Military medical revolution: deployed hospital and en route care

Early Enteral Nutrition in Aeromedically Evacuated Critically Ill/Injured Patients With a Resultant Validation Algorithm for the Theater Validating Flight Surgeon

INTRODUCTION

Early enteral feeding in critically ill/injured patients promotes gut integrity and immunocompetence and reduces infections and intensive care unit/hospital stays. Aeromedical evacuation (AE) often takes place concurrently. As a result, AE and early enteral feeding should be inseparable.

MATERIALS AND METHODS

This retrospective descriptive study employed AE enteral nutrition (EN) data (2007-2019) collected from patients who were U.S. citizens and mechanically ventilated. The dataset was created from the En Route Critical Care, Transportation Command Regulating and Command and Control Evacuation System, and Theater Medical Data Store databases. Comparisons were performed between patients extracted and patients not extracted, patients treated with EN and patients treated without EN, and within the EN group, between AE Fed and AE Withheld. The impact of the nutrition support in the Joint Trauma System Clinical Practice Guidelines (CPG) was assessed using the 'before' and 'after' methodology.

RESULTS

An uptick in feeding rates was found after the 2010 CPG, 15% → 17%. With the next two CPG iterations, rates rose significantly, 17% → 48%. Concurrently, AE feeding holds rose significantly, 10% → 24%, later dropping to 17%. In addition, little difference was found between those patients not enterally fed preflight and those enterally fed across collected demographic, mission, and clinical parameters. Likewise, no difference was found between those enterally fed during AE and those withheld. Yet, 83% of the study's patients were not fed, and 18% of those that were fed had feeding withheld for AE.

CONCLUSIONS

It appeared that the Clinical Practice Guidelines (CPGs) reinforced the value of feeding, but may well have sensitized to the threat of aspiration. It also appeared that early enteral feeding was underprescribed and AE feeding withholds were overprescribed. Consequently, an algorithm was devised for the Theater Validating Flight Surgeon, bearing in mind relevant preflight/inflight/clinical issues, with prescriptions designed to boost feeding, diminish AE withholding, and minimize complications.

Oral and Maxillofacial Surgery Training in the United States: Influences of Dental and Medical Education, Wartime Experiences, and Other External Factors

Here, we trace the history of oral and maxillofacial surgery (OMS) education from the mid-19th century to the present. We consider the effects of separation of dentistry and medicine, discovery of anesthesia, antisepsis, antibiotics, and wars on surgical progress and training. In the 19th century, apprenticeships with well-known surgeons were the norm. In the 20th century, training evolved from nonintegrated dental school and hospital experiences to 3- and then 4-year integrated hospital programs. After World War II individual oral surgeons pursued the MD degree after residency. The formal dual degree OMS paradigm began in the 1970s.

Effect of needle type on plane block spread in a cadaveric porcine model

INTRODUCTION

Plane blocks are an increasingly common type of regional anaesthesia technique in the perioperative period. Increased spread of local anaesthesia during plane blocks is thought to be related to an increased area of pain coverage. This study sought to assess differences in injectate spread comparing Tuohy needles with standard insulated stimulating block needles.

METHODS

10 Yorkshire-Cross porcine cadavers were used in this study. Immediately following euthanasia, the cadavers underwent bilateral ultrasound-guided transversus abdominis plane (TAP) block injection with radiopaque contrast dye, with one side placed with a 20 g Tuohy needle, and the other side with a 20 g insulated stimulating block needle. Injectate spread was assessed using plain film X-ray and area of spread was measured to compare differences.

RESULTS

All 10 animals underwent successful ultrasound-guided TAP block placement. In all 10 animals, the area of contrast spread was greater with the Tuohy than stimulating needle. Wilcoxon signed-rank test was used to analyse the difference between the groups. The average difference between the two sides was 33.02% (p=0.002).

CONCLUSIONS

This is the first study to demonstrate differences in injectate spread with different needle types. This suggests enhanced spread with Tuohy needle compared with standard block needle, and may encourage its use during plane blocks.

