a. Bleeding

- Reassess sites of major hemorrhage and associated hemostatic interventions. Ensure that bleeding is stopped. If bleeding persists, consider changing or adding additional hemostatic adjuncts (eg. Combat gauze, chitosan based dressings, or X-Stat) and/or re-applying circumferential pressure bandages and wound packing, where applicable.
- iTClamp should be considered to close bleeding open wounds or can be used concurrently with hemostatic agents.
- If major bleeding cannot be stopped with dressings, consider application of a tourniquet if:
  - Extremity hemorrhage appears life threatening (g. MWD has suffered a complete traumatic limb or tail amputation), AND
  - Bleeding remains refractory to other methods of hemostasis (g. direct pressure, pressure dressing, etc.), AND
  - The anatomical site is amenable to tourniquet application (g. limbs and tail wounds)
  - When a tourniquet is warranted (as per above), consider applying a wide, elastic, non-windlass, moldable tourniquet (e.g. SWAT-T®), if available.
  - Immobilize and Elevate the area when practical and feasible. Keep the MWD as calm as possible to avoid inadvertent elevations in arterial blood pressure.
  - Expose and clearly mark all tourniquets with the time of tourniquet application. Note tourniquets applied and time of application; time of re-application; time of conversion; and time of removal on the canine TCCC Casualty Card. Use a permanent marker to mark on the tourniquet and the casualty card.

* Note: Pelvic binders have not been evaluated in dogs. However because pelvic fractures in dogs are very unlikely to result in life threatening hemorrhage, pelvic binders are not recommended in MWDs at this time.

b. IV/IO Access

- Intravenous (IV) or intraosseous (IO) access is indicated if the MWD is in hemorrhagic shock or at significant risk of shock (and may therefore need fluid resuscitation), or if the MWD needs medications, but cannot take them by mouth.
- An 18-gauge IV or saline lock is preferred. Place in the cephalic (dorsal/anterior aspect over the radius) or lateral saphenous (hind limb over the lateral distal tibia) vein. The external jugular vein can be considered as an alternative option. For external jugular vein access, due to the increased length and flexibility of the MWD’s neck as compared to a person, a longer catheter (eg.14 or 16 gauge x 3.25 inch) is preferred over an 18 gauge x 1.25 to 1.5 inch catheter commonly used for peripheral vein access.
- If vascular access is needed but not quickly obtainable via the IV route, use the IO route,
- Recommended sites for IO placement in a canine include the:
  - Proximal, lateral humerus at the caudal aspect of the greater tubercle, or
  - Proximal, medial tibia caudal to the distal aspect of the tibial tuberosity
  - Recommended IO catheter size is 25mm x 15 gauge (BLUE) for MWDs over 40#

c. Tranexamic Acid (TXA)

- If a MWD is anticipated to need significant blood transfusion (for example: presents with hemorrhagic shock, one or more major amputations, penetrating torso or abdominal trauma, or evidence of severe bleeding):
- Administer 10 mg/kg of tranexamic acid as a slow IV push or in 100 ml Normal Saline or Lactated Ringer’s as soon as possible but NOT later than 3 hours after injury. When given, TXA should be administered over 10 minutes by IV/IO infusion.
- Begin a second infusion of 10 mg/kg of TXA as a continuous infusion over 8 hours after initial fluid resuscitation has been completed.

d. Fluid resuscitation

- Assess for hemorrhagic shock (pale mucus membranes, inappropriate mentation in the absence of head trauma, weak or absent femoral pulse).
- The resuscitation fluids of choice for MWDs in hemorrhagic shock, listed from most to least preferred, are: canine chilled or fresh whole blood; canine plasma and RBCs in a 1:1 ratio; canine plasma or RBCs alone; crystalloid (Lactated Ringer’s, Normosol R or Plasma-Lyte A) Hextend/Hespan. (NOTE: Hypothermia prevention measures [Section 7] 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 MWD is conscious and can swallow.

- If in shock and canine blood products are available:
  - Resuscitate with canine whole blood [initial dose is one 500 mL unit as a bolus or titrated depending on situation], or, if not available
  - Canine plasma and canine RBCs in a 1:1 ratio [initial dose is one 250 mL unit of plasma plus one 250 mL unit of pRBC bolused or titrated depending on situation], or, if not available
  - Reconstituted dried canine plasma, canine liquid plasma or thawed canine fresh frozen plasma [initial dose is one 250 mL unit of any of the above mentioned plasma products bolused or titrated depending on situation] alone or canine pRBCs alone [initial dose is one 250 mL unit of pRBC bolused or titrated depending on situation]

*Note: DO NOT administer human blood products to a canine. Human blood products have a high probability of causing a hemolytic reaction when transfused into a canine.

- Reassess the MWD after each unit. Continue resuscitation until a palpable femoral pulse, improved mental status or systolic BP of 80-90 is present.
- If in shock and blood products are not available due to tactical or logistical constraints:
  - Lactated Ringer’s, Normosol R or Plasma-Lyte A
  - Reassess the MWD after each 500 ml IV/IO bolus.
  - Continue resuscitation until a palpable femoral 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.

- If a MWD with an altered mental status due to suspected TBI has a weak or absent femoral pulse, resuscitate as necessary to restore and maintain a normal femoral pulse. If BP monitoring is available, maintain a target systolic BP of at least 90 mmHg.
- Reassess the MWD frequently to check for recurrence of shock. If shock recurs, re-check all external hemorrhage control measures to ensure that they are still effective and repeat the fluid resuscitation as outlined above.

e. Refractory Shock

- If a MWD in shock is refractory to fluid resuscitation and canine blood products are not available, consider:
- The use of synthetic colloids (Hextend® and/or Hespan®) – 150-200 mL bolus IV/IO. Can repeat if shock state is not resolved.
- 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 above with repeated NDC or finger thoracostomy/chest tube insertion.