Page 53 - JSOM Winter 2018

FIGURE 5 100 Potentially preventable prehospital deaths based on to supplement Tactical Field Care by a team located near
the 2012 Eastridge study on combat fatalities. the point of injury, or it could be used to supplement
TACEVAC Care on an evacuation platform. Whenever tac-
tically feasible, 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 15-30 minutes without ARC. For
these casualties, Advanced Resuscitative Care is likely to be
the only thing that will effectively prevent their death.

3. The team providing ARC should first ensure that all of the
hemorrhage control interventions recommended in Tactical
Field Care have been successfully accomplished:
– Extremity hemorrhage has been controlled with
tourniquets;
– Junctional and other external hemorrhage has been con-
trolled with hemostatic dressings, XStat, and junctional
tourniquets as needed;
– Pelvic binders have been applied for suspected pelvic
NCTH and thoracic hemorrhage responsible for the remain- fractures;
ing 36%. Thus, for an assumed group of 100 potentially pre- – The first dose of TXA has been administered without
11
ventable prehospital combat deaths: delay if hemorrhagic shock is present or judged likely
to occur;
– 92 of those deaths would have occurred as a result of
hemorrhage. – If the casualty is in traumatic cardiac arrest, bilateral
– 67% of those deaths—62 individuals—would have been NDC should have been performed.
due to NCTH.
– 64% of NCTH deaths—40 individuals—would have re- 4. Indications for Whole Blood Transfusion:
sulted from NCTH in the abdomen or pelvis. *Follow the JTS Damage Control and Whole Blood Trans-
fusion Clinical Practice Guidelines (CPGs) except as follows:
Effective interventions to mitigate mortality resulting from ab- *TCCC-specific considerations:
dominopelvic hemorrhage therefore offers an opportunity to – Casualty has known prior external hemorrhage (even if
save 40 out of every 100 potentially preventable prehospital that hemorrhage is now controlled) or suspected non-
deaths in future combat casualties—if the interventions can be compressible torso hemorrhage (NCTH)
performed shortly after the time of wounding. AND
– Systolic Blood Pressure (SBP) is less than 90mmHg
OR
Proposed ARC Change Wording
– Point of Injury lactate is 4mmol/L or greater
*Insert a new section with the text below between the Tactical
Field Care” and “Tactical Evacuation Care” sections of the 5. Whole Blood Transfusion Procedure in ARC:
TCCC Guidelines *Follow the JTS Damage Control and Whole Blood Transfu-
*New text in red sion CPGs except as follows:
*TCCC-specific considerations:
Advanced Resuscitative Care (ARC) a. Resuscitation should be initiated with FDA-compliant
Cold-Stored Low Titer Type O Whole Blood (LTOWB)
1. Combat casualties who are in shock from noncompressible
torso hemorrhage (NCTH) in the prehospital setting have as the preferred option and every effort should be made
a high mortality rate and need life-saving interventions to to have it available.
be performed as soon as possible. The two most important b. LTOWB from a unit-based, pre-screened and pre-titered
of these interventions can be provided by Advanced Re- walking blood bank (WBB) should be used as the sec-
suscitative Care in TCCC: transfusion of whole blood to ond option if FDA-compliant cold-stored LTOWB is not
provide optimal resuscitation for the casualty’s shock and available.
Zone 1 REBOA (Resuscitative Endovascular Balloon Oc- c. If there is a pre-screened—but untitered—unit-based
clusion of the Aorta) to temporarily control NCTH below WBB designed to collect whole blood, utilize only Type
the diaphragm. O units of whole blood as the third option.
2. ARC is an advanced capability in TCCC. Although whole d. If there is a unit-based WBB designed to collect, type,
blood resuscitation can be provided by a single prehospital and transfuse type-specific whole blood, that is a fourth
provider in some settings, to do both robust whole blood option.
resuscitation and possibly subsequent REBOA, requires a *NOTE: Option (d) may result in morbidity or even death
team of 4 or more specially trained and equipped individu- due to ABO mismatch if the wrong blood type is transfused.
als. When a casualty meets the indications for whole blood *NOTE: 1:1 RBCs and plasma should be used in the sub-
resuscitation, transfusion should be initiated as quickly as optimal circumstance that FDA-compliant whole blood is not
possible, followed rapidly by Zone 1 REBOA if that proce- available, but FDA-compliant red blood cells and plasma are
dure is indicated as outlined below. ARC could be provided available.

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