FM 8-230

FIELD MANUAL

MEDICAL
SPECIALIST
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DISTRIBUTION RESTRICTION: This publication contains technical or operational information that is for official
government use only. Distribution is limited to US government agencies. Requests from outside the US govern­
ment for release of this publication under the Freedom of Information Act or the Foreign Military Sales Program
must be made to HQ TRADOC. Ft Monroe. VA 23651.

HEADQUARTERS, DEPARTMENT OF THE ARMY

AUGUST 1984
FIELD MANUAL *FM 8-230
NO. 8-230 HEADQUARTERS
DEPARTMENT OF THE ARMY
Washington, DC. 24 August 1984

MEDICAL SPECIALIST

Preface

This manual is for use in training the Medical Specialist, MOS 91B10, in
field medical activities, patient care procedures, and general nursing care
duties involved in patient care and treatment. It also serves as a ready
reference for use by other Army Medical Department units and activities. The
material in this manual is applicable to peacetime, nuclear war, and nonnuclear
war.

Use of trade names in this manual is for clarity only and does not constitute
endorsement by the Department of Defense.

Users of this manual are encouraged to submit recommendations to improve

the publication. Comments should be keyed to the page, paragraph, and line(s)
of the text where a change is recommended. Reasons should be provided for
each comment to insure understanding and complete evaluation. Comments
should be submitted on DA Form(s) 2028 (Recommended Changes to
Publications and Blank Forms) and forwarded to the Commandant, Academy
of Health Sciences, US Army, ATTN: HSHA-TLD, Fort Sam Houston, Texas
78234.

When used in this publication, the terms "he," "him," "his," "man," and
"men" represent both masculine and feminine genders unless otherwise
stated. The terms "patient" and "patients" are considered synonymous with
the terms "casualty" and "casualties."

The contents of this manual are subject to and in consonance with the
following Standardization Agreements:

TITLE NATO STANAG

Documentation Relative to Medical Evacuation,

Treatment, and Cause of Death of Patients 2132

Basic Military Hospital (Clinical) Records 2348

When amendment, revision, or cancellation of this publication is proposed

which will affect or violate the international agreements concerned, the
preparing agency will take appropriate reconciliatory action through
international standardization channels.

*This manual supersedes TM 8-230. 2 November 1970. and FM 8-36, 15 March 1973.

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FM 8-230

TABLE OF CONTENTS

Page

CHAPTER 1. INTRODUCTION ......................................... l·l

Section I. The Army Medical Department..................... l·l

Section II. The Combat Medic.......................................... 1-1
Section III. Interpersonal Relationships........................... 1-4
Section IV. Legal Aspects of Medical Care and
Treatment...................................................... 1-5
Section v. Medical Terminology...................................... 1-8

CHAPTER 2. INTRODUCTION TO THE HUMAN

SYSTEMS ................................................... 2·1

CHAPTER 3. THE INTEGUMENTARY SYSTEM .......... 3-1

CHAPTER 4. THE SKELETAL/MUSCLE SYSTEMS ..... 4·1

Section I. The Skeletal System ....................................... 4-1

Section II. The Muscular System..................................... 4-21

CHAPTER 5. THE CIRCULATORY SYSTEM ................. 5-1

CHAPTER 6. THE RESPIRATORY SYSTEM .................. 6-1

CHAPTER 7. THE NERVOUS SYSTEM ........................... 7-1

CHAPTER 8. THE DIGESTIVE SYSTEM ........................ 8-1

CHAPTER 9. THE UROGENITAL SYSTEM .................... 9-1

CHAPTER 10. THE ENDOCRINE SYSTEM ...................... 10-1

CHAPTER 11. THE SENSORY ORGANS ........................... 11-1

CHAPTER 12. TRIAGE AND PATIENT

ASSESSMENT ........................................... 12-1

Section I. Triage .............................................................. 12·1

Section II. Patient Assessment........................................ 12-4
Section III. Priorities for Medical Evaluation.................. 12-13
Section IV. Troop Medical Clinic/Conduct of Sick Call.... 12-14

CHAPTER 13. FIELD MEDICAL CARE/MEDICAL

EMERGENCIES ........................................ 13-1

Section I. Introduction.................................................... 13-1

Section II. Management of Burns.................................... 13-1
Section III. Impalement Injuries....................................... 13-9
Section IV. Facial, Head, Neck, and Spine Injuries......... 13-14
Section v. Orthopedic Injuries........................................ 13-35
Section V I. Bandages and Binders.................................... 13-54
Section VII. Shock ............................................................... 13-69
Section V III. Control of Hemorrhage................................... 13-80

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 FM 8-230

Page
Section IX. Cardiac Arrest and Cardiopulmonary
Resuscitation............................................... 13-87
Section X. Upper Airway Obstructions........................... 13-96
Section XI. Management of Chest Injuries...................... 13-104
Section XII. Management of the Convulsive and/or
Seizure Patient............................................ 13-113
Section XIII. Abdominal Ailments and Injuries................. 13-116
Section XIV. Irrigation of the Ear....................................... 13-122
Section XV. Management of Eye Injuries......................... 13-128
Section XVI. Application of Restraining Devices............... 13-128
Section XV II. Medical Emergencies..................................... 13-148
CHAPTER 14. CLINICAL PROCEDURES ........................ . 14-1

Section I. Introduction.................................................... 14-1

Section II. V ital Signs...................................................... 14-1
Section III. Asepsis ............................................................ 14-7
Section IV. Obtain a Blood Specimen............................... 14-17
Section v. Administration of Oxygen............................. 14-39
Section VI. Catheterization/The Urinary (Foley)
Catheter ....................................................... 14-55
Section VII. Nasogastric Tubes.......................................... 14-60
Section VIII. Patient/Surgical Preparation......................... 14-68
Section IX. Intravenous Infusion...................................... 14-74
Section x. Measuring Patient Intake/Output................. 14-83
Section XI. Oral and Nasotracheal Suctioning................. 14-86
Section XII. Application of Heat and Cold......................... 14-96
Section XIII. Therapeutic Bath............................................ 14-105
Section XIV . Managing a Patient Requiring Chest Tube
Drainage ...................................................... 14-107
CHAPTER 15. OBSTETRIC AND GYNECOLOGIC
EMERGENCIES .......................................... . 15-1

Section I. The Female Reproductive System................. 15-1

Section II. Pregnancy and Childbirth.............................. 15-1
Section III. Pathophysiology and Mangement of
Gynecologic Emergencies........................... 15-23
Section IV. Management of Obstetric Emergencies........ 15-25
Sectiop v. The Rape V ictim............................................. 15-31

CHAPTER 16. FIELD SANITATION. . ................................ 16-1

Section I. Introduction.................................................... 16-1

Section II. Drinking Water Treatment.......................... .. 16-1
,Section III. Waste Disposal............................................... 16-7
Section IV. Food Sanitation.............................................. 16-10
Section V. Personal Hygiene............................................ 16-11

CHAPTER 17. MEDICAL INFORMATION AND

RECORDS ................................................... 14-1

Section I. Confidentiality of Medical Information........ 17-1

Section II. Medical Records Entries .............................. .. 17-1
Section IIL Recording Diagnoses and Procedures........... 17-5

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FM 8-230

Page
Section IV. Outpatient Treatment Record....................... I7-9
Section v. Health Records............................................... I7-I5
Section V I. Inpatient (Clinical) Treatment Records......... I7-35
Section V II. Preparation and Use of Laboratory Forms... I7-4I
Section V III. Nursing Records and Reports
(Permanent Forms)...................................... I7-46
Section IX. Use of the US Field Medical Card.................. I7-5I

CHAPTER I8. PHARMACOLOGY AND DRUG

ADMINISTRATION ................................. IS-I

CHAPTER 19. ENVIRONMENTAL HEALTH ................... I9-I

Section I. Introduction.................................................... I9-I

Section II. Communicable Diseases................................. I9-I
Section III. Heat Injuries.................................................. I9-5
Section IV. Cold Injuries................................................... I9-9
Section v. Bites and Stings............................................. I9-I7
Section V I. Poisonous Plants............................................ I9-29

CHAPTER 20. NUCLEAR, BIOLOGICAL, AND

CHEMICAL INJURIES ........................... 20-I

Section I. Introduction.................................................... 20-I

Section II. Nuclear Casualties.......................................... 20-I
Section III. Biological Agent Casualties........................... 20-3
Section IV. Chemical Agent Casualties............................ 20-3

CHAPTER 21. MANAGEMENT OF PSYCHOLOGICAL/

BEHAVIORIAL PROBLEMS.................. 2I-I

Section I. Battle Fatigue (Stress)................................... 2I-I

Section II. Alcohol and Drug Abuse................................ 2I-I
Section III. The Suicidal Patient....................................... 2I-9
Section IV . Death and Dying/Postmortem Care.............. 2I-25

GLOSSARY Glossary-I

REFERENCES ......................................................................... Reference-I

INDEX Index-I

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CHAPTER 1

INTRODUCTION

Section I. THE ARMY MEDICAL DEPARTMENT

1-1. General

As a medical soldier, you are a member of a branch of the Army with a long
and proud history of service and achievement. The Army Medical Department
(AMEDD) was established by the Continental Congress on 27 July 1775. Since
that time the AMEDD has cared for American soldiers and has played a vital
role in the growth and advancement of medicine around the world.
Breakthroughs in military medicine have had a significant impact on the
course of civilian medical practice, just as progress in civilian medicine has
affected the military.

1-2. Mission

The AMEDD is responsible for maintaining the health of the Army to

conserve its fighting strength. It is responsible for all medical services
provided within the Department of the Army (DA) and for other agencies and
organizations as prescribed in AR 10-5.

Section II. THE COMBAT MEDIC

1-3. General

a. This section is designed for you, the combat medic-whether you

serve in an infantry platoon, an artillery battery, a cavalry troop, an engineer
battalion, an isolated detachment, or a temporary task force. Although
addressed to you, the section is also designed for your leaders (platoon
sergeants, physicians' assistants, and the leaders of medical elements) so they
will know your capabilities.

b. Your responsibility is heavy, but you can handle it. You have not
been sent out to do an impossible job, just an important one. When it comes to
taking care of the men who are seriously wounded in battle, you are the key
man. The entire medical treatment system behind you-from the most forward
combat zone hospital all the way back to CONUS-depends on you. Consider
this: Every patient of yours who is admitted to a medical treatment facility
represents a success on your part. If you had not kept the man alive, he would
not be admitted to the facility. Medical treatment facilities save about 98
percent of your patients, but they could not do it unless you saved the patients
first.

1-4. Your Main Job

In addition to lifesaving and first aid measures, your job includes the
disposition of patients. When a soldier is wounded, or when you are faced with
a medical problem, ask yourself, "Should I evacuate this man or treat him
here?" Often, the tactical situation and the nature of the man's illness or
injuries require you to treat him. This manual tells you how to treat him.

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1-5. Your Resources

In the field, you can give emergency medical treatment but you do so with
limited resources. Your physical resources are limited by two things: the
tactical situation and how much you can carry. You are trained to improvise in
many situations, and to request assistance in others.

1-6. What a Good Combat Medic Does

a. Most of your time is spent, not in combat and treating patients, but
in waiting. While you are waiting, you care for your equipment and replenish
your supplies; equally important you talk with the troops and advise the
battalion surgeon, the physicians' assistant, and the platoon sergeant on
minor medical problems.

b. You must do your share of the hard work. You are expected to
defend yourself and your patients when necessary. You are not supposed to
carry a radio or parts of crew-served weapons, but do not hesitate to help a
fellow soldier carry a heavy load when you are not in contact with the enemy.

c. Besides doing your share of the work, you will always look out for
the welfare of your troops. Before the unit goes on a mission, check out each
individual. If you find a soldier with a medical problem, advise the platoon
sergeant of the man's condition, capabilities, and limitations. During the
mission, observe each man. If you get to know the men well, you can quickly
tell when one is getting sick and anticipate many medical problems. Make sure
you explain the danger of not using proper personal hygiene; take every
opportunity to encourage preventive measures.

d. At the end of the mission, check each soldier again to see if anyone
is sick or injured. Some will get minor wounds but not complain about them.

e. During rest periods and between missions, you should make sure all
minor medical problems are settled. You may want to go with a trooper on sick
call and learn from the medical officer the best way to continue treating him. If
medication is prescribed, you should be certain it is taken correctly.

1-7. Preoperational Briefings

Commanders usually include medical personnel in briefings of tactical

situations before a mission. The more you know about the mission and its
likely medical hazards, the better you can do your work. When alerted for a
mission, go to the platoon sergeant or the platoon leader and ask about it. Find
out how far the men are going, how many are going, how long they will be
away, and how much enemy action is expected. This information will help you
decide what supplies to take.

1-8. Your Aid Bag

The surgical instrument and supply set, individual, is a general use aid bag
issued by the medical depot with a standard packing list of supplies. This
standard aid bag is a starting point for you. You are responsible for packing
and maintaining your aid bag. The aid bag and basic items carried by an
aidman are shown in Figure 1-1. What you will need to carry in the aid bag
depends upon the nature of the mission. For example, if the mission is to be a
walk to and a look around a village, lasting about 2 hours and taking 15 men,

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with no enemy action expected, you would take a light bag of supplies. If the
mission is to go several miles away, taking 40 men and setting up a night
ambush, with enemy action expected, you would take a different bag of
supplies. If the company is going on an extended mission, you would take still
another aid bag.

CLOSED BAG

���.....iiil" ·······---·•? 'lirt-·•

OPEN BAG WITH CONTENTS

Figure 1-1. Medical aid bag.

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FM 8-230

1-9. Steps in Solving Medical Problems

a. Get a history and do a rapid physical examination of the patient.

For example, determine whether the wound was caused by a bullet, a mortar
round, a booby trap, or a fall from a vehicle. If it is a perforating wound, see if
it has both entrance and exit sites. Determine the number of wounds and find
out if there is severe hemorrhage, internal bleeding, or a broken bone(s).
Quickly assess the vital signs (pulse, blood pressure, respiration) to determine
whether the patient's life is in danger.

b. Make a judgment or a tentative diagnosis. For example, if the

wound is serious, will the patient die soon without definitive medical
treatment? If the wound is not serious, can he continue his mission with some
treatment? What is the tactical situation? How much time do you have? How
much help can you get?

c. Take positive action.

(1) Get yourself and the patient in the safest position consistent
with his injuries and the tactical situation.

(2) Clear the airway and give artificial respiration if necessary.

Control hemorrhage as quickly as possible. Treat for shock, if necessary.

(3) Ask for assistance. Move the patient to a safer location and
request evacuation if indicated.

(4) Reassure the patient. Positive action will reassure him more
than anything you can say to him.

d. For guidance in handling a medical problem beyond your capability,

you may be able to use radio communications if the tactical situation permits.
The operator can connect you with other medical personnel who can assist you
in handling the problem. They can also dispatch personnel and equipment to
help you.

Section III. INTERPERSONAL RELATIONSHIPS

1-10. General

There are two kinds of interactions that take place between individuals and
individuals and groups: actions and reactions, or cause and effect. When these
interactions unite individuals and groups into teams whose members mutually
support one another to accomplish their goals, good interpersonal
relationships are developed. Since the goal of the AMEDD is to restore a
patient to physical and mental health, you must be aware of the importance of
good interpersonal relations among the health care team and between the team
and the patients/casualties.

1-11. Developing Good Interpersonal Relationships

Development of good interpersonal relationships is not always easy. The

number of people involved in providing patient care creates problems of
communication and understanding. Good relations are easier to describe than

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they are to achieve, and there are few successful formulas that apply in all
situations. Some guidance can be given, however, as a means of developing
good interpersonal relations.

a. Understanding Oneself The foundation for good relations with

others is a state of good relations with oneself. Self-understanding and self·
acceptance (based on a realistic picture of oneself and a genuine feeling of self·
worth), justified by performance, are ingredients of effective relationships
with others. Just as each individual is a unique person, each must accept the
right of another to differ within socially accepted limits. Thus, in any situation
where relationships are less than the best, each person must examine himself
to see if he has contributed to the faulty relations.

b. Understanding the Patient 's Need for Privacy.

(1) You must not divulge information concerning the patient

except to those individuals having an official reason to know. Discussions
regarding diagnosis, care, and treatment of patients should be held in private
to prevent their being overheard by individuals who are not concerned with the
medical care being given. Improperly releasing information from a patient's
medical records can result in criminal prosecution or disciplinary action for
violation of the Privacy Act (see AR 340-21). Release of such information
should ordinarily be made only in response to a written request and only after
coordination of the request with the Patient Administration Office.

(2) Special attention must be given to the release of information

obtained under the provisions of the Army Drug and Alcohol Abuse Program
(AR 600-85). Notification of the discovery of potential drug/alcohol abuse is
required in certain cases by that program. Notification is also required in
certain cases where child or spouse abuse is suspected as the result of
providing medical care. These matters must be communicated to medical
superiors to determine if reporting is appropriate.

Section IV. LEGAL ASPECTS OF MEDICAL CARE AND

TREATMENT

1-12. General

a. Those legal aspects of medical care and treatment of importance to

you are covered in this section. This is to alert you to the law as it pertains to
your rendering of medical care and treatment.

b. This discussion includes:

(1) Your legal status as a medical service patient care team

member.

(2) Some medical-legal problems that could arise when you are
assisting with medical care and treatment and when something is done that
interferes with the rights and privileges of a patient.

(3) The application of professional practices acts to your duties.

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(4) Certain Federal laws, such as the Federal Torts Claims Act
(FTCA) and the Gonzalez Act, which apply to your performance of medical
duties.

c. The public has special trust in medical and allied professions and in
the institutions that provide medical care and treatment. To help insure that
this trust is deserved, there are statutes and legal principles which provide
patients with legal remedies when they do not receive proper medical care.
These remedies are available not only in those rare cases where the patient is
harmed intentionally, but also in those cases where the patient is harmed as a
result of negligence (carelessness) on the part of medical personnel.

d. Negligent or intentional failure on your part to provide proper

medical care to your patients may result in court-martial or administrative
actions. Those actions could include MOS reclassification, bar to reenlistment,
or administrative discharge from active duty with less than an Honorable
Discharge.

e. Negligent actions on your part in the performance of your medical

duties may also result in the Army's liability for payment of damages to the
patient.

1-13. Law and the Medical Soldier

a. The medical soldier is authorized to perform his assigned military­

medical duties within the conditions established for their performance. His
legal protection and legal status are established when he works:

(1) Within the scope of his duties (as defined by AR 611-201).

(2) Within the limits of his training.

(3) According to the policies established by his local medical

commander. Army regulations that pertain to providing medical services in
AMEDD treatment facilities are found in the 40-series.

b. Field Manual (FM) 21-13 contains detailed information regarding

the legal status of enlisted personnel as soldiers, subject to and protected by
both civil and military law.

1-14. Negligence as a Medical-Legal Problem

a. There is no one uniform code of medical law, but there are laws that
have special significance in medical care and treatment areas. A basic rule that
applies in providing all medical services is the rule of negligence.
Everyone-military and civilian, professional and medical specialist-has an
absolute duty to conduct himself and operate his property to avoid injury to
the person or the property of others. Although the spirit of service to others is
a key principle in providing all medical duties, there are responsibilities that
extend beyond being kind and thoughtful. When services are rendered, there is
an obligation to use due care to insure that the patient is not injured because of
negligence, which can be defined simply as failure to exercise due care with
respect to one to whom care is due. A more complicated legal definition of
negligence is doing or failing to do the act (in carrying out a duty) that a

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reasonable person in the same or similar circumstances would or would not do

where the acting or nonacting in carrying out the duty is the proximate cause
of injury to another person or to his property.

b. Although negligence results in an unintentional injury, once injury

results, it matters little to the injured patient that it was not intended.
Negligence is one of the most common grounds for lawsuits against medical
facilities and medical personnel. Examples of negligence include the injuries
caused by the use of faulty equipment, burns from applications of hot water
bottles and other heating devices, medication errors, falling out of bed, and
careless handling of sponges and instruments in operating rooms.

c. In AMEDD treatment facilities, when a patient is the victim of

negligent treatment or an accident that may or may not have caused injury,
reporting will be accomplished according to the local standing operating
procedure (SOP) and the local Risk Management Plan.

1-15. The Federal Torts Claim Act (FTCA)

a. This act permits legal action against the Federal government on

damage claims "for injury or loss of property, or personal injury or death
caused by the negligent or wrongful act or omission of any employee of the
government while acting within the scope of his office or employment, under
circumstances where the United States, if a private person, would be liable to
the claimant in accordance with the law of the place where the act or omission
occurred.'' The phrase ''employee of the government'' includes members of the
military forces, while "scope of his office or employment" for military forces is
defined to mean "acting in the line of duty."

b. As the result of a U.S. Supreme Court decision (Peres v. U.S.), an

Active Duty service member is not permitted to sue the Army if his injury was
received incident to his service. This decision prohibits Active Duty personnel
from recovering for injuries they incur while receiving medical care as
receiving such care is incident to their service. However, dependents of service
personnel and retired service members can sue for their own injuries received
in such cases.

c. Under terms of the Gonzales Act, 18 USC 1089, the United States is
the only defendant that may be required to pay damages in a lawsuit arising
out of the provision of military medical care, so long as the health care
provider was acting within the scope of his military duties. These lawsuits are
defended in Federal courts by the Department of Justice. While this statute
protects the health care provider from tort liability (paying money damages),
it does not prevent appropriate disciplinary action being taken (para l-12d).
This statute does not protect a military health care provider who is engaged in
outside employment or is otherwise acting outside the scope of his military
duties.

d. Various states have so-called "Good Samaritan" laws which protect

certain individuals who stop at the scene of an accident or other emergency
and render medical attention. These laws vary from state to state in terms of
who is protected (in some states only physicians are protected) and under what
circumstances. In a very few states, you may be required to render such

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emergency assistance, but as a rule, there is no such requirement. Your local

Staff Judge Advocate Office can provide information concerning such laws in
your state.

Section V. MEDICAL TERMINOLOGY

1-16. General

a. Every specialized field has its own vocabulary to communicate

special concepts and concerns-medicine is no exception. It is important for
you to become familiar with the language of medicine for several reasons.
First, an understanding of medical terminology will enable you to think more
precisely in terms of medical problems. Also, a knowledge of the terminology
will help you communicate effectively with the other health professionals with
whom you will be dealing; to communicate, you must speak the same
language.

b. Medical terms are often derived from Greek and Latin roots. These
root words or key words are the foundation of a word. An example of a root
word is "aden," which means pertaining to a gland. A root word, followed by a
vowel to facilitate pronunciation (as in "adeno"), is known as a combining
form; however, this is not a complete word. Adenocarcinoma (a malignant
growth of gland-like cells) or adenoma (a tumor, usually benign, with a gland­
like structure) are complete words.

c. When using two or more root words, a root word and a combining
form, or a combining form and a whole word put together, the result is called a
compound word. Examples of the first two combinations include chicken pox
and erythrocyte (red blood cell), respectively. Thermometer, speedometer, and
microscope are 2 examples of the latter, whereby "thermo," "speedo," and
"micro" are the combining forms and "scope" and "meter" are the words.

1-17. Prefixes

A prefix is a part of a word that precedes the root word and changes its
meaning. It is usually a preposition or an adverb. The final vowel of the
preposition is dropped when the word to which it is affixed begins with a
vowel. "Dys" is a prefix meaning disordered, painful, or difficult.
Dysrhythmia implies a disordered heart rhythm. "Neuro" (denoting nerve),
another example of a prefix, combines with the term "algia" (pain) to form
neuralgia, which refers to an aching along the course of nerve. Tables 1·1 and
1-2 list some of the more common prefix roots with which you should become
familiar.

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Table 1-1. Common Prefixes Pertaining to the Body

Prefix Meaning

arthro- . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . .. . . . .... . . . . ············· joint

brach- . . . . . . . . . . . . . . . . . . . ... . . . . . . . . . . . . . . . . . . . .. . . . . . . ... . .. . . . . . . . arm
�� ······························································· head
cardi- . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . ... .... . . ... . ..... . .. . . . . . . . .. . . . heart
cephalo- . . . .. . . . . . . . . . .... . . . . . . . . . . . . . . . . . .. . . . . . . . . ....... . . .... . head
cerebra- . . . . . . . . . . . .. . . . ...... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . brain
cholecyst- . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... . . . . ... . . .... . . . . . gallbladder
choli- . . . . . . . . . . . . . . ..... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... . bile
cyst- . . . . . . . . . . . . . . . . . . . . . . . . ..... . . . . . . .. . . . . . . . . . . . .. . . . . . . . . . . . . . . bladder
derma- . . . . . . . . . . . . . . . . . . . . .... . . . . .. . . .. . . . . ....... . . . . . . . . . . . . . . . . skin
entero- . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . .. . . . . . . . . . . .. . . . . . . . .... . . . intestines
gastro- ............................................···....·········· stomach
glosso- ,····························································· tongue
hemo- .: ... . . . . . . .. . . . . . . . . . . . . .. . . . . ...... . . . . . . ....... . . . . .. . ... . . blood
hepato- . . . . . . . . . . . . . . . . . . . . .. . . . . . . . .. . . . .. . ..... . . . . . . . . ..... . . . . . liver
hystero- . . . . . . . . . . . ... . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . .. . . . . .... . . uterus
laparo- . . ... . . . . . . .. . . . . . . . . . .. . . . . . ..... . . . . . . . . . . . . . . . . . . . . . . . . . . . abdomen
myo- . . . . . . . . . . . .. . . . . . . . . . . . . . . . . ..... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . muscle
nephro- . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... . . . ..... . . . . . . .. .... . . . . . . kidney
neuro- . . . . . . . . . . ..... ..... . . . .. . . . . . . . . . . . ... . . .. . . . . . . . . . . . . . ..... . nerve
ophthalmo- . . . . . . . . . . . . . .. . . . . . . .... . . . ... . ... . . . . . . . . . . . . . . . . . . . . eye
oral- . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .... . . . . . . . . ... . . . . . . . . . . . . . . . . . . mouth
osteo- . . . . . . . . . . . .. . . . . . . . . . . . .. . . . . . . ... . . . . . . . . . . . . . . . . . . . . . . . . . . . bone
oto- . . . . . .... . . . . . . . . . .. . . . . .. . . .. . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . ear
pharyn- . . . . . . . . . . . ... . . . . . . .. . ... . . . . .... . . . . ........ . . . . ... . . . . . . . throat
phlebo- . . . . . . . . . . . . . . . . . . . . . . ... . . . . . . . . . . . . . . . ... . . . . . . . . . . . . .... . . vein
pneumo- . . . . . . . .. . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . air, lung
procto- . . . . . . . . . . . . . . . . . . . . . . . . . . . ... . . . . . . . . . . . . .. . . . . . . . . . . . . . . .. . rectum
pyelo- . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . .. . . . . . . . .. . . . . . . . pelvis
rhino- . . . . . . . . . . . . . . . . . . . . . ... . . . . . . . . . . . . . . . . .. . . . . . . . . . . .. . . . . . . . . . nose
thoracic- . . . . . . . . . . . .... . . . . . .. . . . . . .. . ... . . . .. . . . . ... . . . . . . . .... . . . chest

1-9
FM 8-230

Table 1-2. Common Prefixes Pertaining to Conditions

Prefix Meaning

a-, an- . . . . . . . . . . . . . . . . . . . . . . . . . ... . . . . . . . . . . . . . . . . . . . . . . . . . lacking, absence of

ante- . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... . . . . . . . . . . . . . . before
anti- . . . . . . . . . ... . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . against
auto- . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . self
brady- . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . slow
contra- . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... . . . . . . . . . . . . . against, opposed to
dys- . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . difficult, painful
endo- . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .... .... . . . within
hemi- . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . half
hydro- . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . · · · · · · water
hyper- . . . . . . . . . . . . . . . . . ... . . . . . . . . . . . ... . . . . . . . . . . . . . . . . . . . above, increase
hypo- . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . below, under
mal- . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . .... . . ill, poor, bad,
disorder
neo- . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . new, recent
oligi- . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . scanty, few
poly- . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... . . . . . . . . . . . . . . . . . too many, too much
pyo- · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · pus
pyro- . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...... . . . . heat, temperature
tachy- . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . fast

1-18. Suffixes

a. A suffix, or word ending, is a part that follows the root word and
adds to or changes its meaning. It follows the root word without insertion of a
connective "o."

b. The suffix "pnea" means breathing. Dyspnea is interpreted as

difficulty in breathing. "Itis" refers to inflammation, as in neuritis, which
means inflammation of a nerve. Another common suffix is "ology," or the
science of cardiology, which is the science of the heart. Neurology is the
science of the nerves and of the nervous system. Tables 1-3 and 1-4 list some of
the more common suffix roots with which you should be familiar.

1-10
 FM 8-230

Table 1-3. Common Suffixes Pertaining to Conditions of the Body

Suffix Meaning

-algia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... . . . . pain

-cele . . . . . . ... . . ..... . . .. .. . .. . . . . . . . . . . . . . . . . . . . .... . . . tumor, swelling
-clysis . . . .. . ... . . . .. . . . .................. . ........... . . slow injection of a
large amount of fluid
-cyte . . . . . . .......... . . ......... . . . .. . . . . . . . . . . . . . . . . . . cell
-emia ........ ..... . . . . ........ . . . .. . . . . . . . . . . . . . .. . . . . . blood
-esthesia . . . . . ........ . . . . . . . .. . . ..... ............... . sensation
-itis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . inflammation
-lith .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . .. . . . stone
-mania . . ... . . . . . . . . . .. . . . . ............ . . . . . . . . .... . . . . insanity
-oma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .... . . . .. . . . ..... . . tumor
-opia . . . . . . . . . . . . . . . .. . . . . . . . ... . . .... . . . . . .... . . .. . . . . . vision
-pathy . . . .. . . . . . . . . . . . . . ...... . . . . . . . . . . . . . . . . . . . . . . . . . disease
-phobia . . .. . . .... ...... . . ....... . . . . ....... . . . . .. . . . . . fear or dread
- plegia . . . . . . . . . . ........ ....... . . . .. . . . ..... . . . .. . . . . . paralysis
-pnea . . . . .... .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . breathing
- ptosis .... ....... . . . . . . . . . . . .. . . . . . . . . . . . . . .... . . . ... . falling
- rrhea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... . . ...... ........ . flow or discharge
-scopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . .. . looking into
-therapy . . . . . . . . . . . . . . . . . . . . . . . . ..... . . . . . . . . . . . . . . . . . treatment
-thermy .... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . heat
-trophic . . . . . . . . . . ..... . . . ..... ... . . . .. . . . .. . . . . . . . . . . . growth
-uric or uria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . urine

Table 1-4. Common Suffixes Pertaining to Surgical Operations

Suffix Meaning

-ectomy . . . . .. . . . . . . . . . . . . ...... . . . . . . . . . . . . . . . . . . . . . . removal of

-manometer . . . . . . . . . . . . ............ . . . . . . . . . . . . . . . . . used to measure
pressure
-meter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . used to measure
- ( o)rrhaphy . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . repair of
-( o)stomy . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . creation of an opening
- ( o)tomy . . . . . ...... . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . cutting into
-pely . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . ... . . . . . to fasten
-plasty . . . . . . . . . . . . . . . . . . . . . .... . . . . . . . . . . . . . . . . . . . . . . . to form or build up
�co� . . . . . . . . . . . . . . . . . .. . . ........ . . . . . . . . . . . ... . . . . . used to examine by
looking into, or by hearing

1-11
 FM 8-230

CHAPTER 2

INTRODUCTION TO THE HUMAN SYSTEM

2-1. General

a. The science of anatomy is the study of the structure of the body.

Considering the body as a complex machine, anatomy is the study of how that
machine is put together. It deals with the structure of the parts, ranging from
the molecular components of the tiniest cell, to the whole individual, and the
relationship of these parts to one another.

b. Physiology is concerned with the functions, or mechanics of the

body; how it works and what regulates, limits, and protects it. Functions
include digestion, respiration, circulation, and reproduction. Structure and
function are so closely related that it is impossible to understand one without
the other, since the effectiveness with which a function can be carried out
depends largely upon the structure of the part.

c. Pathology is the study of changes in the structure or function of the

body caused by disease or trauma. In this chapter, we will be concerned with
normal structures and functions of the various subsystems of the human body.

2-2. Anatomical Terminology

Terms of position, direction, and location that are used in reference to the body
and its parts include the following:

a. Terms of Position. Anatomical position-an artificial posture of the

human body. See Figure 2-1. This position is used as a standard reference
throughout the medical profession:

(1) The body stands erect with heels together.

(2) Upper extremities are along the sides with the palms of the
hand forward.

(3) The head faces forward.

b. Anatomical Postures. The anatomical postures are:

(1) Erect. The normal posture of the body in a standing position.

(2) Supine. The horizontal position of the body lying flat on the
back.

(3) Prone. The horizontal position of the body lying face down.

(4) Lateral recumbent (Sims position). The horizontal position of

the body lying on the left or right side.

2-1
FM 8-230

MIDLI N E

x y z

\:..
�' --- /
\
"-._
"--

'-

'--
./

.....

�
' /
'

L AT E R A L BORDE

"" /
'\

M E DIAL BORD E R

X IS LATERAL TO Y AN D Z
I , ;
Y IS M E DIAL TO X AND

LATERAL TO Z

IN EXAMPLES SHOWN, BODY IS JN

N ORMAL ANATOMICAL POSIT I O N .

Figure 2-1. The anatomical position.

2-2
 FM 8-230

c. Terms for Anatomical Planes. Imaginary straight line divisions of

the body are called planes. Figure 2-2 illustrates the imaginary planes used to
describe the body.

(1) Sagittal planes. Vertical planes that pass through the body
from front to back. The median or midsagittal plane is the vertical plane that
divides the body into right and left halves.

(2) Horizontal (transverse). Planes that divide the body into two
segments. They are perpendicular to both the sagittal and frontal planes.

(3) Frontal (coronal). Vertical planes that pass through the body
from side to side. They are perpendicular to the sagittal plane.

B.

T HE H O RIZON TAL PLA N E.

A.
THE S AG I TTAL PLANE.

T HE F RO N T AL PLANE.

Figure 2-2. Anatomical planes.

2-3
FM 8-230

d. Terms of Direction and Location.

(1) Anterior (or ventral)-at or near the front side of the body.

(2) Posterior (or dorsal)-at or near the back side of the body.

(3) Medial-toward or near the midline of the body.

(4) Lateral -away from the midline or toward the left or right of
the midline.

(5) Proximal-nearest the point of origin or attachment. Used

most in describing the limbs.

(6) Distal-away from the point of origin or attachment.

(7) Superior (cranial)-above or toward the head.

(8) Inferior (caudal)-below or toward the feet.

e. Terms of Body Regions. The body is a single, total composite

system. Everything works together. Each part acts in association with all
other parts. It is also a series of regions (Figure 2-3). Each region is responsible
for certain body activities. These regions are:

(1) Back and trunk. The torso includes the back and the trunk.
The trunk includes the thorax (chest) and abdomen. At the lower end of the
trunk is the pelvis. The perineum is the portion of the body forming the floor of
the pelvis. The lungs, heart, and digestive system are found in the trunk.

(2) Head and neck. The brain, eyes, ears, mouth, pharynx, and
larynx are found in this region.

(3) Extremities.

(a) Each upper extremity includes a shoulder, arm, forearm,

wrist, and hand.

(b) Each lower extremity includes a hip, thigh, leg, ankle and
foot.

2-4
 FM 8-230

/"�

(''!.1'l/{ 111 1!,

HEAD

\.d!Jl�lh;,/,#,_, ' ----'

SHO

-�
-, ,,.

I'
I " \
'
I
I

TRUNK

FOREARM , II : \ '- UPPER

WRIST
f_I \( '""� \
/
'
'
HIPI' '

't.

FINGERS

I
1:.
1( '"'"�" "'"
\
LOWER MEMBER

r
�
(
/

: --+!-(, ---
I \ \
\ ....l..!-- POPLITEAL
ARE'

LEG

ANKLE

roE s
V
i '

�FOOT

�HEEL

NOTE: The perinea! region (perineum) is on the underside of the trunk,

between the beginnings of the thighs.

Figure 2-3. Regions of the body.

2-5
FM 8-230

f Terms for Directions of Movement.

(1) A bduc tion - movement away from the midline of the body.

(2) A dduction - movement toward the midline of the body.

(3) Lateral rotation-to rotate outward, or away from the body's

midline.

(4) Medial rotation-to rotate inward or toward the body's

mid.line.

(5) Flexion-is the act of bending.

(6) Extension-is the act of straightening.

2-3. Cells

The cell is the basic structural and functional unit of all living things. It may
be defined as the minimal structural unit of protoplasm that can carry on all of
the vital functions characteristic of living things. The human body is
composed of trillions of cells which vary in shape and size. Cells are
microscopic in size with the largest being only about 1/1,000 of an inch.
Because of this, a special unit of measurement, the micron, is used to
determine cell dimensions. (One micron equals 1/1,000 millimeter or about
1/25,000 of an inch.) Each of these cells is a living organism in itself, capable of
existing, performing chemical reactions, and contributing its part to the
overall function of the body. Although all living matter is composed of cells,
animal cells are significantly different from each other. Not only do plant cells
contain chlorophyll, a green coloring matter, but also have a cell wall around
them which is made up of a very complex carbohydrate known as cellulose.
Neither chlorophyll nor cell walls are present in animal cells. A typical animal
cell includes a cell membrane, protoplasm, and a nucleus. A typical animal cell
is illustrated in Figure 2-4.

a. Cell Membrane. The cell or plasma membrane surrounds and

separates the cell from its environment. This membrane allows certain
materials to pass through it as they enter or leave the cell. It is through the cell
membrane that all materials essential to metabolism are received, and all
products of metabolism are disposed of.

b. Protoplasm. The major substance of the cell is known as

protoplasm. It is a combination of water and a variety of materials dissolved
in water. Outside the cell nucleus, protoplasm is called cytoplasm; inside the
cell nucleus, it is called nucleoplasm.

2-6
 FM 8-230

CELL MEMBRANE

CYTOPLASM

CENTR I OLE S

NUCLEUS

11..L'fl,,..,lft---.---:Hr...'"
..- �
""'41 NUCLEAR

MEMBRANE

ENDOPLASMIC

RETICULUM

Figure 2-4. Simple animal cell.

c. Nucleus. The nucleus plays a central role in the cell. It controls all
activities of the cell including growth and reproduction. Information is stored
in the nucleus and distributed to guide the life process of the cell. This
information is in a chemical form called nucleic acids. Two types of structures
found in the nucleus are chromosomes and nucleoli. Chromosomes can be seen
clearly only during cell division. Chromosomes are composed of both nucleic
acids and proteins, and contain genes. Genes are the basic units of heredity
which are passed from parents to their children. Genes guide the activities of
each individual cell.

2-7
FM 8-230

d. Vital Functions. Reduced to the simplest terms, the so-called vital

functions may be identified by four properties: metabolism, growth,
irritability and adaptability, and reproduction.

(1) Metabolism is the ability to carry on all the chemical activities

required for cell function. The processes are involved in energy exchange. It
includes using food and oxygen, producing and eliminating waste, and
manufacturing new materials for growth, repair, and use by other cells.
Growth and metabolism involve many of the same functions, but they are two
different things.

(2) Growth occurs when the metabolic balance is tipped slightly in

favor of building processes over breakdown processes. It is because of the
metabolic processes that cells grow larger and more numerous. The
metabolism of special cells allows them to form structures such as bones and
fibrous tissues, enlarging the entire body. Thus metabolism is the basic
function not only for energy needed by the body, but also for growth itself.

(3) Irritability and adaptability denote the ability to respond to a

change in the environment, that is, to a stimulus. Adaptation is a long-range
response to environmental change, as observed in evolutionary changes over
many generations. The nature of the responses varies with the structure or cell
stimulated, as well as the nature of the stimulus.

(4) Reproduction is the ability to perpetuate an individual's own

kind. Reproduction also insures the continuity of the species. Cell growth and
reproduction usually go together, with both occurring simultaneously. We
know that certain cells, such as blood cells, bone marrow, and layers of the
skin, grow and reproduce all the time. However, many other cells, such as
muscle cells do not reproduce for many years. A few cells, such as neurons, do
not reproduce during the entire life cycle of the human body. Most cells of the
body reproduce continually, though that rate of reproduction usually remains
greatly surpressed. Yet, if there is an insufficiency of a given type of cell in the
body, this type of cell will usually grow and reproduce very rapidly until
appropriate numbers are again available.

2-4. Tissue

Tissue is a cohesive group of similar cells. For example, liver cells are bound
together to form liver tissue, and bone cells are bound together with lime salts
to form bony tissue. The tissues of the body have different characteristics
because the cells which compose them are different both in structure and
function. There are four primary types of body tissue:

a. Epithelial tissue which makes up all covering and lining membranes

of the body and all glands.

b. Connective tissue which supports and connects other tissues.

c. Nervous tissue which is specialized to receive stimuli and conduct

messages over long distances.

d. Muscle tissue which is specialized to contract (shorten) in response

to stimuli from nerves.

2-8
 FM 8-230

2-5. Connective Tissues

Connective tissues are the tissues that support or hold other tissues together,
or fill spaces. Among and outside the cells of the connective tissue is a material
called matrix. The matrix is manufactured by the connective tissue cells. Each
type of connective tissue has its own particular type of matrix. Several major
types of connective tissue (CT) include fibrous CT (FCT), cartilage CT, bone
CT, and fat CT.

2-6. Muscle Tissue

There are muscle tissues and there are organs called muscle tissues. Muscle
tissue and the muscles they make up are specialized to contract. Because of
their ability to shorten (contract), muscles are able to produce motion. Figure
2-5 illustrates the three types of muscle tissue: smooth, striated, and cardiac.

a. Smooth Muscle Tissue. Cells of smooth muscle are long, but remain
as individual cells. Smooth muscle tissue is found generally in the walls of
hollow organs, such as the digestive system, the respiratory system, the blood
vessels, and the urinary bladder.

b. Striated Muscle Tissue. The cells of striated muscle tissue have

united to form fibers. Striated muscle tissues are found making up the skeletal
muscles that assist in activities such as pushing, pulling, running, walking, or
swimming.

c. Cardiac Muscle Tissue. In the myocardium (the muscle layer of the

heart), the cells have also united to form cardiac fibers. These fibers are cross­
striated, but branched. The heart and its component parts will be discussed in
a later chapter.

._____ ---

b. STRIATED

a. SMOOTH MUSCLE

C. CARDIAC MUSCLE

Figure 2-5. Types of muscle tissue.

2-9
FM 8-230

2-7. Nervous Tissue

Nervous tissue is a collection of cells that respond to stimuli and transmit

information.

a. A neuron (Figure 2-6), or nerve cell, is the cell of the nervous tissue
that actually picks up and transmits a signal from one part of the body to
another. A synapse (Figure 2-7) is the point at which a signal passes from one
neuron to the next.

b. The neuroglia (also known as glia) is made up of the supporting cells

of the nervous system. The nervous tissues will be discussed in a later chapter.

CELL BODY - -

AXON - - -

MYELIN - -
SHEATH

NEURILEMMA - -

SCHWANN CELL
NUCLEUS

TERMINAL {
ARBORIZATION "
"
"
BOUTON

Figure 2-6. A neuron.

Figure 2- 7. A synapse.

2-10
 FM 8-230

CHAPTER 3

THE INTEGUMENTARY SYSTEM

3-1. General

The integumentary system includes the integument proper and the

integumentary derivatives. The integument proper is commonly known as the
skin and is the outermost covering of the entire body. The integumentary
derivatives include the hairs, nails, and various glands of the skin. The skin, as
the largest organ of the body, serves the body in many important ways:

a. Protection as a mechanical barrier to the entrance of bacteria and

foreign objects and against minor injury.

b. Regulation of body temperature through control of heat and loss or

retention of water.

c. Sensory perception through neuron endings that transmit

sensations of heat, cold, touch, pain, and pressure.

d. Limited excretion of body wastes through sweat. The skin also

protects inner tissues from drying. Although this is not one of its normal
functions, the skin can absorb water and other substances. This function is
used to advantage in the local application of certain drugs. It can also be
harmful when toxins and chemical agents are absorbed through the skin.

3-2. The Integument Proper

The integument proper (skin) is the outermost layer of the body. The skin
consists of two layers: the outer layer and the inner layer. The outer layer is
called the epidermis and the inner layer is called the dermis.

a. The Epidermis. The epidermis is a stratified squamous epithelium.

This means that it is made up of several layers of cells. There are no blood
vessels or neuron endings in the epidermis. The outermost cells are flat and
resemble scales. These dead cells are constantly flaking off the surface. As this
happens, growing inner epidermal cells are pushing up toward the surface to
replace the outer cells. Skin pigment called melanin is produced in cells located
below the epidermis and injected into the epidermal cells. It determines the
darkness or lightness of skin color. However, the skin color is also due to the
quantity and state of the blood circulating in the dermis. Pinkness, blueness
(cyanosis), or paleness (pallor) of the skin surface is due to the amount of blood
circulation.

b. The Dermis (Dermal Layer). The dermis is the layer of the skin lying
just beneath the epidermis. It is dense fibrous connective tissue consisting of
white and yellow fibers. The dermis has fingerlike projections called papillae.
These papillae extend into the epidermis and keep the dermis and epidermis
from sliding on each other. The dermal layer includes blood vessels, lymph
vessels, nerve endings, hair follicles, and glands.

3-1
FM 8-230

3-3. Integumentary Derivatives (Skin Accessory Organs)

The integumentary derivatives include the glands, hairs, and nails associated
with the skin. All integumentary derivatives are formed from the tissues of the
integument proper (dermis and epidermis). They are appended (attached) to
the integument proper and are often known as the appendages of the skin. (See
Figure 3-1.)

HAIR SWEAT PORE

SEBACEOUS

CELLS

SEBACEOU S

GLA N D

S E BA C E O U S

G LA N D

I N TERNAL ROOT

N A I L BED SHEATH

<c :

A,,'�
PLATE
.
.
EXTERNAL ROOT ... SWEAT
\ c__.<
"v -

"{.__'�;
_) , , \.

''L-- H A I R
SHEATH
ROOT GLAN D

HAIR
FI NGERNAIL

Figure 3-1. The integumentary derivatives.

a. Hairs.

( 1 ) A hair follicle is formed by the extension of the skin (dermis

and epidermis) deeper into the surface of the body. Follicles may extend into
the subcutaneous layer. At the base of the hair follicle is the hair root. The hair
shaft grows out from the root and is made up of cells from the outermost
layers of the epidermis.

(2) Scalp and facial hairs grow continuously. Other hairs of the
body grow to fixed lengths. The types and patterns of hairs are determined for
each individual by genetics.

(3) Friction against the integument is reduced by hairs and outer

dead cells.

3-2
 FM 8-230

b. Glands. The types of glands include the sweat glands, the sebaceous
(fat/oil) glands, and the mammary glands (breasts). The ducts and secretory
parts of these glands are made of epithelial tissues. Backup or supporting
tissue is of fibrous connective tissue.

(1) Sweat glands. Sweat glands consist of a coiled secretory

portion and a duct leading to the surface of the skin. The coiled secretory
portion is located in the dermis or deeper. Sweat glands are found everywhere
on the body in association with the skin. Sweat glands manufacture sweat, or
perspiration, from fluid drawn from blood. Sweat contains salts and organic
wastes and is about 99 percent water. It is discharged through skin openings
called pores. As sweat evaporates, the body is cooled. Sweat formation and
excretion are important mechanisms for reducing body heat.

(2) Sebaceous glands. Sebaceous glands produce an oily substance

called sebum, which lubricates the skin and hairs. The oil keeps the skin and
hairs pliable and helps keep the skin waterproof. The sebaceous glands are
usually found as a part of the walls of hair follicles and their oil flows into the
follicle. In a few places without hairs, they open directly to the skin surface.
When the openings of the sebaceous glands become plugged with dirt, they
form blackheads.

(3) Mammary glands. In the adult human female, the mammary

glands lie in the subcutaneous layer anterior to the chest muscle (pectoralis
major). Their function is to nourish the newborn. A nipple is located near the
center of each breast. Around each nipple is a darkened area known as the
areola. The tip of the nipple has many small openings to allow the passage of
the milk from the milk ducts. These ducts are connected to lobes of glandular
tissue located throughout the breast. Fat and fibrous connective tissue fill in
the spaces among the lobes.

c. Nails. Nails are located in the ends of the digits (thumbs, fingers,
and toes). Nails help to protect the ends of these digits and aid in picking up
objects. Each nail bed is attached to the top of the terminal phalanx (bone of
each digit). The nail itself is made up of cornified (hardened) outer cell layers of
the epidermis. The nails grow continuously from their roots.

3-4. Fascial Tissue

A fascia is a sheet or collection of fibrous connective tissue. The superficial

fascia is the connective tissue which lies immediately beneath the skin and is
often known as the subcutaneous layer. Deep fasciae (plural) form envelopes
for muscles and other organs. Portions of the integumentary system and
fascia} tissue are shown in Figure 3-2.

a. Superficial Fascia.

(1) The superficial fascia is the second envelope of the body. It is

the connective tissue that lies immediately between the skin (integument
proper) and the deep fascial envelope. It is often called the subcutaneous layer,
but it is technically not a part of the integumentary system. Fat deposits
located here store reserve energy for the body and form an insulating layer.
Fat and other fibrous connective tissues in the subcutaneous layer round out
body surfaces and cushion bony parts.

3-3
FM 8-230

( 2 ) The superficial fascia is made up primarily of loose areolar

fibrous connective tissue with the spaces filled by fatty tissue and tissue fluid.
It contains the superficial or cutaneous branches of nerves, arteries, veins, and
lymphatics (NAVL) of the skin.

b. Deep Fasciae.

(1) The deep fasciae include various membranes made of

consolidated or dense fibrous connective tissue. A deep fascia envelops the
entire body as the third envelope. This third envelope is known as the
investing deep fascia. It is beneath the skin and subcutaneous layers.

( 2 ) Deep fasciae also include the envelopes of the muscles and

other organs. Around individual organs (for example, the kidney) it is called a
capsule.

(3) Another form of deep fascia is found in the collections of loose

areolar fibrous connective tissue and fat that are found as filling among the
organs. Similar deep fasciae attach organs to the body wall.

1.

2. SUBCUTANEOUS LAYER

3. INVESTING DEEP FASCIA

ARTERY
SWEAT
VEIN
I
SENSORY N . HAIR ROOT

Figure 3-2. The integument and related structures.

3-4
 FM 8-230

3-5. Serous Cavities of the Body

The term serous refers to a watery-type fluid. Serous cavities are sacs lined
with serous membranes. These cavities serve as lubricating devices. They
reduce the friction during the motion between organs.

a. Bursa.

( 1 ) A bursa (Figure 3-3) is th.., simplest of serous cavities. Each

bursa is a small sac located between two moving structures, usually a muscle
moving over a bony surface. The bursa reduces the friction between the two
structures. For example, a bursa prevents excessive friction between the skin
and patella (kneecap). This bursa, called the prepatellarbursa, allows the skin
to move freely over the patella.
(2) As a fibrous sac, each bursa has a central cavity that is lined
with a serous membrane. This membrane is a simple epithelium. The serous
membrane secretes a serous fluid into the serous cavity. The serous fluid is the
lubricant, minimizing friction.

l. SEROUS (BU RSAL) C A V I TY :

a. SPACE CONTAI N I N G J U S T E N OUGH SEROUS FL U I D T O M O I S T E N

I N N ER S U R FA C E

b. S P A C E A R T I F I C I ALLY W I D E N E D FOR D I AGRAMMAT I C P U RPOS E S .

2. (BURSAL) CAPSULE

a. "BAG - L I K E " - S U R RO U N D I N G T H E SEROUS CAVITY .

b. FCT M EMBRAN E MAI N S T R U C T U RAL ELEM E N T .

c. A S EROUS M E MBRAN E ( S I MPLE SQUAMOUS EP I T H EL I AL T I S S U E )

A S AN I N N ER L I N I NG O F T H E CAPSULE. THE SEROUS MEMBRANE

I NCLOSE S THE S E ROUS CAVITY AND S ECRETES THE SEROUS FLUID.

Figure 3-3. A bursa-the simplest serous cavity.

3.5
FM 8-230

b. Other Serous Cavities of the Body.

( 1 ) Other important serous cavities are associated with the major

hollow organs, referred to as visceral organs. Each lung is encased in a serous
cavity called the pleural cavity. The heart lies in a serous cavity called the
pericardia! cavity. The intestines are allowed to move freely during the
digestive processes within the peritoneal cavity.

(2) Each serous cavity has an inner and an outer membrane. The
inner membrane is intimately associated with the surface of the visceral organ.
The outer membrane forms the outer wall of the cavity. The serous lining of
the cavity secretes the serous fluid into the cavity to act as a lubricant
between the membranes, allowing freer motion for the organs.

3-6
 FM 8-230

CHAPTER 4

THE SKELETAL/MUSC L E SYSTEM

Section I. THE SKELETAL SYSTEM

4-1. General

The skeletal system (Figures 4-l A and 4-lB) provides a framework for the
body, giving it form and protection, and enclosing the vital organs, such as the
brain, heart, and lungs. The skeletal system is composed of:

a. Bones, 206 in number, which form the hard framework of the body.

b. Cartilage, which provides connecting and supporting structures.

c. Ligaments, which bind bones together.

4-2. Basic Structure of a Bone

Bones are formed of a protein matrix, which provides growth, and salts
(basically calcium phosphate salts), which give bones their characteristic hard
texture. Living cells within the matrix constantly repair the structure of bones
and play an important role in the healing of fractures. Other cells (the marrow)
occupy the cavities within the bones and produce blood cells. Bones are living
tissue like muscle, skin, and other tissues; a rich blood supply constantly
provides the oxygen (0 2) and nutrients required by the bones. Each bone also
has an extensive nerve supply. This is why the fracture of a bone will produce
severe pain from irritation of nerves as well as significant bleeding from
damage to its blood vessels. Figure 4-2 represents the basic structure of an
individual bone.

4-3. Bone Marrow

I'wo kinds of marrow, yellow and red, are found in the marrow cavities of
:>ones. Red bone marrow is active blood cell manufacturing material,
producing red blood cells and many of the white blood cells. Deposits of red
bone marrow in an adult are in cancellous portions of some bones-the skull,
ribs, and sternum, for example. Yellow bone marrow is mostly fat and is found
in marrow cavities of mature long bones. The examination of red marrow
deposits is important for diagnostic tests when the condition of developing
blood cells must be determined. For microscopic examination, the doctor
obtains a small amount of marrow through a special needle puncture, usually
in the sternum.

4-4. Shapes of Bones

Bones are classified according to their shape (long, short, flac,, or irregular) or
according to their embryonic origin (membranous or cartilaginous), and their
structure (compact or spongy). Long bones are found in the extremities and
include the humerus, radius, ulna, femur, tibia, fibula, and the phalanges.
Short bones are found in the wrist and ankles and include carpal and tarsal
bones. Flat bones include the ribs, scapula, and some skull bones. Irregular
bones include the vertebrae, coccyx, and mandible.

4-1
FM 8-230

RIB

COSTAL
CARTI LAGE --f+4�p..;::�

LUMBAR
VERTEBRAE

RADIUS

CARPAL
BON ES

FEMUR

TARSAL BON E S

/
METATARSAL --­ PHALANGES

BON ES

Figure 4-lA. The skeleton (anterior).

4-2
 FM 8-230

SKULL �����---1'�

CERVICAL VERTEBRAE

THORACIC VERTEBRAE

SCAPULA

RIB

H UM ERUS

LUMBAR VERTEBRAE

SACRUM

COCCYX

ULNA --1+1'1-11

RADI U S

FEMUR

FI BULA

CALCANEUS

Figure 4-lB. The skeleton (posterior).

4-3
FM 8-230

ARTICULAR
CARTILAGE

EPIPHYSIS

MEDULLA
(SPONGY BON E ) CORTEX
(COMPACT BON E )

\1r
/1 1�/--
i/
PERIOSTEUM

DIAPHYSIS
(SHAFT)

MARROW
/
�
-
ARTERY

N ERVE
} N UTRIENT
VEIN

CANAL

MARROW __ ____,_.��
EPIPHYSIS
CAVITY
(END)
EPIPHYSI
(END)
DIAPHYSIS
(SHAFT)

EPIPHYSIS
(END)

Figure 4-2. A mature long bone (femur).

4-5. Skeletal System

The framework provided by the skeleton permits an erect posture and gives
the body its characteristic form (Figure 4-3).

4-4
 FM 8-230

a. The Skull (Figure 4-3). The skull is a bony framework. It has two
maj or subdivisions: the cranium and the facial skeleton. The most important
are the cranial bones, including the frontal, occipital, temporal, and parietal,
which enclose and protect the brain and the upper j aw, or maxilla, the lower
jaw or r:uandible, and the cheek bones, or zygomatic bones. The mandible is
attached to the skull by modified j oints that permit the lower jaw to move.

(1) The cranial bones are fused at j oints called the coronal suture.
The bones of the cranium are not fully fused and the sutures are soft at birth.
As the baby grows, the bones of the skull fuse firmly, making the skull a rigid
box that does not permit expansion. When bleeding occurs within the adult
skull, or if brain tissue swells, the increase in intracranial volume will increase
pressure and damaged brain tissue can occur.

(2) The facial skeleton consists of bones which surround the nose
and mouth and are mainly flat and irregular in shape. The face is composed of
bones fused together to provide protection for important structures. For
example, the orbit (eye socket) is composed of two facial bones, the maxilla and
the zygoma, as well as the frontal bone of the cranium, to form a solid bony rim
that protrudes around the eye to protect it. The maxilla contains the upper
teeth and forms the hard palate, or the roof of the mouth. The mandible, or
lower j aw, is the only movable facial bone that has a j oint (the
temporomandibular) with the cranium just in front of the ear. The nasal bone
is very short and the majority of the nose is composed of flexible cartilage.

(8) Certain hones of the skull have air-filled spaces called the
panmasal sinuses.

NOTE

The skull includes the flat bones of the

cranium, which are fused, and the fadal
bones. The mandible (lower jaw) is freely
movable.

(4) The upper jaw (maxilla) and the lower jaw (mandible) are parts
of the facial skeleton that surround the mouth.

(5) The hyoid bone is located at the junction between the head and
the neck. It is held in place-and moved around -by groups of muscles above
and below. The root of the tongue is attached to its upper anterior surface. The
larynx is suspended from its inferior surface. These three structures, together,
form the hyoid complex. This complex is a functional unit for swallowing.

4-5
FM 8-230

F R O N T AL BONE

N ASAL BONE

',
I P A R I ETAL BON E

,' \
,
\�_.

T E M PORAL BONE -

ZYGOMA T I C BON E -
------
r ""-,""-'""'t
( J
----+-
""'
"· --,II---- M I D D L E AND

t
I N F E R I OR CONCHAE

M A N D I BL E

CORONAL SUTURE PARIETAL BONE

"'---..

FRONTAL BON E � ---

1 . -- >(\
-1 '
1 ::- -- �""'

0_ (;
\ ,
f E M PO R A L BONE
' "

NASAL B O N E -- - ��-J(/ -- /I
; '.?J l ;,l ;/-
ri
OCC I P I TAL BONE

ZYGOM A T I C BONE -- l --
--��::± _: _ _ ____ TMJ
( T E M POROM A N D I BULAR JOI N T )

\\·-- - - 1�/ r
- ,-r\(� Ji
M A X I L L A -- " -­

.. EXTERNAL A U DI T O R Y MEATUS

--)/ MASTO I D PROCESS

MAN D I B L E STYLO I D PROCESS

'----
--- ----

Figure 4-3. The skull (front and side views).

4-6
 FM 8-230

b. The Spinal Column (Figure 4-4).

( 1 ) The spinal column serves a s the main axis of the body,

providing rigidity but permitting some degree of movement. It also serves as a
protective case, inclosing the spinal cord and the roots of the spinal nerves.
The spinal column is composed of 33 bones called the vertebrae. The skull rests
at the top of the spinal column. From the brain extends the long nerve tracts
that form the spinal cord. This cord is an extension of the brain composed of
virtually all the nerves carrying messages between the brain and the rest of
the body.

(2) The ribs join with the upper vertebrae to form the thorax. The
pelvis, with the lower part of the spinal column, or sacrum, form the pelvic
girdle. The spinal column is divided into five sections (Figure 4-4)-

• Section I -Cervical Spine: comprising the first seven

vertebrae in the neck region.

• Section 2-Thoracic Spine: consisting of 12 vertebrae in

the upper back with which the 1 2 pairs of ribs j oin.

• Section 3-Lumbar Spine: made up of five vertebrae in the

lower back.

• Section 4-Sacrum: j oins with the pelvis at the sacroiliac

j oint, forming part of the pelvic girdle.

• Section 5 - C occyx ( tail bone ) : consists of the

last four vertebrae which are fused together.

(3) The vertebrae are named according to the section of the spine
in which they lie and are numbered from top to bottom. The first seven
vertebrae form the cervical spine (C 1 -C 7 ). The next twelve vertebrae make up
the thoracic or dorsal spine; one pair of ribs articulates (joins) with each of
these vertebrae. The next five vertebrae form the lumbar spine, or the lower
back.

(4) The five sacral vertebrae are fused together to form the
sacrum. The sacrum is j oined to the iliac bones of the pelvis with strong
ligaments to form the pelvic girdle. The last four vertebrae form the coccyx, or
tailbone.

(5) The front part of each vertebrae is a round solid block of bone
called the body. The back part of each vertebrae forms a bony arch (Figure
4-5). These series of arches, from one vertebrae to the next, form a tunnel that
runs the length of the spine and is called the spinal canal. The spinal canal
in closes and protects the spinal cord. Nerves branch off from the spinal cord
between each two vertebrae to form the motor and sensory nerves of the body
(Figure 4-5).

4-7
FM 8-230

7th

VERTEBRAE

THORACIC
VERTEBRAE

SPI NAL CORD

DURA MATER
LUMBAR
VERTEBRAE

Figure 4-4. The spinal column.

(6) The vertebrae are connected by ligaments, and between each

two vertebral bodies is a cushion, the intervertebral disc. These ligaments and
discs allow some motion, such as turning the head or bending the trunk
forward or backward, but they also act to limit motion of the vertebrae so that
the spinal cord will not be injured. When a fracture of the spine occurs,
protection for the spinal cord and its nerves may be lost. Until the fracture is
made stable, the medical specialist, must guard against further injury to the
spinal cord. The spinal column itself is virtually surrounded by muscles;
however, the posterior spinous process of each vertebrae can be felt as it lies
just under the skin in the midline of the back.

4-8
 FM 8-230

SUPERIOR V I EW
PROCESS

ARTICULAR

N E URAL PROCESS

ARCH

S I DE V I EW

BODY SPINAL VERTEBRAL BODY

CORD

N E URAL ARCH

Figure 4-5. Top view of a thoracic vertebrae showing

the spinal canal protecting the spinal cord.

c. The Thorax

( 1 ) The rib cage, or thorax, is made up of the ribs, the 1 2 thoracic

vertebrae, and the sternum (breastbone) (Figure 4-6). There are 1 2 pairs of ribs.
Each rib forms a j oint with its respective thoracic vertebrae and curves around
to form the rib cage. At the front of the rib cage, ribs one through ten connect
with the sternum. For the lower five ribs, cartilaginous bridge is formed. The
sternum forms the middle part of the front of the thoracic cage. The xiphoid
process of the sternum is cartilaginous, pointed, and very tender to palpation.

4-9
FM 8-230

(2) Moderate pivoting of the ribs at their j oints with the vertebrae
allows expansion of the thorax when one inspires (breathes in). As the ribs
pivot upward, the thoracic cavity becomes larger, and air is drawn into the
lungs.

(3) The primary function of the rib cage is to protect the vital
chest contents from injury.

CORACOIO SCAPULA
MANUBRIUM
PROCESS (PART OF PECTORAL GIRDLE)
OF STERNUM
STERNAL NOTCH
SCAPULA CLAVICLE

HUMERUS

STERNAL
ANGLE

XIPHOID
STERNUM
PROCESS

ANTERIOR V I EW POST E R I O R V I EW

Figure 4-6. The thoracic cage.

d. The Upper Extremities. The upper extremities are composed of the

bones of the shoulder girdle (Figure 4-7), arms, forearms, and hands.

( 1 ) The shoulder girdle consists of the scapula (shoulder blade),

clavicle (collar bone), and humerus (Figure 4-7).

4-10
 FM 8-230

SUPERIOR V I EW
PROCESS

N E URAL
ARCH

S I DE V I EW

BODY VERT E BRAL BODY

- ::::::

N EURAL ARCH

Figure 4-5. Top view of a thoracic vertebrae showing

the spinal canal protecting the spinal cord.

c. The Thorax

(1) The rib cage, or thorax, is made up of the ribs, the 1 2 thoracic
vertebrae, and the sternum (breastbone) (Figure 4-6). There are 1 2 pairs of ribs.
Each rib forms a joint with its respective thoracic vertebrae and curves around
to form the rib cage. At the front of the rib cage, ribs one through ten connect
with the sternum. For the lower five ribs, cartilaginous bridge is formed. The
sternum forms the middle part of the front of the thoracic cage. The xiphoid
process of the sternum is cartilaginous, pointed, and very tender to palpation.

4-9
FM 8-230

(2) Moderate pivoting of the ribs at their j oints with the vertebrae
allows expansion of the thorax when one inspires (breathes in). As the ribs
pivot upward, the thoracic cavity becomes larger, and air is drawn into the
lungs.

(3) The primary function of the rib cage is to protect the vital
chest contents from injury.

CORACOID SCAPULA
M A N U B R I UM
PROCESS (PART OF PECTORAL GIRDLE)
OF STERNUM

STERNAL NOTCH
SCAPULA CLAVICLE

GLENOID HUMERUS

ANGLE

XIPHOID
STERNUM
PROCESS

ANTERIOR V I EW POST E R IOR VIEW

Figure 4-6. The thoracic cage.

d. The Upper Extremities. The upper extremities are composed of the

bones of the shoulder girdle (Figure 4-7), arms, forearms, and hands.

(1) The shoulder girdle consists of the scapula (shoulder blade),

clavicle (collar bone), and humerus (Figure 4-7).

4-10
 FM 8-230

(a) The shoulder blade, or scapula (Figure 4-7), is a large

flat, triangular bone held to the rib cage posteriorly by powerful muscles. The
scapula floats freely on the upper posterior ribs, because it is not attached to
the ribs beneath it. The upper outer portion of the scapula forms the socket of
the j oint, where motion is very free in all planes.

(b) The collar bone (clavicle) (Figure 4-7) is a long, slender

bone that lies just under the skin and serves as a support or prop for the upper
extremity. The collar bone is a somewhat f-shaped bone attached by strong
ligaments to the sternum at one end and to the scapula at the other.

ACROMI OCLAV I C ULAR JOINT S T E R N OCLAVICULAR JOINT

S C APULA

Figure 4-7. The shoulder girdle.

(c) The upper arr l, or humerus ( Figure 4-8) j oins

proximally with the scapula and dist Uy with the bones of the forearm-the
radius and ulna-to form the (hinged oint) elbow j oint.

4-11
FM 8-230

PECTORAL

PROXIMAL

SEGM ENT

M I DDLE

S EGMENT

DI STAL
SEGMENT

Figure 4-8. The upper and lower arm.

(d) The radius and ulna form the forearm. An extension of

the ulna, called the olecranon process ("funny bone"), forms part of the elbow
joint. The ulna is narrow and is on the same side of the forearm (the ulnar side)
as the little finger. The ulna serves as a pivot around which the radius turns to
rotate the palm upward (supination) or downward (pronation). At the elbow,
the ulna is larger than the radius, but at the wrist the radius is the larger of the
two.

4-12
 FM 8-230

(2) The hand (Figure 4-9) includes three groups of bones: the wrist
bones (carpals), the hand bones (metacarpals), and the finger bones
(phalanges). The back of the hand is referred to as the dorsum and the front,
the palm. The thumb side of the hand and wrist is called the radial side (after
the radius), and the little finger side is called the ulnar side (after the ulna).

(a) The wrist j oint (Figure 4-9) is a modified ball-and­

socket j oint formed by the radius, ulna, and several small wrist bones (the
carpal bones). The wrist can be flexed and extended and also bent to each side
and rotated to some degree.

(b) Extending from the carpal bones are five meta­

carpals,which serve as the base for each of the fingers (Figure 4-9). In the
thumb there are two bones beyond the metacarpal, the proximal and distal
phalanges. The remaining four fingers of the hand are named in order: the
index, the long, the ring, and the little finger. The phalanges j oin with the
metacarpal and with themselves through simple hinge j oints (Figure 4-9). The
many subtle motions permitted by the j oints of the hands and wrist enable us
to perform highly skilled tasks.

METACARPALS

Figure 4-9. The hand.

4-13
FM 8-230

e. The Lower Extremities. The lower extremities consist of bones of

the pelvis, upper legs, lower legs, and feet. The hip bone, or pelvic girdle
(Figure 4-10), is in reality three bones-the ischium, ilium, and pubis-fused
together to form a bony ring. The two ilia! bones join posteriorly with the
sacrum. Anteriorly, the three bones unite at a socket-like depression, the
acetabulum, which receives the head of the long leg bone, the femur. All three
j oints allow little motion, because they are firmly held together by strong
ligaments. The pelvic ring is strong and stable, designed to support the body
weight and protect the structures within the pelvic cavity (the bladder, the
rectum, and the female reproductive organs).

SAC ROIL IAC JOINT SACRA L PROM ONTORY } PEL VIC

BRIM
I L IAC C R E ST
I L IOPECT I N EAL L I N E5 ( I N LET)
SACRUM
I LIAC

PELVIC BONE
•

FORAM E N
PUBIS

I S C H I UM

Figure 4-10. The hip bone or pelvic girdle.

( 1) The upper leg, or femur (thigh bone) (Figure 4-1 1 ) is the longest
and one of the strongest bones in the body. The femoral head joins with the
acetabulum of the pelvis. This ball-and-socket j oint allows flexion, extension,
adduc tion (motion of the limb toward the midline), abduction (motion of the
limb away from the midline), as well as internal and external rotation of the
lower extremity.

(2) The femur consists of a head, the ball-shaped part that fits into
the acetabulum; a neck, which is about 3 inches (7 .6 cm) long and is set at an
angle; and a shaft. The femoral neck is a common site for fractures, especially
in the elderly (Figure 4-1 1 ).

4-14
 FM 8-230

GREATER TROCHANTER

FEMUR

SHAFT

LATERAL ADDUCTOR
EPICON DYLE TUBERCLE

CON DYLES

PATELLAR SURFACE EPICONDYLE

Figure 4-11. The upper leg or femur.

(3) In the proximal thigh, the prominence of the greater

trochanter of the femur can be easily palpated. This is sometimes called the
"hip bone. " The shaft of the femur is surrounded by muscle (the quadriceps
anteriorly and the hamstrings posteriorly) and is not easily palpated. Just
above the knee, however, the medial and lateral femoral condyles can be felt.

4-15
FM 8-230

(4) Between the thigh and the lower leg is the knee j oint, which is
the joint (Figure 4- 1 2) between the femur and the tibia. The knee is the largest
joint in the body and is essentially a hinge j oint, allowing only Hexion and
extension. Adduction, abduction, and rotation are resisted by complex
ligaments that are quite susceptible to injury.

(5) In front of the knee joint is the patella (kneecap). It lies within
the tendon of the quadriceps muscle and acts to protect the front of the knee
joint from injury (Figure 4- 1 2).

(6) The leg (Figure 4-12) is the portion of the lower extremity
between the knee and the ankle joints. The lower leg consists of two bones, the
tibia and the fibula. The tibia (shin bone) is the larger bone. It lies anterior in
the leg with its front edge just under the skin and is easily palpable. The fibula
is not a component of the knee joint but does make up the lateral aspect of the
ankle joint (lateral malleolus). The medial malleolus or body knob on the inner
side of the ankle, is the end of the tibia.

(7) The ankle is a hinge joint that allows flexion and extension of
the foot and leg. The distal end of the tibia provides a smooth articular surface
for the ankle bone (talus).

(8) In the foot, beneath the ankle bone (talus), sits the heel bone
(calcaneus or os calcis). The talus and calcaneus (as well as five other bones of
the mid·foot) are called tarsal bones. Five metatarsals join with the tarsal
bones, and each gives rise to its respective toe (Figure 4 - 1 3).

f. Joints (Articulations).

(1) Wherever two bones come into contact, a joint articulation is

formed. Some joints allow motion; for example, the hip, knee, or elbow. Other
bones fuse with one another at joints so that a solid, immobile bony structure
results. The skull is composed of several different bones that fuse as the
person grows into adulthood. The infant, whose bones are not yet fused, has
soft spots called fontanelles between the bones. Many j oints of the body are
named by combining the names of the bones forming that joint; for example,
the sternoclavicular joint is the articulation between the sternum and the
clavicle.

4-16
 FM 8-230

PELVIC

PROXIMAL PHALANGES

SEGMENT

} "'"'"""
TARSALS

FIBULA --·

M I DDLE
SEGMENT

Figure 4-13. The foot.

Figure 4-12. The lower extremity.

4-1 7
FM 8-230

(2) A joint consists of the ends of the bones that make up the joint
and the surrounding connecting and supporting tissues (Figure 4- 14). The ends
of bones that articulate with each other are covered with a smooth, shiny
surface called articular cartilage. Inside some joints, most notably the knee,
there are cartilaginous cushions that fill up spaces between the bones and aid
in the gliding motion of that joint. Such a cushion is called a meniscus or
sometimes simply a cartilage. When injured and torn from its attachments,
the meniscus can produce symptoms of locking or catching in the joint.

CD
3

CD - BONES

0 - ARTICULAR CART I LAGES

CD
0- SYNOVIAL :

a. SYNOVIAL MEMBRANE � ·-- A SIMPLE SQUAMOUS EPITHELIAL TISSUE LINING THE

F I BROUS CAPSULE @ AROUN D T H E S Y N OV I A L CAVITY A N D S E C R E T I N G T H E SYN OVIAL F L U I D .
NOTE : D O E S NOT COVER T H E ARTIC ULAR CART I LAGE .

b. SYNOVIAL CAVITY ;;;;;;;:;:;:; - H E R E ART I F I C I ALLY O P E N E D FOR D I AGRAMA T I C P U R P O S E S ,

N O R M A L L Y T H E ARTICULAR C A R T I L A G E S R I D E ON O N E A N O T H E R W I T H A THIN F I LM OF
SYNOVIAL FLUID BETWEEN T H E ARTICULAR CART I L AGES.

CD . F I BROUS CAPSULE ::: :;: : : SURRO U N D I N G J O I N T CAVITY.

CD - LIGAME N T S :

a. HOLD BON E S F R O M B E I N G S E PARATED.

b. MAY BE S E PARATE STRUCTURES OR T H I C K E N I N GS OF T H E FIBROUS CAPS U L E .

CD - SKELETAL MUSCLES \.

Figure 4-14. The typical joint.

4-18
 FM 8-230

(3) In joints that allow motion, the bone ends are held together by
a fibrous tissue capsule. At certain points around the joint, the capsule is lax
and thin to allow motion in a certain plane, while in other areas it is quite thick
and resists stretching or bending. These bands of tough, thick capsule are
called ligaments.

(4) A joint that is virtually surrounded by tough, thick ligaments

(such as the sacroiliac joint) will have little motion. However, a joint with few
ligaments (such as the shoulder) will be free to move in almost any direction
(these are more prone to dislocation).

(5) The degree of freedom of motion of a joint is determined by the

extent to which the ligaments hold the bone ends together and by the
configuration of the bone ends themselves. While the amount of motion varies
from joint to joint, all joints have a definite limit of motion. When a joint is
forced beyond this limit, damage to some structure will occur such as:

(a) The bones forming the joint may fracture (break).

(b) The supporting capsule and ligaments may be

torn. The inner surface of the joint capsule (the synovium) produces a fluid
that nourishes and lubricates the articular cartilage. This is called synovial
fluid. It is thick-almost oily-and clear yellow in color. Normally, only a few
cubic centimeters of synovial fluid are produced to protect the joint. Injury or
disease may result in increased production of synovial fluid and swelling inside
the capsule; for example, the so-called "water on the knee. "

(6) Motion of a joint is produced by the action of muscles. All

muscles of the extremities pass through tendons to two bones (Figure 4-15).
The muscle originates from one bone, and its other end inserts into the second
bone. When the muscle contracts (shortens) (Figure 4-1 5) , the ends of the bones
will be brought closer together, with motion occurring at the intervening joint.
Muscle on the opposite side of the limb will lengthen (relax) to allow this
motion to occur. When motion in the opposite direction is desired, the second
group of muscles will contract and the first will relax, pulling the joint back to
its original position (Figure 4- 1 5).

g . Synovial Joints. Joints are of several types. They may be fibrous

(like those between the skull bones, allowing little motion) or cartilaginous
(like the discs between vertebrae, allowing slight motion). Joints may also
permit free motion. In a synovial joint, the articulating surfaces are covered
with cartilage and surrounded by a fibrous capsule lined with the smooth,
slippery synovial membrane. Synovial joints include:

(1) The gliding joint, which allows only short slipping or gliding
motion. The joint between the carpal and tarsal bones of the wrist and ankle is
a gliding joint.

(2) The hinge joint, which allows only flexion and extension. The
finger joints and the knees are typical hinge joints, with motion restricted to
one plane.

(3) The ball-and-socket joint, which allows movement in many

directions (the hip and shoulder joints).

4-19
FM 8-230

(4) The pivot joint, which allows only rotation around a long axis.
An example of a pivot joint is the joint between the proximal radius and the
ulna. As the hand is turned from palm up to palm down (pronated), the head of
the radius rotates on the pivot formed by the ulna.

(5) The condylar j oint, which allows mainly flexion and extension.
The condylar joint has two articulating surfaces. In this joint, flexion and
extension movements are combined with gliding and rolling movements with
rotation around a vertical axis (the knee joint). Joint motion occurs through
the contraction and relaxation of skeletal muscles, which cross j oints and
attach to bones. The bones serve as levers that enable skeletal muscle to move
body parts.

h. Joints and Bursae. At some j oint locations, the tendon connecting

muscle to bone passes over a j oint; for example, at the shoulder, elbow, knee,
and heel. To reduce pressure, small sacs containing fluid are formed over and
around the tendon. The sac is a bursa, an irritated bursa is bursitis. Bursitis
can be very painful, and normal movement may be impossible.

MUSCLE CON T RA CT E D

,..,
. '\
+
I

.
I
'
. \
' '
' .
' '
' '
·. .
\I
I
I
I
I

MUSCLE RELA X E D

R E LA X E D

Figure 4-15. The mechanism of joint motion.

4-20
 FM 8-230

Section II. THE MUSCULAR SYSTEM

4-6. General

Muscle is characterized by the ability to contract, or to shorten. The power of

contraction enables a muscle to move parts of the body. All movements of the
body, whether conscious or unconscious, are due to the action of muscles.
Muscle makes up much of the fleshy portions of the body. Muscles vary in
shape and structure according to the work they have to do. There are three
main types of muscle: voluntary. involuntary (smooth), and cardiac (heart).

4-7. Types of Muscles

a. Voluntary Muscle. Voluntary muscle is so-called because it is

controlled by will through the central nervous system. All the skeletal muscles
(those attached to the skeleton) are of the voluntary type. Besides the skeletal
muscles, those which move the eye, tongue, and pharynx are voluntary.

( 1 ) Functions. Voluntary muscles cause movement of the body as

a whole and the movements of its parts. They maintain posture, carry on the
rhythmic movements of respiration, produce most of the heat generated by the
body, and serve to protect certain organs.

(2) Structure. Voluntary muscle is made of long, slender fibers

held together by connective tissue to form muscle bundles. Groups of muscle
bundles, enclosed in a fibrous sheath called fascia, form the individual
muscles.

(3) Parts. A skeletal muscle has three main parts: belly, origin,
and insertion. The belly is the body of the muscles. Tendons extend from each
end of the belly and attach to bones. A tendon is a band of tough, nonelastic
fibrous tissue. Tendons unite with the periosteum of bones to form secure
attachments for the muscles. The origin of the muscle is that portion which
accomplishes least movement when the muscle is contracted. The insertion is
the most movable end of the muscle.

(4) Names. Each muscle has a name. Some muscles are given
names derived from their location. Other muscles are named according to
function, shape, size, and/or points of attachment.

b. Involuntary (Smooth Muscle). The involuntary muscles are called

that because the nerve supply is from the autonomic nervous system, which is
not under the control of the will. It is also called smooth muscle. Smooth
muscle is found in the walls of the blood vessels, respiratory passages,
gastrointestinal tract, ureters and urinary bladder, and certain other organs.

( 1 ) Functions. Smooth muscle performs many varied functions. It

regulates the size of blood vessels, which is essential to the maintenance of
blood pressure. It moves food through the intestinal tract. It regulates the
bronchioles (small air passages) in the lungs. Still another function of smooth
muscles is the movement of urine from the kidneys to the urinary bladder.

(2) Structure. Smooth muscle is made of spindle-shaped fibers of

cells. The fibers are arranged in bundles or sheets to form a layer in the walls of
blood vessels and other viscera.

4-21
FM 8-230

c. Cardiac Muscle. Cardiac, or heart, muscle is involuntary muscle, but

is found only in the heart. The structure of cardiac muscle is different from
that of other muscles. Cardiac muscle forms the walls of the heart. The whole
heart works together because all parts are connected with special bands of
cardiac muscle.

d. Action of Voluntary Muscles.

( 1 ) A muscle seldom works alone in carrying out movement.

Usually the performance of a movement, even a simple motion, requires the
combined action of a group of muscles. Many skeletal muscles are arranged in
pairs; for each muscle producing one motion, there is another muscle which
produces the opposite motion. One muscle must relax in part while the other
contracts.

(2) At all times, muscle is in a state of partial contraction called

tone or tonus. Because of this, when a muscle is cut, the two ends pull apart
like the cut ends of a stretched rubber band. Tone in skeletal muscle is
maintained by a reflex and therefore depends on nerve connections to a
functioning spinal cord.

(3) Muscle contraction uses food and oxygen and produces acids
and heat. Muscle activity is the maj or source of the body's heat. Acids
accumulating as a result of continued activity cause fatigue. Muscle fatigue
occurs most rapidly when contractions are frequent; it occurs slowly if rest
periods are taken between contractions. Exercise causes muscles to become
larger, stronger, and better developed. This increase in size is called
hypertrophy. Inactivity results in wasting away of muscles called atrophy.

(4) Voluntary muscle activity results from impulses which arise in

the cortex of the brain and are transmitted to the muscle by the spinal cord
and the motor nerves. Interruption of any part of this pathway will cause
paralysis.

e. Principal Groups of Skeletal Muscles. A description of each of the

skeletal muscles of the body can be found in any of the standard anatomy
books. This manual gives a general discussion of the principal groups of
skeletal muscles and describes individually some of the more important
muscles of the extremities (Figures 4-16A and 4-16B).

(1) Head and face. The muscles of the head and face are small and
numerous. They are involved in the movement of the eye and face, making
possible facial expression, talking, chewing, and swallowing.

(2) Neck. The muscles of the neck move the head from side to side,
forward and backward, and rotate it. Some of them also assist in respiration,
speaking, and swallowing.

4-22
 FM 8-230

(3) Arm. Among the muscles which cause movement of the arms
are the deltoid, biceps, and triceps.

(a) The deltoid is a triangular-shaped muscle located on the

shoulder and upper arm. This muscle lifts the arm forward, sideways, and to
the rear.
(b) The biceps muscle is a long muscle located on the front
of the arm. Its action bends the arm at the elbow.
(c) The triceps muscle is located on the back of the upper
arm. This muscle works against the biceps muscle to extend the lower arm at
the elbow.

(4) Back. The muscles of the back are large and some are broad.
Attached to vertebrae, they keep the trunk in erect posture and aid it in
bending and rotating. In the thoracic region, these muscles assist in
respiration and in the movements of the neck, arm, and trunk.

(5) A bdominal. The abdominal muscles form broad thin layers

which support the internal organs, assist in respiration, and help in flexion and
rotation of the spine. The diaphragm separates the thoracic and abdominal
cavities. It is an important muscle used in breathing.

(6) Perineal. The muscles of the perineum form the floor of the
pelvic cavity.

(7) Thigh. The muscles located on the front and rear of the thigh
cross two j oints, the thigh and knee. When they contract, they extend one
j oint and flex the other.

(a) The quadriceps femoris, a group of muscles located on

the front of the thigh, extends the leg.

(b) Muscles located to the rear and above the thigh

extend, rotate, or abduct the thigh. Among them are the gluteal muscles: the
gluteus maximus, gluteus medius, and gluteus minimus.

(8) Leg. The most important muscles of the leg are the anterior
and posterior groups. An important member of the anterior group is the
anterior tibiales, which flexes the foot. The most superficial, and largest,
muscle of the back of the leg is the gastrocnemius. The gastrocnemius is
commonly called the calf muscle.

4-23
FM 8-230

FRONTALIS
RISORIUS

STERNOCLE I DOMASTOID ORBICULARIS OC ULI

ORBICULARIS ORIS

DELTOID PLATYSMA

PECTORALIS MAJOR
SERRATUS ANTERIOR

BICEPS BRACHll
TRICEPS BRACH l l

EXTERNAL OBLIQUE
ABDOMINALIS RECTUS ABDOM I N I S

"FLEXORS"
EXTENSORS

I LIOPSOAS

FLEXOR TENDONS
ADDUCTOR LON G US

VASTUS MEDIALIS

QUADRI C E PS FEMORIS
SARTORIUS

"EXTENSORS"
GASTROCNEMIUS

SOLE US EXTENSOR T E N DO N S

Figure 4-16A. Superficial muscles of the body (anterior).

4-24
 FM 8-230

OCCIPITALIS

STERNOCLEI DOMASTOID

TRAPEZIUS
DELTOID ---ttt,

TRICEPS BRACHll ----....,1-4++� /llb

v,,.,,._
.._ _ EXTERNAL OBLIQUE
ABDOM INALIS

,=c--1--- GLUTEUS MAXI M US

FASCIA LATA

ADDUCTOR MAGN US
QUADRICEPS
HAMSTRI NG MUSCLES (VASTUS LATERALIS)

GASTROCN EM I US

SOLE US

ACH I LLES T E N DON

PERO N E U S BREVIS

T I BIALIS ANTERIOR

Figure 4-16B. Superficial muscles of the body (posterior).

4-25
 FM 8-230

CHAPTER 5

THE CIRCULATORY SYSTEM

5-1. General

The circulatory system has two major fluid transportation systems: the
cardiovascular and the lymphatic.

a. Cardiovascular System. This system, which contains the heart and

blood vessels, is a closed system, transporting blood to all parts of the body.
Blood flowing through the circuit formed by the heart and blood vessels
(Figure 5-1 ) brings oxygen, food, and other chemical elements to tissue cells
and removes carbon dioxide and other waste products from the cell.

b. Lymphatic System. This system, which provides drainage for tissue

fluid, is an auxiliary part of the circulatory system, returning an important
amount of tissue fluid to the bloodstream through its own system of lymphatic
vessels.

5-2. The Heart

The heart, a highly efficient pump, is a four-chambered muscular organ, lying

within the chest, with about 2/3 of its mass to the left of the midline (Figure
5-2). It lies in the pericardia! space in the thoracic cavity between the two
lungs. In size and shape, it resembles a man's closed fist. Its lower point, the
apex, lies just above the left diaphragm.

a. Heart Covering. The pericardium is a double-walled sac inclosing

the heart. The outer fibrous surface gives support, and the inner lining
prevents friction as the heart moves within its protective j acket. The inner
surface of the pericardia! sac produces a small amount of pericardia!
lubricating fluid that aids in the normal movements of the heart.

b. Heart Wall. This muscular wall is made up of cardiac muscle called

myocardium.

c. Heart Chambers. There are four chambers in the heart. These

chambers are essentially the same size. The upper chambers, the atria, are
seemingly smaller than the lower chambers, the ventricles. The apparent
difference in total size is due to the thickness of the myocardial (muscle) layer.
The right atrium communicates with the right ventricle; the left atrium
communicates with the left ventricle. The septum (partition), dividing the
interior of the heart into right and left sides, prevents direct blood flow from
right to left chambers or left to right chambers. This is important, because the
right side of the heart receives unoxygenated blood returning from the
systemic (body) circulation. The left side of the heart receives oxygenated
blood returning from the pulmonary (lung) circulation. The special structure of
the heart keeps the blood flowing in its proper direction to and from the heart
chambers.

5-1
FM 8-230

HEAD, NECK AND

UPPER MEMBERS

LUNGS

t v
HEART
LIVER

t KIDNEYS

.._ ..,___
D CAPILLARY "BEDS" TRUNK WALL AND
LOWER MEMBERS

A : ATRIUM V : VENTRICLE R : RIGHT l : LEFT

Figure 5-1. Circulation of the blood (diagrammatic).

5-2
 FM 8-230

d. Heart Valves. The four chambers of the heart are lined with
endocardium (membrane tissue). This lining folds on itself and extends into
the chamber opening to form valves. These valves allow the blood to pass from
a chamber but prevents backflow. The atrioventricular valves, between the
upper and lower chambers, are within the heart itself. The semilunar valves are
within arteries attached to the right and left ventricles.

( 1 ) A trioventricular valves. The tricuspid valve is located between

the right atrium and right ventricle. It has three flaps or cusps. The bicuspid
(mitral) valve is located between the left atrium and left ventricle. It has two
flaps or cusps.

(2) Semilunar valves. The pulmonary semilunar (half-moon

shaped) valve is located at the opening into the pulmonary artery that is
attached to the right ventricle. The aortic semilunar valve is located at the
opening into the aorta that is attached to the left ventricle.

THE
STERNUM -M I D DLE
T HE
OF T HE
HEART
BREASTBONE

THE VERTEBRAL COLUMN

Figure 5-2. Heart and thoracic cage.

5-3
FM 8-230

5-3. Flow of Blood Through the Heart

It is helpful to follow the flow of blood through the heart, to understand t e

,
�
relationship of the heart structures. Remember, the heart is the pump and is
also the connection between the systemic circulation and pulmonary
circulation. Blood returning from the systemic circulation must flow through
the pulmonary circulation for the exchange of carbon dioxide and oxygen to
take place. Blood from the upper part of the body enters the heart thro�gh he�
superior vena cava, and from the lower part of the body through the inferior
vena cava (Figure 5-3).

a. Blood from the superior vena cava and inferior vena cava enters the
heart at the right atrium. The right atrium contracts, and blood is forced
through the open tricuspid valve into the relaxed right ventricle.

b. As the right ventricle contracts, the tricuspid valve is closed,

preventing back flow into the atrium. The pulmonary semilunar valve opens as
the blood is forced through it and is pumped into the pulmonary artery.

c. The blood is carried through the lung tissues, exchanging its carbon
dioxide for oxygen in the alveoli. This oxygenated blood is collected from the
main pulmonary veins and delivered to the left atrium.

d. As the left atrium contracts, the oxygenated blood flows through

the open bicuspid (mitral) valve into the left ventricle.

e. As the left ventricle contracts, the bicuspid valve is closed. The

aortic semilunar valve opens as the oxygenated blood is forced through it into
the aorta, the main artery of the body. The oxygenated blood now starts its
flow to all body cells and tissues. The systemic circulation starts from the left
ventricle, the pulmonary circulation from the right ventricle.

NOTE

Veins carry unoxygenated blood and arteries

carry oxygenated blood. The only exception to
this is the pulmonary vein which carries
oxygenated blood from the lungs to the heart
and the pulmonary artery which carries
unoxygenated blood from the heart to the
lungs.

5-4. Blood and Nerve Supply of the Heart

a. Coronary Arteries. The heart gets its blood supply from the right
and left coronary arteries. These arteries branch off the aorta just above the
heart, then subdivide into many smaller branches within the heart muscle. If
any part of the heart muscle is deprived of its blood supply, the muscle tissue
cannot function properly and will die. This is called a myocardial infarction.
Blood from the heart tissue is returned by coronary veins to the right atrium.

5-4
 FM 8-230

AORT IC ARCH

SUPERIOR
VENA CAVA
AURICLE

RIGHT AURICLE

RIGHT ATRIUM

I N F E RIOR
VENA CAVA

A. ANTE RIOR VIEW

LEFT ATRIUM
RIGHT

LEFT VENTRICLE

� .;;:::.....-��- INTERVENTRICULAR
SEPTUM

RIGHT VENTRICLE

8. INTERIOR VIEW

Figure 5-3. The heart chambers and flow of blood.

5-5
FM 8-230

b. Nerve Supply. The nerve supply to the heart is from two sets of
nerves originating in the medulla of the brain. The nerves are part of the
involuntary (autonomic) nervous system. One set branches from the vagus
nerve and keeps the heart beating at a slow, regular rate. The other set, the
cardiac accelerator nerves, speeds up the heart. The heart muscle has a special
ability; it contracts automatically, but the nerve supply is needed to control
the contractions for blood circulation. Within the heart muscle itself are
special groups of nerve fibers that conduct impulses. These groups make up
the conduction system of the heart. When the conduction system does not
operate properly, the heart muscle contractions are uncoordinated and
ineffective. The impulses within the heart muscle are minute electric currents,
which can be picked up and recorded by the electrocardiogram (ECG).

5-5. The Heartbeat and Heart Sounds

a. Heartbeat. This is a complete cycle of heart action-contraction

(systole) and relaxation (diastole). During systole, blood is forced from the
chambers. During diastole, blood refills the chambers. The term cardiac cycle
means the complete heartbeat. The cardiac cycle, repeated continuously at a
regular rhythm, usually 70·80 times per minute. Each complete cycle takes
less than one second-in this brief time, all of the heart action needed to move
blood must take place, and the heart must be ready to repeat its cycle.

b. Heart Sounds. When heard through a stethoscope, heart sounds are

described as "lubb-dup. " The first sound, "lubb, " is interpreted as the sound,
or vibration, of the ventricles contracting and atrioventricular valves closing.
The second, higher-pitched sound, "dup, " is interpreted as the sound of the
semilunar valves closing. The doctor listening to the heart sounds can detect
alterations of normal sounds; the interpretation of these heart sounds is part
of the diagnosis of heart disease.

5-6. Blood Vessels

The blood vessels are the closed system of tubes through which the blood
flows. The arteries and arterioles are distributors. The capillaries are the
vessels through which the exchange of fluid, oxygen, and carbon dioxide takes
place between the blood and tissue cells. The venules and veins are collectors,
carrying blood back to the heart. The capillaries are the smallest of these
vessels but are of the greatest importance in the circulatory system.

a. The Arteries and Arterioles. The system of arteries (Figure 5-4) and
arterioles is like a tree, with the large trunk, the aorta, giving off branches
which repeatedly divide and subdivide. Arterioles are very small arteries,
about the diameter of a hair. In comparison, the aorta is more than 1 inch (2.5
cm) in diameter. An artery wall has a layer of elastic, muscular tissue which
allows it to expand and recoil. When an artery is cut, the artery wall does not
collapse; bright red blood escapes from the artery in spurts. Arterial bleeding
must often be controlled by clamping and tying off (ligating) the vessel. Some
of the principal arteries and the area they supply with blood are-

(1) Carotid arteries, external and internal, supply the neck, head,
and brain through their branches.

(2) Subclavian arteries supply the upper extremities.

(3) Femoral arteries supply the lower extremities.

5-6
 FM 8-230

EXTERNAL CAROTID
RIGHT VERTEBRAL
CAROTI D

BRAC H IOCEPHALIC
---- COMMON CAROTI D

AXI LLARY 'P!�&§�� LEFT S U BCLAVIAN

AXILLARY
S U PERIOR MESENTERIC
THORACIC AORTA

\f\'¥;.:s- r::::
BRACH I A L --.,,...,m- 1 \/\::::/\2/' ""
.. , \,4#+H§4}f�@J.--
�,,,. , C E L IA C A X I S

;:;ctf;feHF\-ff.t-- RENAL

RIGHT COMMON I LIAC

�'tt'tffi8¥�iA-- I N FE RIOR M ES E N TERIC

ABDOM I N A L AORTA

ULNAR

SUPERF ICIAL

PALMER ARCH

POPLITEAL --

PERON EAL -

A N TERIOR TI BIAL --1M1

POSTERIOR T I BIAL ---fi'tflf:::1

DORSALIS PEDIS -�1,1!\ AEJ

ARCUATE

Figure 5-4. Arterial system (diagrammatic).

5-7
FM 8-230

b. Capillaries. Microscopic in size, capillaries are so numerous that

there is at least one or more near every living cell. A single layer of endothelial
cells forms the walls of a capillary. Capillaries are the essential link between
arterial and venous circulation. The vital exchange of substances from the
blood in the capillary with tissue cells takes place through the capillary wall.
Blood starts its route back to the heart as it leaves the capillaries.

c. Veins. Veins (Figure 5-5) have thin walls and valves. Formed from
the inner vein lining, these valves prevent blood from flowing back toward the
capillaries. Venules, the smallest veins, unite into veins of larger and larger
size as the blood is collected in its return to the heart. The superior vena cava,
collecting blood from all regions above the diaphragm, and the inferior vena
cava, collecting blood from all regions below the diaphragm, return the venous
blood to the right atrium of the heart. Superficial veins lie close to the surface
of the body and can be seen through the skin.

(1) The median basilic vein at the antecubital fossa (in the bend of
the elbow) is commonly used for venipuncture to obtain blood specimens or to
inject solutions of drugs or fluid intravenously.

(2) The great saphenous vein is the longest vein in the body,
extending from the foot to the groin. The saphenous vein has a long distance to
lift blood against the force of gravity when an individual is in a standing
position. It is therefore very susceptible to becoming dilated and stretched
with the valves no longer functioning properly. When this occurs, the vein is
said to be varicosed.

5-7. Pulse and Blood Pressure

a. Pulse. Pulse is the alternate expansion and recoil of an artery. With

each heartbeat, blood is forced into the arteries causing them to dilate
(expand). Then the arteries contract (recoil) as the blood moves further along in
the circulatory system. The pulse can be felt at certain points in the body
where an artery lies close to the surface. The most common location for feeling
the pulse is at the wrist, proximal to the thumb (radial artery), on the palm side
of the hand. Alternate locations are in front of the ear (temporal artery), at the
side of the neck (carotid artery), and on the top (dorsum) of the foot (dorsalis
pedis).

b. Blood Pressure. The force that blood exerts on the walls of

vessels through which it flows is called blood pressure. All parts of the
vascular system are under pressure, but the term blood pressure usually refers
to arterial pressure. Pressure in the arteries is highest when the ventricles
contract during systole. Pressure is lowest when the ventricles relax during
diastole. The brachia! artery, in the upper arm, is the artery usually used for
blood pressure measurement.

5-8
 FM 8-230

INTERAL JUGULAR

BRACH IOCEPHALIC EXTERNAL JUGULAR

. SUBCLAVIAN

SUPERIOR
VENA CAVA

I NFERIOR
--+11-jt4--l-----1!!1
VENA CAVA

EXTERNAL

GREAT

POSTERIOR

ANTERIOR T I BIAL --•

SMALL SAPHENOUS ---w-...-.

DORSAL
VENOUS ARCH

Figure 5-5. Venous system (diagrammatic).

5-9
FM 8-230

5-8. Lymphatic System

The lymphatic system consists of lymph, lymph vessels, and lymph nodes
(Figure 5-6). The spleen belongs, in part, to the lymphatic system. Unlike the
cardiovascular system, the lymphatic system has no pump to move the fluid
which it collects, but muscular contractions and breathing movements aid in
the movement of lymph through its channels and its return to the
bloodstream.

a. Lymph and Tissue Fluid. Lymph, fluid found in the lymph vessels,
is clear and watery and is similar to tissue fluid, which is the colorless fluid
that fills the spaces between tissues, between the cells of organs, and between
cells and connective tissues. Tissue fluid serves as the "middleman" for the
exchange between blood and body cells. Formed from plasma, it seeps out of
capillary walls. The lymphatic system collects tissue fluid, and as lymph, it is
starte9- on its way back into the circulating blood.

b. Lymph Vessels. Starting as small ducts within the tissues, the

lymphatic vessels enlarge to form lymphatic capillaries. These capillaries
unite to form larger lymphatic vessels, which resemble veins in structure and
arrangement. Valves in lymph vessels prevent backflow. Superficial lymph
vessels collect lymph from the skin and subcutaneous tissue; deep vessels
collect lymph from all other parts of the body.

c. Lymph Nodes. Occurring in groups of up to a dozen or more, lymph

nodes lie along the course of the lymph vessels. Although variable in size, they
are usually small oval bodies which are composed of lymphoid tissue. Lymph
nodes act as filters for removal of infectious organisms from the lymph
stream. Important groups of these nodes are located in the axilla (armpit), the
cervical region, the submaxillary region, the inguinal (groin) region, and the
mesenteric (abdominal) region.

d. Infection and the Lymphatic System. Lymph vessels and lymph

nodes often become inflamed as the result of infection. An infection in the
hand may cause inflammation of the lymph vessels as high as the axilla. Sore
throat may cause inflammation and swelling of lymph nodes in the neck
(submandibular nodes below the jaw and cervical nodes).

e. Spleen. The largest collection of lymphoid tissue in the body, the

spleen is located high in the abdominal cavity on the left side (LUQ), below the
diaphragm and behind the stomach. It is somewhat long and ovoid (egg­
shaped). Although it can be removed (splenectomy) without noticeable
harmful effects, the spleen has useful functions, such as serving as a reservoir
for blood and red blood cells.

5-10
 FM 8-230

JUGULO-SUBCLAVIAN
JUNCTIONS

THORACIC DUCT

AXILLARY
----'�- LYMPH NODES

INGUINAL
LYMPH NODES

Figure 5-6. Lymphatic system.

5-11
FM 8-230

5-9. The Blood

Blood is the red body fluid flowing through the arteries, capillaries, and veins.
It varies in color from bright red (oxygenated blood) when it flows from
arteries, to dark red (deoxygenated blood) when it flows from veins. The
average man has about 6000 ml of blood.

a. Functions of Blood. The six maj or functions of blood are all carried
out as the blood circulates through the vessels. These functions are-

( 1 ) To carry oxygen from the lungs to tissue cells and carbon

dioxide from the cells to the lungs.

(2) To carry food materials absorbed from the digestive tract to

the tissue cells and to remove waste products for elimination by excretory
organs (the kidneys, intestines, and skin).

(3) To carry hormones, which help regulate body functions, from

ductless (endocrine) glands to the tissues of the body.

(4) To help regulate and equalize body temperature. Body cells

generate large amounts of heat, and the circulating blood absorbs this heat.

(5) To protect the body against infection.

(6) To maintain the fluid balance in the body.

b. Composition of Blood. Blood is made up of a liquid portion (plasma)

and formed elements (blood cells) suspended in the plasma.

(1) Plasma. Making up more than one-half of the total volume of

blood, plasma is the carrier for blood cells, carbon dioxide, and other dissolved
wastes. It brings hormones and antibodies (protective substances) to the
tissues. Other components of plasma are water, oxygen, nitrogen, fat,
carbohydrates, and proteins. Fibrinogen, one of the plasma proteins, helps
blood clotting. When blood clots, the liquid portion that remains is serum.
Blood serum contains no blood cells.

(2) Blood cells. The cellular elements in the blood are red cells
(erythrocytes, or rbc), white cells (leukocytes, or wbc) and blood platelets
(thrombocytes).

5-10. Red Blood Cells (Erythrocytes)

There are about 5,000,000 red blood cells in 1 cubic millimeter (cmm) of blood.
Individual red blood cells are disc-shaped. Red cells are formed in the red bone
marrow. Millions of red cells are destroyed daily, in the liver, the spleen, the
lymph nodes, or in the vascular system itself. In a healthy person, the
destruction rate is equaled by the production rate, maintaining a count of
about 5,000,000 per cubic millimeter. Red blood cells have an average life span
of about 90 to 120 days before becoming worn out.

a. Hemoglobin. Hemoglobin (Hgb) gives red cells their color.

Hemoglobin has the power to combine with oxygen, carrying it from the lungs
to the tissue cells. Hemoglobin assists in transporting carbon dioxide from the
cells to the lungs. This transportation of gases is the principal function of the

5-12
 FM 8-230

red cells. In order to carry oxygen, hemoglobin needs iron which is ordinarily
available in a nutritionally adequate diet.

b. A nemia. Anemia is due to a reduction in the number of red cells or a

reduction in the hemoglobin content of red cells.

5-11. White Blood Cells (Leukocytes)

White blood cells vary in size and shape, and are larger and much fewer in
number than red cells. The average number in an adult is 5,000 to 10,000 in 1
cmm of blood. Their function is primarily one of protection. They can ingest
and destroy foreign particles, such as bacteria, in the blood and tissues. White
cells can pass through the walls of capillaries into surrounding tissues. This
ability to enter tissue makes them very useful in fighting infection-an area of
infection is characterized by a great increase of white cells which gather about
the site to destroy bacteria. An example of this is seen in an ordinary boil
(furuncle). The pus contained in the boil is made up largely of white cells plus
bacteria and dissolved tissue. Many of the white cells are killed in their
struggle with invading bacteria.

5-12. Blood Platelets (Thrombocytes)

Blood platelets, which are smaller than red blood cells, are thought to be
fragments of cells formed in the bone marrow. Platelets number about 300,000
per cmm of blood. Their main function is to aid in the coagulation of blood at
the site of a wound. Platelets release a substance to hasten formation of a
blood clot.

5-13. Coagulation of Blood

a. Blood coagulation (clotting) is the body's major method of

preventing excessive loss of blood when the walls of a blood vessel are broken
or cut open. When undisturbed, blood circulates in its vascular system without
showing a tendency to clot. Physical and chemical factors are changed when
blood leaves its natural environment and it begins to clot almost at once. At
first the clot is soft and jellylike, but soon becomes firm and acts as a plug,
preventing further escape of blood.

b. It takes 3 to 5 minutes for blood to clot, but sometimes it is

necessary to hold back the clotting process. This is done with anticoagulant
drugs.

5-14. Blood Types

All human blood is divided into four main types or groups-0, A, B, AB. This
system of typing is used to prevent incompatible blood transfusion, which
causes serious reactions and sometimes death. Certain types of blood are
incompatible (not suited) to each other if combined. Two bloods are said to be
incompatible when the plasma or serum of one blood causes clumping of the
cells of the other. Two bloods are said to be compatible and safe for transfusion
if the cells of each can be suspended in the plasma or serum of the other
without clumping. Blood typing and cross-matching is done by highly trained
laboratory technicians.

5-13
FM 8-230

a. Importance of Blood Types. Table 5-1 shows that if the donor's

blood is type "O" it is compatible with all types of recipient blood; or, in other
words, type "O" is the universal donor. If the recipient's blood is type "AB,"
it is compatible with all types of donor blood, or, in other words, type " AB" is
the universal recipient. When a blood transfusion is given, the blood type of
both donor and recipient should be identical, and their compatibility must be
proven by a cross-matching test. However, when blood of the same type is not
available and death may result if transfusion is delayed, a type "O" donor
(universal donor) may be used if the cross-matching is satisfactory.

b. Rh Factor. In addition to blood grouping and cross-matching for

compatibility, the Rh factor must be considered. The Rh factor is carried in red
cells, and about 85 percent of all individuals have this factor and are, therefore,
Rh positive. Individuals who do not have the Rh factor are Rh negative. As a
general rule, Rh negative blood can be given to anyone, provided it is
compatible in the ABO typing system, but Rh positive blood should not be
given to an Rh negative individual.

Table 5-1. Blood Types

Recipient

Donor
0 A B AB

0 -------- Compatible Compatible Compatible Compatible

A -------- Incompatible Compatible I ncompatible Compatible
8 -------- Incom patible Incompatible Compatible Compatible
A B ----- Incompatible Incom patible Incompatible Compatible

5-15. Coronary Artery Disease and Angina Pectoris

a. As mentioned before, coronary arteries are blood vessels whose

primary function is to transport blood to the heart muscles and at the same
time remove carbon dioxide and waste products. Sometimes the coronary
arteries become blocked depriving the heart muscles of oxygen and nutrients
and slowing down or stopping the removal of waste products. If this condition
continues without proper treatment, the artery will eventually close off,
resulting in death of the affected tissue.

b. Certain factors contribute to coronary artery disease. Some of these

factors are controllable while others are not. These factors are-

• Hypertension (hign blood pressure)

• Cigarette smoking.

• Diabetes.

• Elevated serum cholesterol.

5-14
 FM 8-230

• Dietary habits (excessive intake of calories, carbohydrates,

and/or saturated fats).

• Obesity.

• Sex (male).

• Hereditary (family history).

• Stress.

c. Early stages of coronary artery disease are asymptomatic. In the

late stages of the disease, the blood flow no longer meets the demands of the
myocardium for oxygen and the patient begins to experience chest pain. This
pain is referred to as angina pectoris (choking of the heart). The patient with
advanced coronary artery disease may have adequate oxygen at rest, however,
during any form of stress or exercise, blood flow to the heart is inadequate.
This results in angina pectoris. A patient can also experience angina pectoris
while at rest. If this occurs, that patient has much more severe coronary artery
disease than the one who only experiences pain with exercise and stress. The
pain (angina) is characterized as a crushing chest pain which usually radiates
to the neck, j aw, shoulders, and upper extremities. The duration of the pain is
usually 2 to 3 minutes. Treatment for this condition is either stopping the
stress or administering nitroglycerin. The drug, nitroglycerin, is a vasodilator.
It causes the coronary arteries to dilate and provides improved blood flow to
the myocardium.

5-16. Myocardial Infarction

a. Myocardial infarction (MI) (heart attack) is a blockage in a coronary

artery with resulting death to the affected tissue.

b. Signs and symptoms of an MI.

(1) Chest pain similar to angina, however, more severe and longer
lasting. The pain may not be relieved with nitroglycerin. The patient usually
complains of severe crushing pain or tightness in the chest. A clenched fist is
usually used to describe the pain. In approximately 25 percent of the patients,
the pain will radiate down the left arm and into the fingers. Usually the pain
radiates to the j aw, neck, upper back, and epigastrium. An M I is sometimes
mistaken for indigestion.

(2) Along with chest pain, the patient complains of nausea.

(3) Diaphoresis (profuse perspiration) usually accompanies an MI.

(4) The patient may also experience a fear of impending doom.

(5) Shortness of breath.

(6) Hypotension or hypertension.

(7) Cyanosis.

5-15
FM 8-230

c. Treating an M I . The physical findings of an MI may not always be

obvious. They vary with the site and extent of cardiac muscle damage.
Therefore, diagnosis in the field will depend primarily on the history of the
current complaint. Treatment and stabilization should be started immediately
with a detailed history. Early treatment can mean the difference between life
and death. The patient should be immediately transported to a medical facility
where definitive treatment can be initiated. Early treatment should include-

(1) Attaching a cardiac monitor (if available).

(2) Administrating oxygen by mask or nasal prongs at a flow rate

of 4 to 6 liters per minute.

(3) Starting an IV infusion (D 5 W at Tko rate).

(4) Monitoring vital signs.

(5) Positioning the patient in a semi-Fowlers or high-Fowlers

(sitting) position to reduce respiratory distress.

5-17. Congestive Heart Failure

a. Congestive heart failure (CHF) is the inability of the heart to pump

blood efficiently. There are several contributing factors to CHF. Some of these
include-

(1) Secondary t o a n MI.

(2) Pulmonary embolism.

(3) Administration of too much IV fluids.

(4) Excessive sodium intake.

b. There are two types of heart failure: acute pulmonary edema and
chronic congestive heart failure.

c. Signs and symptoms of pulmonary edema.

(1) Congestion o f the lungs.

(2) Fatigue.

(3) Dyspnea.

(4) Cough.

(5) Insomnia---often due to increased respiratory effort.

(6) Hemoptysis.

(7) Restlessness.

5-16
 FM 8-230

d. Signs and symptoms of congestive heart failure.

(1) Unexplained weight gain.

(2) Abdominal pain-usually in the upper region of the abdomen.

(3) Mild to moderate respiratory distress.

(4) Diaphoresis.

(5) Weakness.

(6) Anorexia.

(7) Pitting edema.

e. Treatment of heart failure is aimed at improving oxygenation,

increasing myocardial contractability, and reducing venous return. Certain
specific treatments are recommended for the medical specialist and include:

( 1 ) Placing the patient in a sitting position, with the feet dangling.

This position decreases venous return, making breathing easier.

(2) Administering oxygen by mask at a flow rate of 4-6 liters per

minute.

(3) Starting an IV of D 5 W at 10 drops per minute (Tko) rate.

(4) Attaching a cardiac monitor, if available.

(5) Using several types of drugs to improve cardiac function and

assist respiration (if ordered by a physican).

(6) Using rotating tourniquets to slow the venous blood flow.

(7) Monitoring the patient's vital signs.

The primary aim when treating a patient who has CHF is to improve the
cardiac function and correct hypoxia. This is accomplished to some extent by
placing the patient in a sitting position and administering oxygen.

5-17
 FM 8-230

CHAPTER 6

THE RESPIRATORY SYSTEM

6-1. General

a. The cells of the body require a constant supply of oxygen to carry on

the chemical processes necessary to life. As a result of these processes, carbon
dioxide (a waste product) is formed and must be removed from the body.
Oxygen and carbon dioxide are continuously being exchanged, both within the
body and between the body and the atmosphere, by the process known as
respiration.

b. Respiration is the exchange of gases between the atmosphere and

the cells of the body. It is a physiological process. There are two types of
respiration: external and internal. External respiration is the exchange of
gases between the air in the lungs and blood. Internal respiration is the
exchange of gases between the blood and the individual cells of the body.

c. Breathing is the process that moves air into and out of the lungs. It
is a mechanical process. There are two types of breathing: costal (thoracic\ and
diaphragmatic (abdominal). In costal breathing, the maj or structure causing
movement of the air is the rib cage. In diaphragmatic breathing, interaction
between the diaphragm and the abdominal wall causes the air to move into and
out of the lungs.

6-2. Components and Subdivisions of the Respiratory System

See Figure 6-1 for an illustration of the respiratory system.

a. Components. The components of the respiratory system consist of

air passageways and two lungs. Air moves from the outside of the body into
tiny sacs in the lungs called alveoli.

b. Main Subdivisions. The main subdivisions of the respiratory

system may be identified by their relationship to the voice box (larynx).

SUBDIVISIONS FUNCTION

( 1 ) Supralaryngeal Structures Cleanse, warm, moisten,

(above the larynx) (external nose, nasal and test inflowing air.
chambers, and pharynx)

(2) Larynx (voice box) Controls the volume of

inflowing air; produces
selected pitch (vibration
frequency) in the moving
column of air.

(3) Infralaryngeal Structures Distribute air to the

(below the larynx) (trachea and bronchi, alveoli of the lung where
alveoli, lungs, and pleural cavities) t h e a c t u a l e x t er n a l
respiration takes place.

6-1
FM 8-230

PALATE

A
EXTERNAL
.

R. PLEURAL CAVITY L. PLE URAL CAVITY

RIB

RIB

DIAPHRAGM

Figure 6-1. The respiratory system.

6-2
 FM 8-230

6-3. Supralaryngeal Structures

Figure 6·2 (cross-section) indicates the supralaryngeal structures.

a. External Nose. The external nose is the portion projecting from the
face. It is supported primarily by nasal cartilages. It has a midline divider
called the nasal septum, which extends from the internal nose. Paired openings
(nostrils) lead to paired spaces (vestibules). Guard hairs in the nostrils filter
incoming air.

b. Nasal Chambers (Internal Nose). Behind each vestibule of the

external nose is a nasal chamber. Together the two nasal chambers form the
internal nose. These chambers also are separated by the nasal septum.

( 1 ) The walls of the nasal chambers are lined with a thick mucous·
type membrane known as the mucoperiosteum. They have a ciliated (provided
with hairlike proj ections that move fluids to the rear) epithelial surface. They
also have a rich blood supply, which provides warmth and moisture. At times,
they may become quite swollen.

(2) The sense of smell is the result of special nerve endings located
in the upper areas of the nasal chambers.

(3) There are air "cells" or cavities in the skull known as paranasal
sinuses. The paranasal sinuses are connected with the nasal chambers and are
lined with the same ciliated mucoperiosteum. These sinuses are extensions of
the nasal chambers into the skull bones. For this reason, they are known as
paranasal sinuses.

c. Pharynx. The pharynx is the common space in the back of the throat
for the respiratory and digestive systems.

( 1 ) The portion of the pharynx specifically related to the

respiratory system is the nasopharynx located above the soft palate. The two
posterior openings (nares) of the nasal chambers lead into the single space of
the nasopharynx. The auditory (eustachian) tubes also open into the
nasopharynx. The auditory tubes connect the nasopharynx with the middle
ears (to equalize the pressure between the outside and inside of the eardrum).
Lying in the upper posterior wall of the nasopharynx are the pharyngeal
tonsils (adenoids). The soft palate floor of the nasopharynx is a trapdoor that
closes off the upper respiratory passageways during swallowing.

(2) The portion of the pharynx closely related to the digestive

system is the oropharynx. It is the portion of the pharynx below the soft
palate and above the upper edge of the epiglottis. (The epiglottis is the flap
that prevents food from entering the larynx during swallowing.)

(3) The portion of the pharynx that is common to the respiratory

and digestive systems is the laryngopharynx. It is the portion of the pharynx
below the upper edge of the epiglottis. The digestive and respiratory systems
lead into it from above and lead off from it below.

6-3
FM 8-230

Figure 6-2. Supralaryngeal structures.

6-4. Larynx

The larynx, also called the Adam's apple or voice box, connects the pharynx
with the trachea. The larynx, located in the anterior neck region, has a box-like
shape (Figure 6-3). The voice box of the male becomes larger and heavier
during puberty and the voice deepens. The adult male's voice box tends to be
located lower in the neck; in the female, the larynx remains higher and smaller
and the voice is of a higher pitch.

a. The larynx has a vestibule (entrance hallway) that can be covered

over by the epiglottis. The glottis itself is the hole between the vocal cords.
Through the glottis, air passes from the vestibule into the main chamber of the
larynx (below the cords) and then into the trachea. The skeleton of the larynx
is made up of a series of cartilages.

b. The larynx serves two functions and has two sets of muscles-one
for each function.

6-4
 FM 8-230

( 1 ) One set controls the size of the glottis. Thus, it regulates the
volume of air passing through the trachea.

(2) The other set controls the tension of the vocal cords. Thus, it
produces vibrations of selected frequencies (variations in pitch) of the moving
air to be used in the process of speaking.

.--- EPIGLOTT IS ----

11tw�<-;--- CRICOTH YROI D MEMBRAN E --�

\n.i.-�iii:l---- CRICOID CART I LAGE --- w

w
---t ...,
�...." .,..,,..

B.

ANTERIOR V I EW LATERAL V I EW

D.
M I DSAGITTA L SECTION FRONT Al SECTION

Figure 6-3. The larynx.

6-5
FM 8-230

6-5. Infralaryngeal Structures

See Figure 6-4 for an illustration of the infralaryngeal structures.

a. Trachea and Bronchi. The respiratory tree is the set of tube-like

structures that carry air from the larynx to the alveoli of the lungs. The
respiratory tree is so named because it has the appearance of an inverted tree
with its trunk and branches. These tubular parts are held open (made patent)
by rings of cartilage. Their lining is ciliated to remove mucus and other
materials that get into the passageway.

b. Alveoli. The alveoli (alveolus, singular) are tiny spherical (balloon­

like) sacs that are connected to the larger tubes of the lungs by tiny tubes as
alveolar ducts and bronchioles. The alveoli are so small that there are billions
in the adult lungs. This produces a maximum surface area through which
external respiration takes place. External respiration is the actual exchange of
gases between the air in the alveolar spaces and the adj acent blood capillaries
through their air walls.

A. "RESPI RATORY TREE"

TRACHEA

8. ALVEOLI

BIFURCATION

BRONCHI

Figure 6-4. lnfralaryngeal structures.

6-6
 FM 8-230

c. Lungs. A lung is an individual organ composed of tubular

structures and alveoli, bound together by fibrous connective tissue. There are
two lungs, right and left. Each lung is supplied by a primary or mainstream
bronchus leading off of the trachea. The right lung is larger in volume than the
left lung because the left lung must leave room for the heart. The right lung is
divided into three pulmonary lobes (upper, middle, and lower). The left lung is
divided into two pulmonary lobes (upper and lower). A pulmonary lobe is a
major subdivision of the lung and is marked by deep folds.

d. Pleural Cavities. The pleural cavity is a serous cavity with inner and
outer membranes. In the case of the lungs, the inner membrane is known as the
visceral pleura which very closely covers the surface of the lungs. The outer
membrane is known as the parietal pleura, forming the outer wall of the cavity.
The pleural cavities are the potential spaces between the inner and outer
membranes. The pleural cavities allow the lungs to move freely with a
minimum of friction during the expansion and contraction of breathing.
Located in the middle of the thorax, between the two pleural cavities, is the
mediastinum (meaning "I stand between"). The mediastinum is filled with
tissues and organs. Within it, the heart (of the blood circulatory system) is
located at the same level as the lungs.

6-6. Breathing and Its Mechanisms

a. Boyle's law tells us that as the volume (V) of a gas-filled container

increases, the pressure (P) inside decreases; as the volume of a closed container
decreases, the pressure inside increases. When two connected spaces of air
have different pressures, the air moves from the space with greater pressure to
the one with lesser pressure. In regard to breathing, we can consider the air
pressure around the body to be constant. The pressure inside the lungs may be
greater or less than the pressure outside the body. Thus, a greater internal
pressure causes air to flow out; a greater external pressure causes air to flow
in.

b. The upper portion of the body can be compared to a cylinder. This

cylinder is divided into upper and lower cavities by the diaphragm. The upper
is the thoracic cavity and is essentially gas-filled. The lower is the
abdominopelvic cavity and is essentially water-filled.

6-7. Costal (Thoracic) Breathing

a. Inhalation. Muscles attached to the thoracic cage raise the rib cage.
A typical rib might be compared to a handle, attached at one end to the
sternum (breastbone) and at the other end to the vertebral column. This handle
is lifted by the overall movement upward and outward of the rib cage. These
movements increase the thoracic diameters from right to left (transverse) and
from front to back. Thus, the intrathoracic volume increases. Recalling
Boyle's law, the increase in volume leads to a decrease in pressure. The air
pressure outside the body then forces air into the lungs and inflates them.

b. Exhalation. The rib cage movements and pressure relationships are

reversed for exhalation. Thus, intrathoracic volume decreases. The
intrathoracic pressure increases and forces air outside the body.

6-7
FM 8-230

6-8. Diaphragmatic (Abdominal) Breathing

The diaphragm is a thin, but strong, dome-shaped muscular membrane that

separates the abdominal and thoracic cavities. The abdominal wall is elastic in
nature. The abdominal cavity is filled with soft, watery tissues.

a. Inhalation. As the diaphragm contracts, the dome flattens and the

diaphragm descends. This increases the depth (vertical diameter) of the
thoracic cavity and increases its volume. This decreases air pressure within
the thoracic cavity. The greater air pressure outside the body then forces air
into the lungs.

b. Exhalation. As the diaphragm relaxes, the elastic abdominal wall

forces the diaphragm back up by pushing the watery tissues of the abdomen
against the underside of the relaxed diaphragm. The dome extends upward.
The process of inhalation is thus reversed.

6-9. Nervous Control of Breathing

As we have seen, breathing is a combination of many factors. These factors are

integrated and controlled by the nervous system.

a. Respiratory reflexes are controlled by the respiratory center found

in the medullary portion of the posterior brainstem. The level of carbon dioxide
(C0 2 ) in the circulating blood is one of the maj or influences upon the
respiratory reflex.

b. The individual intercostal nerves innervate the intercostal muscles.

c. The muscles attached to and moving the rib cage are innervated by
their appropriate nerves. (Ultimately, almost every muscle in the torso may be
mobilized to assist in breathing.)

d. The diaphragm is innervated by its own individual pair of nerves.

6-10. Functional Blood Supply

There are essentially two blood supplies for the lungs-nutrient blood and
functional blood. Nutrient blood is carried by the bronchial arteries from the
thoracic aorta and provides nourishment and oxygen to the tissues of the lung.
Functional blood is involved in the respiratory exchange of gases between the
alveoli and the capillaries. It is brought to and from the lungs by the
pulmonary cycle of the cardiovascular system.

a. The pulmonary cycle originates in the right ventricle of the heart.

Contraction of the right ventricle forces the blood into the pulmonary arch,
which divides into the right and left pulmonary arteries and paralleling the
branching of the respiratory tree, the arteries divide and subdivide within the
lungs. These arteries lead to capillaries in the vicinity of the alveoli. The walls
of these capillaries are thin enough to accommodate the passage of gases to
and from the alveoli.

b. The blood, now saturated with oxygen, is collected by the

pulmonary venous system and is deposited into the left atrium of the heart.

6-8
 FM 8-230

6-11. Exchange and Transportation of Gases

Oxygen and carbon dioxide are the primary gases involved in respiration. At
the alveoli, gases are exchanged between the air inside and the blood in the
adj acent capillaries. Within the body, gases are exchanged between the blood
of the capillaries and the individual cells of the body. The gases are
transported between the alveoli and the individual cells by the cardiovascular
system.

a. Some of the gases are dissolved directly in the plasma of the blood.

b. However, the greater percentages of the gases are carried within the
substance of the RBCs (red blood cells/erythrocytes). The RBCs, found in large
numbers in the blood, are specially constructed for transporting the gases.
Hemoglobin, a substance. found within RBCs, has a great affinity for oxygen.
Yet, the hemoglobin can readily give up the oxygen wherever it is needed.

6-9
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C HAPTER 7

THE NERVOUS SYSTEM

7-1. General

a. The nervous system is composed of the brain, spinal cord, and

branches from the spinal cord and brain called nerves. The system is divided
anatomically into two parts: the central nervous system and the peripheral
nervous system.

b. The central nervous system includes the brain and the spinal cord.
The peripheral nervous system includes the nerves, which are either sensory or
motor or a combination of both. Sensory nerves are adapted to carry
sensations of touch, taste, heat, cold, and pain. Motor nerves are adapted to
transmit impulses to muscles, causing them to move.

c. That part of the nervous system that regulates functions over which
there is voluntary control is often called the sympathetic nervous system.

d. There is also a subdivision called the autonomic, or involuntary,

nervous system. Automatic functions (such as digestion, control of vessel
dilation, the ability to sweat, and all sensations and responses that cannot be
controlled by a voluntary act of conscious will) are under the direction of this
system.

7-2. The Central Nervous System (CNS)

a. Nerve Cells.

( 1 ) The nerve cell, or neuron, is the basic unit of the nervous

system. Each neuron is composed of a cell body, which contains the nucleus of
the nerve cell; dendrites, which carry impulses to the ce:I body; and axons,
which carry impulses away from the cell body. Collections of cell bodies appear
gray, and therefore are referred to as "gray matter. "

(2) Impulses are transmitted along nerves through a process that

is part chemical and part electrical. It may be helpful to think of the nerves as
"wires, " surrounded by myelin "insulation. " Nerve cells can receive impulses
(excitability), conduct them (conductivity), and transmit them to a second cell
(transmission). Impulses travel from the dendrites to the cell body and then
from the cell body down the axon. When an impulse reaches the end of the
axon, it is transmitted to a second cell across a junction. This junction is called
a synapse (Figure 7-1). The second cell may be another nerve cell or a gland
cell.
(3) Unlike excitability and conductivity (which are electrical in
nature), transmission of impulses from one nerve cell to another is chemical. A
chemical released by the axons crosses the synapse to excite the second cell.

(4) Some drugs and poisons can block this transmission and
prevent excitability of the second cell. Others can lead to a buildup of the
chemical transmitter and excess excitation of the second cell.

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MOTOR N E U RON
MOTOR N E URON "FOOT"

AXON TERMINAL

SYNAPTIC VESICLE
(QUANTUM OF
N E UROTRANSMITTOR)

a.
MITOCHONDRION

POST SYNAPTIC MEMBRANE

PRESYNAPTIC MEMBRANE

SYNAPTIC CLEFT
.:·:·.·:·:·:.... : ·:..:..·:·...

== M USCLE F I BE R

a.

Figure 7-1. A synapse.

b. The Brain.

( 1 ) The brain is the controlling organ of the body and occupies the
entire space within the cranium (skull). It is made up of many different types
of cells. Each type of cell has a specific function: some cells in the brain receive
sensory impulses or messages; other cells are responsible for signaling muscles
and organs to act. Still other cells are responsible for transmitting impulses to
other areas of the brain and to the spinal cord.

(2) The brain is a very soft tissued organ and is richly supplied
with blood vessels. This makes the brain very susceptible to injury. The skull
can protect the brain from external injury because of its rigidity and hardness,
but the same qualities can, in some cases, injure the brain. In some ways, the
brain behaves like a sponge inside a steel case-it cannot expand inside the
rigid skull. Therefore, a swelling of the brain or accumulation of blood inside

pressure (increa sed intrac:-a."lial p:-e&5U..""E" ca"G5e5 � :hat � witit

the skull compresses the brain and increases the pressure inside the skull. This

brain functioning. Furthermore, because the skull is hard, both the brain and

7-2
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the blood vessels on the brain's surface may be damaged if they strike the
skull's inner surface. This condition can occur when the head is struck directly
or when it is rapidly accelerated or decelerated. When struck on the back of the
head, the phenomenon of " seeing stars" is due to the occipital lobe of the brain
(the part that controls vision) striking against the back of the skull.

(3) The brain is divided into three main parts: the cerebrum,
cerebellum, and brain stem (Figure 7-2). The first main portion, or cerebrum is
the largest part of the brain, occupying the top and front of the skull. The
cerebrum is divided from the front to the back of the skull into left and right
cerebral hemispheres. The cerebral cortex is the gray, outer surface layer of the
cerebral hemispheres. This thin layer, 2 to 5 millimeters (mm) thick, contains
nerve cell bodies. Each cerebral hemisphere is further divided into four lobes:
frontal, temporal, parietal, and occipital, named according to the overlying
skull bones. These lobes are separated from each other by fissures, as shown in
Figure 7-2.

CEREBRUM

l L
I
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

CENTRAL SULCUS

PRECENTRAL GYRUS POSTCENTRAL GYRUS

FRONTAL POLE

L
TEMPORAL POLE
_ _ _ _ _ _ _ _ _ _

LATERAL

TEMPORAL LOBE

BRAIN STEM

Figure 7-2. The brain.

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(4) Each nerve cell in the cerebral cortex (cortical nerve cell) has a
specific function, and groups of these cells that perform related functions are
located in different areas of the brain. The eight maj or functions of the brain
are:
(a) Sensation. The brain receives sensory input from all sense
organs, including the eyes, ears, nose, and taste buds, and from all receptors of
pain, pressure, and temperature. This sensory input is then interpreted by the
cerebral cortex.

(b) Voluntary movement. The cerebral cortex directs and

assists voluntary movement by coordinating muscle actions and maintaining
posture and equilibrium.

(c) Mental functions. Mental functions include memory,

foresight, personality, speech, and intelligence, and are functions of the
cerebral cortex.

(d) Emotions. Happiness, sadness, rage, and other emotions

are functions of the thalamus and the cerebral cortex.

(e) Control of autonomic functions. The hypothalamus

directs the autonomic nervous system which innervates smooth muscle,
cardiac muscle, and glands.

({) Control of endocrine function. The hypothalamus triggers

anterior pituitary secretion which regulates the hormone production of target
endocrine glands.

(g) Consciousness. The reticular activating system, which

originates in the brain stem and travels to the cerebral cortex, maintains
wakefulness. Injuries or drugs that affect the reticular activating system
produce uncons.::iousness.

(h) Control of vegetative functions. The medulla, which is

part of the brain stem, controls respiration, heart rate, and blood pressure.
Therefore, injury to the medulla can produce cardiorespiratory arrest.

(5) The areas are given functional names but also may be referred
to by their anatomic location. It is important to be familiar with these areas
because damage to each area (such as that caused by trauma (injury) and
stroke) causes specific clinical signs and symptoms. The cerebrum is more
subj ect to injury than are other parts of the central nervous system.

(6) Injury to the motor cortex, which is located in the frontal lobe,
causes weakness or paralysis on the opposite side of the body because many
nerve fibers from the cortex are crossed in the brain stem and spinal cord. The
left side of the brain controls the right side of the body.

