Page 141 - JSOM Fall 2019

applicability of most of these papers to combat trauma care is Dr Marble called for volunteers to contribute to the sections
questionable. on medical support in the two conflicts as well as medical care
provided off the battlefield. He requested stories of deploy-
The best option for resuscitation of trauma patients is whole ments, case histories, and anything else we consider important
blood, given as soon as possible after the need for resuscitation for inclusion.
is identified. For this reason, the recent Advanced Resuscita-
tive Care in TCCC guidelines added an elevated lactate level 14. New Business: Dr Frank Butler
(>4mmol/L), measured at the prehospital point of care, as an
indication for transfusion. The intent of this recommendation Question: Attendees asked whether there is a recommendation
is to identify casualties in preclinical shock and treat their hy- for sedation included in TCCC, and if so, should the use of
povolemia earlier, rather than waiting for hy potension to oc- this medication be limited to paramedics only?
cur before fluid resuscitation is initiated.
Answer: There is presently no specific recommendation for a
The FDA has also recently approved the battlefield use of the sedative medication in the TCCC Guidelines, although narcot-
French freeze- dried plasma product FLyP, thus offering an- ics and ketamine can have a sedating effect.
other good option if whole blood or blood components are
not feasible. A suggestion was made that a rapid process improvement as-
sessment should be conducted to capture the incidence and
With whole blood and blood components becoming increas- outcomes of benzodiazepine use on the battlefield by Special
ingly available in the prehospital phase of combat casualty Forces medics, since those medications are part of their scope
care, is it time for the CoTCCC to stop recommending the of practice.
use of Hextend and crystalloids altogether? The recent papers Dr Butler also noted that TCCC curriculum development func-
by Shackelford and Kotwal emphasize the need for increased tions will transfer in the near future from the CoTCCC to the
emphasis on early transfusion of blood or plasma. There have newly established Joint Trauma Education and Training Branch.
been no papers from Iraq and Afghanistan that show a similar
benefit from asanguin ous fluids.
Thursday – 22 February 2019
Issues that need to be addressed in developing this proposed
change also include the end-point for resuscitation for casual- 14. Advanced Resuscitative Care (ARC) in TCCC:
ties with and without TBI and noncompressible torso hemor- Dr Frank Butler
rhage. This change effort will continue in the coming months.
There is presently an opportunity to eliminate 40% of the pre-
ventable prehospital deaths in US combat casualties through
12. TCCC Web-Mobile Project: Mrs Cynthia Barrigan
DHA J-9; Mr Harold Montgomery – CoTCCC the use of the newly approved TCCC ARC recommendations.
ARC focuses on the use of early whole blood resuscitation
A standardized TCCC longitudinal curriculum is being de- and far-forward Zone 1 resuscitative endovascular balloon oc-
veloped by the DHA Education and Training Directorate (J7) clusion of the aorta (REBOA) to treat hemorrhagic shock in
IAW with Medical Readiness Training DODI 13422.24. This combat casualties.
initiative is being funded by the DHA Research and Develop-
ment Directorate (J9) as part of the Learning Strategy, Tactics ARC identifies cold-stored, low-titer type O whole blood (CS
and Technology (LSTT) Research Program. The curriculum LTOWB) as the best option for whole blood. Blood typing
consists of four tiers that are role-based. Tier 1 or TCCC for and screening of the donated blood for pathogens results pro-
All Servicemembers (TCCC ASM) for nonmedical personnel is vides FDA compliance and increases safety. CS LTOWB can
the first tier (most basic) tier and has been under development be collected in CONUS or closer to the theater and carried far
by a joint working group chartered by DOD Health Affairs. forward in a cooler.
The TCCC-ASM course will incorporate the latest in adult The 75th Ranger Regiment Type O Low (ROLO) program
learning design. Piloting of the new course will begin at the is the second choice for sourcing donor whole blood. Type O
end of March. The final version is due at the end of July and low-titer donors within the unit are identified ahead of time.
formal TCCC-ASM training in the Services is due to start in When needed, their blood is collected and transfused to casual-
April 2020. Mrs Barrigan previewed the ASM curriculum as- ties needing resuscitation. This process takes longer in that the
sets which included selected instructional video content from blood must be collected before transfusion. There is also an ad-
the course. She also provided an update on the current utili- ministrative requirement to follow up on both donors and re-
zation of the Deployed Medicine (DM) platform (web/mobile cipients. Further, there is the realization that both casualty and
app) and indicated that the DM will serve as a distribution donor are still in a tactical environment and the individual who
platform for the new standardized TCCC training content.
just donated blood may be the next person to be wounded.
13. The United States Army in Afghanistan and Iraq: The Untitered type O whole blood from donors who have been
Tan Books: Dr Sanders Marble, Senior Historian, preidentified as type O beforehand can also be used. The risk
AMEDD Center of History and Heritage of a transfusion reaction is very low, as highlighted in the re-
cent paper by COL Shawn Nessen. Use of untitered type O
The “Tan Books” will be a multivolume history of the Ser-
vices’ combat activities in these two countries. whole blood was common practice in World War II and is still
used by Forward Surgical Teams when there is a need for large
Individual elements of the Army (e.g. JAG, Materiel Command, quantities of blood in mass casualty incidents.
Medical Department) will describe the roles they played, the The final option for obtaining whole blood for prehospital
services they provided, and the functions they fulfilled. These blood transfusion is type-specific whole blood. Although this
will be written in a narrative format for general audiences.
option is used by Role 2 surgical teams embarked on surface

CoTCCC Meeting Minutes | 139