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Eisenhauer I, April MD, Rizzo JA, Fisher AD, Maddry JK, Bebarta VS, Schauer SG. Seasonal Association With Hypothermia in Combat Trauma. Mil Med 2024; 189:2004-2008. [PMID: 38015941 DOI: 10.1093/milmed/usad451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 09/12/2023] [Accepted: 11/08/2023] [Indexed: 11/30/2023] Open
Abstract
INTRODUCTION Hypothermia increases mortality in trauma populations and frequently occurs in military casualties due to the nature of combat environments. The association between hypothermia and the time of year when injured remains unclear. We sought to determine the association between seasonal changes in temperature and hypothermia among combat casualties. MATERIALS AND METHODS This observational study was a secondary analysis of a previously described Department of Defense Trauma Registry dataset which included U.S. military and Coalition casualties who received prehospital care from January 2007 to March 2020 in Afghanistan and Iraq. We tested for associations between hypothermia (<36.2°C) and seasonal ambient temperatures by constructing multivariable logistic regression models. Summer was defined as June through August and winter as December through February. We assumed that the combat operations occurred in the area near the point of first contact with the deployed military treatment facilities. This study was determined to be exempt from Institutional Review Board oversight. RESULTS There were 5,821 that met inclusion for this study. Within the multivariable logistic regression model, we adjusted for injury severity score, mechanism of injury, and imputed transport time, finding that combat casualties were 2.28 (odds ratio, 95% confidence interval 1.93-2.69) times more likely to develop hypothermia in the winter versus summer. When using temperature as a continuous outcome, casualties had a lower emergency department temperature during the winter (parameter estimate -0.133°C, P < 0.001) after adjusting for confounders. In casualties experiencing hypothermia, mortality was higher (4% versus 1%, P < 0.001), and composite median injury severity score values were higher (10 versus 5, P < 0.001). Among hypothermic casualties, serious injuries were significantly more common (all P < 0.001) to the head (15% versus 7%), thorax (15% versus 7%), abdomen (9% versus 6%), extremities (35% versus 22%), and skin (4% versus 2%). CONCLUSIONS We found a seasonal variation in the occurrence of hypothermia in a large cohort of trauma casualties. Despite adjustment for multiple known confounders, our findings substantiate probable ambient temperature variations to trauma-induced hypothermia. Furthermore, our findings, when taken in the context of other studies on the efficacy of current hypothermia prevention and treatment strategies, support the need for better methods to mitigate hypothermia in future cold-weather operations.
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Affiliation(s)
- Ian Eisenhauer
- University of Colorado Center for Combat Medicine and Battlefield (COMBAT) Research, Aurora, CO 80045, USA
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO 80045, USA
- Denver Health Residency in Emergency Medicine, Denver, CO 80204, USA
- Navy Medicine Leader and Professional Development Command, Bethesda, MD 20889, USA
| | - Michael D April
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- 14th Field Hospital, Fort Stewart, GA 31314, USA
| | - Julie A Rizzo
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- Brooke Army Medical Center, JBSA Fort Sam Houston, TX 78234, USA
| | - Andrew D Fisher
- Department of Surgery, University of New Mexico School of Medicine, Albuquerque, NM 87106, USA
- Texas Army National Guard, Austin, TX, USA
| | - Joseph K Maddry
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- Brooke Army Medical Center, JBSA Fort Sam Houston, TX 78234, USA
- U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, TX 78234, USA
- 59th Medical Wing, JBSA Fort Sam Houston, TX 78258, USA
| | - Vikhyat S Bebarta
- University of Colorado Center for Combat Medicine and Battlefield (COMBAT) Research, Aurora, CO 80045, USA
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO 80045, USA
- 59th Medical Wing, JBSA Fort Sam Houston, TX 78258, USA
| | - Steven G Schauer
- University of Colorado Center for Combat Medicine and Battlefield (COMBAT) Research, Aurora, CO 80045, USA
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO 80045, USA
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- Brooke Army Medical Center, JBSA Fort Sam Houston, TX 78234, USA
- U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, TX 78234, USA
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Fisher AD, April MD, Gurney JM, Shackelford SA, Luppens C, Schauer SG. Analysis of emergency resuscitative thoracotomy in the combat setting. BMJ Mil Health 2024:e002797. [PMID: 39209758 DOI: 10.1136/military-2024-002797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2024] [Accepted: 07/28/2024] [Indexed: 09/04/2024]
Abstract
INTRODUCTION Emergency resuscitative thoracotomy (ERT) is a resource-intensive procedure that can deplete a combat surgical team's supply and divert attention from casualties with more survivable injuries. An understanding of survival after ERT in the combat trauma population will inform surgical decision-making. METHODS We requested all encounters from 2007 to 2023 from the Department of Defense Trauma Registry (DoDTR). We analysed any documented thoracotomy in the emergency department and excluded any case for which it was not possible to distinguish ERT from operating room thoracotomy. The primary outcome was 24-hour mortality. RESULTS There were 48 301 casualties within the original dataset. Of those, 154 (0.3%) received ERT, with 114 non-survivors and 40 survivors at 24 hours. There were 26 (17%) survivors at 30 days. The majority were performed in role 3. The US military made up the largest proportion among the non-survivors and survivors. Explosives predominated in both groups (61% and 65%). Median Composite Injury Severity Scores were lower among the non-survivors (19 vs 33). Non-survivors had a lower proportion of serious head injuries (13% vs 40%) and thorax injuries (32% vs 58%). Median RBC consumption was lower among non-survivors (10 units vs 19 units), as was plasma (6 vs 16) and platelets (0 vs 3). The most frequent interventions and surgical procedures were exploratory thoracotomy (n=140), chest thoracostomy (n=137), open cardiac massage (n=131) and closed cardiac massage (n=121). CONCLUSION ERT in this group of combat casualties resulted in 26% survival at 24 hours. Although this proportion is higher than that reported in civilian data, more rigorous prospective studies would need to be conducted or improvement in the DoDTR data capture methods would need to be implemented to determine the utility of ERT in combat populations.