(7) The rest of the frontal lobe is involved in the higher mental
processes of judgment, foresight, and perserverance. People with damage
(injury) to this area often have difficulty making appropriate judgments.

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 FM 8-230

(8) Speech is controlled by a small area of the left temporal lobe.

Damage (injury) to this area causes a variety of difficulties with speech,
ranging from inability to find the correct words to not being able to speak. In
the superior temporal lobes, hearing is controlled by the auditory cortex. The
occipital cortex, located in the posterior part of the cerebrum, is responsible for
sight (visual sensation). The sensory area, located in the parietal lobe, receives
and processes other types of sensory information (such as touch, temperature,
vibration, position sense, and pain). The crossover relationship between the
brain and the body also applies to the transmission of sensory information.
For example, the sensation of a pain caused from a burn on the right hand is
received by the left side of the brain. Damage to the left sensory cortex causes
a loss of perception of the right side of the body.

(9) The second major area of the brain is the cerebellum. The
cerebellum is located in the lower back, or inferoposterior, part of the skull
(Figure 7-2). The cerebellum is divided into two hemispheres. It has a thin
covering of gray matter over a core of white matter. The functions of the
cerebellum are not as well localized to specific areas as the cerebral functions.
Coordination of skilled voluntary muscle movement, posture, and balance are
maintained by the cerebellum. Difficulties in balancing and coordination are
caused by damage to the cerebellum. The difficulties are most noticeable when
the injured person tries to walk. Because of its location in the back of the skull,
the cerebellum rarely is injured except by direct trauma (injury) to this area.

c. The Brain Stem.

( 1 ) The brain stem is the third maj or portion of the brain (Figure
7-2). It is located at the base of the brain, between the spinal cord and the
cerebrum and surrounded by the cerebellum. The brain stem contains nerve
tracts, which are functional units formed by groups of axons that carry
impulses to and from the brain and the spinal cord. These structures also
contain groups of nerve cell bodies (nuclei) that control various body functions.
The medulla oblongata, the lowest area of the stem, located just above the
spinal cord, has centers critical to the maintenance of vital body functions
such as heart rate, respiration, and blood pressure. Damage to these centers,
or interference with their functioning by certain drugs, causes various
cardiorespiratory disturbances, from a slowing of the heart rate (bradycardia)
to cardiopulmonary arrest.

(2) Other centers in the brain stem control the muscles of the eyes,
throat, and face and receive sensory information from these areas. From these
centers (nuclei), nerves run through different bony passages to the facial
structures. Damage to the facial nerve (which can be caused by a skull
fracture) will paralyze some of the facial muscles. Similar damage to the
oculomotor (eyeball) nerve will prevent the pupil on the damaged side of the
body from responding to different light levels.

d. The Spinal Cord.

( 1 ) The second major part of the central nervous system i s the

spinal cord. All of the important centers of the brain are connected by long
tracts of nerves directly with the organs or muscles they control. These tracts
join to form the spinal cord, a continuation of the brain (Figure 7-2). Like the
brain, the spinal cord is protected by a bony structure, the spine. Each section

7-5
FM 8-230

(vertebra,e) of .the spine contaiI_ls an ant�rior bony vertebral body to support

the body s weight and a posterior bony rmg (neural arch) to protect the spinal
cord (Figure 7·3).

NE URAL
ARCH

BODY SPINAL
CORD

Figure 7-3. Spinal vertebra in cross-section.

(2) The spinal cord has a gray matter core surrounded by a layer of
white matter. The gray matter contains cell bodies. The white matter contains
nerve tracts whlch connect the brain with the rest of the body. There are three
important nerve tracts.

(a) The posterior column, which separates position and

vibratory senses.

(b) The lateral spinal thoracic tract, which separates pain

and temperature sensation.

(c) The cortical spinal tract, which controls muscle

movement. The spinal cord transmits messages between the brain and the
peripheral nervous sytem. These messages are passed along a nerve as
electrical impulses, much as messages are passed in a telephone cable.

(3) There are five main areas in which the spinal cord can be
divided: cervical, thoracic, lumbar, sacral, and coccygeal (tailbone) (Figure 7·4).
In each section of the spinal cord, nerve cells control motor function and
sensation for specific parts of the body. At each level of the cord, bundles of
nerve fibers j oin to form nerve roots that leave the front and back sides of the
spinal cord and then join to form peripheral nerves (Figure 7·5). Nerve roots in
different areas control specific functions. For example, inability to move the
shoulder indicates injury to the fifth cervical nerve root (C5). The following list
gives other important relationships between nerve roots and the function of
various body structures.

7-6
 FM 8-230

LUMBAR

Figure 7-4. The five divisions of the spine.

7-7
FM 8-230

• Cervical.
o Shoulder girdle (C5).

o Elbow flexion (C5, C6).

o Elbow extension (C6, CB).

o Wrist movement (C6, C7).

• Thoracic.

o Thoracic region movement and sensation (T4 through TIO).

o Sensation at the nipple level (T4).

o Sensation at the umbilicus (navel) level (TIO).

• Lumbar.

o Hip flexion (L2, L3).

o Hip extension (L4, L5).

o Knee extension (L3, L4).

• Sacral.

o Knee flexion (L5, Sl).

o Ankle movement (Sl, S2).

o Toe movement (L5, S l , S2).

POSTERIOR
(DORSAL) ROOT

POSTERIOR ROOT
GANGLION

SPINAL N ERVE

PERIPHERAL
NE RVE F I B E RS

Figure 7-5. Bundles of nerve fibers joining nerve roots.

7-8
 FM 8-230

Another way of assessing possible damage to specific nerve roots is to test

skin sensation in different areas. Each nerve root has cutaneous (skin) nerves
which supply a given area. The area supplied by cutaneous nerves from a
single nerve root is called a dermatome (Figure 7-6). These cutaneous nerves
are part of the peripheral nervous system (paragraph 7-3).

Figure 7-6. Dermatome in cross-section.

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FM 8-230

7-3. Peripheral Nervous System

a. The peripheral nervous system is complex. Branches from the

spinal nerves j oin together with branches from other spinal cord segments to
form large bundles or plexuses. These plexuses divide further to form the
peripheral nerves that run to the muscles, skin, and other structures in the
extremities. The peripheral nerves may be injured by fractures or lacerations
of the extremities, which may cause local muscular paralysis and loss of
sensation.

b. A group of large nerves in the base of the neck and armpit is the
brachia! plexus. Branches of the hrachial _plexus innervate the arm and the
shoulder. Six major nerves branch from the brachia! plexus:

(1) Axillary nerve. The axillary nerve supplies the deltoid muscle
and skin of the shoulder.

(2) Musculocutaneous nerve. The musculocutaneous nerve

descends laterally to supply the biceps muscle and ends in a cutaneous sensory
nerve in the forearm.

(3) Radial nerve. The radial nerve branches off to the arm and
forearm muscles, to the skin of the posterior arm, and to the posterior forearm.
When the radial nerve is damaged, motion of and sensation in the thumb are
lost.

(4) Superficial radial nerve. The superficial radial nerve is a

cutaneous nerve that innervates the skin of the lateral posterior forearm and
lateral posterior hand.

(5) Deep radial nerve. The deep radial nerve innervates the skin
and the muscles of the ulna (the long bone in the forearm) and the hand.
Because the ulnar nerve crosses the outer part of the elbow, it can he damaged
in injuries to this joint. Such injuries cause sensorimotor loss in the little
finger.

(6) Median nerve. The median nerve innervates muscles of the

forearm and hand, the skin of the thumb, the first three fingers, and the radial
side of the palm.

c. The lumbosacral plexus innervates the legs. Its major branches

include:

( 1 ) Femoral nerve. The femoral nerve innervates the muscles in

the front of the thigh, including the quadriceps group. It also gives qff
cutaneous branches to the skin of the anterior and medial distal thigh and the
medial leg and foot.

(2) Obturator nerve. The obturator nerve innervates muscles of

the medial thigh and the skin of the distal medial thigh.

(3) Sciatic nerve. The sciatic nerve is the largest nerve in the body
and is found in the posterior thigh. It innervates the muscles of the calf and
the back of the thigh and the skin of the lower calf and the upper surface of the
foot.

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 FM 8-230

(4) Superficial peroneal nerve. The superficial peroneal nerve

innervates the lateral leg muscles and the skin on the back (dorsum) of the
foot.

(5) Deep peroneal nerve. The deep peroneal nerve innervates the
anterior and lateral leg muscles and the muscles that move the toes.

(6) Tibial nerve. The tibial nerve innervates the skin and muscles
of the posterior leg and the sole of the foot. Damage to the tibial nerve results
in "footdrop, " the inability to dorsiflex the foot (to bend it backward by
flexing the ankle).

7-4. Autonomic Nervous System

a. The autonomic nervous system stimulates the smooth muscle of the

blood vessels and the bowel, the heart muscle, and some endocrine glands.
This system maintains the various bodily functions over which the individual
has no conscious control, including blood pressure, temperature regulation,
sweating, and peristaltic activity of the bowel. In stressful situations, the
autonomic nervous system also helps the body produce the appropriate "fight
or flight" response, characterized by changes in blood flow and metabolism.

b. The autonomic nervous system is divided into the parasympathetic

nervous system (which controls the involuntary functions mentioned above)
and the sympathetic nervous system (which prepares the body for stress). The
parasympathetic nerves release acetylcholine when stimulated. This chemical
transmitter crosses the synapse (neuromuscular junction) to stimulate the end
organ, or muscle. Effects of acetylcholine (cholinergic effects) include
salivation, pupillary constriction in the eye, slowing of the heart, constriction
of bronchial smooth muscle, and increased intestinal motility.

c. Because atropine inhibits the breakdown of acetylcholine at the

neuromuscular junction (increasing cholinergic activity), it is used clinically to
increase the heart rate. Some insecticides, notably those of the
organophosphate type, block cholinergic activity and can lead to fatal
panlysis and cardiac arrest unless their effects are countered by treatment
with atropine.

d. The sympathetic nervous system has more widespread effects than

the parasympathetic system. Chemical transmitters in the sympathetic
nervous system include norepinephrine, which is released from sympathetic
nerve endings, and epinephrine (Adrenalin), which is released from the adrenal
gland when it is stimulated by the sympathetic nerves. Sympathetic nervous
stimulation increases the heart rate (pulse) and the force of cardiac
contraction. In the blood vessels, sympathetic stimulation of specialized
receptors (called beta-1 and beta-2 adrenergic receptors) can both increase and
decrease the muscular tone of the vessel wall and influences blood pressure
and blood flow to different parts of the body.

e. Damage to the thoracic and lumbar segments of the spinal cord can
cause derangement of the sympathetic nervous system, which originates in
those areas. Such damage can lead to heat loss and shock; as vascular tone
di1ninishes, blood collects in the extremities.

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7-5. Protective Mechanisms for the Central Nervous System

a. The brain and the spinal cord do not have the ability to
regenerate if cells are permanently damaged. Although some brain cells can
take over the functions of other damaged cells, the amount of function
regained cannot be predicted and is usually limited. To prevent additional
damage, any patient with possible neurological injury must be handled very
carefully in the emergency treatment situation.

b. There are several protective mechanisms for the structures of the

central nervous system (Figure 7-7). The skull provides a rigid container for
the brain, and the spine protects the spinal cord. Within these bony structures,
three layers of tissue (called meninges) provide additional protection.

( 1 ) The first of these layers is the dura mater, the thick fibrous
outer covering of the brain. It is attached to the skull except at the falx cerebri,
which separates the two halves of the cerebrum, and the tentorium cerebelli,
which separates the occipital lobe of the cerebrum from the cerebellum. These
dural infoldings provide a suspension system for the brain and help prevent
excessive motion within the skull. The dura mater also forms the outer
covering of the spinal cord.

(2) The second layer of tissue is called the arachnoid membrane.

Between the arachnoid membrane and the dura mater is the subdural space in
which blood vessels and nerves pass to and from the brain.

(3) The third layer is the pia mater, which is closely attached to
the surface of the brain and spinal cord and dips into every fold of their
surfaces. Between the arachnoid membrane and the pia mater is the
subarachnoid space, which is filled with cerebrospinal fluid (CSF). The
cerebrospinal fluid protects the brain and spinal cord by providing a cushion
between them and their adjacent bony structures. Clear and colorless, this
fluid circulates through and around the brain and spinal cord before being
resorbed. When tears in the dura mater occur (usually after skull fractures),
the cerebrospinal fluid may leak out through the nose or the ears. Leakage of
this fluid indicates a critical situation because it signals serious injury to the
central nervous system and possible infection (meningitis).

FORAM EN DENTATE L I G . F I LUM TERMINALE

SPINAL CORD
x EXTRA-- ( E P I - ) DURAL SPAC E

* - IN TRA-(SU B-) DURAL SPACE

mm
BRA I N
- PIA MAT ER DURA MATER - - - ARAC H N O I D MEMBRANE

Figure 7-Z The covering membranes (meninges) suspend and protect the
skull and spinal canal.

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CHAPTER 8

TH E DIG ESTIVE SYSTEM

8-1. General

a. The digestive system is made up of the alimentary tract (food

passage) and the accessory organs of digestion. Part of this system is also
known as the gastrointestinal (GI) tract. Its main functions are to take in
foods, initially process foods, digest the foods, and eliminate waste material.
The products of the accessory organs help to prepare food for digestion and its
absorption.

b. Digestion consists of two processes: one mechanical and the other

chemical. The mechanical part of digestion includes chewing, swallowing,
peristalsis (movement for propelling the stomach contents), and defecation.
The chemical part of digestion consists of breaking food into simple
components that can be absorbed and used by the body cells. In this process,
foods are broken down by enzymes in the digestive juices formed by the
digestive glands. Carbohydrates are changed into glucose (simple sugar), while
fats are changed into fatty acids and proteins are converted into amino acids.
These materials are used by the cells-

• As energy for life processes.

• For growth and repair of body tissues.

8-2. Structure of the Digestive System

The digestive system (Figure 8-1 ) consists of the following:

a. The alimentary canal is about 28 feet long (8.52 m), extending from
the mouth (where food is taken in) to the anus (where solid waste products of
digestion are expelled from the body) . This passageway is divided into: the
mouth, pharynx, esophagus, stomach, small intestine and associated glands,
large intestine (colon), rectum, and anal canal and anus.

b. The accessory organs that aid the process of digestion are the
salivary glands, pancreas, liver, gallbladder, and other intestinal glands.

8-3. Oral Complex

The oral cavity contains structures which together are commonly known as
the mouth. The cavity takes in and initially prepares foods prior to the
digestive process. See Figure 8-2.

a. Lips and Cheeks. The structure of the oral cavity is covered with
fleshy tissues known as cheeks. The margins of the cheeks around the oral
opening are the lips. Muscles in the lips control the opening and closing of the
mouth.

b. Jaws. There are two j aws: the upper j aw, which is called the maxilla
and the lower j aw, which is called the mandible.

(1) In each j aw, there are sockets for the teeth. These sockets are
known as alveoli. The bony parts of the j aws holding the teeth are known as
alveolar ridges.

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(2) The upper jaw is fixed to the base of the cranium while the
lower jaw is movable. There is a special articulation (temporomandibular j oint)
with muscles to bring the upper and the lower teeth together to perform their
functions.

MOUTH --­

(ORAL COMPLEX)

ESOPHAGUS

LIVER
GALL BLADDER

LARGE I NTESTINES

Figure 8-1. The digestive system.

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TEETH LOWER JAW

(INCISORS/MOLARS) (MAN DIBLE)

B.

Figure 8-2. Anatomy of the oral cavity.

c. Teeth.

(1) A tooth (Figure 8-3) has two main parts: the crown and the
root. A root canal passes up through the central part of the tooth. The root is
suspended within a socket (called the alveolus) of one of the j aws of the mouth.
The crown extends up above the surface of the j aw. The root and inner part of
the crown are made of a substance called dentin. The outer portion of the
crown is covered with a substance known as enamel. Enamel is the hardest
substance of the body. The nerves and blood vessels of the tooth pass up into
the root canal from the jaw substance.

(2) There are two kinds of teeth: anterior and posterior. The
anterior teeth are also known as incisors and canine teeth and serve as
choppers. They chop off mouth-sized bites of food items. The posterior teeth
are called molars and are grinders. They increase the surface area of food
materials by breaking them into smaller and smaller particles.

(3) There are two sets of teeth: deciduous and permanent.

Initially, the deciduous set includes 20 baby teeth. These are eventually
replaced by a permanent set of 32 teeth.

d. Palate. The palate serves as the roof of the mouth and the floor of
the nasal chamber above. Since the anterior two-thirds is bony, it is called the
hard palate. The posterior one-third is musculomembranous and is called the
soft palate. The soft palate serves as a trap door to close off the upper
respiratory passageway during swallowing.

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e. Tongue. The tongue is a muscular organ that is capable of internal

movement to shape its body. The tongue is moved as a whole by muscles
outside of it. Interaction between the tongue and the cheeks keeps food
between the molar teeth during the chewing process. When the food is
properly processed, the tongue also initiates the swallowing process.

f. Tas te Buds. Associated with the tongue and the back of the mouth
are special clumps of cells known as taste buds. These taste buds literally taste
the food; that is, they check its quality and acceptability.

g. Salivary Glands. Digestion is the process that converts food into

chemical substances that can be absorbed and assimilated by the body. The
chewing process greatly increases the surface area available. The surfaces are
wetted by saliva produced by the salivary glands in the oral complex.

CROWN TEET H :

l. ST RUCTURE .
GUM
A CROWN I ROOT I

ROOT
ROOT CANAL ROOT CANAL

B. ENAMEL / DENTIN

2. ALVE:OLI OF JAWS

AL VEOLUS

JAW

Figure 8-3. Section of a tooth and jaw.

8-4. Pharynx

The pharynx is a continuation of the back of the mouth region, just in front of
the vertebral column (spine) . It is a common passageway for both the
respiratory and digestive systems.

8-5. Esophagus

The esophagus is a tube with muscular walls. It extends from the pharynx,
down through the neck and the thorax (chest), to the stomach. During
swallowing, the esophagus serves as a passageway for the food from the
pharynx to the stomach.

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8-6. Stomach

a. The stomach is a sac-like enlargement of the digestive tract

specialized for the storage of food. The presence of valves at each end prevents
the stored food from leaving the stomach before it is ready. The pyloric valve
prevents the food from going further. The inner lining of the stomach is in
folds to allow expansion.

b. While the food is in the stomach, the digestive processes are

initiated by juices from the wall of the stomach. The musculature of the walls
thoroughly mixes the food and juices while the food is being held in the
stomach. The stomach has an extra layer of muscle fibers for this purpose.

c. When the pyloric valve of the stomach opens, a portion of the

stomach contents moves into the small intestine.

8-7. Small Intestine and Associated Glands

The chemical process of digestion is facilitated by special chemicals called

digestive enzymes. The end products of digestion are absorbed through the
wall of the intestine into the blood vessels. These end products are then
distributed to body parts that need them for growth, repair, or energy. There
are associated glands-the liver and the pancreas-which produce additional
enzymes to further the process. Most digestion and absorption takes place in
the small intestine.

a. Anatomy of the Small Intestine.

( 1 ) The small intestine is divided into three areas: the duodenum,

jejunum and ileum. The duodenum is C-shaped, about 1 0 inches (25.40 cm)
long in the adult. It is looped around the pancreas. The jejunum is
approximately 8 feet (2.4 m) long and connects the duodenum and the ileum.
The ileum is about 1 2 feet (3.6 m) long. The jej unum and the ileum are attached
to the posterior wall of the abdomen with a membrane called the mesentery.
This membrane allows mobility and serves as a passageway for nerves and
vessels to the small intestine.

(2) The small intestine is tubular. It has muscular walls that

produce a wave-like motion (called peristalsis) which moves the contents
along. The small intestine is just the right length to allow the processes of
digestion and absorption to take place completely.

(3) The inner surface of the small intestine in NOT smooth; it has
folds known as plicae. On the surface of these plicae are fingerlike projections
called villi. These folds and the presence of villi increase the surface area
available for absorption.

b. Liver. The liver is a large and complex organ. Most of its mass is on
the right side of the body and within the lower portion of the rib cage. Its
upper surface is in contact with the diaphragm. The liver is a complex chemical
factory with many functions. These include aspects of carbohydrate, protein,
lipid, and vitamin metabolism and processes related to blood clotting and red
blood cell destruction. Its digestive function is to produce a fluid called bile or
gall.

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c. Gallbladder. Until needed, the bile is stored and concentrated in the

gallbladder, a sac on the inferior surface of the liver. Fluid from the gallbladder
flows through the cystic duct, which j oins the common hepatic duct from the
liver to form the common bile duct. The common bile duct then usually j oins
with the duct of the pancreas as the fluid enters the duodenum.

d. Pancreas. The pancreas is a soft, pliable organ stretched across the

posterior wall of the abdomen. When needed, it secretes its powerful digestive
fluid, known as pancreatic juice, into the duodenum. The pancreatic duct j oins
the common bile duct.

8-8. Large Intestine

a. The primary function of the large intestine is salvaging water and

electrolytes (salts). (Most of the end products of digestion have already been
absorbed in the small intestine by the time they reach the large intestine.)
Within the large intestine, the contents are first a watery fluid. Thus, the large
intestine is important in the conservation of water for use by the body. The
large intestine removes water until a nearly solid mass is formed before
defecation (the evacuation of feces). Vitamin K, which is very important in
blood clotting, is produced by microorganisms located in the large intestine.
Antibiotics potentially may decrease production of vitamin K, but this is
rarely of any practical significance.

b. The maj or subdivisions of the large intestine are the cecum (with
the vermiform or "worm-shaped" appendix), ascending colon, transverse
colon, descending colon, and sigmoid colon. The colon extends along the right
side of the abdomen from the cecum up to the region of the liver (ascending
colon). There the colon bends (hepatic flexure) and continues across the upper
portion of the abdomen (transverse colon) to the spleen. The colon bends again
( splenic flexure) and goes down the left side of the abdomen (descending colon).
The last portion makes an S curve (sigmoid colon) toward the center and
posterior of the abdomen and ends in the rectum of the pelvic cavity. The fecal
mass is stored in the sigmoid colon until it is passed into the rectum.

8-9. Rectum, Anal Canal, and Anus

The rectum is a tubular structure about 6 inches (1 5.24 cm) long and follows
the curve of the sacrum and coccyx until it bends back into the short anal
canal. The anal canal is the last 1 1/2 inches (3.81 cm) beyond the rectum. It
has an external opening (anus) to the exterior at the lower end of the digestive
system. The anus is kept closed by strong sphincter muscles. By the action of
peristalsis, the rectum receives feces and periodically expels this material
through the anus. This elimination of waste is called defecation.

8-10. Time Required for Digestion

The time required for digestion varies greatly depending (among other things)
on the type of meal consumed. In general, though, within a few minutes after a
meal reaches the stomach, it begins to pass through the lower valve of the
stomach. After the first hour the stomach is half empty, and at the end of the
sixth hour none of the meal is present in the stomach. The meal goes through
the small intestine, and the first part of it reaches the cecum in 20 minutes to 2
hours. At the end of the sixth hour, most of it should have passed into the
 FM 8-230

colon; in 12 hours all should be in the colon. Within 24 hours from the time
food is eaten, the meal should reach the rectum. However, part of a meal may
be defecated (eliminated) at one time and the rest at another time.

8-11. Special Protective Mechanisms

a. The digestive system is essentially a continuous tube open at both

ends. Therefore, the cavity connects directly with the surrounding
environment. Along with the ingested food, toxic materials, microorganisms,
and even foreign bodies can pass through the mouth into the digestive system.

b. Within the body, there are many substances that aid in protection
from bacteria, viruses, and other foreign substances. These structures include
cells that can phagocytize (engulf) foreign particles or manufacture antibodies
(which help to inactivate foreign substances). Collectively, such cells make up
the reticuloendothelial system (RES). Such cells are found in bone marrow, the
spleen, the liver, and the lymph nodes.

c. Lymphoid structures make up the largest part of the

reticuloendothelial system. Lymphoid structures are collections of cells
associated with the circulatory system.

( 1 ) Tonsils are masses of lymphoid tissue. Tonsils are found in the

region of the pharynx. Three pairs of tonsils (lingual, pharyngeal, and faucial)
are found at the beginning of the pharynx. Together they form a ring of
lymphoid tissue. This ring, called Waldeyer 's ring, completely surrounds the
entrance to the pharynx from both the mouth (digestive entrance) and the nose
and nasal chambers (respiratory entrance).

(a) In the upper recess of the pharynx is the pair of

pharyngeal tonsils (commonly known as adenoids).

(b) On either side, below the soft palate, are the palatine
(faucial) tonsils. These are the tonsils that one sees most frequently in small
children.

(c) On the back of the root of the tongue are the lingual
tonsils.

(2) Lymphoid aggregates of varying sizes are found in the walls of

the small intestine. In the ileum portion, in particular, these aggregates are
large enough to be observed and are called Peyer 's patches. These might be
considered "tonsils" of the small intestine.

(3) At the beginning of the large intestine, at the inferior end of

the cecum, is a structure known as the vermiform appendix. Since the
vermiform appendix is actually a collection of lymphoid tissue, it should be
considered the "tonsil" of the large intestine.

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C HAPT E R 9

THE UROGENITAL SYSTEM

9-1. General

The urinary and genital systems are discussed together because their various
organs and passages develop from the same embryologic beginnings, and they
share many structures. The urinary system is made up of the organs which
control the discharge of certain waste materials filtered from the blood. The
genital system controls the reproductive processes from which life is created.

9-2. The Urinary System

The maj or parts of the urinary system include two kidneys, two ureters (one
connecting each kidney to the urinary bladder), the urinary bladder, and the
urethra (Figure 9- 1). The urinary system helps the body maintain its delicate
balance of water and various chemicals in the proportions needed for good
health. During the process of urine formation, waste products are removed
from circulating blood for elimination, and useful products are returned to the
blood.

R L

- U RETER -

---- URETHRA

Figure 9-1. The urinary system.

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9-3. Kidneys

a. The kidneys are a pair of reddish-brown organs lying against the

posterior muscular wall of the abdominal cavity, near the level of the last
thoracic vertebrae and the first lumbar vertebrae. The right kidney is usually
slightly lower than the left. Each kidney is a bean-shaped organ 4 to 5 inches
( 1 0. 2 to 12. 7 cm) long .

b. The kidney (Figure 9-2) is composed of an outer shell (or cortex) and
an inner layer (the medulla). The cortex is made of firm, reddish-brown tissue
containing millions of microscopic filtration plants called nephrons. Nephrons
are urine-forming units that receive and filter all of the body's blood
approximately once every 1 2 minutes. During this period, they draw off and
filter the liquid portion of the blood, remove liquid wastes (urine), and return
the usable portion to the circulatory system to maintain the body's fluid
balance.

c. Nephrons are complex structures which perform every aspect of

urine formation. Each nephron has a capsule (Bowman's capsule) containing a
cluster of filtering capillaries called glomerulus. Leading from the capsule is a
continuous looped tubule. The water, salts, waste products, and usable
products pass from the capsule to the tubules; usable products and water are
then reabsorbed. The final waste product (urine) drains from the last loop of
the tubule. The glomerulus, the capsule, and the loops of the tubule together
form a nephron. Each part is essential for the coordination, filtration,
reabsorption, and excretion processes.

d. Channels called collecting tubules form larger tubes and

deliver the urine to the pelvis of the kidney.

ME DULLA

MAJOR CALYX

R E N AL PEL VIS

RENAL PYRAM I D

- URETER

Figure 9-2. Cross section of kidney.

9-2
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9-4. Ureters

The pelvis of each kidney is drained by a ureter, a muscular tube extending

from the kidney to the posterior portion of the urinary bladder. Ureters are
smooth muscle structures, and urine is passed through each ureter by
peristalsis into the bladder. Ureters are about 15 to 18 inches (38 to 45.7 cm) in
length and about 1/5 inch (.5 cm) in diameter.

9-5. Urinary Bladder

The urinary bladder is a muscle sac formed of smooth muscle with a

specialized lining membrane. It is located in the lowest part of the abdominal
cavity and its purpose is to store urine. Normally it holds 300 to 500 ml of
urine. The bladder is emptied by contraction of muscles in its walls, which
force urine out through the urethra.

9-6. Urethra

The urethra is the tube that carries urine from the urinary bladder to the
external opening, the urinary meatus. In the male, the urethra varies in length.
Including the portion within the body, it is about 6 to 7 1/2 inches (15 to 19 cm)
long. It is divided into three areas: the prostatic, which passes through the
prostate gland; the membranous area, beneath the prostate; and the penile
area (anterior), which passes through the penis. The female urethra, about 1
112 inches (3.8 cm) long, extends from the bladder to the urinary meatus, which
is located above the vaginal opening.

9-7. Urine

Normal urine is a transparent (clear) fluid varying in color from amber or pale
yellow to a brownish hue. Freshly voided urine has a characteristic aromatic
odor, while stale urine has a strong ammonia odor. The average quantity of
urine excreted by a normal adult in 24 hours ranges from 1 , 500 to 2,000 ml,
depending upon the fluid intake, amount of perspiration, and other factors.
Urine contains protein wastes (urea), salts in solution, hormones, and
pigments. (Normal urine should not contain blood, albumin, sugar, or pus
cells.)

9-8. Urination

Urination (micturition) is the discharge or voiding of urine. It is accomplished

by a contraction of the bladder and relaxation of the sphincters. In the adult,
urination is largely an autonomic (involuntary) function, which can, however,
be controlled voluntarily. Voluntary contraction of abdominfll rr:nscles can aid
in urination.

9-9. The Genital System

The male and female genital (reproductive) systems have their own specialized
internal and external organs, passageways, and supportive structures. The
parts and functions of these systems are designed to make the process of
fertilization possible. The female cell, the ovum, must be fertilized by the male
cell, spermatozoa. The normal result of fertilization is reproduction.

9.3
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9-10. The Male Reproductive System

The male reproductive system includes the scrotum, testicles, vas deferens
(seminal duct), seminal vesicles, ejaculatory ducts, prostate gland, urethra,
and penis. The penis, testicles, and scrotum are referred to as the external
genitalia (see Figure 9-3).

Ii
'"..,...__ E JACULATORY DUCT

I
PROSTATE GLAN D
- - .·

/
SCROTUM

Figure 9-3. Male urogenital system.

a. The Scrotum, Testicles (Testes), and Epididymis. There are two

testicles (testes), one on each side of the septum of the scrotum. A testicle
(testis) is an oval-shaped gland, about 1 1/2 to 2 inches (3.8 to 5 cm) in length.
Each testicle contains specialized cells that produce germ cells called
spermatozoa (or sperm), and the male hormone, testosterone. The hormone is
absorbed directly into the blood from the testicles. Sperm are produced in
great numbers, starting at the age of puberty. Although microscopic in size,
each sperm has a head, which contains a cell nucleus, and an elongated tail for
movement. Sperm travels from the testicles to a tightly coiled tube, the
epididymis. The vas deferens is a continuation of the epididymis.

b. The Vas Deferens. This duct carries sperm from the scrotum to the
pelvic cavity. As the duct leaves the scrotum, it passes through the inguinal
canal into the pelvic cavity as part of the spermatic cord. Spermatic cords, in
the groin, are supporting structures. Each vas deferens curves around the
bladder and delivers the sperm to one of two storage pouches, called the
seminal vesicles.

c. The Seminal Vesicles and the Ejaculatory Ducts. The seminal

vesicles are located behind the bladder. These vesicles constitute small storage
sacs for sperm and seminal fluid. During the storage of sperm in these vesicles,

9-4
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secretions are added to the sperm to keep them alive aµd motile. These
secretions and the sperm form the seminal fluid (or semen). Ejaculatory ducts
carry this seminal fluid from the seminal vesicles, through the prostate gland,
and empty into the urethra.

d. The Prostate Gland. The prostate gland is a small gland that

surrounds the urethra at the neck of the bladder. Prostatic secretions are
added to the seminal fluid to protect it from urethral secretions and female
vaginal secretions. During the act of intercourse, special mechanisms in the
nervous system prevent the passage of urine into the urethra. Only seminal
fluid, prostatic fluid, and sperm pass from the penis into the vagina during
ejaculation. When the prostate gland becomes enlarged (hypertrophied), it can
seriously constrict the urethra. The size and consistency of the prostate gland
is determined by the physician by means of a rectal examination.

e. The Urethra and the Penis. The urethra, a passageway for seminal
fluid and for urine, has its longest segment in the penis. Several glands add
secretions to the urethra, the largest being two bulbo-urethral (or Cowper's)
glands. The terminal opening of the urethra is in the glans penis, which is
surrounded by a retractable fold of skin called the foreskin, or prepuce.
Surgical removal of this foreskin is called a circumcision, which is performed
to reduce the possibility of an abnormal constriction of the glans, called
phimosis, or to reduce the possibility of irritation from secretions that
accumulate under the foreskin. The penis has a special type of tissue called
erectile tissue. When filled with blood, this special tissue causes the penis to
distend into a state of erection. Thus, the penis becomes a rigid organ that can
enter the vagina.

PROSTATE GLAND

..
"� DUCTUS (VAS)
...... . .

- PENIS DEFEREN S

EPIDIDYMIS

Figure 94. Diagram of the male reproductive system.

9-5
FM 8-230

9-11. The Female Reproductive System

The female reproductive organs include the ovaries, fallopian tubes, uterus,
vagina, and external genitalia (the vulva). The supportive structures for the
internal reproductive organs are a complicated arrangement of pelvic
ligaments, which are formed in part from folds of peritoneum that line the
abdomino-pelvic cavity. A detailed discussion of the female reproductive
system is contained in Section I, Chapter 1 5.

a. The Ovaries. These are two almond-shaped glands, one on either

side of the abdomino-pelvic cavity. The ovaries, like the testicles, produce sex
hormones (estrogen and progesterone) and specialized germ cells, ova, for
reproduction. The female sex hormones are absorbed directly into the blood
and aid in maintaining the normal menstrual cycle. A specialized cell, called an
ovum, is expelled from the surface of an ovary in a process called ovulation,
which occurs about halfway between each menstrual period. An expelled ovum
is picked up by the free end of a fallopian tube for movement to the uterus.

b. Fallopian Tubes. The fallopian tubes are connected to the uterus

and carry the ovum to the cavity of the uterus. There are two fallopian tubes
(oviducts) each curving outward from the upper part of the uterus. Each tube
is approximately 4 inches in length and has a free end which curves around,
but is not attached to, an ovary. The fringed surface of the free end of the
fallopian tube carries an expelled ovum into the tube, and the ovum moves
slowly on its way to the uterus. If fertilization takes place, it normally occurs
as the ovum moves through this tube. The male germ cell, the sperm, must
therefore travel up the female reproductive tract in order to unite with the
female germ cell, the ovum. Of the millions of sperm produced, only one must
unite with one ovum for fertilization to occur.

c. The Uterus. The uterus, shaped somewhat like a pear, is suspended

in the pelvic cavity, supported between the bladder and the rectum by its
system of eight ligaments . The normal position of the body of the uterus is
anteflexion (bent forward over the bladder) (Figure 9-5). The uterus is about 3
inches (7 .6 cm) long and 3 inches (7 .6 cm) thick at its widest part. It has a thick
wall of smooth muscle and a relatively small inner cavity. During pregnancy,
it can increase about 20 times in size. The upper dome-shaped portion of the
uterus is the fundus, the main part is the body, and the lower neck portion is
the cervix ( Figure 9-6). The cervix is a canal that opens into the vagina. The
inner lining of the uterus, the endometrium, undergoes periodic changes
during the regular menstrual cycle, to make the uterus ready to receive a
fertilized ovum. If the ovum is not fertilized, the endometrium gets a message
from hormone influences and sheds its surface cells and built-up secretions.
Some of the extra blood supply, the surface cells, and uterine secretions are
eliminated as menstrual flow.

d. The Vagina. This muscular canal extends from the cervix portion of
the uterus to the vaginal opening in the vestibule of the vulva. The vaginal
canal is capable of stretching widely and serves as the birth canal. Part of the
cervix protrudes into the uppermost portion of the vagina. An important part
of a female pelvic examination is the physical examination of the visible
surface of the cervix and vagina, plus a laboratory examination of cervical and
vaginal secretions. A Pap (Papanicolaou) smear is made by obtaining these
secretions for laboratory examination.

9-6
 FM 8-230

e. The Vulva. The several structures that make up the female external
genitalia form the vulva. These are the mons pubis, the labia, the clitoris, and
the vestibule. The labia, two parallel sets of liplike tissues, are the labia maj ora
(the larger outer folds of tissue) and the labia minora (the small inner folds).
The clitoris is located at the upper meeting point of the labia maj ora and the
labia minora. Between the labia minora is the vestibule, a shallow depression
into which the urethra and the vagina open. The urethral opening is above the
vaginal opening. A series of glands which can become infected open into the
vestibule, the largest being the Bartholin glands at the vaginal opening.

FUN DUS

UTERUS

POST ERIOR
FORNI X

EXTERNAL G E N ITALIA

Figure 9-5. Female urogenital system.

F U N DU }
F A LLOP I A N T U B E
BODY UTERUS

CERVI X
VAG I N A

ANTERIOR VIEW

Figure 9-6. Female reproductive organs (frontal section).

9-7
FM 8-230

9-12. Menstruation

a. The menstrual period is the end of the monthly female reproductive

cycle. This process begins at puberty and is repeated, except when interrupted
by disease or pregnancy, approximately every 28 days until a female passes
through menopause at about 40 to 50 years of age.

b. Each month the endometrium (lining of the uterus) is stimulated by

the female sex hormones to form a special bed. This bed (which is a very thin
layer of cells and blood) is prepared so that if a sperm and an ovum unite,
making a fertilized egg, the uterus will be able to receive it and provide a place
for it to grow.

c. If the ovum is not fertilized, there will be a menstrual period.

During this period, the uterus will shed its recently formed special lining. The
lining, in the form of menstrual flow, will be expelled from the uterus through
the vagina and out of the body. The flow will last about 5 days.

9-8
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C HAPTER 1 0

THE ENDOCRINE SYSTEM

10-1. General

The endocrine system is made up of glands of internal secretion (ductless

glands) located in different parts of the body (Figure 10·1). Hormones
produced by endocrine glands are secreted directly into the circulating blood
and reach every part of the body. These hormones influence the activities of
specific organs and tissues, as well as the activities of the body as a whole.
Small in quantity, but powerful in action, hormones are part of the body's
chemical coordinating and regulating system. There are six recognized
endocrine glands:

• Pituitary body.

• Thyroid gland.

• Parathyroid gland.

• Pancreatic islets (islets of Langerhans).

• Suprarenal (adrenal) glands.

• Gonads (female-ovaries; male-testes).

10-2. The Pituitary Body

The pituitary body is a small and pea-shaped structure attached to the base of
the brain in the region of the hypothalamus ( Figure 10-1 ). It is housed
within a hollow of the bony floor of the cranial cavity called the sella turcica
(Turk's saddle). The pituitary body consists of two glands: the posterior
pituitary gland and the anterior pituitary gland. These glands are initially
separate but join together during development of the embryo.

a. Posterior Pituitary Gland. The posterior pituitary gland is the

portion that comes from and retains a direct connection with the base of the
brain. The hormones of the posterior pituitary gland are actually produced in
the hypothalamus of the brain. From the hypothalamus, the hormones are
delivered to the posterior pituitary gland where they are released into the
bloodstream. There are two recognized hormones of the posterior pituitary
gland:
( 1 ) Antidiuretic hormone (ADH) is involved with the resorption or
salvaging of water within the kidneys. This hormone is produced under thirst
conditions.

(2) Oxytocin is involved with contractions of smooth muscle in

the uterus and with milk secretion.

b. Anterior Pituitary Gland. The anterior pituitary gland originates

from the roof of the embryo's mouth. It then "attaches" itself to the posterior
pituitary gland. The anterior pituitary gland is indirectly connected to the
hypothalamus by means of a venous portal system. Portals are the veins that
carry substances from the capillaries of one point to the capillaries of another
point. In the hypothalamus, certain chemicals known as releasing factors are
produced. These are carried by the portal system to the anterior pituitary

10-l
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gland where they stimulate the cells of that gland to secrete their specific
hormones. The anterior pituitary gland produces many hormones. In general,
these hormones stimulate the target organs to develop or produce their own
products. This stimulating effect is referred to as trophic. Of the many
hormones produced by the anterior pituitary gland, two are of particular
importance:
( 1 ) Somatotrophic hormone (growth hormone), whose target
organs are the growing structures of the body. This hormone influences such
structures to grow as the body matures.

(2) Adrenocorticotrophic hormone (ACTH), which stimulates the

cortex of the suprarenal (adrenal) gland to produce its hormones. The
hormones of the suprarenal cortex are involved with anti-inflammatory
reactions of the body.

THYROID GLAND

ADRENAL

(SUPRARENAL)

GLAND

�Rllt-r--+-- PANCREATIC
ISLETS

GONADS
lllllilll--- TESTIS
(MA L E )

Figure 10-1. The endocrine glands and their locations.

10-2
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10-3. The Thyroid Gland

This gland is in the neck region just below the larynx and surrounds the
trachea. The right and left thyroid lobes are the masses on either side of the
trachea. The isthmus is found across the front of the trachea and connects the
two lobes. Each lobe is supplied by arteries from above and below (superior
and inferior thyroid arteries). The thyroid produces two hormones:

a. Thyroxin, which affects the basal metabolic rate (BMR), or level of

activity of the body. Since iodine is a necessary element in the production of
thyroxin, malformations of the thyroid gland (called goiters) can be observed
where there is little or no iodine available.

b. Calcitonin, which is produced by the thyroid gland, is involved with

calcium metabolism in the body.

10-4. The Parathyroid Glands

The parathyroid glands are two pairs of small, round tissue masses. These
glands are located on the posterior aspects of both thyroid lobes. The hormone
produced by these glands is called parathyroid hormone, or parathormone. It
is involved with the body's calcium metabolism.

10-5. The Pancreatic Islets (Islets of Langerhans)

Within the pancreas are distributed small groups of cells known as islets.
Although the pancreas is a ducted gland of the digestive system, these
isolated islets are, in fact, ductless glands. Insulin and glucagon are the two
most commonly recognized hormones of the islets. These hormones are
involved with glucose metabolism.

10-6. The Suprarenal (Adrenal) Glands

Embedded in the fatty layer above each kidney is a suprarenal gland. Both
suprarenal glands have an internal medulla and an external cortex.

a. Hormones of the Suprarenal Medulla. The medullary portion of each

suprarenal gland produces a pair of hormones: epinephrine (adrenaline) and
norepinephrine (noradrenaline). These hormones are involved in the
mobilization of energy during stress reactions.

b. Hormones of the Suprarenal Cortex. Each suprarenal cortex

produces a variety of hormones that can be grouped into three categories:

(1) Mineralocorticoids, which are involved with the electrolytes of

the body.

(2) Glucocorticoids, which are involved with many metabolic

functions and are anti-inflammatory in nature.

13) Sex hormones.

10-7. The Gonads

The primary sex organs are known as gonads. The gonads produce sex cells
(gametes) and sex hormones. These sex hormones are in addition to those
produced by the suprarenal cortex (see paragraph 1 0-6b)

10-3
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a. Female Sex Hormones. In the female, the ovaries produce two types
of sex hormones during the menstrual cycle. During the first half of the cycle
(days 1 to 14), the estrogens are produced. During the last half of the cycle
(days 1 5 to 28), progesterone is produced. These hormones are involved with
female sexuality and the preparation of female sex organs for reproduction.

b. Male Sex Hormones. In the male, certain cells of the testes produce
the male sex hormones known as androgens (for example, testosterone).
Androgens are involved with male sexuality.

10-4
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CHAPTER 1 1

T H E SENSORY SYSTEM

1 1-1. General

Sensations of smell, taste, sight, hearing, and equilibrium are usually referred
to as special senses. These sensations are received through specialized sense
organs or receptors which are sensitive to specific stimuli. Other sensations
such as touch, pressure, pain, heat, and cold are received through receptors in
the skin, underlying tissue, and viscera. Impulses for both special and other
senses are carried by sensory nerve pathways to the cerebrum. There the
impulses are converted into sensation and perception (awareness or
consciousness of sensation). The parts of the sensory mechanism are ( 1 ) the
sense organ or receptor, (2) the pathway by which the impulse is conducted
into the central nervous system, and (3) the sensory center in the cerebrum.
The sensory mechanisms of the special senses are summarized as follows:

a. Smell. Cells located in the olfactory membrane of the nose are

stimulated by odors. The olfactory membrane is located in the uppermost part
of the nose. Impulses from receptors for odors are transmitted by the olfactory
nerve. Although olfactory receptor cells are quite sensitive, they can also
become fatigued. Smell is considered a primitive sense and the detection of
odor is more highly developed in animals than in man.

b. Tas te. Sense organs for taste are the taste buds, located on the
surface of the tongue. The primary taste sensations are sweet, sour, salty, and
bitter. The actual sensation of taste is influenced by the sense of smell. Taste
sensation is usually dulled when nasal membranes are congested. Impulses
from taste receptors are transmitted by the facial and glossopharyngeal
nerves.

c. Sight. Cells in the retina of the eye are stimulated by light rays
entering the eye. These stimuli create impulses that are carried by the optic
nerve.

d. Hearing. Cells in the cochlea of the inner ear are stimulated by

vibration of sound waves. These stimuli create impulses that are carried by the
acoustic (auditory) nerve.

e. Equilibrium. In addition to receptors for hearing, the internal ear

contains three semicircular canals which regulate the sense of equilibrium.
Change in position of the head causes movement of fluid within the canals. The
fluid movement stimulates nerve endings in the walls of the canals which send
impulses to the brain by the vestibular branch of the auditory nerve.

1 1-2. The Ear

The ear, the organ of hearing, consists of three parts: the external ear, the
middle ear (tympanic cavity), and the internal ear (the labyrinth) (Figure 1 1-1).
These divisions are commonly referred to as the outer ear , the middle ear, and
the inner ear They provide for the reception and conduction of sound and
.

contain one of the principal mechanisms of equilibrium. The structures of the

ear, except the part protruding from the head, are situated within the temporal
bone of the skull.

1 1-1
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AURICLE

T U BE

Figure 11-1. The external, middle, and internal ear, frontal view.

a.. The external ear (Figure 1 1 -2) consists of the shell-shaped portion of
the ear, riilled the auricle (pinna), which proj ects from the side of the head, and
the extEk�al auditory canal leading toward the middle ear. The principal
function of the external ear is the collection and conduction of sound waves to
the middle and inner ear. The auricle is composed of cartilage covered with
membrane and the skin.

(1) The prominent folded rim o f the ear i s the helix.

(2) A deep cavity, the concha, leads into the external auditory
canal.

(3) In front of the concha and projecting backward over the

entrance to the external auditory canal is a small, triangular piece of cartilage
called the tragus. The undersurface of the tragus is covered with soft hairs
which help prevent foreign bodies from entering the ear.

(4) The lobe is the lowest point of the helix. The lobe is composed
of fatty tissue and connective tissue, but does not have any cartilage.

b. The external auditory canal extends from its entrance to the

tympanic membrane (eardrum) which closes its inner end. The canal is formed
of two parts: ( 1 ) its outer (cartilaginous) part which is formed of cartilage and
membrane; and (2) its inner (bony) portion which is formed by a passage in the
temporal bone.

(1) If the auricle (helix area) is pulled up and back, the outer canal
straightens and may be examined or treated more easily. Near the entrance of
the canal, the skin contains wax-producing glands and hair follicles. This wax,
called cerumen, helps prevent the entry of foreign obj ects into the ear.

11-2
 FM 8-230

(2) The tympanic membrane (eardrum) separates the inner end of

the canal from the middle ear. The normal eardrum is partly translucent and
shiny gray (pearl-like). When inflamed, it appears pink or dull red.

c. The middle ear (tympanic cavity) is an irregular space in the

temporal bone filled with air and containing the three ossicles of the ear:
malleus (hammer), incus (anvil), and stapes (stirrup). These bones conduct
vibrations from the eardrum to the internal ear. The eustachian tube connects
the middle ear with the nasopharynx. Its principal function is to keep the air
pressure equal on either side of the eardrum. This is also an avenue of infection
by which disease spreads from the throat to the middle ear.

Figure 11-2. The auricle.

d. The internal ear (labyrinth) contains receptors for hearing and

equilibrium. The receptor for hearing lies within the cochlea which is coiled
and resembles a snail shell.

( 1 ) Sound waves, which pass through the external auditory canal,

vibrate the eardrum and ossicles and are transmitted through the fluid of the
inner ear. Nerve impulses travel through the acoustic (auditory) nerve to the
auditory center of the cerebral cortex.

(2) The internal ear also contains three semicircular canals which
control equilibrium. Change in the position of the head causes movement o�
the fluid within the canals and this fluid movement stimulates nerve endings
in the wall of the canal. These nerve endings serve as receptors and transmit
impulses along the acoustic nerve to the cerebellum.

1 1-3
FM 8-230

11-3. The Eye

The eye is specialized for the reception of light. Each eye is located in a bony
socket or cavity called the orbit, which is formed by several bones in the skull.
The orbit provides protection, support, and attachment for the eye and its
muscles, nerves, and blood vessels.

a. The Eyeball. The interior of the eye ( Figure 1 1·3) is divided into an
anterior cavity (anterior to the lens� and a posterior cavity (posterior to the
lens). A clear watery solution (aqueous fluid) is formed and circulated in the
anterior cavity. A transparent semifluid material (vitreous fluid) is contained
in the posterior cavity. The globular form and firmness of the eyeball is
maintained by its fluid contents which also functions in the transmission of
light.

(1) Eye tissue coats. The eyeball has an outer coat, a middle coat,
and an inner coat.

(a) Outer coat. The outer coat consists of a normally

transparent anterior portion, the cornea, and a fibrous white portion, the
sclera. The cornea focuses and transmits light to the interior of the eye. The
sclera helps maintain the shape of the eyeball and protects the delicate
structures within.

(b) Middle coat. The middle coat consists of the choroid, iris,
and ciliary body. The choroid, the vascular middle layer of the eyeball, lines
the posterior portion of the eye from the ciliary body to the optic nerve. The
iris is a circular, colored, muscular membrane which is suspended between the
cornea and the lens. The pigment in the iris gives the eye its characteristic
color. The round opening in its center is the pupil. The muscle structure of the
iris adjusts the size of the pupil to adapt the eye to the brightness of light. The
ciliary body lies between the iris and choroid; it has a muscular function,
changing the focus of the lens, and a secretory function, producing aqueous
fluid.

(c) Inner coat. The inner coat is the retina which lines the
interior of the eye except toward its anterior inner surface. The visual nerve
cells (rods and cones) are arranged closest together at the central portion of the
retina, the macula lutea. A slight depression in the macula lutea is the fovea
centralis. Medial to the fovea centralis is the area called the optic disk, the site
of exit of the optic nerve. The inner surface of the retina is in contact with the
vitreous and the outer surface with the choroid. The condition known as
"detached retina" means that some portion of the retina has become separated
from the supporting choroid.

(2) The lens. The lens is a small, disk-shaped, transparent

structure about 1/3 inch in diameter. It is situated behind the iris and in front
of the vitreous cavity. The lens is suspended by the suspensory ligament. This
ligament is attached to the ciliary body. Muscular movements of the ciliary
body affect the suspensory ligament and focus the lens. The condition of
"cataract" means that some portion of the lens has become cloudy (opaque).

(3) Aqueous fluid. The aqueous fluid is formed by the ciliary body
and fills the two divisions of the anterior cavity of the eye, called the anterior
and the posterior chamber. Aqueous fluid is crystal clear for transmission of
light rays. Its formation and flow help maintain the normal intraocular
pressure. The aqueous fluid flows from the posterior chamber to the anterior
 FM 8-230

chamber and drains by means of a series of channels into the venous blood.
Interference with the normal formation and flow of aqueous fluid can lead to
development of excessively high intraocular pressure, a condition called
glaucoma.

AQUEOUS HUMOR

SUSPENSORY
LIGAMENT
OF LENS

CONJUNCTIVA

CRYSTALLINE
LENS Jl�---����
LATERAL

OPTIC

Figure 11-3. The eye.

b. The External Eye and Accessory Structures. Viewed from the

surface of the body, the anterior surface of the eye and some of its accessory
structures (such as eyebrows, lids, lashes, and conjunctiva) are readily visible.
An additional essential accessory structure is the lacrimal (tear) apparatus
(Figure 1 1 -4).

( 1 ) Eyebrows and eyelashes. The eyebrow and lashes are usually

considered to have a cosmetic (decorative) function, but the eyelashes protect
against the entrance of foreign objects. On the margin of the eyelids near the
attachment of the eyelashes are the openings of a number of glands. Infection
in these glands is commonly called a sty.

11-5
FM 8-230

(2) Eyelids. The eyelids are thin, moveable, protective coverings

for the eyes. The junctions of the upper and lower eyelids of each eye are
canthi. The inner canthus (Figure 1 1-4) is at the nasal junction and the outer
canthus is at the temporal junction.

--- - - --- PUPIL

LACRIMAL PUNCTUM
I N N E R CANTHUS I RI S

MARG I N OF ORBIT
(BONY CAVITY)

Figure 11-4. The external eye and accessory structure.

(3) Conjunctiva. The conjunctiva (Figure 1 1 ·4) is a delicate

mucous membrane which lines the inside of the eyelids and covers the front
surface of the eyeball. The semitransparent conjunctiva appears white on the
front surface of the eyeball where it covers the sclera and pink where it overlies
lid tissue. Should the conjunctiva itself become inflamed or infected, it appears
red and swollen. (One type of acute bacterial infection of the conjunctiva is
commonly called "pinkeye. ")

(4) The lacrimal apparatus. The lacrimal apparatus consists of the

lacrimal gland, lacrimal ducts, lacrimal sac, and nasolacrimal duct (Figure
1 1·4). Its function is the secretion and drainage of tears. The lacrimal gland is
about the size and shape of a small almond and is located in a small depression
on the lateral side of the frontal bone of the orbit. Many small ducts drain tears
secreted by the glahd to the conjunctiva! surface; the tears drain downward
and toward the inner angle of the eye. The normal blinking of the eyelids helps
spread the tears evenly to provide a lubricating, protective, moist film over the
exposed surface of the cornea. The tears drain into openings near the nasal
portion of each eyelid (lacrimal puncti) and then into the tear ducts, the sac,
and finally into the nose through the nasolacrimal duct. This normal function
and drainage of tears is the natural way in which the eye surface is kept clean
and moist.

(5) Extraocular muscles. There are six sets of muscles located

outside the eyeball. These muscles raise, lower, or rotate the eyeball within its
socket. The muscles of the two eyes normally function in a coordinated manner
so that both eyes move simultaneously and are aimed in the same direction.

1 1-6
 FM 8-230

C H APTER 1 2

TRIAG E AND PATIENT ASSE SSM ENT

Section I. TRIAGE

12-1. General

Triage (pronounced tree-ahzh) is the French word for ' 'sorting. ' ' In medicine, it
refers to the sorting of casualties to establish priorities of treatment and
evacuation. Triage is generally applied to situations in which there are several
casualties; however, the word can also refer to the assessment of one patient
with multiple injuries in order to decide which injury should be treated first. In
this chapter, we will examine triage and the techniques used when dealing with
mass casualty situations.

12-2. Principles of Triage

Whether you are dealing with one patient who has multiple inj uries or many
injured people, the fundamental principles of triage are the same:

a. Asphyxia and hemorrhage are the two immediate threats to life.

b. Salvage of life takes priority over salvage of the limb.

NOTE

These two principles should guide all of your

work with critically injured patients and
dictate the priorities of treatment.

12-3. Triage of the Multiple Injured Patient

You may not have used the word "triage" before, but every time you have
performed the proper sequence of treatment, you were performing triage:
sorting out the patient's problems according to priorities. Triage of the
multiple injured patient begins with the primary survey, with emphasis on
airway, breathing, and circulation (ABC's).

a. Airway. The airway remains the first consideration. The trauma

victim, if unconscious, will have his airway obstructed by the base of his
tongue. The usual solution of tilting the head back is not adequate because
every severely injured, unconscious victim is considered to have a cervical
spine injury until proven otherwise. The approach is modified by using the j aw
thrust method of opening the airway. By using this method, any motion of the
head and/or neck is avoided. The tongue, blood, vomitus, avulsed teeth, or
broken dentures may obstruct the airway of a trauma victim. To insure that
the airway of the trauma victim is open you must:

(1) Open the airway, avoiding any movement of the head or neck.

(2) Clear foreign material manually or with suction. Remember

to always anticipate vomiting.

(3) Keep the unconscious patient turned on one side (after the
spine is properly stabilized) so that foreign materials can drain from the
patient's mouth.

12-1
FM 8-230

(4) Facial fractures around the mouth and trachea are extreme
emergencies and the patient should be evacuated immediately.

b. Breathing. Insure the patient is breathing adequately. If the

victim is not breathing, artificial ventilation must be started promptly and
supplemented as soon as possible with high concentrations of oxygen. Even if
the patient is making respiratory efforts, there are a number of injuries that
can decrease the effectiveness of the respirations. For instance, sucking chest
wounds will prevent adequate expansion of the lung; these wounds must be
closed without delay. To insure respiration in the trauma victim, you must-

(1) Start artificial ventilation for apnea.

(2) Close sucking chest wounds.

(3) Decompress the chest at once or evacuate the victim without

delay if tension pneumothorax is evident.

(4) Note presence of flail chest (stabilize later).

(5) Give oxygen to every severely injured patient.

c. Circulation. When we discuss circulation in the context of trauma,

we are talking principally about control of bleeding and treatment of shock.
Both actions must be accomplished as rapidly as possible once the airway and
breathing have been insured. To insure circulation in a trauma victim, you
must-

(1) Start external cardiac compressions if there i s no pulse.

(2) Control bleeding with direct pressure.

(3) Anticipate shock in every severely injured patient and treat

accordingly.

12-4. The Secondary Survey

Having dealt with the ABC's, you have now taken care of the conditions that
pose an immediate threat to life. Recall, however, the second principle of
triage: salvage of life takes priority over salvage of limb. This means that a
patient may have to be moved before treatment is completed. For instance, a
patient with pericardia! tamponade must be evacuated with all possible speed,
even if splinting of fractures has not been completed.

12-5. Multiple Casualties

Situations involving several casualties may be the most difficult and

challenging you will face. Not only does the multiple casualty situation require
you to employ the skills of judgment and emergency care, but it also demands
that these skills be exercised under frequently difficult conditions.

12-2
 FM 8-230

12-6. Sorting of Casualties

The goal of this process is to accomplish the greatest good for the greatest
number, remembering that the highest priority is keeping the patient alive.
Sorting of casualties (triage) is conducted in several rounds. On the first round,
you should identify those patients who require immediate attention according
to the familiar priorities of airway, breathing, and circulation.

12-7. Categories of Triage

a. Immediate-to Save Life or Limb.

(1) Airway obstruction.

(2) Respiratory and cardiorespiratory failure (cardiores:piratory
failure is not considered an "immediate" condition on the battlefield; it would
be classified as expectant).
(3) Massive external bleeding.
(4) Shock.
(5) Sucking chest wound, if respiratory distress is evident.
(6) Second or third degree burns of the face and neck, or
.perineum (causing shock or respiratory distress).
(7) After casualty with life/limb threatening conditions has been
initially treated, no further treatment will be given until other "immediate"
casualties have been treated.

b. Delayed-Less Risk by Treatment Being Delayed.

(1) Open chest wound.

(2) Penetrating abdomen wound.
(3) Severe eye injury.
(4) Avascular limb without apparent blood supply.
(5) Other open wounds.
(6) Fractures.
(7) Second and third degree burns not involving the face and
neck or perineum.

c. Minimal-Can Be Self Aid or Buddy Aid.

(1) Minor lacerations.

(2) Contusions.
(3) Sprains.
(4) Minor combat stress problems.
(5) Partial thickness burns (under 20 percent).
(6) Patients in this category are not evacuated to a medical
treatment facility.

d. Expectant-Little Hope ofRecovery. This category should be used

only if resources are limited.

(1) Massive head injury with signs of impending death.

12-3
FM 8-230

(2) Burns-more than 85 percent of the body surface area.

N OTE

Casualties with minor injuries can assist with

( 1 ) recording treatment, (2) emergency care,
and (3) defense of the area.

Section II. PATIENT ASSESSMENT

12-8. General

At any level of medical treatment, evaluation of the patient must come before
treatment. A good evaluation should be used to discover a condition rather
than confirm it. Therefore, you must perform a thorough, advanced
examination that proceeds in a logical pattern, uncovering all important
findings needed to make good prehospital treatment decisions. The first in the
sequence of examining the patient is the triage examination or initial patient
assessment.

12-9. Assessment Tools

To perform a complete patient assessment, you need a penlight, wristwatch,

stethoscope, blood pressure cuff, your eyes for inspection, your ears for
hearing, and your hands for palpation.

12-10. Techniques for Patient Assessment

a. Inspection. Look for colors, contours, masses, bleeding, and any

changes in the physical appearance of the part being examined.

b. Auscultation. Listen for breath sounds and apical (heartbeat)

pulse.

c. Palpation. Feel for textures, consistency, depressions, moisture,

and temperature.

12-11. Triage Examination

The triage examination determines if any life-threatening conditions exist; it

allows for simple treatment steps to protect vital functions.

a. Airway. Check for open airway. If the airway is closed, you should
open it with manual maneuvers.

( 1 ) Head tilt-chin lift. This technique provides a consistently

more effective method of opening the airway in the unconscious victim and is
less tiring than other methods.

(2) Head tilt-neck lift. This technique should never be used if

victim has a suspected cervical spinal injury.

12-4
 FM 8-230

(3) Jaw thrust. This technique is the safest first approach to

opening the airway of a victim who has a suspected neck injury because, in
most cases, it can be accomplished without extending the neck.

NOTE

It should be noted that if the victim is making

respiratory efforts, the airway may still be
obstructed. Many times opening the airway is
all that is needed.

b. Breathing. Check for breathing by using the Look, Listen, and Feel
technique. If patient is not breathing, give four quick ventilations.

c. Circulation.

( 1 ) Pulse. Check for a carotid pulse. It is important to check the

carotid pulse because it is most accessible, most reliable, and most easily
learned and remembered. If the carotid pulse is absent, begin cardiac
compressions. In triage, under combat conditions, you should move on to
other injured patients.

(2) Bleeding. Check for persistent external bleeding. If there is

profuse bleeding, apply direct pressure and elevate. In some instances, a
tourniquet may be required.

(3) Level of consciousness. Check the casualty's level of

consciousness (for example, can he talk, does he understand what you are
saying to him). If traumatic injury is present, apply a cervical collar, if
available, or stabilize the neck with sand bags, or a wire ladder splint made
into a cervical collar.

NOTE

See Chapter 13 for specific instructions

concerning the application of the ABC's.

12-12. Vital Signs (Pulse, Blood Pressure, Respiration, and Temperature)

a. Pulse. Normal pulse for adults is 60-80 heartbeats per minute, for
children 80-100, and for infants 1 20-160. Also observe its regularity and
strength.

b. Blood Pressure. Normal blood pressure for an adult is 1 10-146

mm/Hg systolic and 60-90 mm/Hg diastolic. Infant readings are 50·80 mm/Hg
systolic and 40-58 mm/Hg diastolic.

c. Respiration. Normal respiratory rate for adult is 12·20 per minute;

for children, a higher rate is normal. Also, observe the rhythm and depth.

d. Temperature. Normal temperature is 98.6°F (3 7 .0°C). If patient

shows symptoms of shock (weak, rapid pulse; pale skin; skin that is cool and
moist to the touch), control of the shock should be achieved before continuing
with the assessment.

12-5
FM 8-230

12-13. Head-to-Toe Examination

a. General appearance would include the patient's general skin color,

obvious wounds or eviscerations, presence of the odor of alcohol, dress, social
condition, and presence of cigarettes. Skin color may be red (fever,
allergic reactions, carbon monoxide poisoning), white (excessive blood loss,
fright), blue (hypoxemia, peripheral vasoconstriction from cold or shock),
yellow (indicative of liver disease, especially hepatitis; may also be seen in
sclera), or mottled (cardiovascular shock).

b. Degree of distress is the patient's response to his illness or injury

and normally varies among individuals. This is usually classified as mild,
moderate, or severe.

c. State of consciousness is based on the Glascow Coma Scale, which

is explained below. (Pain is elicited by rubbing the sternum while examining
the ribs.)

(I) Eye opening response:

(a) 4-Spontaneous.

(b) 3-Responds to verbal stimuli.

(c) 2-Responds to painful stimuli.

(d) I -No response.

(2) Verbal response:

(a) 5-0riented to person, place, and time.

(b) 4-Confused.

(c) 3-lnappropriate words.

(d) 2-lncomprehensible words.

(e) I -No response.

(3) Motor response:

(a) 6-Follows commands.

(b) 5-Localizes pain.

(c) 4-Withdraws from painful stimuli.

(d) 3-Exhibits flexion to painful stimuli.

(e) 2-Extension to painful stimuli.

(f) I -No response.

12-6
 FM 8-230

d. The patient is scored by adding the numbers the patient receives in

each category of the examination. This score is placed over a maximum score
of 1 5 (the score becomes a fraction; 15/15 would be the score received by a fully
alert patient).

e. Examine:

( 1 ) Scalp. The scalp is examined for the presence of bleeding or

contusions and palpated for tenderness or depression. Do not move the neck!

(2) Forehead. Touch the forehead with the back of your hand to
ascertain both temperature and moisture.

(3) Eye.

(a) Eyelids-check for raccoon eyes (bilateral discoloration

without swelling).

(b) Pupils-check for dilation or constriction, equality or

inequality, roundness, eye movement, and gross acuity (by following finger) .

(c) Conjunctiva-pull one of the lower eyelids down to

check color on the inside of the lid.

(4) Nose. Check for deformity, bleeding, or discharge.

(5) Ears. Inspect for drainage or bleeding without turning

patient's head.

(6) Mastoids. Check for bruising or defined discoloration (Figure

1 2-1) or Battle's sign (bruising behind the ear), which may indicate a skull
fracture.

Figure 12·1. Looking for discoloration.

12-7
FM 8-230

(7) Facial bones. Examine the face for lacerations or contusions;

palpate zygomatic arches, maxilla, and mandible for tenderness (Figures 1 2-2
and 1 2-3).

Figure 12-2. Palpating zygoma for fractures. Figure 12-3. Palpating mandible for fractures.

(8) Mouth. Examine the mouth for loose teeth, abnormal

alignment, oral hydration, and visibly check for perioral cyanosis.

(9) Tracha. Check for midline position, presence of stoma, and

medicalert necklace.

(10) Suprasternal area. Check for retractions, accessory muscle

usage, and subcutaneous emphysema.

( 1 1 ) Neck veins. Check for distension (Figure 1 2-4); if distension is

present, see if the veins fill from above (the head) or below (the heart).

(12) Cervical spine. Check for deformity or midline point

tenderness without moving patient (Figure 1 2-5).

( 1 3) Chest wall. Examine for paradoxical breathing (flail

chest-when a portion of chest wall goes in on inspiration, out on expiration),
splinting, or retractions (Figure 1 2-6).

(14) Ribs. Examine for bruising or tenderness during chest

compression. Do not push over any abrasive bruise (Figure 1 2-7).

( 1 5) Thoracic spine. Palpate for deformity or tenderness without

moving the patient.

(16) Breath sounds. Check in the four quadrants, anterior and

posterior. Bilateral equality is noted, as in the presence of rales (fine crackling
sounds indicating fluid), Rhonchi (coarser sounds indicating fluid in larger
airways; "bubbling"), or wheezes (whistling sounds).

12-8
 FM 8-230

Figure 12-4. Check neck veins for distension. Figure 12-5. Palpating the cervical spine.

Figure 12-6. Checking for fiail chest. Figure 12-7. Examining for rib tenderness.

( 1 7 ) Apical pulse. Auscultate the heart for apical rate and

possibility of muffled heart tones.

( 1 8) A bdomen.

(a) External- ob serve for wounds, distension, or

evisceration of bowel.
(b) Bowel sounds-auscultate for bowel sounds; if absent,
mention the amount of time listening.

(c) Abdominal tenderness-palpate lightly for tenderness;

note presence of rigidity.

12-9
FM 8-230

(19) Lumbar spine. Palpate for deformity or tenderness without

risking spinal inj ury.

(20) Pelvis. Compress the pelvis with hands covering the hip j oint
and iliac crest. Note any pubic tenderness or incontinence (Figure 12-8).

(21) Femoral pulses. Check for presence and bilateral equality.

(22) Lower extremities.

(a) Legs-inspect and palpate both legs for bleeding,

tenderness, and deformity.

(b) Calves and tibias-check the calves for pain on

squeezing and the tibias for pitting edema.

(c) Pedal pulses-palpate both feet for either the dorsalis

pedis pulse or posterior tibial pulse (Figures 1 2-9, 12-10, and 12- 1 1 ) .

(d) Foot movement-examine feet for strength and

sensation by having patient demonstrate ability to wave both feet and then
check strength of extension.

(e) Foot sensation-ask patient to determine which toe is

touched.

(f) Painful withdrawal-test withdrawal to pressure on the

toe nail beds bilaterally.

(g) Reflexes-test knee jerk and ankle j erk reflexes (Figure

1 2- 1 2); also check for Babinski reflexes (Figure 1 2-1 3).

Figure 12-8. Tes ting pelvis for compression pain. Figure 12-9. Palpating for pedal pulses.

12-10
 FM 8-230

Figure 12-10. Palpating for dorsalis pedis pulse. Figure 12-11. Palpating for posterior tibial pulse.

Figure 12-12. Testing knee jerk reflexes. Figure 12-13. Testing Babinski reflexes.

(23) Upper extremities.

(a) Clavicles-palpate both clavicles from the sternum

towards the shoulder for tenderness or deformity.

(b) Arms and forearms-inspect and palpate both arms for

bleeding, tenderness, and deformity.

12-11
FM 8-230

(c) Radial pulses-compare radial pulses for presence and

equality (if unequal, compare blood pressures bilaterally).

(d) Hand movement-instruct patient to wave both hands

to confirm flexion and extension. Check grip strength.

(e) Hand sensation-ask patient to determine which finger

is touched.

(f} Painful withdrawal-test withdrawal to pressure on

thumb nail beds bilaterally.

(g) Reflexes-test biceps reflexes (Figure 1 2-14).

(24) Back. Log roll and observe-log roll the patient unless spine
injury is suspected, and observe for any posterior wounds.

(25) Rhythm strip. If possible, check the heart rhythm on a

cardiac monitor.

Figure 12-14. Testing biceps reflexes.

12-12
 FM 8-230

Section I II. PRIORITIES FOR MEDICAL EVACUATION

12-14. General

Assignment of medical evacuation priorities is necessary because it provides

the supporting medical unit and controlling headquarters with information
that is used in determining the commitment of available evacuation assets. It
is for this reason that correct assignment of evacuation priority is essential.
Overclassification of casualties has been, and continues to be, a problem. They
will be picked up by evacuation resources as soon as possible, consistent with
available transportation means and pending missions.

12-15. Evacuation Priorities

One of three different priorities can be assigned to a casualty, depending on

the severity of their wound(s)/illness:

a. Urgent-this precedence is assigned to emergency cases that

should be evacuated as soon as possible and within a maximum of 2 hours in
order to save life, limb, or eyesight. Casualty's stabilization cannot be
controlled.

(1) Shock-does not respond to I V therapy.

(2) Head injury-increase in intracranial pressure.

(3) Avascular limbs.

(4) Open chest/abdominal wounds.

(5) Uncontrollable bleeding.

(6) Severe burns-20 to 85 percent of the body surface area, or

involving the face and neck.

b. Priority this precedence is assigned to sick and wounded

-

personnel needing prompt medical care. It is used when stabilization is

difficult and the patient should be evacuated within the next 4 hours to
prevent his condition from deteriorating to urgent precedence.

( 1 ) Chest injury with pericardia! tamponade, pneumothorax,

hemothorax, or multiple risk fractures.

(2) Injuries which interfere with respiration.

(3) Abdominal injuries.

(4) Eye injuries.

(5) Spine injuries.

(6) Burns of hands, feet, genitalia, perineum, even if less than 20

percent of the body surface is involved.

12-13
FM 8-230

c. Routine-this precedence is assigned to sick and wounded

personnel requiring evacuation but whose condition is not expected to worsen
significantly. Individuals in this category should be evacuated within 24
hours. Stabilization is under control.

(1) Closed fracture.

(2) Other open wounds .

(3) Psychiatric cases.

(4) Terminal cases.

12-16. Factors Affecting Medical Evacuation Decisions

a. Weather-single biggest factor in determining whether ground or

air transportation can be employed.

b. Resources available-inadequate availability can sometimes delay

evacuation for several hours. This means that careful consideration must be
given before assigning evacuation priority.

c. Medical expertise available.

d. Tactical situation.

Section IV. TROOP MEDICAL CLINIC/

CONDUCT OF SICK CALL

12-17. General

a. A troop medical clinic (TMC) is a medical treatment facility

designed primarily to provide outpatient examination and care for ambulatory
patients, to treat emergency cases, and to arrange for admission to a hospital
of a patient requiring inpatient care. The TMC also performs various
administrative and preventive medicine activities related to the health of the
personnel served. In general, the term "troop medical clinic" designates a
facility situated away from the immediate vicinity of a hospital; the term
"outpatient clinic" is used for a unit of the hospital that provides medical
service primarily for nonhospitalized patients; and the term "aid station"
designates a unit TMC providing primary medical care for troops in the field.

b. TMCs are the first level of medical service for all military
personnel except those troops actually engaged in combat operations. Under
combat or simulated combat conditions, first level medical service for troops is
provided in aid posts and aid stations. TMCs are not merely first aid or sorting
stations; they provide proper diagnosis and treatment for patients or transfer
them to a hospital facility for inpatient care. The majority of patients seeking
medical care do so because of minor sickness or injury. If these individuals are
returned to duty from the TMC level without adequate examination and
treatment, they can become less effective in their assignments.

12-14
 FM 8-230

c. The importance of professional medical care and good

interpersonal patient relationships in TMC-level facilities cannot be
overemphasized or exaggerated; a well-organized and efficiently-operated
TMC is one of the most effective means of providing and extending medical
service to the military community.

d. Some of the more important activities carried on by a TMC are:

• Emergency treatment.

• Sick call.

• Continuing routine treatment for patients who do not require

hospitalization.

• Immunizations.

• Physical examinations.

• Sanitary inspections.

• Maintenance of individual health records.

• In some TMCs, provisions of medical and nursing care and

observations of quarters-status patients who are admitted to the patient care
bed unit of the TMC.

12-18. Routine Duties

The TMC must be kept ready so that patients can be received and treated in a
clean and orderly environment. A common and workable method is to
establish standing operating procedures (SOP) for daily and periodic
routine duties that will not interfere with a smooth, uninterrupted flow of
patients and that will take advantage of periods when the unit is free of
patients. Each individual should have an assigned area of responsibility, to
include treatment rooms, examining rooms, and rooms in common use such as
waiting room, latrines, and corridors.

a. Daily Measures.

( 1 ) At the beginning of the day and before treatment of patients

begins, thoroughly air out the TMC; check emergency equipment, sterilizers,
and treatment area supply levels (drugs, linen, instruments, utensils); check
handwashing facilities for soap and paper towels; make a final check for dust
and for orderly arrangement of equipment.

(2) As a concurrent measure throughout the day, check

examining and treatment rooms after each use, to include removing all soiled
linen, instruments, and gloves; replace supplies as required; and wipe up spills
on floor and furniture immediately.

(3) During the noon period, air the waiting room and treatment
area. Restore order for the afternoon's operations.

12-15
FM 8-230

(4) At the end of the day, carry out general cleanup measures in
order to have the TMC in readiness for the next day's operation. As each area
is cleaned, restock and arrange all equipment in its proper place. Daily cleanup
measures include damp dusting all furniture and damp mopping all floors, to
include corners and behind doors.

b. Periodic Measures. Although these measures are not necessarily a

part of the daily routine, observe them continually and accomplish the
following at periodic intervals: cleaning windows; cleaning and replacing bulbs
in ceiling lights; washing walls and woodwork; cleaning radiators and
baseboards; caring for floors, such as removing wax, rewaxing, and polishing;
and cleaning and rearranging cabinets and storage shelves.

12-19. Patient Receiving and Records Activities

a. General. The medical specialist works closely with and may

perform part of the duties in the receiving and records section of the TMC.
This section usually includes the reception and appointment desk and the
records file. Organization of procedures at this station is essential to assure
that-

( 1 ) All individuals are received in a courteous, friendly, and

professional manner.

(2) All patients are seen by a doctor with minimum delay.

(3) Emergency cases are seen first. Regardless of his reason for
coming to the TMC, each individual who requests to see a doctor must be
permitted to do so.

b. Routine Procedures. Routine procedures established for the

receiving and records stations should include an SOP for-

(1) Handling records.

(2) Recording examination and treatments.

(3) Obtaining X-ray, laboratory studies, and other diagnostic

measures such as consultations.

(4) Making appointments.

(5) Referring patients.

(6) Filing diagnostic reports returned to the TMC as the

referring activity.

(7) Making necessary entries on the daily worksheet, in a ledger,

or on machine records cards to facilitate preparation of the monthly
Outpatients Report, DA Form 3537.

12-16
 FM 8-230

c. Ethical Aspects.

( 1 ) Privileged information. Information given by the patient to

the doctor and all medical and health records are privileged information in
connection with professional medical care. The individual authorized access to
information which is privileged or to information which would cause
embarrassment to the patient will not reveal this information to those not
officially concerned with the patient' s medical treatment.

(2) Female patients. When medical examination or procedures

are performed on adult or child female patients, a female nurse or attendant
must be present. When female personnel are not assigned to the TMC, it is
important to request that the husband, the parent, or a responsible female
adult remain in the waiting room on call as needed as a chaperon. The male
medical specialist assisting with patient care must make certain that an
appropriate chaperon is present before preparing the patient for examination,
before advising the doctor that the patient is ready for examination or
treatment, or before performing any procedure himself.

d. Interpersonal Relations. The manner in which an individual is

received when he comes to the reception desk and the things he observes while
in the receiving area or waiting room create a lasting impression. The family
member or friend who accompanies the patient is also concerned for the care
and attention received. Four factors which foster good interpersonal relations
under all circumstances are courtesy, concern for the individual, sympathetic
understanding, and helpfulness.

12-20. Sick Call

Sick call (AR 40-2) is a daily assembly of sick and injured military duty
personnel. Sick call is held each day at a designated place and time to provide
routine medical examination and treatment for persons on duty status.
Military personnel not reporting for medical treatment at sick call are seen on
an appointment basis except that in an emergency they are seen at any time.
After examination, patients medically unfit for duty are admitted to a hospital
or confined to quarters. Patients not admitted will be given any necessary
treatment. When excused from duty for medical reasons which do not indicate
a need for hospitalization, military personnel may be authorized to occupy a
bed in a TMC or to remain in quarters.

a. Individual Sick Slip. Each person who comes to the TMC on sick
call should present an Individual Sick Slip (DD Form 689). The sick slip is
prepared in the individual's unit orderly room. It is used to inform the unit
commander of the status of an individual in his command who has reported on
sick call. After examination and treatment of the patient, the attending
medical officer indicates the disposition of the patient on the sick slip, which is
returned to the unit commander. In exceptional cases, the treatment facility
initiates the sick slip; for example, when an individual reports directly to the
treatment facility in an emergency. Although the sick slip is not a part of the
health record, it is an important means of communication in regard to the
individual's duty status.

b. Dental Sick Call. Local policy may prescribe use of an Individual

Sick Slip in connection with routine requests for dental attention. Provisions
are made in each dental clinic to hold dental sick call. A definite period is set
aside and personnel report directly to the dental clinic, not to medical sick call.

12-17
FM 8-230

In a dental emergency, as in a medical emergency, patients are seen at any

time. A dental officer of the day is available during other than normal dental
clinic hours. After duty hours, personnel usually report to their regular TMC
or clinic, and TMC personnel call the dental officer of the day.

12-21. Conducting Sick Call

NOTE

This is a typical sick call procedure which is

subj ect to local modification.

a. Military Personne� Usual Procedure.

( 1 ) On arrival at the TMC, the individual reports to the TMC

clerk and gives him the Individual Sick Slip. The clerk checks each slip to see
that it contains the necessary information (individual's name, service number,
grade, and organization) .

(2) The clerk takes each patient's health record from the file for
use by the attending doctor. The date of the patient's appearance on sick call is
entered in the patient's Chronological Record of Medical Care (SF 600).

(3) A medical specialist receives the health record from the clerk;
observes the patient; questions him about his complaint or condition; and
takes his temperature, pulse, and respiration (TPR) for entry on the record.

(a) The TPR is taken and recorded as part of the routine

examination procedure, since the significance of almost any symptom will
change if accompanied by an elevated temperature.

(b) The specialist should talk to the patient, listen to his

complaints, and observe signs and symptoms of distress or discomfort. Signs
and symptoms that are readily observable during the initial contact with the
patient include-

• Skin (observe lips and nail beds also, when applicable):

o Temperature-hot or cold to the touch.

o Color-flushed or pale.

o Rash-location.

o Wounds-location, condition of dressing if one is in

place.

• Eyes and eyelids:

o Pupils-enlarged or pinpoint.

o Sclera-white, yellow, or red.

o Lids-swollen, encrusted, or clear at lid margins.

12-18
 FM 8-230

• Complaint of pain:

o Location.

o Start of pain-how and when.

o Type-sharp or dull, mild or severe, constant or

intermittent.

• State of consciousness:

o Alert.

o Drowsy.

o Orientation to surroundings-knows where he is or

seems confused.

• Nausea or vomiting:

o Time when started.

o If vomited, presence or absence of blood.

o Time, content, and source of last meal that was

eaten.

• Temperature, pulse, respiration:

o Any marked deviation from normal, which is:

°
temperature, 98.6 (oral); pulse, 60 to 80; respiration, 14 to 20.

o Abnormalities of pulse rate and rhythm.

o Difficulty in breathing.

• General posture and gait:

o Sits and stands with or without difficulty.

o Walks with or without difficulty.

(c) Any patient with an obvious rash, an elevated

temperature, a complaint of sore throat, or other upper respiratory symptoms
that might indicate a communicable disease should not be left in a common
waiting room in proximity with other patients. A separate waiting area should
be provided. The SOP may specify that the doctor see the patient in the
segregated area before requesting him to come to the examining room.

(4) The health record is taken to the doctor, who is informed

immediately of any patient who appears to be acutely ill. The doctor calls in
the patients one at a time, questions them, examines them, and determines
what treatment they are to have.

12-19
FM 8-230

(5) If the treatment procedure is one that can be carried out in

the TMC, it will be given either by the doctor or by a designated assistant.

(6) If further diagnostic study is needed and it can be done while

the patient is on a duty status, the doctor directs the clerk to prepare
appropriate forms requesting a laboratory, clinic, hospital, or other suitable
installation to do this work.

(7) If the doctor wants medicine dispensed to a patient, he writes

a prescription and gives it to the patient, directing him to the TMC
pharmacist. If the medicine is not available in the TMC, the patient may be
instructed to take the prescription to a hospital pharmacy or he may have to
return to the TMC after the pharmacist has obtained it.

(8) The doctor makes his entry on the patient's SF 600 and
includes his determination of the patient's duty status: return to full duty;
return to duty with limitations specified; or relieved of duty for "sick in
quarters " or hospitalization.

(9) The doctor makes his entry on the Individual Sick Slip,
indicating his disposition of the patient. (Local policy may include indicating
the time that the patient was dismissed from Sick Call.)

(10) If 'it is necessary to hospitalize a patient, the doctor will

direct the transfer procedure in accordance with local policy. An individual
medical record is prepared for the patient transferred to the hospital. In some
instances the clerk in the TMC will prepare this record; in other instances the
A and D branch of the hospital registrar division prepares it.

(11) Patients requiring relief from duty but not hospitalization are
carried as "sick in quarters. " An individual medical record is prepared by the
TMC clerk for each such case.

b. Nonmilitary Personnel Seen on Sick Call. When nonmilitary

personnel are seen as sick call patients (that is, on a nonappointment basis),
the procedures are usually the same as for military patients except that
Individual Sick Slips are not used and a decision concerning duty status is not
necessary.

c. Screening Patients on Sick Call. During normal sick call hours, the
medical specialist may screen patients according to an SOP prescribed by the
attending doctor. The screening procedure is done to designate priorities for
examination by the doctor. As part of the screening procedure, the medical
officer may permit a qualified nonprofessional assistant to evaluate and treat
certain minor injuries and ailments, such as a scratch or minor abrasion, a cold
with no cough or temperature elevation, or a slight headache. When this type
of screening is permitted, the patient must be permitted to see a medical
officer if he so requests.

d Post Treatment Care on Sick Call. Following prescribed treatment

in the TMC, the patient should not be dismissed until he has received any
necessary instruction, medications, and future appointments. The medical
specialist can do much to insure a better quality of patient care when he is able
to reinforce the doctor's instructions by making sure the patient understands

12-20
 FM 8-230

what he must do as a self-care measure. It is essential that the medical

specialist check the doctor's order on SF 600 and also check with the doctor so
that all instructions he gives are in accordance with the doctor's instructions
to the patient. If the patient on sick call has had medications administered
which may produce drowsiness, any loss of coordination, or a delayed reaction,
the medical specialist may often find it necessary to-

( 1 ) Detain the patient in the TMC for a period of observation.

The patient should not be seated in the common waiting room during this time
unless no other suitable area is available. A cot or recovery bed is often
provided adjacent to the treatment room for this purpose.

(2) Provide an escort if there is any question of the patient's

ability to return alone to his orderly room or quarters.

12-22. Continuing Treatment in the Troop Medical Clinic

The doctor may order the patient to return to the TMC for a series of
treatments over a period of days. ( It may not be necessary for the patient to
see the doctor each time he comes to the TMC for continuing treatments such
as soaks, dressing changes, irrigations, repeated injections, or other treatment
measures for which a written order has been entered on the patient's SF 600.)
This general procedure should be followed:

a. The patient reports to the TMC or clinic at the specified hour.

NOTE

The original Individual Sick Slip may be used

or the patient may have received DA Form
8-97 (Medical and Dental Appointment) at the
time the follow-up appointment was made in
the TMC.

b. The clerk obtains the patient's health record from the file, enters
the date, and gives the record to the medical specialist.

c. The medical specialist is responsible for-

( l) Checking the doctor 's order on SF 600 before any treatment

is given. The order usually includes-

• Type of treatment.

• Number and duration of treatments.

• Dosage of medication.

• The time that the doctor desires to see the patient.

(2) Carrying out the treatment order. He notifies the doctor if

there is an apparent change in the patient's condition. He must not hesitate to
ask the doctor if further explanation is needed. He also must make certain that
he understands the order and knows how to carry it out.

12-21
FM 8-230

(3) Instructing the patient regarding any self-care measures and

the time when the patient is to return to the TMC.

(4) Recording the treatment given on SF 600.

(5) Consulting the doctor immediately if:

• The treatment produces unsatisfactory results.

• The patient reacts unfavorably to the treatment.

• The patient desires to see the doctor.

12-23. Emergency Treatment in the Troop Medical Clinic-General

Instructions

Emergency medical treatment is the early care given to the wounded, injured,
or sick by trained medical personnel. Only some of the general procedures
governing initial management of a patient brought to a TMC for emergency
care will be discussed. In the TMC situation, a medical specialist will function
primarily as the doctor's assistant. If he is the first person to see the patient
who has come or been brought to the TMC for emergency treatment, he must
know how to do first things first.

a. Preparation for Emergency Care. The specialist should be prepared

to receive emergency patients. He should make certain that:

( 1 ) He maintains proficiency in applying the basic ABCD

measures of first aid-

• A-Clear the AIRWAY and restore breathing and

heartbeat.

• B-Stop the BLEEDING by application of digital

pressure to compression points, direct pressure, or pressure dressing to the
wound.

• C-Start shock CONTROL measures by maintaining

aeration and blood circulation.

• D-Apply a wound DRESSING to protect it from

further contamination and control bleeding.

(2) Emergency equipment is ready for use, in its proper location,

and immediately available-not locked up.

(3) He knows how to operate all emergency apparatus and how

to use all items on an emergency tray. In an emergency, there is no time to look
up a technique in a procedure manual, to review an instruction booklet, or to
review an SOP.

12-22
 FM 8-230

b. Initial Patient Care Measures. The medical specialist should

remember the following instructions:

(1) D o not get excited. D o one thing at a time quickly and

efficiently.

(2) Take the patient to an examining or treatment area. Assist

the patient to lie down with his head level. If he has been carried on a stretcher
or litter, do not move him from the stretcher. Unless he is having difficulty in
breathing, keep him lying down with his head level until the doctor gives other
instructions. If he is having breathing difficulty, he may be more comfortable
with the head of the stretcher elevated to support him in a semisitting
position.

(3) Find out what is wrong. Observe the patient. Ask him if he is
in pain and, if so, where he hurts. This brief questioning will help to determine
his state of consciousness.

(4) Look for signs of breathing difficulty, bleeding, shock, or

poisoning. Treatment of these conditions takes precedence over everything
else because they are life-endangering.

(5) Notify the doctor immediately, giving a brief, accurate

description of the nature of the emergency and the patient's condition.

(6) Take and record vital signs.

(7) Loosen and remove enough of the patient's clothing to enable

the doctor to examine the patient, back and front. Handle the patient gently to
avoid injury. If it is necessary to cut his clothing, ask for his permission or for
that of an accompanying relative, if possible. Cut clothing along seams, if
practicable, so that it can be repaired.

(8) Assist the doctor as needed, obtaining any equipment and

carrying out all orders quickly and accurately.

c. Follow-up Measures.

( 1 ) Assure the patient 's relatives or other concerned individuals

who have brought the patient to the TMC that care is being given. Request
them to remain in a designated area in the TMC waiting room until the doctor
can see them. Make them as comfortable as possible.

(2) Handle the patient's personal possessions as carefully as

possible. Safeguard money, identification papers, and other valuables,
following the SOP. If eyeglasses, dentures, a hearing aid, or other prosthetic
appliances are removed from the patient, handle as if they were valuables.

(3) If other patients are waiting for care, explain briefly why
their care is delayed.

(4) Plan to review and discuss the emergency situation with the
doctor and other TMC personnel afterward-how it was handled, what
deficiencies were noted, and what must be done to improve the handling of
future emergencies.

12-23
FM 8-230

12-24. Accident Reporting

a. Installation commanders are authorized to use a duplicate copy of

the sick slip in lieu of DA Form 1051 (Record of Injury) (see AR 385-10) in
cases of nonbattle injury of Army active duty military personnel for whom
sick slips are ordinarily prepared. The individual initiating the sick slip will
check the "Injury" box at the top of the form. Two copies of the form will be
initiated for all injury cases, including suspected poisoning cases. After the
medical officer's section of the form has been completed, the second copy of
the slip will be forwarded to the safety officer concerned by means of a Memo
Routing Slip (OF 41).

b. DA Form 1051 is initiated in three copies by the supervisor of the

individual concerned, and delivered by the patient, if possible, to the TMC or
first aid station. After the medical officer or medical attendant has completed
his section of the form, distribution is made as follows: first copy returned to
supervisor; second copy retained by medical treatment facility; third copy
forwarded to safety officer concerned.

12-24
 FM 8-230

C HAPT E R 1 3

FIELD MEDICAL CARE/

MEDICAL EMERGENCIES

Section I. INTRODUCTION

13· 1. General

Field medical care is best defined as the provision of helpful and needful things
to a sic� or injured person to restore him to the best possible state of physical
and mental health in a field environment. Whether assigned to a field unit,
TMC, or hospital facility, the medical specialist must perform many aspects of
field medical care to the sick and wounded. This chapter outlines and discusses
various field medical procedures that the medical specialist will be expected to
perform. Some of these procedures will have to be modified due to special
circumstances such as equipment shortage, the tactical situation, or the
personnel available.

13-2. Qualities of the Medical Specialist

In order to provide effective field medical care to sick and wounded personnel,
the medical specialist must possess certain personal qualities. Many of them
are inherent while others must be cultivated and improved upon.

a. Aptitude is the ability to anticipate the needs of patients, make

appropriate decisions, and to adapt to various working conditions.
Intelligence and a reasonable degree of manual dexterity indicate an aptitude
for field medical care procedures.

b. A ttitude is the manner of acting, feeling, or thinking that shows an

individual's disposition or opinion. A desirable opinion is one that generates-

• Cooperation and understanding with fellow workers.

• Concern and consideration for the patients' welfare.

• A sense of individual j ob satisfaction.

c. Interest is a strong motivating force to provide satisfactory duty

performance. Interest in a duty assignment can lead an individual to improve
upon abilities and job knowledge.

d. Personal hygiene is the quality that includes both physical

cleanliness and mental hygiene.

Section II. MANAGEMENT OF BURNS

13-3. General

a. Causes. Burns are commonly caused by direct contact with flames,

hot liquids, chemicals, hot metals, hot air, steam, or electric current. Burns can
cause a substantial loss of body fluids which results in shock. There is danger

13-1
FM 8-230

of infection in all burns, especially if there are blisters or a loss of skin. Hot gas
and flame bums of the neck, nose, and mouth are associated with airway
swelling. Even minor bums, incurred in enclosed areas, may cause respiratory
damage.

b. Severity. The severity of burns is measured by the degree or depth

to which tissues are injured and by the extent or percent of body surface
burned.

(1) Degree of bums.

(a) First degree. A first degree bum is superficial and

involves only the outer layers of the epidermis. An example is minor sunburn
in which the skin is red and painful, but with no blisters or fluid loss. It is not
an open wound and does not become infected.

(b) Second degree. The second degree (partial thickness)

burn extends into, but not completely through, the dermis. This type of bum
destroys or damages skin cells, glands, and blood vessels. It is characterized
by redness, pain, blisters, and "weeping" of serum. Body fluids are lost
through the damaged skin. The second degree bum is an open wound and is
susceptible to infection.

(c) Third degree. A third degree (full thickness) burn

destroys all layers of the dermis and may extend through the subcutaneous
tissues into the muscle layer and underlying bone. There may be amputation
of parts. This bum is characterized by insensitivity to pain (nerve branches in
the area are destroyed) and a hard dry surface which is either charred or pearly
white. The surface is usually depressed below that of the surrounding second
degree burn. Large amounts of body fluids are lost into the damaged tissues
and through the destroyed skin layer. A third degree burn is an open wound
highly susceptible to infection.

(2) Percent of body surface area burned.

(a) An early estimate of the percent of body surface area

(BSA) burned is of great importance in determining the amount of fluid
replacement necessary to prevent shock and in the management of mass
casualties. Usually, first degree burns are not included in this estimate. For
practical purposes (especially in an emergency situation), second and third
degree bums are considered to have the same effect when estimating the
percent of body surface burned (for fluid replacement purposes).

(b) The percent of BSA is estimated by using the " Rule of

Nines" shown in Figure 13-1 . The total body surface is divided into the maj or
anatomic parts, each part representing approximately 9 percent or multiples
of 9 except for the perinea! area. The head and neck represent 9 percent; each
arm including the hand, 9 percent; the anterior trunk, 18 percent; the posterior
trunk, 18 percent; each leg including the foot, 1 8 percent; and the perineum
and external genitalia, 1 percent. Proportionate areas of these parts may be
estimated.

13-2
 FM 8-230

Figure 13-1. "Rule of Nines " BSA estimate.

13-4. Pathology of Second and Third Degree Burns

The pathologic process involved in second and third degree burns consists of
three phases:

a. Phase 1. In the first phase there is always some destruction of the

skin, which results in a loss of plasma. In second degree burns, there is a
temporary loss of plasma in the form of edema fluid and a permanent loss
through blister fluid or through "weeping" burned surfaces. Plasma rapidly
seeps into burned tissues and produces widespread edema (swelling). Edema
begins to develop at the time of burning and is evident within a few hours; it
continues for 2 or 3 days. In second and third degree burns (particularly in
third d e g re e ) , there is des truction of red blood cells.

b. Phase 2. The second phase generally begins on the third day after
injury. The coagulum which forms on the surface of second degree burns and
eschar (scab) on third degree burns reduces fluid losses from the surface of the
burn.

c. Phase 3. In the third phase, infection develops. Second and third

degree burns are open wounds and are subject to contamination from the time
they occur.

13-5. Classification of Burns

For emergency treatment purposes, second and third degree burns are
classified by severity as minimal, moderate, or extensive, depending upon the
percent of body surface burned.

13-3
FM 8-230

• Minimal burn 1. Third degree burns of less than 2 percent and

no critical areas burned.

2. Second degree burns of less than 1 5 percent

BSA.

• Moderate burn 1 . Third degree burns of 2 - 1 0 percent BSA not

involving face, hands, feet, or perineum.

2. Second degree burns involving 1 5-25 percent

BSA.

3. First degree burns involving 50-75 percent

BSA.

• Extensive burn Burns of any degree that are complicated by

respiratory injury or other major injury or
fracture, or that involve hands, feet, face, or
perineum.

13-6. Mortality Among Burned Patients

a. As a practical matter, a second or third degree burn of more than

20 percent of the body surface endangers life. In addition, the patient's age
influences the outcome of a burn; the old and the very young do not withstand
burn injuries well. Without adequate treatment, a second or third degree burn
of more than 30 percent is generally fatal to adults. The outlook also varies
according to the location of the injury.

b. Facial burns are often accompanied by complications involving the

eyes or the respiratory passages; a serious risk of infection accompanies burns
of the perineum. Most deaths among burn patients during the first few hours
or days after injury can be attributed to shock. Some form of respiratory
obstruction accounts for most other deaths during this early period.
Pulmonary edema from burns about the face and neck or from inhalation of
noxious agents, superheated air, or superheated vapor are prominent forms of
respiratory obstruction. Gastrointestinal bleeding from a stress ulcer may
account for some early deaths. Later mortality is almost always due to
infection.

13-7. Procedure for Administering Initial Treatment for Burns

a. Survey the Patient.

( 1 ) Respiratory functions of bum patients must be assessed

frequently due to swelling and reduced respiratory function.

(2) Examine for singed nasal hairs, carbon-like material in the

nose or mouth, or black or carbon-flecked sputum. These signs indicate
inhalation burns.

13-4
 FM 8-230

CAUTION

Administer narcotics cautiously to burn

patients because they may compromise
respiration.

b. Determine the Cause of the Bum. If the cause is not evident, ask
the patient or any bystanders for information.

c. Prevent Further Injury to the Patient.

(1) Thermal bums.

(a) Move patient away from any contact with the burn
source.

(b) Remove all clothing and any metal items, such as

j ewelry. Do not remove clothing that is stuck to the burn, cut around the stuck
clothing.

(c) Do not immerse the patient's whole body in water for

more than 2 minutes.

NOTE

Ice or cold compresses may be applied locally

to minor (first and second degree) burns. This
will have a local anesthetic effect and relieve
some pain. It causes vasoconstriction in the
area, helping decrease edema. Ice should not be
applied directly to the burn. Prepare a
container of iced water and immerse the
affected part for 1 0-15 minutes every 30-60
minutes for the first 6 hours. Care must be
taken to avoid causing cold injury to the
·
casualty.

(2) Electrical bums.

(a) Turn off the source of electrical current.

(b) If unable to do so, remove the patient by­

• Standing on a dry surface.

• Using a dry, nonconductive material such as a

wooden pole or rope to physically move him from the source of the current.

NOTE

Electrical burns may cause deep, severe tissue

destruction with only small skin burns at the
point of current entry and exit.

13-5
FM 8-230

CAUTION

1. Patients exposed to electrical currents may suffer

cardiac arrest due to disturbances in their cardiac
rhythm. Apply the ABC's of treatment and administer
CPR if indicated.

2. Do not directly touch a patient receiving an electical

shock. Such contact will extend the current to you.

3. Examine the patient for exit as well as entrance burns

(exit burns may be on soles of feet).

(3) Chemical bums.

(a) Remove and dispose of contaminated clothing.

(b) Brush off solid chemical particles.

CAUTION

Do not touch the chemicals or get them on

your clothing.

(c) Flush the skin with large amounts of water for 20-30
minutes if possible. If the chemical is white phosphorus, flush the burn area
thoroughly and cover it with a wet dressing.

d. Expose the Bum Injury. Expose the entire burned area by

removing the clothing surrounding the affected area. Do not remove any
clothing that is stuck to the burn to avoid increasing tissue damage.

e. Determine the Percent of Body Area Burned. Calculate the percent

of BSA burned (using the "Rule of Nines ") by adding the percentages of the
affected areas (Figure 13-1).

NOTE

The actual percentage of body surface area

burned is used to calculate fluid requirements.
Incorrect estimates will distort the fluid
requirements.

f. Assess and Determine the Depth of the Burns.

(1) FIRST DEGREE-First layer of skin i s red and painful

(sunburn).

(2) SECOND DEGREE-Skin reddened and blistered.

(3) THIRD DEGREE-Full thickness of skin destroyed (burns

down to the fat, muscles, and/or bones).

13-6
 F M 8-230

g. Treat for Shock.

( 1 ) All patients with second and third degree burns of 20 percent

or more body surface area must be treated for shock.

NOTES

1. Burn patients are extremely susceptible to shock due to

loss of large amounts of fluids through the burned area.

2. The head and neck should be elevated if those areas are

burned.

3. Place the patient in a high semi-Fowler position to

assist in respiration. Monitor closely for respiratory
difficulty.

4. Elevate burned extremities above the level of the heart.

Assess for the presence of peripheral pulses and record
presence or absence on FMC. Excessive edema can
impede circulation.

(2) Start an IV with lactated Ringer's solution through a large

bore needle ( 1 4-16 ga).

NOTE

Start the IV in an unburned area, if possible.

Starting it in a burned area increases the
chances of infections.

(a) Calculate the patient's body weight in kilograms by

dividing his weight in pounds by 2.2 (see Table 1 3-1). This will yield the
patient's approximate kilogram weight.

(b) A simple method of fluid replacement for field

management involves patients who have sustained greater than 20 percent
BSA second or third degree burns. A large bore IV is started and the patient
receives 1 liter of lactated Ringer's solution per hour for the first 2 hours. If
the patient cannot be evacuated during that time and must remain in the field
environment, the following calculations will be utilized for fluid replacement:

l. Multiply 1 milliliter of fluid ( 1 .00 cc) times the

percentage of body surface area burned times the kilograms of the body
weight. This will give the total amount of fluids (in cc's) to be administered
during the first 8 hours. EXAMPLE. The patient weighs 165 pounds (75 kgs)
and 30 percent of his body surface area is burned. This equals to 1 .00 cc x 30 x
75 = 2250 cc's for the first 8 hours. In the first 24 hours the patient will
require 1-4 cc's of electrolytes times the percentage of burns times the body
weight in kilograms. This is required to maintain an adequate urine output
(30-50 cc's/hr). (This fluid requirement may be as much as 9000 cc's in the first
24 hours in the above example.)

13-7
FM 8-230

2. Measure the urine output as small, medium, or large

volume and record it on the FMC (indicate the times(s) of output if possible).

3. Patients with extensive burns should have- a Foley

catheter inserted to monitor urine output (See Chapter 14). Urine output
should be maintained at 30-50 cc/hr. If the patient is vomiting, distended,
nauseated, or has burns over 25 percent BSA, a nasogastric tube should be
inserted.

Table 13-1. Pounds/Kilograms and Conversion Table.

Kgs 5 10 15 20 25 30 35 40 45

Lbs 11 22 33 44 55 66 77 88 99

Kgs 50 55 60 65 70 75 80 85 90

Lbs 1 10 121 132 143 154 165 176 187 198

Kgs 95 100 1 05 110 115 120 125 130 135

Lbs 209 220 231 242 253 264 275 286 297

Kgs 140 145 150 155 160 165 170

Lbs 308 319 330 341 352 363 375

NOTES

1. The percentage of body surface area

burned is used as a whole number, not as a
decimal.

2. In the first 24 hours the patient may need

fluids up to, or in exce s s of 4
ml/kilogram/percentage of burns. This
fluid requirement could actually be in
excess of 20,000 cc's for a large person (200
pounds) with extensive burns (75 percent
BSA).

3. Fluid rates adjusted to maintain a drop

rate of approximately 94 per minute
insures the administration of 2250 cc's in 8
hours.

h. Dress the Bums. Do not apply dressings to the patient's face,

hands, feet, or perineum.

13-8
 FM 8-230

CAUTION

Do not apply ointment or grease because they

cause retention of heat in bums. If available,
Silvadene or Sulfamylon cream can be applied.

Give the patient nothing by mouth unless an

IV cannot be started; then only give small sips
of water to a patient who will not reach the
MTF within 3 hours. Do not give excessive
amounts of water because kidney function may
be impaired due to severe burns.

NOTE

Dressings will reduce fluid loss and aid in

preventing the progress of shock. If sterile
dressings are not available, apply the cleanest
cover possible (a clean blanket or sheet).

13-8. Treatment of the Patient with Extensive Burns

With the best of care and treatment conditions, only about 50 percent of
patients with extensive burns survive more than a few days. With the limited
medical capability envisioned during the first 72 hours after onset of a mass
burn situation, survival rate among these patients is expected to be much
lower. Diversion of medical resources to these individuals when their chance
for survival is so limited adds tragedy to disaster because it deprives other
patients less gravely injured of the treatment, care, and supplies which, if
applied early and correctly, can help them back to health. The extensively
burned patient, therefore, has no priority for replacement fluid, dressings,
antibiotics, or time of personnel except for those few moments needed to give
analgestics or other medications available for the relief of pain. Those who
survive the emergency phase are then given treatment and care to the extent
possible that is not detrimental to the welfare of patients in higher priority
treatment categories.

Section III. IMPALEMENT INJURIES

13-9. General

When treating an impalement injury, immediate and positive action is

required by the medical specialist. An understanding of the principles of
emergency care combined with proper application of these principles will
greatly reduce the possibility of post-injury complications including
hemorrhage and shock.

13·10. Initial Treatment for Impalement Injuries

a. Always treat for life threatening conditions first. Check the

patient for consciousness. If he is unconscious, the cardiac and/or respiratory
functions may be impaired.

13·9
FM 8-230

( 1 ) If respiration is impaired, check the airway for obstruction

and ventilate the patient, if necessary.

(2) Check the patient for presence of a pulse. I f none can be

detected, follow established procedure for performing cardiopulmonary
resuscitation.

b. DO NOT remove the obj ect. Its removal may cause severe
hemorrhage or damage of nerves or muscles lying close to the object. Try to
stop any bleeding from the entrance wound by direct pressure on the
surrounding tissue; avoid exerting any force on the impaled object itself.

c. Remove clothing covering the wound. Use a bulky dressing to

stabilize the object. The impaled foreign body should be incorporated within
the dressing so that its motion is reduced after the bandage is applied.

d. Transport patient to more definitive care with the object still in

place.

13-1 1. Impalement Injuries of the Head

a. When evaluating a patient with an impalement head wound, you

should-

( 1 ) Assess the level of consciousness-conscious, confused,

semiconscious, unconscious.

(2) Evaluate eye movements and pupil response-dilated,

constricted, responsive to light, equal or unequal pupil size.

(3) Assess posture and movement (motor system) including

reflexes.

b. Treatment.

(1) Check for life threatening conditions.

(2) Cut through sterile dressings to the halfway point and place
them around the impaled object. The number and placement of the dressing
will depend upon the size and position of the obj ect.

(3) Use additional bulky materials/dressings to build up the area

around the obj ect.

(4) Apply supporting bandage over bulky materials to hold them

in place. Gauze with adhesive tape, cravats, and strips of clothing may be used
as bandaging material. Exercise caution when using elastic bandages since
they can be difficult to apply by one person and may be applied too tightly.

(5) Record the treatment given on the FMC.

(6) Evacuate the patient immediately to the nearest medical

treatment facility.

13-10
 FM 8-230

c. Treatment of impalement injury to the eye.

( 1 ) Place padding around the protruding object, but do not touch

or remove the object (Figure 13-2).

Figure 13-2. Padding placed around protruding object.

(2) Caution the patient not to squeeze his eyelids together.

(3) Cut partially through a first aid dressing so that it will fit
around the object (Figure 1 3-3). This will keep the obj ect from being pushed
further into the eye.

Figure 13-3. Cut first aid dressing.

13-11
FM 8-230

NOTE

Padding must not put pressure on the object.

It should also be built up so that it prevents
the object from moving. The padding may be
cloth material folded to fit the eye area. Tape
may be used to hold the padding in place.

(4) Place the first aid dressing over the injured eye. If necessary,
apply a second dressing so that both eyes are covered.

13-12. Impalement Injuries of the Chest

a. An object that has penetrated the chest wall may also penetrate
and sever or come near a large blood vessel. This can cause a pneumothorax,
tension pneumothorax, or hemothorax. In these conditions, normal lung
expansion cannot occur and the lung is compressed so that volume of air is
lost. Less air can be inhaled and there may be significantly less blood to carry
the reduced amount of oxygen available to the patient.

b. Treatment . Use the same treatment procedures as outlined for

treatment of an impalement head wound.

13-13. Treatment of Impalement Injuries of the Extremities

a. Check patient for immediate life threatening conditions first.

Caution patient to remain still and not remove the impaled obj ect. Expose the
injury by cutting away clothing, shoes, or equipment (Figure 1 3-4). Check the
pulse in the extremity involved, distal to the injury site.

b. Immobilize the impaled object by cutting through sterile

dressings to the halfway point and placing them around the impaled obj ect.
This will help control bleeding and stabilize the obj ect (Figure 1 3-5).

c. Use additional dressings or bulky materials to build up the area

around the object. Two persons should be used to perform this procedure. One
to immobilize the object and prevent any motion and the second to apply the
bulky dressing (Figure 13-6) and bandaging (Figure 1 3-7).

Figure 13-4. Exposed Figure 13-5. Dressing Figure 13-6. Bulky

impalement. around impalement. materials used.

13-12
 FM 8-230

d. Apply the bandage as tightly as possible to stabilize the object,

but not to the point where it will interfere with circulation. Gauze with
adhesive tape, cravats, and strips of clothing may be used as bandaging
material.

e. Secure support bandage with adhesive strips or safety pins (Figure

13-8).

Figure 13-7. Applying Figure 13-8. Securing

bandage over bulky bandage.
support materials.

13-14. Immobilize the Affected Area

Immobilize the injured area by a-

a. Splint. Objects impaled in limbs require that the limb be splinted

in the same manner as a fracture to prevent movement.

b. Sling. When an object is impaled in the upper chest and an arm is

affected, the arm should be placed in a sling and swathe (see paragraph 1 3-52 )
to prevent movement and further damage.

CAUTION

1. The splint or sling should not be anchored to

the impaled obj ect.

2. Avoid undue motion of the impaled obj ect

when applying splints.

NOTE

In some instances, it may be necessary to

shorten the length of the impaling obj ect prior
to evacuating the patient. Due to possible
damage to underlying tissues, any manipula­
tion of the object should be done with minimal
movement.

13-15. Evacuate the Patient.

a. Check the patient's pulse distal to the injury site.

13-13
FM 8-230

NOTE

If indications of shock are noted, follow the

procedure for treating hypovolemic shock.
This procedure may be used for all impalement
injuries.

b. Record the treatment given.

c. Evacuate the patient immediately.

Section IV. HEAD, FACE, NECK, AND SPINE INJURIES

13-16. General

a. With the exception of fractures of the arms or legs, injuries to the

head, face, neck,, and spine are among the most common you will see. There is a
wide range of injuries that can occur in these areas, from minor maxillofacial
abrasions to massive trauma injuries. This section describes these injuries in
detail and provides definitive treatment procedures.

b. The head consists of two maj or structures: the skull and the brain.

( 1 ) Skull. The skull is essentially a hollow structure. On the

outside are the musculature (muscle structures), skin, and appendages of the
face and scalp. The scalp and facial structures are attached to the bones of the
skull by means of a thin, tough, fibrous sheath, the periosteum. Within the
face are the structures of the mouth, nose, and pharynx. The largest hollow of
the skull, the cranium, contains the brain. The cranium completely envelops
the brain except for a hole at the base of the skull through which the spinal
cord connects with the brain. Cranial nerves and blood vessels pass through
small holes in the cranium that are sealed by the cranial lining.

(2) Brain. The brain is the primary organ of life and the chief
component of the central nervous system (CNS) ( see Chapter 7). It is protected
from injury by three separate mechanisms: the skull, the meninges, and the
cerebrospinal fluid (CSF). The CNS consists of the brain, the spinal cord, and
peripheral nerves that control all activities of the body. The brain directly
controls the functions of the eyes, ears, face, heart, and respiratory apparatus
by means of electrical charges that pass between these structures and the
control centers in the brain by the cranial nerves. Interference with these
control centers results in erratic behavior or cessation of function in the organs
and structures they control. Brain cells do not regenerate. Once a brain cell is
qestroyed, it cannot be replaced by a new brain cell. Scar tissue takes its place,
but not its function, which is lost forever. The brain lies very close to but not
directly against the bones of the cranium. It is separated from the cranium by
the meninges and fluid. The outer surface of the brain is intimately covered by
one of the meningeal membranes, the pia mater, which contains many small
blood vessels. The cranium is lined intimately with the dura mater (a tough,
fibrous, relatively thick meningeal membrane). Between the dura and the pia is
a thin subdural space, which contains a little fluid, the delicate net-like
arachnoid membrane, and the subarachnoid space filled with cerebrospinal
fluid. This fluid, which is clear, salty, and very watery, bathes the outer and
certain inner surfaces of the brain and the spinal cord.

13-14
 FM 8-230

13-17. Classification of Head Injuries

Head injuries discussed in this section are limited to those involving the scalp,
cranium, and its contents. Head inj uries are divided into two main classes,
open and closed. (Facial and pharyngeal inj uries are discussed in paragraphs
1 3-22 through 1 3-25).

a. Closed Injuries. No obvious external damage except for a possible

bruise or contusion is present. Injury may be to the brain itself, the pia, or the
arachnoid meninges (Figure 1 3-9). Ruptured blood vessels of the pia are
particularly important in closed injuries. Blood spilled onto brain cells is a
foreign substance and disturbs the functions of these tissues. Blood collecting
within the cranium exerts pressure against the brain when there is no fracture
to the skull, or the skull fracture is such that the integrity of the dura is not
disturbed. If the skull is depressed (displaced inwardly), it may exert direct
pressure on the brain even without formation of a hematoma (blood pool).

SUTURE

NASAL
BONE

SPINAL
CORD
(SEGMENT)

Figure 13-9. View of left side of brain with left side

of skull and the mandible removed.

13-15
FM 8-230

b. Open Wound. In an open wound there is obvious external damage.

Open wounds of the head are subclassified according to whether or not the
integrity of the dura is disturbed.

(I) Nonperforated dura mater. The wound may only be a

laceration of the scalp which, although not to be taken lightly, may not be
serious. Also, there may be one or more fractures of the skull without the dura
being perforated. In either case, internal damage is likely to be or become more
serious than that of the scalp and skull. If the skull is fractured, it will hold in
the same manner as a closed injury against pressure of any hemorrhage that
occurs within the cranium.

(2) Perforated dura mater. The skull is fractured in such a way

that it is no longer a closed vault (part of it may be torn away) and the dura is
open with the meninges exposed to the open air. In some cases, the delicate
meninges are opened with the brain itself exposed or extruding through the
opening.

13-18. Assessment of Head Injuries

All head injuries are potentially dangerous, not only because of the immediate
tissue damage and increased susceptibility to infection, but also because of the
probability that some vital area or special sense is or will become involved. For
these reasons, all signs and symptoms referable to the nervous system must
be carefully noted including the time of their occurrence or observation.

a. State of Consciousness. A notation of the state or states of

consciousness observed in the patient will greatly assist the physician who
treats the patient later. The following descriptive terms should be used, as
appropriate, to define the state of consciousness observed.

• Conscious. Patient is alert and oriented in time and space.

• Confused. Patient is alert but disoriented and excited; he can

take fluids by mouth. The disorientation and excitement may be temporary
and have a psychological basis in addition to, or instead of, brain injury.

• Semicomatose (semiconscious). Patient responds to any

applied stimulus; he cannot be given fluids by mouth. The patient displays
unnatural drowsiness (somnolence)

• Comatose (unconscious). Patient does not respond to any

applied stimulus; he cannot be given fluids by mouth.

b. Pupil Size. Normally, pupils of the eyes become very small in the
presence of strong light and dilate (become larger) as the light fades. Dilation
in the presence of strong light indicates central nervous system impairment.
Normally, the pupils are also matched in size. When neither eye is obviously
injured and the pupils are of unequal size, brain impairment is assumed.

c. Muscles. The musculature on one or both sides of the face may

droop due to a lack of brain stimulation. There may be a loss of speech or an
impairment to speech. Paralysis and a lack of firmness in the muscle mass of
any part of the body without damage in that part, or no evidence of spinal cord
damage, is an indication of impairment in the brain area that controls those
muscles.

13-16
 FM 8-230

d. Vital Signs. The vital signs (temperature, pulse, blood pressure,

and respiration) are important when treating head injuries. Changes in the
vital signs frequently indicate the onset of complications. It is important to
recheck and record vital signs frequently. Be especially alert for changes in
pulse and blood pressure. Rising blood pressure with a slow pulse indicates
increased intracranial pressure. Falling blood pressure with a rapid pulse
indicates shock.

13-19. Symptoms of Closed Head Injuries

a. Headache, nausea, dizziness, and loss of consciousness (which may

be brief, intermittent, or extended) may accompany a closed head injury. If the
injury is from an impact with a blunt surface, an elevated contusion (bruise)
forms when blood and other fluids collect in the subcutaneous tissue between
the dermis and the skull; there may be a fracture of the skull if the skull is
displaced inwardly. Many skull fractures can only be diagnosed by x-ray.
However, there are several important signs to look for if a skull fracture is
suspected. These signs are-

• Deformity, a depression or instability in a part of the skull.

• CSF leakage from the nose, an ear, or a scalp wound.

• Blood oozing from the nose or an ear.

• Ecchymosis (bruising) behind the ear(s) (Battle's sign).

• Ecchymosis in the soft tissue under the eyes ("Raccoon" or

black eyes).

b. In more severe injuries, vomiting and paralysis of muscle groups

may occur. The patient may bleed from the nose, mouth, or ears in the absence
of obvious injury to these parts. CSF coming from the nose or ears indicates a
serious injury. The CSF becomes cloudy when mixed with blood. Signs of
increasing intracranial pressure include-

• Elevated blood pressure.

• Elevated pulse pressure (distance between diastolic and

systolic blood pressure).

• Slow pulse.

• Restlessness.

• Dilation of one or both pupils.

• Decreased respiration.

• Cyanosis.

• Delirium or irritability.

• Paralysis.

13-17
FM 8-230

13-20. Symptoms of Open Head Wounds

The patient may be either conscious or unconscious. Signs of intracranial

pressure and internal damage, if any, are the same as for a closed injury.

a. Lacerations. Lacerations of the scalp bleed profusely because the

blood vessels, which are quite numerous, do not constrict and retract as do
those of other body areas. Scalp lacerations tend to remain open because the
scalp, when intact, envelops the skull very tightly.

b. Skull Fracture. The skull may be misshapen, yielding, or minus

parts or pieces. The most severe open head wound is a skull fracture in which
the brain tissue is exposed through the skull or extruded through the bone
fragments and lacerated scalp. Another type of skull fracture is caused by
penetrating objects. I f the object is protruding, no attempt should be made to
remove it. The protruding end of an impaled object may have to be cut off to
transport the casualty.

13-21. Treatment for Head Wounds

a. Open the Airway. Clear the air passage of any vomitus, mucus, or
debris as necessary; place the patient in the coma position (Figure 1 3-10); turn
the semicomatose or comatose patient from one side to the other every 20
minutes. As the patient's condition stabilizes, turning him every hour may be
sufficient. Always protect the cervical spine. Patients with injuries above the
clavicle are considered to have a cervical spine injury until proven otherwise.

NOTE

Maintaining an open airway is usually not a

problem for patients who have only scalp
lacerations; the first consideration with these
.Patients is to control the profuse bleeding.

Figure 13-10. Coma position.

13-18
 FM 8-230

b. Control Bleeding and Protect the Wound. Do not remove or

disturb any foreign material which may be in the wound; leave any protruding
brain tissue as it is. Apply the dressing over this tissue.

(1) Use a sterile pressure dressing.

• Place the dressing over the wound (Figure 1 3-1 1),

allowing the tails to fully unfold and hang along the side of the patient's
cheeks.
• Grasp one tail, wrap it under the chin, up over the head
covering the dressing, and down the opposite side of the head to the level of
the patient's eyes (Figure 13-1 2).

Figure 13-11. Sterile Figure 13-12. Tails

dressing over the wrapped around chin
wound. and head.

• Grasp the other tail, wrap it under the chin in the

opposite direction and bring it up the side of the head, meeting the first tail at
the level of the patient's eye.

• Cross the tails, wrap one tail around the back of the
patient's head to the opposite ear. Wrap the other tail around the patient's
forehead until it meets the first tail (Figure 13-13).

• Tie the tails over the crossings of the two directional

wrappings (Figure 1 3-14).

NOTE

If blood seeps through the initial dressing, do

not disturb the dressing. Apply a second
dressing over it. This will help reinforce the
primary dressing as well as aid in the clotting
process for controlling the bleeding.

13-19
FM 8-230

Figure 13-13. Tails crossed Figure 13-14. Tied dressing.

around the patient's head.

(2) Use a cravat and 4 by 4 inch gauze pads.

• If a field dressing is not available, place several 4 by 4

inch gauze pads over the wound site.

• Unfold one cravat (triangular bandage) completely.

• Place the cravat over the patient's head with the base
(longest side) hanging over his eyes, and the tips hanging over the back of the
neck (Figure 1 3-15).

• Fold the base upward along the creases by grasping both

ends of the base and turning them upward until the patient's eyes and ears are
uncovered.

• Wrap both tails around the head in opposite directions

(Figure 1 3-1 6).

• Tie the tails at the side of the head (Figure 1 3-1 7).

• Tuck the third tip of the cravat under the band formed by
the long tails at the back of the head. This is to hold the cravat snugly over the
top of the head (Figure 1 3-18).

NOTE

If there is an injury or suspected injury to

the cervical spine, the head must be
immobilized before the patient is turned.
The head must be maintained in a stable
position.

13-20
 FM 8-230

CEN T E R OF BASE

END APEX

Figure 13-15. Cravat placed over Figure 13-16. Cravat wrapped

head. around the head.

EN DS APEX

APEX SA F E TY P I N

Figure 13-1 7. Cravat tied around Figure 13-18. Cravat tucked in on

the head. back of head.

c. Prevent or Treat for Shock. Apply measures for prevention or

treatment of shock with the following exceptions:

(1) Do not use the head-down position.

(2) DO NOT GIVE MORPHINE. Morphine (a depressant)

affects respiration, increases intracranial pressure, and decreases the patient's
level of consciousness.

(3) Do not give fluids by mouth. Initiate a large bore IV at a

"keep open" rate, using dextrose, 5 percent, in water (D5W).

CAUTION

Administering an IV at faster than keep

open rate risks over-hydration that
increases intracranial pressure.

d. Record Treatment Given.

e. Evacuate the Patient.

13-21
FM 8-230

13-22. Face Wounds

The face is very richly supplied with blood vessels. Therefore, injuries to the
face are likely to have profuse bleeding or bruising. Hemorrhage is difficult to
control. Because facial injuries may tend to be quite disfiguring, the medical
specialist may apply dressings to these wounds first, forgetting the priorities
of treatment. Facial wounds are life-threatening only when the airway is
obstructed or there is massive bleeding.

13-23. Treatment for Facial Wounds

a. The most immediate concern in treating a person with facial

wounds is to insure an adequate airway. Clear the mouth of blood, mucous,
broken teeth, detached bone fragments, removable dentures, and other foreign
material. I f the patient is unconscious, the base of the tongue may rest against
the back of the throat and block off the pharynx. This type of obstruction is
easily relieved by using manual maneuvers to open the airway. Any force
strong enough to produce severe facial injuries may have produced cervical
spine injuries as well. Thus, when opening the airway, avoid hyperextension of
the neck. The jaw thrust is the preferred technique when there is any suspicion
of a cervical spine injury. If necessary, apply digital pressure to control
bleeding while clearing the airway.

b. Place the patient in a comfortable sitting position. Tilt his head

slightly forward to drain blood or mucous out of the mouth. Do not use the
sitting position if-

• It would be harmful to the patient because of other injuries.

• The patient is unconscious, in which case, place him in the

coma position. If there is a suspected injury to the cervical spine, immobilize
the head before turning the patient on his side.

c. Apply a sterile dressing to the wound.

( 1 ) Apply a sterile dressing using local pressure to help control

the bleeding (Figure 1 3-19). The conscious patient or an assistant can hold the
dressing in place.

NOTE

A laceration may extend through the cheek

into the mouth with an obj ect protruding from
the inj ury. Remove the object before
attempting to control the bleeding. This is the
only time that an impaled object can be
removed outside an MTF.

13-22
 FM 8-230

(2) If the patient or an assistant cannot hold the dressing in

place, use one hand to maintain pressure on the dressing over the wound.
Wrap the upper tail over the head and under the chin and hold in place over the
wound.

(3) Wrap the other tail under the chin and over the head in the
opposite direction from the first tail (Figure 1 3-20).

Figure 13-19. Dressing

over the face injury. Figure 13-20. Wrapping
the tails.

(4) Cross the tails over the ear on the dressing side of the head
(Figure 1 3-21).

(5) Wrap the tails in opposite directions around the forehead and
the back of the head.

(6) Tie the tails over the temple area above the ear on the
uninjured side (Figure 1 3-22).

Figure 13-21. Crossing Figure 13-22. Tails tied

the tails. opposite the injury.

13-23
FM 8-230

CAUTION

Do not tie the dressing so tight that it prevents

drainage from the mouth.

d. Secure the dressing with a cravat bandage.

(1) Fold the cravat to 3 inches in width.

(2) Place the cravat over the dressing. Wrap one end over the
head and the other end under the chin.

(3) Cross the end above the ear on the opposite side from the
wound.

(4) Wrap one end around the back of the head and the other end
around the forehead.

(5) Tie the ends above the ear on the injured side.

13-24. Neck Injuries

The neck is the most vital and vulnerable part of the body anatomy. The
airway, the blood supply to the brain, and the nerve supply to the whole body
below the head passes through the neck. Injuries to the neck have enormous
potential for lasting damage. Hemorrhage from a neck wound, unless attended
to immediately, can rapidly become fatal. Major concern in emergency
treatment of patients with neck wounds, other than those involving the spinal
column, is keeping the airway open. The airway may be obstructed by blood,
mucous, edema fluid, plasma (if the throat is burned), and broken parts of the
trachea and larynx. Clearing the mouth (not the pharynx) with the fingers,
together with postural drainage in the coma position may be successful. If not,
an emergency surgical airway must be performed promptly by the most
experienced medical person available.

13-25. Treatment for Neck Injuries

a. Place a sterile dressing over the injury.

• Pass the tails upward over the head on opposite sides and tie
the knot on top of the head, 0R

• Pass the tails around the chest and back downward under the
opposite armpit and tie the tails under the arm.

• NEVER pass the tails around the neck, to avoid pressure on

the trachea.

b. Prevent or treat for shock with the following exceptions:

• DO NOT use the head-down position.

• DO NOT give morphine.

13-24
 FM 8-230

c. Check for signs of closed head injuries.

d. Record treatment given.

e. Evacuate the patient.

13-26. Neck Fractures

a. The cervical vertebrae (skeleton) of the neck consists of the upper

seven vertebrae of the spine. The greatest danger in a neck fracture is damage
to the spinal cord, which can cause permanent paralysis. The nerves that
control the diaphragm are located in the cervical spine. Injury to this area can
cause respiratory difficulty and/or arrest.

b. Extreme care must be taken when moving an individual with a

neck fracture. The injured vertebrae must be immobilized and maintained in
its normal alignment parallel to the spine. Movement of the injured vertebrae
can cause spinal cord damage (compression of the spinal cord) or the spinal
cord may be severed by the movement, causing disastrous results.

13-27. Signs and Symptoms of Neck Fractures

a. Ask the patient about his injury:

• Does he have tingling or numbness in his upper extremities?

• How did he receive the injury (auto accident, fall from a high
place, dive into shallow water)?

• If the patient is unconscious, question others that may have

witnessed the accident.

• Palpate for tenderness or deformities by inserting your hand

under the patient's neck without moving his head. Gently feel the area of the
back of the neck.

• If the patient has pain or increased pain when pressure is

applied to the back of his neck, treat him as having a neck injury. If he has
pain in the shoulder region without signs of shoulder injury accompanied by
pain in the neck, treat him as a neck injury patient.

b. Caution the patient not to move. Explain to the patient that

movement may increase the severity of his injury. Do not frighten him, but
insure that he understands the seriousness of his injury.

13-28. Treatment for Neck Fractures

a. Immobilize the injury.

(1) If the patient is lying on his back, leave him in this position.
If he is face down and has other injuries, or cannot breathe, request assistance
in turning him over.

13-25
FM 8-230

(2) To move the patient before splinting, grasp his head with
your hands and apply gentle traction to maintain the head in alignment while
others move or turn him (Figure 13-23).

Figure 13-23. Turning patient on his back.

b. Apply a cervical collar to the neck.

NOTE

An improvised "collar" can be made from

various materials (folded towel, T-shirt, field
jacket, or other flexible material that will
provide support).

(1) Gently slide one end of the collar under the neck (Figure
1 3-24).
(2) Wrap the collar around the neck. Be careful not to move the
head or neck.

(3) Fasten the collar in place with tape, safety pins, or a cravat
(Figure 1 3-25).

(4) Check the collar for tightness. If the skin at the temples
shows signs of swelling, or if breathing is impaired, you must adjust the collar
so that it is snug but does not fit too tightly.

c. With assistance, move the patient onto a spine board or another

board that is at least 4 inches longer than the patient's height (Figure 1 3-26).

13-26
 FM 8-230

Figure 13-24. Collar under the Figure 13-25. Collar fas tened in place.
patient 's neck.

Figure 13-26. Placing patient on board.

CAUTION

Do not attempt to move the patient onto the

board without assistance.

d. Place a padded object on each side of the patient's head. To

prevent movement, tie his head and the padding to the board.

e. Place the patient and the board on a litter (Figure 1 3-27).

NOTE

If a board is not available, the patient's head

can be immobilized by using padded material
and tying his head to the litter.

f. Record the treatment given.

g. Evacuate the patient.

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FM 8-230

Figure 13-27. Patient with padded head on board and litter.

13-29. Spinal Injuries

a. The spinal column is composed of 33 bones or vertebrae. The upper

24 bones are separated by cartilage disks, the 5 bones of the sacrum form part
of the pelvis, and the remaining 4 bones comprise the coccyx.

b. The spinal column encases the spinal cord. If a vertebrae or disk is

fractured or dislocated, the spinal cord may be injured. Injuries to the spinal
cord can cause paralysis below the point of injury. All patients with known or
suspected spinal injuries must be immobilized before movement.

13-30. Signs and Symptoms of a Spinal Injury

a. Ask the patient if he has any pain, numbness, or tingling. Ask

bystanders about the cause of the injury if the patient is unconscious.
Determine numbness by gently pinching or pricking the injured area. The
patient may not be able to move or may not experience sensation in parts of
the body below the injury.

NOTE

An unconscious patient involved in a situation

in which a spinal injury is suspected should be
treated as if he has a spinal injury.

CAUTION

Do NOT permit any motion of the spine if a

spinal injury is suspected.

13-28
 FM 8-230

b. Gently palpate along the spine for tenderness or deformity. Watch

the patient's reaction for signs of tenderness. Local tenderness over a portion
of the spine may indicate a spinal injury and the patient should be treated
accordingly.

13-31. Treatment for Spinal Injuries

a. Caution the patient not to move. The patient must not move until
the injury has been immobilized. The spinal cord must be protected from
damage when the patient is moved. The head and neck must be maintained in a
stable, neutral position; extension or flexion may cause the spinal cord to be
compressed disastrously and paralysis can result. If the neck is hyperextended
(the head falls backward), posterior compression of the spinal cord by
fractured vertebrae can occur. If the neck is flexed (the head falls forward),
anterior compression of the spinal cord by fractured vertebrae can occur.

NOTE

A patient with pain in his shoulder without

any sign of injury and accompanied by pain of
the neck indicates a spinal injury.

