Page 24 - Journal of Special Operations Medicine - Winter 2015

Figure 5 TCCC casualty card (back; DD Form 1380). There are a number of monitoring devices that have the
potential to guide fluid resuscitation with more preci-
sion than is possible by relying on blood pressure mea-
surements. One example is the cardiovascular reserve
indicator, which uses the characteristics of the arterial
pulse waveform to generate a more precise determina-
tion of intravascular volume status. Another option is to
measure tissue oxygen saturation, which monitors the
adequacy of oxygen delivery by determining the level
of oxygen present in tissues. A third candidate technol-
ogy is a device that could provide prehospital measure-
ments of serum lactate. The latter two devices have the
added benefit of providing a quantitative measure of the
adequacy of tissue oxygenation, which requires both
adequate intravascular volume and adequate oxygen-
carrying capacity.
Photo courtesy of US Government For any of these three devices to be used most effec-

tively in TCCC, they will need to be small, rugged, light,
and inexpensive enough to be fielded widely to military
medics. Additionally, it would be useful to have studies
that show that the use of such monitors in the prehospi-
tal setting improves outcomes in trauma patients.
75th Ranger Regiment: electronic TCCC after-action re-
ports were used to record and supplement the informa- 5. Evaluate the impact of individual and collective
tion captured on the paper TCCC casualty card. 17,25 TCCC prehospital care interventions recommended by
the JTS on combat casualty outcomes, using data from
4. Fund the continued development and expedited field- the DoD Trauma Registry.
ing of technologies that enable prehospital Combat
medical personnel to better judge the adequacy of fluid As noted previously, decisions regarding prehospital
resuscitation. Specific examples of candidate technolo- trauma care must often be made with relatively low-
gies include the tissue oxygen saturation monitor and quality evidence. This is especially true for prehospital
the cardiovascular reserve index monitor. combat casualty care. Further, even in those instances
when high-quality prehospital trauma care evidence is
Determination of the adequacy of tissue perfusion is less available from the civilian sector, it must be considered
simple than it might seem, and fluid resuscitation has with caveats when extrapolating the evidence to the
the potential to be harmful as well as beneficial. Blood military environment. This necessitates the use of robust
pressure is the traditional way to measure the volume feedback methodology so that the impact of TCCC-
of blood in the intravascular space, as well as the func- recommended interventions can be monitored carefully
tioning of the heart as it generates the mechanical force and performance improvement measures implemented,
to circulate this blood. When blood is being lost due to as necessary. Studies such as those performed by COL
hemorrhage, however, the body’s compensatory mecha- John Kragh on tourniquet use, LTC Bob Mabry on sur-
nisms serve to maintain both blood pressure and the per- gical airways, COL Ian Wedmore on HemCon dress-
fusion of critical organs, such as the brain and the heart. ings, COL (Ret) Robb Mazzoli on eye shields, COL
These physiologic responses to blood loss will maintain Russ Kotwal on oral transmucosal fentanyl citrate, and
the blood pressure at a normal or near-normal level Col Stacy Shackelford on prehospital analgesia are es-
despite significant blood loss. Once a threshold point sential to either confirm the success of currently recom-
is reached, however, the compensatory mechanisms fail, mended interventions or identify the need to reconsider
and the body goes into shock. 41 management recommendations for the aspect of care be-
ing studied. 18,20,43–47
It is important not to overshoot the mark on fluid re-
suscitation; animal studies have shown that, in the pres- This is a complex undertaking in that outcomes for ca-
ence of an unrepaired vascular injury, raising the blood sualties are typically impacted by multiple interrelated
pressure beyond a critical threshold through excessive factors and isolating the contribution of any one in-
fluid resuscitation may result in disruption of the form- tervention to survival may be challenging. Despite the
ing clot, rebleeding, and death. 42 challenges, each aspect of prehospital care needs to be

12 Journal of Special Operations Medicine Volume 15, Edition 4/Winter 2015