First Russian experience with endovascular balloon occlusion of the aorta in a zone of combat operations

Resuscitative endovascular balloon occlusion of the aorta has increasingly been used all the world over for arresting ongoing intraabdominal and intrapelvic bleeding accompanied by unstable haemodynamics. However, the use of resuscitative endovascular balloon occlusion of the aorta in a zone of military operations has been limited to sporadic cases only. This article deals with 3 clinical case reports regarding rendering medical care for the wounded presenting with extremely unstable haemodynamics and/or a terminal state in a field hospital, where insertion of a balloon into the aorta made it possible to stabilize the condition, to perform the basic scope of diagnosis, and to finally control the continuing bleeding: in one case - intraabdominal (due to splenic rupture) and in 2 cases - intrapelvic (unstable fractures of pelvic bones). In two cases, despite low readings of blood pressure, puncture of the femoral artery was performed 'blindly' and in one case - in an open fashion. The balloons used were the 7 Fr Rescue Balloon (Japan) and 10 Fr balloons manufactured by the Limited Liability Company 'Minimally Invasive Technologies' (Russia). The balloons were positioned in the aorta also 'blindly' and only in one case we managed to perform an X-ray examination confirming the correct position of the balloon. The mean time of occlusion of the thoracic aorta in the survivors amounted to 20 minutes. The operations were accompanied by intensive therapy and massive haemotransfusion. The introducers were removed using the fascia suture technique (without closure of the arterial wall). Two of the three wounded were saved, to be evacuated to a central hospital and discharged 170 and 75 days thereafter, which was due to long-term treatment of severe concomitant fractures of pelvic bones and lower extremities. No complications on the background of resuscitative endovascular balloon occlusion of the aorta were revealed. Two years after surgery both men continue serving in the Armed Forces, with no significant functional impairments. Our third injured patient delivered in a condition of clinical death, despite restoration of the rhythm after inflation of the balloon unfortunately died. Our case reports demonstrate high efficacy of resuscitative endovascular balloon occlusion of the aorta in unstable haemodynamics induced by combat injury to the abdomen and pelvis. The technique of this method makes it possible not only to stabilize haemodynamics, to improve perfusion of the vital organs but also to staunch continuing haemorrhage, hence allowing additional time to carry out haemotransfusion. In future, resuscitative endovascular balloon occlusion of the aorta may become one of the methods of the extended protocol of prehospital care.

Epidemiology of War-Related Spinal Cord Injury Among Combatants: A Systematic Review

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.

From the battlefield to main street: Tourniquet acceptance, use, and translation from the military to civilian settings

Throughout history, battlefield medicine has led to advancements in civilian trauma care. In the most recent conflicts of Operation Enduring Freedom in Afghanistan/Operation Iraqi Freedom, one of the most important advances is increasing use of point-of-injury hemorrhage control with tourniquets. Tourniquets are gradually gaining acceptance in the civilian medical world-in both the prehospital setting and trauma centers. An analysis of Emergency Medical Services (EMS) data shows an increase of prehospital tourniquet utilization from 0 to nearly 4,000 between 2008 and 2016. Additionally, bystander educational campaigns such as the Stop the Bleed program is expanding, now with over 125,000 trained on tourniquet placement. Because the medical community and the population at large has broader acceptance and training on the use of tourniquets, there is greater potential for saving lives from preventable hemorrhagic deaths.

Fabrication of injectable and superelastic nanofiber rectangle matrices ("peanuts") and their potential applications in hemostasis

Uncontrolled hemorrhage, which typically involves the torso and/or limb junctional zones, remains a great challenge in the prehospital setting. Here, we for the first time report an injectable and superelastic nanofiber rectangle matrix ("peanut") fabricated by a combination of electrospinning, gas foaming, hydrogel coating and crosslinking techniques. The compressed nanofiber peanut is capable of re-expanding to its original shape in atmosphere, water and blood within 10 s. Such nanofiber peanuts exhibit greater capacity of water/blood absorption compared to current commercial products and high efficacy in whole blood clotting assay, in particular for thrombin-immobilized samples. These nanofiber peanuts are capable of being packed into a syringe for injection. Further in vivo tests indicated the effectiveness of nanofiber peanuts for hemostasis in a porcine liver injury model. This new class of nanofiber-based materials may hold great promise for hemostatic applications.

Chinese expert consensus on echelons treatment of pelvic fractures in modern war

The characteristics and treatment of pelvic fractures vary between general conditions and modern war. An expert consensus has been reached based on pelvic injury epidemiology and the concepts of battlefield treatment combined with the existing levels of military medical care in modern warfare. According to this consensus, first aid, emergency treatment and early treatment of pelvic fractures are introduced in three separate levels. In Level I facilities, simple triage and rapid treatment following the principles of advanced trauma life support are recommended to evaluate combat casualties during the first-aid stage. Re-evaluation, further immobilization and fixation, and hemostasis are recommended at Level II facilities. At Level III facilities, the main components of damage control surgery are recommended, including comprehensive hemostasis, a proper resuscitation strategy, the treatment of concurrent visceral and blood vessel damage, and battlefield intensive care. The grading standard for evidence evaluation and recommendation was used to reach this expert consensus.

