Trauma lessons learned during the Afghanistan and Iraqi wars lead the military to release Joint Theater Trauma System Clinical Practice Guideline discussing elements of Damage Control Resuscitation. Those elements along with the use of tourniquets lead to the creation of the following EMS Draft Protocol.
EMS Protocol Draft
Damage Control Resuscitation
7 August 2013
Based on knowledge gained from the military regarding trauma resuscitation, there is new evidence advancing the initial care and resuscitation of patients suffering from significant hemorrhage. This protocol is an update and replacement of the current approach to trauma patient resuscitation.
The use of large volume crystalloid infusion is known to decrease the ability of patients to form clots and therefore should be limited to patients who are rapidly deteriorating despite other interventions.
This protocol is indicated for use in all trauma patients, appearing to be at least 16 years of age, with ongoing significant hemorrhage (SBP < 90 mmHg and/or heart rate > 110 bpm), or who are considered to be at risk of significant hemorrhage.
In patients with evidence of significant hemorrhage:
- Apply tourniquets to extremities as indicated
- Use firm, continuous direct pressure to site of continuing bleeding
- Application of hemostatic gauze (e.g. Trauma Gauze) as indicated
Limit the infusion of crytalloids in patients with SBP > 90 mmHg.
Give 250-500 mL boluses of crystalloid every 10 minutes:
- Hypotensive patients (SBP < 90 or absent radial pulse)
- Patients with isolated head trauma (necessitating a higher blood pressure to maintain cerebral perfusion pressure)
TRANEXAMIC ACID (TXA):
Patients meeting the above indications AND are within 3 hours of injury:
- 1 gram TXA in 100 mL infused over 10 minutes
Use with caution in patients with past history of DVT/PE or hypercoaguable condition.
ALERT RECEIVING FACILITY:
If time permits, notify the receiving facility that the patient will likely meet Massive Transfusion Protocol criteria.
(1) Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial. Lancet 2010; 376: 23–32.
(2) Tranexamic acid decreases mortality following wartime injury: the Military Application of Tranexamic acid in Trauma Emergency Resuscitation Study (MATTERS) MAJ Jonathan J. Morrison, MB ChB, MRCS, RAMC(V), LT COL (sel) Joseph J. Dubose, MD, USAF MC, COL Todd E. Rasmussen, MD, USAF MC, SURG CAPT Mark Midwinter, BMedSci, MD FRCS RN. Arch Surg. 2012; 147:113-119.
(3) Joint Theater Trauma System Clinical Practice Guideline. Damage Control Resuscitation At Level IIb/III Treatment Facilities. July 2012.