The Use of Tranexamic Acid in Tactical Combat Casualty Care

Brendon Drew, DO; Jonathan Auten, DO; Benjamin Donham, MD; Andre Cap, MD, PhD;Travis Deaton, MD; Warren Dorlac, MD; Joseph DuBose, MD, FACS, FCCM;Andrew D. Fisher, MD, PA-C; Alan J. Ginn; James Hancock, MD; John B. Holcomb, MD;John Knight, MD; Ryan Knight, MD; Albert “Ken” Koerner, MD; Lanny Littlejohn, MD;Matthew J. Martin, MD; John Morey; Jonathan Morrison, MD; Martin Schreiber, MD;Philip C. Spinella, MD, FCCM; Ben Walrath, MPH, MD; Frank Butler, MD

Journal of Special Operations Medicine

J Spec Oper Med. Fall 2020, Volume 20, Edition 3.

Abstract & Summary

The literature continues to provide strong support for the early use of tranexamic acid (TXA) in severely injured trauma patients. (1) Questions persist, however, regarding the optimal medical and tactical/logistical use, timing, and dose of this medication, both from the published TXA literature and from the TCCC user community. The use of TXA has been explored outside of trauma, new dosing strategies have been pursued, and expansion of retrospective use data has grown as well. These questions emphasize the need for a reexamination of TXA by the CoTCCC. The most significant updates to the TCCC Guidelines are (i) including significant traumatic brain injury (TBI) as an indication for TXA, (ii) changing the dosing protocol to a single 2g IV/IO administration, and (iii) providing for administration via IV/IO push.

NEW Wording to TCCC Guidelines:

Tactical Field Care & TACEVAC Care

c. Tranexamic Acid (TXA)

•If a casualty will likely need a blood transfusion (for example: presents with hemorrhagic shock, elevated lactate, one or more major amputations, penetrating torso trauma, or evidence of severe bleeding)

OR

•If the casualty has signs or symptoms of significant TBI or has altered metal status associated with blast injury or blunt trauma:

–Administer 2g of tranexamic acid via slow IV or IO push as soon as possible but NOT later than 3 hours after injury.

Management of Hypothermia in Tactical Combat Casualty Care

B. L. Bennett, PhD; Gordon Giesbrecht, PhD; Ken Zafren, MD; Ryan Christensen; Lanny Littlejohn, MD; Brendon Drew, DO; Andrew Cap, MD, PhD; Ethan Miles, MD;Frank Butler, MD; John B. Holcomb, MD; Stacy Shackelford, MD

Journal of Special Operations Medicine

J Spec Oper Med. Fall 2020, Volume 20, Edition 3.

Abstract & Summary

As an outcome of combat injury and hemorrhagic shock, trauma-induced hypothermia (TIH) and the associated coagulopathy and acidosis result in significantly increased risk for death. In an effort to manage TIH, the Hypothermia Prevention and Management Kit™ (HPMK) was implemented in 2006 for battlefield casualties. Recent feedback from operational forces indicates that limitations exist in the HPMK to maintain thermal balance in cold environments, due to the lack of insulation. Consequently, based on lessons learned, some US Special Operations Forces are now upgrading the HPMK after short-term use (60 minutes) by adding insulation around the casualty during training in cold environments. Furthermore, new research indicates that the current HPMK, although better than no hypothermia protection, was ranked last in objective and subjective measures in volunteers when compared with commercial and user-assembled external warming enclosure systems. On the basis of these observations and research findings, the Committee on Tactical Combat Casualty Care decided to review the hypothermia prevention and management guidelines in 2018 and to update them on the basis of these facts and that no update has occurred in 14 years. Recommendations are made for minimal costs, low cube and weight solutions to create an insulated HPMK, or when the HPMK is not readily available, to create an improvised hypothermia (insulated) enclosure system.

NEW Wording to TCCC Guidelines:

Tactical Field Care & Tactical Evacuation Care

7. Hypothermia Prevention

a. Take early and aggressive steps to prevent additional body heat loss and add external heat when possible for trauma and severely burned casualties.

b. Minimize casualty’s exposure to cold ground, wind, and air temperatures. Place insulation material between the casualty and any cold surface as soon as possible. Keep protective gear on or with the casualty if feasible.

c. Replace wet clothing with dry clothing, if possible, and protect from additional heat loss.

d. Place an active heating blanket on the casualty’s anterior torso and under the arms in the axillae (to prevent burns, do not place any active heating source directly on the skin or wrap around the torso).

