DCR AT MEDICAL TREATMENT FACILITY

Although principles remain the same, DCR in medical facilities differs in that there are more resources available, including access to operative surgical control. Also, some therapies such as TXA may have already been given in the pre-hospital phase. Resuscitation to physiologic endpoints such as lactate and base deficit should be considered since tissue hypoxia and oxygen debt are known drivers of coagulopathy. Reversal of tissue hypoxia should thus be a central tenet of hospital-based resuscitation. Specifically:

OPTIMIZATION OF FLUIDS

Volume resuscitation with crystalloids should NOT be first-line of care in MTFs due to the potential for harm. Crystalloid fluids should be reserved for specific clinical uses, such as carrier fluid for intravenous medication or other non-resuscitative uses. The order of priority for fluid administration should be:

- Fully TTD tested (performed in FDA registered testing facility/FDA approved) Whole Blood;
- Blood components at a 1:1:1:1 ratio (plasma:platelets:RBC:CRYO); Note that apheresis platelets may be collected in theater and therefore are not FDA approved and fully tested prior to transfusion.
- Whole blood from a recently tested donor (NOTE: this option is only acceptable in the hospital for emergency indications when full component therapy is not available);
- RBCs plus plasma=1:1 ratio;
- Plasma with or without RBCs; and
- RBCs alone.

BLOOD PRODUCT TRANSFUSION

Cryoprecipitate is available in hospital settings and should be added to the component mix to create a 1:1:1:1 ratio of products in order to adequately supply fibrinogen and other clotting factors (Factors VIII, XIII, and vWF).

When operationally necessary due to component shortages, WB from walking blood banks can be life-saving. For additional information, refer to the JTS Whole Blood Transfusion CPG.41

Continual reassessment of the casualty status is needed during and between transfusions. As the patient stabilizes, component ratios should be replaced by ‘goal-directed’ therapy guided by laboratory evaluation, including CBC, blood gases, calcium levels, PT/INR, Activated Partial Thromboplastin Time (aPTT), and viscoelastic testing (ROTEM® or TEG) if available.

ADJUNCTIVE THERAPIES AT MEDICAL TREATMENT FACILITIES

Hypotensive resuscitation

As in the pre-hospital period, resuscitation of casualties without CNS injury prior to definitive surgical control should maintain a lower target SBP (100 mmHg, range 90-110mmHg) to reduce hemorrhage by minimizing intravascular hydrostatic pressure. Hypotensive resuscitation should not be utilized for patients with isolated CNS injury because of associated adverse outcomes in this population (goal SBP >110mmHg). For additional information, see the JTS Neurosurgery and Severe Head Injury CPG.97

Compressive/hemostatic dressings and devices

Until definitive surgical control is established, prevent further hemorrhage with direct pressure, topical or truncal hemostatic dressings, and/or tourniquets or REBOA to avoid the development of shock. In extremis, procedures such as resuscitative thoracotomy are indicated. Use of these devices should occur as rapidly as hemorrhage is identified and should not unnecessarily delay transport to the operating room.

Prevention or correction of hyperfibrinolysis

TXA should be given to casualties at risk of hemorrhagic shock who have not already received a dose during the pre-hospital phase. THE CASUALTY SHOULD ONLY RECEIVE INITIAL TXA IF ADMINISTERED WITHIN THREE (3) HOURS OF INJURY. When given > 3 hours post-injury, TXA increases the risk of mortality. The mortality data were not analyzed in patients with hyperfibrinolysis documented by viscoelastic testing (ROTEM® or TEG). However, documented hyperfibrinolysis in the setting of ongoing hemorrhage should be treated according to clinical judgment. For eligible casualties (see section above titled Recognition of Patients Requiring DCR), 2 grams of TXA should be administered IV or IO. TXA is ideally administered in 100 ml of normal saline over 10 minutes, but faster administration in more concentrated form can be considered. It should be noted that rapid infusion of TXA has been infrequently associated with transient hypotension.

Prevention of acidosis and hypothermia

Hypothermia is multifactorial and strategies should address as many causes as are identified, including cold exposure, cold resuscitation fluids, significant blood loss, and shock. Hypothermia occurs even when ambient temperatures are elevated and medical personnel are uncomfortably warm, due to blood loss and hypoperfusion. Treatment should include urgent, active re-warming with all available means including heated fluids, heated blankets, ventilators, warm environments, and rapid surgical care to minimize blood and heat loss.

Expeditious delivery to definitive surgical control

As with casualties in the pre-hospital setting, pre-surgical care should be balanced against the need to expeditiously deliver the patient to the operating room.