The Management of Abdominal Evisceration in Tactical Combat Casualty Care: TCCC Guideline Change 20-02.

Historically, about 20% of hospitalized combat injured patients have an abdominal injury. Abdominal evisceration may be expected to complicate as many as one-third of battle-related abdominal wounds. The outcomes for casualties with eviscerating injuries may be significantly improved with appropriate prehospital management. While not as extensively studied as other forms of combat injury, abdominal evisceration management recommendations extend back to at least World War I, when it was recognized as a significant cause of morbidity and was especially associated with bayonet injury. More recently, abdominal evisceration has been noted as a frequent result of penetrating, ballistic trauma. Initial management of abdominal evisceration for prehospital providers consists of assessing for and controlling associated hemorrhage, assessing for bowel content leakage, covering the eviscerated abdominal contents with a moist, sterile barrier, and carefully reassessing the patient. Mortality in abdominal evisceration is more likely to be secondary to associated injuries than to the evisceration itself. Attempting to establish education, training, and a standard of care for nonmedical and medical first responders and to leverage current wound management technologies, the Committee on Tactical Combat Casualty Care (CoTCCC) conducted a systematic review of historical Service guidelines and recent medical studies that include abdominal evisceration. For abdominal evisceration injuries, the following principles of management apply: (1) Control any associated bleeding visible in the wound. (2) If there is no evidence of spinal cord injury, allow the patient to take the position of most comfort. (3) Rinse the eviscerated bowel with clean fluid to reduce gross contamination. (4) Cover exposed bowel with a moist, sterile dressing or a sterile water-impermeable covering. It is important to keep the wound moist; irrigate the dressing with warm water if available. (4) For reduction in wounds that do not have a substantial loss of abdominal wall, a brief attempt may be made to replace/reduce the eviscerated abdominal contents. If the external contents do not easily go back into the abdominal cavity, do not force or spend more than 60 seconds attempting to reduce contents. If reduction of eviscerated contents is successful, reapproximate the skin using available material, preferably an adhesive dressing like a chest seal (other examples include safety pins, suture, staples, wound closure devices, etc.). Do not attempt to reduce bowel that is actively bleeding or leaking enteric contents. (6) If unable to reduce, cover the eviscerated organs with water-impermeable, nonadhesive material (transparent preferred to allow ability to reassess for ongoing bleeding; examples include a bowel bag, IV bag, clear food wrap, etc.), and then secure the impermeable dressing to the patient using an adhesive dressing (e.g., Ioban, chest seal). (7) Do NOT FORCE contents back into abdomen or actively bleeding viscera. (8) Death in the abdominally eviscerated patient is typically from associated injuries, such as concomitant solid organ or vascular injury, rather than from the evisceration itself. (9) Antibiotics should be administered for any open wounds, including abdominal eviscerating injuries. Parenteral ertapenem is the preferred antibiotic for these injuries.

Management of Hemorrhage From Craniomaxillofacial Injuries and Penetrating Neck Injury in Tactical Combat Casualty Care: iTClamp Mechanical Wound Closure Device TCCC Guidelines Proposed Change 19-04 06 June 2019.

The 2012 study Death on the battlefield (2001-2011) by Eastridge et al.1 demonstrated that 7.5% of the prehospital deaths caused by potentially survivable injuries were due to external hemorrhage from the cervical region. The increasing use of Tactical Combat-Casualty Care (TCCC) and other medical interventions have dramatically reduced the overall rate of combat-related mortality in US forces; however, uncontrolled hemorrhage remains the number one cause of potentially survivable combat trauma. Additionally, the use of personal protective equipment and adaptations in the weapons used against US forces has caused changes in the wound distribution patterns seen in combat trauma. There has been a significant proportional increase in head and neck wounds, which may result in difficult to control hemorrhage. More than 50% of combat wounded personnel will receive a head or neck wound. The iTClamp (Innovative Trauma Care Inc., Edmonton, Alberta, Canada) is the first and only hemorrhage control device that uses the hydrostatic pressure of a hematoma to tamponade bleeding from an injured vessel within a wound. The iTClamp is US Food and Drug Administration (FDA) approved for use on multiple sites and works in all compressible areas, including on large and irregular lacerations. The iTClamp's unique design makes it ideal for controlling external hemorrhage in the head and neck region. The iTClamp has been demonstrated effective in over 245 field applications. The device is small and lightweight, easy to apply, can be used by any level of first responder with minimal training, and facilitates excellent skills retention. The iTClamp reapproximates wound edges with four pairs of opposing needles. This mechanism of action has demonstrated safe application for both the patient and the provider, causes minimal pain, and does not result in tissue necrosis, even if the device is left in place for extended periods. The Committee on TCCC recommends the use of the iTClamp as a primary treatment modality, along with a CoTCCC-recommended hemostatic dressing and direct manual pressure (DMP), for hemorrhage control in craniomaxillofacial injuries and penetrating neck injuries with external hemorrhage.

Replacement of Promethazine With Ondansetron for Treatment of Opioid- and Trauma-Related Nausea and Vomiting in Tactical Combat Casualty Care.

The current Tactical Combat Casualty Care (TCCC) Guidelines recommend parenteral promethazine as the single agent for the treatment of opioid-induced nausea and/or vomiting and give a secondary indication of "synergistic analgesic effect." Promethazine, however, has a well-documented history of undesired side effects relating to impairment and dysregulation of the central and autonomic nervous systems, such as sedation, extrapyramidal symptoms, dystonia, impairment of psychomotor function, neuroleptic malignant syndrome, and hypotension. These may be particularly worrisome in the combat casualty. Additionally, since 16 September 2009, there has been a US Food and Drug Administration (FDA) black box warning for the injectable form of promethazine, due to "the risk of serious tissue injury when this drug is administered incorrectly." Conversely, ondansetron, which is now available in generic form, has a well-established favorable safety profile and demonstrated efficacy in undifferentiated nausea and vomiting in the emergency department and prehospital settings. It has none of the central and autonomic nervous system side effects noted with promethazine and carries no FDA black box warning. Ondansetron is available in parenteral form and an orally disintegrating tablet, providing multiple safe and effective routes of administration. Despite the fact that it is an off-label use, ondansetron is being increasingly given for acute, undifferentiated nausea and vomiting and is presently being used in the field on combat casualties by some US and Allied Forces. Considering the risks involved with promethazine use, and the efficacy and safety of ondansetron and ondansetron?s availability in a generic form, we recommend removing promethazine from the TCCC Guidelines and replacing it with ondansetron.