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Storer AP, Edwards TH, Rutter CR, Young GE, Mullaney SB. Causes of mortality in military working dog from traumatic injuries. Front Vet Sci 2024; 11:1360233. [PMID: 39040817 PMCID: PMC11260784 DOI: 10.3389/fvets.2024.1360233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Accepted: 06/18/2024] [Indexed: 07/24/2024] Open
Abstract
Introduction This study aimed to identify the pathophysiologic causes of death following traumatic injuries in military working dogs (MWDs) and determine the risk factors associated with mortality in MWD following traumatic injuries. The results of this study will allow for better targeting of interventions to ameliorate these pathophysiologic causes of death and inform research priorities directed at the pathophysiology that leads to the death of MWDs. Methods The final dataset for this study was compiled by using two previously established datasets. Based on review of available data and supplemental records (when available), MWDs in which a definitive cause of death could be determined were included in the study population. These MWDs were assigned a cause of death based on categories previously identified in studies evaluating service member casualties. A group of MWDs who survived their traumatic injury and had similar mechanisms of injury and types of injury to the deceased MWDs were included to allow for comparison and establishment of risk factors associated with MWD death. Variables collected included breed, age, sex, mechanism of injury, survival/non-survival, type of trauma, mechanism of injury, pathophysiology that led to death and pre-hospital care provided. Statistical analysis included Fishers exact test for categorical variables and univariable and multivariable logistic regression to identify factors associated with the MWD death. Results A total of 84 MWDs (33 non-survivors and 51 survivors) were included in this study. Of the 33 MWDs that died, 27 (81.8%) were noted to be dead on arrival. The pathophysiologic causes of death were found to be hemorrhage (45.5% [n = 15]), head trauma (21.2% [n = 7]), catastrophic tissue destruction (15.2% [n = 5]), pneumothorax (9.1% [n = 3]) and one (3% [n = 1]) of each of the following: septic shock, asphyxiation and burns. Military working dogs that did not receive non-DVM care were 3.55 times more likely to die than those that did receive non-DVM care (95% CI 1.03-12.27). The majority of MWDs died of their injuries before reaching veterinary care. Discussion To increase the survival of MWDs on the battlefield, further research should focus on developing new interventions and techniques to mitigate the effects of the pathophysiology noted to cause MWD death. Furthermore, given that care by a non-DVM was found to be associated with survival, the implementation of pre-hospital care and early resuscitation techniques should be a continued priority for those treating MWDs at both the point of injury and in the prehospital setting.
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Affiliation(s)
- Amanda P. Storer
- School of Veterinary Medicine and Biomedical Sciences - Small Animal Clinical Sciences, Texas A&M University, College Station, TX, United States
| | - Thomas H. Edwards
- School of Veterinary Medicine and Biomedical Sciences - Small Animal Clinical Sciences, Texas A&M University, College Station, TX, United States
- US Army Institute of Surgical Research, Joint Base, Fort Sam Houston, TX, United States
| | - Christine R. Rutter
- School of Veterinary Medicine and Biomedical Sciences - Small Animal Clinical Sciences, Texas A&M University, College Station, TX, United States
| | - Grace E. Young
- United States Military Academy, Department of Chemistry and Life Science, West Point, NY, United States
| | - Sara B. Mullaney
- United States Military Academy, Department of Chemistry and Life Science, West Point, NY, United States
- Medical Center of Excellence, Division of Veterinary Science, Food Protection Branch, Joint Base San Antonio, Fort Sam Houston, TX, United States
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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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Li Y, Chu C, Chen C, Sun B, Wu J, Wang S, Ding W, Sun D. Quaternized chitosan/oxidized bacterial cellulose cryogels with shape recovery for noncompressible hemorrhage and wound healing. Carbohydr Polym 2024; 327:121679. [PMID: 38171689 DOI: 10.1016/j.carbpol.2023.121679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 12/04/2023] [Accepted: 12/06/2023] [Indexed: 01/05/2024]
Abstract
Management of noncompressible torso hemorrhage is an urgent clinical requirement, desiring biomaterials with rapid hemostasis, anti-infection and excellent resilient properties. In this research, we have prepared a highly resilient cryogel with both hemostatic and antibacterial effects by chemical crosslinking and electrostatic interaction. The network structure crosslinked by quaternized chitosan and genipin was interspersed with oxidized bacterial cellulose after lyophilization. The as-prepared cryogel can quickly return to the original volume when soaking in water or blood. The appropriately sized pores in the cryogel help to absorb blood cells and further activate coagulation, while the quaternary ammonium salt groups on quaternized chitosan inhibit bacterial infections. Both cell and animal experiments showed that the cryogel was hypotoxic and could promote the regeneration of wound tissue. This research provides a new pathway for the preparation of double crosslinking cryogels and offers effective and safe biomaterials for the emergent bleeding management of incompressible wounds.
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Affiliation(s)
- Yongsheng Li
- Institute of Chemicobiology and Functional Materials, School of Chemistry and Chemical Engineering, Nanjing University of Science and Technology, 200 Xiao Ling Wei, Nanjing, Jiangsu Province, China
| | - Chengnan Chu
- Jinling Hospital, Medical School of Nanjing University, 305 East Zhongshan Road, Nanjing, Jiangsu Province, China
| | - Chuntao Chen
- Institute of Chemicobiology and Functional Materials, School of Chemistry and Chemical Engineering, Nanjing University of Science and Technology, 200 Xiao Ling Wei, Nanjing, Jiangsu Province, China.
| | - Bianjing Sun
- Institute of Chemicobiology and Functional Materials, School of Chemistry and Chemical Engineering, Nanjing University of Science and Technology, 200 Xiao Ling Wei, Nanjing, Jiangsu Province, China
| | - Jingjing Wu
- Department of Plastic and Aesthetic (Burn) Surgery, The Second Xiangya Hospital, Central South University, 139 Renmin Middle Road, Changsha, Hunan Province, China
| | - Shujun Wang
- Jinling Hospital, Medical School of Nanjing University, 305 East Zhongshan Road, Nanjing, Jiangsu Province, China.
| | - Weiwei Ding
- Jinling Hospital, Medical School of Nanjing University, 305 East Zhongshan Road, Nanjing, Jiangsu Province, China
| | - Dongping Sun
- Institute of Chemicobiology and Functional Materials, School of Chemistry and Chemical Engineering, Nanjing University of Science and Technology, 200 Xiao Ling Wei, Nanjing, Jiangsu Province, China.
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Hall A, Olsen C, Dribben W, Glaser J, Hanson M. Aeromedical Evacuation, the Expeditionary Medicine Learning Curve, and the Peacetime Effect. Mil Med 2024; 189:e843-e847. [PMID: 37715683 DOI: 10.1093/milmed/usad353] [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: 06/02/2023] [Revised: 08/02/2023] [Accepted: 08/24/2023] [Indexed: 09/18/2023] Open
Abstract
INTRODUCTION Organizational proficiency increases with experience, which is known as a learning curve. A theoretical peacetime effect occurs when knowledge and skills degrade during peacetime. In this study, the intertheater evacuation system was examined for evidence of a military learning curve and peacetime effect. MATERIALS AND METHODS Data on medical evacuations from U.S. Central Command occurring between January 1, 2003, and December 31, 2022, were acquired from the TRANSCOM Regulating and Command & Control Evacuation System. Priority mission evacuation time corresponding to peak periods of activity in Iraq and Afghanistan and minimal activity in Afghanistan was analyzed. Any reduction or increase in the delivery time of casualties would be considered a change in proficiency. RESULTS There was a marginal monthly decline of 0.019 days (27.4 min) to perform a priority evacuation from Iraq (95% confidence interval [CI], 0.009 to 0.028 days, P < .001) and a decline of 0.010 days (14.4 min) from Afghanistan (95% CI, 0.003 to 0.016 days, P = .004) over 40 months from peak monthly average times. There was a monthly marginal increase in priority evacuation average time from Afghanistan of 0.008 days (11.5 min) (95% CI, 0.005 to 0.011, P < .001) between January 2013 and December 2020. The number of monthly evacuations estimated to maintain or improve monthly average evacuation time is approximately 50. CONCLUSIONS An intertheater aeromedical evacuation system increased in proficiency during periods of conflict and declined during relative peacetime. There is evidence of a peacetime effect on intertheater aeromedical evacuation.
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Affiliation(s)
- Andrew Hall
- USCENTCOM Office of the Command Surgeon, MacDill AFB, FL 33621, USA
| | - Cara Olsen
- Department of Preventive Medicine & Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | | | - Jacob Glaser
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- Providence Regional Medical Center, Everett, WA 98201, USA
| | - Matthew Hanson
- AFSOC Office of the Command Surgeon, Hurlburt Field, FL 32544, USA
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Wang X, Liu C, Liu C, Shi Z, Huang F. Development of alginate macroporous hydrogels using sacrificial CaCO 3 particles for enhanced hemostasis. Int J Biol Macromol 2024; 259:129141. [PMID: 38176504 DOI: 10.1016/j.ijbiomac.2023.129141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 12/16/2023] [Accepted: 12/28/2023] [Indexed: 01/06/2024]
Abstract
Polymeric hydrogels have increasingly garnered attention in the field of hemostasis. However, there remains a lack of targeted development and evaluation of non-dense polymeric hydrogels with physically incorporated pores to enhance hemostasis. Here, we present a facile route to macroporous alginate hydrogels using acid-induced CaCO3 dissolution to provide Ca2+ for alginate gelation and CO2 bubbles for subsequent macropore formation. The as-prepared pore structure in the hydrogels and its formation mechanisms were characterized through microscopic imaging and nitrogen adsorption/desorption tests. Functional analyses revealed that the macroporous hydrogels exhibited improved rheology, blood absorption, coagulation factor delivery, and platelet aggregation. Ultimately, the introduction of pores significantly enhanced the hemostatic effectiveness of alginate hydrogels in vivo, as demonstrated in rat tail amputation and liver injury models, leading to a reduction in blood loss of up to 77 % or a decrease in bleeding time of up to 88 %. Notably, hydrogels with higher porosity achieved with a CaCO3 to alginate ratio of 40 % outperformed those with lower porosity in the aforementioned properties. Furthermore, these improvements were found to be biocompatible and elicited minimal inflammation. Our findings underscore the potential of a simple porous hydrogel design to enhance hemostasis efficacy by physically incorporating macropores.
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Affiliation(s)
- Xiaoqiang Wang
- State Key Laboratory of Heavy Oil Processing & College of Chemistry and Chemical Engineering, China University of Petroleum (East China), 66 West Changjiang Road, Qingdao, Shandong 266580, China.
| | - Chang Liu
- State Key Laboratory of Heavy Oil Processing & College of Chemistry and Chemical Engineering, China University of Petroleum (East China), 66 West Changjiang Road, Qingdao, Shandong 266580, China
| | - Chengkun Liu
- State Key Laboratory of Heavy Oil Processing & College of Chemistry and Chemical Engineering, China University of Petroleum (East China), 66 West Changjiang Road, Qingdao, Shandong 266580, China
| | - Zhuang Shi
- State Key Laboratory of Heavy Oil Processing & College of Chemistry and Chemical Engineering, China University of Petroleum (East China), 66 West Changjiang Road, Qingdao, Shandong 266580, China
| | - Fang Huang
- State Key Laboratory of Heavy Oil Processing & College of Chemistry and Chemical Engineering, China University of Petroleum (East China), 66 West Changjiang Road, Qingdao, Shandong 266580, China.
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Nichols R, Horstman J, Nitz I. Army Health Systems Doctrine and Training in Relation to Antibiotics: A Systematic Review. Mil Med 2023; 188:1649-1655. [PMID: 35830415 DOI: 10.1093/milmed/usac210] [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: 04/03/2022] [Revised: 06/05/2022] [Accepted: 06/28/2022] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION In the early 2000s when Tactical Combat Casualty Care was developed, the adoption of prophylactic antibiotic use was not mainstream. Back then, guidelines were derivative of civilian trauma guidelines which did not include widespread prophylactic antibiotic use. Current protocols across the DoD have embraced the use of prophylactic antibiotic use before reaching a military treatment facility as evidenced by Tactical Combat Casualty Care guidelines and several Joint Trauma System Clinical Practice Guidelines.This review intends to find trends associated with the use of antibiotics in the military setting and answer the research question: Do current Army doctrine and practices address these issues and how can they be reworked to address them if needed? MATERIALS AND METHODS Methods were developed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The primary author utilized four databases to locate articles: MEDLINE (EBSCOhost), Cochrane Central Register of Controlled Trials (Wiley), CINAHL Complete (EBSCOhost), and Embase (Elsevier). The following keywords were utilized: "Combat casualty," "antibiotic," "trauma," and "prehospital." This ultimately led to 19 articles included in the review. RESULTS Nineteen articles were included in the final review and placed into one of the following categories: Overall antibiotic use, guideline adherence and practices, strains, and infection risk factors. Overall, the Army Health System has shown that there is room for improvement in terms of antibiotic stewardship and training regarding antibiotics. CONCLUSION Infectious diseases pose a substantial risk to combat wounded. The Army Health System must anticipate encountering challenges with delivering care to patients suffering infections in addition to serious combat injuries. A systematic review of the literature highlights several areas for improvement, primarily areas involving pathogen surveillance, treatment of pediatric populations, and the Army's operational domain of training.
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Affiliation(s)
- Ryoma Nichols
- Elson S. Floyd College of Medicine, Washington State University, Spokane, WA 99202, USA
| | - Jordan Horstman
- Kansas City University College of Osteopathic Medicine, Kansas City University, Kansas City, MO 64106, USA
| | - Iver Nitz
- Washington Army National Guard, Medical Detachment, Tacoma, WA 98433, USA
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Thoolen SJJ, Kuypers MI. External Hemorrhage Control Techniques for Human Space Exploration: Lessons from the Battlefield. Wilderness Environ Med 2023; 34:231-242. [PMID: 36906432 DOI: 10.1016/j.wem.2023.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 01/11/2023] [Accepted: 01/12/2023] [Indexed: 03/11/2023]
Abstract
The past few decades of military experience have brought major advances in the prehospital care of patients with trauma. A focus on early hemorrhage control with aggressive use of tourniquets and hemostatic gauze is now generally accepted. This narrative literature review aims to discuss external hemorrhage control and the applicability of military concepts in space exploration. In space, environmental hazards, spacesuit removal, and limited crew training could cause significant time delays in providing initial trauma care. Cardiovascular and hematological adaptations to the microgravity environment are likely to reduce the ability to compensate, and resources for advanced resuscitation are limited. Any unscheduled emergency evacuation requires a patient to don a spacesuit, involves exposure to high G-forces upon re-entry into Earth's atmosphere, and costs a significant amount of time until a definitive care facility is reached. As a result, early hemorrhage control in space is critical. Safe implementation of hemostatic dressings and tourniquets seems feasible, but adequate training will be essential, and tourniquets are preferably converted to other methods of hemostasis in case of a prolonged medical evacuation. Other emerging approaches such as early tranexamic acid administration and more advanced techniques have shown promising results as well. For future exploration missions to the Moon and Mars, when evacuation is not possible, we look into what training or assistance tools would be helpful in managing the bleed at the point of injury.
