Page 145 - Journal of Special Operations Medicine - Fall 2015

c. Reassess prior tourniquet application. Expose the wound c) The highest oxygen concentration (FIO2) possible
and determine if a tourniquet is needed. If it is, replace any should be used for hyperventilation.
limb tourniquet placed over the uniform with one applied *Notes:
directly to the skin 2 to 3 inches above wound. Ensure that – Do not hyperventilate unless signs of impending hernia-
bleeding is stopped. When possible, a distal pulse should tion are present.
be checked. If bleeding persists or a distal pulse is still pres- – Casualties may be hyperventilated with oxygen using
ent, consider additional tightening of the tourniquet or the the bag-valve-mask technique.
use of a second tourniquet side-by-side with the first to 7. Fluid resuscitation
eliminate both bleeding and the distal pulse. a. The resuscitation fluids of choice for casualties in hem-
d. Limb tourniquets and junctional tourniquets should be orrhagic shock, listed from most to least preferred, are:
converted to hemostatic or pressure dressings as soon whole blood*; plasma, RBCs, and platelets in 1:1:1 ra-
as possible if three criteria are met: the casualty is not tio*; plasma and RBCs in 1:1 ratio; plasma or RBCs
in shock; it is possible to monitor the wound closely for alone; Hextend; and crystalloid (lactated Ringer’s or
bleeding; and the tourniquet is not being used to con- Plasma-Lyte A).
trol bleeding from an amputated extremity. Every effort b. Assess for hemorrhagic shock (altered mental status in
should be made to convert tourniquets in less than 2 the absence of brain injury and/or weak or absent radial
hours if bleeding can be controlled with other means. pulse).
Do not remove a tourniquet that has been in place more 1. If not in shock:
than 6 hours unless close monitoring and lab capability – No IV fluids are immediately necessary.
are available. – Fluids by mouth are permissible if the casualty is
e. Expose and clearly mark all tourniquet sites with the conscious and can swallow.
time of tourniquet application. Use an indelible marker. 2. If in shock and blood products are available under
4. Intravenous (IV) access an approved command or theater blood product ad-
a. Reassess need for IV access. ministration protocol:
– If indicated, start an 18-gauge IV or saline lock – Resuscitate with whole blood*, or, if not available
– If resuscitation is required and IV access is not ob- – Plasma, RBCs and platelets in a 1:1:1 ratio*, or,
tainable, use intraosseous (IO) route. if not available
5. Tranexamic acid (TXA) – Plasma and RBCs in 1:1 ratio, or, if not available;
If a casualty is anticipated to need significant blood trans- – Reconstituted dried plasma, liquid plasma, or
fusion (for example: presents with hemorrhagic shock, one thawed plasma alone or RBCs alone;
or more major amputations, penetrating torso trauma, or – Reassess the casualty after each unit. Continue
evidence of severe bleeding) resuscitation until a palpable radial pulse, im-
Administer 1g of TXA in 100mL normal saline or lactated proved mental status, or systolic BP of 80 to
Ringer’s as soon as possible but NOT later than 3 hours 90mmHg is present.
after injury. 3. If in shock and blood products are not available un-
– Begin second infusion of 1g TXA after Hextend or other der an approved command or theater blood product
fluid treatment. administration protocol due to tactical or logistical
6. Traumatic brain injury constraints:
a. Casualties with moderate/severe TBI should be moni- – Resuscitate with Hextend, or if not available;
tored for: – Lactated Ringer’s or Plasma-Lyte A;
1. Decreases in level of consciousness – Reassess the casualty after each 500mL IV bolus;
2. Pupillary dilation – Continue resuscitation until a palpable radial
3. SBP should be >90 mmHg pulse, improved mental status, or systolic BP of
4. O saturation > 90 80 to 90mmHg is present.
2
5. Hypothermia – Discontinue fluid administration when one or
6. PCO (If capnography is available, maintain between more of the above end points has been achieved.
2
35 and 40mmHg) 4. If a casualty with an altered mental status due to sus-
7. Penetrating head trauma (if present, administer pected TBI has a weak or absent peripheral pulse,
antibiotics) resuscitate as necessary to restore and maintain a
8. Assume a spinal (neck) injury until cleared. normal radial pulse. If BP monitoring is available,
b. Unilateral pupillary dilation accompanied by a de- maintain a target systolic BP of at least 90mmHg.
creased level of consciousness may signify impending 5. Reassess the casualty frequently to check for recur-
cerebral herniation; if these signs occur, take the follow- rence of shock. If shock recurs, recheck all external
ing actions to decrease intracranial pressure: hemorrhage control measures to ensure that they
1. Administer 250mL of 3% or 5% hypertonic saline are still effective and repeat the fluid resuscitation
bolus. as outlined above.
2. Elevate the casualty’s head 30 degrees. *Neither whole blood nor apheresis platelets as these products
3. Hyperventilate the casualty. are currently collected in theater are FDA-compliant. Con-
a) Respiratory rate 20 sequently, whole blood and 1:1:1 resuscitation using apher-
b) Capnography should be used to maintain the esis platelets should be used only if all of the FDA-compliant
end-tidal CO2 between 30 and 35mmHg blood products needed to support 1:1:1 resuscitation are not

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