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Affiliation(s)
- Andrew David Fisher
- Department of Surgery, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
- Texas, National Guard, Arlington, Virginia, USA
| | - M D April
- Uniformed Services University, Bethesda, Maryland, USA
| | - J M Gurney
- Joint Trauma System, JBSA Fort Sam Houston, Texas, USA
| | - S A Shackelford
- Defense Health Agency, Colorado Springs Market, Colorado Springs, CO, USA
| | - C Luppens
- Summit Health, Bend, Oregon, USA
- St Charles Medical Center, Bend, Oregon, USA
| | - S G Schauer
- Uniformed Services University, Bethesda, Maryland, USA
- Departments of Anesthesiology and Emergency Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
- Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
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Vernon TE, April MD, Fisher AD, Rizzo JA, Long BJ, Schauer SG. An Assessment of Clinical Accuracy of Vital Sign-based Triage Tools Among U.S. and Coalition Forces. Mil Med 2024; 189:e1528-e1536. [PMID: 38285545 DOI: 10.1093/milmed/usad500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 12/04/2023] [Accepted: 01/04/2024] [Indexed: 01/31/2024] Open
Abstract
INTRODUCTION Early appropriate allocation of resources for critically injured combat casualties is essential. This is especially important when inundated with an overwhelming number of casualties where limited resources must be efficiently allocated, such as during mass casualty events. There are multiple scoring systems utilized in the prehospital combat setting, including the shock index (SI), modified shock index (MSI), simple triage and rapid treatment (START), revised trauma score (RTS), new trauma score (NTS), Glasgow Coma Scale + age + pressure (GAP), and the mechanism + GAP (MGAP) score. The optimal score for application to the combat trauma population remains unclear. MATERIALS AND METHODS This is a secondary analysis of a previously described dataset from the Department of Defense Trauma Registry from January 1, 2007 through March 17, 2020. We constructed univariable analyses to determine the area under the receiving operator characteristic (AUROC) for the scoring systems of interest. Our primary outcomes were early death (within 24 hours) or early massive transfusion, as defined by ≥3 units. RESULTS There were 12,268 casualties that met inclusion criteria. There were 168 (1%) who died within the first 24 hours and 2082 (17%) that underwent significant transfusion within the first 24 hours. When assessing the predictive capabilities for death within 24 hours, the AUROCs were 0.72 (SI), 0.69 (MSI), 0.89 (START), 0.90 (RTS), 0.83 (NTS), 0.90 (GAP), and 0.91 (MGAP). The AUROCs for massive transfusion were 0.89 (SI), 0.89 (MSI), 0.82 (START), 0.81 (RTS), 0.83 (NTS), 0.85 (MGAP), and 0.86 (GAP). CONCLUSIONS This study retrospectively applied seven triage tools to a database of 12,268 cases from the Department of Defense Trauma Registry to evaluate their performance in predicting early death or massive transfusion in combat. All scoring systems performed well with an AUROC >0.8 for both outcomes. Although the SI and MSI performed best for predicting massive transfusion (both had an AUROC of 0.89), they ranked last for assessment of mortality within 24 hours, with the other tools performing well. START, RTS, NTS, MGAP and GAP reliably identified early death and need for massive transfusion, with MGAP and GAP performing the best overall. These findings highlight the importance of assessing triage tools to best manage resources and ultimately preserve lives of traumatically wounded warfighters. Further studies are needed to explain the surprising performance discrepancy of the SI and MSI in predicting early death and massive transfusion.
