Page 138 - JSOM Fall 2019

document that Dsuvia performs equivalently, better, or worse
than OTFC as a prehospital analgesic. And it costs 4 times as
much as OTFC. In the long run, Dsuvia may turn out to be
a better battlefield analgesic than OTFC, but there is not yet
evidence to establish that.
Quality assurance in TCCC training continues to be a problem.
Instances of incorrect messaging in nonstandard TCCC courses
have been directly associated with adverse outcomes, including
a leg amputation from prolonged tourniquet use and respira-
tory arrest from using midazolam after fentanyl lozenges. Some
nonstandard TCCC courses have also been found to contain
inappropriate training, such as the pharmacologic induction of
hypotension in student volunteers to demonstrate the signs and
CoTCCC member Dr Jim Bagian is presently participating in symptoms of shock. Another unacceptable practice reported in
a National Academies of Science, Engineering, and Medicine media coverage of this topic has been the administration of po-
panel that has been convened to look at the lag time between tent analgesic medications to students to illustrate the cognitive
when new innovations in trauma care are recommended and impairment that these medications cause.
when they are actually introduced to combat units. As stated
succinctly by General Joseph Votel, the former Commander of Colloids and crystalloids are the LEAST desirable of the op-
the US Central Command, battlefield trauma care is military tions for fluid resuscitation of hemorrhagic shock. Plasma is a
line leaders’ responsibility – and one that cannot be delegated. much better option and has been shown to improve survival
The CoTCCC-recommended approach for expediting the when administered as the first resuscitation fluid for hypoten-
fielding of an ARC capability is the TCCC Transition Initia- sive trauma patients. The French dried plasma product FLyP
1
™
tive model that was used so successfully by the USSOCOM/ has received an FDA indication for battlefield use as a result of
USAISR team in 2005–2007 to implement TCCC training and input from the recently established DoD-FDA panel. The DoD
equipment throughout the deploying units in the US Special is currently working with the French manufacturer of this
Operations Command. product to explore options for increasing production of FlyP.
The CoTCCC has implemented a new approach to managing Ketamine autoinjectors with the TCCC-recommended analge-
TCCC changes. Guideline changes will now be conducted as sic dose of this medication could be manufactured and would
parallel (vs. sequential) efforts. This change is designed to help avoid the time delay and risk of incorrect dosing created by
expedite the TCCC change process. Changes currently under medics having to draw up ketamine injections from multidose
development – along with the respective Change Leaders are: vials – IF there were an FDA indication for battlefield use of
ketamine. The DoD-FDA panel could undertake this action as
19-01 Tourniquet Review Mr Harold Montgomery well and has been asked to do so by the DoD.
19-02 TXA Relook CAPT Brendon Drew
19-03 Hypothermia Prevention Dr Brad Bennett The TCCC for All Servicemembers (TCCC-ASM) course is a
Relook new, abbreviated TCCC course mandated by DOD Instruction
19-04 iTClamp Relook CDR Dana Onifer 1322.24. TCCC-ASM provides basic TCCC training in exter-
19-05 Evisceration Injuries LTC Jamie Riesberg nal hemorrhage control for Servicemembers who are not envi-
19-06 Fluid Resuscitation Maj Marc Northern sioned to be combatants, such as a Navy finance clerk at the
Pentagon, an Army recruiter, or an Air Force missile techni-
An email forwarded by Command SGM Tim Sprunger at the cian serving at a CONUS Air Force Base. This course parallels
Army Medical Research and Materiel Command noted that the “Stop the Bleed” training promoted by the White House/
the production of morphine autoinjectors has ceased. and that ACS-sponsored campaign of the same name and will be taught
all backorders have been canceled. The demise of this out- during Service basic training. The Stop the Bleed course was in
dated approach to battlefield analgesia in favor of the TCCC turn adapted from the 2-hour course in external hemorrhage
Triple-Option Analgesia plan is a significant advance in battle- control that was developed in 2011 by the CoTCCC for the
field trauma care for the US military.
New Orleans Police Department – at the request of Dr Nor-
Sufentanil sublingual 30μg tab- man McSwain, the NOLA Police Department Surgeon – using
lets have now been approved material from the TCCC curriculum. The new TCCC-ASM
by the FDA. Sold under the curriculum is being developed by an ad hoc working group
brand name Dsuvia, this med- sponsored by the Defense Health Agency; pilot courses are
ication will be available on planned for this spring.
19 Feb 2019 in boxes of 10
individual packaged prefilled 7. Optimizing Partial Zone 1 REBOA: Dr Marty Schreiber –
single-dose applicators (SDAs) Oregon Health and Science University
with 1 tablet per SDA.
Complete REBOA in Zone 1 produces supraphysiologic mean
Of concern, neither the manufacturer nor the military has yet arterial pressures proximal to the occlusion and total body isch-
funded a study that compares the safety and efficacy of Dsuvia emia distal to the occlusion. Ischemia-reperfusion injury is a
to that of OTFC—the currently recommended transmucosal significant danger when the balloon is inflated after extended
opioid analgesic in TCCC—despite a specific recommenda- periods of occlusion. Partial REBOA, in which some blood is al-
tion for such a study in the 2014 Triple-Option Analgesia lowed to continue past the site of balloon inflation, ameliorates
paper. Until this study is performed, there is no evidence to the reperfusion injury without excessive additional blood loss.

136 | JSOM Volume 19, Edition 3 / Fall 2019