POINT OF INJURY, EN-ROUTE, AND REMOTE DCR

For detailed recommendations on prolonged field care (PFC) damage control resuscitation, see the JTS Damage Control Resuscitation for PFC CPG, 01 Oct 2018. https://jts.health.mil/index.cfm/PI_CPGs/cpgs

OPTIMIZATION OF FLUIDS

Volume resuscitation, particularly crystalloid and colloid, should be used sparingly in the pre-hospital setting, given the potential for harm and the limited resources; blood products are preferred for hemorrhagic shock resuscitation.9,95 WB (Group O low titer preferred) or blood components given ideally at a 1:1:1 (plasma, platelets, RBC) ratio should be transfused when shock is present or expected. Blood products should ideally be warmed with approved in-line blood heaters with the goal of transfusing products warmed to 37°C.

Casualties at low risk of developing shock should NOT receive IV fluids or adjunctive medications.

Hypertonic Saline does NOT improve mortality in hemorrhagic shock and should only be used for patients with TBI and evidence/suspicion of raised Intracranial Pressure (ICP).96,97 Vasopressors are NOT recommended for the treatment of hemorrhagic shock.

A key element of fluid optimization is careful documentation of all fluids, interventions, and medications given in the pre-hospital phase.

ADJUNCTIVE THERAPIES IN PFC

Compressive/hemostatic dressings and devices

Prevent further hemorrhage with direct pressure, topical hemostatic dressings, and/or tourniquets, if possible, to minimize the risk of shock. REBOA can be highly effective if rapidly implemented by skilled and designated teams.

Prevention of acidosis and hypothermia

Metabolic acidosis resulting from acute trauma is a consequence of inadequate tissue perfusion leading to lactic acid production and is best addressed with resuscitation with WB or equal ratio components. Crystalloid resuscitation will contribute to the acidosis and should be avoided. Hypothermia is multifactorial and strategies should address as many causes as are identified, including cold exposure, cold resuscitation fluids, significant blood loss, and shock. Hypoperfusion contributes to development of hypothermia due to decreased heat production. Prior to arrival at the military treatment facility, heated fluids, fluid blankets, and ventilators may not be available, but wounds should be covered, “space blankets” (e.g., HPMK) used to cover the casualty, and shock avoided or treated. See JTS Hypothermia Prevention CPG for additional information.98 In patients with isolated extremity injuries treated with tourniquets, the extremity distal to the tourniquet should be left exposed and cooled relative to the patient’s core in order to increase the likelihood of preserving the ischemic limb’s viability.99

Expeditious delivery to definitive surgical control

Casualties may require care as described and emergency procedures for life-threatening conditions in the pre-hospital setting; however, these should be balanced against the need to expeditiously deliver the patient to definitive care. DCS at Role 2 forward surgical units should focus only on control of hemorrhage and prevention of ongoing contamination. Only absolutely necessary procedures should be performed. In general, every effort should be made to deliver the critically injured casualty to the highest available level of care as rapidly as possible.