The Advanced Resuscitative Care (ARC) CPG

The Advanced Resuscitative Care (ARC) CPG is the most advanced TCCC update yet. For those who have been paying attention, it marks a milestone in DoD medicine, by allowing advanced providers with a mastery of the basics to reach into the remaining cause of preventable death: Noncompressible Torso Hemorrhage, or NCTH.

 According to the Eastridge study of 2012, out of 100 preventable combat deaths, the following is true:

•  7 were due to airway obstruction
• 1 was due to tension pneumothorax
• 92 were due to hemorrhage

 Of the 92% of casualties that die of hemorrhage:

•  12 are due to extremity hemorrhage
• 18 are due to junctional hemorrhage
• 62 are due to NCTH

-22 of those are thoracic hemorrhage (might be helped by whole blood resuscitation)

-40 are abdominopelvic hemorrhage (***Could be saved by ARC***)

 The huge majority of these casualties can be saved by effective implementation of Advanced Resuscitative Care.

 In recent years, the model for the Surgical Resuscitative Teams (SRT) has grown in popularity due to the mobility of these assets and their ability to bring the definitive surgical capability to the front lines. Their successes, including some notable after-action reports, have influenced ARC and it seems, the entire direction of the Joint Trauma System (JTS).

 The JTS highlights the desire for increased focus into the area of Advanced Resuscitative Care, and admits that ARC crosses over between multiple roles of care to include Tactical Field Care (TFC), Damage Control Resuscitation, Damage Control Surgery, and Enroute Care, meaning that an increased effort to standardize the phases of care should be made.

 Evidence shows the casualties who receive whole blood products at or near the point of injury have a better chance of survival than those who do not. For casualties that have an internal hemorrhage, whole blood is combined with Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) to tamponade bleeding from abdominopelvic injuries below the diaphragm and increase the survivability before a casualty reaches surgical care.

 “Improving the care provided to casualties with NCTH due to abdominal or pelvic hemorrhage is the most significant opportunity to reduce preventable deaths in combat casualties. At this point in time, the two interventions that offer the greatest potential for further reduction in preventable deaths among combat casualties are early resuscitation with whole blood and Zone 1 REBOA, performed as soon as possible after wounding when indicated. This proposed change to TCCC will explore how best to employ these two interventions in the prehospital care of the combat wounded using a resuscitation team approach.”

The treatments needed to be performed for successful implementation of ARC can be done by the individual medic, however it is proposed that Advanced Resuscitative Care will be best utilized in a team environment with a minimum of four trained providers due the tactical limitations of a single medic, and the overwhelming amount of procedures necessary to successfully complete ARC. If interventions are not performed in a timely manner, studies show that casualties are likely to die of wounds in as little as 15-30 mins from the time of injury.

 The Golden Hour demands that from point of injury during military operations, definitive surgical care is no more than 1 hour away. With the drawdown of conventional forces and increased MEDEVAC times, combined with the likelihood of casualties dying of wounds within 15-30 mins from point of injury, ARC “bridges the gap” between the point of injury and a definitive surgical capability.

 There are several methods currently employed in TCCC to prevent death from NCTH. Some of them include:

•  Avoidance of platelet-impairing NSAIDs
• Circumferential pelvic compression devices for casualties suspected of having pelvic fractures
• Tranexamic acid (TXA)
• Whole Blood
• Freeze Dried Plasma
• Ketamine over Opiate analgesia
• Hypothermia Prevention

Whole Blood has been the fluid of choice since 2014 and recommended by the CoTCCC, however the use of whole blood in conventional units is still uncommon. Every effort moving forward will be to educate and equip conventional units in the use of whole blood. Officially, unofficially, the use of clear fluids to include crystalloids and colloids is not recommended for the treatment of hypovolemic shock.

Cold-stored LTOWB, is still uncommon throughout the DoD. 75th Ranger Regiment and JSOC being the only assaulting forces to routinely carry cold-stored blood and have a blood cold chain in place. More R&D into the blood cold chain would make a major impact in units’ ability to utilize WB at the point of injury.

Ultrasonography is crucial to rule out internal bleeding, however, there is evidence that EFAST does not completely rule out intra-abdominal bleeding, therefore, more specific criteria must be utilized to indicate the use of REBOA in ARC.

The Special Operations Surgical Teams (SOST) have been successful in implementing ARC. Their criteria are as follows:

• Hypotensive (<80 SBP) with abdominal or pelvic injuries
• E-Fast to rule out chest trauma
• A low threshold to place bilateral chest tubes
• Immediate IV or IO access and femoral 18g a-line access- rate-limiting step!!
• 2u whole blood, TXA, antibiotics
• TIVA, induction w Ketamine/Versed
• Low threshold to upsize to 7fr sheath
• +E-FAST- Zone 1 (external landmarks)
• Pelvic fx or junctional bleed- Zone 3

 

According to the ARC CPG, the CoTCCC recommends a similar approach.

