*New CPG Notes: Damage Control Resuscitation in Prolonged Field Care

September 22, 2018

Below are some of the highlights from the DCR in PFC Clinical Practice Guidelines.

The information in this CPG is the standard for a combat medic. 

 

Intro: 

 

The purpose of this CPG is to improve DCR in the Role 1 facility. 

 

FWB resuscitation by military surgical teams drove the changes and accepted strategy for Damage Control Resuscitation in the forward deployed environment. Limited use of crystalloids now accepted in DCR to prevent dilution coagulopathy. 

 

Other recommended adjunctive measures:

 

  • Early use of TXA is not new but continues to be recommended for NCTH and massive blood loss. 
  • Replacing Calcium in patients at risk of hypocalcemia.
  • Prevention of acidosis and hypothermia.
  • Rapid transport to forward surgical capability. 

 

CPG presents information in a “Minimum, Better, Best” format for planning and progressive strategy of treatment in a Role 1 PFC environment.

 

Remote Damage Control Resuscitation vs. Damage Control Resuscitation:

Prehospital vs. hospital settings

Recognizing patients that need (R) DCR:

 

Similar to the 75th hemorrhagic decision matrix for Tactical Damage Control Resuscitation. Brings in advanced monitoring capabilities and focuses on clinical signs:

 

*Do not delay initiating DCR if hemorrhagic shock is clinically suspected: Begin treating immediately once hemorrhagic shock is suspected. 

 

 Injury pattern consistent with massive hemorrhage: 

  • Above the knee amputation (especially with pelvic fracture)
  • Proximal, Bi-lateral, or multiple amputations. 
  • Penetrating or blunt force injuries with suspected truncal hemorrhage. 
  • Severe trauma with altered mental status (in the ab­sence of brain injury) and/or weak or absent radial pulse.

Continue to monitor vital signs and tactically relevant indicators of shock to include:

Altered Mental Status and Absent Radial Pulse

Use all advanced monitoring capabilities for the “best” level of care.

Predictors associated with massive transfusion (i.e., more than 10 units of blood in the first 24 hours) :

  • Penetrating mechanism 
  • Positive focused assessment with sonography for
    trauma (FAST) examination (especially if two or
    more regions are positive) 
  • Lactate concentration greater than 4mmol/L on presentation
  • Base deficit more than 6mEq/L (base excess less than
    −6mEq/L)
  • pH less than 7.25
  • International normalized ratio (INR) 1.5 or greater

Below is from “Tactical Damage Control Resuscitation”Fisher AD, Miles EA, Cap AP, Strandenes G, Kane SF.

This is a really good one to follow. 

 

 

Hemorrhage Control: 

 

Use progressive strategies for controlling hemorrhage according to TCCC guidelines. 

 

*Preventing blood loss is key.

 

Keep an eye out for emerging technologies for treating NCTH.

 

The AAJT was mentioned for hemorrhage control with the disclaimer, “This device, although not well studied…”


Indications for REBOA (See last CRO Article)

 

 

Resuscitation: 

 

This section leads the discussion toward improved walking blood banks and far- forward blood products used on a broader scope. 

 

“Blood products are strongly preferred, and every effort should be made to ensure the capability to transfuse blood products is available near the point of injury. Survival is improved when blood products are transfused within about 30 minutes of injury.”

 

 

Use of Whole Blood During Resuscitation:

Best: Food and Drug Administration–compliant LTOWB supplied by the Armed Services Blood Program. LTOWB (Low-titer group O whole blood)

 

How to do a walking blood bank:

 

LTOWB drawn from prescreened donors at deployed location, either before mission or during combat ca­sualty care. 

–  Identify LTOWB donors before deployment. Test all personnel with group O blood for anti­A and anti­B antibodies; low titer is defined as immuno­ globulin M anti­A and anti­B ratio less than 1:256

 

Better: Administer group­ specific WB from prescreened donors 

  • Group A to group A, group O to group O and LTOWB for group B and group AB.
  • Group specific for all ABO Group
  • The ABO group of the patient must be confirmed us­
    ing Eldon card or other approved ABO testing kit. If the wrong blood group is transfused, there is a possi­bility of fatal transfusion reaction.