Aeromedical evacuation-relevant hypobaria worsens axonal and neurologic injury in rats after underbody blast-induced hyperacceleration

BACKGROUND

Occupants of military vehicles targeted by explosive devices often suffer from traumatic brain injury (TBI) and are typically transported by the aeromedical evacuation (AE) system to a military medical center within a few days. This study tested the hypothesis that exposure of rats to AE-relevant hypobaria worsens cerebral axonal injury and neurologic impairment caused by underbody blasts.

METHODS

Anesthetized adult male rats were secured within cylinders attached to a metal plate, simulating the hull of an armored vehicle. An explosive located under the plate was detonated, resulting in a peak vertical acceleration force on the plate and occupant rats of 100G. Rats remained under normobaria or were exposed to hypobaria equal to 8,000 feet in an altitude chamber for 6 hours, starting at 6 hours to 6 days after blast. At 7 days, rats were tested for vestibulomotor function using the balance beam walking task and euthanized by perfusion. The brains were then analyzed for axonal fiber injury.

RESULTS

The number of internal capsule silver-stained axonal fibers was greater in animals exposed to 100G blast than in shams. Animals exposed to hypobaria starting at 6 hours to 6 days after blast exhibited more silver-stained fibers than those not exposed to hypobaria. Rats exposed to 100% oxygen (O2) during hypobaria at 24 hours postblast displayed greater silver staining and more balance beam foot-faults, in comparison with rats exposed to hypobaria under 21% O2.

CONCLUSION

Exposure of rats to blast-induced acceleration of 100G increases cerebral axonal injury, which is significantly exacerbated by exposure to hypobaria as early as 6 hours and as late as 6 days postblast. Rats exposed to underbody blasts and then to hypobaria under 100% O2 exhibit increased axonal damage and impaired motor function compared to those subjected to blast and hypobaria under 21% O2. These findings raise concern about the effects of AE-related hypobaria on TBI victims, the timing of AE after TBI, and whether these effects can be mitigated by supplemental oxygen.

Use of tranexamic acid in combat casualties. Experience of the Spanish medical corps. Clinical series and literature review

OBJECTIVE

To describe the experience with tranexamic acid (TXA) during the care of combat causalities treated in the Spanish military hospital based in Herat (Afghanistan) and to perform an analysis of the literature related to the military setting.

MATERIAL AND METHODS

With the approval of the appropriate military institutions, an analysis was performed on the use of TXA in combat casualties treated between March and May 2014. Of the 745 patients seen, 10 were due to a firearm/explosive device (combat casualties). A descriptive analysis was performed on the data collected. Absolute and relative frequencies (%) were used for the categorical variables. For central tendency measurements, the arithmetic mean and standard deviation or the median and interquartile range was calculated. The data were obtained from the military records of patients treated in the Herat military hospital.

RESULTS

All the patients in this series received TXA within the first 3 hours after the attack. The most frequent dose used was one gram i.v, with bleeding was controlled in 100% of cases. All the patients survived and none of them had secondary effects. These data agree with that recommended in the combat casualties treatment guide followed by military health in other countries in this setting.

CONCLUSION

All combat casualties were treated with TXA within the first 3 hours. The most frequent dose used was one gram iv and bleeding was controlled in all cases. All the patients survived with no adverse effects being observed.

Provision of nutrition support therapies in the recent Iraq and Afghanistan conflicts

This article describes the experience of nutrition support practitioners, specifically dietitians, providing care to combat casualties. It provides a brief overview of dietitians' induction into armed service but focuses primarily on their role in providing nutrition support during the most recent conflicts in Iraq and Afghanistan. The current system of combat casualty care is discussed with specific emphasis on providing early and adequate nutrition support to U.S. combat casualties from injury, care in theater combat support hospitals (CSHs)/expeditionary medical support (EMEDs), and en route care during critical care air transport (CCAT) up to arrival at treatment facilities in the United States. The article also examines practices and challenges faced in the CSHs/EMEDs providing nutrition support to non-U.S. or coalition patients. Over the past decade in armed conflicts, dietitians, physicians, nurses, and other medical professionals have risen to challenges, have implemented systems, and continue working to optimize treatment across the spectrum of combat casualty care.

