• DESCRIBE the progressive strategy for controlling hemorrhage in tactical field care.
• DEMONSTRATE the correct application of a CoTCCC-recommended hemostatic dressing.
• DEMONSTRATE the correct application of a CoTCCC-recommended junctional tourniquet.
• DEMONSTRATE the correct application of a pelvic binder.

• The casualty is in shock.
• You cannot closely monitor the wound for re-bleeding.
• The extremity distal to the tourniquet has been traumatically amputated.​
• The tourniquet has been on for more than 6 hours.
• The casualty will arrive at a medical treatment facility within 2 hours after time of application….or
• Tactical or medical considerations make transition to other hemorrhage control methods inadvisable.

Fluid resuscitation may be detrimental when given before bleeding is controlled in patients with trauma. The purpose of this study was to determine the effects of delaying fluid resuscitation until the time of operative intervention in hypotensive patients with penetrating injuries to the torso.

This was a prospective trial comparing immediate and delayed fluid resuscitation in 598 adults with penetrating torso injuries who presented with a pre­hospital systolic blood pressure of less than 90 mm Hg. Patients assigned to the immediate-resuscitation group received standard fluid resuscitation before they reached the hospital and in the trauma center, and those assigned to the delayed-resuscitation group received intravenous cannulation but no fluid resuscitation until they reached the operating room.

Among the 289 patients who received delayed fluid resuscitation, 203 (70%) survived and were discharged from the hospital, as compared with 193 of the 309 patients (62%) who received immediate fluid resuscitation. The mean estimated intra­operative blood loss was similar in the two groups. Among the 238 patients in the delayed-resuscitation group who survived to the postoperative period, 55 (23%) had one or more complications (adult respiratory distress syndrome, sepsis syndrome, acute renal failure, coagulopathy, wound infection, and pneumonia), as compared with 69 of the 227 patients (30%) in the immediate-resuscitation group. The duration of hospitalization was shorter in the delayed-resuscitation group.

The purpose of this study was to characterize contemporary use of tranexamic acid (TXA) in combat injury and to assess the effect of its administration on total blood product use, thromboembolic complications, and mortality.  This was a retrospective observational study comparing TXA administration with no TXA in patients receiving at least 1 unit of packed red blood cells. A subgroup of patients receiving massive transfusion (greater than 10 units of packed red blood cells) was also examined.

A total of 896 consecutive combat injury admissions to a Role 3 Echelon surgical hospital in southern Afghanistan were evaluated (of the 896 injured patients, 293 received TXA).  Outcome measures included mortality at 24 hours, 48 hours, and 30 days as well as the influence of TXA administration on postoperative coagulopathy and the rate of thromboembolic complications.

The TXA group had lower unadjusted mortality than the no-TXA group (17.4% vs 23.9%, respectively) despite being more severely injured. This benefit was greatest in the group of patients who received massive transfusion , where TXA was also independently associated with survival and less coagulopathy.

To investigate the mechanism of action of tranexamic acid (TXA) in bleeding trauma patients, the authors examined the timing of its effect on mortality. The working hypothesis was the following-- if TXA reduces mortality by decreasing blood loss, its effect should be greatest on the day of the injury when bleeding is most profuse. However, if TXA reduces mortality via an anti-inflammatory mechanism its effect should be greater over the subsequent days. This paper is an exploratory analysis, including per-protocol analyses, of data from the CRASH-2 trial, a randomized placebo controlled trial of the effect of TXA on mortality in 20,211 trauma patients with, or at risk of, significant bleeding.

The effect of TXA on mortality is greatest for deaths occurring on the day of the injury.  This survival benefit is only evident in patients in whom treatment is initiated within 3 hours of their injury. Initiation of TXA treatment within 3 hours of injury reduced the hazard of death due to bleeding on the day of the injury by 28%.  TXA treatment initiated beyond 3 hours of injury appeared to increase the hazard of death due to bleeding, although the estimates were imprecise.  Early administration of tranexamic acid appears to reduce mortality primarily by preventing exsanguination on the day of the injury.

The objective of this paper was to evaluate battlefield survival in a novel command-directed casualty response system that comprehensively integrates Tactical Combat Casualty Care guidelines and a prehospital trauma registry.  Information was obtained via an analysis of battle injury data collected from the 75th Ranger Regiment, US Army Special Operations Command during combat deployments in Afghanistan and Iraq from October 1, 2001 through March 31, 2010. Casualties were scrutinized for preventable adverse outcomes and opportunities to improve care. Comparisons were made with Department of Defense casualty data for the military as a whole.

A total of 419 battle injury casualties were incurred during 7 years of continuous combat in Iraq and 8.5 years in Afghanistan. Despite higher casualty severity indicated by return-to-duty rates, the regiment’s rates of 10.7% killed in action and 1.7% who died of wounds were lower than the Department of Defense rates of 16.4% and 5.8%, respectively, for the larger US military population. Of 32 fatalities incurred by the regiment, none died of wounds from infection, none were potentially survivable through additional prehospital medical intervention, and 1 was potentially survivable in the hospital setting. Substantial prehospital care was provided by nonmedical personnel.

This study was undertaken to determine the differences in injury patterns between soldiers equipped with modern body armor in an urban environment compared with the soldiers of the Vietnam War.  From July 1998 to March 1999, data were collected for a retrospective analysis on all combat casualties sustained by United States military forces in Mogadishu, Somalia, on October 3 and 4, 1993. This was the largest and most recent urban battle involving United States ground forces since the Vietnam War.

There were 125 combat casualties.  Casualty distribution was similar to that of Vietnam; 11% died on the battlefield, 3% died after reaching a medical facility, 47% were evacuated, and 39% returned to duty.  No missiles penetrated the solid armor plate protecting the combatants’ anterior chests and upper abdomens. Most fatal penetrating injuries were caused by missiles entering through areas not protected by body armor, such as the face, neck, pelvis, and groin. Three patients with penetrating abdominal wounds died from exsanguination, and two of these three died after damage-control procedures.

At the time of this study, United States Army doctrine on prehospital care did not include antibiotic administration by medics in the field. Information on field use of antibiotics in this battle is only anecdotal, but it seems that very few of the casualties received antibiotics before reaching a casualty collection point or hospital. Early administration of antibiotics to combat casualties is recommended in many studies.  The NATO Emergency War Surgery Handbook suggests that parenteral antibiotics be given as early as possible to all patients with penetrating abdominal injuries, open comminuted fractures, and extensive soft-tissue extremity wounds.  Because evacuation to definitive surgical care is likely to be delayed more than 6 hours in future urban conflicts, antibiotic therapy should be initiated by medics in the field, preferably within the first hour of injury.