Page 43 - 2022 Ranger Medic Handbook

Tactical Damage Control Resuscitation
Prevention of hypovolemic shock (inadequate tissue perfusion) is critical in a trauma casualty. Shock can be thought
of as a pause in the act of dying and requires aggressive actions to prevent its progression. Once a casualty has pro-
gressed to shock, he is susceptible to the lethal triad of coagulopathy, hypothermia, and acidosis. Early preventative
actions can delay hypothermia. Controlling blood loss and appropriate blood product administration can delay the
progress of coagulopathy.

TCCC Application SECTION 2
Care Under Fire: Stop life-threatening bleeding.
Tactical Field Care: The first priority is to stop any active hemorrhage. Initiate intravenous (IV) access if indicated. Start
an 18-G or larger IV or saline lock. If resuscitation is required and IV access is not obtainable, use the intraosseous
(IO) route. Assess for hemorrhagic shock; decreased mental status (in the absence of head injury) and weak or absent
peripheral pulses are the best field indicators of shock. If indicated by assessment, initiate fluid resuscitation. If not in
shock, resuscitation is not necessary. If in shock, administer whole blood or blood products in a 1:1:1 ratio. Repeat if
still in shock. Warm fluids are preferred if IV fluids are required. Be aware of warmer constraints as applying pressure to
increase flow may cause ineffective warming and cell lysis. Continued efforts to resuscitate must be weighed against
logistical and tactical considerations and the risk of incurring further casualties. If a casualty with TBI is unconscious
and has no peripheral pulse, resuscitate to restore the radial pulse. Prevention of hypothermia is critical in a shock
patient. Minimize casualty’s exposure to the elements. Keep protective gear on or with the casualty if feasible. Replace
wet clothing with dry if possible. Get the casualty onto an insulated surface as soon as possible. Apply the Ready-Heat
Blanket from the Hypothermia Prevention and Management Kit (HPMK) to the casualty’s torso (not directly on the skin)
and cover the casualty with the Heat-Reflective Shell (HRS). If an HRS is not available, the combination of any blanket
and the Ready-Heat Blanket may also be used. If the items mentioned above are not available, use dry blankets, poncho
liners, sleeping bags, or anything that will retain heat and keep the casualty dry.
TXA Administration: If a casualty is anticipated to need a blood transfusion (e.g., presents with hemorrhagic shock, one
or more major amputations, penetrating torso trauma, or evidence of severe bleeding), administer 2g of tranexamic acid
(TXA) as an IV/IO flush as soon as possible but not later than 3 hours after injury. If initial dose of TXA was 1g, administer
second infusion of 1g TXA after the first unit of blood or blood product treatment. Record on CAX Card “2g TXA given”.
Drug must be properly maintained at 15–30°C/59–86°F. Consider administration of CaGluc 1g slow IV/IO push, if pos-
sible, after 2g of TXA using a second IV/IO site. Do not delay blood product resuscitation for a trauma patient in
shock in order to administer TXA and/or calcium. Repeat calcium after every 4 th unit of blood.
Tactical Evacuation: Reassess need for IV access if not previously established. Reassess for hemorrhagic shock. If
not in shock, then no IV fluids are necessary. Avoid PO fluids for casualties requiring surgical intervention. Continue
resuscitation with whole blood, packed red blood cells (PRBCs), plasma, and platelets in a 1:1:1 ratio as indicated. If
a casualty with TBI is unconscious and has a weak or absent peripheral pulse, resuscitate as necessary to maintain a
systolic blood pressure of 110mmHg or above. Prevention of hypothermia is even more critical for a trauma patient in
moving vehicles or aircraft. Keep protective gear on or with the casualty if feasible. Remove and replace wet clothing
with dry if possible. Get the casualty onto an insulated surface as soon as possible. Apply external warming devices as
depicted in tactical field care if not already accomplished. Use a portable fluid warmer capable of warming all IV fluids
including blood products. Protect the casualty from wind if doors must be kept open.

Extended Care
Fluid Management: Continue resuscitation with whole blood or blood products as indicated. Maintain a palpable radial
pulse or systolic blood pressure of 90–100mmHg in all unconscious patients with noncompressible, internal hemor-
rhage. Maintain a normal radial pulse character or systolic blood pressure > 110mmHg in TBI patients with altered
mental status. If available, insert Foley catheter and titrate IV/IO/NG/PR crystalloid fluids to maintain urine output of
30–50mL/hr.
ROLO Transfusion: All lifesaving TCCC protocols and procedures should be completed while ARFRs obtain blood for
transfusion. Evacuation should not be delayed for field transfusions. ROLO may be considered for trauma casualties
showing signs of hemorrhagic shock; shock from internal, noncompressible, or uncontrollable bleeding; massive blood
loss with tachypnea, tachycardia, systolic hypotension and altered mental status; or extended evacuation.

2022 RANGER MEDIC HANDBOOK 29