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Affiliation(s)
- Tate E Vernon
- Brooke Army Medical Center, JBSA Fort Sam Houston, TX 78234, USA
| | - Michael D April
- 14th Field Hospital, Fort Stewart, GA 31314, USA
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Andrew D Fisher
- Department of Surgery, University of New Mexico School of Medicine, Albuquerque, NM 87106, USA
| | - Julie A Rizzo
- Brooke Army Medical Center, JBSA Fort Sam Houston, TX 78234, USA
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Brit J Long
- Brooke Army Medical Center, JBSA Fort Sam Houston, TX 78234, USA
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Steven G Schauer
- Brooke Army Medical Center, JBSA Fort Sam Houston, TX 78234, USA
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora, CO 80045, USA
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO 80045, USA
- Center for Combat and Battlefield (COMBAT) Research, University of Colorado School of Medicine, Aurora, CO 80045, USA
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Kocik VI, Dengler BA, Rizzo JA, Ma Moran M, Willis AM, April MD, Schauer SG. A Narrative Review of Existing and Developing Biomarkers in Acute Traumatic Brain Injury for Potential Military Deployed Use. Mil Med 2024; 189:e1374-e1380. [PMID: 37995274 DOI: 10.1093/milmed/usad433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 08/31/2023] [Indexed: 11/25/2023] Open
Abstract
INTRODUCTION Traumatic brain injury (TBI) is a leading cause of morbidity and mortality in both adult civilian and military populations. Currently, diagnostic and prognostic methods are limited to imaging and clinical findings. Biomarker measurements offer a potential method to assess head injuries and help predict outcomes, which has a potential benefit to the military, particularly in the deployed setting where imaging modalities are limited. We determine how biomarkers such as ubiquitin C-terminal hydrolase-L1 (UCH-L1), glial fibrillary acidic protein (GFAP), S100B, neurofilament light chain (NFL), and tau proteins can offer important information to guide the diagnosis, acute management, and prognosis of TBI, specifically in military personnel. MATERIALS AND METHODS We performed a narrative review of peer-reviewed literature using online databases of Google Scholar and PubMed. We included articles published between 1988 and 2022. RESULTS We screened a total of 73 sources finding a total of 39 original research studies that met inclusion for this review. We found five studies that focused on GFAP, four studies that focused on UCH-L1, eight studies that focused on tau proteins, six studies that focused on NFL, and eight studies that focused on S100B. The remainder of the studies included more than one of the biomarkers of interest. CONCLUSIONS TBI occurs frequently in the military and civilian settings with limited methods to diagnose and prognosticate outcomes. We highlighted several promising biomarkers for these purposes including S100B, UCH-L1, NFL, GFAP, and tau proteins. S100B and UCH-L1 appear to have the strongest data to date, but further research is necessary. The robust data that explain the optimal timing and, more importantly, trending of these biomarker measurements are necessary before widespread application.
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Affiliation(s)
| | - Bradley A Dengler
- Walter Reed National Military Medical Center, Bethesda, MD, USA
- Center for Neuroscience and Regenerative Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Julie A Rizzo
- Brooke Army Medical Center, JBSA Fort Sam Houston, TX, USA
- Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | | | | | - Michael D April
- Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- 14th Field Hospital, Fort Stewart, GA 31314, USA
| | - Steven G Schauer
- Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- Departments of Anesthesiology and Emergency Medicine, University of Colorado School of Medicine, Aurora, CO 80045, USA
- Center for Combat and Battlefield (COMBAT) Research, University of Colorado School of Medicine, Aurora, CO 80045, USA
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Paulson MW, Rossetto M, McKay JT, Bebarta VS, Flarity K, Keenan S, Schauer SG. Association of Prehospital Neck Wound Survivability and Battlefield Medical Evacuation Time in Afghanistan. Mil Med 2023; 188:185-191. [PMID: 37948214 DOI: 10.1093/milmed/usad080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 02/13/2023] [Accepted: 03/03/2023] [Indexed: 11/12/2023] Open
Abstract
INTRODUCTION The U.S. Military's Golden Hour policy led to improved warfighter survivability during the Global War on Terror. The policy's success is well-documented, but a categorical evaluation and stratification of medical evacuation (MEDEVAC) times based on combat injury is lacking. METHODS We queried the Department of Defense Joint Trauma System Prehospital Trauma Registry for casualties with documented penetrating neck trauma in Afghanistan requiring battlefield MEDEVAC from June 15, 2009, through February 1, 2021. Casualties were excluded if the time from the point of injury to reach higher level medical care was not documented, listed as zero, or exceeded 4 hours. They were also excluded if demographic data were incomplete or deemed unreliable or if their injuries occurred outside of Afghanistan.We designed a logistic regression model to test for associations in survivability, adjusting for composite injury severity score, patient age group, and type of next higher level of care reached. We then used our model to interpolate MEDEVAC times associated with 0.1%, 1%, and 10% increased risk of death for an incapacitated casualty with penetrating neck trauma. RESULTS Of 1,147 encounters, 444 casualties met inclusion criteria. Of these casualties, 430 (96.9%) survived to discharge. Interpolative analysis of our multivariable logistic regression model showed that MEDEVAC times ≥8 minutes, ≥53 minutes, and ≥196 minutes are associated with a 0.1%, 1%, and 10% increased risk of mortality from baseline, respectively. CONCLUSIONS Our data characterize the maximum MEDEVAC times associated with 0.1%, 1%, and 10% increased risk of death from baseline survivability for penetrating battlefield neck trauma in Afghanistan.
