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Although faster evacuation of critically injured casualties to that TXA be administered as soon as feasible after wound-
a surgical capability is inherently a desirable achievement, ing. 33,42 There is Level A evidence that TXA helps to reduce
there is a substantial burden of mortality that occurs within bleeding from various elective surgery procedures. 43-45 and pre-
the Golden Hour: “The peak time to death after severe truncal venting hemorrhagic shock is better than treating it. Optimal
injury is within 30 minutes of injury.” A large study from the use of TXA requires that it be given as soon as possible when
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Pennsylvania trauma registry found that 5% of patients with indicated, 33,46 rather than suggesting that TXA administration
severe injury had died by 23 minutes from time of injury, and anytime within 3 hours after injury is acceptable, as some
50% of patients with severe injury had died by 59 minutes. guidelines do. At present, however, there is no evidence that
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This further shortened to 19 and 39 minutes, respectively, TXA is currently being given immediately after wounding in
for patients with penetrating injury and hypotension, the co- US casualties. A recent study found that only 19% of casual-
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hort with most similarity to severe combat injuries. Another ties in whom TXA was indicated received it in the prehospital
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published study notes that: “Time is the enemy: Mortality in setting. In contrast, the MATTERS paper noted that the 293
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trauma patients with hemorrhage from torso injury occurs casualties who received TXA in that study were administered
long before the “golden hour.” Reaching the goal of zero pre- intravenous administration TXA (mean dose 2.3 gm) within 1
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ventable deaths requires that critical lifesaving interventions hour of injury. A recent prospective randomized trial of pre-
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be performed as quickly as possible when they are indicated, hospital TXA administration in patients with traumatic brain
not after a pre-established time period, such as 60 minutes. injury (who were not hypotensive) identified a survival benefit
with TXA, and found that a 2 gram dose provided the optimal
As noted above, at the time that this proposed change to TCCC benefit. 49
is being considered, the two interventions that hold the most
promise for saving the lives of casu alties with NCTH and shock TCCC has advocated for whole blood as the resuscitation
during the prehospital phase of care are resuscitation with whole fluid of choice for casualties in hemorrhagic shock since 2014
blood and—if the truncal hemorrhage is in the abdomen or pel- and for other blood products when whole blood is not avail-
vis—Zone 1 REBOA. NCTH from both thoracic and abdomi- able. There is now good evidence that prehospital blood
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nopelvic bleeding sites. Zone 1 REBOA will provide additional products improve survival and that early administration of
benefit for those casualties whose NCTH is from abdominal or these products to casualties who require them is essential to
pelvic bleeding sites. These interventions must be integrated into optimal outcomes. Sperry et al have recently published their
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a team resuscitation approach that also includes mastery of the definitive study showing improved survival with prehospital
entire spectrum of lifesaving TCCC interventions. plasma. Prehospital and hospital whole blood is being used
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by multiple civilian trauma systems. However, at the time of
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this proposed change to TCCC, whole blood or 1:1 RBCs and
Current TCCC Recommendations for
Preventing and Treating NCTH plasma are not being administered to most US casualties at the
POI, unless the casualties occur in Special Operations units.
Although the increased use of POI whole blood and REBOA Further, most US ground medics do not carry dried plasma,
are the two interventions for NCTH that are being addressed since an FDA-approved dried plasma product is not yet gen-
in this change, there are already a number of recommendations erally available. 53,54
in place in the TCCC Guidelines that help to reduce NCTH
and treat the hemorrhagic shock that NCTH may produce. 33 The addition of ketamine to the TCCC Guidelines and the
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subsequent development of the TCCC Triple-Option Anal-
Avoidance of platelet-impairing NSAIDs was recommended gesia plan have reduced the requirement for opioids to be
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in the original TCCC paper and reinforced in 2014. Un- used to achieve effective battlefield analgesia. This is especially
10
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fortunately, NSAID use is well-established in military culture important for casualties in hemorrhagic shock, since opioids
for the treatment of the very common musculoskeletal injuries depress cardiopulmonary function.
that combat troops experience. A 2012 study from Afghani-
stan noted that NSAID use—with the attendant impairment Hypothermia in combat casualties potentiates the coagulopa-
of platelet function—was observed in approximately 75% of thy of trauma and increases mortality. 56-58 The strong TCCC
deployed combat troops. 35 emphasis on hypothermia prevention 59,60 helps to reduce the
incidence of coagulopathy and likely improves outcomes in all
TCCC recommends circumferential pelvic compression de- bleeding casualties, including those with NCTH, although the
vices for casualties suspected of having pelvic fractures. magnitude of this benefit has not been well-defined.
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These devices have been associated with reduced bleeding
from this type of injury.
Rediscovering Whole Blood as the
Preferred Resuscitation Fluid
Tranexamic acid (TXA) has been found in multiple studies
to reduce mortality in trauma patients who are bleeding. 37-40 Robertson in 1917 noted that “So far as my experience goes,
One large study based on combat casualty data from the DoD there is no comparison between the results of blood transfu-
Trauma Registry found that TXA use “was not significantly as- sion and saline infusion. The effects of blood transfusion are
sociated with mortality due to lack of statistical power.” How- instantaneous and usually lasting; the effects of saline too often
ever, the authors also noted that “. . . our (hazard ratio) estimates transitory—a flash in the pan—followed by greater collapse
for mortality among patients who received TXA are consistent than before.” Whole blood was used in the resuscitation of
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with previous findings from the CRASH 2 trial.” 41 casualties in hemorrhagic shock in World War II, but when
fractionation of whole blood into blood components became
For casualties who are in shock or who are at high risk of devel- technologically feasible in the 1960s, the use of crystalloid
oping hemorrhagic shock, the TCCC Guidelines recommend solutions (predominantly normal saline and Lactated Ringers

Advanced Resuscitative Care in TCCC | 39