Page 115 - JSOM Fall 2018

that affect coagulopathy are controlled, transient re­ ■ ■ Temperature greater than 95ºF (35ºC)
sponders will likely respond to more resuscitation. A ■ ■ UO greater than 30mL/h or greater than 0.5mL/kg/h
subset of transient responders includes casualties with o Best: In addition to minimum and better, confirm that
slow, noncompressible hemorrhage for whom resusci­ hemorrhagic shock is resolving, using the following lab­
tation can “keep up” with blood loss until surgical he­ oratory values:
mostasis can be obtained, provided casualty has access ■ ■ Hemoglobin concentration greater than 8.0g/dL
to enough blood products and surgery can be obtained. ■ ■ Hematocrit greater than 27%
o Nonresponder: Trends do not improve or continue to ■ ■ Lactate concentration less than 2.5mmol/L
worsen after initial trial of resuscitation. Before declaring ■ ■ Base deficit less than 4 (base excess greater than −4)
a casualty to be a nonresponder, reassess hemostatic pro­ Note: Improving trends are as important as meeting absolute
cedures, assess for missed sources of bleeding, and decom­ goals when assessing response.
press both sides of the chest (needle decompression/finger
thoracostomy/tube thoracostomy). Assess for pericardial
tamponade by ultrasound or as a last resort, blind peri­ If laboratory values do not improve or trend in the wrong direc-
cardiocentesis. If major bleeding cannot be controlled, it tion for two or more different values, either additional resuscitation
is not likely that the casualty will respond; this includes and/or hemorrhage control interventions are needed or the injury is
not survivable given resources and capabilities available. Consider
noncompressible torso hemorrhage where it is not pos­ teleconsultation. Expectant management may be appropriate in some
sible for resuscitation to replace blood loss. If factors circumstances.
affecting coagulopathy (e.g., acidosis and hypothermia)
cannot be corrected (with resuscitation and rewarming), Documentation Should Consist of the Following: 30
it is also unlikely that the casualty will respond.
Note: If a casualty does not respond to resuscitation, a deci­ o Minimum: TCCC Card (DD1380)
sion must be made whether to continue resuscitative efforts. If o Better: PFC flowsheet
the casualty has worsened, further resuscitation is likely futile. ■ ■ During prolonged care, once all available time
If they have not responded but not worsened, a trial of addi­ blocks on the TCCC card are filled and evacuation
tional resuscitation if resources are available can be considered to higher level of care is not imminent, transition to
to assess whether the initial resuscitation was insufficient. PFC flowsheet.
o Best: After­action report in addition to above
Managing a nonresponding casualty is a complex deci­ Note: Blood products transfused, patient and donor identifi­
sion that must balance availability of medical resources, cation must be reported to the COCOM Joint Blood Program
demand of other casualties (or contingencies) for those Office (JBPO). Recipients of emergency collected whole blood
resources, ability of the team to continue the effort of must be enrolled into a follow­up infectious disease monitor­
resuscitation, and other factors. It is highly advised to ing program (contact JBPO or ASBP for guidance).
manage in consultation with medical experts (e.g., by
telemedicine discussion).
Pediatric Considerations
o Critically wounded or ill pediatric patients are more dif­
End Points of Resuscitation
ficult for the Role 1 provider or medic because of the
Goal: Determine when to stop administration of blood prod­ lack of regular exposure to pediatric care. It is recom­
ucts. It may be difficult to determine when to stop resuscitation mended that a pediatric reference card or Broselow tape
and transition to maintenance monitoring and care. Patients be available to identify pediatric ranges for vital signs,
may have abnormal vital signs for many reasons. Obtain tele­ drugs, and supplies.
consultation if targets are not being met and/or trending in the o Total circulating blood volume in children can be es­
wrong direction. timated at 70–80mL/kg for children younger than age
o Minimum: Identify clinical stabilization through ongo­ 12 years. In very young or small children, this is a
31
ing monitoring and examination. very small volume. For example, an average 1­year­old
■ ■ Slowing heart rate, palpable peripheral pulses, brisk American child weighs 10–11kg and has a total blood
capillary refill, warming extremities, improving men­ volume approximately equivalent to two units of blood.
tal status (if no brain injury), slowing/cessation of co­ Underestimating blood loss percentage and over resusci­
agulopathic bleeding (wounds and/or IV site bleeding). tating should both be avoided.
o Better: In addition to minimum, recognize improved vi­ o As in adults, do not hesitate to use an IO catheter as the
tal signs and objective criteria. first and primary line for initial resuscitation. A second
■ ■ SBP at goal IV or IO line should be started as soon as possible for
– Goal SBP is approximately 100mmHg if resusci­ additional drug administration.
tating with blood products (maintain mild hypo­ o TXA is indicated in pediatric casualties. The dose is
tension until definitive bleeding control). 15mg/kg TXA loading dose (maximum, 1g) over 10
– In patients with traumatic brain injury, goal SBP minutes followed by 2mg/kg/h for 8 hours (maximum,
is greater than 110mmHg. 1g). 32
– If unable to resuscitate with blood products, ■ ■ To prepare the second dose as a drip, inject 15mg/kg
a lower blood pressure goal of SBP from 80– TXA into a 100mL bag of NS. Using a dial­a­flow
90mmHg is acceptable. drip set, place the drip rate at 13 mL/h (OR by drip
■ ■ Oxygen saturation (Spo ) greater than 92%, fraction count: 1 drip every 5 seconds for 60 drip/mL tubing;
2
of inspired oxygen (Fio ) required should be less than 1 drip every 18 seconds for 15 drip/mL tubing; 1 drip
2
50% every 27 seconds for 10 drip/mL tubing).
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