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Prehospital Hemorrhage Control and Treatment by Clinicians: A Joint Position Statement. Ann Emerg Med 2023; 82:e1-e8. [PMID: 37349075 DOI: 10.1016/j.annemergmed.2023.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 03/10/2023] [Indexed: 06/24/2023]
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Covey DC. Decreasing lower extremity junctional and perineal injury from explosive blast with a pelvic protection system. Injury 2023:S0020-1383(23)00404-7. [PMID: 37149442 DOI: 10.1016/j.injury.2023.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 03/23/2023] [Accepted: 05/01/2023] [Indexed: 05/08/2023]
Abstract
OBJECTIVE Lower extremity junctional injuries due to explosive blasts are among the most lethal sustained on the battlefield. To help reduce the effects of junctional and perineal trauma from this injury mechanism, a tiered Pelvic Protection System (PPS) was fielded during the war in Afghanistan. METHODS Thirty-six patients with known PPS status who sustained traumatic above knee amputations, with and without perineal injuries, were identified from an operative amputation registry in Helmand Province, Afghanistan, spanning a 12-month period. RESULTS In Group 1 patients with above knee amputations who wore some tier of the PPS system, 47% (8 of 17) sustained junctional/perineal injuries. Of the patients in Group 2 who wore no PPS, 68% (13 of 19) sustained perineal injuries associated with proximal amputations. Overall, these differences were statistically significant (p = 0.0115). CONCLUSION Use of a PPS may reduce the risk of having severe perineal and lower extremity junctional injury in service members sustaining traumatic above knee amputations from an explosive blast.
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Affiliation(s)
- Dana C Covey
- Study Performed at Department of Orthopaedic Surgery, University of California, San Diego, California, United States.
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Parker W, Despain RW, Bailey J, Elster E, Rodriguez CJ, Bradley M. Military experience in the management of pelvic fractures from OIF/OEF. BMJ Mil Health 2023; 169:108-111. [PMID: 32938710 DOI: 10.1136/bmjmilitary-2020-001469] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 06/22/2020] [Accepted: 07/01/2020] [Indexed: 11/03/2022]
Abstract
INTRODUCTION Pelvic fractures are a common occurrence in combat trauma. However, the fracture pattern and management within the most recent conflicts, i.e. Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF), have yet to be described, especially in the context of dismounted complex blast injury. Our goal was to identify the incidence, patterns of injury and management of pelvic fractures. METHODS We conducted a retrospective review on all combat-injured patients who arrived at our military treatment hospital between November 2010 and November 2012. Basic demographics, Young-Burgess fracture pattern classification and treatment strategies were examined. RESULTS Of 562 patients identified within the study time period, 14% (81 of 562) were found to have a pelvic fracture. The vast majority (85%) were secondary to an improvised explosive device. The average Injury Severity Score for patients with pelvic fracture was 31±12 and 70% were classified as open. Of the 228 patients with any traumatic lower extremity amputation, 23% had pelvic fractures, while 30% of patients with bilateral above-knee amputations also sustained a pelvic fracture. The most common Young-Burgess injury pattern was anteroposterior compression (APC) (57%), followed by lateral compression (LC) (36%) and vertical shear (VS) (7%). Only 2% (nine of 562) of all patients were recorded as having pelvic binders placed in the prehospital setting. 49% of patients with pelvic fracture required procedural therapy, the most common of which was placement of a pelvic external fixator (34 of 40; 85%), followed by preperitoneal packing (16 of 40; 40%) and angioembolisation (three of 40; 0.75%). 17 (42.5%) patients required combinations of these three treatment modalities, the majority of which were a combination of external fixator and preperitoneal packing. The likelihood to need procedural therapy was impacted by injury pattern, as 72% of patients with an APC injury, 100% of patients with a VS injury and 25% of patients with an LC injury required procedural therapy. CONCLUSIONS Pelvic fractures were common concomitant injuries following blast-induced traumatic lower extremity amputations. APC was the most common pelvic fracture pattern identified. While procedural therapy was frequent, the majority of patients underwent conservative therapy. However, placement of an external fixator was the most frequently used modality. Considering angioembolisation was used in less than 1% of cases, in the forward deployed military environment, management should focus on pelvic external fixation±preperitoneal packing. Finally, prehospital pelvic binder application may be an area for further process improvement.
