Page 21 - Journal of Special Operations Medicine - Fall 2014

Fluid Resuscitation for Hemorrhagic Shock
in Tactical Combat Casualty Care

TCCC Guidelines Change 14-01 – 2 June 2014

Frank K. Butler, MD; John B. Holcomb, MD; Martin A. Schreiber, MD;
Russ S. Kotwal, MD; Donald A. Jenkins, MD; Howard R. Champion, MD, FACS, FRCS;
F. Bowling; Andrew P. Cap, MD; Joseph J. Dubose, MD; Warren C. Dorlac, MD;
Gina R. Dorlac, MD; Norman E. McSwain, MD, FACS; Jeffrey W. Timby, MD;
Lorne H. Blackbourne, MD; Zsolt T. Stockinger, MD; Geir Strandenes, MD;
Richard B, Weiskopf, MD; Kirby R. Gross, MD; Jeffrey A. Bailey, MD

ABSTRACT
This report reviews the recent literature on fluid re- Proximate Cause for This Proposed Change
suscitation from hemorrhagic shock and considers the Since the last update to the fluid resuscitation recommen-
applicability of this evidence for use in resuscitation dations in the TCCC Guidelines in November 2011, there
of combat casualties in the prehospital Tactical Com- have been a number of publications related to hypoten-
bat Casualty Care (TCCC) environment. A number of sive resuscitation, the use of DP, adverse effects resulting
changes to the TCCC Guidelines are incorporated: (1) from the administration of both crystalloids and colloids,
dried plasma (DP) is added as an option when other prehospital resuscitation with thawed plasma and red
blood components or whole blood are not available; blood cells (RBCs), resuscitation from combined hemor-
(2) the wording is clarified to emphasize that Hextend rhagic shock and traumatic brain injury (TBI), balanced
is a less desirable option than whole blood, blood com- blood component therapy in DCR, the benefits of fresh
ponents, or DP and should be used only when these whole blood (FWB) use, and resuscitation from hemor-
preferred options are not available; (3) the use of blood rhagic shock in animal models where the hemorrhage is
products in certain Tactical Field Care (TFC) settings definitively controlled prior to resuscitation.
where this option might be feasible (ships, mounted
patrols) is discussed; (4) 1:1:1 damage control resus- Additionally, recently published studies describe an
citation (DCR) is preferred to 1:1 DCR when platelets increased use of blood products by coalition forces in
are available as well as plasma and red cells; and (5) Afghanistan during Tactical Evacuation (TACEVAC)
the 30-minute wait between increments of resuscitation Care and even in TFC. Resuscitation with RBCs and
fluid administered to achieve clinical improvement or plasma has been associated with improved survival on
target blood pressure (BP) has been eliminated. Also the platforms that use them, even in the relatively short
included is an order of precedence for resuscitation evacuation times seen in Afghanistan in recent years.
1,2
fluid options. Maintained as recommendations are Prehospital blood products may have an increasingly im-
an emphasis on hypotensive resuscitation in order to portant impact on survival if evacuation times lengthen
minimize (1) interference with the body’s hemostatic as the drawdown in Afghanistan continues and if the US
response and (2) the risk of complications of overre- military is called on to conduct operations in less mature
suscitation. Hextend is retained as the preferred option theaters of conflict. Future conflicts in other geographic
over crystalloids when blood products are not available combatant commands such as the US Pacific Command
because of its smaller volume and the potential for long (PACOM), the US Southern Command (SOUTHCOM),
evacuations in the military setting.
and the US Africa Command (AFRICOM) may have
prolonged evacuation times and may include the need
Keywords: hemorrhage, fluid resuscitation, shock, plasma, to consider preevacuation treatment aboard ships at sea.
blood products, damage control resuscitation

This review presents the recent literature on fluid re-
suscitation and makes updated recommendations for

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