
monitoring as well as initiation of fluid resuscitation avoiding bolus fluids if possible. Elevate injured extremities 30–45°.
Documentation of input/out of fluids must be initiated and evacuated with patient to the next higher facility. Fluid re-
suscitation will be in accordance with the USAISR rule of ten. Assess distal circulation of all extremities by palpating
the radial, dorsalis pedis, and posterior tibial arteries. If a pulse is palpable in one or more arteries in each extremity
escharotomy is not indicated.
Inhalation burns should be assumed with any burns to the face and neck and may require aggressive airway manage-
ment. Inhalation injury is further exacerbated by retained soot and chemicals. Not every patient with soot in the airway
will require airway management. Use clinical judgment and assess the patient before taking the airway. Remember,
inhalation injury is mostly a chemical injury that will benefit from removing the chemical. Suction the airway carefully
using the endotracheal suction tubing if available to remove both secretions and soot or chemical materials. Irrigation
of any kind in the field is not warranted and will most likely move materials to unaffected airways or pulmonary tissue.
Burn Guidelines: Do not administer prophylactic antibiotics for burns without other combat wounds. Splint burned
hands and feet in position of function with dressings separating digits. Aggressively manage pain and hypothermia for
critical burn patients. Commercial burn dressings are not required and add little to patient care. In the acute phase do
not be distracted by a burn. DO NOT OVER RESUSCITATE WITH IV FLUIDS. RECORD STRICT I/OS AND MAINTAIN
0.5–1mL/kg/hr UOP.
Escharotomy: The requirement for escharotomy usually presents in the first few hours following injury. If the need for
either procedure has not presented in the first 24 hours, then circulation is likely to remain adequate without surgical
intervention. Escharotomy is normally performed when an extremity has a circumferential full-thickness burn. If the burn
is superficial or not circumferential and pulses are absent, consider inadequate circulation from other causes such as
hypovolemia, hypotension, or occult traumatic injury. If indicated, extend escharotomy incisions the entire length of the
full-thickness burn and carry across the joint when the burn extends across the joint. In the lower extremity, make a
mid-lateral or mid-axial incision with a surgical knife through the dermis to the level of fat. It is not necessary to carry
the incision to the level of fascia. Although full-thickness burn is insensate, the patient will often require intravenous pain
management during this procedure. Perform pain management or sedation as required. On completion of mid-lateral or
mid-medial escharotomy, reassess the pulses. If circulation is restored, bleeding should be controlled and the extremity
dressed and elevated at a 30–45° angle. Assess pulses hourly for at least 12–24 hours. If circulation is not restored, per-
form a second incision on the opposite side of the extremity. For upper extremities, place the hand in the anatomic posi-
tion (palm facing forward) and make an incision in the mid-radial or mid-ulnar line. Ulnar incisions should stay anterior
(volar) of the elbow joint to avoid the ulnar nerve, which is superficial at the level of the elbow. If pulses are not restored,
a second incision may be necessary on the opposite side of the extremity. If both the hand and arm are burned, con-
tinue the incision across the mid-ulnar or mid-radial wrist and onto the mid-ulnar side of the hand or to the base of the
thumb and then the thumb webspace. Following escharotomy, late bleeding may occur as pressure is decompressed
and circulation restored. Examine the surgical site every few minutes for up to 30 minutes for signs of new bleeding.

2025 RANGER MEDIC HANDBOOK 53

Burn Management Protocol
SECTION 2

54 SECTION 2 PRIMARY TRAUMA PROTOCOLS

Pain Management
Basic Pain Management
Severity of pain is subjective and should be based on individuals and injuries and not this protocol alone. Any use of
narcotic medications will be sedating and degrade the mission performance of patients. There is never an indication for
SQ pain medication and if possible, avoid IM injections of narcotic medications due to the potential for delayed absorp-

SECTION 2
tion. Apnea can occur at any dose of opioids and ketamine when pushed too quickly. Slow IV push is mandatory and
completed over 30 seconds to 1 minute. Always closely monitor patients receiving these medications.

TCCC Application
Care Under Fire: No action required.

Tactical Field Care:

1. Able to fight: Administer combat wound pill pack (CWPP) pain management components (meloxicam, 15mg PO once
a day and acetaminophen, 650mg bilayer caplet, PO q8hr) as soon as possible after wounding.

Have a BVM or naloxone readily available whenever administering opiates.

2. Unable to fight but does not otherwise require IV/IO access: oral transmucosal fentanyl citrate (OTFC), 800–1,600mcg
transmucosal (tape lozenge-on-a-stick to casualty’s finger as an added safety measure). Reassess in 15 minutes.
Add second lozenge, in other cheek, as necessary to control severe pain. Monitor for respiratory depression. OR
ketamine 0.5mg/kg IM/IN OR fentanyl 0.5–1mcg/kg IN (using nasal atomizer device). Repeat dose q30min to 1 hour
as necessary to control severe pain.
3. Unable to fight but IV or IO access obtained: ketamine 0.1–0.3mg/kg slow IV/IO push over 1 minute OR hydromor-
phone 0.5–1mg IV/IO OR fentanyl 0.5–1mcg/kg. Reassess in 10 minutes. Repeat dose q30min as necessary to control
severe pain. Monitor for respiratory depression. Continue to monitor for respiratory depression and agitation. Avoid
0.3–0.8mg/kg Ketamine IV/IO dose.

Limit the use of IV pain medication to a single agent when possible, as poly-pharmacy may exponentially ­increase
unintended side effects in a casualty.

Administer ondansetron 4–8mg IV/IO/ODT q8hr as needed for nausea/vomiting.

Tactical Evacuation: No change to tactical field care actions.

TMEP Application
Start in sequential manner to maximize pain control with mission performance.
1. Acetaminophen 1,000mg PO TID.
2. Nonsteroidal anti-inflammatory drugs: meloxicam 15mg PO qd prn OR ibuprofen 800mg PO q8hr prn OR ketorolac
30mg IM (15mg IV) q8hr prn.
3. Narcotic Medications: oral transmucosal fentanyl citrate 800mcg PO over 15 minutes OR hydromorphone 0.5–1mg
IV/IO OR ketamine 0.1–0.3mg/kg IV/IO q30min.
4. Procedural sedation with available medications.
5. Treat per Nausea and Vomiting Protocol.

Considerations
When tactically feasible, adequately treat pain, as insufficient pain control can lead to post-traumatic stress. Pain should
be assessed at its onset and reassessed frequently. Give repeat dose of pain medication when pain severity begins to
increase. Always consider the different classes of pain medications and their side effects before administering. Any pain
medication can cause apnea and the patient’s respiratory status needs monitoring closely.

2025 RANGER MEDIC HANDBOOK 55

Pain Management Protocol
SECTION 2

56 SECTION 2 PRIMARY TRAUMA PROTOCOLS

Procedural Analgesia

SECTION 2

2025 RANGER MEDIC HANDBOOK 57

Regional Anesthesia
Digital Nerve Block
Approach & Indications: The digital nerve block provides anesthesia to clean and repair wounds to any digit or assist with
management of severe pain of the digit. Current literature classifies injectable anesthetics with epinephrine as contraindicated
due to risk of vascular compromise. Follow maximum dosing and pharmacology protocols for the injectable anesthetic utilized.
SECTION 2

Indications: Laceration or other wound cleaning and repair of digit, nail removal or trephination, or pain relief (ensure to docu-
mented detailed neurovascular exam to include intact flexor and extensor tendon exam prior to anesthetizing digit).
Technique: The procedure can be best accomplished using the transthecal (palmar/plantar) technique. Using standard sterile
precautions, place the patient’s hand on the procedure surface palm up. Locate the flexor tendon sheathe just proximal to the
distal palmar crease. Insert the small-gauge needle at 90°, hit bone, slightly withdraw, and inject in standard fashion ensuring
medication is not administered intravenously. During the injection, you can use the nondominant hand to apply pressure just
proximal to the injection site, to direct the flow distally. The procedure can be performed on the digits of the feet as well using
similar landmarks and methodology.

Hematoma Block
Approach & Indications: The hematoma block provides local anesthesia to assist with management of fracture reduction with-
out the need and risks associated with procedural sedation. Subcutaneous injection of anesthetic prior to actual nerve block
will lessen discomfort. Follow maximum dosing and pharmacology protocols for injectable anesthetic utilized. Use standard
PPE precautions.
Indications: long bone fracture requires anesthesia to assist with reduction of fracture prior to splinting. Most commonly used
for metacarpal or forearm fractures.
Technique: The hematoma block injection site is identified through palpation of the deformity and then cleaned in standard
sterile fashion. The needle is then inserted generally perpendicular to the skin into the fracture site. This may be accomplished
blindly through readjustments until the needle “falls” into the fracture with loss of resistance. Confirmation of needle location
within the fracture site can be obtained by drawing back on the syringe plunger and aspirating hematoma. The hematoma can
then be infiltrated with 8–12mL of anesthetic.

Wrist Block
Approach & Indications: The wrist block provides anesthesia to clean and repair large wounds to the hand or assist with man-
agement of severe pain or crush injury during further treatment or transfer to higher level of care. Ensure proper and accurate
documentation of time and medication used to properly inform the receiving facility and providers. Follow the maximum dosing
and pharmacology protocols for the injectable anesthetic utilized. Always use standard sterile precautions and withdraw prior
to injection to ensure anesthetic is not administered intravenously. Review wrist and hand nerve distributions to determine ap-
propriate single or combination of blocks indicated for the patient. Subcutaneous injection of anesthetic prior to actual nerve
block will lessen discomfort. Generally, administer 5mL of anesthetic when performing block.
Indications: Multiple digit/large hand laceration or other wound cleansing and repair of digits, multiple nail removal or trephina-
tion, or pain relief (ensure to documented detailed neurovascular exam to include intact flexor and extensor tendon exam prior
to anesthetizing digit).
Technique: The ulnar nerve block procedure is accomplished by inserting the needle at 90° at the proximal wrist crease and
just ulnar and deep to the flexor carpi ulnaris tendon. Ensure needle is not within the ulnar artery by aspirating without blood
return prior to injection. The median nerve block procedure is accomplished by inserting the needle at 90° at the proximal palmar
crease in between these two tendons. The median nerve runs between the flexor carpi radialis and palmaris longus tendons. A
pop is often felt when through the fascia, or withdraw the needle after hitting bone to verify position. A fan technique of anes-
thetic administration will ensure complete anesthesia. The radial nerve block procedure is accomplished by inserting the needle
at 90° just distal due to the radial styloid in the anatomic snuff box over the radial side of the wrist.

Fascia Iliaca Block

Approach & Indications: This block allows for anesthesia of at least two of the three major nerves that supply the medial,
anterior and lateral thigh with one simple injection, namely the femoral and lateral femoral cutaneous nerves. Ensure proper
and accurate documentation of time and medication used to properly inform the receiving facility and providers. Subcutaneous
injection of anesthetic prior to actual nerve block will lessen discomfort. Do not exceed 400mg of lidocaine with this injection
or 40mL of 1% lidocaine and follow maximum dosing and pharmacology protocols for the injectable anesthetic utilized. Use
standard sterile precautions.
Indications: The fascia iliac nerve block provides anesthesia to assist with management of hip fracture or dislocation reduc-
tion without the need and risks associated with procedural sedation. It is also very useful for regional pain control with femur
fractures.
Technique: Draw a line between the anterior superior iliac spine (ASIS) and pubic tubercle on the side of the planned block. Di-
vide this line into thirds. Using a blunt-tipped needle, insert the needle 1cm distal to the junction of the lateral 1/3 and 2/3 marks.
Verify this is lateral to the femoral artery and expected to be lateral to the femoral nerve that is adjacent to the artery laterally. Two
distinct pops should be felt during needle insertion as it penetrates the two fascia layers. Insert the needle 1–2mm past the sec-
ond pop. Withdraw to ensure the needle is not located intravascularly and slowly inject the anesthetic. The medication should
flow easily, if not, slightly withdraw as the needle is likely within the muscle. Inject 20–30mL of long-acting anesthetic slowly.

58 SECTION 2 PRIMARY TRAUMA PROTOCOLS

Austere Extended Care
Extended Evacuation in Austere Environment
Extended Austere Care: Due to the extreme nature of Special Operations, the Ranger Medic may find himself in a
situation in which prompt evacuation of casualties to a surgical facility is not possible for long periods of time. In these
situations, the Medic is limited to what he is carrying and the contingencies previously considered and planned for.

SECTION 2
Essentially, extended care begins at the point in which you thought you were going to evacuate your casualties.
The Medic should make all possible attempts to make contact with higher medical capability to confirm extended care
measures.

Extended Care Considerations

Principles of Extended Care: Once the Medic has identified that they have transitioned into extended care, a tactical
pause must be taken. Additional factors may become priorities and to remain effective the Medic must have a plan for
treatment. There are several key principles which aid in preparation and execution of extended austere care.
■ Plan appropriately
■ Understand resuscitation goals
■ Proper pain management and understanding potential drug interactions
■ Monitor/trending vitals to include UOP and physical exams
■ Create an effective plan for treatment and identify possible procedures
■ Performing surgical procedures, within scope of practice, in the absence of timely evacuation
■ Prevent any damage done by treatments and provide effective nursing care
■ Utilize telemedicine as early as possible
■ Effective team dynamics and utilize a rest cycle for sustainability
■ Prepare an effective handover

Extended Care Capabilities: Using the Good, Better, Best model and having a strong understanding of both physical
limitations (i.e., equipment) and mental limitations (i.e., knowledge) will aid the Medic in preparing and executing effec-
tive extended care.
■ Monitor vitals
■ Resuscitate
■ Definitive airway control
■ Be able to ventilate/oxygenate
■ Utilize sedation/pain control
■ Perform physical exams
■ Execute nursing care
■ Perform surgical interventions
■ Understand and execute telemedicine
■ Package and prepare for evacuation

Patient Assessment: After completing the initial MARCH assessment and being alerted of extended evacuation times,
the Medic must transition to completing a more comprehensive assessment and focus on additional tasks. MARCH-E
PAWS-B and RAVINES are two potential options.
■ MARCH-Eyes, Pain, Antibiotics, Wounds, Splinting, Burns
■ Resuscitation/Reduce Tourniquets, Airway (Definitive/Sedation), Ventilation/Oxygenation, Initiate Telemedicine,
Nursing Care, Environmental Considerations, and Surgical Procedures

Vital Signs: Vital signs should be assessed frequently, especially after specific therapeutic interventions, and before and
after moving patients. Any change in vital signs should prompt an assessment to determine the cause and appropriate
action should be taken. Documentation of vital signs in extended care will help with gaining a better understanding of
where your casualty is trending.
■ Good: BP cuff, stethoscope, pulse oximeter
■ Better: EtCO2, Foley
■ Best: Monitor for vital signs

Airway Management: Airway assessments should be done at regular intervals to ensure patency and provide suction
as needed. This is of particular importance after performing any patient movement. Remember to assess cuff pressures.
■ Good: Supraglottic airway
■ Better: Definitive airway management
■ Best: Long duration sedation and definitive airway control

2025 RANGER MEDIC HANDBOOK 59

Extended Care Considerations (cont.)
Breathing/Respiratory Management: If ventilation support is required, place patient on SaVE 2 mini-vent or ventilate
with BVM. Consider alternating between SaVE and BVM to conserve battery strength. Continue needle decompressions
as indicated and change chest seals as required to ensure occlusion. Establish thoracostomy as required. If chest tube
established, routinely check, reinforce, and suction as needed.
■ Good: BMV with PEEP
SECTION 2

■ Better: Supplemental oxygen

■ Best: Portable ventilator

Wound Management: Particular emphasis must be placed on several aspects of long-term wound care to achieve ideal
outcomes for wound management in extended care.
■ Physical Examination:

° Inspection of the wound and surrounding tissues for necrosis/infection

° Passive/active range of motion
° Ultrasound
° Labs
■ Irrigation/Debridement

° Clean water from bottles or canteens may be used to washout wounds.

■ Dressing Changes/Reassessments

° Tourniquets and dressings should be checked and reinforced. Convert tourniquets to pressure dressing as soon
as possible.
■ Splinting/Reduction of fractures
■ Telemedicine

Damage Control Resuscitation (DCR): The goal is to maintain a systolic blood pressure of 90–100mmHg and patient
mentation. Continue fluid resuscitation IAW appropriate protocols. A Foley catheter should be placed as soon as pos-
sible. Record I/O and shoot for 30–50mL/hr (0.5–1mg/kg/hr).
Pain Management/Sedation: It is important to have an understanding of your goals with pain management and sedation.
1. Keep the casualty alive. Do not give analgesia or sedation if there are no other priorities.
2. Sustain adequate physiology to maintain perfusion. Avoid medications that cause hypotension/bradypnea for pa-
tients with hemorrhagic shock or respiratory distress.
3. Relieve pain first.
4. Maintain safety. Agitation and anxiety may result in damage to interventions/equip­ment/patient
5. During painful procedures amnesia may be required. Titrate to effect and duration with a limited amount of medica-
tion, the Medic must get the most out of what he/she carries. Start low and go slow, the less blood volume means less
medication to achieve desired effects. Utilize regional anesthesia when able and trained appropriately.
■ Background Pain: the pain that is always present because of an injury or wound. Keep the patient comfortable at
rest and do not impair breathing/circulation/mentation.
■ Breakthrough Pain: acute pain from movement/manipulation. Manage as needed.
■ Procedural Pain: associated with a procedure. Anticipate and medicate appropriately both before, during, and after
the procedure.
Nursing Care: Utilize passive movement of uninjured extremities to prevent DVT or PE (BPT to manage as applicable).
Also, consider position change on the litter and padding of pressure points. Hypothermia management will remain a
constant concern for the traumatized patient. Apply the HITMAN pneumonic when remembering nursing care:
■ Hydration
■ Infection
■ Tubes
■ Medications
■ Analgesia
■ Nutrition

Equipment & Battery Management: Check battery strengths every time equipment is activated. Consider alternating
between manual and mechanical VS check or ventilation for periods of time. Turn on devices only when needed. Keep
devices as clean and protected as possible. Ensure you train with equipment you plan on using in potential extended
care scenarios. Understand how to troubleshoot your equipment.
Documentation: Maintain Consistent and Accurate Documentation. Upon eventual evac­uation, your management
and interventions will be critical to receiving medical facilities. Record vital signs trends and all fluids infused along with
estimations of blood loss and urine output.

60 SECTION 2 PRIMARY TRAUMA PROTOCOLS

Austere Extended Care Protocol

SECTION 2

2025 RANGER MEDIC HANDBOOK 61

Blood Transfusion
WARNINGS
1. Confirmed O low titer is the only universally compatible FWB type. Second choice should be nontitered O. Other-
wise, transfusions of FWB must be an ABO match. All attempts should be made to transfuse blood from pre-identified
ROLO donors. For female casualties, do not delay transfusion for Rh– blood if needed.
SECTION 2

2. Blood and blood components should only be administered by personnel who are trained in the proper procedure and the
identification and management of transfusion reactions.
3. Use only collection bags designed for the collection of whole blood (WB) and administration sets designed for the
administration of blood and blood components. Failure to do so may lead to fatal thromboembolic events.
4. 0.9% normal saline (NS) is the IV fluid of choice for administering with blood or blood components. Lactated Ringer’s
solution can be used if normal saline is unavailable. Colloids (Hextend) or dextrose-based fluids should NOT be used
at any time.
5. Great care should be taken to practice aseptic technique when performing transfusions in the field to prevent sub-
sequent infection.
6. The largest bore IV catheter should be used. An IO device may be used. Ensure that a strong flush is done and good
flow is obtained prior to using an IO infusion.

S/Sx of Reactions
Allergic Reaction S/Sx: Diffuse, itchy rash most common. Anaphylaxis may also occur.
Anaphylactic Reaction S/Sx: Shock, hypotension, angioedema, respiratory distress
Acute Hemolytic Reaction S/Sx:
1. Acute hemolytic reaction usually has onset within 1 hour. 8. Anxiety, feeling of impending doom
2. Evidence of disseminated intravascular coagulopathy 9. Nausea and vomiting
(DIC) – oozing from blood draw, IV sites 10. Hypotension
3. Flushing, especially in the face 11. Pain, inflammation, and/or warmth at the infusion site
4. Fever, an increase in core temp of more than 2°F (1°C) 12. Red or brown urine (hemoglobinuria): The onset of red
5. Shaking, chills (rigor) urine during or shortly after a blood transfusion may
6. Flank pain or the acute onset of pain in the chest (retro­ represent hemoglobinuria (indicating an acute hemo-
sternal), abdomen, and thighs lytic reaction) or hematuria (indicating bleeding in the
7. Wheezing, dyspnea lower urinary tract).
Febrile Nonhemolytic Reactions S/Sx: Fever not as severe with an acute hemolytic reaction; chills; dyspnea
Transfusion-Related Acute Lung Injury (TRALI) S/Sx: Development of ARDS following transfusion. Often presents
with hypoxemia, hypotension, and frothy, pink pulmonary secretions. Avoid female donors to reduce chances of TRALI.

Management of Reactions
The first step in treating ALL transfusion-related issues is to STOP the transfusion and save all of the blood
products and equipment used for administration and typing for follow-up testing.
Febrile Reaction: Diphenhydramine 25–50mg PO, PR, or IV for urticaria.
Anaphylactic Reaction: Treat IAW Anaphylactic Management Protocol.
1. Epinephrine 0.3mL of 1:1,000 IM (first line) or push dose 2. Airway maintenance and oxygenation.
1:100,000 epinephrine to maintain blood pressure. 3. Resuscitate hypotensive patients with IV fluids.
Acute Hemolytic Reaction:
1. Secure and maintain airway. 6. Administer 25–50mg of diphenhydramine IM or IV to
2. Begin IV infusion of crystalloids. treat the associated histamine release from AHTR. Anti­
3. Goal of fluid replacement is to infuse 100–200mL/hr in histamines should not be mixed with blood or blood
order to support a urine output of 1–2mL/kg/hr. products.
4. The patient should receive a foley catheter to monitor 7. SAVE the rest of the donor blood and any typing infor-
urine output. mation available and evacuate with the patient. This
5. Consider using Acetaminophen 1g PO, PR, or IV (q6hr to will allow for ABO and further diagnostic testing at the
treat discomfort associated with fevers. (Avoid the use of medical treatment facility.
aspirin or other NSAIDs).

Febrile Nonhemolytic Reactions: Treat with antipyretics. Acetaminophen 1g PO, PR, or IV (avoid the use of aspirin
and other NSAIDs). If symptoms abate and there is no evidence of an acute hemolytic reaction, consider restarting the
transfusion.
TRALI: Secure and maintain the airway. Administer supplemental oxygen and maintain continuous pulse oximetry moni-
toring. Treatment may require positive pressure ventilation with a high PEEP. Prepare for surgical airway and mechanical
ventilation if severe hypoxia occurs. Use suction to remove secretions.

62 SECTION 2 PRIMARY TRAUMA PROTOCOLS

Fresh Whole Blood Transfusion (Donor Procedure)

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2025 RANGER MEDIC HANDBOOK 63

Fresh Whole Blood Transfusion (Recipient Procedure)
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64 SECTION 2 PRIMARY TRAUMA PROTOCOLS

Foley Catheterization Procedure

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2025 RANGER MEDIC HANDBOOK 65

Crush Syndrome Management
Crush Syndrome Management Considerations
DEFINITION: Massive, prolonged crush injury resulting in profound muscle and soft tissue damage places the patient at
significantly increased risk for developing circulatory and renal complications.
1. The principles of hypotensive resuscitation according to TCCC DO NOT apply in the setting of extremity crush injury
SECTION 2

requiring extrication.
2. In the setting of a crush injury associated with noncompressible (thoracic, abdominal, pelvic) hemorrhage, aggressive
fluid resuscitation may result in increased hemorrhage.
3. With extremity crush injuries, tourniquets should NOT be applied during Phase 1 unless there is hemorrhage that is
not controllable by other means.
4. Be aware of development of cardiac dysrhythmias due to hyperkalemia immediately following extrication.
5. BE AWARE OF DEVELOPMENT OF CRUSH SYNDROME STARTING AS EARLY AS 4 HOURS POST INJURY.
THESE MEDICATIONS ARE NOT PART OF THE STANDARD AID BAG AND REQUIRE DEVELOPMENT OF A SEPA-
RATE CRUSH INJURY KIT.

Phase 1: Immediate Management (while attempting to extricate)

The following management measures are to be initiated if time from initial crush to extrication exceeds 4 hours, while still
trying to extricate the patient, and complete prior to extrication when crush has been > 4 hours:
1. Maintain patent airway and adequate ventilation.
2. Monitor O2 sat with pulse oximetry and administer high-flow oxygen if indicated.
3. Give initial bolus of 1–2L of crystalloid solution PRIOR to attempts at extrication and continue at 1.5L/hr. In a patient
making urine, physiologic isotonic fluids (plasmalyte or Ringer's lactate) are the fluid of choice to prevent worsening
acidosis and worsen hyperkalemia.
4. Maintain urine output at greater than or equal to 1–2mL/kg/hr and monitor urine output volume. Place a foley when-
ever possible to monitor for accurate urine output.
5. Assess and reassess mental status.
6. Follow Pain Management Protocol
7. Treat with prophylactic antibiotics: ertapenem 1g IV if time and tactical situation allow.
Utilize cardiac monitoring if available to monitor for signs of hyperkalemia. Treat suspected emergent hyperkalemia
accordingly. Cardiac arrest should be treated per standard ACLS protocol with addressing early hyperkalemia as likely
cause with calcium, sodium bicarbonate, insulin with glucose (if available), and albuterol treatments.

Phase 2: Immediately Prior To Extrication

The following management measures are to be attempted immediately after extricating the patient:
1. Cardiac dysrhythmias or arrest are likely immediately following extrication.
2. CPR should be initiated if cardiac arrest develops following extrication IAW ACLS Protocol. DO NOT follow the TCCC
guidelines on cardiac arrest.
3. If extrication is > 4 hours OR in the presence of dysrhythmias, administer 1 amp of calcium chloride or 3 amps of
calcium gluconate slow IV push. Calcium should not be given in bicarbonate-containing solutions due to precipitation
of calcium carbonate.
4. If arrhythmia occurs, calcium should be given repeatedly until arrhythmia resolves. Once arrhythmia has resolved, the
patient should be treated with high dose albuterol, sodium bicarbonate, and insulin with glucose to shift potassium
intracellularly.
5. TQ use in the Crush protocol is based on situation and time: TQ’s should be placed on crushed limbs for extended
crush times combined with the lack of drugs to perform proper ACLS.
Following extrication, once the patient is stabilized, be prepared to treat recurrent dysrhythmias or hyperkalemia. Moni-
tor urine color for myoglobin. Darker urine (red, brown, or black), either consistently or worsening over time, is associ-
ated with increasing myoglobinuria and increased risk of kidney damage. Consider increasing IV fluids to goals at or
above urine output goals of 100–200mL/hr. The fluid rate should be adjusted to maintain this level of UOP. Monitor for
compartment syndrome of the crushed extremity with evidence of pain out of proportion, paresthesia, pallor, paresis,
pulselessness, and poikilothermia.

Phase 3: Evacuate
Urgent: Evacuate to a surgical facility. If compartment syndrome develops, likelihood of loss of limb increases with time
to fasciotomy by a trained medical provider.

66 SECTION 2 PRIMARY TRAUMA PROTOCOLS

Crush Protocol

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2025 RANGER MEDIC HANDBOOK 67

Evacuation
SOF Aircraft Capacities
MH-60 – 2 × litter, 1 × ambulatory (optimal) OR 2 × litter only with auxiliary fuel tank OR
3 × litter (minimal en route treatment) OR 1 × litter and 2–3 × ambulatory.
MH-47 – 8 × litter (floor-loaded)
SECTION 2

MH-6 – 1 × litter (floor-loaded) for emergency contingency only. Never plan an MH6 as a primary CASEVAC platform.
HH-60 – With carousel – 4 × litter; without carousel – 2 × litter, 1 × ambulatory
CV-22 – 5 × litter (floor-loaded)

General Principles of Rescue

During all rescue operations, tactical security and prevention of additional injuries (patients and rescuers) must be under
constant consideration by all participants. The principles or phases of tactical rescue include security of area/force;
assessment of rescue situation; gaining access; rendering emergency care; disentanglement/extrication; removal; stabi-
lization medical care; and evacuation. Contingency planning, training, and rehearsals should always be a consideration.
Consider anchoring of rolled vehicle to prevent shifting of weight. If possible, CCP should be established upwind from
the site. Timing of evacuation requests must be synchronized to expected timeframes of extracting and packaging of
casualties. Keep C2 informed.

Downed Aircraft Casualty Extraction Considerations

A downed aircraft can occur during any phase of tactical operation, having a dramatic effect on the operation, and
should always be an assumed contingency. The immediate concern is securing the site and suppression of enemy ac-
tions. Rescuers should identify themselves as friendly when approaching a downed aircraft. Immediate casualty care
is focused on coinciding extraction from burning aircraft and treatment of life-threatening injuries. Casualty collection
points must be at a minimum safe distance from potential ammunition cook-off. CCP should be established upwind from
site, if possible, as burning aircraft materials can be toxic. Buddy-team search parties conduct methodical searches
around crash site for thrown victims. If possible, anchor the aircraft to the ground to prevent shifting or rolling. CSAR
link-up and assumption of C2 should be rehearsed as contingency for all aircraft operations. N-95 masks should be
included in CSAR kits to protect rescuers.

Vehicular Casualty Extraction Considerations

Vehicle rollovers, IED events, and driving accidents can occur during any phase of a tactical operation. Scene security
and C2 must be established as soon as possible with the understanding that a combat engagement may continue dur-
ing rescue attempts. Suppression of enemy fire remains the primary mission at all times. Ensure the safety of rescuers
and casualties. Assess the scene situation to determine the need for additional assets. Recognize the kinematics that
produced injuries and consider the treatments/equipment required to manage casualties. Identify and manage life-
threatening conditions and defer non-life threats to later stage. Consider CS stabilization as applicable if kinematics or
MOI indicate potential spine injuries. Consider threats to rescuers and casualties to include fire in vehicle, leaking fuels/
products, ammunition cook-off, and other environmental conditions. Manage injuries IAW tactical trauma protocols with
deference to use of conventional/civilian techniques when indicated.

Confined Space/Building Collapse Extraction Considerations

Confined space rescues in the tactical setting include casualties who have fallen into wells, storage tanks, drainage
systems or trenches. Aside from the injuries incurred on initial trauma, closed spaces may contain low amounts of oxy-
gen or potentially hazardous gases or materials. Key information requirements are number of casualties and potential
hazards to patients and rescuers.

Building collapse rescue is complex, usually involves large numbers of personnel and specialized equipment, requires
knowledge of building design and will likely take an extended period of time. Security of the site is paramount. Key
information requirements are the last known positions of personnel prior to the collapse. The organization of small
search teams covering sectors is critical. Aside from trauma injuries involved with the collapse, rapid cardiovascular
compromise is the greatest life threat as victims are extracted. Sudden cardiac arrest may occur from acidosis and
hyperkalemia. Refer to the Crush Syndrome Management Protocol.

Constant awareness of the security situation, flammable materials, and additional hazards are paramount during rescue
operations.

68 SECTION 2 PRIMARY TRAUMA PROTOCOLS

Evacuation Protocol

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2025 RANGER MEDIC HANDBOOK 69

NATO MEDEVAC Request
MEDEVAC REQUEST 9-LINE
LINE 1: Location of Unit HLZ GRID (MGRS):
LINE 2: CALLSIGN AND FREQUENCY AT THE PZ CALLSIGN:
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FREQUENCY:
LINE 3: NUMBER AND PRECEDENCE OF A: Number of Urgent Casualties
CASUALTIES B: Number of Urgent-Surgical Casualties
C: Number of Priority Casualties
D: Number of Routine Casualties
E: Number of Convenience Casualties
LINE 4: SPECIAL EQUIPMENT REQUIRED A: None
B: Hoist
C: Extraction
D: Ventilator
E: Other (specify)
LINE 5: NUMBER OF CASUALTIES BY TYPE L: Number of Litter Casualties
A: Number of Ambulatory Casualties
E: Number of Escorts
LINE 6: SECURITY AT PZ N: No enemy
P: Possible enemy
E: Enemy in area
X: Armed escort required
LINE 7: PZ MARKING A: Panels
B: Pyrotechnics
C: Smoke (designate color)
D: None
E: Other (specify)
LINE 8: CASUALTIES BY NATIONALITY/STATUS A: US/Coalition Military
B: US/Coalition Civilian
C: Non-Coalition
D: Non-Coalition Civilian
E: Opposing Forces/Detainee
F: Child
LINE 9: DESCRIPTION OF TERRAIN N: Nuclear
(In peacetime, description of terrain) B: Biological
C: Chemical
In peacetime: Brief description of significant
obstacles on approach/departure headings and type of
predominant terrain for the HLZ
NOTE: Lines 1–5 required to initiate MEDEVAC spin up

MIST REPORT SIT REPORT

M – MECHANISM OF Mechanism of Injury and time (used when communicating with
INJURY AND TIME OF of injury (if known) PSG/1SG or patient handoff to MEDEVAC)
INJURY (IF KNOWN)
S STABLE/UNSTABLE
I – INJURY OR ILLNESS Injury OR Illness
I NOTABLE INJURIES
S – SYMPTOMS AND A – Airway status
T TREATMENTS RENDERED
VITAL SIGNS B – Breathing rate
(Emphasis on medications, fluids, or
C – Pulse rate
procedures that cannot be seen by
D – Conscious/Unconscious
subsequent Medics/providers)
E – Other signs
D DRUGS ADMINISTERED
T – TREATMENT GIVEN Such as Tourniquet/Time
Applied Drugs administered

70 SECTION 2 PRIMARY TRAUMA PROTOCOLS

Evacuation Patient Packaging

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2025 RANGER MEDIC HANDBOOK 71

Evacuation Patient Handover
SECTION 2

72 SECTION 2 PRIMARY TRAUMA PROTOCOLS

Skedco Horizontal Hoist Procedure

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2025 RANGER MEDIC HANDBOOK 73

Skedco Vertical Hoist Procedure
SECTION 2

74 SECTION 2 PRIMARY TRAUMA PROTOCOLS

CBRN
The goals of CBRN trauma medicine are to limit and minimize exposure/contamination, treat the immediate life threats,
and administer appropriate antidotes or countermeasures. Assessment and treatment of CBRN casualties follow the
modified MARCH algorithm (MARCH)2. Combat the mentality of a CBRN patient dipped in agent as a “candied apple.”
Instead, think of these patients as stepping in a mud puddle.

SECTION 2
Massive hemorrhage, Mask check – control life-threatening bleeding.
Airway, Administer Antidotes (ATNAA, CANA) – establish and maintain a patent airway.
Respiration, Rapid Spot Decontamination (RSDL) – decompress suspected tension pneumothorax, seal sucking chest
wounds, and support ventilation/oxygenation as required.
Circulation, Administer Countermeasures – establish IV/IO access and administer blood products as required to treat
shock.
Head injury/Hypothermia – prevent/treat hypotension and hypoxia to prevent worsening of traumatic brain injury and
prevent/treat hypothermia.

Use CRESS to quickly determine the agent of concern, conduct triage and recognize symptoms.
C – Consciousness (unconscious, convulsing, altered)
R – Respirations (present, labored, absent)
E – Eyes (pupil size, PERRLA)
S – Secretions (absent, normal, increased)
S – Skin (diaphoretic, cyanotic, dry, hot)

CBRN casualties present unique challenges and the Medic must constantly ask what is killing the casualty now. These
patients can suffer from trauma, poisoning, or both trauma and poisoning. Always treat the most immediate life threat.

TCCC Application
Hot Zone: Depending on the agent, consider any area with agent to be the same as receiving effective fire. Always wear
multiple sets of nitrile gloves when operating in a CBRN environment. Treatments in this zone are limited to (MAR)2.
Prevention of additional casualties, Medic safety, and removing the patient from the area are the highest priorities.
Check and find massive hemorrhage. Only expose on the casualty what is needed to save a life. Use the DRY-WET-DRY
technique and RSDL for decontamination.

Warm Zone: These treatments begin when moved to the dirty CCP, are in conjunction with decontamination, and con-
sist of (CHE)2. All hot zone treatments should be reassessed and possibly replaced with clean ones. Use the command
“Expose to treat” in order to quickly communicate to any assistants the immediate need to decontaminate the head/
face and chest to facilitate mask removal and sternal IO placement. This allows ventilatory support and rapid dosing of
countermeasures. Removing contamination by any means available may mean the difference between life and death, as
this limits continued dosing. DO NOT perform any unnecessary procedures in the warm zone. Only address immediate
threats to life that cannot wait for decontamination to be completed. The warm zone is for DECON, not medical care.

Trauma Assessment Principles

Hot Zone: Tourniquets placed over a CBRN suit are prone to fail. Check the casualty’s mask an ensure it is in place.
Assess the patient’s airway and determine if it makes sense to unmask the casualty to provide and airway in a contami-
nated environment. If the Medic is breathing filtered air the casualty should be too. Use a Resuscitator Device Individual
Chemical (RDIC) as needed. Administer Antidotes based on the presumed agent. Use ATNAA/CANA for nerve agent and
CyanoKit for cyanide once removed from the exposure. Assess respiratory changes and determine if they are due to an
agent or trauma. Rapid spot decontamination for any visible agent, around breaches in the suit, and any exposed skin.
Use the DRY-WET-DRY technique and RSDL or soap and water for decontamination.

Warm Zone: Administer countermeasures if required – IV/IO drips, suction, and ventilatory support. Respiratory difficulty
due to poisoning should be treated with ventilatory support if required. Treatment with nebulized albuterol, solumedrol
125mg IV, and/or racemic epinephrine should wait until the cold zone. Assess circulation and provide resuscitation if
required. Nerve agent poisonings may require atropine drips for treatment. Preventing hypothermia is critical and decon-
tamination should occur quickly as the patients will be exposed and wet. Manage head wounds as required.

2025 RANGER MEDIC HANDBOOK 75

SECTION 2

76
Schematic – DIRTY CCP

DEAD STABLE UNSTABLE

EXPECTANT
Ammo/Explosives
Dirty Ground Mat Weapons/Commo
Aid Bag/Airway Box
Kit
Hot Line

Clean Ground Mat Shuffle Pit (Wet or Dry)

2 × Cut out Bags with:

1 × Litter with HPMK
2 × Applicator Mitt
Ambulatory Side
Litter Side 2 × Hook Knife
2 × Trauma Shear
Aid Bag
2 × Sorbent (Dry)
Treatment Kits

SECTION 2 PRIMARY TRAUMA PROTOCOLS

2 × Sprayers (Wet)
1 × Decontaminant
1 × Rinse

5 × 6 mil bags

MCM
CHEM Tape
Decon Mat
Detector

Contamination
Control Line

Notes:
• Triage flows from left to right in the hot zone Aid Bag
• Casualty flow moves from top to bottom in Treatment Kits
this diagram
• Medical Personnel, at least one designated clean MASCAL Box
and one designated dirty
TICS/TIMS
Toxic Inhalation/Eye Exposure Box
This kit is meant to be carried as an adjunct in aid bag as mission dictates the threat to personnel. The surplus
of drugs is meant to provide continuous care and re-dosing as symptoms persist. Be mindful that nebulizers do
not work if they are not kept upright. Collapsible and bendable airway tubes may be needed to provide nebulizer

SECTION 2
treatment to a casualty that is prone. If you use the Omron Nebulizer, read the directions for use and maintenance
before you pack it in your aid bag.
■ 1ea Pelican 1150 Case ■ Eye treatment not in case, carried in Aid Bag:
1ea Toxic Inhalation SOP Quick Ref Card 1ea 1,000mL bag of NS or
1ea Omron Micro Air Nebulizer w/batteries Lactated Ringer’s
1ea Extension Tubing 2ea Morgan Lens
1pkg (5 vials) 5mL 4% Lidocaine HCl 1ea Morgan Lens Admin Set
40mg/mL
1ea 8.4% Sodium Bicarbonate 50mEq/mL – Dilute ■ Carried on Vehicle
1:1 with Normal Saline for use 2ea D Cylinders of O2
15ea bullets 2.5mg Albuterol in 3mL 5ea NRB Masks
4ea vials Dexamethasone IV 20mg/5mL 5ea Nebulizer Masks
5ea 3mL NS Pre-Filled Syringes
3ea 18g Hard Needles ■ Supplemental items:
2ea Neomycin or Gentamicin Ophthalmic Oint. 1ea Peak Flow Meter
2ea Tetracaine Ophthalmic 1ea Capno Check

Toxic Industrial Chemicals/Materials

Inhalation Injury Treatment SOP
Administration via Nebulizer (in order)

1. 1 Albuterol bullet, 2.5mg in 3mL, by nebulizer

2. 1mL 4% lidocaine w/1mL normal saline or 2mL
2% lidocaine w/o NS by nebulizer (for cough/pain
suppression)
3. Administration via IV/IO:
• Dexamethasone: 8mg q6hr (Preferred) Or
• 125mg Solumedrol IV/IM q6hr

If no resolution of symptoms (efficacy is unproven by

research) attempt
• 1mL 8.4% Sodium Bicarbonate w/1mL normal
saline by nebulizer. Do not use undiluted 8.4%
Sodium Bicarbonate
– for acidic inhalation
– do not mix with other drugs

TIC/TIMS
Eye Injury Treatment SOP
1. Tetracaine eye drops for pain
2. 20 min NaCl flush with Morgan Lens
3. Neomycin eye drops prevent eyelids sticking shut
4. Allow eyes to drain. Avoid tight bandaging.

2025 RANGER MEDIC HANDBOOK 77

Chemical Casualty Triage Table
AGENT URGENT PRIORITY ROUTINE EXPECTANT
NERVE Symptoms in two or Recovering Walking and Loss of vital signs
more organ systems, from moderate/ talking after vapor
i.e., respiratory, GI, severe exposure, exposure, consider
SECTION 2

skeletal (seizure asymptomatic liquid miosis or residual

activity) (NOT exposure effects on RTD
including miosis or
rhinorrhea) OR serious
CNS involvement,
unconscious, seizing,
or apneic
VESICANT Acute airway problems Liquid burn greater Liquid burn LESS Severe pulmonary
(coughing, hoarseness, than 1% of BSA than 1% BSA (no edema or clinical
secretions), agent in or critical areas,* critical areas*) signs of respiratory
wounds eye involvement, compromise within
pulmonary 4 hours after
symptoms with exposure
an onset greater
than 4 hours after
exposure
PULMONARY Acute airway problems Onset of symptoms 8 hours since Laryngeal
(coughing, hoarseness, greater than 4 hours exposure with no obstructions or
secretions, wheezing) after exposure signs bronchospasms
and/or severe
pulmonary edema
within 4 hours of
exposure
CYANIDE Serious Recovering from Walking and Coexposure with
cardiopulmonary mild exposure or talking after vapor other toxicants
symptoms (bradypnea post-treatment exposure (pulmonary edema,
or hypotensive), serious miosis, vesicant
CNS involvement, exposure area
unconscious, seizing, of 1% or more),
or apneic signs of anoxic
encephalopathy
NOTE: Triage category will increase for trauma + poisoning.
*critical areas = face, eyes, hands, groin

78 SECTION 2 PRIMARY TRAUMA PROTOCOLS

CBRN – Nerve Agents
Nerve agents are considered the primary agents of threat to the US military because of their high toxicity and effective-
ness through multiple routes of entry. They are absorbed through the eyes, respiratory tract, and skin. Nerve agents are
generally referred to a group of chemicals known as organophosphates. These compounds inhibit acetylcholinesterase
(AChE) thus having acetylcholine (ACh) accumulating in the body causing multiple organ overstimulation. This produces

SECTION 2
a cholinergic crisis from the excessive amounts of ACH: Muscarinic effects of smooth muscle contraction in airways,
GI tract, pupils (miosis); glandular effects from eyes, nose, mouth, sweat, airways and GI tract; effect on vagus nerve
causing bradycardia; nicotinic effects of skeletal muscles with fasciculations seizures, fatigue, and flaccid paralysis (late
sign); preganglionic effects of tachycardia, hypertension.

LD50 or LCT50: The amount of solid, liquid, or vapor sufficient to kill the average person.

Persistent, last longer than 24 hours; nonpersistent, gone in 24 hours or less

Tabun (GA), Sarin (GB), Soman (GD), G, and VX

S/Sx: Mild to moderate vapor exposure S/Sx: CNS-slowness in thinking and decision making. HEENT-miosis, blurred
or dim vision, rhinorrhea, salivation. Respiratory-SOB, chest tightness.

Large vapor exposure S/Sx: CNS-LOC, seizures, flaccid paralysis. Respiratory-apnea GI-involuntary NVD, abdominal
pain.

Liquid on skin exposure: Small-local effects such as sweating and fasciculations. Medium-systemic effects, potential
miosis. Large – CNS and respiratory effects such as respiratory failure, LOC, seizures, apnea, flaccid paralysis, miosis

MANAGEMENT: 1 × ATNAA for any patient with miosis. Mild-1 × ATNAA (self-aid) or 3 × ­ATNAA (buddy-aid). Moderate/
Severe-3 × ATNAA plus 1 × CANA injector even if seizure activity is not evident. Atropine 6mg IM or 8mg IV/IO should
be repeated q 3–5 mins until the drying of secretions is noted. One additional dose of 2 PAM CL should be given 1 hour
after the initial 3 doses if patient is still symptomatic.

Severe nerve agent casualties may need more than 2–3 CANA auto injectors to relieve seizure activity.

DISPOSITION: Refer to chemical casualty triage table

SPECIAL CONSIDERATIONS: Heart rate should not be a distinguishing sign due to its ability to be normal, tachycardia,
or bradycardia. Once removed from exposure vapor nerve agent effects do not worsen.

Packaging: The Antidote Treatment Nerve Agent Auto injector (ATNAA) (NSN: 6505-01-362-7427) is an auto injector
with 2mg of atropine and 600mg of 2PAM CL combined.

The Convulsant Antidote for Nerve Agents (CANA) (NSN: 6505-01-274-0951) contains 10mg of diazepam.

2025 RANGER MEDIC HANDBOOK 79

CBRN – Vesicant Agents
Blister or vesicant agents are second only to nerve agents as a concern to the US Military. These are a concern as there
are large stockpiles of them; they are easily manufactured; and they are both incapacitating and lethal. The severity of
vesicant agents will, in part, be affected by the environmental conditions at the time of exposure. Warm, humid condi-
tions increase the severity of blister agents damage and shorten the time of symptom onset. Cold weather may slow the
SECTION 2

onset and lessen blister severity. M8 Chemical Detection paper will turn red in the presence of liquid mustard. Precursors
and impure agents are also hazardous and are easily manufactured.

Mustards-Sulfur, Mustard (H) or (HD) and Nitrogen Mustard (HN1, HN2, HN3)
S/Sx: Skin: erythema, small vesicles, bullae, direct coagulation necrosis, and skin sloughing with high dose. Eyes: con-
junctivitis with epithelial necrosis, subcorneal edema, and sloughing. Airway: hoarseness, cough, throat, nasal irritation.
Severe patients can have laryngospasms.

MANAGEMENT: Immediate decontamination by any means available (contact time should be less than 2 minutes) and
symptomatic management.

DISPOSITION: Refer to chemical casualty triage table.

SPECIAL CONSIDERATIONS: Sulfur mustard is a very potent, persistent agent that produces relatively few deaths but
will require a lengthy convalescence of personnel affected. Liquid mustard maybe seen as amber (HD) or dark brown (H)
oily liquid that has an odor comparable to onions or garlic. Liquid mustard absorption can be enhanced by thin epithelial
barriers, heat, moisture, and oils on the skin. The fluid in mustard blisters does not contain mustard. The LD50 of mustard
liquid is equivalent to 3–7g (about 1 teaspoon). H1-3 will have shorter latent periods and more severe systemic effects.

Arsenicals-Lewisite (L), MD, ED, PD

S/Sx: Similar to HD with the distinct differences being pain within seconds to minutes after contact, “Lewisite shock” will
have capillary leakage, pulmonary edema (ARDS), hypotension, circulatory failure.

MANAGEMENT: Immediate decontamination by any means available and symptomatic management. British Anti-­
Lewisite 3mg/kg IM × 1 for exposure with immediate pain.

DISPOSITION: Refer to chemical casualty triage table.

Oxime-Phosgene (CX)
S/Sx: urticaria with immediate pain. Produces skin lesions similar to acid burns. Blanching or erythematous ringing of
contact site and wheal formation.

MANAGEMENT: Immediate decontamination by any means available and symptomatic management.

DISPOSITION: Refer to chemical casualty triage table.

CBRN – Cyanide Agents

Hydrogen Cyanide (AC), Cyanogen Chloride (CK)
S/Sx: Rapid symptom onset, seizures, respiratory arrest, incontinence, normal pupils or mydriasis.

MANAGEMENT: Remove from exposure area, restore ventilation, and if symptomatic give 1 Cyano­Kit. May be redosed
every 5 minutes for persistent symptoms. If not available, use sodium nitrite 300mg of 3% solution IV over 5–20 minutes.

DISPOSITION: Refer to chemical casualty triage table.

SPECIAL CONSIDERATIONS: Cyanide is classified as a blood agent which can affect all systems in the body. Decon-
tamination is usually not required due to the patients “off-gassing.” Cyanide can affect people by inhalation, ingestion,
or percutaneous routes. Hydrogen cyanide (AC) can smell like bitter almonds or peach pits, but most people cannot
detect the odor. Cyanogen chloride can be a pungent, biting odor, which can irritate the eyes, nose, and respiratory tract.
The onset of symptoms from cyanide is within seconds of exposure. The differences between nerve agent symptoms
and cyanide symptoms are the lack of secretions and normal pupils or mydriasis, whereas nerve agent poisonings have
copious secretions and meiosis. Any nitrate given within minutes, with mechanical ventilation, can be very effective in
improving patient health.

80 SECTION 2 PRIMARY TRAUMA PROTOCOLS

CBRN – Pulmonary Agents
Lung-damaging agents are not commonly mentioned as major chemical threats. However, troops may be exposed to
these threats through enemy actions or mitigating side effects such as explosions/fires involving vehicles or manufactur-
ing areas, industrial hazards or accidents, or various burning materials.

The 4-hour rule states that if a patient shows breathing difficulty within 4 hours of exposure, prognosis is poor, versus

SECTION 2
patients who do not become symptomatic until after 4 hours.

24 hours is the minimum time for observation and no physical exertion after an exposure to a pulmonary agent.

Agents that are liquids at room tend to give off vapors that can become trapped in clothing. Thus, the agent then begins
to “off-gas,” which could affect personnel without respiratory protection. Therefore, decontaminating a patient with
exposure to one of these agents is still needed. Always wear multiple pairs of nitrile gloves when conducting decontami-
nation. DECON with either RSDL or soap and water. Use the DRY-WET-DRY technique for DECON.

Irrigate the patient’s eyes to a pH 7.0 and provide tetracaine for pain relief.

Treat respiratory symptoms with nebulized albuterol 3mL 0.083% and solumedrol 125mg IV × 1. Consider nebulized
racemic epinephrine for no respiratory improvement. Aggressive airway and respiratory support with PPV and suction-
ing may be required.

Ammonia (NH3)
S/Sx: Mild exposure: eye complaints, hoarseness, strider, cough, SOB, chest pain, wheezing; moderate-severe expo-
sure: hypoxia, chemical pneumonia, hemorrhage

MANAGEMENT: Remove from exposure, decontaminate, and consider advanced airway protocol

DISPOSITION: Refer to chemical casualty triage table

Sulfur Mustard (HD)

S/Sx: Mild exposure: eye complaints, hoarseness, strider, cough, SOB, chest pain, wheezing; moderate-severe expo-
sure: hypoxia, chemical pneumonia, hemorrhage

MANAGEMENT: British anti-Lewisite 3mg/kg IM × 1 for vesicant exposure and immediate pain. Respiratory treatments.

DISPOSITION: Refer to chemical casualty triage table

Chlorine
S/Sx: Mild-suffocation, choking sensation, ocular and/or nasal irritation, chest tightness, cough, exertional dyspnea;
moderate: aforementioned S/Sx plus hoarseness, stridor, pulmonary edema within 2–4 hours; severe: dyspnea at rest,
can cause pulmonary edema in 30–60 seconds, copious airway secretions, sudden death may occur with laryngospasms

MANAGEMENT: Remove from exposure, decontaminate, and respiratory treatments.

DISPOSITION: Refer to chemical casualty triage table.

Peripheral Acting Agents

(Phosgene or CG, Perfluoroisobutylene or PFIB, HC Smoke, Nitrogen Oxides)
S/Sx: Mild: cough, SOB, chest tightness; moderate: ocular irritation and aforementioned; severe: dyspnea at rest, on-
set of pulmonary edema in 30 seconds to 4 hours, copious upper airway secretions, sudden death may occur with
laryngospasms

MANAGEMENT: Remove from exposure, decontaminate, respiratory/airway treatments.

DISPOSITION: Refer to chemical casualty triage table.

SPECIAL CONSIDERATIONS: Phosgene can be found in foam plastics, herbicides, pesticides, and dyes. It can be pres-
ent in the burning objects like plastics, degreasers, and paint strippers. PFIB can be found in “Teflon” or burning military
vehicles. Nitrogen oxides can be found in arc welding areas specifically with enclosed areas and diesel engine exhaust.

2025 RANGER MEDIC HANDBOOK 81

CBRN
MARCH SIGNS AND SYMPTOMS OF NERVE AGENTS
M – Massive hemorrhage/Mask check: always treat MUSCARINIC NICOTINIC
these situations as CUF. Apply TQs, patient’s mask, • Diarrhea • Mydriasis
and move from danger area. • Urination • Tachycardia
SECTION 2

A – Airway/Antidote: always ensure early and • Miosis • Weakness

proper airway management with quick antidote • Bronchorrhea/ • Hypertension
administration Bronchospasms • Fasciculations
R – Respirations/Rapid DECON: positive pressure • Bradycardia
ventilations and rapid spot DECON • Emesis
C – Circulation/Counter measures: start IV/IO drips • Lacrimation
if needed • Salivation/Secretions/
H – Hypothermia/Head injury Sweating

PPE AND DECON CONSIDERATIONS

• Use of mask always required.
• Wearing a minimum of two (2) pairs of nitrile exam gloves will provide needed protection IOT put hands on
patient – as always ensure that you protect yourself first.
• Ensure patient is masked or has protected airway to prevent inhalation injuries
• When removing clothing and equipment ensure they are bagged and disposed of properly
• DECON with RSDL, to include wounds and eyes if needed, soap and water also works well with most CBRN
agents and precursors. DRY-WET-DRY for DECON.
• Place bleach in suction reservoir (if able) to ensure that body fluids are DECONed as well

NERVE AGENTS (G and V SERIES AGENTS)

MARCH PPE AND DECON CONSIDERATIONS
M – Massive hemorrhage/Mask check: ensure the • WEAR MASK.
patient has good mask seal • CBRN gloves needed IOT put hands on patient.
A – Airway/Antidote: ATNAA and CANAA • Ensure patient is masked or has protected airway to
R – Respirations/Rapid DECON: positive pressure prevent inhalation injuries
ventilations and rapid DECON with physical removal • DECON with RSDL, to include wounds and eyes if
of clothing and any liquids on skin needed. Soap and water also work well.
C – Circulation/Counter measures: atropine and
2-Pam drips
H – Hypothermia/Head injury

IMMEDIATE CONSIDERATIONS PFC CONSIDERATIONS

• Miosis is a highly variable sign of contamination • Atropine drip = Draw air from 250mL bag of saline
and does not dictate treatment and inject 50mL of 20/8 atropine. Mark bag with
• Suction will be needed for excess secretions “Atropine 300mL/20mg”. Set drip rate to 300mL/hr
• Patients with mild S/Sx should receive (or 1gtt/sec with 15gtt set line). Once atropinization
1 × ATNAA (self-aid) and 2 × ATNAA (buddy-aid) has been achieved reduce to 10–20% of original
• Patients with severe S/Sx should receive dose.
3 × ATNAA and 1 × CANA • 2-PAM 500mg bolus, a drip rate should be started
• BPT treat q3–5min with atropine auto injectors 30 minutes after original 1200mg dose (ATNAA) AND
• If no CANA, can treat with Versed 10mg IM for symptoms persist. Add 20mL/1g 2-PAM to 250mL
seizures bag of saline. Set drip rate to 270mL/hr
(or 1gtt/sec with 15gtt drop set).

82 SECTION 2 PRIMARY TRAUMA PROTOCOLS

VESICANTS MUSTARD (H) and LEWISITE (L)
MARCH PPE AND DECON CONSIDERATIONS
M – Massive hemorrhage/Mask check: ensure the • Mask recommended.
patient has good mask seal • Wear a minimum of two (2) pairs of nitrile exam
A – Airway/Antidote: no antidote for vesicant, however, gloves IOT put hands on patient

SECTION 2
ensure good and early airway management • Ensure patient is masked or has protected airway to
R – Respirations/Rapid DECON: positive pressure prevent inhalation injuries
ventilations and rapid spot DECON • DECON with RSDL, to include wounds and eyes if
C – Circulation/Countermeasures: start IV needed. Soap and water also work well.
H – Hypothermia/Head injury: treat this patient like a • DRY-WET-DRY
burn patient for hypothermia

IMMEDIATE CONSIDERATIONS PFC CONSIDERATIONS

• Patients with severe pulmonary symptoms within • 20% TBSA burned: 2 injections Pegfilgrastim 6mg
4–6 hours OR TBSA of more than 50% should be SQ day 1/7.
considered expectant • Significant absorption of sulfur mustard can cause
• Maintain 30–50mL/hr UOP injury to bone marrow, lymph nodes, and spleen
• Manage airway aggressively if evidence of upper causing a drop in white blood cells (beginning on
airway burns or fluid accumulation: nebulized days 3–5).
albuterol – 3mL (0.083%), Consider: nebulized • Acute respiratory distress syndrome (ARDS) may
racemic epinephrine: 0.5mL of 2.25% solution in 3mL develop hours to days post exposure
NS, Solu-Medrol 125mg IM/IV • Severe eye lesions need to be treated with
• Flush eyes with saline/water to pH 7.0, tetracaine ophthalmic steroid/antibiotic combination: Tobrex is
2gtt OU current standard
• Treat vesicant exposure (with immediate pain) with • Pulmonary toilet for pseudomembranous formation
British anti-Lewisite (BAL; dimercaprol) – 3mg/kg IM • Silverlon Bandage/Silvadene Cream

TOXIC INDUSTRIAL CHEMICALS/MATERIALS

(CHLORINE/PHOSGENE/CYANOGENS)
MARCH PPE AND DECON CONSIDERATIONS
M – Massive hemorrhage/Mask check: ensure the • As always use of mask recommended.
patient has good mask seal • Wearing a minimum of two (2) pairs of nitrile exam
A – Airway/Antidote: no antidote for chlorine or gloves will provide needed protection IOT put hands
phosgene; however, ensure good and early airway on patient.
management, O2 ASAP and Cyanokit for cyanide • Ensure patient is masked or has protected airway to
if available prevent inhalation injuries
R – Respirations/Rapid DECON: positive pressure • DECON with RSDL, to include wounds and eyes
ventilations and rapid DECON with physical removal of if needed. Soap and water also work well.
clothing and any liquids on skin
C – Circulation/Countermeasures: circulatory support
H – Hypothermia/Head injury

IMMEDIATE CONSIDERATIONS PFC CONSIDERATIONS

• One immediate finding is CNS depression due to • Multiple patients: (may run out of CyanoKit, use
hypoxia; however, cyanogens will cause a drop in BP sodium nitrite). Consider sodium nitrite: 300mg of
so ensure proper circulatory support. Give CyanoKit a 3% solution (10mL of a 3% solution) over 5–20
(× 2 if inadequate response to first) minutes
• 92% O2 (titrate to effect) with positive pressure • Absolute bedrest 36 hours
ventilations due to pulmonary edema, supportive • Monitor patient for ARDS, may be delayed up to
care 72 hours
• Manage airway aggressively if evidence of upper • If patient survives first 48 hours, recovery is likely
airway burns or fluid accumulation: nebulized
albuterol 3mL (0.083%); consider nebulized racemic
epinephrine 2.25% in 15–30mL, Solu-Medrol 125mg
IM/IV.
• Flush eyes with saline/water to pH 7.0, tetracaine
2gtt OU.

2025 RANGER MEDIC HANDBOOK 83

RADIATION POISONING
MARCH PPE AND DECON CONSIDERATIONS
M – Massive hemorrhage/Mask check: ensure the • Airway protection as needed based on isotope.
patient has good mask seal • Wearing one (1) pair of nitrile gloves will provide
A – Airway/Antidote: As needed needed protection IOT put hands on patient.
SECTION 2

R – Respirations/Rapid DECON: Rapid DECON • Ensure patient is masked or has protected airway to
with physical removal of clothing and any particulates prevent inhalation injuries (goggles and mask would
on skin suffice).
C – Circulation/Countermeasures: Prussian Blue, zinc/ • DECON with tape or baby wipes and removal of
calcium DTPA for internal contamination clothing.
H – Hypothermia/Head injury • Wounds should be irrigated to less than 2 ×
background.
• Time, distance, and shielding are the three major
factors in the amount of radiation the patient will
receive. Doubling patient’s distance from the source
with quarter amount of radiation received.

IMMEDIATE CONSIDERATIONS PFC CONSIDERATIONS

• Time to emesis is key to dosage and patient outcome • Supportive care
(< 1 hour is expectant, 1–4 hours is immediate/
delayed, > 4 hours minimal).
• Dosage should be kept as low as reasonably
possible.
• BPT suction airway post vomiting.
• Removal of any foreign objects should be done
so with instruments only and placed as far from
personnel as reasonably possible.

λ Gamma Emitters Radiation Pearls

• Radiation Exposure
Industry Use, of Terrorist Interest. RDD or RED
➣ From existing sources or small-scale criticality
Cobalt 60
incident
Chelating agent: DTPA calcium or zinc, 1g in 5mL
➣ Detection, dosimetry, conduct bioassay post
in 250mL of NS over 30 minutes
mission with medical evaluation
Cesium 137
➣ Radioactive gasses may be present in reprocessing
Chelating agent: Prussian Blue (Radiogardase),
facility or at a damaged nuclear reactor
3g tid
➣ Reverse isolation for severely irradiated casualties
• Corrosive liquids and gasses
β Beta Emitters
➣ Uranium hexafluoride can off gas hydrogen
Strontium 90 fluoride gas
Aluminum hydroxide ➣ Nitric acid used in reprocessing
10% Calcium chloride suspension IV: 200mg to 1g • Heavy metal toxicity
every 1–3 days, slow 1mL/min
Calcium gluconate PO: 10g powder in 30mL water Acute Radiation Syndrome (ARS)
Iridium 192 Whole body dose of greater than 100cGy or 100 rad
DTPA calcium or zinc, 1g in 5mL in 250mL of NS over Hematopoietic syndrome > 200–300cGy
30 minutes for internal contamination Gastrointestinal syndrome > 600cGy
Tritium H3 Neurovascular syndrome > 1200cGy
Beer. Increase diuresis
ARS symptoms do not manifest immediately, our role
α Alpha Emitters involves treating immediate life threats and administra-
Uranium 235, 238 tion of chelating agents and decontamination. Dose
Sodium bicarbonate oral or IV estimation determines prognosis. We have the ability
Americium 241/Plutonium 239 to perform blood collection for later biodosimetry. We
DTPA calcium or zinc, 1g in 5mL in 250mL of NS over do not have cytokines. Initiate stem cell banking recall
30 minutes for sick personnel. Prolonged evacuation times may
necessitate the treatment of ARS.

84 SECTION 2 PRIMARY TRAUMA PROTOCOLS

Chemical Agent Treatment Guide
AGENT SIGNS & SYMPTOMS MANAGEMENT DECONTAMINATION
Nerve Mild: miosis, rhinorrhea, ATNAA RSDL, M291, soap & water,
slight difficulty breathing, CANA water in large amounts, 0.5%
sweating nausea, vomiting ABCDD hypochlorite

SECTION 2
GA, GB, GD, Severe: LOC, apnea,
GF, VX convulsions, copious
secretions, flaccid paralysis
Vesicants Erythema, blisters, Immediate decontamination, RSDL, M291, soap & water,
conjunctivitis, cough symptomatic management water in large amounts, 0.5%
Mustard-HD, H hypochlorite
Lewisite-L
Phosgene
Oxime-CX
Pulmonary Eye & airway irritation, ABCDD, oxygen with or Vapor: fresh air
delayed onset SOB or chest without positive airway Liquid: water irrigation
C, CG tightness, pulmonary edema pressure, rest
Cyanide Seizures, respiratory, and ABCDD, inhaled amyl nitrite, Usually not needed
cardiac arrest IV sodium nitrite, sodium
AC, CK thiosulfate, hydroxocobalamin
Riot Burning and pain on mucous Usually none, effects are Water, alkaline soap
membranes, skin & eyes; self-limiting
CS, CN respiratory discomfort
Acronyms: ABCDD: airway, breathing, circulation, drugs, decontamination; ATNAA: antidote treatment nerve agent autoinjector; CANA:
convulsant antidote for nerve agent; LOC: loss of consciousness; RSDL: reactive skin decontamination lotion; SOB: shortness of breath.

2025 RANGER MEDIC HANDBOOK 85

NOTES
SECTION 2

86 SECTION 2 PRIMARY TRAUMA PROTOCOLS

SECTION 3

SECTION 3
TACTICAL MEDICAL
EMERGENCY PROTOCOLS
(TMEPs) & SICK CALL

87
Medical Patient Assessment
Documentation of all healthcare provided is inherent with any form of care provided by Ranger Medical personnel.
Ranger Medics will document any and all assessments, healthcare, treatments, or procedures as appropriate to the
situation and setting. In the nontactical situation, healthcare will be documented on an SF 600, MHS Genesis electronic
note or trauma run sheet. In the tactical situation, care will be documented on the Ranger ­Casualty Card, DA5767 (TCCC
Card), or may be maintained in a notebook until subsequent annotation to the appropriate format. Referral to, commu-
nication with, or review by a primary provider is required for all patients and notes.

SOAP Note Format

Pertinent Chief Complaint
SECTION 3

Information
(to side of SOAP) C/C: One sentence identifying patient age, gender, race, and occupation and using the
patient’s words describing their primary problem.
A simple list of EXAMPLE:
allergies, current C/C: 21 years old male Caucasian Ranger c/o dry cough × 7 d
medications, and
vital signs. S – Subjective
S: Description of problem based on patient’s history. Do not put words in their mouth,
EXAMPLE: but ask specific questions regarding their complaint. Use OPQRST and AMPLE as a
NKDA guideline in your questions and notes. Identify any pertinent social or family history
Azithromycin as related to the complaint. Give a simple logical timeline and description followed
P – 68 by pertinent positives and negatives based on the review of systems that relate to
B/P – 118/72 their complaint. Include any previous self-treatments or medical treatments from
previous ­e ncounters.
R – 16
T – 99.2 EXAMPLE:
S: Nonproductive cough started 7 days ago upon return from leave in Mexico, treated with
a Z-Pak by MO with no improvement. No PMHx of pneumonia or bronchitis. Nonsmoker.
ROS – NO hemoptysis, fever, dyspnea, wheezing, malaise

O – Objective/Observations
O: Description of your pertinent vital sign findings, mental status, observations,
and examinations with pertinent positives and negatives. Record the results or out-
comes of any labs, imaging, test, or procedures done as part of this visit.