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Affiliation(s)
- William Parker
- Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - R W Despain
- Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - J Bailey
- Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - E Elster
- Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - C J Rodriguez
- Division of Trauma, John Peter Smith Hospital, Fort Worth, Texas, USA
| | - M Bradley
- Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, Maryland, USA
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Berry C, Gallagher JM, Goodloe JM, Dorlac WC, Dodd J, Fischer PE. Prehospital Hemorrhage Control and Treatment by Clinicians: A Joint Position Statement. PREHOSP EMERG CARE 2023:1-15. [PMID: 36961935 DOI: 10.1080/10903127.2023.2195487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/26/2023]
Affiliation(s)
- Cherisse Berry
- Department of Surgery, New York University Grossman School of Medicine, New York, NY
| | | | - Jeffrey M Goodloe
- Department of Emergency Medicine, University of Oklahoma Health Sciences Center, Tulsa, OK
| | - Warren C Dorlac
- Department of Surgery, University of Colorado Health Loveland, Loveland, CO
| | - Jimm Dodd
- Stop the Bleed, American College of Surgeons, Chicago, IL
| | - Peter E Fischer
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN
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Yoganandan N, Moore J, Humm J, Pintar F, Baisden J, Barnes D, Loftis K. Loading rate effect on tradeoff of fractures from pelvis to lumbar spine under axial impact loading. TRAFFIC INJURY PREVENTION 2022; 23:S26-S31. [PMID: 36095155 DOI: 10.1080/15389588.2022.2110589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 08/01/2022] [Accepted: 08/03/2022] [Indexed: 06/15/2023]
Abstract
Objectives: The transmission of impact loading from the seat-to-pelvis-to-lumbar spine in a seated occupant in automotive and military events is a mechanism for fractures to these body regions. While postmortem human subject (PMHS) studies have replicated fractures to the pelvis or lumbar spine using isolated/component models, the role of the time factor that manifests as a loading rate issue on injuries has not been fully investigated in literature. The objective of this study was to explore the hypothesis that short duration pulses fracture the pelvis while longer pulses fracture the spine, and intermediate pulses involve both components.Methods: Unembalmed PMHS thoracolumbar spine-pelvis specimens were fixed at the superior end, and a six-axis load cell was attached. The specimens were mounted on a vertical accelerator, and noninjury and injury tests were conducted by applying short, medium, or long pulses with 5, 15, or 35 ms durations, respectively. Peak axial, shear and resultant forces were obtained. Injuries were documented using posttest x-ray and computed tomography images and scaled using the AIS (2015).Results: The mean age, stature, weight, body mass index, and BMD of twelve specimens were 64.8 ± 11.4 years, 1.8 ± 0.01 m, 83 ± 13 kg, 26.7 ± 5.0 kg/m2, and 114.5 ± 21.3 mg/cc, respectively. For the short, long, and medium duration pulses, the mean resultant forces were 5.6 ± 0.9 kN, 5.9 ± 0.94 kN, and 5.4 ± 1.8 kN, and time durations were 4.8 ± 0.5 ms, 16.3 ± 7.3 ms, and 34.5 ± 7.5 ms, respectively. For the short pulse, pelvis injuries were more severe in 3 out 4 specimens, for the medium pulse, they were distributed between the pelvis and spine, and for the long pulse, spine injuries were more severe in 3 out of 4 specimens.Conclusions: While acknowledging the limitations of the sample size, the results of this study support the hypothesis of the time variable in the tradeoff between pelvis and spine injuries with pulse duration. The tradeoff pattern is attributed to mass recruitment: short pulse biases injuries to pelvis while limiting spinal injuries, and the opposite is true for the longer pulse, thus supporting the hypothesis. It is important to account for the time variable in injury analysis.
