Holding (Silver 48)
Mission
Holding receives casualties from STP or FRSS and manages them through a defined window — nominally up to 48 hours — until they can be evacuated to higher echelon. The mission is physiological stabilization, ongoing resuscitation as needed, vigilance for missed injuries and post-operative complications, and preparation for transport.
The “Silver 48” designator refers to the standard 48-hour holding capability.
Personnel & Task Organization
- Holding officer in charge: typically a Family Medicine, Internal Medicine, or Critical Care-capable physician.
- Critical care nurse(s): continuous monitoring; medication administration; family liaison if applicable.
- ICU corpsmen: bedside care; vitals; documentation.
- Respiratory therapy capability: where available, integrated; otherwise covered by cross-trained personnel.
24-hour coverage requires shift planning that protects sleep and enables sustained vigilance.
Equipment & Logistics
- Monitored beds with continuous vital signs capability.
- Ventilator capability for ventilated patients.
- Oxygen sustainment (sufficient for the holding duration plus contingency margin).
- Medication management with controlled-substance accountability.
- Blood products available for ongoing transfusion needs.
- Active and passive warming for hypothermia management.
- Pressure-area care and basic mobilization equipment.
- Documentation surface, ICU flow sheets, MAR.
AMAL:
Doctrinal References
- MCRP 4-11.1G
- JTS CPG: Damage Control Resuscitation (continued in Holding, 12 Jul 2019)
- JTS CPG: Prolonged Casualty Care Guidelines (21 Dec 2021)
- JTS CPG: Ventilator Management
- JTS CPG: Pain, Anxiety, and Delirium (26 Apr 2021)
- JTS CPG: Acute Kidney Injury
Clinical Practice Guidelines
Post-resuscitative bundle. Analgesia and sedation protocols. Re-evaluation cadence for missed injuries (tertiary survey at 24 hours).
Decision Points
| Decision | Trigger | Outcome |
|---|---|---|
| Transition to Prolonged Holding (Zinc 48) | Evac delay extends beyond standard 48-hour window | Prolonged Holding |
| Return to OR | Bleeding; abdominal compartment syndrome; missed injury | FRSS/DCS |
| Evacuation readiness | Physiologic stability adequate for the planned transport | EVAC |
| Expectant transition | Post-op deterioration without recoverable trajectory; MASCAL pressure on resources | T4 — Mortuary Affairs disposition with documentation |
| Tertiary survey | At 24 hours or when patient is stable and awake | Identify missed injuries; document and address |
Linked ELOs
| TLO | ELO | Primary or Secondary |
|---|---|---|
| Prepare to Receive | PR-6 (individual patient management) | Primary |
| Prepare to Receive | PR-7 (patient holding plan) | Primary |
| Clinical Ops | CO-10 (blood management — sustainment) | Primary |
| Clinical Ops | CO-11 (narcotics management) | Primary |
| Clinical Ops | CO-14 (clinical decision-making) | Primary |
| Trauma Integration | TI-5 (documentation/reporting) | Primary |
| Trauma Integration | TI-6 (patient tracking) | Primary |
| Team Development | TD-7 (ethics — expectant management) | Primary |
Forms & Documentation
- ICU flow sheet.
- Medication Administration Record (MAR).
- Tertiary survey documentation.
- Transfer summary template for receiving facility.
Reference Imagery
Last reviewed: • OPSEC reviewed: