Page 134 - JSOM Winter 2021

In settings such as tactical field care or mass casualty scenar- TCCC and are better addressed in prolonged casualty care
ios, the use of type O fresh whole blood of unknown anti-A and JTS CPGs.
and anti-B titer may be safer than attempting to match blood
groups between donors and recipients. The risk of hemolysis Proposed Change to the TCCC Guidelines
from major mismatch is greater than the risk of transfusing a Current Wording
very high-titer group O unit (very high titers being relatively
uncommon) to a non–group O recipient. Tactical Field Care and TACEVAC Care
Dried plasma remains an acceptable fluid for resuscitation in e. Fluid resuscitation
trauma, particularly in tactical situations where cold chain • Assess for hemorrhagic shock (altered mental status in
storage of alternative blood products is not practical. Units the absence of brain injury and/or weak or absent radial
that do not have the capability to use cold-stored or fresh pulse).
LTOWB for casualties who require fluid resuscitation should • The resuscitation fluids of choice for casualties in hem-
make a maximal effort to obtain a dried plasma product and orrhagic shock, listed from most to least preferred, are:
train their medics in its use. whole blood*; plasma, red blood cells (RBCs) and plate-
lets in a 1:1:1 ratio*; plasma and RBCs in a 1:1 ratio;
(2) Should crystalloid solutions and Hextend be plasma or RBCs alone; Hextend; and crystalloid (lac-
removed as TCCC-recommended fluids for resuscitation tated Ringer’s or Plasma-Lyte A).
of hemorrhagic shock? NOTE: *Hypothermia prevention measures [Section 7]
The preponderance of available evidence demonstrates im- should be initiated while fluid resuscitation is being
proved outcomes and survival in hemorrhagic shock when accomplished.
blood products are utilized to resuscitate these casualties • If not in shock:
rather than crystalloids or colloids. While Hextend, lactated – No IV fluids are immediately necessary.
Ringer’s, and Plasma-Lyte A have been removed from the fluid – Fluids by mouth are permissible if the casualty is
resuscitation guidelines for traumatic hemorrhage, crystalloid conscious and can swallow.
solutions are used for other purposes in tactical field care such • If in shock and blood products are available under an
as burns and reconstitution fluids. approved command or theater blood product adminis-
tration protocol:
(3) What is the optimal target SBP for resuscitation of – Resuscitate with whole blood*, or, if not available
hemorrhagic shock casualties, and does this change when – Plasma, RBCs, and platelets in a 1:1:1 ratio*, or, if
traumatic brain injury is also present? not available
End points of fluid resuscitation may be challenging to mea- – Plasma and RBCs in a 1:1 ratio, or, if not available
sure in tactical field care with limited monitoring equipment – Reconstituted dried plasma, liquid plasma, or thawed
and fluid resuscitation may therefore need to be titrated to a plasma alone or RBCs alone
palpable radial pulse or improved mentation. If blood pressure – Reassess the casualty after each unit. Continue resus-
measurements are available; however, the updated recommen- citation until a palpable radial pulse, improved men-
dation is that fluid resuscitation of casualties in hemorrhagic tal status, or SBP of 80–90mmHg is present.
shock should be continued to a target SBP of 100mmHg un- • If in shock and blood products are not available under
less the casualty has concurrent TBI, in which case the target an approved command or theater blood product admin-
SBP should be 100–110mmHg. While further data may refine istration protocol due to tactical or logistical constraints:
these recommendations, it aligns and synchronizes the TCCC – Resuscitate with Hextend, or if not available
guidelines with current damage control resuscitation and pro- – Lactated Ringer’s or Plasma-Lyte A
longed casualty care recommendations. – Reassess the casualty after each 500mL IV bolus.
– Continue resuscitation until a palpable radial pulse,
(4) Should empiric calcium be added to the TCCC fluid improved mental status, or SBP of 80–90mmHg is
resuscitation guideline? If so, how much and which type present.
of calcium formulation should be used, and when in the – Discontinue fluid administration when one or more
resuscitation sequence should it be given? of the above end points has been achieved.
The available evidence suggests that hypocalcemia is common • If a casualty with an altered mental status due to sus-
in trauma and that it is advisable that calcium levels be ad- pected TBI has a weak or absent radial pulse, resuscitate
dressed and repleted to avoid the deleterious effects of hypo- as necessary to restore and maintain a normal radial
calcemia on platelet function, coagulation and contractility, pulse. If BP monitoring is available, maintain a target
and potentially impact survivability in hemorrhagic trauma SBP of at least 90mmHg.
patients. While recognizing that military trauma patients • Reassess the casualty frequently to check for recurrence
with hemorrhagic shock may present with varying severity of shock. If shock recurs, recheck all external hemor-
of hypocalcemia, it is understood that measurement of ion- rhage control measures to ensure that they are still effec-
ized calcium in a tactical environment can be challenging. If tive and repeat the fluid resuscitation as outlined above.
a laboratory guided replenishment protocol is not feasible, a NOTE: *Currently, neither whole blood nor apheresis
single empiric dose of 1g calcium equivalent should be given platelets collected in theater are FDA compliant because of
IV or IO. In order to not delay fluid resuscitation, consider- the way they are collected. Consequently, whole blood and
ation was given to recommend calcium administration after 1:1:1 resuscitation using apheresis platelets should be used
the initial blood product was transfused. Additional calcium only if all of the FDA-compliant blood products needed
may well be required in large volume resuscitations; however, to support 1:1:1 resuscitation are not available, or if 1:1:1
follow-on dose recommendations remain outside the scope of resuscitation is not producing the desired clinical effect.

132 | JSOM Volume 21, Edition 4 / Winter 2021