(1) I f the patient is lying face up, immobilize him in that

position.

(2) If he is face down and has no other serious injuries or cannot

breathe properly, request assistance to turn him onto his back.

(3) If the patient must be moved before splinting, you must

maintain gentle traction of the head while moving him. To maintain traction,
kneel at the patient's head, place your hands on each side of his head and j aws,
and pull back slightly to immobilize his head and neck (Figure 1 3-28). Keep the
direction of pull in a direct line with his spinal column.

Figure 13-28. Maintaining traction.

13-29
FM 8-230

(4) Gently slide the cervical collar under the neck. Wrap the
collar around the neck and secure it in place.

(5) Place the patient on a spine board.

(6) Place the patient and spine board on a litter.

(7) Record treatment.

(8) Evacuate the patient.

b. Apply a short spine board before extracting a patient from a

vehicle.

( 1 ) Two rescuers are required. No. 2 man pushes the board as far
down into the seat as possible behind the patient while No. 1 man maintains
traction on the patient's head (Figure 1 3-29). It may be necessary to move the
patient slightly forward if the back of the seat has a pronounced curve.

Figure 13-29. Maintaining traction on a sitting

patient 's cervical spine.

NOTE

It may be easier to insert the head end of the

board into the vehicle first, especially if the
vehicle has a low roof. This way, there will not
be a need to maneuver the board around the
patient.

(2) No. 2 man places a cervical collar or a neck roll in the hollow
space between the patient's neck and the board. The collar or neck roll serves
to fill the gap between the patient's neck and the board. The neck roll should
only be large enough to fill the gap; not to exert pressure on the neck.

13-30
 FM 8-230

(3) No. 1 man maintains traction on the patient's head. No. 2

man secures the patient's head to the board by using a cravat, head straps, or
other cloth strips. Pass the cravat downward diagonally across the patient's
forehead, and tie it securely to the head portion of the board.

CAUTION

The patient's head must be firmly secured in

place before the No. 1 man releases the
traction.

(4) Secure the patient to the spine board (Figure 1 3-30) by-

• Placing the buckle of the first strap on the patient's lap.

• Passing the other end through the lower hole in the

board; up the back of the board; through the top hole; under the armpit; over
the shoulder; and across the back of the board at the neck.

• Buckling the second strap to the first one.

• Placing the buckle on the side of the spine board at the

neck.

• Passing the other end of the strap across the shoulder;

under the opposite armpit; through the top hole in the board; down the back of
the board; through the lower hole; and across the lap.

• Securing the end to the first strap by buckling.

Figure 13-30. Patient secured to short

spine board.

13-31
FM 8-230

(5) Tie the patient's hands together and place them on his lap to
keep the arms from moving.

(6) No. 1 man pivots the patient in the seat with his back facing
the opened vehicle door, by grasping his upper body. No. 2 man remains in the
vehicle, grasping the patient's legs, lifting them onto the seat and pivoting the
patient in unison with the No. 1 man.

CAUTION

Do not grasp the short board to move the

patient. Pressure of lifting should be applied
under the patient's arms and legs. Using the
short board to lift the patient will cause
excessive pressure on his neck and spine.

(7) No. 1 man slides a long board in perpendicular to the

patient's back, with the end against his buttocks.

(8) No. 2 man exits the vehicle and positions himself opposite
the No. 1 man. Together, they lay the patient down horizontally on the long
spine board.

(9) Move the patient from the vehicle by grasping the sides of
the long board.

( 10) Line up the holes of the short board with the holes of the long
board and tie the boards together.

c. Place a patient that is not in a vehicle on a long spine board.

( 1 ) Obtain a long board; seek the assistance of at least three

other individuals and explain the procedure to them.

(2) Prepare the spine board.

• Place the spine board in position near the patient.

• Insure that all necessary equipment is ready.

• Have pads available for padding the spine board in the

areas of the natural curve of the neck and small area of the back (Figure 13-3 1).

NOTE

I f a spine board is not available, use a standard

litter or improvise one from a board or door. A
hard surface is more suitable than one that
does not support the patient' s weight. If the
injured patient is in a face-down position,
transport him in that position.

13-32
 FM 8-230

FRACTURE

Figure 13-31. Padding of neck and small of back.

(3) Instruct the patient not to move or attempt to assist in

placing his body on the spine board.

(4) Loosely tie the patient's wrists together at his waist. This
prevents the arms from moving while he is being placed on the spine board.

(5) Use the log-roll technique to place the patient on the spine
board.

(a) Place the spine board parallel to the patient's body.

(b) Kneel at the patient's head, place your hands on each

side of his head and jaws, and pull back slightly to immobilize the head and
neck.

(c) Instruct the three assistants to kneel on either side of

the patient and place their hands on the opposite side at his shoulder and
waist, hip and thigh, knee and ankle.

(d) On your command, have the assistants, in unison, roll

the patient's body slightly toward them while you turn his head, keeping it
parallel with the spine.

(e) Instruct assistant #3 to reach across the patient's body

with one hand, grasp the board at the closest edge, and slide the board against
the patient. With the same hand, assistant #3 then reaches across the board to
the far edge and holds the board in place.

(f) Instruct all assistants to slowly roll the patient

backwards onto the board, keeping his head and spine in a straight line.
NOTE

All assistants should kneel on the same knee

and utilize their own thighs to help support the
patient.

13-33
FM 8-230

(g) If the patient is in the face-down position, the spine

board is still placed on the opposite side of the patient away from the
assistants. Roll the patient away from the assistants (toward the board) using
the same technique as above.

OR

(6) Use the straddle-slide technique to place a patient on the

spine board.

(a) Place the spine board at the patient's head in alignment

(parallel) with his body.

(b) Stand at the patient's head with your feet on each side
of the spine board. Place your hands on each side of his head and j aws. Apply
slight traction to immobilize the head and neck.

(c) Instruct one assistant to straddle the patient while

facing you and gently elevate the patient's shoulders j ust enough to permit
the spine board to slide under them.

CAUTION

Do NOT bend or flex the spine or neck.

(d) Instruct assistant 112 to straddle the patient while

facing you and carefully elevate his hips.

(e) Instruct assistant Ii 3 to stand behind the spine board

and gently slide it under the patient.

(f) Instruct assistant 113 to move the patient's feet and

straddle his legs. Carefully elevate the legs and ankles while sliding the board
completely under the patient.

(7 ) Secure the patient to the spine board.

(a) Secure the patient's forehead with a cravat.

(b) Secure the patient with straps across his chest (include
the arms if the strap is long enough), hips, thighs, and lower legs (Figure
1 3-32).

d. Record the treatment given.

e. Evacuate the patient.

13-34
 FM 8-230

Figure 13-32. Patient secured to a spine board.

Section V. ORTHOPEDIC INJURIES

13-32. General

ThEi evaluation of a patient with possible musculoskeletal damage requires

determining the cause of the injury; obtaining an accurate patient history; and
giving a thorough examination. Take note of the patient in relation to the
environment (possible mechanisms of injury). Ask the patient to identify the
areas of pain and to move each extremity.

a. Types and Causes of Injuries. Orthopedic injuries are the result of

a variety of causes. Types of injuries and causes include-

• Direct injuries (a broken bone at the point of impact with a

solid object, such as a j eep bumper).

• Indirect injuries (a fracture or a dislocation at some distance

along the bone from the point of impact, such as a hip fracture caused by the
knees slamming into a solid object).

• Twisting injuries (fractures, sprains, and dislocations that

occur when there is torsion of the j oint while the end of the limb remains fixed).

• Powerful muscle contractions (muscle tom from the bone or

muscle breaking away a piece of the bone; occurs in seizures or tetanus).

• Fatigue fractures (caused by repeated stress). These most

commonly occur in the feet after prolonged marching ( stress fractures ).

13-35
FM 8-230

• Pathologic fractures (occur in patients with diseases such as

cancer that weaken areas of bones). A fracture may occur with minimal force.
The elderly have more brittle bones and are more prone to pathologic
fractures.

b. Patient His tory. Most patients with musculoskeletal injuries will

complain of pain. Usually the pain is well localized to the area of injury.
Sometimes the patient with a fracture will report having felt something snap.
Try to determine how the injury occurred. For example, for a twisted ankle,
did the injury occur with the ankle bent outward (everted) or bent inward
(inverted)? Does the patient have any serious illnesses, such as cancer, that
might account for an otherwise unexplained fracture.

c. Examination. With rare exceptions, orthopedic injuries are not life

threatening. In the patient with multiple injuries, fractures may be the most
obvious and dramatic, but may not be the most serious. Therefore, you should
do a primary survey and treat any life-threatening conditions first.
Management of orthopedic injuries fit well in the secondary survey.

• Look. Swelling and black-and-blue marks indicate the escape

of blood into the tissues (extravasation). Shortening or angulation between the
joints, deformity or angulation in unusual direction around the j oints, and
internal or external rotation when compared with the opposite extremity
indicate a bone defect. Lacerations or puncture wounds near the site of a bone
fracture are open fractures.

• Listen. Crackling sounds (crepitation) can be heard with a

stethoscope or felt with palpating fingers. The sounds are produced when the
broken bone ends rub together. Do NOT attempt to move the injured area to
evaluate this sign. Percussion over a bony protuberance while listening with a
stethoscope on another bony prominence distal to a fracture will produce a
sound different from the sound produced on an uninjured bone.

• Feel. Palpation along the length of the bone can help detect
deformities, bony protuberances, or angulation that is not seen.

• Check. Pulse and neurological sensation should always be

evaluated distal to the fracture before and after application of splints. In the
arm, you should test the radial and ulnar arteries; in the leg, the dorsalis pedis
and posterior tibial arteries (Figure 1 3-33). If there is not a distal pulse, two or
three gentle manipulations of the extremity should be carried out to try to
restore the blood flow. Do not make prolonged attempts; the loss of blood may
be due to actual vascular injury or to preexisting hardening of the arteries
(arteriosclerosis) rather than simple compressions.

• Evaluate. A neurological evaluation of both motor and

sensory functions should be made. For example, when checking an arm, are the
nerves intact and can the hand demonstrate intact sensory nerves by both
sensation and finger movements?

13-36
 FM 8-230

DORSAL I S POSTERIOR
PEDIS -_.,.�-1 TIBIAL

Figure 13-33. Distal pulses locations. .

• Palpate all bones. When doing the secondary survey, palpate

and manipulate every bone in the body to determine the extent of the injury.
The only exception to the manipulation is with possible spinal column injuries.
Some bones, such as the ribs and the pelvis, can be palpated by applying direct
pressure. EXAMPLE: For pelvis injuries, apply bilateral pressure on the
anterior iliac spines to elicit pain. Pressure over the symphysis pubis will also
flex the pelvic ring to detect any existing fractures.

• Treat as fracture. It is difficult to distinguish between

fractures and sprains without x-ray. If there is a question, immobilize and
treat the injury as if it were a fracture. The pain produced by a fracture will
cause muscle spasms. The patient will guard or not move the fractured bone at
all. Fractures do not produce paralysis. Only nerve damage produces
paralysis. The pain may be so great, however, that the patient does not
voluntarily move the bone or its muscular attachment.

13-33. Management of Orthopedic Injuries

a. The signs and symptoms of orthopedic injuries-fractures,

dislocations, and sprains are given in Table 13-2.

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FM 8-230

Table 13-2. Orthopedic Injuries: Signs and Symptoms.

Fracture Dislocation Snrain

Pain, tenderness. Pain. Pain, tenderness.

Deformity or shortening. Deformity. No deformity.

Loss of use. Loss of movement. Painful movement.

Swelling. Swelling. Swelling.

Ecchymosis. Ecchymosis. Redness.

Grating. Located at j oint.

Guarding.

Exposed bone ends.

• Fractures.

o A fracture is a break in a bone. It may either be closed

(skin is intact) or open (there is a wound over the fracture site). In an open
fracture, the bone may or may not be protruding through the wound. Open
fractures are more serious than closed fractures because the risks of
contamination and infection are greater. A transverse fracture cuts across the
bone at right angles to its long axis and is often caused by direct injury. The
greenstick fracture is an incomplete fracture that commonly occurs in young
individuals whose bones (like green sticks) are still pliable. Spiral fractures
result from twisting injuries; the fracture line has the appearance of a spring.
The fracture line of an oblique fracture crosses the bone at an oblique angle, or
in a slanting direction. In impacted fractures, the broken ends of the bone are
j ammed together and may function as if no fracture is present. A comminuted
fracture is one in which the bone is fragmented into more than two pieces
(splintered or crushed) (Figure 1 3-34).

Figure 13-34. Common fractures.

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 FM 8-230

o Fractures, even open fractures, seldom present an

immediate threat to life. Their treatment should be deferred until life­
threatening conditions have been treated, such as establishing an airway and
controlling hemorrhage. A tourniquet is seldom necessary in treating an open
fracture, even when a limb has been mangled beyond all possibility of salvage.
Only after treating all life-threatening conditions should you identify and
immobilize fractures.

o Immobilization is accomplished by splinting which-

• Prevents a closed fracture from becoming an open

one.

• Prevents damage to surrounding nerves, blood

vessels, and other tissues by the broken bone ends.

• Lessens bleeding and swelling.

• Decreases pain.

• Dislocations.

o A dislocation is the displacement of a bone end from its

articular surface. Sometimes ligaments that hold the bone end in place are also
torn. The shoulder, elbow, fingers, hips, and ankles are the j oints most
frequently affected.

o Symptoms of a dislocation are either pain or a feeling

of pressure over the involved j oint and a loss of motion. The sign of a
dislocation is deformity. If the dislocated bone end is pressing on nerves or
blood vessels, there may also be a compromise of other functions, such as
numbness or paralysis below the dislocation. When dealing with a dislocation,
always check the pulse, strength, and sensation distal to the injury. The
treatment for a dislocation is to immobilize the involved part in the position in
which it is found. Do not straighten or attempt reduction. If there is not a
distal pulse in the involved extremity and it cannot be restored by gentle
manipulation, transport the patient to an MTF promptly.

• Sprains. Sprains are injuries in which ligaments are

partially torn. Sprains occur when a j oint is suddently twisted beyond its
normal range of motion. Sprains most commonly affect the knees and ankles
and are characterized by pain, swelling, and discoloration over the injured
j oint. Unlike fractures and dislocations, sprains usually do not show a
deformity. However, treat the sprain as if it were a fracture and immobilize it.
Elevate the sprained j oint and apply an ice compress, if available.

• Strains. Strains are soft-tissue injuries or muscle spasms

around a j oint and are characterized by pain on movement. There is no
deformity or swelling associated with a strain. Strains are best treated by
avoiding weight-bearing on the injured area. If there is doubt as to the nature
of the injury, immobilize the extremity.

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FM 8-230

13-34. General Principles of Splinting and Immobilization

In the treatment of musculoskeletal injuries, remember the following

principles:

• Severely angulated fractures of long bones should be

straightened before splinting. Explain to the patient that straightening the
fracture may cause momentary pain, but that it will lessen significantly once
the fracture is straightened and splinted. Any overlying clothing should be cut
away.

• Do NOT straighten dislocations and fractures involving the

spine, shoulder, elbow, wrist, or knee.

• The adage "splint them as they lie" should be changed to

"immobilize them where they lie. " Splinting may well be accomplished after
extrication. If a pulse is absent, splinting may necessitate manipulation of the
fracture to its normal position.

• In open (compound) fractures, do not attempt to push bone

ends back beneath the skin surface. Simply cover them with a sterile dressing.

• Immobilize j oints above and below the fracture (at the wrist
and elbow for fractures of the radius and ulna).

• Splinting should be done firmly, but not so tightly as to

occlude circulation. Check distal pulse after the splint is in place to be certain
that the circulation is still adequate. If the pulse disappears, the splint should
be loosened enough to permit its return. If used, air splints or MAST should be
checked and rechecked to make certain that they are not overinflated. The
ankle hitch on a traction splint should be inspe..:ted so that it is not applied too
tightly across the foot; all areas of contact should be padded. The proximal end
of a lower extremity splint should not press against the groin. Board splints
should be long enough, well padded, and well secured to uninjured parts of the
body.

• For fractures above the knee or about the hip, a traction splint
is best (Thomas half ring or Hare traction). Such fractures can be managed by
supporting the extremity with the hip and knee in slight flexion and the
extremity stabilized by strapping it to the uninj ured leg. MAST can splint
both hips and knee j oints.

• For massive trauma to the lower extremities, MAST can be

used as a splint and will also help stop bleeding (see paragraph 1 3- 59 for
MAST application).

• All fractures should be immobilized before moving the

patient.

• Fractures of the tibia or fibula can be managed with traction,

wooden, or wire ladder splints. Whichever splint is used, the knee must also be
immobilized. MAST should not be used for below-the-knee fractures.

• When other materials are not available, the long spine board
can be used to manage almost any fracture.

13-40
 FM 8-230

• An upper extremity fracture can usually be immobilized

against the chest.

• The fingers and toes should be exposed even though they are
included within a splint.

13-35. Types of Splints

Any device used to immobilize a dislocation or fracture is considered a splint.

There are several specific types: rigid, soft, and traction.

a. Rigid.

( 1 ) A rigid splint consists of a firm material, either rigid or

slightly flexible. It is applied along the sides, front, or back of the injured
extremity. When applied, it will prevent motion of the extremity. Examples of
rigid splints include padded wood, such as bass wood, tree limbs, or branches,
metal or stiff plastic, wire ladder, and folded cardboard. The splint must
immobilize both the joint above and below the fracture site.

(2) To apply a rigid splint, the extremity is grasped by one

individual below the fracture site and gentle traction is applied. A second
individual then places the padded splint on the injured extremity and secures
it above and below the fracture site (Figure 1 3-35). Keep the toes and/or fingers
exposed to insure distal circulation.

Figure 13-35. Rigid splint applied.

b. Soft Splints.

( 1 ) An example of soft splints are the air splints (Figure 1 3-36),

which are simple double-walled tubes made of heavy-duty clear plastic. These
splints come in various shapes and sizes, some with zippers and some wit}:iout.

13-41
FM 8-230

The primary advantages of an air splint are comfort to the patient, uniform
contact with the injured extremity, and gentle pressure on bleeding wounds.
Other material suitable for soft splints are pillows and rolled blankets, which
when wrapped and secured are very comfortable and provide effective
immobilization. Slings with swathes and pistol belts are also considered soft
splints and are excellent for immobilizing upper extremities.

(2) Application of air splints depends on whether or not the

splint has a zipper. If there is a zipper, the open splint is gently placed around
the extremity, zipped and inflated, insuring that a distal pulse is present. If a
non-zipper type is used-

(a) Pull the splint onto your arm to hold the splint open;
grasp the hand or foot of the injured extremity.

(b) Apply gentle traction and slide the splint from your arm
to the injured extremity.

(c) Inflate the splint (by mouth), insuring the presence of a

distal pulse.

NOTE

With an open wound or compound fracture, the

air splint should be applied after the
application of a sterile dressing.

Figure 13-36. Air splint.

c. Traction Splints.

( 1 ) A traction splint holds a fracture or dislocation immobile and

maintains steady traction on the extremity. Because the axilla cannot tolerate
the counter traction created by these splints, they are suitable for lower
extremities only. There are two traction splints presently in use, the Thomas
leg splint (Figure 1 3-37) and the Hare traction splint. For best results, a team
of three individuals are needed to apply the Thomas leg splint.

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 FM 8-230

CRAVAT
F OO T R E S T BANDAGE

//
ll A I 1- - R 1 ff f, SPLINT
( PA D D E D»
TRACT ION
STRAP

Figure 13-37. Thomas leg splint.

(2) Application of the Thomas leg splint-

(a) Adjust the splint to the length which best serves the
patient. Too short a splint will not leave sufficient room to apply traction to
the foot. Too long a splint will not permit use of the traction strap. Place the
splint beside the uninjured leg with the ring portion parallel to the ischium
(bone in the buttock) and extend the splint about 6 to 8 inches beyond the foot.
Lock the holding devices.

(b) Place the adjusted splint, with the buckle on the

outside, alongside the broken extremity.

(c) No. I member: apply the traction strap over the shoe on
the patient's foot (Figure 1 3-38). If the patient is shoeless or only has low
quarter shoes, place plenty of soft materials over the areas on which the
traction strap will pass. Fasten the strap, position yourself facing the sole of
the patient's foot, run one hand through the large opening in the footrest and
under the outside rod of the splint, and grasp the back of the patient's heel.
With the other hand, grasp the dorsum of the patient's foot. Apply and
maintain traction throughout the remainder of the application procedure.
Maintenance of traction is very important. Release may cause serious and
unnecessary. damage.

NOTE

No. I member does not release traction or

change hand positions while the splint is being
applied.

(d) No. 2 member: raise and support the extremity;

maintain this support throughout the application.

13-43
FM 8-230

Figure 13-38. Application of traction strap.

(e) No. 3 member: apply the splint by attaching the

supporting equipment as follows:

• With the buckle of the splint to the outside and the

half-ring turned down at a right angle, ease the splint under the leg, setting the
padded half-ring against the ischium (Figure 1 3-39).

• Place a pad over the thigh at the location of the

splint strap and fasten the strap.

• Bring the long free end of the traction strap over

and under the notched end of the splint; then pass it up through the link at the
swivel (Figure 1 3-40A). Secure greater traction by pulling the strap toward the
end of the splint. Fasten the strap securely (Figure 1 3-40B). No. 1 member
must continue to support foot until the footrest is applied (Figure 13-40C).

Figure 13-39. Applying the splint.

13-44
 FM 8-230

Figure 13-40. Securing the traction s trap.

• Apply two cravat bandages to help support the leg.

If triangular bandages are not available, use other strong cloth material that is
at least 3 inches wide. Place each cravat across the rods of the splint (Figure
1 3-41A), with the long end of the bandage to the outside. Make sure that the
cravats are not directly over the fracture. Bring the ends under the splint and
loop them in opposite directions (Figure 1 3-41B). Bring the longer tail over the
patient's leg and tie the two ends over the outside rod (Figure 1 3-41 C). (No. 2
member must continue to support the leg.)

Figure 13-41. Placement of cravats on the Thomas splint.

• Slide the footrest over the end of splint and into

place against the shoe or padding on the sole of foot (Figure 13-42). (No. 1
member continues to hold the patient's foot steady, adjusting the foot position
slightly so that the heel and sole of the shoe or padded foot are in light contact
with the footrest).

• Apply three or four cravat bandages as before to

further support the extremity (Figure 13-43). Make sure that no bandage is
placed directly over the fracture site. (No. 2 member shifts positions, then
releases support as the bandages are tied.)

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FM 8-230

Figure 13-42. Footrest in place.

Figure 13-43. Support of extremity by splint, cravat

bandages, and footrest.

• Finally, apply two cravat bandages to support the

foot and ankle and secure the foot to the footrest (Figure 13-44). Place one
cravat under the back of the shoe, bringing both ends up and crossing them on
top of the shoe; then carry the ends toward the sole of the shoe and tie them on
the outside of the footrest. Apply the second cravat around the toe of the shoe
and footrest and tie. (No. 1 member releases as bandages are applied.)

Figure 13-44. Foot supported and secured.

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 FM 8-230

(3) Move the patient onto a litter.

(a) After the splint has been applied, move the patient onto
a litter.

• No. 2 and 3 members kneel along side the patient on

the side of the splinted limb. No. 1 member kneels on the opposite side. Each
member kneels on the knee nearest to the patient's feet. No. 1 member places
both hands under the patient's back and thighs, No. 2 member supports the
legs, and No. 3 member the shoulders and back. All three then lift the patient
onto the thighs of No. 2 and 3 members.
• No. 2 and 3 members support the patient on their
thighs while No. 1 member places litter in position alongside their knees,
which are touching the ground. No. 1 member then helps No. 2 and 3 members
lower the patient gently onto the litter. As the patient is lowered, he is
positioned so that the footrest on the splint is resting on the litter 2 inches
from the border of and on the litter canvas.

(b) Secure the footrest to the litter with a grooved litter bar.

• No. 1 member: lift and hold the footrest steady a

few inches above the litter canvas.

• No. 3 member: slide the litter bar under the

footrest, guiding the bottom of the footrest into the groove in the litter bar.
Start the bar from the direction of the fractured limb and slide it toward the
other leg.

• Lock the litter bar to the footrest by turning the

handle of the locking cam.

• No. 1 member: lower the footrest so that the litter

bar is on the litter canvas.

• No. 3 member: buckle the litter bar strap tightly

around the litter poles.

NOTE

If a traction strap and a litter bar are not

available, roller bandage, cravat bandages, or
similar strong material may be used as
substitutes.

(c) Cover the patient with blankets or other materials as his

condition and the situation warrant and place him in a position to prevent or
lessen shock.

(4) Application of the Hare traction splint.

• Place the splint beside the patient's uninjured leg

and adjust it to the proper length (Figure 1 3-45). Open and adjust the Velcro
straps.

• Expose the entire injured limb.

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FM 8-230

Figure 13-45. Adjusting the Hare splint.

• No. 1 member secures the leg from movement

while No. 2 member applies the ankle hitch (Figure 1 3-46).

NOTE

The boot is usually left in place.

• No. 1 member lifts and supports the leg at the site

of the suspected fracture while No. 2 member applies traction with his hands.

Figure 13-46. Applying the ankle hitch.

• No. 2 member maintains traction while No. 1

member slides the splint into position under the patient's leg and gently
applies the ischial strap (Figure 1 3-47).

• No. 2 member maintains the traction with his hands

while No. 1 member connects the ankle hitch to the splint (Figure 13-48).

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 FM 8-230

Figure 13-47. Securing ischial strap.

Figure 13-48. Connecting the ankle hitch

to the splint.

• Apply traction with the splint (Figure 13-49).

• When proper traction has been applied with the

splint, fasten the Velcro straps so that the limb is secured to the splint (Figure
1 3-50).

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FM 8-230

Figure 13-49. Applying splint traction.

Figure 13-50. Fas tening the Velcro s traps.

13-36. Management of Fractures

a. Clavicle.
• Clavicular fractures can be detected by palpation and
observation along the shaft of the clavicle.

• You can obtain immediate stabilization by using a sling and

swathe to prevent shoulder motion.

b. Humerus.

• Proximal fractures of the humerus are usually sustained by

falling on an outstretched arm. The diagnosis is sometimes difficult in such
fractures because the broken parts are frequently impacted. Palpating the
length of the humerus and gently rotating the humerus can identify the

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 FM 8-230

presence or absence of most fractures. Fractures of the shaft usually cause

gross deformity, swelling, and pain. In proximal head fractures, pain and
tenderness beneath the deltoid muscle may be the only symptom, but in a
fracture of the shaft, the patient will not be able to move the arm.

• The most effective method of stabilization is the sling and

swathe which immobilize the fracture against the chest. Wood splints can be
added for protection, but cannot be used alone because they do not immobilize
the joint above the fracture. Initial stabilization can also be accomplished by
using a long spine board and sandbags, keeping the patient's upper arm at his
side with the forearm across the abdomen.

c. Hand.

• Fractures of the metacarpals and phalanges may be either

impact or incomplete greenstick. Frequently diagnosis is based on pain alone.
A typical "boxer's fracture" of the fifth metacarpal can result when the victim
delivers a punch. This can be most easily detected by posterior palpation.

• Immobilize the injured hand by use of a splint and sling.

d. Elbow (Distal Humerus and Proximal Radius and Ulna).

• Pain and the inability to move the elbow indicates a fracture.

These fractures are particularly serious because of the proximity of the
fragments to nerves and blood vessels. Elbow fractures are the most frequent
type of fracture associated with severe vascular compromise. Surgery is
frequently necessary to reestablish blood flow to the extremity.

• Do NOT attempt to manipulate a fractured elbow. Immobilize

the injury and evacuate the patient.

e. Forearm (Shaft and Distal Radius and Ulna).

• Fractures of the forearm are usually produced by a fall on the

outstretched arm. Shaft fractures of the radius and ulna are diagnosed by
palpation and rotational movements from the pronation (palms down) to
supination (palms up). Even though inidshaft fractures usually produce great
deformity, it is not uncommon for fractures to be impacted and relatively
stable. Therefore, x-ray is necessary to confirm that no fractures exist.

• The best method of managing this fracture is to apply a sling

and swathe to stabilize the wrist. Complete immobilization must include the
j oint above the fracture, the elbow. This means, of course, that pneumatic
splints or rigid splints must immobilize the arm in full extension. It is difficult
to transport the patient in this position, and it is uncomfortable for the
patient.

• A hemorrhage of 250 to 500 cc's of blood can occur in the area

of the fracture.

• The fracture should be immobilized with 4 inch square gauze

pads and a sling applied in the position of function. Straight splints such as
tongue depressors or short pneumatic splints can also be used. Complications
of these fractures are minimal.

13-51
FM 8-230

f. Pelvis.

• A fractured pelvis commonly results from compression

injuries and falls. Bilateral pressure applied to the anterior superior iliac spine
can cause pain on movement of the pelvis, as can pressure over the symphysis
pubis or bilateral pressure over the greater trochanter.

• Long spine boards or MASTs can immobilize such fractures.

Intravenous fluid replacement must be carried out.

• Blood loss from pelvic fractures is probably the most

extensive of any fractures. As much as two to two and a half liters of blood can
be lost into the retroperitoneal space. Shock can develop from this fracture
alone. Therefore, MASTs are especially beneficial in the management of these
patients.

g. Hip.

• Fractures of the hip can either be of the surgical neck of the

femur (acetabulum) or the shaft. These fractures are generally caused by a fall
or other type of trauma, such as hitting the knees in a head-on vehicle crash.
Shortening and external rotation of the leg with pain when moving the
extremity are frequent physical findings.

• Traction splints are preferred for management of this type of

fracture although a long spine board or the MAST can provide immobilization.
Keep in mind that blood loss is usually minimal but can approach 250 to 500
cc's.

h. Femur.

• Tenderness or midshaft angulation of the femur are the most

common physical findings. Rotation of the extremity can be helpful in the
diagnosis of a femoral fracture.

• Management of this fracture is similar to management of hip

fractures; traction splints are preferred. Pneumatic splints, other than the
MAST, do not immobilize the j oint above the fracture. They can be more
harmful than no splint at all. Vascular obstruction or hemorrhage can occur,
with blood loss from 750 to 1,250 cc's. Traction splinting of the leg should
relieve most vascular obstruction. The simultaneous use of traction splinting
and MAST is often necessary in severe hip or femur fractures when
hypovolemic shock is present or is likely to develop. When this is necessary,
apply the MAST over the traction splint.

i. Knee.

• Fractures of the knee are like those of the elbow. Impaction

with minimal angulation may make these fractures difficult to identify, except
by testing for tenderness.

• When treating a fracture of the knee, the knee must be

immobilized. The hip and femur management techniques are used; however,
pain and occasionally angulation of this fracture may prevent the use of
traction splinting. Splinting the knee in the position most comfortable to the
patient may require the use of wire ladder splints.

13-52
 FM 8-230

• The position of the fracture causes vascular complications

similar to those in elbow fractures. An attempt to reestablish impaired
circulation is necessary, but may not be successful. Only minimal pressure
should be used to correct the deformity. Patients with knee fractures should
receive treatment and transportation before those with fractures in the shaft
of the femur without vascular impairment.

j. Tibia and Fibula.

• Fractures of the tibia and fibula, particularly those near the

ankle, resemble a sprain or strain and can be difficult to identify. Although
angulation may be present in the midshaft, pain and tenderness may be the
only evidence of injury distally.

• Long leg pneumatic splints, traction splints, or rigid splints

are all acceptable methods of immobilizing this fracture. The MAST does not
immobilize the ankle and cannot be used for immobilization of fractures below
the knee.

• Vascular complications, particularly around the ankle, are

common. If vascular impairment is secondary to a fracture dislocation,
reduction should be attempted in the fieldJeven though the wound may be open1
if evacuation will be delayed for more than 6 hours.

k. Foot.

• Like fractures of the hand, fractures of the metatarsals and

phalanges are relatively benign and can be detected by palpation.

• Immobilization can be accomplished by the use of a pneumatic

pillow or rigid splint. Complications rarely occur with these fractures;
however, patients with heel fractures from falls should be examined for
fractures of the hip or spine.

13-37. Management of Dislocations

Dislocations should be immobilized as they are found unless there is an

�bsence of pulse distal to the injury. Dislocations are most easily treated
shortly after they occur before severe muscle spasms develop.

'a. Shoulder.

• Restricted motion will identify this dislocation.

• Immobilize the upper arm with a sling and swathe after

padding the armpit. Frequently it may be necessary to use a pillow or blanket
between the arm and the chest wall because the arm is fixed away from the
chest.

b. Elbow.

• Dislocation of the elbow is diagnosed by painful movements of

the elbow joint. The dislocation occurs when the full body weight is supported
on an extended arm.

13-53
FM 8-230

• Immobilize the elbow with a sling and swathe or with a

padded long arm splint. Full extension or flexion of less than 90° should be
avoided to decrease the chances of vascular complications.

c. Phalanges.
• Both metacarpal-phalangeal and interphalangeal j oint
dislocations are identified by obvious deformity of joints and painful
movement. Dislocations of the metacarpal-phalangeal and interphalangeal
joints are managed by splinting in a position of function.

• Stabilize the fracture and/or dislocation to an adjacent toe or

finger with tape, with padding between the toes or fingers. Traction applied
proximally and distally to the involved joint relaxes the muscular spasm,
allowing movement of the articular surfaces into their normal position.

d Ankle.
• Dislocations of the ankle are frequently associated with
fractures. Generally, there is gross deformity of the ankle and often it is not
possible to distinguish a fracture from a dislocation.

• Treat an ankle dislocation as if it were a fracture-immobilize

the ankle with a splint.

Section VI. BANDAGES AND BINDERS

13-38. General

a. Bandages and binders are used to-

• Apply pressure to control bleeding.

• Provide for immobilization of an injured body part, such as a

fractured arm.

• Hold dressings in place.

• Protect open wounds from contaminants.

• Provide support and aid in venous blood return, such as when

bandaging the leg of a patient suffering from impaired circulation.

b. Bandages and binders are applied so that pressure is evenly

distributed to the affected area. If a joint is involved in bandaging, it is
supported in its normal position with a slight flexion of the j oint. Both the
bandage and binder are wrapped securely to avoid friction or rubbing of the
underlying tissue, which can cause severe irritation. It must be tight enough
to stay in place but not so tight as to cut off circulation.

c. Signs of impaired circulation are paleness or cyanosis, swelling,

coolness, and pain. Leave the tips of the fingers and toes visible on a bandaged
extremity so that you can check for circulation.

13-54
 FM 8-230

d. When possible, elevate the extremity for 1 5 minutes before

applying a bandage. This aids venous blood flow and reduces swelling in the
hand or foot. If the extremity is wrapped while swollen, the bandage will
become loose and slip when the edema subsides. Elevate the extremity by
having the patient lie with the arm or leg resting on a supporting obj ect above
the level of the heart.
e. A bandage or binder is applied over a clean, dry area as a
precaution against microorganisms which grow in warm, damp areas. Be sure
that skin surfaces are not bandaged in contact with each other-they will
sweat and provide a moist environment in which microorganisms can grow.
Always pad (4 x 4 or ABD bandage) adjoining skin surfaces before bandaging
or binding. Also, pad all bony prominences before bandaging to avoid
pressure, which can lead to skin irritation. If left unattended for several days,
such an irritation can become a decubitus ulcer (pressure sore). A bandage or
binder applied to a draining wound must be changed frequently to keep it as
clean and dry as possible. Discard all soiled bandages and binders.

13-39. Types of Bandages

a. There are several types of bandages available for use today (Figure
1 3-5 1 ). The type and width you select will depend upon the purpose of the
bandage. The gauze roller bandage is used less frequently for bandaging the
arm or leg because there is a difference in the size of the extremity. Other
bandages that have more elastic or clinging ability provide a firmer wrapping
that stays in place and provides better support.

E LAST I C BAN DAGE

STERI
LOT ,
HOSP!
SMIT�
WASH
STERI
PAC

K L I N G OR
K E R L E X BAN DAGE BAN DAGE

Figure 13-51. Types of bandages.

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FM 8-230

b. Elastic bandages are made of woven material that can be stretched

and molded around the body part being bandaged. The Ace bandage and
stockinette are two types of elastic material. These bandages can be removed,
rewound, and used again for the same patient. Do not reuse for a different
patient, or when a sterile bandage is required.

c. The cling bandage stretches but is not elastic. It molds around

irregular and hard to bandage areas and is often used for holding dressings in
place on the head, or on the stump of an amputated extremity. The clinging
bandage may then be covered with an elastic bandage for firm support.

d. Approximate lengths and widths needed for bandaging body parts

are:

Body Part Length Width

Head 6 yards 2 inch

Trunk 10 yards 3 to 6 inch

Leg 9 yards 2 to 4 inch

Foot 4 yards 1 V2 to 3 inch

Arm 7 to 9 yards 2 to 3 inch

Hand 3 yards 1 to 2 inch

Finger 1 to 3 yards Y2 to 1 inch

13-40. Apply a Circular Bandage to an Arm

a. Wash your hands.

b. Place the patient in a comfortable position.

c. Remove the used bandage and wash the area that was bandaged (if
needed).

d. Unroll the bandage and anchor it in place.

• Ask the patient to raise the injured arm slightly (about 6 to 1 2

inches) so that you can wrap it. If the patient is unable to lift the arm, you may
need assistance.

• Unwind the bandage toward the right around the patient's

arm. Hold the roll of bandage in your right hand so that it unwinds from the
bottom (reverse hand positions and direction of wrap if you are left-handed).
With moderate tension, hold the bandage in place with your left thumb. If you
hold the bandage too loosely while wrapping, it will come off easily. If the
bandage is wrapped too tightly, it will cut off the patient's circulation.

13-56
 FM 8-230

e. Make two initial circular turns to secure the bandage in place.

Secure the free end of the bandage to the arm directly below the injury site.
For the patient's comfort, the beginning (initial) and terminal end of the
bandage are not to be placed directly over the wound, a bony prominence, the
inner aspect of a limb, or a part that the patient will lie on.

f Each circular turn should overlap one half the bandage width of
the preceding turn. Each successive turn anchors (holds in place) the
underlying layer of bandage. Use as much bandage as is needed to hold the
dressing in place or to immobilize the part.

g. Secure the terminal end of the bandage (Figure 1 3-52). Use tape,
metal clips, safety pins, or a knot.

Figure 13-52. The circular bandage in place.

13-41. Apply a Figure-of-8 Bandage to an Ankle

The figure-of-8 bandage may be used by itself or with a circular, spiral, or

spiral reverse bandage when a j oint is included in the wrapping. The figure-of-8
bandage around the j oint protects, supports, and limits the movement of the
j oint and promotes the venous blood return which reduces swelling or edema.
The advantage of the figure-of-8 bandage is that it can support the j oint in a
position of flexion, or allow limited movement when necessary.

a. Anchor the bandage over the foot (Figure 1 3-53A). Place the initial
anchoring turns around the foot, beginning near the toes.

b. Make a circular turn over the foot and around the ankle (Figure
1 3-53A).

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FM 8-230

• ·For support place the first turn at the upper part of the ankle.
Place each successive turn lower over the ankle and heel.

OR

• For promoting venous blood return, place the first turn lower
on the heel. Place each successive overlapping turn higher onto the ankle.

c. Continue the wrap by making a spiral turn down over the ankle
and around the foot (Figure 13-53B).

d. Alternate the upward and downward spiral turns about the joint
(Figure 1 3-53B). Overlap each layer with one half the bandage width. Make at
least three complete turns. Continue bandaging the lower leg, if necessary.

e. Secure the end of the bandage (Figure 13-53D).

A. c.

Figure 13-53. Figure-of-8 bandage applied to an ankle.

13-42. Apply a Figure-of-8 Bandage to a Hand

a. Anchor the bandage over the fingers (Figure 1 3-54A).

b. Make a circular turn over the hand and around the wrist (Figure
1 3-54B).

c. Continue the wrap by making a spiral turn down over the wrist
and around the hand.

d. Alternate the spiral turns about the joint (Figure 1 3-54C). Overlap
each layer with one half the bandage width. Make at least three complete
turns.

e. Secure the end of the bandage (Figure 1 3-54D).

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 FM 8-230

Figure 13-54. Applying a figure-of-8 bandage to a hand.

13-43. Apply a Figure-of-8 Bandage to a Forearm

a. Anchor the bandage over the wrist (Figure 1 3-55A).

b. Make a spiral turn over the length of the forearm and around the
upper forearm just below the elbow (Figure 1 3-55B).

c. Make two anchor wraps around the upper forearm just below the
elbow (Figure 1 3-55C).

d. Make a spiral tum between the wrist and upper forearm (Figure
1 3-55D).

e. Alternate the spiral turns between the wrist and upper forearm
until a complete cover is provided for the forearm (Figure 1 3-55E).

f Secure the end of the bandage (Figure 1 3-55F).

Figure 13-55. Applying a figure-of-8 bandage to forearm.

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FM 8-230

13-44. Apply a Figure-of-8 Bandage to a Knee

a. Anchor the bandage over the mid-calf of the leg (Figure 13·56A).

b. Make a circular turn over the knee and around the lower thigh
(Figure 1 3-56B).

c. Continue the wrap by making a spiral turn down under the knee
and around the calf of the leg (Figure 13-56C).

d. Alternate the spiral turns about the joint until a complete cover is
provided for the knee (Figure 13·56D).

e. Secure the end of the bandage (Figure 13-560).

Figure 13-56. Applying a figure-of-8 bandage to a knee.

13-45. Apply a Spiral Bandage to a Leg

This procedure is used to apply an elastic bandage to an arm or leg. When the
leg is involved, an elastic stocking may be used instead of the bandage. Read
the directions on the package before applying. Frequently observe the
circulation in the fingers or toes after application.

a. Begin by anchoring the bandage with two circular turns (Figure

1 3-57A). Often, you will need to bandage the foot to aid venous blood return
before you apply a bandage to the leg. Use the figure-of-8 bandage on the foot
and then proceed with the spiral wrapping of the leg, if necessary.

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 FM 8-230

b. With each succeeding tum of the bandage, angle slightly upward

around the leg (Figure 1 3-57B). The direction is upward and around, downward
and around, like a spiral staircase, in the same direction as the blood flow
returning to the heart. Each turn is parallel to the preceding turn and overlaps
about one half the width of the bandage.

c. Wrap the bandage evenly and smoothly (Figure 1 3-57C). Hold the
extermity firmly and wrap it securely. Do not wrap it so tightly that you cut
off the circulation. As you wrap, ask the patient how it feels. Loosen it
immediately if it is too tight.

d. Continue wrapping in the spiral fashion (Figure 1 3-57D). Wrap

until the part is completely covered.

e. Secure the end of the bandage (Figure 1 3-57D). Use tape, clips,
safety pins, or a knot. As before, do not start or finish the bandage over
wounds or bony prominences.

Figure 13-57. Applying a spiral bandage to a leg.

13-46. Apply a Spiral Bandage to a Forearm

'

a. Anchor the bandage with two circular turns.

b. With each succeeding tum of the bandage, angle slightly upward

around the forearm. Overlap the preceding turn about one half the width of the
bandage.

c. Wrap the bandage evenly and smoothly. Do not wrap the bandage
too tightly; you may cut off circulation.

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FM 8-230

d. Continue wrapping in a spiral method until the forearm is

completely covered.

e. Secure the end of the bandage.

13-47. The Spiral Reverse Bandage

This bandage is used to wrap an extremity that has varying thicknesses (such
as the ankle which rises to a thicker area-the calf of the leg). This method of
bandaging provides a means to make a secure, smooth, even-fitting bandage
on an extremity.

a. Anchor the bandage with two complete turns (Figure 1 3-58A and
1 3-58B).

b. Make a spiral reverse tum (Figure 1 3-58C).

• Place your thumb on the upper edge of an anterior tum and

hold firmly.

• Turn the bandage downward over the thumb and toward the
lower edge of the previous tum.

• Cover about one half of the previous lap and continue the tum.

c. Continue making spiral reverse turns (Figure 1 3-58D). Wind the

bandage in the same manner and place it as the previous layers. The spiral
reverse bandage fits the contours of the extremity.

d. Secure the end of the bandage (Figure 1 3-58D).

Figure 13-58. The spiral reverse bandage.

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 FM 8-230

13-48. Apply a Recurrent Bandage

The recurrent bandage is applied to hold pressure dressings in place over the
tip end of a finger, toe, fist, or stump of an amputated extremity, and on the
head. Supplies needed consist of a bandage (elastic, cling, or roller type; width
depends on site: 1 inch wide for finger, 3, 4, or 6 inches wide for stump or head).

a. Unroll the bandage and secure the end with two complete turns
around the stump (Figure 1 3-59A). Wrap the bandage over the tip from the
front to the back, then down over the tip to the front (Figure 1 3-59B). Hold the
top layer of bandage securely on the anterior (front of) leg with your left thumb
at the highest edge (Figure 1 3-59C). Continue to unroll the bandage downward
over the tip of the stump then up the back (Figure 1 3-59D). Hold the bandage
firmly on the posterior (back) aspect of the leg with the index finger.

b. Make a fold at the back and bring the bandage over the tip to the
front. Move each successive turn alternately to the left, then to the right of the
first layer over the tip of the stump in somewhat of a spiral manner (Figure
1 3-59D).

c. Continue wrapping until the stump end is completely covered.

Overlap each layer about one half the width of the previous layer. Continue to
hold each succeeding layer securely in place with your thumb and index finger.

d. When the stump is smoothly, evenly, and totally covered, reverse

the direction of the bandage and make at least two circular turns to cover the
gathered ends that you have been holding with your thumb and index finger
(Figure 13-59E).

f. Secure the ends of the bandage (Figure 13-59E).

Figure 13-59. Applying a recurrent bandage.

13-49. Apply a Scultetus Binder

The scultetus (many-tailed) binder provides abdominal support after an

abdominal operation, post-delivery, or post-paracentesis. The binder is made
by sewing heavy flannel strips 3 to 4 inches wide and 4 feet long in overlapping
layers of 1/2 inch. The middle third section of the strips is sewed together,
leaving 16 inches free on each end.

13-63
FM 8-230

a. Place the binder under the patient's hips. The solid portion of the
binder should be centered under the patient's body, the ends lying flat,
extending straight out from the patient. All tails on the binder overlap the
next one. The unlapped beginning tail is placed face up at the lower edge of the
hips. As each tail is applied, the next tail is unlapped and can be placed
smoothly without wrinkles (Figure 1 3-60).

b. Bring the bottom tail across the lower hips (Figure 1 3-60).

• Begin in the direction in which the tail is going, to provide for

smooth, successive spiral-type layers with a 1/2-inch overlap of each layer. Pull
tightly. If the end is too long, you may need to fold it back on itself just far
enough so that it fits smoothly.

• Incorrect placement of the overlapping tails can cause

pressure and discomfort for the patient.

c. Alternate tails first from one side of the abdomen, then from the
other side (Figure 1 3-60). Proceed toward the waist, slanting each succeeding
tail slightly upward.

d. Secure the final tail with a safety pin. This type of abdominal
bandage provides good support for the patient. If you have pulled it securely
enough as you criss-crossed each strip and then firmly pinned it, the patient
will be able to move freely about without having the bandage come loose.

Figure 13-60. Applying a scultetus binder.

13-50. Apply a T-Binder or a Double T-Binder

These binders are used to keep peri-pads (rectal) and perinea! dressings in place
(Figure 1 3-61). The double T-binder is used for the male patient. Suppliee
needed are pins, T-binder, peri-pad, or dressing.

a. Put on the binder (Figure 1 3-62). Place the band of the binder
around the waist and secure with a pin. Smooth out the tail at the back of the
binder.

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 FM 8-230

'

:: �
�

-- - I /
- -

SI NGLE T

-
---- -

DOUBLE T

Figure 13-61. T-binder and double T-binder.

b. Apply the peri-pad or dressing to the rectal or perinea! area (Figure

1 3-62). Avoid touching the side of the pad or dressing that will come in contact
with the patient's skin.

c. Secure the pad in place. Bring each tail or strip forward, one on
each side of the genital organs, and secure them to the waistband with pins
(Figure 1 3-62).

BELT ABOVE

-- - - - - - ,\
I L IAC CREST
ROLLED ABD PAD
.... :: - - - - - -. ..... : ..... BELT

TAILS
TAILS

POSTERIOR V I EW ANT ERIOR V I E W

Figure 13-62. Applying a double T-binder.

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13-51. The Sling

Patients who have an injury to the arm or shoulder often need to support the
arm in an elevated position to avoid edema, pain, discomfort, and fatigue of
the hand. A commercially made arm support can be placed about the arm and
the straps adjusted around the neck. When this type of arm support is not
available, you must improvise a sling using triangular bandages.

13-52. Apply an Arm Sling to an Arm Injury Not Involving the Shoulder

a. Place the upper end of the triangle over the shoulder on the injured
side (Figure 1 3-63A). When placing the bandage between the chest and the
injured arm be careful not to cause unnecessary movement which may cause
further injury.

b. Place and extend the point (apex) of the bandage beyond the elbow
(Figure 1 3-63A). Carefully bend the injured arm across the body with the
thumb up.

c. Bring the lower end over the injured arm and over the shoulder on
the uninjured side (Figure 1 3-63B). Have the patient keep the elbow bend at a
right angle across the lower chest. The hand should be slightly higher than the
elbow to prevent the fingers from swelling.

d. Bring the upper end around the back of the neck. Tie the two ends
on the uninjured side (Figure 13-63C). Place the knot to the side (hollow) of the
neck so that it will not be uncomfortable if the patient lies down, or will not
cause continuing pull on the back of the neck when the arm is in the sling.

e. Fold the apex of the triangle over the elbow toward the front
(Figure 1 3-63B). Secure it with a safety pin.

NOTE

Pigtailing method: twist the apex and tuck the

twisted end (pigtail) into the bandage at the
elbow.

f. Check the radial pulse and circulation in the fingers frequently.

Observe the color of the fingernail beds; they should be pink. Feel the fingers;
they should be the same temperature as the fingers on the uninjured hand. If
the pulse is weak or absent, or if the fingers are cold and pale, report this
condition to your supervisor immediately.

g. Apply a swathe.

• Fold a triangular bandage to a 6-inch width (Figure 13-63D).

• Place the swathe above the elbow and bring one tail around
the patient's back and under the uninjured arm.

• Bring the second tail across his chest and above the injured
forearm.

• Tie the swathe above the breast pocket on the uninjured side.

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 FM 8-230

SECURED W I T H SAFETY P I N

Figure 13-63. Sling and swathe applied to an arm injury.

13-53. Apply an Arm Sling for an Arm Injury With the Shoulder Involved

a. Place the upper end of the triangle over the shoulder on the
uninjured side. The tail should extend to the center of the back (Figure
13-64A).

b. Place and extend the apex of the bandage beyond the elbow.

c. Bring the lower end of the bandage up over the forearm and under
the armpit on the injured side (Figure 1 3-64B).

d. Tie the two ends in the center of the back (Figure 13-64C).

13-67
FM 8-230

e. Fold the apex of the triangle over the elbow towards the front.
Secure it with a safety pin.

f. Check the radial pulse and circulation in the fingers.

g. Apply a swathe.

• Fold a triangular bandage to a 6-inch width (Figure 1 3-64D).

• Place the swathe flush with the elbow and bring one tail
around patient's back and under the uninjured arm.

• Bring the second tail across his chest and above the injured
forearm.

• Tie the swathe above the breast pocket on the uninjured side.

F R AC T U R E

SECURED WITH S A F E TY PIN

Figure 13-64. Sling and swathe applied to an injured arm

and shoulder.

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 FM 8-230

Section VII. SHOCK

13-54. General

a. The term shock has a variety of meanings. Generally in medicine,

SHOCK means a state of collapse of the cardiovascular system or inadequate
tissue perfusion. Shock occurs when the tissues or organs are inadequately
supplied (perfused) with oxygenated blood. Inadequate perfusion may be
accompanied by decreased arterial blood pressure. Three factors are necessary
to maintain normal perfusion; abnormalities in any of these can produce shock:

• A functioning heart, or pump.

• An adequate blood volume.

• An intact vascular system capable of changes in response to

changes in blood pressure.

b. Certain organs of the body are more susceptible than others to a

lack of adequate perfusion. The brain, spinal cord, and peripheral nervous
system cannot lose perfusion for more than 4 to 6 minutes without permanent
damage to their cells. Damage in the kidney results after inadequate perfusion
for a period of 30 to 40 minutes. The heart requires constant perfusion. A loss
of perfusion for 2 hours to the skeletal muscles causes permanent damage. The
gastrointestinal tract can exist with impaired perfusion for a number of hours.
No part of the body can exist without perfusion for an indefinite period of
time. Permanent injury results when the nervous system is damaged.

c. It is important that all medical personnel understand the concept

of perfusion because it is the main element in shock. There are a number of
separate causes for shock. However, there are only three ways in which each of
these separate causes can induce shock. Whatever the cause, the damage
comes about when perfusion in organs and tissues is inadequate and they start
to die. The three major causes of shock are-

• The heart is damaged and it fails to work as a pump.

• Blood loss causes the volume of fluid within the vascular

container to be insufficient.

• The blood vessels dilate so that the blood within them, even
though it is a normal volume, is insufficient to provide adequate circulation.

d. In all cases the results are exactly the same-an insufficient

perfusion of blood through the organs and tissues of the body. All normal body
processes are affected. When a person is in shock, vital functions slow down. If
the conditions causing shock are not promptly treated, death soon follows.

13-55. Types and Causes of Shock

Hypovolemic shock, the most common type found on the battlefield, is

described in detail. Cardiogenic, septic, and neurogenic shock is discussed
separately and compared to hypovolemic shock. Another type, anaphylactic,
is only discussed in general terms.

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13-56. Hypovolemic Shock

a. Hypovolemic shock occurs when fluid is lost from the

intravascular compartment. This loss may result from internal or external
hemorrhage, burns, vomiting, diarrhea, excess sweating, peritonitis, or
pancreatitis. External hemorrhage is easily recognized as a source of blood
loss. However, internal hemorrrhage may be hidden. Internal bleeding may
occur in the thoracic or abdominal cavities following rupture of the liver, the
spleen, or the great vessels within these cavities. Burns produce extensive and
alarming losses of plasma and other body fluids into the burned tissues.
Significant internal blood loss may occur with bone fractures, especially
fractures of the pelvic and long bones. Pelvic fractures from crush injuries
often tear associated blood vessels; 40 percent of these patients suffer shock.
A fracture of one long bone may result in blood loss of 500 to 1 ,000 cc' s into
the surrounding tissues. Femoral-shaft fractures may produce blood losses of
1 ,000 to 2,000 cc's.

b. When dehydration (loss of body water) is present prior to the

injury, the state of shock is worsened. This is commonly seen in personnel
wounded in the tropics where constant exposure to the sun and high humidity
causes excessive sweating.

c. There are many factors in the body's response to shock. When

blood volume is lost, less blood returns from the body to the heart and
decreases cardiac efficiency. The response is an increase in the discharge of
norepinephrine and epinephrine. An increase of these substances results in
contraction of peripheral blood vessels with a stronger and more rapid heart
beat. These changes return the blood pressure toward normal limits; however,
there is decreased circulation to peripheral tissues. This provides improved
perfusion in the brain and lungs. When the volume of blood loss is so great
that these mechanisms can no longer compensate, the blood pressure remains
depressed. As the body continues to contract peripheral blood vessels, more
and more body areas are deprived of blood flow.

13-57. Signs and Symptoms of Hypovolemic Shock

a. Hypovolemic shock is due to inadequate tissue oxygenation and
the nervous system's response to decreasing blood pressure. The patient in
hypovolemic shock often appears to be simply confused and disoriented. He
may look apprehensive (scared). His respirations are rapid and shallow, and his
pulse is fast and thready. Peripheral veins will be collapsed when you look for
them to start an IV. The skin is usually cold, clammy, and pale. Cyanosis may
be present. Finally, the blood pressure may be falling. DO NOT rely on blood
pressure alone to diagnose shock. Falling blood pressure is a late sign of shock
and signals the collapse of the cardiovascular system.

b. Use the blood pressure and pulse to estimate blood loss. A systolic
blood pressure less than 70 mm Hg together with a pulse rate greater than 1 30
beats per minute implies at least a 40 percent loss of blood volume. When the
blood pressure cannot be obtained at the arm, use the following as a rough
guide: When a femoral pulse is palpable, the systolic blood pressure is
probably at least 70 mm Hg; if a carotid pulse is palpable, the systolic pressure
is probably at least 60 mm Hg; and if a radial pulse is palpable, the systolic
pressure probably exceeds 80 mm Hg. It should be noted that the pulse and
blood pressure should be evaluated to determine management.

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 FM 8-230

c. To estimate blood loss from causes other than trauma, you may
also use the postural test. To perform a postural test, take the patient's pulse
rate while he is lying down. Then have him sit up and quickly retake his pulse.
If the pulse rate increases by more than 20 beats per minute when the patient
sits up, there has been a blood loss of at least one unit (500 cc's). In managing
hypovolemic shock, the goal is to maintain perfusion in the vital body organs
with oxygenated blood. The best indication of brain perfusion is the patient's
level of consciousness. If the patient is conscious and alert, the brain is
adequately perfused. If the patient is confused, disoriented, or unconscious,
brain perfusion is probably inadequate.

d. An effective and simple method of classifying hypovolemic shock

is as follows:

• Class 1 Hemorrhage-slight increase in pulse rate with normal

blood pressure, respirations, and capillary blanch test. The acute blood loss is
about 1 5 percent of the total circulating volume or a maximum of 750 cc's in a
70 kg male.

• Class 2 Hemorrhage-the pulse rate is above 100 with rapid

breathing (tachypnea). The systolic pressure has dropped or is normal with an
increased diastolic pressure. The acute blood loss is about 20-25 percent of the
total circulating volume, or about 1 ,000-1250 cc's.

• Class 3 Hemorrhage-an acute blood loss of about 30 percent

of the circulating volume, 1 500-1800 cc's of whole blood. This patient presents
the classical clinical signs of hypovolemia, including significantly depressed
blood pressure.

• Class 4 Hemorrhage-there is as acute blood loss in excess of

2,000-2500 cc's. Blood pressure is barely or nondetectable. Carotid pulse only
is detectable, if at all. The part of the brain which receives and interprets
sensations (the sensorium) is depressed.

13-58. Treatment for Hypovolemic Shock

a. Evaluate and establish an airway. Insure that the patient's
breathing and ventilation are adequate.

b. Determine adequate circulation by evaluating the cardiac

efficiency. Check for a pulse at one location and record its-

• Character, such as normal, weak, or intermittent.

• Rate.

• Location, such as radial, femoral, or carotid.

NOTE

Capillary filling is abnormal if they take more

than 2 seconds to refill.

c. Perform resuscitation, if necessary.

13-71
FM 8-230

d. Apply military antishock trousers (MAST) (refer to paragraph

1 3-59 for use of MAST) to mobilize 1,500 to 2,000 cc's in the lower extremities
and abdomen and to increase lower extremity peripheral resistance. This
accomplishes three functions:

• It increases cardiac efficiency.

• It provides most blood circulation to the sensitive heart,

brain, and lung.

• It also slows intra-abdominal hemorrhage. The inflation of the

MAST is based on the patient 's blood pressure. Measuring the pressure inside
the trouser compartments is not an adequate method of determining changes
in the patient's blood pressure. The trousers remain inflated until the patient's
blood pressure returns to 100 mm Hg or higher.

e. Administer two large-bore peripheral IVs at a TKO rate. When the

MAST trousers are inflated first, the peripheral veins are much easier to find.

NOTE

If MAST is not available in the field, elevate

the lower extremities by raising the legs from
the hips, keeping the knees straight. This
maneuver will increase the blood flow
returning to the heart and aid in combating
shock. When the patient's legs cannot be
elevated, place him on a litter and elevate the
foot portion of the litter. However, in this
position, the entire weight of the abdominal
organs falls on the diaphragm and the patient
may not be able to breathe as easily and may
require assisted ventilation. DO NOT
ELEV ATE THE FEET MORE THAN 1 2
INCHES.

f. Check vital signs. The patient's vital signs, including pulse,

capillary filling, circulation, respiration, skin color, diaphoresis (profuse
perspiration), level of consciousness, and pupillary changes should be checked
at least every 5 minutes throughout the assessment, stabilization, and
evaluation phases.

g. Evacuate the patient. After stabilizing procedures have been

completed, transport the patient as rapidly as possible to a treatment facility.

13-59. Antishock Garments

a. The Military Antishock Trousers, antishock garment, or

pneumatic counter-pressure device is designed to counteract or reduce internal
bleeding and aid in treating hypovolemic shock. The antishock garment does
this by developing an encircling pressure around the lower extremities, pelvis,
and abdomen. The pressure applied to the legs squeezes up to 2 units of blood

13-72
 FM 8-230

out of these extremities, where it is less critically needed, and into systemic
circulation. This is the same principle used in applying local pressure to
control hemorrhage. Normally, the pressure exerted is 100 mm Hg. This
pressure-

• Stops or slows venous and arterial bleeding in the areas of the

body enclosed by the pressurized garment.

• Forces available blood from the lower body to the heart, brain,
and other vital organs.

• Prevents blood pooling in the lower extremities.

b. There are several advantages with the use of an antishock garment

other than the prevention of further blood loss and the direction of circulating
blood to vital organs. Some of the many advantages are-

• The MAST serves as an air splint for fractures of the lower

extremities or the pelvis. However, femur fractures should be placed in a
traction splint before applying the MAST.

• The garment often stabilizes a patient so effectively and

quickly that other patients with more critical injuries can be treated first.
Patient monitoring is still required.

• Diagnosis and preparation for surgery may be delayed for an

hour or more when a patient is stabilized with the MAST. Without the use of
MAST, often an unstable patient must be prepared for immediate surgery.

• A Foley catheter can be inserted while a patient is in an

inflated MAST.

• Electrocardiograms (ECGs) and x-rays can also be taken

while a patient is in an inflated MAST.

13-60. Indications for Use

Antishock garments are indicated for low volume shock or low resistance
shock. Antishock garments are recommended if-

• Systolic blood pressure is 80 mm Hg or less.

• Systolic blood pressure is less than 100 mm Hg and other

signs of shock are present.

NOTE

They may also be used for neurogenic shock,

for temporary venous volume assistance in
order to get an IV started, or for continuous
pressure.

• Profuse bleeding is present from injuries to the lower

extremities and pelvis, or there is intra-abdominal bleeding.

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FM 8-230

13-61. Contraindications for Use

Contraindications for use of the antishock garment are-

• Bleeding about the diaphragm since the possibility exists of

increasing the bleeding as the blood pressure increases.

• Pulmonary edema will always worsen as fluid is moved up

from the legs.

• Congestive heart failure.

• Heart attack.

• Cerebrovascular accident (stroke).

• Pregnancy, unless the abdominal compartment can be left

uninflated.

13-62. Application of the MAST Garment

a. Lay out the MAST garment (Figure 1 3·65).

b. Place the patient on the garment face up with the top of the
garment just below the lowest ribs.

c. Wrap the left leg of the garment around the patient's left leg and
secure it (Figure 1 3·66A).

d. Wrap the abdominal section around the abdomen and secure it

(Figure 1 3-66B).

e. Wrap the right leg of the garment around the patient's right leg
and secure it (Figure 1 3-66C).

f. Attach the foot pump (Figures 1 3-67).

g. Inflate both legs at the same time until the garment is firm to the
touch or the relief valves allows air to escape.

h. Close the inflation/deflation valves to keep the garment from

deflating.

i. Check the patient's blood pressure. If it is within normal limits,

the abdominal section need not be inflated. If the blood pressure is below
accepted levels, inflate the abdominal section (except on pregnant patients)
while monitoring the patient's blood pressure. Stop inflation and close the
valve when the patient's blood pressure is within normal limits or air escapes
from the relief valves.

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 FM 8-230

Figure 13-65. Layout the MAST garment.

�-- - -- - -
__ . �

Figure 13-66. Applying the MAST garment.

13-75
FM 8-230

Figure 13-6Z Attaching foot pump.

13-63. Deflation/Removal of MAST Garment

a. The garment can be removed only after shock is adequately

managed and vital signs are within acceptable limits. Even at this point, the
deflation is a gradual one. Remember, rapid deflation is equivalent of losing
two units of blood (20 percent of the normal circulating volume)! The garment
is to be removed only in a definitive treatment facility.

NOTE

If the patient is to be evacuated by helicopter,

the pressure in the MAST will increase due to
atmospheric changes. This is also true if the
garment is applied in a cold environment and
the patient is taken into a warm area. The
reverse is true (the pressure decreases) if the
garment is applied at high altitude and the
patient is taken to a lower altitude or from a
warm to a cold environment.

b. Deflation begins with the abdominal section. Slowly release the air
while continuously monitoring the patient's blood pressure. Continue
deflation until the patient's blood pressure shows a drop of 5 mm Hg. Stop the
deflation at this point and administer intravenous fluid or blood until the
blood pressure returns to normal. Continue the slow gradual deflation in this
manner until the abdominal section is completely deflated. Then deflate each
leg individually in the same way.

NOTE

The patient may be transferred to other

facilities or to the operating room with the
MAST garment in place. Transfer of the
patient is not a reason to remove the garment.

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 FM 8-230

13-64. Cardiogenic Shock

Cardiogenic shock is caused by an inadequate function of the heart.

Circulation of the blood requires the constant action of a normal and vigorous
heart muscle. Many types of disease cause the destruction or inflammation of
this muscle. Within limits, the heart can adapt to these injuries; but if too
much weakness or damage occurs, the heart no longer functions well. It may
also be caused by cardiac arrhythmias, chronic congestive heart failure, or
pericardia} tamponade (blood in the pericardia} sac compresses the heart and
prevents effective heart action).

13-65. Signs and Symptoms

The physiologic effects of cardiogenic shock are similar to those of

hypovolemic shock. However, in cardiogenic shock the signs and symptoms
coexist with those of the underlying cardiac problems.

13-66. Treatment for Cardiogenic Shock

a. E stablish an airway.

b. Administer oxygen (if available) and assist ventilation (if

necessary).

c. Monitor vital signs and level of consciousness.

d. Start an IV with dextrose, 5 percent, in water (D5W) at a TKO

rate.

e. Keep the patient at normal temperature. Use blankets if

hypothermia develops.

f. Administer drugs to correct specific cardiac problems only if they

are ordered by the physician.

g. Record treatment given.

e. Evacuate the patient.

13-67. Septic Shock

Septic shock develops in some patients with sepsis (the presence of bacteria in
the blood stream). Sepsis most frequently occurs in a patient who has
infections in other parts of his body. Common conditions that predispose to
sepsis are diabetes, cancer, cirrhosis, immunosuppressive drug therapy,
biliary tract obstruction, ulcerative colitis, and postpartum and postabortion
infections. There are several physiologic effects of septic shock, such as
increased cardiac efficiency, dilated peripheral blood vessels, hypotension, and
peripheral blood pooling. These effects are partly caused by arteriovenous
shunting (circulation of blood from arteries to veins, bypassing the capillary
beds).

13-68. Signs and Symptoms of Septic Shock

The signs and symptoms of septic shock resemble those of hypovolemic shock.
However, in septic shock, the skin may remain warm and dry. The patient in
septic shock usually has an elevated body temperature due to the underlying
infection.

13-77
FM 8-230

13-69. Treatment for Septic Shock

a. Establish an airway.

b. Administer oxygen. Assist ventilation, if necessary.

c. Monitor vital signs and level of consciousness.

d. Start at least one IV line with a large-bore ( 14-16 gauge) catheter.

Infuse normal saline or Ringer's solution at a keep open rate.

e. Keep the patient at normal temperature. Sponge if febrile, using

cool water.

f. Monitor cardiac rhythm (if possible).

g. Record treatment.

h. Evacuate the patient.

13-70. Neurogenic Shock

Neurogenic shock results from loss of normal vasoconstriction. Neurogenic

shock occurs with spinal cord transection or severe spinal cord injuries. Drugs
that depress the central nervous system may produce neurogenic shock. There
are transient and easily correctable forms, such as fainting at the sight of
blood. Neurogenic shock differs from the other types of shock in the loss of
response to decreased blood pressure. Peripheral vasoconstriction no longer
occurs when the blood pressure decreases. The loss of vasoconstriction
increases the capacity of the large veins without increasing the blood volume.
Because the blood volume is then smaller than the vascular space, venous
return decreases. Since the heart receives less blood from the veins, it has less
blood to pump to the arteries and the cardiac efficiency falls, further lowering
blood pressure. Sympathetic stimulation of the heart is also lost in neurogenic
shock. This means that the rate and force of cardiac contractions do not
increase when the blood pressure falls.

13-71. Signs and Symptoms of Neurogenic Shock

Because the sympathetic response to falling blood pressure is absent, the

signs and symptoms of neurogenic shock differ significantly from those of
other types of shock.

• The blood pressure is low, but the pulse may be normal or low.

• The skin is dry, warm, and may even be flushed.

13-72. Treatment for Neurogenic Shock

a. Neurogenic shock may be temporary. If it causes fainting, the

patient should be kept flat, and the underlying problem (an upsetting
environment) should be corrected.

13-78
 FM 8-230

b. For severe neurogenic shock-

(1) Establish an airway.

(2) Administer oxygen and assist ventilation, if necessary.

(3) Monitor vital signs and level of consciousness.

(4) Apply and inflate the MAST.

(5) Start at least one large-bore IV line. Rapidly infuse lactated

Ringer's or normal saline (NS) solution if the MAST has not restored the blood
pressure.

(6) Keep the patient at normal temperature. Use blankets to

prevent hypothermia. Because vasodilation in skin arterioles increases body
heat loss, these patients have difficulty maintaining a normal body
temperature.

(7) Monitor cardiac rhythm, if possible.

c. Record treatment.

d. Evacuate the patient.

13-73. Anaphylactic Shock

Anaphylactic shock occurs when an individual has become sensitized to a

substance and reacts violently to another dose or contact. Anaphylaxis is the
most severe form of an allergic reaction. Substances that most often cause
allergic reactions may be grouped as follows:

• Inhalants (substance breathed in). The inhalation of pollen,

dusts, or materials to which a patient is sensitive may cause rapid and severe
reactions.

• Insect stings. Stings of bees, wasps, yellow j ackets, hornets,

or ants can cause very rapid and severe anaphylactic reaction.

• Ingestables. Eating food such as fish, milk products, chicken,

tomatoes, berries, and mushrooms, or taking medications such as oral
penicillin can cause severe reactions.

• Injectables. Injectable medications such as penicillin, tetanus

antitoxin, and a variety of other vaccines may cause anaphylactic reaction.

• Plants. Touching poison oak, ivy, sumac, and some flowers

will cause a reaction.

13-74. Signs and Symptoms

Anaphylactic reaction occurs in minutes or even seconds following contact

with the substance to which the patient is allergic. The respiratory system,
circulatory system, and skin may all be affected.

13-79
FM 8-230

• Respiratory system. The smaller bronchi constrict and air passage

is increasingly difficult; wheezing results, especially on expiration. Fluid is
drawn into the bronchi and the patient tries to cough it up. There is a tightness
or pain in the chest with an irritating and persistent cough.

• Circulatory system. There is a noticeable drop in the blood

pressure, a weak or rapid pulse, pallor, and dizziness. Faintness, coma, and
even death may follow.

• Skin. Swelling of the lips may be seen. Cyanosis may become

rapidly visible about the lips. The skin may be flushed, itching, or have a
burning sensation, especially the face and upper chest. Hives may spread over
large areas of the body. Edema, especially of the face and tongue, may occur.

13-75. Treatment for Anaphylactic Shock

Death is imminent unless treatment is begun immediately.

a. Establish an airway and administer oxygen (if available). In cases

of airway obstruction from severe glottic edema, a cricothyroidotomy may be
necessary. The most experienced medical person available should perform the
emergency airway procedure, if required.

b. Monitor vital signs and level of consciousness.

c. Start at least one large-bore IV line with D5W or NS and

administer epinephrine as instructed by the physician. If an IV is difficult to
start; give 0.5 ml of 1: 1,000 aqueous epinephrine subcutaneously.

d. Keep the patient at normal temperature.

e. Monitor cardiac rhythm (if possible).

f. Record treatment.

g. Evacuate the patient.

Section VIII. CONTROL OF HEMORRHAGE

13-76. Hemorrhage

a. Hemorrhage is excessive bleeding. It may be caused by a wound or

by a disease. Whatever the cause, it is a serious threat to life and requires
prompt control.

b. When a blood vessel wall is opened, the body reacts with measures
to check bleeding. Two natural body responses to bleeding are blood clotting
and retraction or constriction of blood vessels. The muscles in an injured
vessel contracts and if the vessel is severed, the contraction pulls the damaged
vessel back into the tissues, thus tending to close the leak. These natural
responses must be helped by artificial means to control hemorrhage.

13-80
 FM 8-230

13-77. Treatment for External Hemorrhage

a. Cut, tear, or lift clothing or other material from the wound without
causing additional injury to the patient. .

b. Apply a pressure dressing to the wound. The purpose of applying

the sterile dressing (Figure 13-68) with pressure to a hemorrhaging wound is
threefold-

• Assistance in clot formation. The dressing is an absorbent

material which spreads and slows the flow of the blood that it absorbs. This
spreading and slowing action exposes a relatively large, thin surface of the
outflowing blood to the air and speeds up the clot formation. One dressing
partially filled with the patient's blood is more effective in controlling
hemorrhage than are a series of others because the clot formation is in
progress in the bloody dressing. The clot formation spreads back toward and
into the wound diminishing air exposure. It is the clot that stops the
hemorrhage. When blood begins to clot, it turns darker in color and becomes
progressively darker as the clot takes form. A hard clot is almost black.

• Vessel compression. The applied pressure reduces the size of

the vessel opening, reducing th� amount and the velocity of escaping blood,
aiding clot formation. Hemorrhage does not always immediately stop. At
times, hard pressure on the dressing over the wound may be required for
several minutes until a clot has formed with sufficient strength to hold with
only the help of the dressing ties. Anchor the dressing over the wound with the
dressing knots tied over the wound (Figure 13-69). Anchor the dressing snugly
to prevent slipping, but not excessively tight. (The wounded body part,
especially an arm or leg, will swell after a time. The swelling will tighten the
bandage more, impairing or stopping circulation in the part.) Signs of renewed
hemorrhage from the wound may appear after a dressing is snugly in place.
The reapplication of manual pressure may be all that is necessary to assist in
formation of a clot that will stop the hemorrhage. Signs of renewed bleeding
are the reappearance of fresh blood or an enlargement of the bloodstain on the
outer surface of the dressing. Also, blood trickling between the dressing and
the skin is a sign of continued bleeding.

• Protection from infectious organisms. An external wound

becomes contaminated with microorganisms at the moment of occurrence. The
prompt application of a sterile dressing limits the entrance of additional
infectious organisms. Once a dressing is applied, leave it in place, if possible.
Removal permits entrance of microorganisms and may disturb the blood clot.
Also, leaving the original dressing in place helps medical personnel treating
the wound later to estimate the amount of blood loss. When dressing a wound,
take care to avoid touching the wound or the surface of the dressing that is to
be placed directly on the wound. Breathing on the dressing or wound, or
stirring up dust around the patient will increase the hazards of contamination.

c. Elevate the wounded limb. Hemorrhage, especially venous

bleeding, can be reduced by raising the wounded limb to a level above the
heart. Elevation helps lower the blood pressure at the wound site. Elevation
may be used before, during, or after application of a pressure dressing. Serious
hemorrhage, especially arterial bleeding, may require simultaneous
application of elevation, dressing, and pressure. As elevation drains the limb
by gravity, an initial gush of blood downward from open veins may occur when
the limb is first elevated. Broken bones must be splinted before elevating the
limb.

13-81
FM 8-230

'\

Figure 13-68. Application of pressure dressing. Figure 13-69. Pressure dressing knots
tied over the wound.

d. Use pressure points. A pressure point is a place where a main

artery supplying the wounded area lies near the skin surface and over a bone.
Pressure at these points (Figure 13-70) is applied with the fingers, thumbs, or
hands. The obj ect of the pressure is to occlude the artery between the wound
and the heart by compressing the artery against the bone, thus shutting off
the blood flow from the heart to the wound. It is very difficult to maintain
manual occluding pressure on a pressure point; therefore, this method is used
only until a pressure dressing can be applied.

• Temple or scalp. Hemorrhage from the temple or scalp is

controlled by compressing the main artery to the temple against the
underlying skull bone (Figure 1 3-70A) just in front of the ear and above thP.
prominent cheek bone (zygomatic arch).

• Lower face. Hemorrhage of the face below the level of the eyes
is controlled by compressing the artery in the notch on the under side of the
lower j aw (mandible) (Figure 1 3-70B). Locate this notch by running your finger
from the angle of the jaw forward until the notch is encountered on the under
side.

• Neck. Hemorrhage of the neck is controlled by compressing

the carotid artery against the spinal column by pressing inward and slightly
backward (Figure 1 3-70C). When this pressure point is used, care must be
taken not to choke the patient.

• Shoulder or upper part of upper arm. Hemorrhage from either

of these areas is controlled by compre ssing the artery against either the
clavicle (Figure 1 3-70D) or the first rib; usually pressure against the rib
produces less pain in the patient.

• Mid-upper arm and elbow. Hemorrhage from either of these

areas is controlled by compressing the artery against the bone of the upper
arm (humerus) (Figure 1 3-70E).

13-82
 FM 8-230

Figure 13-70. Pressure points for control of arterial bleeding.

• Forearm. Hemorrhage from the lower arm is controlled by

applying digital pressure at the elbow (Figure 1 3-70F).

• Hand. Hemorrhage from the hand is controlled by applying

digital pressure at the wrist (Figure 1 3-70G).

13-83
FM 8-230

• Thigh. Hemorrhage from the thigh is controlled by digital

pressure against the mid-groin from behind (Figure 1 3-70H), collapsing the
artery against the bone of the thigh (femur). At times, pressure against the
inner aspect of the mid-thigh may be more effective. If the mid-thigh pressure
point is used, pressure should be applied with the heel of the hand while the
hand is closed into a fist and is reinforced by the other hand placed on top
(Figure 1 3-701). Considerable pressure is necessary at this point to collapse the
femoral artery against the femur because both are deeply imbedded in some of
the heaviest musculature of the body.

• Lower leg. Hemorrhage from the leg between the knee and the
foot is controlled by firm pressure at the knee. Pressure at one or both sides of
the knee may be sufficient. If not, hemorrhage is controlled by holding the
front of the knee firmly with one hand (Figure 1 3-70J) and thrusting a fist hard
against the artery behind the knee (popliteal).

• Foot. Pressure by the hand around and just above the ankle is
effective in controlling hemorrhage from the foot (Figure 1 3-70K).

e. Use of the Tourniquet. A tourniquet is a constricting band placed

around the circumference of one of the extremities (arms and legs). When used,
its purpose is to stop hemorrhage. The use of a tourniquet is a LAST resort;
other control measures must be used FIRST.

• Judgement. In emergency medical treatment situations,

mature judgment is required in making the decision to apply or withhold a
tourniquet. Blood flow stops at the tourniquet. Without circulating blood,
cells in the limb distal to the tourniquet soon begin to die. Surgical amputation
of the limb distal to the tourniquet application point does not always follow.
The decision to apply a tourniquet must be done with the realization that the
distal portion of the limb may be sacrificed. The application of a tourniquet
must represent a choice between saving a life and saving a limb. It must NOT
represent a choice between the quick results it produces and the time­
consuming application of a pressure dressing. The decision to apply a
tourniquet is irreversible. Once a tourniquet has been applied, it must be left in
place until it is removed by a physician/physicians' assistant. The
physician/physicians' assistant must see the patient as soon as possible. Do
not loosen the tourniquet in the mistaken belief that the portion of the limb
distal to the tourniquet is being kept alive.

• Guideline. Pressure points, pressure dressings, and elevation

of limbs are used first. Nonetheless, hemorrhage from a maj or artery of the
leg or arm, or from multiple arteries as seen in a traumatic amputation may be
beyond the control of these methods. There is no set rule as to how long one
should continue trying to control hemorrhage by pressure dressing and
elevation. However, in an emergency situation, the absorbent capacity of one
first-aid dressing may be used as a guideline.

o If the blood lost by the patient is contained in the first-aid

dressing applied to the wound, the blood loss is probably not more than 500
ml. This is the amount drawn from a blood donor. Thus, if the dressing
becomes soaked through with blood and signs of clotting are present, continue
pressure with elevation. Additional absorbent material placed over that
already in place will aid in the clot formation and stop the hemorrhage.

13-84
 FM 8-230

o Do not assume that a traumatic amputation is not going

to bleed. Initially a traumatic amputation may have little bleeding. A pressure
dressing and a tourniquet is always needed on traumatic amputations.

f. Application of the tourniquet.

( 1 ) Place the tourniquet around the limb between the wound and
the heart. Never place it directly over a wound or fracture. Place the
tourniquet approximately 2 inches above the wound site. For wounds j ust
below a j oint, place the tourniquet above the joint (Figure 13-7 1).

MA K E A LOOP
(A\ A RO U N D THE LIMB;
\CJ T I E W I T H SQU A. R E
KNOT,

SQU A R E K N O T

® PASS A STICK,
SCABBARD, OR
UNDER
THE
B A Y ON E T
LOOP.

llNO FREE ENO

@ Of S T I C K T O

LIMB TO K E E P

TOURNIQUET
fWOM UNWINDING.

Figure 13-71. Application of a tourniquet to

s top bleeding.

(2) In the absence of an issue tourniquet, an improvised

tourniquet can be made from strong, soft, pliable material such as gauze,
broadcloth bandage, clothing, or kerchiefs. This material is used with a rigid
stick-like object. To minimize skin damage, the improvised tourniquet should
be at least 1 inch wide after tightening. If gauze bandage is used, 3 inch and 4
inch widths are preferable to the 2 inch width.

13-85
FM 8-230

(3) Apply the tourniquet with enough pressure to stop blood

from passing under it. If a pulse has been detectable in the intact wrist or foot
of the affected limb, tourniquet pressure is sufficient when that pulse ceases.
If a pulse cannot be used as an indicator, you must rely on the reduction of
blood flow from the wound. After a tourniquet is properly tightened, arterial
hemorrhage will cease immediately, but venous bleeding in the distal part of
the limb will continue until blood already in them is drained. You should not
continue to tighten the tourniquet in an attempt to stop this drainage. When
the tourniquet is tight, tie the tightening device parallel to the extremity.

(4) Protect the skin beneath the tourniquet from pinching,

twisting, and tourniquet overtightening. Skin is relatively resistant to oxygen
deprivation and may survive even though the limb beneath it requires
amputation later. Damaging the skin with the tourniquet may deprive the
surgeon of skin needed to cover the amputated stump. Skin damage will force
the surgeon to amputate more of the limb than might otherwise have been
necessary. Protect the skin by placing soft, smooth material such as a shirt
sleeve or trouser leg around the limb and beneath the tourniquet before
tightening. Protecting the skin also reduces the amount of pain inflicted on the
patient.

g. Splinting. After arterial hemorrhage has ceased and the tourniquet

is securely in place, splint the extremity to prevent further injury.

h. Covering and marking the patient. The patient's condition and the
weather may require that he be covered. If so, arrange the covering so that the
tourniquet remains in view. In addition, note the presence of a tourniquet by
plainly marking the patient's-

• Forehead with a large letter ' 'T'' mark to indicate that a

tourniquet is in place. Also indicate the time the tourniquet was applied.

• Field medical card with the time and date the tourniquet was
applied.

i. Monitoring. Inspect the tourniquet and dressing every 15 minutes

to assure that arterial hemorrhage has not started again until absence or
stability of the bloodstained area on the outside of the dressing indicates that
venous drainage has stopped. Afterwards the tourniquet and dressing should
be inspected periodically and adjusted if either has slipped. If at any time,
arterial hemorrhage is indicated, tighten the tourniquet further. Retighten the
tourniquet without loosening, lifting, or removing the wound dressing.

13-78. Epistaxis

Although epistaxis (nosebleed) is considered a common occurrence, it can be a

dangerous condition if not treated promptly and correctly. Some individuals
have a history of simple nosebleed not complicated by other conditions. It can
be caused by trauma, crusting of nasal mucosa from dry air, or irritation.
However, in the case of a facial or a head injury, nosebleeding can be serious
and require immediate treatment.

13-86
 FM 8-230

13-79. Treatment for Epistaxis

a. Treatment is usually simple and straightforward. However, if the

patient is losing large amounts of blood, take steps to minimize the blood loss
and prepare the patient for evacuation.

• Determine the cause of epistaxis.

• Tell the patient not to breathe through or blow his nose since
this will aggravate the bleeding.

• Have him sit facing you and tilt his head slightly forward.

• Tell the patient to pinch the fatty part of his nose (around the
nostrils) for approximately 5 to 10 minutes.

• Apply cold compresses, if available, to the bridge of the nose

to aid in slowing down the bleeding.

• If the bleeding continues and there is danger of excessive

blood loss and the possibility of subsequent shock, prepare the patient for
evacuation.

b. Estimate the amount of blood loss. If the patient is vomiting large

amounts of fresh (red) or old (color of coffee grounds) blood, there may be a
significant blood loss. Evacuate the patient.
NOTE
The type and estimated amount of blood
vomited should be reported.

c. Treat for shock, if necessary.

d. Obtain a short history of the patient (if the tactical situation

permits). If the patient has a history of uncomplicated spontaneous bleeding
from the nose, he may be able to control the present nosebleed.

e. Obtain and record the vital signs. Also, record treatment.

f Evacuate the patient, if necessary.

Section IX. CARDIAC ARREST AND

CARDIOPULMONARY RESUSCITATION

13-80. General

a. Cardiac arrest (sudden death) is an abrupt, unexpected cessation of

pulse and circulation. Electrical shock, drowning, or massive blood loss can
cause cardiac arrest. There are two stages of cardiac arrest.

( 1 ) Clinical death is the stopping of the heart beat and

respiration. Time elapsed is zero minutes.

13-87
FM 8-230

(2) Biological death follows clinical death in approximately 4-6

minutes. During this stage irreversible brain damage occurs. Therefore,
emergency life saving actions must begin immediately (within 2 minutes).

b. Cardiac arrest accounts for over 250,000 deaths each year, with
most deaths occurring before the victim reaches the hospital. Many of these
deaths can be prevented by taking quick emergency steps within the first 2
minutes after the arrest.

13-81. Signs and Symptoms of Myocardial Infarction (Heart Attack)

Myocardial infarction is the single largest cause of cardiac arrest. The signs
and symptoms include-

• An uncomfortable pressure\, squeezing, fullness, or pain in the

center of the chest behind the breastbone . This pain may radiate to the
shoulders, neck, and arm, and it may last 2 minutes or longer, or may be
intermittent.

• Sweating, nausea, shqrtness of breath and a feeling of weakness.

13-82. Treatment for Cardiac Arrest

a. Establish Unresponsiveness. Gently shake the patient's shoulder

and ask "are you okay. "

b. Call for Help. If the patient is unresponsive, call for help. Even if
no one is in sight, call out in the hope that someone will hear.

c. Position the Patient. Position the patient in a supine position, if

necessary. Cardiopulmonary resuscitation (CPR) cannot be administered in
any other position. When positioning the patient, use care to prevent further
injuries. Roll the patient over as a unit.

d. Open the Airway. Three methods of opening the airway in an

unconscious patient are-

• Head tilt-neck lift method: Position yourself at the patient's

side, place one hand beneath his neck and the other hand on his forehead.
Gently lift his neck and at the same time apply backward pressure on his
forehead (Figure 1 3-72).

• Head tilt-chin lift method: This technique is used when the

head tilt-neck lift method is inadequate to open the airway. Place the fingers of
one hand under the lower jaw on the bony part near the chin. Place the other
hand on his forehead. Bring the chin forward while lifting so that the teeth are
nearly brought together without completely closing the mouth (Figure 13-73).

13-88
 FM 8-230

Figure 13-72. Head tilt-neck lift method.

Figure 13-73. Head tilt-chin lift method.

• Jaw thrust method: This technique is the safest and first

approach to opening the airway of a patient who has a suspected neck injury.
In most cases, it can be accomplished without extending the neck. Grasp the
angles of the patient's lower jaw and lift with both hands, one on each side,
moving the jaw forward. For stability, rest your elbows on the surface on
which the patient is lying. If the lips close, gently open his lower lip with your
thumb (Figure 13-74).

13-89
F M 8-230

Figure 13-74. Jaw thrust method.

e. Establish Breathlessness. Place your ear over the patient's mouth

and nose, look toward his chest and-(Figure 13-75).

• LOOK for his chest to rise and fall;

• LISTEN for air escaping during exhalation; and

• FEEL for the flow of air on your check. If the patient is not
breathing, you must perform rescue breathing.

Figure 13-75. Establishing breathlessness .

13-90
 FM 8-230

f Perform Rescue Breathing.

( 1 ) Use the thumb and index finger of the hand on the patient's
forehead to pinch off his nostrils so that air will not escape.

(2) Take a deep breath, open your mouth very wide and place it
around the outside of the patient's mouth making a seal.

(3) Blow air into the patient's mouth and at the same time look
out of the corner of your eye to see if his chest is rising. If it is, the lungs are
being ventilated. Ventilation should only be forceful enough to raise the
patient' s chest.

(4) Initially give four quick full breaths without allowing time
for full lung deflation between breaths. If breathing has stopped, even for a
short time, some of the small air sacs of the lungs collapse. Four initial breaths
maintain positive pressure in the lungs, thereby, more effectively filling and
ventilating the air sacs (Figure 1 3-76).

(5) If pulse is present but patient is not breathing, you must

perform rescue breathing. One breath is given every 5 seconds (for a
respiratory rate of 1 2/minute). Between breaths you must put your head close
to the patient's face to look, listen, and feel for spontaneous respirations. The
pulse is checked once each minute.

(----\-:-1
/L__l__;

Figure 13-76. Rescue breathing.

g. Establish Pulselessness.

(1) Keep your left hand on the patient's forehead to maintain an

open airway.

(2) Place the middle and index finger of your other hand on the
patient's adam's apple, then move the fingers down toward the side of his neck
(on the side nearest you), locating the carotid pulse (Figure 13-77).

13-91
FM 8-230

(3) Use the carotid pulse because it is accessible and reliable.

(4) NEVER use your thumb because you may mistake your own
pulse for that of the patient. The thumb has a pulse of its own.

Figure 13-77. Establishing pulselessness.

(5) If a pulse is not detectable, you must perform external chest

compressions.

h. Perform External Chest Compressions.

( 1 ) With the middle and index finger of your hand nearest the
patient's feet, locate the rib cage on the side next to you (Figure 13-78A).

(2) Move your fingers up along the rib cage to the notch where
the ribs meet the sternum in the center of the lower chest (Figure 1 3-78B).

(3) With your middle finger on the notch and index finger next to
it, place the heel of your other hand next to the index finger on the lower half of
the sternum (Figure 1 3-78C).

13-92
 FM 8-230

A[--- --�,---�- ....

-- - - .......

'
�, ,- - - - �-- _, / /
,,,.,,,,. --
/

Y- - -- --=-3{.'--
' J:: - Jr -- - - - _,., ,,,
' I ......,... -
' I\
v- �c _ _ _ _

""- ......_
--- - - ,,
...... __

Figure 13-78. Locating hand position on lower sternum.

(4) Move the first hand from the notch and place it on top of the
hand that is on the sternum. Keep both hands parallel with your fingers
pointing straight away from you. The fingers may be extended or interlaced,
but must be kept off the chest (Figure 1 3-79).

(5) To achieve the most pressure with the least effort, with your
arms straight, lean forward until your shoulders are directly over your hands
(Figure 13-80). Depress the patient's chest 1 1/2 to 2 inches. Completely release
this pressure allowing blood to flow into the heart. Repeat the depressions and
release cycles.

!3-93
FM 8-230

Figure 13-79. Position of both hands and fingers.

Figure 13-80. Chest compressions.

13-83. Perform One Rescuer Cardiopulmonary Resuscitation

a. To provide one rescuer CPR-

( 1 ) Perform 15 compressions at the rate of 80 compressions per

minute. Count one and two and three------to 15.

(2) After administering 15 compressions, quickly move to the

patient's head, open the airway, and deliver two quick full breaths.

(3) Move back to the chest, relocate the hand position, and
administer 15 compressions.

13-94
 FM 8-230

(4) Repeat this procedure for four cycles.

(5) After administering four cycles of 1 5 compressions and 2

ventilations, move to the patient's head, locate the carotid artery, and check
for a pulse. If no pulse is felt, open the airway, administer two full breaths, and
resume CPR.

(6) Check the pulse every few minutes. If a pulse is present,

continue rescue breathing only.

b. Sometimes when performing one rescuer CPR, you may be

approached by another individual who can assist you. You should begin two
rescuer CPR immediately. It is more advantageous to administer two rescuer
CPR rather than one because the patient receives more oxygen, the chest
compressions are not interrupted, and the problem of rescuer fatigue is
lessened. Two rescuer CPR should be performed with one rescuer on each side
of the patient.

13-84. Perform Two Rescuer Cardiopulmonary Resuscitation

a. Changing to two rescuer CPR should be performed without

interruption.

( 1 ) The second rescuer identifies and positions himself on the

opposite side of the patient next to his head.

(2) The second rescuer locates the carotid artery and checks for a
pulse while the first rescuer is performing chest compressions (if compressions
are being done correctly, a mechanical pulse should be felt).

(3) The second rescuer informs the first rescuer to stop chest
compressions while he continues to monitor for a spontaneous pulse or
respiration. First rescuer maintains his hand position.

(4) If no pulse or respiration is felt, the second rescuer interposes

two breaths and informs the first rescuer of his findings and advises him to
continue compressions.

(5) The rate of compressions for two rescuer CPR is 60 per

minute. This is accomplished by the first rescuer counting one-one thousand,
two-one thousand, three-one thousand, four-one thousand, five-one thousand,
one-one thousand, and so on.

(6) After every fifth compression, the second rescuer interposes

one breath. The ratio of compression to ventilation for two rescuer CPR is 5 : 1 .
Administer the ventilation on the UPSTROKE of the fifth compression. The
rescuer performing the compressions does not stop to allow for the ventilation.
The transition from five-one thousand back to one-one thousand should be
smooth without any interruption. A pulse check should be made after the first
minute ( 1 2 cycles) of two rescuer CPR and then every 3 to 4 minutes or when
the rescuers change positions.

13-95
FM 8-230

b. Changing position is essential in preventing fatigue.

( 1 ) The first rescuer informs the second rescuer when he is ready

to change by substituting the count of one-one thousand with change-one
thousand, two-one thousand, and so on.

(2) On the upstroke of the fifth compression, the second rescuer

administers one breath and changes position with the first rescuer.

(3) The first rescuer moves to the patient's head and assumes the
role of the second rescuer. He locates the carotid pulse and checks it for 5
seconds. While this is being done, the second rescuer who has now assumed the
role of the first rescuer finds the correct hand placement and waits for the
rescuer at the head to check for a pulse and respiration. If neither is present, he
administers two full breaths and informs the first rescuer to continue
compressions. The procedure of two rescuer CPR is then resumed and not
interrupted again until a change is necessary.

c. CPR should never be interrupted for more than 5 seconds and

should only be terminated for the following reasons:

• The patient revives.

• The patient is pronounced dead by a physician.

• The rescuer(s) is/are relieved.

• The rescuer(s) becomes exhausted and unable to perform CPR.

Section X. UPPER AIRWAY OBSTRUCTIONS

13-85. General

Most upper airway obstructions are caused by large pieces of meat. However,
a variety of foreign bodies have been the cause of obstructions. Obstructions
may be either partial or complete. The individual with a partial obstruction
may have a good air exchange. With a good air exchange, the patient can
cough forcefully; however, it is common to have wheezing between coughs.
Encourage the patient to continue coughing. Never attempt to interfere with
his efforts to dislodge the foreign substance. A poor air exchange is usually
indicated by high-pitched noises when inhaling and weak, ineffective
coughing, with increased difficulty in breathing accompanied by cyanosis
(bluish color of skin and fingernail beds). Partial obstructions with poor air
exchange are treated as though they are a complete airway obstruction. A
patient with a complete airway obstruction is unable to speak, breathe, or
cough. He will have an absence of air movement and requires immediate
assistance.

13-96
 FM 8-230

13-86. Signs of a Airway Obstructions

a. Signs of a complete airway obstruction in a conscious patient.

• Grasping his throat (Figure 13-81).

• Unable to speak.

• Unable to cough or breathe.

b. Signs of a partial airway obstruction in a conscious patient.

• Wheezing between coughs.

• High-pitched noise when inhaling.

• Weak, ineffective coughing.

• Increased difficulty in breathing.

• Unable to breathe.

Figure 13-81. Patient grasping his

throat.

13-87. Treatment for an Airway Obstruction in a Conscious Patient

a. Apply back blows.

(1) Place yourself to the side and slightly behind the sitting or
standing patient.

(2) Place one hand over his sternum for support.

13-97
FM 8-230

(3) Bend the patient at the waist while providing support with
your hand at his sternum and deliver four sharp blows with your other hand in
rapid succession between his shoulder blades (Figure 13-82).
(4) If the obstruction is not cleared, apply the abdominal thrust
as described below.

CAUTION

Never use back blows for patients' with

fractures or suspected fractures of the neck.
Only use abdominal thrust for these patients.

Figure 13-82. Back blows.

b. Apply abdominal thrust.

(1) Stand behind the standing or sitting patient and wrap your
arms around his waist.

(2) Make a fist with one hand and grasp the closed hand with
your other hand. Place the thumb side of your fist against the patient's
abdomen between the umbilicus and xyphoid process (bottom tip of the
sternum (Figure 13-83).

(3) Press your fist into the patient's abdomen four times with
quick inward and upward thrusts.

NOTE

NEVER place your fist on the xyphoid process

or the lower margin of the rib cage. Pressure on
either of these areas can fracture the sternum
or ribs, which may puncture the lungs.

13-98
 FM 8-230

Figure 13-83. Abdominal thrust.

c. Apply chest thrust (alternate method used on obese or pregnant

patients, or patients with abdominal wounds).

(1) Stand behind the sitting or standing patient.

(2) Place your arms directly under the patient's armpits and
encircle his chest.

(3) Place the thumb side of your fist on the CENTER of his
sternum.

(4) Grasp your fist with your other hand and exert four quick
backward thrusts (Figure 13-84).

NOTE

Back blows and manual thrusts are repeated

until the obstruction is dislodged, or until
advanced medical treatment is begun.

d. If the patient loses consciousness, follow the procedures outlined

in clearing an obstructed airway in the unconscious patient.

13-99
FM 8-230

Figure 13-84. Chest thrust.

13-88. Treatment for an Airway Obstruction in an Unconscious Patient

a. Ventilate the patient.

(1) Establish unconsciousness and call for help.

(2) Open the airway and use the "Look, Listen, and Feel"
procedures to establish breathlessness.

(3) If no respirations are noted, perform rescue breathing by

giving four quick breaths.

(4) If unable to ventilate the patient, reposition his head and

attempt to ventilate again.

b. If you are unable to ventilate the patient, apply back blow::..

(1) Kneel and roll the patient onto his side with his chest against
your thigh.

(2) Deliver four sharp blows to the patient 's back between his
shoulder blades (Figure 13-85).

13-100
 FM 8-230

Figure 13-85. Applying back blows.

c. If unsuccessful, apply abdominal thrusts.

(1) Position the patient on his back and kneel beside him with
your knees close to his hips or straddle him (Figure 13-86).

(2) Open his airway and turn his head to one side.

(3) Place the heel of your dominant hand against the patient's
abdomen, in the middle between the xyphoid process and umbilicus (Figure
1 3-86).

(4) Move forward so that your shoulders are directly over the
patient's abdomen.

(5) Press down on his abdomen with four quick inward and
upward thrusts. Do not press to either side.

Figure 13-86. Abdominal thrusts (unconscious patient).

13-101
FM 8-230

d Apply chest thrust (alternative method used on obese or pregnant

patients or patient with abdominal wounds).

(1) Place the patient on his back and kneel close t o his side.

(2) Open the patient's mouth and turn his head to one side.

(3) Place your hands on the lower half of his sternum as you do in
performing CPR.

(4) Exert four quick downward thrusts that compress his chest
1 1 12 to 2 inches as in CPR.

e. Apply finger sweep.

( 1 ) With the patient's head up, open his mouth by grasping both
his tongue and lower jaw between your thumb and fingers and lifting (tongue­
jaw lift) (Figure 1 3-87). If you are unable to open his mouth, cross your finger
and thumb (crossed-finger method) and push his teeth apart (Figure 13-88).

(2) Insert the index finger of your other hand down along the
inside of his cheek to the base of the tongue.

(3) Use a hooking motion to dislodge the foreign body from the
mouth (Figure 13-89).

Figure 13-87. Opening the patient's mouth (tongue jaw lift).

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Figure 13-88. Opening the patient's mouth (crossed-finger method).

A. B.

Figure 13-89. Using finger to dislodge foreign body.

NOTES

1. I f a foreign body can be seen in the mouth,

remove it with the fingers. If it cannot be
seen, use a combination of back blows and
manual thrusts to expel or dislodge it. Then
remove it with the fingers.

2. Do not force the object deeper into the

airway.

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f. Attempt to ventilate the patient.

• If unable to ventilate the patient, repeat back blows, manual

thrusts, and attempts to ventilate as often as necessary until the airway is
cleared of the obstruction.

• If able to ventilate, perform rescue breathing (if patient has no

spontaneous respirations).

g. Record treatment.

h. Evacuate patient, if necessary.

Section XI. MANAGEMENT OF CHEST INJURIES

13-89. General

Open chest injuries can be the result of many causes, but are always serious.
Unless treated rapidly and correctly, the injury can cause permanent damage
to the brain and nervous system. All penetrating chest wounds are treated as
if they are sucking chest wounds; even though penetrating wounds in the
thorax usually seal themselves. An opening in the chest wall that is
approximately 2/3 the diameter of the trachea will severely compromise
respirations.

13-90. Signs and Symptoms of an Open Chest Wound

• A "sucking" or"hissing" sound, produced whenever the patient

inhales.

• Breathing difficulty.

• A puncture wound of the chest.

• An impaled object protruding from the chest.

• Froth or bubbles around the injury site.

• Coughing up frothy, bright red blood.

• Pain in the chest.

• Pain in the shoulder.

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13-91. Treatment for an Open Chest Wound

a. Expose the wound by unfastening or cutting clothing away.

CAUTION

In a chemically contaminated environment

immediately mask the patient (if not already
masked) and quickly apply a dressing. Do not
remove his clothing.

b. Examine the patient for an exit wound. Carefully palpate and/or

visually examine the patient's chest and back to determine the presence and
location of any exit wounds.

c. Treat the larger wound first.

d. Place an occlusive dressing on the chest wound.

( 1) Cut the two short edges and one long edge of the field first aid
dressing plastic outer wrapper and remove the contents.

NOTE

Vaseline gauze can be used, when available, for

the initial dressing instead of the plastic
wrapper. It can be covered by the sterile side of
its plastic or foil wrapper.

(2) Open the wrapper carefully, touching only the edges. Apply
the inner surface to the wound to provide a sterile covering (Figure 13-90). The
covering should be large enough to extend two or more inches beyond the
edges of the wound.

Figure 13-90. Applying occlusive dressing.

13-105
FM 8-230

NOTE

In an emergency, use anything that can cover

the wound and block air entrance.

(3) Tape the dressing on three sides to provide a flutter-type

valve. As the patient breathes in, the dressing is sucked over the wound
preventing air from entering. When the patient exhales, the open end of the
dressing allows air to escape. Securely taping all edges of the dressing can
cause a build up of air within the thoracic cavity and result in a tension
pneumothorax.

NOTE

The bandage may be tied over the wound using

a field first aid dressing, cravat, or other
material if tape is not available.

e. Dress the wound by placing a field first aid dressing over the three·
sided dressing and tie the dressing ends (tails) on the edge of the dressing
loosely so as not to interfere with the flutter valve effect of the three-sided
dressing (Figure 13-91). The purpose of the field dressing is to protect the
wound and absorb secretions.

Figure 13-91. Applying a field first aid dressing.

CAUTION

Bandages tied tightly around the patient's

chest can interfere with his ability to breathe.

f. Place the patient on his injured side to aid in the maintenance of an

open airway (Figure 13-92). This position allows the good lung to function
properly. It also prevents the collection of fluids in the chest cavity.

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Figure 13-92. Patient on injured side.

g. Monitor the patient closely to maintain an open airway and a good

seal on the wound.

h. Record treatment.

i. Evacuate the patient.

13-92. Closed Chest Wounds

a. The various types of clo�ed chest injuries almost uniformly require

the same initial care. The most important immediate consideration in any
chest injury is to establish and maititain an open airway.

b. Fractured ribs result from direct blows and compression injuries

to the chest. The ribs most often fractured are the fifth through the ninth. The
first four ribs are rarely fractured because they are protected by the shoulder
girdle. The lower (floating) ribs ( 1 1 and 12) are attached only to the spine and
have a greater freedom of movement (Figure 13-93).

c. The most serious injury resulting from rib fractures is the "flail
chest. " This occurs when three or more ribs are fractured in two places or the
sternum (breastbone) is fractured. The portion of the chest wall that is left
unsupported by the fractured ribs causes paradoxical breathing (the reverse of
normal respiration). That is, when the patient inhales, his chest moves inward.
When he exhales, his chest moves outward. The lung under the fracture site
does not expand because of the chest being sucked in during inspiration. This
decreases the patient's oxygen intake.

d. Complications that can arise from closed chest injuries are-

• Pneumothorax-an accumulation of air in the chest cavity,

but outside the lung (a fractured rib lacerating the lung).

• Spontaneous pneumothorax-due to the rupture of a bleb

(blister) on the surface of the lung. A large bleb increases the possibility of a
tension pneumothorax.

• Tension pneumothorax-a condition in which air enters the

chest cavity through a hole in the lung which acts as a one-way valve. This
valve allows air to enter the pleural space continuously, but not to leave the
chest cavity. The increased pressure in the chest causes the lung to collapse
but does not seal the hole in the lung. As the pressure on the affected side

13-107
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continues to rise, the collapsed lung is pressed against the heart and opposite
lung. This causes a mediastinal shift of the larynx, trachea, and heart toward
the unaffected side. The uninjured lung is now mechanically compressed. As
pressure in the chest cavity rises, it may cause the great vessels to become
twisted or kinked and compromise or occlude the circulation. Blood can no
longer be pumped from or return to the heart and death results rapidly.
Definite signs of a tension pneumothorax are-

o Severe respiratory distress.

o Weak pulse and lower blood pressure.

o Bulging of the tissue between the ribs and above the

clavicle.

o Distension of the veins in the neck.

o Tracheal deviation away from the affected side.

o Mediastinal shift away from affected side.

Figure 13-93. Rib cage.

• Hemothorax-an accumulation of blood in the chest cavity,

but outside the lung. A hemothorax will frequently accompany a
pneumothorax. The bleeding may come from lacerated vessels in the chest wall
or lacerated maj or vessels in the chest cavity itself.

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 FM 8-230

• Pulmonary contusion (lung bruise)-results from blunt

injuries to the chest. This type of complication will react like a bruise to any
other part of the body. Blood vessels in the lungs are injured and a
considerable amount of blood is lost into the lung. The patient may or may not
have respiratory distress.

• Rupture of maj or vessels-occurs within the chest cavity

(superior and inferior vena cava, pulmonary arteries and veins, and the aorta).
Injuries to any of these vessels may result in massive hemorrhage. Any
patient in shock with evidence of a chest injury should be suspected of having
injured one of the major vessels.

13-93. Signs and Symptoms of a Closed Chest Injury

• Pain at the site of the injury.

• Pleuritic pain-pain that is increased by or occurs with

respirations. It is localized around the injury site.

• Hypoxia-low oxygen content in the blood.

• Dyspnea-shortness of breath or difficult breathing.

• Cyanosis-bluish color of the lips, fingertips, or fingernail beds.

• Subcutaneous emphysema-air in the subcutaneous tissue of the

neck and chest.

• A rapid, weak pulse with low blood pressure-possible shock.

• Hemoptysis-coughing up blood or blood-tinged sputum.

• Failure of one or both sides of the chest to expand normally and

equally on inspiration.

13-94. Treatment for Closed Chest Injuries

a. Simple rib fracture.

(1) Bind the patient's arms to his chest by using three cravats
(Figure 13-94).

(2) Encourage the patient to take deep breaths to inflate his

lungs. This will prevent hypoxemia and atelectasis (collapsed alveoli) by
increasing the air volume and pressure in the alveoli (air sacs) of the lungs.

(3) Administer oxygen (if available).

(4) Record treatment.

(5) Evacuate patient.

13-109
FM 8-230

Figure 13-94. Binding a patient's broken rib.

NOTE

When binding a patient's arm to his chest, do

not apply the cravats so tightly that they
interfere with his breathing.

b. Flail chest.

(1) Establish the airway.

(2) Administer oxygen (if available).

(3) Assist the patient's respiration by using a Bag-Valve-Mask

System, if available, or administer mouth-to-mouth or mouth-to-nose
resuscitation (if necessary).

CAUTION

When administering assisted ventilation,

monitor the patient closely for signs of a
pneumothorax. Positive pressure breathing
can worsen a pneumothorax or convert it into a
tension pneumothorax.

(4) If a tension pneumothorax is suspected and the patient is

cyanotic or manifests signs of cardiovascular compromise (frank
hypotension-cold clammy skin), insert an 18 or 16 gauge needle into the chest
cavity to decompress the pleural space (Figure 1 3-95). Slowly insert the needle
in the second or third intercostal space at the mid-clavicular line until a "hiss"
of air is heard. Get your ear down there and listen! Secure the needle to the
patient and place a flutter valve, or improvised valve (cut finger of a rubber
glove), over the end of the needle (Figure 13-96). The most experienced medical
person available should perform this procedure.

13-110
 FM 8-230

CAUTION

Do not insert the needle on the underside of the

superior rib. All of the blood vessels and nerves
are in this area.

Figure 13-95. Needle insertion sites for tension pneumothorax.

Figure 13-96. Improvised flutter valve.

(5) Start an intravenous infusion at TKO rate (if available) .

(6) Stabilize the flail segment (Figure 13-97).

13-111
FM 8-230

(7) Apply constant firm manual pressure by using sandbags,

pillows, a folded blanket, a field jacket, or a poncho.

(8) Tape the pressure material in place with strips of tape.

(9 ) Have patient lie on the injured side.

NOTE

The chest should not be wrapped or taped

around its diameter. This limits the ability of
the chest to expand and increases breathing
difficulties.

c. Treat patient for shock (if necessary).

d. Record treatment.

e. Evacuate the patient.

CAUTION

A patient with a pneumothorax who is to be

evacuated by helicopter should have a flutter
valve in place. This is to allow the air to escape
that may accumulate in the chest cavity with
atmospheric pressure changes. If a flutter
valve is not in place, the aircraft should be
flown as low as safety and the tactical
situation permits. Closely monitor the patient.

Figure 13-97. Stabilized flail chest.

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 FM 8-230

Section XII. MANAGEMENT OF THE CONVULSIVE

AND/OR SEIZURE PATIENT

13-95. General

a. Convulsions and seizures can occur at any age and are associated
with many diseases and disorders. They follow no single pattern or form. They
usually last from a few seconds to several minutes, but may be even further
prolonged. Loss of consciousness may or may not occur. Do not use the terms
convulsion and seizure interchangeably.

b. Terminology.

• Convulsion is involuntary muscular contractions, usually

accompanied by unconsciousness.

• Seizure is the entire activity, such as, muscular contractions,

incontinence of bowel and bladder, and unconsciousness.

• Aura is a sensation that warns a person of an uncoming

convulsion.

• Clonic is the alternate muscular contraction and relaxation in

rapid succession.

• Tonic is muscle tension (stiffness or rigidity).

c. Causes.

• Head trauma.

• Epilepsy.

• Cerebral vascular accidents (strokes).

• Drug and alcohol withdrawal.

• High fever.

• Other psychologic and neurologic disorders.

13-96. Types of Convulsions/Seizures with Signs and Symptoms

a. Petit mal. Patient appears to be day dreaming (staring into space).

b. Focal (Jacksonian). Usually involves one part of the body in tonic­

clonic twitching (arm or face). It may progress from fingers, toes, or face
twitching on one side to involve one entire limb or side of the patient's body. It
may progress rapidly to a generalized seizure.

c. Grand mal (generalized). In this type of seizure, there is a loss of

consciousness and an intense tonic-clonic activity. The patient may have
incontinence and tongue biting, along with mental confusion. These symptoms
may be followed by drowsiness or coma.

13-113
FM 8-230

d. Status epilepticus. A series of convulsions without intervening

periods of consciousness and is a medical emergency. Repeated convulsions (if
uncontrolled) can lead to aspiration, anoxia (absence or lack of oxygen), brain
damage, fractures of the long bones or spine, trauma to the head, and injury to
the tongue (due to biting).

13-97. Treatment for Convulsive and/or Seizure Patients

The primary purpose of caring for a convulsive and/or seizure patient is to

prevent him from injuring himself. Expedient actions and evacuation to an
MTF are crucial to the patient's health and welfare.

a. Maintain the patient's airway.

(1) Loosen his clothing at the neck.

CAUTION

Patient may have excessive mucous and other

secretions. Close observation is necessary to
prevent aspiration and suffocation.

(2) Remove his dentures (if applicable) or other loose objects

from his mouth.

WARNING

Do not forcibly open the patient's jaw if his

teeth are clenched. To do so may cause injury
to the teeth and gums.

(3) Insert a padded tongue blade between his back teeth (if j aw is
relaxed) or an oropharyngeal airway (J-tube) to prevent him from biting his
tongue and to assist in maintaining an open airway.

(4) Look for a medical warning tag.

CAUTION

Do not elevate his head since it may cause the

tongue to fall back into the throat and obstruct
the airway.

NOTE

Patient will not swallow his tongue.

(5) Turn his head slightly to one side, if possible.

b. Prevent injury to the patient.

(1) Remove or pad objects that may cause injury to the patient
while he is thrashing about on the ground or floor.

13-114
 FM 8-230

(2) Do not restrain his limbs during the seizure as this can cause
muscle injuries and long bone fractures.

c. Closely observe and accurately record all aspects of seizure

activity.

(1) How long did the seizure last? (Be a s accurate a s possible.)

(2) Was there evidence of cyanosis, breathing difficulty, or a

temporary absence of breathing?

(3) What was the level of consciousness (before, during, and after
the seizure)?

(4) Was the seizure preceded by aura?

(5) Which muscles were involved and where did it start?

(6) What type of contractions (tonic, clonic, or both)?

(7) Was there bowel/bladder incontinence?

(8) Does the patient have a previous history of seizures, head

trauma, or drug/alcohol abuse?

NOTE

In Jacksonian seizures, motor symptoms begin

in a hand or foot and move up the extremity, or
spread from a corner of the mouth.

d. After the convulsive state of the seizure-

(1) Place the patient on his side.

(2) Continue to maintain the airway.

(3) Have suction equipment nearby, if available.

(4) Observe for periods of temporary cessation of breathing.

(5) Place the patient in a quiet, reassuring atmosphere to

minimize agitation and combativeness when he begins to wake up. Sudden
loud noises may cause another seizure.

e. Record the patient's actions and the treatment given.

f. Evacuate the patient. The patient must be seen by a physician for

follow-up care to determine the cause of the seizure.Evacuate the patient on a
litter and administer oxygen en route, if available.

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Section XIII. ABDOMINAL AILMENTS AND INJURIES

13-98. General

a. The term "acute abdomen" is used to indicate the presence of any

one of a wide variety of abdominal disorders. An acute abdomen requires
definitive care and usually surgical intervention. Severe pain is present in an
acute abdomen.

b. The primary concerns in the acute abdomen is to recognize the

situation, perform life-saving measures, and evacuate the patient. It is not
important that the aidman be able to make a differential diagnosis.

c. The more common acute abdominal conditions are described in

Table 1 3-3.

13-99. Signs and Symptoms of an Acute Abdomen

• Abdominal pain. Which quadrant is it in and is it localized or

diffused (Figure 13-98)? If localized, it may give a clue as to the organ
involved.

• A bdominal tenderness. Tenderness may be minimal or such that

the patient may "guard" his abdomen by tightening his stomach muscles and
will not allow his abdomen to be touched.

� /1
� EPIGAS TRIUM

� \ ��)PPER LEFT
QUADRANT I QUADRANT
- -- - - , - - - - -
RIGHT
LOWER : LEFT
LOWER

!�
QUADRANT 1 QUADRANT

,3

Figure 13-98. Quadrants of the abdomen.

• Patient position. The patient does not want to move because it

hurts to do so. The position of the patient is an important clue. In some
diseases, the patient fo comfortable in only one position. For example, with
appendicitis the patient may draw up his right knee or both knees. A specific
position helps to relax the muscles adjacent to the inflamed organ and lessen
the pain.

13-116
 FM 8-230

• Rapid, shallow breathing. If breathing is painful, severe

peritonitis may exist. However, increased respiration with any acute pain is
common.

• Tachycardia.

• Low blood pressure.

• A tense, often distended (enlarged or swollen) abdomen.

• Vomiting. Vomiting is not uncommon with an acute abdomen; it

may be bloody or even fecal in nature.

13-100. Treatment for an Acute Abdomen

a. Gently palpate his abdomen (Figure 1 3-99) for signs of­

(1) Rigidity (stiffness) of the abdominal wall.

(2) Pulsating (throbbing) masses (lumps or enlarged organs).

� PATE ABDOMEN FOR

e RIGID ITY--STIFFNESS OF
ABDOMI NAL WALL

e P U LSATING (THROBBI NG)

" , -- MASSES (LUMPS OF

ENLARGED ORGANS) .

Figure 13-99. Palpate the abdomen.

CAUTIONS

1. Occasionally, a n organ within the abdomen

will be enlarged and very fragile. Palpating
can cause rupturing of an aortic aneurysm
(an out-pouching of the artery wall) and
laceration (tearing) of the spleen.

2. Do not give pain medication to the patient.

Pain medication will conceal the signs and
symptoms prolonging the time required to
diagnose the cause.

13-117
FM 8-230

b. Check his vital signs.

c. Initiate intravenous infusion.

d. Treat for shock, if indicated.

CAUTION

Do not give the patient anything to eat or

drink. This may further complicate his
condition and cause vomiting. The patient
may also require immediate surgery. Food
in the stomach and intestines may cause
complications during surgery (vomiting and
aspiration of stomach contents).

e. Obtain a patient history. Inquire about-

( I) Location of the pain. Certain organs, like the stomach, give

reasonably good localization of pain. In diseases of other organs, the patient
may have pain anywhere in the abdomen.

(2) Radiation of the pain. Certain types of abdominal pain have

typical areas of radiation. The pain of pancreatitis often radiates straight
through to the back. Pain from an inflamed gallbladder may radiate around
the right side to the scapula (shoulder blade).

(3) Quality of the pain. Cramping or intermittent pain suggests

involvement of hollow organs.

• Colic-hollow organ.

• Burning-as with excessive acid.

• Boring-as with pancreatitis.

• Sharp-as with perforated organs.

• Pulling-as with ischemic bowel.

(4) Duration of the pain.

• Since onset-if more than 6 hours-pathological.

• Constant or intermittent.

(5) Intensity of the pain (mild or severe).

• Awakes patient from sleep.

• Causes patient to pass out.

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 FM 8-230

(6) Nature of onset of the pain.

• If pain is rapid in onset-moderately at first and

becoming rapidly worse, consider acute pancreatitis or strangulation of the
small bowel.

• Gradual.

(7) Presence or absence of vomiting.

(8) Change in bowel habits or the stools.

• Constipation or diarrhea.

• Bloody or tarry (black) stools.

• Stool morphology (shape)-cylindrical or ribbon.

• Rectal bleeding.

f. Record the treatment given.

g. Evacuate the patient. When in doubt about the patient's

condition or diagnosis, evacuate him as quickly and gently as possible.

13-101. Open Abdominal Injuries

a. The presence of an open abdominal injury can be a shocking

discovery in the evaluation of a casualty. He is not in immediate danger if
there is no profuse internal bleeding or perforated (punctured) organs. Severe
abdominal wounds with perforated organs or heavy bleeding require
complicated and prolonged treatment procedures to improve life expectancy.
Triage would, therefore, require a priority of EXPECTANT in a mass casualty
situation.

b. The most important concern in the initial treatment of abdominal

injuries is shock caused by internal bleeding. Bleeding may be present initially
or may develop later. The presence or absence of bleeding or the size of the
wound are not safe indicators of the internal damage.

13-102. Treatment for an Open Abdominal Injury

a. Survey the patient.

CAUTION

Do not give the patient anything by mouth due

to possible vomiting and aspiration. Fluids
given by mouth can cause damaged internal
organs to leak and result in further intra·
abdominal contamination.

(1) If the patient is thirsty, use a wet gauze to moisten his lips.

13-119
FM 8-230

(2) Place the patient on his back, unless other wounds prevent
it, to keep the internal organs inside the wound.

(3) Turn the patient's head to one side to keep the airway clear,
should vomiting occur.

CAUTION

When an open abdominal wound has arterial

bleeding, the vessel(s) must be occluded (tied or
clamped) to prevent shock or possible death.
This is done ONLY by more highly trained
medical personnel.

b. Apply a field dressing.

(1) Flex the patient's knees to relax the abdominal muscles and
any internal pressure. This is usually the most comfortable position for
bandaging and transporting the patient.

CAUTION

Do not attempt to replace protruding internal

organs since this can cause further injury.
Carefully place the organs on or near the
wound before applying the dressing and to
prevent further contamination. If a foreign
obj ect is protruding from the abdomen, treat
the patient as for other impalement injuries.

(2) Only sterile field dressings are used to · cover open

abdominal wounds. The dressings must be large enough to cover the entire
mass of extruded organs or area of the wound (Figure 13-100).

Figure 13-100. Field dressing placed on the wound

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 FM 8-230

(3) If the plastic wrapper is large enough to extend well beyond

the protruding bowel, place the sterile side directly over the wound with the
dressing on top.

CAUTION

Do not moisten the dressing. A moist dressing

will act as a wick for bacteria to enter. Do not
apply pressure to abdominal wounds or
exposed internal organs. This can cause
further injury, such as ruptured intestines. To
avoid pressure on the injury, tie the dressing
(tails) loosely at the patient's side, not directly
over the dressing.

(4) If more than one dressing is needed to cover a large wound,

repeat the previous procedures. Do not tie the dressing knots over each other.

(5) Cover field dressings with cravats for added support and
protection. Tie the cravat on the side opposite the dressing ties (Figure
1 3-101).

F I E L D D R E S S I N G S A R E TO BE COV E R E D A N D LOO S E L Y T I E D
W I T H CRAVATS FOR S U PPORT A N D A D D I T IONAL PROT E C T I O N .
ON T H E OPPOS I T E S I D E OF T H E D R E S S I N G T I E S .

Figure 13-101. Cravats tied o n the side opposite the dressing.

c. Insert a large bore IV and infuse lactated Ringer's solution.

NOTE

The IV is started at a rate of 10 milliliters per

hour and is increased if signs of shock develop.
If available, MAST trousers should be applied
to treat shock. DO NOT inflate the abdominal
section if internal organs are protruding from
the wound.

d. Record treatment.

e. Evacuate the patient.

13-121
FM 8-230

• If evacuation to the MTF is delayed, the patient must

be monitored frequently (every 15 minutes or less, if possible) for signs of
shock.

• Evacuate the patient with his knees flexed.

Section XIV. IRRIGATION OF THE EAR

13-103. General

a. Irrigation of the ear is the flushing of the external ear canal with
a gentle stream of solution. The ear may be irrigated to-

• Cleanse the external auditory canal.

• Soften and remove impacted wax (cerumen).

• Apply heat to the tissues of the ear canal.

• Apply antiseptics or medications.

b. Never use irrigation procedures to remove foreign objects such as

beans or corn. Moisture causes vegetable matter to swell. Irrigations are not
used if a patient's eardrum is punctured. The additional irritation can cause
middle ear infection by transmitting debris or discharge from the external
canal to the middle ear.

13-104. Treatment for an Obstructed Ear

a. Verify the need for irrigation of the ear.

b. Perform patient care handwash.

c. Gather the necessary equipment.

( 1 ) Collect the irrigating syringe, protective drapes, otoscope

set, emesis basin, irrigating solution, and at least two 4- by 4-inch sponges.

NOTE

There are three general types of syringes used

to irrigate the ear: a rubber bulb syringe, an
asepto syringe, and a metal Pomeroy syringe
(Figure 13-102). Common solutions used to
irrigate the ear include tap water, normal
saline, hydrogen peroxide and water mix, or a
solution of bicarbonate of soda and water. The
hydrogen peroxide and water mix is often used
to soften and remove impacted ear wax.

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 FM 8-230

RUBBER BULB
ASEPTO (Glass)
POMEROY (Metal)

Figure 13-102. General types of syringes.

(2) Use the otoscope to see the external ear canal. It comes
equipped with specula of differing sizes. The speculum is an instrument used
to expose the interior passage of a body cavity (in this case, the ear).

(3) When viewing the external ear canal with the otoscope, use
the largest speculum that will fit comfortable into the meatus (opening) of the
ear in order to see the largest portion of the external ear. Before and after use,
cleanse the speculum with alcohol.

d. Warm and test the irrigating solution. Warm the irrigating

solution and test the temperature by allowing a small amount of the fluid to
run on the inner part of your wrist. If the solution feels hot, wait until it cools.
It may be necessary to prepare the irrigating solution. Request supervisor's
assistance if solution mixing is necessary. Mixing solutions may be warmed by
placing the container of solution in a pan of warm water. The irrigating
solution should be about body temperature (950 to I 050F). Solutions that
are warmer or cooler than the body temperature feel uncomfortable for the
patient and may cause tissue injury, nausea, or dizziness.

e. Explain the irrigation procedure. Tell the patient what is to be

done and ask for his cooperation and assistance. He may feel some discomfort
when the solution is introduced into the ear, but he must remain as still as
possible. If he moves, the syringe may damage the ear canal or tympanic
membrane.

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f. Insert an otoscope speculum into the external ear canal.

(1) Tip the patient's head toward the shoulder opposite the ear
to be irrigated.

(2) Straighten the external ear canal by gently pulling the

auricle upward and backward (Figure 13-1 03).

Figure 13-103. Straightening the external ear canal.

(3) Turn on the otoscope light and gently insert the speculum
just inside the opening of the ear (Figure 13-104).

(4) Look into the ear canal through the lens of the otoscope.

Figure 13-104. Speculum inserted in the ear opening.

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NOTES

1. Ask the patient if he has had a history of

draining ears or if he has ever had a
perforation (puncture) of the eardrum or
other complications from a previous
irrigation. If the answer is yes, check with
your supervisor before irrigating the
patient's ears.

2. The inner two-thirds of the external meatus

(opening) is sensitive to pressure. To avoid
causing the patient any pain, insert the
speculum gently and not too far into the ear
canal.

g. Observe the external ear canal and tympanic membrane. Check

the external ear canal for redness, swelling, drainage, or foreign bodies. Also
check for bulging or perforation of the tympanic membrane in addition to the
color.

NOTES

1. The external ear canal i s normally clear,

with small amounts of wax. If redness,
swelling, or discharge are present, do not
irrigate the ear, but report it to your
supervisor.

2. A normal, healthy tympanic membrane is

slightly cone-shaped, shiny, translucent,
and pearly gray in color. When disease is
present, the eardrum changes color. If a
blue, yellow, amber, red, or pink color is
observed, it usually indicates disease or
infection and the ear should not be irrigated.

3. An outward bulging of the eardrum

indicates the presence of pus or fluid in the
middle ear. Do not irrigate the ear.

h. Reposition the patient, if necessary. Place the patient in a sitting

or lying position, if necessary. Tilt his head slightly toward the side to be
irrigated.

CAUTION

Do not tum the patient's head toward the

unaffected side. This interferes with the return
of the irrigating solution.

i. Drape the patient. Place a protective drape (towel) under the

affected ear, covering the shoulder and upper arm.

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j. Place one of the sponges in the irrigating solution, wring out

excess solution, and clean any debris from the external ear and meatus of the
ear canal.

NOTE

Cotton swabs can be used for cleansing the

auricle (external ear) area only. This will
prevent carrying any debris or discharge
deeper into the ear canal when the speculum is
inserted.

CAUTION

Do not insert the cotton swab too far into the

ear. This could rupture the tympanic
membrane.

k. Fill the irrigating syringe.

(1) Grasp the syringe bulb end or plunger.

(2) Depress the bulb or plunger of the irrigating syringe.

(3) Place the tip of the syringe into the solution.

(4) Release the bulb or pull back the plunger to fill the syringe.

l. Test the flow of the solution from the syringe. Discharge a small
amount of solution back into the container. This will expel the air and aid in
determining the amount of pressure required to make a steady, gentle stream.
If necessary, fill and refill the syringe several times to obtain a"feel" for a
smooth operation prior to irrigation.

m. Position the emesis basin. Place the emesis basin just below the
ear on the affected side. Press the basin firmly against the patient's neck
(Figure 1 3-105). Instruct him to hold the basin in place.

n. Straighten the ear canal. Gently grasp the auricle of the affected
ear and gently pull up and backward.

o. Irrigate the patient's ear.

( 1 ) Place the tip of the irrigation syringe just inside the meatus
of the ear with the tip directed toward the roof of the ear canal (Figure 1 3-106).
Directing the angle of the flow toward the roof of the ear canal prevents
injuring the eardrum and forcing any material or debris into the canal. A
circular current is set up with fluid flowing in along the top and out the bottom
of the canal.
(2) Depress the bulb or plunger of the irrigating syringe.

(3) Direct a slow, steady stream of irrigating solution against

the roof of the ear canal.

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Figure 13-105. Basin placed below the ear. Figure 13-106. Irrigation syringe
placed inside the ear.

CAUTION

Never completely block the ear canal with the

irrigating syringe. If space is not left around
the syringe tip, the solution will not be able to
return and pressure in the canal will result.

p. Repeat steps k. through o. above until the irrigating solution

returns free of wax and debris.

NOTE

If the physician or supervisor has not specified

the amount of solution to be used, only use 500
cc's. This is sufficient for cleaning the canal. If
no material comes out with the return flow
from the ear, repeat the procedure or notify the
physician.

q. Dry the external ear. Remove the emesis basin and wipe any
solution from the external ear with a 4- by 4-inch sponge.

r. Have the patient keep his head tilted toward the affected side for
a few minutes. This will allow any remaining solution to drain out of the ear.

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s. Remove the drape.

t. Dispose of and/or clean and store the equipment used.

u. Perform patient care handwash.

v. Report and record the irrigation procedure. Include the date and
time of irrigation, kind and amount of solution used, and nature of the return
flow. EXAMPLE: 21 Mar 84, 1 500: Right ear irrigated with 500 cc's warm tap
water. Returning solution contained brown wax particles. John Doe, PFC,
91A10.

Section XV. MANAGEMENT OF EYE INJURIES

13-105. General

a. Emergency medical care for eye injuries is extremely important

to the patient, especially on the battlefield. The eye injury may not only cause
severe pain, but loss of orientation due to loss of or decreased sight. The
patient with an eye injury may have total or at least partial loss of one of his
senses. He must constantly be reassured that what is being done for him is to
save his eyesight.

b. Even though only one eye is injured, both eyes must be

bandaged. Since both eyes move together, any movement of the uninjured eye
will cause the same movement of the injured eye. This involuntary movement
can cause further damage to the injured eye.

13-106. Irrigating the Eyes

Eye irrigation is washing the eye surface or conjunctiva! sac with a gentle
stream of liquid. The conjunctiva (mucous membrane) lines the eyelids and
surrounds the eyeball. Irrigations are given for various forms of conjunctivitis
(inflammation of the conjunctiva), for cleansing, to combat infection, or for
treating chemical injuries to the eyes.

13-107. Procedure for Irrigating the Eyes

a. Verify the requirement for irrigation.

(1) Check the doctor's orders. Follow the supervisor's directive

or the local SOP.

(2) Be sure you have the correct type and proper concentration
of the irrigating solution.

(3) Make sure you know which eye requires treatment.

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NOTE

Right eye-0.D. (oculus dexter);

Left eye-0.S. (oculus sinister);

Both eyes-0.U. (oculus uterque).

b. Verify the patient. Ask the patient his name. Check his
identification band , if available.

c. Inform the patient. Tell him of the need for the eye irrigation.
Explain the procedure.

d. Position the patient.

