Page 116 - JSOM Fall 2018

o Similar to adults, early transfusion therapy should be clinical condition of all the patients requiring the attention of
started sooner rather than later. LTOWB and FWB are the provider making the decision. It will not always be possi­
both acceptable to give to children with life­threatening ble to save all team members.
hemorrhage. There is no contraindication to the use of
any WB product in children. The initial dose for blood A determination that further attempts to save a life are futile
is 10mL/kg, but in children with massive hemorrhage, does not necessarily mean cessation of clinical care for the
blood products can be given in higher doses as fast as patient. All reasonable interventions to reduce pain and suf­
needed to gain hemodynamic stability. Massive transfu­ fering, short of hastening death (e.g., not giving a lethal dose
sion in pediatrics has been defined as more than 40mL/ of opiates) should be provided. At times, agonal respirations
kg of blood products in 24 hours. WB is easier to titrate and bodily movement can take place in the dying process; be
effectively in children than component therapy. prepared for this in the sight of comrades and be prepared
o Children are at high risk of developing hypocalcemia, to explain this. This is not a reason to continue resuscitative
hypomagnesaemia, metabolic acidosis, hypoglycemia, efforts.
hypothermia, and hyperkalemia during transfusion.
Therefore, frequent monitoring (every hour if possible) If a casualty dies, all medical interventions should be left in
and correction of acid/base status, electrolytes, and core place if feasible. If supplies may be needed for future casual­
temperature is indicated during the resuscitation of pe­ ties and resources are critically limited, it may be necessary to
diatric casualties, when available. reuse medical devices (e.g., cricothyrotomy kits, chest tubes).
After death, a casualty should not be used as a blood donor for
End-of-Life/Expectant Management surviving casualties. Every attempt should be made to find al­
ternate donors for any surviving casualties. Transfusing blood
Determining futility of care: despite best efforts, certain injuries
are not survivable in austere environments. The tactical situ­ from a deceased casualty may result in transfusing acidotic
ation, casualty clinical condition, and operational constraints and hypocoagulable blood, thus worsening the surviving casu­
(e.g., mass casualty incidents, logistics) may warrant the con­ alty’s hemostatic physiology and possibly causing death.
sideration of ceasing ongoing, aggressive resuscitative efforts.
Providers facing the dilemmas around patient death and ces­
The provider must use all their operational knowledge to de­ sation of resuscitative efforts should also be cognizant of the
termine the utility of ongoing resuscitation. As a guide only, effects on team members, other patients, and on themselves.
examples of wounds with low chance of survival include: Various strategies for coping with these challenges may be ap­
o Cranial injuries with exposed brain matter (exception propriate in different circumstances. A full exploration of the
may be isolated frontal lobe injuries) or severe TBI with topic is beyond the scope of this CPG; however, some consid­
signs of herniation (i.e., dilated pupils, hypertension eration of these issues should be built into individual and unit
plus bradycardia) or Glasgow Coma Scale score 3–5 training for PFC scenarios.
o Penetrating thoracic or abdominal injuries that:
■ ■ Are hypotensive or nonresponsive after two units Appendix C. Whole Blood Draw and Storage Planning Guide.
blood transfusion, bilateral chest decompression (nee­ Appendix D. Damage Control Resuscitation in Prolonged
dle decompression/finger thoracostomy/tube thoracos­ Field Care Summary Table.
tomy), and assessment for pericardial tamponade.
o Junctional amputations with pelvic disruption Author Contributions
o Out­of­hospital cardiac arrest (despite bilateral chest All authors approved the final version of the manuscript.
decompression), especially if surgical resuscitation is
more than 10 minutes away References
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114 | JSOM Volume 18, Edition 3 / Fall 2018