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suspected, treat by burping or removing the dressing or – If vascular access is needed but not quickly ob-
by needle decompression. tainable via the IV route, use the IO route.
c. Initiate pulse oximetry. All individuals with moderate/ d. Tranexamic Acid (TXA)
severe TBI should be monitored with pulse oximetry. • If a casualty will likely need a blood transfusion (for
Readings may be misleading in the settings of shock or example: presents with hemorrhagic shock, one or
marked hypothermia. more major amputations, penetrating torso trauma,
d. Casualties with moderate/severe TBI should be given or evidence of severe bleeding)
supplemental oxygen when available to maintain an ox- OR
ygen saturation > 90%. • If the casualty has signs or symptoms of significant
6. Circulation TBI or has altered metal status associated with blast
a. Bleeding injury or blunt trauma:
• A pelvic binder should be applied for cases of sus- – Administer 2gm of tranexamic acid via slow IV or
pected pelvic fracture: IO push as soon as possible but NOT later than 3
– Severe blunt force or blast injury with one or hours after injury.
more of the following indications: e. Fluid Resuscitation
■ Pelvic pain • Assess for hemorrhagic shock (altered mental status
■ Any major lower limb amputation or near in the absence of brain injury and/or weak or absent
amputation radial pulse.
■ Physical exam findings suggestive of a pelvic • The resuscitation fluids of choice for casualties in
fracture hemorrhagic shock, listed from most to least pre-
■ Unconsciousness ferred, are:
■ Shock (1) Cold stored low titer O whole blood
• Reassess prior tourniquet application. Expose the (2) Pre-screened low titer O fresh whole blood
wound and determine if a tourniquet is needed. If it (3) Plasma, red blood cells (RBCs) and platelets in
is needed, replace any limb tourniquet placed over a 1:1:1 ratio
the uniform with one applied directly to the skin 2–3 (4) Plasma and RBCs in a 1:1 ratio
inches above the bleeding site. Ensure that bleeding (5) Plasma or RBCs alone
is stopped. If there is no traumatic amputation, a dis- NOTE: Hypothermia prevention measures [Section 7]
tal pulse should be checked. If bleeding persists or a should be initiated while fluid resuscitation is being
distal pulse is still present, consider additional tight- accomplished.
ening of the tourniquet or the use of a second tour- • If not in shock:
niquet side-by-side with the first to eliminate both – No IV fluids are immediately necessary.
bleeding and the distal pulse. If the reassessment de- – Fluids by mouth are permissible if the casualty is
termines that the prior tourniquet was not needed, conscious and can swallow.
then remove the tourniquet and note time of removal • If in shock and blood products are available under an
on the TCCC Casualty Card. approved command or theater blood product admin-
• Limb tourniquets and junctional tourniquets should istration protocol:
be converted to hemostatic or pressure dressings – Resuscitate with cold stored low titer O whole
as soon as possible if three criteria are met: the ca- blood, or, if not available
sualty is not in shock; it is possible to monitor the – Pre-screened low titer O fresh whole blood, or, if
wound closely for bleeding; and the tourniquet not available
is not being used to control bleeding from an am- – Plasma, RBCs, and platelets in a 1:1:1 ratio, or, if
putated extremity. Every effort should be made to not available
convert tourniquets in less than 2 hours if bleeding – Plasma and RBCs in a 1:1 ratio, or, if not available
can be controlled with other means. Do not remove – Reconstituted dried plasma, liquid plasma or
a tourniquet that has been in place more than 6 thawed plasma alone or RBCs alone
hours unless close monitoring and lab capability are – Reassess the casualty after each unit. Continue
available. resuscitation until a palpable radial pulse, im-
• Expose and clearly mark all tourniquets with the time proved mental status or systolic BP of 100mmHg is
of tourniquet application. Note tourniquets applied present.
and time of application; time of re- application; time – Discontinue fluid administration when one or
of conversion; and time of removal on the TCCC Ca- more of the above end points has been achieved.
sualty Card. Use a permanent marker to mark on the – If blood products are transfused, administer one
tourniquet and the casualty card. gram of calcium (30mL of 10% calcium gluco-
b. Assess for hemorrhagic shock (altered mental status in nate or 10mL of 10% calcium chloride) IV/IO
the absence of brain injury and/or weak or absent radial after the first transfused product.
pulse). • Given increased risk for a potentially lethal hemo-
c. IV/IO Access lytic reaction, transfusion of unscreened group O
• Intravenous (IV) or intraosseous (IO) access is indi- fresh whole blood or type specific fresh whole blood
cated if the casualty is in hemorrhagic shock or at should only be performed under appropriate medical
significant risk of shock (and may therefore need direction by trained personnel.
fluid resuscitation), or if the casualty needs medica- • Transfusion should occur as soon as possible after
tions, but cannot take them by mouth. life-threatening hemorrhage in order to keep the
– An 18-gauge IV or saline lock is preferred. patient alive. If Rh negative blood products are not

TCCC Guidelines for Medical Personnel | 13