Page 140 - JSOM Fall 2019

hematoma that may compromise the airway. Consider
placing a definitive airway to avoid airway compro-
mise if there is evidence of an expanding hematoma.
• DO NOT APPLY on or near the eye (within 1 cm of
the orbit).
The iTClamp will be a CoTCCC vote item in the near future.
Source: Courtesy Mr Harold Montgomery. The Change Leader for this proposed change to the TCCC
10. TXA Relook: CDR Travis Deaton, Head of Emergency
Medicine at Naval Hospital San Diego

Guidelines is CAPT Brendon Drew from the First Marine Di-
vision. CDR Deaton is part of CAPT Drew’s team developing
this change.
The original recommendation for tranexamic acid (TXA) ap-
The 2012 study Death on the Battlefield (2001–2011) by Eas- peared in the Tactical Field Care and Tactical Evacuation Care
tridge et al., demonstrated that 7.5% of the prehospital deaths guidelines in 2011. That recommendation was for a 1g dose ad-
caused by potentially survivable injuries were due to external ministered by 10-minute IV infusion before fluid resuscitation,
hemorrhage from the cervical region. The standard of care in and a second 1g dose given after fluid resuscitation is complete.
these cases now is CombatGauge plus direct pressure or XStat, Since 2011, some 400 articles about TXA have been pub-
but these are not always effective at controlling major cervical lished, so experience with the drug in both military and civil-
bleeding, as evidenced by the recent case report by Chovanes et al.
ian settings has expanded considerably.
The iTClamp is a mechanical Practical considerations argue against the original two-dose
®
device for controlling hemor- plan. If only one dose is practical in the field, then what should
rhage in craniomaxillofacial that dose be? The literature supports a 1g dose for bleeding
injuries and penetrating neck patients, as used in the CRASH-2 and MATTERS studies, but
injuries. Its two sets of four emerging research has found that the 2g dose confers a sur-
opposing needles close the vival benefit in severe TBI patients.
edges of a wound and create
pressure on a bleeding site that Medics report that the 10-minute TXA infusion is not ideal
promotes hemostasis. The device does not inflict significant for use on the battlefield and question whether the medication
tissue damage, is easy to train, and is easy and quick to ap- could be administered via slow IV push over 1 minute. Hypo-
ply, and application is easy to remember. Application pain has tension secondary to this mode of administration has not been
been found to be relatively mild. found to be a problem in USSOCOM units that give TXA in
this manner, despite the package insert cautionary note about
The report that provides the evidence supporting the use of this technique of infusion.
the iTClamp in TCCC is nearly complete. The draft wording
for the proposed change to the TCCC Guidelines at present is The literature does support the administration of TXA via the
as follows: IO route, but IM administration needs further assessment be-
fore being recommended. Delay in bioavailability in a casualty
Tactical Field Care Guidelines (Proposed) who may be severely bleeding is the concern, especially when
hypotension has caused vasoconstriction.
3. Massive Hemorrhage (continued)
b. For compressible (external) hemorrhage not amenable Adjusting the dose of TXA in casualties who are known or
to limb tourniquet use or as an adjunct to tourniquet suspected to have ongoing bleeding in an attempt the replace
removal, use CombatGauze as the CoTCCC hemostatic the medication lost to hemorrhage also is being evaluated by
dressing of choice. the change team. Work on this change proposal continues.
• Alternative hemostatic adjuncts:
– Celox Gauze or 11. A Relook at Fluid Resuscitation in TCCC:
– ChitoGauze or Dr Frank Butler
– XStat (Best for deep, narrow-tract junctional The Change Leader for this proposed change to the TCCC
wounds) Guidelines is Major Marc Northern, but he is currently deployed
– iTClamp with a Special Operations Surgical Team. Dr Butler reviewed the
c. For external hemorrhage of the head and neck where evolution of the present TCCC fluid resuscitation recommen-
the wound edges can be easily re-approximated, the iT- dations. The guidelines currently list multiple fluid options in
Clamp may be used either alone or in combination with order of preference, with whole blood being the best option and
other hemostatic adjuncts. Wounds can be packed with Hextend and crystalloids being the least desirable options.
hemostatic gauze or XStat prior to closing the edges
with the iTClamp. A growing body of literature says that crystalloid resuscita-
• The iTClamp does not require additional direct pres- tion is not good for trauma patients. Despite that fact, recent
sure, either when used alone or in combination with papers from both the military and civilian sectors report that
other hemostatic adjuncts. normal saline is the most commonly used resuscitation fluid.
• If the iTClamp is applied to the neck, perform frequent Recent literature on hetastarch resuscitation shows associa-
airway monitoring and evaluate for an expanding
tions with increased mortality and renal damage, although the

138 | JSOM Volume 19, Edition 3 / Fall 2019