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Satanovsky A, Gilor Y, Benov A, Chen J, Shlaifer A, Talmy T, Radomislensky I, Siman-Tov M, Peleg K, Weil YA, Eisenkraft A. Combat Injury Profile in Urban Warfare. Mil Med 2024; 189:973-979. [PMID: 36454618 DOI: 10.1093/milmed/usac366] [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: 07/05/2022] [Revised: 09/19/2022] [Accepted: 11/07/2022] [Indexed: 02/17/2024] Open
Abstract
INTRODUCTION Combat ground maneuvers consist of various platforms and have several environmental characteristics, influenced by the terrain, the operational mission, and the force's capabilities. This study assesses data on injuries sustained during urban warfare, aiming to evaluate the relationship between injury characteristics, maneuver platform, and personal protective gear on the battlefield. MATERIALS AND METHODS IDF soldiers injured infantry soldiers from the "Cast Lead" and the "Protective Edge" operations in the Gaza Strip (2008-2009 and 2014, respectively) were divided into four groups according to the maneuver platform and the environment: mounted infantry (armored and unarmored vehicle) and dismounted infantry (urban and open area). The primary outcome was the severity of the injury, and the secondary outcome was the injured body part. RESULTS Overall, 588 casualties were included in the final analysis, of whom 507 were dismounted infantry soldiers (265 in open terrain and 242 in urban area) and 81 were mounted infantry soldiers (20 in unarmored and 61 were injured in armored vehicles). The Injury Severity Score was similar in all subgroups. Open terrain subgroups were found to have fewer head injuries and higher levels of lower extremity injuries, similar to the unarmored vehicle group. More facial injuries were documented in the urban area group. CONCLUSIONS The Injury Severity Score was not influenced by environmental protection. Although we found differences in the injured body parts, further studies on the exact mechanism of injury are needed to elucidate further the relationship and differences between the various platforms used and injuries seen in urban warfare, aiming for tailor-made protection.
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Affiliation(s)
- Alexandra Satanovsky
- The Israel Defense Force Medical Corps Headquarters, Ramat Gan 5262000, Israel
- Orthopaedic Department, Hadassah Hebrew University Hospital, Jerusalem 91120, Israel
| | - Yuval Gilor
- The Institute for Research in Military Medicine, Faculty of Medicine, The Hebrew University of Jerusalem and the Israel Defense Force Medical Corps, Jerusalem 91120, Israel
| | - Avi Benov
- The Israel Defense Force Medical Corps Headquarters, Ramat Gan 5262000, Israel
- The Azrieli Faculty of Medicine, Bar-Ilan University, Safed 1311502, Israel
| | - Jacob Chen
- The Israel Defense Force Medical Corps Headquarters, Ramat Gan 5262000, Israel
- Deputy Director General of the medical center, Meir Medical Center, Kfar Saba 4428163, Israel
| | - Amir Shlaifer
- The Israel Defense Force Medical Corps Headquarters, Ramat Gan 5262000, Israel
| | - Tomer Talmy
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Irina Radomislensky
- The Israel National Center for Trauma and Emergency Medicine Research, The Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center, Tel HaShomer, Ramat Gan 5266202, Israel
| | - Maya Siman-Tov
- The Israel National Center for Trauma and Emergency Medicine Research, The Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center, Tel HaShomer, Ramat Gan 5266202, Israel
- The Department of Emergency Management and Disaster Medicine, School of Public Health, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6139001, Israel
| | - Kobi Peleg
- The Israel National Center for Trauma and Emergency Medicine Research, The Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center, Tel HaShomer, Ramat Gan 5266202, Israel
- The Department of Emergency Management and Disaster Medicine, School of Public Health, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6139001, Israel
| | - Yoram A Weil
- Orthopaedic Department, Hadassah Hebrew University Hospital, Jerusalem 91120, Israel
| | - Arik Eisenkraft
- The Institute for Research in Military Medicine, Faculty of Medicine, The Hebrew University of Jerusalem and the Israel Defense Force Medical Corps, Jerusalem 91120, Israel
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Gendler S, Gelikas S, Talmy T, Nadler R, Tsur AM, Radomislensky I, Bodas M, Glassberg E, Almog O, Benov A, Chen J. Predictors of Short-Term Trauma Laparotomy Outcomes in an Integrated Military-Civilian Health System: A 23-Year Retrospective Cohort Study. J Clin Med 2024; 13:1830. [PMID: 38610595 PMCID: PMC11012665 DOI: 10.3390/jcm13071830] [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: 01/06/2024] [Revised: 02/03/2024] [Accepted: 03/14/2024] [Indexed: 04/14/2024] Open
Abstract
Background: Trauma laparotomy (TL) remains a cornerstone of trauma care. We aimed to investigate prehospital measures associated with in-hospital mortality among casualties subsequently undergoing TLs in civilian hospitals. Methods: This retrospective cohort study cross-referenced the prehospital and hospitalization data of casualties treated by Israel Defense Forces-Medical Corps teams who later underwent TLs in civilian hospitals between 1997 and 2020. Results: Overall, we identified 217 casualties treated by IDF-MC teams that subsequently underwent a TL, with a mortality rate of 15.2% (33/217). The main mechanism of injury was documented as penetrating for 121/217 (55.8%). The median heart rate and blood pressure were within the normal limit for the entire cohort, with a low blood pressure predicting mortality (65 vs. 127, p < 0.001). In a multivariate analysis, prehospital endotracheal intubation (ETI), emergency department Glasgow coma scores of 3-8, and the need for a thoracotomy or bowel-related procedures were significantly associated with mortality (OR 6.8, p < 0.001, OR = 48.5, p < 0.001, and OR = 4.61, p = 0.002, respectively). Conclusions: Prehospital interventions introduced throughout the study period did not lead to an improvement in survival. Survival was negatively influenced by prehospital ETI, reinforcing previous observations of the potential deleterious effects of definitive airways on hemorrhaging trauma casualties. While a low blood pressure was a predictor of mortality, the median systolic blood pressure for even the sickest patients (ISS > 16) was within normal limits, highlighting the challenges in triage and risk stratification for trauma casualties.
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Affiliation(s)
- Sami Gendler
- Israel Defense Forces, Medical Corps, Tel Hashomer, Ramat Gan 5262504, Israel (J.C.)
| | - Shaul Gelikas
- Israel Defense Forces, Medical Corps, Tel Hashomer, Ramat Gan 5262504, Israel (J.C.)
- Department of Medicine, Sheba Medical Center, Tel-Hashomer 5262504, Israel
| | - Tomer Talmy
- Israel Defense Forces, Medical Corps, Tel Hashomer, Ramat Gan 5262504, Israel (J.C.)
| | - Roy Nadler
- Israel Defense Forces, Medical Corps, Tel Hashomer, Ramat Gan 5262504, Israel (J.C.)
| | - Avishai M. Tsur
- Israel Defense Forces, Medical Corps, Tel Hashomer, Ramat Gan 5262504, Israel (J.C.)
