Page 40 - JSOM Summer 2025

series of physiologic injuries resulting in impaired coagulopa- FIGURE 1 CASEVAC Ecosystem RDT&E design aligned with
thy—is well documented. CoTCCC phases of care in support of optimized hypothermia
management, TCCC provider/ casualty sheltering, and TACEVAC
support for temperature-sensitive items at the point of injury and
While the current guidelines acknowledge the importance of expedited casualty movement to definitive resuscitation.
early and aggressive hypothermia management, exposing ca-
sualties to AoECE conditions during tactical field care (TFC)
will inevitably decrease core temperature. One potential miti-
gation for this is to adjust MARCH to MhARCH, resequenc-
ing hypothermia management to occur immediately after
massive hemorrhage. Units operating in these climates can
3
expect temperatures as low as –54°C (–65°F), which is fur- (Credit: MAJ, Titus J. Rund; OV-1 graphics
ther exacerbated by wind chills. Exposure to these conditions
1
can affect outcomes, as a decrease in core body temperature by CW2 Matthew L. Perkins and
from 37.0°C to 36.2°C (98.6°F to 97.2°F) is a positive predic- SSgt Kyle M. Overholser.)
tor of mortality. For these reasons, the authors recommend
4
a field-expedient shelter composed of a vapor barrier (tarp,
bothy bag, etc.) to create a bubble of warmth during tactical CASEVAC = casualty evacuation; RDT&E = research, development,
field care. testing, and evaluation; TACEVAC = tactical evacuation.
TCCC practitioners operating in AoECE have adopted specific highly susceptible to freezing. While research has been con-
techniques within the MARCH framework to mitigate hypo- ducted into the safety and efficacy of many medication freeze-
thermia during each step. During the massive hemorrhage as- thaw cycles, it is not easily accessible or fully inclusive of all
sessment, TCCC practitioners reach through the sleeves, vents, battlefield medications. Centralizing temperature stress data
5,6
waistband, and other clothing gaps to identify hemorrhage for medications and their containing ampules or vials within
instead of an external blood sweep. This technique aims to a commonly referenced organization, such as a JTS Clinical
discover substantial bleeding that may be masked by several Practice Guideline (CPG), would improve medical logistic
clothing layers while minimizing casualty exposure to the ele- planning in the AoECE. Adhesives on occlusive dressings,
ments. During airway management, diminished hand dexter- cleaning solutions (i.e., alcohol prep pads), and other common
ity from the extreme cold increases cricothyrotomy difficulty TCCC recommended Class VIII may not be effective in the
compared to other adjuncts. For needle thoracostomies, the AoECE. There is no perfect solution for temperature-regulated
second intercostal space is preferred due to its easier access portable storage in light infantry units. Previous attempts to
through insulating clothing. Intravenous (IV) lines are dis- use chemical heaters (i.e., hand warmers) in smaller medica-
couraged outside of a bubble of warmth (i.e., field-expedient tion chests have been ineffective.
shelter or climate-controlled environment) in favor of intra-
muscular (IM) injections. IM administration prevents unneces- This temperature problem extends to resuscitative fluids. Tra-
sary casualty exposure and fluid freezing within IV extensions ditional golden-hour boxes for fresh whole blood are not con-
and saline locks. ducive to preserving the recommended temperature range of
1–6°C (34–43°F) in extreme cold. A walking blood bank is
AoECEs have unique considerations, and many capability a logical solution for fresh, warm blood; however, the citrate
gaps have been identified regarding limitations in the delivery in transfusion bags will freeze if not kept warm. Freeze-dried
of medical care. Addressing these gaps requires rediscovering plasma provides a more temperature-stable fluid; however,
and preserving knowledge from previous cold weather con- the sterile water it requires for reconstitution limits its use to
flicts and developing new solutions with current technology. warm environments. The immediate solution is to store resus-
Much like operating in a chemical, biological, radiological, citative fluids in warmed vehicles. However, all forms of trans-
nuclear, and explosives (CBRNE) environment, the AoECE portation are slower in extreme temperatures and deep snow,
requires technical capabilities tailored to the environment. delaying resuscitative capabilities.
Emphasis is placed on moving a casualty rapidly to a tent or
field-expedient shelter to provide a bubble of warmth and al- It is highly likely that line medics will not be able to effectively
low for better casualty exposure and further TCCC care. A carry the same equipment that they have been accustomed to
casualty evacuation (CASEVAC) ecosystem is undergoing re- carrying during the Global War on Terrorism operations. Al-
search, development, testing, and evaluation (RDT&E) and is ternative solutions using high-mobility off-road vehicles (i.e.,
patent-pending by the Department of Defense (DoD). The CA- snowmachines) for parasitic power generation are currently
SEVAC ecosystem expedites casualty evacuation and improves undergoing RDT&E. This RDT&E effort is assessing the fea-
casualty care by providing a temperature-controlled casualty sibility of parasitic power generation to provide for active ca-
collection point and evacuation method. In AoECE, integrat- sualty rewarming, increased mobility, and the timely delivery
4
ing distributed environmental protection across the formation of temperature-sensitive items (i.e., prehospital blood, medi-
is necessary to meet the standards of prehospital care estab- cations, and other CASEVAC medical supplies) at the point
lished by the Committee on Tactical Combat Casualty Care of injury. 3
(CoTCCC) (Figure 1).
Technological Limitations in Hypothermia Management
Temperature-sensitive medications are often carried close to
the TCCC practitioner’s body instead of an aid bag to pre- Scenario 2
vent freezing. This has been effective for small quantities of A 19-year-old vehicle gunner is brought to the Role 1 after
medications; however, medication chests within the MES are conducting a convoy mission where he was exposed in

38 | JSOM Volume 25, Edition 2 / Summer 2025