(1) If the patient is in bed or on a litter, have him lie on his back
with his head turned slightly to the side to be irrigated.

(2) If he is sitting up, have him tilt his head slightly backward
and to the side that is to be irrigated. Support his head while irrigating the eye.

e. Protect the patient from splash. Cover him with a waterproof

cover and/or towel in areas that may be splashed by the solution.

NOTE

When irrigations are used for any type of

conjunctiva! infection (pink eye), take every
precaution possible to control the spread of the
disease to health care providers, to other
patients, or to the uninfected eye. A
waterproof transparent protective dressing
(Buller's shield) is recommended to protect the
noninvolved eye of the patient. You may
protect your eyes by wearing glasses or
goggles.

f. Position the "catch" basin.

( 1 ) Place an emesis basin next to the affected side of the face in

a position to catch the outflow. If a basin is not available, have the patient hold
a towel or sponge near the eye to catch the fluid.

(2) Show the patient how to hold the basin to the side of the
face to receive the irrigating solution.

g. Position the light. If necessary, position the light so that you can
see. However, do not shine the light directly into the patient's eye(s).

h. Perform patient care handwash.

i. Clean the eyelids. Before irrigation, carefully clean the eyelids

with sterile water. Remove any secretions or particles that may be adhering to
the lashes and that could be carried into the lacrimal area (the tear gland area).

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MOIST HEAT is of great value in cleaning discharge and crusts from the
eyelids. A gauze sponge soaked in comfortably warm water and squeezed free
of excess water can be placed OVER THE CLOSED EYE for several minutes.
This helps loosen and remove adherent crusts and matter. A small piece of
moist cotton or gauze may then be used to remove any remaining debris.

j. Separate the eyelids. Separate the eyelids very gently by placing

the thumb and index finger of your nondominant hand on the cheek and brow
(just below and above the eyelids) and apply gentle tension to open the lids.

CAUTION

N E V E R PUT PRE SSURE ON THE

EYEBALL. Pressure on the eye must be
avoided. The eye is not rigid and is very
sensitive to any pressure.

k. Irrigate the eye.

( 1 ) Make sure that the prescribed irrigation solution is at body

temperature. Direct the flow of the fluid gently from the INNER CANTHUS
to the OUTER CANTHUS along the conjunctiva! sac (Figure 1 3-107).
Instruct the patient to look down. Having the patient look down exposes the
upper part of the eye for irrigation. Instruct the patient to look up. Having the
patient look up exposes the conjunctiva in the lower part of the eye for
irrigation.

(2) Use only that pressure (force) of the liquid stream that is
required to maintain a steady flow. The amount of solution varies with the
desired effect.

(3) Do not touch the eye during irrigation. You must avoid
contamination of the solution or irrigator and possible injury to the eye.

UPPER EYELID PUPIL

IRIS
', MARGIN OF ORBIT
'(
/
(BONY CAVITY)
\

\ OUTER CANTHUS

NASOLACRIMAL DUCT

Figure 13-107. The eye.

13-130
 FM 8-230

l. Dry the eyelids. Gently pat the eyes after the sac has been
thoroughly flushed.

m. Perform patient care handwash.

n. Record the treatment given. Record the kind and amount of fluid
that was used and the effect on the patient.

13-108. Foreign Bodies in the Eye

Pieces of dirt and debris, particles of rust, or similar small obj ects can blow or
fall into the eyes. The material usually sits on the surface of the eyeball or
becomes stuck between the eyelid and eyeball. Often, if the patient closes his
eyes for a few moments, the tears will move the obj ect to the corner of the eye
where it can be removed. Most other obj ects can be safely removed by gently
washing them out with water. Other objects can be removed by gently wiping
them away with a slightly moistened cotton swab or the edge of a clean
handkerchief.

13-109. Treatment for Foreign Bodies in the Eye

a. Locate the foreign body.

CAUTION

If there is any evidence of damage to the

eyeball, or if any object is suspected of sticking
into the eyeball, STOP. Make no attempt at
treatment. You may cause additional tissue
damage. Put a light bandage on both eyes and
evacuate the patient to an MTF.

(1) Method one.

• Pull down on the lower eyelid.

• Have the patient look up while you look for the foreign
object.

• Next, have him look to one side, then the other while
you look for the foreign object.

• Pull the upper eyelid up.

• Have the patient look down while you look for the
foreign object.

(2) Method two.

• Ask the patient to look down.

• Grasp the eyelash of the upper eyelid with your thumb

and index finger.

• Gently pull the lid away from the eyeball.

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FM 8-230

• Place a cotton-tipped applicator horizontally along the

center of the outer surface of the upper eyelid.

• Pull the eyelid forward and upward, causing it to roll or

fold back over the applicator. The under surface of the lid should be exposed.

• Look for the foreign object.

• Release the upper eyelid and pull the lower eyelid down.

• Have the patient look up.

• Look for the foreign object.

b. Remove the located foreign obj ect.

( 1 ) Gently wipe away or pick up the object with a slightly

moistened cotton swab or the edge of a clean handkerchief or other soft cloth
material.

OR

(2) Gently wash the object out by allowing water to flow from
the inner canthus to the outer canthus of the eye (Figure 1 3-107). Use the
thumb and index finger to keep the eye open. (Refer to paragraph 1 3-107,
Procedures for Irrigating the Eyes.)

CAUTION

Do not apply excessive pressure on the eyeball.

If required, pressure should be applied on the
bony area surrounding the eye.

NOTES

I. If any foreign body cannot be removed

easily by one of these methods, bandage the
eye and evacuate the patient.

2. If the patient is having pain or if there is a

loss of vision, bandage both eyes and
evacuate.

c. Obtain a patient history.

( 1 ) Determine the source and type of the foreign body. The type
of foreign body will influence the amount of tissue destruction and the time
necessary for healing. Particles of copper or brass are usually more irritating
then iron or steel.

13-132
 FM 8-230

CAUTION

Never attempt to judge the seriousness of an

eye injury by its external appearance.
Superficial injuries are often more painful than
deep penetrating ones.

(2) Were the particles high velocity or wind blown? High

velocity particles are more likely to penetrate or perforate the cornea. Wind
blow particles are more likely to only embed themselves superficially.

(3) What is the duration and/or time of onset of discomfort?

(4) Have any ointments or irrigation solutions been applied?

(5) Is there any history of previous injuries to the eye?

d Record the treatment given.

e. Evacuate the patient, if necessary.

13-110. Lacerations, Contusions, and Extrusions of the Eye

Tissue damage to the area surrounding the eye or to the eyeball itself is
classified as-

• Lacerations. Torn, ragged or mangled wounds of the tissue

around the eye or to the eyeball.

• Contusions. Bruises of the tissue around the eye or bruises of the

eyeball.

• Extrusions. The eyeball is pushed or forced out of its socket.

13-111. Examine Patient for Eye Injuries

a. Survey the patient.

b. Position the patient.

• Remove the patient's headgear.

• Place the conscious patient in a sitting position.

OR

• Place the unconscious patient on his back with his head

higher than the rest of his body.

13-133
FM 8-230

NOTES

1. Make the patient a s comfortable a s possible

without causing him further injury. A
sitting position helps control pain and
bleeding.

2. Make sure that the unconscious patient's

airway is clear. A small article of clothing
rolled up and placed under the neck will hold
the head in a position to keep the airway
clear.

c. Check the patient' s eyes for-

• Foreign objects protruding from the eye.

• Swelling or lacerations of the eyeball.

• Bloodshot sclera.

• Bleeding surrounding the eye or from the eyeball.

NOTE

During the examination, ask the patient if he is

wearing contact lenses. If he is, record this
information. Never force the eyelid open to
check for contact lenses.

d. Determine the injury category.

• Laceration or contusion (injury to the tissue surrounding the

eye(s)).

• Injury to the eyeball(s).

• Injury to the eye(s) with protruding object(s).

• An extruded or avulsed eyeball.

NOTE

An avulsed eye is one that is torn from the

socket. It is also called an extruded eyeball or
an enucleation.

13-112. Treatment for Lacerations, Contusions, and Extrusions of the Eye

a. Treat an injury to the tissue surrounding the eye(s) (Figure

1 3-108A), if applicable.

( 1 ) Cover the injured eye with an eye pad or other small sterile
dressing to keep it clean or to control bleeding (Figure 1 3-108B). Unlike other
bleeding wounds, do not put pressure on eye wounds because this can cause

13-134
 FM 8-230

more damage. If the eyelid is injured with no injury to the eyeball, a dressing
and bandage is placed over the wound. Handle torn eyelids very carefully to
prevent further injury.

(2) Place a first aid field dressing over the eye pad. Gauze or
other bandaging materials may be used.

(3) Secure the dressing.

(a) Wrap one tail over the top of the head (Figure
13-108C).

(b) Let the other tail hang free under the ear on the injured
side (Figure 13-1080).

(c) Cross the tails under the ear on the inj ured side, then
pass one under the chin (Figure 13-108E) and the other one over the head.

(d) Tie them on the opposite side from the injury (Figure
13-108F).

Figure 13-108. Injury to tissue surrounding the eye(s).

13-135
FM 8-230

NOTES

1. Make sure that the tail under the chin does

not slip down on the neck and interfere with
the patient's breathing.

2. If the injury is to the tissue around the eye

and not the eyeball, only bandage the
injured eye.

3. D o not cover the nose, mouth, or ears with

the dressing.

b. Treat an injury to the eyeball, if applicable.

(1) Follow procedure in a .

(2) Additionally, cover both eyea with pads and dressings.

NOTES

1. Bleeding may not be present.

2. Do not apply pressure to the eyeball. If the

jelly-like vitreous humor fluid is squeezed
from the eyeball, it cannot be replaced nor
can the body replace it by natural
regeneration. Loss of the fluid will result in
blindness.

3. In hazardous surroundings you may leave

the uninjured eye uncovered long enough to
insure the patient's safe exit from the area.

(3) Tell the patient not to squeeze his eyelids together.

Squeezing them together can exert pressure on the eyeball and cause further
damage.

c. Treat an avulsed or extruded eyeball.

CAUTIONS

1. Do not attempt to replace the eyeball into

its socket. Replacement must only be done
by a physician under sterile conditions. To
replace the eyeball under other than sterile
conditions can increase the injury.

2. Detachment of the retina may result from

such an injury if the patient is not kept quiet
and on his back.

( 1 ) Cut a hole in several layers of bulky dressing material, then

moisten the material.

13-136
 FM 8-230

(2) Place the dressing so that the protruding eyeball is

surrounded by the dressing (Figure 13-109). The dressing should be built up
higher than the eyeball. A paper cup or cone-shaped thin cardboard can be use
to cover the eye without placing pressure on it (Figure 1 3- 1 1 0).

Figure 13-109. Dressing around Figure 13-110. Placing a paper cup over
protruding eyeball. protuding eye.

(3) Place a first aid dressing over the eye and built - up,
moistened dressing.

(4) Bandage both eyes (Figure 13-1 1 1) .

Figure 13-111. Both eyes bandaged

with paper cup in place.

13-137
FM 8-230

d. Record the treatment given.

e. Evacuate the patient. If the patient wears glasses, evacuate them

with him even if they are broken. Always evacuate patients with avulsed or
extruded eyes on a litter. They must remain on their back.

13-113. Burns of the Eyes

a. Three major types of burns that can affect the eye are: chemical,
radiant energy (intensely bright light), and thermal. The correct initial
emergency treatment applied to injured eyes will not only help relieve pain but
will also help prevent further injury and possible loss of vision.

b. Chemical burns can cause severe eye injury and require

immediate emergency treatment. Acid and alkali chemicals will eat into eye
tissues if they are not flushed out immediately.

c. Radiant energy injuries are caused by bright visible light (electric

welder arcs or laser sources), ultraviolet, infrared, or other forms of light
energy that are not visible (including microwaves and radar waves) There are
no specific immediate first aid treatment for these burns.

d. Thermal (heat) burns are given the same initial treatment as

other burns of the face. No dressing is applied since burned eyelids swell and
further protect the eyes underneath.

13-114. Treatment for Other Problems in Patient with Bums to the Eyes

a. Check for and treat any life-threatening conditions, such as,

difficult breathing, heart failure, or severe bleeding.

b. Reassure the patient that medical aid will be provided.

( 1 ) When the eyes are burned or injured, individuals are easily

frightened and are fearful of losing their sight.

(2) Never try to cheer a patient with a favorable prognosis since

it could be incorrect.

13-115. Signs and Symptoms of Chemical Burns of the Eyes

• Pain.

• Redness of the sclera and/or conjunctiva.

• Watering or tearing.

• Possible erosion of the corneal surface caused by long exposure

to chemicals.

13-116. Treatment for Chemical Burns of the Eyes

a. Flush the eyes immediately with large amounts of water for 20

minutes.

13-138
 FM 8-230

b. Gently hold the patient's eyes open with your fingertips and pour
large amounts of water directly into the eyes (Figure 1 3-1 1 2).

Figure 13-112. Flushing the patient 's eye

with water.

NOTE

The pain may make it very difficult for the

patient to keep his eyes open.

c. If possible, use sterile water to flush the eyes. If it is not

available, use potable (approved for drinking) water.

d. If water is not available, use an intravenous solution (saline

solution, Ringer's lactate) with tubing.

e. Chemicals (particularly alkalis) tend to stick to the eye and may

not be flushed easily. Continue flushing with water if alkali particles are in the
eye.

f. If only one eye is involved, lean the head toward the injured side
for flushing. Insure that no chemicals enter the uninjured eye.

g. Cover the eyes. Follow procedure outlined in paragraph 13-1 1 2.

NOTE

If eye burns are caused by petroleum products,

flush the eyes with large amounts of water.
Petroleum products such as gasoline, kerosene,
jet fuel, or oil do not have a specific treatment.
These products are very irritating and painful,
but eye damage does not often result from a
short exposure. Flushing the eyes with water
provides relief and helps the patient feel more
comfortable.

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FM 8-230

13-117. Signs and Symptoms of Radiant Energy Burns of the Eyes

The effects of radiant eye burns from electric welding processes often do not
appear until several hours after exposure. Common symptoms are:

• Gritty feeling, as if something is in the eyes.

• Severe pain in the eyes.

• Inability to tolerate light.

• Watering or tearing of the eyes.

NOTE

Recovery and pain relief from these burns will

usually take place within two to three days.

13-118. Treatment for Radiant Energy Burns of the Eyes

No specific treatment is recommended, although bandaging of the eyes often

makes the patient more comfortable.

13-119. Signs and Symptoms of Laser Eye Injuries

• Pain is not usually present.

• Immediate decrease in vision caused by injury to the retina

(inner back portion of the eyeball that is sensitive to light).

13-120. Treatment for Laser Eye Injuries

Immediate first aid is not usually required. Bandaging the eye may make the
patient more comfortable and protect his eyes from further injury by exposure
to other bright lights or sunlight.

13-121. Signs and Symptoms of Thermal Eye Injuries

• Charred or swollen eyelids.

• Singed eyelashes.

• Pain or irritation.

13-122. Treatment for Thermal Eye Injuries

a. Remove the patient from source of danger (fire or extreme heat)

immediately.
b. If patient's clothing is on fire, roll him on the ground to
extinguish the fire and minimize the chance of further burns.

c. Thermal burns of the eyes and eyelids are treated as burns of the
face. No dressing should be used.

NOTE

Treatment for burned eyelids requires

specialized care.

13-140
 FM 8-230

d. Protect patient from exposure to direct sunlight. Prolonged

exposure can result in further tissue inj ury.

e. Record the treatment given.

f. Evacuate the patient.

Section XVI. APPLICATION OF RESTRAINING DEVICES

13-123. General

Restraints are employed to immobilize a patient and to prevent him from

harming himself or others. The patient's response to being restrained is rarely
submissive. In many instances, he views the application of restraints as a
personal, physical assault; he is frightened and responds by becoming
combative. He is fearful of what is happening and is trying to protect his
freedom.

13-124. Principles for the Application of Restraining Devices

a. Do not attempt to apply restraining devices alone. There must be

an adequate number of personnel available to safely and efficiently restrain
the patient.

b. The ankles and wrists must be padded before applying the

restraints. Padding prevents chafing or cutting the skin.

c. Restraints should fit snugly to prevent escape, but should not

restrict circulation or impair breathing. To check the tightness, insert two
fingers under the restraining straps. If the fingers can be comfortably
inserted, the restraining strap is snug and should not restrict circulation or
impair breathing.

d. Restraints must be placed so as not to cause injury or interfere

with therapeutic treatment. However, the restraint must prevent the patient
from removing therapeutic devices.

e. When ankle restraints are applied, wrist restraints must also be

applied. The wrist restraints will prevent the patient from using his hands to
place himself in a position to hang from his ankles or to release the ankle
restraints.

f. Never restrain a patient on a portable commode or rocking chair.

Both can be tipped over.

g. Do not attach the straps to the bed side rails. If the side rails are
lowered, the patient could be injured.

h. Do not restrain a depressed patient or one having an altered level

of consciousness on his back with his limbs at his side. Place these patients in
a prone position prior to applying the restraints. Placement in a prone position
prevents aspiration should the patient vomit.

13-141
FM 8-230

NOTE

Aspiration and suffocation are potential

dangers because the patient may have
difficulty handling his secretions or emesis.

i. Check the patient at least once every half-hour for signs of

distress. The patient needs to know that you are concerned about his physical
and emotional needs and that he is not being punished. The patient needs to
know that he has not been abandoned and that the restraints are a therapeutic
tool used to help him.

j. Release the restraints one at a time and change the patient's

position at least once every 2 hours. Release avoids excessive stiffening of
muscles. Exercise each limb through its normal range of motion.

k. A restraint key must accompany the patient. Whenever a patient

is placed in a locked restraint, all personnel must carry a key. In the event of a
medical or environmental emergency, the restraint can be quickly unlocked.

L A restrained patient should be in a comfortable position. The

head of the bed or litter may be elevated so that the patient can see his
environment. This will assist in the patient's reorientation and decrease his
confusion.

13-125. Prepare to Apply the Restraints

a. Check the doctor 's orders or the Therapeutic Documentation

Care Plan (Nonmedications). Verify restraints or follow your supervisor's
directive indicating that the patient is to be restrained and the type of
restraining equipment to be employed.

NOTE

In a field environment the need for restraints

may be your own decision, especially in the
absence of a senior medical specialist or
physician.

b. Obtain the necessary equipment. Gather prescribed type of

restraining equipment and necessary padding. Improvised restraining
materials may be used. The common improvised materials used are abdominal
(ABD) pads, washcloths, gauze sponges, sponge rubber, roller gauze, and
elastic bandages.

c. Identify the patient. Ask the patient to identify himself. Verify

his name by checking his bedcard and identification band.

d. Explain the procedure. Speak in a quiet, calm, reassuring voice to

explain to the patient why the restraints are being applied and to gain his
cooperation. It may be necessary to repeat the explanation at frequent
intervals, especially if the patient has been medicated with mind-altering
drugs or is confused. It is essential that the patient's family and friends
understand as well.

13-142
 FM 8-230

NOTE

If the patient is agitated or combative, keep

the restraints out of his vision until he is in a
position to be restrained.

e. Provide privacy. Place a screen/curtain around the patient's bed

or close the patient's room door. Provide privacy to avoid upsetting other
patients or causing embarrassment to the patient being restrained.

13-126. Apply the Restraints

Apply wrist and ankle restraints. Use wrist and ankle restraints when it is
necessary to restrict movement of the limbs. They may be used for a patient
who is potentially harmful to himself or to others, to prevent the patient from
removing tubes or other appliances, or to immobilize a part while a procedure
is being done. These restraints may be leather, linen, or improvised from other
materials.

NOTE

Disposable and reusable linen may be used as

wrist and ankle restraints, but only if the
purpose is to limit movement. They are not a
secure method of restraining violent patients.

a. Apply an adjustable limb holder.

(1) Clean the skin o f the wrists and ankles and powder it.

(2) Pad the limb with an ABD pad. Some cloth restraints are
prepadded with soft flannel or cotton which eliminates the need to apply
additional padding.

(3) Position the restraint over the limb and bring the strap,
which is sewn at the taped end, through the slot in the broad end (Figure
1 3-1 1 3).

Figure 13-113. Limbholder or wrist restraint.

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(4) Pull the strap snug enough to restrict free movement of the
extremity and tie the strap to the bedframe.

CAUTION

Do not tie restraints with a square knot. The

square knot will be difficult to release quickly
in the event of an emergency. The bowknot is
easily untied. It should be placed where the
patient cannot untie it.

(5) Repeat the above steps to restrain the other three limbs.

b. Apply improvised restraint.

(1) Clean the skin of the wrists and ankles and powder it.

(2) Pad the limb with any soft cloth, such as towel, clothing,
gauze, compresses, or clean handkerchief.

(3) Secure the restraining material to the limb with a clove

hitch (Figure 1 3- 1 1 4).

STEP 1 STEP 2

STEP 3 STEP 4

Figure 13-114. Improvised restraint.

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(4) Pull the knot to fit the limb snugly and tie both free ends to
the bedframe.

(5) Repeat the steps above for the other three limbs.

c. Apply mitt restraints.

(1) Place the patient's hand i n a naturally flexed position.

(2) Place soft rolled dressing or a washcloth in the patient's

hand and close the hand. The soft material allows unrestricted circulation and
minimal strain to the muscles.

(3) Wrap the entire hand snugly with Kerlix bandage.

NOTE

Commercially prepared mitts may be used if

available.

d. Apply restraint using a sheet and a litter.

NOTE

This restraint is extremely uncomfortable and

it should only be used as a temporary restraint.

( 1 ) Unfold a sheet and stretch it lengthwise, while holding at

opposite comers. Twirl the sheet into a tight roll.

(2) Place the patient in a prone position on the litter with his
head turned to one side.

(3) Place middle of the roll diagonally across the patient's

upper back and shoulder.

(4) Bring both ends of the sheet under the litter. Cross the ends
under the litter. Bring one end up over the shoulder and the other end over the
upper back. Snugly tie the ends in the middle of the upper back.

(5) Secure one wrist to the litter, parallel to his thigh, using a
wrist restraint.

(6) Secure the other wrist, overhead, to the nearest litter­

carrying handle, using a wrist restraint.

NOTE

This position will prevent the patient from

pushing himself up from the litter. It will also
keep his arms and hands within the confines of
the litter.

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d. Apply restraint using a sheet and bed.

(1) Fold a sheet in half, lengthwise.

(2) Tuck approximately 2 feet of one end of the sheet under one
side of the mattress, level with the patient's chest. Make sure there is enough
sheet under the mattress to prevent it from being easily pulled from under the
mattress.

(3) Bring the other end of the sheet under the patient's arms,
over his chest. Tuck the free end of the sheet snugly under the other side of the
mattress. Make the restraint snug enough to prevent the patient from
wiggling free.

NOTE

Sheets may also be applied in the same manner

across the patient's abdomen, legs, knees, and
ankles, if further restriction is desired.

e. Apply field-expedient restraints. Under field conditions,

standard restraining devices may not be available. Nevertheless, violent
patients must be restrained, utilizing materials commonly carried by the
soldier in the field. Field-expedient restraints may be improvised from such
items as two litters, rifle slings, web belts, bandoleers, and cravats. Replace
field-expedient restraints with regular restraints as soon as possible. Do not
use field-expedient restraints for long periods of time. With any field­
expedient restraint, follow the same considerations as in applying regular
restraints.

( 1 ) Mixed equipment. Mixed equipment can consist of rifle

slings, web belts, bandoleers, cravats, and ropes. Apply mixed equipment
restraints as shown in Figure 13-1 15.

Figure 13-115. Mixed equipment restraint.

(2) Double litters with litter straps.

(a) Place the patient on a litter in the prone position with

his head turned to one side.

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(b) Place his hands along his thighs and secure them to the
litter. This prevents the patient from pushing himself off the litter.

(c) Place another litter, carrying side down, on top of the

patient.

(d) Bind the litters together with two or more litter straps.
Place the straps buckles in a position which cannot be loosened by the patient
(Figure 1 3- 1 1 6).

Figure 13-116. Double litter restraint.

f. Record and report action taken. Make sure the date and time the
restraint was applied, type of restraint applied, the reason for application, and
the patient's tolerance of the procedure are noted.

g. Evacuate the patient.

13-127. The Hazards of Restraints

a. Tissue damage under the restraint.

b. Damage to other parts of the body. Shoulder dislocations are

especially problematic if the patient is combative during the application of the
restraints or has a grand mal seizure while restrained.

c. Pressure areas may develop if the patient is kept restrained for

long periods of time and/or does not have frequent position changes.

d. Nerve damage may occur if restraints are applied too tightly or if

they become too constrictive after application.

e. Injury or death to the restrained individual due to fire or other

occurrences. This is especially true if the restraints are tied in knots rather
than bows or if all staff members fail to keep a restraint key easily accessible.

f. Inability to effectively resuscitate a cardiac arrest patient. The

time required to remove the restraints and place a patient in a supine position
may spell the difference between life and death.

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Section XVII. MEDICAL EMERGENCIES

13-128. General

Most of the medical emergencies that you will see in the field have been
previously discussed in other sections of this chapter. This section presents
those emergencies which are more rarely encountered but still require action
on your part. In many instances you will not be able to provide definitive
medical care, but instead will stabilize the casualty as an interim measure.

13-129. Diabetic Emergencies

Diabetes mellitus is a disease that occurs when the pancreas cannot secrete
enough insulin to control blood glucose levels. Insulin is a hormone produced
by beta cells in the islets of Langerhans of the pancreas. When blood glucose
rises, the beta cells release more insulin into the bloodstream, which increases
glucose transport into muscle and fat cells. Insulin also promotes the
synthesis of glycogen, large fat molecules, and protein. Many diabetics take
insulin shots to compensate for their insulin deficiency. However, regulating
the amount of glucose in the blood requires a delicate balance, and the insulin
dose taken may be either too high or too low. When diabetics take too little or
too much insulin, their blood sugar level becomes either too high
(hyperglycemia) or too low (hypoglycemia).

13-130. Diabetic Ketoacidosis

a. Diabetic ketoacidosis occurs when the blood sugar level becomes

too high-either because the insulin dose is too small or has been neglected.
Ketoacidosis is often preceipitated by stress, such as that caused by infection.
When serum insulin is low, glucose cannot enter the muscle and fat cells and
accumulates in the blood. When insulin levels fall, glycogen breakdown
increases; this forms more glucose, which enters the bloodstream, further
increasing the blood glucose levels.

b. The increased number of glucose molecules in the blood increases

the blood's osmotic pressure. In addition, the kidneys, which normally
reabsorb all glucose, begin to excrete glucose into the urine, increasing the
osmotic pressure in the urine. Because the kidneys can only concentrate urine
to a certain osmotic pressure, they must excrete more water with the excess
glucose. Therefore, increased blood glucose produces osmotic diuresis
(increased urine output).

c. If the diabetic does not drink enough water to match the

increased water excretion, he becomes dehydrated. Dehydration may be so
severe that it produces hypovolemic shock. When insulin levels decrease, fat
breakdown increases to provide an alternate energy source for cells that no
longer receives glucose. Fat breakdown products are acids, which are called
wither ketoacids or ketone bodies.

d. When more ketoacids are produced than the kidney can excrete,
they accumulate and produce metabolic acidosis. The lungs attempt to
compensate for the metabolic acidosis by increasing the rate and depth of
respiration to blow off more carbon dioxide and return the pH to normal (7.4).

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e. When the kidneys excrete ketoacids, they also excrete potassium. .

Serum potassium levels do not fall, however, because potassium leaves the
cells (where most body potassium is found) when the body becomes acidotic. In
fact, serum potassium may actually rise. However, dangerously low serum
potassium levels may occur later when ketoacidosis is corrected; this condition
occurs because potassium reenters the cells when the pH returns to normal.

f. The patient in diabetic ketoacidosis has a characteristic fruity­

smelling breath due to the presence of acetone, a ketone body. Diabetic
ketoacidosis usually progresses slowly, over 1 2 to 48' hours, with the patient
gradually becoming comatose.

13-131. Signs and Symptoms of Diabetic Ketoacidosis

• Polyuria (excessive urine output) due to osmotic diuresis.

• Polydipsia (excessive thirst) due to dehydration.

• Polyphagia (excessive hunger), probably due to the body's

inefficient use of nutrients.

• Nausea and vomiting, the latter worsening with dehydration.

• Tachycardia (rapid heart rate).

• Deep, rapid respirations (Kussmaul's breathing), in an attempt

to blow off excess acids by carbon dioxide elimination.

• Warm, dry skin and dry mucous membranes, reflecting

dehydration.

• A fruity odor on the breath due to acetone.

• Occasional fever, abdominal pain, and falling blood pressure.

13-132. Treatment for Diabetic Ketoacidosis

Treatment for ketoacidosis in the field depends on the diagnosis. It is safer to

assume the patient in a coma is suffering from hypoglycemia than
hyperglycemia. If, however, the patient's history and physical exam are
consistent with ketoacidosis, start treatment aimed at hydration and
supporting vital functions by administering 25 to 50 cc's of 50 percent glucose
intravenously. To treat suspected ketoacidosis, you should-

( 1 ) Maintain an open airway. Administer oxygen in comatose

patients. Be alert for vomiting and have suction equipment ready.

(2) Start an IV, draw blood for serum glucose determination,

and administer 1 liter of normal saline at a TKO rate or a rate ordered by the
physician. The patient in ketoacidosis is severely dehydrated, often to the
point of shock, and needs fluid volume.

(3) Monitor cardiac rhythm (if cardiac monitoring equipment is

available).

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13-133. Hypoglycemic Reactions

Hypoglycemia in an insulin-dependent diabetic is often the result of having

taken too much insulin, too little food, or both. The brain depends on a
constant glucose supply for its function. If the glucose level falls very low, the
brain is unable to function properly. This causes severe excitment and then
depression or, in extreme cases, convulsions followed by coma. In contrast to
ketoacidosis, hypoglycemia develops very rapidly. It should be suspected in
any diabetic manifesting bizarre behavior, altered neurologic signs, or
paranoia, hostility, or aggression.

13-134. Signs and Symptoms of Hypoglycemia

• A weak, rapid pulse .

• Cold, clammy, pale skin.

• Weakness and incoordination.

• Headache.

• Irritable, nervous, or bizarre behavior.

• In severe cases, seizures and coma.

13-135. Treatment for Hypoglycemic Reaction

a. Treat an unconscious patient as any other comatose patient, by

establishing an airway and administering oxygen.

b. Start an IV, draw blood for lab tests, and administer 5 percent
dextrose (D5W) at TKO rate. Then give 50 milliliters (ml) of 50 percent
dextrose by IV push. If the coma is indeed caused by hypoglycemia, the
patient will awaken dramatically.

OR

c. Give orange juice sweetened with sugar, cola, or candy instead of

D5W IV if the patient is awake, alert, and able to swallow.

NOTES

1. Diabetics are not the only patients who are

prone to hypoglycemia. Alcoholics, patients
who have ingested certain poisons, and
others may develop the same syndrome.
Therefore, you should not discount the
possibility of hypoglycemia in any comatose
patient. This is particularly true with an
auto accident victim when there appears to
be no real reason for the patient to be in a
coma.
2. Any patient in a coma of unknown cause
should receive glucose.

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13-136. Poisoning

a. Poisoning is mainly a pediatric problem. Of the 1,000,000

poisonings reported in the United States each year, about 75 percent occur in
children under 5, and most are caused by household products. Suicidal and
homicidal attempts account for most adult poisonings.

b. It is beyond the scope of this manual to provide a list of all

poisons. Detailed information can be obtained from all local poison control
centers. In any case of poisoning, your supporting MTF should provide the
specific antidotes for each agent.

c. Poisons can enter the body through ingestion, inhalation, surface

absorption, or inj ection. Ingested poisons usually remain in the stomach a
short time and the stomach absorbs only small amounts. Most absorption
takes place after the poison passes into the small intestine. You should suspect
poisoning in any patient who presents a sudden onset of unexplained illness,
especially an illness characterized by abdominal pain, nausea, vomiting, or
CNS problems. Thus management is aimed at trying to rid the body of the
poison before it reaches the intestines.

d. In order to treat a poisoned patient, you must take a patient

history, including answers to the following questions:

• What was ingested? The poison container and all its

remaining contents, the plant, or a sample of what was ingested should be
collected for the MTF. If a plant was ingested, find out what part of the plant
(root, leaves, stems, flower, fruit) was actually swallowed. If the patient has
vomited, send a sample of the vomitus in a clean, closed container to the MTF.

• When was the substance taken? Decisions about gastric

lavage will depend on how much time has passed.

• How much of the substance was taken?

• Has the patient or a bystander tried to induce vomiting? Has

anything been given as an antidote?

• Does the patient have a psychiatric history?

e. Look for signs characteristic of poisoning by a specific substance.

Note the skin color. For example, flushed, red skin is indicative of carbon
monoxide poisoning. Also check the patient's breath for the presence of
petroleum products, alcohol, or other suggestive odors.

13-137. Treatment for Poisoning

a. Maintain the airway. The sleepy or comatose patient is in

constant danger of asphyxiation and/or aspiration.

b. As a general rule, if the patient has ingested a poison within the

past 3 to 6 hours, the stomach should be emptied, but there are important
exceptions. Never induce vomiting in-

• Stuporous or comatose patients.

• Patients with seizures.

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• Pregnant patients.

• Patients with possible acute myocardial infarction.

• Patients who have ingested corrosives (strong acids or

alkalis).

• Patients who have ingested petroleum products (kerosene,

gasoline, lighter fluid, furniture polish).

c. When in doubt, call for instructions.

d. For practically all other ingested poisons, you should promptly

empty the patient's stomach. Vomiting is the most effective way to empty the
stomach of ingested poisons. Empty the patient's stomach by-

( 1 ) Giving syrup of Ipecac- 1 5 cc with 2 to 3 glasses of water to

a child over 1 year old, and 30 cc with 2 to 3 glasses of water to an adult.

(2) Placing the patient facedown, with his head lower than his
hips, to reduce the possibility of aspiration.

(3) Repeating the dose of Ipecac once if vomiting does not occur
within 20 minutes.

(4) Giving activated charcoal after vomiting stops. Make a

slurry by mixing at least 2 tablespoons of activated charcoal in water just
before administration.

NOTE

Do not mix the activated charcoal with syrup

of Ipecac, because the charcoal will inactivate
the syrup if Ipecac. Avoid activated charcoal
in suspected cyanide poisoning.

(5) Performing gastric lavage if vomiting cannot be induced.

The same contraindications that apply to inducing vomiting also apply to
lavage. To perform gastric lavage-

• Pass a large nasogastric tube into the stomach (use the

oral route for younger children).

• Position the patient on his left side, with his face down,
to increase drainage and minimize aspiration.

• Aspirate the tube with a large syringe before beginning

lavage. Save the contents.

• Instill saline (20 ml for small children, 50 ml for older

children or adults) into the stomach through the nasogastric tube. Aspirate
the tube and save the first aspirate for laboratory analysis.

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• Repeat lavage until the fluid is clear. At this time, give

activated charcoal (at least 3 tablespoons in tap water) through the
nasogastric tube, which can then be pinched off and withdrawn. Never pass a
nasogastric tube in a stuporous or comatrose patient unless the airway has
first been secured with a cuffed endotracheal tube. Likewise, never pass a
nasogastric tube in a patient who has ingested a substance like acid or lye.

(6) Start an IV with D5W at TKO rate. Draw blood for

laboratory studies.

(7) Treat for shock, if necessary.

(8) Record treatment.

(9) Evacuate patient.

13-138. Treatment for Specific Poisonous Ingestions

a. For strong acids, such as toilet bowl cleaners, rust removers, and
phenol, you should-

(1) Never induce vomiting.

(2) Give milk of magnesia, milk, egg white, or flour in water in

an attempt to neutralize and dilute the acid.

(3) Start an IV with D5W at a TKO rate.

b. For strong alkalis, such as drain cleaner, washing soda, ammonia,

and household bleach, you should-

(1) Never induce vomiting.

(2) Give diluted citrus fruit j uice or equal parts of vinegar and
water. Fifty ml of olive oil may ease the pain.

(3) Start an IV with D5W at a TKO rate.

c. For petroleum products, such as kerosene, lighter fluid, gasoline,

furniture polish, and turpentine, you should-

( 1 ) Never induce vomiting unless the patient drank a very large

volume (more than 50 ml) of kerosene or gasoline. In these cases, potential
toxicity to the brain and heart requires elimination of the poison.

(2) Protect the airway.

(3) Perform gastric lavage through a nasogastric tube.

(4) Give 100 percent oxygen with good humidification, if

available.

(5) Start an IV with D5W at TKO rate.

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(6) Monitor cardiac rhythm (if possible).

(7) Anticipate massive secretions and have suction ready, if

available.

d. For methyl alcohol (methanol, wood alcohol), you should-

( 1 ) Induce vomiting if the patient is conscious and give 1 ounce

of 80 proof whiskey every hour (the dose must be reduced in children).
E thanol-the alcohol one normally drinks-inhibits methanol metabolism.

(2) Start an IV with D5W at a TKO rate.

(3) Monitor cardiac rhythm (if possible).

(4) Administer oxygen, if available.

OR

(5) Treat an unconscious patient as any other comatose

patients.

13-139. Carbon Monoxide Inhalation

a. Carbon monoxide causes more poisoning deaths than any other

substance. It is produced during the incomplete burning of organic fuels, most
commonly in automobiles or home heating devices. Because home heating
devices produce carbon monoxide, this poisoning occurs more frequently in the
winter when it accumulates because a flue or ventilating system is blocked.
However, at least half of all successful adult suicides are caused by carbon
monoxide poisoning, and these may occur at any time of the year. An
automobile in a small closed garage can produce a lethal concentration of
carbon monoxide in 15 to 30 minutes. Carbon monoxide is a colorless, odorless,
tasteless gas. These characteristics make its detection in the air difficult and
thus increase the hazard. Usually the victim does not realize what is
happening until it is too late.

b. Carbon monoxide binds to hemoglobin in red blood cells and

displaces oxygen, preventing the transportation of oxygen to the tissues by
the red blood cells. The result is suffocation at the cellular level. The level of
carbon monoxide in the blood does not need to be high for poisoning to occur
because this gas has an affinity for hemoglobin that is 200 times stonger than
oxygen . Because the blood's ability to deliver oxygen is reduced, any
condition that increases the need for oxygen-such as fever or physical
exertion-increases the severity of carbon monoxide poisoning. Carbon
monoxide poisoning is more severe in children, since their resting metabolic
rate is higher than that of adults.

c. The warning symptoms of carbon monoxide poisoning include a

sense of pressure in the head and a roaring in the ears. With acute poisoning,
the patient is confused and unable to think clearly. The patient appears drunk,
often vomits, and becomes incontinent; convulsions and coma then follow.

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d. Examination of such patients reveals a bounding pulse, dilated

pupils, and cyanosis or pallor. Cherry-red lips, although classically described,
is rarely seen. In the comatose patient, rales-indicating pulmonary
edema-may be heard. Symptoms vary greatly between individuals with the
same carbon monoxide exposure. You should consider carbon monoxide
poisoning whenever you are confronted with a group of people with different
symptoms who are sharing accommodations when the symptoms started.

13-140. Treatment of Carbon Monoxide Poisoning

a. Provide maximal oxygenation. To accomplish this, you should­

(1) Remove the patient from the exposure site.

(2) Give him 1 00 percent oxygen by mask.

(3) Support respirations with a bag-valve mask if there is

respiratory depression.

b. Record treatment.

c. Evacuatathapatient. Move the patient rapidly to an MTF where

high oxygen concentrations can be delivered more effectively.

13-141. Absorbed Poisons

a. Poisons, such as organic phosphate and cyanide, can also be

absorbed through the skin. Treatment for absorbed poisons involves removing
the substance from the skin. Flush the area with a copious stream of water. If
dry lime is the poison, brush off the excess before flushing. Flush phenol off
with alcohol in which it is soluble, rather than water, if large quantities of
alcohol are available; if not, use water.

b. Do not waste time removing contaminated clothing or shoes until

the patient has been flushed with water for several minutes; then remove his
contaminated clothing and continue flushing. Do not use specific antidotes
until the skin has been irrigated with copious amounts of water. After
repeated flushing and removal of contaminated clothing, wash areas exposed
to acids with soap and water. Wash areas exposed to alkalis with diluted
lemon juice or vinegar.

13-142. Overdose

a. Obtaining a history from a patient who has taken an overdose is

similar to taking a history from a poisoned patient. You should ask the
following questions:

• What was taken? The bottle and its contents should be

brought to the MTF. Its label may help identify the drug, and the number of
pills remaining may give a clue to how much was ingested.

• When was it taken?

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FM 8-230

• How much was taken?

• Was anything else taken (other drugs or alcohol)?

• What has the patient or bystanders done to try to correct the

situation? Has vomiting been induced? Street resuscitation procedures are
frequently as dangerous as the overdose itself, and exactly what has been done
for the patient is very important. The most common form of street
resuscitation is "stimulation" -cold showers, and vigorous slapping. Check
for broken teeth, blood in the mouth, or other signs of injury. If the patient has
a barbiturate overdose, his friends may have tried to reverse this by giving
him speed (Methedrine or Dexedrine). There is also a myth prevalent on the
streets that salt or milk given intravenously will reverse an overdose. In fact,
salt may cause pulmonary edema, and milk can induce pneumonia. All of these
street remedies will complicate the situation; therefore, you should learn as
much as possible about what has been done.

13-143. Treatment for an Overdosed Patient

a. Maintain an airway.

b. Administer oxygen, if available.

c. Induce vomiting if the drug was taken by mouth. There are,

however, important exceptions. Never induce vomiting in-
1

• �tuporous or comatose patients.

• Patients who have ingested phenothiazines (including
Thorazine, used as tranquilizers). Phenothiazines prevent vomiting, so the
patient will end up with a stomach dangerously full of syrup of Ipecac and
water if attempts are made to induce vomiting.

d. Start an IV with D5W at TKO rate.

e. Monitor cardiac rhythm (if possible).

f. Record treatment.

g. Evacuate patient.

13-144. Narcotics Overdose

a. The narcotic drugs include heroin, morphine, Dilaudid,

methadone, codeine, Demerol, and Darvon. When narcotics are taken in
excess, they cause marked respiratory depression. This is shown initially by
slow, deep breathing that leads rapidly to apnea. Narcotic overdose also
causes hypotension, stupor, and coma. The pupils characteristically become
pinpointed, but this sign may be masked if the patient has overdosed on a
combination of drugs.

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 FM 8-230

b. You should suspect a narcotic overdose in any young patient

found in an unexplained coma, especially when there are needle tracks along
the veins of the arms or elsewhere. Cigarette burns on the chest are also seen
among these patients; bums occur when the patient "nods out" (loses
consciousness) while smoking.

c. Heroin overdose tends to occur in small epidemics. Heroin is sold

on the street in an impure form. When a more concentrated supply of the drug
reaches the street, users can miscalculate their doses and take more than they
had intended.

13-145. Treatment for Narcotic Overdose

a. Maintain an airway.

b. Administer oxygen. Assist ventilation as needed.

c. Start an IV with D5W at TKO rate.

d. Record treatment.

e. Evacuate patient.

13-146. Sedative/Depressant Drugs Overdose

a. Barbiturates are among the most abused drugs. They are used in
more drug-related suicide attempts than any other drug.

b. The chronic barbiturate abuser is characteristically lethargic,

disheveled, and frequently nods off to sleep. The barbiturate abuser may be
taking enormous doses to maintain a habit; therefore, a reduction in daily
doses can lead to a dangerous state of withdrawal.

c. Diagnosing acute barbiturate poisoning may be difficult. A

patient contemplating suicide may have large supplies of several drugs. It
may be difficult to determine which drug(s) a comatose patient has taken.
Patients may attempt suicide with barbiturates while consuming large
amounts of alcohol. The odor of alcohol on the patient's breath can further
confuse the diagnosis. You will often have to rely on circumstantial evidence
such as empty medicine bottles, the characteristic color of tablets in the
mouth, or gastric contents to diagnose barbiturate overdose.

d. Acute barbiturate poisoning mainly affects the CNS and the

cardiovascular system. Signs and symptoms of moderate overdose resemble
those of alcohol intoxication.

e. In severe overdose, the patient is deeply comatose. His pupils

may be constricted early in the course, but later become fixed and dilated. (It
is important for you to remember this sign during resuscitation efforts,
because fixed and dilated pupils do not have the same significance in
barbiturate overdose as in ordinary cardiac arrest.) Respiration is affected
early and becomes very shallow, resulting in hypoventilation. Cheyne-Stokes
breathing can occur. Aspiration and pneumonia are also common. Blood
pressure falls and the patient may develop a shock syndrome, with weak, rapid
pulse, and cold, clammy skin.

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13-147. Treatment of Barbiturate Overdose

a. Maintain an airway.

b. Administer oxygen. Assist ventilation as required.

c. Start an IV with normal saline or D5W and administer at a rate

to maintain blood pressure. If the patient is in shock, the MAST may be
helpful.

d. Monitor cardiac rhythm (if possible).

e. Avoid giving stimulants. Stimulants increase the complications

following barbiturate overdose.

f. Record treatment.

g. Evacuate patient.

13-148. Amphetamine Overdose

a. Amphetamines-such as Dexedrine and Methedrine-are

frequently abused. These drugs stimulate the CNS and produce wakefulness.

b. The amphetamine abuser who has taken large quantities of the

drug over a period of time displays excitement, loss of appetite, tachycardia,
hypertension, sweating, dilated pupils, and tremors. He may demonstrate
frank amphetamine psychosis as well, with paranoia and hallucinations. He
may also be violent and you should be prepared for this reaction.
c. In most cases, the drug will wear off and the user will "crash. "
The patient will then go into a prolonged sleep, followed by a period of extreme
hunger and depression. Field treatment of these patients consists primarily of
reassuring them. If the patient is agitated, you should first ensure your own
safety and then attempt to calm him down.

13-149. Treatment for Amphetamine Overdose

a. Determine whether the patient is violent and summon assistance

if needed.

b. Talk to frightened or agitated patients calmly and reassuringly.

c. Provide the patient with a place to "crash. " The hospital is often
not a very good place for this. A quiet room in the house of a reliable friend
where concerned people will be available to reassure the patient may be better.
Consult the physician to help decide whether to bring the patient to the MTF.

d. Determine whether hospitalization will be necessary. If his blood

pressure is significantly elevated, if arrhythmias are present, or if he is entirely
out of control, hospitalization is required. Use assistance, if needed, to bring
the patient to the MTF.

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13-150. Overdose and Toxic Reaction to Hallucinogens

The symptoms of LSD intoxication includes excitement, panic, hallucinations
(usually visual), unusual body sensations, and often psychotic reactions. Most
authorities now advocate the "talking down" approach in dealing with these
patients, avoiding drugs as much as possible. You should try to get the patient
to a quiet place, away from crowds and noise. An emergency room is far from
ideal in this respect. It is often better if you can arrange to have the patient
looked after by a responsible friend. It is especially important that you deal
with the patient in a calm, understanding manner.

13-151. Aspirin Overdose

a. Aspirin (salicylate) intoxication is primarily a pediatric problem
and is one of the most frequent overdoses in children. Adults can also overdose
on aspirin, either accidentally or in suicide attempts.

b. Salicylate is an acid and causes metabolic acidosis. The patient

tries to compensate for the metabolic acidosis, with its excess carbon dioxide,
by hyperventilating. As time passes, however, the patient tires and
respirations become shallower.

13-152. Signs and Symptoms of Salicylate Intoxication

• Hyperpnea, tachypnea (deep and rapid respirations).

• Fever and sweating.

• Vomiting.

• Dehydration, sometimes so severe that it causes shock.

• Convulsions.

• Coma.
13-153. Treatment for Aspirin Overdose
a. Induce vomiting with syrup of Ipecac, if the patient is conscious.

b. After vomiting stops, give at least 2 tablespoons of activated

charcoal mixed as a slurry in water.

c. Start an IV with D5W at a TKO rate.

d. If the patient's temperature is elevated above I 04°F, sponge his

body with cool water.

e. Record treatment.

f. Evacuate patient.

13-154. Massive Gastrointestinal Bleeding

a. Mass�ve gastrointestinal (GI) bleeding refers to bleeding that is
severe enough to cause hypovolemic shock. Bleeding may occur from any part
of the GI tract. Massive bleeding, however, most frequently occurs from the
duodenum, stomach, or esophagus.

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b. Massive GI bleeding is most often caused by a duodenal peptic

ulcer. Other frequent causes of massive GI bleeding are a gastric peptic ulcer,
gastritis, and esophageal varices (enlarged and twisted veins in the
esophagus).

c. In peptic ulcer disease, digestive enzymes and gastric acid

destroy a small area of the stomach or esophagus lining. If the damaged area
includes the wall of a vein or artery, there is massive bleeding.

d. A duodenal peptic ulcer causes massive GI bleeding more

frequently than does a gastric peptic ulcer. The typical duodenal ulcer patient
is a male, over 33, who works under emotional and physical stress.

e. Gastric peptic ulcer is also more frequent in males, but is not

related to stress. Gastric ulcers most often occur past the age of 40. They may
be benign or may be caused by gastric cancer.

f Acute gastritis is an acute inflammation of the superficial layer

of the stomach lining. The disorder may be caused by viral or bacterial
infection or by ingestion of alcohol or aspirin. Acute gastritis following alcohol
or aspirin ingestion can cause massive GI bleeding. Aspirin and alcohol,
however, also cause peptic ulcers to bleed. Therefore, a patient with a history
of ingesting either drug does not always indicate acute gastritis.

13-155. Signs and Symptoms of Massive Gastrointestinal Bleeding

a. The symptoms of massive GI bleeding include those of

hypovolemic shock. In addition, massive GI bleeding produces hematemesis
(vomiting blood) and/or melena (black, tarry stools). Vomited blood may be
bright red if it is fresh or may resemble coffee grounds if it has been partly
digested.

b. Other signs and symptoms can indicate the cause of GI bleeding.

The ulcer patient may be taking antacids; the acute gastritis patient may have
recently ingested aspirin or alcohol. The patient with bleeding esophageal
varices usually has symptoms of cirrhosis of the liver. These include liver and
spleen enlargement, ascites (fluid in the peritoneal cavity), and dilated
abdominal wall veins.

13-156. Treatment of Massive Gastrointestinal Bleeding

a. Administer oxygen.

b. Take vital signs.

c. Apply and inflate the MAST.

d. Start two or more IV's with large-bore catheters. Then rapidly

infuse lactated Ringer's solution to maintain blood pressure.

e. If ordered by the physician, insert a nasogastric tube to aspirate

blood present in the stomach.

f Maintain the patient in a shock position with his feet elevated.

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g. Keep the patient warm.

h. Monitor the patient's blood pressure, pulse, and state of

consciousness.

i. Record treatment.

j. Evacuate patient.

13-157. Genitourinary Problems

a. It is rarely useful to distinguish the different possible causes of

genitourinary problems in the field.

b. The genitourinary system includes the kidneys, ureters, bladder,

urethra, and the reproductive organs. All of these organs are subject to
trauma or disease. Nontraumatic emergencies involving these organs include
inflammation, infection, and obstruction. EXAMPLE : The passage of a renal
stone, which causes excruciating flank pain-is one of the most severe forms of
pain a person can experience. Treatment in the field is not feasible.

13-158. Patient History-Respiratory Problems

a. Much can be learned from a few well-chosen questions. In taking

a history from a patient with respiratory problems, you need to explore the
patient's chief complaint in greater depth. In most cases the complaint will be
dyspnea. But some patients may have serious respiratory problems without
dyspnea, especially if their respiration has been depressed by drugs or trauma.
Therefore, you must be alert for respiratory problems, even if the patient does
not complain of shortness of breath. Assuming that the chief complaint,
however, is dyspnea, obtain answers to these questions:

• How long has the dyspnea been present? Is the problem

longstanding or of recent onset?

• Was the onset gradual or rapid?

• Is the dyspnea made better or worse by any position?

• Has the patient been coughing? If so, is the cough

productive? What does the sputum look like?

• Is there associated pain? If so, what is its nature?

• Has the patient suffered any medical problems in the past? If

so, when?

• What medications does the patient take regularly?

b. Observations made during history taking can provide valuable

information on the patient's condition. When taking a history, you must also
answer these questions:

• Is the patient anxious, uncomfortable, or in distress?

13-161
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• Does dyspnea make it difficult for the patient to speak? Does

he need to stop to catch his breath when answering questions?

• Does questioning easily distract the patient from

symptoms?

• Are his answers to your questions coherent and appropriate,

or does he answer in a confused and disoriented fashion?

• What position does the patient naturally assume?

c. In making such observations, you are performing the first step of

the assessment of the patient's general appearance and mental status. Thus,
you can note, for example, that the patient in severe respiratory distress is
frightened and intensely uncomfortable, is usually sitting upright, is gasping
or laboring to breathe, and is confused or disoriented.

d. After completing the primary survey, take the patient's vital

signs. Carefully observe his respirations. Are his respirations abnormally
rapid (tachypnea) or unusually deep (hyperpnea)? Is there an abnormal
respiratory pattern?

e. The secondary survey of the respiratory system should begin

with examination. Look for the following signs of respiratory distress:

• The nostrils opening wide on inspiration.

• The Adam's apple pulled upward on inspiration.

• Retraction of the intercostal muscles: the patient retracts

these muscles on inspiration.

• The patient is using his neck and diaphragm muscles

exclusively on expiration.

• Cyanosis is an unreliable sign; however, severe hypoxia may

be present without cyanosis.

f. Next, observe the chest wall. Has its diameter increased (barrel
chest)? Does the chest move symmetrically during respiration? During
expiration, does any area bulge (flail)? Is the trachea in the midline, or does it
deviate toward one side? Is the chest wall deformed or discolored?

g. After observing the patient, auscultate his chest. Firmly apply

the stethoscope to the patient's chest and listen, both anteriorly and
posteriorly, to at least one respiratory cycle at each apex and each base.
Certain abnormal sounds detectable on auscultation of the lungs characterize
different respiratory problems:

• Snoring is a familiar sound, occurring when the upper airway

is partially obstructed by the base of the tongue.

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• Stridor is a harsh, high-pitched sound heard on inspiration

that is characteristic of tight upper-airway obstruction, as in laryngeal edema.
The "seal bark" of the child with croup is an example of stridor.

• Wheezing is a whistling sound heard diffusely in asthma.

• Rhonchi are rattling noises in the throat or bronchi, often

due to partial obstruction of the larger airways by mucous.

• Rales are fine, moist sounds, sometimes crackling or

bubbling in quality, associated with fluid in the smaller airways (pulmonary
edema, pneumonia).

h. Determine if breath sounds are equal on both sides of the chest.

i. Palpate the chest following auscultation. Feel the chest wall of

the trauma victim for tenderness and instability over the ribs. Also palpate for
subcutaneous emphysema (air in the subcutaneous tissues) which can be felt
as a crackling sensation under the fingertips. Symmetry of breathing can be
assessed by placing your thumbs on the xiphoid and spreading your hands
over the anterior chest wall. If breathing is normal, the hands move
symmetrically as the patient breathes.

j. The patient with respiratory problems is not immune to

abnormalities elsewhere. Therefore, complete a head-to-toe survey.

13-159. Epiglottitis

A patient's upper airway can become obstructed by swelling of its tissues.

Epiglottitis leads to marked swelling of the epiglottis and pain on swallowing
and may cause complete airway obstruction.

13-160. Obstructive Airway Diseases

In obstructive airway diseases there is generalized obstruction to airflow

within the lungs. The most common diseases are emphysema, chronic
bronchitis, and asthma. These conditions are often classified together as
chronic obstructive pulmonary disease (COPD) or chronic obstructive lung
disease (COLD).

13-161. Emphysema

a. Emphysema is a pulmonary condition in which the air space

beyond the terminal bronchioles is increased in size because of the destruction
of the alveloar walls. Destruction of the alveolar walls also weakens the walls
of the small bronchioles, lengthening expiration. Because alveolar walls are
destroyed, the lungs hold more air.

b. When the ratio of air to tissue is increased characteristic physical

signs become evident. Because air is a poorer carrier of sound than is tissue,
breath sounds decrease in emphysema. When an overinflated lung is located
between the chest wall and the heart, it is harder to hear heart sounds and to
feel the impulse at the heart apex.

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c. Emphysema leads to three potentially fatal complications: right

ventricular heart failure, acute respiratory infection, and cardiac arrhythmias.
Often, the patient with emphysema is thin, complains of increasing shortness
of breath on exertion, and of progressive limitation of physical activity.
Usually, coughing is not prominent and, when it occurs, produces only small
amounts of whitish-gray, mucus-Hke sputum. Patients with emphysema
usually are not cyanotic. The patient with advanced emphysema has decreased
chest movement, hypertrophied (enlarged) accessory respiratory muscles, and
breathes with pursed lips. Clubbed fingers are another sign of advanced
emphysema.

13-162. Chronic Bronchitis

a. Chronic bronchitis is long-continued form of a pulmonary

condition with a tendency to recurrence after stages of inactivity. Sputum
composed of mucous and pus is common. In chronic bronchitis, the mucous­
secreting cells in the respiratory epithelium produce characteristically large
amounts of sputum.

b. Chronic bronchitis infections produce scarring in the lungs. Thus,

patients with chronic bronchitis may have decreased total lung capacity.

c. Invariably, patients with chronic bronchitis have been heavy

cigarette smokers and, in their forties, usually begin suffering from severe
respiratory problems. Before this, they may have had many respiratory tract
infections. Even between acute infections, chronic bronchitis patients produce
at least 10 ml of green or yellow sputum daily. Like patients with emphysema,
chronic bronchitis patients have prolonged expiration, but they also have
inspiratory airway obstruction. Coarse rales, rhonchi, and wheezes may be
heard through both lung fields.

d. Because the overinflated lungs are not located between the heart
and the chest wall, heart sounds are heard more easily in chronic bronchitis
than in emphysema. Pure pulmonary emphysema and chronic bronchitis
represent two extremes of a single problem. Both conditions can occur in the
same patient, producing signs and symptoms between the two extremes.

13-163. Treatment for Emphysema and Chronic Bronchitis

a. Establish an airway.

b. Place the patient in a sitting or semisitting position.

c. Administer oxygen. Monitor the patient's respiratory rate and

depth. Provide assisted ventilation should respirations become depressed.

d. E stablish an IV line with 5 percent dextrose in water (D5W) to

keep open rate.

e. Administer aminophylline if ordered by the physician by adding

250 mg of aminophylline to a 250-ml bag of D5W, at a rate of 100 ml per hour.

f. Monitor vital signs and level of consciousness.

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 FM 8-230

g. Encourage the patient to cough up any secretions.

h. Record treatment.

i. Evacuate patient, if necessary.

13-164. Bronchial Asthma

a. Bronchial asthma is characterized by an increased reaction to

some stimuli of the trachea, bronchi, and bronchioles, with widespread
narrowing of the airways (bronchospasm).

b. An acute asthma attack reflects airway obstruction due to

bronchospasm, swelling of the mucous membranes in the bronchial walls, and
plugging of the bronchi by thick mucus secretions. The attack may be brought
on by an allergic reaction to inhaled irritants, by respiratory infection, or by
emotional stress (including battle stress). Narrowing of airways and increased
amounts of thick sputum interfere with airflow, especially on expiration.
Airway constriction and increased amounts of sputum result in progressive
difficulty for moving air in and out.

c. In a typical acute asthmatic attack, the patient is found sitting

up, often leaning forward, and fighting to breathe. He may be coughing
spasmodically and unproductively. Use of accessory muscles for respiration is
prominent, and the chest is relatively fixed in the inspiratory position.
Wheezing is usually audible even without a stethoscope, but may be absent if
the attack is severe and there is little air movement.

13-165. Treatment for Bronchial Asthma

a. E stablish an airway.

b. Administer humidified oxygen. If available, a nebulizer unit

attached inline to a bag-valve mask may be useful in such circumstances.

c. Establish an IV line with D5W at 100 cc's per hour rate.

d Administer epinephrine ( 1 : 1 000), 0.3 to 0.5 ml SQ, if ordered by

the physician.

e. If ordered by a physician, administer aminophylline in a dose

level of 250 ml to a 250-ml bag or bottle of D5W. Piggyback this infusion into
the IV and run it at the rate specified by the physician.

f. Administer bronchodilators such as epinephrine, isoproterenol

( Isuprel), and isoetharine (Bronkosol) by aerosol, if ordered by the physician.

g. Monitor vital signs and level of consciousness.

h. Record treatment.

i. Evacuate patient, if necessary.

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NOTES
1. Status asthmaticus i s a severe, prolonged
asthmatic attack that cannot be broken
with epinephrine; the condition is a serious
medical emergency. Upon examination, the
patient's chest will be greatly distended.
The patient will fight desperately to move
air through the obstructed airways and
make prominent use of accessory muscles of
respiration. The patient is usually
exhausted and dehydrated. The treatment is
similar to that used for the acute asthmatic
attack, but there is greater urgency in
starting therapy and getting the patient to
an MTF.
2. When dealing with any asthmatic patient,
maintain a calm, reassuring attitude to
lessen the patient's anxiety associated with
difficulty in breathing.

13-166. Pneumonia
a. Pneumonia is caused by bacteria, viruses, or fungi. The
pneumonia patient usually reports several hours to several days of fever,
weakness, and productive cough, and sometimes chest pain worsened by
coughing. The illness can occur abruptly, with a shaking chill, or set in
gradually, progressively weakening its victim. The elderly and those with
chronic diseases are more prone to pneumonia than are younger, healthier
persons.

b. The pneumonia patient is often feverish, coughing, and may

exhibit minim?J or marked respiratory distress, depending on the degree of
congestion. Auscultation of the chest will reveal rales and rhonchi over the
affected lung.

c. Definitive treatment of pneumonia requires hospitalization. In

the field, not much can be done. Administer oxygen and evacuate the patient
in a comfortable position.

13-167. Drowning
a. Approximately 6,500 people in the United States die each year by
drowning, making it the fourth leading cause of accidental death. Among
adults, alcohol intoxication is a factor in about one-third of the cases. When
treating the near-drowning victim, keep these points in mind:

• As the victim goes under, water enters the mouth and nose,
and he begins to cough and gasp, swallowing large amounts of water.

• A small amount of water is aspirated into the larynx and

trachea, setting off laryngeal muscles (laryngospasm) spasms. In 10 percent of
the victims, laryngospasms seal off the airway and temporarily protects it
from further aspiration. In the other 90 percent, water enters the lower
airways and the laryngospasm offers no protection.

• Laryngospasm or aspirated water leads to asphyxia.

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 FM 8-230

• If the victim aspirates fresh water, it rapidly crosses the

alveolar membranes into the bloodstream. If the victim aspirates salt water,
fluid is drawn into the alveoli from the bloodstream, causing serious
pulmonary edema. Pulmonary edema mechanically obstructs gas exchange
across the pulmonary membranes. Therefore, greater hypoxia occurs with salt
water aspiration than with fresh water aspiration.

• Near drownings in cold water (less than 700F) are of interest

because the cold prolongs survival time. Many patients have been resuscitated
without residual neurologic problems after immersions of 4 to 45 minutes. In
general, successful resuscitations are related to age, water temperature,
duration of immersion, and water cleanliness. The younger the patient, the
colder and cleaner the water, and the shorter the time of immersion, the better
the chances are for successful resuscitation.

b. Two physiologic mechanisms may account for the long survival

times of near drownings in cold water. The first is the relatively rapid onset of
hypothermia in patients in cardiopulmonary arrest who are submerged in cold
water. The cold exerts a protective effect on the brain and other tissues,
decreasing the rate of cellular degeneration that results from anoxia at normal
body temperatures. The second is the mammalian diving reflex, in which the
body redistributes blood flow from nonessential tissues to vital organs. The
diving reflex occurs when the f�ce is immersed in cold water. It is particularly
strong in infants and children, \yhich may help to explain the greater success
of resuscitation in young patients.

13-168. Treatment for Near-Drowning Patients

a. Whether near drowning occurs in fresh water or in salt water,

initial resuscitation involves cardiopulmonary resuscitation. First, try to
reach the victim without endangering yourself. (An unqualified swimmer
should not try to rescue a drowning victim because the rescue attempt may
lead to two drowning victims.) After reaching the victim, establish an airway
and begin ventilation-even before he is removed from the water. Do not waste
time trying to remove water from his lungs early in resuscitation. If the near
drowning occurred in fresh water, the water will have already been absorbed
through the lungs. Even in salt water near drownings, laryngospasm may
have protected the lower airway from aspiration. When dealing with a
swimming pool near drowning, assume that he is the victim of a diving
accident. Protect his cervical spine while giving mouth-to-mouth resuscitation
and removing him from the water.

b. After removing the patient from the water, determine whether a

pulse is present. Begin closed chest compression if it is needed. Protect the
airway from aspiration during vomiting, which usually occurs during
resuscitation from near drowning. Supplemental oxygen in the highest
possible concentration should be administered as soon as possible. Carry out
suctioning as needed.

c. Even if it appears that the patient has recovered at the scene,

transport him to the hospital. Delayed death can occur in near drowning due to
pulmonary edema and aspiration pneumonia. The patient should receive 100
percent oxygen during transport and be given resuscitation if necessary.

13-167
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13-169. Inhalation Burns

a. Fatal burns to the respiratory tract can occur with little or no

external evidence. Toxic combustion products and inhaled chemical irritants
produce varying amounts of damage depending on the nature and duration of
exposure. Inhalation of superheated air by itself rarely damages the lungs
because dry air conducts heat poorly and the mucous membranes of the upper
respiratory tract efficiently cool the air. Furthermore, a blast of hot air causes
reflex closure of the vocal cords, thus further reducing the possibility of direct
thermal injury to the lower respiratory tract. Only the inhalation of steam is
likely to cause thermal injury to the lung mucosa. Combustion products of
some common substances, however, are very toxic to airways and alveoli and
cause upper airway obstruction (due to edema), bronchospasm, and damaged
pulmonary capillaries, allowing fluid to leak out of them into the alveolar
spaces.

b. When taking a history from a patient exposed to fire or toxic

inhalants, gather the following information:

• The nature of the inhalant or the combusted material. Many

irritant gases combine with water to form corrosive acids or alkalis that cause
bums of the upper respiratory tract.

• The duration of the exposure.

• Whether or not the patient was in a closed area when the

exposure took place. Victims trapped in closed areas with smoke or fumes are
more likely to sustain respiratory tract injury, although smoke or fumes in
open areas can also result in damage.

• Whether or not the patient lost consciousness. Reflex

mechanisms that ordinarily protect the lower respiratory tract may have been
impaired if the patient lost consciousness.

c. During the physical examination, carefully check the face and

mouth, inspecting them for burns. Auscultate the chest, listening carefully for
rales and wheezes. Examine the patient 's throat.

13-170. Treatment for Inhalation Burns

a. E stablish and maintain an airway. Assist ventilations as needed.

b. Administer oxygen in the highest concentration available.

c. E stablish an IV line with Ringer's lactate or saline at TKO rate.

d. Monitor vital signs and level of consciousness.

e. Record treatment.

f. Evacuate patient.

13-171. Artificial Airways

a. The oropharyngeal and nasopharyngeal airways are the two most

commonly used airways . Each is designed for use in different situations.

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b. The oropharyngeal airway is a curved device that fits over the

back of the tongue and holds it away from the posterior wall of the throat
(Figure 1 3-1 17). This device is inserted upside down (tip upward) into the
mouth and then rotated as the tip reaches the back of the tongue. Do not push
the tongue backward into the throat while inserting the airway. Do not use the
oropharyngeal airway on a conscious patient. It stimulates gagging and
vomiting in individuals with functioning reflexes.

Figure 13-11 Z The oropharyngeal airway inserted.

c. The nasopharyngeal airway is a soft rubber tube, which is

inserted through the nose into the pharynx behind the tongue, thus allowing
air to pass from the nose to the lower airway. (Hard, plastic nasopharyngeal
airways are unnecessarily traumatic and should not be used.) Lubricate the
device with water-soluble jelly and insert it gently to avoid injury to or cause
bleeding from the nasal passages. Semiconscious patients tolerate this airway
more than the oropharyngeal airway.

13-172. Aids to Artificial Respirations

a. Two ventilation devices are used to treat patients requiring

artificial respiration: the pocket mask and the bag-valve mask.

b. The pocket mask (Figure 13-1 18) with an oxygen inlet valve
eliminates direct contact with the patient's nose and mouth and permits
mouth-to-mouth ventilation with up to 50-percent oxygen with a flow rate of
1 0 liters per minute. An oxygen line connects to the mask's inlet valve. To use
a pocket mask, open the patient's airway and place the rim of the pocket mask
between his lower lip and chin. Retract the lip and hold the mouth open. With
both thumbs along the side of the mask, clamp the remainder of the mask to
the face. Grasp the jaw just beneath the angles with the fingers while
maintaining a backward tilt of the head and a jaw thrust. Then exhale
intermittently into the mask, forcing the breath, which is enriched with
oxygen, into the patient's lungs. If the oxygen flow rate is high enough
(control valve wide open), periodically occlude the opening of the mask with
the tongue and allow the oxygen flow to ventilate the patient. This technique

13-169
FM 8-230

will produce an inspired oxygen concentration much higher than 50 percent.

As with any other means of artificial ventilation, when using the pocket mask,
observe the chest for the rise and fall, which indicates adequate ventilation.
Because both hands can be utilized by the rescuer to maintain an open airway,
masks of this type are easier to use than bag-valve masks.

Figure 13-118. The pocket mask.

c. Bag-valve masks are self-inflating and, when used without

supplemental oxygen, deliver room air (21 percent oxygen) to the patient. If an
oxygen source with a flow rate of 12 liters per minute is attached to the bag­
valve mask, the delivered oxygen concentration can be increased to 40 percent.
Adding an oxygen reservoir to the bag can further increase the inspired
oxygen concentration to about 90 percent.

d. The mask used with a bag-valve device should be transparent so

that vomitus or secretions around the patient's mouth can be seen. To
correctly employ the bag-valve mask-

( 1 ) Apply the mask so that it fits snugly over the patient's chin,
beneath his lower lip, and over the bridge of his nose (Figure 1 3-1 1 9).

(2) Place your thumb and index finger on the mask-thumb

above the index finger and below the valve connection-and use the other
fingers to grip the patient's mandible and form a tight seal.

(3) Tilt the patient's head back to open the airway and
compress the bag with your other hand.

e. Watch for the rise and fall of the chest to be certain that
ventilation is occurring. Often, an oropharyngeal or nasopharyngeal airway is
desirable to keep the airway open.

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 FM 8-230

Figure 13-119. Inserting the bag-valve device.

f. The bag-valve mask is more convenient and delivers a more

enriched oxygen mixture than mouth-to-mouth ventilation. Keep in mind,
however, that the bag-valve mask rarely generates the tidal volumes possible
with mouth-to-mouth ventilation. Gastric distension is a problem with both
techniques.

g. Bag-valve masks with oxygen supplementation may be used to

assist the ventilations of a spontaneously breathing patient. Apply the mask
to the patient's face in the manner described above, and gently squeeze the
bag as the patient takes a breath.

13-173. Demand Valve

Manually triggered ventilation devices, or demand valves, are available in

many hospitals and are acceptable for emergency use if they deliver a flow rate
of at least 100 liters per minute. These. devices may be connected to a mask, an
endotracheal tube, or an esophageal obturator airway and are used to assist
ventilation in a spontaneously breathing patient. A slight negative pressure,
produced by the patient's inspiratory effort, will trigger the oxygen flow. The
flow continues until the negative pressure ceases and exhaled gases exit
through a nonbreathing valve.

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CAUTION

When treating an apnea patient, do not use an

oxygen-powered breathing device for very long
with a mask because it may cause severe
gastric distension. Do not use the device at all
on patients under 12 years of age, except under
very special circumstances, such as airway
obstruction due to croup or epiglottis. Because
demand valves may develop high pressures,
the use of such a device with an endotracheal
tube must be undertaken with caution. Bag­
valve masks provide finer control of
ventilation and better assessment of the
patient's lung compliance.

13-174. Esophageal Obturator Airway

a. The esophageal obturator airway is a long tube that superficially

resembles an endotracheal tube. It is open at the top, sealed at the bottom, and
contains numerous holes on the side near its upper end. A mask fits over the
tube at its upper end, and an inflated cuff is located near its bottom end. When
the esophageal airway is properly placed and the mask is seated firmly on the
face, air that is blown in by mouth or bag-valve mask will enter the patient's
pharynx through the side holes in the obturator. Since the inflated cuff
obstructs the esophagus, and the mask seals off the mouth and nose, air can
only travel into the trachea. Thus, the esophageal obturator prevents
progressive gastric distension during assisted ventilation and also lessens the
regurgitation of stomach contents. Using the esophageal airway, however, is
not without hazards. Rough handling during insertion may damage structures
in the pharynx, and excess inflation of the cuff may rupture the esophagus.

b. To insert the airway, place its top end through the port of the
supplied face mask. Many of these masks have inflatable rims, which should
be fully inflated before the airway is inserted. Slightly flex the patient's head
and pull the jaw forward while the cuffed end of the tube is gently advanced
into the esophagus until the mask sits firmly on the face (Figure 13-120). If the
mouth is dry, the end of the obturator may need to be lubricated with a water­
soluble jelly. Never jam the tube down. If you meet resistance, gently pull the
tube back and try to advance it again. In most cases, the tube will follow the
natural curvature of the throat and move easily into the esophagus. But
because it is always possible to inadvertently intubate the trachea with this
device, check the location of the tube: Tilt the patient's head back, hold the
mask in place, ventilate through the airway, and watch the chest to see if it;,
rises and falls. If the chest moves, the tube is in the esophagus, and the cuff
can be inflated with 20 to 30 ml of air. To recheck the position of the
esophageal airway, ventilate the chest again and listen for breath sounds. If
there is no chest expansion or if breath sounds are absent, the airway may be
lodged in the tachea. If this is the case, remove the airway at once (cuff
deflated) and continue ventilation by another method. Try again to reinsert
the obturator.

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� /
ESOPHAGUS

FLATION C U F F

Figure 13-120. The esophageal obturator airway.

c. Observe these important guidelines when using the esophageal

obturator airway:

( 1 ) Use the esophageal airway only in unconscious patients. Its

use causes gagging and vomiting on conscious and semiconscious patients.

(2) Do not use the esophageal airway on patients less than 1 6

years old or 5 feet tall.

(3) Do not use the esophageal airway on patients who have

esophageal disease, cirrhosis of the liver, or who have ingested caustic
substances.

(4) Do not remove the esophageal obturator airway from an

unconscious patient until the airway has been secured with an endotracheal
tube. Removal of the esophageal airway results in considerable regurgitation
of stomach contents. Unless the trachea has first been protected with a cuffed
�ndotracheal tube, regurgitated material will enter the lungs.

13-173
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C H APT E R 1 4

C LINICAL PROCEDURES

Section I. INTRODUCTION

14-1. General

Providing casualties with immediate medical treatment on the battlefield is

only one phase of your responsibilities as a medical specialist. When you are
assigned to a clinic, hospital, or other medical treatment facility, you will be
confronted with a number of different or unique treatment requirements on a
daily basis. The clinical environment presents an entirely new set of patient
care situations with which you will have to deal.

14-2. Your Role in Clinical Care

The importance of your role in patient care cannot be over-emphasized. Your

technical skill and knowledge are maj or contributing factors in an individual
patient's rapid and successful recovery. The techniques and procedures
explained in the following sections are those that you will be working with in
the course of your normal duties. They represent a wide selection of the
treatment situations to which you will be exposed. While many of these
procedures appear to require little, if any, explanation, they are fundamentally
important and will serve as reference and review material.

Section II. VITAL SIGNS

14-3. General

Temperature, pulse, respiration (TPR), and blood pressure (BP) are called vital
signs because they are important signs that indicate a patient's condition.
Measurement of these signs aids in making a diagnosis and prescribing
treatment. Any marked deviation from the normal range is a signal of distress
from the body; the interpretation of changes is as important as the
measurement itself.

14-4. Body Temperature

Body temperature is the result of a balance between the heat produced and the
heat lost by the body. The hypothalmus is that portion of the brain that
regulates body temperature by speeding up or slowing down the cells use of
food (metabolic rate). The higher the rate of metabolism. the more heat the
body produces. This heat is distributed by the circulating blood. Excessive
heat is eliminated through the skin, lungs, and excreta. When the balance is
disturbed, deviations in body temperature result.

a. Normal Temperature. Body temperature ranges between 96 and

100°F. The normal, or average, temperature of most people is 98.6°F. The
temperature reading that you obtain will vary according to the site you use.
The average oral temperature is 98.6°F. Rectal temperature is usually about
b9
one degree higher 9.6°F), and the axillary (armpit) temperature is about one
degree lower (97.6 F) than when measured orally. A range of 0.5-1.0°F from
the average normal temperature is usually considered to be within normal
limits. When the body temperature changes from the normal average, it warns
of body malfunction, infection, or dehydration.

14-1
FM 8-230

b. A bnormal Temperature.

( 1 ) Pyrexia (fever) is an elevation in temperature above the

normal average. During pyrexia, heat is produced faster than the body can
eliminate it. Fever is a common symptom of infection or other disease.

(2) Hypothermia is a deviation in temperature which persists

below the average normal temperature. A subnormal temperature may be
caused by shock, starvation, or a long-lasting illness. It indicates that body
resistance to disease is low.

14-5. Measuring Body Temperature

a. The body temperature can be measured by the mouth, the rectum,

or the axilla (armpit). The method used depends on patient's age, physical
condition, and equipment available.

b. The clinical thermometer is a glass bulb containing mercury and a

stem in which the mercury can rise. On the stem there is a graduated scale
representing degrees of temperature with the lowest indicating 94°F and the
highest 106°F. Two types, oral and rectal, are commonly used. Various
manufacturers color code the tips of the thermometers for proper
identification: blue tip for oral usage (Figure 14-lA) and red tip for rectal
usage. The standard rectal thermometer (Figures 14-lB and 1 4-lC) comes in
two shapes that are specifically designed to prevent perforation of the anus or
the rectum.

c.

Figure 14-1. Clinical thermometers (oral and rectal).

14-6. Reading the Thermometer

The stem of the mercury-in-glass thermometer contains a temperature

measuring scale. The scale has an arrow marking the normal temperature of
98.6°F. Long lines on the scale represent each degree, with only the even­
numbered degrees written (for example, 94, 96, 98, 100). Short lines between

14-2
 FM 8-230

degree lines represent 0.2 (two tenths) of a degree. All temperatures are
recorded as ending in an even number when using this thermometer (98.2°F,
99.6°F) because it does not measure in odd tenths. To read a clinical
thermometer:

a. Hold the thermometer by the stem at eye level.

b. Notice the ridge side with numbers below and lines indicating
number of degrees above (long lines one degree; short lines
= 0.2 of a
=

degree).

c. Rotate the thermometer back and forth slowly until you can see
the silver mercury strip.

d. Compare mercury strip level to printed markings.

14-7. Methods of Measuring Temperature Using Clinical Thermometers

a. Oral Temperature (Figure 14-2). This is the most convenient

method and can be used for responsive adult patients. Before taking an oral
temperature you should ask the patient if he has recently had any food or
drink or if he has been smoking. If so, wait 15 minutes before taking the
temperature.

CAUTION

When handling thermometers, handle by the

stem end only.

(1) Wash your hands.

2) Check thermometer to be sure it is clean and dry. Shake it

down to 94bF if necessary. When shaking down the thermometer, grasp the
stem end firmly and with a sharp downward wrist motion, shake the
thermometer. Check the mercury column and repeat the shaking procedure, if
necessary, to lower the column to the 94°F mark.

(3) Place bulb end under the patient's tongue (Figure 1 4-2A).
Instruct him to close lips firmly around stem, but not to bite down (Figure
1 4-2B). Leave thermometer in place at least 3 minutes.
(4) Remove thermometer. Wipe with a gauze tissue from stem to
bulb to remove any saliva. Read and record the temperature, using decimals
(for example, "98.4°F").

(5) Place thermometer in "used" oral thermometer holder.

b. Rectal Temperature. This is the most accurate method. It is used

for all infants and young children and for adults who are unconscious,
irrational, or who have difficulty breathing with the mouth closed. It is not
used on patients who have had rectal surgery or have a rectal disorder.

( 1 ) Provide patient privacy (if possible). Then turn him on his

side (Sims position) and expose the buttocks. The top knee should be flexed
(bent).

14-3
FM 8-230

(2) Insure that the tip of the thermometer is well lubricated. Use
sterile lubricant for this procedure.

(3) Lift the upper buttock to expose the anus. Insert the well­
lubricated bulb of the thermometer slowly and carefully about 1 1/2 inches into
the rectum (Figure 14-3).

(4) Hold thermometer in place for 2 minutes.

(5) Remove thermometer. Wipe downward with a gauze tissue

from stem to bulb. Read and record temperature, using the decimal followed
by the initial R (for example, "99.8°F(R) ").

(6) Place rectal thermometer in "used" holder.

THERMOM ETER

Figure 14-2. Measuring patient's oral temperature. Figure 14-3. Insertion of the thermometer
into patient 's rectum.

NOTE

Instruct the patient to take a deep breath; this

will relax the anal sphincter and allow easier
insertion of the thermometer.

c. Axillary Temperature. When temperature can be taken neither

orally nor rectally, it can be taken under the arm where the thermometer bulb
can be surrounded by body tissue. To take the axillary (armpit) temperature,
use an oral thermometer.

( 1 ) Pat the armpit dry with a tissue or towel. Place the bulb of
the oral thermometer in the center of the armpit and pointed towards the
patient's head.

(2) Fold the patient's arm across his chest with his fingers on the
opposite shoulder (Figure 14-4).

(3) Leave thermometer in place for at least 10 minutes.

14-4
 FM 8-230

(4) Remove thermometer. Read and record temperature, using

the decimal followed bv the initial A (for example, " 100.2°F(A)").

(5) Place thermometer in "used" holder.

Figure 14-4. Take an axillary temperature.

14-8. Care of Thermometers (Clinical Environment)

a. Remove contaminated thermometers from "used" holder.

b. Cleanse thermometers with gauze pad soaked with Wescodyne/

Betadine solution. Cleanse each thermometer with a twisting motion from
stem to bulb. Rinse the thermometer under cool running water (if available) or
with a gauze pad saturated with water. Use a twisting motion from stem to
bulb.

CAUTION

Most thermometer contamination is at the

bulb end due to patient contact. Do not retrace
or backtrack cleansing the thermometer.
D o i n g s o would r e c o n t a m i n a t e t h e
thermometer.

c. Place thermometers in a basin of Wescodyne solution, 1 50 ppm,

for 30 minutes.

d. Wash and dry thermometer holders. Place layer of cotton or gauze

pads in the bottom of each.

e. Remove thermometers from Wescodyne solution, rinse under cool

running water and dry.

f. Shake down thermometers to at least 94°F and return to "clean"

holder.

14-5
FM 8-230

NOTE

If using thermometer tray, all containers

should be disinfected at least once daily.
Wescodyne solution should be changed daily or
more often if needed.

14-9. Care of Thermometers (Field Expedient Method)

When assigned as an aidman to a TOE unit, you may have to modify the
method of disinfecting thermometers while on field maneuvers. Prior to taking
a patient's temperature, the thermometer should be thoroughly cleansed.

a. Remove thermometer from its plastic holder.

b. Cleanse thermometer with 70 percent isopropyl alcohol pad. Use a

twisting motion to clean from stem to bulb end.

c. Rinse the thermometer with cool water or with a gauze pad

saturated with water. Use a twisting motion from stem to bulb end.

d. Skake down thermometer to at least 94°F.

NOTE

This procedure is to be used prior to taking

patient's temperature and after temperature is
taken.

14-10. Pil'ltk --

Pulse is defined as the rhythmic expansion and contraction of an artery. This

action is caused by the beating of the heart. When the heart contracts
(systole), the blood is forced from its chambers into the arteries. This action
causes the arteries to dilate (expand). When the heart relaxes (diastole), blood
refills its chambers. This action causes the arteries to contract, or recoil, as the
blood moves further along in the circulatory system. A patient's pulse is
measured to aid in determining his condition by comparing it with a normal
heart rate.

14-11 . Palpation of the Pulse

The pulse can be felt at points where an artery lies close to the skin or where it
crosses over a bony area or hard tissue. The pulse sites (Figure 14-5) can be
found-

a. At the wrist, proximal to the thumb (radial artery), on the palm

side of the hand.

b. At either side of the neck, near the windpipe (carotid artery).

c. On the inside of the elbow about 1/2 inch proximal to the elbow
point (brachia} artery).

d. Below the left nipple (5th intercostal space (apical artery)).

14-6
 FM 8-230

BRACH I AL

RADIAL

ULNAR

FEMORAL

POSTERIOR
TIBIAL

Figure 14-5. Pulse sites.

14-7
FM 8-230

e. In front of the ear (temporal artery).

f. In the middle of the groin and leg joint (femoral artery).

g. In the center of the back of the knee along the inside medial tendon
(popliteal artery).

h. Behind the inner ankle bone (posterior tibial artery).

i. Along the top (dorsum) of the foot (dorsalis pedis artery).

14-12. Pulse Rate

a. Normal Pulse Rate. Generally, the normal pulse is regular in rate,

rhythm, and force (strength). A strong pulse is easily detected by the large
amount of blood being pumped. The average range is between 60 and 100 pulse
beats per minute. The rate of the normal pulse varies slightly in individuals as
indicated in Table 14-1.

Table 14-1. Pulse Rates.

Commonly Accep ted Pulse Rates Beats per Minute

Normal pulse range 60 to 100

Some athletes 45 to 60

Adult males 72

Adult females 76 t.o 80

Child, age 5 95

Child, age 1 1 10

Newborn infant 1 15 to 130

b. A bnormal Pulse Rate.

( 1 ) Bradycardia is a pulse rate below 60 beats per minute. A

patient with heart disease may have a slow heart beat due to intake of cardiac
drugs, such as digitalis. Athletes will tend to have a "normal' ' pulse rate of
less than 60 beats per minute.

(2) Tachycardia is a pulse rate of over 100 beats per minute.

Conditions causing the heart rate to rise are emotion, pain, exercise, excessive
heat, fever, bleeding, and shock, which may raise the heart rate above normal,
thus increasing the pulse rate.

14-13. Characteristics of Pulse Beats

When you count the pulse, the rate, rhythm, and force should be noted. There
are several means of describing the characteristics of a pulse.

14-8
 FM 8-230

a. Pulse is normal when it is even in rate' rhythm and force

'
(strength) (Figure 14-6).

b. An irregular pulse is one that has a period of normal rhythm

broken by periods of irregularity or skipped beats (Figure 14-7).

r.. :'.. .r-.

:,..... ·.
.

Figure 14-6. Regular pulse. Figure 14-7. Irregular pulse.

c. A bounding pulse (Figure 14-8) occurs when exceptionally strong

heartbeats make arteries difficult to compress. This may be caused by
exercise, anxiety, or alcohol.

d. A pulse is weak, thready, or feeble (Figure 14-9) when only small

amounts of blood are being pumped through the arteries.

. .
. ·. . .

Figure 14-8. Bounding pulse. Figure 14-9. A weak, thready pulse.

14-14. Procedure for Measuring and Recording a Patient's Pulse

a. Position the patient either lying down or seated comfortably in a

chair with palms up.

b. Locate the pulse point that is easiest to reach and use. Usual pulse
sites are the radial, brachia!, and carotid sites.

c. Palpate the pulse site by placing either the fingertips of index and
middle fingers on pulse point, or index, middle, and ring fingers on pulse point
(Figure 1 4- 10).

14-9
FM 8-230

Figure 14-10. Palpating a radial pulse.

d. Count pulse for 1 full minute. Note rate, rhythm, and force
(strength).

e. Record the pulse and report as appropriate.

14-15. Respiration

Respiration, commonly called breathing, is the process by which oxygen (0 2 )

and carbon dioxide (C02 ) are interchanged by the body. External respiration
refers to the delivery of oxygen (02 ) to the lungs so that it can be taken into the
blood stream. Internal respiration is the process by which oxygen from the
blood is taken to the cells in the body and carbon dioxide (C02) is removed
from tissues and carried into the blood. Both conscious and unconscious
(involuntary) control of respiration is the function of a respiratory center in the
brain (medulla oblongata).

a. Inhalation is the process of taking air into the lungs. During

inhalation, the diaphragm descends as it contracts and the rib cage is lifted
upward and outward, giving the lungs more room to expand and create a slight
vacuum in the chest that draws air into the lungs.

b. Exhalation is the process of expelling air from the lungs. During

exhalation, the diaphragm rises as it relaxes and the rib cage is drawn down
and inward as air rushes out' of the lungs.

14-16, Normal Breathing Rates

Normal breathing (eupnea) is easily done and does not require conscioqs
thought. Normal respiratory rates are typically one-fourth of the normal heart
rate. Respiratory rates vary according to age; the following are commonly
accepted as being the normal limits:

14-10
 FM 8-230

Respirations per Minute

a. Healthy adult 1 2 to 20

b. Adolescent youth 18 to 22

c. Children 22 to 28

d. Infants 30 or more

14-17. Patterns of Breathing

a. Normal Respiration. A normal, relaxed breathing pattern is

effortless, evenly paced, regular, and automatic. Increased levels of carbon
dioxide or lower levels of oxygen in the blood trigger an increase in the
respiratory rate to restore the chemical balance and rid the body of excess
carbon dioxide.

b. A bnormal Respiration. A head injury or any increased intracranial

pressure (ICP) will depress the respiratory center and result in shallow or slow
breathing. Certain drugs also tend to depress the respiratory rate (for example:
Morphine, Demerol).
c. Breathing Variations.

( 1 ) Dyspnea: Difficult and labored breathing, often with flared

nostrils, anxious appearance, and statements such as " I can't get enough air. "
It is important to know how much exertion or activity causes the dyspnea.
Does it occur when walking, trying to eat a meal, or when trying to talk?

(2) Tachypnea.· Increased or rapid breathing; may be seen in

fever and in a number of other diseases. Breathing rate increases markedly for
each 1 °F increase in temperature.

(3) Slow and shallow: There is a limited amount of air exchanged

and less oxygen is taken in. This type of breathing often leads to hypoxia, or
decreased levels of oxygen in the blood. It is often seen in patients who are
under sedation, recovering from anesthesia, have had abdominal surgery, or
are in a weak or debilitated condition.

(4) Cheyne-Stokes respirations: A pattern of dyspnea followed

by a short period of apnea (no respiration). Respirations· are rapid and gasping
in nature for about 30 to 45 seconds, then are followed by a period of no
breathing for about 20 seconds. It is seen in critically ill patients with brain
conditions, heart or kidney failure, or drug overdose.

(5) Hyperventilation: A pattern of breathing in which there is an

significant increase in the rate of breaths and carbon dioxide is expelled from
the body, causing the blood level of C0 2 to fall. The condition is seen after
severe exertion and during high levels of anxiety or fear and with fever and
diseases such as diabetic acidosis.

(6) Kussmaul 's respirations: The increased rate and depth of

respirations, with panting and long, grunting exhalation. It is frequently seen
in diabetic acidosis and renal failure.

14-11
FM 8-230

d. Noisy Respirations. As a rule of thumb, you should regard �ny

noisy respirations as obstructed breathing. Some of the terms used to descnbe
noisy respirations are-

( I) Rales and rhonchi: Rattling sound caused by secretions in the

lung passageways.

(2) Stertorous: A snoring sound produced when patients are

unable to cough up secretions from the trachea or bronchi.

(3) Stridor: A crowing sound on inspiration due to the

obstruction of the upper air passageways as occurs in croup or laryngitis.

(4) Wheeze: A whistling sound of air forced past a partial

obstruction as found in asthma or emphysema.

14-18. Procedure for Measuring and Recording a Patient's Respirations

For an accurate accounting of the respirations, the patient should be at rest

and unaware of the counting process. If adult patients are aware that you are
counting their respirations, they may voluntarily breathe faster or slower. The
most satisfactory time to count respirations is after the patient's pulse count.

a. After taking the pulse, continue holding the patient's wrist. Lay
the patient's arm across his chest.

b. Count respiratory rate for 1 full minute. Observe rate, depth,

patterns, and sounds of respiration.

NOTE

One respiration in�ludes both the inhalation

and expiration.

c. Record the respirations and report as appropriate.

14-19. Blood Pressure

Blood pre� �ure f§P) may be defined as the pressure exerted by the blood on the
.
walls of tlie' vessefs. All parts of the vascular system are under pressure, but
the term "blood pressure" usually refers to arterial pressure. The pressure is
the product ol ( 1 ) the force of the contraction of the ventricles of the heart, (2)
the amount of blood pumped out of the heart, and (3) the resistance of the
blood vessels to the flow of blood through them. By measuring the blood
pressure, you obtain information about the effectiveness of the heart
contractions, the adequacy of the blood volume in the system, and the
presence of any obstruction or interference of flow through the blood vessels.

14-20. Normal Ranges of Blood Pressure

Blood pressure consists of the systolic pressure written as a fraction over the
diastolic pressure. The systolic pressure is the level present during contraction
of the heart. Diastolic pressure is the pressure during relaxation of the heart.
The average blood pressure in a healthy young adult is considered to be 1 20/80
mm of mercury (Hg); 120 is the systolic pressure, 80 is the diastolic pressure.

14-12
 FM 8-230

J ust as pulse and respiratory rates vary among individuals, so does blood
pressure. The normal blood pressure range is-

MALE FEMALE

Systolic 100-140 Systolic 90-130

Diastolic 60-90 Diastolic 50-80

14-21. Factors Influencing Blood Pressure

As a result of the many factors influencing it, the blood pressure is a dynamic
force that can vary from minute to minute as the heart adjusts to demands and
responses of the body and brain. Many factors exert an influence on blood
pressure:

a. Age: Blood pressure is lower in children than it is in adults.

b. Sex: Blood pressure is higher for men than women of the same age
level.

c. Body Build: Obese persons usually have higher blood pressure

than do those who are of average weight and build.

d. Exercise: Exertion temporarily elevates blood pressure.

e. Pain: Pain will usually elevate blood pressure.

f. Emotion: Fear, worry, or excitement will elevate blood pressure.

g. Drugs: Vasoconstrictors elevate blood pressure. Vasodilators

decrease blood pressure. Narcotics decrease blood pressure.

h. Disease: Any disorder affecting the circulatory or renal system

may increase blood pressure. A disease that weakens the heart may lower the
blood pressure.

i. Hemorrhage: Decrease of blood volume lowers blood pressure and

may lead to shock.

j. Intracranial Pressure: Pressure in the 'space between the skull and

the brain can elevate blood pressure.

14-22. Abnormalities of Blood Pressure

a. Hypertension. Pressure elevated above the normal range is called

hypertension. Prolonged hypertension can cause permanent damage to the
brain, the kidneys, the heart, and the retina of the eye.

b. Hypotension: Low blood pressure is called hypotension.

Hypotension associated with symptoms of shock or circulatory collapse is a
dangerous condition that can rapidly progress to death unless treated.

14-13
FM 8-230

14-23. Blood Pressure Measurement

Blood pressure is measured with a sphygmomanometer (an air-pressure

device) (Figure 14- 1 1) and a stethoscope (Figure 14-12). The cuff of the
sphygmomanometer contains an oblong rubber bag or bladder. When the cuff
is wrapped around the upper arm or the midthigh and inflated with air, the air
pressure registers on the sphygmomanometer gauge. Taking a blood pressure
requires practice. The individual must apply the cuff properly, manipulate the
air bulb, and simultaneously listen through the stethoscope while watching
the gauge.

NOTE

The pressure readings are in millimeters (mm)

of mercury (Hg).

Figure 14-11. Sphygomomanometer (aneroid

and mercury illustrated).

14-14
 FM 8-230

Figure 14-12. Stethoscope.

14-24. Procedure for Measuring and Recording a Blood Pressure Using the
Brachia! Artery

Determining blood pressure by auscultation is the most common method for

determining blood pressure as a stethoscope is used to listen for characteristic
sounds.
NOTE

Insure that cuff is completely deflated and the

gauge registers zero.

a. Decontaminate stethoscope. Clean earpieces and diaphragm with

70 percent alcohol swabs and cotton-tipped applicators.

b. Explain procedure to the patient. Many people may be fearful of

the technique, thinking it will be harmful or painful. Ask your patient if he has
had his blood pressure measured before. If not, make him aware of the
sensations that accompany the technique, most notable the discomfort caused
by the cuff as it is inflated.

c. Position the patient.

(1) Patient should be seated or lying down.

(2) Support the arm to be used, palm up, at the level of the
patient's heart.

CAUTION

If injured, patient should not be moved simply

for the purpose of determining blood pressure.
To do so may aggravate existing inj uries.
Blood pressure should be measured without
moving the patient.

14-15
FM 8-230

d. Expose the patient's upper arm. Remove garment if sleeve is tight.

e. Place the cuff on the patient's arm (Figure 1 4-13). Position the cuff
1 to 2 inches above the elbow. Apply the cuff securely but not overly tight.

( 1 ) If using aneroid-type manometer, clip the gauge to the cuff in

line with palm.

(2) If using mercury manometer, place column on a firm, level

surface, outside patient's field of vision.

Figure 14-13. Cuff placement.

f. Locate pulse of brachia! artery by palpating in the bend of the

elbow.

g. Place the bell or diaphragm of the stethoscope over the pulse point
(Figure 14-14). Do NOT apply the bell or diaphragm too firmly; excessive
pressure distorts the pulse sounds.

Figure 14-14. Placing the s tethoscope.

h. Tighten thumbscrew of air bulb (clockwise) with one hand while

holding stethoscope in place with other hand.
i. Inflate the cuff by pumping air bulb (Figure 14-1 5). You will hear
the pulse sounds as the pressure in the cuff increases, then the sounds will
disappear. Continue inflating the cuff until the pressure gauge indicates about
20-30 mm above where pulse sounds were last heard. It is at this point that the
air pressure has caused the arterial wall to collapse.

14-16
 FM 8-230

Figure 14-15. Inflating the cuff

j. Loosen thumbscrew of air bulb (counterclockwise) and allow the

air to escape slowly (about 2-4 mm Hg per second). At the same time, watch
the gauge. When the first distinct sound is heard, note the number on the
gauge; this is the systolic pressure.

k. Continue to release the air slowly. Look and listen. Note the
number on the gauge at which the last distinct sound is heard. This is the
diastolic pressure.

CAUTION

In some patients, sounds may be heard to

extremely high or low levels.

Section III. ASEPSIS

14-25. General

a. Microorganisms abound in the world and people are constantly

bombarded by them. Only a small percentage of the many types of
microorganisms, called pathogens, cause disease; exposure to pathogens does
not always lead to illness. Hospitals are potential reservoirs for countless
microorganisms, both pathogenic types brought in by patients with infectious
diseases and nonpathogenic types normally carried by everyone. Health care
personnel must be continually vigilant in their efforts to control the growth of
organisms and prevent infections. The most efficient methods are those aimed
at controlling the factors causing infections. For example, reducing the
number of organisms in the patient's environment is accomplished by good
housekeeping procedures, frequent handwashing, and use of aseptic
techniques. Virulence, which is the strength of the organism to cause disease,
is difficult to control in rapidly growing organisms. The medical focus is aimed
first at destroying the invading organism as quickly and completely as
possible, and second, at treating the symptoms of the disease. Patients who

14-17
FM 8-230

are ill or who have undergone the stress of surgery are less resistant to
pathogenic organisms. Health care personnel must use their knowledge and
skills to reduce the stresses affecting their patients and protect them against
hospital-acquired infections.

b. An understanding of aseptic technique and the ability to use it

correctly is an important means of providing for the patients' safety and
welfare. In this section are the principles of asepsis and the procedural skills
involved in maintaining a sterile field, using sterile instruments, opening
sterile packages, putting on sterile gloves, and changing sterile dressings.

14-26. Invasion by Pathogens

a. In spite of modern antibiotic drugs, infections pose an ever-present

potential danger to human beings. Infection develops when pathogens invade
the body and overcome its defenses. Specific information about pathogens
(which are classified as bacteria, viruses, protozoa, helminths, and fungi), their
characteristics, and the diseases they cause can be found in books on
microbiology.

b. The skin and mucous membranes provide the first line of defense
against infection. They protect our bodies from external sources of harm, such
as heat, cold, radiation, chemicals, and microorganisms. Under normal
conditions, countless microscopic organisms exist on the surfaces of the skin,
respiratory passages, the alimentary tract, and the vagina. When any of these
surfaces are broken or injured, pathogens enter the body, where they seek out
tissues suited to their specific needs and then proceed to multiply. As the
pathogens multiply, they damage the normal cells, and the body's response to
the damage gives rise to the symptoms of disease.

14-27. The Development of Infection

a. Health care personnel need to examine the way organisms spread,

how infections occur, and how the body responds to cellular injury, in order to
understand and effectively use aseptic technique as a major intervention.
Pathogenic organisms wait, live, and multiply in reservoirs that may be
human, animal, or nonanimal. However, the most common source of
pathogens is another infected person.

b. In the infectious cycle, pathogens must escape from their reservoir

and find another suitable host. Organisms are transmitted in the following
ways:

(1) Transfer to host via-

• Direct contact with an infected person, contaminated

instruments, or supplies.

• Vectors (carriers) may be human, animal, or insect.

• Fomites, inanimate objects that support organisms, such

as furniture, clothing, food, milk, or water.

14-18
 FM 8-230

• Air currents, such as those produced by coughs, sneezes,

draft, or air conditioning.

(2) Enter the body via-

• Open wounds in the skin.

• Open wounds in mucous membranes.

• Gastrointestinal tract.

• Respiratory tract.

• Genitourinary tract.

(3) Leave the body via-

• Open wounds.

• Gastrointestinal tract.

• Respiratory tract.

• Blood.

c. In health care settings and hospitals, there is a high potential for

pathogenic organisms to cause infections, whether in patients or in health care
personnel (Figure 14-16). Laxity in handwashing between visits to patients,
careless handling of soiled articles, and contamination of wounds readily lead
to infection. The development of an infection depends on three factors:

• The number of organisms entering the body.

• The virulence of the organisms.

• The resistance of the host.

Principles relative to these factors are basic to preventing and controlling

infections, through the use of medical asepsis (isolation precautions) and the
use of surgical asepsis (including reverse isolation).

14-28. Body Response to Injury

a. Inflammation is the body's response to any type of tissue injury.

The injury can be biological (caused by microorganisms), chemical, or physical,
caused by trauma, heat, cold, or radiant energy. The internal defenses are
mobilized to localize the organisms and to limit the effects of the cellular
damage. These defenses involve vascular changes, hormonal response, and
increased white blood cells. Vascular changes produce the signs of the
inflammatory process: swelling or edema of the injured part; redness owing to
the increased blood supply; heat or increased temperature; pain stemming
from pressure on nerves; and loss of function resulting from all of these
changes. Some signs of inflammation-that is, swelling, redness, heat, pain,

14-19
FM 8-230

and loss of function-may not be readily seen when internal organs or tissues
are involved, but they are present to some degree. The signs and symptoms of
the disease it.self are partly due to the inflammatory process. Knowledge of
the inflammatory process enables the medic to assess the patient more
completely. If even one sign of inflammation is present, the alert medic can
look for other signs to determine whether the patient has an infection.

SOURCE
OR
RESERVOIR

I
I I I I l
N EEDLES SYRINGES FORCEPS UTENSILS AIR

I
BODY
HANDS WOUNDS L I N EN
SECRETIONS

Figure 14-16. Common modes of transmission.

b. The following examples illustrate how you can relate the signs of
inflammation to the symptoms produced by specific infections:

Conjunctivitis Appendicitis

Redness of the inner eyelid and the of the appendix, the end of
eyeball the cecum (internal sign)

Heat local warmth, slight tempera­ local warmth, temperature

ture elevation of 100-102°F, 37.7-38.s0c

Swelling mild to moderate puffiness of internally, moderate

lids enlargement of appendix and
neighboring structures

Pain mild to moderate, sensitivity moderate to severe over

to light abdomen

Loss of difficulty in keeping eyelids loss of appetite, nausea,

function open, vision impaired vomiting, decreased
digestive action

c. The acute phase of an infection is characterized by a sudden onset

of symptoms, as well as by the vascular changes of inflammation, especially
swelling caused by fluid collecting in tissue. The acute phase is followed by an
increase in white blood cells to overcome the infection and to clear away the
damaged tissues so that healing can occur.

14-20
 FM 8-230

d. A bacterial infection of the skin or mucous membrane frequently

causes fluid drainage from the wound or broken-down tissue. You must assess
this drainage: its color, consistency, odor (if any), and amount. The color
ranges from creamy yellow to dark green. Because purulent drainage contains
dead phagocytes, bacteria, and tissue, it is thick in consistency. As the
infection clears, the drainage has less odor, becomes more serous or watery,
decreases in amount, and the color lightens. Signs of inflammation subside as
healing occurs.

14-2R Rules for Asepsis

Sterility is the absence of microorganisms. Sterilization can be accomplished

by different methods, such as boiling, dry heat, various chemicals, autoclaving
(steam under pressure), and gases, such as ethylene oxide. There are four
primary rules of asepsis-

a. Know What is Sterile. Most health care facilities now use

commercially prepackaged sterile kits, packs, and supplies. These materials
are disposable and can be discarded after use. When using these sterile
supplies, you must inspect the outer layer or wrapping to insure that it is
intact, without visible holes, tears, or damage. Paper and plastic materials are
used for wrapping, which must be impervious to dust and resistant to
moisture. These precautions are necessary because microorganisms are carried
on dust particles and microscopic droplets of moisture. Some health care
facilities find it more feasible to prepare their own sterile supplies.
Standardized procedures should be followed to clean, assemble, wrap, label,
and sterilize the instruments, linens, supplies, and other items.

b. Know What is Not Sterile. Some things cannot be sterilized and

rendered free of microorganisms, most notable, human skin and mucous
membranes. From a practical point of view, it would be difficult to sterilize
furniture, complex equipment or machinery, and even such things as the air
supply in a room. However, items that cannot be sterilized must be cleaned
thoroughly and disinfected as much as possible. It is important to avoid
creating air currents near a sterile field by shaking linen, coughing, sneezing,
or talking unnecessarily. Even when using sterile items, you must be aware of
what is not sterile. Microorganisms cling to all surfaces, whether solid, liquid,
or gaseous in nature. When any sterile surface touches a nonsterile surface, it
is no longer sterile. The outer wrapping of a sterile package or kit is unsterile,
as is the outside of glass vials and ampules containing medications. The outer
one-inch edge of any sterile field is also considered unsterile because airborne
microorganisms may have settled on it. Any portion of a sterile drape or
equipment that hangs below a table top or waist level is considered unsterile.
Outdated autoclaved canisters as well as cloth- or paper-wrapped items and
sterile items left exposed to the air and unattended even briefly are likewise
regarded as nonsterile.

c. Separate Sterile From Unsterile. The use of commercially prepared

sterile disposables has reduced the need to store sterile items separately. The
sterile packages are individually labeled and wrapped to allow inspection for
intactness. When kept on clean dry shelves1 they will remain sterile for
an indefinite time. However, hospitals that sterilize their own metal canisters
and cloth- or paper-wrapped packs should store sterilized items separately
from unsterile materials as there is no way to visually recognize what has and

14-21
FM 8-230

what has not been rendered sterile. The covers and packages usually look the
same before and after being sterilized, so you must keep them separate and
rely on the use of indicators such as chemical tablets or tapes that turn color
when sterilized. Sterile supplies in metal canisters or cloth-wrapped packages
have a limited shelf life and must be resterilized periodically.

d. Remedy Contamination Immediately. Contamination occurs when

a sterile surface comes in contact with any unsterile surface, whether solid,
liquid, or gas. This can occur when you or others move too quickly and
accidentally touch a sterile object with an unsterile one. The resulting
contamination can be remedied by:

(1) Promptly removing the contaminated object(s) from the area.

(2) Covering the contaminated object(s) with a sterile towel or

drape.

(3) Discarding the contaminated object(s) and starting over if

the sterile field and the set-up (items required to carry out a sterile procedure)
have also been contaminated.

14-30. Principles of Aseptic Surgical Technique

a. The following principles form the basis for surgical asepsis:

(1) Sterile surface touching sterile surface remains sterile.

(2) Sterile surface touching unsterile surface becomes

contaminated.

(3) Sterile materials must be kept dry; moisture transmits

microorganisms and contaminates.

(4) When there is doubt about the sterility of any item, it must
be considered not sterile.

(5) Reaching across or above a sterile field with bare hands or

arms or with other nonsterile items must be avoided.

(6) Coughing, sneezing, or unnecessary talking near or over a

sterile field must be avoided.

(7) When wearing sterile gloves, hands must be kept in sight,

away from all unsterile objects and above waist level.

(8) The wrapper of a sterile pack must be opened away from the
body, the distal flap first, the lateral flaps next, and the proximal flap toward
the body last, thus making it unnecessary to reach over the sterile field.

(9) The sterile zone is confined to the table top or to above waist
level. Anything that hangs, falls, or touches below these levels is considered
contaminated.

( 10) An area of one inch surrounding the outer edge of the sterile
field must be considered unsterile.

14-22
 FM 8-230

( 1 1 ) The sterile field must be kept in sight at all times. Do not

tum your back on it or leave it.

( 12) The floor must be recognized as the most grossly

contaminated area. Clean or sterile items that fall on the floor should be
discarded or decontaminated.

b. Many activities and skills are based on practice of the principles of

medical and surgical asepsis. In medical asepsis, the goal is to keep the
organisms within a given area; in surgical asepsis, the area must be kept free
from organisms. These concepts are equally important. Table 1 4-2 presents a
comparison of factors in medical and surgical asepsis.

Table 14-2. Comparison Factors in Medical and Surgical Asepsis.

Factor Medical Asepsis Surgical Asepsis

Patient Has infection, lowered Potential host. Lowered

resistance to other resistance makes more
infections. susceptible.

Reservoir of The patient-organisms Organisms harbored by

infection spread by direct and others and in the
indirect contact. environment.

Location of Confine organisms within Prevent organisms from

barriers room, unit, or locale. reaching patient or area.

Equipment and Disinfect, sterilize, or Disinfect or sterilize

supplies dispose of after contact before contact with
with patient patient.

Protective Clean items to protect Sterile items (except

clothing: gown, worker from organisms. masks) to protect
gloves, masks Discard after contact with patient. Remedy if
patient contaminated.

Goal of actions CONFINE ORGANISMS and REDUCE NUMBER OF

prevent spread of ORGANISMS and prevent
infection to others. spread of infection to
patient.

14-31. Use of Disinfectants and Antiseptics

a. Disinfectants are agents that destroy pathogenic organisms.

Although the action of sunlight and heat is included in this category,
medically the term applies to chemical agents that kill pathogens outside of
the body. Disinfectants are used on obj ects such as equipment, furniture,
walls, and floors; however, most of these chemicals are too harsh to use on
living tissue.

14-23
FM 8-230

b. Antiseptic agents inhibit the growth of organisms. While

antiseptics also include disinfectants, antiseptics can be used on body tissue.
They can be used to treat wounds, to prepare the skin for operation, and to
reduce organisms on the skin. Disinfectants and antiseptics chosen for use in
hospitals should meet the following criteria:

• Inhibit or kill the pathogens within a reasonable period of

time.

• Not be harmful to materials or surfaces.

• Not be readily neutralized by soaps, detergents, or proteins.

• Be stable in solution.

Among the types of disinfectants and antiseptics frequently employed are the
following: cyanide; phenolics; such as Staphene and Vas-phene; iodine and
iodophors, such as povidone-iodine to destroy bacteria, viruses, and fungi;
alcohol, to inhibit and destroy organisms; and chloride compounds, generally
intended for use on floor surfaces.

14-32. Handwashing

All personnel and patients, regardless of position or diagnosis, should be

recognized as potential carriers of pathogenic organisms. One of the most
critical tasks in medical care duties is that of providing a safe atmosphere for
you as well as for the patient. Because your hands carry millions of germs,
frequent handwashing is one of the simplest techniques to help prevent the
spread of disease and infection. This procedure is designed for use between
routine patients when providing care. The entire procedure can be done
effectively in about 2 minutes.

14-33. Types of Soaps

Soap combines with foreign matter on the skin and lowers the surface tension
(clinging effects) of grease and dirt, thus permitting them to be easily removed
from the skin surfaces. There are various types of soaps currently in use:

a. Antimicrobial-a disinfectant, germicidal, and fungicidal

concentrate (Wescodyne/Betadine). This is a general-purpose germicide,
suitable for hand cleansing as well as for disinfecting various types of
equipment and instruments. This concentrate must be diluted with water to
make at least a 75 parts-per-million (ppm) or higher solution. The clear, dark
amber color of this solution is an indication of its germicidal effectiveness;
when the color fades, a fresh solution must be prepared.

b. Liquid soap-a bacteria-inhibiting (bacteriostatic) liquid soap may

be used for handwashing and disinfecting skin surfaces. The active ingredient
in these types of soaps is hexachlorophene, which has a cumulative effect in
reducing bacteria on the skin.

c. Soap bars-is the least effective method. The bar of soap can be a
germ-carrier itself when contaminated by dirty water. Care must be taken to
rinse the soap well before returning it to the soap dish. This reduces the chance
of contaminating the soap.

14-24
 FM 8-230

14-34. Handwashing Procedure

Proper handwashing consists of three essential elements: soap, friction, and

running water. In a field situation, you will rarely have a sink with faucets at
your disposal. Therefore, you may use other methods for handwashing.

a. Equipment (two-basin method).

(1) Two basins.

(2) Canteen of water.

(3) Soap (bacteriostatic or Wescodyne, if possible).

(4) Paper towels.

(5) Assistant (to pour the rinse water).

b. Fill basin and canteen. Fill basin with just enough water to wash
hands. Fill canteen with water for rinsing.

NOTE

Potable water should be used from a reliable

source (Lyster bag, water pod, and so forth).

c. If Wescodyne/Betadine soap is to be used, mix the solution to

prescribed strength (at least 75 ppm).

d. Remove j ewelry. Jewelry should not be worn when performing

patient care because microorganisms become lodged in the settings or stones
or rings. The only exception is a plain wedding band. Fingernails should be
kept clean and short.

e. Roll sleeves above elbows.

f. Wash both hands and forearms from fingertips to elbow.

(1) Wet hands, wrists, and forearms.

(2) Apply soap.

(3) Using firm circular movements,wash fingers, finger webbing,

and fingernails first.

(4) Wash palms and back of hands second.

(5) Wash forearms to elbows last.

NOTE

Give particular attention to creases and folds

in the skin when washing; these areas
harbor many microorganisms.

14-25
FM 8-230

g. Rinse hands and forearms from fingertips to elbows.

(1) Use canteen of water for rinse.

(2) Have assistant pour rinse water over soapy areas into the
empty basin. He should not touch lip of canteen to skin as this would
contaminate that area.

NOTE

If no assistant is available, you may pour the

rinse water by holding the canteen with clean
paper towels in your free hand.

(3) Hold hands slightly higher than elbows to prevent

recontaminating hands and fingers.

h. Dry hands.

( 1 ) Use clean paper towels for each hand. If not available and
cloth towel is to be used, use opposite end for each hand.

(2) Dry thoroughly from fingertips toward elbow. Do not go back

up toward fingertips as this would recontaminate the area.

i. Dispose of all dirty material in accordance with local policy. There

are other methods and devices for washing hands in field conditions. These
methods and devices are described in FM 21-10.

14-35. Opening Sterile Packs and Sets

a. Sterile materials and supplies are usually prepared commercially

and are disposable for one-time use items. The packages, sets, or kits provide
all of the items commonly required in medical procedures such as
catheterization, suture removal, dressing change, irrigation, enema, and
catheter care. Individually wrapped items can be obtained to supplement the
packs as needed. The package or set is opened by removing the outer plastic or
paper covering, taking out the inner package, and unfolding the wrapper to
form a sterile field from which to work. The principles of asepsis apply
regardless of whether the package is a disposable or a wrapped tray prepared
by a hospital department. The principles to observe when opening sterile
packages are-

• Wash your hands.

• Open sterile packages away from the body.

• Touch only the outside of the wrapper.

• Do not reach across a sterile field.

• Always face the sterile field; go around the sterile field, if

necessary.

14-26
 FM 8-230

• Allow sufficient space (at least 12 inches) between your body

'
and the sterile field.

b. Procedure for opening sterile packs.

( 1 ) Obtain the sterile package containing the required item(s)

(Figure 1 4-17A). The item should be placed on a table or flat surface while
being unwrapped. Disposable packages have a plastic or paper covering.
Hospital-prepared goods have cloth or paper covers and you must check
package indicator for date and sterility of the package. Chemically treated
indicators change color when sterilized. Heat-sensitive tape used at the
external opening of packaged material will show distinctive diagonal stripes
following exposure to a heat sterilization process.

(2) Remove the plastic covering and external wrap from the
package. Remove the contents so as to avoid contaminating them. Touch only
the outer surface of the wrapped contents.

(3) Open the wrapper (Figure 14-1 7B). Remove outside

fastening. With one hand, lift the distal flap up and toward the back, away
from the package. Let the distal flap drop gently over the back of the table. It .
is important to open the distal flap first so that your unsterile arm does not
reach across the sterile contents.

(4) Open left and right flaps (Figures 14-17C and 14-17D). With
your left hand, move the flap up and laterally away from the package.

(5) Open the proximal flap (Figure 1 4-17C). Lift the flap up and
toward you, dropping it gently over the front of the table or your hand. Once
the wrapper of the package has been opened, it should not be folded closed
again. The contents should be used as soon as possible. Avoid contaminating
the articles in the package by using sterile gloves or forceps when handling
them.

14-36. Opening Individually Wrapped Supplies

Almost every sterile item you use is available as an individually wrapped or

separate item, such as sterile packages of applicators, tongue blades, 4 x 4
gauze dressings, Vaseline dressings, ABD dressings, syringe, Foley catheters,
and tube coverings or caps. Instructions usually appear telling where to open
or indicating the direction in which to tear or peel at a certain point. When
opening the package follow these instructions to avoid contaminating the
contents (Figures 14-18A and 14-18B).

a. Grasp the package by the slightly extended edges provided. Bring

both your hands together and grasp the edges of the package.

b. Peel along the sealed edge. Turn your hands outward to separate
the sealed, sterile package. Peel in a downward motion. Do not touch the inside
of the wrapper.

c. Place the package on a flat surface , OR

d. Hand the article to a sterile person , OR

14-27
FM 8-230

e. Lift the sterile item from the wrapper by using sterile forceps
(Figure 14-18). The inside area of the wrapper is sterile and may serve as a
sterile field until the contents are used. Keep your fingers away from the
edges. The sterile person then picks up the sterile item.

A. B.

c.

D.

Figure 14-1 7. Opening sterile packs.

14-28
 FM 8-230

Figure 14-18. Opening individually wrapped supplies.

14-37. Donning and Removing Sterile Gloves

The following procedure should be used when donning and removing sterile
gloves:

a. Obtain package containing correct size gloves.

b. Inspect the package for any signs of possible contamination (water

spots, moisture, or tears in the package). If package appears contaminated,
discard and select another package.

c. Perform patient care handwash.

d. Place package on clean, dry surface and peel back outer wrapper
completely to expose the inner package.

e. Remove the inner package and place it so that the end of the
package nearest you indicates the printed word "cuff. "

f. Unfold the package by grasping the lower corner and opening the
package to a fully flat position (Figure 14-19). Do not touch gloves. Gloves
should be positioned with right hand in line with your right hand, and left
hand in line with your left hand.

g. Grasp lower corners, or area designated in folder, and pull to side

gently, without touching or contaminating gloves.

h. Grasp the cuff of one glove at the folded edge and remove from
wrapper with one hand (Figure 14-20).
i. Step back from the table or tray.

j. While keeping hands above your waist, insert fingers of your other
hand into the glove and pull on by only touching the cuff (Figure 14-21).

14-29
FM 8-230

k. Pick up the second glove by inserting the tips of fingers of gloved

hand under the folded cuff (Figure 14-22).

l. Insert fingers of ungloved hand into glove and pull up without

contaminating either glove (Figure 1 4-23).

NOTE

Touch glove to glove and skin to skin to

maintain sterility.

.......-J-
I
I

L
• l U ....... ..,...:i -
_ ___

Figure 14-19. Package in fully Figure 14-20. Remove from

flat position. wrapper.

Figure 14-21. Insert fingers of Figure 14-22. Pick up second

glove.
other hand

14-30
 FM 8-230

Figure 14-23. Insert fingers of

ungloved hand into glove.

m. Adjust the gloves to fit firmly and comfortably without

contaminating (either pull ·on individual fingers or interlock gloved fingers).

n. To remove gloves, begin by grasping the glove at the heel of the

hand with the other gloved hand.

o. Peel off glove, retaining removed glove in palm of remaining

gloved hand.

p. Insert one or two fingers of ungloved hand under the glove of the
remaining gloved hand. Peel glove off hand without contaminating self.

NOTE

Remember to remove gloves "glove to glove"

and "skin to skin. "

q. Discard gloves according to local SOP.

r. Wash hands.

14-38. Assessment of Wounds

a. Assessment of the patient must include a complete inspection of

all skin areas. Every abrasion, laceration, contusion, reddened pressure area,
ecchymosis, and incision is noted. Be alert for signs of inflammation: redness,
swelling, pain, heat, and loss of function. The location and the appearance of
these skin wounds is charted each day in specific terms, since changes can
occur quite rapidly. Assessment of wounds requires notations about the
dressing even when the wound cannot be observed directly. After a traumatic
injury or surgery, the initial dressing remains in place until the physician
changes it or authorizes you to do so. The appearance of the dressing provides
some information about the wound underneath. Dressings are kept as dry as
possible to reduce capillary attraction of microorganisms and potential
infection. Excessive drainage or increased bleeding should be reported to the
physician.

14-31
FM 8-230

b. An early sign of impaired healing is evidenced by hemorrhage,

visible bleeding, or symptoms of concealed internal bleeding. When this
occurs, the dressings on surgical incisions or wounds must be inspected; also
look at the area under the patient because blood from wounds can leak out and
form pools. Observe drainage tubes frequently for signs of bleeding. Monitor
the patient's vital signs until his condition is stable. Improper healing can
result in-

• An abscess, a localized infection in which there is an

accumulation of pus. The liquid may be white, yellow, pink, or green,
depending on the infecting microorganism.

• Cellulitis, an inflammation of the cellular tissue surrounding

the initial wound.

• Empyema, the collection of pus in an already existing cavity,

such as the gallbladder or lung.

• A fistula, an abnormal passage or communication usually

formed between two internal organs, or leading from an internal organ to the
surface of the body. A fistula may result from an infection. Common
postoperative fistulas are designated according to the organs or parts with
which they communicate, such as rectovaginal, fecal, anal, biliary, and the
like.

• A sinus, a canal or passageway leading to an abscess.

14-39. Dry, Sterile Wound Dressing

a. A dressing is any sterile material used to cover a wound The

sterile dressing-

• Protects the wound from bacteria.

• Protects the environment from bacteria in the wound.

• Absorbs drainage.

b. A well-applied dressing makes the patient feel like he is getting

good health care. Psychologically, this makes the patient feel better.

14-40. Requirement to Change or Reinforce a Dressing

a. The physician or the supervisor orders tells you when to apply a

dressing and how often to change the dressing. This order also specifies if the
wound is to be cleansed.

b. Under field conditions, you will not change the dressing without a
physician's order. Reinforce the dressing and place the date, time, and your
initials on the dressing.

c. Sometimes a dressing may need to be changed because it is soaked

with seepage. If the circumstances or the physician's or the supervisor's order
prohibit the change, reinforce the area by covering it with another dressing.
Label it "reinforcement, " and write the date, time, and your initials on it.

14-32
 FM 8-230

14-41. Dressing Materials

Various types of dressing materials are used when applying or changing a

dressing. The following are those most frequently used:

a. Coarse mesh gauze sponge (Figure 1 4-24A).

( 1 ) Available in several sizes, but the ones used routinely are 2 x

2 in (5.08 x 5.08 cm), 4 x 4 in (10.16 x 10.16 cm), and 4 x 8 in (10.16 x 20.32 cm).

(2) Commonly used as intermediate layers in many dressings.

b. ABD Pad (abdominal pad, combines) (Figure 1 4-24B).

(1) Large, thick, multilayered absorbent dressing.

(2) Used primarily for postoperative abdominal incisions.

c. Telfa pad (Figure 1 4-24C).

(1) Pad with a plastic-like coating on one side of gauze dressing.

(2) Used to prevent the dressing from sticking to the wound.

A. COARSE MESH
GAUZE SPONGE C. TELFA PAD
B. ABO PAD

Figure 14-24. Dressing materials.

d. Petrolatum (Vaseline) gauze (Figure 14-25A).

(1) Consists of gauze coated with petroleum jelly.

( 2) Used to protect tissue from drying, to prevent adherence to

the wound, and to create an airtight seal.

e. Roller gauze bandage (Figure 1 4-25B). A loose mesh material

available in various sizes from 1 to 4 in (2.54 to 10.16 cm) wide and 5 yd
(4.57 m) long.

f. Kling and Kerlix bandage (Figure 1 4-25C).

( 1 ) Loosely woven or knitted roller gauze bandages which are

soft and conform easily.

(2) Used most often to secure dressings, are highly absorptive,

and are appropriate when a bulky dressing is needed.

14-33
FM 8-230

B.
Figure 14-25. Gauze and bandages.
14-42. Tapes

The following tapes are used to secure dressings:

a. Adhesive.

(1) Made from cotton, cloth, paper, or foam.

(2) Available in several widths.

(3) In addition to being used to secure dressings, the adhesive

tapes are used to secure splints, to strap joints to prevent or treat athletic
injuries, and to immobilize various parts of the body.

b. Hypoallergenic.

(1) Made from paper.

(2) Porous-allows air exchange.

c. Plastic.

(1) Transparent.

(2) Porous-allows air exchange.

14-43. Procedure for Changing a Sterile Dressing

a. Identify the patient and provide privacy. Provide privacy if

possible by placing a screen or curtain around the patient or by closing the
door.

b. Explain the procedure. Gain the patient's confidence and

cooperation by telling him why you are changing the dressing and what the
procedure will be.

c. Perform patient care handwash.

d. Obtain necessary equipment and supplies.

( 1 ) Dressings-4 x 4 in (10.16 x 10.16 cm) and 4 x 8 in ( 1 0. 16 x

20.32 cm) sponges.

( 2) Gauze pads or cotton-tipped applicators.

14-34
 FM 8-230

(3) Gloves.

(4) Scissors.

(5) Solution basin, if applicable.

(6) Sterile towels (for sterile field).

(7) Tape.

(8) Adhesive solvent.

(9) Container for adhesive solvent.

( 1 0) Drain, if applicable.

(11) Disinfecting solution, if applicable.

(12) Sterile forceps.

e. Prepare the patient. Position the patient.

(1) Make the wound site easily accessible.

(2) Expose the wound.

(a) Remove the patient's clothing. Do not expose any more

of the patient 's body than is necessary.

(b) Fold the bed linens or pajamas away from the wound
area.

f. Prepare the work area.

(1) Clear all items off the bedside stand.

( 2) Clean and dry area.

(3) Cut the tape strips to the size that is required to secure the
dressing.

(4) Attach one end of each tape strip to an area that can be easily
reached.

(5) Pour adhesive solvent into the solvent basin.

(6) Pour the disinfecting solution into a solution basin.

g. Prepare sterile field, equipment, and supplies.

h. Remove soiled dressing from wound (Figure 14-26).

14-35
FM 8-230

CAUTION

Do not put pressure on the wound. This will

cause unnecessary pain, possible additional
injury, and interfere with the healing process.

(1) Loosen the ends of the tape attached to the patient's skin.

(2) Peel ends toward the wound while holding the skin with the
other hand.

(3) Do not remove tape away from the wound. Doing this will­

(a) Create tension on the wound.

(b) Disrupt the scab.

(c) Tear the skin.

(4) Note any abnormal seepage.

(5) Put on sterile gloves.

(6) Grasp the edge of the dressing with sterile forceps and gently
roll the dressing off the wound. If the dressing sticks to the wound, moisten
the dressing with sterile water to soften the surface of the wound.

( 7) Throw away dressing in a contaminated waste

container.

(8) Do not touch the contaminated side of dressing to you or to

any surface.

i. Remove the adhesive from around the wound.

(1) Gently rub a solvent-soaked cotton-tipped applicator or

gauze pad over the adhesive (Figure 14-26). Removing the adhesive when a
dressing is changed reduces the potential for skin irritation.

L
';4
'i-;;
��)i'J
l!R:�I.:!i�-�

B.

Figure 14-26. Removing sealed dressing and adhesive from around wound.

14-36
 FM 8-230

(2) Observe skin for signs of irritation (redness, rash, or

swelling).
j. Inspect the wound. Look for signs of:

(1 ) Infection.

(2) Redness.

(3) Swelling.

(4) Pus (usually yellow fluid; may be blood tinged, greenish, or

brown).

(5) Putrid (bad) odor.

(6) Color.

(7) Condition of suture (joining of wound edges).

(8) Condition of drains.

(9) Healing.

k. Cleanse the wound if order indicates. Dip the cotton swab into a
cleaning or disinfecting solution.

( 1) Cleansing a linear wound (Figure 14-27).

(a) Stroke 1. Swab the area directly over the wound.

Discard the swab.

(b) Stroke 2. On the patient's right side, swab the area next
to the wound. Discard the swab.

(c) Stroke 3. On the patient's left side, swab the area next
to the wound. Discard the swab.

(d) Stroke 4. On the patient's right side, swab the area next
to the second stroke. Discard the swab.

(e) Stroke 5. On the patient's left side, swab the area next
to the third stroke. Discard the swab.

(2) Cleansing a circular wound (Figure 14-27).

(a) Stroke 1. Starting at the center of the wound, swab the

area in an outward circular spiral.

(b) Stroke 2. Swab the area next to the wound in an outward

circular spiral pattern for two revolutions. Discard the swab.

(c) Stroke 3. From the spot where the first stroke ended,
continue swabbing in an outward circular pattern for two revolutions. Discard
the swab.

14-37
FM 8-230

(d) Stroke 4. From the spot where the third stroke ended,
continue swabing in an outward circular pattern for two revolutions. Discard
the swab.

�WIST STllOKI
FWIST
I_
I I BWAI
I

l
CLEANSING A LINEAR
WOUND
CLEANING A CIRCULAR
WOUND

Figure 14-27. Cleansing linear and circular wounds.

L Apply a sterile dressing (Figure 14-28). Cover the wound with a

sterile dressing.

(1) Lay a dressing over the wound.

(2) Overlap the first dressing with a second dressing.

(3) Overlap the second dressing with a third dressing.

(4) Completely overlap all the dressings with a large dressing.

NOTE

If a drain is in place, cut one of the dressing

squares halfway through with sterile scissors,
and position it around the drain.

A. B. c. D.

rf � [TI
r-- - ,
I
1-... I
I -� I
I
I
I

c c : ::
··t-"
I
iI I
'
I
I
+,
··t-<
I
I
I I I
L - - -J L_ __ _J

FIRST 4X4 SE O 4X4 HIRD 4X4

GAUZE DRESSING GAUZE COVER WITH
GAUZE LARGE DRESSING
DRESSING (OVERLAP DRESSING
FIRST GAUZE> (OVERLAP
FIRST a
SECOND
GAUZES>

Figure 14-28. Applying a sterile dressing.

14-38
 FM 8-230

(5) Remove sterile gloves.

(6) Secure the dressing in place with tape.

(7) Write the date and time the dressing was changed on the tape
and initial it.

m. Remove/discard contaminated materials.

n. Perform patient care handwash.

o. Report and record procedure.

( 1 ) Tell the supervisor that the dressing has been changed.

Report any observations made during the procedure.

(2) Record the following data:

(a) Date of dressing change.

(b) Time of dressing change.

(c) Appearance of wound before cleansing.

(d) Appearance of wound after cleansing.

(e) Amount of drainage.

(f) Characteristics of wound and drainage.

Section IV. OBTAIN A BLOOD SPECIMEN

14-44. General

a. Venipuncture is the act of puncturing a vein with a needle to-

(1) Obtain a blood specimen for laboratory tests.

(2) Inject medications or intravenous solutions.

b. Verupuncture can be done by using either a needle and syringe or

by using th£ Vacutainer system.