- Department of Medicine, Sheba Medical Center, Tel-Hashomer 5262504, Israel
| | - Irina Radomislensky
- The National Center for Trauma & Emergency Medicine Research, Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center, Ramat Gan 5262100, Israel
| | - Moran Bodas
- The National Center for Trauma & Emergency Medicine Research, Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center, Ramat Gan 5262100, Israel
- Department of Emergency & Disaster Management, School of Public Health, Faculty of Medicine, Tel-Aviv University, Tel-Aviv-Yafo 6139001, Israel
| | - Elon Glassberg
- Israel Defense Forces, Medical Corps, Tel Hashomer, Ramat Gan 5262504, Israel (J.C.)
- The Azrieli Faculty of Medicine, Bar-Ilan University, Safed 5290002, Israel
- The Uniformed Services, University of the Health Sciences, Bethesda, MD 20814, USA
| | - Ofer Almog
- Israel Defense Forces, Medical Corps, Tel Hashomer, Ramat Gan 5262504, Israel (J.C.)
- Department of Military Medicine, Faculty of Medicine, Hebrew University, Jerusalem 9112102, Israel
| | - Avi Benov
- Israel Defense Forces, Medical Corps, Tel Hashomer, Ramat Gan 5262504, Israel (J.C.)
- The Azrieli Faculty of Medicine, Bar-Ilan University, Safed 5290002, Israel
| | - Jacob Chen
- Israel Defense Forces, Medical Corps, Tel Hashomer, Ramat Gan 5262504, Israel (J.C.)
- Meir Medical Center, Kfar Saba 4428164, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv 69978, Israel
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3
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Gottfried A, Gendler S, Chayen D, Radomislensky I, Mitchnik IY, Epshtein E, Tsur AM, Almog O, Talmy T. Hemorrhagic Shock in Isolated and Non-Isolated Pelvic Fractures: A Registries-Based Study. PREHOSP EMERG CARE 2024; 28:589-597. [PMID: 38416869 DOI: 10.1080/10903127.2024.2322014] [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: 10/09/2023] [Accepted: 02/15/2024] [Indexed: 03/01/2024]
Abstract
BACKGROUND Pelvic fractures resulting from high-energy trauma can frequently present with life-threatening hemodynamic instability that is associated with high mortality rates. The role of pelvic exsanguination in causing hemorrhagic shock is unclear, as associated injuries frequently accompany pelvic fractures. This study aims to compare the incidence of hemorrhagic shock and in-hospital outcomes in patients with isolated and non-isolated pelvic fractures. METHODS Registries-based study of trauma patients hospitalized following pelvic fractures. Data from 1997 to 2021 were cross-referenced between the Israel Defense Forces Trauma Registry (IDF-TR), documenting prehospital care, and Israel National Trauma Registry (INTR) recording hospitalization data. Patients with isolated pelvic fractures were defined as having an Abbreviated Injury Scale (AIS) <3 in other anatomical regions, and compared with patients sustaining pelvic fracture and at least one associated injury (AIS ≥ 3). Signs of profound shock upon emergency department (ED) arrival were defined as either a systolic blood pressure <90 mmHg and/or a heart rate >130 beats per min. RESULTS Overall, 244 hospitalized trauma patients with pelvic fractures were included, most of whom were males (84.4%) with a median age of 21 years. The most common injury mechanisms were motor vehicle collisions (64.8%), falls from height (13.1%) and gunshot wounds (11.5%). Of these, 68 (27.9%) patients sustained isolated pelvic fractures. In patients with non-isolated fractures, the most common regions with a severe associated injury were the thorax and abdomen. Signs of shock were recorded for 50 (20.5%) patients upon ED arrival, but only four of these had isolated pelvic fractures. In-hospital mortality occurred among 18 (7.4%) patients, all with non-isolated fractures. CONCLUSION In young patients with pelvic fractures, severe associated injuries were common, but isolated pelvic fractures rarely presented with profound shock upon arrival. Prehospital management protocols for pelvic fractures should prioritize prompt evacuation and resuscitative measures aimed at addressing associated injuries.
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Affiliation(s)
- Amir Gottfried
- Israel Defense Forces Medical Corps, Surgeon's General Headquarters, Ramat Gan, Israel
| | - Sami Gendler
- Israel Defense Forces Medical Corps, Surgeon's General Headquarters, Ramat Gan, Israel
| | - David Chayen
- Israel Defense Forces Medical Corps, Surgeon's General Headquarters, Ramat Gan, Israel
- Department of Military Medicine, Faculty of Medicine, Hebrew University, Jerusalem, Israel
| | - Irina Radomislensky
- Israel Defense Forces Medical Corps, Surgeon's General Headquarters, Ramat Gan, Israel
- The National Center for Trauma and Emergency Medicine Research, The Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center, Tel-HaShomer, Israel
| | - Ilan Y Mitchnik
- Israel Defense Forces Medical Corps, Surgeon's General Headquarters, Ramat Gan, Israel
- Department of Military Medicine, Faculty of Medicine, Hebrew University, Jerusalem, Israel
- Department of Orthopedic Surgery, Shamir Medical Center, Zrifin, Israel
| | - Elad Epshtein
- Israel Defense Forces Medical Corps, Surgeon's General Headquarters, Ramat Gan, Israel
| | - Avishai M Tsur
- Israel Defense Forces Medical Corps, Surgeon's General Headquarters, Ramat Gan, Israel
- Department of Military Medicine, Faculty of Medicine, Hebrew University, Jerusalem, Israel
- Department of Medicine, Sheba Medical Center, Tel-Hashomer, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ofer Almog
- Israel Defense Forces Medical Corps, Surgeon's General Headquarters, Ramat Gan, Israel
- Department of Military Medicine, Faculty of Medicine, Hebrew University, Jerusalem, Israel
| | - Tomer Talmy
- Israel Defense Forces Medical Corps, Surgeon's General Headquarters, Ramat Gan, Israel
- Department of Military Medicine, Faculty of Medicine, Hebrew University, Jerusalem, Israel
- Division of Anesthesia, Intensive Care, and Pain, Tel-Aviv Medical Center, Tel-Aviv University, Tel-Aviv, Israel
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Zhang LY, Zhang HY. Torso hemorrhage: noncompressible? never say never. Eur J Med Res 2024; 29:153. [PMID: 38448977 PMCID: PMC10919054 DOI: 10.1186/s40001-024-01760-4] [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: 11/11/2023] [Accepted: 02/29/2024] [Indexed: 03/08/2024] Open
Abstract
Since limb bleeding has been well managed by extremity tourniquets, the management of exsanguinating torso hemorrhage (TH) has become a hot issue both in military and civilian medicine. Conventional hemostatic techniques are ineffective for managing traumatic bleeding of organs and vessels within the torso due to the anatomical features. The designation of noncompressible torso hemorrhage (NCTH) marks a significant step in investigating the injury mechanisms and developing effective methods for bleeding control. Special tourniquets such as abdominal aortic and junctional tourniquet and SAM junctional tourniquet designed for NCTH have been approved by FDA for clinical use. Combat ready clamp and junctional emergency treatment tool also exhibit potential for external NCTH control. In addition, resuscitative endovascular balloon occlusion of the aorta (REBOA) further provides an endovascular solution to alleviate the challenges of NCTH treatment. Notably, NCTH cognitive surveys have revealed that medical staff have deficiencies in understanding relevant concepts and treatment abilities. The stereotypical interpretation of NCTH naming, particularly the term noncompressible, is the root cause of this issue. This review discusses the dynamic relationship between TH and NCTH by tracing the development of external NCTH control techniques. The authors propose to further subdivide the existing NCTH into compressible torso hemorrhage and NCTH' (noncompressible but REBOA controllable) based on whether hemostasis is available via external compression. Finally, due to the irreplaceability of special tourniquets during the prehospital stage, the authors emphasize the importance of a package program to improve the efficacy and safety of external NCTH control. This program includes the promotion of tourniquet redesign and hemostatic strategies, personnel reeducation, and complications prevention.
