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outside existing paradigms, such as non-medical personnel taking ■ Emergency airway interventions should prioritize REVERSIBLE
and record vital signs or Tier 3 TCCC medical personnel maintain- pathology in salvageable patients.
ing vent settings on a stable patient. The MASCAL standard of care ■ Decisions will depend on available resources and skillsets (i.e.,
will be driven by the volume of casualties, resources, and risk or penetrating traumatic brain injury [TBI] triaged differently if no
mortality/morbidity due to degree of injury/illness; as such, remain neurosurgery is available in a timely manner or at all in theater).
agile throughout the MASCAL and trend in both directions based ■ Conserve, ration, and redistribute additional scarce resources (i.e.,
upon resources available. blood, drug).
3. MASCAL management is often intuitive and reactive (due to lack
of full mission training opportunities) and should rely on famil- Massive Hemorrhage – CPT John Maitha
iar terminology and principles. Treatment and casualty movement Background
should be rehearsed to create automatic responses.
4. The tactical and strategic operational context will underpin every Early recognition and intervention for life-threatening hemorrhage
are essential for survival. The immediate priorities are to control
facet of MASCAL in a PCC environment, operational commanders life-threatening hemorrhage and maintain vital organ perfusion with
MUST be involved in every stage of MASCAL response (The mere rapid blood transfusion (see Table 2). 4
fact that a medical professional or team of medical professionals
is forced to hold a casualty longer than doctrinal planning time- Pre-deployment, Mission Planning, and
lines means there is a failure in the operational/logistical evacua- Training Considerations
tion chain. Battle lines, ground-to-air threat, etc. levels may have 1. Conduct unit level blood donor testing (for blood typing, transfu-
shifted.) sion transmitted diseases and Low Titer blood type O titers) and
5. Logistical resupply may need to include non-standard means and develop operational roster.
involve personnel and departments not typically associated with 2. Define Cold Chain Stored Whole Blood (CSWB) distribution
Class VIII in other situations (i.e., aerial resupply, speedballs, quantities in area of responsibility.
caches, local national market procurement). 3. Manage and equip prehospital blood storage program if unit poli-
6. The most experienced person should establish MASCAL roles and cies and procedures allow for prehospital blood storage.
responsibilities, as appropriate.
Airway Management – HMC Wayne Papalski
Key Considerations in MASCAL
■ Usually, simpler is better. Background
■ Focus on those that will preserve scarce resources, such as blood. Airway compromise is the second leading cause of potentially sur-
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■ Triage is a continuous process and should be repeated as often as vivable death on the battlefield after hemorrhage. Complete airway
is clinically and operationally practical. occlusion can cause death from suffocation within minutes. Austere
■ Avoid high resource and low yield interventions. environments present significant challenges with airway management.
Limited provider experience and skill, equipment, resources, and
TABLE 2 PCC Role-Based Guidelines for Massive Hemorrhage Management
PCC Role-based Guidelines for Massive Hemorrhage Management
*All Personnel – Complete Basic TCCC Management Plan for Massive Hemorrhage then:
TCCC - TCCC - TCCC - TCCC -
ASM CLS CMC CPP • Identify life-threatening bleeding that may have started or was not adequately controlled with initial interventions
in TCCC Basic Management Plan for Massive Hemorrhage.
• Check tourniquets to ensure that they have not shifted or loosened.
• Re-assess and re-apply MARCH interventions.
• Perform all recommended interventions from guidelines for above tier level.
• Ensure all interventions noted above are completed by TCCC ASM and CLS personnel.
• Conduct inventory of all resources.
• Document all pertinent information on PCC Flowsheet (attached).
• Additional interventions include:
Role 1a:
• Conduct Triage – Time Assessment.
• Assess extremities distal to pressure dressings to ensure that they are not acting as a venous tourniquet which
could result in compartment syndrome by checking pulses and the skin color distal to the dressing.
• Communicate evacuation and re-supply requirements (i.e., Blood resupply/Speedball).
• Administer Calcium and Tranexamic Acid (TXA) per TCCC guideline.
Role 1b:
• Re-assess and re-apply MARCH interventions.
• Consider tourniquet conversion (> 2 hr but before 6 hr).
• Assess for refractory shock – see Circulation Section.
Role 1c:
• Evaluate for compartment syndrome.
• Consider teleconsultation.
• Continue resuscitation until: min: palpable radial pulse or improved mental status better: SBP > 90mmHg best: SBP
between 100–110mmHg. Discontinue fluid administration when one of the above end points have been achieved.
• Ensure interventions noted above are completed by TCCC ASM, CLS and Combat Medic/Corpsmen (CMC)
personnel.
• Conduct inventory of all resources.
• Document all pertinent information on PCC Flowsheet (attached).
• Additional interventions include:
Role 1a:
• Re-assess all prior MARCH interventions.
Role 1b:
• Assess using ultrasound (if available) including Extended Focused Assessment with Sonography in Trauma, Central
Venous Pressure.
• Determine hypovolemia vs. refractory shock to drive decision on further resource utilization.
Role 1c:
• Convert to type-specific blood replacement, if testing available.
• Establish Foley catheter with goal Urine Output (UOP) of > ½mL/kg per hour.
*Link to Damage Control Resuscitation (DCR) in Prolonged Field Care CPG, 01 Oct 2018 5

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