Page 165 - JSOM Spring 2020

Dr Qassim discussed a case between two coworkers at an Dr Deaton felt it necessary to go over the history of fluid
airport where the casualty was stabbed in the groin and resuscitation to show how far we have come. In 1993 we
bled out due to a severed femoral artery. If EMS would were using two large-bore IV lines and 2L of crystalloid
have had whole blood and possibly trained on REBOA, he (NS or LR) infused rapidly.
felt he had a good chance to survive. He went on to discuss
how as a physician in England they are used in the prehos- *0959: South Tower collapsed – moment of silence observed*
pital environment and have been using REBOA in the field Then in 1994, the Ben Taub Report came out. In their data
for the last 5 years. His team has trained EMS in Paris as they pointed out that in hypotensive penetrating trauma pa-
well with good success. He has concerns on the training in tients who received large-volume crystalloid infusions be-
the US due to the vast inapparencies between EMS agencies fore going into the operating room, these patients did much
(voluntary vs nonvoluntary). worse than the patients who had delayed resuscitation.
We have run two RAPToR courses that last approximately The CoTCCC came out with fluid resuscitation in 1996 – 1)
a day and a half, which includes 8 hours of lectures/discus- At the point of injury fluid resuscitation was to be delayed
sion followed by hands-on training utilizing task trainers. until Tactical Field Care, 2) NO IV fluids for casualties not
Perfused cadavers were also used thanks to Dr Redman. in shock, 3) NO IV fluids for casualties in shock resulting
from uncontrolled hemorrhage, 4) for casualties in shock as
Dr Qassim has been working on getting national sponsors
with some success. He is close to getting the National Asso- a result of hemorrhage that is now controlled, give 1000mL
®
®
ciation of EMS Physicians to assume overall responsibility of Hespan initially, and 5) limit Hespan to 1,500mL or
for the course. There are other places you can get the com- less.
ponents of this course, but all are separate. For example, In 1999, USSOCOM funded a workshop with the Spe-
the THOR website has information and an online training cial Operations Medical Association to look at case stud-
course for whole blood. Another is the STRAC website. ies from Mogadishu. One of the lessons learned from this
workshop was to titrate to mentation. Dr Holcomb and Dr
The way ahead includes: 1) standardizing the curriculum, 2) Champion held a series of fluid resuscitation conferences
cross-discipline agreement, 3) military-civilian partnership, between 2001 and 2002, to lay out where are we going
4) regular courses (nationally), 5) ongoing skills, 6) mainte- with fluid resuscitation. In 2014, the current TCCC rec-
nance/assessment (local), and 7) organizational sponsorship.
ommendations for fluid resuscitation were implemented.
RAPToR Course website: https://www.raptorcourse.com/ Whole blood was at the top of the list.
Next course: 19–20 May 2020 in Houston, Texas The objectives for prehospital fluid resuscitation are 1) en-
hance the body’s ability to form clots, 2) minimize iatro-
There was a brief question and answer session after this
section. genic coagulopathy, 3) provide sufficient intravascular
volume for organ perfusion, and 4) optimize oxygen car-
*0937: Pentagon Hit – Moment of Silence Observed* rying capacity.
Q1: What is the legal aspect of using REBOA in prehospital The question you are probably asking is what is the proxi-
vs hospital and at what level of medical care? mate cause for change?
A1: No law specifically. It should ideally be a physician (or i. Black box warnings
at least physician-directed). In hospital depends on cre- ii. Low titer O whole blood (LTOWB)
dentials and individual training. Prehospital follows same iii. Walking blood bank = 2% used
guidelines. Remember REBOA is a team sport. iv. ARC paper
Q2: Is there an advantage in delaying transportation to
perform this procedure because one cannot do this in a
helicopter?
A2: It is a judgment call at the time.
Q3: Are there other options besides the REBOA to use in
a prehospital environment?
A3: Yes, but in the RAPToR course we do not train in the
AAJT.
Q4: Nonphysicians *1002: Flight 93 crashed in a field – moment of silence
A4: Yes – if appropriately trained and unit willing to take observed
responsibility. Six (6) Questions that Dr Deaton presented to the Commit-
tee moving forward with fluid resuscitation.
Q5: Is it realistic to train a nonsurgeon?
A5: Yes – nonsurgeons are placing in UK and France. Key is 1. Is there a continued role of crystalloids?
skill maintenance (same for surgeons). 2. Is there a continued role of Hextend?
3. Is FFP an adequate alternative?
5. Fluid Resuscitation (change) 4. What is target BP for traumatic hemorrhage with con-
Dr/CDR Travis Deaton, chairman of emergency medicine current TBI?
at Naval Medical Center in San Diego and CoTCCC mem- 5. Should POC lactate or compensatory reserve index
ber, started his remarks with the standard disclaimers and guide intervention?
disclosures with no financial compensation or interests. 6. Should calcium be considered with fluid resuscitation?

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