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Affiliation(s)
- Lian-Yang Zhang
- Department of Trauma Surgery, War Trauma Medical Center, State Key Laboratory of Trauma, Burn and Combined Injury, Daping Hospital, Army Medical University, Chongqing, 400042, China
| | - Hua-Yu Zhang
- Department of Trauma Surgery, War Trauma Medical Center, State Key Laboratory of Trauma, Burn and Combined Injury, Daping Hospital, Army Medical University, Chongqing, 400042, China.
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Talmy T, Malkin M, Esterson A, Yazer MH, Sebbag A, Shina A, Shinar E, Glassberg E, Gendler S, Almog O. Low-titer group O whole blood in military ground ambulances: Lessons from the Israel Defense Forces initial experience. Transfus Med 2023; 33:440-452. [PMID: 37668175 DOI: 10.1111/tme.12995] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 07/24/2023] [Accepted: 08/24/2023] [Indexed: 09/06/2023]
Abstract
BACKGROUND Cold-stored low-titer group O whole blood (LTOWB) has become increasingly utilised in both prehospital and in-hospital settings for resuscitation of traumatic haemorrhage. However, implementing the use of LTOWB to ground medical teams has been limited due to logistic challenges. METHODS In 2022, the Israel Defense Forces (IDF) started using LTOWB in ambulances for the first time in Israel. This report details the initial experience of this rollout and presents a case-series of the first patients treated with LTOWB. RESULTS Between January-December 2022, seven trauma patients received LTOWB administered by ground IDF intensive care ambulances after presenting with profound shock. Median time from injury to administration of LTOWB was 35 min. All patients had evidence of severe bleeding upon hospital arrival with six undergoing damage control laparotomy and all but one surviving to discharge. CONCLUSIONS The implementation of LTOWB in ground medical units is in its early stages, but continued experience may demonstrate its feasibility, safety, and effectiveness in the prehospital setting. Further research is necessary to fully understand the indications, methodology, and benefits of LTOWB in resuscitating severely injured trauma patients in this setting.
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Affiliation(s)
- Tomer Talmy
- Israel Defense Forces, Medical Corps, Ramat Gan, Israel
- Department of Military Medicine, Faculty of Medicine, Hebrew University, Jerusalem, Israel
| | - Michael Malkin
- Israel Defense Forces, Medical Corps, Ramat Gan, Israel
- Department of Military Medicine, Faculty of Medicine, Hebrew University, Jerusalem, Israel
| | | | - Mark H Yazer
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Anat Sebbag
- Israel Defense Forces, Medical Corps, Ramat Gan, Israel
| | - Avi Shina
- Israel Defense Forces, Medical Corps, Ramat Gan, Israel
- Department of Military Medicine, Faculty of Medicine, Hebrew University, Jerusalem, Israel
| | - Eilat Shinar
- Magen David Adom, National Blood Services, Ramat Gan, Israel
| | - Elon Glassberg
- Israel Defense Forces, Medical Corps, Ramat Gan, Israel
- The Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
- The Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Sami Gendler
- Israel Defense Forces, Medical Corps, Ramat Gan, Israel
| | - Ofer Almog
- Israel Defense Forces, Medical Corps, Ramat Gan, Israel
- Department of Military Medicine, Faculty of Medicine, Hebrew University, Jerusalem, Israel
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6
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Bulis S, Talmy T, Radomislensky I, Gelman D, Bushinsky S, Nachum D, Tomer G, Tsur AM, Paulman O, Gendler S, Almog O, Benov A. The Association Between Glasgow Coma Scale Scores and PTSD in Military Trauma Casualties: Does Mental Status Following Injury Play a Role in PTSD Development? Mil Med 2023; 188:428-435. [PMID: 37948204 DOI: 10.1093/milmed/usad180] [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: 12/23/2022] [Revised: 03/23/2023] [Accepted: 08/07/2023] [Indexed: 11/12/2023] Open
Abstract
BACKGROUND Posttraumatic stress disorder (PTSD) is prevalent among military personnel and may arise following a wide range of traumatic exposures. Consciousness level following traumatic injury may play a role in the development of PTSD, but its effects have been primarily investigated in the context of traumatic brain injury. METHODS Registry-based study surveying three databases documenting care from point of injury to long-term rehabilitation of traumatic injuries among military personnel. The study population was divided according to Glasgow Coma Scale (GCS) scores upon emergency department admission (GCS scores 15, 13 and 14, 9-12, and 3-8), with PTSD diagnoses being determined according to disability claim records. Multivariable logistic regression was utilized to determine the association between GCS score at admission and PTSD. RESULTS Overall, 3,376 military personnel hospitalized following traumatic injuries between 1997 and 2020 were included. The majority were male (92.3%), with a median age of 20 (interquartile range 19-22) at the injury time. Of these, 569 (16.9%) were diagnosed with PTSD according to disability claims, with a median follow-up time of 10.9 years. PTSD diagnosis was most prevalent (30.3% of patients), with a GCS score of 13 and 14. In the adjusted multivariable model, a GCS score of 13 and 14 was associated with significantly higher odds of PTSD diagnosis when compared to a GCS score of 15 (odds ratio 2.19, 95% CI, 1.21-3.88). The associations of other GCS groupings with PTSD diagnosis were nonsignificant. CONCLUSIONS Minimally impaired consciousness following traumatic injuries is associated with increased odds of PTSD. The role of patient awareness, analgesia, and sedation following an injury in developing PTSD warrants further investigation and could guide early diagnosis and preventive interventions.
