Page 88 - 2020 JSOM Winter

intravascular drug concentration of TXA and thereby theoret- of TXA administration in combat settings by the 75th Ranger
ically reduce the rates of side effects, including hypotension, Regiment from July 2013 to December 2019. Chart review
seizures, or anaphylaxis. 11–13 was independently conducted by two trained chart abstrac-
tors. Data were collected in a deidentified manner and stored
However, this slow and cumbersome TXA infusion protocol is on a secure server. This PI project received approval from the
not compatible with the operational battlefield environment, 75th Ranger Regimental command prior to data collection,
which is dynamic, resource limited, and often in low-light con- and all publicly disseminated information was approved by
ditions. It is therefore not surprising that difficulty in adminis- the regimental public affairs officer.
tering TXA as a drip over 10 minutes has been identified as a
possible obstacle to compliance, and the Committee on TCCC Chart Abstraction Procedures
has been considering modifications to their TXA administra- A total of 245 charts were screened, 69 of which described
tion protocol since early 2019. 14,15 casualties who had received TXA. Of these 69 charts, three
charts were eliminated for having insufficient TXA documen-
The 75th Ranger Regiment has anecdotally identified three tation, one revealed that no actual TXA was administered due
challenges specific to TXA administration in the battlefield to failure of an IO device, and one described an injury related
environment. First, an IV drip setup is often difficult or even to a training exercise. Of the 64 remaining charts, 58 were
infeasible in this environment. Second, dosing is often inac- excluded for either receiving only a single 1g flush of TXA
curate due to difficulties in calculating and maintaining the (n = 51) or for receiving an initial 1g flush then a second 1g
appropriate drip rate. Third, accidental dislodgement of IV flush prior to evacuation (n = 7), leaving six that met the in-
access during casualty movement is common. clusion criteria for the present case series analysis (N = 6). Of
the six qualifying cases, three were US Servicemembers and
To overcome these challenges, the 75th Ranger Regiment three were Afghan Servicemembers. All qualifying cases were
has been systematically adjusting their TXA protocols. First, from 2019.
in 2014, the 10-minute drip was replaced with a recommen-
dation that the first 1g dose of TXA be administered as a TXA Administration Procedure
slow IV/IO push over 2 minutes. IO TXA administration is For each qualifying case, the flush dose was administered us-
approved by TCCC and has been recommended for human ing a novel method in which 2g of TXA was predrawn into
use after demonstrating equal efficacy as IV TXA in porcine two labeled 10mL syringes (1g TXA each) within 7 days prior
models. 2,16 In 2017, the slow IV/IO push recommendation was to mission start. After IV (n = 4) or IO (n = 2) access was estab-
replaced with a rapid 1g IV/IO flush, commonly administered lished, Ranger medics confirmed placement by first observing
from predrawn 10mL syringes filled with 1g TXA and labeled aspirate on syringe plunger withdrawal, then slowly adminis-
appropriately. In 2019, Ranger medics were given the option tering the first 1–2cc of TXA to assess for extravasation. Once
to flush with 1g or 2g of TXA. Toward ensuring that patients access was confirmed by both visual and tactile inspection, the
receive the full 2g dose, recommendations were modified in remainder of the 2g flush dose was rapidly administered.
late 2019 to mandate the single 2g TXA flush.
Vitals Assessment Protocol
Figure 1 displays the initial phase of the Tactical Damage Con- Vital signs were obtained pre- and post-TXA administration,
trol Resuscitation Protocol currently used by the 75th Ranger including heart rate (HR), systolic blood pressure (SBP), re-
Regiment. This step-by-step protocol includes TXA indica- spiratory rate (RR), and oxygen saturation (Spo ). Vital signs
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2
tions and instructions. For blunt or penetrating trauma, the were measured by the standards of care established by the
casualty is assessed for signs and symptoms of hypovolemic Ranger Medic Handbook rather than by standardized prede-
shock, followed by the 2g TXA flush, followed by rapid blood termined pre- and post-TXA administration intervals. HR
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product infusion. was determined via pulse palpation timed with a wristwatch
or from portable fingertip pulse oximeter. RR was obtained by
However, the clinical effects of the 2g TXA flush has not been visual inspection timed with a wristwatch. SBP estimation was
previously reported in published literature. Therefore, the pur- performed in accordance with Ranger medic protocols, with
pose of this case series is to report the results of six casual- a palpable radial pulse indicating at least 80mmHg (recorded
ties who received 2g TXA flush to treat traumatic battlefield as 80mmHg), and if radial pulse was absent, palpable carotid
injuries. The primary outcomes of interest were hypoten- pulse indicating at least 60mmHg (recorded as 60mmHg).
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sion, seizures, and anaphylaxis immediately following TXA While known to be a non-ideal method, TCCC guidelines and
administration. the Ranger Medic Handbook include the palpable radial pulse
assessment because the more precise sphygmomanometry
method is often not feasible during battlefield care. 2,17,18 Di-
Methods
astolic blood pressures were not obtained. Spo was obtained
2
Setting and Sample from a portable fingertip pulse oximeter.
This case series reviews six casualties receiving a 2g TXA flush
dose for treatment of exsanguinating or potentially exsangui- Adverse Outcomes
nating traumatic injuries suffered on the Afghanistan battle- For the purpose of this PI investigation, the following param-
field in 2019. eters were used to define adverse outcomes. “Hypotension”
was defined as a drop in SBP of 20mmHg or greater using
Process Improvement Procedures the estimations previously described. “Seizure” was defined as
This retrospective case series was conducted as part of a pro- any presence of convulsions that presented after drug admin-
cess improvement (PI) project within the 75th Ranger Regi- istration. “Anaphylaxis” was defined as any development of
ment in December 2019. This PI project evaluated practices urticaria, skin flushing, wheezing, or angioedema.

86 | JSOM Volume 20, Edition 4 / Winter 2020