Administration of Analgesia and Sedation in TCCC
Pain is one of the most common complaints from trauma victims. Reports from recent military conflicts suggest that early pain control may reduce the incidence of long-term deleterious outcomes. There are several studies that demonstrate a relationship with poor management of acute and chronic pain with PTSD, and other mental health issues. The current approach to analgesia at the point of injury is based on the severity of the injury and utilizes a single drug/single dose, and then repeat when necessary. There are medical interventions now offered at the point of injury and during prolonged field care that may require ongoing analgesia and/or dissociative sedation. See Table 2 for the reason to update the analgesia and sedation guidelines and pending publications. The recommendations for analgesia and sedation have direct application to the advanced provider in wilderness medicine.
Fluid Resuscitation for Hemorrhagic Shock in TCCC
In severely wounded military casualties, time to prehospital transfusion initiated within 30 minutes of injury is associated with improved 24-hour and 30-day survival. Consequently, both civilian Fire/EMS and military operational units are now conducting whole blood transfusion at the point of injury. Ongoing research demonstrates that time to transfusion, and maybe more importantly what is being transfused, has a greater impact on mortality. Thus, current research focuses on the optimal fluid resuscitation for trauma victims in hemorrhagic shock. The CoTCCC has made several updates to the fluid resuscitation section, e.g., in 2011, 2014, and now recently in 2020. Since the last 2014 fluid resuscitation TCCC update, newer concepts in resuscitation from hemorrhagic shock continues to evolve. Since 2014, the preferred fluids for resuscitation of casualties in hemorrhagic shock has been the following top three options: 1) whole blood; 2) 1:1:1 plasma, RBCs, and platelets; and 3) 1:1 plasma and RBCs.
The use of whole blood for damage control resuscitation continues to gain broad acceptance for battlefield use. Based on the evidence, the use of cold-stored low titer O whole blood (LTOWB) is now the preferred resuscitation fluid for trauma victims in hemorrhagic shock. Based on the 2020 TCCC approved changes, the top three preferred trauma resuscitation fluids are presented below in order of preference:
- Cold stored low titer O whole blood
- Pre-screened low titer O fresh whole blood
- Plasma, RBCs, and platelets in a 1:1:1 ratio
See Table 2 for the reasons to update the fluid resuscitation guidelines and pending publications. The recommendations for fluid resuscitation have direct application to the advanced provider in wilderness medicine.
Management of Abdominal Evisceration in TCCC
About 20% of combat wounds are abdominal injuries including evisceration that may complicate about 1/3 of battle-related abdominal wounds. Evisceration is an injury with potential for improved outcomes if managed appropriately in the prehospital setting. Traditionally, initial management of abdominal evisceration consists of assessing for and controlling associated hemorrhage, covering the eviscerated abdominal contents with a moist, sterile barrier, and carefully reassessing the patient. However, the CoTCCC has not specifically addressed this issue previously in the trauma guidelines. The intent is to reduce hemorrhage, increase intra-abdominal organ viability, reduce hypothermia, and reduce complications related to sepsis. See Table 2 for the reason for the new addition on the management of abdominal evisceration and pending publications. The recommendations for evisceration management have direct application to the wilderness medicine provider.