Page 112 - JSOM Winter 2025

Specific TCCC Interventions in the fluid administered would remain intravascular for a much
Civilian Pre-Hospital Trauma Care longer period of time than would be the case with crystalloid
As of 2021, many of the above TCCC recommendations are in (Butler 1996).
various stages of transition to the civilian sector. Tourniquets have These initial recommendations continued to evolve throughout
probably been the best example of a successful translation, largely the course of the conflicts in Iraq and Afghanistan as evidence
because of the ease with which external hemorrhage can be iden- from those conflicts became available (Butler 2014, Butler 2007,
tified as well as the ease with which tourniquets can be applied Holcomb 2007). The repositioning of the Committee on TCCC
when needed, but also because of the pioneering efforts of Dr. from the Defense Health Board to the Joint Trauma System in
Jacobs, the Hartford Consensus Group, and the American College 2013 strengthened its ties with the military trauma surgery and
of Surgeons discussed previously.
critical care communities who were responsible for the in-hospital
Prior to the onset of hostilities in Afghanistan in 2001, because of advances in trauma care, including a shift from predominantly red
the widespread and erroneous belief that the risks of tourniquet blood cell (RBC) resuscitation, to a balanced approach using a
use outweighed the benefits, civilian tourniquet use was essentially 1:1:1 volume ratio of plasma:RBCs:platelets and later to the pref-
non-existent. TCCC was virtually the only entity advocating for erential use of low-titer O whole blood (LTOWB.) The life-saving
their prehospital use in trauma patients. By 2008, tourniquet use benefits of whole blood in the resuscitation of combat casualties
was ubiquitous in the U.S. military, but still was not incorporated in hemorrhagic shock has now been well-documented (Gurney
into civilian prehospital trauma care. In their 2019 paper, Good- 2021, Gurney 2020, Holcomb 2018, Gurney 2018, Butler 2018,
win and her co-authors examined the National Emergency Medi- Spinella 2017, Cap 2015, Butler 2014, Strandenes 2014, Spinella
cal Services (NEMSIS) database for the years 2008 through 2016. 2009, Borgman 2007, Butler 2007, Holcomb 2003).
The authors noted that in the years 2008 and 2009, in 8,940,451 The recent conflicts have also provided evidence that whole blood
EMS activations in the civilian sector, there were exactly 0 in- and blood products improve survival when administered in the
stances of tourniquet use. By 2016, there were 3995 instances of prehospital phase of care and thus should be administered as soon
tourniquet use in 29,919,652 EMS activations. The authors attri- as possible when indicated (Gurney 2022, Deaton 2021, Shack-
bute this dramatic change directly to the TCCC initiative, noting elford 2021, Black 2020, Butler 2018, Shackelford 2017, Butler
that:
2017, Butler 2014, Apodaca 2013, Morrison 2013).
Over the past two decades, the early and judicious use of Shackelford et al. reviewed the records of 502 casualties from Af-
tourniquets for prompt control of life-threatening extremity ghanistan and found that—quite literally—minutes matter. When
hemorrhage has become the cornerstone of the US military’s casualties required a transfusion of either whole blood or blood
Tactical Combat Casualty Care (TCCC) program. It has sub- components, the earlier they got them, the better their chances
stantially improved survival, particularly from compressible of surviving were, both at 24 hours and 30 days after wounding
sites of hemorrhage and what were deemed “preventable (Shackelford 2017).
deaths.” (Goodwin 2019)
Later Gurney et al. published several studies designed to deter-
It is not known how many potentially preventable deaths have mine the impact of fresh whole blood as compared to blood
occurred because of the lack of prehospital tourniquet use over the components in improving the survival of casualties who required
years, but there have been numerous papers that clearly document transfusions. The researchers found that for severely injured ca-
the lifesaving benefits of civilian tourniquet use in the recent past sualties the risk of death was almost three times as great in those
(Bulger 2021, Henry 2021, Teixeira 2018, Scerbo 2017, Scerbo casualties who did not receive fresh whole blood (Gurney 2022,
2016, Leonard 2016, Inaba 2015, Snyder 2014, Bulger 2014). De- Gurney 2021, Gurney 2020).
spite the well-documented success of tourniquets at saving lives in
the civilian sector at this point in time, a December 2021 paper The use of whole blood when feasible and RBCs or plasma when
by Bulger noted that in the area surveyed in her study, “Although whole blood is not available may have a much larger impact on
they observed an increase in the use of tourniquets over time, it is casualty survival in future conflicts that may see U.S. troops con-
concerning that overall, only 10% of the cohort received a tourni- ducting combat operations in less mature theaters of conflict than
quet, and in the last year of the study, 2019, only 18% received a Iraq and Afghanistan were in the later years of those wars. Mil-
tourniquet.” (Bulger 2021). itary operations in the U.S. IndoPacific Command in particular
may include shipboard casualties who may have prolonged evacu-
Another TCCC intervention that has translated well into the ci- ation times to a surgical capability.
vilian EMS setting is hemostatic dressings. After having been a
research priority for the U.S. military since the Battle of Moga- On the civilian side, there is starting to be movement away from
dishu (Holcomb 2015, Mabry 2000), hemostatic dressings were the old prehospital fluid resuscitation paradigm of large volume
developed and tested at military medical research laboratories crystalloid. The recognition of LTOWB as a favorable option for
and widely used by combat troops after several years of conflict the resuscitation by civilian organizations such as the American
in Afghanistan and Iraq (Holcomb 2015, Butler 2007). Absent Association of Blood Banks (Yazer 2018) has increased the visi-
from civilian trauma systems prior to their being recommended by bility of this option in the civilian sector and a growing number
TCCC, hemostatic dressings are now widely reported to be used of civilian EMS agencies have recognized that whole blood and
and of benefit in controlling external hemorrhage in the civilian other blood products offer a distinct survival benefit over large
sector (Sigal 2017, Güven 2017, Te Grotenhuis R 2016 , Leon- volume crystalloid solutions in the civilian sector (Sayre 2021,
ard 2016, Travers 2015, Zietlow 2015, Davis 2014, Smith 2013, Yazer 2021).
Brown 2009).
In 2021, Guyette and colleagues conducted a comparison of re-
Prehospital fluid resuscitation for trauma victims in hemorrhagic suscitation with electrolyte solution to resuscitation with blood
shock is a third example of military prehospital innovations products in severely injured patients who were transported by 27
translating well to the civilian sector. The prevailing wisdom helicopter emergency medical services, Prehospital administra-
regarding prehospital fluid resuscitation when the TCCC effort tion of plasma and red blood cells was found to reduce mortality
began in 1992 was to administer large volumes of crystalloid (2 by 62% in comparison to electrolyte solutions (Guyette 2021).
liters of normal saline or lactated Ringers.) The TCCC research- Hashmi et al. reported that the proportion of American College
ers found that this approach was not well-supported by the best of Surgeons-verified trauma centers transfusing whole blood for
evidence available at the time and recommended a different ap- trauma patients was 16.7% (45/269) in 2015; that percentage
proach to prehospital fluid resuscitation, limiting the amount of had increased to 24.5% (123/502) by the first quarter of of 2020
crystalloid administered and using hetastarch solutions so that (Hashmi 2021).

110 | JSOM Volume 25, Edition 4 / Winter 2025