Tactical Medicine: Pharmacology
A field drug reference spanning OTC and pharmacy medications, Ranger Medic combat pharmacology, K9 dosages, hemorrhagic shock classification, and vitals and conversions.
Contents — 23 units
OTC Medications
Over-the-counter medications are available without prescription. These are your first line of defense for common ailments.
EFFECTIVE OTC COMBINATION: Acetaminophen 1000mg + Ibuprofen 400mg taken together is as effective as oral opioids at 2 hours for acute pain. This combination is available without prescription and can be sourced in most countries.
Pain & Fever
| Drug | Adult Dose | Best For | Cautions |
|---|---|---|---|
| Acetaminophen (Tylenol) | 1000mg q6h Max: 3000mg/day | Pain, fever, safe with most conditions | Liver damage if exceeded. No alcohol. |
| Ibuprofen (Advil, Motrin) | 400mg q4-6h Max: 1200mg/day | Pain, inflammation, fever, menstrual cramps | Take with food. Not if kidney issues, stomach ulcers, or bleeding. |
| Naproxen (Aleve) | 220mg q8-12h Max: 660mg/day | Long-lasting pain relief, arthritis | Longer acting, same warnings as ibuprofen. |
| Aspirin | 325-650mg q4h Max: 4000mg/day | Pain, inflammation, heart protection | Can cause bleeding. Not for children (Reye's syndrome). |
Allergy & Cold
| Drug | Adult Dose | Best For | Notes |
|---|---|---|---|
| Diphenhydramine (Benadryl) | 25-50mg q4-6h | Allergies, hives, sleep aid, itching | Causes drowsiness. Good for severe allergies. |
| Cetirizine (Zyrtec) | 10mg once daily | Seasonal allergies, hives | Less drowsy than Benadryl. 24-hour relief. |
| Loratadine (Claritin) | 10mg once daily | Seasonal allergies | Non-drowsy. 24-hour relief. |
| Pseudoephedrine (Sudafed) | 30-60mg q4-6h | Nasal/sinus congestion | Behind pharmacy counter. Raises BP. Don't use if heart issues. |
| Phenylephrine (Sudafed PE) | 10mg q4h | Nasal congestion | OTC version. Less effective than pseudoephedrine. |
| Guaifenesin (Mucinex) | 200-400mg q4h | Chest congestion, mucus | Drink lots of water. Loosens phlegm. |
| Dextromethorphan (DM) | 10-20mg q4h | Cough suppressant | For dry cough only. Don't use if productive cough. |
Digestive
| Drug | Adult Dose | Best For |
|---|---|---|
| Loperamide (Imodium) | 4mg initial, then 2mg after each loose stool Max: 16mg/day | Diarrhea |
| Bismuth subsalicylate (Pepto-Bismol) | 524mg q30min PRN Max: 8 doses/day | Diarrhea, nausea, upset stomach |
| Famotidine (Pepcid) | 10-20mg q12h | Heartburn, acid reflux |
| Omeprazole (Prilosec) | 20mg once daily | Frequent heartburn (14-day course) |
| Calcium carbonate (Tums) | 500-1000mg PRN | Immediate heartburn relief |
| Docusate (Colace) | 100mg daily | Stool softener for constipation |
| Bisacodyl (Dulcolax) | 5-15mg at bedtime | Constipation (stimulant laxative) |
Topical
| Product | Use | Application |
|---|---|---|
| Triple Antibiotic (Neosporin) | Minor cuts, scrapes, burns | Thin layer 1-3x daily |
| Bacitracin | Minor wounds (less allergenic) | Thin layer 1-3x daily |
| Hydrocortisone 1% | Itching, rashes, insect bites, eczema | Thin layer 2-4x daily, max 7 days |
| Clotrimazole (Lotrimin) | Athlete's foot, jock itch, ringworm | 2x daily for 2-4 weeks |
| Miconazole (Monistat) | Yeast infections (vaginal/skin) | Per package directions |
| Lidocaine 4% | Topical pain relief, sunburn | Apply to affected area PRN |
| Benzocaine (Orajel) | Mouth/tooth pain | Apply to affected area q2h PRN |
Pharmacy Requests
Austere Situation: If medical infrastructure is compromised, you may need to request medications directly from pharmacies. Know what to ask for.
INTERNATIONAL OPERATIONS: Medications have different names in different countries. Before deploying OCONUS, identify local brand names and formulations for your essential medications. During the Ukraine crisis, standardized translation lists helped operators source medications across European pharmacies despite language barriers.
Essential Antibiotics to Request
For pharmacist consultation or emergency dispensing:
| Drug | Typical Dose | Covers |
|---|---|---|
| Amoxicillin | 500mg 3x daily x 7-10 days | Respiratory, ear, dental, skin infections |
| Amoxicillin-Clavulanate (Augmentin) | 875mg 2x daily x 7-10 days | Broader coverage including bites |
| Azithromycin (Z-Pack) | 500mg day 1, 250mg days 2-5 | Respiratory, STIs, skin |
| Ciprofloxacin | 500mg 2x daily x 7-14 days | UTI, GI, respiratory |
| Doxycycline | 100mg 2x daily x 7-14 days | Respiratory, tick-borne, STIs, malaria prevention |
| Metronidazole (Flagyl) | 500mg 3x daily x 7-10 days | GI infections, anaerobic bacteria, parasites |
| Trimethoprim-Sulfa (Bactrim) | 1 DS tablet 2x daily x 3-14 days | UTI, skin infections (MRSA coverage) |
Antibiotic Allergies: If allergic to penicillin (amoxicillin), request azithromycin or doxycycline as alternatives. Tell the pharmacist.