e. Enclose the casualty in the exterior impermeable enclosure bag.

f. As soon as possible, upgrade a hypothermia enclosure system to a well-insulated enclosure system using a hooded sleeping bag or other readily available insulation inside the enclosure bag/external vapor-barrier shell.

g. Pre-stage an insulated hypothermia enclosure system with external active heating for transition from the noninsulated hypothermia enclosure systems; seek to improve on existing enclosure system when possible.

h. Use a battery-powered warming device to deliver IV resuscitation fluids, in accordance with current CoTCCC guidelines, at flow rate up to 150mL/min with a 38°C (100°F) output temperature.

i. Protect the casualty from exposure to wind and precipitation on any evacuation platform.

Analgesia and Sedation for Tactical Combat Casualty Care

Andrew D. Fisher, MD; Taylor T. DesRosiers, MD; Wayne Papalski; Michael A. Remley; Steven G. Schauer, DO; Virginia Blackman, PhD; Jacob Brown, 18D; Frank K. Butler, MD; Cord W. Cunningham, MD; Erin M. Eickhoff, DNP, RN; Jennifer M. Gurney, MD; John B. Holcomb, MD; Patricia N. Meza, PhD, RN; Harold R. Montgomery, ATP; Meg Moore, MD; Sergey M. Motov, MD; Tim Sprunger; Stacy A. Shackelford, MD; Brendon G. Drew, DO

Abstract & Summary PENDING

The Management of Abdominal Evisceration in Tactical Combat Casualty Care

Jamie Riesberg, MD; Brian Eastridge, MD; Meg Moore, MD; Marc Northern, MD; Dana Onifer, MD; William Gephardt, PA, RN; Erin Eickhoff; Michael Remley, NRP; Carl Miller

Abstract & Summary

Historically about 20% of combat wounds are abdominal injuries.  Abdominal evisceration (AE) may be expected to complicate as many as 1/3 of battle-related abdominal wounds.   Evisceration is an injury with potential for improved outcomes if managed appropriately in the pre-hospital phases.

While not as extensively studied as other forms of combat injury, abdominal evisceration management recommendations extend back to at least Word War I, when it was recognized as a significant cause of morbidity especially associated with bayonet injury. More recently, abdominal evisceration has been noted as a not infrequent result of penetrating ballistic trauma.  

In an effort to manage abdominal eviscerations, the US Military Services have each published recommendations for the pre-hospital provider, medic and corpsman.   Initial management of abdominal evisceration consists of assessing for and controlling associated hemorrhage, covering the eviscerated abdominal contents with a moist, sterile barrier, and carefully reassessing the patient.  Attempting to establish a standard of care for non-medical and medical first responders and to leverage current wound packaging technologies, the Committee on Tactical Combat Casualty Care (CoTCCC) conducted a systematic review of historical Service guidelines and recent medical studies that include abdominal evisceration.   Recommendations are made for overall management and specific wound dressing considerations.

TCCC Guidelines Comprehensive Review and Edits 2020

Harold R. Montgomery, ATP; Brendon G. Drew, DO; Jeremy Torrisi, ATP; Matthew G. Adams, NREMT; Shawn Anderson, NRP; Michael A. Remley, NRP; Thomas A. Rich, NRP; Dominic Thompson, NRP; Dominique Greydanus, 18D; Travis Shaw, NRP; Tom Culpepper, NRP; Frank K. Butler, MD

Abstract & Summary

  1. Change “Care Under Fire” phase to “Care Under Fire/Threat”.
  2. Add text to Care Under Fire/Threat line 3 to include dragging and/or carrying a casualty to cover when tactically feasible.
  3. Change text in Care Under Fire/Threat line 5 from extricated to extracted.
  4. Add text to Tactical Field Care Airway Management, Paragraph 4-c, bullet 1 to include: and/or leaning forward.
  5. Shift assessment of hemorrhagic shock to an earlier text and reference point in the guidelines.
  6. Add a new first line to paragraph 14. Burns to read: a. Assess and treat as a trauma casualty with burns and not burn casualty with injuries.
  7. Add a new last bullet to paragraph 14-d to read: Consider oral fluids for burns up to 30% TBSA if casualty is conscious and able to swallow.
  8. Swap paragraph 16. Communication and paragraph 17. Cardiopulmonary resuscitation in sequence.
  9. Separate TACEVAC portion of the TCCC guidelines to be managed and published by CoERCCC as the proponent.
  10. All medications in the TCCC guidelines indicated for IV administration will be edited to reflect to also include IO administration.