# Damage Control Resuscitation Articles



## FisherAD1 (Mar 23, 2018)

See the following links for articles that discuss the benefits of blood and the harmful effects of crystalloids.
Why whole blood needs to be in prehospital medicine: Whole Blood in EMS May Save Lives
Why you shouldn't use crystalloids: Three Reasons Not to Use Normal Saline or Crystalloids in Trauma


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## Stretcher Jockey (Mar 23, 2018)

Forward thinking EMS services have been providing blood pre-hospital for a couple years now, which is obviously fantastic. The service Im with currently (EMS on an Air Force base and managed by AFMOA) doesnt allow for blood administration. As such, we are given LR and NS. Fortunately Im about 10 minutes away from a Level 1 trauma center, so my experience with NS as it pertains to hemorrhagic shock is using it to spike blood tubing before I get to the hospital. Because Ive seen enough of these studies to understand the lethal triad and cystalloids impact on it, most of what I do is stop the bleed and a diesel bolus transport. 

Thanks for the excellent articles here, sir. JEMS is a wealth of knowledge.


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## FisherAD1 (Mar 23, 2018)

I thought it might spark some discussion on DCR in combat, or TacMed in general.


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## Devildoc (Mar 29, 2018)

There are about a billion peer-reviewed, validated articles speaking against the use of NS in trauma.  There is more supportive evidence about using LR, but not as a volume expander.  But in any case, blood > crystalloids.  Still, dogma is hard to kill, and a lot of agencies still run NS on everything.

This article is simple-quick, and geared to people not into the literature:

PulmCrit- Get SMART: Nine reasons to quit using normal saline for resuscitation


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## SOSTCRNA (Mar 29, 2018)

We carried only enough NS to run blood products.  We brought our blood everywhere we went and never hesitated to use it.  BTW, love the ROLO program, the Rangers are always cutting edge in combat casualty care.


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## policemedic (Mar 30, 2018)

I agree blood is best but I wonder how we would manage the supply piece if EMS nationwide were to adopt blood or blood products. Can sufficient supplies of donor blood be obtained to supply that much blood, PRBCs, lyophilized plasma etc.?


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## Devildoc (Mar 30, 2018)

policemedic said:


> I agree blood is best but I wonder how we would manage the supply piece if EMS nationwide were to adopt blood or blood products. Can sufficient supplies of donor blood be obtained that supply that much blood, PRBCs, lyophilized plasma etc.?



That's a good question.  Most civilian helo's only carry 2 or 4 units, and I have been away from EMS long enough now that I don't know what the EMS agencies carry who do carry blood products.  My sense is as conservative as a lot of EMS agencies are, we'll never see a large-scale, pre-hospital use of blood products.  

I know there have been on-again/off-again studies on shelf-stable/non-refrigerated hemoglobin-based oxygen carriers, but there's never been any solid movement for a variety of reasons.  When I was working myself through nursing school, I worked part time as a medic on a bus and part time in a research lab at UNC-CH whacking pigs working on such a product (DOD-grant-funded).


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## SPAK (Mar 30, 2018)

Carrying 2-4 units of blood In the field is fairly easy depending on the footprint you need to maintain and how long you’re going to be out. You can always carry more with trade off of space, power requirement, weight, etc. The bigger problem is having an effective blood warmer in a packable size that allows for rapid infusion. Doesn’t necessarily need to have the mechanics to rapidly infuse blood just the capability to warm it under pressure.

We’ve seen a handful of different types and many of them possess good qualities that would be ideal. However, none so far that I have seen  have everything that would be ideal in my opinion. There’s always old school methods of warming blood and they do work. We still use them today when equipment fails, but they do take more time and in the end it’s still not ideal.

If EMS were to carry blood I’m sure it would probabaly be treated the same as narcotics. As long as it’s in the fridge it should be good for the 24hrs that crew is out. In most cases, unless whole blood becomes available for use in the states, 2prbc and 2ffp would probably be a reasonable quantity to expect given the normal transport times from scene to trauma center. There may not even be time to get through the first two units.

