Podcast Episode 47: Andy Fisher and his Damage Control Resuscitation for Prolonged Field Care CPG

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 completcertain 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 independant duty medic or corpsman to weigh the risks versus gain.

NO Hextend and Hetastarch:

The absence of Hextend or hetastarch is the next thing likely noticed after the concession of the TXA alow push. We have made sure that the non-physician has a range of options to provide adequate volume for their trauma patient. Blood products are available via freeze dried plasma, cold stored low titer type-O whole blood delivery from the ASBP, field transfusion from a previously identified type-O low titer donor or a type specific donor. The goal is not to merely raise the blood pressure but to do so with physiologically beneficial products which contribute to oxygen delivery, clotting and everything else the blood organ does.

On September 12, 2013 the US Food and Drug Administration added a black box warning to Hydroxyethyl starch (HES). Here is a summary of the warning for your consideration:

I. Avoid the use of HES in critically ill patients, patients with renal insufficiency, patients with sepsis, and patients at risk of bleeding who are undergoing TPE. HES use in these settings should be limited only to situations where the benefit of its use outweighs the risk. Examples of such situations would include but are not be limited to:
a. Jehovah’s Witnesses with a life-threatening disease amenable to TPE who refuse albumin and plasma replacement fluids.
b. Patients with severe recurrent allergic reactions to albumin.
c. During severe albumin shortages, after assessment of the benefit of the therapy versus risk of replacement alternatives.

II. Avoid the use of HES or use with caution in critically ill patients, patients with renal insufficiency, and patients at risk of bleeding in the setting of leukocytapheresis.

III. Potential granulocyte donors should be questioned and/or screened for evidence of renal insufficiency and underlying renal disease. Consent for collection should include an explicit discussion of this potential risk and education on signs and symptoms to look for as outlined in the FDA black box warning document.

Type O, Low Blood Program

All O donors are identified using MEDPROS. They are then given a brief about the program. Then they meet with the ASBP. They are screened, get second ABO, TTD, and titer testing IgM anti-A/B. All results are posted in TMDS. Our med readiness person downloads all ROLOs for the medics and providers. Then they can get an ID. Before deployment they get TTD testing.

Early Calcium:

Calcium is proving to show some benefit to trauma patients who are likely hypocalcemic before any blood has even been administered. Once a transfusion is given the citrate in the blood bag binds to calcium in the blood which can further exacerbate the hypocalcemia. Calcium helps prevent cardiac dysfunction and hypotension.

o Minimum: Administer 1g of calcium (30mL of 10% calcium gluconate or 10mL of 10% calcium chloride) IV/IO during or immediately after transfusion of the first unit of blood product.

o Better: With ongoing resuscitation, give additional 30mL of calcium gluconate or 10mL calcium chloride after every four units of blood product.

o Best: Monitor serum calcium during ongoing resuscitation and administer calcium gluconate 30mL or calcium chloride 10mL for ionized calcium less than 1.2mmol/L.

Caution:
Calcium gluconate is safer for peripheral use. Calcium chloride may cause severe skin necrosis if extravasation occurs through a partially dislodged IV or IO catheter. The risk of bone necrosis with IO injection of calcium chloride is not known. When using peripheral IV or IO access, use extreme caution to ensure the device is in good intravascular position and no extravasation occurs.

Caution: Do not mix medications and blood products in the same IV line.

Non Responder and Palliative Care

Despite best efforts often times the patient will lose more blood than what is available. In this CPG we added a section for palliative, end of life care.

Also included is a very informative section on resuscitating pediatric patients…

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4 thoughts on “Podcast Episode 47: Andy Fisher and his Damage Control Resuscitation for Prolonged Field Care CPG”

  1. Hey doc…

    Thanks for the awesome post. I’ll only get round to listening to the podcast tonight.

    On the use of HES, the answer seems to be left in the air if you don’t have access to blood or blood products not access to direct donor.
    Is HES then permissable as an expander for admin when you have nothing else except LR and NS?

    Brendon

    1. This is Doc Powell, one of the co-authors of the CPG. Either crystalloid (LR or NS) are preferable: less risk of kidney injury or impairing blood clotting. HES is last resort. Since no risk is 0% or 100%, have to weigh risks of HES (some) vs benefits of volume expansion (some; very patient and provider dependent). Do you not have access to direct donor because of small team size/ solo team member? The big point of the CPG is to reinforce that “bleeding patients should get blood.” Anything that does not deliver the clotting (perhaps even more than the oxygen carrying) capabilities of blood is going to work against resuscitation. It may take a while, but non-blood resuscitation will eventually put the patient at risk of getting worse. Whether this risk comes after the patient arrives at a surgical resuscitation capability that can provide blood, is part of the medic’s very difficult calculus and a decision that certainly could be helped with telemedicine consultation.

  2. I didn’t realize you were right at my back door. I’m an Instructor with TEEX over at the Brayton Fire Training Field. Good podcast, very informative.

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