Page 39 - JSOM Winter 2018

Advanced Resuscitative Care in Tactical Combat Casualty Care:
TCCC Guidelines Change 18-01

14 October 2018

Frank Butler, MD *; John B. Holcomb, MD ; Stacy Shackelford, MD ; Sean Barbabella, MD ;
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Jeff Bailey, MD ; Jay Baker, MD ; Andrew P. Cap, MD, PhD ; Curt Conklin, ATP ; Cord Cunningham, MD ;
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Mike Davis, MD ; Steve DeLellis, PA ; Warren Dorlac, MD ; Joseph Dubose, MD ; Brian Eastridge, MD ;
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Andrew D. Fisher, MPAS, PA-C ; Jacob J. Glaser, MD ; Jennifer Gurney, MD ; Don Jenkins, MD ;
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Jay Johannigman, MD ; David R. King, MD ; Russ Kotwal, MD ; Lanny Littlejohn, MD ;
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Robert Mabry, MD ; Matthew J. Martin, MD ; Ethan Miles, MD ; Harold Montgomery, ATP ;
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D. Marc Northern, MD ; Kevin O’Connor, MD ; Todd Rasmussen, MD ; Jamie Riesberg, MD ;
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Phil Spinella, MD ; Zsolt Stockinger, MD ; Geir Strandenes, MD ; Darin Via, MD ; Michael Weber, MD 35
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Joint Trauma System Directors’ Note ABSTRACT
Advanced Resuscitative Care, as described below, reflects the TCCC has previously recommended interventions that can ef-
work of the Committee on Tactical Combat Casualty Care. It fectively prevent 4 of the top 5 causes of prehospital preventable
is a bold change in the advancement of battlefield medicine. death in combat casualties—extremity hemorrhage, junctional
The interventions recommended in this paper address the larg- hemorrhage, airway obstruction, and tension pneumothorax—
est remaining cause of potentially preventable death on the and deaths from these causes have been markedly reduced in
battlefield, and represent an initiative to bring the capability US combat casualties. Noncompressible torso hemorrhage
for massive resuscitation with whole blood and control of ab- (NCTH) is the last remaining major cause of preventable death
dominopelvic torso hemorrhage closer to the point of injury. on the battlefield and often causes death within 30 minutes of
wounding. Increased use of whole blood, including the capa-
In reviewing this change, we recognized that the proposed in- bility for massive transfusion, if indicated, has the potential to
terventions cross multiple roles of care in a dynamic and fluid increase survival in casualties with either thoracic and/or ab-
environment that includes various combinations of damage dominopelvic hemorrhage. Additionally, Zone 1 Resuscitative
control resuscitation, damage control surgery, tactical field Endovascular Balloon Occlusion of the Aorta (REBOA) can
care, and enroute care. As such, Advanced Resuscitative Care provide temporary control of bleeding in the abdomen and
is not truly specific to TCCC and is presented as the first step pelvis and improve hemodynamics in casualties who may be
in what is envisioned as an area of increased focus and fur- approaching traumatic cardiac arrest as a result of hemor-
ther development by the Joint Trauma System. The goal go- rhagic shock. Together, these two interventions are designated
ing forward will be to synchronize recommendations from the Advanced Resuscitative Care (ARC) and may enable casualties
Defense Committees on Combat Casualty Care for Tactical, with severe NCTH to survive long enough to reach the care
Surgical, and Enroute Care and to integrate efforts for ear- of a surgeon. Although Special Operations units are now using
lier whole blood resuscitation and control of abdominopelvic whole blood far-forward, this capability is not routinely present
torso hemorrhage throughout the continuum of care. in other US combat units at this point in time. REBOA is not
envisioned as care that could be accomplished by a unit medic
In order to responsibly implement the recommendations in this working out of his or her aid bag. This intervention should be
change, there must be accurate and thorough documentation undertaken only by designated teams of advanced combat med-
of the care provided by damage control resuscitation and dam- ical personnel with special training and equipment.
age control surgery teams. It is essential that this information
be entered into the DoD Trauma Registry in order to optimize Keywords: Advanced Resuscitative Care; Committee on Tac-
care for each casualty and to enable continued improvements tical Combat Casualty Care; guidelines
in care for all combat casualties.
—Col Jeff Bailey / Col Stacy Shackelford Proximate Reason for This Proposed Change
The Joint Trauma System: TCCC has previously recommended interventions that can ef-
bold, responsible battlefield medicine. fectively prevent 4 of the top 5 causes of prehospital preventable
1–35 Please see page 55.
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