Page 34 - JSOM Fall 2020

(alternatives) with a heat source inside a water-impermeable Tactical Field Care & Tactical Evacuation Care
outer shell. Commercial insulated and heated hypothermia 7. Hypothermia Prevention
enclosure systems are bulky, heavy, expensive, and not more a. Take early and aggressive steps to prevent additional
effective than improvised systems as long as high-quality insu- body heat loss and add external heat when possible for
lating layers and heat sources are used. trauma and severely burned casualties.
b. Minimize casualty’s exposure to cold ground, wind, and
The use of IV fluid/blood-warming devices is an essential air temperatures. Place insulation material between the
component for managing hypothermia caused by either pen- casualty and any cold surface as soon as possible. Keep
etrating, blunt, or burn trauma and should deliver consistent protective gear on or with the casualty if feasible.
output temperatures at 38° (100°F) but no higher than 42°C c. Replace wet clothing with dry clothing, if possible, and
(108°F) at a flow rate of up to 150mL/min and perform to protect from additional heat loss.
standard within the extremes of military environments. d. Place an active heating blanket on the casualty’s ante-
rior torso and under the arms in the axillae (to prevent
burns, do not place any active heating source directly on
the skin or wrap around the torso).
PROPOSED CHANGE TO THE TCCC GUIDELINES
e. Enclose the casualty in the exterior impermeable enclo-
sure bag.
Current Wording
f. As soon as possible, upgrade a hypothermia enclosure
Care Under Fire system to a well-insulated enclosure system using a
7. Hypothermia Prevention hooded sleeping bag or other readily available insulation
a. N/A inside the enclosure bag/external vapor-barrier shell.
g. Prestage an insulated hypothermia enclosure system
Tactical Field Care with external active heating for transition from the non-
7. Hypothermia Prevention insulated hypothermia enclosure systems; seek to im-
a. Minimize casualty’s exposure to the elements. Keep pro- prove on existing enclosure system when possible.
tective gear on or with the casualty if feasible. h. Use a battery-powered warming device to deliver IV re-
b. Replace wet clothing with dry if possible. Get the casu- suscitation fluids, in accordance with current CoTCCC
alty on to an insulated surface as soon as possible. guidelines, at flow rate up to 150mL/min with a 38°C
c. Apply the Ready-Heat blanket from the Hypothermia (100°F) output temperature.
Prevention and Management Kit (HPMK) to the casual- i. Protect the casualty from exposure to wind and precipi-
ty’s torso (not directly on the skin), and cover the casu- tation on any evacuation platform.
alty with the Heat Reflective Shell (HRS).
d. If a HRS is not available, the previously recommended Level of evidence: 30
combination of the Blizzard Survival Blanket and the The levels of evidence used by the American College of Car-
Ready-Heat blanket may also be used. diology and the American Heart Association were outlined by
e. If the items mentioned above are not available, use dry Tricoci et al. 70
blankets, poncho liners, sleeping bags, or anything that – Level A: Evidence from multiple randomized trials or
will retain heat and keep the casualty dry. meta-analyses
f. Warm fluids are preferred if IV fluids are required. – Level B: Evidence from a single randomized trial or non-
randomized studies
Tactical Evacuation Care – Level C: Expert opinion, case studies, or standards of
7. Hypothermia Prevention care
a. Minimize casualty’s exposure to the elements. Keep pro- Using the taxonomy above, the level of evidence for each state-
tective gear on or with the casualty if feasible. ment below is shown:
b. Replace wet clothing with dry if possible. Get the casu-
alty onto an insulated surface as soon as possible. Recommendations for Additional Research
c. Apply the Ready-Heat Blanket from the Hypothermia and Development
Prevention and Management Kit (HPMK) to the casual- • Comparison of commercial hypothermia warming systems
ty’s torso (not directly on the skin) and cover the casu- in hemorrhagic shock model
alty with the Heat-Reflective Shell (HRS). • Comparison of warming capability between the battery-
d. If an HRS is not available, the previously recommended powered Warrior and Quantum warming devices with
™
™
combination of the Blizzard Survival Blanket and the crystalloid and whole blood at various input temperatures
Ready Heat blanket may also be used. and flow rates
e. Use a portable fluid warmer capable of warming all IV • Logistical comparison of Warrior and Quantum (e.g.,
™
™
fluids including blood products. weight, cube, battery life)
f. Protect the casualty from wind if doors must be kept • Evaluation of various insulated IV tubing wraps
open. • Compare hypothermia enclosure systems (e.g., user-
assembled system, HPMK, HPMK with insulation and
Proposed New Wording (Proposed new material in red text) internal vapor barrier) in normothermic and cold-stressed
volunteers.
Care Under Fire • Conduct cold-chamber studies with human volunteers with
7. Hypothermia Prevention longer cold exposures, potentially with hypothermic con-
a. N/A ditions starting with normothermia (37°C [98.6°F]) and/or

32 | JSOM Volume 20, Edition 3 / Fall 2020