Page 55 - JSOM Winter 2018

8. Document all care provided in ARC, to include as a minimum: – Can lyophilized products be combined to develop a
dried whole blood equivalent?
– Time and mechanism of injury – Is there a benefit or risk to leukoreduction of whole
– Time of arrival at the ARC capability blood that is to be used for trauma patients with life-
– Vital signs on arrival threat ening hemorrhage?
– Diagnostic measures and interventions performed – Can improved rapid screening methods be developed
– Details of the REBOA procedure as noted above. to identify transfusion-transmitted diseases?
– Response to interventions 3. Are pathogen-reduced blood products as efficacious as
– The time and the casualty’s condition upon leaving ARC
nontreated products for treating shock and hemostatic
Levels of Evidence for the Above Recommendations dysfunction?
The levels of evidence used by the American College of Car- 4. Is there a difference in efficacy between pathogen-treated
products in oxygen delivery and hemostatic function?
diology and the American Heart Association were outlined by
Tricoci in 2009:
REBOA Technology and Technique
– Level A: Evidence from multiple randomized trials or 5. Research should be conducted to explore techniques to
meta-analyses. extend the safe aortic occlusion time for Zone 1 REBOA,
– Level B: Evidence from a single randomized trial or non- studying various patterns of both intermittent and par-
randomized studies. tial REBOA and the impact on these various techniques
– Level C: Expert opinion, case studies, or standards of in reducing mortality in NCTH. Every effort should be
care. 152 made to determine the true limits of how long survival
can be prolonged using these techniques in animal models
Using the taxonomy above, the levels of evidence for the rec- of otherwise lethal NCTH, rather than stopping the study
ommendations in this change are shown below.
at an arbitrary cut-off time.
1. Whole blood is more effective at reducing mortality in casu- 6. Another research effort might explore the use of slower
alties suffering from hemorrhagic shock than resuscitation balloon deflation techniques and adjuncts to resuscitation
with the current point of injury resuscitation fluids used by that might mitigate untoward reperfusion effects (hyper-
most of the US military (Hextend or crystalloids): Level B kalemia and acidosis) and allow for longer periods of con-
2. REBOA can reduce the incidence of preventable death re- tinuous Zone 1 aortic occlusion when intermittency is not
sulting from abdominopelvic hemorrhage in combat casu- feasible because of the severity of the casualty’s bleeding.
alties. Level C 7. In particular, the use of calcium supplementation should
be studied as an adjunct to optimizing survival during
Results of the CoTCCC Vote: Zone 1 aortic balloon deflation. In research conducted in
This proposed change as presented above was approved by Dr Matt Martin’s lab, almost all of the animals get hyper-
the required 2/3 or greater majority of the voting members of kalemic upon balloon deflation, but the ones who die are
the CoTCCC. the ones who also have a lower calcium, whereas those
with higher serum calcium levels (8 or higher) tolerate the
Future Directions and Research Priorities Related to ARC hyperkalemia and don’t go into arrest (Dr Matt Martin,
Implementation personal communication, September 2018).
8. There should be further investigation into the use of the
1. A TCCC ARC Rapid Fielding Initiative (RFI) will be re- Rasmussen modification of the Madigan REBOA proto-
quired to optimally translate the concepts outlined in this col. That is, after an initial 15-minute period of occlusion,
paper into realized advances in combat casualty care. This how often will bleeding from a lethal vascular injury have
RFI could be modelled after the successful USSOCOM/ stopped as a result of the initial balloon inflation period
151
USAISR TCCC Transition Initiative that was responsi- with resulting stabilization of the casualty? Is three min-
ble for the first widespread use of TCCC in the US mili- utes truly the shortest balloon deflation period that will
tary. This program should include expedited procurement successfully allow intermittent Zone 1 REBOA to pro-
and fielding of the equipment required to perform ARC, long survival in NCTH?`
followed by delivery of this equipment along with the re- 9. Once a maximal safe Zone 1 REBOA occlusion time is
quired training targeted to units that are about to deploy determined (that is—one that does not produce sudden
and want to field teams with an ARC capability. The pro- cardiac arrest from rapidly-occurring hyperkalemia and
gram should also include meticulous documentation of the acidosis) a survival study should be performed to look for
care provided to casualties treated with ARC as part of this any untoward long-term effects resulting from the occlu-
initiative, along with ongoing JTS performance improve- sion period.
ment recommendations as experience is gained.
10. Better technology—suitable for use an austere envi-
ronments—with which to monitor and control partial
Whole Blood
REBOA would be of benefit to teams performing ARC.
2. How can whole blood availability, efficacy, and safety be Automated, feedback-based balloon volume controllers
improved for ARC? offer the potential to optimize the control of aortic flow
– Further extending the storage limit for whole blood? based on the casualty’s bleeding rate and his or her re-
– Better far-forward transport and storage capability for sponse to whole blood resuscitation. Such technology
whole blood? would allow for optimization of blood pressure both
– Can packaging, processing and storage solutions be proximal and distal to the aortic occlusion. 153
opti mized for whole blood to increase oxygen delivery 11. The critical procedural step in performing REBOA is ob-
and hemostatic function? taining common femoral artery access. Technology and

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