More resources must be implemented in order to be successful in Advanced Resuscitative Care. This is a very resource intensive protocol. The CoTCCC recommends that, at a minimum, the following equipment is available:

• Electronic blood pressure monitoring
• Advanced airway
• Whole blood—Preferably FDA-Compliant Cold Stored
• LTOWB or LTOWB collected from donors in a unit-based Walking Blood Bank, such as that established in the 75th Ranger Regiment. (1:1 RBCs and plasma are better than crystalloids or colloids, but should only be used when, for some reason, whole blood is not available).
• Point-of-care ultrasound and the capability to perform EFAST to in order to identify intrathoracic and intraabdominal bleeding and to rule out hemopericardium before undertaking REBOA
• Tube thoracostomy, ideally with suction—to more definitively rule out intrathoracic bleeding before undertaking REBOA
• Zone 1 REBOA
• Point-of-care lactate monitoring
• Blood warming devices
• Supplemental oxygen
• A timing device for balloon inflation times
• Foley catheter—both to guide resuscitation and to assist in hemostasis
• A reliable plan for complete documentation of casualty care in ARC

 For REBOA, the challenge is to control NCTH while minimizing tissue ischemia, therefore “intermittent Zone 1 REBOA” is recommended in the protocol (see update below).

In addition to whole blood and intermittent Zone 1 REBOA, the benefits of casualties arriving at an MTF with a REBOA catheter in place, even with a deflated balloon greatly increase the capabilities of the surgeon by allowing the option for proximal aortic occlusion for increased ease of identifying and treating the underlying vascular injury.

The most encouraging thing about reading the latest CPG for Advanced Resuscitative Care is that lessons written in blood have not been lost and evidence-based medicine is continuing to progress the field and embrace new technologies with the goal of zero preventable deaths.

 Advanced Resuscitative Care (ARC) 

1. Combat casualties who are in shock from noncompressible torso hemorrhage (NCTH) in the prehospital setting have a high mortality rate and need life-saving interventions to be performed as soon as possible. The two most important of these interventions can be provided by Advanced Resuscitative Care in TCCC: transfusion of whole blood to provide optimal resuscitation for the casualty’s shock and Zone 1 REBOA (Resuscitative Endovascular Balloon Occlusion of the Aorta) to temporarily control NCTH below the diaphragm. 
   
2. ARC is an advanced capability in TCCC. Although whole blood resuscitation can be provided by a single prehospital provider in some settings, to do both robust whole blood resuscitation and possibly subsequent REBOA, requires a team of 4 or more specially trained and equipped individuals. When a casualty meets the indications for whole blood resuscitation, transfusion should be initiated as quickly as possible, followed rapidly by Zone 1 REBOA if that procedure is indicated as outlined below. ARC could be provided to supplement Tactical Field Care by a team located near the point of injury, or it could be used to supplement TACEVAC Care on an evacuation platform. Whenever tactically feasible, a team with an ARC capability should be positioned as close to the point where casualties are likely to be sustained as possible, since many casualties with NCTH will die within 15-30 minutes without ARC. For these casualties, Advanced Resuscitative Care is likely to be the only thing that will effectively prevent their death.

1. The team providing ARC should first ensure that all of the hemorrhage control interventions recommended in Tactical Field Care have been successfully accomplished:

• Extremity hemorrhage has been controlled with tourniquets; 
  
• Junctional and other external hemorrhage has been controlled with hemostatic dressings, XStat, and junctional tourniquets as needed; 
  
• Pelvic binders have been applied for suspected pelvic fractures; 
  
• The first dose of TXA has been administered without delay if the hemorrhagic shock is present or judged likely to occur; 
  
• If the casualty is in traumatic cardiac arrest, bilateral NDC should have been performed. 
  

1. Indications for Whole Blood Transfusion: 
   

*Follow the JTS Damage Control and Whole Blood Transfusion Clinical Practice Guidelines (CPGs) except as follows:

*TCCC-specific considerations:
– Casualty has known prior external hemorrhage (even if that hemorrhage is now controlled) or suspected non- compressible torso hemorrhage (NCTH)

AND

• Systolic Blood Pressure (SBP) is less than 90mmHg OR
• Point of Injury lactate is 4mmol/L or greater

5. Whole Blood Transfusion Procedure in ARC:
*Follow the JTS Damage Control and Whole Blood Transfusion CPGs except as follows:

*TCCC-specific considerations:
a. Resuscitation should be initiated with FDA-compliant Cold-Stored Low Titer Type O Whole Blood (LTOWB) as the preferred option and every effort should be made to have it available.

b. LTOWB from a unit-based, pre-screened and pre-titered walking blood bank (WBB) should be used as the second option if FDA-compliant cold-stored LTOWB is not available.

c. If there is a pre-screened—but untitered—unit-based WBB designed to collect whole blood, utilize only Type O units of whole blood as the third option.

d. If there is a unit-based WBB designed to collect, type, and transfuse type-specific whole blood, that is a fourth option.