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Affiliation(s)
- Matthew W Paulson
- University of Colorado School of Medicine, Aurora, CO 80045, USA
- University of Colorado Center for COMBAT Research, University of Colorado School of Medicine, Aurora, CO 80045, USA
- Colorado National Guard Medical Detachment, Buckley Space Force Base, Aurora, CO, USA
| | - Marika Rossetto
- University of Colorado School of Medicine, Aurora, CO 80045, USA
- University of Colorado Center for COMBAT Research, University of Colorado School of Medicine, Aurora, CO 80045, USA
| | - Jerome T McKay
- University of Colorado School of Medicine, Aurora, CO 80045, USA
- Department of Biomedical Informatics, University of Colorado School of Medicine, Aurora, CO 80045, USA
| | - Vikhyat S Bebarta
- University of Colorado School of Medicine, Aurora, CO 80045, USA
- University of Colorado Center for COMBAT Research, University of Colorado School of Medicine, Aurora, CO 80045, USA
- 59th Medical Wing, JBSA Lackland, TX 78236, USA
| | - Kathleen Flarity
- University of Colorado School of Medicine, Aurora, CO 80045, USA
- University of Colorado Center for COMBAT Research, University of Colorado School of Medicine, Aurora, CO 80045, USA
| | - Sean Keenan
- University of Colorado Center for COMBAT Research, University of Colorado School of Medicine, Aurora, CO 80045, USA
- Joint Trauma System, Defense Health Agency, JBSA-Fort Sam Houston, TX 78234, USA
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Steven G Schauer
- 59th Medical Wing, JBSA Lackland, TX 78236, USA
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX 78234, USA
- U.S. Army Institute of Surgical Research, JBSA-Fort Sam Houston, TX 782347, USA
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Mongold SM, Mancha F, Weymouth WL, Maddry JK, Schauer SG. A Pilot Medic-based Assessment of the Novel Handheld LifeFlow Device for Rapid Infusion of Blood Products. Mil Med 2023; 188:e3382-e3385. [PMID: 36583415 DOI: 10.1093/milmed/usac407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 12/02/2022] [Accepted: 12/07/2022] [Indexed: 12/31/2022] Open
Abstract
INTRODUCTION Uncontrolled hemorrhage remains the leading cause of preventable death in the prehospital, combat setting. Treatment guidelines emphasize immediate hemorrhage control and early resuscitation with whole blood or blood products. Current methods for the delivery of blood products are often insufficient to provide trauma resuscitation. The novel LifeFlow device is a hand-powered device that can rapidly infuse fluids, including blood products. However, successful use of this device in the hands of the intended end user has not been demonstrated. MATERIALS AND METHODS We conducted a pilot study to assess how quickly and effectively medics could set up the LifeFlow device and infuse mock blood products into a casualty. They were provided with a brief block of instruction (<10 min) and the opportunity to handle the device. The time to set up the device and proportion of successful completion were recorded. Participants were surveyed regarding the use of the device including post-study interview. RESULTS Forty medics, who were recruited and eligible to participate, completed the study procedures. All medics were able to successfully set up the device and perform the infusion. We had two instances of fluid leakage owing to malfunctions with the simulation arm, not the LifeFlow device. The mean time to device setup was 112 s (95% confidence interval [CI], 101-124). The mean time for infusion of 500 mL of fluid was 94 s (95% CI, 83-105). The mean time for all procedures was 197 s (95% CI, 178-213). On product feedback, they generally found it easier to use, easy to manipulate, possessing a useful grip, easily set up, and requiring minimal training. CONCLUSIONS The medics were able to reliably assemble and use the LifeFlow rapid infusion device. However, there were concerns about the packaging and the single indication for the device.
