Page 111 - JSOM Fall 2018

An Ongoing Series
An Ongoing Series

Damage Control Resuscitation in Prolonged Field Care

Andrew D. Fisher, MPAS, PA-C, LP ; Geoffrey Washburn, MPAS, APA, PA-C ; Douglas Powell, MD ;
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David W. Callaway, MD ; Ethan A. Miles, MD ; Jacob Brown, 18Z ; Paul Dituro, 18D ;
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Jay Baker, MD ; Jon B. Christensen, APA-C ; Cord W. Cunningham, MD, MPH ;
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Jennifer Gurney, MD ; James Lopata, MPAS, APA-C ; Paul Loos, 18D ; John Maitha, MPAS, APA, PA-C ;
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Jamie Riesberg, MD ; Zsolt Stockinger, MD ; Geir Strandenes, MD ; Philip Spinella, MD ;
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Andrew P. Cap, MD, PhD ; Sean Keenan, MD ; Stacy Shackelford, MD *
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Introduction best" format that presents a hierarchy of approaches to ad­
dress a spectrum of Role 1 situations and available resources.
Early recognition and intervention for life­threatening hemor­ In all cases, this hierarchy builds on itself with “minimum”
rhage are essential for survival. The immediate priorities are to clinical standards still applicable in scenarios with the “best”
control life­threatening hemorrhage and maintain vital organ available resources.
perfusion with rapid blood transfusion. 1
DCR principles practiced in the presurgical phase of resusci­
Experience with fresh whole blood (FWB) resuscitation by tation have been termed remote damage control resuscitation
military surgical teams deployed in US Central Command 2–4 (RDCR). It is important to distinguish between RDCR and
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led to a revolutionary change in resuscitation practices, termed DCR, because capabilities are different in prehospital versus
damage control resuscitation (DCR). As DCR became the ac­ hospital settings.
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cepted standard in military and civilian trauma practice, the
realization that the majority of potentially preventable battle­
field deaths occurred prehospital and were attributed to hem­ Recognizing Patients Who Need (R)DCR
orrhage launched a campaign to bring advanced resuscitation Goal: Recognize patients with traumatic hemorrhage who will
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capabilities closer to the point of injury. 7,8
benefit from implementing DCR early to decrease mortality.
o Initial survey: Recognize hemorrhagic shock based on
Efforts to prevent death from hemorrhage begin with external rapid examination and recognition of severe injury pattern.
hemorrhage control, followed by transfusion of whole blood ■ ■ Injury pattern consistent with massive hemorrhage:
(WB) or reconstituted WB with components in a 1:1:1 unit – Above­the­knee traumatic amputation, especially
ratio when possible. DCR also limits the use of crystalloids if associated with pelvic injury
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to avoid dilutional coagulopathy and incorporates other ad­ – Proximal, bilateral, or multiple amputations (in­
junctive measures to mitigate hemorrhagic shock and acute cluding mangled extremity)
traumatic coagulopathy, including:
– Clinically obvious penetrating injury to chest or
abdomen
• Early use of tranexamic acid (TXA) 10 – Uncontrolled truncal or junctional bleeding
• Calcium repletion in patients at risk of hypocalcemia – Uncontrolled major bleeding secondary to large
• Prevention of acidosis and hypothermia soft­tissue injuries
• Expeditious delivery to a damage control surgical ■ ■ Severe trauma with altered mental status (in the ab­
capability sence of brain injury) and/or weak or absent radial
pulse. 9
The purpose of this prolonged field care (PFC) guideline is to o If initial survey does not indicate severe blood loss, con­
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improve implementation of DCR in the Role 1 PFC environ­ tinue assessment, check vital signs, and assess for signs
ment by augmenting and consolidating the Tactical Combat of shock. Recognize hemorrhagic shock on the basis of
Casualty Care (TCCC) and Joint Trauma System (JTS) guide­ presence of severe traumatic injury associated with the
lines for PFC situations. When patient evacuation is delayed following:
or not available, evidence­based solutions may not be possible. ■ ■ Systolic blood pressure (SBP) less than 100mmHg
In such cases, experience­based solutions may provide the best ■ ■ Pulse greater than 100 bpm
option in a compromised setting with limited resources. The ■ ■ Clinical signs of shock, such as cool extremities, de­
CPG recommendations are presented in a "minimum, better, layed capillary refill
*Correspondence to stacy.a.shackelford.mil@mail.mil
1–20 Please see page 115.
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