Page 23 - JSOM Fall 2020

Management of Hypothermia in Tactical Combat Casualty Care

TCCC Guideline Proposed Change 20-01
June 2020

4
3
B. L. Bennett, PhD ; Gordon Giesbrecht, PhD ; Ken Zafren, MD ; Ryan Christensen ;
1
2
5
8
Lanny Littlejohn, MD ; Brendon Drew, DO ; Andrew Cap, MD, PhD ; Ethan Miles, MD ;
6
7
10
Frank Butler, MD ; John B. Holcomb, MD ; Stacy Shackelford, MD 11
9
ABSTRACT Proximate Reasons for This Proposed Change
As an outcome of combat injury and hemorrhagic shock, Military forces have historically experienced significant loss
trauma-induced hypothermia (TIH) and the associated coagu- of the fighting strength from exposure during cold weather
lo pathy and acidosis result in significantly increased risk for operations that results in hypothermia and other cold-related
death. In an effort to manage TIH, the Hypothermia Prevention morbidities. For over a century, research has been reported
1,2
and Management Kit (HPMK) was implemented in 2006 for on combat casualties with hemorrhagic shock, coagulopathy,
™
battlefield casualties. Recent feedback from operational forces acidosis, and trauma-induced hypothermia (TIH). 3–15 When
indicates that limitations exist in the HPMK to maintain ther- combat casualties incur hemorrhage and shock, the effects of
mal balance in cold environments, due to the lack of insulation. TIH result in significantly increased mortality. Consequently,
Consequently, based on lessons learned, some US Special Opera- hypothermia prevention and rewarming are an essential com-
tions Forces are now upgrading the HPMK after short-term use ponent of prehospital and hospital trauma care guidelines. 16,17
(60 minutes) by adding insulation around the casualty during
training in cold environments. Furthermore, new research in- The Committee on Tactical Combat Casualty Care (CoTCCC)
dicates that the current HPMK, although better than no hypo- decided to review hypothermia prevention and management
thermia protection, was ranked last in objective and subjective guidelines in 2018 and to update them on the basis of the fol-
measures in volunteers when compared with commercial and lowing rationales:
user-assembled external warming enclosure systems. On the ba-
sis of these observations and research findings, the Committee (1) There has been no update in the TCCC Hypothermia Pre-
on Tactical Combat Casualty Care decided to review the hy- vention and Management guidelines (initiated November
pothermia prevention and management guidelines in 2018 and 2005) for 14 years. 18
to update them on the basis of these facts and that no update (2) Hypothermia prevention is the third most frequent life-sav-
has occurred in 14 years. Recommendations are made for mini- ing intervention in battlefield casualties after vascular
mal costs, low cube and weight solutions to create an insulated access and hemorrhage control. Before 2006, wool blan-
19
HPMK, or when the HPMK is not readily available, to create an kets were primarily used to prevent or manage TIH be-
improvised hypothermia (insulated) enclosure system. fore and during medical evacuation. In 2006, CoTCCC
11
published hypothermia prevention guidelines and the US
Keywords: trauma, coagulopathy, shock, hypothermia; re- Central Command Joint Theater Trauma System pub-
warming; improvised lished the first Clinical Practice Guideline to address a
*Correspondence to P.O. Box 235, Bena, VA 23018 or email: blbennetto6@gmail.com
1 CAPT (Ret) Bennett, US Navy, is a former tactical paramedic, and US Navy physiologist; adjunct professor and former vice chairman, Military
& Emergency Medicine Department, Uniformed Services University of the Health Sciences; former Commanding Officer, Field Medical Service
2
School, Marine Corps Base, Camp Pendleton, California. Dr. Giesbrecht is a professor of thermophysiology at the University of Manitoba,
Winnipeg, Manitoba, Canada, where he runs the Laboratory for Exercise and Environmental Medicine. Dr. Zafren is a clinical professor of
3
Emergency Medicine and staff emergency physician at Stanford University, Palo Alto, California, and staff emergency physician at the Alaska
Native Medical Center, Anchorage, Alaska. HMCS (Ret) Christensen, SOIDC, ATP, NRP, US Navy, is a retired Special Operations Independent
4
Duty Corpsman with US Marine Corps Reconnaissance, US Marine Corps Special Operations Command, and Naval Special Warfare units.
6
5 CAPT Littlejohn, US Navy, is an emergency medicine physician serving as the Force Medical Officer, Naval Special Warfare Command. CAPT
Drew, US Navy, is the 1st Marine expeditionary force surgeon; chairman, Committee on Tactical Combat Casualty Care and the Navy emergency
7
medicine Specialty Leader. COL Cap, US Army, is the Division Chief, Acute Combat Casualty Care Research, US Army Institute of Surgical Re-
8
search. LTC Miles, US Army, is the Command Surgeon for the US Army Maneuver Center of Excellence; associate professor military/emergency
9
medicine, Uniformed Services University of the Health Sciences. CAPT (Ret) Butler, US Navy, is a former Navy SEAL platoon commander, oph-
thalmologist, Navy Undersea Medical Officer, former Command Surgeon for US Special Operations Command, and for 11 years, the chairman
of the Department of Defense Committee on Tactical Combat Casualty Care. COL (Ret) Holcomb, US Army, is a professor of surgery at the
10
Center for Injury Science, Department of Surgery at the University of Alabama at Birmingham; former commander of the United States Army
11
Institute of Surgical Research. Col Shackelford, US Air Force, is a trauma surgeon who currently serves as the chief of the Joint Trauma System,
Defense Health Agency, San Antonio, TX.
21