Page 44 - 2021 Advanced Ranger First Responder Handbook

Tactical Damage Control Resuscitation
Extended Care
Prevention of hypovolemic shock (inadequate tissue perfusion) is critical in a trauma casualty. Shock can be thought
of as a pause in the act of dying and requires aggressive actions to prevent its progression. Once a casualty has pro-
gressed to shock, he is susceptible to the lethal triad of coagulopathy, hypothermia, and acidosis. Early preventative
actions can delay hypothermia. Controlling blood loss and appropriate blood product administration can delay the
progress of coagulopathy.

TCCC Application
Care Under Fire: Stop life-threatening bleeding.
Tactical Field Care: The first priority is to stop any active hemorrhage. Initiate IV access if indicated. Start an 18G or
larger IV or saline lock. If resuscitation is required and IV access is not obtainable, use the intraosseous (IO) route. Assess
for hemorrhagic shock; decreased mental status (in the absence of head injury) and weak or absent peripheral pulses
are the best field indicators of shock. If indicated by assessment, initiate fluid resuscitation. If not in shock, resuscitation
is not necessary. If in shock, administer whole blood or blood products in a 1:1 ratio. Repeat if still in shock. Warm fluids
are preferred if IV fluids are required. Be aware of warmer constraints as applying pressure to increase flow may cause
ineffective warming and cell lysis. Continued efforts to resuscitate must be weighed against logistical and tactical con-
siderations and the risk of incurring further casualties. If a casualty with TBI is unconscious and has no peripheral pulse,
resuscitate to restore the radial pulse. Prevention of hypothermia is critical in a shock patient. Minimize casualty’s expo-
sure to the elements. Keep protective gear on or with the casualty if feasible. Replace wet clothing with dry if possible.
Get the casualty onto an insulated surface as soon as possible. Apply the Ready-Heat Blanket from the Hypothermia
Prevention and Management Kit (HPMK) to the casualty’s torso (not directly on the skin) and cover the casualty with the
Heat-Reflective Shell (HRS). If an HRS is not available, the combination of any blanket and the Ready-Heat blanket may
also be used. If the items mentioned above are not available, use dry blankets, poncho liners, sleeping bags, or anything
that will retain heat and keep the casualty dry.
TXA Administration: If a casualty is anticipated to need a blood transfusion (e.g., presents with hemorrhagic shock,
one or more major amputations, penetrating torso trauma, or evidence of severe bleeding). Administer 2g of TXA as an
IV/IO flush as soon as possible but not later than 3 hours after injury. Record on CAX Card “2g TXA given.” Drug must
be properly maintained between 15°C and 30°C/59°F to 86°F. Do not delay blood product resuscitation for a trauma
patient in shock in order to administer TXA.
Tactical Evacuation: Reassess need for IV access if not previously established. Reassess for hemorrhagic shock. If not
in shock, then no IV fluids are necessary. Avoid PO fluids for casualties requiring surgical intervention. Continue resusci-
tation with whole blood. If a casualty with TBI is unconscious and has a weak or absent peripheral pulse, resuscitate as
C necessary to maintain a systolic blood pressure of 110mmHg or above. Prevention of hypothermia is even more critical
for a trauma patient in moving vehicles or aircraft. Keep protective gear on or with the casualty if feasible. Remove and
replace wet clothing with dry if possible. Get the casualty onto an insulated surface as soon as possible. Apply external
warming devices as depicted in tactical field care if not already accomplished. Use a portable fluid warmer capable of
warming all IV fluids including blood products. Protect the casualty from wind if doors must be kept open.
Extended Care
Fluid Management: Continue resuscitation with whole blood or blood products as indicated. Maintain a palpable radial
pulse or systolic blood pressure of 90–100mmHg in all unconscious patients with noncompressible, internal hemor-
rhage. Maintain a normal radial pulse character or systolic blood pressure > 110mmHg in TBI patients with altered
mental status.
Ranger O Low (ROLO) Transfusion: All life-saving TCCC protocols and procedures should be completed while ARFRs
obtain blood for transfusion. Evacuation should not be delayed for field transfusions. ROLO may be considered for
trauma casualties showing signs of hemorrhagic shock; shock from internal, noncompressible, or uncontrollable bleed-
ing; massive blood loss with tachypnea, tachycardia, systolic hypotension and altered mental status; or extended
evacuation.

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