Guidelines and Key Points

# Intravenous (IV) 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.

#### Intravenous (IV) Access Key Points:

NOT ALL CASUALTIES NEED IVS!

DO NOT start IVs on casualties who are unlikely to need fluid resuscitation or IV medications. Do not use for minor injuries as it wastes supplies, takes too much time, and can distract from other more important care or tactical concerns.

The indications for IV access are:

- Fluid resuscitation for hemorrhagic shock or significant risk of shock such as a gunshot wound to the torso.
- The need to give medications but the casualty is unable to swallow, is vomiting, or has a decreased state of consciousness.

DO NOT insert an IV distal to a significant wound! An IV lock is recommended instead of an IV line unless fluids are needed immediately. Flush IV lock with 5cc NS (normal saline) immediately and then every 1-2 hours to keep it open.

# Tranexamic Acid (TXA)

If a casualty is anticipated to need significant blood transfusion (for example: presents with hemorrhagic shock, one or more major amputations, penetrating torso trauma, or evidence of severe bleeding):

- Administer 1 gram of Tranexamic Acid in 100 mL Normal Saline or Lactated Ringers as soon as possible but NOT later than 3 hours after injury. When given, the TXA should be administered over 10 minutes by IV infusion.

- Begin second infusion of 1 gm TXA after Hextend or other fluid treatment.

#### Tranexamic (TXA) Acid Key Points:

Tranexamic Acid (TXA) helps to reduce blood loss from internal hemorrhage sites that can't be addressed by tourniquets and hemostatic dressings.

Tourniquets and Combat Gauze do not work for internal bleeding, TXA does!

Survival benefit of TXA is GREATEST when given within 1 hour of injury. Give it as soon after wounding as possible! But DO NOT GIVE TXA if more than 3 hours have passed - survival is DECREASED if TXA is given after 3 hours.

Possible side effects of TXA include nausea, vomiting, diarrhea, visual disturbances and hypotension if given as a bolus. Do not be deterred by possible side effects. The important thing is to stop the bleeding and save the casualty’s life.

TXA should NOT be given with Hextend or through an IV line with Hextend in it. Infuse slowly over 10 minutes. Rapid IV push may cause hypotension. If there is a new-onset drop in BP during the infusion - SLOW DOWN the TXA infusion then administer blood products or Hextend.

# Fluid Resuscitation

1. The resuscitation fluids of choice for casualties in hemorrhagic shock, listed from most to least preferred, are:

- Whole blood*
- Plasma, red blood cells (RBCs) and platelets in a 1:1:1 ratio*
- Plasma and RBCs in a 1:1 ratio
- Plasma or RBCs alone
- Hextend
- Crystalloid (Lactated Ringers or Plasma-Lyte A)

2. Assess for hemorrhagic shock (altered mental status in the absence of brain injury and/or weak or absent radial pulse).

NOTE: Hypothermia prevention measures (See Hypothermia Pocket Guide) should be initiated while fluid resuscitation is being accomplished.

If not in shock:

- No IV fluids are immediately necessary.
- Fluids by mouth are permissible if the casualty is conscious and can swallow.

If in shock and blood products are available under an approved command or theater blood product administration protocol:

- Resuscitate with whole blood*, or, if not available;
- Plasma, RBCs and platelets in a 1:1:1 ratio*, or, if not available;
- Plasma and RBCs in 1:1 ratio, or, if not available;
- Reconstituted dried plasma, liquid plasma or thawed plasma alone or RBCs alone;
- Reassess the casualty after each unit. Continue resuscitation until a palpable radial pulse, improved mental status or systolic BP of 80-90 is present

If in shock and blood products are not available under an approved command or theater blood product administration protocol due to tactical or logistical constraints:

- Resuscitate with Hextend, or if not available;
- Lactated Ringers or Plasma-Lyte A;
- Reassess the casualty after each 500 mL IV bolus;
- Continue resuscitation until a palpable radial pulse, improved mental status, or systolic BP of 80-90 mmHg is present.
- Discontinue fluid administration when one or more of the above end points has been achieved.

#### Fluid Resuscitation Key Points:

Shock is inadequate blood flow to the body tissues. Shock can have many causes, but on the battlefield, it is typically caused by severe blood loss. Hemorrhagic shock is the leading cause of preventable death on the battlefield. REMEMBER! The most reliable signs of shock on the battlefield are: A decreased level of consciousness (without TBI) and/or a weak or absent radial pulse.

The first step in fluid resuscitation is to assess for shock. If not in shock, no IV fluids are necessary but fluids by mouth are permissible. If in shock and blood products are available, transfuse with the best available products.

If blood products are not available, transfuse with Hextend or crystalloid. Hextend is preferred over crystalloid because the volume needed is less, and it lasts longer.

Do not pause between units of resuscitation fluids. Reassess after each unit of blood product or 500 cc of Hextend or crystalloid. Continue until a palpable radial pulse, improved mental status or systolic BP of 80-90 is achieved.

Shock increases mortality in casualties with head injuries, so you have to be more aggressive with your fluid resuscitation. Resuscitate until there is a NORMAL, not just palpable, radial pulse, or a systolic BP of at least 90.

If a casualty with an altered mental status due to suspected TBI has a weak or absent peripheral pulse, resuscitate as necessary to restore and maintain a normal radial pulse. If BP monitoring is available, maintain a target systolic BP of at least 90 mmHg.

Reassess the casualty frequently to check for recurrence of shock. If shock recurs, recheck all external hemorrhage control measures to ensure that they are still effective and repeat the fluid resuscitation as outlined above.

The goal of fluid resuscitation is NOT to restore a normal blood pressure. The goal of fluid resuscitation is an improved state of consciousness or palpable radial pulse, corresponding to a systolic blood pressure of 80 to 90 millimeters mercury.

If the blood pressure goes up too much, this may interfere with the body’s attempt to clot or disrupt a clot that has formed, essentially “popping the clot.”

Also remember to initiate hypothermia prevention measures while fluid resuscitation is being accomplished.

Hypotensive Resuscitation Saves Lives in Non-Compressible Hemorrhage! DO NOT start your fluid resuscitation by giving two liters of LR or NS wide open before re-assessing your casualty!

REMEMBER! If the casualty is not in shock, don’t use your IV fluids.

SAVE IV FLUIDS FOR CASUALTIES WHO REALLY NEED THEM. The next person to get shot may die if he or she doesn’t get fluids.

*Currently, neither whole blood nor apheresis platelets collected in theater are FDA-compliant because of the way they are collected. Consequently, whole blood and 1:1:1 resuscitation using apheresis platelets should be used only if all of the FDA-compliant blood products needed to support 1:1:1 resuscitation are not available, or if 1:1:1 resuscitation is not producing the desired clinical effect.

#### Refractory Shock

If a casualty in shock is not responding to fluid resuscitation, consider untreated tension pneumothorax as a possible cause of refractory shock. Thoracic trauma, persistent respiratory distress, absent breath sounds, and hemoglobin oxygen saturation < 90% support this diagnosis. Treat as indicated with repeated NDC or finger thoracostomy/chest tube insertion at the 5th ICS in the AAL, according to the skills, experience, and authorizations of the treating medical provider. Note that if finger thoracostomy is used, it may not remain patent and finger decompression through the incision may have to be repeated. Consider decompressing the opposite side of the chest if indicated based on the mechanism of injury and physical findings.