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Affiliation(s)
- Stijn J J Thoolen
- Neural Systems Group, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA; Centre for Human and Applied Physiological Sciences, King's College London, United Kingdom.
| | - Maybritt I Kuypers
- European Astronaut Centre, European Space Agency, Cologne, Germany; Department of Emergency Medicine, Amsterdam UMC, University of Amsterdam, the Netherlands
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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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Lv M, Jia Y, Zong Z, Jiang R, Du W, Zhang L, Ye Z, Zhong X. Method for Teaching Life-Saving Combat First-Aid Skills With live-actor Patients Using a Wearable Training Apparatus. Mil Med 2022; 187:757-763. [PMID: 34273161 DOI: 10.1093/milmed/usab286] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 11/23/2020] [Accepted: 07/14/2021] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Training combat personnel in combat first-aid skills has faced many challenges over time, such as the need to combine tactics with medicine and to overcome combat personnel's lack of medical background knowledge. Therefore, many simulation methods are currently being developed, each of which has its advantages and disadvantages. In this study, a combined simulation method involving live-actor patients using a wearable training apparatus was developed, and the effects of this method were observed. MATERIALS AND METHODS Focusing on the major causes of preventable deaths among victims killed in action, wearable training apparatuses simulating massive hemorrhage, airway obstruction, and tension pneumothorax were designed and produced. Methods of simulating these three injury types using live-actor patients with these training apparatuses were developed, and medical teachers evaluated the simulation effects. The live-actor patients were incorporated into a tactical scenario to train and test nonmedical and medical students in year 3, respectively. High-fidelity simulator-based training and traditional training without simulation served as the control. A post-training survey using a 7-point Likert scale evaluated the trainees' feelings toward these training approaches. RESULTS Three types of training apparatuses were developed to simulate three life-threatening injuries, and the simulation effects of the live-actor patients using these apparatuses were highly recognized by medical teachers. Both live-actor patients and high-fidelity simulator-based training improved performance significantly more than traditional training. However, the improvement due to training with live-actor patients was greater than that due to high-fidelity simulator-based training for nonmedical students, whereas there was no difference between these two simulation methods for medical students. A post-training survey revealed that all the trainees were confident in practicing first-aid skills after training, and they all agreed that live-actor patients could combine tactical situations with first aid better than high-fidelity simulators. The nonmedical students strongly agreed that live-actor patients were more helpful in the training of injury evaluation than high-fidelity simulators. CONCLUSIONS The method using wearable training apparatus-based live-actor patients was satisfying and effective for teaching life-saving combat first-aid skills, especially for nonmedical students.
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Affiliation(s)
- Minrui Lv
- State Key Laboratory of Trauma, Burn and Combined Injury, Department for Combat Casualty Care Training, Training Base for Army Health Care, Army Medical University, Chongqing 400038, China
| | - Yijun Jia
- State Key Laboratory of Trauma, Burn and Combined Injury, Department for Combat Casualty Care Training, Training Base for Army Health Care, Army Medical University, Chongqing 400038, China
| | - Zhaowen Zong
- State Key Laboratory of Trauma, Burn and Combined Injury, Department for Combat Casualty Care Training, Training Base for Army Health Care, Army Medical University, Chongqing 400038, China
| | - Renqing Jiang
- State Key Laboratory of Trauma, Burn and Combined Injury, Department for Combat Casualty Care Training, Training Base for Army Health Care, Army Medical University, Chongqing 400038, China
| | - Wenqiong Du
- State Key Laboratory of Trauma, Burn and Combined Injury, Department for Combat Casualty Care Training, Training Base for Army Health Care, Army Medical University, Chongqing 400038, China
| | - Lin Zhang
- State Key Laboratory of Trauma, Burn and Combined Injury, Department for Combat Casualty Care Training, Training Base for Army Health Care, Army Medical University, Chongqing 400038, China
| | - Zhao Ye
- State Key Laboratory of Trauma, Burn and Combined Injury, Department for Combat Casualty Care Training, Training Base for Army Health Care, Army Medical University, Chongqing 400038, China
| | - Xin Zhong
- State Key Laboratory of Trauma, Burn and Combined Injury, Department for Combat Casualty Care Training, Training Base for Army Health Care, Army Medical University, Chongqing 400038, China
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Gurney JM, Staudt AM, Del Junco DJ, Shackelford SA, Mann-Salinas EA, Cap AP, Spinella PC, Martin MJ. Whole blood at the tip of the spear: A retrospective cohort analysis of warm fresh whole blood resuscitation versus component therapy in severely injured combat casualties. Surgery 2022; 171:518-525. [PMID: 34253322 DOI: 10.1016/j.surg.2021.05.051] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 05/26/2021] [Accepted: 05/31/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Death from uncontrolled hemorrhage occurs rapidly, particularly among combat casualties. The US military has used warm fresh whole blood during combat operations owing to clinical and operational exigencies, but published outcomes data are limited. We compared early mortality between casualties who received warm fresh whole blood versus no warm fresh whole blood. METHODS Casualties injured in Afghanistan from 2008 to 2014 who received ≥2 red blood cell containing units were reviewed using records from the Joint Trauma System Role 2 Database. The primary outcome was 6-hour mortality. Patients who received red blood cells solely from component therapy were categorized as the non-warm fresh whole blood group. Non- warm fresh whole blood patients were frequency-matched to warm fresh whole blood patients on identical strata by injury type, patient affiliation, tourniquet use, prehospital transfusion, and average hourly unit red blood cell transfusion rates, creating clinically unique strata. Multilevel mixed effects logistic regression adjusted for the matching, immortal time bias, and other covariates. RESULTS The 1,105 study patients (221 warm fresh whole blood, 884 non-warm fresh whole blood) were classified into 29 unique clinical strata. The adjusted odds ratio of 6-hour mortality was 0.27 (95% confidence interval 0.13-0.58) for the warm fresh whole blood versus non-warm fresh whole blood group. The reduction in mortality increased in magnitude (odds ratio = 0.15, P = .024) among the subgroup of 422 patients with complete data allowing adjustment for seven additional covariates. There was a dose-dependent effect of warm fresh whole blood, with patients receiving higher warm fresh whole blood dose (>33% of red blood cell-containing units) having significantly lower mortality versus the non-warm fresh whole blood group. CONCLUSION Warm fresh whole blood resuscitation was associated with a significant reduction in 6-hour mortality versus non-warm fresh whole blood in combat casualties, with a dose-dependent effect. These findings support warm fresh whole blood use for hemorrhage control as well as expanded study in military and civilian trauma settings.
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Affiliation(s)
- Jennifer M Gurney
- US Army Institute of Surgical Research, San Antonio, TX; Joint Trauma System, San Antonio, TX; Uniformed Services University of the Health Sciences, Bethesda, MD.
| | | | | | - Stacy A Shackelford
- Joint Trauma System, San Antonio, TX; Uniformed Services University of the Health Sciences, Bethesda, MD
| | | | - Andrew P Cap
- US Army Institute of Surgical Research, San Antonio, TX; Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Philip C Spinella
- Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Matthew J Martin
- Uniformed Services University of the Health Sciences, Bethesda, MD; Department of Surgery, Scripps Mercy Hospital, San Diego, CA. https://twitter.com/docmartin22
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11
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Woo M, Mishra P, Lin J, Kar S, Deas N, Linduff C, Niu S, Yang Y, McClendon J, Smith DH, Shelton SL, Gainey CE, Gerard WC, Smith MC, Griffin SF, Gimbel RW, Wang KC. Complete and Resilient Documentation for Operational Medical Environments Leveraging Mobile Hands-free Technology in a Systems Approach: Experimental Study. JMIR Mhealth Uhealth 2021; 9:e32301. [PMID: 34636729 PMCID: PMC8548972 DOI: 10.2196/32301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 09/03/2021] [Accepted: 09/16/2021] [Indexed: 11/30/2022] Open
Abstract
Background Prehospitalization documentation is a challenging task and prone to loss of information, as paramedics operate under disruptive environments requiring their constant attention to the patients. Objective The aim of this study is to develop a mobile platform for hands-free prehospitalization documentation to assist first responders in operational medical environments by aggregating all existing solutions for noise resiliency and domain adaptation. Methods The platform was built to extract meaningful medical information from the real-time audio streaming at the point of injury and transmit complete documentation to a field hospital prior to patient arrival. To this end, the state-of-the-art automatic speech recognition (ASR) solutions with the following modular improvements were thoroughly explored: noise-resilient ASR, multi-style training, customized lexicon, and speech enhancement. The development of the platform was strictly guided by qualitative research and simulation-based evaluation to address the relevant challenges through progressive improvements at every process step of the end-to-end solution. The primary performance metrics included medical word error rate (WER) in machine-transcribed text output and an F1 score calculated by comparing the autogenerated documentation to manual documentation by physicians. Results The total number of 15,139 individual words necessary for completing the documentation were identified from all conversations that occurred during the physician-supervised simulation drills. The baseline model presented a suboptimal performance with a WER of 69.85% and an F1 score of 0.611. The noise-resilient ASR, multi-style training, and customized lexicon improved the overall performance; the finalized platform achieved a medical WER of 33.3% and an F1 score of 0.81 when compared to manual documentation. The speech enhancement degraded performance with medical WER increased from 33.3% to 46.33% and the corresponding F1 score decreased from 0.81 to 0.78. All changes in performance were statistically significant (P<.001). Conclusions This study presented a fully functional mobile platform for hands-free prehospitalization documentation in operational medical environments and lessons learned from its implementation.
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Affiliation(s)
- MinJae Woo
- School of Data Science and Analytics, Kennesaw State University, Kennesaw, GA, United States
| | - Prabodh Mishra
- Department of Electrical and Computing Engineering, Clemson University, Clemson, SC, United States
| | - Ju Lin
- Department of Electrical and Computing Engineering, Clemson University, Clemson, SC, United States
| | - Snigdhaswin Kar
- Department of Electrical and Computing Engineering, Clemson University, Clemson, SC, United States
| | - Nicholas Deas
- School of Computing, Clemson University, Clemson, SC, United States
| | - Caleb Linduff
- Department of Electrical and Computing Engineering, Clemson University, Clemson, SC, United States
| | - Sufeng Niu
- Linkedin Inc, Mountain View, CA, United States
| | | | - Jerome McClendon
- Department of Automotive Engineering, Clemson University, Clemson, SC, United States
| | - D Hudson Smith
- Watt Family Innovation Center, Clemson University, Clemson, SC, United States
| | - Stephen L Shelton
- Department of Emergency Medical Services, Prisma Health Richland Hospital, Columbia, SC, United States
| | - Christopher E Gainey
- Department of Emergency Medical Services, Prisma Health Richland Hospital, Columbia, SC, United States
| | - William C Gerard
- Department of Emergency Medical Services, Prisma Health Richland Hospital, Columbia, SC, United States
| | - Melissa C Smith
- Department of Electrical and Computing Engineering, Clemson University, Clemson, SC, United States
| | - Sarah F Griffin
- Department of Public Health Sciences, Clemson University, Clemson, SC, United States
| | - Ronald W Gimbel
- Department of Public Health Sciences, Clemson University, Clemson, SC, United States
| | - Kuang-Ching Wang
- Department of Public Health Sciences, Clemson University, Clemson, SC, United States
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12
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Shi C, Li S, Wang Z, Shen H. Prehospital aortic blood flow control techniques for non-compressible traumatic hemorrhage. Injury 2021; 52:1657-1663. [PMID: 33750584 DOI: 10.1016/j.injury.2021.02.070] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 02/21/2021] [Accepted: 02/22/2021] [Indexed: 02/02/2023]
Abstract
Non-compressible hemorrhage in the junctional areas and torso could be life-threatening and its prehospital control remains extremely challenging. The aim of this review was to compare commonly used techniques for the control of non-compressible hemorrhage in prehospital settings, and thereby provide evidence for further improvements in emergency care of traumatic injuries. Three techniques were reviewed including external aortic compression (EAC), abdominal aortic junctional tourniquet (AAJT), and resuscitative endovascular balloon occlusion of the aorta (REBOA). In prehospital settings, all three techniques have demonstrated clinical effectiveness for the control of severe hemorrhage. EAC is a cost- and equipment-free, easy-to-teach, and immediately available technique. In contrast, AAJT and REBOA are expensive and require detailed instructions or systematic training. Compared with EAC, AAJT and REBOA have greater potentials in the management of traumatic hemorrhage. AAJT can be used not only in the junctional areas but also in pelvic and bilateral lower limb injuries. However, both AAJT and REBOA should be used for a limited time (less than 1 hour) due to possible consequences of ischemia and reperfusion. Compared with EAC and AAJT, REBOA is invasive, requiring femoral arterial access and intravascular guidance and inflation. Mortality from non-compressible hemorrhage could be reduced through the prehospital application of aortic blood flow control techniques. EAC should be considered as the first-line choice for many non-compressible injuries that cannot be managed with conventional junctional tourniquets. In comparison, AAJT or REBOA is recommended for better control of the aorta blood flow in prehospital settings. Although these three techniques each have advantages, their use in trauma is not widespread. Future studies are warranted to provide more data about their safety and efficacy.
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Affiliation(s)
- Changgui Shi
- Department of Surgery, Changzheng Hospital, Naval Medical University, Shanghai, China; Department of Orthopedics, Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Song Li
- Department of Surgery, Changzheng Hospital, Naval Medical University, Shanghai, China; Department of Orthopedics, Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Zhinong Wang
- Department of Surgery, Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Hongliang Shen
- Department of Surgery, Changzheng Hospital, Naval Medical University, Shanghai, China.
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13
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Remote ischemic preconditioning improves tissue oxygenation in a porcine model of controlled hemorrhage without fluid resuscitation. Sci Rep 2021; 11:10808. [PMID: 34031524 PMCID: PMC8144617 DOI: 10.1038/s41598-021-90470-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Accepted: 05/10/2021] [Indexed: 11/08/2022] Open
Abstract
Remote ischemic preconditioning (RIPC) involves deliberate, brief interruptions of blood flow to increase the tolerance of distant critical organs to ischemia. This study tests the effects of limb RIPC in a porcine model of controlled hemorrhage without replacement therapy simulating an extreme field situation of delayed evacuation to definitive care. Twenty-eight pigs (47 ± 6 kg) were assigned to: (1) control, no procedure (n = 7); (2) HS = hemorrhagic shock (n = 13); and (3) RIPC + HS = remote ischemic preconditioning followed by hemorrhage (n = 8). The animals were observed for 7 h after bleeding without fluid replacement. Survival rate between animals of the RIPC + HS group and those of the HS group were similar (HS, 6 of 13[46%]-vs-RIPC + HS, 4 of 8[50%], p = 0.86 by Chi-square). Animals of the RIPC + HS group had faster recovery of mean arterial pressure and developed higher heart rates without complications. They also had less decrease in pH and bicarbonate, and the increase in lactate began later. Global oxygen delivery was higher, and tissue oxygen extraction ratio lower, in RIPC + HS animals. These improvements after RIPC in hemodynamic and metabolic status provide essential substrates for improved cellular response after hemorrhage and reduction of the likelihood of potentially catastrophic consequences of the accompanying ischemia.
