Page 127 - Journal of Special Operations Medicine - Summer 2014

noted that there is now a multinational prehospital rate) were again achieved with 5% albumin resuscita-
transfusion registry in development. tion. No significant difference found among other fluids
(survival rates 10–25%).
Norwegian Far­Forward Blood/Plasma Program
These study results suggest that albumin is a better
CDR Geir Strandenes choice than artificial colloids (Hextend, Voluven) and
some crystalloids for prehospital resuscitation from
CDR Strandenes is the physician for the Norwegian Na- hemorrhagic shock in this parenchymal bleeding model.
val Special Operations Commando (NORNAVSOC).
His unit has developed a training and research program Drs. Champion and Butler noted, however, that albumin
for the use of whole blood and freeze-dried plasma is not recommended for use in casualties with traumatic
(FDP) as primary resuscitation fluids for hemorrhagic brain injury (TBI) because of the increase in mortality
shock. NORNAVSOC’s protocol for prehospital use of associated with albumin use in patients with both severe
fresh whole blood/cold stored whole blood in combat TBI and hemorrhagic shock. This would be problematic
casualties has recently been accepted for publication.
in considering albumin for battlefield use, where shock
and TBI are often present in the same casualties.
CDR Strandenes related that his experience is that if
an intraosseous site is to be used to transfuse blood via
gravity only, the sternum is clearly the preferred site. PHTLS TCCC Courses
His research has demonstrated that a donor’s ability to Mr. Mark Lueder
perform combat skills is maintained immediately after
the donation of a unit of whole blood. The advances in Mr. Lueder from the Prehospital Trauma Life Support
prehospital blood and plasma administration pioneered (PHTLS) Executive Committee observed that PHTLS
by NORNAVSOC are now being transitioned to the He- began to be taught in TCCC courses in 2010 and that
licopter Emergency Medical System in Norway. NAEMT has contributed significant resources, both per-
sonnel and funds, to develop TCCC teaching sites. There
are now two PHTLS TCCC courses—a 2-day course for
Hemostatics Resuscitation R&D
medical personnel and a 1-day course for nonmedical
Dr. Bijan Kheirabadi personnel. PHTLS at this point has more than 350 certi-
fied TCCC instructors and has taught the course in 26
Dr. Kheirabadi from the USAISR described his recent countries. Activity is very heavy on the TCCC portion of
research on resuscitation fluids in an animal model of the NAEMT website, and the TCCC precourse was com-
noncompressible hemorrhage. Resuscitation was accom- pletely sold out at the EMS Expo last year in Las Vegas.
plished with Hextend, Dextran 70, or albumin. Hex tend
and Dextran 70 were both observed to impair coagu-
lation, whereas albumin did not. Survival was none of CoTCCC under the JTS—The Way Ahead
eight of the Hextend animals, two of eight of the Dextran Dr. Frank Butler
70 animals, and four of eight of the albumin group. Dr.
Kheirabadi noted that the animals in this study received Dr. Frank Butler discussed the functioning of the
a much larger dose of Hextend based on body mass than CoTCCC now that it is a component of the JTS instead
would have been recommended by TCCC. of the Defense Health Board. One important aspect re-
mains unchanged: the TCCC Guidelines produced by
In subsequent studies using the same noncompressible the CoTCCC are evidence-based, best-practice battle-
hemorrhage model, animals (rabbits) were resuscitated field trauma care guidelines, but they are only recom-
with a limited volume of freeze-dried plasma (FFP), 5% mendations. Turning best-practice guidelines into lives
albumin, and Hextend according to the battlefield re- saved requires action on the part of both senior line
suscitation protocol (15mL/kg in two bolus injections) commanders and medical leaders in the military.
to a hypotensive target pressure. The survival rates were
40% (4 of 10) for FFP and Hextend but 90% (8 of 9) A number of recent preventable deaths and preventable
for albumin, with the least amount of blood loss and adverse outcomes in U.S. casualties have emphasized the
lower shock indices. In the next experiments, animals need for better strategic TCCC messaging and improved
were resuscitated by the same method (two bolus injec- interaction with the services and with combatant com-
tions targeted to a hypotensive pressure) using a new mands. TCCC will never have maximum effectiveness
synthetic colloid (Voluven, 15mL/kg) or crystalloids for U.S. Forces until line commanders make it part of
(normal saline [NS], 30mL/kg or 5% hypertonic saline their warrior culture, as was done in the 75th Ranger
[HS], 7.5mL/kg) and compared with 5% albumin. The Regiment. Specific actions proposed to help enable this
best results (lowest blood volume and highest survival transition include:

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