14-45. The Vacutainer System

a. The Vacutainer system (Figure 1 4-29) is a type of syringe that

consists of-

(1) A vacuum tube with a rubber stopper.

(2) A double-pointed needle. Two types of needles can be used:

14-39
FM 8-230

(a) Single draw needles for single blood specimens.

(b) Multiple draw needles for multiple blood specimens. The

shaft of the multiple draw needle is covered with a rubber sheath. The sheath
slips back over the needle when the needle enters the stoppered vacuum tube
to prevent blood from dripping into the holder.
(3) A plastic holder with a guideline. The needle is supplied in a
sterile package. (The needle that is inserted in the vein must be sterile.)

b. The Vacutainer system provides a fast and easy way of collecting

several blood specimens with only one needle puncture. However, this system
has some drawbacks:

( 1 ) It cannot be used when sterile blood specimens are needed for

bacteriologic studies or cultures.

(2) It is impossible to draw back on the plunger to determine if

the needle is in the vein.

(3) The suction of the vacuum in the tube can sometimes collapse
the vein.

T H E V A C U T A I N E R S Y S T E M C O N S I ST S O F
EVACUATED TUBE WITH RUBBER STOPPER.

[Jl - �-)/
�
DOUBLE POINTED NEE � PLASTIC HOLDER WITH GUIDELINE

NOTE: HOLDER AND NEEDLE ARE ALSO SUPPLIED ASSEMBLED,

IN STERILE PACKAGE.

Figure 14-29. Vacutainer system.

14-46. Procedure for Obtaining a Blood Specimen Using the Vacutainer

System

a. Obtain the necessary equipment and supplies.

( 1 ) Blood specimen collection vacuum tubes. (Verify what type

of tube is to be used. For some tests, an anticoagulant is used in the tubes to
prevent clotting. In some laboratories, color coding is used on tubes for
different tests.)

14-40
 FM 8-230

(2) Constricting band (flexible latex band or commercial band).

(3) Vacutainer system (plastic holder and single or multiple draw

needle).

(4) Betadine or alcohol swab (prepackaged). (Betadine is

preferred because it is more effective in reducing the number of skin
pathogens.)

(5) Protective pad.

(6) Sterile 2 inch by 2 inch gauze sponge.

(7) Plastic strip.

(8) Rubber band.

(9) Gum-backed labels.

b. Label specimen tube.

( 1 ) Write patient's name, hospitalization and social security

numbers, prefix code, ward or clinic designation, name of facility, and date.

(2) Apply label to specimen tube.

c. Perform patient care handwash.

d. Assemble Vacutainer holder and needle without contaminating

sterile parts.

(1) Put short end of needle into threaded end of holder.

(2) Attach firmly using a clockwise motion.

(3) Remove needle cover and inspect needle for burs, barbs, or
discoloration. (Needle should have glossy, stainless appearance.)

e. Insert blood specimen tube into Vacutainer holder.

(1) Insert rubber-stoppered end of vacuum tube into holder.

(2) Advance until leading edge of stopper meets guideline on

holder.

f. Identify the patient.

(1) Inpatient: Ask the patient his name, and compare name to
bed card and Identaband.

(2) Outpatient: Ask the patient his name, and compare it to the
medical records or laboratory request.

g. Position the patient. Assist the patient into a comfortable sitting

or lying position-never standing.

14-41
FM 8-230

h. Expose arm for venipuncture.

(1) Roll the sleeve well above the elbow area.

(2) Extend the patient's arm with his palm up. Support the arm
by using a pillow, table, or other flat surface.

i. Select vein for venipuncture. Palpate and select one of the most
prominent veins (Figure 1 4-30) in the antecubital fossa (hollow or depressed
area in the j oint between arm and forearm).

(1) First choice: The median cubital vein is-

• Usually visible.

• Large and palpable.

• Well supported.

• The least likely to roll.

(2) Second choice: The cephalic vein.

(3) Third choice: The basilic vein is-

• Usually the most prominent vein.

• Least desirable. Vein tends to roll, making venipuncture

difficult.

CEPHALIC VEIN

�
BASILIC VEIN

MEDIAN CUBIT

BASILIC VEIN

MEDIAN
CEPHALIC VEIN
ANTEBRACHIAL VEIN

Figure 14-30. Prominent veins.

14-42
 FM 8-230

j. Prepare sponge for use.

( 1 ) Open the Betadine or alcohol swab and the 2 inch by 2 inch

sponge. Do not remove them from the packages until they are ready to be
used.

(2) Place packages within easy reach.

k. Apply constricting band.

(1) Latex tubing (Figure 14-31).

(a) Wrap the tubing around the limb about 2 inches above
venipuncture site. Use sufficient pressure to stop venous return without
stopping arterial flow. (You should be able to feel a radial pulse.)

(b) Hold one end of tube so that it is longer than the other
end.

(c) Form a loop with the longer end. Pass this loop under
the shorter end so that the tails of the tubing are turned away from proposed
site of inj ection.
(d) Instruct the patient to open and close his fist several
times and to hold his clenched fist to trap blood in veins. This causes the veins
to distend. If the vein of choice does not distend, gently tapping the
venipuncture site may help distension.

Figure 14-31. Constricting bands.

14-43
FM 8-230

(2) Commercial constricting band.

(a) Follow step 14-46k( l )(a) above.

(b) Secure the band by overlapping Velcro ends.

(c) Follow step 14-46 k(l)(d) above.

L Palpate selected vein. Palpate distended vein lightly with your

index finger (Figure 14-32). Move the finger an inch or two in either direction
to determine the size and direction of the vein.

MEDIAN BASILIC VEIN

Figure 14-32. Palpate the distended vein.

m. Cleanse the skin.

(1) Cleanse skin over selected area with the Betadine or alcohol
swab (Figure 1 4-33). Use firm, circular movements from the center outward.
This motion will move surface skin contaminants away from the proposed
venipuncture site.

(2) Discard swab.

(3) Allow the skin to dry, or dry with sterile gauze, if available.

CAUTION

Do not palpate the area again after cleansing.

14-44
 FM 8-230

Figure 14-33. Cleanse skin over selected area.

n. Prepare for venipuncture.

(1) Remove protective cover from needle.

(2) Position needle in line with vein and hold patient's arm below
cleansed area with free hand.

(3) Place your thumb 1 inch below entry site and draw patient's
skin to hold skin taut over selected puncture site.

o. Puncture the vein.

( 1 ) Take the needle, bevel up (Figure 1 4-34), and place it in line

with the vein. Pierce the skin at approximately a 1 5° to 45° angle. (Enter the
vein with the bevel up so that the sharp tip can pierce the skin first, preparing
the way for the rest of the needle. Entering the vein with the bevel down
causes painful tearing of the skin.)

Figure 14-34. Needle, bevel up.

14-45
FM 8-230

(2) Decrease angle until needle is almost parallel to skin surface.

(3) Direct needle into the vein, piercing vein wall. When the vein
is punctured, you will feel a slight "give" on entry into the lumen (passage) of
the vein.

(4) Advance needle slightly and watch for increased blood flow.
Blood will appear in the hub of the needle.

CAUTION

Use care to prevent puncturing the opposing

vein wall.

(5) If the vein is not punctured, pull the needle back slightly, but
not above the skin surface. Try to direct the needle point into the vein again.

CAUTION

If the needle is withdrawn above the skin

surface, obtain a new needle before trying
venipuncture again.

(6) If venipuncture is still unsuccessful-

(a) Release the constricting band.

• Latex tubing: Pull on the long end of the loop.

• Commercial band: Release Velcro fastener.

(b) Place a 2 inch by 2 inch sponge lightly over the

venipuncture site.

(c) Quickly withdraw the needle.

(d) Immediately apply firm pressure over the site.

(e) Notify supervisor before attempting to enter another

vein.

p. Collect specimen. Hold the Vacutainer needle and unit steady with
the hand used to do the venipuncture (Figure 1 4-35). Keep the needle at the
same angle. This action prevents the needle from slipping out of the vein and
from through-and-through penetration of the vein walls.

( 1 ) Place the index and middle fingers of your free hand behind
the flange of the holder.

(2) Place thumb of same hand on end of tube. Push on tube as far
forward as possible. When the needle enters the tube stopper, the vacuum
draws blood into the tube.

(3) Instruct patient to relax and ask him to unclench his fist
after needle has entered vein.

14-46
 FM 8-230

Figure 14-35. Withdrawal of blood.

(4) When tube is two-thirds full or if blood stops flowing into the
tube, prepare to withdraw the needle.

NOTE

For multiple specimens, remove the filled tube

and insert another tube. Repeat this procedure
until the desired number of tubes are filled.

(5) Release constricting band after the required number of tubes

are filled (Figure 1 4-36).

Figure 14-36. Release of constricting band.

14-47
FM 8-230

q. Withdraw needle.

CAUTION

Do not withdraw the needle before the

constricting band is released because of danger
of blood loss and/or possible formation of
hematomas. Hematomas are tumor-like
clusters of blood under the skin.

(1) Place 2 inch by 2 inch sponge lightly over venipuncture site

(Figure 14-37).

(2) Withdraw needle smoothly and quickly and immediately

press a 2 inch by 2 inch sponge firmly over the venipuncture site. Keep the
patient's arm fully extended. This position minimizes leakage around and
through the venipuncture site and prevents bruising and possible formation of
hematomas.

(3) Tell the patient to elevate his arm slightly, to keep it fully
extended, and to apply firm manual pressure to the site for 2 to 3 minutes. If
the patient is unable to do this for himself, you must do it for him.

Figure 14-37. Place sponge over venipuncture site.

CAUTION

If a patient is receiving therapy to prevent or

reduce blood clotting, continued bleeding may
be a complication. Apply manual pressure to
the venipuncture site for a longer period.

14-48
 FM 8-230

r. Remove specimen tube from holder.

( 1) Pt.it the protective cover over the needle.

(2) Pull the tube out of the holder.

(3) Gently invert tube several times to mix anticoagulant or

other fixing agent, if used.

s. Apply plastic strip after bleeding stops.

t. Provide for patient's safety and comfort. Assist patient in rolling

down his sleeve or putting on his garment.

u. Dispose of and/or store equipment.

(1) Collect all equipment and remove it from the area.

(2) Place all used sponges and other disposable material in the
trash receptacle.

(3) Store the tourniquet and Vacutainer according to local SOP.

(4) Dispose of needle in the destructo-clip.

NOTE

If you accidentally puncture yourself with a

used needle, tell your supervisor immediately,
force the puncture site to bleed, and wash area
well. Some diseases, such as hepatitis, can be
transmitted by direct or indirect contact.

v. Check completeness of laboratory request (SF 546, Chemistry I;

SF 549, Hematology; or local use laboratory request). As a minimum check
for-

(1) Complete patient identification.

(2) Requesting physician's signature.

(3) Ward number, clinic, or dispensary designation.

(4) Date and time of specimen collection.

(5) Test(s) requested.

(6) Specimen source-blood.

(7) REMARKS-admission diagnosis or type of surgery.

14-49
FM 8-230

(8) Completion of "urgency" block-

(a) ROUTINE.

(b) TODAY.

(c) PREOP.

(d) STAT.

Section V. ADMINISTRATION OF OXYGEN

14-47. General

a. Regardless of the source of respiratory insufficiency, certain

general principles of patient management apply prior to the administration of
oxygen (02 ):

• Any patient in respiratory distress should receive 0 2 .

• Any patient whose illness or injury suggests the possibility of

hypoxia should receive 02 .

If there is any question whether 02 should be administered or withheld (as in

cases of suspected hypoxia), administer 0 2 .

b. Oxygen is a colorless, odorless gas normally present in the

atmosphere in a concentration of approximately 21 percent. It is normally
stored in steel cylinders under a pressure of approximately 2,000 pounds per
square inch (psi). These cylinders (Figure 1 4-38) are given letter designations
according to their size: "E" which is 4.5 inches by 30 inches and "G" which is
8.5 inches by 55 inches.

c. Oxygen flow is controlled by a regulator that reduces the

cylinder's high pressure to a safe range of approximately 50 psi and controls
the flow from 1 to 1 5 liters per minute. The regulator is attached to the
cylinder by a yoke designed so that it will fit only one type of gas cylinder. Gas
cylinders are colored-coded by contents; in the United States, oxygen
cylinders are always green.

14-48. Oxygen Masks and Cannulas

a. Different masks and cannulas are available to provide oxygen to

the patient with respiratory insufficiency. The main characteristics of these
masks and cannulas are summarized in Table 1 4-3.

( 1 ) The simple plastic face mask (Figure 14-39) can deliver up to

60 percent oxygen, depending on the oxygen flow rate and the patient's depth
of respiration. Exhaled air is vented through holes in each side of the mask. At
low flow rates with deep respirations, the patient may draw in a larger amount
of outside air, thus diluting the oxygen concentration received. Generally, a
flow rate of between 8 and 12 liters per minute will insure adequate oxygen
delivery.

14-50
 FM 8-230

(2) The venturi mask is designed to mix oxygen with air and
permit the delivery of accurate low oxygen concentrations. Masks are
available to delivery 24 percent, 28 percent, 35 percent, and 40 percent oxygen.
They are especially useful in the management of patients with chronic
obstructive pulmonary disease and carbon dioxide (C02 ) retention.

(3) Nonbreathing masks have an oxygen reservoir. They are also

equipped with a one-way valve to allow the inhalation of oxygen from the
reservoir bag and exhalation through the valve. The oxygen flow rate is
adjusted to prevent collapse of the bag during inspiration. The flow rate with
this type of mask is usually 10 to 1 2 liters per minute. If the mask is fitted
tightly to the face, it can delivery 02 concentrations approaching 100 percent.
This mask is well suited to situations where there is severe hypoxia.

(4) Nasal cannulas (prongs) (Figure 1 4-40) are made of plastic

tubing and have two plastic tips that are inserted into the nostrils (Figure
1 4-40A). They will deliver an oxygen concentration of from 25 to 40 percent
with a 4 to 6 liter per minute flow rate Nasal prongs are usually well tolerated
but can cause soreness around the nostrils. They can deliver a limited amount
of maximum oxygen concentration.

! !

Figure 14-3$. Oxygen (02) cylinders.

14-51
FM 8-230

Table 14-3. Types of Masks and Cannulas for Providing Supplemental Oxygen

Flow Rate
Used (liters 02 Concentrations
Device per minute) Delivered (percentage) Comments

··-

Nasal cannula 4·6 25·40 Usually well

tolerated.

Plastic face
mask 10 50-60

Venturi mask
24 percent 4 24 Long-term
treatment of
patients with
COPD; limited
usefulness in
the field.

28 percent 8 28

35 percent 8 35

40 percent 8 40

Nonbreathing
mask 1 0. 1 2 90 Permits
administration
of high
concentration
of 02 .

Figure 14-39. The plastic face mask.

14-52
 FM 8-230

Figure 14-40. Nasal cannula.

b. The plastic face mask or nonbreathing mask is preferred in most
cases because they can deliver higher concentrations of oxygen. There are
some patients, however, who can barely tolerate the mask and complain of a
suffocating feeling; for these patients the nasal cannula can be used. No
matter which device is chosen, explain to the patient its function and why it is
required. Let the patient know that the mask may feel confining but that it
actually provides more air than unaided breathing. This explanation may help
the patient accept the mask with less anxiety.

14-49. Administration of Oxygen

Use the following procedure in the administration of oxygen:

a. Secure the oxygen cylinder in an upright position.

b. With the wrench supplied, slowly open and quickly close the
cylinder to flush out any debris.

c. Inspect the regulator valve to insure that it is the right type for an
oxygen tank and that the washer is intact.

d. Install and tighten the regulator securely on the cylinder (Figure

1 4-41).

e. Open the main cylinder valve (Figure 1 4-41A) slowly to

approximately one half turn beyond the point where the regulator valve
becomes pressurized.

f. Open the control valve (Figure 14-41C) to the desired flow rate as
indicated on the regulator gauge (Figure 14-41D).

g. To stop oxygen administration-

(1) Shut off the regulator control valve until the flow rate i s zero.

(2) Shut off the main cylinder valve.

(3) Bleed the control valve and main cylinder valve by opening
the control valve until the needle or ball indicator shows zero flow.

(4) Close the control valve.

14-53
FM 8-230

CYLI N D ER REGU LATOR

/
ADAPTER
A - CYLINDER VALVE
FOR
ATTACHING 8 - HIGH PRESSURE GAUGE
OXYGEN C - FLOW-AD.JUSTING HANDLE
TUBING
0 - RATE-OF-FLOW METER

Figure 14-41. 02 cylinder with regulator.

14-50. Safety Precautions When Handling Oxygen Cylinders

a. Keepcombustible materials such as oil or grease away from the

cylinders, regulators, fittings, valves, or hoses.

b. Close all valves when oxygen cylinders are not in use, even if they
are empty.

c. Secure oxygen cylinders to prevent them from tipping over. In

transit, keep them in an appropriate rack or carrier, or space permitting, strap
them onto the litter with the patient.

d. When working with an oxygen cylinder, always remain to one side.

Never place any part of your body over the cylinder valves. A defective
cylinder can launch a loosely fitting regulator with enough force to severely
injure anyone in its path.

e. DO NOT smoke in any area where oxygen cylinders are in use or

are being stored.

f. DO NOT subject the oxygen cylinders to temperatures above

120°F .

g. DO NOT use oxygen cylinders without properly fitted regulator

valves. Never attempt to modify a regulator valve designed for another type of
gas cylinder for use with an oxygen cylinder.

14-54
 FM 8-230
Section VI. CATHETERIZATION/THE URINARY
(FOLEY) CATHETER

14-51. General

a. The Foley, or indwelling, catheter is inserted into the bladder to

maintain a free flow of urine and is used for a variety of purposes:

• Emptying the bladder to allow an infected area to heal free of

contaminated urine.

• Keeping an incontinent (unable to control bladder function)

patient dry.

• Retraining or restoring normal bladder function.

• Maintaining an accurate intake and output record.

b. Foley catheters are available in various sizes; the size to be used

depends upon the physical structure of the patient. The physician may
designate the catheter size when he writes the order for the catherization. The
Foley catheter is a double lumen rubber tube; the main tube is identified by the
openings in the tip and the wide base at the opposite end. The second tube is
connected and sealed along the side of the main tube; the end of the tube is
fixed in a manner that allows it to be inflated with air or sterile liquid, causing
an inflated balloon to be formed around the main tube. This be.Hoon prevents
the catheter from slipping out of the bladder. The plastic drain tube with the
attached plastic drain pouch is inserted into the main tube of the catheter. The
complete drainage set up is known as a closed drainage system (Figure 1 4-42).

CLOSED
O RA i NAGE
TUBE A N D
BAG SET

r
._
� ,
·��0
-- -- -� : :. - -

- -

Closu Urinary
Or�in'Je B•g

Figure 14-42. Foley catheter set up.

14-55
FM 8-230

c. It is unlikely that you will have to perform urinary bladder

catheterization in a field situation; however, when you are working in a
hospital or clinical environment, there may be a requirement for you to use this
skill. Catheterization can be an unpleasant experience for the patient; gaining
his trust and confidence can do a great deal to make him more comfortable
during the procedure.

14-52. Catheterization of the Urinary Bladder

a. Equipment necessary for the procedure.

• Sterile gloves.

• Sterile cleansing sponges.

• Antiseptic solution (pHisoHex or Betadine).

• Foley catheter with 5 ml balloon (normally a No. 14 French for

women or a No. 1 6 for men).

• Sterile towels.

• Syringe with needle, containing 5 ml saline solution.

• Clamp.

• Water·soluble lubricant.

• Connecting tube and collecting bag.

• Sterile basin.

NOTE

Prepackaged catheterization sets are now

widely available and suitable for this
procedure. When such a set is to be used, the
equipment listed above will not be needed.

b. Catheterization of a male patient (Figure 1 4-43).

(1) Place a towel beneath the patient's penis.

(2) Wash your hands and put on sterile gloves. Arrange

equipment on the sterile towel so it is handy.

(3) Retract the patient's foreskin (if present) with the left hand
and hold the penis by the shaft. This hand is now no longer sterile.

(4) Use the clamp to pick up a sterile sponge soaked in antiseptic

solution with the right hand. Wash the glans in a circular motion from the
urethral meatus outward. Cleanse the glans thoroughly three to five times
using a new, sterile sponge each time.

14-56
 FM 8-230

(5) Touch nothing but the catheter with the right hand. Liberally
lubricate the catheter with sterile surgical lubricant.

(6) Raise the shaft of the penis straight up with the left hand and
gently introduce and pass the catheter. Slowly advance it almost to its
bifurcation (the Y-shaped division in the catheter tube) before inflating the
balloon.

(7) Inflate the balloon using the syringe containing �aline

solution.

NOTE

Some catheters require a needle to inflate

the balloon and others have a Leuer-Lok
connector. Be aware of the type you use to
prevent problems when trying to inflate the
balloon.

(8) Pull back gently on the catheter until slight resistance is felt.
This indicates that the balloon is flush against the bladder wall.

(9) After obtaining a urine specimen, connect the catheter to the

drainage system. Many prepackaged catheter kits already have the catheter
and drainage systems connected.

(10) Tape the tubing {not the catheter) to the inner surface of the
thigh. Avoid placing tension on the catheter.

( 1 1 ) Never allow the bladder to empty all at once if it is full. Drain

500 cc's of urine at one time, clamp the catheter for 1 5 minutes, then drain
another 500 cc's. Continue this procedure until the bladder is empty.

Figure 14-43. Male catheterization.

14-57
FM 8-230

c. Catheterization of a female patient (Figure 1 4-44).

( 1 ) Place the patient in a supine position (on her back), with

knees bent. Place pillows or padding under the buttocks to insure that her hips
are canted upward.

(2) Use the same sterile procedure described in paragraph

1 4-52 b above.

(3) Clean the urethral meatus thoroughly with antiseptic

solution.

(4) Lubricate the catheter tip and advance it gently into the
urethra.

(5) Follow the remainder of the procedure outlined in paragraph

1 4-52b (7) through (1 1).

Figure 14-44. Female catheterization.

14-53. Care/Management of the Patient with a Foley Catheter

a. Procedure for care of a Foley catheter.

( 1 ) Wash your hands thoroughly to reduce pos sible

contaminaLion.

i2) Place the patient in a supine position.

(3) Observe the skin at point of insertion and surrounding area.

Check for redness, skin eruptions, or swelling.

dry. Apply antiseptic ointment to urethral meatus if ordered or in accordance

(4) Gently cleanse the area with soap and water, rinse and blot

with local SOP.

14-58
 FM 8-230

(5) Insure that the tubing remains close to the patient's body.

(a) Place nonallergenic tape around the drain tube

approximately 1 2 to 1 8 inches from the point of insertion and secure it to the
skin on the patient's thigh or abdomen.

(b) Place the tube so that it is comfortable for the patient

and there is no tension or unnecessary pull on the skin.

(6) Maintain tubing alignment.

(a) The drainage tube should lie on top of the bed in a

straight line. It must be kept free of kinking, twisting, and the pressure of
added weight.

(b) Tubing must not be clamped together to allow urine to

flow freely into the bottle.

(7) Keep the gravity-flow drainage even.

(a) Pin or tape the longest part of the tube to the bed linen
to prevent the tubing from falling over the side of the bed. This also keeps the
tubing above the drainage bottle to maintain an even free-gravity flow.

(b) Attach the drainage container to the side of the bed

frame.

(c) Change the position of the drainage container as you

change the position of the patient.

(8) Empty the drainage container.

(a) The drainage container can be emptied without

disconnecting the closed system.

(b) Remove the cap from the drainage container outlet tube,
release drainage clamp, and let contents flow into a graduated pitcher.

(9) Measure and discard, or save, the urine as indicated by the

order.
( 1 0) Position the bed side rails and leave the patient safe and
comfortable.

(11) Record all applicable information on the patient's chart.

b. Additional catheter care infoqnation.

( 1 ) At times, the patient will say,,that he has the urge to urinate.

Check the catheter and drainage tube to insure that both are free of any solid
matter. If clogging has occurred, the catheter may need to be irrigated with
sterile saline solution to remove it.

(2) A second source of discomfort may be the position of the

catheter in the bladder. The opening of the catheter may be lying against the
bladder wall or it may be above the urine level so that it is impossible for the

14-59
FM 8-230

urine to drain. Gently reposition the patient so that the flow will be
continuous. Catheter size may affect urine flow, particularly if the catheter
tube is too small for adequate drainage.

(3) Careful monitoring of the catheter patient will do a great deal

to insure that pain and/or discomfort are kept to a minimum and that the
catheterization procedure will serve its purpose.

Section VII. NASOGASTRIC TUBES

14-54. General

Gastrointestinal intubation is the insertion of a specific tube through the nose

(naso) or throat into the stomach (gastro) or the intestine. The primary reasons
for this relatively common procedure are to-

a. Drain the stomach or intestinal tract by means of a suction

apparatus. It is used to prevent postoperative vomiting, postoperative
obstruction of the intestinal tract, and gas formation in the stomach or
intestine after an operation.

b. Diagnose a disease or to identify and determine the cause of a

pathological condition.

c. Wash out stomach contents, as in the case of a person who has

ingested poison.

d. Provide a route for feeding a patient who is unable to take food by

mouth.

14-55. Types of Nasogastric Tubes

Several types of nasogastric tubes are commonly used for intubation; each has
a specific purpose in addition to decompression and drainage of the
gastrointestinal tract. The two most common types are the Levin tube and the
vented sump (Salem sump).

a. The Levin tube (Figure 14-45) is a single lumen (bore) tube

approximately 3 feet in length, fitted with holes along one side 6 to 9 inches
from its distal tip.

b. The Salem sump tube (Figure 14-46) is a double lumen tube

approximately 3 to 4 feet in length. The large lumen is designed to function in
the same manner as a Levin tube. The second lumen (the small blue tube) is a
vent which is left open to the atmosphere and equalizes the pressure or suction
in the stomach. This reduces the chances of the sump becoming blocked by
being pulled up against the lining of the stomach.

14-60
 FM 8-230

� VENTED LUMEN VENT HOLE

It:: -- . . .
.... <-.
("[ === ·:)
SUCTION HOLES
· - ·

SUCTION LUMEN

Figure 14-46. Salem sump tube.

Figure 14-45. Levin tube.

14-56. Insertion of the Nasogastric Tube

a. Prepare the intubation equipment.

( 1 ) Assemble an emesis basin, tissues, a water-based lubricant, a

20 to 50 cc's aspirating syringe, adhesive tape, and a glass of water.

(2) If the tube needs added stiffness for insertion, immerse it in a

pan of ice until the desired degree of stiffness if obtained (usually 15 to 30
minutes).

b. Explain the procedure to the patient.

( 1 ) The patient may be in pain and frightened of the procedure.

You need to reassure him that you will be as gentle as possible and that you
will tell him what is being done as the procedure progresses.

(2) Explain to the patient that passing the tube down the back of
the throat is painless, but that it could cause gagging. Tell him to breathe
deeply through his mouth so that he will be less likely to become nauseated
and vomit.

c. Position the patient.

( 1 ) The patient is usually placed in the Fowler's position (head

raised 1 8 to 20 inches above the body) to allow the tube to move by gravity
down the digestive tract. This also enables the patient to expel vomitus if
necessary.

(2) The supine position can be used if the patient's condition

warrants it.

d. Provide the patient with an emesis basin and tissues.

e. Measure the tube for insertion distance. Measure the distance

from the patient's nose to the nearest earlobe and down to the navel. This is
approximately the distance from the lips to the stomach. Mark this distance
by placing a piece of tape at this point on the tube.

14-61
FM 8-230

f. Assume a comfortable working position and lubricate the tip of the

gastric tube.

( 1 ) Stand at the right side of the patient. Grasp the tip of the
tube in the right hand and hold the remainder of the tube in the left hand.
(Reverse hand positions if left handed.)

(2) For easier insertion, use water or a water-base lubricant to

moisten the tip of the tube. Do not use an oil-base lubricant.

g. Begin the tube insertion procedure.

(1) Have the patient swallow a mouthful of water as the tube is

passed down the esophagus to the stomach. Bend the patient's head forward
so that his chin rests on his neck.

(2) The tube is inserted one of two ways:

(a) Through the mouth-pass the tube over the top and
middle of the tongue toward the back of the throat.

(b) Through the nose (Figure 14-47)-pass the tube gently

up one nostril and down the back of the throat, rotating it slowly between your
thumb and index finger. Check the position of the tube as it passes down the
back of the patient's throat by having him open his mouth and holding down
his tongue with a tongue depressor.

I
· - -- \

('.
I

��
, I

Figure 14-47. Tube insertion through nose.

h. Push the tube slowly, firmly, and gently into the stomach.

(1) Attempting to pass the tube too fast stimulates the nerve
endings in the back of the throat which in turn stimulates the vomiting center
of the brain, causing the patient to vomit.

14-62
 FM 8-230

(2) Continue to have the patient swallow water as the tube is

passed (Figure 1 4-48). Movement of the throat caused by swallowing will ease
the tube's passage.

Figure 14-48. Movement of tube down throat.

i. Test to see if the tube is in the stomach.

( 1 ) Attach an aspirating syringe to the open end of the tube and

pull the plunger back. This action should pull gastric juice through the tube
into the syringe.

(2) Use a bulb or Asepto syringe to inject 1 5 to 30 cc of air into

the suction lumen of the tube while you listen with a stethoscope placed over
the stomach. You should be able to hear a " gurgling" sound as the air in
injected.
CAUTION

The tube MUST be tested to determine if it is

in the trachea instead of the stomach:

(a) Observe the patient for cyanosis (bluish

tinge to the skin) or dyspnea (difficult
breathing).

(b) Place the free end of the tube in a glass of

water and observe for air bubbles.

(c) Hold the free end of the tube near your ear
and listen for a crackling sound.

(d) Instruct the patient to try and hum. If he

is unable to do this, the tube is properly
placed. If any of the conditions noted in (a),
(b ), or (c) are observed, REMOVE THE
TUBE IMMEDIATELY.

14-63
FM 8-230

j. Secure the tube to the patient's face with adhesive tape.

( 1 ) When the tube is placed in the patient's stomach, tape the

outside end to the bridge of his nose and to his forehead or cheek.

(2) Insure that the tube lays flat and is not kinked or twisted.

k. Attach the free end of the tube to the suction machine.

( 1) The physician orders the kind of suction machine used to

remove gas and drainage from the stomach. He states the degree of suction
and whether continuous or intermittent (on-off) suction is indicated.

(2) If there is no suction action after the tube is attached, call

your supervisor immediately so that appropriate corrective action can be
taken.

NOTE

As the patient's condition improves, the

physician may test his tolerance for gastric
content by clamping the tube for a few hours.
During this time, loop the tubing in a loose
circle, secure it with adhesive tape, and pin it
to the patients' hospital clothing. This will
help prevent uncomfortable pulling for the
patient.

14-57. Gastric Tube Irrigation

a. Irrigation is the process of clearing the blocked or plugged

passageway of the gastric tube.

b. If the tube becomes plugged, the physician will order an irrigation

to be done at stated intervals.

c. Gastric tube irrigation procedure.

( 1 ) Obtain an aspirating syringe, irrigating solution (usually

normal saline), and a receptacle for the returned solution. This is a clean
procedure but not a sterile one.

(2) Disconnect the gastric tube from the drain tube on the
suction machine and turn off the suction power. Hold the gastric tube in a fist­
like grasp with the last three fingers of your left hand.

(3) Hold the aspirating syringe between the index finger and
thumb of your left hand. Place the tip of the syringe in the solution and use
your right hand to pull the plunger up to obtain 1 5 to 30 cc of solution.

(4) Attach the filled syringe to the free end of the gastric tube
and inject 10 to 1 5 cc of solution slowly into the tube. Pull back on the plunger
to withdraw. Repeat this process until the passageway is clear.

14-64
 FM 8-230

CAUTION

If fresh bleeding is apparent, stop the

procedure and notify the physician
immediately.

(5) Observe the contents of the irrigating solution. Note the

color, consistency, and odor on the patient's chart.

(6) When the irrigation is complete, attach the gastric tube to

the drain tube of the suction machine and turn the power on to the machine.

NOTE

Other methods can be used to unplug the

tubing:

(a) Change the position of the tube by gently

pushing it in and pulling it out. Suction
must be turned off and the tube
disconnected from the suction machine.

(b) Use a gentle "milking" action on the tube

to free the blockage. Hold the tube securely
and gently squeeze the tubing between
your palm and fingers. Move carefully
along the tubing in this manner until
suction is restored.

(7) Insure that the patient is left clean and comfortable after the
irrigation procedure is complete.

14-58. Care of the Patient with a Nasogastric Tube

a. One of the most uncomfortable aspects of the nasogastric tube is

the constant irritation by the tube on the back of the throat. The physician
may permit the patient to suck on ice chips, throat lozenges, or hard candy to
keep his throat and the tube slightly moist.

b. The patient's nose may also become tender, sore, and cracked.
Good hygiene procedure must be followed to keep this irritation to a minimum
and reduce the chance of infection.

c. The patient is often hypersensitive to odors; his room and

belongings must be kept immaculately clean and sanitary. Unsavory stimuli
in the environment can cause him to become nauseated and to vomit.

d. When caring for patients with a gastric tube, you should

remember to:

(1) Provide frequent and meticulous oral hygiene and nose care­

(a) Since a patient with a gastric tube is to be given nothing

by mouth, 'the mouth can become very dry and the lips may become cracked.

14-65
FM 8-230

(b) To keep the mouth and lips moist, swab the oral cavity
with a cotton swab that has been moistened in equal parts of glycerine and
lemon juice. Mouth wash may also be used if the patient is able to spit the
liquid out; it must not be swallowed.

(2) Provide for the patient's freedom of movement as much as

possible by securing the suction tubing to the patient's clothing or skin.

(3) Insure that the patient does not lie on the tubing; do not
permit the tubing to become kinked.

(4) When you are checking suction machine operation, first

check to see that it is properly attached to the wall outlet and the patient, that
the power is turned on, and that the tubes are not kinked; also check to see
that the drainage bottle is not overflowing. If the machine still does not
provide suction after these checks have been made, notify your supervisor at
once.

(5) Observe and record the contents of drainage bottles

accurately. Report any unusual contents immediately to your supervisor.

14-59. Suction Devices Used with Nasogastric Tubes

a. Portable electric suction machine (Figure 1 4-49).

( 1 ) This machine has a gauge that permits regulation of the

amount of suction. It is particularly useful when the drainage becomes thick
and viscous.

(2) When the machine is used, your main responsibility will be to

see that the drainage bottle does not overflow. If this should occur, drainage
could back up into the vacuum bottle, then into the motor itself.

Figure 14-49. Portable electric suction machine.

14-66
 FM 8-230

b. Gomco thermotic pump (Figure 1 4-50).

( 1 ) This is an electric pump that provides intermittent suction

through alternating air pressure by expanding and contracting the air. Suction
can be regulated by a "low" or "high" pressure button.

(2) Again, close observation of the drainage bottle contents is

important to prevent overflow. Check the machine frequently to be sure that it
is pulling the drainage from the stomach or intestine. As the pressure
alternates during the suction cycle, red and green lights will alternate on the
operating unit.

Figure 14-50. Gomco thermotic pump.

14-67
FM 8-230

Section VIII. PATIENT/SURGICAL PREPARATION

14-60. General

Most wounds will require suturing or other minor surgical procedure. The
wound area must be thoroughly cleansed prior to any operative procedure in
order to remove any bacteria. You will frequently be called upon to prepare a
wound area for a physician. The general rules of medical and surgical asepsis
must be followed to prevent infection with possible loss of limb or life.

14-61. Procedure for Operative Treatment Preparation

a. Assemble and prepare equipment.

(1) Sponge basin.

(2) Solution cup.

(3) Gauze pad, 4 inch by 8 inch.

(4) Asepto syringe.

(5) Safety razor and blade.

(6) Sterile water or saline.

(7) Povidone-iodine (Betadine) solution.

(8) Protective pad.

(9) Sterile gloves.

(10) Antimicrobial soap.

b. Prepare the patient.

(1) Position the patient as indicated by the physician or your

supervisor.

(2) Place the protective pad under the area to be treated.

(3) Explain the procedure to the patient to insure his

understanding and cooperation.

(4) Expose the wound/injury site by removing or cutting away

clothing and bandages of dressings. Do not expose any more of the patient's
body than is necessary.

(a) Moisten any stuck bandages/dressings with sterile

saline to loosen them.

(b) Use blunt-tipped bandage scissors to cut clothing and

bandages.

(5) Focus available light on the area to be treated.

c. Perform patient care handwash.

14-68
 FM 8-230

d. Prepare to treat wound.

(1) Remove stoppers/caps from solution bottles.

(2) Open prep set.

(a) Open outer wrapper with bare hands.

(b) Glove one hand and open inner wrapper.

CAUTION

Do not touch unsterile items with gloved hand.

Keep gloved hand above work surfaces.

(c) Use your ungloved hand to pick up bottle and pour a

small amount of solution into trash receptacle.

(d) Pick up sterile basin with gloved hand, step back

slightly and pour sterile solution into basin.

(e) Pour povidone-iodine into solution cup.

(f) Glove bare hand.

e. Irrigate the wound.

(1) Use an aseptic syringe.

(2) Use large amounts of saline solution. If saline solution is not

available, use sterile water.

CAUTION

Do not begin irrigation except under the direct

supervision of a physician. Bleeding may occur
when the wound is irrigated as clots are
dislodged and washed away.

f. Cleanse the wound area.

( 1) Place a sterile gauze pad over the wound and hold in place.

(2) Cleanse the skin area using povidone-iodine solution.

(3) Cleanse the area 3 to 4 inches (7 .62 to 10.16 centimeters)

around the wound.

(4) When cleansing the wound area, use gentle friction and a
circular motion, working outward from the edges of the wound.

g. Shave the wound area.

( 1 ) Check the physician's orders t o b e sure that the shaving

procedure is to be accomplished.

14-69
FM 8-230

(2) Shave any hair you can see at the edge of the wound or in the
area being cleansed.

(3) Shave an area at least 3 inches (7.62 centimeters) around ·

the wound and scrub with antimicrobial soap.

NOTES

1. D o not shave inside the wound. Any hair

inside can be removed after the area is
anesthetized.

2. Apply tension to the skin by gently pulling

the skin taut. Shave with short gentle
strokes to minimize pulling.

3. Clip long, thick hair first; then shave.

h. Repeat cleansing procedure.

( 1 ) Upon completion, rinse with sterile saline to remove loose

hair and prevent hair from entering wound.

(2) Blot skin dry with sterile gauze.

(3) Replace sterile gauze over wound.

(4) Notify physician that wound area has been prepared. Do not
dress wound in the event that sutures are required.

i. Remove gloves and place them in the contaminated waste

container.

j. Remove prep equipment.

( 1 ) Remove protective pad from under patient. Use care not to

contaminate clean area.

(2) Discard all disposable items in the contaminated waste

container.

(3) Clean and store nondisposable items according to local SOP.

k. Perform patient care handwash.

l. Record procedure on Field Medical Card or Chronological Record

of Medical Care Card.

14-62. Wound Irrigation

A wound irrigation (washing) is performed to-

a. Clean a wound by using large amounts of fluid to remove

secretions, clots, foreign matter, or microorganisms.

14-70
 FM 8-230

b. Instill (administer drop-by-drop) medication in a wound.

14-63. Procedure for Irrigating a Wound

a. Verify that a wound irrigation is to be performed.

( 1 ) C heck the physician ' s order s , the Therapeutic

Documentation Care Plan, or follow supervisor's instructions.

(2) The instructions will specify the amount and type of solution
to be used to irrigate the wound.

b. Obtain the necessary equipment and supplies.

(1) Asepto (bulb-ended) syringe (300 to 500 milliliter capacity). If

this syringe is not available, use the largest regular syringe stocked.

(2) Prescribed irrigating solution (normal saline is usually the

preferred irrigating solution).

(3) Emesis basin.

(4) Sterile gloves.

(5) Mask.

(6) Sterile dressing.

(7) Sterile 4 inch by 8 inch gauze sponges.

(8) Sterile solution basin.

(9) Protective pad.

( 1 0) Sterile drapes or towels.

c. Provide privacy and explain the procedure to the patient.

( 1 ) Place a screen or curtain around the patient's bed. If he is in a

private room, close the door.

(2) Explain the procedure to the patient to lessen his

apprehension and gain his confidence and cooperation.

d. Position the patient to allow maximum exposure of the wound.

e. Position the protective pad.

(1) Assist the patient, i f necessary, t o raise his body.

(2) Place the protective pad directly under the wound. The pad
serves as protection for the patient's bedding.

f. Carefully remove soiled dressings and bandages.

14-71
FM 8-230

g. Perform patient care handwash.

h. Put on protective face mask to prevent contamination of the

wound by microorganisms.

(I) Place the mask on your face and pull the elastic band over
your head.

(2) Do not touch or adjust your mask while you are irrigating the
wound.

z. Prepare wound irrigation equipment.

(1) Create a sterile field.

(2) Remove the solution basin from its package using sterile
technique.

(3) Pour the prescribed irrigation solution into the basin without
contaminating the sterile field.

(a) Insure that you are using the correct solution before you
begin.

(b) If you are using a standard sterile water solution or

normal saline solution, check the date and time on the bottle. If you open a new
bottle, write the date and time that it was opened.

NOTE

Once opened, the water or saline solution is

considered sterile for 24 hours.

(c) Open the package containing the Asepto syringe and

place it on the sterile field using sterile technique.

(d) Open the 4 inch by 8 inch sponges and place them on the
sterile field using sterile technique.

j. Don sterile gloves.

k. Place sterile drapes around the wound area to absorb excess

drainage flow from the wound during the irrigation procedure.

L Position the basin on the sterile drape adjacent to the area of the
body to be irrigated.

m. Irrigate the wound.

(I) Grasp the syringe, depress the bulb, and insert the tip of the
syringe into the irrigating solution.

(2) Release the bulb and allow the bulb to fill.

1 4-72
 FM 8-230

(3) If you are using a regular syringe, pull back on the plunger to
aspirate the solution into the syringe.

(4) Hold the tip of the syringe as close to the wound as possible
without touching it.

(5) Depress the bulb (or plunger) of the syringe and direct the
flow of solution to all parts of the wound. Use firm pressure, but not excessive
force.

NOTES

1. Pay particular attention to those areas

showing debris, exudate (cellular material
deposited by blood vessels, usually as the
result of inflammation), and/or drainage.

2. Take extra care when irrigating a wound in

which an abscess has formed.

a. If the pressure within an abscess is

unrelieved, it may cause a sinus tract.

b. All internal surfaces of the wound should

be inspected for tracts. You may have to
use your gloved hand or a sterile object to
gently pull back the flesh. Use care to
prevent tearing of healing tissues.

(6) Repeat steps ( 1 ) through (5) until all of the irrigating solution
is used or until all debris, exudate, or drainage is flushed out of the wound.

(7) Observe the wound drainage for quality and characteristics

of debris, such as pus, blood color, odor, and consistency.

n. Dry the wound and apply a sterile dressing, if applicable.

(1) Remove a 4 inch by 8 inch sterile gauze sponge from the

sterile field.

(2) Pat the wound dry, starting from the center and moving
outward toward the edges.

(3) Remove emesis basin and drapes.

(4) Apply a sterile dressing to the wound, if applicable.

(5) Remove protective pad.

o. Reposition the patient.

p. Clean and store irrigation equipment.

(1) Discard contaminated waste according to local SOP.

14-73
FM 8-230

(2) Clean and store nondisposable items according to local SOP.

q. Perform patient care handwash.

r. Report and record necessary information on patient's chart.

14-64. Patient Isolation

a. The primary purpose of placing patients in isolation is to minimize

the possible spread of communicable diseases. The physician will determine
the equipment for isolation; however, the responsibility for proper
management of the isolated patient belongs to everyone involved including
the patient himself.

b. Care for the isolated patient is essentially the same as it is for any
patient, but there must be a marked increase in the emphasis on the principles
of medical asepsis. For more detailed information concerning the management
of isolated patients, refer to your local infection control or isolation SOP.

Section IX. INTRAVENOUS INFUSIONS

14-65. General

a. Intravenous infusions (IV) are started for two primary reasons.

( 1 ) To provide a route for replacement of fluid, electrolytes, or

blood products.

(2) To provide a direct way of administering drugs. In cases of

low cardiac output (shock), blood is shifted away from the skin and skeletal
muscles; drugs administered subcutaneously or intramuscularly are absorbed
at a slow and unpredictable rate. Intravenous infusion insures that drugs
reach the circulatory system promptly.

b. Intravenous needles (cannulas) are designed for three different

applications.

(1) Hollow needle (also known a s the butterfly).

(2) Plastic catheter inserted over a hollow needle (angiocath).

(3) Plastic catheter inserted through a hollow needle.

The over-the-needle catheter is generally preferred because it is more easily
secured and less cumbersome than the other types. The catheter used should
be a large bore (14 to 1 6 gauge for an adult), particularly if large quantities of
fluid must be infused.

14-74
 FM 8-230

14-66. Procedure for Starting an Intravenous Infusion

a. Explain to the patient what is going to be done.

( 1 ) Very few people are entirely free from anxiety about needles
and IV's; when they are ill, these anxieties increase.

(2) Try to reduce this fear by explaining why the IV line is

necessary and exactly what you are going to be doing.

b. Assemble the supplies and equipment needed.

(1) Select the fluid ordered by the physician and inspect the
container.

(2) The container should be checked for leakage, contamination,

cloudiness, and expiration date.

(3) Select the appropriate infusion set and cannula.

c. Also assemble the following:

(1) Antiseptic cleansing solution (preferably an iodine swab).

(2) Sterile 2 inch x 2 inch gauze dressing.

(3) Adhesive tape cut into strips of appropriate length.

(4) Constricting band (preferably soft rubber).

d. To select a suitable vein:

( 1 ) Apply the constricting band at the patient's midarm above

the elbow. Check to make sure that a pulse is still present after the band is in
place.

(2) Inspect the hand and forearm for a vein that appears to be
straight and lies on a flat surface. It should be well fixed, not roll, and should
feel springy when palpated. You should avoid:

(a) IV's in those areas that require immobilizing a joint.

(b) Areas where an arterial pulse is palpable close to the

vein.
(c) Veins of the lower extremities which can hamper the
patient's ambulation.

(d) Veins near injured areas or distal to injuries.

e. Prepare the venipuncture site.

( 1 ) Scrub the selected area with iodine swab, starting from the
area above the vein.

(2) Wipe the area in widening circles around the site, leaving a
wide margin.

14-75
FM 8-230

f. Enter the vein.

(1) Stabilize the vein by applying pressure on it below the point

of entry.

(2) Puncture the skin with the bevel of the needle pointing
upward.

(a) Enter the vein from either side or from above.

(b) You should be able to feel the needle "pop" through into
the vein.

(c) When you have entered the vein, blood will return
through the needle.

(3) I f using an over-the-needle catheter, advance it

approximately 2 millimeters beyond the point where the blood return was first
encountered.

(4) Slide the catheter over the needle into the vein and withdraw
the needle.

( 5) Release the constricting band and connect the infusion line to

the catheter.

(6) Observe line for fluid flow in a steady stream. If flow is slow,
pull back very slightly on the catheter to move the tip from the wall of the
vein.

(7) After a good flow is established, check for infiltration.

(8) Cover the puncture site with povodine-iodine ointment, cover

with sterile dressing, and tape the catheter securely in place.

(9) Loop the IV tubing and tape it to the skin adj acent to the
infusion site.
CAUTION
Do not tape the connecting point between the
catheter and the infusion set.

( 1 0) Adjust the infusion flow to the rate ordered by the physician.

14-67. Solutions Used in Intravenous Therapy

a. Dextrose in water (D5W) solution-used to treat dehydration, to

supply small amounts of calories for energy, and to supply water for body
needs.
b. Lactate Ringer' s solution-resembles the electrolyte structure of
normal blood serum. Used to treat dehydration and to restore normal fluid
after extracellular shift (a result of burns or infection).

c. Normal saline, 0.9 percent solution-used to correct excessive fluid

loss or to correct excessive acid or alkalinity in body fluids.

14-76
 FM 8-230

14-68. Care of the Patient with an Intravenous Infusion

a. After starting an IV infusion, it will be necessary for you to

maintain the infusion and manage the procedure in a safe and accurate
manner. You must strictly adhere to aseptic procedures and techniques.

b. Proper patient care also requires you to take steps to intervene to

prevent IV infusion complications and disturbances while managing the
patient. Table 1 4-4 shows possible complications and the proper corrective
actions. Table 1 4-5 shows possible IV disturbances and the intervention
measures to be taken.

Table 14-4. Complications of IV Therapy

CORRECTIVE PREVENTIVE
COMPLICATIONS SYMPTOMS CAUSES ACTIONS MEASURES

1. Infiltration • Discoloration • Solution is • Stop infusion. • Use splint for

catheter/ of site. flowing at a stability (a splint
needle becomes sluggish • Remove IV and prevents dislodge·
dislodged or • Swollen site. rate. restart it in an ment of IV
penetrates alternate catheter/needle).
through the e Pain, location.
vein allowing tenderness, • Tape catheter/
IV fluid to leak burning, or • Apply cold needle securely.
and to accumu­ irritation at the pack to site if Avoid looping of
late into infusion site. infiltration has tubing below bed
surrounding occurred within level.
venipuncture the past one­
tissue). half hour. A
cold pack will
help reduce the
pain and
swelling.

e Apply warm
wet compresses
to promote
absorption if
infiltration has
occurred for
over 30
minutes. A
warm wet
compress will
stimulate
circulation,
therefore
promoting the
absorption of
the infiltrated
solution into
surrounding
tissues.

14-77
FM 8-230

Table 14-4. Complications of IV Therapy, continued

CORRECTIVE PREVENTIVE
COMPLICATIONS SYMPTOMS CAUSES ACTIONS MEASURES

2. Phlebitis • Swelling and • Injury to • Stop infusion. • Keep the infusion

(inflammation redness around vein during flowing at the
of the wall of venipuncture venipunc- • Remove IV and prescribed rate.
the vein). site. ture or from restart it in an
Associated later needle alternate • Stabilize the
problems of • Thnderness of movement. location. catheter/needle
phlebitis tissue around with a splint.
include- venipuncture • Irritation to • Document
site. vein by- observations. • Select a large vein
- thrombo- when irritating
phlebitis, which • Foul-smelling • Long-term drugs and fluids
is an inflamma- discharge from therapy. are given.
tion of the vein venipuncture
accompanied site. • I rritating or • Maintain strict
by the forma- inc om- aseptic techniques.
tion of the clot. patible
additives. • Change catheters
• thrombosis, and tubing every
which is the • Use of vein 48 to 72 hours.
formation of a that is too
clot in a blood small to • Change bags,
vessel without handle the bottles, and
accompanying amount or dressings every 24
inflammation. type of hours.
solution.

• Sluggish
flow rate
that allows
clot to form
at end of
needle.

3. Circulatory • Rise in blood Fluid is • Slow down the • Check the flow
overload (state pressure. delivered infusion to rate at frequent
of increased too fast. keep the vein intervals to insure
circulating • Dilation of open. the desired rate is
volume usually veins with neck being maintained.
due to veins • Raise patient's
transfusions or sometimes head to slow
administering visibly down the rapid
too much I V engorged. circulation to
fluid that the heart.
increase the • Rapid
blood pressure breathing, • Notify the
in the veins). shortness of physician.
breath, rales.

• Wide variance
between liquid
input and urine
output.

14-78
 FM 8-230

Table 14-4. Complications of IV Therapy, continued

CORRECTIVE PREVENTIVE
COMPLICATIONS SYMPTOMS CAUSES ACTIONS MEASURES

4. Air embolism • Abrupt drop • Solution • Notify • Clear all air from
(the obstruc- in blood runs dry. supervisor tubing before
tion of a blood pressure. immediately. attaching it to the
vessel by air • Air bubbles patient.
carried via the • Chest pain. are present • Administer
bloodstream). in I V oxygen. • Monitor solution
• Weak, rapid tubing. closely and obtain
pulse. e Turn the new container, if
patient on his required. Do not
e Cyanosis left side and allow solution to
(slightly blue, place him in a run dry.
dark purplish, shock position
or gray to keep air in • Check to see that
discoloration of the right side all connections are
the skin. of the heart . secure.
This position
e Loss of allows the
consciousness. pulmonary
artery to
absorb small
air bubbles.
5. Infection (the e Swelling, • Poor aseptic • Stop infusion. • Use complete
state or redness, and technique. aseptic techniques
condition in soreness • Report when initiating an
• Unsterile
which the body around infusion observations to IV infusion.
veni-
or part of it is site (localized supervisor.
puncture
invaded by infection is • Anchor catheter/
technique.
disease- usually • Send I V needle firmly with
e Contami-
producing accompanied equipment to tape.
nation of
bacteria or by inflam- the laboratory
equipment
viruses). mation, but
during for bacterial I Check vein daily
inflammation analysis. for evidence of
manu-
may occur tenderness of
facture,
without • Clean site, signs of inflam-
storage or
infection). apply anti- mation.
use.
microbial
• Failure to
• Foul-smelling, ointment, and • Apply anti-
keep the
yellowish apply a new microbial ointment
site clean or
discharge from sterile dressing. to infusion site at
to change
venipuncture the time of
the I V
site. • Document all insertion and at
equipment
changes of periodic intervals
regularly.
• Sudden rise in dressing and in accordance with
• Cross-
temperature equipment with the local SOP.
contami-
and pulse. your initials,
nation from
one patient time, and date.

to another.
• Excessive
movement
of the
needle.

14-79
FM 8-230

Table 14-5. Disturbances of IV Therapy

SIGNS OF INTERVENTION
COMPLICATIONS DISTURBANCES CAUSES MEASURES

Disturbance of • Flow rate slowing • Solution container • Frequent observa­

infusion (any down or speeding is empty. tions of flow rate and

disturbance or up. equipment.

failure of • Drip chamber is

infusion • Solution flow less than half • Stop flow and notify

equipment to stopping. full. supervisor.

deliver correct
prescribed • Control clamp • Squeeze drip chamber

solution is closed. until it is half full.

infusion rate).
• Defect in the • Consult supervisor
equipment. and readjust it to
restore prescribed
• Tubing is kinked drip rate.
or caught under
patient. • Report defect
immediately to
supervisor.

• Untangle the line or

reposition patient so
that the solution
flows through the
tube at the prescribed
. rate.

14-69. Procedure for Managing a Patient with an Intravenous Infusion

a. Document the IV therapy.

( 1 ) Label the IV site dressing once the infusion has started and
with each change of dressing.

(2) Change the dressing every 24 hours to keep the site clean and
to prevent irritation and contamination.

(3) To label the IV dressing-

(a) Cut a piece of adhesive tape and write your initials, the
time, and the date.

(b) Place the labeled tape gently over the dressing.

CAUTION

Do not label the tape after it has been placed

on the dressing. This could irritate or injure
the IV site.

14-80
 FM 8-230

(4) Label solution containers after the infusion has started and
with each change of solutions. Bags and/or bottles should be changed every 24
hours to prevent irritation and contamination.

(5) To label containers, cut a piece of adhesive tape and write the
patient's name and ID number, the flow rate, the date and time the container
was started, and your irutials. Place the tape on the bag or bottle.

(6) Prepare and attach a solution timing label.

(a) Place a piece of adhesive tape vertically on the

container.

(b) Write on the tape the approximate time the solution

should reach each volume mark on the container.

(c) Indicate on the bottom of the label the time the

container should be empty.

(7) Label IV tubing once the infusion has started and with each
change of tubing. Tubing should be changed every 48 to 72 hours. (Your local
SOP will specify the exact frequency for tubing changes.)

(8) To label IV tubing-

(a) Wrap a strip of tape around the tubing, leaving a tab.

(b) Mark the date and time the tubing was changed on the
tab.

(9) Record the following information on the appropriate patient

chart:

(a) Date and time of puncture.

(b) . Type of solution.

(c) Flow rate.

(d) Type and gauge of needle/cannula set.

(e) Insertion site.

(f) Patient's condition.

b. Replace the intravenous solution container. Adhere to strict

aseptic techniques throughout the following replacement procedure:

(1) Perform a patient care handwash.

(2) Select a new container of the correct solution.

(3) Clamp the tubing shut to prevent air from entering during
the replacement procedure.

14-81
FM 8-230

(4) Remove the old container from the IV stand. If a solution bag
is used, remove the spike.

(5) Hang the new container on the IV stand. Insert spike in new
bag, if applicable.

(6) Adjust the flow rate in accordance with instructions.

(7) Label the solution container.

c. Replace the IV tubing.

( 1 ) Change tubing in accordance with local SOP. (This is also a

convenient time to change the IV site dressing .)

(2) Perform a patient care handwash.

(3) Slow the infusion to keep the vein open. Flow rate should be
adjusted to 7 to 10 drops per minute.

(4) Disconnect the old tubing from the bottle or bag.

(5) Cover the open end of the disconnected tubing with the spike
cover from the new tubing. Be careful to maintain sterility-the other end of
the tubing is still connected to the catheter.

(6) Prime the new tubing and substitute for the old tubing.

(a) Place a sterile gauze under the catheter/needle hub.

(b) Grasp the new tubing between the fingers of one hand.

(c) Grasp the catheter/needle hub with a sterile gauze pad

between thumb and index finger and carefully disconnect the old adapter.

(d) Remove the protective cap from the new tubing adapter
and quickly connect the adapter to the hub.

(e) Secure tubing and dressing to the patient's arm.

d. Change the dressing. Use the following procedure to change the

dressing every 24 hours:

(1) Perform a patient care handwash.

(2) Obtain the necessary equipment­

(a) Adhesive tape.

(b) Antiseptic swab.

(c) Sterile gauze pads, 2 inch x 2 inch.

(d) Antimicrobial ointment.

14-82
 FM 8-230

(3) Hold needle hub while loosening the old dressing. Discard the
old dressing in the contaminated waste container.

(4) Clean skin around the insertion site with antiseptic swab.
Check for infection and inflammation.

(5) Apply small amount of microbial ointment over the insertion

site to help prevent infection.

(6) Secure catheter/needle, tubing, and new dressing to patient's

arm.

e. Discontinue the infusion.

(1) Perform patient care handwash.

(2) Remove tape and dressing without dislodging needle.

(3) Clamp the tubing to stop the flow of solution. This will keep
the solution from leaking into the tissue.

(4) Remove the needle gently and press an antiseptic sponge

over the injection site.

(a) Do not twist, raise, or lower the needle-this could

damage the vein.

(b) Pull the needle straight out without hesitation,

following the course of the vein.

(c) Apply pressure with a gauze sponge for a short time.

Follow this with a small dry pressure dressing (use either a plastic strip or an
antiseptic sponge secured in place with a piece of tape).

(d) Remove the IV equipment and store/dispose of

according to your local SOP.

Section X. MEASURING PATIENT INTAKE/OUTPUT

14-70. General

a. Observations concerning a patient's intake and output provide the

physician with essential information about the patient's fluid balance. This
information is considered to be an important sign regarding a patient's
condition. Most postoperative patients and patients with indwelling catheters
or those on IV infusion therapy are designated as requiring intake-output
measurement. If there is any doubt that a patient is taking enough fluid for
optimum kidney function or there is a need to verify the effectiveness of a
drug, all fluids consumed or excreted are measured to aid in making a
diagnosis.

14-83
FM 8-230

b. Definitions.

( 1 ) Intake. Intake consists of all fluids taken into the patient's

body. Items that require intake measurement include-

(a) All fluids taken orally.

(b) Foods such as gelatin, ice cream, or ice that are fluid at
room temperature.

(c) Foods such as melons that contain a lar� amount of

liquid.

(d) Intravenous infusions.

(e) Blood transfusions.

(f) Nasogastric and bladder irrigations that are not

returned.

(2) Output. Output consists of all liquids released by the body.

Items that require output measurement include-

(a) Urine-both voided and drained.

(b) Liquid stool.

(c) Vomitus.

(d) Drainage from any suction device such as a nasogastric

tube.

c. Intake and output records. A DD Form 792 (Twenty-Four Hour

Patient Intake and Output Worksheet) is kept at the patient's bedside. It
provides space in which to record the time, type, description, and amount in
cubic centimeters (cc's) of fluid intake and output. Intake equivalents are
shown on this form, with a list of serving levels (in cc' s) of the most common
serving containers used in the health care environment.

14-71. Procedure for Measuring a Patient's Intake

a. Verify the requirement to measure the patient's intake.

b. Explain the procedure to the patient.

( 1 ) Tell him that all fluids taken by mouth must be recorded for
accurate measurement.

(2) Insure that he is aware of any restrictions on the amount of

fluids he may consume.

(3) Encourage him to drink extra liquids if the physician or

supervisor has indicated a need to force fluids.

14-84
 FM 8-230

c. Identify the items requiring intake measurement including-

(1) Fluids taken orally.

(2) Intravenous infusion fluids.

(3) Blood transfusions.

(4) Irrigating solutions not returned.

CAUTION

If a patient is on restricted fluids or has only

certain amounts of fluids available for
consumption during a shift, note the amount
allowed. DO NOT GUESS.

d. Calculate amount of fluid intake.

( 1 ) Use graduated calibrated containers (cylindrical vessels

marked by a series of lines).

(2) Be aware of the amounts customarily contained in drinking

utensils to determine the amount consumed. Plastic utensils contained in field
equipment have different capacities.

(3) For partially consumed contents, estimate the portion

consumed by noting the amount the container holds. Subtract the existing cc' s
from the total amount in a full container to determine the amount consumed.

(4) For IV intake:

(a) Estimate the amount of fluid remaining in the glass

bottle by reading the fluid level on the graduated scale or tape.

(b) Estimate the amount of fluid remaining in the plastic

bag by grasping the sides of the bag, pulling them until taut, and reading the
fluid level on the tape or graduated scale.

(c) Subtract existing cc's from the total number of cc's in a

full container to determine the amount infused.

(d) Record intake. Enter time that IV is discontinued and

amount of solution infused. Compute total intake at the end of an 8-hour shift,
or as directed.

14-72. Procedure for Measuring a Patient's Output

a. Verify the requirement to measure the patient's output.

b. Explain the procedure to the patient. Remind ambulatory patients

to-

( 1 ) Male patients-void in urinal provided in designated area or

in a graduated container.

14-85
FM 8-230

(2) Female patients-void in bedpan or in specially designed

container placed under toilet seat. Contents of this container must be poured
into a graduated vessel for accurate measurement.

c. Identify the types of output items that require measurement. An

output estimate will be used if accurate measurement is not possible.

d. Measure output.

( 1 ) Collect urine, liquid stool, vomitus, and nasogastric drainage

in appropriate vessels.

(2) Pour into calibrated graduated container.

(3) Place graduate on level surface to read scale. Note level

reached by top of fluid in graduate.

NOTE

Accurate output measurement is sometimes

impossible. Estimate output amount as small,
moderate, or large when- ( 1 ) the patient is
urine or stool incontinent; (2) the patient has
not vomited into a container; (3) you encounter
wound drainage, bleeding, or profuse
perspiration.

e. Clean and store or discard supplies and equipment.

(1) Discard disposable items in proper waste receptacle.

(2) Dispose of collection vessel contents in accordance with local

SOP.

(3) Wash, rinse, and store vessels.

f. Perform patient care handwash.

g. Record output in appropriate section of DD Form 792.

(1) Note time, type, and amount of output.

(2) Color, odor, and consistency are also to be noted, if required.

Section XI. ORAL AND NASOTRACHEAL SUCTIONING

14-73. General

a. Suctioning is performed for the purpose of removing accumulated

secretions from the patient's nose, mouth, and/or tracheobronchial tree .in
order to maintain an open airway as well as to remove lung secretions that

14-86
 FM 8-230

block gaseous exchange. Removal of these secretions can be carried out

through the oropharyngeal (mouth) or nasotracheal (nose) routes or through
artificial airways such as endotracheal or tracheostomy tubes. (An
endotracheal tube is inserted into the trachea through the nose or mouth; a
tracheostomy tube is inserted through a surgical incision into the trachea.)

b. Suctioning is performed on patients who have lost their ability to

swallow and to cough up secretions, due to unconsciousness, a stroke, or other
disease process. The suctioning procedure should be performed ONLY when
needed. Frequent suctioning causes trauma to the mucous linings of the
respiratory tract. Edema and hemorrhage can occur in the airway from
irritation caused by the suctioning catheter.

c. Nasotracheal suctioning c·an also cause the following

complications:

(1) Trauma to the mucosal linings of the respiratory tract.

(2) Hypoxemia.

(3) Infections in the lungs (pneumonia).

(4) Atelectasis (collapsed lung).

(5) Cardiac arrest.

Postoperative patients must be turned and encouraged to cough and deep

breathe frequently (usually every 2 hours) following surgery. This practice will
be helpful in preventing postoperative complications�such as pneumonia and
reducing the need for suctioning.

d. There is no specific order to follow when suctioning a patient using

different routes. Whenever routes are changed, the catheter and gloves must
be changed. Numerous organisms are normally found in the nose and pharynx.
Sterile techniques must be used for all nasotracheal suctioning to prevent the
introduction of "foreign" organisms into the lungs.

14-74. Procedure for Performing Oral and Nasotracheal Suctioning

a. Verify need for suctioning. Check patient for:

( 1 ) Increased respirations accompanied by labored or difficult

breathing.

(2) Moist, noisy, rattling, or gurgling sounds while breathing.

(3) Secretions drooling from the mouth.

(4) Check the physician's orders, Nursing Care Plan, or the

supervisor's directive. These documents will normally indicate the frequency
of suctioning.

b. Perform patient care handwash.

14-87
FM 8-230

NOTES

1. When performing suctioning, every effort

must be made to prevent the introduction of
pathogens into the patient's lower airways.

2. Clean technique and thorough handwashing

are essential for suctioning of the oral and
nasal cavities. Sterile technique i s
MANDATORY for deep suctioning i n the
tracheobronchial tree and suctioning
through the endotracheal and tracheostomy
tubes. Follow aseptic techniques for all
suctioning of the airway to minimize the
spread of microorganisms that are not
normally found in the air passages.

c. Obtain the necessary equipment.

( 1 ) Disposable suction equipment (if available) contains a

catheter, gloves, carton for solution, and packet of solution.

OR

(2) Sterile, disposable suction catheters (sized by use of the

French scale: the smaller the number, the smaller the catheter ( 1 2 is smaller
than 1 4 according to this scale). These two sizes are the most commonly used
for suctioning the adult patient.

AND

(3) Sterile saline.

(4) Sterile solution basin.

(5) Sterile gloves.

(6) Suction apparatus Wigure 14-5 1).

NOTE

Suctioning of the airway requires a source of

vacuum. Most hospitals that have piped-in
oxygen also have a piped-in vacuum source
(Figure 14-51A). When a piping system is not
available, portable suction units must be used
(Figure 1 4-51B). Most portable suction units
must be connected to an electrical source;
however, a portable field unit is nonelectrical.

14-88
 FM 8-230

Figure 14-51. Suction apparatus.

d. Identify the patient.

( 1 ) If the patient is conscious, ask him his name and check his
bed card or identification band

(2) If the patient is unconscious, compare the name on the bed

card and identification band . I nsure that the name is the same on both.

e. Explain the procedure. Explain the suctioning procedure to the

patient to lessen his fears and gain his cooperation.

f. Provide privacy. Place screen or curtain around the patient's area

or close the door if he is in a room.

g. Position the patient. Place the patient in a semi-Fowler's position.

( 1 ) The semi-Fowler's position is a semi-sitting position in which

the patient manages secretions better and breathes easier.

(2) In some cases (such as spinal injuries), the patient will have
to be suctioned in whatever position he is in at the time.

h. Check pressure on the suction apparatus.

(1) Turn on the suction apparatus.

(a) Suction pressure is usually expressed in inches (in) of

mercury (Hg) on the portable unit and in millimeters (mm) of mercury (Hg) on
the wall-mounted units.

14-89
FM 8-230

(b) Recommended pressure settings for adult patients:

• Portable unit-7 to 15 inches Hg.

• Wall-mounted unit-120 to 1 50 mm Hg.

(c) If pressures are not within these limits, notify your

supervisor before continuing. .

(2) Place thumb over the end of the suction tubing and observe
the pressure gauges (Figure 14-52).

CAUTION

If the pressure is too low, the secretions cannot

be removed. If the pressure is too high, the
mucous lining may be forcibly torn away and
pulled into the catheter openings.

(3) Turn off the suction unit after the correct pressure has been
verified.

i. Prepare the necessary materials. Open the disposable suction set

(if used) or prepare materials for separate setup.

(1) Open the sterile solution basin on the bedside table.

(2) Pour sterile solution into solution basin without

contaminating solution, basin, or sterile field.

CAUTION

Catheters should not be left in solutions. Even

antibacterial solutions can promote the growth
of certain types of bacteria.

(3) Open suction catheter package (following package directions)

to expose the suction part of the catheter.

(4) Open sterile gloves. If gloves are wrapped separately from

suction catheter, open catheter package first.

j. Oxygenate the patient (tracheal suctioning only). Provide

additional oxygen for the patient prior to endotracheal stimulation and
suctioning to prevent further hypoxemia (oxygen deficiency in the blood).

( 1 ) If the patient is on oxygen therapy, increase the percentage

of oxygen to 100 percent for 1 minute.

(2) If the patient is not on oxygen, have him take a minimum of

five deep breaths.

14-90
 FM 8-230

B.

Figure 14-52. Checking pressure gauges of suctioning apparatus.

NOTES

1. Suctioning not only removes accumulated

secretions but the oxygen as well.

2. If the patient is not on oxygen therapy, the

bag-valve-mask method can also be used for
oxygenation.

3. Endotracheal suctioning is used for patients

receiving oxygen and for those with
artificial airways.

k. Put on sterile gloves. Put sterile glove on dominant hand. Some

suction kits provide only one glove for use on the dominant hand that handles
sterile items.

l. Remove catheter from package. Remove the sterile catheter from

the package with gloved hand. Keep the catheter coiled to prevent
contamination.

m. Attach catheter to suction tubing. Attach suction catheter to

tubing from suction apparatus. Attach the suction part of the catheter to the
tubing held by the ungloved hand (Figure 1 4-53).

(1) Turn the suction apparatus on with ungloved hand.

(2) Hold the catheter in the gloved hand and insert the tip in the
basin of sterile solution.

14-91
FM 8-230

(3) Place thumb over the suction port and observe saline
entering the drainage bottle.

Figure 14-53. Connecting catheter to suction

apparatus.

NOTE

If no saline enters the drainage bottle, the

catheter is blocked and another catheter
should be used.

n. Suction the patient.

(1) Oral route.

(a) Insert the tip of the catheter into the patient's mouth
without suction.

NOTE

If the patient is uncooperative (clenches teeth,

bites, or chews catheter), suction by the
nasopharynx may be required for removing
secretions from the back of the throat. In this
case, insert the catheter into the nose, without
suction, 3 to 5 inches. Apply suction, and
withdraw the catheter using a rotating motion.
This will also remove secretions from the nose.

CAUTION

Be aware that advancing the catheter too far

into the back of the patient 's throat may
stimulate the patient's gag reflex, which could
lead to vomiting and aspiration of stomach
contents.

14-92
 FM 8-230

(b) Apply suction by placing the thumb of the ungloved

hand over the suction port. This aspirates secretions from the back of the
throat, along the outer gums and cheeks, and around the base of the tongue.

(c) Suctioning should not be continuous for more than 1 0 to

1 5 seconds. Suctioning removes oxygen as well as secretions; therefore, longer
periods of continuous suctioning may result in an oxygen deprivation that is
too severe for the patient.

(d) If the patient is alert and cooperative, tell him to cough

to help bring secretions up to the back of the throat so they can be easily
removed.

(e) Clear the catheter by inserting the tip in the saline

solution and suction the solution through the catheter until it is ".lear.

NOTE

If an oral pharyngeal airway is in place, insert

the catheter alongside the airway, then back
into the pharynx.

(f) Repeat steps (b) and (c) above until all secretions
have been aspirated.
NOTES

1. When the patient ' s breathing efforts

become less labored and difficult, and noisy,
rattling, or gurgling sounds are no longer
noted, the suctioning should be
discontinued.

2. With some patients, the complete absence of

gurgling or rattling sounds cannot be
achieved. If the sounds are still present after
aspirations, notify the supervisor.

3. If the suctioning must be repeated, allow the

patient to rest between each aspiration.

(g) Turn off the suction apparatus and disconnect the

suction catheter from the tubing. Discard the catheter in the contaminated
trash receptacle.

(2) Nasotracheal route.

(a) Instruct the patient to open his mouth and stick out his
tongue (Figure 1 4-54A).

(b) Insert the suet.ion catheter into the nasopharynx

without suctioning (Figure 14-54B).

14-93
FM 8-230

�----- ---------------,

Figure 14-54. Inserting catheter into trachea.

NOTES

1. To estimate the distance the catheter i s to

be inserted, measure from the patient's nose
to the ear, then to the larynx.

2. Generally, it i s easier to insert a catheter

into the right nostril than into the left, due
to less septal deviation (a slight deformity of
the wall separating the two nasal cavities,
causing a partial or complete blockage of the
nostril). If an obstruction is met, remove the
catheter and try the left nostril. If an
obstruction is still met, remove the catheter
and call for assistance.

(c) Stimulate the cough reflex by gently moving the

catheter.

(d) Quickly and gently advance the catheter into the

trachea when the patient coughs.

NOTES

1. When the patient coughs, the epiglottis (a

lid-like cartilage overhanging the larynx and
trachea) is raised (opened), permitting easier
inser tion of the catheter.

2. If the patient can cough up enough

secretions to clear his lungs and/or the
bronchial tree adequately, the rest of the
procedure may not be necessary.

(e) Suction secretions by placing your thumb over the

suction port.

14-94
 FM 8-230

(f) Aspirate the patient for brief periods and allow him to
rest between suctionings. Introduce the catheter carefully and suction
thoroughly but quickly.

(g) Check the patient during and after the procedure for
skin coloration change or increased pulse rate.

NOTE

Pulse rate increases with hypoxemia. Listen

for changing breathing sounds. As secretions
are removed, breathing should become quiet
again.

(h) Rinse the catheter as required between suctionings.

o. Remove catheter and glove(s).

( 1 ) Disconnect the catheter from the suction tubing and discard

in trash receptacle.

(2) Remove glove(s) and discard in trash receptacle.

p. Leave the patient comfortable.

(1) Straighten and tighten bed linens.

(2) Place the patient in the semi-Fowler's position if his

condition permits.

(3) Raise the bedside rails, if indicated.

(4) Place call bell/light within easy reach of the patient.

q. Discard used items.

(1) Discard disposable items in trash receptacle.

(2) Clean and store nondisposable items in accordance with the

local SOP.

(3) Replenish supplies as needed.

r. Record procedure. Record the following:

(1) Time.

(2) Respirations (rate, labored, noisy).

(3) Procedure: route (oral, nasopharynx, nasotracheal).

(4) Type and amount of secretions obtained.

14-95
FM 8-230

Section XII. APPLICATION OF HEAT AND COLD

14-75. General

'!'he application of heat and cold discussed in this section is limited to those
commonly administered in a ward or clinic. A doctor's order or local SOP is
necessary for all applications of heat and cold. The physician will usually
indicate the form of application, the area to be covered, the temperature of the
application, and the duration and frequency of treatment. It is your
responsibility to apply the prescribed form of heat or cold so that the
treatment is beneficial, rather than injurious, to the patient.

14-76. Effects of Heat

Heat applied to the skin surfaces provides soothing comfort and speeds up the
healing process. Heat dilates the superficial blood vessels (vasodilation) in the
area of application. This increases blood supply and adds nutrients and oxygen
to the tissues, supporting and maintaining body tissue and stimulating the
growth of new tissue. There is an increase in white blood cells, which ward off
infection, combat disease organisms, and aids to decrease the formation of pus
(suppuration). The dilated blood vessels and increased blood supply in the area
of heat application cause the skin to appear pinkish or reddish, although this
color is more difficult to detect in dark-skinned or black patients. Heat is used
to relieve pain due to muscle spasm, to relieve inflammation, to promote
localization of purulent material (containing pus) and its drainage, and to
relieve chilling.

14-77. Effects of Cold

a. When cold is applied to the skin or a part of the body, constriction

of the superficial blood vessels (vasoconstriction) occurs. The skin becomes
pale and cool. The diminished blood flow in the area of application reduces the
oxygen and nutrients available to the cells and slows down cellular
metabolism. This decreased cellular activity leads to the numbing or
anesthetic effect associated with cold. Prolonged exposure to cold lessens pain
as well as sensation. If cold continues to interfere with adequate circulation, it
can cause damage to body tissues, such as necrosis (death of tissue) caused by
severe frostbite.

b. Medically, the effects of cold applications are employed to reduce

edema resulting from sprains, strains, and contusions. Hypothermia is often
used to cool the patient's body in order to reduce metabolic needs and the
amount of anesthetic required during prolonged surgery. Cold packs are used
to control bleeding (ice collars applied after tonsillectomy) and aid in the
reduction of edema following an injury. The physician usually will indicate the
temperature to be used for cold applications (tepid, cool, cold, or very cold).

14-78. Effects on the Autonomic Nervous System

Although the procedure of applying heat or cold to the body is relatively

simple, the effect on the body is much more complex. Changes in the body 's
external temperature activate the autonomic nervous system, which produces
systemic responses in the body.

a. Heat. The systemic response begins with the thermal receptors in

the skin, which send messages to the temperature control center in the brain
(hypothalmus) indicating that the skin is now warmer. The hypothalmus
responds by dilating the vessels in the area to allow more blood to flow
through them and to distribute the heat. This regulatory function helps to

14-96
 FM 8-230

maintain a uniform internal temperature and to prevent damage to the tissue

cells. The amount of blood diverted to the skin through vasodilation reduces
the amount of blood circulating through internal organs and other structures.
This protects the internal organs and delicately balanced body functions from
harmful effects due to increased temperature. Application of heat to a small
area of skin produces a milder systemic response than application to a larger
area. Systemic circulatory changes may cause faintness, a faster pulse, and
some degree of dyspnea. For these reasons, you must take the patient's vital
signs frequently, and observe the skin when heat is applied to a large area of
the body.

b Cold. The systemic effects of cold are the reverse of those

.

occurring in the application of heat. The diversion of blood volume from the
skin to the vital interior organs insures their continuing function. The body
acts to conserve body heat when cold affects the entire body or large portions
of it. Muscles are stimulated to contract; the resulting shivering action
produces some heat and squeezes more blood out of vessels with in the muscles.

14-79. Patient Safety

a. The body is able to tolerate large changes in external

temperatures; however, moist applications to the skin of temperatures that
are warmer than 1 10°F (43.3°C) or colder than 40°F (4.4°C) can seriously
damage body tissue. Individual sensitivity to temperature changes varies; the
very young and the very old particularly are unable to tolerate such changes.
When the temperature affects a large body area, the skin becomes less tolerant
to extremes of temperatures. The skin is better able to tolerate brief
treatments than prolonged applications of heat or cold. Also, thin-skinned
areas of the body and those not usually exposed tend to be more sensitive to
temperature changes than areas like the palm of the hand or the sole of the
foot, which are exposed and have thicker layers of skin.

b. There is always a problem when the treatment is ordered by

descriptive adjective, since the questions of "how hot is hot?" and "how cold
is cold?" must be answered. The range of temperature from hot to cold, in
relation to therapeutic applications, falls within these limits:

ACCEPTED TEMPERATURE RANGES FOR APPLICATION OF HEAT:

Fahrenheit Centigrade

1 05° to 1 1 5° very hot 41 ° to 46°

98° to 1 05° hot 37° to 4 1 °

93° to 98° warm 34° to 37°

14-97
FM 8-230

ACCEPTED TEMPERATURE RANGES FOR APPLICATION OF COLD:

Fahrenheit Centigrade

80° to 93° tepid 26. 7° to 33.9°

65° to 80° cool 18.3° to 26. 1°

55° to 65° cold 12.3° to 18.3°

Below 55° very cold below 12. 5°

Added to the temperature in degrees is the moisture factor-moist heat and

cold are both more penetrating and more intense in their effect on body tissue.

14-80. Local Application of Heat

A local application is one that is used on a specific part of the body. These
applications are usually in the form of either dry or moist heat. To protect the
patient from bums due to heat applications-

a. Measure the temperature with a solution (bath) thermometer, if

possible.

NOTE

When a thermometer is not available, place the

pack against the inner aspect of your arm. If
any doubt exists that the application is too
hot, cool it down. You must always remember
that what might feel comfortably warm on
normal, healthy skin could be dangerously hot
if applied to the skin of infants, old people, or
individuals with impaired circulation.

b. Always use a protective cloth cover. Never apply directly against

the skin.

c. Observe the condition of the skin frequently for signs of burning or

blistering and be attentive to any complaints by the patient.

d. Caution the patient not to attempt to increase the temperature of

water in hot water bottles.

( 1 ) Dry heat. Heat is commonly used as dry applications and

may be applied by a hot water bottle or a chemical heating pad. There are also
various other methods such as thermoregulated electric pad and heat cradle,
but these are used infrequently.

(a) Hot water bottle.

1. Fill a pitcher with hot water. Test the temperature

with a bath thermometer. The temperature should not be more than
120°F.

14-98
 FM 8-230

2. Pour water into bottle to one-half capacity. Expel air

by gradually resting the bottle flat on a table until the water reaches the neck
of the bottle. Expelling the air makes the bottle pliable so that it will conform
to body contours.

3. Secure the stopperless closure by folding over the

the neck tabs in proper sequence (A tab first, B tab second, and so on) (Figure
1 4-55).
4. Test for leaks. Wipe surface dry. Cover with a hand
towel or other dry cloth cover.

5. Apply to prescribed area. Tell the patient that it is

intended only for the area to which applied.

6. Check skin area before refilling and reapplying. Do

not apply if an area of heat-induced redness is apparent.

Figure 14-55. Preparation of hot water bottle.

(b) Chemical heating pad, water-activated (Figure 1 4-56) .

1. The chemical heating pad comes complete with a

stick and a waterproof cover.

2. Clear the opening in the upper corner of the pad with

the small stick and pour in 30 cc's of cold water.

3. Manipulate (knead) the bag briskly between your

hands to mix the water and chemicals. Place the bag in the waterproof
container, or wrap it in a towel or other covering, and apply the pad to the
patient as directed.

14-99
FM 8-230

CAUTION

The amount of heat that continues to be

generated for several hours by chemical
reaction cannot be controlled; you must check
frequently to be sure the pad is not too hot for
the patient. Apply additional padding between
the patient and the heating pad if it is too hot.

P O U R I N WAT E R H E RE .

OUTER COVER I N N E R CAS E

Figure 14-56. Chemical heating pad,

water-activated.

(2) Moist heat. Moist heat is usually applied as a soak, compress,

or pack. Solutions such as sterile water, normal saline, and a number of
medicated solutions will usually be specified by the doctor if other than tap
water is to be used. You must remember that water is more effective than air
as a conductor of heat. In addition to observation for reaction to heat, skin
exposed to moisture for a prolonged period must be observed for any sign of
maceration (destructive softening, puffiness, or wrinkling of the surface).
Maceration is prevented by exposing the skin to air for 1/2 to 1 hour between
reapplications of moist heat; this step is important when moist heat is
prescribed as a "continuous application. "

14-81. Arm or Foot Soaks

a. A soak is the direct immersion of a body part (arm or foot) in warm

water or in a medicated solution. Tap water is generally used for soaks. The
physician usually indicates the type of solution, the body area to be soaked,
the temperature of the solution (usually 1 05°-uo°F), and the duration of the
treatment.

b. Procedure.

( 1 ) Assemble supplies and equipment. Choose a container for the

solution sufficiently large enough to accommodate the area to be soaked.

(2) Explain the procedure to the patient. Heat the solution to the
prescribed temperature.

14-100
 FM 8-230

(3) Position the patient. Drape him so that the area is exposed,
but maintain his privacy and warmth.

NOTE

If patient has soiled dressings, use aseptic

technique to remove them and discard the
soiled dressing in accordance with local SOP.

(4) Pour the heated solution into the soaking basin. If

medication is to be added to the solution, this is the time to add it. Be sure that
it is mixed thoroughly with the solution.

(5) Test the temperature of the solution and keep it constant

during the treatment. If no thermometer is available, use the anterior aspect of
your wrist to test the temperature. A solution that feels hot on the wrist will
probably be too hot for the patient.

(6) Immerse the specified body part gradually into the solution
so that the patient becomes accustomed to the temperature change. Soak the
body part for the specified period of time.

(7) Remove affected body part from the solution. Support the
body part as you remove it and remove the soaking basin. Dry the affected
part thoroughly. If there is an open wound, pat dry around it, not directly on
it. Apply a dressing if needed.

NOTE

When ordered for treatment of an open wound,

sterile equipment and solution are used to
reduce contamination; once the part is
immersed, however, any organisms present
contaminate the solution and sterility cannot
be maintained. The initial use of sterile
equipment and a sterile towel to dry the area
provides a margin of safety.

14-82. Local Application of Moist Heat, Clean Technique

a. Use clean technique for local applications, compresses, or packs

applied to intact skin. The difference between a compress and a pack is in the
material used and the body area on which it is used. A pack (also referred to as
massive wet dressings) is usually applied to an extensive body area such as an
entire leg or arm; a compress is normally applied to a limited body area and
consists of warm, moist gauze pads or clean folded washcloths.

b. Compresses and packs differ from soaks in that they are used for a
longer period of time and are usually applied at a higher temperature. They are
applied at the hottest temperature the patient can tolerate without burning
the superficial tissue. The material can be wrung out manually (hands or
forceps) so that it does not drip on the patient when applied, but it must
remain moist enough to conduct the desired amount of heat.

14-101
FM 8-230

c. Because compresses and packs usually cool off rapidly, the length
of time they retain heat depends on the temperature of the solution, the
thickness of the material, and the type of insulation used. Generally, they
remain hot for 1 5 to 20 minutes, then have to be reheated and reapplied.

d. Procedure for applying moist, hot compresses to a bed patient.

( 1 ) Place a hot plate on a table convenient to use. Plug in the

plate and turn switch to low heat setting.

(2) Place basin of water, at a temperature of 1 1 0°-1 1 5°F, on the

hot plate. Do not allow solution to be hotter than the hands can comfortably
stand. Place gauze pads or folded washcloths in the hot solution.

(3) Place patient in comfortable position, with protective pad

under the body part to be treated in order to protect bed.

(4) Lift hot wet compress from basin. Wring out as dry as
possible. Test heat of compress against inner surface of forearm. Lay hot
compress gradually on area to be treated, lifting corners to eliminate any
steam.

(5) Observe skin carefully for redness before reapplying

compress. If no unfavorable skin reaction is observed, exchange the cooled
compress for a heated one, continuing reapplications for the prescribed length
of time, usually for 20 minutes.

(6) Turn off hot plate and disconnect wall plug after each
treatment. Compress may be reused if not soiled.

NOTE

If compresses are to be self-applied by the

patient, demonstrate the entire procedure to
the patient and have him repeat it. Check from
time to time to see that instructions are being
followed and to observe skin area.

e. Moist hot packs (clean).

•
( 1 ) Gather appropriate equipment. Place a hot plate on a table
convement to use.

(2) Place basin of solution, at a temperature of 1 10°- 1 1 5°F on

the hot plate. Solution should be no hotter than your hands can comfortably
stand. Place two bath towels (folded in half) in the basin of hot solution.

(3) Place patient in comfortable position with extremity to be

treated elevated properly and completely exposed. Place protective pads under
the extremity and over the pillows. On top of protective bed covering, place
dry bath towel and rubber or plastic sheeting to bind the hot pack in place.

14-102
 FM 8-230

(4) Wring out and test hot towels by touching one to your
forearm. Place one hot folded towel under and one over the extremity to be
treated in order to completely inclose it. Fold plastic or rubber layer over the
extremity to inclose the hot moist towels. Then fold over the dry towel and pin
or fold securely to keep the pack in place.

(5) Apply hot water bottles or chemical heating pad to the

outside of the towel binding as needed to maintain the pack's heat.
(6) Reapply hot pack as prescribed, checking condition of the
skin each time. When properly applied, it is possible to maintain the required
amount of heat and moisture for about 1 hour with each hot towel application.

(7) When hot pack is discontinued, pat skin dry.

(8) If pack is to be continued day and night, set up a schedule for

reapplying to allow a required period of skin exposure to air. Use clean towels
next to the skin to prevent a sour odor. Wash and gently dry the inclosed skin
area to remove perspiration and skin secretions before the air exposure period.

14-83. Local Applications of Cold

a. Cold is applied to small localized areas of the body in dry form by

means of an ice bag or in moist form by means of iced, moist compresses.
Continuing contact with cold produces numbness as well as constriction of
hood vessels. While both of these effects may be desired, the area to which cold
is applied must be watched closely since the patient may not complain of
symptoms indicating possible tissue damage. Local signs of unfavorable
reactions to cold include pallor, blueness, or mottling (blotchy) discoloration of
the skin. If these signs are noticed, discontinue the application immediately
and report the observation. When continuous moist cold is ordered, remove for
20 minutes every 2 hours.

b. Application of ice bag. The ice bag may be a dual-purpose, hot

water bottle or an ice collar. (A securely tied plastic sack or latex rubber glove
may also be used when a flexible, lightweight container is needed to apply ice
to an eye or the nose.)

(1) Crack or crush the ice to eliminate large pieces or sharp

edges.

(2) Fill the container only half full with ice; expel all air so that it
will be flexible. Close securely and test for leaks.

(3) Wipe the surface of the container dry. Inclose it completely in

a dry cloth, cloth bag, stockinette, several layers oI gauze, or a hand rowel.

(4) Apply container so that it is in contact with the designated

local area, propping where necessary to relieve weight and pressure.

(5) Check and refill as necessary to keep the local area cold for
the prescribed period.

NOTE

Always change the cover if it becomes moist.

14:103
FM 8-230

(6) Observe the skin area carefully. Discontinue application and

report unfavorable reactions immediately (STAT).

(7) When treatment is discontinued, drain, wash, dry, and inflate

the bag with air before returning it to its proper storage place.

c. Application of cold compresses. The compress should be several

layers thick and of sufficient size to cover the designated area. Gauze pads or
clean, folded washcloths are used. These are often self-applied, following
instruction and initial assistance.

(1) Place protective cover under the part to be treated to protect

the bedding.

(2) Place large pieces of ice and a small amount of water in a

hand basin or sponge bowl. Place compresses or clean folded washcloth (in
sufficient number to permit frequent exchange) in the ice water.

(3) Squeeze excess moisture from a chilled compress and apply

the compress quickly to designated area. Do no cover the compress.

(4) As the compress loses its coolness, exchange it for a freshly

chilled and moistened one. This step is repeated every 5 or 6 minutes for the
1 5- or 20-minute application period.

(5) When treatment is discontinued, wash and dry the basin.

(6) Start each application with clean water and ice. Replace
gauze or washcloth as they become soiled.

14-84. General Application of Cold

A general application is one that is applied to the entire body. Cooling of the
entire body is usually accomplished by means of a special hypothermia unit
(cooling blanket) used under the supervision of an anesthetist, or by using a
cooling sponge bath.

14-85. Sterile Technique for Applications

a. Sterile technique must be followed when applying moist hot or

cold applications to broken, infected, or burned skin area, and medical asepsis
must be observed when draining wounds are involved. An important goal is to
prevent the contamination of a wound and to control the spread of organisms
from an infected wound. The clean procedures described for soaks, compresses,
and packs must, therefore, be modified to include the use of aseptic supplies
and techniques.

b. Sterile applications are most often used for smaller body parts,
and various medications can be prescribed by the doctor. The necessary
supplies include-

• Bottle or flask of sterile solution.

• Disposable sterile irrigating set.

14-104
 FM 8-230

• Sterile gauze dressings.

• Sterile gloves or forceps, as required.

If the irrigating set is not used, a sterile basin may be needed to hold the
solution. When using the sterile irrigating set, the solution is poured
aseptically into the container and drawn up in the Asepto syringe, and the
sterile dressings are moistened with the solution. Sterile gloves or forceps may
be needed to wring out the excess solution from the compresses and apply
them in place. A sterile dry pad or dressing applied over the moist one helps
retain the temperature of the compress or pack.

Section XIII. THERAPEUTIC BATHS

14-86. General

a. When there is a need to quickly decrease a patient's temperature, a

tepid or cold sponge bath may be required. This technique is based on the
principle that the body loses heat through the conduction of heat to a cooler
substance such as water or alcohol.

b. To verify that a sponge bath is needed, the patient's rectal

te�erature should be taken. If the rectal temperature is greater than 106°F
(41 C), immediate cooling of the patient is necessary. The rectal temperature
should be checked every 10 minutes and not allowed to fall to less than 101 °F
(38°C).

c. The following equipment is needed to administer a tepid sponge

bath:

(1) Two bath blankets.

(2) Basin of tepid water.

(3) Two bath towels.

(4) Eight wash cloths.

(5) Rectal thermometer.

(6) Sphygmomonometer.

(7) Stethoscope.

14-87. Administering the Sponge Bath

a. Before starting sponge bath, the patient's vital signs must be

taken. These vital signs will serve as a baseline for comparison to determine

14-105
FM 8-230

the effectiveness of the treatment. The most important vital sign is the
patient's temperature. Before sponging the patient, apply cold, wet
compresses to the groin, axillae , and neck.

b. Sponging is done by slowly stroking the skin surface area with

long, soothing strokes, using the wet washcloths. The areas to sponge are the
face, trunk, and abdomen for about 5 minutes, the entire back and buttocks for
about 5-10 minutes, then each extremity for about 5 minutes. Each area
should be gently dried with a towel after it is sponged.

c. Observe the patient closely for shivering. If shivering occurs,

cover him completely with the bath blanket and apply gentle friction to the
torso and extremities. Remember the patient's first reaction to the bath is
chilliness; this disappears as the body adjusts to the cold temperature. The
bath must be continued for at least 25-30 minutes. The rectal temperature
must be checked every 10 minutes after the bath is stopped. The temperature
can be expected to drop further to normal. The bath should be discontinued if
cyanosis and/or shivering does not stop when friction (rubbing) is applied to
the skin.

d. In the field you must decide when a tepid, cold, or alcohol sponge
bath is necessary. If the patient's temperature is 106°F (4 1°C) or higher, a
sponge bath is indicated. You will need-

(1) Tepid water,

(2) Ice, if available.

(3) Alcohol, if available.

In certain situations it may not be feasible to remove the patient's clothes.

Therefore, you must be able to improvise as needed to cool the patient
immediately.

14-88. The Field Expedient Sponge Bath

a. Unbutton the clothing as much as possible after the temperature is

taken, then apply cool compresses to the groin, axillae, and neck.

b. After the cool compresses are applied, use a cravat or field

dressing to sponge the patient, using soothing strokes over the skin, one side
at a time.

CAUTION

Do not use alcohol in sensitive areas of the

body such as the face, axillae, or groin.

c. Another method used to cool the patient is to pour water over him
and use whatever is available to fan him for approximately 20 minutes. After
20 minutes, check the vital signs and temperature. If temperature is still
above 101°F (38°C), repeat the procedure.

14-106
 FM 8-230

<!-- Observe the pa�ient closely for shivering. Shivering increases the
_ happens, the effectiveness of the bath is
production of body heat; if this
lessened.

e. �to� treatment if pulse increases, cyanosis (bluish discoloration) is

noted, or shivenng starts.

14-89. Completion of the Sponge Bath

After the bath, provide for the patient's safety and comfort. Dry the patient
and provide dry clothing, if necessary. Record the treatment vital signs'
length of treatment time, date, patient's tolerance, and type of hath.

Section XIV. MANAGING A PATIENT REQUIRING

CHEST TUBE DRAINAGE

14-90. General

a. Normal breathing in a human operates on the principle of negative

pressure (the pressure in the chest cavity is lower than the pressure of outside
air, causing air to rush into the lungs). Whenever the chest is opened (by
surgery or trauma), there is a loss of negative pressure, which can cause a
collapse of the lungs.

b. Pleura is the membrane that covers the chest walls and lungs and
produces a serous fluid (moist and slippery secretions) to reduce friction
during respiration. The parietal pleura lines the chest cavity and the visceral
pleura covers the lungs. When conditions produce a space between these
pleural layers, breathing is changed and the lungs can no longer fully expand
(Figure 14-57).

RIBS

+-DIAPHRAGM

--- · -- ·----------'
Figure 14-57. The respiratory system.

14-107
FM 8-230

c. Blood and air collect in the pleural space as a result of pP.netrating

wounds, a fractured rib that punctures a lung, the rupture of a blister (bleb) on
the lung surface, or a surgical procedure. A chest tube is inserted by a
physician as an emergency treatment or at the completion of surgery. It is
connected to an underwater-seal drainage bottle or to a disposable pleural
drainage system.

d. There are many connections in the drainage system, and the

breakdown of any one could cause a second collapse of a lung. Most equipment
problems are the result of the system not being airtight. This is usually caused
by a loose hose or connector and can lead to serious complications if not
detected and corrected.

e. There are two basic types of apparatus used for underwater-seal

chest drainage:

( 1 ) Drainage without suction, including 1-, 2-, and 3-bottle

setups. The I-bottle setup is most commonly used when suction assistance is
not required.

(2) Drainage with suction is used when water-seal drainage alone

does not eliminate free air from the pleural cavity in sufficient quantities to
permit lung expansion.

14-91. Managing a Patient Requiring Chest Tube Drainage

a. Wash hands and put on sterile gloves.

b. Attach drainage tube from the pleural cavity to the tubing that
leads to a long tube with the end submerged in sterile normal saline (Figure
14-58).

I/
.p

I�
.,. -;;:;
-- ­
// .

r� . .. -
'·
,,

1 ··
"
"
)!
ONE·BOffiE SYSTEM TWO·BOTTLE SYSTEM

THREE·BOTTLE SYSTEM

Figure 14-58. Drainage system.

14-108
 FM 8-230

c. Tape points where tubing is connected. Taping the connections

insures that the tubing and connectors do not become loose or slip apart and
an airtight seal is maintained.

d. Place tube approximately 1 inch (2.5 cm) below the water level
(Figure 1 4-59).

e. Vent short tube so that it is left open to the atmosphere (Figure

1 4-59).

RUBBER TUBING CONNECTED

TO CHEST CATHETER

STERILE WATER OR
NORMAL SALINE

[
TIP OF TUBE PLACED 3 TO BOTILES SECURED
5 cm BELOW WATER LEVEL TO FLOOR

WATER SEAL

Figure 14-59. Tube below water level and vent short tube.

f. Mark original fluid level with tape on the outside of the drainage
bottle (Figure 1 4-60). Mark hourly/daily increments as ordered (date and time)
at the drainage level.

CAUTION

Grossly bloody drainage will appear in the

bottle during the immediate postoperative
period and if more than 100 cc/hr, notify your
supervisor immediately .

14-109
FM 8-230

NOTES

1. Marking will show the amount of fluid loss

and the rate fluid is collecting in drainage
bottle.

2. Drainage usually declines progressively

after 24 hours.

3. When drainage bottles are changed or

discontinued, subtract the measured water
from the total to obtain the fluid drainage
total.

DRAINAGE BOTTLE

c
c
875
s 750
TAPE STRIP

c 625
A
L 500
E
375
9120 llOOHRS

9120 l'°OHIS
1 � 250
L 125
�

Figure 14-60. Original fluid level mark.

g. Assure that the chest drainage system is airtight at all times.

( 1 ) Vigorous bubbling of the chest tube bottle when suction is

not being applied indicates a leak in the system. All connections should be
checked to insure that an airtight system exists. Vigorous bubbling may be
caused by a loose connection or a defect in the lung. Report this to your
supervisor immediately.

(2) If a connector is completely disconnected or the drainage

bottle is broken, immerse the end of the tube in a container of sterile water,
thereby providing a water seal. Notify your supervisor immediately. An entire
sterile drainage system will need to be reconnected to the chest tube.

14-110
 FM 8-230

NOTE

When the system is not completely airtight

and in water seal, the patient will have an
immediate pneumothorax. If a container of
sterile water is not available, attach a Heimlich
valve (Figure 14-61) to the open end of the
tubing and the system will be complete until
the underwater seal can be obtained. A field
expedient Heimlich valve can be made by
dampening the inside of a penrose drain and
taping it to the open end of the tube or taping a
finger of a sterile glove to the open end of the
tube and cutting the tip of the finger (Figure
14-61). These methods provide a flutter valve
effect which will allow air to escape on
expiration and seal on inspiration so that air
cannot enter the plural cavity through the
tubing.

Figure 14-61. Finger of glove as Heimlich

{flutter) valve.

h. Fasten tubing to drawsheet with rubber bands and safety pins.

This will allow gravity flow to occur.

14-11 1
FM 8-230

CAUTION

1. Kinking, looping, or pressure on the

drainage tube can produce back pressure,
and possibly force drainage back into the
pleural space, impede drainage from the
pleural space, or cause a tension
pneumothorax.

2. Tubing should not loop or interfere with the

patient's movement.

3. Do not clamp a chest tube unless directed by

and under the supervision of a physician.

i. Allow the patient to assume a comfortable position.

( 1) Encourage good body alignment.

(2) Encourage patient to change positions frequently.

(3) Place a rolled towel under the tubing when the patient is in
the lateral position.

NOTES

1. Often patients are most comfortable in the

Fowler's or semi-Fowler's position.

2. Proper positioning helps breathing and

promotes better air exchange. Pain
medication may be indicated to enhance
comfort and deep breathing.

3. Frequent position change prevents postural

deformity and contractures, as well as
promoting drainage.

4. The rolled towel will protect the tubing from

the weight of the patient's body.

j. Initiate range-of-motion exercises of the arm and shoulder on the

affected side several times daily to help avoid ankylosis (stiff joint) of the
shoulder and assist in lessening postoperative pain and discomfort.

k. "Milk" the tubing in the direction of the drainage bottle on an

HOURLY basis. (See Figure 1 4-62).

l. Insure that there is fluctuation of the fluid level in the long glass
tube.

14-112
 FM 8-230

NOTES

1. Changes in the water level in the tube

i n d i c a t e s t h a t there i s effective
communication between the pleural cavity
and the drainage bottle, provides a visual
indication that the system is operating
properly, and is a gauge of intrapleural
pressure.

2. Changes in the level of fluid i n the tubing

will stop when-

(a) The lung has reexpanded.

(b) The tubing is obstructed by blood clots or

fibrin.

(c) A loop develops.

A B.

Figure 14-62. "Milking" by hand (A) or by

mechanical device (B).

m. Observe for air leaks in the drainage system:

( 1 ) This is indicated by constant bubbling in the underwater-seal

bottle. However, if the system is hooked to a suction device, the underwater­
seal bottle will bubble.

(2) For just a few seconds, clamp the tubing close to the chest
wall if there are any air leaks, but ONLY WHEN ORDERED B Y THE
PHYSICIAN.

14-113
FM 8-230

CAUTION

1. Leaking and trapping air in the pleural

space can result in a tension pneumothorax.

2. If the leak is in the patient and the tube is

clamped for more than a few seconds, air
may back up in the pleural cavity and
extend the patient's pneumothorax.

n. Report excessive bubbling in the water-seal chamber immediately

in accordance with local SOP.

o. Observe for and immediately report the following:

(1) Rapid, shallow breathing.

(2) Cyanosis (bluish skin color).

(3) Complaints of pressure in chest or sharp chest pain.

(4) Subcutaneous emphysema (palpate for " crackling"

sensation).

( 5) Symptoms of hemorrhage.

NOTES

1. Many clinical conditions may cause these

signs and symptoms.

2. Cyanosis results from poor oxygenation of

the circulating blood.

3. When palpating for subcutaneou s

emphysema, the "crackling" sensation may
also be felt.

p Encourage the patient to breathe deeply and cough at frequent

intervals�

( 1 ) Deep breathing and coughing assist in raising the

intrapleural pressure, thus emptying the accumulation in the pleural space
and removing secretions from the tracheobronchial tree, with an expansion of
the lung and prevention of atelectasis (collapsed or airless lung).

(2) If there are signs of incision pain, adequate pain medication is

indicated.

q. Stabilize the drainage bottle on the floor with tape or in a special

holder.

14-114
 FM 8-230

CAUTION

If any part of the apparatus is damaged, the

closed system of drainage will be destroyed
and the patient will be endangered by
atmospheric pressure in the pleural space, with
possible collapse of the lung. The drainage
system must be kept airtight to reestablish
negative intrapleural pressure.

r. If the patient must be transported on a stretcher, place the

drainage bottle below chest level, as close as possible to the floor. The drainage
apparatus must be kept at a level lower than the patient's chest, to prevent
backflow of fluid into the pleural space.

s. Assist physician in removing tube.

(1) Remove tape, dressing, and sutures.

(2) Instruct the patient to perform the Valsalva maneuver

(forcible exhalation against a closed glottis, holding the breath).

(3) Quickly remove the chest tube.

(4) Simultaneously, apply a small bandage made airtight with

petrolatum gauze covered by 4 inch by 4 inch gauze.

(5) Cover thoroughly and seal with adhesive tape.

NOTES

1. The tube i s removed as directed after the

lung has re-expanded (usually from 24 hours
to several days).

2. It is the physician's responsibility to

remove the tubes and apply the dressing
after tube removal.

3. During tube removal, the priorities are

preventing air from entering the pleural
cavity as the tube is withdrawn and
preventing infection.

(6) Dispose of soiled items in accordance with the local SOP.

Nondisposable items should be thoroughly cleaned and stored.

14-92. Indications of a Properly Working Drainage System

a. Observe for moderate bubbling in the suction control chamber of

the Pleur-Evac or bottle system (if the patient is receiving suction or has a
pneumothorax).

(1) I f bubbling stops, check for properly operating suction

apparatus.

14-115
FM 8-230

(2) Excessive bubbling may indicate an air leak in the tubes or

the patient's chest. Notify your supervisor immediately.

b. Observe for water level fluctuation in the water-seal chamber or

Pleur-Evac bottle system, as patient inhales or exhales.

( 1 ) If fluctuation ceases, check for kinked, looped, or wedged

tubes. Look for clots in the tubes. Notify your supervisor if these measures do
not help.

(2) Cessation of fluctuation may mean that the lung has re­
expanded and no longer requires drainage.

14-93. Observations to be Made During Chest Drainage Procedure

a. Observe the following through the plastic connector between the

chest tube and the drainage tube:

(1) Amount of drainage.

(2) Color.

(3) Consistency.

(4) Bloody drainage.

CAUTION

If any bloody drainage in excess of 1 00 ml per

hour is noted, notify your supervisor
IMMEDIATELY.

(5) Maintain up-to-date information on the drainage bottle label.

(6) Check the plastic connector hourly for the first 24 hours after
chest tube insertion and every 8 hours thereafter.

b. Record the following information on the appropriate documents:

(1) Date and time of drainage bottle change.

(2) Amount, type of fluid, and color (example: pinkish; light red;
dark red; or yellowish).

(3) Name of person changing drainage bottle.

(4) Statement indicating drainage specimen was/was not sent to

the laboratory.

14-116
 FM 8-230

C H APT E R 1 5

O B STET R IC A N D GYNECO LO G IC
E M E R G ENC IES

Section I. THE FEMALE REPRODUCTIVE SYSTEM

15-1. General

In this chapter, the basic structures and functions of the female reproductive
system will be discussed, as well as the stages of pregnancy and the
progression of normal labor and delivery.

15-2. Anatomy and Physiology

a. The female reproductive system includes the ovaries, fallopian

tubes, uterus, and vagina. The female reproductive organs are located in the
pelvic cavity. The uterus is situated in the pelvic cavity between the bladder
and the rectum. The bladder orifice, or urethra, is above the vaginal opening.
The rectum and its opening, the anus, is located below the vagina. The vaginal,
urethral, and rectal orifices open into the perineum (Figure 15-1). Any trauma
to the reproductive organs can also cause injury to the bladder, urethra,
rectum, and/or anus because of the close location of these organs to each other.

b. The ovaries, two almond-shaped organs that produce ova (eggs),

are located in the left and right lower quadrants. During reproductive years,
the ovaries release a mature ovum about once a month. Progesterone and
estrogen, the female sex hormones, also are produced by the ovaries. In the
nonpregnant woman, estrogen and progesterone secretions vary each month.
In the pregnant woman, these hormone secretions vary according to the stage
of pregnancy.

(1) Estrogen thickens the lining of the uterus (endometrium),

fallopian tubes, and vagina. In addition, estrogen produces secondary female
sexual characteristics. Estrogen also affects kidney functions. It decreases
sodium chloride which decreases urine output and increases extracellular fluid
volume.

(2) Progesterone can act only on tissues that have been filled by
estrogen. Progesterone prepares the reproductive tract for implantation of a
fertilized egg. It also prepares the breasts for lactation (milk production).

c. The fallopian tubes permit passage of the ova from the ovaries to
the uterus. At their ovarian ends, the fallopian tubes are funnel-shaped and
fringed with small, finger-like structures, which insure that the ova reach the
fallopian tubes from the ovaries. The fallopian tubes are narrower at their
uterine ends.
d. The ovum travels through the fallopian tube into a pear-shaped,
muscular organ called the uterus (womb). In the nonpregnant woman, the
uterus is about 3 inches high, 2 inches wide, and 1 inch thick. It is located
between the bladder and the rectum. In the pregnant woman, the uterus
enlarges and rises upward. By the end of pregnancy, the uterus is
approximately 1 2 inches high, 9 inches wide, and 8 inches thick.

e. The uterus has three layers: the perimetrium, the myometrium,

and the endometrium. The perimetrium is the peritoneal covering of the uterus
that separates it from the abdominal cavity. The myometrium, a thick,

15-1
FM 8-230

muscular wall, forms most of the uterus. The thickness of the endometrium,
the inner lining of the uterus, varies cyclically each month in nonpregnant
women.
f. During the early part of the menstrual cycle, the endometrium
thickens to prepare for ovulation �release of a mature ovum). If the ovum is
fertilized, it will implant in the endometrium and develop into a fetus. If the
ovum is not fertilized, however, the uterus sheds its endometrial lining 1 4 days
after ovulation. A menstrual period, a discharge of bloody fluid from the
uterus, is produced by the shedding of the endometrial lining.

g. During labor and delivery, the fetus and placenta pass through the
cervix and the neck of the uterus, which is fully dilatea at delivery. The cervix
connects the uterus to the vagina. The vagina is a muscular tube leading to the
external genitalia. The vagina serves also as the birth canal during labor and
delivery.

h. The ovaries, fallopian tubes, uterus, and vagina receive blood from
the ovarian, uterine, and vaginal arteries. The blood supply to the internal
reproductive organs is complex and if injured and/or left untreated, bleeding
may be excessive and/or fatal.

. . .'�� . .

VAGINAL O R I F I C E

Figure 15-1. Perineum.

15-2 .
 FM 8-230

i. The external female genitalia include the vulva! structures, the

labia maj ora and the labia minora. The labia maj ora are large, rounded, lateral
skin folds. The labia minora are smaller skin folds that are between the labia
maj ora and vaginal opening and are usually hidden by them.

j. The breasts are secretory glands located on the anterior chest wall.
During pregnancy, estrogen and progesterone act on the.-breasts to prepare
them for lactation following delivery. After delivery, hormones (prolactin and
oxytocin) secreted by the pituitary gland, stimulate the breasts to produce
milk.

Section II. PREGNANCY AND CHILDBIRTH

15-3. General

Pregnancy begins when an ovum unites with a sperm cell that has been
introduced into the female reproductive tract. The union of the ovum and
sperm cell is called fertilization, and occurs in the outer third of the fallopian
tube. The fertilized ovum passes into the uterus and implants in the
endometrium. Implantation usually occurs in the upper part of tne uterus.

a. The fertilized ovum develops into a fetus. The fetus is nourished by

the placenta. The placenta, a special disk-shaped organ, develops during
pregnancy and attaches to the inner wall of the uterus. Oxygen and nutrients
pass from the mother 's bloodstream into the fetal bloodstream through the
placenta. Carbon dioxide and waste products also pass from the fetal blood
vessels into the mother's blood vessels through the placenta. Maternal and
fetal blood vessels are in close contact with the placenta, but the two
bloodstreams do not mix.

b. Fetal blood enters and leaves the placenta through blood vessels
contained in the umbilical cord (Figure 1 5-2). These umbilical blood vessels
enter the fetus through the umbilicus, or navel. Two umbilical arteries carry
unoxygenated blood from the fetus to the placenta. A single umbilical vein
returns oxygenated blood to the fetus. The combined blood flow into the
placenta from the fetal and maternal circulation is large in volume; therefore,
any disturbance to the placenta (example, separation from the uterine wall or
change in position) will cause extensive bleeding and can endanger both the
fetus and the mother. In addition, blood supply to the entire uterus increases
during pregnancy; therefore, uterine injuries also can produce extensive
bleeding.

c. While in the uterus, the fetus is inclosed in the amniotic sac (bag of
waters). This sac contains amniotic fluid in which the fetus floats freely. The
amniotic fluid helps protect the fetus from mechanical inj ury. At the end of
pregnancy, the amniotic sac contains about 1 liter of amniotic fluid. During or
before labor, this sac ruptures, and amniotic fluid flows out through the cervix
and the vagina. This is the "breaking of the waters. " It usually means that
delivery will occur within a few hours. During this time, the baby's head
begins to enter the birth canal (Figure 1 5-3).

15-3
FM 8-230

LUNGS

U M B I L ICAL
ART E R I E S

Figure 15-2. Fetal blood supply. Figure 15-3. Movement of baby through
birth canal.

d. Although it is impossible to determine exactly when fertilization

actually occurs, it is easy to determine when the last menstrual period began.
The date of the last menstrual period will provide an approximate date of
delivery-called the estimated date of confinement. Each 4-week period of
pregnancy is called a lunar month. There are 10 lunar months in a normal
pregnancy. Each 3-month period is called a trimester.

e. During the first 4 weeks of pregnancy (1 st lunar month), the

pregnant woman stops menstruating, her breasts enlarge, and she sleeps more
than usual. Because the pregnant uterus presses on the bladder, she may also
urinate more frequently.

f. From the 5th through the 8th week (2d lunar month) she may
experience nausea and vomiting (morning sickness) in addition to the above
symptoms. In the 9th through 1 2th weeks of pregnancy (3d lunar month), the
uterus can be felt above the symphysis pubis, and urinary frequency returns to
normal. The pregnant woman begins to feel fetal movement between the 1 6th
and 18th weeks (4th lunar month).

g. The fetal heart sounds can be heard after the 1 2-14 week with an
ultrasonic stethoscope and at 20 weeks or 5 months with a fetoscope. By the
end of the 24th week (6th lunar month), the examiner can feel fetal movement.
Figure 1 5-4 shows the location of the top of the uterus at each month of
pregnancy.

15-4
 FM 8-230

A.

c.
5th MONTH

BLADDER
VAGI NA

PUBIS

D. E.
MONTH

PLA C E N T A

Figure 15-4. Fundus uteri at each month of pregnancy.

15-5
FM 8-230

h. During the 37th through 40th week (10th lunar month), the uterus
drops back down as the presenting part descends into the pelvis. The uterus
presses on the bladder and rectum, causing urinary frequency and constipation.

i. Labor is the process by which the uterus expels the fetus, placenta,
and membranes through the birth canal (vagina) by means of uterine
contractions. Labor is divided into three stages and will be discussed later in
this chapter.

j. Before labor begins, the head of the fetus settles into the pelvis.
The cervix then begins to efface (thin). Effacement may be completed before
labor begins or may continue during the first stage of labor.

k. At the beginning of labor, contractions are far apart. As labor

progresses, contractions occur closer together. During the most active stage of
labor, contractions occur every 2 to 3 minutes and last 30 to 45 seconds.

l. The first stage begins with the first uterine contraction and ends
when the cervix is completely effaced and dilated (open). A completely dilated
cervix is about 10 centimeters wide. The first stage lasts about 1 2 hours in a
woman who has previously borne a child. The amniotic sac frequently ruptures
when the cervix is completely expanded. A small amount of blood and mucus
may be expelled from the vagina at the start of labor. This blood and mucus
has formed a plug in the cervix and is called the "bloody show"; it appears as
the cervix (the mouth of the uterus) begins to open.

m. The second stage of labor begins when the cervix is fully dilated
and ends with the birth of the baby. Normally, the head descends first; this
type of delivery is called cephalic (head). If the buttocks descend first, it is
called a breech delivery. During the second stage of labor, the woman will bear
down with each contraction. As the presenting part of the fetus presses on the
rectum, the woman will feel an urge to defecate. The presenting part will
appear and disappear at the vaginal opening between contractions.
Eventually, the presenting part will remain visible between contractions. This
is called crowning (Figure 1 5·5). In a normal delivery, the head will appear first
and the shoulders and trunk soon after. The second stage of labor lasts about
an hour in a woman having a first baby and from 1 5 to 20 minutes in a woman
who has previously borne a child.

n. The third stage of labor is from the birth of the baby to the
complete expulsion of the placenta and membranes. When the placenta
separates from the uterine wall, a small amount of blood gushes out through
the vagina. The placenta and membranes are then expelled from the uterus
and through the vagina by uterine contractions (Figure 1 5·6). The third stage
of labor usually lasts about 1 5 minutes.

15-6
 FM 8-230

15-4. Normal Delivery (Childbirth)

a. Assisting in the birth of a baby is one of the few instances in which

you have the opportunity to participate in a unique situation because you are
dealing with two patients, the mother and the baby, both of whom require
skilled attention.

b. When you arrive at the scene of a woman in labor, you must first
determine whether there is time to transport the patient to the hospital. To
make this decision, you should answer the following questions:

( 1 ) Has the mother had a baby before? Labor during a first

pregnancy is usually slower than in subsequent pregnancies; therefore, there
may be more time for transport during a first labor.

(2) How frequent are the contractions? Contractions more than 5

minutes apart are a good indication that there will be enough time to get the
patient to a nearby hospital. Contractions less than 2 minutes apart, especially
in a multiparous woman (a woman who has had more than one pregnancy)
signal impending delivery.

(3) Has the amniotic sac ruptured and, if so, when? If the sac
ruptures more than 12 hours before birth occurs, the likelihood of fetal
infection is increased, and the hospital staff should be alerted. Furthermore,
delivery may be more difficult when the amniotic sac has ruptured
prematurely because amniotic fluid serves as a lubricant.

(4) Does the mother feel as though she has to move her bowels?
This sensation is caused by the fetal head in the vagina pressing against the
rectum and indicates that delivery is imminent.

Figure 15-5. Crowning. Figure 15-6. Delivery of the placenta.

15-7
FM 8-230

(5) I s the baby's head presenting and visible through the vaginal
opening (crowning)? The mother should be examined to see if this is occurring.
When crowning does occur, the vaginal opening will bulge outward and the
presenting part of the fetus will be visible at the opening (see Figure 15-5).
Crowning indicates that the fetus is about to be born and that there will not be
time to go to the hospital before delivery. The examination is a visual
inspection only. If there is enough time to transport the patient to the
hospital, she should be placed in a reclining position. Any underclothing that
may obstruct delivery should be removed. You should:

• Never allow the mother to go to the toilet.

• Never hold the mother's legs together.

• Never attempt to delay or restrain delivery in any way.

To do so can result in the death of both the mother and the baby.

c. The patient should be positioned on her back and made as

comfortable as possible. Make the environment as clean as possible using a
clean sheet, articles of clothing, and/or newspaper. If available, a folded sheet
drape should be placed under her buttocks. She then should bend her knees
and spread her thighs apart as shown in Figure 1 5-7. As soon as the medical
specialist and the assistant finish positioning the mother, the assistant should
start an intravenous (IV) line of lactated Ringer's solution at TKO (to keep
open) rate. You should move to the mother's head and be prepared to turn it to
the side if she vomits. An oxygen tank and suction apparatus should be
available, if possible.

J I! : 1111 :r ::

Figure 15-7. Mo ther in birth position.

d. Hands should be washed thoroughly before the obstetrical (OB) kit

is opened (if an OB kit is available). Betadine scrub solution should be kept
with the kit for this purpose. The OB kit should be opened and you should put
on sterile gloves. The mother should be draped with four towels so that
everything except the vaginal opening is throughly covered. If the baby is

15-8
 FM 8-230

coming fast, it is more important for you to assist in the delivery than to put
on drapes or gloves. You should encourage the mother to relax and to take
slow, deep breaths through her mouth and should continue to reassure her and
explain everything that is being done.

e. Your role is to assist the mother in the delivery. You do not

actually deliver the baby or pull the baby out. The baby is born with the
assistance of the mother; you guide it and support it as it passes through the
vagina (birth canal) and is born.

f When the baby's head begins to emerge from the vagina, it should
be supported gently to prevent explosive delivery. The head is the largest part
of the baby's body; once the head is born, the rest will come out almost
spontaneously. This procedure is illustrated in Figure 15-8.

Figure 15-8. Support baby 's head at birth.

g. You should never attempt to pull the baby from the vagina. If the
membranes cover the head after it emerges, the amniotic sac should be torn
with fingers or forceps and removed from the infant's face to permit the
amniotic fluid to escape, enabling the infant to breathe.

CAUTION

ANY INSTRUMENT TO TEAR THE

AMNIOTIC SAC SHOULD BE USED
WITH EXTREME CARE.

h. You must be sure the umbilical cord is not wrapped around the
infant's neck; if so, it should be slipped gently over the shoulder or head as
illustrated in Figure 15-9.

15-9
FM 8-230

Figure 15-9. Slipping cord over baby 's head.

i. If this maneuver fails and the cord is still wrapped tightly around
the baby 's neck, umbilical clamps (or tie off with a string) should be placed
rapidly on the cord 2 inches apart and the cord should be cut between the
clamp or string to release pressure from the infant's neck (Figure 1 5-10).

Figure 15-10. Cutting the cord.

15-10
 FM 8-230

j. Continue to support the head as the shoulders emerge (Figure

1 5- 1 1 ) .

Figure 15-11. Supporting the head as shoulders emerge.

k. The shoulders and body should be delivered as shown in Figures

1 5- 1 2A and 1 5- 1 2B. You should avoid touching the mother's anus during
delivery.

Figure 15-12A. Assisting in delivery of shoulders.

15-1 1
FM 8-230

Figure 15-12B. Assisting in delivery of shoulders.

l. The time of birth should be recorded.

m. After the baby is fully delivered, it should be supported along the

length of your arm, with one arm and shoulder supported by your cupped
fingers. The infant's head should be held downward to aid in drainage (see
Figure 1 5-13). Wrap the baby in a clean blanket, article of clothing, or
newspaper to keep the infant warm. It is essential to prevent heat loss from
the infant.

Figure 15-13. Pos t-delivery action.

n. Newborn infants must be held carefully because they are slippery.

Blood and mucus from the nose and mouth should be wiped away with a piece
of sterile gauze. The mouth and both nostrils should be suctioned with a bulb
aspirator. You should squeeze the bulb before inserting the tip of the aspirator
and then place the tip in the mouth or nostrils and release the bulb slowly. This
procedure is illustrated in Figure 15-13. Clear the bulb syringe of its contents
and repeat suctioning the infant as often as needed.

15-12
 FM 8-230

o. If the baby does not breathe spontaneously, you should stimulate

the infant by rubbing the back gently or slapping the sole of the feet. If there is
still no response, you should start mouth-to-mouth or mouth-to-nose
resuscitation, remembering that newborn infants are very little and require
very small puffs of air. Mechanical resuscitation devices should never be used
on a newborn infant. If spontaneous breathing begins, 5 liters of oxygen (Oi)
should be administered by mask for a few minutes until the baby's color is
pink. If breathing is still absent, however, and no precordial (atrium) pulse can
be determined with the stethoscope, cardiac compression should be started
and cardiopulmonary resuscitation (CPR) should be continued en route to the
medical treatment facility (MTF). The baby should be kept wrapped in a
blanket as much as possible.

15-5. Care of the Umbilical Cord

a. If the infant has been delivered normally and is breathing well, the
cord should be clamped about 6 inches from the infant's navel with two clamps
set 3 inches apart as shown in Figure 1 5-14.

Figure 15-14. Tying off the umbilical cord.

b. I f clamps are unavailable, two umbilical ties can be substituted.

The cord should be cut between the two ties and handled gently because it will
tear easily. The end of the cord that is attached to the infant must be examined
to be certain there is no bleeding. If there is bleeding from the cut end, the cord
nearest the clamp should be tied and re-examined. The baby should then be
wrapped in a sterile blanket to maintain body temperature.

15-6. The Placenta

a. The third stage of labor is the delivery of the placenta and

membranes (afterbirth). One individual should stand at the mother's head and
keep an eye on the infant, while you tend to the delivery of the placenta. The
placenta usually is delivered spontaneously within 1 5 to 30 minutes after the
infant's birth (Figure 1 5-6).

15-13
FM 8-230

b. Bleeding can be expected as the placenta separates from the

uterine wall. When vaginal bleeding occurs, the uterus should be gently
massaged as shown in Figure 15-15. The uterine massage will stimulate the
uterus to contract, thus constricting blood vessels within its walls and
decreasing bleeding. Allowing the infant to nurse following the delivery of the
placenta will control bleeding because nursing stimulates the release of
oxytocin. Oxytocin, in addition to causing milk ej ection, stimulates uterine
contraction which constricts uterine blood vessels.

c. You should never pull the umbilical cord to deliver the placenta.
Pulling can invert the uterus (cause it to turn inside out). When the placenta is
delivered, it should be placed in a basin, towel, or plastic bag and taken to the
medical treatment facility where it will be examined for completeness. This
procedure is necessary because pieces of placenta retained in the uterus cause
persistent bleeding.

d. The perineum (the skin between the anus and the vagina) should be
examined for lacerations, and pressure applied to any bleeding tears with a
sanitary napkin. A sanitary napkin should be placed over the vagina and the
mother's legs lowered; she then should be prepared for transport to a medical
treatment facility. If the physician orders it, an IV line of lactated Ringer's
solution may be started. Ten units of oxytocin (Pitocin) may be added to the
IV solution and administered at the prescribed rate of flow.

e. If the placenta is not delivered within 15 to 30 minutes after

the baby is delivered, the mother and baby should be transported without
delay to a medical treatment facility so a physician can remove it. If the
placenta does not deliver and there is heavy bleeding, do not wait at all, but
transport the mother and baby immediately.

f If the mother is hemorrhaging, do the following things during

transport:

(1) Place the mother in the shock position with the legs elevated
and keep her warm.

(2) Give oxygen (0 2 ), if available.

(3) Place a sterile pad (sanitary napkin) over the vaginal opening.
DO NOT put anything into the vagina.

(4) Gently massage the mother's lower abdomen as shown in

Figure 15-15 to cause the uterus to contract and expel the placenta. You will
feel a grapefruit-sized obj ect, which is the uterus. DO NOT push the uterus
toward the vagina, but rub it with a light circular motion. You will be able to
feel it contract and become firm.

(5) I f the baby is in good condition, place the baby at the

mother's breast to encourage it to nurse. Breast stimulation will help the
uterus to contract and thereby reduce bleeding.

15-14
 FM 8-230

g. Normally, after the placenta and membranes are expelled, there is

a loss of about V2 pint of blood. Always take the placenta to the medical
treatment facility for a doctor to examine so that he can be sure none of it is
left in the uterus. Even a small part of it retained in the uterus can cause
continued bleeding and infection.

h. After the placenta and membranes are expelled, put a sterile pad
over the vaginal opening. Lower the mother's legs and support them together.
Normally, nothing more will be passed from the vagina. Care should be taken
to insure the mother, baby, and placenta arrive at the medical treatment
facility safely.

Figure 15-15. Massaging the uterus.

15-7. Complications of Delivery

a. Three types of problems that can accompany delivery will be

discussed in this section:

• Postpartum hemorrhage.

• Uterine inversion.

• Pulmonary embolism.

You should be prepared to treat each of these situations as it occurs.

15-15
FM 8-230

b. Postpartum hemorrhage occurs after delivery and is characterized

by internal or external bleeding.

(1) Internal bleeding may b e caused by-

• Retained placental tissue.

• Inadequate uterine contractions.

• Clotting disorders.

If bleeding is severe, uterine massage as shown in Figure 15-1 5 should be

continued and the baby should be allowed to nurse. You can add 10 units of
oxytocin (Pitocin) to the IV solution of lactated Ringer's and administer at the
prescribed rate of flow. If bleeding persists, the circulation can be supported
with an IV line of normal saline, lactated Ringer's solution, or plasma
derivative. The patient should be transported rapidly to a medical treatment
facility and the usual measures for shock should be applied. Vaginal
examination or blind packing of the vagina should be avoided. Gentle uterine
massage should be continued en route to the hospital.

(2) External bleeding is bleeding from perineal tears and can be

managed with firm pressure. It may be essential to open the labia to apply
packs to the bleeding site.

c. Inversion or turning inside out of the uterus can occur as a result

of excessive pressure on the uterus or from pulling on the umbilical cord in an
effort to deliver the placenta. Shock commonly accompanies uterine inversion.
Should this condition occur in the field, you should perform the following
procedures:

(1) Keep patient flat.

(2) Administer oxygen (02 ), if available.

(3) Start two IV lines with Ringer's solution or colloid, running

them as fast as necessary to maintain blood pressure (B/P).

(4) Never try to remove the placenta if it is still attached. Try

once to replace the uterus manually by exerting pressure first on the area
closest to the cervix. If the uterus cannot be replaced easily, pack all
protruding tissues lightly with moist, sterile towels, and move the patient
rapidly to a medical treatment facility.

d. Sudden dyspnea, trachypnea, trachycardia, and/or hypotension in

the deliverying or delivered mother can signal pulmonary embolism, either
from a blood clot or from amniotic fluid. Field treatment is the same as for any
patient with pulmonary embolism and includes administration of oxygen,
electrocardiogram monitoring, and rapid transport to a medical treatment
facility.

15-16
 FM 8-230

15-8. Abnormal Deliveries

Deliveries in which the fetal head does not present first are classified as
abnormal deliveries. Three abnormal presentations will be discussed in this
section.

• Breech presentation.

• Prolapsed umbilical cord.

• Limb presentation.

These three situations can be potentially life threatening to the infant and you
should become familiar with the special problems of each emergency situation.

a. Breech Presentation. Breech presentation occurs when the

buttocks rather than the head present first. Breech delivery is not simple. If
delivery is imminent, the mother should be prepared as discussed earlier and
the buttocks and trunk of the baby should be allowed to deliver spontaneously
(Figure 1 5-16). Once the legs are clear, the baby's body should be supported on
the palm of the hand and the anterior surface of the arm, thus allowing the
head to deliver. If the head is not delivered within 3 minutes, action must be
taken to prevent suffocation of the baby. Suffocation can occur when the
baby's face is pressed against the vaginal wall or when the umbilical cord is
compressed by the baby's head in the vagina. To establish an airway for the
baby, you should-

(1) Place a gloved hand in the vagina, positioning the palm

toward the baby's face.

(2) Form a "V" with the fingers on either side of the baby's
nose.

(3) Push the vaginal wall away from the baby's face until the
head is delivered.

(4) To relieve pressure on the umbilical cord, use one of the

techniques listed below:

(a) Place the patient in a Trendelenburg (supine) position.

(b) Place a gloved hand inside the vagina with fingers

separated and allow the cord to pass through the opening created by the
fingers between the cervical side wall and the baby's head.

(5) Never try to pull the baby out of the vagina or allow an
explosive delivery. If the head DOES NOT deliver within 3 minutes after an
airway has been established, the mother should be placed in a supine position
and transported immediately to the nearest medical treatment facility. The
baby 's airway should be maintained throughout transport.

15-17
FM 8-230

Figure 15-16. Breech presentation.

b. Prolapsed Umbilical Cord. Prolapsed umbilical cord occurs when

the cord comes out of the vagina before the baby as shown in Figure 1 5- 1 7 . The
baby is in danger of suffocation; therefore, you should do the following:

(1) Immediately place the mother into Trendelenburg's or knee­

chest position.

(2) Administer oxygen to the mother, if available.

(3) Keep the mother warm.

(4) With the gloved hand in the vagina, gently elevate the baby's
head or presenting part to relieve pressure on the cord. Once this is done, do
not withdraw your hand. You must keep pressure off the cord until delivery of
the baby (see Figure 1 5-18).

(5) NE VER attempt to push the cord back, or reposition the

cord.

15-18
 FM 8-230

(6) Transport the mother and the baby to the hospital at once
while elevating the baby's head. The pressure should be evenly distributed to
avoid injury to the baby's soft skull.