Minimum: Confirm unscreened donors with Eldon Card

*Recommend understanding the transfusion notes in this CPG to become proficient in planning and implementing a blood program (not summarized).

 

Hemostatic Adjuncts: 

The goal is to use medications to optimize the casualty’s ability to form blood clots. 

TXA:

Minimum: If the tactical situation does not permit 10 min infusion, can be given IVP.

The best is still to infuse over 10 mins in 100mL bag- keeping in mind that you “own” the possibility of transient hypotension.   

Calcium: 

Minimum: Administer 1g of calcium (30mL of 10% cal­cium gluconate or 10mL of 10% calcium chloride) IV/ IO during or immediately after transfusion of the first unit of blood product. 

Better: With ongoing resuscitation, give additional 30mL of calcium gluconate or 10mL calcium chloride after every four units of blood product. 

Best: Monitor serum calcium during ongoing resuscita­tion and administer calcium gluconate 30mL or calcium chloride 10mL for ionized calcium less than 1.2mmol/L. 

 

Assessing Response to Resuscitation: 

This section goes into three types of responders:

  • Responder
  • Transient Responder
  • Non-Responder

 

End Points of Resuscitation: 

Minimum: Identify clinical stabilization through ongo­ing monitoring and examination.
Slowing heart rate, palpable peripheral pulses, brisk capillary refill, warming extremities, improving men­tal status (if no brain injury), slowing/cessation of co­agulopathic bleeding (wounds and/or IV site bleeding).

Better: In addition to minimum, recognize improved vi­tal signs and objective criteria. 

  • SBP at goal 

-Goal SBP is approximately 100mmHg if resusci­tating with blood products (maintain mild hypo­ tension until definitive bleeding control). 

-In patients with traumatic brain injury, goal SBP is greater than 110mmHg.

-If unable to resuscitate with blood products, a lower blood pressure goal of SBP from 80– 90mmHg is acceptable.

  • Oxygen saturation (Spo2) greater than 92%, fraction of inspired oxygen (Fio2) required should be less than 50% 
  • Temperature greater than 95oF (35oC) 
  • UO greater than 30mL/h or greater than 0.5mL/kg/h

Best: In addition to minimum and better, confirm that hemorrhagic shock is resolving, using the following lab­oratory values: 

  • Hemoglobin concentration greater than 8.0g/dL 
  • Hematocrit greater than 27% 
  • Lactate concentration less than 2.5mmol/L 
  • Base deficit less than 4 (base excess greater than −4)
    Note: Improving trends are as important as meeting absolute goals when assessing response.

 

Documentation Should Consist of the Following:

  • At a minimum the TCCC card should be filled out (DD-1380)
  • Better would be the PFC flowsheet (prolongedfieldcare.org)
  • Best is AAR with the above. 

 

Pediatric Considerations:

  • Lack of regular exposure to pediatrics is an issue for Role 1 medical providers.
  • The average 1 year old has a total blood volume approximately equivalent to two units of blood. Underestimating blood loss percentage and over resusci­tating should both be avoided. 
  • Use of IO and second medication port should be used on pediatrics. 
  • TXA is indicated in pediatric casualties. The dose is 15mg/kg TXA loading dose (maximum, 1g) over 10 minutes followed by 2mg/kg/h for 8 hours (maximum, 1g).
  • LTOWB and FWB are both acceptable to give to children with life­-threatening hemorrhage. There is no contraindication to the use of any WB product in children. The initial dose for blood is 10mL/kg, but in children with massive hemorrhage, 
  • Children are at high risk of developing hypocalcemia, hypomagnesaemia, metabolic acidosis, hypoglycemia, hypothermia, and hyperkalemia during transfusion. 

 

End Of Life/Expectant Management:

Despite best efforts, certain injuries are not survivable in austere environments.

Expectant:

  • Cranial injuries with exposed brain matter 
  • Penetrating thoracic or abdominal injuries that are hypotensive or non-responsive after two units of blood, and bilateral needle decompression/finger thoracostomy, tubal thoracostomy, and assessed for pericardial tamponade. 
  • Junctional amputations with pelvic disruption
  • Out of hospital cardiac arrest
  • Cervical spine trauma with cardiovascular collapse
  • Obvious massive trauma, such as total body disruption and decapitation 
  • Nonresponders