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14
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Sommer A, Mark N, Kohlberg GD, Gerasi R, Avraham LW, Fan-Marko R, Eisenkraft A, Nachman D. Hemopneumothorax detection through the process of artificial evolution - a feasibility study. Mil Med Res 2021; 8:27. [PMID: 33894775 PMCID: PMC8070275 DOI: 10.1186/s40779-021-00319-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Accepted: 04/01/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Tension pneumothorax is one of the leading causes of preventable death on the battlefield. Current prehospital diagnosis relies on a subjective clinical impression complemented by a manual thoracic and respiratory examination. These techniques are not fully applicable in field conditions and on the battlefield, where situational and environmental factors may impair clinical capabilities. We aimed to assemble a device able to sample, analyze, and classify the unique acoustic signatures of pneumothorax and hemothorax. METHODS Acoustic data was obtained with simultaneous use of two sensitive digital stethoscopes from the chest wall of an ex-vivo porcine model. Twelve second samples of acoustic data were obtained from the in-house assembled digital stethoscope system during mechanical ventilation. The thoracic cavity was injected with increasing volumes of 200, 400, 600, 800, and 1000 ml of air or saline to simulate pneumothorax and hemothorax, respectively. The data was analyzed using a multi-objective genetic algorithm that was used to develop an optimal mathematical detector through the process of artificial evolution, a cutting-edge approach in the artificial intelligence discipline. RESULTS The in-house assembled dual digital stethoscope system and developed genetic algorithm achieved an accuracy, sensitivity and specificity ranging from 64 to 100%, 63 to 100%, and 63 to 100%, respectively, in classifying acoustic signal as associated with pneumothorax or hemothorax at fluid injection levels of 400 ml or more, and regardless of background noise. CONCLUSIONS We present a novel, objective device for rapid diagnosis of potentially lethal thoracic injuries. With further optimization, such a device could provide real-time detection and monitoring of pneumothorax and hemothorax in battlefield conditions.
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Affiliation(s)
- Adir Sommer
- The Medical Corps, Israel Defense Forces (IDF), Tel Hashomer, 5262000, Ramat Gan, Israel.
| | - Noy Mark
- The Medical Corps, Israel Defense Forces (IDF), Tel Hashomer, 5262000, Ramat Gan, Israel
| | - Gavriel D Kohlberg
- Department of Otolaryngology - Head and Neck Surgery, University of Washington, Seattle, WA, 98195, USA
| | - Rafi Gerasi
- The Medical Corps, Israel Defense Forces (IDF), Tel Hashomer, 5262000, Ramat Gan, Israel
| | - Linn Wagnert Avraham
- The Institute for Research in Military Medicine, the Faculty of Medicine, the Hebrew University of Jerusalem and the IDF Medical Corps, 9112102, Jerusalem, Israel
| | - Ruth Fan-Marko
- The Hebrew University School of Medicine, 9112102, Jerusalem, Israel
| | - Arik Eisenkraft
- The Institute for Research in Military Medicine, the Faculty of Medicine, the Hebrew University of Jerusalem and the IDF Medical Corps, 9112102, Jerusalem, Israel
| | - Dean Nachman
- The Institute for Research in Military Medicine, the Faculty of Medicine, the Hebrew University of Jerusalem and the IDF Medical Corps, 9112102, Jerusalem, Israel.,The Hebrew University School of Medicine, 9112102, Jerusalem, Israel.,Department of Medicine, Hadassah Medical Center, 9112102, Jerusalem, Israel
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15
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Hatzfeld JJ, Hildebrandt G, Maddry JK, Rodriquez D, Bridges E, Ritter AC, Gardner CL, Bebarta VS, Cap AP. Top 10 Research Priorities for U.S. Military En Route Combat Casualty Care. Mil Med 2021; 186:e359-e365. [PMID: 33399866 DOI: 10.1093/milmed/usaa480] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Revised: 09/12/2020] [Accepted: 01/04/2021] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION Within the Military Health System, the process of transporting patients from an initial point of injury and throughout the entire continuum of care is called "en route care." A Committee on En Route Combat Casualty Care was established in 2016 as part of the DoD Joint Trauma System to create practice guidelines, recommend training standards, and identify research priorities within the military en route care system. MATERIALS AND METHODS Following an analysis of currently funded research, future capabilities, and findings from a comprehensive scoping study, members of a sub-working group for research identified the top research priorities that were needed to better guide evidence-based decisions for practice and policy, as well as the future state of en route care. RESULTS Based on the input from the entire committee, 10 en route care research topics were rank-ordered in the following manner: (1) medical documentation, (2) clinical decision support, (3) patient monitoring, (4) transport physiology, (5) transfer of care, (6) maintaining normothermia, (7) transport timing following damage control resuscitation or surgery, (8) intelligent tasking, (9) commander's risk assessment, and (10) unmanned transport. Specific research questions and technological development needs were further developed by committee members in an effort to guide future research and development initiatives that can directly support operational en route care needs. The research priorities reflect three common themes, which include efforts to enhance or increase care provider capability and capacity; understand the impact of transportation on patient physiology; and increase the ability to coordinate, communicate, and facilitate patient movement. Technology needs for en route care must support interoperability of medical information, equipment, and supplies across the global military health system in addition to adjusting to a dynamic transport environment with the smallest possible weight, space, and power requirements. CONCLUSIONS To ensure an evidence-based approach to future military conflicts and other medical challenges, focused research and technological development to address these 10 en route care research gaps are urgently needed.
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Affiliation(s)
| | - George Hildebrandt
- U.S. Army Medical Evacuation Proponency, Futures and Concepts Center - Army Futures Command, Ft. Rucker, AL 36362, USA
| | - Joseph K Maddry
- 59th Medical Wing/Science & Technology, Joint Base San Antonio-Lackland, TX 78236, USA.,US Army Institute of Surgical Research, JBSA-Fort Sam Houston, TX 78234, USA
| | - Dario Rodriquez
- USAF School of Aerospace Medicine, Wright-Patterson Air Force Base, OH 45433, USA
| | - Elizabeth Bridges
- University of Washington School of Nursing, - Seattle, WA 98195, USA
| | - Anne C Ritter
- Combat Casualty Care Research Program, Ft Detrick, MD 21702, USA
| | - Cubby L Gardner
- Air Force Medical Readiness Agency, Falls Church, VA 22042, USA.,Combat Casualty Care Research Program, Ft Detrick, MD 21702, USA
| | - Vikhyat S Bebarta
- University of Colorado School of Medicine, Aurora, CO 80045, USA.,59th Medical Wing/Science & Technology, Joint Base San Antonio-Lackland, TX 78236, USA
| | - Andrew P Cap
- US Army Institute of Surgical Research, JBSA-Fort Sam Houston, TX 78234, USA
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16
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Schauer SG, Naylor JF, Maddry JK, Kobylarz FC, April MD. Outcomes of Casualties Without Airway Trauma Undergoing Prehospital Airway Interventions: A Department of Defense Trauma Registry Study. Mil Med 2021; 185:e352-e357. [PMID: 31865392 DOI: 10.1093/milmed/usz349] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION Airway obstruction is the second leading cause of preventable death on the battlefield. Most airway obstruction occurs secondary to traumatic disruptions of the airway anatomical structures. However, casualties may require airway interventions for other indications (e.g., depressed mental status). We describe casualties undergoing airway intervention in the prehospital, combat setting without apparent upper airway trauma. MATERIALS AND METHODS We used a series of emergency department procedure codes to identify patients within the Department of Defense Trauma Registry (DODTR) from January 2007 to August 2016. This is a subgroup analysis of those patients with a documented prehospital airway intervention and no apparent airway trauma as defined by abbreviated injury scale of 0 for body regions 1 (head/neck) and 2 (face). RESULTS Our predefined search codes captured 28222 DODTR subjects of whom 409 (1.4%) met criteria for study inclusion. Subjects included members of host nation forces (34%) and civilians (30%). Most subjects sustained injuries in Afghanistan (82%). Explosive (57%) and gunshot wounds (36%) were the most frequent mechanisms of injury. Median injury severity scores were 17. The most common anatomical locations of injuries for included subjects included extremities (53%) and thorax (29%). A majority of subjects underwent intubation (89%); comparatively few casualties underwent placement of a nasopharyngeal airway (2%) or supraglottic airway (2%). The proportion of subjects surviving to hospital discharge was 80% and was highest among subjects undergoing intubation (82%). CONCLUSIONS In this subgroup analysis of casualties without apparent upper airway trauma, survival rates were lower when compared to our previous report. Higher quality data are necessary to better understand the resuscitation needs of this critically ill subset of combat casualties.
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Affiliation(s)
- Steven G Schauer
- U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, TX 78212.,59th Medical Wing, JBSA Lackland, TX 78236.,Brooke Army Medical Center, JBSA Fort Sam Houston, TX 78234
| | - Jason F Naylor
- Madigan Army Medical Center, Joint Base Lewis McChord, WA 98431
| | - Joseph K Maddry
- 59th Medical Wing, JBSA Lackland, TX 78236.,Brooke Army Medical Center, JBSA Fort Sam Houston, TX 78234
| | - Fred C Kobylarz
- Army Medical Department Center and School, JBSA Fort Sam Houston, TX 78234.,Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA 19107
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17
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Edwards TH, Dubick MA, Palmer L, Pusateri AE. Lessons Learned From the Battlefield and Applicability to Veterinary Medicine-Part 1: Hemorrhage Control. Front Vet Sci 2021; 7:571368. [PMID: 33521075 PMCID: PMC7841008 DOI: 10.3389/fvets.2020.571368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 12/14/2020] [Indexed: 11/25/2022] Open
Abstract
In humans, the leading cause of potentially preventable death on the modern battlefield is undoubtedly exsanguination from massive hemorrhage. The US military and allied nations have devoted enormous effort to combat hemorrhagic shock and massive hemorrhage. This has yielded numerous advances designed to stop bleeding and save lives. The development of extremity, junctional and truncal tourniquets applied by first responders have saved countless lives both on the battlefield and in civilian settings. Additional devices such as resuscitative endovascular balloon occlusion of the aorta (REBOA) and intraperitoneal hemostatic foams show great promise to address control the most difficult forms (non-compressible) of hemorrhage. The development of next generation hemostatic dressings has reduced bleeding both in the prehospital setting as well as in the operating room. Furthermore, the research and fielding of antifibrinolytics such as tranexamic acid have shown incredible promise to ameliorate the effects of acute traumatic coagulopathy which has led to significant morbidity and mortality in service members. Advances from lessons learned on the battlefield have numerous potential parallels in veterinary medicine and these lessons are ripe for translation to veterinary medicine.
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Affiliation(s)
- Thomas H Edwards
- US Army Institute of Surgical Research, Joint Base San Antonio, San Antonio, TX, United States
| | - Michael A Dubick
- US Army Institute of Surgical Research, Joint Base San Antonio, San Antonio, TX, United States
| | - Lee Palmer
- Special Forces Group, Alabama Army National Guard, Auburn, AL, United States
| | - Anthony E Pusateri
- US Army Institute of Surgical Research, Joint Base San Antonio, San Antonio, TX, United States
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18
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Khorram-Manesh A, Plegas P, Högstedt Å, Peyravi M, Carlström E. Immediate response to major incidents: defining an immediate responder! Eur J Trauma Emerg Surg 2020; 46:1309-1320. [PMID: 30953109 PMCID: PMC7691304 DOI: 10.1007/s00068-019-01133-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Accepted: 04/01/2019] [Indexed: 12/02/2022]
Abstract
PURPOSE There is a gap in time between the occurrence of a mass casualty incident (MCI) and the arrival of the first responders to the scene, which offers an opportunity for the public (immediate responders) to perform life-saving measures. The purpose of this study was to identify these measures and the public's willingness to conduct them. METHOD An extensive literature review was performed to identify the possible measures that can be undertaken by the public. A group of experts were asked to prioritize and rank the feasibility of performing the measures by the public. Finally, the public was asked whether they were willing to do the chosen measures before and after an appropriate education. RESULTS Twenty different measures were identified and presented in a questionnaire as statements, which were prioritized and ranked by the expert group into four categories: what (1) should be done, (2) is good to know how, (3) is not necessary to know, and (4) should not be done. All statements were converted into understandable statements and were sent to the public. There were some differences and some agreements between the experts and the public regarding what an immediate responder should do. However, the willingness of the public to perform most of the measures was high and increased after being offered an appropriate education. CONCLUSION The use of immediate responders is a life-saving approach in MCIs and in situations when every minute counts and every human resource is an invaluable asset. Multiple steps, such as education, empowerment, and access, should be taken into consideration to enable bystanders to effectively help struggling survivors.
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Affiliation(s)
- Amir Khorram-Manesh
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
| | - Patricia Plegas
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Åsa Högstedt
- Emergency and Disaster Medicine, Faculty of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mahmoudreza Peyravi
- Unit of Prehospital Dispatching Center, Region Västra Götaland, Gothenburg, Sweden
| | - Eric Carlström
- Health and Crisis Management and Policy, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- USN School of Business, University of South-Eastern Norway, Vestfold, Norway
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19
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Johnson SA, Lauby RS, Fisher AD, Naylor JF, April MD, Long B, Schauer SG. An Analysis of Conflicts Across Role 1 Guidelines. Mil Med 2020; 187:e263-e274. [DOI: 10.1093/milmed/usaa460] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 09/21/2020] [Accepted: 11/18/2020] [Indexed: 11/13/2022] Open
Abstract
Abstract
Introduction
Role 1 care is vital to patient survival and includes many echelons of care from point-of-injury first aid to medical attention at battalion aid stations. Many guidelines are written for Role 1 care providers to optimize care for different scenarios. Differences in the guidelines lead to confusion and discrepancies between the types of treatment medical care providers provide. Although the guidelines were written for different areas of care, uniformity between the guidelines is needed and will lead to a reduced mortality rate.
Materials and Methods
It was determined that the Tactical Combat Casualty Care Guidelines, Prolonged Field Care Guidelines, Joint Trauma System Clinical Practice Guidelines, and Standard Medical Operating Guidelines from medical evacuation were the military medical guidelines most relevant to Role 1 care. These Guidelines were compared side by side to determine the differences between them.
Results
Although the guidelines were largely similar, many major differences were found between them. Our online tables contain large inconsistences between guidelines including direct contradictions in conversion of junctional tourniquets and the administration of tranexamic acid.
Conclusions
Role 1 care is vital to patient survival, including care from point of injury to battalion aid stations, but the guidelines available to instruct this care and the guidance on which personnel should provide this care are conflicting. This lack of clarity and consistency may adversely impact treatment outcomes. The reduction or elimination of conflicting information across the various guidelines, augmentation of guidance for pediatric care, more specific guidance for unique levels of care, and clearer delineation of the Role 1 phases of care (as well as which guidelines are most appropriate to each) should be considered as urgent priorities within the military medical community.