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Affiliation(s)
- Shir Bulis
- Israel Defense Forces Medical Corps, Surgeon General's Headquarters, Israel Defense Forces, Ramat Gan 5262000, Israel
| | - Tomer Talmy
- Israel Defense Forces Medical Corps, Surgeon General's Headquarters, Israel Defense Forces, Ramat Gan 5262000, Israel
- Department of Military Medicine, Faculty of Medicine, Hebrew University, Jerusalem 9574869, Israel
| | - Irina Radomislensky
- The National Center for Trauma and Emergency Medicine Research, The Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center, Tel-HaShomer 5262000, Israel
| | - Daniel Gelman
- Israel Defense Forces Medical Corps, Surgeon General's Headquarters, Israel Defense Forces, Ramat Gan 5262000, Israel
- Department of Military Medicine, Faculty of Medicine, Hebrew University, Jerusalem 9574869, Israel
| | - Shir Bushinsky
- Paul Baerwald School of Social Work and Social Welfare, The Hebrew University of Jerusalem, Jerusalem 91905, Israel
| | - Dikla Nachum
- Israel Defense Forces Medical Corps, Surgeon General's Headquarters, Israel Defense Forces, Ramat Gan 5262000, Israel
| | - Gaia Tomer
- Israel Defense Forces Medical Corps, Surgeon General's Headquarters, Israel Defense Forces, Ramat Gan 5262000, Israel
| | - Avishai M Tsur
- Israel Defense Forces Medical Corps, Surgeon General's Headquarters, Israel Defense Forces, Ramat Gan 5262000, Israel
| | - Omer Paulman
- Israel Defense Forces Medical Corps, Surgeon General's Headquarters, Israel Defense Forces, Ramat Gan 5262000, Israel
| | - Sami Gendler
- Israel Defense Forces Medical Corps, Surgeon General's Headquarters, Israel Defense Forces, Ramat Gan 5262000, Israel
| | - Ofer Almog
- Israel Defense Forces Medical Corps, Surgeon General's Headquarters, Israel Defense Forces, Ramat Gan 5262000, Israel
- Department of Military Medicine, Faculty of Medicine, Hebrew University, Jerusalem 9574869, Israel
| | - Avi Benov
- Israel Defense Forces Medical Corps, Surgeon General's Headquarters, Israel Defense Forces, Ramat Gan 5262000, Israel
- The Azrieli Faculty of Medicine, Bar-Ilan University, Safed 1311502, Israel
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Talmy T, Cohen-Manheim I, Radomislensky I, Gelikas S, Tsur N, Benov A, Koler T, Glassberg E, Almog O, Gendler S. Implications for future humanitarian aid missions: Lessons from point-of injury and hospital care for Syrian refugees. Injury 2023; 54:110752. [PMID: 37142481 DOI: 10.1016/j.injury.2023.04.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 04/01/2023] [Accepted: 04/19/2023] [Indexed: 05/06/2023]
Abstract
BACKGROUND Warzone humanitarian medical aid missions are infrequent and applying lessons from these missions is vital to ensuring preparedness for future crises. Between 2013-2018, the Israel Defense Forces Medical Corps (IDF-MC) provided humanitarian medical aid to individuals injured in the Syrian Civil War who chose to seek medical assistance at the Israeli-Syrian border. Patients requiring care surgical or advanced care were transferred to civilian medical centers within Israel. This study aims to describe the injury characteristics and management of hospitalized Syrian Civil War trauma patients over a five-year period. METHODS Retrospective cohort analysis cross-referencing data from the IDF trauma registry, documenting prehospital care, and the Israel National Trauma Registry, documenting in-hospital care, between 2013 and 2018. Syrian trauma patients hospitalized in Israeli hospitals were cross-referenced between the two registries. Multivariable logistic regression was applied to identify independent factors associated with in-hospital mortality. RESULTS Overall, 856 hospitalized trauma patients were included following definitive cross-matching. The median age was 23 years, and 93.3% were males. Blast (n = 532; 62.1%) and gunshot (n = 241; 28.2%) were the most common injury mechanisms. Injury Severity Score was ≥25 for 28.8% of patients and most common body regions with severe injury (Abbreviated Injury Scale≥3) were the head (30.7%) and thorax (25.0%). Intensive care unit admission was required for 40.1% of patients, and the median hospital stay was 13 days. In-hospital mortality was recorded for 73 (8.5%). Signs of shock upon emergency department admission and severe head injury were significantly associated with mortality in the adjusted model whereas age of <18 years was associated with decreased odds for in-hospital mortality. CONCLUSIONS Trauma patients hospitalized in Israel following injuries sustained in the Syrian Civil War were characterized by a high prevalence of blast injuries with concomitant involvement of several body regions. Future missions should ensure preparedness for complex multi-trauma, often involving the head, and ensure high intensive care and surgical capacities.
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Affiliation(s)
- Tomer Talmy
- Israel Defense Forces Medical Corps, Surgeon General's Headquarters, Ramat Gan, 5265601, Israel; Department of Military Medicine, Hebrew University of Jerusalem, Faculty of Medicine, Jerusalem 9112102, Israel.
| | - Irit Cohen-Manheim
- Israel National Center for Trauma & Emergency Medicine Research, The Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center, Tel-Hashomer, Ramat-Gan, 5265601, Israel
| | - Irina Radomislensky
- Israel National Center for Trauma & Emergency Medicine Research, The Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center, Tel-Hashomer, Ramat-Gan, 5265601, Israel
| | - Shaul Gelikas
- Israel Defense Forces Medical Corps, Surgeon General's Headquarters, Ramat Gan, 5265601, Israel; Sheba Medical Center Hospital, Tel Hashomer, Ramat Gan, Israel
| | - Nir Tsur
- Israel Defense Forces Medical Corps, Surgeon General's Headquarters, Ramat Gan, 5265601, Israel; Department of Otolaryngology-Head and Neck Surgery, Rabin Medical Center, Tel Aviv University, Petach Tiqva, Israel
| | - Avi Benov
- Israel Defense Forces Medical Corps, Surgeon General's Headquarters, Ramat Gan, 5265601, Israel; The Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
| | - Tomer Koler
- Israel Defense Forces Medical Corps, Surgeon General's Headquarters, Ramat Gan, 5265601, Israel
| | - Elon Glassberg
- Israel Defense Forces Medical Corps, Surgeon General's Headquarters, Ramat Gan, 5265601, Israel; The Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel; The Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Ofer Almog
- Israel Defense Forces Medical Corps, Surgeon General's Headquarters, Ramat Gan, 5265601, Israel; Department of Military Medicine, Hebrew University of Jerusalem, Faculty of Medicine, Jerusalem 9112102, Israel
| | - Sami Gendler
- Israel Defense Forces Medical Corps, Surgeon General's Headquarters, Ramat Gan, 5265601, Israel
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8
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Talmy T, Greenstein I, Gendler S, Chayen D, Radomislensky I, Ahimor A, Koler T, Glassberg E, Almog O. Survival following Prehospital Traumatic Cardiac Arrest Resuscitation in the Israel Defense Forces: A Retrospective Study. PREHOSP EMERG CARE 2023; 28:438-447. [PMID: 37578901 DOI: 10.1080/10903127.2023.2241542] [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: 04/10/2023] [Revised: 06/12/2023] [Accepted: 07/20/2023] [Indexed: 08/16/2023]
Abstract
BACKGROUND Prehospital traumatic cardiac arrest (TCA) is associated with a poor prognosis and requires urgent interventions to address its potentially reversible causes. Resuscitative efforts of TCA in the prehospital setting may entail significant resource allocation and impose added tolls on caregivers. The Israel Defense Forces Medical Corps (IDF-MC) instructs clinicians to perform a set protocol in the case of TCA, providing prompt oxygenation, chest decompression and volume resuscitation. This study investigates the settings, interventions, and outcomes of TCA resuscitation by IDF-MC teams over 25 years in both combat and civilian settings. METHODS Retrospective study of the IDF-MC Trauma Registry between 1997-2022. Search criteria were applied to identify cases where the TCA protocol was initiated. A manual review of cases matching the search criteria was performed by two curators to determine the indications, interventions, and outcomes of casualties with prehospital TCA. Patients for whom interventions were performed outside of the TCA protocol, such as with measurable vital signs, were excluded. The primary outcome was survival to hospital admission, with the secondary outcome being return of vital signs in the prehospital setting. RESULTS Following case review, 149 patients with prehospital TCA were included, with a median age of 21 (interquartile range 19-27). Eighty-four (56.4%) presented with TCA in military or combat settings, with gunshot wounds and blast injuries being the most common mechanisms in this group. For 56 casualties (37.8%), all components of the protocol were performed (oxygenation, chest decompression, and volume resuscitation). Five (3.4%) casualties had return of vital signs in the prehospital setting, but none survived to hospital admission. CONCLUSION The prognosis of prehospital TCA is poor, and efforts to address its potentially reversible causes may often be futile. These notions may be further emphasized in military settings, where resources are limited, and extensive penetrating injuries are more common.
