Page 135 - JSOM Winter 2021

Proposed change the CoTCCC and published in the updated guidelines on 5
November 2020.
Tactical Field Care and TACEVAC Care
d. Fluid resuscitation Level of evidence (AHA/ACC)
• Assess for hemorrhagic shock (altered mental status in The levels of evidence used by the American College of Cardi-
the absence of brain injury and/or weak or absent radial ology and the American Heart Association were described by
pulse). Tricoci in 2009: 103
• The resuscitation fluids of choice for casualties in hem- Level A: Evidence from multiple randomized trials or meta-
orrhagic shock, listed from most to least preferred, analyses.
are: cold stored low titer O whole blood; pre-screened Level B: Evidence from a single randomized trial or non-
low titer O fresh whole blood; plasma, red blood cells randomized studies.
(RBCs) and platelets in a 1:1:1 ratio*; plasma and RBCs Level C: Expert opinion, case studies or standards of care.
in a 1:1 ratio; plasma or RBCs alone.
NOTE: *Hypothermia prevention measures [Section 7] According to this taxonomy, the levels of evidence assigned to
should be initiated while fluid resuscitation is being the following aspects of fluid resuscitation from hemorrhagic
accomplished. shock are provided below.
• If not in shock: 1) Is there a specific blood product that is preferred over oth-
– No IV fluids are immediately necessary. ers for resuscitation of casualties in hemorrhagic shock in
– Fluids by mouth are permissible if the casualty is TCCC? Yes – Cold stored low titer O whole blood. Level B
conscious and can swallow. 2) Should crystalloid solutions and Hextend be removed as
• If in shock and blood products are available under an TCCC-recommended fluids for resuscitation of casualties
approved command or theater blood product adminis- in hemorrhagic shock? Yes. Level A
tration protocol: 3) What is the optimal target SBP for resuscitation of hem-
– Resuscitate with cold stored low titer O whole blood, orrhagic shock casualties, and does this change when
or, if not available traumatic brain injury is also present? A target SBP of
– Pre-screened low titer O fresh whole blood, or, if not 100mmHg for casualties without TBI and a range of 100–
available 110mmHg for those with TBI. Level C
– Plasma, RBCs and platelets in a 1:1:1 ratio, or, if not 4) Should empiric calcium be added to the TCCC fluid re-
available suscitation guideline? If so, how much and which type of
– Plasma and RBCs in a 1:1 ratio, or, if not available calcium formulation should be used, and when in the re-
– Reconstituted dried plasma, liquid plasma or thawed suscitation sequence should it be given? Yes – 1g of calcium
plasma alone or RBCs alone given IV or IO after the first transfused product. Level C
– Reassess the casualty after each unit. Continue resus-
citation until a palpable radial pulse, improved men-
tal status or SBP of 100mmHg is present. Considerations for Further Research
– Discontinue fluid administration when one or more and Development
of the above end points has been achieved. 1. Radial pulse, mental status, and, where available, noninva-
• If blood products are transfused, administer one gram sive blood pressure measurements provide surrogate mark-
of calcium (30mL of 10% calcium gluconate or 10mL ers for tissue profusion. The need exists for lightweight
of 10% calcium chloride) IV/IO after the first transfused and portable biosensors to provide easily discernable infor-
product. mation on oxygen debt and endpoints for resuscitation to
• Given increased risk for a potentially lethal hemolytic guide prehospital fluid strategies.
reaction, transfusion of unscreened group O fresh whole 2. Clinical decision-making is limited in TCCC by the lack of
blood or type-specific fresh whole blood should only available laboratory data. Lightweight and portable point-
be performed under appropriate medical direction by of-care lactate and calcium testing would provide critical
trained personnel. information for initiating resuscitation, continuing blood
• Transfusion should occur as soon as possible after product utilization in a resource-constrained environment
life-threatening hemorrhage in order to keep the patient and provide guidance for continued calcium administration
alive. If Rh-negative blood products are not immediately when appropriate.
available, Rh-positive blood products should be used in 3. Available data on albumin in fluid resuscitation remains
hemorrhagic shock. mixed, especially with regard for moderate to severe TBI
• If a casualty with an altered mental status due to sus- in multi-trauma patients. Further investigation into the op-
pected TBI has a weak or absent radial pulse, resuscitate timal osmotic balance and dose may provide another fluid
as necessary to restore and maintain a normal radial resuscitation option that does not require cold storage and
pulse. If BP monitoring is available, maintain a target minimizes transfusion transmitted illness risks.
systolic BP between 100 and 110mmHg. 4. For low titer group O donors, current guidelines require
• Reassess the casualty frequently to check for recurrence anti-A and anti-B titers less than 1:256. Historical data
of shock. If shock recurs, re-check all external hem- suggests the risk of hemolytic reaction is minimal despite
orrhage control measures to ensure that they are still the measurement of anti-A and anti-B titers. Funding for
effective and repeat the fluid resuscitation as outlined determining the safety profiles and refinement of the defi-
above.
nition for low titer group O whole blood may increase the
CoTCCC Vote: This change was approved by the required number of eligible donors and decrease the cost of screen-
three-quarters or greater majority of the voting members of ing potential donor pools.

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