Prolonged Field Care Podcast 47: Andy Fisher And His Damage Control Resuscitation For PFC

So what is different than what we already have in the THOR  recommendations, the JTS DCR clinical Practice Guideline and the Ranger  Regiment TDCR? No hextend?! Calcium with the 1st unit of blood?! TXA  slow push?! What if the patient is not responding to resuscitation  efforts? This is a guideline truly written for the Medic working despite  lack of help or resources in an austere environment…  

When reviewing and editing this evidence-based consensus guideline there  were lengthy discussions about the realities of some of the issues  mentioned above. One of the biggest questions came when discussing TCCC  because there are slight differences with the CoTCCC guidelines which  were written specifically for a medic treating a patient sequentially in  the combat environment.  

I will attempt to explain the thought process of the group of authors as  I understood the conversations and email chains in order to help you  make a better decision for your practice. That fact alone makes this  guideline different. It is specifically written for an independent duty  medic or corpsman who has the flexibility to make decisions about the  care based on available evidence for the patient which may or may not  yet exist in which case expert consensus was used.  

Guidelines for medics must be written in a linear manner because they do  not merely manage the care of a patient as part of a large team working  together, they manage, prioritize, and physically complete each task  one after another. Training other team members to complete certain tasks  can greatly assist the medic. Gains in the quality of care and outcomes  can come from optimizing a dedicated trauma system. When that system is  a single person working problems in series, the variables must be  looked at in a sequential manner because that is how they are performed.  The administration of TXA comes to mind when talking about these minute  changes.

TXA Slow Push:  TXA is not the cornerstone of austere resuscitation, administration of  blood is. Since the CRASH2 TXA trial results and per manufacturer  recommendations, it has been recommended that TXA be given slowly over  10 minutes so as to not cause transient hypotension. The provider should  absolutely be aware of this possibility no matter how small of a chance  it may have of occurring. Once aware and taken into account, a decision  can be made for the current situation. Do they have time to get out an  IV bag, reconstitute the TXA, Inject it into the bag, start a new IV/IO  site, hook up the line, count the drips, adjust the drip rate multiple  times and then check on the drip rate multiple times so as to make sure  that 10 minutes is vehemently adhered to? Does this bring the risk of  transient hypotension to absolute zero or does it merely reduce an  already small chance? This guideline gives the medic the same guidance  and recommendations from conclusions of the original study with the  caveat not to waste time they or the patient may not have due to the  situation or environment. If that IV line is already the second line, it  may be needed for other adjuncts including calcium, pain control,  sedation, antibiotics, antiemetics, etc. 10 minutes is a long time when  someone is writhing in pain, vomiting, mentally altered while bleeding  out. If on the other hand, a patient arrives to your aid station with 2  IVs, blood hanging, with appropriate sedation and analgesia, there is  likely time to adhere to the slow drip over 10 minute recommendation.  Again, it is the prerogative of the independent duty medic or corpsman  to weigh the risks versus gain.