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Affiliation(s)
- Tomer Talmy
- Israel Defense Forces Medical Corps, Surgeon General's, Headquarters, Israel Defense Forces, Ramat Gan, Israel
- Department of Military Medicine, Hebrew University, Jerusalem, Israel
| | - Ithamar Greenstein
- Israel Defense Forces Medical Corps, Surgeon General's, Headquarters, Israel Defense Forces, Ramat Gan, Israel
| | - Sami Gendler
- Israel Defense Forces Medical Corps, Surgeon General's, Headquarters, Israel Defense Forces, Ramat Gan, Israel
| | - David Chayen
- Israel Defense Forces Medical Corps, Surgeon General's, Headquarters, Israel Defense Forces, Ramat Gan, Israel
- Department of Military Medicine, Hebrew University, Jerusalem, Israel
| | - Irina Radomislensky
- The National Center for Trauma and Emergency Medicine Research, The Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center, Tel-HaShomer, Israel
| | - Alon Ahimor
- Israel Defense Forces Medical Corps, Surgeon General's, Headquarters, Israel Defense Forces, Ramat Gan, Israel
| | - Tomer Koler
- Israel Defense Forces Medical Corps, Surgeon General's, Headquarters, Israel Defense Forces, Ramat Gan, Israel
| | - Elon Glassberg
- Israel Defense Forces Medical Corps, Surgeon General's, Headquarters, Israel Defense Forces, Ramat Gan, Israel
- The Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
- The Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Ofer Almog
- Israel Defense Forces Medical Corps, Surgeon General's, Headquarters, Israel Defense Forces, Ramat Gan, Israel
- Department of Military Medicine, Hebrew University, Jerusalem, Israel
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9
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Shakargy JD, Gendler S, Talmy T, Shushan G, Radomislensky I, Tsur AM, Almog O, Avital G, Benov A, Gelikas S. Blast Injury Patterns Among Israel Defense Forces Fatalities. Mil Med 2023; 188:e1788-e1794. [PMID: 36205252 DOI: 10.1093/milmed/usac280] [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: 06/08/2022] [Revised: 08/03/2022] [Accepted: 09/09/2022] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION The incidence of blast injuries on the battlefield has risen over the last several decades. In order to improve prevention and treatment, it is essential to understand the severity and bodily distribution of these injuries. This study aims to characterize blast injury patterns among IDF fatalities. MATERIALS AND METHODS This is a descriptive, retrospective study on postmortem reports of military-blast fatalities between the years 1982 and 2021. Body regions injured according to the Abbreviated Injury Scale (AIS) were described. The frequency of body region injury combinations was mapped, and the correlation between injured body regions was calculated using Pearson's coefficient. Analysis of a subgroup with a postmortem computed tomography (CT-PM) or autopsy was performed, describing severe (AIS ≥ 3) injury patterns. RESULTS Overall, 222 fatalities suffered from blast injury, with most injuries affecting the upper and lower extremities (63.7% and 66.5%, respectively), followed by the head (57.1%) and the thorax (56.6%). The median number of injured body regions was 4 (interquartile range, 2-5). The most frequent injury combinations were the upper and lower extremities (51%), the upper extremities and the thorax (45%), and the lower extremities and the thorax (41%). In all, 47/222 (21.2%) fatalities had a documented autopsy or CT-PM report. Among the fatalities with CT-PM or autopsy, the head (63.8%) and the thorax (57.4%) were most frequently severely injured (AIS ≥ 3). CONCLUSIONS Among blast fatalities in the military setting, the extremities were most commonly injured. However, data suggest that the head and thorax are more likely to sustain severe blast injuries resulting in mortality. Blast injuries in this cohort were characterized by concomitant involvement of several regions. Development of protective gear to minimize the multisystem injuries inflicted by blast injuries is warranted and should be focused on distinct types and anatomical distribution of severe blast injuries as reported in this study. LEVEL OF EVIDENCE Level III, Retrospective analysis.
