Shock — Blood Loss or Trauma

1. Lay the patient flat or elevate legs slightly — avoid if spinal or leg injury is suspected.
2. Start IV fluids — Ringer's Lactate or saline.
3. Administer TXA if not already given.
4. Keep the patient warm to slow shock progression.
5. Prepare for immediate evacuation once stabilized.

Cardiac Arrest

1. If no pulse or breathing, begin CPR — 30 compressions (2 inches deep) followed by 2 breaths.
2. Attach AED and follow prompts. Shock only if VFib or VTach is detected.
3. Administer 1 mg epinephrine IV every 3–5 minutes.
4. Continue resuscitation until pulse returns or evacuation is required.

Gunshot or Shrapnel Wounds

1. Confirm the area is safe before initiating treatment.
2. Apply tourniquet or hemostatic gauze to control active bleeding.
3. Locate all entry and exit wounds — treat both.
4. Do not remove embedded objects.
5. Start IV fluids for volume replacement.
6. Administer morphine for pain management and ceftriaxone for infection prevention.
7. Dress all wounds and monitor vital signs continuously.
8. Prepare the casualty for immediate evacuation.

Burns & Blast Injuries

1. Move the casualty away from the heat source or extinguish flames with water or rolling.
2. Never tear away clothing that is stuck to the skin.
3. Apply clean, dry bandages to burned areas.
4. Do not apply ointments in the field.
5. Manage pain with morphine or ketamine.
6. Keep the patient hydrated and covered to maintain warmth.
7. Monitor the airway closely — swelling can close the throat rapidly.

Seizures

1. Protect the patient from nearby objects. Clear equipment and debris from the immediate area.
2. Do not restrain. Do not place anything in the mouth.
3. Administer diazepam or lorazepam 1–2 mg IV or IM.
4. After the seizure stops, check airway and breathing immediately.

Hypoxia / Low Oxygen

1. Use a pulse oximeter to measure oxygen saturation.
2. If SpO₂ falls below 90%, administer oxygen or assist breathing with a bag-valve mask.
3. If breathing stops entirely, begin CPR immediately.

Tension Pneumothorax

1. Suspect if the casualty has progressive breathing difficulty, decreasing SpO₂, and absent breath sounds on one side.
2. Perform needle decompression — insert a 14G needle at the 2nd intercostal space, midclavicular line.
3. Listen for a rush of air confirming successful decompression.
4. Replace the vented chest seal if one is already in place.
5. Monitor closely and repeat the procedure if symptoms return.

Penetrating Abdominal Wounds

1. Do not attempt to remove penetrating objects — stabilize in place with bulky dressings.
2. If organs are exposed (evisceration), do not attempt to push them back.
3. Cover exposed organs with a clean, moist dressing or occlusive wrap to prevent drying.
4. Lay the casualty flat. If conscious and no spinal injury suspected, bend knees slightly to relax abdominal tension.
5. Do not give oral fluids or food — surgical intervention will be required.
6. Start IV fluids for volume support. Monitor closely for signs of shock.
7. Administer broad-spectrum antibiotics (ceftriaxone) — abdominal wounds carry high infection risk.
8. Prepare for immediate evacuation — abdominal injuries are not field-treatable beyond stabilization.

Traumatic Amputation

1. Apply a tourniquet immediately — 2–3 inches above the amputation site. Do not wait for bleeding to assess.
2. If tourniquet is not available, pack the wound tightly with hemostatic gauze and apply firm pressure.
3. Do not attempt to reattach the limb in the field.
4. Wrap the amputated part in a clean, moist dressing and place in a sealed bag. Keep cool but do not freeze.
5. Label the bag with the time of amputation.
6. Treat for shock — start IV fluids and monitor blood pressure and pulse.
7. Administer morphine for pain management.
8. Keep the casualty warm and still. Reassess tourniquet tightness every 5 minutes.
9. Prepare for immediate evacuation.

Impalement Injuries

1. Never remove an impaled object in the field — removal can cause sudden massive hemorrhage.
2. Stabilize the object in place using bulky dressings or improvised padding on all sides.
3. Secure the stabilization so the object cannot shift during transport.
4. Control bleeding around the object with direct pressure — do not press on the object itself.
5. If the object is too long for transport, cut it down carefully while maintaining stabilization at the wound site.
6. Start IV access and fluid replacement. Monitor for internal bleeding.
7. Administer pain management and broad-spectrum antibiotics.
8. Position the casualty to minimize movement of the impaled object during evacuation.
9. Immediate evacuation — surgical removal only.