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Affiliation(s)
- Sarah A Johnson
- US Army Institute of Surgical Research, JBSA Fort Sam Houston, TX 78234-7767, USA
| | - Ryann S Lauby
- US Army Institute of Surgical Research, JBSA Fort Sam Houston, TX 78234-7767, USA
| | - Andrew D Fisher
- Medical Command, Texas Army National Guard, Austin, TX 78703-1222, USA
- UNM School of Medicine, Department of Surgery, Albuquerque 87106, New Mexico
| | - Jason F Naylor
- Department of Emergency Medicine, Madigan Army Medical Center, Joint Base Lewis-McChord, WA 98431, USA
| | - Michael D April
- 2nd Stryker Brigade Combat Team, 4th infantry division, Fort Carson, CO 80913, USA
| | - Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, JBSA Fort Sam Houston, TX 78234, USA
| | - Steven G Schauer
- US Army Institute of Surgical Research, JBSA Fort Sam Houston, TX 78234-7767, USA
- Department of Emergency Medicine, Brooke Army Medical Center, JBSA Fort Sam Houston, TX 78234, USA
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
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20
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Baker JB, Marc Northern MD, Frament C, Aaron Baker D, Remick K, Seery J, Stephens L, Shackelford S, Gurney J. Austere Resuscitative and Surgical Care in Support of Forward Military Operations-Joint Trauma System Position Paper. Mil Med 2020; 186:12-17. [PMID: 33185671 DOI: 10.1093/milmed/usaa358] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 07/13/2020] [Accepted: 09/14/2020] [Indexed: 11/13/2022] Open
Affiliation(s)
- Jay B Baker
- Medical Corps, U.S. Army, Special Operations Command Europe, APO, AE 09131, Germany
| | - Maj D Marc Northern
- Medical Corps, U.S. Air Force, Air Force 720th Special Operations Surgical Team, University of Alabama at Birmingham, Birmingham, AL 35233, USA
| | - Colin Frament
- Specialist Corps, U.S. Army, Office of the Joint Staff Surgeon, 9999 Joint Staff Pentagon, Washington, DC 20318, USA
| | - D Aaron Baker
- Medical Corps, U.S. Army, 1st Special Forces Command (Airborne), Fort Bragg, NC 28310, USA
| | - Kyle Remick
- Medical Corps, U.S. Army, Professor of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Jason Seery
- Medical Corps, U.S. Army, Army Central Command, SC 29152, USA
| | - Lance Stephens
- Medical Service Corps, U.S. Navy, Special Reconnaissance Team TWO, Virginia Beach, VA 23459, USA
| | - Stacy Shackelford
- Medical Corps, U.S. Air Force, Joint Trauma System, Defense Health Agency Combat Support, San Antonio, TX 78234, USA
| | - Jennifer Gurney
- Medical Corps, U.S. Air Force, Joint Trauma System, Defense Health Agency Combat Support, San Antonio, TX 78234, USA
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Muller KL, Facciolla CA, Monti J, Cronin A. Impact of Succinct Training on Open Cricothyrotomy Performance: A Randomized, Prospective, Observational Study of U.S. Army First Responders. Mil Med 2020; 185:e1779-e1786. [PMID: 32567654 DOI: 10.1093/milmed/usaa035] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 12/30/2019] [Accepted: 02/09/2020] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Primary airway failure has become the second most common cause of potentially survivable battlefield fatality. Cricothyrotomy is taught to all U.S. military providers as a means of securing an airway in extremis. However, retrospective studies show that cricothyrotomy failure rates for U.S. military first responders performing the procedure in combat is 33%. Our hypothesis was that these rates could be improved. MATERIALS AND METHODS We conducted a randomized, prospective, observational study to evaluate the effects of inexpensive, succinct training on open cricothyrotomy performance by studying two unique U.S. Army First Responder participant groups. One participant group consisted of regular U.S. Army Medics (68 Ws). The second group was Special Operations Combat Medics. We evaluated both groups' baseline ability to correctly perform a cricothyrotomy and then randomly assigned individuals within each group to either a training or practice group. RESULTS The training group had a higher proportion of success and performed the cricothyrotomy faster than the practice group with 68 Ws group appearing to benefit most from training: their procedural success rates increased by an average of 23%, and their average time-to-correct-placement decreased by 21 seconds-a 33% improvement over baseline. CONCLUSION With one manikin, a qualified trainer, and $35 worth of expendable supplies, 10 medics could be trained in the procedure in just 2-3 hours. Our study suggests that this simple intervention has the potential to significantly improve U.S. Army First Responders' ability to correctly perform an open cricothyrotomy and drastically decrease the time needed to perform this lifesaving procedure correctly, possibly saving one in four potentially survivable combat casualties suffering from airway compromise.
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Affiliation(s)
- Kurtis L Muller
- Special Warfare Medical Group (Airborne) 1975 Combat Medic Rd, Fort Bragg NC 28310
| | | | - Jonathan Monti
- Madigan Army Medical Center 9040A Jackson Ave, Joint Base Lewis-McChord, WA 98431
| | - Aaron Cronin
- Madigan Army Medical Center 9040A Jackson Ave, Joint Base Lewis-McChord, WA 98431
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Qin H, Liu D, Chen S, Lyv M, Yang L, Bao Q, Zong Z. First-aid Training for Combatants Without Systematic Medical Education Experience on the Battlefield: Establishment and Evaluation of the Curriculum in China. Mil Med 2020; 185:e1822-e1828. [PMID: 32601667 DOI: 10.1093/milmed/usaa152] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
INTRODUCTION For combatants without systematic medical education experience (CSMEE), it is necessary to participate in first-aid on the battlefield, but currently there is no effective training curriculum for CSMEE in Chinese military. MATERIALS AND METHODS A list of first-aid techniques based on expert consensus was formed, and then a curriculum was established according to the list. The effectiveness of the curriculum was further evaluated by comparing the scores among group A (the reserve officers trained by this curriculum), group B (the reserve officers in the military medical college trained by professional medic training system), and group C (the fresh officers trained by the Outline of Military Training and Assessment of Chinese military), through a 5-station assessment in a simulated battlefield environment, which included the following 5 techniques: tourniquet for massive extremities hemorrhage, thyrocricocentesis, thoracentesis, fixation of long bone fractures, and wound dressing with hemostatic bandage. RESULTS The training curriculum entitled "Implementation and Assessment Standards of First-aid Training for Combatants on the Battlefield" was established. The comparison of average scores in the 5-station assessment showed that group A had better scores than group C in tourniquet for massive extremity hemorrhage, thyrocricocentesis, and thoracentesis, with no significant differences compared with group B. Also, no significant difference between groups A and B in overall completion time and overall scores was observed, whereas an excellent candidate rate in overall score of group B was better than that of group A (87.4% vs. 80.9%, χ2 = 4.40, p = 0.036), and group A was better than group C (80.9% vs. 37.5%, χ2 = 62.01, p < 0.001). CONCLUSION The established training curriculum is indeed effective, which improved the CSMEE's first-aid capacity on the battlefield, and is equivalent to the level of medics.
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Affiliation(s)
- Hao Qin
- Department of War Wound Rescue Skills Training, Base of Army Health Service Training, Army Medical University, Chongqing 400038, China.,Unit 77115 of the Chinese People's Liberation Army, Chengdu, Sichuan 611235, China
| | - Daocheng Liu
- Department of Emergency, Xinqiao Hospital, Army Medical University, Chongqing 400037, China
| | - Sixu Chen
- Department of Emergency, Xinqiao Hospital, Army Medical University, Chongqing 400037, China
| | - Mingrui Lyv
- Department of War Wound Rescue Skills Training, Base of Army Health Service Training, Army Medical University, Chongqing 400038, China
| | - Lei Yang
- Department of War Wound Rescue Skills Training, Base of Army Health Service Training, Army Medical University, Chongqing 400038, China
| | - Quanwei Bao
- Department of Emergency, Xinqiao Hospital, Army Medical University, Chongqing 400037, China
| | - Zhaowen Zong
- Department of War Wound Rescue Skills Training, Base of Army Health Service Training, Army Medical University, Chongqing 400038, China.,Department of Emergency, Xinqiao Hospital, Army Medical University, Chongqing 400037, China
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Hoffmann C, Poyat C, Alhanati L, Haus-Cheymol R, de Rudnicki S, Bouix-Picasso J, Donat N. French military deaths in Afghanistan: a retrospective analysis of 450 combat casualties between 2010 and 2012. BMJ Mil Health 2020; 167:140. [PMID: 32817240 DOI: 10.1136/bmjmilitary-2020-001593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 07/16/2020] [Accepted: 07/18/2020] [Indexed: 11/03/2022]
Affiliation(s)
| | - C Poyat
- Burn Centre, Percy Military Teaching Hospital, Clamart, France.,French Military Health Service, Val-de-Grâce Military Academy, Paris, France
| | - L Alhanati
- 3rd Specialized Medical Unit, 1st Chieftaincy of the Health Service-Special Forces, Pau, France
| | - R Haus-Cheymol
- Defence Health Expertise and Strategy Division, French Military Health Service, Arcueil, France
| | - S de Rudnicki
- Anaesthesia and Intensive Care Department, Percy Military Teaching Hospital, Clamart, France
| | - J Bouix-Picasso
- French Military Health Service, Val-de-Grâce Military Academy, Paris, France
| | - N Donat
- Burn Centre, Percy Military Teaching Hospital, Clamart, France
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Wang L, You X, Dai C, Tong T, Wu J. Hemostatic nanotechnologies for external and internal hemorrhage management. Biomater Sci 2020; 8:4396-4412. [PMID: 32658944 DOI: 10.1039/d0bm00781a] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
An uncontrolled hemorrhage can easily lead to death during surgery and military operations. Despite the significant advances in hemostatic research, there is still an urgent and increasing need for safer and more effective hemostatic materials. Recently, nanotechnologies have been receiving increasing interest owing to their unique advantages and have been propelling the developement of hemostatic materials. This review summarizes the fundamentals of hemostasis and emphasizes the recent developments regarding hemorrhage-related hemostatic nanotechnologies. In terms of external accessible hemorrhage management, natural and synthetic polymers and inorganic components that have been used in traditional hemostats provide novel nanoscale solutions. Regarding internal noncompressible hemorrhage management, current research endeavors are dedicated to the development of substitutes for blood components, and nanoformulated hemostatic drugs. This review also briefly discusses the main and persistent problems of hemostatic nanomaterials, including safety concerns and clinical translation challenges. This review is hoped to provide critical insight into hemostatic nanomaterial development.
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Affiliation(s)
- Liying Wang
- Key Laboratory of Sensing Technology and Biomedical Instrument of Guangdong Province, School of Biomedical Engineering, Sun Yat-sen University, Guangzhou, Guangdong 510006, PR China.
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Qin H, Yang L, Liu D, Chen S, Lyu M, Bao Q, Lai X, Liu H, Chen Q, Zong Z. Efficacy of a Temporary Hemostatic Device in a Swine Model of Closed, Lethal Liver Injury. Mil Med 2020; 185:e742-e747. [PMID: 31711174 DOI: 10.1093/milmed/usz372] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 09/08/2019] [Accepted: 09/10/2019] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Solid abdominal organ hemorrhage remains one of the leading causes of death both on the battlefield of modern warfare and in the civilian setting. A novel, temporary hemostatic device combining CELOX and direct intra-abdominal physical compression was invented to control closed SAOH during transport to a medical treatment facility. MATERIALS AND METHODS A swine model of closed, lethal liver injury was established to determine hemostasis. The animals were randomly divided into group A (extra-abdominal compression), group B (gauze packing), group C (intra-abdominal compression), group D (CELOX coverage), and group E (intra-abdominal compression and CELOX coverage) with six swines per group. Survival time (ST), blood loss (BL), vital signs, pathologic examination, and CT-scan were monitored to further observe the effectiveness of the device. RESULTS Group E had an average 30-minute extension in ST (74.3 ± 15.4 minutes versus 44.0 ± 13.8 minutes, p = 0.026) with less BL (46.0 ± 13.0 versus 70.8 ± 8.2 g/kg, p = 0.018), and maintained mean arterial pressure≥70 mmHg and cardiac output ≥ 3.5 L/minute for a longer time. No significant differences were observed in ST and BL of groups B and E, and there were no marked differences in ST and BL of groups A, C, and D. No CELOX clots were noted in the spleen, pancreas, lungs, heart, kidneys, or the adjacent large vessels in groups D and E. Compared to group A, the CT-scan showed better hepatic hemorrhage control in group E. CONCLUSIONS The device, which combined 20 g of CELOX particles and 20 pieces of CELOX (8 g) sponge tablets with 50-mmHg intra-abdominal compression for 10 minutes, prolonged the ST by an average of 30 minutes with less BL. It was not markedly different from the full four quadrants gauze packing of liver in hemostatic effect, with no CELOX clot formation in other organs.
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Affiliation(s)
- Hao Qin
- Department of War Wound Rescue Skills Training, Base of Army Health Service Training, Army Medical University, Chongqing 400038, China.,Unit 77115 of the Chinese People's Liberation Army, Chengdu, Sichuan 611235, China
| | - Lei Yang
- Department of Emergency, Xinqiao Hospital, Army Medical University, Chongqing 400037, China
| | - Daocheng Liu
- Department of Emergency, Xinqiao Hospital, Army Medical University, Chongqing 400037, China
| | - Sixu Chen
- Department of War Wound Rescue Skills Training, Base of Army Health Service Training, Army Medical University, Chongqing 400038, China
| | - Mingrui Lyu
- Department of Emergency, Xinqiao Hospital, Army Medical University, Chongqing 400037, China
| | - Quanwei Bao
- Department of Emergency, Xinqiao Hospital, Army Medical University, Chongqing 400037, China
| | - Xinan Lai
- Research Institute of Surgery, Army Medical University, Chongqing 400042, China
| | - Huayu Liu
- Department of Trauma Surgery, Daping Hospital, Army Medical University, Chongqing 400042, China
| | - Qiang Chen
- Department of Anesthesiology, Daping Hospital, Army Medical University, Chongqing 400042, China
| | - Zhaowen Zong
- Department of War Wound Rescue Skills Training, Base of Army Health Service Training, Army Medical University, Chongqing 400038, China.,Department of Emergency, Xinqiao Hospital, Army Medical University, Chongqing 400037, China
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Bonk C, Weston B, Davis C, Barron A, McCarty O, Hargarten S. Saving Lives with Tourniquets: A Review of Penetrating Injury Medical Examiner Cases. PREHOSP EMERG CARE 2019; 24:494-499. [DOI: 10.1080/10903127.2019.1676344] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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DeForest CA, Blackman V, Alex JE, Reeves L, Mora A, Perez C, Maddry J, Selby D, Walrath B. An Evaluation of Navy En Route Care Training Using a High-Fidelity Medical Simulation Scenario of Interfacility Patient Transport. Mil Med 2019; 183:e383-e391. [PMID: 29547887 DOI: 10.1093/milmed/usx129] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Revised: 11/10/2017] [Accepted: 12/09/2017] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION Military prehospital and en route care (ERC) directly impacts patient morbidity and mortality. Provider knowledge and skills are critical variables in the effectiveness of ERC. No Navy doctrine defines provider choice for patient transport or requires standardized provider training. Frequently, Search and Rescue Medical Technicians (SMTs) and Navy Nurses (ERC RNs) are tasked with this mission though physicians have also been used. Navy ERC provider training varies greatly by professional role. Historically, evaluations of ERC and patient outcomes have been based on retrospective analyses of incomplete data sets that provide limited insight on ERC practices. Little evidence exists to determine if current training is adequate to care for the most common injuries seen in combat trauma patients. MATERIALS AND METHODS Simulation technology facilitates a standardized patient encounter to enable complete, prospective data collection while studying provider type as the independent variable. Information acquired through skill performance observation can be used to make evidence-based recommendations to improve ERC training. This IRB approved multi-center study funded through a Congressionally Directed Medical Research Program grant from the Combat Casualty Care Intramural Research Joint En Route Care portfolio evaluated Navy ERC providers. The study evaluated 84 SMT, ERC RN, and physician participants in the performance of critical and secondary actions during an immersive, high-fidelity, patient transport simulation scenario focused on the care during an interfacility transfer. Simulation evaluators with military ERC expertise, blinded to participant training and background, graded each participant's performance. Inter-rater reliability was calculated using Cohen's Kappa to evaluate concordance between evaluator assessments. Categorical data were reported as frequencies and percentages. Performance attempt and accuracy rates were compared with likelihood ratio chi-square or Fisher's exact test where appropriate. Tests were two-tailed and we considered results significant, that is, a difference not likely due to chance exists between groups, if p < 0.05. Confidence intervals were used to present overlap in performance between provider types. RESULTS Critical and secondary actions were assessed. A majority of providers completed at least one of the critical life-saving actions; only one participant completed all critical actions. Evaluation of critical actions demonstrated that a tourniquet was applied by 64% of providers, blood products administered by 46%, needle decompression performed by 51%, and a complete handoff report performed by 48%. Assessment of secondary actions demonstrated analgesic was accurately administered by 24% of all providers, and 44% reinforced the "hemorrhaging amputation site dressing." CONCLUSION Over 98% of participants failed to properly perform all critical actions during the interfacility transfer scenario, which in a real-life combat casualty transport scenario could result in a preventable death. Study results demonstrate serious skill deficits among all types of Navy ERC providers. These data can be used to improve the training of Navy ERC providers, ultimately improving care to injured soldiers, sailors, airmen, and marines.