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Affiliation(s)
- Sarah M Mongold
- Brooke Army Medical Center, JBSA Fort Sam Houston, TX 78234, USA
| | - Fabiola Mancha
- US Army Institute of Surgical Research, JBSA Fort Sam Houston, TX 78234, USA
| | - Wells L Weymouth
- Winn Army Community Hospital, Hunter Army Airfield, GA 31314, USA
| | - Joseph K Maddry
- Brooke Army Medical Center, JBSA Fort Sam Houston, TX 78234, USA
- US Army Institute of Surgical Research, JBSA Fort Sam Houston, TX 78234, USA
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- 59th Medical Wing, JBSA Lackland, TX 78236, USA
| | - Steven G Schauer
- Brooke Army Medical Center, JBSA Fort Sam Houston, TX 78234, USA
- US Army Institute of Surgical Research, JBSA Fort Sam Houston, TX 78234, USA
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
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Craig CM, Schwieters KR, Drahos BA, Morris NL. A Pilot Study on the Role of Experience and Patient Gender on MARCH Treatment Sequence. Mil Med 2023; 188:e2041-e2048. [PMID: 36515148 DOI: 10.1093/milmed/usac383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 09/30/2022] [Accepted: 11/16/2022] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION The brevity of training for soldiers and combat medics to learn how to provide treatment on the battlefield may restrict optimal performance for treating chest and airway injuries, particularly when treating female soldiers. The present study tested treatment performance on patient simulators by battlefield medic trainees to determine whether there is a need for more extensive training on chest and airway procedures on female soldiers. MATERIALS AND METHODS Battlefield medic trainees treated male and female patient simulators in counterbalanced order. The assessment considered the effects of patient gender and order on procedures performed, particularly critical chest and airway interventions such as needle chest decompression (NCD), and considered the appropriate order of treatment tasks. Four coders rated video footage of three simulated procedures, i.e., tourniquet, chest seal (front and back application), and NCD, using a binary coding system to determine completeness and order correctness according to the Massive hemorrhage, Airway, Respiration, Circulation, and Head injury/Hypothermia (MARCH) mnemonic. RESULTS Results from analysis of variance showed that when presented with a female patient first, trainees performed significantly fewer total procedures on both the female and male simulators. More experienced trainees completed significantly more procedures compared to trainees with minimal experience. Results from the binary logistic regression showed that trainees with more experience and trainees presented with the male patient simulator first performed significantly more procedures in the correct order. Finally, an examination of the NCD procedure found that trainees presented with the female patient simulator first had more errors and that trainees with less experience were less likely to perform the procedure adequately. CONCLUSIONS The findings suggest that treating a female patient first may lead to undertreatment of both patients. Furthermore, the observed differences in treating sensitive areas of the body (e.g., near female breasts) suggest providing greater opportunities for trainees to practice often missed or incorrectly performed procedures. Treating a female patient remains a novel experience for many trainees, such that trainees are less likely to fully treat a female patient and are less likely to treat female soldiers for the most life-threatening injuries. In fact, the initial presentation of the female patient simulator appeared to affect experienced trainees, suggesting that removing the experience of novelty and stress requires more extensive exposure and alternative training. The study's small sample size with a wide range of trainee experience may limit the findings, which may fail to capture some study effects. Finally, the study did not request trainees' experience treating female soldiers, so future studies should examine the extent to which experience is predictive of performance. There is a need for more interactive approaches in patient simulations to provide opportunities for practice, especially those that require the treatment of sensitive areas.
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Affiliation(s)
- Curtis M Craig
- HumanFIRST Laboratory, Department of Mechanical Engineering, University of Minnesota, Minneapolis, MN 55455, USA
| | - Katelyn R Schwieters
- HumanFIRST Laboratory, Department of Mechanical Engineering, University of Minnesota, Minneapolis, MN 55455, USA
| | - Bradley A Drahos
- HumanFIRST Laboratory, Department of Mechanical Engineering, University of Minnesota, Minneapolis, MN 55455, USA
| | - Nichole L Morris
- HumanFIRST Laboratory, Department of Mechanical Engineering, University of Minnesota, Minneapolis, MN 55455, USA
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April MD, Fisher AD, Hill R, Rizzo JA, Mdaki K, Bynum J, Schauer SG. Adherence to a Balanced Approach to Massive Transfusion in Combat Casualties. Mil Med 2023; 188:e524-e530. [PMID: 34347081 DOI: 10.1093/milmed/usab313] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 06/01/2021] [Accepted: 07/22/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Hemorrhage is the most common cause of potentially preventable death on the battlefield. Balanced resuscitation with plasma, platelets, and packed red blood cells (PRBCs) in a 1:1:1 ratio, if whole blood (WB) is not available, is associated with optimal outcomes among patients with hemorrhage. We describe the use of balanced resuscitation among combat casualties undergoing massive transfusion. MATERIALS AND METHODS We conducted a secondary analysis of data from the Department of Defense Trauma Registry (DODTR) spanning encounters from January 1, 2007, to March 17, 2020. We included all casualties who received at least 10 units of either PRBCs or WB. We categorized casualties as recipients of plasma-balanced resuscitation if the ratio of plasma to PRBC units was 0.8 or greater; similarly, we defined platelet-balanced resuscitation as a ratio of platelets to PRBC units of 0.8 or greater. We portrayed these populations using descriptive statistics and compared characteristics between non-balanced and balanced resuscitation recipients for both plasma and platelets. RESULTS We identified 28,950 encounters in the DODTR with documentation of prehospital activity. Massive transfusions occurred for 2,414 (8.3%) casualties, among whom 1,593 (66.0%) received a plasma-balanced resuscitation and 1,248 (51.7%) received a platelet-balanced resuscitation. During the study period, 962 (39.8%) of these patients received a fully balanced resuscitation with regard to both the plasma:PRBC and platelet:PRBC ratios. The remaining casualties did not undergo a balanced resuscitation. CONCLUSIONS While a majority of massive transfusion recipients received a plasma-balanced and/or platelet-balanced resuscitation, fewer patients received a platelet-balanced resuscitation. These findings suggest that more emphasis in training and supply may be necessary to optimize blood product resuscitation ratios.
