Page 39 - Journal of Special Operations Medicine - Fall 2014

– Reassess the casualty after each unit. Con- crystalloid resuscitation in hypotensive trauma pa-
tinue resuscitation until a palpable radial tients with penetrating torso injuries – Level B
pulse, improved mental status or systolic BP 2. Early resuscitation with 250mL of 7.5% HTS or
of 80–90mmHg is present. 7.5% HTS/dextran did not improve 28-day survival
3. If in shock and blood products are not avail- in comparison to NS – Level B
able under an approved command or theater 3. Resuscitation using a 1:1 ratio of plasma and PRBCs
blood product administration protocol due to improves survival over higher ratios of PRBCs to
tactical or logistical constraints: plasma – Level B
– Resuscitate with Hextend, or if not available; 4. Resuscitation with fresh whole blood improves sur-
– Lactated Ringer’s or Plasma-Lyte A; vival in comparison to resuscitation with 1:1 plasma
– Reassess the casualty after each 500mL IV and PRBCs – Level B
bolus; 5. Resuscitation with RBCs, plasma, and warm FWB
– Continue resuscitation until a palpable ra- (but not apheresis platelets) was found in one study
dial pulse, improved mental status, or sys- to improve survival compared with treatment with
tolic BP of 80–90mmHg is present. RBCs, plasma, and apheresis platelets (but not FWB)
– Discontinue fluid administration when one or – Level B
more of the above end points has been achieved. 6. Transfusion of a ratio of >1:8 apheresis platelets to
4. If a casualty with an altered mental status due RBCs (compared with ratios with smaller volumes of
to suspected TBI has a weak or absent periph- platelets) is associated with improved survival at 24
eral pulse, resuscitate as necessary to restore hours and at 30 days in combat casualties requiring
and maintain a normal radial pulse. If BP mon- a MT within 24 hours of injury – Level B
itoring is available, maintain a target systolic
BP of at least 90mmHg.
5. Reassess the casualty frequently to check for Considerations for Further Research
recurrence of shock. If shock recurs, recheck and Development
all external hemorrhage control measures to 1. Conduct a retrospective study of combat casualty
ensure that they are still effective and repeat the outcomes in the DoDTR as a function of the type
fluid resuscitation as outlined above. and volume of prehospital fluids administered as
*Neither whole blood nor apheresis platelets as these well as the status of the casualty (shock versus no
products are currently collected in theater are FDA com- shock) and the nature of the hemorrhage (controlled
pliant. Consequently, whole blood and 1:1:1 resuscita- versus uncontrolled).
tion using apheresis platelets should be used only if all 2. Explore all options to make an FDA-approved dried
of the FDA-compliant blood products needed to sup- plasma product available for all US military combat
port 1:1:1 resuscitation are not available, or if 1:1:1 re- medical providers. This product should be able to
suscitation is not producing the desired clinical effect.” be transfused to casualties of any blood type; should
be able to withstand the temperatures encountered
Vote: This change was approved by the required two- in military prehospital settings; should have a long
thirds or greater majority of the voting members of the shelf life, and should not be packaged in breakable
CoTCCC.
containers.
Level of evidence (AHA/ACC ) 3. Fund studies in the civilian sector to compare the
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survival benefit from prehospital fluid resuscitation
The levels of evidence used by the American College of with plasma alone compared with resuscitation with
Cardiology and the American Heart Association were crystalloids or colloids as well as with 1:1 plasma and
described by Tricoci in 2009:
RBCs. Include a subgroup analysis of controlled ver-
Level A: Evidence from multiple randomized trials sus uncontrolled hemorrhage patients. Also recom-
or meta-analyses. mend including relevant surrogate outcomes (indices
Level B: Evidence from a single randomized trial or of coagulopathy, shock, platelet dysfunction, etc.) that
nonrandomized studies. could be more readily explored in smaller studies.
Level C: Expert opinion, case studies, or standards 4. Fund research and development efforts designed to
of care. enhance the availability, safety, efficacy, and shelf life
of whole blood and blood components in the far-
Using this taxonomy, the levels of evidence for the fol- forward combat environment.
lowing aspects of fluid resuscitation from hemorrhagic 5. Study methods for increasing the availability, safety,
shock are provided below.
efficacy, and shelf life of cold stored plasma, plate-
1. Early hypotensive resuscitation with crystalloid lets, and whole blood in the deployed combat
improves survival compared with larger-volume environment.

Fluid Resuscitation for Hemorrhagic Shock in TCCC 31