Critical Medications
| Drug | Purpose | Notes |
|---|---|---|
| Epinephrine Auto-Injector | Severe allergic reaction | EpiPen or generic. Life-saving. |
| Albuterol Inhaler | Asthma, breathing difficulty | Rescue inhaler for bronchospasm |
| Prednisone | Severe allergic reaction, asthma | 40-60mg x 5-7 days for allergic reactions |
| Ondansetron (Zofran) | Severe nausea/vomiting | 4-8mg q8h, dissolving tablets available |
| Naloxone (Narcan) | Opioid overdose reversal | Often available without Rx in pharmacies |
Pain Management
| Drug | Dose | Notes |
|---|---|---|
| Tramadol | 50-100mg q4-6h | Moderate pain, less restricted than other opioids |
| Cyclobenzaprine (Flexeril) | 5-10mg 3x daily | Muscle relaxant for spasms |
| Gabapentin | 300mg 3x daily (titrate up) | Nerve pain, some availability issues |
| Lidocaine Patches | 1-3 patches daily (12h on/12h off) | Localized pain relief |
How to Talk to Pharmacists
- Be honest about your situation
- Describe symptoms clearly
- Mention any allergies
- Ask about interactions with current meds
- Request generic versions (cheaper)
- Ask about emergency supply policies
Many states allow pharmacists to prescribe or provide emergency supplies of essential medications.
Natural Remedies
When modern medicine is unavailable, these evidence-based natural remedies can help. Not a replacement for professional care when available.
Wound Care
| Remedy | Use | How |
|---|---|---|
| Raw Honey | Wound healing, burns, infection prevention | Apply directly to wound, cover with bandage. Change daily. |
| Aloe Vera | Burns, sunburn, skin irritation | Apply gel from plant directly to skin. |
| Plantain Leaf | Insect stings, minor cuts, drawing out infection | Crush fresh leaf into poultice, apply to wound. |
| Yarrow | Stop bleeding, wound healing | Crush leaves, apply to wound. Traditional "soldier's woundwort." |
| Tea Tree Oil | Antiseptic, antifungal | Dilute (5 drops per tbsp carrier oil). Do not ingest. |
Honey: Use raw, unpasteurized honey. Medical-grade Manuka honey is best. Regular store honey is less effective.
Pain & Inflammation
| Remedy | Use | How |
|---|---|---|
| Willow Bark | Pain, fever (contains salicin - natural aspirin) | Tea: 1-2 tsp dried bark in hot water, steep 15 min. 3x daily. |
| Turmeric | Inflammation, joint pain | 1/2 tsp powder in warm water or food. Add black pepper for absorption. |
| Ginger | Nausea, inflammation, digestion | Fresh tea, chew raw, or candied. 1-2g daily. |
| Peppermint | Headache, muscle pain, digestion | Tea, or apply diluted oil to temples/muscles. |
| Clove | Tooth pain (contains eugenol) | Apply clove oil to tooth/gum, or chew whole clove. |
Infection Fighting
| Remedy | Use | How |
|---|---|---|
| Garlic | Antibacterial, antiviral, antifungal | Crush and let sit 10 min (activates allicin). Eat raw or in food. 2-3 cloves daily. |
| Oregano Oil | Powerful antimicrobial | 2-4 drops in water, 3x daily. Very strong - dilute. |
| Echinacea | Immune support, cold/flu | Tea or tincture at first sign of illness. Take for 7-10 days max. |
| Elderberry | Viral infections, flu | Syrup: 1 tbsp 4x daily during illness. Do not eat raw berries. |
| Goldenseal | Mucous membrane infections | Tea or capsules. Short-term use only (1-2 weeks). |
Digestive
| Remedy | Use | How |
|---|---|---|
| Ginger | Nausea, vomiting, motion sickness | Tea, candied, or chew fresh. Safe during pregnancy. |
| Peppermint | IBS, bloating, gas | Tea after meals. Enteric-coated capsules for IBS. |
| Chamomile | Stomach upset, cramping, sleep | Tea: 1-2 bags in hot water, steep 5 min. |
| Activated Charcoal | Poisoning, gas, diarrhea | 500-1000mg for GI issues. For poisoning: 50-100g with water. |
| Apple Cider Vinegar | Heartburn, digestion | 1-2 tbsp in water before meals. |
Activated Charcoal for Poisoning: Give within 1 hour of ingestion. Does NOT work for: alcohol, heavy metals, lithium, acids, petroleum products. Call Poison Control first: 1-800-222-1222
Field Medicine
Only use plants you can positively identify. Misidentification can be fatal. When in doubt, do not use.
