Tactical Field Care – Circulation, Bleeding, Shock & Resuscitation

Pelvic Fractures in Combat Casualties

• Incidence & Mortality
• 26 % of service members KIA in OEF/OIF had pelvic fractures.
• Bleeding pelvic fractures + hemodynamic instability → up to 40 % mortality.
• Common Mechanisms
• Dismounted IED attacks (often with amputations).
• Severe blunt trauma: motor-vehicle crashes, aircraft mishaps, hard parachute landings, high-fall injuries.
• Indications to Apply a Pelvic Binder (apply during Tactical Field Care when ANY present)
• Pelvic pain.
• Major lower-limb amputation / near-amputation.
• Physical-exam findings suggestive of fracture.
• Unconsciousness.
• Shock.
• Life-Threatening Fracture Patterns
• Open-Book injury – symphysis & SI-ligament tears; pelvis “opens like a book.”
• Vertical-Shear injury – one hemipelvis forced cephalad.
• Lateral-Crush/Compression – hemipelvis driven inward/outward.
• Exam Findings Suggestive of Pelvic Fracture
• Pelvic pain; bruising/lacerations over ring; deformity/instability.
• Unequal leg length; external rotation of limbs.
• Scrotal, perineal, perianal bruising.
• Blood: urethral meatus, rectum, vagina; massive hematuria.
• Neuro deficits in lower extremities.
• Treatment in TCCC
• Binder is definitive field intervention; fractures often multi-break.
• Commercial Devices (any of 5 may be used):
• Pelvic Binder
• T-POD
• SAM Pelvic Sling II
• SAM Junctional TQ (doubles as binder)
• Junctional Emergency Treatment Tool (JETT)
• Placement Principles
• Center over greater trochanters—not iliac wings (40 % misplacement study).
• Secure knees/feet to limit external rotation and enhance reduction.
• DO NOT log-roll suspected pelvic-fx casualties.
• Binder may be slid to upper thighs for groin/abd access (e.g., REBOA).
• Re-assess need q 8-12 h; loosen if hemodynamically stable.
• Binder can mask fx on CT—inform receiving facility.

Tourniquet Repositioning (“High-and-Tight” → Definitive)

• Goal: restore proximal limb perfusion by moving occlusion 2-3 in above wound on skin.
• Steps

1. Re-assess original TQ, expose wound, confirm need.
2. Place second TQ directly on skin 2-3 in proximal to bleeding site.
3. Loosen first TQ; verify hemorrhage control & presence/absence of distal pulse.
4. If bleed/pulse persists → tighten second TQ further or leave first TQ side-by-side.
5. If TQ not required → remove & document time.
   • Key Reminders
   • Eliminate distal pulse to ensure hemostasis & prevent venous congestion.
   • Limb injury rare if TQ < 2 h (routine surgical TQ times often several hours). • Life > limb—accept small ischemic risk to prevent exsanguination.

Tourniquet Conversion

• Objective: Replace limb/junctional TQ with hemostatic or pressure dressing ≤ 2 h when safe.
• Conversion Criteria—ALL must be TRUE

1. Casualty NOT in shock.
2. Wound can be closely monitored.
3. TQ not controlling amputated-limb bleed.
   • Procedure
4. Expose wound by cutting clothing.
5. Pack with Combat Gauze (hemostatic) + apply pressure dressing.
6. Loosen original TQ; slide just proximal to dressing & leave loosely in place.
7. Observe continuously for re-bleed.
   • Decision Points / Timelines
   •

Documentation of Tourniquet Use

• Mark every TQ with application time (permanent marker).
• Record on TCCC Card: times of application, re-application, conversion, removal.
• Expose device for visibility.

Blood Loss & Hemorrhagic Shock

• Definition: Inadequate tissue perfusion/oxygenation due to insufficient blood volume.
• Battlefield Recognition (simple, low-tech)
• Decreased LOC (absent TBI).
• Weak/absent radial pulse.
• Progressive Signs / Approximate Volumes
• Normal – 5000\,\text{mL}; alert, full pulse.
• 500\,\text{mL} loss – vitals near normal.
• 1000\,\text{mL} loss – HR > 100, normal BP supine.
• 1500\,\text{mL} loss – anxious, weak pulse, HR > 100, RR ≈ 30.
• 2000\,\text{mL} loss – confused, HR ≥ 120, SBP↓, RR > 35.
• 2500\,\text{mL} loss – unconscious, no radial pulse, marked tachy/late brady, SBP↓.