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Affiliation(s)
- Josef Daniel Shakargy
- The Trauma and Combat Medicine Branch, Surgeon General's Headquarters, Israel Defense Forces, Ramat Gan 02149, Israel
| | - Sami Gendler
- The Trauma and Combat Medicine Branch, Surgeon General's Headquarters, Israel Defense Forces, Ramat Gan 02149, Israel
| | - Tomer Talmy
- The Trauma and Combat Medicine Branch, Surgeon General's Headquarters, Israel Defense Forces, Ramat Gan 02149, Israel
- Department of Military Medicine, Hebrew University of Jerusalem, Faculty of Medicine, Jerusalem 91120, Israel
| | - Guy Shushan
- The Trauma and Combat Medicine Branch, Surgeon General's Headquarters, Israel Defense Forces, Ramat Gan 02149, Israel
- Ground forces Technology Unit, Tel-Hashomer, Israel Defense Forces, Ramat Gan 02149, Israel
| | - Irina Radomislensky
- The Israel National Center for Trauma & Emergency Medicine Research, Gertner Institute of Epidemiology and Health Policy Research, Tel Aviv 5262000, Israel
| | - Avishai M Tsur
- The Trauma and Combat Medicine Branch, Surgeon General's Headquarters, Israel Defense Forces, Ramat Gan 02149, Israel
- Sheba Medical Center Hospital-Tel-Hashomer, Ramat Gan 5262000, Israel
| | - Ofer Almog
- The Trauma and Combat Medicine Branch, Surgeon General's Headquarters, Israel Defense Forces, Ramat Gan 02149, Israel
- Department of Military Medicine, Hebrew University of Jerusalem, Faculty of Medicine, Jerusalem 91120, Israel
| | - Guy Avital
- The Trauma and Combat Medicine Branch, Surgeon General's Headquarters, Israel Defense Forces, Ramat Gan 02149, Israel
- Division of Anesthesia, Intensive Care & Pain Management, Tel-Aviv Sourasky Medical Center, Tel-Aviv 6423906, Israel
| | - Avi Benov
- The Trauma and Combat Medicine Branch, Surgeon General's Headquarters, Israel Defense Forces, Ramat Gan 02149, Israel
- The Azrieli Faculty of Medicine, Bar-Ilan University, Safed 5290002, Israel
| | - Shaul Gelikas
- The Trauma and Combat Medicine Branch, Surgeon General's Headquarters, Israel Defense Forces, Ramat Gan 02149, Israel
- Sheba Medical Center Hospital-Tel-Hashomer, Ramat Gan 5262000, Israel
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10
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Guinzburg A, Gelikas S, Tsur AM, Nadler R, Sorkin A, Avital G, Radomislensky I, Bodas M, Segal D, Benov A, Chen J. The association between helicopter emergency medical services and early casualty survival: a nationwide study. Eur J Emerg Med 2022; 29:397-403. [PMID: 35900102 DOI: 10.1097/mej.0000000000000940] [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: 11/26/2022]
Abstract
BACKGROUND Helicopter emergency medical services (HEMS) allow for shorter transport duration in long-distance evacuations and facilitate advanced en-route medical care access. Studies comparing HEMS with ground emergency medical services (GEMS), including the outcome of prehospital mortality, are lacking. OBJECTIVE This study aimed to evaluate the association between HEMS and early mortality in Israel. SETTING A retrospective cohort study was conducted of the cross-referenced Israel Defense Forces Trauma Registry and Israel National Trauma Registry databases. OUTCOME MEASURES AND ANALYSIS Univariable logistic regression was used to assess the association between HEMS and early mortality, defined as mortality within 1 day of the injury. Regression analysis was further performed stratifying by event type (military or civilian) or type of injury (penetrating or nonpenetrating). RESULTS A total of 2344 casualties were included in the study, of whom 756 (32.3%) were evacuated by air. Early mortality rates were 90/1588 (5.7%) and 37/756 (4.9%) in GEMS and HEMS groups, respectively. Regression analysis found no significant analysis between HEMS and early mortality [OR, 0.86 (95% CI, 0.57-1.26)]. Stratified by event type, a nonsignificant association between HEMS and early mortality was demonstrated for combat [OR, 1.69 (95% CI, 0.79-3.92)] and noncombat [OR, 0.73 (95% CI, 0.4-1.25)] events. HEMS was associated with decreased early mortality among casualties with a penetrating injury [OR, 0.59 (95% CI, 0.34-0.98)] but not associated with early mortality among casualties with a nonpenetrating injury [OR, 0.84 (95% CI, 0.43-1.52)]. CONCLUSION HEMS was not associated with a decrease in early mortality among trauma casualties in this study encompassing the prehospital and hospital scenes. There was a positive trend and a decrease in mortality from penetrating injuries. Further research to ascertain which casualties benefit from HEMS is warranted and will allow for more precise use of this expensive resource.
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Affiliation(s)
- Ariel Guinzburg
- The Trauma and Combat Medicine Branch, Surgeon General's Headquarters, Israel Defense Forces, Ramat Gan
| | - Shaul Gelikas
- The Trauma and Combat Medicine Branch, Surgeon General's Headquarters, Israel Defense Forces, Ramat Gan
| | - Avishai M Tsur
- The Trauma and Combat Medicine Branch, Surgeon General's Headquarters, Israel Defense Forces, Ramat Gan
- Department of Medicine 'B', Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, Affiliated to Sackler School of Medicine, Tel Aviv
| | - Roy Nadler
- The Trauma and Combat Medicine Branch, Surgeon General's Headquarters, Israel Defense Forces, Ramat Gan
- Department of Medicine 'B', Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, Affiliated to Sackler School of Medicine, Tel Aviv
| | - Alex Sorkin
- The Trauma and Combat Medicine Branch, Surgeon General's Headquarters, Israel Defense Forces, Ramat Gan
- Department of Plastic Surgery, Shamir Medical Center, Zerifin
| | - Guy Avital
- The Trauma and Combat Medicine Branch, Surgeon General's Headquarters, Israel Defense Forces, Ramat Gan
- Division of Anesthesia, Intensive Care, and Pain Management, Tel-Aviv Medical Center, Tel-Aviv University, Tel-Aviv
| | - Irina Radomislensky
- The National Center for Trauma and Emergency Medicine Research, The Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center, Tel-Hashomer
| | - Moran Bodas
- The National Center for Trauma and Emergency Medicine Research, The Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center, Tel-Hashomer
- Department of Emergency Management and Disaster Medicine, School of Public Health, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv
| | - David Segal
- Meir Medical Center, Kfar Saba
- Sackler School of Medicine, Tel Aviv University, Tel Aviv
| | - Avi Benov
- The Trauma and Combat Medicine Branch, Surgeon General's Headquarters, Israel Defense Forces, Ramat Gan
- The Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
| | - Jacob Chen
- The Trauma and Combat Medicine Branch, Surgeon General's Headquarters, Israel Defense Forces, Ramat Gan
- Meir Medical Center, Kfar Saba
- Sackler School of Medicine, Tel Aviv University, Tel Aviv
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11
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Stausberg T, Ahnert T, Thouet B, Lefering R, Böhmer A, Brockamp T, Wafaisade A, Fröhlich M. Endotracheal intubation in trauma patients with isolated shock: universally recommended but rarely performed. Eur J Trauma Emerg Surg 2022; 48:4623-4630. [PMID: 35551425 PMCID: PMC9712316 DOI: 10.1007/s00068-022-01988-x] [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: 01/19/2022] [Accepted: 04/20/2022] [Indexed: 11/29/2022]
Abstract
PURPOSE The indication for pre-hospital endotracheal intubation (ETI) must be well considered as it is associated with several risks and complications. The current guidelines recommend, among other things, ETI in case of shock (systolic blood pressure < 90 mmHg). This study aims to investigate whether isolated hypotension without loss of consciousness is a useful criterion for ETI. METHODS The data of 37,369 patients taken from the TraumaRegister DGU® were evaluated in a retrospective study with regard to pre-hospital ETI and the underlying indications. Inclusion criteria were the presence of any relevant injuries (Abbreviated Injury Scale [AIS] ≥ 3) and complete pre-hospital management information. RESULTS In our cohort, 29.6% of the patients were intubated. The rate of pre-hospital ETI increased with the number of indications. If only one criterion according to current guidelines was present, ETI was often omitted. In 582 patients with shock as the only indication for pre-hospital ETI, only 114 patients (19.6%) were intubated. Comparing these subgroups, the intervention was associated with longer time on scene (25.3 min vs. 41.6 min; p < 0.001), higher rate of coagulopathy (31.8% vs. 17.2%), an increased mortality (8.2% vs. 11.5%) and higher standard mortality ratio (1.17 vs. 1.35). If another intubation criterion was present in addition to shock, intubation was performed more frequently. CONCLUSION Decision making for pre-hospital intubation in trauma patients is challenging in front of a variety of factors. Despite the presence of a guideline recommendation, ETI is not always executed. Patients presenting with shock as remaining indication and subsequent intubation showed a decreased outcome. Thus, isolated shock does not appear to be an appropriate indication for pre-hospital ETI, but clearly remains an important surrogate of trauma severity and the need for trauma team activation.