*NOTE: Option (d) may result in morbidity or even death due to ABO mismatch if the wrong blood type is transfused. *NOTE: 1:1 RBCs and plasma should be used in the suboptimal circumstance that FDA-compliant whole blood is not available, but FDA-compliant red blood cells and plasma are available.

*NOTE: Use of non–FDA-compliant whole blood requires additional post-transfusion monitoring per DoD directives.

• Continue resuscitation until an SBP of 80–90mmHg is present. 
  
• If the casualty has an altered mental status due to suspected TBI, resuscitate as necessary to restore and maintain a target SBP of at least 90mmHg. 
  
• During resuscitation, blood products should be warmed using a fluid warmer and infused rapidly. 
  
• As whole blood transfusion is being performed, consider obtaining early common femoral artery access so that REBOA can be undertaken quickly after the first unit of whole blood has been administered should the casualty subsequently be found to meet the criteria for REBOA. 
  

6. Indications for REBOA in ARC:
*See Appendix B in the Joint Trauma System REBOA CPG: “SBP < 90 with Transient or No Response to Initial ATLS Resuscitation.” (6 July 2017)

*TCCC-specific considerations:

• Relevant Tactical Field Care interventions (external 
  hemorrhage control, pelvic binding, and TXA) have been accomplished;
  AND 
  
• Advanced monitoring (Electronic blood pressure measurement) has been established;
  AND 
  
• ARC resuscitation has been previously initiated with whole blood if feasible or other blood products as noted previously;
  AND 
  
• SBP remains < 90mmHg immediately after 1 unit of whole blood or 1 unit each of RBCs and plasma have been administered as quickly as possible;
  AND 
  
• The Casualty has penetrating or severe blunt force injury to the abdomen or pelvis and a positive FAST exam or is judged to be at high risk for abdominopelvic NCTH or is noted to have a difficult-to-control junctional hemorrhage. 
  AND 
  
• Intra-thoracic bleeding and cardiac tamponade have not been found on bilateral chest tube insertion and an EFAST exam. 
  

7. REBOA Procedure in ARC
*REBOA in TCCC Advanced Resuscitative Care will be done in accordance with the current version of the REBOA CPG posted on the Joint Trauma System website with the following exceptions to make it more suitable for the TCCC setting:

*TCCC-specific considerations:

• Placement of REBOA should be done in consultation with a surgeon at the receiving medical treatment facility (MTF), if at all possible. This will both provide expert assistance on the decision to use REBOA and alert the receiving MTF so that they can prepare for the casualty. 
  
• Teams with an ARC capability should have a CoTCCC- recommended junctional tourniquet available to control access site bleeding should that be encountered. 
  
• If the junctional tourniquet has already been used for another casualty, 30 minutes of direct pressure with 
  

Combat Gauze or another TCCC-recommended hemostatic dressing should be used to control access site bleeding.

d. Ketamine can be used for procedural analgesia and sedation. Opioids should be avoided in hypotensive casualties.

e. All REBOA in TCCC is Zone 1, since intra-abdominal hemorrhage originating above the aortic bifurcation cannot be definitively ruled out by a negative FAST exam.

f. Once the casualty has been determined to meet the criteria for REBOA, the procedure should be undertaken promptly, since further decreases in systolic blood pressure will make common femoral arterial access significantly more difficult to obtain.

g. Placement of the balloon in aortic Zone 1 is guided by the markings on the ER-REBOA catheter.

h. Fully inflate the balloon in Zone 1. Start with 8–10mL of any crystalloid IV fluid. Confirm full occlusion by noting that the contralateral femoral pulse is extinguished.

i. If the contralateral femoral pulse is still present, add 2 more mL of IV fluid and recheck the pulse. Repeat until the pulse is extinguished or a maximum of 24mL of fluid has been used.

j. Leave the balloon inflated for 15 minutes. The SBP should increase quickly and substantially after balloon inflation when the bleeding site is distal to Zone 1.

k. After 15 minutes, slowly deflate the balloon completely over 30 seconds.

l. Re-assess the casualty. If he or she has an SBP of 80mmHg or greater, leave the balloon deflated.

m. Continue to monitor.
n. If the SBP drops below 80mmHg, re-inflate the balloon and use either Option 1 or Option 2 as guidance for further inflation.

o. Balloon Inflation Timing—Option 1:

As long as the periods of balloon deflation without SBP dropping below 80mmHg continue to be 3 minutes or longer, use 10-minute inflation periods followed by another deflation out to a maximum of 120 minutes. Continue resuscitation with whole blood.