That being said, I agree that it would be probably take a rather large movement to start seeing pre-hospital blood products on a wide scale use outside of combat.  In all candor, I’d be happy to see tourniquets properly placed by pre-hospital responders. That’s not meant to be insulting to anyone. Only to highlight that in many civilian areas the use of tourniquets is still taboo. Giving blood is great, stopping the bleeding is first.


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## policemedic (Mar 30, 2018)

@SPAK , you’re absolutely right about the issues surrounding carrying blood in an aid bag.  I’d rather carry a few units of blood with minimal NS than a bunch of IVF that can’t carry oxygen or assist w/clotting.  However, there’s more involved than some bags of blood and fluid.

The issues with EMS using blood products aren’t technical.  They’re regulatory, and to a great extent have to do with the jealous guarding of fiefdoms.  In some states, Texas for example, paramedic scope of practice is determined solely by the squad’s medical director.  This is as it should be.  However, in states like Pennsylvania, scope of practice is defined by law and includes specifically named procedures and drugs.  The difference between these polar opposites is often rooted in who runs EMS; in PA it is primarily nurses, who have a vested interest in keeping (some areas of) paramedic practice below that of a nurse, regardless of education or training.  Of course, there are exceptions and outliers but they just prove the rule.

TQ use is spreading, but it’s taken a long time and it certainly isn’t accepted everywhere though without question it is standard of care.  From a law enforcement perspective, it took me ~7 years to get TQs issued to non-SWAT officers in my department.  The good thing is that between my department and others in our jurisdiction, there are >5000 TQs being carried by cops daily.  That’s police only; fire department paramedics and EMTs are issued with them as well.  Some are reluctant to use them, though we have seen some legitimate applications.


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## SPAK (Mar 30, 2018)

you’re absolutely right, there are bigger hurdles to overcome before the technical/practical application can even be discussed. Personally I think it’s a shame to guard something so tightly that can potentially be life saving, but that is also coming from a much different perspective than typical civilian trauma that LE/MIL seem to have greater appreciation for.

It would be interesting to see the data on how many traumatic injures here in the states would have benefitted from prehospital blood administration. Might be surprising either way....

Those are some great strides getting TQs distributed out to that degree! We’re making progress here locally as well. It’s starting to catch on, but even within the trauma system we find ourselves dispelling old myths re: TQ use.


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## policemedic (Mar 31, 2018)

Anecdotally, my trauma center administers blood to penetrating trauma patients several times a week.  Of that number, only a subset of those patients are brought in by EMS; many are transported by police with little care other than (perhaps) TQ placement.  That’s not data, it’s just an observation.  In my opinion, the short transport times to any of the half dozen or so trauma centers in my city wouldn’t merit out-of-hospital blood administration, but places with longer transport times may find it leads to better outcomes.  TXA and abx are a different matter, and should definitely be available to EMS.

One of our members here was involved in a study that looked at administration of an oxygen carrying blood substitute in penetrating trauma by paramedics.  I’m sure he’ll turn up; his view on this should be interesting.


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## SPAK (Mar 31, 2018)

Agree, from what I’ve seen as well, normal transport in the urban setting probably wouldn’t need it. Prolonged transport outside the cities may have more benefit, though I’d speculate that the incidence of penetrating trauma is probably lower in those areas relative to the urban environment.


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## snapt (Apr 18, 2018)

On a recent PFC podcast on burns the MD suggests if using NS for burn resuscitation and not having LR available adding BiCarb to it. Anybody have this in their protocols or experience with it? My googling has turned up the contrary recomendations due to Na+ issues of adding Bicarb to NS.


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## FisherAD1 (Apr 18, 2018)

The PFC burn CPG states LR or plasmalyte. https://jts.amedd.army.mil/assets/d...urn_Wound_Management_PFC_13_Jan_2017_ID57.pdf


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## SPAK (Apr 18, 2018)

I’m not sure about adding bicarb to NS. Depending on how much bicarb is added, that would essentially be similar to giving hypertonic saline.