Intravenous (IV) Access

• Indications
• Hemorrhagic shock or high risk (torso GSW, etc.).
• Need for meds when oral route impossible.
• Preferred Device
• Single 18-ga catheter + saline lock.
• Principles
• Not all casualties need IVs; avoid distal to major wound.
• Saline lock easier for movement, conserves fluids; flush 5\,\text{mL} NS immediately then q 1–2 h.
• Starting IV consumes time & situational awareness—balance against tactical risk.

Intraosseous (IO) Access

• Use when IV can’t be obtained rapidly & fluids/meds urgent.
• FAST1® (sternal)
• Contraindications: <50\,\text{kg} / <12 y o, sternal fracture/flail chest, local trauma/infection, severe osteoporosis, prior sternotomy scar.
• Remove within 24 h.
• EZ-IO (humeral, tibial, etc.)
• Widely used; must match needle set to site.
• Training ONLY on simulators (risk of retained needle, osteomyelitis).

Tranexamic Acid (TXA)

• Indications (give ASAP, ≤3 h)
• Likely need for transfusion: hemorrhagic shock, ≥1 major amputation, penetrating torso trauma, severe bleeding.
• Significant TBI or altered mental status from blast/blunt force.
• Dose & Timing
• First dose: 1\,\text{g} TXA in 100\,\text{mL} NS over 10 min IV/IO (slow push if needed).
• OPTIONAL second 1\,\text{g} dose prepared likewise (protocol dependent).
• Give BEFORE blood products (or immediately prior); do NOT mix with Hextend.
• Mechanism
• Antifibrinolytic: prevents breakdown of formed clots; does NOT create new clots.
• Evidence
• Two major trials show survival benefit, greatest if within 1 h; benefit persists ≤3 h; harm >3 h.
• Side Effects
• N/V/D, visual changes, hypotension if pushed rapidly, theoretical ↑ thrombo-risk.
• Storage
• 59°–86°\,\text{F} (15–30 °C); insulate from extremes; body-heat in cold.

Fluid Resuscitation Strategy (TFC)

• Assessment
• Shock = altered mental status (no TBI) and/or weak/absent radial pulse.
• Control bleeding FIRST.
• If NOT in Shock
• No IV fluids needed immediately.
• Encourage oral fluids if able, even with abdominal wounds (aspiration rare).
• Prevent dehydration (↑ mortality).
• If IN Shock (after hemorrhage control) – Preferred Fluids (best → least)

1. Cold-stored low-titer O whole blood.
2. Pre-screened low-titer O fresh whole blood.
3. Plasma + RBC + platelets (1:1:1).
4. Plasma + RBC (1:1).
5. Plasma OR RBC alone.
6. Hextend.
7. Crystalloids (Lactated Ringer’s, Plasma-Lyte A).
   • Initiate hypothermia prevention concurrently.
   • End-Points (reassess after each unit)
   • Palpable radial pulse OR improved mental status OR SBP ≈ 100\,\text{mmHg}.
   • Stop fluids once achieved—avoid over-resuscitation (“popping the clot,” dilutional coagulopathy).
   • Calcium Administration
   • After first blood product, give 1\,\text{g} calcium (30 mL 10 % calcium gluconate OR 10 mL 10 % calcium chloride) IV/IO.
   • Rh Considerations
   • Use Rh-positive if Rh-neg unavailable—life-threatening hemorrhage takes priority.
   • Unscreened type-specific or unscreened O whole blood only by trained personnel with medical direction.
   • Refractory Shock – Consider Tension Pneumothorax
   • Signs: thoracic trauma, resp distress, absent breath sounds, SpO₂ <90\%.
   • Treat: repeat needle D, or finger thoracotomy/chest tube @ 5th ICS AAL; may need bilateral.

Objectives of Prehospital Fluid Therapy

1. Support clot formation at active bleeds.
2. Minimize iatrogenic edema/dilutional coagulopathy.
3. Restore circulating volume & organ perfusion pre-surgery.
4. Optimize oxygen-carrying capacity.

Why NOT Crystalloid / Colloid?

• Albumin – \uparrow cost; kidney injury; contraindicated TBI.
• Normal Saline – induces hyperchloremic acidosis.
• Hypertonic Saline (7.5 %) – transient benefit; not FDA approved; no outcome superiority.
• Quotation: “Triumph of hope & wishful thinking over physiology & experience.” – COL Cap 2017.