Page 137 - Journal of Special Operations Medicine - Fall 2014

a. Reassess need for IV access.
– If indicated, start an 18-gauge IV or saline lock.
– If resuscitation is required and IV access is not obtainable, use intraosseous (IO) route.
5. 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.
6. Traumatic Brain Injury
a. Casualties with moderate/severe TBI should be monitored for:
1. Decreases in level of consciousness
2. Pupillary dilation
3. SBP should be >90mmHg
4. O sat > 90
2
5. Hypothermia
6. Pco (If capnography is available, maintain between 35–40mmHg)
2
7. Penetrating head trauma (if present, administer antibiotics)
8. Assume a spinal (neck) injury until cleared.
b. Unilateral pupillary dilation accompanied by a decreased level of consciousness may signify impending cerebral hernia-
tion; if these signs occur, take the following actions to decrease intracranial pressure:
1. Administer 250mL of 3% or 5% hypertonic saline bolus.
2. Elevate the casualty’s head 30 degrees.
3. Hyperventilate the casualty.
a) Respiratory rate 20
b) Capnography should be used to maintain the end-tidal CO between 30–35
2
c) The highest oxygen concentration (Fio ) possible should be used for hyperventilation.
2
*Notes:
– Do not hyperventilate unless signs of impending herniation are present.
– Casualties may be hyperventilated with oxygen using the bag-valve-mask technique.
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

TCCC Updates 129