Common Medicinal Plants (North America)
| Plant | Identification | Medicinal Use |
|---|---|---|
| Plantain (Plantago) | Oval leaves with parallel veins, grows in lawns/paths | Poultice for stings, bites, wounds. Chew and apply. |
| Yarrow | Feathery leaves, flat white flower clusters | Stop bleeding, wound healing. Crush leaves, apply. |
| Mullein | Large fuzzy leaves, tall flower spike | Respiratory issues. Tea from leaves. Oil for ear infections. |
| Pine Needles | 5-needle clusters (White Pine) safest | High in Vitamin C. Tea for colds, scurvy prevention. |
| Willow Bark | Long narrow leaves, grows near water | Pain relief (natural aspirin). Tea from inner bark. |
| Dandelion | Yellow flower, jagged leaves, milky sap | Diuretic, liver support. Entire plant edible. |
Improvised Medical Supplies
| Need | Improvised Solution |
|---|---|
| Antiseptic wash | Salt water (1 tsp per cup), diluted alcohol, or clean urine (sterile) as last resort |
| Wound dressing | Clean cloth, moss (sphagnum is antibacterial), inner bark |
| Splint material | Sticks, bark, rolled newspaper, cardboard |
| Suture/closure | Duct tape, superglue (cyanoacrylate), butterfly from tape |
| Tourniquet | Belt, torn cloth (2"+ wide), stick for windlass |
| Oral rehydration | 6 tsp sugar + 1/2 tsp salt per liter water |
| Water purification | Boil 1 min (3 min above 6500ft), 2 drops bleach/liter wait 30 min |
Oral Rehydration Solution (ORS)
1 liter clean water + 6 level teaspoons sugar + 1/2 level teaspoon salt
Use for: Diarrhea, vomiting, heat illness, blood loss recovery
Drink: Small sips frequently. Adult: 200-400ml after each loose stool.
Pine Needle Tea (Vitamin C)
- Collect fresh green needles from White Pine, Spruce, or Fir
- Avoid: Yew, Norfolk Island Pine, Ponderosa Pine (toxic)
- Chop needles finely
- Steep 1-3 tablespoons in hot water for 10-15 minutes
- Strain and drink
Contains: 4-5x more Vitamin C than oranges by weight
TOXIC LOOKALIKES: Yew (red berries), Water Hemlock (looks like parsnip), and many others are deadly. Never consume a plant unless you are 100% certain of identification.
Medicine Stockpile
Build your medical supplies before you need them. A well-stocked medicine cabinet can handle most emergencies.
Tier 1: Basic Home Kit (Everyone)
- Acetaminophen (Tylenol) - 500mg tablets
- Ibuprofen (Advil) - 200mg tablets
- Diphenhydramine (Benadryl) - 25mg capsules
- Loperamide (Imodium) - 2mg tablets
- Antacids (Tums or Pepcid)
- Triple antibiotic ointment
- Hydrocortisone cream 1%
- Bandages, gauze, medical tape
- Thermometer
- Tweezers, scissors
Tier 2: Extended Kit (Prepared Households)
Add to Tier 1:
- Pseudoephedrine (Sudafed) - decongestant
- Guaifenesin (Mucinex) - expectorant
- Cetirizine or Loratadine - non-drowsy antihistamine
- Omeprazole (Prilosec) - acid reducer
- Docusate (Colace) - stool softener
- Bismuth subsalicylate (Pepto-Bismol)
- Clotrimazole cream - antifungal
- Saline nasal spray
- Eye drops (artificial tears)
- Oral rehydration salts
- SAM splint or rolled magazines
- Israeli bandage or pressure dressing
- Tourniquet (CAT or SOFTT-W)
Tier 3: Austere/Remote Kit
Add to Tiers 1 & 2 (consult physician for Rx items):
- Antibiotics: Amoxicillin, Azithromycin, Ciprofloxacin, Metronidazole
- Epinephrine auto-injector
- Prednisone tablets
- Ondansetron (Zofran) dissolving tablets
- Naloxone (Narcan)
- Suture kit or skin stapler
- Lidocaine for injection
- Chest seals
- Hemostatic gauze (QuikClot, Celox)
- NPA airway
- Pulse oximeter
- Blood pressure cuff
Storage Tips
- Store in cool, dry, dark place
- Check expiration dates annually
- Most medications remain effective 1-2 years past expiration
- Keep inventory list with dates
- Rotate stock (use oldest first, replace)
- Vacuum seal for long-term storage
- Include dosage charts and instructions
Expiration Reality: Studies show most medications retain 90%+ potency for years past expiration. Exceptions: liquid antibiotics, insulin, nitroglycerin, EpiPens (replace when expired).