Figure 15-1 7. Prolapsed umbilical cord.

Figure 15-18. Initial corrective action-prolapsed cord.

NOTE

Breech presentation and prolapsed umbilical

cord are the only two circumstances in which
the medical specialist should place his hand in
the mother's vagina.

15-19
FM 8-230

c. Limb Presentation. The presentation of an arm or leg through the

vagina is an indication for immediate transport to the nearest medical
treatment facility-the only place where such a delivery should be attempted.

15-9. Multiple Births

Multiple births usually do not present any unique problems. Twins are
delivered in the same manner as single babies. Twins should be expected if the
mother's abdomen appears unusually large, or if it remains large after the first
baby is delivered. I f twins are expected, the mother should be transported to
the nearest medical treatment facility as rapidly as possible consistent with
the mother's safety. The cord should be tied to prevent hemorrhage from the
twins after the first baby is born. The mother should be transported to the
nearest medical treatment facility for the delivery of the second twin if the
second baby is not delivered within 10 minutes of the first. Twins are usually
smaller than single births, like premature infants, and need special protection
against a fall in body temperature. It is very important that the twins be kept
warm during transport to the nearest medical treatment facility.

15-10. Premature Birthb

a. Premature birth is defined as any baby born after 1 9 weeks but

before 37 weeks of pregnancy. Low birth weight infants weigh less than 5.5
pounds (2.500 grams) and may also be premature. Premature births need
special care. Birth weight alone is not an adequate definition for prematurity
because low birth weight infants may be fully mature. Premature babies may
be over 5.5 pounds (2,500 grams) if they are edematous, or if the mothers are
diabetic. To distinguish premature from mature infants, you should observe
the creases on the soles of the baby's feet, the breast size, type of scalp hair,
and presence or absence of cartilage in their outer ears. Premature infants
develop problems because they are so small and their organs are immature.
Premature infants have trouble maintaining a normal body temperature
because they have more surface area relative to their size than older infants
and, therefore, lose heat more rapidly in a cool environment; they also
have less subcutaneous fat to insulate them against heat loss.

b. Small blood losses are also more serious in premature infants

because of their small size. The 5.5 pound infant has a total blood volume of
about 275 milliliters (ml). Therefore, 30 ml blood loss represents 1 0 percent of
the infant's total blood volume.

c. Premature infants often develop respiratory problems because

their lungs are immature. Alveoli and alveolar capillaries begin developing at
28 weeks gestation. Surfactant, which lowers alveolar surface tension and
allows even expansion of the alveoli, develops at about 28 weeks gestation.

d. Hypoxemia due to respiratory problems leads to cardiovascular

problems in the premature infant. Before birth, blood is shunted past the lungs
and oxygenated in the placenta. After birth, special mechanisms change the
blood flow pattern so that blood is oxygenated in the lungs. These special
mechanisms, however, depend on adequate oxygenation of the blood by the
lungs. When oxygenation is inadequate because of lung immaturity, blood
continues to be shunted past the lungs. This worsens the hypoxemia.

15-20
 FM 8-230

Hypoxemia, because of respiratory and cardiovascular problems, produces

cyanosis and leads to bradycardia and hypotension. Bradycardia in newborn
' infants is a heart rate less than 1 00 beats per minute.

e. The premature infant also does not tolerate asphyxia that

normally occurs during labor and delivery as well as the full term infant. The
mature infant survives some asphyxia during labor and delivery by
metabolizing liver and heart glycogen stores. The premature infant has less
stored glycogen and, therefore, is less able to tolerate asphyxia.

f. To manage the premature infant, you should-

( 1 ) Keep the baby warm; wrap the baby in aluminum foil and
blankets to reduce heat loss (Figure 1 5-19).

(2) Keep the baby's mouth and nose clear of fluid with a bulb
syringe.

(3) Prevent bleeding from the umbilical cord because these

infants cannot tolerate the loss of even small amounts of blood.

(4) Give oxygen (if available) into a tent constructed from

aluminum foil above the infant's head. DO NOT BLAST it directly into the
infant 's face.

(5) Prevent contamination because premature infants are highly

susceptible to infection.

Figure 15-19. Premature infants need special care.

15-21
FM 8-230

15-11. APGAR Scoring

It is essential for the newborn to be completely evaluated immediately after

birth to determine adequacy of vital function. The scoring system is based on
heart rate, respiratory effort, muscle tone, reflect irritability, and color. Sixty
seconds after the birth of the infant, these five signs are evaluated and each
given a score of 0, 1 , or 2. When added together, numerical ratings yield a total
score of 10. The total score of 10 indicates that the infant is in excellent
condition. The majority of infants are vigorous and have a total score of 7 to
10; they cough or cry within seconds of delivery and require no further
resuscitation. Infants with a score in the 4 to 6 range are moderately
depressed. They may be pale or blue 1 minute after delivery with poorly
sustained respiration and flaccid muscle tone. Such infants will require some
form of resuscitation. In the APGAR scoring, the five signs to be evaluated are
most easily remembered by using the acronym APGAR as shown in Table
15-1.
Table 15-1. APGAR Scoring System

Score (points given according to status)

Clinical Signs 0 1 2

A- Appearance Blue, pale Body pink, Completely pink

(color) extremities
blue

P- Pulse Absent Slow or less Greater than

(heart rate) than 1 00 beats 100 beats per
per minute minute

G- Grimace No response Grimace Cough or sneeze

(reflex reflex
irritability) irritability)

A- Activity Limp Some flexion Active motion

(muscle tone) of extremities

R- Respiration Absent Slow, irregular Good crying

(respiratory
effort)

15-12. Delivery Without Sterile Supplies

At times it is necessary to assist a patient in delivering a baby when proper

equipment and supplies are not available. The technique described below will
be useful under those circumstances.

a. Place the mother on a firm surface on her back as shown in Figure

1 5-7, with her knees up, her feet flat on the surface, and her legs spread apart.
The mother's head and shoulders should be propped up with one or two
pillows. Lift the buttocks about 2 inches above the table surface by placing a
pad (newspaper, sheets, or blankets) under the buttocks.

15-22
 FM 8-230

b. Clean sheets and towels which have not been used since previous
laundering are safe and may be used for preparing the patient. Sheets and
newspaper should be spread around the delivery area to help mop up the large
quantities of amniotic fluid that will be released during birth.

c. Your hands should be washed as thoroughly as possible. Conduct

the delivery of the baby as if gloves were available. As soon as the baby is
born, turn the head to one side and use a clean finger to finger sweep (wipe) out
the baby's mouth, taking precaution not to induce vomiting (Figure 1 5-20).

d. DO NOT tie or clamp the cord with string, shoelaces, or the like,
and DO NOT CUT THE CORD. Keep the baby at the side of the mother's
buttocks at the same level or below the entrance of her vagina but out of the
pool of amniotic fluid and blood. As soon as the placenta is delivered, wrap it in
newspaper or a towel, leave it attached to the baby, and place it with the baby
who can now be moved. The placenta always should be slightly above the
baby. This can be accomplished by placing it on folded blankets or towels
stacked beside the infant. The mother, baby, and the placenta can now be
transported as safely and as rapidly as possible to the nearest MTF.

e. The baby must be kept warm. If necessary, wrap it in an article of

clothing or whatever is available. In case of hemorrhage by the mother, the
baby should be put to the breast and the uterus gently massaged as described
in Figure 15-15.

Figure 15-20. Finger sweep.

Section III. PATHOPHYSIOLOGY AND MANAGEMENT

OF GYNECOLOGIC EMERGENCIES

15-13. General

In general, there is little that you can do to treat gynecologic emergencies in a

field environment. Most common gynecologic emergencies require the
attention of a physician or the use of specialized treatment resources not found
in the aid bag or emergency vehicle. However, you can greatly aid the
physician and the hospital staff by obtaining an adequate history from the
patient.

15-23
FM 8-230

15-14. Abdominal Pain

A gynecologic problem, that is, a problem related to the female reproductive

organs, should be suspected in any woman who complains about abdominal
pain. The following questions should be asked to obtain information necessary
for possible treatment.

a. When was the patient 's last menstrual period? Was it unusual in
any way? Has she had any bleeding between menstrual periods or bleeding
following menopause?

b. Has she missed a menstrual period? Does she use any form of
contraception? Could she be pregnant?

c. Has she had any vaginal discharge? What color was it? Was it foul
smelling?

d. Where is the pain located? What is it like (sharp, dull, constant,

intermittent)? What makes it better? What makes it worse? Is it made worse
by sexual intercourse? How long has it been between the onset of the pain and
the last menstrual period?

e. Pelvic inflammatory disease (PID) often results from gonorrhea

and is one of the most common sources of abdominal pain in women. The pain
is localized to one of the lower quadrants. It may spread to the right shoulder
and is often quite severe. In many cases, the pain begins about the time of the
menstrual period. It may be accompanied by fever and vomiting. The pain
frequently is worsened by sexual intercourse. The patient usually complains of
moderate to heavy vaginal discharge. The patient's recent menstrual history
is often characterized by missed periods and by bleeding between periods.

f Physical examination often reveals a very ill-appearing patient. In

general, blood pressure is normal and pulse is elevated. Fever may be present.
Palpating the abdomen causes moderate to extreme pain and should be done
very gently. No treatment in the field is necessary for patients with PID. Such
patients should be made comfortable in whatever position they prefer and
transported gently to the hospital.

g. Other possible sources of abdominal pain in women include ectopic

pregnancy (that is, the fetus growing in a location outside of the uterus, for
example, in the fallopian tube), ruptured ovarian cyst, and nongynecologic
causes such as appendicitis and cystitis (bladder inflammation).
Differentiating these conditions in the field is not vitally important, because
management for the most part consists of support and transportation of the
patient. Ectopic pregnancies, however, must be distinguished from other
causes of abdominal pain as they can lead to hypovolemic shock. Recognition
and treatment of ruptured ectopic pregnancies are discussed in paragraph
15-19 below.

15-15. Vaginal Bleeding

a. Vaginal Bleeding with No History of Trauma. In questioning a

patient who complains of vaginal bleeding, it is important for you to try to
estimate the amount of blood lost. What may seem like an alarming amount to
the patient may be clinically insignificant. The patient should be asked how

15-24
 FM 8-230

long she has been bleeding and how many sanitary napkins and/or tampons
she has used. You should determine whether the bleeding has been heavier or
lighter than during a normal menstrual period, as well as what the patient has
used to absorb the blood (towels generally soak up less blood than a sanitary
napkin). Blood loss can be assessed further in the physical examination by
checking for variations in pulse rate because of change in posture. An increase
in pulse rate of more than 20 beats per minute when the patient goes from a
supine to a sitting position suggests blood loss greater than one unit. If this
finding is positive, you should treat the patient like any other patient in
impending shock by:

• Administering oxygen (if available).

• Placing the patient supine with the legs slightly elevated.

• Starting an IV line with lactated Ringer's solution and

infusing it rapidly.

• Closely monitoring the vital signs en route to the hospital.

b. Vaginal Bleeding Accompanied by Genital Trauma. Rape or other

trauma may result in lacerations of the external female genitalia. Lacerations
may be accompanied by heavy bleeding. Usually this bleeding can be
controlled simply by applying external pressure over the laceration. Bleeding
from the internal genitalia can be massive. It is both useless and dangerous to
introduce packs blindly into the vagina in an attempt to control the bleeding.
A pack should be used only if bleeding is life threatening, in which case a
sterile towel or sterile 2-inch gauze tape should be packed tightly into the
vagina. The Military Anti-Shock Trousers (MAST) apparatus will probably
not help control bleeding from the internal genitalia but will provide an
autotransfusion effect of approximately two units and should, therefore, be
applied. In a case of massive hemorrhage, the patient with severe vaginal
bleeding needs at least one and preferably two or three IV lines for rapid
infusion of lactated Ringer's solution, or a plasma derivative. Other standard
measures for shock can be applied. Vital signs must be monitored minute by
minute, and transportation to the hospital should be rapid.

Section IV. MANAGEMENT OF OBSTETRIC

EMERGENCIES

15-16. General

a. Emergency obstetrics situations in which you will be likely to

become involved include normal labor and delivery, complications of labor and
delivery, and conditions that can be life threatening to the pregnant woman or
to the fetus before labor.

b. Serious medical problems that the pregnant woman may

encounter before labor are termed antepartum complications. In this section,
several antepartum complications are discussed, including hemorrhage,
supine hypotensive syndrome, and toxemia.

15-25
FM 8-230

15-17. Antepartum Hemorrhage Complications

Hemorrhage complications occurring before delivery are classified as

antepartum complications. Five antepartum hemorrhage conditions are
discussed in this section: abortion, ectopic pregnancy, abruptio placentae,
placenta previa, and uterine rupture.

15-18. Abortion

Abortion is defined as loss of pregnancy before the 20th week of gestation (the
20th week of fetal growth). It often is referred to as a "miscarriage. "
Abortions can occur spontaneously or can be induced. Induced abortions
performed under sterile conditions in authorized medical settings are termed
therapeutic abortions. Abortions that occur naturally fall into one of the four
categories discussed below.

a. Threatened Abortion (Figure 15-21A). Signs and symptoms of

threatened abortion include vaginal bleeding, pain resembling menstrual
cramps, and, occasionally, dilation of the cervix. This condition can progress
to complete abortion, or may subside and the pregnancy may continue. A
woman with a threatened abortion should be evaluated at the hospital. The
treatment is bedrest.

b. Inevitable A bortion (Figure 15-21B). An abortion that cannot be

prevented is termed an inevitable abortion. Signs of an impending abortion
include vaginal bleeding (which can be very heavy), uterine contractions, and
cervical dilation. For a patient with such symptoms, you should start an IV
line with lactated Ringer's solution. The patient should be transported to the
hospital as quickly as possible.

c. Incomplete A bortion (Figure 15-21 C). An incomplete abortion

occurs when part of the fetus is expelled and a portion of the products of
conception remain within the uterus. This situation causes hemorrhage and
continued cervical dilation. The patient should be treated for shock if it is
present. Products of conception protruding from the cervix should be gently
removed to prevent sepsis. You should consult a physician for instruction in
treating a patient with an incomplete abortion.
'

d. Missed A bortion (Figure 15-21D). In a missecf abortion, the fetus

dies before 20 weeks gestation but is retained in the uterus for at least 2
months after death. When the uterus hardens, fetal heart sounds are no longer
present. The patient with a missed abortion should be taken to the hospital for
further treatment.

15-26
 FM 8-230

A. B.
T H R EATE N ED I N E V I TABLE

CERVIX C LOSED �
CERVIX E F FAC E D

M I N IMAL B L E ED I N G
;::��/
?
�//
AND D I LAT E D --�

c. D.

I N COM P L E T E M I SSED

F E T U S DEAD

RETA I N ED AND MAC E RA TED

PLACE NT AL TISSUE

Figure 15-21. Types of abortion.

15-19. Ectopic Pregnancy

a. The fertilized ovum may implant abnormally in the fallopian tube,

ovary, or abdomen, rather than in the uterus. Implantation in the fallopian
tube (tubal pregnancy) is far more common than implantation in either the
ovary or the abdomen ( such a condition is very rare). Ectopic pregnancy is also
10 times more frequent in women who become pregnant with an intrauterine
device (IUD) in place.

b. Fertilization normally occurs in the fallopian tubes. In a tubal

pregnancy, the fertilized ovum fails to travel into the uterus and is implanted
in the fallopian tube as shown in Figure 1 5-22. Abnormalities of either the
ovum or the fallopian tubes can prevent the ovum from reaching the uterus.

c. When the fertilized ovum implants in the muscular layer of the

fallopian tube, it invades maternal blood vessels. The fallopian tube does not
enlarge as the fetus grows, and the tube eventually ruptures. This rupture may
be either internal in the tube lumen or external in the abdominal cavity, and
the resulting blood loss may be entirely hidden.

d. The patient with a ruptured tubal pregnancy may complain of

severe pain localized to one lower quadrant. She may have vaginal bleeding. If
blood enters the abdominal cavity, it will irritate the peritoneum and cause
fever. The accumulated blood produces a mass that is tender to palpation.

15-27
FM 8-230

e. As blood loss continues, hypovolemic shock develops. The pulse

becomes rapid and the skin becomes pale, cold, and moist. When the body can
no longer compensate for the decreased blood volume, the blood pressure falls.
Hypovolemic shock due to ruptured ectopic pregnancy should be treated in the
same way as hypovolemic shock due to other causes. To treat this type of
shock in a pregnant patient, you should:

• Administer oxygen (if available).

• Support ventilation, if necessary.

• Take vital signs.

• Apply and inflate the MAST. (Do not inflate abdominal

section. )

• Start two or more large-bore (1 4- to 16-gauge needles) IV lines,

and then rapidly infuse lactated Ringer's solution.

• Place the patient in a supine position with her feet elevated 30°
(no higher than 12 inches).

• Keep the patient warm.

• Monitor state of consciousness, pulse, and blood pressure

during transport.

O V UM

Figure 15-22. Tubal pregnancy.

15-20. Abruptio Placentae

Abruptio placentae occurs when a normally implanted placenta separates

prematurely from the uterine wall during the last trimester of pregnancy. The
patient experiences severe lower abdominal pain and the uterus becomes rigid.
Shock may be more severe than the apparent blood loss would seem to
indicate. Figure 15-23 shows the baby and abruptio placentae.

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 FM 8-230

UT E R I N E
WALL

AMNIOTIC
SAC

Figure 15-23. Baby and abruptio placentae.

15-21. Placenta Previa

Placenta previa is a condition in which the placenta-rather than the baby-is

the presenting part. This condition occurs in the third trimester. Again,
hemorrhage may be severe from the highly vascular placental tissue. Pain is
frequently absent in this disorder. Figure 1 5-24 shows the baby and placenta
previa.

15-22. Uterine Rupture

a. Uterine rupture is manifested by sudden, severe abdominal pain.

Bleeding may not be apparent externally, but profound shock can occur from
internal hemorrhage.

b. To treat the patient for shock, you should:

(1) Place the patient horizontally on a stretcher, preferably on

her left side.

(2) Administer oxygen (if available).

(3) Apply the MAST to produce autotransfusion. (Do not inflate

abdominal section.)

(4) Start at least two large-bore IV lines, and administer 5

percent dextrose in normal saline (D5NS), 5 percent dextrose in lactated
Ringer's solution, or a plasma derivative as rapidly as needed to maintain
blood pressure.

(5) Transport the patient to the hospital.

15-29
FM 8-230

Figure 15-24. Baby and placenta previa.

15-23. Other Antepartum Conditions

You may also encounter other serious antepartum conditions such as supine
hypotensive syndrome and toxemia.

a. Supine Hypotensive Syndrome. The pregnant woman near term

has a large, heavy mass in her abdomen. When she is supine, this mass, which
includes the weight of the uterus, fetus, and placenta, tends to compress the
inferior vena cava. Venous return to the heart is thereby reduced and, as a
result, cardiac efficiency decreases. These changes are especially pronounced
when the mother's vascular volume is low to begin with, such as in antepartum
hemorrhage. When a pregnant patient near term who is hypotensive or
complains of dizziness is encountered, she should be placed on her left side.
Severe hypotension indicates a possibility of significant internal hemorrhage.
Severe hypotension should be treated like hypovolemic shock as discussed
above.
b. Toxemia of Pregnancy. Toxemia of pregnancy has two stages,
preeclampsia and eclampsia. Preeclampsia is characterized by hypertension
(blood pressure greater than 140/90), proteinuria (protein in the urine), and
edema during the last 3 months of pregnancy. Eclampsia follows preeclampsia
and includes convulsions and coma in addition to the signs of preeclampsia.

(1) In preeclampsia, renal blood flow and glomerular filtration

are below the normal level for pregnant women. Thus, urine output and sodium
excretion decrease. This condition increases extracellular fluid volume and
produces edema in the ankles, fingers, and face. Other symptoms of
preeclampsia are headache, midupper quadrant abdominal pain, and blurred
vision. Elevated blood pressure and edema, however, are necessary for a

15-30
 FM 8-230

diagnosis of preeclampsia. You, therefore, should report the blood pressure

and the presence or absence of edema in every pregnant woman examined. The
patient with preeclampsia should be evaluated by a physician in the
emergency department for possible hospitalization. When transporting the
patient, you should remember to be prepared to treat preeclampsia, because it
can progress to eclampsia with convulsions and coma.

(2) Eclampsia can occur before, during, or after labor. It begins

with convulsions that are usually followed by coma.

(a) The eclamptic patient, like the preeclamptic patient, has

pronounced hypertension and edema. Her urine will be scant and bloody. She
also may show signs and symptoms of pulmonary edema.

(b) Although the physician should be contacted for specific

directions in treating eclampsia, you can do the following:

1. Establish and maintain an airway; administer

oxygen (if available).

2. Start an IV line with D5W to keep open. DO NOT

USE normal saline or lactated Ringer's solution, as they will increase the fluid
overload.

3. Transport the patient to the hospital as soon as

possible.

NOTE

In antepartum hemorrhage of any kind, you

should not attempt to examine the patient
internally.

Section V. THE RAPE VICTIM

15-24. General

Rape presents a difficult and complex problem, involving physical and

emotional trauma as well as possible legal ramifications. It is essential that a
complete history be obtained from the rape victim. In questioning the patient,
you must use tact and sensitivity. The patient may find it extremely difficult
to discuss what has happened and may fear or feel hostile toward a male
medical specialist. A FEMALE CHAPERONE SHOULD AL WA YS BE PRESENT
DURING AN EXAMINA TION OF A FEMALE PA TIENT. Every effort should be
made to understand the patient's feelings and to respond with kindness and
reassurance. The emotional trauma of rape is usually more prolonged and
severe than the physical trauma. The attitude shown toward the patient
during her care can have a serious influence on her future psychological and
physical recovery.

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FM 8-230

15-25. Clinical Procedures

a. A primary assessment should be conducted of the rape victim. You

should observe whether the patient's clothes are torn or in disarray. You also
should check for trauma elsewhere on the patient's body, especially around the
thighs, lower abdomen, and buttocks. If vaginal bleeding is significant, it
should be treated as outlined in paragraph 15-15.

b. The report you submit should state only what the patient said, not
what you observed. Your personal opinion should not be included in the report.
Every rape is a potential court case, and the report is a legal document.
Therefore, you should be thorough and accurate.

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C HAPT E R 1 6

FIE LD SANITATION

Section I. INTRODUCTION

16-1. General

a. This chapter provides information and instruction in the

employment of established, practical measures designed to prevent disease
and preserve the health of troops under field conditions.

b. Manpower is the Army's most valuable asset. Everything possible

must be done to conserve this asset. In recent wars, more deaths resulted from
disease than from enemy action. During the Civil War, a total of 1 99,720
soldiers died from disease compared to 1 38,154 battlefield deaths. Records of
World War II, the Korean, Lebanese, and Vietman conflicts show 15,828,940
disease casualties as opposed to 640,254 combat casualties.

c. The control or prevention of disease is the responsibility of every

soldier. By practicing proper personal hygiene, food and water sanitation,
waste disposal, and insect and rodent control, the potential for disease can be
kept to a minimum.

16-2. Command Emphasis

a. The commander of a military organization is responsible for the

health of his command. In fulfilling this responsibility, he is assisted by a staff
of medical personnel. Using the technical advice and guidance of these
individuals, he issues orders and enforces measures that will most effectively
maintain sanitation and protective practices conducive to the health and well­
being of his troops. The maintenance of their health and, consequently, their
fighting efficiency is one of his greatest responsibilities.

b. To provide a healthy field environment for the troops, the

company, battery, or detachment commander appoints a field sanitation team
and arranges for the team members' training that they need to accomplish
their duties (AR 40-5). The duties include instructing, supervising, inspecting,
and reporting, as applicable, to insure that field sanitation facilities are
established and maintained, and effective hygiene and sanitation measures are
practiced by troops.

16-3. Medical Specialist

The medical specialist may be, and in many situations is, the key medical
advisor to the commander. You must know the basic elements of hygiene and
sanitation to effectively advise the commander.

16-1
FM 8-230

Section II. DRINKING WATER TREATMENT

16-4. General

a. Isolated units may not be able to obtain water from established

water points. In this case, they must obtain and treat their own water.

b. The sources of water are public water supply systems, surface

water (lakes, rivers, streams, and ponds), ground water (wells and springs),
rain water collected from roofs or other catchment surfaces, ice or snow, and
distilled sea water. The source that appears to be the cleanest should be
selected. Water taken from any of these sources must be properly treated
before use since these sources are presumed to be contaminated. There are four
·

ways of disinfecting water in the field:

( 1 ) Chlorination by calcium hypochlorite. This is supplied in 0.5

gram ampules along with chlorine residual testing vials and tablets
(Chlorination Kit, Water Purification); or in bulk powder (Calcium
Hypochlorite, 6-oz j ar).

(2) Iodine tablets, supplied in bottles of 50.

(3) Commercial bleach (5 percent sodium hypochlorite).

(4) Boiling.

16-5. Disinfecting Water in a Water Purification (Lyster) Bag

a. Set up Lyster bag. (See Figure 16-1.)

SHALLOW SOA KAGE PIT

Figure 16-1. Lyster bag set up.

16-2
 FM 8-230

b. Fill the Lyster bag with water.

(1) Clean the Lyster bag thoroughly before filling it with water.

(2) Use settled or filtered clear water, if possible.

(3) Fill the bag to the 36-gal mark (approximately 4 inches from
the top). BE CAREFUL-when full the bag weighs about 300 pounds.

c. Mix stock disinfecting solution.

( 1 ) Add contents of three ampules of chlorine to a canteen cup

half full of water.

(2) Stir with a clean implement to dissolve the calcium

hypochlorite.

NOTES

1. Stock solution is a mixture of chlorine

adequate to provide the initial treatment
prescribed by the command surgeon. See the
Job Performance Aid (JPA) packed with the
Chlorination Kit, Water Purification, for
procedures used in opening the ampules.

2. The command surgeon may prescribe other

dosages, but the normal dosage is 5 mg/1
chlorine residual (three ampules for the initial
dose) (see Table 1 6-1). Chlorine residual is the
amount of chlorine remaining after the
disinfection demand has been satisfied.

Table 16-1. Chlorine Dosage Requirements

1 1

5 3 or 4

10 5 or 6

d. Add the stock solution to the Lyster bag.

(1) Pour the stock solution from the canteen cup into the Lyster
bag.

(2) Mix it well using a clean mixing device.

16-3
FM 8-230

(3) Cover the Lyster bag and flush the faucets by running a small
quantity of water through them.

CAUTION

The water is not safe to drink or use at this time.

(4) Allow the chlorine to react with the water contaminants for
10 minutes.
e. Test the water for chlorine residual.

( 1 ) Select the testing vial (1 mg/1, 5 mg/1, or 1 0 mg/1) for

required residual testing.

(2) Crush one chlorine test tablet (packed in the bottle inside the
plastic testing tube) in the cap of the testing vial using the bottom of the test
tablet bottle.

(3) Place the powder in the vial.

(4) Flush a faucet of the Lyster bag.

(5) Fill the testing vial to the lower edge of the color band with
water from the Lyster bag.

(6) Place the cap on the testing vial and shake it until the
crushed tablet is completely dissolved.

( 7) Compare the color of the solution to the color band.

(8) If the color of the water is as dark as the color band, the
chlorination is acceptable. Discard the water used for testing.

(9) If the desired residual has been satisfied, wait an additional

20 minutes to provide a total disinfection (contact) time of 30 minutes.

( 1 0) If the color of the water is lighter than the color band, more
chlorine is necessary. Repeat (1) through (7) above, using an additional chlorine
ampule. Wait an additional 10 minutes before retesting. If the residual is the
desired color, proceed to (9) above.

f. Recheck the chlorine residual.

( 1) After the 30 minute contact time and before using the water
for any purpose, recheck for chlorine residual by following the same procedure
as (1) through (7) above.

(2) I f the chlorination is now acceptable, the water may be used.

(3) If the chlorination is not acceptable, repeat the entire
chlorination and testing procedure (steps c through e above) again beginning
with the mixing of the stock disinfecting solution.

16-4
 FM 8-230

NOTES

1. Routinely recheck large containers of water for

chlorine residual 2 or 3 times a day, since the
chlorine residual decreases with time and
increased temperature.

2. A 400-gallon trailer arriving from an approved

supply point must be tested for chlorine
residual in accordance with the procedure
outlined in e. above. If the required chlorine
residual is met, the water is safe. If there is no
chlorine residual, dissolve 30 chlorine ampules
in a canteen cupful of water or dissolve one
mess kit spoonful of the bulk powder (Calcium
Hypochlorite, 6-oz jar) in a canteen cup of
water. Pour this stock solution into the water
trailer. Stir the water with a clean stirring
device. Wait 10 minutes, then test the chlorine
residual.

3. If the desired residual has been reached, wait

20 minutes, then release the water for
drinking. If the desired residual has not been
reached, repeat the procedures above with 10
ampules or 1/a mess kit spoonful of the bulk
powder.

16-6. Disinfecting Water in a Canteen

When safe water is not available, each soldier must produce his own potable
water by using his canteen and iodine purification tablets, calcium
hypochlorite ampules, or commercial bleach (for example, Clorox).

a. Treat a canteen of water using iodine tablets.

(1) Fill the canteen with the cleanest, clearest water available.

(2) Take needed iodine tablets from the bottle. Check for good
tablets not crumbled or stuck together. If the tablets are stuck together or
crumbled, replace them.

(3) Add one iodine tablet to a I -quart canteen of clear water (two
tablets if the water is cloudy or very cold). Double these amounts for the
2-quart canteen.

(4) Place the cap on the canteen.

(5) Wait 5 minutes.

(6) Shake the canteen vigorously, loosen the cap, invert the
canteen, and allow leakage to rinse the threads around the neck of the canteen.

(7) Tighten the canteen cap.

(8 ) Wait an additional 20 minutes before using the water for any

purpose.

16-5
FM 8-230

b. Treat a canteen of water using calcium hypochlorite ampules.

(1) Fill the canteen with the cleanest water available.

(2) Fill a canteen cup half full of water.

(3) Add the calcium hypochlorite from one ampule to the canteen
cup filled half full of water.

(4) Stir with a clean device until the powder is dissolved.

(5) Fill the cap of a plastic canteen half full of the solution. Use a
capful for the 2-quart canteen.

(6) Add this solution to the water in the canteen.

(7) Place the cap on the canteen and shake the canteen
thoroughly.

(8) Loosen the cap slightly and invert the canteen, letting the
water leak onto the threads around the neck of the canteen.

(9) Tighten the canteen cap again and wait 30 minutes before
using the water for any purpose.

c. Treat a canteen of water using a commercial household bleach.

( 1 ) Add two drops of bleach to a 1-quart canteen full of clear

water (if the water is cloudy or very cold, add four drops of bleach to the
canteen). Double these amounts for the 2-quart canteen.

(2) Place and tighten the cap on the canteen.

(3) Shake the canteen thoroughly.

(4) Loosen the cap slightly and invert the canteen, letting the
treated water leak onto the threads around the neck of the canteen.

(5) Tighten the canteen cap.

(6) Wait 30 minutes before using the water for any purpose.

NOTE

Refer to FM 21-10 for additional information

concerning field hygiene and sanitation.

d. Disinfect drinking water by boiling. Boil the water for at least 2

minutes. Allow the water to cool before drinking. In an emergency, boiling for
1 5 seconds will help reduce the harmful organisms. Protect the water; boiling
will not prevent recontamination.

16-6
 FM 8-230

Section III. WASTE DISPOSAL

16-7. General

a. Waste includes all types of refuse resulting from the living

activities of humans or animals, such as-

(1) Feces.

(2) Liquid (wash, bath, kitchen, and urine).

(3) Garbage (food).

(4) Rubbish (nonfood).

b. Waste must be disposed of properly to prevent the spread of

disease (dysentery, cholera, and typhoid). The methods used for the disposal of
wastes depend upon the military situation and the unit location.

1 6-8. Methods of Disposal and Types of Devices

a. Methods of disposal.

(1) Burial. Human wastes are usually disposed of by burial. If

soil conditions (hard, frozen, or rocky) make digging difficult, a pail or burn­
out latrine may be used.

(2) Burning. Solid garbage and combustible rubbish may be

burned in temporary camps (longer than one week in duration). Garbage and
rubbish must be buried when the tactical situation precludes burning.

(3) Soakage. Liquid wastes from bath and kitchen are drained
into either a soakage pit or trench.

b. Types of waste disposal devices (Figure 16-2) are-

(1) Cat hole latrine.

(2) Straddle trench (short bivouac).

(3) Deep pit latrine.

(4) Pail latrine.

(5) Burn-out latrine.

(6) Trough urinal.

(7) Garbage pits.

(8) Soakage pit.

(9) Soakage trench.

16-7
FM 8-230

Figure 16-2. Types of waste disposal devices.

16-8
 FM 8-230

'

·u<---
� --
l' - -- - --_J
;::;:>
(j) " �;.-

�
I�
: : i :
SOAKAG£ PIT

G RA V E L
P A I L W I TH P E R F OR A T E D
®
BOTTOM

Figure 16-2. Types of Waste Disposals - continued

16-9
FM 8-230

Section IV. FOOD SANITATION

16-9. General

Even the most appetizing food can cause illness if it has become contaminated
with disease organisms through improper handling. Outbreaks of food
poisoning, dysentery, infectious hepatitis, and typhoid fever can result from
unsanitary practices in kitchens and dining areas. Persons who handle food
must always maintain the highest standards of personal hygiene and
sanitation.

16-10. Food Sanitation Measures

a. Cook hot foods sufficiently. For example, pork and pork products
should be cooked throughout to a minimum internal temperature of 150°F in
order to kill the trichinae (trichinosis).

b. Do not drink any liquids, eat food, or use ice from an unapproved
civilian vendor.

c. Wash your hands before eating, whenever possible.

d. Keep hot foods hot until eaten. Hot food temperature should be at
least l 40°F.

CAUTION

Proteins, dairy products, and sauces spoil

quickly. They must be kept hot (140°F) or cold
(45°F or below).

e. Refrigerate or ice down cold food. Cold food temperature should be

45°F or below.

f Inspect canned foods for damage and/or contamination. Do not use

cans if damage is evident (rust, badly dented, top and/or bottom of can
bulging).

g. Clean mess kit and utensils. Wash in warm soapy water. Rinse in
clear boiling water. Disinfect by immersing in a second can of clear boiling
water for 30 seconds.

NOTE

See FM 21-10 for additional information

concerning food sanitation.

16-11. Insect Control

a. Keep food and garbage covered.

b. Use screens or nets to keep flies out of the food preparation area.

c. Spray outside infested areas. Read the label on the pesticide

container before use. Apply the pesticide as instructed. Use care when
spraying the food service facility. DO NOT spray the food storage and
preparation area while preparing or serving food. Aerosol spray may be used in

16-10
 FM 8-230

the preparation area to keep the fly population down; however, care must be
taken to keep the insecticide out of the food and off the food contact surfaces
of the equipment and utensils.

16-12. Rodent Control

a. A rodent can be any one of several animals; however, this

discussion will be limited to control of rats and mice.

b. Methods of rodent control:

(1) Store soft-packaged food in metal containers.

(2) Close cracks and openings in the food storage area.

(3) Bury or burn garbage/rubbish.

(4) Trap/poison rodents that get into the food storage area.

(5) Keep garbage/rubbish that is not burned in tightly closed

containers.

Section V. PERSONAL HYGIENE

16-13. General

a. Personal Hygiene. Personal hygiene is often thought of as being

the same as personal cleanliness; while cleanliness of the body is important, it
is only one of the many essentials of healthful living. Personal hygiene is
practiced by an individual to-

• Protect his own health.

• Protect the health of his unit and other units.

• Improve morale.

b. Personal Cleanliness. Before it was known how disease organisms

were spread, civilized people gave attention to personal cleanliness because of
a desire to please themselves as well as to be attractive to others. It is now
known that there are also sound medical reasons for keeping the body clean.
Dirt, filth, and invisible disease organisms are inseparable. Keeping the body
and clothing clean are simple, effective means of reducing the number of
disease organisms which can invade the body. Personal cleanliness is only one
of the measures practiced in personal hygiene to prevent disease.

16-11
FM 8-230

16-14. Maintaining Personal Hygiene and Proper Foot Care

a. Practice personal hygiene.

(1) Cleanse your skin, hair, and teeth daily, or a s often as

possible.

(2) Change clothing daily or as often as possible. Avoid wearing

unwashed clothing for long periods of time (this is an open invitation to lice
and disease).

b. Take proper care of your feet.

(1) Wash your feet daily.

(2) Dry them thoroughly, especially between the toes.

(3) Apply foot powder lightly and evenly twice a day.

(4) Change socks at least daily.

c. Wear proper footwear.

(1) Use only issued footwear.

(2) Make sure footwear is properly fitted so that your feet will
not slide forward or backward when walking.

(3) Avoid binding or pressure spots.

NOTE

See FM 21-10 for additional information on

personal hygiene.

16-12
 FM 8-230

C H APTER 1 7

M EDICAL INFORM ATION AND RE CORDS

Section I. CONFIDENTIALITY OF MEDICAL

INFORMATION

17·1. General

This section discusses Department of the Army (DA) policies and procedures
concerning the confidentiality of private medical information.

17·2. Explanation of Terms

a. Private Information. Information that belongs only to a patient

and should not be open to public scrutiny. This information, if divulged, may
cause personal embarrassment or harm.

b. Confidentiality. Guarding the privacy of medical information.

Information gained through the examination or treatment of a patient is
private and confidential. Medical confidentiality is NOT, however, a security
classification of CONFIDENTIAL.

c. Privileged Communications. A communication made within a

confidential relationship that as a matter of public policy is protected.
Information disclosed by patients to Army Medical Department (AMEDD)
f.
health ersonnel is not privileged. See paragraph 1 5 1C(2), Manual for Courts·
Martia , 1969 (Revised).

d. Medical Information. This is information that pertains to

evaluations, findings, diagnosis, or treatment of a patient. The term also
includes any other information given to AMEDD health personnel in the
course of treatment or evaluation. Medical information is confidential and
private. Paramedical documents such as immunization registers and
dosimetry records are not considered medical information even though they
are kept in the same file with medical records.

17·3. Responsibilities

a. The medical treatment facility (MTF) commander will issue local

rules to enforce the policies and procedures stated in this section.

b. Persons and agencies within DA that use medical information for

official purposes must protect the privacy and confidentiality of that
information.

17-4. Protection of Confidentiality

DA policy states that medical confidentiality for all patients will be protected
as fully as possible.

a. Within DA, medical information will be used in diagnosis,

treatment, and prevention of medical and dental conditions. It will also be
used in connection with the health of a command, medical research, and other
official purposes.

17·1
FM 8-230

b. At no time will personnel who are not involved in a patient's care

or in medical research have access to the patient's records. Exceptions to this
are allowed when access is required by law, regulation, or judicial proceeding;
when needed for hospital accreditation; or when authorized by the patient.

( 1 ) Medical information is seen by clerical and administrative

personnel (such as secretaries, stenographers, and medical record
administrators). This is needed for an MTF to properly process medical
records; however, it does not give those persons any inherent right of access.
All of them have a professional and ethical obligation to keep medical
information confidential and private when working with it.

(2) Unauthorized disclosure of medical information is grounds

for administrative or disciplinary action against the informant.

c. When medical information is officially requested for a use other

than patient care, only enough will be given to satisfy the request.

17-5. Disclosure Procedures

Although medical information is private and confidential, it may be disclosed
under certain conditions. All requests for medical information will be handled
by the patient administrator. In his absence, requests will be handled by
another chosen representative of the MTF commander. Medical information
obtained from nonmilitary sources will be filed with, but not considered a part
of, the patient's medical record. Such information is available for further
diagnosis and treatment of the patient and other official DA uses. Any further
redisclosure is prohibited. This information is the property of the nonmilitary
facility and can be released only by that facility. The patient or other requester
will be told that additional information is contained in the record and it may be
requested from the originating facility. This does not apply to medical
information on patients treated under supplemental or cooperative care. Such
information may be released as a part of the patient's medical record.

a. Official Department of the Army Requests. Army personnel

seeking medical information about a patient must request it in writing from
the MTF commander. They must present their official credentials and state
their need, citing the authority supporting the need.

( 1 ) DA Form 4254-R (Request for Private Medical Information)

(Figure 17·1) will be used for requests. This form will be locally reproduced.
Submitted forms are filed under file number 901-02, AR 340-1 8-9, by the
receiving MTF.

17-2
 FM 8-230

REQUEST FO R P RIVATE M EDICAL IN FO RMATION

For use o f this form, see A R 4 0 - 6 � : 'the proponent agency is the O H i c • o f The Surgeon General

P A T I E N T ' S NAME AND SO C I A L S E C U R I T Y N U M B E R M E D I C A L T R EA T M E N T F A C I L I T Y

I OATE

6 NO V 83
,Name and Location)

D o£, JOHN P 555-33-6"661 5 7H A4ASll

N TC/ CA L IFORNIA
REASO N F O R REQUEST

A SSA UL T

P R I VA T E M E D I C A L I N FO R M A T I O N SO U G HT (SpecJly datu ol hospltallza tlon or clinic vlaira and diagnosis, ii known)

IN HOSP 7 - 26 OC T 8 3
INFOR.MA T!ON NEEDED TO COMPL E TE
L JN£ OF DU7 Y DE TERMINA TION.

MBER - -

ED WARD J. R COR
R E Q U E S T O R' S N A M E , T I T L E , O RG A N I Z A T I O N A N O sO-C1_A_C SE c u R I T Y N U

ICH7t CP?: IN, 2./6 I/VF, 888 - 88-9876

FOR USE OF MEDICA L TREA TMENT FACILITY ONL Y
C h r:- c k app!scdble box
, A F P RO V E D [J D I SA P P RO V E D (State reason for disapproval)

S U M M A R Y OF P RI V A T E M E D I C A L I N FO R M A T I O N R E L E A S E D

I
S I G N A T U R E O F A P P R O V I N G O F F I C I A L. DATE

DA FORM 4254-R, 1 Jul 74 (Pop,. lfn 6 " lOW', im•1• 1iu 7 " 9-411 0".)

Figure 1 7-1. DA Form 4254-R.

17-3
FM 8-230

(2) MTF commanders or patient administrators will determine

the legitimacy of the request. Advice of the local Staff Judge Advocate should
be sought if there is any doubt about the need for information or about the
credentials of the requester.

(3) In certain situations (cases of rape, assault, or death), the

need for the information may be urgent. In these cases, both the request for
information and permission for disclosing it may be given verbally.
Immediately after giving permission, the MTF commander or his
representative will prepare a memorandum on the release. The requesting
agent will follow up his verbal request with a written one using DA Form
4254-R.

b. Official Request from Personnel Outside Department of the Army.

See Chapter 3, AR 340-21 .

c. Unofficial Requests. See Chapter 2, AR 40-66.

d. Requests from Patients. If a patient requests information from his

medical record or copies of the documents in it, it will be given to him. Access
to the information will be denied, however, if a physician or dentist judges that
it could adversely affect the patient's physical or mental health. When such a
decision has been made, the information may be released to another physician
or dentist, one named by the patient. In such a case, the patient must be told
that he may name the physician or dentist (paragraph 2-6e, AR 340-2 1). Such
medical records will be identified with a conspicuous strip of tape (see
paragraph 4-4a(10), AR 40-66). Direct access by a patient to his original record
will be allowed only in the presence of the custodian or his designee.

e. Release of Medical Information to Members of the Public. See

paragraph 2-9a, AR 340-1 7.

17-6. Alcohol and Drug Abuse Records

No information concerning the treatment, identity, prognosis, or diagnosis for

alcohol or drug abuse patients will be released except in accordance with the
provisions of AR 600-85.

Section II. MEDICAL RECORDS ENTRIES

17-7. General

a. Content. Entries will be made on medical record forms by the

health care provider who observes, treats, or cares for the patient. Although
AR 40-66 prescribes the amount of information that must be given for entries,
health care providers must always remember that entries serve as a useful
record for continued and future care. Therefore, all entries must be clinically
pertinent and kept up-to-date.

17-4
 FM 8-230

b. Legibility. All entries must be legible; they are usually typed but
may be handwritten. Handwritten entries will be made in permanent black or
blue-black ink, except when pencil entries are either directed or necessary
under field conditions. Rubber stamps may be used only for standardized
entries, such as routine orders.

c. Signatures. All entries must be signed. The first entry made by a

specific person will be signed; later entries on the same page by that person
will be signed or initialed. Military members must add grade and corps. A
rubber-stamped signature will not be used in place of written signatures or
initialing. However, the use of rubber block stamps under written signatures
is recommended because it establishes a method to identify the authors of
entries. Block stamps for military members should contain printed name,
grade, and corps.

d. Dating Entries. All entries must be dated. Dates will be written in

the day-month-year sequence; month will be stated by name, not by number.
For example, a correct entry is 1 7 Jun 84.

e. Corrections to Entries. To correct an entry, a single line is drawn

through the incorrect information; this information must remain readable. The
new information is then added, dated, and signed (with title) by the person
making the correction.

17-8. Patient Identification

The " Patient's Identification" section will be completed when each record
document is begun. Patient identification will be typed or handwritten in black
or blue-black ink. Patient identification must include at least the patient's
name, rank, grade, or status.

17-9. Facility Identification

The MTF providing care will be clearly named in all medical records and
reports (such entries on SF 600 (Chronological Record of Medical Care) will be
made by rubber stamp when possible). Since patients are often treated at
several MTFs, the MTF that is custodian of the patient's records will be
named also. For outpatient records and health records, this may be done using
the patient recording card.

Section III. RECORDING DIAGNOSES AND

PROCEDURES

17-10. General

a. Diagnostic nomenclature will be recorded in language accepted as

good professional usage. Vague and general expressions will be avoided.

17-5
FM 8-230

b. The affected body part will always be stated when relevant to the
condition and when not given in the name of the condition. In addition, the
body part will be described in as much detail as is needed (that is, skin of,
tissue of, region of). Terms such as "right," "left, " "bilateral," "posterior, "
and "anterior" will also be added when applicable. For dental diagnoses and
procedures see TB MED 250.

c. Few abbreviations should be used in medical records. Only those

listed in the appendix of AR 40-66 and the medical terminology section are
authorized. The chief of the MTF clinical and professional services will insure
that those listed are properly used. Abbreviations not listed in the appendix of
AR 40-66 may be used in long narratives but only if defined in the text. For
example: Nerve condition time (NCT) is changed by many factors. NCT varies
with electrolytes or with temperature.

17-11. Special Instructions for Certain Diseases

Food poisoning and food infection are terms that refer to certain diseases in
which the causative organism or agent enters the body via food or drink. Food
infection applies to a disease caused by ingesting pathogenic organisms that
lodge in the gastrointestinal tract. Food poisoning applies to a disease caused
by ingesting food that contains a preformed toxin of bacterial origin. Neither
term is correct for recording illness from nonbacterial poisons. Illness due to
food that was toxic in its natural state (for example, fungi, shellfish) should be
recorded as "toxic effect of noxious foodstuffs " (naming the food). If due to
food which becomes adulterated with nonbacterial poison (for example,
cadminum) during preparation, the illness should be recorded as a poisoning
and the cause named. In all cases, the suspected food and the organism or
causative agent should be named.

17-12. Special Instructions for Certain Diagnoses

a. Alcoholism and Nondependent A buse of Alcohol The term

"alcoholism" is used only for persons whose alcohol intake is great enough to
damage their physical health or their personal or social function. For other
individuals whose use of alcohol has brought them to medical attention, the
appropriate term is "nondependent abuse of alcohol. " This term applies to
people formerly diagnosed as " simple drunkenness" cases. It also applies to
people not suffering from alcoholism but who are seen by a physician because
of driving-while-intoxicated charges, an altercation involving alcohol,
AWOLs, or absences from work due to overuse of alcohol.

b. Nondependent A buse ofDrugs (Improper Use ofDrugs). This term

is used for a person who is treated or observed because of the effects of drug
use (including positive test findings). It is not used for people addicted to or
dependent on drugs. The known or suspected drug will be named.

c. Malingerer. This term is used for a person who claims to be ill or

unduly exaggerates a disability. It is used only when the medical officer
believes there is no actual illness or disability or only a slight one (see
paragraph 194, Manual for Courts-Martial).

17-13. Recording Psychiatric Conditions

See paragraph 3-7, AR 40-66.

17-6
 FM 8-230

17-14. Recording Injuries

a. Details To Be Recorded.

( 1 ) The same details will be given and the same terms used when
recording both battle and nonbattle injuries. To be complete, the recording of
an injury must include the details given below. On DA Form 3647 (Inpatient
Treatment Record Cover Sheet) (ITRCS), the details listed in (c) through (h)
below will be recorded in I tern 33.

(a) The nature of the injury. The exact nature of the injury
must be recorded as well as the condition caused by it. Conditions like
traumatic bursitis, traumatic neuritis, traumatic myositis, or traumatic
synovitis must be explained by describing the original injury. For example, a
contused wound resulting in bursitis would be recorded as bursitis due to
contusion.

(b) The part or parts of the body affected. In the case of

fractures and wounds, state if any nerves or arteries were involved; maj or
nerves or blood vessels must be named.

(c) The external causative agent. In the case of acute

poisoning for example, the poison must be named.

(d) How the injury occurred. State what the person was
doing when injured (in action against the enemy, work detail, marching, or
drilling). For motor vehicle accidents, state the kind of vehicle involved and if
military owned or otherwise.

(e) When the injury was self-inflicted. If the injury was

deliberately self-inflicted, state if it was an act of misconduct (to avoid duty) or
an act of the mentally unsound (a suicide or attempted suicide).

(f) The place where injured. If on-post, state the building or

area (barracks, mess tent, motor pool); if off-post, state the place and person ' s
status (home on leave, in transit while AWOL).

(g) The date of the injury.

(2) Examples of properly recorded diagnoses are as follows:

(a) " Fracture, open comminuted, upper third of shaft of

femur, left, no nerve or artery involvement; bullet entering anterior upper
portion of left thigh and lodging in femur. Caused by rifle bullet, accidentally
incurred when patient' s rifle discharged while he was cleaning it in Arms
Room, Bldg 902, Ft Dix, NJ, 8 Jul 84. "

(b) " Bursitis, acute, knee, right, due to contusion, anterior

aspect. Accidentally incurred when patient tripped and fell, striking kneP on
floor while entering Barrack 1 380, Ft Sam Houston, TX, 9 Jul 84. "

b. Wound or Injury Incurred in Combat.

( 1 ) In addition to the details described in a above, records of

wounds or injuries incurred in combat must state:

17-7
FM 8-230

(a) The wound resulted from enemy action. The definition

of wounded in action (battle casualty) is given in Appendix C, AR 40-400. The
abbreviation WIA (wounded in action) will be used. However, this
abbreviation by itself is not acceptable as a diagnosis.

(b) The kind of missile or other agent that caused the

wound.

(c) The time the wound occun-ed.

(d) The general geographic location where the person was

wounded. Entries such as "near Saigon, Vietnam " are sufficient; map
coordinates alone are not sufficient.

(2) The following is an example of a correctly recorded WIA case:

"WIA wound, penetrating, left arm; entrance, posterior lateral, proximal
third, severing brachia! artery without nerve involvement. Incurred during
search and destroy mission when struck by enemy mortar shell fragments, 1 6
D ec 69 near Bao Tri, RVN. "

c. Injuries or Diseases Caused by Chemical or Bacteriological Agents

by Ionizing Radiation.

( 1 ) For the injuries, record the name of the agent or type of

ionizing radiation (if known). If the agent or radiation is not recognized, record
any known properties of it (odor, color, physical state).

(2) Record the date, time, and place where contamination took
place. .
(3) E stimate and record the tune that lapsed between
contamination and self-decontamination or first aid (if any). The procedures
will also be stated.

(4) For those injured by ionizing radiation, estimate and record

the distance from the source. If the exposure is to external gamma radiation,
state the dosage ("measured 200 R"). If not known, the dosage should be
estimated and recorded ("est 1 50 R").

(5) State, if known, whether exposed through airburst, ground

burst, water surface burst, or underwater burst.

17-15. Recording Deaths

a. The following terms will be used to record a death when the cause
is unknown.

(1) Sudden death. Used i n the case o f sudden death known not to
be violent.

(2) Died without sign of disease. Used in case of death other than
sudden death known not to be violent.

(3) Found dead. Used in cases not covered by (2) above when a
body is found.

b. For additional information, see Section II, AR 40-66.

17-8
 FM 8-230

Section IV. OUTPATIENT TREATMENT RECORD

17-16. General
a. Treatment Record. DA Form 3444 (Outpatient Treatment
Record) (OTR) will be prepared for all patients treated as outpatients other
than active duty personnel.
b. Responsibilities. Medical and dental officers and other care
providers will insure that information is promptly and accurately recorded on
OTR medical and dental forms. They will also insure that records prepared and
received from other MTFs are promptly reviewed and filed in the OTR.

c. Outpatient Treatment Record Forms and Documents.

( 1 ) DA Form 3444 (see Figure 17-2) series folders will be used as

OTR file folders. On these folders, the "Outpatient Treatment" box is checked
if the folder is used as a medical record and the "Dental (Non-military)" box if
used as a dental record. (For the preparation and filing of the DA Form 3444
series folder, see Chapter 4, AR 40-66.)

(2) The forms used in medical OTR are listed in Table 17-1. These
forms will be filed from top to bottom in the order they are listed in the table.
Copies of the same form will be grouped and filed in reverse chronological
order; that is, the latest on top.

17-17. Initiating and Keeping Outpatient Treatment Records

The OTR will be kept at the MTF that provides primary medical care. Only
one medical OTR and one dental OTR will be kept at the MTF for each patient.
Keeping partial or multiple records is prohibited except in obstetrical cases
(see paragraph 1 7-2 1d).

17-18. Transferring Outpatient Treatment Records

To insure a patient's record is complete, the MTF providing care should
include all outpatient records prepared at other facilities. OTR should be
transferred to the next MTF when patients are transferred.

a. Mailing Outpatient Treatment Records.

( 1 ) When a patient moves, the OTR may be handcarried or

mailed to the next MTF. However, the following OTR must be mailed and will
be sent directly to the next MTF, ATTN: Patient Administration Division.
They will not be sent to installations, organizations, or area commanders or to
personnel officers.

• Special category records.

• OTR of patients who will be ineligible for care at a

military MTF after the move.

17-9
FM 8-230

(2) When mailing an OTR to the next MTF, the procedures

below will be followed:

(a) The MTF will complete DD Form 2138 (Request for

Transfer of Outpatient Records) and instruct the sponsor to present the card
at the next MTF.

(b) When the losing MTF receives the DD Form 2138, it

will mail the OTR to the requesting MTF. The losing MTF will file the DD
Form 2 138 alphabetically and keep the form until the retirement of that year's
records.

(3) A patient whose OTR must be mailed ((1) above) may be

given a copy of certain parts of the OTR or an extract. This may be done if the
patient needs medical care en route to or upon arrival at another MTF. The
extract or copies will be given to the patient or any other authorized person as
described in b below. Documentation of the treatment en route should be
included in the original OTR; the patient should be told to give this
documentation to the next MTF.

b. Handcarrying Outpatient Treatment Records. If the patient (other

than those described in a( l ) above) requests it, he may handcarry the OTR to
the next MTF . These procedures will be followed when OTR are handcarried:

( 1 ) The patient will sign for the OTR on DA Form 3705 (Receipt
for Outpatient Treatment/Dental Records). When preparing DA Form 3705,
the "address" blocks must be completed. Once signed, DA Form 3705 will be
filed like DD Form 2 138.

(2) An adult's OTR will not be released to anyone other than the
patient unless a signed authorization is presented to the MTF. Any statement
approving release to another person will be acceptable if signed and dated by
the patient. This statement will be attached to the DA Form 3705.

c. Troop-Unit Changes of Station. When troop units change station,

the losing and gaining MTFs will coordinate to transfer the OTRs. If mailed,
the losing MTF will securely package and seal all OTRs destined for the same
MTF and send them by registered mail.

17-10
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FM 8-230

Table 1 7-1. Forms and Documents of the Medical OTR

LEFT SIDE OF FOLDER

Form No. Form Title and Notes

DA Form 3180/3180A Personnel Screening and Evaluation Record.

(See AR 50-5 and Chapter 4, AR 380-380.)

*SF 601 Health Record- Immunization Record.

*SF 545 Laboratory Report Display. Filed with

SFs 546 through 557 mounted.

*SF 519/5 1 9A Medical Record-Radiographic Report.

SF 520 Clinical Record-Electrocardiograph Record.

Reports of electrocardiograph examinations
with adequate representative tracings should be
attached to the back of this form or on another
attached sheet of paper.

DA Form 3647 Inpatient Treatment Record Cover Sheet.

(Formerly DA Forms 8-275 series and DD Form
481 series.) File with it a copy of SF 502 (if
prepared). Also filed here is SG Form 84, AF
Form 565, NAVMED 6300/5, or DD Form 1 380
(formerly DA Form 8-27).

Authorization for release of medical information.

File with this a synopsis of any information
released and related correspondence. (The
synopsis may be entered on SF 544, which
would be filed here.)

Administrative documents and other

correspondence.

17-12
 FM 8-230

Table 1 7-1. Forms and Documents of the Medical OTR-continued

RIGHT SIDE OF FOLDER

DA Form 4515 Personnel Reliability Program Record

Identifier. See AR 50-5.

*SF 600/SF 558 Health Record-Chronological Record of

Medical Care. File here also any other basic
chronological medical care records (for example,
SF 558 (Medical Record- Emergency Care and
Treatment) and AMOSIST Encounter Forms).

DA Form 3763 Community Health Nursing-Case Referral.

See paragraph 4-2b, AR 40-407.

DA Form 4530 Electroencephalogram Request and History.

DA Form 4700 Medical Record-Supplemental Medical Data.

SF 5 1 3 Medical Record-Consultation Sheet.

S F 522 Medical Record-Request for Administration

of Anesthesia and for Performance of
Operations and Other Procedures.

Other SF 500 series forms in numerical

sequence.

DD Form 771/771-1 Eyewear Prescription/Eyewear Prescription­

Plastic Lenses.

Reports or certificates prepared by

neuropsychiatric consultation services.

Correspondence on hearing aids.

Medical documents from civilian sources.

DA Form 3365 Authorization for Medical Warning Tag.

*DA Form 4410-R Disclosure Accounting Record.

*DD Form 2005 Privacy Act Statement-Health Care Records.

*This form must be included in all OTRs.

17-13
FM 8-230

17-19. Transfer Requests Other Than DD Form 2138

Although DD Form 2 1 38 is the only form authorized for use as a request for
transferring OTR in ordinary circumstances, this does not preclude prompt
response to other types of requests such as DD Form 877 (Request for
Medical/Dental Records or Information). Charge-out information for such
requests will be filed and kept at the losing MTF as described in AR 40-66.

17-20. Disposition of Outpatient Treatment Records

Outpatient Treatment Records will be disposed in accordance with AR

340-18-9.

17-21. Preparation of Outpatient Treatment Records

Each contact with the AMEDD as an outpatient will be recorded in the OTR.
Periods of treatment as an inpatient will be described on DA Form 3647 and
SF 502 (Medical Record-Narrative Summary) and put into the OTR.

a. Preparation and Use of SF 600. SF 600 is the basic record form of

the medical OTR. It is a chronological record of outpatient visits. For the
preparation and use of SF 600, see paragraph 5-14a( l ) and 5-14a(3) through (7)
of AR 40-66. See Figure 1 7-3.

b. Preparation and Use of SF 601 and PHS Form 731.

( 1 ) An SF 601 (Health Record- Immunization Record) will be

prepared and permanently kept for each person who has an OTR. It will be put
into the record when:

(a) The OTR is initiated.

(b) The patient next reports for immunizations or

sensitivity tests.

(c) Reactions are noted.

(2) PHS Form 731 (International Certificates of Vaccination)

will be prepared or posted when a patient reports to an MTF for
immunizations. Only the following identification information is entered on the
form:

(a) The patient's name on the "Traveler's Name" line.

(b) The patient's address on the address line.

(c) The county of the individual 's address on its

appropriate line.

(3) Individuals preparing SF 601 and PHS Form 73 1 will insure

that all entries are recorded on both forms and that both forms are current
with each other.

17-14
 FM 8-230

(4) In accordance with international rules, entries on PHS Form

731 for immunization against smallpox, yellow fever, and cholera will be
authenticated. Each entry must show the DOD immunization stamp and the
signature of the medical officer or his chosen representative. (See AR 40-562.)
For other entries on PHS Form 731 and all entries on SF 601 , the signature
block may be stamped or typewritten and initialed by the medical officer.

c. Preparation of the Outpatient Treatment Record Folder for

Patients Allergic to Medications. On the outside front cover of the DA Form
3444 series folder, the "Medical Condition" block will be marked and a DA
Label 162 (Emergency Medical Identification Symbol) affixed. This will be
done when SF 601 , PHS Form 731, or DA Form 3365 (Authorization for
Medical Warning Tag) is prepared. (See AR 40-15 and AR 40-562.)

d. Obstetrical Cases. A pregnancy diagnosis will be entered on SF

600. After the pregnancy, all forms related to it will be filed in the Inpatient
Treatment Record (ITR). When the records are filed, the following will be
entered on SF 600: " Prenatal care records filed in ITR of (patient's name,
FMP, and SSN), (location of MTF), and (date). "

17-22. Use of Outpatient Treatment Records

The OTR will be given to physicians, dentists, and other medical personnel
attending an outpatient or inpatient. When an outpatient is to be treated over
a short period of time in a clinic, the OTR may be kept in that clinic; however,
it will be made available to other medical personnel when required during this
retention period. Further, the OTR should accompany a patient admitted to a
military MTF and be constantly available for use by the attending physician.
A strict audit trail will be kept for any OTR temporarily out of the file.

Section V. HEALTH RECORDS

17-23. General

The primary purpose of the health record (HREC) is to insure that AMEDD
personnel have a concise but complete medical history of everyone on active
duty or active duty for training. It will help medical officers advise
commanders on retaining and using their personnel. Similarly, the record will
help physical evaluation boards appraise the physical fitness of Army
members and their eligibility for benefits.

17-24. Responsibilities

a. Unit Commanders. Unit commanders will insure that HRECs are

always available to AMEDD personnel. They will also insure that information
in the HREC is kept private and confidential. If a commander acquires the
HREC or r�ords belonging in HREC, he will insure that they are treated
confidentially and sent to the proper HREC custodian without delay. In some
instances, some commanders may act as the custodians of their units' HRECs
or appoint a competent person to do so. They may act as custodians only if no
AMEDD personnel are locally available.

17-15
FM 8-230

b. AMEDD Officers.

(1) AMEDD officers will serve as custodians of the HRECs. In

their charge are the HRECs for members of the units to which they supply
primary medical care. Also in their charge are the HRECs of other individuals
they are currently treating. AMEDD officers will use the HRECs for
diagnosis and treatment. They . will also use them for conservation and
improvement of health. In doing so, they will see that all needed information is
promptly entered into the HREC in their custody. If any such information is
omitted, they will take the needed action to have it included.

(2) When an AMEDD officer examines or treats a person whose

HREC is not in his custody (that is, "casuals"), he will send copies of the
proper records to the person's HREC custodian. These records will be sent
sealed in an envelope stamped or plainly marked " Health Records. " In
addition to the address, the envelope also will be plainly marked " Health
Record of (person's name, grade, and SSN) . " The person's unit of assignment
will also be shown. (If the HREC custodian is not known, the document will be
sent to the MEDDAC (Medical Department Activity) or MEDCEN (Medical
Center) commander of the person's assigned installation.)

17-25. For Whom Prepared and Kept

HRECs will be prepared and kept for all Army personnel. These include active
duty personnel, Reserve Component personnel, and cadets of the US Military
Academy. When transferred to Army custody, HRECs for members of the
Navy and Air Force will also be kept.

17-26. Forms and Documents of the Health Record

The medical forms authorized for use in the HREC are listed in Table 1 7-2. To
make access to information easier in these folders, the forms will be filed from
top to bottom in the order they are listed in the tables. Copies of the same form
will be grouped and filed in reverse chronological order; that is, the latest on
top.

17-16
 FM 8-230

Table 1 7-2. Forms and Documents of the Health Record

LEFT SIDE OF FOLDER

Form No. Form Title and Notes

DA 4186 Medical Recommendation For Flying Duty.

See AR 40-501 .

D A Form 3 180/3 1 80A Personnel Screening and Evaluation Record.

See AR 50-5.

*SF 601 Health Record- Immunization Record.

DD Form 1 1 41 Record of Occupational Exposure to Ionizing

Radiation. Also automated dosimetry records,
DD Form 1952 (Dosimeter Application and
Record of Occupational Radiation Exposure),
results of investigation of alleged or actual
overexposure, and any other record of personnel
dosimetry. See AR 40-14.

*SF 545 Laboratory Report Display. (Formerly

SF 5 14.) Filed with SFs 546 through 557
mounted.

*SF 519/5 19A Medical Record-Radiographic Report.

SF 520 Clinical Record-Electrocardiograph Record.

Reports of electrocardiograph examinations
with adequate representative tracings should be
attached to the back of this form or on another
attached sheet of paper.

DA Form 3647 Inpatient Treatment Record Cover Sheet.

(Formerly DA Forms 8-275 series and DD
Forms 481 series.) File with it a copy of SF 502
(Medical Record-Narrative Summary), if
prepared. File here also SG Form 84, AF Form
565, NAVMED 6300/5, DD Form 1 380
(formerly DA Form 8-27 (Emergency Medical
Tag)), or any other narrative summaries from
the Veterans Administration, Public l-Iealth
Service, or other Government MTF.

DA Form 3365 Authorization for Medical Warning Tag.

17-17
FM 8-230

Table 1 7-2. Forms and Documents of the Health Record-continued

RIGHT SIDE OF FOLDER

DA Form 45 1 5 Personnel Reliability Program Record

Identifier. See AR 50-5.

*SF 600/SF 558 Health Record-Chronological Record of

Medical Care. File here also any other basic
chronological medical care records (for example,
SF 558 (Medical Record- Emergency Care and
Treatment) and AMOSIST Encounter Forms).

SF 602 Health Record-Syphilis Record. (Formerly

DA Form 8-1 14.)

Civilian or foreign military treatment

records.

DA Form 199 Physical Evaluation Board Proceedings.

*DA Form 181 1 Physical Data and Aptitude Test Scores upon
Release from Active Duty. See AR 601-210. For
personnel separated to continue on active duty
in the same or another status, file this form
directly in front of the last SF 88 in the HREC
continued in use. For personnel reentering
service after the HREC has been retired, file
this form as the last document in the temporary
HREC; when the permanent HREC is received,
file the form directly in front of SF 88.

DA Form 2 1 73 Statement of Medical Examination and Duty

Status.

DA Form 3349 Medical Condition-Physical Profile Record.

(Formerly DA Form 8-27 4.) File here also any
correspondence on a revision of physical profile
serials.

DA Form 3947 Medical Board Proceedings. (Formerly

DA Form 8-1 18.)

DA Form 4060 Record of Optometric Examination. (This

form became obsolete after l October 1 974.)

DA Form 4530 Electroencephalogram Request and History.

DA Form 4700 Medical Record-Supplemental Medical Data.

*SF 88 Report of Medical Examination.

*SF 93 Report of Medical History. (Formerly

SF 89.) File here any other medical history
form.

17-18
 FM 8-230

Table 1 7-2. Forms and Documents of the Health Record-continued

SF 5 1 3 Medical Record-Consultation Sheet.

S F 522 Medical Record-Request for Administration

of Anesthesia and for Performance of
Operations and Other Procedures.

Other SF 500 series forms in numerical

sequen�.

DD Form 77 1/771-1 Eyewear Prescription/Eyeware Prescription­

Plastic Lenses.

DD Form 2215 Reference Audiogram.

DD Form 2216 Hearing Conservation Data.

Reports or certificates prepared by

neuropsychiatric consultation services or
psychiatrists.

Correspondence on hearing aids.

Documents and correspondence on flying status.

That is, restrictions, removal of restrictions,
suspensions, and termination of suspensions.
See AR 600-107.

Other medical documents important enough to

keep on file. This includes correspondence on
release of medical information, statements
instead of physical examinations for the
promotion of officers and warrant officers, and
so forth.

DA Form 4465 ADAPCP Military Client Intake and Follow-up

Record. File here also any other authorized
alcohol and drug forms.

*DA Form 4410-R Disclosure Accounting Record. To be

included if DD Form 722 is used as the folder
instead of the DA Form 3444 series.

*DD Form 2005 Privacy Act Statement--Health Care Records.

To be included if DD Form 722 is used as the
folder instead of the DA Form 3444 series. See
paragraph 1-6c, AR 40-1

*This form must be included in all health records.

17-19
FM 8-230

17-27. Access to Health Records

All personnel having access to HRECs will protect the privacy of medical
information. The extent of access allowed certain personnel is described below.

a. Medical Personnel. AMEDD personnel are allowed direct access to

HRECs for purposes of diagnosis, treatment, and the prevention of medical
and dental conditions. They also have access to work for the health of a
command and to do medical research.

b. Service Members. If a service member requests information from

his HREC or copies of the documents in it, they will be given to him. For
special category records, see paragraph 2·6e, AR 340·3 1 .

c. Inspectors. Personnel inspecting an MTF are allowed direct access

to the HRECs. This includes personnel conducting Technical Proficiency
Inspections under AR 20· 1 ; it also includes Technical Standardization
Inspections conducted by the Defense Nuclear Agency. Inspectors may have
access to the HRECs to evaluate the compliance of AMEDD personnel with
regulations. All inspectors must respect the confidentiality of the HRECs
they inspect.

d. Graves Registration Personnel. Graves registration personnel are

allowed direct access to the HREC of personnel killed in action or missing.
They may have access to extract medical and dental information needed by
their service.

e. Other Nonmedical AMEDD Personnel. Nonmedical personnel

may need information from a person's HREC for official reasons. Such
personnel include unit commanders, inspectors general, officers of the Judge
Advocate General's Corps, military personnel officers, and members of the US
Army Criminal Investigation Command or military police performing official
investigations. When officially needed, information from the HREC or copies
of documents in it will be supplied by the MTF commander or patient
administrator.

17-28. Cross-Servicing of Health Records

AR 40·66 and similar regulations in the other services allow and direct cross·
servicing of the HREC. Procedures for maintaining and transferring Navy and
Air Force HRECs are similar to those described for Army HRECs.

a. When members of other services are attached to Army MTFs for

primary care, custody will be assumed for their HREC. These will be
maintained as discussed in this regulation.

b. HRECs not sent with Navy and Air Force patients will be
requested when needed for treatment. Similarly, Army HRECs will be sent to
Navy or Air Force HREC custodians when Army personnel are given care by
MTFs of those services.

c. When cross-servicing HRECs, Army personnel are not required or

allowed to check or complete records for any periods before the HREC came
under Army custody.

17-20
 FM 8-230

17-29. DA Form 3444 Series Folder

For preparation of this folder, see Chapter 4, AR 40-66 (Figure 17-2). For
health records, check the "Health" box under "Type of Record"; for dental
records, check the "Dental (military)" box. Handwritten entries will be made
irt' dark ink and boldly printed. (The member's current organization; for
example, "Company A, 163d Infantry," will be handwritten but must be done
in soft pencil.)

17-30. SF 600

One copy of SF 600 will be put in the health record. (See Figure 1 7-3.) The
following parts of the form are completed:

a. Person's name.

b. Sex.

c. Year of birth.

d. Component. (Do not include branch.)

e. Department.

f Grade.

g. Organization.

h. SSN.

DQ£ J OH N P.
5
PATIENT IDENTIFICATION ( l ·u thtJ \pu�t for .\fuhu'1 1Cu/ PATIENT ' S NAME ( Lt1JI. Finl. ,\fi � initial) EX
Imprin t ) /l1

VE2 95R8 S N�MEI

0

A D ltANK/GltADE
RELATtONSHIP R COM E STATUS /SERVI CE
AR
ORGANIZATION S P 4
SPONSOR'
555 - 3 3 - 6 6 6 6 6 INF D / I/
SSAN OR IDENTIFICATION NO
2
CHIONOlOGICAl IECOID OF MEDICAL CAIE
Standard Form 600
61»--106---01
Figure 1 7-3. SF 600 (Patient Data).

17-21
FM 8-230

17-31. SF 601 and PHS Form 731

a. One copy of SF 601 will be put in the health record. The

identification parts of this form will be completed as described for SF 600 in
Figure 1 7-3. At reception stations, procedures will be set up to insure that
immunization information is entered on the copy of SF 601 . For persons
allergic to medication, the "Medical Condition" block on the front of the
HREC folder will be checked. Also, DA Label 162 will be put on the front of
the folder.
b. A copy of PHS Form 73 1 will be sent with the health record for
later entries of immunization data. This form should be clipped or fastened to
SF 601 and it will not be punched. The name and SSN of the person will be
typed or written in ink on the front of the form. The address put on the form
for officers and warrant officers is HQDA (DAPC-PSR-R), Alexandria, VA
22332. The address for enlisted personnel is Commander, US Army Enlisted
Records Center, Fort Benjamin Harrison, IN 46249. The name of the person's
unit will be entered below the double line at the bottom of the form; it will not
be entered until he reaches his first training or duty station.

17-32. SF 88 and SF 93

The original copies of SF 88 (Report of Medical Examination) and SF 93

(Report of Medical History) will be put in the health record.

17-33. CDC 9.2936A

If a CDC 9.2936A (Venereal Disease Epidemiologic Report) has been received

with a person's records, it will be stapled to a blank letter-sized sheet of paper.
It will then be fastened in the health record under SF 601 .

17-34. Transferring Health Records

a. Sending Health Records. Both parts (health and dental) of a

person's HREC are transferred when his Military Personnel Records Jacket
(MPRJ) is transferred (AR 740-1 0). When a person is to be transferred to
another unit or station, the military personnel officer of the losing unit will get
both parts of the HREC from their respective custodians. The HREC will be
sent with the MPRJ except when:

(1) The losing and gaining units receive primary (outpatient

type) care from the same medical and dental facilities. In this case, the military
personnel officer will inform the HREC custodians about the unit change. The
person's unit designation will be changed on the folders of both the health and
dental records.

(2) An inpatient is assigned to a medical holding unit that

already has the health record. The MTF commander will inform the military
personnel officer that the MTF has the health record. When requesting the
MPRJ, the MTF commander will also request the dental record.

(3) The HREC custodian sends the records directly to the

gaining custodian. If the HREC custodian feels a person should not hand
carry his HREC, he will send it directly to the commander of the person's next
MTF. The servicing military personnel officer will be promptly informed that
the HREC will be sent and not carried. If the custodian does not know the
address of the person's next MTF, he will send the HREC to the servicing
military personnel officer; it will be sent to the person's next HREC custodian.

17-22
 FM 8-230

b. AMEDD Personnel.

( 1 ) The officer in charge must insure that any health problems of

a newly arrived individual are treated. Thus, he must insure that the person's
HREC is reviewed when received. This review may be made by the medical
officer, a physicians' assistant (MOS 91 1 A), or other qualified individuals.
(The HRECs of all personnel working with nuclear weapons or nuclear reactors
will be reviewed by medical officers or designated physicians' assistants in
accordance with the Personnel Reliability Program (AR 50-5).) Each MTF
commander will establish qualifications for people who are not physicians to
review the HRECs. Each MTF will also perform audit reviews to insure the
HRECs are referred to medical officers when needed. The responsible medical
personnel will develop written quidelines for the review of the HRECs by
nonmedical officers. These guidelines will insure that reviews check for
pending actions, health care problems, and record inadequacies. When writing
guidelines, the medical officer must insure that reviews include the actions
listed below. These may be modified or expanded to fit the local situation:

(a) Consultation reports will be studied for incomplete or

pending actions and profile recommendations.

(b) X-ray reports will be studied for unresolved

pathological findings.

(c) Laboratory reports will be studied for unresolved

abnormalities.

(d) Drug reactions and idiosyncratic responses will be

noted.

(e) Recurrent problems such as repeated bouts of

pneumonia, urinary tract infections, cardiac arrhythmias, emotional problems,
and drug and alcohol abuse will be noted.

(f) Significant deviations from normal weight, blood

pressure, and hearing and visual acuity will be noted.

(g) The HREC folder will be checked to insure that the

person's blood type is entered. Also, it will be checked to insure that any
allergic reaction to medication was entered and DA Label 1 62 affixed (AR
40-15).

(2) The medical officer will review all noted health problems to
determine if examination or treatment is needed. All pertinent findings will be
recorded on SF 600. Also recorded will be the date of the HREC review and the
name of the reviewer.

(3) If the individual's record shows that he has been diagnosed

as an alcohol or drug abuser within the previous 360 days, the Alcohol and
Drug Control Officer will be notified (AR 600-85).

(4) If a CDC 9.2936A is in the individual's record, the medical

officer will immediately have the person examined and start an SF 602 (Health
Record-Syphilis Report), if needed. If the CDC 9.2936A is not for syphilis,
comments on the examination and any treatment given will be made on SF
600. When no longer useful in the case, the CDC 9.2936A will be removed from
the HREC and destroyed.

17-23
FM 8-230

c. Health Records Not Received. The military personnel officer will

request information on the missing records from the individual ' s last known
unit. If neither he nor the last unit can find an officer ' s or warrant officer ' s
HREC, the military personnel officer will send a request for the missing
HREC to HQDA (DAPC-PSR·R), Alexandria, VA 22332. If an enlisted
member ' s HREC cannot be found, a request will be sent to Commander, US
Army Enlisted Records Center, Fort Benjamin Harrison, IN 46249. A copy of
this request will be kept in the member ' s MPRJ until a reply has been
received. If the individual is transferred before the reply arrives, the copy of
the request will be indorsed to his next unit. When the request reaches the
individual ' s next unit, it will be put in his "temporary" HREC. (A notation of
a reply to the request will be made on SF 600 and the reply inserted in the
HREC.)

d. Movements of Units with the Medical Treatment Facility. When a

unit and its attached MTF move, the unit's HRECs will be retained and
moved by the MTF. This will be done only if the MTF continues to give
primary medical and dental service to the unit during and after the move. If
another MTF will give primary service to the unit during or after the move,
the HRECs will be sent to the record custodian of the MTF that provides care
during the move.

17-35. "Temporary" and "New" Health Records

a. "Temporary " Health Record. When receipt of a health record is

delayed, a temporary one will be prepared if the individual needs any medical
attention. This will also be done if any documents meant to be included in a
health record arrive before it. A manila folder rather than the DA Form 3444
series folder will be used. The date the temporary record was begun will be
printed on the folder. Documents concerning the member ' s medical care will be
added to the temporary health record as they are used; they will not be
prepared until needed. For example, SF 601 would not be prepared for a
temporary health record until an immunization was given. When a delayed
HREC is received, the forms in the temporary record will be filed in it.

b. "New " Health Record. If a delayed HREC is not received within

60 days after a temporary record is prepared, a new HREC will be prepared.
This will also be done when information is received that a record has been
destroyed.

( 1 ) When a new health record is prepared, an SF 601 will be

added if necessary.

(2) Should a lost health or dental record be found after a new

record has been prepared, the new record forms will be filed in the original
record. The custodian will note on SF 600 or SF 603 (Health Record-Dental)
that the original health or dental record was received.

c. Personnel Returned to Military Control. When personnel who have

been missing in action, interned, or captured are returned to military control,
their original HREC will be acquired and continued in use.

17-24
 FM 8-230

17-36. Filing the Health Record

a. Health Record Files. Health records will be filed at the MTF that
provides primary medical care. The records may be filed alphabetically or in
terminal digit sequence. A charge-out system will be used when the HREC is
temporarily removed from the record room.

b. Keeping Health Record Files Current. The following procedures

will be followed to keep HREC files current:

( 1 ) The MTF and division surgeon will give the military

personnel office (MILPO) a list of the MTFs and the units they serve.

(2) The MILPO will give the MTF quarterly personnel rosters of
the units they serve.

(3) HREC files for active duty personnel will be screened

semiannually against current personnel rosters. This will insure that the file
holds only the records of personnel served by the MTF. When an HREC or
medical form is found to be held by the wrong custodian, MTF records
personnel will send the documents to the correct custodian.

c. Handling Identifiable Health Records and Medical Forms. When a

record or form contains enough information that it can be identified as
belonging to a specific person, it is an identifiable form. To keep files current,
identifiable HRECs and forms will be handled as follows:

(1) When a member outprocesses at an MTF, the MTF will give

the serving MILPO his HREC. This is done so that it can be sent with the
MPRJ to the new custodian. When the HREC is sent to the MILPO, the MTF
will record identification of the new custodian so that any late-arriving medical
records, such as laboratory slips or SF 600s can be forwarded to him.

(2) When the MTF cannot find the member's health or dental
record, a suspense card will be prepared. This card will contain the member 's
name, rank, SSN, the complete address of his new unit, the MEDDAC that
serves his new unit, and the date the card is put in suspense. The suspense
card will be kept in a charge-out folder; the folder kept in the files where the
member 's records should have been. These suspense cards will be kept until
the record is found and sent to the new custodian or until the files have been
given two semiannual reviews, whichever comes first. They will then be
destroyed.

d. Handling Stray Records and Forms. Stray records and forms

found during the semiannual files review will be handled as follows:

(1) The record and forms will be screened against the MTF files
(including the suspense cards). Those that can be identified (matched with a
record or suspense card) will be sent to the proper custodian. The letter of
transmittal will name the member 's assigned unit.

(2) When the proper custodians cannot be determined, the MTF

will make a list of the members to whom the records belong. This list will give
each member's full name and SSN. The list will be sent to the MILPO. With it
will be sent a cover letter requesting that the names be checked against
installation rosters, clearance files, and with the Standard Installations/
Division Personnel System (SIDPERS) Interface Branch that keeps a

17-25
FM 8-230

worldwide locator file. It will request that the member's unit of assignment be
named, if possible. The MILPO response will be kept by the MTF in a
reference paper file (File Number 901-07) for 1 year. (See AR 340-18-9 for
information on reference paper files.)

(3) If the MILPO cannot find the address of the proper custodian
before the files are given two semiannual reviews, the MTF will draft a letter
stating that the serving MILPO has done the proper screening and cannot find
the correct custodian. With this letter, the identifiable records and forms will
be disposed of as outlined in Table 1 7-3.

Table 1 7-3. Disposition of Stray Records and Forms

R
U A R
L
E If the records or forms belong to then send them to (see Note)

warrant 9fficer
1 An Army officer HQDA (DAPC-PSR-R)
or Alexandria. VA 22332

2 Army enlisted personnel Commander

US Army Enlisted Records and
Evaluation Center
Fort Benjamin Harrison. IN 46249

3 Army retired personnel Commander

US Army Reserve Components
Personnel and Administrative Center
9700 Page Boulevard
St. Louis. MO 63132

4 Navy/Marine personnel Chief, Bureau of Medicine and

Surgery
ATTN: Code 7424
Navy Department
Washington, DC 20372

5 Air Force personnel Headquarters, US Air Force

ATTN: AFMPC/DPMDR
Randolph Air Force Base, TX 78148

Note: HRECs that contain only blank forms will not be sent to the agencies
listed above. Reusable folders and forms will be returned to stock; folders and
forms that cannot be reused will be destroyed.

17-26
 FM 8-230

e. Handling Unidentifiable Records and Forms. An unidentifiable

record or form is one that contains either no data or such a small amount that
trying to identify the person it belongs to is impossible. Before destroying
these records, the patient administrator will send a report to the MTF
committee that audits medical records. This report will list the type of record;
that is, laboratory forms, X-ray reports, SF 600s, and the number of each type
to be destroyed. This report and the committee's action on it will be entered in
the committee minutes. Following the committee ' s approval, the patient
administrator or his chosen representative will destroy these records and
forms.

17-37. Disposition of Health Records

Upon discharge, release from active duty, retirement, death, or transfer from
US Army Reserves (USAR) to Army National Guard (ARNG), HRECs will be
disposed of in accordance with Appendix E, AR 635-10. ARNG HRECs will be
disposed of like an MPRJ. (For officers and warrant officers, see NGR 640-1 00;
for enlisted personnel, see NGR 600-200.)

17-38. Preparation of the Health Record

Throughout the soldier's military career, each contact with the AMEDD as a
patient is recorded in the HREC. Periods of treatment as an inpatient,
described on DA Form 364 7 and SF 502, are put in the health record. Quarters
referrals are reported as to duration and treatment. Outpatient medical care is
recorded each time the person is seen. Medical care at MTFs that do not keep
the HREC is recorded and sent to the HREC custodian.

17-39. Use of the Health Record

a. Use Within Medical Treatment Facilities. Precise procedures for

using the HREC within MTFs are not set by this publication. Such procedures
should be set locally to insure the most efficient handling of the HRECs. The
procedures set by MTF commanders will insure that:

( 1 ) HRECs are readily available to AMEDD personnel who are

treating patients.

(2) Access to information in the HREC is controlled.

b. Use in Primary (Outpatient) Medical Care.

( 1 ) Normally a person's health record will be kept by the MTF

that gives his unit primary medical care. Each time the person is treated, the
health record will be removed from the file and used by the physician. Each
time a physician uses a record, he will comment on the case on the SF 600.
When an MTF refers a patient elsewhere for outpatient care, the health record
may be sent also. This is decided by either the referring or consulting
physician. If it is sent, the consulting physician will comment in the record on
his findings and treatment. If it is not sent, the consulting physician will enter
his findings on SF 5 1 3 (Medical Record-Consultation Sheet) or any other
medical forms (including SF 600) he deems proper. These consultation and
treatment records will be filed in the person's HREC.

17-27
FM 8-230

(2) A person may report for outpatient treatment to an MTF

that does not keep his health record. In this case, the findings and treatment
will be recorded on an SF 600 and any other medical forms that are needed.
After treatment, the SF 600 and other records will be sent to the custodian of
the person's health record.

c. Use in Inpatient Care.

( 1 ) Normally, the HREC will be sent to the MTF when a person

is admitted for treatment. When an MTF receives the HREC (or a portion of
it), the patient administrator becomes the custodian. He will insure it is
accessible to authorized personnel. When received, the HREC will be sent to
the patient's ward. It will be kept there during his stay for use by his
attending physician and other medical personnel involved in his case. The
patient administrator will insure that a copy of each of the forms required for
the HREC prepared by the MTF is put in the HREC. He will also insure that
the entries needed for inpatients on SF 600 are made.

(2) When a patient is released from the MTF, the patient

administrator will forward the HREC as follows:

(a) For attached patients returned to duty. Send the HREC

to the record custodian of the MTF that provides the person with primary
outpatient care. If the primary MTF is unknown, send the HREC to the
hospital commander at the person's assigned installation.

(b) For assigned patients returned to duty. Send the HREC

to the military personnel officer of the person's assigned unit. If the person is
locally reassigned, send the HREC to the custodian as in (a) above.

(c) Patients transferred to another medical treatment

facility. Send the HREC with the inpatient record to the other MTF.

(d) For deceased patients. Send the HREC to the officer

holding the patient's personnel records.

(e) For patients A WOL in excess of ten days. Send the

HREC to the custodian of the MPRJ.

17-40. Preparation and Use of SF 600

SF 600 is a chronological record of each treatment in a person's military health
history. The MTF initiating an SF 600 will complete the identification data at
the bottom of the form. Entries on the form may be typed but will usually be
written in ink; if written, entries must be legible. Each entry will show the date
and time of visit and the MTF involved; these entries will be made by rubber
stamp when possible. (As long as the patient is treated by the same MTF, the
name of that MTF need not be repeated in every dated entry.) Each entry on
the form will also be signed by the person making it. (See Figure 17-4 for
examples of entries of SF 600.)

17-28
 FM 8-230

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H E A LT H R E CORD C H R O t.IOLOGICAL R E C O R D OF MEDICAL CARE

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CHRONOLOGICAL RECORD Of MEDICAL CARI
Standard Form 600
600- 106--0 I

Figure 17-4. SF 600 (Medical Care).

17-29
FM 8-230

a. En tries for Outpatient Care.

( 1 ) Entries should be concise but complete; that is, medically and

adj udicatively adequate. They should include:

(a) A description of the nature and history of the patient's

chief complaint or condition.

(b) Findings of any examination or test.

(c) Diagnoses and impressions (if made).

(d) Treatment, disposition, and any instructions given to

the patient for follow-up care. All prescribed drugs will be recorded. These
entries may be recorded in a "subjective, obj ective, assessment plan" format.
SF 558 (Emergency Care and Treatment) will be used for emergency cases.

(2) Each visit will be recorded and the complaint described even
if the patient is returned to duty without treatment. If a patient leaves before
being seen, this will also be stated.

(3) When admission as an inpatient is imminent, the entries

discussed in ( 1 ) above may be made on SF 509 (Medical Record-Doctor's
Progress Notes) instead of SF 600. This will then be the inpatient admission
note filed in the patient's inpatient record. Other referred or deferred inpatient
admissions will be recorded on SF 600.

(4) All requests for consultation, prescriptions, or other services

will be recorded on SF 600.

(5) With patients seen repeatedly for special procedures or

therapy (for example, physical and occupational therapy, renal dialysis, or
radiation), the therapy will be noted on SF 600 and interim progress
statements will be recorded. Also, a final summary will be given when the
special procedures or therapy are ended. This summary will include:

• Results of evaluative procedures.

• Treatment given.

• Reaction to treatment.

• Progress noted.

• Condition on discharge.

• Any other pertinent observations.

Initial notes, interim progress notes, and any summaries may be recorded on
any authorized form but must be referenced on SF 600.

(6) If an injury is treated, the cause and circumstances ("how­

when-where-leave status") will be entered.

17-30
 FM 8-230

(7) For persons taking part in rnsearch projects as test subjects,

entries will include:

• The drugs given or appropriate identifying code.

• Investigative procedures performed.

• Significant observations, including effects.

• The physical and mental state of the subj ect.

• Tests and laboratory procedures performed.

(8) Outpatient care received at civilian facilities will also be

recorded on SF 600. If available, copies of records concerning this care will be
put in the HREC. Personnel who prepare payment vouchers for civilian care
(AR 40-3) will acquire a summary of diagnosis and treatment when processing
the vouchers. They will then send this information to the person's HREC
custodian.

b. Entries for Periods of Medical Excuse from Duty. Except during

combat, each admission to an MTF or referral to quarters will be recorded on
SF 600.

( 1 ) In addition to the information described in a above, entries

for MTF admissions will include:

• The time and date of admission.

• The name and location of the MTF.

• The cause of admission.

(2) In the case of referral to quarters, detailed comments will be

made regarding:

• Care given.

• E stimated duration.

• Extensions of quarters status.

• When the patient will be returned to duty.

c. Entries for Physical Examinations. The term " Physical

Examination" and the date will be entered on SF 600 for each complete
physical examination made and recorded on SF 88. Entrance medical
examinations will not be entered.

d. Entries for Orthopedic Footwear. When a person is authorized the

issue of orthopedic footwear, the term "orthopedic footwear authorized" will
be entered on SF 600. Also entered will be the prescription and date.

17-31
FM 8-230

e. Entries for Syphilis Treatment. The preparation of an SF 602 and

the date it was done will be noted on SF 600. Later information recorded on the
SF 602 will not be noted on SF 600.

f. Entries for Drug A buse Treatment. When a person has been

j udged by a clinical evaluation to be an alcohol or other drug abuser, entries
will be made on the SF 600. (See paragraph 6-3a(6), AR 600-85.)

17-41. Preparation and Use of SF 601 and PHS Form 731

An immunization record on SF 601 will be prepared and kept for each person
who needs an HREC. The PHS Form 731 is a personal record of
immunizations received; it is normally needed for international travel.
Usually, active duty personnel have custody of their PHS Forms 731; they will
insure their safekeeping. PHS Forms 731 for Reserve Components personnel
will be filed with their personnel records. The form will usually be issued to the
person only upon mobilization, activation, or when traveling internationally.

a. Responsibilities.

( 1 ) The unit commander will insure that each assigned or

attached member receives the immunizations required by AR 40-562. To do
this, he will periodically check the immunization status of each unit member.
He will then consult with the local medical officer to insure that
immunizations are given when due.

(2) When personnel report for immunization, the medical officer

will check the accuracy of the entries on SF 601 and PHS Form 731 . He will
insure that immunizations given are recorded on both forms and that the
entries are properly authenticated.

b. Authentication of Entries. In accordance with international rules,

entries on PHS Form 731 for immunizations against smallpox, yellow fever,
and cholera will be authenticated. Each entry must show the DOD
immunization stamp and the signature of the medical officer or his chosen
representative (AR 40-562). For other entries on PHS Form 731 and all entries
on SF 601 , the signature block may be stamped or typewritten and
authenticated by initialing.

c. Entries.

(1) Immunizations and sensitivity tests will be recorded on SF

601 .

(2) Remarks and recommendations for any entry on SF 601 may

be added at the MTF. The reasons for waiving any immunization will be
recorded in enough detail for later medical evaluation. Any attacks of diseases
for which immunizing agents were used must be noted; the year and place of
attack must also be given. Any untoward reactions to immunizations
(including vaccines, sera, or other biologicals) will be recorded.

17-32
 FM 8-230

d. Loss of SF 601 or PHS Form 731. If PHS Form 731 is lost, a

duplicate will be made by transcribing the SF 601 kept in the HREC. If the SF
601 kept in the HREC is lost, a duplicate will be made by transcribing the
PHS Form 73 1 . If both forms are lost, new forms will be prepared.

e. Disposition on Separation from Service. When released from

active duty or separated from the service, personnel will be encouraged to keep
their PHS Form 731 for future use.

17-42. Preparation and Use of S F 602

a. The medical officer who diagnoses syphilis will prepare an SF 602

(original only) on the infected person. Examinations and laboratory procedures
used to make the diagnosis will be noted on SF 600 when the case is given
outpatient treatment; SF 602 is completed after the diagnosis is made and
antiluetic therapy is begun. When SF 602 is prepared, the medical officer will
enter all identification data at the bottom of the form. A careful history and
physical examination will be made; all pertinent findings will be recorded in
Sections I and II. A detailed account of all laboratory studies and all
treatments will be entered in Sections III and IV. In Section II, the patient
will sign and date his statement. Section VII on the form will not be used.

b. The medical officer treating or observing the case will record each
periodic follow-up in Section V of the form. The period of time follow-up
examinations must be made before the record may be closed is given in TB
MED 230. The medical officer who treats and follows up syphilis cases will
keep suspense files or appointment records needed to insure that current cases
are observed long enough.

c. The medical officer treating the patient closes the record by

signing Section VI of the form. After closing, it will be kept as a permanent
part of the HREC. The record will be closed for any one of the following
reasons:

(1) The treatment and follow-up are completed with satisfactory

results.

(2) The patient is separated from active service.

(3) The patient deserts or is otherwise lost to military control.

(4) The patient dies.

d. A syphilis record will be reopened for the following reasons:

( 1 ) Rel,apse. The patient record files in the HREC will be used for
needed information. On that form, entries about the case will be continued.

(2) Reinfection. If reinfection occurs before the record is closed,

the current record will be continued. Also, the follow-up will be extended for an
additional period of observation. Interim progress notes will be entered; they
will give all pertinent information and state a new diagnosis. They will also
cite the clinical and laboratory data that prove the new diagnosis. If
reinfection occurs after the record is closed, a new syphilis record will be
prepared.

17-33
FM 8-230

e. When the patient and his HREC are transferred before the record
is closed, the medical officer of the losing command will put a statement in the
health record that the person needs more follow-up studies. This statement
will be fastened with SF 602 at the top of the inner right-hand side of the
HREC. Once noted by the physician giving the follow-up care, the SF 602 will
be put in its normal place in the record.

17-43. Other Forms Filed in the Health Record

a. When the following forms are prepared, one legible copy will be
filed:

(1) DA Form 3647.

(2) SF 502.

(3) DA Form 1 99 (Physical Examination Board Proceedings,

prepared in accordance with AR 635-40).

(4) DA Form 3947 (Medical Board Proceedings, prepared in

accordance with AR 40-3).

b. Copies of the other HREC forms will be filed as follows:

( 1) SF 88 and SF 93. The original of each of these forms prepared

under AR 40-501 will be filed.

(2) DD Forms 771 (Eyewear Prescrip tion) and 771-1 (Eyewear

Prescription-Plastic Lenses). Each time one of these forms is prepared, a copy
will be filed permanently in the HREC.

(3) DA Form 3349 (Medical Condition-Physical Profile Record).

When a person's physical profile serial is revised in accordance with AR
40-501, a copy of this form will be put in the HREC.

(4) DA Form 4465 (ADAPCP Military Client Intake and Follow­

up Record). This form will be prepared, kept, and used in accordance with AR
600-85.

(5) Dosimetry records. DD Form 1 141 (Record of Occupational

Exposure to Ionizing Radiation), automated dosimetry records, DD Form
1952 (Dosimeter Application and Record of Occupational Radiation
Exposure), and earlier records of personnel dosimetry must be kept in the
HREC. When a person changes station or leaves the service, these records will
be moved with his HREC. The dosimetry records of personnel whose work
exposes them to ionizing radiation may be removed from their HREC and filed
separately. This is done when the medical officer who keep8 and uses the
records does not have easy access to the HREC of these personnel. In thelie
cases, the separate file of dosimetry records will be kept as described in AR
40-14.

17-34
 FM 8-230

(a) When dosimetry records are temporarily withdrawn

from the HREC, OF 23 (Charge-Out Record) will be filed in their place. Under
the column " Identification of Record" on OF 23, enter the numbers of the
forms removed. In the column "Charged To, " enter the name of the medical
officer (or other authority) borrowing the records and the name and address of
the MTF (or activity) where these records will be kept. Enter the date the
record is removed in the "Date Charged Out" column.

(b) The OF 23 will not be removed from the HREC until the
dosimetry records have been returned.

17-44. Maintenance of Health Records Under Combat Conditions

a. Theater commanders are authorized to name units or areas

covered by the provisions of this paragraph and to change them as needed in
current military circumstances. Under combat conditions, military personnel
officers will keep the HRECs of US military personnel. They will file both
parts of the HREC with the MPRJ. They will also file in the HREC the
documents they receive from the MTF and send the HREC with the MPRJ
when a person's MPRJ moves. Normally HRECs will not be sent to or kept at
an MTF; this will be done only when the HREC is needed and requested by a
fixed hospital for treatment of a patient. Evaluations or releases of medical
information contained in the HREC will be sent to the closest MTF.

b. Identification entries on SF 600 and DD Form 1 380 (Field

Medical Card) (FMC) for outpatient treatment will include at least the
patient's name, grade, and SSN; other data will be entered as time permits.
These forms will be kept at the MTF only until treatment is completed (and
statistical or other reports prepared). They are then sent to the military
personnel officer keeping the HREC.

( 1 ) DD Form 1380. Instructions for preparing the FMC are given

in paragraph 17-63. When the FMC is put into the HREC, it will be mounted
on an SF 600. To mount it, staple along the top margin only so that no entries
on the SF 600 are hidden and both sides of the FMC can be read.

(2) SF 600. SF 600 is prepared the same under combat conditions

as under normal ones (paragraph 1 7-30).

RECORDS, AR 40-66
Section VI. INPATIENT (CLINICAL) TREATMENT

17-45. General

a. An ITR will be prepared for:

(1) Every bed patient (military/civilian) in a hospital, fixed
health clinic, or convalescent center.
(2) Each liveborn infant delivered in one of those MTFs.

17-35
FM 8-230

(3) Carded for record only (CRO) cases (paragraph 3·12,

AR 40-66).

(4) NATO patients.

b. An ITR will not be prepared for:

( 1) Stillbirths.

(2) MTFs supporting combat operations if the surgeon considers

their use impractical and FMCs are used (Section 4, FMC).
c. For nonfixed MTF using ITR, instructions for preparation will be
provided by MEDDAC/MEDCEN in whose geographical area the nonfixed
facility is operating. Disposition will be in accordance with AR 340-18-9.

17-46. Responsibilities
a. Each MTF commander will insure that an adequate and timely
ITR is prepared for each patient who must have one.

b. Health care providers will record promptly and correctly all

patient observations, treatments, and care.

17-47. Forms and Documents

a. All ITR forms will be fastened into the proper DA Form 3444
series folder. During treatment, the forms will be arranged in the order
prescribed by the MTF commander. When the patient is discharged or
transferred, the forms will be arranged in the order they are listed in Table
1 7-2. The same numbered forms will be grouped chronologically (an exception
to this is laboratory and radiology orders).

b. All ITRs transferred with a patient are to be kept as a part of his

current ITR. However, forms from transferred records will not be interfiled.

c. Although administrative documents are not a part of the ITR

itself, they should be filed in the ITR folder.

17-48. Preparation and Use of Inpatient Treatment Records

ITRs must be accurate, complete, and current. The ITR must reflect the
patient ' s current status and treatment. An ITR cover sheet "worksheet" is
prepared in the admitting office. This cover sheet and all available medical
records will be given to the attending physician without delay.

17-49. Inpatient Treatment Records of AWOL Patients

The ITR of a patient who has been AWOL for 1 0 consecutive days will be
closed and disposed of in accordance with AR 340·18·9.

17-36
 FM 8-230

17-50. Use of SF 539

a. SF 539 (Abbreviated Medical Record) (Figures 1 7-5A and 1 7-5B)

may be used for cases of a minor nature that require no more than 72 hours
hospitalization. For example, it may be used for lacerations, plaster casts,
removal of superficial growths, and accident cases held for observation.

b. SF 539 may be used by military members who are hospitalized for

uncomplicated conditions not requiring hospitalization in the civilian sector
(for example, measles and upper respiratory infection).

c. For further information, see paragraph 7-20, AR 40-66.

17-51. Use and Preparation of DA Form 4256

a. Use of DA Form 4256 (Clinical Record-Doctor's Orders)

(Paragraph 7-22, AR 4()-66). DA Form 4256 (Figure 1 7-6) is a three-copy,
carbonless form. The original copy (white) remains with the patient ' s
permanent record. The second copy (pink) is sent to the pharmacy, where it is
kept until the patient is discharged. The pharmacy must receive a copy of all
orders to insure appropriate surveillance of food-drug and laboratory-drug
interactions. The ward copy (yellow) is used to give orders to the nursing staff.
It may be used as a medication or treatment reminder and will be discarded
when no longer needed.

b. Preparation. All entries will be made with ballpoint pen using blue­
black or black ink. Entries must be legible on all three copies. In each " Patient
Identification" section, addressograph plates should be used. If not, print
patient name (last, first, middle initial), rank, grade or status, SSN, sex, and
age of patient. More than one order may be written in each section , but
no more than one may be written on a single line. The prescriber will record
the date and time each order is written. Each order must be accounted for
separately; use of the entry "ROUTINE ORDERS" is prohibited. However, a
group of orders written at the same time for a patient needs only one
signature.

c. Method of Discontinuing Orders. To discontinue a medication or

treatment, the prescriber must write and sign a stop order. Automatic stop
orders (for example, for antibiotics or controlled drugs) will be governed by
written local policy. When an order is stopped, it must be accounted for and
then noted on DA Form 4677 (Therapeutic Documentation Care Plan (Non­
Medication)) or DA Form 4678 (Therapeutic Documentation Care Plan
(Medicated)). This is done by putting " DC/DATE/INITIALS" and drawing a
single line through the " HR" and "Date Completed/Dispensed" blocks beside
stopped order.

d. Verbal Orders. Verbal orders will be used only for emergency

" STAT" orders. The nurse accepting the order must write it on the form and
enter after it "VERBAL ORDER (doctor ' s name/nurse ' s name, grade, ANC) ".
The prescriber must countersign as soon as possible after the emergency.

17-37
FM 8-230

MEDICAL RECORD I ABBREVIATED MED ICAL RECORD

PERTINENT HISTORY. C H I E F COMPLAINT. ANO CONDITION O N ADM ISSION r f.'1d11 1lfllt 0( 111lllmM011 1

PHYSICAL E X A "1 1NATl0h

SIGNATURE OF PHYSICIAN DATE IDENTI F ICATION NO. ORGANIZATION

N1Amr l 11 s t . lirat, l'tE:GISTEl't NO. WARD NO.

middle . •r•de d11He; ho•p1tal or m•d1c111 / t1tc:1lity)
•ATIENT'S IDENTIFICATION (For rypt!d or '"' ' ' r r r n er.tr1e• •ire

1-A
Jo"1£S, J,�'l.Mlf L ·

AlllEYIATED MEDICAL IECOID

0 F"C.. "1 1 2 - � °t - G, 2 \ "'f - - -
M. 43 AND

ti-. �o. 1 1/.s o s I N.+=

GENERAL SIEJtYtc:IS AOMINISntATION
INTDIAGENCY. COMMITTEE: ON MEDICAL RECORDS
,,Mtt 101.11�
OCTOBER 1175 .......

Figure 1 7-5A. SF 539, A bbreviated Medical Record.

17-38
 FM 8-230

DOCTOR"S ORDERS lDatt" and 1ign all ordt,,)

TEMPERATURE-PULSE-RESPIRATION NURSE'S NOTES

DATE
T R 5100L$ WEIGHT MEDICATION AND NURSE'S NOTES
AND TIME

---- +----IC -- +---+-- ---+---+- ------ ----- ---- ----

------+-----if---f--+-----f-- ->- ------ ··- - ---

-------

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- GPO 1982 0 387-355

Figure 1 7-5B. SF 539, Abbreviated Medical Record (continued).

17-39
FM 8-230

C L I N I C A L R EC O R D - DOCTOR'S O R D E R S
For u se o f this form, se e A R 40-400; the proponent agency i s the Office o f The Surgeon General.

THE DOCTOR S H A L L R E CORD DATE, T I M E AND S I G N EACH S E T O F O R D E R S . IF PRO B L E M OR I E N T E D •AE' D I C A L R E CORD

S Y S T E M IS U S E D , WRITE PR O B L E M NUMBER IN COLUMN I N D I CATED B Y ARROW B E LOW.

PATIENT I D E N T I F ICATION TIME OF O R D E R LIST T I M E

M AE-'\• 111 , To e.y

ORDER

N.
NOTED AND
SIGN

v <j t, - 3 ,s - S Z. 1 2..
M-54 M 3'1
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N U RSI N G UN IT ROOM N O B E D NO.

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P A T I E NT I D E N T I F ICATION

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PATIENT I D E N T I F ICATION

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Figure 1 7-6. DA Form 4256, Clinical Record-Doctor's Orders.

17-40
 FM 8-230

17-52. Use of DA Form 5009-R

DA Form 5009-R (Medical Record-Release Against Medical Advice) (Figure

1 7-7) will be used when the patient leaves the MTF at his own insistence and
against advice of the attending physician(s). DA Forms 5009-R will be
reproduced locally.

Section VII. PREPARATION AND USE OF

LABORATORY FORMS

17-53. General

a. Laboratory forms are used to request laboratory tests and to

report the results of those tests. The forms are three-part sets (original and
two copies). When requesting a test, the whole set is sent to the laboratory.
After the results are recorded, the third copy is kept in the laboratory files. For
disposition instructions, see AR 340-18-9. The original is routed for immediate
filing in the ITR, OTR, or HREC. The second copy is routed to the requesting
practitioner for use and disposition.

b. Carbon copies of laboratory reports will not be filed in the Medical

Record. The MTF commander will insure that each patient's laboratory test
reports are prepared correctly.

17-54. Instructions for Filling Out Forms

General instructions for preparing these forms are given in Table 1 7-4.
Instructions for each form are given in Table 1 7-5.

17-41
FM 8-230

R E LEASE AGAINST MEDICAL ADVICE

MEDICAL R E CORD
I For use of this form, see A R 40-66; proponent agency is the Office of The Surgeon General.

STATEMENT OF PATIENT RELEASING HOSPITAL FROM LIABILITY

UPON LEAVING HOSPITAL AGAINST MEDICAL ADVICE

1. This is to CERTIFY that I am leaving (Name o f Med Treatment Facility )

at my own insistence and against the advice of the hospital authorities and my attending physician(s).

2. I have been advised of the dangers involved in leaving the hospital at this time.

3. I hereby release the hospital, its staff and the Federal Government of all responsibility for any ill effects brought about
by my failure to remain in the hospital.

( Signature of Patien t ) (Signature of Witness)

--

( Date and Time)

STATEMENT OF REPRESENTATIVE OF PATIENT RELEASING HOSPITAL FROM LIABILITY

UPON LEA YING HOSPITAL AGAINST MEDICAL ADVICE

1 . This is to CERTIFY that I (Name), ( Relationship to Patient)

of (Name of Patient) insist that he /she be discharged from

(Name of Med Treatment Facility) without the authorization of the

patient's attending physician(s).

2. I have been informed of the dangers to the patient in his/her leaving the hospital at this time, including the possibility
that it may worsen or aggravate the patient's condition.

3. I hereby release the hospital, its staff and the Federal Government of all responsibility for any ill effects brought about

by (Name of Patient) leaving the hospital against medical advice.

( Signature of Representative) (Signature of Witness)

( Date and Time)

Jo NEq 1 J OHNN Y
PAT I E N T I D E N T I F I C A T I O N REGISTER NUMBER WARD NUMBER

I I
011 - 55 - 3 6 6 1
M £- 7 46 YR S.
c j/3 51 INF

DA F O R M 5009- R , OCT 8 1

Figure 1 7-7. DA Form 5009-R, Medical Record-Release against Medical

Advice.

17-42
 FM 8-230

Table 1 7-4. General Instructions for Preparing Laboratory Forms

Completed by
Block Laboratory Instructions Remarks
Clinic/Ward

Patient x Enter patient's name, Enter this information

Identification register number and FMP/ correctly. If possible,
SSN of inpatients (only enter it by mechanical
FMP/SSN of outpatients) , imprinting, using the ward
treating MTF, ward or plate or patient's record­
clinic, date test is ing card. If not, use ball­
requested . point pen or typewriter.
Urgency x Check the proper box. This block is not on SF
Specimen Lab. X Enter the specimen or 5 5 3 or 5 54 . This entry
Report No. laboratory report number. may be used to identify
and monitor the request
form in the la boratory.
Patient Status x Check the proper box. " N P" and " D OM" are not
used by the Army.

Specimen x Check the proper box or Some forms request other

Source write in the needed specimen information:
information. a. On the SF 5 4 8 , give
specimen interval
information.
b. On SF 5 5 3 and 5 54 ,
give infection information.
Extra information is
needed on these forms to
identify sensitivities and
the infecting organisms.
Enter this information in
the " Clinical Information"
and " Antibacterial
Therapy" blocks.
c. On SF 5 5 6 , give spec­
imen source information for
obstetric patients.
Requesting x Enter clearly the name of The signature is not
Physician ' s the practitioner ordering needed.
Signature the test. If a military
member, enter also grade
and corps.
Reported by x The technologist signs The chief of the laboratory
here after the test results will insure that test results
have been verified as are accurate.
correct.
Date x Enter date the report is
completed by the
laboratory.
Lab I D No. x Enter laboratory identi­ Like the Specimen/Lab.
fication number. Apt. N o . , this entry may be
used to identify and
monitor the request form.
Remarks x Enter any special informa­
tion for the practitioner or
the patient's records.
Specimen x x Enter date and time the This block is completed by
Taken specimen is taken. whoever takes the speci­
men, either the laboratory
or ward/clinic personnel.
Tests x Put an "X" beside the On most forms the cor­
Requested test that is needed. For rect box is marked (X).
tests not listed, write their
names at the bottom of
the list.
Results x Write or stamp the results
for each test performed.

17-43
FM 8-230

Table 1 7-5. Specific Instructions for Preparing Laboratory Forms

Form Use Remarks

SF 5 4 5 A display form for mounting Instructions for mounting laboratory forms

laboratory forms. are printed on the bottom of this form.
When a patient needs the same type of test
several times, use the same display sheet
for each test result form. When only a few
tests are made, mount the forms on
alternate strips (for example, 1 , 3 , 5 , 7 ) .
When there is a mixed assortment o f forms,
mount them i n the most practical sequence.
After mounting the forms, check the proper
boxes in the lower right corner to show
what forms are displayed .

SF 546 Requesting blood chemistry At the bottom of the list of tests, there
tests. is a block for requesting a battery or profile
of tests. When requesting this, write in the
name of the profile.

SF 547 Requesting blood gas

measurements, T3, T4,
serum iro n , iron binding
capacity, glucose tolerance,
and other chemistry tests.

SF 548 Requesting chemistry tests Remember that a check in the "Other" box
on urine specimens. under " S pecimen Interval" must be
explained.

SF 549 Requesting routine

hematology ( i ncluding
differential morpholog y ) ,
coagulation measurements,
and other hematology tests.

SF 5 50 Requesting urinalysis tests Use " HCG" for requesting and reporting
(both routine and micro­ measurements of human chorionic
scopi c ) . gonadotropin.

Use " PSP" for requesting and reporting

phenolsulfonephthalein measurements.

SF 5 5 1 Requesting tests that Definitions for the serology test

measure serum antibodies abbreviations are as follows:
(including tests for syphilis). RPR- Rapid Plasma Reagin card test for
syphilis.
COLD A G G - Cold Agglutinins.
A S O - Antistreptolysis 0 titers.
C PR - C - Reactive Protein.
FTA - ABS- Fluorescent Treponemal
Antibody - A bsorption Test.
Febrile A G G - Febrile Agglutinins.
COMP F I X - Complement Fixation.
HAI- Hemagglutination-lnhibition
TPHA- Treponema Pallidum
Hemagglutination
Write the name of the specific antibody
determination in the COMP FIX or HAI block.

17-44
 FM 8-230

Table 1 7-5. Specific Instructions for Preparing Laboratory Forms - continued

Form Use Remarks

SF 5 5 2 Requesting tests for

intestinal parasites, malaria,
other blood parasites, and
most feces tests.

SF 5 5 3 Requesting most bacterio­ Complete section marked " A nti-

logical isolations and bacterial Therapy" with the antibiotic
sensitivities medications the patient is receiving;
" Clinical Information" includes fever, site of
infection, or culture; and " I nfection would
include tentative diagnosis which could
assist in identifying infecting organism. SF
5 5 3 and SF 5 54 may take as long as 7 2
hours t o be completed by the laboratory.

SF 5 54 Requesting tests for Same as above.

fungi, acidfast bacteria
(tuberculosis), and viruses.

SF 5 5 5 Requesting spinal fluid tests When requesting bacteriological studies on

spinal fluid specimens, submit an SF 5 5 3 or
5 5 4 also. Bacteriological cultures must grow
at least 24 hours before the results can be
observed. The extra request form allows
complete identification of the specimen. It
also allows the quick return of the cell count
and chemistry results to the physician
without his having to wait for the
bacteriological results.

When requesting electrophoresis

measurements, submit also a n SF 5 5 7 .
These measurements take many hours to
complete and the report is a tracing by
densitometer on special paper. The extra
request form allows complete identification
of the specimen; it also allows the cell count
and chemistry results to be returned quickly
to the physician without waiting for the
electrophoresis results to be completed.

SF 556 Requesting blood grouping, Do not use this form as

blood typing, and blood a request for blood crossing

SF 557 Requesting tests, such as

electrophoresis and assays
of coagulation factors,
which are not ordered on
other forms.

D D Form Requesting Drug Screening

1 89 2 Urinalysis Tests.
( D ru g
Screening
Urinalysis
Record)

17-45
FM 8-230

Section VIII. NURSING RECORDS AND REPORTS

(PERMANENT CLINICAL FORMS)

17-55. General
Initiation of permanent clinical records is an essential part of the inpatient
admission procedure (AR 40-407). A permanent outpatient treatment record is
maintained on each outpatient seen in an Army MTF. Authorized clinical
record forms which nursing personnel are responsible for or use frequently are
described in this section.

17-56. Recording Data

All entries will be made with a pen, using reproducible black or blue-black ink,
except when specifically stated otherwise.

17-57. Correcting Errors

Erasures are prohibited. A line will be drawn through an incorrect entry, and
the initials of the person making the entry will be placed above the lined-out
portion. The correct information or statement will be recorded following the
lined-out entry.

17-58. DA Form 4256

For additional information concerning DA Form 4256, see AR 40-407 or AR

40-66.

17-59. SF 510

a. General. SF 510 (Clinical Record-Nursing Notes) is a single sheet,

identical on both sides, which is maintained in the patient's chart. Nursing
notes will be written by the person whose name and grade appear on the notes
(Figures 1 7-8 and 1 7-9).

b. Preparation. Enter all patient identification, including SSN and

other data as indicated in spaces at the bottom of the form.

c. Admission and Discharge Notes. Initial entry will include date,

time, manner of admission, reported known allergies, and a brief, clear
description of symptoms and pertinent observations. In the absence of a
discharge planning form, note the date, time, manner of discharge, and concise
summary of discharge plan. This will include documentation of health
teaching appropriate to the disease and desired behavior outcome.

d. Content. Nursing Notes will contain objective observations of the

patient's condition, to include physical and mental status, symptoms,
response to diagnostic or therapeutic procedures, or any changes noted. The
Nursing Notes must reflect the patient response/status to all nursing care
measures documented on the Medical Record Nursing Assessment and Care
Plan (DA Form 3888 and DA Form 3888-1). Since Nursing Notes aid in
diagnosis, furnish reference material for research and teaching, and provide
important evidence in the event of litigation; it is essential that all entries
contain significant and pertinent data relative to nursing care. At the
minimum, entries are required on SF 510 once every shift for intensive nursing
care and moderate nursing care patients; every 24 hours for minimal nursing
care patients; and once a week for self-care patients.

17-46
 FM 8-230

e. Medications. Accomplishment of orders for Narcotic and PRN or

STAT medication will be entered on SF 510. Each entry will include time,
medication, and indication for administration. Assessment of effectiveness of
action of medication will be noted following administration. If, for any reason,
scheduled medication or treatment is not given, enter this fact and reason for
its omission.

f Special Procedures. Diagnostic, therapeutic and special nursing

procedures, and usual occurrences will be described in SF 510. Notation will
include time, name of procedure, by whom performed, brief description of what
was done, patient's condition before and during the procedure, and the
patient's reaction after the procedure.
NOTE

Nursing Notes may also be written in the

" signs and symptoms, observations,
assessment, and plan" (SOAP) format as
shown below.
17-60. SF 5 1 1

a. Preparation of SF 511 (Clinical Record-Temperature - Pulse­

Respiration). Enter patient's identification data and social security number in
the space at bottom of the form. This form will be maintained in the patient's
chart (Figure 1 7-10).
b. Recording Data. Number the " Hospital Day" line of blocks with
day of admission as 1 , and continue consecutively. The day of surgery or other
event is the operative day. The day following surgery is noted as the first post­
operative day. The day and hour blocks will be properly labeled. Represent
temperature by dots (.) placed between the columns and rows of dots and
joined by straight lines. If route of determination is other than oral, it should
be indicated by (R) for rectal and (A) for axillary. Show pulse determination by
use of (o) connected by straight lines. Enter respiration and blood pressure on
the indicated rows below the graphic portion. Record frequent blood pressure
readings on the form's graphic portion by entering an "X" between the
columns and row of dots at points equivalent to systolic and diastolic levels.
Connect the two with a vertical solid line. Use blank lines at bottom of the
sheet to record special data such as 24-hour total of patient's intake and
output.

( 1) When the diastolic blood pressure falls below the recorded

pulse symbol (o), and the straight line connection is drawn between the blood
pressure symbol (x), the connecting line will be drawn to the edge of the blood
pressure symbol on each side, top and bottom to form the connecting link but
never completely through the pulse symbol or the temperature symbol.

(2) If the systolic blood pressure and the pulse are to be recorded
on the same line, the pulse will be recorded with its normal symbol and the
systolic pressure symbol will be recorded around it with an imaginary (x). In
Figure 1 7-10, the straight connecting line (o) will be drawn as described above
and the same basics will be used in the application of recording a temperature
and blood pressure. Symbols for vital signs will never be drawn completely
through each other when recorded on the temperature, pulse, and respiration
(TPR) graphic sheet.

17-47
FM 8-230

N U R S I N G N OTES
CLINICAL RECORD ( Sign all notes )

DATE OBSERVATIONS
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112- 3 5 - 1 254
Standard Form 510
Gener1I Services Admin istr1tion and
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t...:L C M 4A FPMR 101-1 1 . 806--8-0ctober 1975

SlG-109

USA Het>DA<!.

Figure 1 7-8. SF 510, Clinical Record-Nursing Notes.

17-48
 FM 8-230

N U R S I N G N OTES
CLIN ICAL RECORD : S1en ull nutn 1

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NURSING NOTES
St•rid•rd Form 510
Gener1l Services Admin istr1tion and
lnter1aency Committee on Medical Records
FPMR 1 0 1 - 1 1 806-8-0ctober 1975
M - 3z I ST D I v c L R co . SlG-109

Figure 1 7-9. SF 510, Clinical Record-Nursing Notes in SOAP format.

17-49
FM 8-230

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M E D I CAL R E C O R D V I TA L SIGNS RECORD

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or w r i t t e n e n t r i e s
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f> P C. G:> l 'l - 3o - 3 o l :Z..

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Prescribed by GSA 1nd lnt1111pncy

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Figure 1 7-10. SF 511, Medical Record- Vital Signs Record.

17-50
 FM 8-230

17-61. Temporary Nursing Records

The following DA forms are part of the Temporary Nursing Record, and
information on these forms can be found in Chapter 3, AR 40-407.

a. DA Form 3872-Nursing Service Personnel Time Schedule.

b. DA Form 3889-Nursing Unit 24-Hour Report.

c. DA Form 3889-1 -Nursing Unit 24-Hour Report-Continuation

Sheet.

d. DA Form 3950-Temperature, Pulse, and Respiration Record

Worksheet.

e. DA Form 395 1-Nursing Service-Assignment Roster.

f DD Form 792-24-Hour Patient Intake and Output Worksheet.

g. DA Form 1 924-Surgical Checklist.

h. DA Form 4028-Prescribed Medication.

Section IX. USE OF THE US FIELD MEDICAL CARD

17-62. General

a. The US Field Medical Card (DD Form 1 380)(AR 40-66) is used to

record data similar to that recorded on the ITRCS. The FMC will be used by
aid stations, clearing stations, and nonfixed troop or health clinics working
overseas, on maneuvers, or attached to commands moving between stations.
It may also be used to record an outpatient visit when the HREC is not readily
available at an MTF. The FMC is used in the theater of operations during time
of hostilities. It also may be used to record CRO cases.
b. The FMC is made so that it can be attached to the casualty. The
cards are issued as a pad, with each pad consisting of an original card, a sheet
of carbon paper, a carbon protective sheet, and a duplicate.

c. Use of the FMC is covered by NATO STANAG 2132 .

17-63. NATO STANAG 2348 Requirements

The ITRs of NATO personnel treated by Army MTFs are prepared the same
as ITRs for other patients. This applies to DA Form 1 380 (Record of
Individual Performance of Reserve Duty Training), DD Form 1 380, and DD
Form 602. In addition, the following policies cover NATO personnel:

a. If a service member is transferred to hospitals of other nations, his

ITR will go with him. When he is discharged from an Army MTF, his record
will be sent to his national military medical authority. (See Table 2-4, AR
40-400 for a list of these authorities.) Sometimes DD Form 1 380 or DD Form
602 (STANAG 2 1 32) will be prepared as well as an ITR. If so, these forms will
go with the ITR.

17-51
FM 8-230

b. The amount of information put in an ITR should be STANDARD

for all forces. All items normally recorded for US personnel will be recorded for
NATO personnel. In addition, the marital status of the NATO member will be
recorded.

17-64. Preparation of Field Medical Cards

a. An MTF officer will complete the FMC or supervise its

completion. However, the company aidman first attending the casualty may
initiate an FMC. To do this, he will record the name, SSN, and grade of the
patient (Figure 1 7-1 1 ). He will also briefly describe the medical care of
treatment given and enter as much information as time permits (Figure 1 7-1 1 ).
After doing this, he will put his initials in the far right side of the signature
block (Item 29, Figure 1 7-1 1). The supervising AMEDD officer will then
complete, review, and sign the FMC.

b. An FMC will be prepared for any patient treated at an MTF. For

transfer cases, the FMC will be attached to the patient's clothing. It will
remain with him until his arrival at a hospital, his death and interment (burial),
or his return to duty. If a patient dies, the FMC will remain attached to the
body until interment when it will be removed. If the body cannot be identified
when it is to be interred, the registration number given the remains by the
Graves Registration Service will be noted on the FMC.

c. Under combat conditions, the aidman may only partially complete

the FMC for patients being treated. Otherwise, all entries will be completed as
fully as possible. The blocks that must be complete are 1 , 2, 4, 13, 14, 20, 21 (if
a tourniquet is applied), 22, and 29. This also applies to the battalion aid
station when patients are being transferred to another MTF during a combat
situation. Instructions for completing items on the ITR cover sheet apply to
similar items on the FMC; all abbreviations authorized for use on the cover
sheet may also be used on the FMC. Except for those listed below, however,
abbreviations may not be used for diagnostic terminology.
Ahr W-Abraded wound

Cont W-Contused wound

FC-Fracture (compound) open

FCC-Fracture (compound) open comminuted

FS-Fracture simple (closed)

LW-Lacerated wound

MW-Multiple wounds

Pen W-Penetrating wound

Perf W-Perforating wound

SV-Severe

SL-Slight

17-52
 FM 8-230

d. FMC may also be used for "CARDED FOR RECORD ONLY"

cases. Certain cases not admitted to MTF will be CRO. For CRO cases, DA
Form 3647 or DD Form 1 380 will be prepared; and a registrar number
assigned. When DA Form 3647 is used, Items 7, 10, 1 4, 24, 27, 30, and the
name of the admitting officer need not be completed. When the FMC is used,
I tern 1 1 need not be completed.

17-65. Supplemental Field Medical Cards

When more space is needed, another FMC will be attached to the original. This
second one will be labeled in the upper RIGHT corner" FMC #2" and will show
the patient' s name, grade, SSN, and nation. See Figure 17-12.

1 2

Ll-5 A..
1 NAMIE /Last - F!rsJ-M1ddl• m1t1a1J I NOM. PAeNOMS $EAV1Cli NUMBER 1 NUMErl'.J 4 N P. T I Q N , NATIQr , f a g Et<!IS
MAfRICULC Un•SJ

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SEAVICe5 1er;i :7·-.
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12 FP.CIUTY WHERE TAGGE D t UEU D E TABUSSEMEi'�T 3 O�fE k'�H TAG3i:.DIDATE E T --­
DE LA FICHE HEURl [) l T '"-BLISSEM5:NT Di:. LA F•CHE

JS o r,
11 DIAGNOS!S(lncludma c111H) / OlAGNOSTIC IC.use compr1u) NATURE OF CASUALT't' UR ILL"IESS 1'l 0A1� & HOUR
NA TUAE DE LA B!..ESSURE Q:_o MALAWIE INJtii::ie:J . DATE

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6LES�E

15 LINE OF DUTY/EN
Ra.ATJON AVEC LE SERVICE

f2Ajff�J:tf��f��f�J £: i �:!1��f:g�ofi��c,:;ro�7'6t. 3d":n�ls� g?J:,s=���u�':il��,':,1 1 n:tEATMSNT I TtlAITF.ME-,T f• ·

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27 DtSPOSIT lON
AU BLESSE
- OISPOSAL / OESTINAT!ON DONNEE 29 MEDICAL OFFICE:.fl (S1r;natur11 & Grade/ !SIGNATURE ET GRADE:. OU MEDECIN
� 1/ <
'-' , -..,.. .,}

DD FORM 1380. 1 JUN'" U. S. FIELD MEDICAL CARD I FICHE MEDICAcE DE L' AVANT ET ATS-UNIS

Figure 1 7-11. DD Form 1380, US Field Medical Card.

FM C#2
(Lui - F1r11-1.i1ddl• mrtial) I NOM. PReNOMS 2 SEAVIC& NUMBER I NUMERO 3 GRADE I GRA::E: � N.�T!ON I NA T I ON { � . Et.;its
Un1s)
1 NAMI
MATRICULE

6 BRANCH ANO TRA0£ tARMEE ( e g lnlentcne,' 7 UNIT ! UNITE 8 SER\.lCi:: ' Yrs/ I our.EE DES
SEAVIC!:S/e �- 2 5, 121

12 FACILITY WHERE TAGGED I LIEU 0 ETABLI5SEMENT 1 3 04 �= ,1.�0 HOllR TllGGE:OIOATE ET

DE LA FICHE HiUf.( D HABLISSEMliNT DE LA FICHE

Figure 17-12. "FMC #2".

17-53
FM 8-230

17-66. Disposition of Field Medical Cards

a. For Patients Admitted and Discharged and CRO Cases. The

original FMC of CRO case or of an admission with a disposition other than to a
hospital will be sent to higher headquarters within the command for coding.
After coding, the FMC will be disposed of in accordance with AR 340-18-9.

b. For Transfer Patients. When a patient arrives at a hospital, his

FMC will be used to prepare his ITR. This FMC will then become part of his
ITR (see Table 7-1 , AR 40-66).

c. For Outpatients. The original of an FMC used to record outpatient

treatment will be filed in the patient's HREC or OTR.

d. Carbon Copies. All carbon copies of FMC will be destroyed locally

after 3 months.
17-67. DA Form 4006

DA Form 4006 (Field Medical Record Jacket) may be used as an envelope for
the FMC. To keep the jacket from being opened while the patient is in transit,
pertinent personnel and medical data on the patient may be recorded on the
outside. The movement of the patient may also be recorded. When the jacket
has been so used, it must become a part of the ITR.

17-68. Instructions for Completing DD Form 1380

a. Item 1 (Name).

b. Item 2 (Service Number). Enter SSN for US military personnel.

Enter service number for foreign military personnel (including prisoners of
war). Leave blank for all others.

c. Item 3 (Grade). Enter patient's grade. Use abbreviations listed in

Table 1 7-6.

d. Item 4 (Nation). Enter country of whose armed forces the patient is

a member (for example, enter "USA" for US Armed Forces).

e. Item 5 (Force). Enter specific armed service of patient.

f. Item 6 (Branch and Trade). Enter branch or corps for US officers.

Enter Special Skill Identifier (SSI) or brief description of occupation (for
example, "rifleman; " for foreign military enter similar information).

g. Item 7 (Unit). Enter military unit. For civilian, enter enough

information to identify patient (for example, "wife, Army SGT").

h. Item 8 (Service). Enter length of service for military personnel.

Include all active duty during previous tours or enlistment even if interrupted.
Show length of service less than 1 month in days (for example, "23/365")
service less than 2 years in completed months (for example, " 1 3/24") and
service of more than 2 years in completed years (for example, "3 YRS" for 3
years and 9 months).

i. Item 9 (Age). Enter patient's age.

17-54
 FM 8-230

j. Item 10 (Race). Enter ' 'Cau " for Caucasian; "Neg" for Negroid·
'
"0th" for other races; " Unk" for unknown.

k. Item 11 (Religion). Enter patient's religious preference. If none,

enter "None. "

l. Item 12 (Facility Where Tagged). Enter MTF and location.

Describe location in broad geographic terms (for example " Near Cu Chi
' '
RVN").

m. Item 13 (Date and Hour Tagged). Enter date and time initial
treatment was started. Enter time using the 24 hour system.

n. Item 14 (Diagnosis). Enter disease or injury requiring treatment.

(1) Punctured, penetrating, or missile wounds. Give point of

entry and name organs, arteries, or nerves involved, if known.

(2) Injuries not incurred in combat. State the nature of the

injury; the causative agent; the body parts affected; the circumstances
causing the inj ury; if accidentally incurred, deliberately self-inflicted, or
deliberately inflicted by another; and the place and date.

(3) Injuries incurred in combat. Add to the details described in

(2) above that the inj ury was the result of enemy action. Also include causative
agent and general geographical location (for example, "Near Seoul, Korea").

(4) Injuries or diseases caused by chemical or bacteriological

agents or by ionizing radiation. Add to the details described in (2) above, the
name of the agent or type of ionizing radiation. (If the name is not known,
provide information that is known about the physical, chemical, or
physiological properties of the agent (odor, color, physical state)). Also state
date, time, and place of contamination; time between contamination and
treatment; and nature of treatment. For those affected by ionizing radiation,
also report the approximate distance from the source; if exposure was to
gamma rays, the actual or estimated dosage (for example, "est 1 50 rad" or
"measured 200 rad") and if exposed via airburst, ground burst, water surface
burst, or underwater burst.

o. Item 15 (Line of Duty). Enter "Yes" or "No. "

p. Item 16 (Injury). If injury, check Item 16 and indicate whether

injury was caused by enemy action or not caused by enemy action; that is, if
enemy action check "Yes. "

q. Item 1 7 (Sick). If disease (sick), check Item 1 7 and indicate whether

disease was caused by enemy action or not caused by enemy action.

r. Item 18 (Date and Hour of Injury). Self-explanatory. If injury

occurred prior to treatment, estimate as accurately as possible the date and
time of injury.

s. Item 19 (What Patient Was Doing When Injured). Enter

circumstances leading to injury.

