Page 104 - JSOM Spring 2024

– Consider, based on the mechanism of injury and physical findings, whether decompression of the opposite side of
the chest may be needed.
– Continue to reassess!
• If the initial NDC was successful, but symptoms later recur:
– Perform another NDC at the same site that was used previously. Use a new needle/catheter unit for the repeat NDC
– Continue to reassess!
– If the second NDC is also not successful: continue on to the Circulation section of the TCCC Guidelines.
b. All open and/or sucking chest wounds should be treated by immediately applying a vented chest seal to cover the defect.
If a vented chest seal is not available, use a non-vented chest seal. Monitor the casualty for the potential development of a
subsequent tension pneumothorax. If the casualty develops increasing hypoxia, respiratory distress, or hypotension and a
tension pneumothorax is suspected, treat by burping or removing the dressing or by needle decompression.
c. Initiate pulse oximetry. All individuals with moderate/severe traumatic brain injury (TBI) should be monitored with pulse
oximetry. Readings may be misleading in the settings of shock or marked hypothermia.
d. Casualties with moderate/severe TBI should be given supplemental oxygen when available to maintain an oxygen satura-
tion >90%.
e. If the casualty has impaired ventilation and uncorrectable hypoxia with decreasing oxygen saturation below 90%, consider
insertion of a properly sized nasopharyngeal airway, and ventilate using a 1000mL resuscitator bag valve mask.
f. Use continuous EtCo and Spo monitoring to help assess airway patency.
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6. Circulation
a. Bleeding
• A pelvic binder should be applied for cases of suspected pelvic fracture:
– Severe blunt force or blast injury with one or more of the following indications:
■ Pelvic pain
■ Any major lower limb amputation or near amputation
■ Physical exam findings suggestive of a pelvic fracture
■ Unconsciousness
■ Shock
• Reassess prior tourniquet application. Expose the wound and determine if a tourniquet is needed. If it is needed, replace
any limb tourniquet placed over the uniform with one applied directly to the skin 2–3 inches above the bleeding site.
Ensure that bleeding is stopped. If there is no traumatic amputation, a distal pulse should be checked. If bleeding per-
sists or a distal pulse is still present, consider additional tightening of the tourniquet or the use of a second tourniquet
side-by-side with the first to eliminate both bleeding and the distal pulse. If the reassessment determines that the prior
tourniquet was not needed, then remove the tourniquet and note time of removal on the TCCC Casualty Card.
• Limb tourniquets and junctional tourniquets should be converted to hemostatic or pressure dressings as soon as possi-
ble if three criteria are met: the casualty is not in shock; it is possible to monitor the wound closely for bleeding; and the
tourniquet is not being used to control bleeding from an amputated extremity. Every effort should be made to convert
tourniquets in less than 2 hours if bleeding can be controlled with other means. Do not remove a tourniquet that has
been in place more than 6 hours unless close monitoring and lab capability are available.
• Expose and clearly mark all tourniquets with the time of tourniquet application. Note tourniquets applied and time of
application; time of re-application; time of conversion; and time of removal on the TCCC Casualty Card. Use a perma-
nent marker to mark on the tourniquet and the casualty card.
b. Assess for hemorrhagic shock (altered mental status in the absence of brain injury and/or weak or absent radial pulse).
c. IV/IO Access
• Intravenous (IV) or intraosseous (IO) access is indicated if the casualty is in hemorrhagic shock or at significant risk of
shock (and may therefore need fluid resuscitation), or if the casualty needs medications, but cannot take them by mouth.
– An 18-gauge IV or saline lock is preferred.
– If vascular access is needed but not quickly obtainable via the IV route, use the IO route.
d. Tranexamic Acid (TXA)
• If a casualty will likely need a blood transfusion (for example: presents with hemorrhagic shock, one or more major
amputations, penetrating torso trauma, or evidence of severe bleeding)
OR
• If the casualty has signs or symptoms of significant TBI or has altered mental status associated with blast injury or blunt
trauma:
– Administer 2g of TXA via slow IV or IO push as soon as possible but NOT later than 3 hours after injury.
e. Fluid Resuscitation
• Assess for hemorrhagic shock (altered mental status in the absence of brain injury and/or weak or absent radial pulse).
• The resuscitation fluids of choice for casualties in hemorrhagic shock, listed from most to least preferred, are:
(1) Cold stored low titer O whole blood
(2) Pre-screened low titer O fresh whole blood
(3) Plasma, red blood cells (RBCs) and platelets in a 1:1:1 ratio
(4) Plasma and RBCs in a 1:1 ratio
(5) Plasma or RBCs alone
NOTE: The measures described in the Hypothermia Prevention section should be initiated while fluid resuscitation is being
accomplished.

102 | JSOM Volume 23, Edition 1 / Spring 2024