Page 164 - Journal of Special Operations Medicine - Summer 2015

Committee on Tactical Combat Casualty Care Meeting:

3–4 February 2014, Atlanta, Georgia

Meeting Minutes: 17 April 2015

3 February 2015
Combat Medic Presentation: SFC Matt Hoard 4 years that it was fielded as the US Army and US Special
Operations Command (USSOCOM) hemostatic dressing
SFC Hoard, a Special Forces medic, discussed a casualty sce- of choice.
nario in Afghanistan in 2013 in which a rocket-propelled gre- B. The recent change in fluid resuscitation from hemorrhagic
nade round impacted an RG-33 armored vehicle and resulted shock in TCCC recommended the following order of
in bilateral lower extremity injuries to a team member. The precedence:
Junctional Emergency Treatment Tool (JETT ; North Ameri-
™
can Rescue LLC; http://www.narescue.com) was applied and 1. Whole blood
was effective at controlling the bleeding. However, two issues 2. 1:1:1 red blood cells (RBCs): thawed fresh frozen
arose. First, the JETT became dislodged during patient trans- plasma (FFP):platelets
fer; second, the receiving Forward Surgical Team was unfamil- 3. 1:1 RBCs: FFP
iar with the JETT and cut it off when the casualty arrived at 4. (four-way tie): liquid (never frozen) plasma, thawed
that facility. The Soldier subsequently died of his wounds. FFP, reconstituted dried plasma, RBCs only
8. Hextend (Hospira, Inc.; www.hospira.com)
The Abdominal Aortic and Junctional Tourniquet (AAJT; 9. (Tie) lactated Ringer’s or Plasma-Lyte A (Baxter Inter-
™
Chinook Medical Gear Inc.; www.chinookmed.com) was also national Inc.; www.Baxter.com)
discussed and it was noted that the AAJT is now approved
for a 4-hour application. In testing at the US Army Institute C. Damage control resuscitation, as developed by the US-
of Surgical Research (USAISR), however, a Combat Ready AISR and implemented by the Department of Defense
Clamp (CrOC ; Combat Medical Systems; www.combatmed- (DoD) Joint Trauma System (JTS), has been definitively
™
icalsystems.com) was applied at the umbilicus to occlude flow proven to save lives. Efforts to expand prehospital blood
in the distal abdominal aorta (analogous to the AAJT) for 2 product use, especially whole blood, should be continued
hours. This application resulted in muscle necrosis and bowel and expanded.
ischemia. Application of the AAJT also results in significant D. Normal saline (NS) is NOT recommended as a resuscita-
pain (as do extremity tourniquets) and is difficult for a casu- tion fluid, because of studies showing that NS is associated
alty to tolerate. with hyperchloremic metabolic acidosis.
E. Tourniquets: a 2-hour recheck of tourniquets applied dur-
Tactical Combat Casualty Care (TCCC) Update: ing Care Under Fire or Tactical Field Care is now man-
Dr Frank Butler dated to determine if tourniquet removal is feasible and
hemorrhage control can be maintained with Combat
CAPT (Ret) Frank Butler, chair of the Committee on Tactical Gauze or other means. This does not replace the frequent
Combat Casualty Care (CoTCCC), provided a review of re- rechecks of tourniquets to assess for continued efficacy
cent changes to the TCCC Guidelines and other current TCCC in bleeding control. Also, if the site of extremity bleeding
issues. is not immediately obvious to the TCCC provider, initial
tourniquet placement during Care Under Fire should be
A. QuikClot Combat Gauze (Z-Medica; www.z-medica.com “high and tight” until circumstances permit a more pre-
®
™
/healthcare) remains the first choice for a hemostatic cise determination of the location of the bleeding site; if
dressing in TCCC. ChitoGauze (HemCon Medical Tech- this option is used, it should be followed by a subsequent
®
nologies Inc.; www.hemcon.com/Home.aspx) and Celox relocation of the tourniquet to a site just proximal to the
™
gauze (Medtrade Products Ltd.; www.celoxmedical.com/ bleeding, when feasible.
usa/products/celox-gauze) have now been recommended F. The CoTCCC now recommends the use of ondansetron,
by the CoTCCC as alternatives if Combat Gauze is not as opposed to the previously recommended prometha-
available. These two hemostatic dressings have been zine, for control of opioid- or trauma-induced nausea and
shown to be equal in efficacy to Combat Gauze. They have vomiting. This recommendation was approved by a vote
not been tested in the US Army Institute of Surgical Re- of 41-0. The dose is 4mg with a repeated dose of another
search (USAISR) safety model, as Combat Gauze has, but 4mg in 15 minutes if the first dose is ineffective. The max-
both are chitosan-based products in a gauze format (simi- imum dose is 8mg every 8 hours. Ondansetron may be
lar to the previously used HemCon dressings). No adverse given intravenously (IV), intramuscularly (IM), interosse-
events were noted as a result of HemCon use during the ously (IO), or by oral dissolvable tablets (ODT), but the

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