a. Bleeding
- A pelvic binder should be applied for cases of suspected pelvic fracture: Severe blunt force or blast injury with one or more of the following indications:
- Pelvic pain
- Any major lower limb amputation or near amputation
- Physical exam findings suggestive of a pelvic fracture
- Unconsciousness
- Shock
- Reassess prior tourniquet application. Expose the wound and determine if a tourniquet is needed. If it is needed, replace any limb tourniquet placed over the uniform with one applied directly to the skin 2-3 inches above the bleeding site. Ensure that bleeding is stopped. If there is no traumatic amputation, a distal pulse should be checked. If bleeding persists or a distal pulse is still present, consider additional tightening of the tourniquet or the use of a second tourniquet side-by-side with the first to eliminate both bleeding and the distal pulse. If the reassessment determines that the prior tourniquet was not needed, then remove the tourniquet and note time of removal on the TCCC Casualty Card.
- Limb tourniquets and junctional tourniquets should be converted to hemostatic or pressure dressings as soon as possible if three criteria are met: the casualty is not in shock; it is possible to monitor the wound closely for bleeding; and the tourniquet is not being used to control bleeding from an amputated extremity. Every effort should be made to convert tourniquets in less than 2 hours if bleeding can be controlled with other means. Do not remove a tourniquet that has been in place more than 6 hours unless close monitoring and lab capability are available.
- 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 TCCC Casualty Card. Use a permanent marker to mark on the tourniquet and the casualty card.
b. Assess for hemorrhagic shock (altered mental status in the absence of brain injury and/or weak or absent radial pulse).
c. IV/IO Access
- Intravenous (IV) or intraosseous (IO) access is indicated if the casualty is in hemorrhagic shock or at significant risk of shock (and may therefore need fluid resuscitation), or if the casualty needs medications, but cannot take them by mouth.
- An 18-gauge IV or saline lock is preferred.
- If vascular access is needed but not quickly obtainable via the IV route, use the IO route.
d. Tranexamic Acid (TXA)
- If a casualty will likely need a blood transfusion (for example: presents with hemorrhagic shock, 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 mental status associated with blast injury or blunt trauma"
- Administer 2 gm of tranexamic acid via slow IV or IO push as soon as possible but NOT later than 3 hours after injury.
e. Fluid resuscitation
- Assess for hemorrhagic shock (altered mental status in the absence of brain injury and/or weak or absent radial pulse).
- The resuscitation fluids of choice for casualties in hemorrhagic shock, listed from most to least preferred, are:
1. Cold stored low titer O whole blood
2. Pre-screened low titer O fresh whole blood
3. Plasma, red blood cells (RBCs) and platelets in a 1:1:1 ratio
4. Plasma and RBCs in a 1:1 ratio
5. Plasma or RBCs alone
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 casualty is conscious and can swallow.
If in shock and blood products are available under an approved command or theater blood product administration protocol:
- Resuscitate with cold stored low titer O whole blood, or, if not available
- Pre-screened low titer O fresh whole blood, or, if not available
- Plasma, RBCs, and platelets in a 1:1:1 ratio, or, if not available
- Plasma and RBCs in a 1:1 ratio, or, if not available
- Reconstituted dried plasma, liquid plasma or thawed plasma alone or RBCs alone
- Reassess the casualty after each unit. Continue resuscitation until a palpable radial pulse, improved mental status or systolic BP of 100 mmHg is present.
- Discontinue fluid administration when one or more of the above end points has been achieved.
- If blood products are transfused, administer one gram of calcium (30 ml of 10% calcium gluconate or 10 ml of 10% calcium chloride) IV/IO after the first transfused product.
Given increased risk for a potentially lethal hemolytic reaction, transfusion of unscreened group O fresh whole blood or type specific fresh whole blood should only be performed under appropriate medical direction by trained personnel.
Transfusion should occur as soon as possible after life-threatening hemorrhage in order to keep the patient alive. If Rh negative blood products are not immediately available, Rh positive blood products should be used in hemorrhagic shock.
If a casualty with an altered mental status due to suspected TBI has a weak or absent radial pulse, resuscitate as necessary to restore and maintain a normal radial pulse. If BP monitoring is available, maintain a target systolic BP between 100-110 mmHg.
Reassess the casualty 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.
f. Refractory Shock
- If a casualty in shock is not responding to fluid resuscitation, consider 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 with repeated NDC or finger thoracostomy/chest tube insertion at the 5th ICS in the AAL, according to the skills, experience, and authorizations of the treating medical provider. Note that if finger thoracostomy is used, it may not remain patent and finger decompression through the incision may have to be repeated. Consider decompressing the opposite side of the chest if indicated based on the mechanism of injury and physical findings