Military Resuscitation - Northern Ohio Trauma System

11/11/2020

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Matthew L. Moorman, MD, MBA, FACS, FAWM, FCCMChief, Division of Trauma, Critical Care, & Acute Care SurgeryClinical Associate Professor of SurgeryCase Western Reserve University School of Medicine

10th Annual Trauma Symposium

Military Resuscitation



What has 20 years of war taught us about prehospital trauma care?

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How do we maintain the skills learned from 20 years of war…if the wars end?

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NOTS 2020 – Military Resuscitation 5

Disclosures

No financial disclosures or conflicts of interest

Employment / Affiliation:

• University Hospitals, Cleveland, Ohio, USA

• Case Western Reserve University, Cleveland, Ohio, USA

• United States Air Force / Air National Guard

The views expressed are those of the author only and do not represent the

official position of any U.S. Government agency, University Hospitals, or Case

Western Reserve University


Battlefield Trauma Care: Then (2001) – “Civilian-Based Care”

Civilian training NOT developed for combat

Medics taught NOT to use tourniquets

No adjunct hemostatic agents

Large volume crystalloid fluid resuscitation for shock

Two large bore IVs on all casualties with significant trauma

No focus on prevention of trauma-related coagulopathy

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Survivor Bias

What about the ones that don't make it that far?

We learn to treat what we see in the ER


Battlefield Trauma Care Evolution

"Rest assured that your son/daughter is going to get the same care here in Iraq

that he/she would have received back home in a big Level 1 trauma center"

"Rest assured that your son/daughter is going to get the same care here in our

Level 1 trauma center that he/she would have received in the military in Iraq"

Which is it now ?

?

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Preventing Prehospital Trauma Deaths


Resources Make a Difference

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Tactical Combat Casualty Care

Care Under Fire

Tactical Field Care

Tactical Evacuation Care

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Tactical Field Care


Tactical Field Care

Safety, triage, control MASSIVE HEMORRHAGE

Tourniquets

• Extremity or junctional

• 2-3 inches above injury. 2nd tourniquet if needed

• Combat Gauze (Quick Clot)

- Direct pressure 3 minutes

• iTClamp

- Head & neck

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Tactical Field Care

Airway

• C-collar not necessary for casualties sustaining only penetrating injuries

Respirations

• Needle, finger thoracostomy

Circulation

• Pelvic binder

• Recheck tourniquets

- move, tighten, double-up

- remove <2 hrs if able. if on >6 hrs, don't remove in field

- try to change to pressure dressing if controllable, no shock, no amputation

• IV or IO access


Tactical Field Care

Fluid Resuscitation

• Do they need it?

- Mental status, radial pulse

• Products of choice in descending order:

- Whole Blood

- Plasma + PRBCs + PLT in 1:1:1 ratio

- Plasma + PRBCs in a 1:1 ratio

- Plasma (dried, liquid, thawed) or PRBCs alone

- Hextend

- LR or Plasmalyte

Goal: palpable radial pulse, improved mental status, or SBP 80-90

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Tactical Field Care

Tranexamic Acid (TXA)

• If anticipate significant blood transfusion (e.g., shock, amputations, pen torso, other severe bleeding)

- 1 gm TXA in 100 ml NS or LR asap, given over 10 minutes

– Transient HYPOtension

– NOT later than 3 hourrs after injury

- 2nd dose of 1 gm after initial fluid resuscitation is complete, given over 8 hours

TXA is not a pressor !

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Why MARCH vs ABCDE ?

Too many deaths due to uncontrolled, but potentially

controllable, hemorrhage


Causes of Battlefield Preventable Deaths

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Tourniquets


Tourniquets

First documented use ~ 1674

Previously thought to result in 100% amputation

• Lose the limb to save the life

Now standard issue for U.S. soldiers

J Vasc Surg 2012;55:286-90

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Tourniquet Mixed History

Injuries and Diseases of War, 1918

"The systematic use of the elastic tourniquet cannot be too

severely condemned. …usually indicates the person

employing it is quite ignorant "

Spanish Civil War 1936

"…more limbs and lives are lost at the front

from the improper use of the tourniquet than are

saved by its proper use"

J Vasc Surg 2012;55:286-90


Tourniquet Mixed History

WWII

"Soldiers regularly misuse tourniquets…applied them unnecessarily…left them on too

long…concealed them by blankets. Limbs were doomed!"

Korea / Vietnam:

• Anecdotal positive stories, little data

Iraq / Afghanistan

• Universally positive

J Vasc Surg 2012;55:286-90

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Combat Application Tourniquet (CAT)


Special Operations Force Tactical Tourniquet (SOFTT)

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Junctional Tourniquets


Most Tourniquet Knowledge is New

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290327 341

0

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100

150

200

250

300

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400

1950-1959 1960-1969 1970-1979 1980-1989 1990-1999 2000-Today

Tourniquet Publications

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Tourniquets Save Lives


Tourniquets Save Lives

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Common Tourniquet Errors

Injury did not need a tourniquet

Improvised tourniquets = high failure rates

Too loose

• Still have a pulse ?- Venous outflow OFF but inflow ON = worse bleeding

Too high

• Put just above injury

Too few

• Use 2 if needed

Taken down too soon, too late

• 2 hours? 6 hours?


