Page 128 - JSOM Winter 2021

Fluid Resuscitation in Tactical Combat Casualty Care

TCCC Guidelines Change 21-01

4 November 2021

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Travis Deaton, MD ; Jonathan Auten, DO ; Richard Betzold, MD ; Frank Butler, MD ;
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Terence Byrne, SOCM ; Andre Cap, MD, PhD ; Ben Donham, MD ; Joseph DuBose, MD ;
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Andrew D. Fisher, MD, PA-C ; James Hancock, MD ; Victor Jourdain, MD ; Ryan Knight, MD ;
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Lanny Littlejohn, MD ; Matthew Martin, MD ; Kevin Toland, SOIDC ; Brendon Drew, DO 16
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ABSTRACT
Hemorrhagic shock in combat trauma remains the greatest life have been publications that raise concerns about the use of
threat to casualties with potentially survivable injuries. Ad- crystalloid and colloid solutions in hemorrhagic shock as well
vances in external hemorrhage control and the increasing use as literature that addresses the issue of hypocalcemia in hem-
of damage control resuscitation have demonstrated significant orrhagic shock. These observations have necessitated a relook
success in decreasing mortality in combat casualties. Presently, at the topic of fluid resuscitation for hemorrhagic shock in the
an expanding body of literature suggests that fluid resusci- TCCC environment.
tation strategies for casualties in hemorrhagic shock that in- Several policy and regulatory changes have influenced the
clude the prehospital use of cold-stored or fresh whole blood practice of prehospital care in the deployed environment.
when available, or blood components when whole blood is These include the issuance of a Federal Drug Administration
not available, are superior to crystalloid and colloid fluids. On (FDA) black box warning on hetastarches including Hex-
the basis of this recent evidence, the Committee on Tactical tend, the Armed Services Blood Program Office (ASBPO)
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Combat Casualty Care (TCCC) has conducted a review of production and sourcing of FDA licensed CS-LTOWB, and
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fluid resuscitation for the combat casualty who is in hemor- the Emergency Use Authorization of Freeze-Dried Plasma for
rhagic shock and made the following new recommendations: uncontrolled hemorrhage in military trauma. 9
(1) cold stored low-titer group O whole blood (CS-LTOWB)
has been designated as the preferred resuscitation fluid, with Another important development in this area is that the Amer-
fresh LTOWB identified as the first alternate if CS-LTOWB is ican Association of Blood Banks has now recognized LTOWB
not available; (2) crystalloids and Hextend are no longer rec- as a universal donor whole blood product for patients in hem-
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ommended as fluid resuscitation options in hemorrhagic shock; orrhagic shock. Their 2018 recommendation states that:
(3) target systolic blood pressure (SBP) resuscitation goals have “Recipients shall receive ABO group-compatible Red Blood
been redefined for casualties with and without traumatic brain Cell components, ABO group-specific Whole Blood, or low
injury (TBI) coexisting with their hemorrhagic shock; and (4) titer group O Whole Blood (for non–group O or for recipients
empiric prehospital calcium administration is now recom- whose ABO group is unknown.” The definition of “low titer”
mended whenever blood product resuscitation is required. is deferred to local transfusion services.
Keywords: fluid resuscitation; blood transfusion; calcium; hem- When FDA-compliant CS-LTOWB is not available, a second
orrhage; shock; traumatic brain injury; traumatic injury; dam- option for whole blood for emergency transfusion in trauma
age control resuscitation patients is fresh whole blood (FWB). New programs and
training courses to facilitate the use of FWB in military set-
tings have been developed. In addition to the Ranger Group
O Low-Titer (ROLO) program that was initiated in 2015,
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Proximate Cause for This Change
the US Special Operations Command recently extended their
Whole blood was recommended by the Committee on TCCC FWB program to include all their component forces under the
(CoTCCC) in June of 2014 as the preferred prehospital fluid command-sanctioned Special Operations Low-Titer O Whole
for resuscitation from hemorrhagic shock. Since that update Blood (SOLO) Program. Conventional US Marine Corps in-
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to the TCCC Guidelines, the ongoing monitoring of new pa- fantry forces have also reported successful training and imple-
pers in the medical literature conducted by the CoTCCC has mentation of fresh whole blood use under the Valkyrie FWB
noted a number of publications that attest to the benefit of program. 13,14 There is additional interest from prehospital
earlier use of whole blood or blood components. There have providers outside of the military with FWB training programs
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also been publications that have documented increased sur- now reported in civilian EMS and law enforcement programs
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vival with increasing SBP in TBI patients. Additionally, there including the Texas Rangers. 15
1–16 Please see affiliations on page 134.
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