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Affiliation(s)
- Michael D April
- 40th Forward Resuscitation and Surgical Detachment, 627 Hospital Center, 1st Medical Brigade, Fort Carson, CO 80913, USA
- Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Andrew D Fisher
- University of New Mexico Hospital, Albuquerque, NM 87131, USA
- Texas Army National Guard, Austin, TX 87131, USA
| | - Ronnie Hill
- U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, TX 78763, USA
| | - Julie A Rizzo
- Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, TX 78763, USA
| | - Kennedy Mdaki
- U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, TX 78763, USA
| | - James Bynum
- U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, TX 78763, USA
| | - Steven G Schauer
- Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, TX 78763, USA
- Department of Emergency Medicine, Brooke Army Medical Center, JBSA Fort Sam Houston, TX 78234, USA
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Carius BM, Bebarta GE, April MD, Fisher AD, Rizzo J, Ketter P, Wenke JC, Salinas J, Bebarta VS, Schauer SG. A Retrospective Analysis of Combat Injury Patterns and Prehospital Interventions Associated with the Development of Sepsis. PREHOSP EMERG CARE 2023; 27:18-23. [PMID: 34731068 DOI: 10.1080/10903127.2021.2001612] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Combat injury related wound infections are common. Untreated, these wound infections may progress to sepsis and septic shock leading to increased morbidity and mortality rates. Understanding infectious complications, patterns, progression, and correlated prehospital interventions are vital to understand the development of sepsis. We aim to analyze demographics, injury patterns, and interventions associated with sepsis in battlefield settings. MATERIALS AND METHODS This is a secondary analysis of previously published data from the Department of Defense Trauma Registry (DoDTR) from 2007 to 2020. We searched for casualties diagnosed with sepsis (excluding line-sepsis) throughout their initial hospitalization. Regression models were used to seek associations. RESULTS Our initial request yielded 28,950 encounters, of which 25,654 (88.6%) were adults that met inclusion, including 243 patients (0.9%) diagnosed with sepsis. Patients included US military (34%), non-North Atlantic Treaty Organization (NATO) military (33%) and humanitarian (30%) groups. Patients diagnosed with sepsis had a significantly lower survival rate than non-septic patients (78.1% vs. 95.7%, p < 0.001). There was no significant difference in administration of prehospital antibiotics between septic and the general populations (10.6% vs. 12.3%, p = 0.395). Prehospital intraosseous access (OR 1.56, 95% CI 1.27-1.91, p = 0.207) and packed red cell administration (1.63, 1.24-2.15, 0.029) were the interventions most associated with sepsis. CONCLUSIONS Sepsis occurred infrequently in the DoDTR when evacuation from battlefield is not delayed, but despite increased intervention frequency, developing sepsis demonstrates a significant drop in survival rates. Future research would benefit from the development of risk mitigation measures.
