Page 46 - JSOM Winter 2018

teams in certain settings, such as in very austere environments Remember the TCCC Basics
where laparotomy is not feasible or during mass casualty inci-
dents where surgical control of NCTH may be delayed. Advanced Resuscitative Care should not be undertaken until
the lifesaving interventions already recommended in the exist-
Although whole blood resuscitation can be provided by a ing TCCC Guidelines have been accomplished:
single prehospital provider in some settings, to accomplish – External hemorrhage control should be accomplished
robust whole blood resuscitation, perform ultrasound, insert with limb tourniquets, hemostatic dressings, XStat, and
chest tubes, establish an advanced airway, and possibly per- junctional tourniquets as needed.
form subsequent REBOA, requires a team of four or more – The airway should be opened if needed.
specially trained and equipped advanced providers. When a – Suspected tension pneumothorax should be treated with
casualty meets the indications for whole blood resuscitation, needle decompression.
transfusion should be initiated as quickly as possible, followed – Circumferential pelvic compression devices applied as
rapidly by Zone 1 REBOA if that procedure is indicated as indicated.
outlined below. ARC could be provided to supplement Tacti- – TXA should be given immediately if indicated and not
cal Field Care by a team located near the point of injury, or it already given.
could be used to supplement TACEVAC Care on an evacua- – If the casualty is in cardiac arrest, bilateral NDC should
tion platform. Whenever tactically feasible and operationally be performed. 1
indicated, a team with an ARC capability should be positioned
as close to the point where casualties are likely to be sustained
as possible, since many casualties with NCTH will die within Additional Capabilities (beyond Standard TFC) that Should
15–30 minutes without ARC. For these casualties, Advanced Be Available in ARC
21
Resuscitative Care may be the only thing that will effectively – Electronic blood pressure monitoring
prevent their death from exsanguination. – Advanced airway
– Whole blood—Preferably FDA-Compliant Cold Stored
Note that ARC is NOT Prolonged Field Care (PFC). The US LTOWB or LTOWB collected from donors in a unit-
military has recently increased its focus on strategies to im- based Walking Blood Bank, such as that established in
prove outcomes in casualties who require field medical care the 75th Ranger Regiment. (1:1 RBCs and plasma are
91
for periods that exceed doctrinal planning timelines—up to 72 better than crystalloids or colloids, but should only be
hours. Recommendations for care provided in such circum- used when, for some reason, whole blood is not avail-
stances have been named Prolonged Field Care and PFC is a able. 50,112 )
rapidly evolving new dimension to combat casualty care. 111 – Point-of-care ultrasound and the capability to perform
EFAST to in order to identify intrathoracic and intra-
ARC is a different concept and is focused on the initial re- abdominal bleeding and to rule out hemopericardium
suscitation and stabilization of critically injured casualties in before undertaking REBOA
order to enable them to reach the next phase of care alive and – Tube thoracostomy—ideally with suction—to more de-
with the best chance of survival. ARC needs to be performed finitively role out intrathoracic bleeding before under-
as soon as possible after wounding and there is no representa- taking REBOA
tion in this proposed change that ARC will allow a critically – Zone 1 REBOA
injured casualty to be sustained in the field for a prolonged – Point-of-care lactate monitoring
period of time. Any casualty who needs the interventions in – Blood warming devices
ARC needs a surgeon and definitive hemorrhage control as – Supplemental oxygen
soon as possible. – A timing device for balloon inflation times
– Foley catheter—both to guide resuscitation and to assist
However, there is an expanding array of resuscitation teams in hemostasis
in the US military that are designed to provide a bridging ca- – A reliable plan for complete documentation of casualty
pability between TCCC and the casualty’s arrival at the first care in ARC
surgical capability. ARC will have a distinct role in enhancing
the capability of these austere care teams to provide lifesaving Indications for Whole Blood Transfusion in ARC
trauma care with fewer required resources and more mobility
than forward surgical teams. These teams may in time have Which casualties require whole blood transfusion in ARC?
an increasingly important role in medical planning as they be- Combat medical personnel should adhere to the JTS Dam-
come better able to extend survival time for casualties with age Control and Whole Blood Transfusion Clinical Practice
NCTH prior to damage control surgery. 26 Guidelines (CPGs) insofar as possible:
*TCCC-specific considerations include:
The intermittent REBOA technique outlined below resulted
in 100% survival out to 120 minutes in the presence of an – The casualty has known prior external hemorrhage
otherwise lethal vascular injury in an animal model of truncal (even if that hemorrhage is now controlled) and/or is
hemorrhage. If these findings translate well to combat casu- suspected to have NCTH AND
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alties with abdominopelvic NCTH, they have the potential to – Systolic Blood Pressure (SBP) is less than 90mmHg OR
transform battlefield trauma care and significantly reduce a – Point-of-care lactate is 4mmol/L or greater 107,108,113-115
remaining cause of potentially preventable death in US combat
wounded. This would have significant implications for both The use of 90mmHg SBP as a threshold value for initiating
improving casualty survival and enabling more flexibility in whole blood resuscitation is consistent with both the current
operational planning, JTS CPG for DCR and the present TCCC Guidelines. 33,112

44 | JSOM Volume 18, Edition 4 / Winter 2018