J Spec Oper Med. Winter 2018;18(4):37-55.

# Advanced Resuscitative Care in Tactical Combat Casualty Care: TCCC Guidelines Change 18-01:14 October 2018.

Butler FK Jr, Holcomb JB, Shackelford S, Barbabella S, Bailey JA, Baker JB, Cap

AP, Conklin CC, Cunningham CW, Davis M, DeLellis SM, Dorlac WC, DuBose JJ,

Eastridge B, Fisher AD, Glasser JJ, Gurney J, Jenkins DA, Johannigman J, King DR,

Kotwal RS, Littlejohn LF, Mabry RL, Martin MJ, Miles EA, Montgomery HR, Northern

DM, O'Connor KC, Rasmussen TE, Riesberg JC, Spinella PC, Stockinger Z, Strandenes

G, Via DK, Weber MA.

TCCC has previously recommended interventions that can effectively prevent 4 of the top 5 causes of prehospital preventable death in combat casualties-extremity hemorrhage, junctional hemorrhage, airway obstruction, and tension pneumothorax- and deaths from these causes have been markedly reduced in US combat casualties. Noncompressible torso hemorrhage (NCTH) is the last remaining major cause of

preventable death on the battlefield and often causes death within 30 minutes of wounding. Increased use of whole blood, including the capability for massive transfusion, if indicated, has the potential to increase survival in casualties with either thoracic and/or abdominopelvic hemorrhage. Additionally, Zone 1 Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) can provide temporary control of bleeding in the abdomen and pelvis and improve hemodynamics in casualties who may be approaching traumatic cardiac arrest as a result of hemorrhagic shock. Together, these two interventions are designated Advanced Resuscitative Care (ARC) and may enable casualties with severe NCTH to survive long enough to reach the care of a surgeon. Although Special Operations units are now using whole blood far-forward, this capability is not routinely present in other US combat units at this point in time. REBOA is not envisioned as care that could be accomplished by a unit medic working out of his or her aid bag. This intervention should be undertaken only by designated teams of advanced combat medical personnel with special training and equipment.