Page 52 - JSOM Fall 2023

Slow Intravenous Infusion of a Novel Damage Control
Cocktail Decreases Blood Loss in a Pig Polytrauma Model

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Nathan J. White, MD, MS *; Chloe Asato, BS ; Andrew Wenthe, BS, MS, SOCM ;
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Xu Wang, MD ; Kristyn Ringgold, PhD ; Alexander St. John, MD, MS ;
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Chang Yeop Han, PhD ; Jennifer C. Bennett, DVM, MS ; Susan A. Stern, MD 9
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ABSTRACT
Background: Our objective was to optimize a novel damage place in the prehospital environment. In the Special Forces
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control resuscitation (DCR) cocktail composed of hydro- community, hemorrhage from explosions and gunshot wounds
xyethyl starch, vasopressin, and fibrinogen concentrate for the has consistently been the leading cause of potentially surviv-
polytraumatized casualty. We hypothesized that slow intra - able death for the past 20 years, including, crucially, death
venous infusion of the DCR cocktail in a pig polytrauma model from noncompressible torso hemorrhage (NCTH). Impor-
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would decrease internal hemorrhage and improve survival tantly, polytrauma that includes both TBI and hemorrhagic
compared with bolus administration. Methods: We induced shock often coincide. This is critical because even brief epi-
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polytrauma, including traumatic brain injury (TBI), femoral sodes of hypotension induced by hemorrhage can exacerbate
fracture, hemorrhagic shock, and free bleeding from aortic TBI mortality. 7–9
tear injury, in 18 farm pigs. The DCR cocktail consisted of 6%
hydroxyethyl starch in Ringer’s lactate solution (14mL/kg), The concept of advanced resuscitative care was introduced by
vasopressin (0.8U/kg), and fibrinogen concentrate (100mg/kg) the Committee on Tactical Combat Casualty Care (TCCC) to
in a total fluid volume of 20mL/kg that was either divided in meet the need for better treatment of battlefield hemorrhage,
half and given as two boluses separated by 30 minutes as con- including NCTH. Advanced resuscitative care interventions
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trol or given as a continuous slow infusion over 60 minutes. include frontline whole blood transfusion, tranexamic acid,
Nine animals were studied per group and monitored for up and zone 1 (i.e., above the celiac artery) resuscitative endo-
to 3 hours. Outcomes included internal blood loss, survival, vascular balloon occlusion of the aorta (REBOA). However,
hemodynamics, lactate concentration, and organ blood flow operationalizing whole blood transfusions and REBOA on the
obtained by colored microsphere injection. Results: Mean in- battlefield is difficult because of the lack of immediate supply
ternal blood loss was significantly decreased by 11.1mL/kg and logistics.
with infusion compared with the bolus group (p = .038). Sur-
vival to 3 hours was 80% with infusion and 40% with bolus, Combat medics are tasked to sustain a casualty for up to 72
which was not statistically different (Kaplan Meier log-rank hours prior to turning over to a higher echelon of care. The
test, p = .17). Overall blood pressure was increased (p < .001), quality of care and likelihood of survival, however, are highly
and blood lactate concentration was decreased (p < .001) with contingent on the resources available to the medic on scene.
infusion compared with bolus. There were no differences in Typically, a 30-person element will have up to four medics,
organ blood flow (p > .09). Conclusion: Controlled infusion with the average closer to three. In an ideal situation, two will
of a novel DCR cocktail decreased hemorrhage and improved carry their own med bags while the other two carry Golden
resuscitation in this polytrauma model compared with bolus. Minute Containers (Bloodstone, Tampa, FL) that include
The rate of infusion of intravenous fluids should be considered blood coolers to facilitate whole blood transfusion. It is likely,
as an important aspect of DCR. however, that at least one will carry a casualty litter instead of
a med bag or blood cooler. In some cases, when vehicles are
Keywords: hemorrhage; resuscitation; hemorrhagic shock, employed as a mode of transportation, medics are afforded
traumatic brain injury; fibrinogen; vasopressin; combat space for a truck bag in a designated “med vic” to store extra
casualty care supplies; however, this is not always the case and cannot be
relied upon. Within each med bag, medics will typically carry
two to four extremity tourniquets, a junctional tourniquet, a
pelvic binder, endotracheal tubes, a bag valve mask, a manual
Introduction
suction pump, intravenous/intraosseous access supplies, drugs,
Hemorrhage is the leading cause of preventable death from blood draw/administration supplies, saline (to reconstitute
battlefield injuries, and more than 90% of these deaths take drugs), hypertonic saline, a pulse oximeter, and sometimes a
*Correspondence to whiten4@uw.edu
1 Dr Nathan J. White is affiliated with the University of Washington School of Medicine, Department of Emergency Medicine, Seattle, WA, and
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the University of Washington Resuscitation Engineering Science Unit (RESCU), Seattle. Chloe Asato is affiliated with the John A. Burns School
of Medicine, University of Hawaii, Honolulu, HI. Andrew Wenthe is affiliated with the U.S. Navy, Active Duty, Special Operations Combat
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Medic–SOCM, Fort Bragg, NC. Dr Xu Wang, Dr Kristyn Ringgold, Dr Alexander St. John, and Dr Chang Yeop Han are affiliated with the
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University of Washington School of Medicine, Department of Emergency Medicine, Seattle, and the University of Washington Resuscitation En-
gineering Science Unit (RESCU), Seattle. Dr Jennifer C. Bennett is affiliated with the University of Washington School of Medicine, Department
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of Emergency Medicine, Seattle, the University of Washington Resuscitation Engineering Science Unit (RESCU), Seattle, and the University of
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Washington Department of Comparative Medicine, Seattle. Dr Susan A. Stern is affiliated with the University of Washington School of Medicine,
Department of Emergency Medicine, Seattle, and the University of Washington Resuscitation Engineering Science Unit (RESCU), Seattle.
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