Work-Up Results EXAMPLE:

O: A&OX3, (-) fever, VS – WNL
(if applicable) Normal lung sounds (-) rales, (-) rhonchi, (-) crackles
(-) cervical lymphadenopathy
A simple list of Nonproductive cough and nasal congestion witnessed
findings from any
previous labs, A – Assessment
x-rays, or tests
including the A: Sum up your assessment or diagnosis based on the subjective and objective/
date done. observations. Paint a textual picture what you are thinking the condition is and why.
A single-word diagnosis is not required as long as you explain your rationale in your
EXAMPLE: decision. Provide a differential diagnosis to explain why you think it is not another
CXR-WNL diagnosis.
(09 Sep 10) EXAMPLE:
A: V iral URI – given nonproductive cough, congestion, rhinorrhea, VS-WNL, unremarkable
exam, and no evidence of serious bacterial infection, viral URI is most likely.
Patient Information Dx: Pneumonia – doubt given with no dyspnea, no fever, VS WNL, no concerning find-
(on form) ings on auscultation.
GERD – doubt given sudden onset and no reflux symptoms.
NAME (L, F, MI) Asthma – doubt given no PMHx, no wheezing on exam
SSN P – Plan of Action
DOB
UNIT P: Provide the details of the course of treatment for today. Include any immediate
SEX or future work-up requirements (lab, x-ray, tests). Include instructions to patient if
Contact Number condition worsens or does not improve within a specified time period or if patient
is to return for follow-up. Include any modification or profile to duty/training status.
Student Status
(if applicable) EXAMPLE:
A: Stop taking azithromycin
Pseudoephedrine 1 q12hr × 7 days, Acetaminophen q6hr PRN
If cough persists > 72hr, RTC for CXR, PFT, and consider trial of albuterol
PT at own pace/distance × 5 days

88 SECTION 3 TACTICAL MEDICAL EMERGENCY PROTOCOLS (TMEPs) & SICK CALL

Medical Patient Assessment Protocol

SECTION 3

2025 RANGER MEDIC HANDBOOK 89

Abdominal Pain
(Includes Surgical Abdomen, GERD, Dyspepsia)
DEFINITION: Common causes in young healthy adults include appendicitis, cholecystitis, pancreatitis, perforated ulcer,
and diverticulitis. Consider constipation/fecal impaction as a potential cause of abdominal pain.

S/Sx: Epigastric burning pain, present bowel sounds, nausea and/or vomiting, absence of rebound tenderness, if diar-
rhea is present, treat per Gastroenteritis Protocol.

MANAGEMENT:
1. Famotidine 20mg PO bid OR rabeprazole 20mg PO qd OR proton pump inhibitor of choice.
2. Increase PO hydration.
SECTION 3

3. Avoid triggers (acidic/spicy foods/tobacco); wait 3 hours between eating and lying down.
4. Antacid of choice (antacids will mask other S/Sx). Treat per Nausea/Vomiting Protocol as required.

Note: Determine pregnancy status of females with abdominal pain to evaluate for ectopic pregnancy. Follow
appro­priate protocol only after ruling out ectopic pregnancy.

DISPOSITION: Observation and reevaluation; Priority evacuation if symptoms not controlled by this management within
12 hours.

Acute Surgical Abdomen

S/Sx Suggesting Urgent Evacuation: Severe, persistent, or worsening abdominal pain is the key sign; rigid abdomen,
rebound abdominal tenderness, fever, absence of bowel sounds, focal percussive tenderness, uncontrollable vomiting,
presence of bloody vomitus or stools, presence of black tarry stools, presence of coffee ground vomitus, positive find-
ings of Murphy’s, McBurney’s, or Grey-Turner sign.

MANAGEMENT:
1. Start IV with crystalloid, 1L bolus, followed by crystalloid 150mL/hr.
2. Keep NPO except for medications or PO hydration.
3. Ertapenem 1g IV qd OR ceftriaxone 1g IV qd, PLUS metronidazole 500mg PO q8hr.
4. Treat per Pain Protocol.
5. Treat per Nausea and Vomiting Protocol

DISPOSITION: Urgent evacuation to a surgical facility.

Allergic Rhinitis / Hay Fever

DEFINITION: Inflammation of the nasal passages due to environmental allergy.

S/Sx: Clear nasal drainage; pale, boggy or inflamed nasal mucosa; with or without complaints of nasal congestion;
watery or red eyes; sneezing; normal temperature; history of environmental allergy.

MANAGEMENT:
1. Fluticasone 1 spray each nare bid +/– loratadine 10mg PO qd OR fexofenadrine 180mg PO qd OR cetirizine 5–10mg
PO qd AND/OR if no previous available, then diphenhydramine 25–50mg PO q6hr if tactically feasible (drowsiness
is a side-effect).
2. Increase oral fluid intake.
3. If prolonged management, consider fluticasone 2 sprays in each nostril daily. Nasal saline spray may be very helpful
in clearing upper airway secretions.

DISPOSITION: Evacuation usually not required

90 SECTION 3 TACTICAL MEDICAL EMERGENCY PROTOCOLS (TMEPs) & SICK CALL

Altitude Medical Emergencies
Altitude Illnesses
Acute Mountain Sickness (AMS): Typically occurs at altitudes > 8,000 ft (2,500 m ­ eters). Onset typically occurs 6–12
hours after ascent but can occur as quickly as 3 hours after ascent. The key to prevention is prophylactic acetazolamide
and a combination of slow, graded ascent and staged ascent. A slow, graded ascent is no more than 1,650 ft/day (500
meter) when above 10,000 ft (3,000 meters), and limit sleeping altitude to 1,000 ft above previous night’s altitude. A
staged ascent is spending 2–3 days at moderate altitude 8,000–10,000 ft (2,500–3,000 meters).
High Altitude Cerebral Edema (HACE): Rare below 11,500 ft. Headache is common at altitude. Ataxia and altered
mental status at altitude are HACE until proven otherwise.
High Altitude Pulmonary Edema (HAPE): Caused by the hypoxia of altitude, HAPE is the most common cause of death

SECTION 3
from altitude illness. Usually occurs above 8,000 ft. Respiratory distress at high altitude is HAPE until proven otherwise.
HACE AND HAPE MAY COEXIST IN THE SAME PATIENT!

Signs/Symptoms
S/Sx: AMS is generally benign and self-limiting, but symptoms may become debilitating. Worsening condition should
prompt consideration of a more life-threatening condition (HAPE or HACE). AMS Diagnosis: recent ascent > 8,000 ft
(2,500 meter), plus a headache AND at least of the following: anorexia, nausea, vomiting, insomnia, dizziness, lighthead-
edness, lassitude, weakness, or fatigue. No correlation with fitness level (likely genetic predisposition).
HACE: Unsteady, wide, and unbalanced (ataxic) gait and altered mental status are hallmark signs.
HAPE: Dyspnea at rest is the hallmark sign. Other symptoms may include cough, crackles upon auscultation, tachypnea,
tachycardia, fever, central cyanosis, or decreased physical exercise tolerance. Measure SpO2% and compare to other
people around. If measured SpO2% is less than others’ and the patient has symptoms, then descent must be initiated.

Initial Management & Extended Management

1. Halt ascent. Immediately descend at least 1,500 ft for HACE, HAPE, or refractory AMS if tactically feasible.
2. If AMS Symptoms Present: Acetazolamide 250mg PO bid UNLESS PATIENT IS ALLERGIC TO SULFA or is already
taking as prophylaxis. Dexamethasone 4mg PO/IV/IM q6hr if patient is allergic to sulfa. If dexamethasone is adminis-
tered, no further ascent until asymptomatic for 18 hours after last dexamethasone dose. Descend if symptoms worsen.
3. If HACE Symptoms Present: Ataxia or Altered Mental Status: Dexamethasone 10mg IV/IM STAT, then 4mg IV/
IM q6hr. Individuals with HACE should not be left alone and especially not be allowed to descend alone. Administer
supplemental oxygen, if available.
4. If HAPE Symptoms Present: Shortness of Breath at Rest: Nifedipine 10mg PO/SL STAT; then 20mg q6hr if blood
pressure is stable. For extended management, consider sildenafil 50mg q8hr OR Tadalafil 10mg q12hr (do not use
in HACE; the drop in blood pressure will worsen the symptoms of this disease). Administer supplemental oxygen, if
available. Consider salmeterol 2 inhalations q12hr. OR albuterol 2 inhalations q6hr.
5. Minimize patient exertion during descent for HAPE since this will exacerbate symptoms.
6. Treat per Pain Management Protocol but avoid the use of narcotics since they may depress respiratory drive and
worsen high altitude illness. Treat per Nausea and Vomiting Protocol.
7. For signs or symptoms of either HAPE or HACE, if immediate descent is not tactically feasible and a GAMOW bag
is available, use a GAMOW bag in 1-hour treatment sessions with bag inflated to a pressure of 2 psi (approximately
100mmHg) above ambient pressure. Four or five sessions are typical for effective treatment. GAMOW BAG TREAT-
MENT IS NOT A SUBSTITUTE FOR DESCENT.
8. Treat per Dehydration Protocol.
DISPOSITION: Most cases of AMS are relatively mild, resolve in 2–3 days, and do not require evacuation. Avoid vigorous
activity for 3–5 days. Priority evacuation for AMS patients who worsen despite therapy. Urgent evacuation for patients
with suspected HACE or HAPE. Individuals who have recovered from HACE or HAPE should not re-ascend without
medical officer clearance.

Prophylaxis & Pretreatment

AMS Emergency Rapid Ascent/HAF Insertion at Altitude > 11,500 ft: With prior medical officer approval, consider
pretreatment of unit personnel with acetazolamide 125mg PO bid OR dexamethasone 4mg PO/IV/IM q6hr (for operations
< 48 hours). Dexamethasone prevents symptoms but does not help with acclimation.
AMS Prevention/Pretreatment: Acetazolamide 125mg PO bid, started 24 hours before ascent to altitude > 8,000 ft.
Takes 8 hours after the first dose to have efficacy. Cease pretreatment after 2–3 days at target altitude or during descent.
If true sulfa allergy, do not use acetazolamide and supplement with dexamethasone. If sulfa ABX allergy, continue to use
acetazolamide with medical officer approval. For personnel who have a history of previous HAPE, nifedipine, acetazol-
amide, sildenafil, tadalafil, salmeterol, and albuterol may be used (individually or in combination).

2025 RANGER MEDIC HANDBOOK 91

Altitude Medical Emergency Management Protocol
SECTION 3

92 SECTION 3 TACTICAL MEDICAL EMERGENCY PROTOCOLS (TMEPs) & SICK CALL

Anaphylaxis Reaction Emergencies
Anaphylactic shock is a life-threatening medical emergency that is caused by a generalized allergic reaction affecting
the cardiovascular, respiratory, cutaneous, and gastrointestinal systems. It is a severe immune-mediated reaction that
occurs when a previously sensitized patient is reexposed to an offending allergen such as: bee/wasp stings, penicillin
or other drug allergies (especially when given IM/SC/IV), seafood (especially shrimp/shellfish), and nuts of various types.
Allergens may produce an allergic reaction by being ingested, inhaled, injected, or absorbed through the skin/mucous
membranes. Shock is produced by the release of histamine that causes “leaky” vessels resulting in hives/edema and
hypotension; it also causes bronchospasm/wheezing. This produces both a volume problem and a vascular resistance
problem. Anaphylactic shock differs from less severe allergic reactions in that it is characterized by hypotension and
obstructed airflow (upper and/or lower) that can be life-threatening.

SECTION 3
Signs/Symptoms
S/Sx: Wheezing (bronchospasm), dyspnea, stridor (laryngeal edema), angioedema, urticaria (hives), hypotension, tachy-
cardia. Clinical observation is the only diagnostic test. Use rapidity of onset and constellation of symptoms to suggest
the diagnosis. A prior history of similar symptoms may be the only other clue. Observe closely with frequent assess-
ment/reassessment of mental status, vital signs, and pulse oximetry. Anaphylaxis is likely if ANY of the following three
criteria are met:
■ Acute onset (minutes to several hours) with involvement of skin and or mucosal tissue (hives, pruritus, swollen lips/
tongue) plus 1 of the following: respiratory compromise (e.g., dyspnea, wheezing, stridor or other signs of broncho-
spasm) or cardiovascular compromise (eg, decreased blood pressure, syncope).
■ Two or more of the following that occur quickly (minutes to several hours) after exposure to a likely allergen: involve-
ment of skin-mucosa, respiratory compromise, reduced blood pressure, persistent GI symptoms (e.g., vomiting,
abdominal pain).
■ Reduced blood pressure (systolic < 90 for adult) after exposure to a known allergen for the patient.

Initial Management & Extended Management

For patients with S/Sx of airway involvement and/or circulatory collapse:
Epinephrine is the mainstay of therapy. Administer Epi-Pen OR epinephrine 0.3–0.5mg (0.5mL of 1:1,000 IM into the
anterolateral thigh. DO NOT USE INTRAVENOUSLY. Repeat epinephrine q5min prn. Administer oxygen with pulse ox-
imetry monitoring. If severe respiratory distress exists, aggressive airway management with bag-valve-mask and airway
adjuncts (oral and nasopharyngeal airways). Control airway early if no response to epinephrine. Initiate IV normal saline
TKO (saline lock). Administer 500–1000cc crystalloid or colloid bolus for hypotension then titrate to establish systolic
blood pressure > 90mmHg or palpable radial pulse if BP cuff not available. Although epinephrine is the treatment for
true anaphylaxis, consider treating concurrent symptoms with the following medications. Administer diphenhydramine
50mg IV/IM/PO for skin findings/puritisis. Administer dexamethasone 10mg IV/IM/PO for repeat anaphylaxic reactions. If
wheezing is present after epinephrine administration, consider Albuterol, 2–3 puffs q5min, repeat up to 3 times. Consider
additional H2 blocker (famotidine 20mg PO bid) as 3–5 day course of additional antihistamine.

Considerations
Immediate definitive airway if impending airway obstruction from angioedema is suspected. Delay may lead to complete
obstruction, difficult intubation and cricothyroidotomy. Give 6–8L O2/min via face mask if required or up to 100% if
airway controlled. Albuterol metered dose inhaler (2–3 puffs) for bronchospasm. Place patient in recumbent position
and elevate lower extremities.

Crystalloid (saline) fluid bolus IV titrated to restore and maintain blood pressure. Recurrence of symptoms may occur in
up to 20% of patients (generally within 6 hours but recurrences up to 72 hours following initial resolution of symptoms
have been reported).

Apply ice to minimize any local reaction sites. If due to bee/wasp sting(s), carefully remove all stingers. Avoid applying
pressure to venom sac while stinger is inserted in patient.

2025 RANGER MEDIC HANDBOOK 93

Anaphylactic Shock Management Protocol
SECTION 3

94 SECTION 3 TACTICAL MEDICAL EMERGENCY PROTOCOLS (TMEPs) & SICK CALL

Asthma
(Reactive Airway Disease)
DEFINITION: Inflammatory disorder of the airway with bronchiolar hyperresponsiveness and narrowing of the distal
airways; acute exacerbation seen with change in environment or level of allergen or irritant.
S/Sx: Wheezing, dyspnea, difficulty with speaking in full sentences, chest tightness, decreased oxygen saturation,
respiratory distress
MANAGEMENT:
1. Initiate pulse oximetry monitoring.
2. Albuterol (metered dose inhaler – works best when used with spacer), 2–3 puffs q5min, up to 3 times and assess.
3. If there is no response to albuterol, initiate urgent evacuation and continue albuterol MDI 4 puff q10min AND/OR

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consider epinephrine 0.5mg (0.5mL of 1:1,000 solution) IM (DO NOT INJECT INTRAVENOUSLY).
4. May repeat one dose in 5–10 minutes.
5. Initiate IV access with saline lock.
6. Dexamethasone 10mg IV/IM OR methylprednisolone 125mg IV/IM.
7. Administer oxygen if SpO2 < 92%.
8. If there is fever, pleuritic chest pain and productive cough, treat per Bronchitis/Pneumonia Protocol.
9. If airway compromise, refer to Airway Management Protocol.
10. If available, administer medications via nebulizer (albuterol 2.5mg tid over 5–15 minutes).
11. Clinical consideration: pair with fluticasone with provider consult.
DISPOSITION: If the patient responds to management, observe for 4–6 hours, especially if epinephrine was adminis-
tered. Return-to-duty if there is no wheezing or dyspnea and normal oxygen saturation. Continue albuterol (2 puffs q6hr)
and reevaluate in 24 hours. Continue prednisone 60mg qd × 4 days.

Consider fluticasone 250mg/salmeterol 50mg (Advair) 1 puff bid × 14 days. Urgent evacuation if no response to treat-
ment. Urgent evacuation if symptoms persist.
SPECIAL CONSIDERATIONS: Other disorders to consider: anaphylactic reaction, spontaneous pneumothorax, HAPE,
and pulmonary embolism.

Barotrauma
DEFINITION: Physical damage to body tissues caused by difference in pressure between an air space inside or beside
the body and surrounding fluid.
S/Sx: Pain/pressure in the ear(s), sinuses, teeth; pulmonary overinflation syndrome may present with chest pain, dys-
pnea, mediastinal emphysema, subcutaneous emphysema, pneumothorax, and arterial gas embolism (AGE).
MANAGEMENT: Middle ear – If a tympanic membrane rupture is present or suspected:
1. Protect the ear from water, diving, flying, or further trauma, DO NOT use ear drops.
2. Pseudoephedrine 60mg PO q4–6hr prn AND/OR oxymetazoline 2–3 sprays each nostril bid (no longer than 3 days).
Refer to higher level of care when feasible. Consider moxifloxacin 400mg PO qd only if gross contamination is sus-
pected. Paranasal sinus barotraumas – pseudoephedrine 60mg PO q4–6hr prn.
3. Pulmonary barotraumas to include subcutaneous emphysema – If no respiratory distress, monitor patient closely.
Use pulse oximetry if available. If respiratory distress occurs – Treat per Spontaneous Pneumothorax Protocol.
4. If arterial gas embolus is suspected, administer 100% oxygen and 1L normal saline IV 150mL/hr. Urgent evacuation
to recompression chamber. If an unpressurized airframe is used, avoid altitude exposure greater than 1,000 ft.
5. Treat per Pain Management Protocol. (Avoid narcotics if recompression is anticipated.)
DISPOSITION: Urgent evacuation for cerebral arterial gas embolus or pneumothorax with respiratory distress. Mild to
moderate middle ear, sinus, or pulmonary barotraumas without respiratory distress, observation and Routine evacua-
tion. Routine evacuation for consultation for tympanic membrane rupture.
SPECIAL CONSIDERATIONS:
1. Pulmonary overinflation syndrome (POIS) may occur from ascent from depth if compressed air was used or exposure
to blast overpressure.
2. The most commonly affected site is the middle ear and tympanic membrane, but paranasal sinuses and teeth may
be affected.
3. Pulmonary barotrauma occurs when compressed air is breathed at depth followed by ascending with a closed airway
(i.e., breath-holding) and can cause pneumothorax or arterial gas embolism.

2025 RANGER MEDIC HANDBOOK 95

Behavioral Emergency Management
(Includes Psychosis, Depression, Suicidal Impulses)
Behavioral Conditions
In a tactical setting, consider sleep deprivation as a cause. Etiologies are numerous and will often dictate the manage-
ment; thus, mental status changes could be caused by head trauma, metabolic and endocrine disease processes,
environmental toxins, infections, combat stress disorder, hypoxia, hyperthermia, hypothermia, pharmaceutical agent use
(i.e., mefloquine), or withdrawal. Consider diabetic hypoglycemia as a cause of altered mental status.
S/Sx: Acute behavioral changes include withdrawal, depression, aggression, confusion, or other behavioral patterns
atypical for the individual.
SECTION 3

Psychosis is an acute change in mental status characterized by altered sensory perceptions that are not congruent with
reality: auditory and/or visual hallucinations; may include violent or paranoid behavior; disorganized speech patterns are
common; may include severe withdrawal from associates.

Initial Management & Extended Management

1. Remove all weapons or potential weapons from patient AND treating medic.
2. Check pulse oximetry.
3. Place patient in safe environment under continuous surveillance
4. Give contents of 1 sugar packet sublingually to treat for possible hypoglycemia.
5. Take core temperature. If temperature is below 95°F, treat per Hypothermia Protocol. If temperature is above 101°F,
treat per Meningitis Protocol. If temperature is above 103°F, treat per Meningitis and Hyperthermia Protocols
6. For acute agitation, combativeness, or violent behavior, restrain patient with at least four individuals and give mid-
azolam 5mg IM OR diazepam 10mg IM. Repeat after 30 minutes prn.
7. If sedated or restrained, maintain constant vigilance for a change in the hemodynamic status or loss of airway reflexes.
8. Evacuate urgent as tactically feasible.

AMSIT Patient History Neurological Assessment

Appearance, Behavior, & Speech (ill or Mental Status Motor Status
distressed, posture & body language, willingness • Orientation • Posture
to talk, manner, evidence of emotions, attention • Affect • Strength in basic
span, speech patterns) • Speech (content & process) muscle movements
Mood & Affect (anger, fear, anxiety, elation, • Resistance to
Cranial Nerves
intensity and changes in mood) passive movement
I Olfactory (identify an odor or
Sensorium (oriented to time and place, • Tremors or
distinguish between 2 odors)
recent and remote events, concentration and involuntary
II Optic (visual acuity test)
calculation) movements
III Oculomotor (assess 6 cardinal
Intellectual Function (education, vocabulary
use, appropriate for age)
eye movements & pupillary Sensation Status
reaction) • Senses light touch
Thought (logical, reasonable, speed,
IV Trochlear (assess 6 cardinal • Senses pain or
hallucinations, self-image, insight awareness)
eye movements) pricks
V Trigeminal (facial sensitivity & • Senses temperature
Glasgow Coma Scale biting/clinching teeth) • Senses vibration
VI Abducens (eye movement (tuning fork)
Eye Opening Verbal Response
looking left and right)
Spontaneous 4 Oriented 5 Coordination
VII Facial (smile, frown, raise
To Voice 3 Confused 4 • Gait and stance
brows, and taste)
To Pain 2 Inappropriate Words 3 Finger to nose Heel
VIII Vestibulocochlear (hearing-
None 1 Incomprehensible Words 2 to shin
rubbing fingers & equilibrium)
None 1
IX Acoustic (gag reflex and Reflexes
Motor Response identify tastes) • Deep tendon
Obeys Commands 6 X Vagus (gag reflex and speech) reflexes (biceps,
Localizes Pain 5 XI Spinal accessory (head triceps, knees,
Withdraws (Pain) 4 movement and shoulder ankles)
Flexion 3 shrugging) • Plantar reflexes
Extension 2 XII Hypoglossal (stick out tongue
None 1 and move left and right)

Document as: E ___ + V ___ + M ___ = ____

96 SECTION 3 TACTICAL MEDICAL EMERGENCY PROTOCOLS (TMEPs) & SICK CALL

Behavioral Emergency Management Protocol

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2025 RANGER MEDIC HANDBOOK 97

Assessment & Management of Suicidal Risk
Suicide
Suicide remains a serious public health problem, with more than 47,000 people taking their lives every year (CDC, 2019).
Suicide was the tenth leading cause of death for all ages in 2016 and the second leading cause of death for persons
aged 24 and younger. Among military members and veterans, suicide and other forms of suicidal self-directed violence
have steadily increased over the past decade. According to estimates from the National Veteran Suicide Prevention
Annual Report (2019), veterans account for approximately 13.5% of deaths by suicide among US adults. While even
the most accurate suicide data do not predict suicide in a given individual, thorough clinical assessment informed by
demographic and other suicide-related associations may improve risk-appropriate management. The following protocol
represents the VA/DoD Clinical Practice Guidelines for the assessment and management of suicidal risk.
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Table 1: Warning Signs

Warning Signs: Observations that signal an increase in the probability that person intends to engage in suicidal
behavior in the immediate future (i.e. minutes and days). Warning signs present tangible evidence to the clini-
cian that a person is at heightened risk for suicide in the short term. Warning signs may be experienced in the
absence of risk factors.

Direct Warning Signs portend the highest likelihood of suicidal behaviors occurring in the near future:
Suicidal Communication: Writing or talking about suicide, wish to die, or death (threatening to hurt or kill self)
or intention to act on those ideas.
Preparations for Suicide: Evidence or expression of suicide intent, and/or taking steps towards implementation
of a plan. Makes arrangements to divest responsibility for dependent others (children, pets, elders), or making
other preparations such as updating wills, making financial arrangements for paying bills, saying goodbye to
loved ones, etc.
Seeking Access or Recent Use of Lethal Means: Owning or planning to acquire weapons, medications, toxins,
or other lethal means.

Other Indirect Warning Signs presentation(s) or behavioral expressions that may indicate increased suicide
risk and urgency in a patient at risk for suicide:
Substance abuse: Increasing or excessive substance use (alcohol, drugs, smoking)
Hopelessness: Expresses feeling that nothing can be done to improve the situation
Purposelessness: Express no sense of purpose, no reason for living, decreased self-esteem
Anger: Rage, seeking revenge
Recklessness: Engaging impulsively in risky behavior
Feeling trapped: Expressing feelings of being trapped with no way out
Social withdrawal: Withdrawing from family, friends, society
Anxiety: Agitation, irritability, angry outbursts, feeling like wants to “jump out of my skin”
Mood changes: Dramatic changes in mood, lack of interest in usual activities/friends
Sleep: Insomnia, unable to sleep or sleeping all the time
Guilt or shame: Expressing overwhelming self-blame or remorse

98 SECTION 3 TACTICAL MEDICAL EMERGENCY PROTOCOLS (TMEPs) & SICK CALL

Assessment & Management of Suicidal Risk (cont.)

Table 2: Risk Factors

Acute Risk Factors: Acute (of brief duration) and stressful episodes, illnesses, or life events. While not usually
internally derived, these events can build on and challenge a person’s coping skills.
Chronic Risk Factors (Preexisting): Relatively enduring or stable factors that may increase a person’s suscep-
tibility to suicidal behaviors, such as genetic and neurobiological factors, gender, personality, culture, socioeco-
nomic background, and level of isolation.
Psychological Factors:

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• Suicide of relative, someone famous, or peer
• Suicide bereavement
• Loss of loved one (grief)
• Loss of relationships (divorce, separation)
• Loss of status/respect/rank (public humiliation, being bullied or abused, failure work/task)
Social Factors:
Stressful Life Events (acute experiences) Legal Problems (difficulties)
• Breakups and other threats to prized relationships • DUI/DWI, lawsuit, criminal offense, incarceration
• Other events (e.g. fired, arrested, evicted, Lack of Social Support
assaulted) • Poor interpersonal relationships (partner, parent,
• Chronic stressors (ongoing difficulties) children)
Financial Problems • Geographic isolation from support
• Unemployment, underemployment • Recent change in level of care (discharge from
• Unstable housing, homeless inpatient psychiatry)
• Excessive debt, poor finances (foreclosure, alimony,
child support)
Medical Conditions:
• History of traumatic brain injury • Mood or affective disorder (major depression,
• Terminal disease bipolar disorder)
• HIV/AIDS • Personality disorder (especially borderline)
• New diagnosis of major illness • Schizophrenia
• Having a medical condition • Anxiety
• Worsening of chronic illness • PTSD
• Intoxication • Panic disorder
• Substance withdrawal (alcohol, opiates, • Substance use disorder
cocaine, etc.) • Eating disorder
• Use of prescription medication with warning for • Insomnia or other sleep disorder
increased risk of suicide
• Chronic pain
Military Specific: Preexisting & Nonmodifiable:
• Disciplinary actions (UCMJ) – Reduction in rank • Gender (male)
• Career-threatening change in fitness • Race (white)
for duty • Marital status (divorce, separate, widowed)
• Perceived sense of injustice or betrayal (unit/ • Family history of suicide/attempt or mental illness
command) • Child maltreatment (physical/psychological/sexual)
• Command/leadership stress, isolation from unit • Sexual trauma
• Transferring duty station • Lower education level
• Administrative separation from service/unit • Same-sex orientation (LGBT)
• Adverse deployment experience • Cultural or religious beliefs

2025 RANGER MEDIC HANDBOOK 99

Assessment & Management of Suicidal Risk (cont.)

Table 3: Protective Factors

Capacities, qualities, environmental, and personal resources that increase resilience; drive an individual toward
growth, stability, and/or health and/or to increase coping with different life.
Social Context Support System
Strong interpersonal bonds to family/unit members and community support
• Employed
• Intact marriage
SECTION 3

• Child-rearing responsibilities
• Responsibilities/duties to others
• A reasonably safe and stable environment
Positive Personal Traits
• Help seeking
• Good impulse control
• Good skills in problem-solving, coping and conflict resolution
• Sense of belonging, sense of identity, and good self-esteem
• Cultural, spiritual, and religious beliefs about the meaning and value of life
• Optimistic outlook – Identification of future goals
• Constructive use of leisure time (enjoyable activities)
• Resilience
Access to Healthcare
• Support through ongoing medical and mental healthcare relationships
• Effective clinical care for mental, physical, and substance use disorders
• Good treatment engagement and sense of the importance of health and wellness

Table 4: Level of Risk for Suicide

Risk for
Suicide Attempt Indicators for Suicide Risk Contributing Factors
High Risk • Persistent suicidal ideation or thoughts • Acute state of psychiatric disorder or
• Strong intention to act or plan acute psychiatric symptoms
• Not able to control impulse • Acute precipitating event(s)
OR • Inadequate protective factors
• Recent suicide attempt
Intermediate Risk • Current suicidal ideation or thoughts • Existence of warning signs or risk factors
• No intention to act AND
• Able to control the impulse
• Limited protective factors
• No recent attempt or preparatory
behavior or rehearsal of act
Low Risk • Recent suicidal ideation or thoughts • Existence of protective factors
• No intention to act or plan AND
• Able to control the impulse
• Limited risk factors
• No planning or rehearsing a suicide act
• No previous attempt

100 SECTION 3 TACTICAL MEDICAL EMERGENCY PROTOCOLS (TMEPs) & SICK CALL
Assessment & Management of Suicidal Risk Protocol

SECTION 3

2025 RANGER MEDIC HANDBOOK 101

Leader’s Suicide Risk Assessment Tool (L-SRAT)
L-SRAT Instructions
The L-SRAT is not a formally researched test. When a Leader uses the L-SRAT out of concern about a specific Ranger, the
leader should consult with a behavioral health (BH) professional. The L-SRAT is not a substitute for direct input from a BH
professional regarding potential suicide risk concerns. The L-SRAT also is not a substitute for leader judgment in respond-
ing to crisis situations. Rather, it provides a structure to assist leaders to seek and communicate important information to
BH professionals about specific known suicide risk factors. The L-SRAT also provides specific recommendations to pursue
key suicide risk mitigation actions.

Leader should fill out an L-SRAT if a Ranger is:

SECTION 3

1. Considered “High” risk but especially if he/she is experiencing occupational problems, discipline/legal problems,
financial problems, relationship problems, substance misuse, suicidal thoughts/actions and/or is in possession of
a firearm.
2. Admitted for inpatient behavioral health hospitalization (on or off post).
3. Involved in an incident reported on the blotter that is related to an L-SRAT risk factor.
4. Referred for administrative chapter that requires behavioral health review IAW Army Regulation.
5. Leader has concern about a Ranger’s suicide risk. If there are immediate safety concerns, escort the Ranger to
Embedded Behavioral Health or the Emergency Department.

The L-SRAT is not intended to be used like an “interview” based solely on how a Ranger responds. It should be filled
out based on a leader’s knowledge and information obtained from the Ranger, other members in the chain of com-
mand, and available support resources (e.g., Behavioral Health, Armed Forces Community Services, etc.). Caution
should be used to prevent unnecessary disclosure of the Ranger’s personal information gathered with the L-SRAT so
store completed L-SRAT forms in a secure manner such as in the Ranger’s personnel file.

How is the L-SRAT filled out?

1. Start with the “Identified suicide risk factors” column of the L-SRAT and review the first Risk Factor.
2. If the Risk Factor is PRESENT then record it and review the Mitigating Actions in the corresponding “Initial unit
action to mitigate suicide risk” column.
a. For each Mitigating Action, record “Completed” or “Not Completed”:
i. If the Mitigating Action has been completed then fill in the date of completion in the “Date” column.
ii. If the Mitigating Action has not been completed then fill in the no later than (NLT) target date for the Mitigating
Action to be completed.
iii. If the Mitigating Action is not applicable in the Ranger’s situation then leave the “Date” column blank.
b. When utilizing a mentor, use discretion and select an individual who is mature with a demonstrated ability to provide
effective mentorship in the particular area of concern. In addition, consider the input from the Ranger on selecting
the mentor to increase the Ranger’s investment in the mentoring relationship.
c. When referring a Ranger to Behavioral Health, give the BH professional a copy of the completed L-SRAT.
3. If the Risk Factor is ABSENT record “No” and enter “N/A” for the Mitigating Actions.
4. Repeat until responses are recorded for all Risk Factors and Mitigating Actions.
5. Once all of the Risk Factors and Mitigating Actions have been recorded, contact your Ranger Embedded Behavioral
Health Provider, Physician or PA. BH professionals should make final determinations about suicide risk. Sharing the
L-SRAT information with the BH professional will enhance the ability of the BH professional to make an appropriate
risk determination. However, regardless of the risk level estimate assessed at the time, the Ranger’s risk factors may
change at any point based on external stressors or intervening events.

102 SECTION 3 TACTICAL MEDICAL EMERGENCY PROTOCOLS (TMEPs) & SICK CALL
Leader’s Suicide Risk Assessment Tool (L-SRAT) (cont.)
LEADER'S SUICIDE RISK ASSESSMENT TOOL (L-SRAT)

Ranger: Leader/Unit/Contact Info: Date:

Identified suicide risk factor Present? Initial unit action to mitigate suicide risk Completed? Date Notes (Optional)
1) Discipline/Legal Problems: Is a) Ensure adequate contact between the Ranger
the Ranger currently under military and support assets (IG, JAG/TDS, Chaplain).
or civilian investigation for any b) Ensure the Ranger receives written criteria, unit
suspected violations or pending plan of support, and minimum of weekly feedback for
UCMJ/Article 15 action, how to meet requirements/standards until the Ranger
administrative separation/ achieves the requirements/standards identified.
elimination, or bar to reenlistment?
c) If applicable, ensure the Ranger has full awareness
of Command's intention to initiate administrative

SECTION 3
separation/elimination.
d) If pending separation/elimination, provide the
Ranger with full access to transition services.
2) Occupational Problems: Is a) Ensure the Ranger receives written criteria, unit
the Ranger pending any adverse plan of support, and minimum of weekly feedback for
action (e.g., flag, reduction in how to meet requirements/standards until the Ranger
rank, removal from position of achieves the requirements/standards identified.
responsibility, poor performance
review, or non-selection for b) Ensure contact between the Ranger and a unit
promotion or attendance to mentor familiar with the Ranger’s individual situation
schools, etc.) or receiving until the Ranger achieves the benchmarks set up by
repeated corrective counseling the mentor.
statements without alterations in
problematic behavior?

3) Firearms: Does the Ranger a) Continue to support privately owned firearm safety
have a privately owned firearm? training and measures such as gun locks, safes,
storing ammunition separately from firearm, etc.

b) Offer storage location outside the home for

privately owned firearm.
4) Relationship Problems: Is the a) Ensure contact between the Ranger and a unit
Ranger pending and/or planning a mentor who has been through similar relationship
divorce/break-up or experiencing problems until the Ranger achieves the benchmarks
other relationship problems (e.g., set up by the mentor.
frequent arguments with b) Ensure the Ranger has adequate opportunity
spouse/partner, isolation from to attend behavioral health appointments,
family, or loss of child custody, couples therapy, or meet with the Chaplain.
etc.)?

5) Financial Problems: Does the a) Ensure contact between the Ranger and a unit
Ranger have significant difficulties mentor familiar with the Ranger’s individual situation
paying bills or demonstrate obvious until the Ranger achieves the benchmarks set up by
signs of poorly considered the mentor.
purchase(s) (e.g., car, home, etc.) b) Ensure the Ranger has adequate opportunity to
well outside known estimated attend financial guidance appointments at the Armed
income? Forces Community Services (AFCS).
c) Refer the Ranger to the servicing Legal Assistance
Office for assistance with potential financial relief and
stay of court proceedings under the Servicemember's
Civil Relief Act.
6) Substance Misuse: Does the a) Refer the Ranger to Substance Use Disorder
Ranger have a history of alcohol or Clinical Care (SUDCC; formerly ASAP) at time of
drug related incidents and/or testing incident and collaborate with SUDCC Providers on
positive on a urinalysis? the treatment plan.
b) Contact SUDCC Providers about
recommendations for further evaluation, care, or
specialty referrals if there are indicators of ongoing
substance misuse or rehabilitation failure.
7) Suicidal Thoughts/Actions: Has a) Contact the Embedded Behavioral Health (EBH)
the Ranger expressed suicidal Team Leader, BH Officer, or assigned Battalion BH
thoughts, attempted suicide, or been Provider about recommendations for evaluation, care,
hospitalized on a psychiatric ward or specialty referrals.
within the past 2 years, or has the b) Ensure the Ranger has adequate opportunity to
Ranger attempted suicide or been attend behavioral health treatment appointments.
hospitalized on a psychiatric ward c) Follow current Safety Precautions recommended
multiple times in his/her life? by Behavioral Health Providers.

ATTENTION: This tool does not in any way replace the importance of involving a professional who is credentialed to assess for suicide risk, rather it can assist in the risk
assessment process. If you have immediate safety concerns about a Ranger, escort him/her to Embedded Behavioral Health during business hours or the Emergency
Department after business hours.

Version: 20160925

2025 RANGER MEDIC HANDBOOK 103

Bronchitis
DEFINITION: Inflammation of trachea, bronchi, and bronchioles resulting from upper respiratory tract infection (URI) or
chemical irritants; viruses are the most common cause.

S/Sx: Preceding URI symptoms, cough (initially unproductive, then productive), fatigue, +/– fever > 100.4, +/– dyspnea,
injected pharynx, may have wheezing or unremarkable lung sounds, sputum (color does not differentiate between viral
or bacterial)

MANAGEMENT:
1. Increase PO fluids.
2. Acetaminophen 1,000mg PO q6hr prn fever and Ibuprofen 800mg PO q8hr.
SECTION 3

3. Treat symptoms with antitussive, decongestants, expectorant, as needed.

4. If wheezing present, Albuterol MDI 2 puffs q4–6hr.
5. Ensure smoking cessation and enforce hydration. Consider throat lozenges for accompanying pharyngitis. Consider
O2 if SpO2 < 92%. If symptoms worsen or persist, consider treatment as per Pneumonia Protocol.

DISPOSITION: Evacuation usually not required. Observation or Routine evacuation as necessary. Urgent evacuation for
severe dyspnea or hypoxia.

SPECIAL CONSIDERATIONS: Consider high altitude pulmonary edema (HAPE) at high altitudes. Consider pulmonary
embolism (PE) and pneumothorax (fever and productive cough are atypical for these). Acute bronchitis is a common and
generally self-limiting condition that usually does not require antibiotics. Cough may linger for several weeks.

104 SECTION 3 TACTICAL MEDICAL EMERGENCY PROTOCOLS (TMEPs) & SICK CALL
Cellulitis / Cutaneous Abscess
DEFINITION: Acute superficial bacterial skin infection due to trauma, scratching or other lesions. Generally begins about
24 hours following a break in the skin, but more serious types of cellulitis may be seen as early as 6–8 hours following
animal or human bites.

S/Sx: Local warmth; painful, erythematous, swollen, tender area; induration, regional lymphadenopathy, Fever may
or may not be present; Typically, erythema spreads without treatment; Rapidly spreading and very painful infections
suggest the possibility of necrotizing fasciitis, a life-threatening infection of the deeper tissues that should be treated
per Sepsis/Septic Shock Protocol and URGENT evacuation to a surgical facility; Fluctuant, tender, well-defined mass
indicates abscess formation.

SECTION 3
MANAGEMENT:
1. Clean and dress wound and surrounding area.
2. Use a pen to mark the demarcation border of the infection and reevaluate in 24 hours.
3. A ntibiotics: Mild: doxycycline 100mg PO bid + amoxicilin 250mg bid OR trimethoprim-sulfamethoxazole (DS) 1–2
tabs bid × 5 days. Moderate: cephalexin 500mg PO qid × 7 days OR clindamycin 450mg PO tid × 7 days for first-
line failure/concern for MRSA. For human/animal bite, use amoxicillin/clavulanic acid 875mg PO bid for 7–10 days.
4. If no other antibiotics available, then moxifloxacin 400mg PO qd for 10 days.
5. Limit activity until infection resolves.
6. Add ertapenem 1g IV/IM qd if worsening at 48 hours or no improvement after 48 hours of treatment and seek evac/
higher care and look for abscess.
7. Treat per Pain Management Protocol. Cellulitis will not resolve if there is an abscess present.
8. IF ABSCESS IS PRESENT: Incise and drain (I&D) if the environment permits:
a. Establish sterile incision site with Chlorhexidine or comparable antiseptic.
b. Local anesthesia using Lidocaine.
c. Incise the length of the abscess cavity, but no further.
d. Incision should be parallel to skin tension lines if possible.
e. irrigate with adequate crystalloid solution or potable water.
f. Pack the wound loosely with iodoform or dampened gauze, if available. On subsequent dressings, you can wick
the wound. Bandage site and perform wound checks daily. DO NOT SUTURE THE SITE.
g. Abscess < 5cm in size do not require packing and studies show packing increases post procedural pain, pain at
48 hours, and more commonly require narcotics for pain control.
9. Duration of treatment should only be 5 days, reassessed and extended if the cellulitis is slow to resolve (J of I­nfection
Vol 81, issue 4 Oct 2020).
10. a. TMP/SMX (trimethoprim/sulfamethoxazole) dose is 1–2 DS tabs twice daily, effective against MRSA.
b. Doxycycline does not have very good strep coverage, recommendation is to use doxy + amoxicillin.
c. Cephalexin is effective against group A Strep and MSSA but not against MRSA coverage.

DISPOSITION: Reevaluate daily and watch for progression of erythema while on antibiotics. Cellulitis in critical areas
(head, neck, hand, joint involvement, perineal) requires Priority evacuation. Use of IV antibiotics requires Priority evacu-
ation or medical officer consultation. Instruct patient to keep area covered and avoid close contact to prevent spreading
infection to others or swimming to worsen infection.

SPECIAL CONSIDERATIONS: If abscess formation occurs, only attempt I&D in the tactical setting IF:
a. Patient is compromising mission due to inability to perform.
b. Delay I&D until mission completion is not possible.
c. The abscess is clearly well demarcated and superficial.
d. Local anesthesia and antiseptic are available.

2025 RANGER MEDIC HANDBOOK 105

Chest Pain
**Refer to Current ACLS Protocols if tactically feasible and if ACLS equipment and drugs are available. This
protocol assumes no access to ACLS medications or monitoring/defibrillation equipment. Do not delay evacuation if
tactically feasible.

DEFINITION: Possible myocardial infarction or reason to rule out cardiac-related chest pain.

S/Sx (Cardiac): The presence of one or more of the following risk factors increases the likelihood of coronary artery
disease: smoking, diabetes, hypertension, elevated cholesterol, obesity, family history of MI at a young age, and patient
age over 40.

The following are signs and symptoms suspicious for myocardial infarction as the etiology for chest pain: Substernal
SECTION 3

chest pain that may radiate to the left arm, neck, or jaw; Pain described as pressure or squeezing; Pain exacerbated
with exertion and relieved with rest; Associated dyspnea, diaphoresis (sweating), nausea, lightheadedness, or syncope;
Tachycardia, irregular heart rhythm, or severe bradycardia; Bilateral rales/crackles in the lungs on auscultation; Signifi-
cant hypertension or hypotension.

MANAGEMENT:
1. Aspirin 324mg PO (nonenteric coated) – chew to speed absorption.
2. Oxygen (if indicated) and pulse oximetry monitoring.
3. If available, Nitroglycerin 0.4mg SL initially, repeat q5min for total of 3 doses if not contraindicated (not hypotensive
and not taking medications to treat erectile dysfunction)
4. IV access with saline lock. Administer 250–500mL crystalloid solution as needed to correct hypotension with frequent
reassessment.
5. After above, treat per Pain Management Protocol.
6. Avoid all physical exertion. Allow the patient to rest in a position of comfort. Frequently reassess the patient including
hemodynamic status.

DISPOSITION: Urgent evacuation. Evacuation platform should include ACLS certified medical personnel and the equip-
ment, supplies, and medications necessary for ACLS care. Do not delay evacuation if unsure of chest pain etiology.
Strongly consider early contact with a medical officer or medical treatment facility for consultation. Frequently reassess
the patient suspected of a noncardiac etiology to ensure stability and accuracy of the diagnosis.

SPECIAL CONSIDERATIONS/OTHER ETIOLOGIES OF CHEST PAIN:

1. The following signs and symptoms MAY suggest a GI etiology such as gastroesophageal reflux disease (GERD):
dyspepsia, dysphagia, burning quality to chest pain, exacerbated by lying flat, foul or brackish taste in mouth. A trial
of antacids or famotidine 20mg PO bid may be useful if evacuation will be delayed.
2. Severe chest pain following forceful vomiting may indicate esophageal rupture. Administer IV crystalloid solution
150cc/hr and Ertapenem 1g IV and evacuate as Urgent.
3. Sudden onset of pleuritic chest pain with dyspnea may indicate pulmonary embolus or spontaneous pneumothorax.
Auscultate the lungs; unilaterally diminished breath sounds suggest pneumothorax which may require decompres-
sion. Administer oxygen, establish IV access, and evacuate as Urgent.
4. The following signs and symptoms MAY suggest a musculoskeletal etiology: pain isolated to a specific muscle or
costochondral joint pain exacerbated with certain types of movements, noncentral chest pain reproduced upon pal-
pation. A trial of NSAIDs such as Ibuprofen 800mg PO tid may be useful if evacuation will be delayed.
5. Chest pain with gradual onset and exacerbated by deep inspiration and accompanied by fever and productive cough
MAY indicate lower respiratory tract infection. Consider treatment per Bronchitis/Pneumonia Protocol.

106 SECTION 3 TACTICAL MEDICAL EMERGENCY PROTOCOLS (TMEPs) & SICK CALL
Compartment Syndrome
DEFINITION: A progressive ischemic injury to tissue and muscle that results from increased pressure within a closed
compartment of the body. A serious complication following wound closures, deep contusions, and long bone fractures
resulting in necrotic tissue, nerve and vascular damage. May be seen in shrapnel wounds within 48–96 hours of trauma.

S/Sx: Pain that is disproportionate from original injury; persistent deep ache or burning pain; paresthesia (onset 30
minutes to 2 hours due to ischemic nerve dysfunction; muscle weakness in affected area; tense with swollen shiny skin;
pain with passive stretch of muscles; tense compartment with firm feeling, decreased sensation and muscle weakness
(onset generally over 24 hours; pain with pressure over the compartment area; feeling of pressure in affected area; late
symptoms are diminished sensation distal to compartment area and diminished or absent pulses distal of to the injury.

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MANAGEMENT:
1. Remove any constricting clothing, splints or bandages.
2. Closed or partially closed wounds should opened, irrigated, and dressed with wound remaining open.
3. Manage pain as per Pain Management Protocol.
4. Gain IV access.
5. Ertapenem 1g IV qd OR ceftriaxone 2g IV qd OR moxifloxacin 400mg PO qd.
6. Fasciotomy only if properly trained and online medical direction.

DISPOSITION: Urgent evacuation to a surgical facility.

Conjunctivitis
DEFINITION: Eye conjunctiva inflammation due to allergic, viral, or bacterial cause.

S/Sx: All causes (burning, irritation, tearing); allergic (bilateral, serous or mucoid discharge, itching, redness, accom­
panying sneezing); viral (bilateral or unilateral, redness, watery discharge, conjunctiva swelling, tender preauricular
node, sandy/gritty/foreign body sensation, associated URI); bacterial (bilateral or unilateral, eye injection, mucopurulent
or purulent discharge)

MANAGEMENT:
1. Remove contact lens if worn.
2. Assess for visual acuity and document before/after all treatments.
3. Tetracaine 0.5%, 2 drops in the affected eye one-time only for exam and pain relief. DO NOT dispense to patient.
4. Check for foreign body to include eyelid eversion of upper and lower lids and assess using fluorescein stain for abra-
sion/ulcer. Irrigate with normal saline prn.
a. (Allergy): Attempt initial treatment with Artificial Tears, then if no resolution × 2 days naphazoline 2 drops q6hr × 3
days OR naphazoline/pheniramine 1 drop q6hr prn × 3 days.
b. (Viral): Natural Tears and treat per upper respiratory tract infection/common cold.
c. (Bacterial): Erythromycin 0.5% ophth oint q4hr × 3–5 days OR fluoroquinolone ophth drops – 1 drop in the affected
eye q6hr while awake for 5 days.
5. Treat per Pain Management Protocol (rare).
6. Reassess q24hr until resolved.

DISPOSITION: Generally, does not require evacuation. Evacuate Routine if S/Sx do not resolve with treatment.

2025 RANGER MEDIC HANDBOOK 107

Constipation / Fecal Impact
DEFINITION: Infrequent, hard, dry stools.

S/Sx: Recent history of infrequent passage of hard, dry stools or straining during defecation; abdominal pain, which is
typically poorly localized with cramping; if pain becomes severe and is associated with nausea/vomiting and complete
lack of flatus or stools, consider a bowel obstruction.

MANAGEMENT:
Generally, dietary modification to include increased fiber intake will resolve simple constipation conditions. First line is
30g dietary fiber daily along with 80–120oz of water.
1. If severe pain, rigid board-like abdomen, fever, and/or rebound tenderness develop, or moderate to large amounts of
SECTION 3

blood are present in the stool, then treat per Abdominal Pain Protocol.
2. Polyethylene glycol 17g in 4–8oz 2–3 times a day. Can increase to every 4 hours if needed. Ensure patient is well-
hydrated. Expect results in 2–3 days. Increase or decrease frequency of Polyethylene glycol to goal of soft, spongy
consistency.
3. If no relief, bisacodyl (Dulcolax) 10mg PO tid prn OR docusate 100mg PO bid.
4. If above measures fail, perform digital rectal examination to check for fecal impaction. If fecal impaction is present,
perform digital disimpaction, if trained.
5. Treat per Pain Management Protocol (no narcotics – they cause constipation). With all treatments, increase PO fluid
and fiber (fruits, bran, and vegetables) intake (both episodically and continuing lifestyle).

DISPOSITION: Evacuation is usually not required for this condition. Routine evacuation if no response to therapy.

SPECIAL CONSIDERATIONS: Differential diagnosis include acute appendicitis, volvulus, ruptured diverticulum, bowel
obstruction, pancreatitis, or parasitic infections. Acute onset, severe

Contact Dermatitis
DEFINITION: Skin reaction to external substance (plants, chemicals, topical medications, metals).

S/Sx: Acute onset of skin erythema and intense itching (pruritis); may see edema, papules, vesicles, bullae, discharge,
and/or crusting may be visible.

MANAGEMENT:
1. Remove offending agent and evaluate pattern.
2. Change clothes when possible and bag original clothes until they can be machine washed.
3. Wash area with mild soap and water.
4. Apply cold wet compress to affected area to help decrease itching.
5. If available, apply triamcinolone cream 0.1% (OR if on face, 1% hydrocortisone cream) to the affected area OR if
suspected poison ivy/oak/sumac, then Zanfel cream bid.
6. Give diphenhydramine 25–50mg PO q6hr prn itching, if tactically feasible. (Sedation may occur.)
7. In severe cases (hands/feet/face/genital or > 30% BSA), prednisone 60mg PO daily × 5 days burst or taper dose
down every 3 days for 14- to 21-day course OR dexamethasone 10mg IM qd for 5 days OR methylprednisolone
125mg IM × 5 days.

DISPOSITION: Priority evacuation for severe symptoms: intraoral or eye involvement, or > 50% BSA involvement. Rou-
tine evacuation for any cases not showing improvement < 24 hours after steroids. Monitor for secondary infection; treat
per Cellulitis Protocol if suspected on the basis of increasing pain, redness, or purulent crusting.

SPECIAL CONSIDERATIONS:
1. Insect bite(s) as a differential diagnosis – also accompanied by itching, but with discrete red papular lesions(s).
2. Cellulitis as a differential diagnosis – bright red, painful, nonpruritic, and typically becomes steadily worse without
antibiotics.
3. Fungal infection as a differential diagnosis – not always pruritic; infection site(s) slowly enlarge without therapy.
4. Effects are particularly dangerous if contact in or around the eyes.

108 SECTION 3 TACTICAL MEDICAL EMERGENCY PROTOCOLS (TMEPs) & SICK CALL
Corneal Abrasions / Corneal Ulcers
DEFINITION: A traumatic disruption of the epithelial covering of the cornea with three major concerns: intense eye pain,
corneal ulcer (vision-threatening infection), and potential for ruptured globe.

S/Sx: History of eye trauma or contact lens wear; severe eye pain; tearing; blurred vision; light sensitivity; fluorescein
stain positive; white or gray spot on cornea for corneal ulcer (usually need tangential penlight exam to see); for sudden
onset of eye pain after trauma in a patient with LASIK surgery, consider LASIK flap dislocation.

MANAGEMENT:
1. Remove contact lens if worn.
2. Assess for visual acuity and document before/after all treatments.

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3. Tetracaine 0.5%, 2 drops in the affected eye one time only for exam and pain relief. DO NOT dispense to patient.
4. Check for foreign body to include eyelid eversion of both upper and lower lids and assess using fluorescein stain for
abrasion/ulcer. Irrigate with normal saline prn.
5. Moxifloxacin 0.5% drops (1 drop qid) OR erythromycin 0.5% ophth oint q4hr × 3–5 days (inadequate coverage for
contact lens wearers) OR fluoroquinolone ophth drops – 1 drop in the affected eye q6hr while awake for 5d OR
bacitracin ointment qid – all applied until the corneal epithelium is healed.
6. Treat per Pain Management Protocol.
7. Reduce light exposure, stay indoors if possible – sunglasses if not possible.
8. For corneal abrasions: monitor daily for worsening signs and symptoms of a corneal ulcer (increasing pain and
development of a white or grey spot at abrasion site). DO NOT PATCH.
9. Assess using fluorescein stains daily — abrasions should get progressively smaller. Continue antibiotic drops until
24 hours after cornea becomes fluorescein negative (no bright yellow spot).
10. PO analgesics PRN IAW Pain Management Protocol.
11. IF CORNEAL ULCER PRESENT: Fluoroquinolone 1 drop in the affected eye q6hr while awake for 5 days. Urgent
evacuation to ophthalmologist. Moxifloxacin 400mg PO once a day may be added if evacuation is delayed or the
victim’s pain is becoming worse.

DISPOSITION: Reassess q24hr to ensure improvement. Evacuation may not be needed for corneal abrasion if improv-
ing with treatment.

Priority evacuation for Corneal Ulcer. Urgent evacuation for LASIK flap dislocation.

SPECIAL CONSIDERATIONS:
1. Contact lens corneal abrasions are at a high risk for development of a corneal ulcer. They should not be patched and
require more intensive antibiotic therapy.
2. Consider LASIK Flap dislocation for anyone that sustains eye trauma after LASIK surgery.
3. Consider Herpes Simplex or Fungal infections as well and contact a medical officer.

Cough
DEFINITION: Usually viral etiology but may also occur with high altitude pulmonary edema (HAPE) and pneumonia.

S/Sx: Cough with or without scant sputum production; often accompanied by other signs and symptoms of upper
respiratory tract infection (i.e. sore throat and rhinorrhea).

MANAGEMENT:
1. If associated with upper respiratory infection S/Sx, treat per protocol.
2. If absence of fever and URI S/Sx, treat per Bronchitis Protocol.
3. If fever, tachycardia. tachypnea, shortness of breath, treat per Pneumonia Protocol.
4. If at altitude, treat per Altitude Medical Emergency Protocol.

DISPOSITION: Correlate signs/symptoms to medical condition and manage by appropriate protocol.

DIFFERENTIAL: Causes of chronic cough include GERD, asthma, and PND.

2025 RANGER MEDIC HANDBOOK 109

Deep Venous Thrombosis (DVT)
DEFINITION: Potentially life-threatening condition in which a clot is present in the large veins of a leg and may dislodge
and localize in the pulmonary system, a pulmonary embolism.
S/Sx: History of recent trauma, air travel, altitude exposure, birth control pills, or family history of DVT; asymmetric pain
and swelling in a lower extremity (often the calf muscles); warmth over affected area; increased pain in the affected calf
muscles with dorsiflexion of the foot; palpable venous “cord.”
MANAGEMENT:
1. Monitor patient with pulse oximetry (sudden decrease in oxygen saturation or new chest pain/shortness of breath
suggests a pulmonary embolism).
2. Elevate the limb slightly, especially if the patient is experiencing swelling or pain, to reduce edema and promote
venous return. Avoid excessive manipulation or pressure on the affected limb, which could potentially dislodge the
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thrombus (blood clot) and lead to a pulmonary embolism (PE).

3. For associated respiratory distress (tachypnea, tachycardia, dyspnea, chest pain) consider pulmonary embolus and
treat per Chest Pain Protocol.
DISPOSITION: Priority evacuation if no respiratory distress or chest pain. Urgent evacuation If respiratory distress or
chest pain are present
SPECIAL CONSIDERATIONS: May be confused with a ruptured Baker’s cyst in a tactical setting.

Dehydration
DEFINITION: Inadequate fluid intake exacerbated by physical exertion or illness.
S/Sx: Lightheadedness (worse with sudden standing); mild headache (especially in the morning); dry mucosa; de-
creased urinary frequency and volume; dark urine (tea colored); degradation in performance
MANAGEMENT:
1. Assess for underlying condition and treat as per appropriate protocol in conjunction with this protocol.
2. Increase oral fluids if tolerated.
3. If available, use carbohydrate/electrolyte drink mixes for fluid replacement diluted to a 1:4 solution.
4. Avoid fluids containing caffeine.
5. If unable to tolerate PO fluids, use an initial bolus of 1L crystalloid IV, followed by repeat attempt at PO hydration. If
still unable to tolerate PO hydration, repeat 1L bolus of crystalloid IV.
6. Treat per Nausea/Vomiting Protocol as needed.
DISPOSITION: Monitor closely for recurrence of dehydration. Priority evacuation if dehydration persists after treatment.
SPECIAL CONSIDERATIONS:
1. Troops in the field are often chronically dehydrated.
2. Prolonged missions, acute diarrhea (gastroenteritis), viral/bacterial infections, and environmental factors (heat stress
or strenuous activity) all may exacerbate dehydration.
3. May also occur in cold or high altitude environments.

Dengue Fever
DEFINITION: A flaviviral disease transmitted by the Aedes aegypti and albopictus mosquitoes.
­­
S/Sx: Can be dormant for 1–7 days. Patients will have high fever with at least two of the following: severe HA, severe
retro-orbital PN, arthralgias, myalgias, rash, or petechiae. Hemorrhagic manifestations may include purpura/ecchy-
mosis, epistaxis, gum bleeding, blood in emesis, urine, or stool, or vaginal bleeding.
MANAGEMENT: Refer to higher medical care if suspected DF. Management is mostly supportive focusing mostly on
maintaining blood pressure and perfusion. Initiate Tylenol 1,000mg q6hr.
DISPOSITION: Urgent evacuation for suspected DF, dengue hemorrhagic fever (DHF), or dengue shock syndrome (DSS).
SPECIAL CONSIDERATIONS: Most commonly found in tropical Asia, Central and South America, and the Ca-
ribbean Dengue is the leading mosquito-borne infection. The Aedes prefers to feed in the daytime. Their bites can
go unnoticed. One mosquito can infect multiple people. Dengue can be transmitted by blood transfusions and organ
transplants but no recorded person-to-person transmission. Someone can be infected with any of the dengue viruses
and never develop DF. There is no vaccine or chemoprophylaxis for any of the dengue viruses. The primary means of
prevention is eliminating the mosquito breeding habits, wearing clothing properly, using insect repellent, and mosquito
nets. If a person has been infected with the dengue virus previously and is exposed again, they are at risk for either DHF
or DSS, which could be fatal.

110 SECTION 3 TACTICAL MEDICAL EMERGENCY PROTOCOLS (TMEPs) & SICK CALL
Dental Pain
DEFINITION: Most common causes are deep decay, fractures of tooth crown/root, acute periapical (root end) abscesses, or
pericoronitis (pain associated with an impacted wisdom tooth).
S/Sx: Intermittent or continuous pain (usually intense), heat or cold sensitivity; visibly broken/cracked tooth; severe pain
on percussion; intraoral swelling/abscess; partially erupted wisdom tooth.
MANAGEMENT:
1. Treat per Pain Management Protocol. Consider application of clove oil–soaked gauze for pain relief.
2. If signs and symptoms of infection are present, administer amoxicillin/clavulanic acid 875mg PO bid for 7 days OR
ceftriaxone 1g IV/IM qd × 7 days OR if previous unavailable, then azithromycin 500mg PO initially followed by 250mg
PO qd × 4 days.

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3. If gums appear swollen and red, encourage increased oral hygiene and warm saline rinses bid. Consider local or
regional anesthesia if trained.
DISPOSITION: Evacuation usually not necessary. Routine evacuation if not responding to therapy or requiring IV antibiotics.

Determination of Death
DEFINITION: Immediate determination of death is appropriate in a trauma patient without pulse or respirations in the
setting of multiple casualties when resuscitative efforts would hinder the care of more viable patients. It is assumed that
personnel do not have access to ECG, or other monitoring equipment to evaluate heart rhythm, or deliver countershocks.
S/Sx: Obvious death – persons who, in addition to absence of respiration, cardiac activity and neurologic reflexes have
one or more of the following: decapitation; massive crushing and/or penetrating injury with evisceration of the heart,
lung, or brain; incineration; decomposition of body tissue; rigor mortis or post-mortem lividity.
MANAGEMENT:
1. In the setting of obvious death, resuscitative efforts should not be initiated.
2. If resuscitative efforts have been initiated, discontinuation should be considered: After 15 minutes (if the cause is un-
known or due to trauma) or after 30 minutes (when the cause is due to hypothermia, electrical injury, lightning strike,
cold water drowning, or other cause known to require a prolonged resuscitative effort) when: There is persistent
absence of pulse and respirations despite assuring airway and ventilation as well as administration of resuscitative
fluids and medications; no response to deep pain above or below the clavicles; absence of SpO2 and EtCO2, from a
correctly placed endotracheal tube or alternative airway.
3. If there is any question as to the discontinuation of resuscitative efforts, continue ACLS/ALS treatment protocol and
then a medical officer should be contacted for guidance.
4. In traumatic arrest, consider and as tactically feasible, conduct bilateral finger thoracostomy and airway maneuver or
advanced airway placement with re-evaluation prior to discontinuing resuscitation.
DISPOSITION: Evacuation of the remains when tactically feasible. In the event of return of spontaneous circulation,
Urgent evacuation.
SPECIAL CONSIDERATIONS: Patients that are struck by lightning, have hypothermia, cold-water drowning, or intermit-
tent pulses may require extended cardiopulmonary resuscitation.

Electrocution
DEFINITION: Death or serious injury caused by electric shock, electric current passing through the body. Injury can occur
through both direct electrocution and from blast/blunt trauma injuries.
MANAGEMENT: Follow Tactical Trauma Assessment Protocol with additional key notes outlined in this Protocol. Light-
ning strikes deliver direct current (DC) electrocution and domestic electrocution is classically alternating current (AC).
Maximal injury due to DC is usually cardiac and respiratory arrest, and AC injury can cause ventricular fibrillation. Fixed
and dilated pupils are often due to transient autonomic disturbance, but be sure to rule out closed head injury first.
Rhabdomyolysis and compartment syndrome can develop. For lightning strike casualties conduct reverse triage as
apnea/asystole is commonly transient and can resolve with BLS/ACLS support until return of respirations and pulse.
DISPOSITION: Evacuate any patients with systemic symptoms to higher level of care.

2025 RANGER MEDIC HANDBOOK 111

Envenomation – Arthropod
(Spider & Scorpion)
DEFINITION: Toxic envenomations from arthropods are generally not life threatening, but can cause conditions requiring
treatment and potential hospitalization. Most suspected “spider bites” are MRSA abscesses. Assume abscess unless
the spider bite was witnessed.
Black Widow:
S/Sx: Pinching bite followed by local swelling and burning; large muscle group spasms/tremors; abdominal pain and/
or rigidity within 60 minutes (may mimic appendicitis or acute surgical abdomen); nausea and vomiting; diaphoresis;
hypertension; tachycardia.
MANAGEMENT:
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1. Treat per Pain Management Protocol (narcotic analgesia).

2. Midazolam 2–5mg IV/IM for relief of muscle spasm.
3. Diphenhydramine 25–50mg q6hr prn PO/IV.
4. In cases of suspected black widow spider bites, consider other causes for acute abdominal pain.
Brown Recluse:
S/Sx: Local pain and ulceration at site within 2–8 hours with surrounding erythema; Hemorrhagic vesicle progressing to
slowly enlarging eschar; fever, chills, nausea, joint pain.
MANAGEMENT:
1. Elevate bite site.
2. Avoid strenuous activity.
3. Treat per Pain Management Protocol (narcotic analgesia).
4. Diphenhydramine 25–50mg q6hr prn PO/IV.
5. Monitor and treat per Cellulitis Protocol.
Scorpion:
S/Sx: Local pain, swelling, and erythema; nausea and vomiting; paresthesia; tongue fasciculations; sympathetic (tachy-
cardia, hypertension, hyperthermia) or parasympathetic (hypotension, bradycardia, hypersalivation, incontinence) over-
drive can develop; seizures; agitation; blurry vision/rotary eye movements.
MANAGEMENT:
1. Treat per Pain Management Protocol.
2. Treat per Nausea and Vomiting Protocol.
3. Supportive care as necessary per appropriate protocol.
4. Diphenhydramine 25–50mg q6hr prn PO/IV.
5. Apply ice or cold water.
DISPOSITION: Urgent evacuation for development of abdominal rigidity, development of systemic signs, or for anaphy-
laxis. Routine evacuation for tissue necrosis of brown recluse bite. Evacuation typically not required for localized insect
stings and scorpion bites.

