Fluid Resuscitation for Hemorrhagic Shock in Tactical Combat Casualty Care: TCCC Guidelines Change 14-01 - 2 June 2014

## Frank K. Butler, MD; John 8. Holcomb, MD; Martin A. Schreiber, MD; Russ S. Kotwal, MD; Donald A. Jenkins, MD; Howard R. Champion, MD, FACS, FRCS; F. Bowling; Andrew P. Cap, MD; Joseph J. Dubose, MD; Warren C. Dorlac, MD; Gina R. Dorlac, MD; Norman E. McSwain, MD, FACS; Jeffrey W Timby, MD; Lorne H. Blackbourne, MD; Zsolt T. Stockinger, MD; Geir Strandenes, MD; Richard B, Weiskopf, MD; Kirby R. Gross, MD; Jeffrey A. Bailey, MD

Journal of Special Operations Medicine. 2014 Fall;14(3):13-38.

#### Description with Key Points:

This article discusses changes in the Tactical Combat Casualty Care (TCCC) guidelines that are based on a review of the literature on fluid resuscitation in hemorrhagic shock. The evidence extracted from the literature review was applied to the resuscitation of combat casualties in the prehospital environment and used to develop updated TCCC fluid resuscitation guidelines.

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Order of precedence for resuscitation fluid options:

1. Whole blood
2. 1:1:1 plasma, Red Blood Cells (RBCs), and platelets
3. 1:1 plasma and RBCs
4. Reconstituted Dried Plasma, liquid plasma, or thawed plasma alone or RBCs alone
5. Hextend
6. LR or Plasma-Lyte A

* *Normal Saline (NS) is not recommended for hemorrhagic shock, but may be indicated for dehydration.

- Dried plasma (DP) is added as an option when other blood components or whole blood are not available
- Hextend is a less desirable option than whole blood, blood components, or DP and should be used only when these preferred options are not available
- 1: 1: 1 damage control resuscitation (DCR) is preferred to 1:1 DCR when platelets arc available as well as plasma and red cells;
- The 30-minute wait between increments of resuscitation fluid administered to achieve clinical improvement or target blood pressure (BP) has been eliminated.
- The volume of fluid used in the resuscitation of casualties in hemorrhagic shock is an important factor in determining outcomes. The optimal volume may vary based on the type of injuries present, but large-volume crystalloid fluid resuscitation for patients in shock caused by penetrating torso trauma has been shown to decrease patient survival compared with resuscitation with restricted volumes of crystalloid.
- Hextend may decrease complications of crystalloid resuscitation such as ARDS and ACS, but does not decrease the dilutional coagulopathy caused by crystalloid resuscitation.

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# Take Home Message:

Fluid Resuscitation should be based on the established order of precedence and available blood products and fluids.
Blood products are becoming increasingly available in the prehospital setting and are the resuscitation fluids of choice when feasible.
An approved protocol should be used to optimize the benefits and safety of blood components administered in the prehospital combat setting
All medical personnel who will be responsible for administering blood products in the prehospital combat setting should be trained in the approved protocol.