Page 114 - JSOM Fall 2018

TXA is an antifibrinolytic medication that helps to stabilize o Minimum: Document signs and symptoms that could
blood clots and may improve survival from hemorrhage. TXA indicate hypovolemic shock and the response to resus­
should be administered for casualties with signs of hemor­ citation in order of early to late appearance in shock.
rhagic shock and all casualties who meet criteria for DCR ■ ■ Mental status
within 3 hours of injury. TXA should not be given more than ■ ■ Respiratory rate
3 hours after injury, because this has been associated with in­ ■ ■ Heart rate
creased mortality. 10,25,26 ■ ■ Peripheral pulses
o Minimum: Administer TXA 1g IV as soon as possible ■ ■ Blood pressure
after injury (not more than 3 hours after injury). ■ ■ Also document temperature and pulse oximetry
■ ■ Administration of undiluted TXA by slow IV push o Better: In addition to minimum requirements, monitor
is acceptable if supplies or tactical situation prevent capnometry (displaying end­tidal CO (EtCO ) value,
2
2
100mL IV infusion. Ideally, slow IV push should ideally with waveform).
be given over 10 minutes; however, it may be given o Best: Portable monitor providing continuous vital signs
faster when the tactical situation indicates, accepting display; capnography
the risk of transient hypotension. Use greater caution • Urine output
when the casualty is already hypotensive before TXA Urine output (UO) is a valuable indicator of adequate re­
administration. suscitation from hemorrhagic shock.
o Best: administer TXA as soon as possible (within 1 o Minimum: If patient can void, capture urine in premade
hour) after injury and give a second dose of TXA 1g IV or improvised graduated cylinder.
over 8 hours. ■ ■ Collect all spontaneously voided urine and carefully
■ ■ Administer initial 1g of TXA IV/IO in 100 mL of measure; more than 180mL every 6 hours is ade­
normal saline (NS) over 10 minutes. quate for adults.
®
■ ■ To prepare the second dose as an 8­hour drip, inject – A Nalgene (Thermo Fisher Scientific, http://www
1g TXA into a 100mL bag of NS. Using a dial­flow .nalgene.com/) water bottle is an example of an
drip set, place the drip rate on 13mL/h (OR by drip improvised graduated cylinder.
count: 1 drip every 5 seconds for 60 drip/mL tubing; o Best: Place Foley catheter and record UO hourly.
1 drip every 19 seconds for 15 drip/mL tubing; 1 drip • Laboratory tests
every 29 seconds for 10 drip/mL tubing). The utility of laboratory tests in the field setting should
– OR inject 1g TXA into a 250mL bag of NS. Us­ not be overlooked for simpler and readily available mea­
ing a dial­a­flow drip set, place the drip rate on surements, like UO. When a portable laboratory device is
30mL/h and administer over 8 hours. used, it may be useful to trend the following laboratory test
values along with vital signs and UO to obtain a more exact
Calcium administration replaces serum calcium lost during clinical picture.
hemorrhage and transfusion of citrated blood products. Cal­ o Minimum: None
cium helps prevent cardiac dysfunction and hypotension. o Better: Check initial point­of­care lactate concentration.
o Minimum: Administer 1g of calcium (30mL of 10% cal­ o Best: Monitor one or more of the following laboratory
cium gluconate or 10mL of 10% calcium chloride) IV/ values every 60 minutes until the patient is stabilized,
IO during or immediately after transfusion of the first then every 6 hours:
unit of blood product. ■ Lactate
o Better: With ongoing resuscitation, give additional ■
■ ■ pH and base deficit
30mL of calcium gluconate or 10mL calcium chloride ■ Hemoglobin/hematocrit
after every four units of blood product. ■ ■ INR
o Best: Monitor serum calcium during ongoing resuscita­ ■
tion and administer calcium gluconate 30mL or calcium
chloride 10mL for ionized calcium less than 1.2mmol/L. Note: Neurologic examination and vital signs trends are essential to
identifying a deteriorating patient with traumatic brain injury (TBI). Mon-
itoring EtCO is critical for patients with severe TBI. Ensure this capability
2
Caution: Calcium gluconate is safer for peripheral use. Calcium chlo- is available.
ride may cause severe skin necrosis if extravasation occurs through a
partially dislodged IV or IO catheter. The risk of bone necrosis with
IO injection of calcium chloride is not known. When using peripheral Assessing Response to Resuscitation
IV or IO access, use extreme caution to ensure the device is in good
intravascular position and no extravasation occurs. Overview: Assessing response to resuscitation is a dynamic
process that is most accurate when all available data are used
to paint a composite picture of the casualty. This whole pic­
Caution: Do not mix medications and blood products in the same IV ture is more accurate than any single normal (or abnormal)
line. Use a separate line or flush well between giving medications and component.
blood products.
Casualties will follow one of three trajectories in response to
resuscitation: responder, transient responder, or nonresponder.
Monitoring
o Responder: Clinical and objective trends improve after
Goal: Maintain adequate oxygenation and ventilation, avoid resuscitation and remain stable.
hypotension, trend response to resuscitation. o Transient responder: Trends improve after resuscitation,
• Vital signs then decline. This decline should prompt reassessment
Document vital signs frequently (every 15 minutes initially, of hemostatic procedures, assessment for missed hem­
then every 30–60 minutes once stable for more than 2 orrhage, assessment of acidosis or hypothermia, and a
hours) on a flow sheet. 30 trial of repeated resuscitation. If bleeding and factors

112 | JSOM Volume 18, Edition 3 / Fall 2018