Envenomation – Insect, Hymenoptera

(Bee, Wasp, Hornet)
DEFINITION: Toxic envenomations from bees, wasps, and hornets are all capable of causing life-threatening anaphy-
laxis, especially in personnel with known hypersensitivity. Personnel with known reactions should maintain their own
epinephrine administration kit (Epi-Pen).
S/Sx: Pain; swelling/edema; puncture site(s) from stinger or fangs; warmth; erythema; signs of anaphylaxis
MANAGEMENT: If signs and symptoms of anaphylaxis present, treat per Anaphylaxis Protocol.
Hymenoptera (Bee, Wasp, Hornet):
1. Remove stinger by scraping from side.
2. Apply ice or cold water.
3. Apply topical 1% hydrocortisone cream.
4. Apply topical lidocaine.
5. Ibuprofen 800mg PO tid × 7 days.
6. Diphenhydramine 25–50mg q6hr prn PO/IV.
DISPOSITION: Urgent evacuation for development of systemic signs or for anaphylaxis. Evacuation typically not re-
quired for localized insect stings and scorpion bites.
SPECIAL CONSIDERATIONS: Tactical medics must always be aware of unit personnel with known insect hypersensitivities.

112 SECTION 3 TACTICAL MEDICAL EMERGENCY PROTOCOLS (TMEPs) & SICK CALL
Envenomation – Marine
DEFINITION: Marine envenomation results from stings by jellyfish, fire corals, stingrays, sea urchins, bristle worms, fish
spines, and sea snakes. All of these envenomations are more likely to occur in intertidal regions, reefs, and surf zones.

Jellyfish Sting: Contact with jellyfish tentacles causes immediate, intense sharp and burning pain, followed by local,
linear erythematous eruption; Severe stings can cause anaphylactic reaction, hematuria, vomiting, syncope, hypoten-
sion, or paralysis; (Envenomation by fire coral is similar to jellyfish, but less severe and rarely causes complications. Pain
symptoms usually resolve within 12 hours).

Bristleworm Sting: Is caused by contact with bristle-like setae on feet of animal. Contact is like brushing against a
cactus plant and may result in many fine bristles embedded in the skin. Causes painful inflammation, which is almost

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never serious.

Stingray Puncture: Spine on tail contains retroserrated teeth, with a venom gland along the groove. Envenomation
causes immediate, intense pain at site of injury out of proportion to what it looks like, edema. Pain tends to peak 30–60
minutes after puncture and can last for several days. Rare systemic symptoms include limb paralysis, hypotension, and
bradycardia.

Sea Urchin Puncture: Frequently cause multiple deep puncture wounds when stepped on. Puncture and envenomation
cause immediate, intense pain, erythema, and local swelling. If more than 15–20 punctures are present, then severe
systemic symptoms can occur.

Fish Spine Puncture: First symptom is usually immediate localized pain out of proportion to clinical manifestations,
lasting minutes to hours. Puncture wound is usually cyanotic, with surrounding erythema and edema. Pain is often noted
in proximal lymph nodes.

Symptoms can progress to delirium, malaise, nausea, vomiting, and elevated temperature. Infrequently leads to shock
and death.

Sea Snake Bite: Fang and teeth marks consist of small puncture wounds and may number from 1 to 20. Latent period
of 10 minutes to several hours between bite and onset of symptoms. May initially present with mental status changes,
including euphoria, anxiety or restlessness. Progresses to dry throat, nausea, vomiting, generalized weakness and pa-
ralysis, leading to respiratory distress/failure.

Blue Ringed Octopus Bite: Bite is painless and may go unnoticed. Patient may become paralyzed with respiratory
distress. Symptoms are usually rapid in onset and extremely variable in severity.

Sting Management (Jellyfish, Sea Wasp):

1. Remove stinger, tentacles, etc. if possible with gloved hand, forceps or tape.
2. Immediately flush with dilute acetic acid (vinegar). Alternative flush is isopropyl alcohol and seawater. Do not use
fresh water.
3. Topical lidocaine.
4. Topical steroids.
5. Follow Pain Management Protocol.

Bite Management (Sea Snakes, Blue-Ringed Octopus):

1. Treat as a snake envenomation.

Puncture Management (Sea Urchin, Stingray, Fish Spines, Bristleworms):

1. Remove all penetrating foreign bodies with gloved hand, forceps or tape.
2. Irrigation with cold seawater.
3. Soak the affected area in non-scalding water (110–115 degrees) for 30–90 minutes to inactivate toxins.
4. Ultrasound (preferred imaging) or x-ray (if available for retained foreign body).
5. Antibiotics for deep puncture wounds: Moxifloxacin 400mg qd.
6. Follow Pain Management Protocol.

DISPOSITION: Urgent evacuation if evidence of severe envenomation (cardiovascular collapse, anaphylaxis, paralysis,
ascending edema of limb). Evacuation not required if signs and symptoms do not indicate severe envenomation after
24 hours of observation.

2025 RANGER MEDIC HANDBOOK 113

Envenomation – Snake
DEFINITION: Snake bites and actual envenomation is rare. More care should be taken to avoid snakes and potential
bites than the likelihood of an actual envenomation.

Crotalidae (Pit Vipers, Rattlesnake, Moccasin, Bush Master):

S/Sx: Sudden pain; erythema; ecchymosis; hemorrhagic bullae; bleeding from site; metallic taste; hypotension/shock;
swelling/edema.

Elapids (Coral Snake, Sea Snake, Mamba, Cobra, Taipan, Kraits):

S/Sx: Cranial nerve dysfunction (i.e., ptosis, difficulty swallowing); paresthesia; fasciculations; weakness; altered mental
status
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MANAGEMENT:
1. If signs and symptoms of anaphylaxis present, treat per Anaphylaxis Protocol.
2. General supportive care as necessary through emergency protocols.
3. Treat per Pain Management Protocol using narcotics. Avoid NSAID use.
4. Treat per Nausea and Vomiting Protocol.
5. If toxic snakebite suspected (significant pain, edema, evidence of coagulopathy or neurologic signs/symptoms):
a. Minimize activity and place on a litter.
b. Remove all constricting clothing and jewelry.
c. Initiate saline lock in unaffected extremity.
d. Monitor and record vital signs and extent of edema every 15–30 minutes.
e. IV crystalloid for hypotension as necessary.
f. Immobilize affected limb in neutral position.
g. A compression wrap (proximal to distal) may be helpful with an elapidae (neurotoxic) snake (cobra, mamba, coral
snake), but is not indicated with crotalidae (pit viper) bites.
h. The need for a fasciotomy is difficult to determine in a snake bite unless compartment pressures have been taken.
i. Cold therapy and suction therapy are ineffective in snakebites.

DISPOSITION: Urgent evacuation if treated for anaphylaxis. Urgent evacuation for elapidae bites or if evidence of se-
vere envenomation (systemic signs and symptoms, progressive ascending edema) exists. Evacuation not required for
crotalidae bites if signs and symptoms do not indicate anaphylaxis or development of severe envenomation after four
hours of observation.

SPECIAL CONSIDERATIONS:
1. Only a minority of snakebites from toxic snakes involve severe, life-threatening envenomations.
2. Incision, excision, electrical shock, tourniquet, oral suction, and cryotherapy should NOT be performed to treat
snakebites.
3. Suction device is not effective for removing snake venom from a wound. If previously placed, it should be left in place
until patient reaches higher level of care.

114 SECTION 3 TACTICAL MEDICAL EMERGENCY PROTOCOLS (TMEPs) & SICK CALL
Epistaxis
DEFINITION: Anterior or Posterior Nosebleed

S/Sx: Nosebleed, often previous history of nosebleeds

MANAGEMENT:
1. Clear nares/airway by having patient sit up and lean forward and blow nose.
2. Oxymetazoline nasal spray 2 squirts in each nostril.
3. Pinch anterior area of nose firmly for full 10 minutes WITHOUT RELEASING PRESSURE.
4. Assess for continued bleeding and have patient clear/blow nose.
5. If bleeding continues, pack with Afrin-soaked gauze bilaterally along floor of nasal cavity × 24 hours.

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6. Once bleeding has stopped (after 30 minutes), remove the Afrin nasal sponge and apply Bactroban to the affected
nostril bid – tid × 7 days.
7. Clear clots and other material from airway (if required) by having patient sit up, lean forward, and blow his/her nose.
8. If bleeding continues, pack with TXA-soaked gauze bilaterally along floor of nasal cavity × 30 minutes then execute
step 6).
9. IF BLEEDING CONTINUES despite packing or rebleeding occurs after 24 hours: Prepare 14 French Foley cath-
eter. (Tip is cut to minimize distal irritation). Advance catheter along floor of nose (straight in) until visible in mouth. Fill
balloon with 5mL of normal saline. Retract catheter until well opposed to posterior nasopharynx. Add an additional
5mL of normal saline to balloon. Clamp in place without using excessive anterior pressure. Moxifloxacin 400mg PO
qd until packing is removed. Leave balloon and packing in place for 72 hours.

DISPOSITION: Evacuation may not be required if epistaxis is mild, anterior, and resolves with treatment. Urgent evacu-
ation for severe epistaxis not responding to therapy or if Foley catheter is used.

SPECIAL CONSIDERATIONS:
1. Common at high altitude and in desert environments due to mucosal drying. Administer petroleum-based lubricant
to internal nasal passages for prevention.
2. May be anterior or posterior.
3. Posterior epistaxis may be difficult to stop and may cause respiratory distress due to blood flowing into the airway.
This type of epistaxis is uncommon in young healthy adults. It is more commonly seen in older, hypertensive patients.

Flank Pain
(Includes Renal Colic, Pyelonephritis, Kidney Stones)
DEFINITION: Flank pain possibly caused by renal colic, pyelonephritis, or kidney stones.

S/Sx: Flank Pain; urinary tract infection (dysuria and/or polyuria); back pain; nausea/vomiting; costovertebral angle
tenderness; fever; hematuria.

MANAGEMENT:
1. Treat per Pain Management Protocol with ketorolac if kidney stone suspected.
2. Treat per Nausea and Vomiting Protocol.
3. Treat per Dehydration Protocol.
4. If fever present treat with antibiotics and evacuate:
a. Trimethoprim-sulfamethoxazole 1 tab PO bid OR amoxicillin/clavulanic acid 875mg PO bid.
b. Ceftriaxone 1g bid IV/IM OR ertapenem 1g IV/IM if unable to tolerate PO or unresponsive to oral treatment.

DISPOSITION: Priority evacuation

SPECIAL CONSIDERATIONS:
1. May progress to life-threatening systemic infection.
2. May be associated with testicular torsion. Ensure normal external GU exam first.

2025 RANGER MEDIC HANDBOOK 115

Frostbite & Frostnip
DEFINITION:
Frostnip: superficial freezing of the skin, a precursor to frostbite, that produces reversible skin changes that usually re-
solve with warming. FROSTBITE: occurs when tissue freezes and crystals form in the extracellular space between cells.

S/Sx: Edema; tenderness; loss of sensation (often loss of previous painful sensation); inability to move or flex affected
areas; blisters (clear-fluid blisters indicate less severe/hemorrhagic blisters indicate a deeper, more severe injury); skin
color may be pale, yellowish, or waxy-looking; frozen area will feel solid or wooden and may have a lifeless appearance.

MANAGEMENT:
1. Prevent additional freezing and/or progression of injury.
SECTION 3

2. DO NOT attempt rewarming or thawing if there is a chance that refreezing will occur.
3. Treat per Pain Management Protocol prior to attempting rewarming. FROSTNIP:
a. Administer passive re warming with warming devices such as warm blankets, insulated ready-heat, or HPMK.
b. Manage mild to moderate pain as per Pain Management Protocol.
c. After rewarming, assess every 6 hours for tissue damage or signs of infection. Give NSAIDs prn × 5 days.

Frostbite:
1. Administer passive rewarming with warming devices as above OR if available, preferred is rapid rewarming in 104–
108°F (40°C) water.
2. Gain IV access.
3. Administer warmed crystalloid fluids (1,000–1,500mL) to reduce blood viscosity and capillary sludging.
4. For pain, treat with narcotics or for severe pain as per Pain Management Protocol.
5. Clean and dress any blisters that have burst while avoiding bursting any intact blisters.
6. Splint fingers/toes and separate digits with nonadherent gauze.
7. Elevate extremities to reduce edema.
8. Initiate NSAID regimen until evacuated.

DISPOSITION: Urgent evacuation if risk of refreezing or rewarming is not an option. Priority evacuation for frostbite.
Frostnip generally will not require evacuation if resolved (any indication of infection or tissue damage should be evacu-
ated as routine.

SPECIAL CONSIDERATIONS:
1. Ensure complete differential diagnosis from hypothermia (hypothermia may occur in conjunction with frostbite and
should be managed first).
2. Do not allow patient any type of tobacco product.
3. Do not rub or massage injured tissue in the re-warming process.
4. Rangers are more susceptible to cold at high altitudes or windy conditions below 32°F.

116 SECTION 3 TACTICAL MEDICAL EMERGENCY PROTOCOLS (TMEPs) & SICK CALL
Fungal Skin Infection
DEFINITION: Dermatophyte (tinea) infections are common worldwide and are common causes of tinea corporis, tinea
pedis, tinea cruris, and tinea capitis.
Tinea Corporis: A dermatophyte infection of the skin that occurs predominantly on the core (body surfaces other than
the feet, groin, face, scalp hair, and beard hair), also known as ringworm. Tinea corporis is typically acquired by skin-to-
skin contact. S/Sx: Initially: Pruritic, circular or oval, erythematous, scaling patch or plaque that spreads centrifugally.
An annular, raised border, plaque appears after a few days in a “ringed appearance.” Treatment: Apply terbinafine or
Itraconazole once to twice per day × 1–3 weeks.
Tinea Pedis: An infection of the skin that occurs on the feet (also known as athlete’s foot). Tinea pedis is typically
acquired by direct skin contact, usually from showers or locker rooms. S/Sx: Pruritus; erythematous erosions or scales
between toes, soles, medial, or lateral aspect of the foot. Treatment: Apply topical terbinafine 1% once to twice daily

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× 4 weeks.
Tinea Cruris: A dermatophyte infection of the skin that occurs in the crural fold (also known as jock itch). Tinea cruris is
typically associated with an active tinea pedis infection. S/Sx: Initially begins with an erythematous patch on the proxi-
mal medial thigh, then spreads centrifugally with slightly elevated erythematous, sharply demarcated borders with tiny
vesicles possibly present. The infection may spread to the perineum, gluteal cleft, buttocks, but sparing the scrotum in
males. Treatment: Apply terbinafine or Itraconazole once to twice per day × 1–3 weeks.
Tinea Capitis: A dermatophyte infection of the skin that occurs in the scalp. Tinea capitis is typically associated with
direct contact from an infected person or object (i.e., hat or comb). S/Sx: Pruritis and scaly patches present on scalp.
Treatment: Oral systemic antifungal therapy (griseofulvin, terbinafine, fluconazole, or itraconazole). Topical antifungal
creams are ineffective.
SPECIAL CONSIDERATIONS: Dermatophyte infections that do not resolve with topical antifungal creams should be
treated with oral systemic antifungals. Consult a medical provider for any dermatophyte infections that do not respond
to topical antifungal creams. A boggy, pustular area on the scalp (kerion) can develop secondary to tinea capitis. Do
not confuse with abscess and do not I&D. Treatment is oral antifungals in consultation with a medical provider. Note:
fungal infections can be complicated and diverse in nature, so consult a medical provider if you are unsure of the nature
of the infection.

Gastroenteritis
(Diarrhea/Nausea/Vomiting)
DEFINITION: Usually due to an acute viral infection of the GI tract, but bacteria or parasite infections are common in
deployed environments.
S/Sx: Acute onset of nausea, vomiting, and diarrhea; fever may or may not be present; abdominal cramping, discomfort,
or distension may or may not be present; possible S/Sx of dehydration.
MANAGEMENT:
1. If severe pain, rigid board-like abdomen, fever, and/or rebound tenderness develop, or moderate to large amounts of
blood are present in the stool, then treat per Abdominal Pain Protocol.
2. Treat per Nausea and Vomiting Protocol and/or Dehydration Protocol.
3. Either allow diarrhea to pass for 24 hours OR if diarrhea has already persisted for > 24 hours, then consider admin-
istering loperamide 4mg PO initially, then 2mg PO after every loose bowel movement with a maximum dose of 16mg
per day (do not use loperamide in the presence of fever or bloody stools).
4. If bloody diarrhea, fever > 100.4°F at onset/development or persists > 48 hours after initial treatment, azithromycin
500mg PO qd for 3 days or ciprofloxacin 500mg PO bid for 3–5 days.
5. Bloody diarrhea should remit within 2–3 days of starting antibiotics. Consider metronidazole 500mg PO tid for 5 days
if persist and consider advanced workup or evacuation.
DISPOSITION: Urgent evacuation if grossly bloody stools or circulatory compromise. Priority evacuation if dehydra-
tion occurs despite above therapy. Routine evacuation if diarrhea persists after 3 days of therapy or if it develops while
already on antibiotics.
SPECIAL CONSIDERATIONS:
1. Antibiotics are generally not needed for routine bacterial causes.
2. Emerging fluoroquinolone resistance among enteropathogenic E. Coli and Campylobacter and recent black box
warning makes azithromycin the new primary agent for therapy.
3. Consider antibiotic-related diarrhea if on antibiotics at onset.
4. Consider parasitic infection if symptoms persist for 3 or more days.
5. Must rule out malaria if fever and GI symptoms exist in a malarious area.
6. Azithromycin is considered treatment of choice for traveler’s diarrhea.

2025 RANGER MEDIC HANDBOOK 117

Headache
DEFINITION: Headache
S/Sx: Headache; if the headache is atypical for the patient or “thunderclap/worst HA of life” or neurological exam
changes, check for elevated blood pressure (if possible), fever, neck rigidity, visual symptoms, mental status changes,
weakness, and dehydration.
MANAGEMENT:
1. Perform full neurological exam and document.
2. If history of trauma or blast proximity, treat per Concussion/mTBI Protocol.
3. If the patient has fever, signs of altered mental status while not at altitude, nuchal rigidity, photophobia, or petechial
rash, then assess per Meningitis Protocol.
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4. If at altitude, treat per Altitude Medical Emergency Protocol.

5. If atypical or “thunderclap/worst HA of life,” evacuate urgent for CT scan to rule out life-threatening intracranial
pathology.
6. If headache is accompanied by nausea and/or vomiting, treat per Nausea and Vomiting Protocol.
7. Treat per Pain Management Protocol.
8. If dehydration is suspected, treat per Dehydration Protocol.
9. Oxygen can be attempted to treat cluster headache.
DISPOSITION: Evacuation is usually not required if the headache responds to therapy. Acute headache in the presence
of fever, severe nausea and vomiting, mental status changes, focal neurological signs, or preceding seizures, loss of
consciousness, or a history of “thunderclap/it’s the worst headache of my life” constitutes a true emergency and requires
Urgent evacuation. Also consider Urgent evacuation for anyone without a prior history of headaches if their pain is severe.
SPECIAL CONSIDERATIONS: The number of differential diagnoses for the acute headache is large and includes dis-
orders that encompass the spectrum of minor to severe underlying disorders.

Headache
(Migraine Origin)
DEFINITION: Chronic episodic headache disorder capable of altering daily function lasting 4–72 hours.

S/Sx: Prior history of diagnosed migraines; Headache that begins with mild pain that escalates into a unilateral and
throbbing pain lasting 4–72 hours; no immediate history of head trauma or blast exposure; headache intensified with
physical movement; may have accompanying nausea, vomiting, photophobia, phonophobia; may be preceded by an
aura of visual disturbances, sensory disruption in arms or face, and speech difficulties.

MANAGEMENT:
1. Perform a complete neurological exam to exclude other etiologies (If patient is compliant enough) and refer to ap-
propriate protocol if indicated.
2. If suspected migraine, move to a dark, cool, quiet environment (if possible).
3. Initiate treatment with available triptan: Rizatriptan 5–10mg PO (may repeat 1 dose in 2hr prn) OR Sumatriptan 6mg
subcutaneous (may repeat 1 dose in 2 hours prn).
4. Acetaminophen 1,000mg q6hr AND aspirin 325mg q6hr AND caffeine 200mg q6hr (single combined drug option is
Excedrin Migraine).
5. Consider prevention or management of nausea and vomiting with promethazine 25mg IV/IM/PO q6hr prn AND
diphen­hydramine 25–50mg IV/IM/PO q6hr prn.
6. Encourage sleep, hydration, and light meals if possible.

DISPOSITION: Priority evacuation if condition does not improve with continual repeat treatments, condition worsens, a
single episode is persistent greater than 24 hours, or individual becomes a risk to the mission.

SPECIAL CONSIDERATIONS:
1. Do not assume new headache with neurologic abnormalities is a migraine. Treat per stroke/ACLS guidelines or Men-
ingitis Protocol based on clinical scenario.
2. Generally avoid the use of narcotics, but if primary management is unresolved with intense pain that is compromising
mission, consider IAW Pain Management Protocol.
3. NSAIDs are generally ineffective but may provide some relief if no other options are available.
4. Migraine-prone individuals should be identified before deployment.

118 SECTION 3 TACTICAL MEDICAL EMERGENCY PROTOCOLS (TMEPs) & SICK CALL
HIV Post-Exposure Prophylaxis
HIGH-RISK EXPOSURES: Percutaneous injury (needle stick or other contaminated penetrating injury); exposure or ex-
change of body fluids with persons at high risk for HIV; transfusion of blood products that have not undergone standard
US blood bank or equivalent testing for transmissible diseases; when attempting to evaluate a high-risk exposure, take
into account the source of the bodily contamination. For example, blood from a fellow Soldier would fall into a low-risk
category for exposure.

MANAGEMENT:
1. Immediately wash area with soap and water to clean area and minimize exposure.
2. Use a rapid HIV test kit (if available) to determine if therapy should be initiated. In high-risk situations, do not delay
initiation of therapy if the test kit is not available. HIV PEP should be started within 1–2 hours of exposure.

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3. Consult with unit medical officer ASAP to discuss the case and obtain further guidance after any significant exposure.
a. If the rapid HIV test is positive, initiate PEP.
b. If high-risk exposure occurs and a rapid HIV test is unavailable, initiate PEP.
c. If a rapid HIV test is negative, seek medical officer guidance to determine the need for PEP.
d. Initiate antiretroviral triple therapy according to the following priority of drugs. Choose only 1 of the follow-
ing drug treatment options: Tenofovir disoproxil 300mg/emtricitabine 200mg (Truvada) qd PLUS raltegravir
(Isentress) 400mg bid OR dolutegravir (Tivicay) 50mg qd. The alternative regimen is: tenofovir disoproxil 300mg/
emtricitabine 200mg qd PLUS darunavir (Prezista) 800mg AND ritonavir (Norvir) 100mg qd.
4. For GI side-effects of medication, treat per Nausea and Vomiting Protocol.
5. Maintain hydration and nutrition status.
DISPOSITION: Urgent evacuation if a significant exposure occurs and highly active antiretroviral therapy (HAART) is not
available. Routine evacuation if HAART is available and Rapid HIV Test is positive. Consult unit medical officer to de-
termine the need for, and the priority of evacuation, if high-risk exposure has occurred and a Rapid HIV Test is negative

SPECIAL CONSIDERATIONS:
1. Initiation of the HAART should ideally occur within 2 hours of exposure, but still has some effect up to 72 hours after
exposure.
2. Antiretrovirals have a significant side-effect profile, including nausea, vomiting, and diarrhea.
3. Obtain a sample of the source’s blood for HIV and hepatitis testing, if possible.
4. Use of a commercially available rapid HIV test kit that uses either an oral specimen or whole blood is recommended
for source testing to determine if HAART therapy should be initiated. This should occur within 1–2 hours. The test
requires 20–40 minutes to obtain results.

POSTEXPOSURE PROPHYLAXIS HOTLINE: CALL 1-888-448-4911 24/7 WITH ANY QUESTIONS

2025 RANGER MEDIC HANDBOOK 119

Hyperthermia
Heat Injuries
Heat injuries fall into a continuum of heat cramps to heat exhaustion to heat stroke. While the mechanism of heat
cramps is not fully understood, there is convincing evidence to suggest it is the result of sodium depletion or over­
hydration. Heat exhaustion and heat stroke represent a spectrum of disorders, which range in intensity and the severity
of tissue damage. The pathophysiology of heat exhaustion and heat stroke are so similar that they may represent a
continuum of disease rather than separate, distinct diseases and both are characterized by sodium and water deple-
tion. Heat cramps, heat exhaustion, and heat stroke are all illnesses related to a failure of the body to maintain fluid and
electrolyte balance to the challenge of adapting to added heat loads. These conditions may develop over several days,
allowing adequate time for effective intervention. The maintenance of adequate diet and fluid intake is essential. The use
of dietary supplements can lead to dehydration and increased likelihood of heat injury. When faced with increased heat
loads, the body is dependent on sweating to maintain a constant body temperature. The sources of the heat load may
SECTION 3

be external (a hot day), internal (a road march with 50 pounds of gear), or both (a road march in the desert sun). If the
heat load exceeds the body’s ability to lose heat, a heat injury will result.

Heat Cramps
The term “heat cramps” is actually a misnomer, as muscle cramping more likely results from sodium depletion during
intense activity, not heat. In fact, cooling of a fatigued muscle is often a contributing factor. Heat cramps typically occur in
individuals undergoing prolonged, intense activity in a hot and humid environment. Heat cramps are brief, intermittent, and
very painful but can be largely prevented by maintaining an adequate salt and fluid balance prior to and during exertion.
S/Sx: Painful, tonic contractions of skeletal muscles frequently preceded by palpable or visible fasciculation. Fatigue,
dizziness, nausea, and vomiting are common.
MANAGEMENT: Obtain hydration and diet history to guide management and identify likely electrolyte cause. Use iSTAT
or similar point of care lab testing device to evaluate electrolytes if available. Oral electrolyte rehydration and foods are
the initial management of choice. IV crystalloid solution is indicated if more rapid treatment is needed. Mild stretching
and massage of the contracting muscle will provide some relief to the intense discomfort. May return to activity after
symptoms resolve but patient is at risk for return of heat cramps or other heat injury.

Heat Exhaustion/Stroke
Heat exhaustion is the most common heat illness. Although heat exhaustion in a military setting often manifests after
extreme exertion, in reality, it likely develops over several days and is a result of cardiovascular strain as the body tries to
maintain normothermia in a hot environment. Heat exhaustion occurs when the demands for blood flow (to the skin for
temperature control through convection and sweating, to the muscles for work, and other vital organs) exceed the car-
diac output. A body that has developed a state of salt depletion over several days, in combination with extreme exertion,
is at risk for heat exhaustion. Recent upper respiratory infection can be both predictive and prognostic of a heat stroke.
S/Sx: Profound fatigue, chills, nausea/vomiting, tingling of the lips, shortness of breath, orthostatic dizziness, headache,
syncope, hyperirritability, anxiety, piloerection, heat cramps, heat sensations in head and upper torso. Casualty may or
may not feel thirsty. Tachypnea, tachycardia, orthostatic hypotension may be present. Core temperature may be normal
or greater than 104ºF. Heat stroke can be defined as a heat injury with central neurological symptoms such as altered
mental status or seizures.
MANAGEMENT: Heat Exhaustion: Reduce the load on the heart with rest and cooling. Place casualty in shade and
remove heavy clothing. Apply cool water to the skin, if available. Correct water and electrolyte depletion by administer-
ing oral or IV fluids. IV fluids replenish the volume and correct symptoms quickly. Patients with resting tachycardia or
orthostatic hypotension should initially receive up to 1–2L boluses of crystalloid solution and monitored for these vital
signs to correct. If patient can tolerate oral fluids, use an oral electrolyte solution or sports drink. SM should limit activity
for minimum of 24 hours and ease into return in activity in slow stepwise approach.
MANAGEMENT: Heat Stroke: Heat stroke is a true emergency and needs to be managed by rapid active cooling (ice bath
immersion or rotation of ice sheets). In a patient with an undefined heat injury and temperature > 104º, or hyperthermia and
altered mental status treat as heat stroke per the protocol. Do not rely solely on temperature to diagnose but have a high index
of suspicion with appropriate risk factors and clinical setting and treat presumptively.

Hyponatremia
In addition to these standard heat injuries, hyponatremia, or emergently low serum sodium, may be classified as a heat
injury. Hyponatremia in our population most commonly occurs due to excessive free water intake that overwhelms the
body’s ability to maintain a normal serum electrolyte concentration. This excessive free water leads to a dilution of the
serum sodium and can have central nervous system effects such as seizures or altered mental status.
Treat all apparent heat injuries with primary concern for heat stroke. After treating or ruling out heat stroke, evaluate and
treat as indicated for hypoglycemia. In a patient thought to have a heat injury due to environmental factors with altered
mental status or seizures with a core temperature < 104°F and normal or treated glucose level, attempt to gain history
of excessive free water intake or recurrent clear vomiting. With a negative evaluation for heat stroke and hypoglycemia
in patient with altered mental status or seizures, treat for presumptive hyponatremia. Treatment includes continuing
emergent evacuation and administering a single 250mL hypertonic saline (3%) bolus. Ensure large-bore IV access for
administration and be cognizant of venous extravasation and risk with hypertonic saline.
***Please see CPG for the Prevention, Diagnosis, and Management of Exertional Heat Illness for special considerations.

120 SECTION 3 TACTICAL MEDICAL EMERGENCY PROTOCOLS (TMEPs) & SICK CALL
Hyperthermia (Heat) Management Protocol

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2025 RANGER MEDIC HANDBOOK 121

Hypothermia Management
Hypothermia
Hypothermia, acidosis, and coagulopathy constitute the “triad of death” in trauma patients. The understanding of hypo­
thermic coagulopathy with increased mortality is critical. Prevention of hypothermia must be emphasized in combat
operations and casualty management and all levels of care. Hypothermia occurs regardless of the ambient temperature;
hypothermia can, and does, occur in both hot and cold climates. Prevention of hypothermia is much easier than treat-
ment of hypothermia; therefore, prevention of heat loss should start as soon as possible after the injury. Keep in mind
that hypothermia becomes a cardiac event as much as a temperature event.

TCCC Application
SECTION 3

Care Under Fire: No specific action.

Tactical Field Care: All attention should be directed towards preventing heat loss. Stop bleeding and resuscitate ap-
propriately. If available, warm fluids should be used. This will start generating internal heat that facilitates rewarming.
Minimize the casualty’s exposure to the elements. Keep protective gear on or with the casualty if feasible. Remove and
replace wet clothing with dry if possible. Get the casualty onto an insulated surface as soon as possible. Apply the
Ready-Heat Blanket from the Hypothermia Prevention and Management Kit (HPMK) to the casualty’s torso (not directly
on the skin) and cover the casualty with the Heat-Reflective Shell (HRS). If an HRS is not available, the previously rec-
ommended combination of the Blizzard Survival Blanket and the Ready-Heat Blanket may also be used. If the items
mentioned above are not available, use dry blankets, poncho liners, sleeping bags, or anything that will retain heat and
keep the casualty dry. Warm fluids are preferred if IV fluids are required. Placement of a temperature dot on the forehead
of the patient will assist in monitoring changes in the patients’ response to treatment, and will serve as a visual “clue” to
remind providers to monitor the patient’s temperature throughout the evacuation process

Tactical Evacuation: Use a portable fluid warmer capable of warming all IV fluids including blood products. Protect the
casualty from wind if doors must be kept open.

Extended Care
Hypothermia will result in decreased clotting ability in the trauma casualty. Prevention is the key to management, since
only limited rewarming is possible in the field. Minimize the casualty’s exposure to the elements. Keep protective gear
on or with the casualty if feasible. Remove wet clothing and replace with dry garments if possible. Wrap the casualty
with available insulating material (e.g., CoTCCC-recommended commercial systems, sleeping bags, or anything that will
retain heat and keep the casualty dry). If resuscitation is required, use warmed IV fluids if possible.

122 SECTION 3 TACTICAL MEDICAL EMERGENCY PROTOCOLS (TMEPs) & SICK CALL
Hypothermia Prevention & Management Protocol

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2025 RANGER MEDIC HANDBOOK 123

Ingrown Toenail
DEFINITION: Ingrown toenail with inflammatory response.

S/Sx: Pain, edema, erythema, and hyperkeratosis at lateral nail fold; pressure over the nail margins increases the pain;
inflammatory or infectious responses are generally localized.

Initial management is prevention. Appropriate nail hygiene is important. Toenails should be cut straight across, and
the corners should not be rounded off. For mild ingrown toenail initial management should be conservative. The use of
topical antibiotics or drainage of paronychia is appropriate if present. Conservative management is initiated with once to
twice daily warm water soaks with mild traction being applied to the ingrown nail area. Elevation of the nail with a cotton
tip applicator, dental floss or other instrument to pry the nail out of the skin is appropriate. If forceps and appropriate
SECTION 3

monitoring is available a small piece of gauze or cotton can be placed under the ingrown nail and removed and replaced
daily to allow the nail to grow.

Partial or complete nail removal is typically indicated in chronic inflammation/infection, with severe pain of both medial
and lateral nail folds, especially if the condition has lasted one month or greater.
1. Partial toenail removal: Clean the site with soap, water, and Betadine; Perform a digital block at the base of the toe
using lidocaine 1%; apply constricting band to base of toe; remove the lateral quarter of the nail toward the cuticle
(or whole nail), using a sharp scissors with upward pressure; bluntly dissect the nail from the underlying matrix with
a flat object, elevate the nail and grasp it with a hemostat or forceps, removing the piece; clean the nail grooves to
remove any debris; remove constricting band; control bleeding with direct pressure and dry the underlying nail bed.
2. Apply Mupirocin 2% ointment to exposed nail bed.
3. Dress with a nonadherent dressing and dry bandage.
4. Instruct the patient to wash the area daily.
5. Recheck wound and change dressing daily.
6. Instruct patient to wear less-constricting shoes and to trim their nails straight across. Optimal care is to limit walking
and marching for 3–5 days.
7. Treat per Pain Management Protocol.
8. Systemic antibiotics are typically not needed in these procedures; however, if an infection is suspected (increasing
pain, redness, and swelling), then treat as per Cellulitis Protocol.

DISPOSITION: Evacuation is usually not required if the condition responds to therapy. The nail bed may have serous
drainage for several weeks but will usually heal within 2–4 weeks.

SPECIAL CONSIDERATIONS:
1. Consider toenail removal only if close follow-up is possible.
2. Local anesthetic with epinephrine for a digital block is still controversial although medically acceptable.

124 SECTION 3 TACTICAL MEDICAL EMERGENCY PROTOCOLS (TMEPs) & SICK CALL
Insomnia
DEFINITION: Primary insomnia is sleeplessness not caused by another sleep, medical, psychiatric disorder, medica-
tions, or other substances. Secondary insomnia is a result of one of the above causes. Common in deployed setting
with changes of > 4 time zones.

S/Sx: Perceived reduction of sleep time; difficulty initiating sleep on schedule; daytime sleepiness or tiredness; difficulty
concentrating; anxiety; moodiness.

MANAGEMENT:
1. Practice consistent sleep hygiene of a sleep/wake schedule in a cool, dark, quiet environment (if possible). The CBT-I
app should be used/offered as initial therapy. Cognitive behavioral therapy for insomnia is the first line and mainstay

SECTION 3
of treatment.
2. Reduce intake of stimulants, especially caffeine or energy drinks, and avoid heavy late-night meals or high-calorie
snacks before bedtime. Also avoid working out 2–3 hours before bedtime.
3. Encourage a 30-minute “wind down” time before attempted sleep and decreased electronic screen stimulation for
2 hours prior to bed (TV, cell phones, tablets etc.).
4. The use of first generation antihistamines can be used if initiation of sleep is the biggest complaint. Dosing consists
of 25–50mg. Consider melatonin 3mg PO approximately 30–120 minutes before bedtime OR in consultation with a
medical provider, Zolpidem 5–10mg PO at bedtime or eszopiclone 2mg immediately at bedtime. Do not use these
agents for longer than 2 weeks, abuse potential and side-effect profile are high. Any choice of pharmacotherapy
should not be used for more than two weeks.

DISPOSITION: Evacuation not required unless individual’s performance becomes a risk to mission, self or others.

SPECIAL CONSIDERATIONS:
1. Ensure differential diagnosis from sleep apnea, psychiatric or behavioral disorders and other medical reasons.
2. The body’s circadian rhythm generally takes 1 day per time zone traveled to adjust to the new time zone or activity
schedule.
3. Sleep management medications are intended to assist in adjustment of sleep schedule and not as a convenience
during long travel.

Joint Infection
DEFINITION: Bacterial joint infection, infected bursitis, septic arthritis, septic joint; may result from penetrating trauma
(e.g., animal bites or shrapnel).

S/Sx: History of adjacent penetrating trauma or infection; single red, swollen joint; fever; pain with axial load; inability
to straighten/flex joint.

MANAGEMENT:
1. IMMOBILIZE THE JOINT.
2. Gain IV access.
3. For septic joint: ceftriaxone 2g IV/IM bid OR ertapenem 1g IV/IM qd. For septic bursitis: treat per Cellulitis Protocol.
4. Treat per Pain Management Protocol.

DISPOSITION: Priority evacuation

SPECIAL CONSIDERATIONS:
1. May result from penetrating trauma (especially animal or human bites), gonorrhea, or iatrogenic causes (i.e., attempted
aspiration of joint effusion).
2. Consider also an acute joint effusion due to blunt trauma or overuse (usually less red and no fever).

2025 RANGER MEDIC HANDBOOK 125

Laceration
DEFINITION: Laceration

S/Sx: Simple uncomplicated laceration of skin without involvement of deeper structures.

MANAGEMENT:
1. Irrigate and clean wound thoroughly. Pressure with clean, potable water is as effective as hospital-based sterile water
irrigation.
2. Prepare area in sterile fashion.
3. Provide local anesthesia with 1% lidocaine with or without epinephrine depending on site.
4. Close with nonabsorbable suture, Dermabond, or Steri-Strips as dependent on depth of wound. Absorbable sutures
SECTION 3

should only be used to close a laceration if: the laceration is on the face or hand or if subcutaneous sutures are being
used for wound closure.
5. If dirty wound or environment, antibiotics should be considered.
6. Check tetanus status and treat as needed; do not suture if wound is > 12 hours hold (> 24 hours on face), or if
puncture/bite wound.
7. Nonabsorbable sutures should be removed in 7–10 days. Most animal bites should not be closed with suture, consult
a provider on when to close lacerations from animal bites. After sutures, place a dressing with antibiotic cream and
do not soak in water while sutures are in place, keep dry for 24–48 hours.

DISPOSITION: Evacuation usually not required.

Loss of Consciousness (without Seizures) / Syncope

DEFINITION: The most common cause of loss of consciousness in healthy adults is orthostatic hypotension (associ-
ated with sudden standing) or vasovagal syncope (associated with sudden adverse stimulus – injections are a common
cause).

S/Sx: Unconsciousness

MANAGEMENT:
1. If no respirations or pulse, follow BLS guidelines. If associated with trauma (blast, fall, MVA, etc.) in last 14 days, then
manage per mTBI Protocol.
2. Management of orthostatic hypotension and vasovagal syncope is accomplished by placing the patient in a supine
position, ensuring the airway is open. Patients experiencing these two disorders should regain consciousness within
a few seconds. If they don’t, consider other etiologies and proceed to the steps below.
3. Place either 1 tube oral glucose gel or contents of one packet of sugar in buccal mucosal region (DO NOT use oral
glucose if patient remains unconscious).
4. Gain IV access.
5. Naloxone 2mg IV/IM. Repeat q2–3min prn to max dose of 10mg.
6. If no response, treat per appropriate protocol per Special Considerations.
7. Pulse oximetry monitoring.
8. Oxygen if available.

DISPOSITION: Urgent evacuation, unless loss of consciousness clearly due to orthostatic hypotension or vasovagal
hypotension. The evacuation package should include personnel certified in Advanced Cardiac Life Support (ACLS), with
equipment, supplies and medications necessary for ACLS care.

SPECIAL CONSIDERATIONS: Also consider hypoglycemia, anaphylactic reaction, medication, recreational drug use,
head trauma, hyperthermia, hypothermia, myocardial infarction, pulmonary embolism, lightning strikes, and intracranial
bleeding. Obtain ECG if able in all undifferentiated syncope patients.

126 SECTION 3 TACTICAL MEDICAL EMERGENCY PROTOCOLS (TMEPs) & SICK CALL
Malaria
DEFINITION: Protozoan infection transmitted by the female Anopheles mosquito; prevention through personal preven-
tive measures is the key (antimalarial meds, DEET, permethrin, bed nets, and minimized skin exposure). Malaria should
be in the differential diagnosis of any patient with a fever in an endemic area. Malaria CDC Hotline: 770-488-7788,
After Hrs: 770-488-7100.
S/Sx: Hx of travel to malaria-endemic area; noncompliance with antimalarial medications and/or personal preventa-
tive measures. Prodrome of malaise, fatigue, and myalgia may precede febrile paroxysm by several days; paroxysm
characterized by abrupt onset of fever, chills, rigors, profuse sweats, HA, backache, myalgia, abdominal pain, nausea,
vomiting, diarrhea (may be watery and profuse) in P. falciparum; intermittent or continuous fever in P. falciparum malaria;
classic “periodicity” is usually absent. Profuse sweating between febrile paroxysms; tachycardia, orthostatic hypoten-

SECTION 3
sion, tender hepatomegaly, and delirium (cerebral malaria).
MANAGEMENT: If available, test with rapid assay test (BinaxNow NSN 6550-08-133-2341) or blood smear or if limited
lab capability, CBC looking for anemia and low platelets. If unavailable and malaria is suspected, treat empirically. Can
use acetaminophen 1,000mg q6hr prn for fever. Do not use same treatment as was used for prophylaxis. If any treat-
ments are started medics must contact a medical officer.
1. Malarone (atovaquone 250mg/proguanil 100mg) 4 tabs PO qd × 3 consecutive days with food or milk OR
2. Coartem (artemether 20mg/lumefantrine 120mg) 1tab initial dose, repeat single dose 8 hours later, then one dose PO
bid for following 2 days with food or milk OR
3. Quinine sulfate 542mg base PO tid for 3–7 days PLUS doxycycline 100mg PO bid for 7 days AND if known
­chloroquine-resistant use: option 1) or 3) and ADD primaquine phosphate 30mg (can cause hemolytic anemia in
G6PD deficiency) base PO qd × 14 days as well.
DISPOSITION: Urgent treatment and evacuation for complicated malaria (cerebral/altered mental status, pulmonary
changes with fever, or abnormal vital signs) these indicate a medical emergency. Priority evacuation for uncomplicated
cases (normal vital signs, normal mental status, no nausea and vomiting, no cough/shortness of breath).
SPECIAL CONSIDERATIONS:
1. Malaria MUST be considered in all febrile patients currently in or recently returned in, a malarious area.
2. It is not uncommon for malaria to present like pneumonia or gastroenteritis (with vomiting and diarrhea).
3. It is appropriate to treat suspected malaria cases empirically if diagnostic test (blood smears or rapid test) are not
available.
4. However, the BinaxNow rapid Diagnostic test is now FDA approved and should be used, if available, to guide treat-
ment selection.
5. The use of chemoprophylaxis does not rule out malaria.
6. Consider bacterial meningitis in evaluating the patient – treat for both disorders if meningitis is suspected.
7. Patients who cannot tolerate PO meds MUST be evacuated.
PROPHYLAXIS AND POST EXPOSURE PROPHYLAXIS
1. Insecicides and preventing mosquito bites are primary prevention.
2. Chemoprophylaxis most commonly done with doxycycline 100mg daily, begin 1–2 days before travel and continue
for 4 weeks after leaving. Cannot miss a dose to be effective.
3. For terminal prophylaxis primaquine 52.6mg daily for 14 days (contraindiciated in G6PD deficiency, ensure all are
screened prior to prescribing).

2025 RANGER MEDIC HANDBOOK 127

Meningitis
DEFINITION: Inflammation of the meninges and spinal cord by bacterial, viral, or fungal agents.
S/Sx: Classic features include: severe headache, high fever, pain with any neck movement (particularly forward flexion),
altered mental status; may also include: photophobia, nausea and vomiting, malaise, seizures; positive Brudzinski (pain
on head and neck flexion, causing hips/knees to flex) and Kernig’s (neck pain with hip flexion and knee extension) signs.
May have petechiae in meningococcemia (mask and gown PPE if suspected)
MANAGEMENT:
1. If meningitis is suspected, treatment should be initiated immediately.
2. Gain IV access.
3. Dexamethasone 10mg IV/IM q6hr.
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4. Ceftriaxone 2g IV q12hr (IM route possible alternative but prefer IV route).

5. Treat per Pain Management Protocol.
6. Treat per Nausea and Vomiting Protocol.
7. If seizures occur, treat per Seizure Protocol.
8. For prophylaxis of close contacts: Rifampin 600mg PO bid for 2 days OR ceftriaxone 250mg IM once.
DISPOSITION: Urgent evacuation.
SPECIAL CONSIDERATIONS:
1. May be bacterial, viral, or fungal. The bacterial type may cause death in hours, even in previously healthy young
adults, if not treated aggressively with appropriate antibiotics.
2. Consider malaria as a differential diagnosis. Treat for both if malaria cannot be ruled out.

Motion Sickness & Prevention

DEFINITION: Not a true sickness, but a normal response to a situation in which sensory conflict about body motion
exists among visual receptors, vestibular receptors, and body proprioceptors. Referred to as air sickness, car sickness,
sea sickness, and physiologic vertigo.

S/Sx: Nausea; vomiting; diaphoresis; pallor; hypersalivation; yawning; hyperventilation; anxiety; panic; malaise; fatigue;
weakness; confusion; dizziness.

PREVENTION:
1. Meclizine 25mg PO taken 30–60 minutes before travel and bid OR 1× scopolamine transdermal patch 1.5mg behind
ear up to 4 hours prior to travel.
2. If possible, sit in middle of plane/boat or fix vision on horizon while avoiding fixation on moving objects.
3. Minimize food intake before travel and increase airflow around face.

MANAGEMENT:
1. Manage as per Nausea and Vomiting Protocol.
2. For severe responses or vertigo, consider Midazolam 1–2mg IV q6–12hr.

DISPOSITION: Evacuation not required unless individual’s performance becomes a risk to mission, self, or others. Con-
sider routine evacuation or complete reevaluation if S/Sx do not alleviate < 24 hours after last motion travel.

SPECIAL CONSIDERATIONS:
1. Ensure differential diagnosis from altitude illness, gastroenteritis, central neurologic cause or stroke (evaluate and
treat per ACLS guidelines), and toxin exposure.
2. All above medications may cause drowsiness and should be considered for mission impacts.

128 SECTION 3 TACTICAL MEDICAL EMERGENCY PROTOCOLS (TMEPs) & SICK CALL
Nausea & Vomiting
DEFINITION: Nausea and vomiting usually as a result of underlying medical condition and managed in conjunction with
other protocols.

S/Sx: Nausea and vomiting

MANAGEMENT:
1. Ondansetron 4–8mg IV/IM/SL or 8mg PO q4hr prn OR promethazine 25mg IV/IM/PO q6hr prn.
2. Treat per Dehydration Protocol.
3. Use in conjunction with appropriate protocols.

DISPOSITION: Evacuate per protocol for underlying condition.

SECTION 3
SPECIAL CONSIDERATIONS:
1. Avoid rapid IV administration of promethazine.
2. DO NOT give subcutaneous promethazine.
3. Promethazine may cause drowsiness and therefore not recommended during combat operations or training.

Otitis Externa
(Outer Ear Infection or Swimmer’s Ear)
DEFINITION: Bacterial or fungal infection of external ear canal, “swimmer’s ear.”

S/Sx: Ear pain and pain with passive ear movement, tragus swelling, erythema, pruritis in area; possible exudate and
erythema in ear canal, decreased auditory acuity, sensation of fullness, and moisture in ear.

MANAGEMENT:
1. If external canal exudate is present, Ofloxacin Otic 0.3% 10 drops in affected ear daily × 7–10 days OR gatifloxacin
ophthalmic 0.3% 5 drops tid–qid × 7–10 days (for both – administer while awake and laying on unaffected side for at
least 5 minutes); ophthalmic used to minimize meds carried.
2. Place sterile dry dressing wick into ear canal to keep canal open and allows meds to reach inner canal with canal
edema.
3. Acetaminophen 1,000mg PO q6hr prn pain.
4. No internal hearing protection until resolution.
5. If no response or worsens, treat with ciprofloxacin 750mg PO bid and urgent evacuation (concern for malignant otitis
externa).

DISPOSITION: For uncomplicated cases, no evacuation is necessary. Urgent evacuation for complicated cases not
responding to therapy or if condition worsens despite 12–24 hours of treatment with ciprofloxacin.

2025 RANGER MEDIC HANDBOOK 129

Otitis Media
(Middle Ear Infection)
DEFINITION: Eustachian tube dysfunction, viral infection, or bacterial infection of middle ear.

S/Sx: Ear pain, +/– fever, decreased hearing, sensation of ear fullness; erythema and bulging of TM are hallmark signs
but loss of landmarks typically seen in adults, increased pressure may cause TM rupture and discharge; often noted with
accompanying URI symptoms, recent air travel, or recent ascent to altitude.

MANAGEMENT:
1. Acetaminophen 1,000mg PO q6hr AND/OR ibuprofen 800mg PO tid prn pain AND pseudoephedrine 60mg qid.
2. Oxymetazoline nasal spray 2 squirts per nostril bid (max 3 days).
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3. If grossly apparent, or no resolution in 1–2 days, or bacterial, then add antibiotics: amoxicillin/clavulanate acid
875/125mg PO bid × 10 days OR azithromycin 500mg PO initially followed by 250mg PO qd × 4 days OR ceftriaxone
250mg IM single dose.

DISPOSITION: For uncomplicated cases, no evacuation is necessary. Routine evacuation for complicated cases not
responding to therapy.

SPECIAL CONSIDERATIONS:
1. Increased pressure in the middle ear may cause intense pain and may result in rupture of the tympanic membrane
(characterized by sudden decrease in pain and drainage from ear canal).
2. If water immersion is anticipated, use ear plugs to prevent cold water entry, which will cause vertigo.

130 SECTION 3 TACTICAL MEDICAL EMERGENCY PROTOCOLS (TMEPs) & SICK CALL
Pharyngitis
(Oral Pharyngeal Infections Including Viral,
Strep, Epiglottitis, Peritonsillar Abscess, Mononucleosis)
DEFINITION: Inflammation of the fauces and pharynx leading to sore throat or discomfort swallowing and/or talking
due to multiple etiologies. Most common causes in young healthy patients include viral URIs, group A beta-hemolytic
strep (GABHS) pharyngitis, odontogenic (dental origin), cutaneous sources or postinjury (wound or fracture) infections.

S/Sx:
GABHS Pharyngitis: Pain, fever, malaise, absence of cough, odynophagia, tonsillar exudates, tender cervical adenopathy.
Peritonsillar Abscess: Pain, possibly unilateral sore throat, fever, malaise, trismus, odynophagia, muffled voice (hot

SECTION 3
potato voice), unilateral tonsillar enlargement, unilateral uvula deviation to unaffected side.
Epiglottitis: Sore throat, odynophagia, fever, muffled voice, drooling, stridor, hoarseness, dyspnea (less common in
adults), tripoding/sniffing position, oral cavity/oropharynx normal in most patients, pooled secretions, laryngotracheal
complex tender to palpation (particularly in the hyoid region).
Mononucleosis: triad of fever/tonsillar pharyngitis/lymphadenopathy; fatigue and possibly LUQ pain to splenomegaly
(seen in 50–60% of patients).

Viral (Non-GABHS): S/Sx of URTI with no red flags of other etiologies.

MANAGEMENT:
GABHS Pharyngitis:
1. Evaluate and treat IAW CENTOR Criteria (Exudate on Tonsils, Fever, No Cough, Anterior Cervical Lymphadenopathy).
2. Treat empirically for 3 or greater S/Sx CENTOR criteria with benzathine penicillin G
3. 2 million units IM once (if available) OR penicillin 500mg PO qid × 10 days. If 2 or less S/Sx CENTOR criteria, then
treat symptomatically per non-GABHS management.

Peritonsillar Abscess:
1. If potential for airway compromise, Urgent evacuation for surgical intervention.
2. Needle aspiration IF TRAINED with priority evacuation. If not trained, and no airway compromise, then Priority evacu-
ation. Continue to treat symptomatically and with clindamycin 450mg PO tid OR amoxicillin/clavulanate 875mg bid
× 10 days.

Epiglottitis:
1. Manage airway and breathing first IAW Airway Management Protocol (avoid airway manipulation if possible).
2. Place patient in position of comfort.
3. Monitor pulse oximetry.
4. Oxygen prn if possible.
5. Gain IV access.
6. Ceftriaxone 1g IV/IM qd × 7 days AND clindamycin 600mg IV q6hr OR clindamycin 300–450mg PO q6hr × 7 days.
7. Treat per Pain Management Protocol.
8. Consider dexamethasone 10mg IV for any airway involvement.

Mononucleosis:
1. Treat per URI Protocol.
2. Profile for no high-impact physical training, sports, jumping/FRIES × 6 weeks if able to confirm no splenomegaly on
ultrasound to prevent splenic rupture; no corticosteroids.

Viral (Non-GABHS): Treat per Upper Respiratory Tract Infection.

DISPOSITION: Urgent evacuation if any airway compromise is present. Routine evacuation if no airway compromise
and the infection is not widespread.

SPECIAL CONSIDERATIONS:
1. These infections may progress rapidly from minor to airway/life-threatening.

2025 RANGER MEDIC HANDBOOK 131

Pneumonia
DEFINITION: Acute lung (pulmonary parenchyma) infection due to virus, mycoplasma, or other bacteria

S/Sx: Fever > 100.4°F, chills, productive cough (dark yellow, green, red tinged), chest pain with breathing (pleuritic), mal-
aise, wheezes, rhonchi and/or rales, decreased breath sounds (may be absent over affected lung), dyspnea, tachypnea,
shortness of breath, tachycardia, possible decrease in pulse oximetry, egophony, bronchophony and tactile fremitus.

MANAGEMENT:
1. Acetaminophen 1,000mg PO q6hr prn pain/fever.
2. Antibiotic
a. PCN NON-allergic: Amoxicillin 1g tid PLUS macrolide (preferred) or doxy 100mg bid for 5 days
SECTION 3

b. PCN Allergic: cephalosporin PLUS macrolide (preferred) or doxy

c. Macrolide options: azithro 500mg daily for 3 days or clarithromycin 500mg bid or 1g extended release daily
d. Cephalosporin options: cefpodoxime 200mg bid or cefditoren 400mg bid or cefdinir 300mg bid or 600mg
daily. Duration: 5 days
3. Albuterol MDI 2 puffs qid prn wheezing.
4. Increase PO hydration.
5. Pulse oximetry.
6. Oxygen if indicated.
7. If at altitude > 8000 ft, descend 1,500–3,000 ft; differential diagnosis should include HAPE, PE, and pneumothorax
Ensure smoking cessation and enforce hydration. Consider throat lozenges for accompanying pharyngitis.

DISPOSITION: Urgent evacuation for severe dyspnea or hypoxia. Observation or Routine evacuation as necessary.

SPECIAL CONSIDERATIONS: Consider high altitude pulmonary edema (HAPE) at high altitudes. Consider pulmonary
embolism (PE) and pneumothorax (fever and productive cough are atypical for these).

Pulmonary Embolism (PE)

DEFINITION: Obstruction of a pulmonary artery or one of its branches by a thrombus (clot), tumor, air, or fat that origi-
nated else where in the body. Massive pulmonary emboli will result in obstructive shock.

S/Sx: Acute onset of dyspnea, tachypnea, tachycardia, localized chest pain, anxiety, diaphoresis (sweating), decreased
oxygen saturation, full breath sounds with no wheezing, no prominent cough, and low-grade fever; usually proceeded
by DVT with lower extremity pain, swelling, and tenderness with history of trauma, air travel, or long periods in sitting
positions.

MANAGEMENT: Use a risk stratification tool such as PERC or Wells. PERC negative if age < 50, HR < 100, SpO2 > 95%,
no leg swelling, no hemoptysis, no recent surgery/trauma, no prior PE/DVT, and no hormone use (testosterone or birth
control). History of malignancy with treatment within 6 months or palliative care is also a risk factor for PE.
1. Monitor with pulse oximetry and provide oxygen (if available).
2. Treat per Pain Management Protocol.
3. Consider myocardial Infarction and treat as per Chest Pain Protocol.
4. If at altitude > 8,000 ft, descend 1,500–3,000 ft as per HAPE Protocol.
5. If available, it is important to apply supplemental oxygen to maintain SpO2 > 98%, establish IV access, prepare to
support blood pressure with fluids and vasopressors if SBP persistently < 90.
6. PE can also be a cause of sudden unconsciousness or syncope.

DISPOSITION: Urgent evacuation

132 SECTION 3 TACTICAL MEDICAL EMERGENCY PROTOCOLS (TMEPs) & SICK CALL
Rabies Post-Exposure Prophylaxis
DESCRIPTION: An RNA virus transmitted through the saliva of an infected animal by biting, licking of an abrasion/
wound, or contact with mucosa.

Hx: Hx of being bitten/licked by potentially infected dogs, bats, raccoons, coyotes, foxes, skunks, cats, horses, cows,
sheep, or around aerosolized excrements of bats.

S/Sx: Incubation period: Incubation in humans typically 4 days–3 months. Period can be shorter if bitten in the face
or bitten by an animal with a high viral count in its saliva. PT will have intense pruritus, pain, paresthesia at the bite
sight, malaise, fatigue, HA, fever, anorexia, apprehension, anxiety, insomnia, depression. Classic rabies patients
will progress into coma ending with death.

SECTION 3
MANAGEMENT:
1. If suspected bite from infected animal. Evacuate at earliest opportunity for vaccine but absolutely within 48 hours.
2. Initially debride, vigorously clean, and copiously irrigate the wound using iodine solution which will increase the ef-
ficacy (vaccine failures are associated with poor wound care).
3. Give tetanus booster
4. IF PREIMMUNIZED, purified chick embryo cell (PCEC) vaccination 2 doses 1.0mL IM day 0 and 3, administered in
deltoid area (for children anterolateral aspect of the thigh is acceptable) and NEVER in the gluteal area.
5. IF NOT PREIMMUNIZED, inject Human Rabies Immunoglobulin around the site and remaining (< 50%, not able to
be injected around wound) deep IM distant from vaccine site. Also, 4 doses of PCEC IM in deltoid days 0, 3, 7, 14.
Immunoglobulin should never be administered in the same syringe or in the same anatomical site as the day 0 PCEC
dose.

SPECIAL CONSIDERATIONS: Rabies is a universally fatal disease. Rabies virus can live dormant in bat feces, so
exercise caution when going into caves. Bat bites often are unnoticed. They may only manifest by small abrasions with
prolonged bleeding. If there is a suspected bat bite or PT awakens with bat in room; consider evacuation for vaccine
and HRIG.

Rectal Bleeding
DEFINITION: Bleeding per rectum.

S/Sx: Bright red blood per rectum. Anal pain with defecation usually indicates hemorrhoids or anal fissures. Significant
bleeding can result in hypotension. Red flags include dark/tarry stools (melena), abdominal pain, postural hypotension,
fever, weight loss.

MANAGEMENT: Obtain vitals. If hemodynamically stable, perform rectal exam in an attempt to identify external source
of bleeding. If hemorrhoid or anal fissure is identified as source of bleeding, treat conservatively with increased fiber
intake and topical creams. If hemodynamically unstable, continue to monitor, volume resuscitate as needed, and evacu-
ate to higher care.

DISPOSITION: Urgent evacuation if hemodynamically unstable or there is persistent significant bleeding. Priority evacu-
ation if red flags are present.

SPECIAL CONSIDERATIONS: Certain medications (iron supplements, bismuth subsalicylate [Pepto-Bismol]) can cause
dark stools that may be mistaken for melena.

2025 RANGER MEDIC HANDBOOK 133

Rhabdomyolysis
DEFINITION: Breakdown or necrosis of skeletal muscle cells that release cellular contents into the circulation. Typical
causes: Limb ischemia, carbon monoxide poisoning, electrical or thermal burns, blunt trauma or crush injury, snake Bite,
hyperthermia, hypothermia, and physical exertion.

S/Sx: Acute muscle pain (myalgias); muscle weakness; fever; malaise; nausea or vomiting; tea-colored urine; oliguria/
anuria; dipstick positive for blood, but no intact RBC on a spun specimen (due to myoglobin in urine).

MANAGEMENT: Aggressive hydration is the cornerstone of treatment.

1. Crystalloid solution 1–2L bolus IV/IO followed by 500mL–1L/hr. In a patient making urine, any isotonic fluid is accept-
able (you do not need to avoid potassium containing fluids if patient is making urine). Titrate fluids to achieve target
SECTION 3

urine output of > 200mL/hr.

2. Monitor intake/output hourly.
3. If unable to monitor due to clinical condition, insert Foley catheter to facilitate measuring urine output.
4. Reassess vital signs and mental status frequently. Utilize cardiac monitoring if available.

Potential Problems/Complications:
a. Cardiac dysrhythmia treatment: 1g calicum chloride or 3g calcium gluconate q5 minutes until arrhythmia has
resolved, then adminster glucose+insulin.
b. If dysrhythmia occurred, loop diuretics may be needed to eliminate potassium.
c. Persistent oliguria despite adequate fluid resuscitation.
d. Avoid loop diuretics such as furosemide, which may increase myoglobin precipitation in kidneys and provoke
acute renal failure.
e. Compartment syndrome: see Compartment Syndrome Protocols.

DISPOSITION: Priority evacuation

Sepsis / Septic Shock

DEFINITION: Severe life-threatening condition resulting from the presence of harmful microorganisms in the blood or
other tissues and the body’s response to their presence, potentially leading to the malfunctioning of various organs,
shock, and death.

S/Sx: Hypotension; fever; tachycardia; altered mental status; dyspnea

MANAGEMENT: Do not attempt to treat without contacting a medical officer.

1. Obtain IV/IO access.
2. Ertapenem 1g IV/IO qd OR ceftriaxone 2g IV/IO qd.
3. If patient is hypotensive, give 1L crystalloid solution fluid bolus. Consider additional fluids if still hypotensive, then an
additional liter titrated to maintain systolic blood pressure > 90mmHg or palpable radial pulse. Maintain aggressive
fluid management.
4. Initiate vasopressor medications if persistent hypotension despite > 2L IVF boluses. (norepinephrine or epinephrine).
Epinephrine (1:100,000) 0.5–2mL q5–15 minutes or drip prn. Epinephrine 10μg in large IV q5–15min if persistent
hypotension despite > 2L IVF boluses. Initiate evacuation.
5. Upon consultation with medical officer, consider stress dose steroids (hydrocortisone 200mg IV daily) for septic
shock refractory to vasopressors.
6. Monitor for decreased mental status and be prepared to manage airway.

DISPOSITION: Urgent evacuation

SPECIAL CONSIDERATIONS:
1. Ensure complete medical history and documentation of any preceding events are sent to medical provider.

134 SECTION 3 TACTICAL MEDICAL EMERGENCY PROTOCOLS (TMEPs) & SICK CALL
Smoke Inhalation
DEFINITION: Common after closed space exposure to fire; consider airway burns, carbon monoxide poisoning, other
toxin inhalation, and need for hyperbaric oxygen.

S/Sx: History of smoke exposure; burns (singed nares, facial burns); coughing; stridor; +/– carbonaceous sputum;
respiratory distress (may be delayed in onset).

MANAGEMENT:
1. Remove from environmental exposure and allow patient to rest.
2. Administer oxygen if available.
3. Refer to Airway Management Protocol and consider the use of early cricothyroidotomy if airway burns/edema or

SECTION 3
singed nasal hair, facial burns are present/suspected.
4. Albuterol by metered dose inhaler 2–4 puffs q1hr or nebulizer if available.
5. Dexamethasone 10mg IV/IM qd.
6. Patient exertion will exacerbate symptoms and should be avoided.

DISPOSITION: Urgent evacuation for respiratory distress, suspected inhalation burns. Priority evacuation if not in dis-
tress but significant inhalation suspected.

SPECIAL CONSIDERATIONS:
1. Consider possible carbon monoxide (CO) poisoning and need for hyperbaric oxygen in all significant cases of smoke
inhalation.
2. Normal oxygen saturation by pulse oximetry DOES NOT rule out the possibility of CO poisoning.
3. Consider cyanide poisoning (treat with hydroxocobalamin) or coexisting trauma in hypotensive burn patient.

Spontaneous Pneumothorax
DEFINITION: Acute onset of pneumothorax usually without obvious or known chest trauma.

S/Sx: Spontaneous unilateral chest pain; dyspnea – typically mild; no wheezing; cough; decreased or absent breath
sounds on affected side

Clinically significant pneumothorax can be diagnosed with ultrasound. Lung point, loss of lung sliding, or barcode sign
support diagnosis of pneumothorax.

MANAGEMENT:
1. Pulse oximetry monitoring.
2. Oxygen if available (use oxygen for all suspected spontaneous pneumothoraces).
3. Consider needle decompression for suspected tension pneumothorax.
4. If needle decompression allows for patient improvement, followed by worsening of condition, consider repeat needle
decompression.
5. Consider tube thoracostomy if recurrence of respiratory distress after 2 successful needle decompressions OR Evac-
uation time > 1 hour OR patient requires positive pressure ventilation.
6. If at altitude, descend as far as tactically feasible.
7. If evacuation will occur in an unpressurized aircraft, consider decompression for high altitude evacuation and recom-
mend lowest tactically feasible altitude.
8. Treat per Pain Management Protocol.

DISPOSITION: Urgent evacuation for significant respiratory distress despite therapy. Priority evacuation for patients
whose respiratory status is stable.

SPECIAL CONSIDERATIONS:
1. Consider also: anaphylaxis, pulmonary embolism, high altitude pulmonary edema (HAPE), asthma, myocardial infarc-
tion and pneumonia.
2. More common in tall, thin individuals and smokers.
3. Clinically significant pneumothorax can be diagnosed with ultrasound. Lung point, loss of lung sliding, or barcode
sign support diagnosis of pneumothorax.

2025 RANGER MEDIC HANDBOOK 135

Subungal Hematoma
DEFINITION: Collection of blood under the nail; typically occurs after trauma to fingernail or toenail.

S/Sx: Pain and purplish-black discoloration under nail.

MANAGEMENT:
DO NOT DRAIN IF NO PAIN or if suspected underlying fracture.
1. Decompress the nail with a large gauge needle or electrocautery by rotating needle through the nail directly over the
discolored area until the underlying blood has been released and the pressure is relieved. Make sure that it is intro-
duced into the affected nail with a gentle but sustained rotating motion.
2. Gentle pressure on the affected nail and absorbing/wicking with alcohol swabs may help to evacuate more blood.
SECTION 3

3. Treat per Pain Management Protocol.

4. If a fracture is suspected, tape the injured finger or toe to an adjacent digit.

DISPOSITION: Evacuation should not be required for this injury if the subungual hematoma is successfully treated and
healing does not hinder mission performance.