Intravenous (IV) Insertion

1. Clean the insertion point with an alcohol pad.
2. Insert an IV cannula into a visible vein at a 15–30° angle.
3. Confirm placement — blood flashback should appear in the cannula chamber.
4. Secure the cannula with tape or a dressing and attach IV tubing.
5. Keep the bag elevated for steady flow.

Intraosseous (IO) Access

1. Use IO if no accessible vein is available — insert into the tibia or humerus.
2. Confirm placement — aspirate bone marrow or flush with saline; resistance should drop.
3. Secure the IO needle and attach IV tubing.
4. All IV medications and fluids are compatible with IO access.
5. IO is a temporary measure — transition to IV as soon as possible.

Tourniquet Application

1. Apply 2–3 inches above the wound — never over a joint.
2. Tighten until bleeding stops completely.
3. Record the time of application on the tourniquet or the patient's skin.
4. Do not remove in the field — this is a hospital-level decision.

Wound Packing

1. Use hemostatic gauze for junctional wounds where a tourniquet is not possible.
2. Pack the gauze tightly into the wound cavity using your finger or a packing tool.
3. Apply firm, continuous direct pressure for 3 full minutes.
4. Secure with a pressure bandage.
5. Do not remove packing in the field.

Chest Seal Application

1. Dry and clean the skin around the chest wound.
2. Apply a vented chest seal over the wound on exhale.
3. Press firmly to ensure full adhesion on all edges.
4. Monitor for tension pneumothorax — burp or replace the seal if pressure builds.
5. Treat entry and exit wounds separately with individual seals.

Needle Decompression

1. Identify the 2nd intercostal space at the midclavicular line on the affected side.
2. Insert a 14G needle perpendicular (90°) through the chest wall.
3. A rush of air confirms successful decompression.
4. Leave the needle in place and secure. Monitor for symptom return.
5. Repeat on the same side if symptoms recur.

Nasopharyngeal Airway (NPA) Insertion

1. Select the correct size — measure from the nostril to the earlobe.
2. Lubricate the NPA with gel or water.
3. Insert gently through the right nostril with a slight rotating motion.
4. Advance until the flared end sits flush against the nostril.
5. Do not force — switch to the left nostril if resistance is met.

Emergency Cricothyrotomy — Last Resort Airway

1. Use only when all other airway maneuvers have failed and the casualty cannot breathe.
2. Position the casualty on their back with the neck extended.
3. Locate the cricothyroid membrane — the soft indentation between the thyroid cartilage (Adam's apple) and the cricoid cartilage below it.
4. Stabilize the larynx with your non-dominant hand.
5. Make a 1–2 cm vertical skin incision over the membrane, then a horizontal stab incision through the membrane itself.
6. Insert a cuffed tube or improvised airway (pen barrel, cut syringe) into the opening.
7. Secure the tube. Ventilate with a bag-valve mask.
8. Confirm airway — chest rise, breath sounds, and improving SpO₂.
9. Immediate evacuation — this is a temporary emergency airway only.

Whole Blood Transfusion

1. Whole blood is the preferred resuscitation fluid for hemorrhagic shock when available.
2. Confirm blood type compatibility before transfusion — O-negative is universal donor for emergencies.
3. Establish IV or IO access. Use a blood administration set with an inline filter.
4. Warm blood to body temperature if possible — cold blood worsens hypothermia and coagulopathy.
5. Transfuse at the rate needed to maintain systolic BP above 90 mmHg.
6. Monitor for transfusion reactions — fever, chills, back pain, or sudden drop in BP. Stop immediately if any occur.
7. Alternate with crystalloid fluids (Ringer's Lactate) to prevent volume overload.
8. Document blood type, unit ID, and start time.

Plasma-Only Resuscitation

1. When whole blood is unavailable, use Fresh Frozen Plasma (FFP) as a second choice.
2. FFP replaces clotting factors lost in hemorrhage — critical for preventing coagulopathy.
3. Do not use FFP as a substitute for hemorrhage control — it is supplemental.

Hypothermia — Core Temp Below 95°F

1. Move the casualty out of the cold environment immediately.
2. Remove wet clothing carefully — handle gently to avoid triggering cardiac arrhythmia.
3. Wrap in a hypothermia blanket or dry insulating layers. Cover the head.
4. Do not apply direct heat to extremities — warm the core only (armpits, groin, chest).
5. Administer warm IV fluids if available and the casualty is conscious.
6. Monitor pulse and breathing continuously — hypothermia suppresses both.
7. If cardiac arrest occurs, begin CPR and maintain until core temperature rises.