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Affiliation(s)
- Christine A DeForest
- Department of Emergency Medicine, Naval Medical Center Camp Lejeune, 100 Brewster Bvd, Jacksonville, NC
| | - Virginia Blackman
- Daniel K. Inouye Graduate School of Nursing, Uniform Services University of Health Sciences, Bldg E, Rm 2044, 4301 Jones Bridge Road, Bethesda, MD
| | - John E Alex
- Department of Emergency Medicine, United States Naval Hospital Okinawa, 3 Chome Nodake, Ginowan, Okinawa Prefecture 901-2203, Japan
| | - Lauren Reeves
- Air Force En route Care Research Center, 59th Medical Wing/Surgical Operations Group/U.S. Institute of Surgical Research, 3698 Chambers Pass STE B, JBSA, FT Sam Houston, TX
| | - Alejandra Mora
- Air Force En route Care Research Center, 59th Medical Wing/Surgical Operations Group/U.S. Institute of Surgical Research, 3698 Chambers Pass STE B, JBSA, FT Sam Houston, TX
| | - Crystal Perez
- Air Force En route Care Research Center, 59th Medical Wing/Surgical Operations Group/U.S. Institute of Surgical Research, 3698 Chambers Pass STE B, JBSA, FT Sam Houston, TX
| | - Joseph Maddry
- Air Force En route Care Research Center, 59th Medical Wing/Surgical Operations Group/U.S. Institute of Surgical Research, 3698 Chambers Pass STE B, JBSA, FT Sam Houston, TX
| | - Domenique Selby
- 1st Medical Battalion, 1st Marine Logistics Group, Bldg 22164, Camp Pendleton, CA
| | - Benjamin Walrath
- Department of Emergency Medicine, Naval Medical Center San Diego, 34800 Bob Wilson Dr, San Diego, CA
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Saldanha V, Tiedeken N, Godfrey B, Ingalls N. Wartime Soft Tissue Coverage Techniques for the Deployed Surgeon. Mil Med 2019; 183:e247-e254. [PMID: 29590411 DOI: 10.1093/milmed/usy022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Revised: 01/25/2018] [Accepted: 02/04/2018] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Since the start of the conflict in the Middle East in 2001, military orthopedic surgeons have faced complex orthopedic injuries including high-energy soft tissue wounds, traumatic amputations, and open fractures. Although orthopedic surgeons are well trained in the management of osseous injuries, the treatment of soft tissue injuries can be technically challenging and unfamiliar. Early washout, debridement of devitalized tissue, external fixation of bony injuries, and antibiotic therapy remain the foundation of early wound management. However, these unique extremity injuries have no standard plan of care, and definitive treatment options continue to evolve. The following report highlights the typical cases seen in the wartime setting and offers possible solutions for the associated soft tissue injuries. METHODS A single orthopedic surgeon at a Role 3 combat support hospital performed all cases in this series. This study is a report of the cases that the orthopedic surgeon encountered while deployed and the various techniques that can be used to manage the complex wounds seen in a deployed setting. FINDINGS Twelve patients were included in this report and the data are shown. Of the 12 patients, 6 were injured by an improvised explosive device (IED), 4 were injured by a high-velocity gunshot wound (HVGSW), 1 was injured by a gunshot wound (GSW), and 1 was injured in an auto versus pedestrian motor vehicle crash. The wound sizes ranged from 10 to 300 cm2. All patients required more than one irrigation and debridement before wound closure. There was a successful outcome in 11 of the 12 patients. The only patient without a known successful outcome was lost to follow up. Six patients were treated with split thickness skin graft (STSG) alone. Four patients were treated with STSG plus an additional means of coverage. One patient was treated with a random flap and one patient was treated with a full thickness skin graft. Integra was used in two of the patients. Each of the patients in whom integra was used had exposed bone and had a successful outcome with respect to tissue coverage. DISCUSSION This study details different soft tissue coverage techniques that must be learned and possibly employed by the deployed surgeon. Limitations of this study include its retrospective nature and the selected sampling of cases. At initial presentation, the management of war wounds secondary to high-velocity gunshot wounds and improvised explosive devices can be quite daunting. Adhering to firm surgical principles of thorough and meticulous debridement is the foundation of later soft tissue reconstructive options. Once the tissue is deemed clear of infection and contamination, there are myriad treatment options utilizing flaps, synthetic materials, and skin grafting. These are relatively straightforward techniques that the general orthopedic surgeon can utilize while deployed in a combat setting. In the end, it is critical for deployed surgeons to learn multiple techniques to provide definitive soft tissue coverage in a wartime theater.
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Affiliation(s)
- Vilas Saldanha
- Department of Surgery, University of Nevada School of Medicine, 1701 W Charleston Blvd, Suite 490, Las Vegas, NV.,99th Medical Group, Mike O'Callaghan Federal Medical Center, 4700 N, Las Vegas Blvd, Nellis AFB, NV
| | - Nathan Tiedeken
- Department of Orthopaedic Surgery, Albert Einstein Medical Center, 5501 Old York Road, Philadelphia, PA 19141
| | - Brandon Godfrey
- 99th Medical Group, Mike O'Callaghan Federal Medical Center, 4700 N, Las Vegas Blvd, Nellis AFB, NV
| | - Nichole Ingalls
- Department of Surgery, University of Nevada School of Medicine, 1701 W Charleston Blvd, Suite 490, Las Vegas, NV.,99th Medical Group, Mike O'Callaghan Federal Medical Center, 4700 N, Las Vegas Blvd, Nellis AFB, NV
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Damage control surgery in neonates: Lessons learned from the battlefield. J Pediatr Surg 2019; 54:2069-2074. [PMID: 31103271 DOI: 10.1016/j.jpedsurg.2019.04.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 01/19/2019] [Accepted: 04/01/2019] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Mortality for neonates requiring surgery for serious pathology such as NEC, remains high. Damage control surgery (DCS) has evolved as an operative strategy in battlefield trauma that sacrifices the completeness of the initial surgery to address the deadly triad of acidosis, hypothermia and coagulopathy. This approach is now used routinely in sick adults with nontrauma surgical emergencies. Here we describe our experience of using DCS in neonates. METHOD Neonates undergoing DCS at our hospital from 1/8/2010 to 30/11/17 had data collected prospectively. RESULTS 27 neonates (median age 21 days; gestation 29 weeks; weight 1200 g; M:F 18:9) underwent DCS. Diagnosis (NEC 23, volvulus 2, meconium peritonitis 1, spontaneous perforation 1). Preoperative physiology: median temperature 35.5 °C, lactate 3.7, Activated prothrombin time 49; on a median of 1 inotrope (range 0 to 4); 19 had surgery on the intensive care unit. Surgery involved resection of dead bowel with the ends ligated and the abdomen left open. Operation took 38 min (26-80 min) and crew-resource management techniques were used to optimize efficiency. Second look occurred at 48 h (24-108 h) when the physiology had normalized. There were a total of 32 anastomoses in 18 patients with one leak; 3 patients had stomas for distal rectal disease. Overall mortality was 15% (4/27) or 18% in the NEC group (4/23). CONCLUSION Though techniques such as "clip and drop" exist, they have not been routinely incorporated into an operative strategy for sick neonates based on physiological derangement. The two benefits from our DCS approach were a low mortality and an avoidance of stomas. This approach deserves more investigation to see whether it is as effective in babies and children with nontrauma associated abdominal catastrophes as it is in adults. TYPE OF STUDY Case controlled study. LEVEL OF EVIDENCE Level III.
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Liu W, Xi G, Yang X, Hao X, Wang M, Feng Y, Chen H, Shi C. Poly(lactide-co-glycolide) grafted hyaluronic acid-based electrospun fibrous hemostatic fragments as a sustainable anti-infection and immunoregulation material. J Mater Chem B 2019; 7:4997-5010. [PMID: 31411610 DOI: 10.1039/c9tb00659a] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Poly(lactide-co-glycolide) (PLGA) copolymers are promising synthetic materials in the biomedical field. However, in wound management, their hydrophobic properties limit their further application because of their poor adhesion to the surface of moist wounds. Furthermore, the lack of hemostatic materials with sustainable anti-infection and immunoregulation functions remains a highly significant clinical problem, as commercially available hemostatic products, such as Arista™, Celox™ and QuikClot™, do not have sufficient infection prevention and immunoregulation properties. Herein, we employ electrospinning, ammonia dissociation and surface grafting techniques to develop a series of PLGA-based hemostatic materials, including a PLGA electrospun fibrous membrane, PLGA-NH2 fibrous particles and PLGA-hyaluronic acid fibrous fragments (PLGA-HA FFs). Notably, we load azithromycin on the PLGA-HA FFs to endow them with anti-infection and immunoregulation properties. The hemostatic mechanism analysis demonstrates that the PLGA-HA FFs show superior hemostasis performance compared to traditional gauzes. The results show that the PLGA-HA FFs can act as a versatile platform with high encapsulation of azithromycin (83.03% ± 2.81%) and rapid hemostasis (28 ± 2 s) as well as prominent cytocompatibility towards L929 cells, RAW 264.7 cells and red blood cells. We believe that the current research proposes a possible strategy to synthesize materials that achieve not only safe and effective hemostasis, but also have anti-infection and immunoregulation properties for the development of further hemostatic products.
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Affiliation(s)
- Wen Liu
- School of Ophthalmology & Optometry, Eye Hospital, School of Biomedical Engineering, Wenzhou Medical University, Wenzhou, Zhejiang 325027, China. and Wenzhou Institute of Biomaterials and Engineering, Wenzhou Institute, University of Chinese Academy of Sciences, Wenzhou, Zhejiang 325011, China and Engineering Research Center of Clinical Functional Materials and Diagnosis & Treatment Devices of Zhejiang Province, Wenzhou Institute of Biomaterials and Engineering, Wenzhou, Zhejiang 325011, China.
| | - Guanghui Xi
- School of Ophthalmology & Optometry, Eye Hospital, School of Biomedical Engineering, Wenzhou Medical University, Wenzhou, Zhejiang 325027, China. and Wenzhou Institute of Biomaterials and Engineering, Wenzhou Institute, University of Chinese Academy of Sciences, Wenzhou, Zhejiang 325011, China and Engineering Research Center of Clinical Functional Materials and Diagnosis & Treatment Devices of Zhejiang Province, Wenzhou Institute of Biomaterials and Engineering, Wenzhou, Zhejiang 325011, China.
| | - Xiao Yang
- School of Ophthalmology & Optometry, Eye Hospital, School of Biomedical Engineering, Wenzhou Medical University, Wenzhou, Zhejiang 325027, China. and Wenzhou Institute of Biomaterials and Engineering, Wenzhou Institute, University of Chinese Academy of Sciences, Wenzhou, Zhejiang 325011, China and Engineering Research Center of Clinical Functional Materials and Diagnosis & Treatment Devices of Zhejiang Province, Wenzhou Institute of Biomaterials and Engineering, Wenzhou, Zhejiang 325011, China. and School of Chemical Engineering and Technology, Tianjin University, Tianjin 300350, China.
| | - Xiao Hao
- Hebei General Hospital, Shijiazhuang, Hebei 050051, China
| | - Mingshan Wang
- The First Affiliated Hospital of Wenzhou Medical University, Wenzhou Medical University, Wenzhou, Zhejiang 325000, China
| | - Yakai Feng
- School of Ophthalmology & Optometry, Eye Hospital, School of Biomedical Engineering, Wenzhou Medical University, Wenzhou, Zhejiang 325027, China. and Wenzhou Institute of Biomaterials and Engineering, Wenzhou Institute, University of Chinese Academy of Sciences, Wenzhou, Zhejiang 325011, China and Engineering Research Center of Clinical Functional Materials and Diagnosis & Treatment Devices of Zhejiang Province, Wenzhou Institute of Biomaterials and Engineering, Wenzhou, Zhejiang 325011, China. and School of Chemical Engineering and Technology, Tianjin University, Tianjin 300350, China.
| | - Hao Chen
- School of Ophthalmology & Optometry, Eye Hospital, School of Biomedical Engineering, Wenzhou Medical University, Wenzhou, Zhejiang 325027, China. and Wenzhou Institute of Biomaterials and Engineering, Wenzhou Institute, University of Chinese Academy of Sciences, Wenzhou, Zhejiang 325011, China and Engineering Research Center of Clinical Functional Materials and Diagnosis & Treatment Devices of Zhejiang Province, Wenzhou Institute of Biomaterials and Engineering, Wenzhou, Zhejiang 325011, China.
| | - Changcan Shi
- School of Ophthalmology & Optometry, Eye Hospital, School of Biomedical Engineering, Wenzhou Medical University, Wenzhou, Zhejiang 325027, China. and Wenzhou Institute of Biomaterials and Engineering, Wenzhou Institute, University of Chinese Academy of Sciences, Wenzhou, Zhejiang 325011, China and Engineering Research Center of Clinical Functional Materials and Diagnosis & Treatment Devices of Zhejiang Province, Wenzhou Institute of Biomaterials and Engineering, Wenzhou, Zhejiang 325011, China.
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Furlan JC, Gulasingam S, Craven BC. Epidemiology of War-Related Spinal Cord Injury Among Combatants: A Systematic Review. Global Spine J 2019; 9:545-558. [PMID: 31431879 PMCID: PMC6686388 DOI: 10.1177/2192568218776914] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
STUDY DESIGN Systematic review. OBJECTIVES War-related spinal cord injuries (SCIs) are commonly more severe and complex than traumatic SCIs among civilians. This systematic review, for the first time, synthesized and critically appraised the literature on the epidemiology of war-related SCIs. This review aimed to identify distinct features from the civilian SCIs that can have an impact on the management of military and civilian SCIs. METHODS Medline, EMBASE, and PsycINFO databases were searched for articles on epidemiology of war-related SCI among combatants, published from 1946 to December 20, 2017. This review included only original publications on epidemiological aspects of SCIs that occur during an act of war. The STROBE statement was used to examine the quality of the publications. RESULTS The literature search identified 1594 publications, of which 25 articles fulfilled the inclusion and exclusion criteria. The studies were classified into the following topics: 17 articles reported demographics, level and severity of SCI, mechanism of injury and/or associated bodily injuries; 5 articles reported the incidence of war-related SCI; and 6 articles reported the frequency of SCI among other war-related bodily injuries. Overall, military personnel with war-related SCI were typically young, white men, with predominantly thoracic or lumbar level, complete (American Spinal Injury Association [ASIA] Impairment Scale A) SCI due to gunshot or explosion and often associated with other bodily injuries. Marines appear to be at a greater risk of war-related SCI than the military personal in the Army, Navy, and Air Force. CONCLUSIONS The war-related SCIs among soldiers are distinct from the traumatic SCI in the general population. The majority of the current literature is based on the American experiences in most recent wars.