LR would be primary, blood if they need resuscitation, NS if you had to.

In war type injuries it’s not uncommon to see burns in conjunction with other injuries that need to be addressed simultaneously: head trauma, blood loss, etc. It becomes a balance of priorities and resources available in addressing which issue is going to take precedence.


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## Devildoc (Apr 18, 2018)

policemedic said:


> Anecdotally, my trauma center administers blood to penetrating trauma patients several times a week.  Of that number, only a subset of those patients are brought in by EMS; many are transported by police with little care other than (perhaps) TQ placement.  That’s not data, it’s just an observation.  In my opinion, the short transport times to any of the half dozen or so trauma centers in my city wouldn’t merit out-of-hospital blood administration, but places with longer transport times may find it leads to better outcomes.  TXA and abx are a different matter, and should definitely be available to EMS.
> *
> One of our members here was involved in a study that looked at administration of an oxygen carrying blood substitute in penetrating trauma by paramedics*.  I’m sure he’ll turn up; his view on this should be interesting.



I didn't work on it in the field, but I did in the lab, the product was HBOC-201, made by Biopure.  Here is one of our articles:

http://www.resuscitationjournal.com/article/S0300-9572(02)00053-9/abstract

I left the lab in the early 2000s after nursing school, so I don't know where it went as far as further research and clinical trials.


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## Devildoc (Apr 18, 2018)

SPAK said:


> In war type injuries it’s not uncommon to see burns in conjunction with other injuries that need to be addressed simultaneously: head trauma, blood loss, etc. It becomes a balance of priorities and resources available in addressing which issue is going to take precedence.



The need for LR in significant burns is much, much more important once the patient hits the unit.  In the initial short term, there isn't likely to be a huge difference in outcome if you use NS instead of LR, but in the long term, LR has definite advantages.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4029282/pdf/1757-7241-21-86.pdf


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## FisherAD1 (Apr 18, 2018)

In a PFC situation, you may have to hold onto the patient for a few days. Therefore, carrying the optimal fluid would be more beneficial to your patient if TACEVAC may not show for a few days.


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## policemedic (Apr 18, 2018)

FisherAD1 said:


> In a PFC situation, you may have to hold onto the patient for a few days. Therefore, carrying the optimal fluid would be more beneficial to your patient if TACEVAC may not show for a few days.



True. The other concern, particularly with burn patients in PFC is having enough fluids regardless of whether you use Parkland or modified Brooke. I tend to think fluid volume needs in severe burn resuscitation tend to be underestimated, formula be damned. 

That’s without touching the issue of sufficient analgesia. 

Burns suck.


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## SPAK (Apr 18, 2018)

In some hospitals I’ve worked at the tendency is the opposite. I’ve seen way too much fluid given. Then again, there’s a lot of catching up to be done from what the military has learned from past lessons learned, even then it’s not perfect.

In the field however, totally different scenario. Given a conservative 80 kg person with a 50 percent burn, fluid requirement using rule of 10s, most of us can’t carry that much fluid for even the first 24hrs. If I had the space and weight allowance, I’d probably be taking blood over fluids if given the option.

Agree.... burns suck.


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## Devildoc (Apr 18, 2018)

Burns are a whole 'nother animal.  I worked in a burn ICU at UNC hospitals. It was extraordinarily demanding, physically and intellectually. We gave a metric shit-ton a fluid, LR.  We gave blood when it was indicated, but what they needed was the LR. We would give easily 50, 60 liters in 24, 36 hours.

Before I was qualified to take a burn patient on my own I had to take a 50 hour course, and then orient for 12 weeks.  

I kinda miss complex trauma and the complex surgical cases in the trauma-surgery ICU, but I absolutely without any doubt do not miss the burn ICU.


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## FisherAD1 (Apr 18, 2018)

For those interested and have access to JSOM, here is first ROLO use. Military Prehospital Use of Low Titer Group O Whole Blood.  - PubMed - NCBI.


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