Heat Stroke — Core Temp Above 104°F

1. Move the casualty to shade or a cool environment immediately.
2. Remove excess clothing and equipment.
3. Apply cold, wet cloths to the neck, armpits, and groin.
4. Fan the casualty to accelerate cooling.
5. Start IV fluids — cold saline is preferred if available.
6. Do not give fluids orally if the casualty is confused or unconscious.
7. Monitor for seizures and prepare to treat if they occur.

Skin & Eye Contact

1. Remove the casualty from the contaminated area — do not enter without appropriate PPE.
2. Remove all contaminated clothing. Cut away if necessary — do not pull over the head.
3. Flush affected skin with large volumes of clean water for at least 15 minutes.
4. For eye exposure, irrigate continuously with clean water or saline — keep the eye held open.
5. Do not apply creams, neutralizing agents, or bandages over chemical burns in the field.

Inhalation Exposure

1. Move the casualty to fresh air immediately.
2. Administer 100% oxygen via mask as soon as possible.
3. If breathing is absent or inadequate, use a bag-valve mask.
4. Monitor for airway swelling — intubation or cricothyrotomy may be necessary if the airway closes.
5. Do not induce vomiting for any chemical exposure.

Radiation Exposure — Immediate Response

1. Remove the casualty from the radiation source immediately. Distance reduces exposure rapidly.
2. Remove contaminated clothing and equipment — this eliminates up to 90% of external contamination.
3. Flush all exposed skin with large amounts of water and soap. Do not scrub — gentle washing only.
4. Flush eyes with water or saline if exposed. Do not allow the casualty to eat, drink, or touch their face before decontamination.
5. Establish IV access and begin supportive fluid therapy.
6. Do not induce vomiting if radiation material was ingested — consult Medical HQ.

Acute Radiation Syndrome (ARS) — Signs & Response

1. Early symptoms (minutes to hours): nausea, vomiting, headache, disorientation.
2. Delayed symptoms (days to weeks): hair loss, skin burns, immune suppression, bleeding.
3. Treat symptoms as they present — nausea, pain, wounds, and infection follow standard protocols.
4. All confirmed or suspected radiation casualties require evacuation and specialist evaluation.
5. Do not allow contaminated casualties to mix with the general casualty pool — maintain separation.

Snake & Venomous Animal Bites

1. Keep the casualty calm and still — movement accelerates venom spread.
2. Immobilize the affected limb below heart level.
3. Remove rings, watches, or tight clothing near the bite site — swelling will occur.
4. Do not apply tourniquets, cut and suck the wound, or apply ice.
5. Mark the edge of swelling with a pen and note the time to track spread.
6. Start IV access. Administer fluids for blood pressure support if shock develops.
7. Antivenom is the definitive treatment — evacuation to a medical facility is required.
8. Monitor airway — some venoms cause rapid throat swelling.

Insect Stings & Anaphylactic Risk

1. Assess immediately for signs of anaphylaxis — throat tightening, hives, drop in BP.
2. If anaphylaxis is present, administer epinephrine 0.3 mg IM immediately. Refer to Anaphylaxis protocol.
3. For localized reactions, remove the stinger by scraping — do not squeeze it.
4. Apply cold compress to reduce local swelling and pain.

Fractures — Closed & Open

1. Do not attempt to realign the bone — immobilize in the position found.
2. Apply a SAM splint or improvised splint extending one joint above and below the fracture.
3. For open fractures, cover the wound with a sterile dressing before splinting.
4. Check circulation, sensation, and movement distal to the injury before and after splinting.
5. Elevate the limb if no vascular compromise is suspected.
6. Administer pain management and prepare for evacuation.

Dislocations

1. Do not attempt field reduction unless evacuation is impossible and neurovascular compromise is present.
2. Immobilize the joint in the position found using a splint or sling.
3. Apply ice or a cold compress if available to reduce swelling.
4. Monitor distal pulse, sensation, and movement continuously.
5. Administer pain management and prioritize evacuation.

Head Trauma & TBI

1. Keep the casualty still — assume a cervical spine injury until ruled out.
2. Apply a cervical collar if available.
3. Monitor GCS (Glasgow Coma Scale) — check eyes, verbal, and motor response.
4. Do not give morphine or sedatives to a head-injured casualty — it masks deterioration.
5. Keep the head at 30° elevation if no spinal injury is suspected.
6. Control external bleeding with gentle pressure only — no tight bandaging over a skull fracture.
7. Immediate evacuation. TBI deteriorates rapidly without surgical intervention.