Pediatric Dosing
Children are not small adults. Dosing is based on weight. When in doubt, call poison control: 1-800-222-1222
Acetaminophen (Tylenol)
10-15 mg/kg every 4-6 hours
Maximum: 75 mg/kg/day (not to exceed 4000mg)
| Weight | Age (approx) | Dose |
|---|---|---|
| 6-11 lbs | 0-3 months | 40mg (1.25ml infant drops) |
| 12-17 lbs | 4-11 months | 80mg (2.5ml infant drops) |
| 18-23 lbs | 1-2 years | 120mg |
| 24-35 lbs | 2-3 years | 160mg |
| 36-47 lbs | 4-5 years | 240mg |
| 48-59 lbs | 6-8 years | 320mg |
| 60-71 lbs | 9-10 years | 400mg |
| 72-95 lbs | 11 years | 480mg |
| 96+ lbs | 12+ years | 640-1000mg (adult dose) |
Ibuprofen (Advil, Motrin)
5-10 mg/kg every 6-8 hours
Maximum: 40 mg/kg/day (not to exceed 1200mg)
Not for infants under 6 months
| Weight | Age (approx) | Dose |
|---|---|---|
| 12-17 lbs | 6-11 months | 50mg (1.25ml) |
| 18-23 lbs | 12-23 months | 75mg |
| 24-35 lbs | 2-3 years | 100mg |
| 36-47 lbs | 4-5 years | 150mg |
| 48-59 lbs | 6-8 years | 200mg |
| 60-71 lbs | 9-10 years | 250mg |
| 72-95 lbs | 11 years | 300mg |
| 96+ lbs | 12+ years | 200-400mg (adult dose) |
Diphenhydramine (Benadryl)
1-1.25 mg/kg every 6 hours
Maximum: 300mg/day
Not recommended for children under 2
| Weight | Age (approx) | Dose |
|---|---|---|
| 20-24 lbs | 2-3 years | 6.25mg (consult doctor) |
| 25-37 lbs | 4-5 years | 6.25mg |
| 38-49 lbs | 6-8 years | 12.5mg |
| 50-99 lbs | 9-11 years | 12.5-25mg |
| 100+ lbs | 12+ years | 25-50mg (adult dose) |
When to Seek Emergency Care (Children)
- Fever >100.4°F in infant under 3 months
- Fever >104°F at any age
- Difficulty breathing or blue lips
- Won't stop crying, inconsolable
- Seizure
- Rash that doesn't blanch (press and release - stays red)
- Not urinating (dry diaper >8 hours)
- Severe vomiting/diarrhea with signs of dehydration
- Lethargy, difficult to wake
- Bulging soft spot (infants)
Quick Reference
ADULT DOSES ONLY. Pediatric dosing requires weight-based calculations. See Pediatric Dosing section in Public Access.
ALWAYS determine if patient has allergies before administration.
For opioids: have Naloxone ready. For benzodiazepines: have Flumazenil ready.
Pain Management
| Drug | Dose | Route | Indication |
|---|---|---|---|
| Acetaminophen | 650mg x2 q8h | PO | Mild-mod pain |
| Meloxicam | 15mg daily | PO | Mild-mod pain |
| OTFC (Fentanyl) | 800mcg | Transmucosal | Mod-severe, NOT shock |
| Ketamine | 50mg / 20mg | IM,IN / IV,IO | Mod-severe, IN shock |
| Morphine | 5mg | IV/IO | Alternative to OTFC |
Antibiotics
| Drug | Dose | Route | Use If |
|---|---|---|---|
| Moxifloxacin | 400mg daily | PO | Can take PO |
| Ertapenem | 1g daily | IV/IM | Unable to take PO |
| Cefazolin | 2g q8h | IV/IM | Open fractures, traumatic wounds |
| Ceftriaxone | 1-2g q12-24h | IV/IM | Meningitis, severe infections |
Critical Medications
| Drug | Dose | Route | Indication |
|---|---|---|---|
| TXA | 2g bolus | IV/IO | Hemorrhage (<3hr post injury) |
| Epinephrine | 0.3-0.5mg | IM | Anaphylaxis |
| Epinephrine | 1mg q3-5min | IV/IO | Cardiac arrest (ACLS) |
| Naloxone | 0.4-2mg | IV/IM | Opioid reversal |
| Atropine | 2mg, double q5min | IV/IM | Nerve agent (until dried out) |
| Atropine | 1mg q3-5min | IV/IM | Bradycardia (ACLS 2024, max 3mg) |
Other Medications
| Drug | Dose | Route | Indication |
|---|---|---|---|
| Ondansetron | 4mg q8h | ODT/IV/IM | Nausea/vomiting |
| Diphenhydramine | 25-50mg q4-6h | IV/IM/PO | Allergic reaction |
| Dexamethasone | 4mg qid | PO/IV/IM | AMS, HACE, inflammation |
| Acetazolamide | 125mg BID | PO | Altitude illness prevention |
| Albuterol | 2 puffs q4-6h | MDI/Neb | Bronchospasm |
Pain Protocol
What is the pain level and casualty status?
Mild to Moderate Pain (Still Able to Fight)
Combat Wound Medication Pack (CWMP)
Acetaminophen 650mg bilayer - 2 tablets PO q8h (max 4g/day)
Meloxicam 15mg PO daily
Mission Impact: None to minimal
Moderate to Severe Pain - NOT in Shock
Oral Transmucosal Fentanyl Citrate (OTFC)
800mcg transmucosal (max 1600mcg/day)
Add second 800mcg in 15 min if needed
- Place lozenge between cheek and gum
- Do NOT chew
- Tape to finger or attach to uniform with safety pin
- Have Naloxone ready
Disarm casualty. Secure weapons and communications.
