Page 148 - 2020 JSOM Winter

– Consider, based on the mechanism of injury and been in place >6 hours unless close monitoring and
physical findings, whether decompression of the lab capability are available.
opposite side of the chest may be needed. • Expose and clearly mark all tourniquets with the
– Continue to re-assess! time of tourniquet application. Note tourniquets
• If the initial NDC was successful, but symptoms later applied and time of application; time of reapplica-
recur: tion; time of conversion; and time of removal on the
– Perform another NDC at the same site that was TCCC Casualty Card. Use a permanent marker to
used previously. Use a new needle/catheter unit mark on the tourniquet and the casualty card.
for the repeat NDC b. Assess for hemorrhagic shock (altered mental status in
– Continue to re-assess! the absence of brain injury and/or weak or absent radial
• If the second NDC is also not successful: continue on pulse).
to the Circulation section of the TCCC Guidelines. c. IV Access
b. All open and/or sucking chest wounds should be treated • Intravenous (IV) or intraosseous (IO) access is indi-
by immediately applying a vented chest seal to cover the cated if the casualty is in hemorrhagic shock or at
defect. If a vented chest seal is not available, use a non- significant risk of shock (and may therefore need
vented chest seal. Monitor the casualty for the potential fluid resuscitation), or if the casualty needs medica-
development of a subsequent tension pneumothorax. If tions, but cannot take them by mouth.
the casualty develops increasing hypoxia, respiratory – An 18-gauge IV or saline lock is preferred.
distress, or hypotension and a tension pneumothorax is – If vascular access is needed but not quickly ob-
suspected, treat by burping or removing the dressing or tainable via the IV route, use the IO route.
by needle decompression. d. Tranexamic Acid (TXA)
c. Initiate pulse oximetry. All individuals with moderate/ • If a casualty will likely need a blood transfusion (for
severe TBI should be monitored with pulse oximetry. example: presents with hemorrhagic shock, one or
Readings may be misleading in the settings of shock or more major amputations, penetrating torso trauma,
marked hypothermia. or evidence of severe bleeding)
d. Casualties with moderate/severe TBI should be given OR
supplemental oxygen when available to maintain an ox- • If the casualty has signs or symptoms of significant
ygen saturation >90%. TBI or has altered metal status associated with blast
6. Circulation injury or blunt trauma:
a. Bleeding – Administer 2g of tranexamic acid via slow IV or
• A pelvic binder should be applied for cases of sus- IO push as soon as possible but NOT later than 3
pected pelvic fracture: hours after injury.
– Severe blunt force or blast injury with one or e. Fluid Resuscitation
more of the following indications: • Assess for hemorrhagic shock (altered mental status
■ Pelvic pain in the absence of brain injury and/or weak or absent
■ Any major lower limb amputation or near radial pulse.
amputation • The resuscitation fluids of choice for casualties in
■ Physical exam findings suggestive of a pelvic hemorrhagic shock, listed from most to least pre-
fracture ferred, are:
■ Unconsciousness (1) Cold stored low titer O whole blood
■ Shock (2) Pre-screened low titer O fresh whole blood
• Reassess prior tourniquet application. Expose the (3) Plasma, red blood cells (RBCs) and platelets in a
wound and determine if a tourniquet is needed. If it 1:1:1 ratio
is needed, replace any limb tourniquet placed over (4) Plasma and RBCs in a 1:1 ratio
the uniform with one applied directly to the skin 2–3 (5) Plasma or RBCs alone
inches above the bleeding site. Ensure that bleeding NOTE: Hypothermia prevention measures [Section
is stopped. If there is no traumatic amputation, a dis- 7] should be initiated while fluid resuscitation is be-
tal pulse should be checked. If bleeding persists or a ing accomplished.
distal pulse is still present, consider additional tight- • If not in shock:
ening of the tourniquet or the use of a second tour- – No IV fluids are immediately necessary.
niquet side-by-side with the first to eliminate both – Fluids by mouth are permissible if the casualty is
bleeding and the distal pulse. If the reassessment de- conscious and can swallow.
termines that the prior tourniquet was not needed, • If in shock and blood products are available under an
then remove the tourniquet and note time of removal approved command or theater blood product admin-
on the TCCC Casualty Card. istration protocol:
• Limb tourniquets and junctional tourniquets should – Resuscitate with cold stored low titer O whole
be converted to hemostatic or pressure dressings as blood, or, if not available
soon as possible if three criteria are met: the casualty – Pre-screened low titer O fresh whole blood, or, if
is not in shock; it is possible to monitor the wound not available
closely for bleeding; and the tourniquet is not being – Plasma, RBCs, and platelets in a 1:1:1 ratio, or, if
used to control bleeding from an amputated extrem- not available
ity. Every effort should be made to convert tourni- – Plasma and RBCs in a 1:1 ratio, or, if not available
quets in <2 hours if bleeding can be controlled with – Reconstituted dried plasma, liquid plasma or
other means. Do not remove a tourniquet that has thawed plasma alone or RBCs alone

146 | JSOM Volume 20, Edition 4 / Winter 2020