Testicular Pain
DEFINITION: Testicular pain due to torsion, epididymitis, orchitis, STDs, hernias, masses, and trauma.

S/Sx: Testicular torsion: Sudden onset testicular pain; usually associated with activity; associated testicular swelling;
abnormal position of the affected testicle; symptoms may be increased by testicular elevation; usually associated with
pain-induced nausea and vomiting; Loss of cremasteric reflex is the best diagnostic indicator for testicular torsion.

Epididymitis: Gradual onset of worsening pain; may have fever and/or dysuria; can also be traumatic; symptoms may
be relieved with elevation; significant swelling may be present.

MANAGEMENT:
1. If pain is sudden onset and the testicle is lying abnormally in the scrotum, an attempt to manual detorse the testicle
is warranted. A single attempt to rotate the testicle outward (like opening the pages of a book 180 to 720 degrees)
should be made. If pain increases, one attempt to rotate the opposite direction should be made again up to 720
degrees. Successful detorsion will result in relief of pain.
2. Gradual onset pain with a normal lying testicle should be treated per Urinary Tract Infection Protocol.
3. Treat pain per Pain Management Protocol.
4. Treat per Nausea and Vomiting Protocol.

Treat epididymitis with sexually transmitted infection treatment.

1. Ceftriaxone 500mg IV/IM × 1 AND Doxycycline 100mg bid × 10 days (can replace Doxycycline with Azithromycin 1g
PO once if compliance is in question, although not recommended).

DISPOSITION: Urgent evacuation for testicular torsion. For other causes of testicular pain, treat cause and consider
evacuation if symptoms persist more than 3 days.

SPECIAL CONSIDERATIONS:
1. The primary concern in testicular pain is differentiating testicular torsion from other causes of testicular pain.
2. Testicular torsion is a medical emergency requiring urgent correction to prevent loss of the affected testicle.
3. Other common causes of testicular pain include epididymitis and orchitis, infections commonly caused by STDs, as
well as hernias and testicular masses.
4. Consider testicular cancer and further evaluation in cases with persistent mass.

136 SECTION 3 TACTICAL MEDICAL EMERGENCY PROTOCOLS (TMEPs) & SICK CALL
Upper Respiratory Infection / Common Cold
DEFINITION: Inflammation of nasal passages due to a respiratory virus
S/Sx: Nasal congestion; sneezing; post-nasal drainage; sore throat; cough; hoarseness; malaise; headache; low-grade
fever; body ache; fatigue
MANAGEMENT:
1. Increase PO hydration.
2. Acetaminophen 1,000mg PO q6hr AND/OR ibuprofen 800mg PO q8hr.
3. Treat symptomatically with pseudoephedrine 60mg PO q6hr OR fexofenadine 60mg/pseudoephedrine 120mg PO bid
OR loratadine 10mg/pseudoephedrine 120mg PO qd.
4. Consider oxymetazoline 2–3 sprays each nostril bid (not to exceed 3 days). Lozenges for sore throat.

SECTION 3
DISPOSITION: Evacuation usually not required. Monitor for worsening conditions.

Urinary Tract Infection

DEFINITION: Infection of urinary tract; more common in females, tactical setting, dehydration, kidney stones.
S/Sx: Dysuria; increased urinary urgency and frequency; cloudy, malodorous, or dark urine may be present; suprapubic
discomfort; normally no CVAT/back/flank pain; normally no fever, hx of STD exposure.
MANAGEMENT:
1. For others, cephalexin 500mg PO qid × 7–10 days OR trimethoprim-sulfamethoxazole 1 PO bid for 7–10 days in
males (bid for 5–7 days or 3–5 days respectively in females).
2. Treat per Pain Management Protocol.
3. If fever, back pain, flank pain, and/or costovertebral angle tenderness develop, suspect kidney infection and treat
per Flank Pain Protocol.
4. Encourage PO hydration.
DISPOSITION: Usually responds to therapy and evacuation not required if it does. Routine evacuation for worsening
signs and symptoms. Priority evacuation for pyelonephritis (see Flank Pain Protocol).
SPECIAL CONSIDERATIONS:
1. More common after instrumentation, in females, or in tactical settings with dehydration and/or kidney stones.
2. Symptoms may be confused with a sexually transmitted disease (STD).

Sexually Transmitted Infection

DEFINITION: Bacterial, viral, fungal, or parasitic infection that is passed from one person to another through sexual
contact.
S/Sx: Bumps, sores, or warts: These can appear around the genitals, rectum, or mouth, and may be painful or itchy.
a. Discharge: discharge is a common symptom.
b. Pain: Pain or tenderness in the genital area, buttocks, or inner thighs, or pain during urination.
MANAGEMENT:
1. Send to a medical treatment facility for STI testing
2. Seek guidance from medical provider
3. Treat pain symptoms per pain protocol
GONORRHEA / CHLAMYDIA:
If < 35 years old, treat for sexually transmitted infection, ceftriaxone 500mg IV/IM × 1 AND doxycycline 100mg bid × 7
days (can replace doxycycline with azithromycin 1g PO once if compliance is in question).
SYPHILIS:
1. Penicillin G 2.4 million units IM single injection
2. Penicillin allergy: doxycycline 100mg PO BID × 7–10 days
HSV-2:
1. Acyclovir 400mg PO TID × 7–10 days or valacyclovir 1g PO BID × 7–10 days

2025 RANGER MEDIC HANDBOOK 137

NOTES
SECTION 3

138 SECTION 3 TACTICAL MEDICAL EMERGENCY PROTOCOLS (TMEPs) & SICK CALL
SECTION 4

RANGER MEDIC

SECTION 4
PHARMACOLOGY & FORMULARY

139
Pharmacology Standards & Guidelines

LEVEL 1 – PROFICIENT AND TRAINED

Level 1 pharmaceuticals designated as “Proficient and Always Carried” are those drugs that a Ranger Medic car-
ries on virtually all assault missions. A Ranger Medic is expected to know the class, dose, indications, significant
contraindications, significant side-effects, mission impacts, and K9 dosages of these medications at all times.

This category is within the expected knowledge base for a Ranger Medic to be considered Basic Mission Quali-
fied (BMQ). A Medic must demonstrate proficiency in these medications through the Ranger Medic Assessment
& Validation (RMAV) to be considered BMQ.
Level 1 – Proficient and Always Carried drugs are designated in GREEN

*Indicates always carried medication

SECTION 4

LEVEL 2 – PROFICIENT
Level 2 pharmaceuticals designated as “Proficient” are those drugs that a Ranger Medic administers as directed
by standing Ranger Protocols. An FMQ Ranger Medic is expected to know the class, dose, indications, significant
contraindications, significant side effects, mission impacts, and K9 dosages of these medications at all times.

This category is the within the expected knowledge base for a Ranger Medic to be considered Full Mission Quali-
fied (FMQ). A Medic must demonstrate proficiency in these medications through the Ranger Medic Assessment
& Validation (RMAV) to be considered FMQ.
Level 2 – Proficient drugs are designated in AMBER

LEVEL 3 – FAMILIAR
Pharmaceuticals designated as “Familiar” are those drugs that a Ranger Medic administers as directed by spe-
cific protocols or require familiarization for contingency health management. A Ranger Medic is expected to be
familiar the class, dose, indications, contraindications, side-effects, mission impacts, and K9 dosages of these
medications. The Ranger Medic Handbook is a reference for the rare use of these medications.
This category is the within the familiarization expectation for a Ranger Medic to be considered Full Mission Quali-
fied Plus (FMQ+). A medic must demonstrate familiarization with these medications through the Ranger Medic
Assessment & Validation (RMAV) to be considered FMQ+.
Level 3 – Familiar drugs are designated in RED

MISSION IMPACTS
Certain drugs in all categories have very specific mission impacts. Some are directly related to mission performance
while others serve as a warning for potential mission impacts.

Specific drugs are categorized as “grounding” for any aviation personnel or for Rangers to conduct in-flight operations.
Aviation grounding status also is grounding status for Rangers performing military free-fall operations. REMINDER: Any
flight or MFF personnel grounded due to medication use or a medical condition MUST be cleared by a flight surgeon or
an aeromedical physician assistant before returning to flight/MFF status.

Mission Impact drugs are designated by the helicopter/warning symbol.

This list of pharmaceuticals is as of the current publication date of the Ranger Medic Handbook.
Rangers Medics will adhere to current list as it is updated.

140 SECTION 4 RANGER MEDIC PHARMACOLOGY & FORMULARY

Rules of Drug Administration
Unless specifically noted, the drug dosages listed are for an adult.

ALWAYS DETERMINE IF THE PATIENT HAS ANY ALLERGIES TO MEDICATIONS BEFORE ADMINISTRATION

Reversals: For opioids, always have naloxone ready to administer. For benzodiazepines, always have flumazenil ready
to administer.

Antibiotics: If allergic to one class of medications, use alternate class of medications (cephalosporins/penicillins, tetra-
cyclines, quinolones, macrolides).

Right Patient Check for Contraindications

Right Indication Check for Potential Interactions
Right Drug Be Prepared for Potential Side-Effects
Right Dose Understand the Pharmacokinetics of Your Actions
Right Route
Right Time

SECTION 4
Documentation: Document on casualty card or SF600 all drugs administered (type, dose, route) to include outcomes
or reactions.

Safety in Pregnancy
FDA pregnancy categories A, B, C, D, and X have been replaced with the narrative sections and subsections below.
Safest to greatest risk categories are “drug of choice,” then “may use during pregnancy,” “caution advised,” “consider
alternative,” then “avoid use.”

Pregnancy (includes Labor and Delivery):

■ Pregnancy Exposure Registry
■ Risk Summary
■ Clinical Considerations
■ Data

Lactation (includes Nursing Mothers)

■ Risk Summary
■ Clinical Considerations
■ Data

Females and Males of Reproductive Potential

■ Pregnancy Testing
■ Contraception
■ Infertility

IV Fluid Rates in Drops Per Minute

mL/hr 50 75 80 100 125 150 175 200 250
10gtt 8 13 13 17 21 25 29 33 42
15gtt 12 19 20 25 31 37 44 50 62
60gtt 50 75 80 100 125 150 175 200 250

2025 RANGER MEDIC HANDBOOK 141

ACETAMINOPHEN (TYLENOL) *
Class: CNS agent – nonnarcotic, analgesic, antipyretic
Action: Analgesia action possibly through peripheral nervous system; fever reduction through direct action on hypo-
thalamus heat-regulating center resulting in peripheral vasodilation, sweating, and dissipation of heat; has minimal
effect on platelet aggregation, bleeding time, and gastric bleeding
Dose: 325–975mg PO q6hr (max: 3g qd)
Onset/Peak/Duration: onset varies/peak 1–3 hours/duration 3–4 hours
Indications: For mild to moderate pain management, headache, fever reduction
Contraindications: Acetaminophen hypersensitivity; use with alcohol
Adverse/Side-effects: Negligible with recommended dose; rash, acute poisoning, anorexia, nausea, vomiting, diz-
ziness, lethargy, diaphoresis, chills, epigastric or abdominal pain, diarrhea, hepatotoxicity: elevation of liver function
tests, hypoglycemia, hepatic coma, acute renal failure; chronic ingestion: neutropenia, pancytopenia, leukopenia,
thrombocytopenic purpura, renal damage
SECTION 4

Interactions: Cholestyramine may decrease absorption; barbiturates, carbamazepine, phenytoin, rifampin, and ex-
cessive alcohol use may increase potential for hepatotoxicity
Mission Impact: None to minimal mission impact
K9 Dosage: DO NOT GIVE

ACETAZOLAMIDE (DIAMOX)
Class: CNS agent – carbonic anhydrase inhibitor; diuretic, anticonvulsant
Action: Diuretic effect due to inhibition of carbonic anhydrase activity in proximal renal tubule, preventing formation of
carbonic acid; anticonvulsant action effect thought to involve inhibition of CNS carbonic anhydrase, retarding abnor-
mal paroxysmal discharge from CNS neurons, decreases production of aqueous humor
Dose: Altitude Illness: PREVENTION: PO 125mg bid; begin the day before the ascent, may discontinue if staying
at same altitude for 2–3 days or if descending. Treatment: PO 250mg bid; Note: With high altitude cerebral edema,
dexamethasone is the primary treatment; however, acetazolamide may be used adjunctively with the same treatment
dose
Indications: For acute high-altitude sickness, seizures, drug-induced edema, and for CHF edema
Contraindications: Sulfonamide and thiazide hypersensitivity; marked renal and hepatic dysfunction; adrenocortical
insufficiency; hyponatremia, hypokalemia, hyperchloremic acidosis; pregnancy category may use during pregnancy
and caution advised while breastfeeding.
Acetazolamide is CONTRAINDICATED in people who are G6PD deficient. All US Active Duty Soldiers are tested
for G6PD deficiency upon accession into the military.
Adverse/Side-effects: Paresthesia, sedation, malaise, disorientation, depression, fatigue, muscle weakness, flaccid
paralysis, anorexia, nausea, vomiting, weight loss, dry mouth, thirst, diarrhea, agranulocytosis, bone marrow depres-
sion, hemolytic anemia, aplastic anemia, leukopenia, pancytopenia, hyperglycemia, hyperuricemia, increased cal-
cium, potassium, magnesium, sodium excretion, gout exacerbation, dysuria, glycosuria, urinary frequency, polyuria,
hematuria, crystalluria, metabolic acidosis, hepatic dysfunction
Interactions: Renal excretion of amphetamines, ephedrine, flecainide, quinidine, procainamide, TCAs may be de-
creased, thereby enhancing or prolonging their effects; renal excretion of lithium and phenobarbital is increased;
amphotericin B and corticosteroids may accelerate potassium loss; increased risk for salicylate and digitalis toxicity
Mission Impact: GROUNDING medication for personnel on flight status
K9 Dosage: Give only if indicated/directed for human use. 250mg q12hr beginning 24 hours prior to ascent OR
500mg q24hr

142 SECTION 4 RANGER MEDIC PHARMACOLOGY & FORMULARY

ACETYLSALICYLIC ACID (ASPIRIN)
Class: NSAID; salicylate; anti-inflammatory, analgesic, antipyretic
Action: Inhibits prostaglandin synthesis involved in the production of inflammation, pain, and fever; enhances antigen
removal and reduces spread of inflammation; peripheral analgesic action with limited CNS action in the hypothalamus;
antipyretic by indirect centrally mediated peripheral vasodilation and sweating; powerfully inhibits platelet aggregation
and ability of blood to clot; high levels can impair hepatic synthesis of blood coagulation factors VII, IX, and X, possibly
by inhibiting action of vitamin K
Dose: 325–650mg PO/PR q4–6hr (max: 4g qd); MI prophylaxis PO 80–325mg qd (chewable or nonenteric coated)
Indications: For mild to moderate pain management, fever reduction, and to decrease inflammation; also used for
acute rheumatic fever, systemic lupus, rheumatoid arthritis, osteoarthritis, bursitis, calcific tendonitis, to reduce recur-
rence of TIA and risk of stroke, as prophylaxis and to prevent recurrence of MI
Contraindications: Salicylate and NSAID hypersensitivity; patients with “aspirin triad” (aspirin sensitivity, nasal pol-
yps, asthma); chronic rhinitis or urticaria; GI ulcer, bleeding; hypo­prothrombinemia, vitamin K deficiency, hemophilia,
bleeding disorders; CHF; pregnancy category may use low-dose during pregnancy and consider alternative while

SECTION 4
breastfeeding; do NOT use in children or teenagers with viral illnesses due to link with Reyes syndrome
Adverse/Side-effects: Rash, urticaria, easy bruising, petechiae, bronchospasm, laryngeal edema, confusion, dizzi-
ness, drowsiness; tinnitus, hearing loss, nausea, vomiting, diarrhea, anorexia, heartburn, stomach pain, GI bleeding,
ulceration; thrombocytopenia, hemolytic anemia, prolonged bleeding time
Interactions: Aminosalicylic acid and carbonic anhydrase inhibitors increase risk of toxicity; ammonium chloride,
acidifying agents decrease renal elimination and increase toxicity; oral hypoglycemic agents increase hypoglycemic
activity; corticosteroids increase ulcer potential; methotrexate toxicity is increased; anticoagulants and herbals (fever­
few, garlic, ginger, ginkgo) increase bleeding potential
Mission Impact: Use of aspirin is to be minimized in the deployed and combat environment due to known
coagulopathy issues
K9 Dosage: Only buffered aspirin 10–25mg/kg PO q8–12hr

ALBUTEROL (PROVENTIL) *
Class: Autonomic nervous system agent – sympathomimetic, β-adrenergic agonist, bronchodilator
Action: Acts more prominently on β2-receptors (particularly smooth muscles of bronchi, uterus, and vascular supply
to skeletal muscles) than on β1 (heart) receptors; minimal or no effect on α-adrenergic receptors; inhibits histamine
release by mast cells; produces bronchodilation, by relaxing smooth muscles of bronchial tree which decreases airway
resistance, facilitates mucus drainage, and increases vital capacity
Dose: MDI 2 puffs q4–6hr prn; NEB 0.5mL of 0.5% soln (2.5mg) in 5mL NS nebulized tid–qid
Indications: For prevention of exercise-induced bronchospasm, or relief of bronchospasm associated with acute or
chronic asthma, bronchitis, or other reversible obstructive airway disease; also used 20–30 minutes before inhaled
steroids to allow for deeper penetration of the steroids into the lungs
Contraindications: Pregnancy category caution advised during pregnancy and while breastfeeding
Adverse/Side-effects: Hypersensitivity reaction, tremor, anxiety, nervousness, restlessness, convulsions, weakness,
headache, hallucinations, palpitation, hyper- or hypotension, bradycardia, reflex tachycardia, blurred vision, dilated
pupils, nausea, vomiting, muscle cramps, hoarseness. Albuterol will also result in increase in a physiologic increase
in serum lactate.
Albuterol will result in tachycardia because of adrenergic effect on the AV node. Albuterol will also result in increase in
a physiologic increase in serum lactate.
Interactions: Additive effect with epinephrine and other sympathomimetic bronchodilators; MAOIs and TCAs potenti-
ate action on vascular system; beta-adrenergic blockers antagonize effects
Mission Impact: GROUNDING medication for personnel on flight status

2025 RANGER MEDIC HANDBOOK 143

ALUMINUM HYDROXIDE, MAGNESIUM HYDROXIDE (MAALOX)
Class: Antacid
Action: Neutralizes gastric acid, increases gastric pH
Dose: Oral liquid 200mg/200mg/5mL; 10–20mL q6hr prn; max: 80mL/24hr
Indications: Relief of indigestion, heartburn, and GI upset.
Contraindications: Hypersensitivity, renal impairment pregnancy category may use during pregnancy and while
breastfeeding.
Adverse/Side-effects: Abdominal cramps, constipation, fecal impaction, nausea, vomiting
Interactions: May decrease efficacy of most oral medications by inhibiting gastric absorption unless separated by
2 or more hours.
Mission Impact: None
SECTION 4

AMOXICILLIN/CLAVULANATE (AUGMENTIN)
Class: Antimicrobial – antibiotic, aminopenicillin β-lactamase inhibitor
Action: Interferes with cell wall replication in certain organisms through osmotic instability and β-lactamase inhibitor
Dose: PO immediate release: 500mg q8–12hr or 875mg bid; PO extended release: 2,000mg bid
Indications: Lower respiratory tract infections, otitis media, sinusitis, skin and skin structure infections, urinary tract
infections, animal bites (dog)
Contraindications: Serious and occasionally fatal hypersensitivity (anaphylactic) reactions can occur in individuals
with history of penicillin hypersensitivity; do not use in patients with a history of liver failure; pregnancy category may
use during pregnancy and while breastfeeding
Adverse/Side-effects: Diarrhea/loose stools, nausea, skin rashes and urticaria, vomiting, vaginitis, hypersensitivity
reactions, hepatic dysfunction, blood and lymphatic dysfunction (likely hypersensitivity-related)
Interactions: May increase effect anticoagulants, decrease effectiveness of oral contraceptives.
Mission Impact: GROUNDING for personnel on flight status
K9 Dosage: 10–20mg/kg PO bid × 5–7 days

ATOVAQUONE-PROGUANIL (MALARONE)
Class: Antimicrobial; antimalarial
Dose: Prophylaxis: 250mg/100mg qd; start 1 to 2 days prior to entering a malaria-­endemic area, continue throughout
the stay and for 7 days after returning; Treatment: 1,000mg/400mg qd × 3 days
Indications: Prophylaxis and treatment of Plasmodium falciparum malaria
Contraindications: Hypersensitivity to atovaquone or proguanil, renal impairment, pregnancy category avoid use
during pregnancy and while breastfeeding
Adverse/Side-effects: Headache, abdominal pain, nausea, vomiting, diarrhea, dizziness, cough (pediatrics), liver
transaminase elevations, possible association with seizures and psychotic events (e.g., hallucinations), cutaneous
reactions, including photosensitivity, erythema multiforme and Stevens-Johnson syndrome
Mission Impact: None

144 SECTION 4 RANGER MEDIC PHARMACOLOGY & FORMULARY

ATROPINE SULFATE
Class: CNS agent – anticholinergic parasympatholytic, antidysrhythmic, antimuscarinic belladonna alkaloid
Action: Blocks acetylcholine at parasympathetic neuroeffector sites; increases cardiac output and heart rate by block-
ing vagal stimulation in heart; dries secretions by blocking vagus
Dose: Organophosphate poisoning (CBRN nerve agent):1–6mg IV/IM q3–5min PRN × 2–12hr. Bradycardia: 0.5mg
IV/IM q3–5min (max 3mg)
Indications: Bradycardia, organophosphate poisoning, reversal of anticholinesterase agents, and decreasing secre-
tions before surgery
Contraindications: Hypersensitivity to belladonna alkaloids, glaucoma, GI obstructions, ulcerative colitis, tachycar-
dia/tachydysrhythmias, asthma, acute hemorrhage, myocardial ischemia, pregnancy category caution advised during
pregnancy and while breastfeeding
Adverse/Side-effects: Headache, dizziness, involuntary movements, confusion, psychosis, anxiety, drowsiness, in-
somnia, hypotension, blurred vision, photophobia, pupil dilation, dry mouth, nausea, vomiting, constipation, abdomi-

SECTION 4
nal distention, rash, urticaria, dry skin, urine retention.
Interactions: increase anticholinergic effects of tricyclics, decreased absorption with ketoconazole, decreased effect
of atropine with antacids

AZITHROMYCIN (ZITHROMYCIN, Z-Pak)

Class: Antimicrobial – antibiotic; macrolide
Action: Reversibly binds to 50S ribosomal subunit of susceptible organisms inhibiting protein synthesis; effective
against mild to moderate infections caused by pyogenic streptococci, Streptococcus pneumoniae, Haemophilus in-
fluenzae, Mycobacterium avium intracellulare, and Staphylococcus aureus
Dose: Pneumonia: 500mg PO on day 1, then 250mg qd × 4 days; 500mg PO qd × 3 days; or suspension 2g single
dose. STI (gonococcal): 1g PO × 1 in adjunction with ceftriaxone.
Indications: For pneumonia, lower respiratory tract infections, pharyngitis, tonsillitis, gonorrhea, nongonococcal urethri-
tis, skin infections, otitis media, and acute bacterial sinusitis
Contraindications: Macrolide hypersensitivity; pregnancy category may use during pregnancy and while breastfeeding
Adverse/Side-effects: Headache, dizziness; nausea, vomiting, diarrhea, abdominal pain; hepatotoxicity
Interactions: Antacids may decrease peak level; may increase toxicity of ergotamine; food will decrease the amount
of azithromycin absorbed by 50%
Mission Impact: GROUNDING medication for personnel on flight status

BACITRACIN
Class: Antimicrobial – antibiotic
Action: Polypeptide derived from Bacillus subtilis culture; bactericidal/bacteriostatic that appears to inhibit cell wall
synthesis; activity similar to penicillin; active against many gram-positives including Streptococcus, Staphylococcus,
Pneumococcus, Corynebacteria, Clostridia, Neisseria, Gonococcus, Meningococcus, Haemophilus influenzae, and
Treponema pallidum; ineffective against most other gram-negatives
Dose: Topical ointment to AAA bid–tid, clean affected area prior to application
Indications: For topical treatment of superficial skin infections
Contraindications: Atopic individuals; pregnancy category may use during pregnancy and while breastfeeding
Adverse/Side-effects: Bacitracin hypersensitivity (erythema, anaphylaxis)
Interactions: No clinically significant interactions established when given topically

2025 RANGER MEDIC HANDBOOK 145

BENZATHINE-PENICILLIN G (BICILLIN)
Class: Antimicrobial – anti-infective, β-lactam antibiotic, natural (first generation) penicillin; must be cold stored
Action: Acid-stable, penicillinase-sensitive, long-acting form of penicillin G; absorbed slowly due to extremely low
water solubility; produces lower blood concentrations of penicillin G but has longer duration. Effective against many
strains of Staphylococcus aureus, gram-positive cocci, and gram-negative cocci. Also effective against gram-positive
and gram-negative bacilli
Dose: 1.2 million units IM single dose
Indications: Group A streptococcal pharyngitis; infections susceptible to penicillin G such as streptococcal, pneu-
mococcal, and staphylococcal
Contraindications: Hypersensitivity to penicillins or cephalosporins; lactation; pregnancy category may use during
pregnancy and while breastfeeding
Adverse/Side-effects: Local pain, tenderness, and fever associated with IM injection; chills, fever, wheezing, anaphy-
laxis, neuropathy, nephrotoxicity, pruritis, and urticaria
SECTION 4

Interactions: May decrease efficacy of oral contraceptives

BENZONATATE (TESSALON PERLES)

Class: Nonnarcotic antitussive
Action: Produces local anesthetic effect of stretch receptors on vagal afferent fibers in the respiratory passages,
lungs, and pleura
Dose: 100–200mg PO tid as needed (max single dose: 200mg; max dose: 600mg qd)
Indications: Relief of cough
Contraindications: Hypersensitivity; pregnancy category caution advised during pregnancy and consider alternative
during breastfeeding
Side-effects: chest numbness, chills, confusion, dizziness, headache, hallucination, sedation, pruritus, rash, consti-
pation, nausea, congestion.
Interactions: None
Mission Impact: None

BISACODYL (DULCOLAX)
Class: Laxative, stimulant, diphenylmethane
Action: Direct action on the intestine by increasing motor activity
Dose: 5–15mg PO. Swallow the tablets whole with a full glass of water or juice. Do not crush or chew the tablets. The
tablets should work within 6–10 hours
Indications: Used to treat constipation or to clean out the intestinal tract before bowel examinations or bowel surgery
Contraindications: Ileus, intestinal obstruction, acute surgical abdominal conditions like acute appendicitis, acute
inflammatory bowel diseases, severe dehydration, known hypersensitivity to substances of the triarylmethane group,
pregnancy category may use during pregnancy and while breastfeeding
Adverse/Side-effects: Rarely, abdominal discomfort and diarrhea have been reported
Interactions: Dairy products, antacids, H2-blockers, PPIs. Tablets have a special coating and therefore should not be
taken together with milk or antacids

146 SECTION 4 RANGER MEDIC PHARMACOLOGY & FORMULARY

BLOOD
Class: Blood Product
Indications: IAW Tactical Damage Control Resuscitation Protocol
Interactions: Do not administer in same line as calcium or with calcium containing fluids
Considerations: Whole blood should be stored at 1–6°C and can be stored for 21 days using anticoagulant CPG or
35 days using anticoagulant CPDA-1. Fresh Whole Blood (FWB) can be stored at room temperature and is suitable
for use up to 24 hrs. If FWB is refrigerated within 8 hrs of collection, it becomes Stored Whole Blood (SWB). Must
maintain a temp tolerance device on SWB. Once SWB is out of temp tolerance it must be transfused within 4 hrs or
must be destroyed.

BUPIVACAINE (MARCAINE)

SECTION 4
Class: Local anesthetic
Action: Decreases the neuronal membrane’s permeability to sodium ions, this results in inhibition of depolarization,
blocking conduction
Dose: 0.25% infiltrated locally (max: 400mg of bupivacaine/d); note: aspirate before every injection
Onset/Peak/Duration: Onset is fast/Peak 30–45 minutes/Duration 2–8 hours; note: epinephrine reduces the rate of
absorption and peak plasma concentration of bupivacaine
Indications: Local or regional anesthesia; diagnostic and therapeutic procedures
Contraindications: Hypersensitivity to bupivacaine hydrochloride; amide-type local anesthetics; note: do not use as
intravenous regional anesthesia, may cause cardiac arrest and death, pregnancy category consider alternative use
during pregnancy and may use while breastfeeding
Adverse/Side-effects: Most effects are dose related, often due to accelerated absorption: Bradycardia, cardiac ar-
rest, heart block, hypotension, palpitations, ventricular arrhythmias, anxiety, dizziness, restlessness, nausea, vomiting,
hypersensitivity reaction, weakness, blurred vision, miosis, tinnitus, apnea
Interactions: Blood pressure–lowering medications may be enhanced; enhances other local anesthetic effects
Mission Impact: GROUNDING medication for personnel on flight status

CALCIUM CHLORIDE 10%

Class: Mineral - Calcium Salt
Action: Essential component and participant in the clotting cascade and ionotropic and vasopressor effects.
Dose: Calcium Chloride infusion in 100mg or 250mg NaCl or slow push IV/IO 1g over 1–2 minutes after 2nd unit of
blood and after every 4 units.
Indications: Blood transfusion
Contraindications: Hypersensitivity to drug/class, hypercalcemia, caution with systemic illness or arrhythmias; preg-
nancy category category may use during pregnancy and while breastfeeding
Adverse/Side Effects: Arrhythmias, extravasation necrosis, flushing, dizziness
Interactions: Minimal prehospital interaction

2025 RANGER MEDIC HANDBOOK 147

CALCIUM GLUCONATE *
Class: Mineral - Calcium Salt
Action: Essential component and participant in the clotting cascade and ionotropic and vasopressor effects.
Dose: 1g infusion in 100mg or 250mg NaCl or slow push IV/IO over 1–2 minutes after 2nd unit of blood and after every
4 units. 30mg of 10% Calcium Gluconate equals a 1g dose of 10% Calcium Chloride.
Indications: Blood transfusion
Contraindications: Hypersensitivity to drug/class, hypercalcemia, caution with systemic illness or arrhythmias; preg-
nancy category category may use during pregnancy and while breastfeeding
Adverse/Side Effects: Arrhythmias, extravasation necrosis, flushing, dizziness
Interactions: Minimal prehospital interaction
Mission Impacts: 1–3g of Calcium Gluconate dose range is based on mission requirements and logistical constraints.
Medics may only be carrying limited Calcium Gluconate.
SECTION 4

CEFAZOLIN SODIUM (ANCEF)

Class: Antimicrobial – first-generation cephalosporin
Action: Inhibits susceptible bacterial cell wall synthesis rendering cell wall osmotically unstable. Activity against gram-
negative organisms is limited
Dose: 1–2g IM/IV q8hr (max 12g/d)
Indications: Open bone fractures or joint disruptions as presurgical prophylaxis
Contraindications: Hypersensitivity to any cephalosporin and related antibiotics; lactation; pregnancy category may
use during pregnancy and while breastfeeding
Adverse/Side-effects: Anaphylaxis, fever, diarrhea, anorexia, abdominal cramps, maculopapular rash, urticaria
Interactions: Minimal prehospital interactions
Mission Impact: GROUNDING medication for personnel on flight status
K9 Dosage: 0.5–1g (25mg/kg) IV daily; give over 5 minutes

CEFTRIAXONE (ROCEPHIN)
Class: Antimicrobial – antibiotic; third-generation cephalosporin
Action: Preferentially binds to penicillin-binding proteins (PBPs) and inhibits bacterial cell wall synthesis; effective
against most
Enterobacteriaceae, gram-positive aerobic cocci, Neisseria meningitides, and gonorrhoeae; some effect against
Treponema pallidum
Dose: For moderate to severe infections, 1–2g IV/IM q12–24hr (max: 4g/d); for meningitis, 2g IV/IM q12hr; for uncom-
plicated gonorrhea 250mg IM × 1; dilute in 1% lidocaine for IM
Indications: For infections of the middle ear, lower respiratory tract, skin and skin structures, bones and joints, men-
ingitis, intra-abdominal, urogenital tract, pelvis, septicemia; used for surgical prophylaxis
Contraindications: Cephalosporin hypersensitivity; pregnancy category may use during pregnancy and while
breastfeeding
Adverse/Side-effects: Pruritus, fever, chills, pain, induration at IM site, phlebitis at IV site, diarrhea, abdominal
cramps, pseudomembranous colitis, biliary sludge
Interactions: Probenecid decreases renal elimination; alcohol produces disulfiram reaction
Mission Impact: GROUNDING medication for personnel on flight status
K9 Dosage: 1g IV/IM qd

148 SECTION 4 RANGER MEDIC PHARMACOLOGY & FORMULARY

CETIRIZINE (ZYRTEC)
Class: ENT agent – H1-receptor antagonist; nonsedating antihistamine
Action: Potent H1-receptor antagonist and antihistamine; low lipophilicity and H1-­receptor selectivity and thus no
significant anticholinergic or CNS activity; reduces local and systemic effects of histamine release
Dose: 5–10mg PO qd
Indications: Seasonal and perennial allergic rhinitis and chronic idiopathic urticaria
Contraindications: H1-receptor antihistamine hypersensitivity; pregnancy category may use during pregnancy and
caution advised while breastfeeding
Adverse/Side-effects: Constipation, diarrhea, dry mouth; drowsiness, sedation, headache, depression
Interactions: Theophylline may decrease clearance leading to toxicity; do not use in combination with OTC
antihistamines
Mission Impact: GROUNDING medication for personnel on flight status

SECTION 4
CIMETIDINE (TAGAMET)
Class: GI agent – antisecretory H2-receptor antagonist
Action: Antihistamine with high selectivity for reversible competitive inhibition of histamine H2-receptors on parietal
cells of the stomach (minimal effect on H1-receptors) and thus decreases gastric acid secretion, raises the pH of the
stomach, and indirectly reduces pepsin secretion
Dose: Oral: 300mg QID or 800mg at bedtime or 400mg bid for up to 8 weeks
Indications: For treatment of duodenal/gastric ulcer, prevention of ulcer recurrence, gastroesophageal reflux, chronic
urticaria, acetaminophen toxicity
Contraindications: H2-receptor antagonist hypersensitivity; pregnancy category may use during pregnancy and while
breastfeeding
Adverse/Side-effects: Fever, cardiac arrhythmias and cardiac arrest after rapid IV bolus; diarrhea, constipation,
abdominal discomfort; increased prothrombin time, neutropenia, thrombocytopenia, aplastic anemia, hypospermia,
exacerbation of preexisting arthritis; drowsiness, dizziness, light-headedness, depression, headache, reversible con-
fusion states, paranoid psychosis; rash, Stevens-Johnson syndrome, reversible alopecia, gynecomastia, galactor-
rhea, reversible impotence
Interactions: Decreases hepatic metabolism of warfarin, phenobarbital, phenytoin, diazepam, propranolol, lidocaine,
theophylline, thus increasing their activity and toxicity; antacids may decrease absorption

2025 RANGER MEDIC HANDBOOK 149

CIPROFOXACIN (CIPRO)
Class: Antimicrobial – antibiotic; quinolone. All fluoroquinolones now have a US Black Box Warning due to seri-
ous adverse reactions including tendonitis and tendon rupture, peripheral neuropathy and CNS effects. How-
ever, in some rare cases, benefits may outweigh the risks of fluoroquinolone use. Fluoroquinolones require
prior approval from unit physician or physician assistant
Action: Synthetic broad-spectrum bactericidal agent; inhibits DNA-gyrase, an enzyme necessary for bacterial DNA
replication, transcription, repair, recombination, and transposition; effective against many gram-positive and gram-
negative organisms including Citrobacter diversus, Enterobacter cloacae, Enterobacter aerogenes, Escherichia coli,
Haemophilus influenzae, Klebsiella pneumoniae, Neisseria gonorrhoeae, Proteus miribilis, Proteus vulgaris, Pseudo-
monas aeruginosa, Serratia marcescens, Staphylococcus aureus, Streptococcus pyogenes, Shigella, and Salmonella;
less active against gram-­positive than gram-negative bacteria, although active against many gram-positive aero-
bic bacteria, including penicillinase-producing, non–­penicillinase-producing, and methicillin-resistant staphylococci;
however, many strains of streptococci are relatively resistant; inactive against most anaerobic bacteria; resistant to
some strains of methicillin-resistant Staphylococcus aureus (MRSA)
SECTION 4

Dose: 250–750mg PO bid or 200–400mg IV q8–12hr

NOTE: Not first-line treatment
Indications: For infections of the lower respiratory tract, skin and skin structures, bone and joints, GI tract, urinary
tract, prostate; also used for nosocomial pneumonia, acute sinusitis, and postexposure prophylaxis for anthrax
Contraindications: Quinolone hypersensitivity; syphilis, viral infection; tendon inflammation or tendon pain; preg-
nancy category consider alternative during pregnancy and avoid while breastfeeding
Adverse/Side-effects: Nausea, vomiting, diarrhea, cramps, gas, pseudomembranous colitis; tendon rupture; head-
ache, vertigo, malaise, peripheral neuropathy, seizures
Interactions: May increase theophylline levels; antacids, sucralfate, iron decrease absorption; may increase PT for
patients on warfarin; may cause false positive on opiate screening tests
Mission Impact: GROUNDING medication for personnel on flight status
K9 Dosage: DO NOT GIVE

CLINDAMYCIN (CLEOCIN)
Class: Antimicrobial – antibiotic
Action: Suppresses protein synthesis by binding to 50S subunits of bacterial ribosomes; effective against strains of
anaerobic streptococci, Bacteroides (especially B. fragilis), Fusobacterium, Actinomyces israelii, Peptococcus, Clos-
tridium sp., and aerobic gram-positive cocci, including Staphylococcus aureus, Staphylococcus epidermidis, strepto-
cocci (except S. faecalis), and pneumococci
Dose: 600–1,800mg/d in 2–4 divided doses; up to 2,400mg/d in 4 divided doses may be given for severe infections.
Cleocin T: topically AAA bid
Indications: For moderate to severe infections; topical applications used in treatment of acne vulgaris
Contraindications: Clindamycin or lincomycin hypersensitivity; history of regional enteritis, ulcerative colitis, or
­ ntibiotic–associated colitis; pregnancy category may use during pregnancy and while breastfeeding
a
Adverse/Side-effects: Fever, serum sickness, sensitization, swelling of face, generalized myalgia, superinfections,
proctitis, pain, induration, sterile abscess; thrombophlebitis; hypotension, cardiac arrest (rapid IV); diarrhea, abdominal
pain, flatulence, bloating, nausea, vomiting, pseudomembranous colitis; esophageal irritation, loss of taste, medicinal
taste (high IV doses), jaundice, abnormal liver function tests; leukopenia, eosinophilia, agranulocytosis, thrombocyto-
penia; skin rashes, urticaria, pruritus, dryness, contact dermatitis, gram-negative folliculitis, irritation, oily skin
Interactions: Chloramphenicol and erythromycin are possibly antagonistic; neuromuscular blocking action enhanced
by neuromuscular blocking agents (atracurium, tubo­curarine, pancuronium)
Mission Impact: GROUNDING medication for personnel on flight status.
K9 Dosage: DO NOT GIVE

150 SECTION 4 RANGER MEDIC PHARMACOLOGY & FORMULARY

CYCLOBENZAPRINE (FLEXERIL)
Class: Autonomic nervous system agent – central acting; skeletal muscle relaxant
Action: Structurally and pharmacologically related to TCAs; relieves skeletal muscle spasm of local origin without
interfering with muscle function; believed to act primarily within CNS at brain stem with some action at spinal cord
level; depresses tonic somatic motor activity, although both gamma and alpha motor neurons are affected; increases
circulating norepinephrine by blocking synaptic reuptake, thus producing antidepressant effect; has sedative effect
and potent central and peripheral anticholinergic activity
Dose: 5–10mg PO tid prn muscle spasm (max: 60mg/d); do not use longer than 2–3 weeks
Indications: As adjunct to rest and physical therapy for short-term relief of muscle spasm associated with acute
musculoskeletal conditions
Contraindications: Recovery phase of MI; cardiac arrhythmias, heart block or conduction disturbances; CHF, hyper­
thyroidism; pregnancy category caution advised during pregnancy and consider alternative while breastfeeding
Adverse/Side-effects: Tongue and face edema, sweating, myalgia, hepatitis, alopecia; toxic potential of TCAs; tachy-

SECTION 4
cardia, syncope, palpitation, vasodilation, chest pain, orthostatic hypotension, dyspnea; arrhythmias; dry mouth, in-
digestion, unpleasant taste, coated or discolored tongue, vomiting, anorexia, abdominal pain, flatulence, diarrhea,
paralytic ileus; drowsiness, dizziness, weakness, fatigue, asthenia, paresthesia, tremors, muscle twitching, insomnia,
euphoria, disorientation, mania, ataxia; pruritus, urticaria, rash; increased or decreased libido, impotence
Interactions: Alcohol, barbiturates, other CNS depressants enhance CNS depression; potentiates anticholinergic
effect of phenothiazine and other anticholinergics; MAOIs may precipitate hypertensive crisis
Mission Impact: GROUNDING, Causes drowsiness in most people.
K9 Dosage: DO NOT GIVE

DEXAMETHASONE (DECADRON)
Class: Hormones and synthetic substitutes – steroid; adrenocorticoid; glucocorticoid
Action: Long-acting synthetic adrenocorticoid with intense glucocorticoid activity and minimal mineralocorticoid
­activity; Anti-inflammatory and immunosuppression properties; prevents accumulation of inflammatory cells at sites
of infection; inhibits phagocytosis, lysosomal enzyme release, and synthesis of selected chemical mediators of inflam-
mation; reduces capillary dilation and permeability
Dose: 0.25–4mg PO bid–qid; 8–12mg IM/IV q1–3wk. AMS: 8mg qid; HACE: Initial: 8mg as a single dose; Mainte-
nance: 4mg PO qid until symptoms resolve
Onset/Peak/Duration: Onset hours/Peak in 8–12 hours/Duration 72 hours
Indications: For inflammatory conditions, allergic states, and cerebral edema
Contraindications: Systemic fungal infection, acute infections, tuberculosis, vaccinia, varicella, live virus vaccines (to
patient, family members), amebiasis; pregnancy category caution advised during pregnancy and consider alternative
while breastfeeding
Adverse/Side-effects: Euphoria, insomnia, convulsions, increased ICP, vertigo, headache, psychic disturbances;
CHF, hypertension, edema; hyperglycemia; cushingoid state; hirsutism; cataracts, increased IOP, glaucoma, exoph-
thalmos; peptic ulcer or perforation, abdominal distension, nausea, increased appetite, heartburn, dyspepsia, pan-
creatitis, bowel perforation, oral candidiasis; muscle weakness, loss of muscle mass, vertebral compression fracture,
pathologic fracture of long bones, tendon rupture; acne, impaired wound healing, petechiae, ecchymoses, diaphore-
sis, dermatitis, hypo- or hyperpigmentation, skin atrophy
Interactions: May inhibit antibody response to vaccines and toxoids
Mission Impact: GROUNDING medication for personnel on flight status.
K9 Dosage: 3–4mg (0.5mg/kg) IV/IM

2025 RANGER MEDIC HANDBOOK 151

DEXTROSE (D50)
Class: Endocrine agent – caloric, monosaccharide
Action: Needed for adequate utilization of amino acids, decreases protein and nitrogen loss, and prevents ketosis
Dose: 0.5–1g/kg (1–2mL/kg) up to 25g (50mL) of 50% solution IV; if tolerating PO, provide glucose tabs
Indications: For treatment of hypoglycemic episode
Contraindications: Hyperglycemia, delirium tremens, cranial or spinal hemorrhage, CHF
Adverse/Side-effects: Confusion, loss of consciousness, dizziness; hypertension, CHF, pulmonary edema; glyco­
suria, osmotic diuresis; hyperglycemia, rebound hypoglycemia; chills, flushing, rash, urticaria
Interactions: No clinically significant interactions established

DIAZEPAM (VALIUM) – CONTROLLED MEDICATION IV

SECTION 4

Class: CNS agent – benzodiazepine; anticonvulsant; anxiolytic

Action: Anticonvulsant and antianxiety psychotherapeutic drug with action at both limbic and subcortical levels of
CNS; increases total sleep time, but shortens REM and stage 4 sleep
Dose: 5–10mg slow IV push, repeat in 3–4hr; 2–10mg PO tid–qid
Onset/Peak/Duration: Onset/Peak/Duration 2–4 hours
Indications: For anxiety, seizures, skeletal muscle spasm relief; also used as an amnesic, for treatment of restless leg
syndrome, acute alcohol withdrawal, and is the drug of choice for status epilepticus
Contraindications: Shock, coma, alcohol intoxication, depressed vital signs; acute narrow-angle glaucoma, untreated
open-angle glaucoma; MAOIs; pregnancy category consider alternative during pregnancy and while breastfeeding
Adverse/Side-effects: Throat and chest pain; drowsiness, fatigue, ataxia, confusion, paradoxical rage, dizziness,
vertigo, amnesia, vivid dreams, headache, slurred speech, tremor; EEG changes, tardive dyskinesia; hypotension,
tachycardia, edema, cardiovascular collapse; blurred vision, diplopia, nystagmus; xerostomia, nausea, constipation,
hepatic dysfunction; incontinence, urinary retention, gynecomastia (prolonged use); hiccups, coughing, laryngo-
spasm; venous thrombosis, phlebitis
Interactions: Alcohol, CNS depressants, anticonvulsants, and herbals potentiate CNS depression; cimetidine in-
creases levels and toxicity; may decrease effects of levodopa; may increase phenytoin levels; smoking decreases
sedative and antianxiety effects
Mission Impact: Drowsiness. GROUNDING medication for personnel on flight status.
K9 Dosage: For seizures, 15–30mg (0.5–1mg/kg) IV or 30–60mg (1–2mg/kg) rectally q4hr. For sedation combined with
opioid, 7.5mg (0.25mg/kg) IV/IM q4hr

152 SECTION 4 RANGER MEDIC PHARMACOLOGY & FORMULARY

DIPHENHYDRAMINE (BENADRYL) *
Class: ENT agent – H1-blocker; antihistamine
Action: H1-receptor antagonist and antihistamine as it competes for H1-receptor sites on effector cells; significant
central anticholinergic activity as it prolongs action of dopamine by inhibiting its uptake and storage, thus decreasing
Parkinsonism and drug-induced extrapyramidal symptoms
Dose: 25–50mg IV/IM/PO q4–6hr
Onset/Peak/Duration:
IV – Onset immediate/Peak in 1–3 hours/Duration 6–8 hours
IM – Onset 30 minutes/Peak 1–3 hours/Duration 6–8 hours
PO – Onset 15–60 minutes/Peak in 1–3 hours/Duration 6–8 hours
Indications: For allergic conditions; treatment or prevention of motion sickness or vertigo; blood or plasma reactions;
treatment of Parkinsonism and drug-induced extrapyramidal reactions; also used with epinephrine for anaphylaxis;
may be used as a cough suppressant, a sedative-hypnotic or for intractable insomnia

SECTION 4
Contraindications: Antihistamine hypersensitivity, lower respiratory tract symptoms, asthma; narrow-angle glaucoma,
prostatic hypertrophy, bladder neck obstruction, GI obstruction, pregnancy category may use during pregnancy and
consider alternative while breastfeedings
Adverse/Side-effects: Drowsiness, dizziness, headache, fatigue, disturbed coordination, tingling, heaviness and
weakness of hands, tremors, euphoria, nervousness, restlessness, insomnia, confusion, excitement, fever, palpita-
tion, tachycardia, hypo- or hypertension, cardiovascular collapse, tinnitus, vertigo, dry nose/mouth, nasal stuffiness,
blurred vision, diplopia, photosensitivity, dry eyes, nausea, epigastric distress, anorexia, vomiting, constipation, diar-
rhea, urinary frequency or retention, dysuria, thickened bronchial secretions, wheezing, chest tightness
Interactions: Alcohol, other CNS depressants, and MAOIs compound CNS depression
Mission Impact: GROUNDING, Sedative effects on patient should be considered in tactical situation
K9 Dosage: 50mg IM/SQ/PO. Impacts sense of smell

DOCUSATE (COLACE)
Class: GI agent – stool softener
Action: Anionic surface-active agent with emulsifying and wetting properties; detergent action lowers surface tension,
permitting water and fats to penetrate and soften stools for easier passage
Dose: 50–500mg/d PO divided qd–qid
Indications: For treatment of constipation associated with hard and dry stools, also used prophylactically in patients
taking narcotics or patients who should avoid straining during defecation
Contraindications: Atonic constipation, nausea, vomiting, abdominal pain, fecal impaction, structural anomalies of
colon and rectum, intestinal obstruction or perforation; patients on sodium restriction or with renal dysfunction; con-
comitant use of mineral oil; pregnancy category may use during pregnancy and while breastfeeding
Adverse/Side-effects: Mild abdominal cramps, diarrhea, nausea, bitter taste; rash
Interactions: Increases systemic absorption of mineral oil

2025 RANGER MEDIC HANDBOOK 153

DOXYCYCLINE
Class: Antimicrobial – antibiotic; tetracycline
Action: Semisynthetic broad-spectrum antibiotic derived from oxytetracycline, but more completely absorbed with
effective blood levels maintained for longer periods and excreted more slowly than most other tetracyclines, thus it
requires smaller and less frequent dosing; primarily bacteriostatic in effect
Dose: As antimalarial, 100mg PO qd starting 1–2 days prior to 4 weeks after exposure; as antimicrobial, 100mg PO
q12hr on day 1, then 100mg qd; for travelers’ diarrhea, 100mg PO QD during risk period; for gonorrhea, 200mg PO
immediately, followed by 100mg bid × 3 days; for syphilis 100mg PO tid × 10 days; for acne, 100mg PO qd–bid
Indications: For suppression and chemoprophylaxis of chloroquine-resistant malaria, short-term prophylaxis and
treatment of travelers’ diarrhea caused by enterotoxigenic strains of Escherichia coli, chlamydial and mycoplasmal
infections, gonorrhea, syphilis in penicillin-allergic patients, rickettsial diseases, acute exacerbations of chronic bron-
chitis, and treatment of acne
Contraindications: Tetracycline hypersensitivity; use during period of tooth development including last half of preg-
nancy causes permanent yellow discoloration of teeth, enamel hypoplasia, and retardation of bone growth, pregnancy
SECTION 4

category may use for anthrax infection and otherwise consider alternative during pregnancy and avoid use while
breastfeeding
Adverse/Side-effects: Interference with color vision; anorexia, nausea, vomiting, diarrhea, enterocolitis; esophageal
irritation; rashes, photosensitivity reaction; superinfections
Interactions: Antacids, iron preparation, calcium, magnesium, zinc, kaolin-pectin, sodium bicarbonate can signifi-
cantly decrease absorption; effects of both doxycycline and desmopressin antagonized; increases digoxin absorption
and risk of toxicity; methoxyflurane increases risk of renal failure. Antacids (Pepto-Bismol, Kaopectate, Mylanta)
can significantly decrease the absorption effects of doxycycline.

EPINEPHRINE (INCLUDING EPI-PEN) *

Class: Autonomic nervous system agent – natural and synthetic catecholamine; α- and β-adrenergic agonist;
bronchodilator
Action: Sympathomimetic that acts directly on both alpha and beta receptors; the most potent activator of alpha re-
ceptors; strengthens myocardial contraction; increases systolic but may decrease diastolic blood pressure; increases
cardiac rate and output; constricts bronchial arterioles and inhibits histamine release, thus reducing congestion and
edema and increasing tidal volume and vital capacity
Dose: Anaphylaxis: 0.3–0.5mg IM q10–15min (1:1,000 soln = 1mg/1mL) ACLS: 1mg IV/IO q3–5min for cardiac arrest
Onset/Peak/Duration: IV/IM – Onset Rapid/Duration 1–2 minutes
Indications: For hypersensitivity and anaphylactic reactions, acute asthma attack, bronchospasm, mucosal conges-
tion, syncope due to heart block or carotid sinus hypersensitivity, and to restore cardiac rhythm in cardiac arrest;
prolong action and delay absorption of anesthetics; control superficial bleeding
Contraindications: Sympathomimetic amine hypersensitivity; narrow-angle glaucoma; hemorrhagic, traumatic, or
cardiogenic shock; cardiac dilatation, cerebral arteriosclerosis, coronary insufficiency, arrhythmias, organic heart or
brain disease; (use with local anesthesia of fingers, toes, ears, nose, genitalia has been demonstrated safe); pregnancy
category caution advised during pregnancy and consider alternative while breastfeeding
Adverse/Side-effects: Nervousness, restlessness, sleeplessness, fear, anxiety, tremors, headache, CVA, weak-
ness, dizziness, syncope, pallor, sweating, dyspnea; nausea, vomiting; precordial pain, palpitations, hypertension,
MI, tachyarrhythmias; bronchial and pulmonary edema; urinary retention; tissue necrosis; metabolic acidosis; altered
state of perception and thought, psychosis
Interactions: May increase hypotension in circulatory collapse; additive toxicities with other medications
Mission Impact: GROUNDING medication for personnel on flight status

154 SECTION 4 RANGER MEDIC PHARMACOLOGY & FORMULARY

ERTAPENEM (INVANZ) *
Class: Antimicrobial – antibiotic, carbapenem, β-lactam
Action: Broad-spectrum antibiotic that inhibits cell wall synthesis of gram-positive and gram-negative bacteria by its
strong affinity for bacterial cell wall penicillin-binding proteins (PBPs); highly resistant to most bacterial β-lactamases;
effective against most Enterobacteriaceae, Pseudomonas aeruginosa, and Acinetobacter spp.; poorly effective
against enterococci, particularly vancomycin-resistant strains
Dose: 1g IV/IM q24hr (for IV reconstitute with 10mL NS; for IM 3.2mL 1.0% lidocaine without epinephrine)
Indications: For complicated infections of abdomen, pelvis, urinary tract, and skin; also used for community-acquired
pneumonia
Contraindications: Carbapenem, β-lactam, or amide-type local anesthetic (i.e., lidocaine) hypersensitivity; pregnancy
category may use during pregnancy and while breastfeeding
Adverse/Side-effects: Injection site phlebitis or thrombosis; asthenia, fatigue, death, fever, leg pain, anxiety, altered
mental status, dizziness, headache, insomnia; chest pain, hypo- or hypertension, tachycardia, edema; abdominal

SECTION 4
pain, diarrhea, acid reflux, constipation, dyspepsia, nausea, vomiting, increased LFTs; cough, dyspnea, pharyngitis,
rales, rhonchi, respiratory distress; erythema, pruritus, rash
Interactions: Probenecid decreases renal excretion
Mission Impact: GROUNDING medication for personnel on flight status

ERYTHROMYCIN OPHTHALMIC OINTMENT

Class: Macrolide antibiotic
Dose: One-half inch ribbon of ointment q3–4hr or 2–6 × daily.
Indications: For superficial ocular infections of the cornea and conjunctiva
Contraindications: Hypersensitivity, astemizole, cisapride, pimozide, terfenadine therapy, pregnancy category may use
during pregnancy and while breastfeeding
Adverse/Side-effects: Minor ocular irritations and redness
Interactions: Terfenadine, atorvastatin, lovastatin, pravastatin, simvastatin, carbamazepine, digoxin, diltiazem, midaz­
o­lam, oral contraceptives, ototoxic drugs, penicillins, warfarin
Mission Impact: Blurred vision

ESZOPICLONE (LUNESTA) – CONTROLLED SUBSTANCE IV

Class: Sedative-hypnotic
Action: May potentiate effects of inhibitory neurotransmitter γ-aminobutyric acid (GABA) by binding close to or with
benzodiazepine receptors
Dose: 2mg up to 3mg immediately at bedtime. Maintenance dose 3mg
Indications: Insomnia
Contraindications: Hypersensitivity, pregnancy category consider alternative during pregnancy and avoid use while
breastfeeding
Adverse/Side-effects: Agitation, anxiety, confusion, depression, dizziness, hallucinations, HA, nervousness, neural-
gia, unusual dreams, chest pain, peripheral edema, dry mouth, gynecomastia, diarrhea, indigestion, hepatitis, nausea,
vomiting, decreased libido, dysmenorrhea, UTI, asthma, respiratory tract infection, pruritus, rash, or heat stroke
Interactions: Clarithromycin, ketoconazole, itraconazole, rifampin, and alcohol
Mission Impact: Grogginess. Puts patient at higher risk for heat injury. GROUNDING medication for per-
sonnel on flight status

2025 RANGER MEDIC HANDBOOK 155

FENTANYL – CONTROLLED SUBSTANCE II
Class: CNS agent – potent narcotic (opiate) agonist
Action: Action similar to that of morphine with more rapid and less prolonged analgesia and sedation, but less emetic
effect
Dose: 800mcg/dose (max 1600mcg/day); lozenge on a stick to be placed in mouth between cheek and lower gum and
sucked, not chewed (have opioid antagonist [naloxone] immediately available!) IV: For severe pain 50–100mcg IV/IO/IM
(consider doubling IV/IO dose for IM) q1–2hr prn
Onset/Peak/Duration: TD: Onset 15 minutes; peak 20–40 minutes; duration 2–3 hours. IV/IO: Onset immediate; peak
30–60 minutes; duration 2–4 hours
Indications: For moderate to severe pain management
Contraindications: MAOIs; myasthenia gravis; pregnancy category consider alternative during pregnancy and may
use while breastfeeding (caution advised in patients trying to conceive)
Adverse/Side-effects: Sedation, euphoria, dizziness, diaphoresis, delirium, convulsions, bradycardia, hypotension,
SECTION 4

circulatory depression, cardiac arrest; miosis, blurred vision; nausea, vomiting, constipation, ileus; muscle and tho-
racic muscle rigidity; urinary retention, rash; laryngospasm, bronchoconstriction, respiratory depression or arrest
Interactions: Alcohol and other CNS depressants potentiate effects; MAOIs may precipitate hypertensive crisis
Mission Impact: GROUNDING medication for personnel on flight status

FEXOFENADINE (ALLEGRA)
Class: ENT agent – H1-receptor antagonist; nonsedating antihistamine
Action: Competitively antagonizes histamine at the H1-receptor site; does not bind with histamine to inactivate it; not
associated with anticholinergic or sedative properties; inhibits antigen-induced bronchospasm and histamine release
from mast cells
Dose: 60mg PO bid or 180mg PO qd
Indications: For symptom relief from seasonal allergic rhinitis (nasal congestion and sneezing, watery or red eyes,
itching nose, palate, or eyes) and chronic urticaria
Contraindications: Fexofenadine hypersensitivity; pregnancy category may use during pregnancy and caution ad-
vised while breastfeeding
Adverse/Side-effects: Headache, drowsiness, fatigue, nausea, dyspepsia, throat irritation
Interactions: No clinically significant interactions established

156 SECTION 4 RANGER MEDIC PHARMACOLOGY & FORMULARY

FLUCONAZOLE (DIFLUCAN)
Class: Antifungal
Action: Damages fungal cells by interfering with a cytochrome P450 enzyme needed in cell membrane synthesis
Dose: Skin infection: 150mg, 1 pill per week × 4 weeks. Oropharyngeal candidiasis: The recommended dosage of
fluconazole for oropharyngeal candidiasis is 200mg on the first day, followed by 100mg once daily. Clinical evidence
of oropharyngeal candidiasis generally resolves within several days, but treatment should be continued for at least
2 weeks to decrease the likelihood of relapse. Vaginal candidiasis: The recommended dosage of fluconazole for
vaginal candidiasis is 150mg as a single oral dose
Indications: Vaginal candidiasis (vaginal yeast infections due to Candida), oropharyngeal and esophageal candidiasis,
fungal skin infections
Contraindications: Hypersensitivity to fluconazole, pregnancy category avoid use during pregnancy and may use
while breastfeeding
Adverse/Side-effects: Exfoliative skin disorders including Stevens-Johnson syndrome and toxic epidermal necrosis

SECTION 4
Interactions: Erythromycin; heart medications
Mission Impact: Aviation personnel are grounded for the initial 24 hours of antifungal therapy and until the medical
condition no longer interferes with safely performing aviation duties and the patient is free of side-effects

FLUTICASONE (FLONASE)
Class: Anti-inflammatory corticosteroid; skin and mucous membrane agent
Action: Inhibits cells involved in the inflammatory response of asthma (mast cells, eosinophils, basophils, and lympho-
cytes). Also inhibits secretion of chemical mediators such as histamines
Dose: 1 spray in each nostril bid OR 2 sprays in each nostril daily
Indications: For management of nasal symptoms of seasonal and perennial allergic and nonallergic rhinitis in adults
and children > 4 years old
Contraindications: Hypersensitivity, pregnancy category consider alternative during pregnancy and may use while
breastfeeding
Adverse/Side-effects: Irritation of nasal mucous membranes, blood in nasal mucous, runny nose, abdominal pain,
diarrhea, dizziness, flulike symptoms
Interactions: Drugs with immunosuppressive properties, other steroid drugs, suspected chickenpox or measles,
anti­viral drugs

2025 RANGER MEDIC HANDBOOK 157

GATAFLOXACIN OPHTHALMIC (ZYMAR)
Class: Antimicrobial – antibiotic, ocular fluoroquinolone
Dose: Days 1 and 2: instill 1 drop in affected eye(s) q2hr while awake, up to 8 × daily. Days 3–7: Instill 1 drop in affected
eye(s) up to 4 times/day while awake. To instill in eye, tilt head back, place medication in conjunctival sac and close
eye(s). Apply light finger pressure on lacrimal sac for 1 minute following instillation. To avoid bottle contamination, do
not touch tip of container to any surface. Replace cap after use
Indications: Eye infections
Contraindications: Hypersensitivity to any component of product, pregnancy category may use during pregnancy
and while breastfeeding
Adverse/Side-effects: Upon instillation, may cause temporary blurring of vision or stinging. If stinging, burning, or
itching becomes pronounced, or redness, irritation, swelling, decreasing vision, or pain persists or worsens, discon-
tinue and consider alternative therapy. Lid margin crusting, white crystalline precipitates, and foreign body sensation
in the eye have been reported. Bad/bitter taste in mouth, nausea, discontinue at first sign of skin rash or other allergic
reaction, corneal staining, tearing and photophobia
SECTION 4

Interactions: When gatifloxacin is absorbed into the bloodstream, there may be an interaction between gatifloxacin
and any of the following:
■ antacids (containing aluminum, calcium, and magnesium)
■ digoxin
■ probenecid
■ vitamins (containing zinc, calcium, magnesium, or iron)

Mission Impact: Aviation personnel are grounded for the initial 24 hours of antibiotic therapy and until the medical
condition no longer interferes with safely performing aviation duties and the patient is free of side-effects

GUAIFENESIN
Class: ENT agent – antitussive, expectorant
Action: Enhances reflex outflow of respiratory tract fluids by irritation of gastric mucosa; aids in expectoration by
reducing adhesiveness and surface tension of secretions
Dose: 100–400mg PO q4hr or 600–1,200mg XR PO q12hr (max: 2.4g/d)
Indications: Relief of dry, nonproductive coughs associated with colds and bronchitis
Contraindications: Guaifenesin hypersensitivity; pregnancy category may use during pregnancy and caution advised
while breastfeeding
Adverse/Side-effects: Low incidence of nausea; drowsiness
Interactions: By inhibiting platelet function, may increase risk of bleeding in patients receiving heparin

HYDROCORTISONE CREAM
Class: Skin and mucous membrane agent – synthetic hormone; adrenal corticosteroid, glucocorticoid, mineralocorti­
coid, anti-inflammatory
Action: Stabilizes leukocyte lysosomal membranes, inhibits phagocytosis and release of allergic substances, sup-
presses fibroblast formation and collagen deposition
Dose: Topically AAA qd–qid
Indications: To reduce inflammation in various skin conditions
Contraindications: Steroid hypersensitivity, viral or bacterial diseases of skin; varicella or vaccinia on surfaces with
compromised circulation; pregnancy category caution advised during pregnancy and while breastfeeding
Adverse/Side-effects: Anaphylactoid reaction, aggravation or masking of infections, skin thinning and atrophy, acne,
impaired wound healing, petechiae, ecchymosis, easy bruising, hypopigmentation or hyperpigmentation, hirsutism,
acneiform eruptions, subcutaneous fat atrophy, allergic dermatitis, urticaria, angioneurotic edema, increased sweating
Interactions: Estrogens potentiate effects; immune response to vaccines may be decreased

158 SECTION 4 RANGER MEDIC PHARMACOLOGY & FORMULARY

HYDROMORPHONE (DILAUDID) – CONTROLLED SUBSTANCE II
Class: CNS agent – narcotic (opiate) agonist; analgesic
Action: Semisynthetic derivative structurally similar to morphine with 8–10 × more potent analgesic effect, more rapid
onset, shorter duration of action, less hypnotic effect, and less tendency to produce nausea and vomiting; also has
antitussive properties
Dose: 1mg IV; 1–2mg IM q4–6hr prn
Onset/Peak/Duration:
IV – Onset in 10–15 minutes/Peak in 15–30 minutes/Duration 2–3 hours
IM – Onset in 15 minutes/Peak in 30–60 minutes/Duration 4–5 hours
Indications: For moderate to severe pain management, and control of persistent nonproductive cough
Contraindications: Opiate hypersensitivity, acute bronchial asthma, COPD, decreased respiratory reserve, severe
respiratory depression, opiate-naïve patients; pregnancy category consider alternative during pregnancy and caution
advised while breastfeeding (caution advised in patients trying to conceive)

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Adverse/Side-effects: Nausea, vomiting, constipation; euphoria, dizziness, sedation, drows­iness; hypotension, brady­
cardia, tachycardia; respiratory depression; blurred vision
Interactions: Alcohol and other CNS depressants compound sedation and CNS depression; herbal (St. John’s wort)
may increase sedation
Mission Impact: GROUNDING medication for personnel on flight status
K9 Dosage: 3–6mg (0.1–0.2mg/kg) IV/IM q2–4hr using lower dose if IV

IBUPROFEN (MOTRIN, ADVIL)