17-55
FM 8-230

t. Item 20 (Treatment Given). Enter any antibiotics, drugs, blood

plasma, and other treatment given. Enter name of antibiotic and/or drugs, and
each dose, hour, and date it was given. If more space is needed, use Item 32 on
reverse side of the FMC.

u. Item 21 (Tourniquet). Enter "Yes" or"No. " If yes, enter date and
time applied.

v. Item 22 through 26. Enter the dose, time, and date if any of the
drugs in Items 22 through 26 were given.

w. Item 27 (Disposition). Enter one of the following:

( 1 ) "Transfer. " When transferred to another MTF. When MTF

is not known, enter general destination and means of transportation.

(2) "Duty. " Inpatient return to duty.

(3) "Died. " Died after admission.

(4) "CRO. " For military patients carded for record only and
returned to duty, enter "CRO-Duty. " For deaths carded for record only,
enter "CRO-Death." (Death on Arrival (DOA).)

x. Item 28 (Hour and Date of Disposition). Self-explanatory.

y. Item 29 (Medical Officer). Enter signature, grade, and organization

of MTF commander, medical officer, or selected enlisted members authorized
to sign the FMC.

z. Item 30 (Religious Information). Completed by chaplain.

aa. Item 31 (Diet). Check appropriate box.

bb. Item 32 (Remarks). Use this item to continue or expand any

information given on the front of the form, cross-reference the item being
continued. Use this item also to give any additional information that might be
needed for a patient being evacuated through the MTF. For transfer cases,
enter the date and hour of transfer. When additional treatment is given en
route, state the nature of the treatment, where it was given, and the date and
hour it was given. For deaths en route, state the date, hour, cause, and
approximate place of death as well as any other pertinent information. For
patients returned to duty when they arrive at the MTF, enter that they were
returned, the date, the MTF, and the hour returned. For these cases, no ITRCS
is needed but IPDS (Individual Patient Data System) coding is required.

17-56
 FM 8-230

Table 1 7-6. Officer and Enlisted Grade Structure.

I ARMY MARINES
NAVY/
COAST GUARD A I R FORCE
DATA
C ODES

G EN E RA L OF THE FLEET A D M I RAL G ENERAL OF T H E G5

ARMY ( GA) ( FADM) A I R FORCE
(GenAF)

G EN E RAL(GEN) G E N E RAL ( G E N ) A D M I RAL ( A D M ) G E N ERAL ( G EN ) G3

LIEUTENANT LI EUTENANT VICE A D M I RAL LIEUTENANT G3

G E N E RAL G E N ERAL (VADM) GEN ERAL
( LTG) ( LtGen) (LtGen)

MAJOR G E N E RAL MAJO R G E N E RAL REAR A D M IRAL MAJ O R G E N E RAL G2

(MG) ( M aj Gen) ( RADM) ( Maj Gen)

BRIGADIER BRIGA D I E R COMMODORE BRIGADIER G1

G E N E RAL ( B G ) GENERAL ( BrigGen) ( C ommodore) G E N ERAL ( BGen)

COLONEL ( C O L) COLONEL (Col) CAPTAIN ( CAPT) COLONEL (Col) 06

LI EUTENANT LIEUTENANT COMMANDER LIEUTENANT 05

COLONEL ( LTC! COLONEL ( LtCol) ( C D R) COLONEL (LtCol)

MAJOR ( MAJ) MAJOR ( M aj) L I EUTENANT MAJ O R ( MAJ) 04

COMMANDER
( LCDR)

CAPTAIN ( C PT) CAPTAIN ( Capt) LI EUTENANT CAPTAIN (Capt) 03

( LT)

F I RST F I RST LIEUTENANT, F I RST 02

( L I E UTEANT ( 1 LT) LIEUTENANT J U N I O R GRADE LIEUTENANT
( 1 st Lt) ( LTJG) ( 1 stLt)

SECOND SECOND ENSIGN ( ENS) SECOND 01

LIEUTENANT ( 2 LT) LIEUTENANT LIEUTENANT
( 2 dLt) ( 2 dLt)

C H I E F WARRANT C H I E F WARRANT C H I E F WARRANT CHIEF WARRANT W4

OFFICER (CW4) OFFICER (CW04) OFFICER (CW0-4) OFFICER (CW0-4)

CHIEF WARRANT C H I E F WARRANT C HIEF WARRANT CHIEF WARRANT W3

OFFICER (CW3) OFFICER (CW03) OFFICER (CW0-3) OFFICER (CW0-3)

CHIEF WARRANT CHIEF WARRANT CHIEF WARRANT C H I E F WARRANT W2

OFFICER (CW2) OFFICER (CW02 OFFICER (CW0-2) OFFICER (CW0-2)

WARRANT OFFICER WARRANT OFFICER WARRANT OFFICER WARRANT OFFICER W1

(W0 1 ) (WO) (W0- 1 ) (WO)

SERG EANT MAJ O R SERGEANT MAJOR MASTER C H I E F CHIEF MASTER E9

OF THE ARMY OF T H E MARINE PETTY OFFICER S ERGEANT O F THE
(SMA) CORPS OF T H E NAVY AIR FORCE
( SgtMaj) ( M CPON) ( M SAF)

17-57
FM 8-230

Table 1 7-6. Officer and Enlisted Grade Structure-continued.

NAVY/ DATA
ARMY MARINES COAST GUARD A I R FORCE CODES

COMMAND SERGEANT SERGEANT MAJOR MASTER C H I E F CHIEF MASTER E9

MAJ O R (CMS) (Sgt Maj) PETTY OFFICER SERGEANT ( MSgt)
(MCPO)

STAFF SERGEANT MASTER G U N NERY E9

MAJ O R (SSM) S E RGEANT
(MGySgt)

F I RST SERGEANT FI RST SERGEANT SENIOR C H I EF S E N I O R MASTER ES

( 1 SG ) ( 1 st Sgt) PETTY OFFICER SERGEANT (S MSgt)
(SCPO)

MASTER SERGEANT MASTER SERGEANT ES

(MSG) ( MSgt)

PLATOON SERGEANT GU NNERY SERGEANT CHIEF PETTY MASTER SERGEANT E7

PSG) or (GySgt) OFFICER (CPO) ( M sgt)
SERGEANT FIRST
C LASS (SFC)

SPECIALIST 7 E7
(SP7)

STAFF SERGEANT STAFF SERGEANT PETTY OFFICER TECH N I CAL E6

(SSG) (SSgtl F I RST CLASS SERGEANT (TSgt)
( P0 1 )

SPECIALIST 6 E6
(SP6)

SERGEANT (SGT) SERGEANT (Sgt) PE:TTY OFFICER STAFF SERGEANT E5

(SGT) (P02) (SSgt)

SPECIALIST 5 E5
(SP5)

C ORPORAL (CPL) CORPORAL ( Cpl) PETTY OFFICER SERGEANT (Sgt) E4

THIRD CLASS
( P03)

SPECIALIST 4 (SP4) E4

PRIVATE FIRST LANCE CORPORAL SEAMAN AIRMAN FI RST E3

CLASS (PFC) ( LCpl) (Seaman) CLASS (ALC)

PRIVATE ( PVTl PRIVATE FIRST SEAMAN AI RMAN (Arnn) E2

CLASS ( PFC) APPRENTICE (SA)

PRIVATE ( PVT) PRIVATE ( Pvt) SEAMAN RECRUIT A I RMAN BASIC E1

(SR) (AB)

17-58
 FM 8-230

C HAPT E R 1 8

PHARMACOLOGY AND DRUG

ADMINISTRATION
18-1. General

Safe and effective administration of drugs is an essential part of patient care.

The medical specialist may be required to administer prescribed drugs. Since
administration of drugs is an accepted function of a professional nurse, it is
customary that instruction and supervised experience in drug administration
be conducted by an Army Nurse Corps officer in AMEDD training and
medical treatment facilities . The medical specialist who has demonstrated his
competence in administering drugs will perform this duty in accordance with
written local policy directives.
18-2. Definitions

a. Pharmacology. The science of drugs, especially the actions of

drugs on the body. No drug can introduce a new action in the body; it can only
modify actions already there. Drugs can either increase or decrease the actions
or functions of cells.
b. Therapeutics. The actions of drugs in the treatment of disease.
c. Drug. Any substance, or mixture of substances, used in the
treatment, prevention, or diagnosis of disease. The terms drug and medication
can be used interchangeably.
d. Poison. A substance which, when absorbed or ingested into the
body, may alter physiology by damaging body tissues or cells.
e. Toxicology. The study of poisons and their actions, the treatment
of poisoning, and the use of antidotes.
f Pharmacy. The art and science of preparing and dispensing drugs
for medical purposes. Pharmaceutical is the adjective which means
"pertaining to pharmacy. "
g. USP. The United States Pharmacopeia is an official reference on
the source, preparation, potency, and doses of commonly used and valuable
drugs.
h. NF. The National Formulary is an official companion reference to
the USP. It contains many commonly used drugs and preparations not
included in the USP. It designates their sources, methods of preparation,
standards of purity, and dosage.
i. PDR. This abbreviation refers to Physician's Desk Reference,
published yearly by a private company. Drug manufacturers cooperate in the
preparation of this book, and major products of the companies are listed.

18-3. Drug Legislation

State and Federal legislation provide for the enforcement of drug standards to
protect the public from fraud or from exposure to unsafe or unreliable drug
preparations. Three Federal laws covering drugs are the Food, Drug, and
Cosmetic Act (FDCA), the Harrison Narcotic Act, and the Drug Abuse
Control Act.

18-1
FM 8-230

a. The Food, Drug, and Cosmetic Act. The FDCA provides broad
coverage on the manufacture and distribution of drugs in interstate commerce
to prevent false and misleading statements and to provide for controlled
dispensing of drugs considered unsafe for self-medication. Amendments to the
FDCA require that drug preparations be labeled and that all habit-forming
and potentially toxic drugs have on the label this statement: "CAUTION:
Federal law prohibits dispensing without prescription. "

b. The Harrison Narcotic Act. This act i s the Federal narcotic control
law which regulates the importation, manufacture, prescription, sale, and use
of drugs defined as addictive. All derivatives of opium and cocaine are covered
except for some specific exemptions. The law provides for distribution of
controlled drugs through medical channels and for legal medical use only. All
personnel handling the drugs specified in the law are accountable for their use.
Careful and accurate records must be maintained, subject to Federal
inspection and, except as specified in the law, the possession of narcotics is a
Federal crime.

c. The Drug Abuse Control Act. This act governs the distribution
and control of barbiturates, amphetamines, and habit-forming drugs. Drugs
which have a potential of abuse because they produce a depressant,
stimulating, or hallucinogenic effect on the central nervous system also come
under this law.

18-4. Drug Nomenclature

Three name classifications of drugs are the chemical-scientific name, the
generic name, and the brand or trade name.

a. Chemical-Scientific Name. This name specifically identifies the

compound and is useful to technically trained personnel.

b. Generic Name. The generic or official name of a drug is assigned by

the producer of the drug in collaboration with the Food and Drug
Administration and Council on Drugs of the American Medical Association.
The generic name may be used by any interested person and is usually the
name found in the USP and NF. The generic listing is often used in the Federal
Supply Catalog and in AMEDD pharmacies. A generic drug name is not
capitalized; for example, aluminum hydroxide.

c. Brand or Trade Name. Trade names are copyrighted terms

selected by a manufacturer to designate a particular product. Copyright laws
prevent any other person from using the name, and other laws prevent
pharmacists from substituting chemically identical products for the trade
name article. When there are no longer any legal restrictions on the use of a
brand name, the most widely accepted and familiar name may become the
official or generic name. Aspirin is an example-in 1 963, this drug, previously
listed as acetylsalicylic acid, officially became aspirin, USP.

18-5. Sources of Drugs

There are five main sources from which drugs are obtained.

a. Mineral. Many mineral substances found in nature are used in

drugs. Examples: iodine, zinc oxide, and magnesium sulfate (epsom salt).

18-2
 FM 8-230

b. Plant. Certain drugs are derived from vegetables and plants.

Examples: digitalis, morphine, and senna pod extract.

c. Animal. The organs, tissues, and body fluids of animals (including

man) are the source of some drugs. Examples: certain hormones, antitoxic
serums, and gamma globulin from human blood.

d. Synthesis. Synthesis is the artificial building of a chemical

compound by the union of its elements. Drugs such as epinephrine that were
once available only from natural sources can now be artifically reproduced
through synthesis. Other drugs such as the sulfonamides were originally
created through synthesis.

e. Microorganisms. Microorganisms such as fungi and bacteria are

also sources of drugs. Examples: penicillin, tetracycline, and some vaccines.

18-6. Types of Drug Preparations

Drugs are compounded into various types of preparations (Figure 18-1),

depending upon each drug's physical characteristics, the purpose for which
intended, and the method by which it is to be administered. Some drugs are
prepared in more than one form so they may be administered several ways. To
give them bulk or form, drugs may be mixed with other substances called
vehicles which have no action or medicinal value. For a drug in aqueous
solution, water is the vehicle; for a drug in an ointment, fatty substances such
as petrolatum or lanolin are used as the vehicle. Drugs or mixtures of drugs
that are divided into definite doses are dosage forms. Examples of these forms
are capsules, tablets, ampules, and cartridge units. Some dosage forms
prepared for oral administration are coated with a special coating (enteric) that
resists the action of the stomach juices but dissolves in the intestine. This
helps prevent nausea, irritation of the stomach lining, or destruction of the
drug. Scored tablets are marked with an indented line across the surface so
that they can be broken in half, if a half dose is required. Drugs prepared with
flavored coatings or those in flavored vehicles are exceptionally hazardous to
children if left within easy reach. All drugs dispensed from an AMEDD
pharmacy bear labels stating, "CAUTION: Keep out of reach of children. "

a. Solid Preparations.

(1) Capsule. A drug placed in a gelatin container.

(2) Tablet. A drug compressed or molded into a flat disk or other

shape.

(3) Pill. A powdered drug molded into a sphere. The word "pill"
as a general term used for tablets is a misuse of the word.

(4) Lozenge. A drug preparation in a flat disk which is to be held

in the mouth until dissolved.

(5) Suppository. A drug which is molded into shape for insertion

into a body opening other than the mouth. Its vehicle, such as cocoa butter,
melts at body temperature and the drug is released.

18-3
FM 8-230

(6) Ointment. A drug suspended in a semi-solid base such as

petrolatum.

(7) Powder. A drug which is ground up and used in powder form.

b. Fluid Preparations.

( 1 ) Fluid extract. A concentrated fluid preparation. Fluid

extracts are 1 00 percent strength ( 1 ml of the preparation contains 1 Gm of the
crude drug).

NOTE
The abbreviation for gram is Gm, with
the first letter always capitalized. The
abbreviation for milligram is mg and for
milliliter is ml. Milliliter is the preferred
fractional measure of the liter; formerly
cubic centimeter (cc) was used.

(2) Tincture. An alcoholic solution of a drug. Tinctures of potent

vegetable drugs are 10 percent in strength; those of less potent drugs are 20
percent in strength.

(3) Elixir. A solution containing water, alcohol, sugar, and

flavoring substances, in which one or more drugs may be dissolved.

(4) Spirit. An alcoholic or hydroalcoholic solution of a volatile

drug.

l_;�

B. RECTAL SUPPOSITORIES
c;, � �. �
�
A. PILLS AND TABLETS

C. SOFT GELATIN
� CAPSULES
D. HARD GELATIN
CAPSULES
�
•
Figure 18-1. Solid preparation of drugs.

18-4
 FM 8-230

c. Abbreviations. The following abbreviations are commonly used in

prescriptions, written orders, and on labels of drug containers. The
abbreviation and its meaning must be learned; the derivation is necessary only
to show the connection with the abbreviation. Most are Latin words or phrases
which are abbreviated as shown in Tables 1 8- 1 , 18-2, and 18-3.

Table 18-1. A bbreviations Used in Dosage and Directions.

Abbreviation Derivation Meaning

aa . ana of each
ad . ad up to
ad lib ad libitum as much as desired
b . bis . . twice
C . centigrade
c cum . with
cc cubic centimeter
caps capsula capsule
F . Fahrenheit
Gm . gram . gram, grams
gr granum, grana grain, grains
gtt gutta . drop, drops
IM intramuscular
IV . intravenous
kg . kilogram thousand grams
l liter . liter
Lb., lb . . libra pound
mg milligram thousandth of a gram
ml . milliliter thousandth of a liter
ocul . oculus . the eye
o.d . . oculo dextro . in right eye
o.s. oculo sinistro in left eye
o.u. oculus uterque . in each eye
p.o . . per os by mouth
q.s. quantum sufficit a sufficient quantity
8 recipe take
s sine . without
SQ, s.c., sub q sub cutem . subcutaneous
sig . signa . label, let it be labeled
s.o.s . . . si opus sit . . if necessary
SS semis . one-half
tab tablet
tsp teaspoon teaspoonful
tbsp tablespoon tablespoonful
3 . drachma . dram
3 . uncia . ounce

18-5
FM 8-230

Table 18-2. Abbreviations Indicating Time of

Administration.
Abbreviation Meaning

a.c . . before meals

b.i.d . . twice a day
h. hour
h.s . . . at bedtime
p.c . . after meals
p.r.n. when needed
q.a.m . . . every morning
q.d . . every day (dailyl
q.p.m./h.s. every afternoon/night
q.2h., q.3h., q.4h . . every 2, 3, or 4 hours
q.i.d., or 4 i.d . . four times a day
q.o.d. every other day
stat . at once
t.i.d . . three times a day

Table 18-3. Abbreviations Indicating Hours of

Administration.

Abbreviations Meaning

q.i.d. 0800, 1 200, 1600, 2000

q.2h . . 0600, 0800, 1000, 1 200, etc.
q.3h . . 0900, 1 200, 1500, 1800, etc.
q.4h. . 0800, 1 200, 1600, etc.
q.6h. . 0600, 1200, etc.
b.i.d. . 1000, 1600
t.i.d . . 1000, 1 500, and 1 800
a.c . . Y2 hour before meals: 0630, 1 1 30, 1630
p.c . . 0800, 1 400, 1800

18-7. Prescriptions

a. Definition. A prescription is an order written by a physician or a

dentist to a pharmacist, directing him to supply the patient named in the
prescription with the quantities of drugs specified. Directions for use of the
drugs are given by the physician or dentist and written on the label by the
pharmacist. A prescription is a legal document and must be signed by an
individual authorized to write prescriptions. Prescription forms must be
dated, the patient specifically identified, and in the AMEDD, the metric
system used.

18-6
 FM 8-230

b. Parts. A prescription consists of-

(1) Date i t was written.

(2) Name of the patient and, in the military, his ward or

organization.

(3) The symbol R, an abbreviation of the Latin word "Recipe"

meaning "Take thou. . . "

NOTE

This list contains examples of hours of

administration of drugs when the instructions
of the physician indicate only the number of
doses to be given each day. A local policy
directive should be consulted since hours of
administration of drugs are customarily
coordinated with local hospital hours for meal
service, "lights out " at night, or other routine
hospital activities.

(4) Names and quantities of the drugs. Army prescriptions are

written in English with amounts in the metric system.

(5) Instructions to the pharmacist.

(6) Instructions to the patient.

(7) Signature of the physician.

18-8. Pharmaceutical Weights and Measures

a. Two systems of weighing and measuring drugs are used, the

metric system and the apothecary system. The metric system is the official
system used by the Army. However, there may be occasions when drugs are
prescribed in the apothecary system and a medical specialist qualified to
administer drugs must know how to convert apothecary measurements to
metric measurements. Table 18-4 lists metric doses with approximate
apothecary equivalents. These equivalents represent the quantities usually
prescribed under identical conditions in either the metric or the apothecary
systems of weights and measures.

b. Certain abbreviations are commonly used and are shown in Table

1 8-4.

18-7
FM 8-230

Table 18-4. Metric Doses with Approximate Apothecary Equivalents.

Liquid Measure Liquid Measure

Approximate Approximate
Metric Apothecary Metric Apothecary
Equivalents Equivalents

1 ,000 ml . . . . . . 1 quart 3 ml . . . . . . . 45 minims

750 ml . . . . . 1 % pints 2 ml . . . . . . . 30 minims
500 ml . . . . . . 1 pint 1 ml . . . . . . . 1 5 minims
250 ml . . . . . . 8 fluid ounces 0.75 ml . . . . . . . 12 minims
200ml . . . . . . 7 fluid ounces 0.6 ml . . . . . . . 10 minims
100 ml . . . . . . 31!. fluid ounces 0.5 ml . . . . . . . 8 minims
50 ml . . . . . . 1 % fluid ounces 0.3 ml . . . . . . . 5 minims
30 ml . . . . . . 1 fluid ounce 0.25 ml . . . . . . . 4 minims
1 5 ml . . . . . . 4 fluid drams 0.2 ml . . . . . . . 3 minims
IO ml . . . . . . 2 % fluid drams 0.1 ml . . . . . . l Y2 minims
8 ml . . . . . . 2 fluid drams 0.06 ml . . . . . . . 1 minim
5 ml . . . . . . 1 V. fluid drams 0.05 ml . . . . . . % minim
4 ml . . . . . . 1 fluid dram 0.03 ml . . . . . . . % minim

Weight Weight
Approximate Approximate
Metric Apothecary Metric Apothecary
Equivalents Equivalents

30 Gm . 1 ounce 30 mg . . . . . 1/2 grain

15 Gm . 4 drams 25 mg . . . . . 3/8 grain
lO Gm . 2 Y2 drams 20 mg . . . . . . 1/3 grain
7.5 Gm . 2 drams 1 5 mg . . . . . . 1/4 grain
6 Gm . 90 grains 12 mg . . . . . . 1/5 grain
5 Gm . 75 grains lO mg . . . . . . 1/6 grain
4 Gm . 60 grains ( 1 dram) 8 mg . . . . 1/8 grain
3 Gm . 45 grains 6 mg . . . . . . 1/10 grain
2 Gm . 30 grains ( Y2 dram) 5 mg . . . . . . 1/12 grain
1 .5 Gm . 22 grains 4 mg . . . . . . 1/15 grain
l Gm . . . . 1 5 grains 3 mg . . . . . . 1/20 grain
0.75 Gm . . . . . 12 grains 2 mg . . . . . . 1/30 grain

I
0.6 Gm . . . . . 10 grains 1.5 mg . . . . . . 1/40 grain
0.5 Gm . . . . . 7 % grains 1 . 2 mg . . . . . . 1/50 grain
0.4 Gm . . . . . 6 grains 1 mg . . . . . . 1/60 grain
0.3 Gm . . . . . 5 grains 0.8 mg . . . . . . 1/80 grain
0.25 Gm . . . . . 4 grains 0.6 mg . . . . . . 1/100 grain
0.2 Gm . . . . . 3 grains 0.5 mg . . . . . . 1/120 grain
0 . 1 5 Gm . . . . . 2% grains 0.4 mg . . . . . . 1/150 grain
0.12 Gm . . . . . 2 grains 0.3 mg . . . . . . 1/200 grain
O.l Gm . . . . . 1 % grains 0.25 mg . . . . . . 1/250 grain
75 mg . . . . . 1 V. grains 0.2 mg . . . . . . 1/300 grain
60 mg . . . . . 1 grain 0.15 mg . . . . . . 1/400 grain
50 mg . . . . . % grain 0.12 mg . . . . . . 1/500 grain
40 mg . . . . . 'la grain 0.1 mg . . . . . . 1/600 grain

18-9. The Metric System

The metric system is used in measuring length, volume, and weight. The meter
is the basic unit of length, the liter is the basic unit of volume or capacity, and
the gram is the basic unit of weight. Subdivisions and multiples of metric units
are based upon the decimal system, which means that they are divided or
multiplied by 10, 100, or 1 000 parts.

18-8
 FM 8-230

a. Subdivisions. When added to meter, liter, and gram, the prefixes

below show that the basic metric unit is to be subdivided.

(1) Milli- means 1/1000 of a unit (0.0001). Examples: millimeter

(length), milliliter (volume), and milligram (weight).

(2) Centi- means 1/100 of a unit (0.01 ). Examples: centimeter,

centiliter, and centigram.

(3) Deci- means 1/10 of a unit (0. 1). Examples: decimeter,

deciliter, and decigram.

b. Multiples. These are expressed by adding the following prefixes to

meter, liter, and gram:

(1) Kilo- means 1000 times a unit (kilometer, kiloliter, and

kilogram).

(2) Recto- means 100 times a unit (hectometer, hectoliter, and

hectogram).

(3) Deka- means 10 times a unit (dekameter, dekaliter, and

dekagram).

c. Importance of the Decimal Point. The placement of the decimal

point in the metric system indicates the decimal progression by tens,
hundreds, or thousands. In writing the fractional part of a metric unit, a zero is
placed before the decimal point to help prevent misreading the decimal
fraction, which could be very dangerous when working with drugs. Table 18-4
shows that fractional parts of metric units are preceded by zero.

18-10. Converting Between Units in the Metric System

As a general rule, drug quantities less than 0.1 Gm are expressed as

milligrams; quantities more than 0 .1 Gm are expressed as grams.

a. Grams to Milligrams. To convert grams to milligrams, move the

decimal point three places to the right (multiply by 1 000). Examples: 0.075 Gm
= 75 mg; 0.25 Gm = 250 mg.

b. Milligrams to Grams. To convert milligrams to grams, move the

decimal point 3 places to the left (divide by 1 000). Examples: 1 000 mg = 1 Gm;
500 mg = 0.5 Gm.

18-11. Converting Measurements From Apothecary to Metric

When an apothecary measurement must be converted to a metric

measurement and there is no conversion table available for referral, it is
essential to know how to convert the necessary measurements by calculation.

18 9
-
FM 8-230

a. To convert grains to milligrams, multiply grains by 60 to obtain

milligrams. Example: How many milligrams in 1/4 grain of morphine
sulphate?

60
1/4 X 60 = 4 = 15 Answer: 15

b. To convert fluid ounces to milliliters, multiple by 30. Example:

How many milliliters in 10 fluid ounces of water?

1 0 x 30 = 300 Answer: 300 ml

c. To convert minims to milliliters, divide minims by 1 5. Example:

How many milliliters in 1 0 minims of solution?

�
1 5/ 1 0.00 Answer: 0.66 ml

18-12. Calculation of Doses From Tablets or Capsules

If the dose to be given does not correspond with the dose indicated on the drug
container label, it is necessary to calculate how many tablets or capsules
available will contain the required dose. The rule to be used is-divide the
desired dose by the dose on hand to determine the number of tablets or
capsules required.

a. Example 1. The order is written to give tetracycline hydrochloride

0.5 Gm. The label on the drug container reads, "tetracycline hydrochloride
0.25 Gm. "

0.50
0.25 = 2 Answer: Give 2 capsules, each
containing 0.25 Gm.

b. Example 2. The order is written to give tetracycline hydrochloride

500 mg. The label on the drug container reads, "tetracycline hydrochloride
0.25 Gm. " An additional step is needed in this example; since the order is
written in milligrams, grams must be converted to milligrams.

Step 1 : Convert grams to milligrams. 0.25 = 250 mg.

500
Step 2: 250 = 2 Answer: Give 2 capsules, each
containing 0.25 Gm.

18-13. Calculation of Doses From Drugs in Solution

Drugs for injection are usually dispensed as sterile solutions in sealed, single­
dose glass ampules or in rubber-stoppered, multiple-dose vials. The strength of
the solution is written on the label of the drug container; for example, " 1 0 mg
per ml." The problem is to determine what quantity of solution available
contains the dose of drug required. The rule to be used for this type of problem
is: amount of drug is to finished solution as the ratio of strength. The method
of solving the problem is by ratio and proportion.

18-10
 FM 8-230

a. Example 1. solution of diphenhydramine hydrochloride contains

10 mg per ml. The dose to be given is 5 mg.

Amount of drug finished solution ratio of strength

5 mg X ml : 10 mg : 1 ml

5 mg X ml : : lO mg : 1 ml

10 x = 5
5
x = 10 = 0.5 ml

Answer: Give 0.5 ml of solution, which contains 5 mg

diphenhydramine hydrochloride.

b. Example 2. A solution of chlorpromazine hydrochloride contains

25 mg per ml. The dose to be given is 0.025 Gm.

Step 1. Change grams to milligrams-0.025 Gm = 25 mg.

Step 2. Amount of drug: finished solution : : ratio of strength

25 ml : x ml : 25 mg : 1 ml

25 x = 25

x = 1 ml

Answer: Give 1 ml of solution which contains 25 mg of chlorpromazine

hydrochloride.

18-14. Calculations of Intravenous Drop Rates

Intravenous (IV) fluids are administered at prescribed rates of flow which are
expressed as cc/hr or ml/hr. The rate of flow must be measured precisely so
that the patient does not receive too great or too little a volume of fluids. To
calculate the flow rate, the medical specialist must know the rate of delivery
for the IV tubing set being used. The most common IV tubing used has a
delivery rate of 20 drops per cc. This means that 20 drops from the drip
chamber will be equal to 1 cc of IV fluid administered. Other IV tubing sets
have delivery rates of 60 drops per cc, 1 5 drops per cc, or 10 drops per cc. The
IV tubing package will state the rate of delivery for that particular IV set. The
medical specialist must also know the volume to be infused over the prescribed
time.

18-11
FM 8-230

Example: The physician orders an IV rate of 100 cc/hr. The tubing used
delivers 20 drops per cc.

Rate = 100 cc/hr

gtt/cc = 20

Time in minutes = 60

gtt/min = volume to be infused X gtt/cc of administration set

infusion time in minutes

100 x 20
60 = 33.33

You will adjust the IV flow rate to 33 drops per minute to deliver 100 cc/hr. If
your calculated flow rate comes out as a decimal, round it off to the nearest
whole number.

18-15. Actions of Drugs

Drugs act by increasing or decreasing the actions or functions of body cells.

Stimulation results in increased cell activity. Depression results in decreasing
cell activity. Drugs which act at the site of application on the skin or mucous
membrane have a local action. Drugs which act after absorption into the blood
stream and distribution to all parts of the body have a systemic action. It is
important to realize that some drugs applied externally to the skin or mucous
membrane (such as nose drops containing phenylephrine) are absorbed and
have both a local and a systemic action; others, although taken internally
(such as aluminum hydroxide), have a local action because they are not
absorbed from the mucous membrane of the gastrointestinal tract.

18-16. Administration of Drugs

Administration of drugs and medicines deals with the various methods by

which they are applied to the body for local effect, or introduced into the body
for systemic or general effect. Some drugs may be used either way.

18-17. External Administration

Topical (external) application of a drug is usually made for the local effect it
will have on the skin or mucous membrane of a specific area. Sometimes such
an application is made for its effect on underlying tissues. The preparations
most commonly used are-

a. Solutions. Applied locally as antiseptics, cleaning agents,

astringents, vasoconstrictors. counterirritants, or emollients (soothing agents).
Solutions are also used as wet dressings, mouthwashes, gargles, irrigations,
and soaks. Since solutions evaporate, the effect produced is often temporary.

b. Ointments. Provide a means of applying drugs for a prolonged

local effect. The drug is mixed in a fatty material such as lard, petrolatum, or
lanolin, which becomes soft or liquid when warm but does not evaporate. Thus,
the drug is kept in contact with the body for a long period. Ointments are not
used on discharging wounds because they prevent free drainage.

18 12
-
 FM 8-230

c. Suppositories. Used for insertion into a body cavity; for example,

in the rectum or vagina. The drug is mixed with a solid inert base which melts
at body temperature. The mixture is shaped into a cone or cylinder which can
be easily inserted. An example of a suppository base is cocoa butter. After the
base melts in the cavity, the active drug comes in contact with the mucous
membrane. If the nature of the drug is such that it is absorbed through the
membrane, a systemic effect may be produced. An example of a drug which
?
pro l!-ces a systemic effect when administered as a rectal suppository is
aspirm.

18-18. Internal Administration

Drugs may be given internally by several methods. When they are so given,
the effect may be upon the whole body, or on one of the systems, or only at the
site where the drug is administered. The common methods of internal
administration are-

a. Oral The most common way to give a medicine is by mouth, either

in solid or liquid form. Giving a drug by mouth is the simplest way; it requires
no special apparatus; it is painless; and absorption takes place in a natural
manner.

b. Sublingual. A limited number of drugs are administered by placing

a tablet or drop under the tongue. The drug is held there until dissolved. It is
not swallowed, and a drink must not be taken until it has completely dissolved.
The absorption and action of drugs given this way is rapid. (The drug most
commonly used sublingually is nitroglycerine.)

c. Rectal. Medications are given by rectum for the purpose of

evacuating the colon, for local treatment of a diseased rectum or colon, or for
general absorption. To induce a bowel movement, drugs may be given by an
enema. Irrigations may be used to medicate the mucous membrane of the
rectum or colon. Rectal suppositories also are frequently used. Another
method by which substances are administered through the rectum is
proctoclysis. Fluid is allowed to run into the rectum slowly, drop by drop, so
that it is absorbed and does not enlarge the rectum. The disadvantages of
rectal administration are the uncertainty of absorption and the chance that the
drug may be expelled.

d. Inhalation. Medications may be administered by inhaling them

into the lungs. This may be done by inhalation of aqueous preparations such as
medicated steam, sprays, or aerosols. Drugs given by inhalation include
various preparations for respiratory infections and diseases, medicinal gases
such as oxygen, and certain general anesthetics. Oily preparations are not
given by inhalation since the oil would damage lung tissue.

e. Injection. Drugs given by injection are administered with a sterile

needle and syringe; inj ection methods are also referred to as parenteral
( outside the intestine). An injection is used when rapid action by the drug is
desired, when the drug might be destroyed by digestive juices or vomited if
given by mouth, or when the patient is unconscious or injured so that he
cannot be given the medication by mouth.

18-13
FM 8-230

(1) Subcutaneous (hypodermic). The drug is inj ected into the

tissue just beneath the skin. A preparation for subcutaneous use must be a
sterile liquid capable of complet.e absorption or it will iriitate the tissues.
Although the subcutaneous injection may be given in almost any area of the
body, the usual sites are the lateral (outer) aspect of the upper arms, the lower
abdomen, and the anterior (front) of the thighs.

(2) Intramuscular. The drug is injected into a muscle in the

buttocks region, or in the upper arm or thigh. The needle is inserted, at a right
angle to the skin, through the skin and subcutaneous tissue into the
underlying muscle. This method gives more rapid absorption of the drug than
a subcutaneous injection.

(3) Intravenous. Drugs administered by vein act very rapidly

because the entire dose passes directly into the blood stream. A comparatively
small amount of sterile solution is given by intravenous injection; large
amounts, administered drop by drop, are given by intravenous infusion. The
usual site of injection is into the median basilic or median cephalic vein at the
bend of the elbow. Intravenous injection is used when the drug is too irritating
to be injected into other tissues, when immediate action is necessary, or when
circulation is so poor that absorption from other tissue would be retarded. The
IV administration of drugs is the responsibility of a medical officer or nurse; it
is not a routine procedure performed by nonprofessional nursing personnel.
When so performed, it must be in accordance with local policy directives.

(4) Intradermal. The drug is injected into the upper layers of

skin, rather than under the skin as in a subcutaneous injection. Minute
amounts (0. 1 ml and less) are given intradermally, usually to test for drug
sensitivity before administering larger amounts by other methods.
Absorption from intradermal inj ection is slow. The medial (inner) surface of
the forearm is the site most frequently used.

(5) Intraspinal (intrathecal). Drugs injected into the spinal canal

are usually injected into the subarachnoid space. Some anti-infective drugs as
well as spinal anesthesia are administered in this manner. The administration
of drugs in this manner is the responsibility of the medical officer.

(6) Other. Drugs may also be injected into the peritoneum

(intraperitoneal), into the heart muscle (intracardiac), into bone (intraosseous),
and j oints (intrasynovial). All of these procedures must be carried out by a
medical officer.

18-19. Factors Influencing Dosage and Actions of Drugs

Experience has shown that people usually react to similar drugs in similar
ways. The responsibility of prescribing the dosage of drugs rests with the
medical officer. Dosage is the determination and regulation of doses. Dose is
the quantity of drug to be given at one time. The individual responsible for
administering the dose prescribed should be informed about the factors
considered by the doctor when the drug is ordered-

a. Primary Factors. These include the drug, the dose, the patient, and
the judgment of the medical officer prescribing the drug.

18-14
 FM 8-230

( 1 ) The drug. The potency of a drug may be altered by the age of

the drug, its form, or the way in which it is administered.

(2) The dose. A minimal dose may be prescribed. This is the

smallest amount of drug that will produce a therapeutic effect. A maximal
dose is the largest amount of drug that will produce the desired effect without
accompanying symptoms of toxicity.

(3) The patient. The body weight, sex, age, and physical or
emotional condition of the patient may affect the action of a drug. In general, a
heavy person requires more of a drug than a small person. When a definite
concentration of drug in the blood is desired, the dosage is frequently
determined by computing the amount of drug per kilogram of body we!ght.
Dosage of drugs for pregnant women is an important factor that must be
taken into consideration because of the possible effect on the fetus. Older
people and children usually require less than the usual dosage of a drug.
Pediatric dosage forms containing suitably reduced concentrations of drug
may be specified by the physician as the dosage form to be administered.

(4) Judgment. The written order for a drug is based on the

medical officer's j udgment of what is required for a specific patient and the
order may not be altered by the individual who is to administer the drug. If the
drug ordered is not available or is not in the form required for administration,
the medical officer must be informed and a new order obtained.

b. Other Factors. Other factors that are considered by the medical

officer in determining the dosage include-

( 1 ) Idiosyncrasy. An unusual reaction to a drug which differs

from its characteristic pharmacological action. An example of idiosyncrasy
whould be excitement or restlessness after receiving a drug that normally
produces relaxation or sleep.

(2) Hypersensitivity. A patient with this response is allergic to

the drug or the vehicle in which it is incorporated. The tissues react with
symptoms ranging from itching, skin rash, or hives, to respiratory difficulty
and shock (circulatory collapse).

(3) Side effect. A drug given for a certain effect may have other
effects sometimes undesirable. These reactions are called side effects. For
example, morphine acts with a desirable effect when given to relieve severe
pain but causes an undesirable side effect by depressing respiration.

(4) Tolerance. This is a lack of reaction to a drug, usually

resulting from prolonged use. When this occurs, the dose must be
progressively increased to get the desired effect. Tolerance may be acquired
for morphine, barbiturates, and other drugs.

(5) Antagonistic action. Drugs that have an opposite effect to

other drugs are considered antagonistic. Such drugs can be very useful in
counteracting undesired effects as in the case of poisoning.

18-15
FM 8-230

(6) Cumulative effect. Sometimes, after numerous doses, a drug

accumulates, or builds up, in the body and continues to produce effects after
its use has been discontinued. This is due to the inability of the body to dispose
of the drug as rapidly as it is being given. An example of a drug which has this
stockpiling effect is digitalis.

(7) Habituation. This is emotional dependence upon a drug.

Barbiturates are among the drugs whose prolonged use can produce
habituation.

(8) Addiction. Addiction is a condition in which continued use of

a drug is necessary for the body to function normally. In addiction there is
usually tolerance as well, so relatively large doses of the drug must be taken to
obtain the drug effect. Among the drugs which may produce addiction are
morphine and other opium derivatives and drugs described by law as
narcotics.

18-20. Responsibility of the Medical Specialist in Drug Administration

Although it is the responsibility of the doctor to prescribe medication, it is the

medical specialist's responsibility to follow orders intelligently and with a
constant awareness of variations which occur in procedures for pouring and
administering drugs and in reactions of patients to drugs. He must comply
with several basic rules when he is assigned to administer drugs. He must-

• Be familiar with the drug prescribed.

• Not hesitate to check with a nurse, doctor, or pharmacist if he has

any doubt as to the nature of the prescribed medication, dosage, or method of
administration.

• Use proper techniques in the preparation of drugs he will

administer.

• Remain with the patient until the medication has been swallowed
if it is administered orally.

• Always record the medication on the patient's medical record in

accordance with local policy.

• Observe the patient closely for any signs of unfavorable reactions

and report them at once to a nurse or doctor.

18-21. General Rules for Preparation and Administration of Medication by

Any Method!?

General rules for preparation and administration of medications by any

method are summarized in table form for ready reference (Table 18·5).

18-16
 FM 8-230

Table 18-5. General Rules for Preparation and Administration of Medications

by Any Method.

DO DO NOT

1. Have written order from the doctor for all Caution. Do not allow any distraction
medications. such as conversation while prepar­

2. When the therapeutic documentation care ing and administering medication of

any kind at any time.
plan (medicated) is used:
a. Make certain that the data on the sheet
corresponds exactly with the doctor's
written order.
b. Identify each medication prepared by
comparing it with the medication sheet.
3. Know how drugs act; whether a local or • Do not give a drug with which you are
systemic effect is desired and what possible unfamiliar.
bad effects might occur.
4. Wash hands immediately before preparing
medication.
5. Read the drug container label three times • Do not use drugs from unlabeled con·
when preparing a medication. Make this a tainers or from a container whose label
deliberate procedure, checking the drug label is not legible.
against the order or the medicine card each
time:
a. Before taking container from shelf.
b. Before removing drug from container.
c. Before returning the container to its
proper place.
6. Measure the dose accurately. If liquid, • Do not give drugs that have been
measure at eye level. If calculation is nee· poured by some other person.
essary, recheck calculation. If any doubt
exists, verify by checking with some respon­ • Do not return any excess drug to the
sible person-nurse, doctor, pharmacist. container.

7. Request that all ambulatory patients

remain at their bedsides, as medication will
be brought to them.
8. Identify the patient by asking his name and • Do not rely on room, bed number, or
checking his identification band. name on bedcard to identify patient.

9. Remain with the patient until oral medi· • Do not leave a medication at bedside
cation has been swallowed. EXCEPTION: unless specifically ordered to do so by
If a written order requires medication at the the physician.
bedside, record the order on the medication
card. At time of administration:
a. Check supply of drug at bedside.
b. Verify by requesting patient to repeat
doctor' s instructions.

10. Use memo pad and pencil for on-the-spot • Do not rely on memory for important
observations. observations.

18-22. Preparation and Administration of Oral Medications

a. Observe carefully the general rules listed in Table 18-5.

18-17
FM 8-230

b. Check equipment required. This will include: medication orders,

tray or medicine cart, medicine glasses or calibrated paper cups, dropper,
graduate or dropper calibrated in minims, pitcher of water, paper cups for
water, drinking tubes, tongue blade or glass stirring rod, paper tissues, paper
towels, memo pad, pencil, and watch with second hand.

c. Prepare individual medications.

( 1 ) PUls, tablets, and capsules. Shake required number into

container cap and transfer to medicine glass or cup.

(2) Liquid medications poured from bottle.

(a) Place cap upside down on shelf or table. Hold medicine

glass so that the calibration mark of the prescribed amount is at eye level
(Figure 18·2) and place thumbnail on this mark.

)fl
/
/ WRONG
/
/
/
/
/

Figure 18·2. Technique for measuring liquids.

18-18
 FM 8-230

NOTE

When liquid is poured into a cylinder,

surface forces cause its surface to become
concave; that is, the portion in contact with
the cylinder is drawn upward. This is known
as a meniscus (Figure 1 8-2) and in
determining the volume of liquid, the
reading must be made at the bottom of the
meniscus. This can be done by holding the
container up so that the level of liquid is at
the line of sight or, with heavy objects,
lowering the body until the line of sight is
even with the level of liquid.

(b) Hold bottle label next to palm of hand, and pour from
side opposite label so that if a drop runs down outside of bottle it will not
obscure the label. Wipe neck of bottle with a damp paper towel before
replacing cap.

(c) Dilute poured medication, unless otherwise indicated,

with about 1 5 ml water or as illustrated.

(3) Liquid medication measured in drops. Draw up approximate

amount of solution into dropper. Count aloud the prescribed number of drops
into the medicine glass. Discard solution remaining in the dropper. Dilute
measured drops with 1 5 ml water, unless given other instructions.

(4) Liquid medication measured in minims. Use minim­

calibrated dropper or minim-calibrated graduate when medication order
requires minim measurement. A minim and a drop are NOT equivalent
measures.

(5) Powders and granules. Measure required amount into glass

or cup, but do not add water until at the patient's beside. At this time, add
water and stir. Rinse glass with small additional amount of water to remove all
residual drug and give this to the patient also.

(6) Cough syrups. Do not dilute with water. Have patient drink
water before taking medication and instruct him not to drink for 1 5 minutes
after taking medication.

(7) Sublingual medications. If sublingual (under the tongue)

medications are to be used, give no water and instruct the patient not to
swallow saliva until the taste of the drug has disappeared. These medications
dissolve rapidly and are absorbed rapidly through the oral mucous membrane;
they are less effective if swallowed.

(8) Lozenge. If a lozenge is given, tell the patient to hold it in his

mouth and let it dissolve slowly. There will be a relatively high concentration
of drug in the mouth and in the swallowed saliva; this effect is desirable for
absorption.

(9) Drugs with special requirements prior to administration.

Before administering a drug such as digitalis, record the patient's name, the
time, and the apical pulse rate. DO NOT administer digitalis to a patient
whose apical pulse is below 60 beats per minute.

18-19
FM 8-230

18-23. General Procedures for Preparing Medication for Injection

a. Patient Safety. Patient safety is a critical factor. You must learn

how to administer medications correctly. Once the medication is injected, you
cannot retrieve it. Incorrect injections may seriously harm or kill a patient.
Aseptic technique must be strictly maintained during the preparation and
administration of a drug. Foreign particles or other types of contamination on
a needle could be injected directly into the body. A secondary infection may be
introduced through the needle puncture in the skin. Improper technique or a
dull needle can cause irreparable damage to a major nerve or other structure.

CAUTION

Read syringe calibrations carefully to insure

correct dosage. Observe the patient closely
for any signs of adverse reaction to the
medication.

b. Instruments Used to Administer a Parenteral Injection.

Administering medicine by injection requires needles and syringes that are
sterile, accurate in measuring dosages, and convenient for use. This equipment
should produce as little discomfort or danger to the patient as possible when
medication is injected. Figure 18-3 illustrates a disposable rigid plastic
container, a disposable needle, and a syringe.

�
BJ--)

DISPOSABLE SYRINGE AND NEEDLE (parts labelled )

/PROTECTIVE COVER
I
Q >

€����c=-�'�--J:�)=��
/
SHAFT OF
BEVEL

NEEDLE

PLUNGER NEEDLE ADAPTER

NEEDLE HUB
BARREL

Figure 18-3. Disposable needle, syringe,

and container.

( 1 ) Needle. The needle is a tube with a cutting edge that

punctures beneath the protective area of the skin. It is made of steel or other
metal and is generally disposable. The parts of a needle consist of a lumen
(cavity through which medication flows), bevel (slanted tip/cutting edge), hub,
and cannula (shaft) (Figure 1 8-4). The needle comes in standard lengths from
1/2 inch to 6 inches long. The length is determined by measuring from the tip
of the point to the j unction of the shaft. The needle used must be sharp and
smooth to prevent damage to the patient. The choice of needle gauge and
length depends upon the thickness (viscosity) of the medication. The gauge
(size) is indicated by numbers 14 to 27. The higher the gauge number, the
smaller the diameter of the needle. A small gauge (large diameter) is needed for
viscous medications; a large gauge (small diameter) is needed for thin or
watery medications (Figure 1 8-5).

18-20
 FM 8-230

[ �=======�-
l HUB ---+--- CA NNULA ( SH A FT) ---+ BEVEL
Figure 18-4. Parts of a needle.

l "RffiuL"A R'sT ANDARD 1 rFoRolls. sER"u'Ms - 1

I I
2

I I I I
SIZES FOR G E NERAL USE I I A S P I R AT I N G , E T C .

I I I I
I I I I
I I
I I
(f) I I
LU
I I I
u
z

GAUGE 27

LENGTH 1 /2 " 1 /2" 5/8" 3 / 4 " 3/ 4 " 1" 1" 1 Y2 " 1 %"
1 Y.. " 1 Y• " 2" 2"
1 %" 1 %"

Figure 18-5. Needle sizes.

(2) Syringe. The syringe is the instrument used for givmg

inj ectable liquids. It consists of a barrel, plunger, and needle adapter that
attaches the needle (Figure 18-6). The plunger pushes the medication through
the barrel into the needle. The barrel is marked in cc's (ml ' s). Syringes come in
different sizes and lengths. The size of the syringe used depends on the amount
of solution and the type of medication. The outside appearance of a syringe
may be confusing because some syringes are marked in very small units, yet
they may be longer than others marked in larger units. Check calibrated
markings closely. The amount of medication in a syringe is read from the top

18-21
FM 8-230

part of the black tip of the plunger, which is the part nearest the needle. The
type of medication determines whether a glass syringe or d!-sposable plast�c
syringe should be used. As a general rule, you may use disposable plastic
syringes unless you have specific guidance to do otherwise.

> ..- $- N > M �

l111d111il1111l1111l1111l1111 I
3cc in 1 /1 Occ .

1 0c c . in 1 /5cc .

5 10 15 20 25 3 0 CC

111111111I1111I1111I111 1I1111I

I 30cc.

NEEDLE i---- BARREL

A D A PTER
in 1cc.

---�
·
\
PLUNGER �

Figure 18-6. Examples of syringes .

18-24. Preparing the Syringe for Use

Although the following information applies to the disposable type of syringe,

the principles are the same for the reusable type. When preparing syringes-

• Use aseptic technique in handling the syringe and needle. Protect

the surfaces that must remain sterile: the needle, tip, inner barrel, and plunger.

• Discard the syringe or needle if it becomes contaminated.

a. Select the Appropriate Syringe and Needle.

( 1 ) As you prepare to give an injection, the first step is to select

the appropriate size and type of needle and syringe. The needle and syringe
may be supplied in a preassembled unit; some hospitals stock them separately
and the desired types can be selected.

(2) Guidelines for types of needles and syringes have been

established for the various methods of injecting parenteral medications. When
giving intramuscular injections, the 3 ml syringe and a 19 or 22 gauge, 1 1/2
inch needle are generally employed. The 3 ml syringe and a 25 gauge� 5/8 inch
needle are used to give a subcutaneous injection. These sizes are modified as
necessary to accommodate different medications, sizes of dose, and the needs
of the patient.

18-22
 FM 8-230

b. Remove Protective Package.

(1) Rigi,d Plastic Package.

(a) Select the desired size of needle and syringe.

(b) Twist the plastic cap counterclockwise (Figure 1 8-7).

This breaks the sterile seal of the plastic syringe package.

Figure 18-7. Opening rigid plastic package.

(c) Remove the sheath from the barrel of the syringe

(Figure 1 8-8). The barrel of the syringe and the protective needle slip out of the
top of the sheath. Tap the needle protector lightly to make it easier to remove.

(d) Remove the protective sheath from the needle by

pulling it straight off. DO NOT CONTAMINATE. The sheath is used to
protect the needle after the dose has been drawn into the syringe. If the needle
comes off with the sheath, replace it, give the unit a twist to anchor the needle
in place, and then pull off the sheath. The syringe is now ready for use.

Figure 18-8. Removing syringe from protective

plastic package.

18-23
FM 8-230

(2) Pape� Wrapped Syringe.

(a) Select the desired size and type of syringe.

(b) Check the package for holes or water spotting. If any

defect is found, discard the equipment.

(c) Peel open the wrapper. The procedure is the same as

that for opening sterile dressings.

(d) Pick up the syringe and remove the protective sheath

from the needle. DO NOT CONTAMINATE the needle or the syringe. The
sheath is used to protect the needle after the medication has been drawn up.
The syringe is now ready to use.

(3) Carpuject or Tubex Metal Syringe (Figure 18-9).

(a) Obtain the unit dose cartridge and the cartridge holder.

(b) Withdraw the plunger of the cartridge holder

(Figure 18-9A). Carpuj ect-pull the plunger back. Tubex-grasp the barrel in
one hand and pull back on the plunger until it drops downward and locks at a
90 degree angle.

(c) Insert the unit dose cartridge with needle into the barrel
and secure it (Figure 1 8-9B and C). Insert the needle end into the barrel and
secure it by rotating clockwise. The threads at the front end of the barrel mesh
with those on the cartridge.

A B

c D

Figure 18-9. Preparing Carpuject syringe for use.

18-24
 FM 8-230

(d) Attach the plunger to the end of the unit dose cartridge
(Figure 18-9D). Rotate the plunger so that the end threads join those on the
cartridge to form a stable unit.

(e) The unit is now ready for use. Calculate the dosage. If a
smaller amount is to be given, remove the needle protector and expel the
excess amount carefully. Recap the needle.

(f} To remove the cartridg.e, reverse this proced'!-1-re, cut off

the end of the needle, and dispose of the cartridge. Return the cartridge holder
to the medication preparation area.

(4) Vari-ject System.

(a) Obtain the syringe and the unit dose cartridge.

(b) Snap off the protective caps of the syringe and the
medicine vial (Figure 1 8-lOA). Place your thumbs under the lips of the caps
and push upward.

(c) Insert the unit dose cartridge into the syringe and
secure it (Figure 1 8-lOB). Rotate the cartridge clockwise to engage the threads
on the rubber stopper to the inside of the barrel. Rotate three full turns until
you feel resistance, then one more full turn to insure that the needle is in
contact with th� medicine.

(d) The syringe is now ready for use (Figure 18-lOC).

Calculate the dosage. If a smaller amount is to be given, remove the needle
protector, expel the excess amount, and recap the needle.
(e) To remove the cartridge, reverse this procedure, cut or
break off the needle, and dispose of the cartridge. Return the cartridge holder
to the medication preparation area .

Figure 18-10. Preparing the Vari-ject syringe for use.

18-25
FM 8-230

c. Parenteral Solutions. Medications for injection are dispensed in

various kinds of units: glass ampules containing a single dose, the single dose
vial, and the multiple dose vial. The unit dose cartridge consists of a vial with
an attached needle for use with the Tubex or the Carpuj ect holders. Parenteral
medications must be sterile and should not irritate the local tissues.

( 1 ) Use of ampules. Ampules, which are made of glass and

contain a single standard dose of the drug, consist of a body holding the
medication; the constricted portion, or the neck; and a narrow stem on the top.
Most manufacturers now prescore, or etch, the neck so that the glass will
break more evenly with slight pressure. If the ampule is not prescored, use a
small file to etch a breaking line (Figure 18-1 1). Before opening the ampule,
make sure that all of the medication is in the ampule body, not in the stem.
Tap or flick the stem several times with your finger to free any trapped
solution, or grasp the stem and slowly make a circle with the ampule. The
centrifugal force of this action causes the solution to leave the stem. Before
breaking open the ampule, wrap the neck with a sponge or gauze to avoid
accidental cuts. To withdraw medication from an ampule:

F� INJ[Lfl
U SP
BODY -

PRE-SCOR ED AMPULE
NECK WITH FILE

Figure 18-11. Types of glass ampules.

(a) Compare the medication order with the doctor's order.

It is essential to follow the five rights of medication administration.

• Right patient .

• Right drug.

• Right dose.

• Right route .

• Right time.

18-26
 FM 8-230

(b) Obtain the ampule of medication and calculate the

dosage.

(c) Dislodge the fluid from the stem by tapping the stem or
using centrifugal force.

(d) Open the ampule. File the neck if necessary to make a

smooth line for breaking. Wrap it with gauze, paper tissue, or a sponge. Place
both your thumbs together and apply pressure away from you to snap the top
off (Figure 1 8-12A and B).

Figure 18-12. Opening glass ampules.

(e) Insert the needle and draw up the correct dosage (Figure
1 8-13). Hold the ampule betwc-en your index and middle fingers while grasping
the syringe with your thumb and fourth finger. Pull back on the syringe
plunger to the correct measure on the scale with your other hand. When
inserting the needle, avoid touching the sides of the ampule. Make sure that
the needle is below the level of the solution to avoid drawing in air.

18-27
FM 8-230

Figure 18-13. Drawing medication

from ampule.

(f) Expel air bubbles from the syringe and verify the
correct dose (Figure 18- 14). Air bubbles must be expelled before the dose can
be measured accurately. Draw more air into the syringe to make a larger
bubble, then hold the syringe and needle up at a 90 degree angle, tap with your
finger to move the air bubble to the top under the needle, and slowly push the
plunger to expel the air. Stop when one drop of liquid appears in the bevel of
the needle. Verify your calculation and the amount of medicine in the syringe
with the medication record. Place the needle protector over the needle until
ready for use.

Figure 18-14. Expelling air bubbles from syringe.

(2) Use of Vials. A vial is a small bottle that contains one or more
doses of medication. Single dose vials are small, usually 1 or 2 ml in size;
multiple dose vials are 5, 10, 20, 30 ml or larger in size. The solution is kept
sterile by a rubber stopper attached to the bottle with a metal band. The
desired amount of the medicine is removed by inserting the needle of the
syringe through the rubber stopper, after it has been wiped with an alcohol
swab, and drawing up the solution (Figure 18-1 5).

18-28
 FM 8-230

Figure 18-15. Examples of medication vials.

(3) Other drug forms. Drugs that are unstable in a solution are
prepared in a powdered or solid form. The solute in the vial is mixed with a
diluent (diluting agent) before the drug is drawn up into a syringe. Sterile
water and sterile normal saline are typical diluents. The label or the drug
insert packaged with the vial provide instructions concerning the type of
diluent to use and the proper amount to mix with the drug.

(a) When using vials, withdrawal of solution creates a

vacuum unless an equal amount of air is injected since the bottle is a closed
system. Calculations for the dosage can be double-checked by drawing air into
the syringe to the point on the scale that equals the desired dose and then
injecting this amount into the vial.

(b) When the needle is inserted into the vial, care must be
taken to avoid coring the stopper (Figure 1 8-16A). The sharp edges of the
needle can create small cores or plugs that can be pushed into the bottle. The
recommended method is to insert the needle at a slight angle with a forward
thrust and simultaneously exert a slight lateral pressure until the needle has
pierced the rubber stopper (Figure 1 8- 16B and C).

(c) Corings could plug the needles and become a possible

source of contamination. The following procedure will be used for withdrawing
medications from a vial:

1. Compare the medication order with the doctor's

order.

18-29
FM 8-230

2. Obtain the vial of medicine and calculate the dosage.

Observe the five rights; read the label carefully. Do not hesitate to have
another person verify the dosage, especially if it is a fraction of the amount
provided in the vial.
3. Clean the vial stopper. Take an antiseptic compress
and rub the stopper in a vigorous rotary motion. This helps to prevent
contamination by microorganisms when you insert the needle.
4. Draw an amount of air into the syringe equal to the
dose of the medicine. Pull the plunger of the syringe back to the exact mark on
the barrel equaling the prescribed amount of the drug.
5. Insert the needle into the vial and draw up the
correct dose. Insert the needle at a slight angle to prevent coring. Hold the vial
between your thumb and third finger, with your index finger as a counterforce
on the bottom of the vial.
6. With the needle tip through the stopper and above
the liquid line,
push the plunger into the barrel to inject the air replacement.
Hold the vial at eye level.

7. Turn the vial upside down; with the needle inserted

into the medicine,
pull the plunger down the barrel of the syringe until 0.2 cc
more than the required amount of medicine is in the syringe (Figure 1 8-17).
8. Remove the needle from the vial, verify the dose,
and expel the air bubbles from the syringe. Verify the dosage in the syringe
with the medication record; expel any extra medication, if necessary.
9. Protect sterility of the needle and prepare to give
the drug. Replace the needle in the needle guard (do not contaminate the needle
by touching the outside of the sheath).

INCORRECT CORRECT
METHOD METHOD

Figure 18-16. Inserting needle in vial.

18-30
 FM 8-230

Figure 18-1 7. Drawing

medication into syringe.

18-25. Subcutaneous Injections

a. Subcutaneous inj ections have been used since 1 855, when

Alexander Wood, M.D., of Edinburgh published the first accounts of drugs
inj ected subcutaneously via a needle and syringe. Techniques have changed
very little over the years.

b. Medications administered by the subcutaneous route are absorbed

rapidly by the body. This route is often used to give medications to nauseated,
vomiting, unconscious, or irrational patients. Preoperative medications,
narcotics to relieve pain, and insulin are usually injected.

c. There are several areas of the body available as sites for

subcutaneous injections:

• The lateral and posterior surfaces of the upper arms.

• The skin over the scapula on the back.

• The surface around the lower edge of the rib cage.

18-31
FM 8-230

• The buttocks.

• The anterior and lateral aspects of the thighs.

• The surface over the lower abdomen.

The skin in these areas is thinner, easier to penetrate, and capable of

stretching to accommodate small doses of medication. For most patients, the
preferred sites are the lateral surfaces of the upper arm or the back, and lateral
aspects of the thigh. If the patient receives repeated medications, you should
follow a rotation plan to avoid tissue fibrosis, which could cause pain and
disfigurement.

d. Diabetic patients who must give themselves inj ections of insulin

are taught to use various areas of the body, and to rotate these sites. For
example, the patient can easily reach the abdomen and thighs. However, when
insulin is administered by another person, posterior sites can be used.

e. The following procedures are used when administering a

subcutaneous inj ection:
( 1 ) Wash your hands. Obtain all necessary equipment and
supplies, including the filled syringe with needle protected by covering,
medicine identification (card, label), and antiseptic sponges.

(2) Explain the procedure to the patient. Check the patient's

identification. Tell him that you are going to give him a shot in the arm or
whatever site is selected, and that there will be momentary discomfort.

(3) Select the injection site and cleanse the area. Expose the area
and insure that you have ample lighting so that you easily see the injection
site. Open the antiseptic sponge package and cleanse the selected site using a
circular motion until approximately a 2-inch area is cleansed. Allow the skin to
dry; the antiseptic evaporates quickly from the skin.

(4) Pick up the prepared syringe. Remove the needle guard by

pulling it straight away from the guard to avoid contamination. If you
contaminate the needle, it must be removed and replaced with a sterile one.
Hold the syringe in your left hand with the needle pointing upward.

(5) Support the skin at the site. By picking up the skin with your
thumb and index finger, you can assess the thickness of the skin and
subcutaneous layer into which you will inj ect the drug.

(6) Insert the needle at a 45 degree angle into the skin. Hold the
barrel in your hand between the thumb and index finger, letting the syringe
rest on the remaining three fingers. Insert the needle through the patient's
skin with a firm, quick, forward thrust. Release the skin and hold the syringe
securely. (See Figure 18-18. )

18-32
 FM 8-230

(7) Pull back on the plunger to aspirate for blood. If your needle
has hit a blood vessel, you can injure the inner blood vessel wall by injecting
medications that are not prepared for IV use. Also, if you inject the medication
directly into the circulatory system, the effect is almost instantaneous and can
produce a shock effect. If blood appears in the syringe, withdraw the needle.
Discard both the needle and the syringe, and start again. lnj ecting bloody
solution into the subcutaneous tissue can produce a chemical irritation.

(8) Inject the medicine. With your right thumb, press the
plunger into the barrel slowly and steadily until all of the medication is
inj ected.

(9) Remove the needle. Do this quickly; pull it straight out at the
same angle at which it was inserted. Put the used needle back in its guard.

(10) Massage the site with an antiseptic sponge. Use a gentle

circular motion to help disperse the medication in the subcutaneous tissue so
that it will absorb readily. The peak action of a subcutaneous injection is
expected within 30 minutes. Discard the sponge in a designated container.
Apply a Band-Aid if there is superficial bleeding. Some people who have a very
intricate superficial vascular system will bleed slightly regardless of how
careful you are.

MUSCLE

Figure 18-18. Administering a subcutaneous

injection.

18-33
FM 8-230

( 1 1 ) Dispose of the used equipment (Figure 18-19). Take the

syringes and needles to the work area and discard them in the designated
needle and syringe container. Bend the needle so that the tip breaks off the
syringe and remains lodged with the hub of the needle or use a snipper to cut
off the needle. Discard the broken syringe and needle in a designated
container.

Figure 18-19. Disposal of used equipment.

18-26. Intramuscular Injections

Intramuscular (IM) injections are utilized if the patient cannot take medicine
orally or if the medication is not prepared in an oral form. Intramuscular
injections provide quick but sustained action because muscular tissue is
highly vascular. Selection of the inj ection site is a critical decision for the
health practitioner. Improper site selection can result in damaged nerves,
abscesses, necrosis and sloughing of skin, as well as pain. Therefore, the stage
of development, body build, and the individual's physical condition must be
considered when giving an inj ection. From 2 to 5 cc of fluid may be injected
into a muscle, depending on the size of the patient. If more than 5 cc of
medication must be given at one time, the doses should be divided in half and
given in two different sites.

18-34
 FM 8-230

a. Injection Sites for Adults.

( 1 ) The usual sites for IM injection in the adult are the deltoid
muscle in the arm, the gluteal muscles, and the ventrogluteal and vastus
lateralis muscles of the thigh.

(2) The mid-deltoid muscle is a common location for IM

injections (Figure 18-20); however, the actual area involved is limited because
of the major vessels, nerves, and bones. Only small amounts of medication can
be injected in this site. The area for the arm inj ection is rectangular, on the
lateral upper third of the arm, about 2 inches below the shoulder, or at the
lower edge of the acromion.

----- ACROMION

L
( &);l
I I MID-D ELTOID
I --:-
I ----- AREA

BRACHIAL
VESSELS

Fig_ure 18-20. Administering intramuscular

·

injection (deltoid muscle).

(3) The gluteal muscles are generally used for IM injections

(Figure 18-21). When using this site you must be careful to avoid injuring the
large nerves and blood vessels located in this area. The fleshiest portion of the
buttocks is not the safest for inj ections because the sciatic nerve and the
superior gluteal artery lie underneath. Injections in this area can cause severe
pain and even paralyze the lower extremity when these structures are
damaged.
(4) To locate a safe area for injection, use one of two methods.
The first is to divide the buttocks into fourths,or quadrants.Palpate the ridge
of the ilium and draw an imaginary line down to the lower edge of the
buttocks. Draw a horizontal line from the upper edge of the acetabulum over to
the spine and use the upper outer quadrants for intramuscular injection.

18-35
FM 8-230

Figure 18-21. Administering intramuscular

injection (gluteal muscles).

(5) The second method is to locate an imaginary line from the

posterior iliac spine to the greater trochanter of the femur. Give the injections
above and lateral to the line; this avoids the danger area (Figure 18-22A).

(6) You will find it easier to give IM injections, and the patient
will have less discomfort if the muscle is relaxed. Since the gluteal muscles are
tense when the hip is extended or the leg is externally rotated, the muscles are
relaxed when the patient (1) lies in a prone position with toes turned inward, (2)
lies in a Sims position, or (3) stands with the toes pointed inward.

(7) The ventrogluteal area (Figure 18-22B), also known as von

Hochstetter's site, is a safe IM injection site. The muscle layer is thick and has
a very small fatty layer. This site can be used both for adults and children and
is especially helpful if the patient must recline in either the Sims or the prone
position.

(8) To locate the injection site, place your palm over the head of
the femur, put your index finger on the anterior iliac spine, and spread your
middle finger as far as possible to touch the iliac crest. The center of the V
bounded by your fingers is the precise injection site.

(9) The vastus lateralis muscle is also a common IM inj ection

site for both adults and children. The area extends from the mid-anterior front
of the thigh to the mid-lateral thigh, a hand's width below the proximal end of
the greater trochanter and a hand's width above the upper knee (Figure 18-23).

18-36
 FM 8-230

ANTERIOR SUPERIOR
I LIAC SPINE
VENTROGLUTEAL AREA

.·
.
. . '-<------:--�:�,:_::-::::·.: :, . . ... .. . . . .. .. . .

+.'" -
·
. .. ·. · · .
···
· · · ·

G R EATER TROCHANTER SCIATIC NERVE

Figure 18-22. Alternate injection sites.

GREATER
TROCHANTER

-- - -

I
1 ,

I
I I
�
Ld ! -I -�- MID-PORT ION
VASTUS LATERALIS

1
1_ _ _ _

Figure 18-23. Vastus lateralis muscle

injection site.

18-37
FM 8-230

b. Administration of the IM Injection (Figures 18-24 and 18-25).

Preparation of the needle and syringe and drawing up the correct dose follow
the procedures discussed in previous paragraphs. Read the medication labels
three times so that you can check the accuracy of the medication and desired
dose as you remove the medication from storage, as you draw up the
medication, and as you return the unused medication to the storage area or
discard the empty vial or ampule.

( 1 ) Wash your hands and obtain the necessary equipment and

supplies. Place the prepared medication on a tray and take it to the patient,
together with the record.

(2) Explain the procedure to the patient. Verify the identification

of the patient. Always tell the patient what you are going to do even though
there is a possibility he cannot understand (for example, infant, small child,
confused or unconscious person).

(3) Select the injection site and cleanse it with an antiseptic

sponge (Figure 18-24A). Expose the injection site in order to have an
unobstructed view. If the gluteal region is being used, have the patient lie on
his abdomen with his toes turned slightly inward. This position provides the
greatest muscle relaxation. Remove an antiseptic sponge from the package
and cleanse the injection site. Use a firm circular motion to cleanse a 2-inch
area and allow the area to dry.

(4) Spread the skin at the site (Figure 18-24B). Press firmly
around the site to compress the subcutaneous and muscle tissue. The taut skin
reduces resistance to the needle when it enters the tissues.

(5) Insert the needle quickly at a 90 degree angle (Figures 18-24C

and 18-24D). Grasp the barrel of the syringe firmly between your thumb and
index finger like a dart and plunge the needle firmly into the muscle at a 90
degree angle to the full depth of the needle.

18-38
 FM 8-230

A B

c D

Figure 18-24. Preparing to administer IM injection.

(6) Pull back on the plunger to aspirate for blood (Figure 18-25A).
You will need to reposition your hand to hold the barrel of the syringe and to
steady the needle while you draw back on the plunger with your dominant
hand. If blood returns in the syringe, withdraw the needle and syringe and
discard them. Begin the procedure after drawing up solution in a new needle
and syringe.

(7) Inject the medication (Figure 18-25B). Using the fingers as a

counterforce, push the plunger into the barrel with a slow continuous
movement.

(8) Withdraw the needle (Figure 18-25C). Apply pressure with the
antiseptic sponge at the needle site as you remove the needle with a qui.ck,
upward motion. This external pressure also helps to keep the medicine from
leaking into the tissues.

18-39
FM 8-230

�9) �assage t�e injection si�e (Figure 18-25D). Doing this with a
gentle but firm circular motion helps to disperse the medicine so that it can be
absorbed more quickly.

c D

Figure 18-25. Administering IM injection.

18-27. Intradermal Injections

Intradermal inj ections are commonly used to inject minute amounts of a drug
into the outer layers of the skin (Figure 1 8-26). A positive reaction to antigens
such as bacteria, pollen, or foods causes the skin to become red and indurated.
In the intradermal route, the amount of solution injected is usually 0 . 1 ml. You
must be extremely careful to measure the dosage accurately because the
solutions are capable of producing severe reactions; only a small amount is
required. Use a syringe that has calibration marks to assure accurate
measurement of 0.01 ml dosages, such as the tuberculin and the Ul OO/ml
insulin syringes. Select a fine gauge (25, 27, or 29), short ( 1/4 to 5/8 inches in
length) needle. The dorsal aspect of the forearm is the customary injection site

18-40
 FM 8-230

for intradermals, but when this site cannot be used or in cases of extensive
skin-testing, the dorsal and lateral sides of the upper arm can be used because
they are readily observable. Insert the needle at an angle of about 10 degrees
between the upper layers of the skin. The injected solution will raise the
epidermis to form a bubble. It is then slowly absorbed from the site because
the blood vessels are located in the deeper structures of the skin.

} DERMIS

} SU B C U T A N E O U S

Figure 18-26. Intradermal injection.

a. Procedure for Preparation of Medication.

(1) Assemble your supplies. Needle, syringe, and medication are

required.

(2) Wash your hands.

(3) Identify the medication. Compare the medication with the

order.

(4) Cleanse the vial s topper. Wipe it with an alcohol compress.

(5) Remove the needle and syringe from the protective sheath.

(6) Pick up the vial and insert the needle.

(7) Withdraw the correct dosage of the medication into the

syringe. Keep the needle sterile by using the needle protector.

(8) Remove the needle from the vial. Place the vial to one side.

b. Give an Intradermal Injection.

( 1 ) Explain the procedure to the patient. Take the prepared

needle and syringe on a medicine t:ray with the medication record to the
patient. Verify patient identification.

(2) Select the injection site. Expose the area, usually the anterior
forearm, so that you have an unobstructed view.

18-41
FM 8-230

(3) Cleanse the injection site. Remove the antiseptic sponge from
the package and use a firm, gentle circular motion to clean an area
approximately 2 inches in diameter.

(4) Expel air bubbles. Hold the syringe vertically and gently
push on the plunger to expel air bubbles. Recheck the accuracy of the dose to
be given.

(5) Grasp the forearm to be injected. While standing in front of

the patient, turn the patient's anterior forearm upward, facing you. Grasp the
arm on the posterior side, toward the middle of the forearm. With your
nondominant thumb on one side of the arm and your index finger on the other
side, pull the anterior skin taut.

(6) Insert the needle. With the bevel of the needle facing upward,
insert the needle under the outer layer of the skin at an angle almost parallel to
the skin (10 to 15 degrees) (Figure 18-26). Insert the needle so that only the
bevel penetrates the skin. A void penetration next to hair follicles.

(7) Inject the solution slowl'?'. If you have inserted the needle
correctly, a small circular bubble of solution forms just under the thin outer
layer of the skin. You should be able to feel some resistance at the needle point
if it is in the dermal layer. If the tip moves freely, you have inserted the needle
too deeply. In this event, withdraw the needle slightly and check again for
resistance. Continue to reassure your patient as you inject the solution and
observe for unusual reactions.

(8) Withdraw the needle. Wipe the area very gently with the
antiseptic sponge as you remove the needle. Do not apply pressure. You must
not disperse the medicine into the underlying tissues.

(9) Caution patient not to rub or scratch the injection site even
though it may itch. Irritation of the site may give a false positive reading.

( 10) Remove the equipment. Return the supplies to the

designated storage area and dispose of the used needle and syringe in the
designated containers.

( 1 1 ) Record the procedure. For example: 8:10 P.M .-Tetanus

antitoxin 0.1 ml given I.D. on right forearm. 8:25 P.M.-Skin test positive for
TAT, 1 cm wheal at injection site.

18-28. The Tine Test

a. The tine test is one of several screening tests for tuberculosis and
is used primarily for mass screening.

b. A preparation of concentrated old tuberculin (OT) is used. The

individually packaged puncture device (Figure 1 8-27) contains a dried dose of
OT on the tines and is discarded after one-time use. All positive reactions
except vesiculating reactions should be retested by the Mantoux method.

18-42
 FM 8-230

Figure 18-27. Tine device.

c. Procedures for the tine test.

( 1 ) Assemble the supplies. An alcohol/acetone swab and a tine

set are required.

(2) Wash your hands.

(3) Identify the patient and explain the procedure.

(4) Expose the right forearm. Cleanse the arm with an

alcohol/acetone swab, then discard the swab in a designated container.

(5) Puncture the forearm (Figure 18-28). Remove the tine set
from the package and discard after use. The tuberculin on the tines is inj ected
into the skin.
(6) Instruct the patient. The site must be inspected in 48 or 72
hours. Follow your agency's procedure.

(7) Record the test. Mark it on the patient's record.

(8) Read the reaction (Figure 18-29). Inspect the site in 48 to 72
hours. NEGATIVE TEST: Nothing has appeared on the skin except the
puncture sites. POSITIVE TEST: Presence of reddish, raised indurations of
2 mm or more around one or more of the puncture sites.

18-43
FM 8-230

NOTE

Alcohol/acetone or acetone swabs must be used

to cleanse the area when administering the tine
test. Alcohol, when used alone, will inactivate
the tuberculin culture.

Figure 18-28. Administering tine test.

NEGATIVE

: �·.:s. ·'"' ' .

,j_
... · · : t�·A
'":41f"••:
I'
•
••
. ..
. .

:: .
.·

.,�. r.�·.... .. /.. . :. .

.. ...... · �
·:·:. . . :. . . · ··. . . .
.

POSITIVE REACTIONS

Figure 18-29. Reading tine test reactions.

18-44
 FM 8-230

18-29. Administration of Eye Drops and Eye Ointments

a. Containers. Drug preparations for the eye are dispensed from the
pharmacy in individual dropper bottles, dispensing squeeze vials, or ointment
tubes. These containers are labeled "ophthalmic" and usually identified with
an individual patient's name. When the drug is administered, take the
prepared medicine card identifying the eye to be treated, the properly
identified drug container, and a container of tissue wipes to the patient's
bedside.

b. Physical Considerations-the Conjunctiva. In treating the eye,

remember a few basic facts concerning its structure. The conjunctiva (the
mucous membrane which covers the front portion of the eyeball and lines the
eyelid) absorbs medication placed in the eye. If the medication is applied to the
inner surface of the lower lid, the natural blinking reflex of the eye distributes
the ointment.

c. Precautions in Instilling Medications.

( 1 ) Wash hands immediately before treating the eyes. Have

fingernails short and clean.

(2) After removing cap from ointment tube, squeeze a small

amount on sterile gauze to remove any crust that might have formed; discard
this gauze.

(3) Do not invert dropper after withdrawing solution as there is

danger that small particles of rubber might become mixed with the
medication.

(4) Do not touch tip of dropper or tip of squeeze vial or ointment

tube to the skin of the face or lids. This will contaminate the sterile medication.

d. Instillation of Eye Drops or Eye Ointment.

(1) Instruct patient to tilt head backward and look upward with
eyelids open.

. (2) Place forefinger on skin below lower eyelid and pull down
gently. This creates a small conjunctiva! pocket in the lower lid in which to
instill the medication.

. �3) With .the tip of the dropper close to but not touching the
pocket, instill the reqwred number of drops of medication. If ointment is used
run a thin ribbon of ointment just above surface of the pocket, from the inne;
aspect to the outer aspect of the conjunctiva! pocket.

. . (4) Relea�e t�e skin held by the fingertip. The normal blink reflex
� distnbute
.
the I?edication evenly. No rubbing or pressure on the upper lid
is necessary or desrrable.

. (5) Blot closed margin of eyelid gently with a clean tissue and
wipe to remove excess medication. Blot from inner canthus (junction of the
eyelids) outward.

18-45
FM 8-230

18-30. Administration of Nose Drops

Vasoconstrictor drugs are dispensed in solution, in dropper bottles, or in jellies

in nasal-tipped applicator tubes. These drugs are instilled into the nostrils to
shrink the nasal mucosa. This will open the nasal passages and allow better
drainage of the paranasal sinuses. Position the patient properly or the instilled
medication will run into the nasopharynx, be expectorated by the patient, and
lose its intended effect. After washing hands:

a. Position the patient flat in bed, with his head extended over the
edge of the bed.

b. Place prescribed number of drops of the solution in each nostril.

Instruct the patient to remain in position for 3 minutes.

c. Do not return a dropper which has touched the nostril to the bottle
of solution, as the entire bottle will be contaminated. Use individual clean
droppers for each instillation. Discard any solution remaining in the dropper.

18-31. Administration of Ear Drops

Ear drops may be ordered for treatment of infections of the external ear or for
skin disorders that are noninfectious. Since otitis (external ear disorders) can
be extremely painful, handle the auricle and tragus gently. Ear drops such as
Burow' s solution may be ordered to soothe and cleanse the inflamed
membranes of the ear canal. Other prescribed drops may be solutions of
antibiotics. To instill ear drops, obtain the medicine card, the prescribed drops,
and some cotton compresses. After washing hands:
a. Check the medication for accuracy and have the prescribed
number of drops in the dropper.

b. Tilt the patient's head so that the affected ear is uppermost.

c. Gently pull the auricle of the ear up and back on an adult, down
and back on a child.

d. Direct the tip of the dropper toward the vestibule of the ear. Instill
the required number of drops.

e. Place a cotton compress in the vestibule but do not push into the
ear canal. The compress will serve as a wick.

18-32. Administration of Drugs by Aerosol Inhalation

Drugs in a distilled water solution are administered by aerosol inhalation

(Figure 1 8-30). A nebulizer attached to a compressed air (or oxygen) supply
converts the solution into a fine mist which is inhaled deeply into the trachea
and bronchi. (An ordinary spray atomizer cannot be used for aerosol inhalation
because the droplets are too large and disperse in the throat, rather than deep
in the respiratory tract.) When continuous aerosol therapy is necessary, a
specially designed jet humidifier is used in combination with an oxygen hood
or croupette. The drugs used in aerosol therapy may be a mucolytic detergent
agent to liquefy bronchial secretions: an antibiotic drug in solution; a broncho­
dilator; or a combination of all three types of medication. When aerosol
therapy is ordered, the patient needs special instruction for effective
administration of the medication. When oxygen is used, all safety precautions
for the use of oxygen must be observed.

18-46
 FM 8-230

a. Equipment. Various styles and types of nebulizers are utilized

depending upon local availability and policy. Compressed air or oxygen is used
to produce nebulization of the medication. The nebulizer is connected to the air
or oxygen supply using oxygen tubing; an oxygen humidifier is not used
unless ordered. The measured amount of medication and diluting solution is
placed in the nebulizer and the oxygen or air flow is adjusted according to the
physician's order or manufacturer's instructions.

POUR IN SOLUTION �
/!
- - "' .....

/
,.,, ..... I} - ....... _
/ '\

- - - .//
I It

,----=-=-=-= /
--=-::-::_::_:-::_-:::(
([ \

;;
!!\1��������;:J )
---,.-,,�
- ',

STEM

- - - - - - - - -------
'
\\ .,:
\\ / '\I I
I
\ \\ I I I
\ 11 11 I I I
' 11 11 / I
'-. \\ II / I

....... ....... �_ _ _ ,,,,.,,.

CON NECTED BY RUBBER TUBE TO
O X Y G E N CYLINDER REGULATOR

Figure 18-30. Nebulizer for aerosol inhalation.

b. Administration.

( 1 ) Have the patient sit upright, supported in a chair or by the

elevated hospital bed.

(2) Instruct patient in use of nebulizer in accordance with the

manufacturer's instructions. The patient should inhale deeply through his
mouth. The treatment is continued until all medication in the nebulizer is used,
or for a specified time if ordered.

(3) Following each treatment, rinse the nebulizer thoroughly

with cold water to remove any residual medication and to prevent clogging.
Use an individual nebulizer for each patient. When this is not possible,
disinfect the nebulizer by proper use of the prescribed chemical germicide.

18-33. Administration of Rectal Suppository

Drugs contained in a rectal suppository may be intended for a local effect on

the mucous membrane of the rectum or for general systemic effect following
absorption. Thus, if the suppository is expelled before it has melted, little or no
therapeutic effect can be anticipated. The medical specialist must always
know why the suppository is being administered; for example, is it a local
analgesic, an evacuant to induce a bowel movement, or an antispasmodic for
relief of asthma?

18-47
FM 8-230

a. Equipment. Prescribed suppository (often stored in the

refrigerator), rectal glove, surgical lubricant, tissue, and emesis basin.

b. Procedure. Screen patient; turn patient on side to expose anal

sphincter; lubricate suppository and gloved index finger. Instruct patient to
breathe through the mouth to relax the anal sphincter, and insert suppository.
With gloved finger, advance suppository into the rectum. Apply pressure over
anal sphincter until the reflex to expel the suppository has subsided.

18-34. Doses and Uses of Drugs in Field Medical Sets

a. Drugs discussed in this section are those frequently used by a

medical specialist in the field, a TMC, or a hospital emergency room. Local
policy will limit the medications a medical specialist may administer or
dispense.

b. Drugs are presented under generic or nonproprietary names and

are listed under a therapeutic usage classification.

18-35. Analgesics

a. Nonnarcotic.

(1) Aspirin. Aspirin is an analgesic and an antipyretic. As an

analgesic, it is effective in treating mild pain, such as headaches and minor
muscular pain. As an antipyretic, aspirin is used to reduce body temperature
in patients with a fever (it does not affect normal body temperature). Aspirin is
normally issued as 0.324 g. tablets with the normal adult dose being 1 to 2
tablets every 4 to 6 hours. Since aspirin may cause gastric irritation, patients
should be told to drink a full glass of water when taking the drug, or take it
with milk or meals.

(2) Acetaminophen tablets (Tylenol). A proven analgesic and

antipyretic. Tylenol is particularly well suited as an analgesic-antipyretic in
the presence of aspirin allergy. Tylenol has rarely been found to produce side
effects; however, large doses may contribute to liver failure. Usual dosage for
adults is 1 or 2 tablets every 4 to 6 hours.

b. Narcotic. Narcotics are derivatives of opium. They depress the

central nervous system and respirations, are constipating, and may cause
addiction. They must be accounted for in the narcotic register. Normally, a
medical specialist will only administer narcotics in actual combat situations.
The most commonly used narcotic to relieve severe pain is morphine. When
used, the normal dose administered is 10 mg. Morphine can severely depress
respirations and level of consciousness. Morphine is not administered to
patients with an altered level of consciousness, head injury, or impaired
respirations.
18-36. Anesthetics
These drugs produce anesthesia in a limited area around the site of their
injection or application by preventing transmission of pain impulses along the
sensory nerves. They are used by the medical specialist to anesthetize an area
of the body prior to treatment or to relieve pain.
 FM 8-230

a. Lidocaine hydrochloride. This drug is supplied as a 1 or 2 percent

solution for inj ections. Often, it is also combined with epinephrine to prolong
the anesthetic action. Lidocaine is used in local surgical procedures to produce
local anesthesia in a dose determined by the physician. When supplied as a
jelly, it can be applied topically to produce local anesthesia.

b. Tetracaine hydrochloride. This drug normally is supplied as

ophthalmic ointment. It is used in the eye to relieve local pain due to injection
or injury. It does not dilate the pupil of the eye or cause other noticeable side
effects.

c. Cetylpyridinium chloride and benzocaine lozenges (Cepacol). These

are used for temporary relief of pain or discomfort due to minor sore throat and
pain and discomfort associated with tonsillitis and pharyngitis. Allow to
dissolve slowly in the mouth. Cepacol is also used as a mouth wash.

d. Eugenol (oil of cloves). Eugenol is a surface anesthetic.It is used in

dentistry to give temporary relief from toothache. Eugenol is supplied in a
bottle for topical application by means of a cotton compress. Application of
eugenol is a temporary measure and the patient should be referred to a dentist
immediately.

18-37. Antacids (Aluminum Hydroxide-Magnesium Trisilicate Tablets)

Antacid tablets (Gelusil) are used to relieve acidity in the stomach and the pain
that may accompany the acidity. Patients should be told to chew the tablets
and to swallow with water. By chewing the tablets, the effectiveness of the
antacid is greatly increased. This drug comes in liquid form also.

18-38. Antibiotics

The proper choice of an antibiotic in the treatment of a disease and the total
amount administered is of particular importance. The authorized prescriber
will select a drug and a total dose of the drug the patient must receive. This
will be based on the particular disease and the patient's overall condition. It is
important that the patient receive the correct amount of drug at the proper
time. Any variation from this dosage regimen may decrease the effectiveness
of the antibiotic. The antibiotics discussed are those topical antibiotics a
medical specialist will most frequently use.

a. Bacitraci;. or Neomycin Ointment. These antibiotic preparations

are supplied in 1/2 ounce (1 4.70 ml) tubes for local application to superficial
skin infections, such as an infected insect bite. The skin area should be
cleansed of any crusts or purulent secretions by thorough washing with a
surgical soap or detergent-antiseptic solution before the ointment is applied. A
dressing is omitted unless the area must be protected from contact with
clothing.

b. Antibiotic Ophthalmic (Eye) Ointments. These are sterile ointment

preparations (such as polymyxin B, bacitracin, and neomycin ophthalmic
ointment) used to treat bacterial infections of the eyelids and surface of the
eye. They are supplied in small, applicator-tipped tubes for use on an
individual patient. Before each application, it is desirable to clean away the
crusts that accumulate along the infected lid margins. Warm moist
compresses to the eye _are recommended cleansing agents. A thin ribbon of

18-49
FM 8-230

ointment is applied to the inner lining of the lower lid and the natural blinking
of the eye distributes the ointment. Antibiotic ointments may also be ordered
as prophylactic treatment when the cornea has been injured. Antibiotic eye
ointments are used only when prescribed by a medical officer.

c. Polymyxin B-Neomycin-Hydrocortisone (Cortisporin Otic). This

drug is for the treatment of superficial infections of the external auditory canal
caused by organisms susceptible to the action of the antibiotic. Dosage for
adults: 4 drops of the solution should be instilled into the affected ear three or
four times a day.

18-39. Sulfonamides

Silver Sulfadiazine (Silvadene) Cream is a topical antimicrobial drug indicated

as an adjunct for the prevention and treatment of wound sepsis in patients
with second and third degree burns.

18-40. Antifungal Agents

a. Tolnaftate (Tinactin) Solution 1 Percent. This drug is used to treat

a variety of fungal infections, such as athlete's foot and ringworm. The drug is
normally applied twice daily for at least two to three weeks.

b. Fungicidal Foot Powder. This powder normally is supplied in 1

ounce (14.18 g) cans. It is dusted onto the skin in the treatment of fungus
infections of the skin, especially athlete's foot. It should be applied in the
morning.

18-41. Antihistamines

The drugs discussed below have as a side effect drowsiness or dizziness.

Individuals receiving these drugs should be cautioned against driving an
automobile or engaging in other activities requiring alertness.

a. Triprolidine Hydrochloride and Pseudoephedrine Hydrochloride

(Actifed). This drug is an ingredient in a combined-drug tablet used to treat the
symptoms of hay fever and colds. The usual dose is one tablet three times a
day. Side effects occur with less frequency than with Benadryl, but the
individual must be cautioned that he might become drowsy or dizzy.

b. Brompheniramine Maleate (Dimetapp). Dimetapp is for the

symptomatic treatment of seasonal and perennial allergic rhinitis, allergic
manifestation of upper respiratory illnesses, acute sinusitis, nasal congestion,
and otitis. Administer with care to patients with history of cardiac, peripheral
vascular diseases, or hypertension. Dosage for adults is one tablet every 1 2
hours.

18-42. Antiparasitic Agents

a. Gamma. Benz�ne . Hexachloride Ointment (Kwell) Rx. This

.
ointment normally is supplied m 1 ounce (59. 1 5 ml) tubes. It is for topical use
against lice and mites which cause scabies (itch). Usually one application of the
ointment is enough. It is irritating to mucous membranes and should not be
allowed to touch the eves. The individual should not bathe or wash the hair for

18-50
 FM 8-230

24 hours following application of the drug. After a cleansing bath and

shampoo, clean clothing and bed linen should be used. The infested clothing
and bed linen must be laundered. The preparation may not destroy the nits
(eggs) of body lice, so a second application may be necessary one week later.
The hairy parts of the body should be closely examined for nits as they cling to
hair shafts.

b. Lindane, 1 Percent. This powder is used to treat pediculosis

(infestation by lice). It should be dusted on the hairy portions of the body and
left there at least 24 hours. The treatment should be repeated after one week.
The powder should also be dusted onto the seams of the oatient's clothine: and
bed linen. After the delousing treatment. the clothing and bed linen are changed
and the infested articles are laundered. The patient should be dusted again if he
bathes between the two dustings.

18-43. Antiseptics

Providone-Iodine (Betadine) is a solution that contains iodine and is useful as

an antiseptic prior to surgery. It is used to cleanse the area around the site of
the incision. Providone-iodine should be used undiluted. The patient must be
questioned about allergies to iodine prior to use.

18-44. Astringents

An astringent (aluminum acetate and acetic acid solution, Burow's solution) is

a soothing, wet dressing for relief of inflammatory conditions of the skin such
as insect bites, poison ivy, swelling, or athlete's foot.

18-45. Oxidizing Agent

Hydrogen peroxide (a cleaning agent) is used for suppurating wounds and

inflamed mucous membranes. It aids in the arrest of minor bleeding by
promoting healing and toughening skin.

18-46. Emollients and Protectives

a. Emollients.

( 1 ) Petrolatum gauze is used to protect the skin area

surrounding a draining wound. Normally, it is supplied in sterile foil-sealed
packets. The required length of gauze is removed, using aseptic technique.
Once the packet has been opened, the sterility of the remaining contents is
lost.

(2) Surgical lubricant is a sterile jelly supplied in tubes. It is a

water-soluble preparation used on the skin and for lubrication of catheters,
rectal thermometers, and rectal gloves. It contains a preservative to maintain
its sterility after the seal is broken, provided that aseptic technique is used in
squeezing the required amount from the tube and in replacing the cap.

b. Protectives.

(1) Benzoin tincture, compound. This drug is normally issued in

a 1 pint (0.47 liter) can. When it is used to protect the skin under adhesive
otrapping, it is painted on the required area with an applicator swab. It must

18-51
FM 8-230

then dry on the skin before the adhesive is applied. Because of its aromatic
nature, benzoin tincture is also added to the water used for steam inhalations
to relieve bronchial congestion and irritation.
(2) Calamine lotion, phenolated, mentholated. This drug is used
as a soothing and drying lotion with phenol and menthol added for their
antipruritic effect.

18-47. Vasoconstrictors

a. Systemic. Epinephrine (Adrenalin) (a systemic vasoconstrictor) is

normally supplied in a clear, sterile solution of 1 : 1 ,000 for subcutaneous or
intramuscular inj ections, the amount determined by a physician. It is inactive
when given orally. For topical application to check hemorrhage, as in
nosebleed, concentrations of 1 : 1 ,000 to 1 : 1 0,000 are used. A 1 percent solution
is used for inhalation. Epinephrine must be used cautiously in patients with
cardiovascular disease or high blood pressure as it acts as a vasoconstrictor
and a heart stimulant. Its effect on blood vessels is marked. A wide white area
may develop at the site of injection of epinephrine. Epinephrine is also used in
subcutaneous injection to treat severe asthma and allergic or anaphylactic
reactions.

b. Topical

(1) Phenylephrine hydrochloride (Neo-Synephrine).

Phenylephrine hydrochloride is generally used in 0.25 percent of 1 percent
solutions, or in the form of a 0.5 percent j elly for application to nasal
membranes. Used in this manner, the drug causes a local vasoconstriction and
acts as a nasal decongestant for about 4 hours. Phenylephrine hydrochloride
should be used cautiously in patient with heart disease or high blood pressure.

(2) Oxymetazoline hydrochloride (Afrin). Oxymetazoline

hydrochloride is a long-acting nasal decongestant with a duration of action of
12 hours. This drug must also be used cautiously in patients with heart disease
or high blood pressure.

18-48. Anti-Inflammatory Agents

Hydrocortisone Cream 1 Percent is used topically to treat numerous types of

local dermatitis conditions. The drug should be applied in a thin film over the
affected area. Hydrocortisone is often found in combination with topical
antibiotics, such as neomycin, hydrocortisone, polymyxin B, and Bacitracin
ointment. When using a drug combining an antibiotic and hydrocortisone, the
drug must be continued for 2 to 3 days after the signs of infection disappear.

18-49. Antidiarrheal Agent

Kaolin-pectin (an antidiarrheal agent) is normally supplied as a powder to

which water must be added. Kaolin-pectin is effective in treating only very
minor forms of diarrhea. Its normal dose is 4 to 6 tablespoonfuls after each
bowel movement.

1 8-52
 FM 8-230

18-50. Expectorant

Guaifenesin syrup (an expectorant) is used in the relief of dry unproductive

coughs associated with the common cold, pertussis, measles, and influenza.
l J sual adult dosage is 1 to 2 teaspoonfuls every 3 to 4 hours.

18-51. Emetic

Ipecac syrup is used as an emetic to induce vomiting for emergency treatment

of drug overdose and in certain cases of poisoning.

CAUTION

DO NOT give to an unconscious patient. Usual

dosage is 1 5 cc with warm water.

18-53
 FM 8-230

C HAPTER 1 9

ENVIRONMENTAL HEALTH

Section I. INTRODUCTION

19-1. General

History has shown that more time was lost due to environmental illnesses and
injuries than to combat injuries. The death rate from illness and injuries have
also surpassed those due to combat injuries. As recently as the Vietnam
conflict, the communicable illness and injury rate exceeded the combat
injuries by a margin of 4 to 1 .

19-2. Employment of Protective Measurer

The number of environmental illnesses and m1uries can be reduced

significantly by applying simple commonsense protective measures. As the
unit medical specialist, you can assist the commander in identifying problem
areas and developing protective measures. The use of insect repellents can
reduce the number of mosquito bites, which in turn can reduce the number of
malaria cases. Treating water with iodine or other purification materials can
reduce the probability of personnel getting typhoid fever from drinking
contaminated water. Keeping food cold, 45°F, in storage or hot, 140°F, on the
serving line can reduce the chances of food poisoning.

Section II. COMMUNICABLE DISEASES

19-3. General

Communicable disease is an illness due to a specific infectious agent or its

toxic products which arises through transmission of that agent or its products
from an infected person or animal or a reservoir to a susceptible host, either
directly or indirectly, through an intermediate plant or animal host, a vector,
or the environment.

19-4. Types of Organisms Which Cause Communicable Diseases

The following is a classification of disease organisms and examples of the

diseases they can cause:

• Bacteria: plaque, staphylococcal wound infections, typhoid

fever, gonorrhea.

• Viruses: influenza, hepatitis, measles, rabies, yellow fever.

• Rickettsia: typhus, rocky mountain spotted fever.

• Fungi, yeasts: athletes foot, yeast infections.

• Protozoa: malaria, amebiasis.

• Helminths (worms): hookworms, filariasis.

19-1
FM 8-230

19-5. Infection

An infection is a condition caused by the entry and development or

multiplication of pathogens. Pathogens are disease-producing micro·
organisms. Pathogenic agents of one kind or another are present in all areas
where life exists naturally. They inhabit the air, soil, and water. They are also
in waste products, respiratory tract, alimentary tract, and skin of humans and
animals. Some of these organisms can survive for only a few minutes outside
the human body, while others can survive for years.

19-6. Communicability and Transmission

a. The communicability of the causative organisms is affected by the

following:

• Reservoir-Any person, animal, plant, soil, or substance in

which an infectious agent lives and multiplies, on which it depends for
survival, from which it can be transmitted to a susceptible host.

• Transmission-Any mechanism by which an infectious agent

is spread through the environment, or directly to another person. It includes
the exit from an infected host and the entry to a susceptible host.

• Host-A person or other living animal that gives subsistence

to an infectious agent under natural conditions. A host may have variable
symptoms or an inapparent (asymptomatic) infection. Figure 1 9- 1 illustrates
the chain of infection.

b. Principles of communicable disease prevention and control are

illustrated in Figure 1 9-2.

RESERVO I R
I SOU RC E )

CASE PHYS I CAL CONTACT

CARR I ER DROPLETS, A I R, DUST
All I HAL I N SECTS
WATER
FOOD
FOH i TES

Figure 19-1. Chain of infection.

19-2
 FM 8-230

PERSONAL PERSONAL PERSONAL

BREAK HYG I EN E HYG I EN E HYG I EN E
L I N KS I SOLAT I ON EN V I RONMENTAL I MMUN I ZATI ON
BY : QUARAN T I N E SAN I TAT I ON PROPHYLAX I S
SURVE I LLANCE AI R
TREATMENT WATER
FOO D
WASTE
I N SECTS

Figure 19-2. Principles of control.

19-7. Reservoirs of Disease

Maj or reservoirs of disease and control measures include:

Reservoirs Control

a. Humans Medication to prevent malaria.

Treatment of venereal disease
contact.

b. Animals (mammals) Immunization of pets.

Quarantine of animals.

c. Arthropods (ticks, Insecticides.

insects) Control of breeding areas.
Immunizations.

19-8. Modes of Transmission

The maj or routes or modes of transmission control measures are:

Mode of Transmission Control

a. Airborne droplets/nuclei Cover nose and mouth while

(tuberculosis, influenza, coughing.
other respiratory Avoid crowds during flu season.
infections)

b. Fecal-oral (dysenteries, Wash hands after using latrine.

Hepatitis A) Stay home from work when ill with
disease.

19-3
FM 8-230

c. Skin, mucous membrane Handwashing.

(impetigo, carbuncles Isolation.
common cold, venereal Treatment of patient.
diseases, hookworm) Wearing of shoes.
Proper disposal of wound dressings.

d. Food and water Handwashing by food handlers.

(dysentery, hepatitis, Proper cooking of food.
staph enteritis) Chlorination of water.

e. Fomites-articles Proper washing of linens.

contaminated with Sanitize eating utensils.
infections, micro-
organisms (bed linens, eating
utensils, handkerchiefs)

f. Arthropods (mosquitoes, Insecticide sprays, repellents.

ticks) Immunizations.

19-9. Communicable Diseases of Military Importance and Their Control

a. Respiratory diseases (common cold, influenza, pneumonia) .

(1) Modes of transmission-coughing, sneezing, and oral

contact.

(2) Control measures-individual immunizations, personal

hygiene, and adequate ventilation.

b. Intestinal diseases (diarrhea, dysentery, and typhoid).

( 1 ) Modes of transmission-contaminated food and water, flies,

and infected individuals.

(2) Control measures-eat only approved food and drink only

treated water, dispose of waste matter properly, maintain good personal
hygiene (wash your hands before eating), practice insect and rodent control,
and keep immunizations current.

c. Insect-borne diseases (malaria, typhus, and encephalitis).

( 1 ) Modes of transmission-insect bites and mechanical

transmission (disease-causing organisms deposited by insects on food, drink,
or open sores).

(2) Control measures-keep immunizations current; take

prescribed prophylaxis (malaria pills); bathe daily and change your clothing
daily (if not daily, as often as the circumstances will permit); blouse your pants
legs, button your shirt sleeves and collar; use insect repellents; and spray
pesticides to eliminate or control insects.

NOTE

See FM 21-10 for insect control methods.

19-4
 FM 8-230

CAUTION

When using pesticides in control programs,

follow the container's label instruction.

d. Venereal diseases (syphilis, gonorrhea, Herpes Simplex II).

(1) Mode of transmission is contact with infected persons.

(2) Control measures-

• Attend sex education classes and obey "off limits"

restrictions.

• Maintain personal hygiene (wash genitals thoroughly;

use condoms).
• Identify and report all infected sexual partners.

• Report visible signs of infection.

o MALE-Sore(s) on genitals or discharge from penis.

o FEMALE -Vaginal discharge, lesions of the skin

and mucous membranes, or moist papules in folds of skin in the genitalia.

• Secure prompt medical treatment.

NOTE

Contracting venereal disease (VD) is not a

cause for disciplinary action, but failure to
report for proper medical treatment or
violating "off limits" restrictions could result
in such action.

Section III. HEAT INJURIES

19-10. General

a. Heat Injuries. Heat injuries are frequently preventable conditions.

Prevention depends on the availability and consumption of adequate amounts
of water, acclimatization, and protection from undue heat exposure. A
soldier's ability to function in a hot climate will depend largely on factors such
as general health, age, acclimatization, obesity (being overweight), and use of
drugs or alcohol.

( 1 ) A general preventive measure is to drink sufficient amounts

of liquids and replace body salt lost through perspiration. Instruction to
individuals on how to live and work (or fight) in hot climates will also
contribute to the prevention of heat injuries. Heat injuries can be fatal if not
treated promptly and correctly. The availability of sufficient water during

19-5
FM 8-230

training or combat operations in hot weather is very important. Perspiration

can cause the loss of more than a quart (480 cc's) of body fluids (water) in an
hour. Since the body depends on water to help cool itself, lost fluids must be
replaced immediately. The best way for soldiers to function in extreme hot
climates is to drink water frequently. Individuals should not rely on thirst
alone as an indicator for water replacement needs.

(2) Individuals who have suffered one heat injury are prone to
suffer another one. A patient suffering from a heat injury should have
recovered enough not to risk a recurrence before returning to duty. Other
conditions which may increase heat stress and cause heat injury include
infections, pyrexia (fever), a recent illness or injury, obesity, dehydration,
exertion, heavy meals, and alcohol or drugs.

b. Diet. A balanced diet usually provides enough salt even in hot

weather. However, when soldiers are on reducing or other special diets, salt
may need to come from other sources. A special diet must be prescribed by a
physician or dietitian to insure that it provides all essential requirements.

c. Clothing and Equipment. The types of clothing and equipment a

soldier wears and the way he wears them also affect the body and
acclimatization. Clothing protects the body from radiant heat but excessive or
tight-fitting clothing, web equipment, and packs reduce the ventilation needed
to cool the body. During periods of inactivity when such items are not needed,
they should be removed, mission permitting.

19-11. Category of Heat Injuries

The categories of heat injuries are­

• Heat cramps.

• Heat exhaustion.

• Heat stroke.

19-12. Heat Cramps

Heat cramps are caused by an excessive loss of salt in the body. Salt
imbalance causes changes in nerve impulses to muscles which, in turn, cause
spasms and the inability of muscles to relax. After prolonged exertion in hot
weather, the signs and symptoms of heat cramps will appear in the arms, legs,
and/or stomach.

a. The signs and symptoms of heat cramps.

• The patient is experiencing muscle cramps of his extremities

and/or abdomen after prolonged exertion in hot weather. He grasps or
massages the affected arm or leg, or bends over at the waist (indicating cramps
of the abdomen).

• The patient is pale and has wet skin.

• He is experiencing dizziness and extreme thirst.

19-6
 FM 8-230

b. Treatment for heat cramps.

(1) Have individual drink 250 cc's (1/4 canteen) o f water.

( 2) Administer one canteen of water with Y4 teaspoon of table

(C-ration packet) salt added. Have the patient drink the canteen of salt
solution over a 30-minute period.

CAUTION

Do not give the patient salt water if he is

nauseated. Have him drink a canteen of
unsalted water.

(3) If conditions permit, move the patient to a shaded area.

(4) Have him sit or lie in a comfortable position.

(5) Loosen all tight-fitting clothing.

(6) Allow him to rest until cramps have subsided.

c. Record the treatment given if he is being evacuated.

d. Evacuate the patient to an MTF if cramping symptoms persist.

19-13. Heat Exhaustion

Heat exhaustion is caused by dehydration and loss of body salt. It is basically

a hypovolemic problem (an abnormal decrease in the volume of circulating
fluid (plasma) in the body).

a. Signs and symptoms of heat exhaustion.

• The patient feels dizzy, weak, and/or faint.

• His skin feels cool and moist to the touch.

• He may feel nauseous (sick to his stomach) or may have a

headache.

b. Treatment for heat exhaustion.

(1) Have the patient drink one canteen of water to relieve the
symptoms.

(2) If he complains of cramps, give him one canteen of water with

Y4 teaspoon of table salt added. Have him drink the canteen of salt solution
over a 30-minute period.

CAUTION

Do not administer salt if the patient is

nauseated. Have him drink a canteen of
unsalted water.

19-7
FM 8-230

NOTE

If the patient is unable to drink water due to

nausea and/or if symptoms have not improved
within 20 minutes after liquids have been
given orally, then he must be evacuated to an
MTF.

(3) If conditions permit, move the patient to a shaded area. Have

him lie in a comfortable, supine (flat on his back) position.

(4) Loosen all tight-fitting clothing.

(5) Elevate his feet above the level of his heart. If a litter is
available, have the patient lie on the litter in a supine position and elevate the
foot of the litter.

c. Record the treatment given if the patient is being evacuated.

d. Evacuate the patient to the nearest MTF if symptoms persist.

19-14. Heat Stroke

Heat stroke (hyperthermia) is a MEDICAL EMERGENCY caused by failure

of the heat-regulating mechanism of the body. Persons who are not
acclimatized to heat, the elderly, and those with cardiovascular (heart and
blood vessel) problems are particularly vulnerable. Also, obesity, dehydration,
excessive use of alcohol or drugs, poor health, and the lack of sleep contribute
to the possibility of hyperthermia.

a. Signs and symptoms of heat stroke.

• The patient may have a headache and visual disturbance

(impaired vision).

• He may have a high fever (elevated temperature) and will not

be sweating (skin may appear dry). His skin will appear abnormally hot to the
touch.

NOTE

Oral temperature may range up to 105 °F

(40°C) or higher and the rectal temperature
may range up to 107 °F (42°C) or higher.

• His pulse may be rapid or irregular.

• The patient may have muscle cramps and convulsions.

• The patient may feel dizzy or nauseated.

• The patient may be unconscious.

b. Treatment (emergency management) for heat stroke. Reduce the

body temperature to 102°F (39°C) as quickly as possible, using one or more of
the methods indicated below.

19-8
 FM 8-230

CAUTION

If individual is unconscious, insure that he has

adequate respiration (open the airway) and
adequate circulation. Also, insure that the
patient has not gone into shock. If necessary,
initiate treatment for shock.

• First Method. If a thermometer is available, immerse patient

in cool water (including torso, trunk, and extremities). While patient is
immersed, massage his arms and legs (extremities). Massaging allows skin
capillaries to dilate and transmit a cooling effect.

CAUTION

It is vital to determine when the patient's

temperature cools to 1 02°F (39°C). When this
happens, he must then be taken out of the
water immediately. Once the patient's
temperature falls to 102°F, it will drop even
more rapidly if he is left immersed and worsen
his condition.

• Second Method. If no thermometer is available, immerse only

the patient's trunk in the cool water. Be careful not to overcool him, as this
would cause the patient's temperature to go to the other extreme (below
98.6 °F (37°C). Massage the patient while immersed in cool water to help skin
(capillaries) transmit cooling effect.

• Third Method. If facilities are not available for immersing the

patient, pour cool water over the patient or sponge him liberally, then fan him
to permit the cooling effect of evaporation.

c. Record the treatment given.

d. Evacuate the patient to an MTF as soon as possible for definitive

treatment. If available, place ice bags at the sides of the patient's neck and
under his armpits while transporting to the MTF.

Section IV. COLD INJURIES

19-15. General

a. Cold weather operations pose a particular threat to the combat

soldier since it is possible for him to sustain a serious injury unrelated to
combat or training.

b. Cold injuries to the body can occur when an individual is exposed

for prolonged periods to temperatures at or below 50°F, or to extreme cold for
shorter periods.

19-9
FM 8-230

c. Such exposure can cause surface tissue damage or it can cause

generalized body chilling which can result in death.

d. Specific preventive measures are directed toward conserving total

body heat and avoiding prolonged exposure to cold and moisture. Regular
water intake is especially necessary in cold weather to avoid dehydration.

e. The medical specialist must be able to recognize the signs and

symptoms of all forms of cold injury. While some injuries are superficial and
not serious enough to require evacuation, others can cause permanent injury
or death. The windchill chart (Table 19-1) will help you to judge the severity of
the environment. Some weather conditions require reducing the exposure time
of individuals engaged in patrols, guard duty, or motor movement in unheated
vehicles despite the adequacy of clothing and equipment. These possible
conditions can frequently be anticipated by the use of meteorological data and
existing weather conditions to predict the hazard for the following 1 2-hour
period.

Table 19-1. Windchill Chart

LOC A L T E M PE R A T U R E 1 ° F 1
Wind speed I M P H I 32 23 14 5 -4 -13 -22 -2 1 -4 0 -4 9 - 58

�
EQU I V A L E N T TE M PE RA T U R E 1°F1

C A L:\1 32 2 :3 J4 5 -4 -J3 -3 1 -4 0 -4 9 - 58

I
5 29 20 JO J -9 -1 8 -28 -37 -4 7 -5 6 -6 5
JO JH 7 -4 -J5 -26 -37 -4 8 -59 -1 0 -8 J -9 1
J5 J3 -1 -13 -25 -7 -49 -6 J -73 -85 -9 7 - 1 09
20 7 -6 -J9 -32 -44 -57 -70 -8 3 -96 - 1 09 -121
2;, :l - JO -24 -37 -50 -64 -77 - 90 - 1 04 -1 1 7 -117
30 l - l :l -27 -4 1 - 54 -68 -8 2 -97 - 1 09 - 1 23 -137
35 -l -15 -29 -4 3 -57 -71 -85 - 99 -1 1 3 - 1 27 - 142
31
-

40 -3 -17 - -45 -59 -74 -8 7 - 1 02 -1 16 -131 -145

45 -3 18 - 32 -4 6 -6 1 -7 5 - 89 - 1 04 -1 18 - 1 32 -147
50 -4 -18 -33 -47 -62 -76 -9 1 - 1 05 - 1 20 - 1 34 - 1 48
L I TTLE D A N G E R FOR CO N S I DE RA B LE V E RY G R E AT D A N G E R
P RO P E R L Y CLOT H E D D A ;-..; G E R
PE RSO N S
D A N G E R FROM F R E E Z I NG OF E X POSE D F L E S H

19-16. Chilblain
Chilblain results from repeated prolonged exposure of bare skin to
temperatures from 60°F ( 1 6°C), down to 32°F (0°C), for acclimated, dry
unwashed skin. It is usually not serious enough to require evacuation.

a. Signs and Symptoms of Chilblain.

• Skin becomes acutely red, swollen, hot, tender, and/or itching.

• Bleeding lesions may surface from continued exposure.

19-10
 FM 8-230

CAUTION

Continued exposure may lead to ulcerative

(surface) or hemorrhagic (bleeding) lesions.
Lesions are sores that occur where layers of
skin have broken down.

b. Treatment for Chilblain.

(1) Within minutes rewarm the affected part of the body.

• FACE. Cover the affected area of face with warm hands

until feeling/sensation returns.

• HANDS. Have the patient place his bare hands next to

the skin in the opposite armpit.

• FEET. In the most sheltered area available, place the

bare feet under the clothing and against the abdomen of another soldier.

(2) Protect lesions with a field dressing. Do not apply ointments

because the moisture will cause further skin breakdown in a cold environment.

c. Record the Treatment Given.

d. Evacuate the Patient. Evacuate all persons with cold injuries to an

MTF.

19-17. Frostbite
Frostbite results when tissues exposed to temperatures below 32°F (0°C)
freeze. The degree of injury depends upon the windchill factor, duration of
exposure, and adequacy of protection. Individuals with a history of cold injury
are prone to repeated episodes. A sudden blanching of the skin occurs in the
nose, ears, cheeks, face, fingers, or toes, followed by a momentary tingling
sensation. When the face, hands, or feet stop hurting, look for frostbite.
Frostbite is divided into two categories:

• Superficial.

• Deep.

a. Signs and Symptoms of Superficial Frostbite. The most commonly

affected areas are the hands, feet, ears, and exposed areas of the face.

• Redness, followed by powdery flaking of the skin. Affected

areas of dark-skinned persons may appear dull and grayish.

• Blister formations 24 to 36 hours after exposure, followed by

flaking of superficial skin in large sheets.

b. Signs and Symptoms of Deep Frostbite.

• Lack of pain or loss of feeling in the affected area.

• When the frostbitten area thaws, it is painless, pale yellow,

and waxy-looking.

19-11
FM 8-230

• Frozen tissue may feel solid or "wooden" to the touch, but not
brittle.

• When exposed to inside temperatures, the skin surface

collects drops of moisture. Unless rewarming is rapid, blisters appear in 1 2 to
36 hours.

• Discoloration (red-violet) appears suddenly 1 to 5 days after the

injury.

• Gangrene usually results when the patient does not receive

proper treatment.

c. Treatment for Frostbite.

( 1 ) Determine whether the frostbite is superficial or deep and

treat accordingly.

• If the exposure time was short, the frostbite will

probably be superficial.

• If the exposure time was for a longer duration, the

frostbite will probably be deep.

NOTE

Do not rub the frostbitten area with snow or

apply cold water soaks, or rewarm the affected
area by massaging or exposing it to open fire.

(2) Move the casualty to a warm and sheltered area.

(3) Rewarm the face, nose, or ears by placing your hands on the
frozen area.

(4) Rewarm frostbitten hands by placing them under clothing

and against the body. Close the clothing to prevent further loss of body heat.

(5) Rewarm the feet by removing the boots and socks. Place the
bare feet under the clothing and against the abdomen of a buddy. Once the feet
are warmed, put on dry socks and boots, if available. If the patient must wear
the wet socks and boots, he should exercise his feet by wiggling his toes.

NOTE

1. I f another soldier is unavailable, you may have

to use your own body heat.
2. Identify multiple casualties by severity of cold
injury and determine whether the frostbite
patient is in need of immediate care or can walk
to the MTF.

19-12
 FM 8-230

(6) Loosen constricting clothing and remove jewelry. Loose

layers of clothing are effective insulators. Air is trapped between layers of
clothing and is warmed by the body.

(7) Increase insulation and exercise.

NOTE

Do not allow patient to use alcohol or tobacco.

Alcohol increases loss of body heat; tobacco
causes constriction of blood vessels in the
extremities.

(8) Reassure the patient.

(9) Protect frozen tissue from further cold or trauma.

( 10) Deep frostbite-occurs most seriously in the feet and less

common in the hands and ears.

(a) Move the patient to a sheltered area.

(b) Immediately make arrangements to get the patient to

an MTF.

CAUTION

Avoid thawing if it is possible that the injury

may refreeze before reaching the MTF.

(c) If possible, do not let the patient walk if his feet are
frozen.
(d) Avoid treating or thawing the affected area.

d. Record the Treatment Given.

e. Evacuate the Patient.

19-18. Hypothermia

Hypothermia is whole body cooling, with core body temperature (temperature

measured centrally from within the rectum) below 95°F (35°C). Hypothermia
is a MEDICAL EMERGENCY. Predisposing factors of hypothermia are
fatigue, poor physical conditioning, dehydration, faulty blood circulation,
alcohol or other drug intoxication, trauma, and immersion. Hypothermia may
be accompanied by varying degrees of frostbite.

a. Signs and Symptoms of Hypothermia.

• Shallow or absence of respiration.

• Faint or unpalpable peripheral (apical) pulse.

• Patient is at first cold, then stops shivering.

19-13
FM 8-230

• Loss of sensation or feeling.

• Sluggish or absence of pupillary reflexes.

• Mental disorientation, withdrawn appearance, depressed

mood, uncoordinated movements, and/or slurred speech. Listlessness,
indifference, and/or glassy stare are also good clues.

b. Treatment for Hypothermia.

(1) Determine the patient's level of consciousness.

CAUTION

Dangers exist from cardiac arrhythmia and

shock. Cardiac arrhythmia may occur when the
heart reaches a low temperature.

(2) Move the patient to a sheltered area to prevent further heat

loss.

(3) Replace the patient 's wet clothing with dry clothing,
blankets, or sleeping bags. Provide heat by using a hot water bottle, electric
blanket, campfire, or your own body heat. The most effective method, if
available, is to immerse the patient 's torso (not the limbs) in a tub of warm
water (1 05°F (42°C) to l l 0°F (44°C)).

CAUTION

The patient is unable to generate his own body

heat. Therefore, merely placing him in a
blanket or sleeping bag is not sufficient.

(4) Provide the patient with something warm/hot and nutritious

to drink. Calories may be added by using sugar or glucose tablets in hot, sweet
drinks.

NOTE

Hypothermia patients have revived after as

long as 30 minutes of immersion in cold water.

c. Record the Treatment Given.

d. Evacuate the Patient to the Neares t MTF.

19-19. Immersion and Trench Foot

a. Immersion foot is an injury sustained as a result of prolonged

exgosure (usually in excess of 1 2 hours) in water at temperatures usually below
50 F (10°C). It is not limited to the feet, but may involve other areas following
immersion. Exposure for several days in water at 70°F (21°C) at tropical
latitudes has produced severe injury.

19-14
 FM 8-230

b. Trench foot is an injury sustained as the result of exposure to cold

and wet conditions, short of freezing. The average duration of exposure
resulting in trench foot is 3 days.

c. The signs and symptoms of immersion foot or trench foot can be

divided into three phases·

• The anesthetic phase, with loss of pain sensation and a weak

pulse in the injury area.

• The reactive hyperemic phase, in which the limbs feel hot and
as if burning with shooting pains.

• The vasospastic phase, in which the blood vessels contract,

causing a decreased pulse and skin discoloration.

• Blisters, swelling, redness, skin surface heat, hemorrhage, and

gangrene may develop in any phase.

d. Treatment for immersion foot/trench foot.

( 1 ) Gradually rewarm the affected area by exposure to warm air.

NEVE R MASSAGE THE SKIN.

NOTE

Avoid extreme heat and ice application. In a

field environment, warm air from a heated
source may not be available. Rewarm as for a
frostbite casualty.

(2) Dry the affected area immediately.

(3) Protect the affected area from trauma and secondary

infections. Dry, loose clothing or several layers of warm coverings are
preferable to heat.

(4) Elevate the affected parts. (This aids in reducing the amount
of edema fluid.)

e. Record the treatment given.

f Evacuate the patient to an MTF as soon as possible.

19-20. Snow Blindness

a. Snow blindness occurs when the ultraviolet rays of the sun are
reflected from a snow covered surface. This condition can occur even in cloudy
weather. In fact, it is more likely to occur in hazy, cloudy weather than when
the sun is shining.

19-15
FM 8-230

b. Signs and symptoms of snow blindness.

• The patient experiences a scratchy feeling in his eyelids. It

may feel as if he has sand in his eyes.

• Observe his eyes for redness and watering.

• Ask him if he has a headache.

c. Treatment for snow blindness.

( 1 ) Blindfold the patient using a dark cloth. If the patient has

not developed a severe case of snow blindness, an emergency pair of
sunglasses (Figure 19-3) may be made from a thin piece of wood or cardboard
the width of the face. Cut slits for the eyes and attach strings to hold the
improvised glasses in place.

Figure 19-3. Improvised sunglasses.

(2) Reassure the patient.

d. Record the treatment given if evacuation is necessary.

e. Evacuate the patient to an MTF, if necessary.

19-16
 FM 8-230

Section V. BITES AND STINGS

19-21. General
In the Continental United States, insect bites and stings from venomous
arthropods may result in severe reactions and can cause death. Arthropods
most frequently reported as responsible for bites and stings are wasps, bees,
ants, spiders, and scorpions. In certain geographical locations in CONUS,
some arthropods have only seasonal importance while others are present
throughout the year. Because of the potential for arthropod poisoning to
humans, their identification, distribution, behavior, and control are important
factors in the prevention of insect bites and stings.

19-22. Black Widow Spiders

a. The black widow spider (Figure 1 9-4) is easily identified by its

jetblack color and the reddish hourglass-shaped figure found on the underside
of its abdomen. This spider is found in grass, shrubs, rock piles, latrines, and
similar locations. The black widow spider prefers to remain hidden and is
generally nonagressive; however, if molested, it will bite.

-·�� v,-
-">c� . .
-�J " -�..
--
---.. � - -�-- - _/-
-
/
�--
'··-... ....
- - -----

Figure 194. Black widow spider.

b. Signs and symptoms of a black widow spider bite.

• A dull, numbing pain at the bite site.

• Two red puncture marks with only a slight, local topical

reaction.

• Severe muscular pain and spasms. The pain peaks in 1 to 3

hours and persists for 1 2 to 48 hours.

• Profuse sweating.

• Nausea.

• Rigid and boardlike abdomen with pain.

• Tightness in the chest with pain during inhalation.

• Possible convulsions, paralysis, or signs of shock.

19-17
FM 8-230

c. Treatment for a black widow spider bite.

(1) Expose bite area by-

(a) Removing clothing and/or shoes to the extent necessary

to expose the bite area.

(b) Removing jewelry as soon as possible to prevent

restricting circulation as swelling (edema) occurs. If the jewelry cannot be
removed because of swelling, place ice locally to reduce or prevent further
swelling.

(c) Jewelry should be given to the patient, placed in his

pocket, or otherwise protected/secured.

(2) Ask the patient if he can identify what bit him.

(3) Do not apply a tourniquet or attempt to remove the venom

by incision or suction.

(4) Keep patient quiet and warm.

(5) Cleanse the bite area.

(6) Apply ice to the bite area, if available. Ice relieves pain and
swelling and slows down circulation, restricting the spread of the venom.

(7) Monitor vital signs.

(8) Treat for anaphylactic shock, if necessary.

d. Record the treatment given.

e. Evacuate the patient to the nearest MTF.

19-23. Brown Recluse Spiders

a. The recluse spider (Figure 1 9-5) is about 3/8 inches long and is
differentiated from other brown spiders by a dark brown violin shaped area on
its back. This spider is found primarily in grass and weed shelters, around
rocky bluffs, and in rock piles. It sometimes seeks refuge in blankets, bedrolls,
shoes, clothing, or wadded-up paper. The brown recluse spider prefers to
remain hidden and is generally nonaggressive; however, when molested, it will
bite.

b. Signs and symptoms of a brown recluse spider bite.

• Mild to severe pain at the bite site. This usually occurs 1 to 8

hours after the bite, as there is little (if any) immediate pain.

• Redness at the bite site.

• Star-shaped, firm area of deep purple color at the bite site

(usually 3 to 4 days following the bite).

19-18
 FM 8-230

• A central area of depression and ulceration (usually 7 to 1 4

days following the bite).

• Chills, nausea, and vomiting.

• Scar formation which follows approximately 2 1 days after the

bite.

c. Treatment for a brown recluse spider bite.

(1) Calm the patient with reassuring words.

(2) Clean the bite site.

(3) Monitor the patient's vital signs.

d. Record the treatment given.

e. Evacuate the patient to the nearest MTF.

Figure 19-5. Brown recluse spider.

19-24. Scorpions

a. Scorpions are easily recognized by their crablike appearance with a

long, segmented tail which ends in a sharp spine or stinger (Figure 1 9-6).
Scorpions are most commonly found in warm climates. They prefer damp
locations and are particularly active during the night. Most scorpions found in
the US are capable of only causing painful stings.

b. Signs and symptoms of scorpion stings.

• Severe pain at the sting site.

• Burning sensation at the sting site.

• Local swelling and discoloration at the sting site.

19-19
FM 8-230

NOT�

The above symptoms are characteristic of the

harmless species of scorpions.

• Other signs and symptoms of the deadly species are-

o "Pins and needles " sensation at the sting site.

o Impaired speech and drowsiness.

o Nose, mouth, and throat itching.

o Generalized/localized muscle spasms.

o Respiratory distress.

NOTE

Scorpion stings of the deadly species normally

do not cause swelling or discoloration.

Figure 19-6. Scorpion.

c. Treatment for a scorpion sting.

NOTE

If a person is stung by a scorpion on the face,

neck, or genital organs, he should be treated
immediately by a medical officer.

( 1 ) Immobilize the patient. Apply a constricting band proximal

to the sting site. The band is sufficiently tight when one finger can be inserted
between the band and the body part.

(2) Pack the area with ice and extend it beyond the constricting
band. This is done to restrict venous flow but not to stop arterial flow.

19-20
 FM 8-230

(3) Remove the constricting band after 5 minutes.

(4) Monitor the patient's vital signs.

d. Record the treatment given.

e. Evacuate the patient to the nearest MTF, if necessary.

19-25. Bees, Wasps, Hornets, and Yellow Jackets

a. The bee has a characteristic rounded abdomen. When it stings, its

stinger remains in the victim. The bee will fly away and die. On the other hand,
a wasp, hornet, or yellow jacket has a slender, elongated body and retains its
stinger and can sting repeatedly (Figure 19-7).

HONEYBEE HORNET YELLOW JACKET

Figure 19-7. Bee, hornet, yellow jacket, and wasp.

b. Signs and symptoms of bee, wasp, hornet, and yellow j acket

stings.

• Pain at the sting site.

• Development of a wheal and redness at the sting site. Intense

swelling may develop in the area of the sting.

• Itching and anxiety indicate a mild reaction.

• Wheezing, vomiting, dizziness, abdominal pain, tightness in

the chest, or generalized edema. Any of these signs/symptoms indicate a
moderate reaction which usually appears within 20 minutes.

• Labored breathing, difficulty in swallowing, and confusion

indicate a severe reaction.

• Shock. If present, immediately initiate treatment for

anaphylactic shock.

19-21
FM 8-230

c. Treatment for bee, wasp, hornet, and yellow jacket stings.

( 1 ) Remove the stinger from the sting site (bee stings), by gently
scraping it with the fingernail, a knife blade, or a thin metal object. (Removal
prevents further venom inj ection from the venom sac.) Do not jerk the stinger
out as this action releases more venom.

(2) Wash the sting site with soap and water.

(3) Apply an ice pack or a solution of 10 percent ammonia.

(4) Treat for shock, if necessary.

d. Record the treatment given.

e. Evacuate the patient to the nearest MTF, if necessary.

19-26. Fire Ants

a. The fire ant was brought into the United States from South
America in earth used as buoyance in cargo ships. They were first found in
the Mobile, Alabama area. Since there are no natural enemies to this insect in
th� United States, they have invaded all of the Gulf Coast States.

b. Signs and symptoms of fire ant bites.

• Severe burning pain at the bite site.

• Wheal formation. The wheal will usually last a few minutes.

• A clear, fluid-filled bubble at the bite site. This bubble usually

forms within minutes of the bite.

• A cloudy, fluid-filled bubble at the bite site. This bubble

usually appears 2 to 4 hours after the bite.

• A bubble with a red base. This bubble usually appears 8 to 1 0

hours after the bite.

• Tenderness at the bite site.

• A lesion at the bite site. The lesion usually appears 3 to 8 days

after the bite and may leave a scar.

c. Treatment for fire ant bites.

(1) Wash the bite site with soap and water.

(2) Apply an ice pack or cold compress to the bite site.

(3) Treat for anaphylactic shock, if necessary.

19-22
 FM 8-230

d. Record the treatment given.

e. Evacuate the patient to the nearest MTF, if necessary.

19-27. Ticks

a. Ticks are common in woods and fields throughout the United

States. They are divided into two groups: the hard ticks and the soft ticks. The
hard tick has a hard shield on its back, and its mouth parts can be seen from
above (Figure 1 9-8). The soft tick does not have a hard shield on its back, and
its mouth parts cannot be seen from above (Figure 19-9).

Figure 19-8. Hard ticks. Figure 1!+9. Soft ticks.

b. Signs and symptoms of tick bites.

• Tick with mouth parts inbedded in patient's skin.

• Itching and/or redness at the bite site, tick already removed.

• Pain in patient's arms or legs.

NOTE

After several days, the patient may develop

tick paralysis which could result in respiratory
failure.

• Breathing difficulties a few days following the tick bite.

CAUTION

Some species of ticks transmit Rocky

Mountain Spotted Fever which may appear 3
to 1 2 days after the bite.

c. Treatment for tick bites.

( 1 ) Perform rescue breathing immediately if breathing

difficulties are present.

19-23
FM 8-230

(2) Remove the tick by-

(a) Soaking a tissue/gauze pad with mineral, salad, or

machine oil, or alcohol and covering the tick (at the bite site). This blocks the
tick's breathing pores, causing it to withdraw.

(b) If the tick does not disengage after V2 hour, remove it

with tweezers or forceps. Grasp it as close to its mouth as possible. Do not
grasp the tick's abdomen since germs may be injected into the patient by the
pressure.

(3) Wash the bite site with soap and water.

d. Record the treatment given.

e. Evacuate the patient to the nearest MTF, if necessary.

19-28. Unknown/Nonspecific Insect Bites

a. Many insects not involved in disease transmission are medically

important because of their bite or sting and cause concern by their presence.

b. Signs and symptoms of unknown/nonspecific insect bites.

• Breathing difficulties.

• Possible shock.

• Swelling at the bite site.

• Pain at the bite site.

c. Treatment for unknown/nonspecific insect bites.

(1) Perform rescue breathing, i f necessary.

(2) Perform anaphylactic shock treatment, if necessary.

(3) Wash the bite site with soap and water.

(4) Apply an ice pack or cold compress to the bite site.

(5) Monitor the patient's vital signs.

d. Record the treatment given.

e. Evacuate the patient who shows signs of respiratory distress

and/or shock and who is not responding to initial treatment given.

19-29. Types of Snakes

a. Except for a few species in Southeast Asia and Africa, snakes are
shy and will usually avoid contact with humans unless injured, trapped, or
disturbed. However, both poisonous and nonpoisonous snakes show some

19-24
 FM 8-230

agressiveness during their breeding periods. All species of snakes can swim
and many are able to stay under water for long periods without drowning.
Snakebites sustained in water are as dangerous as those sustained on dry land.

b. Nonpoisonous snakes (Figure 19-10) have four to six rows of teeth

and do not have fangs.

