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Florek CA, Cozzone E, Williams DL, Armbruster DA. A controlled release antibiotic wound protectant gel formulated for use in austere environments. J Biomed Mater Res B Appl Biomater 2024; 112:e35455. [PMID: 39177322 DOI: 10.1002/jbm.b.35455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Revised: 06/10/2024] [Accepted: 07/08/2024] [Indexed: 08/24/2024]
Abstract
Battlefield wounds are at high risk of infection due to gross contamination and delays in evacuation from forward-deployed locations. The aim of this study was to formulate an antibiotic wound gel for application by a field medic in austere environments to protect traumatic wounds from infection during transport. Formulation development was conducted over multiple phases to meet temperature, handling, in vitro elution, and in vivo tissue response requirements. Thermal properties were evaluated by vial inversion, DSC, and syringe expression force in a temperature range of 4-49°C. Handling was evaluated by spreading onto blood-contaminated tissue and irrigation resistance. Controlled antibiotic release was evaluated by a modified USP immersion cell dissolution method. Local tissue effects were evaluated in vivo by subcutaneous implantation in rats for 7 and 28 days. An oleogel composition of cholesterol, hydrogenated castor oil, soybean oil, and glyceryl monocaprylocaprate met the target performance criteria. Peak expression force from a 5 mL syringe at 4°C was 48.3 N, the dropping point temperature was 68°C, and the oleogel formulation could be spread onto blood-contaminated tissue and resisted aqueous irrigation. The formulation demonstrated sustained release of tobramycin in PBS at 32°C for 5 days. Implantation in a rat dorsal pocket demonstrated a slight tissue reaction after 7 days with minimal to no reaction after 28 days, comparable to a commercial hemostat control. Material resorption was evident after 28 days. The formulation met target characteristics and is appropriate for further evaluation in a large animal contaminated blast wound model.
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Affiliation(s)
| | | | - Dustin L Williams
- Department of Orthopaedics, University of Utah, Salt Lake City, Utah, USA
- Department of Biomedical Engineering, University of Utah, Salt Lake City, Utah, USA
- Department of Pathology, University of Utah, Salt Lake City, Utah, USA
- Department of Physical Medicine and Rehabilitation, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
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Causbie JM, Wisniewski P, Maves RC, Mount CA. Prophylactic antibiotic use for penetrating trauma in prolonged casualty care: A review of the literature and current guidelines. J Trauma Acute Care Surg 2024; 97:S126-S137. [PMID: 38689405 DOI: 10.1097/ta.0000000000004355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2024]
Abstract
ABSTRACT Prolonged casualty care (PCC), previously known as prolonged field care, is a system to provide patient care for extended periods of time when evacuation or mission requirements surpass available capabilities. Current guidelines recommend a 7- to 10-day course of ertapenem or moxifloxacin, with vancomycin if methicillin-resistant Staphylococcus aureus is suspected, for all penetrating trauma in PCC. Data from civilian and military trauma have demonstrated benefit for antibiotic prophylaxis in multiple types of penetrating trauma, but the recommended regimens and durations differ from those used in PCC, with the PCC guidelines generally recommending broader coverage. We present a review of the available civilian and military literature on antibiotic prophylaxis in penetrating trauma to discuss whether a strategy of broader coverage is necessary in the PCC setting, with the goal of optimizing patient outcomes and antibiotic stewardship, while remaining cognizant of the challenges of moving medical material to and through combat zones. Empiric extended gram-negative coverage is unlikely to be necessary for thoracic, maxillofacial, extremity, and central nervous system trauma in most medical settings. However, providing the narrowest appropriate antimicrobial coverage is challenging in PCC because of limited resources, most notably, delay to surgical debridement. Antibiotic prophylaxis regimen must be determined on a case-by-case basis based on individual patient factors while still considering antibiotic stewardship. Narrower regimens, which focus on matching up the site of infection to the antibiotic chosen, may be appropriate based on available resources and expertise of treating providers. When resources permit in PCC, the narrower cefazolin-based regimens (with the addition of metronidazole for esophageal or abdominal involvement, or gross contamination of central nervous system trauma) likely provide adequate coverage. Levofloxacin is appropriate for ocular trauma. Ideally, cefazolin and metronidazole should be carried by medics in addition to first-line antibiotics (moxifloxacin and ertapenem, Literature Synthesis and Expert Opinion; Level V).