Non-invasive respiratory volume monitoring in patients with traumatic thoracic injuries

Background

Respiratory decompensation is common after traumatic thoracic injuries such as multiple rib fractures and pulmonary contusions. A continuous, non-invasive, impedance-based respiratory volume monitor generates right and left tidal volume measurements, reflecting air exchange in the lungs and derives an instantaneous respiratory rate. The feasibility of using unilateral respiratory volume monitor–based tidal impedance measurements to monitor respiratory status in trauma patients is evaluated.

Methods

Three intensive care unit patients with three or more rib fractures following blunt trauma had continuous respiratory volume monitor measurements with a novel non-invasive impedance-based device (ExSpiron, Respiratory Motion Inc., Waltham, MA) and corresponding clinical data to permit analysis. Tidal impedance measurements were collected from both the injured and non-injured sides and converted into bilateral respiratory volume monitor measurements using advanced algorithms.

Results

In Patient 1, following evacuation of a pneumothorax, the respiratory volume monitor showed a significant increase in tidal measurements coupled with a compensatory decrease in tidal measurements on the uninjured side and a decrease in respiratory rate. In Patient 2, tidal measurements were only slightly decreased on both the injured side and uninjured side; respiratory rate remained unchanged. This patient remained stable and required no intervention. Patient 3 demonstrated a sustained decrease in tidal measurements on the injured side that corresponded with radiograph findings and clinical deterioration leading to the need for endotracheal intubation.

Conclusions

The results from these cases demonstrate that respiratory volume monitor can generate unilateral respiratory tidal measurements and respiratory rate in patients with traumatic thoracic injuries. Continuous respiratory volume monitor in patients with thoracic trauma has strong potential for application in the military, aeromedical, and other austere environments where respiratory monitoring is problematic. Future studies to investigate the utility of this technology are warranted.

Paediatric traumatic cardiac arrest: data from the Joint Theatre Trauma Registry

BACKGROUND

Traumatic cardiac arrest (TCA) in children is associated with a low probability of survival and poor neurological outcome in survivors. Since 2003, over 600 seriously injured local national children have been treated at deployed UK military medical treatment facilities during the Iraq and Afghanistan conflicts. A number of these were in cardiac arrest after sustaining traumatic injuries. This study defined outcomes from paediatric TCA in this cohort.

METHODS

A retrospective database review was undertaken using the UK Joint Theatre Trauma Registry. This includes UK military, coalition military, civilians and local security forces personnel who prompted trauma team activation. All children in this series were local nationals. Patients aged less than 18 years who presented between January 2003 and April 2014, and who underwent cardiopulmonary resuscitation, were included.

RESULTS

27 children with TCA were included. Four children survived to discharge from the medical treatment facility (14.8%), though limited data are available regarding the long-term neurological outcome in these patients.

CONCLUSIONS

This study demonstrates that the outcomes for paediatric TCA in our military field hospitals were similar to other paediatric civilian and adult military studies, despite patients being injured by severe blast injuries. Further work is needed to define the optimal management of paediatric TCA.

Acute nontraumatic general surgical conditions on a combat deployment

BACKGROUND

Literature is lacking on acute surgical problems that may be encountered on military deployment; even less has been written on whether or not any of these surgical problems could have been avoided with more focused predeployment screening. We sought to determine the burden of illness attributable to acute nontraumatic general surgical problems while on deployment and to identify areas where more rigorous predeployment screening could be implemented to decrease surgical resource use for nontraumatic problems.

METHODS

We studied all Canadian Armed Forces (CAF) members deployed to Afghanistan between Feb. 7, 2006, and June 30, 2011, who required treatment for a nontraumatic general surgical condition.

RESULTS

During the study period 28 990 CAF personnel deployed to Afghanistan; 373 (1.28%) were repatriated because of disease and 100 (0.34%) developed an acute general surgical condition. Among those who developed an acute surgical illness, 42 were combat personnel (42%) and 58 were support personnel (58%). Urologic diagnoses (n = 34) were the most frequent acute surgical conditions, followed by acute appendicitis (n = 18) and hernias (n = 12). We identified 5 areas where intensified predeployment screening could have potentially decreased the incidence of in-theatre acute surgical illness.

CONCLUSION

Our findings suggest that there is a significant acute care surgery element encountered on combat deployment, and surgeons tasked with caring for this population should be prepared to treat these patients.