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Affiliation(s)
- Narayan Yoganandan
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Jason Moore
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - John Humm
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Frank Pintar
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Jamie Baisden
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | | | - Kathryn Loftis
- AFC DEVCOM Analysis Center, Aberdeen Proving Ground, Maryland
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Abstract
IntroductionThe purpose of this study was to evaluate the utilization of pelvic binders, the proper placement of binders, and to determine any differences in blood product transfusions between combat casualties with and without a pelvic binder identified on initial imaging immediately after the injury.MethodsWe conducted a retrospective review of all combat-injured patients who arrived at our military treatment hospital between 2010 and 2012 with a documented pelvic fracture. Initial imaging (X-ray or computed tomography) immediately after injury were evaluated by 2 independent radiologists. Young-Burgess (YB) classification, pelvic diastasis, correct binder placement over the greater trochanters, and the presence of a pelvic external fixator (ex-fix) was recorded. Injury severity score (ISS), whole blood, and blood component therapy administered within the first 24-hours after injury were compared between casualties with and without a pelvic binder.Results39 casualties had overseas imaging to confirm and radiographically classify a YB pelvic ring injury. The most common fracture patterns were anteroposterior (53%) and lateral compression (28%). 49% (19/39) did not have a binder or ex-fix identified on initial imaging or in any documentation after injury. Ten patients had a binder, with 30% positioned incorrectly over the iliac crest. ISS (34 ± 1.6) was not statistically different between the binder and the no-binder group. Pubic symphysis diastasis was significantly lower in the binder group (1.4 ± 0.2 vs 3.7 ± 0.5, P < .001). There was a trend toward decreased 24-hour total blood products between the binder and no-binder groups (75 ± 11 vs 82 ± 13, P = .67). This was due to less cryoprecipitate in the binder group (6 ± 2 vs 19 ± 5, P = .01).ConclusionsPelvic binder placement in combat trauma may be inconsistent and an important area for continued training. While 24-hour total transfusions do not appear to be different, no-binder patients received significantly more cryoprecipitate.
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Zong ZW, Chen SX, Qin H, Liang HP, Yang L, Zhao YF. Chinese expert consensus on echelons treatment of pelvic fractures in modern war. Mil Med Res 2018; 5:21. [PMID: 29970166 PMCID: PMC6029371 DOI: 10.1186/s40779-018-0168-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 06/13/2018] [Indexed: 01/18/2023] Open
Abstract
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.
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Affiliation(s)
- Zhao-Wen Zong
- State Key Laboratory of Trauma, Burn and Combined Injury, Department of War Wound Rescue Skills Training, Base of Army Health Service Training, Army Medical University, ChongQing, 400038, China.
| | - Si-Xu Chen
- State Key Laboratory of Trauma, Burn and Combined Injury, Department of War Wound Rescue Skills Training, Base of Army Health Service Training, Army Medical University, ChongQing, 400038, China
| | - Hao Qin
- State Key Laboratory of Trauma, Burn and Combined Injury, Department of War Wound Rescue Skills Training, Base of Army Health Service Training, Army Medical University, ChongQing, 400038, China
| | - Hua-Ping Liang
- First Department, Research Institute of Surgery, Daping Hospital, Army Medical University, Chongqing, 400042, China
| | - Lei Yang
- State Key Laboratory of Trauma, Burn and Combined Injury, Department of War Wound Rescue Skills Training, Base of Army Health Service Training, Army Medical University, ChongQing, 400038, China
| | - Yu-Feng Zhao
- Department of Trauma Surgery, Daping Hospital, Army Medical University, ChongQing, 400042, China
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Loftus A, Pynn H, Parker P. Improvised first aid techniques for terrorist attacks. Emerg Med J 2018; 35:516-521. [DOI: 10.1136/emermed-2018-207480] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 05/01/2018] [Accepted: 05/10/2018] [Indexed: 11/03/2022]
Abstract
Terrorist acts occur every day around the world. Healthcare professionals are often present as bystander survivors in these situations, with none of the equipment or infrastructure they rely on in their day-to-day practice. Within several countries there has been a move to disseminate the actions to take in the event of such attacks: in the UK, Run, Hide, Tell, and in the USA, Fight Back. This paper outlines how a very basic medical knowledge combined with everyday high-street items can render highly effective first aid and save lives. We discuss and summarise modern improvised techniques. These include the <C> ABCDE approach of treating catastrophic haemorrhage before airway management, bringing together improvised techniques from the military and wilderness medicine. We explain how improvised tourniquets, wound dressings, splinting and traction devices can be fabricated using items from the high street: nappies, tampons, cling film, duct tape and tablecloths. Cervical spine immobilisation is a labour-intensive protocol that is often practised defensively. With little evidence to support the routine use of triple immobilisation, this should be replaced with a common sense dynamic approach such as the Montana neck brace. Acid or alkali attacks are also examined with simple pragmatic advice. Analgesia is discussed in the context of a prehospital setting. Pharmacy-obtained oral morphine and diclofenac suppositories can be used to treat moderate pain without relying on equipment for intravenous/intraosseous infusion in prolonged hold situations. The differentiation between concealment and cover is summarised: scene safety remains paramount.
