Page 172 - Journal of Special Operations Medicine - Summer 2015

e. Expose and clearly mark all tourniquet sites with the 5. Reassess the casualty frequently to check for recur-
time of tourniquet application. Use an indelible marker. rence of shock. If shock recurs, recheck all external
5. Intravenous (IV) access hemorrhage control measures to ensure that they
– Start an 18-gauge IV or saline lock if indicated. are still effective and repeat the fluid resuscitation as
– If resuscitation is required and IV access is not obtain- outlined above.
able, use the intraosseous (IO) route. *Neither whole blood nor apheresis platelets as these products
6. Tranexamic acid (TXA) are currently collected in theater are FDA-compliant. Conse-
If a casualty is anticipated to need significant blood trans- quently, whole blood and 1:1:1 resuscitation using apheresis
fusion (for example: presents with hemorrhagic shock, one platelets should be used only if all of the FDA-compliant blood
or more major amputations, penetrating torso trauma, or products needed to support 1:1:1 resuscitation are not avail-
evidence of severe bleeding) able, or if 1:1:1 resuscitation is not producing the desired clini-
– Administer 1g tranexamic acid in 100mL normal saline cal effect.
or lactated Ringer’s as soon as possible but NOT later 8. Prevention of hypothermia
than 3 hours after injury. a. Minimize casualty’s exposure to the elements. Keep
– Begin second infusion of 1g TXA after Hextend or other protective gear on or with the casualty if feasible.
fluid treatment. b. Replace wet clothing with dry if possible. Get the casu-
7. Fluid resuscitation alty onto an insulated surface as soon as possible.
a. The resuscitation fluids of choice for casualties in hem- c. Apply the Ready-Heat Blanket from the Hypothermia
orrhagic shock, listed from most to least preferred, are: Prevention and Management Kit (HPMK) to the ca-
whole blood*; plasma, RBCs and platelets in 1:1:1 ra- sualty’s torso (not directly on the skin) and cover the
tio*; plasma and RBCs in 1:1 ratio; plasma or RBCs casualty with the Heat-Reflective Shell (HRS).
alone; Hextend; and crystalloid (lactated Ringer’s or d. If an HRS is not available, the previously recom-
Plasma-Lyte A). mended combination of the Blizzard Survival Blanket
b. Assess for hemorrhagic shock (altered mental status in and the Ready Heat blanket may also be used.
the absence of brain injury and/or weak or absent radial e. If the items mentioned above are not available, use
pulse). dry blankets, poncho liners, sleeping bags, or anything
1. If not in shock: that will retain heat and keep the casualty dry.
– No IV fluids are immediately necessary. f. Warm fluids are preferred if IV fluids are required.
– Fluids by mouth are permissible if the casualty is 9. Penetrating eye trauma
conscious and can swallow. If a penetrating eye injury is noted or suspected:
2. If in shock and blood products are available under a) Perform a rapid field test of visual acuity.
an approved command or theater blood product ad- b) Cover the eye with a rigid eye shield (NOT a pressure
ministration protocol: patch).
– Resuscitate with whole blood*, or, if not available c) Ensure that the 400mg moxifloxacin tablet in the com-
– Plasma, RBCs, and platelets in a 1:1:1 ratio*, or, bat pill pack is taken if possible and that IV/IM antibi-
if not available otics are given as outlined below if oral moxifloxacin
– Plasma and RBCs in 1:1 ratio, or, if not available; cannot be taken.
– Reconstituted dried plasma, liquid plasma or 10. Monitoring
thawed plasma alone or RBCs alone; Pulse oximetry should be available as an adjunct to clini-
– Reassess the casualty after each unit. Continue cal monitoring. All individuals with moderate/severe TBI
resuscitation until a palpable radial pulse, im- should be monitored with pulse oximetry. Readings may be
proved mental status, or systolic BP of 80– misleading in the settings of shock or marked hypothermia.
90mmHg is present. 11. Inspect and dress known wounds.
3. If in shock and blood products are not available un- 12. Check for additional wounds.
der an approved command or theater blood product 13. Analgesia on the battlefield should generally be achieved
administration protocol due to tactical or logistical using one of three options:
constraints:
– Resuscitate with Hextend, or if not available; Option 1
– Lactated Ringer’s or Plasma-Lyte A; Mild to Moderate Pain
– Reassess the casualty after each 500mL IV bolus; Casualty is still able to fight
– Continue resuscitation until a palpable radial – TCCC Combat pill pack:
pulse, improved mental status, or systolic BP of – Tylenol—650mg bilayer caplet, 2 PO every 8 hours
80–90mmHg is present. – Meloxicam—15mg PO once a day
– Discontinue fluid administration when one or Option 2
more of the above end points has been achieved. Moderate to Severe Pain
4. If a casualty with an altered mental status due to Casualty IS NOT in shock or respiratory distress AND
suspected TBI has a weak or absent peripheral Casualty IS NOT at significant risk of developing either
pulse, resuscitate as necessary to restore and main- condition
tain a normal radial pulse. If BP monitoring is – Oral transmucosal fentanyl citrate (OTFC) 800μg
available, maintain a target systolic BP of at least – Place lozenge between the cheek and the gum
90mmHg. – Do not chew the lozenge

162 Journal of Special Operations Medicine Volume 15, Edition 2/Summer 2015