Training Forward Surgical Teams for Deployment: The US Army Trauma Training Center

Since the late 1980s, the US Army has been deploying forward surgical teams to the most intense areas of conflict to care for personnel injured in combat. The forward surgical team is a 20-person medical team that is highly mobile, extremely agile, and has relatively little need of outside support to perform its surgical mission. In order to perform this mission, however, team training and trauma training are required. The large majority of these teams do not routinely train together to provide patient care, and that training currently takes place at the US Army Trauma Training Center (ATTC). The training staff of the ATTC is a specially selected 10-person team made up of active duty personnel from the Army Medical Department assigned to the University of Miami/Jackson Memorial Hospital Ryder Trauma Center in Miami, Florida. The ATTC team of instructors trains as many as 11 forward surgical teams in 2-week rotations per year so that the teams are ready to perform their mission in a deployed setting. Since the first forward surgical team was trained at the ATTC in January 2002, more than 112 forward surgical teams and other similar-sized Department of Defense forward resuscitative and surgical units have rotated through trauma training at the Ryder Trauma Center in preparation for deployment overseas.

Trauma resuscitation and monitoring: military lessons learned

Over the past 13 years, the military health care system has made improvements that are associated with an unprecedented survival rate for severely injured casualties. Monitoring for indications of deterioration as the critically injured patient moves across the continuum of care is difficult given the limitations of routinely used vital signs. Research by both military and civilian researchers is revolutionizing monitoring, with an increased focus on noninvasive, continuous, dynamic measurements to provide earlier, more sensitive indications of the patient's perfusion status.

Thromboelastography (TEG) and rotational thromboelastometry (ROTEM) for trauma induced coagulopathy in adult trauma patients with bleeding

BACKGROUND

Trauma-induced coagulopathy (TIC) is a disorder of the blood clotting process that occurs soon after trauma injury. A diagnosis of TIC on admission is associated with increased mortality rates, increased burdens of transfusion, greater risks of complications and longer stays in critical care. Current diagnostic testing follows local hospital processes and normally involves conventional coagulation tests including prothrombin time ratio/international normalized ratio (PTr/INR), activated partial prothrombin time and full blood count. In some centres, thromboelastography (TEG) and rotational thromboelastometry (ROTEM) are standard tests, but in the UK they are more commonly used in research settings.

OBJECTIVES

The objective was to determine the diagnostic accuracy of thromboelastography (TEG) and rotational thromboelastometry (ROTEM) for TIC in adult trauma patients with bleeding, using a reference standard of prothrombin time ratio and/or the international normalized ratio.

SEARCH METHODS

We ran the search on 4 March 2013. Searches ran from 1970 to current. We searched The Cochrane Library, MEDLINE (OvidSP), EMBASE Classic and EMBASE, eleven other databases, the web, and clinical trials registers. The Cochrane Injuries Group's specialised register was not searched for this review as it does not contain diagnostic test accuracy studies. We also screened reference lists, conducted forward citation searches and contacted authors.

SELECTION CRITERIA

We included all cross-sectional studies investigating the diagnostic test accuracy of TEG and ROTEM in patients with clinically suspected TIC, as well as case-control studies. Participants were adult trauma patients in both military and civilian settings. TIC was defined as a PTr/INR reading of 1.2 or greater, or 1.5 or greater.

DATA COLLECTION AND ANALYSIS

We piloted and performed all review stages in duplicate, including quality assessment using the QUADAS-2 tool, adhering to guidance in the Cochrane Handbook for Diagnostic Test Accuracy Reviews. We analysed sensitivity and specificity of included studies narratively as there were insufficient studies to perform a meta-analysis.