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Affiliation(s)
- Jacqueline M Causbie
- From the Department of Internal Medicine (J.M.C.), Madigan Army Medical Center, Joint Base Lewis-McChord, Washington; Department of Medicine (P.W., C.A.M.), Uniformed Services University of the Health Sciences, Bethesda, Maryland; 2nd Medical Battalion (P.W.), 2nd Marine Logistics Group, Camp Lejeune; and Sections of Infectious Diseases (R.C.M.) and Critical Care Medicine (R.C.M.), Wake Forest University School of Medicine, Winston-Salem, North Carolina
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Quinn J, Panasenko SI, Leshchenko Y, Gumeniuk K, Onderková A, Stewart D, Gimpelson AJ, Buriachyk M, Martinez M, Parnell TA, Brain L, Sciulli L, Holcomb JB. Prehospital Lessons From the War in Ukraine: Damage Control Resuscitation and Surgery Experiences From Point of Injury to Role 2. Mil Med 2024; 189:17-29. [PMID: 37647607 DOI: 10.1093/milmed/usad253] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 06/26/2023] [Indexed: 09/01/2023] Open
Abstract
The ongoing war in Ukraine presents unique challenges to prehospital medical care for wounded combatants and civilians. The purpose of this article is to identify, describe, and address gaps in prehospital care, casualty evacuation, and medical evacuation throughout Ukraine to share lessons for other providers. Observations and experiences of medical personnel were collected and analyzed, focusing on pain management, antibiotic use, patient assessment, mass casualty triage, blood loss, hypothermia, transport immobilization, and clinical governance. Gaps identified include limited access to pain management, lack of antibiotic guidance, inadequate patient assessment and triage, access to damage control resuscitation and blood, challenged transport immobilization practices, and challenges with clinical governance for both local and foreign providers. Improved prehospital care and casualty and medical evacuation in Ukraine are required, through increased use of empiric pain management, focused antibiotic guidance, enhanced patient assessment and triage in the form of training, access to prehospital blood, and better transport immobilization practices. A robust and active lessons learned program, trauma data capture, and quality improvement process is needed to reduce preventable morbidity and mortality in the war zone. The recommendations presented in this article serve as a starting point for improvements in prehospital care in Ukraine with potential to change prehospital training for the NATO alliance and other organizations operating in similar areas of conflict. Graphical Abstract.
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Affiliation(s)
- John Quinn
- Prague Center for Global Health, Prague 120 00, Czech Republic
- East Surrey Emergency Department, Redhill RH1 5RH, UK
| | - Serhii I Panasenko
- Department of Surgery No 3, Poltava State Medical University, Poltava 36039, Ukraine
| | | | - Konstantyn Gumeniuk
- Ukrainian Armed Forces (UKR), Headquarters of Medical Forces of Military Forces, Kyiv 03168, Ukraine
| | - Anna Onderková
- Department of Oncology, Division of Surgery, University College London Hospital, London NW1 2BU, UK
| | - David Stewart
- Emergency & Deployed Medicine San Diego, California, USA
| | | | | | | | - Tracey A Parnell
- Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Leonid Brain
- NewYork-Presbyterian Brooklyn Methodist Hospital Emergency Department
| | - Luke Sciulli
- Auton Lab, Carnegie Mellon University, Pittsburgh, Pennsylvania, USA
| | - John B Holcomb
- Prague Center for Global Health, Prague 120 00, Czech Republic
- Emergency & Deployed Medicine San Diego, California, USA
- Department of Surgery, Division of Trauma and Acute Care Surgery, University of Alabama at Birmingham, Birmingham, AL
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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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Glick Y, Furer A, Glick K, Yitzhak A, Brosh T. The Israeli Defense Forces Point of Injury Antimicrobial Treatment Protocol - A New Protocol and Review of the Literature. Mil Med 2019; 184:78-82. [PMID: 30901438 DOI: 10.1093/milmed/usy292] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Revised: 09/26/2018] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION Combat wound infection is a common and serious complication, leading to significant morbidity and mortality. In 2005, a point of injury antimicrobial protocol was published by the Israel Defense Forces, in which Moxifloxacin was chosen. During 2016-2017, a revision of this protocol was performed and concluded with the publication of an updated protocol. The purpose of this report is to present this process and the revised protocol, together with a review of the literature. METHODS We searched "Medline" and "Google Scholar" for studies dealing with antimicrobial prophylaxis in trauma, for militaries' point of injury antimicrobial protocol protocols and for established surgical antimicrobial prophylaxis protocols. RESULTS Point of injury antimicrobial protocol is aimed at preventing early infection and its complications. The choice of Moxifloxacin for this purpose may not be optimal since Moxifloxacin spectrum might be overly broad, there is scant evidence supporting it for this indication, and the available preparation does not meet distinctive technical requirements. Contrarily, Ceftriaxone seemed to have suitable microbiological, pharmacological and technical features. CONCLUSION Point of injury antimicrobial protocol should be used especially when evacuation and definitive surgical treatment are delayed. According to present scientific data and operational needs, Ceftriaxone was chosen for most penetrating injuries, with Metronidazole addition for penetrating abdominal and cranial trauma.
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Affiliation(s)
- Yuval Glick
- Israel Defense Forces Medical Corps, Surgeon General's Headquarters, Military POB 02149 Tel Hashomer, Ramat Gan, Military Postal Code, Israel
| | - Ariel Furer
- Israel Defense Forces Medical Corps, Surgeon General's Headquarters, Military POB 02149 Tel Hashomer, Ramat Gan, Military Postal Code, Israel
| | - Karina Glick
- Internal Medicine Department "A', Assuta Ashdod University Hospital, 7 Ha-Refua St., Ashdod, Israel
| | - Avraham Yitzhak
- Israel Defense Forces Medical Corps, Surgeon General's Headquarters, Military POB 02149 Tel Hashomer, Ramat Gan, Military Postal Code, Israel
| | - Tal Brosh
- Israel Defense Forces Medical Corps, Surgeon General's Headquarters, Military POB 02149 Tel Hashomer, Ramat Gan, Military Postal Code, Israel.,Faculty of Health Sciences, Ben-Gurion University of the Negev, Ben-Gurion Blvd., Be'er-Sheva, Israel.,Infectious Diseases Unit, Assuta Ashdod University Hospital, 7 Ha-Refua St., Ashdod, Israel
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