Page 38 - Journal of Special Operations Medicine - Fall 2014

has been shown to decrease patient survival com- Reassess for hemorrhagic shock (altered mental sta-
pared with resuscitation with restricted volumes of tus in the absence of brain injury and/or change in
crystalloid. pulse character.) If BP monitoring is available, main-
9. Larger volumes of infused crystalloids have also tain target systolic BP 80–90mmHg.
been associated with increased mortality in trauma a. If not in shock:
patients in studies where the authors did not cat- – No IV fluids necessary.
egorize patients by controlled versus uncontrolled – PO fluids permissible if conscious and can
hemorrhage. swallow.
10. The smaller required volume and sustained intra- b. If in shock and blood products are not available:
vascular presence of Hextend as recommended by – Hextend 500mL IV bolus
TCCC is important to combat medical personnel – Repeat after 30 minutes if still in shock.
who treat casualties in austere environments where – Continue resuscitation with Hextend or crys-
evacuation times may be prolonged. Hextend may talloid solution as needed to maintain target BP
also decrease complications of crystalloid resuscita- or clinical improvement.
tion such as ARDS and ACS, but does not decrease c. If in shock and blood products are available under
the dilutional coagulopathy caused by crystalloid an approved command or theater protocol:
resuscitation. – Resuscitate with 2 units of plasma followed
11. When tactical and logistical constraints prevent the by PRBCs in a 1:1 ratio. If blood component
use of the recommended blood products, hypoten- therapy is not available, transfuse fresh whole
sive resuscitation with Hextend as outlined in the blood. Continue resuscitation as needed to
current TCCC guidelines should continue to be maintain target BP or clinical improvement.
used for the resuscitation of casualties in hemor- d. If a casualty with an altered mental status due
rhagic shock. to suspected TBI has a weak or absent periph-
12. The emerging evidence on hetastarch use and acute eral pulse, resuscitate as necessary to maintain
kidney injury has not documented a problem with a palpable radial pulse. If BP monitoring is
Hextend use for the indication (hemorrhagic shock) available, maintain target systolic BP of at least
and in the volumes recommended by TCCC. 90mmHg.

PROPOSED CHANGE TO THE TCCC GUIDELINES PROPOSED CHANGE
Current Wording Tactical Field Care and TACEVAC Care
7. Fluid resuscitation
Tactical Field Care
a. The resuscitation fluids of choice for casualties
7. Fluid resuscitation in hemorrhagic shock, listed from most to least
Assess for hemorrhagic shock; altered mental status preferred, are: whole blood*; plasma, RBCs and
(in the absence of head injury) and weak or absent platelets in 1:1:1 ratio*; plasma and RBCs in 1:1
peripheral pulses are the best field indicators of shock. ratio; plasma or RBCs alone; Hextend; and crys-
a. If not in shock: talloid (lactated Ringer’s or Plasma-Lyte A).
– No IV fluids necessary b. Assess for hemorrhagic shock (altered mental sta-
– PO fluids permissible if conscious and can tus in the absence of brain injury and/or weak or
swallow absent radial pulse).
b. If in shock: 1. If not in shock:
– Hextend, 500mL IV bolus – No IV fluids are immediately necessary.
– Repeat once after 30 minutes if still in shock. – Fluids by mouth are permissible if the casu-
– No more than 1000mL of Hextend alty is conscious and can swallow.
c. Continued efforts to resuscitate must be weighed 2. If in shock and blood products are available
against logistical and tactical considerations and under an approved command or theater blood
the risk of incurring further casualties. product administration protocol:
d. If a casualty with an altered mental status due to – Resuscitate with whole blood*, or, if not
suspected TBI has a weak or absent peripheral available
pulse, resuscitate as necessary to maintain a pal- – Plasma, RBCs, and platelets in a 1:1:1 ratio*,
pable radial pulse. or, if not available
– Plasma and RBCs in 1:1 ratio, or, if not
available;
Tactical Evacuation Care
– Reconstituted dried plasma, liquid plasma
7. Fluid resuscitation or thawed plasma alone or RBCs alone;

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