Class: NSAID (nonselective COX-1); anti-inflammatory, analgesic, antipyretic
Action: Propionic acid inhibitor prototype that blocks prostaglandin synthesis, modulates T-cell function, inhibits
inflammatory cell chemotaxis, decreases release of superoxide radicals or increases scavenging of these compounds
at inflammatory sites, inhibits platelet aggregation and prolongs bleeding time
Dose: 400–800mg PO tid–qid (max: 3,200mg/d)
Indications: For mild to moderate pain management, symptomatic relief of arthritis, and to reduce fever
Contraindications: NSAID- or aspirin-induced urticaria, severe rhinitis, bronchospasm, angioedema, nasal polyps;
active peptic ulcer, bleeding abnormalities; pregnancy category caution advised during 1st trimester and avoid use
> 19 week gestation. Drug of choice while breastfeeding (caution advised in patients trying to conceive)
Adverse/Side-effects: Headache, dizziness, light-headedness, anxiety, emotional labil­ity, fatigue, malaise, drowsi-
ness, anxiety, confusion, depression, aseptic meningitis, hypertension, palpitation, CHF, peripheral edema; amblyopia
(blurred vision, decreased visual acuity, scotomas, changes in color vision), nystagmus, visual-field defects; tinnitus,
impaired hearing; dry mouth, gingival ulcerations, dyspepsia, heartburn, nausea, vomiting, anorexia, diarrhea, con-
stipation, bloating, flatulence, epigastric or abdominal discomfort or pain, GI ulceration, occult blood loss; thrombo-
cytopenia, neutropenia, hemolytic or aplastic anemia, leukopenia; decreased Hgb/Hct; acute renal failure, polyuria,
azotemia, cystitis, hematuria, nephrotoxicity, decreased creatinine clearance; maculopapular and vesiculobullous skin
eruptions, erythema multiforme, pruritus, acne; fluid retention with edema, Stevens-Johnson syndrome, toxic hepati-
tis, hypersensitivity reactions, anaphylaxis, bronchospasm, serum sickness, SLE, angioedema
Interactions: Oral anticoagulants and heparin may prolong bleeding time; may increase lithium and methotrexate
toxicity; herbals (feverfew, garlic, ginger, ginkgo) may increase risk of bleeding; do not take aspirin concurrently; con-
current alcohol use may increase risk of GI ulceration and bleeding tendencies

2025 RANGER MEDIC HANDBOOK 159

KETACONAZOLE
Class: Antimicrobial – antifungal agent, imidazole derivative
Action: Alters the permeability of the cell wall by blocking fungal cytochrome P450; inhibits biosynthesis of triglyc-
erides and phospholipids by fungi; inhibits several fungal enzymes that results in a build-up of toxic concentrations
of hydrogen peroxide
Dose: Oral: 200mg once daily; may increase to 400mg once daily if response is insufficient. Continue until active
fungal infection is resolved; some infections may require a treatment duration of up to 6 months; tinea cruris, tinea
pedis: topical cream: apply to the affected and immediate surrounding area once daily for tinea corporis, cruris: 2
weeks; tinea pedis: 6 weeks; seborrheic dermatitis: topical cream: apply to the affected area twice daily for 4 weeks
or until clinical response is noted. Foam: apply to affected area twice daily for 4 weeks. Gel: apply to the affected
area once daily for 2 weeks. Shampoo 2%: Apply 5–10mL to wet scalp, lather, leave on 3–5 minutes, and rinse; apply
twice weekly for 2–4 weeks
Indications: Topical – Treatment of tinea corporis (ringworm), tinea cruris (jock itch), and tinea pedis (athlete’s foot)
caused by Trichophyton rubrum, treatment of seborrheic dermatitis. Systemic – Treatment of susceptible fungal infec-
tions in patients who have failed or who are intolerant to other antifungal therapies
Contraindications: Not indicated for the treatment of onychomycosis, cutaneous dermatophyte infections, or Can-
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dida infections; ketoconazole hypersensitivity; alcoholism, fungal meningitis; ocular administration; administration
of the following drugs with ketoconazole is contraindicated: dofetilide, quinidine, pimozide, cisapride, methadone,
disopyramide, dronedarone, and ranolazine. Ketoconazole can cause elevated plasma concentrations of these drugs
and may prolong QT intervals, sometimes resulting in life-threatening ventricular dysrhythmias, such as torsades de
pointes; administration with benzodiazepines; pregnancy category caution advised during pregnancy and may use
while breastfeeding
Adverse/Side-effects: Orthostatic hypotension, peripheral edema, fatigue, insomnia, malaise, nervousness, pares-
thesia, erythema, urticarial, anaphylactoid reaction.
Interactions: Topical treatment has no known drug interactions. Systemic treatment coadministration with mid-
azolam, triazolam, and alprazolam may result in elevated plasma concentrations of the benzodiazepines, leading to
prolonged hypnotic and sedative effects. There are many other drug interactions that require you to consult with a
provider and pharmacology resources prior to administration
Notes: Systemic – Hepatic function tests (baseline), including weekly ALT for the duration of treatment; calcium and
phosphorous (periodically with long-term use); adrenal function as clinically necessary. Use ketoconazole only when
other effective antifungal therapy is not available or tolerated and the potential benefits are considered to outweigh
the potential risks

KETAMINE * – CONTROLLED SUBSTANCE III

Class: Dissociative
Action: Produces a cataleptic-like state causing dissociation from the surrounding environment by direct action on
the cortex and limbic system. Ketamine is a noncompetitive NMDA receptor antagonist that blocks glutamate. Smaller
doses produce analgesia, and modulate central sensitization, hyperalgesia and opioid tolerance. Reduces polysy­
naptic spinal reflexes.
Dose: Sedation: 1–1.5mg/kg slow IV push titrate to effect, followed by half induction dose PRN q10–20min. 4–5mg/kgIM,
repeat doses q30min prn for maintenance. Do not administer faster as this may result in respiratory depression/apnea
Pain: 0.1–0.3mg/kg slow IV push over 30 seconds–1 minute. IM/IN = 0.2–0.6mg/kg
Avoid: 0.3–0.8mg/kg IV due to adverse effects
Onset/Peak/Duration:
IV – Onset in 30 seconds/Duration 5–10 minutes
IM – Onset in 3–4 minutes/Duration 12–25 minutes
IN – Onset in 5–10 minutes/Duration 12–25 minutes
Indications: General sedative and analgesic; anesthetic agent for procedures
Contraindications: Hypersensitivity to ketamine, cardiovascular disease category consider alternative during preg-
nancy and caution advised while breastfeeding
Adverse/Side-effects: Hypertension, respiratory depression, emergence reactions (delirium, hallucinations, confusion)
Interactions: Effects of ketamine are increased when combined with other analgesics or muscle relaxants
Mission Impact: GROUNDING medication for personnel on flight status
K9 Dosage: 100–150mg (5mg/kg) IV/IM (best given in conjunction with midazolam 2–10mg for profound sedation)

160 SECTION 4 RANGER MEDIC PHARMACOLOGY & FORMULARY

KETOROLAC (TORADOL) *
Class: NSAID; anti-inflammatory, analgesic, antipyretic
Action: Inhibits COX-1 and -2 enzymes, resulting in decreased formation of prostaglandin precursors
Dose:
IM – 30mg as a single dose or 15–30mg q6hr
IV – 15mg slow IV push as a single dose or 15mg q6hr (maximum: 120mg/d)
Onset/Peak/Duration:
IV/IM – Onset in 30–60 minutes/Peak in 1–2 hours/Duration 4–6 hours
Indications: For short-term moderate pain management
Contraindications: Ketorolac hypersensitivity; nasal polyps; angioedema or bronchospastic reaction to aspirin or
other NSAIDs; severe renal impairment or renal failure due to volume depletion; patients with risk of bleeding; active
peptic ulcer disease; pre- or intraoperatively; pregnancy category avoid use during pregnancy and may use while
breastfeeding (caution advised in patients trying to conceive)

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Adverse/Side-effects: Drowsiness, dizziness, headache; nausea, dyspepsia, GI pain, hemorrhage; edema, sweating
Interactions: May increase methotrexate and lithium levels and toxicity; herbals (fever­few, garlic, ginger, ginkgo)
increase bleeding potential

LACTATED RINGER’S (LR)

Class: Plasma volume expander – crystalloid; isotonic salt solution
Action: Each 1L contains 6.0g sodium chloride (Na+ 130mEq/L, Cl– 109mEq/L) and other electrolytes (K+ 4mEq/L, Ca2+
3mEq/L, lactate 28mEq/L, and 9kcal/L); pH 6.4; remains in the intravascular space for only a very limited time as it
diffuses rapidly throughout the extracellular space
Dose: 500–1,000mL IV
Indications: For fluid replacement and plasma volume expansion and for adjunctive treatment of shock and hypo-
volemic states caused by hemorrhage, burns, surgery, sepsis, trauma, dehydration, or illness; also used for irrigation
Contraindications: CHF; do not use with blood or blood products
Adverse/Side-effects: Fluid overload, CHF, edema, electrolyte imbalance, hypertension
Interactions: Calcium in LR can bind to other drugs and reduce efficacy, also has potential for creating emboli if given
with blood or blood products
K9 Dosage: Bolus of 1L over 30 minutes, then reassess VS; repeat if no response. Do not exceed 2L in 1 hour

LEVETIRACETAM (KEPPRA)
Class: Antiepileptic
Action: Unknown
Dose: 1,000–4,000mg IV; 1,000mg IV for seizure prevention; 4,000mg for seizure treatment
Indications: For seizure prevention in moderate to severe TBI and treatment of active seizures
Contraindications: Hypersensitivity to drug, pregnancy category caution advised during pregnancy and while
breastfeeding
Adverse/Side-effects: The most common adverse effects of levetiracetam treatment include CNS effects such as
somnolence, decreased energy, headache, dizziness, mood swings and coordination difficulties
Interactions: No significant pharmacokinetic interactions

2025 RANGER MEDIC HANDBOOK 161

LEVOFLOXACIN (LEVOQUIN)
Class: Antimicrobial – antibiotic; fluoroquinolone. All fluoroquinolones now have a US Black Box Warning due to
serious adverse reactions including tendonitis and tendon rupture, peripheral neuropathy and CNS effects.
However, in some rare cases, benefits may outweigh the risks of fluoroquinolone use. Fluoroquinolones re-
quire prior approval from unit physician or physician assistant.
Action: Broad-spectrum antibiotic that inhibits DNA bacterial topoisomerase II, an enzyme required for DNA replica-
tion, transcription, repair, and recombination; prevents replication of certain bacteria resistant to β-lactam antibiotic
Dose: Community-acquired pneumonia – 750mg/d PO/IV × 7 days; skin infection – 750mg/d × 5–14 days; rhinosinus-
itis (bacterial) – 500mg/d × 5–7 days; for chronic bacterial prostatitis: 500mg PO qd × 28 days; for UTIs: 500–750mg
PO qd × 7 days
Indications: For treatment of maxillary sinusitis, acute exacerbations of bacterial bronchitis, community-acquired
pneumonia, uncomplicated skin/skin structure infections, UTI, acute pyelonephritis; chronic bacterial prostatitis; bac-
terial conjunctivitis
Contraindications: Quinolone hypersensitivity; hypokalemia; tendon pain; syphilis; viral infections; phototoxicity;
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pregnancy category consider alternative during pregnancy and avoid while breastfeeding
Adverse/Side-effects: Prolonged QT syndrome, tendon rupture, headache, insomnia, dizziness; nausea, diarrhea,
constipation, vomiting, abdominal pain, dyspepsia; rash, pruritus; decreased vision, foreign body sensation, transient
ocular burning, ocular pain, photophobia; chest or back pain, fever, pharyngitis
Interactions: Magnesium- or aluminum-containing antacids, sucralfate, iron, and zinc may decrease absorption;
NSAIDs may increase risk of CNS reactions including seizures; may cause hyper- or hypoglycemia in patients on
oral hypoglycemic agents; may cause false positives on opiate screening tests; avoid exposure to excess sunlight or
artificial UV light; avoid NSAIDs while taking levofloxacin
Mission Impact: GROUNDING medication for personnel on flight status

LIDOCAINE (XYLOCAINE)
Class: Amide-type local anesthetic; cardiovascular agent; class IB antiarrhythmic
Action: Anesthetic effect similar to that of procaine; class IB antiarrhythmic action by suppressing automaticity in the
His-Purkinje system and by elevating the electrical stimulation threshold of ventricles during diastole
Dose: For local anesthesia, infiltrate 0.5–2% injection with and without epinephrine; max dose – 4.5mg/kg/dose
(without epinephrine); 7mg/kg (with epinephrine)
Onset/Peak/Duration: Procedural local injection – Onset 1–3 minutes/Duration 10 minutes; dosing with epinephrine –
Onset 1–3 minutes/Duration infiltration ~2 hours, nerve block ~3–3.5 hours
Indications: For surface, infiltration, and nerve block anesthesia; also used for rapid control of ventricular arrhythmias
Contraindications: Amide-type local anesthetic hypersensitivity; systemic injection in presence of severe trauma or
sepsis, blood dyscrasias, supraventricular arrhythmias, untreated sinus bradycardia, severe degrees of sinoatrial, atrio-
ventricular, and intraventricular heart block; pregnancy category may use during pregnancy and while breastfeeding
Adverse/Side-effects: Drowsiness, dizziness, light–headedness, restlessness, confusion, disorientation, irritability,
apprehension, euphoria, wild excitement, numbness of lips or tongue, hot and cold paresthesia, chest heaviness,
difficulty speaking, difficulty breathing or swallowing, muscular twitching, tremors, psychosis; convulsions, respiratory
depression and arrest, hypotension, bradycardia, conduction disorders, heart block, cardiovascular collapse, and
cardiac arrest in high doses; tinnitus, decreased hearing; blurred or double vision, impaired color perception; local
erythema and edema; anorexia, nausea, vomiting; excessive perspiration, thrombophlebitis; urticaria, rash, edema,
anaphylactoid reaction
Interactions: Barbiturates decrease activity; cimetidine, β-blockers, quinidine increases effects; phenytoin increases
cardiac depressant effects; procainamide compounds neurologic and cardiac effects
Mission Impact: GROUNDING medication for personnel on flight status

162 SECTION 4 RANGER MEDIC PHARMACOLOGY & FORMULARY

LOPERAMIDE (IMODIUM) * DO NOT ALLOW OPEN ACCESS

Class: GI agent – antidiarrheal

Action: Synthetic piperidine derivative that inhibits GI peristaltic activity by direct action on circular and longitudinal
intestinal muscles; prolongs intestinal content transit time, increases consistency of stools, and reduces fluid and
electrolyte loss
Dose: 4mg PO, followed by 2mg after each unformed stool (max: 16mg/d)
Indications: For acute nonspecific diarrhea, chronic diarrhea associated with inflammatory bowel disease
Contraindications: Conditions in which constipation should be avoided, severe colitis, acute diarrhea caused by
broad-spectrum antibiotics (pseudomembranous colitis) or from organisms that penetrate the intestinal mucosa (toxi-
genic Escherichia coli, Salmonella, or Shigella); pregnancy category caution advised during pregnancy and may use
while breastfeeding
Adverse/Side-effects: Rash; fever; drowsiness, fatigue, dizziness, CNS depression with overdose; abdominal disten-
sion, discomfort or pain, bloating, constipation, nausea, vomiting, anorexia, dry mouth; toxic megacolon in patients

SECTION 4
with ulcerative colitis
Interactions: Caution when dosing in conjunction with prolonging QTc medications.
Mission Impact: GROUNDING medication for personnel on flight status

LORATADINE (CLARITIN)
Class: ENT agent – H1-receptor antagonist – nonsedating antihistamine
Action: Long–acting histamine antagonist with selective peripheral H1-receptor sites that blocks histamine release;
disrupts capillary permeability, edema formation, and constriction of respiratory, GI, and vascular smooth muscle
Dose: 10mg/d PO, take on an empty stomach
Indications: Symptom relief from seasonal allergic rhinitis; idiopathic chronic urticaria
Contraindications: Loratadine hypersensitivity; pregnancy category may use during pregnancy and caution advised
while breastfeeding
Adverse/Side-effects: Dizziness, dry mouth, fatigue, headache, somnolence, altered salivation and lacrimation,
thirst, flushing, anxiety, depression, impaired concentration; hypo- or hypertension, palpitations, syncope, tachy-
cardia; nausea, vomiting, flatulence, abdominal distress, constipation, diarrhea, weight gain, dyspepsia; arthralgia,
myalgia; blurred vision, earache, eye pain, tinnitus; rash, pruritus, photosensitivity
Interactions: No clinically significant interactions established

2025 RANGER MEDIC HANDBOOK 163

MECLIZINE (ANTIVERT)
Class: H1-receptor antagonist; antihistamine, antivertigo agent
Action: Long-acting piperazine antihistamine with marked effect in blocking histamine-induced vasopressive re-
sponse, but only slight anticholinergic action; marked depressant action on labyrinthine excitability and on conduction
in vestibular – cerebellar pathways; exhibits CNS depression, antispasmodic, antiemetic, and local anesthetic activity
Dose: For motion sickness, 25–50mg PO 1 hour before travel, may repeat q24hr prn for duration of journey; for ver-
tigo, 25–100mg/d PO in divided doses
Indications: For management of nausea, vomiting, and dizziness associated with motion sickness and vertigo associ-
ated with diseases affecting the vestibular system
Contraindications: Hypersensitivity to meclizine; pregnancy category may use during pregnancy and consider alter-
native while breastfeeding
Adverse/Side-effects: Drowsiness; dry mouth; blurred vision; fatigue
Interactions: Alcohol and CNS depressants may potentiate sedative effects; do not drive or engage in potentially
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hazardous activities until response to drug is known

Mission Impact: GROUNDING medication for personnel on flight status

MELATONIN
Class: Hormone produced by the pineal glands involved in mammalian circadian rhythms.
Dose: 0.3–3mg for short periods of time (no longer than 2 weeks). Do not exceed 3mg due to paroxysmal hyperstimu-
lation from elevated melatonin levels.
Indications: Insomnia and sleep disturbances
Contraindications: Hypersensitivity
Adverse/Side-effects: Stomach discomfort, morning grogginess, daytime “hangover”, feeling of a heavy head, de-
pression, HA, lethargy, amnesia, increased seizure activity, suppression of male libido, hypothermia, retinal damage,
and gynecomastia
Interactions: ASA, NSAIDs, benzodiazepines, β-blockers, corticosteroids, alcohol
Mission Impact: GROUNDING medication for personnel on flight status

MELOXICAM (MOBIC) *
Class: NSAID; COX-2 Inhibitor, anti-inflammatory, analgesic, antipyretic
Action: Inhibits cyclooxygenase
Dose: 7.5–15mg PO qd
Indications: For mild to moderate pain management, osteoarthritis, rheumatoid arthritis
Contraindications: NSAID or salicylate hypersensitivity; rhinitis, urticaria, angioedema, asthma; severe renal or he­p­atic
disease; pregnancy category caution advised in 1st trimester and avoid use remainder of pregnancy. Consider alterna-
tive while breastfeeding (caution advised in patients trying to conceive)
Adverse/Side-effects: Edema, flulike syndrome, pain; abdominal pain, diarrhea, dyspepsia, flatulence, nausea, con-
stipation, ulceration, GI bleed, anemia; arthralgia; dizziness, headache, insomnia; pharyngitis, upper respiratory tract
infection, cough; rash, pruritus; urinary frequency, UTI
Interactions: May decrease effect of ACE inhibitors and diuretics; may increase lithium levels and toxicity; aspirin may
increase GI bleed risk; warfarin and herbals (feverfew, garlic, ginger, ginkgo) may increase bleeding

164 SECTION 4 RANGER MEDIC PHARMACOLOGY & FORMULARY

METHOCARBOMOL (ROBAXIN)
Class: Somatic nervous system agent – central-acting, skeletal muscle relaxant
Action: Causes skeletal muscle relaxation by general CNS depression
Dose: 500mg up to 1.5g PO qid × 2–3 days; 500mg recommended starting dose
Indications: For management of discomfort associated with acute musculoskeletal disorders as adjunct to physical
therapy and other measures
Contraindications: Comatose; CNS depression; acidosis, kidney dysfunction; pregnancy category caution advised
during pregnancy and consider alternative while breastfeeding
Adverse/Side-effects: Fever, anaphylactic reaction, flushing, syncope, convulsions; urticaria, pruritus, rash, thrombo­
phlebitis, pain, sloughing; conjunctivitis, blurred vision, nasal congestion; drowsiness, dizziness, light-headedness,
headache; hypotension, bradycardia; nausea, metallic taste
Interactions: Alcohol and other CNS depressants enhance CNS depression

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Mission Impact: GROUNDING medication for personnel on flight status

METHYLPREDNISOLONE (SOLU-MEDROL)
Class: Hormones and synthetic substitutes – adrenal corticosteroid, glucocorticosteroid, anti-inflammatory
Action: Intermediate-acting synthetic steroid with less sodium and water retention effects than hydrocortisone; inhib-
its phagocytosis and release of allergic substances; modifies immune response to various stimuli; anti-inflammatory
and immunosuppressive
Dose: 125mg IV q6hr or 150mg IM q6hr
Indications: For management of acute and chronic inflammatory diseases, control of severe acute and chronic al-
lergic processes, acute bronchial asthma.
Contraindications: Systemic fungal infections; pregnancy category caution advised during pregnancy and may use
while breastfeeding
Adverse/Side-effects: Euphoria, headache, insomnia, confusion, psychosis; CHF, edema; nausea, vomiting, peptic
ulcer; muscle weakness, delayed wound healing, muscle wasting, osteoporosis, aseptic necrosis of bone, spontane-
ous fractures; cushingoid features, growth suppression in children, carbohydrate intolerance, hyperglycemia; cataracts;
leukocytosis; hypokalemia
Interactions: Amphotericin B, furosemide, thiazide diuretics increase potassium loss; may enhance virus replication
or increase attenuated virus vaccine adverse effects; isoniazid, phenytoin, phenobarbital, rifampin increase metabo-
lism and decrease effectiveness

2025 RANGER MEDIC HANDBOOK 165

METRONIDAZOLE (FLAGYL, METROGEL)
Class: Antimicrobial – antibiotic, antitrichomonal, amebicide
Action: Synthetic compound with direct trichomonacidal, amebicidal, and antibacterial activity (anaerobic bacteria
and some gram-negative bacteria); effective against Trichomonas vaginalis, Entamoeba histolytica, Giardia lamblia,
obligate anaerobic bacteria, gram-negative anaerobic bacilli, and Clostridia; microaerophilic streptococci and most
aerobic bacteria are resistant
Dose: For giardia 250mg PO tid × 5–7 days; for amebiasis (dysentery) 500–750mg PO tid × 7–10 days; for pseudo-
membranous colitis, 250–500mg PO tid–qid; for trichomoniasis, 2g PO once or 500mg PO bid × 7 days; for bite wound
(animal/human) 500mg q8hr × 3–5 days; for bacterial vaginosis 500mg PO bid for 7 days
Indications: For giardiasis, trichomoniasis, amebiasis, and amebic liver abscess; topical for rosacea
Contraindications: Blood dyscrasias; active CNS disease; pregnancy category may use during pregnancy and cau-
tion advised while breastfeeding
Adverse/Side-effects: Hypersensitivity (rash, urticaria, pruritus, flushing), fever, fleeting joint pains, Candida over-
growth; vertigo, headache, ataxia, confusion, irritability, depression, restlessness, weakness, fatigue, drowsiness,
SECTION 4

insomnia, paresthesia, sensory neuropathy; nausea, vomiting, anorexia, epigastric distress, abdominal cramps, diar-
rhea, constipation, dry mouth, metallic or bitter taste, proctitis; polyuria, dysuria, pyuria, incontinence, cystitis, de-
creased libido, nasal congestion; ECG changes (flattening of T wave)
Interactions: Oral anticoagulants potentiate hypoprothrombinemia; alcohol and solutions of citalopram, ritonavir,
lopinavir, and IV formulations of sulfamethoxazole, trimethoprim, nitroglycerin may elicit disulfiram reaction due to the
alcohol content; disulfiram causes acute psychosis; phenobarbital increases metabolism; may increase lithium levels;
fluorouracil, azathioprine may cause transient neutropenia
Mission Impact: GROUNDING medication for personnel on flight status.

MIDAZOLAM (VERSED) * – CONTROLLED SUBSTANCE II

Class: CNS agent – Benzodiazepine
Action: Binds to specific sites on GABA type A receptors within the brain.
Dose: 0.07–0.08mg/kg IM (average or typical adult dose is 5mg IM).10mg IM for seizure control. 2–5mg IV/IO slowly
q2–3min to maximum adult dose of 10mg. Titrate to achieve necessary level. (The patient is somewhat somnolent,
but still easily arousable.)
Onset/Peak/Duration:
IV – Onset in 1–5 minutes/Peak rapid/Duration 2–6 hours
IM – Onset in 5–15 minutes/Peak in 15–60 minutes/Duration 2–6 hours
Indications: Sedation in combination with analgesia to perform brief, but painful procedures, treatment of active
seizures, sedation of agitated patients
Contraindications: Known sensitivity to benzodiazepines, acute narrow angle glaucoma, injectable midazolam
should not be administered to adult or pediatric patients in shock or coma, or in acute alcohol intoxication with
depression of vital signs, pregnancy category consider alternative during pregnancy and may use short-term while
breastfeeding
Adverse/Side-effects: Laryngospasm, bronchospasm, wheezing, shallow respirations, bradycardia, tachycardia,
vomiting, retrograde amnesia, hallucination, confusion, blurred vision, diplopia, nystagmus, pinpoint pupils, anaphy-
lactoid reactions, hives, rash, pruritus, yawning, lethargy, chills, weakness
Interactions: Use with caution when other medications capable of producing central nervous system depression
are used
Mission Impact: GROUNDING medication for personnel on flight status
K9 Dosage: For sedation combined with opioid, 7.5mg (0.25mg/kg) IV/IM q4hr
Notes: Monitor patients continuously for early signs of hypoventilation, airway obstruction, or apnea. Use with caution
in patients with severe fluid or electrolyte disturbances.

166 SECTION 4 RANGER MEDIC PHARMACOLOGY & FORMULARY

MODAFINIL (PROVIGIL) – CONTROLLED SUBSTANCE IV
Class: CNS stimulant
Dose: 200mg daily. Shift work sleep disorder 200mg 1 hour prior to start. Max dose 400mg
Indications: Improve wakefulness in patients with narcolepsy, obstructive sleep apnea-hypopnea syndrome, and
shift work sleep disorder
Contraindications: Hypersensitivity, pregnancy category avoid use during pregnancy and caution advised while
breastfeeding
Adverse/Side-effects: Aggressiveness, agitation, anxiety, confusion, delusions, depression, hallucinations, HA, in-
somnia, mania, nervousness, psychosis, suicidal ideations, nausea, rash, Stevens-Johnson syndrome, anaphylaxis,
or angioedema.
Interactions: Amitriptyline, diazepam, propanolol, carbamazepine, cimetidine, clarithromycin, erythromycin, flucon-
azole, oral contraceptives, dexamethasone, rifampin, warfarin
Mission Impact: Must be approved by medical officer and command leadership prior to administration. Individual

SECTION 4
must be screen tested in noncombat environment prior to administration during operational timeframes.

MORPHINE SULFATE (MSO4) – CONTROLLED SUBSTANCE II

Class: CNS agent – narcotic (opiate) agonist; analgesic
Action: Natural opium alkaloid with agonist activity as it binds with three types of the same receptors as endogenous
opioid peptides; analgesia at supraspinal level, euphoria, respiratory depression and physical dependence; sedation
and miosis; dysphoric, hallucinogenic, and cardiac stimulant effects
Dose: 5–10mg slow IV push, titrate to pain
Onset/Peak/Duration:
IV – Onset in 5–20 minutes/Peak in 20 minutes/Duration 4–5 hours
IM – Onset in 10–30 minutes/Peak in 30–60 minutes/Duration 4–5 hours
Indications: For severe acute and chronic pain management, preanesthesia and as adjunct to anesthesia, and for
relief of dyspnea from acute left ventricular failure and pulmonary edema
Contraindications: Opiate hypersensitivity; seizures; acute bronchial asthma, chronic pulmonary disease, severe
respiratory depression; chemical-irritant induced pulmonary edema; BPH; diarrhea due to poisoning until toxic mate-
rial has been eliminated; following biliary tract surgery and surgical anastomosis; pancreatitis; acute ulcerative colitis;
severe liver or renal insufficiency; hypothyroidism; pregnancy category consider alternative during pregnancy and may
use while breastfeeding (caution advised in patients trying to conceive)
Adverse/Side-effects: Pruritus, rash, urticaria, edema, anaphylactoid reaction; sweating, skeletal muscle flaccidity;
cold, clammy skin, hypothermia; euphoria, insomnia, disorientation, visual disturbances, dysphoria, paradoxical CNS
stimulation (restlessness, tremor, delirium, insomnia), convulsions; decreased cough reflex, drowsiness, dizziness,
deep sleep, coma; miosis; bradycardia, palpitations, syncope; flushing of face, neck, and upper thorax; orthostatic
hypotension, cardiac arrest; constipation, anorexia, dry mouth, biliary colic, nausea, vomiting, elevated LFTs; urinary
retention or urgency, dysuria, oliguria, reduced libido or potency; severe respiratory depression or arrest; pulmonary
edema
Interactions: CNS depressants, sedatives, barbiturates, alcohol, benzodiazepines, and TCAs potentiate CNS-­
depressant effects; MAOIs may precipitate hypertensive crisis; phenothiazines may antagonize analgesia
Mission Impact: GROUNDING medication for personnel on flight status
K9 Dosage: 2–3mg IV OR 10–20mg IM/SQ. Nausea/emesis and defecation common. Reverse with 1mg naloxone
IV/IM/SQ

2025 RANGER MEDIC HANDBOOK 167

MOXIFLOXACIN (AVELOX) *
Class: Antimicrobial – antibiotic; fluoroquinolone. All fluoroquinolones now have a US Black Box Warning due to
serious adverse reactions including tendonitis and tendon rupture, peripheral neuropathy and CNS effects.
However, in some rare cases, benefits may outweigh the risks of fluoroquinolone use. Fluoroquinolones re-
quire prior approval from unit physician or physician assistant.
Action: Broad spectrum bactericidal agent that inhibits DNA-gyrase topoisomerase II, an enzyme necessary for bac-
terial replication, transcription, repair and recombination; effective against gram-positive and gram-negative organ-
isms, Staphylococcus aureus, Streptococcus pneumonia, Haemophilus influenzae, Klebsiella pneumoniae, Moraxella
catarrhalis, Chlamydia pneumoniae, Mycoplasma pneumoniae, and other microbes
Dose: 400mg PO/IV qd × 5–10 days
Indications: For acute bacterial exacerbation of chronic bronchitis, acute sinusitis, community-acquired pneumonia,
skin infections
Contraindications: Quinolone hypersensitivity; hepatic insufficiency; syphilis; arrhythmias; myocardial ischemia or
infarction; hypokalemia, or those receiving class IA or class III antiarrhythmic drugs; pregnancy category avoid use
SECTION 4

during pregnancy and caution advised while breastfeeding

Adverse/Side-effects: Tendon rupture; QTc prolongation; dizziness, headache, peripheral neuropathy, nausea, di-
arrhea, abdominal pain, vomiting, taste perversion, abnormal LFTs, dyspepsia, tendon rupture
Interactions: Iron, zinc, antacids, aluminum, magnesium, calcium, sucralfate decrease absorption; atenolol, erythro­
mycin, antipsychotics, TCAs, quinidine, procainamide, amiodarone, may cause false positive on opiate screening
tests
Mission Impact: GROUNDING medication for personnel on flight status.

MUPIROCIN (BACTROBAN)
Class: Antimicrobial – antibiotic; pseudomonic acid
Action: Inhibits protein synthesis by binding with bacterial transfer RNA; effective against Staphylococcus aureus
(including methicillin-resistant [MRSA] and β-lactamase–­producing strains], Staphylococcus epidermidis, Staphylo-
coccus saprophyticus, and Staphylococcus pyogenes
Dose: Topically apply tid–qid × 1–2 weeks; reevaluate for response after 3–5 days
Indications: For impetigo or nasal carriage due to Staphylococcus aureus, β-hemolytic streptococci, and Strepto­
coccus pyogenes; superficial skin infections
Contraindications: Hypersensitivity to any of its components; pregnancy category may use during pregnancy and
while breastfeeding
Adverse/Side-effects: Headache, burning, stinging; pruritis, erythema, dry skin, tenderness, swelling, rash; nausea;
local pain; rhinitis, congestion, pharyngitis
Interactions: None
Mission Impact: None

168 SECTION 4 RANGER MEDIC PHARMACOLOGY & FORMULARY

NALOXONE (NARCAN) *
Class: CNS agent – narcotic (opiate) antagonist
Action: Pure opiate antagonist without agonistic (morphine-like) properties that displaces opioids at receptor sites.
Acts by completing the μ, μ, and × opiate receptor sites and forcing
Dose: 0.4–2.0mg IV, repeat q2–3min prn
Onset/Peak/Duration:
IV – Onset in 1–2 minutes/Peak in 5–15 minutes/Duration 45 minutes or longer
IM – Onset in 2–5 minutes/Peak in 5–15 minutes/Duration 45 minutes or longer
Indications: Narcotic overdose and reversal of effects of natural and synthetic narcotics (opiates), including respira-
tory depression, sedation, and hypotension; drug of choice for suspected acute opioid overdose or unknown inges-
tion with respiratory depression.
Contraindications: Hypersensitivity; pregnancy category may use during pregnancy and while breastfeeding
Adverse/Side-effects: Analgesia reversal, tremors, hyperventilation, drowsiness, sweating; increased BP, tachycar-

SECTION 4
dia; nausea, vomiting; elevated PTT
Interactions: Reverses analgesic effects of narcotic (opiate) agonists and agonist-antagonists.
Mission Impact: GROUNDING medication for personnel on flight status.
K9 Dosage: 1mg (0.02–0.04mg/kg) IV/IM

NAPHAZOLINE (NAPHCON-A, VASCON, CLEAR EYES)

Class: Autonomic nervous system agent – sympathomimetic, α-adrenergic agonist, vaso­constrictor, decongestant
Action: Stimulates α-adrenergic receptors in arterioles of conjunctiva and nasal mucosa to produce rapid and pro-
longed vasoconstriction, reducing fluid exudation and mucosal engorgement; systemic absorption may cause CNS
depression rather than stimulation.
Dose: 1–2gtt in each eye q6hr prn (remove contact lenses before use if worn). Limit use to 72 hours.
Indications: Ocular vasoconstriction and decongestion
Contraindications: Hypersensitivity, narrow angle glaucoma, MAOIs, hyperthyroidism, diabetes mellitus, ocular
trauma; pregnancy category may use during pregnancy and while breastfeeding
Adverse/Side-effects: Keratitis, coma, hypertension, bradycardia, blurred vision, hyperglycemia, respiratory depres-
sion, tachycardia, shock like hypotension, increased intraocular pressure, irritation, drowsiness, weakness, headache,
nausea, hypothermia, rebound congestion and chemical rhinitis with continued use
Interactions: Vasoconstrictive nasal decongestants ay reduce analgesic effect, TCAs and maprotiline may potentiate
pressor effects
Mission Impact: GROUNDING medication for personnel on flight status

2025 RANGER MEDIC HANDBOOK 169

NAPROXEN (NAPROSYN)
Class: NSAID; anti-inflammatory, analgesic, antipyretic
Action: Propionic acid derivative with properties similar to ibuprofen; inhibits COX-1 and -2 enzymes inhibiting pros-
taglandin synthesis and platelet aggregation; prolongs bleeding time
Dose: 250–500mg PO bid (max: 1,000mg qd)
Onset/Peak/Duration: Onset: 30–60 minutes, Peak: 2–4 hours, Duration: < 12 hours
Indications: For mild to moderate pain management and symptomatic treatment of acute and chronic arthritis
Contraindications: Hypersensitivity; peptic ulcer; history of asthma, rhinitis, urticaria, bronchospasm or shock caused
by aspirin or other NSAIDs; hyperkalemia; liver or renal impairment or disease, recent MI or CABG; pregnancy category
caution advised during 1st trimester and avoid use > 19 weeks in pregnancy. Consider shorter acting alterative while
breastfeeding (caution advised in patients trying to conceive)
Adverse/Side-effects: Headache, drowsiness, dizziness, lightheadedness, depression; palpation, dyspnea, periph-
eral edema, CHF, tachycardia; blurred vision, tinnitus, hearing loss; anorexia, heartburn, indigestion, nausea, vomiting,
thirst, GI bleeding, elevated LFTs; thrombocytopenia, leukopenia, eosinophilia, pruritus, rash, ecchymosis, nephrotox-
SECTION 4

icity, increased risk of stroke or MI; pulmonary edema

Interactions: Herbals (feverfew, garlic, ginger, ginkgo) may increase bleeding

NITROFURANTOIN (MACROBID)
Class: Antimicrobial – miscellaneous
Action: Nitrofurantoin is reduced by bacterial flavoproteins to reactive intermediates that inactivate or alter bacterial
ribosomal proteins leading to inhibition of protein synthesis, aerobic energy metabolism, DNA, RNA, and cell wall
synthesis. Nitrofurantoin is bactericidal in urine at therapeutic doses
Dose: PO 100mg bid × 5 days for females, × 7 days for males
Indications: Acute, recurrent, and prophylactic treatment for cystitis; chronic suppression of recurrent UTIs
Contraindications: Hypersensitivity to drug or any component of the formulation; anuria, oliguria, or significant im-
pairment of renal function, pregnancy category consider alternative during 1st trimester and avoid use 38–42 weeks,
but otherwise may use in pregnancy. Avoid use while breastfeeding
Adverse/Side-effects: ECG changes, chills, confusion, depression, drowsiness, headache, malaise, numbness, par-
esthesia, psychotic reaction, alopecia, dermatitis, skin rash; Stevens-Johnsons syndrome; decreased hemoglobin,
hepatitis; candida; weakness; amblyopia; cough; cyanosis; dyspnea; fever, hepatotoxicity
Interactions: Minimal interactions
Mission Impact: GROUNDING medication for personnel on flight status

OFLOXACIN OTIC (FLOXIN)

Class: Antimicrobial – antibiotic, fluoroquinolone
Action: broad-spectrum fluoroquinolone against gram-positive and gram-negative aerobic and anaerobic bacteria.
Inhibits bacterial DNA replication and some aspects of its transcription, repair, recombination, and transposition
Dose: 10gtt in affected ear(s) qd × 7 days
Indications: Otitis externa in adults and pediatric patients (> 6 months) due to Escherichia coli, Pseudomonas aerug­
i­nosa, and Staphylococcus aureus
Contraindications: Hypersensitivity to ofloxacin or other quinolone antibacterial agents; tendon pain; lactation; preg-
nancy category may use during pregnancy and while breastfeeding
Adverse/Side-effects: Hypersensitivity; fungal or bacterial superinfection with prolonged use, tendon inflammation/
rupture; pruritis; earache; dizziness; headache; vertigo
Interactions: Minimal prehospital interactions
Mission Impact: GROUNDING medication for personnel on flight status

170 SECTION 4 RANGER MEDIC PHARMACOLOGY & FORMULARY

OMEPRAZOLE (PRILOSEC)
Class: GI agent – proton pump inhibitor (PPI)
Action: Antisecretory compound that is a gastric acid pump inhibitor; suppresses gastric acid secretion by inhibiting
the H+, K+–ATPase enzyme system (the acid [proton H+] pump) in the parietal cells, which relieves gastrointestinal
distress and promotes ulcer healing
Dose: 20mg PO qd × 4–8 weeks
Indications: Duodenal ulcer, gastroesophageal reflux disease (GERD), heartburn, and erosive esophagitis; used in
conjunction with clarithromycin and metronidazole to treat duodenal ulcers associated with Helicobacter pylori
Contraindications: PPI hypersensitivity, pregnancy category caution advised during pregnancy and may use while
breastfeeding
Adverse/Side-effects: Headache, dizziness; rash; abdominal pain, diarrhea, nausea, vomiting, constipation; hema-
turia, proteinuria
Interactions: May increase diazepam, phenytoin, and warfarin levels

SECTION 4
ONDASETRON (ZOFRAN) *
Class: GI agent – 5-HT3 antagonist, antiemetic
Action: Selective serotonin (5-HT3) receptor antagonist, acting centrally in the chemoreceptor trigger zone and pe-
ripherally on the vagal nerve terminals; serotonin is released from the wall of the small intestine, stimulates the vagal
efferents through the serotonin receptors, and initiates the vomiting reflex
Dose: 4–8mg PO q4hr prn; 4–8mg slow IVP or IM q4hr prn
Onset/Peak/Duration:
IV – Onset in 10–30 minutes/Duration 8 hours
Indications: Prevention of nausea and vomiting
Contraindications: Hypersensitivity to ondansetron; pregnancy category caution advised during pregnancy and while
breastfeeding
Adverse/Side-effects: Dizziness, light-headedness, headache, sedation; diarrhea, constipation, dry mouth, fatigue,
fever, hypoxia
Interactions: Rifampin may decrease ondansetron levels; use with antimalarial drugs may cause decreased efficacy
or increased blood toxicity; caution when dosing in conjunction with prolonging QTc medications
Mission Impact: GROUNDING medication for personnel on flight status

OXYMETAZOLINE (AFRIN)
Class: ENT agent – vasoconstrictor (decongestant), sympathomimetic
Action: Sympathomimetic agent that acts directly on alpha receptors of sympathetic nervous system. No effect on
β-receptors.
Dose: Spray into each nostril 2 times, twice daily. Not to exceed 3 consecutive days due to rebound congestion. Do
not tilt head backward while spraying.
Indications: Epistaxis, Use as an adjunct to Valsalva maneuver to clear ears and sinuses during compression and
decompression, nasal congestion.
Contraindications: Severe damage to tympanic membrane/sinuses from barotrauma, lactation, pregnancy category
may use during pregnancy and while breastfeeding
Adverse/Side-effects: Sneezing, burning and stinging of nasal mucosa, rhinitis, rebound congestion

2025 RANGER MEDIC HANDBOOK 171

PLASMA-LYTE A
Class: Plasma volume expander – crystalloid; isotonic salt solution
Action: Sterile, nonpyrogenic isotonic solution. Each 100mL contains 526mg of sodium chloride, USP (NaCl); 502mg
of sodium gluconate (C6H11NaO7); 368mg of sodium acetate trihydrate, USP (C2H3NaO23H2O); 37mg of potassium
chloride, USP (KCl); and 30mg of magnesium chloride, USP (MgCl26H2O).
Dose: 500–1,000mL IV
Indications: A source of water and electrolytes or as an alkalinizing agent. Plasma-Lyte A is compatible with blood
or blood components
Contraindications: Known hypersensitivity of the product.
Adverse/Side-effects: Peripheral/pulmonary edema, anaphylactic reaction, and the following manifestations: tachy-
cardia, palpitations, chest pain, chest discomfort, dyspnea, respiratory rate increased, flushing, hyperemia, asthenia,
feeling abnormal, piloerection, edema peripheral, pyrexia; infusion site reactions
Interactions: Caution is advised when administering to patients treated with drugs that may increase the risk of so-
SECTION 4

dium and fluid retention, such as corticosteroids or patients with congestive heart failure

POLYETHYLENE GLYCOL (MIRALAX)

Class: Osmotic laxative
Action: Increases water in the stool resulting in softer stool and increased frequency of bowel movements
Dose: 17g (1 heaping tablespoon) dissolved in 8oz of beverage once daily as needed
Indications: Occasional constipation
Contraindications: Hypersensitivity, bowel obstruction, renal disease, pregnancy category may use during preg-
nancy and while breastfeeding
Adverse/Side-effects: Diarrhea, abdominal bloating, abdominal pain, nausea, cramping
Mission Impact: None

PREDNISONE
Class: Systemic corticosteroid
Action: Synthetic glucocorticoid; controls/prevents inflammation by governing the rate of protein synthesis, suppress-
ing migration of leukocytes, reversing capillary permeability and stabilizing lysosomes
Dose: Asthma attack or post anaphylaxis: 60mg PO per day × 4–5 days. Tapered dosing (systemic poison ivy, other
anaphylactoid reactions) – 60mg PO per day (days 1–5), 40mg PO per day (days 6–10), 20mg PO per day (days 11–15)
Indications: Asthma, anaphylaxis or other systemic swelling/edema
Contraindications: Hypersensitivity, systemic fungal infections, peptic ulcers, hypertension, osteoporosis, pregnancy
category consider alternative during pregnancy and may use while breastfeeding
Side-effects: Bradycardia, CHF, edema, euphoria, headache, nausea, vomiting, peptic ulcer, muscle weakness, de-
layed wound healing, hypertension
Interactions: Barbiturates, diuretics; may inhibit antibody response to live vaccines or toxoids; may inhibit efficacy
of hormonal birth control
Mission Impact: None

172 SECTION 4 RANGER MEDIC PHARMACOLOGY & FORMULARY

PRIMAQUINE
Class: Antimicrobial – antimalarial
Action: Antiprotozoal agent that disrupts mitochondria and binds to DNA. Acts on primary exoerythrocytic forms of
Plasmodium vivax and Plasmodium falciparum. Destroys late forms of P. vivax preventing relapse
Dose: 30mg PO once daily × 14 days immediately following departure form malaria-endemic areas. Screen for G6PD
deficiency prior to providing as it can cause fatal hemolysis in severally G6PD deficient patients
Indications: Interruption of transmission of malaria, prevents relapse of P. vivax and P. ovale following travel to en-
demic areas
Contraindications: G6PD deficiency, rheumatoid arthritis, lupus, hemolytic drugs, bone marrow depression, NADH
methemoglobin reductase deficiency, pregnancy category avoid use during pregnancy and while breastfeeding infant
with G6PD deficiency but otherwise may use while breastfeeding (obtain negative pregnancy test before starting
medication)
Side-effects: Hematologic reactions to include acute hemolytic anemia if G6PD deficient; early hemolytic reaction

SECTION 4
symptoms include darkening of the urine, decrease in urine volume, chills, fever, precordial pain, cyanosis; leuko-
cytosis, leukopenia, anemia, granulocytopenia, confusion, mental depression, visual accommodation disturbances,
hypertension, arrhythmias.
Interactions: Increased toxicity of both quinacrine and primaquine
Mission Impact: None

PROMETHAZINE (PHENERGAN)
Class: GI agent – phenothiazine; antiemetic, antivertigo
Action: Long-acting phenothiazine derivative with prominent sedative, amnesic, antiemetic, and anti–motion-sickness
actions and marked antihistamine activity; antiemetic action due to depression of CTZ in medulla; as with other anti-
histamines, it exerts antiserotonin, anticholinergic, and local anesthetic action
Dose: 12.5–25mg PO/IM/IV (IM must be deep injection into glut muscle, see adverse effects below) q4–6hr prn
Onset/Peak/Duration:
IV – Onset in 3–5 minutes/Duration 4–6 hours
IM – Onset in 20 minutes/Duration 4–6 hours
PO – Onset in 15–60 minutes/Duration 4–6 hours
Indications: For symptomatic relief from nausea, vomiting, motion sickness, or headache.
Contraindications: Phenothiazine hypersensitivity; narrow-angle glaucoma; stenosing peptic ulcer, BPH; bladder
neck obstruction; epilepsy; bone marrow depression; comatose or severe depressed states; Reye’s syndrome, en-
cephalopathy, hepatic diseases; pregnancy category caution advised during pregnancy and consider alternative while
breastfeeding
Adverse/Side-effects: Deep sleep, coma, convulsions, cardiorespiratory symptoms, extrapyramidal reactions, night-
mares, CNS stimulation, abnormal movements; irregular respirations, respiratory depression; sedation drowsiness,
confusion, dizziness, disturbed coordination, restlessness, tremors; transient mild hypo- or hypertension; anorexia,
nausea, vomiting, constipation; leukopenia, agranulocytosis; blurred vision, dry mouth, nose, or throat; photosensitiv-
ity; urinary retention. If administering IV dilute and administer slowly, discontinue if severe burning occurs, can cause
tissue and digit necrosis.
Interactions: Alcohol and other CNS depressants add to CNS depression and anticholinergic effects
Mission Impact: GROUNDING medication for personnel on flight status

2025 RANGER MEDIC HANDBOOK 173

PSEUDOEPHEDRINE (SUDAFED)
Class: Autonomic nervous system agent–sympathomimetic; alpha/beta-adrenergic agonist, decongestant
Action: Sympathomimetic amine that produces decongestion of respiratory tract mucosa by stimulating the sym-
pathetic nerve endings including alpha-, beta-1 and beta-2 receptors causing vasoconstriction; Stimulates beta-
androgenic receptors causing bronchial relaxation and increasing heart rate and contractility
Dose: 30–60mg PO q4–6hr OR 120mg XR PO q12hr
Onset/Peak/Duration: Onset in 30 minutes/Peak in 1–2 hours/Duration of 3–8 hours
Indications: Symptomatic relief of nasal and eustachian tube congestion, rhinitis, and sinusitis; promotes nasal sinus
drainage and relief on sinus congestion
Contraindications: Sympathomimetic amine hypersensitivity; severe hypertension; coronary artery disease; MAOIs;
glaucoma; hyperthyroidism; BPH; pregnancy category avoid use during 1st trimester and caution advised during 2nd
and 3rd trimesters in pregnancy. May occasionally use and while breastfeeding.
Adverse/Side-effects: Stimulation, tremulousness, difficulty voiding; arrhythmias, palpitation, tachycardia; nervous-
SECTION 4

ness, chest tightness, dizziness, headache, sleeplessness, numbness; anorexia, dry mouth, nausea, vomiting, dia-
phoresis, restlessness; heart palpitations when given with pre-workout
Interactions: Sympathomimetics and β-blockers increase pressor effects and toxicity; MAOIs may precipitate hyper-
tensive crisis; decreases antihypertensive effects of guanethidine, methyldopa, reserpine; avoid use with pre-workout
Note: Do not allow open access to this medication

RABEPRAZOLE (ACIPHEX)
Class: GI agent – proton pump inhibitor (PPI)
Action: Gastric PPI that specifically suppresses gastric acid secretion by inhibiting the H+, K+-ATPase enzyme system
(the acid [proton H+] pump) in the parietal cells of the stomach; does not exhibit H2-histamine receptor antagonist
properties
Dose: 20mg PO qd
Indications: For healing and maintenance of erosive or ulcerative gastroesophageal reflux disease (GERD), duodenal
ulcers, and hypersecretory conditions
Contraindications: PPI hypersensitivity; pregnancy category caution advised during pregnancy and consider alterna-
tive while breastfeeding
Adverse/Side-effects: Headache; Stevens-Johnson syndrome, toxic epidermal necrolysis, erythema multiforme
Interactions: May decrease absorption of ketoconazole; may increase digoxin levels

174 SECTION 4 RANGER MEDIC PHARMACOLOGY & FORMULARY

RIZATRIPTAN (MAXALT)
Class: CNS agent – sumatriptan; autonomic nervous system agent; adrenergic antagonist; serotonin 5-HT(1B /1D) re-
ceptor agonist
Action: Selective (5-HT1B /1D) receptor agonist reverses the vasodilation of cranial blood vessels associated with mi-
graine headache
Dose: 5–10mg PO (may repeat 1 dose in 2 hours prn); max dose of 30mg/24hr
Indications: Acute migraine headache with or without aura
Contraindications: Hypersensitivity; coronary artery disease or CAD risk factors of hypertension, hypercholesterol-
emia, obesity, diabetes, smoking or strong family history; concurrent administration of ergotamine drugs, sumatrip-
tan, or MAOIs; basilar or hemiplegic migraine, pregnancy category consider alternative during pregnancy and while
breastfeeding
Adverse/Side-effects: Asthenia; fatigue; pain; pressure sensation; paresthesia; throat pressure; warm/cold sensa-
tions; dizziness; headache; decreased mental acuity; euphoria; tremor; coronary artery vasospasm; transient myocar-

SECTION 4
dial ischemia; myocardial infarction; ventricular tachycardia; ventricular fibrillation; chest pain/tightness; palpitations;
dry mouth; nausea; vomiting; diarrhea; dyspnea; flushing; hot flashes
Interactions: Propranolol; dihydroergotamine; methysergide; other 5-HT1 agonists; Gingko; Ginseng; echinacea; St.
John’s wort
Mission Impact: GROUNDING medication for personnel on flight status

SCOPOLAMINE (TRANSDERM SCOP)

Class: Autonomic nervous system agent – parasympatholytic; anticholinergic, antimuscarinic, antispasmodic
Action: Alkaloid of belladonna with peripheral action resembling those of atropine, but in contrast, produces CNS
depression with marked sedative and tranquilizing effects for use in anesthesia; potent mydriatic and cycloplegic
action inhibiting secretions of salivary, bronchial, and sweat glands with less prominent effect on heart, intestines,
and bronchial muscles
Dose: For motion sickness, 0.25–0.6mg PO 1 hour before travel OR topical transdermal disc patch applied to dry
surface behind ear q72hr starting 12 hours before travel
Indications: Prophylactic agent for motion sickness; used as mydriatic and cycloplegic in ophthalmology; preanes-
thetic agent to control bronchial, nasal, pharyngeal and salivary secretions; control of spasticity and drooling in para-
lytic and spastic states
Contraindications: Anticholinergic, belladonna, or barbiturate hypersensitivity; asthma; hepatitis; narrow angle glau-
coma; GI or GU obstructive diseases; myasthenia gravis; pregnancy category caution advised during pregnancy and
while breastfeeding
Adverse/Side-effects: Fatigue, dizziness, drowsiness, disorientation, restlessness, hallucinations, toxic psychosis;
dry mouth and throat, constipation; urinary retention; decreased heart rate; dilated pupils, photophobia, blurred vision,
follicular conjunctivitis; depressed respiration; local irritation, rash
Interactions: Amantadine, antihistamines, TCAs, quinidine, disopyramide, procainamide add to anticholinergic ef-
fects; decreases levodopa effects; methotrimeprazine may precipitate extrapyramidal effects; decreases absorption
and antipsychotic effects of phenothiazines

2025 RANGER MEDIC HANDBOOK 175

SODIUM CHLORIDE, 0.9% (NORMAL SALINE)
Class: Plasma volume expander – crystalloid; isotonic salt solution
Action: Each 1mL contains 9g sodium chloride (Na+ 154mEq/L; Cl– 154mEq/L); pH 5.7; expands circulating volume
by approximating sodium content of the blood; but it remains in the intravascular space for only a very limited time as
it diffuses rapidly throughout the extracellular space
Dose: 500–1,000mL IV; 5–50mL IV for medication dilution or as flush
Indications: For fluid replacement and plasma volume expansion when blood or plasma is not available, and for
adjunctive treatment of shock and hypovolemic states caused by hemorrhage, burns, surgery, sepsis, trauma, dehy-
dration, or heat injury; also used for dilution of medications, as IV flush agent, for saline locks, and irrigation of eyes
and wounds
Contraindications: Congestive heart failure (CHF)
Adverse/Side-effects: Fluid overload, CHF, edema, electrolyte imbalance, hyperchloremic metabolic acidosis,
hypertension
SECTION 4

Interactions: No clinically significant interactions established

SODIUM CHLORIDE, 3% or 23.4% (HYPERTONIC SALINE) *

Class: Plasma volume expander – crystalloid; hypertonic salt solution.
Action: Each 100mL of 3% sodium chloride injection USP contains: sodium chloride USP 3g; each 10mL of 23.4%
sodium chloride injection USP contains: sodium chloride USP 2.34g
Dose: 250mL IV bolus of 3% or 30mL bullet of 23.4%
Indications: For AMS IAW Hyperthermia Management Protocol and concern for emergent hyponatemia; for TBI IAW
Head Injury Management Protocol
Contraindications: CHF; do not use with blood or blood products, presence of normal or elevated plasma electrolyte
concentrations
Adverse/Side-effects: Fluid overload, CHF, edema, electrolyte imbalance, hypertension
Interactions: None

SUFENTANIL (DSUVIA)
Class: CNS agent – potent narcotic (opiate) agonist
Action: Action similar to morphine with more rapid and less prolonged analgesia and sedation, but less emetic effect
Dose: 30mcg sublingual ODT q1hr prn pain
Onset/Peak/Duration: Onset 15 minutes; Peak 30–40 minutes; Duration 3 hours
Indications: For moderate to severe pain management
Contraindications: Significant respiratory depression; known hypersensitivity to sufentanil; pregnancy category may
use during pregnancy and consider alternative while breastfeeding
Adverse/Side-effects: Nausea, headache, vomiting, dizziness, hypotension, severe respiratory depression
Interactions: Macrolides, azole-antifungals, rifampin, phenytoin, alcohol, benzodiazepines, opioids, MAOIs, SSRIs,
TCAs
Mission Impact: GROUNDING medication for personnel on flight status

176 SECTION 4 RANGER MEDIC PHARMACOLOGY & FORMULARY

SUMATRIPTAN (IMATREX)
Class: Antimigraine
Action: Insert action
Dose: Tabs 25–100mg PO single dose q2hr. Max 300mg/d. SC injection initial 6mg repeated in 1–2 hours if needed.
Max 6mg q24hr. If migraine symptoms return, 50mg PO q2hr, up to 200mg
Indications: Relief of acute migraine headaches
Contraindications: Basilar migraine, cardiovascular disease, concurrent use of ergotamine-containing drugs, hyper­
sensitivity, ischemic heart disease, use within 14 days of MAOIs, within 24 hours of serotonin receptor agonist, preg-
nancy category caution advised during pregnancy and may use while breastfeeding
Adverse/Side-effects: Anxiety, dizziness, drowsiness, fatigue, fever, malaise, sedation, seizures, vertigo, arrhyth-
mias, coronary artery vasospasm, chest tightness, hypertension, palpitations, abnormal vision, nasal irritation, photo­
phobia, tongue numbness, abdominal discomfort, dysphagia, muscle cramps, myalgia, dermatitis, diaphoresis,
flushing, pallor, or pruritus

SECTION 4
Interactions: Antidepressants, sertraline, and MAOIs
Mission Impact: GROUNDING medication for personnel on flight status

TERBINAFINE (LAMISIL)
Class: Antimicrobial – antibiotic; antifungals
Action: Inhibits sterol biosynthesis in fungi; ergosterol, the principal sterol in the fungal cell membrane, becomes
depleted and interferes with cell membrane function, thus producing antifungicidal effect
Dose: For tinea pedis, tinea cruris, and tinea corporis, topically AAA qd–bid × 1–7 weeks; for onychomycosis, 250mg
PO qd × 6 weeks for fingernails and 12 weeks for toenails (monitor baseline LFTs, repeat at least monthly)
Indications: For topical treatment of superficial mycoses such as interdigital tinea pedis, tinea cruris, and tinea cor-
poris due to Epidermophyton floccosum, Trichophyton mentagrophytes, or T. rubrum; for oral treatment of onychomy­
cosis due to tinea unguium
Contraindications: Terbinafine hypersensitivity; pregnancy category B; elevated LFT or known liver disease, hepatitis
or mononucleosis, pregnancy category may use during pregnancy and caution advised while breastfeeding.
Adverse/Side-effects: Pruritus, local burning, dryness, rash, vesiculation, redness, contact dermatitis at application
site; headache; diarrhea, dyspepsia, abdominal pain, neutropenia; taste disturbances
Interactions: May increase theophylline levels; may decrease cyclosporine and rifampin levels

TETRACAINE OPHTH
Class: Local anesthetic
Dose: 1–2gtt 2–3 minutes before procedure. DO NOT DISPENSE TO PATIENT
Indications: As a topical optic anesthetic (may aid in ocular exam to relieve blepharospasm); removal of foreign bodies
Contraindications: Not for prolonged use, pregnancy category may use during pregnancy and while breastfeeding
Adverse/Side-effects: Stinging, conjunctival redness, tearing swelling, sensitivity to light, transient eye pain, hyper-
sensitivity reactions
Mission Impact: GROUNDING medication for personnel on flight status

2025 RANGER MEDIC HANDBOOK 177

TRANEXAMIC ACID (TXA) *
Class: Antifibrinolytic agent; synthetic lysine amino acid derivative
Action: Displaces plasminogen from surface of fibrin by binding to high-affinity lysine site of plasminogen, which
diminishes dissolution of hemostatic fibrin, which decreases bleeding
Dose: Administer 2g of TXA IV/IO as soon as possible but not later than 3 hours after injury
Indications: For patients anticipated to need significant blood transfusion presenting with hemorrhagic shock, one or
more major amputations, penetrating torso trauma or evidence of severe bleeding
Contraindications: Active intravascular clotting, pregnancy category consider alternative during pregnancy and while
breastfeeding
Adverse/Side-effects: Blurred vision or impaired color vision; gastrointestinal disturbances (nausea, vomiting, diar-
rhea) may occur but disappear when the dosage is reduced; transient hypotension has been observed when intra­
venous injection is too rapid
Interactions: Should not be administered concomitantly with factor IX complex concentrates or anti-inhibitor coagu-
SECTION 4

lant concentrates, as the risk of thrombosis may be increased

Mission Impact: Store at 25°C (77°F); excursions permitted to 15°–30°C (59°–86°F)

TRIMETHOPRIM-SULFAMETHOXAZOLE (TMP-SMZ, BACTRIM, SEPTRA)

Class: Antimicrobial – antibacterial, sulfonamide
Action: Fixed combination of TMP=SMZ, synthetic folate antagonists and enzyme inhibitors that prevent bacterial
synthesis of essential nucleic acids and proteins; effective against Pneumocystis carinii pneumonitis, Shigellosis en-
teritis, most strains of Entero­bacteriaceae, Nocardia, Legionella micdadei, and Legionella pneumophila, and Haemo­
philus ducreyi
Dose: 1 tablet (DS) PO bid × 10 days for cellulitis, 3–5 days for UTI
Indications: For cellulitis, pneumonitis, enteritis, severe complicated UTIs, acute otitis media, acute episodes of
chronic bronchitis, prevention of traveler’s diarrhea, cholera
Contraindications: TMP, SMZ, sulfonamide, or bisulfite hypersensitivity; group A β-hemolytic streptococcal pharyn-
gitis; megaloblastic anemia due to folate deficiency; use caution with severe allergy or bronchial asthma, G6PD defi-
ciency, and sulfonamide derivative drug (acetazolamide, thiazides, tolbutamide) hypersensitivity; pregnancy category
consider alternative during pregnancy and avoid use while breastfeeding
Adverse/Side-effects: Rash, toxic epidermal necrolysis; nausea, vomiting, diarrhea, anorexia, hepatitis, pseudo-
membranous enterocolitis, stomatitis, glossitis, abdominal pain; kidney failure, oliguria, anuria, crystalluria; agranu-
locytosis, aplastic anemia, megaloblastic anemia, hypoprothrombinemia, thrombocytopenia; weakness, arthralgia,
myalgia, photosensitivity, allergic myocarditis.
Interactions: CNS depressants, alcohol, and phenothiazines augment CNS depression; food significantly decreases
extent and rate of absorption, do NOT give with or immediately after a meal
Mission Impact: None

178 SECTION 4 RANGER MEDIC PHARMACOLOGY & FORMULARY

ZOLPIDEM (AMBIEN) – CONTROLLED SUBSTANCE IV
Class: CNS agent – nonbenzodiazepine; anxiolytic, sedative-hypnotic
Action: Nonbenzodiazepine hypnotic that does not have muscle relaxant or anticonvulsant effects; preserves deep
sleep (stages 3 and 4) at hypnotic doses
Dose: 5–10mg PO qhs, limited to 7–10 days
Indications: For short-term treatment of insomnia
Contraindications: Pregnancy category consider alternative during pregnancy and caution advised while breastfeeding
Adverse/Side-effects: Headache on awakening, drowsiness or fatigue, lethargy, drugged feeling, depression, anxiety,
irritability, dizziness, double vision; doses > 10mg may be associated with anterograde amnesia or memory impairment;
dyspepsia, nausea, vomiting; myalgia
Interactions: CNS depressants, alcohol, and phenothiazines augment CNS depression; food significantly decreases
extent and rate of absorption, DO NOT give with or immediately after a meal

SECTION 4
Mission Impact: Drowsiness

NEW DRUGS
Class:

Action:

Dose:

Indications:

Contraindications:

Adverse/Side-effects:

Interactions:

Mission Impact:

K9 Dosage:

Class:

Action:

Dose:

Indications:

Contraindications:

Adverse/Side-effects:

Interactions:

Mission Impact:

K9 Dosage:

2025 RANGER MEDIC HANDBOOK 179

NEW DRUGS
Class:

Action:

Dose:

Indications:

Contraindications:

Adverse/Side-effects:

Interactions:

Mission Impact:
SECTION 4

K9 Dosage:

Class:

Action:

Dose:

Indications:

Contraindications:

Adverse/Side-effects:

Interactions:

Mission Impact:

K9 Dosage:

Class:

Action:

Dose:

Indications:

Contraindications:

Adverse/Side-effects:

Interactions:

Mission Impact:

K9 Dosage:

180 SECTION 4 RANGER MEDIC PHARMACOLOGY & FORMULARY

DRUG QUICK REFERENCE
ACETAMINOPHEN (Tylenol): 325–1,000mg PO q4–6hr KETOROLAC (Toradol): 15mg IV or 30mg IM q6hr
prn (max: 3g/d) LIDOCAINE: Infiltration 0.5%–2% injection
ALBUTEROL MDI: 2 puffs q4–6hr prn LOPERAMIDE: 4mg PO then 2mg after each unformed
CALCIUM CHLORIDE: 1g IV/IO q4 units of blood stool (max 16mg/day)
transfused MELOXICAM (Mobic): 7.5–15mg PO qd
CALCIUM GLUCONATE: 1–3g IV/IO q4 units of blood MIDAZOLAM (Versed): 2mg slow IV push q2–3min to
transfused max dose of 10mg OR 5–10mg IM for seizure control
DEXAMETHASONE (Decadron): 4mg PO q6–12hr; 10mg MOXIFLOXACIN: 400mg PO/IV QD 5–10d
IV/IM single dose NALOXONE (Narcan): 0.4–2.0mg IV; repeat q2–3min to
DIPHENHYDRAMINE (Benadryl): 25–50mg IV/IM/PO max of 10mg prn
q4–6hr NAPROXEN: 250–500mg PO bid
EPINEPHRINE (1:1,000): 0.3–0.5mg IM q10–15min NORMAL SALINE (HYPERTONIC): 30mL 23.4% bullet
ERTAPENEM (Invanz): 1g IV/IM q24hr for impending herniation or 250mL bolus of 3% for
FENTANYL ORAL LOZ: 800–1,600mcg (max: 1,600mcg/d) emergent hyponatremia
FENTANYL: 50–100mcg IV/IM q1–2hr prn ONDANSETRON (Zofran): 4–8mg slow IV push or IM

SECTION 4
HYDROMORPHONE (Dilaudid): 1mg PO/SC/IM/IV q4hr prn OR 4–8mg PO q4hr prn
q2–4hr prn PROMETHAZINE (Phenergan): 12.5–25mg PO/IM/IV
IBUPROFEN: 600mg PO tid q4–6hr prn
KETAMINE: pain: 0.1–0.3mg/kg IV; sedation: 1–1.5mg/kg TRANEXAMIC ACID (TXA): 2g IV/IO ASAP
slow IV push until nystagmus, bump 20–25mg q10–20min

Ketamine Drip
Ketamine drip (for sedation): Sedation loading dose first (1.5mg/kg IV/IO over 60 seconds).
MIX: 250mg (1/2 vial of 500mg/5mL) in 250mL of normal saline (1mg/mL solution).
Initial drip dose:
Best: Using an IV pump, set to µg/kg/min dose desired. Increase or decrease dose by 5–1µg/kg/min increments.
Better: Using a dial flow adaptor, initial drip rate in mL/h equals the casualty’s weight in kg divided by 2 (sedations)
or 4 (pain).
Minimum: Count drip rate. Increase or decrease rate by 1–2 drips/min (very slowly) to achieve goal.