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Affiliation(s)
| | | | - Michael D April
- Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA.,40th Forward Resuscitation and Surgical Detachment, Fort Carson, Colorado, USA
| | - Andrew D Fisher
- Department of Surgery, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA.,Medical Command, Texas Army National Guard, Austin, Texas, USA
| | - Julie Rizzo
- Madigan Army Medical Center, Joint Base Lewis McChord, Washington, USA.,US Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas, USA
| | - Patrick Ketter
- US Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas, USA
| | - Joseph C Wenke
- US Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas, USA
| | - Jose Salinas
- US Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas, USA
| | - Vikhyat S Bebarta
- Center for COMBAT Research, Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Steven G Schauer
- Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA.,US Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas, USA.,Brooke Army Medical Center, JBSA Fort Sam Houston, Texas, USA
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Schauer SG, April MD, Fisher AD, Weymouth WL, Maddry JK, Gillespie KR, Salinas J, Cap AP. Hypothermia in the Combat Trauma Population. PREHOSP EMERG CARE 2022; 27:934-940. [PMID: 36037100 DOI: 10.1080/10903127.2022.2119315] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 07/29/2022] [Accepted: 08/25/2022] [Indexed: 10/15/2022]
Abstract
BACKGROUND The MARCH (Massive hemorrhage, Airway, Respirations, Circulation, and Hypothermia/Head injuries) algorithm taught to military medics includes interventions to prevent hypothermia. As possible sequelae from major trauma, hypothermia is associated with coagulopathy and lower survival. This paper sought to define hypothermia within our combat trauma population using an outcomes-based method, and determine clinical variables associated with hypothermia. METHODS This is a secondary analysis of a previously described dataset from the Department of Defense Trauma Registry focused on casualties who received prehospital care. A receiver operating curve was constructed and Youden's index was used to define hypothermia within the predetermined population based on mortality risk. A multivariable regression model was used to identify associations. RESULTS There were 23,243 encounters that met the inclusion criteria for this study with patients having received prehospital care and documentation of at least one emergency department temperature. An optimal threshold of 36.2° C was found to predict mortality; 3,159 casualties had temperatures below this threshold (14%). Survival to discharge was lower among casualties with hypothermia (91% versus 98%). Hypothermic casualties were less likely to undergo blanket application (38% versus 40%). However, they had higher proportions with Hypothermia Prevention and Management Kit application (11% versus 7%) and radiant warming (2% versus 1%). On multivariable regression modeling, none of the hypothermia interventions were associated with a decreased likelihood of hypothermia. Non-hypothermia interventions associated with hypothermia included prehospital intubation (OR 1.57, 95% CI 1.45-1.69) and blood product administration. CONCLUSIONS Hypothermia, including a single recorded low temperature in the patient care record, was associated with worse outcomes in this combat trauma population. Prehospital intubation was most strongly associated with developing hypothermia. Prehospital warming interventions were not associated with a reduction in hypothermia risk. Our dataset suggests that current methods for prehospital warming are inadequate.
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Affiliation(s)
- Steven G Schauer
- U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas, USA
- Brooke Army Medical Center, JBSA Fort Sam Houston, Texas, USA
- Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Michael D April
- Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
- 40th Forward Resuscitation and Surgical Detachment, Fort Carson, Colorado, USA
| | - Andrew D Fisher
- University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
- Texas Army National Guard, Austin, Texas, USA
| | - Wells L Weymouth
- 160th Special Operations Aviation Regiment, Hunter Army Airfield, Georgia, USA
| | - Joseph K Maddry
- U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas, USA
- Brooke Army Medical Center, JBSA Fort Sam Houston, Texas, USA
- Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
- 59th Medical Wing, JBSA Fort Sam Houston, Texas, USA
| | - Kevin R Gillespie
- U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas, USA
| | - Jose Salinas
- U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas, USA
| | - Andrew P Cap
- U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas, USA
- Brooke Army Medical Center, JBSA Fort Sam Houston, Texas, USA
- Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
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The Las Vegas Military-Civilian Partnership: An origin story and call to action. J Trauma Acute Care Surg 2022; 93:S169-S173. [PMID: 35617460 DOI: 10.1097/ta.0000000000003701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
LEVEL OF EVIDENCE IV.
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Schauer SG, April MD. Large-Scale Combat Operations and Implications for the Emergency Medicine Community. Ann Emerg Med 2022; 80:456-459. [DOI: 10.1016/j.annemergmed.2022.04.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Indexed: 11/01/2022]
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Fisher AD, Lavender JS, April MD, Hill R, Bynum J, Schauer SG. A Descriptive Analysis of Supermassive Transfusion Recipients Among US and Coalition Forces During Combat Operations in Afghanistan and Iraq. Mil Med 2021; 188:e1022-e1027. [PMID: 34741519 DOI: 10.1093/milmed/usab455] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Revised: 09/09/2021] [Accepted: 10/20/2021] [Indexed: 01/12/2023] Open
Abstract
INTRODUCTION Hemorrhage is the leading cause of potentially preventable death on the battlefield. Resuscitation with blood products is essential to restore circulating volume, repay the oxygen debt, and prevent coagulopathy. Massive transfusion (MT) occurs frequently after major trauma; a subset of casualties requires a supermassive transfusion (SMT), and thus, mobilization of additional resources remains unclear. MATERIALS AND METHODS This is a secondary analysis of a previously described dataset from the Department of Defense Trauma Registry. In this analysis, we isolated U.S. and Coalition casualties that received at least 1 unit of packed red blood cells (PRBCs) or whole blood (WB). Given a lack of consensus on the definition of SMT recipients, we included those patients receiving the top quartile of PRBC and WB administered within the first 24 hours following arrival to a military treatment facility. RESULTS We identified 25,897 adult casualties from January 1, 2007 to March 17, 2020. Within this dataset, 2,608 (9.0%) met inclusion for this analysis. The median number of total products administered within the first 24 hours was 8 units of PRBC or WB. The upper quartile was 18 units (n = 666). Compared to all other blood product recipients, patients in the SMT cohort had a higher median injury severity score (27 vs 18, P < 0.001), were most frequently injured by explosives (84.9% vs 68.6%, P < 0.001), had a higher mean emergency department (ED) pulse (128 vs 111, P < 0.001), a lower mean systolic blood pressure (122 vs 132 mm Hg, P < 0.001), and a higher mean international normalized ratio (1.68 vs 1.38, P < 0.001). SMT patients experienced lower survival to hospital discharge (85.8% vs 93.3%, P < 0.001). CONCLUSIONS Compared to all other PRBC and WB recipients, SMT patients experienced more injury by explosives, severe injury patterns, ED vital sign derangements, and mortality. These findings may help identify those casualties who may require earlier aggressive resuscitation. However, more data is needed to define this population early in their clinical course for early identification to facilitate rapid resource mobilization. Identifying casualties who are likely to die within 24 hours compared to those who are likely to survive, may assist in determining a threshold for a SMT.
