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primary resuscitation fluid. There were no access complica- care necessarily involves challenging existing dogma and im-
tions. This report contains the notable finding that 18 of their plementing changes to the previous standards. 105
84
20 casualties had an initial SBP below 90mmHg and that all
survived their initial laparotomy, however, since this care was Preventing Hemodynamic Decompensation
provided to foreign nationals who were subsequently trans- in NCTH
ferred to host nation medical treatment facilities, there was no
follow-up after transfer. Figure 4 lists the tasks involved in pre- Avoidance of platelet-impairing NSAIDs in combat forces
paring for and performing far-forward REBOA in this SOST. and early administration of TXA in casualties at risk for hem-
orrhagic shock may help to promote hemostasis and reduce
FIGURE 4 Tasks in the resuscitation of a hypotensive casualty with blood loss from noncompressible bleeding sites. The use of
NCTH by an austere surgical team. pelvic binding devices may also help to reduce the bleeding
associated with pelvic fractures. 36

Blood loss of sufficient magnitude to cause hemorrhagic shock
produces inadequate tissue oxygenation, followed by hemody-
namic collapse as manifest by hypotension. In casualties with
suspected NCTH, the goal should be to prevent hemodynamic
decompensation and cardiovascular collapse if possible, rather
than to treat those conditions after they occur. As noted pre-
viously, in civilian trauma patients who present to the ED in
shock (SBP <90) and who require an emergent trauma lapa-
Photo courtesy Maj Marc Northern. that incidence of mortality has not improved over the past two
rotomy, the mortality has been found to be 46%,
and
13,14,22
decades.
When significant reductions in intravascular volume occur in
casualties with NCTH, compensatory mechanisms such as ac-
tivation of the sympathetic nervous system and selective vaso-
constriction may preserve the SBP at a normal level until well
Although these initial reports of successful far-forward REBOA after anaerobic metabolism has begun. Occult shock (prior
106
are encouraging, it is important to note that the procedures to a decrease in SBP) may be detected by an increased lactate
described in both the Manley and the Northern case series in- level. 107-109 Initiation of whole blood transfusion when elevated
volved REBOA being accomplished by well-trained surgeons lactate levels are noted in the prehospital phase of care may
or emergency medicine physicians who were functioning as help to prevent or delay the development of subsequent he-
part of an austere surgical team that had basic operative ca- modynamic compensation, with its attendant increase in mor-
pabilities and could obtain direct control of torso hemorrhage tality. Other indicators such as a decrease in the intravascular
at laparotomy following REBOA. It is likely that the use of Compensatory Reserve Measurement may also be useful in
110
REBOA in true presurgical settings will be even more challeng- the near future for the early detection of decreased intravascu-
ing. This highlights the critical importance of using a “focused lar volume prior to the development of hypotension.
empiricism” approach to implementing advances in battle-
104
field trauma care. This approach should include careful atten- Discussion
tion to defining, training for, fielding, and refining this new
capability, as well as to thorough documentation and analysis Advanced Resuscitative Care
of casualty outcomes. The central focus of this proposed change is to recommend
that: 1) the use of LTOWB be expanded and moved closer
Direct comparisons between the outcomes reported in the two to the point of injury than has been the case in the past for
far-forward REBOA papers discussed above and the higher most US forces; and that 2) Zone 1 REBOA be used to control
mortality noted by Harvin and Marsden in hypotensive pa- life-threatening abdominopelvic NCTH when the initial whole
tients who undergo trauma laparotomies 13,14 as well as the blood resuscitation has failed to raise the casualty’s SBP to at
25% mortality in combat casualties noted by Marsden are least 90mmHg. These two interventions together comprise a
14
not possible because the 24-hour and 30-day outcomes for new capability in battlefield trauma care referred to in this
the casualties in the Manley and Northern studies are not document as “Advanced Resuscitative Care” or ARC. It is not
known. The majority of deaths from hemorrhage, however, envisioned that these two interventions are ones that could be
occur within 3 hours of admission to an MTF. The Man- accomplished by a unit medic working out of his or her aid
2
ley and Northern reports cited above do, however, serve to bag, but rather would be accomplished by a purposed team of
demonstrate that Zone l REBOA and whole blood resuscita- advanced combat medical providers with special training and
tion are feasible in an austere environment when performed by equipment.
a highly trained resuscitation team, and may improve survival
in combat casualties with NCTH, especially those with ab- Advanced Resuscitative Care (ARC) as outlined in this paper
dominopelvic bleeding. could be employed in selected tactical settings to improve casu-
alty survival. ARC entails more than Tactical Field Care (TFC)
The 2018 paper by Greene notes the current controversies or Tactical Evacuation (TACEVAC) Care as defined previously
surrounding the use of the novel REBOA procedure but, as for TCCC. It is less than a true surgical capability, but the ARC
33
noted by Col Todd Rasmussen, effecting advances in trauma recommendations below may be of significant use to surgical
Advanced Resuscitative Care in TCCC | 43