Onset: 15 min | Peak: 20-40 min | Duration: 2-3 hours
K9 Dosage: DO NOT GIVE to K9s
Moderate to Severe Pain - IN Shock/Respiratory Distress
Ketamine (Ketalar)
50mg IM or IN - repeat q30min PRN
OR
20mg slow IV or IO - repeat q20min PRN
Endpoint: Control of pain OR development of nystagmus
Max dose: 4g/day
Be prepared to suction (increases secretions). Be prepared for ventilatory support. Contraindication: Severe TBI (may worsen)
K9 Dosage: 75-150mg (2-5mg/kg) IM. Onset 2-5 min. Consider Midazolam adjunct.
Ondansetron (Zofran) - Anti-nausea
4mg ODT/IV/IO/IM q8h PRN
Consider for nausea/vomiting with pain medications.
Antibiotics
Early administration of antibiotics is recommended for ALL open combat wounds.
If allergic to one class, use alternate: Cephalosporins/Penicillins, Tetracyclines, Quinolones, Macrolides.
Moxifloxacin (Avelox)
Fluoroquinolone antibiotic
400mg PO daily
Use if: Casualty can take oral medications
Part of: Combat Wound Medication Pack
Mission Impact: GROUNDING for flight personnel
Ertapenem (Invanz)
Carbapenem antibiotic (beta-lactam)
1g IV/IM q24h
Use if: Unable to take oral medications
Reconstitution:
- IV: 10ml Normal Saline
- IM: 3.2ml 1% Lidocaine (without epinephrine)
Mission Impact: GROUNDING for flight personnel
Cefazolin (Ancef)
1st generation cephalosporin
2g IV/IM q8h (max 12g/day)
Use for: Open bone fractures, joint disruptions, pre-surgical prophylaxis, traumatic wounds
2g dose required: 1g does not achieve adequate blood levels in contaminated traumatic wounds. Use 2g for all combat/field injuries.
K9 Dosage: 0.5-1g (25mg/kg) IV daily, give over 5 min
Mission Impact: GROUNDING for flight personnel
Ceftriaxone (Rocephin)
3rd generation cephalosporin
Moderate-severe infections: 1-2g IV/IM q12-24h (max 4g/day)
Meningitis: 2g IV/IM q12h
Gonorrhea: 250mg IM x1
IM Administration: Dilute in 1% lidocaine
K9 Dosage: 1g IV/IM daily
Mission Impact: GROUNDING for flight personnel
Azithromycin (Zithromax)
Macrolide antibiotic
Pneumonia: 500mg PO day 1, then 250mg daily x4 days
STI (gonococcal): 1g PO x1 with ceftriaxone
Note: Food decreases absorption by 50%
Mission Impact: GROUNDING for flight personnel
Doxycycline
Tetracycline antibiotic
Antimalarial: 100mg PO daily (start 1-2 days prior, continue 4 weeks after)
Antimicrobial: 100mg PO q12h day 1, then 100mg daily
Travelers' diarrhea: 100mg PO daily during risk period
CRITICAL ADMINISTRATION: Sit upright for 30 minutes after taking. Lying down causes pill esophagitis - severe chest pain (15/10). Take with full glass of water. Increased sun sensitivity. Use sun protection. Difficult to avoid operationally but awareness prevents surprise. Malaria prevention: Missing a SINGLE dose can result in acquiring P. falciparum. Strict compliance required.
Note: Antacids (Pepto, Mylanta) significantly decrease absorption
Contraindication: Pregnancy (tooth discoloration)
Emergency Drugs
Epinephrine (including Epi-Pen)
Alpha/beta-adrenergic agonist, catecholamine
Anaphylaxis: 0.3-0.5mg IM q10-15min (1:1000 = 1mg/1ml)
Cardiac Arrest (ACLS): 1mg IV/IO q3-5min
Onset: Rapid | Duration: 1-2 minutes
Mission Impact: GROUNDING for flight personnel
Atropine Sulfate
Anticholinergic, parasympatholytic
Bradycardia (ACLS 2025): 1mg IV/IM, repeat q3-5min (max 3mg)
Nerve Agent/Organophosphate: 2mg IV/IM initial, double dose q5min until dried out
ACLS UPDATE: Bradycardia dose increased from 0.5mg to 1mg (2024). Nerve agent protocol per Joint Trauma System CBRN guidelines - based on Iranian experience (1980s), Japan subway attacks, and Syrian chemical incidents.
Nerve Agent Endpoint: Continue doubling dose until secretions are controlled ("dried out")
Action: Blocks acetylcholine, increases heart rate, dries secretions
Contraindications: Glaucoma, GI obstruction, tachycardia, myocardial ischemia
Naloxone (Narcan)
Opioid antagonist
0.4-2mg IV/IM
Repeat q2-3min PRN
Max: 10mg
Indication: Opioid overdose reversal (respiratory depression, sedation, hypotension)
Note: Titrate to effect - maintain pain control
K9 Dosage: 1mg (0.02-0.04mg/kg) IV/IM
Tranexamic Acid (TXA)
Antifibrinolytic agent
Preferred: 2g IV/IO bolus ASAP
DO NOT administer >3 hours post injury
Alternative Protocol: 1g bolus + 1g infusion. If using two-dose protocol, second dose must run over 8 HOURS (not bolus). Slow infusion critical for efficacy.