MAIN RESULTS

Three studies were included in the final analysis. All three studies used ROTEM as the test of global haemostatic function, and none of the studies used TEG. Tissue factor-activated assay EXTEM clot amplitude (CA) was the focus of the accuracy measurements in blood samples taken near to the point of admission. These CAs were not taken at a uniform time after the start of the coagulopathic trace; the time varied from five minutes, to ten minutes and fifteen minutes. The three included studies were conducted in the UK, France and Afghanistan in both civilian and military trauma settings. In two studies, median Injury Severity Scores were 12, inter-quartile range (IQR) 4 to 24; and 22, IQR 12 to 34; and in one study the median New Injury Severity Score was 34, IQR 17 to 43.There were insufficient included studies examining each of the three ROTEM CAs at 5, 10 and 15 minutes to make meta-analysis and investigation of heterogeneity valid. The results of the included studies are thus reported narratively and illustrated by a forest plot and results plotted on the receiver operating characteristic (ROC) plane.For CA5 the accuracy results were sensitivity 70% (95% CI 47% to 87%) and specificity 86% (95% CI 82% to 90%) for one study, and sensitivity 96% (95% CI 88% to 100%) and specificity 58% (95% CI 44% to 72%) for the other.For CA10 the accuracy results were sensitivity 100% (95% CI 94% to 100%) and specificity 70% (95% CI 56% to 82%).For CA15 the accuracy results were sensitivity 88% (95% CI 69% to 97%) and specificity 100% (95% CI 94% to 100%).No uninterpretable ROTEM study results were mentioned in any of the included studies.Risk of bias and concerns around applicability of findings was low across all studies for the patient and flow and timing domains. However, risk of bias and concerns around applicability of findings for the index test domain was either high or unclear, and the risk of bias for the reference standard domain was high. This raised concerns around the interpretation of the sensitivity and specificity results of the included studies, which may be misleading.

AUTHORS' CONCLUSIONS

We found no evidence on the accuracy of TEG and very little evidence on the accuracy of ROTEM. The value of accuracy estimates are considerably undermined by the small number of included studies, and concerns about risk of bias relating to the index test and the reference standard. We are unable to offer advice on the use of global measures of haemostatic function for trauma based on the evidence on test accuracy identified in this systematic review. This evidence strongly suggests that at present these tests should only be used for research. We consider more thoroughly what this research could be in the Discussion section.

Military trauma system in Afghanistan: lessons for civil systems?

PURPOSE OF REVIEW

This review focuses on development and maturation of the tactical evacuation and en route care capabilities of the military trauma system in Afghanistan and discusses hard-learned lessons that may have enduring relevance to civilian trauma systems.

RECENT FINDINGS

Implementation of an evidence-based, data-driven performance improvement programme in the tactical evacuation and en route care elements of the military trauma system in Afghanistan has delivered measured improvements in casualty care outcomes.

SUMMARY

Transfer of the lessons learned in the military trauma system operating in Afghanistan to civilian trauma systems with a comparable burden of prolonged evacuation times may be realized in improved patient outcomes in these systems.

A Decade of Advances in Military Trauma Care

Background:

While combat casualty care shares many key concepts with civilian trauma systems, its unique features mandate certain practices that are distinct from the civilian ones.

Methods:

This is a review of the most current literature on combat casualty care, based on computer database searches for studies on combat casualty care and military medicine. Studies were selected for inclusion in this review based on their relevance and contribution.

Results:

Over the last decade, meticulous, international data collection and research efforts have led to significant improvements in military trauma care. Combat medicine has focused on the causes of preventable deaths and targeted on bleeding control and resuscitation strategies, as well as improved evacuation. En route care and forward surgical interventions have resulted in unprecedented low fatality rates and the saving of more lives.

Conclusion:

This overview of the developments in combat casualty care in recent years emphasizes medical practices that are characteristic of combat medicine, yet with the potential to save lives in other scenarios, as well.

[Evolution of US military transfusion support for resuscitation of trauma and hemorrhagic shock]

Military conflicts create a dynamic medical environment in which the number of severe trauma cases is compressed in both time and space. In consequence, lessons are learned at a rapid pace. Because the military has an effective organizational structure at its disposal and the logistical capacity to rapidly disseminate new ideas, adoption of novel therapies and protective equipment occurs quickly. The recent conflicts in Iraq and Afghanistan are no exception: more than three dozen new clinical practice guidelines were implemented by the US Armed Forces, with attendant survival benefits, in response to observation and research by military physicians. Here we review the lessons learned by coalition medical personnel regarding resuscitation of severe trauma, integrating knowledge gained from massive transfusion, autopsies, and extensive review of medical records contained in the Joint Theater Trauma Registry. Changes in clinical care included the shift to resuscitation with 1:1:1 component therapy, use of fresh whole blood, and the application of both medical devices and pharmaceutical adjuncts to reduce bleeding. Future research will focus on emerging concepts regarding coagulopathy of trauma and evaluation of promising new blood products for far-forward resuscitation. New strategies aimed at reducing mortality on the battlefield will focus on resuscitation in the pre-hospital setting where hemorrhagic death continues to be a major challenge.