Page 112 - JSOM Fall 2018

■ ■ Clinical signs of coagulopathy (e.g., thin, nonclotting tourniquet, resuscitation should address hyperka­
bleeding from multiple sites, bleeding from minor lemia and reperfusion syndrome, similar to crush
wounds such as intravenous [IV] or intraosseous injuries. See PFC Clinical Practice Guideline (CPG)
[IO] sites) Crush Syndrome Under Prolonged Field Care. 23
o Advanced capabilities: When additional laboratory ca­ o Wound packing notes
pability and/or ultrasound are available, confirm evi­ ■ ■ If bleeding continues through the hemostatic dress­
dence of hemorrhagic shock using laboratory and/or ing, reassess the wound. If the wound is fully packed
imaging studies. Do not delay initiating DCR if hemor- and additional hemostatic dressings are available,
rhagic shock is clinically suspected: Begin treating im- consider removing the first dressing and packing
mediately once hemorrhagic shock is suspected. a second dressing. If additional space exists in the
wound cavity, augment the first dressing with a sec­
Predictors associated with massive transfusion (i.e., ond hemostatic dressing or gauze dressing.
more than 10 units of blood in the first 24 hours) may ■ The effectiveness of wound packing may be im­
help identify patients who will require massive transfu­ ■ proved when skin closure over the packing can be
sion. The more predictors present, the higher the risk of achieved, either with suture, skin staples, iTClamp ®
massive transfusion. 13–22 (Innovative Trauma Care, https://www.innovative
■ ■ Penetrating mechanism traumacare.com/), or application of a chest seal.
■ ■ Positive focused assessment with sonography for o Emerging technologies that may be considered for inter-
trauma (FAST) examination (especially if two or nal hemorrhage control
more regions are positive) ■ Abdominal Aortic and Junctional Tourniquet (AAJT):
■ ■ Lactate concentration greater than 4mmol/L on ■ This device, although not well studied, is the only
presentation noninvasive device available for aortic occlusion. Ap­
■ ■ Base deficit more than 6mEq/L (base excess less than plication of the AAJT (Compression Works; http://
−6mEq/L) compressionworks.com) may be considered for oc­
■ ■ pH less than 7.25 clusion of the distal aorta when the injury pattern
■ ■ International normalized ratio (INR) 1.5 or greater
suggests bleeding in the pelvis and/or junctional lower
extremities.
Hemorrhage Control – If there is bleeding above the level of the umbili­
cus, in the upper abdomen or chest, application of
Goal: Stop external hemorrhage and reduce internal hemor­ the AAJT may increase bleeding.
rhage to the greatest extent possible. The first step in DCR is – Ideally, ultrasound of the abdomen and chest
limiting blood loss by early and effective hemorrhage control. should be performed to look for bleeding before
Interventions to control external hemorrhage are well described AAJT application.
in the TCCC guidelines and should be applied as indicated. – Per manufacturer's guidelines, the AAJT should
■ ■ CoTCCC recommended limb tourniquets not be applied in the abdominal position for
■ ■ Wound packing more than about 30 minutes.
■ ■ Pressure dressings – In the absence of evidence­based protocol, provid­
■ ■ Hemostatic dressings (Combat Gauze [Z­Medica; ers may consider: after 15–30 minutes of active
https://www.z­medica.com/Products], Celox Gauze resuscitation with blood products and attention to
[Med­trade Products, www.celoxmedical.com], Chito external hemorrhage control, the AAJT should be
Gauze [HemCon Medical Technologies Inc.; https:// slowly released.
www.tricolbiomedical.com/product/chitogauze­pro/], – If the systolic blood pressure drops below
and XStat [RevMedx, https://www.revmedx.com/]) 90mmHg, reinflate the balloon and transfuse
■ ■ Junctional tourniquets an additional unit of blood before releasing the
■ ■ Pelvic binders
balloon again. Look for other causes of hemody­
namic instability.
Tourniquet notes 9 – Continue to repeat as resources allow until blood
■ ■ Tourniquets (limb and junctional) should be transi­ pressure stabilizes or arrival at surgical capability.
tioned to pressure dressings within 2 hours when cri­ ■ Resuscitative endovascular balloon occlusion of the
teria for conversion are met (i.e., the casualty is not ■ aorta (REBOA): Only an advanced resuscitation
in shock, it is possible to monitor the wound closely team with the capabilities for massive transfusion,
for bleeding, and the tourniquets are not being used ultrasound, and arterial access would be expected to
to control bleeding from an amputated extremity). obtain the capability for REBOA placement. This de­
Tourniquets that have been in place longer than 6 vice may be considered for occlusion of the aorta at
hours should not be removed unless close monitoring either the position of the diaphragm (zone I, for ab­
and laboratory capability are available.
dominal hemorrhage or traumatic arrest) or the distal
If the tactical situation or injury pattern does not al­ aorta above the aortic bifurcation (zone III, for pelvic
low for transition of a tourniquet to a pressure dress­ and/or junctional lower extremity hemorrhage). Bal­
ing, recognize that the priority is life over limb. At loon time should be limited to 30 minutes for zone I.
times, the decision to leave a tourniquet in place and Maximum zone III inflation time is not known, but
commit the patient to an amputation is difficult. Con­ is likely in the range of 2–3 hours. See Joint Trauma
sider telemedicine consultation. System REBOA CPG. Aggressive blood product re­
24
■ ■ If a tourniquet has been applied for longer than suscitation and balloon deflation protocol must be
2 hours and the decision is made to reduce the followed, even without surgical intervention.

110 | JSOM Volume 18, Edition 3 / Fall 2018