Criteria: Hemorrhagic shock, major amputations, penetrating torso, severe bleeding, pelvic fracture
Contraindications: Subarachnoid hemorrhage, active intravascular clotting
Note: Do NOT mix with blood products or Hextend
Dextrose 50% (D50)
Caloric, monosaccharide
0.5-1g/kg (1-2ml/kg) up to 25g (50ml) of 50% solution IV
If tolerating PO: provide glucose tabs
Indication: Hypoglycemic episode
Contraindications: Hyperglycemia, cranial/spinal hemorrhage
Sedation & Anxiolytics
MIDAZOLAM NOW PREFERRED: FDA now approves midazolam for seizures. Being adopted for nerve agent autoinjectors. Advantage: IM and intranasal routes available.
Midazolam (Versed) - PREFERRED
Benzodiazepine, anticonvulsant - CONTROLLED IV
Seizures/Nerve Agent: 5mg IM or IN (intranasal)
Sedation: 1-2.5mg IV slow push, titrate to effect
Routes: IV, IM, IN (intranasal) - significant advantage over diazepam
Indications: Seizures, nerve agent-induced seizures, procedural sedation, anxiety
Onset: IV 1-3 min, IM 15 min, IN 10-15 min
Contraindications: Shock, acute narrow-angle glaucoma
Mission Impact: GROUNDING - causes drowsiness
Diazepam (Valium) - Alternative
Benzodiazepine, anticonvulsant, anxiolytic - CONTROLLED IV
5-10mg slow IV push, repeat in 3-4h
2-10mg PO tid-qid
Note: Historically used in nerve agent autoinjectors due to FDA approval. Midazolam now preferred when available.
Indications: Anxiety, seizures, muscle spasm, status epilepticus, acute alcohol withdrawal
Contraindications: Shock, coma, alcohol intoxication, narrow-angle glaucoma
Mission Impact: GROUNDING - causes drowsiness
K9 Dosage: Seizures: 15-30mg (0.5-1mg/kg) IV or 30-60mg (1-2mg/kg) rectally q4h. Sedation with opioid: 7.5mg (0.25mg/kg) IV/IM q4h.
Diphenhydramine (Benadryl)
H1 blocker, antihistamine
25-50mg IV/IM/PO q4-6h
Onset: IV immediate, IM 30 min, PO 15-60 min
Duration: 6-8 hours
Indications: Allergic conditions, motion sickness, Parkinsonism, sedation, cough suppression
Mission Impact: GROUNDING - sedative effects
K9 Dosage: 50mg IM/SQ/PO (impacts sense of smell)
Cyclobenzaprine (Flexeril)
Central-acting skeletal muscle relaxant
5-10mg PO tid PRN muscle spasm (max 60mg/day)
Do not use longer than 2-3 weeks
Indications: Short-term relief of muscle spasm
Contraindications: MI recovery phase, cardiac arrhythmias, heart block, CHF
Mission Impact: GROUNDING - causes drowsiness
K9 Dosage: DO NOT GIVE
Eszopiclone (Lunesta)
Sedative-Hypnotic - CONTROLLED IV
2-3mg immediately at bedtime
Indications: Insomnia
Mission Impact: GROUNDING - higher risk for heat injury
Altitude & Environment
Acetazolamide (Diamox)
Carbonic anhydrase inhibitor, diuretic
Prevention: 125mg PO BID (start 1-2 days prior to ascent)
Treatment: 250mg PO BID until symptoms resolve
Indications: Acute high-altitude sickness (AMS) prevention/treatment, seizures
Note: With HACE, dexamethasone is primary treatment; acetazolamide is adjunctive
Mission Impact: GROUNDING for flight personnel
K9 Dosage: 250mg q12h beginning 24h prior to ascent OR 500mg q24h
Dexamethasone (Decadron)
Glucocorticoid steroid
AMS: 4mg PO qid
HACE: 8mg initial, then 4mg PO qid until symptoms resolve
General: 0.25-4mg PO bid-qid
Onset: Hours | Peak: 8-12 hours | Duration: 72 hours
Indications: Cerebral edema, inflammatory conditions, allergic states
Mission Impact: GROUNDING for flight personnel
K9 Dosage: 3-4mg (0.5mg/kg) IV/IM
Malarone (Atovaquone-Proguanil)
Antimalarial
Prophylaxis: 250mg/100mg PO daily (start 1-2 days prior, continue 7 days after)
Treatment: 1000mg/400mg PO daily x 3 days
Indication: P. falciparum malaria prevention and treatment
Side Effects: Headache, abdominal pain, N/V/D, possible seizures/psychotic events
Mission Impact: None
Albuterol (Proventil)
Beta-adrenergic agonist, bronchodilator
MDI: 2 puffs q4-6h PRN
Nebulizer: 0.5ml of 0.5% solution (2.5mg) in 5ml NS tid-qid
Indications: Exercise-induced bronchospasm, acute asthma, bronchitis, reversible airway disease
Mission Impact: GROUNDING for flight personnel
GI & Other
Cimetidine (Tagamet)
H2-receptor antagonist
300mg PO qid OR 800mg at bedtime OR 400mg BID x 8 weeks
Indications: Duodenal/gastric ulcer, GERD, chronic urticaria, acetaminophen toxicity
Docusate (Colace)
Stool softener
50-500mg/day PO divided qd-qid
Indications: Constipation with hard/dry stools, prophylaxis with narcotic use
Bisacodyl (Dulcolax)
Stimulant laxative
5-15mg PO (works within 6-10 hours)
Note: Swallow tablets whole with water/juice. Do NOT crush/chew. Do NOT take with dairy or antacids.
