INTRODUCTION

RAPID UPDATE, Jun 2023

- Calcium administration changed to 1 gram calcium
- Tranexamic acid (TXA) 2gm bolus is now favored over the traditional 1gm prehospital bolus followed by 1gm infusion over 8 hours. The 2gm TXA bolus should be given as close to the time of injury as possible and not outside of the 3 hours window.

Early recognition and intervention for life-threatening hemorrhage are essential for survival. The immediate priorities are to control life-threatening hemorrhage and maintain vital organ perfusion with rapid blood transfusion.1

Experience with fresh whole blood (FWB) resuscitation by military surgical teams deployed in US Central Command 2–4 led to a revolutionary change in resuscitation practices, termed damage control resuscitation (DCR).5 As DCR became the accepted standard in military and civilian trauma practice, the realization that the majority of potentially preventable battlefield deaths occurred prehospital and were attributed to hemorrhage6 launched a campaign to bring advanced resuscitation capabilities closer to the point of injury.7,8

Efforts to prevent death from hemorrhage begin with external hemorrhage control, followed by transfusion of whole blood (WB) or reconstituted WB with components in a 1:1:1 unit ratio when possible.9 DCR also limits the use of crystalloids to avoid dilutional coagulopathy and incorporates other adjunctive measures to mitigate hemorrhagic shock and acute traumatic coagulopathy, including:

- Early use of tranexamic acid (TXA)10
- Calcium repletion in patients at risk of hypocalcemia
- Prevention of acidosis and hypothermia
- Expeditious delivery to a damage control surgical capability

The purpose of this prolonged field care (PFC) guideline is to improve implementation of DCR in the Role 1 11 PFC environment by augmenting and consolidating the Tactical Combat Casualty Care (TCCC) and Joint Trauma System (JTS) guidelines for PFC situations. When patient evacuation is delayed or not available, evidence-based solutions may not be possible. In such cases, experience-based solutions may provide the best option in a compromised setting with limited resources. The CPG recommendations are presented in a "minimum, better, best" format that presents a hierarchy of approaches to address a spectrum of Role 1 situations and available resources. In all cases, this hierarchy builds on itself with “minimum” clinical standards still applicable in scenarios with the “best” available resources.

DCR principles practiced in the presurgical phase of resuscitation have been termed remote damage control resuscitation (RDCR).12 It is important to distinguish