Page 142 - Journal of Special Operations Medicine - Fall 2015

the application of the junctional tourniquet once it is – Plasma and RBCs in 1:1 ratio, or, if not available;
ready for use. Apply hemostatic dressings with direct – Reconstituted dried plasma, liquid plasma, or
pressure if a junctional tourniquet is not available or thawed plasma alone or RBCs alone;
while the junctional tourniquet is being readied for use. – Reassess the casualty after each unit. Continue
c. Reassess prior tourniquet application. Expose the resuscitation until a palpable radial pulse, im-
wound and determine if a tourniquet is needed. If it is, proved mental status, or systolic blood pressure
replace any limb tourniquet placed over the uniform (BP) of 80-90 mmHg is present.
with one applied directly to the skin 2 to 3 inches above 3. If in shock and blood products are not available un-
wound. Ensure that bleeding is stopped. When possible, der an approved command or theater blood product
a distal pulse should be checked. If bleeding persists or administration protocol due to tactical or logistical
a distal pulse is still present, consider additional tighten- constraints:
ing of the tourniquet or the use of a second tourniquet – Resuscitate with Hextend, or if not available;
side-by-side with the first to eliminate both bleeding – Lactated Ringer’s or Plasma-Lyte A;
and the distal pulse. – Reassess the casualty after each 500 mL IV bolus;
d. Limb tourniquets and junctional tourniquets should be – Continue resuscitation until a palpable radial
converted to hemostatic or pressure dressings as soon pulse, improved mental status, or systolic BP of
as possible if three criteria are met: the casualty is not 80 to 90mmHg is present.
in shock; it is possible to monitor the wound closely for – Discontinue fluid administration when one or
bleeding; and the tourniquet is not being used to con- more of the above end points has been achieved.
trol bleeding from an amputated extremity. Every effort 4. If a casualty with an altered mental status due to sus-
should be made to convert tourniquets in less than 2 pected TBI has a weak or absent peripheral pulse,
hours if bleeding can be controlled with other means. resuscitate as necessary to restore and maintain a
Do not remove a tourniquet that has been in place more normal radial pulse. If BP monitoring is available,
than 6 hours unless close monitoring and lab capability maintain a target systolic BP of at least 90mmHg.
are available. 5. Reassess the casualty frequently to check for recur-
e. Expose and clearly mark all tourniquet sites with the rence of shock. If shock recurs, recheck all external
time of tourniquet application. Use an indelible marker. hemorrhage control measures to ensure that they
5. Intravenous (IV) access are still effective and repeat the fluid resuscitation as
– Start an 18-gauge IV line or saline lock if indicated. outlined above.
– If resuscitation is required and IV access is not obtain- *Neither whole blood nor apheresis platelets as these products
able, use the intraosseous (IO) route. are currently collected in theater are FDA compliant. Conse-
6. Tranexamic acid (TXA) quently, whole blood and 1:1:1 resuscitation using apheresis
If a casualty is anticipated to need significant blood trans- platelets should be used only if all of the FDA-compliant blood
fusion (for example: presents with hemorrhagic shock, one products needed to support 1:1:1 resuscitation are not avail-
or more major amputations, penetrating torso trauma, or able or if 1:1:1 resuscitation is not producing the desired clini-
evidence of severe bleeding): cal effect.
– Administer 1g of TXA in 100mL normal saline or lac- 8. Prevention of hypothermia
tated Ringer’s as soon as possible but NOT later than 3 a. Minimize casualty’s exposure to the elements. Keep pro-
hours after injury. tective gear on or with the casualty if feasible.
– Begin second infusion of 1g TXA after Hextend or other b. Replace wet clothing with dry if possible. Get the casu-
fluid treatment. alty onto an insulated surface as soon as possible.
7. Fluid resuscitation c. Apply the Ready-Heat Blanket from the Hypothermia
a. The resuscitation fluids of choice for casualties in hem- Prevention and Management Kit (HPMK) to the casu-
orrhagic shock, listed from most to least preferred, are: alty’s torso (not directly on the skin) and cover the casu-
whole blood*; plasma, red blood cells (RBCs), and alty with the Heat-Reflective Shell (HRS).
platelets in 1:1:1 ratio*; plasma and RBCs in 1:1 ratio; d. If an HRS is not available, the previously recommended
plasma or RBCs alone; Hextend; and crystalloid (lac- combination of the Blizzard Survival Blanket and the
tated Ringer’s or Plasma-Lyte ® A). Ready Heat blanket may also be used.
b. Assess for hemorrhagic shock (altered mental status in e. If the items mentioned above are not available, use dry
the absence of brain injury and/or weak or absent radial blankets, poncho liners, sleeping bags, or anything that
pulse). will retain heat and keep the casualty dry.
1. If not in shock: f. Warm fluids are preferred if IV fluids are required.
– No IV fluids are immediately necessary. 9. Penetrating eye trauma
– Fluids by mouth are permissible if the casualty is If a penetrating eye injury is noted or suspected:
conscious and can swallow. a. Perform a rapid field test of visual acuity.
2. If in shock and blood products are available under b. Cover the eye with a rigid eye shield (NOT a pressure
an approved command or theater blood product ad- patch.)
ministration protocol: c. Ensure that the 400mg moxifloxacin tablet in the com-
– Resuscitate with whole blood*, or, if not available bat pill pack is taken if possible and that IV/IM antibi-
– Plasma, RBCs, and platelets in a 1:1:1 ratio*, or, otics are given as outlined below if oral moxifloxacin
if not available cannot be taken.

130 Journal of Special Operations Medicine Volume 15, Edition 3/Fall 2015