250mg Ketamine / 250mL Saline Bag

Ketamine Drip Dosing Tables
Ketamine Drip Rate for Dial Flow (starting dose highlighted)
Patient’s Weight, kg
Dose 60 80 100
mg/kg/hr Infusion Rate, Dial Flow Setting
0.5 30 40 50
0.75 45 60 75
1 60 80 100
1.25 75 100 125
1.5 90 120 150
1.75 105 140 175
2 120 160 200
Ketamine Drip Rate for × drip set
1.5 60 80 100
Drip Set Size Infusion Rate, 1 drip/X seconds
10 1 drop per 4 seconds 1 drop per 3 seconds 1 drop per 2.4 seconds
15 1 drop per 2.67 seconds 1 drop per 2 seconds 1 drop per 1.6 seconds
20 1 drop per 2 seconds 1 drop per 1.5 seconds 1 drop per 1.2 seconds
Note: Ranger medics will use their best judgement in determining drip estimation in varying drop set sizes.

2025 RANGER MEDIC HANDBOOK 181

PHARMACOLOGY NOTES
SECTION 4

182 SECTION 4 RANGER MEDIC PHARMACOLOGY & FORMULARY

SECTION 5

SPORTS MEDIC
SCOPE OF PRACTICE

SECTION 5

183
Shoulder – Traumatic & Acute Pain
SECTION 5

184 SECTION 5 SPORTS MEDIC SCOPE OF PRACTICE

Arm/Elbow – Traumatic & Acute Pain

SECTION 5

2025 RANGER MEDIC HANDBOOK 185

Hand/Wrist – Traumatic & Acute Pain
SECTION 5

186 SECTION 5 SPORTS MEDIC SCOPE OF PRACTICE

Hip – Traumatic & Acute Pain

SECTION 5

2025 RANGER MEDIC HANDBOOK 187

Leg – Traumatic & Acute Pain
SECTION 5

188 SECTION 5 SPORTS MEDIC SCOPE OF PRACTICE

Knee – Traumatic & Acute Pain

SECTION 5

2025 RANGER MEDIC HANDBOOK 189

Ankle – Traumatic & Acute Pain
SECTION 5

190 SECTION 5 SPORTS MEDIC SCOPE OF PRACTICE

Clearing the Spine and Joint for Mechanical Issues at the Joint Pain
1st perform joint movement that hurts as a “test”

Movement: Looking upward as far as you can go

• After reaching end range, bring your neck back to the starting position.
• Repeat 10 times.
• If pain is produced in your neck or joint, and does not decrease with more
reps, stop.
• After completing 10 times, recheck the movement that causes your joint
to hurt.
• If the movement is less painful, continue this neck extension and recheck
the joint movement until it abolishes or stops improving.
• If this movement does not change your joint pain, move to the specific
exercise for your joint pain.

Starting position: ears over shoulders

1st perform joint movement that hurts as a “test”

Movement: Prone on elbows and placing your chin on the tips of

SECTION 5
your fingers

• This is not a repeated movement, but a static hold for 30sec–1min.

• After holding, lie prone and rest for 30 seconds.
• If pain is produced your neck or upper back and it does not decrease in this
position with time, stop.
• After lying prone in this position for 30 seconds, recheck the movement
that causes your joint to hurt.
• If the movement is less painful, repeat this static position for 60 seconds
and recheck the joint movement until it abolished or stops changing.

Starting position: lie prone

1st perform joint movement that hurts as a “test”

Movement: Holding your thumbs up, raise your arms over your head while
looking upward

• After reaching end range, return to starting position.

• Repeat 10 times.
• If pain is produced in your neck or joint, and does not decrease with more
reps, stop.
• After completing 10 times, recheck the movement that causes your joint
to hurt.
• If the movement is less painful, continue this neck extension and recheck
the joint movement until it abolishes or stops improving.
• If this movement does not change your joint pain, move to the specific
exercise for your joint pain.
Starting position: standing

2025 RANGER MEDIC HANDBOOK 191

Clearing the Spine and Joint for Mechanical Issues at the Joint Pain (cont.)
1st perform joint movement that hurts as a “test”

Movement: Squat as far as you can until you reach your end range

• After reaching end range, return to the standing position.

• Repeat 5–7 times.
• After completing 5–7 times, recheck the movement that causes your joint
to hurt.
• If the movement is less painful, repeat 5–7 more times and recheck joint
movement until pain is abolished or stops changing.

Starting position: Standing with arms at

side and palms facing backwards

1st perform joint movement that hurts as a “test”

SECTION 5

Movement: Extend the elbow as straight as you can

• Grasping a shelf and using your supporting hand to push up on your elbow
can assist in achieving end range motion.
• After reaching end range, return to the starting position.
• Repeat 5–7 times.
• After completing 5–7 times, recheck the movement that causes your joint
to hurt.
• If the movement is less painful, repeat 5–7 more times and recheck joint
movement until pain is abolished or stops changing.

Starting position: standing or sitting with

opposite hand supporting your elbow

1st perform joint movement that hurts as a “test”

Movement: Perform a Push Up motion leaving your hips close to

the ground

• After achieving full elbow extension, return to the starting position.

• Repeat 10 times.
• If pain is produced in your lower back or joint, and does not decrease with
more reps, stop.
• After completing 10 times, recheck the movement that causes your joint
to hurt.
• If the movement is less painful, continue this low back extension and
recheck the joint movement until it abolishes or stops improving.
• If this movement does not change your joint pain, move to the specific
exercise for your joint pain.
Starting position: lie prone with hands in
the Push Up position

192 SECTION 5 SPORTS MEDIC SCOPE OF PRACTICE

Clearing the Spine and Joint for Mechanical Issues at the Joint Pain (cont.)
1st perform joint movement that hurts as a “test”

Movement: Kneeling hip is pushed forward until you reach end range.
Using your fist to push on the back of your hip can assist in achieving end
range of motion

• After reaching end range, return to the starting position.

• Repeat 5–7 times.
• After completing 5–7 times, recheck the movement that causes your joint
to hurt.
• If the movement is less painful, repeat 5–7 more times and recheck joint
movement until pain is abolished or stops changing.

Starting position: Kneeling lunge

1st perform joint movement that hurts as a “test”

Movement: Press your thigh back, extending your knee to end range

SECTION 5
• After reaching end range, return to the starting position.
• Repeat 5–7 times.
• After completing 5–7 times, recheck the movement that causes your joint
to hurt.
• If the movement is less painful, repeat 5-7 more times and recheck joint
movement until pain is abolished or stops changing.

Starting position: standing with foot of

knee to be extended in front and placing
your hands above your knee

1st perform joint movement that hurts as a “test”

Movement: Move knee over the front ankle to end range

• After reaching end range, return to the starting position.

• Repeat 5–7 times.
• After completing 5–7 times, recheck the movement that causes your joint
to hurt.
• If the movement is less painful, repeat 5–7 more times and recheck joint
movement until pain is abolished or stops changing.

Starting position: Kneeling lunge

2025 RANGER MEDIC HANDBOOK 193

NOTES
SECTION 5

194 SECTION 5 SPORTS MEDIC SCOPE OF PRACTICE

SECTION 6

MPC/CANINE TRAUMA
& TACTICAL MEDICAL
EMERGENCY PROTOCOLS (TMEPs)

SECTION 6

195
Canine Patient Assessment
General Guidelines
Medics should perform only procedures necessary to treat life-threatening emergencies and prepare multipurpose ca-
nines (MPC) for MEDEVAC. Canine patients differ slightly in anatomy, physiology, and pharmacology from injured adult
humans, but the same trauma principles apply. Knowledge of these key differences will increase success of resuscitative
efforts to our MPCs. Routine care of MPCs requires guidance from veterinary personnel. Veterinary care is not always
available within your AO; it is often limited to major transport hubs.

Canine Vital Signs And Normal Values

1. Temperature: Normal Rectal Temp is 99.5°F to 102.5°F
a. May increase up to 106°F after exercise/work without deleterious effects.
b. An acclimated and conditioned dog should recover to a normal temperature within 10–15 minutes after exercise.
2. Pulse: Normal pulse rate varies from 60 to 120 bpm in conditioned dogs and increases with exercise/excitement.
a. The femoral artery, or grasping the chest at the heart, are the easiest locations to feel a pulse. The femoral artery
is located on the inside of a dog’s rear limb at the division between the sartorius muscle and gracilis/adductor
muscles. In simpler terms, it is generally just behind the femur on the inside of the hind leg. Apply light pressure
and you should feel the pulse with two fingertips.
b. Alternate distal sites include:
1. Medially above the large foot pad on the backside of the front limb.
2. Medially two finger widths below the hock on the front/inside of the hind limb.
c. Variations will exist between individual dogs.
d. Count the number of beats for 15 seconds and then multiply by 4 to get beats per minute. Alternatively, you can
count for 10 seconds and multiply by 6 or count for 6 seconds and multiply by 10.
e. Pulses should be strong, succinct, and synchronous with heart beats.
3. Respiration rate: 10–30 respirations per minute. Controlled panting is normal, meaning panting should stop with any
significant stimulus (Ball, Kong, treat, tug, smell of isopropyl alcohol).
SECTION 6

4. Capillary refill time (CRT): less than 2 seconds.

5. Mucous membranes (MM): generally pink and moist. Many dogs will have pigmented membranes.
6. Skin turgor: pinch the skin between the shoulder blades and lift up, pulling out any slack. Release and the skin
should immediately fall back into place if properly hydrated.
7. EtCO2: normal 35–45mmHg
8. Pulse Ox: > 95% SpO2. Place the probe on the tongue or any highly vascularized, nonpigmented area (lip, vulva,
prepuce, between toes, etc.). Nonin finger probes only work on the tongue. Sedation with dexmedetomidine lowers
SpO2 reading on the tongue.
9. Indirect blood pressure (BP): > 90mmHg systolic, > 60mmHg MAP, > 40mmHg diastolic. Use pediatric-sized non­
invasive blood pressure cuffs (neonate 5, pediatric 6–8). The cuff should be tight without overlapping. Use pediatric
settings on BP machine. Placement options below in order of ease.
a. Tail: place at the tail base (closest to body) with the artery indicator zone on the bottom side.
b. Front limb: place above the carpus with indicator zone on the back side.
c. Hind limb: place below the hock over the metatarsals with indicator zone on top of the foot and slightly off-center
medially.
10. Labs: human analyzers may be used for canines.
a. Chemistry, HCT, and ABG parameters similar to humans.
b. Canine albumin values are falsely low using human analyzers, and not accurate for diagnostic purposes.
c. Urine output 1–2mL/kg/hr. Urinalysis results comparable to humans.

Canine CPR
1. If MPC is unresponsive, not breathing AND the tactical situation permits, then begin CPR. Lay the animal on either side.
2. Hand placement can be directly over the heart (where the elbow crosses the chest above the sternum when the
forearm is pulled caudally) or over the widest part of the chest.
3. 100 to 120 compressions per minute. Sustain compressions for at least 2 minutes per cycle before checking status.
Compress one-third to one-half the chest width. Check status – palpate femoral pulse (Radial pulse is not easily
palpable in a dog.)
4. Establish airway as rapidly as possible (Intubate or tracheostomy without interrupting compressions).
5. Ventilate at 8–10 breaths per minute; use oxygen if it is available.
6. With more help or higher level of care you can begin advanced life support procedures.

196 SECTION 6 MPC/CANINE TRAUMA & TACTICAL MEDICAL EMERGENCY PROTOCOLS

Canine Trauma & Shock Management

S/Sx OF CANINE TRAUMA & SHOCK

S/Sx of Shock: Advanced:
1. Pale, gray, blue MM 1. Loss of consciousness.
2. Prolonged CRT, > 3 seconds 2. Dilated pupils.
3. Weak, “thready” pulses 3. Dyspnea.
4. Tachycardia, > 160 bpm 4. Hypothermia, < 98°F.
5. Tachypnea, > 30 bpm (differentiate from panting) 5. Mechanism: Often seen with penetrating wounds
6. Decreased consciousness of the neck, chest, abdomen, and hip
7. Hypotension
8. Collapse

Canine TCCC Management

Canine trauma management follows the same TCCC/MARCH principles as for humans. This section covers specific de-
viations and/or requirements from human protocols, which may improve survivability of MPC trauma patients. Handlers
are trained in these principles and will usually be the first to initiate aid.

Safety. Injured MPCs may bite from fear and/or pain, even with decreased consciousness. Wounded MPCs must be
muzzled when performing assessment and procedures unless presenting with respiratory distress. Sedation/pain meds
are authorized for MPCs not amenable to physical exam or treatment.

Care Under Fire:

Handler is okay: Handler will move himself and injured MPC to cover. Handler and/or Medic perform quick head-to-toe
check assessing level of consciousness and correcting life-threatening hemorrhage if the situation permits.

Handler Wounded: Wounded Rangers are first priority. Remove the injured MPC to cover if tactically feasible. Every

SECTION 6
handler should have members of their platoon identified and comfortable working with the MPC. This person will help
maintain control of the injured MPC while another Medic or ARFR provides care.

Tactical Field Care: MPC moves to CCP with other casualties. Medic triages other casualties before attending to MPC’s
wounds. Handlers and/or other EMT/RFR will provide initial care until Medics can divert their attention. Remove equip-
ment and tactical vests to fully assess the chest area. Provide sedation/pain meds (dosages on MPC Card) as needed
in conscious patients to complete exams and treatments. Communicate MPC casualty status and evacuation require-
ments through normal C2 channels.

Tactical Evacuation: MEDEVAC per usual manner according to precedence (Urgent, Priority, Routine). However, MPCs
will not precede other casualties of the same category. Handlers or trained representatives must remain with the MPC
throughout transport. Always reassess the patient and all interventions after movement. Always complete a K9 Casualty
Card and maintain with the patient throughout transport. Complete a casualty AAR in the normal manner and include
the RVET on all communications. MPC casualty information is maintained in the Prehospital Trauma Registry the same
as Rangers.

Point of Injury:
M3ARCH Always try to consider what is killing the animal and treat that first. Use the algorithm when you are not sure.
1. Muzzle: Although our dogs are generally sociable with other Rangers, any dog in pain will likely bite. These dogs bite
really hard . . . Muzzle them first. Generally our handlers carry a medical muzzle in their lower leg pocket.
2. Massive hemorrhage: Control extremity bleeding with combat gauze and pressure bandages. CAT tourniquets are
large and effectiveness can be tricky. If used, place above the stifle or elbow for injuries distal. SOF-T tourniquets are
100% useless on dogs. Pack GSWs to the neck, hip and shoulder with combat gauze using hemostats or Rochester-
Carmalt 8” (curved) or Rochester-Pean (curved) 8” forceps. X-stat has been ineffective at staying in the GSW track of
a hip and did not create tamponade or effective hemostasis in one Ranger MPC.
3. Medication: (Consider) an alert injured dog may need its pain managed and sedated just to pack a wound/treat an
injury, catheterize, bandage, etc. Unconscious dogs do not need sedation. In an alert dog, start on M3ARCH and if
necessary sedate. The following are protocols that may be used based on the medications available to Ranger Med-
ics and handlers in combat:

2025 RANGER MEDIC HANDBOOK 197

CTCC
Determine LOC

a. Alert dog with strong pulse (e.g., bleeding a little but not bleeding out, can’t restrain for fractured leg splint/ban-
dage or pad laceration or need to pack a GSW through the neck, leg or hip that only has minor bleeding, sedate
a healthy dog for blood donation)
0.5mL (0.25mg) of dexmedetomidine
+1.5mL (150mg) of ketamine
+ 1–2mL (2–10mg) midazolam
Approximately 4mL total volume in 5mL syringe, give IM.
SECTION 6

Takes 10 minutes and lasts up to 40 minutes

b. Responds to voice commands, beginning of shock, losing consciousness has a weak pulse, is bleeding profusely
in pain but will not hold still
1.5mL (150mg) of ketamine
+ 1–2mL (2–10mg) midazolam
Approx. 3.5mL total volume in 5mL syringe, give IM
c. Unconscious dog, no response, barely detectable pulse
DOES NOT GET SEDATED
4. Airway: First check the airway to ensure it is clear using a finger sweep. Then determine the dog’s breathing pattern,
rate, and if it is having difficulty to determine if interventions are necessary.
a. NPAs are not functional in MPCs.
b. Orotracheal intubation is easier than for humans. Intubation is only possible if there is loss of consciousness or
significant sedation. If under cover, use a size 9 or 10 ET tube (ETT) found in the Handler’s IFAK. Place the MPC in
sternal recumbency with the head held out, extending the neck. Assistant grasps over the top of the muzzle. He
then pinches the top lips behind the top canines with one hand and uses the other to open the lower jaw. The as-
sistant then pulls the tongue out and downward between the lower canine teeth, opening the mandible (use gauze
if you can, it is slippery). Medic/handler can then insert the ETT between the arytenoids similar as for a person.
Use an 8" curved Rochester-Pean (or Carmalt) forceps or tongue depressor with light source to reach back to the
soft palate and gently flip down the epiglottis to visualize the arytenoids.
NOTE: After the ET tube is inserted, pass a 2" roll of Elastikon or Coflex over the end of the ET tube and secure in the
dog’s mouth as a gag. Use 1" white athletic tape (handler’s aid kit) to keep the dog’s mouth shut around this temporary
gag (see pictures on page 198). This will give you time to remove or resedate the dog and prevent him from chewing
through the tube if he wakes up.
c. Perform a surgical tracheostomy if upper airway is obstructed and the animal is unconscious (or properly sedated).
The cricothyroid membrane is difficult to access in dogs. Make at least a 3” midline incision from a point that is
three finger widths from the thoracic inlet (base of the neck) rostral (toward the head). Now make a midline incision
through the facial layer of muscle and blunt dissect (fingers) to the trachea. Make a stab incision between tracheal
rings to access the tracheal lumen. Insert the handler’s 9–10mm ETT (preferred) up to the thoracic inlet or use the
standard 6mm Cric kit tube when an ETT is unavailable. Secure in place as usual.

198 SECTION 6 MPC/CANINE TRAUMA & TACTICAL MEDICAL EMERGENCY PROTOCOLS

d. Emma/EtCO2 monitor (reference range is 35–45mmHg). Opioids (e.g., fentanyl CRIs) can depress the CNS, leading
to a higher CO2 reading. Pain will cause an animal to hyperventilate and decrease the CO2 reading.
5. Respirations
a. Remove the vest. Check both sides of the chest and neck. Thirty percent of our penetrating GSWs to the thorax
communicated with a GSW to the neck.
b. In the conscious patient with an actively sucking wound – use a large, vented occlusive dressings. It is difficult to
get them to adhere; bigger is better. Try to cover as much surface area as possible with the occlusive dressing.
Wrap the chest circumferentially with an Elastikon bandage if adherence is a problem. Be careful not to restrict
breathing. Be prepared to treat a pneumothorax or hemothorax.
c. Dogs with pneumothorax and/or hemothorax often have increased resistance when bagging and may present
EtCO2 two ways when intubated: they may have (1) a low EtCO2 reading because the volume of air crossing the
sampling device (emma) is decreased from the restriction of tidal volume movement caused by the tension pneu-
mothorax or (2) a high EtCO2 reading when sufficient tidal volume is available to move but venous return to the
heart is decreasing from pressure. This causes less blood to move to the lungs, which increases the concentration
of CO2 that is released when it finally arrives. The wave form is normally square with the right side of the square/
plateau slightly higher. Pneumothoraxes often show a short plateau wave form where the left side of the plateau
is higher. Open chest lacerations/finger thoracostomies need positive pressure ventilation. Increased compliance
while bagging may indicate hemopneumothorax/pneumothorax/hemothorax and the need to be decompressed.
d. Needle decompression: Place between 6th to 8th intercostal spaces cranial to the rib using a standard 14-gauge
catheter. Place in highest portion of chest when laterally recumbent to remove air and lower third (near sternum) to re-
move fluid. Repeat needle decompression often indicates need for tube or finger thoracostomy. NOTE: 92% of dogs
have a fenestrated mediastinum but bilateral decompression may be indicated clinically in a smaller percentage.
e. Chest tube: Indicated if needle decompression does not resolve pneumothorax or hemothorax is present. Place
the dog in lateral recumbency with the affected side up. Pull skin cranially. If conscious, block the rib in front and
the rib behind with 1–2mL of lidocaine (about an inch proximal to your entry point). Use a 28–36 French chest tube
(same as a human). Place mid-thorax between the 7th and 8th intercostal spaces (dogs have 13 ribs per side).

SECTION 6
Enter the chest at the highest point of the chest wall. Direct tubes in cranioventrally (toward the head and sternum)
direction. Place entry point cranially over ribs to avoid vessels and nerves. Have an assistant pull the loose skin
cranial before the incision is made in the 7th or 8th intercostal space to obtain a better seal.
6. Circulation: Make sure there is not major bleeding and control as necessary. Penetrating wounds to the neck that
you believe communicate with the thorax (or severe major vasculature of the neck), obvious penetrating wounds to
the chest, abdomen, or hip are all considered significant mechanisms of injury. Treat for hemorrhagic shock if two or
more clinical signs below are seen):
a. Pulse > 160bpm
b. Loss of consciousness
c. Weak femoral pulse
d. HR > systolic BP
e. Systolic BP < 90
f. Tacky mucous membranes
g. EtCO2 < 35mmHg
h. Estimated 400mL blood loss or more (one saturated roll of Kerlix)
i. Mechanism of injury includes a penetrating wound to the neck, chest, abdomen, or hip

Resuscitate until femoral pulses are palpable or systolic pressure > 90mmHg. Intravenous route is preferred; Secondary
route is IO (lateral humoral head or tibial crest). Incorporate fluid therapy as needed. Resources will often limit canine
blood availability to 1 unit, which is generally with the Ranger MEDEVAC asset in theater. Encourage handlers to manage
and carry that unit of blood on target OR convince the company commander to take the Battalion’s animal care tech.
If blood products are unavailable, make sure that it is asked for in line 4 of the 9-line request so other assets in theater
can begin to pull blood from their walking canine blood banks before your patient arrives. Absolutely no human blood
product should go to a Ranger MPC; it has contributed to the death of a Ranger MPC as recently as 2017. If no canine
blood is available, then bolus 500–700mL of crystalloid over 20–30 minutes, reassess vitals, and repeat only if no change
in vitals and there is no foreseeable extraction for the MPC within the next 15 minutes. Do not exceed 2L in 1 hour. Follow
fresh whole blood transfusion protocol if second dog is available. This is most practical after evacuation to higher care.
Monitor for circulatory overload the same as humans.

2025 RANGER MEDIC HANDBOOK 199

7. Hypothermia: Dry the animal’s coat as much as possible. Prevent loss of body heat using warming blankets. Use
fluid warming devices if saline lock initiated. Protect against wind and elements.
AND
Head Trauma: The most common cause for head trauma/TBI may occur with blast injuries. Of the six blast injuries sus-
tained so far by our MPCs, two died immediately and the other four did not report any issues related to head trauma and
returned to duty. Suspect head trauma/TBI if the MPC is in close proximity to explosions/blasts or other nearby Rangers
are affected. Altered consciousness and pupillary function (equality and reactivity) are vital when assessing the patient.
a. Key to field management is prevention of hypoxia (maintain SpO2 > 90, preferably > 95) and hypotension (maintain
systolic > 90mmHg). Maintain an airway and ventilate at 12–20bpm with approximately 400–500mL tidal volume.
Do not hyperventilate.
b. Elevate the head/body upward 30° if hemodynamically stable. Keep the body and neck in a straight line by placing
the patient on a board or litter and propping up the end toward the head. Do not place material directly under the
head causing a bend in the neck, which may decrease venous return to the heart.
c. Levels of consciousness: Alert, obtunded (verbal), stuporous (pain), and comatose (unconscious) is similar to
AVPU. An obtunded animal should still respond to noise or touch. Stupor indicates a loss of consciousness (LOC);
they respond only to noxious stimuli (pinch across the toes with fingers). Comatose dogs exhibit no response to
repeated noxious stimuli.
d. Perform a full exam for other injuries, especially thoracic auscultation, and perform regularly throughout the mis-
sion. Treat subsequent injuries as needed.
e. Ruptured tympanic membranes require veterinary-specific otic cones to diagnose. The canine ear canal is ex-
tremely long and has a 90° bend.
f. All blast injuries and/or suspected head trauma/TBI require follow-up with a veterinarian for monitoring, thoracic
radiographs, and TM assessment

RAC (Only on the Stuporous or Unconscious MPC)

SECTION 6

Always try to consider what is killing the animal and treat that first. Use the algorithm when you are not sure.

Ten of 18 combat deaths in Ranger MPCs involved penetrating wounds to the thorax, making up 55% of all our KIAs.
These wounds are 35% of all combat-related injuries sustained by Ranger MPCs. No Ranger MPC has survived a pen-
etrating chest wound to date. Dogs often die quickly from chest wounds because they have no functional body armor,
a larger heart (dog at 7g/kg bwt, so 223g vs a human at 5g/kg bwt and a 247g heart), and they are almost always shot
through both sides of their chest, which doubles the chance of pulmonary vessel involvement. Half of our MPC combat-
related deaths are because they bleed out into their chests. In contrast, 4/29 MPC combat-related injuries were to the
extremities alone and none of those animals died. This deviation in protocol from M3ARCH is one attempt to save more
dogs with a penetrating GSW to the thorax wound pattern. We are also awaiting the development of lighter and more
flexible, thoracic body armor.

The new algorithm is used only in the stuporous or unconscious dog (both indicate LOC). Check pulse and breathing
for signs of life before wasting resources and time on a dead animal. If the animal is apneic and pulseless – perform a
bilateral finger thoracostomy in the 6th or 7th ICS, look for blood and reassess.
1. Respirations (Alive)
The goal is to identify any chest or neck (neck wounds often communicate with the chest wounds in our MPCs) wound
while also paying attention to respirations during your search. If there is no wound in the chest or neck, move back to
M3ARCH. If there is an assistant, have them look for massive hemorrhage while you roll through RAC. If there is a wound
in the chest, make a mental note, check for the exit wound, but do not bother covering them with a chest seal in this
algorithm. A thoracic wound with either progressively rapid shallow breathing or no breathing with a distended/swelling
chest needs decompressed with a 14G needle. This enters at the 6th or 7th ICS on the highest point/mid-point (of the
chest). If the first NCD needle fails, try once more on the opposite side of the chest and move on to airway. Place chest
tubes, if necessary, only after airway and circulation have been addressed.

200 SECTION 6 MPC/CANINE TRAUMA & TACTICAL MEDICAL EMERGENCY PROTOCOLS

2. Airway
Obviously look for an airway obstruction and clear it if present or if it is possible. To date,
the Regiment has had one significant MPC airway obstruction, it never lost consciousness,
never received a tracheotomy, and survived. The idea in this algorithm is to quickly secure an
airway in an apneic canine patient that has been shot in the chest. Intubation is much faster
and easier in a dog than a tracheotomy. In the unconscious animal insert a 10mm ET tube
using your large Rochester Curved Carmalt (or Penn) forceps (found in your chest tube kits)
to flip the epiglottis down. Visualize the arytenoids with a head lamp and insert the ET tube
to the level of the thoracic inlet. If carried, place a roll of Coflex or Elastikon over the end of
the ET tube to the back of the mouth and tape in place with athletic
tape to create a bite block. If the animal wakes up this will prevent him
from chewing through the tube until you can sedate him. Apply your
Emma and bag when indicated. If bagging is necessary (Apneic, EtCO2
above 50mmHg) – be sure to pay attention to bag compliance (you do
not want to push through a pneumothorax). If the animal is breathing
move on to circulation. If the animal is apneic while intubated and there
is resistance to bagging, consider NCD or finger thoracostomies for
pneumo/hemothorax. Finger thoracostomies would require bagging
the apneic patient and likely require assistance in a canine patient that is breathing.
3. Circulation
By this point you have already checked a femoral pulse and know whether it is weak or not. An unconscious dog with
a penetrating chest wound automatically makes the animal a candidate for hypovolemic shock and should be treated
for it. IV catheterization > IO. TXA may be given (5mL or 500mg IV) in the flush once followed by canine blood > canine
fresh frozen plasma > Plasmalyte A or LR > 0.9% saline. Give 1 unit of blood or a quarter shock dose of crystalloids (app
700mL) and reassess. After RAC, move back to MARCH.
NO HUMAN BLOOD WILL BE ADMINISTERED TO MPC.

SECTION 6
Antibiotic Therapy for Penetrating Wounds: There are very little data on the use of ertapenem (Invanz) in dogs.
Plumb’s recommended dose is 15mg/kg IV or IM so about 450mg IV/IM (4.5mL once reconstituted) twice a day.

Canine Casualty Card: Medics must complete a casualty card provided by the handler or found on the unit portal under
the RMED/RVET section. Send casualty assessment and AAR through appropriate channels with inclusion of the RVET
and Bn Vet Tech. MPC casualties are stored in the PHTR the same as Rangers’.

Evacuate: Evacuate to a veterinary treatment facility with surgical capabilities or human equivalent (FH, FST) depending
on MEDEVAC times and patient precedence. Canine casualties may be evacuated with human casualties. A MEDEVAC/
CASEVAC plan MUST be worked out for the dog during mission planning. Make sure either the handler or platoon Medic
briefs what facility will be used during the mission brief so the GFC and MEDO know where to send it. There is ALWAYS
confusion with what evacuation asset will be used and where a dog casualty will go after extracted from combat. Most
commanders are not willing to risk the lives of air crewmen for a lone dog casualty on a hot LZ. This means the MPC of-
ten extracts with unit. Make sure the driver or pilot of the CASEVAC platform knows where to take dog casualties before
the mission starts. Ensure the MEDO relays line 4 information (e.g., canine blood!) to the receiving veterinarian. Ensure
any handler not on the mission knows he needs to take a (spare) MPC to the veterinarian in case blood is needed. Finally
make sure everyone has the veterinarian’s contact information and calls them immediately.
4. Handlers or a trained representative should always escort MPC casualties.
5. Conscious canines are difficult to evacuate on human litters (even if strapped down). Most handlers carry canine
specific litters.

Splinting/bandaging: Immobilize fractures when packaging for MEDEVAC to alleviate pain and reduce further soft tis-
sue damage. One joint above and one joint below the fracture require stabilization to be effective.
1. This effectively limits splinting to fractures below the elbow and the stifle.
2. Use a Telfa on open wounds followed by white conforming gauze or kerlix to hold in place. Leave the center two toes
exposed. Always start bandaging at the toes and wrap proximally, regardless of the fracture location.
3. Place a second layer over the holding gauze (second roll of Kerlix, cast padding, or cotton). Compress (do not con-
strict) with Coflex (or VetWrap) leaving a ½" of the gauze exposed on each end. A final wrap around the chest or pelvis
(usually with Elastikon carried by the handler) will help hold in place.
4. Place a SAM splint, or equivalent devise, the entire length of the leg. Place on the lateral aspect of the limb from the
toes to above the shoulder or hip joint.

2025 RANGER MEDIC HANDBOOK 201

Canine Field Blood Transfusion Procedure
Coordination WILL be made with either the RVET, Battalion 68T, or deployed veterinary assets to maintain at least 1 unit
of whole blood at all times. Do not ever let a human receive dog blood. One unit of whole dog blood should be drawn
every 3 weeks and (if a blood bank is not available) stored at 2–4°C (35.6–42.8°F). This blood will be clearly marked “K-9”
and travel with the handler, 68T, designated dog blood mule, or MEDEVAC asset in an approved container while MPC
teams are on mission. Follow temperature recommendations for each product. It must then immediately be transferred
back into the designated blood refrigerator upon RTB. Three Ranger MPCs had no drop off in performance (after a
450mL donation) when given 24 hours to recover and no crystalloid fluids to replace the loss. Each dog went through this
protocol for two blood draws 3 weeks apart and were not affected when compared to controls. Two dogs on deployment
will have no issue alternating blood donations every three weeks. One-dog deployments occur and they cannot donate
every 3 weeks for themselves. Coordinate with the RVET to have canine plasma available if no other MPC are available
for whole blood donations during single MPC deployments.
Indications for transfusion are the same as for people (i.e., hemorrhagic shock therapy). This protocol is designed for
use on the battlefield using the standard collection set. However, situations may occur in which the Medic must perform
these procedures while assisting at veterinary or medical treatment facilities following MEDEVAC. Any healthy MPC is
authorized as a donor because the risk of infectious disease is presumably low. Do not use indigenous dogs for fear of
personnel safety, bloodborne disease transmission, and zoonotic diseases, such as rabies.
Dogs have eight identified blood types. They do not have naturally occurring antibodies, and the first transfusion usually
does not cause allergic reactions (the first one is “free” in an emergency) within the first 3 days. Meaning, there is no need
to blood type or cross match the first transfusion a dog receives on the battlefield. An MPC that previously received a
transfusion will be identified on his medical card. Discuss their medical requirements with the RVET prior to deployment.

Donor:
1. Shave the hair and aseptically prep the skin over the jugular furrow as much as possible.
2. Prepare the collection system.
3. Handler places the dog in a sit if trained, or lateral recumbency. Tilt the head up straightening the neck to expose
SECTION 6

the jugular vein.

4. Occlude the jugular vein by holding firm pressure at the thoracic inlet (clavicle region).
5. Insert the needle (not a catheter – they tend to coagulate) into the jugular vein (toward the head).
6. Collect the standard 450mL (weighs 474g). To speed up the process place the bag below the collection site.
7. Hold pressure at the collection site after removing the needle until bleeding stops.
8. An IV catheter can be placed to replace volume. Give 1L of crystalloids to replace volume, if time allows.
**Dogs have a large splenic blood reserve and recover faster than humans
after donating. Work performance does NOT deteriorate following donation if
the animal is given 24 hours to recover. The MPC donor will usually have to be
sedated. If two dogs are being used for a mission, pulling blood from a donor
on the battlefield leaves you with potentially two compromised animals for at
least 40 minutes. Donating in the field can only occur if the unit is stationary
long enough to pull blood and/or has the personnel to carry or recover the
second dog. Ensure handlers clip their dog’s jugular and cephalic vein access
sites every 2 weeks if a second dog is an option.
NOTE: When needed use dexmedetomidine, ketamine, midazolam combo
dose. Reverse dexmedetomidine’s effects with an equal volume of antisedan
IM after collection if necessary. Consider the tactical situation and use your
judgment when considering the sedation of a second dog.

Recipient:
Set up and administer in same fashion as for people.
1. Initiate an IV or IO .
2. Gather baseline vitals. (If in a controlled environment, collect a serum
separator and CBC blood vial.)
3. Do not give acetaminophen.
4. Give 50mg diphenhydramine IM if signs of reaction occur.
5. Administer antibiotics if aseptic collection from the donor is impossible.
6. Submit AAR to the RVET and/or Bn Vet Tech.

202 SECTION 6 MPC/CANINE TRAUMA & TACTICAL MEDICAL EMERGENCY PROTOCOLS

Canine Injection & IV Sites
IM INJECTION SITES:
Use a 20–22 gauge, 1-in. needle for IM and IV injections.
1. Thigh muscles: back of hind limb. Isolate the muscle belly mid-thigh and insert the needle at a 45-degree angle to
avoid hitting the sciatic nerve.
2. Back muscles: inject approximately three finger widths cranial to the wing of the ileum in the muscle on either side of
the spinous processes. Insert the needle at a 45-degree angle to avoid hitting bone.

IV SITES:
Use an 18-gauge IV catheter for MPC. Shave the area and clean before placing a catheter, if possible. Placement sites
listed below in order of ease and precedence.
1. Cephalic vein: located on the front of the forelimb between the elbow and carpus (wrist).
2. Lateral saphenous: vein on outside of the hind limb can be used if access to the cephalic vein is unsuccessful.
3. External jugular: located in jugular furrow on either side of the trachea. Pressure must be placed at the cardiac inlet
(near clavicle in people) to cause distension. Insert the catheter down away from the head. Insert blood collection
needle up toward the head.

IO SITES:
Easy IO 15mm or 25mm (either hand or power driven) work best. They cannot be used in the sternum of a dog. Humeral
head and proximal tibia are best, similar to human applications. Insert and set up the same as for humans. Placement
listed below in order of best flow.
1. Humerus: Place patient in lateral recumbency and kneel with spine against your legs. Firmly grasp the front limb at
the elbow to stabilize the limb. Drive the IO device into the flat, dorsolateral surface of the humeral head (top outside
surface) just behind the deltoid tuberosity (notch).
2. Tibia: Flat area on dorsomedial aspect of tibia (top inside shin near the knee joint) on the hind leg.

Jugular Cephalic Vein

SECTION 6
Humerus -
Lateral View

EZIO placement
caudal to deltoid
tuberosity

Deltoid
tuberosity

2025 RANGER MEDIC HANDBOOK 203

Canine Tactical Medical Emergencies
C1. Canine Heat Injury
DEFINITION: Hyperthermia as a result of heavy physical exertion and/or extended exposure to hot environments. Nor-
mal temperature range for a dog is 99.5°–102.5°F, most acclimated/conditioned dogs can work up to 106°F. Dogs not
affected by heat injury normalize their temperature within about 15 minutes.
S/Sx: Mild Heat Injury (Heat Stress): Excessive thirst, can still control panting (will stop panting when exposed to
stimulus such as a ball or treat for instance), discomfort associated with physical activity (wants to hide, go lay down).
Management Mild Heat Injury: Remove MPC from the heat source/stop exercise, cool with fans or move to an air-
conditioned area. Monitor for several hours by taking rectal temperature. Watch for progression by looking for changes
in mentation, blood in the urine, petechiae, weakness, collapse, signs of shock (rapid breathing, rapid heart rate, weak
pulse, pale membranes, anxiety or restlessness.
S/Sx Moderate Heat Injury (Heat Exhaustion): Signs of mild heat injury are present but include weakness anxiety and
UNCONTROLLED panting (pants through exposure to stimulus such as a ball or treat). CNS signs are not present.
Temp is often over 106°F.
MANAGEMENT: Moderate Heat Injury: Remove MPC from the heat source/stop exercise, cool with fans or move to
an air-conditioned area. Wet the fur with lukewarm water. Caution: Using high pressure to hose down animals can
cause stress and anxiety, compounding the problem. Wet towels, bottles, or low-pressure hosing can be used. Ice baths
and ice sheets may cool the animal too fast and can only be used if core temperature is monitored intensely. All cooling
must stop at 104°F. Once the animal’s body temperature is below 103°F provide supportive warming and dry the animal
to prevent rebound hypothermia. Give small, frequent drinks of cool water; do not give a full bowl – vomiting may occur.
If water is unavailable for soaking the fur of the animal, then apply copious amounts of isopropyl alcohol on the inguinal
and axillae areas. Intravenous fluid may be given to replace dehydration losses and help cool the animal. These can be
found at the back of this section on the MPC card (for instance, a 70lb dog can receive 560mL/hr of LRS for 2 hours if
he is assessed 5% dehydrated). IV fluids at room temperature will also help cool the animal. Monitor the temperature
SECTION 6

frequently and discontinue cooling once achieving 104°F; rebound hypothermia may result with rapid cooling.
S/Sx Severe Heat Injury (Heat Stroke): Includes many of the signs of moderate heat injury but the difference includes
varying degrees of CNS signs. CNS signs include changes in mentation and level of consciousness (from depressed
looking to coma), seizures, abnormal pupil size, blindness, head tremors and ataxia. Most temperatures are above 107°F,
but it has occurred as low as 105.8°F. Severe heat injuries are associated with a 50–64% mortality rate
Management Severe Heat Injury: Any animal considered a severe heat injury should be evacuated as an URGENT
patient when feasible. Treatment in severe heat injury is the same for a moderate heat injury (remove from heat source/
stop exercise, wet the fur with lukewarm water, etc.) but may require other measures to treat shock, dehydration,
protect the airway (if there is loss of consciousness), or treat seizures. Treat concurrent shock (e.g. weak femoral pulses,
MAP < 60, systolic BP < 90) with room temperature fluid therapy (1/4 shock dose of crystalloid fluids is approximately
700mL then reassess). Warm fluids are required after the animal’s temperature drops below 103oF. Again, in the ab-
sence of shock use the MPC card and replace dehydration loses with fluid therapy (i.e., at 560mL/hr for 2 hours if 5%
dehydrated). Intubation (use a bite block) in the apneic, unconscious patient may be necessary, especially while cooling
an unconscious patient down with running water. Monitor mental status closely and initiate the seizure protocol (10mg
of midazolam or diazepam IV, IO or intranasal as needed) if necessary. Discontinue cooling at 104°F. Begin drying and
warming at 103°F. Keep systolic BP > 90mmHg, MAP > 65mmHg, RR 8–10 bpm, EtCO2 25–60mmHg, SpO2 > 95% with
supplemental O2. If cerebral edema is suspected 30–60g of mannitol IV over 30 minutes with 15mg of dexamethasone
IV (or 900mg of methylprednisolone IV) once. If ventricular arrhythmias are recognized/present only treat them if animal
is hemodynamically unstable at 1.5–2.3mg/min (2mg/kg IV bolus, then 50–75mcg/kg/min) of lidocaine in a CRI/syringe
pump. Monitor blood glucose for hypoglycemia q4–6hr if possible (normal glucose is 60–110mg/dL). Supplement main-
tenance IV fluids with dextrose to 5% and with KCl at 20mEq/L routinely to maintain normoglycemia and normokalemia
(normal potassium is 3.7–5.8mmol/L). Vomiting and/or diarrhea often occurs (sometimes with gastrointestinal bleeding),
begin famotidine at 30mg IV or PO q12hr, 16mg of ondansetron IV or PO q12–24hr and 1g of sucralfate PO q8hr. No
food or water until vomiting has resolved. Antibiotic treatment may begin with cefazolin (Ancef) 600mg IV over 5 minutes
q8hr OR ertapenam 500mg IV q12hr if GI hemorrhage is present.
DISPOSITION: Evacuate to veterinary treatment facility for further treatment.
SPECIAL CONSIDERATIONS: Critical care monitoring from veterinary personnel required after initial resuscitation due
to sepsis and/or DIC.

204 SECTION 6 MPC/CANINE TRAUMA & TACTICAL MEDICAL EMERGENCY PROTOCOLS

C2. Canine Gastric Dilatation Volvulus (GDV)
DEFINITION: GDV is an urgent surgical condition in which the stomach becomes distended by excessive gas (dilata-
tion) and can then twist (volvulus), cutting off blood supply returning to the heart. All Ranger MPCs have a surgery to
prevent the volvulus; however, dilatation may still occur. This is an emergency condition resulting in profound shock,
leading to death.

S/Sx: Abdominal distention, nonproductive vomiting/retching, abdominal pain, signs of agitation/discomfort, SHOCK,
may lead to DIC.

MANAGEMENT:
1. Treat for shock first: Insert a large bore catheter in each CEPHALIC vein and start resuscitative fluid therapy. Treat to
a systolic BP above 90mmHg; does not require hypotensive resuscitation.
2. Decompress the stomach: Usually you need to lay the dog in left lateral recumbency (with the right side up). Ana-
tomically in GDV, the big fundus of the stomach will most often be located on the right side. Auscultate the right side
(should sound like a basketball when your finger flicks or “pings” it) and palpate for gas distention, this helps identify
the optimal location for trochar placement. Make sure you insert where the ping is loudest, a dull thud may indicate
the presence of the spleen. Do not insert the needle near a thud. Hold pressure underneath the stomach on the
downside, pushing the stomach upward against the body wall. Insert a 14G, 3-in. catheter two finger widths past the
last rib at the highest point on the side. You must go through the abdominal wall and stomach wall, meaning it must
be a quick, forceful movement. Remove the metal stylet when in the stomach, and air should escape. If not, remove
the catheter and try again.
*To increase speed of air evacuation place a 60mL syringe with 3-way stopcock to the catheter to facilitate faster
aspiration.
NOTE: It is common for the spleen to block access to the stomach. If blood is seen in the catheter, remove it immedi-
ately, then try again in a different location.

DISPOSITION: Evacuate immediately to veterinary care even if stable. Surgical correction is required.

SECTION 6
SPECIAL CONSIDERATIONS: MEDEVAC at a low altitude to reduce further expansion of air in the stomach. Dilatation
of the stomach may recur, be prepared to decompress again.

C3. Canine Altitude Sickness And Pulmonary Edema

To date no Ranger MPC has had a recognized issue with altitude in training or while deployed.

DEFINITION: Hypoxia and/or pulmonary edema usually occurring at altitude above 8,000 ft. Clinical signs uncommon
in dogs, but possibility increases with greater activity levels.

S/Sx: Reduced appetite, listlessness, decreased coordination, dark tongue coloration, cough, dyspnea.

MANAGEMENT:
1. Descend from altitude.
2. Provide flow-by supplemental oxygen at 5L/min if available (place oxygen tubing near the nose and secure on the
muzzle; or make an oxygen mask with a cut plastic bottle running the oxygen tubing through the bottom). 3. Admin-
ister 3–4mL (0.5mg/kg) Dexamethasone SP (4mg/mL) IV or IM.

DISPOSITION: Evacuate to veterinary care if nonresponsive to treatment.

SPECIAL CONSIDERATIONS: PROPHYLAXIS: Acetazolamide (Diamox) 250mg q12hr orally beginning 24 hours prior
to ascent, and continue 48 hours after reaching maximum altitude. If using 500mg sustained release tablets, give one
500mg tablet q24hr. Prophylaxis is not needed for K9s if providers do not prescribe medication for Rangers.

C4. Canine Seizure Management

DEFINITION: Emergency seizure treatment required for status epilepticus or seizures secondary to other injuries. Status
epilepticus is a seizure caused by abnormal electrical activity in the brain that is unprovoked. Provoked seizures may be
caused by head trauma, heat stroke, toxin ingestion, etc.

S/Sx: Status epilepticus is seizures lasting more than 5 minutes or 2 or more seizures occurring without recovery (return
to consciousness) in between.

2025 RANGER MEDIC HANDBOOK 205

MANAGEMENT:
1. Gain IV access.
2. Treat underlying cause, if possible.
3. Monitor body temperature; treat hyperthermia if temperature rises above 104°F.
4. Administer an anti-convulsant– diazepam (Valium) 15–30mg (0.5–1mg/kg) IV or 30–60mg (1–2mg/kg) per rectum (2–3
minutes onset) OR midazolam (Versed) 7.5mg (0.25mg/kg) IV/IM. Levetiracetam (Keppra) 30–60mg/kg (600–900mg)
IV for status epilepticus or acute repetitive seizures. For refractory epilepsy: regular tablets 20mg/kg (600mg – use
of 750mg tab is safe) PO q8hr, extended-release tablets 30mg/kg (900mg – use of 1,000mg tab is safe) PO q12h.
DISPOSITION: Evacuate to veterinary care as soon as possible. Requires critical care monitoring.
SPECIAL CONSIDERATIONS: Seizures may recur. Contact a veterinarian for guidance if one is not located in your location.

C5. Canine Toxicities – Explosives, Others

Training Aid/Agent Toxicosis: Our MPC are exposed to certain small quantities of explosives known as training aids
and may accidently ingest them which could lead to toxicosis in the animal.
1. Nitrate/nitroglycerin-based explosives (C4, TNT, water gel, dynamite, RDX, det cord):
Clinical signs – Ingestion may result in hypersalivation, severe CNS abnormalities (ataxia, incoordination, seizures,
tremors), gastrointestinal irritation (nausea, vomiting), and methemoglobinemia (signs of methemoglobinemia include:
cyanosis, weakness, syncope = loss of consciousness, respiratory distress). Onset of signs usually occurs between
3 and 12 hours after ingestion.
2. Smokeless powder explosive
Clinical signs – Ingestion may result in hypotension, CNS depression (which manifests as ataxia, depressed menta-
tion, incoordination), and methemoglobinemia (cyanosis, weakness, syncope, respiratory distress).
Treatment – Monitor blood pressure and fluid resuscitate as needed. Close monitoring of CBC’s necessary for po-
tential methemoglobinemia.
3. Potassium and sodium chlorate explosives
Clinical signs – Ingestion may also result in methemoglobinemia (cyanosis, weakness, syncope, and respiratory dis-
tress), CNS abnormalities (ataxia, incoordination, and depressed mentation), gastrointestinal irritation (nausea, vomiting,
SECTION 6

abdominal cramping and pain, hemorrhagic diarrhea with melena or hematochezia), hematuria, hemoglobinuria, and
renal and liver failure.
Treatment of Training Aid Toxicosis
1. If ingestion occurred ≤ 4 hours before presentation and the MPC is conscious and has normal CNS responses,
induce vomiting.
a. Apomorphine is first choice. ¼ (6mg) tablet in the conjunctival sac or 0.03mg/kg IV.
b. Hydromorphone is second choice 3mg IM
c. 3% hydrogen peroxide (household formula is 3%) Maximum of 30mL can be given orally as the last option. This
method will create esophageal erosion.
d. Don’t try to make an MPC gag manually
2. If ingestion occurred > 4 hours before presentation, or if the dog has abnormal mentation or is unconscious or seiz-
ing, do not induce vomiting.
a. 45g of activated charcoal with sorbitol as an initial dose. Sorbitol is a laxative. This is about 30mL of Toxiban (w/
sorbitol). May require sedation with cuffed ET tube, orogastric intubation and a funnel to get the slurry in.
b. A second dose 4–6 hours later without sorbitol
c. If seizures are present give 10mg of midazolam IV or IN or 10mg of diazepam IV, IN or per rectum. Alternatively
600–900mg of levetiracetam (Keppra) IV can be given.
d. If methemoglobinemia is present (blue tinge to unpigmented skin, brown blood, brown urine, tachypnea, tachycardia, leth-
argy, recumbence) 30–60mg of methylene blue (MB) 1% (3–6mL) can be given as a slow bolus IV. If respiratory distress per-
sists then repeat dose once or twice. MB will cause a Heinz body anemia so CBC must be monitored every 8 hours if used.
Rat Poison: Is a vitamin K antagonist so it interferes with the production of coagulation proteins. This eventually inhibits
hemostasis.
Clinical signs – Some form of hemorrhage is often seen such as bruising of skin and mucous membranes, especially
the axillae and inguinal regions. Blood may be seen in the urine or coming from the nose. It can also cause weakness,
a painful abdomen, pale mucus membranes, coughing, wheezing, and (rarely) petechiae. Dyspnea can occur from in-
trathoracic or intrapulmonary bleeding. Collapse is possible if pericardial hemorrhage occurs. Pale mucous membranes
will occur if anemia is severe.
Treatment – 1.5–2.5mg/kg (45–75mg) of vitamin K1 (phytonadione) supplementation BID PO in a fatty meal for up to
4 weeks may be required. Supplied as 25–50mg tablets or 10mg/mL injection that must be given IM or SC. Have a
veterinarian check PT time 72 hours after last dose to know when to stop. Canine FFP or whole blood may be required
to replace clotting factors and/or RBCs.

206 SECTION 6 MPC/CANINE TRAUMA & TACTICAL MEDICAL EMERGENCY PROTOCOLS

Antifreeze: Minimum lethal dose of undiluted ethylene glycol (what makes up most antifreeze) in an MPC is about 132mL.
Clinical signs – within 1 hour of exposure vomiting, polydipsia, polyuria, and neurologic signs such as ataxia, stupor,
and knuckling can occur. Oliguric (abnormally small amounts of urine). Renal failure occurs between 36 and 72 hours.
These animals are lethargic, dehydrated, vomit, can have diarrhea, salivate excessively, sometimes have oral ulcers,
breathe fast, can seizure, or present in a coma.
Treatment – Generally requires veterinary care facility. If unavailable: Induce vomiting if within 2 hours of ingestion. Acti-
vated charcoal is ineffective. If the animal is still producing urine and not already oliguric or anuric, then 4-methypryrazole
(fomepizole – costs $1,000) can be given IV at 20mg/kg (600mg) initially then 15mg/kg (940mg) 12, 24, and 36 hours
later to block metabolism of ethylene glycol by alcohol dehydrogenase. 5.5mL/kg (165mL) of 20% ethanol (e.g., 40 proof
“everclear”) in IV fluids can be given over 6 hours for five treatments and then over 8 hours for 4 more treatments. It com-
petitively inhibits ethylene glycol from getting broken down by the enzyme (alcohol dehydrogenase). The metabolites
are the problem. Metabolic acidosis likely needs monitored and treated with NaHCO3 in fluids. Use 0.3 – (0.5 × 30kg) ×
(24 – plasma HCO3) gives you the mEq of bicarbonate to administer. Give half this dose IV slowly and monitor plasma
bicarbonate every 4 hours. Fluid therapy to replace dehydration (% dehydrated × bwt in kg × 0.6, so 5% dehydrated
× 30kg × 0.6 = 0.9L) can be administered over 2–4 hours while simultaneously monitoring urine output (normal urine
output is 30–60mL/hr). If urine output is less than 15mL/hr the MPC is oliguric. Oliguria and anuria in dogs with ethylene
glycol toxicity have a poor prognosis. Anuric animals should only have small amounts of fluid given to replace loses from
respiration, defecation etc. If the animal is not anuric, continue kidney diuresis at maintenance rates of 60mL/kg/day
(75mL/hr) with LR or Plasma-Lyte, continuing to monitor urine output.

C6. Canine CBRNE

Triage: Take care of yourself and other Rangers first. Move affected Soldiers first. Use the following guide when man-
power can be spared for an MPC.

M4A2R2C2H2 In a CBRNE environment terminate the exposure first. Move out of the contaminated area. Dogs do not
have masks so inhalation is a major concern. Consider what is killing the animal and treat that first. Use the algorithm

SECTION 6
when not sure.

M1ove the MPC out of the affected area (terminate the exposure). M2uzzle the MPC. M3assive hemorrhage (treat).
M4edicate (consider sedation and pain Medication, again – not needed if there is a loss of consciousness).

A1ntidote (which antidotes depend on the signs, symptoms and knowledge of the agent(s) being used against you via
M8 paper or JCAD reading) A2irway (check that it is clear – choking agents need intubated early on).

R1apid Decontamination There is not really a spot decon for the dog. A full decontamination can occur while awaiting
evacuation to the decontamination site. Full decontamination should occur again at the designated decon site – see at
the end of this section. R2espirations If there is no physical wound, wheezing or coughing could be a choking agent or
nerve agent; hypoventilation could be from an opioid agent; apnea or dyspnea could be from cyanide; tracheal/pulmo-
nary rales (clicking) could be from mustard exposure.

C1irculation treat hypovolemia as before C2ountermeasures (oxygen, ventilation support and albuterol may be required
for Lewisite/Mustard or choking agents).

H1ypothermia and H2ead Trauma: Same as before.

Nerve agent signs: DUMBBBELLSS (Diaphoresis is sweating – dogs do not sweat!, Urination, Miosis – pinpoint
pupils, Bronchospasm – tightness of chest cannot be conveyed to you by the dog but you may hear wheezing when
auscultating the chest, Bronchorrhea – excess watery discharge from lungs leads to productive cough, Bradycardia
(Normal dog 70–120bpm) Emesis – vomiting, Lacrimation, Loose stool, Salivation, Spasms/Seizures. Remember
that miosis is not an early sign if it is absorbed dermally.

Miosis of R eye. Nerve

Example of a
agent would cause
Seizure in a Dog
miosis in both

2025 RANGER MEDIC HANDBOOK 207

Nerve Agent Tx: You have minutes to hours depending on what agent, where the animal absorbs it (inhaled vs ab-
sorbed) and how much was absorbed.

Antidote: Mild signs 1–2 ATNAA (2.1–4.2mg atropine and 600 to 1,200mg pralidoxime chloride), 1 CANA (10mg diaz-
epam), Severe signs (i.e., respiratory coughing and seizing) give 3–4 ATNAAs (6.3 – 8.4mg atropine and 1,800–2,400mg
pralidoxime chloride), 2 CANAs (20mg diazepam). Scopolamine at 0.03mg/kg (about 0.9mg for an MPC) PO q12–24hr
can be used as an alternative to atropine. Scopolamine acts as an antimuscarinic like atropine but may have better
CNS effects.

Decontaminate: 4% chlorhexidine and water (process described at the end of this section). Do not use RSDL, it may
react when bound with a chemical agent to bleach if bleach is used at the decontamination site. RSDL also only works
in short haired areas or the hairless areas of the abdomen of a dog.

Treat to ease of breathing or cessation of secretions (do not worry about fixing miosis or muscle fasciculation initially,
this response is usually delayed sometimes by months)!

Long-term: Atropine (0.4mg/mL) × 50mL in 250mL NaCl (20mg/300mL). Drip rate is 300mL/hr. When the pupils finally
begin to dilate and/or heart rate normalizes reduce drip rate to 30–60mL/hr and continue to monitor.

PREVENTION: No mask. Pyridostigmine bromide 0.5mg/kg (15mg) PO q8hr (half the human dose).

BZ Agent Signs: Almost the opposite of nerve agent. BZ agent will cause mydriasis (dilated pupils), dry mucus mem-
branes, tachycardia, hyperthermia, hypertension, warm skin, and seizures are possible.

BZ Agent Tx: Physostigmine at 0.025–0.5mg/kg (7–15mg) given slowly IV or IM. Do NOT sedate patient. Remove from
the exposure.
Decontaminate: Route of absorption is by inhalation only, removing from the source is all that is necessary.

Blister Agent Signs: Can be immediately painful (Lewisite) or delayed (Sulfur mustard). In dogs the hair stands up (pilo-
erection). Blisters do NOT occur. The skin becomes moist and hyperemic instead. Sloughing can occur later. Lewisite –
SECTION 6

immediate pain, restlessness vomiting, bloody diarrhea, shock, weakness, anemia, pulmonary edema, blepharospasm
(squinting). HD and HN (Mustard) – asymptomatic latent period for a few hours then: Skin redness/ulcers, respiratory –
cough, nasal discharge, difficult breathing, tracheal and pulmonary rales (clicking), GI – oral ulceration, abdominal pain,
vomiting, bloody diarrhea, systemic – excitation, salivation, bradycardia, decreased WBC and platelet count, shock.

Blister Agent (Lewisite) Tx: Dimercaprol (BAL) 2.5–5mg/kg given IM q4hr for 2 days, topical BAL ointment as needed.
Use a chelating agent: 1) CaEDTA at 1% (10mg/mL) in 5% Dextrose at 27.5mg/kg q6hr for 2 to 5 days or 2) Sodium
Thiosulfate at 150mg/kg (4.5g). Adding 18mL of 25% (250mg/mL) Na Thiosulfate into 250mL of NaCl and bolus that
over 10min gives the patient 4.5g.

Blister Agent (Lewisite and Sulfur Mustard) Tx: Provide topical ocular analgesia, early intubation and use of ventilator/
PEEP and CPAP machine. Albuterol at 0.05mg/kg PO, antiemetic and antibiotics when secondary lung infections occur.
Control of bronchospasm may require more than just albuterol, if steroid is used be aware that secondary lung infection
risk is increased. Dexamethasone (0.025mg/kg q24 hours PO so about a 0.5mg – 1mg tablet) or prednisolone (1mg/kg
q12hr for up to a week PO then 0.5mg/kg for another week)

Decontaminate: RAPID Decon (within 2 minutes) is vital! 4% chlorhexidine (process described at the end of this sec-
tion). Do not use RSDL, it may react when bound with a chemical agent to bleach if bleach is used at the decontamina-
tion site. RSDL also only works in short haired areas or the hairless areas of the abdomen of a dog. Flush the eyes with
large amounts of water. Eye ointment for pain control only after thorough decon and examination. Steroid/antibiotic
combination eye ointment works best for saving the eye.

Cyanide Signs: Generally not used as a munition due to insufficient amounts delivered and the nature of the chemical.
Exposure more likely through ingestion poisoning or possibly by inhalation within enclosed spaces (tunnels/gas cham-
bers). Inhalation: effects begin within 15 seconds, death within 6–8 minutes of a lethal dose.

Ingestion: Upset stomach for 7 minutes followed by increased depth and rate of breathing. Within 15 minutes the
animal will likely lose consciousness. Convulsions/seizures, apnea, then the heart stops within 30 minutes. The loss of
consciousness and seizures shortly after inhalation is similar to nerve agent inhalation; however, the cyanide casualty is
not cyanotic (blue), pupil size is normal or dilated, and there are no secretions and no muscle fasciculation.

208 SECTION 6 MPC/CANINE TRAUMA & TACTICAL MEDICAL EMERGENCY PROTOCOLS

Cyanide Tx: Hydroxocobalamin (vitamin B12a) complexes with cyanide to form cyanocobalamin (vitamin B12). Requires
IV access. 150mg/kg (4500mg or 1 cyanokit). It must be reconstituted/shaken for 30 seconds. More effective when com-
bined with sodium thiosulfate 12.5g IV over 30 minutes. Second treatment option requires a two-step process: 1) amyl
nitrite (crush an ampule and find a way to get the dog to inhale) or sodium nitrite at 300mg IV or IO over 5–10 minutes.
These agents create a methemoglobinemia. The ferric ion (Fe3+) in methemoglobin has a higher affinity for cyanide than
the cytochrome oxidase molecule in the mitochondria. 2) sodium thiosulfate (12.5g over 30 minutes) which is a sulfur
donor. The sulfur is used as a substrate to eventually convert cyanide to thiocyanate. Remember, the antidotes have to
be given slowly, nitrite can cause hypotension and too much will overproduce methemoglobin causing a decrease in
oxygen carrying capability. Administration of 100% O2 is significantly helpful despite the fact that the poison prevents
the use of oxygen in cellular respiration. Mechanical ventilation may be needed, circulatory support with crystalloid fluid
administration, vasopressors if fluid administration does not correct hypovolemia. Dopamine at 10mcg/kg/min is prob-
ably ideal as it is a less potent inotrope than epinephrine or dobutamine and less vasoconstricting than norepinephrine.

Decontamination of Cyanide: Self-protection and then remove animal from the exposure source to fresh air. Dermal
absorption does not occur and the substance is highly volatile. Decontamination is generally unnecessary unless liquid
contamination has occurred to the coat. If this occurs, wash with water alone or water and soap.

Opiate Toxicity Signs: May occur if the animal is exposed to heroin or fentanyl/carfentanyl when clearing a building that
turns out to be a drug facility or has a drug cache. Could be a weaponized agent someday. Occurs within 1–2 minutes
by inhalation, 1–2 hours by ingestion. Altered mental status, animal may look dizzy or lethargic and end up in a coma,
hypersalivation, hyperthermia, ataxia, bradycardia (normal HR 70–120), hypotension (normal systolic BP > 90mmHg,
MAP > 65mmHg), hypoventilation, neck rigidity, and seizures.

Opiate Toxicity Tx: Naloxone is a pure opiate antagonist. It reverses most of the effects of high-dose opiate administra-
tion to include respiratory and CNS depression. Dose in dogs is 0.04mg/kg to 0.1mg/kg (or about 1.2mg to 3mg for
an MPC) IV, IN (atomizer), IM, SQ recommendation is to give a ¼ of the max dose and repeat every three minutes until
desired affect is achieved (half-life is about 1 hour in humans). Naltrexone 2–5mg/kg (60–150mg for an MPC) PO q24hr
may be used when injectable naloxone is not available. Nalmefene 0.03mg/kg (0.9mg) IV has a much longer plasma

SECTION 6
half-life (11 hours) than naloxone. It is no longer available in the United States. It is/was used as an opiate reversing agent
and to manage human alcohol dependence and addictive behaviors.

Choking Agent Signs: Ammonia, chlorine, phosgene, HC smoke, PFIB (perfluoroisobutylene), nitrogen oxide and phos-
gene. Ammonia (as well as sulfur mustard) work on the central airways and burn the tissue. This can cause laryngo-
spasm and eventual collapse. Sulfur mustard will block airways when pseudomembranes slough off within the airway.
The others are all peripheral acting agents except for chlorine which affects the patient peripherally and centrally. PFIB
is released when Teflon burns (lines many military vehicles). Nitrogen oxide is released when gunpowder burns. Central
agents tend to have immediate effects that include laryngospasm, sneezing that is painful, hoarseness to their bark,
noise on exhalation, coughing and wheezing while breathing. Peripherally acting agents can have a latent period of 30
minutes to 72 hours. Major effects do not occur until hours later. If major signs show in less than 4 hours the prognosis is
lower. Shortness of breath from pulmonary edema occurs. As damage progresses, this dyspnea becomes more severe
and coughing develops with a clear foamy sputum. Phosgene patients can lose as much as 1L of serum into their lungs
from protein denaturation.
Choking Agent Tx: Terminate the exposure. No mask for a dog so the animal must be moved from the contaminated
environment. Establishing an airway in an animal that has stridor is important but may require sedation and the use
of a bite block. Airway/trachea may require frequent suction with a squib to keep it clear. Ensure normovolemia and
treat with crystalloid fluids if the animal seems dehydrated. 100% oxygen if needed. Enforce rest. Reserve antibiotics
for confirmed secondary infections when possible. Steroid or albuterol therapy may be necessary for bronchospasm
(albuterol at 0.05mg/kg PO, dexamethasone 0.025mg/kg q24hr PO; so about a 0.5–1mg tablet or prednisolone 1mg/kg
q12hr for up to a week PO, then 0.5mg/kg for another week). Positive airway pressure helps oxygen delivery in the face
of pulmonary edema but can decrease thoracic venous return and contribute to hypotension. Ensure blood pressure
which may require fluid therapy. If a ventilator can be used, set as suggested below. Some BVMs have a PEEP setting.

2025 RANGER MEDIC HANDBOOK 209

Table 7: Mechanical Ventilator Settings & Key Parameters
PARAMETER NORMAL LUNGS ABNORMAL LUNGS
FiO2 100%, then reduce to < 60% 100%, then reduce to < 60%
Tidal Volume (V T ) 5–15mL/kg 5–15mL/kg
Breathing Rate (f) 8–20bpm 8–20bpm
Minute Ventilation (VE) 150–250mL/kg/min 150–250mL/kg/min
Peak Inspiratory Pressure (PIP) 10–20cmH2O 15–25cmH2O
Positive End-Expiratory Pressure (PEEP) 0–2cmH2O 2–8cmH2O
Trigger Sensitivity –2cmH2O or 2L/min –2cmH2O or 2L/min
Inspiratory:Expiratory Ratio (I:E) 1:2 1:2
Inspiratory Time ≈ 1 sec ≈ 1 sec

Decontamination of Choking Agents: Not absorbed dermally, decontamination is only necessary to remove fluid, if
present from the coat/skin of the animal and prevent vapor exposure from that source.

Biological Agents: Among likely biowarfare agents, MPCs may be susceptible to plague (Yersinia pestis), tularemia,
brucellosis, Q-fever, and anthrax. Dogs are believed to be less susceptible than humans to all of these diseases.

PREVENTION: Doxycycline (6mg/kg or about 180mg/d). Doxycycline is generally considered efficacious against all
biowarfare agents of concern, and the prophylactic dose may provide additional protection for MPCs. Ciprofloxacin
(20–25mg/kg or about 600–750mg) q12hr may also be used.
SECTION 6

Decontamination: Soap and water. MPC equipment should be decontaminated with 5% hypochlorite solution.

