Page 133 - Journal of Special Operations Medicine - Fall 2014

b. For compressible hemorrhage not amenable to tourniquet use or as an adjunct to tourniquet removal (if evacuation time
is anticipated to be longer than 2 hours), use Combat Gauze as the CoTCCC hemostatic dressing of choice. Celox Gauze
and ChitoGauzemay also be used if Combat Gauze is not available. Hemostatic dressings should be applied with at least 3

minutes of direct pressure. Before releasing any tourniquet on a casualty who has been resuscitated for hemorrhagic shock,
ensure a positive response to resuscitation efforts (i.e., a peripheral pulse normal in character and normal mentation if
there is no traumatic brain injury (TBI). If the bleeding site is appropriate for use of a junctional tourniquet, immediately
apply a CoTCCC-recommended junctional tourniquet. Do not delay in the application of the junctional tourniquet once
it is ready for use. Apply hemostatic dressings with direct pressure if a junctional tourniquet is not available or while the
junctional tourniquet is being readied for use.
c. Reassess prior tourniquet application. Expose wound and determine if tourniquet is needed. If so, replace tourniquet over
uniform with another applied directly to skin 2–3 inches above wound. If a tourniquet is not needed, use other techniques
to control bleeding.
d. When time and the tactical situation permit, a distal pulse check should be accomplished. If a distal pulse is still present,
consider additional tightening of the tourniquet or the use of a second tourniquet, side by side and proximal to the first,
to eliminate the distal pulse.
e. Expose and clearly mark all tourniquet sites with the time of tourniquet application. Use an indelible marker.
5. Intravenous (IV) access
– Start an 18-gauge IV or saline lock if indicated.
– If resuscitation is required and IV access is not obtainable, use the intraosseous (IO) route.
6. Tranexamic Acid (TXA)
If a casualty is anticipated to need significant blood transfusion (for example: presents with hemorrhagic shock, one or more
major amputations, penetrating torso trauma, or evidence of severe bleeding):
– Administer 1g of tranexamic acid in 100mL normal saline or lactated Ringer’s as soon as possible but NOT later than 3
hours after injury.
– Begin second infusion of 1g TXA after Hextend or other fluid treatment.
7. Fluid resuscitation
a. The resuscitation fluids of choice for casualties in hemorrhagic shock, listed from most to least preferred, are: whole
blood*; plasma, RBCs, and platelets in 1:1:1 ratio*; plasma and RBCs in 1:1 ratio; plasma or RBCs alone; Hextend; and
crystalloid (lactated Ringer’s or Plasma-Lyte A).
b. Assess for hemorrhagic shock (altered mental status in the absence of brain injury and/or weak or absent
radial pulse).
1. If not in shock:
– No IV fluids are immediately necessary.
– Fluids by mouth are permissible if the casualty is conscious and can swallow.
2. If in shock and blood products are available under an approved command or theater blood product administration
protocol:
– Resuscitate with whole blood*; or, if not available,
– Plasma, RBCs, and platelets in a 1:1:1 ratio*; or, if not available,
– Plasma and RBCs in 1:1 ratio; or, if not available
– Reconstituted dried plasma, liquid plasma, or thawed plasma alone or RBCs alone;
– Reassess the casualty after each unit. Continue resuscitation until a palpable radial pulse, improved mental status
or systolic BP of 80–90mmHg is present.
3. If in shock and blood products are not available under an approved command or theater blood product administration
protocol due to tactical or logistical constraints:
– Resuscitate with Hextend; or if not available,
– Lactated Ringer’s or Plasma-Lyte A;
– Reassess the casualty after each 500mL IV bolus;
– Continue resuscitation until a palpable radial pulse, improved mental status, or systolic BP of 80–90mmHg is
present.
– Discontinue fluid administration when one or more of the above end points has been achieved.
4. If a casualty with an altered mental status due to suspected TBI has a weak or absent peripheral pulse, resuscitate as
necessary to restore and maintain a normal radial pulse. If BP monitoring is available, maintain a target systolic BP of
at least 90mmHg.
5. Reassess the casualty frequently to check for recurrence of shock. If shock recurs, recheck all external hemorrhage
control measures to ensure that they are still effective and repeat the fluid resuscitation as outlined above.
*Neither whole blood nor apheresis platelets as these products are currently collected in theater are FDA-compliant. Conse-
quently, whole blood and 1:1:1 resuscitation using apheresis platelets should be used only if all of the FDA-compliant blood
products needed to support 1:1:1 resuscitation are not available, or if 1:1:1 resuscitation is not producing the desired clinical
effect.
8. Prevention of hypothermia
a. Minimize casualty’s exposure to the elements. Keep protective gear on or with the casualty if feasible.

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