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Evaluation of full pelvic ring stresses using a bilateral static gait-phase finite element modeling method. J Mech Behav Biomed Mater 2018; 78:175-187. [DOI: 10.1016/j.jmbbm.2017.11.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Revised: 09/27/2017] [Accepted: 11/03/2017] [Indexed: 11/21/2022]
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Jiao J, Wang JW, Xiao F, Huang YC. The association between the levels of CRP, IL-10, PLA2, Fbg and prognosis in traumatic fracture of lower limb. Exp Ther Med 2016; 12:3209-3212. [PMID: 27882139 PMCID: PMC5103766 DOI: 10.3892/etm.2016.3746] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Accepted: 09/20/2016] [Indexed: 01/14/2023] Open
Abstract
The aim of the present study was to examine changes of sera levels of C-reactive protein (CRP), interleukin-10 (IL-10), phospholipase A2 (PLA2) and fibrinogen β polypeptide chain gene (Fbg) in patients with traumatic fracture of lower limb, and to evaluate their association with prognosis. The changes in sera levels of CRP, IL-10, PLA2 and Fbg were observed at the time of injury, 24 h, and 5 and 7 days after surgery in 90 patients with traumatic fracture of lower limb. In addition, 50 cases, who presented for health examination, were included as the normal controls. The expression of sera levels of CRP, IL-10, PLA2 and Fbg in patients with traumatic fracture of lower limb, was markedly higher than that in the normal controls prior to surgery (P<0.05). The concentration of CRP significantly increased within 24 h after emergency, but decreased gradually as the wound healed, compared to the controls. Pre- and postoperative IL-10 levels increased within 24 h and then decreased gradually. The level of PLA2 in patients before and after surgery was increased, and then decreased gradually. The level of Fbg in patients with trauma was increased after 24 h and then decreased, and increased gradually. The correlation of serum CRP and IL-10 levels (r=0.634, P<0.05), and that of PLA2 and IL-10 levels (r=0.617, P<0.05) were positive. In conclusion, the expression of CRP, IL-10, PLA2 and Fbg levels in traumatic fracture of lower limb markedly increased and was closely associated with prognosis. CRP, IL-10, PLA2 and Fbg levels may therefore serve as useful indexes in determining the progression and prognosis of patients with traumatic fracture of lower limb.
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Affiliation(s)
- Jing Jiao
- Department of Orthopedics, Wuhan Pu'ai Hospital, Wuhan, Hubei 430034, P.R. China
| | - Jun-Wen Wang
- Department of Orthopedics, Wuhan Pu'ai Hospital, Wuhan, Hubei 430034, P.R. China
| | - Fei Xiao
- Department of Orthopedics, Wuhan Pu'ai Hospital, Wuhan, Hubei 430034, P.R. China
| | - Yu-Cheng Huang
- Department of Orthopedics, Wuhan Pu'ai Hospital, Wuhan, Hubei 430034, P.R. China
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