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Affiliation(s)
- Julio C. Furlan
- Department of Medicine, Division of Physical Medicine and Rehabilitation, University of Toronto, Toronto, Ontario, Canada
- Lyndhurst Centre, Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
| | - Sivakumar Gulasingam
- Department of Medicine, Division of Physical Medicine and Rehabilitation, University of Toronto, Toronto, Ontario, Canada
- Lyndhurst Centre, Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
| | - B. Catharine Craven
- Department of Medicine, Division of Physical Medicine and Rehabilitation, University of Toronto, Toronto, Ontario, Canada
- Lyndhurst Centre, Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
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Lairet J, Bebarta VS, Maddry JK, Reeves L, Mora A, Blackbourne L, Rasmussen T. Prehospital Interventions Performed in Afghanistan Between November 2009 and March 2014. Mil Med 2019; 184:133-137. [PMID: 30901391 DOI: 10.1093/milmed/usy311] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Revised: 10/01/2018] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE Care provided to a casualty in the prehospital combat setting can influence subsequent medical interactions and impact patient outcomes; therefore, we aimed to describe the incidence of specific prehospital interventions (lifesaving interventions (LSIs)) performed during the resuscitation and transport of combat casualties. METHODS We performed a prospective observational, IRB approved study between November 2009 and March 2014. Casualties were enrolled as they were cared for at nine U.S. military medical facilities in Afghanistan. Data were collected using a standardized collection form. Determination if a prehospital intervention was performed correctly, performed incorrectly, or was necessary but was not performed (missed LSIs) was made by the receiving facility's medical provider. RESULTS Two thousand one hundred and six patients met inclusion criteria. The mean age was 25 years and 98% were male. The most common mechanism of injury was explosion 57%. There were 236 airway interventions attempted, 183 chest procedures, 1,673 hemorrhage control, 1,698 vascular access, and 1,066 hypothermia preventions implemented. There were 142 incorrectly performed interventions and 360 were missed. CONCLUSIONS In our study, the most commonly performed prehospital LSI in a combat setting were for vascular access and hemorrhage control. The most common incorrectly performed and missed interventions were airway interventions and chest procedures respectively.
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Affiliation(s)
- Julio Lairet
- Department of Emergency Medicine, Emory University School of Medicine, 531 Asbury Circle, Annex Building Suite N340, Atlanta, GA.,Headquarters Georgia Air National Guard, 1000 Halsey Avenue Bldg. 447, Marietta, GA.,Atlanta VA Medical Center, 1670 Clairmont Rd, Decatur, GA
| | - Vikhyat S Bebarta
- 59th MDW/Chief Scientist Office, United States Air Force En Route Care Research Center, 3698 Chambers Pass Ste B, JBSA Ft Sam Houston, TX.,Department of Emergency Medicine, University of Colorado School of Medicine, 12401 E. 17th Avenue, Aurora, CO
| | - Joseph K Maddry
- 59th MDW/Chief Scientist Office, United States Air Force En Route Care Research Center, 3698 Chambers Pass Ste B, JBSA Ft Sam Houston, TX
| | - Lauren Reeves
- 59th MDW/Chief Scientist Office, United States Air Force En Route Care Research Center, 3698 Chambers Pass Ste B, JBSA Ft Sam Houston, TX
| | - Alejandra Mora
- 59th MDW/Chief Scientist Office, United States Air Force En Route Care Research Center, 3698 Chambers Pass Ste B, JBSA Ft Sam Houston, TX
| | - Lorne Blackbourne
- Trauma Medical Director, St David's Round Rock Medical Center, 2400 Round Rock Ave, Round Rock, TX
| | - Todd Rasmussen
- F. Edward Hébert School of Medicine, Uniformed Services University of Health Sciences, 4301 Jones Bridge Rd, Bethesda, MD
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Furlan JC, Kurban D, Craven BC. Traumatic spinal cord injury in military personnel versus civilians: a propensity score-matched cohort study. BMJ Mil Health 2019; 166:e57-e62. [PMID: 31154341 DOI: 10.1136/jramc-2019-001197] [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: 02/18/2019] [Revised: 04/04/2019] [Accepted: 04/10/2019] [Indexed: 11/03/2022]
Abstract
INTRODUCTION Military personnel are exposed to mechanisms of bodily injuries that may differ from civilians. A retrospective cohort study (RCS) and a propensity score-matched cohort study (PSMCS) were undertaken to examine the potential differences in injury epidemiology, management and outcomes after spinal cord injury (SCI) between military personnel and civilians. METHODS Using a Canadian multicentre SCI database, data of all individuals with sufficient data from October 2013 to January 2017 were included in the RCS (n=1043). In the PSMCS, a group of 50 military personnel with SCI was compared with a group of 50 civilians with SCI who were matched regarding sex, age, and level, severity and mechanism of SCI. RESULTS In the RCS, military personnel with SCI (n=61) were significantly older and predominantl males when compared with civilians with SCI (n=982). However, the study groups were not statistically different with regards to their: level, severity and mechanisms of SCI; frequency of associated bodily injuries; and need for mechanical ventilation after SCI. In the PSMCS, the group of military individuals with SCI (n=50) was similar to the group of civilians with SCI (n=50) regarding pre-existing medical comorbidities, degree of motor impairment at admission, initial treatment for SCI and clinical and neurological outcomes after SCI. CONCLUSIONS The results of these studies suggest that military SCI group has disproportionally older men at the time of injury compared with civilians with SCI. However, the military and civilian SCI groups had similar outcomes of alike initial treatment when both groups were matched regarding their demographic profile and injury characteristics.
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Affiliation(s)
- Julio C Furlan
- Division of Physicial Medicine and Rehabilitation, Toronto Rehabilitation Institute - Lyndhurst Centre, Toronto, Ontario, Canada .,Division of Physicial Medicine and Rehabilitation, University of Toronto, Toronto, Ontario, Canada
| | - D Kurban
- Rick Hansen Institute, Vancouver, British Columbia, Canada
| | - B C Craven
- Division of Physicial Medicine and Rehabilitation, Toronto Rehabilitation Institute - Lyndhurst Centre, Toronto, Ontario, Canada.,Division of Physicial Medicine and Rehabilitation, University of Toronto, Toronto, Ontario, Canada
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Harrison WY, Wardian JL, Sosnov JA, Kotwal RS, Butler FK, Stockinger ZT, Shackelford SA, Gurney JM, Spott MA, Finelli LN, Mazuchowski EL, Smith DJ, Janak JC. Recommended medical and non-medical factors to assess military preventable deaths: subject matter experts provide valuable insights. BMJ Mil Health 2019; 166:e47-e52. [DOI: 10.1136/jramc-2019-001193] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Revised: 03/28/2019] [Accepted: 03/29/2019] [Indexed: 11/04/2022]
Abstract
IntroductionHistorically, there has been variability in the methods for determining preventable death within the US Department of Defense. Differences in methodologies partially explain variable preventable death rates ranging from 3% to 51%. The lack of standard review process likely misses opportunities for improvement in combat casualty care. This project identified recommended medical and non-medical factors necessary to (1) establish a comprehensive preventable death review process and (2) identify opportunities for improvement throughout the entire continuum of care.MethodsThis qualitative study used a modified rapid assessment process that includes the following steps: (1) identification and recruitment of US government subject matter experts (SMEs); (2) multiple cycles of data collection via key informant interviews and focus groups; (3) consolidation of information collected in these interviews; and (4) iterative analysis of data collected from interviews into common themes. Common themes identified from SME feedback were grouped into the following subject areas: (1) prehospital, (2) in-hospital and (3) forensic pathology.ResultsMedical recommendations for military preventable death reviews included the development, training, documentation, collection, analysis and reporting of the implementation of the Tactical Combat Casualty Care Guidelines, Joint Trauma System Clinical Practice Guidelines and National Association of Medical Examiners autopsy standards. Non-medical recommendations included training, improved documentation, data collection and analysis of non-medical factors needed to understand how these factors impact optimal medical care.ConclusionsIn the operational environment, medical care must be considered in the context of non-medical factors. For a comprehensive preventable death review process to be sustainable in the military health system, the process must be based on an appropriate conceptual framework implemented consistently across all military services.
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Bukoski A, Uhlich R, Bowling F, Shapiro M, Kerby JD, Llerena L, Armstrong JH, Strayhorn C, Barnes SL. Perceptions of Simulator- and Live Tissue-Based Combat Casualty Care Training of Senior Special Operations Medics. Mil Med 2019; 183:78-85. [PMID: 29635549 DOI: 10.1093/milmed/usx136] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2017] [Accepted: 01/02/2018] [Indexed: 01/20/2023] Open
Abstract
The relative effectiveness of live tissue (LT)- and inanimate simulation (SIM)-based training of combat medics is the subject of intense debate. A structured interview was utilized to determine the training modality preferences and the perceived value of LT- and SIM-based combat casualty care training of 25 senior special operations medics. Participant demographics and training experience, Likert scale-based assessment of training modality value, selection of preferred training modality for 11 combat casualty care procedures, and 12 open-ended questions probing opinions of the limitations and benefits of LT- and SIM-based training were collected from this convenience sample. All participants indicated significant combat medic experience and training. Of the 11 procedures questioned, LT was identified as superior for seven with mixed responses for the remaining four. LT was consistently identified as an essential training modality with tactile sensation and the physiologic responses of animal models to injury and therapy as primary benefits. Across procedures, 100% of participants felt that LT should be used in combat casualty care training and 96% felt that SIM should also be utilized. Repeatability and accuracy of size/weight were identified as key benefits of SIM training. Respondents reported that capability, self-confidence, success, and resilience of the combat medic all benefitted from LT training. The overriding theme was the general superiority of LT with recognition of the unique and complementary benefits of SIM.
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Affiliation(s)
- Alex Bukoski
- Department of Veterinary Medicine and Surgery, College of Veterinary Medicine, University of Missouri, 900 East Campus Drive, Columbia, MO 65211
| | - Rindi Uhlich
- Department of Surgery, Division of Acute Care Surgery, School of Medicine, University of Missouri, 1 Hospital Drive, Columbia, MO 65212
| | - F Bowling
- United States Special Operations Command, 7701 Tampa Point Blvd, MacDill AFB, FL 33621
| | - Mark Shapiro
- Department of Surgery, Division of Trauma and Surgical Critical Care, Duke University Medical Center, 2301 Erwin Road, Durham, NC 27710
| | - Jeffrey D Kerby
- Department of Surgery, Division of Acute Care Surgery, School of Medicine, University of Missouri, 1 Hospital Drive, Columbia, MO 65212
| | - Luis Llerena
- University of South Florida Health, Center for Advanced Medical Learning and Simulation (CAMLS), 124 South Franklin Street, Tampa, FL 33602
| | - John H Armstrong
- University of South Florida Health, Center for Advanced Medical Learning and Simulation (CAMLS), 124 South Franklin Street, Tampa, FL 33602
| | - Catherine Strayhorn
- Information Visualization and Innovative Research (IVIR), 1626 Barber Road, Suite A, Sarasota, FL 34240
| | - Stephen L Barnes
- Department of Surgery, Division of Acute Care Surgery, School of Medicine, University of Missouri, 1 Hospital Drive, Columbia, MO 65212
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Ray S, Singh MV, Goyal S, Singh RJ, Sharma R. Tactical combat casualty care in the navy – Challenges and way ahead. JOURNAL OF MARINE MEDICAL SOCIETY 2019. [DOI: 10.4103/jmms.jmms_67_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Staudt AM, Savell SC, Biever KA, Trevino JD, Valdez-Delgado KK, Suresh M, Gurney JM, Shackelford SA, Maddry JK, Mann-Salinas EA. En Route Critical Care Transfer From a Role 2 to a Role 3 Medical Treatment Facility in Afghanistan. Crit Care Nurse 2018; 38:e7-e15. [PMID: 29606685 DOI: 10.4037/ccn2018532] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND En route care is the transfer of patients requiring combat casualty care within the US military evacuation system. No reports have been published about en route care of patients during transfer from a forward surgical facility (role 2) to a combat support hospital (role 3) for comprehensive care. OBJECTIVE To describe patients transferred from a role 2 to a role 3 US military treatment facility in Afghanistan. METHODS A retrospective review of data from the Joint Trauma System Role 2 Database was conducted. Patient characteristics were described by en route care medical attendants. RESULTS More than one-fourth of patients were intubated at transfer (26.9%), although at transfer fewer than 10% of patients had a base deficit of more than 5 (3.5%), a pH of less than 7.3 (5.2%), an international normalized ratio of more than 2 (0.8%), or temporary abdominal or chest closure (7.4%). The en route care medical attendant was most often a nurse (35.5%), followed by technicians (14.1%) and physicians (10.0%). Most patients (75.3%) were transported by medical evacuation (on rotary-wing aircraft). CONCLUSION This is the first comprehensive review of patients transported from a forward surgical facility to a more robust combat support hospital in Afghanistan. Understanding the epidemiology of these patients will inform provider training and the appropriate skill mix for the transfer of postsurgical patients within a combat setting.