p. Balloon Inflation Timing—Option 2:
If the casualty does not maintain an SBP of 80mmHg or higher for at least 3 minutes after balloon deflation, then re-inflate the balloon and use a maximum of 30 minutes total balloon inflation time. Continue resuscitation with whole blood.

q. If the casualty has stabilized (SBP remains above 80mmHg without balloon inflation) after the inflation times specified above but is more than 4 hours from the care of a surgeon, remove the sheath and hold pressure for 30 minutes with a junctional tourniquet or with Combat Gauze or another TCCC-recommended hemostatic dressing. Evaluate for distal pulses in the extremity.

r. If the casualty has stabilized as noted above but is within 4 hours of surgical care, leave the sheath in place, and flush the side port every 15–30 minutes with 3mL of IV fluid.

s. Document distal pulses frequently.

t. Once REBOA has been performed, every effort should again be made to communicate with the surgeon who will be receiving the casualty and obtain his or her recommendations for subsequent management.

u. Document all aspects of the REBOA procedure.

 8. Document all care provided in ARC, to include as a minimum:

• –  Time and mechanism of injury 
  
• –  Time of arrival at the ARC capability 
  
• –  Vital signs on arrival 
  
• –  Diagnostic measures and interventions performed 
  
• –  Details of the REBOA procedure as noted above. 
  
• –  Response to interventions 
  
• –  The time and the casualty’s condition upon leaving ARC

1. You need authorization. Before starting down the road of doing a field blood transfusion you have to have authorization from your medical director and higher command. This battle can be tricky, especially on the conventional side, or places where the good news hasn't spread yet (Whole Blood is the resuscitative fluid of choice, and recommended by the overall authority on the matter; the Committee on Tactical Combat Casualty Care). There's a bunch of retards out there... which brings us to our next point:

2. Proper training. Anytime you are working with putting blood from one person to another it is a high-risk endeavor. The reason it is allowed in a field situation within our line of work is a very simple Risk vs. Reward equation. What is the worst thing that can happen if I don’t give the patient blood? He dies. The same answer goes for the question, what is the worst thing that can happen if I do give him blood?

When giving blood, if it is done improperly, or done without knowing 100% without a doubt the blood types of both donor and recipient, you stand a chance of having a life-threatening event. Proper training teaches you the steps leading up to, actions on, and corrective actions in case of a transfusion reaction. You have to have a thorough knowledge of the s/s of hemolytic reactions, anaphylactic reactions, and so on and so forth, as well as the drugs used to counteract these potential complications as they happen.  

**Remember to use your resources. A great one is the Whole Blood Toolkit, by Next Generation Combat Medic. 

3. You’ll need appropriate supplies. At the minimum, you’ll need:

 

• - Donor bags
• Filtered tubing
• Large bore catheters (16 preferred)
• Saline locks
• Flush
• Fluid warmers
• Hemolytic/Anaphylaxis drugs

4. Titer testing. The Army and the Air Force have the ability to run specific titer testing for your O type blood. The Navy and Marine Corps team does not have the ability to pull blood tubes and send them in for testing. We have found a workaround through a mutually beneficial relationship with the local Armed Services Blood Program (ASBP). For those that do not know the ASBP, they are an organization that is organic to MTFs that holds blood drives around military bases and other government installations, and provide blood to all MTFs and deploying Units. We have worked a relationship here that works like this: We give them full units of blood to increase their stock, they turn around and test the blood for their titer level, blood type, and all pertinent blood born pathogens. After testing the OIC of the ASBP provides us with a list of all results including titer level for all units collected. We turn around and use that list as our primary donor list in the case we need to activate our walking blood bank. LTOWB (Low-titer group O) is the preferred universal donor, due to its low probability of hemolytic and anaphylactic reaction.

 5. IMPORTANT: titers must be verified no more than 90 days prior to deployment. While deployed titer results are considered valid for 1 year.

 6. If you have run through all of your pre-identified donors (Low-titer group O) it is possible to go type to type specific (A to A, B to B). If you haven’t done a full type-drive prior to deployment, you will need to use Eldon cards to type both donor and recipient prior to beginning transfusion.

 Final Considerations: 

 Nobody should be doing this without authorization. Blood transfusions are a great tool for keeping a patient alive that otherwise wouldn’t survive, they are also potentially dangerous.

There are no cutting corners, if you have a program in place, or are in the process of building one, you have to be thorough and follow the protocols, to a “T.”

Our titer drives (that’s what we call when we send all of our O type guys in to give a unit and have their blood tested) might not work at alternate facilities, it will be up to you the medic/corpsman to create and nurture that relationship.

If you are unsure of something and don’t have the ability to ask or find out DO NOT DO IT!