Damage Control: Prehospital Care of the Patient With Vascular Injury

Abstract The recent decade of war experienced by the United States and its coalition partners has produced sweeping changes in the prehospital management of combat casualties. Collectively called Tactical Combat Casualty Care (TCCC), these new wartime prehospital trauma care strategies have centered on identification of the common causes of preventable battlefield mortality and the deployment of tailored management strategies directed at avoiding these deaths. Blood vessel trauma and disruption with subsequent hemorrhage remains the most common cause of preventable death in the combat wounded, so TCCC has a strong emphasis on the management of vascular injuries. Tourniquets are used aggressively on the battlefield to control extremity hemorrhage; hemostatic dressings, such as Combat Gauze, are used for compressible hemorrhage that occurs in anatomic locations not amenable to tourniquet use; new interventions for junctional hemorrhage control are being introduced; and tranexamic acid, an antifibrinolytic agent, is now being used to help improve survival in casualties with noncompressible hemorrhage. There is also an increased focus on the prevention and management of trauma-associated coagulopathy, on hypothermia prevention, and on the use of hypotensive resuscitation instead of large-volume crystalloid fluid resuscitation. Prehospital damage control resuscitation with 1 : 1 plasma and packed red blood cell (PRBC) transfusion is used as soon as blood products are logistically feasible. Finally, evacuation strategies that call for more highly-skilled medical providers during transport and minimized transport time to definitive care have gained wide acceptance. The combination of these prehospital measures (with improved definitive care, advances in strategic evacuation, and improvements in personal protective equipment) have produced unprecedented casualty survival rates in the conflicts in Iraq and Afghanistan. Many of these strategies are also gaining increased acceptance in civilian trauma systems.