Page 147 - Journal of Special Operations Medicine - Spring 2015

of tourniquets to assess for continued efficacy in 4. COL Jim Czarnik discussed trauma considerations
bleeding control. If the site of extremity bleeding in Operation United Assistance. He observed that
is not immediately obvious to the TCCC provider, US military operations in recent years have been
initial TQ placement during Care Under Fire centered on the conflicts in Afghanistan and Iraq and
should be “high and tight” in tactical situations that we must now begin early to plan and train for
until circumstances permit a more precise determi­ much more austere deployed environments, as typi­
nation of bleeding location and relocation of the fied by those in AFRICOM.
tourniquet to a site just proximal to the bleeding.
f. The CoTCCC has approved the use of ondanse­ 5. MAJ Kyle Faudree from the 160th Special Opera­
tron, as opposed to the previously recommended tiuons Aviation regiment discussed the Innovative
promethazine, for control of opioid­ or trauma­ Technologies iTClamp. This is a small device (similar
induced nausea and vomiting by a vote of 41 to to a chip clip but much sturdier) designed to close
0. The dose is 4mg with repeat of another 4mg skin lacerations and wounds and therefore promote
in 15 minutes if the first dose is ineffective; 8mg hemorrhage control. Dr John Holcomb, Dr Don Jen­
every 8 hours is the maximum dose. Ondansetron kins, and MSG Curt Conklin also expressed their
should be given IV, IM, IO, or by Oral Dissolvable support for this device.
Tablets (ODT), but NOT in the oral formulation. There was concern from the group that this
Ondansetron has a very favorable side effect pro­ device would work only on linear wounds and hide
file as compared to promethazine. the bleeding as opposed to stopping it. Packing the
g. The use of tranexamic acid (TXA) to promote he­ wound with Combat Gauze followed by application
mostasis was discussed at length. The CRASH­2 of the iTClamp to seal the wound would perhaps be
and MATTERS studies showed that early use of more effective if the wound morphology was favor­
TXA can be lifesaving. Multiple papers in the or­ able for this approach. A proposed change paper
thopedic and spinal surgery literature have shown suggesting the incorporation of this device into the
that early use of TXA reduces surgical blood loss TCCC Guidelines is being prepared.
without causing an increase in thromboembolic
events. Dr Butler’s presentation on this topic sug­ 6. Dr Phillip Spinella, a pediatric intensivist, discussed
gested further research efforts into TXA autoinjec­ options for far­forward blood product administration
tors and further promotion of immediate use of on the battlefield. Options include whole blood, RBCs,
TXA as close to the time of wounding as feasible. thawed plasma, and freeze­dried plasma. Dr. Spinella
h. TCCC has been shown to reduce the incidence believes that whole blood is the simplest and most ef­
of preventable deaths in combat casualties but is fective blood product to use in the combat prehospi­
still being implemented unevenly throughout the tal environment. He noted that the Royal Caribbean
Armed Services and the Geographic Combatant Cruise Liners have a whole blood transfusion program
Commands. Mitigation strategies to remedy this for use in their ships at sea and that in 40 months there
situation are currently being explored by the JTS. were 40 whole blood emergent transfusions (1­6 units
i. The Army Department of Combat Doctrine Devel­ per patient, one allergic reaction, and no infectious
opment (DCDD) recently recommended the SAM complications). Dr. Spinella favors a low titer type O
Junctional Tourniquet as the Army solution for a strategy for far­forward whole blood transfusions.
junctional tourniquet. This recommendation was
approved by the US Army Medical Command. 7. CDR Geir Strandenes from the Norwegian Navy Spe­
cial Operations unit also recommended the use of low
3. MAJ Neil David gave a presentation based on his titer type O whole blood in far­forward environments.
time as the Deployed Prehospital Director for the His unit uses group A for blood type A and type O
Joint Trauma System. He noted the need to have a (preferably low titer) for all others; he also discussed
way to train deployed personnel on the TCCC up­ how that program has been implemented with Nor­
dates. He also noted that medics like the new TCCC wegian Maritime Special Operations. His unit has a
cards (DD 1380s), but that the TCCC cards do not program that includes a donor pool of all unit person­
reliably get into the casualty’s medical record. We nel who are low titer type O, blood donor prescreen­
must train medical treatment facility personnel to ask ing, protocols for emergency whole blood drives, and
for them when the casualty arrives and ensure that the use of cold­stored type O low titer whole blood to
they are entered into the medical record. resuscitate casualties in hemorrhagic shock.

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