Nuclear and Radiologic Agents: Dogs exposed to nuclear weapons or radioactive material will have blast injuries,
thermal and radiation injuries. Acute Radiation injuries will include those to the:
1. Bone marrow/hematopoietic system (0.3 and 10Gy). Survival rates decrease as the dose increases. Animals die from
infection or hemorrhage (no platelets or WBCs).
2. GI tract (6 to greater than 10Gy). Survival is unlikely, changes to bone marrow and GI tract are destructive and gener-
ally irreversible. Death from infection, dehydration, and electrolyte imbalance generally within 2 weeks.
3. Neurologic and cardiovascular system (20 to greater than 50Gy). Death from circulatory collapse and increased pres-
sure from edema, vasculitis and meningitis inside the cranial vault. Death can occur within 3 days.

Burns will occur even without acute radiation injuries. Blistering, redness, itching, and ulceration occur. Healing occurs
but large doses can cause hair loss, fibrosis, increased or decreased skin pigmentation.

Management and Treatment of Nuclear and Radiologic Injury: Remove from the source, M3ARCH for major trauma,
decontaminate, then monitor airway, circulation, and breathing (check blood pressure, electrolyte status and urine out-
put for radiation injuries) IV fluids may be necessary, anti-emetics and analgesia. Long term CBC count for lymphocytes
or possible transfusion of dog blood when necessary. Dose can be estimated in humans based on lymphocyte count
over the first 8–12 hours after exposure (taken every 2–3 hours or after every 6 hours for the next 2 days. Treat vomiting
and track time of onset for vomiting, diarrhea, and itching, reddening, and blistering of the skin. It may be possible to
use an Andrews Lymphocyte Nomogram to extrapolate dose/prognosis from the human chart. Radioactive iodine is
associated with nuclear energy, Medical diagnostic and treatment procedures, and natural gas production. In a nuclear
weapon detonation, it is produced as a byproduct from the fission reaction of uranium. It is released in the fallout and is
a hazard to those that survive the initial blast. In the body the thyroid will take up radioiodine along with normal iodine.
Taking potassium iodide (KI) fills up the thyroid with normal iodine preventing the damage it would receive from radioac-
tive iodine. For MPCs, KI should be administered within 4 hours before or after the exposure. KI is generally issued in
130mg tablets. Administer half a tablet (65mg) once a day to a MPC by mouth until told to discontinue. Evacuate when
possible and safe to do so. Protect yourself and the dog from KI and other radionuclides in the fallout by remaining
inside and minimizing the opening of doors and windows, turning off fans, air conditioners, and forced-air heating units
that bring fresh air in from the outside Humans (and animals) should avoid fruits, vegetables, and milk from the area until
shown to be free of contamination.

210 SECTION 6 MPC/CANINE TRAUMA & TACTICAL MEDICAL EMERGENCY PROTOCOLS

Interesting facts: Hiroshima was a 15KT bomb. Ninety percent of people within 500 meters of ground zero died. At 1 mile
from the center, two-thirds were casualties and one-third died. At 1.2 miles, half were casualties and 10% died. At 2.4
miles, 10% were casualties. Cumulative death rates rose dramatically in the first 2 weeks, with 90% of them within the
first 3 weeks. Time shielding and distance from the center mattered for survival. Those in solid concrete buildings had
better chances of survival than those in wooden building. Large numbers of deaths were caused by houses collapsing.
Canine Chemical Protective Equipment: Currently there is no issued equipment for MPCs. Protective gear is limited
to booties and eye protection (RexSpecs) if the unit purchases this itself. The outer bag from an MRE, extra butyl-rubber
protective gloves or JSLIST gloves, tape, or canvas over wrap may be used in place of booties. SERPACWA (skin expo-
sure reduction paste against chemical warfare agent) may be used in nonhaired areas. There is no chemical protective
suit or mask for a dog at this time. Due to the inhaled risk of most chemical agents, the use of a MPC in an environment
known to have been exposed to a chemical warfare agent is not recommended. Any handler team inadvertently exposed
to a chemical environment may use MRE bags/gloves/booties/eye protection and SERPACWA for the animal in an at-
tempt to mitigate contamination while evacuating.
Generalized Canine Decontamination: CBRNE-contaminated animals will only be handled by individuals in MOPP4
and may require plastic aprons to prevent the suit from getting wet. An alert MPC will need to be sedated. Immediate
decontamination can occur as soon as the animal can be removed from the contaminated environment, even before
evacuation. This would be done to mitigate the rapid effects of nerve and mustard agent when there is any delay in
transport to a larger patient decontamination site. Another thorough decontamination then occurs at the patient de-
contamination site.

SECTION 6

2025 RANGER MEDIC HANDBOOK 211

MPC Immediate Decontamination: METT-TC will determine when these supplies are carried. Only one 500mL bottle of
water is needed. A chlorhexidine surgical scrub brush, a small bottle of 4% chlorhexidine scrub and a microfiber towel
are required. If mustard is suspected, flush the eyes with bottled water. Remove and discard the animal’s vest. Four
percent chlorhexidine is used and suds are generated over the entire body of the animal using the surgical scrub brush
with minimal water from the 500mL bottle. It is not a bath, no rinse occurs. The suds are worked directly onto the dry
hair of the rest of the animal’s coat. The soft plastic teeth side of the brush does not abrade the skin and helps work the
suds into the coat. RSDL is not required and may react with bleach needed later. After 5 minutes the chlorhexidine suds
are wiped off the coat with a dry microfiber towel. Remember it only requires a tsp of mustard agent (to cover 20% of the
body surface area) to be lethal for a human. That amount can be absorbed in less than 2 minutes.
MPC Patient Thorough Decontamination: When the MPC patient is evacuated to the patient decontamination site, the
same decontamination process will occur as accomplished during immediate decontamination. This is done to remove
anything that was missed. As the animal is brought in to the warm zone two extra handlers (ideally the battalion animal
technician and another dog handler) dressed in MOPP4 and plastic aprons will need to be available. Again, alert animals
will be sedated to keep them from licking themselves and soaking the JSLIST suit of the decon team. One individual will
hold the dog, protecting the airway while the other decontaminates the animal as described above in initial decontamina-
tion. After the chlorhexidine has set for the required five minutes, and the animal is sufficiently sedated, remove the collar,
intubate if necessary, rinse off (use the 0.5% bleach water if that is all that is available) if necessary (determine via JCAD)
and moved through the shuffle pit. A half-gallon of 5% (house hold) bleach goes in a 5 gallon bucket, then fill the bucket
to the top with clean water to reach 0.5% bleach solution. Once cleared by JCAD (with or without the bleach wash) the
animal is handed over the Hot Line to two other individuals in the cold zone (ideally the regimental veterinarian and the
regimental animal tech). A clean chain/biothane leash with a chain/biothane collar (from the cold side) will be applied in
the cold zone. The animal will then be checked for residual agent using the Joint Chemical Agent Detector Monitor and
moved to the triage and treatment area. After treatment the animal should be rinsed with plain water to remove any excess
chlorhexidine or bleach to prevent a skin reaction. The contaminated handler would simultaneously proceed through
the ambulatory patient decontamination area but likely be decontaminated by others. Care must be taken such that the
animal, in its excitement, does not soak and contaminate the chemical protective suits of the handlers in the warm zone.
SECTION 6

212 SECTION 6 MPC/CANINE TRAUMA & TACTICAL MEDICAL EMERGENCY PROTOCOLS

MPC Reference Card
Below is a quick reference of the most commonly used drugs and resuscitative fluid calculations for MPC triage and POI
care. This reference is precalculated for the average, 31.8kg MPC and is a condensed version of the actual MPC Reference
Card each handler carries for their specific MPC.

MWD Name: CLYDE Weight: 70.0 lb 31.8 kg

Gender MI Date Card Created: 27 JAN 2019 Normal Values
Breed Belgian Malinois ET Tube Size: 10mm Temp: 99–102.5°F
DOB 12-Jun-11 Pulse: 70–120 bpm
Anticipation/Excitement/Pain: 100–160 bpm
Microchip number Exercising: Up to 300bpm (sled dogs)
Permanent duty site FT. BENN, GA Shock: Usually 160–200bpm
Deployment status CAT I Resp: 16–30 bpm (resting) Usually panting
after exercise or hot outside temp
Last FAVN (date and pass/fail) JAN 2019: PASS
BP: 110–160 Sys/60–90 Dia/85–120
Most recent vaccinations: Rabies: 25 JAN 19 DA2PP: 25 JAN 19 Lepto: 25 JAN 19 MAP Resusitation End Point MAP > 65
Gastropexied? YES Shock Index: HR/SBP < 1.0
Previous heat injury? NONE PCV: 35–45%
TP: 6.5–8g/dL Acute blood loss often has
Master problem list
normal PCV and low TP
Diet (type and amount) Lactate < 2.5mmol/L
Current medications None
Emergency Drug Dosage Units MWD’s dose Units Route
Atropine (bradycardia, bronchoconstriction)---------------------> 0.04 mg/kg 1.3 mg IV or IM
Atropine (organophosphate, carbamate toxicity)---------------> 0.2-0.5 mg/kg 6.4 mg 1/4 dose IV, rest IM or SC
Epinephrine (Hrt stopped, unresp CPR, shock from allerg rxn) 0.01-0.02 mg/kg 0.3 mg IV, IT, IM or SC
Levetriacetam/Keppra seizures (Can use diazepam/midazolam) 30mg/kg IV / 20 mg/kg PO 954.5 mg IV 636.4 mg PO q 8hr
Diphenhydramine (Benadryl) Allergic Reactions-----------> 4 mg/kg 127.3 mg IM
Dexamethasone SP (Allergic Reactions)--------------------------> 0.5 mg/kg 15.9 mg IM or SC
Tranexamic Acid (TXA) (Massive Hemorrhage) 15 mg/kg 477.3 mg IV intitially, then same amt over 24hrs
(Abbreviations): IV= intravenous, IM= intramuscular, SC= subcutaneous, IT= intratracheal, PO=oral
Emergency Fluid Considerations L/per day mL/per hour
Maintenance fluid needs (60mL/kg/day) 1.9 L 79.5
1/4 Shock dose IV Fluids (crystalloid - Plasmalyte, LRS, etc) 700 mL - Give this as fast as possible, then re-assess heart rate, mm, pulse, etc
Full Shock dose of IV fluids (crystalloid - Plasmalyte, LRS, etc) 2864 mL

SECTION 6
Hetastarch dose of IV fluids 159 mL Max Dose/24hr: 636 mL
MWD Name: CLYDE Weight: 70.0 lb 31.8 kg
Sedation Mild (Losing consciousness, bleeding, weaker pulse, still
moving but doesn't hold still & needs treatment) Dosage Units MWD’s dose Units Route mL
Midazolam OR diazepam (if 5mg/mL) 0.3 mg/kg 9.5 mg IM, SC, IV 1.909090909
Ketamine (if 100mg/mL) 5 mg/kg 159.1 mg IM, SC, IV 1.590909091
Sedation Deep (Alert animal, normal pulse that needs treated) Dosage Units MWD’s dose Units Route mL
Dexmedetomide (dose range is 0.001-0.020mg/kg) 0.008 mg/kg 0.3 mg IM, SC 0.509090909
Midazolam OR diazepam (if 5mg/mL)--------------------> 0.3 mg/kg 9.5 mg IM, SC, IV 1.909090909
Ketamine (if 100mg/mL)---------------------------------------> 5 mg/kg 159.1 mg IM, SC, IV 1.590909091
Sedation (For alert animal, normal pulse when no ket/mid available) Dosage Units MWD’s dose Units If 0.5mg/mL Units/Route
Dexmedetomide (dose range is 0.001–0.020mg/kg) 0.013 mg/kg 0.4 mg 0.8 mL IM
Analgesia (pain mgmt) NO Advil (ibuprofen) or Tylenol! Dosage Units MWD’s dose Units Route mL
2% Lidocaine Max Dose (local/skin/nn blocks for lacs) 5 min 5 mg/kg 159.1 mg SC, IM 7.95454545
Bupivacaine (0.5% Marcaine) Max Dose (nerve blocks) 30 min 2 mg/kg 63.6 mg SC, IM 12.7272727
Rimadyl (carprofen/NSAID)-----------------------------------> 2.2 mg/kg 70.0 mg PO, SC Every 24 hr
Mobic (meloxicam/NSAID) Don’t combine w/other NSAIDs--> 0.1 mg/kg 3.2 mg PO, Every 24 hr
Hydromorphone -------------------------------------------------------> 0.1 mg/kg 3.2 mg IV, IM Every 2–6 hr
Naloxone (opioid overdose) 0.04–0.16 mg/kg 1.3 mg IV, IM, SC 3.181818182
Fentanyl 50mcg/mL loading dose - excruciating pain 0.01 mg/kg 0.3 mg IV, IM 6.363636364
CRNA Ax in a syringe for dogs Induction Dose / Route
Fentanyl 150mcg (3mL) + midazolam 5mg (1mL) + ketamine 200mg (2mL) + 3mL IM, IV, IO lasts 20-30 minutes
dexmedetomidine 0.25mg (0.5mL) Dex will cause bradycardia (40–60 bpm) - Okay as long as BP is good
For reference, the CRNA Ax in a syringe human mix is: Maintenance Dose
Fentanyl 100mcg (2mL) + midazolam 5mg (1mL) + ketamine 100mg (1mL) 1–2mL as needed IM, IV, IO (App every 20–30 minutes)
(Add 1mL fentanyl, 1mL ketamine, 0.5mL dexmedetomidine) to this mix

Chemical Attacks (Save yourself first, MOPP gear then decon the MPC)
Nerve Agent Attack (Sarin, Soman Tabun, Vx) Signs: Constricted pupils, difficult breathing, secretions, rapid pant, decr HR, muscle facsiculations.
Tx: 1-3 ATNAA injectors + 1 CANA injector IM. Add 1 Atropen q 3min until secretions stop breathing eases.
BZ Agent Attack Signs: Dialated pupils, incr HR, Behavioral changes, incoordination may not respond to commands
Tx: Physostigmine salicylate 1-10mg IV Slow, IM Decon and DON’T SEDATE!
Arsenic Blister Agent Attack (Lewisite) Signs: Redness, edema of the skin, cough nasal disch, restlessness, bloody diarhea, vomiting
Tx: 100mg dimercaprol IM (aka BAL) 4.5g Na thiosulfate IV, 1.5mg albuterol PO
Cyanide Signs: Stops breathing, seizuring coma within minutes, death in 5-10 minutes.
Tx: 21mg Na nitrate IM, 600mg Na thiosulfate IM/4500mg hydroxocobalamin IV 300mg (10mL ampule of 3%) sodium nitrate IV followed by 12.5g sodium thiosulfate IV over 30 min

2025 RANGER MEDIC HANDBOOK 213

SECTION 7

PEDIACTRIC TACTICAL COMBAT

CASUALTY CARE
SECTION 7

214
Pediatric Tactical Combat Casualty Care Guidelines
Patient assessment and TCCC application largely remain unchanged for pediatric prehospital trauma patients, as com-
pared to adults, except for the following considerations:
Massive hemorrhage: Owing to much smaller blood volumes in children than in adults, immediate control of massive
hemorrhage is necessary to prevent hemorrhagic shock, and blood-based resuscitation must begin rapidly with any
significant loss of blood. Use tourniquets high and tight. U.S. military-approved tourniquets are effective in children with
limb circumferences ≥13cm (around 5 inches), generally children aged 2 years and over. Use of commercial windlass
tourniquets will likely require more wraps around the limb and more turns of the windlass to achieve hemostasis as
compared to adults. If the tourniquet is ineffective, use direct pressure, hemostatic gauze, and/or pressure dressings to
stop life-threatening extremity hemorrhage. If the casualty is younger than 2 years of age or has a limb circumference
< 13cm, use an improvised windlass tourniquet or elastic (ACE) bandage wrapped tightly. Circumferential and direct
manual pressure is highly recommended at arterial pressure points.
Airway: A crying pediatric casualty’s airway is intact. If the child is semiconscious or unconscious, their tongue is the
most common source of airway obstruction. The younger the child, the larger the occiput compared to the rest of the
body and the greater the importance of ensuring full head extension (by using a shoulder roll). Inadequate head exten-
sion results in airway occlusion. Although TCCC should always consider cervical spine injury in trauma, survivable
pediatric cervical spine fractures are extremely rare and should not take precedence over establishing a patent airway.
Airway adjuncts (oropharyngeal/nasopharyngeal airways) can be used to maintain a patent airway. An adult bag valve
mask (BVM) can be used for pediatric ventilatory support, but only use enough pressure to generate adequate chest
rise, which is much less than required for an adult (avoid hyper- or overinflation). In extreme circumstances, surgical
cricothyroidotomy can be performed on casualties younger than 8 years old, but caution must be taken in younger chil-
dren because of immature thyroid cartilage and the small size or limited space of the cricothyroid membrane. Standard
adult cricothyroid tubes are too large to fit a pediatric trachea, but pediatric endotracheal tubes can be modified to fit
the cricothyroid membrane.
Resuscitation: Unlike in adult shock, hypotension is a late finding in the pediatric population. Children should be resus-
citated early, before the onset of hypotension. Early signs of shock (before hypotension) include tachycardia and capillary
refill ≥ 3 seconds. Signs of uncompensated shock include altered mental status, weak distal pulses, and hypotension.
Permissive hypotension after hemorrhage is NOT RECOMMENDED in children. Adequate blood-based resuscitation
should improve heart rate, respiratory rate, capillary refill, mental status, hypotension, and urine output (goal = 1mL/kg/hr).

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Respiration: A pediatric respiratory rate is normally higher compared to an adult (Figure 1). Prehospital preventable
death due to tension pneumothorax is exceedingly low and therefore, in the setting of hemorrhagic shock, resuscitation
with blood products should be given before attempting chest decompression. When present, tension pneumothorax can

Figure 1: Range of Normal Pediatric Vital Signs

Systolic/diastolic Mean arterial
Respiratory rate, blood pressure, pressure,
Age Heart rate, bpm breaths per min mmHG mmHg
Newborn
100–205 40–60 65–85/35–55 45–60
(birth–28d)
Infant
100–180 30–55 75–105/35–55 50–60
(1–12mo)
Toddler
95–140 22–40 85–105/40–65 50–60
(1–3yr)
Preschooler
80–120 20–30 90–110/45–70 60–70
(3–5yr)
School-aged child
75–120 18–25 95–120/55–75 65–70
(5–11yr)
Adolescent to
60–100 12–20 110–130/60–90 70–85
adult (12–18yr)
BPM = beats per minute.

2025 RANGER MEDIC HANDBOOK 215

present dramatically in pediatric patients, where chest asymmetry may be significant. The limited intercostal space of the
pediatric thorax makes finger thoracostomies difficult; therefore, forceps-assisted thoracostomy and/or needle decom-
pression devices should be the first approach. The fourth intercostal space, mid-axillary line, to a depth of 1–1.5 inches is
preferred over the second intercostal space, mid-clavicular line, because of the thymus. Fourteen- or 16-gauge, 1.5-inch
needles are of adequate length to access the pleural cavity for all pediatric casualties weighing 36kg or less. The NDC
catheter may act as a tube thoracostomy and may not require an additional chest tube in infants.
DIAGRAM 1: PEDIATRIC Circulation: Establish intravenous/interosseous (IV/IO) access and administer blood prod-
INTRAOSSEOUS SITES. ucts as required to treat shock. Pediatric IV access is often hard to obtain in hypovolemic
shock, given the small size of their veins. Early use of pediatric IOs is encouraged. Fifteen-
millimeter (pink) IO needles are rarely helpful, as they tend to fall out due to the infant’s
underlying subcutaneous fat. Larger adult IO needles can be used in pediatric casualties,
but these will likely stand outside the skin. Blue needles are preferred. Extra caution with
yellow needles, as through-and-through potential in small limbs can lead to compartment
syndrome from infused fluids. Be aware to stop the introduction when the bone marrow
is reached. As such, hand twist IO needles into place, rather than using a drill, and pad
the exposed needle with large amounts of gauze to prevent needle dislodgement. Proper
placement becomes more important to avoid the growth plates. Based on locations of the
injuries, consider bilateral proximal/distal tibial and bilateral distal femur IOs, as the primary
sites in pediatrics (Diagram 1). If these sites are distal or not available due to the injury pat-
tern, humeral IO needle placement in younger children may be considered.
Pediatric hemorrhagic shock should always be treated with blood products, preferably with whole blood and tranexamic
acid: start with blood products at 10–20mL/kg in a bolus and tranexamic acid at 15mg/kg in a bolus (max 2g); administer
a slow IV/IO push within 3 hours of injury, and avoid crystalloids/colloids if possible. Resuscitate to normal vital signs
based on age (Figure 1) and improving physical examination findings, such as distal extremity capillary refill, cyanosis,
mottling and pallor, and mental status. Hypocalcemia may occur in children with massive transfusion. Consider admin-
istering calcium to these patients. Calcium gluconate is preferred over calcium chloride due to the risk associated with
extravasation in smaller pediatric veins.
Head Injury/Hypothermia: If unable to accurately capture pediatric blood pressure and pulse oximetry (evaluating for
hypotension and hypoxia), normalize adequate circulation and respiration to prevent worsening of traumatic brain injury.
A brief neurological assessment should be performed using AVPU (Alert, Verbal, Pain, Unresponsive; Figure 2), validated
as a better tool than the Glasgow Coma Scale for pediatric neurologic assessment. If the pupils are sluggish, nonreactive
SECTION 7

to light, or dilated, head injury and/or inadequate brain perfusion should be suspected. In severe head injury, consider
weight-based hypertonic saline administration.
Pediatric casualties have a higher body surface area to mass ratio, contributing to difficulty in maintaining their body
temperature (lethal triad of trauma). Keep them warm with blankets, warmed fluids, and a warm environment. Their
glycogen stores are also lower than those of adults, leading to decreased metabolic compensation during trauma and
thermoregulation, especially in infants.
Vital Signs: Pediatric patients may not manifest significant changes in vital signs until they are in severe shock. Vital sign
ranges vary by patient age (Figure 1). The lowest acceptable systolic blood pressure is calculated by multiplying the pa-
tient’s estimated age by 2 years and adding 70 (i.e., 5-year-old: 5 × 2 = 10, + 70 = 80mmHg). Adult pulse oximetry finger
probes may be used on children (> 10 years of age and/or 30kg) if their finger reaches the end of the probe. Younger
children require a pediatric pulse oximeter to prevent inaccurate readings.
Estimate of Pediatric Weights: Obtain a dosing weight as soon as possible using adjuncts such as a Broselow™ tape,
PAWPER, or CoTCCC Pediatric Trauma Tape (PTT). Direct measurement of weight is always preferred. Length-based
weight estimates/tools are more accurate than age-based methods. In low- and middle-income countries, weight is of-
ten overestimated by the Broselow™ tape in these populations. For children who appear over- or underweight, consider
adjusting to a lower or higher weight category for medications. For equipment sizing, length-based weight estimates
are adequate.
Analgesia: Pain is often undertreated in pediatric casualties due to poor recognition and underdosing. In patients who can-
not communicate, use an assessment tool such as the revised Face, Legs, Activity, Cry, and Consolability scale (FLACC-R;
Figure 3) to improve recognition of pain. Pain medications should always be given using weight-based dosing.
Ibuprofen (if > 6 months of age) and acetaminophen are appropriate for mild pain and should be used as adjuncts in
severe pain. Ketamine and opioid medications can be introduced for moderate to severe pain. Pediatric patients have a
higher volume of distribution and are more prone to side effects or oversedation. Consider pre-treating for nausea with

216 SECTION 7 PEDIATRIC TACTICAL COMBAT CASUALTY CARE

ondansetron. Also, provide frequent reassessments of cardiopulmonary status through vitals and AVPU assessments
after giving ketamine or opioids. Intranasal and rectal routes of medication administration are very effective in children.
Transmucosal fentanyl lozenges should not be given to casualties under the age of 16. Have naloxone available for
reversal of opioid medications to manage respiratory depression if it occurs.
Antibiotics: Recommended for all combat wounds. If a child can take oral medication, start with the same adult
guidelines: cephalexin, 25mg/kg orally every 6hr (max 500mg/dose). If IV/IO/IM dosing is necessary, give ceftriaxone,
50–100mg/kg IV/IO/IM, every 24hr (max 2g/dose). Consider ertapenem for all abdominal or polytrauma wounds, where
both aerobic and ­anaerobic organisms could be the source of infection (< 12 years: 15mg/kg IV/IM every 12hr: > 12 years:
20–40mg/kg IV/IM once).
Burns: Children have smaller airways than adults, making them more susceptible to edema and obstruction from inhala-
tion injuries. Be vigilant for signs of respiratory distress / evidence of burns in the oropharynx, and be prepared for early
airway intervention.
Given their higher body surface to mass ratio, children are more prone to hypothermia and fluid loss from burns. The
estimation of total body surface area (TBSA) differs from that used for adults because of children’s larger heads and
smaller thighs. To estimate burn size, use the Lund and Browder chart, or use the child’s palm and fingers, which equals
1% of their body surface area. Only include partial thickness (or worse) burns in the fluid resuscitation calculation.
Children have a higher fluid requirement per kilogram of body weight than adults. Greater than 10% TBSA of partial
thickness (or worse) burns requires IV fluid resuscitation. If the child is not taking oral fluids well, shows signs of dehydra-
tion, or has other injuries, consider fluid resuscitation and/or maintenance fluids even with smaller burns. Calculate initial
fluid needs based on the Pediatric Parkland formula (3mL × kg × % TBSA burned = total mL in first 24 hr). For children
over 40kg, use “rules of 10s.” Remember that children are especially susceptible to abdominal and respiratory fluid
overload during resuscitation. If an escharotomy is indicated, be aware that children have thinner skin, smaller limbs, and
different body fat distribution than adults. The margin for error is extremely small, especially in infants.
Splinting: Most pediatric fractures are not surgical and will only require splinting or casting. Ensure there is additional
padding to protect bony prominences. SAM splints can be bent into shape, but do not cut them to size as internal
aluminum can cause skin and soft tissue injuries. Pediatric fractures are a risk for compartment syndrome, including
supracondylar and tibial fractures.
Given the emotional immaturity of some children, they will require sedation in addition to pain control during reduction
and splinting. IN/IV fentanyl and midazolam are ideal for simple reductions/procedures. Ketamine is recommended if

SECTION 7
reduction is anticipated to take more than 20min or if pain cannot be adequately controlled by other means. Gross
deformity of the elbow often require urgent surgical intervention. Consider hematoma or peripheral nerve blocks as
adjuncts to pain control.

Triage
Communication: Regardless of age and injury, children may feel upset or have strong emotions after an emergency. It
is important to explain the “need to know” information in simple terms, so the child can understand. Sit down or squat
to be at the child’s eye level. Allow time for the child to ask questions and be patient with the child’s responses. Medical
providers should acknowledge the child’s feelings and reassure the child that it is okay to feel their emotions. If possible,
use the parents/caregivers to comfort the child and use visual aids to explain medical concepts. Do not talk down to
the child or make false promises, like stating that an intervention will not hurt if it is likely to cause some degree of pain.
Evacuation: Most existing litter systems are not pediatric-size specific, making safely securing casualties challenging.
Consider using ACE wraps, rolled towels/clothes/medical tape or modified straps to adequately secure children. Before
evacuating a child, consider the medical rules of engagement and the type of facility the child will be relocated to.

Class VIII Considerations and Modifications of Adult Equipment

■ Recommended minimum equipment: 100mL normal saline bags, 10mL normal saline pre-filled syringes, 3mL or
smaller syringes, intranasal mucosal atomizer device.
■ Oral/nasal gastric tubes are required for effective positive-pressure ventilation and can facilitate rehydration and
feeding in severely injured patients (i.e., those with burns).
■ Adult needle decompression devices may be used for pediatric tension pneumothoraces. Adult BVMs may be rotated
180° and used as a full-face mask (with the rounded portion covering the nose/eyes). Remember to only use enough
pressure to generate adequate chest rise, much less than required for an adult.
■ An aluminum malleable splint can be used for pressure points into the femoral triangle and combined with a U.S.
military approved tourniquets as a pelvic binder.

2025 RANGER MEDIC HANDBOOK 217

Figure 2: AVPU Mental Status Exam
AVUP: A quick method to evaluate pediatric mental status, Alert = best, Unresponsive = worst.
The four possible recordable outcomes are as follows:
■ Alert: The patient is fully awake but may not necessarily be oriented. The child will spontaneously open eyes,
respond to voice (may be confused), and have bodily motor function.
■ Verbal: When you talk to the child, they respond in some manner, categorized as any measures of eyes, voice or
motor response. For example, the response by eyes opening, moaning/grunting, or slight movement of extremity.
■ Pain: The child responds to pain stimulus through any measures of eyes, voice, or motor response.
■ Unresponsive: No response to verbal or pain stimulus.

Figure 3: FLACC-R Pain Assessment

0 1 2
Face Smile or no expression Occasional grimace, Frequent or constant chin
withdrawn, disinterested, quivering, clenched jaw,
appears worried panicked expression
Legs Normal position, relaxed, Uneasy, restless, tense, Kicking or legs drawn up,
normal tone occasional tremors constant tremors
Activity Lying quietly, normal Squirming, shifting, tense, Arched, rigid or jerking, gasping
position, moves easily, shallow respirations respirations or breath holding
breathing normally
Cry No cry Moans or whimpers, occasional Crying steadily, screams, sobs,
complaints frequent complaints
Consolability Content, relaxed Reassured by occasional Difficult to console, resists
touching or talking, distractible comfort attempts
0–3 = mild pain; 4–6 = moderate pain; 7–10 = severe pain.
FLACC-R = Face, Legs, Activity, Cry, and Consolability scale (revised).
SECTION 7

Commonly Used Weight-Based Medications

Resuscitation Analgesia/sedation
Whole blood 10–20mL/kg IV/IO Ketamine
Analgesia • 0.5mg/kg IV
Plasma 10–20mL/kg IV/IO • 1mg/kg IM/IN*
Tranexamic acid 15mg/kg IV/IO Sedation • 1–1.5mg/kg IV
Calcium gluconate 60mg/kg IV/IO • 4–5mg/kg IM*

Calcium chloride 20mg/kg IV/IO

Opioid analgesia Sedation

Fentanyl • 0.5–1µg/kg IV+ Midazolam • 0.05–0.1mg/kg IV++
• 2µg/kg IN* (first dose max 2.5mg)
• 0.05–0.15mg/kg IM*
Hydromorphone 0.01–0.015mg/kg IV+ • 0.2–0.3mg/kg IN*
+Given higher concentrations of opioid analgesia commonly available through the military Authorized Medical Allowance List, dilution

with normal saline may be necessary to obtain appropriate dose.

*All intranasal/intramuscular administration of medications, use the highest concentration available. If > 0.5mL of total IN volume, split the
dose between nostrils, as too much volume in a single nostril will not be absorbed but swallowed.
++ Start all pediatric single doses no more than 2.5mg and repeat every 3–5 minutes as necessary, to maximum of 10mg.

IM = intramuscular, IN = intranasal, IO = intraosseous, IV = intravenous.

218 SECTION 7 PEDIATRIC TACTICAL COMBAT CASUALTY CARE

NOTES

SECTION 7

2025 RANGER MEDIC HANDBOOK 219

SECTION 8

MEDICAL PLANNING &

CASUALTY COLLECTION OPERATIONS
SECTION 8

220
Casualty Response Planning Overview
In planning and training for combat casualty management, the focus is on the possible, not the impossible. Essentially,
there are three groups of casualties that will be encountered. In the first group, no matter what you do, the wounded will
live. In the second group, no matter what you do, the wounded will die. In the third group, if you do the right thing, at the
right time, your treatment and evacuation will make the difference between life and death, or between greater and lesser
disability. The Casualty Response System is focused on this third group as there is a much greater probability of positively
affecting mission and patient outcomes.

Decisions in tactical casualty management are not made by persons far removed from the event. The casualty response
system will be a flattened organization with decentralized decision-making that empowers first responders, tactical lead-
ers, and medical providers at all levels. As all will have direct ownership of the system, they will invest in realistic casualty
management training in order to become more efficient and effective at and near the point of injury. Ultimately, this will
equate to lives saved.

Medical planning in Ranger units depends heavily on the experience and knowledge of the Ranger medical Team. ALL
Tactical Medics, from the most junior to the most senior, must become skilled planners. Effective medical planning
requires that the planner be well integrated into the unit’s (platoon/company/battalion/regimental) mission planning staffs.
Many medical issues that arise during planning are regulated, decided or solved by other members of the unit staff includ-
ing the S3 (operations), S3 (air), S4 (logistics), commanders, executive officers, first sergeants, and platoon sergeants.
Good working relationships and effective communications must be maintained for successful medical planning. Medical
planners must be fluent in the unit’s planning sequences (compressed or deliberate) and have a good understanding of
the role they play therein. Medical planners must be involved as early as possible in planning sequences for ALL training
exercises and real-world contingencies.

The medical plan will include an overall “casualty response” plan in which every unit member has a role. When a casualty
occurs, it is not just the Medic’s problem; it is a tactical problem that must be planned for and solved by the entire unit.
Units will integrate a casualty response phase into all of their tactical battle drills. Unit members and leadership must
be well versed in the casualty response plan. Medical personnel have a tendency to focus on providing critical patient
care once they begin treating casualties, and as such may not be able to maintain sufficient situational awareness to
execute the plan. The unit must be able to execute the casualty response plan around the Medic while the Medic treats
the wounded. Battlefield distracters, wound distracters, and C2 issues and shortcomings all have an impact on both the
commander’s and Medic’s decision-making during an ongoing mission.

Ranger Casualty Response Planning

The backbone of this section is based on the intricacies of a forced-entry combat operation or the execution of a special
operations contingency. For Ranger and SOF units, the initial entry into combat operations is likely to be in a new theater
of operations or one of extended distances to casualty care assets. As additional military forces follow-on and develop a
theater, the medical support becomes much simpler to plan as there are more assets available. During combat operations

SECTION 8
in which the Ranger unit is deploying to a developed theater (such as Iraq or Afghanistan), the unit can quickly adapt to
existing medical assets and resources to develop the casualty response plan.

The compressed time nature of contingency operations requires the medical planner be well versed in the unit planning
methodology and the high expectations of a developed plan. Using the planning methodology outlined here for any type
of exercise or deployment, the medical planner will gain better understanding and habits to execute such a plan under
any circumstances. However, there is no such thing as a “usual” planning technique. Every mission, regardless of timeline,
assets, or constraints, is unique and must have a developed casualty response plan.

2025 RANGER MEDIC HANDBOOK 221

Predeployment Requirements
The 75th Ranger Regiment has very specific predeployment Soldier readiness processing (SRP) requirements, allowing the
unit to be deployed on a compressed time sequence anywhere in the world. Prior to any deployment or assumption of
OPALERT, unit Medics should review the current Regimental Medical SOP (RTC 350-29) that outlines SRP requirements.
Rangers will be briefed on the medical threats and preventive medicine measures that will keep them healthy in a particular
area of operations. If a compressed time sequence deployment, Rangers will be briefed on critical preventive medicine
measures significantly different than normal operating procedures. Also, during the predeployment phase is the time to
conduct predeployment inspections of individual Ranger’s IFAKs, Advanced-RFR Bags, active Ranger O Low Titer (ROLO)
rosters (battalions conduct ROLO within 30 days prior to assuming OPALERT; active ROLO roster is valid for 120 days),
and squad casualty evacuation equipment serviceability and to verify the ability to draw medical chemical defense material
(MCDM)from the installation MTF and blood products from the partnering blood donor center.

Medical Threat Assessment

The medical planner must assess all medical threats the unit may face during the operation. This assessment includes
environmental health hazards as well as specific threats from enemy weapons systems. Through the medical threat as-
sessment, the medical planner will identify preventive measures the unit can employ to minimize these threats. Once the
preventive measures appropriate to the mission have been selected, medical planners must be prepared to make recom-
mendations to unit commanders, leaders, and Rangers on how to employ them. The overall goal is to have healthy Rang-
ers ready to perform a mission, keep them healthy during the mission, and safely bring Rangers back home.

Identify the Area of Operations (AO). The medical planner must develop a clear understanding of medical threats and
assets in the countries, regions, and environments where the operation will be conducted. The locations of targets, stag-
ing bases, etc. must be known in order to adequately plan for medical threats. The most important area to assess is the
target area. This is the area or region in which the unit will be conducting tactical missions. The host country or staging
area must also be evaluated. This is the secure region used as a base of operations. The threats here may or may not be
the same as those of the target area.

The following websites are good sources for determining host nation clearance guidelines:

Electronic Foreign Clearance Guide (NIPR): https://www.fcg.pentagon.mil; (SIPR): https://www.fcg.pentagon.smil.mil

Identify Medical Intelligence and Health Threats. Medical Intelligence is a key component of all training and contingency
operations. Information on hazardous plants & animals, prevalent diseases, required immunizations & chemoprophylaxis,
climatology, and medical & hospital capabilities in the areas involved should be gathered. The National Center for Medical
Intelligence (NCMI) is a primary source for medical intelligence. NCMI collects and disseminates information on disease
occurrence, medical capabilities, health services, and environmental health hazards specific to regions around the world.

The unclassified NIPR internet address for the NCMI is https://www.intelink.gov/ncmi/index.php. The classified SIPR inter-
net address for NCMI is http://www.afmic.dia.smil.mil
SECTION 8

Another good open source website for determining host nation sustainment preparation and medical infrastructure is
https://www.pixtoday.net

MEDCOP (health services placemat) – (SIPR): https://hqsaid01.ds.centcom.smil.mil/medcop/# (health services placemat),

is helpful for determining current conventional and SOF medical assets in theater.

Some other sources for medical intelligence are:

Centers for Disease Control and Prevention (CDC) http://www.cdc.gov/
U.S. State Department Travel Warnings & Consular Information https://www.state.gov/travel/
World Health Organization (WHO) Homepage http://www.who.int/en/
U.S. Army Public Health Command (formerly known as the Army Center for Health Promotion and Preventive Medicine)
NIPR: http://phc.amedd.army.mil/ SIPR: https://phc.army.smil.mil

The medical planner must also maintain an awareness of the unit’s medical readiness status. A review of immunization and
health records should be conducted well before the operation begins.

The types of enemy weapons the unit may encounter, including chemical and biological weapons must also be deter-
mined. The planner will make recommendations to prevent and treat the injuries these weapons may inflict, such as the
use of body armor, chemoprophylaxis, or protective masks.

222 SECTION 8 MEDICAL PLANNING & CASUALTY COLLECTION OPERATIONS

MEDICAL THREAT ASSESSMENT
■ NCMI SIPR/NIPR website – find country/area of operations
É Host country (ISB/FSB) and https://www.pixtoday.net
É Target country
■ Determine known health threats & risks
É Diseases/illnesses
É Environmental threats (plants, animals, climate, terrain)
■ Current unit SRP status
■ Preventive medicine guidelines (what is required before, during, and after)
■ Enemy weapons, munitions, and tactics, to include CBRN?
■ How ready is the unit if it encounters diseases/illnesses?
■ What preparation is needed by the unit?
■ Do Rangers need special preventive medicine items issued?

Higher Headquarters Orders and Guidelines

Higher Headquarters Medical Guidelines and Requirements. The operational headquarters will often publish specific
guidelines regarding casualty evacuation and hospitalization as well as preventive medicine requirements in its operations
orders (OPORDs). The planner must determine if unit members will have to take medications before, during, and after the
mission to prevent illnesses such as malaria. A key question asked is, “Does the unit need to change normal procedures
to meet higher headquarters mission guidelines or requirements?”

HIGHER MEDICAL GUIDELINES & REQUIREMENTS

■ Chemoprophylaxis
É Antimalarial drugs
É Other preventive measures
■ Special SRP requirements
■ WHO Traveler Advisory
■ USSOCOM/USASOC/theater guidelines
■ Regiment/battalion guidelines
■ Do we need to change anything in the way we normally do business?

Requests for Information (RFI). Medical planners will be familiar with the processes for requesting updates to dated

SECTION 8
information about disease or environmental threats. Sources for such periodic reports and publications may lie within the
chain of command, or may be external, such as international health organizations. Maps, imagery, and information on
medical facilities in the staging or target areas will also be needed for planning.

REQUESTS FOR INFORMATION (RFI)

■ Request updates to NCMI information
■ Maps/imagery
■ Host nation (ISB) medical capabilities
É Hospitals/medical facilities
É Nationwide medical training/competency
■ Any information not covered in NCMI online resources or higher guidelines
■ Submit through medical, intelligence (S2), and/or operations (S3) channels
■ Ask for more information for what you need to know

2025 RANGER MEDIC HANDBOOK 223

Determine Medical Assets
On a given operation, the unit will be supported by its internal medical assets. External medical personnel, equipment, or
units may also be attached or used as needed. A thorough understanding of all medical assets available to the mission
is crucial. This includes the proper unit designations or names, number of personnel by specialty, treatment & evacuation
capabilities, logistical requirements, task organization, and command & control. It is important to ensure that all external
medical assets are well connected into the unit’s structure operationally, logistically, and administratively.

Evacuation Assets. There are two types of evacuation during tactical evacuation (TACEVAC) operations: casualty evacu-
ation (CASEVAC) and medical evacuation (MEDEVAC). CASEVAC implies the use of nonmedical platforms to evacuate
casualties. These mission platforms are ground vehicles, watercraft, or aircraft typically used by the unit for infiltration,
exfiltration, or resupply. These vehicles do not usually have organic medical personnel or equipment onboard unless
prepositioned in the operational plan. These assets are more suited for routine evacuation of nonemergent casualties, but
prestaged medical personnel and equipment can facilitate the treatment and transport of the more seriously wounded.
Medical planners should plan for the use of CASEVAC assets as much as possible, as these assets are often the most
readily available for rapid evacuation.

Furthermore, CASEVAC assets are usually armed and are thus better prepared to conduct evacuation while the fight with
the enemy is still ongoing. MEDEVAC refers to the use of dedicated medical platforms whose primary mission is the
evacuation of casualties. Most often conducted by aircraft, MEDEVAC can also be carried out using medically staffed and
equipped front line ambulances (FLAs, MRAP, Stryker). MEDEVAC platforms are usually assigned to a regulated region,
are not under the direct control of the tactical unit and must be requested through operational channels in the execution
sequence. Controllers in operations centers receive MEDEVAC requests and launch or divert MEDEVAC assets as required
on a prioritized basis.

Unit medical planners will determine the casualty evacuation assets that will likely be needed to support the unit’s mission
whether by air, ground, or water. Assets should be matched to the expected needs in pre-mission planning.

Med planners should also be knowledgeable of Strategic evacuation (STRATEVAC) from the joint operations area (JOA)
MTF to a home or allied nation MTF with higher capability of care (e.g., transfer to a Role 4) through the Theater Patient
Movement Requirements Center TPMRC (a component of USTRANSCOM). TPMRC assist patients who require transfer
to a military treatment facility. Coordination with TPMRC may be necessary IOT decompress casualties from the JOA MTF
for patient holding capacity.

DETERMINE MEDICAL ASSETS

■ Organic, attached, air, ground, theater, JTF, host nation, ISB, FSB, etc…
■ CASEVAC/MEDEVAC support
É How many and what type?
É Capabilities and limitations?
É Hoist and high angle extraction?
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É Medical personnel and equipment on board? Level of training?

■ Determine nearest surgical capability
É Where are your casualties being evacuated to?
É What are the capabilities/limitations?
É What is their MASCAL or overload plan for their system?
■ Determine staging base area medical support
É Can they provide labs, x-rays, medications, preventive medicine, etc?
■ What are the gaps in care or requirements that exceed tier medical capabilities?
■ Are there conventional assets aligned to that combatant command that can meet those requirements?
■ Discuss request for force options with the S3/G3 cell to determine feasibility (e.g., mobilization and command/
support relationship considerations).

Familiarization with Evacuation Assets. In premission planning, there are key questions that must be answered concern-
ing CASEVAC and MEDEVAC. How many and what type of platforms are available? What are the capabilities, limitations
and restrictions of the platforms? Are air evacuation assets capable of hoist or high-angle extractions? What medical
equipment is on board each platform? Who are the assigned medical personnel and to what levels are they trained?

224 SECTION 8 MEDICAL PLANNING & CASUALTY COLLECTION OPERATIONS

Requesting Evacuation. MEDEVAC requests are normally transmitted using the standard NATO 9-Line MEDEVAC Re-
quest Format. The MEDEVAC request provides controllers in operations centers with the critical information needed to
launch and manage MEDEVAC platforms. The standard format can be used to request any kind of evacuation asset: air,
ground, or waterborne. CASEVAC requests can be tailored specifically to the unit mission and operating area, but typically
consist of the first 5 lines of a MEDEVAC request. This works for CASEVAC platforms since they are normally already part
of the tactical operation, and the pilots/drivers have a clear understanding of the battle space through previous coordina-
tion and ongoing communications. Though the request from the tactical element on the ground is normally transmitted by
radio; the request from the unit’s C2 may be by other means such as e-mail, operational chat room (mIRC or TransVerse)
or telephone. The unit C2 must be aware of these requirements to better streamline the evacuation request process during
the execution phase.

MEDEVAC REQUEST 9-LINE

LINE 1: LOCATION OF UNIT HLZ GRID (MGRS):
LINE 2: CALLSIGN AND FREQUENCY AT CALLSIGN:
THE PZ FREQUENCY:
LINE 3: NUMBER AND PRECEDENCE OF A: Number of Urgent Casualties
CASUALTIES B: Number of Urgent-Surgical Casualties
C: Number of Priority Casualties
D: Number of Routine Casualties
E: Number of Convenience Casualties
LINE 4: SPECIAL EQUIPMENT REQUIRED A: None
B: Hoist
C: Extraction
D: Ventilator
E: Other (specify)
LINE 5: NUMBER OF CASUALTIES BY TYPE L: Number of Litter Casualties
A: Number of Ambulatory Casualties
E: Number of Escorts
LINE 6: SECURITY AT PZ N: No enemy
P: Possible enemy
E: Enemy in area
X: Armed escort required
LINE 7: PZ MARKING A: Panels
B: Pyrotechnics
C: Smoke (designate color)

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D: None
E: Other (specify)
LINE 8: CASUALTIES BY NATIONALITY/STATUS A: US/Coalition Military
B: US/Coalition Civilian
C: Non-Coalition
D: Non-Coalition Civilian
E: Opposing Forces/Detainee
F: Child
LINE 9: DESCRIPTION OF TERRAIN Brief description of significant obstacles on approach/
(In peacetime, description of terrain) departure headings and type of predominant terrain for
the HLZ

Additional Evacuation Request Information. Depending on how developed the theater of operations has become or the
number of units being supported by a particular evacuation asset, there may be additional information requirements. Such
requirements can both allow evacuation C2 to better prioritize assets and notify receiving facilities of patient conditions.
After a patient is assessed, a MIST report will be transmitted in the same manner as the 9-line MEDEVAC. The MIST report
both informs the MEDEVAC crew of patient status and notifies the receiving facility of incoming patient requirements. The
MIST report is not required to launch an evacuation asset but is to be transmitted as soon as possible.

2025 RANGER MEDIC HANDBOOK 225

MIST REPORT
M – MECHANISM OF INJURY AND TIME OF INJURY Mechanism of injury and time of injury (if known)
(IF KNOWN)
I – INJURY OR ILLNESS Injury or Illness
S – SYMPTOMS AND VITAL SIGNS A – Airway status
B – Breathing rate
C – Pulse rate
D – Conscious/unconscious
E – Other signs
T – TREATMENT GIVEN Such as tourniquet/time applied
Drugs administered

Rehearsals with External Assets. The unit’s leaders and tactical Medics will coordinate face-to-face with external evacu-
ation personnel prior to mission execution to assure a clear understanding of procedures by all personnel. The rule, not
the exception, is that live rehearsals with evacuation assets are conducted to prepare for smooth handover of casualties.
Unit Operators, medical teams, aid & litter teams, and C2 must practice with the evacuation platforms prior to mission
execution. During the real evacuation of a wounded Ranger is not the time to learn how to position and secure a litter to
the evacuation platform.

Surgical and Area Medical Support Assets. The medical treatment facilities to which combat casualties will be trans-
ported must be identified. Their capabilities and capacities (especially surgical) should also be documented. With this
knowledge, planners can predict how many of what type of casualties could overwhelm a given facility, and casualty flow
can be directed accordingly. Furthermore, casualties can be routed directly to facilities with greater capabilities if dictated
by the severity of their injuries. For casualties with severe injuries, evacuation to a fully capable field hospital has been
found to produce better outcomes than evacuation to a treatment facility with limited surgical and intensive care capabili-
ties if the evacuation times are comparable.
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226 SECTION 8 MEDICAL PLANNING & CASUALTY COLLECTION OPERATIONS

MEDICAL TREATMENT FACILITIES
Per Allied Joint Publication-4.10(A), the following define the levels of medical treatment facilities in a theater of opera-
tions.
ROLE 1 MTF (Maritime Echelon 1) – provides primary health care, specialized first aid, triage, resuscitation and
stabilization. The basic Role 1 capabilities include basic occupational and preventive medical advice to the chain of
command, routine sick call and the management of minor sick and injured personnel for immediate return to duty,
as well as casualty collection from the point of wounding and preparation of casualties for evacuation to the higher
level MTF. Nearly all Ranger health care capabilities are considered Role 1 unless augmented by external assets made
organic to the task force. Generally, the Regiment maintains role-1 capability within the confines of tactical health care/
casualty response on target and aid stations established at forward operating bases.
ROLE 2 MTF – A Role 2 medical facility is an intermediate structure capable of receiving casualties, providing triage
and stabilization for further evacuation, treatment and holding of patients until they can be returned to duty or evacu-
ated. Role 2 minimum capability includes: Re-supply to Role 1, Evacuation from Role 1, Limited holding capacity,
Personnel reinforcement to Role 1, Patient record maintenance, Tracking of evacuated patients, Operational stress
management, Laboratory capability, Basic imaging capability (e.g., radiology, ultrasound), and emergent dental. Under
specific conditions, Ranger units may be augmented by other units to have a Role 2 capability organic to a special
operations task force.
ROLE 2 (+) MTF (Maritime Echelon 2) – Augmented Role 2 (Role 2+) medical facilities consist of Role 2 minimum
capability augmented by any or all the following: Emergency surgery, Intensive care, Essential post operative care,
and Blood replacement.
ROLE 3 MTF – Facilities include the capability of Role 2 extended by surgery, intensive and post-operative care,
medical, dental and nursing care, and relevant diagnostics. Role 3 units can provide lower level units medical person-
nel replacement. Resupply of Role 2 facilities and either control of or ready access to patient evacuation assets are
included within the minimum capability. In addition to beds required for the seriously ill, the holding capacity will be
sufficient to allow diagnosis, treatment and holding of those patients who can receive adequate treatment and be
returned to duty within the evacuation policy.
ROLE 3 (+) MTF (Maritime Echelon 3) – Augmented Role 3 (Role 3+) medical facilities include one or more of the fol-
lowing: specialist surgery (neurosurgery, maxillofacial, burns, etc.), advanced and specialist diagnostic capabilities (CT
scan, arthroscopy, sophisticated lab tests, etc.), major medical, dental and nursing specialties, preventive medicine,
and environmental health capability.
ROLE 4 MTF (Maritime Echelon 4) – A facility that provides definitive care of patients for whom the treatment re-
quired is longer than that dictated by the theatre evacuation policy or for whom the capability usually found at Role 3 is
inadequate. This would normally include definitive care specialist surgical and medical procedures, reconstruction and
rehabilitation. This care is usually highly specialized, time consuming, and normally provided in the casualty’s country
of origin. Under very unusual circumstances, a Role 4 medical facility may be established in the Theater of Operations.

Face-to-face coordination with appropriate external medical assets is critical. The medical planner must visit the support-
ing medical facilities to gain an understanding of their physical layouts, unique equipment, procedures, casualty manage-
ment, and patient accountability. Also, unit medical personnel must know how to follow up with the unit casualties as

SECTION 8
commanders will require serial reports on their status.

Deployed troops will suffer routine illnesses and noncombat injuries that may require medical attention exceeding the tacti-
cal Medic’s scope of practice. Area medical support assets are those facilities that provide medical services other than
combat trauma care to meet these needs. Established policies and procedures for Operators’ care at area medical support
facilities should be conveyed to unit leaders and medical personnel.

2025 RANGER MEDIC HANDBOOK 227

FAMILIARIZATION WITH MEDICAL ASSETS
■ Published references
É Field Hospital
É Forward Surgical Resuscitative Detachment (FRSD)
É Medical Company Area Support (MCAS)
■ Review these key Army Health System and Force health Protection publications at https://armypubs.army.mil/:
É FM 4-02 Army Health System
É ATP 4-02.3 Army Health System Support to Maneuver Forces
É ATP 4-02.55 Army Health System Support Planning
■ Can you see their layout/equipment?
■ Can you conduct familiarization training as required?
■ What are their capabilities and limitations?
■ Can you talk to them and what can they know about you and your mission?

Special Operations and Augmentation of Surgical or Medical Support Assets. In special operations contingencies,
the evacuation and receiving facilities options may be greatly different from the medical support in a developed theater.
The “golden hour” can be significantly extended in distance and time from the point of injury to an established medical
or surgical facility with proper implementation of special operations surgical assets. The current battlefield and future
contingency operations nullify the option of calling in a MEDEVAC or quickly evacuating a casualty to a field hospital. The
evacuation and long-range care capability may need to be completely planned and coordinated using the assets organic to
the special operations task force. In these cases, it is critical that these capabilities be augmented into the special opera-
tions task force when time and OPSEC allows. The intent remains to get a traumatized casualty appropriate en route care
to an advanced surgical or medical capability as quickly as possible. Such contingencies will require augmentation from
other units or attachments to conduct en route casualty stabilization on a designated platform or sequence of platforms
until the casualty reaches a fixed facility. Augmentation capabilities requirements must be identified early in the planning
process to allow adequate time for the planning and coordination. Once this medical asset is identified, it must integrate
early into the planning and synchronization process. Assets will need to be prestaged at specific locations or on evacua-
tion platforms in order to provide the unit with the upmost capability. Unit leadership will develop a thorough understand
that these special medical assets become part of the overall unit plan and execution. The unit may have to adjust combat
loads in order to stage or infiltrate medical support assets as required. Ultimately, the unit commander is responsible for the
allocation, synchronization, and employment of all the augmented medical resources available to complete the unit’s mis-
sion. The medical planner’s responsibility is to ensure the commander and staff is well informed of requirements, capabili-
ties, limitations, and employment methods of medical augmentation. Subsequently, the medical planner must provide the
medical augmentation with the constraints and restrictions that they must operate within the mission. Special operations,
by its very nature, tend to be a joint, interagency, and international affair. Therefore, the medical planner must widen their
SECTION 8

viewpoint to all available medical resources and capabilities within reach. Familiarization with the medical unit capabilities
of other military services and international assets is imperative to mission success. Additionally, the use of host-nation
medical capabilities must be factored in as an option if necessary.

Primary and Alternate Planning. As with all military operations, the unit and the medical planner will develop back-up
plans. A unit should never launch on a combat mission with a single planned means of casualty evacuation. Alternatives
for all possible routes of evacuation to and from the objective (e.g., air, ground, water) should be written into the medical
plan. Alternate receiving facilities should be identified in case mass casualty situations occur or conditions prohibit evacu-
ation to primary facilities. Additionally, weather and environmental conditions can have detrimental effects on pre-planned
evacuation operations that can be mitigated by a good alternate plan. As the medical planner develops the tactical medi-
cal support plan the following must be considered: Primary and alternate means of evacuation including the capabilities,
limitations, distances and communications methods; primary and alternate receiving medical treatment facility to include
capabilities, limitations, bed status and mass casualty over-flow contingencies.

228 SECTION 8 MEDICAL PLANNING & CASUALTY COLLECTION OPERATIONS

Tactical Medical Support Plan Development
Understand the Tactical Commander’s Plan. The tactical medical planner must understand the overall scheme of ma-
neuver of the forces arrayed on the battlefield. This understanding is gained by attending all of the operations planning
meetings and ensuring that medical operations are well synchronized into the tactical plan. Tactical plans may evolve
rapidly, so the medical planner must keep abreast of changes, and should participate in course of action development to
determine how the various options can be supported medically.

Casualty Estimation. Medical and tactical planners should predict where casualties are likely to occur and develop ca-
sualty management and evacuation plans for all phases of the operation (infiltration, assault, clear/secure, consolidation,
exploitation, defense, and exfiltration). Other key elements to consider are the layout of the target and template of enemy
positions as projected by intelligence and operations staffs. Understanding the commander’s tactical plan will indicate how
best to develop the medical support plan.

Casualties should be expected and planned for in all phases of any tactical
operation from en route, infiltration, assembly, assault, actions on the objective,
consolidation, defense, exfiltration, and return to base.

The casualty estimation also includes projecting possible disease nonbattle injuries (DNBI). Based on known medical
threats, unit activities, previous events, and individual health profiles, determine the potential nonbattle injuries that may
occur. DNBIs can also include traumatic injuries that did not occur as a result of firefights such as parachute landing
injuries or vehicle accidents. Keep in mind that some minor casualties may not come to the attention of the Medic until
post mission after return to base. Include in your plan a post mission screening for potential casualties who may require
medical treatment.

To assist medical planners with causality estimation, ATP 4-02.55 recommends the medical casualty estimation tool
(MACE). The United States Medical Center of Excellence developed the automated MACE tool to assist medical planners
with medical and casualty estimation. The MACE tool provides medical and casualty estimates based on parameters such
as length of operations and engagements, weather, and terrain based on historical casualty data.

The requesting individual must contact the Computational Sciences Division for access to the MACE tool via email (NIPR)
mail to: [email protected]; [email protected] and
address your request with ATTN: CSD.

CASUALTY ESTIMATION
■ Analyze the target and the templated enemy positions
■ Analyze the commander’s assault plan
■ Plan to take casualties during every phase of the operation (infiltration, assault, clear/secure, consolidate,
defend, exfiltration).

SECTION 8
É Where do you foresee taking casualties?
É Where is it most critical for the Medics to be located?
É Do you need to task organize your medical team?
É Where does the unit need to establish CCP’s?
É What evacuation methods need to be considered?
É Where is the closest HLZ or AXP?
É Where do you emplace and preposition medical assets/augmentation?
■ Review preventive medicine issues and anticipate DNBI
É What are the health threats?
É What actions will prevent or decrease disease and non-battle injuries?

In addition to casualty estimates, the U.S. Army Combined Arms Support Command (CASCOM) has developed supple-
mental planning tools to forecast CLS VIII requirements, water consumption, and fuel consumption calculators for evacu-
ation planning. CASCOM website: https://cascom.army.mil/asrp/sust-est.html

Tools:
1. QLET – Quick Logistics Estimations tool (has CLS I water and CLS VIII forecasting based on unit UIC)
2. Food and Water Tool (may assist with nutrition planning to prevent DNBI, confer with S4/G4 unit commodity specialist

The Special Operations Forces (SOF) Logistics handbook is also available on the website for reference.

2025 RANGER MEDIC HANDBOOK 229

Issue Initial Medical Planning Guidance to Subordinates. Medical planners should constantly disseminate information
to subordinate elements and junior Medics. Information provided should be as comprehensive as possible consistent with
operational security considerations. Planning guidance should include the medical threat, medical assets, copies of higher
OPORDs/OPLANs, and information that will assist subordinates with medical planning at their level. Guidance from above
helps junior Medics better prepare themselves and their equipment for tactical operations.

Determine Casualty Flow from Target to Hospitalization. The tactical Medic will always have a detailed understanding
of the casualty flow up to two levels above themselves, including patient regulating, casualty accountability, and hospi-
talization requirements. Furthermore, casualty flow is planned from the point-of-injury all the way back to admission to a
Continental United States (CONUS) medical facility. However, in an established combat theater, a casualty may be admit-
ted, treated and even released from an intermediate facility between the battlefield and CONUS.

CASUALTY FLOW CONSIDERATIONS

■ Where will the unit’s casualties be evacuated to?
■ Will evacuation be conducted by ground or air (or water) assets to a casualty collection point?
■ How will evacuation be conducted to casualty transload points?
■ What are the distances and times of travel?
■ Will expected casualties be able to make it that far? If not, what parts of the plan need to be adjusted?
■ Who will evacuate the casualties (unit, frequency, callsigns)?
■ Will medical assets be properly positioned to ensure continuity of care?
SECTION 8

Determine Key Locations. Key locations for medical assets are determined based upon the casualty estimation and the
commander’s tactical assault plan.

DETERMINE KEY LOCATIONS

■ Based on your casualty estimation and the tactical assault plan…
É Where should the CCP be located?
É Where should patient exchanges be located? (CEP, CCP, HLZ, AXP)
É Where are the projected blocking positions, fighting positions, etc…?
É Where is the CP/TOC?
É Who is in charge of each key location?
É Primary and alternate locations?
É What are the ground movement routes?
É What are the main and alternate routes (BLOC/supply bundles)?
É Is there a decompression plan (e.g., STRATEVAC) to sustain patient holding capacity for the MTF?
É Do the fuel capacities of the evacuation assets support the plan (confirm with S3/G3 air on FARP requirements).

230 SECTION 8 MEDICAL PLANNING & CASUALTY COLLECTION OPERATIONS

Establish the Tactical Medical Support Plan. The medical support plan can be developed alongside tactical plans, but
often it is difficult to lock in the medical plan until tactical planners have settled on the preferred course of action. A basic
tactical medical support plan should include the following elements:
3. The distribution, task organization, and tactical movement (infiltration/exfiltration) of medical elements, all synchro-
nized with each other and the overall tactical plan;
4. The casualty flow plan from point of injury, through evacuation, to a medical treatment facility, including primary and
secondary evacuation routes, method, and modes (aid & litter, air, ground, water);
5. Primary and alternate sites for CCPs, casualty evacuation locations;
6. A medical communications plan;
7. A medical re-supply plan if the operation will continue for a length of time; and
8. Management plans for wounded hostile combatants and noncombatant casualties.

Air Tactical Evacuation Plan. The following information should be gathered in the formulation of a tactical air evacuation
plan:

AIR CASEVAC PLAN

■ What is the type of air CASEVAC mission?
É Dedicated – an air asset whose purpose after infiltration is casualty evacuation. It is outfitted and manned for
casualty management.
É Designated – an air asset that will be the aircraft instructed to evacuate casualties. May be equipped for
casualties if requested.
É On-call – air assets that are held in reserve or must be launched to respond to casualty evacuation. May also
apply to MEDEVAC covering the area.
■ Aircraft type?
■ Maximum casualty load?
■ How are casualties to be loaded?
É Packaging requirements: litters, Skedcos, etc.?
É Is the aircraft equipped with litter stanchions?
É Loading procedures? Approach procedures?
■ What medical capability is on the aircraft?
É Flight Medic or medical officer?
É Casualty management equipment?
É Medical resupply bundles?
É Does the unit need to outfit the platform with medical capability?
■ Request procedures?
É Procedures for requesting CASEVAC?
É 9-Line MEDEVAC request versus modified format?
É Communication requirements?

SECTION 8
■ Launch authority?
É Who is the launch authority for the aircraft?
É What are the impacts on Ranger CASEVAC operations?
■ Landing requirements?
É Special HLZ considerations?
É Special markings required?
■ Special equipment required?

2025 RANGER MEDIC HANDBOOK 231

Ground Tactical Evacuation Plan. There are two major components of a ground tactical evacuation plan. The first is
ground evacuation in the target area and the second is from the target area to higher echelon of care. The security of the
ground element is a critical aspect of moving casualties within or out of the target area. The unit must ensure that a fighting
element will protect the evacuation asset from enemy attack.

Ground tactical evacuation at the objective consists of moving casualties from their points of injury to casualty collection
points or evacuation points. Aid & litter teams will be formed by personnel within the fighting elements. These personnel
will be trained, equipped and rehearsed to conduct this mission prior to launching the tactical mission. Vehicles of op-
portunity such as abandoned or captured enemy vehicles on the target can be used to move casualties. For instance, in
an airport/airfield seizure, the unit could use baggage carts to move casualties.

Planning for evacuation by ground from the objective to a medical facility incorporates the same kind of information as
planning for air evacuation, except for questions unique to the vehicles. One critical aspect of ground evacuation, however,
is whether the unit will conduct the evacuation using its own assets or call on another unit.

GROUND CASEVAC PLAN – TWO PHASES

1. Actions required on the target.
■ How should Rangers move casualties on the target to the CCP?
É Aid & litter teams
É Skedco, litter, etc…
É Ranger ground mobility (Quad, MEDSOV, GMV, RSOV, Stryker, MEV, MRAP)
2. Actions required for evacuation away from the target.
■ What is the type of ground CASEVAC mission?
É Dedicated – a ground asset whose purpose after infiltration is casualty evacuation. It is outfitted and
manned for casualty management
É Designated – a ground asset that will be the vehicles instructed to evacuate casualties. May be equipped for
casualties if requested.
É On-call – ground assets that are held in reserve or must be launched to respond to casualty evacuation. This
may be vehicles of opportunity (tactical or captured).
■ Vehicle type and maximum casualty load?
■ How are casualties to be loaded?
É Packaging requirements: litters, Skedcos, etc.?
É Is the vehicle equipped with a carrying configuration?
É Loading procedures?
■ What medical capability is on the vehicle?
É Medics? Medical officers?
É Casualty management equipment?
■ Request Procedures?
SECTION 8

É Procedures for requesting ground CASEVAC?

É 9-Line MEDEVAC request versus modified format?
É Communication requirements (freq/callsign)?
■ Launch authority?
É Who is the launch authority for the vehicles?
■ Link-up requirements
É At your CCP or an AXP?
É Marking/signaling procedures?

232 SECTION 8 MEDICAL PLANNING & CASUALTY COLLECTION OPERATIONS

QRF Capabilities and Integration
Medical Communications. The Tactical Medical Support Plan includes a plan for medical communications. In formulating
this plan, the following should be considered:

COMMUNICATIONS REQUIREMENTS
■ Do all Medics have radios?
■ Can a Medic contact a higher care provider for guidance?
■ Types of radios/COMSEC?
■ Medical command & control delineation
■ Callsigns/frequencies/SOI
■ Evacuation request frequencies?
■ Evacuation asset frequencies?
■ Casualty reporting/accountability?
■ What is the PACE plan (primary, alternate, contingency, emergency)?
■ Re-supply requests

Medical Re-Supply Requirements & Methods. Medical planners must develop a thorough understanding of the unit’s
normal medical equipment, supplies, load plans, and premission shortages. For the development of the medical support
plan, determinations are made regarding the equipment and supplies that will be initially carried onto the target, and a
further plan established for a first and second echelon of re-supply. The tactical medical planners should also understand
the acquisition and availability of blood products, special vaccines, antidotes, and antivenins as required.

CLASS VIII RE-SUPPLY REQUIREMENTS & METHODS

■ How do you request re-supply?
■ Resupply can be requested via line 4 of the MEDEVAC request if the configured CLS VIII has been precoordinated
■ What are the re-supply methods?
É Speedballs?
É Drag-off bundles?
É CDS?
■ Medical packing lists? Do you need to reconfigure/repack (aid bag, pelican)?
■ How do you request specific line items?

