Page 145 - JSOM Fall 2018

– A casualty with no vital signs has return of conscious­ tourniquet side­by­side with the first to eliminate
ness and/or radial pulse. both bleeding and the distal pulse. If the reassess­
4. If the initial NDC fails to improve the casualty’s signs/ ment determines that the prior tourniquet was not
symptoms from the suspected tension pneumothorax: needed, then remove the tourniquet and note time of
– Perform a second NDC on the same side of the chest removal on the TCCC Casualty Card.
at whichever of the two recommended sites was not • Limb tourniquets and junctional tourniquets should
previously used. Use a new needle/catheter unit for the be converted to hemostatic or pressure dressings
second attempt. as soon as possible if three criteria are met: the ca­
– Consider, based on the mechanism of injury and physi­ sualty is not in shock; it is possible to monitor the
cal findings, whether decompression of the opposite side wound closely for bleeding; and the tourniquet is not
of the chest may be needed. being used to control bleeding from an amputated
5. If the initial NDC was successful, but symptoms later recur: extremity. Every effort should be made to convert
– Perform another NDC at the same site that was used tourniquets in less than 2 hours if bleeding can be
previously. Use a new needle/catheter unit for the repeat controlled with other means. Do not remove a tour­
NDC. niquet that has been in place more than 6 hours un­
– Continue to reassess! less close monitoring and lab capability are available.
6. If the second NDC is also not successful: • Expose and clearly mark all tourniquets with the time
– Continue on to the Circulation section of the TCCC of tourniquet application. Note tourniquets applied
Guidelines. and time of application; time of reapplication; time
b. Initiate pulse oximetry if not previously done. All indi­ of conversion; and time of removal on the TCCC Ca­
viduals with moderate/severe TBI should be monitored sualty Card. Use a permanent marker to mark on the
with pulse oximetry. Readings may be misleading in the tourniquet and the casualty card.
settings of shock or marked hypothermia. b. IV Access
c. Most combat casualties do not require supplemental • Reassess need for IV access.
oxygen, but administration of oxygen may be of benefit – IV or IO access is indicated if the casualty is in
for the following types of casualties: hemorrhagic shock or at significant risk of shock
• Low oxygen saturation by pulse oximetry (and may therefore need fluid resuscitation), or if
• Injuries associated with impaired oxygenation the casualty needs medications, but cannot take
• Unconscious casualty them by mouth. An 18­gauge IV or saline lock is
• Casualty with TBI (maintain oxygen saturation > preferred.
90%) – If vascular access is needed but not quickly ob­
• Casualty in shock tainable via the IV route, use the IO route.
• Casualty at altitude c. Tranexamic Acid (TXA)
• Known or suspected smoke inhalation • If a casualty is anticipated to need significant blood
d. All open and/or sucking chest wounds should be treated transfusion (for example: presents with hemorrhagic
by immediately applying a vented chest seal to cover the shock, one or more major amputations, penetrating
defect. If a vented chest seal is not available, use a non­ torso trauma, or evidence of severe bleeding):
vented chest seal. Monitor the casualty for the potential – Administer 1gm of tranexamic acid in 100mL
development of a subsequent tension pneumothorax. If normal saline or lactated Ringers as soon as possi­
the casualty develops increasing hypoxia, respiratory ble but NOT later than 3 hours after injury. When
distress, or hypotension and a tension pneumothorax is given, TXA should be administered over 10 min­
suspected, treat by burping or removing the dressing or utes by IV infusion.
by needle decompression. – Begin second infusion of 1gm TXA after initial
5. Circulation fluid resuscitation has been completed.
a. Bleeding d. Fluid resuscitation
• A pelvic binder should be applied for cases of sus­ • Assess for hemorrhagic shock (altered mental status
pected pelvic fracture: in the absence of brain injury and/or weak or absent
– Severe blunt force or blast injury with one or radial pulse).
more of the following indications: • The resuscitation fluids of choice for casualties in
– Pelvic pain hemorrhagic shock, listed from most to least pre­
– Any major lower limb amputation or near am­ ferred, are: whole blood*; plasma, RBCs and plate­
putation lets in a 1:1:1 ratio*; plasma and RBCs in a 1:1
– Physical exam findings suggestive of a pelvic fracture ratio; plasma or RBCs alone; Hextend; and crystal­
– Unconsciousness loid (lactated Ringer’s or Plasma­Lyte A). (NOTE:
– Shock Hypothermia prevention measures [Section 7]
• 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 2­3 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 is conscious and can swallow.
distal pulse should be checked. If bleeding persists – If in shock and blood products are available un­
or a distal pulse is still present, consider additional der an approved command or theater blood prod­
tightening of the tourniquet or the use of a second uct administration protocol:

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