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Affiliation(s)
- Amanda M Staudt
- Amanda M. Staudt serves as an epidemiologist, Jennifer D. Trevino is a program manager, Krystal K. Valdez-Delgado is a research nurse coordinator, and COL Elizabeth A. Mann-Salinas is the Task Area Manager for the Systems of Care for Complex Patients Task Area at the US Army Institute of Surgical Research in San Antonio, Texas.,Shelia C. Savell serves as the Senior Scientist for the USAF En Route Care Research Center at the 59th MDW/ST, Chief Scientists Office in San Antonio, Texas.,COL Kimberly A. Biever is a critical care clinical nurse specialist and serves as a consultant to the Surgeon General for En Route Critical Care Nursing, Human Resources Command, Fort Knox, Kentucky.,Mithun Suresh is a physician working in the Epidemiology/Biostatistics Division of the Research Directorate at the US Army Institute of Surgical Research in San Antonio, Texas.,COL Jennifer M. Gurney serves as the Chief of Trauma Systems Development and Col Stacy A. Shackelford serves as the Chief of Education and Performance Improvement for the Joint Trauma System in San Antonio, Texas.,Maj Joseph K. Maddry serves as the Director for the USAF En Route Care Research Center at the 59th MDW/ST and is Director of the Clinical Resuscitation, Emergency Sciences, and Toxicology Research Program, Chief Scientists Office in San Antonio, Texas
| | - Shelia C Savell
- Amanda M. Staudt serves as an epidemiologist, Jennifer D. Trevino is a program manager, Krystal K. Valdez-Delgado is a research nurse coordinator, and COL Elizabeth A. Mann-Salinas is the Task Area Manager for the Systems of Care for Complex Patients Task Area at the US Army Institute of Surgical Research in San Antonio, Texas.,Shelia C. Savell serves as the Senior Scientist for the USAF En Route Care Research Center at the 59th MDW/ST, Chief Scientists Office in San Antonio, Texas.,COL Kimberly A. Biever is a critical care clinical nurse specialist and serves as a consultant to the Surgeon General for En Route Critical Care Nursing, Human Resources Command, Fort Knox, Kentucky.,Mithun Suresh is a physician working in the Epidemiology/Biostatistics Division of the Research Directorate at the US Army Institute of Surgical Research in San Antonio, Texas.,COL Jennifer M. Gurney serves as the Chief of Trauma Systems Development and Col Stacy A. Shackelford serves as the Chief of Education and Performance Improvement for the Joint Trauma System in San Antonio, Texas.,Maj Joseph K. Maddry serves as the Director for the USAF En Route Care Research Center at the 59th MDW/ST and is Director of the Clinical Resuscitation, Emergency Sciences, and Toxicology Research Program, Chief Scientists Office in San Antonio, Texas
| | - Kimberly A Biever
- Amanda M. Staudt serves as an epidemiologist, Jennifer D. Trevino is a program manager, Krystal K. Valdez-Delgado is a research nurse coordinator, and COL Elizabeth A. Mann-Salinas is the Task Area Manager for the Systems of Care for Complex Patients Task Area at the US Army Institute of Surgical Research in San Antonio, Texas.,Shelia C. Savell serves as the Senior Scientist for the USAF En Route Care Research Center at the 59th MDW/ST, Chief Scientists Office in San Antonio, Texas.,COL Kimberly A. Biever is a critical care clinical nurse specialist and serves as a consultant to the Surgeon General for En Route Critical Care Nursing, Human Resources Command, Fort Knox, Kentucky.,Mithun Suresh is a physician working in the Epidemiology/Biostatistics Division of the Research Directorate at the US Army Institute of Surgical Research in San Antonio, Texas.,COL Jennifer M. Gurney serves as the Chief of Trauma Systems Development and Col Stacy A. Shackelford serves as the Chief of Education and Performance Improvement for the Joint Trauma System in San Antonio, Texas.,Maj Joseph K. Maddry serves as the Director for the USAF En Route Care Research Center at the 59th MDW/ST and is Director of the Clinical Resuscitation, Emergency Sciences, and Toxicology Research Program, Chief Scientists Office in San Antonio, Texas
| | - Jennifer D Trevino
- Amanda M. Staudt serves as an epidemiologist, Jennifer D. Trevino is a program manager, Krystal K. Valdez-Delgado is a research nurse coordinator, and COL Elizabeth A. Mann-Salinas is the Task Area Manager for the Systems of Care for Complex Patients Task Area at the US Army Institute of Surgical Research in San Antonio, Texas.,Shelia C. Savell serves as the Senior Scientist for the USAF En Route Care Research Center at the 59th MDW/ST, Chief Scientists Office in San Antonio, Texas.,COL Kimberly A. Biever is a critical care clinical nurse specialist and serves as a consultant to the Surgeon General for En Route Critical Care Nursing, Human Resources Command, Fort Knox, Kentucky.,Mithun Suresh is a physician working in the Epidemiology/Biostatistics Division of the Research Directorate at the US Army Institute of Surgical Research in San Antonio, Texas.,COL Jennifer M. Gurney serves as the Chief of Trauma Systems Development and Col Stacy A. Shackelford serves as the Chief of Education and Performance Improvement for the Joint Trauma System in San Antonio, Texas.,Maj Joseph K. Maddry serves as the Director for the USAF En Route Care Research Center at the 59th MDW/ST and is Director of the Clinical Resuscitation, Emergency Sciences, and Toxicology Research Program, Chief Scientists Office in San Antonio, Texas
| | - Krystal K Valdez-Delgado
- Amanda M. Staudt serves as an epidemiologist, Jennifer D. Trevino is a program manager, Krystal K. Valdez-Delgado is a research nurse coordinator, and COL Elizabeth A. Mann-Salinas is the Task Area Manager for the Systems of Care for Complex Patients Task Area at the US Army Institute of Surgical Research in San Antonio, Texas.,Shelia C. Savell serves as the Senior Scientist for the USAF En Route Care Research Center at the 59th MDW/ST, Chief Scientists Office in San Antonio, Texas.,COL Kimberly A. Biever is a critical care clinical nurse specialist and serves as a consultant to the Surgeon General for En Route Critical Care Nursing, Human Resources Command, Fort Knox, Kentucky.,Mithun Suresh is a physician working in the Epidemiology/Biostatistics Division of the Research Directorate at the US Army Institute of Surgical Research in San Antonio, Texas.,COL Jennifer M. Gurney serves as the Chief of Trauma Systems Development and Col Stacy A. Shackelford serves as the Chief of Education and Performance Improvement for the Joint Trauma System in San Antonio, Texas.,Maj Joseph K. Maddry serves as the Director for the USAF En Route Care Research Center at the 59th MDW/ST and is Director of the Clinical Resuscitation, Emergency Sciences, and Toxicology Research Program, Chief Scientists Office in San Antonio, Texas
| | - Mithun Suresh
- Amanda M. Staudt serves as an epidemiologist, Jennifer D. Trevino is a program manager, Krystal K. Valdez-Delgado is a research nurse coordinator, and COL Elizabeth A. Mann-Salinas is the Task Area Manager for the Systems of Care for Complex Patients Task Area at the US Army Institute of Surgical Research in San Antonio, Texas.,Shelia C. Savell serves as the Senior Scientist for the USAF En Route Care Research Center at the 59th MDW/ST, Chief Scientists Office in San Antonio, Texas.,COL Kimberly A. Biever is a critical care clinical nurse specialist and serves as a consultant to the Surgeon General for En Route Critical Care Nursing, Human Resources Command, Fort Knox, Kentucky.,Mithun Suresh is a physician working in the Epidemiology/Biostatistics Division of the Research Directorate at the US Army Institute of Surgical Research in San Antonio, Texas.,COL Jennifer M. Gurney serves as the Chief of Trauma Systems Development and Col Stacy A. Shackelford serves as the Chief of Education and Performance Improvement for the Joint Trauma System in San Antonio, Texas.,Maj Joseph K. Maddry serves as the Director for the USAF En Route Care Research Center at the 59th MDW/ST and is Director of the Clinical Resuscitation, Emergency Sciences, and Toxicology Research Program, Chief Scientists Office in San Antonio, Texas
| | - Jennifer M Gurney
- Amanda M. Staudt serves as an epidemiologist, Jennifer D. Trevino is a program manager, Krystal K. Valdez-Delgado is a research nurse coordinator, and COL Elizabeth A. Mann-Salinas is the Task Area Manager for the Systems of Care for Complex Patients Task Area at the US Army Institute of Surgical Research in San Antonio, Texas.,Shelia C. Savell serves as the Senior Scientist for the USAF En Route Care Research Center at the 59th MDW/ST, Chief Scientists Office in San Antonio, Texas.,COL Kimberly A. Biever is a critical care clinical nurse specialist and serves as a consultant to the Surgeon General for En Route Critical Care Nursing, Human Resources Command, Fort Knox, Kentucky.,Mithun Suresh is a physician working in the Epidemiology/Biostatistics Division of the Research Directorate at the US Army Institute of Surgical Research in San Antonio, Texas.,COL Jennifer M. Gurney serves as the Chief of Trauma Systems Development and Col Stacy A. Shackelford serves as the Chief of Education and Performance Improvement for the Joint Trauma System in San Antonio, Texas.,Maj Joseph K. Maddry serves as the Director for the USAF En Route Care Research Center at the 59th MDW/ST and is Director of the Clinical Resuscitation, Emergency Sciences, and Toxicology Research Program, Chief Scientists Office in San Antonio, Texas
| | - Stacy A Shackelford
- Amanda M. Staudt serves as an epidemiologist, Jennifer D. Trevino is a program manager, Krystal K. Valdez-Delgado is a research nurse coordinator, and COL Elizabeth A. Mann-Salinas is the Task Area Manager for the Systems of Care for Complex Patients Task Area at the US Army Institute of Surgical Research in San Antonio, Texas.,Shelia C. Savell serves as the Senior Scientist for the USAF En Route Care Research Center at the 59th MDW/ST, Chief Scientists Office in San Antonio, Texas.,COL Kimberly A. Biever is a critical care clinical nurse specialist and serves as a consultant to the Surgeon General for En Route Critical Care Nursing, Human Resources Command, Fort Knox, Kentucky.,Mithun Suresh is a physician working in the Epidemiology/Biostatistics Division of the Research Directorate at the US Army Institute of Surgical Research in San Antonio, Texas.,COL Jennifer M. Gurney serves as the Chief of Trauma Systems Development and Col Stacy A. Shackelford serves as the Chief of Education and Performance Improvement for the Joint Trauma System in San Antonio, Texas.,Maj Joseph K. Maddry serves as the Director for the USAF En Route Care Research Center at the 59th MDW/ST and is Director of the Clinical Resuscitation, Emergency Sciences, and Toxicology Research Program, Chief Scientists Office in San Antonio, Texas
| | - Joseph K Maddry
- Amanda M. Staudt serves as an epidemiologist, Jennifer D. Trevino is a program manager, Krystal K. Valdez-Delgado is a research nurse coordinator, and COL Elizabeth A. Mann-Salinas is the Task Area Manager for the Systems of Care for Complex Patients Task Area at the US Army Institute of Surgical Research in San Antonio, Texas.,Shelia C. Savell serves as the Senior Scientist for the USAF En Route Care Research Center at the 59th MDW/ST, Chief Scientists Office in San Antonio, Texas.,COL Kimberly A. Biever is a critical care clinical nurse specialist and serves as a consultant to the Surgeon General for En Route Critical Care Nursing, Human Resources Command, Fort Knox, Kentucky.,Mithun Suresh is a physician working in the Epidemiology/Biostatistics Division of the Research Directorate at the US Army Institute of Surgical Research in San Antonio, Texas.,COL Jennifer M. Gurney serves as the Chief of Trauma Systems Development and Col Stacy A. Shackelford serves as the Chief of Education and Performance Improvement for the Joint Trauma System in San Antonio, Texas.,Maj Joseph K. Maddry serves as the Director for the USAF En Route Care Research Center at the 59th MDW/ST and is Director of the Clinical Resuscitation, Emergency Sciences, and Toxicology Research Program, Chief Scientists Office in San Antonio, Texas
| | - Elizabeth A Mann-Salinas
- Amanda M. Staudt serves as an epidemiologist, Jennifer D. Trevino is a program manager, Krystal K. Valdez-Delgado is a research nurse coordinator, and COL Elizabeth A. Mann-Salinas is the Task Area Manager for the Systems of Care for Complex Patients Task Area at the US Army Institute of Surgical Research in San Antonio, Texas. .,Shelia C. Savell serves as the Senior Scientist for the USAF En Route Care Research Center at the 59th MDW/ST, Chief Scientists Office in San Antonio, Texas. .,COL Kimberly A. Biever is a critical care clinical nurse specialist and serves as a consultant to the Surgeon General for En Route Critical Care Nursing, Human Resources Command, Fort Knox, Kentucky. .,Mithun Suresh is a physician working in the Epidemiology/Biostatistics Division of the Research Directorate at the US Army Institute of Surgical Research in San Antonio, Texas. .,COL Jennifer M. Gurney serves as the Chief of Trauma Systems Development and Col Stacy A. Shackelford serves as the Chief of Education and Performance Improvement for the Joint Trauma System in San Antonio, Texas. .,Maj Joseph K. Maddry serves as the Director for the USAF En Route Care Research Center at the 59th MDW/ST and is Director of the Clinical Resuscitation, Emergency Sciences, and Toxicology Research Program, Chief Scientists Office in San Antonio, Texas.
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Lack W, Seymour R, Bickers A, Studnek J, Karunakar M. Prehospital Antibiotic Prophylaxis for Open Fractures: Practicality and Safety. PREHOSP EMERG CARE 2018; 23:385-388. [PMID: 30141716 DOI: 10.1080/10903127.2018.1514089] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
OBJECTIVE Early antibiotic administration has been associated with a significant decrease in infection following open fractures. However, antibiotics are most effective at a time when many patients are still being transported for care. There is limited evidence that antibiotics may be safely administered for open fractures when being transported by life-flight personnel. No such data exists for ground ambulance transport of patients with open fractures. The purpose of the study was to assess the safety and feasibility of prophylactic antibiotic delivery in the prehospital setting. METHODS We performed a prospective observational study between January 1, 2014 and May 31, 2015 of all trauma patients transferred to a level 1 trauma center by a single affiliated ground ambulance transport service. If open fracture was suspected, the patient was indicated for antibiotic prophylaxis with 2 g IV Cefazolin. Exclusion criteria included penicillin allergy, higher priority patient care tasks, and remaining transport time insufficient for administration of antibiotics. The administration of antibiotics was recorded. Patient demographics, associated injuries, priority level (1 = life threatening injury, 2 = potentially life threatening injury, 3 = non-life threatening injury), and timing of transport and antibiotic administration were recorded as well. RESULTS EMTs identified 70 patients during the study period with suspected open fractures. Eight reported penicillin allergy and were not eligible for prophylaxis. The patient's clinical status and transport time allowed for administration of antibiotic prophylaxis for 32 patients (51.6%). Total prehospital time was the only variable assessed that had a significant impact on administration of prehospital antibiotics (<30 minutes = 29% vs. >30 minutes = 66%; p < 0.001). There were no allergic reactions among patients and no needle sticks or other injuries to EMT personnel related to antibiotic administration. CONCLUSIONS EMT personnel were able to administer prehospital antibiotic prophylaxis for a substantial portion of the identified patients without any complications for patients or providers. Given the limited training provided to EMTs prior to implementation of the antibiotic prophylaxis protocol, it is likely that further development of this initial training will lead to even higher rates of prehospital antibiotic administration for open fractures.
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Obstetric Trauma and Surgical Emergencies in the Military Operational Environment. CURRENT TRAUMA REPORTS 2018. [DOI: 10.1007/s40719-018-0126-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Abstract
OBJECTIVE This study evaluated how Tactical Emergency Casualty Care (TECC) training prepared law enforcement officers (LEOs) with the tools necessary to provide immediate, on-scene medical care to successfully stabilize victims of trauma. METHODS This was a retrospective, de-identified study using a seven-item Fairfax County (Virginia USA) TECC After-Action Questionnaire and Arlington County (Virginia USA) police reports. RESULTS Forty-six encounters were collected from 2015 through 2016. Eighty-four percent (n=39) of the encounters were from TECC After-Action Questionnaires and 15% (n=7) were from police reports. The main injuries included 13% (n=6) arterial bleeds, 46% (n=21) mild/moderate bleeds, 37% (n=17) large wounds, 20% (n=9) penetrating chest wounds, and 13% (n=6) open abdominal wounds. One-hundred percent of officers reported success in stabilizing victim injuries. Seventy-four percent of officers (n=26) did not encounter problems caring for a patient while 26% (n=9) encountered a problem. Ninety-seven percent (n=37/38) answered Yes, the training was sufficient, and three percent (n=1) indicated it was OK. CONCLUSION This is the most comprehensive study of TECC use among LEOs to date that supports the importance of TECC training for all LEOs in prehospital trauma care. Results of this study showed TECC training prepared LEOs with the operational tools necessary to provide immediate, on-scene medical care to successfully stabilize victims of trauma. Continuing to train increasing numbers of LEOs in TECC is key to saving the lives of victims of trauma in the future. RothschildHR, MathiesonK. Effects of Tactical Emergency Casualty Care training for law enforcement officers. Prehosp Disaster Med. 2018;33(5):495-500.