SECTION 8
Briefs, Rehearsals, and Precombat Inspections
The operations order (OPORD) at all levels will include the tactical medical support plan. For forced-entry type missions
in which the assault force is making an initial entry into an operational area, the medical component must be extensive
and informative.

MEDICAL & CASUALTY RESPONSE OPORD BRIEFING AGENDA

■ Health threat
■ Casualty response concept of the operation
■ Key locations (CCPs, HLZs, AXPs, etc)
■ Casualty flow (to key locations to HLZ/AXP to MTF)
■ Requesting procedures (CASEVAC, MEDEVAC, assistance, re-supply, including net/freq/callsign of supporting
elements)
■ Medic callsigns/frequencies
■ Casualty accountability

2025 RANGER MEDIC HANDBOOK 233

Rehearsals. Rehearsals familiarize unit members with the mission plan and visualize the expected action. Depending on
the level and repetition of rehearsal, unit members can develop a thorough familiarity with the sequence of events that
will be executed. A rehearsal should be conducted as a scripted event that lays out the operational plan in a sequence of
overlapping events. Contingencies and complications can be injected to assess unit member reactions and to practice
alternate plans.

Full dress rehearsals provide the most detailed understanding of the operation and involve all unit members executing
their expected tasks flowing through the expected timeline of the event. A full dress rehearsal is a military field exercise;
a training event preparing for the real event at a similar location layout. A Reduced Force Rehearsal involves only key
leadership of subordinates and operational units. Terrain model rehearsals, also known as ROC drills or sandbox drills, use
miniature depictions of the operational area. Terrain model rehearsals are historically the most commonly used method for
rehearsal of military operations. Map rehearsals can be used virtually anywhere using actual maps, imagery or sketches
of operational areas.
A communications rehearsal, also known as a COMMEX, is a combination of testing communications systems as well as
unit members running through the sequence of events through radio calls. For the communications equipment tests, using
the same equipment, same frequencies, and same distances specified in the operational plan will provide the unit with
the best insight into whether their equipment will function properly. If possible, line-of-sight obstacles such as buildings
or terrain should be interposed between radios to exactly replicate conditions at the target. Casualty response specific
execution checklist calls must be integrated into the overall unit EXCHECK. Example calls may be CCP established,
evacuation asset in place/on station, casualty HLZ (CEP or AXP) established, and most importantly the radio notification
call for a casualty report. Contingency or deviation calls may be required for mass casualty situations, accidents/incidents
involving aircraft or vehicles, and changes from primary to alternate aircraft/vehicles, key locations, evacuation assets, or
receiving medical facilities.

REHEARSALS
■ RFR drills
■ Squad casualty response drills (care under fire, TFC and evacuation)
É Each element should rehearse alerting aid & litter team and movement of a casualty
■ Aid & litter team drills
É Alert and movement
É Evacuation equipment prep
É Clearing/securing weapons
■ Evacuation request and loading procedures
■ COMMEX
■ Unit-wide casualty tracking/accountability
SECTION 8

■ CCP operations
É Assembly, security & movement
É Recon, clear and secure CCP location
É CCP markings, link-up procedures, and vehicle parking
É Choke point/CCP command post
É Triage, treatment and management of casualties
É Casualty accountability & reporting
É Marking & tagging
É Equipment removal tagging/consolidation
■ Review of execution checklist calls pertinent to the casualty response plan

234 SECTION 8 MEDICAL PLANNING & CASUALTY COLLECTION OPERATIONS

Precombat Inspections. Every combat unit will conduct precombat inspections (PCIs) prior to launching on a mission.
PCI are conducted from the lowest leadership levels to the highest; no individual will be exempt.

PRE-COMBAT INSPECTIONS
■ Individual Rangers
É Ranger Bleeder Kits (BCKs)
É TQ on kit serviceable
■ Squad casualty response kit
É ARFR bag
É Evacuation equipment (Skedco, litters, etc.)
É Vehicle mounted aid bags
■ Ability to store and transport blood with proper cold-chain management
■ RMED individual equipment (weapon, NVG, radio, packing list, mission specific)
■ RMED aid bags (pack and/or reconfigure as required)
É Select appropriate aidbag system per mission requirements
É Ensure packing list IAW recommended Ranger Medic standards
■ Re-supply packages (pack and/or reconfigure per mission requirements)
É Reconfigure per mission specifics (ground, air, etc.)
É Utilize speedballs, bundles, or pull-off configured as required
É Pre-position as required with aircraft and vehicles or at staging base with BLOC and logistics teams
■ Evacuation assets (quads, vehicles, etc.)
■ Pre-mission conditions check with supporting MTF and evacuation assets

Sustained Combat Operations & Time-Sensitive Targets

When a unit is deployed and operating in a particular area of operations, several planning mechanisms will become more
streamlined and habitual. The casualty response brief will be minimized to essential changes of information. While still
covering the essential information, the brief will be tailored to a single slide within the overall OPORD or CONOP. This is
especially useful in time sensitive operations in which there may be only a few hours to minutes prior to launching the as-
sault force on the mission. It is best to maintain a single slide in which critical information is routinely updated. This allows
for making specific minimal changes based on the mission at hand.

Time Sensitive Targets (TST). The key to successful time sensitive target planning is maximizing coordination’s prior to
the unfolding events. The medical planner should have already made face-to-face or phone contact with evacuation as-
sets, receiving hospital facilities and other unit planners.

SECTION 8
The essentials of planning TST casualty response remains consistent with normal planning except that it is done rapidly
and heavily based on precoordinated activities. The planner must be well versed in the unit compressed planning se-
quence and use of appropriate computer software, communications capabilities and methods to check status of assets.
As soon as the unit receives the WARNORD of an upcoming mission, the medical planner must immediately initiate their
planning sequence of events. WARNORD briefs are usually conducted quickly upon receipt from the higher HQ or the unit
commander. The medical planner must be considered a key leader in the unit planning sequence for TST missions. Criti-
cal pieces of information are the target location, projected HLZs, and available evacuation and treatment facility assets.

Generally, the primary means of evacuation will be CASEVAC using the mission platforms used for infiltration and exfiltra-
tion. The alternate evacuation means will mostly be using the conventional assets from their bed down locations. However,
each mission must be tailored to available assets. Unless the unit is augmented, the receiving facility will be the nearest
Role 2 or higher capability within range of the target. The planner must be careful in selecting the receiving MTF while
considering distances, capabilities, and the current status of each facility. The planner must always establish a primary,
alternate, and perhaps a tertiary receiving facility. Ensure you have a good understanding of which facilities should receive
casualties with specific injuries such as head injuries or burns.

2025 RANGER MEDIC HANDBOOK 235

Once the commander has established the basic tactical CONOP, determine the casualty estimate and select appropriate
locations for primary and alternate CCPs as well as evacuation HLZs/CEPs. Identify personnel designated to perform aid &
litter team duties on target. Confirm the JOC/TOC battle captain/NCO understands the procedures for requesting external
evacuation support and notification of receiving medical facilities of inbound casualties.
SECTION 8

Develop the casualty response CONOP based on all information gathered. Modify the one-slide casualty response CONOP
and ensure it is integrated into the unit CONOP. Disseminate all information to subordinate Medics and unit personnel.
Brief the casualty response plan in the unit brief and send the medical CONOP to higher HQ as required. When feasible
and approved within OPSEC guidelines, notify receiving medical facilities and evacuation assets of the upcoming mission.

Conduct pre-combat inspections of individual Rangers, Medic aid bags, squad ARFR kits, aid & litter team equipment,
CASEVAC platform medical equipment, and re-supply packages.

Postmission, ensure that all medical supplies and equipment is refit and restocked. Conduct postmission screening of all
assault force members for unreported injuries. Follow-up with receiving facilities on status of any casualties evacuated.
Provide an update to the commander on casualty status. Conduct an AAR of the mission to identify any lessons learned
and/or modifications to future CONOP plans. Additionally, a casualty after-action review/report will be submitted on each
Ranger/MWD casualty within 72 hours post mission.

236 SECTION 8 MEDICAL PLANNING & CASUALTY COLLECTION OPERATIONS

TST Planning
■ Receive WARNORD of pending TST mission
É Confirm target location grid
É Confirm preliminary HLZ information (or infiltration locations/methods)
É Confirm status of task force organic medical personnel and evacuation capabilities
É Determine any medical augmentation requirements and initiate appropriate requests
■ Assess distances and response times based on target location and/or HLZs (based on appropriate routes
through terrain obstacles such as mountains or around enemy areas)
É Confirm travel distance and time to the target
É Confirm distance from target to primary, alternate, and tertiary receiving facilities
É Confirm distance to target, response time, distance to destination and time to destination for primary, second-
ary and tertiary forms of evacuation. Ensure response time includes notification and spin-up time for launch of
the asset.
É Determine if specific receiving medical facilities need to be designated for specific injuries (head injuries or
burns)
■ Confirm readiness of receiving facilities and external evacuation assets
É Contact primary and secondary medical receiving facilities to confirm their bed status and readiness to accept
casualties.
É Contact primary and secondary evacuation assets to confirm their readiness status.
É Contact CSAR coverage asset and confirm readiness status and response times.
■ Finalize tactical medical support plan based off of commander’s tactical CONOP
É Conduct casualty estimate on target to determine where casualties are likely to occur
É Confirm/Assess best locations for primary and alternate CCPs on target
É Confirm/Assess best locations for primary and alternate evacuation HLZs/CEPs
É Confirm/Determine personnel tasked to be aid & litter teams on target
É Confirm JOC/TOC battle captain/NCO knows appropriate evacuation JOC/TOC drill for requesting external
evacuation and notification of receiving facility (to include 9-line MEDEVAC request transmission procedures)
É Develop casualty response CONOP using the one-slide with changes as required.
■ Perform pre-combat inspections
É Check individual Rangers for bleeder control kits, squad casualty response kits, and identified aid & litter team
equipment
É Check individual medic aid bag and kit
É Check CASEVAC assets equipment and re-supply packages
■ Post-mission activities
É Restock and refit any expended medical supplies and equipment in RFR kits, Medic aid bag or CASEVAC
platforms.
É Conduct AAR of mission to gather lessons learned and/or modifications to future CONOPS
É Follow-up on casualties with receiving facilities and provide an update to the commander
É Perform maintenance on Medic equipment to include weapons, NVGs, radios, and medical equipment

SECTION 8
É Conduct screening of mission personnel for any injuries sustained and not previously reported to include post-
blast assessments

2025 RANGER MEDIC HANDBOOK 237

Casualty Collection Point Operations
Casualty collection point (CCP) operations must be a well-planned and rehearsed. In the planning phase, both unit leader-
ship and members of the CCP element have critical responsibilities. In the execution phase, the members of the CCP must
act as a cohesive team with every member fulfilling his responsibilities. A CCP will never be exactly the same as it was on
a previous mission. However, there are critical guidelines in the planning and execution of any CCP.

CCP SITE SELECTION

■ Reasonably close to the fight
■ Near templated areas of expected high casualties
■ Cover and concealment
■ In building or on hardstand (exclusive CCP building limits confusion)
■ Access/trafficable to evacuation routes/assets (foot, vehicle, aircraft)
■ Proximity to lines of drift on the objective
■ Adjacent to objective choke points (breeches, HLZs, etc.)
■ Avoid natural or enemy choke points
■ Area allowing passive security (inside the perimeter)
■ Good drainage
■ Expandable if casualty load increases
■ Consider placement of CCP locations near recognizable landmarks such as airfield control towers, fire stations,
religious buildings, or local medical facilities.

UNIT LEADERSHIP CCP DUTIES & RESPONSIBILITIES

■ Planning Phase
➢ Evacuation plan by phase of the operation
➢ CCP locations, HLZ/AXP locations
➢ Security of CCP, security of HLZ/AXP
➢ Allocate aid & litter teams and carry evacuation equipment
➢ Accountability/reporting plan
➢ Distribution/task organization of medical personnel
➢ Pre-combat inspections of junior Medics, Squad Casualty Response Kits, and individual Ranger BCK/RFR tasks
➢ Conduct casualty response rehearsals
SECTION 8

■ Execution Phase
➢ Establish and secure CCP
➢ Provide assistance to Medics with ARFR augmentation and directing aid & litter teams
➢ Gather and distribute casualty equipment and sensitive items
➢ Accountability and reporting to higher
➢ Request evacuation and establish CASEVAC link-up point
➢ Manage KIA remains (or as coordinated by BLOC/S4)

238 SECTION 8 MEDICAL PLANNING & CASUALTY COLLECTION OPERATIONS

BATTALION-LEVEL MEDICAL PERSONNEL CCP DUTIES & RESPONSIBILITIES
■ Planning Phase
➢ Provide recommendations and advise to leadership on medical support
➢ Recommend to the unit leadership & coordinate as required:
• CCP Locations of subordinate units by phase
• Medical task organization & distribution
• Ground (on the target) evacuation plan & assets for all targets
• Air/ground (off the target) evacuation plan & assets for all targets
• CCP, HLZ, and evacuation asset security for all targets
➢ Augmentation requirements of subordinate units
➢ Link-in with the tactical operations center
■ Execution Phase
➢ Triage, treatment, monitoring, and packaging
➢ Delegation of treatment
➢ Request assistance from other medical or platoon assets
➢ Provide guidance and recommendations to leadership on casualty management

UNIT MEDICS CCP DUTIES & RESPONSIBILITIES

■ Planning Phase
➢ Provide recommendations and advise to leadership on medical support
➢ Medical support planning by phase of the operation
➢ Casualty response & evacuation plan by phase of the operation
➢ Recommend to the unit leadership & coordinate as required:
• CCP locations by phase
• Medical task organization & distribution
• Ground (on the target) evacuation plan & assets
• Air/ground (off the target) evacuation plan & assets
• CCP, HLZ, and evacuation asset security
➢ Pre-combat inspections of junior Medics, Squad Casualty Response Kits, and individual Ranger BCK/RFR
tasks
■ Execution Phase
➢ Triage, treatment, monitoring, and packaging
➢ Delegation of treatment
➢ Request assistance from other medical or unit assets
➢ Provide guidance and recommendations to leadership on casualty management & evacuation

SECTION 8

2025 RANGER MEDIC HANDBOOK 239

CCP OPERATIONAL GUIDELINES
■ 1SG/PSG is responsible for casualty movement and everything outside the CCP
➢ Provides for CCP structure and organization (may be color coded with Chemlights)
➢ Maintains C2 and battlefield situational awareness
➢ Controls aid & litter teams, and establishes security
➢ Strips, bags, tags, organizes, and maintains casualty equipment outside of treatment area as possible
➢ Ensures reallocation of equipment as required (weapons systems, etc.)
➢ Accountable for tracking casualties and equipment into and out of CCP and provides reports to higher
➢ Casualties move through CCP entrance/exit choke point which should be marked with an IR Chemlight
■ Medical personnel are responsible for everything inside the CCP
➢ Triage officer sorts and organizes casualties at choke point into appropriate treatment categories
➢ Medical officers and/or Medics organize medical equipment/supplies and render treatment to casualties
➢ Directs ARFRs, RFRs, A&L Teams assist with treatment and packaging of casualties
■ Minimal casualties should remain with original element or assist with CCP security if possible
■ KIAs should remain with original element or be transported to the BLOC
■ All CCP personnel:
• Maintain security
• Maintain adequate treatment
• Maintain situational awareness
• Maintain organization
• Maintain control of equipment & supplies

CCP WITHIN A BUILDING GUIDELINES

■ Ensure building is cleared and secured
■ Enter and assess the building prior to receiving casualties
➢ Use largest rooms
➢ Consider litter/Skedco movement (can you do it in the area?)
➢ Separate rooms for treatment categories?
➢ Determine location of choke point/triage
➢ Minimize congestion
■ Remove/re-locate furniture or obstructions
■ Color-code rooms to treatment categories (mark doors, etc.)
SECTION 8

240 SECTION 8 MEDICAL PLANNING & CASUALTY COLLECTION OPERATIONS

EVACUATION GUIDELINES
■ Know the evacuation asset
➢ Medical provider on board?
➢ Monitoring equipment on board?
➢ How many CAX can evacuate on asset?
■ Packaging requirements for asset
➢ Type litters?
➢ Are there stirrups? Floor-loading?
■ Determine flow of casualties to the asset
➢ Large asset (multiple CAX)
• Routine on first
• Priority on next
• Critical (urgent) on last, so they are first off at destination
➢ Small asset
• Critical (urgent) and priority evacuated first

The following diagrams are common templates for the layout and organization of casualty collection points. No template is
perfect and it should be reasonably modified based on the setting, terrain, and mission circumstances.

CCP/CEP Template 1
(Adjacent to Breech)

SECTION 8

2025 RANGER MEDIC HANDBOOK 241

CCP/CEP Template 2
(Flow Through Style)

CCP/CEP Template 3
(Building – Rooms)
SECTION 8

242 SECTION 8 MEDICAL PLANNING & CASUALTY COLLECTION OPERATIONS

CCP/CEP Template 4
(Building – Open/Hanger)

CCP/CEP Template 5
(Open Area/Filed)

SECTION 8

2025 RANGER MEDIC HANDBOOK 243

CCP/CEP Template 6
(U-Shaped)

After Action Review. No mission (training or combat) is complete until an after action review (AAR) has been completed.
After each operation, an assessment of its conduct from beginning to end is conducted to gather all possible lessons.
Units will often need to provide detailed reports to higher headquarters about the conduct of a combat operation. The plan-
ning and execution of the unit’s casualty response will often bring critical lessons learned to the forefront. Keep in mind that
a lesson is not learned until the problem has been identified, the unit has solved the problem, and the solution becomes the
normal way of operating in the future. The list of questions below is a basic topic list for the AAR.
SECTION 8

AFTER ACTION REVIEW (AAR) IN TRAINING OR COMBAT

■ Was the mission executed as planned?
■ What went right?
■ What went wrong?
■ What could have been done better?
■ What could be fixed by planning/preparation?
■ What could be fixed by training?
■ What could be fixed by equipment modification?
■ Identify and record sustains & improves by phase of the operation

244 SECTION 8 MEDICAL PLANNING & CASUALTY COLLECTION OPERATIONS

Relief-in-Place Operations
Staging Base Relief-in-Place
Ranger units have been continuously deployed to combat since October of 2001. Units conduct relief-in-place operations
as Ranger units deploy to and re-deploy from the area of operations. It is critical that the unit pass on everything possible
that it has learned, experienced and coordinated with the incoming unit. By no means does this relinquish responsibility of
the incoming unit to confirm and conduct further coordination. Ensure you provide a good turnover to the incoming team.
Keep in mind, you will be the incoming Medic on your next rotation and would expect the same.

Tactical Relief-in-Place
Ranger units may turn over a target or seized terrain to a follow-on unit. Until the incoming unit makes adjustments to its
tactical plan, it is best for them to assume the positions and procedures previously conducted. The senior Ranger tacti-
cal medical provider will link up with their counterpart of the incoming unit and provide as much information as possible

TACTICAL RELIEF-IN-PLACE
■ Current primary and alternate CCPs and HLZs
■ Current external evacuation assets and receiving medical facilities supporting the area and any problems
­encountered.
■ Ensure the incoming unit understands the capabilities and limitations of supporting evacuation and medical
treatment facilities.
■ Where, how many, and what types of casualties sustained during the previous operation.
■ Any health trends that the relieving unit should be aware of.
■ Potential hazards to unit personnel such as contaminated water or HAZMAT.
■ Turnover of detainees or EPWs should include any medical conditions noted.

SECTION 8

2025 RANGER MEDIC HANDBOOK 245

NOTES
SECTION 8

246 SECTION 8 MEDICAL PLANNING & CASUALTY COLLECTION OPERATIONS

SECTION 9

HAZARDOUS TRAINING
MEDICAL COVERAGE

SECTION 9

247
HAZARDOUS TRAINING MEDICAL COVERAGE DUTIES & RESPONSIBILITIES
Senior Coverage Medic
■ Plan & coordinate medical support requirements & considerations

■ Identify hospitals and evacuation routes

Conduct hospital site survey as required
Conduct face-to-face with hospital ER
Conduct route recon from target to hospital
■ Establish target medical coverage plan and casualty flow
■ Brief OIC/NCOIC medical support plan
Clarify OIC/NCOIC responsibilities and guidance
Clarify medical responsibilities and guidance
■ EXECUTION duties:
Patient treatment & monitoring on target and en route
Advise OIC/NCOIC as required
Update OIC/NCOIC/higher HQ on condition of evacuated casualties
Inform unit medical officer of all casualties
■ After training event
Follow-up any evacuated casualties and update C2 and medical director
Clean, refit, store all coverage equipment
Submit AAR IAW unit or event-specific requirements

OIC/NCOIC of Event
■ Overall responsible for administrative coverage (including medical)
■ Request/track external medical support requirements
■ Ensure appropriate type and number of vehicles with assigned drivers are dedicated to medical coverage
■ Ensure appropriate communications equipment is allocated to medical personnel.
■ Link medical coverage plan with overall administrative coverage plan.
■ EXECUTION duties:
Collect casualty data and report to higher HQ
Request MEDEVAC
Identify and establish MEDEVAC HLZ
SECTION 9

248 SECTION 9 HAZARDOUS TRAINING MEDICAL COVERAGE

HAZARDOUS TRAINING MEDICAL COVERAGE PLANNING
Maps & Route Recons
■ Request/purchase/acquire appropriate maps of training areas, adjacent military installations, and cities
■ Conduct map and ground recon of training areas (specifically key entrance & exit points).
■ Identify hospitals/fire/EMS locations

Identify Special Coverage Considerations

■ Weather
■ Animals
■ Plants
■ Terrain hazards (high angle or high altitude)

Identify Hospitals
■ Primary and alternate evacuation hospital (one should be a Level 1 trauma center)
■ Conduct hospital site survey and face-to-face
■ Determine hospital communications: o ER phone line
➢ ER ambulance line
➢ Patient admin phone line
➢ Security line phone line
■ Determine routes and directions to hospitals
■ Where are special injuries evacuated?
➢ Neurosurgical
➢ Burns
➢ Trauma centers
• Level 1 (neurosurgeon on staff 24 hours)
• Level 2 (neurosurgeon on call, but not on site 24/7)
Vehicle Requirements
■ Driver: A dedicated driver – NOT the medic covering the event. Must be familiar with training area and evacua-
tion routes.
■ Ambulance: A dedicated, climate controlled, covered vehicle capable of carrying at least 1 litter. The vehicle
must provide environmental control and adequate space for medical equipment. Mark vehicle as appropriate
(ambulance symbols or lights).
➢ Optimal vehicles:
• Van (15PAX only)
• Large SUV (Expedition, Tahoe, etc…)
• FLA (M996/M997)
➢ Suboptimal vehicles
• Open HMMWV / GMV
• MEDSOV (tactical operations only – not for admin coverage)
• Small SUV (Explorer, Durango, Cherokee, etc…) or small van (7PAX)
Communication Requirements
■ Equipment

SECTION 9
➢ FM radios or installation “brick” radios
➢ Cellphone
■ Radio nets & frequencies
➢ Administrative coverage (DZSO Net)
➢ Exercise/target control or observer/controller nets
➢ Tactical nets
■ En route evacuation communications
• Cellphone to notify receiving facilities
• Borrowed local radios
■ Establish speed dials / specific channels
➢ Receiving medical facilities and evacuation assets

2025 RANGER MEDIC HANDBOOK 249

EQUIPMENT REQUIREMENTS MEDICAL COVERAGE DURING TACTICAL EXERCISES
S tandard Medical Equipment ■ Plan for all casualties to be evacuated to Level 1 or 2 Trauma
■ Rigid litter Centers ONLY.
■ Splint sets ■ If evacuation time to primary center is more than 20 minutes’
training is considered HIGH RISK.
■ Oxygen/masks/BVM
■ Obtain PDSS Checklist from MEDO.
■ Suction, mechanical & manual
■ All casualties go through the tactical evacuation channels
■ Mechanical traction splint
unless life, limb or eyesight is threatened. A Ranger exercise
■ Vital signs monitor does not “go admin” unless absolutely required to save the
■ Litters injured Ranger.
■ Blankets/hypothermia management ■ All patients are treated to U.S. Standard of Care and unit
■ Trauma aid bag protocols.
■ Pain management
■ Vehicles do not enter or move on drop zones without DZSO
permission and notification of the tactical C2.
Special Equipment Considerations ■ Use of white lights during night operations will be minimized
to patient care.
■ Hot weather
➢ Ice sheets ■ If possible, utilize the tactical unit’s capabilities to move casu-
➢ Fans (battery operated) alties to minimize impact on the ongoing exercise.
➢ Cold packs ■ Notify receiving medical facilities of incoming casualties and
status.
■ Cold weather
➢ Rescue wraps/patient heaters
■ Keep training event OIC/NCOIC informed of patient status with
routine updates
➢ IV fluid warmer
■ Vehicles do not enter or move on drop zones without DZSO
■ Rescue permission and notification of the tactical C2.
➢ High-angle rescue kit
■ Inform unit medical officers of casualties and status.
➢ Skedco
■ Blood products for high-risk training
PRE-COVERAGE INSPECTIONS
*NO RANGER IS EXEMPT FROM PCIs*
Inspect/Inventory Medical Equipment
Inventory IAW Hazardous Coverage Checklist
Function check all mechanical devices and monitors
Check battery charges
Inspect Vehicle(s)
■ PMCS of vehicle
■ Fuel level
■ Dispatch or rental agreement
■ Maps/routes posted

Support Equipment
■ Communications equipment
SECTION 9

■ Strobe lights/flashlights/headlamps
■ Night vision
■ GPS
■ Rescue equipment

PRE-COVERAGE REHEARSALS
■ Drive routes to hospitals during daytime and nighttime. Determine/record time from training site to hospital.
Consider civilian traffic pattern interference on evacuation route.
■ Brief OIC, NCOIC, OPFOR, and role-players on medical coverage plan and actions. Specifically, CCP or
MEDEVAC locations and casualty notification/evacuation request procedures.
■ Conduct rehearsal of casualty movement in the exercise area and prep for evacuation.

250 SECTION 9 HAZARDOUS TRAINING MEDICAL COVERAGE

75th Ranger Regiment Trauma Management Team

Hazardous Training Medical Coverage Checklist

SECTION 9

Medic Name Date

Training Event Location

SR Medic or Range NCOIC/OIC Name & Countersign:

2025 RANGER MEDIC HANDBOOK 251

SECTION 10

PACKING LISTS
SECTION 10

252
Kit / Aid Bag Minimum Stock
The following list is what each medic should carry at a minimum and used as a guide to pack their Kit and Aid Bag.
The medic must have enough supplies to treat two multi-system trauma casualties. Items packed in the Kit provide
immediate initial care to life-threatening injuries on a trauma casualty without external bags and equipment.
Common Name Quantity Notes
Massive Hemorrhage Control
Tourniquet 2
Hemostatic Dressing 2
Pressure Dressing 2
Pelvic Binder with Puck and Pump 1
Wound Packing Gauze 2
Airway Management
Cricothyroidotomy Kit 2
Nasopharyngeal Airway 28fr w/lubricant 1
Bougie Device 1
Suction, Hand-Held Manual Device 1
EtCO 2 Device 1 With EMMA adapter × 2
Respiratory Management
10G or 14G / 3.25" NCD 4
Vented Chest Seal 4
Occlusive Dressing 4 Used for securing chest tube/cric
Bag-Valve Mask 1
Chest Tube Kit 1
Pulse Oximetry Device 1
Stethoscope 1
Circulation/Fluid Resuscitation Management
Intraosseous Device 2 Sternal Capable IO × 1, IO × 1
IV Starter Kit 2
NS Flush 10mL 4
Fluid Warmer 1 With cartridges × 2
100mL or 250mL NaCl IV Bag 2
Blood Collection Bag 1
Filtered Tubing 2 “Y” or “Single”
BP Cuff Manual 1
Sharps Shuttle 1
Blood Product Storage 1 Single/Double Unit Containers last approximately 8–12 hr,
4 Unit Container lasts approximately 24 hr
Pressure Infuser 1
Disability/Immobilization
Cravat 2
Splint, Malleable 2
Ace Wrap 2
Miscellaneous
Casualty Card 4
Marker 2
Tape 2
Shears 2
Scalpels 4
9" peans 1
Narcotics Box 1 At the discretion of Senior Medical personnel.
Recommended medics carry a minimum of: 1 × Ketamine,
1 × opioid, and 1 × benzodiazepine.
Medication Box 1 At the discretion of the Senior Medical personnel.
Recommended medics carry a minimum of: 1 × naloxone,
SECTION 10

1 × ondansetron, 1 × antibiotic, 1 × NSAID, 1 × EPI, 2 × TXA,

1 × calcium, 1 × antihistamine, 1 × Albuterol MDI
1mL syringe 3
3mL syringe 3
10mL syringe 3
18G hard needle 5
23G hard needle 5
MASCAL Card 1
Chem Lights (Red, Blue, Green) 1 Set 2 × Red, 2 × Blue, 2 × Green
Light Source 2
Gloves
Spare batteries for electronics
Sterilization equipment 4 (i.e. alcohol, betadine, etc.)

2025 RANGER MEDIC HANDBOOK 253

Advanced Ranger First Responder Medical Kit Contents
The following list is what each Advanced Ranger First Responder should carry at a minimum and used as a guide
to pack their medical kit.
Common Name Quantity Notes
Massive Hemorrhage Control
Tourniquet 2
Hemostatic Dressing 2
Pressure Dressing 2
Pelvic Binder with Puck and Pump 1
Wound Packing Gauze 2
Airway Management
Nasopharyngeal Airway 28fr w/lubricant 1
Respiratory Management
10G or 14G/3.25" NCD 2 10G preferred
Vented Chest Seal 2
Finger Thoracostomy Kit 1
Pulse Oximetry Device 1
BVM 1 Mission Dependent
Circulation/Fluid Resuscitation Management
Intraosseous Device 2 Sternal Capable IO × 1, IO × 1
IV Starter Kit 2
NS Flush 10mL 2
Blood Collection Bag 1
Filtered Tubing 1 “Y” or “Single”
Sharps Shuttle 1
Blood Product Storage 1 Single/Double Unit Containers last approximately
8–12 hr, 4 Unit Container lasts approximately 24 hr
Disability/Immobilization
Splint, Malleable 1
Ace Wrap 2
Miscellaneous
Casualty Card 2
TXA with Protective Case 1
Shears 1
Marker 2
3" Tape 1
10mL syringe 2
100mL or 250mL NaCl IV Bag 1
18G Hard Needle 2
Light Source 1
Gloves

Ranger Bleeder Control Kit Contents

The bleeder control kit will be worn on the left side of the body or the lower back.
Common Name Quantity Notes
Massive Hemorrhage Control
Tourniquet 2
Hemostatic Dressing 2
Pressure Dressing 1
SECTION 10

Wound Packing Gauze 1

Airway Management
Nasopharyngeal Airway 28fr w/lubricant 1
Respiratory Management
Vented Chest Seal 2
10G or 14G/3.25" NCD 1 10G preferred
Circulation/Fluid Resuscitation Management
IV Starter Kit 1
Miscellaneous
Casualty Card 1

254 SECTION 10 PACKING LISTS

SECTION 11

REFERENCES
& ABBREVIATIONS

SECTION 11

255
1SG first sergeant ASAP as soon as possible
1T2X1 USAF AFSC pararescuemen ASMB area support medical battalion
4N0X1 USAF AFSC aerospace medical specialist ASMC area support medical company
5392 USN NEC naval special warfare AT/NC atraumatic, normocephalic
medic (SOCM) ATLS advanced trauma life support
61N USA flight surgeon ATM advanced trauma manager/
65B USA AOC physical therapist management
65D USA AOC physician assistant ATP advanced tactical practitioner
68J USA MOS medical logistics ATT …at this time
specialist AWLS advanced wilderness life support
68W USA MOS healthcare specialist AXP ambulance exchange point
68W-R-W1 USA MOS healthcare specialist – BALCS body armor load carriage system
ranger qualified-ranger unit service– BAS battalion aid station
special operations combat medic bid twice a day
68W-V-W1 USA MOS healthcare specialist – BCK bleeder control kit
ranger school qualified – Bingo out of fuel
special operations combat medic BKA below-the-knee amputation
68W-W1 USA MOS healthcare specialist – BLOC battalion logistics operations center
special operations combat medic BLS basic life support
68S USA MOS preventive medicine BLUF bottom line up front
specialist BM bowel movement
68T USA MOS veterinary specialist BMNT before morning nautical twilight
68X USA MOS mental health specialist BN battalion
70B USA AOC medical service corps BP blood pressure or blocking position
70H USA AOC medical operations officer BPM beats per minute
70K USA AOC medical logistics officer BRBPR bright red blood per rectum
8404 USN NEC field medical service BS bowel sounds
technician BSI body substance isolation
8427 USN NEC special amphibious BVM bag-valve-mask
reconnaissance corpsman BW biological warfare
AA assembly area Bx biopsy
AAR after action review c with (cum)
AAS acute abdominal series C Celsius or centigrade
ABD abdomen C2 command & control
ABG arterial blood gas CA civil affairs
ABLS advanced burn life support CAD coronary artery disease
Abx antibiotics CAM chemical agent monitor
AC before eating (ante cibum) CAMS civil affairs medical sergeant
A/C aircraft CANA convulsant antidote for nerve agents
ACE ammunition, casualty, equipment CARP calculated air release point
ACL anterior cruciate ligament CAT computed axial tomography
ACLS advanced cardiac life support CAT combat application tourniquet
ACP alternate command post CAX casualties
AE aeromedical evacuation CBC complete blood count
AECC aeromedical evacuation control CBRN chemical, biological, radiological, nuclear
center cc cubic centimeter
AELT aeromedical evacuation liaison team CC chief complaint
AF afebrile CCP casualty collection point
AFSC air force specialty code (MOS) CDC centers for disease control
AFSOC air force special operations CDR commander
command CENTCOM United States central command
AGL above ground level CEP casualty evacuation point
AKA above-the-knee amputation CHI closed head injury
ALCON all concerned CHOPS chief of operations
ALS advanced life support CJTF combined joint task force
AMCIT American citizen CLS combat lifesaver
AMEDD army medical department CMB combat medical badge
AMS acute mountain sickness CMD command
A&O X - alert and oriented times orientation CMO civil-military operations
AO area of operations CNS central nervous system
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AOR area of responsibility C/O complaining of

AP anteroposterior CO commanding officer
ARDS acute respiratory distress syndrome CO carbon monoxide
ARF airfield reaction force CO2 carbon dioxide
ASA acetylsalicylic acid (aspirin) COA course of action

256 SECTION 11 REFERENCES & ABBREVIATIONS

COB close of business (time of day) or EDRE emergency deployment readiness
civilians on the battlefield exercise
CONOP concept of the operation EENT early evening nautical twilight
CONUS continental United States EFMB expert field medical badge
COP command outpost or common EKG electrocardiogram
operating picture EKIA enemy killed in action
CoTCCC committee on tactical combat EJ external jugular
casualty care EMG electromyogram
COTS commercial-of-the-shelf (purchase) EMS emergency medical system or
CP command post service
CPAP continuous positive airway pressure EMT emergency medical technician
CPR cardiopulmonary resuscitation or EMT-B emergency medical technician-basic
critical, priority, routine EMT-I emergency medical technician-
CQB close quarters battle intermediate
CQC close quarters combat EMT-P emergency medical technician-
CQM close quarters marksmanship paramedic
CR casualty response EOM extraocular muscles
Cric cricothyroidotomy EOMI extraocular muscles intact
CRTRL casualty response training for ranger EPW enemy prisoner of war
leaders ET endotracheal (tube)
CSAR combat search and rescue ETOH ethanol alcohol
CSF cerebral spinal fluid EWIA enemy wounded in action
CSS combat service support EXCHECK execution checklist
CTA clear to auscultation Exfil exfiltration
CTM combat trauma management EXORD execution order
CUF care under fire F Fahrenheit
CWIED command wired improvised FABER flexion, abduction and external rotation
explosive device FARP forward aerial refueling point
CWPP combat wound pill pack FB foreign body
CXP casualty exchange point F&D fixed and dilated
CXR chest x-ray FamHx family history
DA department of the army or F/C fevers, chills
direct action FDA food and drug administration
DACO departure airfield control FH field hospital
officer/operations FITT frequency, intensity, time, type
D/C discontinue or discharge FKIA friendly killed in action
DDx differential diagnosis FMC final manifest call or field medical card
DEA drug enforcement agency FMED flight medic
DHB defense health board FOB forward operating base
DIRLAUTH direct liaison authorized FOOSH fall on out-stretched hand
DLS dirt landing strip FP family practice
DMO diving medical officer FRAGO fragmentation order
DMT diving medical technician FRIES fast rope insertion/extraction system
DO doctor of osteopathy FSB forward staging base
DOA dead on arrival FST FTX forward surgical team field training
DOB date of birth exercise
DOD department of defense F/U follow-up
DOE dyspnea on exertion FUO fever of unknown origin
DOW died of wounds FWIA friendly wounded in action
DNBI disease/non-battle injury Fx fracture
DNR do not resuscitate g gram(s)
DPL diagnostic peritoneal lavage G gauge (needle)
DPN drops per minute G6PD glucose-6 phosphate dehydrogenase
DPT diphtheria, pertussis, tetanus GAF ground assault force
DSN defense switching network GCS Glasgow coma scale
DTG date time group DDTTTTZMMMYY GERD gastroesophageal reflux disease
DTR deep tendon reflex GFC ground force commander
DVT deep venous thrombosis GI gastrointestinal
Dx diagnosis GPS global positioning system
DZ drop zone GRG grid reference guide
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EA each GSW gunshot wound

EBL estimated blood loss gtt drops
ECC emergency cardiac care GU genitourinary
ECG electrocardiogram GWOT global war on terrorism
EDC estimated date of confinement HA headache

2025 RANGER MEDIC HANDBOOK 257

HACE high altitude cerebral edema JOMAC judgement, orientation, mentation,
HAF helicopter assault force abstraction, calculation
HAHO high altitude, high opening JVD jugular venous distention
(parachute) JCCP joint casualty collection point
HALO high altitude, low opening JSOC joint special operations command
(parachute) JSOM journal of special operations medicine
HAPE high altitude pulmonary edema JSOMTC joint special operations medical
HAZMAT hazardous materials training center
Hct hematocrit JSOTF joint special operations task force
HE high explosive kg kilogram
HEENT head, eyes, ears, nose, throat K potassium
Hg mercury KIA killed in action
Hgb hemoglobin L left
HLZ helicopter landing zone LA lymphadenopathy
HM3 USN hospital corpsman 3rd class lac laceration
(E4) LASER light amplification by stimulated
HM2 USN hospital corpsman 2nd class emission of radiation
(E5) LASIK laser-assisted in situ keratomileusis
HM1 USN hospital corpsman 1st class LBP low back pain
(E6) LE lower extremities
HMC USN chief hospital corpsman LIH left inguinal hernia
(E7) LLL left lower lobe
HMCS USN senior chief hospital corpsman LMP last menstrual period
(E8) LOC loss of consciousness
HMCM USN master chief hospital corpsman LOD line of duty
(E9) LP lumbar puncture or listening post
HN USN hospitalman (E3) or host nation LR lactated ringers
HPI history of present illness LLQ left lower quadrant
HPS human patient simulator LTT live tissue training
hr hour LUL left upper lobe
HR heart rate LUQ left upper quadrant
HS bedtime (hours of sleep) MACE military acute concussion evaluation
HSV herpes simplex virus MAPCODE monitor, antibiotics, pain control,
HTN hypertension contact MO, oxygen, document, evacuate
HTS hypertonic saline MARCH massive hemorrhage, airway,
Hx history respiration, circulation, head injury/
IAPP inspection, auscultation, palpation, hypothermia
percussion MAST military anti-shock trousers
IAW in accordance with… MASSCAL mass casualty
ICRC international committee of the MASSCAX mass casualty
red cross MBITR multi-band intra team radio
ICW in conjunction with… MC medical control
I&D ID incision and drainage infectious disease MC medical corps
IDC see IDHC MDMP military decision-making process
IDHC USN independent duty hospital MEDLOG medical logistics
corpsman MEDO medical operations officer
IDMT USAF independent duty medical MEDOPS medical operations
technician MEDSOV medical special operations vehicle
IED improvised explosive device MES medical equipment set
IM intramuscular MGMT management
IMC initial manifest call MI myocardial infarction
IN Intranasal MICH modified individual combat helmet
Infil infiltration mmHg millimeters of mercury
I&O intake and output MMR measles, mumps, rubella
IO intraosseous MOA memorandum of agreement
IOT in order to… MOI mechanism of injury or memorandum
IPPB intermittent positive pressure of instruction
breathing MO medical officer
IPR in process review MOS military occupational specialty
IRF immediate reaction force MOU memorandum of understanding
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ISB intermediate staging base MOUT military operations in urban terrain

ISO in support of… MPC multipurpose canine
IV intravenous MRI magnetic resonance imaging
IVO in vicinity of… MROE medical rules of engagement
JOC joint operations center MTF medical treatment facility

258 SECTION 11 REFERENCES & ABBREVIATIONS

MVA motor vehicle accident PE physical exam or pulmonary embolism
NAD no acute distress PEA pulseless electrical activity
NAEMT national association of emergency medical PECC patient evacuation control center
technicians PEPP pediatric emergencies for pre-hospital
NCM nurse case manager providers
NEC naval enlisted classification (MOS) PERRLA pupils equal, round, reactive to light and
NEO non-combatant evacuation operation accommodation
NET no earlier than… PFT pulmonary function test
NGO non-government organization PHA periodic health assessment
N-Hour notification hour P-HR parachute hour
NKA no known allergies NKDA no known PHTLS pre-hospital trauma life support
drug allergies PHTR pre-hospital trauma registry
NLT no later than… PIR priority intelligence requirements
NMA non-medical attendant PJ USAF pararescueman
NOK next of kin PLF parachute landing fall
NPA nasopharyngeal airway PM preventive medicine
NPO nothing by mouth (nil per os) PMCS preventive maintenance checks & services
NS normal saline PMHx past medical history
NREMT national registry of emergency PMI point of maximal impulse
medical technicians PNOK primary next of kin
NSAID nonsteroidal anti-inflammatory drug PO by mouth (per os)
NSR normal sinus rhythm POC point of contact
NTG nitroglycerin POD period of darkness
N/V/D nausea, vomiting, diarrhea POI point of injury or program of instruction
NVG night vision goggles POW prisoner of war
NWB non-weight bearing PPD purified protein derivative
OB obstetrics PPE personal protective equipment
OBJ objective ppm parts per million
O/C observer/controller PPV positive pressure ventilation
OCO OCONUS contingency operations PR per rectum or personnel recovery
OCOKA observation and fire, concealment and PRK photorefractive keratectomy
cover, obstacles, key terrain, and avenues PRN as often as needed (pro re nata)
of approach PSHx past surgical history
OCONUS outside continental United States PSI pounds per square inch
OD right eye (oculus dexter), overdose Pt patient
ODT orally disintegrating tablets PT physical therapist or physical training
OE otitis externa PTSD post-traumatic stress disorder
OEF operation enduring freedom PUD peptic ulcer disease
OIF operation Iraqi freedom PULHES physical profile factors:
OM otitis media P - physical capacity or stamina, U - upper
OND operation new dawn (Iraq) extremities, L-lower extremities, H- hearing
OPA oropharyngeal airway and ears, E - eyes, S- psychiatric
OPLAN operations plan PZ pickup zone
OPORD operations order q every (quaque)
OPREP operational report QC quality control
OPQRST onset, provokes, quality, radiates, qd every day
severity, time qhr every hour
OPSEC operations security q _hr every _ hours
OPSO operations officer q_min every _ minutes
OPV oral polio vaccine qid four times a day (quater in die)
ORP objective rally point qod every other day
OS left eye (oculus sinister) QRF quick reaction force
OTSG office of the surgeon general qt quart
PA physician assistant qty quantity
PALS pediatric advanced life support R right
PAX personnel RASP ranger assessment & selection
PB patrol base program
PC precious cargo (operational) RAW ranger athlete warrior (program)
PC after eating (post cibum) RBC red blood cell
PCI pre-combat inspection RCMS ranger casualty management system
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PCN penicillin RC regional command

PDHA pre/post deployment health RCO regimental commander
assessment RCP runway crossing point
PDHRA post deployment health reassessment R&D research and development
PDSS pre-deployment site survey RDA recommended dietary allowance

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RECC ranger enhanced care clinic SEM systolic ejection murmur
REM rapid eye movement SF special forces
RFI request for information SFG special forces group
RFM release for medical (standards) or SFMS special forces medical sergeant
regimental finance management SITREP situation report
RFR ranger first responder SL sublingual
RFS release for standards SLLS stop, look, listen, smell (tactical)
Rh Rhesus blood factor SMO senior medical officer
RHQ regimental headquarters Sn signs
RGR ranger SNL standard name line (last, first, MI, rank,
RIH right inguinal hernia SSN, unit, DOB)
RLL right lower lobe SocHx social history
RLCS ranger load carriage system SOAR special operations aviation regiment
RLQ right lower quadrant SOB shortness of breath
RLTW rangers lead the way SOCM special operations combat medic
RMAV ranger medic assessment and SOCMSSC special operations combat medic skills
validation sustainment course
RMed ranger medic SOF special operations forces
RMED regimental medical section SOI signal operating instructions
RMEDFM regimental medical force modernization SOMA special operations medical association
RMEDO regimental medical operations officer SOP standard operating procedures
RML right middle lobe SOR statement of requirements
R/O rule out SP start point
ROC ranger operations company SQ subcutaneous
ROE rules of engagement SQD squad
ROM range of motion SRMED senior ranger medic
ROS review of systems SRP soldier readiness processing
RP rally point SRT surgical resuscitation team
R-PA regimental physician assistant S/Sx signs and symptoms
RPSYCH regimental psychologist SSN social security number
RR respiratory rate STANAG standardization agreement
RRC regimental reconnaissance company STD sexually transmitted disease
RRF-1 ranger ready force one SURG surgeon (battalion, regimental, or
RRF-2 ranger ready force two command)
RRF-3 ranger ready force three SURT small unit ranger tactics
RRR regular rate and rhythm SVBIED suicide vest borne improvised
RRT regimental reconnaissance team explosive device
R&S reconnaissance and surveillance Sx symptoms
RSM regimental sergeant major Tab tablet
RSOV ranger special operations vehicle TACEVAC tactical evacuation
RSRMED regimental senior medic TBD to be determined
RSTB regimental special troops battalion TBSA total body surface area
RSURG regimental surgeon TCCC tactical combat casualty care
RTB return to base or ranger training TC3 tactical combat casualty care
brigade/battalion TCR trauma center rotation
RTC return to clinic Td tetanus-diphtheria toxoid
RUL right upper lobe TF task force
RUQ right upper quadrant TFC tactical field care
RVET regimental veterinarian TGT target
Rx prescription, treatment TIC troops in contact or toxic industrial
s without (sine) chemical
S1 personnel and administration tid three times a day (ter in die)
S2 intelligence and security TIM toxic industrial materials
S3 operations and training TKO to keep open
S4 logistics and supply TLP troop leading procedures
S5 civil affairs and information operations TM tympanic membrane
S6 signal and communications TMEP tactical medical emergency protocol
S8 force modernization, plan, R&D TMT trauma management team
SA situational awareness TNTC too numerous to count
SARC USN surface amphibious reconnaissance TOC tactical operations center
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corpsman TOD time of death

SCUBA self-contained underwater breathing TOT time on target
apparatus TQ tourniquet
SCRK squad casualty response kit tsp teaspoon
SEA senior enlisted advisor TST time sensitive target

260 SECTION 11 REFERENCES & ABBREVIATIONS

TTP tenderness to palpation or tactics, VD venereal disease
techniques & procedures VDO vehicle drop off
TTWB toe-touch weight bearing VOIED victim operated improvised explosive
Tx treatment device
U army special qualification identifier – VSS vital signs stable
ranger qualified & ranger unit service W1 special operations combat medic
ud as directed (ut dictum) additional skill identifier
UE upper extremities WALK warrior aid & litter kit
UIC unit identification code WARNORD warning order
URI upper respiratory tract infection WBAT weight bearing as tolerated
USA United States Army WBC white blood cell
USAF United States Air Force WD well developed
USAISR United States Army Institute of Surgical WHO world health organization
Research Winchester out of ammunition
USASOC United States Army Special Operations WIA wounded in action
Command WMD weapons of mass destruction
USN United States Navy WN well nourished
USSOCOM United States Special Operations WNL within normal limits
Command WP white phosphorus
USUHS uniformed services university of health W/U wheels up (aircraft departure)
sciences XO executive officer
UTI urinary tract infection Y/O years old
UXO unexploded ordinance >, <, = greater than, less than, equal
V army special qualification identifier for
ranger-parachutist LATIN:
VA visual acuity dominatus mastery in
VBIED vehicle borne improvised explosive comminus close combat
device rememdium medicine

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2025 RANGER MEDIC HANDBOOK 261

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262 SECTION 11 REFERENCES & ABBREVIATIONS

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2025 RANGER MEDIC HANDBOOK 263

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264 SECTION 11 REFERENCES & ABBREVIATIONS

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2025 RANGER MEDIC HANDBOOK 265

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266 SECTION 11 REFERENCES & ABBREVIATIONS

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2025 RANGER MEDIC HANDBOOK 267

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268 SECTION 11 REFERENCES & ABBREVIATIONS

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2025 RANGER MEDIC HANDBOOK 269

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270 SECTION 11 REFERENCES & ABBREVIATIONS

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2025 RANGER MEDIC HANDBOOK 271

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272 SECTION 11 REFERENCES & ABBREVIATIONS

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2025 RANGER MEDIC HANDBOOK 273

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274 SECTION 11 REFERENCES & ABBREVIATIONS

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2025 RANGER MEDIC HANDBOOK 275

Reference Charts
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276 SECTION 11 REFERENCES & ABBREVIATIONS

Conversion Charts

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2025 RANGER MEDIC HANDBOOK 277

Neuro Exam Reference Chart
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278 SECTION 11 REFERENCES & ABBREVIATIONS

ARDSnet Vent Settings
PBW and Tidal Volume for Females PBW and Tidal Volume for Males
Height (in) PBW 4ml 5ml 6ml 7ml 8ml Height (in) PBW 4ml 5ml 6ml 7ml 8ml
4' 0" (48) 17.9 72 90 107 125 143 4' 0" (48) 22.4 90 112 134 157 179
4' 1" (49) 20.2 81 101 121 141 162 4' 1" (49) 24.7 99 124 148 173 198
4' 2" (50) 22.5 90 113 135 158 180 4' 2" (50) 27.0 108 135 162 189 216
4' 3" (51) 24.8 99 124 149 174 198 4' 3" (51) 29.3 117 147 176 205 234
4' 4" (52) 27.1 108 136 163 190 217 4' 4" (52) 31.6 126 158 190 221 253
4' 5" (53) 29.4 118 147 176 206 235 4' 5" (53) 33.9 136 170 203 237 271
4' 6" (54) 31.7 127 159 190 222 254 4' 6" (54) 36.2 145 181 217 253 290
4' 7" (55) 34.0 136 170 204 238 272 4' 7" (55) 38.5 154 193 231 270 308
4' 8" (56) 36.3 145 182 218 254 290 4' 8" (56) 40.8 163 204 245 286 326
4' 9" (57) 38.6 154 193 232 270 309 4' 9" (57) 43.1 172 216 259 302 345
4' 10" (58) 40.9 164 205 245 286 327 4' 10" (58) 45.4 182 227 272 318 363
4' 11" (59) 43.2 173 216 259 302 346 4' 11" (59) 47.7 191 239 286 334 382
5' 0" (60) 45.5 182 228 273 319 364 5' 0" (60) 50.0 200 250 300 350 400
5' 1" (61) 47.8 191 239 287 335 382 5' 1" (61) 52.3 209 262 314 366 481
5' 2" (62) 50.1 200 251 301 351 401 5' 2" (62) 54.6 218 273 328 382 437
5' 3" (63) 52.4 210 262 314 367 419 5' 3" (63) 56.9 228 285 341 398 455
5' 4" (64) 54.4 219 274 328 383 438 5' 4" (64) 59.2 237 296 355 414 474
5' 5" (65) 57.0 228 285 342 399 456 5' 5" (65) 61.5 246 308 369 431 492
5' 6" (66) 59.3 237 297 356 415 474 5' 6" (66) 63.8 255 319 383 447 510
5' 7" (67) 61.6 246 308 370 431 493 5' 7" (67) 66.1 264 331 397 463 529
5' 8" (68) 63.9 256 320 383 447 511 5' 8" (68) 68.4 274 342 410 479 547
5' 9" (69) 66.2 265 331 397 463 530 5' 9" (69) 70.7 283 354 424 495 566
5' 10" (70) 68.5 274 343 411 480 548 5' 10" (70) 73.0 292 365 438 511 584
5' 11" (71) 70.8 283 354 425 496 566 5' 11" (71) 75.3 301 377 452 527 602
6' 0" (72) 73.1 292 366 439 512 585 6' 0" (72) 77.6 310 388 466 543 621
6' 1" (73) 75.4 302 377 452 528 603 6' 1" (73) 79.9 320 400 479 559 639
6' 2" (74) 77.7 311 389 466 544 622 6' 2" (74) 82.2 329 411 493 575 658
6' 3" (75) 80.0 320 400 480 560 640 6' 3" (75) 84.5 338 423 507 592 676
6' 4" (76) 82.3 329 412 494 576 658 6' 4" (76) 86.8 347 434 521 608 694
6' 5" (77) 84.6 338 423 508 592 677 6' 5" (77) 89.1 356 446 535 624 713
6' 6" (78) 86.9 348 435 521 608 695 6' 6" (78) 91.4 366 457 548 640 731
6' 7" (79) 89.2 357 446 535 624 714 6' 7" (79) 93.7 375 469 562 656 750
6' 8" (80) 91.5 366 458 549 641 732 6' 8" (80) 96.0 384 480 576 672 768
6' 9" (81) 93.8 375 469 563 657 750 6' 9" (81) 98.3 393 492 590 688 786
6' 10" (82) 96.1 384 481 577 673 769 6' 10" (82) 100.6 402 503 604 704 805
6' 11" (83) 98.4 394 492 590 689 787 6' 11" (83) 102.9 412 515 617 720 823
7' 0" (84) 100.7 403 504 604 705 806 7' 0" (84) 105.2 421 526 631 736 842
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Source: ARDSNet Studies

2025 RANGER MEDIC HANDBOOK 279

ARDSnet Vent Settings

OXYGENATION GOAL: PaO2 55–80mmHg or SpO2 88–95%

Use a minimum PEEP of 5cm H2O. Consider use of incremental
FiO2/PEEP combinations such as shown below (not required) to
achieve goal.

Lower PEEP/higher FiO2

FiO2 0.3 0.4 0.4 0.5 0.5 0.6 0.7 0.7

NIH NHLBI ARDS Clinical Network
Mechanical Ventilation Protocol Summary PEEP 5 5 8 8 10 10 10 12

FiO2 0.7 0.8 0.9 0.9 0.9 1.0

INCLUSION CRITERIA: Acute onset of
1. PaO2/FiO2 ≤ 300 corrected for altitude PEEP 14 14 14 16 18 18–24
2. Bilateral (patchy, diffuse, or homogeneous) infiltrates
consistent with pulmonary edema Higher PEEP/lower FiO2
3. No clinical evidence of left atrial hypertension
FiO2 0.3 0.3 0.3 0.3 0.3 0.4 0.4 0.5
PART I: VENTILATOR SETUP AND ADJUSTMENT PEEP 5 8 10 12 14 14 16 16
1. Calculate predicted body weight (PBW)
Males = 50 + 2.3 [height (inches) –60]
Females = 45.5 + 2.3 [height (inches) –60] FiO2 0.5 0.5–0.8 0.8 0.9 1.0 1.0
2. Select any ventilator mode PEEP 18 20 22 22 22 24
3. Set ventilator settings to achieve initial VT = 6mL/kg
PBW.
4. Reduce VT by 1mL/kg at intervals ≤ 2 hours until 6mL/kg PBW. PLATEAU PRESSURE GOAL: ≤ 30cm H 2O
5. S et initial rat to approximate baseline minute ventilator Check Pplat (0.5 second inspiratory pause), at least q4h and after
(not > 35 bpm). each change in PEEP or VT.
6. A djust VT and RR to achieve pH and plateau pressure If Pplat > 30cm H 2O: decrease VT by 1mL/kg steps (minimum =
goals below. 4mL/kg).
If Pplat > 25cm H 2O and V T < 6mL/kg, increase VT by 1mL/kg until
Pplat > 25cm H2O and V T = 6mL/kg.
If Pplat > 30cm and breath stacking or dys-synchrony occurs:
may increase V T in 1mL/kg increments to 7 or 8mL/kg if Pplat
remains ≤ 30cm H2O.

pH GOAL: 7.30–7.45 B. S PONTANEOUS BREATHING TRIAL (SBT):

Acidosis Management: (pH < 7.30) If all above criteria are met and subject has been in the study
If pH 7.15–7.30: Increase RR until pH > 7.30 or PaCO2 < 25 for at least 12 hours, initial a trial of UP TO 10 minutes of
(Maximum set RR = 35). spontaneous breathing with FiO2 ≤ 0.50 and PEEP ≤ 5:
1. Place on T-piece, trach collar, or CPAP ≤ 5cm H2O with PS ≤ 5.
If pH < 7.15: Increase RR to 35. 2. Assess for tolerance as below for up to two hours.
If pH remains < 7./15, VT may be increased in 1mL/kg steps until a. S
pO2 ≤ 90: and/or PaO2 ≥ 60mmHg
pH > 7.15 (Pplt target of 30 may be exceeded). b. Spontaneous V T ≥ 4mL/kg PBW
c. RR ≤ 35 min
Alkalosis Management: (pH < 7.45) Decrease vent rate if d. pH ≥ 7.3
possible. e. No respiratory distress (distress = 2 or more)
➢ HR ≥ 120% of baseline
➢ Marked accessory muscle use
➢ Abdominal paradox
➢ Diaphoresis
➢ Marked dyspnea
3. If tolerated for at least 30 minutes, consider extubation.
4. If not tolerated, resume pre-weaning settings.

I: E RATIO GOAL: Recommended that duration of inspiration be Definition of UNASSISTED BREATHING

≤ duration of expiration.
(Different from the spontaneous breathing
PART II: WEANING criteria as PS is not allowed)
A. Conduct a SPONTANEOUS BREATHING TRIAL daily when:
iO2 ≤ 0.40 and PEEP ≤ 8 OR FiO2 ≤ 0.60 and PEEP ≤ 5.
1. F 1. Extubated with face mask, nasal prong oxygen, or room air, OR
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2. PEEP and FiO2 ≤ values of previous day. 2. T-tube breathing, OR

3. P atient has acceptable spontaneous breathing efforts. (May 3. Tracheostomy mask breathing, OR
decrease vent rate but 50% for 5 minutes to detect effort.) 4. CPAP less than or equal to 5cm H2O without pressure support
4. N o neuromuscular blocking agents or blockade. or IMV assistance.

280 SECTION 11 REFERENCES & ABBREVIATIONS

Ranger
RangerCasualty Card
Casualty Card (adopted
(adopted as DA as DA
Form Form 7656)
7656)

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284
TBI RETURN TO DUTY PROGRESSION
Cognitive/Mood/Migraine
Stage Vestibular/Ocular-Motor/Cervical Physical Activities Activities Education
1 Daily activity that does not provide Light leisure activity, including Rest with minimal, • Rest, limited activity to promote
symptoms – (No exercise) walking on level surface limited cognitive activity recovery and eliminate symptoms
Low light, low noise environment – Light reading • DSM-5 Measure – Adult
(stay at home) • Sleep hygiene education &
TV limited to
24–48 hours of symptom-limited 1–2 hours/day handout
cognitive and physical rest followed • 3000mg molecularly distilled
by a gradual increase in activity, pharmaceutical grade European
staying below symptom-exacerbation pharmacopeia DHA/EPA
thresholds Omega-3 fatty acids
• 4x900mg Turmeric/Curcumin
daily
• Exogenous Ketones
• No alcohol or tobacco
• No video games/phones
• Driving appropriateness
2 • Progression: (progress in sub Light physical activities to Count from 0 to 100 by • Nutrition consult/anti-
TBI RTD CARD

SECTION 11 REFERENCES & ABBREVIATIONS

symptomatic effort levels) begin include walking, treadmill, 3s (all of this out loud) inflammatory diet handout
following 24–48 hr rest stationary bike, elliptical at • No alcohol
Count from 100 to 0 by
low pace and resistance
3s Basic • No video games/phones
Double leg stance Eyes Open Monitor HR and keep in Zone • No driving until vision & vestibular
Pixy Cubes – 4-block.
(EO)/Eyes Closed (EC) 0, 1, 2 – Daily exercises is at symptoms resolve
2, 3, 4 color progression
80–90% of HR that brings
Single leg stance (EO/EC) (Record # Solved)
on symptoms (May use
Single leg stance foam (EO/EC) Bruce Protocol or Buffalo Jigsaw Puzzle: Activity Rest
Concussion Treadmill Test ~200 pieces
Double leg bend and reach to floor Physical 30 min 4 hr
(BCTT))
Single leg bend and reach to floor Cognitive 30 min 60 min
Single leg alternating step up
toe taps
Alternating step ups/stair climber
TBI RETURN TO DUTY PROGRESSION (CONT.)
Cognitive/Mood/Migraine
Stage Vestibular/Ocular-Motor/Cervical Physical Activities Activities Education
3 Light Occupation-Oriented Activity Monitor HR may go up to high Weapon assemble/ • No video games, limit phone use/
(progress in sub symptomatic effort Zone 2 – Daily exercise is at disassembly screen time
levels) 80–90% of HR that brings on Count from 0 to 200 • Alcohol may worsen symptoms;
symptoms (May use Bruce by 3s avoid or minimize to speed full
Same as Phase 2: adding helmet, Protocol or (BCTT)) Count from 200 to 0 recovery.
kit, ruck by 3s
• No activities with excessive head
Walking Uneven surfaces Pixy Cubes – 16-block movements
WITH grid lines 2, 3,
Walking farmers carry ≤ 20lb 4 color progression
Walking alternating Shoulder Press (Record # Solved) Activity Rest
≥ 20lb Physical 60 min 4 hr
Walking with alternating heat Cognitive 30 min 60 min
rotation
Walking with alternating head
flex/extension
Turkish Get ups ≤ 20lb
SL RDL ≤ 20lb

4 Moderate Activity – (progress in sub Monitor HR should be into Count from 0 to 300 • No Combatives or collision sports
symptomatic effort levels) zone 3 by 7s • No weapons firing
• Daily Exercises is at Count from 300 to 0
by 7s
TBI RTD CARD (cont.)

Same as above add NVG to walking 80–90% of HR that brings

activity on symptoms (May use Pixy Cubes – 16-block Activity Rest
Bruce Protocol or (BCTT)) WITHOUT gridlines.
Double leg jump rope/hopping 60 min 2 hr
• Resistance Training with no 2, 3, 4 color progression
vestibular load (Record # Solved) Physical 60 min 4 hr
Single leg jump rope/hopping
500-piece jigsaw puzzle 90 min 6 hr
SL Balance Ball throws (rebounder) 20:10 Circuit – 1 Min Rest
– 5 Rounds NeuroTracker SOF 20 min 40 min
OLY Lifts (technique only) Protocol Cognitive 30 min 60 min
A. DB Walking Lunges (Self-limiting)
Agility Ladder Training 40 min 80 min
B. Incline Bench Press
(Sub symptom effort)

2025 RANGER MEDIC HANDBOOK

C. Barbell Glute Bridge
D. Band Lat Pull Down
E. Machine Row
F. Goblet Squat

285
*Weight as tolerated

SECTION 11
SECTION 11

TBI RETURN TO DUTY PROGRESSION (CONT.)

286
Cognitive/Mood/Migraine
Stage Vestibular/Ocular-Motor/Cervical Physical Activities Activities Education
5 Vestibular/Ocular-Motor Screening RTD Stress Test – Monitor NeuroTracker SOF • No combatives or collision sports
(VOMS) Heart Rate throughout test Protocol (Self-limiting) • No weapons firing

Treadmill (If treadmill only Activity Rest

goes to 15% grade) 30 min 2 hr
3.5 (4.5) mph @ 14% (10%) Physical 60 min 4 hr
grade × 3 min
90 min 6 hr
4.5 (5.5) mph @ 16%
(12.5%) grade × 3 min
5.0 (6.0) mph @ 18% (15%)
grade × 3 min

1–2 min rest and then: (10 sec

between activity)

Trap Bar Dead lift 185#

× 10 reps
Burpees x20
Bench Press 135# × 10 reps

SECTION 11 REFERENCES & ABBREVIATIONS

Assault Bike 2 miles in < 6
TBI RTD CARD (cont.)

minutes or Rower 1400m in

< 6 minutes
Continuous Step-ups 12
inches, in kit or vest
× 3 min
Rest 3 min and repeat

6 Shooting at range – assess tolerance to Walking in kit with NVG’s over NeuroTracker SOF • No combatives or collision sports
small arms blast uneven terrain Protocol (Self-limiting)
7 Shooting – stepwise integration of Running in kit with NVG’s NeuroTracker SOF • No crew-served weapons,
movement and vestibule-ocular over uneven terrain and climb Protocol (Self-limiting) mortars, breeching
systems (CQB crawl-walk-run over wall
8 reintegration)
9 Return to Full Duty **If symptoms are present
for 30 days place consult to
Neuropsychology and Neurology**
NOTES

SECTION 11

2025 RANGER MEDIC HANDBOOK 287

NOTES
SECTION 11

288 SECTION 11 REFERENCES & ABBREVIATIONS

THE RANGER CREED
Recognizing that I volunteered as a Ranger, fully knowing the hazards
of my chosen profession, I will always endeavor to uphold the prestige,
honor, and high esprit de corps of my Ranger Regiment.
Acknowledging the fact that a Ranger is a more elite soldier who arrives
at the cutting edge of battle by land, sea, or air, I accept the fact that as
a Ranger, my country expects me to move further, faster and fight harder
than any other soldier.
Never shall I fail my comrades. I will always keep myself mentally alert,
physically strong, and morally straight, and I will shoulder more than
my share of the task, whatever it may be, one hundred percent and
then some.
Gallantly will I show the world that I am a specially selected and well
trained soldier. My courtesy to superior officers, neatness of dress, and
care of equipment shall set the example for others to follow.
Energetically will I meet the enemies of my country. I shall defeat them
on the field of battle for I am better trained and will fight with all my might.
Surrender is not a Ranger word. I will never leave a fallen comrade to
fall into the hands of the enemy and under no circumstances will I ever
embarrass my country.
Readily will I display the intestinal fortitude required to fight on to the
Ranger objective and complete the mission, though I be the lone survivor.

RANGERS LEAD THE WAY

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