Benzonatate (Tessalon Perles)
Nonnarcotic antitussive
100-200mg PO 3x daily PRN (max single: 200mg, max daily: 600mg)
Indication: Relief of cough
Mission Impact: None
Cetirizine (Zyrtec)
H1-receptor antagonist, non-sedating antihistamine
5-10mg PO daily
Indications: Seasonal/perennial allergic rhinitis, chronic urticaria
Note: Do not combine with OTC antihistamines
Mission Impact: GROUNDING for flight personnel
Bupivacaine (Marcaine)
Local anesthetic
0.25% infiltrated locally (max 400mg/day)
Aspirate before every injection
Onset: Fast | Peak: 30-45 min | Duration: 2-8 hours
Note: Epinephrine reduces absorption rate and peak concentration
Contraindication: Do NOT use as IV regional anesthesia (can cause cardiac arrest)
Mission Impact: GROUNDING for flight personnel
Prohibited Drugs
DO NOT GIVE TO K9: Acetaminophen; Ciprofloxacin; Clindamycin; Cyclobenzaprine; Fentanyl/OTFC
Use with Caution: Diphenhydramine - impacts sense of smell; NSAIDs - can cause GI bleeding
K9 Quick Reference
K9 Drug Quick Reference
| Drug | K9 Dose | Notes |
|---|---|---|
| Ketamine | 75-150mg (2-5mg/kg) IM | Onset 2-5 min, consider Midazolam adjunct for emergence |
| Midazolam | 0.2-0.4mg/kg IM | Seizures, ketamine adjunct |
| Naloxone | 1mg (0.02-0.04mg/kg) IV/IM | Opioid reversal |
| Diazepam | Seizures: 0.5-1mg/kg IV, 1-2mg/kg rectally | q4h as needed |
| Diphenhydramine | 50mg IM/SQ/PO | Impacts sense of smell |
| Dexamethasone | 3-4mg (0.5mg/kg) IV/IM | - |
| Cefazolin | 0.5-1g (25mg/kg) IV daily | Give over 5 min |
| Ceftriaxone | 1g IV/IM daily | - |
| Amoxicillin/Clav | 10-20mg/kg PO BID x 5-7d | - |
| Aspirin (Buffered) | 10-25mg/kg PO q8-12h | Only buffered aspirin |
| Acetazolamide | 250mg q12h or 500mg q24h | Start 24h prior to ascent |
K9 Pain Management
Ketamine - K9 Pain Management
Primary analgesic for MWD
75-150mg (2-5mg/kg) IM
Onset: 2-5 minutes
- Drug of choice for MWD pain management
- Consider Midazolam adjunct for emergence reactions
- Be prepared for increased salivation
- Monitor airway closely
Buffered Aspirin - K9
NSAID analgesic
10-25mg/kg PO q8-12h
Important: Only use buffered aspirin formulation
Use for: Mild to moderate pain, inflammation
Warning: Can cause GI bleeding with prolonged use
NEVER give Fentanyl/OTFC to K9s!
K9 Emergency Drugs
Naloxone - K9
Opioid reversal
1mg (0.02-0.04mg/kg) IV/IM
Indication: Reversal of opioid effects (if accidentally exposed)
Diazepam - K9 Seizures
Anticonvulsant
15-30mg (0.5-1mg/kg) IV
OR
30-60mg (1-2mg/kg) rectally q4h
Sedation with opioid: 7.5mg (0.25mg/kg) IV/IM q4h
Dexamethasone - K9
Glucocorticoid
3-4mg (0.5mg/kg) IV/IM
Use for: Allergic reactions, inflammation, cerebral edema
Classes of Shock
Classes of Hemorrhagic Shock
| Parameter | Class I | Class II | Class III | Class IV |
|---|---|---|---|---|
| Blood Loss (ml) | <750 | 750-1500 | 1500-2000 | >2000 |
| Blood Loss (%) | <15% | 15-30% | 30-40% | >40% |
| Pulse Rate | <100 | 100-120 | 120-140 | >140 |
| Blood Pressure | Normal | Normal | Decreased | Decreased |
| Pulse Pressure | Normal | Narrowed | Narrowed | Narrowed |
| Respiratory Rate | 14-20 | 20-30 | 30-40 | >35 |
| Urine Output (ml/hr) | >30 | 20-30 | 5-15 | Negligible |
| Mental Status | Slightly anxious | Mildly anxious | Anxious, confused | Confused, lethargic |
| Fluid Replacement | Crystalloid | Crystalloid | Blood + Crystalloid | Blood + Crystalloid |
Note: These guidelines are for a 70kg adult. Individual responses may vary based on age, medications, and pre-existing conditions.