Eye Trauma

1. Do not apply pressure to an injured eye.
2. Cover with a rigid eye shield — if unavailable, use a paper cup taped in place.
3. Cover both eyes to reduce sympathetic movement.
4. Do not attempt to remove embedded objects from the eye.
5. For chemical exposure, irrigate with clean water or saline continuously until evaluated.

Anaphylaxis — Severe Allergic Reaction

1. Identify signs: sudden hives, throat swelling, difficulty breathing, drop in blood pressure, rapid weak pulse.
2. Administer epinephrine 0.3 mg IM into the outer thigh immediately — use auto-injector if available.
3. Lay the casualty flat and elevate the legs unless breathing is compromised.
4. Start IV access and administer saline for volume support.
5. If symptoms persist after 5 minutes, administer a second dose of epinephrine.
6. Monitor airway continuously — be prepared to assist ventilation if the throat closes.
7. Prepare for immediate evacuation.

Spinal Injury — Identification

1. Suspect spinal injury in any casualty with: mechanism of significant force to the head, neck, or back; complaint of neck or back pain; numbness, tingling, or weakness in limbs; or unconsciousness from trauma.
2. Ask a conscious casualty — do not move them until spinal injury is ruled out.
3. Look for midline tenderness on the spine when safe to assess.
4. In an unconscious trauma patient, always assume spinal injury.

Spinal Immobilization

1. Apply a cervical collar to stabilize the neck — size appropriately to fit snugly.
2. If no collar is available, manually hold the head in a neutral inline position until one is secured.
3. Move the casualty only with a log roll — minimum 3 personnel, one controlling the head.
4. Transfer onto a rigid stretcher or spine board and secure with straps at chest, hips, and legs.
5. Pad gaps between the body and board to prevent pressure injuries during transport.
6. Maintain neutral head alignment throughout transport — use head blocks or rolled blankets.

Pelvic Fractures

1. Suspect pelvic fracture after high-energy trauma (blast, vehicle impact, fall from height) with pain on hip palpation.
2. Do not rock or compress the pelvis to test — this can worsen internal bleeding.
3. Apply a pelvic binder or improvised sheet wrap at the level of the greater trochanters (not the waist).
4. Tighten firmly to compress and stabilize. Secure with a clamp or knot.
5. Lay the casualty flat. Do not bend the hips or knees — this destabilizes the pelvis.
6. Start aggressive IV fluid resuscitation — pelvic fractures can cause several liters of internal blood loss.
7. Administer TXA immediately if not already given.
8. This is a high-priority evacuation — definitive treatment is surgical.

Internal Hemorrhage — General Signs

1. Symptoms: progressive hypotension, tachycardia, abdominal rigidity or distension, flank bruising (Grey-Turner sign), or periumbilical bruising.
2. Field treatment is limited — maintain IV fluids to sustain BP above 90 systolic, administer TXA, and evacuate immediately.
3. Do not apply external pressure to the abdomen in an attempt to control internal bleeding.

MARCH — Primary Casualty Assessment

Secondary Survey

1. Once MARCH is addressed, perform a full head-to-toe assessment.
2. Check for additional wounds, fractures, and signs of internal injury.
3. Document all injuries, treatments applied, and time of each intervention.
4. Record vital signs — pulse, SpO₂, respiratory rate, blood pressure, and GCS.
5. Reassess every 5 minutes or following any significant intervention.

Triage Categories

CASEVAC Preparation

1. Stabilize the casualty to the highest level possible before moving.
2. Secure all IV lines, airways, and dressings for transport.
3. Complete a MIST handover — Mechanism, Injuries, Signs, Treatment given.
4. Mark triage category visibly on the casualty (forehead, hand, or triage tag).
5. Position T1 casualties to maintain airway during transport — recovery position if unconscious.
6. Move T4 casualties only after T1–T3 are secured for evacuation.
7. Transmit casualty report to Medical HQ before or during evacuation.

Vital Sign Reference Table

Drowning — Immediate Response

1. Remove the casualty from water — do not enter without flotation support if current or depth is a risk.
2. Begin rescue breaths in the water if trained and safe to do so — do not delay for dry land.
3. On land, lay flat and assess breathing and pulse immediately.
4. If no breathing, begin CPR — prioritize ventilation, start with 5 initial breaths before compressions.
5. Do not waste time attempting to drain water from the lungs — it does not improve outcome.
6. Administer oxygen at 100% as soon as available.
7. Treat for hypothermia — water immersion drops core temperature rapidly.
8. Even if the casualty appears to recover fully, evacuate for observation — secondary drowning can occur up to 24 hours later.