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Affiliation(s)
- Andrew D Fisher
- Medical Command, Texas Army National Guard, Austin, TX 78763, USA.,Department of Surgery, University of New Mexico School of Medicine, 1 University of New Mexico, Albuquerque, NM 87131, USA
| | | | - Michael D April
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Ronnie Hill
- United States Army Institute of Surgical Research, San Antonio, TX 78234, USA
| | - James Bynum
- United States Army Institute of Surgical Research, San Antonio, TX 78234, USA
| | - Steven G Schauer
- United States Army Institute of Surgical Research, San Antonio, TX 78234, USA.,Department of Emergency Medicine, Brooke Army Medical Center, JBSA Fort Sam Houston, TX, 78234, USA
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Fisher AD, April MD, Naylor JF, Kotwal RS, Schauer SG. The Battalion Aid Station-The Forgotten Frontier of the Army Health System During the Global War on Terrorism. Mil Med 2021; 188:e1240-e1245. [PMID: 34651651 DOI: 10.1093/milmed/usab401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Revised: 08/31/2021] [Accepted: 09/17/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The battalion aid station (BAS) has historically served as the first stop during which combat casualties would receive care beyond a combat medic. Since the conflicts in Iraq and Afghanistan, many combat casualties have bypassed the BAS for treatment facilities capable of surgery. We describe the care provided at these treatment facilities during 2007-2020. METHODS This is a secondary analysis of previously described data from the Department of Defense Trauma Registry. We included encounters with the documentation of an assessment or intervention at a BAS or forward operating base from January 1, 2007 to March 17, 2020. We utilized descriptive statistics to characterize these encounters. RESULTS There were 28,950 encounters in our original dataset, of which 3.1% (884) had the documentation of a prehospital visit to a BAS. The BAS cohort was older (25 vs. 24, P < .001) The non-BAS cohort saw a larger portion of pediatric (<18 years) patients (10.7% vs. 5.7%, P < .001). A higher proportion of BAS patients had nonbattle injuries (40% vs. 20.7%, P < .001). The mean injury severity score was higher in the non-BAS cohort (9 vs. 5, P < .001). A higher proportion of the non-BAS cohort had more serious extremity injuries (25.1% vs. 18.4%, P < .001), although the non-BAS cohort had a trend toward serious injuries to the abdomen (P = .051) and thorax (P = .069). There was no difference in survival. CONCLUSIONS The BAS was once a critical point in casualty evacuation and treatment. Within our dataset, the overall number of encounters that involved a stop at a BAS facility was low. For both the asymmetric battlefield and multidomain operations/large-scale combat operations, the current model would benefit from a more robust capability to include storage of blood, ventilators, and monitoring and hold patients for an undetermined amount of time.
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Affiliation(s)
- Andrew D Fisher
- Medical Command, Texas Army National Guard, Austin, TX 78763, USA.,Department of Surgery, University of New Mexico School of Medicine, Albuquerque, NM 87131, USA
| | - Michael D April
- 40th Forward Resuscitation and Surgical Detachment, 627th Hospital Center, 1st Medical Brigade, Fort Carson, CO 80913, USA.,Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Jason F Naylor
- Madigan Army Medical Center, Joint Base Lewis-McChord, WA 98431, USA
| | - Russ S Kotwal
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA.,Joint Trauma System, Defense Health Agency, JBSA Fort Sam Houston, TX 78234, USA
| | - Steven G Schauer
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA.,United States Army Institute of Surgical Research, San Antonio, TX 78234, USA.,Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX 78234, USA
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