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Affiliation(s)
- Timo Stausberg
- Department of Trauma and Orthopedic Surgery, Cologne-Merheim Medical Centre (CMMC), University of Witten/Herdecke, Ostmerheimerstr.200, 51109, Cologne, Germany.
| | - Tobias Ahnert
- Department of Trauma and Orthopedic Surgery, Cologne-Merheim Medical Centre (CMMC), University of Witten/Herdecke, Ostmerheimerstr.200, 51109, Cologne, Germany
| | - Ben Thouet
- Department of Trauma and Orthopedic Surgery, Cologne-Merheim Medical Centre (CMMC), University of Witten/Herdecke, Ostmerheimerstr.200, 51109, Cologne, Germany
| | - Rolf Lefering
- Institute for Research in Operative Medicine (IFOM), University of Witten/Herdecke, Cologne, Germany
| | - Andreas Böhmer
- Department of Anaesthesiology and Intensive Care Medicine, Cologne-Merheim Medical Centre (CMMC), University of Witten/Herdecke, Cologne, Germany
| | - Thomas Brockamp
- Department of Trauma and Orthopedic Surgery, Cologne-Merheim Medical Centre (CMMC), University of Witten/Herdecke, Ostmerheimerstr.200, 51109, Cologne, Germany
| | - Arasch Wafaisade
- Department of Trauma and Orthopedic Surgery, Cologne-Merheim Medical Centre (CMMC), University of Witten/Herdecke, Ostmerheimerstr.200, 51109, Cologne, Germany
| | - Matthias Fröhlich
- Department of Trauma and Orthopedic Surgery, Cologne-Merheim Medical Centre (CMMC), University of Witten/Herdecke, Ostmerheimerstr.200, 51109, Cologne, Germany
- Institute for Research in Operative Medicine (IFOM), University of Witten/Herdecke, Cologne, Germany
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12
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Levin D, Zur M, Shinar E, Moshe T, Tsur AM, Nadler R, Yazer MH, Epstein D, Avital G, Gelikas S, Glassberg E, Benov A, Chen J. Low-Titer Group O Whole-Blood Resuscitation in the Prehospital Setting in Israel: Review of the First 2.5 Years' Experience. Transfus Med Hemother 2022; 48:342-349. [PMID: 35082565 DOI: 10.1159/000519623] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 09/08/2021] [Indexed: 12/20/2022] Open
Abstract
Introduction The Israeli Defense Forces Medical Corps (IDF-MC) implemented the use of low-titer group O whole blood (LTOWB) as the first-choice resuscitation fluid in the IDF airborne Combat Search and Rescue Unit (IDF-CSAR) for aerial evacuation of both military and civilian casualties in June 2018 for injured patients with hemorrhagic shock and at least one of the following: systolic blood pressure <90 mm Hg, heart rate >130 beats/min, deterioration of consciousness without head injury or hemoglobin concentration ≤7 g/dL. Method All casualties treated with LTOWB by IDF-CSAR providers from June 2018 to January 2021 were included. Demographic and prehospital treatment data were collected in order to check compliance and adherence to the IDF-MC guidelines. This is a follow-up retrospective report. Results Overall, 1,608 LTOWB units were supplied to the IDF-CSAR during the study period. Of these, 33 were transfused to 27 casualties; 17 (69%) with blunt injury, 8 (29.6%) with penetrating injuries, and 1 (3.7%) with gastrointestinal bleeding without trauma. The leading cause of injury was motor vehicle accidents. A total of 23 casualties received 1 unit of LTOWB, 3 received 2 units and 1 patient received 4 units. Two casualties were children. The median heart rate was 120 beats/min, 8 (29.6%) casualties had heart rates >130 beats/min. Median systolic blood pressure was 95 mm Hg, 7 (26%) casualties had blood pressure <90 mm Hg. The median Glasgow Coma Score was 14. No adverse reactions were documented following the administration of LTOWB. 77.8% of patients received LTOWB in adherence to the guidelines. Conclusion Appropriate administration of LTOWB has improved over time in IDF-CSAR. Using LTOWB is feasible and simpler than administering packed red blood cells and plasma concurrently. Further efforts are needed to introduce LTOWB in other prehospital and in-hospital scenarios, with an increase in the maximum antibody titer threshold, to meet the expected increase in demand.