Hemostatic Dressings

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Hemostatic Dressings

Kaolin impregnated gauze


Hemostatic Resuscitation

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Predictors of Massive Transfusion

3 out of 4 of the following = 70% risk of MT (85% if all 4)

SPB < 100 mmHg

HR > 100 bpm

Hematocrit < 32%

pH < 7.25

Other risk factors:

• Lactate > 2.5

• INR > 1.5

• BD > 6 mEq/L

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Historic Resuscitation Paradigm

Crystalloid 3:1 Ratio

Blood

FFP

Transient or no response ?

6-10 u PRBC

Crystalloid

"Crystalloid resuscitation will contribute to the acidosis and

should be avoided"

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Paradigm Shift

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2.5

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0.51

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0:22 - 1:4 1:3.9 - 1:2.1 1:2 - 1:0.59

Hemorrhage

Sepsis

MOF

Airway/Breathing

CNS

38% absolute and 62% relative reduction in hemorrhagic death

compared to 1:4

18.5/20 (92.5%)

14/20 (70%)

11.5/33 (35%)

1:1 ratio decreases death from hemorrhage

FFP:RBC Ratio

% o

f d

ea

th b

y ca

use

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Fresh whole blood

1:1:1:1

PRBCFFPPltsCryo



Products of choice in descending order:

• Low Titer O Whole Blood

• Plasma + PRBCs + PLT in 1:1:1 ratio

• Plasma + PRBCs in a 1:1 ratio

• Plasma (dried, liquid, thawed) or PRBCs alone

• Hextend

• LR or Plasmalyte

• Cryoprecipitate should be added 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).

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Early Calcium

• 1g IV/IO after first unit, q4units

• Keep iCa >1.3mmol/L

Hextend, Hespan

Factor VII

Vasopressors

HTS


TXA

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TXA

Why Do They Do That? Tricks & Trends in Trauma 46

TXA – Tranexamic Acid

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Fibrin cross-links platelets in a new clot

Plasmin activated by clotting process

• Breaks fibrin

• tPA – plasminogen activator

Fibrin vs. Plasmin

• Fibrin wins when you need it to…Plasmin wins when you don't

TXA stops formation of plasmin



Anti-fibrinolytic

Anti-inflammatory

1.5% survival advantage, NNT 67

- 2.1% if given in first hour (EMS !)

- NNT is only 22 if given for SBP <75 mmHg

~$30/dose (Bivens, JEMS 2018)

• …$660 - $2000 per life saved

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Why Do They Do That? Tricks & Trends in Trauma 50Lancet 2010;276:23-32

CRASH-2

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MATTERs


TXA – Why the confusion ?

Who benefits? Who might be harmed?

• ~46% = no clot lysis

aka "Fibrinolytic shutdown"

- Die from multi-organ failure

- TXA may harm

• ~18% = too much clot lysis

- Die from bleeding

- TXA may help

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Thromboelastogram (TEG)


"While we await the results of additional prospective clinical trials, the use of empiric antifibrinolytics in trauma patients should be

selective"

"Appreciation that fibrinolysis shutdown is the most common phenotype after severe injury warrants careful re-consideration of

the empiric use of antifibrinolytic in trauma"

"His pressure was a little soft….I gave some TXA and it came right up"

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Who Should Get TXA ?

Adults, SBP ≤ 75 mmHg

With predictors (?) of fibrinolysis or known fibrinolysis (TEG)

< 3 hours from injury

1 g over 10 mins, then 1 g over 8 hrs


Endpoints of Resuscitation

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Endpoints of Resuscitation

Responder

Transient Responder

Non-Responder

Physical Exam

• Mental status, peripheral pulse

SBP 90-110 mm Hg (head injury >110)

Hg / HCT [>8 / 27]

Lactate [>2.5]

INR [<1.5]

BD [>-4]

TEG

When to stop?

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Prehospital ?


Trauma / Hemorrhage = Early Mortality

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TXA

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Prehospital ?

Yes !

- but how?

- $$$$


Civilian-Military Partnerships

2017 National Defense Authorization Act

established the Joint Trauma Education and Training

Directorate

"…each branch of the military maintain and measure critical

wartime medical readiness skills and core competencies"

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Sources

Tactical Combat Casualty Care (TCCC) Guidelines for Medical Personnel, 1 August 2019

Joint Trauma System Clinical Practice Guideline (JTS CPG) Damage Control Resuscitation

(DCR) [CPG ID:18] 21 Jul 2019

Joint Trauma System Clinical Practice Guideline (JTS CPG) Damage Control Resuscitation

(DCR) in Prolonged Field Care (PFC) [CPG ID:73]

https://jts.amedd.army.mil/index.cfm/PI_CPGs/cpgs


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Military Resuscitation - Northern Ohio Trauma System

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