Page 141 - JSOM Fall 2018

• Reassess prior tourniquet application. Expose the should be initiated while fluid resuscitation is being
wound and determine if a tourniquet is needed. If it accomplished.)
is needed, replace any limb tourniquet placed over – If not in shock:
the uniform with one applied directly to the skin 2–3 o No IV fluids are immediately necessary.
inches above the bleeding site. Ensure that bleeding o Fluids by mouth are permissible if the casualty
is stopped. If there is no traumatic amputation, a dis­ is conscious and can swallow.
tal pulse should be checked. If bleeding persists or a – If in shock and blood products are available under an
distal pulse is still present, consider additional tight­ approved command or theater blood product admin­
ening of the tourniquet or the use of a second tour­ istration protocol:
niquet side­by­side with the first to eliminate both o Resuscitate with whole blood*, or, if not available
bleeding and the distal pulse. If the reassessment de­ o Plasma, RBCs and platelets in a 1:1:1 ratio*, or, if
termines that the prior tourniquet was not needed, not available
then remove the tourniquet and note time of removal o Plasma and RBCs in a 1:1 ratio, or, if not available
on the TCCC Casualty Card. o Reconstituted dried plasma, liquid plasma or
• Limb tourniquets and junctional tourniquets should thawed plasma alone or RBCs alone
be converted to hemostatic or pressure dressings o Reassess the casualty after each unit. Continue re­
as soon as possible if three criteria are met: the ca­ suscitation until a palpable radial pulse, improved
sualty is not in shock; it is possible to monitor the mental status or systolic BP of 80­90 is present.
wound closely for bleeding; and the tourniquet – If in shock and blood products are not available un­
is not being used to control bleeding from an am­ der an approved command or theater blood product
putated extremity. Every effort should be made to administration protocol due to tactical or logistical
convert tourniquets in less than 2 hours if bleeding constraints:
can be controlled with other means. Do not remove o Resuscitate with Hextend, or if not available
a tourniquet that has been in place more than 6 o Lactated Ringer’s or Plasma­Lyte A
hours unless close monitoring and lab capability are o Reassess the casualty after each 500mL IV bolus.
available. o Continue resuscitation until a palpable radial
• Expose and clearly mark all tourniquets with the time pulse, improved mental status, or systolic BP of
of tourniquet application. Note tourniquets applied 80–90mmHg is present.
and time of application; time of reapplication; time o Discontinue fluid administration when one or
of conversion; and time of removal on the TCCC Ca­ more of the above end points has been achieved.
sualty Card. Use a permanent marker to mark on the • If a casualty with an altered mental status due to sus­
tourniquet and the casualty card. pected TBI has a weak or absent radial pulse, resus­
b. IV Access citate as necessary to restore and maintain a normal
• Intravenous (IV) or intraosseous (IO) access is indi­ radial pulse. If BP monitoring is available, maintain
cated if the casualty is in hemorrhagic shock or at a target systolic BP of at least 90mmHg.
significant risk of shock (and may therefore need • Reassess the casualty frequently to check for recur­
fluid resuscitation), or if the casualty needs medica­ rence of shock. If shock recurs, recheck all external
tions, but cannot take them by mouth. hemorrhage control measures to ensure that they are
– An 18­gauge IV or saline lock is preferred. still effective and repeat the fluid resuscitation as out­
– If vascular access is needed but not quickly ob­ lined above.
tainable via the IV route, use the IO route. Note:
c. Tranexamic Acid (TXA) *Currently, neither whole blood nor apheresis platelets col­
• If a casualty is anticipated to need significant blood lected in theater are FDA­compliant because of the way they
transfusion (for example: presents with hemorrhagic are collected. Consequently, whole blood and 1:1:1 resusci­
shock, one or more major amputations, penetrating tation using apheresis platelets should be used only if all of
torso trauma, or evidence of severe bleeding): the FDA­compliant blood products needed to support 1:1:1
– Administer 1gm of tranexamic acid in 100mL resuscitation are not available, or if 1:1:1 resuscitation is not
normal saline or lactated Ringer’s as soon as pos­ producing the desired clinical effect.
sible but NOT later than 3 hours after injury. e. Refractory Shock
When given, TXA should be administered over • If a casualty in shock is not responding to fluid re­
10 minutes by IV infusion. suscitation, consider untreated tension pneumotho­
– Begin the second infusion of 1gm TXA after ini­ rax as a possible cause of refractory shock. Thoracic
tial fluid resuscitation has been completed. trauma, persistent respiratory distress, absent breath
d. Fluid resuscitation sounds, and hemoglobin oxygen saturation < 90%
• Assess for hemorrhagic shock (altered mental status support this diagnosis. Treat as indicated with re­
in the absence of brain injury and/or weak or absent peated NDC or finger thoracostomy/chest tube in­
radial pulse). sertion at the 5th ICS in the AAL, according to the
• The resuscitation fluids of choice for casualties in skills, experience, and authorizations of the treating
hemorrhagic shock, listed from most to least pre­ medical provider. Note that if finger thoracostomy is
ferred, are: whole blood*; plasma, red blood cells used, it may not remain patent and finger decompres­
(RBCs), and platelets in a 1:1:1 ratio*; plasma and sion through the incision may have to be repeated.
RBCs in a 1:1 ratio; plasma or RBCs alone; Hextend; Consider decompressing the opposite side of the
and crystalloid (lactated Ringer’s or Plasma­Lyte A). chest if indicated based on the mechanism of injury
(NOTE: Hypothermia prevention measures [Section 7] and physical findings.

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