Crush Syndrome

1. Do not rapidly remove crushing weight from a casualty trapped for more than 15 minutes without IV access established first.
2. Establish IV access and begin aggressive fluid resuscitation — Ringer's Lactate, 1–1.5L/hr — before and during extrication.
3. After extrication, monitor for cardiac arrhythmia caused by sudden release of potassium from damaged muscle tissue.
4. Do not elevate crushed limbs — keep level.
5. Monitor urine output — dark brown urine indicates myoglobinuria (kidney damage). Increase fluids.
6. Prepare for rapid deterioration and prioritize evacuation to surgical care.

Compartment Syndrome

1. Suspect if limb pain is disproportionate to injury, especially on passive stretch of the muscle.
2. Additional signs: tense, hard limb; pallor; paresthesia (tingling/numbness); paralysis.
3. Remove all constricting bandages, splints, or clothing from the limb immediately.
4. Keep the limb at heart level — do not elevate.
5. This is a surgical emergency — field treatment is limited to removing constriction. Evacuate urgently.

⚠ CLASSIFICATION: RESTRICTED — SENIOR MEDICAL CLEARANCE REQUIRED

The following protocols apply to casualties exposed to anomalous biological agents, including direct physical contact with contained or uncontained SCP entities, exposure to anomalous organic material, or onset of unexplained biological symptoms in a containment environment.

Anomalous Tissue Response

1. Isolate the casualty from other personnel immediately — do not allow contact until exposure type is confirmed.
2. Observe for non-standard wound behavior: tissue that does not bleed, wounds that close without treatment, or wounds that expand without cause.
3. Do not apply standard hemostatic agents to wounds exhibiting anomalous closure — interaction effects are unclassified.
4. Document all physical changes with timestamps. Photography required every 5 minutes if transformation is active.
5. Do not administer sedatives unless the casualty is actively combative — sedation may accelerate certain biological anomalies.
6. Notify Medical HQ and Containment Lead simultaneously. Do not treat in isolation.
7. If tissue transformation is observed spreading beyond the initial wound site, initiate Biological Quarantine Protocol and await specialist response.

Anomalous Vital Sign Presentation

1. A casualty may present with vital signs that are absent, inverted, or outside physiologically possible ranges as a direct result of anomalous exposure — this does not confirm death.
2. Confirm death only after consulting the attending Senior Medical Officer and cross-referencing known entity behavioral data.
3. Do not enter a body bag protocol for anomalous casualties without a second confirmation from Medical HQ.
4. Casualties with absent pulse but preserved behavioral function are to be treated as Category-VEIL and handed to Containment.

⚠ CLASSIFICATION: RESTRICTED — SENIOR MEDICAL CLEARANCE REQUIRED

Cognitohazard and memetic exposure incidents must be reported to Medical HQ within 3 minutes of identification. This protocol does not replace the active Memetic Containment Protocol — it supplements it from a medical response perspective.

Identifying Exposure

1. Suspect cognitohazard or memetic exposure if a casualty presents with sudden behavioral change, compulsive action, fixation on a specific object or concept, or repetitive speech without prior psychiatric history.
2. Additional indicators: unexplained nosebleeds, acute headache, visual disturbances, sudden emotional flatness, or uncontrollable laughter or crying.
3. Do not ask the casualty to describe what they saw, heard, or perceived — this may spread or reinforce the memetic effect.
4. Do not look at any materials, screens, or surfaces the casualty was exposed to without certified memetic protection eyewear.

Immediate Medical Response

1. Physically separate the casualty from all other personnel — minimum 10 meters or a sealed room.
2. Do not restrain unless the casualty is a physical threat — physical restraint does not prevent memetic spread.
3. Treat physical symptoms as they present — headache, nosebleed, and seizures follow standard protocol.
4. Administer lorazepam 1–2 mg IM if the casualty is acutely distressed or exhibiting compulsive behavior that risks self-harm.
5. Do not attempt psychological de-escalation using logic or argument — it is ineffective against active memetic influence.
6. Maintain observation and document all behavioral changes. Do not leave the casualty unattended.
7. Await arrival of a Memetic Containment Specialist before any further intervention.