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Affiliation(s)
- Dan Levin
- Trauma and Combat Medicine Branch, Israel Defense Forces Medical Corps, Tel Hashomer, Ramat Gan, Israel
| | - Maoz Zur
- Military Medical Academy, Medical Corps, Israel Defense Forces, Shefayim, Israel
| | - Eilat Shinar
- Magen David National Blood Services, Ramat Gan, Israel.,Faculty of Health Sciences, Ben Gurion University of the Negev, Be'er Scheva, Israel
| | - Tzadok Moshe
- Magen David National Blood Services, Ramat Gan, Israel.,Faculty of Health Sciences, Ben Gurion University of the Negev, Be'er Scheva, Israel
| | - Avishai M Tsur
- Trauma and Combat Medicine Branch, Israel Defense Forces Medical Corps, Tel Hashomer, Ramat Gan, Israel.,Department of Medicine B, Sheba Medical Center, Tel Hashomer, affiliated with Sackler Faculty of Medicine, Tel Aviv University, Ramat Gan, Israel
| | - Roy Nadler
- Trauma and Combat Medicine Branch, Israel Defense Forces Medical Corps, Tel Hashomer, Ramat Gan, Israel.,Department of General Surgery and Transplantation - Surgery B, Chaim Sheba Medical Center, Tel Hashomer, affiliated with the Sackler School of Medicine, Ramat Gan, Israel
| | - Mark H Yazer
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Pathology, Tel Aviv University, Tel Aviv, Israel
| | - Danny Epstein
- Trauma and Combat Medicine Branch, Israel Defense Forces Medical Corps, Tel Hashomer, Ramat Gan, Israel.,Critical Care Division, Rambam Health Care Campus, Haifa, Israel
| | - Guy Avital
- Trauma and Combat Medicine Branch, Israel Defense Forces Medical Corps, Tel Hashomer, Ramat Gan, Israel.,Division of Anesthesia, Intensive Care and Pain Management, Tel Aviv Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Shaul Gelikas
- Trauma and Combat Medicine Branch, Israel Defense Forces Medical Corps, Tel Hashomer, Ramat Gan, Israel
| | - Elon Glassberg
- Trauma and Combat Medicine Branch, Israel Defense Forces Medical Corps, Tel Hashomer, Ramat Gan, Israel.,The Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel.,The Uniformed Services, University of the Health Sciences, Bethesda, Maryland, USA
| | - Avi Benov
- Trauma and Combat Medicine Branch, Israel Defense Forces Medical Corps, Tel Hashomer, Ramat Gan, Israel.,The Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
| | - Jacob Chen
- Trauma and Combat Medicine Branch, Israel Defense Forces Medical Corps, Tel Hashomer, Ramat Gan, Israel.,Meir Medical Center, affiliated with Sackler School of Medicine, Tel Aviv University, Kfar Saba, Israel
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13
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High Success Rate of Prehospital and En Route Cricothyroidotomy Performed in the Israel Defense Forces: 20 Years of Experience. Prehosp Disaster Med 2021; 36:713-718. [PMID: 34743777 DOI: 10.1017/s1049023x21001199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
INTRODUCTION Securing the airway is a crucial stage of trauma care. Cricothyroidotomy (CRIC) is often addressed as a salvage procedure in complicated cases or following a failed endotracheal intubation (ETI). Nevertheless, it is a very important skill in prehospital settings, such as on the battlefield. HYPOTHESIS/PROBLEM This study aimed to review the Israel Defense Forces (IDF) experience with CRIC over the past two decades. METHODS The IDF Trauma Registry (IDF-TR) holds data on all trauma casualties (civilian and military) cared for by military medical teams since 1997. Data of all casualties treated by IDF from 1998 through 2018 were extracted and analyzed to identify all patients who underwent CRIC procedures.Variables describing the incident scenario, patient's characteristics, injury pattern, treatment, and outcome were extracted. The success rate of the procedure was described, and selected variables were further analyzed and compared using the Fisher's-exact test to identify their effect on the success and failure rates. Odds Ratio (OR) was further calculated for the effect of different body part involvement on success and for the mortality after failed ETI. RESULTS One hundred fifty-three casualties on which a CRIC attempt was made were identified from the IDF-TR records. The overall success rate of CRIC was reported at 88%. In patients who underwent one or two attempts, the success rate was 86%. No difference was found across providers (physician versus paramedic). The CRIC success rates for casualties with and without head trauma were 80% and 92%, respectively (P = .06). Overall mortality was 33%. CONCLUSIONS This study shows that CRIC is of merit in airway management as it has shown to have consistently high success rates throughout different levels of training, injuries, and previous attempts with ETI. Care providers should be encouraged to retain and develop this skill as part of their tool box.
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14
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Avital G, Gelikas S, Radomislensky I, Tsur AM, Sorkin A, Shinar E, Bodas M, Yazer MH, Cap AP, Chen J, Glassberg E, Benov A. A prehospital scoring system for predicting the need for emergent blood product transfusion. Transfusion 2021; 61 Suppl 1:S195-S205. [PMID: 34269466 DOI: 10.1111/trf.16529] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 03/11/2021] [Accepted: 03/12/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Several tools have been proven to predict the need for massive transfusion in trauma casualties, yet tools that are easily applicable in the prehospital setting for predicting the need for any blood product transfusion in the emergency department (ED) are lacking. METHODS A retrospective analysis of the cross-referenced Israeli Defense Forces Trauma Registry and the Israeli National Trauma Registry databases was performed to identify predictors for any blood product transfusion in the ED. A scoring system was developed after internally validating the prediction model. Division to risk groups was performed. RESULTS Seven variables (systolic blood pressure, heart rate, arterial oxygen saturation, trunk involvement, mechanism of injury, chest decompression, and tourniquet application) were included in the scoring system, ranging from 0 to 11.5. Risk groups for ED transfusion included very low (0.8%), low (3.2%), intermediate (8.5%), and high (31.2%) risk. CONCLUSION A scoring system for predicting the need for any blood product transfusion in the ED was developed, based on information readily available in the early stages of prehospital resuscitation, allowing the receiving medical facility to prepare for that need.
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Affiliation(s)
- Guy Avital
- The Trauma and Combat Medicine Branch, Surgeon General's Headquarters, Israel Defense Forces, Ramat Gan, Israel.,Division of Anesthesia, Intensive Care, and Pain Management, Tel-Aviv Medical Center, Tel-Aviv University, Tel-Aviv, Israel
| | - Shaul Gelikas
- The Trauma and Combat Medicine Branch, Surgeon General's Headquarters, Israel Defense Forces, Ramat Gan, Israel
| | - Irina Radomislensky
- The National Center for Trauma and Emergency Medicine Research, The Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center, Tel-HaShomer, Israel
| | - Avishai M Tsur
- The Trauma and Combat Medicine Branch, Surgeon General's Headquarters, Israel Defense Forces, Ramat Gan, Israel.,Department of Medicine 'B'. Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer; affiliated with Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Alex Sorkin
- The Trauma and Combat Medicine Branch, Surgeon General's Headquarters, Israel Defense Forces, Ramat Gan, Israel.,Department of Plastic and Reconstructive Surgery, Shamir Medical Centre, Zrifin, Israel
| | - Eilat Shinar
- National Blood Services, Magen David Adom, Ramat Gan, Israel
| | - Moran Bodas
- The National Center for Trauma and Emergency Medicine Research, The Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center, Tel-HaShomer, Israel.,Department of Emergency Management and Disaster Medicine, Schoole of Public Health, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv-Yafo, Israel
| | - Mark H Yazer
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Pathology, Tel Aviv University, Tel Aviv, Israel
| | - Andrew P Cap
- Division of Transfusion Medicine, Department of Laboratory Medicine and Pathology, US Army Institute of Surgical Research and Uniformed Services University, JBSA-FT Sam Houston, San Antonio, Texas, USA
| | - Jacob Chen
- Meir Medical Center, Kfar Saba, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Elon Glassberg
- The Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel.,Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA.,Surgeon General's Headquarters, Israel Defense Forces, Ramat Gan, Israel
| | - Avi Benov
- The Trauma and Combat Medicine Branch, Surgeon General's Headquarters, Israel Defense Forces, Ramat Gan, Israel.,The Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
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