Page 271 - PJ MED OPS Handbook 8th Ed

b. IV/IO Access:
i) 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.
1) An 18 gauge IV or saline lock. 14 or 16 gauge for blood products preferred for hemor-
rhagic shock.
2) If vascular access is needed but not quickly obtainable via the IV route, use the IO
route. Start 2 × IOs for true hemorrhagic shock.
c. Tranexamic Acid (TXA):
i) 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
ii) If the casualty has signs or symptoms of significant TBI or has altered mental status asso-
ciated with blast injury or blunt trauma:
1) Administer 2g of tranexamic acid via slow IV or IO push as soon as possible but NOT
later than 3 hours after injury.
d. Fluid Resuscitation:
i) Assess for hemorrhagic shock (altered mental status in the absence of brain injury and/or
weak or absent radial pulse).
ii) The resuscitation fluids of choice for casualties in hemorrhagic shock, listed from most to
least preferred, are: cold stored whole blood; fresh whole blood; plasma and RBCs in a 1:1
ratio; plasma or RBCs alone; then crystalloids (Lactated Ringer’s or Plasma-Lyte A).
NOTE: Hypothermia prevention measures [Section 7] should be initiated while fluid resus-
citation is being accomplished.
1) If not in shock:
i. No IV fluids are immediately necessary
ii. Fluids by mouth are permissible if the casualty is conscious and can swallow and
has no major abdominal injury
2) If in shock and blood products are available under an approved command or theater
blood product administration protocol:
i. Resuscitate with whole blood; OR if not available
a. Plasma and RBCs in a 1:1 ratio; OR if not available
b. Reconstituted dried plasma, liquid plasma or thawed plasma alone or RBCs
alone
ii. Reassess the casualty after each unit. Continue resuscitation until a palpable radial
pulse, improved mental status or systolic BP of 80–90 is present.
3) If in shock and blood products are not available under an approved command or the-
ater blood product administration protocol due to tactical or logistical constraints:
i. 1–2L of lactated Ringer or Plasma-Lyte A
ii. Reassess the casualty after each 500mL IV bolus.
iii. Continue resuscitation until a palpable radial pulse, improved mental status, or sys-
tolic BP of 80–90mmHg is present

NOTE: If TBI is suspected and casualty has a weak or absent radial pulse, resuscitate as
necessary to restore and maintain a normal radial pulse. If BP monitoring is available, re-
suscitate to systolic of 100mmHg for uncontrolled hemorrhage or 110mmHg for controlled
hemorrhage.

Appendix 1: TCCC Protocols n 269