Field Indicators
FIELD REALITY: Class I-IV hemorrhage classifications are difficult to assess outside the operating room. Estimating blood loss in austere conditions is unreliable. Use Shock Index and clinical signs below for field assessment.
Shock Index (SI) - Field Assessment Tool
Shock Index = Heart Rate / Systolic Blood Pressure
Normal: 0.5 - 0.7
| Shock Index | Interpretation | Action |
|---|---|---|
| 0.5 - 0.7 | Normal | Monitor |
| 0.7 - 1.0 | Mild shock | Aggressive monitoring, prepare for resuscitation |
| 1.0 - 1.4 | Moderate shock | Begin resuscitation |
| >1.4 | Severe shock | Critical - aggressive resuscitation |
Quick Rule: Your heart rate should never be higher than your blood pressure. If HR > SBP, the patient is in shock.
Shock Assessment - Clinical Signs
- Altered mental status (in absence of TBI)
- Weak or absent radial pulse
- Capillary refill >2 seconds
- Decreased blood pressure
Pulse Pressure Estimation
| Pulse Location | Estimated SBP |
|---|---|
| Radial pulse present | ~80 mmHg |
| Femoral pulse present | ~70 mmHg |
| Carotid pulse present | ~60 mmHg |
These are quick estimates only. Use actual BP measurement when possible.
The Lethal Triad: Hypothermia + Acidosis + Coagulopathy = Death
Resuscitation
Fluid Resuscitation Priority
- Whole Blood Transfusion (warmed) - Preferred
- Components in 1:1 ratio (Plasma:RBCs:Platelets)
- ROLO (Ranger O Low-titer)
- Freeze-Dried Plasma (FDP)
- Hextend 500ml bolus
- Lactated Ringers OR Plasma-Lyte A
Resuscitation Endpoints: Palpable radial pulse; Improved mental status; SBP 90-100 mmHg (hemorrhagic shock); SBP >110 mmHg (TBI with altered mental status)
Tranexamic Acid (TXA)
2g IV/IO bolus ASAP
DO NOT administer >3 hours post injury
Criteria: Hemorrhagic shock, major amputations, penetrating torso, severe bleeding, pelvic fracture
Alt: 1g bolus + 1g infusion over 8 hours
Calcium Supplementation
CaCl 10cc slow IV/IO push OR CaGluc 30cc slow IV/IO push
After 2g TXA (use second IV/IO site)
Repeat after every 4th unit of blood
Normal Vitals
Normal Adult Vital Signs
| Vital Sign | Normal Range |
|---|---|
| Heart Rate | 60-100 bpm |
| Respiratory Rate | 12-20 breaths/min |
| Blood Pressure | 90-120 / 60-80 mmHg |
| SpO2 | 95-100% |
| Temperature | 97.8-99.1°F (36.5-37.3°C) |
Glasgow Coma Scale (GCS)
| Response | Score |
|---|---|
| Eye Opening | |
| Spontaneous | 4 |
| To voice | 3 |
| To pain | 2 |
| None | 1 |
| Verbal Response | |
| Oriented | 5 |
| Confused | 4 |
| Inappropriate words | 3 |
| Incomprehensible sounds | 2 |
| None | 1 |
| Motor Response | |
| Obeys commands | 6 |
| Localizes pain | 5 |
| Withdraws from pain | 4 |
| Flexion (decorticate) | 3 |
| Extension (decerebrate) | 2 |
| None | 1 |
Total: 3-15 | Severe TBI: 3-8 | Moderate TBI: 9-13
Conversions
Weight Conversions
| 1 kg | 2.2 lbs |
| 1 lb | 0.45 kg |
| 40 kg | 88 lbs |
| 60 kg | 132 lbs |
| 80 kg | 176 lbs |
| 100 kg | 220 lbs |
Temperature
| °F | °C | Note |
|---|---|---|
| 98.6°F | 37.0°C | Normal |
| 95°F | 35.0°C | Hypothermia onset |
| 100°F | 37.8°C | Low-grade fever |
| 104°F | 40.0°C | High fever |
°F = (°C × 1.8) + 32
°C = (°F - 32) / 1.8
Volume
| 1 L | 1000 ml |
| 1 tsp | 5 ml |
| 1 tbsp | 15 ml |
| 1 oz | 30 ml |
| 1 cup | 240 ml |
IV Fluid Rates
IV Fluid Rates (Drops/Min)
| ml/hr | 10 gtt | 15 gtt | 60 gtt |
|---|---|---|---|
| 50 | 8 | 12 | 50 |
| 100 | 17 | 25 | 100 |
| 125 | 21 | 31 | 125 |
| 150 | 25 | 37 | 150 |
| 200 | 33 | 50 | 200 |
Drip Rate Formula
Drops/min = (Volume in ml × Drop factor) / Time in minutes
Drop factors:
- Macro drip: 10 or 15 gtt/ml
- Micro drip: 60 gtt/ml
Burn Fluid Resuscitation (Rule of Ten)
%TBSA x 10ml/hour for adults 40-80kg
(+100ml/hr for every 10kg above 80kg)
Indication: Burns >20% TBSA