Figure 19-10. Tooth marks of nonpoisonous snakes.

c. Poisonous snakes include the pit vipers (rattlesnakes, water

moccasins, and copperheads) and coral snakes.

( 1 ) Pit vipers (Figure 19-1 1 ) have two rows of teeth and fangs
that create puncture wounds.

(a) North American pit viper snakes are also characterized

by vertical pupils, a flat triangular-shaped head distinct from the neck, and a
deep pit between the eyes and nostrils.

(b) These snakes may be more than 5 feet in length, and all
are capable' of inj ecting hemotoxin venom. This venom can disintegrate red
blood cells in humans and animals. The cottonmouth water moccasin can
inj ect both hemotoxin and neurotoxin venom.

FANG MARKS POISONOUS PIT VIPER

TEETH MARKS

\ (
Figure 19-11. Fang marks of poisonous pit viper snakes.

19-25
FM 8-230

(2) Coral snakes have different markings and colors, depending

upon their variety. The average coral snake is usually less than 2 feet long with
a body diameter of about Y2 inch, and has short, rigid, grooved fangs. The
Eastern coral, Texas coral, and Barber's coral have broad alternating bands of
red and black separated by narrow bands of yellow circling their bodies in a
regular pattern. These snakes have round pupils. The Sonora coral has broad
alternating bands of red and black, separated by narrow white bands circling
its body in a regular pattern. The coral snake venom is a neurotoxin (destroys
nerve tissue) .

d. Signs/symptoms of snakebites.

• Immediate pain.

• Progressive swelling at the bite site.

• General skin discoloration (bluish) .

• Dizziness .

• Blurred vision.

• Hearing difficulty .

• Fever and/or chills .

• Severe headache .

• Vomiting and nausea.

• Breathing difficulty .

NOTES

1. The patient may exhibit one or all o f the above

signs/symptoms.

2. If the snake can be killed without risking

another bite, it should be brought to the MTF
for identification.

3. Some snakebite symptoms may not develop

until 6 to 8 hours later.

e. Treatment for a nonpoisonous snakebite.

( 1 ) Cleanse the bite area using soap and water or an antiseptic

solution (such as iodine).

(2) If the patient does not have a current immunization, tetanus

toxoid, refer him to an MTF for the immunization.

(3) Return the patient to duty.

19-26
 FM 8-230

NOTE

If the bite cannot be positively identified as

nonpoisonous, treat it as a poisonous
snakebite.

f. Treatment for a poisonous snakebite.

(1) Place the patient in a prone position (preferred).

(2) Keep him as calm as possible.

(3) Tell him not to move.

(4) Explain what you are doing.

(5) Tell him that evacuation will be accomplished as soon as

possible.

(6) Expose the wound as necessary by removing patient's

clothing, shoes, and jewelry.

(7) If the patient has been bitten on an extremity, keep the bitten
part at or below the heart level to slow down the spread of the poison to the
heart.

(8) Exercise caution regarding placement of the arm if the

patient is being moved by a stretcher. If the bite is on the hand or arm, it may
already be swelling and stretcher straps will increase the pressure and
possibly cut off circulation.

CAUTION

Do not give the patient any medication

containing alcohol or sedatives. While certain
analgesics may decrease the pain, they may
also increase the effects of the toxin. Do not
allow the the patient to eat or smoke.

(9) Place constricting bands (Figure 19-12) one or two fingers'

width above and below the bite site. These bands should be only tight enough
to stop superficial venous and lymphatic circulation but not interfere with the
arterial pulse. You should be able to insert one finger between the constricting
bands and the skin with minimal pressure. If the bite is on the hand or foot,
only one band should be placed above the ankle or the wrist (depending on the
location of the bite).

( 10) If swelling spreads, move the bands beyond the edges of the
swelling.

( 1 1 ) Cleanse the wound area, using soap and water or an

antiseptic solution.

( 1 2) DO NOT cut the wound.

19-27
FM 8-230

(13) Place an ice bag or a chemical ice bag over the bite area, but
not in direct contact with the skin. The ice bag should remain over the area
until the patient reaches the MTF, but no longer than a few hours. Do not use
dry ice, ethyl chloride, or wet ice brine. Be careful not to freeze the area or
severe damage can result to the vascular structures and limbs. Only a cooling
is to be attempted.

( 1 4) Monitor the patient to prevent cold injury.

NOTES

1. If signs/symptoms of poisonous
(envenomation) snakebite are present, and the
snake has been identified, a medical specialist
who is authorized to use and carry antivenin
should administer it. However, this should be
done only if you can positively identify the
snake. Its use presents risks and only those
with specialized training should attempt using
the antivenin. Test the patient for sensitivity.
The method of administration should follow
package instructions. The medical specialist
should also be able to deal with severe
hypersensitivity reactions to the serum.

2. A possible complication is respiratory failure.

If the patient stops breathing, perform rescue
breathing. If there is no pulse, perform
cardiopulmonary resuscitation (CPR).

Figure 19-12. Placing constricting bands.

g. Record the treatment given.

h. Evacuate the poisonous snakebite patient to the nearest MTF.

19-28
 FM 8-230

Section VII. POISONOUS PLANTS

19-30. General

a. Contact poisoning is a skin eruption which is caused by direct or

indirect contact with the sap (or juice) of poisonous plants. In the United
States alone, several thousand cases of contact poisoning occur each year. The
most common plants which cause these skin eruptions are poison ivy, poison
oak, and poison sumac.

b. These skin eruptions can be prevented by learning how to identify

poisonous plants and by taking the proper control measures.

( 1 ) The skin eruptions first appear as redness and swelling

accompanied by severe burning and itching.

(2) Blisters appear later.

c. Poisonous plants are most likely to exist in areas of dense

vegetation. Poison ivy, poison oak, and poison sumac contain a sticky sap
which has a toxic ingredient known as urushiol.

( 1 ) Urushiol is contained in all parts of these plants and is even

present in their dead stems and roots.

(2) Urushiol is the agent that causes the skin irritation. Contact
with urushiol may also be made indirectly by touching urushiol-contaminated
tools, weapons, clothing, and pets, and from another person having urushiol on
the skin or clothing. Even smoke from plants that are burning contain droplets
of urushiol which can get on the skin or enter the nose, throat, and lungs.

19-31. Preventive Measures for Poisonous Plant Injuries

a. Be able to identify the plants which cause contact poisoning.

b. Avoid selecting bivouac areas which are infected with poisonous

plants.

c. Wear gloves and be fully clothed (with sleeves unrolled and

buttoned and collar buttoned) when working in an area likely to have
poisonous plants.

d. Wash all exposed skin areas with a strong soap solution or with
alcohol if exposure to poisonous plants is known or suspected.

e. Use hot water and soap to wash all clothing and equipment known
or suspected to be contaminated.

f. Bum poisonous plants on the DOWNWIND side of the bivouac or

troop area to avoid contamination with the smoke which contains urushiol
droplets.
C AU T I ON

Urushiol droplets contained in the smoke will

cause internal swelling which could result in
extreme breathing difficulty.

19-29
I
FM 8-230

19-32. Treat Poisonous Plant Injuries

a. Recognize the poison ivy (Rhus radicans) plant (Figure 19-13).

(1) Poison ivy grows as a small plant, either vine, or shrub.

(2) It grows everywhere in the United States except California

and parts of the adjacent states. Eastern oak leaf ivy is one of its varieties.

(3) The leaves of this plant always consist of three glossy

leaflets.

(4) This plant may also be known as three-leaf ivy, poison

creeper, climbing sumac, poison oak, and mercury.

Figure 19-13. Poison ivy.

b. Recognize the poison oak (Rhus diversiloba) plant (Figure 19-14).

(1) Poison oak grows a s a shrub and sometimes a s a vine.

(2) It grows throughout the United States.

(3) It is sometimes called poison ivy.

(4) Its leaves always consist of three smaller leaflets.

19-30
 FM 8-230

Figure 19-14. Poison oak.

c. Recognize the poison sumac (Rhus vernix) plant (Figure 19-1 5).

(1) Poison sumac grows as woody shrubs or small trees having

compound leaves and clusters of small greenish flowers, succeeded by red,
hairy fruits.

(2) It grows in most of the eastern third of the United States.

(3) This plant may also be known as swamp sumac, poison

dogwood, and thunderwood.

Figure 19-15. Poison sumac.

19-31
FM 8-230

d. Signs and symptoms of contact poisoning.

• Redness and swelling of involved skin.

• Headache.

• Burning sensation on involved parts of the body.

• Skin eruptions (rash).

• Skin itching.

NOTE

The rash may appear from within a few hours

to as many as 48 hours after exposure.

• Blisters on the involved skin. The blisters break after 2 to 4

days and leave a raw surface which becomes encrusted. They will usually heal
within 2 weeks.

NOTE

The redness and swelling generally appear

first, followed by the blisters.

e. Treatment for contact poisoning.

( 1 ) Thoroughly wash the exposed area(s) of the patient's skin

with soap and water or with alcohol to remove or reduce the amount of
urushiol on the skin.

(2) Confine the washing to the affected area to avoid spreading

the poison to other parts of the body.

(3) Wash the area several times in succession. Use a fresh

solution for each wash.

(4) Apply alcohol to the affected area to further cleanse it and to

help prevent secondary infections.

(5) Apply Calamine lotion to soothe the contaminated area and

help in healing. DO NOT apply Calamine lotion to raw areas, as this may cause
infection.

(6) Administer Benadryl to decrease the allergic reaction.

(7) Do not dress the affected area, as this will cause retention of
moisture and will not allow the contaminated area to dry.

19-32
 FM 8-230

(8) Avoid contact with the contaminated water in the event you
are allergic to the source.

(9) Thoroughly wash your hands and any part of your body
which may have come in contact with the urushiol; also, remove all of your
clothing exposed to urushiol. This will help in preventing your contracting the
poison following the administration of treatment to the patient.

f. Record the treatment given.

g. Evacuate the patient, if necessary. Depending on the severity of

the contamination, limited duty or evacuation to an MTF may be necessary.

19-33
 FM 8-230

C HAPTER 2 0

NUC LEAR, BIOLOGICAL, AND

CHEMICAL IN.JURIES

Section I. INTRODUCTION

20-1. General

The introduction of nuclear, biological, or chemical (NBC) warfare on the

battlefield will greatly strain the capabilities of the medical specialist in his
role as the first level of medical care to combat forces.

20-2. Employment of NBC Weapons

The enemy may use one or more types of warfare agents in the same area of
operations. You may encounter patients suffering from the effects of radiation
and chemical agents at the same time. Sections II through IV discuss the
types of injuries you will see and will need to provide care for. Additionally,
you will continue to see injuries and illnesses caused by other sources in
addition to those caused by NBC warfare.

Section II. NUCLEAR CASUALTIES

20-3. General

Nuclear injuries can be divided into three types: blast, thermal, and radiation
sickness. Each type of injury can occur without the others, all three can occur
at the same time, or in a combination of any two.

20-4. Blast Injuries

a. The types of blast injuries caused by nuclear weapons are more

varied than those caused by conventional weapons. Blast injuries are the
result of the direct action of the blast wave over pressure, the indirect action of
flying debris, or the violent slamming of individuals against other objects.
Blast injuries may be complicated by thermal and/or radiation injuries.

b. Signs and symptoms of blast inj uries are­

• Wounds.

o Cuts.

o Abrasions.

• Impalements.

• Soft tissue cavitation (with or without perforating wounds of

the chest or the abdomen).

c. The treatment for nuclear blast inj uries is the same as for any
other type of blast injury caused by day to day accidents or conventional
weapons. (See Chapter 13 for treatment of trauma injuries.)

20-1
FM 8-230

20-5. Thermal Injuries

a. Large numbers of burn casualties from most conventional

weapons are uncommon. However, in nuclear warfare, burns are frequently
seen injuries. This creates a very serious problem for health service support
personnel.

b. The signs and symptoms of thermal injuries are the same as for
burns from any other heat source and include discoloration, blisters, charred
skin and tissue, and severe edema in all burn areas. Clothing may be stuck to
the skin over large areas of the body. The respiratory track may be involved
due to inhalation of heat with burns extending deep into the alveoli.

c. The treatment for thermal injuries is the same as for non-nuclear

burns. See Chapter 13 for treatment procedures.

20-6. Radiation Injuries

a. Radiation injury (sickness) can result from-

• A single exposure to radiation at the time of detonation of a

nuclear weapon, or

• An exposure to high levels of fallout radiation, or

• Exposure to induced radiation, or

• A repeated exposure to any of these sources.

b. The sickness pattern is manifested in three syndromes. These are

the hematopoietic, gastrointestinal, and central nervous system syndromes.
The hematopoietic (bone-marrow depression) syndrome occurs at lower doses
than the others and is the most common form of radiation sickness seen in
nuclear combat. As the lethality probability nears 100 percent with higher
doses, the gastrointestinal syndrome will dominate. This syndrome develops
from a combination of bone-marrow depression and gastrointestinal tract
damage. The central nervous system syndrome appears when supralethal
doses are absorbed. Aircrews exposed to prompt nuclear radiation from high
level detonation and personnel protected from blast and thermal effects by
below surface sites are more susceptible to this syndrome.

c. The signs and symptoms of radiation sickness follow similar

patterns as the syndromes. They can be divided into three phases.

( 1 ) Acute incapacitation. The initial phase o f transient acute

incapacitation is during the first few hours of exposure and is characterized by
the rapid onset of nausea, vomiting, and malaise. This phase only lasts for a
few hours and should not be severe enough to require evacuation if exposure is
to low doses of radiation.

(2) Latent period. Following recovery from the initial phase

there will be a period during which the exposed individual will be symptom­
free. The length of this period varies with the dose and nature of the initial
phase. The longest period is 2 to 6 weeks preceding bone-marrow depression.
Prior to the gastrointestinal syndrome, it lasts from a few days to a week. It is
shortest preceding the nervous system syndrome, lasting from a few hours to
3 days.

20-2
 FM 8-230

(3) Clinical period. During the gastrointestinal syndrome there

will be a severe fluid loss and bloody diarrhea; the bone-marrow depression
syndrome will follow. The bone-marrow depression will be manifested by
problems of bleeding, anemia, and decreased resistance to infection.

d. The central nervous system syndrome is associated with higher

acute doses of radiation. The clinical picture for this syndrome is a steadily
deteriorating state of consciousness with eventual coma and death.

e. Treatment for radiation sickness by the medical specialist consists

of fluid replacement when fluid loss is significant and symptomatic care until
the patient is evacuated to an MTF for definitive care/treatment.

Section III. BIOLOGICAL AGENT CASUALTIES

20-7. General
The microorganisms used for the production of biological agents are disease­
producing organisms which may have been altered or may actually be the
disease organism as found in every day life. Other biological agents, such as
yellow rain, are laboratory made. The synthesized agents are known as micro­
toxins (toxins). The biological agents may be delivered to the battlefield by the
use of modern weapons, as well as through contaminated food products, water,
and insect vectors.

20-8. Signs and Symptoms of Biological Agent Casualties

The signs and symptoms of biological agents are as unlimited as the sources of
infective disease organisms. The signs and symptoms are the same as for
nonwarfare-agent infections and diseases. (FM 8-33 provides the signs and
symptoms for most disease-producing organisms.) The signs and symptoms
for some toxins are massive mucous membrane tissue hemorrhage and severe
skin rashes.

20-9. Treatment for Biological Agent Casualties

Treatment for biological agent patients may be the same as for nonwarfare­
agent patients with the same type of illness. Example: biological agent­
induced typhoid fever would be treated the same as for nonwarfare-agent­
induced typhoid. (See FM 8-33 for specific treatment.) The treatment for
toxins is symptomatic.

Section IV. CHEMICAL AGENT CASUALTIES

20-10. General

Chemical warfare agents affect specific body functions and systems. The
agents are classified by their physiological action and military use.

20-3
FM 8-230

a. PhysiologicalAction.

• Nerve agents such as Soman (GD), Tabun (GA), Sarin (GB),

and VX inhibit cholinesterase enzymes throughout the body. Since the normal
function of these enzymes is to hydrolyze acetylcholine wherever this
compound is liberated, such inhibition results in the accumulation of excessive
concentrations of acetylcholine at its various sites of action. These include:

o The endings of the parasympathetic nerves to the smooth

muscle of the iris, ciliary body, bronchial tree, gastrointestinal tract, bladder,
and blood vessels; to the secretory glands of the respiratory tract; to the
cardiac muscle; and to the endings of the sympathetic nerves to the sweat
glands.

o The endings of motor nerves to voluntary muscles and of

nerves to autonomic ganglia.

o The central nervous system.

• Blister agents (vesicants, which include the mustards,

arsenicals (Lewisite), and phosgene oxime) produce the following:

o Local irritation and damage to the skin and mucous

membranes.

o Pain and injury of the eyes.

o Reddening and blistering of the skin.

Also, when inhaled, blister agents damage the respiratory tract, with resultant
development of bronchopneumonia. If tissue damage is severe, shock may
occur. Systemic absorption of the vesicant may also be followed by bone­
marrow depression.

• Choking agents, such as phosgene, irritate and damage the

lower respiratory tract, resulting in pulmonary edema and possibly secondary
pneumonia.

• Blood agents (cyanides) stop essential physiological

processes. Blood agents such as hydrocyanic acid (AC) and cyanogen chloride
(CK) are absorbed into the blood and are carried to all body tissues where the
action is a local one inhibiting oxidative processes so that oxygen cannot be
transferred from red blood cells to tissue cells. With hydrogen cyanide,
respiration is first stimulated and then depressed; convulsions may occur.
Cyanogen chloride rapidly causes dyspnea (labored breathing) and has an
additional local irritant action on the nose, throat, eyes, and respiratory tract.

b. Military Use.

• Toxic chemical agents are used to produce serious injury or

death. They include nerve agents, blister agents, and blood agents.

• Incapacitating agents are used to produce temporary

physical or mental effects, or both.

20-4
 FM 8-230

20-11. Protective Measures and Handling of Casualties

a. The protective mask with hood must be put on at once when the
alarm or the command is given, or when any of the following conditions are
observed:

• Your position is hit by a concentration of artillery, mortar, or

rocket fire, or by aircraft bombs.

• Your position is under attack by aircraft spray.

• Smoke or mist of an unknown source is present or

approaching.

• A suspicious liquid is present.

• You are entering an area known to be or suspected of being

contaminated with a toxic chemical.

• You have several of the following symptoms:

o An unexplained runny nose combined with-

o A feeling of choking or tightness in the chest or throat.

o Dimming of vision and difficulty in focusing the eyes on

close obj ects.

o Irritation of the eyes (could be caused by presence of

several toxic chemical agents).

o Unexplained difficulty in breathing or increased rate of

breathing.

• Inappropriate laughter or unusual behavior noted in others,

or a sudden feeling of depression, dread, anxiety, restlessness, muscle
tightness, dizziness or light-headedness, slurred speech, stumbling, or dryness
of mouth noted in yourself.

b. Hold your breath until the mask is on and the facepiece is cleared
and checked. The mask should be worn until test procedures indicate that no
chemical agent is in the air and the "all clear" signal is given. (See FM 2 1 -40
for unmasking procedures. ) If vomiting occurs, the mask should be lifted
momentarily, with the eyes closed and the breath held, and replaced, cleared,
and properly checked before another breath is taken.

c. Casualties contaminated with a chemical agent will endanger

unprotected personnel. Handlers of these casualties must wear the chemical
protective overgarment, mask, and gloves.

d. Most chemical agents can poison water and food. They can make
supplies or equipment dangerous to handle without wearing a mask and
rubber gloves. Water and food supplies suspected of contamination should be
examined by chemical test procedures before consumption. The water should
be decontaminated, if necessary. Contaminated food should be discarded or
the outer layers removed (see TM 3-220) and the residue examined before it is
used. The contaminated material should be washed thoroughly with copious

20-5
FM 8-230

�mounts of water (or otherwise decontaminated) by personnel wearing masks,

impermeable protective gloves, chemical protective overgarments, and
impermeable shoes or boots.

e. Military commanders and medical personnel should be continually

on the alert for the possibility of anxiety (combat stress) reactions among
. combat personnel during toxic chemical attacks. All possible steps must be
taken to prevent or control the anxiety situations.

20-12. Personal Decontamination

Following contamination of the skin, clothing, or eyes with a chemical agent,

personal decontamination must be carried out immediately since there is a
definite time limit after which decontamination is useless. Decontamination
consists of either removal or neutralization of an agent, or both, before serious
injury occurs. For step by step procedure, refer to TM 8-285 or FM 8-9.

20-13. Nerve Agents

a. Chemical nerve agents are very fast-acting. A soldier exposed to a

significant dose of these agents will be unable to aid himself and will need
immediate care.

b. Nerve agents are among the deadliest of chemical agents. Nerve

agents enter the body by inhalation, by ingestion, and through the skin.
Depending on the route of entry and the amount, nerve agents can produce
injury or death within minutes and achieve their effects with small amounts.
Nerve agents are absorbed rapidly and the effects are felt immediately upon
entry into the body.

c. Signs and symptoms of nerve agent poisoning.

(1) Early symptoms in the usual progression.

• Runny nose.

• Red, tearing eyes.

• Sudden headache.

• Excessive flow of saliva (drooling).

• Tightness in the chest, creating difficulty in breathing.

• Reduced vision.

• Muscular twitching in the area of exposed/contaminated

skin.

• Stomach cramps.

• Nausea.

20-6
 FM 8-230

(2) Severe symptoms. A nerve agent casualty in the SEVERE

stage may exhibit all or most of the following symptoms, plus any of the
EARLY symptoms.

• Strange and confused behavior.

• Gurgling sounds made when breathing.

• Severely pinpointed pupils.

• Severe muscular twitching.

• Loss of bladder/bowel control.

• Convulsions.

• Not breathing.

• Vomiting.

NOTE

Soldiers exhibiting severe symptoms will NOT

be able to care for themselves.

d. Treatment for nerve agent poisoning.

(1) Mask the patient, i f necessary.

(a) Position the patient face up (Figure 20-1).

(b) Open the patient's mask carrier and remove the mask.

(c) Situate yourself near the patient's head.

(d) SQUAT (do not kneel) low behind the patient's left
shoulder, facing his feet.

Figure 20-1. Positioning the patient.

20-7
FM 8-230

(e) Open the mask.

• Grasp the mask with your thumbs outside and your

fingers inside the cheek pouches (Figure 20·2).

• Spread the mask open and position it on the

patient's chin.

({} Lift the head and slide the head harness over it as
follows:

• Position your thumbs through the two bottom

straps of the head harness.

• Cup the patient's head with the fingers of your

hands and lift it slightly.

Figure 20-2. Opening the mask.

• Move your thumbs back and down behind the

patient's ears.

• Make sure the head pad is centered in the middle of

the back of the head.

NOTE

If the casualty is able to follow directions,

instruct him to clear his mask.

(g) Check for a complete mask seal by covering the mask's

inlet valves. The mask will collapse if properly fitted, indicating a good seal.

20-8
 FM 8-230

NOTE

There is no way to be sure that an unconscious,

nonbreathing casualty's mask has a good seal.

(h) Pull the protective hood over the head, neck, and
shoulders.

(2) Administer the nerve agent antidote.

(a) Position yourself near the patient's left thigh (this will
make it easier to reach into his mask carrier).

NOTE

If the patient has already received three doses

of antidote, proceed to step (2)(p) below.

(b) Remove one set of antidote autoinjectors (Figure 20-3)

from the inside pocket of the patient 's mask carrier.

PRALIDOXIME CHLORIDE INJECTOR

F O R U S E IN N E R V E A G E N T P O I S O N I N G O N L

300mg m t ( 2rn l )

AtroPen Cfl Auto- Injector

ATROPINE INJECTION 2mg ;;:;;:;�·.:;:::.::::

Figure 20-3. Nerve agent antidote autoinjectors ,

NOTE

Do not use your autoinjector on a casualty. If

you do, you may not have any antidote for self­
aid.

(c) Hold the set of injectors by the plastic clip (Figure 20-4),
with the big injector on top and in front of your body at eye level.

20-9
FM 8-230

Figure 20-4. Holding the set of injectors.

(d) Grasp the atropine autoinjector (the smaller of the two

injectors) with your thumb and first two fingers of your other hand (Figure
20-5).

CAUTION

Do not cover/hold the needle end with your

hands or fingers- you may accidentally inj ect
yourself.

Figure 20-5. Grasping the injectors.

20-10
 FM 8-230

(e) Pull the injector out of the clip with a smooth motion.

({) Form a fist around the inj ector.

(g) Place the green (needle) end of the injector against the
patient's outer thigh muscle (Figure 20-6).

Figure 20-6. Injecting the patient 's thigh.

(h) Apply firm, even pressure to the injector until it

functions by pushing the needle into the patient's muscle, making sure you do
not hit any objects in his pocket.

CAUTION

Do not use a jabbing motion to inject the

patient.

(i) Hold the inj ector in place for at least ten seconds by
counting one thousand one, one thousand two, and so forth.

(j) Remove the injector.

CAUTION

Watch out for the needle. Do not accidentally

inject yourself.

20-11
FM 8-230

NOTE

If the individual is very thin, you can inject

him in the buttocks. Be careful to inject him
only in the upper outer part of the buttocks
(either side) because there is a nerve that
crosses the buttocks and hitting this nerve can
cause paralysis (Figure 20-7).

Figure 20-7. Buttock injection sites.

(k) Place the used injector carefully between the last two
fingers of the hand that is holding the clip (Figure 20-8).

(l) Pull the 2 PAM Cl injector (the larger of the two

injectors) (Figure 20-9) from the clip and inject the patient in the same manner
as steps (e) through (j) above, holding the black (needle) end against the
patient's outer thigh (or buttock).

(m) Drop the clip without dropping the used injectors.

(n) Attach the used autoinjectors to the patient's clothing

by-

• Pushing the needles of the used injectors, one at a

time, through the left pocket flap. This will tell other medical personnel how
many injectors were administered to the patient.

• Bend the needle to form a hook. Be careful not to

tear your protective gloves while bending the needle.

20-12
 FM 8-230

Figure 20-8. Placing the used injector between the last

two fingers.

Figure 20-9. Pulling out the 2 PAM Cl injector.

(o) Immediately repeat the above steps, using the second

and third sets of antidote autoinj ectors.

NOTE

If a patient requires additional antidote,

administer atropine only until his heart rate is
above 90 beats a minute.

20-13
FM 8-230

(p) Administer artificial respiration if needed or oxygen if

available.

(q) Administer anticonvulsant medication if convulsions

are not controlled by atropine.

(3) Evacuate the patient if necessary.

20-14. Blood Agents

a. Blood agents (cyanides) are very fast-acting chemical poisons. A
soldier exposed to a significant dose will be unable to aid himself and will need
immediate care.

b. Blood agents produce their effects by interfering with the body

cells' absorption of oxygen. Inhalation is the usual route of entry.
Hydrocyanic acid (AC) and cyanogen chloride (CK) are the important agents in
this group. Cyanogen chloride also acts as a choking agent.

c. The· standard protective mask gives adequate protection against

field concentrations of blood agents. The chemical protective overgarment, as
well as the mask, is needed to protect individuals from liquid AC.
d. Signs and symptoms of blood agent casualties.

NQ'fE

Other chelnical agents may be mixed with

blood agents during a chemical attack.

• A fast breathing rate (blood agents affect the circulatory and

respiratory systems by preventing body cells from using oxygen).

• Dizziness and headache.

• Cherry red skin.

• Heart rate slows down.

• Convulsions.

• Eyes, nose, throat, and lungs have a stinging sensation.

CAUTION

Cyanogen chloride (CK) also causes damage to

the tissues in the lungs. Any damage to the
respiratory tract may result in fluid in the
lungs and blood-tinted frothing at the mouth.

• Reddish fluid will be coming from the mouth.

• Hyperventilation, followed by a depressive phase of

hypotension, and shallow respiration.

• Respiratory arrest.

20-14
 FM 8-230

e. Treatment for blood agent casualties.

( 1 ) Immediately mask the casualty, if necessary. Determine

whether or not he is breathing. If he is not breathing, put his mask on first
(paragraph 20-1 3 d(l) above) and then apply the back-pressure, arm-lift method
of artificial respiration.

CAUTI ON

Place the patient on an uncontaminated

surface if possible (such as, poncho or plastic
bag).

(2) Administer antidote. Administer sodium nitrite and sodium

thiosulfate intravenously, if available. The recommended treatment is an
intravenous injection of sodium nitrite 4 to 5 mg/kg of body weight followed
by a slow inj ection of sodium thiosulfate 200 mg/kg of body weight.

NOTE

Above antidotes to be administered by medical

personnel only. This is not self-aid or buddy aid
treatment.

20-15. Blister Agents

a. Blister agents (vesicants) are mustard (HD), nitrogen mustards

(NH), Lewisite (L), and other arsenicals; mixtures of mustards and arsenicals;
and phosgene oxime (CX).

b. Vesicants act on the eyes, lungs, and skin. They burn and blister
the skin or any other part of the body that they touch. They damage the
respiratory tract when inhaled and cause vomiting and diarrhea when
absorbed. The nitrogen mustards and the arsenicals are the most dangerous in
causing vomiting and diarrhea.

c. Some vesicants often have a more serious effect than is

immediately apparent. Vesicants are insidious in action with little or no pain
at the time of exposure, except Lewisite and phosgene oxime which cause
immediate pain on contact. The physiological effects of blister agent exposure
usually take a few hours to appear. The soldier may be exposed to a blister
agent for a long time and not realize it. However, when the symptoms do
appear, they are usually widespread.

d. In the event of exposure to a blister agent, decontamination must

begin immediately; speed is absolutely essential. Every soldier is responsible
for his own personal decontamination if he is physically capable. If he is
incapacitated, decontamination must be performed by others as soon as
possible.

e. Signs and symptoms of blister agent eye burns.

( 1 ) The eyes are the most vulnerable body part to blister agents
(vesicants) and are usually the first to be affected. The symptoms are-

20-15
FM 8-230

• Inflammation of the inner eyelids.

• Redness of the eyes.

• Swelling of the eyelids.

• Watery eyes.

f Treatment for blister agent eye burns. Decontaminate the eyes as

follows:

(1) Remove the patient's canteen and open it.

CAUTION

Patient must be masked in order to avoid

inhaling contaminated air.

(2) Have him take a deep breath and hold it. He must NOT
breathe while the mask is off. The breath should be held as long as possible.
The mouth should be kept closed during the decontamination procedure to
prevent absorption of the contaminant through the mucous membranes.

(3) Lift the mask from his chin to expose his eyes.

(4) Flush or irrigate one eye at a time.

• Insure that all liquid blister agents are flushed. The risk
of leaving the agents in the eyes is much greater than the risk of eye exposure
to blister agent vapors.

• If the patient is wearing contact lenses, remove them

before treating the eyes.

• Tilt his head to one side and have him look up.

• Slowly pour water into each eye so that the water will run
off without further contamination.

(5) Reseal and clear the patient's mask.

g. Signs and symptoms of blister agent injuries involving the skin

and respiratory tract do not occur immediately after exposure. They usually
occur 4 to 6 hours after exposure. However, symptoms may appear from 24 to
48 hours later. Skin contamination may be detected with M8 chemical detector
paper or visually by observing for swelling, redness, or blisters.
Contamination of the skin or face may also be indicated by signs of extreme
pain exhibited by the casualty. The severity of a chemical burn is directly
related to the concentration of the agent and the duration of the contact with
the skin.

20-16
 FM 8-230

(1) Skin:

• Swelling, inflammation.

• Redness, sunburn-like.

• Itching, burns, and/or blisters (usually large).

(2) Respiratory tract:

• Throat burns and feels dry.

• Voice becomes hoarse.

• A dry, harsh cough develops.

• Respiratory tract becomes inflamed.

(3) Other signs/symptoms:

• Headache.

• Nausea .

• Runny nose .

• Frequent sneezing.

h. Treatment for blister agent skin and respiratory tract inj uries.

( 1 ) Do not put field dressings over injured (blistered) areas. Such

action may spread the contamination or cause pain to the patient.
(2) If necessary, have the patient decontaminate himself using
his M258Al kit. The key to successful use of the decontamination kit is
IMMEDIATE action upon finding the contamination. Decontamination
procedures should begin within 60 seconds of contamination; otherwise, this
procedure may be of little use. Decontamination of the skin should be done in a
sheltered area. A sheltered area provides protection from further
contamination by a blister agent. The medical specialist should stress the
importance of the buddy system for decontaminating the skin that cannot be
reached or seen by the individual.

CAUTION

If blisters have already appeared, do not

decontaminate the blistered area.

(3) Treatment for respiratory tract injuries are to maintain the

airway until the patient can be evacuated.

20-17
FM 8-230

20-16. Choking Agents

a. Choking agents are chlorine and phosgene. The main lethal effect
is that they disrupt the alveolar capillary integrity of the lungs and cause a
leaking of plasma and fluids into the alveoli. This results in a progressive
oxygen shortage and can cause death due to pulmonary edema. This form of
death has been called "DRY LAND DROWNING . "

b. The early symptoms of choking agent poisoning are­

• Local irritation.

• Dry throat.

• Coughing.

• Tightness in chest .

• Nausea.

• Vomiting.

• Headache.

NOTE

The early signs and symptoms will subside

rapidly and the individual can continue his
mission without incapacitation. These
symptoms are very general and in some
instances of little value in prognosis. Some
patients with severe cough fail to develop
serious lung injury, while others with no signs
or symptoms go to fatal pulmonary edema, so
it is vital that the medical specialist observe
all individuals for possible signs of respiratory
distress even though the mission is being
carried on.

c. Delayed severe signs and symptoms of choking agent poisoning

usually appear 4 to 1 2 hours after initial contact or exposure and are-

• Anxiety.

• Severe coughing.

• Rapid shallow breathing.

• Chest wall retraction.

• Tachycardia.

• Cyanosis.

• Production of frothy, blood-tinted sputum.

20-18
 FM 8-230

• Shock.

• Respiratory arrest.

NOTE

Death can occur within 48 hours. A casualty

who survives for more than 48 hours usually
recovers without after effects.

d. Treatment for choking agent poisoning.

(1) Treat symptomatic conditions a s they develop.

(2) For patients with severe symptoms, movement should be

limited; they should be kept comfortable and warm until evacuated.

(3) Administer oxygen, if available.

(4) Evacuate the patient.

20-19
 FM 8-230

C HAPTER 2 1

MANAGEMENT OF PSYCHOLOGICAL/
BEHAVIORAL PROB LEMS

Section I. BATTLE FATIGUE (STRESS)

21-1. General

During combat, soldiers can experience conditions of overwhelming stress,

both physical and emotional. The conditions that can produce battle fatigue
include physical exertion, the requirement for constant alertness, the trauma
of seeing other soldiers wounded or killed, the fear of being killed or maimed,
and the necessity of killing. Transient (temporary) debilitating psychological
disorders may develop, even in previously stable personalities. Psychological
reactions to combat are generally not so incapacitating as to demand removal
from the combat environment. When a soldier can no longer function
effectively in his j ob, the medical specialist or other soldiers may provide
appropriate initial treatment or psychological first aid.

21-2. Types of Psychological Reactions

Although psychological reactions may manifest themselves in many ways,

there are two types of reactions thought to be the most common in a combat
situation:

a. Battle Fatigue. This stress reaction, which has fear as its biggest
factor, is brought about primarily by extended exposure to a combat situation.
It is frequently seen in units that have been committed to long-term
continuous combat. Battle fatigue is also referred to as combat stress reaction,
shell shock, psychoneurosis, anxiety state, psychoneurosis mixed, conversion
hysteria, combat fatigue, flying fatigue, operational fatigue, or traumatic war
neurosis. Although there are other psychological reactions such as transient
battle reactions (discussed below), this chapter will deal primarily with battle
fatigue, its symptoms, and its treatment.

b. Transient Battle Reactions. These reactions are also temporarily

debilitating in nature but may be more drastic than battle fatigue. Fatigue is
normally not a factor in transient reactions. Soldiers not previously engaged in
combat may experience transient battle reactions; however, most individuals
can adapt and learn to cope with abnormal amounts of stress.

21-3. Battle Fatigue and Its Severity

Battle fatigue is a psychological condition encompassing the physical and

emotional stresses e�perienced in combat. These stresses are experienced by
every individual in a combat situation. Physical fatigue and/or fear (emotional
fatigue) can produce battle fatigue. Battle fatigue can be exhibited by minor
reactions such as impairment of self-confidence, trembling or irritability, or
more severe reactions such as panic running, hallucinations, or hysterical
paralysis. Battle fatigue may occur in individuals who have been in continuous
prolonged combat, individuals not previously in combat but who experience a
short-term intense combat situation, or those soldiers who spend long periods
of time waiting to go into combat. From 70 to 90 percent of battle fatigue
patients can return to duty after rest and treatment. Those patients who do

21-1
FM 8-230

not respond after 48 hours of treatment require evacuation for definitive

psychiatric care. Battle fatigue can be broken down into three levels of
severity:

• Mild-the soldier relates sensations of fear in battle with no

evidence of anxiety. This level does not require removing a soldier from
combat.

• Moderate-the soldier displays tears, gross trembling, or

difficulty on concentrating.

• Severe- the soldier can no longer relate to his environment and

can suffer from hysterical blindness and paralysis.

21-4. Emotional Reactions of Battle Fatigue

a. Fear-an emotional experience in response to real danger. Under

combat conditions, this can include-

• Fear of death, pain, injury, or mutilation.

• Fear of incapacitation through over-reaction to a frightful

experience.

• Exhibiting fear and losing prestige with peers in the combat

group.

b. Panic-the pathological counterpart of normal fear, involving

temporary maj or disorganization of thinking and loss of control.

c. A nxiety-an expectation of danger, involving feelings of

apprehension, uncertainty, and insecurity.

d. Noise Sensitivity-becoming sensitive to noise. Can lead to

abnormal noise sensitivity which is a nervous reaction to a noise that does not
represent a threat.

e. Sleeping Difficulty-a normal reaction resulting from tension, the

need to remain alert, lack of comfort, and presence of combat noises. Can lead
to abnormal sleeping difficulty, when the nighttime environment becomes
terrifying for no apparent reason.

f. Apathetic Tendency-a frequent response to the stress of battle

which results in some decrease in drive, flow of speech, initiative, readiness to
undertake new tasks or problems, range of interests, and feeling of well-being.
These complaints may be of considerable magnitude and they constitute a true
apathy or depression extending well beyond the period of battle stress.

g. Irritability-a normal characteristic of someone subjected to long,

continuous battle.

h. Resentment-a normal response for the soldier who has lost close
friends and has faced danger. Resentment is strong where there is shirking or
discrimination against the combat soldier.

21-2
 FM 8-230

i. Postcombat Behavior-various temporary behavior patterns

exhibited after combat. These include overwhelming physical fatigue
combined with apathy and subnormal reactions to stimuli. Eventually, tension
creates a "letdown" and, consequently, the soldier can react with alcohol,
sexual or social behavioral excesses.

k. Depression-a low level of functioning which manifests itself

through feelings of sadness, despair, hopelessness, dejection, discouragement,
self-condemnation, and/or disorders in eating and sleeping. Depression may
develop during a lull in combat or as postcombat behavior.

NOTE

By knowing these definitions, the concerned

soldier or supervisor can determine the
severity of battle fatigue. You should advise
your supervisor or unit commander about the
suspected status of the battle-fatigued soldier.
The responsible level of command can then
take definite action.

21-5. Lethality and Its Effect on Battle Fatigue

Lethality refers to the accuracy and killing power of modern weapons. The
high intensity and greater deadliness of modern weapons and weapons
systems will increase the level of individual psychological stress. The
battlefield environment may now include possible use of nuclear, biological,
and/or chemical weapons. These weapons increase the number of soldiers killed
or wounded in combat; this in turn creates fear which is a maj or cause in the
increased rate of battle fatigue cases.

21-6. Principles of Battle Fatigue Treatment

There are three principles of treatment for battle fatigue-proximity,

immediacy, and expectancy. When treated according to these principles, an
estimated 80 to 90 percent of battle fatigue soldiers develop no long-term
disability. In addition, the chances of later psychiatric problems (delayed or
hidden reactions) are reduced.

a. Proximity-treatment as far forward as practicable increases the

potential for full recovery. It also reduces the suggestion of serious disability
and usually avoids the necessity of evacuation that would upset the soldier's
morale and disrupt his sense of group identity.

b. Immediacy-initial treatment (psychological first aid) is to be

applied as soon as possible to limit later effects.

c. Expectancy-refers to the ideas that you should communicate to

the battle-fatigued soldier:

• Instill the expectation of a rapid recovery after a brief rest.

You should also avoid giving the impression that the soldier has an incurable
mental illness.

21-3
FM 8-230

• Reassure the soldier of the fact that he is expected to return to

duty. He will realize that his skills are needed and that he is a part of the
combat team. In this way, he is also reassured that battle fatigue is only
temporary.

NOTE

The soldier should wear his uniform and be

treated in a "non-hospital" environment. This
includes being housed in tents rather than in a
hospital-type ward with involvement in light
duty and exercise. This environment suggests
to him that he is taking only a brief therapeutic
rest and will soon be ready for duty. The
soldier should be encouraged to believe that
fatigue, not s tress, is the greatest factor
involved.

21-7. Symptoms of Battle Fatigue

a. Common Reactions to Combat.

( 1 ) There is a wide range of reactions to fear and anxiety that

affect all soldiers to some degree. Within this variety of reactions, you will
need to recognize those that are manageable and found in combat. You should
also be able to recognize those soldiers with more severe (disruptive) stress
reactions.

(2) Not all stress reactions can be recognized immediately;

however, your observations of changes or modifications in behavior among
personnel in your unit can identify the early stages of stress reactions. In
many instances, you may have to rely on information from supervisors or from
the soldier 's close associates.

b. Manageable Reactions.

(1) Muscular tension-increases with exhaustion.

• Headaches.

• Inability to relax.

• Cramps.

(2) Shaking and tremors.

• Mild shaking-may appear when undergoing shelling or

bombing. Appears and disappears rapidly and is a normal reaction to
dangerous conditions.

• Marked or violent shaking-sometimes incapacitating;

may also persist after the cause has ceased.

21-4
 FM 8-230

(3) Perspiration-it is normal to experience either mild or heavy

sweating or sensation of chills under combat stress.

(4) Digestive and urinary systems reactions.

• Nausea and vomiting which may occur during or

immediately after a fire fight, shelling, or intensive battle conditions.

• Loss of appetite.

• Acute abdominal pain which may occur during shelling.

• Urinary frequency, particularly at night, or urinary

incontinence during actual battle.

• Inability to control bowel functions may occur under

catastrophic combat stress.

(5) Circulatory and respiratory systems reactions.

• Heart palpitations.

o Elevated blood pressure and increased pulse rate are

common reactions.

o Rapid heartbeat, a sense of pressure in the chest, and

chest pains may be felt.

• Hyperventilation-may be identified by rapid

respirations, shortness of breath, dizziness, and a choking sensation.

• Sensations of faintness or giddiness-may occur with

physical fatigue and extreme stress, together with generalized muscular
weakness and lack of energy.

(6) Sleep disturbances.

• Difficulty in falling asleep.

o Inability to sleep when the tactical situation permits

or in the absence of disruptions due to the combat situation.

o Physical environment may not permit restful sleep

(excessive heat, cold, insects, or lack of food or water).

• Nightmares.

o Terror dreams, battle dreams, and nightmares of

other kinds may cause sleeping difficulty.

o Sleep disturbances in the form of dreams are part of

the coping process. This process of "working through" combat experiences is
a means of increasing the tolerance level to combat.

21-5
FM 8-230

• Restless sleep. When a person is asleep, the sleep may

not be restful or refreshing. The individual wakes up as tired as when he went
to sleep.

• Excessive sleep. This can be a sign of extreme

depression or possible drug abuse.

(7) Death anxiety.

• Fear of death, pain, and/or injury causes anxiety

reactions. After a soldier has been in combat and has seen his fellow soldiers
killed or wounded, he loses whatever feeling of invulnerability he may have
had.

• The death of a buddy can lead to a serious loss of

emotional support along with feelings of guilt. The soldier may feel blessed
that he was not killed and he may experience guilt about having such feelings.

(8) Body arousal. In response to a threat, the brain sends out

chemicals that arouse various body systems, making the body ready to fight
or take flight.

• Hyperalertness. The general focusing on certain

external stimuli that may signal danger. A hyperalert soldier is ready to
immediately respond to danger. His senses are alert to danger and possible
threats, such as the noise of a mortar being fired which can send him running
for cover long before the shell lands in the vicinity.

• Startle reactions. These reactions are a part of an

increased sensitivity to minor external stimuli known as the on-guard
reaction. These reactions include leaping, jumping, cringing, j erking, or other
forms of involuntary self-protective motor responses to sudden noises. This
type of reaction may occur not only to noises but also to sudden movement or
sudden light. A sound as simple as the crumpling of cellophane may cause
someone to j ump and/or become angry. The unexpected movement of a person
or animal may result in inadvertent weapon firing.

(9) Irritability-ranges from angry looks or sharp words to acts

of violence.

• Snappishness, verbal flareups, and tears are common.

Irritability is manifested externally by over-reaction to normal, everyday
comments or incidents, flareups with profanity, and tears in response to even
relatively minor frustrations.

• Explosions of aggressive behavior. Sporadic and

unpredictable explosions of aggressive behavior (violence) may occur with
little or no provocation. The stimulus may be a noise, an accidental bumping,
or a normal conversation.

21-6
 FM 8-230

( 1 0) Short attention span. Individuals under stress may have a

short attention span and find it difficult to concentrate. A short attention span
can cause a soldier to have difficulty following orders. The soldier may hear,
but fail to comprehend, what others are saying. He may also have difficulty
following directions, aiding others, or performing unfamiliar tasks.

( 1 1 ) Depression (numbing of normal responsiveness). Soldiers

may respond to stress with protective defensive reactions against painful
perceptions. Emotional dulling (or numbing) is a result. These reactions are
easily observed changes in the individual's usual personality:

• Low energy level. This can result in decreased effective­

ness on the job, decreased ability to think clearly, excessive sleeping or
difficulty in falling asleep, and chronic tiredness. Such qualities as pride,
shame, grief, and gratitude may no longer be of importance to the soldier.

• Social withdrawal. A soldier may be less talkative than

usual or show limited response to jokes. He may be unable to enj oy relaxation
and companionship, even when the tactical situation permits. Tears and/or
crying may be noted.

• Change in outward appearance. In a depressed mood,

very little body movement and an almost blank, expressionless (mask-like)
face may be noted.

( 1 2) Substance abuse. Some soldiers may use substances such as

alcohol or other drugs as a means of escaping stress. The use of these
substances in a combat area can make soldiers less capable of functioning on
the j ob. The soldiers may be less able to adapt to the tremendous demands
placed upon them during combat.

c. Disruptive Reactions.

(1) Soldiers with more severe (disruptive) stress reactions are

those who:

• Cannot function on the j ob.

• Compromise their own safety and the safety of others.

• Exhibit panic running (rushing about without any

self-control).

• Have vi_sual and/or hearing problems (perceived by the

individual), and partial paralysis. These physical symptoms enable the
individual to escape or avoid a stressful situation. The paralysis is usually
confined to one arm or leg. A prickling sensation, tics, or rigidity of the larger
j oints may occur.

• Utter incoherent language. A soldier may babble like a

child, be unable to speak logically, and have a bewildered appearance.

• Have loss of appetite which results in the loss of. 5

pounds per week or more.

21-7
FM 8-230

• Suffer from persistent and severe abdominal pain.

• Have continuing inability to control bowel function

after stress stimulus (combat) has ended.

21-8. Initial Treatment Procedures for Battle Fatigue

a. Treat the Battle Fatigue Casualty.

( 1 ) Provide initial treatment as time and tactical situation

permit. The initial treatment for battle fatigue should be based on the factors
of proximity, immediacy, and expectancy (PIE).

(2) Provide a place for the soldier to rest. At least 4 hours rest
should be provided in a comparatively secure area.

(3) Provide food, when available.

(4) Provide an opportunity for the individual to ventilate (put his

strong feelings into words). An individual with battle fatigue needs to express
pent-up thoughts and feelings. Problems seem more tangible and manageable
once they have been put into words. Working with a group of two or more
persons can help reverse the stress reactions by using the soldier's natural
coping skills (strength) in a group environment. The individual should be
allowed to express emotions without interruption. Tears, anger, intense fear,
and worries are commonly expressed. Arguments or opposing positions should
be avoided and the soldier should be able to express feelings that are usually
considered to be "unacceptable. "

b. Evacuate the Soldier or Return Him to Duty.

( 1 ) Evacuate the soldier. Recognize disruptive battle fatigue

reactions and recommend immediate evacuation if the tactical situation
permits. Soldiers who have undergone 48 hours of treatment without
resolution of symptoms should be evacuated for definitive psychiatric care. It
may be necessary to use physical restraint on soldiers with disruptive battle
fatigue reactions.

(2) Return the soldier to duty if he is able to function on the j ob.

A soldier's unit is stronger when he is functioning on the job. Without the
soldier, a greater burden is placed on those who remain in the unit. Returning
him to his original unit (and to his original job) is the best mental health
assistance that can be provided and is the ' 'treatment of choice. ' ' To return to
normal duty after severe stress, most soldiers need to perform familiar useful
work and re�eive group support. The soldier's unit can provide such an
environment. Despite anxieties and traumatic experiences, every soldier is
expected to perform combat duties. Experience in past wars is clear-failure to
return to duty can lead to permanent disability.

21-8
 FM 8-230

Section II. ALCOHOL AND DRUG ABUSE

21-9. General

a. Alcohol and drug abuse is an increasingly serious problem in the

military services. It affects combat readiness, job performance, and the health
of military personnel and their families. It also costs millions of dollars in lost
time and productivity; more specifically, it affects the individual.

b. The reasons for alcohol and drug abuse are as varied as the
individuals who use them. People apparently abuse these substances to
change the way they feel. They may want to feel better and happier or escape
from pain, stress, or frustration. Some may want to remember or to forget;
others may want to be accepted or just be sociable. Other people abuse alcohol
and/or drugs to escape boredom or out of curiosity. Peer pressure can also be a
very strong motivating factor in their abuse.

c. People often feel better about themselves when they use alcohol or
drugs, but these effects do not last. Alcohol and drugs never solve
problems-they merely postpone them. People who abuse alcohol and drugs to
solve one problem run the risk of continued usage, which creates new problems
and makes old problems worse.

d. In your work environment, there may be situations in which

alcohol or drug abuse is suspected. In such situations, it will be necessary to
use your knowledge of the appropriate signs and symptoms to determine
suspicion of alcohol or drug abuse and to report your findings.

e. This section will assist you in identifying a suspected alcohol or

drug abuser. To accomplish this, it is necessary to be aware of the terminology
associated with, as well as the signs and symptoms of, alcohol or drug abuse.
In addition, it will be necessary to know the proper procedures and referral
methods that are necessary when handling a patient who is a suspected
abuser.

21-10. Terms Specific to Alcohol and Drug Abuse

a. Drug or Substance Abuse. Drug or substance abuse is the

pathological use of a chemical substance (licit or illicit) which results in
impairment of a person's social or occupational functioning for a duration of at
least several months.

b. Drug Dependence. Drug dependence is the use of a drug to such an

extent that there is an increased tolerance for the drug or stopping the use of
the drug would result in withdrawal symptoms.

( 1 ) Psychological dependence exists when a drug's effect

becomes necessary for an individual's continued mental well-being.
Withdrawal of the drug results in compulsive drug-seeking behavior.

(2) Physical dependence exists only if withdrawal symptoms

occur when the drug use stops or if tolerance to the drug has developed.

NOTE

Withdrawal symptoms are physical (such as

vomiting, m u s c l e tremo r s ) and not
psychological.

21-9
FM 8-230

c. Tolerance. Tolerance is a physical condition that develops from the

continued use of certain drugs and which requires larger amounts of these
drugs to produce the same effects.

21-11. Classification of Drugs

Drugs are classified as central nervous system (CNS) depressants, narcotics,

stimulants, or hallucinogens.

NOTE

Drugs are classified by their intended use and

dosage level. For example, Valium can be
classified as a muscle relaxant, an antianxiety
agent, and a psychotherapeutic agent.
Phencyclidine (PCP), for example, i s
pharmacologically classified a s a basal
anesthetic, but at abuse-level dosage, it acts as
a hallucinogen.

a. CNS Depressants.

(1) Alcohol (ETOH).

(2) Barbiturates (sedative/hypnotics).

• Pentobarbital (Nembutal) (Yellows).

• Secobarbital (Seconal) (Reds).

• Combination of Amobarbital and Secobarbital

(Rainbows).

(3) Nonbarbiturates (sedatives/hypnotics).

• Dalmane.

• Chloral hydrate.

• Methaqualone (Quaalude).

• Paraldehyde.

• Valium.

• Librium.

b. Narcotics (Analgesics).

• Opium.

• Morphine.

• Heroin.

21-10
 FM 8-230

• Demerol.

• Methadone.

c. Stimulants.

(1) Amphetamines.

• Dexedrine.

• Benzedrine.

• Methedrine.

(2) Cocaine.

(3) Caffeine.

(4) Nicotine.

d. Hallucinogens (Psychedelics).

• Marijuana, hashish tetrahydrocannabinol (THC).

• LSD (lysergic acid diethylamide).

• Psilocybin.

• Mescaline.

• Dimethyltryptamine (DMT), diethyltryptamine (DET), 2,

5-dimethxoxy-4-methylamphetamine (DOM or STP), 3, 4 methylenedioxy·
amphetamine (MDA)

• Phencyclidine (PCP).

21-12. Signs and Symptoms of Use and Abuse of Depressants, Narcotics,

Stimulants, and Hallucinogens

You need to recognize the signs and symptoms of depressants, narcotics,

stimulants, and hallucinogens. Early recognition and referral of an abuser of
these substances could play an important role in rehabilitating him and
possibly saving his life.

a. Depressants.

(1) Intoxication.

(a) Mental.

• Memory losses (blackouts).

• Decreased emotional control (such as inappropriate

crying or laughing).

21-11
FM 8-230

• Impaired judgment.

• Inability to speak coherently.

(b) Physical.

• Decreased muscular control (staggering, loss of

reaction time).
• Breathing difficulty (respiratory depression).

• Nausea and vomiting.

CAUTION

These combined effects can lead to the

individual inhaling his own vomitus and
suffocating.

(2) Alcohol abuse.

(a) Liver disorders.

• Alcoholic (Laennec's) cirrhosis-chronic diffuse

liver disease which can lead to serious metabolic problems and death. May also
be seen as fatty cirrhosis or fatty liver when the liver breakdown is associated
with extensive fatty infiltration.

• Alcoholic hepatitis-an acute inflammation of the

liver which results in excess plasma bilirubin. The excess bilirubin causes
yellowish skin and eyes (jaundice) and may result in death.

(b) Stomach disorders.

• Gastritis-an acute inflammation of the stomach

lining which causes pain, nausea, vomiting, and loss of appetite (anorexia).

• Gastric ulcers-an erosion of the stomach wall by

digestive juices which causes pain and bleeding and may lead to perforation,
infection, and death.

(c) Circulatory disorders.

• Anemia-a red blood cell shortage which results in

weakness and fatigue that is typically caused by iron or vitamin deficiency.

• Heart disease-weakening of the heart muscles

leading to congestive heart failure.

(d) Nervous system disorders.

• Brain cell deterioration which leads to impairment

of memory, judgment, balance; severe organic brain syndrome may be
observed.

21-12
 FM 8-230

• Psychotic disorders (alcohol hallucinosis, toxic

psychosis) which may be characterized by disorientation, confusion,
hallucinations, and/or incoherent speech.

b. Drugs.

( 1 ) Barbiturates/abuse. There are no known specific physical

disorders commonly associated with barbiturate abuse.

(2) Narcotics.

(a) Drug intoxication.

• Rush (warm flushing of the skin and sensations in

the lower abdomen described by addicts as similar to sexual orgasm).

• Euphoria.

• Drowsiness.

• Decreased anxiety.

• Decreased appetite.

• Decreased sexual drive.

• Decreased blood pressure.

• Decreased respiration.

• Constipation.

• Tolerance develops.

• Psychological dependence may develop.

• Physical dependence may develop.

(b) Abuse.

NOTE

Most disorders and diseases associated with

narcotic abuse (hepatitis, venous collapse,
poisonings, malnutrition) are the indirect
result of the drug abuse and are caused by poor
diet or lack of hygiene.

(c) Withdrawal symptoms.

• Tearing, runny nose, sweating.

• Yawning.

21-13
FM 8-230

• Nausea and vomiting.

• Diarrhea.

• Muscle aches and abdominal cramps.

• Anxiety and irritability.

• "Goose-flesh".

(d) These symptoms usually begin 3 to 8 hours after the

last dose of the drug, peak at 36 to 72 hours, and diminish within 5 to 1 0 days.

c. Stimulants.

(1) Intoxication.

• Euphoria .

• Increased self-confidence.

• Alertness and energy.

• Irritability.

• Talkative.

• Insomnia.

• Loss of appetite.

• Rapid pulse.

• Dry mouth.

• Dilated pupils.

• Shakiness .

(2) Problems caused by abuse.

• Weight loss .

• Exhaustion.

• Mental deterioration.

0 Impaired judgment.

0 Increased suspiciousness.

0 Increased aggressiveness.

21-14
 FM 8-230

• Indirect effects (due to poor diet, lack of hygiene, and

self-injection with contaminated products).

o Skin ulcers.

o Abscesses (pockets of infection in organs, blood

vessels, joints, and the brain caused by contaminated drugs and needles).

• Overdose (usually clears up within 1 0 days after last

dose).

o Violent behavior.

o Toxic psychosis (paranoid ideation, hallucinations).

• Tolerance develops.

• Psychological dependence may develop.

(3) Drug withdrawal has the following features:

• Depression-may be severe or suicidal.

• Exhaustion.

• Muscle cramps.

d. Hallucinogens.

(1) Intoxication.

(a) Mental symptoms.

• Altered thinking and feeling states.

• Distorted perceptions.

0 Time and space.

0 Visual, auditory, and tactile (touch) sensations.

• Hallucinations .

• Impaired judgment.

• Increased suggestibility .

(b) Physical symptoms.

• Increased pulse rate

• Dilated pupils.

• Lack of coordination in extremities.

21-15
FM 8-230

(2) Abuse of hallucinogens can cause the following symptoms:

• "Bad trips" -usually temporary adverse drug reactions

such as severe panic, withdrawal, delusions, and hallucinations.

• "Flashbacks" -a spontaneous hallucinogenic experience

without any drug intake that may occur weeks or months after the last drug
use.
• Toxic psychosis-may be caused by the drug or by it
being mixed in contaminants.

o Paranoid ideation.

o Hallucinations.

• Psychological dependence may develop (rare).

• Tolerance develops rapidly but disappears with drug

withdrawal.

• No well defined withdrawal syndrome.

21-13. Psychosocial Signs/Symptoms of Alcohol/Drug Abusers

The following are additional psychosocial signs and symptoms of alcohol/drug

abusers:

a. General personality changes.

b. Mood/behavioral changes­

• Irritability.

• Nervousness.

• Agitation.

• Argumentative attitude.

c. Changes in work habits-

• Lowered quality/quantity of output.

• Inconsistent work pace (likely to change frequently without

apparent reason).

• Errors in judgment.

• Lack of interest in work.

21-16
 FM 8-230

d. Frequent or increased-

• Tardiness to work.

• Absence from work area.

• Marital problems.

• Financial difficulties.

• Avoidance of family and friends.

• Deterioration of appearance, dress, and personal hygiene.

• Physical changes such as marked weight loss, exhaustion, and

a lack of coordination.

• Frequent changes on or off the job.

• Slurred speech.

• Frequent skin problems (ulcerations, abscesses).

• Dilated or constricted pupils.

21-14. Procedures for Reporting and Referring of a Suspected Alcohol/

Drug Abuser to a Physician

a. In a medical treatment facility (for example, ward, clinic,

dispensary), the medical specialist will inform the patient's physician of
suspected alcohol/drug abuse.

b. At unit level (for example, company, battalion), the medical

specialist will-

( 1 ) Annotate on the DD Form 689 (Individual Sick Slip) that the

suspected abuser exhibits behavior other than normal.

(2) Refer the suspected abuser to a physician at the nearest

medical treatment facility. Inform the physician directly of the information
and observations regarding the patient.

NOTE

In the medical chain of command, only the

physician can notify the unit commander of the
suspected alcohol/drug abuser.

21-17
FM 8-230

Section III. THE SUICIDAL PATIENT

21-15. General

a. Suicide is a major problem in our country. It is the tenth leading

cause of death in the United States and the third 1 eading cause of death for
adolescents and adults under thirty. Additionally, the suicide rate for this
group is increasing.

b. Seventy-five percent of potential suicides visit a medical facility

within 6 months prior to their death. Timely awareness of pre-suicidal signs
and symptoms can lead to correct intervention and prevention. For each
documented suicide, a comparable number of persons die as a result of actions
which likely were intended to be self-destructive but could not be verified. For
example, such actions could be ''accidental' ' overdoses of medication or taking
needless chances while driving.

c. In wartime, the suicide rate among soldiers tends to decrease.

Aggressive drives are channeled toward the enemy. However, some deaths due
to inappropriate behavior during combat may, in reality, be suicides.

d. A soldier who is a potential suicide may be identified by the

medical specialist, after which he will be referred to trained medical personnel
for appropriate action. For each of the individuals who committed suicide, it is
estimated that an additional 10 individuals attempted suicide but survived.
On the basis of numbers alone, it is likely that you may be involved directly
with persons who are potentially suicidal.

21-16. Definitions and Terms

a. Behavior Signs. Actions or behaviors that a person takes, such as

spending more money than usual or increasing alcohol consumption. These
signs may also give some indication of the person's thinking.

b. Crisis. The point at which customary problem-solving or decision­

making methods are no longer adequate. At this turning point, a person may
choose suicide as a way to solve the problem.

c. Depression. Refers to feelings (moods) of sadness, despair, and

discouragement, and as such may be a normal state. Depression which may be
disruptive to the soldier is commonly manifested in decreased thinking
processes or purposeful physical activity, guilt, self-condemnation,
hopelessness, and disorders of eating and sleeping.

d. Intervention. Treatment by health care personnel when there is

some question of the individual's ability to cope with his own resources and
requires assistance. This action is also known as ''crisis intervention'' when
the individual shows signs of reaching a crisis point.

e. Stress. Any situation or action that places physical or

psychological demands upon a person. Exhaustion refers to prolonged and
unrelieved strain and tension generated in a person by situations encountered
in life.
f. Stressors. Specific situations that may trigger stress in a person
(for example, taking a test, playing a game of football, receiving or not
receiving a promotion, a permanent change of station).

g. Suicide. The act of intentionally killing oneself.

21-18
 FM 8-230

h. Suicidal A ttempt. The act of self-damage inflicted with self­

destructive intention, however vague and ambiguous. Sometimes this
intention has to be inferred from the person's behavior.

i. Verbal Signs. Spoken words or acts or interpersonal

communication, such as telephone calls or an ordinary conversation. These
signs may reveal the thoughts of a person.

21-17. Suicide Factors

a. A person who decides to commit suicide has become overwhelmed

by problems he cannot face and solve. He feels powerless to find a 1'1olution to
his intolerable situation and may think that no one really cares about him. He
may be suspicious of the people who try to help him and suicide may seem to
be the only way out.

b. Basically, it is not the patient's problems that make his life seem
intolerable; it is the way he feels about these problems. For example, blindness
may be a reason for one person to attempt suicide but a motivating factor for
another person to become a great composer. Many factors influence a patient's
decision to try to end his own life; loneliness seems to be a primary reason. The
patient who does not identify himself with some group (such as a family,
church, or community) is more susceptible to suicidal tendencies. The
psychiatric patient who is also physically ill may resort to suicide, particularly
if he is in pain, his prognosis is poor, he feels that he is a burden to others, or he
is severely disfigured. Loss of a loved one accompanied by feelings of guilt and
depression or inability to transfer affections to someone else may be an
influencing factor in suicide. Loss of prestige or decline in social position may
also be contributing factors.

c. A patient's psychiatric condition may cause him to attempt

suicide. The patient who is recovering from an attack of depression may feel
unable to cope with the stress and strain of living. He may be discouraged to
the point of trying to take his own life. The patient who recognizes the
symptoms of an oncoming attack of depression may feel he cannot go through
the painful experience again. A patient may have delusions or hallucinations
which threaten him or command him to kill himself. A confused, disoriented
patient suffering from an organic mental disorder or from substance abuse is
also likely to commit suicide. This is especially true at night when he tends to
be the most confused.

d. It is also possible for a patient to have an unconscious motive

which drives him to attempt suicide. For example, the patient who cannot
direct his aggression against a person whom he hates may turn these feelings
of hatred and aggression against himself. When he kills himself, he is
symbolically killing the hated person. A patient may kill himself for spite or
revenge. He may feel that by destroying himself he can make certain persons
grieve and repent for real or imagined wrongs that they have done to him. Or,
he may feel that only death is severe enough punishment for his own imagined
wrongs. Not every patient who attempts suicide plans for the outcome to be
self-destruction. He may see a suicidal attempt as the only way to get people
to understand exactly how badly he feels and to do something for him. He
intends for someone to rescue him in time to prevent death.

21-19
FM 8-230

21-18. Planned and Unplanned Suicides

One patient may plan suicide for weeks or months; another one may act on
impulse. The patient who plans his suicide sche-nes to obtain and hide
necessary articles. He carefully works out every step in the plan. He may have
two or more plans in the event one fails. The patient who attempts suicide
impulsively may act in response to bizarre ideas or voices he hears. He
attempts suicide when an opportunity arises. Such an opportunity may be
presented by careless personnel who are not alert to hazards or who
inadequately observe and supervise patients' activities.

21-19. Physical and Psychosocial Symptoms and Warning Signs

a. Physical Symptoms.

( 1 ) Many of the physical symptoms of suicidal intent are due to

depression. However, stress caused by traumatic personal injury, severe
illness, or pain may trigger this depression and these symptoms.

(2) An individual who uses drugs or alcohol may also exhibit

some of these physical symptoms.

b. Procedures and Steps.

( 1 ) Observe the individual for physical symptoms of suicidal

intentions. Physical symptoms of suicidal intentions are-

(a) Change in eating habits.

• Extreme weight gain.

• Extreme weight loss.

(b) Change in sleeping habits (must be more than a casual

cycle of change).

• Inability to sleep.

• Excessive sleep.

(c) Change in normal energy level.

• Low energy level (chronic tiredness) .

• Overactivity (agitation) .

• Restlessness .

• Physical exhaustion.

• Change in mental response.

• Difficulty in decision making.

• Confused thinking.

• Short attention span.

21-20
 FM 8-230

(d) Complaints about physical problems. The potentially

suicidal individual may come to you with a physical complaint. You need to be
alert to possible emotional problems which may be signaled by surface
physical complaints, such as-

• Chest, stomach, back.

• Head, extremities.

• Constipation.

• Decreased sexual desire or performance.

(e) Personal injury/accidental dismemberment (careless­

ness around field equipment may cause accidental loss of limbs).

(2) Observe individual for psychosocial symptoms of suicidal

intentions.

NOTE

Psychosocial symptoms are nonphysical symptoms

that refer to human emotions and to any change in
the life pattern of an individual. Many of these
symptoms are caused by stress due to a recent
situation.

(a) An individual who abuses drugs or alcohol may exhibit

some of these psychosocial symptoms. Observe the individual for-

• Depressed moods (feels low, sad, gloomy).

• Expresses low self-esteem.

• Is fearful and/or trembling.

(b) Changes in appearance can be indicative of a person's

mood and deteriorating self-image.

• Self-neglect.

o Personal hygiene.

o Lack of concern for appearance.

• Body movements.

o Sluggish-moves in "slow motion. "

o Posture stooped and bent.

• Facial expression-blank or sad.

21-21
FM 8-230

• Changes in work habits.

o Lowered quality/quantity of work.

o Inconsistent work pace, likely to change

frequently without apparent reason.

o Lack of interest in his work.

• Changes in usual patterns of behavior.

• Loss of interest in recreation or hobbies.

• Loss of interest in people.

o Avoidance of family and friends.

o Decreased sexual drive.

• Marital and family problems.

o Separation/divorce.

o Difficulties with spouse.

o Child-rearing problems.

o Loss of self-control.

o Social isolation.

• Financial problems.

o Debts.

o Living within a restrictive budget.

• Interpersonal problems.

o Lovers' quarrels.

o Difficulty in accepting authority.

o Homesickness.

o Loss of supportive community or family ties.

o Difficulty with people at work.

(3) Observe individual for signs of suicidal intentions.

(a) Warning signs.

• Statements of hopelessness/helplessness (fol'

example, "l can't take it any longer. ").

21-22
 FM 8-230

• Statements of loss of meaning in life (defeat, failure)

(for example, "I never seem to do things right. " "I never asked to be born. ").

• Statements of an end to a personal relationship (for

example, ''My girlfriend ran off with someone else.' ').

• Questions about death and/or suicide.

(b) Direct verbal signs indicate recognition of a need for

immediate intervention.

• Statements that the soldier intends to commit

suicide must be taken seriously especially when physical or psychosocial
symptoms are also noted.

• Statements that the soldier has a specific plan to

commit suicide. This may include the time, date, and means to be used. Such a
person is a greater risk because he is more likely to follow through with his
expressed plan.

(c) Behavioral signs are nonverbal communication that

indicate a need for outside assistance (intervention). You should be alert for a
pattern of behavioral warning signs that indicates possible suicidal intentions,
such as-

• Preparations for death (making a will; making

funeral arrangements).

• Drastic change in possessions/finances (giving

expensive gifts; giving away prized possessions).

• Putting his affairs in order.

• Extreme risk-taking behavior.

o Driving a car or motorcycle at an excessive rate

of speed.

o Refusal to follow medical advice or take life­

essential prescribed medication.

o Refusal to use safety equipment or follow safety

rules.

• Increased alcohol use.

• Withdrawal from social relationships.

• History of suicide attempt(s).

o A person who has already attempted suicide

once is statistically more likely to attempt suicide again.

21-23
FM 8-230

o Information about an attempt to commit suicide

may come from medical records, friends, veri.,al interaction with the
individual, or other sources.

o Physical signs (such as scars on the wrist) may

be noted.

o Deliberate attempts to commit suicide by means

of a gun; jumping from a high place; overdose of medication (most common);
wrist slashing; or hanging.

(4) Intervene and take immediate action when the soldier shows
sign of suicidal intentions.

(a) Communicate with the soldier.

• Tell him that you care and hope that solutions to his
problems can be found.

• Convey a willingness to listen and try to

understand him.

(b) Assessment of suicidal risk is not easily accomplished.

If there is any suspicion of possible suicidal intentions, you should take the
individual to specially trained personnel, such as a Behavioral Science
Specialist (91G) or a Neuropsychiatric Specialist (91F).

(c) If an individual confronts you with an immediate means

of suicide (such as medication, a knife, or a gun) intervention may be
necessary-but extreme caution should be exercised so as not to endanger
yourself or others.

(5) Notify supervisor of possible need for immediate

intervention. DO NOT LEAVE THE INDIVIDUAL ALONE.

• If physical and psychosocial symptoms are observed and

indirect verbal and behavioral warning signs are noted, immediately request
evacuation, or contact the hospital for an emergency appointment.

• Accompany the individual to the referral agency or to the

consulting professional for assessment, or turn the individual over to the
evacuation personnel.

NOTE

An individual who is a potential suicide should

be referred to medical personnel for appropriate
action. The survival ratio for attempted suicides
as opposed to aborted suicide attempts is 10: 1 .

21-24
 FM 8-230

Section IV. DEATH AND DYING/POSTMORTEM CARE

21-20. General

a. All of us must eventually die, since death follows living; it is a

natural process. In our society, birth is a cause for celebration, but death
normally is a dreaded and unspeakable issue.

b. Death reminds us of our human weaknesses in spite of all our

modern advances. We may want to delay death, but we cannot escape it.
Death is the last and loneliest experience for all of us. Therefore, it is difficult
to help others face it.

c. As a medical specialist, you are frequently faced with the reality of

another person's death; this is often painful and stressful. It is only natural for
fears of death and personal concerns to intensify whenever you are in contact
with someone who is dying. To effectively work with the dying patient, you
must recognize and understand the individual's needs, feelings of tension, and
discomfort.

21-21. Characteristic Elements and Health Care Action

Denial, anger, bargaining, depression, and acceptance are the five basic stages
of dying. The patient may or may not follow these stages in a fixed pattern. He
may go back and forth, or he may never get beyond a certain stage, such as
denial.

a. Denial.

(1) Patient reaction. The patient may-

• Seek additional opinions from other physicians.

• Request that certain tests be repeated or flatly refuse the

results and say that these results belong to another person.

• Express denial verbally (for example, "No, not me! " "It
can't be true! " or "There must be some mistake! ").

(2) Health care provided by the medical specialist.

• Listen-but do not contradict the patient.

• Reinforce prescribed medications/diet routine indicated

by the physician.

• Respect the patient's wish to deny impending death.

b. Anger.

(1) Patient reaction. Patient may-

• Attack you or other members of the staff on a personal or

professional level and may tend to be very critical of the care received (even
that received from his family).

21-25
FM 8-230

• Feel angry inwardly/outwardly, making you the object of

his anger.

NOTE

You should be aware of the negative feelings of

the patient and not take these angry feelings
personally.

• Replace the denial stage with questions and feelings of

rage, resentment, and envy. This is characterized by "Why me?" "Why is this
happening to me?" " I didn't do anything to deserve this punishment. "

(2) Health care provided by the medical specialist.

• Be patient and tolerant.

• Let the patient know that you accept and understand his
feelings.

• Permit the patient to express his anger and any other

feelings that he may have.

NOTE

Do not react with anger or avoidance. Just

allow the patient to express his anger. Do not
attempt to answer all of his questions.

c. Bargaining.

( 1 ) Patient reaction (this stage may be short, irregular, and

possibly not even apparent). Patient may-

• Attempt to postpone death.

• Replace the previous question of "Why me?" to "Yes, it

is me, but ... ," or "Why now?"

NOTE

The medical specialist may hear the patient

say that he would do anything if he could live a
little longer ("I promise I will... ).
"

(2) Health care provided by the medical specialist.

• Listen and be available to the patient for assistance.

• Know that when the patient bargains it is helpful to him.

• Do all you can to keep the patient comfortable.

 FM 8-230

NOTE

Remember that this stage may not always be

perceptible since the patient may bargain
privately.

d. Depression.

(1) Patient reaction. The patient may-

• Be anxious to put his affairs in order.

• Feel a sense of great loss.

• Have apparent feelings of sadness and guilt over not

having provided for his family.

(2) Health care provided by the medical specialis t. Allow the

patient to mourn, cry, or talk about his losses.

e. Acceptance.

(1) Patient reaction. The patient-

• Has prepared to die.

• Is now at peace.

• Is tired.

(2) Health care provided by the medical specialist.

• Respect the patient's need for quiet and offer

reassurance by being there when possible.

• Although you may feel sad or uncomfortable about the

dying patient, you must learn to control your feelings so that they will not
affect the patient.

• Do not whisper, as this may upset the patient if he can

hear you talking but cannot understand what is being said.

NOTE

The last sense believed to leave the body is

that of hearing. The patient often understands
what is being said even though he may not be
able to answer verbally.

21-22. Hospital Death

When a patient dies in a hospital, the physician is responsible for examining

the body, declaring the patient legally dead, and notifying the next of kin. You,
as the medical specialist, are expected to perform postmortem (after death)
care. When providing this care, you must conduct yourself so as to preserve
the dignity and respect of the body.

21-27
FM 8-230

21-23. Procedures for Providing Postmortem Care in a Hospital

Environment

a. Obtain Special Instructions. Ask your supervisor for any special

instructions in caring for the deceased.

b. Perform Initial Postmortem Care.

( 1 ) Place screens around the oed, draw the curtains around the
bed, or close the door to provide privacy for the body.

(2) Close the patient's eyelids by applying light pressure

downward with your fingertips.

(3 ) Adjust the bed to a flat position. Use one pillow under the
head of the body to prevent discoloration of the face. (Facial discoloration
results when blood is pooled in the head region.)

(4) Inspect the body for soiling. Wash soiled areas. You should
wear gloves during cleaning. Change the hospital gown if it is soiled.

(5) Align the body in the natural anatomical position: supine (on
the back) position, arms at the side, and palms turned toward the thighs. Poor
alignment will result in deformities due to rigor mortis (profound stiffening of
the limbs and body as a result of death).

(6) Replace the bed linens, if soiled, and straighten top bedding.

(7) Clean and replace dentures according to local SOP. Comb the
hair. If necessary, close or support the patient's mouth by using rolled ABD
pads to prevent the jaw from sagging. (Most local policies discourage the use
of chin straps since discoloration of the face may occur.)

(8) Clean the deceased patient's area and remove all unnecessary
equipment.

NOTE

If the family wishes to view the body, it is

accomplished at this point. Be supportive
and compassionate with the relatives and
friends who visit the body.

(9) Perform a patient care handwash.

c. Perform Final Pos tmortem Care. Final postmortem care on the

ward begins after the patient's family has viewed the body. After it has been
viewed, prepare it for transfer to the morgue.

(1) Obtain the necessary equipment.

(a) Gather commercially or locally prepared death pack or

equipment according to local SOP. Generally, a death pack includes:

• Mortuary sheet.

• Absorbent cotton or some type of underpads.

21-28
 FM 8-230

• Gauze or bandage rolls (ties).

• Safety pins.

• Instruction sheets for completing required forms.

• Required forms:

o Death tags (3).

o Hospital Report of Death.

o Authorization for Autopsy.

o Disposition of Body.

o Local forms.

• State death certificate information work­

sheet.

• Form for organ donor designation.

(b) Gather additional equipment.

• Clean sheets.

• Diapers .

• Basin of warm water and soap.

• Clean gloves.

• Paper bag.

• Acetone/benzine (optional) per local SOP.

• Stretcher.

• Litter straps (2) .

• Laundry hamper/bag.

• Comb.

• Washcloth, towel.

(2) Provide privacy. Continue to provide privacy for the body by

placing screens around the bed, drawing the curtains around the bed, or
closing the door.

(3) Put on clean gloves.

21-29
FM 8-230

(4) Remove clothing, bedding, and personal belongings.

• Top bedding except for a drape sheet.

• Pajamas/gown.

• Soiled dressings (discard with contaminated waste).

• Jewelry and personal items (get-well cards, eyeglasses,

religious articles).

NOTE

Throughout final care, note and remove any

remaining jewelry and personal articles. Notify
your supervisor regarding any such items
found. Never leave valuables unattended.

(5) Tie off or clamp all drains and tubes.

• Do not remove any drains or tubes from the body unless

specifically directed by your supervisor.

• If there is to be an autopsy, tubes are generally left in the

body.

• Prevent unnecessary exposure of the body.

(6) Wash the body and remove adhesive markings from the skin
(if applicable). Remove adhesive markings with solvent as prescribed in the
local SOP.

(7) Apply new dressings over wounds, using a minimum amount

of tape and dressings.

NOTE

New dressings reduce the possibility of odor

caused by microorganisms.

(8) Pad the anal and urinary areas with adult diapers or by
folding a drawsheet and pinning it in place. The perinea! pad is placed to
absorb feces and urine which are expelled as the sphincters relax; also, this pad
is used to absorb drainage from the vagina.

(9) Remove gloves if you are wearing them.

( 10) Secure ankles and wrists.

• Pad ankles with an ABD pad and secure them with a

gauze roller bandage or according to the local SOP.

• Pad wrists with an ABD pad, cross the right wrist over
the left wrist, and secure them with a roller gauze bandage or according to the
local SOP.

21-30
 FM 8-230

(11) Attach two body tags to the body.

• Obtain completed and signed death tags from your

supervisor.

• Tie a death (body) tag to the right great toe.

• Tie a death (body) tag to the left wrist.

NOTE

Do not tie the tag so tight as to cause pressure.

Pressure causes severe skin discoloration.

( 1 2) Wrap the body.

• With assistance, roll the body to the side of the bed.

• Place one clean sheet diagonally under the body.

NOTE

Method of wrapping the body may differ

between hospitals. In some hospitals the body
is placed in a zippered bag; in others, a
specially prepared shroud is used. Follow your
local SOP.

• Roll the body back to the center of the sheet.

• Fold the upper corner of the sheet loosely over the head
and face. Fold the lower corner over the feet.

• Fold the right and left corners of the sheet over the body.

• Fasten the sheet corners with a safety pin.

( 1 3) Attach signed exterior body tag to the outside of the sheet.

( 14) Transfer the body to a cart or stretcher.

• With assistance, lift the wrapped body onto the

cart/stretcher.
• Secure the body to the cart/stretcher with straps at the
chest and just above the knees. Avoid using pressure (this will cause
discoloration of the skin).

• Cover the wrapped body with a clean sheet.

( 15) Transport the body to the morgue.

• Obtain all records and forms which are to accompany the

body to the morgue from your supervisor.

21-31
FM 8-230

• Notify the morgue that the body is being transferred.

NOTE

A ward staff member must accompany the

body when it is being transported to the
morgue. Service elevators and seldom used
corridors should be used for transporting.
Avoid transferring the body in the view of
visitors and patients; they may become
depressed, develop anxious feelings, or become
frightened.

• Assist the morgue attendant with the transfer of the

body from the cart/stretcher to the morgue equipment.

• Give the morgue attendant all the available records.

• Return the stretcher to the ward and clean it according

to the local SOP.

(16) Perform a patient care handwash.

d. Clean the Deceased Patient's Area. Give the patient's area a

terminal cleaning. Follow the principles of medical asepsis and local SOP.

e. Report the Procedure. Report completion of postmortem care to

your supervisor.

21-32
 FM 8-230

GLOSSARY

Section I. ACRONYMS AND ABBREVIATIONS

ABC's airway, breathing, and circulation surveys

ABO Blood typing system

ABG arterial blood gases

AC hydrocyanic acid (blood agent)

ACTH adrenocorticotrophic hormone

ADH antidiuretic hormone

ADAPCP Alcohol and Drug Abuse Prevention and Control

Program

AF Air Force

AMEDD Army Medical Department

AMOSIST Automated Military Outpatient System

ANC Army Nurse Corps

AR Army Regulation

ARNG Army National Guard

ATTN attention

AWOL absent without leave

BMR Basal metabolic rate

B/P or BP blood pressure

BSA body surface area

Bx biopsy

C centigrade

Cau Caucasian

CBC complete blood count

cc cubic centimeter

CDC Center for Disease Control

CHF congestive heart failure

CK cyanogen choloride (blood agent)

Glossary-I
FM 8-230

cm centimeter

cmm cubic millimeter

CNS central nervous system

C0 2 carbon dioxide

COLD chronic obstructive lung disease

CONUS Continental United States

COPD Chronic obstructive pulmonary disease

CPR cardiopulmonary resuscitation

CRO carded for record only

CSF cerebrospinal fluid

ex phosgene oxime (blister agent)

CT connective tissue

D5NS 5 percent dextrose in normal saline

D5W dextrose 5 percent in water

DA Department of the Army

DET diethyltryptamine

DIFF differential count

DMT dimethyltryptamine

DOA death on arrival

DOD Department of Defense

DOM or STP 2 , 5-dimethxoxy-4-methylamphetamine

ECG or EKG electrocardiogram

EEG electroencephalogram

est estimate

ETOH alcohol

Glossary-2
 FM 8-230

F Fahrenheit

FBS fasting blood sugar

FCT fibrous connective tissue

FDCA Food, Drug, and Cosmetic Act

FM field manual

FMC Field Medical Card

FMP family member prefix

Fr French (denotes size of catheter or tube)

FTCA Federal Torts Claims Act

g grain

ga gauge

GA Tabin (nerve agent)

gal gallon

GB Sarin (nerve agent)

GB series gallbladder series

GD Soman (nerve agent)

GI gastrointestinal

GI series gastrointestinal series

Gm gram

HCT hematocrit

HD mustard (blister agent)

Hgb hemoglobin

HQDA Headquarters, Department of the Army

hr hour

HREC health record

Glossary-3
FM 8-230

ICP intracranial pressure

ID identification

IM intramuscular

in inch

IPDS Individual Patient Data System

ITP inpatient treatment record

ITRCS inpatient treatment record cover sheet

IUD intrauterine device

IV intravenous

IVP intravenous pyelogram

JPA job performance aid

K potassium

Kg kilogram

L Lewisite (blister agent)

Lab. laboratory

lbs. pounds

lig. ligament

LP lumbar puncture

LSD lysergic acid diethylamide

LUL left upper lobe (of lung)

LUQ left upper quadrant

Lymphs lymphocytes

m meter

MAST military anti-shock trousers

M.D. medical doctor

Glossary-4
 FM 8-230

MDA methylenedioxyamphetamine

MEDCEN Medical Center

MEDDAC Medical Department Activity

mg milligram

MG/L milligram per liter

MI myocardial infarction

MILPO Military Personnel Office

ml milliliter

mm millimeter

MM/Hg or mm hg milliliters of mercury

MOS military occupational speciality

mph miles per hour

MPRS military personnel records j acket

MTF medical treatment facility

NATO North Atlantic Treaty Organization

NATO STANAG North Atlantic Treaty Organization Standardization

Agreement

NAVL nerves, arteries, veins, and lymphatics

NAVMED Navy medical

NBC nuclear, biological, or chemical

NCT nerve condition time

NF National Formulary

Neg Negroid

NGR National Guard Regulation

NH nitrogen mustard (blister agent)

NO. number

NS normal saline

Glossary-5
FM 8-230

02 oxygen

OB obstetrical

0.D. oculus dexter-right eye

OF optional form

o.s. oculus sinister-left eye

OT old tuberculin

OTH other

OTR outpatient treatment record

o.u. oculus uterque-both eyes

oz ounce

Pap Papanicolaou

PCP phencyclidine

PDR Physician's Desk Reference

PE physical examination

PERLA pupils equal and react to light

PHS Public Health Service

PID pelvic inflammatory disease

ppm parts-per-million

PREOP preoperative

psi pounds per square inch

rad radiation absorbed dose

RBC/rbc red blood cell

RTC return to clinic

RES reticuloendothelial system

Rh Rhesus factor

RLL right lower lobe (of lung)

Glossary-6
 FM 8-230

RLQ right lower quadrant

RML right middle lobe (of lung)

Rpt report

RTD return to duty

RUL right upper lobe (of lung)

RUQ right upper quadrant

SF Standard Form

SG Surgeon General

SIDPER Standard Installation Division Personnel System

SL sublingual, under the tongue

SOAP subjective (signs and symptoms), objective

(observations), assessment, and plan (a format
for progress notes)

SOP standing operating procedure

Sp Gr specific gravity

SQ subcutaneous

SSE soap suds enema

SSI special skill identifier

STAT/stat Statim (immediately)

SSN social security number

TB MED technical bulletin, medical

THC tetrahydrocannabinol

TKO/Tko to keep open

TMC troop medical clinic

TPR temperature, pulse, and respiration

TOE Table of Organization and Equipment

Glossary-7
FM 8-230

unk unknown

USAR United States Army Reserves

USC United States Code

USP United States Pharmacopeia

VD venereal disease

vx unnamed nerve agent

WBCfw bc white blood cell

WIA wounded in action

yrs years

Section II. DEFINITIONS AND TERMS

Addiction A marked psychological and

physiological dependence on a
substance such as alcohol or a drug,
which has gone beyond voluntary
control.

Anaphylaxes An unusual or exaggerated allergic

reaction to foreign proteins or other
substances.

Aneurysm A permanent blood-filled dilation of a

blood vessel resulting from disease or
injury of the blood vessel wall.

Antibody A protein substance in the body that

develops the body's immunity to a
specific pathogen.

Battle casualty Any casualty incurred in action. " In

action' ' characterizes the casualty
status as having been the direct result
of hostile action; sustained in combat
or relating thereto; or sustained going
to or from a combat mission provided
that the occurenct was directly related
to hostile action. Included are persons

Glossary-8
 FM 8-230

killed or wounded mistakenly or

accidentally by friendly fire directed at
a hostile force or what is thought to be
a hostile force.

Body resistance The body's ability to oppose an

infection, but does not imply
immunity.

Brackish water Highly mineralized, salty-tasting water

that contains dissolved solids in excess
of 500 parts per million.

Carded for record

only (CRO) A term which applies to those special
cases for which a medical record is
required to be prepared in the same
manner as for an admission, although
no admission has actually occurred.

Cartilage A tough, white connective tissue that

covers the joint surfaces of bone.

Chlorination Disinfection of water by the addition of

a chlorine compound such as calcium
hypochlorite.

Chlorine demand The amount of chlorine which reacts

with and is consumed by organic
material, bacteria, and other
substances in water.

Chlorine dosage The amount of chlorine added to a given

quantity of water.

Chlorine residual The amount of chlorine remaining after

the demand has been satisfied. Dosage
minus demand equals residual.

Clinic A medical treatment facility intended

for and staffed and equipped to
provide emergency treatment and
ambulatory services. A clinic may be
equipped with beds for observation of
patients awaiting transfer to a
hospital, and for those cases which
cannot be cared for on an outpatient
status, but which do not require
hospitalization.

Contagion Communication of a disease from one

person to another by direct or indirect
contact.

Glossary-9
FM 8-230

Contaminate To soil, pollute, or taint; any contact

with unsterile or radioactive materials
or surfaces.

Contaminated water Water that is unfit for human

consumption even though it may be
palatable. Contaminated water
contains disease-producing organisms
and/or excessive amount of mineral
and organic matter, toxic chemicals, or
radioactive materials.

Convalescent leave Convalescent leave is an authorized

leave status granted to active duty
uniformed service members while
under medical or dental care which is a
part of the care and treatment
prescribed for his recuperation
(convalescence).

Cravat Triangular bandage that is used for

fashioning a sling or swathe.

Crepitation Crackling; the sensation felt or heard

over the fracture site when broken
bone ends rub together.

Definitive medical
treatment That specialized care of the sick and
wounded given by highly trained
medical personnel, ordinarily the
physician.

Delivery The protedure of delivering a liveborn

infant or stillbirth (and placenta) by
manual, instrumental, or surgical
means.

Diaphysis The main, central shaft of a long bone.

Died of wounds received

in action (DOW) The term used to describe all battle
casualties who die of wounds or other
injuries received in action after having
reached any medical treatment facility.

Disease A condition in which physical and/or

mental health is impaired as the result
of some process other than that caused
by accident, violence, or poisoning.

Disinfect To reduce the numbers of micro­

organisms, usually by germicides or
boiling water.

Glossary-IO
 FM 8-230

Disinfection Treatment with chemicals or by boiling

to destroy disease-producing
organisms.

Dislocation Displacement of a bone from its j oint.

Dispensary health clinic See Clinic.

Ecchymosis The purplish discoloration of skin

caused by the passage of blood from
ruptured blood vessels into
subcutaneous tissue; bruise.

Emergency medical care The early care given by trained medical

personnel.

Epigastrium The upper and middle regions of the

abdomen with the sternal angle.

Epiphysis The end portions of a long bone.

Ethanol Ethyl alcohol; the type of alcohol

present in alcoholic beverages.

Existed prior to
service (EPTS) A term added to a medical diagnosis to
signify that there is clear and
unmistakable evidence that the disease
or injury, or the underlying condition
producing the disease or injury, existed
prior to the individual's entry into
military service.

Fomites Any objects (books, clothing) that can

harbor and transmit infectious
organisms.

Forceps An instrument used to grasp, pull, and

extract objects; there are many types,
varying according to their usage.

Fracture A break in the continuity of bone.

Closed fracture One in which the skin overlying the site

is intact.

Comminuted fracture One in which the bone is broken into

more than two pieces.

Greenstick fracture An incomplete fracture commonly found

in children.

Impacted fracture One in which the broken ends of the

bone are j ammed together.

Glossary-11
FM 8-230

Oblique fracture One in which the fracture line crosses

the bone at an oblique angle or in a
slanting direction.

Open fracture One in which there is an open wound

over the fracture site.

Spiral fracture One in which the fracture line twists

around and through the bone.

Transverse fracture One in which the fracture line is straight

across at a right angle to the long axis
of the bone.

Geriatric A term that refers to the elderly.

Germicide A chemical substance that destroys

bacteria.

Habituation A situation in which a patient produces

a tolerance to a drug and becomes
psychologically dependent on the drug.

Hallucinogen An agent or drug that has the capacity

to stimulate hallucinations.

Hexachlorophene A bactericidal or bacteriostatic

substance contained in certain soaps.

Hives A vascular reaction of the skin marked

by the transient appearance of smooth,
slightly elevated patches (wheals)
which are redder or paler than the
surrounding skin and often attended
by severe itching. Hives are usually
caused by reactions to foods, drugs, or
emotional stress.

Hospital A health treatment facility capable of

providing definitive inpatient care. It
is staffed and equipped to provide
diagnostic and therapeutic services in
the field of general medicine and
surgery, preventive medicine services,
and has the supporting facilities to
perform its assigned mission and
functions.

Hygiene The individual employment of practices

that will keep one healthy. These
practices include proper diet and body
cleanliness.

Glossary-12
 FM 8-230

Hyperglycemia An abnormally increased concentration

of sugar in the blood.

Hyperthermia An abnormally increased body

temperature; hyperpyrexia.

Hypoglycemia An abnormally diminished concentration

of sugar in the blood.

Hypothermia An abnormally reduced body

temperature.

Infection A condition in which the body is

invaded by a pathogenic agent that
under favorable conditions multiplies
and produces injurious effects.

Immobilization Prevention of the movement or use of

an injured structure.

Inpatient An inpatient is an individual, other than

a transient patient, who is admitted
(placed under treatment or observation)
to a bed in an MTF which has
authorized or designated beds for
inpatient medical or dental care.

Inpatient treatment
record (ITR) The medical record used at an MTF for
recording inpatient medical or dental
care. It is begun on admission to the
MTF and completed at the end of
hospitalization. This record applies to
all beneficiaries.

Inpatient Treatment Record

Cover Sheet ( ITRCS) A medical and administrative summary
of each continuous, uninterrupted
period of inpatient treatment and is
prepared for each case an ITR is
needed. (For CRO cases, the ITRCS
may be the entire ITR.) ITRCS are
also essential documents for HREC
and OTR. In addition, they serve as
source documents for statistical
information of maj or military and
medical interest.

Insulin A hormone secreted by the islets of

Langerhans in the pancreas; essential
for proper metabolism of blood sugar
and maintenance of proper blood sugar
levels.

Glossary-13
FM 8-230

Intoxication A state of being excited or stupefied by

alcohol or a narcotic to the point where
physical and mental control is
markedly diminished.

Killed in action
(KIA) Refers to personnel who are killed or
who die of wounds or other injuries
received in action before reaching any
MTF.

Lavage A washing-out of a hollow organ (such

as the stomach).

Length of patient stay The number of occupied bed days from

date of admission to disposition. This
excludes days subsisting out, on
convalescent leave, on other authorized
or unauthorized leave, or on pass in
excess of 7 2 hours.

Ligament A strong band of tissue that connects

two or more bones.

Marrow The soft, fatty substance that fills the

medullary canal; responsible for the
formation of blood.

Medical Center A medical center is a large hospital

which has been so designated and
staffed and equipped to provide health
care for authorized personnel; includes
a wide range of specialized and
consultative support for all medical
facilities within a specific geographic
area of responsibility; and
postgraduate education in health
professions.

Medical records Refers to inpatient treatment records,

outpatient treatment records, health
records, x-rays, and US Field Medical
Cards.

Medical Treatment
Facility (MTF) Any facility that receives, sorts, treats,
and dispositions the sick and wounded.
The facility may be fixed, nonfixed,
numbered and unnumbered. This
includes aid stations, clearing stations,
clinics, hospitals, convalescent centers,
dental clinics, veterinary dispensaries,
and veterinary hospitals.

Glossary-14
 FM 8-230

Medullary canal The hollow central portion of the bone;

contains the bone marrow.

Methanol Methyl alcohol; wood alcohol; poisonous

if ingested, causing extreme metabolic
acidosis and blindness.

Military personnel Any person on active duty or active

duty for training in the US Armed
Forces, including cadets of the Armed
Forces academies.

Narcotic A drug used to depress the central

nervous system, thereby relieving pain
and producing sleep.

Nonbattle injury An injury which is not the direct result

of action by or against an organized
enemy or other battle casualties which
may be so classified by departmental
regulation.

Outpatient An individual receiving health service

for an actual or potential disease or
injury that does not require admission
to a medical facility for inpatient care.

Outpatient treatment
record (OTR) A medical record documenting
outpatient treatment of the nonactive­
duty beneficiary.

Palatable water Water that is pleasing to the taste but

which may be unsafe (contaminated).

Parts per million (ppm) A unit of measurement for expressing

the number of units of a substance in
one million units of water by weight.

Pathogen Microorganism capable of producing

disease.

Pathogenic Capable of producing disease.

Periosteum The outermost layer of bone.

Peritoneum The membrane that lines the abdominal

cavity.

Physical dependence See addiction.

Polydipsia A condition of excessive thirst.

Polyphagia A condition of excessive hunger.

Glossary-15
FM 8-230

Polyuria A condition of excessive urination.

Position of function Maintenance of the normal position of a

j oint or limb.

Potable water Water that is safe for human

consumption. Potable water is free
from disease-causing organisms and
excessive amounts of mineral and
organic matter, toxic chemicals, and
radioactive materials. The water may
not be pleasing to the taste.

Prime beneficiary An individual who because of his status

is eligible for medical care in
accordance with AR 40-3.

Primary cause of
admission The immediate condition which
necessitated the patient's admission to
the MTF.

Psychological dependence See addiction.

Purulent (suppurative) Forming or containing pus.

Pus A liquid product of inflammation made

up of tissue debris, bacteria,
leukocytes, and serum.

Quadrant The term used to designate one of the

four quarters of the abdomen.

Quarters patient An active duty uniformed service

member receiving medical or dental
treatment for a disease or injury that
is of such a nature that inpatient care
is not required, but he cannot perform
his duties. The quarters patient is
treated on an outpatient basis, remains
in his quarters between treatment, and
normally returns to duty within a
72-hour period.

Reduction Restoration of the ends of a fractured

bone to their normal anatomical
position.

Retroperitoneum The area behind the peritoneum.

Glossary-16
 FM 8-230

Sanitation The effective use of measures that

create and maintain healthful
environmental conditions. Among
these measures are the safeguarding of
food and water and the control of
disease-carrying insects and animals.

Self-aid, first-aid,
and buddy aid Emergency medical procedures carried
out by anyone, whether trained or
untrained in medicine.

Sling A bandage that is suspended from the

neck to support an injured arm or
hand.

Splint Any device used to immobilize a

fracture or dislocation.

Spore A reproductive cell produced by plants

and some protozoans that has a thick
wall enabling it to withstand
unfavorable environments.

Sprain Injury in which ligaments are partially

torn.

Strain Soft-tissue injuries or muscle spasms

around a joint.

Swathe A bandage used in conjunction with a

sling that is wrapped around the body
to secure the injured arm.

Tendon A fibrous cord or band that connects a

muscle to a bone.

Tolerance A diminished susceptibility to the

effects of a drug or toxic substance
acquired after continued ingestion of
it.

Toxin A poisonous substance of plant or

animal origin.

Traction Method used to realign fractures and

dislocations by application of a pulling
force to the site.

Transient patient A patient en route from one medical

treatment facility to another medical
treatment facility.

Glossary-17
FM 8-230

Transmission Transfer from one individual to another,

such as a disease or hereditary
characteristic.

Urticaria Hives.

Vasoconstriction The narrowing of the diameter of a

blood vessel.

Vasodilation The widening of the diameter of a blood

vessel.

Venomous poison A poison derived from reptiles or insect

bites.

Virulence Relative power or strength of a

pathogen to produce disease.

Water treatment Removal of undesirable elements in

water through coagulation,
sedimentation, filtration, and/or
disinfection.

Withdrawal A symptom produced by abstinence

from a drug to which one is addicted.

Glossary-18
 FM 8-230

R E F E R E N C ES

ARMY REGULATIONS (AR)

10-5 Department of the Army

20-1 Inspector General Activities and Procedures

40-2 Army Medical Treatment Facilities: General

Administration

40-3 Medical, Dental, and Veterinary Care

40-5 Health and Environment

40-14 Control and Recording Procedures for Exposure to

Ionizing Radiation and Radioactive Materials 1

40-15 Medical Warning Tag and Emergency Medical

Identification Symbol

40-66 Medical Record and Quality Assurance Administration

40-400 Patient Administration

40-407 Nursing Records and Reports

40-501 Standards of Medical Fitness

40-562 Immunization Requirements and Procedures

50-5 Nuclear and Chemical Weapons and Material:

Nuclear Surety

340- 1 7 Release of Information and Records from Army Files

340-18 The Army Functional Files System

340-21 The Army Privacy Program

380-380 Automated Systems Security

385-10 Army Safety Program

600-85 Alcohol and Drug Abuse Prevention and Control Program

600-107 Medical Restriction/Suspension From Flight Duty,

Nonmedical Suspension, Flying Evaluation Boards, and
Flight Status Review System

601-2 10 Regular Army and Army Reserve Enlistment Program

6 1 1-201 Enlisted Career Management Fields and Military

Occupational Specialties

635-10 Processing Personnel for Separation

635-40 Physical Evaluation for Retention, Retirement, or

Separation

Reference-I
FM 8-230

640-10 Individual Military Personnel Records

NATIONAL GUARD REGULATIONS (NGRI

600-200 Enlisted Personnel Management

640-100 Officer and Warrant Officer Military Personnel Record

Jacket

FIELD MANUALS (FM)

8-9 NATO Handbook on the Medical Aspects of NBC
Defensive Operations

8-33 Control of Communicable Diseases in Man, 1 3th Edition

8-35 Evacuation of the Sick and Wounded

21-10 Field Hygiene and Sanitation

21-1 1 First Aid for Soldiers

21-40 NBC (Nuclear, Biolo�cal, and Chemical)

27-14 Legal Guide for Soldiers

TECHNICAL BULLETINS, MEDICAL (TB MED)

81 Cold Injury

230 Treatment and Management of Venereal Disease

250 Recording Dental Examinations, Diagnosis, and

Treatment

507 Occupational and Environment Health Prevention,

Treatment, and Control of Heat Injury

530 Occupational and Environmental Health Food Service

Sanitation

TECHNICAL MANUALS (TM)

3-220 Chemical, Biological, and Radiological (CBR)
Decontamination

5-632 Medical Entomology Operational Handbook

8-285 Treatment of Chemical Agent Casualties and

Conventional Military Chemical Injuries

Manual for Courts-Martial, 1969, (Revised)

STANDARDIZATION AGREEMENTS (STANAG's)

2132 Documentation Relative to Medical Evacuation,
Treatment, and Cause of Death of Patients

2348 Basic Military Hospital (Clinical) Records

Reference-2
 FM 8-230

IN DEX

Paragraph Page
Abdominal ailments and injuries

Acute abdomen 1 3-98 13-116

Signs and symptoms 1 3-99 1 3- 1 1 6

Treatment 1 3-100 1 3-1 1 7

Open abdominal injuries 1 3-101 1 3-1 1 9

Treatment 1 3-102 1 3- 1 1 9

Accident reporting 1 2-24 1 2-24

Adrenal (suprarenal) glands 10-6 10-3

Airways, artificial 13-171 1 3-168

Aids to 1 3-172 1 3-159

Airway disease, obstructive 1 3-160 13-163

Airway, esophageal obturator 1 3- 1 74 13-172

Airway obstructions, upper 1 3-85 13-96

Signs of 1 3-86 1 3-97

Treatment, conscious patient 1 3-87 1 3-97

Unconscious patient 1 3-88 1 3-100

Alcohol and drug abuse 2 1-9 21-9

Drug classification 21-1 1 21-17

Psychosocial signs of abuse 21-13 21-16

Reporting and referral procedures of

suspected alcohol/drug abuser 21-14 21-17

Signs and symptoms of abuse 21-12 21-1 1

Specific terms 21-10 21-9

Suicidal Patient 21-15 21-18

Factors 21-17 21-19

Physical and psychosocial symptoms and

warning signs 21-19 21-9

Planned and u nplanned suicides 21-18 21-20

Terms and definitions 21-16 21-18

lndex-1
FM 8-230

Paragraph Page

Anal canal 8-9 8-9

Anaphylactic shock 1 3-73 13-79

Signs and symptoms 1 3-74 1 3-79

Treatment 13-75 13-80

Anatomical terminology 2-2 2-1

Angina pectoris 5-5 5-6

Antishock garments 13-59 1 3-72

Application of 1 3-62 13-74

Contraindications for use 13-61 1 3-74

Deflation/removal 1 3-63 13-76

Indications for use 13-60 13-73

Anus 8-9 8-9

Application of heat and cold 1 4-74 14-87

Application of cold 1 4-83, 1 4-103

1 4-84 1 4·-104

Arm or foot soaks 1 4-81 14-100

E ffects of cold 1 4-77 1 4-96

Effects of heat 14-76 1 4-96

Effects on the autonomic nervour system 1 4-78 1 4-96

Local application of heat 14-80, 14-98

14-82 14-101

Sterile application technique 1 4-85 1 4-104

Army Medical Department

History 1-1 1-1

Mission 1 -2 1-1
Asepsis

Body response to injury 14-28 1 4-19

Development of infection 14-27 1 4- 1 8

Index-2
 FM 8-230

Paragraph Page
Donning and removing sterile gloves 14-37 14-29

Dressing materials 14-41 14-33

Dry, sterile wound dressing 14-39 1 4-32

Handwashing procedure 14-34 14-25

Opening individually wrapped supplies 1 4-36 14-27

Opening sterile pack and sets 1 4-35 1 4-26

Pathogen invasion 1 4-26 1 4-18

Principles of aseptic technique 1 4-30 1 4-22

Procedures for changing a dressing 14-43 1 4-34

Requirement to change or reinforce a dressing 1 4-40 14-32

Rules 1 4-29 1 4-21

Tapes 1 4-42 1 4-34

Types of soaps 14-33 1 4-24

Use of disinfectants and antiseptics 14-3 1 14-23

Wound assessment 14-38 14-31

Asthma, bronchial 1 3-164 13-165

Treatment 13-165 1 3- 1 65

Battle fatigue (stress)

Introduction 21-1 21-1

Bandages and binders 1 3-38 13-54

How to apply

Circular bandage to an arm 1 3-40 1 3-56

Figure-of-8 bandage to an ankle 1 3-41 13-57

Figure-of-8 bandage of a forearm 1 3-43 1 3-59

Figure-of-8 bandage to a hand 1 3-42 13-58

Figure-of-8 bandage to a knee 13-44 1 3-60

Recurrent 1 3-48 13-63

Scultetus 13-49 1 3-63

Index-3
FM 8-230

Paragraph Page
Spiral reverse 13-47 13-62

Spiral to a forearm 1 3-46 1 3-61

Spiral to a leg 1 3-45 1 3-60

T-binder or double T-binder 1 3-50 1 3-64

Types 1 3-39 1 3-55

Blood

Cells

Red 5-10 5-1 2

White 5-1 1 5-13

Coagulation 5-13 5-13

Gases, exchange and transportation 6-1 1 6-9

Platelets 5-12 5-13

Pressure 5 -7, 5 -8
14-3, 14-1
14-19 14-12

Specimen

Procedure for obtaining

Using the Vacutainer System 14-46 14-40

Vacutainer System 14-45 14-39

Venipuncture 14-44 14-39

Types 5-14 5-13

Vessels, heart 5-6 5-6

Body cavities, serous 3-5 3-5

Bone

Basic structure of 4-2 4-1

Marrow 4-3 4-1

Shapes 4-4 4-1

Index-4
 FM 8-230

Paragraph Page
Breathing

Blood supply 6-10 6-8

Costal (thoracic) 6-7 6-7

Diaphragmatic (abdominal) 6-8 6-8

Nervous control of 6-9 6-8

Mechanisms 6-6 6-7

Bronchitis, chronic 1 3-162 13-164

Treatment 1 3- 1 63 13-164

Burns 1 3-3 13-1

Classification 13-5 1 3-3

Inhalation 1 3-169 1 3- 1 68

Initial treatment 13-7 1 3-4

Mortality of 1 3-6 1 3-4

Pathology 1 3-4 13-3

Treatment, extensive burns 1 3-8 13-9

Carbon monoxide inhalation 1 3-139 13-154

Treatment 1 3-140 1 3-155

Cardiac arrest 13-80 13-87

Signs and symptoms 1 3-81 13-88

Treatment 1 3-82 1 3-88

Cardiogenic shock 13-64 1 3-77

Signs and symptoms 13-65 13-77

Treatment 1 3-66 1 3-77

Cardiopulmonary resuscitation 1 3-80 1 3-87

One rescuer 13-83 13-94

Two rescuers 1 3-84 13-95

Index-5
FM 8-230

Paragraph Page
Casualties

Multiple 1 2-5 1 2-2

Sorting 1 2-6 1 2-3

Cells 2-3 2-6

Red blood 5-10 5-12

White blood 5-1 1 5-13

Catheterization 14-5 1 14- 55

Care and management of Foley catheter patient 1 4-53 14-58

Urinary bladder 1 4-52 1 4-56

Urinary (Foley catheter) 1 4-51 14-55

Chest injuries

Closed wounds 13-92 13-107

Signs and symptoms 13-93 13-109

Treatment 13-94 13-109

Open wounds 13-89 1 3-104

Signs and symptoms 1 3-90 13-105

Treatment 13-91 1 3-105

Chest tube (drainage) 1 4-90 14-107

Indications of properly working system 14-92 14-1 1 5

Observations made during drainage procedure 1 4-93 1 4-1 1 6

Patient management 14-91 1 4-108

Childbirth 1 5-4 thru 1 5-7--

1 5-12 1 5-23

Circulatory system 5-1 5-1

Blood vessels 5-6 5-6

Lymphatics 5-8 5-10

Coagulation 5-13 5-1 3

Cold injuries 1 9- 1 5 thru 19-16··

19-19 19-19

lndex-6
 FM 8-230

Paragraph Page

Congestive heart failure 5-1 7 5-15

Combat medic

Aid bag 1-8 1 -2

Interpersonal relationships 1-10 1-4

Development of 1-1 1 1-4

Main job 1-4, 1-1

1 -6 1 -2

Preoperational briefings 1-7 1-2

Responsibilities 1-3 1-1

Resources 1-5 1 -2

Solving medical problems 1-9 1-4

Convulsions and/or seizures 13-95 13-1 1 3

Treatment 1 3-97 1 3- 1 1 4

Types with signs and symptoms 1 3-96 1 3- 1 1 3

Coronary artery disease 5-1 5 5-14

DA Form 4006 1 7-67 1 7-54

Death and dying/postmortem care 2 1-20 21-25

Characteristics, elements, and

health care action 2 1-21 21-25
Hospital death 2 1 -22 21-27

Postmortem care procedures in

hospital environment 2 1 -23 21-28

Demand valve 1 3-173 1 3- 1 7 1

Diabetic

Emergencies 13-129 13-148

Ketoacidosis 1 3-130 13-148

Signs and symptoms 1 3- 1 3 1 13-149

Treatment 1 3- 1 3 1 13-149

Digestive system 8-1 8-1

Special protective mechanisms 8-11 8-7

Index-7
FM 8-230

Paragraph Page

Structure of 8-2 8-1

Time required for 8-1 0 8-6

Dislocations, management of 13-37 13-53

Drowning 13-167 13-166

Treatment for near-drowning patients 13-168 1 3-167

Ear 1 1-2 1 1-1

Ear, obstructed

Irrigating 1 3-103 1 3-122

Treatment 1 3-104 1 3-122

Emphysema 1 3-161 13-163

Treatment 13-163 1 3-164

Endocrine system 10-1 10-1

Environmental health 19-1 19-1

Bites and stings 1 9-21 thru 19-1 7--

19-29 19-28

Cold injuries 19- 1 5 thru 1 9-9--

19-20 19-28

Communicability and transmission 19-6 19-2

Communicable diseases 19-3 19-1

Heat injuries 19-10 thru 19-5--

19-14 19-9

Infection 19-5 19-2

Modes of transmission 19-8 19-3

Poisonous plants 19-30 1 9-29

Preventive measures 19-31 19-29

Treatment 19-32 19-30

Reservoirs of disease 19-7 1 9-3

Types of organisms 1 9-4 19-1

lndex-8
 FM 8-230

Paragraph Page
Epiglottitis 1 3-159 13-163

Epistaxis (nose bleed) 1 3-78 1 3-86

Treatment 1 3-79 1 3-87

Esophagus 8-5 8-4

Evacuation 1 2-14 12-13

Factors affecting 1 2-16 1 2-14

Priorities 1 2-15 1 2-13

Examination

Head-to-toe 1 2-13 1 2-6

Triage 1 2- 1 1 1 2-4

Eye 1 1-3 1 1 -4

Burns 1 3- 1 1 3 13-138

Chemical burns

Signs and symptoms 1 3-1 1 5 1 3-138

Treatment 1 3- 1 1 6 1 3-138

Foreign bodies 1 3-108 13- 1 3 1

Treatment 1 3-109 1 3-1 3 1

Injuries, management of 13-105 1 3- 1 28

Irrigating procedures 13-106, 13-128

1 3-107 1 3-128

Lacerations, contusions, extrusions 1 3- 1 10 1 3-133

Examination for 13-1 1 1 13-133

Laser eye injuries

Signs and symptoms 1 3-1 1 9 1 3-140

Treatment 13-120 1 3-140

Radiant energy burns

Signs and symptoms 1 3-1 1 7 1 3-140

Treatment 1 3- 1 1 8 13-140

Index-9
FM 8-230

Paragraph Page
Thermal eye injuries

Signs and symptoms 1 3-121 13-140

Treatment 13-122 1 3-140

Treatment, other problems 13- 1 1 4 1 3-138

Facial wounds 13-22 1 3-22

Treatment 1 3-23 1 3-22

Field medical care 1 3-1 13-1

Female reproductive system 9-1 1 , 9-6

1 5-1 1 5-1
1 5-2

Field sanitation 1 6-1 16-1

Command emphasis 1 6-2 1 6-1

Drinking water treatment 16-4 .• 16-2

16-5, 1 6-2
1 6-6 16-5

Food sanitation 1 6-9, 16-10

1 6-10 16-10

Insect control 16- 1 1 1 6-10

Personal hygiene 16-13, 1 6- 1 1

1 6-14 16-12

Rodent control 16-12 1 6- 1 1

Waste disposal 1 6-7 16-7

Fractures, management of 13-36 13-50

Gastrointestinal bleeding, massive 1 3-154 13-159

Signs and symptoms 13-155 1 3-160

Treatment 1 3- 1 56 13-160

Genital system 9-9 9-3

Genitourinary problems 1 3-157 13-161

lndex-10
 FM 8-230

Paragraph Page
Glands

Parathyroid 10-4 10-3

Suprarenal (adrenal) 10-6 10-3

Thyroid 10-3 10-3

Gonads 10-7 10-3

Gyncological emergencies 15-13, 15-23

1 5-14 1 5-24
15-15 15-24

Head injuries 13-16 13-14

Assessment 13-18 13-16

Classification 13-17 13-15

Closed head injuries 13-19 13-17

Open head injuries 13-20 13-18

Treatment 13-21 13-18

Heart 5-2 5-1

Attack (myocardial infarction) 13-81 13-88

Blood and nerve supply 5-4 5-4

Blood vessels 5-6 5-6

Blood flow through 5-3 5-4

Congestive failure 5-17 5-1 6

Heartbeat and sounds 5-5 5-6

Hemorrhage 13-76 13-80

Treatment, external 13-77 13-81

Human systems

Circulatory 5-1 5-1

Digestive 8-1 8-1

Endocrine 10-1 10-1

Integumentary 3-1 3-1

Index-11
FM 8-230

Paragraph Page
Muscular 4-6 4-21

Nervous 7-1 7-1

Respiratory 6-1 6-1

Skeletal 4-1 4-1

Urogenital 9-1 9-1

Hygiene and cleanliness 16-13, 1 6- 1 1

1 6-14 1 6-12

Hypoglycemia reactions 1 3-133 13-150

Signs and symptoms 13-134 13-150

Treatment 13-135 13-150

Hypovolemic shock 13-56 13-70

Signs and symptoms 1 3-57 13-70

Treatment 13-58 13-71

Impalement injuries 1 3-9 13-9

Evacuation 1 3-15 13-13

Immobilization 1 3-14 13-13

Initial treatment 1 3-10 1 3-9

Treatment

Chest 13-12 13-12

Extremities 13-13 1 3-12

Head 1 3-1 1 13-10

Infralaryngeal structures 6-5 6-6

Integumentary system 3-1 thru 3-1--

3-4 3-3

Inhalation burns 13-169 13-168

Treatment 1 3-170 13-168

Intravenous infusion 1 4-65 14-74

Care and management of patient with

IV infusion 1 4-68, 1 4-77
1 4-69 14-80

lndex-12
 FM 8-230

Paragraph Page
IV start procedures 1 4-66 1 4-75

Solutions used in IV therapy 1 4-67 14-76

Intestines

Associated glands 8-7 8-5

Large 8-8 8-6

Small 8-7 8-5

Kidney 9-3 9-2

Larynx 6-4 6-4

Legal aspects

Federal Torts Claim Act 1-15 1-7

Law and the medical soldier 1-13 1-6

Negligence 1-12, 1-5,

1-14 1-6

Lymphatic system 5-8 5-8

Male reproductive system 9-1 0 9-4

Medical evacuation 1 2-15, 12-13

1 2- 1 6 1 2-14

Medical information and records 1 7-1 1 7-1

Alcohol, drug abuse records 1 7-6 1 7-2

Confidentiality 1 7-4 1 7-1

Disclosure procedures 1 7-5 1 7-2

Explanation of terms 1 7-2 1 7-1

Health records 1 7-23 thru 1 7-1 5--

1 7-28 1 7-20

Additional forms in health record 1 7-43 1 7-34

CDC 9.29364 1 7-33 1 7-34

DA Form 3444 series folder 1 7-29 1 7-21

Disposition 1 7-37 1 7-27

lndex-13
FM 8-230

Paragraph Page
Filing 1 7-36 17-25

Maintenance under combat conditions 17-44 1 7-35

Preparation and use 17-38, 1 7-27

1 7-39 17-27

Preparation and use of SF 600 17-40 1 7-28

Preparation and use of SF 601 and

PHS Form 731 17-41 1 7-32

Preparation and use of SF 602 17-42 1 7-33

SF 88 and SF 93 1 7-32 1 7-22

SF 600 17-30 1 7-21

SF 601, PHS Form 731 1 7-31 17-22

"Temporary" and "New" health records 1 7-35 1 7-24

Transferring 1 7-34 1 7-22

Inpatient treatment records 1 7-45 1 7-35

AWOL patients 17-49 17-36

Forms and documents 1 7-47 1 7-36

Preparation and use 17-48 17-36

Responsibilities 1 7-46 17-36

Use and preparation of DA Form 4256 17-51 1 7-37

Use of SF 539 17-50 17-37

Use of Form 5009-R 1 7-52 1 7-41

Laboratory forms

Instructions for filling out 17-54 1 7-41

Preparation and use 17-53 1 7-41

Medical records entries 1 7-7 1 7-4

Nursing records and reports 1 7-55 17-46

DA Form 4256 1 7-58 17-46

Error correction 17-57 1 7-46

Index-14
 FM 8-230

Paragraph Page
Recording data 1 7-56 1 7-46

SF 510 1 7-59 17-46

SF Form 5 1 1 1 7-60 17-47

Temporary records 1 7-61 1 7-51

Outpatient treatment records 1 7-16 thru 1 7-9

1 7-22 1 7-15

Patient and facility identification 1 7-8, 1 7-5,

1 7-9 1 7-5

Recording diagnoses and procedures 1 7-10 17-5

Recording injuries and deaths 1 7-14, 1 7-7,

1 7-15 17-8

Recording psychiatric conditions 1 7-13 1 7-6

Responsibilities 1 7-3 1 7-3

Special instructions 1 7-1 1 , 1 7-6,

1 7-12 1 7-6

US Field Medical Card 1 7-62 1 7-5 1

Disposition 1 7-66 17-54

Instructions for completing 1 7-68 1 7-54

NATO STANAG 2348 requirements 1 7-63 1 7-51

Preparation 1 7-64 1 7-52

Supplemental cards 17-65 17-53

Medical specialist, qualities of 1 3-2 13-1

Medical terminology 1-16 1-8

Prefixes 1-17 1-8

Suffixes 1-18 1-10

Menstruation 9-1 2 9-8

Muscles, types of 4-6, 4-21

4-7 4-21

lndex-15
FM 8-230

Paragraph Page
Myocardial infarction, signs and symptoms of 5-1 6, 5-15,
13-81 13-88

Nasogastric tubes 14-54 14-60

Care of patient with nasogastric tube 14-58 14-65

Insertion procedure 14-56 14-61

Irrigation 14-57 14-64

Suction devices used 14-59 14-66

Types 1 4-55 14-60

Neek fractures 13-26 13-25

Signs and symptoms 13-27 13-25

Treatment 13-28 13-25

Neck injuries 1 3-24 1 3-24

Treatment 13-25 13-24

Nervous system 7-1 7-1

Autonomic 7-4 7-1 1

Central 7-2 7-1

Peripheral 7-3 7-10

Protective mechanisms 7-5 7-12

N eurogenic shock 1 3-70 1 3-78

Signs and symptoms 1 3-71 13-78

Treatment 1 3-72 13-78

Nuclear, biological, and chemical injuries 20-1 20-1

Biological agent casualties 20-7 20-3

Chemical agent injuries 20-10 20-3

Personal decontamination 20-12 20-6

Blister agents 20-15 20-15

Blood agents 20-14 20-14

Index-1 6
 FM 8-230

Paragraph Page
Choking agents 20-16 20-18

Nerve agents 20-13 20-6

Protective measures and handling of casualties 20-1 1 20-5

Types of nuclear injuries 20-2 20-1

Blast injuries 20-4 20-1

Radiation injuries 20-6 20-2

Thermal injuries 20-5 20-2

Obstetric and gynecologic emergencies 15-13 15-23

Abdominal pain 15-14 15-24

Abnormal deliveries 15-8 15-17

Abortion 15-18 15-26

Abruptio placentae 15-20 15-28

APGAR scoring 15- 1 1 15-22

Caring for the rape victim 1 5-24 15-31

Clinical procedures (rape victim care) 1 5-25 15-32

Delivery complications 15-7 1 5-15

Delivery without sterile supplies 15-12 15-22

Female reproductive system,

anatomy and physiology 15-2 1 5-1

Multiple births 15-9 1 5-20

Normal delivery 15-4 1 5-7

Other antepartum conditions 1 5-23 15-30

Placenta previa 1 5-21 15-29

Pregnancy and childbirth 1 5-3 1 5-3

Pregnancy, ectopic 15-19 1 5-27

Premature births 15-10 1 5-20

The placenta 15-6 1 5-13

Umbilical cord care 15-5 15-13

Index-1 7
FM 8-230

Paragraph Page
Uterine rupture 1 5-22 1 5-29

Vaginal bleeding and hemorrhage complications 1 5-15, 15-24,

1 5-17 15-26

Oral and nasotracheal suctioning 14-73 14-86

Procedure 14-74 14-87

Oral complex 8-3 8-1

Orthopedic injuries 13-32 13-35

Management of 13-33 13-37

Overdose 13-142 13-155

Amphetamine 13-148 13-158

Treatment 13-149 13-158

Aspirin 13-151 13- 1 59

Signs and symptoms 13-152 13- 1 59

Treatment 13-153 13-159

Hallucinogens and toxic reactions 1 3-150 13-159

Narcotic 13-144 13-156

Sedative/depressant drugs 13-146 1 3-157

Treatment 13-147 13-158

Treatment 13-143, 13-156,

13-145 13-157

Oxygen 14-47 14-50

Administration 1 4-49 1 4-53

Masks and cannulas 14-48 14-50

Safety precautions when handling 02 cylinders 14-50 14-54

Pancreatic islets (islets of Langerhans) 10-5 10-3

Parathyroid gland 1 0-4 10-3

Patient assessment 12-8 12-4

Assesment tools 12-9 12-4

Techniques 1 2-10 12-4

lndex-18
 FM 8-230

Paragraph Page
Patient intake/output 14-70 14-83

Intake measurement procedure 14-71 14-84

Output measurement procedure 1 4-72 14-85

Patient/ surgical preparation 14-60 14-68

Patient isolation 14-64 14-74

Prep for operative treatment 14-61 14-68

Wound irrigation 14-62, 14-70

14-63 14-7 1

Pharmocology and drug administration 18-1 18-1

Administration by aerosol inhalation 18-32 18-46

Administration of ear drops 18-31 18-46

Administration of eye drops and ointments 18-29 18-45

Administration of nose drops 18-30 18-46

Administration by rectal suppository 18-33 18-47

Analgesics 18-35 18-48

Anesthetics 18-36 18-48

Antacids 18-37 18-49

Antibiotics 18-38 18-49

Anti diarrheal agents 18-49 18-52

Anti fungal agents 18-40 18-50

Antihistamines 18-41 18-50

Anti-inflammatory agents 18-48 18-52

Antiparasitic agents 18-42 18-50

Antiseptics 18-43 18-51

Astringents 18-44 18-51

Calculation of dosage 18-12 18-10

18-1 3 18-10

Calculation of intravenous drip rates 18-14 18-1 1

Definitions 18-2 1 8-1

lndex-19
FM 8-230

Paragraph Page
Drug actions 1 8- 1 5 1 8-12

Drug administration 1 8-16, 1 8-12,

1 8- 1 7, 18-12
1 8-18 1 8- 1 3

Drugs in Field Medical Sets 1 8-34 18-48

Drug legislation 1 8-3 1 8-1

Drug preparations 1 8-6 1 8-3

Drug sources 1 8-5 1 8-2

Emetic 18-51 1 8-53

Emollients and protectives 18-46 18-51

Expectorant 18-50 1 8-53

Factors influencing drug dosage

and action 1 8- 1 9 1 8-14

General rules for preparation and

administration 18-2 1 18-16

Inj ections

Intradermal 1 8-27 18-40

Intramuscular 18-26 18-34

Subcutaneous 1 8-25 1 8-31

Medical specialist responsibilities 1 8-20 1 8-16

Metric system and conversions 1 8-9, 1 8-8,

1 8- 1 0, 18-9
1 8- 1 1

Nomenclature 18-4 1 8-2

Oral medications 18-22 1 8-17

Oxidizing agents 18-45 18-5 1

Preparing medications for injection 1 8-23 18-20

Prescriptions 1 8-7 1 8-6

Sulfanamides 1 8-39 1 8-50

Syringe preparation 18-24 18-50

lndex-20
 FM 8-230

Paragraph Page
Tine test 18-28 18-42

Vasoconstrictors 18-47 18-52

Weights and measures 1 8-8 1 8-7

Pituitary body 10-2 10-1

Pharynx 8-4 8-4

Pneumonia 1 3-166 13-166

Poisoning 13-136 1 3- 1 5 1

Treatment, general 13-137 1 3- 1 5 1

Treatment, specific 1 3- 1 38 1 3- 1 53

Poisons, absorbed 13-141 13-155

Pressure, blood 14-3, 14-1

14-19 14- 1 2

Abnormalities 1 4-22 14- 1 3

Influencing factors 1 4-21 1 4- 1 3

Measurement 14-23 1 4-14

Measuring and recording procedures

14-24 14-15
( brachia! artery)

Normal range 14-20 1 4- 1 2

Pulse 1 4-3, 14- 1

14-9 1 4-6

Beat characteristics 1 4- 1 3 1 4-8

Measuring procedures 14-14 14-9

Palpitation 14- 1 1 14-6

Rate 14- 1 2 14-8

Psychological/behavioral problems

Battle fatigue (stress) 21-1 21-1

Emotional reactions 21-4 2 1-2

Lethality and effect on battle fatigue 21-5 2 1 -3

Principles of treatment 21-6 2 1 -3

Index-21
FM 8-230

Paragraph Page
Severity 21-3 2 1-1

Symptoms of battle fatigue 21-7 21-4

Treatment procedures 21-8 2 1-8

Types of reactions to battle fatigue 21-2 21-2

Rape

Caring for victim 1 5-24 1 5-31

Respiration 1 4-3, 14-1

1 4-15 14-10

Breathing patterns 1 4-17 1 4- 1 1

Breathing rates 14-16 14-10

Measuring and recording 14-18 14-12

Respiratory problems, patient history 1 3-158 13-161

Respiratory system 6-1 6-1

Components and subdivisions 6-2 6-1

Rectum 8-9 8-6

Restraining devices 13-123 13-141

Applying 1 3-126 1 3-143

Hazards of 1 3-127 13-147

Preparing to apply 13-125 13-142

Principles for application 13-124 13-141

Sensory organs 1 1-1 1 1-1

Ear 1 1-2 1 1 -1

Eye 1 1 -3 1 1 -4

Septic shock 1 3-67 13-77

Signs and symptoms 13-68 13-77

Treatment 13-69 13-78

Serous cavities 3-5 3-5

Index-22
 FM 8-230

Paragraph Page
Shock 13-54 13-69

Anaphylactic 13-73 13-79

Cardiogenic 13-64 13-77

Hypovolemic 13-56 13-70

Neur.)genic 13-70 13-78

Septic 13-67 1 3-77

Types and causes 13-55 13-69

Sick call 12-20 1 2-17

Conducting 12-21 12-18

Sling 13-51 13-66

Arm sling, shoulder involved 13-53 13-67

Arm sling, shoulder not involved 1 3-52 1 3-66

Skeletal system 4-1 thru 4-1 - -

4-5 4-4

Spinal injuries 13-29 13-28

Signs and symptoms 13-30 1 3-28

Treatment 13-31 13-29

Splinting and immobilization 1 3-34 13-40

Sphnts, types of 13-35 13-41

Stomach 8-6 8-5

Suicide �1-15 thru 21-8--

21-19 21-24

Supralaryngeal structures 6-3 6-3

Suprarenal (adrenal) glands 10-6 10-3

Temperature 14-4 14-1

Body 14-4 14-1

Measuring 14-5 14-2

lndex-23
FM 8-230

Paragraph Page
14-86 14-105
Therapeutic bath

14-87 14-105
Administering the bath

14-89 14-107
Completion of the sponge bath

14-88 14-106
Field expedient bath

Thermometer

14-8 1 4-5
Care (clinical)

14-9 14-6
Care (field expedient)

14-7 14-3
Clinical

14-6 14-2
Reading

10-3 10-3
Thyroid gland
Tissues 2-4 2-8

Connective 2-5 2-9

Fascia! 3-4 3-3

Muscle 2-6 2-9

Nervous 2-7 2-10

Triage 1 2-1 12-1

Categories 12-7 12-3

Examination 1 2- 1 1 , 1 2-4
12-13 12-6

Multiple injured patients 12-3_, 12-1,

1 2-5 12-2

Principles of 12-2 12-1

Secondary surveys 12-4 1 2-2

Sorting 1 2-6 12-3

Troop medical clinic 12- 1 7 12-14

Accident reporting 12-24 12-24

Continuing treatment 12-22 12-21

Emergency treatment, general instructions 12-23 12-22

lndex-24
 FM 8-230

Paragraph Page
Patient receiving 1 2-19 12-15

Records activities 1 2-19 1 2-16

Routine duties 12-18 12-15

Urogenital system 9-1 9-1

Ureters 9-4 9-3

Urethra 9-6 9-3

Urination 9-8 9-3

Urinary bladder 9-5 9-3

Urinary system 9-2 9-1

Urine 9-7 9-3

Vital signs 12-12 12- 5

Inde:x:-25
 FM 8-230

24 A U G UST 1 984

By O rder of the S ecretary of the Army:

J O H N A. WICKHAM, J R .
General, United States A rmy
Chief of Staff

Offici a l :

ROBERT M . J OYCE
Major General United States A rmy
The A djutant General

DISTRIBUTIO N :

A ctive A rmy, ARNG, andUSAR: To be distributed i n accordance with DA Form 1 2 · 1 1 A, R eq u i re­

me nts for the Field -Medica l Support Guitie (Qty rqr block no. 83).

Additiona l copies may be req u i s it i o n ed fro m the US Army Adjutant G eneral Publications Center,
2800 Eastern Bou levard, B a ltimore, M D 2 1 22 0 .