Page 22 - Journal of Special Operations Medicine - Fall 2014

the resuscitation of casualties who are in hemorrhagic co-chaired by COL John Holcomb and Dr Howard
shock during TCCC. Champion and produced the 2003 TCCC fluid resusci-
tation guidelines below 10,11 :
Background
1. Assess for hemorrhagic shock; altered mental sta-
New concepts in resuscitation from hemorrhagic shock tus (in the absence of head injury) and/or weak or
(or renewed interest in older concepts) have been emerging absent peripheral pulses are the best field indicators
in recent years. A report from 1993 noted that initial of shock;
resuscitation for hemorrhagic shock in trauma patients 2. If the casualty is not in shock, then no IV fluids are
was done almost exclusively with crystalloids. A 2013 indicated;
3
report on fluid resuscitation included a statement that 3. Oral (PO) fluids are permissible if the casualty is
minimization of crystalloids is a widely adopted practice conscious and can swallow;
in the resuscitation of patients suffering from hemor- 4. If in shock, administer a 500mL bolus of Hextend:
rhagic shock. How did we make the journey between Repeat once after 30 minutes if the casualty is still in
4
these two positions? shock. In general, do not give more than 1000mL of
Hextend.
When the first TCCC report was being written, the rec-
ommended prehospital fluid resuscitation per the Ad- The fluid resuscitation guidelines just outlined are still in
vanced Trauma Life Support (ATLS) course was 2L of use by the US military. This approach to battlefield fluid
crystalloid (normal saline [NS] or lactated Ringer’s solu- resuscitation was revisited by an MRMC-sponsored
tion [LR]). The Ben Taub report published in 1994, how- conference on this topic held in January 2010. Sixty-five
5
ever, found that large-volume crystalloid resuscitation participants with expertise in fluid resuscitation were in-
for hypotensive patients with penetrating torso trauma vited to present and to review the evidence in favor of or
prior to definitive surgical repair of the bleeding site pro- refuting the “hypotensive resuscitation with Hextend”
duced a significantly lower survival rate compared with strategy. A consensus document was produced and no
that obtained from delaying aggressive volume replace- change to this approach to battlefield fluid resuscitation
ment until after surgical control of the bleeding. Based was recommended. Note that by this point in time,
12
6
on this study, with supporting data from multiple animal packed RBCs (PRBCs) had also been recommended for
studies, the original TCCC recommendations regarding use if available in the TACEVAC phase of care.
13
fluid resuscitation on the battlefield were:
The most recent change to fluid resuscitation in TCCC
1. Obtaining intravenous (IV) access and fluid resusci- was proposed by CAPT Jeff Timby and adopted by
tation should be delayed until TFC; the Committee on Tactical Combat Casualty Care
2. No IV lines or IV fluids were recommended for casu- (CoTCCC) in 2011. Additional elements added by this
14
alties not in shock; change included:
3. No IV fluids were recommended for casualties in
shock resulting from uncontrolled hemorrhage; 1. In TFC, if a casualty with altered mental status due
4. 1000mL of Hespan was recommended as initial to suspected TBI has a weak or absent peripheral
treatment for casualties in shock resulting from hem- pulse, resuscitate as necessary to maintain a palpable
orrhage that has been controlled; and radial pulse.
5. The recommended maximum volume of Hespan was 2. The concept of 1:1 plasma and RBC resuscitation
1500mL. 7,8 during the TACEVAC phase of care was incorpo-
rated. The use of FWB was also recommended as a
The expert panel that was convened by the US Special secondary option if combat medical personnel are
Operations Command in 1999 to discuss the US casual- trained in this technique and an approved protocol
ties in the battle of Mogadishu, however, recommended is in place.
unanimously that casualties with a decreased state of 3. BP monitoring should be available in TACEVAC and
consciousness resulting from hemorrhagic shock should should be used to guide resuscitation in this phase of
be resuscitated with fluids immediately. The consensus care. The target systolic BP (SBP) is 80 to 90mmHg
approach was to restore some measure of perfusion with- unless TBI is present, in which case the target SBP is
out raising the BP sufficiently to disrupt a forming clot 90mmHg or higher.
or create a dilutional coagulopathy. This approach was 4. If blood products are not available in this phase of
9
echoed in a series of jointly sponsored US Army Medical care and 1000mL of Hextend has been administered,
Research and Materiel Command (MRMC) and Office continue resuscitation with Hextend or crystalloid
of Naval Research (ONR) Fluid Resuscitation Confer- solution as needed to maintain the target BP or to
ences held in 2001 and 2002. These conferences were produce clinical improvement.

14 Journal of Special Operations Medicine Volume 14, Edition 3/Fall 2014