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Schauer SG, Naylor JF, Maddry JK, Hinojosa-Laborde C, April MD. Trends in Prehospital Analgesia Administration by US Forces From 2007 Through 2016. PREHOSP EMERG CARE 2018; 23:271-276. [DOI: 10.1080/10903127.2018.1489022] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Chambers JA, Seastedt K, Krell R, Caterson E, Levy M, Turner N. “Stop the Bleed”: A U.S. Military Installation’s Model for Implementation of a Rapid Hemorrhage Control Program. Mil Med 2018; 184:67-71. [DOI: 10.1093/milmed/usy185] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Accepted: 07/11/2018] [Indexed: 11/14/2022] Open
Affiliation(s)
- James Alan Chambers
- 11th Surgical Operations Squadron, 1060W. Perimeter Road, Suite 3K02, Joint Base Andrews, MD
| | - Kenneth Seastedt
- 11th Surgical Operations Squadron, 1060W. Perimeter Road Joint Base Andrews, MD
| | - Robert Krell
- Memorial Sloan Kettering Cancer Center, 1275 York Ave New York, NY
| | | | - Matthew Levy
- Johns Hopkins University Hospital, 600 North Wolfe Street, Baltimore, MD
| | - Nancy Turner
- 11 MDOS Squadron Readiness Liaison, 1050W. Perimeter Road Joint Base Andrews, MD
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Rall JM, Redman TT, Ross EM, Morrison JJ, Maddry JK. Comparison of zone 3 Resuscitative Endovascular Balloon Occlusion of the Aorta and the Abdominal Aortic and Junctional Tourniquet in a model of junctional hemorrhage in swine. J Surg Res 2018; 226:31-39. [DOI: 10.1016/j.jss.2017.12.039] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Revised: 11/19/2017] [Accepted: 12/28/2017] [Indexed: 11/24/2022]
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McMahon RA, Fletcher JL, Aden JK, Holland SR, Trexler ST, Blackbourne LH. Preinjury statin use and thromboembolic events in trauma: a 10-year retrospective evaluation. J Surg Res 2018; 226:100-111. [PMID: 29661275 DOI: 10.1016/j.jss.2017.12.018] [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: 07/14/2017] [Revised: 10/13/2017] [Accepted: 12/13/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Traumatic injury is well known to increase the risk of venous thromboembolic events (VTEs), occurring in up to 58% of trauma patients. Statin medications have significant anti-inflammatory properties and have been shown to reduce the risk of VTE. We hypothesized that trauma patients who received statin medication before injury would have a lower incidence of VTE after injury. METHODS A 10-y retrospective review identified all patients admitted to our trauma service with an injury severity score >9 and an intensive care unit stay of >3 d. This population was categorized as either "statin recipient" (SR) or "statin naïve," with subsequent categorical division by occurrence of VTE. Our primary outcome measure was the occurrence of documented VTE in both statin naïve and SR subjects. RESULTS A total of 2519 trauma patients were included with 97 (3.8%) developing VTE. Pretrauma statin use in males remained as an independent predictor of VTE (odds ratio = 2.25, 95% confidence interval = 1.25-4.04, P < 0.01). The median time to VTE onset was 3 d longer in SRs (10.0 d; confidence interval = 7.3-12.7, P < 0.05). CONCLUSIONS Pretrauma statin use does not appear to have a protective benefit of VTE prevention in trauma patients, as we have shown pretrauma SR male trauma patients to have a twofold increased incidence of VTE. However, when considering the 3 d longer median time to VTE onset found in SRs, we consider the protective benefit of statin use reported in the current literature as likely attributable to this observed delayed onset.
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Affiliation(s)
- Ryan A McMahon
- Department of Surgery, San Antonio Military Medical Center, Fort Sam Houston, Texas.
| | - John L Fletcher
- Department of Surgery, San Antonio Military Medical Center, Fort Sam Houston, Texas
| | - James K Aden
- Department of Surgery, San Antonio Military Medical Center, Fort Sam Houston, Texas
| | - Seth R Holland
- Department of Surgery, San Antonio Military Medical Center, Fort Sam Houston, Texas
| | - Scott T Trexler
- Department of Surgery, San Antonio Military Medical Center, Fort Sam Houston, Texas
| | - Lorne H Blackbourne
- Department of Surgery, San Antonio Military Medical Center, Fort Sam Houston, Texas
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Abstract
OBJECTIVE To describe the accuracy and precision of noninvasive hemoglobin measurement (SpHb) compared with laboratory or point-of-care Hb, and SpHb ability to trend in seriously injured casualties. METHODS Observational study in a convenience sample of combat casualties undergoing resuscitation at two US military trauma hospitals in Afghanistan. SpHb was obtained using the Masimo Rainbow SET (Probe Rev E/Radical-7 Pulse CO-Oximeter v 7.6.2.1). Clinically indicated Hb was analyzed with a Coulter or iStat and compared with simultaneous SpHb values. RESULTS Twenty-three patients were studied (ISS 20 ± 9.8; age 29 ± 9 years; male 97%; 100% intubated). Primary injury cause: improvised explosive device (67%) or gunshot (17%). There were 49 SpHb-Hb pairs (median 2 per subject). Bias: 0.3 ± 1.6 g/dL (95% LOA -2.4, 3.4 g/dL). The SpHb-Hb difference < ± 1 g/dL in 37% of pairs. Eighty-six percent of pairs changed in a similar direction. Using an absolute change in Hb of >1 g/dL, a concurrent absolute change in SpHb of >1 g/dL had a sensitivity: 61%, specificity 85%, positive predictive value: 80%, and a negative predictive value: 69%. The SpHb signal was present in 4643 of 6137 min monitored (76%). CONCLUSIONS This was the first study to describe continuous SpHb in seriously injured combat casualties. Using a threshold of 1 g/dL previously specified in the literature, continuous SpHb is not precise enough to serve as sole transfusion trigger in trauma patients. Further research is needed to determine if it is useful for trending Hb changes or as an early indicator of deterioration in combat casualties.
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Remote Damage Control Resuscitation in Austere Environments. Wilderness Environ Med 2018; 28:S124-S134. [PMID: 28601205 DOI: 10.1016/j.wem.2017.02.002] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Revised: 01/27/2017] [Accepted: 02/23/2017] [Indexed: 12/13/2022]
Abstract
Hemorrhage is the leading cause of preventable military and civilian trauma death. Damage control resuscitation with concomitant mechanical hemorrhage control has become the preferred in-hospital treatment of hemorrhagic shock. In particular, plasma-based resuscitation with decreased volumes of crystalloids and artificial colloids as part of damage control resuscitation has improved outcomes in the military and civilian sectors. However, translation of these principles and techniques to the prehospital, remote, and austere environments, known as remote damage control resuscitation, is challenging given the resource limitations in these settings. Rapid administration of tranexamic acid and reconstituted freeze-dried (lyophilized) plasma as early as the point of injury are feasible and likely beneficial, but comparative studies in the literature are lacking. Whole blood is likely the best fluid therapy for traumatic hemorrhagic shock, but logistical hurdles need to be addressed. Rapid control of external hemorrhage with hemostatic dressings and extremity tourniquets are proven therapies, but control of noncompressible hemorrhage (ie, torso hemorrhage) remains a significant challenge.
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Hickman DA, Pawlowski CL, Sekhon UDS, Marks J, Gupta AS. Biomaterials and Advanced Technologies for Hemostatic Management of Bleeding. ADVANCED MATERIALS (DEERFIELD BEACH, FLA.) 2018; 30:10.1002/adma.201700859. [PMID: 29164804 PMCID: PMC5831165 DOI: 10.1002/adma.201700859] [Citation(s) in RCA: 260] [Impact Index Per Article: 43.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/11/2017] [Revised: 06/18/2017] [Indexed: 05/03/2023]
Abstract
Bleeding complications arising from trauma, surgery, and as congenital, disease-associated, or drug-induced blood disorders can cause significant morbidities and mortalities in civilian and military populations. Therefore, stoppage of bleeding (hemostasis) is of paramount clinical significance in prophylactic, surgical, and emergency scenarios. For externally accessible injuries, a variety of natural and synthetic biomaterials have undergone robust research, leading to hemostatic technologies including glues, bandages, tamponades, tourniquets, dressings, and procoagulant powders. In contrast, treatment of internal noncompressible hemorrhage still heavily depends on transfusion of whole blood or blood's hemostatic components (platelets, fibrinogen, and coagulation factors). Transfusion of platelets poses significant challenges of limited availability, high cost, contamination risks, short shelf-life, low portability, performance variability, and immunological side effects, while use of fibrinogen or coagulation factors provides only partial mechanisms for hemostasis. With such considerations, significant interdisciplinary research endeavors have been focused on developing materials and technologies that can be manufactured conveniently, sterilized to minimize contamination and enhance shelf-life, and administered intravenously to mimic, leverage, and amplify physiological hemostatic mechanisms. Here, a comprehensive review regarding the various topical, intracavitary, and intravenous hemostatic technologies in terms of materials, mechanisms, and state-of-art is provided, and challenges and opportunities to help advancement of the field are discussed.
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Affiliation(s)
- DaShawn A Hickman
- Case Western Reserve University School of Medicine, Department of Pathology, Cleveland, Ohio 44106, USA
| | - Christa L Pawlowski
- Case Western Reserve University, Department of Biomedical Engineering, Cleveland, Ohio 44106, USA
| | - Ujjal D S Sekhon
- Case Western Reserve University, Department of Biomedical Engineering, Cleveland, Ohio 44106, USA
| | - Joyann Marks
- Case Western Reserve University, Department of Biomedical Engineering, Cleveland, Ohio 44106, USA
| | - Anirban Sen Gupta
- Case Western Reserve University, Department of Biomedical Engineering, Cleveland, Ohio 44106, USA
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Planchon J, Vacher A, Comblet J, Rabatel E, Darses F, Mignon A, Pasquier P. Serious game training improves performance in combat life-saving interventions. Injury 2018; 49:86-92. [PMID: 29042033 DOI: 10.1016/j.injury.2017.10.025] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Revised: 10/08/2017] [Accepted: 10/10/2017] [Indexed: 02/02/2023]
Abstract
AIM In modern warfare, almost 25% of combat-related deaths are considered preventable if life-saving interventions are performed. Therefore, Tactical Combat Casualty Care (TCCC) training for soldiers is a major challenge. In 2014, the French Military Medical Service supported the development of 3D-SC1®, a serious game designed for the French TCCC program, entitled Sauvetage au Combat de niveau 1 (SC1). Our study aimed to evaluate the impact on performance of additional training with 3D-SC1®. MATERIAL AND METHODS The study assessed the performance of soldiers randomly assigned to one of two groups, before (measure 1) and after (measure 2) receiving additional training. This training involved either 3D-SC1® (Intervention group), or a DVD (Control group). The principal measure was the individual performance (on a 16-point scale), assessed by two investigators during a hands-on simulation. First, the mean performance score was compared between the two measures for Intervention and Control groups using a two-tailed paired t-test. Second, a multivariable linear regression was used to determine the difference in the impacts of 3D-SC1® and DVD training, and the order of presentation of the two scenarios, on the mean change from baseline in performance scores. RESULTS AND DISCUSSION A total of 96 subjects were evaluated: seven could not be followed-up, while 50 were randomly allocated to the Intervention group, and 39 to the Control group. Between measure 1 and measure 2, the mean (SD) performance score increased from 9.9 (3.13) to 14.1 (1.23), and from 9.4 (2.97) to 12.5 (1.83), for the Intervention group and Control group, respectively (p<0.0001). The adjusted mean difference in performance scores between 3D-SC1® and DVD training was 1.1 (95% confidence interval -0.3, 2.5) (p=0.14). Overall, the study found that supplementing SC1 training with either 3D-SC1® or DVD improved performance, assessed by a hands-on simulation. However, our analysis did not find a statistically significant difference between the effects of these two training tools. 3D-SC1® could be an efficient and pedagogical tool to train soldiers in life-saving interventions. In the current context of terrorist threat, a specifically-adapted version of 3D-SC1®may be a cost-effective and engaging way to train a large civilian public.
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Affiliation(s)
- Jerome Planchon
- Department of Anaesthesiology and Intensive Care, Begin Military Teaching Hospital, French Military Medical Service, Saint Mande, France.
| | - Anthony Vacher
- Action and Cognition in Operational Situations Department, Institut de Recherche Biomedicale des Armées, French Military Medical Service, Brétigny sur Orge, France.
| | - Jeremy Comblet
- Military Medical Center, Rochefort, French Military Medical Service, France.
| | - Eric Rabatel
- Tactical Care Training Department, French Military Medical Service Academy-École du Val-de-Grâce, Paris, France.
| | - Françoise Darses
- Action and Cognition in Operational Situations Department, Institut de Recherche Biomedicale des Armées, French Military Medical Service, Brétigny sur Orge, France.
| | - Alexandre Mignon
- iLUMENS, Department of Medical Simulation, Paris-Descartes University, Paris, France.
| | - Pierre Pasquier
- Department of Anaesthesiology and Intensive Care, Percy Military Teaching Hospital, French Military Medical Service, Clamart, France.
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A Randomized Comparison of Bougie-Assisted and TracheoQuick Plus Cricothyrotomies on a Live Porcine Model. BIOMED RESEARCH INTERNATIONAL 2017; 2017:4215159. [PMID: 29359151 PMCID: PMC5749220 DOI: 10.1155/2017/4215159] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Accepted: 12/03/2017] [Indexed: 11/25/2022]
Abstract
Objectives Cricothyrotomy is a rescue procedure in “cannot intubate, cannot oxygenate” scenarios where other methods of nonsurgical airway management have failed. We compared 2 cuffed cricothyrotomy sets, bougie-assisted cricothyrotomy (BACT) and novel percutaneous TracheoQuick Plus, on a live porcine model in a simulated periarrest situation. Methods Thirty-four anesthetized minipigs were randomly allocated into two groups: BACT technique (n = 17) and TracheoQuick Plus (n = 17). The primary outcome was duration of cricothyrotomy while secondary outcomes were total success rate, number of attempts, location of incision, changes in heart rate, oxygen saturation, and the incidence of complications. Results BACT was significantly faster than TracheoQuick Plus cricothyrotomy, with a median time of 69 sec (IQR 56–85) versus 178 sec (IQR 152–272). The total success rate was without difference. 94% of BACT was performed successfully on the first attempt, while in the TracheoQuick Plus group, it was only 18% (P < 0.001). Trauma to the posterior tracheal wall was observed once in the BACT group and 5 times in the TracheoQuick Plus group. Oxygen saturation was significantly higher in the BACT group both during and after the procedure. Conclusions BACT is superior to TracheoQuick Plus cricothyrotomy on a live animal model.
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Abstract
OBJECTIVE To determine whether time to administration of antibiotics decreased after the implementation of an open fracture working group and antibiotic prophylaxis protocol. DESIGN Retrospective cohort study. SETTING One Level 1 Trauma Center. PATIENTS Patients 18 years of age and older who sustained an open fracture and presented directly to our emergency department. INTERVENTION Prompt irrigation and debridement in the operating room and fracture stabilization dictated by the treating surgeon. Fifty patients were reviewed as the preintervention group, comprising the period before conception and before intervention. Fifty patients were included after the initiation of our protocol during the same time period 1 year later. MAIN OUTCOME MEASUREMENTS Time from entrance to the emergency department to ordering of antibiotics, time from ordering to administration of antibiotics, and time from entrance to the emergency department to administration of antibiotics. RESULTS After protocol implementation, time from admission to antibiotic administration decreased significantly from 123.1 to 35.7 minutes (P = 0.0003). Each component decreased significantly: admission to order decreased from 94.1 to 26.1 minutes, and order to administration decreased from 29.0 to 9.5 minutes (P = 0.0046 and P = 0.0003). CONCLUSION Our study demonstrates a significantly reduced time to antibiotic prophylaxis for patients with open fractures after the implementation of a multidisciplinary working group. We hope that this provides a model for institutions to improve care and outcomes of these injuries. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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